Patrick Guilbert
b) Réponse du Dr D. Scotto di Fasano, du 25.03.1996, pour le Centre pénitentiaire de Marseille (France)
”Mon Cher Confrère,
Suite à votre envoi du questionnaire, je vous adresse les réponses correspondantes:
1. Un détenu qui pratique le jeune doit être suivi sur le plan clinique, biologique ainsi que sur l'évolution de son poids. Si une anomalie fonctionnelle survient, il est adressé à l’hôpital des Baumettes. Toute perte de poids supérieure à 10 % du poids initial nécessite son hospitalisation. Excepté des médicaments à visée psychique, tous les autres traitements non vitaux sont interrompus. Si le cas s'aggrave, on averti le Juge d'Application des Peines.
2. La décision de suivi du gréviste est d'ordre exclusivement médical.
3. On déclare le détenu gréviste comme un individu libre sur son choix médical, seules des contingences d'ordre vital donnent au médecin la seule initiative du traitement.
4. Ces articles de loi sont toujours en vigueur. Le refus du médecin peut aboutir à des poursuites.
5. Examens somatiques et bilans biologiques (iono, R.A, glycémie) prise de poids et T.A, contrôles ECG, éventuellement examens ophtalmologique et neurologique.
6. Cf. plus haut.
7. Je n'ai pas de chiffre mais si la grève est intégralement suivie par le détenu, une reconsidération du dossier est entreprise par la magistrature.
Recevez, Mon Cher Confrère, l'expression de mes sentiments les meilleurs. ”
c) Réponse du Dr P. E. Brown du 25.3.1996, pour la Grande- Bretagne
“Hunger strikes in prisons.
1. Hunger strikes represent a specific behaviour disorder designed to exert pressure upon the Prison Authorities in order to achieve an objective, to which, in the opinion of the prisoner, he considers himself entitled. The condition is entirely distinct from pathological eating disorders such as anorexia nervosa, bulimia, psychotic depression, dementia, paranoid delusional states or organic physiologic disorders. If it is evident that none of these conditions are present, physical examination is entirely negative and specialised opinion confirm this not to be the case, the initial procedure is to hold a very thorough discussion with the prisoner, pointing in precise terms the possible adverse effects of starvation upon general health. He should be told that he will be offered meals of his own choice, at the appropriate times and there will be no compulsion by health care staff as to whether he eats it or not. If he refuses, the food is removed from his cell and he is always left with unlimited supplies of water or other drinks of his choice. It is sometimes appropriate to locate the prisoner in a small, possibly five-bedded ward where he will have the company of other patients. It is to be noted that "peer pressure" is often highly successful and, in any case, if he is offered small amounts of food from fellow prisoners, it is perfectly acceptable for health care staff to "turn a blind eye". In this manner, many hunger strikers have found it virtually impossible to continue their food refusal. Every time food or drink is taken, this fact must be recorded by health staff.
The doctor should explain to his patient that, in order to assess the likely rate at which physical deterioration progresses, it is essential, with his full informed consent, to monitor the daily deterioration that his body is undergoing. The data required includes daily weight, temperature, pulse, respiratory rate and blood pressure, recorded alongside observed approximate food and fluid intake, if any, together with urinary output. Periodic assessment of renal, liver and haematological functions should be made, with the patient's permission, and a daily ward test of a urine specimen, especially for ketonuria, should be carried out. The significance of abnormal findings should be explained to the patient and agreement obtained to allow the doctor to report fully the current medical state of the patient to the prison authorities. This does not imply that the medical team should, at any time, become involved in the conflict between the patient and the authorities. The patient has the right to read, and have copies of, any clinical reports which the doctor has prepared.
2. The enforcement of any procedure upon the patient by prison authorities, legal or governmental bodies or the patient’s family is only acceptable if the patient, for any reason, including loss of consciousness, is unable to express a conscious wish to the contrary. If he has already made it perfectly clear, in writing, and before witnesses, that no resuscitation measures are to be taken and, at that time, he was of normal sound mind, it may well be that the doctor, assisted by a specialised second opinion, will decide to allow events to take their course. There is, under these circumstances, a duty on the part of the doctor, to inform the prison authorities that a grave risk to life exists. The doctor does, however, retain total independence in decision making on medical matters.
3. Forced feeding is never indicated at the onset of a hunger strike, nor in the event of physical deterioration. If the patient loses consciousness, such a procedure may be available, provided that he has not specifically refused such measures, while conscious, and of a sound mind in the days preceding a coma.
4. Always providing that the patient has not been mentally ill throughout, and prior to the onset of hunger strike, British law will not threaten a doctor who has adhered closely to the above principals. However, it may be that it would be wise to consider an outside hospital admission in order to provide a higher standard of nursing care than that which might be available within the prison.
laboratory investigations and to record such data on a daily basis.
6. The grounds for the decision to hospitalise are as detailed above, and it should be emphasised that nursing facilities for a terminally ill patient may be more appropriate in an outside general hospital.
7. As far as statistical data on hunger strikes in the UK is concerned, I do not at present have any up to date figures. Suffice it to say that death due to hunger striking is indeed a very rare event.
8. The most severe hunger strike case, for which I have taken medical responsibility, lost over 50% of his body weight. I requested, and obtained, a judicial review of the case and, at that time, the guidelines as above for the management of such cases were clearly agreed by the judge. The patient became aware that judicial advice had be sought and on the realisation that no resuscitation would be made available to him, unless he agreed to such measures, he immediately called a halt to his activity and took nourishment. It is of interest to add that some months later he was diagnosed as suffering from "severe depressive illness", for which he was transferred to an outside mental hospital.
This case illustrates the considerable difficulty experienced by competent psychiatrists in distinguishing the food refusal of the manipulative, often psychopathic, prisoner, and those who are clinically depressed from the outset. It can be very fine distinction and the management of such individual case is largely dependent upon the consensus opinion expressed by more than one single psychiatrist. Quite apart from the original intentions of the hunger striker at the onset, the physiological and biochemical changes, which take place as starvation becomes prolonged, in themselves, are conducive to mental instability, unrealistic attitudes, paranoia and erratic behaviour, terminating in severe depressive illness requiring urgent psychiatric treatment.
Many determined hunger strikers, do in consequence, subsequently require certification under section 47 or 48 of our mental Health Act 1983 and become formal patients in an outside mental Hospital where compulsory treatment is possible. It is to be noted however, that even formal patients suffering from recognisable mental illness do have rights and it is only in life threatening situations that medical intervention, including rehydration, are required in which every such case receive treatment under common law. The very few cases, who have quite manifestly remained of completely sound mind and die of starvation as a result, cannot be subjected to compulsory treatment. As mentioned earlier, these cases usually die in an outside hospital where the nursing facilities may well be superior to the available within the Prison Health Care System. In my own experience these cases are usually of serious political significance and martyrdom may well play an essential part in the patient’s motivation.”
d) Réponse du Dr J. Espinosa du 22.03.1996, pour l’Espagne “Lamento mi retraso pero he estado de viaje. A continuación respondo a las preguntas de su cuestionarjo, referentes a los problemas derivados de la huelga de hambre. Las contestaciones representan la situación real en la Institución Penitenciaria española :
1. En España, la huelga de hambre en prisión implica obligatoriamente al equipo médico de la cárcel, que cuenta con un protocolo que debe cumplir, que incluye la información al paciente de bs riesgos que conlleva y de las exploraciones sanitarias a que va a ser sometido, para que dé su consentimiento.
2. La decisión la toma siempre el médico, que decide todas las medidas a tomar, incluyendo el traslado inicial a la enfermería de la prisión, para un mejor control y seguimiento y, eventualmente, también el traslado a un hospital o la alimentación forzada. Estas decisiones han de ser comunicadas al Juez de vigilancia, quien también, si no está de acuerdo con la decisión del médico, puede dictar un Auto exigiendo el traslado al hospital o el inicio de la alimentación forzada.
3. En España no es posible adoptar una posición personal ante las cuestiones derivadas de la huelga de hambre porque existe una Sentencia del Tribunal Constitucional que obliga a tomar
todas las medidas que sean necesarias, incluyendo la alimentación forzada, en caso de riesgo para la vida del huelguista. Dicho Tribunal dictaminó que la vida era un bien fundamental, que habia que preservar, por encima del derecho a la libertad del sujeto.
4. El derecho del enfermo a refutar el tratamiento, que la Ley espanola admite, no puede aplicarse en el caso de huelga de hambre a partir del momento en que exista riesgo para la vida del sujeto, en función de la Sentencia antes citada. Por tanto, el médico tiene el deber de atenderlo contra su voluntad.
El Reglamento Penitenciano recientemente aprobado dice en su artículo 210 : "Asistencia obligatoria en casos de urgencia vital : El tratamiento médicosanitano se llevara a cabo siempre con el consentimiento informado del interno. Sólo cuando exista peligro inminente para la vida de éste se podrá imponer un tratamiento contra la voluntad del interesado, siendo la intervención médica la estrictamente necesaria para intentar salvar la vida del paciente y sin perjuicio de solicitar la autorización judicial correspondiente cuando ello fuera preciso".
5. Desde el momento en que comienza la huelga de hambre se ha de cumplimentar por el inédico el protocolo que adjunto.
Se interviene forzadamente cuando el equipo sospecha que existe riesgo para la vida del sujeto. 6. Pérdida de peso, aparición de signos clinicos de deshidratación y desproteinización, alteración analítica o complicaciones imprevistas, fundamentalinente cardiacas, renales o cerebrales.
7. Existen pero no dispongo de ellas.
8. No conozco ningún caso especial. Todos bs casos son difíciles para bs profesionales al tener que intervenir contra lavoluntad del sujeto. Además, la huelga de hambre la suelen protagonizar los miembros de bandas armadas, que divulgan los datos personales de los médicos que intervienen, con la finalidad de intimidarles. En un caso, incluso, han llegado a asesinar a un médico del hospital de Zaragoza.
Afectuosos saludos.”
e) Réponse du Dr Th. J. Hans de Man du 18.03.1996, avec statistiques relatives au jeûne de protestation aux Pays-Bas
“Dear Colleague,
In consequence of a two weeks holiday at last I find by now the opportunity to answer your questionnaire on Hunger Strikes in Prison.
1. Firstly a few remarks on the Johannes Wier Publication to adapt it for the situation in prisons and remand houses. I sent these remarks to all Medical Services in our prisons, remand houses and youth institutions :
Some hunger strikers insist to be examined and advised by a so-called «trusted doctor», but are not able to name any ; in those cases the prison doctor may make the suggestion of asking another prison doctor, attached in some other prison or remand house to act as «trusted doctor» to the patient. Of course, it is the detainee to decide if he or she accepts this «second opinion» doctor.
Any examination and/or consultation by a doctor who is not employed by the Ministry of Justice falls under the responsibility of the prison’s governor and needs consult of the prison doctor and the Inspector of Prison health Care at the Ministry of Justice.
Admittance in the Penitentiary Hospital in Scheveningen can be realised without permission of the hungerstriking detainee (as opposite to admittance in a civil hospital, which always needs the permission of the patient).
Reason is, that the Penitentiary Hospital has the legal status of a remand house, so transferral is a penitentiary measure, which can be done against the will of the patient (but never contrary
to his or hers health!).
The Declaration of Non-Intervention Model (Chapter VI of the publication) is not fully applicable for the penitentiary situation. For instance : a detainee has never the right to require admittance in a «civil» hospital, and does not have the right to refuse admittance in the Penitentiary Hospital in Scheveningen (see above).
2. As explained above, transferral to the Penitentiary Hospital (but only that!) can occur without permission of the hungerstriking detainee. So, the doctor in charge is not always fully independent in decision making on medical matters.
Force-feeding is never allowed, except in those cases where a hungerstriker is psychotic, according to the results of a psychiatric examination.
3. As explained above, I fully support the Johannes Wier publication. So I will never allow any doctor, nurse or prison officer to force-feed a hungerstriking prisoner, premised that he or she has made undoubtedly clear that it is his or her will not to be force-fed.
Physical deterioration is a biological consequence of the food refusal. So it is the doctor’s duty to explain his patient what is going on from time to time, from day to day, and to explain the ultimate consequences.
4. Every citizen is obliged to offer help to anyone being in danger. But in Dutch jurisprudence it is generally seen as a more serious crime not to respond to the expressed wish of a patient, not to be helped or treated. (This is not limited to hungerstriking people, but to all patients).
5. The usual clinical and laboratory follow up is described in the Johannes Wier publication (Chapter VII). The prison doctor is always responsible for its implementation.
6. The decision (or advise, as you want) to hospitalise a patient is based upon the (medical) ascertainment that the institution is not able to offer the physical and mental care which the detainee needs.
So, not primarily the fact that the prison does not like to have a succumbing hunger striking detainee within its walls will lead to his or hers transferral to any hospital, being it a civil hospital (for which permission from the Prison Service is needed), being it the Penitentiary Hospital in Scheveningen (which has the legal status of a remand house, as mentioned above). 7. Giving you the following data we need to consider that any incident is reported to the Inspectorate of Prison Health Care, no matter if it is a «real» hunger strike or just a food or drink refusal for one day (The following data have been collected from prisons, remand houses, youth institutions and the so-called TBS-clinics) :