In “Why Doctors Should Intervene”, Terrance Ackerman discusses various constraints on autonomy. For example, he explains how mental and social constraints have the ability to impede autonomous behavior. In class, we have debated over the relationship between incompetence and a lack of autonomy. However, we have not discussed in depth another constraint mentioned by Ackerman: physical constraints.
Ackerman states, “There are physical constraints- confinement in prison is an example- where internal or external circumstances bodily prevent a person from deliberating adequately or acting on life plans,” (1985). Thus, imprisonment removes not only the freedom from an individual but also the autonomy as well, which poses ethical questions. For instance, pregnant prisoners experience morally unjust treatment. A recent study published a “report card” for various components of medical care for pregnant prisoners. According to the scoring in the report, thirty-right states failed prenatal care, thirty-one states do not have a policy to hold the institution accountable without adequate justification, and forty states have laws that may allow shackling during labor (The Rebecca Project for Human Rights, 2010). Although all of the aforementioned statistics present ethical issues, the use of shackles strikes me the most.
http://www.theguardian.com/commentisfree/2012/jun/06/women-born-free-give-birth-in-chains
To begin with, as illustrated, the use of restraints during labor appears extremely painful. One woman explains how she had deep cuts from the shackling during labor and delivery (Law, 2015). In addition, shackles, especially waist chains, limit a physician’s ability to assess the condition of the mother and the baby, which puts both individuals at risk. Furthermore, restraints can limit mobility, which will interfere with vaginal delivery or slow down the process of an emergency cesarean section. Thus, institutions are violating the principle of nonmaleficence by causing additional harm or additional risk of harm to the patients.
Moreover, one can argue the role of a lack of freedom in the diminished autonomy. For example, since the women committed a crime and lost their freedom, then they do not have the right of autonomy. Although status affects autonomy, such as a minor, the status of an imprisoned person should not override the status of a human being. Human beings posses a high moral status that enable them to make autonomous decisions. However, by removing the autonomy of the pregnant prisoners, then the institutions are treating them as less than human.
Furthermore, institutions and physicians usually make their decisions about autonomy based on competency and understanding. For instance, physicians may deem an individual with a mental disease as incompetent, so a proxy will make the medical decisions for him or her. In the case of the pregnant prisoners, however, competency does not seem to matter. Although the women have the mental capacity to make their decisions about prenatal care and the labor and delivery process, they do not have the opportunity to do so. Therefore, the typical criteria for determining competency does not apply to prisoners either, which one cannot morally justify.
Moreover, Ackerman articulates that doctors should intervene in certain situations, including those with physical constraints. However, as illustrated above, physicians should not impede on the autonomous behavior of incarcerated pregnant patients, for it results in morally unjustifiable treatment of the women.
Ackerman, T. F. (1982). Why Doctors Should Intervene. The Hastings Center Report, 12(4), 14-17. Retrieved March 26, 2015, from http://www.jstor.org/stable/10.2307/3560762?ref=no-x-route:368d91fb989e22ecddae6d166c31991c
The prison system is corrupted on so many levels in that the social infrastructure needs to be completely torn down and rebuilt. Competent prisoners are treated as their incompetent counterparts based on the sole purpose that they have committed a crime. Yes, these prisoners may (or may not) have disobeyed the written law but they are still human and deserve to be treated as such. Therefore, it is the duty of the physician to intervene on the patients’ behalf, especially pregnant women in the prison system. Dealing with pregnancy in the real world can be very challenging, therefore, being pregnant in prison should be even more challenging. Impeding on the autonomy of incarcerated pregnant women is certainly unjustifiable.
You bring up a very interesting point about the ethics of prisons. While I agree that physical constraints are a violation of a person’s autonomy because it limits the decisions they are literally able to make, I feel that they are permissible in the case of prisons because in any society where there is a higher order that governs over a group of people, any person who chooses to violate the set laws of the governing body chooses to surrender their autonomy in that context. However, I do disagree with the use of physical restraints during the case of giving birth. In this case, the unborn child is being put in danger because of the punishment afforded to the mother. The unborn child is obviously unable to object on its own and cannot protect itself either. As a result, there has to be a level of moral protection given to the baby. As a result, I think that it is necessary to refrain from using physical restraints on a woman in labor.
Perhaps the restraints are used during labor to prevent harm. Not harm to the mother but harm to medical staff and possibly society if the prisoner was able to escape the hospital. It, however, seems very unlikely that the prisoner would be able to escape due to her exhausted state in labor and because of hospitals’ security systems. It also seems unlikely that the prisoner would physically harm medical staff because female prisoners are not in prison for violent crimes a majority of the time and because she is probably too weak to be able to attack anyone while in labor. Protective measures for society and people who come in contact with prisoners are certainly needed, but not to this extent. In this case, nonmaleficence can be examined to consider which option has the potential to cause more harm, no shackles or shackles on the prisoner. In this case, it seems clear that using shackles has the potential to cause much more harm to the prisoner and baby than the slight potential harm that could occur if the patient did not have shackles and acted violently.
It would be interesting to consider the health implications for the children of the women who were pregnant with them while in jail. Lack of prenatal care is associated with a 40% increase in the risk of neonatal death. Additionally, mothers who do not receive prenatal care are over three times more likely to give birth to a low-weight baby. Low birth weights are association with health problems that manifest themselves later in life. For example, as stated in the Barker hypothesis, low birth weights can result in the development of cardiovascular disease. Given these consequences and the consideration of the principle of non-maleficence in the case of incarcerated pregnant women, we must also consider the well-being of these women’s’ future children.
This is an interesting topic to talk about. You mention the moral status of a prisoner not revoking their moral status as a human being. I agree on the point that they as human beings do have some rights as a human being that cannot be revoked even by their status. However I would argue that their autonomy has been taken away justly because they did not act morally and it is not a fundamental moral status to be endowed to all humans but something to be earned. Thus by refusing to act as a moral human being they have lost their status to be a functioning member of society. This is much like how we treat children, those deemed incompetent, or those dangerous to society. We remove their autonomy because they either do not know better or may cause harm to society. This falls under the principle of non-maleficence. In this way we are treating prisoners a lot like patients who have depression. Since autonomy and competence are so highly linked, this makes sense as prisoners can be seen a incompetent in regards to dealing to societies rules. Thus the shackles during pregnancy are a consequence of their lack of competence, not autonomy. We fear they may try to escape during pregnancy and thus because they do no follow societies rules we restrain them. I do not think this is morally incorrect to restrain prisoners, however the type of restraints I will agree is too extreme and too limiting. Thus for this situation to be resolved we should just change the way the prisoners are restrained or contained. If we fear they will act violent to the staff then such extreme restraints maybe necessary however in most cases to prevent prisoner escape having a guard on site maybe all that is necessary.