Editorial

Citation

Greifinger, R. and Allen, S.A. (2015), "Editorial", International Journal of Prisoner Health, Vol. 11 No. 3. https://doi.org/10.1108/IJPH-07-2015-0016

Editorial

Article Type: Editorial From: International Journal of Prisoner Health, Volume 11, Issue 3.

Robert Greifinger and Scott A. Allen

Asserting control: a cautionary tale

There is an inherent conflict built in to the field of correctional medicine. Medicine and nursing are healing professions. Prisons are institutions of order and control, using confinement as punishment, though presumably not for punishment. Most of the time, the conflict remains below the surface. On most days, the work of health professionals in practicing medicine goes on in harmony with the institution's primary security-oriented mission. On most days, the health professional would not object to the institution's emphasis on control of the day-to-day movements and activities of the prisoners. The institution's staff is typically supportive, or at the very least, tolerant of the work of the healers.

What happens when a prisoner manifests problem behavior that threatens the order of the institution – but may also be a manifestation of illness? What then? For those who work in correctional settings, this is a very common conundrum.

Typically, in such cases, custody staff responds reflexively by asserting institutional authority and control over the prisoner. The authority of the institution overpowers the autonomy of the prisoner patient. The rationale provided is the institution's legitimate need to assert control over the individual and for the purpose of maintaining institutional order.

Security is not in and of itself objectionable to correctional health providers, and in fact correctional health professionals appreciate a secure working environment. Who can object to the goal of safety? So, not uncommonly, health professionals acquiesce to the authority of the security apparatus and the imposition of extreme limits on the autonomy of the patient. Health professionals too often do so even when such infringements may be counter-therapeutic, and in some cases, contrary to the stated objectives of security and safety.

In this issue, LeBlanc et al. provide one such cautionary tale. In an effort to keep a prisoner safe and secure, the institution imposes restrictions and punishments, with the apparent acquiescence of health professionals. But rather than securing safety or security, the punitive approach proves counter-productive. In the end, neither health nor safety is achieved.

In such cases, why do health professionals acquiesce? No doubt, health professionals are influenced by so-called "dual-loyalty" conflicts between their obligations to the patient that may conflict with their real or perceived obligations to the institution. More often, though, health professionals are co-opted by benign sounding arguments offered by security. Infringements on autonomy are not punishments, they declare – they are necessary interventions to keep the prisoner "safe."

Therein lies the seduction. Indeed, while health professionals cannot object to the goal of safety, the institutional reflex of bearing down on the autonomy of the individual offending prisoner presumes that is the only valid approach to the perceived threat, when indeed, most health professionals must understand that often such interventions are counter-therapeutic. This presumption is often wrong; indeed, there are options.

In fact, the involvement of health professionals in punitive and abusive practices is often rationalized in similar ways. The force-feeding of hunger strikers is commonly justified as an intervention to "preserve life" and not a profound infringement on patient autonomy and dignity. Similar, the application of restraints is often justified to keep the patient safe, when just as often, they are applied to patients for less noble reasons. (In the USA, restraints applied by health professionals instead of security staff are called "therapeutic restraints," yet it is not clear what the actual therapeutic rationale is in many cases.) These arguments are distractions or sleights of hand. Why, then, are health professionals so commonly co-opted by their institutions?

Perhaps it is a subconscious compromise. We survive by "staying in our lane." We provide diagnoses, medications and treatments. Custody staff is in charge of discipline keeping everyone "safe."

Health professionals working in detention settings must constantly be alert to these inchoate seductions, which arise routinely, predictably and often innocently from the legitimate impulses of non-therapeutic security protocols and practices. In particular, health professionals have an affirmative obligation to intervene when they believe that a behavior may be the result of an illness, be it physical or mental.

The case described by LeBlanc et al. raises the issue to another level. What are the obligations of the health professional when the conditions of confinement, or specific responses of security to specific behaviors are counter-therapeutic or even pathogenic? Punishments including segregation and isolation may be common responses by institutions to undesirable behavior, but they are certainly not rational or evidence based. On the contrary, to the extent they have been studied, they are more often than not harmful and counter-productive. They are rather primitive and blunt reflexive responses by the institutions to undesirable behaviors. Control outstrips beneficence.

Multi-disciplinary teams consisting of security and health professionals, as well as other disciplines, are one method for health professionals to influence the practices of the institution – with the objective of introducing some nuance and insight to understanding human behavior, based on professional skill and clinical evidence. It is professionally appropriate to give second thought to reflexive security responses to behaviors that may be due to under-treated mental illness. Speaking up in these cases is a professional duty. But no matter how health professionals approach this common scenario, they have a professional duty to exercise their independent clinical judgment with evidence-based strategies to address medical and mental health issues with a sound therapeutic rationale.

Too often, medicine is ranked second by institutions devoted to security. On our initial foray behind bars, many of us are told that we are "guests in security's house." To the contrary, health professionals, at least theoretically, should have autonomy and authority over the medical treatment. In reality, however, asserting that autonomy and authority can be an enormous challenge. The challenge, however, cannot be simply rationalized away. Health professionals have an affirmative responsibility to intervene on behalf of their patients if they believe their patient's health needs are being ignored or they are being harmed.