Medical Treatment, Prisoner Right to and Right to Refuse Essay

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The right to treatment or to refuse treatment falls under the purview of biomedical ethics. Bioethics is a branch of ethics that consists in the application of ethical reasoning to issues that arise in the delivery of health care. It had its beginnings with Hippocrates, who is credited with formulating the first code of ethics for physicians. This was the famous Hippocratic Oath, which spelled out the obligations of health care professionals. Delivery of health care within corrections facilities is complicated by numerous constraints, not the least of which is the state of mind of patients who live under profoundly stressful conditions. Patient health care may be impeded by a lack of resources, physical inaccessibility, or shortage of competent medical staff. Ironically, treatment may be imposed on an inmate who uses personal harm as a protest method, for example, to draw concessions for better living conditions.

The rights and duties of the patient and the physician regarding the option of life-sustaining treatment is a hotly contested issue in U.S. health care. One of the most fundamental principles of U.S. health care law is that competent patients have the right to accept or reject any medical treatment. Physicians are required to respect the right of competent adults to make decisions concerning their own health care. Physicians and other health care professionals who refuse to honor the expressed wishes of their competent patients may face civil and administrative sanctions. In a corrections setting, however, prisoners are already deprived of basic liberties. Inmates forfeit freedom of movement, sometimes even to the point of prolonged isolation; control of bodily functions such as eating, sleeping, exercise, and hygiene are strictly regulated by the prison. How far a prisoner is entitled to a healthy life or a premature death is a legal and ethical question that has never been well settled.

Autonomy and Informed Consent

Most people appeal to the principle of respect for personal autonomy to justify the right to make medical decisions. The term autonomy derives from a combination of the Greek word: “auto” meaning self and “nomos” meaning law. Broadly understood, the principle of autonomy says that everyone has a fundamental right to self-determination. According to this principle, people act autonomously when their actions are the result of their own choices and decisions. For the general population, this principle is based upon the assumption that mentally competent patients are uniquely qualified to decide what is in their own interest, and that they have a right to determine what shall be done with their own bodies. Thus, a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable for damages. In short, most people believe that the most important right that patients possess is the right of self-determination, the right to make the ultimate decision concerning what will or will not be done to their bodies.

The doctrine of informed consent, with its corollary informed refusal, has been developed in the American health care law as the primary means of protecting a patient’s right to control his or her medical treatment. Under this doctrine, no medical procedure may be undertaken without the patient’s consent and without having first furnished the patient with the information needed to obtain an informed consent. A patient who is not informed of alternative forms of treatment and their associated risks is denied the opportunity to make an informed medical decision. A physician who supplies the patient with the information the patient needs is absolved of liability pursuant to any civil or criminal action. As long as competent patients are furnished with the necessary information, they must accept the consequences of their decision.

The right of self-determination, which underlies the doctrine of informed consent, implies the right to refuse medical treatment. A competent adult is generally entitled to decline medical treatment, even if the decision may entail risks as serious as death. While a physician may consider his patient’s decision medically unsound or irrational, the physician is bound in law by the patient’s choice. The physician may try to reason and dissuade the patient from carrying out his or her “irrational” decision; however, the physician cannot overrule the patient’s decision. To respect the ethical views of physicians, U.S. health care law permits any physician who feels uncomfortable honoring a patient’s wishes to transfer the patient to a physician who is able to honor the patient’s wishes and values. In rare cases where transfer is impossible, the wishes of the patient must override those of the physician. In other words, under no circumstances should patients be forced to undergo or be denied medical treatment against their will.

To protect and preserve patients’ rights to accept or refuse treatment, some states have adopted the legal device of an advance directive, also called a living will. An advance directive is a document intended to govern the kind of life-sustaining treatment that an otherwise competent person would receive should the person later become mentally incapacitated. It carries with it the implicit assumption that the competent person does not lose his or her right to make medical decisions simply because he or she has become mentally incapacitated. Even though both the common law and the U.S. Constitution protect an individual’s right to refuse medical treatment, an argument still exists that a patient’s right to refuse treatment may be overridden on the grounds that very ill patients are frequently in excruciating pain or despondent. According to this argument, pain or distress clouds the judgment of patients and thus prevents them from making truly informed and rational decisions. Patients would be harmed by giving them the option to decide whether or not to accept medical treatment. In fact, the refusal of treatment may be seen as a form of suicide; according to this view, physicians who honor patients’ desire to refuse medical treatment violate their Hippocratic Oath by enabling preventable deaths.

In response to the argument that the desire of patients should always be respected, opponents insist that the right of self-determination is not absolute. There clearly are circumstances in which the state can justifiably violate peoples’ right to self-determination. Most people accept John Stuart Mill’s harm principle, according to which the state may restrict the people from doing harm to others. The harm principle is especially relevant in considering a patient’s right to make medical decisions if the patient is an incarcerated felon. The risk that the incarcerated patient poses to members of the community in terms of cost and order arguably justifies the imposition or withholding of treatment as determined by prison officials.

Treatment Decisions and the Incarcerated

Inmates of the criminal justice system in the United States have an established Eighth Amendment guarantee of access to basic medical care. The degree of care a prisoner actually receives is affected by a number of factors. Overcrowded facilities may not allow sufficient attention to be paid by medical staff to all prisoners requesting care. Underresourced prisons may not have adequate staff or infirmary facilities, and budget considerations may make secure transfer of patients to hospitals cost-prohibitive. Prisoners who are considered dangerous may pose a risk to medical staff and require security measures to ensure the safety of doctors and nurses. Inmates in solitary confinement may not be as accessible to medical and psychiatric professionals as necessary for their well-being.

Prisoners cannot shop around for better care and are entirely dependent on their facility’s good will, competence, and ability to deliver adequate health care. Violations of a prisoner’s right to treatment are experienced most acutely by inmates serving lengthy sentences, many of whom are elderly. Inmates with chronic diseases, such as diabetes, must rely on the prison health care system to monitor their condition and properly treat them. Prisoners with mental health issues are common, with the Los Angeles County jails sometimes being called the largest mental health system in the United States. Depression and psychosis are often worsened by prison conditions and markedly so in supermax and secure housing units where prisoners may be entirely isolated for weeks or years at a time.

Though the actual delivery of adequate health care in many corrections facilities may be problematic, the prisoners’ right to it is well established. More complicated is a prisoner’s right to refuse treatment. Courts may order treatment for a mentally ill prisoner, over the objections of the patient, in order that he or she may be competent to participate in a hearing or trial or to be executed. In Washington v. Harper (1990), the U.S. Supreme Court upheld the prison’s right to forcibly treat psychotic inmates who had not been ordered to be made competent, in the interest of preserving the security and order of the prison environment. In Riggins v. Nevada (1992), however, the court clarified that a prisoner who is competent owing to medication may refuse further treatment unless the state can show that a decline in competence will result in the prisoner becoming dangerous or unfit to stand trial or execution.

Because of the crowded, confined living conditions inherent in prisons, prisoners may not refuse treatment for communicable diseases. Even religious objections may be overridden in the interest of preserving discipline and preventing epidemics.

Widespread hunger strikes by inmates throughout California in 2013 followed hunger strikes by prisoners held at the U.S. military prison in Guantanamo Bay, Cuba. Refusing to eat has a long tradition as an effective means of protest for people with few other means of drawing public attention. Self-directed starvation eventually results in death, putting prison officials in the position of making concessions to prisoner demands or allowing inmates to die. Individual states are at variance in what their constitutions allow. Connecticut’s supreme court supports prison policy to force-feed a prisoner to prevent starvation and death, whereas California’s highest court has ruled against force-feeding of prisoners and even allows prisoners a kind of advanced directive to prevent treatment once they have lost the ability to speak for themselves.


  1. Mappes, Thomas and David Degrazia, eds. Biomedical Ethics. New York: McGraw-Hill, 2006.
  2. Metzner, Jeffrey L. and Jamie Fellner. “Solitary Confinement and Mental Illness in U.S. Prisons: A Challenge for Medical Ethics.” Journal of the American Academy of Psychiatry and the Law, v.38/1 (2010).
  3. Michel, Vicki. “Suicide by Persons With Disabilities Disguised as the Refusal of Life-Sustaining Treatment.” In Biomedical Ethics. Thomas A. Mappes and David Degrazia, eds. New York: McGraw-Hill, 1995.
  4. Munson, Ronald. Intervention and Reflection: Basic Issues in Medical Ethics. 8th ed. Beverly, MA: Thomson Wadsworth, 2008.
  5. Parker, Frederick R., Jr., and Charles J. Paine. “Informed Consent and the Refusal of Medical Treatment in the Correctional Setting. (Death and Dying Behind Bars).” Journal of Law, Medicine & Ethics, v.27/3 (1999).
  6. Thompson, Christie. “Prison Hunger Strike Raises Issue of Force Feeding on U.S. Soil.” Salon (July 15, 2013). (Accessed September 2013).

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