Incarceration complicates the ethical provision of clinical care through reduction in access to treatment modalities and institutional cultures that value order over autonomy. Correctional care clinicians should expand their guiding principles to consider autonomy and health justice for their patients, which in turn should prompt development of processes and care plans that are patient-centered and account for the inherent restrictions of the setting.
CaseDr. François is the medical director of a prison where more than 200 women are incarcerated. Over the past week, several nurses have contacted her both in person and through the prison's electronic health record to report that Jane, a woman with insulindependent type II diabetes who is incarcerated at the facility, has refused her insulin injections during the past week. Blood sugar measurements taken three times each day have been in the 300 to 500 range. Several of the nurses with whom Dr. François talks face-to-face report they feel anxious about the persistence of Jane's refusal. Dr. François reads Jane's electronic health record and sees that she experienced a motor vehicle accident five years ago, which resulted in a two-week hospitalization. Jane has chronic neck and back pain as a result of the accident and reported that she was prescribed gabapentin by a primary care clinician in the community to control her pain. Clinicians at the prison are discouraged from prescribing gabapentin unless other pain control options have been tried due not only to this drug's risk for cultivating dependence, but also to the diversion risk within the prison [1]. As a result, Jane has not been prescribed gabapentin at the prison and instead has a prescription for ibuprofen.Dr. François requests to speak with Jane to try to better understand her situation. When Jane arrives at the prison's medical ward, she tells Dr. François that her pain is unbearable and, specifically, that it keeps her from sleeping or moving comfortably. She states, "I need my gabapentin, this is torture!" When Dr. François asks her about her adherence to her insulin regimen, Jane tells her, "The only thing you people care about is whether I take my insulin. Why doesn't anyone care about my pain?" Dr. François tries to