Bill Totten's Weblog

Wednesday, August 23, 2006

God Mode

by Luke Mitchell

Harper's Magazine Notebook (August 2006)

He has chosen death:
Refusing to eat or drink, that he may bring
Disgrace upon me; for there is a custom,
An old amd foolish custom, that if a man
Be wronged, or think that he is wronged, and starve
Upon another's threshold till he die,
The common people, for all time to come,
Will raise a heavy cry against that threshold,
Even though it be the King's.

- W B Yeats

Last August, seventy-six foreign nationals held at the US Naval Station at Guantanamo Bay, Cuba, began what was likely the largest hunger strike ever to take place at an American-run prison. By September, when the protest reached its peak, more than a quarter of the prison's nearly 500 inmates were refusing to eat. Pentagon officials were dismissive of the strikes, which they called "voluntary fasts". Defense Secretary Donald Rumsfeld even compared the process of starvation, in which the body, deprived of nutrition, eats its own organs, to going "on a diet". But given the means by which the strike would be controlled, such nonchalance made a certain sense. Rather than let the men die, our government simply tied them to chairs and made them eat.

There was no special art to it. Military guards bound the men to the chairs by their ankles, waists, wrists, shoulders, and heads, and military nurses forced flexible plastic tubes through their nostrils, down their throats, and into their stomachs. In went the food. Nor was the feeding necessarily sadistic. Lawyers for the prisoners say that the doctors sometimes used excessively thick tubes that caused internal bleeding and that they deliberately overfed the prisoners, causing them to vomit and to defecate in their clothing and on their chairs; but Pentagon officials deny these charges, and outside physicians who have witnessed the feedings support the official accounts. No, what was peculiar about the force-feeding was that the Pentagon seemed so perfectly convinced it had done something that was, for once, beyond criticism.

When the first known instance of Guantanamo-sanctioned force-feeding took place, in 2002, a Guantanamo spokesman named James Bell explained that Naval doctors would put a feeding tube into any prisoners who threatened to succeed at dying, "Regardless of whether they were involved in killing thousands of innocent people in the World Trade Center attacks or not", Bell said, "we have a responsibility to maintain their health and welfare, and that certainly includes taking actions to preserve their lives". Four years later, Dr William Winkenwerder Jr, who is the assistant secretary of defense for health affairs and the chief architect of the Guantanamo force-feed policy, told the New York Times that force-feeding was both ethical and necessary. "There is a moral question", he said, "Do you allow a person to commit suicide? Or do you take steps to protect their health and preserve their life?" Winkenwerder added that he and his colleagues at the Pentagon had considered this question carefully and concluded that preventing suicide was ethical. "The objective in any circumstance", he said, "is to protect and sustain a person's life".

Most Pentagon officials, of course, are focused on objectives other than protecting and sustaining the lives of foreign nationals. But I was more bothered by Winkenwerder's claim that he had decided upon the policy only after deliberately contemplating its ethical implications. The United States has force-fed many people - American slaves who hoped to escape servitude, American women who sought the right to vote - but the practice has been little utilized in modern times, primarily because most people find it repugnant. At a 1975 conference in Tokyo, members of the World Medical Association crafted an unambiguous ban on force-feeding, which was later endorsed by the American Medical Association. In 2000 a US District Court judge found that a federal prisoner could not be force-fed, despite the fact that Federal Bureau of Prison guidelines allowed for it. ("I just don't think the government has put forward any kind of compelling interest that would allow me to override a person's last, ultimate means of protesting government", the judge wrote.) And when county prison officials in Bangor, Maine, did manage to obtain a court order last October to force-feed a suicidal burglar on a hunger strike, the doctors at the Eastern Maine Medical Center refused to perform the procedure. Jill McDonald, a spokesman for the hospital, told the Bangor Daily News that the hospital could not operate without a patient's consent, "We are not parties to court orders", McDonald said. "We are under a different set of obligations".

Had Winkenwerder really engaged in a long dialogue with doctors and other specialists only to conclude, contrary to thirty years of established medical guidance, that binding people to chairs and forcing food down their throats was his only ethical option as a medical professional? I called the public affairs number at the Pentagon on the off chance that he would agree to an interview and, somewhat to my surprise, was told that he would.

Winkenwerder was reasonably affable on the telephone but also clearly aware that what he said could have political implications. He was a health-insurance executive in Massachusetts before he took responsibility for the medical policies of the United States military; in the picture next to his online biography, he wears a two-tone broker shirt and a pocket square. Two publicists listened in on our conversation.

Winkenwerder said that a physician's obligations are complex. He cited the World Medical Association's 1991 Malta Declaration, a follow-on to the Tokyo Declaration that more specifically addresses hunger-strike issues. The preamble notes that doctors treating hunger strikers are faced with a conflict between "a moral obligation on every human being to respect the sanctity of life" and "the duty of the doctor to respect the autonomy which the patient has over his person". Winkenwerder read a passage aloud to me in order to underscore the ambiguity inherent to that conflict:

"This conflict is apparent where a hunger striker who has issued clear instructions not to be resuscitated lapses into a coma and is about to die. Moral obligation urges the doctor to resuscitate the patient even though it is against the patient's wishes. On the other hand, duty urges the doctor to respect the autonomy of the patient."

"So that's the moral question", he said. "That's the moral issue". And he was right, of course. Autonomy is the central question. The Malta Declaration, a notably sensible and humane document, despite its having been written by a committee, is quite clear about this. It turned out, though, that Winkenwerder had not read me the entire passage:

"However, the doctor should clearly state to the patient whether or not he is able to accept the patient's decision to refuse treatment or, in case of coma, artificial feeding, thereby risking death. If the doctor cannot accept the patient's decision to refuse such aid, the patient would then be entitled to be attended by another physician."

In short, the doctor should be allowed to practice medicine by the light of his or her own conscience, and the patient should have access to a doctor who can accept his or her decision to refuse artificial feeding. Had Winkenwerder really thought this through? Was he trying to trick me somehow? An AMA official later told me she had heard of four Guantanamo doctors who apparently did not think it was ethical to participate in involuntary feeding and so didn't. The doctors were not punished, but nor could hunger strikers choose to be "treated" by them.

Winkenwerder, though, was driving at a larger point. "So with the Malta Declaration", he continued:

"When the hunger striker has become confused and is therefore unable to make an unimpaired decision or has lapsed into a coma, the doctor shall be free to make the decision for his patient as to further treatment which he considers to be in the best interest of that patient ..."

My own confusion deepened. The Pentagon was putting tubes into men so healthy they had to be bound to special chairs, and Winkenwerder was talking about the ethics of feeding people in comas. I asked him if "unable to make an unimpaired decision" or "lapsed into a coma" really were the relevant criteria for force-feeding the hunger strikers at Guantanamo.

"That's their criteria", Winkenwerder said, acknowledging my confusion. "And here's the distinction with ours. And this is not as wild a difference as some have made it out to be. And I'd ask you to think about this yourself." What came next genuinely surprised me. "We would prefer not to have people lapse into coma or to be near death when we make that decision", Winkenwerder said, meaning the decision to force-feed. "In other words, if we're there to protect and sustain someone's life, why would we actually go to the point of putting that person's life at risk before we act? So I think we're operating on a very similar set of ethical reasoning, but it's applied at an earlier stage."

That is, Winkenwerder and his doctors were forcing perfectly healthy prisoners to eat even before they were at risk of starving. Absurd as it sounds, he was describing, with medical precision, the Bush doctrine of "forward deterrence", in which potential enemies are confronted on their own territory before they become an actual threat. He was describing the same policy that was driving the entire war on terror.

I asked Winkenwerder if his preemptive force-feeding policy was the same as forward deterrence. The analogy was obvious to me, but he seemed offended by the question.

"Our intentions are good", he said a moment later, not quite plaintively. "We are seeking to preserve life".

There is a certain kind of video game, called a first-person shooter, in which you run through a maze and fire at whatever comes your way. These games are challenging because ammunition is limited, because every living thing is trying to kill you, and because (as a result) you can't stop thinking, even for a minute. The first-person shooter exists in a nightmarish Hobbesian state of nature. In a computer game, though, the state of nature is eternally malleable. You can use cheat codes to remove gravity, add extra "lives", increase the amount of gore, and so on. The most powerful cheat is called god mode. In god mode, you never run out of ammunition and nothing can ever kill you. You are free to turn your mind off for a moment and enjoy the synthetic beauty of the game.

I mention this as a contemporary example of a longstanding opposition in the American psyche between liberty and death. In the old American religion we were supposed to be able to choose between one and the other. The basic premise, according to Patrick Henry, the state of New Hampshire, and countless Mel Gibson movies, was that the absence of liberty actually required death. The new American religion, however, insists that we choose life.

"Life" in America is not a simple matter of cell division, though. It is an issue. When we think about life, we think about abortion or the recent trials of Terry Schiavo. We think about the sanctity of life. Indeed, our president celebrated the first anniversary of his inauguration by establishing a holiday called National Sanctity of Human Life Day, which, were it not for his involvement in what has come to be called the "culture of life", might seem an odd move by a man who has launched two wars and vociferously supported the death penalty.

It is easy to understand "culture of life" to mean "culture in which abortion is outlawed", and in fact the phrase was invented by Pope John Paul II for a 1995 encyclical, Evangelium vitae, which addresses abortion in some depth. But the pope was at least as concerned with matters of power and control - and therefore of liberty - as he was with death, itself. Suicide, for example, was not to be rejected because of the anguish it caused the survivors or because it was a needless squandering of a precious gift. It was to be rejected because this act of defiance was often committed specifically in the name of freedom. To John Paul's way of thinking, that desire for freedom was the very essence of the sin. "In its deepest reality", the pope wrote, "suicide represents a rejection of God's absolute sovereignty over life and death".

In this light, Winkenwerder's notion of protecting "life" begins to make sense. Consider the major national security initiatives of the last few decades, and especially the last few years: the doctrines of "overwhelming force" and "shock and awe", in which massive technological superiority diminishes the chance of actual battlefield injury or death (on the part of our own forces); "missile defense", which theoretically, if not actually, renders impotent all nuclear weapons but our own; unmanned Predator drones, whose focused air strikes put no American life in jeopardy; motion-detecting fortifications along our southern border to ward off threats both economic and martial; surveillance of our every utterance by computers carefully programmed to detect the words most preferred by our enemies; and, of course, force-feeding, in which we preempt even the prick to our conscience that is the essence of a principled suicide. Consider that the man in charge of medical ethics for the most powerful killing machine in history spent most, of his professional career in the insurance trade, a business based on the premise that if we just spend enough money, we can reduce the level of risk in our lives to zero.

We, as a nation, seem to be seeking a technological circumstance that allows the United States not just to dominate but to dominate so absolutely and effortlessly that we need not even think about our enemies, much less fear them - something that allows us to turn off our minds and enjoy the synthetic beauty of the game. The phrase the Pentagon uses is "Full-spectrum Dominance". I call it god mode.

You have to understand", Winkenwerder said. "Our policy is not to prevent people from hunger striking. Our policy is to sustain life, is to prevent people from dying as a result of hunger striking."

The doctor was becoming increasingly exasperated. It seemed to me that allowing people to hunger strike and preventing them from dying as a result were mutually contradictory aims. After all, ifa hunger strike is the final attempt by the powerless to assert their autonomy - "a person's last, ultimate means of protesting" - then force-feeding is the ultimate rejection of that autonomy. In that it reduces its subject to a state of total submission, powerless even within the bounds of his or her own flesh, force-feeding is no less violent an act than is rape.

But Winkenwerder was sincere in his defense, if somewhat inconsistent, and the longer I spoke to him the more I came to realize that it was this very inconsistency that allowed him to be sincere. He spoke repeatedly of the complexity of the debate - "There are many issues in the world of medicine, in the world of health care", he said, "about which good people with good intentions can have differing opinions" - and he seemed genuinely to believe that it was important to justify his policies in terms of ethics rather than in terms of discipline or punishment.

"You know", he said, "there are other parallels in medical practice. I can certainly recall earlier in my career attending to young women who were anorexics, who literally wouldn't eat. And I think if we had stood by and respected their autonomy they would have died."

I was taken aback by the comparison. I asked if he meant to compare his prisoners to anorexic girls. He said, "No, no, no. I'm not. And don't say that, because I didn't do that. I'm just giving you an example of the fact that there are other situations in which people take actions that place their life or their health in serious jeopardy and medical professionals take actions to prevent them from harming themselves." I tried to draw a distinction between mental pathology and political speech. I mentioned the case of Bobby Sands, the Irish Republican Army member who died after a sixty-six-day hunger strike in 1981. "Well, I don't know what was going on with Bobby Sands", Winkenwerder said. "I haven't studied that case".

Winkenwerder never did make clear to me what was so complex about the decision to force a man to eat. Maybe he couldn't. Or maybe he conceived of that complexity as a final form of defense, an imaginary "safe place" of the sort that psychiatrists advise their patients to escape to in times of crisis. A few weeks after I spoke to him, though, an anonymous official did explain to the Toronto Star that the death of a Guantanamo prisoner would be disastrous for the administration. "The worst case would be to have someone go from zero to hero", the official said. "We don't want a Bobby Sands".

At Guantanamo, the preemptive force-feeding continues, but, like shock and awe and missile defense and every other doomed attempt to remove fear and ambiguity from our fallen world, it has failed to achieve its end. In June, as we all know, three prisoners in that facility, all of whom had failed in their attempt to starve, managed instead to hang themselves with their own bed sheets. The test of god mode in America today is whether that fact, which men like Winkenwerder no doubt will call "complex", is simple enough to prick your conscience.

Luke Mitchell is a Senior Editor of Harper's Magazine.

Bill Totten


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