Miss Danielle Fung is a final year medical student with a keen interest in offender healthcare. She writes this personal opinion piece as part of her medical elective with Integritas Healthcare…
On strike
Hunger striking is an emotive, enduringly controversial topic. Exploring it in the context of a real life (or in this case, now dead) prisoner’s story sets it in context but makes it no more palatable. And that is what we’re going to do now as, 40 years ago today, a hunger striking Member of Parliament (MP) died in a British prison.
Who was this MP? Why did he hunger strike to death? Why do other prisoners do it? What do medical ethical codes and international humanitarian law (IHL) say about managing hunger strikes? And, boiling it all down to the main point of interest to someone like me who is working within a medical NGO with a heart for detainees, how should secure environment healthcare professionals treat their hunger striking patients?
Let’s find out…
BOBBY SANDS MP
Bobby Sands was a member of the IRA, a paramilitary group seeking independence for Northern Ireland. Following the bombing of the Balmoral Furniture Company in Dunmurry, in 1976 he was imprisoned for a second time and sent to the infamous Maze Prison.
He and his comrades started protesting against the fact that they had ceased to be regarded as political prisoners - a class of prisoner traditionally afforded certain privileges such as being permitted to wear their own clothes and not being obliged to do prison chores. So, rather than putting on prison uniforms, they went naked or wore just blankets - earning themselves the nickname ‘blanket men’. And rather than slopping out their cells every morning, they smeared their own faeces over their cell walls - a ‘dirty protest’.
Bobby Sands on hunger strike in HMP Maze, as re-created by Sarah-Louise Bedford from a photograph
They then upped the stakes with a phased hunger strike. Bobby was the first striker, commencing his hunger strike on 1st March 1981. During the following 66 days he managed to get elected as an MP before dying in the prison hospital on 5th May.
OTHER SUFFERERS
The following week the first two of nine other hunger striking comrades died. In total, including Bobby, ten men died between 5th May and 20th August, taking between 46 and 73 days to succumb to death. They were all under 30 years of age.
Thirteen additional men who had joined the hunger strike went on to survive, including one man who had refused food for 70 days. They lived due to medical emergencies (such as suspected perforation of a duodenal ulcer) necessitating urgent treatments or, as was legal then, their families making clear that they would act to authorise life-saving medical interventions.
Interacting with and caring for hunger strikers can take its toll. Over the following few years, alcoholism, absenteeism and suicide blighted the staff side of HMP Maze. These other sufferers included Dr David Ross, the prison doctor who had cared for the hunger strikers day-in, day-out throughout much of 1981: he died after shooting himself in the abdomen.
Methods & Motives
Not all hunger strikes are the same. ‘Dry strikes’ consist of the refusal of fluids as well as food. They are relatively rare, not least because death results far sooner than is desirable when trying to negotiate with one’s opponents. Other prisoners conduct limited food refusals - declining some but not all foods.
Detainees have far less autonomy than free citizens. The decision as to whether or not to open one’s mouth - to speak, to eat, and to drink - is one of the few things within their control. Hunger striking is therefore a logical means of protesting behind bars.
Many countries’ prison authorities recognise a food refuser as being on hunger strike once (s)he has completed 72 hours of voluntary, total food refusal for an intended purpose. Intention is key: although a food refuser may be willing to pursue their goal regardless of the risk to their life, if their actual goal is to end their own life, then their actions are usually deemed to be a suicide attempt rather than a hunger strike.
The main aim of the 1981 HMP Maze hunger strike was to reinstate ‘political prisoner’ status for detained IRA members. And this ‘I want something to change’ motivation is a common, though not universal, thread running through the majority of hunger strikes. Prisoners most often hunger strike as a means of trying to get better or less restrictive prison conditions or to try to have their court cases reheard or their sentences reviewed. A high profile contemporaneous case is that of the jailed Russian opposition leader, Alexei Navalny, who recently went on hunger strike in a bid to obtain better medical treatment within his prison.
A poster depicting a Suffragette being force fed by a prison doctor and his assistants.
(Image is the property of Museum of London.)
ForceD Feeding
Back in Britain though, another famous example of hunger strikers is the early 20th Century suffragettes - women (and not a few men) who campaigned for women to be granted the right to vote. Jailed for relatively petty crimes (such as smashing windows and other acts of criminal damage) committed as part of their campaign, they too were denied the status of political prisoners.
In response, they closed their mouths, going on hunger strike. The government of the day feared that at least one would die in custody with likely risk of increased public sympathy for their demands. So the prison doctors of the day complied with government directions to forcibly feed these mentally competent prisoners. The film Suffragette contains a graphically accurate depiction of this procedure as it was conducted at that time.
Later on in the campaign, a law (the so-called Cat and Mouse Act) was passed in order to temporarily release hunger strikers who were nearing death, so obliging them to recover in the community before bringing them back to prison where the vicious cycle would often re-start. It is poignant to note the use of the word ‘torture’ in the pro-suffragette depictions of their ill-treatment.
Medical ethics
Four well-respected pillars supporting the broad pavilion of international medical ethics are autonomy, beneficence, non-maleficence and justice. In a nutshell, this means that doctors should have respect for patients’ right to self-determination, consider what is most just for the society within which their patients live, act for their patients’ good, and definitely not set out to harm their patients.
Therefore, it is a very serious decision to force feed a patient who has exercised his or her right to autonomy and made a capacitous decision to hunger strike. And in 1975 the World Medical Assembly (WMA), an organisation founded in the aftermath of World War II to provide international consensus on medical ethics and clarity about medical practice, condemned forced feeding within the Declaration of Tokyo:-
PREAMBLE
It is the privilege of the physician to practise medicine in the service of humanity, to preserve and restore bodily and mental health without distinction as to persons, and to comfort and to ease the suffering of his or her patients. The utmost respect for human life is to be maintained even under threat, and no use is to be made of any medical knowledge contrary to the laws of humanity.
For the purpose of this Declaration, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.
DECLARATION
1. The physician shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victim’s beliefs or motives, and in all situations, including armed conflict and civil strife.
7. A physician must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The physician’s fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose.
8. 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 a voluntary refusal of nourishment, he or she shall not be fed artificially, as stated in WMA Declaration of Malta on Hunger Strikers. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician. The consequences of the refusal of nourishment shall be explained by the physician to the prisoner.
(Extracts of the Declaration of Tokyo (emphasis in bold added), as revised in 2016)
Reassuringly, this declaration cuts through all the convoluted arguments created by the various definitions of torture within International Humanitarian Law (IHL). Doctors who are members of any national medical association - including the British Medical Association (BMA) and American Medical Association (AMA) - signed up to the WMA are left in no doubt as to what the vast majority of their worldwide colleagues believe torture to be.
The above-mentioned Declaration of Malta on Hunger Strikers was adopted by the WMA in 1991. It combines medical ethics with practical advice on how best to manage hunger striking patients. Key points include:-
identify the hunger striker’s goal;
offer regular medical examination including serial weight measurements;
offer detailed information about the side-effects and risks of prolonged fasting;
consider psychiatric assessment to confirm capacity to refuse life-saving treatment;
offer ongoing treatment for other pre-existing or emerging health problems;
keep checking that food refusal is voluntary, as peer-pressure may be a factor;
offer medical intervention for potential medical emergencies including, if appropriate, the option of resuscitation;
offer palliative care, as the hunger strike progresses.
And the declaration’s bottom line couldn’t be clearer:-
23. All kinds of interventions for enteral [food delivered by mouth or a tube to the stomach or small bowel] or parenteral feeding [nutrition delivered into a large vein] against the will of the mentally competent hunger striker are “to be considered as “forced feeding”. Forced feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment. Equally unacceptable is the forced feeding of some detainees in order to intimidate or coerce other hunger strikers to stop fasting.
(Principle 23 of Declaration of Malta on Hunger Strikers (emphasis in bold and explanations in square brackets added), as revised in 2017)
Both the International Committee of the Red Cross and the BMA’s Medical Ethics Today have eminently useful summarisations of these ethical codes and principles.
International humanitarian Law
Today though, some doctors have to negotiate a professional minefield.
In certain countries, there is tension between what a piece of IHL actually states and how a signatory nation has interpreted and enshrined it into its own national legislation. Take, for example, aspects of the European Convention of Human Rights (ECHR):-
ARTICLE 2 Right to life
1. Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.
2. Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary: (a) in defence of any person from unlawful violence; (b) in order to effect a lawful arrest or to prevent the escape of a person lawfully detained; (c) in action lawfully taken for the purpose of quelling a riot or insurrection.
ARTICLE 3 Prohibition of torture
No one shall be subjected to torture or to inhuman or degrading treatment or punishment.
An extreme interpretation of Article 2 may cause a nation to legislate that, in addition to its citizens having a ‘right to life’, the state has a duty to preserve the life of each citizen over which it has a measure of control - for example, detainees. Yet when these life-sustaining measures are carried out regardless of a detainee’s wishes, they may be in contravention of Article 3 of the ECHR - the right not to be ill-treated at all, yet alone ill-treated in a manner that could be said to amount to torture. In other words, one legal right can become elevated to that of a duty trumping all other rights. And this tension is demonstrated quite clearly in the treatment of force-fed Spanish detainee Mr De Juana whose case the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) investigated and corresponded over with the Spanish Government in 2007.
The Road to Guantanamo
Elsewhere it gets far more worrying. Certain other countries’ governments issue far less benevolent edicts with some of their politicians and lawyers riding roughshod over IHL. They may not be signed up to the Council of Europe’s ECHR or the United Nations’ Optional Protocol to the Convention Against Torture (OP-CAT) or even its more basic Convention Against Torture (CAT). Perhaps even more seriously though, others are signatories yet choose to ignore or ‘reinterpret’ their legal obligations.
Secure environment healthcare professionals operating within such countries have it very tough indeed, most especially if they share the same authority structure as surrounding discipline teams…
Recreation of forced feeding as alleged to be practised within Guantanamo Bay
The Guantanamo Bay hunger strikes came to light in 2005 when about a third of the prisoners started food refusals. The camp authorities responded by authorising the forced feeding of those who were deemed to be causing themselves harm. The strikes were reported again in 2013, following on from which the United States government refused to disclose any further information regarding hunger strikes at the camp.
An extract from the book Torture Team, by leading IHL authority Philippe Sands, gives convincing evidence of additional medical complicity in ill-treatment during interrogation at Guantanamo as far back as 2003. Quoting a commentated extract from the detention log of fluid-refusing prisoner Mr Al-Qahtani who was resisting interrogation:-
A couple of hours later, at 0645, the doctor ‘attempted to put in an IV and was unsuccessful’. At 0730 the doctor ‘ran an IV by putting in a temporary shunt to allow continuous IV’. At 0745 the detainee ‘bent over and bit the IV tube completely in two. The guard strapped him to a stretcher and the corpsman attached a new IV. The detainee struggled through the entire process, but could no longer reach the IV.’… Another example was on 1 December at 0745: ‘Corpsman administers IV. Detainee’s head is restrained by MP to prevent detainee from biting IV’.
(extract from page 206 of Torture Team by Philippe Sands)
Secure environment healthcare professionals often feel pressure to make small compromises in how they adhere to medical ethical gold standards. Yet just one small step onto a slippery slope can prompt a slide towards the gates of disaster.
Medical ethical codes exist for good reason. We break them, bend them to our will, or even just ignore them at our peril.
Miss Danielle Fung, with Dr Rachael Pickering
PS If you’d like to support Integritas’ anti-torture & ill-treatment work, we welcome donations towards the Gerry Serrano Centre.