Personal Views: Hunger striking prisoners: the doctors' dilemma
Authors: Bernadette Gregory
Journal: BMJ (2005)

News of further hunger strikes and force feeding at Camp X-Ray, the temporary US detention centre at Guantanamo Bay, Cuba, again brings into sharp relief the ethical debate on the position of doctors in a hunger strike by prisoners. A series of hunger strikes has occurred at the camp since it was opened, but they have gone largely unnoticed. What little coverage the media have given them seems to accept without question the right of prison authorities to force feed hunger striking prisoners against their will.

The World Medical Association, in its 1975 Declaration of Tokyo and again in the 1991 Declaration of Malta, prohibits the use of force feeding of hunger strikers. Details at Guantanamo Bay are predictably sketchy, but prison authorities seem to justify force feeding on the basis of preventing suicide. Any justification that is based on an assumption that a hunger strike is a form of prolonged suicide has been almost universally rejected. The aim of suicide is death. Hunger strikers do not want to die; they want to live. They want to live with a better quality of life—for instance through improvements in basic prison conditions, access to justice, or by making a political point for the greater good of society as they see it.


Doctors who participate in these practices need to examine their own consciences


For many prisoners food refusal is their only weapon, given their background of a lack of basic human rights and legal representation and deprived of any other forms of protest. It is often the only way of bringing their protest into the public domain. Pressure is exerted on the authorities only when prisoners are at the brink of death or when deaths have occurred. Prisoners may not want to die but recognise that their aims may be achieved only through death.

The US authorities may continue to assert that holding prisoners at Guantanamo Bay without charge or trial or full access to legal representation is not an abuse of human rights. However, they know that if prisoners at Guantanamo Bay die on hunger strike the world's attention will suddenly focus on the camp in a way that it has not done before. Force feeding the prisoners—using the excuse of preventing suicide—is a cynical way to ensure that prisoners will not die. The prisoners' last weapon of protest has been taken away, and the world continues to tacitly collude with the US version of human rights.

Doctors in these circumstances have a dilemma. Their immediate superiors and the government assert their right to prevent suicide and maintain health and security within their prisons. The doctors' inclination is also to prevent death, particularly in an otherwise healthy person. On the other hand international medical authorities—as well as prohibiting force feeding—also promote the right of the individual to self expression: to protest as they wish and, crucially, to assert the right to refuse medical treatment.

Fundamental to doctors' responsibilities in attending a hunger striker is the recognition that prisoners have the same right as any other patient to refuse medical treatment. The doctor must establish that the prisoner on hunger strike is making that decision freely and has the capacity to make the decision to refuse medical treatment. Satisfied of this, doctors must resist coercion to treat patients against their expressed will. Doctors may not agree with the aims of the prisoner or the steps the prisoner is taking, but they must respect the prisoner's informed decision. Doctors do not have to agree that a decision by a patient to refuse a blood transfusion or refuse chemotherapy for a potentially treatable cancer is sensible or rational, but in law they do have to respect that patient's informed decision, even if it results in death. So it must be with the decision of the hunger striker.

Some governments and authorities have respected this position and allowed hunger strikers to die. This most famously occurred in Northern Ireland in 1980 and 1981 when 10 prisoners died. In South Africa in the 1980s and Turkey in the 1990s doctors have stood out against their government's declarations to force feed hunger striking prisoners and have refused to treat them.

Let us be under no illusion as to what force feeding means. Anyone who has tried to pass a nasogastric tube or insert an intravenous infusion into an uncooperative and confused postoperative patient knows how grim that can be. Force feeding against someone's will must entail force, restraint, or sedation. It does not conjure up a pretty picture. Doctors who participate in these practices need to examine their own consciences. But we must also recognise that such situations are not easy. How many of us would stand up as individuals against our immediate superiors and our governments in such circumstances? It is therefore incumbent on those in the wider medical profession to open their eyes to the situation, to open the ethical debate again, and put the spotlight on the US and its treatment of prisoners at Guantanamo Bay.