DoH-Oct2006

Handbook of WMA Policies
World Medical Association ½ D-1991-01-2006

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 1992
and revised by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
PREAMBLE
1. 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 often a form of protest by people who lack other ways of making their de-
mands known. In refusing nutrition for a significant period, they usually hope to
obtain certain goals by inflicting negative publicity on the authorities. Short-term or
feigned food refusals rarely raise ethical problems. Genuine and prolonged fasting
risks death or permanent damage for hunger strikers and can create a conflict of values
for physicians. Hunger strikers usually do not wish to die but some may be prepared
to do so to achieve their aims. Physicians need to ascertain the individual’s true inten-
tion, especially in collective strikes or situations where peer pressure may be a factor.
An ethical dilemma arises when hunger strikers who have apparently issued clear in-
structions not to be resuscitated reach a stage of cognitive impairment. The principle
of beneficence urges physicians to resuscitate them but respect for individual auto-
nomy restrains physicians from intervening when a valid and informed refusal has
been made. An added difficulty arises in custodial settings because it is not always
clear whether the hunger striker’s advance instructions were made voluntarily and with
appropriate information about the consequences. These guidelines and the background
paper address such difficult situations.
PRINCIPLES
2. Duty to act ethically. All physicians are bound by medical ethics in their professional
contact with vulnerable people, even when not providing therapy. Whatever their role,
physicians must try to prevent coercion or maltreatment of detainees and must protest
if it occurs.
2. Respect for autonomy. Physicians should respect individuals’ autonomy. This can in-
volve difficult assessments as hunger strikers’ true wishes may not be as clear as they
appear. Any decisions lack moral force if made involuntarily by use of threats, peer
pressure or coercion. Hunger strikers should not be forcibly given treatment they re-
fuse. Forced feeding contrary to an informed and voluntary refusal is unjustifiable. Arti-
ficial feeding with the hunger striker’s explicit or implied consent is ethically accept-
able.
D-1991–01-2006½ Pilanesberg
Hunger Strikers

3. ‘Benefit’ and ‘harm’. Physicians must exercise their skills and knowledge to benefit
those they treat. This is the concept of ‘beneficence’, which is complemented by that
of ‘non-maleficence’ or primum non nocere. These two concepts need to be in balance.
‘Benefit’ includes respecting individuals’ wishes as well as promoting their welfare.
Avoiding ‘harm’ means not only minimising damage to health but also not forcing
treatment upon competent people nor coercing them to stop fasting. Beneficence does
not necessarily involve prolonging life at all costs, irrespective of other values.
4. Balancing dual loyalties. Physicians attending hunger strikers can experience a con-
flict between their loyalty to the employing authority (such as prison management) and
their loyalty to patients. Physicians 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.
5. Clinical independence. Physicians must remain objective in their assessments and not
allow third parties to influence their medical judgement. They must not allow them-
selves to be pressured to breach ethical principles, such as intervening medically for
non-clinical reasons.
6. Confidentiality. The duty of confidentiality is important in building trust but it is not
absolute. It can be overridden if non-disclosure seriously harms others. As with other
patients, hunger strikers’ confidentiality should be respected unless they agree to
disclosure or unless information sharing is necessary to prevent serious harm. If
individuals agree, their relatives and legal advisers should be kept informed of the
situation.
7. Gaining trust. Fostering trust between physicians and hunger strikers is often the key
to achieving a resolution that both respects the rights of the hunger strikers and mini-
mises harm to them. Gaining trust can create opportunities to resolve difficult situ-
ations. Trust is dependent upon physicians providing accurate advice and being frank
with hunger strikers about the limitations of what they can and cannot do, including
where they cannot guarantee confidentiality.
GUIDELINES FOR THE MANAGEMENT OF HUNGER STRIKERS
1. Physicians must assess individuals’ mental capacity. This involves verifying that an
individual intending to fast does not have a mental impairment that would seriously
undermine the person’s ability to make health care decisions. Individuals with
seriously impaired mental capacity cannot be considered to be hunger strikers. They
need to be given treatment for their mental health problems rather than allowed to fast
in a manner that risks their health.
2. As early as possible, physicians should acquire a detailed and accurate medical history
of the person who is intending to fast. The medical implications of any exist-ing
conditions should be explained to the individual. Physicians should verify that
hunger strikers understand the potential health consequences of fasting and forewarn
them in plain language of the disadvantages. Physicians should also explain how da-
mage to health can be minimised or delayed by, for example, increasing fluid intake.
Since the person’s decisions regarding a hunger strike can be momentous, ensuring full
Handbook of WMA Policies
World Medical Association ½ D-1991-01-2006

patient understanding of the medical consequences of fasting is critical. Consist-ent
with best practices for informed consent in health care, the physician should en-sure
that the patient understands the information conveyed by asking the patient to repeat
back what they understand.
3. A thorough examination of the hunger striker should be made at the start of the fast.
Management of future symptoms, including those unconnected to the fast, should be
discussed with hunger strikers. Also, the person’s values and wishes regarding medi-
cal treatment in the event of a prolonged fast should be noted.
4. Sometimes hunger strikers accept an intravenous saline solution transfusion or other
forms of medical treatment. A refusal to accept certain interventions must not preju-
dice any other aspect of the medical care, such as treatment of infections or of pain.
5. Physicians should talk to hunger strikers in privacy and out of earshot of all other
people, including other detainees. Clear communication is essential and, where neces-
sary, interpreters unconnected to the detaining authorities should be available and they
too must respect confidentiality.
6. Physicians need to satisfy themselves that food or treatment refusal is the individual’s
voluntary choice. Hunger strikers should be protected from coercion. Physicians can
often help to achieve this and should be aware that coercion may come from the peer
group, the authorities or others, such as family members. Physicians or other health
care personnel may not apply undue pressure of any sort on the hunger striker to sus-
pend the strike. Treatment or care of the hunger striker must not be conditional upon
suspension of the hunger strike.
7. If a physician is unable for reasons of conscience to abide by a hunger striker’s refusal
of treatment or artificial feeding, the physician should make this clear at the outset and
refer the hunger striker to another physician who is willing to abide by the hunger
striker’s refusal.
8. Continuing communication between physician and hunger strikers is critical. Physi-
cians 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
meaningfully. These findings must be appropriately recorded.
9. When 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 life. Consideration needs to be given to any advance
instructions made by the hunger striker. Advance refusals of treatment demand res-
pect if they reflect the voluntary wish of the individual when competent. In custodial
settings, the possibility of advance instructions having been made under pressure
needs to be considered. Where physicians have serious doubts about the individual’s
intention, any instructions must be treated with great caution. If well informed and
voluntarily made, however, advance instructions can only generally be overridden if
they become invalid because the situation in which the decision was made has changed
radically since the individual lost competence.
D-1991–01-2006½ Pilanesberg
Hunger Strikers

10. If 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 cul-
tural values as well as their physical health. In the absence of any evidence of hunger
strikers’ former wishes, physicians should decide whether or not to provide feeding,
without interference from third parties.
11. Physicians may consider it justifiable to go against advance instructions refusing treat-
ment because, for example, the refusal is thought to have been made under duress. If,
after resuscitation and having regained their mental faculties, hunger strikers continue
to reiterate their intention to fast, that decision should be respected. It is ethical to al-
low a determined hunger striker to die in dignity rather than submit that person to re-
peated interventions against his or her will.
12. Artificial feeding can be ethically appropriate if competent hunger strikers agree to it.
It can also be acceptable if incompetent individuals have left no unpressured advance
instructions refusing it.
13. Forcible feeding is never ethically acceptable. Even if intended to benefit, feeding ac-
companied by threats, coercion, force or use of physical restraints is a form of inhu-
man and degrading treatment. Equally unacceptable is the forced feeding of some de-
tainees in order to intimidate or coerce other hunger strikers to stop fasting.