A patient is brought in to the Emergency Department following an overdose on fentanyl. He received naloxone from a bystander and police officers were present at the scene. The patient had outstanding warrants; therefore, he was placed under arrest before being brought to the hospital via EMS.
Physicians interact with law enforcement personnel in a variety of ways and settings. Many argue that these uniformed personnel play an important role in the health-care system and that their presence is beneficial in certain clinical circumstances. Police presence in clinical settings, however, has the potential to impact patient care in a way that is detrimental to the fundamental goals of health-care providers: to provide high-quality, patient-centred care and optimize health outcomes.
As hospitals, medical schools and health-care organizations publicly denounced police violence last year, these acts of solidarity neglected to acknowledge how police presence and power imbalances manifest within the health-care system and how this is at odds with the professional and moral obligations of physicians.
Experiences and encounters with the police outside the hospital can have detrimental effects on health, but the presence of the police within our health-care system has consequences, too. Health-care professionals must critically reflect on, and question, the role of police in clinical settings and consider how the presence of police may compromise the doctor-patient relationship, patient confidentiality and the quality and safety of care that all patients deserve.
Police officers remain by the bedside during the assessment and insist on leaving the handcuffs on the patient. The officers are asked to step outside of the room, which they oblige. However, the patient continues to refuse to disclose his medical history and drug use habits due to fear of the officers over-hearing and using this information against him.
While these encounters may be complex, it is the responsibility of health-care providers to advocate for their patients. The presence of an officer at the bedside directly compromises the right to privacy and confidentiality that all patients have. Whether or not the police are immediately present at the bedside can still influence care by impacting patient autonomy and informed decision-making. A lingering police presence can pressure patients into agreeing to treatments or interventions to appear cooperative to police. Patients may perceive that their care team is colluding with police, resulting in a belief that their best interests are no longer being prioritized. That could translate to patients withholding information vital to their care, questioning their providers’ motives and non-adherence to care recommendations.
“Health-care professionals must question the role of police in clinical settings.”
It is important to highlight how police presence disproportionately undermines the care that patients from structurally marginalized groups receive; notably, those who historically and currently are marginalized and over-policed such as those who are racialized, Indigenous and/or members of 2SLGBTQ+ communities. The resultant mistrust in the police has been shown to translate to the health-care system, ultimately leading to the under-utilization of health-care services. When police are present in a hospital, patients no longer perceive the hospital as a “safe haven” and experience significant emotional distress and poorer outcomes, and this impact can extend to other patients, family members and staff in the hospital.
The patient is eventually medically cleared and discharged back into police custody. He received harm reduction counselling but is unable to accept or carry a naloxone kit as he is in custody. Given that the patient is unsure if he will be held in jail or let out on bail, he declines an outpatient addictions referral.
Provinces and health-care systems differ in the policies guiding the authority of the police within their walls. Some hospitals grant police the ultimate authority to make decisions about how patients are treated within the health-care system – authority that supersedes that of the physicians, whose moral and legal responsibilities are to provide care that may conflict with the obligations of the police force. For instance, hospital policies may allow law enforcement personnel the right to stay with the patient throughout the entire stay in hospital but this interferes with the patient’s fundamental right to privacy and confidentiality.
Additionally, while the use of physical restraints may be common practice in policing, these practices can, unfortunately, translate to the bedside when restraints are inappropriately enforced. For example, pregnant patients escorted by an officer may labour and deliver while handcuffed to the bed – a cruel practice that is banned across many jurisdictions and prohibited by many human rights organizations.
Many of our institutional policies remain misaligned with evidence and best practices for patient-centred, trauma-informed care and are not in keeping with the Canadian Medical Association’s Code of Ethics or rulings from the Supreme Court of Canada. This lack of standardized policies to protect vulnerable patients is a structural barrier that allows police presence and actions in hospitals to often go unchallenged.
Despite the myriad potential consequences to care, health-care professionals are not adequately trained to reflect on and question the role and presence of police officers in the health-care system. Police presence influences how members of the health-care team perceive and treat patients, creating the assumption of guilt and exacerbating biases even when there is no risk of violence from police-escorted patients. It also amplifies existing stereotypes associated with policing and criminality that are reflected within hospitals through the disproportionate use of physical restraints and overrepresentation of Black people in the forensic psychiatric system.
Without adequate training, health-care professionals may also fail to recognize the degree to which they participate in policing behaviour. For example, in psychiatric settings, doctors have the authority to detain patients in hospital and may oppose them in legal hearings if patients appeal. While this is typically done with the best of intentions, providers also must be aware that patients may experience this as coercive and alienating. The knowledge that their health-care provider may also act in a policing and detaining role can undermine a patient’s trust in the therapeutic relationship, resulting in poorer care.
The professional obligations of doctors and police are not identical. Interactions with law enforcement personnel are inevitable but health-care professionals must act critically when navigating these interactions while acting in the best interests of patients, upholding their rights to privacy and confidentiality, promoting patient autonomy and practicing trauma-informed, patient-centred care that is minimally coercive.
Acknowledgements: The authors wish to thank Maya Liepert at the University of Calgary for her role in contributing to the background work for this article and providing constructive feedback on the initial draft.
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So beautifully written. Thank you We need more of this
I was taught to put the patient care first, in nursing school. We were told to consider security risk (ask about that), but we were also warned not to let police intimidate or bully us, esp when it’s healthcare turf. If someone is not adequately cared for, and their essential medical needs are not screened and met, they may go on to die in police custody. eg heart problems, head injury, internal bleeding, dehydration, impending alcohol or drug ingestion/overdose, etc.
Your article is complex but very well presented. While I have no experience with these issues, I agree they need attention. It seems logical that the health related professions work together to address situations like this and others they encounter. A team approach (representatives from all health related professions) must work with social workers and police and other related services otherwise these issues will not resolve.
Elizabeth Rankin BScN
I am so glad to see this issue gaining more attention, and to see a familiar face in the conversation (hi Claire!). As a related, but perhaps tangential offshoot of this conversation, I have been thinking a lot about the ability of healthcare providers and institutions to actually create culturally safe space for, particularly, Black and Indigenous persons, and our duty to communicate the limitations of the safety we can actually provide. Layered within the legislation that governs healthcare professionals includes a duty to report, under specific conditions, to institutions that we know are steeped in and reproduce colonialism and colonial harm- the well documented harms of Child and Family Services systems in Canada perpetrated against Indigenous peoples come to mind for me, but policing is another important example that affects so many racialized, marginalized, and oppressed people and groups. I continue to wrestle with how to best cope with the tangle of legal requirements of being a regulated healthcare professional, protecting clients and children who are vulnerable, and the reality that the hierarchies our systems are built on, like colonialism, white supremacy and ableism, will cause disproportionate harm to equity requiring groups who enter or encounter those systems. I am hopeful that as Indigenous Nations are less restricted in their ability to exercise their sovereignty and self-determination, like the Cowessess First Nation taking control of their child welfare system, we will be able to follow their leadership in not only how to care for and support Indigenous clients, but how we can evolve and indigenize our existing societal systems to prevent harm and generate health. In the meantime, I would welcome advice or ruminations from anyone else who has been contending with the delicate balance the current system presents, or avenues they see for changing the current status quo!
The questions you’re raising are absolutely part of this conversation! I’ll preface this by saying these are my thoughts and not necessarily those of my co-authors. Policing isn’t limited to just the police, it’s a force exerted in many ways by different state institutions (including CFS), with the greatest force applied to marginalized people – in this case Black and Indigenous communities, whose children are vastly overrepresented in the child welfare system. I also wrestle a lot with the ethical dilemma of working within an institution meant to help, while trying to avoid doing more harm. I try to look for opportunities to use the weight of the “doctor” title to advocate for patients, and focus as much on patients’/families’ strengths as I do on weaknesses or problems. Within mental health specifically, I try to be as clear and honest as possible with patients about what they can expect (eg “these are the circumstances under which an involuntary assessment might be necessary, and I want to avoid going that route if at all possible, so let’s discuss how to move forward together”). My hope in these conversations is that HCWs get more comfortable acknowledging the inherent contradictions and limitations in the system as it exists now. If we accept that many parts of these systems are harmful, we can then begin to move forward with change. I also hope that Indigenous nations can take more sovereign action and lead care in ways that are most appropriate – and that calls for humility on the part of settlers, recognizing that our answers are not always right.