Ayla Raabis explores the state of autonomy in clinical settings for incarcerated patients in Canada and adopts a relational perspective to better understand how to promote autonomy.

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In Canada, approximately 35,500 people are currently incarcerated. There is a massive overrepresentation of Indigenous and Black people within this group, reflecting enduring legacies of colonialism and racism. Many incarcerated individuals have histories of trauma, substance use, and homelessness. Incarcerated people unsurprisingly experience significantly poorer health than the broader population.

While incarcerated individuals are legally entitled to healthcare, the reality is often inferior treatment with rampant systemic concerns. Even when incarcerated patients access care outside the prison walls, they face significant challenges. Concerns about staff safety and escape are frequently cited to justify restrictions. It must be acknowledged that cases of violence have occurred in Canada though most healthcare providers do not feel unsafe when caring for incarcerated patients. Further research into causes of violence, individualized risk assessments, and using the least restriction possible is essential here.

Photo Credit: flickr. Image Description: Hands holding metal bars in a prison.

From limited access to treatment options to correctional staff involvement in medical encounters, incarcerated patients face unique constraints to their autonomy. Most troubling is the role of correctional officers, who frequently and inappropriately become involved in healthcare decision-making, despite lacking any legal authority to do so. Beyond these obvious breaches, the influence of institutionalization can erode incarcerated people’s autonomy in more insidious ways.

To understand these challenges fully, we must use a relational perspective on autonomy, drawing from feminist bioethics. This view recognizes that autonomy is not exercised in isolation; it is shaped by one’s social conditions and relationships. Incarceration, a form of total institutional control, profoundly disrupts these dynamics.

Imprisonment strips people of choices, fostering dependency and undermining self-determination or even just one’s belief in their capacity to make choices for themselves. This loss of agency does not vanish upon walking through the hospital doors; it may even deepen in the similarly institutionalized environment.

Relationships that support one’s ability to act with autonomy are often restricted in prison, leaving incarcerated patients without critical networks of support. Imagine making life altering medical decisions without access to your loved ones to help you process your emotions and consider what it truly important to you.

Another concern is the development of adaptive preferences, a term describing preferences shaped by limited choices. For incarcerated individuals, this might manifest as a decision to avoid certain desired treatments—such as opioid use disorder therapies—due to fears of mistreatment within the carceral system. Thus, even when options are technically available, such adaptive preferences constrain true autonomous decision-making.

Finally, the concept of informed consent – an essential but not encompassing aspect of autonomy – requires heightened scrutiny in the context of incarceration. Incarcerated patients face unique barriers, including limited access to knowledge sources and a heightened power imbalance with healthcare providers. These factors demand a more rigorous approach that recognizes patient’s vulnerability.

So, how do we address these challenges?

First, listen to people with lived experience of incarceration. Most importantly this means listening to each individual and considering them an expert in their own health and care. It also means doing more research and integrating insights from people who are currently or formerly incarcerated.

Second, ensure the bare minimum. Provide healthcare for incarcerated people outside prisons whenever possible. Correctional officers should never act as de facto decision-makers, and privacy must be achieved to foster trust and the meaningful exchange of information.

Third, de-institutionalize care. Reduce the restrictions of incarceration, such as restraints and surveillance, and eliminate unnecessarily restrictive policies wherever feasible. Facilitate contact with loved ones, whose support can help patients align healthcare decisions with their own values. Acknowledge and address adaptive preferences where possible, while respecting that some may be intelligible responses to unavoidable limitations.

Fourth, healthcare providers must strive to communicate information in ways that acknowledge the vulnerabilities of incarcerated patients. This might mean spending extra time ensuring patients understand their options, recognizing the potential gaps in their access to information, and holding a higher standard for what constitutes informed consent.

Lastly, consider alternatives to incarceration. Canadian prisons perpetuate poor health outcomes through racist and marginalizing practices, with little evidence they achieve their stated goals. While a full examination of this provocation is beyond the scope of this editorial, I encourage further reading on this critical issue.

The road to just healthcare is long and fraught, but it begins with recognizing the humanity and autonomy of those most marginalized by our society. Incarceration imposes many restrictions, and while we ought to consider alternatives to this practice altogether, one value should remain unwavering regardless: access to ethical healthcare must never be restricted.

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Ayla Raabis is an Internal Medicine resident at Dalhousie University and a student in the MHSc in Bioethics program at the University of Toronto Department of Public Health Sciences.