Let’s Take the Punishment out of Healthcare
by Karim Sariahmed and Vanessa Van Doren
One of my patients was sitting in a harshly lit room, tired, bruised, and sleep deprived from spending most of her night in the emergency room. When I asked, as gently as I could, what happened — how she got here — she replied, “I already told you guys! How many times are you gonna make me repeat this?”
I was sent by my psychiatry team to talk to her after she got to the hospital in the middle of the night. The police were called following the altercation in which she was injured, but the primary team realized she had some mental health needs as well. I was at least the third person asking her to relate a possibly traumatic personal history. A police officer was most likely the first.
There had been many opportunities for the retelling of her story to lead to suspicion and anger. As a medical student, I usually see myself at the bottom of the medical power structure, but this patient showed me otherwise. To her, I was part of a class of authority figures including both healthcare providers and police officers. This perspective makes sense, and providers need to think about the reality it reflects: Power dynamics can overshadow your training, especially when you’re caring for someone without much power. Even in a hospital, where people hope to be cared for and healed, these dynamics are heavily influenced by America’s criminal justice system. Health workers need to actively distinguish ourselves from that context in order to do right by our patients.
In the hospital, particularly in the ED, police officers are often the patient’s first interaction. Many patients are brought to the ED by the police. One study showed that 80% of surveyed law enforcement agencies responded to one or more specific types of medical emergencies and 50% provided some level of patient care. More than half of U.S. hospitals now have security officers with firearms. Having armed security available to deal with “agitated” patients may also lead busy emergency room physicians to rely on security first, rather than using more effective non-coercive de-escalation techniques. Thus, law enforcement officers easily assimilate into “the team,” and they can influence how care is handled.
To understand how police presence erodes patients’ trust in their doctors and the healthcare system, we have to first acknowledge that people may be generally afraid of the police. Police in the United States are exceptionally violent because that is how they are trained to respond. Despite the fact that police fatalities in the line of duty are rare, our police are trained extensively in the use of force but receive very little training on nonviolent de-escalation. This is a uniquely American phenomenon: In the first six months of 2015 alone, four hundred Americans lost their lives to police gunshots. In Germany, just four people were fatally shot by police over the same time period. Canada averages 12 fatal shootings per year, and Japan often goes years without a single police shooting. British officers shoot their guns an average of five times a year. Many of the poor and dispossessed people in this country learn early on that the police in their neighborhoods are not there to keep them safe. Black people like Sandra Bland, Philando Castile, Alton Sterling, and Eric Garner have been killed on camera or died in police custody. The people responsible are rarely reprimanded and often get paid time off.
Police violence doesn’t just happen in the street. Even in the healthcare system, interaction with the police can be unavoidable. That fear carries over when you become a patient, and not just for people of color, but for undocumented people, victims of sexual assault, patients with psychiatric issues, poor people, and others who see state institutions as a source of authority and surveillance but not necessarily structural support. Because of this, in many contexts where medicine has contact with law enforcement, the police and related agencies are able to make decisions that affect the course of medical care, despite having no medical training.
Law enforcement’s undue influence over healthcare punishes some of the people who are already the most underserved. Earlier this year, a 26-year-old undocumented mother with a brain tumor was removed from the hospital and detained by Immigration and Customs Enforcement agents before she could even have her surgery. Many are afraid to even call an ambulance because of stories like this. Just last week, a 10-year-old girl was detained by Border Patrol for deportation hearings. They followed the ambulance transporting her for emergency surgery.
Patients with mental illness have called the police for help and have subsequently been killed by them, and many patients with mental illness are sent to prison rather than a psychiatric hospital. Rape victims who go to the police for help have been mocked, interrogated, and ultimately prevented both from receiving medical care and from having evidence collected. Tens of thousands of rape kits remain untested in the United States. Pregnant inmates routinely receive inadequate prenatal care and often give birth with little to no medical care, often handcuffed to a prison cot.
Police officers even have the authority to stop people with medical emergencies from going to the emergency department, even if it results in their death or delayed care. This was the case for a Wisconsin man whose girlfriend was pulled over for speeding while rushing him to the hospital during a severe asthma attack. The police officer refused to allow them to continue to the hospital, and he died. The police officer’s action was described as “proper protocol.”
My experience working in the ED forced me to revisit why patients might be scared of health workers too. From the heinous experiments on enslaved women by James Marion Sims to the covert and intentional denial of treatment to black men in Tuskegee Syphilis Study, there is a long history of physicians causing active harm. This potential for harm is not just a relic of the past. Physicians have participated in large-scale forced sterilization as recently as 2010. Psychologists and medical doctors of the American Psychological Association crafted policy with the CIA to grease the wheels for torture and ‘enhanced interrogation’ under the Bush administration. Punitive incarceration of the mentally ill remains the status quo in areas that could be transformed by strong healthcare leadership and more resources for those with disabilities. These issues form a border between healthcare and the carceral state. Health workers need a clear moral grounding to guide us in this controversial territory.
Safety is the innuendo health workers sometimes use to transition between the language of health and the legal language of discipline and punishment. Our institutional protocols and organizational relationships sometimes make it seem natural to pivot between the two. “Discharge to prison” isn’t just a phrase heard thrown around in the hospital; it’s a real endpoint for psychiatric care. Much of our prison population suffers from mental illness that goes untreated or disregarded. Health workers who see themselves as upholders of the law easily compromise their duty to provide care when they see undocumented people or psychiatry patients as criminals rather than humans. Patients have even been shot or tased by security while expecting to receive care. Health workers can have a significant amount of influence over these possibilities if we understand them more objectively.
The relationship between doctors and the police is never taught explicitly. As a person on my way to becoming a doctor, it is clear to me that the lack of instruction doesn’t mean there aren’t any expectations. As we go through our clinical rotations in medical school, many of us feel an increasingly tense contradiction of being a healer in a punitive, militaristic society. The formal feedback we receive in training — the driving force behind our grades and ability to get into a good residency — usually prioritizes obedience or assimilation. Trying to be a “good team player” can mean stepping back from conflict instead of standing for our moral convictions. Constraining our sphere of work in order to avoid controversy will only result in more abuse.
These tensions surfaced in July when a nurse resisted a tacit assumption of collegiality between health workers and police officers. A viral video shows a police officer who physically assaulted and then arrested a nurse who refused to take a blood sample from an unconscious patient. The police officer had no warrant or technical authority. An unconscious patient is unable to give consent, making such an act expressly forbidden by both hospital policy and state law. This was not an isolated incident; this officer felt entitled to exert his authority in a clearly medical domain because he works in a context where the police routinely overstep ethical and legal boundaries.
If police officers are able to make inappropriate medical decisions with impunity — decisions that cost patients their lives — and if health workers cannot or refuse to stop them, is it any surprise that patients are afraid of the police and distrustful of health workers?
Instead of informal liaising with the police, we need systematic and clear boundaries on where their disciplining role ends and where our healing role begins. It was scary to watch a nurse get assaulted for doing her job. We felt shocked and threatened, and that feeling resulted in a swift policy change: Police officers now have to check in to the University of Utah Hospital at the front desk like everyone else; they don’t get special access to the ED. This is one way to make our hospitals feel like sanctuaries rather than prisons. Practicing in groups that refuse to enable immigration offices looking to deport our patients is another.
It is not enough for healthcare workers to feel shocked when patients’ rights are violated. We can resolve those feelings by taking action to protect our patients from violence at the hands of law enforcement. When health workers across the board stand up for ourselves and stand up with our patients, healing will displace punishment as the value that structures our society. This means contesting the boundary between medicine and our abusive criminal justice system to ensure that our moral commitments overcome our fear of controversy.
Karim Sariahmed is a 3rd year medical student at the Louis Katz School of Medicine at Temple University and a member of Put People First! PA. He is working very hard to be worthy of his patients’ trust some day. You can find him on Twitter.
Vanessa Van Doren is a medical student at Case Western Reserve University in Cleveland, Ohio. She is a student board member of Physicians for a National Health Program and is active in her local chapters of White Coats for Black Lives, Universities Allied for Essential Medicines, Protect Our Patients, and the American Medical Student Association.
