A hunger striker looks so frail and yet commands a political force that is the inverse of that frailty, a force that stems not only from the demand of justice it performs but also from the very form of that performance: the protracted and painful yet carefully managed process of deliberate self-harm. Indeed, it is difficult not to consider willed self-starvation under detention or in prison as an act of defiance, even a form of asymmetric warfare, against the state, one that is exacerbated all the more when that starvation is performed en masse. Such an act, whether individual or collective, points to an antagonism that is experienced and in turn performed on a decidedly corporeal register.
When life is forged into a weapon by the hunger striker, the typical response of the state is to try to prevent the hunger striker’s death. For while it is clear that what makes this war asymmetric is the differential of power between the hunger striker — however organized and collective the strike may be — and the modern state, with its enormous apparatus of repression, what makes it a war resides in the ultimate stakes of the antagonism: the power of life and death. This is the minimal definition of sovereign power, which harnesses the collective power of bodies into an ensemble of institutions that arrogates to itself, as Max Weber has forcefully put it, “the monopoly of the legitimate use of physical force.” An insurgency will attempt to grasp this power away from the sovereign state insofar as it is a real contestant.
However, what makes a hunger strike a peculiar form of insurgency is that the struggle turns violence upon itself by adopting self-destruction as the dominant technique of political action. Such a paradoxical insurgency is only possible and plausible because life itself has become a value, a stake of modern politics, one that, as Michel Foucault teaches us through the concept of “biopower,” must not only be ruled over but diligently and efficiently governed.
As I have argued in my book, Starve and Immolate: The Politics of Human Weapons (2014), the contemporary state-form intermingles the traditional prerogatives of sovereign power, such as making war, making peace, making law, with specifically biopolitical imperatives that arise from the increased value placed on human life as such. The state, through its ensemble of institutions and practices, thereby performs and bolsters itself as the protector of the living while extending its reach into domains and processes of life hitherto relatively untouched by power. As a result, we witness the novel merger of the power of life and death (sovereignty) and the power over life and death (biopolitics) into a complex assemblage: biosovereignty. This multifaceted and evolving power formation imbues the state with a vitalist, securitarian logic. Against this new power formation, self-destructive political action such as a hunger strike is first and foremost a counter-sovereign act, attempting to wrench away the power of life and death from the state into the hands of the insurgent(s), even while it may be carried out in the name of another sovereignty. At the same time, however, this kind of action is itself enabled, occasioned, and shaped by the power formation it resists insofar as it is biosovereignty that renders human life and wellbeing into the practical and discursive objects of power in the first place. Hence, such a corporeal act of defiance operates on a terrain that is always-already biopolitical insofar as it takes for granted the preeminence of the “sanctity of life” as the background of this asymmetric war.
What are the weapons of this war? If refusal of nourishment is the weapon of the hunger strikers, the imposition of nourishment by way of medical treatment becomes the state’s weapon. A strange weapon, indeed, which entails administering nourishment intravenously or through nasal tubes. Through this act, the state issues the reminder not only that it has the ultimate command on life and death but also the rationality and legitimacy to exercise this right in the form of a “benevolent” and “humane” power to “make live.” The feeding of hunger strikers is often justified on grounds of the state’s “responsibility to protect” the lives under its control.
But since “saving” lives boils down to a question of keeping the hunger strikers alive or resuscitating them from the edge of life by way of an often nonconsensual act of feeding, the administration of nourishment points to the individualization of an ongoing war. Many hunger strikers call this procedure “force-feeding,” recognizing and experiencing the real violence wrapped in the coating of humanitarian benevolence and care. Life against death, protection against harm, forced nourishment against willed starvation: the body becomes a battlefield upon and for which this war is fought.
Needless to say, the considerations for the decision on whether or not to intervene medically are extremely complex and demanding for the physician. At a general level, it is impossible to avoid the political questions raised by the hunger strike itself: what are the injuries and injustices, grievances and demands articulated by the struggle and to what extent are they predicated on the continuation of the hunger strike? However, even from a purely medical perspective, intervention to feed a hunger striker raises ethical questions that are dire, especially in conditions where the hunger striker has explicitly denied consent to be resuscitated. Should the right of the hunger striker to decide what happens to his or her body override the obligation of the physician to save that hunger striker’s life? In turn, one can raise many questions about how that decision is made by the hunger striker, culminating in the expression or denial of consent to treatment: was it made with a clarity of mind, with a full sense of the consequences of refusing treatment? What were the conditions in which that declaration was indicated? Did fear of quitting the hunger strike and potential reverberations of quitting (possibility of ostracism by comrades, reprisals from political organizations, pressure on families) play a role? It is also important to take into consideration the aftermath of the declaration: Did the hunger striker show any signs of hesitation or change of mind after the declaration was made? Have the conditions of the hunger striker changed in a way that might alter the previous decision — for example, by a transfer out of a prison ward or into a different hospital, with or without proximity to family, peers, or governmental officials?
Mostly, physicians genuinely grapple with these highly complex series of questions on a case by case basis. Partially in reaction to governmental pressures on medical staff around the globe to feed fasting prisoners in order to prevent deaths, the World Medical Association has stipulated guidelines and procedures that should regulate the conduct of the medical community. According to the Declaration of Tokyo, issued in 1975, prisoners on hunger strike would not be artificially fed, if the physicians confirmed them as “capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment.” According to the Declaration on Hunger Strikers, also known as the Malta Declaration of 1991, which provides the framework of basic human and patient rights, the physician caring for the hunger striker should not forcibly feed the patient without the patient’s consent. When the patient loses consciousness, the physician must take into consideration the patient’s prior declarations of informed refusal of food. If there is an informed and voluntary refusal, the Declaration posits that force-feeding is unjustifiable. In the absence of the possibility of ascertaining consent, the Malta Declaration relegates the decision to intervene to the individual physician. The options available to physicians in this situation are either to decline treatment, in line with the declared will of the hunger striker, or to go ahead with treatment despite the hunger striker’s prior instructions to the contrary, especially if the physician considers that the refusal of treatment is a result of peer pressure. It is also possible for the physician to resign from his or her role in order to avoid making this decision. In any case, the physicians should have the freedom to decide without pressure from nonmedical authorities. If the hunger striker repeats the refusal of treatment after resuscitation, the physicians should respect this decision and not impose further nonconsensual treatment.
Unfortunately, nonconsensual medical interventions have been used around the world for the termination of hunger strikes. One of the earliest and highly publicized instances of this practice goes back to the early 20th century, when British suffragettes on the hunger strike were forcibly and repeatedly resuscitated. While artificial feeding has become less common since the 1970s, as, for example, the hunger strikes of political prisoners in Northern Ireland in 1980 and 1981 were not subjected to artificial feeding, thus resulting in casualties, this practice has continued well into the present, especially in those sites that have been the arena of protracted, repeated, and collective hunger strikes, such as the prisons of Guantánamo Bay, Turkey, and Israel, among others.
In Guantánamo Bay, for example, the predominant response of medical staff to the various waves of hunger strikes by the detainees and prisoners has been unequivocally to resuscitate. As a result, no deaths from self-starvation have occurred in Guantánamo (Patrick Anderson, “There Will Be No Bobby Sands in Guantánamo Bay,” 2009). However, the descriptions by hunger strikers tied to restraining chairs being fed by nasal feeding tubes have been chilling indeed. In 2005, acknowledging the administration of “involuntary” feedings upon prisoners on hunger strike, United States Department of Defense officials emphasized the humane and professional conduct of the medical staff and the necessity to carry out these interventions to secure the health of the prisoners. According to Joint Task Force Guantanamo Deputy Commander Brig. Gen. John Gong, “We have an ultimate responsibility that every detainee on our watch is taken care of” (Kathleen T. Rhem, “Guantánamo Tube Feedings Humane, Within Medical Care Standards,” 2005). Officials also argued that most cases of artificial feeding were consensual, despite counter-allegations. Secretary of Defense Rumsfeld contended that it was up to the commanders and medical experts to intervene when they saw fit. In 2006, the instructions for the treatment of detainees issued by Department of Defense gave further official affirmation to the procedure of “involuntary” feeding on hunger strikers in critical condition as a necessary measure to “prevent death or serious harm.” Overall, the procedure of artificial feeding in Guantánamo by military medical staff has continued, some prisoners being fed thousands of times, despite widespread criticism from the broader medical community and their condemnation of this practice as “cruel, humiliating, and degrading treatment” (David J. Nicholl et al., “Forcefeeding and Restraint of Guantánamo Bay Hunger Strikers,” 2006).
In the case of Turkey, practices of artificial feeding were occasioned by the state’s attempt to contain the hunger strike of political prisoners affiliated with more than a dozen of outlawed leftist parties and organizations. This mass hunger strike, which later turned into a “fast unto death,” was initiated in October 2000 in some twenty prisons around the country and continued in the newly opened high security prisons against which the movement was directed in the first place. Called off only in January 2007, the hunger strike ended with 122 casualties (though not all were due to self-starvation), but the further escalation of the death toll was prevented, at least in part, by state-sanctioned practices of artificial feeding. This was considered by state officials to be an effective and efficient method to attenuate public support for the prisoners’ struggle, which the state calculated was based on the impact generated by prisoner deaths due to self-starvation.
Most physicians publicly argued against medical intervention on ethical and political grounds, claiming that its nonconsensual nature violated the basic and universally accepted value of patient autonomy. In the absence of informed consent, most physicians held that the decision to resuscitate a hunger striker must be left to the individual physician who should not be pressured by either the Ministry of Health or the Medical Association. As an ethical matter, the physicians contended that this decision must also be independent of political considerations and calculations. Despite the objections of physicians, the Ministry of Health decreed hospitals to feed the hunger strikers and embraced resuscitation as a way to prevent prisoner deaths. Moreover, the same decree insinuated that those physicians who refused to conduct artificial feeding would face judicial consequences and would even be prosecuted for “aiding and abetting” terrorism.
Hence, the members of the Turkish Medical Association (TMA) had to navigate a complex terrain woven together by the dictates of their own conscience, the standards of medical practice, the expectations of the public, the declarations of refusal by the prisoners, the state’s decree on artificial feeding, and the political struggle around the high security prisons.
While the TMA officially refused the state’s attempt at instrumentalizing medicine to “make live,” many allegations have since surfaced that state-sanctioned medical intervention did take place. Former participants of the hunger strike narrate how they were resuscitated from the verge of death, often multiple times, despite repeated declarations against treatment or silent acts of refusal. These veterans tell how they fought corporeal battles — pulling out the intravenous needle when they gained consciousness only to find it put back in while they were unconscious to pull it out again when they regained consciousness and so on — while they univocally contend that resuscitation through artificial feeding should be considered a form of torture. Since these allegations have been aired, the supporters of prisoners have conducted campaigns to publicize these medical interventions as “force-feeding,” drawing special attention to the disabilities and complications caused by the improper termination of hunger strikes. In particular, they have pointed to how the negligent or intentionally malignant administration of artificial feeding (by the exclusion of a much needed vitamin B in the solution given intravenously) has caused serious disabilities in many prisoners. One of the most prevalent effects of this process has been the increase in those diagnosed with the Wernicke-Korsakoff syndrome, a thiamin (vitamin B1) deficiency, due to starvation but sometimes aggravated by the improper termination of a hunger strike. In severe cases, individuals with Wernicke-Korsakoff syndrome have experienced permanent impairment of memory functions and severe damage to the central nervous system, practically becoming immobilized and in need of continuous health care.
The controversy stirred by the weaponization of medicine by the state has pushed authorities in Turkey to move away from relying on the precedent of past practices or ad hoc executive decrees to sanction artificial feeding and to ensure the legitimacy of medical intervention by the force of law. In this light, for example, the amendment to the Turkish Penal Code and the Law for the Administration of Prisons (Law No. 4806), passed on February 5, 2003, has upheld the practice of medical intervention (formerly sanctioned by an executive decree issued by the Ministry of Justice), stipulating that it should be administered in case of the endangerment of life or loss of consciousness, regardless of the consent of the prisoner concerned. The same law stipulates that those preventing the nourishment of prisoners (including those who encourage or convince prisoners to conduct a hunger strike) would be punished with 2 to 4 years of imprisonment. In the case that the death of the hunger striker followed such action, the sentence would be increased to 10-20 years (Article 307/b in Penal Code). The same stipulations were adopted in the new Turkish Penal Code (Law No. 5237) passed on September 26, 2004.
Turkey is not alone in this move. In a similar vein, the recent “Law to Prevent Harm Caused by Hunger Strikes,” passed by the Israeli Knesset in July 30, 2015, sanctions nonconsensual medical treatment that is aimed at the preservation of life, to be administered with a judicial decision. Dubbed as the “force-feeding bill,” the controversial law was widely opposed in the public sphere and also criticized by the Israeli Medical Association. It is well-known that hunger strikes have been periodically performed by Palestinian prisoners and administrative detainees since 1968, at times individually to protest particular injustices, but also collectively as a means of contesting their conditions of confinement and advancing their struggle for political recognition. In this light, the recent law has been interpreted as a move not only to don the already-existing and nonconsensual artificial feeding practices with the legitimacy of the law but also to eliminate the growing solidarity and support for these prisoners outside of prison, especially as they near their deaths.
Examples can be multiplied, but the pattern remains surprisingly constant across different contexts. When medicine is enlisted in the service of the state, either simply by repeated practice or by legal sanction, it further localizes and concretizes an asymmetric war in each body, turning infirmaries and intensive care units into intensive zones of conflict in the process. The medicalization of this conflict reveals not only the biopoliticized form that this war has taken but also the new, complex, and intensified power formation in the process of consolidation, one that conjoins and infuses sovereign right with new governmental techniques that issue from and are directed at the “protection of life.” It attempts to transform those physicians who, acting at the extremities of the state, at its point of contact with the insurgent bodies, are confronted with the decision to carry out artificial feeding, into active vehicles of biosovereignty. Equipped with plastic feeding tubes, intravenous solutions, and syringes as their weapons, physicians are asked to fight against the self-starvation inflicted by the hunger strikers, to incorporate the hunger striker’s insurgent body into the body of the state. Rather than politically address the conditions that give rise to such self-destructive struggles and the demands that ensue from them, biosovereign states choose simply to “make live,” thus affirming the “sanctity of life” by instrumentalizing medicine while undermining the possibility of a “just life,” as Walter Benjamin would call it, for all. When the body is resignified as the symbolic and material battlefield in a highly irregular, violent, and notorious form of biopolitical warfare, it is hard to speak of a victory for anyone after all.