The March 28, 2011 report highlights the conflicts that arise when medical officials are torn between their duties to their patients and their obligations to an employer, government agency, insurer or the military – a common problem in immigration facilities, prisons and other detention centers.
The relationship between doctor and patient is sacrosanct and deserves special recognition, treatment and protection under the law. Indeed, the World Medical Association’s International Code of Ethics affirms that “a physician shall owe his patients complete loyalty and all the resources of their science.”
When doctors and health care professionals are caught between two parties with different or discordant aims and objectives, they have what is known as a “dual loyalty” conflict.
“In many cases, health professionals who succumb to the pressure to fulfill third party needs at the expense of their patients end up breaching the ethical obligations of their profession and violating the human rights of the very person who is entitled to the health professionals’ strongest loyalty,” the PHR report stated. “Ethically, with very rare and well-circumscribed exceptions, a health professional is obligated to act in the interest of the patient above all other concerns.”
Cases in which a medical professional’s loyalty to a patient is inhibited are most common in closed environments such as prisons, jails, detention centers, mental health facilities and the military. “Health professionals working in these environments often find it difficult to provide the best possible care for their patients because they feel pressure to participate in institutional security, cost cutting, and helping to meet other institutional objectives.”
The U.S. immigration detention system is ripe for dual loyalty conflicts because the government is an interested party, security concerns are strong, transparency and accountability are lacking, employees are encouraged to reduce costs, and the role of health care professionals is ambiguous.
Staff shortages are a common way to keep costs low. The PHR report cites a resignation letter from a registered nurse at the Eloy Detention Center in Arizona. She described the medical situation at the facility as “total disorganization,” with a “severe nursing shortage on nights and weekends, and a pharmacy that was unstaffed and containing only a minimal stock of drugs on weekends.” The medical director was “wont to change or stop stable psychiatric patients’ medication solely for cost effectiveness, resulting in unmanageable behavior or suicide attempts.”
Immigration and Customs Enforcement (ICE) detains around 400,000 people annually, with about 33,000 in custody at any given time. To hold all of these people, ICE owns and operates detention centers and also contracts with private companies and local jails. The average length of detention is 30 days but many detainees are held for much longer periods of time before being released or deported.
Some detainees are already suffering from chronic health conditions when they enter the system, and the substandard health care and/or difficulty accessing necessary medical and mental health services during detention can cause their health to deteriorate quickly and substantially, often irreversibly. Between October 2003 and October 2010, 113 people died in ICE custody. Many were natural or unavoidable deaths but some were preventable or questionable. [See: PLN, Feb. 2009, p.10].
The PHR report chronicles the story of Francisco Castaneda, an immigrant from El Salvador. While incarcerated he sought medical help for an extremely painful and bleeding lesion on his penis. ICE Health Service Corps denied a recommendation for a biopsy to diagnose penile cancer, which it deemed an “elective procedure.”
As Castaneda’s condition worsened he was treated with antibiotics and ibuprofen. A tumor developed eleven months later, and days before a scheduled biopsy he was suddenly freed. Emergency room doctors confirmed he had cancer and recommended amputation of his penis. Despite that procedure and chemotherapy, it was too late. Castaneda subsequently died of cancer that was not diagnosed or treated while he was in ICE detention. [See: PLN, June 2011, p.24; Oct. 2010, p.44; April 2010, p.46; Sept. 2008, p.32].
Treatment for “detainees who complain or act out due to mental conditions beyond their control” frequently consists of being “sent to segregation units or held down in restraints because staff is unable or unwilling to help them control their behavior,” according to the report. “Even those on suicide watch are routinely assigned to segregation in place of receiving necessary psychiatric care.”
Further, ICE regularly forces detainees to take medications, mostly psychotropic drugs. The Washington Post documented more than 250 cases between 2003 and 2008 in which ICE administered such drugs as a “pre-flight cocktail” to sedate detainees while they were being deported by plane. Such forced drugging constitutes a significant dual loyalty conflict for medical professionals. [See: PLN, Jan. 2009, p.10].
The PHR report makes seven recommendations to prevent health care staff from being subjected to dual loyalties: 1) medical workers in detention centers should report to health organizations independent of agencies or contractors overseeing the centers; 2) address chronic staffing shortages; 3) ensure clear lines of accountability; 4) create an independent oversight organization; 5) create an ombudsman office for detainees to easily report grievances regarding access to medical care; 6) make the Performance Based National Detention Standards (PBNDS) legally enforceable in all facilities that house immigration detainees; and 7) revise PBNDS so the standards are based on an administrative model of temporary custody rather than the current penal, corrective model.
Most importantly, the PHR report stresses that the “ultimate responsibility for handling dual loyalty conflicts appropriately must lie with the health professionals themselves.” The report is available on PLN’s website.
Source: “Dual Loyalties: The Challenges of Providing Professional Health Care to Immigration Detainees,” Physicians for Human Rights (March 2011)
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