Dual loyalty conflicts in medicine

In October 2017, 20 doctors at Warsaw’s Paediatric Hospital went on hunger strike, demanding greater health expenditure from the government; and in 2015 two doctors staged a 24-hour hunger strike at London’s Parliament Square in protest at the treatment of NHS whistleblowers.

In the Polish strike, doctors were monitored by colleagues, with those whose health raised concerns being replaced by healthy volunteers; and the London case was self-limiting. Thus, some hunger strike protests or demands trying to effect political change cause, at worst, discomfort to participants. But hunger strikes undertaken by the incarcerated can sometimes be lethal, posing legal and ethical challenges for medical personnel.

Two recent studies by Gulati et al of the University of Limerick and University College Cork consider these issues in the <em>Irish Journal of Psychological Medicine</em>, with one addressing ‘Hunger strikes in prison: A legal perspective for psychiatrists’. They highlight guidelines from the World Medical Association, noting that autonomy is favoured over beneficence; that the neutrality of physicians is to be upheld; and that “force-feeding of an individual with capacity who refuses the same is not acceptable”.

Which makes perfect sense. The only problem is that lodged in our skulls, psychiatrists included, is an often impenetrable barrier separating the ice-block of legal reasoning from a cauldron of disparate beliefs, political opinions and views. My inference is that this separation is acknowledged in Gulati et al’s second study, ‘Hunger strikes in prisons: A narrative systematic review of ethical considerations from a physician’s perspective’, where they state: “Whilst there seems to be an overall consensus favouring autonomy over beneficence, tensions along this fine balance are magnified in jurisdictions where legislation leads to a dual loyalty conflict for the physician.”

The extent to which “dual loyalty conflicts” can arise can be gauged from the titles of two chapters in the British Medical Association’s <em>Medicine Betrayed: The participation of doctors in human rights abuses (1992)</em>. With chapter four entitled ‘Medical involvement in torture’ and chapter five entitled ‘Abuse of psychiatry for political purposes’, here are reminders that one’s professional status does not confer immunity from uncivilised behaviour.

A more recent reminder is supplied by Bringedal et al in the <em>Journal of Medical Ethics</em> (2018, 44: 239‒43) in their paper ‘Between professional values, social regulations and patient preferences: Medical doctors’ perceptions of ethical dilemmas’. This Norwegian survey of over 1,200 doctors requested them to define whether a supplied range of different circumstances constituted a medical dilemma. One was the ethics of force-feeding a person on hunger strike and 76 per cent judged it to qualify as a medical dilemma. To my surprise, however, only 42 per cent said they would not force-feed a hunger striker and 39 per cent admitted they did not know what they would do. In the context of a supposedly enlightened Scandinavian model of social attitudes, these data are concerning.

Equally concerning is an apparent unquestioning attitude to the widely accepted concept of autonomy, with Garasic and Foster, writing in <em>Medicine and Law</em> (2012, 31: 589-98) to remind us of “a huge and dangerous political elephant in the room”. In ‘When Autonomy Kills: The case of Sami Mbarka Ben Garci’, we read that: “Autonomy rights (and therefore the right to die) are often accorded to hunger strikers who come from classes perceived to be undesirable, but withheld (or trumped by other considerations) in the case of strikers from more desirable classes.”

When the Muslim Tunisian Sami Mbarka Ben Garci was imprisoned in Pavia, Italy, charged with rape, he went on hunger strike, asserting his innocence. Assessed as competent, his autonomy was respected and he died on 5 September 2009.

Garasic and Foster note the silence of the Roman Catholic Church in this case: “It is not usually slow to comment about cases where the sanctity of life is at stake. Was this because, as well as not being seen as part of the body politic, [Ben Garci] was not part of the Catholic body ecclesiastical?”

This approach to autonomy, illustrated by the Ben Garci case, prompts the thought that treatment decisions are seldom made in a political vacuum, in which case the concept of autonomy in the context of hunger strikes may not always be a clear-cut one.

If it is acceptable not to force-feed a mentally competent hunger striker who wishes to die, is it acceptable to force medication on a mentally incompetent individual who doesn’t wish to die, to make that person sane so that they can be executed? Writing in <em>Medicine Healthcare and Philosophy </em>(2013, 16: 795-806), Garasic considers ‘The Singleton case: Enforcing medical treatment to put a person to death’. In October 2003 the United States Supreme Court ruled that Arkansas prison officials could force schizophrenic convicted murderer Charles Singleton to take drugs that would render him sufficiently sane to receive a lethal injection. He was executed on 6 January 2004, having undergone a series of therapeutic interventions aimed at achieving a decidedly non-therapeutic outcome: Death.   

The conflicts between patient autonomy, medical ethics and political jurisdictions ought to be capable of resolution. Who would have thought that ‘ought’ could tax we humans so much?