What Are Physicians' Responsibilities to Patients Whose Health Conditions Can Influence Their Legal Proceedings?

Abstract

Correctional populations are disproportionately affected by conditions that affect cognition, such as psychiatric illness and head trauma. Honoring bioethical principles in the care of such patients can be particularly difficult in the correctional setting. However, the approach should not change markedly because a patient is incarcerated. That is, the same standards of respecting patient autonomy and confidentiality should be maintained, and the fact that correctional populations are already marginalized makes it all the more important for clinicians to honor these principles. Physicians should act in the best interest of their patients; in jails this might include disclosing information to and consulting with a patient's legal defense. However, this step should only be taken with a patient's consent or, in cases in which the patient does not have decision-making capacity, when it seems consistent with a patient's wishes. CaseDr. Obaje is a primary care physician who works at a county jail, where most of her patients are undergoing court processes. This afternoon, Jonathan, a 52-year-old man with a known history of poorly controlled type II diabetes and a 20-year history of opioid use, is brought to the jail's medical ward for a routine chronic care visit. This is the first time that Dr. Obaje has met Jonathan since his incarceration four weeks ago. Jonathan's blood sugars have ranged between 80 and 150 since his incarceration, and he does not currently seem to be experiencing any withdrawal symptoms. However, during the appointment, Jonathan struggles to provide a health history, shares tangential information, and repeats some information several times. After Dr. Obaje briefly leaves the room to answer a nurse's question, Jonathan does not appear to remember having met her when she returns.Based on this memory lapse and Jonathan's history, Dr. Obaje worries that Jonathan could be exhibiting cognitive impairment. Jonathan reports that he has been transiently homeless during the past decade and that during several periods of homelessness he experienced violence, including blows to the head. She asks Jonathan about his mood, www.amajournalofethics.org 878 and he confirms that he "often feels down" and states that "sometimes I get so angry, and I'm not sure why." On the Mini-Mental State Examination, Jonathan receives a score of 21 out of 30, and Dr. Obaje diagnoses him with mild cognitive impairment (MCI) [1].Dr. Obaje refers Jonathan for mental health care not only for treatment but also to rule out reversible causes of cognitive decline. She also asks her mental health colleagues to evaluate how Jonathan's cognitive impairment influences his decision-making capacity and judgment. Dr. Obaje wonders whether information about Jonathan's cognitive symptoms could be important for his legal defense. CommentaryMedical and mental health clinicians working in the correctional setting are likely to encounter scenarios similar to Dr. Obaje's encounter with Jonathan. Conditions that might be associated with cogniti...

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