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Legal and Bioethical Complexities in the Role of Medical Professionals in Hunger Strikes: A Comprehensive Analysis
Corresponding author: Gaurang Narayan, Junior Resident, Department of Obstetrics and Gynaecology, Indira Gandhi Government Medical College, Nagpur, India gaurang.narayan@gmail.com
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Abstract
With an emphasis on the confluence of moral and legal issues within the context of Indian law, this review delves into the historical roots and current ramifications of hunger strikes as a peaceful mode of protest. Hunger strikes are an effective tactic for peacefully addressing perceived injustices and have their roots in India’s Gandhian era. Nonetheless, given the force-feeding technique and the participation of medical personnel, their method presents difficult legal and bioethical issues. Utilising pertinent case studies, this analysis seeks to clarify the developing legal and moral terrain surrounding hunger strikes, providing insights into the finely balanced relationship between personal autonomy, the right to protest, and the duty of care maintained by healthcare professionals.
INTRODUCTION
Hunger strikes, a nonviolent form of protest where individuals intentionally refrain from nourishment to highlight perceived injustices, have deep historical roots. This method of resistance gained prominence during India’s Gandhian era, showcasing its potential to peacefully challenge oppressive forces. The intersection of legal and ethical dilemmas within the framework of Indian law is particularly evident in the context of hunger strikes. Despite their long-standing history, hunger strikes present intricate legal and bioethical challenges, especially concerning force-feeding and the involvement of medical professionals. This review aims to examine relevant case examples that illuminate the evolving legal and ethical landscape surrounding hunger strikes and shed light on the role of medical professionals in such contexts.1,2
Biochemical Adaptation during Hunger Strikes
Understanding the physiological changes that occur during hunger strikes is crucial for comprehending the complexities associated with this form of protest. The body undergoes a series of biochemical adaptations to cope with the lack of nutrition. Initially, the body relies on liver glycogenolysis and later muscle glycogenolysis for energy. Beyond 24 hours, the liver initiates de-novo synthesis of glucose through gluconeogenesis, depleting glycogen stores. After approximately three days, the body enters ketosis, a process involving the breakdown of liver fat stores. However, this leads to acidosis, compensatory respiratory alkalosis, and eventually results in fluid-electrolyte imbalance and death.3
Role of Doctors in Forceful Hunger Feeding
The involvement of medical professionals in force-feeding during hunger strikes raises ethical and legal dilemmas. While ethical principles argue against allowing individuals to intentionally endanger their lives, legal perspectives often take precedence in such matters.
Legal Issues
The Hippocratic Oath, a foundational ethical code for physicians, conflicts with the idea of allowing a person to knowingly risk their life. Yet, the legal stance differs significantly. In the medical community, force-feeding by doctors is considered a form of torture, as stated in Article 8 of the World Medical Association Declaration of Tokyo, 1975. Both the World Medical Association and the United States Code of Federal Regulation reinforce this stance.4 The Malta Declaration, a cornerstone in international medical ethics, explicitly prohibits force-feeding of hunger strikers, branding it as “degrading and inhuman.” However, the European Court of Human Rights has sanctioned force-feeding when it is deemed essential to preserve the lives of prisoners, citing the state’s duty to protect lives.5
Legal Precedents in India
P. Rathinam v. Union of India (1994): In this landmark case, the Supreme Court of India affirmed the right to life under Article 21 of the Constitution and held that the right includes the right to die with dignity. The court acknowledged the individual’s autonomy to make choices regarding their life, even if it involved refusing food voluntarily.6
Aruna Ramchandra Shanbaug v. Union of India (2011): While not directly related to hunger strikes, this case addressed the right to die with dignity. The Supreme Court, acknowledging the importance of individual autonomy, allowed passive euthanasia under certain circumstances. This ruling reflects the judiciary’s inclination towards respecting personal choices, even those pertaining to life and death.7
Francis Coralie Mullin v. The Administrator, Union Territory of Delhi (1981): This case emphasized the right to life with dignity as an integral part of Article 21. The court held that the right to life encompasses the right to live in a proper environment, free from any form of torture or cruel, inhuman, or degrading treatment.8
These cases collectively establish a legal foundation that recognizes the right to autonomy, dignity, and life. Articles 14, 19, and 21, which touch upon bodily autonomy and the right to life with dignity, assert and set a precedent for understanding individual choices even in situations of self-imposed harm, such as hunger strikes.
Ethical Issues: The ethical dimension of hunger strikes raises questions about the duty of medical professionals in such circumstances. While legal perspectives provide a framework, medical ethics play a crucial role in guiding practitioners.
Medical professionals find themselves in a delicate position when confronted with hunger strikes. The Hippocratic Oath, which emphasizes the duty to preserve life, appears to clash with the ethical principle of respecting patient autonomy. Doctors may face ethical challenges when deciding whether to intervene in hunger strikes.
Case Example - Irom Sharmila’s Fast (2000-2016)
Irom Sharmila’s prolonged hunger strike against the Armed Forces (Special Powers) Act (AFSPA) exemplifies the complexities faced by doctors. Despite her steadfast refusal to eat, she was force-fed through nasal tubes. This case underscores the tension between medical ethics and the duty to preserve life.9
Medical Issues
Forceful re-feeding in hunger strikers may lead to the development of the nutritional refeeding syndrome (RFS). This syndrome is characterized by hypophosphatemia, alongside abnormal sodium and fluid balance, hypokalemia, and hypomagnesemia. Individuals with a history of alcohol abuse may also experience thiamine deficiency during forceful re-feeding.10
CONCLUSION
In the realm of hunger strikes, the legal and ethical facets are intertwined, and Indian law has evolved to recognize individual autonomy and the right to life with dignity. The judiciary has consistently upheld these principles, acknowledging the complexity of personal choices, even when they involve actions that may harm the individual. The role of doctors in hunger strikes remains a challenging terrain, requiring a delicate balance between medical ethics, legal obligations, and the respect for individual autonomy. As legal and ethical perspectives continue to evolve, a nuanced approach that considers both individual rights and societal interests is essential to navigate the complexities surrounding hunger strikes in India. The legal and bioethical complexities surrounding hunger strikes and force-feeding necessitate a nuanced understanding of the delicate balance between individual autonomy, medical ethics, and state obligations. As debates continue on the morality and legality of force-feeding, it is imperative to consider the broader implications on human rights, medical practices, and societal values. The ongoing discourse should not only address the immediate concerns of hunger strikes but also contribute to a more comprehensive framework that respects individual choices while upholding ethical standards.
END NOTE
Author Information
Gaurang Narayan Junior Resident, Department of Obstetrics and Gynaecology, Indira Gandhi Government Medical College, Nagpur, India E-mail: gaurang.narayan@gmail.com
Conflict of interest
None declared
References
- Management of hunger strike: A medical, ethical and legal conundrum. Med Leg J. 2020;88(4):215-9.
- [CrossRef] [PubMed] [Google Scholar]
- Today in History: On 16th Sep 1932 Mahatma Gandhi went on a hunger strike to protest against caste separation law [Internet]. [cited 2021 Sep 17] Available from: https://www.jagrantv.com/en-show/this-day-in-history-mahatma-gandhi-went-on-a-hunger-strike-in-1932-in-protest-of-caste-separation-law-rc1023105
- Bailey and Love’s Short Practice of Surgery (26th edition). CRC Press; 2013. p. :1517 p.
- [Google Scholar]
- On the Force-Feeding of Prisoners on Hunger Strike - PubMed [Internet]. [cited 2021 Sep 17] Available from: https://pubmed.ncbi.nlm.nih.gov/30284658/
- The Role of Doctors in Hunger Strikes. Kennedy Inst Ethics J. 2017;27(3):341-369.
- [CrossRef] [PubMed] [Google Scholar]
- P Rathinam v Union Of India - Indian Law Portal [Internet]. Available from: https://indianlawportal.co.in/p-rathinam-v-union-of-india/#:~:text=P.Rathinam%20v.%20UOI%2C%20was%20the%20first%20case%20that
- 2022. Aruna Ramchandra Shanbaug vs Union of India Case Summary 2011 SC - Law Planet - Legal News Law Updates & Law Exams Preparation [Internet]. lawplanet.in.. [cited 2023 Dec 13]. Available from: https://lawplanet.in/aruna-ramchandra-shanbaug-vs-union-of-india/
- 2020. Solution IL Francis Coralie vs Union Territory of Delhi Case-Comment [Internet]. Indian Legal Solution; Available from: https://indianlegalsolution.com/francis-coralie-vs-union-territory-of-delhi-case-comment/
- How love and a taste of honey brought one Indian woman’s 16-year hunger strike to an end. The Guardian [Internet] 2018. Available from: https://www.theguardian.com/world/2018/nov/11/irom-sharmila-love-story-worlds-longest-hunger-strike
- [Google Scholar]
- Management of patients during hunger strike and refeeding phase. Nutr Burbank Los Angel Cty Calif. 2014;30(11–12):1372-8.
- [CrossRef] [PubMed] [Google Scholar]
