- Prolonged hunger strikes can cause severe health complications, including heart failure, neurological damage, electrolyte imbalance, and a life-threatening condition called refeeding syndrome when eating resumes.
- They also create major ethical and legal dilemmas, as doctors must balance respecting a competent person’s right to refuse food with their duty to preserve life, making force-feeding a highly controversial practice.
Whether they are political prisoners or activist detainees, hunger strike is probably the strongest form of non-violent protest that can be undertaken by an individual with nothing else to fall back on. It is also one of the most destructive acts in terms of physical damage. Through starving themselves and, in some cases, dehydrating themselves the striker turns his or her own body into an instrument of resistance, forcing the institution to make a decision: intervene, going against the will of the individual, or do nothing as the body begins to fail to the point of death.
The physiology of starvation
Within the first couple of days of starvation, the body uses up the glucose stores that are present in the liver. Once these are used up, the body falls into a state of ketosis where the fat stores are used for energy production along with the formation of ketones as their metabolic waste. This signals the beginning of a series of physiological declines that can eventually affect almost all organs of the body if left untreated.
The time period varies depending on an individual’s state of health, age, and body composition, but a healthy individual who drinks plenty of water can survive for about six to eight weeks, whereas an ill individual may not survive more than three weeks. However, once water is also denied (“dry” hunger strike), then a very short survival rate is observed, wherein within the first day there will be dehydration and lethargy, followed by failure of major organs after the third day.
Cardiovascular system becomes highly vulnerable during this period. Starvation may cause arrhythmias, heart failure, and, sometimes, sudden cardiac death due to the progressive lack of vitamins and electrolytes. Cases of development of stress cardiomyopathy, acute weakening of heart muscles – during just two weeks of refusal of food have been reported. Over 40 days, the risks of complications become very high and include electrolyte imbalance, arrhythmias, multiorgan failure. After 45 days, the risks of death increase dramatically and usually occur due to infections or cardiovascular problems.
The most serious and hardly reversible consequences are those related to neurological damage. Following 41 cases of long-term hunger strikers with fasting period from 130 to 324 days and only partial nutrition, researchers found that all of them experienced neurological damage resembling the Wernicke-Korsakoff syndrome – disorder which causes confusion, memory impairment, impaired ocular movements and coordination. All 41 cases have experienced altered states of consciousness lasting three to thirty-one days and amnesia. Researchers stated that the brain injury in these patients was more serious than injury in muscles and peripheral nerves and recovery was partial.
The danger doesn’t end when eating resumes
Surprisingly, one of the riskiest parts of a hunger strike isn’t the strike itself, but its conclusion. Re-feeding syndrome, a deadly condition, can occur within the first five days after a striker starts to eat again. As the body that was starved now starts to metabolize food, a spike in insulin production causes the rapid relocation of phosphate, potassium, and magnesium from the blood to the cells. The electrolyte imbalance caused by this phenomenon can lead to heart rhythm abnormalities, breathing issues, and brain problems, which is why the guidelines for treatment of hunger strikers categorize individuals who fasted for 15 days as being at significantly increased risk, and beyond 28 days as being at high risk.
The ethical fault line: autonomy versus intervention
It would be easy for health-care professionals to address the hazards of hunger strikes if such acts took place in isolation from everything else. Hunger strikes pose an immediate dilemma between one of the oldest ethical dilemmas in medicine – that of a doctor’s right to save his/her patient’s life, and the patient’s rights to say no.
According to The World Medical Association’s Declaration of Malta which is the main international document on the subject, physicians have to recognize the rights of an autonomous competent hunger striker in spite of the possible negative consequences of that recognition. In its turn, forced feeding of a competent hunger striker who voluntarily refuses such procedures is considered unethical according to the same document. Furthermore, The World Medical Association states that the procedure of forced feeding can be regarded as the example of inhuman and degrading treatment.
That is why there arises the concept of the “dual loyalty” of physicians practicing in prisons, detention centres, or in the custody of the military because while they work for the same institution as the person conducting a hunger strike, their ethical duty is always towards the specific patient in front of them rather than their employer. It is explicitly stated in the Declaration of Malta that the nature of this ethical responsibility does not depend on the employment situation.
The legal approaches have not always agreed with the position of medical community. In some countries, courts have approved force-feeding under the pretext that the state is interested in the maintenance of life or order in institutions in which the process takes place. Sometimes, some courts even distinguished between hunger strikes motivated by “genuine” political and religious conviction and the ones intended to manipulate legal processes. That is how the tension between judiciary and medicine is often raised in cases involving hunger strike, and that is where the biggest disputes emerge: is the process of forced feeding an act of life-sustaining, or, as stated by WMA, coercion which is essentially equivalent to torture?
A protest that implicates everyone around it
What distinguishes the hunger strike from other types of protest is that it is not just an appeal to the sympathy of an audience, but an active decision by doctors, prison guards, and courts to intervene into another individual’s body. The scientific literature unambiguously notes that starvation leads to serious consequences, some of which become irreversible after a certain time. It is also obvious from the ethics literature that any intervention against a competent individual’s voluntary refusal is not without consequences, which do not lie in the violation of electrolyte balance, but in undermining bodily autonomy and the very concept of medicine. The way to mediate between the two types of damage, rather than avoid either of them, is what makes the medical care of hunger strikers such a complex ethical issue.
Foltynova, K. (2021, May 22). Anatomy of a hunger strike: Why is it done and what does it do to the human body? RadioFreeEurope/RadioLiberty.
Paul, T. J., & Stokken, G. (2024). Acute Cardiomyopathy in a Prisoner on a Hunger Strike. Cureus, 16(1), e51949. Runcie, J., & Thomson, T. J. (1970). Prolonged starvation–a dangerous procedure?. British Medical Journal, 3(5720), 432–435. https://doi.org/10.1136/bmj.3.5720.432
Sharma R, Jain A, Kumar A, Bhadada SK, Grover S, Puri GD. Management of hunger strike: A medical, ethical and legal conundrum. Med Leg J. 2020 Dec;88(4):215-219. doi: 10.1177/0025817220923653. Epub 2020 May 21. PMID: 32437298.
California Department of Corrections and Rehabilitation. (2018). Hunger Strike, Fasting, and refeeding care guide [Care guide]. WMA – The World Medical Association-WMA Declaration of Malta on hunger strikers. (n.d.). WMA – the World Medical Association-WMA Declaration of Malta on Hunger Strikers. https://www.wma.net/policies-post/wma-declaration-of-malta-on-hunger-strikers/
WMA – The World Medical Association-WMA Declaration of Malta on hunger strikers. (n.d.). WMA – the World Medical Association-WMA Declaration of Malta on Hunger Strikers. https://www.wma.net/policies-post/wma-declaration-of-malta-on-hunger-strikers/
Clear Cut Health Desk
New Delhi, UPDATED: July 17, 2026 17:36 IST
Written By: Mitali Tapar
Designation: Manager – MLE at Devinsights
