The case for forcefeeding hunger strikers

The saving of human life should be the overriding consideration in this dilemma

By SHIMON GLICK
Beduin demonstrators hold signs during a protest in the southern town of Rahat in support of Islamic Jihad activist Mohammed Allan (photo credit: REUTERS)
Beduin demonstrators hold signs during a protest in the southern town of Rahat in support of Islamic Jihad activist Mohammed Allan
(photo credit: REUTERS)
WHEN DEALING with hunger-striking prisoners, democratic and liberal societies face an acute ethical dilemma. This was evident in the Israeli media’s recent preoccupation with the fate and treatment of Mohammed Allan, a Palestinian hunger-striking prisoner, whose case reached the Supreme Court.
The World Medical Association and the Israel Medical Association (IMA) have taken the position that feeding hunger- striking prisoners against their will is “inhuman and degrading,” and have forbidden physicians to take part in such activities, even to the point of threatening disciplinary action against violators of the IMA position. However, a number of leading Israeli bioethicists, physicians, philosophers and legal experts, myself included, have taken issue with this approach and argue that the saving of human life should be the overriding consideration in this dilemma.
The IMA position, we contend, is in direct contradiction to a 1996 District Court ruling which stated that in our culture, when there is a conflict between human life and human dignity, the value of human life should take precedence.
This decision was in line with an earlier Supreme Court ruling imposing life-saving surgery on a prisoner. In his ruling, Supreme Court Judge Moshe Beisky wrote, “The principle of sanctity and rescue of human life as a supreme value justifies our not following those rules, which espouse almost rigidly the prohibition against invading the body of an individual without his consent, without taking into account the consequences….
When an individual is in danger of death or certain serious injury to his health, we are definitely allowed to do surgery or other involvement in his body even without his consent.”
Both court rulings are in accord with the Patient Rights Law, which permits imposition of life-saving treatment on a non-consenting patient, if an institutional ethics committee feels that, after such treatment, the patient will give retroactive consent. Similarly a 1990 American Supreme Court decision stated, “We do not think a state is required to remain neutral in the face of an informed and voluntary decision by a physically able adult to starve to death.” The European Court of Human Rights and courts in a number of other democratic countries have similarly permitted imposed feeding on hunger-striking prisoners when they reach a stage where there is clear danger to life.
Israel also has a law, based on Leviticus 19:16, enjoining people not to “stand idly by when your neighbor’s life is threatened.” In other words, requiring individuals to come to the aid of others facing sudden danger to life or limb.
When the authorities confront a prisoners’ hunger strike there are basically three available options: permit the strike to continue until death of the prisoners; impose feeding on the hunger strikers; or accede to the strikers’ demands.
The first alternative has been used in a number of countries. Perhaps the best known case was under former British prime minister Margaret Thatcher, who permitted 10 Irish strikers to starve to death in the early 1980s and subsequently came under severe, almost universal criticism for her decision.
Tens and perhaps hundreds of other hunger-striking prisoners have also been permitted to die, for example, Kurds in Turkey and blacks in apartheid South Africa. Some right-wing spokesmen in Israel have proposed that Palestinian hunger-striking prisoners be similarly permitted to die. However, I do not think that modern Jewish and democratic Israel would find such a course acceptable.
The second alternative is to impose feeding on the prisoners. Boston University’s George Annas, an expert on law and medicine, although an opponent of force-feeding, has written, “We restrict the rights of prisoners in many ways.
Force-feeding them rather than permitting them to starve themselves to death is probably one of the most benign.”
Moreover, no prison in a democratic country to my knowledge permits the The saving of human life should be the overriding consideration in this dilemma The case for forcefeeding hunger strikers Individual physicians should be free to act in accordance with their consciences without dictation from outside sources suicide of a prisoner, although this limitation too is an infringement of the prisoner’s autonomy. And if a prisoner makes an unsuccessful suicide attempt, he/she would be treated in all democratic countries, even over his/her strong objections.
Another key point is that in reality virtually none of the hunger strikers wants to die. If this is so, one may argue that by feeding them we actually respect their autonomy. Data also show that hunger strikers who have been force-fed are ultimately grateful for being saved. This puts them in the category for which the Patient Rights Law allows an ethics committee to permit feeding even against the patients’ will.
It is argued that feeding by nasogastric tube represents torture. Insertion of a nasogastric tube is indeed not pleasant, but it is a daily procedure in every hospital.
And it is certainly far less torture than the alternative – weeks of starvation until death. If carried out with gentleness and respect for the patient, as it should be, it is not “torture.”
The third alternative is to accede to hunger-strikers’ demands. This approach makes a hunger strike the prisoners’ ultimate weapon and could lead to total prison anarchy. Any prisoner could demand freedom from prison under the threat of a total fast. No society can countenance such an approach.
What constitutes an ethical and balanced approach to the dilemma? One should certainly permit prisoners to declare a hunger strike, which may be virtually their only means of protest to bring attention to their demands, which may or may not be justified. This approach is in contrast to the infamous situation in the American Guantanamo Bay prison, where as soon as a prisoner misses nine meals, he is force-fed in the prison itself by prison staff.
WE PROPOSE that only when the prisoner reaches a point of serious danger to life and health, he/she should be transferred from the prison to a hospital, where he/she is to be treated like any other patient, and certainly not by the prison staff. Physicians not associated with prison authorities who can establish a positive, trusting relationship with the prisoner should negotiate with him/her on how to begin feeding.
To the IMA’s credit, they have done impressive work by quiet negotiations with hospitalized prisoners to end their fasts, and no fasting Palestinian prisoner has died in recent years. But it should be made clear to the prisoner that under no circumstances will he/she be permitted to die, and that when danger to life and health is imminent, the prisoner will be fed. The prisoner then has the choice of cooperating with the feeding or resisting.
Under those circumstances most prisoners will be willing to be treated without the necessity of restraint or coercion.
This is sharply at odds with the IMA position, which insisted in the Allan case on waiting until the prisoner lost consciousness before treating him. That approach is faulty on several counts. For one, it still violates the prisoner’s autonomy while exposing him/her to the danger of sudden death or permanent brain injury.
In the process of his treatment, Allan had to be intubated and subjected to mechanical ventilation, a treatment causing considerably more suffering than does feeding by a nasogastric tube.
Ethics is unquestionably culturally dependent. Different cultures have dramatically different approaches to sensitive subjects such as abortion, euthanasia and surrogate motherhood. Much of the Western world, led by the US, has pushed patient autonomy as the dominant ethical principle among competing values. This emphasis is praiseworthy and has contributed greatly to the practice of medicine.
But it must be recognized that in the complex world of physician-patient relationships other values exist as well, and societies should be free to reach their particular equilibrium in accord with their own culture and value systems.
In this difficult conflict, individual physicians should be free to act in accordance with their consciences without dictation from outside sources, be they governmental or organizational. There is no room for thought control or cultural imperialism, in which all are regimented into a single approach. Professor emeritus Shimon Glick, a founding member of the Ben-Gurion University Medical School and a former dean of the Faculty of Health Sciences, is an internationally renowned expert on medical ethics


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