United for No Injustice, Oppression or Neglect


Nursing Ethics in Prison Questioned

John Stanly, M.D.

There can be no greater covenant than that between patient and nurse. Compassionate delivery of health care above all other goals is implicitly understood and supercedes that of the physician. Nursing ethics forbid participation in state mandated executions, while physicians commonly play a subsidized role. The nurse speaks for those weakened by disease in times of need and advocates on their behalf for appropriate medical care. It is in this context that I question the dual responsibility of nurse and guard combined as a Medical Technical Assistant (MTA) in our prisons. Can this hybrid be expected to serve a dual ethic? Typically a Licensed Vocational Nurse or Registered Nurse with custodial training, the MTA job description includes both nursing duties and inmate supervision. Discipline is part of the job. Can compassion and correction coexist? Is it acceptable to comfort with one hand and punish with the other? Perhaps only a mother is qualified to do so in our society an!

d even then may be accused of schizotypal behavior. It is too much to ask of any human to be both a disciplinarian and health care provider for the sole reason that the temptation to discipline via health care violates our basic human rights.

The International Council of Nursing has affirmed the Geneva Convention and has explicitly reviewed the role of the nurse in prisons since at least 1975. Nurses are forbidden from participating in interrogations, security procedures or torture and are bound to report physical or mental ill treatment to national and/or international organizations. Position statements from the American Nursing Association and the Code of Nurses consistently support the right to medical care of all individuals independent of their place in society. The Council further compels nursing organizations to assist and advise nurses placed in such a dilemma. Formal review of the MTA position by state nursing associations is presently lacking.

In fairness, the California Department of Corrections officially demands MTAs to uphold the ethics of the nursing profession. Ideally an efficient use of manpower, an MTA could be used to assist a physician as well as unlock doors and move patients securely per protocol. In practice, however, the department is so short staffed that greater responsibility is bestowed upon the MTA. 

Most worrisome of their duties is that of triage. Sorting of patients into a prioritized order, as we have all encountered in the emergency room setting, is not an easy job. Serious problems often present with vague symptoms or normal vital signs. One of the most common complaints voiced by inmates statewide is uncompassionate triage of medical problems. All medicines, even over the counter remedies, must be obtained from the health care staff. Unless the inmate plans for illnesses weeks in advance, access to antacids, headache and cold medicines must be triaged. If not deemed an emergent condition, the MTA issues an appointment in a week - provided a five dollar co-payment is first received. Screening usually involves a phone call from a guard in a housing unit to the MTA in the clinic. Inadequate urgency voiced at this initial contact translates into a longer wait. Indeed, some inmates have died waiting. Others are threatened with a Rules Violation Report and disciplinary !

action if they donít have a fever when presenting to the clinic with an acute illness. Malingering, or the manipulative seeking of health care, is commonly suspected in prison as it is in the public sector. In general, true cases are rare and the adroit nurse can best deal with this with understanding, rather than discipline. Already saddled with a co-payment equal to a weeks salary, the inmate has little incentive to fake illness. 

MTAs are not evil. They are merely human and tasked to do a job that challenges their ethics on a daily basis. Stressed with an overpopulated prison system and understaffed nursing, physician and dental personnel, the system is failing. The true nurse is supposed to be the advocate of the inmate and facilitate health care. Instead, prison perverts these responsibilities by incorporating the nurse into the system. The freedom to seek another health care provider is lost in prison hence the ill inmate is at the mercy of the MTA. Any system that intrudes on the trust between patient and nurse in the delivery of proper, compassionate and timely health care should be questioned. 

Recent anti-crime legislation has expanded the California prison system beyond all others in the western world. We imprison the largest percentage of our own people amongst the developed nations and much of the third world. However, we have been cheap in our fiscal responsibility to ensure operating costs are adequate. The MTA job description appears to be a budgetary value on the surface but insidiously erodes at human rights in practice. I believe the post should be eliminated and the staff rehired as true nurses in order to do their true job. I am asking state and national nursing associations to evaluate this position and take a stand. Californians must acknowledge a fiscal responsibility to care for our prisoners in an ethical manner. We fought hard for human rights and demand other nations to uphold these values, but have let these rights slip in our own backyard. We are no longer at the forefront of righteousness. We continue to build new prisons yet cannot fulfill ou!

r custodial responsibilities. Something must change. Either we greatly increase the budget of the Department of Corrections or re-evaluate who should be in prison. Alternatives to incarceration that maintain the safety of the public are available and represent the most cost effective and humane path to follow. Nonviolent criminals do not need to be behind bars and no one deserves to be denied health care.

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