Correctional systems should formally solicit input on healthcare planning and surrogate assignment from incarcerated patients before they lose their decision-making abilities, according to a study recently published in AMA Journal of Ethics.

Researchers stated that the incarcerated population is at higher risk for substance use disorder, chronic illness, serious mental illness, and cancer; yet, patients who are incarcerated have limited decision-making ability surrounding health care while serving their sentences and face challenges when correctional facilities formally assign surrogates to them during incarceration. This leaves the incarcerated population extremely vulnerable.

In this study, researchers presented the advantages and disadvantages of potential surrogate decision makers for the incarcerated. Family members are the most common and likely default surrogates for patients who are incarcerated but become estranged from their incarcerated relatives and lack knowledge of their personal healthcare preferences. Correctional custodians may presume knowledge of a patient’s healthcare desires but have potential conflicts of interest along with financial and security concerns that rank above the patient’s best interests.

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Correctional physicians have more sophisticated medical knowledge and follow a code of ethics that guides decision making for patients who are incarcerated but may lack knowledge of specific patient preferences and have potential conflicts of interest along with a lack of medical resources. Lastly, friends of the incarcerated inside and outside the correctional facility may have intimate relationships with the patient, but there is no system in place to confirm the validity of intimacy. In addition, the assignment of prison friends as surrogates validates the relationships made in a stigmatized and dehumanized setting.

Researchers concluded that correctional facilities should use a patient-centered approach when considering potential surrogates for unrepresented patients who are incarcerated and develop better strategies for advance healthcare planning by asking the patient’s input before their incarceration. States and other jurisdictions should not assign default surrogates for people who are incarcerated and should carefully consider and document each patient’s unique case. Lastly, the legal and medical communities should sponsor research to gain a better understanding of the needs and preferences of incarcerated patients. 


Tobey M, Simon L. Who should make decisions for unrepresented patients who are incarcerated? AMA J Ethics. 2019;21(7):E617-E624.