Abstract
A Palestinian administrative detainee in Israel asked for the author to care for him as an independent physician while in hospital on two hunger strikes, lasting 66 and 55 days, respectively. Hunger striking is placed in the context of other forms of food refusal and artificial feeding. The various perspectives on the challenge of the medical care of hunger strikers are reviewed, as seen by the state, the public, the doctor and the patient. Institutional statements on the management of hunger strikers are reviewed and the local political considerations are highlighted. In conclusion, a trusting doctor–patient relationship is presented as the crucial element for securing a successful outcome, preserving the prisoner's life and dignity with no significant political damage incurred by the State.
Introduction
I present and discuss my own first-hand experience of looking after a political prisoner on hunger strike in Israel. Force-feeding of prisoners on hunger strike has been extensively discussed in the legal literature both in the European and American contexts. 1 There is almost no first-hand description and discussion by the doctors who care for these patients. Local Israeli contextual and structural factors serve as a backdrop to a clinical situation that raised questions about the professional identity of the doctor. I will come to share Glick's conclusion that doctors looking after these patients should concentrate more on engendering trust and less on protecting the patient's autonomy, on both principled and pragmatic grounds. 2
Case presentation
K. a 37-year-old man from Jenin in the West Bank, evidently a prominent Islamic Jihad opinion leader, was detained by the Israeli Security Service (ISS) in December 2011. Immediately following his arrest, he declared a hunger strike in protest against his administrative detention without trial, and against the affront to his dignity in the way he claimed he was treated during his arrest. At first, he was admitted to the prison infirmary, but as his condition deteriorated he was transferred to a succession of civilian hospitals for intravenous re-hydration. On the 52nd day of his fast, he was admitted to the Rifka Ziv Hospital in Safed in the Galilee. This time he refused to cooperate with the hospital staff and demanded that an independent physician of his choosing be called in, through the non-governmental organisation, Physicians for Human Rights – Israel, PHR. Living in Safed myself, I was asked to volunteer to go and see the patient, although I am not a member of PHR. With the permission of the head of the hospital department, and with clearance from the Israel Prison Service (IPS), I went to meet the patient in his room, where I found him shackled to the hospital bed by both ankles and one wrist. There were three armed guards in the room, one with an assault rifle, and I was joined by a physician from the International Red Cross Committee (ICRC) and his interpreter. K. looked surprisingly well, but my initial reading of the literature had indicated that he was in immediate danger of cardiac arrest due to electrolyte imbalance, notwithstanding his generally good condition. 3 He explained to me that he did not want to die, but that he was adamant to continue his hunger strike. His main concern was that the IPS should not find out anything about his medical condition or his medical care. His argument was that the hospital needed the clinical data in order to treat him appropriately should his condition deteriorate, but the IPS did not – and if he were to accept an intravenous infusion, they would publicise that he had broken his fast, thus undermining his political leverage. I explained the immediate danger, and from his questions it was clear that he too had done his reading and understood the risk he was taking. There followed a series of consultations with the hospital management and its legal advisor, with the ICRC, and with the Prison Medical Officer, resulting in a formal promise by the hospital not to divulge any information to the IPS all the while that he is in hospital. The next day, K. consented to blood tests and intravenous fluids and electrolytes. The IPS promptly published a statement through the Al-Jazeera news service that he had broken his hunger strike, and we realised that the guards in his room were simply reporting what they saw. Understanding that the IPS would present whatever he does as breaking the strike, he changed tack and preferred that PHR publish everything that he was taking as a factual account. Following this, he consented also to vitamin supplements which are needed to prevent Wernicke's encephalopathy. At this stage, he proposed a compromise whereby a court of appeal would cut his detention short and he would end his fast. The appeal was rejected and he continued to fast and lose strength. Under pressure from his family, whose hospital visits were permitted by the IPS, he consented to add intravenous glucose. Next, the hospital doctors proposed that he be given peripheral parenteral nutrition PPN – that is amino-acids, fats and carbohydrates intravenously, in order to reverse the progressive breakdown of his body tissues, in particular his heart muscle, and the inevitability of death. During many hours of intimate discussion with my patient, he identified a significant distinction between force-feeding and PPN. He wished to define tube feeding as an ordinary eating action, but PPN as a medical intervention, not eating, as continuing to fast. He was clearly talking about an essentially political definition of PPN as medical treatment for continuing starvation, designed to maintain both the hunger striker's life and his political agenda at the same time. He asked for a written document to this effect as a condition for accepting the intervention. The ICRC and the hospital management refused to issue this statement. The hospital management convened the ethics committee in emergency session late that night, who took the hint, and not wanting to get involved in the theoretical definition, but relying on the 1996 Patients' Rights Law, decided that PPN should be instituted forthwith with or without consent – that is, it sanctioned PPN under protest. Until this point, the medical representative of the ICRC had been extremely helpful and relayed back to us that the ICRC was highly impressed with Israel's management so far. At this point, he warned us quite clearly that we would find no support at all for a policy of PPN with the patient in restraints. PHR-Israel was prepared to issue a document recognising PPN as medical intervention without breaking the fast, but before the treatment was instituted the patient heard that his further appeal to the High Court of Justice was to be heard the next day, and he withdrew his consent to PPN pending the court hearing, fearing that he might lose their sympathy if they heard that he was receiving intravenous nutrition. The court ruled in his favour, curtailed his detention and stipulated that he not be re-detained without the ISS providing fresh evidence against him. Later that day, day 66 of his fast, he announced the end of his fast, started PPN voluntarily, and subsequently re-feeding by mouth. His recovery was complicated by intestinal obstruction requiring laparotomy, but he was eventually discharged back to the prison to sit out the rest of his detention there.
In June 2015, K. once again asked me to see him in hospital, this time in the centre of the country. He was on day 43 of another hunger strike, faced with almost three months more of administrative detention, after already spending a year inside. This time he was far more stringent and took nothing whatsoever by mouth other than water, and adamantly refused medical care, laboratory examinations, and injections. He rejected visits from the ICRC seeing them as pointless from his point of view. The hospital medical staff asked me to use my relationship with him to get him to let me examine him physically. Although K. allowed me a very superficial professional assessment of his condition – colour, tongue, tissue turgor, pulse, oedema, eye movements and foot drop – what he wanted of me was to raise the level of publicity and media interest in his case. He wanted to be released and if not, to be treated more humanely in hospital where he was under 24-h surveillance by armed guards in the room as well as closed-circuit television cameras, with the guards eating mouth-watering hot meals in his presence, turning on the lights at night, and all the time he was shackled to the bed, without showers or bed baths. I raised the issue informally with the chairman of the Israel Medical Association (IMA) at a dinner at the British Embassy that night. He visited him very shortly after, and after 55 days without food, re-feeding was started. The process was again complicated by intestinal obstruction but he eventually recovered. Within a couple of weeks, he was released from detainment and returned home.
In the course of my contact with K., there developed a truly trusting relationship, despite my being a Jewish religious Zionist sporting a kippah and beard. I learned of his family and of his career, from mathematics student to local grocer, of his faith and his convictions, of his personal non-violence but belief in the power of the spoken word. I came to respect him as a person of intelligence, courage and integrity. That there was something mutual going on I know from reports of a speech he made in Jenin after his release the first time round, and from his asking to see me specifically on the second. That trust, I claim, made the process of management possible and enabled the positive outcomes. Neither he nor the Israeli authorities wanted him to die, each for their own reasons, but neither could afford to lose face, and that did not make the course easy to navigate.
Both episodes were accompanied by widespread sympathy hunger strikes among dozens more Palestinians in Israeli jails. Although he achieved most of his immediate aims on both occasions, shortly after this second episode the Parliament passed a law that it had previously been forced to shelve, enabling a district court judge to authorise force-feeding of political hunger strikers deemed by the doctors to be “in danger”. 4 This legislation was strongly opposed by the Israel Medical Association (IMA) who defined force-feeding as torture. 5 The IMA's opposition has been challenged by a group of senior physicians who see saving life as the overriding principle of medical ethics. 6
Discussion
Recent experience with Palestinian hunger strikers in Israel, and the conflicting legal and professional reactions, gives us pause to re-consider the ethics of medical force-feeding of political prisoners. We may encounter refusal to eat in a whole set of different clinical contexts, posing a challenge as how to save the patient in an ethically justifiable way and without undue affront to dignity. So we will first locate the political hunger strike among other situations of refusal to eat, and examine the significant ethical differences among them. There are different modalities of force-feeding and we ask whether different ways of doing it provide different ethical justifications or prohibitions. We will then present five different principled approaches to the political hunger striker, followed by a review of the various positions of international and national bodies and medical associations.
Food refusal
Doctors often meet patients refusing to feed. The sick child and the debilitated old person may both refuse food, and it takes skilled nursing and medical care to maintain their necessary nutrition. These patients are temporarily disabled and are assumed to acquiesce in medical re-hydration and feeding even if physically they resist at the time. Benign coercion is the order of the day and rarely gives rise to ethical tensions. In palliative terminal care, there may be a place for withholding rather than pushing food and drink, for a dehydration death is thought to be a swift and gentle one, but only where the patient would have wanted this. 7 Psychopathic self-starvation is sometimes seen in psychiatric hospitals, but this is clearly part of the mental derangement of the patient, a symptom of the illness, and is reasonably treated as such, including the use of force to prevent the patient dying before the underlying disease is brought under control. The absence of patient consent is justified by the pathological absence of competence. Suicidal depression may present as self-starvation, but the ethical considerations are no different from the prevention of any other form of self-harm in this situation, such as restraints. Starvation is seen as the patient's weapon aimed at herself, so why should we not disarm her? Anorexia nervosa presents a more challenging case, where the food refusal is pathognomonic for the disease. In all other respects, the patient is competent, and the decision not to eat seems rational to the patient. There is no effective drug treatment available, so it is not a matter of keeping the patient alive till the treatment works. All other psychological and behavioural treatments relate directly to the eating disorder, and force-feeding will interfere with, not complement, the treatment. Nonetheless, it is a potentially fatal disease which cannot always be vanquished. 8 Relying on the Patients' Rights Law, force-feeding has been approved by the courts in Israel in a case of immediate danger to life. 9 Anorexia nervosa has been described as an expression of “autonomous despair”, and in this respect compared with political hunger striking. In both cases, the competent patient can see no other way out of an impossible situation. 10
Hunger strikers are not suicidal, indeed they want to live and see their agenda fulfilled. They are fully competent and rational people with biologically intact appetites, but they want to manipulate their surroundings into submitting to their demands, whatever they may be. Often hunger strikers do not reach the stage of extreme danger to life because they do no really fast completely. Ghandi is the classic example of this. Indeed, with zero fluid intake they would die within days. Some eat surreptitiously, others sporadically, but a few really do not take any food or nutritional supplements at all and truly endanger their lives. Other fighters for the cause, both in and out of uniform, are also prepared to die but do not wish to. But their death is in the end at the hands of the enemy even when it is a heroic death while trying to evacuate a wounded comrade under fire. So this too is not a completely comparable situation to the hunger striker. Hunger striking, then, is a special case which needs independent consideration on its own merits. The hunger strike is a communicative act used as a last resort, in despair, when all other expression has fallen on deaf ears, un jeûne de protestation in French. At a more immediate personal level, it has some affinity with self-harm in prisoners, where the pain they inflict on themselves, and the medical response to the bodily damage, serves to reaffirm their identity which is whittled away by the tedium and sensory deprivation of prison life, especially solitary confinement. 11 Hunger striking, however, is a public action that depends totally on publicity for its political effect. Some “dirty hands” politicians may say that giving into manipulation leads to further manipulation and the eventual collapse of law and order, and therefore some hunger strikers might regrettably have to bear the consequences of their actions and die. 12 If all hunger strikers were left to die without giving in to their demands, future protestors would look for other more effective means of achieving their goals and no one would go on hunger strike any more. Our problem is whether the doctor into whose care the hunger striker is entrusted should take the same line. If doctors refuse to stand idly by while their patients starve to death, and routinely institute force-feeding at an early stage, they would achieve the same goal of making the hunger strike a useless political ploy. No one would start out on what is clearly an empty threat. Sometimes, the politicians too cannot afford for the striker to die, as in our case – for fear of igniting a new intifada, so the tables are turned, with the politicians wanting him alive and the ICRC doctor opposing force-feeding on ethical grounds of dignity and autonomy. In order to avoid things getting to crisis point, some governments force feed at a much earlier stage of the hunger strike, after the omission of just a few meals, so that the prisoner never reaches danger point and doctors are not involved. Guantanamo Bay is an example of this approach.
The conservative position
In general medicine, there are those who accept the withholding of futile medical interventions but insist on continuing to provide nutrition to terminal patients. Some thinkers, mainly religious, put the basic requirements of food, drink and air in a special category, insisting that in no case may these three be withheld from a patient. 13 Pilkington argues that responsibility for death lies with he who omits to institute artificial nutrition and hydration, and he cannot blame the underlying fatal disease. 14 Not distinguishing between feeding and nutrition, they demand tube-feeding, naso-gastric or gastric (PEG) – if nutrition cannot be provided by normal feeding, then it must be provided in other artificial ways. In order to set limits on the invasiveness of terminal care, we must resort to some sort of distinction between ordinary non-medical procedures, and extra-ordinary medical technologies including oral syringe feeding, gastric tube feeding oral or nasal, and percutaneous gastrostomy. However, some Christian and Jewish theologians see any tube feeding as an ordinary procedure and therefore required in all cases. 15 When they say that all forms of feeding are ordinary and not medical, they are simply qualifying the definition of medical intervention to exclude any intervention that provides air, food or fluids, even though in every other aspect it is clearly a medical intervention. They should, and usually do, insist on artificial respiration and hydration as well.
The liberal position
As far as the doctor is concerned, patients have the right to refuse medical interventions. If the only problem in force-feeding were the affront to the dignity of the autonomously resistant patient, there would be no difference which method were used. However, the medical context of our dilemma would seem to put medical interventions in a different category from non-medical interventions. Prisoners are denied many freedoms, and if the prison warder forces a cup of water into the hunger striker's mouth, that might not be the doctor's business. It is when the patient is under medical care and subject to medical interventions that our dilemma reveals itself. A possible definition of a medical intervention would include one that is attended by special risks and also calls for special professional skill. The implication of considering artificial feeding a medical intervention is that its use against the patient's wishes should be considered in the same way as any other medical intervention. Our patient, K., challenged this conventional wisdom and was concerned to draw the line in a different place – not between ordinary eating and artificial nutrition, but between enteral (gastric tube) and parenteral (intravenous) nutrition. Being prepared to accept life-saving
Side-effects and dangers of artificial feeding
Pain
There is a clear gradation of cruelty in administering these treatments. Even if the patient does not resist, tube feeding is the most uncomfortable and degrading, followed by PEG and then intravenous infusion.
Indignity
Forcing food into the mouth or via a naso-gastric tube is essentially undignified, as is the unwanted intrusion into any of our bodily orifices. Intravenous infusion does not carry the same physical indignity. The staff might agonise over the alternatives of physical as against chemical restraint. 16 Tranquilising drugs, themselves necessarily given under some degree of restraint in the agitated patient, do make life on the ward quieter and less tense. From the autonomy perspective, it is ethically identical if you limit the patient's freedom by physical or by chemical means. There is a difference in the overt indignity of a waking patient tied to the bed as compared to the drugged patient snoring quietly. There does seem to be a scale of indignity whereby physical restraint is worse than chemical restraint. Continuing from there, force-feeding is worse than PPN under physical restraint.
Risks
There is also a clear gradation of risk attending these different routes of feeding. Cup or syringe feeding may occasionally cause aspiration, but tube feeding does so often. The tubes become infected and may erode the tissues they come in contact with, the nose, throat and oesophagus. Excessive force in the face of fierce resistance can even cause perforations and haemorrhage. 17 Jotkovits lists the following complications, albeit in the context of the patient with advanced dementia: aspiration pneumonia in up to 66% of patients, tube occlusion in up to 34%, leaking in up to 20%, and local infection in up to 16%. PEG is a surgical procedure with all the usual attendant possible complications of pain, bleeding and infection. 18 Perioperative mortality rates from 6 to 24% have been reported, depending on the condition of the patient. 19 In young fit patients, as political prisoners so often are, complication rates should be far lower, but as the fast progresses, these patients too become extremely frail. Prolonged intravenous nutrition is even more prone to cause serious blood-borne infection, thrombosis and sepsis. All artificial feeding is attended by the risk of dangerous fluid and electrolyte disturbances, and vitamin deficiencies. Any gastric feeding may cause over-distension of the stomach. So over and beyond the ethical considerations of saving life and respecting autonomy, we now also face a spectrum of bodily indignities and of medically induced risks.
The ethical arguments
The State
Republicanism considers the relationship between the citizen and the State, or more broadly, between the individual and the body politic. At one level, incarceration in prison suspends individual human rights, not just in withdrawing the right to free movement but in other spheres too. Prison is a total institution where individual autonomy is meaningless. Food refusal is a disciplinary offense in prison, which leads to retributive responses, including solitary confinement, cessation of family visits, and force-feeding. The Prison Service may convey to its doctors that there is no dilemma at all. 20 This definition of the nature of imprisonment is hotly disputed and clearly not accepted by international conventions. This argument would make hunger striking prisoners different from political hunger strikers who are not in prison – suffragettes and the like – who retain their rights. Other republican arguments are proposed by Jacobs. 21 The State is duty-bound to preserve the health and the life of its prisoners, hence force-feeding is totally justifiable. Force-feeding is required pre-trial in order to keep the prisoner alive long enough to stand before the court. She argues that the authority of a judge in this case is required so as to overwhelm the prisoner's autonomy, thus enabling the doctor to force treatment on his refusing patient. The opposite conclusion is reached by Filc's radical egalitarian version of republicanism that requires the doctor to respect the prisoner's right to resist, and to relate to the political structural factors that led to the hunger strike in the first place. 22
The public23
We must respect the liberty of a person only so long as his actions do no harm to others, says John Stuart Mill. 24 It has been argued that if hunger striking leads to public disorder, then the prisoner loses his right to resist and force-feeding is justified. 25 Gross maintains that our dilemma is not between the saving patient's life and his autonomous wish to starve to death, but rather the tension is between the autonomy of the hunger striker patient and the obligation of the doctor to act for the common good. 26 If the Palestinian political hunger striker threatens Israeli security by his actions, the doctor must take the side of the latter and prevent the martyr death by force-feeding. Barilan describes political hunger strikers as violent opponents in an armed conflict. As such, autonomy is denied to them as it is to any other enemy combatant, and we are required to disarm them, i.e. force-feed them. He contrasts political hunger strikers with those who are campaigning for their own human rights, where the doctor should respect their autonomously formed wish to die rather than continue to suffer the denial of their human rights. 27 His analysis oversimplifies matters – the conflict between the Israeli State and the Palestinian people is not a symmetrical armed conflict between two armed forces. Palestinian prisoners on hunger strike cannot easily be seen as armed adversaries in an even conflict. The curtailment of the human rights of the administrative detainee without trial reflects, in their view, the curtailment of the human rights of a whole population that lives under occupation. So the boundary between the political and the human rights categories is blurred and the neat practical solution of force-feeding the former but not the latter does not hold water. This brings up the question of the social accountability of medicine. 28 As soon as medicine goes beyond its brief of treating individual sick patients, it enters on a relationship with society which has its benevolent side, such as health promotion and preventive medicine, but also its downside, in collaboration with governments and establishments whose policies may not always earn universal acclaim. A public health goal of abolishing health inequity might fly in the face of government monetarist policies. To whom is medicine socially accountable – to the “general population” or to its democratically elected government? What if the doctor thinks that peace in the Middle East requires the end of the Israeli occupation, but his democratically elected government thinks otherwise? Surely the hunger striker's life should not hang on the individual doctor's political opinion, nor should every doctor have to accept government opinion. Gross' approach cannot solve our problem. Furthermore, the common good argument cuts both ways, for the political hunger striker thinks he is acting for the common good by protesting in the only way left to him against what he sees as the iniquitous policies of those in power. This is an autonomous act not aimed at personal best interests but at achieving the desired political goal. Taking this republican approach, rather than the more familiar liberal approach, the doctor is required to defend the patient's right to protest even at the cost of his life. Communitarian perspectives sit comfortably with public health ethics, but less so with clinical ethics’ liberal philosophy that puts the patient’s best interests first.
The patient
Rejecting the notion that imprisonment deprives the prisoner of his medical autonomy, the main justification for non-intervention is respect for the non-coerced self-determination of the patient. However, overriding the patient's autonomy is part of everyday medical practice known as the therapeutic privilege – we withhold information when this is in the patient's best interest, and we take little notice of patients' protests when they seem to stem from panic or poor comprehension either of their medical condition or of the therapeutic options, and when urgency dictates action more than ethical deliberation. The assumption is that the reasonable patient will eventually agree that we did the right thing at the time, and this assumption would not normally apply to prisoner hunger strikers, though some anecdotes say otherwise. 29 There is also reason to think that when a group of political prisoners go on hunger strike, not all of them are acting fully autonomously in the first place. Empirically, many have admitted after the end of the strike that they felt extreme group pressure to join in, against their better judgement.
The doctor
Medical ethics are a special professional ethics, subject to more considerations than general ethics, even for the strict utilitarian. 30 Not always writ large, rescue and the preservation of life are basic medical obligations, over and above a default Good Samaritan duty that applies equally to laymen to confront suffering rather than ignore it. In Israeli law, following Jewish religious law, this is indeed spelled out. 31 The value of life in Israeli life is demonstrated not only by the laws relating to the end of life, but also by the exceptionally high rate of patients maintained long term on artificial ventilation, and by the exceptionally generous public funding for reproductive technologies. 32 The Patients Rights Law goes so far as to oblige the doctor to forcibly administer life-saving treatment when the patient is facing death even against the patient's resistance. 33 Although the Patients Rights Law relates primarily to medical emergencies, some see it as sufficient to cope with the situation of force-feeding hunger strikers. 34 The justification for the new special Amendment to cover hunger strikers specifically was that they cannot be presumed to give retrospective consent after being saved by force-feeding. A further difference was that the new special law for hunger strikers institutes force-feeding at the instigation of a court judge in response to a physician's application. There is no need for the patient to be in immediate danger, only that the patient's life is endangered. This leaves open the possibility of a court order to force feed at an earlier stage, well before the patient deteriorates to the level of a medical emergency. Opposition to the new amendment was based on its allowing force-feeding earlier than medically vital, and also on its requiring the judge to include considerations of the public interest, the common good, and not only purely clinical considerations. For the mainly religious opposition, imago dei requires us always to strive to save life. 35
Dialogue with the patient
The history of hunger striking over the past century suggests that hunger strikers are rarely successful in achieving their political, as opposed to their personal, aims in the short term, and that the mortality rate is low, supporting the idea that mostly the strikers are persuaded to give up. 36 According to one source, over the last 50 years no more than five prisoners in Israel have died from hunger strikes, all as a direct result of aggressive force-feeding, but none of the hunger strike itself. 37 In those many countries which use force-feeding routinely, this may be done safely only where the prisoner does not put up too much resistance. This observation opens the window of opportunity to dialogue with the striker. One of the demands of the international statements is that the prisoner be allowed access to an independent physician. Insofar as any physician in the public sector is truly independent, and she too often works under some degree of constraint, she may form a therapeutic relationship with the patient, a relationship that develops trust and serves to restore dignity. Nys has recently given an account of the way trust is related to autonomy. 38 Since political hunger strikers are not suicidal, the doctor can look for those chinks of light that give the patient a glimmer of hope, and function as an advocate for the patient's best interests with the authorities.
The normative positions
International medical associations have unanimously instructed doctors not to engage in force-feeding. The Malta Declaration of the WMA says that it is never ethically acceptable and calls it inhuman and degrading. 39 In its letter to its members, the IMA goes further and unambiguously calls force-feeding as torture. 40 A Special Rapporteur, an independent expert appointed by the Human Rights Council of the UN, reported on the right to health of detainees at Guantanamo Bay, concluding that force-feeding is intolerable and may be tantamount to torture. 41 It is inconsistent with the principle of individual autonomy, the policy of the WMA in the Declarations of Tokyo and Malta endorsed by the AMA as well as the position of doctors of the ICRC. It is a violation of the right to health. The ICRC also forbids coercive feeding which can be considered a form of torture. 42 PHR-Israel issued more equivocal guidelines in 2004 that sanction first-time resuscitation of moribund hunger strikers, but not subsequently, if the prisoner re-asserts his wish to die of hunger. Otherwise, force-feeding is forbidden, following the WMA Declaration. 43 The European Court of Human Rights has ruled that forced-feeding is not inhuman and degrading if aimed at saving the life of the hunger-striker. 44 Intravenous feeding is considered as less intrusive than tube-feeding. The European Committee for the Prevention of Torture also does not endorse force-feeding but if medically necessary as assessed by independent experts it should be carried out in suitable conditions and in the least traumatic way possible. 45 The legal situation varies across different countries, but in reality force feeding is used in many countries routinely and in some cases, prisoners have indeed been left to die, such as in Ireland, 46 Italy 47 and Turkey. 48 In one case in South Africa, hunger striking prisoners detained without trial were informed at the time of hospitalisation that there would be no forced feeding but also that the doctor would not discharge them back to detention, which he considered to be equivalent to torture. 49 In each case, different cultural and political contexts prevailed, and the definition of who was successful, the government or the prisoner, depends to a large degree on whose perspective you take. The most highly debated recent example is Guantanamo Bay where the USA tried at first to exclude this prison from their jurisdiction because it is on land leased long-term in Cuba. However, President Obama did finally take responsibility and instructed the camp to be dismantled. 50 This has not happened.
Summary
Part of the biopolitics of hunger striking is the medicalisation of its management. A truly adamant government does not need doctors at all – either leave the prisoner to die in his cell, or use prison warders to force-feed them under restraint much earlier in the course of the strike. This situation may also occur when the government is faced with mass hunger strikes among its prisoners, where providing an independent personal physician for each prisoner is not feasible. Medicalising the management helps government present itself as civilized, and at the same time co-opts the profession to act in support of its policies. This loss of professional freedom is precisely where doctors in the prison service face such a conflict of loyalties. The manipulative nature of the prisoner's hungers strike sets up a dual loyalty dilemma for the doctor. Assuming the imprisonment is legal and warranted, the doctor is torn between the interests of society and the medical duty to save life. Since the hunger striker does not wish to die, the doctor cannot stand by and let him do so. Although there seems to be a simple moral dilemma in force-feeding – the obligation to preserve life when you can on one horn, and the obligation to respect the autonomous patient's wishes on the other 51 – the situation has been more accurately described as the doctor functioning in a “malignant triangle” that includes the government policies, the doctor's struggle to maintain professional independence, and the changing mental state of the patient. 52 The privileged space of the doctor–patient relationship becomes porous and open to the gaze of the media, family and political and human rights groups. Public exposure is precisely what the hunger striker wants. Simple accounts of autonomy and of medical duty collapse in this situation. Local context is important in political, cultural and religious terms. Given the cultural differences across the world, there cannot be an international standard, and each society will rule according to its local norms, while respecting the right of other societies to rule and behave differently – for example, autonomy gaining the upper hand in the USA and the preservation of life in Israel. Whatever the context, however, the hunger-striking prisoner who is considered an expendable outsider, an undesirable foreigner who is not seen as part of the body politic, is particularly vulnerable to abuse and indignity. 53 Experience has shown that it is possible to resolve hunger strikes with patience and sensitivity as long as the doctor is truly independent and resists cooption by either party – the striker or the authorities. An emphasis on this aspect of hunger strike care was expressed by Glick in his 1997 paper and again in evidence before the Israel National Bioethics Council in its discussions on this issue in 2014. 54 Negotiated trust and professional non-judgementalism are the keys to successful management, as always. The implication of failure is force-feeding to preserve the patient's life, which though necessary as a basic duty of the doctor, constitutes a severe infringement of the patient's dignity at the very least. In the current case, the obscure debate on the status of PPN opened the space for resolution, but it could only take place in the context of a mutually respectful and trusting relationship. The doctor has to take the imaginative leap into the patient's world even when it is anathema to him personally.
Footnotes
Acknowledgements
I thank the hospital director, Professor Oscar Embon, and Drs Raymond Farah and Alexander Waxman of Ziv Medical Centre, Safed for their cooperation, and Drs Deena Orkin, Nikoloz Sadradza, Frank Arnold and Zvi Bentwich and PHR-Israel staff members for the part each played in the management of this case. Responsibility for the report, its analysis and the conclusions is all my own.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The author has acted as an unpaid consultant for Physicians for Human Rights – Israel.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Patient consent
The patient provided written consent to reportage of his case, signed in the presence of his lawyer and witnessed by him – deposited with the Journal editor.