Where medicine meets discipline

Medicine on the outside is based upon principles like confidentiality, trust, privacy, and justice. Being a prisoner compromises one's rights, obviously, but when the roll of the clinic staff swings from care provider to disciplinarian, I become uneasy.

Inmates can get "charged" while serving their time for breaking the prison rules. Some infractions can result in being "written up" or "thrown in the hole" (the seg unit) for a period of time until an internal court evaluates the offender's behavior. These violations are then considered when the offender is evaluated for parole. There are many rules to be broken. Inmates are forbidden from touching each other in any way. Hugging is viewed as sexual misconduct. (I doubt anyone would ever give me an accurate sexual history due to concerns for disciplinary action...I ask anyway). Sharing medicine or food is also not allowed. I still haven't figured out where the line is between a patient's right to autonomy and willful noncompliance, which can result in a write-up.

Another interesting charge is "abuse of clinical services." Sending excessive kites or being disrespectful to staff can result in this charge. I have had more than one patient complain about a nurse who has singled them out and written them up for abusing our clinic. At times, I tend to sympathize with the patient, as I have occasionally observed aggressive nurses antagonizing certain difficult patients.

I had my own run in with a difficult patient last week during a diabetes visit. After just a few questions about her peripheral neuropathy, the patient became frustrated and basically went off on me about her chronic pain in a hostile way. I left the room and asked the nurses to show her out. This nurse then wrote the patient up for being verbally abusive. The next day, the same patient tossed her used insulin syringe through the slot in the med window, and now she is in the hole.

While I agree that inmates need to be respectful of staff and it is totally inexcusable for them to be tossing sharps around, I am sure that any therapeutic relationship I might have had with this patient has been destroyed. It's a strange and uncomfortable position to be in. The ethical challenges of prison medicine are tricky to navigate.