Ethical Considerations of the Incarceration Epidemic

Updated: Jan 23


Three steps forward, two-and-a-half steps to the side. Forty-eight square feet to survive — up to twenty-three hours per day. This is the size of an average prison cell in the United States; suffocating is an understatement [1]. The United States represents five percent of the world population — but nearly 25% of the global prison population. The number of incarcerated persons annually supasses population growth, with an increase of 700% in the past fifty years [2]. The numbers are jarring, but perhaps more concerning are the conditions and blatant biases with which incarcerated persons are dealt. However, overcrowding is not the only issue that plagues American prisons. Prison-patients experience considerably lower standards of care that both ethically and legally oppose the premise of human rights, healthcare, and medical research in the United States.


The Constitution of the United States, a document forged to ensure basic rights for all citizens, prohibits cruel and unusual punishment in its Eighth Amendment [3]. The 1976 Supreme Court ruling Estelle v. Gamble further set the foundation that the State is obligated to “provide adequate medical care to those whom it has incarcerated” [4][5]. The Hippocratic Oath, though not legally binding, is a well-known commitment physicians make to provide ethically competent care [6]. Despite these legal and ethical precedents, the conditions of American prisons create an atmosphere that disallows medical confidentiality and autonomy.


Historically, incarcerated populations have been the forefront of research subjects due to the inexpensive ease with which they can be exploited. The United States intentionally injected Guatemalan prisoners with syphilis for public health research in the 1940s. Investigative testing for drug toxicity was also conducted primarily (90%) on prisoners by 1972 [7]. Now, inmates are legally considered a vulnerable population under federal regulation, specifically for the purpose of medical research [8]. However, historical research injustices are still fresh, and the vulnerability of inmates extends beyond their care as research subjects. Overcrowded prison conditions make it difficult to achieve medical privacy because prison settings can be cramped, ridden with constant surveillance, and exert near total control over the lives of inmates [9]. The presence of bedside guards and nearby peers contests the principles of medical confidentiality outlined in the Health Insurance Portability and Accountability Act (HIPAA), as well as questions the ethical standards physicians uphold toward inmates [10].


Moreover, many prisoners feel motivated to participate in research studies “as a means of gaining access to a treatment that was not readily available to them,” and data suggests that fewer inmates would enroll in studies if they had access to the treatment otherwise. Though prisoner participation in research is technically voluntary, it is evidently necessary in certain cases to receive adequate medical care. Court rulings do not describe the extent of healthcare that inmates are constitutionally ensured, particularly in comparison to the general public [11]. Therefore, the correctional system often provides a selection of treatments that are minimally acceptable — offering far less choice and breadth in the medical care available to inmates.


As a whole, there are higher rates of physical and mental illness among incarcerated persons, including substance abuse disorders and suicide ideation [7]. There is also an increased rate of disease transmission due to close inmate proximity and interaction[12]. Consequently, it is expensive to supply medical care to the ill and growing incarcerated population in the United States. The provision of resources is also unpopular to fund, furthering the obligation that inmates feel to be research subjects in order to maintain their health [11]. One of the most notable examples is the prevalence of Human Immunodeficiency Virus (HIV). Among incarcerated persons, HIV persists at a rate over five times greater than that among the general population [13]. The ethical flaws of inmate privacy and research alone are troubling; when coupled with the longstanding social stigma of HIV, an especially adverse atmosphere for medical treatment can be created [14].


Mass incarceration, or the excessive use of correctional control, is pervasive in America. In the last decade, “a court-ordered investigation of Corizon in Idaho revealed ‘inhumane’ conditions… terminally ill inmates were left for periods of time without food or water and slept in soiled linens” [15]. Incarcerated persons continually face inequities in medical care reception due to constrained resources, an abundance of peers, and legal codes that neglect to outline the specifics of care. Access to healthcare is presumably a novelty among inmates who are less likely to have utilized medical services prior to incarceration [16].


Healthcare in the correctional setting discloses breaches of privacy and quality care that would be inarguably illawful among the general public — prisons should be no different. It infringes on “cruel and unusual punishment” to allow the current treatment of inmates to remain. American prisons set forth a window of opportunity to ameliorate public health, yet the presence of illness among incarcerated persons remains high. Expanding treatment availability, increasing access to mental health courts, and training medical professionals in correctional settings are a few of the many ways to target ethical violations in prisons [17]. Moreover, the inequities of this epidemic will not be truly remedied until there is a drastic reduction in the unnecessary incarceration of thousands. An improvement in decarceration policies, and a national shift in focus to the social determinants of health are indispensable to improving healthcare conditions for all.


Is it not “cruel and unusual punishment” to allow the current treatment and condition of inmates to remain?


References:

  1. What is the Average Size of a Jail Cell? (2020, April 16). Reference. https://www.reference.com/world-view/average-size-jail-cell-6e821c6fbe267eb4.

  2. Criminal Justice Fact Sheet. (2021, May 24). NAACP. https://naacp.org/resources/criminal-justice-fact-sheet.

  3. Eighth Amendment. Constitution Annotated. https://constitution.congress.gov/browse/amendment-8/.

  4. West v. Atkins, 487 U.S. 42 (1988). Justia Law. https://supreme.justia.com/cases/federal/us/487/42/.

  5. Estelle v. Gamble, 429 U.s. 97 (1976). Justia Law. https://supreme.justia.com/cases/federal/us/429/97/.

  6. Hippocratic Oath. (2021). Encyclopedia Britannica. https://www.britannica.com/topic/Hippocratic-oath.

  7. Shackled by Science: The Exploitative Use of Prisoners in Scientific Experiments. (2018). Harvard Civil Rights–Civil Liberties Law Review. https://harvardcrcl.org/the-shackles-of-science-the-exploitative-use-of-prisoners-in-scientific-studies/.

  8. Coughlin, S. S., Lewis, S. R., & Smith, S. A. (2016). Ethical and Social Issues in Health Research Involving Incarcerated People. Journal of health care for the poor and underserved, 27(2A), 18-28. http://doi.org/10/1353/hpu.2016.0053.

  9. Fuller, L., & Eves, M.M. (2017). Incarcerated Patients and Equitability: The Ethical Obligation to Treat Them Differently. The Journal of clinical ethics, 28(4), 308-313. PMID: 29257766.

  10. Health Insurance Portability and Accountability Act of 1996. (2018). Centers for Disease Control and Prevention. https://www.cdc.gov/phlp/publications/topic/hipaa.html.

  11. Christopher, P. P., Stein, M. D., Johnson, J. E., Rich, J. D., Friedmann, P. D., Clarke, J., & Lidz, C. W. (2016). Exploitation of Prisoners in Clinical Research: Perceptions of Study Participants. IRB, 38(1), 7–12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4793400/.

  12. Infectious Diseases in Prison. World Health Organization. https://www.euro.who.int/__data/assets/pdf_file/0006/249198/Prisons-and-Health,-9-Infectious-diseases-in-prison.pdf.

  13. Golrokhi, R., Farhoudi, B., Taj, L., Pahlaviani, F. G., Mazaheri-Tehrani, E., Cossarizza, A., SeyedAlinaghi, S., Mohraz, M., & Voltarelli, F. A. (2018). HIV Prevalence and Correlations in Prisons in Different Regions of the World: A Review Article. The open AIDS journal, 12, 81–92. https://doi.org/10.2174/1874613601812010081.

  14. Tran, B. X., Phan, H. T., Latkin, C. A., Nguyen, H., Hoang, C. L., Ho, C., & Ho, R. (2019). Understanding Global HIV Stigma and Discrimination: Are Contextual Factors Sufficiently Studied? International journal of environmental research and public health, 16(11), 1899. https://doi.org/10.3390/ijerph16111899.

  15. Markowitz, Eric. Making Profits on the Captive Prison Market. (2016, September 4). The New Yorker. https://www.newyorker.com/business/currency/making-profits-on-the-captive-prison-market.

  16. Simon, L. (2017, September). Ethics at the Intersection of the Criminal Justice and Health Care Systems. AMA Journal of Ethics, 19(9), 873-876. https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2018-04/fred1-1709.

  17. Dumont D. M., Brockmann B., Dickman S., Alexander N., Rich J.D. Public health and the epidemic of incarceration. Annu Rev Public Health. 2012;33:325-339. doi:10.1146/annurev-publhealth-031811-124614.

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