Establishing Orthopaedic Standards of Care for Incarcerated Patients

The United States has the largest incarcerated population in the world; in 2020, 1.18 million people were incarcerated in state or federal prisons or local jails^1,2. Individuals who are incarcerated receive their health care primarily from federal and state government-sponsored facilities, with the provision of this care guaranteed by the 1976 Supreme Court case Estelle v. Gamble³. In this ruling, the Court defined deprivation of health care as a violation of the Eighth Amendment to the U.S. Constitution and established “deliberate indifference” to the health-care needs of prisoners as unconstitutional⁴. Modern correctional health is founded on these principles; however, serious obstacles continue to challenge health-care providers working to meet the needs of incarcerated patients^1,5. Although there may be logistical challenges in providing care to incarcerated patients that differ from those for the general patient population (Table I), it is important to remember that both the Geneva Convention and Supreme Court rulings affirm the right of incarcerated individuals to receive medical care, and, as health-care providers, we must strive to overcome these challenges, rather than simply accept them.

TABLE I.

Ethical Considerations Regarding Circumstances of Care for Incarcerated Patients

Situation	Obstacles	Suggestions	Risks	Ethical Principles
Timely intervention required	Delay in authorization	Contact administrator or consider direct admission	Increased use of resources Progression to more complex treatment	Duty to rescue Utilitarianism Justice
Immobilization recommended	Security (potential use for weaponry)	Preference for plastic braces or assistive devices instead of metal	Injury to others Insufficient immobilization for patient	Nonmaleficence Justice
Rehabilitation	Unavailable resources	Patient education Self-administered exercises	Inadequate rehabilitation leading to suboptimal outcomes Different standard of care	Justice (disparities) Beneficence
Follow-up	Unreliable transportation	Systemization and communication with provider and facility	Missed complications Inadequate progression of functional status	Nonmaleficence Beneficence Solidarity Integrity
Poor access to advanced imaging	Resource availability	Establish protocol for advanced imaging with providing institution	Delayed treatment Practical barrier to implementation	Justice Access to care

Musculoskeletal and connective tissue diseases are the second-most common category of illness among incarcerated patients, but providing orthopaedic care for these patients often presents practical and ethical challenges to the orthopaedic surgeon³. Orthopaedic surgical care, especially fracture care, requires longitudinal treatment with serial radiographs and varied activity restrictions. It is crucial to engage in thorough shared decision-making processes with incarcerated patients in a manner that is as engaged as clinicians would be with any other patient population⁶. For conditions typically treated with a surgical procedure, it is essential to discuss the recommended treatment, associated risks, and benefits, just as we would with any other patient population. This ensures that the decision to pursue surgical or nonoperative options is based on an objective evaluation of the patient’s unique circumstances, rather than any preconceived biases. Additionally, potential lack of access to physical therapy or reliable transportation for follow-up may make adherence to treatment protocols challenging for incarcerated patients. Although it is incumbent on physicians to advocate for these services when they constitute the standard of care, they cannot ensure that access is provided by the facility. These challenges have been compounded by the COVID-19 pandemic, which further restricted travel and in-person clinical assessments. This article explores how the unique setting of prisons and jails impacts the delivery of orthopaedic care to patients who are incarcerated. In turn, we apply 4 major ethical principles, beneficence, nonmaleficence, autonomy, and justice, to discuss and understand the responsibilities of physicians when caring for patients who are incarcerated.

The State of Medical Care for Incarcerated Patients

With the rapid growth of the incarcerated U.S. population in the past 4 decades, researchers have attempted to understand the individual and community-level effects of this mass incarceration on health^7,8. Schnittker et al. found that individuals with a history of incarceration report more chronic health problems after their period of incarceration than before and a negative change in health status⁹. Massoglia found that individuals who had been incarcerated had infectious diseases at disproportionately higher rates¹⁰. Anecdotal reports have illustrated how prisons can neglect the health of those under their responsibility. One such case reported by Taylor Elizabeth Eldridge of The Appeal shed light on this in the care of Gerry Armbruster¹¹. In May 2014, Mr. Armbruster reported tingling and numbness in his arms and hands while he was incarcerated at Southwestern Illinois Correctional Center in East St. Louis, Illinois. The physician assigned to him at the prison did not refer him to a specialist or prescribe any treatment despite his progressive symptoms, and Mr. Armbruster was unable to seek a second opinion while incarcerated. Five months later, 10 days after his release from prison, Mr. Armbruster underwent urgent spinal surgery to alleviate the spinal cord stenosis that had been developing for months. The reality that there are barriers to incarcerated patients readily seeking a second opinion puts a greater onus on those caring for this population to perform a thorough evaluation when determining treatment.

In contrast to the literature and other reporting of poor health effects of imprisonment, other studies have borne out data that incarcerated patients may experience a mortality benefit while under the purview of the state. Based on administrative data in Ohio from 1992 to 2017, Norris et al. found that incarcerated defendants had a 60% lower mortality rate during the time of incarceration compared with matched peers who were charged but not sentenced¹². However, this effect disappeared upon release and has remained nonsignificant after release for more than 15 years¹². We and authors of similar research assert that these findings are due to decreased homicide, suicide, and overdose for this high-risk population as well as that increased medical care and other necessities of living are available in prison. This decrease in mortality is due to the relatively high mortality risk for their peers outside of the justice system and illustrates some of the health-care access barriers that exist in the United States. The potential for positive health outcomes for this population only increases the necessity of quality care provided by orthopaedic surgeons who may encounter this population.

Institutional Experience

At the institution of one of the authors (T.M.M.) in New York City, orthopaedic surgical care is routinely provided to incarcerated patients. Patients presenting from jails or prisons who require inpatient care are admitted to a closed unit complete with holding cells and shared patient wards separate from the general patient population. An administrative partnership between the hospital and the prison facilitates the transport of incarcerated patients, the safekeeping of medical records, and consultation with various medical specialties corresponding to individual patient needs. This partnership also includes guidelines on communication with patients, similar to dyad agreements between other institutions and incarcerating entities.

Law enforcement officers guard the entrance of all personnel into the ward and their exit through barricaded entry points. In many instances, providers are instructed to take numerous precautions, including limiting access to potentially dangerous medical tools such as injections, scalpels, or suturing materials, although there are ethical concerns with this practice. Law enforcement officers check and secure their firearms before entering the ward. Further, providers are often instructed not to divulge detailed discharge planning to incarcerated patients to prevent escape attempts or deliberate extensions of their hospital stay. However, it is essential to maintain open communication with incarcerated patients, respecting their autonomy and right to information about their own care. This includes discussing the conditions necessary for their discharge, such as the ability of prisons to provide access to sanitary conditions to prevent infection and provide medical devices that aid in recovery.

In cases of emergencies, consultation is routed to a defined area of the emergency department, and procedures are conducted in this area. Incarcerated prisoners remain restrained except in cases in which it hinders treatment. Limitations on what information with regard to disposition can be divulged to the incarcerated patient is one of many challenges to delivering care to incarcerated patients. During the COVID-19 pandemic, an increasing number of evaluations were conducted via a televisit, a trend that was necessary to comply with public health directives. Physical examination maneuvers were often communicated to a health-care professional on site in the infirmary, whereas the orthopaedic provider observed and evaluated the patient via telehealth platforms. This mode of care delivery presented challenges similar to those in the general population, such as technological barriers, difficulties assessing wounds or special maneuvers during a physical examination, interruptions, and limited control over the clinical environment. As we move beyond the pandemic, it is crucial to ensure that all patients, including those who are incarcerated, have equal access to urgent care. This commitment to equitable care extends to surgical procedures, which are planned and coordinated through admissions to the inpatient prison ward, ensuring that both minor and major surgical procedures are conducted in a timely and efficient manner.

Caring for a Vulnerable Population: Ethical Obligations and Challenges

Although all medical professionals navigate ethical considerations in their practice, those treating incarcerated patients may face additional logistical challenges that can lead to ethical dilemmas. These challenges arise from the unique circumstances of treating individuals whose civil rights are legally restricted, but who are nonetheless legally entitled to the same standard of health care as non-incarcerated individuals. It is therefore crucial for health-care providers to not only understand medical ethics but also advocate unequivocally for the necessary care for each patient, regardless of their incarceration status. The 4 pillars of medical ethics, namely beneficence, nonmaleficence, autonomy, and justice, provide an analytic framework for the moral obligations of health professionals. The first 2 originated during Hippocrates’ time, and established the doctor’s responsibility “to help and do no harm.”^13,14 The principles of autonomy and justice evolved later, with Beauchamp and Childress’ book, Principles of Biomedical Ethics, solidifying the importance of the 4 taken together as the foundational framework for moral medical decision-making¹³. These concepts are widely accepted as important principles and undergird additional guidelines to which surgeons should adhere, for example, the American Academy of Orthopaedic Surgeons (AAOS) Code of Ethics and Professionalism¹⁵. We will therefore employ these 4 principles to address the unique challenges of caring for individuals who are incarcerated.

Beneficence refers to the obligation of a physician to act for the benefit of the patient and is a foundational value for health-care ethics¹⁴. Beneficence requires that surgeons provide relief through providing medical care: as such, beneficence requires action on the part of the surgeon¹³. Alleviating the pain of incarcerated patients from chronic or acute musculoskeletal conditions aligns with the principle of beneficence. Furthermore, beneficence calls for physicians to prevent harm, which includes advocating for the removal of harm-causing conditions¹³. Although surgeons cannot control the prison environment, they have the capacity and the obligation to advocate for their patients’ legal right to adequate health care, including the removal of possibly harmful conditions. This advocacy should not be compromised and may take many forms. For instance, surgeons can explain any medical or physical limitations to the accompanying officer to influence how a detainee is positioned or restrained¹⁶. They can also follow up with the correctional facility to ensure that physician-mandated orders and prescriptions are being followed¹⁶. Upholding the principle of beneficence means not accepting compromises in care, but rather persistently advocating for the best possible care for all patients, without consideration of race, religion, sex, culture, incarceration status, or other factors.

Justice in the medical context is defined as fair, equitable, and appropriate treatment of persons, in this case regardless of their legal status¹⁴. This principle requires that health-care providers do not let biases or preconceptions about incarcerated patients, who are often stereotyped as unreliable, dangerous, or manipulative, impact their decision-making or care^16,17. Justice demands that the care provided to patients is not influenced by their legal standing, whether they have been charged with, convicted of, or are innocent of a crime¹⁸. To ensure justice, health-care providers should focus solely on the patients’ medical needs and not be influenced by the patients’ charge or conviction. If there is a circumstance in which a surgeon’s personal bias or prejudice could compromise the care that a patient receives, the surgeon should seek an alternative provider for that patient. Upholding justice means treating everyone the same, providing equal care to all patients, whether they are incarcerated or not.

Patient autonomy refers to the right of competent adults to make informed decisions about their medical care and is a core ethical practice in American health care^19,20. This principle is of particular importance in the field of orthopaedic surgery because shared decision-making is integral in weighing surgical options and adhering to treatment recommendations such as weight-bearing status, follow-up, and physical therapy²¹. Although incarcerated patients may face unique challenges due to their circumstances, it is important to remember that they retain their right to make autonomous decisions about their health care. Elective procedures for incarcerated patients may be difficult to undergo because of the aforementioned access barriers. Incarcerated patients are beholden to third parties for access to their health-care services and have little, if any, control with regard to their transitions of care or choice of provider²². Similarly, many people with specific health insurance plans may be limited to a certain facility or a choice of a few clinicians, similar to the limitations that incarcerated patients encounter. Nevertheless, these limitations do not negate the right of all patients to be fully informed about their treatment options and to participate in decisions about their care. Even in the context of these challenges, the principle of patient autonomy remains paramount and must be respected and upheld.

Closely related to the principle of autonomy is veracity. Veracity refers to the principle of communicating the truth. It forms the foundation for the doctor-patient relationship, and has implications for all 4 principles of bioethics²³. The treatment of incarcerated patients may create conflict between veracity and security measures. Physicians should familiarize themselves with the hospitals’ policies with regard to care for incarcerated patients and any required safety measures, while working within these limits to guarantee patients’ welfare and autonomy²⁴. Any withholding of medical information should be weighed against the ethical implications, should only be considered in emergency situations, and should be used only after every precaution to ensure patient and provider safety has been taken²⁵. Although the hospital staff may feel intimidated by law enforcement officials, it is crucial to note that law enforcement officials do not hold medical decision-making authority²⁶. Incarcerated patients, as with all other patients, maintain the right to make decisions about their care, and the provider is obligated to protect the open communication that undergirds their ability to make informed choices about their medical care.

Nonmaleficence refers to the obligation not to inflict harm on others¹⁴. In this way, it is related to the duty not to act, separating it from beneficence. Surgeons may rightfully express concern that the prison environment may put patients at additional risk for infection, wound complications, stiffness after surgery, and other untoward events. However, it is crucial to avoid making assumptions about the risk level for a specific procedure, such as a total knee arthroplasty for an incarcerated patient with severe osteoarthritis, based solely on the patient’s incarceration status. Instead, the same risk assessment should be applied as would be applied for a non-incarcerated patient with the same comorbidities. Similarly, the prolonged rehabilitation process and closer follow-up required with nonoperative management of a tibial shaft fracture should be considered in the context of the specific capabilities of the facility, which can vary widely. In North Carolina, a small number of jails have around-the-clock medical care, whereas others have no health-care providers on staff and require transport to a local hospital for any medical need²⁷. In all cases, the physician should share any concerns with the patient and engage in shared decision-making when weighing treatment options. This approach respects the principle of nonmaleficence by ensuring that decisions are based on an objective evaluation of the patient’s unique circumstances, rather than any preconceived biases.

Policy Recommendations and Preventive Ethical Standards

Physicians are guided by broad ethical standards that dictate the nature of the physician-patient relationship, such as the AAOS Code of Ethics and Professionalism, the American Medical Association (AMA) ethics principles, and the New Geneva Declaration²⁸. These standards apply to all patients, including those who are incarcerated. Within the confines of the law, the surgeon should aim to be as transparent as possible in communicating with incarcerated patients about their care. If the recommended treatment differs from the patient’s initial preferences, the surgeon should disclose the rationale for the treatment decision. The surgeon’s primary responsibility is to advocate for the patient’s well-being, even if this requires advocating for additional resources or interventions not typically provided in the prison system. Incarcerated patients are a vulnerable population susceptible to disparate standards of care. It is therefore recommended that health-care providers have access to a multidisciplinary committee informed by bioethicists to establish care guidelines and review challenging cases. These policies should support and protect the health-care providers for whom they are created. The physician should have clear guidelines for specific patient scenarios, but these guidelines should not compromise the patients’ right to information about their own care. These assessments and reviews should be completed in an interdisciplinary fashion that includes a discussion between the operating surgeon, relevant care team providers, and members of the ethical committee when available.

A facility providing orthopaedic care to incarcerated patients must be able to address emergency and urgent injuries and also have resources in place for appropriate postoperative care. Although the surgeon has limited ability to directly oversee the care provided by the state and federal facilities to which incarcerated patients are discharged, they can advocate for sufficient resources to care for operative wounds, casts, splints, and dressings. The AMA Declaration of Professional Responsibility dictates that physicians must “advocate for the social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”²⁹ This professional ethical responsibility should be explicitly addressed by surgeons and hospitals providing care for incarcerated patients by ensuring that tangible efforts are being made to improve access to care for these patients.

Summary

The correctional health system places surgeons in tension with several principles of ethical health-care delivery, namely autonomy, justice, and nonmaleficence. These constraints are, in part, due to the environment perpetuated by the U.S. criminal justice system. Although existing special models of care for incarcerated orthopaedic patients may meet basic legal minimum requirements, the system perpetuates circumstances in which the ethical standards of our medical profession may not always be upheld. It is imperative that, as physician-leaders responsible for improving the care of all patients, the surgical community takes steps to adopt policies that bridge the gaps in care that exist for patients who are incarcerated. Specifically, we suggest the following 5 steps: (1) establishing clear communication channels between health-care providers and correctional facilities to ensure continuity of care, (2) implementing regular training for health-care providers on the unique challenges and ethical considerations of treating incarcerated patients, (3) advocating for the allocation of resources to ensure that correctional facilities can provide appropriate postoperative care, (4) developing guidelines for shared decision-making processes that respect the autonomy of incarcerated patients, and (5) creating an ethical committee to review challenging cases and establish care guidelines that uphold the principles of medical ethics. These steps represent a commitment to improving the care of incarcerated patients and upholding the ethical standards of our medical profession.