By Stacey Kusterbeck
Clinicians encounter incarcerated patients in both inpatient and ambulatory settings. Multiple ethical complexities come up with patient care in this population.1 “Dual loyalty issues can arise, given that the priorities of healthcare providers and jails or prisons are different,” says Holland Kaplan, MD, assistant professor of clinical ethics and general internal medicine at the Center for Medical Ethics and Health Policy at Ben Taub General Hospital.
Healthcare providers’ primary ethical obligation is to promote the health of the patient. The correctional facility’s main priority is ensuring safety and security.
Clinicians often have these ethical questions, reports Kaplan:
- if they must disclose a patient’s health information to the correctional institution;
- whether they can request that a security officer step outside of a patient room during an examination or if restraints or shackles can be removed;
- whether incarcerated patients have a right to decline care or be discharged against medical advice;
- who should serve as a surrogate decision-maker for an incarcerated patient without capacity;
- whether the correctional facility can restrict communication with a patient’s family members;
- whether they can communicate the timing of a patient’s discharge with the patient.
“Ethicists can be helpful by facilitating ethical decision-making, helping clinicians navigate dual loyalty conflicts, advocating for patient rights, mediating discussions between clinicians and correctional facilities, guiding clinicians in navigating privacy and confidentiality laws and policies, and contributing to policy development at their institution surrounding care of incarcerated patients,” says Kaplan.
Clinicians caring for an incarcerated patient should consider requesting an ethics consult in these situations, says Kaplan:
- When conflicts over dual loyalty are impeding clear decision-making. “In cases of dual loyalty conflicts, ethicists can help clinicians tease apart where their perceived obligations are coming from and how to manage those conflicts,” says Kaplan.
- When patient rights appear to be compromised. Clinicians question whether they are required to disclose clinical information to the correctional facility, or whether interventions can be done coercively without the patient’s consent. For example, a patient who is engaged in a hunger strike might decline to have a nasogastric tube placed. The correctional officer might insist the nasogastric tube be placed. “This puts the physician in a challenging situation where they have to balance dual loyalties,” says Kaplan.
- When privacy or confidentiality concerns arise. Patients might feel uncomfortable providing accurate information if a correctional officer is in the room. Likewise, patients may not feel their privacy is being respected if a correctional officer is in the room when sensitive physical examinations are being done. “Sometimes correctional officers will ask about medical information that should be protected, such as discharge timing or whether a patient has a particular condition,” says Kaplan.
- When there is uncertainty about surrogate decision-making or family communication. Typically, there is a process for approval within the correctional facility. For physicians, this can make speaking directly with the patient’s family logistically challenging and burdensome.
- When healthcare providers are experiencing moral distress. Many clinicians who work in non-carceral hospitals rarely see incarcerated patients. Therefore, ethical issues that arise with this patient population are more likely to cause moral distress.
To educate clinicians on the ethical issues that arise with incarcerated patients, ethicists can use various didactic approaches, such as workshops, seminars, and grand rounds, suggests Kaplan. “It can also be helpful to have an individual from the institution serving as a liaison with the correctional facility to stay up to date on policy changes,” adds Kaplan.
Ethicists also can assist with updating hospital policies to ensure ethical care of incarcerated patients. “Policy development should focus on confidentiality, patients’ right to decline treatment, the use of restraints and security measures, and decision-making processes for incapacitated incarcerated patients,” says Kaplan.
In the emergency department (ED) setting, some unique ethical issues arise when incarcerated patients present. “Sometimes people need an emergency procedure or surgery, or we find a condition that has a high mortality rate, such as an aneurysm that is at risk for rupture,” says Lauren T. Southerland, MD, MPH, associate professor in the Department of Emergency Medicine at The Ohio State University.
Incarcerated patients, just like any patient, often want a moment to talk to their families. The patient might tell healthcare providers that what matters most to them is that their families are informed. However, communication delays occur because the emergency physician or surgeon is not allowed to directly reach out to the patient’s family. Instead, the doctor must alert the warden, who then informs the next of kin. “This can take a long time, and during emergencies, minutes matter. This means an incarcerated person is going into surgery or has a deadly condition and is not able to talk to their loved ones or relay messages. It is incredibly demoralizing and hard on the patient and their families,” says Southerland.
Incarcerated individuals with health problems may delay seeking care because of copay charges.2 “This leads to delayed diagnoses,” says Southerland. For example, a patient may report severe abdominal pain for several days and only be transferred to the ED after their appendix has already ruptured, leading to infection and higher risks with surgery.
Another ethical issue that arises in the ED involves refusal of care. An incarcerated person may refuse care, but if that care is recommended by the medical team, sometimes the warden can override the patient’s refusal. “This happens especially for patients with mental health issues or behavioral concerns,” says Southerland.
References
1. Nguyen NV, Riggan KA, Eber GB, et al. A primer on carceral health for clinicians: Care delivery, regulatory oversight, legal and ethical considerations, and clinician responsibilities. Mayo Clin Proc. 2025;100(2):292-303.
2. Lupez EL, Woolhandler S, Himmelstein DU, et al. Health, access to care, and financial barriers to care among people incarcerated in US prisons. JAMA Intern Med. 2024;184(10):1176-1184.
Clinicians encounter incarcerated patients in both inpatient and ambulatory settings. Multiple ethical complexities come up with patient care in this population.
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