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Health care and the prisoner: a human rights perspective
Journal of Clinical Forensic Medicine (1997)4, 181-184
© APS/HarcourtBrace& Co Ltd 1997
PRISON MEDICINE
Health care and the prisoner: a human rights perspective A. Coyle International Centre for Prison Studies, King's College, University of London, London, UK Journal of Clinical Forensic Medicine (1997), 4, 181-184
INTRODUCTION
over 1 million people in prison. The figures for China are unknown, but estimates range from 5-10 million people. In the UK, the number of people in prison has gone up by 50% in the last 4 years. The numb4r of women in prison in England and Wales has actually doubled during that period. This explosion in the number of men and women in prison has had several important consequences. In some countries it has meant inhumane levels of overcrowding. Overcrowding is a relative term. In England, it means two prisoners sharing a cell which was built to hold one person. In Russia, it means 90 prisoners sharing 40 beds in a room which was originally intended to hold 20 people. In many countries, it has meant prisoners spending almost the whole of each day locked in these overcrowded cells with nothing to do. In some countries it has meant a massive increase in public expenditure. In the USA in 1981, the State of California spent 3% of its budget on prisons and 18% on higher education. In 1994, it spent 8% on prisons and 8% on higher education? One response to this burgeoning cost has been a move in some countries, including the UK, toward involving commercial companies in what has become the prison industry. Consortia of private security firms and building companies have been given contracts to finance, design, build and manage prisons. In some instances contracts have been awarded for terms of over 25 years, in a manner which in effect commits successive governments to financing high levels of imprisonment for many years to come on a hirepurchase basis. The most disturbing consideration of all is that there is no logical reason as to why the seemingly inexorable increase in levels of imprisonment should be halted unless there is a deliberate decision on the part of humankind to do so. We find it difficult to believe that the number of men and women in prison in England and Wales has risen to 63 000. What is to prevent it rising to 100 000, 200 000 or even 300 000?
Prison as a place of punishment is a relatively modern concept, having been in existence in its present form for less than 3 centuries. Before that time, prisons existed merely as places where people were held to await trial, until a debt or fine was paid, or while awaiting some other judicial disposal such as execution or exile. The prison as a place for punishment per se had its genesis in the north west of the USA and in western Europe. It is now an integral feature of most societies, having been spread in the course of the last hundred years or so by erstwhile colonial powers to many societies where the concept of imprisonment is not indigenous. Despite the fact that the prison is now as much a part of many societies as the school or hospital, it is interesting that there is still debate about its main purpose. Some will argue that it is there to punish wrongdoers; others believe it is there to deter potential criminals or to protect the public. Still others believe its purpose is to reform criminals and turn them into lawabiding citizens. Even in the U K Home Secretaries, who have parliamentary accountability for prisons, adopt differing positions. A White Paper published when David Waddington was Home Secretary ~ described imprisonment as 'an expensive way of making bad people worse'. Speaking to the Conservative Party Conference in 1993, one of Waddington's successors, Michael Howard, announced 'Prison works') In 1997, his successor Jack Straw, said 'I have no interest in chanting a simple mantra that 'prison works'? Whatever the differing views about the purposes of imprisonment, there has been great enthusiasm in most countries to have more of it. Since 1981, the prison population in the USA has risen by over 300% to 1.6 million men and women. In Russia, there are Dr Andrew Coyle, International Centre for Prison Studies, King's College, University o f London, London, U K 181
182
Journalof Clinical Forensic Medicine
But that would be impossible, would it not? That would be equivalent to the current level of imprisonment in the USA and until recently, that was thought to be impossible.
I N T E R N A T I O N A L
C E N T R E
F O R
• •
P R I S O N
S T U D I E S
It was within this context that the International Centre for Prison Studies (ICPS) was established within King's College, University of London, in April 1997. ICPS has set itself the daunting task of assisting governments and other relevant agencies to develop appropriate policies on prisons and the use of imprisonment. The Centre works on a project or consultancy basis with international agencies, governmental and non-governmental organizations. It aims to make the results of its work widely available to groups and individuals, both nationally and internationally, who might not normally use such work. Such people will include policy-makers, practitioners and administrators, the media and the general public. It is hoped that public education will help to increase an understanding of the purpose of prison and what can be expected of it. ICPS has two clear objectives. They are: • To develop a body of knowledge, based on international covenants and instruments, about the principles on which the use of imprisonment should be based, which can be used as a sound basis for policies on prison issues. • To build up a resource network for the spread of best practice in prison management worldwide to which prison administrators can turn for practical advice on how to manage prison systems which are just, decent, humane and cost-effective. It aims to achieve these objectives by undertaking a series of activities which include: • Carrying out, organizing and publishing research into the purposes of imprisonment and making this available to policy-makers, practitioners, administrators, the media and the general public • Disseminating information about the international covenants and instruments relating to detention and imprisonment in a manner which is accessible to prison personnel • Sharing experience about how the international instruments relating to detention and imprisonment should be applied in practice • Undertaking practical prison projects, which take account of the cultural, social and financial
•
•
realities in the countries involved, at the request of international agencies, national governments and non-governmental organizations Developing and evaluating models of best practice Building up a database of good models of prison management and effective projects and making this available on a worldwide basis Making use of an international network of individuals and agencies with a record of achievement in this field of work Organizing seminars, conferences and publishing reports.
ICPS is already involved with intergovernmental agencies, such as the United Nations and the Council of Europe, with government departments and nongovernmental agencies on a number of projects.
Box Examples of the work of ICPS • The role of imprisonment within society • How prisons can best serve society - - Who should be sent there? - - Who should not be sent there? - - How to obtain the best value for public money • The balance in prisons between justice, security, good order and humanity • Applying the agreed international standards to imprisonment • Specific groups of prisoners, including: -Pre-trial and remand prisoners - - Maximum security prisoners - - Women prisoners -Juvenile prisoners - - Mentally-disordered prisoners Racial, religious, cultural and other minorities -Prisoners under a death sentence • Creating awareness among prisoners of the consequences of their actions • Prison regimes • Preparing prisoners for release • Links between the prison and society • Prison management • Staff issues, including: -Recruitment -Training and development -Motivation -Demilitarization • Regional cooperation among prison systems • How to make prisons self-sufficient in poor and developing countries • Placing the prison within the culture of the local society • Different models of prison and imprisonment
Health care and the prisoner: a human rights perspective H E A L T H CARE P R O B L E M S IN P R I S O N S
Some of the most intractable problems surrounding the whole subject of imprisonment concern health care issues. The mental health of prisoners is a matter of universal concern. A study carried out in 19915 estimated that 37% of convicted men and 56% of convicted women in prison in England and Wales suffer from some form of psychiatric disorder. One of the most disturbing findings of a parallel study of remand prisoners 6 found that: remands in custody of the mentally disordered were not carried out because of the nature of their offences, but because of their need for social and psychiatric help... Conditions of gross overcrowding allied to poor conditions of detention bring specific health dangers. A mission to a remote region of Kazakhstan in 1997, of which the present author was a member, was informed that 21% of prisoners in that country suffer from some form of tuberculosis. In the opinion of the medical member of the mission, who is an expert in tuberculosis, this is probably an underestimate of the actual figure. These figures are mirrored in a number of other countries. A significant number of these prisoners contracted the disease while in prison. Their release at the end of sentence poses a substantial threat to the health of the community they will live in. Prison systems also face severe challenges in the treatment of prisoners who have contracted the HIV virus or AIDS.
R O L E OF T H E P R I S O N M E D I C A L OFFICER
The professional position of doctors who work in prisons is extremely sensitive. The reality of caring for the health of people who are deprived of their liberty presents a whole series of dilemmas. By definition, the patients who are being treated are not free men and women. They may on occasion be under pressure to accept treatment which they do not really want, or to take drugs in the hope of obtaining early release. In some countries, prison administrators may require doctors working for them to cross the line between treatment for the benefit of the patient and treatment for the sake of a quiet institution. Doctors may see injuries resulting from illegal actions by prison staff who expect the doctor to cover up what has happened. Doctors may see illnesses which result from malnutrition, poor hygiene or other inadequacies on the part of the prison administration. They may face the unenviable choice of speaking out at the risk of dismissal or of keeping quiet in order to continue to be able to help prisoners.
183
Prison doctors are often expected to carry out official duties within the prison administration. They may, for example, be required to certify that accommodation is fit for use. They may be required to confirm that certain prisoners are fit to be punished. More controversially, in some countries they may be expected to oversee corporal and capital punishment or to take part in the forced feeding of hunger strikers. In some states of the USA, doctors are directly involved in execution by lethal injection. A recent study of this issue 7 concluded: We found that physicians are involved in all methods of executions, especially ones performed by lethal injection, in violation of professional ethical guidelines. Physicians continue to consult on lethal dosages, examine veins, start intravenous lines, witness executions and pronounce death.
INTERNATIONAL INSTRUMENTS
In a discussion such as this, it is useful to refer to international declarations and principles. In 1975, the World Medical Association unanimously adopted the Declaration of Tokyo - Guidelines for Medical Doctors Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention or Imprisonment. This became a source document in respect of medical ethics. The Declaration sets out in its first paragraph a basic philosophy: The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty, and whatever the victim's beliefs or motives, and in all situations, including armed conflict and civil strife. The Declaration of Tokyo formed the starting point for a more general code of ethics which was drafted by the Council for International Organisations of Medical Sciences at the request of the World Health Organisation and which was subsequently adopted by the United Nations General Assembly in 1982 under the heading Principles of Medical Ethics Relevant to the Role of Health Personnel Particularly Physicians in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. There are six basic principles. The first is that Prisoners shall be afforded medical care of the same quality and standard as is available to the general public.
184
Journalof Clinical Forensic Medicine
The second makes it clear that it is a gross contravention of ethics for medical staff to condone or participate in torture, cruel, inhuman or degrading treatment or punishment. The third principle deals with the issue of the role of doctors in prison management. It is a contravention of medical ethics for health personnel, particularly physicians, to be involved in any professional relationship with prisoners or detainees 'the purpose of which is not solely to evaluate, protect or improve their physical or mental health'. The principle deals with the sensitive matter of the involvement of doctors in making judgements about a person's fitness to be punished.It states that health personnel may not participate in the interrogation of prisoners or certify their fitness for punishment where their treatment could adversely affect their health and where it is not in accordance with international norms. The physical restraining of prisoners is an area with potential for the abuse of human rights. It states that health personnel may only assist in the restraint of prisoners where it is necessary for the protection of their health or that of others and where it presents no hazard to their health. Principle six underlines the fact that hese principles must be adhered to at all times and under all circumstances.
CONCLUSION The prison is a place of great symbolism. This begins the moment a prisoner comes through the gate of the prison. Clothes are taken from prisoners and they must take a bath or shower. The prisoners are given a set of uniform clothing and a number, which will become more important than their own name. This symbolism will continue until the moment of release. It is important that the doctor should be a symbol of the fact that humanity, decency and respect for human beings does not end at the gate of the prison. The interface between the prison and the health care of those who are detained there often presents the doctor with the greatest challenge to his or her Hippocratic oath. REFERENCES
1. Home Office. Crime, Justice & Protecting the Public, London: HMSO, Cmnd 965, 1990 2. Howard M. Speech to Conservative Party Conference. October 1993 3. Straw J. New Approaches to Crime & Punishment. Speech at the Launch of the International Centre for Prison Studies, October 1997 4. Donzinger S. The Real War on Crime: Report of the National Criminal Justice Commission New York: Harper Perennial, 1996 5. Gunn J, Maden T, Swinton M. Mentally Disordered Prisoners. London: Home Office, 1991 6. Dell S, Grounds A, James K. Mentally Disordered Remand Prisoners, London: Home Office, 1991 7. Breach of Trust, Physicians Participation in Executions in the United States. Report prepared by The American College of Physicians, Human Rights Watch, National Coalition to Abolish the Death Penalty and Physicians for Human Rights, March 1994
© APS/HarcourtBrace& Co Ltd 1997
PRISON MEDICINE
Health care and the prisoner: a human rights perspective A. Coyle International Centre for Prison Studies, King's College, University of London, London, UK Journal of Clinical Forensic Medicine (1997), 4, 181-184
INTRODUCTION
over 1 million people in prison. The figures for China are unknown, but estimates range from 5-10 million people. In the UK, the number of people in prison has gone up by 50% in the last 4 years. The numb4r of women in prison in England and Wales has actually doubled during that period. This explosion in the number of men and women in prison has had several important consequences. In some countries it has meant inhumane levels of overcrowding. Overcrowding is a relative term. In England, it means two prisoners sharing a cell which was built to hold one person. In Russia, it means 90 prisoners sharing 40 beds in a room which was originally intended to hold 20 people. In many countries, it has meant prisoners spending almost the whole of each day locked in these overcrowded cells with nothing to do. In some countries it has meant a massive increase in public expenditure. In the USA in 1981, the State of California spent 3% of its budget on prisons and 18% on higher education. In 1994, it spent 8% on prisons and 8% on higher education? One response to this burgeoning cost has been a move in some countries, including the UK, toward involving commercial companies in what has become the prison industry. Consortia of private security firms and building companies have been given contracts to finance, design, build and manage prisons. In some instances contracts have been awarded for terms of over 25 years, in a manner which in effect commits successive governments to financing high levels of imprisonment for many years to come on a hirepurchase basis. The most disturbing consideration of all is that there is no logical reason as to why the seemingly inexorable increase in levels of imprisonment should be halted unless there is a deliberate decision on the part of humankind to do so. We find it difficult to believe that the number of men and women in prison in England and Wales has risen to 63 000. What is to prevent it rising to 100 000, 200 000 or even 300 000?
Prison as a place of punishment is a relatively modern concept, having been in existence in its present form for less than 3 centuries. Before that time, prisons existed merely as places where people were held to await trial, until a debt or fine was paid, or while awaiting some other judicial disposal such as execution or exile. The prison as a place for punishment per se had its genesis in the north west of the USA and in western Europe. It is now an integral feature of most societies, having been spread in the course of the last hundred years or so by erstwhile colonial powers to many societies where the concept of imprisonment is not indigenous. Despite the fact that the prison is now as much a part of many societies as the school or hospital, it is interesting that there is still debate about its main purpose. Some will argue that it is there to punish wrongdoers; others believe it is there to deter potential criminals or to protect the public. Still others believe its purpose is to reform criminals and turn them into lawabiding citizens. Even in the U K Home Secretaries, who have parliamentary accountability for prisons, adopt differing positions. A White Paper published when David Waddington was Home Secretary ~ described imprisonment as 'an expensive way of making bad people worse'. Speaking to the Conservative Party Conference in 1993, one of Waddington's successors, Michael Howard, announced 'Prison works') In 1997, his successor Jack Straw, said 'I have no interest in chanting a simple mantra that 'prison works'? Whatever the differing views about the purposes of imprisonment, there has been great enthusiasm in most countries to have more of it. Since 1981, the prison population in the USA has risen by over 300% to 1.6 million men and women. In Russia, there are Dr Andrew Coyle, International Centre for Prison Studies, King's College, University o f London, London, U K 181
182
Journalof Clinical Forensic Medicine
But that would be impossible, would it not? That would be equivalent to the current level of imprisonment in the USA and until recently, that was thought to be impossible.
I N T E R N A T I O N A L
C E N T R E
F O R
• •
P R I S O N
S T U D I E S
It was within this context that the International Centre for Prison Studies (ICPS) was established within King's College, University of London, in April 1997. ICPS has set itself the daunting task of assisting governments and other relevant agencies to develop appropriate policies on prisons and the use of imprisonment. The Centre works on a project or consultancy basis with international agencies, governmental and non-governmental organizations. It aims to make the results of its work widely available to groups and individuals, both nationally and internationally, who might not normally use such work. Such people will include policy-makers, practitioners and administrators, the media and the general public. It is hoped that public education will help to increase an understanding of the purpose of prison and what can be expected of it. ICPS has two clear objectives. They are: • To develop a body of knowledge, based on international covenants and instruments, about the principles on which the use of imprisonment should be based, which can be used as a sound basis for policies on prison issues. • To build up a resource network for the spread of best practice in prison management worldwide to which prison administrators can turn for practical advice on how to manage prison systems which are just, decent, humane and cost-effective. It aims to achieve these objectives by undertaking a series of activities which include: • Carrying out, organizing and publishing research into the purposes of imprisonment and making this available to policy-makers, practitioners, administrators, the media and the general public • Disseminating information about the international covenants and instruments relating to detention and imprisonment in a manner which is accessible to prison personnel • Sharing experience about how the international instruments relating to detention and imprisonment should be applied in practice • Undertaking practical prison projects, which take account of the cultural, social and financial
•
•
realities in the countries involved, at the request of international agencies, national governments and non-governmental organizations Developing and evaluating models of best practice Building up a database of good models of prison management and effective projects and making this available on a worldwide basis Making use of an international network of individuals and agencies with a record of achievement in this field of work Organizing seminars, conferences and publishing reports.
ICPS is already involved with intergovernmental agencies, such as the United Nations and the Council of Europe, with government departments and nongovernmental agencies on a number of projects.
Box Examples of the work of ICPS • The role of imprisonment within society • How prisons can best serve society - - Who should be sent there? - - Who should not be sent there? - - How to obtain the best value for public money • The balance in prisons between justice, security, good order and humanity • Applying the agreed international standards to imprisonment • Specific groups of prisoners, including: -Pre-trial and remand prisoners - - Maximum security prisoners - - Women prisoners -Juvenile prisoners - - Mentally-disordered prisoners Racial, religious, cultural and other minorities -Prisoners under a death sentence • Creating awareness among prisoners of the consequences of their actions • Prison regimes • Preparing prisoners for release • Links between the prison and society • Prison management • Staff issues, including: -Recruitment -Training and development -Motivation -Demilitarization • Regional cooperation among prison systems • How to make prisons self-sufficient in poor and developing countries • Placing the prison within the culture of the local society • Different models of prison and imprisonment
Health care and the prisoner: a human rights perspective H E A L T H CARE P R O B L E M S IN P R I S O N S
Some of the most intractable problems surrounding the whole subject of imprisonment concern health care issues. The mental health of prisoners is a matter of universal concern. A study carried out in 19915 estimated that 37% of convicted men and 56% of convicted women in prison in England and Wales suffer from some form of psychiatric disorder. One of the most disturbing findings of a parallel study of remand prisoners 6 found that: remands in custody of the mentally disordered were not carried out because of the nature of their offences, but because of their need for social and psychiatric help... Conditions of gross overcrowding allied to poor conditions of detention bring specific health dangers. A mission to a remote region of Kazakhstan in 1997, of which the present author was a member, was informed that 21% of prisoners in that country suffer from some form of tuberculosis. In the opinion of the medical member of the mission, who is an expert in tuberculosis, this is probably an underestimate of the actual figure. These figures are mirrored in a number of other countries. A significant number of these prisoners contracted the disease while in prison. Their release at the end of sentence poses a substantial threat to the health of the community they will live in. Prison systems also face severe challenges in the treatment of prisoners who have contracted the HIV virus or AIDS.
R O L E OF T H E P R I S O N M E D I C A L OFFICER
The professional position of doctors who work in prisons is extremely sensitive. The reality of caring for the health of people who are deprived of their liberty presents a whole series of dilemmas. By definition, the patients who are being treated are not free men and women. They may on occasion be under pressure to accept treatment which they do not really want, or to take drugs in the hope of obtaining early release. In some countries, prison administrators may require doctors working for them to cross the line between treatment for the benefit of the patient and treatment for the sake of a quiet institution. Doctors may see injuries resulting from illegal actions by prison staff who expect the doctor to cover up what has happened. Doctors may see illnesses which result from malnutrition, poor hygiene or other inadequacies on the part of the prison administration. They may face the unenviable choice of speaking out at the risk of dismissal or of keeping quiet in order to continue to be able to help prisoners.
183
Prison doctors are often expected to carry out official duties within the prison administration. They may, for example, be required to certify that accommodation is fit for use. They may be required to confirm that certain prisoners are fit to be punished. More controversially, in some countries they may be expected to oversee corporal and capital punishment or to take part in the forced feeding of hunger strikers. In some states of the USA, doctors are directly involved in execution by lethal injection. A recent study of this issue 7 concluded: We found that physicians are involved in all methods of executions, especially ones performed by lethal injection, in violation of professional ethical guidelines. Physicians continue to consult on lethal dosages, examine veins, start intravenous lines, witness executions and pronounce death.
INTERNATIONAL INSTRUMENTS
In a discussion such as this, it is useful to refer to international declarations and principles. In 1975, the World Medical Association unanimously adopted the Declaration of Tokyo - Guidelines for Medical Doctors Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention or Imprisonment. This became a source document in respect of medical ethics. The Declaration sets out in its first paragraph a basic philosophy: The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty, and whatever the victim's beliefs or motives, and in all situations, including armed conflict and civil strife. The Declaration of Tokyo formed the starting point for a more general code of ethics which was drafted by the Council for International Organisations of Medical Sciences at the request of the World Health Organisation and which was subsequently adopted by the United Nations General Assembly in 1982 under the heading Principles of Medical Ethics Relevant to the Role of Health Personnel Particularly Physicians in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. There are six basic principles. The first is that Prisoners shall be afforded medical care of the same quality and standard as is available to the general public.
184
Journalof Clinical Forensic Medicine
The second makes it clear that it is a gross contravention of ethics for medical staff to condone or participate in torture, cruel, inhuman or degrading treatment or punishment. The third principle deals with the issue of the role of doctors in prison management. It is a contravention of medical ethics for health personnel, particularly physicians, to be involved in any professional relationship with prisoners or detainees 'the purpose of which is not solely to evaluate, protect or improve their physical or mental health'. The principle deals with the sensitive matter of the involvement of doctors in making judgements about a person's fitness to be punished.It states that health personnel may not participate in the interrogation of prisoners or certify their fitness for punishment where their treatment could adversely affect their health and where it is not in accordance with international norms. The physical restraining of prisoners is an area with potential for the abuse of human rights. It states that health personnel may only assist in the restraint of prisoners where it is necessary for the protection of their health or that of others and where it presents no hazard to their health. Principle six underlines the fact that hese principles must be adhered to at all times and under all circumstances.
CONCLUSION The prison is a place of great symbolism. This begins the moment a prisoner comes through the gate of the prison. Clothes are taken from prisoners and they must take a bath or shower. The prisoners are given a set of uniform clothing and a number, which will become more important than their own name. This symbolism will continue until the moment of release. It is important that the doctor should be a symbol of the fact that humanity, decency and respect for human beings does not end at the gate of the prison. The interface between the prison and the health care of those who are detained there often presents the doctor with the greatest challenge to his or her Hippocratic oath. REFERENCES
1. Home Office. Crime, Justice & Protecting the Public, London: HMSO, Cmnd 965, 1990 2. Howard M. Speech to Conservative Party Conference. October 1993 3. Straw J. New Approaches to Crime & Punishment. Speech at the Launch of the International Centre for Prison Studies, October 1997 4. Donzinger S. The Real War on Crime: Report of the National Criminal Justice Commission New York: Harper Perennial, 1996 5. Gunn J, Maden T, Swinton M. Mentally Disordered Prisoners. London: Home Office, 1991 6. Dell S, Grounds A, James K. Mentally Disordered Remand Prisoners, London: Home Office, 1991 7. Breach of Trust, Physicians Participation in Executions in the United States. Report prepared by The American College of Physicians, Human Rights Watch, National Coalition to Abolish the Death Penalty and Physicians for Human Rights, March 1994