Every year, more than 4,000 inmates nationwide die inside jails or prisons, and many more are in the process of dying. Susan is just one of them, but she is my patient.
I step into her solitary cell on the medical unit and place a trash bin behind me to prop open the heavy metal door. I survey her room — whitewashed brick walls decorated with outdated family pictures, a toilet and sink, two pairs of sneakers squared up on a carefully laid towel. Susan, nearly 50 years old, lies crumpled on the bed.
“Why are you sleeping all day?” I ask.
“Just doing time. Tired of staring at these four walls.”
She knows, as I do, that her medical condition is deteriorating. Susan will likely not survive the decades left on her sentence. As she contemplates the long days ahead that will lead to death, I plow through my well-learned to-do list — review labs, adjust medications, and fine-tune a treatment plan with her other care providers. But even in efficient-doctor mode, a question gnaws at me: Is it possible to have a good death in prison?
It is one of those moments when priorities of the criminal justice system — punishment and rehabilitation of offenders — seem at odds with my priorities as a physician, which are to promote quality and quantity of life. Practicing medicine in a prison means sometimes reframing the ethical principles at the core of my profession. While I can practice beneficence (do good) and non-maleficence (do no harm), how can I respect my patients’ autonomy when they don’t have much? How can I strive for just end-of-life care within the constraints of the system?
The implications of dying while incarcerated extend far beyond any theoretical grappling with these ethical ideals. The mortality rate behind bars is rising. As America “grays,” there is a parallel aging of the prison population, with a 234 percent increase in prisoners over age 55 in the past 14 years — from 43,300 in 1999 to 144,500 in 2013. According to recent data from the federal Bureau of Justice Statistics, the death rate in jails jumped 8 percent between 2011 and 2012, the first uptick since 2009. Deaths — mostly from heart disease and cancer — are highest among prisoners and jail detainees over age 50.
As increasing numbers of prisoners require end-of-life care, states bear an inordinate financial burden — it costs at least twice as much to care for inmates over age 55 than younger ones. In an effort to curb the tremendous expense and effort needed to care for dying inmates, some correctional systems divert end-of-life care back to communities. For example, many states — including Massachusetts — offer the possibility of geriatric release and medical (or compassionate) early release, which allows some inmates with terminal illness to be transferred out of correctional facilities.
I opt for compassionate release programs whenever possible, since they give my patients the opportunity to die in a noninstitutionalized setting, near whatever social support is available. Community-based resources can then take over the expense of care and placement. Compassionate-release programs also allow patients to die as people, instead of as criminals branded with an inmate number.
Compassionate-release programs gained infamy in 2009, when the only person ever convicted in the 1988 Lockerbie airline bombing was released early from a Scottish prison on the basis of diagnosed terminal prostate cancer. Much to the chagrin of his 270 victims’ families, he ultimately died at home in Libya two years later. US parole boards considering an individual for compassionate release take into account not only a medical prognosis, but also the nature of the individual’s criminal offenses, the interests of their victims’ families, and the likelihood that — given an inmate’s failing health — they would commit more crimes.
As a prison doctor, I feel a tremendous weight of responsibility for public safety when recommending this designation. To do so, I have to hear the terrible details of my patients’ crimes. I struggle as my patients’ health care provider and advocate to assess objectively whether they are truly a danger to society. But it is often a moot point— the system is so backlogged that, while dying inmates wait out the paper shuffle, prisons become de facto nursing homes. Even though compassionate release programs are ethically and fiscally ideal in many ways, they are often not logistically feasible.
In light of these challenges, Connecticut recently began offering an innovative option — a privately run nursing home for prisoners. Several other states are following suit. Though the Connecticut program initially met significant public resistance — spurring a “no prisoners in our backyards” campaign — nearly all of the facility’s 95 beds are now occupied. Inmates are considered for admission only on the basis of their medical needs, and applications are individually reviewed by the commissioner of the Department of Corrections, rather than wending through parole boards.
When community-based options are not available, prison hospice care ensures that a good death behind bars is indeed possible. There are currently more than 75 prison hospice programs in the United States. As the recent Oscar-nominated HBO documentary “Prison Terminal” painstakingly details, in-prison hospice care is a powerful and redeeming experience for both the patient-inmates and their families, as well as for the trained inmate volunteers who provide it. Prison hospice care is not without its unique set of challenges, but it’s much less expensive than hospitalization.
I am neither judge nor jury. I don’t know, nor do I want to know, if my patients “deserve a good death.” I do believe they deserve to die with as much dignity as possible. Some may question hand-wringing over people who have committed crimes that threaten our personal comfort and safety. That’s understandable. But as Dostoyevsky wrote, “The degree of civilization in a society can be judged by entering its prisons.” While forgiveness might be impossible, there is always room for compassion.
Dr. Jaimie Meyer is an infectious disease physician and assistant professor of medicine in the Yale School of Medicine’s AIDS Program.