Question Health Care

In this QHC Case Collective post, I include key points and resources from Episode 1 of the QHC Podcast, recorded 27 April 2026. I interviewed Dr Mark Kuczewski to investigate how organizations’ policies shape care of patients in law enforcement custody. My paraphrase and partial analysis of the case follows below; the original case appears in this article. Considerations about what to do and what to ask about cases like this one also follow below.

—Christy Rentmeester, QHC Podcast host

Case

ICE officers bring a woman to an emergency department. She is in her mid-20s, pregnant, and might be in labor. Clinicians and trainees in the emergency department have to determine whether to admit this patient to the hospitals’ labor and delivery unit. So they need to speak with her about her history and symptoms and examine her. The case suggests that ICE officers do not leave while the patient is interviewed and physically examined. Also according to the case, the hospital’s policy about law enforcement personnel who accompany detained patients specifies that law enforcement personnel are allowed to “guard” a patient during a clinical encounter. It’s unclear what “guarding” means here, but the case does state that the hospital’s policy does not define the scope of a detainee/patient’s right to privacy. The case does specify that the hospital’s policy explicitly directs that one arm of a detainee/patient is to be handcuffed to a bed rail. The case does not specify who cuffs the patient to the bed. Nor does it specify whether or to what extent cuffing interfered with clinicians delivery of health services to the patient. Finally, the case states that an ICE officer moves the patient’s food to a place beyond her reach and continues to do so for hours.

Most health care organizations have at least one policy meant to guide clinicians’ interactions with patients who are detained by law enforcement. (In organizations’ policies, patients in custody of law enforcement personnel might be referred to as “carceral” patients if they are serving a prison sentence, awaiting a court proceeding, or awaiting deportation; patients suspected of having participated in a crime might be called “forensic” patients.) An organization’s policy about “carceral” or “forensic” patients should acknowledge the policy’s intersections with other policies on topics such as privacy, confidentiality, informed consent or refusal, and voluntariness of decision-making.

1. Which professional decisions or actions does a policy make easier or harder?

One good general definition of moral distress is this: a set of experiences of well-intentioned, well-trained clinicians whose moral agency is restricted by policies that make it hard to practice in patient-centered ways. When clinicians’ moral agency is restricted, they can’t act as they are motivated to act in service to patients, and they experience moral distress.

Revision of any policy that routinizes moral distress among clinicians should be an organizational priority. Organizational policy-making processes should generally include input from a cross-disciplinary range of thoughtful clinicians who have duties to respond with care to patients’ needs and vulnerabilites.

2. When a policy was written, did it include perspectives of persons who have professional duties to promote patients’ best health interests?

If not, that policy could be hard to defend that policy as patient-centered. Business units within a health care organization (eg, risk management, general counsel, security) that wrote a policy are usually also responsible for updating or revising it.

A patient-centered policy about how a patient-detainee is treated should reference organizational policies that acknowledge key clinical ethics concepts (eg, privacy, voluntariness) and practices (eg, privacy protection, informed consent or refusal). Policies intended to guide uses of physical restraints (eg, cuffs, straps) or chemical restraints (eg, drugs) are particularly important.

3. How should clinicians and trainees respond in cases in which a policy endorses use of restraints that are neither commensurate nor proportional to risk, if any, posed by a patient-detainee?

If a “forensic” or “carceral” patient policy is not patient-centered, but requires, in order to be implemented, decisions and actions by moral agents who have duties to promote patients’ best interests, then that policy is likely to routinize moral distress among clinicians who serve patients accompanied by law enforcement personnel. Where there is moral distress or divergence from patients’ needs and vulnerabilities, there are good reasons to ask questions like these.