Nursing Ethics in Prison Questioned
John Stanly, M.D.
There can be no greater covenant than that between patient and nurse.
Compassionate delivery of health care above all other goals is implicitly
understood and supercedes that of the physician. Nursing ethics forbid
participation in state mandated executions, while physicians commonly play
a subsidized role. The nurse speaks for those weakened by disease in times
of need and advocates on their behalf for appropriate medical care. It
is in this context that I question the dual responsibility of nurse and
guard combined as a Medical Technical Assistant (MTA) in our prisons. Can
this hybrid be expected to serve a dual ethic? Typically a Licensed Vocational
Nurse or Registered Nurse with custodial training, the MTA job description
includes both nursing duties and inmate supervision. Discipline is part
of the job. Can compassion and correction coexist? Is it acceptable to
comfort with one hand and punish with the other? Perhaps only a mother
is qualified to do so in our society an!
d even then may be accused of schizotypal behavior. It is too much to
ask of any human to be both a disciplinarian and health care provider for
the sole reason that the temptation to discipline via health care violates
our basic human rights.
The International Council of Nursing has affirmed the Geneva Convention
and has explicitly reviewed the role of the nurse in prisons since at least
1975. Nurses are forbidden from participating in interrogations, security
procedures or torture and are bound to report physical or mental ill treatment
to national and/or international organizations. Position statements from
the American Nursing Association and the Code of Nurses consistently support
the right to medical care of all individuals independent of their place
in society. The Council further compels nursing organizations to assist
and advise nurses placed in such a dilemma. Formal review of the MTA position
by state nursing associations is presently lacking.
In fairness, the California Department of Corrections officially demands
MTAs to uphold the ethics of the nursing profession. Ideally an efficient
use of manpower, an MTA could be used to assist a physician as well as
unlock doors and move patients securely per protocol. In practice, however,
the department is so short staffed that greater responsibility is bestowed
upon the MTA.
Most worrisome of their duties is that of triage. Sorting of patients
into a prioritized order, as we have all encountered in the emergency room
setting, is not an easy job. Serious problems often present with vague
symptoms or normal vital signs. One of the most common complaints voiced
by inmates statewide is uncompassionate triage of medical problems. All
medicines, even over the counter remedies, must be obtained from the health
care staff. Unless the inmate plans for illnesses weeks in advance, access
to antacids, headache and cold medicines must be triaged. If not deemed
an emergent condition, the MTA issues an appointment in a week - provided
a five dollar co-payment is first received. Screening usually involves
a phone call from a guard in a housing unit to the MTA in the clinic. Inadequate
urgency voiced at this initial contact translates into a longer wait. Indeed,
some inmates have died waiting. Others are threatened with a Rules Violation
Report and disciplinary !
action if they don’t have a fever when presenting to the clinic with
an acute illness. Malingering, or the manipulative seeking of health care,
is commonly suspected in prison as it is in the public sector. In general,
true cases are rare and the adroit nurse can best deal with this with understanding,
rather than discipline. Already saddled with a co-payment equal to a weeks
salary, the inmate has little incentive to fake illness.
MTAs are not evil. They are merely human and tasked to do a job that
challenges their ethics on a daily basis. Stressed with an overpopulated
prison system and understaffed nursing, physician and dental personnel,
the system is failing. The true nurse is supposed to be the advocate of
the inmate and facilitate health care. Instead, prison perverts these responsibilities
by incorporating the nurse into the system. The freedom to seek another
health care provider is lost in prison hence the ill inmate is at the mercy
of the MTA. Any system that intrudes on the trust between patient and nurse
in the delivery of proper, compassionate and timely health care should
be questioned.
Recent anti-crime legislation has expanded the California prison system
beyond all others in the western world. We imprison the largest percentage
of our own people amongst the developed nations and much of the third world.
However, we have been cheap in our fiscal responsibility to ensure operating
costs are adequate. The MTA job description appears to be a budgetary value
on the surface but insidiously erodes at human rights in practice. I believe
the post should be eliminated and the staff rehired as true nurses in order
to do their true job. I am asking state and national nursing associations
to evaluate this position and take a stand. Californians must acknowledge
a fiscal responsibility to care for our prisoners in an ethical manner.
We fought hard for human rights and demand other nations to uphold these
values, but have let these rights slip in our own backyard. We are no longer
at the forefront of righteousness. We continue to build new prisons yet
cannot fulfill ou!
r custodial responsibilities. Something must change. Either we greatly
increase the budget of the Department of Corrections or re-evaluate who
should be in prison. Alternatives to incarceration that maintain the safety
of the public are available and represent the most cost effective and humane
path to follow. Nonviolent criminals do not need to be behind bars and
no one deserves to be denied health care.
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