Maurice,

The Valais Cantonal court judgement was based on the principle that the government is responsible for the welfare of its prisoners. To execute its judgement, it must find and appoint a medically qualified person. The prisoner is under the medical supervision in the Geneva University Hospital.

The case is going to the Swiss Federal Court and may even go the European Court for Human Rights. However the medical staff opposition to force feeding a patient or prisoner against his will
on ethical ground remains.

I can understand deprivation of their liberty of movement but I can't see how one can deprive a prisoner of expression of views and will within the confines of a prison. I think that consent or dissent regarding a clinical trial (not of the prisoner's design or intent) may be affected by duress but not the personal decision to stop eating. ..Maurice.

It would appear that from what Kim wrote, Swiss law is anachronistic with regard to voluntary fasting by prisoners. ..Maurice.

I'll start with the obvious aside: Rappaz was apparently convicted by a court of competent jurisdiction in a country with a democratically elected government. He likely had the opportunity to participate in the election of the legislature. That was his opportunity to protest cannibis laws. Despite the assertion that laws should not legislate morality that is exactly the purpose. Legislation is the penultimate codification morality (judicial review is the ultimate). The fact that we say something shouldn't be done is intrinsically a moral judgement. Law, by its very nature, is the imposition of the will of the legislature on the constituency. The differences are quantitative in many cases- differing only by degree- not qualitative.

By subsequently violating established laws he suffers legally and legislatively prescribed punishment. I'm frankly not surprised his appeals were rejected. As far as a protest- what convict does not desire freedom?

This is otherwise a very complicated question.

The first issue that must be resolved is the convict's purpose in fasting. If merely to make a political statement or protest that is most certainly different from a planned slow suicide. The government might legitimately prevent a convict from either but the ability to do so depends on how the penal system allocates convict rights and penal responsibilities for convict welfare.

Even in circumstances wherein the government might legitimately “require” a convict to eat or drink the government must still have a mechanism to enforce such a requirement. “Rights” whether belonging to individuals or the government must have someone against which they may be enforced. In the US most rights are against the government- free speech, religion, assembly, etc. Some “rights” are surrendered voluntarily as a condition of being allowed certain privileges- states set speed limits in congruence with federal requirements in order to gain access to road construction funds, individuals surrenders the “right” to drink under some circumstances in order to maintain a valid driver's license. So, even if the government has a “right” to force a convict to eat or drink there may still be the logistic hurdle of enforcement for a variety of reasons.

The analogy to research with regard to refusal is interesting yet seems incomplete. Health care might be legitimately refused even by those who are incompetent to consent/assent to research. Research, by it's nature rarely offers direct benefit to the actual participant- at best it offers a statistically significant but unproven opportunity for improvement. That's why it's called research not therapy. The end point of the research is rarely improvement in the individual participant's health or welfare. In particular, convicts may feel that “voluntary” participation might earn them extra privileges or rewards- perhaps better health care. Further, once enrolled, convicts may feel additional pressure to remain enrolled even to their detriment. This is another form of therapeutic misconception.

The basis for this dichotomy rests in the distinction between recognized outcomes.Health care as part of a therapeutic doctor-patient relationship should be directed at the welfare of the patient. Research does not have that as a primary goal. Quite simply, therapeutic misconception does not exist (or should not) in the realm of treatment as opposed to research.

In contrast, well-informed patients should be allowed to accept or refuse any particular therapy. It is important to note that respect for patient autonomy, as opposed to actual autonomy, forms the basis for consent. Consent does not permit access by the patient of whatever desire strikes the patient. Instead consent is a mechanism by which a patient may choose an available therapy. The patient may
request literally anything. Yet, as clearly demonstrated by the Bouvia case in the '80's, a right to die does little more than prohibit the government from impeding the request. It does not obligate another person to assist. Further, it may not offer an option for a qualified provider to participate.

So the bottom line is that if Rappaz were in an American prison his imprisonment would raise the consciousness of our foolish “war on drugs” and it's relationship to narcoterrorism but would likely not result in his being force fed. Most doctors would ignore a court order to feed him as long as he remains competent. Few courts would issue such an order since the only enforcement would be contempt citation.

John,

Thanks for bringing up additional legal points. I agree with your first point. The Swiss constitution allows all its citizen to launch referendum on any topic by collecting predetermined number of signatures and depositing them with the local, cantonal or federal government. I believe that Mr Rappaz failed to win any referendum at the state or federal level for free cultivation or distribution of cannabis/hemp.

The welfare of the prisoners is the responsibility of the state and its prison and justice system. By extension the state must keep them healthy and fit so that they fully complete their prison term and punishment. Thus maybe from legal point of view it makes sense to pass a force feed court order.

In the past research on prisoners was misused to test for chemical and biological agents, radiation etc. That is why it is banned. Capital punishment in China has started the organ trade bazaar and maybe execution of prisoners maybe linked with the demand for organs for transplant.

Today the Swiss Supreme Court (Tribunal Federal) has rejected the appeal of Mr. Rappaz to set him free. The court clearly stated that going on fast unto death is not a valid reason for liberating prisoners.

Gandhi always won his carefully selected fast unto death over issues which won a majority of Indian public opinion and many influential writers and intellectuals in the US/UK as well. Kim I need to read some of the links provided, will come back soon.

Maurice,

I agree with your analysis of Mr Rappaz position to change the Swiss ban on cultivation and distribution of cannabis. However his fast unto death was initially set to free himself from prison and then champion his cause. That is why there is little public sympathy. He could have contested for elections or launched referendum at the local, state or federal level to champion his cause, but failed to do so. Public sympathy and support is essential for successful outcome of hunger strikes. As long as Mr. Rappaz remains in Geneva (the capital of human rights) and the University hospital, there is very low probability of his being force fed.

The use of force feeding of prisoners as a military policy is troubling and against human rights. International Red Cross, Amnesty International, WHO, World Medical Council, IOM, AMA must take joint action to condemn, ban and abolish this practice in all countries.

Gandhi will remain happy in the heaven if the right to go on hunger strike or fast unto death is not denied even for unpopular or lost causes.

Krishan, those 57 kg are just a tiny part of his case. He has been cultivating cannabis on his ranch for the last 2 decades, hemp and cannabis products of close to 10 tons have been confiscated, he has reportedly earned more than 2 million Swiss francs (~ 2 million USD) and was convicted for money laundring.

German Article: http://www.tagesanzeiger.ch/schweiz/standard/Rappaz-stoesst-in-der-Bevoelkerung-auf-wenig-Sympathien/story/20464312?dossier_id=663

He started his fast on 26 August that is over 85 days ago. How long can one survive on complete fast?

Maurice,

Thanks. Swiss newspapers are full of stories and have raised suspicions and questions about possible cheating. I think based on the the review paper data, one can easily state that the fast is real and there is no cheating involved. The next health check up may bury any doubts about cheating.

Samia,

Welcome and thanks for your contribution. I hope both you and Pascal will contribute regularly. It is always good to have one more bioethics specialist.

The Valais Canton Parliament passed a resolution against commuting his sentence or setting him free yesterday. Mr. Rappaz has refused to express any regret or remorse for his past actions. The newspaper Tribune de Geneve gave 2 possible headlines of the next few days.

Rappaz life saved by medical intervention

Rappaz death due to his own obsessive blindness


However still believing in a few Gandhi principles, I feel that his life should be saved by force feeding. I think the case poses a real ethical Catch 22 situation for the medical profession. Frequently the medical profession goes to extreme extent of therapeutic overkill to keep terminal patients alive in a vegetative state. In this case force feeding can save the life of Mr. Rappaz, yet the medical professions stays aloof? Are they assisting in his suicide?

News

It seems that Mr. Rappaz converted to Buddhism in the early 1970s. His new religion forbids cultivation, promotion, smoking and commerce of such drugs. Moreover the Buddhists must not be self centered but respect third party opinion and the society rules. In the Sunday Le Matin, the head of Buddhist in Switzerland (nominee of Dalai Lama) has declared that he will meet Rappaz and persuade him to end his fast.

The latest news was that Mr Rappaz is ready to end his fast under certain conditions


Kim,

Gandhi was never force fed and all his fasts were not directed against the British rule. He fasted to promote inter religious tolerance as well. May be in his time the concept of force feeding did not exist as I do not recall reading it in the biographies of the last few Viceroy or Governor Generals of the British Crown in India.

The way you describe force feeding, I am against such methods. So maybe self imposed end to fasting is the only solution despite medical complications as outlined by Maurice comments above. This can come only through medical advice and suggestions

Samia,

I think time has come to depenalize the so called "Soft" drugs and move to the tolerance as in the Netherlands as it seems a lost battle. Some of these soft drugs are used in tribal societies and for religious rituals.

Gandhi influence makes me believe that Mr Rappaz has suffered enough, he has lost his house and farm and there is no need for him to end his life. He must end his fast on his own.

Mr DeBakey, the heart surgery pioneer was operated despite his clear instructions not to undergo heart surgery at his advanced age. He was the oldest patient to undergo his own invented surgical procedure in 2005. The hospital ethics committee approved the surgical procedure despite DeBakey initial opposition.

Mr Rappaz has fasted 5 times on previous occasions, for as long as 75 days twice and won his arguement each time. He is now on 89th day of fasting and the danger of some vital organ or system failure is real. He is completely ruined, crushed and a broken man having lost his firm and house and in debt. It seems he has lost his battle this time due to lack of public concern or support from public opinion.

He is willing to negotiate and has asked for 6 months of conditional liberty to move his agricultural machinery from his farm and his household affairs to a storage facility. He has stated that he will return to prison to complete his prison term and be a model prisoner. However his constantly shifting positions and inability to respect past promises makes him an unreliable person.

Advice by head of Buddhist leader coupled with medical advice to persuade him to end his fast on his own without preconditions seems at the moment only option left.

Samia thanks for correcting my impression about force feeding. I did not know it was used by the British so early. From my memory I do not recall that the British Raj used it on Gandhi who fasted on at least 20-21 occasions during his lifetime. Each time he won the consession or pledge for reforms and real concrete action. Gandhi had extensive media exposure each time he started his fast and ended it voluntarily and gained extensive public sympathy. At least 4 of the last Governor General of India starting from Lord Irwin (Halifax) and Lord Wavell tried to negotiate with Gandhi and were considered failures by the British Government in London as soft on Gandhi. The other 2 used repressive methods and imprisoned him many times and were considered failures by all (Indians, rulers, UK Government, media). Only Earl Mountbatten by giving India independance despite Churchill strong opposition won the hearts in India.

Kim,

deBakey case story was extensively covered in the New York Time and other media at that time.

http://en.wikipedia.org/wiki/Michael_E._DeBakey

Some more info about Mr. Rappaz. Swiss Newspapers report that the farmer switched to cannabis farming in 2001 with the authorization of the Federal government and has regularly paid all federal and state taxes and income tax. He was sentenced to 6 years imprisonment in 2006 for cultivation and commercial sales and distribution of cannabis. At the same time a police inspector accused and guilty of child molestation, was sentenced to 400 hours of civic work of common general interest. Mr Rappaz cited this discrepancy in Swiss Justice. He has served 14 months in prison and completed 3 months on fast.

The dilemma for the Swiss justice is: it is unethical to let a prisoner die and unethical for medics to force feed him. A third way out for religious, family and medical advice for him to end his fast on his own

Since the courts have not given in and since the doctors have not given in and since the Swiss society has not expressed a changed vision of the case, there is no alternative that I can see other than allowing Bernard Rappaz the decisional autonomy which in a humanitarian way he deserves if he doesn't deserve anything else. If he continues to have the mental decisional capacity as he did at the onset of his fast then he certainly has ethical support for making that current decision. And nobody can say he is committing suicide since his primary intention was apparently not to kill himself but to call attention to his plight and provide his release from prison. As long as he is not causing harm to others by his decision, he should do what he thinks is best for himself and his cause. There shouldn't be any disagreement by anyone including the courts, the doctors or Swiss society about that. If not, they need a little ethics education. ..Maurice.

All quite and no news during the past 2 days. The Swiss Government has refused to intervene and pass a law against force feeding. The canton of Neuchatel has banned force feeding by law. The judgement of the Swiss Federal Court and decision of the Valais authority for 6 month suspension of prison is awaited.

With the formation of the official trade organization for Medical marijuana in the US, the commerce has spread and news stories stated that one US state has collected over 1.2 billion dollars as tax revenues from cannabis trade? Links not provided.

As a true Buddhist, Mr Rappaz should end his fast and save his life as it is against the the basic doctrine of Buddha's teachings. It is not worth dying for promoting free trade in cannabis?

But whether a person has demonstrated "spiritual growth", I think, is a value set and determined by others and somehow I think that spiritual growth, if wanted by the individual, should be an autonomous act and goal. I say, if Rappaz still has capacity to make life and death decisions.. let him be. ..Maurice.

Those judges who delay the decision might be said to be complicit in Mr. Rappaz death if death occurs before a decision is made. It will not be the final judgment, of course, which raises the complicity but, despite the most likely knowledge of the judges that a decision must be emergent and failing to make a decision in time, it is their delay which in this case would bind them to complicity. I am no lawyer but from a purely ethical point of view, the relationship between the delay of decision and Mr. Rappaz's death, if should occur in the meantime represents a failure of trust by the judicial system.

Think of this: if a hospital ethics committee gets a call where a prompt consultation by the committee must be made in the next few hours because a clinical decision must be urgently made (admittedly a rare occurrence), the committee would make an effort to facilitate the gathering of the meeting to meet the need of the patient. ..Maurice.

Kim: Troubling? Of course. And if you are just imagine being in the shoes of those who must actually make the decisions here. Everyone in this case deserves our compassion. Remember that when ethicists find a case interesting, it's a little bit like the situation where your doctor finds your case interesting: it's usually bad news.
And you do know: the fact that measures have not been assessed on the internet does not mean they have not been considered and weighed, as you are no doubt aware...

About an alleged complicity of the court in taking time. One of the things this case clearly shows, is that the ethical implications as viewed from medicine and as viewed from the legal domain apparently look very different...Adapting to the needs of a sick person is normal in medicine. It's what you call for, what I would do, what we all consider second nature here. Legal proceedings, however, usually don't function on the principle of adapting to the needs of convicted criminals. And in this case, many people on the legal side feel that they emphatically shouldn't be seen to give in to his demands.

This is why, in the end, a solution with a sentence interruption seems the most likely. This *is* normal in case of a serious danger to health. Here, *not* to give one would be to make an exception, which the authorities have repeatedly said they now don't want to do.

So now, yes, we are all waiting to see what decisions will be made. The court has already seen this case once during the summer, by the way, and back then they had requested that 'all measures compatible with the Constitution be taken to save his life'. He had then been jailed at home for the summer. Such a solution, with the patient exiting jail while we wait for the verdict, or otherwise sitting his sentence in a modified form, is theoretically possible again.

Krishan, we are not making any decision: all ethics committees are consultative.
Also, your comment seems to imply that the 'right decision' would be to save the patient's life in the end, whatever he had refused. This is actually the crux of the matter. It is far from clear that such a decision would be justifiable. Or effective.

On the political side: the Wallis authorities have announced today that they are not interrupting his sentence. They invite him to end his fast.

Maurice, yes there is that. Mr Rappaz is in one of the major Swiss teaching hospitals. If and when he ends his fast, medical supervision of his refeeding will be very good indeed. Of course, even in very good hands these are risky circumstances...

Kim, hopefully the ethics committee will not make the final decision but only facilitate the stakeholders to make some ethical final decision.

With regard to what happens pathophysiologically in fasting and then what has been found to occur during refeeding, you must read the article I referenced in a previous comment:
(Medical
Progress). West J Med 1982 Nov; 137:379-399
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1274154/pdf/westjmed00207-0055.pdf

..Maurice.

Krishan, in your initial description of the question, you wrote "Public opinion polls in Swiss Romande show that a majority is against force feeding or setting him free on humanitarian grounds." I may have missed it in subsequent postings but what about public opinion regarding "hunger striking", Is the action considered altruistic or is it considered a form of self-enhancing publicity which only harms the public by its unnecessary distraction from more worthy issues than the progressive sickness followed by death of one individual for some cause which may not necessarily be considered important or if even important but not worthy of dying for, by most of society. If "hunger-striking"of that individual is considered an unnecessary burden on the courts, the government and society in general then this could explain the delays and confusion in the management of such "strikes". Also it seems easier to respond to the usual in public"work strike" for a cause, which may have public support for that cause, with police actions, batons and water cannons promptly applied than to frustratingly respond to that individual's public fasting for a cause. Interesting societal contrast. ..Maurice.

Mr Rappaz appeals/petitions to courts, administration and political authorities have all been rejected. In view of the total blockage of the Swiss legal, justice and administrative system and closed door on Mr Rappaz, a support group in France was formed to provide international support. The Euro Ecology leader and European parliament leader Mr. Daniel Cohn Bandit and several French personalities have joined. The vice President of the Consultive Committee of the UN Council for Human Rights, Mr Jean Ziegler (a Swiss citizen, politician) has called for saving of Mr Rappaz life on humanitarian grounds on the 100th day of his fast. French press has started covering the story as the interest in the Swiss media has declined.

Hmmn.. what this all tells me is the Swiss Federal Court when faced with a prisoner who continues on a hunger strike to death that between death and reprieve for the prisoner's marijuana illegal activities, that death is a more appropriate ending for such activities. By putting this man in jail, a decision obviously challenged by the prisoner, it is now the court's to take the responsibility of deciding between death and reprieve. Obviously, they elected death. ..Maurice.

Here are some direct links to the Swiss press coverage (in French)

Affaire Rappaz: le chanvrier valaisan prend des vitamines
Romandie.com - ‎Il y a 3 heures ‎
Bernard Rappaz poursuit sa grève de la faim mais consent à prendre des vitamines, du sucre et du sel. Son avocat, qui a épuisé toutes les démarches légales ...
Affaire Rappaz 20 minutes.ch Rappaz absorbe du sucre, du sel et des vitamines 24heures.ch 102ème jour de grève de la faim pour le chanvrier suisse ! vivre-a-chalon.com TSR.ch
13 autres articles »Envoyer par e-mailFREE RAPPAZ !
Tribune de Genève (Blog) - ‎Il y a 6 heures ‎
Bernard Rappaz est un paysan âgé de 57 ans, objecteur de conscience et défenseur de l'énergie éolienne. Partisan résolu de la légalisation du cannabis, ...

The European Court of Human Rights, Strasbourg has rejected the petition by Mr. Rappaz thus closing the door on his last hope for freedom. In fact the legal, political and majority of public opinion is for "Let him die" and a convicted prisoner on hunger strike should not be liberated.

http://genevedemain.blog.tdg.ch/archive/2010/12/20/laissons-rappaz-mourir.html
http://www.24heures.ch/actu/suisse/bernard-rappaz-epuise-recours-possibles-2010-12-20

I hope Buddhist religious convictions will make Rappaz change his mind and end his fast, Loss of a human life for cannabis trade is not worth the efforts

Unfortunately, Kim, there is "learning": 1) Obey the law 2) Don't pressure others to ignore the law solely for one individual 3) Take responsibility for your own outcome if you decide to go on and persist on a fast to death.

This lesson should satisfy others in Switzerland and perhaps elsewhere who wish to copy the decisions as made by Mr. Rappaz. Unfortunately, there is an odor of unhumanistic actions or inactions by some which as odor affects taste, kind of sours any such "learning" from the Rappaz case. ..Maurice.

Just found this german article that Mr. Rappaz is going to end his hunger strike tomorrow:
http://www.tagesanzeiger.ch/schweiz/standard/Hanfbauer-Bernard-Rappaz-beendet-Hungerstreik/story/19212289

Obivously he started taking salts, vitamins and sugared tea some time ago, which explains why he survived the 120 days. I congratulate him on his decision to put an end on this drama.

In summation, it isn't worth dying for a cause which has no listeners except oneself. Any other new learning points with this news? ..Maurice.

Mr Rappaz recovery from a prolonged fast of 120 days passed normally and he has gained 14 kg since ending his fast on 25 December 2010. Mr. Rappaz was released from the hospital on 10 January 2011 and transferred to his prison. He has given a media interview denying any cheating and recognized his defeat. He says he is mentally strong after doing 75 days fast on 2 previous occasions and a last one of 120 days as a test of his limits.

Time has come to close this discussions and I once again sincerely thank all the participants for their contributions.

I too want to thank you all for participating in this discussion. However, I share Maurice's doubts. Had this happened in a different country, and had the question been 'how would this be handled in Switzerland', I may have commented here by citing national and international ethical guidelines as well. But part of the difficulty of this case was precisely in knowing how much scope courts would allow for ethical guidelines. And how strongly doctors would stand by the central core of 'the patient comes first'. Now that this story is over, I feel I have learned many important things about my medical colleagues, as well as about courts, and politicians in Switzerland. I'm not confident though that I've learned much about how such a situation would be handled in the US. But perhaps it can't be otherwise. After all, I'm not really certain this situation would have been handled in just the same way had it happened in a different part of Switzerland, or 10 years apart, or to someone who had committed a different crime, and so on...

As to the comment on marijuana, Maurice: I'm not sure. Switzerland is a country where the growth and sale of marijuana is a crime, but not its use. Many people are quite open about consuming it recreatively, and they need fear neither the police nor any serious social stigma. Medical THC can be prescribed and the only reason that's infrequent is that the indications are infrequent. Indeed, this was one of the reasons Mr Rappaz received so little public support. Some seem to have felt that even greater toleration of cannabis was simply of too little import to be worth dying for.

Anyhow: thanks again to all.

From the English language Swiss site "The Local" http://www.thelocal.ch/188/20110511/

"On Tuesday, he was found guilty by a court in Martigny on charges of violating drug laws, money laundering and falsifying court documents from 2002 to 2006, the Corriere del Ticino newspaper reported.

Rappaz is already serving jail time for similar charges in the period 1997-2001 and has launched hunger strikes to protest against what he claims is a too severe sentence."

Seems like the courts are picking on this "poor" man. ..Maurice.

An update Swiss news release in October 2011 says that Mr. Rappaz must continue imprisoned for another 12 months. Of interest is the apparently current video of Bernsrd's arrival in court.

http://www.videoportal.sf.tv/video?id=be42fef0-d93d-4609-8b16-ce017bdd2446

Tell me that the chubby Mr. Rappaz is being undernourished in prison! ..Maurice.