New Delhi: Medical ethics revised and endorsed repeatedly since 1993 by the World Medical Association (WMA) emphasizes that it is unethical to forcibly treat those on hunger strike if they have refused treatment.“All kinds of interventions for enteral (feeding through a tube straight into the stomach) or parenteral (intravenous-IV) feeding against the will of the mentally competent hunger striker are to be considered as ‘forced feeding’. Forced feeding is never ethically acceptable,” states the WMA declaration.“Hunger strikes are usually a form of protest by people who lack other ways of making their demands known. In refusing nutrition for a significant period, prisoners and detainees may hope to obtain certain goals by inflicting negative publicity on the authorities,” states the declaration.The Delhi high court has refused Wangchuk’s wife Gitanjali Angmo’s plea to shift him to a private hospital and has upheld the government’s decision to shift him to hospital as Wangchuk “did not check himself into any hospital facility” despite failing health.However, medical ethics on the issue as articulated by the WMA states: “The principle of beneficence urges physicians to resuscitate them but respect for individual autonomy restrains physicians from intervening when a valid and informed refusal has been made. This is the same as an individual’s right to refuse lifesaving treatment.” The latter is a right that has been upheld by Indian courts including the Supreme Court, which has held that an individual possessed of a free and competent mental state is entitled to decide whether or not to accept medical treatment even if this means they will die.“The right of such an individual to refuse medical treatment is unconditional. Neither the law nor the Constitution can compel an individual who is competent and able to take decisions, to disclose the reasons for refusing medical treatment nor is such a refusal subject to the supervisory control of an outside entity,” stated the Constitution Bench in its judgement in the Common Cause vs Union of India case of 2018.The WMA too states that it is ethical to allow a determined hunger striker to die with dignity rather than submit that person to repeated interventions against his or her will. The WMA declaration points out that though physicians attending hunger strikers can experience a conflict between their loyalty to the employing authority and their loyalty to patients, even physicians with dual loyalties were bound by the same ethical principles as other physicians. “…that is to say that their primary obligation is to the individual patient. They remain independent from their employer in regard to medical decisions. Physicians must not allow themselves to be pressured to breach ethical principles, such as intervening medically for non-medical reasons,” states the WMA.The health bulletin issued by the union health ministry states stated that though Wangchuk’s condition warranted immediate medical intervention, “the patient has declined intravenous fluids, oral rehydration solution (ORS) and all medications”. However, the court was told by Wangchuk’s treating doctor that he had started taking ORS without sugar and potassium tablets.The WMA urges national medical associations to support any physicians experiencing pressure to compromise their ethical principles. It adds that the world body would support physicians and national medical associations confronted with political pressures as a result of defending an ethically justifiable position. The Indian Medical Association (IMA) the largest association of doctors in India is a member of the WMA. However, neither the IMA president nor the national secretary responded to TOI’s queries regarding the position of the IMA on Indian doctors and their role in the treatment of Sonam Wangchuk who was forcibly removed from the protest site and taken to Safdarjung Hospital.Dr RV Ashokan, former national president of the IMA stated that at no point should a physician concede to the coercive directives of the state. “Even WMA may not be able to capture all situations. It is a difficult area to navigate for a clinician. Between the thin line of saving a life and a patient’s expressed refusal, it is entirely left to the clinician in charge. No law or guideline can be binding and the physician has to follow her/his conscience. This response is culturally sensitive as well,” said Dr Ashokan.
