"Rectal Feeding"-Unethical Medical Officer Participation at CIA Secret Interrogation Facilities.

This Viewpoint discusses recently released information regarding the practice of "rectal feeding" among detainees at Guantanamo Bay and Central Intelligence Agency (CIA) secret prisons.

Prison research: a bioethics or an ethics issue? / Investigación en prisión: ¿una cuestión de bioética o de ética? / Investigação em contexto prisional: Um questão de bioética ou de ética?

Abstract: The hypothesis of reducing aggressiveness through transcranial direct current stimulation was recently tested on a cohort of inmates in Spain. The experiment, including 1.5 mA electric shocks, was an external research initiative that received the initial acquiescence of the carceral system. An alarm was raised at the time the research was published, encouraging the directorate of prisons to stop the ongoing replication of the experiment. Nevertheless, no (bio)ethics committee, in the universities or among bioethics experts, has questioned the research. In this think piece, we aim to again discuss some ethical approaches to these clinical interventions on crime. After its positivistic period, the field of criminology has been questioning the simple psychobiological approach to crime because of the reductionistic view of this phenomenon and its harmful consequences. Thus, we address academic experimentation under prison governance and the "re" roles of prisons. We argue that the minor disadvantages of such research, if performed with consent, could be positive if the research can minimize the harmfulness of prison itself; thus, penitentiary treatment and science should go together. Prison administrations, in addition to their duty to protect the individuals under their control from ethically biased research, must promote reintegration. We conclude that human rights are over criminal policy and science and that ethics are over narrower bioethics.

Resumen: La hipótesis de la reducción de la agresividad por medio de estimulaciones transcraneales ha sido recientemente testada sobre encarcelados en España. El experimento, que incluyó descargas eléctricas de 1.5mA, fue una iniciativa de investigadores externos que encontró la aquiescencia inicial del sistema carcelario. La alarma surgió en el momento en que se publicó la investigación, alentando a la dirección de las prisiones a detener la replicación del experimento. Sin embargo, hasta entonces, ningún comité encontró ningún inconveniente, ni en las universidades ni entre expertos en bioética. En este artículo de reflexión pretendemos argumentar algunos enfoques éticos de estas intervenciones clínicas sobre la delincuencia. De nuevo, ya que la criminología, después de su periodo positivista, ha venido cuestionado el mero enfoque psicobiológico de la delincuencia. Así, abordamos el experimento académico dentro de la gobernanza penitenciaria y los roles "re" de las prisiones. Argumentamos que no es tanto que no se pueda investigar con internos, sino que posibles inconvenientes de tales investigaciones puedan servir, bajo consentimiento, para minimizar los inconvenientes de la misma pena de prisión. La administración, además del deber de proteger a sus individuos de investigaciones éticamente sesgadas ha de fomentar la reintegración. Concluimos que los derechos humanos han de estar por encima de la política criminal y de la ciencia, y la ética por encima de una más limitada bioética.

Resumo: A hipótese de diminuir a agressividade através da estimulação elétrica transcraniana foi recentemente testada num grupo de reclusos em Espanha. A experiência, que incluiu choques elétricos de 1,5mA, partiu de uma iniciativa de investigadores externos que encontraram a aquiescência no sistema prisional. O alarme surgiu no momento em que a investigação foi publicada, o que levou a direção administrativa das prisões a interromper a replicação do estudo. No entanto, até ao momento, nenhuma comissão de (bio)ética encontrou qualquer inconveniente, nem nas universidades, nem entre os especialistas em bioética. Com este artigo, pretendemos discutir algumas abordagens éticas dessas intervenções clínicas no crime. A criminologia tem vindo a questionar, após o seu período de investigação positivista, a abordagem psicobiológica do crime, devido à visão redutora desse fenómeno e das suas consequências nefastas. Assim, neste artigo, abordamos a experiência académica dentro da governança prisional e os fins da prisão. Concluímos que as pequenas desvantagens da investigação seriam positivas se pudessem, sob consentimento, minimizar os malefícios da própria prisão, o que significa que o tratamento penitenciário e a ciência deveriam andar 'de mãos dadas'. A administração das prisões, para além do dever de proteger os indivíduos de estudos que acarretem problemas éticos, deve promover a reintegração. Concluímos, assim, que os direitos humanos estão acima da política e da ciência criminais, e a ética acima da bioética mais restrita.

Ending Restraint of Incarcerated Individuals Giving Birth.

Advocates have long suggested making shackling incarcerated people during childbirth illegal. Yet exceptions would likely still allow prison personnel to implement restraint and leave clinicians no course for freeing a patient. This article argues that clinicians' assessments of laboring individuals' clinical needs must be prioritized, ethically and legally. This article also explains that, without strong policies in place, some clinicians will not feel empowered to demand that a patient be freed during labor. Beyond prohibiting restraint of laboring individuals, health care organizations must support clinicians seeking to execute their ethical duties to care well and justly for patients. Toward this end, this article proposes a model policy.

Hunger strike in prison: medical, ethical and legal aspects.

BACKGROUND: A hunger strike is a common form of protest in prison and is a potential cause of many types of problems, both for facility administrators and health care staff. Issues of conflict of rights and obligations involved, and how to treat people who are subject, have created major controversies. OBJECTIVES: To identify and review published studies that discuss the medical, ethical and legal considerations of managing a hunger strike in a prison setting from a physician's perspective. METHODS: A database search using "Medline" "Ovid" and "Science Direct was conducted to identify relevant publications. We included case series, guidelines and, review articles. RESULTS: The physician must clearly inform the striker of the risks and provide clinical assessment and regular monitoring of the concerned. The role of the psychiatrist is to detect an initial mental pathology underlying or secondary to fasting and assess the capacity of the striker's judgment. Thus, the clinician is faced with two paradoxical obligations: to assist and respect the striker's will. In addition, medical intervention is possible if the prognosis is life-threatening even without the patient's consent. CONCLUSION: The current practice of non-consensual attitude among hunger-striking seeking in detention needs a closer inquiry. Medical practitioners should be aware of their ethical and legal responsibilities, and that they should act independently of government or institutional interests.

Pharmacological Approaches to Managing Violence and Aggression in Prison Populations: Clinical and Ethical Issues.

Violence and aggression are common problems encountered in prison, which frequently require clinical intervention. This increased prevalence is partially attributable to the high morbidity of psychiatric and personality disorders in prison inmates. As prisons are non-therapeutic environments, the provision of clinical care becomes more complex. This article examines the general principles of management of violence and aggression in prison settings, with a particular focus on the clinical and ethical considerations that guide pharmacological approaches. Use of psychotropic medication to address these problems is reserved for situations where there is (i) a diagnosable psychiatric disorder, or (ii) a significant risk of harm to an individual without urgent intervention. Initial focus should be on environmental and behavioural de-escalation strategies. Clear assessment for the presence of major mental illness is crucial, with appropriate pharmacological interventions being targeted and time-limited. Optimising management of any underlying psychiatric conditions is an important preventative measure. In the acute setting, rapid tranquilisation should be performed according to local guidelines with a focus on oral prior to parenteral administration. Clinicians must be mindful of capacity and consent issues amongst prisoners to protect patient rights and guide setting of care.

Walking the Line: Balancing Access to Research and Protecting Prisoners.

Prisoners are often excluded from participating in clinical research (ie clinical trials and clinical investigations related to medicinal products and medical devices) due to the historical precedent of their abuse and exploitation. The exclusion of prisoners from clinical research is often deemed necessary to guarantee their protection from such abuse and exploitation. However, in this article, we argue that the right to science, which encompasses the right to access the benefits of science and research participation, is an emerging human right that is applicable to prisoners and may only be limited when this is necessary and proportionate. Whether this is necessary depends in part on the validity of a prisoner's informed consent. We discuss the importance of prison conditions for voluntary consent and examine the relationship between prison overcrowding and sub-par prison conditions by analysing the jurisprudence of the European Court of Human Rights on Article 3 of the European Convention on Human Rights on the prohibition of torture and inhuman treatment. We contend that the special circumstances of being in prison warrant additional protective measures, concurring with the Belgian Advisory Committee on Bioethics that research without the explicit aim of improving the situation of the individual prisoner or the prison community should be excluded. Given the complexity of the question of whether prisoners can give valid informed consent, rigorous oversight by an ethics committee with expertise concerning the prison system is necessary to provide a proportional balance between offering prisoners access to research and protection from abuse and exploitation.

Ethical Challenges of HIV Partner Notification in Prisons.

Partner services provide a safe and humane way for people living with HIV (PLWH) to alert their sex and/or drug-injecting partners to the possibility of HIV exposure and the need for HIV testing, yet little is known about the ethical challenges of delivering partner services in prisons. In this article, we consider 7 key ethical and methodological questions that should be considered when developing, testing, or implementing partner services in prison settings. These questions relate to the ethics of: (1) mandatory HIV testing, (2) health illiteracy, (3) level of prison staff involvement, (4) protecting confidentiality, (5) minimizing harm, (6) achieving equivalency with community standards of care, and (7) providing HIV prevention and treatment services to index patient and their partners. By assisting PLWH in prison to inform partners with whom they may have shared HIV exposure either before or during incarceration, partner services can help to identify cases of undiagnosed HIV infection for testing and linkage to medical care. The acceptability and effectiveness of a future partner services model for PLWH in prison depends critically on answering these 7 questions to assure the highest ethical standards of research and practice.

The Harms of a Penal Colony.

More than just a jail, Rikers has become a site of shifting discourse on punishment and justice in the United States. In the book Life and Death in Rikers Island, Homer Venters argues that the systematic failures of jails to provide appropriate safety and care constitute human rights violations and public health risks. The former chief medical officer and commissioner of correctional health services for the NYC Health and Hospitals system, Venters offers critical insight on the Rikers jail system. "Because jails are chaotic and concealed from outside view," he asserts, "we only become aware of them when very bad outcomes occur, such as deaths." Life and Death's success lies in how it blends Venters's experiences on the ground as a health care professional with the empirical data he's been able to collect and analyze over the tenure of his career. According to Venters, all suicides, homicides, and accidental deaths in jail are jail attributable, as they reflect system-wide failures in safety.

The psychiatric management of prisoners on hunger strike: developing a management algorithm using the Delphi technique.

PURPOSE: The assessment and management of prisoners on hunger strikes in a custodial setting is complex. There is limited clinical guidance available for psychiatrists to draw upon in such cases. The purpose of this paper is to develop a management algorithm through expert elicitation to inform the psychiatric care of prisoners on a hunger strike. DESIGN/METHODOLOGY/APPROACH: A Delphi method was used to elicit views from Irish forensic psychiatrists, a legal expert and an expert in ethics using a structured questionnaire. Themes were extracted from the results of the questionnaire to propose a management algorithm. A consensus was reached on management considerations. FINDINGS: Five consultant forensic psychiatrists, a legal expert and an expert on psychiatric ethics ( n=7) consented to participation, with a subsequent response rate of 71.4 per cent. Consensus was achieved on a proposed management algorithm. Assessment for mental disorder, capacity to refuse food and motivation for food refusal are seen as key psychiatric tasks. The need to work closely with the prison general practitioner and the value of multidisciplinary working and legal advice are described. Relevant aspects of law included mental health, criminal law (insanity) and capacity legislation. ORIGINALITY/VALUE: This study outlines a management algorithm for the psychiatric assessment and management of prisoners on a hunger strike, a subject about which there is limited guidance to date. Although written from an Irish perspective, this study outlines key considerations for psychiatrists in keeping with international guidance and therefore may be generalisable to other jurisdictions.

Professional Boundaries in Corrections.

Boundary violations occurring in corrections settings require special attention. There is a unique relationship between officers and inmates, governed by policies and procedures as well as ethics in general (e.g., the lack of ability for a person in a controlled environment to consent to a relationship due to power imbalance). Recent high-profile cases between corrections officers and inmates demonstrate the complexities inherent in these relationships. We examine several recent cases and offer analysis of the factors leading to these dangerous encounters. We discuss how a special relationship develops between a corrections employee and an inmate and how that can lead to blackmail, the introduction of contraband to the prison, or other illegal activity. It is easy to state that one should not engage in sexual encounters, but it is harder to discuss and identify feelings that develop in correctional settings, such as transference and counter-transference feelings in a therapeutic relationship. Lessons of professionalism from the doctor-patient relationship parallel the relationships between officers and inmates.

Child Abuse, Incarceration, and Decisions About Life-sustaining Treatment.

Most critical care interventions for children occur in the framework of a supportive environment with loving parents that are present at the bedside to help to guide medical interventions through shared decision-making. What happens, however, if the parents are precluded from being at the bedside because of legal entanglements? How should clinical decisions progress in those cases? In this Ethics Rounds, we present the case of an infant with severe hypoxic-ischemic encephalopathy at birth whose mother was incarcerated shortly after delivery. We explore clinical and legal challenges that the medical team faces in determining best interests for the infant in this context and difficulties in deciding what therapies to provide and for how long.

Hunger strikes in prisons: a narrative systematic review of ethical considerations from a physician's perspective.

OBJECTIVES: We sought to identify and review published studies that discuss the ethical considerations, from a physician's perspective, of managing a hunger strike in a prison setting. METHODS: A database search was conducted to identify relevant publications. We included case studies, case series, guidelines and review articles published over a 20-year period. Non-English language publications were translated. RESULTS: The review found 23 papers from 12 jurisdictions published in five languages suitable for inclusion. CONCLUSIONS: Key themes from included publications are identified and summarised in the context of accepted guidelines from the World Medical Association. Whilst there seems to be an overall consensus favouring autonomy over beneficence, tensions along this fine balance are magnified in jurisdictions where legislation leads to a dual loyalty conflict for the physician.

How do policymakers interpret and implement the principle of equivalence with regard to prison health? A qualitative study among key policymakers in England.

BACKGROUND: The principle of equivalence in prison health has been established for nearly four decades. It seeks to ensure that prisoners have access to the same level of healthcare as members of society at large, which is entrenched within the international legal framework and England's national health policies. AIMS: This study examined how key policymakers interpret and implement the principle of equivalence in English prisons. It also identified opportunities and threats associated with the application of the principle. METHODS: In total, 30 policymakers took part in this research. These participants engaged in policymaking activities and occupied positions of authority in the prison field. RESULTS: Despite the policymakers' consensus on the importance of the equivalence principle, there was a varying degree of understanding regarding what constitutes 'equivalence'. Participants described how the security culture impedes prisoners' access to healthcare services. Additionally, the increasing size and complexity of the prison population, coupled with a diminishing level of resources, reduce the level of care being provided in prisons and thus compromise implementation of equivalence in English prisons. CONCLUSIONS: Inconsistent interpretation of equivalence, the prevailing security drive, increasing numbers and health complexities of prisoners and fiscal austerity threaten the implementation of equivalence in English prisons. This research calls for new guidance on how to interpret and implement equivalence, along with measures to educate prison governors and staff on the prison rehabilitation value, ensure greater investment in prison health and consider alternatives to imprisonment to future-proof the principle of equivalence in the English prison system.

Prison Health Care Governance: Guaranteeing Clinical Independence.

Clinical independence is an essential component of good health care and health care professionalism, particularly in correctional settings (jails, prisons, and other places of detention), where the relationship between patients and caregivers is not based on free choice and where the punitive correctional setting can challenge optimal medical care. Independence for the delivery of health care services is defined by international standards as a critical element for quality health care in correctional settings, yet many correctional facilities do not meet these standards because of a lack of awareness, persisting legal regulations, contradictory terms of employment for health professionals, or current health care governance structures. We present recommendations for the implementation of independent health care in correctional settings.

Ethical issues of prison nursing: A qualitative study in Northern Italy.

BACKGROUND: Prisons are contexts where nurses are required to have specific skills to ensure that, in a setting designed for the expiation of crime, prisoners receive the same type of care as anyone else. But this is not always the case, giving rise to ethical issues. RESEARCH QUESTIONS: 'How do correctional nurses describe their working experience in prisons? What issues emerged?' METHODOLOGY: This is a qualitative descriptive study. Following purposive sampling, we conducted five focus groups. Thematic analysis was used to analyse the data. Participants and research context: Our sample included 31 correctional nurses in seven prisons in Northern Italy. Ethical considerations: The scientific merit of this study was recognized by the Academic Board of the University of Genoa. Approval to conduct the study was obtained from the Liguria Regional Government that funded this study and from the Local Health Authority that was the prison nurses' employer. Formal consent was obtained from all the nurses who volunteered to participate in this study. FINDINGS: Five themes emerged from the focus groups: (1) prisoners' healthcare needs, (2) negotiation between custody and care, (3) satisfaction of working in prisons, (4) obstacles to quality care and (5) safety. 'Manipulation' was a transversal theme that emerged from all the focus groups. DISCUSSION: The problems generated by the clash between prison security and nursing care priorities did not enable nurses to practice autonomously and provide the best possible to care prisoners, giving rise to ethical issues and moral distress. This in turn causes high nursing turnover rates that negatively impact continuum of care. CONCLUSION: In Italy, correctional nurses urgently require specific education interventions with the participation of all those who work in prisons. Interventions based on the post-modern concept of restorative nursing could offer prison nurses the opportunity to both resolve ethical issues and reduce moral distress.

Ethical conflicts in nursing care in the prison context.

OBJECTIVE: The general objective of the study is to gather the corresponding evidence with the ethical conflicts that may affect penitentiary nurses. METHODS: The methodology used consists methodology used consists in a systematic review of narrative analysis in the mayor data-bases by means of an applied search strategy and critical appraisal skills programme español (CASPe). RESULTS: A total of 167 studies published between 1998 and 2017 were identified, of which 60 met the inclusion criteria. CONCLUSION: The main conclusion is the need for research on the ethical problems related to the treatment of prisoners and on the search for the benefits of the inmates. In addition to the need for a training in ethics for the prison professionals, the identification of the real health-care needs of the prison population, and the collaboration between the prison assistance and the health system.

Health care needs assessment among adolescents in correctional institutions in Zambia: an ethical analysis.

BACKGROUND: While health care needs assessments have been conducted among juveniles or adolescents by researchers in developed countries, assessments using an ethics framework particularly in developing countries are lacking. We analysed the health care needs among adolescents at the Nakambala Correctional Institution in Zambia, using the Beauchamp and Childress ethics framework. The ethics approach facilitated analysis of moral injustices or dilemmas triggered by health care needs at the individual (adolescent) level. METHODS: The research team utilized 35 in-depth interviews with juveniles, 6 key informant interviews and 2 focus group discussions to collect data. We analysed the data using thematic analysis. The use of three sources of data facilitated triangulation of data. RESULTS: Common health problems included HIV/AIDS, STIs, flu, diarrhoea, rashes, and malaria. Although there are some health promotion strategies at the Nakambala Approved School, the respondents classified the health care system as inadequate. The unfavourable social context which included clouded rooms and lack of adolescent health friendly services unfairly exposed adolescents to several health risks and behaviours thus undermining the ethics principle of social justice. In addition, the limited prioritisation of adolescent centres by the stakeholders and erratic funding also worsened injustices by weakening the health care system. Whereas the inadequate medical and drug supplies, shortage of health workers in the nearby health facilities and weak referral systems excluded the juveniles from enjoying maximum health benefits thus undermining adolescents' wellbeing or beneficence. Inadequate medical and drug supplies as well as non-availability of adolescent friendly health services at the nearest health facility did not only affect social justice and beneficence ethics principles but also threatened juveniles' privacy, liberty and confidentiality as well as autonomy with regard to health service utilisation. CONCLUSION: Adequately addressing the health needs in correctional institutions may require adopting an ethics framework in conducting health needs assessment. An ethics approach is important because it facilitates understanding of moral dilemmas that arise due to health needs. Furthermore, strategies for addressing health needs related to one ethics principle may have a positive ripple effect over other health needs as the principles are intertwined thus facilitating a comprehensive response to health needs.