Vulnerabilities of aging prisoners in Switzerland
The worldwide phenomenon of population aging and a rise in indeterminate and long-term sentences due to a “punitive turn” in justice have led to rising numbers of aging prisoners. Unlike older adults in the community, aging prisoners are defined as those aged 50 years and older. Their health needs are distinct when compared to other inmate groups or the general population. They suffer from higher somatic and psychiatric morbidities, making them frequent users of prison health services. This great demand for health care strains prison budgets and capacities as prisons are not adapted to respond to such a specialized population. This thesis discusses vulnerabilities of aging prisoners in order to identify moral obligations that can be derived from them to provide older prisoners with specific interventions that respond to their increased health care needs. One type of care will receive special consideration, namely end-of-life care. This will lay the groundwork for designing appropriate interventions and policies for this group.
To identify vulnerabilities of aging prisoners, two definitions will be used: Luna’s layers of vulnerability and Hurst’s claim-based model. The first makes a general distinction between vulnerabilities of aging prisoners arising from the prisoner status and those that are attributable to old age, and how they impact on health. The claim-based model is specific to detecting vulnerabilities that result from an unfulfilled health care claim, which for aging prisoners, is the same that applies to all prisoners, namely the principle of equivalence of care. Based on this principle, aging prisoners should receive a level of care equivalent to the one received by older adults in the community.
This thesis draws from the results of the study about health care of older prisoners (Agequake-study) as well as the study with mental health professionals working in prisons (Confidentiality-study). Both studies were conducted in Switzerland, which is a research context that presents specific challenges by way of its fragmented and diverse prison health system, for example in terms of language-diversity and organizational differences. The findings showed that confidentiality between prisoner-patients and mental health professionals is compromised due to dual-loyalty conflicts and paternalistic breaches of confidentiality. Aging prisoners are presenting challenges especially related to housing and end-of-life care and necessitate specific interventions. Elderly female prisoners, representing a double-minority in prison, suffer from vulnerabilities, such as social isolation and limitations in their access to health care. These vulnerabilities are attributable to a lack of gender and age specific interventions. Concerning end-of-life in prison, prisoner-participants shared their views on dying in prison, revealing obstacles in fostering their autonomy and removing all barriers to a “death without indignities”. Questions were raised about the acceptability of assisted suicide for prisoners. Finally, compassionate release, which is the early release of seriously ill and aging prisoners, is confronted with several obstacles: the prevalence of a punitive strategy of crime control and obstructions in the underlying legal processes due to competing justifications.
The results allowed the identification of several vulnerabilities relevant to aging prisoners. The prisoner-layer, revealed a loss of autonomy, social isolation, and psychological suffering that is induced, especially when the prisoner-layer overshadows all other aspects of a person. As a consequence, prisoners are only being treated as criminals and no longer as persons, causing a loss of dignity. In health care, the doctor-patient relationship suffers because of issues related to dual-loyalty of physicians and when the duty of protection of prisoners merges into paternalism. Additionally, access to health care is not always up to the standard set by the principle of equivalence. The age-layer exacerbates some of these vulnerabilities, as aging prisoners use health care services more often and have more complex health needs. Other vulnerabilities are specific to old-age, such as negative health outcomes resulting from an unsuitable prison environment and the uncertainty and lack of perspective that accompany indeterminate sentences. Thus three obligations arise for the care of aging prisoners: avoiding double-loyalty and paternalism in the doctor-patient-relationship, adapting the environment to the health needs of older prisoners, and facilitating access to all types of care available to older adults in the community.
The vulnerabilities identified for aging prisoners are also relevant to end-of-life care for seriously ill and older prisoners. First, the access to all types of end-of-life care is mandated by the principle of equivalence but raises questions about autonomy, paternalism, and possibilities to grant more social contacts. Second, a death with dignity necessitates control over treatment decisions and a supportive environment, while natural deaths in prison are often treated in the same way as prison suicides. Finally, providing prisoners with adequate end-of-life care includes offering such care inside prisons or making outside services available to prisoners. One possibility to grant access to outside services, namely compassionate release, is underused as it faces challenges that could be resolved by better communication between the professions that are involved and an improved design and application of legal provisions.
Thus, aging prisoners are a group characterized by a number of vulnerabilities whose combination leads to specific obligations that need to be translated into interventions and policies to safeguard their dignity and rights.