Ethical position on Force feeding
On hunger strikes during which the physical integrity of the hunger striker(s) is an issue, because the fasting has been prolonged for a sufficient amount of time, the 2006 revised WMA Malta Declaration reaffirms that the final decision to act or not must lie with the (bedside) clinician. That is to say, it is the physician who best knows the prisoner, and not someone new from the outside, or a non-medical authority (such as the Prison Director) nor even the family who must decide what to do if and when a fatal outcome becomes a possibility. It is certainly not a decision to be made by a Judge or Minister or any other political authority, whose main interests may well, in many cases, not be the welfare of the fasting prisoner(s).
Article 19 of the Guidelines of the revised WMA Malta Declaration states clearly:
19. Physicians may consider it justifiable 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 in dignity rather than submit that person to repeated interventions against his or her will.
This article reaffirms that a patient's right to autonomy may overrule the principle of "beneficence". It is however possible, as clearly stated here, for the clinical physician (i.e. the physician who has followed the case, and who best knows the hunger striker) to decide whether or not to administer artificial feeding. This may be to "no-longer-competent-to-make-decisions" hunger striker, or in extreme cases, to an unconscious hunger striker, if in the physician's best knowledge and conscious, s/he is convinced the prisoner would have wanted to live. This decision should be put down in writing, and signed by the physician. If the hunger striker had told the physician in confidence that he or she authorized such an intervention, this should be put down in the medical file.
Inversely, the revised Declaration proscribes any "yo-yo type" feeding situation, wherein physicians would wait until hunger strikers were simply too weak to protest and struggle, or had lapsed into a state of mental confusion, and then intervened alleging that "force was not used". Then, when the revived hunger strikers – several days later – wrenched out all tubing, the physicians would simply wait again for the hunger strikers to become too weak to protest and the intervention would be repeated… This type of situation was a reality, for several years, in a hunger strike in a country in North Africa[13]. The "yo-yo", going back and forth from conscious to unconscious, and "playing" with the prisoners' becoming confused or unconscious is not justifiable from an ethical point of view.
More insight into such cases is to be found in the background paper accompanying the 2006 WMA Malta Declaration[14].
It is for this type of case that the wording of the final sentence of Article 19 was inserted into the revised WMA Malta Declaration.