Definition

A hunger strike is a voluntary form of food refusal by a competent individual, free from external coercion, aimed at enforcing a demand. In incarcerated individuals, demands often involve changes in detention conditions or protest against specific measures during imprisonment. A hunger strike is not a medical or psychiatric diagnosis, but prolonged food and/or fluid deprivation can lead to significant medical complications. The duration and severity of the hunger strike can be actively controlled by the individual. In the absence of sufficient energy and protein intake, the body utilizes its own reserves to maintain blood sugar levels, first consuming fat reserves, then breaking down muscle and organ tissue for energy. Salt and vitamin deficiencies further exacerbate the negative impact on the body. ¹

Clinical Aspects

While clinical situations rarely become critical, hospitalization is often considered. Medical teams in prisons and hospitals face challenges involving somatic, psychological, legal, and human rights issues related to hunger strikes. Hunger strikes can result in severe health complications, some of which are irreversible or fatal, requiring specialized medical management. The onset of complications depends on the type of fasting and, crucially, the individual's health status at the beginning of the hunger strike. Physicians must repeatedly and objectively inform incarcerated individuals about the potential risks of prolonged fasting. ^1,2

Prevalence and Types of Fasting

Although hunger strikes are relatively common in prisons, studies on the subject are limited. In France, over 1,500 cases per 100,000 inmates (1.5%) occur annually. In Swiss correctional facilities, a similar incidence of 1-3% among inmates is estimated. ^1,3

Complications

A hunger strike in a person of normal weight generally leads to death after an average of 50-75 days. Average weight loss is approximately 0.5 kg/day, with greater losses in the first week due to fluid depletion, followed by gradual, continuous weight reduction. Medical complications may arise after an 18% weight loss, and life-threatening conditions occur after a 30% loss. Severe electrolyte imbalances are typically observed only after 30 days of fasting. Supplementation with micronutrients (electrolytes, vitamins, minerals, and trace elements) can mitigate complications and prolong survival but does not prevent progressive energy depletion and eventual death. ^2,3,4

Approach to Hunger Strike According to SAMS Guidelines

Physicians and healthcare professionals working in prisons often encounter inmates on hunger strike. A hunger strike is often the last resort for individuals who feel they have no other way to make their voices heard. The primary aim is not to die but to draw attention to their demands. Participants are generally aware of the possibility of a fatal outcome if the situation escalates into an unsolvable conflict.

To determine the appropriate response, the initial situation must be assessed:

1. The incarcerated person is competent, refuses artificial nutrition, and there is no immediate life-threatening risk. Forced feeding in this situation is considered torture by the European Court of Human Rights.
2. The incarcerated person is competent, refuses artificial nutrition, and continuation of the hunger strike poses a life-threatening risk.
3. The incarcerated person has become incompetent due to the hunger strike, has documented refusal of artificial nutrition in a valid advance directive, and refusal poses an immediate life-threatening risk.
4. The incarcerated person is incompetent (due to the hunger strike or other reasons), has no valid advance directive refusing artificial nutrition, and refusal poses an immediate life-threatening risk.

Artificial nutrition is medically indicated in situation 4 according to SAMS guidelines and can usually be carried out without coercion. In the other situations, forced feeding would violate these guidelines and established medical practice. ¹

Recommendations for Medical Management

The initial recommended energy intake is based on Refeeding Syndrome Risk Category 3 (very high risk) and is gradually increased to full energy requirements over 10 days. BW = Body Weight; d = Day ^5,6

Macronutrient Distribution

40-60% carbohydrates, 15-20% protein, 30-40% fat

Sodium Balance

Prophylactic Administration of Electrolytes and Vitamins

Prophylactic administration of phosphate, potassium, magnesium, and thiamine is crucial for patients at very high risk of refeeding syndrome to prevent complications caused by severe electrolyte imbalances or thiamine deficiency.

Vitamins, Minerals, and Trace Elements

• Thiamine supplementation: 200-300 mg orally or intravenously, at least 30 minutes before initiating refeeding
• Day 1-3: Thiamine 200-300 mg orally or intravenously
• Day 1-10: Multivitamin preparation twice daily orally or intravenously (200% of water- and fat-soluble vitamins, and 100% of trace elements)

Sufficient and Early Electrolyte Replacement

• Potassium: 2-4 mmol/kg BW
• Phosphate: 0.3-0.6 mmol/kg BW
• Magnesium: 0.05-0.1 mmol/kg BW
• Calcium: 0.05-0.1 mmol/kg BW

Goals of Daily Adjusted Nutritional and Fluid Therapy

• Avoid electrolyte imbalances, deficiencies, salt, and water overload.
• Prevent complications, morbidity, and mortality.
• Prevent malnutrition and nutrient deficiencies.
• Gradual increase and optimization of food intake.

Note: Coercive measures can be perceived as traumatic not only by patients but also by the caregiving team. Therefore, the decision should—if possible—be discussed with the involved team (physicians, nursing staff, and security personnel) and supported by all parties.

The nutritional therapeutic measures align closely with the recommendations for patients at high risk of refeeding syndrome. (Link to Refeeding Chapter)

Monitoring

Monitoring Patients with a Very High Risk of Refeeding Syndrome (RFS)

Most studies indicate that RFS occurs within the first 72 hours after the start of nutritional therapy. During this period, the metabolic state shifts from catabolism to anabolism, with associated electrolyte and fluid shifts. Therefore, the following monitoring schedule is suggested:

The Role of the Psychiatrist

• It is crucial to assess the patient before any potential physical and mental deterioration due to prolonged fasting occurs.
• The primary task of the psychiatrist in dealing with a hunger striker is to determine the patient’s decision-making capacity. Competent patients should be regarded as autonomous, and their decisions must be respected.
• If a hunger striker is incompetent due to a psychiatric disorder (e.g., delusions of poisoning in schizophrenia), coercive measures may be necessary. Appropriate treatment of the psychiatric disorder may lead to the termination of the hunger strike.
• The purpose and motivation of the hunger strike, as well as individual and cultural factors, should be considered when assessing decision-making capacity.

Legal Basis: Hunger Strike and Forced Feeding

• The legal foundations for this complex situation are extensively described in the publication by Müller et al. In the penal and custodial law of the Canton of Bern, forced feeding is permitted if there is a serious danger to the hunger striker, and it cannot be assumed that the individual is acting of their own free will. (Cf. Article 61 of the Bernese Law on Penal and Custodial Measures from 25.6.2003 (SMVG, BSG 341.1)).
• In most other cantons, however, a comparable legal basis is lacking. Where there is no legal foundation, cantonal correctional authorities can act based on the so-called "police general clause" under restrictive conditions.
• According to the SAMS guidelines, an incarcerated individual on a hunger strike must be medically evaluated within 24 hours. Psychiatric assessment and support from the psychiatric service must be guaranteed from the outset.
• The incarcerated individual has the right to medical care equivalent to that of the general population. In any case, medical confidentiality must be maintained under the same legal provisions that apply to individuals in freedom (Art. 321 of the Swiss Criminal Code). Medical records, in particular, must be kept under the physician's responsibility.
• The fundamental ethical and legal principles for the exercise of medical practice, especially those regarding patient consent and confidentiality, also apply to individuals under detention.
• Before hospitalization of a person on a hunger strike, the possibility of an advance directive should be considered. According to medical-ethical guidelines, the wishes of a competent person regarding physical integrity should be respected even during a hunger strike in prison.