ON BEING A DOCTOR “THE PRISON PATIENT”

1. ON BEING A DOCTOR“THE PRISON PATIENT” Story by Matthew DS Klein, MD Klein DS. The prison patient. Ann Intern Med. 1997;127:648-9. Jeremy Graham, MA DO FACP Darryl Potyk, MD FACP Judy Swanson, MD Rachel P Safran, MD

2. WHY MEDICAL HUMANITIES? • Develop / promote interpretive skills • Maintain value-driven patient care • Endorse therapeutic discourse • Maintain emphasis: patient-as-person • Address ethical and emotive domains • Promotes meaning-centered practice

3. What is “Dual Loyalty?” Opposing / competing obligations to third parties, such as employers, governments and insurers, often test the devotion that health professionals are required to give to their patients.  Physician is torn between two different players which often have different or competing aims and objectives FROM: http://phrtoolkits.org/toolkits/asylum-detention/background/dual-loyalty/

4. What is the responsibility of a Physician encountering Dual Loyalty? The American College of Physicians Ethics Manual 6th Edition, specifically addresses the care of prisoners as a component of Physician and Society. The Ethics guidelines acknowledges the tension of the Dual Loyalty, and emphasizes that the physician’s ultimate responsibility is to the individual patient: American College of Physicians Ethics Manual 6th Edition (www.acponline.org)

5. Should prison physicians know the events that led to patients’ incarceration? Most US prisons’ policy is against Physicians knowing the charges/crimes of their patients. Another way to reframe this question is: how relevant are the different parts of a social history, to provide care? Can “knowing too much” of any patient’s social history hinder their medical care? Are there other instances in which we choose to NOT know certain information?   See discussions Bellin E, Klein DS in: Ann of Int Med 128 (12 ) p 1049

6. How do Physicians respond to the care of “undesirable” patients? Emotional disengagement Substandard care relationships: Disease becomes seen as “their own fault” by physicians, and that they don’t deserve the same level of care that would be given to a patient of a loving and supportive middle class family. The physician’s attitude negatively influences other staff also caring for the patient. The patient who feels judged, may avoid needed care.

7. How can Physicians foster care for patients perceived as “undesirable”? Mindful evaluation of why the situation is so painful can help. Physicians can be perfectionists -- difficulties with any can lead to emotional avoidance. Re-framing expectations is healthful. Hill, Terry. How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research. Philos Ethics Humanit Med. 2010; 5: 11. Groves, James E. Taking Care of the Hateful Patient.NEngl J med 1978;298:883-887 Gorlin, R. Physicians’ reactions to patients. A key to teaching humanistic medicine.NEngl J med 1983; 308: 1059 – 1063

8. Power Relationships and Patient Care:Vulnerable Patients What factors enhance a power differential, when treating prisoners? -knowledge of the crime committed -societal designation of inmates as “undesirable” (discussed elsewhere) - limited choice of provider, particularly given movement restrictions - presence of custody officials and restrictive clothing/cuffs

9. Power Relationships:Prisoners’ Vulnerability to Medical Sciences Experiment without consent has long been carried out on US prisoners: 1913 to 1951, Dr. Leo Stanley experimented prisoners at San Quentin, attempting to implant animal testicles into humans. 1940s: Illinois prisoners submitted to experimental cases of malaria. 1950: Dr. Joseph Stokes of the University of Pennsylvania infected 200 female prisoners with viral hepatitis. 1962: FDA rule revisions make prisoners the core subjects of Phase I testing for new drugs’ toxicity. 1972: FDA officials report than over 90 percent investigational drugs were first tested on prisoners. 1970s: Institutional Review Board governance standards created to include prisoners among a number of specific “vulnerable populations”

10. What standards exist for Prisoners’ Medical Care? • There is substantial case law supporting prisoners’ rights to access adequate health care while incarcerated, unfortunately there is little consensus as to what qualifies as “adequate” or if providing what some consider a bare minimum is truly ethical regardless of being legal.

11. What standards exist for Prisoners’ Medical Care? The Supreme Court held in Estelle v. Gamble that the 8th Amendment required the federal government, and through the 14th Amendment the states, to provide medical care to prisoners. The court established a two-pronged test to determine an “adequate” standard of care. The test holds that a prisoners’ right is violated if: 1) prison officials manifest “deliberate indifference” to prisoners’ medical needs and 2) those medical needs are “serious”.

12. What standards exist for Prisoners’ Medical Care? Plata vs. Scharzenegger was the largest ever prison class action civil rights lawsuit where prisoners alleged that the California Department of Corrections and Rehabilitation (CDCR) inflicted cruel and unusual punishment by being deliberately indifferent to serious medical needs. The courts approved an injunction requiring CDCR to provide “only the minimum level of medical care required under the 8th Amendment.” An evidentiary hearing revealed the persistence of sub-adequate and “appalling” conditions. The CDCR was ultimately held in civil contempt and the medical health care system was placed in receivership.

13. RESOURCES FOR PHSYCIANS CARING FOR PRISONERS: http://www.wma.net/en/20activities/20humanrights/30doctorsprison/ The World Medical Associations’ accredited course on the ethical work of physicians in prison settings. Delivered in conjunction with the Norwegian Medical Association. http://phrtoolkits.org/toolkits/asylum-detention/background/dual-loyalty/ A human-rights oriented discussion and resource set regarding the “Dual Loyalty” problem physicians may face in serving both a social agency, and their individual patient. Examines the problem physicians may encounter from a perspective of serving the primary goal of individual rights http://www.unodc.org/documents/balticstates/EventsPresentations/FinalConf_24-25Mar11/Pont_25_March.pdf A current presentation from The United Nations Organization on Drugs and Crime on the global standards for ethics in the medical care of prisoners, as delivered by Jorg Pont in Vienna.