Ah yes, arguably the most difficult, complicated, and frustrating patient found in corrections… the hunger striker. The simple mentioning of the term brings a shudder to all those working in the correctional field. These patients command an exhaustive number of resources, effort, and time. So, how do we manage them without driving ourselves mad and pulling out all our hair?
Understanding and Classifying Hunger Strikers
The first part of the process involves an attempt to better understand the situation and then define the type of patient involved. Not all hunger strikers are hunger strikers?? What? That’s correct. The term is used too generally and doesn’t accurately describe the variations of patients seen within this category. Not everyone refusing to eat is willing to take their fasting to the grave and not everyone refusing to eat has the mental capacity to understand what they are doing. Thus, we must first define the type of patient involved.
So, how do we define/categorize these patients? First and foremost, we must ensure they have the capacity to understand their actions. By definition, a hunger striker is an individual who is actually fasting, they are doing it voluntarily, and they are doing it for a specific purpose. Thus, those with intellectual delay/disability, those severely mentally ill, those with a medical process hindering their cognitive abilities, or those otherwise incapable of unimpaired rational judgment and/or decision-making are most assuredly not a true hunger striker and should be managed much differently. For the sake of this discussion, we will focus on those knowingly and voluntarily fasting for a specific purpose.
Categories of Food Refusers
And now on to the categories. First up, the food refusers. These individuals are further separated into the subcategories of reactive food refusers and determined food refusers. Reactive food refusers are the most common and are likely the ones responsible for the bad taste you get in your mouth when you hear the term “hunger striker”. These individuals have no intention of actually taking their plight to the grave, but boy do they pretend to. As the name implies, these individuals are utilizing their refusal of food as a means of attempted blackmail or “hostage taking” in “reaction” to an apparent mistreatment.
Given that they are not actually committed to dying over this reported injustice, their goal is to make some change or gain some privilege as quickly as possible. They attempt to accomplish this by making as much noise as possible in hopes of expediting their desired outcome. I can feel the head nodding of the audience with the thought, “yup, I know these patients all too well”.
And now the second subcategory, the determined food refusers. These individuals are very different from the ones previously described. They do not make noise or desire attention. Rather, they prefer to suffer in silence and oftentimes their actions are brought on by a feeling of hopelessness. They do not have a specific purpose and thus are not categorized as “hunger strikers”. Although comparisons with suicide in connection with hunger strikers are very often unjustified and inappropriate, this subset of food refusers’ actions could legitimately be described as an attempted suicide. Often, food refusing for these individuals is seen as a last resort or a cry for help, making correct identification and intervention paramount.
Managing True Hunger Strikers
And now for the “true” hunger strikers. Those actually not eating, doing it voluntarily, doing it for a specific purpose, and willing to take it to the point of death. These truly committed and motivated individuals, although rare, can create some serious ethical dilemmas as their hunger strike persists.
So, how do we manage these individuals? The answer lies in a multidisciplinary approach. Due to the significant variation seen amongst food refusers and hunger strikers, there is no “one size fits all” solution. It is essential that a team comprised of medical, mental health, security, and legal professionals is constructed and meets regularly to discuss the individual.
In the case of a “dry” hunger striker, one refusing food and water/liquids, or those with significant medical comorbidities, decompensation can occur quickly, and they may need to be monitored several times a day, whereas reactive food refusers still drinking water/liquids and occasionally eating may require only once daily monitoring. The essential component is to meet and discuss the individual’s case regularly and make adjustments to the care plan as necessary.
Ethical and Legal Considerations
And now for the last, and most complex situation, what to do when the hunger strike is taken to the brink of death? This situation has resulted in a multitude of responses, decisions, and official statements/declarations by several different organizations over the last 50 years. So, can we forcefully intervene? I think CorrectCare Magazine said it best in their Fall 2023 article “HUNGER STRIKES & FOOD REFUSALS” when they wrote, “Several courts have held that prison administrators have not only a right but a duty to intervene and force a patient to take nourishment if the strike puts them at risk of serious injury or death (Austin v. Tennis 3d Cir. 2010; Owens v. Hinsley, 7th Cir. 2011). However, it is always best practice to obtain court approval for this type of intervention before implementation.” In my experience, there can be significant state by state variation regarding a decision on this highly-debated topic, and thus further solidifying the importance of obtaining court approval before implementation of forced nutritional intervention.
Key Takeaways
So, what did we learn? First, not all hunger strikers are hunger strikers. It is imperative to correctly identify motivations to appropriately categorize the type of patient involved. Second, there is no “one size fits all” solution. Successful management involves an individualized and multidisciplinary team approach. Third, it is essential to obtain court approval before implementation of forced nutritional intervention. And lastly, although hunger strikers will continue to plague the lives of all those in corrections, hopefully, with additional understanding, management can be just a little less stressful.
Dr. Nicholas Longnecker, MD CCHP CMO
Chief Medical Officer