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Position Statements
Correctional Health Care Professionals’
Response to Inmate Abuse Introduction
Through national standards, public openness, litigation, and
accreditation, correctional facilities continue to improve
professionalism and safety in our nation’s jails, prisons, and
juvenile confinement facilities. Today’s professional
correctional administrator ensures public safety by developing,
adhering to, and enforcing sound policies and procedures and by
following applicable local, state, and federal laws governing
the management of detainees and prisoners.
At the same time, it is recognized that mistreatment of inmates
can and has occurred. Acknowledging the challenges experienced
by health professionals who may encounter, observe, or become
aware of mistreatment of inmates, NCCHC has developed this
position statement to assist health professionals in responding
to those situations in a manner that is consistent with
well-established principles of medical ethics, applicable laws,
and NCCHC standards.
NCCHC is committed to the humane treatment of inmates. We
reaffirm this position in concert with recent and past
statements of our supporting organizations, including the
American Bar Association, the American College of Physicians,
the American Medical Association, the American Nurses
Association, the American Psychiatric Association, the American
Psychological Association, and the American Public Health
Association.
NCCHC, through its standards, has consistently affirmed the
components of a policy against mistreatment. The Standards
for Health Services in Prisons (2003) preclude, for example,
health staff participation in nonclinically ordered restraint
and seclusion, except to monitor health status (P-I-01 Use of
Restraint and Seclusion in Correctional Facilities), or in the
collection of forensic information (P-I-03 Forensic
Information). They require informed consent of the patient for
“all examinations, treatments, and procedures” (P-I-05 Informed
Consent), recognize the patient’s right to refuse treatment
(P-I-06 Right to Refuse Treatment), and protect inmates as
subjects in human research (P-I-07 Medical and Other Research).
Other standards require medical autonomy in clinical decision
making (P-A-03 Medical Autonomy), maintenance of confidentiality
of health information (P-H-02 Confidentiality of Health Records
and Information), and patient privacy (P-A-09 Privacy of Care).
NCCHC standards require documentation of patients’ health status
at each encounter (P-H-04 Availability and Use of Health
Records), with special attention to the medical and mental
health of inmates under close confinement (P-E-09 Segregated
Inmates).
These standards approach but do not address directly the dilemma
of a health professional who (1) is asked to participate, even
indirectly, in abusive control or coercion of an inmate; or (2)
witnesses inmate mistreatment or its medical or mental health
consequences. NCCHC addresses these concerns in this position
statement. Background
The discussion of the health professional’s role in
correctional settings is framed by a number of key ethical
principles, including those of autonomy, nonmaleficence, and
medical neutrality. These principles are now well-established in
the medical profession.
Autonomy: The principle of medical autonomy dictates that the
health professional act primarily in patients’ interests above
all others and dictates that medical judgments be based on the
needs of patients. In general, patients’ legitimate medical
needs take priority over nonmedical matters in governing the
actions of the health professional.
Nonmaleficence: The principle of nonmaleficence dictates that
health professionals refrain from participating in actions that
may cause harm to patients. This principle is probably most
familiar as the phrase “First, do no harm.”
Medical neutrality: The principle of medical neutrality dictates
that the health professional treat patients regardless of their
background, status, affiliations, or position. It is commonly
cited in the practice of treating all wounded in time of war,
whether the wounded are comrades or enemies.
The discussion also inevitably includes the key conflict of dual
loyalty. Dual loyalty is defined as a conflict between
professional duties to a patient and obligations—express or
implied, real or perceived—to the interests of a third party
such as an employer, insurer, or the state. Dual loyalty is a
potent and common moral conflict for health care professionals
in institutional and managed care settings. Health professionals
may find the principles of autonomy, nonmaleficence, or medical
neutrality challenged by conflicting objectives of their
institution. Definitions
Mistreatment is the preferred general clinical term
used to identify actual or potential harm to a patient from
another person. Mistreatment may include physical abuse, sexual
abuse, emotional abuse, neglect, and financial exploitation.
Some forms of mistreatment may be unintentional. Other forms of
mistreatment are more serious, and may lead to civil and even
criminal sanctions.
Abuse is a more specific term that usually assumes
deliberate intent. It has been defined as “the willful
infliction of physical pain, injury or mental anguish;
unreasonable confinement; or the willful deprivation of services
which are necessary to maintain a person's physical or mental
health.”1
In the free world as well as in corrections, staff who observe
patient abuse are usually required to report the incident to the
proper authorities.
A third term, most often applied in a technical and legal sense
to military and government action, is torture. While the
word may sometimes be used more casually in common parlance, the
technical term should apply only to extreme forms of
mistreatment, and then only when accompanied by a specific
purpose such as obtaining information or a confession.2
Position Statement
Should correctional health staff witness or become aware of
an inmate being subjected to harm in any of the forms described
above, it is their duty to report this activity to the
appropriate authorities in order to protect patients and other
inmates. The following principles are to guide correctional
health care professionals in averting and reporting the
mistreatment of inmates.
1. Correctional health care professionals’ duty is to the
clinical care, physical safety, and psychological wellness of
their patients.
2. Correctional health care professionals should not condone or
participate in cruel, inhumane, or degrading treatment of
inmates. When such abusive treatment is either witnessed or
suspected, they should identify and report such incidents to the
appropriate authority.
3. Correctional health care professionals should refrain from
participating, directly or indirectly, in efforts to certify
inmates as medically or psychologically fit to be subjected to
abusive treatment.
4. Correctional health care professionals should refrain from
being present in the interrogation room, asking or suggesting
questions, or advising authorities on the use of specific
techniques of interrogation.
5. Correctional health care professionals should refrain from
gathering health information for forensic purposes or sharing
confidential health information or its interpretation to
authorities for use in cruel, inhumane, or degrading treatment
of inmates.
6. Correctional health care professionals should abstain from
authorizing or approving any physical punishment of their
patients, and should refrain from being used as an instrument of
their employer to weaken the physical or mental resistance of
inmates.
7. Correctional health care professionals should review their
employer’s policies and procedures, and work to ensure that they
appropriately address how inmates are to be managed and what
staff should do when abusive actions are suspected or witnessed.
8. Correctional administrators should ensure that policies and
procedures address protections for employees who report the
abusive actions of others.
9. Professional custody and health administrators should support
efforts to eliminate abusive behavior toward inmates by assuring
that all staff receive regular training on appropriate and
professional behavior in dealing with inmates. Use of experts
outside of the correctional system can be helpful in providing
objective training on this issue.
Adopted by the National Commission on Correctional Health
Care Board of Directors
October 14, 2007
Notes
1. State of New Jersey, N.J.S.A. 52:27G-2(a)
2. The United Nations defined torture in 1984 as “any act by
which severe pain or suffering, whether physical or mental, is
intentionally inflicted on a person for such purposes as
obtaining from him or a third person information or a
confession, punishing him for an act he or a third person has
committed or is suspected of having committed, or intimidating
or coercing him or a third person, or for any reason based on
discrimination of any kind, when such pain or suffering is
inflicted by or at the instigation of or with the consent or
acquiescence of a public official or other person acting in an
official capacity.” The International Committee of the Red Cross
notes that “the legal difference between torture and other forms
of ill treatment lies in the level of severity of pain or
suffering imposed. In addition, torture requires the existence
of a specific purpose behind the act—to obtain information, for
example.” |
