ASSISTANCE IN HUNGER STRIKES
a manual for physicians and other health
personnel dealing with hunger strikers
JOHANNES
WIER FOUNDATION FOR HEALTH AND HUMAN RIGHTS
I Preface
Hunger strike and the role of the doctor
who assists a hunger striker have increasingly gained attention of the medical profession,
politicians and the general public.
In the Netherlands in recent years there
has been a dramatic increase in the number of hunger strikes. Hunger strike or 'voluntary
total fasting' is often called the 'weapon of the powerless', particularly those deprived
of some basic human freedoms such as refugees and prisoners.
Voluntary total fasting affects the
health and eventually threatens the life of an essential healthy person, who ultimately
turns his life into an appealing tool of protest, often of political nature, which is
often compelling enough for his opponents to evoke strong reactions.
Many hunger strikes last only a few
days; increasingly however doctors have to deal with hunger strikes which last much
longer, particularly among refugees. In such cases, especially when accompanied by a
thirst strike, the hunger strike is likely to lead to severe medical, ethical and social
problems.
The hard and acute dilemma the doctor of
a hunger striker faces is his professional obligation to preserve life as much as possible
while he has to respect the personal autonomy of the hunger striker. This dilemma has led
in the past, and in several countries still does lead to, forcible feeding against the
expressed will of the hunger striker.
Many national medical associations speak
out against forcible feeding, and the Declarations of Tokyo (1975) and Malta (1991,1992)
of the World Medical Association prohibit forcible feeding The prohibition of forcible
feeding however, has not diminished the doctors dilemma's.
Since the 1970's there has, in the
Netherlands, been a tradition that so-called "doctors of confidence" provide
medical and psychological assistance to hunger strikers. They may be general practitioners
or public health doctors, but they are always independent
from the government or other authorities, like the administration of prisons or
refugee centres. Some Dutch doctors have been "doctors of confidence" for hunger
strikers in Northern Ireland (imprisoned members of the Irish Republican Army - IRA) and
Germany (imprisoned members of the Red Army Fraction - RAF)
Since the beginning of the nineties
numerous hunger strikes have been undertaken by refugees in the Netherlands, mostly
individuals but sometimes large groups are involved.
In 1991 a group of 180 Vietnamese
refugees (spread over the whole country in centres for asylum seekers) started a long
lasting hunger strike in the Netherlands. This wide-spread and widely media covered action
learned that the average physician lacked sufficient knowledge on the subject, and that
appropriate information was not available.
These observations motivated the
Johannes Wier Foundation for Health and Human Rights (JWF) to organise a seminar
'Assistance for Hunger Strikers in 1992 in cooperation with the Royal Dutch Medical
Association (KNMG) anc the Pharos Foundation for Refugee Health Care.
The meeting was attended by doctors,
nurses and lawyers; the lectures and discussions of this seminar have been the basis for
this manual, which is especially written for doctors and other health personnel involved
in the assistance for hunger strikers. The Dutch version of this manual is currently being
used in centres for asylum seekers and detention facilities.
International contacts learned that
there is a need for an English translation of this manual.
The Johannes Wier Foundation decided to
publish an English edition, edited for the international professional reader*. For the
introduction chapter in this English edition we gratefully made use of the chapter on
hunger strikes in the report "Medicine Betrayed" of the British Medical
Association (BMA), published by Zed Books in 1992. The Johannes Wier Foundation owes
acknowledgment to the BMA for its permission to use the text from its book.
* Copies of this manual can he ordered
by mail or fax to the office of the Johannes Wier Foundation
III.
Medical backgrounds of hunger strike
Jeanne
Smeulers, M.D., Ph.D., internist.
Every doctor who is
confronted with a hunger strike will be faced with some difficult decisions and dilemmas.
As literature teaches us, there are no fully satisfactory solutions. However, it is
possible to set a well-considered policy that is ethically sound and as fair as possible.
What strikes us first is the panic of
the environment against the peacefulness and clear determination of the person who refuses
to eat. This also occurred in the Roman Empire during the government of Tiberius at the
beginning of the Christian era. The empire was declining, murder and torture had become
widespread. Nerva, the well-known lawyer and friend of the emperor, decided to go on
hunger strike because he could no longer bear to see the misery around him. He wanted to
die honourably before action would be taken against him. As soon as Tiberius heard this,
he went to Nerva's bedside and begged him to stop. Tiberius' arguments are interesting: it
would weigh heavily on him that he had known this, his reputation would be severely
damaged, if his most intimate friend escaped from life without any motive, wrote Tacitus1.
Panic in those days and ever since.
The argumentation of Tiberius also sounds familiar, although nowadays governments will
usually not phrase it so openly and clearly. Amid this panic surrounding a hunger striker,
it is the doctors' first duty to remain calm. He is expected to form a clear picture and
acquire knowledge of what happens during a hunger strike and what should be discussed with
the hunger striker.
Before we look at these aspects in
detail, it might be useful to mention some examples from the distant and recent past. The
seriousness of the problems will then become clearer. All possible reactions to hunger
strikes can be found: to ignore them completely (also by doctors); transport the prisoner
and just tell him during the transportation 'there are no hunger strikers", “we do
not recognize this”2; compel
doctors to force-feed a hunger striker; doctors who do so voluntarily; arrest and torture
of doctors who object3; let the hunger striker die without any concession of
the government4; imprison them, certify them insane; secretly video-tape the
physical examination in order to suggest to the outside world that the exiled hunger
striker is in good condition5; a doctor who refuses to give advice when
symptoms develop because his patients are on hunger strike6; a government that
releases hunger strikers from prison and re-detains them again once they have recovered a
little (suffragettes in England in 1913, according to the so-called “Cat and Mouse
Act")7; doctors giving injections; people who tie the prisoner; laugh at him.
A sad and dreadful gamut
A. What should the hunger striker know
about the doctor
The hunger striker should
be informed about the doctor concerned, his views, his willingness to follow him, so the striker can decide whether he wants to be
assisted by this doctor.
Independence of the doctor
Is he impartial in the
conflict?
Does he consider the
hunger striker as his patient, independent of institutions or the authorities?
Is he completely
independent in-his actions?
Can he provide assistance
from a medical-ethical point of view?
What are the ethical
principles of his country, does he follow them?
Does he respect the
inviolability of the person?
Does he consider a hunger
strike a suicide?
Will he certify the
hunger striker insane and put him in a psychiatric hospital?
Will he surround him with
all the necessary medical care?
Will he inform him about
the course?
See also B; the questions
mentioned under A and B are of course related to each other.
B. What should the doctor know about
the hunger striker
The doctor should make an inventory of
the hunger strike and striker so as to inform the latter and make a decision about whether
he is willing and able to assist the person or group.
Intention
Is the hunger strike intended to be
limited or until death?
Does the strike concern refusal of
nourishment or also of fluid?
Is it one person or a group?
Does the hunger striker have confidence
in the doctor?
State of health
Are there any recent or past diseases?
Assistance
Does the hunger striker allow physical
examination, laboratory analysis of blood and urine, X-rays, measuring of weight, blood
pressure and pulse? Does he want the doctor to take action when complications arise, does
he want to take medication in those cases?
Does he agree the doctor should visit
him daily and inform him about the course?
Does he agree to hospitalisation if
necessary?
Should his relatives be informed?
Does he agree to intervention in case of
coma?
Is he willing to take salt and potassium
suppletion, possibly mineral water and
vitamins?
If relevant: does he want an
interpreter, does he want to choose one himself?
C. What the doctor should know about
the course of a hunger strike
It
is essential to know the course, because otherwise medical assistance is not possible. A
lack of knowledge will make it impossible for a doctor to keep the patient well-informed
and therefore to meet the requirements mentioned under A and B
Thirst strike as well
This cannot be continued
for more than a few days, one week at the most The physical condition will decline rapidly
and it is very hard to carry on the thirst strike. Mrs Emmeline.Pankhurst described her
own experiences in 1913 very clearly:
The hunger strike I have
described as a dreadful ordeal, but it is a mild experience compared with the thirst
strike, which is from beginning to end simple and unmitigated torture. Hunger striking
reduces a prisoner’s weight very quickly, but thirst striking reduces weight so
alarmingly that prison doctors were at first thrown into absolute panic of fright. Later
they became somewhat hardened, but even now they regard the thirst strike with terror. I
am not sure that I can convey to the reader the effect of days spent without a single drop
of water taken into the system. The body cannot endure loss of moisture. It cries out in
protest with every nerve. The muscles waste, the skin becomes shrunken and flabby, the
facial appearance alters horribly, all these outward symptoms being eloquent of the acute
suffering of the entire physical being. Every natural function is, of course, suspended,
and then poisons which are unable to pass out of the body are retained and sometimes there
is fever. The mouth and tongue become coated and swollen, the throat thickens, and the
voice sinks to a thready whisper.7
(PICTURE DID NOT SCAN –
caption follows:)
The suffragettes went on
hunger strike for their rights as political prisoners,. Force feeding was introduced in
1909 to break their spirits. Food was pumped down a gastric tube, which was passed through
the nose (photo) or mouth.
Risk groups
Risks groups include people who run the
risk of having complications at an early stage during a hunger strike, which may cause
problems regarding perseverance. This concerns people who suffered or still suffer from
certain diseases, like cardiovascular diseases, kidney diseases, diabetes mellitus,
epilepsy, gastric or intestinal haemorrhages, or people on medication.
Unknown kidney diseases may show at an
early stage and lead to severe complications and early death if no action is taken.
Women are more acidose-prone compared to
men and loose weight more quickly.
Duration
Literature provides the
duration in days before death occurred in 13 hunger strikers4,8,9; 45, 74, 79,
66, 59, 61, 61, 42, 69, 73, 59, 67, 61 This averages 63 days, variation 42-79 days.
Sixty days, or two months, should be regarded as the limit if no complications
occur.
A normally nourished man
has enough fuel for 80 days, even if he uses 2,000 calories a day. However, as hunger
strikes never last that long, it can be concluded that the adaptation mechanism fails.10
Weight loss
The following data on weight loss in
grams per day are known 4,10-12; 280, 680, 720, 318, 344, 333, 357, about 660
in the first week, then 269.
If we omit the 660 in the first week,
the mean is 412 g per day. This would mean a weight loss of 12 kg per month.
Another deduction; Beresford4
mentions weight loss in two hunger strikers: 11.3 kg in 32 days; 10 kg in 30 days. This is
about 10 kg a month.
The degree of weight loss does not
depend on the original weight. Rapid weight loss at the beginning is mainly caused by
water and salt loss. The degree of weight loss is also dependent on fluid intake and salt
use.
Fluid intake
It should be advised to drink 1 ½ to
2 l of water/tea a day. During the hunger strike, ingestion
of this amount of fluid may become increasingly difficult. If so, it should be discussed
whether intravenous fluid suppletion is acceptable to the striker. Non prisoners tend to
accept this more easily12.
Metabolic changes
In normal circumstances, brain tissue
can only use glucose for its energy supply. When fasting, the supply of glucose in the
body (liver) is exhausted after about three days, which would soon be fatal. However, an
adaptation mechanism becomes effective, which aims to make the energy last as long as
possible, preserve the brain metabolism, and spare the muscle tissue. Basically, the
adaptation of-the body includes the following:10
- gluconeogenesis from the glycerol
portion of fat and from amino acids (mainly alanine);
- decline in extracerebral glucose
use. This causes a decline in blood sugar during the first days, after that it remains
stable;
- the kidneys play an
important role in glucose production and nitrogen retention: urea is not the end product
but ammonia. As a result less water and nitrogen are lost;
- apparently, brain tissue
can use not only glucose but also ketone bodies for its energy supply. Insulin plays an
important role here, because this adaptation does not Occur in diabetic keto-acidosis.
Therefore hunger striking diabetics will soon meet severe problems
The degree of adaptation
cannot be predicted, so neither how long the
hunger strike can be continued. It is possible however, to note when adaptation fails and
the energy required for the brain metabolism is not available anymore. Mom information on
this subject will follow below,
Course
The following data were
compiled from several articles on fasting and hunger strikes4,8,10-13
The first week
The hunger strike is generally
tolerated well. There are only few risks provided that the fluid intake is sufficient.
Hunger pain and gastric spasms disappear after a few days, sometimes only after one or two
weeks. The blood sugar level drops initially (0.6-0.8 mmol/l) and remains stable on a
lower level. Physical exercise is possible. It is important to provide sufficient
possibilities to relax, like reading, music,
radio, visitors.
The first month
In due course, a number of changes
become important apart from the weight loss mentioned before, like orthostatic hypotension
and bradycardia. These impede mobility, causing dizziness and sometimes headaches, Fatigue
occurs more quickly, as well as muscular pain during small exertions, difficulties with
reading, decreased alertness. Decline of body temperature, some-times abdominal spasms or
hiccups.
After three weeks the condition may
have deteriorated to an extent that hospitalisation should be considered so as to enable
better and more specialised care.
NB.: Some symptoms mentioned below may
already occur in the first month. There are no general “rules”.
Sickness phase
The hunger striker starts to feel really
ill. The turning-point nearly always occurs around the 40th day.
It is striking that the author Franz
Kafka mentions exactly the same time limit in his story A Hunger Artist14
written in 1921-22. The story concerns a professional hunger artist, hired by an
impresario. He fasts and the people come to watch him. After 40 days the impresario wants
him to start eating again, because after that day the audience loses interest. Kafka's
story is remarkably correct we now know that after 40 days a hunger striker obviously
starts to feel ill. Therefore, it is increasingly embarrassing for the audience to look at
him.
The general feeling of
sickness can he accompanied by the following symptoms and signs: loss of hearing,
deteriorating eyesight, double vision and (in the final phase) even blindness, nystagmus,
ataxia, unclear speech, nausea, vomiting of bile, jaundice, dry scaly skin, decubitus, and
gingival, gastrointestinal, oesophageal haemorrhages.
The psyche remains clear
until the end. There is no mental deterioration, but concentration problems, difficulties
in formulating, apathy, mental lability. These symptoms are certainly also caused by
extreme fatigue.
The final phase
This is characterized by
euphoria, contusion, followed by coma and death. It all happens very fast: one should not
think there is time left to 'negotiate'. Death will occur within a few hours. So there is
no lime to lose. A decision concerning medical intervention must have been made before
this moment, a team of informed specialists as well as an ambulance should be ready.
The features of brain
damage (Wemicke‘s encephalopathy) and the risk to irreversible damage were described by
Frommel c.s.12.in one hunger striker on the 38th day: disturbances of eye
mobility, vertical nystagmus, mild tremor, ataxia, diminished tendon reflexes, subnormal
level of consciousness. At that moment intervention was started, with informed consent
acquired previously of the person concerned: intravenous feeding and suppletion including
vitamin B complex during three days. After six days he was able to feed him-self by mouth,
ataxia persisted for one month, dizziness for three months.
Complications
Although all symptoms mentioned above
are complications, the following symptoms
suggest additional risks in an early stage: decline of kidney function, gastric
haemorrhage hypokalaemia, convulsions, delirium.
Diagnostics during a hunger strike
What should a doctor know in order to be
able to assist a hunger striker and keep him informed about the course? The enumeration
below only lists the most necessary items. During the hunger strike it will become clear
what else is needed.
The original values are very important
and should be recorded in the medical file at the onset.
Daily:
Measure weight, blood pressure, pulse.
Physical examination depending on symptoms.
Weekly or depending on symptoms and
abnormalities:
Laboratory:
- blood: glucose, sodium, potassium,
creatinine:
- urine: volume, reduction, ketone
bodies, if necessary 2~hour excretion of e.g. sodium (in hospital).
The decision about specialised treatment
in hospital depends on the physical signs. Consultation of the confidence doctor should
continue in hospital.
Artificial feeding
All
hunger strikers, from suffragettes at the beginning of this century to recent prisoners in
Morocco3, experience and describe this as torture.15 The same
applies to bystanders, e.g. Daily Mail correspondents, who resigned in 1909 because they
did not agree with the newspaper's policy. “We cannot denounce torture in Russia and
support it in England" they wrote to the Times7.
It
also applies to the doctors involved. In 1912, doctors in England offered resistance to
their role in force-feeding imprisoned suffragettes on hunger strike. In 1974, doctors did
the same with regard to force feeding tour Irish prisoners including the Price sisters. In
both cases, they published articles about the dangers. They were supported by the British
Medical Association and in 1975 also by the World Medical Association (Declaration of
Tokyo). Strikingly, the doctors' motives in 1912 were not different from those in 1974,
the journals in which they published their articles were also the same (The Lancet and
British Medical Journal).16,.17-20 Doctors wrote to the British Medical
Association that the same force-feeding methods were used in 1912 and 1974.21
This
makes one wonder whether doctors tail to learn from the past, because both in 1912 and in
1974 the doctors only decided they did not want to force-feed anymore when the procedure
had appeared to be extremely risky. By the way, the risk had not changed either over the
62 years: death due to aspiration pneumonia, gastritis, asphyxia, arrythmia.
A
different matter is that there are no data showing that doctors who proceeded to
force-feed acted medically adequate, because the condition of the saved hunger striker was
not exactly perfect after “the treatment". They were seriously emaciated, tired,
exhausted.2
An
example is a prisoner in the United States who went on hunger strike four times in 250
days. Each time he was force-fed after a few days, and than started to eat voluntarily
again. Still, emaciation was serious: a total weight loss of 14 kg.13
Apart from the medical-ethical issue
about the violation of the rights of a person by applying force-feeding, it can be stated
that medical practice shows that the method, to put it euphemistically, cannot be
considered a perfect treatment.
Convalescence
When the hunger strike is terminated,
a period of recovery begins. Depending on the duration of the hunger strike, the
convalescence period will be short (for example after only one week without nourishment)
or months if the hunger strike lasted much longer. In case of a duration longer than three
weeks, a convalescence of about three months should be expected. Only then 85-95% of the
original weight is regained.
Severely undernourished people are
usually able to take in food orally rather quickly, sometimes already after a couple of
days. However, assistance remains necessary. Immediately after the termination of a hunger
strike, one should be careful not to give too much carbohydrates, especially if there was
no supplement of salt during the hunger strike. The resulting rapid increase in weight is
not formation of tissue but mainly water. An example is the three prisoners, belonging to
the German "Rote Armee Fraktion", who went on a 44day hunger strike in 1978 in a
Dutch prison. During the first three days of refeeding, each person gained 3 kg. This is
obviously too much.
The
doctor’s responsibility does not stop when the hunger strike ends. Guidance should be
continued for a few months, not every day but
for instance weekly. Not only physical care is of importance, especially psychosocial
guidance is often still as necessary as it was during the hunger strike.
Recent
literature does not provide any data, because, understandably, ex-hunger strikers do not
write about it. A description from the past is that by Vera Fichner from tsarist Russia, late 1900. The hunger strike was ended, because
not all prisoners agreed to continue. After this, Fichner collapsed completely:
But
though my system did not succumb to the great test during the actual fast, the
after-effects were terrible. In addition to my mental depression, my nerves were
completely disorganised; every controlling centre refused to act In many ways my
will-power seemed not to have become weakened, but to have disappeared entireIy.6
I
know I have only discussed some aspects of a hunger strike. Hopefully, every doctor who
becomes involved will find information in this outline which may improve professional
assistance both practically and medically as well as psychosocially, and not only during
but also after the hunger strike, it - as all doctors hope for - it can be terminated in
an acceptable way for the person concerned
Literature
1. Tacitus.
Jaarboeken [Annals]. Vertaling, inleiding en aantekenin gen. J.W.
Meijer. Ambo, Baarn, 1990.
2.
Martsjenko A. Van Taroesa naar
Tsjoena [From Tarousa to Chouna]. Translation S. Visser. van Oorschot, Amsterdam, 1976.
3. Raat
A M. Hunger strikers in Morocco. Lancet 1989, 2, 982-983
4. Beresford
D. Ten men dead. The story of the 1981 Irish hunger strike. Grafton Books, London, 1987.
5 Sakharov.
The videos. Index on Censorship 1986, 15, nr 2, 37.
6. Fichner V.
Memoirs of a revolutionist (1927). Reprinted by Greenwood Press, New York, 1968.
7. Mackenzie
M. Shoulder to shoulder. A documentary. Penguin Books, 1975.
8. van Geuns
H A, Lachinsky N, Menges L J, Smeulers J. Hongerstaking [Hunger strike]. Wereldvenster,
Baarn, 1977.
9. Force-feeding
in prison. Brit Med J 1976, 4, 82~824 (Medico-legal).
10. Saudek C D,
Felig P J. The metabolic events of starvation. Am
J Med 1976,60, 117-126.
11. Romme M A J, van Ree
F, van Aalderen H J, Sacksioni J, v.d. Hout P. Hongerstaking. Een casuistische mededeling.
[Hunger strike. A case report.] Med Contact 1978, 33, 793-799.
12. Frommel D, Gautier M,
Questriaux E, Schwarzenberg L. Voluntary total fasting: a challenge for the medical
community. Lancet 1984,1. 1451-1452.
13. Miller W P. The
hunger-striking prisoner. J Prison & Jail Health 1987,6, no1,40-61.
14. Kafka Franz. Em
Hungerkunstler (1921-22) IA Hunger Artist]. Fischer. Frankfurt a/M, 1961.
15. Lytton Lady Constance.
Prisons and prisoners. Experiences of a suffragette (1914). EP Publishing Limited,
Wakefield, 1976.
16. Forcible
Feeding. Brit Med J 1974,1.653 (Medical news).
17. Force-feeding in
prisons. Brit Med J 1974, 2, 513 (Parliament).
18. Moore M. Force
feeding of prisoners. Lancet 1974, 1,1109
(letter).
19. Prisoners on
Hunger Strike. Lancet 1974, 2, 233 (Parliament).
20. Dwangvoeding van
hongerstakende suffragettes [Force feeding in hunger-striking suffragettes]. Bladvulling
Nededands Tijdschrift voor Geneeskunde 1981, 125,1691. Reprint
of the column on foreign news, Nederlands Tildschrijftvoor Geneeskunde 1912,56. 11,218.
21. The participation of
doctors in human rights abuses. In-. Medicine Betrayed. British Medical Association/Zed
Books, London. 1992, 119~149.
V.
The "doctor of confidence"
The
role of a doctor involved in a hunger strike is usually not limited to his specific
expertise. The dependent position in which most hunger strikers, like asylum seekers and
prisoners, find themselves implies that the relationship between the hunger striker and
his doctor is not necessarily based on trust. After all, the doctor is often employed by
the authority the hunger striker is opposing. It will not always be understandable to
refugees, often coming from countries with repressive and violent governments, that their
doctor is employed by the government, which is in conflict with the hunger strikers. The
conflict between the interests of his patient and those of his employer can also cause
difficulties for the doctor (see also contributions by Smeulers and Gevers).
It
needs no explanation that hunger strikers need medical attention and treatment, which can
be provided by the Medical Officer of the detention facility or the health authority
responsible for asylum seekers.
In
some cases it may be advisable to appoint a 'doctor of confidence' who is completely
independent from any authority such as the Prison Administration or the Government
Department responsible for refugee matters.
The
feasibility of such an appointment and the decision of which doctor to invite depends much
on the conditions of the country involved, the legal regulations and the preference of the
hunger striker, who ultimately has to decide. Experience in the Netherlands has learned
that suitable 'doctors of confidence usually are general practitioners and public health
doctors (e.g. from a District Health Authority) who have sufficient independence.
(PICTURE DID NOT SCAN –
caption follows:)
Group
of Vietnamese refugees, participating in a mass hunger strike of 180 Vietnamese refugees
in protest against extradition (The Netherlands 1991) Photo: Rob Huibers
Conditions
for the proper functioning of a 'doctor of confidence' are:
1
- Total medical independence.
This implies: freedom to treat for the
benefit of the hunger striker(s); organizational and informative freedom, also with
respect to the management and staff of the organization the doctor is working for. This
independence should be unquestionable, which is especially important if the organization
(also) has a different and potentially conflicting relationship with the hunger striker.
2
- Willingness of the hunger striker to trust this doctor.
A confidence doctor does not necessarily
agree with the aim of the hunger strike. He takes up a neutral position. However, this
doctor promotes the medical and social interests. This also means that he will encourage
communication: open contacts with the management (of asylum seekers centre or
penitentiary) and media, receiving visitors and mail, good contacts with legal
representative.
3
- Coping with dilemma's.
The 'doctor of confidence' should be
aware of and fully accept the very difficult, at time emotional and time-consuming
involvement which his job may require. This involvement implies solving ethical dilemma's,
providing empathy while shunning political identification, showing creativity in contacts
with legal advisers, authorities and media, and withstanding pressure to give in to
political pressure.
VI. Guidelines for medical
and nursing support
1.
Make sure the communication with the hunger striker is optimal. If necessary, call in an
independent interpreter.
2.
Assess whether a confidence doctor is needed, whose independent position should be
stressed.
3.
Try to get a clear picture of the cause and the objective of the hunger strike. Is it also
a thirst strike? How long do they want to continue the strike? Have they been engaged in a
hunger strike before, for example in the country of origin, if so, was it successful?
4.
Is it a group strike? If so, is there a spokesperson? Are there any relatives?
Are there any minors or
pregnant women?
Does the group allow the
individual hunger striker to make his own decision? (Important to talk to everyone
individually).
5.
The non medical interests can be taken care of by another agent: the lawyer or a
representative of an organized interest group.
6.
Suggest that this agent is always present when the hunger striker talks to the authorities
opposed by the action or the media. Establish that this agent will act on behalf of the
hunger striker, if the latter has become mentally incapable.
7.
As a doctor, provide information on the mental and physical consequences of a hunger
strike as soon as possible but no later than the third day, and in case of a thirst strike
on the first day. A confidence doctor should have been appointed by then (if the hunger
striker wishes so). See chapter II for more information.
If the doctor of the
refugee centre or detention facility is absent, the medical service of the institution
(e.g. nurse) should call in a locum. This applies especially when risk factors (see 8)
exist or in case of a thirst strike.
The importance of
sufficient fluid intake (2 I/day) and good physical care should be stressed.
8.
Determine whether there are any risk factors like diabetes, epilepsy, gastric disorders. A
hunger strike can also be discouraged on strictly medical grounds in pregnant women or
children.
9.
Stress the importance of good medical and nursing support and make clear arrangements
about it. This applies to physical examination, laboratory analyses, use of medicines and
vitamins. Is only intravenous fluid suppletion accepted or also drip feeding?
10. It is sensible to make
arrangements in an early stage about what should be done if the physical condition
deteriorates or if the hunger striker lapses into coma.
Preferably, these arrangements should be
put in writing.
If the hunger striker indicates not to
accept artificial feeding -including forced feeding - or any medical treatment until the
aim is achieved, it is necessary to point out that you cannot make such an important
decision on your own. According to the guidelines (Declaration of Tokyo) you should insist
on the opinion of an independent other doctor (the 'second opinion'). If the mental
capacity of the hunger striker is doubted, a judgement of a psychiatrist is required at an
early stage
A model for a 'statement of
non-intervention' is provided in chapter VII.
It is important to note that the
doctor's professional secrecy applies to such a 'statement of non-intervention'. If a
doctor wants this statement to be known to others, he requires the permission of the
hunger striker. One should be particularly aware of this when dealing with the press and
media (see 5: contact with the media by a non medical agent).
As the 'statement of non-intervention'
is meant to be used when the hunger striker is not able to express his own will anymore,
it is inherent to the statement that, if necessary and when the hunger striker is in coma,
the statement can be made public by the doctor of confidence. This is inevitable in order
to reach the purpose the hunger striker aims for by means of the statement.
11. The 'statement of non-intervention'
should regularly be evaluated in consultation with the hunger striker to allow changes
(which may well occur due to circumstances or change of will).
12. Visit the hunger striker at least
daily, pay attention to his physical condition. Parameters such as weight, fluid balance
and blood pressure can also be determined by a nurse.
When and which laboratory analyses
should be done, depends on the condition and pathology of the person concerned before the
hunger strike began (especially disorders of the kidney functions). See chapter III for
more information. If necessary, a local internist should be consulted.
A detailed medical file should be kept
as well as a nursing report.
13. If a hunger strike lasts longer than
for example one week, it is advisable to inform your colleagues (including locums, other
GP's and specialists in the local hospital) about the strike.
14. If the doctor of confidence is not
the hunger striker's GP, inform the latter - with permission of the hunger striker - about
the course of the strike.
Indications for hospitalisation
Firstly, it is important that the
decision to hospitalise the hunger striker is made according to his wish. Therefore, it
should be timely discussed.
The following parameters can be examined
in a non clinical setting and each may give cause for hospitalisation:
-
weight loss of more than 10% of the original weight (more in people with extra reserves)
-
disorders in consciousness/psychological decompensation
-
signs of heart failure (dyspnoea, oedema)
-
signs of severe dehydration and kidney failure:
- orthostatic hypotension (difference in systolic
pressure between recumbent and standing position of more than 25 mmHg)
-
severe hypothermia: less than 35.5oC
-
severe bradycardia: less than 35/mm, or irregular pulse
What to do after the hunger strike
15. Advise on refeeding: small frequent
portions of easily digestible food, about 3,000 kcal a day.
16. Evaluate the hunger strike with the
hunger striker. Repeat this after for instance one week (depending on the mental condition
and the "result" of the hunger strike).
It is up to the doctor of confidence to
decide about the desirability of a written statement in which the doctor states that he
refuses to accept liability for any permanent damage in the hunger striker. A doctor of
confidence in Germany has been charged to be responsible for sustained damages. The legal
status and desirability of such a statement depends on the situation and the legal
circumstances in the country concerned.
Such a statement formulated by a doctor
still does not protect him against all liability. The concrete actions of a doctor will
still be essential. It seems to be more important to act according to the professional
standards and to report everything in a file, than to have a statement as mentioned above.
If the damage results from a mistake by
a doctor, he is responsible, with or without a statement.
In the case of death of the hunger
striker, it is an unnatural death. Therefore, postmortem examination should be performed
by a medical examiner or the coroner. In general autopsy will not be necessary if all
medical data are recorded.
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
2.1
A doctor should acquire a detailed medical history of the patient where possible.
2.2
A doctor should carry out a thorough examination of the patient at the onset of the hunger
strike.
2.3
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.
2.4
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.
2.5
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.
2.6
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 patient wishes to continue should also ascertain on a are with
regard to treatment on a daily basis whether or not the with his hunger strike. The doctor
daily basis what the patient's wishes should he become unable to make an informed
decision. These findings must be recorded in the doctor’s 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. |