Emedinews : In what direction would Anna’s fast end?

Most Satyagraha should end up in a win-win situation. No party should seem to look that they have won. What can happen during a Satyagraha?

1. The fast is broken after demands are met.
2. The demands are not met but the fast is broken on the promises made.
3. The demands are not met but the fast is broken after a committee is constituted to look into the demands.
4. The fast is broken on the mediation by a religious or an important person in the society.
5. The fast is broken after the President of the country intervenes.
6. The fast is broken on medical grounds.
7. The fast is broken by the order of a court.
8. The fast is broken on the intervention of local administration or the local police.
9. The fast is broken on the request of the followers.
10. Some shift from complete fast to a relay fast.

#AskDrKK: What is the purpose of Satyagraha or hunger strike?

#DrKKAnswers: Most hunger strikers do not wish to die as per the medical literature.

HCFI Update: Formula of three for hunger strike and Satyagraha

Rough formula of 3 is that one cannot live for three minutes without air, three days without water and three weeks without food said Padmashri and Dr B C Roy National Awardee Dr KK Aggarwal President Heart Care Foundation of India and President MTNL Perfect Health Mela.

But this formula is for healthy muscular and fatty people. People who are in their extremes of ages or are suffering from a chronic ailment, pregnant ladies, diabetics should not fast without a doctor’s clearance.

Dr Aggarwal said that a large number of people are joining Anna Hazare for fast. All are not fit and may loose health. Medically observed spiritual fats can be helpful for the body but prolonged unsupervised fast can be life risky. 

Here are some facts: 

1. Fasting is willingly abstaining from some or all food, drink, or both, for a period of time.

2. An absolute fast is abstinence from all food and liquid for a defined period.

3. Partially restrictive fast is limited to particular foods or substances.

4. The fast may be intermittent in nature

5. Fasting medically means the metabolic status of a person who has not eaten overnight, and to the metabolic state achieved after complete digestion and absorption of a meal. A person is assumed to be fasting after 8–12 hours.

6. Metabolic changes after fasting begin after absorption of a meal (typically 3–5 hours after a meal). Medically it is called "post-absorptive state" as against "post-prandial" state of ongoing digestion.

7. A diagnostic fast refers to prolonged fasting (from 8–72 hours depending on age)

8. The longest known fast for a human is 132 days (without food).

9. Glucose is the body's primary fuel source and is essential for the brain's functioning. When denied glucose for more than 4–8 hours, the body turns to the liver for glycogen, a storage form of glucose, to be used for fuel. A process called glycogenolysis converts glycogen into a usable form of fuel. At this point, the body also uses small amounts of protein to supplement this fuel. This fuel will last for up to 12 hours before the body needs to turn to glycogen stored in muscles, lasting for a few more days.

10. If glucose is still denied at this point, muscle wasting is prevented by temporarily switching to fat as the fuel source, meaning fat is converted into ketone through catabolism. Ketones, while not sugars, can be used by the brain as a fuel source as long as glucose is denied. The body continues to use fat for as long as there is fat to consume.

11. If the fast is not broken, starvation begins to occur, as the body begins to use protein for fuel.

12. Health complications associated with fast-induced starvation include electrolyte imbalances, thinning hair, cardiac arrhythmias and renal failure. Death can occur if fasting is pursued to the point of complete starvation.

13. Hypovolemia refers to any condition in which the extracellular fluid volume is reduced. It can be produced by dehydration.

Gandhigiri: the Path of Satya, Non violence, Sarvodaya and Satyagraha

The science behind Anna movement based on Gandhigiri Gandhigiri always works, weather it was Mahatma Gandhi, the movie “Lago Raho Munnabhi” or the Gandhian Anna. The Gandhian principles were so framed that it always united the common man.The four basic principles Gandhi taught were of Satya (truthfulness); Ahimsa (non violence); Sarvodaya (welfare.... more     http://www.itimes.com/users/iti475269/blogs

GUIDELINES FOR THE MANAGEMENT OF HUNGER STRIKERS

WMA Declaration of Malta on Hunger Strikers

1. Physicians must assess individuals' mental capacity. This involves verifying that an individual intending to fast does not have a mental impairment that would seriously undermine the person's ability to make health care decisions. Individuals with seriously impaired mental capacity cannot be considered to be hunger strikers. They need to be given treatment for their mental health problems rather than allowed to fast in a manner that risks their health.
2. As early as possible, physicians should acquire a detailed and accurate medical history of the person who is intending to fast. The medical implications of any existing conditions should be explained to the individual. Physicians should verify that hunger strikers understand the potential health consequences of fasting and forewarn them in plain language of the disadvantages. Physicians should also explain how damage to health can be minimised or delayed by, for example, increasing fluid intake. Since the person's decisions regarding a hunger strike can be momentous, ensuring full patient understanding of the medical consequences of fasting is critical. Consistent with best practices for informed consent in health care, the physician should ensure that the patient understands the information conveyed by asking the patient to repeat back what they understand.
3. A thorough examination of the hunger striker should be made at the start of the fast. Management of future symptoms, including those unconnected to the fast, should be discussed with hunger strikers. Also, the person's values and wishes regarding medical treatment in the event of a prolonged fast should be noted.
4. Sometimes hunger strikers accept an intravenous saline solution transfusion or other forms of medical treatment. A refusal to accept certain interventions must not prejudice any other aspect of the medical care, such as treatment of infections or of pain.
5. Physicians should talk to hunger strikers in privacy and out of earshot of all other people, including other detainees. Clear communication is essential and, where necessary, interpreters unconnected to the detaining authorities should be available and they too must respect confidentiality.
6. Physicians need to satisfy themselves that food or treatment refusal is the individual's voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities or others, such as family members. Physicians or other health care personnel may not apply undue pressure of any sort on the hunger striker to suspend the strike. Treatment or care of the hunger striker must not be conditional upon suspension of the hunger strike.
7. If a physician is unable for reasons of conscience to abide by a hunger striker's refusal of treatment or artificial feeding, the physician should make this clear at the outset and refer the hunger striker to another physician who is willing to abide by the hunger striker's refusal.
8. Continuing communication between physician and hunger strikers is critical. Physicians should ascertain on a daily basis whether individuals wish to continue a hunger strike and what they want to be done when they are no longer able to communicate meaningfully. These findings must be appropriately recorded.
9. When a physician takes over the case, the hunger striker may have already lost mental capacity so that there is no opportunity to discuss the individual's wishes regarding medical intervention to preserve life. Consideration needs to be given to any advance instructions made by the hunger striker. Advance refusals of treatment demand respect if they reflect the voluntary wish of the individual when competent. In custodial settings, the possibility of advance instructions having been made under pressure needs to be considered. Where physicians have serious doubts about the individual's intention, any instructions must be treated with great caution. If well informed and voluntarily made, however, advance instructions can only generally be overridden if they become invalid because the situation in which the decision was made has changed radically since the individual lost competence.
10. If no discussion with the individual is possible and no advance instructions exist, physicians have to act 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.
11. Physicians may consider it justifiable 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.
12. Artificial 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.
13. Forcible feeding is never ethically acceptable. Even if intended to benefit, 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.

(Adopted by the 43^rd World Medical Assembly, St Julians, Malta, November 1991
and revised at the 44^th WMA Marbella, Spain, September 1992and revised by the 57^th WMA General Assembly, Pilanesberg, South Africa, October 2006)

Preamble

1. Hunger strikes occur in various contexts but they mainly give rise to dilemmas in settings where people are detained (prisons, jails and immigration detention centres). They are often a form of protest by people who lack other ways of making their demands known. In refusing nutrition for a significant period, they usually hope to obtain certain goals by inflicting negative publicity on the authorities. Short-term or feigned food refusals rarely raise ethical problems. Genuine and prolonged fasting risks death or permanent damage for hunger strikers and can create a conflict of values for physicians. Hunger strikers usually do not wish to die but some may be prepared to do so to achieve their aims. Physicians need to ascertain the individual's true intention, especially in collective strikes or situations where peer pressure may be a factor. An ethical dilemma arises when hunger strikers who have apparently issued clear instructions not to be resuscitated reach a stage of cognitive impairment. The principle of beneficence urges physicians to resuscitate them but respect for individual autonomy restrains physicians from intervening when a valid and informed refusal has been made. An added difficulty arises in custodial settings because it is not always clear whether the hunger striker's advance instructions were made voluntarily and with appropriate information about the consequences. These guidelines and the background paper address such difficult situations.

PRINCIPLES

1. Duty to act ethically. All physicians are bound by medical ethics in their professional contact with vulnerable people, even when not providing therapy. Whatever their role, physicians must try to prevent coercion or maltreatment of detainees and must protest if it occurs.
2. Respect for autonomy. Physicians should respect individuals' autonomy. This can involve difficult assessments as hunger strikers' true wishes may not be as clear as they appear. Any decisions lack moral force if made involuntarily by use of threats, peer pressure or coercion. Hunger strikers should not be forcibly given treatment they refuse. Forced feeding contrary to an informed and voluntary refusal is unjustifiable. Artificial feeding with the hunger striker's explicit or implied consent is ethically acceptable.
3. 'Benefit' and 'harm'. Physicians must exercise their skills and knowledge to benefit those they treat. This is the concept of 'beneficence', which is complemented by that of 'non-maleficence' or primum non nocere. These two concepts need to be in balance. 'Benefit' includes respecting individuals' wishes as well as promoting their welfare. Avoiding 'harm' means not only minimising damage to health but also not forcing treatment upon competent people nor coercing them to stop fasting. Beneficence does not necessarily involve prolonging life at all costs, irrespective of other values.
4. Balancing dual loyalties. Physicians attending hunger strikers can experience a conflict between their loyalty to the employing authority (such as prison management) and their loyalty to patients. Physicians with dual loyalties are bound by the same ethical principles as other physicians, that is to say that their primary obligation is to the individual patient.
5. Clinical independence. Physicians must remain objective in their assessments and not allow third parties to influence their medical judgement. They must not allow themselves to be pressured to breach ethical principles, such as intervening medically for non-clinical reasons.
6. Confidentiality. The duty of confidentiality is important in building trust but it is not absolute. It can be overridden if non-disclosure seriously harms others. As with other patients, hunger strikers' confidentiality should be respected unless they agree to disclosure or unless information sharing is necessary to prevent serious harm. If individuals agree, their relatives and legal advisers should be kept informed of the situation.
7. Gaining trust. Fostering trust between physicians and hunger strikers is often the key to achieving a resolution that both respects the rights of the hunger strikers and minimises harm to them. Gaining trust can create opportunities to resolve difficult situations. Trust is dependent upon physicians providing accurate advice and being frank with hunger strikers about the limitations of what they can and cannot do, including where they cannot guarantee confidentiality.

Baba Ramdev Special: How to medically face a patient of Satyagraha with signs of starvation?

I recall days of my joining in MBBS in 1975 when I met Vinoba Bhave ji for the first time and when I was an intern, I was a part of the medical team who looked after him when he undertook  a fast unto death. It was a willful decision taken by Vinoba ji after he was diagnosed to be suffering from LBBB heart rhythm and a pacemaker was advised to be put on him. Instead of going for an artificial machine, he decided to call it a day and quit the world. It became a debate of the nation whether a person can decide to fast unto death or not. A case was also filed in the local court that Vinobaji is trying to commit suicide but before the date of hearing, Vinobaji left his body on the day of Amavasya, 10 am on Diwali day. Ever since that subject has been hitting my mind and the memories of Vinoba Bhave ji became afresh with the recent episodes  of Anna Hazare going on Satyagraha and later Baba Ram Dev sitting on fast unto death.

I also recall my days in 1986 when I was doing my Fellowship in Non-invasive Cardiology in Birmingham Alabama USA when I came across article in US media about physician assisted suicide, a term not defined by Medical Council of India.

Physician assisted suicide was an unethical act in American dictionary at that time. From medical point of view, if we see a patient sitting on Satyagraha with a vow to fast unto death for practical purposes, he or she is committing suicide and if we as doctors are silent witness to the same, we are liable to be charged as an unethical act of assisting in that physician assisted suicide.

We should refuse to attend to any such patient and if we attend then it becomes our duty to forcibly treat that patient even if it amounts to calling Police or the local administrative authorities. As medical fraternity, we should refuse to attend to such patients if we are not allowed to act and treat them medically.

I know in Vinoba Bhaveji’s time doctors from MGIMS, Nagpur and many invited from Bombay behaved like a near spectators and were unable to offer any help to the dying saint.  We are seeing the same phenomenon happening with Baba Ram Dev and the local treating doctors showing their helplessness.