How should physicians approach to ‘Hunger Strike’?
Bulletin of Medical Ethics, 2002 Sep (181): 13 – 8.
Berna Arda( MD, PhD) Ankara University School of Medicine, Dept. of Deontology
No doubt, each phase in the evolutionary development of medicine has come up with its own characteristics. The identity of physicians has undergone a great scale of changes in parallel with these developments. No matter in which phase we are, this identity should bear some indispensable factors in its essence. These factors define a ‘professional identity’ beyond the ‘personal identity’ of the physician which consists of sexual, local, ethnic, national, religious and ideological values. What characterizes the physician’s attitude, even in situations he experiences identity conflict, is whether he should give priority to the values his professional identity refers and guaranties. What makes the physician ‘reliable’ and has made the institution of medicine survive for thousands of years lies in the fact that there exists not only a humanist but also a universal identity shadowed over the identity of physician. It has had its own solid principles about which physicians to be regarded as eligible for the profession.
Haven’t all the other physician oaths derived from the Hippocratic Oath been a contract between the members of the society and the physicians on the basis of ‘honesty’, ‘reliability’, ‘secrecy’, respect for the personal identity’ and ‘discrimination of all sorts’ since the period of Hippocrates in which medicine was a profession with its own rules, characteristics, scope and which functioned like a guild. In this oath phenomenon whose ritualistic factors are more apparent, a sense of worry to guarantee and preserve its own presence over each of its new fellow professional has been existent, hasn’t it? In this ritualistic context, the physician conveys the message ‘you can trust me, I will use my professional knowledge and skill for your own benefits’
Physician-Patient relationship has undergone a great deal of change throughout the evolution of medicine, and has had a lot of different aspects. One of those of aspects is a kind of active-passive relationship in which the physician is active and the patient is completely passive. Another is the one in which the physician tells the patient what to do, say, one which is overwhelmingly pre-determined by the physician and practiced by the patient, which is called ‘guiding-cooperating’. The third type of physician - patient relationship between the physician and the patient is called ‘sharing’ in which the physician helps the patient as a professional and which is realized by way of mutual participation and cooperation. Especially in remedial medicine, the physician-patient relationship should be based on mutual ‘trust’ . Today there has been a change from a paternalist model in which the physician guides and maintains a relation based on sharing. It is possible to observe that one of the pinpointing factors of the physician-patient relation is the socio-cultural characteristics of the society itself; and that a widespread paternalistic relation in which the patient is passive has emerged; and that this kind of a relation has been adopted and practiced widely within the circle of both the physicians and the patients.
It is possible to say that the element of ‘trust’ on which the physician-patient relation referred to above has been built, has changed its nature from an ‘unconditional trust’ to an ‘informed consent’. This situation results from the distrust originated from some inhuman practices such as the ones of the Nazi’s. In other words, the idea that ‘the physician decides about the welfare of the patient’ has been replaced by the idea that ‘the physician provides the patient with the information needed by the patient about the illness and the remedy thereto’. In modern medicine the concept of informed consent is highly important. Together with the concept of informed consent which can be summarized as the consent of the patient about the treatment to be received after having been informed about his/her illness and the treatment thereto, the ethical and legal responsibilities of the physician have been revised; and it has been brought up that the physician has to respect the decision of the patient putting aside his authoritative and paternalist figure. Still, however, is it possible to perceive the ‘principle of autonomy’ as the autonomy of only the patient disregarding the autonomy of the physician when discussing the above mentioned relation, no matter when and where it happens? Daily life brings such unusual situations that the physicians are put in many dilemmas. Thus, it is possible to say that the decision-making process is not so easy for the physicians; but the pre-conception of the benefit of the patient can be only basis of such a decision.
Medicine as a profession is an activity considering human life ‘sacred and valuable’ and based on preserving life. Considering various behavior that human societies display, it is clear that there have been situations in which the physicians has had to make difficult and odd decisions as a professional. It is obvious that a great many solid examples of this kind happen everyday in the practice of medicine; physicians often have to decide on the line between life and death; and during the course of this decision making process, we may observe a clash between the tradition of medicine which dates back to ancient times and the conditions of our modern time; and the physician should come to a decision which is a product of his personal assessment and the traditional rules of medicine. Whatever the external factors determining a professional practice are, there are some elements in the core of the profession which constitute the indispensable parts of the profession, in other words there are some elements in the absence of which this professional identity is questioned. For medical doctors, this core covers some universal factors such as humanism, honesty, and respect for human values. Because of its early emergency in history and the nature of medicine, professionals of medicine have been crowned by such crystallized values and maybe that’s why in no other profession are these values conspicuous. One of the mainstays of the trust in the physician-patient relationship and for the general medicine is that acting for the welfare of the patient is a must for the physician and the medicine. Today as mentioned above since World War II, there has been an ever growing increase in patient rights as a concept the practice of medicine. Put it in a different way, today medicine is not a practice ‘against the patient’s will’ but ‘for the patient together with the patient’, which requires that the physicians inform the patient about his illness and make thereby him a part of the decision making process. This process appears to be much more effective. In the light of all these developments, one of the principles medical ethics has considered vital, without doubt, is ‘autonomy’ and ‘putting this autonomy into practice’.
Another point to be stressed is that, today, the physician oaths and their contents have undergone a great deal of changes. Therefore, the oath rituals with the witness of the Greek Gods have changed its form, gained a secular form and turned out to be oaths over beliefs and values that the physician considers sacred. In this context the aim is to be reached is not which factors are to be involved in the physician oath but is to replace an ‘archaic’ text with a text which is of more modern, humanist, universal factors. Today, the effort to make the modern elements of the oath texts dominant should also be seen as an effort to sustain their functions active and alive. One of the unchanged characteristic of the physician oath is the ‘impartiality of the physician’. Impartiality and informing the society about it is one of the features which makes the physician and the institution of medicine ‘reliable’, isn’t it? Because of some authority abuse in the institution of medicine in history, the autonomy of the patient and the paternalism of the physician have reflected on the practice of medicine in a balanced way. For that reason, some concepts such as ‘coercive intervention’ and ‘coercive hospitalization’ are conflicting and controversial issues in ethical aspects. The thing that makes the physician’s medical and surgical intervention legal and acceptable lies in the fact that the patient consents these. In this respect, there is little to do for a patient when there is no such consent and/ or it is not directly declared. This situation creates a questionable issue in terms of medical ethics, it creates a situation for which the physician is legally held responsible as well.
In the incidence of hunger strikes in Turkey physicians must execute their professions with the responsibility of impartiality, putting human life into top priority. It is not within the scope of the physician to define these actions and they are also not expected to act as an ‘executer’ on the behalf of government. As regards this, the role tailored for the physician to stop an ongoing action is not accepted and giving such a role to the physician is not right either. It is clear that the physicians have been wrongly accused and a professional identity crisis has been emerged since December 2000. In this context it can be noted that respecting the decision of the patients does not mean ‘supporting the protest’ because the identity of impartial physician makes it impossible to take a political position.
When considered theoretically, hunger strikes are personally decided actions. So, hunger strikes are thought to be related to the autonomy of the person himself and the counter action can only be rested on this concept. Should a person try to deprive himself of the things that sustain his life, putting an end to his life provides the only autonomy for this person. Putting it in another way, we are talking about a kind of freedom which can emerge in unfavorable situation and which has no chance of being realized in a favorable situation. In case of hunger strikes which have lost their individual nature and which have gone through changes both in their scope and meaning, it is a must for hunger strikes to be redefined by lawyers, sociologists, psychologists and psychiatrist by clarifying their reasons.
Where is our standing point as the physicians of Turkey, where there are hunger strikes and death fasts and especially under the conditions where individual capability has been disabled?
It must be stressed that the consent of the patient is highly important physicians should not intervene the patient without the consent of the patient. And it can be predicted ‘if Hippocrates were alive’ he would include the term ‘respect for the autonomy of the patient’ into his oath. No wonder, in a practice whose priority is ‘life and preserving life’, what should be done is to let the physicians make use of the reflexes that has been in practice in medicine for thousands of years. Preventing it seems impossible and meaningless.
It is possible to come across patients refusing treatment and to live for one reason or another during the professional life of a physician. In such controversial situations between the physician and the patient the common response of the physician is to persuade and motivate the patient to regain the desire to live. However these efforts may result in failure. Unlike the education and experience of the physician he/she has, the patient may choose the option not to receive any treatment and terminate his life. No matter how difficult it is to accept the situation as a physician in Turkey, the ethical responsibility of the physician is only for the patient not for anybody or any institution. Because each biological structure is unique, taking an action to dissuade a patient from his decision and every action taken by the physician to stop the irreversible outcome of the situation must not put the physician in a guilty position. In case of unconsciousness of the patient, the decision should be left to the physician himself but he should also be informed that he has the right to refuse to provide treatment if he fears that he may violate the patients’ rights under the influence of his ideological, sexual, religious identity. It would be a right step to let the physician, who is distressed and under pressure, act freely instead of labeling him as ‘ strike breaker’. It can no longer be ignored that leaving the prognosis into a certain process, taking human rights as a starting point, creates striking ethical problems for the physician himself and the society he lives in.
It has already been referred to the principle of autonomy of medicine and its application here-in-above. The boundary and validity of autonomy and its position in suppressed groups is a controversial and questionable issue in ethical aspect. What is the role of the physician in this process? As the autonomy is doubtful and when the validity of consent is questionable, we should be on the side of preserving life, shouldn’t we? The fourth item of Malta Declaration is as follows;
The ultimate decision on intervention or non- intervention should be left with the individual doctor without the intervention of third parties whose primary interest is not the patient’s welfare. However, the doctor should clearly state to the patient whether or not he is able to accept the patient’ s decision to refuse treatment or, in case of coma, artificial feeding, thereby risking death. In the doctor cannot accept the patient’ s decision to refuse such aid, the patient would then be entitled to be attended by another physician ( 1 ).
But this item has been partially ignored by local approach and it hasn’ t given enough importance to “the moral status of physicians” . Another important point in our local conditions is that nobody can answer the question related to what and how a physician should act and react in situations in which the suppressed situation cannot be relieved. It is not fair to be held responsible for things we are not responsible for and guilty of things we can contribute to like physicians. All of the collections of newspapers published in this period can evaluate in the light of ethics( 2-10).
To sum up, in the field of human rights it would be right to express that Turkey has enough experience to provide her physicians with. On the basis of this experience and by sharing and enriching it with our physicians, we shall convey our national experience and suggestions to World Medical Association and other related institutions and this experience and suggestions are likely to play a role in the revision and forming of the related reports and declarations. It is clear that professional associations of physicians have the determination and power to do a lot to save and protect the identity of the physician from the crisis erupted in media especially started in the last month of 2000.
1- Malta Declaration. Ethical Codes and Declarations Relevant to the Health Professions, Amnesty International Compilation, p.13 - 15, UK, May 1994.
2- Engin A: Two physicians’ letter and medical ethics(in Turkish), the Cumhuriyet, 11 Dec 2000.
3- Atabek E: Don’ t intervene, they die (in Turkish), the Cumhuriyet, 11 Dec 2000.
4- Bursali O: Death fastes(in Turkish). The Cumhuriyet , 12 Dec 2000.
5- Öztürk O: Death fast, suicide, human rights...(in Turkish) the Cumhuriyet, 15 Dec 2000.
6- Eksi O: How many people support ?(in Turkish) the Hurriyet, 16 Dec 2000.
7- Bila F: Medical intervention debate.(in Turkish) the Milliyet, 22 Dec 2000.
8- Bila H: Ethics. (in Turkish) the Cumhuriyet, 20 Dec 2000.
9- Bila H: Watching the death. (In Turkish.) the Cumhuriyet, 22 Dec 2000.
10- Yazici H: The consent of patient is basic.(in Turkish.) the Radikal , 3 Jan 2001.