He sits heavily in the chair, flanked by prison guards. The thick manacles glisten and the chains run from each wrist, down to the floor and up again to the guards’ own. The problem, as stated in the referral, is a relatively simple one. I don’t think I will need to examine him, which is a relief because that would require a lot of micro-logistics and Dickensian clanking.
I look at him, and he meets my eye. My role here is straightforward. Take a history, organise investigations. But look at those chains. Two. It would be easy for me to turn the computer screen to one side, out of view, and Google his name. There would be a newspaper report, a court document perhaps. He must have hurt someone physically, to earn those chains. Of, if the violence was not direct, then he must have harmed people in some other way. Perhaps it was something truly unspeakable… but come on, I’m being distracted. To do my job here I have to do the opposite of what I usually do – avoid the personal history, avoid the background, avoid making an emotional connection… in short, bypass the deeply ingrained habit of engaging the empathy chip. Treat him as an organism. Politely, nicely, kindly even, but not at an emotional level. Strange paradox. The only way I can be a doctor to him is by not knowing him.
Yes, he deserves medical care. He is a citizen, he paid taxes. The state does not include sub-standard medical care as part of his punishment. In the Emergency Department, I wouldn’t pause to think. I’d run to the trolley, do the ABC’s, get a cannula in, treat him aggressively, ask questions afterwards (or just move on to the next case without thinking too much). Perhaps it’s easier in the ED, because emergency care is more corporeal. Relationships are not required. But here, in the clinic, it should be two-way.
The way he is staring at me… it’s as though he knows what I’m thinking. There’s a look of resignation on him. He’s been here before. He’s seen other well-meaning but slightly confused medics. He’s waiting for me to start.
Colleagues of mine go to prisons all the time. Hepatitis C is highly prevalent, and specialist nurses or consultants visit regularly to assess, scan and make decisions about anti-viral treatment. How do they manage it? I should ask. Perhaps they just don’t think too deeply about the reasons. They all have personalities after all; you can still engage.
Doctors’ attitudes toward treating prisoners have not been studied deeply, but Tuite and colleagues published a small survey in 2006. Over 70% sometimes or always asked the prison guards if the patient was a safety risk. It is not clear whether this question was asked in front of the prisoner. To do so would seem rude. But does rudeness matter? Many responded that they asked the prison guard to leave, in an effort to maintain confidentiality. This is the natural instinct of every doctor, but the safety question would have to come first. Do I really want to be alone with this person? When I see a prisoner in chains, I don’t worry about confidentiality too much. In my mind it is one of those rights that has been forfeited. Perhaps that is an over-punitive mindset.
The Secret Doctor, writing in BMA news, spoke about her (I think it was a her) impatience with prison guards when they refused to undo the chains in intensive care, even though the patient was critically ill. The patient was Category A, and rule were rules.
I was being unreasonable, but he was my patient right? A critically unwell man and I wanted to give out critical illness amnesty. I mean at least while he didn’t even have the capacity to breath. The guards looked at me, unemotional, with faces that said ‘governor says no’. I felt like they did not understand, but how could they? I had hardly explained where I was coming from. I left.
In the end, she concluded that both prisons and hospitals have rules, and sometimes they clash. We have to live with that.
Bethan Roberts, writing another BMA blog in 2019, described her job as a prison GP. She didn’t go into the ethics, or her personal attitudes, rather she emphasised the vulnerable nature of the prison population and the fact that average life expectancy was only 56. Interestingly, a lot of her work appeared to be removed from patients. It is not clear, reading the blog, whether she developed much familiarity, sense of affection, or empathy with her patients.
Most would argue that in these circumstances we should be non-judgmental, morally-blind, and absolutely focussed on the individuals needs. This ideal extends beyond prisoners, to those whose health is harmed by their own actions or choices. We are non-judgmental; we have to be. Yet… when faced with a towering, gym-honed man bound to two guards, it is forgivable for the mind to wander.
When I worked in ICU, many years ago, a gangster was admitted (the rumours spread, and it was on the news) with life-threatening injuries. I re-sited his lines under the gaze of a gun-toting policeman. There were more police outside the unit, in case his enemies broke in to ‘finish it’. He survived. As he left, a wag said, ‘Mmmm… pretty high chance of disease recurrence.’ I wasn’t there, but heard the joke second hand as it was so good. I did wonder though, if he left the same man, or had been transformed by the experience, destined to make peace wherever he went. Then I realised that for all the privileged insights we as doctors are given to the motives and ambitions of our patients, we are not there to judge, let alone influence. We are there to make them better. They are not interested in our opinions.