Abstract
Hunger strike is a protest where an informed person refuses essential nourishment with the intention of accomplishing a specific goal. Hunger strikes conflict with medical, ethical, humanitarian and legal values. A multidisciplinary approach is important when dealing with hunger strike patients. On one hand, there is the wish to preserve life, and on the other to respect the strikers’ autonomy and their wishes, values and advanced directives (or living will). Most hunger strikes are short-lived, but in complex and prolonged circumstances, legal advice must be sought from health service solicitors and a doctor’s medical indemnity organisation. There is an emergent need to have defined guidelines for the management of these hunger strikes to be followed.
Introduction
Hunger strike is when a person having decision-making ability refuses to take vital nourishment unless and until his specified demands are acceded to. 1 As Tagawa’s study noted, there are two components of a hunger strike: the former is fasting and the latter a statement by the hunger striker that he/she will not take nourishment/hydration partially or fully unless and until his/her demands are fulfilled. 2 Generally, a hunger strike begins when a person misses nine consecutive meals or suffers weight loss to a level which is less than 85% of the ideal body weight (IBW). 3
Hunger strikes are a common form of protest and used for many types of problems. The management of hunger strikers has always been controversial and poses a conflict between medical, ethical, humanitarian and legal values. 4 A multidisciplinary approach is of the utmost importance when caring for hunger strike patients. We share our experience and suggest an algorithm to be followed for stepwise management of hunger strikers in accordance with medical, ethical and legal principles.
Case report
A 40-year-old male was admitted via an emergency ward (in one of the premier tertiary level multi-specialty teaching institutes of North India) with complaints of dizziness, dyspepsia and loose stools. He had been on indefinite hunger strike for four months and taking only water and coconut water. For the last week, he had stopped all intake of enteral fluids and refused intravenous fluids as well. He had more than 25% loss (60 kg to 45 kg) of weight over the past two months. His hunger strike was aimed at telling the masses about environment protection measures.
At presentation to the hospital, the patient was alert, but appeared dehydrated and emaciated. Examination revealed hypotension (BP 90/60 mm Hg), with postural fall of 20 mm systolic BP). His blood sugar at the time of admission was 45 mg/dl. The implications of the existing clinical status were discussed with the patient, but he denied all interventions. A close monitoring of patient’s vital parameters, sensorium, urine output, electrolytes, blood sugars and ketone levels were done (Table 1). A detailed psychiatric evaluation was negative for ideation for death wishes, suicidal ideation, depressive cognition, delusions, hallucination or free floating anxiety. His sugar levels at 02:30 h, 03:30 h and 06:00 h after admission were found to be 51 mg/dl, 48 mg/dl and 50 mg/dl. Despite repeated counselling by the attending emergency physicians, the patient continued to refuse feeds and any medical interventions. Subsequently, a multidisciplinary team comprised of internist, hospital administrator, intensivist, endocrinologist and psychiatrist was set up to decide how to manage the patient. After detailed discussions, the patient accepted to take alternative Ayurvedic treatment and expressed his desire to go out in sunlight for meditation, which he believed would help him to gain energy.
Monitoring of parameters for re-feeding syndrome and starvation ketosis.
He continued to have hypoglycaemia along with raised ketone bodies levels and compensated metabolic acidosis till 18 h post-admission. Despite repeated counselling, he refused to accept either orally or intravenously. After 18 h of admission, by involvement of local authorities and detailed counselling by the multidisciplinary team members, District Magistrate and police officials about his deteriorating starvation ketosis, the patient consented to the administration of IV dextrose with 300 mg thiamine and high potency multivitamin supplementation. His energy requirements were supplemented and close monitoring of electrolytes in accordance with the NICE guidelines for prevention of re-feeding syndrome started slowly at around 450 kcal/day. 5 , 6
By 36 h, the team was able to convince the patient to take liquids (milk, coconut water) through a nasogastric tube (Table 1). The patient’s status improved over the subsequent four days, his ketosis resolved, and there were no electrolyte abnormalities so he was discharged in a stable condition.
Stepwise management of hunger strike patient.
Why should an emergency physician be aware of this?
Medical issues
Hunger strikes pose an ethically, medically and often legally challenging situation for the treating physicians. On one hand, it requires physicians to intervene clinically to preserve life, on the other hand, they have to respect a striker’s autonomy, and his refusal to take nutrition or medication. 7 As the healthcare staff is morally and ethically bound to obtain consent before providing medical help, the treating physician needs to evaluate and make a reasonable effort to persuade the striker to consent to medical treatment. 8
The management of a hunger striker is complex because prolonged starvation may induce electrolyte imbalance, hypothermia, vitamin and mineral depletion, infections and renal failure. 9 Physicians should take a complete and accurate medical history, conduct a thorough medical examination including serial weight measurements of the hunger striker and closely monitor fluids and electrolytes (Figure 1). The striker’s wishes, values and living will about treatment should be documented and consequences for his/her health explained in simple language. 10 The striker should be informed of possible measures to minimise or delay damage to health, for example, by increasing thiamine and fluid intake. Most hunger strikers usually allow ingestion of some fluids, sugar, salt and thiamine, thereby minimising the risks of permanent nutritional disability and without asserting any sort of intent to fast till death. 10 Regular medical examinations should be carried out with the consent of the hunger striker. Generally, in the first three days, the body uses energy from glucose followed by processing of body fat (a process called ketosis). Later, the body enters ‘starvation mode’ and targets body ‘mines’ (muscles and vital organs) for energy. 11 Once feeding is reinstituted, every care must be taken to prevent re-feeding syndrome by prior supplementation of 300 mg of thiamine and other B complex vitamins, starting feeding 0.0418 MJ/kg/day and gradually increasing the same (Figure 1). Hydration should also be corrected carefully with correction/supplementation of potassium by 2–4 mmol/kg/day, phosphate by 0.3–0.6 mmol/kg/day, and calcium and magnesium by 0.2 mmol/kg/day intravenously or 0.4 mmol/kg/day orally. 5
Also, continued communication between hunger striker and treating physician is vital; extensive commiseration and empathic efforts are needed to persuade the striker to end the fast, and physicians should ascertain his state of mind on a day-to-day basis (Figure 1). All information must be documented appropriately. If the striker’s health is at risk and involuntary feeding is essential, this should be initiated only with the knowledge and written approval of the hospital management who in turn may seek advice from lawyers. 11
Ethical issues
The principle of beneficence requires physicians to keep a patient alive but when a striker has made an informed refusal, his individual autonomy limits a physician’s scope to treat. Physicians must apply their clinical acumen while respecting a striker’s wishes and values and follow the same ethical principles as they do with other patients. ‘Avoiding harm’ means not only minimising causing damage to health but also not forcing a patient of sound mind to accept treatment or to stop fasting. 12 , 13
The mental capacity of an individual who intends to hunger strike should be assessed, as it may impede the striker’s ability to take sound health-care decisions. 11 , 14 Patients with disturbed mental capacity may be unable to appreciate the consequences of a hunger strike and make an informed decision. When a physician takes over the case, he may realise the hunger striker has impaired mental capacity and it may not be possible to discuss the options, but due respect and consideration must be given to advance directives, if any, made by the striker. 15 Advance refusals of treatment must be followed if they reflect the voluntary wish of the striker when he was competent. If there are no advance directives, no evidence or note exists in clinical records, and no discussion is possible with the striker, physicians should act to preserve the individual’s health without interference from any third party. The World Medical Association (WMA) has stated that forced feeding is unethical and it is an act of torture. 16 The right to go on a hunger strike as a form of protest should be respected, unless and until, its prolongation reaches a stage of clear and present danger to the life and health, when the saving of life must take precedence over considerations of autonomy.
While dealing with an unconscious striker, decisions must be taken by giving due consideration to patient values, best interests and expressed wishes. Even after regaining mental faculties, if the hunger striker reiterates his intention to continue fasting, that decision must be respected. It is ethical to allow a determined hunger striker to die with dignity rather than forcing clinical interventions against his wishes. Artificial feeding is ethically appropriate if competent hunger strikers consent to it. WMA (Tokyo declaration) has also stated that if a striker is capable of rational and unimpaired decision-making and is well aware of the consequences of refusing nourishment, he should not be artificially fed. 10 , 12
Undue pressure should not be put on the striker to suspend the strike and artificial feeding should be given to preserve one’s life or any unprecedented irreversible disability. In the Declaration of Malta (1991) (revised in 1992), it has been stated that if the treating physician intends towards the need for compulsory intervention, the ‘patient would then be entitled to be attended by another doctor’. So, it is imperative that, for medical assessment to be legitimate, hunger strikers are assessed on their mental state and genuine intentions and a hunger striker must feel convinced that the treating physician is acting independently and impartially.
Legal aspects
Although there is consensus, ethically legal guidance is limited. Fortunately, most hunger strikes self-resolve. Short-term or feigned sustenance denials are easier to manage than sustained refusal. WMA (2006) has also stressed the importance of physicians’ neutrality to avoid a dual loyalty conflict and suggests favouring autonomy over beneficence.
Legal literature has not differentiated hunger strike as an expression of resentment or a recognised right to refuse feeding. 1 WMA in Declaration of Malta and Declaration of Tokyo Hunger Strikes and UN Commission on Human Rights (2006) has described force-feeding as amounting to torture. 16 Any force or induced pressure should never be used to end the strike. The Declaration of Tokyo specifically states that if a striker is capable of making a rational judgment to refuse nourishment, he should not be fed artificially. 17 Furthermore, many nations have adopted legal guidelines which assure their citizens are entitled to refuse nourishment as well as medical treatment as a logical proposition to the ‘right to health’. 18 In the UK, a court decision has approved the principle of self-determination and autonomy reaffirming the striker’s rights to refuse treatment. 19 , 20 There are no such standardised directions in India, but in a recent judgment it has been argued that a hunger strike is not illegal or unconstitutional and cannot amount to a crime. It empowers mentally sound strikers to express their concerns and demands by opting for peaceful methods; they should not be forced to end their strikes by forced-feeding or retaliatory torture which amounts to violation of international law and one's rights.
Conclusion
The role of a treating physician is not limited to medical management but includes balancing clinical, ethical, humanitarian and legal values. Although most hunger strikes are short-lived, complex and prolonged strikes require that legal advice is sought from health service solicitors and a doctor’s own medical indemnity organisation. There should be clear and defined guidelines to address these issues in future.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.