The psychiatric management of prisoners on hunger strike: developing a management algorithm using the Delphi technique

• DOI: https://doi.org/10.1108/IJPH-06-2017-0030
• Date: 11 March 2019
• Pages: 66-75
• Published date: 11 March 2019
• Author: Gautam Gulati,Brendan D. Kelly,Conor O’Neill,Paul O’Connell,Sally Linehan,Eimear Spain,David Meagher,Colum P. Dunne
• Subject Matter: Health & social care,Criminology & forensic psychology,Prisoner health,Sociology,Sociology of crime & law,Public policy & environmental management,Policing,Criminal justice

The psychiatric management of prisoners

on hunger strike: developing a management

algorithm using the Delphi technique

Gautam Gulati, Brendan D. Kelly, Conor O’Neill, Paul O’Connell, Sally Linehan, Eimear Spain,

David Meagher and Colum P. Dunne

Abstract

Purpose –The assessment and management of prisoners on hunger strikes in a custodial setting is

complex. There is limited clinical guidance available for psychiatrists to draw upon in such cases.

The purpose of this paper is to develop a management algorithm through expert elicitation to inform the

psychiatric care of prisoners on a hunger strike.

Design/methodology/approach –A Delphi method was used to elicit views from Irish forensic

psychiatrists, a legal expert and an expert in ethics using a structured questionnaire. Themes were extracted

from the results of the questionnaire to propose a management algorithm. A consensus was reached on

management considerations.

Findings –Five consultant forensic psychiatrists, a legal expert and an expert on psychiatric ethics (n¼7)

consented to participation, with a subsequent response rate of 71.4 per cent. Consensus was achieved on a

proposed management algorithm. Assessment for mental disorder, capacity to refuse food and motivation

for food refusal are seen as key psychiatric tasks. The need to work closely with the prison general practitioner

and the value of multidisciplinary working and legal advice are described. Relevant aspects of law included

mental health, criminal law (insanity) and capacity legislation.

Originality/value –This study outlines a management algorithm for the psychiatric assessment and

management of prisoners on a hunger strike, a subject about which there is limited guidance to date.

Although written from an Irish perspective, this study outlines key considerations for psychiatrists in keeping

with international guidance and therefore may be generalisable to other jurisdictions.

Keywords Ireland, Prison, Capacity, Prisoner, Food refusal, Hunger strike

Paper type Research paper

Introduction

A“hunger strike”is by definition food refusal as a form of protest or demand (Crosby et al., 2007).

Whilst the time-based consideration in defining a hunger strike is debated, US prison and

immigration service definitions use a cut-off of 72 h of food refusal in defining a hunger strike (Wei

and Brendel, 2010).

Hunger strikes in prison have been reported in several countries including Turkey, South Africa,

Ireland and the US Naval base at Guantanamo Bay, Cuba (Crosby et al., 2007). In Ireland, hunger

strikes came to national attention in 1981, after the deaths of ten individuals protesting against

the withdrawal of special category status for paramilitary prisoners by the then British

Government (Beresford, 1997). Food refusal has been noted as a “particularly Irish form of

protest”(High Court of Ireland, 2015).

A referral to assess a prisoner on hunger strike in contemporary prison psychiatry is relatively

uncommon but nonetheless challenging. There is limited specific guidance as to how to proceed

(Wei and Brendel, 2010) with such a referral. The role of the medical professional is fraught with

Received 30 June 2017

Revised 8 May 2018

Accepted 30 May 2018

The authors would like to thank

Dr Noreen Moloney, University of

Limerick, for comments on the

manuscript.

Gautam Gulati is based at the

Department of Psychiatry,

University Hospital Limerick,

Limerick, Ireland and Graduate

Entry Medical School,

University of Limerick,

Limerick, Ireland.

Brendan D. Kelly is based at the

Department of Psychiatry,

Trinity College Dublin,

Dublin, Ireland.

Conor O’Neill, Paul O’Connell

and Sally Linehan are all based

at Central Mental Hospital,

Dublin, Ireland.

Eimear Spain is based at the

Faculty of Education and Health

Sciences, School of Law,

University of Limerick, Limerick,

Ireland.

David Meagher is based at the

Department of Psychiatry,

Graduate Entry Medical

School, University of Limerick,

Limerick, Ireland.

Colum P. Dunne is based at the

Graduate Entry Medical

School, University of Limerick,

Limerick, Ireland.

PAG E 66

j

INTERNATIONALJOURNAL OF PRISONER HEALTH

j

VOL. 15 NO. 1 2019, pp. 66-75, © Emerald Publishing Limited, ISSN 1744-9200 DOI 10.1108/IJPH-06-2017-0030