Routine shackling of incarcerated patients violates foundational international human rights principles, including those contained in the Universal Declaration of Human Rights, the International Convention on the Elimination of All Forms of Racial Discrimination, and the International Covenant on Civil and Political Rights.^15-17  These principles are designed to protect human dignity and protect persons from discrimination and cruel, inhuman, and degrading treatment. In accordance with these Mandela Rules and the Charter of Fundamental Rights of the European Union, the head of the British prison service proclaimed that the “shackling of patients in hospital[s] should not occur,” emphasizing that “security is important, but it should never blind us to the overriding need for compassion and humanity.”^18,19 In the Netherlands, chains are never used and handcuffs are used only in exceptional circumstances.¹⁸  Our work amended shackling practices to introduce a risk-stratified, individualized protocol for American hospitals that aligns with human rights principles better upheld by Western nations. ^{21, 22}

We began by writing and circulating a petition to hospital affiliates and community members to raise awareness and support.²³ Amassing 780 signatures across 129 institutions nationally, the petition demonstrated a consensus for change that enabled us to engage the hospital’s executive leadership in policy reform. Next, we solicited input from key hospital stakeholders including public safety and patient-facing staff such as nurses, as well as medical, nursing leadership, and legal hospital leadership. Identifying shared values for patient care helped generate feedback to balance concerns for safety and liability with human dignity. We then engaged with hospital administration and proposed a modification to existing hospital policy.  Following multiple meetings with and input from key stakeholders, the policy on shackling incarcerated patients was officially modified in February 2023. The core of the modified policy is a process that allows for the removal or modification of shackling in certain incarcerated patients and provides hospital personnel with a detailed protocol for the assessment and implementation of this policy. The policy outlines a schema for communication and decision-making among carceral facilities, hospital security, and the patient’s healthcare team with the goal of providing dignified and humane care to incarcerated patients while maintaining hospital security.

The discourse around shackling practices reached beyond the walls of our hospital, inciting a national discussion not only regarding the issue of shackling patients, but how this practice could be brought to an end. In parallel to the conversations we were leading and progress we were making within Boston Medical Center, we also launched the Stop Shackling Patients Coalition (SSP) – a body of clinicians, public health practitioners, human rights advocates, and community members who share the goal of humanizing the inpatient treatment of incarcerated patients. SSP has now grown into a diverse task force and learning collaborative that meets to empower healthcare institutions from across the United States to change their shackling policies.