Marquette Cummings died an egregious death—not because of how he died, but rather who killed him. After being stabbed in the eye by another incarcerated person, Cummings was taken from St. Clair Correctional Facility in Springville, Alabama to the University of Alabama at Birmingham Hospital in critical condition. Even though Cummings’s mother said he was responding to visual cues, Cummings was given a DNR order—not under the direction of a doctor, but at the direction of Cummings’s prison warden, Carter Davenport. Davenport would later order the hospital to take Cummings off life support, despite his mother’s objections. Cummings would die just a day after he arrived at the hospital. Davenport was sued alongside the Alabama Department of Corrections and the hospital staff, and the Alabama Supreme Court ruled that Davenport did not have the authority to interfere with the hospital’s care.
But it didn’t seem to matter—in 2017, Billy Smith, a prisoner from Elmore Correctional Facility, was injured in a fight with another incarcerated person and later beaten by guards. At Jackson Hospital in Montgomery, Smith’s mother, Teresa Smith, would find him on life support, and with a band reading “DNR”—“do not resuscitate”—hanging from his wrist. Prison officials in the room, according to Ms. Smith, refused to answer questions about what happened. Weeks later, against the wishes of Ms. Smith, prison authorities took Smith off life support. When Ms. Smith asked them why, they gave a chilling answer—”I asked why I didn’t have a right to say anything about it…And they told me he belonged to the state.”
Could Cummings and Smith have been saved? Maybe not. But why were prison officials making those judgments and not medical professionals? The deaths of these two prisoners are examples of prison staff making medical decisions that they do not have the knowledge to make, something that may be more common than we realize. These deaths are also enabled by how correctional healthcare in the U.S. is set up.
How Does This Happen?
Regardless of what the corrections agencies will tell you, healthcare in correctional facilities is fundamentally different than in the community. In most states, prison healthcare is the responsibility of the correctional authority itself—the same entity responsible for punishing them. Placing both incarceration and healthcare under the same entity gives prison officials positions of power over medical professionals, providing them a path to interfere with care delivery in multiple ways:
- Conflicts of interest: Prison healthcare providers, like health providers in the community, have a duty to care for their patients, but they also have a duty toward the prison staff who employ them. Providers may sometimes obey prison staff over giving correct care out of fear of retaliation.
- Harm to the patient-doctor relationship: A healthy relationship between patients and their providers is crucial to their health. Placing prison healthcare providers under the administration of prison officials, who incarcerated persons might fear or resent, may lead patients to distrust their own providers. This is especially the case if prison healthcare providers are also involved in forensic (non-therapeutic) measures ordered by prison staff, such as body cavity searches.
- Overruling of medical decisions: Most importantly, placing nonmedical staff as the managers of medical professionals allows them to override or ignore medical decisions. Even if prison staff are not being malicious, they may potentially put patients in danger.
The UN recognized these problems when they drafted the Nelson Mandela Rules—the world’s guidelines for the treatment of incarcerated people. According to the Rules, correctional medical professionals must be fully independent from correctional leadership. The Rules, however, do not say how to put this into practice. How can correctional providers be independent from their very workplaces?
How to Implement Clinical Independence
In 2018, a group of scientists and doctors from across Europe and the U.S. faced the question of how correctional medical professionals can be independent from jails and prisons. The solution to true independence was neither medical nor policy, but somewhere in between. The group formed several recommendations:
- Include medical ethics in new staff training, to ensure understanding as to the importance of clinical independence.
- Use different medical providers for forensic purposes (e.g. cavity searches) and for providing medical care, to maintain the integrity of the provider-patient relationship and prevent the impression that providers are “on the side” of prison authorities.
- Encourage the formation of medical boards and professional organizations specifically for correctional healthcare providers.
- Institute regular inspections of healthcare delivery and quality by external, independent bodies.
- Maintain independent budgets for healthcare and for prison administration budget, to prevent prison administrative needs from overtaking healthcare needs.
- Have jails and prisons employ medical providers that also work in the community. This will avoid professional isolation and encourage equivalent care.
These solutions, while important, would still leave correctional providers under the authority of prison staff. The most effective way to implement clinical independence in correctional settings, then, would be to remove providers from prison oversight completely. Instead, correctional medical professionals should be employed by healthcare authorities, not directly by corrections authorities. For example, the prison health services division could be moved under the Department of Health, and not the Department of Corrections. Not only would this give providers a more overtly medicine-focused environment, but it would also give jail and prison healthcare a separate budget. Prison officials would no longer be able to have providers engage in punitive interactions with incarcerated persons. Health authorities might also serve as professional representation for correctional medical professionals. Most importantly, though, putting prison providers in an agency separate from corrections would prevent prison staff from directly interfering with patient care.
As it stands now, the biggest obstacle to the Nelson Mandela Rules not being implemented in U.S. policy is the lack of specific directives. The Rules are good for general principles, but laws and policies must be specific. Hopefully, we have given some practical ways for clinical independence to be put into practice in our jails and prisons. Cummings and Smith are gone, but reforms may be able to prevent more deaths like theirs.