A patient’s right to self-determination is part of their inherent human dignity. Provision 1 of the Code of Ethics for Nurses calls us to practice with compassion and respect for the inherent dignity, worth, and unique attributes of every person. Individuals forfeit many of their rights when incarcerated. Is one of them self-determination?
Consider this situation: The inmates in several institutions in a large state prison system have organized a hunger strike to protest excessive use of solitary confinement of gang members. Nurse Darden works in one of these prisons where she witnesses some of her patients being coerced by other inmates to participate in the hunger strike. She also sees hunger striking patients being offered special privileges by prison staff to break their fast.
The Ethical Principle of Autonomy
Patient self-determination is based on the principle of respect for autonomy. Autonomy in health care refers to the patient’s right to “accept, refuse, or terminate treatment without deceit, undue influence, duress, coercion, or prejudice” (Code of Ethics, 2015, pg 2). In the case above, Nurse Darden may not be able to put words to her concerns, but she is seeing examples of coercion that is affecting the health of her patients. Two conditions are necessary for a patient decision to be autonomous.
Autonomy Means Voluntary
The incarcerated patient population may not be behind bars voluntarily, but correctional nurses have an obligation to assure that health decisions are made freely even though our patients are inmates. Incarceration does not take away all human rights. Prisoners, in the past, have been subjected to experimentation and been the unwilling objects of research projects. While these extreme abuses have been stopped, undue influence can still be exerted on those whose rights are already affected by incarceration. Loss of health care autonomy is not part of the punishment of incarceration.
Autonomy Requires All the Information
In order to make an informed decision, patients need accurate and understandable information, and the time to process it. Written information may be helpful, but many correctional patients have learning disabilities or are unable to read. Correctional nurses may need to use other methods such as pictures and simple verbal explanations to be sure patients fully understand treatment decisions. Patients who truly lack the capacity to make a health decision need a formally designated surrogate. This may be a family member, the courts or a legally appointed advocate.
Self-Determination Can Not Risk the Health of Others
While nurses need to respect patient autonomy, individual treatment choices can sometimes affect the health of others. For example, a patient with active tuberculosis can not choose to forgo treatment. Individual self-determination, then, is limited by the rights, health, and welfare of others. A more challenging area of self-determination is that of taking psychotropic medications. Mentally ill correctional patients in crisis can sometimes be restrained and given medication against their will for the purposes of order and the safety of others. However, forced psychotropic medications must be administered for the safety and welfare of the patient, and for as short a time as possible.
Nurse Darden’s Options
Nurses have a moral obligation to preserve, protect, and support patient self-determination in issues related to their health and well-being. Here are some ways Nurse Darden might respond to the ethical situation she has encountered in her institution.
- Encourage Informed Consent – Develop informational materials about the physical, mental, and emotional effects of hunger striking.
- Seek Leadership and Peer Support – Talk about the situation with management and peers to determine ways to encourage patient autonomy within the organizational culture.
- Work with Individual Patients – Particularly vulnerable patients may need one-on-one intervention to be sure they understand the implications of all potential decisions. Patients who are mentally, psychologically or physically disabled may be particular targets of inmate or officer coercion and need special attention.
What do you think about Nurse Darden’s situation? What should she do, if anything? Share your suggestions in the comments section of this post.
jailaid says
Even so, correctional health nurses are obligated to provide nursing care consistent with their respective state nurse practice acts and rules.
Seth says
Great topic! I’ve encountered hunger strikes a lot over the years. Here are helpful steps that I have found:
1. Always approach the striking patients individually. Each person’s health is different, and individuals all respond differently when interacting with nursing. The hunger strikers as a group are the responsibility of the prison administration.
2. Ask the patient why they not eating. In the above scenario, the reason is known, but in other instances I am sometimes surprised to learn that no other staff member has spoken with the patient about this yet. Sometimes it is something as simple as, “I sent a sick call slip for my diabetes 5 days ago, and I’ve heard nothing back.” Sometimes these situations can be resolved fairly easily with a small amount of information that wasn’t previously known to the patient, but can be shared.
3. Refer the case to a mental health professional. Some patients have severe mental health symptoms such as delusions that influence their decisions not to eat. As noted in the article, severe mental health diagnoses can interfere with an individual’s ability to make autonomous decisions about their health, and it is always necessary to screen for this.
4. Begin a food log that is completed by custody staff, with the % of food from each tray that is consumed. It’s helpful to compare real data of food consumption to what the patient’s statement that they have not been eating.
5. Offer to have a conversation with the patient about how their health might be affected by fasting, based on their unique diagnoses. While strikers are more motivated to strike than they are to prioritize their health for a period of time, they still do care about their health. They are usually interested in learning more about the potential health implications of their decisions, and will incorporate this information in their decision of when to end their strike.
6. Schedule weekly weights, and when medically appropriate, vital checks. The patient can always choose to refuse these services, but they nearly always WANT their weight loss and adverse health affects to be documented, as this adds legitimacy to advancing the cause they are striking for.
7. Based on the weight data from the previous step, monitor the patient’s BMI over time. Laws in some states have a provision to obtain a court order to force feed a patient if their BMI drops below a certain value. This is based on patient’s restriction of autonomy to choose to end their own life while in custody.
8. Ask the patient if they are taking liquids. In some unusual cases, the patient wants to obtain a quick result from their strike, and can do so in a shorter period of time by becoming severely dehydrated.
9. Don’t panic, but do keep administration apprised of any acute risks among striking patients. Far too often, in my opinion, medical supervisors and other administrators will take actions too quickly to either give in to the demands of the strikers, or treat a situation like it is a medical emergency when clearly it is not. The vast majority of people can fast safely for long periods of time, and whittle their body weight down to pretty low levels before they start encountering significant and permanent adverse health outcomes. In my observation, I have seen several patients approach being 15% below the low end of healthy BMI, and then end their fast. The reason for this is their body starts the starvation process, and the overwhelmingly powerful desire to eat takes over the desire to continue the fast. I have only ever seen patients with severe mental illness drop below the 15% threshold, but I have read of cases where some very determined person with a sound mind has still allowed themselves to starve.
10. Avoid placement of the patient in suicide watch as a punishment, or as even a mismatched precaution, for the patient being on a hunger strike. Sometimes administration will pressure nursing to use this tactic. This is a misuse of this housing, which impinges on the autonomy of the patient.
Deborah Shelton says
Excellent discussion. thank you!