Skip to main content
SpringerLink
Log in

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

  • Published:
Theoretical Medicine and Bioethics Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  1. Even though there are no available data to support this claim; thousands of detainees have gone on a hunger strike in the last few years in countries like the US, the UK, Turkey, Israel, and Iran, but only a very limited number of hunger strikes were reported to have reached a life threatening level for the participants, and even fewer cases were reported to have had fatal consequences.

  2. See Brockman [15] for a discussion of various motivations behind food refusals in prisons based on actual case examples.

  3. This is not to deny that there are cases where prisoners attempt suicide by starvation. Even in such cases forcible feeding is not necessarily justified, as it is arguably permissible for competent adults to inflict self-harm [15]. Since my discussion here is limited to a particular form of food refusal, namely, hunger strikes, I will ignore the relevant questions about starvation as a method of suicide. The point I make here is that a food refusal as an attempt at suicide is not a hunger strike.

  4. See, for instance, the most recent collective hunger strikes in Turkey by Kurdish prisoners [4].

  5. More than 30,000 inmates joined the hunger strike shortly after it was initiated on July 8, 2013 [20].

  6. Allen and Reyes [22] propose the following actions that might help physicians working in prison settings to build such trust: maintaining effective communication between a caring and competent provider and the patient, respecting the dignity of the patient, guaranteeing clinical autonomy of health professionals, respecting privacy and confidentiality, transparency of process, use of independent clinicians for second opinions, careful consultation with trusted counsellors, possibly clergy, and others towards the goal of building trust.

  7. There are a few examples that illustrate how the involvement of outside doctors might be beneficial [12, 26, 27].

  8. There are very difficult problems about getting written directives from hunger strikers that I cannot get into in this article due to the limited space.

  9. See Altun et al. [31] for some examples.

  10. I would like to thank an anonymous referee for bringing this up.

References

  1. Laxmidas, Shrikesh. 2013. Angola teenager held for insulting president starts hunger strike. Reuters, November 6. http://www.reuters.com/article/2013/11/06/us-angola-youth-idUSBRE9A50PP20131106. Accessed Nov. 2014.

  2. Iranian prisoners launch hunger strike. 2013. Al Jazeera, November 5. http://www.aljazeera.com/news/middleeast/2013/11/iranian-prisoners-launch-hunger-strike-2013115143246356619.html. Accessed Nov. 2014.

  3. Bigg, Claire, and Natalya Dzhanpoladova. 2013. Defendant in Russia’s “Bolotnaya” case on hunger strike for 50 days. Radio Free Europe, November 6. http://www.rferl.org/content/bolotnaya-krivov-feature/25160206.html. Accessed Nov. 2014.

  4. Kurdish mayor on hunger strike against “wall of shame.” 2013. AlJazeera, November 5. http://stream.aljazeera.com/story/201311052100-0023166. Accessed Nov. 2014.

  5. California prison hunger strike: 30,000 inmates refuse meals. 2013. Huffington Post, July 9. http://www.huffingtonpost.com/2013/07/09/california-prison-hunger-strike-30000_n_3567639.html. Accessed Nov. 2014.

  6. Reilly, Ryan J. 2013. Guantanamo Bay hunger strike numbers grow. Huffington Post, April 15. http://www.huffingtonpost.com/2013/04/15/guantanamo-bay-hunger-strike_n_3087299.html. Accessed Nov. 2014.

  7. Jones, Sophia. 2012. More than 700 Kurdish prisoners now on hunger strike in Turkey. NPR, October 24. http://www.npr.org/blogs/thetwo-way/2012/10/24/163569699/more-than-700-kurdish-prisoners-now-on-hunger-strike-in-turkey. Accessed Nov. 2014.

  8. World Medical Association. 2006. WMA declaration of Malta on hunger strikers. http://www.wma.net/en/30publications/10policies/h31/. Accessed Nov. 2014.

  9. Johannes Wier Foundation for Health and Human Rights. 1995. Assistance in hunger strikes: A manual for physicians and other health personnel in dealing with hunger strikers. Amersfoort: JWFHHR.

    Google Scholar 

  10. Reyes, Hernan. 2007. Force-feeding and coercion: No physician complicity. Virtual Mentor 9(10): 703–708.

    Article  Google Scholar 

  11. Annas, George J. 2006. Hunger strikes at Guantanamo: Medical ethics and human rights in a ‘legal black hole’. New England Journal of Medicine 355: 1377–1382.

    Article  Google Scholar 

  12. WMA declaration of Malta—a background paper on the ethical management of hunger strikes. 2006. World Medical Journal 52(2): 36–43.

  13. Golden, Tim. 2006. Tough US steps in hunger strike at camp in Cuba. New York Times, February 9. http://www.nytimes.com/2006/02/09/politics/09gitmo.html?adxnnl=1&pagewanted=all&adxnnlx=1319382300-2wj4k4Ay0XrcJcjLc/7pKA. Accessed Oct. 2014.

  14. Frommer, Frederic J. 2013. Judge rejects effort to end Guantanamo force-feeding. Huffington Post, July 16. http://www.huffingtonpost.com/2013/07/16/guantanamo-force-feeding_n_3605247.html. Accessed Oct. 2014.

  15. Brockman, Bea. 1999. Food refusal in prisoners: a communication or a method of self-killing? The role of the psychiatrist and resulting ethical challenges. Journal of Medical Ethics 25: 451–456.

    Article  Google Scholar 

  16. Woman jailed in Iran for attending volleyball match on ‘dry’ hunger strike. 2014. The Guardian, November 4. http://www.theguardian.com/world/2014/nov/04/ghoncheh-ghavami-jailed-iran-volleyball-match-hunger-strike. Accessed Nov. 2014.

  17. Crosby, Sondra S., Caroline M. Apovian, and Michael A. Grodin. 2007. Hunger strikes, force-feeding, and physicians’ responsibilities. Journal of the American Medical Association 298(5): 563–566.

    Article  Google Scholar 

  18. Chowdhury, Mosiuddin A., and Robert Batey. 1996. Complications and outcome of percutaneous endoscopic gastrostomy in different patient groups. Journal of Gastroenterology and Hepatology 11(9): 835–839.

    Article  Google Scholar 

  19. Brown v. Plata, 131 S. Ct. 1910, 1923 (2011)

  20. Medina, Jennifer. 2013. Hunger strike by California inmates, already large, is expected to be long. New York Times, July 10. http://www.nytimes.com/2013/07/11/us/hunger-strike-by-california-inmates-already-large-is-expected-to-be-a-long-one.html?_r=0. Accessed Oct. 2014.

  21. Gross, Michael. 2015. Sanctity of life and the right to life: Force-feeding hunger strikers. In Autonomy, altruism and authority in medical ethics: A Feischrift in honor of Professor Shimon Glick, ed. Alan Jotkowitz, and Shifra Shvarts, 47–58. Hauppauge: Nova Science Publishers Inc.

    Google Scholar 

  22. Allen, Scott, and Hernan Reyes. 2009. Clinical and operational issues in the medical management of hunger strikers. In Interrogations, forced feedings, and the role of health professionals: new perspectives on international human rights, humanitarian law, and ethics, ed. Ryan Goodman and Mindy Jane Roseman, 189–204. Cambridge, MA: Harvard University Press.

  23. Glick, Shimon M. 1997. Unlimited human autonomy—a cultural bias? New England Journal of Medicine 336: 954–956.

    Article  Google Scholar 

  24. Gross, Michael. 2013. Force-feeding, autonomy, and the public interest. New England Journal of Medicine 369(2): 103–105.

    Article  Google Scholar 

  25. Annas, George J., Sandra S. Crosby, and Leonard H. Glantz. 2013. Guantanamo Bay: A medical ethics–free zone? New England Journal of Medicine 369(2): 101–103.

    Article  Google Scholar 

  26. Reyes, Hernan. 1998. Medical and ethical aspects of hunger strikes in custody and the issue of torture. In Maltreatment and torture, ed. M. Oehmichen. Lubeck: Verlag Schidt-Romhild. https://www.icrc.org/eng/resources/documents/article/other/health-article-010198.htm. Accessed June 15, 2015.

  27. Soyer, Ata. 2000. Açlık grevleri/ölüm oruçları, TTB ve son tartişmalar [Hunger strikes/death fasts, TMA and the recent discussions]. Toplum ve Hekim 15(6): 1–15.

  28. Fessler, D.M.T. 2003. The implications of starvation induced psychological changes for the ethical treatment of hunger strikers. Journal of Medical Ethics 29: 243–247.

    Article  Google Scholar 

  29. Kalk, W.J., M. Felix, E.R. Snoey, and Y. Veriawa. 1993. Voluntary total fasting in political prisoners: Clinical and biochemical observations. South African Medical Journal 83(6): 391–394.

    Google Scholar 

  30. Annas, George J. 1995. Hunger strikes. British Medical Journal 311: 1114–1115.

    Article  Google Scholar 

  31. Altun, Gurcan, Bulent Akansua, Betul Ugur Altun, Derya Azmak, and Ahmet Yilmaz. 2004. Deaths due to hunger strike: Post-mortem findings. Forensic Science International 146: 35–38.

    Article  Google Scholar 

Download references

Acknowledgments

I would like to thank Robin Fiore and two anonymous reviewers of Theoretical Medicine and Bioethics for their valuable comments and criticisms. This work was funded by a grant from the Arsht Ethics Initiatives at the University of Miami Ethics Programs and made possible by a generous gift from philanthropist Adrienne Arsht.

Author information

Authors and Affiliations

  1. Department of Philosophy, Boğaziçi University, 34342 Bebek, Istanbul, Turkey

    Nurbay Irmak

Authors
  1. Nurbay Irmak
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nurbay Irmak.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Irmak, N. Professional ethics in extreme circumstances: responsibilities of attending physicians and healthcare providers in hunger strikes. Theor Med Bioeth 36, 249–263 (2015). https://doi.org/10.1007/s11017-015-9333-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11017-015-9333-9

Keywords

Search

Navigation