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Legal and ethical implications of medically enforced feeding of detained asylum seekers on hunger strike

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Abstract

The current practice of non-consensual medical treatment of hunger-striking asylum seekers in detention needs closer inquiry. An Australian Government regulation empowers the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) to authorise non-consensual medical treatment for a person in immigration detention if they are at risk of physical harm, but there are doubts about whether the regulation would withstand legal challenge. Authorisation by DIMIA does not compel medical practitioners to enforce treatment if such action is contrary to their "ethical, moral or religious convictions". The World Medical Association has established guidelines for doctors involved in managing people on hunger strikes. The Declaration of Tokyo (1975) and the Declaration of Malta (1991) both prohibit the use of non-consensual force-feeding of hunger strikers who are mentally competent. If called upon to treat hunger strikers, medical practitioners should be aware of their ethical and legal responsibilities, and that they should act independently of government or institutional interests.
MJA Vol 180 1 March 2004 237
CLINICAL ETHICS
The Medical Journal of Australia ISSN: 0025-729X 1
March 2004 180 5 237-240
©The Medical Journal of Australia 2004
www.mja.com.au
Clinical Ethics
HUNGER STRI KES BY ASYLUM SEEKER S have occurred in
Australia since the introduction of the policy of mandatory
detention over a decade ago.1 At times, the number of
asylum seekers involved in this form of protest has reached
crisis point, with over 200 detainees embarking on a hunger
strike at the Woomera Immigration Reception and Process-
ing Centre in 2002. Hunger strikes are a politically charged
issue, with the former Australian Minister for Immigration,
Multicultural and Indigenous Affairs (Phillip Ruddock)
asserting that such actions are manipulative efforts by
detainees to gain refugee status.2-4
The Australian Department of Immigration and Multi-
cultural and Indigenous Affairs (DIMIA) can authorise
physicians, under Migration Regulation 5.35, to provide
non-consensual medical treatment. In 2001, DIMIA issued
about 40 authorisations for compulsory medical treatment.4
Such actions risk violating international medical guidelines.
It is therefore timely to examine both the legal and ethical
implications for doctors if they coercively rehydrate or force-
feed detained asylum seekers.
Reasons for food refusal
The World Medical Association (WMA) has defined a
hunger striker as a “mentally competent person who has
indicated that he [or she] has decided to refuse to take food
and/or fluids for a significant interval”.5 The motivations
underlying hunger strikes by asylum seekers are complex. A
study in the United States indicated that asylum seekers
embark on hunger strikes in the early phase of detention to
express their distress and opposition to incarceration. In the
later stages of detention, especially after refugee claims have
been rejected, hunger strikes commonly represent a desire to
die rather than to be forcibly repatriated to situations of
danger.6
The relationship between hunger strikes and mental ill-
ness is complex. A study of hunger-striking political prison-
ers in South Africa found that 77% were clinically
depressed.7 Nevertheless, the presence of mental illness
does not mean ipso facto that a hunger striker is not
competent to make decisions about pursuing the protest.
Asylum seekers held in immigration detention centres in
Australia may have been exposed to high levels of trauma in
their countries of origin and during their journey to Aus-
tralia.8 After arrival, they experience ongoing stresses,
including separation from family, interviews with immigra-
tion officials, and delays in the asylum application process.
They also experience social isolation, boredom and frustra-
tion. Rates of depression and related disorders in detention
appear to be extraordinarily high, particularly among those
held for prolonged periods.9,10 It is imperative that a com-
prehensive psychiatric assessment is made early in a hunger
strike to decide whether depressive or other symptoms are
primarily reactive to environmental circumstances, or
whether the competence of the person to decide to pursue
the strike is impaired by a severe depressive illness or
associated morbid mental state.
Legal aspects
The Australian Government introduced a regulation in
1992 which empowers DIMIA to authorise medical treat-
Legal and ethical implications of medically enforced feeding
of detained asylum seekers on hunger strike
Mary A Kenny, Derrick M Silove and Zachary Steel
ABSTRACT
The current practice of non-consensual medical treatment
of hunger-striking asylum seekers in detention needs closer
inquiry.
An Australian Government regulation empowers the
Department of Immigration and Multicultural and Indigenous
Affairs (DIMIA) to authorise non-consensual medical
treatment for a person in immigration detention if they
are at risk of physical harm, but there are doubts about
whether the regulation would withstand legal challenge.
Authorisation by DIMIA does not compel medical
practitioners to enforce treatment if such action is contrary
to their “ethical, moral or religious convictions”.
The World Medical Association has established guidelines
for doctors involved in managing people on hunger strikes.
The Declaration of Tokyo (1975) and the Declaration of
Malta (1991) both prohibit the use of non-consensual force-
feeding of hunger strikers who are mentally competent.
If called upon to treat hunger strikers, medical practitioners
should be aware of their ethical and legal responsibilities,
and that they should act independently of government or
MJA 2004; 180: 237–240
institutional interests.
School of Law, Murdoch University, Murdoch, WA.
Mary A Kenny, BJuris, LLB(H ons), LLM, Senior Lecturer, School of Law,
Murdoch University.
School of Psychiatry, University of New South Wales, and
Centre for Popula tion Mental Health Research, South
Western Sydney Area Health Service, Liverpo ol, NSW.
Derrick M Silove, FRANZCP, MD, Professor, School of Psychiatry,
University of New South Wales;
Zachary Steel, BA (Hons), MPsychol (Clinica l), Senior Lecturer, School of
Psychiatry, University of New South Wales.
Reprints will not be available from the authors. Correspondence:
Ms Mary Anne Kenny, School of Law, Murdoch University, South Street,
Murdoch, WA 6050. m.kenny@murdoch.edu.au
CLINICAL ETHICS
238 MJA Vol 180 1 March 2004
CLINICAL ETHICS
ment to be given to a person in immigration detention
without their consent (Migration Regulations 1994 (Cwlth),
Regulation 5.35). The regulation is invoked when a Com-
monwealth Medical Officer or registered medical practi-
tioner provides written advice to the Secretary of DIMIA
that:
if medical treatment is not given to a particular detainee,
there will be a serious risk to his or her life or health; and
that the detainee refuses to give, or is not reasonably
capable of giving, consent for the medical treatment.
The Secretary of DIMIA can then authorise non-consen-
sual treatment, including the use of reasonable force (eg, the
use of restraints and sedatives). Authorisation by DIMIA
does not compel medical practitioners to enforce treatment
if such action is contrary to their “ethical, moral or religious
convictions”.11
According to Hansard, the regulation received no parlia-
mentary attention or debate at the time of its introduction.
Nor has it been the subject of any challenge in Australian
courts. Yet legal opinion suggests that, if challenged in
court, the regulation would most likely be struck out.12 It is
noteworthy, too, that the Human Rights and Equal Oppor-
tunity Commission has recommended that Parliament
repeal the regulation.1
A long-established common law principle upholds the
right to individual self-determination, including the choice
to refuse treatment. Persons deemed to be of full mental
capacity can refuse treatment, even if that act is tantamount
to suicide. A medical practitioner who performs medical
treatment without the patient’s consent can be held to have
committed an assault.13 This could give rise to a claim of
damages.
Arguments have been put that there are exceptions to this
common law principle, particularly when it is in the state’s
interest to intervene. It has been argued that force-feeding of
hunger-striking prisoners represents the state’s duty to
preserve the life of detainees, an imperative that overrides
issues of autonomy.14 Yet, in the United Kingdom, a series
of court decisions has endorsed the principle of autonomy
and self-determination in relation to hunger strikes,
reaffirming the prisoner’s rights to refuse treatment.15
In summary, there are serious questions about whether
the existing Australian regulation would be upheld if chal-
lenged in court, as the instrument is not consistent with
common law principles and may be in breach of inter-
national human rights law.
Clinical complexities
The medical literature indicates that death from hunger
strikes can occur between 42 and 79 days of a complete fast.
After about a week, the hunger striker experiences dramatic
weight loss. In the following weeks, the liver and intestines
atrophy, followed by the heart and kidneys. The pulse slows
and blood pressure falls. Patients complain of fatigue,
headache, faintness and dizziness. By about the 40th day,
the striker becomes seriously ill, is bedridden and suffers
concentration problems and apathy.16 ,17
The course of physical and cognitive deterioration means
that assessment of a hunger striker’s mental state and inten-
tions needs to be undertaken early, while they remain men-
tally competent.18 As mentioned, in such an assessment, the
evidence needs to be weighed up as to whether manifestations
of despair and demoralisation are a realistic response or
reflect a form of mental illness that in itself impairs compe-
tency. If symptoms of despair and hopelessness are reality-
based, then standard antidepressant treatments may not
necessarily be effective, especially if the environmental condi-
tions generating the despondency (prolonged incarceration
and threat of forced repatriation) are not alleviated. The case
study in the Box illustrates this dilemma.
Ethical issues
From an ethical perspective, the practitioner caring for
hunger strikers confronts the tension between, on the one
hand, the imperative to preserve life and, on the other,
respect for the autonomy of the individual. Australian
practitioners face the added complexity of reconciling ethi-
cal and medical issues with the priorities of government
policy, particularly the state’s interest in maintaining order
Case study — realistic despair or mental illness?
A young male detaine e commenced a hung er stri ke in a remote
detention centre after his claim for refugee status had been
rejected. The initial strike was a prot est about his treatment in
detention, which he alleged had involved a period of solitary
confinement and physical restraint. During the first strike, he was
rehydrated intravenously under Regulation 5.35. Some months later
he again refused food and was rehydrated and fed through a
nasogastric tube on several occasions under Regulation 5.35. He
developed symptoms of severe depression with associated weight
loss of over 10 kg. After 2 months of failed treatment with an
antidepressant, he was transferred to a metropolitan hospital.
Attending clinicia ns judged that he was no longer on active hunger
strike and that his symptoms of anorexia, hopelessness, loss of
interest, and vague suicidal thought s amount ed to clinical
depression. Electroconvulsive therapy, intravenous hydration and
nasogastric feeding were recommended by the treating staff. The
patient refused consent, leading to Regulation 5.35 being invoked.
There was some initial improvement in the patient’s cond ition with
this regimen of enforced treatment, b ut his depression then
worsened while treatment was ongoing and he again refused food.
Nasogastric feeding was recommended. The patient instructed his
lawyers that he did not wish this procedure to be administered,
as it caused him pain and discomfort. The hospital staff asserted
that they were acting under the authority of the Secretary of the
Department of Immigration, Multicultural and Indigenous Affairs
(DIMIA). Although the patient was despondent, his concerns about
his plight appeared to be reality-based, and his lawyers judged that
the patient was acting competentl y in ch oosing not to have further
treatment. The lawyers advised the hospital that they would
challeng e the authority of Re gulation 5.35, and indicated that they
would seek an injunction to prevent the administration of further
enforced treatment. It was pointed out that t he Regulation did not
require a medical practitioner to act contrary to standing ethical
guidelines.
As it transpired, no further treatment was necessary, as the patient
voluntarily recommenced fluid and food intake. He was eventually
released into the community on a bri dging visa pending
determination of his claim.
MJA Vol 180 1 March 2004 239
CLINICAL ETHICS
and security in detention centres during a period of political
controversy about detention. DIMIA itself discharges com-
plex and potentially conflicting roles: this single government
authority is responsible for apprehending and detaining
asylum seekers, for determining their refugee status, for
discharging an ongoing duty of care, and for enforcing
repatriation of those whose claims for asylum fail.
Yet international ethical guidelines are unequivocal in
their directives to practitioners managing hunger strikers.
According to the WMA’s Declaration of Tokyo (1975):
Where a prisoner refuses nourishment and is considered by
the doctor as capable of forming an unimpaired and rational
judgement concerning the consequences of such a voluntary
refusal of nourishment, he or she shall not be fed artificially.
The decision as to the capacity of the prisoner to form such
a judgement should be confirmed by at least one other
independent doctor. The consequences of the refusal of
nourishment shall be explained by the doctor to the pris-
oner.19
The principles of the Tokyo Declaration were endorsed by
a position statement of the Royal Australasian College of
Physicians in July 1993.20
The preamble to the Declaration of Malta (1991) (revised
in 1992) underlines the ethical risks facing doctors working
with government agencies:
The ultimate decision on intervention or non-intervention
should be left with the individual doctor without the inter-
vention of third parties whose primar y interest is not the
patient’s welfare.5
At the same time, this provision does not allow a physician
acting alone to compel treatment, as the Declaration makes
it clear that if a physician tends towards compulsory inter-
vention the “patient would then be entitled to be attended
by another doctor”. However, the Declaration of Malta does
provide that a doctor may make his or her own decision
regarding treatment if hunger strikers are in a state in which
they “become confused and [are] therefore unable to make
an unimpaired decision or [have] lapsed into a coma”.
The difficulty with adhering to universal principles is that
hunger strikes almost always occur in a context of compet-
ing interests and conflicting administrative and clinical
priorities. Clinicians often are at the centre of such institu-
tional pressures, particularly when their employment con-
tract makes them directly responsible to detention or
government authorities who have an interest in ensuring the
quick termination of actions perceived as undermining the
peaceful and effective management of detention centres.21
Such ethical dilemmas confronting the practitioner in the
detention centre environment are not dissimilar to those
facing clinicians in other custodial settings. Detailed ethical
guidelines have already been developed for these set-
tings.22,23
A decision not to intervene and to allow a person to die is
extremely difficult for a physician to make. Fortunately,
most hunger strikes end without fatalities. It is imperative,
however, that hunger strikers be fully assessed early in their
strike to assess both their mental state and their genuine
intentions, ideally in the form of a confidential advance
directive. For such a medical assessment to be legitimate,
the hunger striker must feel convinced that the doctor is
acting independently and impartially, and not only in his or
her capacity as an employee of the detention centre or
hospital. The striker also must be advised in detail about the
medical consequences of refusing food and about the value
of supplementing the fast with essential minerals and vita-
mins to prevent irreversible neurological damage.
In the case study outlined, the health professionals
involved were dealing with a distressing situation of a young
man who was deteriorating physically and mentally. The
health professionals undoubtedly believed they were acting
in what they perceived to be his best medical interests, but
their reliance on (or compliance with) the immigration
regulation inevitably raises concerns about the truly inde-
pendent nature of such judgements.
Conclusions and recommendations
Reports of force-feeding of detainees by doctors are a cause
for great concern. Whether the physicians involved are
acting in ignorance of international guidelines or under
duress, it is important to reiterate that, in most cases, such
actions contravene the basic human rights of asylum seek-
ers. Doctors coming into contact with a detainee on hunger
strike should be aware of their professional, legal and ethical
obligations. Despite serious doubts about the legitimacy of
Regulation 5.35, until it is challenged in the courts it will
provide authority to administer treatment against the con-
sent of a detainee. However, medical practitioners may be
acting unethically by relying on this provision.
If contemporary international and local ethical guidelines
on the medical management of hunger strikers are inade-
quate or inappropriate, then representations need to be
made to the WMA and the relevant specialist colleges to
consider a review. At present, however, doctors who violate
the ethical guidelines promulgated by these bodies risk
facing the charge of unethical conduct. A wider campaign of
medical education is needed to ensure that all practitioners
are aware of their medical, ethical and legal responsibilities if
ever called upon to manage hunger strikers. Consideration
could be given to developing independent ethics panels to
guide individual doctors, given the highly complex and
politicised context in which hunger strikes occur, whether
among asylum seekers or other detainees.21
References
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240 MJA Vol 180 1 March 2004
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(Receiv ed 20 Aug 2003, acc epted 25 Nov 2003)
... A requirement for the credibility of that judgement is that it is based on an informed choice e.g., about a termination of the strike or an application of medical measures. To enable that, freedom from coercion, a sharing of information and an exchange of values between the doctor and the striker and the autonomous decision of a striker are key (Crosby et al., 2007;Gulati et al., 2018;Jacobs, 2012;Kenny et al., 2004;Oguz & Miles, 2005;Reyes, 2007;Silove et al., 1996;WMA, 2017). Another important requirement for the strikers' decisions to be autonomous is that strikers are competent to make such decisions. ...
... Another important requirement for the strikers' decisions to be autonomous is that strikers are competent to make such decisions. Doctors have to assess whether strikers gauge the exact scope of the decision and make sure that the strikers' competence is not significantly impaired by severe mental illness or other pathological mental states (García-Guerrero, 2013;Gulati et al., 2018;Kenny et al., 2004;Silove et al., 1996;Wei & Brendel, 2010;WMA, 2017). Confidential conversations with the hunger strikers are required for this assessment, where it is within the physicians' responsibility to assess the strikers' true intention and will, independently of the influence of others (especially in decisions about the rejection or acceptance of possible medical interventions). ...
... To provide health care also requires physicians to preserve their clinical independence and to direct their actions mainly towards their individual patients' interests rather than towards the interests of the physicians' employers or the authorities. The various demands on a doctor in a hunger strike may lead to role conflicts (Kenny et al., 2004). The problem of maintaining clinical independence in a setting of conflicting loyalties is described as a key challenge in health care for hunger strikers in custodial settings (Briskman & Zion, 2014;Gulati et al., 2018;Sanggaran et al., 2016). ...
Article
Full-text available
Purpose Role expectations of physicians providing health care for hunger strikers have been discussed in the context of prisons and detention centres. Ethical guidance for physicians in these situations is codified in the Declaration of Malta. In the last years, new forms of collective, public hunger strikes of asylum seekers have occurred. We have aimed at reconstructing the experiences of health-care personnel involved in one of such cases. Methods Semi-structured interviews with nine participants (physicians and paramedics) that had been involved in a public collective hunger strike of asylum seekers in Germany were conducted. Results We identified three health-care provider groups: voluntary physicians, emergency service providers and medical consultants for the authorities. Role conflicts arising from multiple loyalty situations with obligations towards different stakeholders (e.g., strikers, employers, authorities) were perceived as the greatest challenge especially for voluntary doctor and emergency service provider participants. Such conflicts culminated in feeling instrumentalized for political goals. Conclusion The results illustrate that professional challenges in the health care during a public collective hunger strike differ in various aspects from those described in the literature on custodial settings. We recommend expanding and adapting the medico-ethical guidance.
... Ethical conflicts for physicians may be highlighted by jurisdictional law. In relation to the position in Australia (Kenny, Silove & Steel, 2004), a useful distinction could be made from a position taken by a Government Department which 'authorises' non-consensual medical treatment. The key argument arising would be that 'authorising' is not the same as 'ordering'. ...
... Kenny, Silove and Steel (2004) writing from an Australian perspective and looking at hunger strikes in detained asylum-seekers, noted that there may be pressures on the treating physician based on legal directives from an employing authority that may contradict ethical positions adopted worldwide. They report that such hunger strikes have occurred in Australia since the introduction of the policy of mandatory detention for asylum seekers, and that these came to the forefront of public attention when 200 detainees embarked on a hunger strike at the Woomera Immigration Reception and Processing Centre in 2002. ...
... Le médecin doit respecter la volonté du patient après l'avoir informé des conséquences de ses choix. Si cela met sa vie en danger, le médecin doit tout mettre en oeuvre pour le convaincre d'accepter les soins indispensables [7,8] Vadémécum clinique du médecin devant une grève de la faim [9,[22][23][24] CONCLUSION La grève de la faim est une situation assez fréquente à laquelle tout médecin exerçant en milieu pénitentiaire est amené à être confronté. Une hospitalisation est nécessaire en cas de défaillance d'organe, de pathologie intercurrente menaçant le pronostic vital, ou d'une surveillance médicale insuffisante en milieu carcéral. ...
Article
Full-text available
Background: A hunger strike is a common form of protest in prison and is a potential cause of many types of problems, both for facility administrators and health care staff. Issues of conflict of rights and obligations involved, and how to treat people who are subject, have created major controversies. Objectives: To identify and review published studies that discuss the medical, ethical, and legal considerations of managing a hunger strike in a prison setting from a physician's perspective. Methods: A database search using «Medline» «Ovid» and «Science Direct was conducted to identify relevant publications. We included case series, guidelines and, review articles. Results: The physician must clearly inform the striker of the risks and provide clinical assessment and regular monitoring of the concerned. The role of the psychiatrist is to detect an initial mental pathology underlying or secondary to fasting and assess the capacity of the striker's judgment. Thus, the clinician is faced with two paradoxical obligations: to assist and respect the striker's will. In addition, medical intervention is possible if the prognosis is life-threatening even without the patient's consent. Conclusion: The current practice of non-consensual attitude among hunger-striking seeking in detention needs a closer inquiry. Medical practitioners should be aware of their ethical and legal responsibilities, and that they should act independently of government or institutional interests.
... Some recent medical studies are robust about sanctions that are required for healthcare professionals involved in force-feeding, recommending that organized medicine must appeal to civilian state oversight bodies and federal regulators of medical science to revoke the licenses of health professionals participating in such activities at Guantanamo Bay (Dougherty et al. 2013). Such ethical and legal implications have also been reviewed in other settings, for example, in detained asylum seekers in Australia (Kenny et al. 2004). Pressure from prison or other authorities (judicial, political) is not unexpected. ...
... Because Common Law sanctions forced psychiatric treatment even on competent persons, judges have relied on this provision to force-feed hunger-striking prisoners. Such an attitude is especially common in relation to solitary strikers whose requests are not political in nature (Kenny, Silove, and Steel 2004). It follows that the labelling of a hunger strike as a manifestation of psychiatric disorder opens the way to force-feeding. ...
Article
In its Malta Declaration, The World Medical Association prohibits force-feeding of hunger strikers as “degrading and inhuman,” even when this is the only way to save their lives. The European Court of Human Rights ruled that lifesaving force-feeding is compatible with the state’s duty to protect the lives of prisoners. To understand how such extreme divergence of opinions has become possible, this paper offers a critical examination of the social history of prisoners’ hunger strikes, the philosophy of nonviolence, and the debate on its medicalization. The discourse by actors, professionals, regulators, and scholars on hunger strikes is divided into three paradigms: the “communicative,” the “extreme violence,” and the “psychiatric.” I argue that another paradigm is in play, and its incorporation may enrich and balance the discourse. This is the “wounded combatant” paradigm, according to which hunger strikers are like enemy soldiers who are injured in battle.
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Hapishanelerdeki açlık grevlerinin ve kendini yakmanın rasyonel olarak benimsenen tepkiler mi yoksa mahkumların yaygın olarak geliştirdiği ruhsal bozuklukların sonuçları mı olduğu konusunda bir tartışma var. Fedakarlık üzerine nörobiyolojik ve evrimsel araştırmalar ve deneyler, düşünsel ve politik bakış açılarından yoksun oldukları için fedakarlık davranışını bir dereceye kadar açıklayabilir. Öz-feda davranışın nedenleri, önleme amacıyla tıp doktorları tarafından (doğru, ancak tam olarak değil) yorumlanmıştır. Bu tür öz-feda davranışları, cezaevlerinde de görülen intihar davranışıyla karıştırılmamalıdır. Hapishanede kendini feda etme, bir siyasi katılım yöntemi anlamına gelebilir ve bir mahkûmun serotenerjik düzensizlik veya başka herhangi bir psikopatolojiyle ilgili akıl hastalığının bir sonucu değil, zor durumlara ve adaletsizliklere makul bir tepkidir. Grup özdeşleşmesi, ideoloji, tarihsel olumlama ve şehit mitolojisi fedakarlığın benimsenmesi/yok sayılması ve fedakârlık davranışının ciddiyetinin belirlenmesindeki nedenlerdir. Bu makale, kendini feda etme davranışını açıklamada sosyal psikoloji, ideoloji ve tarihsel miras arasında ayrılmaz bir ilişki olduğunu ileri sürerek bu ikilemi ele almaya çalışmaktadır. Bu amaçla, normatif ve rasyonel şiddet kullanım teorilerini fedakarlığa uyarlayacağım ve açlık grevlerinin ardındaki melez saikleri arayacağım. Ardından aşırı grup yanlısı davranışlara ışık tutan Kimlik Füzyon Teorisi ile özverili davranış arasındaki bağlantı tartışılacaktır.
Article
Wernicke encephalopathy (WE) is a neuropsychiatric condition associated with thiamine deficiency that includes a triad of mental status changes, ophthalmoplegia, and ataxia. Worsening WE may lead to Korsakoff syndrome(KS), in which cognitive impairments such as confabulation and memory deficits and also psychiatric symptoms may occur. Diagnosis of Wernicke-Korsakoff syndrome can be complicated in many cases. We present the case of a prisoner who commenced a hunger strike and developed WE. The preceding factors were associated with his oral intake refusal, which originated from his mental disorder with psychotic content. We discuss the clinical and treatment concerns for this complicated condition.
Article
Hunger strike is a protest where an informed person refuses essential nourishment with the intention of accomplishing a specific goal. Hunger strikes conflict with medical, ethical, humanitarian and legal values. A multidisciplinary approach is important when dealing with hunger strike patients. On one hand, there is the wish to preserve life, and on the other to respect the strikers’ autonomy and their wishes, values and advanced directives (or living will). Most hunger strikes are short-lived, but in complex and prolonged circumstances, legal advice must be sought from health service solicitors and a doctor’s medical indemnity organisation. There is an emergent need to have defined guidelines for the management of these hunger strikes to be followed.
Chapter
Die Betreuung von Migranten und Flüchtlingen erfordert auch in Gesundheitsberufen das Wissen um sowohl medizinische, wie auch ethische und menschenrechtliche Standards, die oft nicht ausreichend bekannt sind, und zurzeit zunehmend weniger Berücksichtigung finden. Diese sind besonders unter Berücksichtigung der besonderen Vulnerabilität vieler Patienten durch Verfolgung, Krankheit, aber auch durch Probleme im Aufnahmeland, wie soziale Unsicherheit, Trennung von Angehörigen und Umgang mit den europäischen medizinischen Rechts- und Sozialsystemen, als besondere Herausforderung zu sehen. Unser Kapitel integriert eine interdisziplinäre Übersicht der entsprechenden Rahmenbedingungen, die für Gesundheitsberufe im Kontakt mit Migranten und besonders mit Flüchtlingen von Bedeutung sind.
Chapter
The detention of migrants and asylum seekers has become a common practice in both developing and high-economy regions. The fact of detention but also the conditions of detention are the subject of much criticism. They have been shown to frequently violate international human rights standards and to have an adverse impact on the psychological health and, later, the integration of migrants. In this chapter the authors outline standards and risks, based on research data and a case example, but also alternatives to detention as outlined by UNHCR.
Article
Thirty-three political prisoners on hunger strike (voluntary total fast--VTF) for 6-24 days were admitted to two hospitals in Johannesburg in 1989. They had been detained without trial for 4-32 months. Sound doctor-patient relationships were established by emphasis of the principle of full patient participation in clinical decision-making at every level, by rejection of police interference in patient care, and by refusal to discharge subjects back into detention. Depression and abdominal pains were the predominant symptoms. In 6 lean subjects with complete data the expected initial period of rapid weight loss was not observed. Before hospitalisation most subjects became dehydrated from inadequate fluid intake and an apparent absence of thirst. Serum creatinine concentrations were a better indication of dehydration than serum urea levels. Mild hyponatraemia was found in one-third of patients. Refeeding after 6-27 days of VTF was initiated with a dilute lactose-free formula diet, and was uncomplicated. Close clinical monitoring of subjects during VTF is essential, and it is recommended that prisoners should be admitted to hospital at 10% of weight loss, if not before. The health care of prisoners can best be provided by professionals independent of the police and prison services.
Article
Hunger strikes have confronted physicians with complex ethical dilemmas throughout history. Asylum seekers under threat of forced repatriation have emerged as a new category of hunger strikers, posing novel challenges for management. The management of 3 Cambodian asylum seekers on hunger strike admitted to a hospital in Sydney, New South Wales, Australia, posted important ethical dilemmas for the physicians and mental health experts involved in their care. Several factors confounded the task of assessment and decision making, including language and cultural barriers, the patients' past exposure to persecution by authorities, and the complexities of the legal procedures being pursued. Different rules appeared to govern the actions of the hunger strikers, the medical team, and the immigration authorities, creating a ¿malignant triangle¿ of mounting confrontation. Recent recommendations for the management of asylum-seeking hunger strikers include the appointment of an external physician of confidence and the writing of a confidential advance directive specifying the hunger striker's wishes about resuscitation in the event of collapse. In addition, we consider the value of constituting an ad hoc ethics committee to advise the responsible physician on points of conflict in managing the hunger strike. The advantages and limitations of these proposals in relation to the particular cultural, historical, and contextual issues relevant to asylum seekers are examined herein.
Article
Food refusal occurs for a variety of reasons. It may be used as a political tool, as a method of exercising control over others, at either the individual, family or societal level, or as a method of self-harm, and occasionally it indicates possible mental illness. This article examines the motivation behind hunger strikes in prisoners. It describes the psychiatrist's role in assessment and management of prisoners by referring to case examples. The paper discusses the assessment of an individual's competence to commit suicide by starvation, legal restraints to intervention, practical difficulties and associated ethical dilemmas. Anecdotal evidence suggests that most prisoners who refuse food are motivated by the desire to achieve an end rather than killing themselves, and that hunger-strike secondary to mental illness is uncommon. Although rarely required, the psychiatrist may have an important contribution to make in the management of practical and ethical difficulties.
Article
In the past, most refugees who permanently resettled in the traditional recipient countries of North America, Europe, and Australasia were screened prior to arrival in a host country. In the last decade, increasing numbers of unauthorized refugees or asylum seekers, those who formally lodge application for refugee status in the country in which they are residing, have applied for protection after crossing the borders of these countries. Concerns about uncontrolled migration have encouraged host countries to adopt policies of deterrence in which increasingly restrictive measures are being imposed on persons seeking asylum. These measures include, variously, confinement in detention centers, enforced dispersal within the community, the implementation of more stringent refugee determination procedures, and temporary forms of asylum. In several countries, asylum seekers living in the community face restricted access to work, education, housing, welfare, and, in some situations, to basic health care services. Allegations of abuse, untreated medical and psychiatric illnesses, suicidal behavior, hunger strikes, and outbreaks of violence among asylum seekers in detention centers have been reported. Although systematic research into the mental health of asylum seekers is in its infancy, and methods are limited by sampling difficulties, there is growing evidence that salient postmigration stress facing asylum seekers adds to the effect of previous trauma in creating risk of ongoing posttraumatic stress disorder and other psychiatric symptoms. The medical profession has a role in educating governments and the public about the potential risks of imposing excessively harsh policies of deterrence on the mental health of asylum seekers. JAMA. 2000;284:604-611
Article
The possible mental health impact on asylum seekers of Australia's policy of mandatory detention is an issue of special relevance to health professionals and the public. Independent commissions of inquiry in Australia have found varying degrees of mental distress to be common in detained asylum seekers. Research studies in Australia and elsewhere suggest that detained asylum seekers may have suffered greater levels of past trauma than other refugees, and this may contribute to their mental health problems, with their detention providing a retraumatising environment. Studies are urgently required to examine the mental health consequences of detention, and to determine the effect of detention on acculturation and adaptation for asylum seekers subsequently released into the community.
Article
The process of applying for refugee status in Australia is complex, lengthy and often poorly understood by asylum seekers. The psychological reaction patterns of detainees whose claims for asylum are unsuccessful are characterised by stages of increasing depression, punctuated by periods of protest, as feelings of injustice overwhelm them. These reactions have a marked secondary impact on their children in detention. The prolonged detention of asylum seekers appears to cause serious psychological harm. Even if many of those who spend long periods of time are not deemed to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants.
World Medical Association Declaration of Malta on hunger strikers (adopted by the 43rd World Medical Assembly in Malta and revised at the MJA
World Medical Association. Declaration of Malta on hunger strikers (adopted by the 43rd World Medical Assembly in Malta, November 1991 and revised at the MJA Vol 180 1 March 2004 CLINICAL ETHICS 44th World Medical Assembly in Marbella, Spain, November 1992). Geneva: WMA, 1992.