decisions

1

EthicsandLawinCorrectional

HealthCare

AnApproachforProblem

SolvinginCorrectionalHealth

Care

TheFramework

MedicalIndications

PatientPreferences

QualityofLife

ContextualFeatures

TheProcess

ConfrontingtheProblem

IdentifyingStakeholdersandOther

KeyConflictElements

CollectingInformation

FramingtheProblem

SolvingtheProblem

Today’sFocus

ConfrontingtheProblem

IdentifyingtheKeyConflictElements

CollectingInformation

TheExerci

WorkinPairs

TimedInterviews

One=Interviewee

TheOther=EthicsConsultant

AfterFirstInterview,SwitchRoles

AfterBothInterviews,Discussion

ContactInformation

etteMcKinney

InstitutefortheMedicalHumanities

Room2.210,AshbelSmithBuilding

301UniversityBoulevard

Galveston,TX77555-1311

E-mail:emmckinn@

Phone:409-772-2376

Fax:409-772-5640

EthicsinCorrectionalHealth*

*ThefollowingframeworkisanadaptationofanearliermodelproducedinClinicalEthicsbyAlbertR.

Jonn,MarkSiegler,andWilliamWinslade.

MedicalIndications

patientadequatelyexpressthenature

ofhisorhermedicalproblem?Canthepatientunderstandthe

questionsaskedabouthisorherproblem?

mptomsformthecoreofthecomplaint?

Whatcaredoesthepatientek?

thepatient’shistory?Arerecordsavailable?

thediagnosis?Coulditbeminor?Coulditbe

vere?Istheautomaticassumptionthatitisminor?(e.g.

constipationversusintestinalblockage)Istheproblemacute?

Chronic?Critical?Emergent?Reversible?Howdoyouknow?

Whatinformationwouldbeneededtodiagnoinanother

tting?(e.g.,anon-correctionaltting)Whatattitudesand

beliefsaboutthepatientplayedaroleinthediagnosis?

theprognosis?Whataspectsofthepatient’s

physicalandsocialenvironmenthavebeentakeninto

consideration?(e.g.,timeuntilrelea,prisonhardships,

treatmentpolicies)

tmentavailableintheimmediatetting?

Anothertting?Whatoptionsforeffectivetreatmentare

availabletothepatient?Whatarethegoalsoftreatment?

staclescouldpreventachievingtreatment

goals?(e.g.,lockdowns,staffshortages,drugavailability,costs)

etheplansincaoftherapeutic

failure?Whatalternativesareavailabletothepatient?Tothe

healthcareprovider?

thepatient’sbenefitsfromthe

healthcareavailablebemaximizedandtheharmsminimized?

PatientPreferences

atientmentallyandlegallycompetentto

makehisorherownmedicaldecisions?Badonwhatcriteria?

Isthepatientadangertohimlforothers?Ifnotcompetent,who

isthepropersurrogate?Doestheprisonhaveapolicyabout

surrogacy?Whatpenologicalinterestsorbudgetaryconcerns

mightaffectoptionsanddecisions?

atientiscompetent,whatisthe

patient’spreference?Onwhatisheorshebasingthepreference

(e.g.,religiousbeliefs,pastexperience,fears)

patientbeeninformedinlanguagehe

orshecancomprehendabouttherisksandbenefitsofthe

treatmentoptionsavailable?Thenatureofthetreatment

recommendedorchon?Outcomestoexpect?Hasthepatient

givenun-coercedinformedconnt?Canheorsheexplain

broadlywhatthetreatmententails,whyheorsheneedsit,and

whatthetreatmentixpectedtoaccomplish?

patientexpresdpreferencesabout

resuscitation,particulartypesoftreatments,orend-of-lifeissues?

HasthepatientexecutedAdvanceDirectives?(e.g.,livingwill)

ation/atientunwillingorunableto

cooperateinmedicaltreatment?Ifnot,whynot?Whatis

negotiable?Whatwillhappenifthepatientcontinuestoresist?Is

thepropodtreatmentreasonableunderthecircumstances?What

wouldadisinterestedpartythinkisreasonable?Istherealess

frightening,lesspainful,orlessoffensivewaytoachievean

effectiveresult?Ifso,whatbenefitsandburdensareassociated?

Whataspectsofthepatient’ssocialorphysicalenvironment

couldbecontributingtothepatient’sresistanceorinabilityto

comply?(e.g.,lossofadvantages,distancetotheinfirmary,

adverdrugreactions,treatmentineffectiveness,adversarial

relationships,undiagnodmentalillness,etc.)

QualityofLife

etheprospectswithorwithout

treatmentforareturntoordinaryprisonroutine?Forreturntoa

normallifeoutsideofprison?Whatphysical,mental,andsocial

deficitsisthepatientlikelytoexperienceifthetreatment

succeeds?Ifitfails?Ifnotreatmentismadeavailable?

as(assumptions,beliefs,conclusions)might

prejudicetheprisonofficial,correctionalofficer,orhealthcare

professionalwhofirstencountersthepatient’sneedorrequestfor

healthcare?Whatbias(assumptions,beliefs,conclusions)

mightinfluencetheasssmentsofthepatient’squalityoflife?

(lifeexpectancy,benefitsofcare,physicalcomfort,race,x,

religion,xualorientation,disability,age,prisonntence

length,etc.)

isonorbudgetarypolicies(writtenor

unwritten)maycreateconflictsinthewaythepatient’squalityof

lifeisassd?

eanyplanorrationaleto

foregotreatment?Wouldsuchaplanbeconsideredreasonableto

adisinterestedperson?

reanyplansforcomfortorpalliative

care?Ifso,howwilltheybeaccomplished?Willpainbe

adequatelycontrolled?Iscompassionatereleaanoption?

ContextualFeatures

htinfluence

treatmentdecisions(stakeholders)?(e.g.,publicofficials,prison

administrators,correctionalofficers,dentalhealthcareworkers,

physicians,nurs,pharmacypersonnel,mentalhealthworkers,

otherinmates,family,courts,managedcarecompanies,the

media)Whatmattersmightinfluencetreatmentdecisions?(e.g.,

budgetissues,penologicalinterests,prisonorhealthcarepolicies,

pharmacypolicies,conflictsofinterest,facilities,transportation,

communication,recordkeeping,bias,fears,lackofcontinuity

ofcare,personnelshortages,law,beliefs,confidentiality)

ghtinfluencethepatient’saccessto

care?(e.g.,patient’scompetence,languagedifficulties,patient’s

ignoranceofneed,patient’sbeliefsaboutqualityofcare,patient’s

fearoflosingprivilegesoradvantages,patient’sfearof

harassmentormistreatment,assumptionsaboutthepatientorthe

complaint,scheduling,personnelshortages,penologicalinterests,

etc.)

aturesofcorrectional

healthcareandthephysicalandsocialaspectsofprisonlifemay

interferewithsuccessfullyprovidinghealthcare?(e.g.,curity

goals,largefacilities,agingpopulation,widespreadinfectious

dia,condarygainsforinmates,budgetconstraints,policies

againstprovidingcertaintreatments,potentiallyviolent

encounters,dehumanizingattitudesandbehaviors,poorhealth

habitsandriskybehaviorsamonginmates)

CLINICALETHICSMASTERWORKSHEET

ConflictKeyElements

thestakeholders,thepartiesinvolvedintheconflict?Whohassomething

togainorlo?

eachpartywant?

eachpartybelieveisthereasonfororsourceoftheconflict?

ethebasicfactsoftheca?

ecesofinformationaremissing?(UtheClinicalEthicsinCorrectional

theblanks

rassumptionsandbias.)

MedicalIndications

Communication

Complaint

Diagnosis

Prognosis

Treatment

Obstacles

TherapeuticFailure

BenefitMaximization

PatientPreferences

Competence

TreatmentPreference

InformedConnt

AdvanceDirectives

Cooperation/Compliance

QualityofLife

HealthProspects

Bias

PrisonPolicies

PlantoForegoTreatment

PalliativeCare

ContextualFeatures

InfluencesinTreatmentDecisions

AccesstoCare

TheCorrectionalEnvironment

gtheProblem

thekeystakeholders?

etheirduties(moral,legal,andprofessional)?

etheirneedsorwants?

hicsissuesareinvolved?

galissuesmaybeinvolved?

theproblem?(Istheremorethanone?Cantheproblembedefinedin

morethanoneway?)

ntextualfeatureswillinfluencethesolution?

ollectingalloftherelevantinformation,check

tto

conflictremainsaftercommunicationcorrections,movetotheSolutionProcess.

onProcess

ritiqueor

evaluateanyresponuntilveralpossiblesolutionshavebeengenerated.

Ifveralstakeholders’positionsmustbeconsidered,generatepossible

responsforeachposition.

quiresnotingthelegitimatevaluesandgoalsof

,

ethicalprinciples,moraltheories(e.g.,utilitarianism,deontology),

religiousviews,culturalperspectives,andprofessionalandlegalstandards

maybeudinjustifications.

ptionsmaximize

thebenefitsandminimizetheharms?Whichoptionsbestfitwiththe

patient’svaluesandgoals,thehealthcareprofessions’valuesandgoals,

andlegitimatepenologicalinterests?Cananyoptionsbecombinedto

createimprovedoptions?Doanynewoptionmerge?Ifso,justifyand

evaluatethem.

erthecontext,thestakeholders,thetimeframe,andanyother

theoption

thatbestaddresstheimmediatecircumstances.

SolutionChecklist:

epropodsolutionrespectthepatientasaperson?

utcomereasonableandfair?

enefitsoutweightheburdens?

hesolutionapplyifthepatientwerenot

incarcerated?

esolutionfulfilllegalrequirements?

esolutionfulfillprofessionalresponsibilities?

olutioninaccordwithprisonpolicy?Ifso,isthe

prisonpolicyethical(reasonable,fair,equallyapplied,in

tunewithprofessionalresponsibilities,appropriatetothe

situation?)

esolutionfittheproblemathand(intermsof

resourcesavailableandthepatient’shealthcareneeds)?

hesolutionbedifferentforanotherperson(becau

ofrace,religion,gender,mentalstatus,educationlevel,or

othercharacteristicsorsocialcircumstances)?

repolicyimplicationsbuiltintothesolution?Canit

begeneralizedtoapplytoothersimilarsituations?