Dissertation Title:  "The Right to Health, the Power to Punish, and the Duty to Advocate"Paper 1: The Right to Health and the Power to Punish

If prisoners have a moral right to health (RTH), then why should this be so? Moral rights do not depend on any legal systems or other social institutions; instead, they place demands on what laws and institutions we should have. They are shown to exist by moral argument. What arguments or rationales might justify a moral RTH for prisoners?

How one may answer this question depends on whether we should generally see all people as having a RTH. If one believes that people do not generally have this right, then one needs to explain why protecting health is of such moral importance that we should have obligations to meet prisoners’ health needs when we do not owe them similar obligations in relation to other needs. Furthermore, one also needs to explain why prisoners should have a RTH while other people should not. The standard argument offered by those on this side is that prisoners are a special case of people to whom we owe assistance meeting their health needs because certain health needs may lead to harms and suffering so serious that not assisting them would constitute cruel or inhumane punishment, or torture. They argue that since people have a right to be free from torture, then society has obligations to protect and promote prisoners’ health. I show that this argument is self-defeating: either it cannot adequately explain the obligation to assist prisoners in meeting health needs, or it cannot explain why non-prisoners should not also be owed similar assistance.

By contrast, if one believes that people generally do have a RTH, then one is called on to justify this view by showing that a RTH follows from a general theory of justice and health, such as that developed by Norman Daniels. Provided such a theory, then the burden of showing that it is permissible to punish people in ways that involve restricting this right is on those who contend as much. In this context, the strongest objections to the view that prisoners have a RTH involve claims that the principles of justice that ground our RTH also allow punishments that involve imposing restrictions on it. I show that these objections to a theory like Daniels’s are either unsound, or overstated.

Paper 2: Health And Health System Reform in the Colombian Prison System Between 1998 And 2015

Background: The WHO Regional Office for Europe (WHO/Europe) recommends that responsibility for prison health should be transferred from the ministries of justice or interior to the national health authority, and that the provision of healthcare in prison should be contracted to the general health system. There is little evidence to support these recommendations, however, and it is not obvious that they are applicable to contexts beyond Europe. Colombia introduced reforms to its prison health systems similar to those recommended by the WHO/Europe between 1998 and 2016, making it an interesting case to study.

Methods: We evaluated these reforms using a mixed-methods approach comprising documentary analysis of secondary sources, institutional-ethnographic research, key-informant interviews, and a health survey among a probability sample of inmates in a large prison located in Bogota. Using WHO’s “building blocks” framework, we analyzed changes to the prison health system’s organization and governance, financing, health workforce, accessibility of essential medicines, and the delivery of health services.

Results: Between 1998 and 2015, Colombia integrated the prison and general health care systems — which historically were independent from each other with parallel governance, financing, and healthcare delivery mechanisms — by transferring the responsibility for prisoners’ healthcare from the National Institute of Prisons and Correctionals (INPEC) to insurance agencies and service providing institutions contracted from the general health system. Most of the changes that were introduced during this period were reversed in 2016: the prison health system was once again segmented from the general health system and a new institutional arrangement was created to take charge of it.

Conclusions: None of the reforms appear to have achieved progress towards the realization of prisoners’ right to health. Instead, our findings suggest that the reforms may have been retrogressive.

Paper 3: Justice and Medical Professionalism: Should doctors be accountable patient advocates?

Medical professionalism has traditionally been thought to require a kind of partisanship that bars doctors from giving weight in their clinical decision-making to considerations other than about their own patients’ best interests. This traditional view implies that doctors should not be required to play the role of steward of shared health-system resources, since stewards are accountable to all those who have a stake in how those resources are used for the reasonableness and fairness of their resource-allocation decisions. A division of labor is often proposed to preserve doctors’ role as their patients devoted advocates by assigning the role of steward to administrators or policymakers. Stewards must restrict doctors’ clinical autonomy and authority as necessary to ensure they stay within the limits required by justice. However, many doctors believe that these restrictions impinge on their ability to pursue their patients’ best interests, and thus necessarily pose a threat to what is valuable in medical professionalism.

It appears that we face a dilemma: justice requires stewardship, yet medical professionalism allegedly rules it out. Some commentators have suggested that the right response to this dilemma is to make a direct claim that justice should be primary in guiding the design of social institutions, including professional roles and their norms. This implies that we must rethink the traditional view that doctors’ clinical-decision making must be guided exclusively by a concern for their own patients’ bests interests. Yet many people believe that the traditional conception of medical professionalism captures the kind of doctor-patient relationships that we would ideally want. So, they might worry that revising this conception necessarily means that we must instead settle for a less desirable version of medical professionalism. My goal in this essay is to address this worry.

My central thesis is that it is possible to articulate a conception of medical professionalism that is worth valuing, but whose requirements do not clash with those of justice in the way the traditional view suggest. I shall try to show that the conflict between the role of patient advocate and that of steward of shared resources is largely overstated by the traditional view, because it ignores that the values that underlie the requirements of patient advocacy also depend on the value that underlies the need to set limits to it, namely, justice.