The hunger strike as political, medical, moral and human rights problem

 

The hunger strike as political, medical, moral and human rights problem ............................. 1

The hunger strike as political, medical, moral and human rights problem ............................. 2

Abstract .................................................................................................................. 2

Defining the hunger strike ......................................................................................... 3

The ubiquity of hunger strikes ................................................................................... 5

The health outcome of the hunger strike .................................................................... 6

The functionality of the hunger strike ......................................................................... 6

The ethical dimension ............................................................................................... 8

The medical dimension ........................................................................................... 11

Understanding the physiological processes and outcomes of the hunger strike . 12

The human rights dimension .................................................................................... 12

The issues giving rise to the hunger strike ........................................................... 12

The response to the hunger strike ........................................................................ 13

The political dimension ........................................................................................... 14

Conclusions ........................................................................................................... 14


 

 

 


 

The hunger strike as political, medical, moral and human rights problem

 

Abstract

Hunger strikes are a tool of the desperate and sometimes the deluded. They can pose acute difficulties to the striker, to the striker's supporters, to medical staff and to human rights organizations. They represent a very particular form of protest in which the striker gambles her or his health, or even life, against the moral or strategic response of the power holder who has the means to grant or withhold concessions. Most hunger strikes resolve themselves in a short time, either because the striker intended only a short symbolic protest or the experience of the strike causes the hunger striker to end her or his action quickly. However extended periods of food refusal, including those conducted as part of a mass political action, can lead to deaths or long-term physical and mental deterioration. They reflect politically-motivated action; a health and ethical dimension; they touch on the moral values of the striker, carer and state decision-maker and challenge both supporters of the hunger striker and civil society organizations which work to promote human rights. Current autonomy-based ethical standards call on doctors (and arguably other health professionals) to respect patient autonomy and to abjure non-consensual feeding. However some professionals oppose acquiescing in the possible self-inflicted death of a patient and are sympathetic to the involuntary feeding of the striker. Some governments require health professionals to forcibly feed hunger-striking prisoners, raising issues of dual loyalty obligations. The ethical considerations escalate as the hunger strike progresses and the questions of patient competence and best interests become more complex and the political environment evolves. This paper discusses the hunger strike as a political, medical, moral and human rights problem.

 

 

Paper presented at the International Academy of Law and Mental Health, at the Université René Descartes (Paris V) and Sorbonne, in Paris, France, 4-10 July 2005.

 

 


 

 

The hunger strike as political, medical, moral and human rights problem

 

Hunger strikes can represent to the striker (particularly if incarcerated) one of the few, if not the only, means to protest against what they feel is an injustice being directed towards them. It can achieve important personal, social or political gains, or it can leave behind dead and damaged strikers who slowly starved themselves with no positive outcome at the end of the process. Hunger strikes have been analysed from a variety of standpoints: historical, physiological, neurological, clinical, political, psychological, nutritional, therapeutic and ethical, and in some investigations the fact of a hunger strike is only incidental to the study. In addition, a number of memoirs have enriched our understanding of the hunger strike experience. The main population groups studied or reviewed are prisoners or, increasingly, asylum-seekers, though press reports remark on food refusal undertaken by a wide range of protesting individuals including doctors.

Defining the hunger strike

The hunger strike is a particular form of voluntary food refusal within a spectrum ranging from fasting consequent to mental illness though to slow suicide. The spectrum of types of food refusal is illustrated in table 1. The work “strike” conveys the combative stance of the person undertaking the food refusal, with its echoes of industrial action to achieve a goal. Other parallels with the industrial strike exist. The strike can involve any number of strikers, can be tactical or spontaneous, it can be short term or for an extended period, it can be a “risk all” undertaking. It can be total or partial.

 

In this paper I use the term “hunger strike” to refer to food refusal commenced by a competent person, to achieve a goal which is seen by the striker (though not necessarily by others) as a desirable outcome. Others have referred to “decision-making capacity” rather than “competence”, drawing attention not only to psychological factors bearing on capacity to make decisions but also to the group dynamics of the hunger strike. Table 1 situates hunger strikes within the spectrum of different forms of food refusal. These are not rigid categorisations but hunger strikes would cluster in the third, fourth and fifth categories – food refusal to protest/publicise, to achieve political goals or to achieve personal goals. Of course a single hunger strike could embody all three motivations. Similarly, a person with a mental disorder could nevertheless refuse food to obtain a goal rather than merely as a manifestation of mental illness. However this paper will focus on hunger strikes and not other forms of food refusal.

 

Table 1: Types of food refusal according to motive

Motivation for refusal

Example

Religious fasting

The Hindu religion, for example, encourages fasting on specified days for up to 24 hours (though usually it involves avoiding solid food and taking nutrient liquids such as milk or juices)

Food refusal arising from mental disorder

Food-related disorders such as anorexia nervosa or more general disorders such as depression can manifest in refusal to take food

Food refusal to protest the status quo and gain publicity

Food refusal to protest at destruction of rainforests

Food refusal to achieve political goals

Protest to win right of prisoners to be regarded as political prisoners

Food refusal to achieve personal goals

Protest to win reinstatement in job following dismissal

Suicide by food refusal (at any age)

 

Food refusal (in terminally ill or aged)

Form of protest or alternative to physician-assisted suicide

The ubiquity of hunger strikes

On any single day, a search of the press using an internet search engine is likely to identify numerous reports of hunger strikes. They range from the transient and rare hunger strike through to common, persistent and enduring strikes. There are several countries where hunger strikes have been used either widely or strategically used to press for changes in political policy. Turkey and the Occupied Palestinian Territories have experienced mass hunger strikes in recent years and the hunger strikes in Northern Ireland and Spain in the early 1980s were most widely analysed strikes in Europe at the time. Hunger strikes in other countries have been reported on, analysed and campaigned on in the news media, the medical literature, and by human rights organizations. The hunger strike may appeal as a tactic for those with a goal to achieve or a protest to make because it is so simple to carry out, has a potent tradition and can easily be modified tactically according to needs.

 

The health outcome of the hunger strike

 

The failure of the body to receive regular supplies of nutritionally balanced food and water leads to loss of body tissue. Between 48 and 72 hours, ketosis sets in. Hunger pangs and stomach cramps dissipate; provided adequate water is taken the fast can continue safely. After two to three weeks the striker becomes weak, dizzy, feels cold, suffers a slowing of the heart and feels either light-headed or mentally sluggish.

The functionality of the hunger strike

The hunger strike is a form of protest in which the striker asserts his or her autonomy by undertaking a damaging act. By contrast the response of the authorities (governmnet, prison management or other agency) can respect the striker's autonomy or forcibly feed the striker – an act which might rescue the striker from physical damage but which strongly articulates the state's power over the striker.

Hunger strikes usually have at least two audiences: the public (or a particular sector of the public) and the decision-makers. But it can also be an individual protest in which the audience is negligible and the decision-maker recalcitrant. In this context the strike is a form of protest in which mobilising public opinion may not be possible. All hunger strikes represent a type of protest in which the striker inflicts (or threatens to inflict) damage on his or her own body on the understanding or hope that the authorities who are the target of his or her protest will be moved to accede to the striker’s demands.

In some countries, forcible feeding is routinely used against hunger strikers and the function of the protest take on a different tone. In such cases the hunger striker is challenging the authority of the detaining body. The fact that the hunger strike cannot proceed may undercut its effectiveness though the assertion of state power to forcibly feed a striker may add to public disquiet about the government role and may strengthen the hand of organizations using the hunger strike tactic .

 

The outcome of a hunger strike can range across the following spectrum

 

  • Complete success for the striker – the demands are conceded without any long-term harm coming to the prisoner.
  • Apparent failure for the striker who has to stop the strike due to government’s failure to respond or who continues the strike and suffers irreversible harm or dies
  • Partial victory/failure: some concessions are made but all goals of the strike are not met
  • Complex outcomes: for example a “victory” by a government as measured by the early termination of the hunger strike or failure of the strikers to gain concessions but with the effect of alienating public opinion

 

To the extent that governments (or other targets of hunger strikes) will concede to the striker, they will do so for one or more of several possible reasons.

 

  • Concern for the prisoner’s fate
  • Fear that harm to the prisoner will undermined prison or social discipline
  • Fear that harm to the prisoner will provoke violence by the prisoner’s supporters
  • Fear that harm to the prisoner will alienate public opinion
  • Review of policy making it compatible with the position of the hunger striker

 

Existing ethical guidance for hunger strikes

 

Before reflecting on some of the ethical conundrums posed by hunger strikes it might be useful to refer to the two major existing standards directly addressing this subject.

 

The first – the World Medical Association’s Declaration of Tokyo (1975) states that

 

Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner. ( Para 5)

 

This paragraph appears in a declaration prohibiting medical involvement in torture and clearly addresses hunger strikes in that context. The strikers are likely to be prisoners and likely to be at risk of torture. When they refuse to take food they should not be force fed by a doctor.

 

The second ethical standard is the Declaration of Malta of the WMA, adopted in 1991 and edited in 1992. This standard tries to take account of the two conflicting principles of preserving life where possible and respecting the autonomy of the patient. The Declaration notes, in preambular paragraph 4:

 

The ultimate decision on intervention or non-intervention should be left with the individual doctor without the intervention of third parties whose primary interest is not the patient's welfare. 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.

 

It later states in the guidelines:

 

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, always taking into account the decision he has arrived at during his preceding care of the patient during his hunger strike, and reaffirming article 4 [see above].

 

Other ethical standards enjoin the physician to work for the best interests of the patient, to avoid doing harm, to respect confidentiality and so on. The decisions taken by a doctor will reflect their understanding of medical ethics but also the manner in which they resolve dual loyalty tensions – particularly where the authorities require them by law to feed the prisoner irrespective of the prisoner’s wishes.

 

The ethical dimension

 

Working in unethical places

 

The ethical aspect of managing a hunger strike is complex and challenging. The additional demands placed on doctors working in places of detention complicate matters further. Resolving dual loyalty conflicts can become increasingly difficult where procedures and institutional demands may conflict with the values of the doctor. Many hunger strikes take place as a result of human rights violations inflicted on prisoners. Doctors working within such an environment may find it difficult to give primacy to the prisoner’s well-being. Hunger striking detainees held without trial in the war on terror have gone on hunger strike and most probably force fed

 

One area raising concerns is the detention of asylum-seekers and the ensuing protests by hunger strikes. This form of protest by people who are asserting their right to seek asylum raises particular ethical concerns. Apart from ever-present tension between life-preservation and patient autonomy there is the difficulty of reconciling “ethical and medical issues with the priorities of government policy, particularly the state’s interest in maintaining or and security in detention centres during a period of political controversy about detention.”

 

Decision-making and autonomy

 

It is a principle of common law and reflected in many codes of medical ethics that a competent person can consent, or withhold consent, to a medical procedure. However prisoners are routinely stripped of such attributes.

 

Role of third parties in decision-making

 

  • Opponents of the hunger strike or the striker’s cause . Those who hold custody of the hunger striker are usually opposed to the hunger strike and may press the doctor to either forcibly feed the prisoner or persuade the striker to resume taking food.

 

  • Supporters of the hunger striker . These may include significant fractions of the public but also members or supporters of the hunger striker’s political or social organization. Family members may support the hunger striker’s action though not always. Fellow hunger strikers are also an important influence. The individuals most likely to have an impact on the course of the hunger strike will be those close to the striker and who are most actively promoting the strike.

 

  • State law . In some countries, the state legalises forcible feeding either by regulation or by court order. In the USA, for example, a number of state court decisions have ruled in favour of forcible feeding. An Illinois appellate court ruled, in 2001, that there were “ compelling penological objectives [in support of forcible feeding] such as the preservation of life, prevention of suicide, and the enforcement of prison security, order, and discipline.” In the case of the Commonwealth of Pennsylvania v Kallinger, the court supported forcible feeding and referred, inter alia, to “the need to preserve the integrity of the physicians and psychiatrists working within the penal system” though by this they meant the preservation of the life-saving role of health professionals rather than their need to respect the patient’s wishes. Other US courts have ruled that prisoners do have a right to refuse feeding. In the United Kingdom, the position of successive governments for the past 30 years has remained opposed to forcible feeding.

 

Response to group pressure on individual strikers

 

Wherever there is a group struggle – whether strike, hunger strike or demonstration – there is always a possibility that some participants are taking part because of group pressure. In short mass hunger strikes, the cost of brief discomfort to the reluctant participant may be seen as a small price to pay for maintaining solidarity and avoiding the stigma of “betraying” the group. However where fasting is likely to be prolonged and possibly ending in the death of the striker, the tension between maintaining solidarity and avoiding self harm may be irresolvable. It is not the role of the physician to seek to persuade the striker to take a particular course of action. However they should be prepared to make some effort to determine the true feeling of the individual striker and act in accordance with those wishes (or make way for a doctor who can).

 

Children involved in hunger strikes

 

Hunger strikes involving children are rare. Mok and Nelson reported a hunger strike involving children in a Hong Kong refugee camp in1996. They described the case of 14 Vietnamese children, aged one to 12 years, who took part in a hunger strike at a refugee detention centre in Hong Kong, and who were admitted to the Prince of Wales Hospital. Not having encountered such cases before, nor having any guidance, the doctors responded to the children as if they were victims of abuse and the children were not discharged until assurances were received that they would be fed properly.

 

However, it is clear that children are affected by hunger strikes conducted by family members, particularly where this is happening in the context of asylum-related incarceration as has been practised in Australia for several years. In rare cases the child may refuse food – a manifestation of psychological disturbance rather than hunger strike.

 

Striker’s progressive loss of competence and the living will

 

The Declaration of Malta offers guidance on this issue, though leaves it to the doctor to decide on the course of action which best meets the needs of the individual striker. Where a doctor feels unable to fulfil the wishes of the hunger striker as expressed before he or she lost competence, then that doctor should withdraw in favour of a doctor who can meet the request of the striker.

 

Impact on changes in the scenario after the striker has lost competence

 

Where no mechanism has been arrived at to review the course of a hunger strike in the light of changing circumstances, the doctor would need to act in accord with the Malta Declaration. This may be the case where, for example, concessions have been foreshadowed or a change of policy appears possible but only after the striker has reached a point of no return. In such cases the doctor would have grounds for resuscitating the striker.

 

Involuntary feeding

 

The existing ethical standards are clear that an informed competent person can refuse nourishment. However the doctor must weigh up a number of different factors before deciding whether or not involuntary feeding is indicated.

 

The refusal of food (or medicine) occupies a special place in the ethical landscape. This is most clearly illustrated by comparing the following scenario. Life prisoner 1 tells guards that he is innocent and is going to start a hunger strike until he is released from prison, even if he dies in the attempt. Prisoner 2 tells the guards that he sees no future in spending the rest of his life in prison and has decided to kill himself. He will do this by no longer eating. Doctors assess each prisoner and find each is competent, clear-headed and committed to follow through their chosen course of action.

Ethics would require that the decision of the hunger striker would be respected. What would the proper response to the second prisoner’s plan of slow suicide? Is it different to suicide by positive action (such as cutting a vein)?

 

The medical dimension

 

The ethical principles cited above, and others, imply that doctors should respect the decision-making of the striker, where competent, and should be prepared to transfer clinical responsibilities to another doctor if they are unable, for whatever reason, to respect the wishes of the striker. The medical problems arising in hunger strike include:

 

Providing accurate meaningful medical information to the striker

 

For both medical and ethical reasons it is essential that individuals undertaking hunger strikes are provided with accurate and comprehensible information about the effects of fasting and the likely evolution of the strike. At this point the clinician will have to make a decision about the competence of the striker to refuse food and assess the extent to which the strike is being carried out voluntarily. One mechanism to protect the rights of the prisoner is to make available to the prisoner a doctor who is independent of the institution, government and other third parties. Such a scheme has been operating in the Netherlands for many years and the vertrouwensarts (doctor of confidence) is able to provide advice impartially and confidentially to the hunger striker.

 

Medical management

 

As the strike continues, medical professionals should be available to monitor the health of the striker and to offer help without putting pressure on the striker to terminate their action (or to continue the strike).

 

Responding to an unusual medical condition effectively and ethically

 

The striker’s health will deteriorate during the course of a prolonged strike. However, some medical problems may arise which are not directly the result of the hunger strike (though undoubtedly a debilitated state may exacerbate the effects of such a disorder.) Thus a respiratory tract infection may require treatment independent of the striker’s refusal to countenance measures intended to weaken the strike. Discussing this with the striker will benefit from trust in the doctor since the striker may be pre-disposed to refuse medical help. If the doctor is not independent of the detaining authorities this may be even more likely.

 

Decision-making during the decline of the striker’s health

 

The progressive weight loss of the striker will lead to increasing debilitation and confusion. At some point, in the absence of feeding, the striker will lose competence to make decisions. The doctor will have three possible sources of guidance at this point: his or her own ethical analysis of what is best for the patient; a “living will” prepared by the striker indicating the striker’s wishes in the case of loss of competence or the views of a surrogate decision-maker nominated by the striker before losing competence.

 

Resuscitating the starved prisoner

The prisoner who terminates a hunger strike for whatever reason will need to be fed. However those who have undergone a long strike (more than 40 days) or who are showing signs of particular physical distress will need careful resuscitation. Overloading the body with nutrients at this point could be fatal.

 

Diagnosing and treating long-term sequelae

There are a number of well-documented sequelae to prolonged food refusal, particularly arising due to a deficit in thiamine including Wernicke encephalopathy (a complex of ophthalmoplegia , ataxia , and an acute confusional state) or Wernicke-Korsakoff syndrome (where learning and memory deficits are additionally present).

Understanding the physiological processes and outcomes of the hunger strike

 

In some cases of hunger-strike-related deaths, pathologists or other specialists have investigated the underlying physiological processes. These add to the very limited studies on the physiology of starvation.

 

The human rights dimension

The issues giving rise to the hunger strike

 

Human rights organizations promote respect for the rights articulated in international and regional instruments and standards. Their viewpoint may or may not coincide with that of the individual hunger striker though different human rights bodies may approach this complex subject in different ways. Where the striker is protesting at an abuse of internationally recognized human rights then there is a coincidence of analysis and the human rights organization would argue that most effective way to respond to the hunger strike was to end the abuse which provoked it. Thus, strikes carried out to call for an end to torture or for the delivery of adequate health care in the face of grossly inadequate medical services are likely to evoke positive support from human rights bodies whether or not the human rights body supported the wider demands of the prisoners or their organizations. At the other end of the spectrum a hunger strike seeking to oppose principles of law and human rights – for example to quash the convictions of racist or homophobic abusers – would not evoke support for these goals (though ill treatment of the hunger strikers would conflict with human rights and could provoke protests by human rights bodies).

 

In some cases the hunger strike may concern an issue over which there is no clear position in human rights terms. Thus, for example, the right of political prisoners to carry out ideological “training” within the prison is an undefined “right”. Thus a hunger strike to achieve this object may not be supported or opposed from a human rights standpoint. In such a case, the human rights organization may focus on ensuring that the rights of the hunger striker are protected. These include freedom from torture or other cruel, inhuman or degrading treatment, access to medical care, and non-discrimination.

 

Amnesty International does not support or oppose involuntary feeding of hunger strikers though it takes note of a number of medical ethical standards which oppose such feeding and is opposed in all circumstances to the infliction of cruel, inhuman or degrading treatment on hunger strikers.

 

The response to the hunger strike

 

A hunger striker has the right to access to doctors and other health care personnel even though they may not seek medical care for malnutrition. Any restriction of access to health care personnel, whether absolutely or conditional on the striker giving up their hunger strike, would be contrary to international human rights standards.

 

The use of artificial feeding to “break” the strike may represent a breach – albeit potentially life-saving – of the will of the striker or it may represent an example of cruel, inhuman or degrading treatment. The measures used to break the hunger strikes of English suffragettes at the beginning of the twentieth century were clearly intended to be very unpleasant, as indeed they were. In one extraordinary case in Morocco in the 1980s, two men were held in the basement of a hospital and force fed over a period of more than five years. The conditions in which they were held and the treatment they suffered were clearly cruel and degrading. Staff who protested were harassed or disciplined.

 

The political dimension

 

Hunger strikes can indicate a failure by the state to respect the rights of prisoners and others. From the suffragettes on, people with a legitimate grievance have refused food to protest and to achieve their goals. In political prisons around the world, hunger strikes continue to be a regular occurrence, usually being met with forcible feeding. In some cases the use of hunger strike may mix concerns about human rights abuses such as torture with other political goals. And in yet other cases the hunger strike will be directed against decisions taken by a government; such decisions may be legitimately taken but poorly regarded by at least some citizens. And, of course, some hunger strikes may seek to achieve goals which conflict with or are not supported by human rights standards.

 

The political background to a hunger strike will both shape the conduct of the strike and the response mounted by a government. Intransigent governments may, at the one time, be more likely to provoke hunger strikes and to implement forcible feeding policies. Where forcible feeding is avoided, individual autonomy is respected but lives may be lost as a result. This makes resolution of the issues underlying hunger strikes important.

 

The experiences of Northern Ireland in the 1980s and Turkey in the 1990s and recent times have revealed some of the political discussions – at national and international level – which arise because of the loss of life arising from prolonged mass hunger strikes. Much analysis remains to be done on these events.

 

Conclusions

 

Hunger strikes are just one form of food refusal but a form of action which raises a number of dilemmas for the protesters, for their supporters, for health care professionals, for human rights organizations and for governments. While important ethical standards are available to guide the behaviour of health personnel, there remains an inherent difficulty for the health professional in two dimensions: the first is balancing the duty to preserve life where possible and respecting the autonomy of the striker; and the second is balancing professional and ethical decision-making on a complex health matter and giving way to the right of the state to insist on the doctor behaving like a good employee.

 

The health professional must inform, must listen to and must respect the decision of the informed and competent hunger striker. At the same time he or she must be sensitive to the potential cost of the hunger strike and the changing circumstances which may cast the strike in a different light. Trying to balance these responsibilities requires clearly stated support from health professional bodies and the NGO community.

 

 

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Appendix:

 

World Medical Association Declaration on Hunger Strikers

Adopted by the 43rd World Medical Assembly Malta, November 1991and editorially revised at the 44th World Medical Assembly Marbella, Spain, September 1992

PREAMBLE

  1. The doctor treating hunger strikers is faced with the following conflicting values:
    1. There is a moral obligation on every human being to respect the sanctity of life. This is especially evident in the case of a doctor, who exercises his skills to save life and also acts in the best interests of his patients (Beneficence).
    2. It is the duty of the doctor to respect the autonomy which the patient has over his person. A doctor requires informed consent from his patients before applying any of his skills to assist them, unless emergency circumstances have arisen in which case the doctor has to act in what is perceived to be the patient's best interests.
  2. 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.
    1. Ruling in favour of intervention may undermine the autonomy which the patient has over himself.
    2. Ruling in favour of non-intervention may result in a doctor having to face the tragedy of an avoidable death.
  3. A doctor/patient relationship is said to be in existence whenever a doctor is duty bound, by virtue of his obligation to the patient, to apply his skills to any person, be it in the form of advice or treatment.

This relationship can exist in spite of the fact that the patient might not consent to certain forms of treatment or intervention.

Once the doctor agrees to attend to a hunger striker, that person becomes the doctor's patient. This has all the implication and responsibilities inherent in the doctor/patient relationship, including consent and confidentiality.

  1. The ultimate decision on intervention or non-intervention should be left with the individual doctor without the intervention of third parties whose primary interest is not the patient's welfare. 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.

GUIDELINES FOR THE MANAGEMENT OF HUNGER STRIKERS
Since the medical profession considers the principle of sanctity of life to be fundamental to its practice, the following practical guidelines are recommended for doctors who treat hunger strikers:

  1. DEFINITION
    A hunger striker is a mentally competent person who has indicated that he has decided to embark on a hunger strike and has refused to take food and/or fluids for a significant interval.
  2. ETHICAL BEHAVIOUR
    1. A doctor should acquire a detailed medical history of the patient where possible.
    2. A doctor should carry out a thorough examination of the patient at the onset of the hunger strike.
    3. Doctors or other health care personnel may not apply undue pressure of any sort on the hunger striker to suspend the strike. Treatment or care of the hunger striker must not be conditional upon him suspending his hunger strike.
    4. The hunger striker must be professionally informed by the doctor of the clinical consequences of a hunger strike, and of any specific danger to his own particular case. An informed decision can only be made on the basis of clear communication. An interpreter should be used if indicated.
    5. Should a hunger striker wish to have a second medical opinion, this should be granted. Should a hunger striker prefer his treatment to be continued by the second doctor, this should be permitted. In the case of the hunger striker being a prisoner, this should be permitted by arrangement and consultation with the appointed prison doctor.
    6. Treating infections or advising the patient to increase his oral intake of fluid (or accept intravenous saline solutions) is often acceptable to a hunger striker. A refusal to accept such intervention must not prejudice any other aspect of the patient’s health care. Any treatment administered to the patient must be with his approval.
  3. CLEAR INSTRUCTIONS
    The doctor should ascertain on a daily basis whether or not the patient wishes to continue with his hunger strike. The doctor should also ascertain on a daily basis what the patient's wishes are with regard to treatment should he become unable to make an informed decision. These findings must be recorded in the doctors personal medical records and kept confidential.
  4. ARTIFICIAL FEEDING
    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, always taking into account the decision he has arrived at during his preceding care of the patient during his hunger strike, and reaffirming article 4 of the preamble of this Declaration.
  5. COERCION
    Hunger strikers should be protected from coercive participation. This may require removal from the presence of fellow strikers.
  6. FAMILY
    The doctor has a responsibility to inform the family of the patient that the patient has embarked on a hunger strike, unless this is specifically prohibited by the patient.

 

van der Helm-van Mil AH, van Vugt JP, Lammers GJ, Harinck HI. Hypernatremia from a hunger strike as a cause of osmotic myelinolysis. Neurology . 2005;64:574-5.

Johannes Wier Stichting. Hunger strikes.

O'Malley, P.Biting at the Grave: The Irish Hunger Strikes and the Politics of Despair. Belfast: The Blackstaff Press, 1990.

Fessler DMT. The implications of starvation induced psychological changes for the ethical treatment of hunger strikers. J Med Ethics 2003; 29:243-7.

Sahin HA, Gurvit IH, Bilgic B, Hanagasi HA, Emre M. Therapeutic effects of an acetylcholinesterase inhibitor (donepezil) on memory in Wernicke-Korsakoff's disease. Clin Neuropharmacol 2002;25:16-20.

Kenny MA, Silove DM, Steel Z. Legal and ethical implications of medically enforced feeding of detained asylum seekers on hunger strike. Med J Aust 2004; 180:237-40. A guide to the ethical analysis of the hunger strike is contained in an online course for prison physicians by the World Medical Association in collaboration with the Norwegian Medical Association at: http://lupin-nma.net/ (accessed 27 June 2005).

Garcia de Olalla P, Cayla JA, Mila C, Jansa JM, Badosa I, Ferrer A, Ros M, Gomez i Prat J, Armengou JM, Alonso E, Alcaide J. Tuberculosis screening among immigrants holding a hunger strike in churches. Int J Tuberc Lung Dis. 2003 Dec;7(12 Suppl 3):S412-6.

Lytton C. Prisons and Prisoners. Some Personal Experiences. London: Virago 1988 [originally published 1914]; Ratushinskaya I.Grey is the Colour of Hope. London: Hodder and Stoughton, 1988.

Doctors have been reported to have undertaken hunger strikes in Australia (for recognition of overseas qualifications), Hungary (for more funds for cardiology department); Israel (over working conditions) ; India (protesting at pay and conditions); Pakistan (to protest at killings of doctors – this was described as a “six hour hunger strike”); Poland (for better equipment and salaries),

A person who refuses all food and takes only water, perhaps with some salt or vitamins, will live no longer than 11 weeks. Where people on hunger strike are reported to have survived for longer periods on strike it means either that that have been fed involuntarily or that they are taking some nourishment, usually in liquid form. The effect of taking minimal nutrition is to extend the period before irreversible harm occurs and, thus, over which negotiations can take place. Hunger strikes of this kind can last up to a year.

The World Medical Association Declaration on Hunger Strikers (Declaration of Malta) defines a hunger striker as “a mentally competent person who has indicated that he has decided to embark on a hunger strike and has refused to take food and/or fluids for a significant interval.” Available at http://www.wma.net/e/policy/h31.htm . Note the elements of statement of intent and the carrying out of refusal to take food “for a significant interval” (which is not defined).

Oguz NY, Miles SH. The physician and prison hunger strikes: reflecting on the experience in Turkey. Journal of Medical Ethics 2005;31:169-72. Oguz and Miles argue that peer pressure can coerce a prisoner to undertake a hunger strike against their own wishes.

Brumberg JJ. Fasting Girls: The History of Anorexia Nervosa. New York: Vintage Books, 2000.

The “five demands” of the IRA political prisoners had been – since 1976 – the right not to wear a prison uniform; the right not to do prison work; the right of free association with other prisoners; the right to organize their own educational and recreational facilities; the right to one visit, one letter and one parcel per week.”. O’Malley P. Biting at the Grave etc. When a hunger strike commenced in October 1980,the statement announcing the hunger strike began: “We, the Republican Prisoners of War in the H-Blocks, Long Kesh, demand as a right, political recognition and that we be accorded the status of political prisoners.” Cited in Moen D. Irish Political Prisoners and Post Hunger-Strike Resistance to Criminalisation. British Criminology Conference: Selected Proceedings. Volume 3, 2000. Available at http://www.britsoccrim.org/bccsp/vol03/moen.html (accessed 27 June 2005).

There is a growing literature concerning food refusal by the elderly which mimics a feeding disorder. Duggal A, Lawrence RM. Aspects of food refusal in the elderly: the "hunger strike". Int J Eat Disord. 2001;30:213-6.

The use of food refusal in preference to physician-assisted suicide is described in a number of publications: Drayer RA et al. Patients who refuse food and fluids to hasten death. N Engl J Med 2003;349: 1777-9; Ganzini L et al. Nurses' experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med 2003; 349:359-365 (reporting findings that hospice residents preferred death by cessation of eating/drinking to physician-assisted suicide – a finding which “stunned” the principal researcher ( Arehart-Treichel J. Terminally ill choose fasting over MD-assisted suicide. Psychiatric News 2004; 39: 15. http://pn.psychiatryonline.org/cgi/content/full/39/2/15 ); Quill TE, Lo B, Brock DW. Palliative options of last resort: a comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. JAMA 1997;278:2099-2104. For the position paper of the American College of Physicians and the American Society of Internal Medicine, see: Quill TE, Byock IR. Responding to intractable terminal suffering: the role of terminal sedation and voluntary refusal of foods and fluids. Ann Intern Med 2000;132:408-14.

A database search for press reports of hunger strikes published in 2005 yielded more than 450 reports from 50 countries – from Azerbaijan to Zimbabwe. (Data kindly supplied by Dr J Krabhuis, Highland-Data ( justus.krabshuis@highland-data.com , http://highland-data.com , 28 June 2005.)

Beynon J. Hunger strike in Turkish prisons. Lancet. 1996;348:737; Anderson S. The hunger warriors. New York Times Magazine, 21 October 2001.

‘Jail protesters can ‘starve’, Israel vows.’ MelbourneAge, 17 August 2004, reporting that 1500 Palestinian prisoners began a hunger strike two days earlier. The strike lasted 19 days. Ten months later a new mass hunger strike was reported, starting 21 June 2005. (AFP, 21 June 2005)

See discussion in Medicine Betrayed, chapter 7.

Not all hunger strikes are for causes which would have universal support or which would be in the striker’s long term interests. For example, in 2000 sixty prisoners in an institution in Canada went on hunger strike to protest at the provincial government’s decision to ban smoking in all state prisons. See: Spurgeon D. Canadian prisoners strike over smoking ban. ­BMJ 2000; 321:402. One effect of the ban was a rapidly escalating black market price for cigarettes in the prison.

The hunger strike carried out in the Soviet gulags or other places where public scrutiny is limited or does not exist, such as US detention centres holding “enemy combatants”, represent examples of this kind of strike.

This is far from automatic; the routine use of forcible feeding in US prisons to address hunger strikes does not appear to provoke criticism in the public, and is accepted by some ethicists.

In an extended article on the Turkish hunger strikes, Scott Anderson comments that the “ 1980-81 hunger strike by the Irish Republican Army – abandoned after 10 men died – could be considered a partial success in that it strengthened a perception of the Thatcher government as callous and swelled IRA recruitment.” (New York Times Magazine, 21 October 2001)

Physicians for Human Right. Dual Loyalties and Human Rights in Professional Practice. Proposed Guideline and Institutional Mechanisms. Boston: PHR, 2002. The recommendation contained in this report was as follows: “The health professional should, if prepared to treat a hunger striker, respect the rights and freedom of choice of a detained hunger striker regarding medical intervention and intravenous feeding without the intervention of a third party whose primary interest may not be the patient’s welfare”. (p.76)

Ref.

Silove D, Curtis J, Mason C, Becker R. Ethical considerations in the management of asylum seekers on hunger strike. JAMA 1996; 276: 410-5; Kenny MA, Silove DM, Steel Z. Legal and ethical implications of medically enforced feeding of detained asylum seekers on hunger strike. Med J Aust 2004; 180:237-40.

Kenny et al. ibid. pp.238-9.

People ex rel. Illinois Dept of Corrections v. Millard , 335 Ill. App. 3d 1066, 1072, 782 N.E.2d 966 (2003). Available at: http://www.state.il.us/court/Opinions/AppellateCourt/2003/4thDistrict/January/Html/4010857.htm ; see also Court of Appeals, State of Washington. McNabb v Department of Corrections ( No. 23310-3-III), filed 2 June 2005; available at http://www.courts.wa.gov/opinions/index.cfm , also refusing the right of the prisoner to refuse food. This decision was applauded by Dr. Marc Stern, chief physician for the prison system, who was quoted in the Seattle Times as asking:" Where does the patient autonomy end and where does the state autonomy begin?” He went on to say: "We do have cancer patients who can't eat and choose to not eat. In that case, the patient has autonomy. You have the right to die in a dignified way. But being perfectly healthy and saying, ‘I’m not going eat,’ that’s where your [the prisoner’s] autonomy ends and our [the doctor’s] autonomy begins.” Seattle Times, 3 June 2005; available at: http://seattletimes.nwsource.com/html/localnews/2002297397_fast03m.html (accessed 26 June 2005)

Commonwealth v. Kallinger, 134 Pa. Commw. 415, 580 A.2d 887 (1990)

Zant v. Prevatte, 248 Ga. 832, 286 S.E.2d 715 (1982).

See British Medical Association. Medicine Betrayed: The Participation of Doctors in Human Rights Abuses. London: Zed Books, 1992.

Mok A, Nelson EAS. Chi ldren on hunger strike: child abuse or legitimate protest? BMJ 1996; 312:501-2.

Zwi KJ, Herzberg B, Dossetor D, Field J. A child in detention: dilemmas faced by health professionals. MJA 2003; 179 (6) : 319-22. Available at: http://www.mja.com.au/public/issues/179_06_150903/zwi10115_fm.html (accessed 27 June 2005). See also: Sultan A, O’Sullivan K. Psychological disturbance s in asylum seekers held in long term detention: a participant-observer account. MJA 2001; 175: 593-6. Available at: http://www.mja.com.au/public/issues/175_12_171201/sultan/sultan.html

Faintuch J, Soriano FG, Ladeira JP, Janiszewski M, Velasco IT, Gama-Rodrigues JJ. Refeeding procedures after 43 days of total fasting. Nutrition 2001;17:100-4..

Paralysis or weakness of one or more of the muscles that control eye movement reflecting a neurologic disorder.

Failure of muscle coordination.

Altun G, Akansu B, Altun BU, Azmak D, Yilmaz A. Deaths due to hunger strike: post-mortem findings. Forensic Sci Int. 2004 Nov 10;146(1):35-8;

See, for example, Cuba: Critical Health Condition - Hunger Strike: Leonardo Miguel Bruzón Avila. AI Index: AMR 25/004/2003. http://web.amnesty.org/library/index/ENGAMR250042003; Malaysia: Detained Islamists’ hunger strike highlights continued denial of right to trial. AI Index: ASA 28/003/2004, 15 March 2004. http://web.amnesty.org/library/index/ENGASA280032004; Tunisia: Health concern for hunger strike prisoner. AI Index: MDE 30/022/2000, 27 September 2000 http://web.amnesty.org/library/index/ENGMDE300222000 ; Turkey: prisoners on hunger-strike close to death – stop ill-treatment of prisoners, says Amnesty International. AI Index: EUR 44/88/96, 13 June 1996 http://web.amnesty.org/library/index/ENGEUR440881996; Turkey: Justice Ministry must speak before prison hunger strike claims lives. AI Index: EUR 44/03/98, 9 January 1998 http://web.amnesty.org/library/index/ENGEUR440031998; Turkey: Fear of torture for relatives and supporters of hunger striking prisoners. AI Index: EUR 44/69/00, 13 December 2000 http://web.amnesty.org/library/index/ENGEUR440692000.

The most notable standards are the World Medical Association’s Declarations of Tokyo and Malta (Available at: http://www.wma.net)

The reason for Amnesty International’s position is that it involuntary feeding need not necessarily be carried out in a cruel fashion and there is no international court ruling suggesting that force feeding is inherently cruel, inhuman or degrading.

Lytton op cit.

AI. Medical concern. Prolonged hunger strike, Morocco. AI Index MDE 29/07/89, September 1989.

 

 
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