Food refusal in prisoners: a communication or a method of self-killing? The role of the psychiatrist and resulting ethical challenges.

Food refusal occurs for a variety of reasons. It may be used as a political tool, as a method of exercising control over others, at either the individual, family or societal level, or as a method of self-harm, and occasionally it indicates possible mental illness. This article examines the motivation behind hunger strikes in prisoners. It describes the psychiatrist's role in assessment and management of prisoners by referring to case examples. The paper discusses the assessment of an individual's competence to commit suicide by starvation, legal restraints to intervention, practical difficulties and associated ethical dilemmas. Anecdotal evidence suggests that most prisoners who refuse food are motivated by the desire to achieve an end rather than killing themselves, and that hunger-strike secondary to mental illness is uncommon. Although rarely required, the psychiatrist may have an important contribution to make in the management of practical and ethical difficulties.