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 strikers^4,8,9; 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 strikes^4,8,10-13

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 35.5^oC

- 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.