ROYCE C. LAMBERTH, United States District Judge.
Before the Court is the petitioner's motion for a preliminary injunction [306] seeking to enjoin the respondents (hereinafter, the government) from force-feeding hunger-striking detainees held at the United States Naval Base at Guantanamo Bay, Cuba. Upon consideration of the petitioner's motion [306], the government's opposition [319], the petitioner's reply [320], the petitioner's and government's respective briefs regarding any claims remaining to be decided in this case [341, 344], the petitioner's status report [346] filed December 16, 2014, the applicable law, and the entire record herein, the Court will DENY the petitioner's motion for a preliminary injunction.
Petitioner Mohammad Ahmad Ghulam Rabbani is a Pakistani national who has been detained at Guantanamo Bay for more than ten years without ever having been charged with a crime. Pet'r's Mot. Prelim. Inj. 1. Since February 2013, Rabbani, along with other detainees, has engaged in a hunger strike to protest his detention. Id. In response to Rabbani's hunger strike, the medical staff at Guantanamo Bay determined that it was necessary to forcibly feed the petitioner through an enteral feeding process. See Resp't's Opp'n 5-6, 13-14. On occasions when Rabbani has refused either to walk voluntarily to his enteral feeding session or to return to his cell following a session, Guantanamo Bay guards have employed Forced Cell Extraction ("FCE") procedures to move the petitioner. Id. 15. Rabbani is not seeking to enjoin force feeding as a method for preventing death or serious bodily injury to hunger-striking detainees. Id. at 2 (The "[p]etitioner wishes to make clear that he is not seeking an injunction to permit him to continue his hunger strike until death."). Instead, the thrust of Rabbani's grievance is that the enteral feeding
Confronting a force-feeding fact pattern substantially similar to — if not even more "forcible and violent" than — Rabbani's, Judge Kessler recently denied a petitioner's motion for a preliminary injunction to enjoin the methods and protocols governing the force-feeding process at Guantanamo Bay. Dhiab v. Obama, No. 05 Civ. 1457, 74 F.Supp.3d 16, 2014 WL 5795483 (D.D.C. Nov. 7, 2014). Prior to Judge Kessler's Memorandum Opinion, Petitioner Dhiab had narrowed his claims to those concerning (1) the insertion and removal of a nasogastric tube; (2) the use of auscultation — "a procedure to ensure that the nasogastric tube is properly pushed into the stomach, rather than the lungs"; (3) the use of a Five Point Restraint Chair during enteral feeding; (4) force-feeding in the absence of imminent risk; and (5) whether non-medical officials have final authority to allow force-feeding. Id. at 21-22, 23-30, at *3, *5-10. In reaching the conclusion that Dhiab's petition was insufficient for a preliminary injunction, Judge Kessler evaluated the remaining force-feeding claims under the "deliberate indifference" standard established by the Supreme Court in Estelle v. Gamble, 429 U.S. 97, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976).
Following Judge Kessler's denial of Dhiab's petition for a preliminary injunction, this Court ordered the parties to notify the Court of "what, if any, claims remain to be decided in this case that were not already addressed" by Judge Kessler in Dhiab. Order, Nov. 12, 2014, ECF No. 340. Petitioner Rabbani responded that the Court (1) "must decide whether this case implicates the Fifth Amendment due process right to refuse medical treatment," and (2) must determine whether FCEs are lawful. Pet'r's Notification 1, Nov. 19, 2014, ECF No. 341. On the Fifth Amendment question, Rabbani argues that Judge Kessler erred in using the Estelle deliberate indifference standard, and instead should have employed the standard of proof articulated in Turner v. Safley, 482 U.S. 78, 107 S.Ct. 2254, 96 L.Ed.2d 64 (1987). In Turner, the Supreme Court held that "when a prison regulation impinges on inmates' constitutional rights, the regulation is valid if it is reasonably related to legitimate penological interests." Id. at 89, 107 S.Ct. 2254 (emphasis added). Rabbani, therefore, largely seeks to relitigate the legal standard of proof at issue in Guantanamo Bay force-feeding cases. According to Rabbani, then, the FCE question as well as a new question regarding the government's purported refusal to test Rabbani for lipoid pneumonia, which Rabbani raises for the first time in a status report filed December 16, 2014, are the only remaining fact-based inquiries not addressed by Judge Kessler in Dhiab.
To satisfy the requirements of the traditional four-factor test for a preliminary injunction, a plaintiff "must establish that he is likely to succeed on the merits, that he is likely to suffer irreparable harm in the absence of preliminary relief, that the balance of equities tips in his favor, and that an injunction is in the public interest." Winter v. Natural Res. Def. Council, Inc., 555 U.S. 7, 20, 129 S.Ct. 365, 172 L.Ed.2d 249 (2008); see also Abdullah v. Obama, 753 F.3d 193, 197 n. 4 (D.C.Cir.2014) (clarifying that "the traditional four-factor preliminary injunction test, unsurprisingly, applies to Guantanamo detainees"). Here, Rabbani fails demonstrate that he is likely to succeed on the merits of his force-feeding, FCE, and lipoid pneumonia testing claims, rendering analysis of the remaining three factors of the preliminary injunction test superfluous.
Rabbanie contends that the primary question before the Court is "whether this case implicates the Fifth Amendment due process right to refuse medical treatment." See Notification 1. However, the Court need not answer such a question, and, thus, need not definitively determine whether Estelle's deliberate indifference standard or Turner's reasonably related standard applies to Rabbani's force-feeding claims because these claims fail, at the preliminary injunction stage, under either Estelle or Turner.
Estelle's deliberate indifference standard governs a court's review of the adequacy of medical care received by prisoners under the Eighth Amendment's prohibition against "cruel and unusual punishments." Estelle, 429 U.S. at 104, 97 S.Ct. 285; U.S. Const. amend. VIII. While Dhiab, like Rabbani, positioned his motion for a preliminary injunction as a Fifth Amendment due process claim, see Mot. Prelim. Inj. 20, Dhiab, No. 05 Civ. 1457 (D.D.C. Apr. 18, 2014), ECF No. 203 (citing Cruzan v. Director, Missouri Department of Health, 497 U.S. 261, 278-79, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990), for the due process right to refuse unwanted medical treatment); Notification 1, Judge Kessler found that Dhiab was actually challenging the "day to day procedures" involved in carrying out force-feedings, rather than challenging a constitutional right to be free from force-feeding entirely, Dhiab, 74 F.Supp.3d at 21-22, 23, 2014 WL 5795483, at *3, *5.
If deliberate indifference represents the appropriate standard of proof to apply to Rabbani's force-feeding-related claims, then this Court would adopt Judge Kessler's Memorandum Opinion in Dhiab, 74 F.Supp.3d 16, 2014 WL 5795483.
First, Turner applies when a prisoner's constitutional right is at stake. 482 U.S. at 89, 107 S.Ct. 2254. Here, while a purported right to be free from force-feeding may possibly qualify under the rubric of the constitutional right to refuse unwanted medical treatment, see Aamer v. Obama, 742 F.3d 1023, 1038-39 (D.C.Cir.2014), the Court agrees with its colleague, Judge Kessler, that challenges to individual procedures that the government uses to force-feed hunger-striking detainees — e.g., the use of nasogastric tubes, the method of auscultation, the use of Five Point Restraint Chairs, etc. — would likely not rise to a constitutional claim. See Dhiab, 74 F.Supp.3d at 23-24, 2014 WL 5795483, at *5. Rabbani admits that he is not claiming a categorical right to refuse force-feeding, Mot. Prelim. Inj. 2, 32 (The "[p]etitioner wishes to make clear that he is not seeking an injunction to permit him to continue his hunger strike until death.")), but instead is challenging the process used to decide that force-feeding is appropriate as well as the methods used to accomplish the force-feeding procedure. Consequently, the question for the Court is not whether the government can force-feed Rabbani — it can — but rather whether the specific manner in which it force-feeds Rabbani is lawful. The Court finds that an inquiry into the methods of force-feeding is more closely related to Estelle's application to how medical care is delivered than to Turner's application to whether a detainee can refuse medical treatment in the first instance.
Second, even if the government's methods of force-feeding implicate a due process right to refuse medical treatment, the Court of Appeals for the District of Columbia Circuit has declared that "the due process clause does not apply to aliens without property or presence in the sovereign territory of the United States." Kiyemba v. Obama, 555 F.3d 1022, 1026 (D.C.Cir.2009) (collecting cases) ("Kiyemba I") vacated and remanded, 559 U.S. 131, 130 S.Ct. 1235, 175 L.Ed.2d 1070 (2010), and judgment reinstated and modified, 605 F.3d 1046 (D.C.Cir.2010). Given that Rabbani is a nonresident alien, it would appear that existing Circuit precedent forecloses any remedy for an alleged Fifth Amendment due process violation and, accordingly, rebuts Rabbani's argument that Turner, which only applies to constitutional claims, is the appropriate standard here.
Applying Turner to the present facts does not alter Judge Kessler's conclusion that a preliminary injunction is improper. Again, the Turner Court held that "when a prison regulation impinges on inmates' constitutional rights, the regulation is valid if it is reasonably related to legitimate penological interests." 482 U.S. at 89, 107 S.Ct. 2254. It is true that the Supreme Court has established a "constitutionally protected liberty interest in refusing unwanted medical treatment," Cruzan, 497 U.S. at 278, 110 S.Ct. 2841, and that the Circuit in Aamer left open the possibility that force-feeding implicates such a liberty interest, 742 F.3d at 1038-39. It is also true that both parties implicitly agree — and this Circuit has held — that the government has a legitimate interest in keeping Guantanamo detainees alive. E.g., Notification 4; Resp't's Resp. 3; see also Aamer, 742 F.3d at 1040-41 (recognizing "the government's legitimate penological interest[]... in preserving the [detainee]'s life"). Therefore, the question here would be whether the force-feeding of Rabbani is reasonably related to the government's interest in preserving his life.
To determine the reasonableness of a regulation, the Supreme Court identified four relevant factors: (1) whether there is "a valid, rational connection between the prison regulation and the legitimate governmental interest put forward to justify it"; (2) "whether there are alternative means of exercising the [asserted constitutional] right that remain open to prison inmates"; (3) "the impact accommodation of the asserted constitutional right will have on guards and other inmates, and on the allocation of prison resources generally"; and (4) whether there are "ready alternatives" to the regulation. Turner, 482 U.S. at 89-91, 107 S.Ct. 2254 (internal quotation marks and citations omitted). While Rabbani seeks to emphasize the importance of the fourth factor, "ready alternatives," Notification 1, 4, the Circuit has explained that the first factor, "a valid, rational connection," weighs heaviest on a court's Turner analysis, Hatim v. Obama, 760 F.3d 54, 59 (D.C.Cir.2014) ("Although we examine each factor, the first is the most important."); Kimberlin v. U.S. Dep't of Justice, 318 F.3d 228, 233 (D.C.Cir.2003) (describing the first factor as the "most important factor"); Amatel v. Reno, 156 F.3d 192, 196 (D.C.Cir.1998) ("Although the [Turner] factors are intended as guides to a single reasonableness standard, the first factor looms especially large. Its rationality inquiry tends to encompass the remaining factors, and
As a threshold matter, Turner is invoked when a court is examining a "regulation" as a whole — i.e. whether force-feeding, generally, impinges on a detainee's constitutional right. Turner, 482 U.S. at 89, 107 S.Ct. 2254 (the purpose of the test is to "determin[e] the reasonableness of the regulation at issue"); see also Aamer, 742 F.3d at 1041 (noting that a petitioner may, in a non-preliminary injunction motion, attempt to show the district court that "there are `ready alternatives' to force-feeding that the government might employ to achieve these same legitimate interests"; not that there are ready alternatives to the specific methods used to force-feed detainees). Protection of a constitutional right to refuse unwanted medical care does not command the Court to evaluate each and every aspect of the force-feeding process under Turner. Accordingly, Turner is not the appropriate test to determine how the government carries out a given regulation. Cf. Estelle, 429 U.S. at 104-05, 97 S.Ct. 285 (the deliberate indifference standard applies to the adequacy of medical treatment for prisoners). As mentioned above, while the act of force-feeding may implicate the Fifth Amendment due process clause, the use of nasogastric tubes, the method of auscultation, and the use of Five Point Restraint Chairs, among other specific methods for performing a force-feeding, are not due process concerns, but rather — at most — represent Eighth Amendment issues. Id.
Thus, Turner is satisfied if the Court accepts that the right to be free from unwanted medical care is not unconstitutionally infringed by Rabbani's force-feeding. Indeed, at the preliminary injunction stage, the Circuit already reached an analogous conclusion in Aamer. 742 F.3d at 1041. And here, the petitioner presents the Court with no additional factual or legal reasons — beyond those already presented and resolved in Aamer and Dhiab — to question, under the elevated bar for granting a preliminary injunction, the methodology used by the medical staff at Guantanamo Bay to determine that force-feeding is necessary to keep Rabbani alive. Rabbani's principal contention that, contrary to Circuit law, he has always been force-feed before facing actual risk of death or great bodily injury, see Notification 4; Aamer, 472 F.3d at 1041, is contradicted by the affidavit of Commander [redacted], the Senior Medical Officer of the Guantanamo Bay Joint Medical Group ("JMG"). Opp'n Ex. 7 (Declaration of Commander [redacted], M.D., May 7, 2014). Commander [redacted] details the reasons underlying the JMG's determination to force-feed Rabbani, id. ¶¶ 4-7, and concludes that, "if enteral feeding was discontinued, significant risks to [Rabbani's] life and health could immediately result." Id. ¶ 15. Commander [redacted] declaration provides, at the very least, "a valid, rational connection between" the decision to force-feed Rabbani and the "legitimate governmental interest" in preserving Rabbani's life. Turner, 482 U.S. at 89, 107 S.Ct. 2254.
Such a conclusion is bolstered by the deferential standard traditionally applied to prison operations — a standard this Court finds especially germane in the context of medical care given to prisoners. E.g., Overton v. Bazzetta, 539 U.S. 126, 132, 123 S.Ct. 2162, 156 L.Ed.2d 162 (2003) ("We must accord substantial deference to the professional judgment of prison administrators...."); Amatel, 156 F.3d at 204 ("[C]ourts must give a large measure of deference to the prison administrators who are actively involved in the daily operations of the institution."); see also Beard v. Banks, 548 U.S. 521, 530, 126 S.Ct. 2572, 165 L.Ed.2d 697 (2006) (At the summary judgment stage, the Supreme Court noted that it "must distinguish between evidence of disputed facts and disputed matters of professional judgment. In respect to the latter, [the Court's] inferences must accord deference to the views of prison authorities."). In fact, the Circuit has made clear that Guantanamo Bay administrators, in particular, must be afforded great deference under Turner. See Hatim, 760 F.3d at 58-60; see also Munaf v. Geren, 553 U.S. 674, 689, 128 S.Ct. 2207, 171 L.Ed.2d 1 (2008) ("[C]ourts traditionally have been reluctant to intrude upon the authority of the Executive in military and national security affairs." (internal quotation marks and citation omitted)).
Even when considering the three remaining Turner factors, Rabbani's claim fails in the balance. The second factor asks whether Rabbani has alternative means of exercising his right to refuse unwanted force-feedings. Turner, 482 U.S. at 90, 107 S.Ct. 2254. One plain alternative for Rabbani to avoid involuntary enteral feeding is to voluntarily eat.
Regarding the third factor, while the government may argue that any alterations to its current force-feeding policy would endanger its legitimate interest in preserving the lives of detainees and call into question its authority over security decisions at Guantanamo Bay, it is not obvious to the Court that accommodating more of Rabbani's requests to avoid force-feeding would meaningfully exert the resources of the prison. Yet regardless of how the Court would resolve the third factor, the first, second, and fourth factors militate in favor of the government.
The fourth factor — whether there are "ready alternatives" to the force-feeding practices — is a focal point of Rabbani's argument that the manner in which he is force-fed is constitutionally unlawful. See, e.g., Mot. Prelim. Inj. 32-34; Notification 4. Rabbani wishes to narrow the final Turner factor to evaluating whether there are ready alternatives to a number of the individual steps that make up the force-feeding process. But again, the Court finds that Turner governs whether force-feeding generally infringes on a constitutional right to be free from unwanted medical treatment. Consequently, the question is whether there are "obvious, easy alternatives" to force-feeding in order to nourish a hunger-striking detainee, not whether there are alternative means for each procedure employed by the government as part of the force-feeding process. See Turner, 482 U.S. at 90, 107 S.Ct. 2254. In evaluating this case for its likelihood of success on the merits, the Court perceives no ready alternatives to force-feeding when an inmate is voluntarily starving himself and nourishment is the only way to keep him alive.
Thus, as with the deliberate indifference standard, analysis under Turner's reasonably related standard prevents Rabbani from demonstrating a likelihood of success on the merits.
Rabbani also argues that the forcible removal of detainees from their cells to the force-feeding location is unlawful under either Turner or Estelle. See Mot. Prelim. Inj. 5, 41; Notification 7-8. The Court finds that such a claim is highly unlikely to succeed on the merits.
Accordingly, the Court is unconvinced that Guantanamo Bay guards exceed their authority by forcibly extracting a detainee who is deemed by medical staff to require enteral feeding and refuses to leave his cell on his own accord. The Court concludes that FCEs fall squarely within the discretionary decisionmaking that case law grants Guantanamo Bay staff under either Estelle or Turner. That Rabbani experienced pain when, upon refusing to walk voluntarily to the force-feeding location, Guantanamo Bay guards "truss[ed] him... under full restraint" and "carr[ied] his immobilized body away for force-feeding" is inadequate evidence to demonstrate deliberate indifference by the guards. A highly physical encounter
Regarding the applicability of Turner to the FCE claim, Rabbani does not put forth a specific constitutional right — other than insinuating an Eighth Amendment violation — that FCEs allegedly contravene. However, even if FCEs impinge a specific constitutional right, they are reasonably related to legitimate penological interests, such as prison security, Hatim, 760 F.3d at 59, and preserving the lives of detainees, Aamer, 742 F.3d at 1040-41. Rabbani's emphasis on the fact that Guantanamo Bay guards do not actively pursue alternative means of extraction misinterprets the requirements under Turner. See Notification 7. There is no constitutional obligation for Guantanamo Bay protocols to "mandate the consideration of `ready alternatives'" to FCEs for controlling uncooperative detainees. See id. "[Turner] is not a `least restrictive alternative' test: prison officials do not have to set up and then shoot down every conceivable alternative method of accommodating [Rabbani]'s constitutional complaint." Turner, 482 U.S. at 90-91, 107 S.Ct. 2254 (citing Block v. Rutherford, 468 U.S. 576, 587, 104 S.Ct. 3227, 82 L.Ed.2d 438 (1984)); cf. Overton, 539 U.S. at 132, 123 S.Ct. 2162 ("The burden... is not on the [government] to prove the validity of prison regulations but on the prisoner to disprove it."). While "the existence of obvious, easy alternatives may be evidence that the regulation is not reasonable," there are no such obvious, easy alternative means for transporting a noncompliant detainee to the force-feeding location that are readily apparent to the Court. Id. at 90, 107 S.Ct. 2254. Furthermore, even if ready alternatives to FCEs existed, such a finding would surely not offset the three other Turner factors, all of which weigh against Rabbani.
In a status report filed on December 16, 2014, Rabbani notes a "serious downturn in the state of his health." Status Report 2, ECF No. 346. Rabbani then seeks to link his ailments to the prior use of olive oil as a lubricant on force-feeding tubes — a practice that persisted until the summer of 2014. Id. at 2. According to Dr. Steven Miles, who submitted a declaration as part of Dhiab's motion for a preliminary injunction, such a use of olive oil can potentially "cause a condition called lipoid pneumonia." Mot. Disc. Ex. A ¶ 10, Dhiab, June 20, 2014, ECF No. 265-1. Rabbani asserts that the government rejected his request that the medical staff at Guantanamo Bay test him for lipoid pneumonia. Id. at 3-4. Rabbani argues that the government's refusal "presents an additional issue for this Court's decision: whether that refusal meets the `deliberate indifference' standard of proof set forth in Estelle...." Id. at 4. The status report is fashioned as an addendum to the petitioner's previously filed motion for a preliminary injunction, and not as a new motion.
Petitioner's status report merely presents an example of different medical opinions, not deliberate indifference on the part of the government. The government avers that "(1) a standard chest x-ray taken of Petitioner in August 2014 for routine tuberculosis screening had shown no signs of pneumonia or other lung infection, and (2) Petitioner had not reported any respiratory complaints for the past several months." Status Report at 3. The fact that Rabbani can point to a medical journal article stating that "(1) more than half of persons with lipoid pneumonia are asymptomatic, (2) chest x-rays have a relatively low rate of diagnostic accuracy for lipoid pneumonia, and (3) there are much more accurate tests for diagnosing lipoid pneumonia," id. at 4, does not transform the government's medical decision not to test Rabbani into deliberate indifference. There is no evidence, explicit or implicit, from the communications between Rabbani's counsel and the government, id. Ex. C, that the Guantanamo Bay medical staff "possesse[s] a ... culpable state of mind" sufficient for the Court to find that their decision not to perform further testing on the asymptomatic petitioner equates to cruel and unusual punishment. Wilson v. Seiter, 501 U.S. 294, 297, 111 S.Ct. 2321, 115 L.Ed.2d 271 (1991).
Additionally, the link Rabbani attempts to draw between the government's prior use of olive oil to lubricate force-feeding tubes — which creates the basis for his argument of deliberate indifference as to lipoid pneumonia testing — and his medical condition is, at best, speculative. Rabbani seeks to blame the government's use of olive oil during the force-feeding process for his current medical problems, and, thus, create the sense that a pattern of government neglect, or worse, exists. While substantive evidence that the government has engaged in a pattern of "reckless" medical practices may provide additional support for a claim that the government's refusal to test for lipoid pneumonia reflects deliberate indifference, Rabbani can demonstrate no such pattern here. Indeed, there appear to be multiple alternative explanations for the petitioner's worrisome condition: namely, Rabbani's nearly two-year-long hunger strike, or, perhaps even his voluntary consumption of olive oil "separate from the enteral feeding" process, Opp'n Ex. 7 ¶ 10. Therefore, without credible evidence of prior government deliberate indifference as to his medical issues, Rabbani's already tenuous claim that the government's rejection of his request for testing meets the Estelle standard rests on even shakier grounds, and is insufficient to satisfy the petitioner's lofty burden for a showing of deliberate indifference. See Estelle, 429 U.S. at 105-06, 97 S.Ct. 285 (a finding of deliberate indifference must be consistent with a finding of "an unnecessary and wanton infliction of pain").
Thus, for the foregoing reasons, the Court DENIES the petitioner's motion for a preliminary injunction.
Before the Court are the petitioner's motion for a preliminary injunction [306], the government's opposition [319], the petitioner's reply [320], the petitioner's and government's respective briefs regarding any claims remaining to be decided in this case [341, 344], and the petitioner's status report [346] filed December 16, 2014. For the reasons explained in the accompanying Memorandum Opinion issued this date, it is hereby