Incarcerated Patients and Equitability: The Ethical Obligation to Treat Them Differently

Fuller, Lisa; Eves, Margot M.

doi:10.1086/jce2017284308

Cited by 8 publications

(12 citation statements)

References 7 publications

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“…k Fuller and Eves articulate the corresponding ethical conflicts in such a scenario. 14 Although incarcerated patients have different rights and expectations in the corrections setting, they are still entitled to fairness and nondiscrimination when obtaining healthcare. 14 Thus, if corrections staff or wardens intervene in the medical decision-making process without legal authority, this violates ethical principles of respect for persons and protection of prisoners as a vulnerable population.…”

Section: Incarcerated Patients Who Lack Decision-making Capacitymentioning

confidence: 99%

“…14 Although incarcerated patients have different rights and expectations in the corrections setting, they are still entitled to fairness and nondiscrimination when obtaining healthcare. 14 Thus, if corrections staff or wardens intervene in the medical decision-making process without legal authority, this violates ethical principles of respect for persons and protection of prisoners as a vulnerable population. 14 Moreover, respecting the patient's ability to make his or her own healthcare decisions (or follow the surrogacy hierarchies if a patient lacks decisional capacity) preserves critical ethical values in the healthcare interaction.…”

Section: Incarcerated Patients Who Lack Decision-making Capacitymentioning

confidence: 99%

“…Despite some states that legally permit staff in the correctional system or a physician from serving as a medical decision-maker if the patient lacks decision-making capacity, several authors note that this raises significant ethical conflicts. 10,12,14,17 Unlike people in a close relationship with the patient, corrections staff or physicians may not be aware of the patient's goals, preferences, and values, which would undermine the ethical value of respect. More importantly, corrections staff operate with a different set of values and competing duties.…”

Section: Special Considerations For Incarcerated Patientsmentioning

confidence: 99%

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Medical decision-making when the patient is a prisoner

Larsen

Drabiak

2022

Clinical Ethics

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Although prisons provide on-site primary care, the corrections system relies on external hospitals to provide a variety of healthcare services. Compared to the general population, incarcerated patients experience higher rates of chronic medical conditions, mental illness, substance abuse, cancer, traumatic brain injury, assault, and communicable disease. Certain specialties of clinicians are likely to encounter patients who are incarcerated, which makes it important for clinicians to understand how medical decision-making may differ when the patient is a prisoner. The corrections system retains custody of inmates and is responsible for their welfare, including facilitating necessary medical care. However, this does not permit corrections personnel or a warden to automatically assume the role of the patient's medical decision-maker. Except for narrow exceptions, prisoners do not lose their rights to medical decision-making. In some instances, corrections staff or the prison warden have improperly asserted authority to act as the patient's medical decision-maker, such as when the patient lacks decision-making capacity. This violates ethical principles of bodily integrity, respect, and fairness. This paper provides an overview of medical decision-making for incarcerated patients, how surrogate decision-maker hierarchies apply to incarcerated patients without decision-making capacity, and special considerations for this subset of patients.

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Section: Incarcerated Patients Who Lack Decision-making Capacitymentioning

confidence: 99%

Section: Incarcerated Patients Who Lack Decision-making Capacitymentioning

confidence: 99%

Section: Special Considerations For Incarcerated Patientsmentioning

confidence: 99%

See 1 more Smart Citation

Medical decision-making when the patient is a prisoner

Larsen

Drabiak

2022

Clinical Ethics

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“…If a patient has no available family or friends to serve as a surrogate (a so-called unrepresented patient), corrections staff may assert that they can act as decision makers without being formally designated as such. 7 When employees of correctional facilities assume health care decision-making authority for incarcerated people, however, ethical conflicts can arise. The primary duty of correctional staff is to maintain custody and control of incarcerated people.…”

Section: Challenges For Selecting Surrogatesmentioning

confidence: 99%

“…They may incorrectly infer that family or friends are unable to act as surrogates and thus follow decision-making practices that they would not use for patients outside correctional facilities. If a patient has no available family or friends to serve as a surrogate (a so-called unrepresented patient), corrections staff may assert that they can act as decision makers without being formally designated as such …”

Section: Challenges For Selecting Surrogatesmentioning

confidence: 99%

Surrogate Decision Making for Incarcerated Patients

2019

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When patients are too ill to make their own health care decisions and lack a previously designated decision maker, identifying the appropriate surrogate can be a complex process. For example, clinicians may use surrogacy ladders (hierarchical lists of individuals who could serve as decision makers), which are delineated in state statutes. 1 Although patients with incapacitating illness are inherently vulnerable, there are additional considerations for people who are incarcerated, and these may not be addressed in state laws. We discuss the selection of surrogates for incarcerated patients and who should or should not serve in this role.In the United States in 2017, approximately 2.1 million people were incarcerated in jails or prisons, and the median age is increasing. 2,3 The prevalences of infectious diseases, traumatic brain injury, and severe mental illness are high. 3 Some people may lose decisional capacity at some point during their incarceration, either temporarily or permanently.

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Decision-Making for Hospitalized Incarcerated Patients Lacking Decisional Capacity

Batbold,

Duke,

Riggan

et al. 2024

JAMA Intern Med

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ImportanceIncarcerated patients admitted to the hospital face threats to their rights to privacy and self-determination in medical decision-making. Little is known about medical decision-making processes for hospitalized incarcerated persons who lack decisional capacity.ObjectiveTo characterize the prevalence of incapacity among hospitalized incarcerated patients and describe the decision-making processes, including who served as surrogate decision-makers, involvement of prison employees in medical decisions, and ethical concerns emerging from the patients’ care.Design, Setting, and ParticipantsRetrospective descriptive and qualitative study of medical records for all patients admitted from prison for at least 24 hours between January 1, 1999, and September 1, 2019, at a large Midwestern academic medical center. Data analysis was performed from March 15, 2021, to December 14, 2022.Main Outcomes and MeasuresPrevalence of prison-to-hospital admissions for patients with a loss of capacity and characteristics of medical decision-making.ResultsDuring the 20-year study period, 462 patients from the prison were admitted to the hospital, totaling 967 unique admissions. Of these, 131 admissions (14%) involved patients with a loss of capacity and 43 admissions (4%, representing 34 unique patients) required surrogate decision-making. Ten of these patients had advance directives. Surrogate decision-makers often faced decisions about end-of-life care (n = 17) or procedural consent (n = 23). A family member was identified as surrogate decision-maker in 23 admissions. In 6 cases with a kindred surrogate, additional consent was requested from a prison employee. In total, prison employees were documented as being present during or participating in major medical decisions for half of the admissions. Five themes emerged from thematic analysis: uncertainty and misinformation about patient rights and the role of prison employees in medical decision-making with respect to these two themes, privacy violations, deference to prison officials, and estrangement from family and friends outside of the prison.Conclusions and RelevanceIn this first in-depth description, to date, of decision-making practices for hospitalized incarcerated patients lacking decisional capacity, admissions of these patients generated uncertainty about their rights, sometimes infringing on patients’ privacy and autonomy. Clinicians will encounter incarcerated patients in both hospital and clinic settings and should receive education on how to support ethically and legally sound decision-making practices for this medically vulnerable population.

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Incarcerated Patients and Equitability: The Ethical Obligation to Treat Them Differently

Cited by 8 publications

References 7 publications

Medical decision-making when the patient is a prisoner

Medical decision-making when the patient is a prisoner

Surrogate Decision Making for Incarcerated Patients

Decision-Making for Hospitalized Incarcerated Patients Lacking Decisional Capacity

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