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The Physician and Prison Hunger Strikes: Reflecting on the Experience in Turkey

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The Physician and Prison Hunger Strikes: Reflecting on the Experience in Turkey 169 GLOBAL MEDICAL ETHICS J Med Ethics: first published as 10.1136/jme.2004.006973 on 28 February 2005. Downloaded from The physician and prison hunger strikes: reflecting on the experience in Turkey N Y Oguz, S H Miles ............................................................................................................................... J Med Ethics 2005;31:169–172. doi: 10.1136/jme.2004.006973 The medical ethics of a physician’s relationship with a strike in the sense that it harms health or causes death. prisoner who is participating in a collective hunger strike Most hunger strikes include the ingestion of has become a major public, professional, and some water or other liquids, salt, sugar, and governmental concern in The Republic of Turkey. This vitamin B1 for a certain time without asserting intent to fast to death. During the last hunger article examines the Turkish experience and debate about strike in Turkey, a new term, ‘‘death fast,’’ arose. physician ethics during prison hunger strikes. It is hoped A person on a death fast takes water, salt, sugar, that this analysis will be of use to those formulating policy and vitamin B1 and asserts that the fasting will in similar situations. continue to death unless the aims of the strike are met.14 The ingested vitamins decrease the ........................................................................... chance of permanent nutritional disability (neuropathy or congestive heart failure) if the he Declaration on Hunger Strikers (Declaration of strike should end. Although death fasts cause Malta) defines a hunger striker as ‘‘a a progressive and eventually lethal protein and Tmentally competent person who has indi- caloric malnutrition, the fluids and ingested cated that he has decided to embark on a hunger nutrients extend the duration of negotiation strike and has refused to take food and/or fluids with regard to the aims of the strike. Most for a significant interval’’.1 Tagawa identifies two hunger strikers are trying to effect political key elements in a hunger strike: the fasting and change rather than trying to become martyrs, the statement by the striker to another party that commit suicide, or maim themselves with nutri- the striker will refuse some or all forms of tional deficiencies. A death fast increases the nourishment or hydration until a specific condi- pressure on the negotiation. tion is met.2 This definition focuses attention on a choice by one individual, rather than a group of THEEXPERIENCEINTURKEY people and the reasonableness or likelihood that The medical ethics of hunger strikes have been the aim of a responsive change will occur. As we intensely debated in Turkey during the collective shall see, this definition is insensitive to the prison hunger strikes of 1996 which recom- http://jme.bmj.com/ complexity of evaluating the decision to strike by menced in 2000 and have lasted to the present a person who is part of a social collective which is time. The prisoners’ aims of the 1996 strike were organising strikes by many individuals. for relief from being beaten, placed in isolation We define a hunger strike as ‘‘an action in cells, denied medical care, or being moved to which a person or persons with decision making prisons far from their families and lawyers.15 capacity (often, but not always, in prison) refuses to ingest vital nourishment until another During that strike, the Ministry of Health maintained that government employed physi- party accedes to certain specified demands.’’ on October 2, 2021 by guest. Protected copyright. Hunger strikes have a rich political history.3–6 cians who worked with prisoners in government Various governments have taken various posi- hospitals were obliged to save human life, tions on how, or whether, to balance a prisoner’s including assisting in force feeding and provid- claimed right to privacy, self expression, and ing medical treatment to unconscious hunger bodily integrity with the state’s authority to strikers. In response, the Turkish Medical See end of article for Association (TMA) asserted that feeding and authors’ affiliations manage the prison environment, prevent suicide, ....................... and ensure prisoner health.2 4 5 7–13 Legal litera- treating the hunger strikers against their will ture has struggled with the differences and violated the principle of informed consent with Correspondence to: similarities between a hunger strike as a form regard to the right to refuse medical treatment. Professor N Y Oguz, This view of the relevance of informed consent as Ankara University School of expression and the recognised personal right of Medicine, Department to refuse of medical feeding. A hunger strike may it pertains to hunger striking was articulated by of Medical Ethics, be considered from three perspectives. Firstly, the World Medical Association (WMA).1 This Morfoloji Yerleskesi there is the individual’s decision to strike (for placed physicians in a difficult position. Most Sihhiye, Ankara 06100, physicians are government employees and 80% Turkey; oguzx001@ example, does a prisoner have this right of yahoo.com political expression? How does one evaluate the belong to the TMA. Physicians also had serious freedom and authenticity of this decision in a difficulty in assuring prisoner patient confidenti- Received 24 October 2003 prison environment?). Secondly, there is the ality. Twelve prisoners died and many more In revised form legitimacy of the aims of the strike (for example, suffered permanent neurological damage during 29 January 2004 16 17 Accepted for publication are the striker’s aims fundamentally incompa- the 1996 strike. This experience led to intense 14 February 2004 tible with a legitimate state’s policies for operat- discussions about the need for an ethics state- ....................... ing a prison?). Thirdly, there is the conduct of ment to guide medical practice during hunger www.jmedethics.com 170 Oguz, Miles strikes; however, many meetings failed to reconcile the strikes in prisons and hospitals, former prisoners, their J Med Ethics: first published as 10.1136/jme.2004.006973 on 28 February 2005. Downloaded from various views on the duties of physicians. friends, and the relatives of prisoners went on hunger strikes In August 2000, the government began to implement a in private homes. In November 2001, governmental forces long debated plan to place prisoners in F-type prisons in attacked houses where people were on hunger strikes. which cells holding one to three persons replaced large Several people died during the attack, although it is not communal cellblocks. The government promoted the new clear whether these deaths were a result of suicide or prisons as conforming to European Union standards calling government force.22 29 The government again declared that for prisoners to be placed in cells rather than open wards.16 18 the strikers would be force fed and proposed amending the Though most parties agreed that crowded wards posed public Turkish Penal Code to allow a sentence of 20 years in prison health risks, the government also saw the new prisons as a for those who encourage hunger strikes.30 way to regain control over prisoners’ organisations in communal cell blocks.15 Prisoners, their relatives, human DISCUSSION rights advocates, and the TMA opposed the shift to small cells Much of medical ethics in life and death decisions is maintaining that social control was the primary reason for grounded on reconciling respect for the sanctity of life with the new government policy. They also cited the adverse social respect for individual decisions. The decision to refuse and psychological consequences of isolating the prisoners nutrition is one of the few ways in which a person without and the prisoners’ greater vulnerability to torture.19–21 access to weapons or poisons can make a life or death On 20 October 2000, four illegal political organisations decision. In ordinary clinical settings, it is widely agreed that initiated prison hunger strikes across Turkey.17 Strikers a person may choose to refuse life sustaining food. The prison organised into cohorts that began refusing food at different hunger strike raises the issue of whether the ethics that times to spread out the duration of the strike. As during the pertain to free citizens also pertain to the physician’s rela- 1996 strikes, trusted physicians gave prisoners medical advice tionship with a prisoner patient. Prison authorities have a on how to take vitamins to prevent permanent neurological legitimate interest in preventing suicide and in maintaining defects after the strike. The government cited the coordinated social control over health and security in the prison nature of the strikes, including the use of cell phones from environment. However, in either clinical or political inside prisons, as evidence for uncontrolled communication settings, the choice to refuse food can be an authentic, between prisoners and as confirming the need to re-establish albeit lethal, expression of values that may end the control over inmates. By November, the government showed chooser’s life. Studies showed that prisoners who go on no sign of accepting the strikers’ goals. The hunger strikers hunger strikes have a high prevalence of depression or made the fast more rigorous and announced that participants post-traumatic stress disorder but are not especially likely would die, rather than fast, to advance their collective goals.22 to be suicidal or incapable of making a decision to go on Citing the need for swift action
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