Original article

Prison medicine, public health policy and ethics: the Geneva experience

DOI: https://doi.org/10.4414/smw.2011.13273
Publication Date: 07.11.2011
Swiss Med Wkly. 2011;141:w13273

Bernice S. Elger

Institute for Biomedical Ethics, University of Basel, Switzerland

Summary

The health care of prisoners represents a public health priority. However, in many countries, the pursuit of public health goals in prison is not granted. Introducing condom distribution and syringe exchange in prisons remains the exception.

This article describes the example of a Swiss canton in which the legal framework enables health-care personnel to put into practice health care that is equivalent to the care available to non imprisoned persons including harm reduction measures for prisoners. The article describes the medical institutions in charge of health care for prisoners and the legal and ethical framework, its repercussions on the clinical and public health context, as well as persisting difficulties.

The Geneva experience shows that in spite of the legal context, preventive measures, free informed consent and confidentiality have to be constantly defended by physicians and public health authorities. Both need to be regularly educated on their obligations towards prisoner patients. A complaint mechanism granted to detainees as part of the legal framework is important to adapt existing practice to new challenges.

Key words: prison medicine; public health policy; ethics; Geneva

Introduction

The health care of prisoners is not only important from a human rights perspective, but represents a public health priority. In prisons, the transmission of blood-borne infections, be it HIV or hepatitis, continues to occur [1–4]. The surveillance and prevention of infections associated with injecting drug use in the prison setting remain a high public health priority. Offering harm reduction measures to prisoners is part of the principle of equivalence of health care enshrined in soft law from the United Nations (UN) and the Council of Europe [5–7]. The European Court of Human Rights has considered insufficient health care a form of inhumane and degrading treatment and therefore a violation of article 3 of the European Convention on Human Rights [8]. Not providing harm reduction measures in prisons has been included as an example of a violation of this human rights article [7, 9]. In most countries, the protection of prisoners’ right to health care and the pursuit of public health goals in prison are not granted [10]. Although some harm reduction measures such as the distribution of bleach and methadone treatment are being established [11], introducing condom distribution and in particular syringe exchange in prisons is considered a catch 22 and remains infrequent [1, 12–14]. In the Madrid recommendation, experts in harm reduction and in the control of communicable diseases draw attention to the urgent need for action and outline the recommendations for health protection in prisons [15].

We will describe here the example of a Swiss canton in which the legal framework enables health-care personnel and public health authorities to put equivalent health care into practice, including harm reduction measures for prisoners. The aim of this article is to describe not only the medical institutions in charge of health care for prisoners, but also to summarise the legal framework, its repercussions on the clinical and public health context, as well as persisting difficulties.

Health care for prisoners in Geneva: the legal framework

The legal framework in Geneva relevant to prison health care includes different cantonal laws and recommendations [16–19]. Article 30 [19] regulates “Medical control and hospitalisation”. It stipulates that “[t]he detainee undergoes a medical examination: a) at his request; b) if his health status causes a danger to him/herself or to others”. It goes on to say that “[i]n the case of emergency or medical necessity, a detainee can be transferred to the university hospital or to the psychiatric inpatient unit”. Since 2000, these different regulations are summarised and supplemented in a detailed executive regulation which has the legal status of a decree of the State Council [20]. It should be noted that in this decree, preventive health care is named first and therefore recognised as an important part of the principle of equivalence. The State Council “confirms that all persons deprived of liberty must benefit from preventive measures and health care equivalent to those put into place for the general population” [20][Art 4].

The decree confirms the previous decision of the State Council which was to assign the organisation and supervision of medical, socio-therapeutic and preventive care for detainees to the cantonal department of health. The structures in charge of these tasks are named explicitly. A medical unit at the Champ-Dollon prison administers “outpatient primary health care, dental care, and psychiatric, ENT, ophthalmology and other specialty care according to need” [Art 6a] (Champ Dollon is the largest remand prison in Switzerland housing between 400 and 500 detainees with recent peaks even beyond 500 detainees). The decree also names the outpatient clinic at the juvenile detention centre (“la Clairière”), two inpatient units and a socio-therapeutic centre. The latter three are also accessible for detainees from the French and Italian speaking regions of Switzerland, as it is specified in the “Concordat”, an inter-cantonal regulation settling collaborations between cantons concerning detention. The two inpatient units are, first, a “hospital unit for psychiatric inpatient care to detainees”, and, second, a hospital unit for medical and surgical inpatient care to detainees. Both units provide access to all diagnostic and therapeutic equipment from the University Hospital of Geneva (UHG) as well as to all specialty consultations available in the UHG. The third mentioned inter-cantonal structure is a centre providing socio-therapeutic care to detainees suffering from severe personality disorders.

The most important concern expressed in the decree by the State Council is that prison medicine has the obligation to guarantee detainees access to the same health care that is offered in Geneva to non detained persons. The decree stipulates the following details: at entry, all prisoners are seen by health personnel under conditions maintaining confidentiality and permitting the detection of medical problems, including the continuation of medications, the treatment of withdrawal symptoms, and screening for traumatic lesions and infectious diseases. The “medical unit provides to each […] detainee written information about the organisation of health care and the preventive measures in the prison”. All detainees must be able to have access, at any time, to health-care personnel. The request for a medical consultation is done in a confidential way without any influence of prison or judicial authorities. For medical emergencies, a nurse is permanently present in the prison and a physician is on call 24h per day, and detainees can be transferred to the emergency room of the University Hospital at any time based only on a medical decision made by the nurse or the physician.

According to the decree, outpatient treatment in Champ Dollon must include physiotherapy and dental care as well as screening for tuberculosis, which must be proposed to all detainees at prison entry. The State Council prescribes that a medical record is established for each patient according to the standards of the University Hospital of Geneva (UHG) and that, if necessary, detainees can be scheduled for outpatient consultations in the UHG emergency room as well as for specialty consultations available at the UHG. It states that “These consultations are carried out under conditions respecting confidentiality and privacy of the detainees” (decree 2000, 9.1.d.).

Apart from general access to health care, the decree also regulates access to hospitalisation and access to external physicians. All detainees can be admitted to the inpatient units upon a medical decision and patient’s consent, with the exception of involuntary commitment according to general cantonal law. Concerning involuntary commitment, a noteworthy change in cantonal law took place in 2006 [21]: before September 2006 all admissions of detainees to the psychiatric inpatient unit were by definition non-voluntary. In 1980 the legislator doubted that detainees are in a position to provide voluntary informed consent to psychiatric hospitalisation. In 2006, however, in line with the recommendations from the Council of Europe, the concept of free consent and equivalent treatment of detainees and non detainees was affirmed and extended fully to psychiatric care. Concerning access to external physicians, the decree (art. 9.4) states that any detainee is allowed to request an appointment with his/her treating physician. External treating physicians have to be given access to the patient and his/her medical record in the prison under conditions of confidentiality, with the consent of the detainee. The recommendations of the external treating physician are communicated to the prison physician who takes them into consideration for any further therapeutic decision.

An entire chapter of the decree treats the duties related to the respect of the principles of medical ethics and of patients’ rights in more detail. It specifies that “free and informed consent is the prerequisite of any medical act. The patient must receive all information useful for his or her health state and medical treatments. Patients have the right to consult their medical record and to receive a copy of it […] Confidentiality must be strictly respected. Medical information must not be provided to prison or judiciary authorities, with the exceptions defined by law” (art. 9.3). These exceptions are the same as for patients not in prison. At the end of the chapter on prisoner patients’ rights, the State Council makes an explicit reminder that, concerning all topics of patients’ rights mentioned, such as patient information, confidentiality, consent and research for example, the same cantonal laws are applicable to prisoner patients as to non prisoner patients.

Concerning research with prisoners, “medical or epidemiological research is allowed if the protocol is approved by the research ethics commission of the University Hospital of Geneva” (art. 9.3c).

All prisoner patients “have the possibility to complain to the head of the prison medicine unit, or the medical director of the University Hospital, or in case of negligent care to the Cantonal Commission in charge of the surveillance of medical activities” (art. 9.3d).

The decree contains an entire chapter on preventive measures: “the medical service at the prison communicates to the prison director any appropriate recommendations about prison conditions which might influence the health of detainees, such as conditions related to the environment, nutrition and hygiene. […] concerning infectious diseases, information is regularly provided to detainees and all prison personnel, in particular about hepatitis, HIV, tuberculosis, and dermatological diseases, in collaboration with the cantonal health service providing medical care to prison officers” (9.5). Most importantly, the decree stipulates that detainees must have access to all harm reduction measures known to prevent the transmission of infectious diseases, including condoms and injection devices (syringe and needle exchange etc.) if other treatment options based on abstinence have proven to be impossible in the prison and if the medical personnel considers that a significant risk of transmission exists.

The State Council draws attention to the needs of vulnerable groups. Special measures have to be put into practice concerning detained mothers and their small children (paediatric care, protection of the mother child relationship). The prison medical service is also charged with providing particular attention to the medical and psycho-social needs of juvenile detainees.

Among the categories specially mentioned by the State Council are detainees suffering from medical conditions with a fatal prognosis in the near future, detainees suffering from conditions for which the treatment cannot be provided in the context of detention, severely handicapped prisoners and very old detainees. In these cases the decree urges the medical service to communicate, with the consent of the patient, the necessary information to the competent authority in order to permit a humanitarian decision based on objective medical data.

The final dispositions of the decree treat the interface of the medical structures with the prison administration and security personnel. It is mentioned that prison officers must assure the transport of detainees to the medical consultations and that they are responsible for the prevention of jailbreak. The decree assigns a duty to the prison director to ensure that all prison personnel including guards have received clear instructions concerning complete confidentiality during medical consultations (no presence of prison officers) and that the confidentiality of medical records is maintained (no access for prison officers). The prison director is also mandated to ensure, within the limits of his/her competency, full support for the measures put into place by the medical service. Conversely, the health personnel working in prison medicine are reminded to respect general measures concerning the security and confidentiality applicable to all personnel working in prisons.

The decree prescribes oversight measures: once a year, the prison director and the directorate general of the UHG are under the obligation to meet and carry out a general evaluation of the application of the dispositions of the present decree and to provide an annual report to the cantonal government.

 

In summary, the most important aspects of the decree are that it does not only state principles, but also provides for their execution through a very detailed description of measures, including preventive health care measures, and health care structures to be implemented under the responsibility of the cantonal department of health. Hence, the decree is useful for health personnel to maintain the standards in future conflicts with the prison administration or judicial authorities. The mechanisms of annual surveillance by the directorate general (meeting) and the cantonal government (report) ensure a direct responsibility of the highest political structures with respect to prison medicine.

Health care for prisoners in the Canton of Geneva: the reality

The aim of this section is to provide examples of (i) how the principle of equivalence of care is realised in the clinical context and (ii) how the legal context permits implementation of harm reduction measures. The most important prerequisite to implement equivalent health care for prisoners is professional independence of the health personnel. As stipulated in the decree, the medical personnel working in prison medicine are under the authority of the department of health and are independent from the administrative and judiciary authorities.

Preventive health care

Examples of preventive health care practiced in Geneva are screening to identify detainees who have experienced any kind of violence, and harm reduction measures throughout the entire prison stay. The numbers of consultations as well as the screening procedure for violence have been described elsewhere [22–26]. In line with the principle of equivalence, prisoners presenting with drug misuse related problems should have access to the same preventive health measures as patients in Switzerland, especially since the transmission of HIV and other blood-borne viruses has been documented for prisons [4, 27, 28]. Harm reduction measures in Switzerland include methadone maintenance treatments, the exchange and distribution of syringes to people dependent on drugs without charge, and condom distribution. The Geneva Champ Dollon prison has offered these aspects of preventive health care to prisoners, including syringe exchange, since the 1990s [29]. The decision to distribute condoms in 1985 was emblematic and a world first.

Another part of preventive health care in Geneva is systematic screening for violence. At entry to prison, health-care personnel ask all detainees whether they have encountered any violence from the police. In addition, prisoners are encouraged to report any violence occurring during incarceration. If a detainee complains about violence, a summary of the medical history and the findings of the physical examination are transmitted to the authorities, only if the detainee gives informed consent.

Medical research

A recent report in the US has proposed changes to US federal law in order to grant detainees access to medical treatment available only as part of a research project [30]. Such experimental treatment can be life saving in some cases of multi drug resistant HIV [31]. In Geneva, this access is granted. Examples of research carried out with detainees in Geneva in the past are summarised in Table 1. In order to prevent abuse, in Geneva the same standards for non prisoner patients apply to research involving prisoner patients. Research is only permitted after the voluntary and informed consent of prisoners. It has to be carried out by qualified researchers and needs approval from the competent ethics committee in the UHG. The committee takes into account special aspects related to research in prison. Based on our experience in Geneva, the first and most important aspect to the granting of free and informed consent is that the equivalence and independence of non-research health care is guaranteed. Indeed, the obvious condition to ensure ethical research on prisoners is that there are no constraints or pressures. Prisoners might accept entry into a research protocol in order to receive good overall care (investigations, therapeutic interventions, monitoring and follow up) if health care provision for prisoners is inadequate. Furthermore, prisoners should be able to consult a "trusted and independent" physician before consenting to research. This independent prison physician might be in a better position than the ethics committee to evaluate whether a detainee is under any form of pressure to participate in research. This could also be the case if participation in research is a (or even the only) way for detainees to obtain judicial benefits such as a less harsh prison sentence or early release. Hence the issue of the quality of (non research) health care and the competence and independence of these health care providers are of fundamental importance as prerequisites for any research activities. The fact that the prison medical service in Geneva has been independent from the prison administration for more than 30 years, as well as the legal framework granting equivalence of health care, was therefore an important reason to permit ethical research involving prisoners.

Table 1: Examples of research carried out with detainees in Geneva in the past (overview, non exhaustive).
Prospective study on effects of early weeks of incarceration as a psychosocial stressor (“life event”) on mental health and functioning [32].
Study of the treatment of withdrawal symptoms of prisoners’ suffering from opiate dependence on entry to prison [33].
AIDS in prison: study on the educational effects of an information brochure about infectious diseases and preventive measures including condom distribution since 1986, providing of bleach and syringe exchange [34].
Retrospective study on deaths among detainees in Geneva [35].
Publication of case reports involving hunger and thirst strikers [36] and body packers [37].
Prospective and retrospective studies on drug prescription and insomnia [22, 38, 39] and retrospective study on psychiatric and somatic symptoms [40, 41].
Route of administration of illicit drugs among remand prison entrants [42].
Study about the prevalence of Chlamydia infections in adult [43] and juvenile detainees [44], as well as on measles immunity [45].
When treatment for hepatitis C (interferon, antiviral medication) was accessible only as part of research protocols, prisoners had access to these protocols at the university hospital.

Patient’s consent and treatment refusals

To illustrate the practice in place concerning patient's consent as a prerequisite to any medical intervention, we will describe here the handling of patients’ refusals of medical care. Respect for treatment refusals has been granted for competent prisoners in Geneva according to the same standards used for non prisoner patients, including cases of hunger strike. Detainees have the option to go against medical advice and to refuse treatment even if this could imply serious health consequences. If possible and if the patient agrees, the prison physician in charge has contacted the former treating physician and asked his/her opinion in difficult cases. As part of this approach, no forced screening for tuberculosis has taken place. Instead, as for non prisoner patients in Geneva, if an infected prisoner exposes other persons to the risk of contracting tuberculosis, the only accepted measure has been forced respiratory isolation in the hospital. Such isolation can be mandated if a sufficiently high suspicion for tuberculosis exists and will be maintained until a diagnosis is made and, if indicated, treatment is accepted. In line with the respect for treatment refusals, no forced treatment for hunger strikers has been carried out in Geneva. The confidential relationship of prisoner patients and their physicians is considered an important factor that has so far permitted the avoidance of any death due to hunger strike: when approaching death or when significant neurological impairment was observed, all detainees have freely agreed to re-alimentation.

Finally it should be noted that the medical personnel do not use restraints. Practice inside the prison hospital units is the same as those in the Geneva community psychiatric hospitals. Use of force is only permitted in a transitory way lasting less than an hour to enable non-voluntary hospitalisations according to the criteria of cantonal law also valid for non prisoner patients. These criteria include the fact that an emergency situation exists together with an important danger to the patient him/herself or to others, and the medical indication for psychiatric treatment. The use of restraints is avoided inside the hospital. Instead, detainees are transferred to a “calming cell” that is part of the psychiatric ward. This cell contains no items that might be used for self harm or harm to other persons or objects. Prison physicians and nurses are trained with regard to the strict policy to avoid the use of force. Negotiation about medication intake and hospitalisation with the consent of the patient are the means that have proven to be most successful in psychiatric emergencies in the prison context. However, involuntary hospitalisation and forced treatment of psychiatric patients are possible using the same criteria as in the community.

Confidentiality

Granting strict confidentiality is indispensable to ensure the implementation of prevention and treatment of highly stigmatising diseases in prison. Information about diagnosis or prognosis is not transmitted to non health personnel. Non health professionals are advised to use gloves and to avoid contact with bodily fluids on a routine basis. Confidentiality in prison medicine is even more explicit than in the outside world. While physicians working in the UHG routinely exchange information with external treating physicians of their patients under the assumption of implicit consent, physicians working in one of the prison units have always asked patients’ explicit consent before an outside treating physician is contacted. Furthermore, prisoner patients’ consent for the transfer of any record or medical summary to another physician is never implied, but is always explicit. Exceptions are made only if explicit consent is not possible, if the consent of the patient seems likely and if the prison physician considers that transmission of information is in the interest of the patient and urgent, and will prevent significant harm. In all other cases, the receiving physician will be asked to provide written evidence that the detainee has consented to the transmission of the medical documents.

Professional competence (medical, ethical)

All physicians working in the prison medicine units receive university-based training. This comprises of medical training according to the standards of the UHG and includes rotations of physicians and nurses between prison medicine and other divisions of the UHG in the Department of community and primary care medicine and in the Department of psychiatry. Special training on the particular medical aspects in prison medicine, such as treatment of the body pack syndrome and of hunger strikers for example, has been an obligatory part of the rotation in the prison medicine units. Training is also necessary concerning special tasks of the prison medical service in preparing prisoners for release, for example preventing opioid overdose and preparing treatment for prisoners who are to be expelled from Switzerland. In addition, university-based ethical education includes obligatory courses on humanitarian medicine and human rights in places of detention for 1st year medical students since 2005 and continued education for physicians of the University Hospital of Geneva since 2007.

Difficulties in maintaining the standards stipulated by the decree

Overcrowding

The remand prison in the canton of Geneva, Champ Dollon, was built for 270 detainees. The number of detainees regularly exceeds this limit with an average of 400 detainees in 2000 and 470 detainees in 2006. Since 2006, peaks occurred where the prison had to house more than 500 inmates. The overcrowding influences medical care. Although the medical resources are constantly being adapted, for example a larger prison psychiatry hospital is under construction, the health personnel have been struggling repeatedly with a high number of requests for medical consultation which exceed the capacities of the outpatient unit. Even more important have been the limitations of transportation resources. Prison and police officers are needed to accompany prisoner patients to the inpatient and outpatient consultation structures. The overcrowding causes a relative shortage of prison officers which markedly limits the numbers of medical consultations in spite of available physician time.

Shortcomings in the screening for violence

An independent evaluation in 2006 [46], carried out at the request of the Geneva parliament, of the screening system for violence at prison entry showed that reporting was incomplete due to organisational problems relating, among other things, to prison overcrowding and the lack of adequate rooms to conduct confidential interviews at entry. Several experts had been commissioned with the evaluation by the cantonal parliament in 2005 after a written complaint from detainees about the conditions of imprisonment, undue delay of trials and police violence. The medical service had been partly aware of the problems in its screening system, but changes had been delayed due to logistical and organisational problems [26]. This example shows that complaint and evaluation mechanisms are of great value to initiate correction of emerging problems. In 2007, medical visits at entry were reorganised. In the medical unit, detainees are always seen for consultation in the same confidential way that applies to non detainees. Visual surveillance of consultations in exceptional cases is an acceptable alternative while ensuring confidentiality of verbal exchanges. Such cases concern consultations at entry where the risk of danger of arriving detainees is difficult to predict.

Constructional inadequacies

The canton of Geneva has recently enforced its no-smoking-policy. Smoking is banned entirely in the University Hospital. Patients who want to smoke gather outside the hospital doors. Due to constructional limitations, the general medicine prison unit in the UHG provides neither outdoor space for detainees nor a smoking room. The CPT, during its visit to Geneva prison facilities in 2007 (see www.cpt.coe.int/documents/che/2008-33-inf-fra.pdf), noted that the lack of outdoor space in this unit is not in line with article 27.1 of the European prison rules which states that “[e]very prisoner shall be provided with the opportunity of at least one hour of exercise every day in the open air, if the weather permits” [47]. As a consequence, ethical and management problems exist because prisoner patients do not have the option to leave the unit and to smoke outside the hospital as free patients. Instead, prisoners who smoke are routinely offered nicotine replacement therapy.

Respect for confidentiality in the University Hospital

Respect for confidentiality requires vigilance by all hospital physicians: detainees have refused medical exams because armed transporting guards insisted on staying inside the medical consultation room. Some physicians approved the presence of the guards believing that this is required policy for detainees. In another case, a detainee had agreed to a medical specialty exam in the presence of transporting guards but later complained to the prison physician about the lack of confidentiality. These events show the need for continued enforcement and training of health personnel regarding confidential medical consultations and the role of police officers and transporting personnel. All physicians need to be educated about their obligation to ask police officers or guards to leave the examination room. In line with the recommendations of the Swiss Academy of Medical Sciences (SAMS) [48], physicians may ask for exceptions in case of dangerous patients. It is noteworthy that the president of the SAMS sub-commission who issued these recommendations, J.P. Restellini, has worked for many years in prison medicine in Geneva. The elaboration of the recommendations was clearly influenced by the Geneva experience and they are now an important source of standard setting.

Respect for the rights of juvenile detainees

Switzerland has ratified the UN Convention on the Rights of the Child with more than one reservation. Among them is the reservation that Switzerland does not enforce strict separation of juvenile and adult detainees as prescribed by the Convention. In 2006, a cantonal decision was made by the government to respect the UN Convention on the Rights of the Child without reserve in Geneva. Before 2006, juvenile detainees were housed in the prison for adults, albeit not in the same cells. Both the psychiatric and the general medical prison hospital unit have treated juvenile detainees in the past. Again, juvenile detainees were hospitalised in the same unit as adults, but never shared the same room with an adult prisoner. If juvenile detainees are not permitted to be hospitalised in the secured units for adult prisoners this increases costs. During hospitalisation outside the two hospital prison units, for example in a paediatric ward, two guards have to secure the entry to the hospital room at all times. The hospital has accepted a compromise which does not strictly respect the UN convention. Juvenile detainees suffering from psychiatric problems will be hospitalised in the appropriate paedo-psychiatric units with two guards in front of the room, mainly because the adult part of the psychiatric hospital does not accept patients under the age of 18. However, in the UHG, patients older than 15 years in need of hospitalisation for general medical or surgical problems are, in general, treated in adult units. This fact was used as a reason to support the hospitalisation of juvenile detainees older than 15 years in the adult general medicine prison ward. In this unit, adult prisoners have the right to receive visits from family members or friends only once a week. The prison administration has given its permission for visits from family members as required by the UN Convention on the Rights of the Child, but these visits remain dependent on authorisation by the competent judges.

Separation of primary care medicine and psychiatry

In most countries, psychiatric and general medical care of prisoner patients is provided by separate departments or institutions. As noted by a governmental report on prison medicine in France [49], this leads to significant problems. The report states that the cooperation of the different actors fails too often. Psychiatric services and general medical services do not collaborate sufficiently concerning medical records and concerning the care for individual patients. The lack of a common strategy is especially detrimental with respect to patients suffering from any kind of substance abuse (article 2.2). In this context, R. Gastone comments that medical care should become the activity of a single service of general internal medicine, and no longer, as is the case in the present system in France, be under the responsibility of two distinctly separate departments – one in charge of caring for the body, and the other in charge of caring for the mind [50]. Prison medicine in Geneva was deliberately constructed as a single service comprising of psychiatry and general medicine. In 2006, during the reorganisation of the University Hospital departments, it was decided to separate the single service and attach psychiatry and primary care physicians to their respective departments. However, a centre was created to coordinate both activities. The consequences of the separation in terms of advantages or disadvantages have not yet been fully explored. Close collaboration between both departments involved in prison medicine is important and efforts are made to maintain uniform care strategies for all prisoner patients including those dependent on drugs.

Conclusions

The legal framework in Geneva permits the implementation of equivalence of care including prevention. Factors that have facilitated equivalent health care are the fact that sufficient public financial resources have been made available by the Canton of Geneva, as well as the political and legal support of health personnel when the prison authorities had to be convinced to accept syringe exchange and condom distribution within the prison. This was possible in particular because the decree of the State Council stipulates that the prison authorities have to cooperate with preventive health care measures. The fact that Geneva is a small canton, where exchange between health-care personnel and the government frequently took place, facilitated this process.

Finally it should be noted that the legal framework does not prevent all difficulties. Health-care personnel need to stay vigilant in order to defend the principle of equivalence. All medical personnel working in the prison, and also hospital personnel who may come into contact with detainees, need to be aware of their professional duties towards detainee patients. We have shown how the decree permits the introduction of necessary changes to maintain appropriate health care standards in prison medicine in spite of adverse conditions. The complaint mechanisms granted to detainees as part of the legal framework have played an important role in adapting the existing practice to new challenges. However, as has been illustrated by the consequences of overcrowding and no-smoking hospital policies, important delays in the range of several years are often unavoidable in adapting existing structures and financial resources to maintain or finally implement equivalent standards in prison medicine.

The maintenance of these high standards will depend on the ability of the university hospital and the public health authorities to defend detainee’s rights in a climate of general shortening of resources in health care in Switzerland. Political support of human rights issues in Geneva has a long tradition and will be of crucial importance for the health care of detainees in the future.

Funding / potential competing interests: Funding was provided by a research fund of the University of Geneva. There are no conflicts of interest.

Information about the author: Prof. B. Elger (MD PhD, MA theol) has been teaching health law and bioethics at the University of Geneva for the past sixteen years. Her activities included work as a chief resident in internal medicine in the prison medicine department of the University hospital of Geneva. In 2011 she accepted the call to become ordinary professor and head of the Institute for Biomedical Ethics at the University of Basel, Switzerland.

Correspondence

Correspondence: Professor Bernice S. Elger, MD PhD, MA theol, IBMB, Missionsstrasse 24, CH-4055 Basel, Switzerland, b.elger@unibas.ch

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