Health Care Ethics Behind Bars

Centre for Health Care Ethics

Lakehead University

March 2012

Disclaimer

• The views, opinions and information expressed here are not designed to represent those of any employer, professional or educational affiliation.

• The presenter declares no conflict of interest.

Thank you to the valued panel members…

• George

• Stephanie

• Denise

Behind Bars…Why not?

• Are medical confidentiality, patient’s consent, and health care professionals’ duties to care compatible with safety and security in prison?

• What better place to challenge our understanding of ethical theories and principles?

• What better place to explore being ethical in our work with others?

My definition:

• is relational

• How we decide we are going to behave…

Let’s put the seniors in jail, and the criminals in a nursing home.

• This way the seniors would have access to showers, hobbies, and walks, they’d receive unlimited free prescriptions, dental and medical treatment, wheel chairs etc. and they’d receive money instead of paying it out.

• They would have constant video monitoring, so they could be helped instantly, if they fell, or needed assistance. Bedding would be washed twice a week, and all clothing would be ironed and returned to them.

• A guard would check on them every 20 minutes, and bring their meals and snacks to their cell. They would have family visits in a suite built for that purpose.

• They would have access to a library, weight room, spiritual counseling, pool and education.

• Simple clothing, shoes, slippers, P.J.’s and legal aid would be free on request. • Private, secure rooms for all, with an exercise outdoor yard, with gardens. • Each senior could have a P.C. a T.V. radio, and daily phone calls.

There would be a board of directors to hear complaints, and the guards would have a code of conduct, that would be strictly adhered to.

• The “criminals” living in the nursing home would get lousy food, be left all alone, and unsupervised, lights off at 8pm, and showers once a week, live in a tiny room, pay $3,000 per month and have no hope of ever getting out.

http://opinion.financialpost.com/2010/11/11/lets-put-seniors-in-jail-and-criminals-in-nursing-homes/

History Lesson

“Prison doctors were originally employed by the state to mediate the use of punishment and decide which prisoners should be exempt from certain aspects of the harsh prison regime” (Gordon,

1922, cited in Birmingham, Wilson, & Adshead, 2006, p.5)

What is… Health Care Behind Bars?

• Hidden community

– Vulnerable population

– High risk population

• Basic health care services

• Urgent & emergency health care

• Health care team

• Health promotion & disease prevention

Typical Inmate

• Disproportionally from poor, under-educated, minority groups

• Poor access to health care services

• High environmental and social health risk factors

• More prevalent rates of chronic disease, infectious disease, mental illness, substance abuse

Criminal Justice System

• Jails- shorter stay, but back in the community

• Provincial Correctional Institutions

• Federal Correctional Institutions

• Police officers, courts, probation & parole…

Priorities Behind Bars

• Security & surveillance

• Safety within the institution

• Safety of the public

• Rehabilitation or Punishment

• Cost (prisoners are expensive!)

– Super-jails

Duties of Care for HCP’s

• Providing holistic care & caring

• Trust & respect

• Dignity

• Compassion & empathy

• Supporting autonomy, choice, independence

• Promote beneficence and minimize maleficence

• Advocating for justice and equity

Holistic Health Care

Holistic Needs of Inmates: Care in Custody

• Acute & chronic disease treatment & management

• Trauma & emergency injuries

• Substance abuse treatment

• Mental and emotional health issues

• Spiritual and cultural needs

Profile of a Typical Inmate

Bad behaviour or bad people?

Where to begin… where to go from here?

Acknowledging Other’s Realities

“Hey, nurse!”

Ethical Issues in Health Care Behind Bars

• Autonomy

• Beneficence

• Non-maleficence

• Justice

Case Study Example

• “Lucy Hornshaw is surrounded by murderers and sex offenders every day in her job. She is a nurse and health care manager… where all 189 inmates have life sentences…more than half are over the age of 45…There is a high incidence of chronic disease and complex conditions, including diabetes and chronic obstructive pulmonary disease. ‘Because of the prisoners’ lifestyles you can add ten years to their ages- so someone who is 50 effectively has the health needs of someone…who is 60…” (Duffin, 2010, p. 16)

Autonomy

• Right to be informed

• Use of restraints

• Right to Choice

– 1 doctor

– 1 psychiatrist

– 1 nurse on duty

Limits of Confidentiality in Prison

• Limits to physical privacy

• Admission of guilt for crimes committed

Beneficence

• Good of the individual or Good of the Institution?

• Good of the individual or Good of the public?

Public Health Perspective

• Sexually transmitted infections (STI’s- syphilis, gonorrhea, chlamydia)

• Tuberculosis (TB)

• HIV/AIDS

• Hepatitis B & C

• Continuity of care with treatments

HIV & Incarcerated Persons

• US study from 2004: – HIV prevelence 5x greater, AIDS 4x greater

– Testing for HIV is completely voluntary, but often routine

– 2/3 of inmates with HIV diagnosed and had treatment initiated in prison

– Recent studies indicate a high level of drug resistant HIV in this population

– Monitored reincarceration within 3+ months, blood work revealed benefits of treatment lost

Opioid Replacement Therapies & Harm Reduction Strategies

• Methadone Maintenance Treatment

– Risk of diversion within the prison

– Initiation within prisons floods community methadone clinic resources

• Suboxone (buprenorphine and naloxone)

• Needle exchange programs

Non-maleficence

• Use of health care unit for non-health care purposes

• Segregation of mental ill offenders

• Professionals’ ability to remain objective, impartial, neutral?

• Inequities in care due to fears related to inquests and/or legal actions

Justice

• Jails as mental health facilities?

“Guidelines for good medical practice do not reflect the complex reality of the ethical problems that

arise in prison. Perhaps the best a doctor working in prison can do is realise that there are ethical

dilemmas everywhere, try to recognise them and feel the tension.”

(Birmingham, Wilson, & Adshead, 2006, p.4)

A number of factors to consider…

Impacts of violence…

Impacts of poverty…

“In” prison or “Out” of society?

Mental Health Issues

• Globe and Mail, Nov 2010:

– The percentage of mentally ill individuals in both systems (federal and provincial) is growing by 5-10 per cent each year, according to psychiatric experts and available statistics.

• http://www.theglobeandmail.com/news/national/ontario/mentally-ill-

offenders-swamping-prisons/article1803550/ • April 2011:

http://www.theglobeandmail.com/news/national/ontario/ontario-judge-rules-mentally-ill-can-be-held-in-jails/article1988905/

Aboriginal Issues

• “2007/2008, Aboriginal adults accounted for…18% admitted to provincial and territorial custody…”

• “Aboriginal females are more represented among the female correctional population than are Aboriginal males within the male correctional population”

• “Certain studies (LaPrairie, 2002; Cattarinich, 1996) have put forth that the representation of Aboriginal people in correctional services would be less pronounced if factors such as age, level of education and employment status were taken into account”

http://www.statcan.gc.ca/pub/85-002-x/2009003/article/10903-eng.htm

Opportunities for Positive Changes

• Telemedicine

• Ongoing ethics education for all staff, whether health care professionals or not (Custody & Caring, Biennial Intn’l Conference held in Saskatchewan Oct 2011)

• Recognizing the impact of the social determinants of health

• Political and legal changes

• Collaboration during incarceration and post-discharge

References

• Anno, B.J. & Spencer, S.S. (2006). Medical ethics and correctional health care. In M. Puisis (Ed.), Clinical Practice in Correctional Medicine (2nd edition). Philadelphia, PA: Elsevier.

• Austin, W. (2001). Relational ethics in forensic psychiatric settings. Journal of Psychosocial Nursing & Mental Health Services, 39(9), 12-17.

• Birmingham, L., Wilson, S., & Adshead, G. (2006). Prison medicine: Ethics and equivalence. British Journal of Psychiatry, 1884-6. DOI: 10.1192/bjp.bp.105.010488

• Dolan, K. A., Shearer, J., White, B., Zhou, J., Kaldor, J., & Wodak, A. D. (2005). Four-year follow-up of imprisoned male heroin users and methadone treatment: Mortality, re-incarceration and hepatitis C infection. Society for the Study of Addiction, 100, 820-828. doi:10.1111/j.1360-0443.2005.01050.x

• Duffin, C. (2010). Doing time: Health care in the criminal justice system. Nursing older people, 22(10), 14-18.

• Hammett, T. M., Gaiter, J.L., & Crawford, C. (1998). Reaching seriously at-risk populations: Health interventions in criminal justic settings. Health Education and Behavior, 25(1), 99-120.

• Hill, T. (2008). Bioethics and morality behind bars. Academic and Health Policy Conference on Correctional Health. Quincy, Massachusetts.

• Paris, J.E. (2008). Medicine and society: Why prisoner’s deserve health care. American Medical Association Journal of Ethics, 10(2), 133-115.

• Shields, K. E., & de Moya, D. (1997). Correctional health care nurses’ attitudes towards inmates. Journal of Correctional Health Care, 4(1), 37-59.

• Springer, S. A., Pesanti, E., Hodges, J., Macura, T., Gheorgeh, D., & Altice, F. L. (2004). Effectiveness of antiretroviral therapy among HIV-infected prisoners: Reincarceration and the lack of sustained benefit after release to the community. Clinical Infectious Diseases, 30(12), 1754-1760.

Web Resources

• Why prisoners’ deserve health care by Joseph E. Paris: http://virtualmentor.ama-assn.org/2008/02/msoc1-0802.html

• Hard time and health care: The squeeze on medicine behind bars by E. Bernadette McKinney: http://virtualmentor.ama-assn.org/2008/02/msoc2-0802.html

• Ethical dilemmas in correctional nursing: http://correctionalnurse.net/2009/10/01/ethical-dilemmas-in-correctional-nursing/

• CBC Report: Prisons & Mental Health: http://www.cbc.ca/thecurrent/2011/04/01/prisoners-mental-health/index.html