The rules of medical ethics and medical professional codes do not allow for discrimination in the provision of health care to prisoners and detainees. Individuals under arrest or any form of detention must have access to a standard of health care and services, and compassionate care, which are equivalent to that of the surrounding general population. This applies to health professionals who work directly in prisons or other detention centres, and equally to health professionals working in the national health services to whom prisoners may be referred. One consequence of neglect of detainee is that they learn to mistrust doctors, leading to them to avoid seeking medical help after imprisonment.[1] There may be other reasons for prisoners not to trust the prison doctor. Doctors working in prisons are often underpaid, ill-considered by their superiors, and receive no training on prison health issues. As a result they are not very motivated in performing their jobs, which leads the prisoners to mistrust their services. Prison doctors in situations where torture is a reality will also be, rightly or wrongly, seen as accomplices of “the system” and also be mistrusted.
Hunger strikes are a particularly difficult situation for doctors to deal with. Most fasting prisoners do so for two or three weeks, and those on strikes rarely suffer any harm. As they go on longer, the risks to the hunger striker increase. In an ideal situation, an independent doctor will have explained the risks of prolonged hunger strike, and taken instructions on what the person wants to happen if he or she ceases to be capable of rational thought. This should happen in an environment where the patient’s confidentiality can be respected, and where he or she can be protected from undue pressure from political colleagues. In cases where prison doctors have been following hunger strikers before and during the fast, and know what the patients’ positions and convictions are, physicians should respect the principles stated in the Declaration of Malta on hunger strikes. This declaration allows physicians to act in the best perceived interests of their patients, while respecting autonomy. If a physician is called upon to take care of a hunger striker already in a comatose state, he or she will have no choice and will have to provide reanimation. A physician should not rely on what amounts to “hearsay” in such cases. The opinions of the immediate family should be taken into consideration, but are not paramount. Neither the opinions of the authorities nor those of the patient’s political colleagues should be given any weight.
[1] Smidt-Nielsen K. The participation of health personnel in torture. Torture, 1998; 8(3):91-94.