Medical decision-making when the patient is a prisoner

Abstract

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.

Best practice guidelines for evaluating patients in custody in the emergency department

“…The US Supreme Court held that those incarcerated may be involuntarily medicated if they are a danger to themselves or others and the treatment is in their medical interest. 22,31,32 If a patient in custody without decision-making capacity demonstrates either verbal or non-verbal refusal of interventions such as laboratory workup or physical evaluation, physicians may honor this refusal when proceeding is likely to cause more harm than benefit.…”

“…Like any other patient, adult patients in custody who have decision‐making capacity can provide informed consent and refusal for any medical intervention except in limited circumstances discussed below 19 . These patients have the right to be properly informed of their diagnosis, prognosis, and treatment options 20–22 . If an EP suspects a patient lacks capacity, they must perform a standard evaluation for decision‐making capacity 23 .…”

“…19 These patients have the right to be properly informed of their diagnosis, prognosis, and treatment options. [20][21][22] If an EP suspects a patient lacks capacity, they must perform a standard evaluation for decisionmaking capacity. 23 Some jurisdictions recommend that a psychiatrist be involved in capacity determinations, but doing so is at the EP's discretion.…”

“…EPs also must balance these duties when having to treat those in custody with psychotropic medications. The US Supreme Court held that those incarcerated may be involuntarily medicated if they are a danger to themselves or others and the treatment is in their medical interest 22,31,32 …”