Fifty Years of Care and Carcerality

AbstractNancy Dubler founded the Montefiore Bioethics Consultation Service in the late 1970s on the cusp of two epidemics: AIDS and mass incarceration. In New York these two phenomena intersected with devastating consequences. By the late 1980s, the HIV infection rate among incarcerated people in New York State was the highest in the nation. Hospitals across the state built locked units staffed by correctional officers to manage the influx of incarcerated patients dying from AIDS-units that persist to this day. Dubler's earliest scholarship reflects this ethically fraught context. In this article we will first retrace Dubler's work on carceral medicine, in which she advocated for quality, compassionate healthcare for incarcerated patients even as she foregrounded the impossibility of delivering truly equitable care in a carceral setting. We will then show how healthcare providers in prisons, jails, and hospitals continue to struggle with the ethical dilemmas of caring for patients in what Dubler called "non-health-care spaces." In exploring these issues, we draw from our own experiences as ethics consultants and educators working with providers caring for incarcerated patients in New York State. In particular, we focus on how the carceral context may impact medical decision-making and how clinical ethicists (and providers) should respond. Nearly 50 years after Estelle v. Gamble established the right to healthcare in prisons and jails, we observe that providers continue to struggle with many of the ethical challenges Dubler identified decades ago.