When an inmate refuses proffered medical care, however, a problem of a different nature arises. The inmate’s own health, the health of staff and other inmates, and the security of the institution as a whole may be affected. Correctional staff must be cautious to ensure that the inmate’s refusal does not become a cause celebre leading to facility security being undermined.

This article will discuss key points that professionals should consider when confronting an inmate who refuses to accept proffered medical care. While each case is necessarily unique, there are some general ideas to keep in mind.

The Right to Refuse Treatment
Some 15 years ago, the U.S. Supreme Court held in Cruzen v. Missouri Department of Health that, as a rule, “A competent person has a constitutional right to refuse unwanted medical treatment.” Once an inmate becomes incarcerated, however, that constitutional right is no longer absolute. Instead, courts have recognized that an inmate’s right to refuse medical care must be balanced against the state’s interests in (1) protecting and preserving life, (2) preventing suicide, (3) protecting the interests of third parties and (4) maintaining prison security, order and discipline. (See, e.g., Thor v. Superior Ct.)

As a practical matter, most inmate refusals are inconsequential and result in no long-lasting or significant health consequences. Refusing to take prescribed medication, to submit to a physical examination or to tender a health care request form are frequent events in any correctional facility. It may be that an inmate is simply attempting to manipulate the health care staff or to express dissatisfaction with “the system,” which hardly warrants any unusual attention.

The specific circumstance, however, may cause an inmate’s refusal to accept medical care to run contrary to one of the recognized interests of the state, and if the refusal jeopardizes one of those interests, the judiciary has shown no unwillingness to recognize the superiority of the state’s interests.

Courts have, for example, authorized correctional officials to force-feed inmates, to administer psychotropic drugs without an inmate’s consent and to compel inmates to undergo dialysis because, under the facts at issue, the courts found that the state’s interests were superior to the inmate’s constitutional right to refuse care.

There is no specific law regarding when a state’s interest trumps an inmate’s constitutional right to refuse medical care. Each case is fact-specific. The inmate’s medical condition, the prognosis, the benefits and burdens of the treatment, and the impact of the refusal on other inmates (e.g., the “copycat” phenomenon) are all factors that weigh upon this issue.

The bottom line, it appears, is that once incarcerated, an inmate’s right to refuse medical care has significant boundaries.

Responding to a Refusal of Care
Any refusal of health care by an inmate should be addressed and properly documented. Proper documentation alerts other health care providers to the inmate’s history and may assist the professional in making future treatment decisions. In addition, proper documentation helps the medical professional recall isolated and seemingly insignificant events months and years later.

There is no golden rule regarding how to chart a refusal of medical care. Obviously, the specific care that was refused and the inmate’s reason for the refusal should be recorded, along with the date and time. The inmate should be told of the possible consequences of the refusal, and he should sign or initial the entry. The key is to include enough information in the entry so that other professionals are alerted and can react appropriately. It also will help the medical professional to accurately recall the event later relying solely on what was written.

Some correctional facilities use special forms when an inmate refuses medical care. These forms provide spaces for the information referred to above and often include a space for the inmate to sign indicating that he is, in fact, refusing the specific care at issue. In addition, if the inmate refuses to sign the form, typically a space is provided for a witness (i.e., another health care provider or a correctional officer) to sign verifying that the inmate refused the specific medical care but declined to sign the form. These forms are excellent tools and reflect that the inmate’s refusal of medical care is not being taken lightly.

Lastly, the inmate should be questioned about why he is refusing the proffered medical care. Flushing out the motivations can help the medical professional address the inmate’s circumstance.

The decision on whether to alert a physician or other medical professional about the refusal depends on the inmate’s specific health care needs, the medical care at issue and the health consequence, if any, of the refusal.

Refusing Care and Civil Rights
One controversial byproduct of inmates’ rights to refuse medical care arises when an inmate who refuses treatment then turns around and claims that the medical professionals who offered the declined treatment were deliberately indifferent to the inmate’s serious medical needs. While at first blush this might sound twisted, courts have repeatedly addressed lawsuits filed by an inmate who complains that proper medical care was not provided even though, the evidence shows, he actually refused the care in question.

In ruling on these cases, the courts have analyzed such claims in two different ways.

First, courts have recognized that an inmate’s refusal of medical care indicates that the underlying medical health problem cannot have been overly serious. This approach simply reflects common sense—if the health problem that the inmate allegedly suffers from were serious, he would accept medical care to treat it. Since the inmate refuses to accept the tendered medical care, the underlying condition must not be serious. As the court explained in Thomas v. Gish:

“The fact that the plaintiff voluntarily declined treatment belies any inference that his need was serious. That would be an exotic theory of liability—a cousin to a prisoner’s refusing medical treatment and then complaining that the person had exhibited deliberate indifference to his medical needs by failing to treat him—and one perhaps vulnerable to a defense of crying wolf.”

Second, courts reject such claims finding an absence of deliberate indifference by the defendants. These courts recognize that a medical professional cannot be criminally dangerous or reckless where the professional is offering medical treatment that the inmate, for whatever reason, simply refuses to accept.

The court in Grant v. O’Leary held that, “The plaintiff cannot refuse treatment and food and then complain that the defendants were deliberately indifferent to his medical and nutritional needs.”

The court’s decision in Williams v. Fishburn was even more blunt in refusing to accept such a theory: “The plaintiff simply cannot create a constitutional violation by refusing treatment.”

Conclusion
An inmate’s refusal of medical care should be addressed methodically. Attention should be paid to the refusal but, because of the potential manipulation issues, the attention should not, at least initially, be too extraordinary. Proper documentation should be used and appropriate follow- up assessments should be made. Because of the potential impact on the inmate as well as others, medical professionals should work closely with correctional staff to ensure that the refusal does not mushroom into something overly serious.

— About the author: Robert P. Vogt, JD, is a partner with Weldon-Linne & Vogt, a Chicago-based law firm that specializes in defense of malpractice claims against health care professionals. He is the immediate past chairman of the Academy of Correctional Health Professionals. To contact him, e-mail bvogt@wlv-online.com.