New Column! Corr Ethics
By Dean Rieger, MD, MPH and Mike Puerini, MD, CCHP-A
Posted on April 15, 2009 – We all want to “do the right thing,” and we all have found ourselves in positions where it was not clear what the right thing is or, worse, where several different courses of action seem to be correct. Although ethics refers to a broad area of philosophical study, medical ethics is a branch of applied ethics which applies values and moral judgments to medicine.
With this article we are introducing a new column addressing ethical and moral conundrums particular to the practice of medicine in a correctional environment. For this column to succeed as a stimulating and useful exercise, we need active reader participation. We want to know what ethical challenges you are facing. Tell us about the ones you think you have solved or tell us about the ones that are currently wreaking havoc for you. Even if we cannot offer you a coherent solution, we can probably help you move a few steps closer to a desirable outcome.
Some of our challenges parallel challenges faced in the outside medical community. Who among us has not faced the difficulty of wanting to discharge a patient from an inpatient setting, but found the receiving setting incapable of providing proper care? Other challenges are peculiar to our world. How can we easily provide continuing clinical care to the inmate who is actively suing us? Does thelawsuit disrupt the physician-patient relationship?
The most obvious source of ethical challenges that we face is the interface between the general practice of medicine in which we are advocates for our patients, and custody, which seeks to minimize the freedom available to inmates. But there are many other sources of conflict. How do we handle it when a female inmate wants an abortion, but the jurisdiction is avowedly anti-abortion? What about the classical conflict when an inmate does not demonstrate serious mental illness, but medication can create a safer environment, one in which assaults are less likely? And then there are the end-of-life conundrums surrounding living wills and advance directives.
Have you or your system addressed a particularly vexing challenge, and do you think you have a great solution? Would it be helpful to the rest of us?
What is the worst ethical dilemma in which you found yourself and what did you do about it?
Dilemma #1
We want to get you started, thinking about what is right and wrong, and how to navigate these waters, so here is a dilemma for you to think about:
Your patient in segregation is “known” to be dangerous, assaulting staff in the past, and has used requests for health care services as opportunities to get out of the segregation unit and assault both inmates and staff. Security staff insists that he must stay in the segregation unit for the safety of the institution staff and other inmates. You are concerned that what looks like a tiny skin lesion may be a cancer and want the inmate brought to you, to a setting where the excisional procedure can be performed. Your jailer has told you that this inmate will not be brought out for an elective procedure; after all, within two or three months he will be leaving the jail and going to the department of corrections.
Please send us your comments on this scenario. We hope to publish reader comments in the next issue. But send us your scenarios, too, so that we can share the challenge with others.
About the Columnists
For those of you who don’t know us, we will introduce ourselves.
Dr. Reiger began in corrections about 31 years ago, providing services at the women’s prison in Michigan. He continued as medical director for the State Prison of Southern Michigan, a men’s facility housing about 5700 inmates, including the reception center, and then moved into a regional medical director position. After leaving Michigan, Dean served Indiana for 12 years as state DOC medical director before joining Correct Care Solutions as its chief medical officer. For several years, Dean edited CorrDocs and has served on various SCP committees.
Dr. Puerini started in corrections as a part-time medical consultant in a juvenile facility 17 years ago. He has provided primary care in a mid-sized state prison in Oregon for the past 12 years. Mike has been active in SCP as the West Coast Director and is the chair of the Policy and Practice Steering Committee.
Between us we have almost 40 years of experience in correctional settings ranging from tiny jails to huge prisons, from maximum security settings to unfenced boot camps, and in both juvenile and adult facilities serving both genders. We anticipate applying this experience in a practical if not pragmatic manner.
Please contact us with your responses to the scenario described in this column or with a challenge you would like to see us address. Readers may contact us at mike.t.puerini@doc.state.or.us or drieger@ccsks.com.
