Unique challenges face clinicians delivering care behind bars

AMA Wire
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The United States incarcerates a greater proportion of its population than any other nation on Earth, including disproportionate shares of racial and ethnic minorities. Clinicians in correctional settings are uniquely challenged when trying to offer good care while respecting patients’ autonomy, and must respond to the fact that patients who experience incarceration have poorer health outcomes and shorter life expectancy.

Take a moment to consider this question: A patient in a county jail shows symptoms of possible cognitive impairment. Should his physician inform the patient’s legal counsel?

  • Yes, even if the patient does not consent or lacks capacity to consent.
  • Yes, but only with the patient’s consent.
  • The physician should inform the patient but not the patient’s legal counsel.

Give your answer and find responses to this question in the September issue of the AMA Journal of Ethics®, which features numerous perspectives on incarceration and correctional health care. Writers contributing to this issue of the journal explore the complex ways in which incarceration can influence patients’ health and health care both during and after their time in prison or jail, as well as the challenges clinicians face in navigating their responsibilities to these vulnerable patients both in the correctional setting and in the community.

Articles include:

Ethics Students Go to the Jail.” Clinical ethics students, who were either in a bioethics master’s degree program or in the fourth year of medical school, spent two days observing health care in an urban jail as part of an educational initiative. Students submitted reflections on their experience, in which they drew attention to concerns about privacy, physical restriction, due care, drug addiction, mistrust, and the conflicting expectations that arise when incarcerated people become patients.

Surgery in Shackles: What Are Surgeons’ Obligations to Incarcerated Patients in the Operating Room? Incarcerated patients often require surgery outside of the correctional setting. In such cases, they may be shackled to the operating table in the presence of armed corrections officers who observe them throughout the procedure. In this circumstance, privacy protection—central to the patient-physician relationship—and the need to control the incarcerated patient for the safety of health care workers, corrections officers and society must be balanced. 

How to Talk with Patients about Incarceration and Health.” While clinicians are taught how to discuss ways that culture, religion or sexuality can affect health outcomes, they are not instructed on how to talk about incarceration history with patients when it might be affecting their health. This case scenario presents a “structural vulnerability” screen, a theoretical approach that clinics or individuals can take to better understand how structures of power—for example, mass incarceration—directly and indirectly affect patients.

Compassionate Release Policy Reform: Physicians as Advocates for Human Dignity.” A rapidly aging correctional population has led to an increasing number of patients with serious progressive and terminal illnesses in correctional settings. “Compassionate release” describes a range of policies offering early release or parole to incarcerated patients with serious or debilitating illnesses. This article argues that physicians have an obligation to advocate for the appropriate application and use of compassionate release.

What the Code says

The AMA Code of Medical Ethics’ Opinions Related to Health Care for Incarcerated People.” The relationship between clinicians and incarcerated patients provides unique challenges for informed consent, respect for autonomy and quality health care delivery. While the AMA Code of Medical Ethics does not speak directly to improved access to health care for incarcerated patients, it does speak to the role of the clinician in protecting patients from health care-related mistreatment in the correctional system.

The journal’s September podcast explores various perspectives on incarceration and correctional health care. Guests include: Troy Williams, founder of San Quentin Radio; Dan McGuire, a second-year physician assistant student who works in a correctional setting; and Lisa Puglisi, MD, the co-director of a New Haven, Connecticut, clinic for people transitioning to the community after prison.

Case study discussion

Through Sept. 18, visit the AMA Journal of Ethics Discussion Forum to consider a case study in which an incarcerated patient refuses her insulin injections unless she receives gabapentin, which she says she was prescribed outside the correctional setting for chronic back and neck pain. Physicians are discouraged from prescribing gabapentin because of its risk for cultivating dependence and the risk of divergence within the prison. How should the patient’s physician respond?

Join Tom Peteet, MD, and Matt Tobey, MD, MPH, the authors of a commentary on this case, for this dialogue about how clinicians should weigh autonomy and health justice in caring for incarcerated patients, while accounting for the inherent restrictions of the setting. The discussion is open to AMA members and non-members. Visit the discussion page.

Submit manuscripts and artwork

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

The Conley Art of Medicine and Ethics Essay contests for medical students, residents, and fellows is now open through Sept. 25, with $3,000 prizes for winning entries and up to two $1,000 honorable mentions.

The journal is currently accepting applications from medical students, residents and fellows (MDs or DOs) in U.S.-based programs to serve as theme issue editors for monthly issues to be published from November 2018 through October 2019. Find out more.

A look ahead

Upcoming issues of the AMA Journal of Ethics will focus on the roles of clinicians in access to safe water as well as the ethics of collaborative health systems design. Sign up to receive email alerts when new issues are published.

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