Ethical Dilemmas and Challenges in Correctional Healthcare

Ethical Dilemmas and Challenges In
Correctional Healthcare
Presenter: Presenter:
Herbert Kaldany, D.O. Susan Rashid, D.O.

New Jersey Department Of Correctional Medicine Fellow
Corrections
Director of Psychiatry, Mental Health, Board Certified Family Medicine Physician
Addictions and Wellness Board Eligible Correctional Medicine Physician
MPH Candidate
Presented For The George Washington Nova Southeastern University
University (GW) – Training To Teach In Medicine Candidate
The School Of Medicine & Health Sciences Harvard Medical School
Clinical Public Health – Criminal Justice
Health (CJH) Webinars
Friday November 19, 2021
TABLE OF CONTENTS 2
Table Of Contents
01 02 03
Learning
Introduction Ethics Case
Objective
1
s
04 05 06
Ethics Case 2 Conclusion
Analysis
QUOT 3
Quote
E
“Medical ethics is a fascinating discipline, as

it deals with issues replete with complex
philosophical, moral, and ethical
considerations
that are rarely black or white.”
—Gad Saad
01 INTRODUCTIO
N
4
Introduction
Herbert Kaldany D.O.
Board Certified In Psychiatry
New Jersey Department Of Corrections Director

of Psychiatry, Mental Health, Addictions and
Wellness
01 INTRODUCTIO
N
5
Introduction
Susan Rashid D.O.
I am a Board Certified Family Medicine Physician.
I am completing a Correctional Medicine Fellowship
with Nova Southeastern University.
I am also a Master Of Public Health Candidate with
Nova Southeastern University.
I have recently been chosen as one of the selected

scholars among a competitive pool of applicants for
the prestigious Training To Teach In Medicine Program
at Harvard Medical School in Boston, Massachusetts.
02 GOALS AND
OBJECTIVES
6
Goals and Objectives

1. Identify the ethical dilemma as it presents in your
clinical case within the correctional setting.
2. Analyze the multifaceted components of

Mission: Encourage the use of ethical dilemma and challenges in correctional
bioethics committees in a healthcare.
clinical correctional
healthcare setting 3. Consider the principles of a community bioethical
committee as it clarifies the direction to be taken
with the ethical dilemma in the correctional
healthcare setting.
4. Consider the valuable components of

implementing a bioethics committee in the
correctional healthcare setting – legal definitions,
financial, moral, curbs inherent biases.
02 Goals and Objectives
GOALS AND
OBJECTIVES
7
1.Transgender Case: sexual

reassignment surgery outcome without
Present two healthcare the use of a bioethical committee.
cases that illustrate ethical Elements - patient autonomy vs.
dilemmas and challenges medically indicated procedures.
in correctional healthcare.
2.Jehovah’s Witness Case: comparing
outcomes between hospital systems
with a bioethical committee vs.
without a bioethical committee.
03 Ethics Case #1 8
Transgender
Case
03 Transgender Case Ethics Case #1 9
An illustration of a correctional healthcare case handled in

the prison system without a bioethics committee review
Case Presentation:
MA is a 38 yo transgendered Caucasian incarcerated since

2002 on a 40 year
sentence for murdering a female sex worker and drinking
her blood.
MA carries a medical diagnosis of:

• Asthma
• Thyroid carcinoma
• B/L hearing loss with hearing aids
• Abuse of cocaine, amphetamines, opioids and
hallucinogens
• Gender Dysphoria with attraction to males
• Severe Anti-Social Personality Disorder with
psychopathic traits
• Self-inflicted orchiectomy in 2017 – Medical
Hospitalization

Case Presentation continued:
Psychiatric Hospitalizations started at age 6 over 14 times prior to this

incarceration with various disorders including:
• Schizophrenia,
• Bipolar disorder,
• Dissociative identity disorder
• ADHD
At age 10, the patient killed the neighbor’s cat with a knife in response
to being told to clean the room.
MA Reports being sexually abused at the hands of 2 step-sisters who
are about 10 years older.
No overt psychotic symptoms have been elicited in over 15 years although
antipsychotics have been used intermittently for periods of rage resulting
in violence to cellmates, officers and self.
The current meds are Cabergoline, Synthroid, Zyrtec, Advair,
Delestrogen 10mg IM weekly.
03 Ethics Case #1 1
Transgender Case 1
An illustration of a correctional healthcare

Case Presentation continued… case handled in the prison system without a
bioethics committee review
The ethical/clinical dilemma we will walk you

through is whether to perform a
sexual reassignment/reaffirming surgery
following the partial penilectomy in 2019.
Three experts examined MA over the years.

Expert #1:
case handled in the prison system without a
Prior to the first self-inflicted orchiectomy in 2017, the first
expert was a Supervising Academic Psychiatrist.
Expert #1
He observed that the provision of hormone replacement therapy
for 7 years resulted in decreased violent behavior related to
anger issues.
He was concerned that performing the gender reassignment

surgery would potentially cause more harm than benefit.
He reached this conclusion based on the potentially
irreversible outcome of the transgender reassignment
surgery.
If the patient was not satisfied with the outcome, the concern was
that the patient’s anger issues would resurface.
Case Presentation
continued…
03
Expert #2:
Transgender Case Ethics Case #1 13

As a second opinion, a renowned national

expert in Psychiatry with a specific focus
on Transgender treatment was consulted
to conduct a full assessment regarding
SRS.
He concluded that the psychopathic traits were Expert #2
too prominent to justify SRS.
In essence, the expert did not conclude that

the patient had a Gender Dysphoria
presentation that required SRS, but the
expert did conclude that the patient could
be safely treated with the continuation of
hormone replacement therapy.
Case Presentation
continued…
Ethics Case #1 1
03 4
Transgender Case
The patient was not satisfied

with the conclusion of Expert #1
and Expert #2 and requested a Case Presentation continued…
third expert consultation of
the patient’s selection.
03
Expert #3:
Transgender Case
Ethics Case #1 1
5
Case Presentation continued… Expert # 3:
As a third opinion, a renowned national expert in Psychiatry

with a specific focus on Transgender treatment was
selected by the patient for the consultation to conduct a
full assessment regarding SRS.
This expert concluded that surgery was indicated even

in the face of acknowledged psychopathic traits.
He concluded that the transgender issues were more

prominent in the patient and met the criteria for
SRS.
Expert #3
03 Transgender Case Ethics Case #1
16
An illustration of a correctional healthcare case

handled in the prison system without a
The primary medical service concluded not to proceed forward with SRS
Case Presentation continued…
for 2 years.
The first medical hospitalization occurred in 2017 following a self-inflicted

partial orchiectomy. This hospitalization was at the contracted DOC
hospital and did not result in SRS. It should be noted that this hospital
had no bioethics committee that was involved in the case.
A second event occurred in 2019 when the patient attempted self – surgery
via a partial penilectomy and was rushed to a different hospital then
the one contracted with DOC. It should be noted that this hospital had
a bioethics committee involved in this case.
This hospital has a SRS surgeon on staff and the case was sent to the
bioethics committee.
03
Ethics Case #1
1
Transgender Case 7

An ad hoc bioethics
committee was convened
emergently due to the
urgency of the
situation and agreed to
proceed
with SRS.
It was performed
within
24 hours of
admission.
03
Ethics Case #1
18
Transgender Case
The patient was then discharged
to the female prison for
follow up care without the
need for further surgical
intervention since 2019.
The patient has

now
requested a return
to the male prison.
03 Ethics Case #1 19
Transgender Case
case handled in the prison system without
a bioethics committee review
Learning Points:
• Activate a medical-ethics committee with

medical decision-making

complex housing decisions regarding the
LGTBQI incarcerated population
03 Ethical Dilemmas Being Considered:
Ethics Case #1 20
Ethical Dilemmas For Transgender Case:
• The first two consulting physicians concluded that performing

the SRS procedure would do more harm than following the
patient’s self-determination for having the procedure done.
• The physician’s do no harm principle overruled the patient’s

self-determination for SRS.
• The third consulting physician was brought in to the case at the

request of the patient in order to bolster the position of the
patient’s self-determination.
• There was an inequity in terms of the value placed on each of

the two ethical positions presented.
• Despite this third physician’s position, there was no SRS

procedure performed.
03 Ethical Dilemmas Being Considered:
Ethics Case #1 2
1
Ethical Dilemmas For Transgender Case:
• This treatment plan resulted in the patient self-mutilating two times.
• The first incident required hospitalization to repair a partial orchiectomy. At that

hospitalization, no bioethics committee was consulted and no SRS was approved.
• In essence, what this hospital supported was physician do no harm over patient’s
autonomy.
• The second incident required hospitalization to repair a partial penilectomy. During

this hospitalization, a bioethics committee was convened and concurred that SRS was
indicated and was performed.
• This hospital valued patient’s autonomy over physician do no harm.
• Patient’s autonomy vs. physician’s do no harm

03
Ethics Case #1 22
What Would You Do Now?

Questions Left To Answer For Both The Medical And Mental Health Team:
• Does the medical and mental health team need to decide for this
patient on special housing?
• Do gender dysphoric patients need special housing?
• A correctional health bioethics committee would be beneficial

in addressing these questions.
Jehovah’s
Witness Case
04 Jehovah’s Witness Case
Ethics Case #2 24
Case Presentation:
39 year old African American incarcerated male who is

Jehovah’s Witness by faith has a past medical
history significant for:
• Major Depression With Psychotic Features
• Anti-Social Personality Disorder
• Intentional Self-Harm Behavior
• The patient’s self-harm behavior consisted of cutting

his wrist, which resulted in his hemoglobin to be at
critically low levels.
Jehovah’s Witness Case

Case Presentation continued… An illustration of a correctional healthcare
The ethical/clinical dilemma we will walk you

through is whether to provide a blood transfusion
for a Jehovah’s Witness incarcerated patient who is
at a critically low hemoglobin level, has questionable
medical decision-making capacity,
and has no advance directive or a
designated healthcare proxy that is in place.
Two hospital systems managed the patient

over the years.
04 Jehovah’s Witness Case Ethics Case #2 26
Hospital A: An illustration of a correctional healthcare

During the year of 2019, the incarcerated patient went to

Hospital A multiple times for emergent blood
transfusion
after his self-harm behavior.
This behavior would result in his hemoglobin to be at

critically low levels.
Hospital The incarcerated patient would deny blood transfusion
A products based on his religious beliefs.
At Hospital A, the psychiatry and the hospitalist team

deemed the incarcerated patient lacking medical-
decision making capacity.
Hospital A: An illustration of a correctional healthcare

Hospital The incarcerated patient did not have an advance directive

A or a designated surrogate healthcare decision maker or
proxy.
The hospitalist team provided emergency care

Without formal consent invoking two
physicians to agree that emergency care was
necessary.
The hospital therefore would administer

transfusions
over his objections.
Hospital B An illustration of a correctional healthcare

Case Presentation:
Hospital B
Towards the end of 2019, after another self injurious
episode,
the incarcerated patient was taken to Hospital B for
emergent evaluation for the need for blood
transfusion.
The incarcerated patient was found to have a

hemoglobin of 2.8.
This was an acute change and considered a

life-threatening clinical finding.
The incarcerated patient also denied blood

transfusion
products based on his religious beliefs.

The psychiatry team concluded that

the incarcerated patient did have
medical-decision making capacity. Hospital B
However, the hospitalist team

concluded that the incarcerated
patient did not have medical-
decision making capacity.

Ethics Case #2 30

Hospital B
Case Presentation:
As a result of the conflicting conclusions regarding

medical-decision making capacity, the hospitalist team
requested a Healthcare Ethics Consult (HCE)
for further evaluation of the case.
The Hospital B Ethics Committee reviewed the case

and came to the conclusion that the patient
had medical-decision making capacity.
Therefore, the hospitalist team

did not provide emergent blood transfusion and
honored the patient’s autonomy.
Hospital B
04
Ethics Case #2
3
1
Case
P
r
e
s
The incarcerated e
patient was sent n
t
back to the prison a
with the ti
hemoglobin of o
n
2.8 . c
o
04
Ethics Case #2
32

Case Presentation
continued…
He served
his end of
prison
sentence on
4/17/2020, and the
patient was alive
at that time.
Ethics Case #2 33

Learning Points:

medical decision-making
• Activate a medical-ethics committee

with complex healthcare decisions
regarding
incarcerated populations who do not have an
advanced directive and/or a designated
healthcare proxy
04
Ethics Case #2 34
What Would You Do Now?

Questions Left To Answer For Both The Medical And Mental Health:
• Should a Jehovah’s Witness incarcerated patient that lacks

medical decision making capacity and exhibits self-injurious
behavior resulting in a low hemoglobin receive a blood
transfusion?
• In the next episode of a self-injurious behavior resulting in a

low hemoglobin, should the correctional healthcare team
consider sending him to the emergency room for a blood
transfusion evaluation? Why or why not?
• A correctional health bioethics committee would be beneficial

in
addressing these questions.
04 Ethical Questions To Consider:
Ethics Case #2 35
Ethical Questions With Hospital A Medical Management:
Did the hospital physician respect the incarcerated patient’s

autonomy?
Why was a value-based decision for this patient not honored?

A Jehovah’s Witness has the right to refuse a blood
transfusion
based on his religious beliefs.
Was a thorough formal capacity assessment performed?
Why was a Healthcare Ethics Consult not placed?

04 Ethical Questions To Consider:
Ethics Case #2 36
Ethical Questions With Hospital B Medical Management:
Did the hospital physician adhere to the ethical practices of beneficence and
non-maleficence with the medical management of this incarcerated patient?
Is a critical hemoglobin level of 2.8 viable to medical decision making capacity?
Once the incarcerated patient returns to the correctional facility in a critical stage,
what should the Correctional Medicine Physician do next?
Who is now responsible for the healthcare decisions of this incarcerated patient
at
the correctional facility?
With no advanced directive, no surrogate decision maker, or proxy,

questionable/controversial decision-making capacity, what is the
appropriate medical management of this patient at the correctional
facility?
05 Bioethics Committee In
Analysi
s
3
7
Correctional
Healthcare
• One of the benefits of having a bioethics committee in
correctional healthcare is to promote and introduce
a patient-centered care model.
• Another benefit for a bioethics committee in correctional

healthcare is to sort out the dilemmas of clinical duties vs.
security duties.
• Another benefit would be the promotion of a discussion

with the healthcare team regarding advanced directives,
designating a healthcare proxy, and medical decision
making capacity evaluation.
• A bioethics committee in correctional healthcare can

assist in ethics-related education and policy development
within their specific institutions.
06 Conclusion
Conclusion 38
Questions To Consider
• Are decisions of a hospital based bioethics committee able to carry

weight in the correctional setting?
• In other words, does a hospital based bioethics committee have

jurisdiction in the hospital setting regarding care of an offender or
does it end once discharged from the hospital?
• Is the decision of a hospital based bioethics committee binding to

the primary care service of the hospital?
• To use a sports analogy, is this type of committee decision

deemed
as binding arbitration or non-binding?
06 Conclusion
Conclusion 39
Questions To Consider
• How does a correctional setting go about creating a bioethics

committee?
• Who would ideally be included and why?
• What are the pitfalls of a bioethics committee?
• Our presentation indicates that a bioethics team would eliminate

bias. Is that true or does such a committee have its own
inherent bias?
Questions 40
Questions
Questions?
Comments?”
QUOT 41
Quote
E
“Medical ethics is a fascinating discipline, as

it deals with issues replete with complex
philosophical, moral, and ethical
considerations
that are rarely black or white.”
—Gad Saad
CONTACT 42
INFORMATION
Contact Information
Susan Rashid, D.O. Herbert Kaldany, D.O.

Email: Email:
srashid8916@gmail.com Herbert.Kalany@doc.nj.gov
43
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Ethical Dilemmas and Challenges In

Herbert Kaldany, D.O. Susan Rashid, D.O.

“Medical ethics is a fascinating discipline, as

New Jersey Department Of Corrections Director

I have recently been chosen as one of the selected

Goals and Objectives

2. Analyze the multifaceted components of

4. Consider the valuable components of

1.Transgender Case: sexual

An illustration of a correctional healthcare case handled in

MA is a 38 yo transgendered Caucasian incarcerated since

MA carries a medical diagnosis of:

An illustration of a correctional healthcare case handled in

Case Presentation continued:

Psychiatric Hospitalizations started at age 6 over 14 times prior to this

An illustration of a correctional healthcare

The ethical/clinical dilemma we will walk you

Three experts examined MA over the years.

He was concerned that performing the gender reassignment

An illustration of a correctional healthcare

As a second opinion, a renowned national

In essence, the expert did not conclude that

The patient was not satisfied

As a third opinion, a renowned national expert in Psychiatry

This expert concluded that surgery was indicated even

He concluded that the transgender issues were more

An illustration of a correctional healthcare case

The first medical hospitalization occurred in 2017 following a self-inflicted

An illustration of a correctional healthcare case

The patient has

• Activate a medical-ethics committee with

• Activate a medical-ethics committee with

Ethical Dilemmas For Transgender Case:

• The first two consulting physicians concluded that performing

• The physician’s do no harm principle overruled the patient’s

• The third consulting physician was brought in to the case at the

• There was an inequity in terms of the value placed on each of

• Despite this third physician’s position, there was no SRS

Ethical Dilemmas For Transgender Case:

• This treatment plan resulted in the patient self-mutilating two times.

• The first incident required hospitalization to repair a partial orchiectomy. At that

• The second incident required hospitalization to repair a partial penilectomy. During

• This hospital valued patient’s autonomy over physician do no harm.

• Patient’s autonomy vs. physician’s do no harm

What Would You Do Now?

• Do gender dysphoric patients need special housing?

• A correctional health bioethics committee would be beneficial

the prison system without a bioethics committee review

39 year old African American incarcerated male who is

• Major Depression With Psychotic Features

• Anti-Social Personality Disorder

• Intentional Self-Harm Behavior

• The patient’s self-harm behavior consisted of cutting

Jehovah’s Witness Case

The ethical/clinical dilemma we will walk you

Two hospital systems managed the patient

Hospital A: An illustration of a correctional healthcare

During the year of 2019, the incarcerated patient went to

This behavior would result in his hemoglobin to be at

At Hospital A, the psychiatry and the hospitalist team

Hospital A: An illustration of a correctional healthcare

Hospital The incarcerated patient did not have an advance directive

The hospitalist team provided emergency care

The hospital therefore would administer