Force-feeding and medical ethics
Prison medicine’s roles in therapy and discipline, 1909–80 – by Ian Miller
Should hunger strikers be force-fed? How should prison doctors care for starving prisoners? And in what ways does hunger striking impact upon prison medical activity? Medical professionals first posed these ethically driven questions in 1909 when prison doctors began to force-feed imprisoned suffragettes in Winson Street Gaol, Birmingham. Throughout the 20th century, the medical-ethical dimensions of hunger-strike management continued to pose problems when Irish republicans, World War I conscientious objectors, IRA members and other prisoner groups staged protests involving food refusal. More recently, the force-feeding of detainees in Guantánamo Bay and African-American prisoners in California has brought the issue once again to the fore of international public debate.
Recent research brings fresh perspectives to this complex topic, extending beyond the purely political to focus on the history of the body, medical intervention to prevent starvation, and the ethical behaviour of prison staff. In particular, it examines two contrasting policies: force-feeding versus allowing prisoners to starve. One of the project’s key findings is that medical ethics on issues such as force-feeding were deeply informed by the 20th-century evolution of bioethics into a discrete discipline. This shifted ideas about human rights and escalating concern about prison welfare and prisoner rights. By interweaving these lines of inquiry, new research is able to make a significant contribution to histories of medicine in the British Isles, medical ethics and bioethics, as well as medicine and gender, informing Anglo-Irish and Anglo-Northern Irish relations.
Hunger strikers, prison staff and government bodies left an array of official, autobiographical and propagandistic accounts of force-feeding and self-imposed starvation. These provide opportunities for the historian to recapture the physical and psychological ordeal of prison hunger striking. One of the most important questions first raised by the militant suffragettes – and which remains a current debate in relation to Guantánamo Bay prisoners – is whether prison force-feeding is therapeutic or coercive. Is it really used as a kind mechanism that prevents prisoners from starving or is it instead used to subjugate rebellious prisoners?
Between 1909 and 1914, those that advocated force-feeding insisted that prison doctors were fully complying with their ethical obligation to preserve life and health in the controversial cases of militant suffragettes. The Home Office portrayed prison feeding procedures as therapeutic in nature, not disciplinary, and as indispensable life-preserving mechanisms. Officials presented so-called ‘artificial feeding’ as safe, humane and ethically uncomplicated. Nonetheless, suffragettes portrayed the procedure as torturous, degrading and life-threatening. From the prisoner’s perspective, force-feeding was not life-saving; instead, it caused vomiting, nightmares and intense pain.
However, while force-feeding was initially most associated with the suffragettes, the procedure was used on a plethora of political and non-political prisoners throughout much of the 20th century. Irish republican Eamon O’Dwyer later recounted his experiences of being force-fed at Mountjoy Prison, Dublin:
”I certainly did not like this pipe being passed down through my throat and I began to have a horror of it. I must admit that I was very much afraid of it, and often in years afterwards I woke up and felt this damn pipe or tube going down my neck like a snake. Every one of the crowd who suffered this vomited terribly. The days passed with this as the only relief from the monotony of being held in the cell.”
For O’Dwyer, force-feeding was not only highly uncomfortable, but also left a lasting emotional impression.
In 1917, Irish republican Thomas Ashe notoriously died in Mountjoy following a bout of force-feeding. Liquid food had accidentally slipped into Ashe’s lungs and precipitated a fatal heart attack, causing national outrage in Ireland. After Ashe died, the government mostly abandoned force-feeding in Ireland. Given this context, it seems remarkable that the procedure continued to be sanctioned for British conscientious objectors throughout World War I. In 1917, J W Illingworth was force-fed with a nasal tube 135 times in Birmingham Prison. Between 1917 and 1918, Frank Higgins was force-fed 22 times at Newcastle Prison, followed by a prolonged period involving 188 feedings.
Yet when conscientious objector William Edward Burns died in Hull Prison in 1918 following a period of force-feeding, the Home Office feared that public opinion would be inflamed and drawn towards the cause of conscientious objection in much the same way that Ashe’s death had allowed republicans to amass support for Irish independence. Burns had decided to pursue a hunger strike on the basis that he was receiving inadequate medical attention. By refusing food and worsening his health, he sought to secure a transfer to a nursing home. Nonetheless, he was force-fed with one pint of milk and one pint of cocoa through a stomach tube. During a second feeding, he began to spasm, splutter and regurgitate his food. After Burns had settled down, Dr Howlett, the prison doctor, continued his work. The following morning, the prisoner awoke with an alarmingly high temperature, of 101 degrees Fahrenheit, and a sharp pain in his side. Fearing that Burns had developed pneumonia, Howlett removed him to a hospital cell, where he continued to be force-fed twice a day until he eventually died. Burns had fatally taken action in a prison environment that disallowed protest – no matter how valid – and discouraged autonomy. Although it is possible that Howlett genuinely believed that force-feeding held some therapeutic benefit, it seems likely that he also recognised the disciplinary value of the procedure in restoring order and quelling recalcitrance.
Even despite these well-publicised casualties, prison doctors continued to force-feed fasting prisoners. Recent research has uncovered 7,734 occurrences of force-feedings in English prison between 1913 and 1940. Although detailed archival evidence does not exist relating to the period after World War II, frequent journalistic reportage indicates that the procedure remained in common use in prisons until the 1970s. The vast majority of convict hunger strikers endured less than one day of force-feeding before they resumed eating, demonstrating the efficacy of gastric technologies in suppressing institutional protest. Those subject to force-feeding included prisoners who were suicidal, mentally ill, in need of medical care, or simply unable to eat their unpalatable prison food. Starting in 1935, Henry Gordon Everett, imprisoned for attempted suicide, endured 474 feedings with a nasal tube over approximately 15 months.
In the 1970s, the controversial feedings in British prisons of IRA prisoners Frank Stagg and Michael Gaughan, and feminist civil rights campaigners Marion and Dolores Price, led to public pressure being placed on the Home Secretary to abandon the practice. Stagg’s jaw was dislocated during the procedure, Gaughan died from a lung puncture caused by a stomach tube, while the Price sisters weakened to a state approaching death. Consequently, the World Medical Organisation declared force-feeding as a torturous, degrading mechanism of punishment in 1975. This formed part of a broader recognition of prisoner rights in the modern period.
But what other options existed for prison medical staff to deal with hunger strikers? Was allowing prisoners to starve to death really more ethical than feeding them? Many prison doctors undoubtedly felt uncomfortable about force-feeding, yet overseeing a slow prison death through food refusal raised its own ethical problems. We can use autobiographical and oral-history testimony to recapture the experience of slow starvation and shed light on the physical and psychological aspects of prison fasting. Although the prolonged deaths of Terence MacSwiney (1920) and Bobby Sands (1981) remained firmly entrenched in popular memory, thousands of other politically motivated prisoners, now often forgotten, endured protracted periods of prison starvation. They experienced physical and emotional collapse, hallucinations, rapid wasting and delusions. By 1981, shifting bioethical regimes ensured that the Maze Prison hunger strikers, including Sands, could not be fed. Prison doctors could now only provide relief, chart the deteriorating health of hunger strikers and strive to offer humane care in a challenging ethical situation.
Examining the history of force-feeding from medical-ethical perspectives holds the potential to shed new light on a number of policy areas. These include: shifting attitudes towards the imprisoned body; the impact of developing 20th-century concerns about prisoner and human rights on institutional life; medicine’s function in periods of intense national or international conflict; and the contested role of prison medicine as either benevolent or disciplinary. In addition, it brings into sharper historical focus important experiential aspects of key political movements (including feminism, conscientious objection and Irish republicanism) to be uncovered and understood in new ways.
Ian Miller is a Wellcome Trust Research Fellow in Medical Humanities at the Centre for the History of Medicine in Ireland, University of Ulster. His publications include A Modern History of the Stomach: Gastric illness, medicine and British society, 1800–1950 (2011), Reforming Food in Post-Famine Ireland: Medicine, science and improvement, 1845–1922 (2014) and Water: A global history (2015). He has published extensively on prison medicine and force-feeding, and would be very interested in sharing his research findings (firstname.lastname@example.org).