In his Sept 29 address to the United Nations General Assembly, President Barack Obama told the world that for those “who question the character and cause of my nation” two “concrete actions” should be taken as proof that the USA really has changed: the prohibition, “without exception or equivocation” of the use of torture and ordering the prison at Guantanamo Bay to be closed. Both are critical steps for my country to try to regain its position in the world as a human rights leader.

Since President Obama took office, the US Department of Justice has released a series of legal memoranda detailing justifications for the use of torture techniques in post 9/11 interrogations. The legal arguments made in these memos have been widely and properly criticised. In addition to representing bad law that the Department of Justice can no longer support, they have another notable characteristic in common. The lawyers relied on doctors to tell them what they were monitoring was not torture, and the doctors relied on the lawyers to tell them that the techniques used were legal (ie, not torture). It really did take physicians and lawyers working together to get the USA to rely on torture for security.

We have already learned a great deal about the inner thoughts of Bush administration lawyers and CIA physicians and psychologists on torture techniques and justifications. In stark contrast, we know virtually nothing about the physicians and lawyers who have been involved in force-feeding hunger strikers at Guantanamo Bay since 2005. This is probably because, unlike torture, the practice continues to this day. Neither the legal justification memorandums, nor the classified force-feeding protocol at Guantanamo have been made public. What we have instead are a series of dog and pony shows for official visitors to Guantanamo and public statements made by a few Department of Defense medical officials. On a recent media tour of Guantanamo, for example, the senior medical officer told reporters that he was “extremely proud” to be there, but refused to give his name. He described the process of force-feeding prisoners in restraint chairs as “endearing”, said the nasogastric tubes were “gently inserted”, and that Ensure was being supplied in three flavours: strawberry, butter pecan, and chocolate.

Despite the upbeat talk to reporters, hunger strikes are extremely difficult for prison officials and physicians to deal with, especially if they are done in groups, as they are in Guantanamo where about 30 prisoners are currently on hunger strike. Hunger strikers are not suicidal in that their goal is to change a policy or the conditions of their confinement, not to die. The primary issue the continuing hunger strikes at Guantanamo raise with the medical profession and human rights groups is the use of military physicians to break the hunger striker's will by force-feeding in eight-point restraint chairs. Two new books highlight the problems and help us understand why force-feeding has proven so much more difficult to end than torture.

Military Medical Ethics is a bloodless report of an Institute of Medicine (IOM) workshop that explored “dual loyalty”—a physician's loyalty to both the military and the patient. On one side, Department of Defense representatives defended their policy which provides that military physicians will not let any prisoner “self-injure” or commit suicide, and that force-feeding to prevent self-injury or suicide is ethical at least as long as the military follows rules similar to those for domestic US prisons. Countering that view were participants from human rights non-governmental organisations and the International Committee of the Red Cross, who noted the unanimous ethical condemnation of the practice by medical organisations. Not dealt with in any depth were more practical questions of whether it is ever possible for military physicians to gain the trust of their prisoner–patients sufficiently to actually forge a doctor–patient relationship, or how it might even be possible for military physicians to disobey an order to force-feed a prisoner for the sake of maintaining prison discipline and security. IOM workshops do not make recommendations. The workshop summary does, however, dramatically demonstrate that, for the first time in the history of the US military, the Department of Defense has a medical policy that goes directly against a well recognised international medical ethics standard.

Interrogations, Forced Feedings, and the Role of Health Professionals grew out of another workshop sponsored by Harvard Law School's Human Rights Program. Like the IOM report, the most striking feature of the book is the contrast between the views of the US military and those of human rights groups. Edmund Howe, a leading expert on US military medical ethics, argues that the strongest rationale for military physicians to force-feed hunger strikers is that it respects the prisoners by respecting “the sanctity of their lives”, albeit at the expense of their autonomy. Although he believes that saving the hunger striker's life is the only real argument in favour of force-feeding, Howe concedes that under current protocol force-feeding is initiated long before the hunger striker is in any medical danger, and he has a difficult time justifying force-feeding before it is medically necessary to preserve the prisoner's life or health. By contrast, James Welsh of Amnesty International summarises his organisation's 30-year involvement in the prison hunger strike question, beginning with the Red Army Faction's hunger strikes in West German prisons in 1977. All hunger strikes have their own unique settings and provide ample opportunities for clashes between physicians and prison officials. Welsh's conclusions on Guantanamo are, nonetheless, unequivocal. He describes the methods used to break hunger strikes there as “transparently oppressive” and as constituting “a form of cruel, inhuman, and degrading treatment intended to break the strike and to form part of the stripping away of prisoners' human rights”.

It is tempting to think that the physicians and hunger strike dispute, at least in the USA, will be settled with the closing of Guantanamo, but this may simply move the dispute to the states assuming, as I do, that some of the prisoners at Guantanamo will be transferred to US prisons. This is because one of the main arguments in favour of force-feeding made by the military has been that they are following techniques used in US prisons. And this is at least partially true. According to one Department of Justice memo, there was a “successful” hunger strike at the federal supermax prison by Al Qaeda prisoners in 2006, and there are several cases in US courts in which prisoners currently being force-fed are challenging their force-feeding as unconstitutional. These cases raise the question of whether force-feeding is “cruel and unusual punishment” under the 8th amendment, or done in a way that “shocks the conscience” as prohibited by the 5th and 14th amendments—not, as in Guantanamo, whether it is a violation of Common Article 3 of the Geneva Conventions.

It will take more than another workshop to solve the force-feeding problem. At least two alternative actions seem plausible. The first is for the Department of Defense (and/or President Obama) to rescind current guidance and reassert traditional US military doctrine that no physician in the US military need compromise medical ethics to serve their country. The second alternative is one I suggested at the IOM workshop: “the opposing positions of the Department of Defense and the World Medical Association should be brought to a neutral authoritative body, such as the state boards that license US civilian and military physicians” for resolution.

As a member of the Committee on Human Rights of the National Academies, GJA helped develop plans for the IOM Workshop on Military Medical Ethics. He also attended the Harvard workshop which the Interrogations book grew out of but did not contribute to the book.