A number of commentators have remarked on the distrust inmate-patients and their caregivers have for each other. One authority, for example, observed these facts: In a prison, the state retains the physician, and therefore inmates, who cannot personally choose their doctor, often lack confidence in his skills and sincerity, and may even refuse his treatment. The notion that underlies many malpractice suits, namely that the patient has sought out and retained this particular doctor and therefore is presumed to trust him and assent to his treatment, is absent in institutional cases. Instead, the prison doctor may come to see himself as personally responsible for the prison's medication supplies, … all to be jealously defended against the inmate. … The doctor assumes that every patient is trying to con him, and may resist inmates' complaints. Further, the doctor may find himself making moral judgments which affect his treatment of different patients (particularly in cases of self-inflicted wounds).
Plotkin, supra note 40, at 165–66. Nancy Dubler elaborated on this view in the more specific context of the dying patient: In contrast to nonincarcerated patients, inmates do not assume that the system is acting in their best interests. Dying prisoners may not be convinced that the system is acting in their best interests. Dying prisoners may not be convinced that decisions to limit care and permit death have been preceded by the full range of efforts to extend and support life. Sadly, the problem lies not in their unfounded suspicions, but in the accuracy of their assessment. In the nonincarcerated world, one important focus is on preventing overtreatment and inappropriately aggressive care at the end of life. In many correctional institutions, however, it is still necessary to ensure that inmate patients receive intensive care to extend life when that is medically appropriate.
Dubler, supra note 40, at 149. Physicians who practice in the free-world managed care environment might be viewed through the same lens of suspicion, both because their patients are required to choose them from a limited list and because their financial well-being varies inversely with the cost of the care they dispense. A physician who practices under a capitated arrangement, for example, could easily come to envision as a potential economic loss any patient who presents himself for care. A salaried physician in the prison system similarly could think of an inmate-patient as demanding his time without offering any corresponding compensation. Further, given the perceived incidence of malingering among prison inmates, the institutional physician might be inclined to see his patients in much the same way as a capitated physician in the free world would see a hypochondriac. Yet, market-driven demands exist in the free world system which, though imperfect in practice, are designed to ensure physician compliance with professional standards of care, thereby rewarding the most efficacious treatment patterns. These demands are translated into economic incentives to which physicians employed in the penal system are not subject.
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