X If no discussion with the individual is possible and no advance instructions exist, physicians have to act in accordance in what they judge to be the person’s best interests. This means considering the hunger strikers’ previously expressed wishes, their personal and cultural values as well as their physical health. In the absence of any evidence of hunger strikers’ former wishes, physicians should decide whether or not to provide feeding, without interference from third parties. X Physicians may consider it justifable to go against advance instructions refusing treatment because, for example, the refusal is thought to have been made under duress. If, after resuscitation and having regained their mental faculties, hunger strikers continue to reiterate their intention to fast, that decision should be respected. It is ethical to allow a determined hunger striker to die in dignity rather than submit that person to repeated interventions against his or her will. X Artifcial feeding can be ethically appropriate if competent hunger strikers agree to it. It can also be acceptable if incompetent individuals have left no unpressured advance instructions refusing it. X Forcible feeding is never ethically acceptable. Even if intended to beneft, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment. Equally unacceptable is the forced feeding of some detainees in order to intimidate or coerce other hunger strikers to stop fasting. As we can see, the WMA considers force‑feeding ethically unacceptable. There is a confict of values between the duty of care to safeguard life and the right to physical integrity. Physicians should, however prevent any act that could amount to torture or inhuman and degrading treatment. If a decision is nevertheless taken to force‑feed a prisoner on hunger strike, such a decision should be based upon medical necessity and should be carried out under suitable conditions that refect the medical nature of the measure. The decision‑making process should follow an established procedure, which contains sufcient safeguards, including independent medical decision‑making. Psychiatric assessment of the mental health of an inmate on hunger strike can be helpful in determining those cases where the reasons behind food refusal are of a psychiatric nature. Further, psychiatric examinations throughout the course of a hunger strike would assist the treating medical team in detecting any mental deterioration that could afect hunger strikers’ capacity to make well‑informed choices about their life and health. Legal recourse should be available and all aspects of implementation of the decision should be Prison health care and medical ethics Page 44