By Ryan DuBosar
An increasing number of incarcerated patients are unable to make health care decisions for themselves, and physicians outside of the correctional facility world may not understand how to help them access surrogates to be their advocates.
This is one of several challenges in care for incarcerated patients that Kenneth M. Prager, MD, FACP, reviewed during a Thursday session, "Hot Topics in Ethics," at Internal Medicine Meeting 2024.
The U.S. has the largest incarcerated population in the world: 2.2 million people. Prisoners are disproportionately from Black and Hispanic populations, and have worse health outcomes than those on the outside. "These people have a disproportionate amount of HIV, tuberculosis, other communicable diseases; they suffered disproportionately during the height of the COVID epidemic," said Dr. Prager, a member of ACP's Ethics, Professionalism, and Human Rights Committee, which sponsored the talk.
It's also an aging population. Between 2007 and 2010, there was a dramatic increase in the number of adults ages 65 years or older in federal or state custody. By 2030, adults older than age 55 years will make up more than one-third of the federal prison population, he said.
"The older people who are incarcerated are going to have more medical problems," said Dr. Prager, a co-chair of the ethics committee for Columbia University Medical Center in New York City. "Understandably, some of them will be imprisoned long enough so that they may develop dementia, and so there's going to be decision-making issues concerning these patients that may raise ethical questions."
Physician engagement with this population is often limited, according to Dr. Prager. Locked doors lead to decreased physician exposure, with prisoners in isolation having even greater reductions in physician engagement, and the ubiquitous presence of correctional officers often intimidates physicians and nurses, "especially if [prisoners] have shackles on them."
One article recently reported that 65% of physicians and 21% of nurses seeing an incarcerated patient in a hospital do not ask the officer to leave the room before the examination, he noted.
Patient autonomy can be impaired by confusion and lack of knowledge about prisoners' decision-making rights and surrogacy access, Dr. Prager said. Hospital or carceral policies that prohibit communication with family or friends may further limit shared decision making, even though incarcerated patients have the right to include such people in their care.
Incarcerated patients can receive fewer medical interventions while hospitalized, whether it's medical consultations, physical therapy, or social work assessments. In addition, there can be a tendency by physicians to underprescribe controlled substances, biologic agents, or prescriptions for opioid use disorder. "This is a critical failing in the health care system," Dr. Prager said.
He next recounted highlighted how restraints are used in situations in where they might not be needed. Restraints require the exercise of restraint and should be used in least restrictive manner possible, he advised. However, in practice, incarcerated patients often remain shackled throughout hospitalization. Dr. Prager cited case reports of patients shackled with metal cuffs even when intubated, paralyzed, or in labor.
When an incarcerated patient is unable to make their own care decisions, the appropriate role of prison officials is to facilitate contact with surrogates and coordinate logistics of patient care. Decision making by prison officials is not supported ethically or legally unless the individual is uniquely qualified to represent the patient’s goals and values, Dr. Prager said.
"There may be circumstances where a person has a unique relationship with the incarcerated individual who trusts the prison official, and the prison official may be able to speak on behalf of the patient," Dr. Prager said. "But unless that criterion is met, the prison official should not be really involved in decisions being presented."
Based on his experiences, Dr. Prager encourages clinicians and ethics experts to act carefully when faced with the dilemma of decision making for persons.
"Current research is clearly sparse," he said, "and we should encourage clinicians and ethics committees to carefully consider the pros and cons of possible surrogate decision-making candidates in states where a surrogate is not specified by law, where evidence of a patient's preference is not available." ■