The vital issues surrounding independent medical assessment of hunger strikers and force-feeding are discussed in the lead Editorial in this week's edition of The Lancet. The Editorial is tied to the publication later this month of guidelines for the clinical management of hunger strikers in detention settings and prisons, by the Offender Health section of the UK Department of Health (DH). While this publication is awaited, the draft guidelines are published on www.thelancet.com.
The clinical management of hunger strikers is complicated because of the starvation-induced effects of electrolyte imbalance, vitamin and mineral depletion, infection, hypothermia, and renal failure. An understanding of the physiology, and how best to manage the changes, is essential. Those hunger strikers who agree to some supplements need different care, as do those who agree to refeeding, which can lead to Wernicke-Korsakoff syndrome. The Department of Health guidelines cover all aspects of the clinical management and also the legal framework for the UK, where detainees have the right to refuse food and drink, and force feeding a mentally competent person is illegal.
Food refusal used as a form of protest against prison conditions, to access justice, or to make political demands may be a prisoner's only weapon. Usually, hunger strikers do not aim to die, but some are prepared to do so if their demands are not met, putting doctors in a difficult position faced with preventable death. Force feeding was commonplace in many countries, and is still used in Guantánamo Bay. In a 2006 issue of The Lancet, force feeding of Guantanamo Bay hunger strikers was condemned by David Nicholl and 250 leading international medical colleagues. Force feeding continues at Guantánamo's hospital despite its prohibition by the World Medical Association (WMA) in Declarations, to which the American Medical Association is a signatory, and despite the provisions of the Geneva Conventions.
The Editorial criticises the lack of emphasis given in the DH graft guidelines to the critical importance of access to a doctor who can offer impartial, independent, and expert advice and care to hunger strikers. An independent physician, whom the striker trusts, and who explains the risks and effects of fasting, can lead to a change of intent. In other cases, assistance with writing advance directives can allow the striker's wishes to be carried out should mental capacity become impaired.
The Editorial concludes: "There is a clear and urgent need for guidelines on the clinical management of hunger strikers to be disseminated to all medical workers who may need them, and for the guidelines to be followed. Crucially, independent medical assessment of hunger strikers must become a routine part of their care. Prisoners or detainees who choose to become hunger strikers are entitled, worldwide, to the highest clinical standards of care available. Force feeding has no place in that care."
The Lancet Press Office T) +44 (0) 20 7424 4949 E) pressoffice@lancet.com
Full Editorial: http://press.thelancet.com/forcefeeding.pdf
Journal
The Lancet