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World Medical Association Declaration – WMA Declaration of Malta on Hunger Strikes, 2017

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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
and revised by the 68th WMA General Assembly, Chicago, United States, October 2017

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 usually a form of protest by people
who lack other ways of making their demands known. In refusing nutrition for a signi cant period, prisoners
and detainees may hope to obtain certain goals by in icting negative publicity on the authorities. Short-term
food refusals rarely raise ethical problems. Prolonged fasting risks death or permanent damage for hunger
strikers and can create a con ict of values for physicians. Hunger strikers rarely wish to die but some may be
prepared to do so to achieve their aims.
2.
Physicians need to ascertain the individual’s true intention, especially in collective strikes or situations
where peer pressure may be a factor. An emotional challenge arises when hunger strikers who have apparently
issued clear instructions not to be resuscitated reach a stage of cognitive impairment. The principle of
bene cence urges physicians to resuscitate them but respect for individual autonomy restrains physicians from
intervening when a valid and informed refusal has been made. This has been well worked through in many
other clinical situations including refusal of life saving treatment. An added di culty 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.
PRINCIPLES
3.
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.
4.
Respect for autonomy. Physicians should respect individuals’ autonomy. This can involve di cult
assessments as hunger strikers’ true wishes may not be as clear as they appear. Any decisions lack moral force
if made by use of threats, peer pressure or coercion. Hunger strikers should not forcibly be given treatment
they refuse. Applying, instructing or assisting forced feeding contrary to an informed and voluntary refusal is
unjusti able. Arti cial feeding with the hunger striker’s explicit or necessarily implied consent is ethically
acceptable.
5.
‘Bene t’ and ‘harm’. Physicians must exercise their skills and knowledge to bene t those they treat. This is
the concept of ‘bene cence’, which is complemented by that of ‘non-male cence’ or primum non nocere. These
two concepts need to be in balance. ‘Bene t’ 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. Bene cence does not necessarily involve prolonging life at
all costs, irrespective of other determinants.
Physicians must respect the autonomy of competent individuals, even where this will predictably lead to harm.
The loss of competence does not mean that a previous competent refusal of treatment, including arti cial
feeding should be ignored.
6.
Balancing dual loyalties. Physicians attending hunger strikers can experience a con ict between their
loyalty to the employing authority (such as prison management) and their loyalty to patients. In this situation,
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. They remain independent from their employer in regard to
medical decisions.
7.
Clinical independence. Physicians must remain objective in their assessments and not allow third parties
to in uence their medical judgement. They must not allow themselves to be pressured to breach ethical
principles, such as intervening medically for non medical reasons.

8.
Con dentiality. The duty of con dentiality is important in building trust but it is not absolute. It can be
overridden if non-disclosure seriously and imminently harms others. As with other patients, hunger strikers’
con dentiality and privacy 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.
9.
Establishing 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 minimises harm to them. Gaining trust can
create opportunities to resolve di cult situations. 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
situations in which the physician may not be able to maintain con dentiality.
10. Physicians must assess the mental capacity of individuals seeking to engage in a hunger strike. This
involves verifying that an individual intending to fast is free of any mental conditions that would undermine the
person’s ability to make informed health care decisions. Individuals with seriously impaired mental capacity
may not be able to appreciate the consequences of their actions should they engage in a hunger strike. Those
with treatable mental health problems should be directed towards appropriate care for their mental conditions
and receive appropriate treatment. Those with untreatable conditions, including severe learning disability or
advanced dementia should receive treatment and support to enable them to make such decisions as lie within
their competence.
11. 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 existing 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 damage to health
can be minimised or delayed by, for example, increasing uid and thiamine intake. Since the person’s decisions
regarding a hunger strike can be momentous, ensuring full patient understanding of the medical consequences
of fasting is critical. Consistent with best practices for informed consent in health care, the physician should
ensure that the patient understands the information conveyed by asking the patient what he or she
understands.
12. A thorough examination of the hunger striker should be made at the start of the fast including measuring
body weight. Management of future symptoms, including those unconnected to the fast, should be discussed
with hunger strikers. Also, the person’s values and wishes regarding medical treatment in the event of a
prolonged fast should be noted. If the hunger striker consents, medical examinations should be carried out
regularly in order to determine necessary treatments. The physical environment should be evaluated in order
to develop recommendations for preventing negative e ects.
13. Continuing communication between the physician and hunger strikers is essential. Physicians 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. The clinician should identify whether the individual
is willing, in the absence of their demands being met, to continue the fast even until death. These ndings must
be appropriately recorded.
14. Sometimes hunger strikers accept an intravenous solution transfusion or other forms of medical
treatment. A refusal to accept certain interventions must not prejudice any other aspect of the medical care,
such as treatment of infections or of pain.
15. 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 necessary, interpreters unconnected to the detaining
authorities should be available and they too must respect con dentiality.
16. 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 authorities, the peer group, 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
suspend the strike. Treatment or care of the hunger striker must not be conditional upon suspension of the
hunger strike. Any restraint or pressure including but not limited to hand-cu ng, isolation, tying the hunger
striker to a bed or any kind of physical restraint due to the hunger strike is not acceptable.
17. If a physician is unable for reasons of conscience to abide by a hunger striker’s refusal of treatment or
arti cial feeding, the physician should make this clear at the outset, and must be sure to refer the hunger
striker to another physician who is willing to abide by the hunger striker’s refusal.
18. 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 and respect must be given to any advance instructions made by the hunger striker. Advance
refusals of treatment must be followed if they re ect 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.
19. If no discussion with the individual is possible and no advance instructions or any other evidence or note
in the clinical records of a discussion exist, physicians have to act in what they judge to be in 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. 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.
20. Physicians may rarely and exceptionally consider it justi able to go against advance instructions refusing
treatment 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 allow a determined hunger striker to die with dignity rather than
submit that person to repeated interventions against his or her will. Physicians acting against an advanced
refusal of treatment must be prepared to justify that action to relevant authorities including professional
regulators.
21. Arti cial feeding, when used in the patient’s clinical interest, can be ethically appropriate if competent
hunger strikers agree to it. However, in accordance with the WMA Declaration of Tokyo, 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 decision, he or she shall not be fed arti cially. Arti cial
feeding can also be acceptable if incompetent individuals have left no unpressured advance instructions
refusing it, in order to preserve the life of the hunger striker or to prevent severe irreversible disability. Rectal
hydration is not and must never be used as a form of therapy for rehydratation or nutritional support in fasting
patients.
22. When a patient is physically able to begin oral feeding, every caution must be taken to ensure
implementation of the most up to date guidelines of refeeding.
23. All kinds of interventions for enteral or parenteral feeding against the will of the mentally competent
hunger striker are “to be considered as “forced feeding”. Forced feeding is never ethically acceptable. Even if
intended to bene t, feeding accompanied by threats, coercion, force or use of physical restraints is a form of
inhuman and degrading treatment. Equally unacceptable is the forced feeding of some detainees in order to
intimidate or coerce other hunger strikers to stop fasting.
THE ROLE OF NATIONAL MEDICAL ASSOCIATIONS (NMAS) AND THE WMA
24. NMAs should organize and provide educational programmes highlighting the ethical dimensions of
hunger strikes, appropriate medical approaches, treatments, and interventions. They shall make e orts to
update physicians’ professional knowledge and skills.
NMAs should work to provide mechanisms for supporting physicians working in prisons/jails/immigration
detention centers, who may often nd themselves in con ict situations and, as stated in the WMA Declaration
of Hamburg, shall support any physicians experiencing pressure to compromise their ethical principles.
NMAs have a responsibility to make e orts to prevent unethical practices, to take a position and speak out
against ethical violations, and to investigate them properly.
25. The World Medical Association will support physicians and NMAs confronted with political pressures as a
result of defending an ethically justi able position, as stated in the WMA Declaration of Hamburg.

 

 

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