Abstract
Several bioethicists have recently advocated the force-feeding of prisoners, based on the assumption that prisoners have reduced or no autonomy. This assumed lack of autonomy follows from a decrease in cognitive competence, which, in turn, supposedly derives from imprisonment and/or being on hunger strike. In brief, causal links are made between imprisonment or voluntary total fasting (VTF) and mental disorders and between mental disorders and lack of cognitive competence. I engage the bioethicists that support force-feeding by severing both of these causal links. Specifically, I refute the claims that VTF automatically and necessarily causes mental disorders such as depression, and that these mental disorders necessarily or commonly entail cognitive impairment. Instead, I critically review more nuanced approaches to assessing mental competence in hunger strikes, urging that a diagnosis of incompetence be made on a case-by-case basis—a position that is widely shared by the medical community.
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Notes
I distinguish moral autonomy from personal autonomy (see [1]). Hereafter, the term ‘autonomy’ will mean moral autonomy, and as such may be readily applied to prisoners.
The terms ‘mentally incompetent,’ ‘cognitively incompetent,’ and simply ‘incompetent’ are used synonymously herein. The same goes for mentally, cognitively, and simply competent. Following Tom Beauchamp and James Childress [6], it is sufficient for my purposes here to understand competence as the ability to make medical decisions. While moral autonomy is an all-or-nothing concept, competence comes in degrees: individuals may be more or less able to make medical decisions. However, for practical purposes, here I use competence as an all-or-nothing concept as well.
“Competence judgments serve a gatekeeping role in health care by distinguishing persons whose decisions should be solicited or accepted from persons whose decisions need not or should not be solicited or accepted” [6, p. 69].
Mental disorders, or illnesses, may or may not include cognitive impairment. However, for the sake of simplicity, these terms are treated as synonymous, unless otherwise specified.
Original translation into English.
Another descriptive statement that requires empirical support is the authors’ bold (and quite outrageous) claim that the prisoner would provide retroactive consent to force feeding. The authors fail to support that claim as well. In fact, I know of only two cases in the literature when this was the case [3, 10].
This Act is introduced elsewhere [1].
Terence MacSwiney, the mayor of York during the English-Irish unrest in 1920, embarked on a VTF. He died on day 74 [15].
Altun et al. discuss post mortem findings in three of the same prisoners; they seem to hint at the impossibility of VTF in these prisoners as well [16].
Peter Kerndt et al., for example, point out that VTF often leads to a sense of euphoria, while it has been documented that prolonged periods of semi-starvation lead to mental lethargy as well as lability, apathy, and irritability [15]. In addition, a review article suggests that malnutrition negatively affects the absorption of oral thiamine supplements from the gut, meaning that the longer the malnutrition, the worse the absorption [17].
A review paper does suggest that 75% of patients with WE who do not receive treatment will suffer from permanent brain damage [17].
That said, one study of four people in France, who engaged in VTF in protest against the nuclear arms race in 1983, documented WE in one of them which lead to the cessation of her VTF on day 38 [20]. However, the patient healed almost completely after standard therapy. On the other hand, a 1982 review paper does not mention WE or any cognitive impairments as a complication of experimental and non-experimental VTF and semi-starvation [15].
I avoid discussing the partly arbitrary nature of these medical diagnoses, particularly in psychiatry, since while imperfect, these diagnoses are essential. I briefly touch on this below.
In fact, I think that this statement, paraphrasing Weingarten, is too strong. No one is fully competent. Rather, hunger strikers are roughly as competent as prisoners who are not fasting, and both groups are roughly as competent as most other people.
Gross also calls Garasic’s argument that links VTF to depression and other mental disorders ‘promising’ and ‘weighty’ [24].
Elsewhere, Lederman and Lederman [1] respond to other arguments made by Garasic, Gross, and others who justify force-feeding, particularly by medical professionals.
Lederman and Lederman further criticize the empirical basis for the link Garasic makes between depression, competence and hunger strike [1].
Wei and Brendel [5] refuse to restrict this goal to a political goal, as most authors do; they simply concede that a prisoner may refuse food for any goal that they prioritize.
This is not to say that all diagnoses of incompetence are necessarily accurate: “In the final analysis, the assessment of decisional competence remains heavily a matter of clinical judgment, although some studies indicate that these clinical judgments too are often not reliable” [6, p. 115].
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Acknowledgements
Dr. Michael Weingarten passed away while this manuscript was being reviewed. I mourn his passing. I thank Mayli Mertens, Voo Teck Chuan, Marcus Labude, and Owen Schaefer for their constructive comments.
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Lederman, Z. Prisoners’ competence to die: hunger strike and cognitive competence. Theor Med Bioeth 39, 321–334 (2018). https://doi.org/10.1007/s11017-018-9439-y
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DOI: https://doi.org/10.1007/s11017-018-9439-y