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. 2023 Apr 20;31(1):121–131. doi: 10.1080/13218719.2023.2175069

Death by hunger strike: suicide or not?

Joseph H Obegi 1,✉
PMCID: PMC10916891  PMID: 38455271

Abstract

Conventional thinking holds that most inmates who hunger strike do not desire to die. Rather, they want prison officials to concede to their demands. In this paper, I examine whether death by hunger strike can be classified as suicide. After reviewing definitions of suicide and suicidal intent, I conclude that some deaths by hunger strike can be readily classified as suicides. I further propose that conditional intention is a useful way to understand the complex motivations of hunger strikers. I close by discussing the implications of conditional intention for the assessment of suicidal intent among hunger strikers and for the duty of mental health providers to prevent suicide.

Keywords: conditional intention, food refusal, hunger strike, suicidal intent, suicide

When an incarcerated person dies of a hunger strike, is it suicide? Consider the following example:

An incarcerated person is upset with the conditions of his confinement. In protest, he refuses food and water. He states he will resume eating and drinking only when his demands are met. He has no medical or mental illness, retains the capacity for medical decision-making, and denies suicidal ideation or intent. Some days thereafter, he signs paperwork indicating refusal of all life-saving measures, including artificially administered feeding and hydration, and a preference for palliative care only. Prison officials do not acquiesce to his demands, and two weeks later, he dies from complications of malnutrition and dehydration.1

According to conventional thinking, this death is not a suicide because the aim of the incarcerated person (hereafter, Hunger Striker) is to obtain concessions, not to die (Xenakis, 2017). Yet, how do we reconcile Hunger Striker’s stated aims and denial of suicidal intent with his lethal behavior? Given that he was the agent of his demise, why is it difficult to classify the case as a suicide?

The crux of the problem is how suicide is defined. In this paper, I argue that Hunger Striker’s death is properly categorized as a suicide. I intend to show that: (a) conventional views of hunger strike deaths as something other than suicides are flawed, (b) definitions of suicide arrive at discrepant conclusions about Hunger Striker’s death, and (c) conditional intent can resolve the discrepancy. Finally, I discuss the practical and ethical implications of understanding Hunger Striker’s death as a suicide.

Conventional views of death by hunger strike

A hunger strike is ‘an action in which a person or persons with decision-making capacity . . . refuses to ingest vital nourishment until another party accedes to certain specified demands’ (Oguz & Miles, 2005, p. 169). Despite the potential lethality of refusing food, death by hunger strike rarely occurs in corrections (Reeves et al., 2017). Still, not all authors agree on whether such deaths are ever considered suicides or whether hunger strikers are suicidal. Some have asserted that hunger strikers are not suicidal but accept that death may occur: ‘Detainees who undertake hunger strikes do not intend or want to die, but understand that the consequence of their actions may end in their demise’ (Xenakis, 2017, p. 314; see also G. D. Annas, 2016; Oguz & Miles, 2005). Less frequently, authors have asserted that deaths by hunger strike are not suicides (Altun et al., 2004) or that hunger strikers are not suicidal (G. J. Annas, 1995). Others have acknowledged that suicide is one potential motivation for hunger strikes (Daines, 2007). Most advise ruling out suicidal intent, particularly among those suffering from depression (G. D. Annas, 2016; Brockman, 1999; Daines, 2007; Keram, 2015).

When applied to Hunger Striker, these differing views expose conundrums. Since Hunger Striker dies via volitional behavior (food refusal), what kind of death is it if not suicide? If Hunger Striker accepts he may die and controls his fate and yet denies wanting to die, does he have suicidal intent or not? These conundrums are further highlighted by two rational analyses: reasoning by exclusion and legal causation. A medical examiner often determines whether a death is a suicide through a process of exclusion based on the four causes of death: natural, accidental, homicide and suicide (Bertolote & Wasserman, 2021). Because Hunger Striker’s death is not natural (i.e. it was not caused by a pre-existing medical condition), not accidental (he consciously engaged in life-threatening behavior) and not a homicide (another person did not kill him), we are left to classify his death as suicide. (Classifying Hunger Striker’s death as undetermined is illogical given that we know how he died.)

Alternatively, we could analyze Hunger Striker’s death using legal causation (Moore, 2011), as in determining who is responsible for the harm (i.e. Hunger Striker’s death).2 Because legal theory attempts to establish the source of responsibility for actions, it can clarify whether Hunger Striker was causally responsible for his own death. From this perspective, the answer is plain: but for refusing food, Hunger Striker would not have died. Since Hunger Striker is the cause of his death, then suicide is the appropriate determination.

Interestingly, neither of these analyses relies on knowing Hunger Striker’s intent. Regardless of whether Hunger Striker intended to die, reasoning by exclusion or applying legal causation would lead us to classify his death as suicide. In contrast, nearly all definitions of suicide rely on intent, be they written by philosophers (for a review see Cholbi, 2021) or clinical researchers (Goodfellow et al., 2019, 2020). According to definitions by these groups, a death is considered suicide if it is an intentional act of self-killing. However, several authors have pointed out that different intent-based accounts of suicide do not classify the same deaths as suicide (e.g. Cholbi, 2021), a problem to which I now turn.

Defining suicide and suicidal intent

If suicide is an intentional self-killing, is Hunger Striker’s death a suicide? I explore three broad definitions of suicide to shed light on this question. The first two definitions are intention-based accounts and represent what have been called the strong and weak views of intention (Dowie, 2020). The third definition, proposed by Dowie (2020), is a purist view in which intention is discarded (or nearly so, as I will later explain).

The strong view of suicidal intention is perhaps the most conventional. Among philosophers like Hill (2011), this view holds that deaths are suicides when the person intends to die by an act he believes will result in death and then engages in that act. Clinical researchers have also adopted the strong view. In one nomenclature of suicidal behaviors, suicide is defined as a ‘death caused by self-inflicted injurious behavior with any intent to die as a result of the behavior’ (Matarazzo et al., 2015, p. 19), where intent means ‘an individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions’ (p. 19). In other words, suicidal behavior involves wanting to be dead and then purposely engaging in behavior expected to bring about death. Thus, the strong view acknowledges only intended acts and only the intended effects of those acts.

For the overwhelming majority of self-killings, definitions using the strong view are serviceable. However, they falter when applied to less conventional self-killings in which intent is ambiguous or complex. An often-cited counterexample is that of Soldier, who sacrifices her life by jumping on a grenade to save her squad. Although plainly a self-killing, the strong view of intention forces the conclusion that Soldier’s death was not suicide: she did not wish for death or intend to die. Rather, dying was a kind of side effect of her intent to save her comrades (Cholbi, 2011). Similarly, the strong view would not classify Hunger Striker’s death as suicide. His express intent was not to die but to live and to have his demands met. That Hunger Striker died was merely an unintended consequence of the lethal method he used to pressure prison officials.

The weak view of suicidal intention reaches a different conclusion about the deaths of Soldier and Hunger Striker. The weak view broadens intentionality to include unintended but foreseeable effects, not just intended effects. For example, Cholbi (2011) defines suicide as when ‘the person believed that the act, or some causal consequence of that act, would make her death likely and she engaged in the behavior to intentionally bring about her death’ (p. 21). Here ‘to intentionally bring about death’ does not necessarily mean the person desires to die, only that the person rationally accepts that death is a probable outcome of her act. Back to the counterexample of Soldier: Cholbi explains that Soldier knows with near certainty that jumping on the grenade will kill her; that is, she foresees her death as a side effect of her desire to save her fellow soldiers. That she covers the grenade with her body despite this knowledge indicates death has her ‘rational endorsement’; she considered and accepted the danger inherent in her choice. Because Soldier acts intentionally, and the circumstances of her death have her rational endorsement, her death is a suicide, even though her death is not what she intended or desired.3

Applying Cholbi’s (2011) definition to Hunger Striker, we can classify his death as a suicide. Hunger Striker operates on the common knowledge that death is the eventual outcome of starvation. (In fact, he leveraged this knowledge hoping the threat of his death would pressure prison officials to make concessions.) Thus, Hunger Striker, like Soldier, rationally endorsed the prospect of his death: he foresaw the risk of death and accepted it as a tolerable outcome if prison authorities would not concede to his demands. Hunger Strikers’ action (food refusal) was intentional, and his action resulted in his death, even though dying was not what he intended.

The purist view is dramatically different from either the strong or weak view of intention. Presented by Dowie (2020), the purist view aims for a definition free of intention: Just as homicide means one person kills another – with no reference to intention – suicide is simply self-killing. More specifically, a death is considered suicide when the agent is the ‘but for’ cause of her death. In Dowie’s view, then, Solider and Hunger are readily classified as suicides. In the case of Solider, if she had not jumped on the grenade, she would not have died. Similarly, if he had not persistently refused food, Hunger Striker would not have died.

However, Dowie (2020) does not completely discard intentionality. Rather, she reserves it for a secondary classification. Once a death is determined to be suicide, she categorizes the type of suicide using the law’s approach to categorizing homicides.4 Her types of suicide correspond to types of homicidal intent (which themselves correspond to degrees of culpability): self-murder, voluntary self-manslaughter, involuntary self-manslaughter and mistaken, accidental or negligent suicides. For example, the case of a person who ends his life after his spouse leaves him could be classified as voluntary self-manslaughter, whereas the case of a person who dies after jumping from a great height because she harbors the delusion she can fly could be classified as involuntary self-manslaughter.

To classify Hunger Striker’s death into one of Dowie’s (2020) legalistic categories – such as voluntary or involuntary self-manslaughter – we are faced again with the question of Hunger Striker’s intention. Should the strong view apply or the weak view of suicide? I propose the solution to this dilemma is to appreciate that Hunger Striker’s intention was conditional.

Conditional intention

In everyday life, we often make backup plans in case the future does not unfold as we hope. For example, we may think, ‘I will do Y if X happens (or does not happen)’ (Ludwig, 2015). In other words, we form a conditional intention. Similarly, suicidal people commonly frame dying conditionally: either I live as I wish or I must die (Shneidman, 1998). Yet, to my knowledge, conditional intention, as a philosophical concept, has not been applied to understanding suicidal intent.

A conditional intention is ‘a commitment to a contingency plan, a commitment about what to do upon (learning of) a certain contingency relevant to one’s interests obtaining’ (Ludwig, 2015, p. 32). We can characterize Hunger Striker’s conditional intention as I will die by food refusal if my demands are not met. Demands are not met is the contingency or the reason-providing condition. Once the contingency obtains, it triggers the commitment I will die by food refusal. In this view, Hunger Striker’s food refusal was intentional, and his death was what he intended because it was justified and set in motion by a reason he provided.

Hunger Striker’s intention does have an unusual feature that makes it difficult to recognize as conditional. Ordinarily, the commitment to carrying out a conditional intention requires the initiation of an action. Imagine the conditional intention, I will rent a car if my own car is not repaired by tomorrow. When tomorrow comes and repairs are still unfinished, my commitment to rent means I must initiate some act (e.g. calling a rental car company to secure a car) to realize my intent to rent a car. In Hunger Striker’s case, however, no new action is necessary for him to realize his conditional intent to die: he is already refusing food. Hunger striker uses the same means – food refusal – to pursue his demands and to end his life. Thus, there is no outwardly discernible change in his action of refusing food to indicate that his conditional intention to die has been triggered.

There are, however, some clues. Conditional intention involves a commitment to action, and this commitment exerts ‘rational pressures’ to prepare for that action and to prepare in ways that are logically consistent with the commitment (Yaffe, 2004). In the rental car example, my commitment to renting a car pressures me to prepare to rent if my vehicle is not repaired in time. I may research the location of the nearest rental car company, check rental rates and arrange for a ride should I need it. Similarly, Hunger Striker’s conditional intention to die if his demands are not met pressures him to prepare for death. When he signs orders prohibiting resuscitation and artificial feeding, he is responding to the rational pressures exerted by his commitment. Thus, those actions are clinical evidence of his conditional intention to die. Hunger Striker’s refusals and requests for palliative care are also evidence of his conditional intention to die because he performs these actions in the context of advanced malnutrition and imminent medical danger.

Understanding Hunger Striker’s intention as conditional has implications for how the strong and weak views classify his death. Although the strong view asserts a person must intend to kill herself, it does not require her to unconditionally intend to do so. That said, once Hunger Striker’s contingency of unmet demands obtains, and the commitment to die by food refusal is triggered, his conditional intention becomes indistinguishable from the strong view of intention. Interestingly, interpreting the strong view as accommodating conditional intention changes how the strong view would classify Hunger Striker’s death. His death was a suicide because he had the conditional intent to die, which means his death by food refusal was clearly intended. This is the opposite conclusion we would draw using the strong view if we did not consider Hunger Striker as harboring a conditional intention.

Conditional intention also clarifies the application of the weak view. The weak view of suicidal intention holds that people need not expressly intend to die; they need only believe the act makes death more likely and find this increased likelihood of death tolerable or acceptable (i.e. they rationally endorse death as an outcome). The structure of conditional intent – ‘I will do Y if X happens (or does not happen)’ – is an expression of rational endorsement. It evidences a consideration of circumstances and what one will do if those circumstances manifest. In forming a conditional intent, Hunger Striker has sized up the situation, imagined various futures (living with his demands met versus living without them met) and concluded, even if imprudently, that dying is an acceptable outcome if his circumstances remain unchanged.

To summarize, conditional intention clarifies the intentionality of Hunger Striker’s death. It permits us to represent the relationship between his pursuit of living if certain demands are met and his contingency plan of dying if those demands are not met. By characterizing Hunger Striker’s intention as conditional, the strong and weak views of suicide would both classify Hunger Striker’s death as suicide.

Implications for the assessment of suicidal intent

While we may conclude Hunger Striker’s death is a suicide using the benefit of hindsight, identifying Hunger Striker’s suicidal intent in real-time is a more difficult task. Below, I offer several comments and guidelines, some of which are informed by the previous discussion.

Hunger strikes are difficult to recognize as unfolding suicide attempts, partly due to the narrative that surrounds them and partly because they are an unconventional method of suicide. Unlike suicide, which most understand as a purposeful killing of oneself, people who hunger strike and the public see hunger striking as a political strategy meant to sway public opinion and pressure officials using the threat of death. Ordinarily, this means delaying death for as long as possible rather than swiftly dying. Moreover, as Wee (2007) has persuasively argued, communications from and about hunger strikers tend to absolve them of their responsibility for starving themselves and displace it onto the authorities. The content of these communications, Wee (2007) argues, often suggests the strikers have ‘no choice’ or are ‘victims’ of hunger strikes and that the authorities must not ‘let them die’. When clinicians uncritically adopt these views, they run the risk of overlooking the possibility that hunger strikers may have made a choice to end their lives should their demands remain unmet.

Hunger strikes are also difficult to recognize as suicide attempts because they are unlike most suicidal methods:5 hunger strikes rely on a natural and biological process (hunger) instead of a device, such as a firearm or a length of rope, or physical danger, such as a considerable height or an oncoming train. We are also accustomed to thinking of suicide as involving an observable, physical action that is performed (e.g. discharging a firearm, hanging, ingesting drugs or poison), the result of which is a fatal injury that happens more or less immediately. In contrast, a hunger strike is a mental act accompanied by an act of omission: deciding not to eat or drink leads to abstaining from the physical act of self-nourishment. Furthermore, the lethality of hunger strikes also grows slowly, taking up to weeks depending on the health of the incarcerated person (Chalela & Lopez, 2013). Because death by hunger strike is rare in corrections (Reeves et al., 2017), death may feel like such a remote outcome that clinicians may feel little urgency to assess for suicidal intent.

Finally, advanced hunger strikes involve refusing treatment. Usually, we are inclined to understand treatment refusal as an assertion of autonomy. When the refusal is made by a capacitated person, we feel ethically bound to respect the decision. In doing so with hunger strikers, we may inadvertently overlook a volitional intent to die. It is critical to recognize that refusing treatment is necessary to carry out suicide by hunger strike. Indeed, the refusal may actually be a continuation of the suicide attempt (Dresser, 2010). In addition, the time lapse between the initiation of a hunger strike and its fatal consequence makes it appear as if the incarcerated person has allowed death to happen versus bringing about death himself. For all of these reasons, clinicians must carefully rule out suicidal intent.

Thinking in terms of conditional intention may help clinicians discern which of the following two intentions is present among hunger-striking inmates:

  1. I will die by food refusal if my demands are not met.

  2. I will refuse food until one of the following occurs: some or all my demands are met; I suspect my demands will not be met; my demands are unequivocally denied; or the personal cost of food refusal becomes too high (e.g. degree of discomfort, risk of death or disability).

For the conditional intention to die, several features raise the index of suspicion: duration, medical danger and unreasonable persistence. The longer the hunger strike, the more likely a conditional intention to die exists. Recent research offers some guidance regarding duration. Reeves et al. (2017) found that hunger strikes in the New Jersey Department of Corrections lasted 10 days on average, with 71% lasting three days or less and only 5% lasting more than 30 days. Medical danger should also be considered: food refusal without supplements (e.g. sugar, salt, vitamins) or fluids is more dangerous than abstaining from food only (Chalela & Lopez, 2013; Crosby et al., 2007). As the risk of death or permanent injury increases, and the patient is informed of those risks, conditional intent to die should be suspected. When hunger strikes persist after prison officials have unambiguously informed the inmate his demands will not be met, conditional intent to die should also be suspected, particularly when the strike is of a meaningful length, and serious medical danger exists.6 Close consultation with the treating physician is essential.

When clinicians find a nonlethal motivation for hunger striking – to draw attention to a cause or individual plight or to bargain (Daines, 2007) – they should not cease assessment (i.e. not succumb to ‘search satisfying’; Croskerry, 2003). Conditional intention yokes nonlethal motivations with suicidal intent. Thus, suicidal intent and other motives are not mutually exclusive. Concluding, for example, that He just wants more comfortable living conditions, so he’s not suicidal risks ignoring (or, at least discounting) the possibility that suicidal intent is also present.

Clinicians should be on the lookout for discrepancies between the inmate’s report and actions. Inmates with a conditional intent to end their lives may repeatedly deny suicidal ideation and intent. Paradoxically, they appear to resign themselves to fate despite their hand in charting a course toward death. Denial of suicidal ideation and intent does not indicate their absence or the absence of risk (Blinder, 2004). In fact, denial of suicidal thinking is common among ideators, suicide attempters and suicide decedents (Obegi, 2021). There should be a high index of suspicion whenever hunger strikers deny suicidal ideation yet also make preparations for death.

Ruling out suicidal intent is not a simple matter, and a single interview to determine intent is rarely sufficient. The differential diagnosis of suicidal intent will often take time because hunger strikers are not often fully cooperative or disclosing. Inference of conditional intent to die requires time to painstakingly collect the necessary behavioral data from medical, nursing and custody staff. Furthermore, the end of a hunger strike cannot be construed as definitive evidence that no conditional intention to die existed. Alternative hypotheses must be ruled out. For example, ambivalence about death may have ended the strike, psychotherapeutic treatment may have mitigated factors driving suicidal intent, demands may have been partially met, or staff actions may have given the hunger striker hope that prison authorities would eventually make concessions. Even when clinicians are diligent in their assessment and document a clinical formulation of the inmate’s choices, some uncertainty about the clinical picture is likely to remain.

A capacity assessment may also reveal whether suicidal intent is present. It can establish whether the patient appreciates the lethality of food and treatment refusal, and it can clarify whether the patient knows death is a foreseeable and rationally endorsed outcome of his choices. From the perspective of Cholbi’s (2011) definition of suicidal acts, this conclusion considers that hunger-striking patients could be acting with the intention to end his life, even though dying is not their express desire.

Implications for the duty to prevent suicide

When a hunger striker is thought to harbor suicidal intent, clinicians will be confronted with questions about their duty to prevent suicide. In Hunger Striker’s case, if he is acting with the intent to die yet retains capacity, what is our responsibility to prevent his death? When Hunger Striker refuses both medical and mental health treatment, and this refusal is necessary to carry out his intentional self-killing, how can we intervene? Is the duty to prevent suicide blocked by capacitated treatment refusal?

Because treatment requires consent, Hunger Striker’s refusals impose limits on what mental health providers are permitted to do. Ordinarily, the law expects mental health providers to take reasonable steps to prevent suicide when it is foreseeable. Common preventative measures involve securing the patient’s safety by limiting access to lethal means, creating a plan to manage suicidal thoughts and urges, prescribing psychiatric medication and using involuntary hospitalization when the risk of suicide is imminent. However, Hunger Striker’s approach to suicide thwarts these measures: he retains capacity, refuses all treatment and cannot be separated from his chosen lethal means. Building rapport and empathic understanding, in the hope that this will open the door to collaborative treatment focused on suicidality, are the main goals. Recruiting the assistance of family members – even without the patient’s consent, which is permissible given the imminent suicide risk – is another option.

When it becomes clear that force-feeding is the only means of saving the Hunger Striker’s life, clinicians may feel mounting pressure to justify force-feeding by concluding that his medical decision-making capacity is compromised. Conceding to such pressure is to compromise the integrity of the mental health profession. Clinicians will also face an ethical double-bind: advocating to save Hunger Striker’s life (i.e. beneficence) via a nonpsychiatric procedure versus advocating for the Hunger Striker’s right to autonomy and dignity. Rationalizing the former is to rely on, at least in part, a paternalistic belief that suspending autonomy is in Hunger Striker’s best long-term interest. However, advocating for force-feeding is to condone the invasion of a sacrosanct aspect of autonomy – bodily integrity – despite capacitated treatment refusal and the absence of an obvious mental illness.

I believe mental health providers do not have a role in advocating for or against force-feeding. Professionally, it would be inappropriate to advocate for forced-feeding because the procedure is outside the practical scope of mental health professionals. Supplying artificial nutrition and hydration is a medical intervention, not a psychiatric or psychological one. Moreover, advocating for force-feeding means abandoning a core ethical principle of respecting autonomy. Hunger Striker’s autonomy manifests as the right to consent to and refuse treatment, the right to self-direction and the right to bodily integrity. In mental healthcare, we only rationalize intrusions upon autonomy when a mental disorder poses a risk to the patient’s safety.

Be that as it may, prison officials will understandably seek the counsel of mental health providers, and this will bring to the fore another layer of ethical complexity: dual agency (Burns, 2007). Clinicians must differentiate actions that are in the best interest of the patient from those in the best interest of the prison. The decision to force-feed marks a fuzzy boundary between the clinician’s duty to prevent suicide and the prison official’s comparable duty. One way to balance these competing interests is to assume the role of educator rather than advocate.7 It is critical for providers to not only explain the clinical picture of suicide risk but also: (a) to explain the limited role of psychiatric and psychological treatment when a capacitated patient is in the advanced stages of malnutrition, and, (b) to outline the ethical position that bars them (the providers) from endorsing force-feeding. These explanations allow clinicians to clarify the conflicts and to affirm their commitment to ethical principles and standards. A reasonable response to pressures to act beyond our scope or to alter clinical opinions is to plainly state: ‘Force-feeding is a legal matter that I cannot assist you with. You may wish to seek legal counsel.’8 Without a doubt, clinicians will understandably feel varying degrees of helplessness and frustration during the process.

Conclusion

When a healthy and capacitated inmate dies by self-induced starvation, clinicians, prison officials and coroners may understandably disagree about whether the death was a suicide. Using the example of Hunger Striker, I have attempted to show that some deaths by hunger strike can be classified as suicides if we define suicides as self-killings caused by the decedent rather than as deaths accompanied by suicidal intent. I also proposed that understanding hunger strikers as acting with conditional intention to die can clarify intentions that are ambiguous and difficult to assess. Finally, I argued that interpreting death by hunger strike as a possible suicide invokes the duty to prevent suicide but at the same time circumscribes it.

Ethical standards

Declaration of conflicts of interest

Joseph H. Obegi has declared no conflicts of interest

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study

Author note

The views expressed in this article are the author’s and do not reflect the official policy of the Department. This article does not contain any studies with human participants or animals performed by any of the authors.

Notes

1

This is a de-identified case. Key details have been changed for illustrative purposes.

2

By applying legal theory to suicide, I do not mean to imply that suicide is a crime or to express some moral judgment about suicide.

3

Intended and unintended effects are addressed by the doctrine of double effect. Briefly, this doctrine describes when it is permissible for an action to incidentally cause serious harm (the unintended effect) in the pursuit of some good end (the intended effect; McIntyre, 2019). Some ethicists, such as Beauchamp and Childress (2013), assert that intentionality includes both intended and unintended effects; both effects are ‘willed’ but only the former is wanted.

4

Decades ago, Litman (1968) took a similar approach.

5

I am indebted to O’Keeffe (1984) for describing most of these differences.

6

Some authors advise assessing a hunger striker’s determination on the basis that more determined inmates are at higher risk of death (e.g. Reyes, 1998). My position is that ‘determination’ is actually the presence of a conditional intent to die.

7

I thank Catherine Cohen for helping me appreciate this distinction.

8

I am not suggesting that clinicians take any role in legal strategies to force-feed Hunger Striker. To do so is to indirectly advocate for force-feeding. However, clinicians should appreciate that correctional officials are not bound by our professional ethics. Thus, we should not be surprised when they petition the court to force-feed over a competent prisoner’s objections, as they have in the United States (e.g. McNabb v. Dep’t of Corr., 2008), although not always successfully (Thor v. Superior Court, 1993). For a detailed discussion, see Bennett (1983).

References

  1. Altun, G., Akansu, B., Altun, B. U., Azmak, D., & Yilmaz, A. (2004). Deaths due to hunger strike: Post-mortem findings. Forensic science International, 146(1), 35–38. 10.1016/j.forsciint.2004.03.022 [DOI] [PubMed] [Google Scholar]
  2. Annas, G. D. (2016). Hunger strikes by inmates. In Rosner R. & Scott C. L. (Eds.), Principles and practice of forensic psychiatry (3rd ed.). CRC Press. [Google Scholar]
  3. Annas, G. J. (1995). Hunger strikes: Can the Dutch teach us anything? BMJ (Clinical Research ed.), 311(7013), 1114–1115. 10.1136/bmj.311.7013.1114 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics. Oxford University Press. [Google Scholar]
  5. Bennett, S. C. (1983). The privacy and procedural due process rights of hunger striking prisoners. New York University Law Review, 58, 1157–1230. [Google Scholar]
  6. Bertolote, J., & Wasserman, D. (2021). Development of definitions of suicidal behaviours: From suicidal thoughts to completed suicides. In Wasserman D. (Ed.), Oxford textbook of suicidology and suicide prevention (pp. 87–91). Oxford University Press. 10.1093/med/9780198834441.001.0001 [DOI] [Google Scholar]
  7. Blinder, M. (2004). Suicide, psychiatric malpractice, and the bell curve. Journal of the American Academy of Psychiatry and the Law Online, 32(3), 319–323. [PubMed] [Google Scholar]
  8. Brockman, B. (1999). Food refusal in prisoners: A communication or a method of self-killing? The role of the psychiatrist and resulting ethical challenges. Journal of Medical Ethics, 25(6), 451–456. 10.1136/jme.25.6.451 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Burns, K. A. (2007). The red zone—Boundaries of clinical vs forensic work in clinical settings. In Thienhaus O. J. & Piasecki M. (Eds.), Correctional psychiatry: Practice guidelines and psychiatry. (pp. 19–1). Civic Research Institute. [Google Scholar]
  10. Chalela, J. A., & Lopez, J. I. (2013). Medical management of hunger strikers. Nutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition, 28(1), 128–135. 10.1177/0884533612462896 [DOI] [PubMed] [Google Scholar]
  11. Cholbi, M. (2011). Suicide: The philosophical dimensions. Broadview Press. [Google Scholar]
  12. Cholbi, M. (2021). Suicide. In Zalta E. N. (Ed.), The Stanford encyclopedia of philosophy (Winter 2021 ed.). Stanford University. https://plato.stanford.edu/archives/fall2017/entries/suicide [Google Scholar]
  13. Crosby, S. S., Apovian, C. M., & Grodin, M. A. (2007). Hunger strikes, force-feeding, and physicians’ responsibilities. JAMA, 298(5), 563–566. 10.1001/jama.298.5.563 [DOI] [PubMed] [Google Scholar]
  14. Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine: Journal of the Association of American Medical Colleges, 78(8), 775–780. 10.1097/00001888-200308000-00003 [DOI] [PubMed] [Google Scholar]
  15. Daines, M. K. (2007). Hunger strikes in correctional facilities. In Thienhaus O. J. & Piasecki M. (Eds.), Correctional psychiatry: Practice guidelines and strategies (pp. 8–1– 8–13). Civic Research Institute. [Google Scholar]
  16. Dowie, S. E. (2020). What is suicide? Classifying self-killings. Medicine, Health Care, and Philosophy, 23(4), 717–733. 10.1007/s11019-020-09964-1 [DOI] [PubMed] [Google Scholar]
  17. Dresser, R. (2010). Suicide attempts and treatment refusals. The Hastings Center Report, 40(3), 10–11. 10.1353/hcr.0.0269 [DOI] [PubMed] [Google Scholar]
  18. Goodfellow, B., Kõlves, K., & de Leo, D. (2019). Contemporary definitions of suicidal behavior: A systematic literature review. Suicide & Life-Threatening Behavior, 49(2), 488–504. 10.1111/sltb.12457 [DOI] [PubMed] [Google Scholar]
  19. Goodfellow, B., Kõlves, K., & De Leo, D. (2020). Contemporary classifications of suicidal behaviors. Crisis, 41(3), 179–186. 10.1027/0227-5910/a000622 [DOI] [PubMed] [Google Scholar]
  20. Hill, D. J. (2011). What is it to commit suicide? Ratio, 24(2), 192–205. 10.1111/j.1467-9329.2011.00493.x [DOI] [Google Scholar]
  21. Keram, E. (2015). Hunger strikes. In Trestman R. L., Appelbaum K. L., & Metzner J. L. (Eds.), Oxford textbook of correctional psychiatry (1st ed., pp. 365–369). Oxford University Press. [Google Scholar]
  22. Litman, R. E. (1968). Psychological-psychiatric aspects in certifying modes of death. Journal of Forensic Sciences, 13(1), 46–54. [PubMed] [Google Scholar]
  23. Ludwig, K. (2015). What are conditional intentions? Methode: Analytic Perspectives, 30(6), 30–60. [Google Scholar]
  24. Matarazzo, B. B., Homaifar, B. Y., Farro, S. A., & Brenner, L. A. (2015). The language of suicide. In Bryan C. J. (Ed.), Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings (pp. 14–32). Routledge. [Google Scholar]
  25. McIntyre, A. (2019). Doctrine of double effect. In Zalta E. N. (Ed.), The Stanford encyclopedia of philosophy (Spring 2019 ed.). Stanford University. https://plato.stanford.edu/archives/spr2019/entries/double-effect/ [Google Scholar]
  26. McNabb v. Dep’t of Corr., 163 Wn.2d 393, 180 P.3d 1257, 2008. Wash. LEXIS 363 (Supreme Court of Washington, April 10, 2008, Filed) [Google Scholar]
  27. Moore, M. S. (2011). Intention as a marker of moral culpability and legal punishability. In Duff R. & Green S. P. (Eds.), Philosophical foundations of criminal law. (pp. 179–205) Oxford University Press. [Google Scholar]
  28. O’Keeffe, T. M. (1984). Suicide and self-starvation. Philosophy, 59(229), 349–363. 10.1017/s0031819100069941 [DOI] [Google Scholar]
  29. Obegi, J. H. (2021). How common is the recent denial of suicidal ideation among ideators, attempters, and suicide decedents? A literature review. General hospital Psychiatry, 72, 92–95. 10.1016/j.genhosppsych.2021.07.009 [DOI] [PubMed] [Google Scholar]
  30. Oguz, N. Y., & Miles, S. H. (2005). The physician and prison hunger strikes: Reflecting on the experience in Turkey. Journal of Medical Ethics, 31(3), 169–172. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Reeves, R., Tamburello, A. C., Platt, J., Tepper, D., & Edelman, K. (2017). Characteristics of inmates who initiate hunger strikes. The journal of the American Academy of Psychiatry and the Law, 45(3), 302–310. [PubMed] [Google Scholar]
  32. Reyes, H. (1998). Medical and ethical aspects of hunger strikes in custody and the issue of torture. In Oehmichen M. (Ed.), Maltreatment and torture. Schmidt-Romhild. [Google Scholar]
  33. Shneidman, E. S. (1998). The suicidal mind. Oxford University Press. [Google Scholar]
  34. Thor v. Superior Court, 5 Cal. 4th 725, 855 P.2d 375, 21 Cal. Rptr. 2d 357, 1993. Cal. LEXIS 3430, 93 Cal. Daily Op. Service 5658, 93 Daily Journal DAR 9579 (Supreme Court of California July 26, 1993, Decided).
  35. Wee, L. (2007). The hunger strike as a communicative act: Intention without responsibility. Journal of Linguistic Anthropology, 17(1), 61–76. 10.1525/jlin.2007.17.1.61 [DOI] [Google Scholar]
  36. Xenakis, S. N. (2017). Ethics dilemmas in managing hunger strikes. The journal of the American Academy of Psychiatry and the Law, 45(3), 311–315. [PubMed] [Google Scholar]
  37. Yaffe, G. (2004). Conditional intent and Mens Rea. Legal Theory, 10(4), 273–310. 10.1017/S135232520404025X [DOI] [Google Scholar]

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