Ageing prisoners and ethics behind bars : law, human rights and health care - old (age) problems and new challenges

The structure of penal institutions and their impact on inmates raises complex ethical and human rights issues. The circumstance that the number of prisoners who are older and/or suffer from mental disorders is steadily growing in Switzerland and worldwide in general, creates additional problems. Therefore, the aims of this thesis are to provide information on the current health care situation of ageing prisoners in Switzerland, to better understand the legal and practical settings of health care provision for ageing prisoners and to analyse the ethical issues that arise from the need to provide adequate health care to inmates in the context of an increasingly ageing prison population. This thesis is divided in a general introduction, seven chapters and a general discussion. The introduction provides general information on institutions and their characteristics, the role of punishment in institutions and the numerical changes of the prison population in the correctional system. Furthermore, an overview of possible reasons for the tremendous growth of the prison population is given. Special focus is put on the sub-group of ageing prisoners and their features. Their needs in accommodation and health care are presented in detail. The introduction then proceeds with a brief description of the ethical issues in relation to the health care for ageing prisoners and continues with an overview about project details of the “Agequake in Prisons” project. A first theoretical overview about the challenges that the prison system has to face with the growing number of ageing prisoners and their special needs is given in Chapter 1. Special emphasis is put on the accommodation of older prisoners and the end-of-life care and death in prison. The principle of equivalence of care is used as a framework. Chapter 2 contains a review of national and international guidelines, legal frameworks and other documents relating to the health care needs of ageing prisoners. The results on the existence or non-existence of regulations that address the health care of ageing prisoners are critically examined. In this analysis focus is particularly put on Europe and the United States of America (USA). Chapter 3 explores current expert perspectives on Western European prison health care services and investigates if ageing prisoners receive equivalent care. Here, the difficulties of providing equivalent health care to ageing prisoners are described in detail. The factors that contribute to these difficulties are looked at. Possible solutions for the described problems are provided which shall give guidance to people working in correctional facilities. Chapter 4 reflects on the disease burden of ageing prisoners and the different impact that age and length of imprisonment have on their health. The topic of end-of-life in prison is covered in Chapter 5. More and more prisoners grow old in prison and are likely to die there. Non-physician assisted suicide is under certain conditions available to the public in Switzerland. In this chapter it is argued that it should be made available for prisoners, too. Chapter 6 and Chapter 7 give an insight into the topic of restraint measures. While Chapter 6 addresses restraint measures in hospitals in Germany, Chapter 7 explores the new legal regulation of restraint measures in Switzerland. The last part of this thesis contains a general discussion of the presented work and summarises its findings. Furthermore, the implications of this study for research and practice in correctional facilities are described. It should be noted that Chapters 1, 2, 3, 4, 5, 6 and 7 have been published in different European and American journals; therefore it is possible that there is an overlap between the description of the background, ethical issues and methods used. Although, the delivery of health care for ageing prisoners does meet the standard of equivalent health care in certain prisons, it is of great concern that it is not achieved in every Swiss prison according to the Stakeholders that were interviewed. This thesis provides an insight into some of the most challenging aspects of old age inside prisons such as the provision of equivalent health care and contributes to the understanding of how the health care provision for ageing prisoners could be made more effective.