Moors murderer, Ian Brady, is fighting to end his life. This week he has appeared in public for the first time since his trial in the 1960s. He has been force-fed for the past 13 years and is begging to be ruled sane and transferred to a prison in Scotland where he will be allowed to starve himself to death.
To many people - and certainly to the surviving parents of his victims - this “monster” does not deserve to make his own decision about when and how he should die. They argue that he condemned others to a life of pain and sadness. Accordingly he should be made to endure jail “for the term of his natural life”.
But is it this simple? What is the position of nursing staff in institutions who are faced with someone who is prepared to die via a hunger strike – should they be stopped and can staff be forced to stop them?
This is an issue I have considered since working as a student nurse in Belfast in 1981, when 10 IRA prisoners, led by Bobby Sands, starved themselves to death as a political protest. At the time we weren’t taught about the ethics of this as part of our nursing course.
More recently, in Cuba, we have learnt that prisoners are being force fed in Guantanamo Bay by doctors and nurses. There has been a great deal of international outrage expressed in the media with many pleas to President Obama to intervene and stop an activity equated with torture. The British Medical Association has pointed out that force-feeding “competent adults […] involved in a voluntary hunger strike violates international standards of medical ethics”.
There are fewer more emotive or ethically challenging issues than self-starvation. Surely, we might think, no sane person would choose to starve themselves to death? At the same time, we are likely to be troubled by the thought that any care professional would force sustenance on a patient. Or that any organisation or authority would insist that people should be held down and fed against their wishes.
Should a ‘monster’ have choices?
Brady is reported as saying that “he would rather die quickly than rot slowly in jail”. A previous attempt to achieve this failed with a judge describing Brady’s hunger strike as symptomatic of “his obsessive need to exercise control”.
Brady’s plight is unlikely to evoke much sympathy from those who know details of the heinous crimes he committed with Myra Hindley. Many will remember the suffering of the families and in particular, the late Winnie Johnson, who fought unsuccessfully for 48 years to find the grave of her son, Keith, who was murdered by Brady.
Whereas some will declare that Brady’s wishes are undeserving of respect, ethicists and healthcare professionals must consider the values at stake and offer a more reasoned view that is in keeping with our professional purpose: to promote health, alleviate suffering and contribute to a good death.
Respect for human rights trumps all
It wasn’t until I saw Steve McQueen’s film “Hunger” about Bobby Sands’ death, that I came to more fully appreciate the personal, professional and political implications of self-starvation. Professionals now have much more education and guidance regarding challenging ethical issues such as force-feeding.
The Nursing and Midwifery Code for nurses is clear: “You must ensure that you gain consent before you begin any treatment or care.” and “You must respect and support people’s rights to accept or decline treatment and care.” The ethical principles underpinning healthcare practice more generally seem to point also in one direction: respect the autonomy of the person; do good and minimise harm; allocate resources fairly and do not engage in discriminatory practice (regardless, it seems necessary to add, of the crimes, callousness, suffering caused or psychopathic status of the patient).
But might it be argued Brady is insane, lacking autonomy, and with no right to refuse nutrition? Here even the law is unhelpful as two recent cases show. In the case of “L” a judge ruled that while it was in her best interests to be provided with sustenance, this should not be forced. If necessary, she should have palliative care so that she “suffers the least distress and retains the greatest dignity until such time as her life comes to an end”. In the case of “E” the judge ruled that she could be force-fed “in her best interests”. The judge said that “E is a special person, whose life is of value. She does not see it that way now, but she may in future”.
Despite his monstrous deeds, Brady is entitled to respect for his human rights and dignity taking into account the fact that his life is not of value to him. The decision to take our own life is the ultimate choice. Health professionals work relentlessly to provide compassionate care and may feel that they have failed when a person takes their own life. They are perhaps more accustomed to, and accepting of, patient refusals and a decision to allow someone to die when treatment and care is considered futile. We need to be mindful of our own motivation to save life at all costs, disregarding the wishes of the individual concerned whether they are in hospital or prison.
A matter of conscience
We would do well also to remember a question posed by Mary Warnock in 1984: The question must ultimately be what kind of society can we praise and admire? In what sort of society can we live with our conscience clear?
Is it a society that permits force-feeding perhaps with the intention of preventing some political fallout? Or worse, to punish or seek revenge for past wrongs?
Or is it a society in which we consider force-feeding as torture and assume an ethical stance lobbying politically to stop force-feeding and avoid hunger strike situations? Is it a society in which professional values are safeguarded, and, where necessary, we respond compassionately to support what could well be a rational suicide?