Assessing coercion among hunger strikers: A primer

Oh, I’m so glad I’m not a correctional psychiatrist in California right now. Late last week, nearly a quarter of the inmates in the entire state prison system began a unified, declared hunger strike. I’ve evaluated and worked with individual prisoners on a hunger strike before, but nothing on this scale.

Fortunately, standards and policies are in place that a jail or prison can rely upon when managing the individual hunger striker. Common elements of this policy would include a formal notice to custody and to the medical department about an inmate’s declared hunger strike.

Even without formal notice, a policy might require both the medical and psychology departments to be notified when an inmate refuses a set number of meals. At that point, a mental health referral is made to rule out psychiatric illness such as psychosis or depression and to assess the inmate’s competency to refuse food, hydration, or medical procedures. The medical department would assess the inmate to determine his nutritional status on a regular basis through daily weights and laboratory values. As the strike progresses, the inmate may require inpatient medical monitoring of hydration status. In extreme cases, a correctional facility may seek a court order to feed an inmate involuntarily.

Throughout this process, the facility uses a multidisciplinary approach to continuously educate the inmate about the medical consequences of starvation, to assess ongoing mental capacity, and to monitor the patient’s willingness to consent to medical care. The correctional clinician also may be asked to talk to the inmate about what he would want done if he lost the capacity to make medical decisions.

Force-feeding of prisoners carries obvious ethical and practical consequences for the correctional clinician. On the one hand, we are obligated to respect individual autonomy and freedom, but we are appositely required to protect individual health and safety. Because of the potential for behavioral contagion, hunger strikes also can lead to unrest in the facility and further consumption of health care resources. Institutional safety is a dual concern for the correctional clinician.

The 2006 World Medical Association’s Declaration of Malta on Hunger Strikers contains international guidelines for the management of hunger strikes. A key component is an assessment to determine whether a mental impairment undermines the inmate’s ability to make health care decisions. In that case, the inmate is a patient rather than a hunger striker, and the clinician must provide treatment rather than allow deterioration or death. Conversely, if the decision to fast is made free of disability or coercion, the Declaration of Malta bars forced feeding as unethical.

The Malta guidelines also state that "physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities, or others, such as family members."

There’s the dilemma. In the case of mass hunger strikes such as the current one in California, the strike is a political movement designed to force the state prison system to modify its use of long-term segregation. The strike was planned in advance through social media and is fueled by the support of individual celebrities and advocacy organizations. Considerable public attention and scrutiny have been given to the strike by online and traditional media. A single prisoner’s decision to strike may be attributable to his individual beliefs and values but now could also be tied to overwhelming peer intimidation and public pressure. It would be unethical for a clinician to allow a vulnerable prisoner to place his health at risk as a result of coercion.

To my knowledge, no procedures or guidelines exist to help the clinician assess the voluntariness of a hunger strike, so I’m going to propose an assessment. In my opinion, a coercion assessment would include consideration of the inmate’s history as well as current functioning within the facility. I would look for factors that might make him more vulnerable to harassment or intimidation, such as small physical stature, serious mental illness, intellectual disability, history of peer-on-peer victimization, or placement on protective custody. I would review his history of previous institutional protests, if any, such as a documented history of formal protest through the administrative grievance system, pro se lawsuits or individual hunger strikes.

I would also ask the following questions: When did you decide to strike? What led to this decision? Has anyone on the tier talked to you about your decision? What about your family? What would have happened if you hadn’t joined the strike? Have others on your tier refused to fast? What happened to them? What do you hope will happen as a result of this strike? Has anyone offered you any privileges or made any threats related to your decision to strike?

Depending upon the results of this evaluation, the inmate could be offered protective custody, transfer to another facility, or movement to a tier – where inmates are not participating in the strike.

In light of the public attention given to mass hunger strikes lately, anyone working in a jail or prison now should be prepared to handle a coercion assessment.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Oh, I’m so glad I’m not a correctional psychiatrist in California right now. Late last week, nearly a quarter of the inmates in the entire state prison system began a unified, declared hunger strike. I’ve evaluated and worked with individual prisoners on a hunger strike before, but nothing on this scale.

Fortunately, standards and policies are in place that a jail or prison can rely upon when managing the individual hunger striker. Common elements of this policy would include a formal notice to custody and to the medical department about an inmate’s declared hunger strike.

Even without formal notice, a policy might require both the medical and psychology departments to be notified when an inmate refuses a set number of meals. At that point, a mental health referral is made to rule out psychiatric illness such as psychosis or depression and to assess the inmate’s competency to refuse food, hydration, or medical procedures. The medical department would assess the inmate to determine his nutritional status on a regular basis through daily weights and laboratory values. As the strike progresses, the inmate may require inpatient medical monitoring of hydration status. In extreme cases, a correctional facility may seek a court order to feed an inmate involuntarily.

Throughout this process, the facility uses a multidisciplinary approach to continuously educate the inmate about the medical consequences of starvation, to assess ongoing mental capacity, and to monitor the patient’s willingness to consent to medical care. The correctional clinician also may be asked to talk to the inmate about what he would want done if he lost the capacity to make medical decisions.

Force-feeding of prisoners carries obvious ethical and practical consequences for the correctional clinician. On the one hand, we are obligated to respect individual autonomy and freedom, but we are appositely required to protect individual health and safety. Because of the potential for behavioral contagion, hunger strikes also can lead to unrest in the facility and further consumption of health care resources. Institutional safety is a dual concern for the correctional clinician.

The 2006 World Medical Association’s Declaration of Malta on Hunger Strikers contains international guidelines for the management of hunger strikes. A key component is an assessment to determine whether a mental impairment undermines the inmate’s ability to make health care decisions. In that case, the inmate is a patient rather than a hunger striker, and the clinician must provide treatment rather than allow deterioration or death. Conversely, if the decision to fast is made free of disability or coercion, the Declaration of Malta bars forced feeding as unethical.

The Malta guidelines also state that "physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities, or others, such as family members."

There’s the dilemma. In the case of mass hunger strikes such as the current one in California, the strike is a political movement designed to force the state prison system to modify its use of long-term segregation. The strike was planned in advance through social media and is fueled by the support of individual celebrities and advocacy organizations. Considerable public attention and scrutiny have been given to the strike by online and traditional media. A single prisoner’s decision to strike may be attributable to his individual beliefs and values but now could also be tied to overwhelming peer intimidation and public pressure. It would be unethical for a clinician to allow a vulnerable prisoner to place his health at risk as a result of coercion.

To my knowledge, no procedures or guidelines exist to help the clinician assess the voluntariness of a hunger strike, so I’m going to propose an assessment. In my opinion, a coercion assessment would include consideration of the inmate’s history as well as current functioning within the facility. I would look for factors that might make him more vulnerable to harassment or intimidation, such as small physical stature, serious mental illness, intellectual disability, history of peer-on-peer victimization, or placement on protective custody. I would review his history of previous institutional protests, if any, such as a documented history of formal protest through the administrative grievance system, pro se lawsuits or individual hunger strikes.

I would also ask the following questions: When did you decide to strike? What led to this decision? Has anyone on the tier talked to you about your decision? What about your family? What would have happened if you hadn’t joined the strike? Have others on your tier refused to fast? What happened to them? What do you hope will happen as a result of this strike? Has anyone offered you any privileges or made any threats related to your decision to strike?

Depending upon the results of this evaluation, the inmate could be offered protective custody, transfer to another facility, or movement to a tier – where inmates are not participating in the strike.

In light of the public attention given to mass hunger strikes lately, anyone working in a jail or prison now should be prepared to handle a coercion assessment.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Oh, I’m so glad I’m not a correctional psychiatrist in California right now. Late last week, nearly a quarter of the inmates in the entire state prison system began a unified, declared hunger strike. I’ve evaluated and worked with individual prisoners on a hunger strike before, but nothing on this scale.

Fortunately, standards and policies are in place that a jail or prison can rely upon when managing the individual hunger striker. Common elements of this policy would include a formal notice to custody and to the medical department about an inmate’s declared hunger strike.

Even without formal notice, a policy might require both the medical and psychology departments to be notified when an inmate refuses a set number of meals. At that point, a mental health referral is made to rule out psychiatric illness such as psychosis or depression and to assess the inmate’s competency to refuse food, hydration, or medical procedures. The medical department would assess the inmate to determine his nutritional status on a regular basis through daily weights and laboratory values. As the strike progresses, the inmate may require inpatient medical monitoring of hydration status. In extreme cases, a correctional facility may seek a court order to feed an inmate involuntarily.

Throughout this process, the facility uses a multidisciplinary approach to continuously educate the inmate about the medical consequences of starvation, to assess ongoing mental capacity, and to monitor the patient’s willingness to consent to medical care. The correctional clinician also may be asked to talk to the inmate about what he would want done if he lost the capacity to make medical decisions.

Force-feeding of prisoners carries obvious ethical and practical consequences for the correctional clinician. On the one hand, we are obligated to respect individual autonomy and freedom, but we are appositely required to protect individual health and safety. Because of the potential for behavioral contagion, hunger strikes also can lead to unrest in the facility and further consumption of health care resources. Institutional safety is a dual concern for the correctional clinician.

The 2006 World Medical Association’s Declaration of Malta on Hunger Strikers contains international guidelines for the management of hunger strikes. A key component is an assessment to determine whether a mental impairment undermines the inmate’s ability to make health care decisions. In that case, the inmate is a patient rather than a hunger striker, and the clinician must provide treatment rather than allow deterioration or death. Conversely, if the decision to fast is made free of disability or coercion, the Declaration of Malta bars forced feeding as unethical.

The Malta guidelines also state that "physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities, or others, such as family members."

There’s the dilemma. In the case of mass hunger strikes such as the current one in California, the strike is a political movement designed to force the state prison system to modify its use of long-term segregation. The strike was planned in advance through social media and is fueled by the support of individual celebrities and advocacy organizations. Considerable public attention and scrutiny have been given to the strike by online and traditional media. A single prisoner’s decision to strike may be attributable to his individual beliefs and values but now could also be tied to overwhelming peer intimidation and public pressure. It would be unethical for a clinician to allow a vulnerable prisoner to place his health at risk as a result of coercion.

To my knowledge, no procedures or guidelines exist to help the clinician assess the voluntariness of a hunger strike, so I’m going to propose an assessment. In my opinion, a coercion assessment would include consideration of the inmate’s history as well as current functioning within the facility. I would look for factors that might make him more vulnerable to harassment or intimidation, such as small physical stature, serious mental illness, intellectual disability, history of peer-on-peer victimization, or placement on protective custody. I would review his history of previous institutional protests, if any, such as a documented history of formal protest through the administrative grievance system, pro se lawsuits or individual hunger strikes.

I would also ask the following questions: When did you decide to strike? What led to this decision? Has anyone on the tier talked to you about your decision? What about your family? What would have happened if you hadn’t joined the strike? Have others on your tier refused to fast? What happened to them? What do you hope will happen as a result of this strike? Has anyone offered you any privileges or made any threats related to your decision to strike?

Depending upon the results of this evaluation, the inmate could be offered protective custody, transfer to another facility, or movement to a tier – where inmates are not participating in the strike.

In light of the public attention given to mass hunger strikes lately, anyone working in a jail or prison now should be prepared to handle a coercion assessment.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.