The revised WMA Malta Declaration on Hunger Strikes (2006)
Why was there a need for a full revision of the WMA 1991 Declaration of Malta on Hunger Strikes ?
The need to review and revise the 1991 WMA Declaration on Hunger Strikes was decided at discussions within the World Medical Association's Ethics Committee at the end of 2000. A first proposal to substantially modify the existing 1991 "Malta" text, to accommodate for the new realities in the field – namely the hunger strikes in Turkey in the nineties – was dropped, so as to take into account other issues beyond the situation in Turkey.
- The hunger strikes in Turkey in the 90's led to an unprecedented number of deaths – at least 60 – 70 prisoners died from fasting, probably more. The prisoners who died from their hunger strike, died after prolonged periods of time, which implied they had not been "totally fasting", but had in fact died from prolonged malnutrition, and not from "acute malnutrition". This was therefore a situation completely different from that of the 1981 Irish Hunger Strikes, where the fasting had been total, with only water intake.
The reasons for the Hunger Strikes in Turkey, and the way they were ultimately "managed" by the authorities, are a very complex issue, and go beyond the medical discussion here. However, some of the specifics of the Turkish strikes need to be mentioned, as they break down once held "assumptions" about hunger strikes in prisons. This lesson will only deal with the medical aspects of the hunger strikes, and the duties of doctors confronted with such dilemmas.
- One major concern already mentioned in the original "1991 WMA Malta Declaration", but which needed to be recalled and emphasized, was the necessary "voluntary" character of hunger strikes. Respect of autonomy implied there should be no form of coercion – either by fellow prisoners or by prison authorities. The different "pressures" that can be exerted on Hunger Strikers in custodial settings have been considered in the preceding lessons of this Chapter 5. The specific peer pressure exercised on hunger strikers (by fellow prisoners) was a significant issue in hunger strikes in the late 1990's. The duty of doctors to ascertain the voluntary nature of each prisoner's participation in a hunger strike was thus recalled in the revised WMA Malta Declaration and in its explanatory "Background Paper" in the World Medical Journal.
- The detention of prisoners during the so-called "global war on terrorism", particularly in such contexts as detention in Guantánamo have been widely documented in the media, and an great amount of information accessible to the public can now found on the Internet. Articles on the different ethical aspects of the management of these hunger strikes have also been written (see References tab above).
- The issue of force-feeding has lately been in the forefront of the controversies engendered by hunger strikes. Force-feeding had not been a major problem when the 1991 WMA Malta Declaration was drawn up. For this reason, the difference between "force-feeding" and "artificial feeding" was not considered in detail. This distinction now clearly warranted clarification, and the difference between the two needed to be spelled out. This has been done in the revised 2006 Declaration of Malta and its Background Paper.
- Finally, last but by no means least, a firm position against Force Feeding needed to be considered, and was taken by the World Medical Association, to ensure physicians would unequivocally know they should not participate in any such coercive procedures.