This post is a part of our Bioethics in the News series
By Karen Kelly-Blake, PhD
The U.S. project of mass incarceration reveals that more than 2 million people are jail-involved at any given time. That rate far exceeds that of any other nation in the world. Incarcerated patients are sicker, bearing an increased burden of chronic disease, namely addiction, viral infections, and mental illness. Conditions often exacerbated by solitary confinement. Moreover, those incarcerated are disproportionately from communities of color suffering from historical racial discrimination. Consider the following: Whites (non-Hispanic) comprise 64% of the U.S. population, 39% of the U.S. incarcerated population, and the national incarceration rate (per 100,000) is 450; Hispanics make up 16% of the U.S. population, 19% of incarcerated population, and the national rate is 831; Blacks are 13% of the U.S. population, 40% of the incarcerated population, and the national incarceration rate is 2,306 per 100,000.
In the 1976 Estelle vs. Gamble ruling the U.S. Supreme Court established that “deliberate indifference to healthcare for inmates constituted cruel and unusual punishment, and was thus prohibited by the U.S. Constitution.” In April of this year, a class action lawsuit was filed in the State of Illinois arguing, “health care inside the Illinois Department of Corrections systematically puts inmates at risk of pain, injury, and death.” In effect, Illinois has been put on notice that the correctional health care it provides (or the lack of provision), violates the 1976 Supreme Court ruling. Of course, Illinois is not the only state faced with this problem. A recent ruling found the Alabama Department of Correction’s mental health care system to be “horrendously inadequate.”
The challenges to delivering health care in correctional institutions are similar to those experienced in delivering care in any under-resourced setting that serves vulnerable patients. Overcrowding and understaffing are oft-cited explanations for the inadequacy of correctional health care delivery. An additional, deeply concerning factor is the privatization of prisons with related underbids, cost overruns, and vast gaps in the actual services provided. With increasing numbers of women cycling in and out of prison, women prisoners have specific health needs related to the increased likelihood of being victims of domestic and sexual violence. There is a pressing need for correctional health care services to address these health issues.
As a matter of justice, incarcerated patients should receive the same level of care that they would receive in a community setting. Unfortunately, this notion is not politically popular. Nevertheless, work is being done to merge correctional health and public health to ensure continuity of care once prisoners are released. Significantly, the Affordable Care Act (ACA) specifically addresses the importance of ensuring that the jail-involved have access to the same benefits as the non-incarcerated. The ACA expansion of Medicaid eligibility supplies a critical opportunity to treat prisoners once released. Untreated substance abuse and mental illness among the jail-involved increases their likelihood of future imprisonment.
Health care providers often find themselves serving two masters in correction settings. Providers have a duty to provide care that is in the best interest of the patient, but equally, they are also employed by the institution that has other, often conflicting interests, namely to confine, punish, and possibly, rehabilitate. This conflict is referred to as dual loyalty. The virtual societal silence on larger issues about the nature of the institution of incarceration is problematic and makes many correctional health providers “complicit as the United States has embarked on a vast and unprecedented social program of mass incarceration.” Given this state of affairs, providers should use their professional power and work to advocate for and insist upon substantial reforms in clinical care within prisons. A key critical reform is to eliminate solitary confinement. Medical providers also must advocate for change in the criminal justice system. The current project of mass incarceration in the U.S. harms the individual health of prisoners and the public health of the community.
Because of lawsuits or the threat of lawsuits on behalf of prisoners, as well as the dedication of committed health care professionals, activists, and advocates, the quality of health care in prisons has steadily improved. Yet there remains vast room for improvement in clinical care. Physicians hold leadership and management positions in correctional institutions. Combined with the social privilege afforded them in the U.S., physicians have the power, and I would argue the obligation, to spearhead reforms in correctional health care and ensure that the incarcerated sick are at no greater risk than the non-incarcerated of pain, injury, or death.
Karen Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine at Michigan State University.
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More Bioethics in the News from Dr. Kelly-Blake: White Horse, White Faces: The Decriminalization of Heroin Addiction; Racism and the Public’s Health: Whose Lives Matter?; Concussion in the NFL: A Case for Shared Decision-Making?