Hunger strikes can raise ethics issues for doctors
　

By Shelley Huang
STAFF REPORTER
Monday, Nov 24, 2008, Page 3

The wave of recent hunger strikes by detained former and current government officials, including former president Chen Shui-bian (陳水扁), Yunlin County Commissioner Su Chih-fen (蘇治芬) and Chiayi County Commission Chen Ming-wen (陳明文) has not only attracted widespread media attention, but also raised ethical problems for doctors dealing with the hunger strikers.

On Nov. 16, Chen Shui-bian was rushed to the Far Eastern Memorial Hospital after complaining of soreness and discomfort in his chest. It was the fifth day of his hunger strike. He was transferred to Taipei County Hospital in Banciao (板橋) the next day for security reasons.

Yang Chang-bin (楊長彬), the hospital deputy director, said at the time that Chen Shui-bian had high levels of ketone in his blood and was experiencing bloating.

Hunger strikers experience serious risks to their health after three to five days, when the glucose that the body relies on for metabolic processes runs out and the body turns instead to processing fats for energy, said Ho I-chen (何一成), deputy director of the ReShining Clinic.

Fasting or hunger striking may cause elevated levels of ketone, which the brain relies on during lipid synthesis and for energy, Ho said.

When ketone levels are too high, it can lead to ketoacidosis, a potentially lethal condition, he said.

By supplementing the body with glucose, such as through intravenous infusion, the body’s metabolism returns to normal and ketone levels drop very quickly, he said.

When a serious risk is posed to a hunger striker’s health, methods of stabilizing blood pressure and blood sugar levels include feeding nutrients through a nasogastric tube and intravenous infusion of glucose and saline, he said.

A nasogastric tube is a clear plastic tube that is inserted through the nose, down the back of the throat, through the esophagus and into the stomach.

The tube can be used to remove air and digestive juices from the stomach and has also been used as a feeding tube for patients in a coma, Ho said.

There have been many recorded instances in countries around the world of prisoners and detainees being force-fed while in prison, but the practice has been deemed unethical by the World Medical Association (WMA).

Article 21 of the WMA’s Declaration on Hunger Strikers, updated in October 2006, states: “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.”

“[Glucose intravenous infusion], if performed under the consent of the patient, is not a form of forcible feeding,” said Wu Chun-ying (吳俊穎), attending physician of Taichung Veterans General Hospital’s Division of Gastroenterology and Hepatology and a former member of the Bureau of Health Promotion’s Ethics Committee.

However, “intravenous infusion is only a temporary measure and is not a long-term substitute for food intake,” Wu said.

“Forcible feeding is defined as forcing food into the patient’s mouth against the patient’s will,” he said.

If the physician performs forcible feeding without the patient’s consent, he has violated the Standard Operating Procedure of health care, he said.

If the patient is not in critical condition and is still conscious and capable of making decisions regarding his or her own health, then the physician should communicate with the patient about his or her condition and discuss the available treatments and the consequences of choosing to receive or not receive certain treatments, Wu said.

However, in the case of an emergency where the patient could die if immediate measures are not taken, the physician must evaluate which method is the most appropriate to protect the life of the patient, he said.

In the case of hunger strikes, insertion of a nasogastric tube is preferred over force-feeding through the mouth, which is unsafe as it can trigger gagging reflexes and result in suffocation, he said.

The physician must perform such measures in order to preserve the patient’s life, even if it is against the patient’s will, but “only in times of emergency,” he said.

“The practice of force-feeding is not clearly detailed in the current medical laws in Taiwan,” said Lin Yi-lung (林義龍), chairman of the Association of Medical Law in Taichung. “Since it is not clearly punishable by law, the issue becomes one of ethics.”

Medical personnel in Taiwan are not bound by WMA declarations, which are not legally binding, he said.

“When a criminal or a person suspected of criminal activity has been detained or imprisoned and refuses to eat, the detention center cannot allow the hunger strike to go on if the person’s life is in critical condition,” Lin said.

“A [prisoner or detainee] who goes on hunger strike is enacting his right of resistance against the government. But if in doing so the person puts his life in danger, then the detention center has the right and duty to save the person’s life, even if forcible measures must be taken,” Lin said.

“In this case, they are not violating the law,” Lin said.

The detention center that sends the detainee to the hospital authorizes the hospital to provide health care to the patient in order to save his or her life, in which case the detention center acts on behalf of the patient to give consent for receiving treatment, he said.

In this case, neither the detention center nor medical personnel have violated any law concerning forced medical treatment, he said.

Chen Shui-bian’s lawyer Cheng Wen-long (鄭文龍) and Far Eastern Memorial Hospital spokesperson Sophie Hsieh (謝淑惠) both confirmed that the former president had consented to intravenous infusion when he was taken to the hospital on Nov. 16.

Strawberries stage ‘memorial service’ for human rights
　

INVITATIONS: Student protesters sent notices of the death of the nation’s human rights to President Ma Ying-jeou and other politicians across party lines
　

By Flora Wang
STAFF REPORTER
Monday, Nov 24, 2008, Page 3
　

The Wild Strawberry Student Movement held a mock “memorial service” yesterday for human rights at the National Taiwan Democracy Memorial Hall.

Wearing white head coverings and face masks, a few dozen protesters gathered at Liberty Square, carrying placards that read “Freedom of speech” and “Free from violence” and offering their “condolences” to rights they said have been trampled by the government.

The memorial service “symbolizes our sadness toward [the government’s] violations of human rights during [Association for Relations Across the Taiwan Strait Chairman] Chen Yunlin’s [陳雲林] stay in Taiwan,” said Lo Shih-hsiang (羅士翔), a spokesman for the movement.

The students began their silent sit-in on Nov. 6 to protest what they called excessive police force against demonstrators who opposed Chen’s visit between Nov. 3 and Nov 7.

After police removed the students from outside the Executive Yuan, they moved their demonstration to the square on Nov. 7.

The group has continued its demonstrations at the square every day, calling for immediate amendments to the Assembly and Parade Law (集會遊行法) to scrap regulations requiring police approval for demonstrations.

The students had sent out “notices of death” of the nation’s human rights to politicians across party lines, including President Ma Ying-jeou (馬英九), Premier Liu Chao-shiuan (劉兆玄), Chinese Nationalist Party (KMT) Chairman Wu Poh-hsiung (吳伯雄) and Democratic Progressive Party (DPP) Chairperson Tsai Ing-wen (蔡英文), and to National Police Agency Director-General Wang Cho-chiun (王卓鈞) and National Security Bureau Director-General Tsai Chao-ming (蔡朝明). Only Tsai attended the mock funeral.

When approached by reporters, Tsai said she wanted to encourage the students, but that she did not want their demonstration to be labeled as an activity organized by the pan-green camp.

Speaking on the assembly law, Tsai said the former DPP administration “failed to pay enough attention or push for amending or abolishing the Assembly and Parade Law. We feel very sorry.”

The students also expressed opposition yesterday to a requirement by the Ministry of Justice that schools nationwide recruit personnel to implement government ethics policies.

The ministry sent formal notices to all government branches asking schools, government agencies and state-run enterprises to recruit the personnel.

The move drew widespread criticism across party lines, with many legislators calling the measure reminiscent of the Martial Law era, when all schools had human resource units in charge of spying on public servants and reporting back to the ministry.

The DPP caucus said the ministry’s requirement may violate the 1992 Act Governing the Establishment of the Government Employee Ethics Units and Officers (政風機構人員設置條例), which says the legislature, local councils, military agencies and public schools do not need to establish such units.

“The students of the Wild Strawberry Student Movement are worried that schools ... will be threatened by the White Terror again,” the students said in a press release.

China rebuts ‘slanderous’ report on torture

AP, BEIJING
Monday, Nov 24, 2008, Page 5
　

The Chinese Foreign Ministry rejected a UN panel’s report alleging that police in China used torture, calling the accusations “untrue and slanderous” and saying some panel members were prejudiced against Beijing.

In a 15-page report released on Friday in Geneva, the UN Committee against Torture said it was “deeply concerned about the continued allegations, corroborated by numerous Chinese legal sources, of the routine and widespread use of torture and ill-treatment of suspects in police custody, especially to extract confessions or information to be used in criminal proceedings.”

Chinese Foreign Ministry Spokesman Qin Gang (秦剛) said some members of the committee were “prejudiced” against China, had ignored evidence presented by the Chinese government on the issue of torture and were citing unverified or fabricated information.

“They put untrue and slanderous comments into the committee’s final conclusion, which lacks justice and professional objectiveness, against which [sic] China firmly opposes,” Qin said in a statement on the ministry’s Web site.

Qin did not elaborate on his claims.

The UN report alleged the use of torture in police custody in present and past incidents.

It called for a “full and impartial” investigation into those who were detained in the June 1989 military assault on student-led protests in Tiananmen Square and urged the Chinese government to compensate and apologize to their families.

The US State Department said last year that between 10 and 200 Tiananmen activists were estimated to still be in prison.

Hundreds of people are believed to have been killed in the crackdown.

The panel urged Beijing to abolish all forms of forced labor, which are imposed for minor crimes and often without trial. China should also stop the use of “secret prisons” and the harassment of lawyers and human rights campaigners who highlight abuses, and should investigate the March crackdown on anti-government forces in Tibet, during which exile groups say at least 140 people were killed and more than 1,000 detained, the panel said.

While acknowledging that China has made an effort to outlaw torture in some instances, the panel said Beijing still had to do more to meet its obligations under the 1984 UN Convention Against Torture.

Qin said China has fulfilled the obligations set out in the UN convention and that it continued to make efforts to address the issue.

Ma has to answer to the public
　

By Chen Mao-hsiung 陳茂雄
Monday, Nov 24, 2008, Page 8

The government has decided to hand out consumer vouchers to every citizen, including the wealthy. It is the first policy of President Ma Ying-jeou’s (馬英九) to receive more praise than criticism.

If the scheme had taken the form of a tax rebate, the policy would have only served the rich. If the wealthy were excluded from the scheme, those able to consume would not participate and most vouchers would be exchanged for cash at a lower rate. This would not stimulate consumer spending and would be considered part of a social welfare program at best.

Given that household sizes vary, it would have been unfair if the distribution process had been based on households. Distributing the vouchers to individuals was the correct decision. Although the proposed budget of NT$82.9 billion (US$2.5 billion) will not necessarily boost consumption, it could reduce public resentment.

The most serious problem facing the country is its withering consumer market. Since soaring unemployment is attributed mainly to businesses closures, the government should give first priority to stimulating consumer spending. It is still questionable whether the vouchers will be able to rescue the economy. After all, some people might convert their vouchers into cash and save the money.

The real purpose of the vouchers is to reduce social resentment. Everybody knows that the government is trying to save the economy, although the plan, despite the multi-billion dollar budget, will serve more as an advertisement than a real stimulus.

The Ma government’s biggest weakness is that it does not know how to calm public complaints. This is the first time it has found a way to effectively reduce public dissatisfaction, but unfortunately there are many more complaints for the administration to work on.

Most Taiwanese are finding it hard to make ends meet, but they never consider the reasons behind that fact and only want someone to take responsibility. When a disaster happens, natural or man-made, the public always expects someone to take responsibility.

Ma believes that his administration is not in the wrong, and therefore should not be held accountable for the economic meltdown, and this has added more fuel to public indignation.

When the Pachang Creek (八掌溪) tragedy happened in 2000, then-vice premier Yu Shyi-kun stepped down to take political responsibility. Former minister of education Huang Kun-huei (黃昆輝) did the same when an auditorium roof collapsed at National Feng-yuan Senior High School in 1983. When a political appointee takes office, he or she should be prepared to step down, unlike civil service bureaucrats. If Ma continues to treat political officials as civil officials, it will be hard to reduce public resentment.

Pan-blue politicians and supporters do not like former president Chen Shui-bian (陳水扁). Still, he managed to deal with political officials in ways Ma cannot do. Some pan-green individuals have complained that Chen was too ruthless because whenever something happened, he would sacrifice his ministers or aides.

Political appointees don’t always step down because they made a mistake but rather to take responsibility to help reduce public anger. Where Chen’s concern was the reaction of voters and using his administration as a tool to win supporters, Ma’s only concern is his administration and the hope that it will be as efficient as possible.

Grassroots officials should take care of their staff in order to bring out the best in the team. Ma has forgotten that he is responsible for the entire nation, not just his administration. Three Cabinet officials have been impeached by the Control Yuan, but the premier said they were only reprimanded. There are only two kinds of punishment for political officials — discharge and reprimand. So for a political appointee to be reprimanded is serious, no matter what the premier said. Ma’s protection of his administration will only make the public think that all he really cares about is his team.

Ma asked public officials not to accept wreaths and to eat lunch boxes rather than lunching at restaurants. Many people also asked that he not contain consumer spending. The government’s decision to issue consumer vouchers means that it has understood the economics of consumption. Let’s just hope it will start understanding other issues as well.

Chen Mao-hsiung is a professor at National Sun Yat-sen University.

Taiwan doesnt’ want puppet leader

Monday, Nov 24, 2008, Page 8

Four cross-strait agreements were signed at the meeting between Straits Exchange Foundation (SEF) Chairman Chiang Pin-kung (江丙坤) and Association for Relations Across the Taiwan Strait (ARATS) Chairman Chen Yunlin (陳雲林) earlier this month. Last Monday, Chiang and Mainland Affairs Council Chairwoman Lai Shin-yuan (賴幸媛) finally gave the legislature a belated report on the pacts. This rash attempt to dodge public supervisionwas strongly criticized in the legislature.

The fact is that both the form and content of the Chiang-Chen meetings were conducted within the framework of the Chinese Nationalist Party (KMT)-Chinese Communist Party (CCP) communication platform. And they are pressing on: The next meeting within this framework will be held in Shanghai next month as the two parties prepare to establish a cross-strait economic framework. It is clear that they want to continue to manipulate public perception of the Chiang-Chen talks. If President Ma Ying-jeou (馬英九) continues to behave like a puppet, he will end up like the last Chinese emperor Puyi (溥儀), living in exile in a puppet state.

The attempt to solve the cross-strait issue through peace talks between the KMT and the CCP has been part of China’s united front strategy ever since then-chairman of the Standing Committee of China’s National People’s Congress Ye Jianying (葉劍英) proposed his nine principles for peaceful unification with Taiwan in 1981. This wishful thinking is based on the idea that the Chinese civil war is not over and that Taiwan’s sovereignty and democratization must be undone.

This view has remained constant through Deng Xiaoping’s (鄧小平) six points and Jiang Zemin’s (江澤民) eight points to the communiques issued by Chinese President Hu Jintao (胡錦濤) and former KMT chairman Lien Chan (連戰) and Hu and People First Party Chairman James Soong (宋楚瑜).

Faced with China’s attempts to ignore the fact that Taiwan is an independent and sovereign state, former president Chiang Ching-kuo (蔣經國) refused to have any contacts, negotiations or compromises with China, his so-called “three noes.” Former president Lee Teng-hui (李登輝) insisted on talks between two equal states in his six points, which led to the birth of the SEF and ARATS.

However, after the KMT’s return to power, Ma resumed talks following a decade-long hiatus. But what is left of the old framework is only an empty shell, and the promise that second track party to party talks or private exchanges would not override official talks and replace the central government’s role has been proven to be just empty talk.

The first Chiang-Chen meeting in Beijing in June and their second meeting in Taipei this month were both orchestrated by the KMT-CCP communication platform. Before the four agreements signed this month have been reviewed by the legislature, the government has already decided to hold the Shanghai meeting, and it plans to invite more than 100 people from Taiwan’s financial, industrial and commercial sectors along with Chinese industrialists to provide policy guidance.

We can no longer talk about merely allowing private enterprise to pressure the government or letting the party lead the government — pressing on like this before the results of the first meeting have been dealt with is evidence that business is all-important and that what ever the party says goes, reducing Ma to a rubber stamp.

The issues Lien will discuss as the leader of the delegation to the Shanghai meeting — allowing financial institutions from each side to establish cross-strait entities, cross-strait cooperation in financial supervision and allowing Chinese investors to invest in Taiwan — are all issues that still haven’t been properly evaluated by Ma or his government.

On one hand, the KMT is trying to make the government do the impossible, while on the other hand, it is cheering on the CCP and thoroughly destroying the conditions for negotiations. How will the SEF and the ARATS be able to negotiate in the future? Even more serious, on what grounds do these two despotic parties neglect consulting with the public and ignoring the official channels between the two governments, instead making their own unilateral decision on issues that involve the interests and well being of the general public?

This situation is repeated time and again which raises the question of whether Ma only is capable of suppressing the public with the police force and letting the Cabinet override the legislature while he capitulates before the KMT-CCP communication platform. It is not very strange that someone has said that Ma is “truly” stupid when it comes to China and only “acts” stupid when it comes to Taiwan.

In June, the CCP Politburo held an extended meeting in Beidaihe, which included representatives from all agencies involved with Taiwan: the United Front Work Department, the Chinese People’s Political Consultative Conference, the CCP Central Committee’s General Office and the Taiwan Affairs Office. The meeting concluded that economic, cultural and social exchanges with Taiwan should be expanded until 2012 to increase dependence, and that after Ma’s re-election in 2012, China will immediately propose political demands in order to resolve the Taiwan issue before 2016.

The meeting also specified three targets for intensified united front work: Those with political power, those with cultural knowledge and the wealthy. Looking at recent developments, one cannot help but wonder if several powerful and rich Taiwanese already are humming the Chinese tune.

In democracies, relations between states follow clear rules. If party exchanges become the fulcrum around which China’s control and manipulation of Taiwan turns, then what is the difference between the KMT and any other fifth column?

Ma claims that military and foreign affairs are the president’s responsibility, but if he continues to be unable to stop the KMT-CCP communication platform from growing more powerful, he may not necessarily become a “last emperor,” but will be more like a child emperor under Hu’s supervision. Even if he may be happy seeing himself that way, the Taiwanese public will follow their own will. And they do not intend to become slaves in a vanquished country.