Medical ethics

Have you ever heard of Martin Hurson? How about Raymond McCreesh? I must admit that these names meant nothing to me even though in 1981 I used to read the newspapers avidly. Of course, if you had said Bobby Sands, I would have known instantly what you were talking about; the hunger strike by the provisional IRA members in the Maze prison. I think it was about their wanting to be recognized as prisoners of war while the British government saw them as simply criminals.

Depending on how you viewed the Irish cause, you either saw them as martyrs or murderers. I don't want to debate the rights or wrongs of Ireland, but to consider how we ought to deal with hunger strikes. This has been prompted by an article in today's Lancet .

The article has been prompted by the current situation in Guantanamo, and of course, The Lancet, as a left-wing journal, wants to hold Obama to his promises to end torture in the USA. As the author says, hunger strikes are extremely difficult for prison officials and physicians to deal with, especially if they are done in groups, as they are in Guantánamo where about 30 prisoners are currently on hunger strike. Hunger strikers are not suicidal in that their goal is to change a policy or the conditions of their confinement, not to die. The primary issue the continuing hunger strikes at Guantanamo raise with the medical profession and human rights groups is the use of military physicians to break the hunger striker's will by force-feeding in eight-point restraint chairs.

Apparently army doctors have been taking part in the forced feeding of inmates against the rules and regulations of the World Medical Association.

A hunger strike is a non-violent protest that aims to provoke feelings of guilt in others in order to change a policy. It has a long history, particularly in India and Ireland. In both countries those who felt that they had been swindled would camp on the perpetrators doorstep and starve themselves.

In modern days the most prominent instance was by the suffragettes on both Britain and America. Marion Dunlop was the first in 1909. Because the authorities did not want her to become a martyr, she was released. Other suffragettes were subjected to force-feeding, which the suffragettes categorized as a form of torture. Several of them died as a result of force-feeding. In 1913 the Prisoner's Temporary Discharge of Ill Health Act changed policy. Hunger strikers were tolerated but when they became sick the prisoners were released, only to be rearrested to finish their sentences when they had recovered.

In the end what won women the vote was their willingness to act as substitute men in factories and farms during the Great War.

Irish republicans first used the hunger strike as a weapon in 1917. It was countered by the British with force-feeding, which culminated in 1917 in the death of Thomas Ashe in Mountjoy Prison. In October 1920, the Lord Mayor of Cork, Terence MacSwiney, died on hunger strike in Brixton prison. Three other IRA men, Joe Murphy, Conor McElvaney and Michael Fitzgerald, also died on hunger strike in this protest. John and Peter Crowley, Thomas Donovan, Michael Burke, Michael O'Reilly, Christopher Upton, John Power, Joseph Kenny and Seán Hennessy at the prison of Cork had their hunger strike called off by the Sinn Fein leadership after the deaths of MacSwiney, Murphy and Fitzgerald. Some of the strikers had fasted for 94 days – such a long period makes it likely that they were surreptitiously taking food.

Although there was a natural sympathy for the underdog, there was little agreement with some of the views of the Sinn Fein leadership. They defended anti-semitic rioters in Limerick, denounced socialists and pacifists as conscious tools of the British Empire, and successively praised Tsarist Russia and Wilhelm II as morally superior to Great Britain.

Eventually, there was an agreement between Britain and Ireland which established the Irish Free State, though it was impossible to incorporate the Protestant North within the Catholic South without a blood bath.

Oppression of Catholics in the North by the Protestant government reignited the troubles in Ireland in the 1960s. Again, the hunger strike was used as a weapon. Bobby Sands was the first of ten Irish republican paramilitary prisoners to die during the hunger strike in 1981. There was support for the hunger strikers from Irish republicans and the broader nationalist community on both sides of the Irish border. After the deaths of the men and severe public disorder, the British government granted partial concessions to the prisoners, and the strike was called off. The hunger strikes gave a huge propaganda boost to a severely demoralized Provisional IRA. Bobby Sands, who was elected to the UK Parliament is still remembered but few but ardent republicans remember the names of the others. In the end, the IRA agreed a deal with the British. It was a deal that they could have had at almost any time during the troubles. It was brokered by John Major and Tony Blair. It is probable that the hunger strikes prolonged the conflict rather than shortened it. The IRA was always going to be defeated militarily and Londoners, who had survived the Blitz, were not going to be cowed by the Irish bombers. The real enemy of the IRA was the Protestant North which would never come to an agreement with the IRA while the South was in their view, priest-ridden.

British animal-rights activist Barry Horne died on November 5, 2001 after a series of four hunger strikes, the longest of which lasted 68 days leaving him partially blind and with kidney damage. Almost nobody sympathized with his views. Sine the same group resorted to kidnapping the dead body of a farmer’s mother, who would sympathize with them.

On the 15th of August 1987 at the Nallur Murugan Temple Thileepan began his fast. His main objective was to bring awareness and action to a list of public demands made by himself and the Tamil Tigers. The Tamils live mainly in the north of Sri Lanka and are Hindus and probably of Indian origin, whereas the majority of Sinhalese are Buddhist. Although several groups requested him to stop the fast, Thileepan died on the 26th of September 1987. There was widespread grief in Tamil areas. Thousands of people from the North and East flooded Jaffna in northern Sri Lanka as news of his death spread. His death created an anti-Indian mood in Jaffna, which had been pro-India till then.

From the above, it can be seen that hunger strikes are a double edged weapon. If the authorities call the bluff of the striker then he or she dies. The authorities are caught is a vice; let the striker die and they are accused of callousness, force feed him and they are accused of torture. If the striker dies then it does not guarantee martyrdom; if the cause is unpopular then the public are likely to cry, “Good riddance.” No-one would weep if the Yorkshire Ripper or the Southam pedophile starved themselves to death.

The inmates of Guantánamo are the basis of the current Lancet article. In 2006 the New York Times reported that hunger strikers in Guantánamo were being strapped into restraining chairs for hours a day for force-feeding. The number of strikers peaked at 131 around the fourth anniversary of 9/11. There was concern over the international impact if a striker were to die. Prisoners’ lawyers called the methods brutal and inhumane, and said other coercive methods were used, such as being placed in cold air-conditioned isolation cells. The assistant secretary of defense for health affairs said it was a moral question: allow suicide, or take steps to preserve life.

Article 6 of the 1975 World Medical Association Tokyo Declaration states that doctors can undertake force-feeding under certain very restricted rules and only where a second, independent physician is consulted and agrees that the prisoner is not rational. "Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment 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 judgment should be confirmed by at least one other independent physician. The consequences of the refusal of nourishment shall be explained by the physician to the prisoner."

The World Medical Association recently revised and updated its Declaration of Malta on Hunger Strikers. Among many changes, it unambiguously states that force feeding is a form of inhuman and degrading treatment in its Article 21. The American Medical Association is a member of the World Medical Association, but the AMA's members are not bound by the WMA's decisions, and neither organization has formal legal powers.
The British government under Maggie Thatcher took the decision not to force-feed the Irish terrorists, a decision that was probably correct. Probably the Americans should do the same. It comes hard for a physician to stand by and watch a person commit suicide, but medicine can only be offered with consent.