wma declaration of malta on hunger strikers

8/12/2019 WMA Declaration of Malta on Hunger Strikers

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WMA Declaration of Malta on Hunger Strikers

Adopted by the 43rdWorld Medical Assembly, St. Julians, Malta, November 1991and editorially revised by the 44thWorld Medical Assembly, Marbella, Spain,September 199

and revised by the !"thWMA #eneral Assembly, $ilanesber%, South A&rica,'ctober (()

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 oten a orm o protest by

people who lack other ways o making their demands known. !n

reusing nutrition or a signiicant period, they usually hope to obtain

certain goals by inlicting negative publicity on the authorities. "hort#

term or eigned ood reusals rarely raise ethical problems. $enuine

and prolonged asting risks death or permanent damage or hunger

strikers and can create a conlict o values or physicians. Hungerstrikers usually do not wish to die but some may be prepared to do so

to achieve their aims. %hysicians need to ascertain the individual&s true

intention, especially in collective strikes or situations where peer

pressure may be a actor. 'n ethical dilemma arises when hunger

strikers who have apparently issued clear instructions not to be

resuscitated reach a stage o cognitive impairment. The principle o

beneicence urges physicians to resuscitate them but respect or

individual autonomy restrains physicians rom intervening when a valid

and inormed reusal has been made. 'n added diiculty arises in

custodial settings because it is not always clear whether the hunger

striker&s advance instructions were made voluntarily and with

appropriate inormation about the conseuences. These guidelines and

the background paper address such diicult situations.

PRINCIPLES


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1. uty to act ethically. 'll physicians are bound by medical ethics in

their proessional contact with vulnerable people, even when not

providing therapy. *hatever their role, physicians must try to prevent

coercion or maltreatment o detainees and must protest i it occurs.

+. espect or autonomy. %hysicians should respect individuals&

autonomy. This can involve diicult assessments as hunger strikers&

true wishes may not be as clear as they appear. 'ny decisions lack

moral orce i made involuntarily by use o threats, peer pressure or

coercion. Hunger strikers should not be orcibly given treatment they

reuse. -orced eeding contrary to an inormed and voluntary reusal is

unjustiiable. 'rtiicial eeding with the hunger striker&s explicit or implied

consent is ethically acceptable.

. &/eneit& and &harm&. %hysicians must exercise their skills and

knowledge to beneit those they treat. This is the concept o

&beneicence&, which is complemented by that o &non#maleicence& or

primum non nocere. These two concepts need to be in balance.

&/eneit& includes respecting individuals& wishes as well as promoting

their welare. 'voiding &harm& means not only minimising damage to

health but also not orcing treatment upon competent people nor

coercing them to stop asting. /eneicence does not necessarily involve

prolonging lie at all costs, irrespective o other values.

0. /alancing dual loyalties. %hysicians attending hunger strikers can

experience a conlict between their loyalty to the employing authority

(such as prison management) and their loyalty to patients. %hysicianswith 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.

. 2linical independence. %hysicians must remain objective in their

assessments and not allow third parties to inluence their medical

judgement. They must not allow themselves to be pressured to breach

ethical principles, such as intervening medically or non#clinical

reasons.


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3. 2onidentiality. The duty o conidentiality is important in building

trust but it is not absolute. !t can be overridden i non#disclosure

seriously harms others. 's with other patients, hunger strikers&

conidentiality should be respected unless they agree to disclosure orunless inormation sharing is necessary to prevent serious harm. !

individuals agree, their relatives and legal advisers should be kept

inormed o the situation.

4. $aining trust. -ostering trust between physicians and hunger

strikers is oten the key to achieving a resolution that both respects the

rights o the hunger strikers and minimises harm to them. $aining trust

can create opportunities to resolve diicult situations. Trust is

dependent upon physicians providing accurate advice and being rank

with hunger strikers about the limitations o what they can and cannot

do, including where they cannot guarantee conidentiality.

GUIDELINES !R "HE MANAGEMEN" ! HUNGER S"RI#ERS

1. %hysicians must assess individuals& mental capacity. This involves

veriying that an individual intending to ast does not have a mentalimpairment that would seriously undermine the person&s ability to make

health care decisions. !ndividuals with seriously impaired mental

capacity cannot be considered to be hunger strikers. They need to be

given treatment or their mental health problems rather than allowed to

ast in a manner that risks their health.

+. 's early as possible, physicians should acuire a detailed and

accurate medical history o the person who is intending to ast. Themedical implications o any existing conditions should be explained to

the individual. %hysicians should veriy that hunger strikers understand

the potential health conseuences o asting and orewarn them in plain

language o the disadvantages. %hysicians should also explain how

damage to health can be minimised or delayed by, or example,

increasing luid intake. "ince the person&s decisions regarding a hunger

strike can be momentous, ensuring ull patient understanding o the

medical conseuences o asting is critical. 2onsistent with best


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practices or inormed consent in health care, the physician should

ensure that the patient understands the inormation conveyed by

asking the patient to repeat back what they understand.

. ' thorough examination o the hunger striker should be made at the

start o the ast. 5anagement o uture symptoms, including those

unconnected to the ast, should be discussed with hunger strikers.

'lso, the person&s values and wishes regarding medical treatment in

the event o a prolonged ast should be noted.

0. "ometimes hunger strikers accept an intravenous saline solution

transusion or other orms o medical treatment. ' reusal to acceptcertain interventions must not prejudice any other aspect o the medical

care, such as treatment o inections or o pain.

. %hysicians should talk to hunger strikers in privacy and out o

earshot o all other people, including other detainees. 2lear

communication is essential and, where necessary, interpreters

unconnected to the detaining authorities should be available and they

too must respect conidentiality.

3. %hysicians need to satisy themselves that ood or treatment reusal

is the individual&s voluntary choice. Hunger strikers should be protected

rom coercion. %hysicians can oten help to achieve this and should be

aware that coercion may come rom the peer group, the authorities or

others, such as amily members. %hysicians or other health care

personnel may not apply undue pressure o any sort on the hunger

striker to suspend the strike. Treatment or care o the hunger striker

must not be conditional upon suspension o the hunger strike.

4. ! a physician is unable or reasons o conscience to abide by a

hunger striker&s reusal o treatment or artiicial eeding, the physician

should make this clear at the outset and reer the hunger striker to

another physician who is willing to abide by the hunger striker&s reusal.

6. 2ontinuing communication between physician and hunger strikers


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is critical. %hysicians 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 meaningully.

These indings must be appropriately recorded.

7. *hen 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 lie.

2onsideration needs to be given to any advance instructions made by

the hunger striker. 'dvance reusals o treatment demand respect i

they relect the voluntary wish o the individual when competent. !n

custodial settings, the possibility o advance instructions having been

made under pressure needs to be considered. *here physicians have

serious doubts about the individual&s intention, any instructions must be

treated with great caution. ! well inormed and voluntarily made,

however, advance instructions can only generally be overridden i they

become invalid because the situation in which the decision was made

has changed radically since the individual lost competence.

18. ! 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 cultural values as well

as their physical health. !n the absence o any evidence o hunger

strikers& ormer wishes, physicians should decide whether or not to

provide eeding, without intererence rom third parties.

11. %hysicians may consider it justiiable to go against advance

instructions reusing treatment because, or example, the reusal is

thought to have been made under duress. !, ater resuscitation and

having regained their mental aculties, hunger strikers continue to

reiterate their intention to ast, that decision should be respected. !t is

ethical to allow a determined hunger striker to die in dignity rather than

submit that person to repeated interventions against his or her will.

1+. 'rtiicial eeding can be ethically appropriate i competent hunger


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strikers agree to it. !t can also be acceptable i incompetent individuals

have let no unpressured advance instructions reusing it.

1. -orcible eeding is never ethically acceptable. 9ven i intended to

beneit, eeding accompanied by threats, coercion, orce or use o

physical restraints is a orm o inhuman and degrading treatment.

9ually unacceptable is the orced eeding o some detainees in order

to intimidate or coerce other hunger strikers to stop asting.

wma declaration of malta on hunger strikers

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