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ANALYSIS: Hunger strikes can raise ethics issues for doctors

The wave of recent hunger strikes by detained former and current government officials, including former president Chen Shui-bian (陳水扁), Yunlin County Commissioner Su Chih-fen (蘇治芬) and Chiayi County Commission Chen Ming-wen (陳明文) has not only attracted widespread media attention, but also raised ethical problems for doctors dealing with the hunger strikers.

On Nov. 16, Chen Shui-bian was rushed to the Far Eastern Memorial Hospital after complaining of soreness and discomfort in his chest. It was the fifth day of his hunger strike. He was transferred to Taipei County Hospital in Banciao (板橋) the next day for security reasons.

Yang Chang-bin (楊長彬), the hospital deputy director, said at the time that Chen Shui-bian had high levels of ketone in his blood and was experiencing bloating.

Hunger strikers experience serious risks to their health after three to five days, when the glucose that the body relies on for metabolic processes runs out and the body turns instead to processing fats for energy, said Ho I-chen (何一成), deputy director of the ReShining Clinic.

Fasting or hunger striking may cause elevated levels of ketone, which the brain relies on during lipid synthesis and for energy, Ho said.

When ketone levels are too high, it can lead to ketoacidosis, a potentially lethal condition, he said.

By supplementing the body with glucose, such as through intravenous infusion, the body’s metabolism returns to normal and ketone levels drop very quickly, he said.

When a serious risk is posed to a hunger striker’s health, methods of stabilizing blood pressure and blood sugar levels include feeding nutrients through a nasogastric tube and intravenous infusion of glucose and saline, he said.

A nasogastric tube is a clear plastic tube that is inserted through the nose, down the back of the throat, through the esophagus and into the stomach.

The tube can be used to remove air and digestive juices from the stomach and has also been used as a feeding tube for patients in a coma, Ho said.

There have been many recorded instances in countries around the world of prisoners and detainees being force-fed while in prison, but the practice has been deemed unethical by the World Medical Association (WMA).

Article 21 of the WMA’s Declaration on Hunger Strikers, updated in October 2006, states: “Forcible feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment.”

“[Glucose intravenous infusion], if performed under the consent of the patient, is not a form of forcible feeding,” said Wu Chun-ying (吳俊穎), attending physician of Taichung Veterans General Hospital’s Division of Gastroenterology and Hepatology and a former member of the Bureau of Health Promotion’s Ethics Committee.

However, “intravenous infusion is only a temporary measure and is not a long-term substitute for food intake,” Wu said.

“Forcible feeding is defined as forcing food into the patient’s mouth against the patient’s will,” he said.

If the physician performs forcible feeding without the patient’s consent, he has violated the Standard Operating Procedure of health care, he said.

If the patient is not in critical condition and is still conscious and capable of making decisions regarding his or her own health, then the physician should communicate with the patient about his or her condition and discuss the available treatments and the consequences of choosing to receive or not receive certain treatments, Wu said.

However, in the case of an emergency where the patient could die if immediate measures are not taken, the physician must evaluate which method is the most appropriate to protect the life of the patient, he said.

In the case of hunger strikes, insertion of a nasogastric tube is preferred over force-feeding through the mouth, which is unsafe as it can trigger gagging reflexes and result in suffocation, he said.

The physician must perform such measures in order to preserve the patient’s life, even if it is against the patient’s will, but “only in times of emergency,” he said.

“The practice of force-feeding is not clearly detailed in the current medical laws in Taiwan,” said Lin Yi-lung (林義龍), chairman of the Association of Medical Law in Taichung. “Since it is not clearly punishable by law, the issue becomes one of ethics.”

Medical personnel in Taiwan are not bound by WMA declarations, which are not legally binding, he said.

“When a criminal or a person suspected of criminal activity has been detained or imprisoned and refuses to eat, the detention center cannot allow the hunger strike to go on if the person’s life is in critical condition,” Lin said.

“A [prisoner or detainee] who goes on hunger strike is enacting his right of resistance against the government. But if in doing so the person puts his life in danger, then the detention center has the right and duty to save the person’s life, even if forcible measures must be taken,” Lin said.

“In this case, they are not violating the law,” Lin said.

The detention center that sends the detainee to the hospital authorizes the hospital to provide health care to the patient in order to save his or her life, in which case the detention center acts on behalf of the patient to give consent for receiving treatment, he said.

In this case, neither the detention center nor medical personnel have violated any law concerning forced medical treatment, he said.

Chen Shui-bian’s lawyer Cheng Wen-long (鄭文龍) and Far Eastern Memorial Hospital spokesperson Sophie Hsieh (謝淑惠) both confirmed that the former president had consented to intravenous infusion when he was taken to the hospital on Nov. 16.
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