The most inviolable of medical ethics - and the most inviolable of health rights - is the primacy of each patientís autonomy. No medical intervention, be it examination, investigation or treatment, can be performed in the absence of a patientís informed consent or in the face of a patient's informed refusal. In medical jurisprudence terms, foregoing consent constitutes potential battery in the absence of necessity or statutory sanction.
Real hunger strikes involve actual fasting, which has to be voluntary and has to be pursued for a specific purpose. Fasting prisoners with a mental disorder or who otherwise do not have the mental capacity for rational judgement and decision-making cannot be considered as giving informed refusal to feeding. Informed refusal can be judged by careful questioning to elicit answers that demonstrate a capacity to communicate, to understand relevant information, to appreciate the situation and its consequences and to manipulate information rationally.
Hunger strikes constitute a form of protest first used in Europe by the early 20th century British suffragette movement - the controversial medical act of force-feeding was performed for the first time on them by court order in 1909. More recently the Irish hunger strikes in the Maze prison in the early 1980s led to 10 fatalities, and in Turkey in 1996 led to at least twelve. The key aspect of determined hunger strikers is not the pressure the prisoner hopes to exert by fasting, but rather the despair that generates a form of protest that is tantamount to suicide. When it became clear the hunger strikes in Ulster were serious, the prison doctors respected their expressed will and force-feeding was not contemplated at any time.
The World Medical Association has drawn up codes of ethics which give specific guidance on the issue of force-feeding. Article 5 of the Declaration of Tokyo published in 1975 forbids force-feeding, and was intended to provide support for doctors confronted with prisoners who were victims of torture. [click here] If such prisoners went on a hunger strike, doctors would not be compelled to force-feed or resuscitate them, thereby making them ďfitď enough to go back to be tortured again.
The World Medical Association subsequently adopted the 1991 Declaration of Malta [click here] which deals with the issue of hunger strikers without making reference to torture. Although the Tokyo and Malta Declarations apply to different situations, they share the common denominator of being concerned with the patientís welfare. Doctors have a duty of care for their patients, including hunger-striking prisoners. If the prisoner has clearly stated that he refuses to be force-fed, then the doctor must use his clinical and moral judgement to do his best for the patient. Taking action for the patientís benefit may sometimes mean disregarding his express wishes if the doctor is convinced that the patient will ultimately be glad to be brought back from the verge of death. The Malta Declaration offers doctors the opportunity to give the fasting prisoner a last chance. If, however, a prisoner at an advanced stage of a hunger strike is restored to consciousness or to a physiological situation where there can be no doubt about his state of mind, and that prisoner clearly indicates disapproval of the doctorís action, then the doctor must step back and not intervene again. In such cases it can be argued that ensuring the patientís welfare means allowing fasting prisoners the last possibility of freedom of action, and letting them at least die with dignity. Thus both the rights of detainees and medical ethics coincide on this issue.
The bottom line is that doctors must never collaborate with coercive feeding, with prisoners being restrained so as to be fed and with intravenous drips or oesophageal tubes being forced into them.