The brief hunger strike of security prisoners in Israel several months ago prompted the IMA Ethics Bureau to address the status and role of doctors charged with professional responsibility for the health of hunger strikers.
Naturally, this is a highly sensitive social issue in which lofty values of respect of an individual’s right over his body clash with political, national or religious positions and the desire to prevail over the hunger striker at any price. The medical ethics question is exacerbated since, in most cases, the issue pertains to prisoners whose freedom has been denied. The dilemma is further heightened in Israel because the principle of “the sanctity of life” takes precedence, in some parts of Israeli society, over any other value, including individual freedoms. In 1996, in response to a request by the State, Judge Sirota permitted force-feeding of a group of hunger strikers comprised of followers of Uzi Meshulam. In this case the court deviated from the accepted bio-ethical approach in the West. In the inevitable clash between violating the prisoners’ dignity on the one hand and keeping them alive by force on the other hand, the court chose in favor of the right to life (Judgment 829/96-A, from 9.5.1996).
Force-feeding of hunger strikers is considered to be a form of torture. The World Medical Association’s (WMA) 1975 Tokyo Declaration prohibiting the participation of doctors in the practice of torture also prohibits doctors’ involvement in force-feeding.
Dramatic events in several countries – Ireland, Turkey and South Africa for example – in which hunger strikers died as a result of their prolonged strike, prompted the WMA to formulate the 1992 Madrid Declaration, dedicated in its entirety to the role and responsibility of doctors caring for hunger strikers.
At the end of their discussion on the issue, the members of the IMA Ethics Bureau adopted, with minor changes, the main points of the 1992 Madrid Declaration.
1. A hunger striker is a mentally competent individual who has indicated his desire to refuse to take food and/or fluids for an unlimited period of time, with the knowledge that this could cost him his life.
2. The doctor must receive a comprehensive detailed medical history of the hunger striker and carry out a thorough medical examination at the onset of the hunger strike.
3. The doctor must inform the hunger striker of the risks involved in such a strike, including the risk that the strike may cost him his life.
4. The doctor must inform the hunger striker whether he will be willing to accept the latter’s request to refuse food and/or liquids, including intravenous feeding should the hunger striker lose consciousness.
5. A doctor may not apply any kind of pressure with the aim of dissuading the hunger striker from continuing the strike.
6. A doctor will not participate in force-feeding a hunger striker.
7. A hunger striker is entitled to request a second medical opinion and is entitled to request that the second doctor will be responsible for his continued treatment. In the case of an incarcerated hunger striker, the matter will be coordinated with the prison doctor.
8. The doctor is entitled to offer the hunger striker the option of continuing to receive medication if the striker received medication prior to the hunger strike, as well as the option of receiving fluids during the hunger strike.
9. A doctor is entitled to demand, in cases of coercive participation, to remove the hunger striker from the presence of fellow strikers.
10. The doctor should ascertain on a daily basis whether or not the patient wishes to continue with his hunger strike and that this decision was made of his own free will and without external pressure of any kind.
11. The doctor should also ascertain on a daily basis how the hunger striker wishes to be treated should he lose consciousness and is unable to make an informed decision. These findings must be recorded in the doctor’s medical records and kept confidential.
12. Should a hunger striker lose consciousness and is no longer able to express his free will - the doctor shall be free to decide, based on his best judgment, how to continue treatment of the hunger striker, keeping the latter’s best interest in mind and taking into consideration the hunger striker’s wishes and desires as he expressed them during the strike.
13. The doctor has a responsibility to inform the hunger striker’s family that the individual embarked on a hunger strike, unless this is specifically prohibited by the hunger striker himself.