A Narrative Review of Dual Loyalty Conflicts in Custodial Settings and Implications for Community Practice

Dual loyalty dilemmas are conflicts between health care professionals' obligations toward their patients and third-party interests. These conflicts are more common and starker in custodial settings, such as jails and prisons, military detention facilities, immigration detention centers, and involuntary psychiatric institutions. Despite encountering patients in custody, health care professionals (HCPs) in community settings have limited knowledge and training. In this narrative review, we examined dual loyalty conflicts faced by HCPs working in custodial settings and then applied the identified themes to community-based hospitals where HCPs care for patients in custody. We searched databases for original papers relating to patients in custody and dual loyalties and then abstracted key themes, findings, and characteristics of the conflicts. There are five categories of competing loyalties that give rise to dual loyalty conflicts: institutional and organizational entities, legal and regulatory guidelines, ethical and moral responsibilities, social and public responsibilities, and other individuals. Themes include the inappropriate withholding or delaying of care, the provision of intervention despite patient refusal, the violation of patients' rights to privacy, cruel non-clinical interventions (e.g., torture), and the failure to document or report information accurately. Mitigation strategies in the literature emphasize expanding human rights education, improving patient communication around possible conflicts, and raising clinician awareness of institutional policies. Common in the care of patients in custodial settings worldwide, dual loyalty conflicts can impact patient care. However, pursuing mitigation strategies can lessen their impact.