Hunger strike is a regularly reported problem in prison. Although clinical situations are rarely severe, hospitalisation is often considered. In consequence, it is not only physicians working in prisons, but also hospital medical teams who face challenges related to hunger strike, involving somatic, psychological, legal and human rights aspects. Furthermore, deontological rules must be strictly respected when delivering care, particularly in prison setting. Starvation involves metabolic changes and can cause severe, and sometimes even irreversible or fatal complications. Moreover, the phase of re-alimentation should not be trivialised, as re-feeding syndrome is a potentially fatal phenomenon. This article provides guidance for monitoring and management of patients on hunger strike.

Hunger strike among detainees: guidance for good medical practice

Physicians and other licensed health professionals are involved in force-feeding prisoners on hunger strike at the US Naval Base at Guantanamo Bay (GTMO), Cuba, the detention center established to hold individuals captured and suspected of being terrorists in the wake of September 11, 2001. The force-feeding of competent hunger strikers violates medical ethics and constitutes medical complicity in torture. Given the failure of civilian and military law to end the practice, the medical profession must exert policy and regulatory pressure to bring the policy and operations of the US Department of Defense into compliance with established ethical standards. Physicians, other health professionals, and organized medicine must appeal to civilian state oversight bodies and federal regulators of medical science to revoke the licenses of health professionals who have committed prisoner abuses at GTMO.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S1049023X13008868

Hunger strikers: ethical and legal dimensions of medical complicity in torture at Guantanamo Bay

In 2015, the Israeli Knesset passed the force-feeding act that permits the director of the Israeli prison authority to appeal to the district court with a request to force-feed a prisoner against his expressed will. A recent position paper by top Israeli clinicians and bioethicists, published in Hebrew, advocates for force-feeding by medical professionals and presents several arguments that this would be appropriate. Here, we first posit three interrelated questions: 1. Do prisoners have a right to hunger-strike? 2. Should governing institutions force-feed prisoners and/or is it ethical to force-feed prisoners? 3. Should healthcare professionals force-feed prisoners? We then focus on the first and third questions. We first briefly provide several arguments to support the right of prisoners to refuse treatment. Next, we critically review the arguments presented in the Israeli position paper, demonstrating that they are all misguided at best. Lastly, we briefly present arguments against force-feeding by medical professionals. We conclude that healthcare providers should not participate in the force-feeding of prisoners.

The land of no milk and no honey: force feeding in Israel.

In its Malta Declaration, The World Medical Association prohibits force-feeding of hunger strikers as “degrading and inhuman,” even when this is the only way to save their lives. The European Court of Human Rights ruled that lifesaving force-feeding is compatible with the state’s duty to protect the lives of prisoners. To understand how such extreme divergence of opinions has become possible, this paper offers a critical examination of the social history of prisoners’ hunger strikes, the philosophy of nonviolence, and the debate on its medicalization.
	 The discourse by actors, professionals, regulators, and scholars on hunger strikes is divided into three paradigms: the “communicative,” the “extreme violence,” and the “psychiatric.” I argue that another paradigm is in play, and its incorporation may enrich and balance the discourse. This is the “wounded combatant” paradigm, according to which hunger strikers are like enemy soldiers who are injured in battle.

The Role of Doctors in Hunger Strikes

Hunger strikes potentially present a serious challenge for attending physicians. Though rare, in certain cases, a conflict can occur between the obligations of beneficence and autonomy. On the one hand, physicians have a duty to preserve life, which entails intervening in a hunger strike before the hunger striker loses his life. On the other hand, physicians' duty to respect autonomy implies that attending physicians have to respect hunger strikers' decisions to refuse nutrition. International medical guidelines state that physicians should follow the strikers' unpressured advance directives. When physicians encounter an unconscious striker, in the absence of reliable advance directives, the guidelines advise physicians to make a decision on the basis of the patient's values, previously expressed wishes, and best interests. I argue that if there are no advance directives and the striker has already lost his competence, the physician has the responsibility to resuscitate the striker. Once the striker regains his decision-making capacity, he should be asked about his decision. If he is determined to continue fasting and refuses treatment, the physician has a moral obligation to respect this decisions and follow his advance directives.

Professional ethics in extreme circumstances: responsibilities of attending physicians and healthcare providers in hunger strikes

A discussion by Hernan Reyes, MD, renowned medical ethics expert in crisis situations, of the World Medical Association's guidelines on the force-feeding of prisoner hunger strikers as stated in the Declarations of Malta and Tokyo. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

/pdf/force-feeding-and-coercion-no-physician-complicity-4fijneitmb.pdf

Force-feeding and coercion: no physician complicity.

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Force-feeding and coercion: no physician complicity.