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. Prisoners forfeit many of their rights when entering a correctional facility. 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 Peyton works in one of these prisons where she witnesses some of her patients being coerced by other inmates to be a part of the hunger strike. She also sees hunger striking patients being offered special privileges by prison staff for breaking their fast.
Often patient self-determination issues are framed in the context of end-of-life treatment decisions. For example, a patient has a right to refuse cancer treatment that they feel will not improve their quality of life in their remaining days. But, in the case of correctional patients, freedom of choice is severely limited in so many areas of life. In this stark environment, self-determination in health decisions may also be clouded by the limitations of incarceration.
The Ethical Principle of Autonomy
Patient self-determination is based on the principle of respect for autonomy. Autonomy in health care refers to the patients 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 Peyton 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 prisoners. 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 abated, undue influence can still be exerted on those whose rights are already abridged 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 lake the capacity to make a health decision need a formally designated surrogate. This may be the courts or a legally acquired decision-maker.
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 inmates 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 Peyton’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 Peyton 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 Peyton’s situation? What should she do, if anything? Share your suggestions in the comments section of this post.