There are urgent calls to abandon the restraining of prisoners receiving palliative care, with the ongoing practice blamed on the Australian justice and health systems colliding.

Prisoners receiving palliative care in Australia, either in a hospital or a palliative care unit, may still be subject to prison policies regarding restraint even though care is being provided outside of a prison environment, experts say.

“Health care professionals involved in caring for hospitalised prisoner patients [have] described a ‘seemingly opaque system’ around the protocols and points of contact for removing shackles,” wrote Lara Pemberton from the Biomedicine Discovery Institute at Monash University and colleagues in a Perspective, published in the Medical Journal of Australia today.

The processes for getting the shackles removed from a restrained prisoner is also “time-consuming and deliberative — time that a dying person may not have,” Ms Pemberton wrote.

In some jurisdictions in Australia, health care staff must follow formal pathways “to request a review of a patient’s risk assessment”.

Shackling prisoners in palliative care 'must stop'  - Featured Image
Health care professionals have described a ‘seemingly opaque system’ around the protocols for removing shackles of prisoner patients (Chinnapong / Shutterstock)

The practice has also been under scrutiny in the United States, with Dr Tyler Lescure writing that doctors have a “moral quandary” when administering palliative care to incarcerated patients.

“The current practice of hospitals is to defer entirely to prison policy when interacting with incarcerated patients,” Dr Lescure wrote.

“This is not acceptable. We can no longer be bystanders in the mistreatment of people who arrive at our doors to receive care and neglect their right to be free of inhumane punishment.”

Ms Pemberton and colleagues agreed, writing that “it is beyond time that we abandon the practice of restraining dying prisoner patients.”

“It is essential that the practice of restraining dying prisoner patients is reviewed and overhauled so that prisoners can be granted the fundamental human right of a dignified death,” they wrote.

The Australian Medical Association (AMA)’s position statement on medical ethics in custodial settings states that “medical personnel should never proceed with medical acts on restrained people, except for those with potential for immediate and serious risk for themselves and others”.

Although standards exist to limit the use of restraints both in Australia and internationally, reports of prisoner patients dying while shackled to their beds still materialise, Ms Pemberton wrote.

In one case recorded in the United States, a patient on a ventilator was shackled to a bed, leaving the treating doctors stunned.

“I leaned back abruptly, as if stumbling on a crime scene, and stared at the shackle,” the doctor wrote.

“The patient could not move; he was dependent on medications to support his blood pressure, a ventilator to breathe, and blood would soon flow through a machine in the absence of working kidneys … I hurried to another unit to continue rounds, but no longer felt I was in the business of healing.”

Excluding prisoners from Medicare and the PBS

While palliative care for prisoners is in the spotlight this week, there are again calls for prisoners to no longer be excluded from Medicare and Pharmaceutical Benefits Scheme (PBS) subsidies.

In a submission to the Pharmaceutical Benefits Advisory Committee’s March 2024 meeting, the AMA raised concerns about inequitable health care for Australians in custody.

“It is appalling and an affront to Australia’s human rights status that prisoners in this country aren’t allowed to receive the same quality of health care as the wider community,” AMA President, Professor Stephen Robson said.

“Because of legislation dating back to 1973, people in custodial settings are not able to receive treatment under the country’s universal health insurance scheme, Medicare, nor are they allowed to receive medicines subsidised by the PBS.”

Prisoners and young people in detention are excluded from receiving Medicare and PBS subsidies under section 19(2) of the Commonwealth Health Insurance Act 1973. This exclusion was designed to avoid duplication of services – with state and territory governments funding prison-based health services – but experts say it is a source of inequity between prisoners and the general population.

The call for greater change

Prisoner populations in Australia are ageing at a pace that far exceeds the general population (here). Former prisoners also visit a general practitioner at twice the rate of the general population once released.

“There are compelling human rights, public health, economic and criminal justice grounds on which to argue for better health care for ex-prisoners,” said Jane Hwang, a Postdoctoral Research Fellow in the Justice Health Research Program at the University of New South Wales Sydney, writing recently in InSight+.

“To do so, multiple levels of change and concerted efforts between stakeholders across prisons, health and social services will be required.

“I call for improved systems for medical information sharing between justice and health sectors, the introduction of Medicare to prisons, and improved awareness for community-based aged and health care providers regarding this group.”

The impact of hepatitis C

Due to the criminalisation of injecting drug use, research from the Kirby Institute has found there is a high prevalence of hepatitis C in prison populations (approximately 20%).

Incidental hepatitis C infection is also high in prisons due to lack of prevention measures and the sharing of needles.

Without a national strategy or framework for treating hepatitis C in prisons, Australia will struggle to meet its hepatitis C elimination goals, Monash University senior research officer, Rebecca Winter, and Kirby Institute research project manager, Yumi Sheehan. recently told InSight+.

“Prison settings need continued resourcing to ensure that comprehensive hepatitis C care is available to all people in prison through primary care-led services,” they said.

“In tandem, community services need bolstering.”

Read the Perspective in the Medical Journal of Australia.

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