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ONE DROP OF BLOOD

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Medical participation in invasive procedures performed on prisoners for non-therapeutic reasons is different in degree only, not kind, from medical participation in execution. Caregivers’ judgment about what is acceptable toward persons in prison is easily distorted by conflicting demands and social prejudices. Education, oversight, and a clear sense of professional mission are necessary if these caregivers are to avoid harming their patients. ***
The first day of October 1999, I sat at a picnic table in the prison yard, taking in the sun and saying good-bye to the women who had become my friends, exchanging addresses as if these friendships really would cross the fence and follow me in my new life. “Miss Power,” the yard guard yelled, “they’re looking for you down in Admissions. Get down there right away. Don’t go back to your unit to sign out or anything.”

I looked around at the women at the table. We all knew this could be the last time we would see one another. Although I was not scheduled for release until 9:00 the next morning, the reality of prison is that anything can happen. More likely, though, I was being called to have blood drawn so that my DNA could be filed in the registry of convicted felons’ identifying data. Although the Massachusetts legislature had passed the authorizing legislation more than a year previously, prison advocates had won an injunction while the constitutionality of the procedure was challenged. Earlier in the week, the courts had ruled, and the injunction had been lifted.

We had heard stories, the day before, of a day-long lockdown at the minimum security facility across the street, visits cancelled, phones shut off, no outside communication even to attorneys, while the fifty women there had been pricked, fingerprinted, and registered. We had heard that the women released from here this morning were required to submit to the procedure before the gates were opened for them. We had heard that the $135 cost of the procedure had been docked from the money they had saved in order to start a new post-prison life. I had had time to think about compliance, about defiance—time not just to feel my outrage rise at the idea of this invasion, but also to recall myself to my desire to be at peace, to bring peace, to be peace in the face of every possibility of conflict. I breathed deeply and started walking toward the Admissions building, trying to hold on to an openness toward the human being I was about to encounter, trying not to become closed off by fear and anger.

I was directed to take a seat across the desk from Sgt. G—, at her most intimidating in the dark blue IPS (prison police) uniform, eyes that never looked directly into yours, a voice and diction that dominated almost casually, confident in brute power. She read me a directive about the procedure, the court ruling, and the sanctions that would be imposed on me if I refused (up to 30 days in maximum security). She asked if I would comply. I started to say that I would, but stopped to ask if I would be given the piece of paper she had just read to me. Somehow it seemed important to document what was happening. She said, “Yes,” and I replied that while I would not comply, I would not resist. Her look told me she did not appreciate the difference, and I am not sure I could have articulated it. She escorted me across to the cubicle where Lt. T— waited, along with a nurse in a flowered smock.

At their instruction, I first sat at the sort of one-armed chair used for blood drawing, then got up instead to have my fingerprints impressed onto two cards that would receive the blood sample and verify that it was indeed me this DNA would identify. It was a messy job, since Lt. T— admitted that she was not particularly experienced at it, and I was as passive as it is possible to be and still remain standing. Though generally known for her unpredictable torrents of verbal abuse, Lt. T— remained polite throughout, and I kept working to keep an open heart.

Once again I was seated at the chair. I signed the cards, further verification of the sample’s identity. The signature was barely legible, as by now I was trembling. The problem with refusing to retreat into enmity, with simply reflecting and witnessing the violation being done, is that you really have to feel the violation—the hatred from society for you and your kind, the powerlessness to defend even that one boundary of your own body’s skin and intimate fluids.

I was approached by the nurse. I recognized her only vaguely, as she worked mostly in the clinic in this building and almost never in the clinic where I received what care I occasionally needed. She broke open a package of finger-stick apparatus, took my hand, and prepared to draw the few drops of required blood. “Aren’t you ashamed of yourself?” I asked her past the tears that blocked my throat. “Is this what you went to nursing school for? Does this seem to you like taking care of a sick person? Aren’t you ashamed of yourself?” She only looked away.

Two weeks later I shared the story with my family. I still felt bruised, still cried when I talked about it. I was seeking what the psychologists Matthew and Sheila Linn call enlightened witness, retelling the story in the company of people who would affirm that I had indeed been injured, who would help me reset what had been broken so that I could heal. My brother, an oncology phlebotomist, was fully prepared to sympathize until he realized that the physical act had been “just a finger-stick.” I have always thought of him as an extraordinarily sensitive and ethical practitioner. Yet he had no frame of reference to comprehend the betrayal and invasion I felt at having a nurse participate in the drawing of my blood for the purpose of DNA registry.

The other inmates felt that betrayal and invasion. We all keened our sorrow at it, not just the ones who were habitually defiant and angry. The sergeant and the lieutenant knew it. The Deputy Superintendent who watched from the hallway to see what I was going to do in response knew it. The Director of Security who had locked down the whole facility across the street for the procedure knew it. But the medical personnel would have gone right on taking samples, wondering at our hostile response. After all, it was only a finger prick.

The Prison Medical Care Environment
Caregivers arrive at prison work with the compassion that so often characterizes people who choose to work in health care. But despite their often heroic efforts to care for and advocate for their patients, medical staff working in prisons report battling or even falling into negative attitudes about the inmates they serve. Prison inmates are a despised population, characterized by popular culture, the news media, and many politicians as less than human, beyond social redemption, frighteningly dangerous.

Overwhelmingly, the people who end up in prison come from groups already disenfranchised in an increasingly competitive society. Often they have found the social skills of domination and manipulation more effective than those of negotiation and mutual respect. They may be ugly by conventional standards, scarred by burns, cuts, poor reconstructive surgery after auto accidents, abscesses resulting from drug abuse, lost or rotten teeth. Many are mentally ill. They are not from the middle class; they do not dress, act, look, or talk like the middle class professional nurses and doctors to whom they bring their woes, only some of which are medical and even fewer of which are amenable to treatment. They hurt. They are demanding and whiney and angry.

They are here for punishment, yet they imagine themselves entitled to a standard of medical care equivalent to that of the outside community. (In fact, courts established and guaranteed that standard because without it, prison medical care was so scandalously inadequate that in was deemed to violate prisoners’ right to be free of cruel and unusual punishment).

Even the legitimate medical needs of an incarcerated population who took fair care of themselves would overwhelm the resources a resentful society allocates to the project of providing for their care. Ironically, as the standard of medical care has declined for the community outside prison, a new resentment arises among prison medical staff, who perceive the care delivered in prisons to be better than that available in their own HMOs.

The prison’s need for order only barely and grudgingly accommodates sick bodies’ needs for medication to be dispensed at prescribed times. In the 90 minutes allocated for the evening med lines, more than 100 inmates will show up at the clinic window, show an ID, and expect a dose of antibiotics, antihistamines, antipsychotics, anti-inflammatories… The medication may or may not have arrived from the pharmacy halfway across the state, may have been misfiled alphabetically by a nurse rushing to finish her work, may have been used for a different inmate/patient whose own order had run out.

Meanwhile, the Shift Commander, the highest ranking security person on the premises, whose priority is the orderly running of the prison for his eight hours, becomes a hovering, hulking force to the nurse who is taking too long in her struggle to get the right medicine to the right inmate.

All of this erodes the caregivers’ compassion even before they are faced with the prison staff’s unrelenting pressure to make sure that the prison experience is sufficiently punishing. Adequate treatment of chronic conditions is suspect, as is palliative care. Officers who supervise the dispensing of medications, inspecting each mouth after the inmate swallows, one after another for three hours, are not shy about making their resentment known when the order is merely for pain relief. After all, if Advil and Sudafed are available in the Canteen store (even at $4.95 for 24 tablets), why shouldn’t inmates be required to provide their own? It becomes possible to face an inmate with a visibly swollen abscessed tooth, crying in pain, and say, “No doctor’s order, no meds. That’s the way it is. Put in a slip”

In such an environment the therapeutic relationship between the medical caregiver and the inmate patient is extraordinarily fragile. Neglect becomes commonplace: a missed melanoma diagnosis despite repeated attempts by the inmate patient to get a second opinion about a suspicious growth; a septic spider bite that blisters half of a patient’s buttocks and leaves a hole two inches across, half an inch deep, for which the patient is offered Tylenol and never scheduled for a visit with the doctor; an inmate who comes into the prison taking a potent AIDS cocktail that must continue with no more than a few days’ interruption or whole new resistant strains of the virus will arise in her body, who is not seen by a doctor for over three weeks. These are the ordinary stories of the prison where I resided for six years. Is it any wonder, then, that we experienced the participation of medical staff in the drawing of our blood for inclusion in a DNA database as one more violation?

The Case Against Medical Collaboration
To answer my brother’s skepticism, referred to above, about why a finger-stick should be regarded as deeply offensive when it seems so trivial, let us first examine the nature of the relationship between persons who work in prisons, whether in medical care, security, or administration, and the prisoners in their care and custody. Prison inmates are a special class of citizens; for purposes of punishment, rehabilitation, and public safety, they are legally deprived of many of the freedoms guaranteed to other US citizens. While a certain amount of social prejudice attaches to this status, there is no moral principle that justifies treating prison inmates as less than persons. US Supreme Court decisions have codified this principle by ruling that loss of freedom is itself the required punishment. Violations of autonomy and dignity that exceed those required by the security needs of the incarcerating facility have been disallowed as cruel and unusual punishment in violation of the Eighth Amendment to the Constitution.

To realize this moral status of inmates, it is enough for a nurse or physician working in a prison to imagine hitting or kicking the inmate. The act would clearly be wrong, even if only a moderate punch, one that would inflict no lasting damage, were contemplated. Yet medical personnel regularly break the bones of, poison, cut open, and perform other assaults on the bodily integrity of their patients. They are justified in doing so because the patients have consented to medical care, that is, to a particular relationship of vulnerability based on a presumed benefit to be gained from the caregiver’s knowledge and skill.

Absent that agreement, medical personnel have no more right to invade people’s bodies than do schoolteachers or bus drivers.
The two terms of voluntary consent and presumed benefit are so central to the definition of the care provider/patient relationship that they are enacted in law as well as being the foundation of professional ethics codes. In ordinary medical practice, the act of obtaining any sample for laboratory tests in which blood or tissues are analyzed is considered invasive and requires patient consent. Issues of consent are particularly important when the use to which lab results are to be put is not related to a health benefit for the person whose blood is being drawn.
Not all acts performed by medically trained persons and using the paraphernalia of medicine meet the criteria of being both voluntary and presumably beneficial. Medical research uses the tools and knowledge of medicine with the goal of presumed benefit to the society rather than to the participating subjects.

This non-medical relationship is addressed by a separate and elaborate set of ethics as well as by strict regulatory oversight. Its departure from the ends of medicine while using medicine’s means is clearly recognized in the twin demands that it yield more benefit than harm and that protection for participants’ autonomy be evidenced by informed consent. Certain categories of persons whose capacity to give informed consent is in doubt (including prison inmates) are now excluded from medical research.

Some medically trained personnel participate in legal executions by lethal injection, an act that Michael Davis, in “The State’s Dr. Death: What’s Unethical About Physicians Helping at Executions?” argues “is no more necessarily a medical procedure than execution by firing squad is a military procedure.” Its non-medical nature arises both from its being of a non-therapeutic nature (to put it mildly) and from its being administered without informed consent. Illinois law allows doctors to participate in executions, an act which is forbidden by the ethics of the Illinois State Medical Society, by declaring that they are “non-doctors for the purposes of the Illinois Medical Practice Act whenever they assist in executions.”

This declaration may solve the narrowly phrased ethico-legal questions, but it cannot answer the human moral one: just what is the caregiver’s relationship with the inmate if it is not one of nurse or physician to patient? On what basis, then, does the sometimes-doctor or erstwhile nurse approach a human being with a sharp instrument, and cut her, however slightly?

It is by no means a trivial question. Medical personnel are not exempt from the inhumanities of their moment of history. In discussing recent revelations about Turkish physicians’ collaboration with security forces in the torture of Kurdish people, mainly through failure to identify at autopsy deaths that resulted from torture, M. Gregg Bloche raises the question of medicine’s ever-present social purpose. Health professionals in all societies, Bloche says, serve non-therapeutic ends. In our society, these range from convicting criminals to determining access to jobs and insurance. Situations inevitably arise which create conflict between commitment to an individual patient’s well-being and the social purposes of medicine.

“Where human rights abuses are endemic,” he writes, “the social uses of clinical skills put physicians at risk of becoming collaborators.” These abuses are not found only in dictatorships in faraway places. Prison physicians’ failure to document major injuries has hindered legal efforts to stop violence against inmates in Alabama and Georgia. He suggests the need to understand these “systemic, unreflective forms of collaboration … to clarify the boundaries between tolerable and unacceptable medical work that serves non-therapeutic ends.” I suggest that the prison nurse’s finger-prick is a very good place to start.

Certainly the nurse who performed the minor and seemingly trivial act of drawing blood without my consent for purposes of law enforcement rather than for my health, who was dressed in her flowered smock, with her alcohol swab and a look-you-in-the-eyes-with-a-smile face as if, for all the world, she were there to do me some good, regarded herself as more ordinary than monstrous. But the boundary between the medical use of her skills and tools and some other kind of act was about to be crossed.

Writing in the Encyclopedia of Medical Ethics, Nancy Neveloff Dubler details the continual pressure on professional medical judgment exerted in prison settings:
bq. Often providers are asked to act as impartial arbiters of potentially explosive or violent situations. Thus they are asked to witness forced transfers or to supervise punishment. It is assumed that heir presence will prevent violence or that their skill and special status will render searches less painful and intrusive and the punishment less destructive. Acquiescing in these requests, however, may destroy the provider’s ability to act as the patient’s advocate.

Other assignments that tend to undermine the provider-patient relationship include collecting forensic information for prosecutors…The institutional pressure for provider participation may be enormous, yet many scholars and commentators have argued, consistent with comprehensive standards published by the national Commission of Correctional Health Care and by the American Public Health Association that if professional ethics would prohibit an action in a community setting, they prohibit it in a correctional setting as well.

The procedure violates express ethical codes of several professional organizations, as well as the intent of others. The Recommendation on Ethical and Organizational Aspects of Health Care in Prison from the Council of Europe Committee of Ministers provides the clearest and most far-reaching prohibition on such activities:
bq. Any derogation from the principle of freedom of consent should be based upon law and guided by the same principles which are applicable to the population as a whole …Body searches are a matter for the administrative authorities and prison doctors should not become involved in such procedures. However, an intimate medical examination should be conducted by a doctor when there is an objective medical reason requiring her/his involvement … Prison doctors…should collect and analyse specimens only for diagnostic testing and solely for medical reasons.

The International Council of Nurses concurs. In policy statements on nurses’ role in care of prisoners and on torture and the death penalty, the ICN emphasizes nurses’ responsibility to the patient:

Nurses have a primary responsibility to promote health, to prevent illness, to restore health and to alleviate suffering. Their primary responsibility is to those people who require nursing care. Nurses are often the first health professionals to detect ill-treatment of detainees and prisoners. It is important that they adhere to ethical principles … Nurses who have knowledge of ill-treatment of detainees and prisoners must take appropriate action to safeguard their rights. Nurses employed in prison health services do not assume functions of prison security personnel….

The nurse shall not voluntarily participate in any deliberate infliction of physical or mental suffering.
Although other professional organizations explicitly address only participation in the extreme case of execution, they also emphasize the importance of protecting the therapeutic relationship. The Jail and Prison Health Committee of the American Public Health Association, the American Medical Association, the American College of Physicians, and the American Nurses Association declared those organizations’ opposition to medical participation in executions based on the contradiction to the “fundamental role of the health care professional as healer and comforter. It threatens the integrity of the relationship between prison health care professionals and their prisoner patients.” They caution against the misuse of means that are the same as those “used by health professionals to comfort, to heal, and to preserve life.”

Conclusion
That October day in the Admissions section of the prison, I felt as though I had been held down and cut open, my most secret name taken from me and written in the book of the despised. In the process of pursuing this question, a quest to restore my own sense of inviolable dignity, I have learned that what happened to me that day did indeed violate standards of professional conduct for medical care providers working in prisons. The problem was not that the standards did not exist. It was, rather, that in the closed environment of the punishment-model prison, the medical personnel were ignorant of the standards of their own profession and incapable of intuiting them on their own.

Medical professionals need guidance and support, in the form of curriculum while in training as well as professional ethical codes, in order to avoid having their intimate knowledge of the ways of the human body used against persons who are supposed to be in their care. The International Council of Nurses has called for both of these. But the work environment of medical professionals in prisons is a closed system. Prejudice and pressure can combine to make pledges taken at the time of professional certification seem remote and irrelevant. The promise that one’s job is to be protected if one refuses to violate that pledge is no comfort when the Shift Commander has the authority to have one escorted off the prison grounds in handcuffs. The ICN recognizes this and calls for its national affiliates, the National Nurses Associations, to provide “access to confidential advice, counsel, and support for prison nurses.” But even more is called for.

The non-therapeutic use of invasive procedures is a line that physicians and nurses should not cross in their care for persons in prison. This limit ought to be incorporated explicitly into employment contracts and into the contracts that private medical service contractors negotiate with corrections departments. Professional organizations’ efforts to have licensing boards prohibit medical personnel from participating in executions should be extended to exclude medical participation from all invasive procedures undertaken against a prisoner’s will for non-therapeutic reasons.

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About Katherine Power

I didn’t set out to be a terrorist. As a student activist, I moved from protesting the war in Viet Nam to waging guerrilla war to overthrow the government….

Recent and Upcoming Appearances and Publications
1/15/2014 Complexity and Social Change, Occupy Radio
10/31/2013 Surrender, Oregon State University, Corvallis, OR
10/25/2013 Surrender, Taos Community Theater, Taos, NM

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