Box 2: Excerpt from the updated policy on the Care of Incarcerated Patients – Boston Medical Center. In addition to the Care of Prisoners documentation by nurses, any member of the incarcerated person’s interdisciplinary healthcare team shall assess the incarcerated person’s health status to determine if Special Circumstances are present for shackle removal or modification to the least restrictive alternative. This Recurring Shackle Assessment (RSA) shall be documented every twelve hours. If the patient meets criteria for Special Circumstances, the healthcare team will determine whether the patient is eligible for Compassionate Shackle Removal (See “Compassionate Shackle Removal for Hospitalized Patients). If Special Circumstances are discovered at any other time than during a RSA, restraint removal or modification can also occur. Compassionate Shackle Removal for Hospitalized Patients Compassionate Shackle Removal is a concept where, in exceptional cases, the patient’s clinical team may request the patient’s custodial agency to recommend removal of handcuffs and shackles while the patient is receiving care at BMC. Consideration for these requests should be discussed with the patient Care Team to evaluate the patient’s physical ability to cause harm to themselves or others, or attempt escape. If the Care Team agrees the patient meets the criteria for compassionate shackle removal, the Attending Physician is encouraged to advocate to the custodial agency for the removal of the shackling devices outlined in Figure 1 (Appendix A).
Both policy and practice have begun to change. On May 13, 2023, the Massachusetts Medical Society resolved to condemn universal shackling, as well as advocate for individualized assessments for the removal of shackles and use of the least restrictive alternative. 24 Additionally in May 2023, a patient who was incarcerated, sedated, and intubated in Boston Medical Center was unshackled by correctional officers after the care team adhered to the new policy. Next steps include developing a plan in collaboration with the hospital to provide ongoing staff education about the modified policy. This is important because the protocol is driven by the ability of physicians, nurses, and other patient-facing staff to assess and recognize patients in Special Circumstances. EHR flowsheets will be developed by the hospital information technology team. Ongoing and iterative improvement will be important for sustainable implementation.
We encountered obstacles in parsing through patient and physician rights, engrained clinical practices, stigma, and culpability. Determining who can request the modification or removal of shackles, and who wields the practical authority to approve or deny such requests was complex. This stems from limited interactions, often through third-party health care or security contractors, between the carceral system and hospital-based medical care. Clearing the haze required us to identify written policies wherever possible and collaborate with colleagues from across clinical specialties, hospital administration, public safety, and legal services. SSP overcame barriers to change in a stepwise process that can serve as a model for other initiatives at the intersection of human rights and medicine.
The harmful and discriminatory routine shackling of incarcerated patients brazenly continues to occur across the American healthcare system. It is our hope that this model will be adopted by other healthcare institutions nationally to provide for regular assessment and advocacy of all incarcerated patients, ending universal shackling practices. As healthcare professionals, we are compelled to scrutinize entrenched practices that perpetuate harm, and we must humanize the care of incarcerated patients.
References
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  2. Lescure T. No Patient Should Have to Die in Shackles. The Washington Post | Opinion. https://www.washingtonpost.com/opinions/2021/10/05/no-patient-should-have-die-shackles/. Published October 5, 2021. Accessed October 12, 2021.
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  4. First Step Act of 2018, United States Congress, Public Law 115–391 S.756, 115th Congress
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  14. United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules).  As adopted by the 70th Session of the UN General Assembly. 08 January 2016.
  15. United Nations. UN General Assembly Resolution 217A: Universal Declaration of Human Rights. 10 December 1948.
  16. United Nations. UN General Assembly Resolution 2106: International Convention on the Elimination of All Forms of Racial Discrimination. 21 December 1965
  17. United Nations. UN General Assembly Resolution 2200A: International Covenant on Civil and Political Rights. 16 December 1966
  18. European Union. Charter Of Fundamental Rights Of The European Union. 07 December 2000. https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:12012P/TXT&from=SL
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  21. Ombudsman South Australia. Ombudsman investigation into the Department for Correctional Services in relation to the restraining and shackling of prisoners in hospitals. July, 2012. https://www. ombudsman.sa.gov.au/publication- documents/investigation-reports/2012/ correctional_services_july_2012.pdf (accessed June 20, 2023).
  22. HM Prison and Probation Service. Prevention of escape: external escorts policy framework. Ministry of Justice and HM Prison and Probation Service, UK. 2023. https://assets. publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/ file/1143131/prevention-escape-external- escorts.pdf (accessed June 20, 2023).
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  24. Massachusetts Medical Society Resolution A-22 A106: Condemning the Universal Shackling of Every Incarcerated Patient in Hospitals. Adopted May 2023.