



Image courtesy of Gregor Fischer

They came for him on October 23, 2008. Eight medical staff, corrections officers, and guards took William Coleman out of his solitary cell, down a bright hall, and into a medical examination room. The officers stood guard outside while a medical internist told Coleman to get on the vinyl-covered examination table. They were going to feed him. Coleman told them he did not want to be fed. But they weren’t asking for his consent; he had no choice.

It had been more than a year since Coleman had chewed anything.

He’s not suicidal; he’s in prison for something he says he didn’t do. Like 2.2 million people incarcerated in prisons and jails in the US, his body is not his own. The only way for him to protest his conviction, to exercise his first amendment rights, he says, is to stop eating solid food.

He stopped eating on September 17, 2007. Most of the time he drinks water, juice, and nutrient drinks like Ensure. When he’s physically able, he escalates his protest by refusing even liquids. At those times he gargles with milk or sucks on cough drops to get the metallic taste of starvation out of his mouth. His is the longest hunger strike in the US that I can find record of.

He’s lost 106 pounds–half his body weight–and a few uniform sizes.

Still, no one inside or outside has paid much attention. They never have. And so, in 2008, Coleman stopped drinking. That’s when they strapped him down and force-fed him.

There are two places in the US where you can be fed against your will: a Catholic hospital and a prison.

Staff turned off the video camera typically used to record medical procedures. They strapped Coleman down at “four points” with seatbelt-like “therapeutic” restraints. Edward Blanchette, the internist and prison medical director at the time, pushed a thick, flexible tube up Coleman’s right nostril. Rubber scraped against cartilage and bone and drew blood. Coleman howled. As the tube snaked into his throat, it kinked, bringing the force of insertion onto the sharp edges of the bent tube. They thought he was resisting so they secured a wide mesh strap over his shoulders to keep him from moving. A nurse held his head. Blanchette finally realized that the tube had kinked and pulled it back out. He pushed a second tube up Coleman’s nose, down his throat, and into his stomach. Blanchette filled the tube with vanilla Ensure. Coleman’s nose bled. He gagged constantly against the tube. He puked. As they led him back to his cell, the cuffs of Coleman’s gray sweatshirt were soaked with snot, saliva, vomit, and blood.

“I have been tortured,” he would say later. And it was enough to make Coleman start drinking fluids again. For a while. When he stopped a few months later, the prison force-fed him again, and twelve more times over the next two years. By last year they could no longer use Coleman’s right nostril. A broken nose in his youth and repeated insertion of the tube have made it too sensitive.

***

There are two places in the US where you can be fed against your will: a Catholic hospital and a prison. This uncomfortable fact is the result of our social and legal systems’ plodding evolution in the wake of medical advancements. Over the past five decades, medical innovation has paved the way for new treatments and procedures; regulation and best medical practices take longer to shake out. “For years to come we will be encountering new bridges that neither the law, nor society, has yet crossed,” lawyer William Colby writes in his book Unplugged: Reclaiming Our Right to Die in America.

Colby represented the family of Nancy Cruzan, a persistent vegetative-state patient, in a landmark 1990 case that helped to establish legal precedent for patient autonomy—a person’s right to make their own medical decisions; in Cruzan’s case, the right to remove a feeding tube. But Colby published Unplugged after the death of Terri Schiavo in 2005, a replay of the Cruzan case on media steroids. Schiavo had collapsed in her home in February 1990 after a cardiac arrest. Eight years later, after no signs of improvement, her husband, Michael, decided to remove her feeding tube. Her parents and siblings, all devout Catholics, disagreed and launched a media campaign to keep the tube. The courts ultimately sided with Michael, citing wishes Schiavo expressed before her hospitalization. Her youth and gender made her a media cause and compelled a transfixed public to protect her. They also compelled the Catholic Church, the second-largest operator of hospitals in the US, to clarify its position on feeding tubes.

I watched Schiavo’s long, publicized death from a chair by my father’s deathbed. As a journalist, I covered the Catholic Church’s anachronistic reaction, writing about the legal caveats and institutional powers that permitted Church hierarchy to assert its doctrine in American hospitals. Schiavo’s parents lost their case, but Terri’s legacy is still felt in the wards of Catholic hospitals where the decision to remove a feeding tube remains the prerogative of hospital administrators, not patients.

I asked myself where else a person could be fed against their wishes. The answer pointed me to prison, and to William Coleman.

***

My phone rings and William Coleman’s voice—familiar, urgent, wan—is in my ear. I ask what I always ask, what answerers of phones always ask. “How are you, Bill?”

Partly, I already know the answer: Coleman’s will is strong, but his body is now weak. He’s lost four teeth to malnutrition. He hasn’t been outside since March. No one really knows the damage that starvation has done to his liver, his pancreas. And then there’s the depression, the anxiety. Bad memories may be the least of Coleman’s worries but they’re the most present. In a solitary medical cell, they’re all he’s got.

“Listen,” he says feverishly, “I have to get out of here.” I hear yelling in the background and what sounds like the scuffle of furniture. A slamming door. “A guy in solitary,” Coleman says, “I’m sorry.”

Coleman wants me, this morning, to call his lawyer in Connecticut. Specifically, he wants me to help him get out of the medical facility he’s recently been moved to. Generally, he wants me—a stranger with enough interest in his case to write him letters and to set up an account with Securus, the costly prison telephone system—to create a national movement to have him exonerated of his conviction. Or at least to get the Connecticut Department of Corrections to stop shoving a tube up his nose when they feel like it.

For reasons mostly unquestioned by the public, courts routinely permit wardens to intubate hunger-striking prisoners, by force if necessary. Most of these cases, decided in local courtrooms, never see the light of media. Unlike the young and vulnerable Terri Schiavo, convicted criminals are often harder to rally public sympathy around. Whatever prior court cases and their media campaigns may have done for patients’ rights, judges deciding prisoner feeding tube cases still defer to prison authority.

That’s what happened when William Coleman tried to have his forced feedings stopped.

In a twenty-eight page decision released last March, the Connecticut Supreme Court said, “We must determine whether the commissioner’s interests outweigh the incarcerated defendant’s common-law right to refuse nutrition and liquids without interference.”

From Europe to East Asia, hunger-striking has been used for centuries to demand rights, most often by those who have little other way, beyond sacrifice of their own body, to protest.

Prisoners don’t have full constitutional rights, although the Model Sentencing and Corrections Act of 1978 guarantees equal treatment, due process, and administrative appeals. Amendment VIII prohibits cruel and unusual punishment, although courts have roundly failed to consider force-feeding as such.

The justices express more concern for prison “safety, security and order” than for individual rights. Without citing any examples of disorder, they insist that Coleman’s denial of prison meals will upend the facility where he is incarcerated: “Inmates outnumber staff” and the “negative impact” of protests can lead to “disturbances and riots” which interrupt “showers, work, school assignments, religious services, recreational activities, visits and substance abuse programs.”

They also imagine copycat hunger strikes—“Inmates would be distressed, would go on [hunger strikes] themselves, and would attempt suicide”—and low morale, which could result in absenteeism and therefore an inability to “provide care and security.”

“The nasogastric procedure carries the fewest risks, and is the easiest to perform.” Ultimately, because force-feeding serves the state’s purpose (to keep him alive? to make him contrite? to punish him?) and the state is noble, just, and well-meaning, force feeding Coleman can’t be “inhuman or degrading.”

***

“The violation is over in seconds, but for those seconds the retching, suffocating nightmare is unendurably awful, like drowning on dry land. And for the days or weeks that the tube lives in you, like some parasitoid alien organism, you gag a little every time you swallow, the tube rasping against your throat.”

–Mark Dery, “A Season in Hell”

From Europe to East Asia, hunger-striking has been used for centuries to demand rights, most often by those who have little other way, beyond sacrifice of their own body, to protest. Before Ireland became Christian, self-starvation was known as Troscadh, a non-violent way to shame wrongdoers. In India the protester traditionally sat on the front step of the person who owed them money or had offended them. A Google alert reminds me daily that active hunger strikes are occurring around the world: a First Nations chief seeking rights for the indigenous in Canada; political prisoners in Turkey; Iranian and Afghan refugees in Berlin, Germany; indigenous prisoners in Santiago, Chile.

Today, force-feeding is internationally recognized as torture. The nature of the violation hinges on one thing: consent. Sex, organ donation, sterilization—all are life-affirming when done with consent. All are criminal acts when done without an individual’s approval.

The use of rubber feeding tubes to forcibly end hunger strikes is well documented throughout the twentieth century. In 1914 American journalist Djuna Barnes wrote a “stunt story” for New York World Magazine, “How it Feels to be Forcibly Fed,” to understand what her “English sisters” were experiencing: Dozens of British women who demonstrated for the right to vote, including Emmeline Pankhurst, founder of the Women’s Social and Political Union, were routinely arrested and put in prison. When they refused to eat, the staff held or tied them down with sheets and used tubes to feed them.

“It is utterly impossible to describe the anguish of it,” Barnes wrote. “There it is—the outraged will. If I, playacting, felt my being burning with revolt at this brutal usurpation of my own functions, how they who actually suffered the ordeal in its acutest horror must have flamed at the violation of the sanctuaries of their spirit.”

What Barnes was getting at is that the nature of the violation hinges on one thing: consent. Sex, organ donation, sterilization–all are life affirming when done with consent, and criminal acts when done without.

Today, force-feeding is internationally recognized as torture. Most Western medical organizations have roundly denounced it. The World Medical Association (in the 1975 Declaration of Tokyo and the 1991 Declaration of Malta) and the American Medical Association have both unequivocally condemned the use of force to feed a prisoner who is “capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment.”

In March of 2006, when news broke that hunger-striking prisoners at Guantanamo Bay were being force-fed, 250 international doctors (including American Oliver Sacks) published a letter in the medical journal The Lancet that called on the US government to stop the practice. They wrote, “Physicians do not have to agree with the prisoner, but they must respect their informed decision.”

***

It’s because of Nancy Cruzan that we can talk about “respecting” a patient’s “informed decision.” In 1983, 25-year-old Cruzan was in a car accident on a country road in Missouri. She was thrown from the car and when paramedics arrived, they found her face down in a pool of water in a ditch, unconscious and not breathing. They resuscitated her—mechanically forced air into her lungs—and rushed her to the hospital. Because she was unconscious and could not eat, she was given a feeding tube. Four years went by. After accepting that their daughter would not recover, Cruzan’s family decided that it was time to remove the tube. The hospital refused.

In Unplugged, lawyer Colby writes that Joe Cruzan, Nancy’s father, “talked with the probate judge about simply taking Nancy home to remove the tube, and the judge told Joe that an overly-zealous prosecutor could charge him with murder if he did.”

The case made its way to the US Supreme Court in 1990. As picketers outside held signs that read “Starvation = Murder” and “Please feed Nancy!” the court decided that the Cruzans had not proven Nancy would have wanted the tube removed. But Cruzan v. Director definitively established the sanctity of “self-determination,” citing an earlier case that ruled “no right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference of others, unless by clear and unquestionable authority of the law.” The Cruzans were eventually able to convince the court that their daughter would have wanted the tube removed. Nancy died twelve days later, eight years after her accident.

A subsequent case to assert that a patient could deny medical treatment was the 1997 Washington v. Glucksberg. Dr. Harold Glucksberg, along with three other doctors and three patients, sought to establish that the Washington State constitution did not prohibit aid in dying—that a doctor could prescribe lethal medication to a terminal patient who wanted to avoid a long and painful death. The Supreme Court did not agree that aid in dying was constitutional in the state, but it reinforced Cruzan’s “right to die” jurisprudence.

Cruzan and Glucksburg establish that anyone can accept or deny medical treatment, including a feeding tube, even if the decision means certain death. They also clearly distinguish the difference between suicide and refusal of treatment, a subtle but important point often lost on opponents of tube removal and aid in dying for terminal patients—as it was lost on the Connecticut Supreme Court, which found that the Department of Corrections could continue to feed Bill Coleman to prevent his “suicide.”

“Rape is actually a very reasonable analogy. You feel like you’re physically protruding… putting something in someone’s body they are actively resisting. Eventually somebody has to hold them down. It turns your stomach.”

The guise of “suicide prevention” continues to polarize patient autonomy discussions. Still, three US states have legalized aid in dying. Washington voters approved the Death with Dignity bill in 2008, as Oregon voters had done in 1994. And on New Year’s Eve 2009, Montana’s State Supreme Court ruled that the state constitution did not prohibit aid in dying.

Following the Montana ruling, the Catholic Church decided that three states was an ominous pattern. The Church, which includes aid in dying (or “assisted suicide” or “euthanasia”) on its “pro-life” platform—alongside sanctions against contraception, abortion, fertility treatments, sterilizations, and stem cell research—launched an initiative to combat legalization nationwide, utilizing parish awareness campaigns and the “pro-life” machine already in place to combat abortion. In November, the Church and its allies leveraged more than five million dollars to narrowly defeat a “Death with Dignity” bill in Massachusetts. Yet the Church’s campaign against aid in dying doesn’t only affect terminal patients who want to medically end their lives. Issues of autonomy and consent have also come under Church attack—and not only of the “reproductive choice” kind.

The Catholic Church was also vocal in the Cruzan and Schiavo cases, filing amicus curia briefs in both. Four years after Schiavo’s death, the United States Conference of Catholic Bishops changed their Ethical and Religious Directives (ERDs) to shift feeding tube decision-making authority from patients and their families to hospital administration. To make this change, they recategorized feeding tubes as comfort care, not medical care. This is a small fact of misplaced Church intrusion—until you consider that the Catholic Church is the second-largest provider of healthcare in the country (after Veteran’s Affairs), managing more than 630 hospitals, or one-fifth of all hospital beds.

Not all Catholic hospitals follow the ERDs, just as not all Church attendees follow the tenets of the Church on, say, contraception (studies show that 98 percent of sexually experienced Catholic women have used contraception). Enforcement of hospital practices is up to the local Catholic bishop and just as some bishops are more attentive than others, some doctors at Catholic hospitals—who may or may not be Catholic—don’t always do what their employer’s god tells them. Still, the efforts required of uninformed patients and their families to counter the hospital’s wishes can be insurmountable.

The position of Catholic leadership on intubation is not against the law because of legal clauses that protect the institution’s “conscience.” A patient’s request for removal will trump the Church’s any day, should the patient or their family have the extraordinary means to know their options, find a different hospital, or seek legal counsel.

For a hunger-striking prisoner, avoiding a feeding tube is nearly impossible.

***

Individuals enact institutional decisions, and force-feeding a competent person is considered unethical by most of the world’s doctors. So, I wondered, why are prison doctors still doing it?

I asked Arthur Caplan, bioethicist and director of the Medical Ethics Division at NYU Langone Medical Center. “It’s important to remember that in the realm of ethics, everything is self-regulated. The American Medical Association (AMA) could never pull somebody’s license. They don’t have that kind of authority. The chance of somebody being sanctioned by the state medical board for force-feeding? Not gonna happen. They barely get sanctioned for executions, which is clearly against the code of ethics of all American groups. So is force-feeding, more or less.

“You know, I met Bill. At the trial,” Caplan added.

Despite months of letters and phone calls, I hadn’t met Coleman in person. (My request for a visit, after the trial but prior to the State Supreme Court’s decision, was denied by the prison warden—as has been all media access to Coleman. “It is the collective consensus that permitting your interview to take place would only further exacerbate inmate Coleman’s condition, and we do not wish to contribute to his detriment.”) In any of the pictures of him I’d seen, mostly attached to local news reports about the case, he looks immobile, slightly rumpled, pale. In one from the district trial he is wearing a white collared shirt and a yellow tie. His hair is short and graying and his face is partially obscured by a white paper cup.

“Describe him for me,” I asked.

“Nervous, agitated, articulate,” Caplan told me, “Very much a guy who felt put-upon, a guy who felt innocent and made that clear. He was smart, had certainly read all the relevant documents and medical association codes of ethics, all the literature on Terri Schiavo. He knew the stuff.” My second letter from Coleman was a full-sized manila envelope, stuffed with photocopies of court documents, articles, his own written testimony—all highlighted, starred, and underlined.

“I wouldn’t describe him, however, as likable. I would describe him as ‘in your face,’” Caplan said. “I didn’t dislike him but he’s not somebody I thought was warm and fuzzy.

“The reason I mention warm and fuzzy,” Caplan continued, “is that sometimes you may get further with those doctors coming over from UConn if you’re warm and fuzzy.” Like many states, Connecticut contracts medical staff for its prisons from the state university system.

I told Caplan I had spoken to Coleman the day before. He was off liquids again, but instead of obeying the court order, the prison was letting his health decline, become dire, then feeding him a little bit.

“Cruel. They’re letting him slide,” Caplan says. “If you’re gonna feed him then feed him. If you’re gonna sort of dangle him out there… It’s cruel.”

In his letters to me, Coleman repeatedly called this the “torture gap.” He wanted them to feed him regularly with enough nutrients to keep him healthy, as he interpreted the court decision, or to keep him comfortable and let him die according to his living will. Force-feeding like this felt punitive; it wasn’t preserving his life; it was stringing it out.

“Does it matter if he’s guilty or innocent?” I asked. I’d told Coleman’s story to a couple of friends and colleagues. Every person I spoke with wanted to know what Coleman had been convicted of.

“It shouldn’t,” Caplan said.

I asked if Coleman’s willingness to die was a sign of mental incompetence.

“Can you rationally want to kill yourself? Yes,” Caplan said. “There are rational suicides. Weirdly, with religion, most of them are celebrated and turned into saints. Jews too—the martyrs at Masada [where Jewish tradition has it that dozens of Sicarii rebels committed mass suicide rather than surrender to Roman forces in the first century CE]. There are many decisions to end your life that are admired and extolled. The person who blows himself up by throwing himself on a hand grenade in war, fighting to the death, suicide missions. There are lots of those. Yes,” he said, “I think you can rationally want to kill yourself.”

Caplan’s examples made me think of other martyrs I would add to the list. I thought of the Catholic Church’s three intubated women, Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo, who had been “killed” by the courts and were, at least in Schiavo’s case, venerated at “pro-life” conferences across the country. I thought of Armond and Dorothy Rudolph, whose Albuquerque, New Mexico, assisted living home attempted to kick them out at the ages of ninety-two and ninety in 2011 when they decided to stop eating and drinking. I thought of Robert Baxter, the terminal leukemia patient who brought a winning case before the Montana Supreme Court, making aid in dying legal there. Baxter died at his home the night the district court decision was announced.

Caplan brought up Bobby Sands. In the 1980s, during Margaret Thatcher’s tenure, many Irish Republicans were imprisoned for militantly opposing British rule of Ireland. They staged a hunger strike to protest prison conditions and to be reclassified from criminals to political prisoners. Bobby Sands and nine others famously starved themselves to death. Their murals now decorate the streets of Ireland.

***

Why did boisterous national conversations arise around the cases of three young women who were kept “alive” on feeding tubes (but not the other tens of thousands of feeding tube patients in hospitals every day)? Why was Bill Coleman sitting in a Connecticut cell, under court order to be fed, and not on the front cover of national newspapers? What’s different about a tube inserted in a prison instead of a hospital?

The origin of the modern hospital can be traced to the early Catholic Church—which set up shelters for soldiers returning from the Crusades. The modern American prison too has religious origins. Writes Winnifred Fallers Sullivan in the introduction to her 2009 book, Prison Religion: Faith-Based Reform and the Constitution, “Prisons were promoted in the early Republic as a more humane form of punishment, a more Christian alternative to what was perceived to be the casual brutality of corporal punishment as practiced in Europe.”

I don’t know if Coleman’s an “innocent man wrongfully convicted” as the pink and black website kept by his brother Geoff reads across the top. I do know that most of the world agrees that force-feeding someone, anyone, even a prisoner who is convicted of raping his wife and has refused solid food for five years, is torture.

Bioethicist and lawyer Jacob Appel writes in “Force-Feeding: Treatment or Torture? Legal and Ethical Aspects of Physician Participation in the Termination of Hunger Strikes in American Prisons” at Public Affairs Quarterly that the “divine paternalism” and “‘revered’ supremacy” of the medical profession were only meaningfully countered by the autonomy movement of the 1960s and ’70s. Until that time, it was common for women to enter the hospital for a biopsy and come out of anesthesia with a full mastectomy, no questions asked, no options discussed.

In 1972, after a leak to a newspaper, the public learned of the forty-year Tuskegee syphilis experiment, where nearly four hundred poor black men with syphilis were not informed of their illness nor treated for it. New medical technologies which provided treatment options to the sick, civil rights movements which asserted equal rights for minorities, and an escalating distrust of the medical community combined to develop the principle of informed consent: an individual must be informed of all medical options and their consequences and, in consultation with their doctor, may agree to or refuse any of them. Appel notes that the publication of Principles of Biomedical Ethics by Tom Beauchamp and James Childress in 1977 “enshrined” the principle of autonomy in medical ethics. (Appel’s article cites Coleman’s case and calls for state medical licensing bodies and national medical associations to sanction doctors who perform force-feedings.)

The prison system, on the other hand, was never subject to calls for individual autonomy. Sullivan writes in Prison Religion: “The modern state is also perhaps at its most religious when it exerts total control over its citizens and attempts to coercively remake them into new human beings. Religious and political authority and sovereignty in prison are homologous with each other in several ways: state/church, judge/god, crime/sin, prisoner/penitent. Even when explicitly religious language is absent, the sacred haunts the prison and all who work there.”

While prison reform movements continue and a body of work has proven that incarceration as practiced in American institutions today is essentially ineffective, authority, discipline, and good behavior continue to characterize the roles of prison officials, staff, and prisoners. Particularly in our Western culture, the Church continues to provide the most influential model of leadership, discipline, redemption, and moral behavior.

Prisons and hospitals are places where we put people who aren’t normal. They are kept outside society for reform or healing. Both institutions are operated in such a way, at least rhetorically, as to make demands of their wards for improvement. When we talk about “good” patients, we talk about their will to live, their obedience to doctors’ orders, their positive outlook, as if these mental and emotional characteristics will heal their bodies. A “model” prisoner exhibits similar characteristics—he is deferential, well behaved, contrite—but it is physical discipline that is intended to reform his sick mental state.

I don’t know if Coleman’s an “innocent man wrongfully convicted” as the pink and black website kept by his brother Geoff reads across the top. I do know that most of the world agrees that force-feeding someone, anyone, even a prisoner who is convicted of raping his wife and has refused solid food for five years, is torture.

***

The day after I had breakfast with Arthur Caplan I met with Jacob Appel. I asked Appel the same thing I asked Caplan.

“If force-feeding is not medically ethical, why were the University of Connecticut doctors still force-feeding Coleman?”

“They’re wildly outside the mainstream of modern American practice,” Appel said. “Prisons hire those who will do what’s necessary.”

I told Appel that the prison was, in Caplan’s words, “letting him slide,” that the medical staff were letting his health run out, then feeding him a little bit.

“It may be torture and it may be terrifically unpleasant. But their real goal is to meet the court order and they’re afraid to do anything more because they’ll open themselves to legal challenge. I would venture the guess that the people involved in this would like it to go away.”

“All I have left is my credibility, which I vigorously protect,” Coleman wrote to me last month…. I don’t think I have the heart to tell him that credibility is exactly what he doesn’t have or he wouldn’t be sitting in MacDougall right now.

I knew that if I were a prison doctor, I’d want Coleman to go away. If I were in Coleman’s uniform, I wouldn’t be very pleasant either. How could I be after so many years of court appeals, the shame of conviction, hunger, and solitary. But the difference, as I saw it, was Coleman’s vulnerability, his lack of resources. What Appel made me see is that prison doctors are vulnerable too, although in a very different but meaningful way. Their medical ethics, their sense of what is right and wrong, is compromised by their employer. Doctors are unable to honor the doctor-patient relationship because it is usurped by the employer-doctor relationship; the latter determines their livelihood. (Doctors in Catholic hospitals who do not agree with Catholic doctrine are also vulnerable.)

Of the medical community, Appel told me, “The truth is, most doctors don’t know this is going on. The more doctors I talk to about this say, ‘You can’t do that.’ They just assume that force-feeding isn’t done.”

“Do you think attention given to Guantanamo made those force-feedings seem like a special case?” I asked.

“Not only do I think that but I think a person looking at this in a cursory manner thinks that. It’s a reasonable conclusion to draw. In a way [Guantanamo] was presented as that, an extraordinary set of circumstances, not a natural outflow of American law.”

Appel continued, “I would add, for what it’s worth: once in my life, I put a feeding tube in someone who didn’t want it.” An elderly person had, when competent, said that he wanted everything done to continue his life. Then he became demented.

“Ethically, it wasn’t a transgression—we were honoring his wishes—but practically it was one of the most unpleasant things I’ve done in my life. I would never do it again, even if somebody wanted me to.”

“Tell me how unpleasant,” I said.

“Rape is actually a very reasonable analogy. You feel like you’re physically protruding… putting something in someone’s body they are actively resisting. Eventually somebody has to hold them down. It turns your stomach.”

***

Coleman still has a semi-permanent feeding tube in his nose. The nurses were instructed to feed him one can of Ensure a day, about 350 calories. Last week they raised it to two. He’s still sliding. Some days he’s more alert than others. He’s lethargic, spending much of each day in bed in his cell, too tired to talk, to make his bed, to walk.

He could have been released for good behavior years ago but refused to leave a guilty man. He’s refused to sign the sex offender registry, which could result in the state issuing a warrant to keep him in prison until he does. The state prison system could transfer him to the federal system, most likely a facility in Texas, where force-feeding is administered by a special medical unit. Because he’s a British citizen, he could be deported, but he’s challenging deportation; he doesn’t want to leave the country while his children, whom he hasn’t seen in more than five years, are still here.

So even though his sentence ended on December 31, Coleman is trying to stay in prison. “All I have left is my credibility, which I vigorously protect,” Coleman wrote to me last month. He believes refusing to leave testifies to his innocence. I don’t think I have the heart to tell him that credibility is exactly what he doesn’t have or he wouldn’t be sitting in MacDougall right now. What he does have is conviction; not anybody can give up solid food for as long as he has. Still, commitment to his long hunger strike doesn’t prove he’s innocent.

He doesn’t know what the state will do now that his sentence is over; prison officials aren’t discussing it with him, and the court has postponed a decision. Each night when Coleman goes to bed, he expects them to come for him, to take him in handcuffs to the airport. If he’s put in prison in the UK, he won’t be force-fed. He will—be allowed to—starve himself to death.

Some of the ideas in this article were presented at “Freedom of Choice at the End of Life: Patients’ Rights in a Shifting Legal and Political Landscape” at New York Law School on November 16, 2012.

Research for this article was funded by a Knight Grant for Religion in American Public Life by the Annenberg School for Communication and Journalism at the University of Southern California.

Ann Neumann is a writer and hospice volunteer living in New York. She edits The Revealer, a publication of The Center for Religion and Media at New York University.