D-1991-01-1992_OVE

L’ASSOClAnON MEDICAU MONDIALI. INC LA ASOCIACION MeDICA MUNDIAL. INC
THE WORLD MEDICAL ASSOCIATION. INC•.
P.O. Box 63 – 28, Avenue d.. Alpes
01212 FERNEY·VOLTAIRE Cedex. France
Telex: 385755F WMASFVF
Cabie Add….. : WOMEDAS. Ferney-VoltaJre
Telephone: 50407575
Tet.fu: 50″0 5& 31
September 1992
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Original: English
WORLD MEDICAL ASSOCIATION DECLARATION OF MALTA
on
HUNGER STRIKERS
Adopted by the 43rd World Medical Assembly
Malta, November 1991 .
and editorially revised at the
44th World Medica! Assembly .
Marbella, Spain, September 1992
PREAMBLE
PREAMBLE
1. The doctor treating hunger strjkers is faced with the following conflicting values:
1.1 There is a moral obligation on every human being to respect the sanctity of
life. This is especiafly evident in the case of a doctor, who exercises his
skills to save ute and also acts in the best interests of his patients
(Beneficence).
1.2 It is the duty of the doctor to respect the autonomy which the patient has
over his person. A doctor requires informed consent from his patients ·
before applying any. of his skills to assist them, .unless emergency
circumstances have arisen in which case the doctor has to act In what is
perceived to be the patienfs best interests. .
2. This canfUct is apparent where a hunger striker who has issued clear instructions
not to be resuscitated lapses into a coma and is about to die. Moral obligation
urges the doctor to resuscitate the patient even though it is against the patienrs
wishes. On the other hand, duty urges the doctor to respect the autonomy of the
patient.
2.1 Ruling in favour of intervention may undermine the autonomy which the
patient has over himself.
2.2 Ruling in favour of non-intervention may result in a doctor having to face
the tragedy of an avoidable death.
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3. A doctor/patient relationship is said to be in existence whenever a doctor is duty
bound, by virtue of his obligation to the patient, to apply his skills to any person,
be it in the form of advice or treatment
This relationship can exist in spite of the fact that the patient might not consent
to certain forms of treatment or intervention.
Once the doctor agrees to attend to ahunger striker, that person becomes the
doctors patient This has all the implication and responsibilities inherent in the
doctor/patient relationship, inclUding consent and confidentiality.
4. The ultimate decision on intervention or non-intervention should be left with the ·
individual doctor without the intervention of third parties whose primary interest Is
not the patient’s welfare. However, the doctor should clearly state to the patient
whether or not he is able to accept the patient’s decision to refuse treatment or.
In case of coma, artificial feeding, thereby risking death. If the doctor cannot
accept the patient’s decision to refuse such aid, the patient would then be entitled
to be attended by another physician.
GUIDELINES FOR THE MANAGEMENT OF HUNGER STRIKERS
Since the medical profession considers the principle of sanctity of life to be
fundamental to its practice, the following practical guidelines are recommended for
doctors who treat hunger strikers:
1. DEFINITION
A hunger striker is a mentally competent person who has indicated that he has
decided to embark on a hunger strike and has refused to take food and/or
fluids for a significant interval.
fluids for a significant interval.
2. ETHICAL BEHAVIOUR
2.1 A doctor should acquire a detailed medical history of the patient where
possible.
2.2
2.3
2.4
2.5
A doctor should carry out a thorough examination of the patient at the
onset of the hunger.;~ike. . . _
Doctors or other health care personnel may not apply undue pressure .
of any sort on the hunger striker to suspend the strike. Treatment or
care of the hunger striker must not be conditional upon him suspending
his hunger strike.
The hunger striker mustbe professionally informed by the doctor of the
clinical consequences of a hunger strike, and of any specific danger to
his own particular case. An informed decision can only be made on the
basis of clear communication. An interpreter should be used if
indicated.
Should a hunger striker wish to have a second medical opinion, this
should be granted. Should a hunger striker prefer his treatment to be
continued by the second doctor. this should be permitted. In the case of
the hunger striker being a prisoner, this should be permitted by
arrangement and consultation with the appointed prison doctor.
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2.6 Treating infections or advising the patient to increase his oral Intake of
fluid (or accept intravenous saline solutions) is often acceptable to a
hunger striker. A refusat to accept such intervention ..must not prejudice
any other aspect of the patients health care. Any treatment
administered to the patient must be with his approval.
3. CLEAR INSTRUCTIONS
The doctor should ascertain on a daily basis whether or not the patient wishes
to continue With his hunger strike. The doctor should also ascertain .on a dally
basis what the patient’s wishes are with regard to treatment should he become
unable to make an informed decision. These findings must be recorded tn the
doctors personal medical records and kept confidential.
4. ARTIFICIALFEEDING
‘Nhen the hunger striker has become confused and is therefore unable to
make an unimpaired decision or has lapsed into acoma, the doctor shall be
free to make the decision for his patient as to further treatment which he
considers to be in the best Interest of that patient. always taking into account
the decision he has arrived at during his preceding care of the patient during
his hunger strike, and reaffirming article 4 of the preamble of this Declaration.
5. COERCION
Hunger strikers should be protected from coercive participation. This may
require removal from the presence of fellow strikers.
6. FAMILY
The doctor has a responsibility to inform the family of the patient that the
The-dodOr -haS-aI responsibJi(fy1o”rnfolrn’ ‘WteC>’falfalfy1ofWfi_re’lHliPilftd
patient has embarked-on a hunger strike, unless this is specifically prohibited
by the patient.
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