WMA Declaration of Malta on Hunger Strikers

Adopted by the 43rd World Medical Assembly, St. Julians, Malta, November 1991 and editorially revised by the 44th World Medical Assembly, Marbella, Spain, September 199 and revised by the !"th WMA #eneral Assembly, $ilanesber%, South A&rica, 'ctober (()

PREAMBLE

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Hunger strikes occur in various contexts but they mainly give rise to dilemmas in settings where people are detained (prisons, jails and immigration detention centres). They are o ten a orm o protest by people who lack other ways o making their demands known. !n re using nutrition or a signi icant period, they usually hope to obtain certain goals by in licting negative publicity on the authorities. "hort# term or eigned ood re usals rarely raise ethical problems. $enuine and prolonged asting risks death or permanent damage or hunger strikers and can create a con lict o values or physicians. Hunger strikers usually do not wish to die but some may be prepared to do so to achieve their aims. %hysicians need to ascertain the individual&s true intention, especially in collective strikes or situations where peer pressure may be a actor. 'n ethical dilemma arises when hunger strikers who have apparently issued clear instructions not to be resuscitated reach a stage o cognitive impairment. The principle o bene icence urges physicians to resuscitate them but respect or individual autonomy restrains physicians rom intervening when a valid and in ormed re usal has been made. 'n added di iculty arises in custodial settings because it is not always clear whether the hunger striker&s advance instructions were made voluntarily and with appropriate in ormation about the conse(uences. These guidelines and the background paper address such di icult situations.

PRINCIPLES

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)uty to act ethically. 'll physicians are bound by medical ethics in their pro essional contact with vulnerable people, even when not providing therapy. *hatever their role, physicians must try to prevent coercion or maltreatment o detainees and must protest i it occurs.

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,espect or autonomy. %hysicians should respect individuals& autonomy. This can involve di icult assessments as hunger strikers& true wishes may not be as clear as they appear. 'ny decisions lack moral orce i made involuntarily by use o threats, peer pressure or coercion. Hunger strikers should not be orcibly given treatment they re use. -orced eeding contrary to an in ormed and voluntary re usal is unjusti iable. 'rti icial eeding with the hunger striker&s explicit or implied consent is ethically acceptable.

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&/ene it& and &harm&. %hysicians must exercise their skills and knowledge to bene it those they treat. This is the concept o &bene icence&, which is complemented by that o &non#male icence& or primum non nocere. These two concepts need to be in balance. &/ene it& includes respecting individuals& wishes as well as promoting their wel are. 'voiding &harm& means not only minimising damage to health but also not orcing treatment upon competent people nor coercing them to stop asting. /ene icence does not necessarily involve prolonging li e at all costs, irrespective o other values.

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/alancing dual loyalties. %hysicians attending hunger strikers can experience a con lict between their loyalty to the employing authority (such as prison management) and their loyalty to patients. %hysicians with dual loyalties are bound by the same ethical principles as other physicians, that is to say that their primary obligation is to the individual patient.

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2linical independence. %hysicians must remain objective in their assessments and not allow third parties to in luence their medical judgement. They must not allow themselves to be pressured to breach ethical principles, such as intervening medically or non#clinical reasons.

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2on identiality. The duty o con identiality is important in building trust but it is not absolute. !t can be overridden i non#disclosure seriously harms others. 's with other patients, hunger strikers& con identiality should be respected unless they agree to disclosure or unless in ormation sharing is necessary to prevent serious harm. ! individuals agree, their relatives and legal advisers should be kept in ormed o the situation.

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$aining trust. -ostering trust between physicians and hunger strikers is o ten the key to achieving a resolution that both respects the rights o the hunger strikers and minimises harm to them. $aining trust can create opportunities to resolve di icult situations. Trust is dependent upon physicians providing accurate advice and being rank with hunger strikers about the limitations o what they can and cannot do, including where they cannot guarantee con identiality.

GUIDELINES !R "HE MANAGEMEN" ! HUNGER S"RI#ERS

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%hysicians must assess individuals& mental capacity. This involves veri ying that an individual intending to ast does not have a mental impairment that would seriously undermine the person&s ability to make health care decisions. !ndividuals with seriously impaired mental capacity cannot be considered to be hunger strikers. They need to be given treatment or their mental health problems rather than allowed to ast in a manner that risks their health.

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's early as possible, physicians should ac(uire a detailed and accurate medical history o the person who is intending to ast. The medical implications o any existing conditions should be explained to the individual. %hysicians should veri y that hunger strikers understand the potential health conse(uences o asting and orewarn them in plain language o the disadvantages. %hysicians should also explain how damage to health can be minimised or delayed by, or example, increasing luid intake. "ince the person&s decisions regarding a hunger strike can be momentous, ensuring ull patient understanding o the medical conse(uences o asting is critical. 2onsistent with best

practices or in ormed consent in health care, the physician should ensure that the patient understands the in ormation conveyed by asking the patient to repeat back what they understand. .. ' thorough examination o the hunger striker should be made at the start o the ast. 5anagement o uture symptoms, including those unconnected to the ast, should be discussed with hunger strikers. 'lso, the person&s values and wishes regarding medical treatment in the event o a prolonged ast should be noted. 0. "ometimes hunger strikers accept an intravenous saline solution trans usion or other orms o medical treatment. ' re usal to accept certain interventions must not prejudice any other aspect o the medical care, such as treatment o in ections or o pain. 1. %hysicians should talk to hunger strikers in privacy and out o earshot o all other people, including other detainees. 2lear communication is essential and, where necessary, interpreters unconnected to the detaining authorities should be available and they too must respect con identiality. 3. %hysicians need to satis y themselves that ood or treatment re usal is the individual&s voluntary choice. Hunger strikers should be protected rom coercion. %hysicians can o ten help to achieve this and should be aware that coercion may come rom the peer group, the authorities or others, such as amily members. %hysicians or other health care personnel may not apply undue pressure o any sort on the hunger striker to suspend the strike. Treatment or care o the hunger striker must not be conditional upon suspension o the hunger strike. 4. ! a physician is unable or reasons o conscience to abide by a hunger striker&s re usal o treatment or arti icial eeding, the physician should make this clear at the outset and re er the hunger striker to another physician who is willing to abide by the hunger striker&s re usal. 6. 2ontinuing communication between physician and hunger strikers

is critical. %hysicians should ascertain on a daily basis whether individuals wish to continue a hunger strike and what they want to be done when they are no longer able to communicate meaning ully. These indings must be appropriately recorded. 7. *hen a physician takes over the case, the hunger striker may have already lost mental capacity so that there is no opportunity to discuss the individual&s wishes regarding medical intervention to preserve li e. 2onsideration needs to be given to any advance instructions made by the hunger striker. 'dvance re usals o treatment demand respect i they re lect the voluntary wish o the individual when competent. !n custodial settings, the possibility o advance instructions having been made under pressure needs to be considered. *here physicians have serious doubts about the individual&s intention, any instructions must be treated with great caution. ! well in ormed and voluntarily made, however, advance instructions can only generally be overridden i they become invalid because the situation in which the decision was made has changed radically since the individual lost competence. 18. ! no discussion with the individual is possible and no advance instructions exist, physicians have to act in what they judge to be the person&s best interests. This means considering the hunger strikers& previously expressed wishes, their personal and cultural values as well as their physical health. !n the absence o any evidence o hunger strikers& ormer wishes, physicians should decide whether or not to provide eeding, without inter erence rom third parties. 11. %hysicians may consider it justi iable to go against advance instructions re using treatment because, or example, the re usal is thought to have been made under duress. ! , a ter resuscitation and having regained their mental aculties, hunger strikers continue to reiterate their intention to ast, that decision should be respected. !t is ethical to allow a determined hunger striker to die in dignity rather than submit that person to repeated interventions against his or her will. 1+. 'rti icial eeding can be ethically appropriate i competent hunger

strikers agree to it. !t can also be acceptable i incompetent individuals have le t no unpressured advance instructions re using it. 1.. -orcible eeding is never ethically acceptable. 9ven i intended to bene it, eeding accompanied by threats, coercion, orce or use o physical restraints is a orm o inhuman and degrading treatment. 9(ually unacceptable is the orced eeding o some detainees in order to intimidate or coerce other hunger strikers to stop asting.