Role of doctor in hunger strike

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PMID: 30115194

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https://www.wma.net/policies-post/wma-declaration-of-malta-o…

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Here is a thorough breakdown of the doctor's role in a hunger strike, drawing from the WMA Declaration of Malta (the primary international guideline), forensic medicine textbooks, and peer-reviewed evidence.

Role of a Doctor in a Hunger Strike

What Is a Hunger Strike?

A hunger strike is the deliberate refusal of nutrition as a form of passive resistance - typically used by prisoners, detainees, or political activists to protest against conditions or achieve a specific demand. It is distinct from suicidal starvation, religious fasting, or psychiatric refusal to eat, though each requires its own evaluation.

Governing Framework: WMA Declaration of Malta

The primary international guidance is the WMA Declaration of Malta on Hunger Strikers (first adopted 1991, revised 2006). It establishes the following core principles for physicians:

1. Duty to Act Ethically

All physicians are bound by medical ethics when dealing with hunger strikers, even if they are not providing active therapy. The physician must:

Prevent coercion or maltreatment of detainees
Protest if coercion or maltreatment occurs
Maintain their role as a healer, not as an instrument of authority

2. Assess Competence and Voluntariness

Before any clinical or ethical decision is made, the physician must determine:

Whether the hunger strike is voluntary and free from coercion (peer pressure from fellow inmates, family pressure, or institutional intimidation can undermine true autonomy)
Whether the person has decision-making capacity to understand the consequences of fasting
The true motivation behind the strike: political protest, psychiatric illness, or coercion by others?

As noted in Kaplan & Sadock's Comprehensive Textbook of Psychiatry (the leading psychiatric textbook): "The correctional psychiatrist must be available to evaluate such an inmate's psychiatric condition and whether there [is capacity to understand the medical decisions being made]."

3. Respect for Autonomy (vs. Beneficence - the Core Tension)

This is the central ethical dilemma. The physician faces a conflict between two core principles:

Principle	Implication
Autonomy	Competent individuals have the right to refuse treatment, including nutrition
Beneficence / Non-maleficence	The doctor has a duty to preserve life and health

The WMA Declaration of Malta decisively prioritizes autonomy for competent individuals:

Hunger strikers must not be forcibly given treatment they refuse
Forced feeding contrary to an informed and voluntary refusal is unjustifiable and constitutes a human rights violation
The physician must respect a competent advance directive ("living will") even if the striker later becomes incompetent

A 2018 systematic review (Gulati et al., Irish Journal of Psychological Medicine) covering 23 papers from 12 jurisdictions concluded: "there seems to be an overall consensus favouring autonomy over beneficence, though tensions are magnified where legislation creates dual loyalty conflicts."

4. Monitoring and Medical Care

The physician has a positive duty to provide ongoing medical monitoring, regardless of any ethical disagreement about the strike itself:

Regular clinical assessment: vital signs, weight, hydration status, electrolytes, blood glucose, renal function
Document findings objectively
Advise on the medical risks and consequences of continued fasting (so the striker can make a truly informed decision)
Watch for refeeding syndrome if feeding resumes after prolonged starvation

From forensic medicine: "Loss of weight and acidosis with ketone bodies in urine are the criteria to advise forced feeding" in jurisdictions where forced feeding is legally sanctioned - Essentials of Forensic Medicine & Toxicology, 36th ed.

5. Force Feeding - Legal vs. Ethical Distinction

This is a major area of controversy:

International ethics (WMA Malta): Force-feeding a competent, voluntarily fasting person is unethical and constitutes cruel, inhuman, and degrading treatment. Physicians must not participate.
Indian law / some legal systems: Article 21 of the Indian Constitution guarantees the right to life but does not include a right to die, so arrest and forcible feeding of hunger strikers is held to be lawful under Indian jurisprudence. This creates a direct conflict between the physician's legal obligation and ethical duty.
WMA Declaration of Tokyo (Tokyo Declaration): "Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such voluntary refusal, he/she shall not be fed artificially."

When is artificial feeding ethically acceptable?

When the hunger striker explicitly consents to it
When the striker becomes incompetent (e.g., semi-comatose) and had left no unpressured advance directive refusing it
When the physician has strong clinical grounds to believe the striker does not truly intend to die (the "manipulation/blackmail" scenario recognized by the WMA)

6. Dual Loyalty Conflict

Physicians - especially those working in prisons or detention centers - face pressure from:

The employing authority (prison administration, government) pushing for intervention
The patient's rights which require respecting autonomy

The WMA is unequivocal: the primary obligation is always to the individual patient, not to the employer or state. The physician must remain clinically independent and resist pressure to breach ethical principles for non-clinical reasons.

7. Right to Conscientious Objection with Referral

If a physician, for reasons of conscience, cannot abide by a hunger striker's refusal of treatment or artificial feeding:

They must make this clear at the outset
They must refer the striker to another physician willing to respect that refusal
They cannot simply abandon the patient

8. Communication and Documentation

Provide the striker with clear information about medical risks so they can make an informed decision
Explain any proposed interventions
Document all assessments, the striker's stated wishes, and any advance directives
This documentation protects both the patient's rights and the physician's legal position

9. Role of the Correctional Psychiatrist (Specific Context)

As outlined in Kaplan & Sadock's Comprehensive Textbook of Psychiatry:

Assess psychiatric diagnosis: Is the refusal driven by depression, psychosis, or a personality disorder rather than rational political protest?
Assess motivation: Collective strikes may involve peer pressure, negating genuine voluntariness
Assess capacity: Can the person truly understand the consequences of their actions?
Treat underlying psychiatric illness if present, which may change the clinical picture
Must not participate in executions or other activities that harm the patient

Summary Table

Physician's Duty	Requirement
Ethical conduct	Bound by medical ethics regardless of setting
Assess voluntariness & capacity	Mandatory before any intervention
Respect autonomy	Do not force-feed a competent, voluntary faster
Provide medical monitoring	Ongoing - vital signs, labs, nutritional status
Advise on risks	Inform the striker fully
Dual loyalty	Primary duty is to the patient, not employer
Conscience clause	Must disclose objections and arrange referral
Document	All decisions and advance directives
Psychiatric evaluation	For motivation, capacity, mental illness

Key Reference Points

WMA Declaration of Malta (2006 revision) - the global standard
WMA Declaration of Tokyo - prohibits artificial feeding of a competent refuser
Kaplan & Sadock's Comprehensive Textbook of Psychiatry - correctional psychiatry guidelines
Essentials of Forensic Medicine & Toxicology (36th ed., 2026) - Indian legal perspective
Gulati et al. 2018 Systematic Review - PMID 30115194, evidence-based review across 12 jurisdictions
Gétaz et al. 2012, Swiss Medical Weekly - PMID 22987064, practical guidance for good medical practice

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