Incarcerated Individuals with Rheumatic Conditions

The January wildfires that laid waste to more than 57,000 acres in Los Angeles and killed 30 people also raised ethical questions around the use of incarcerated individuals to fight fires in California—and more broadly, highlighted issues involving the exploitation, coercion and human rights violations, such as inadequate medical care, of imprisoned people.

Although participation in California’s Fire Camp Program is voluntary, prisoners are paid categorically higher wages for fighting wildfires than for other jobs available to prisoners in correctional facilities, creating a potentially exploitive or coercive situation.^1,2 Further, incarcerated firefighters face a significantly higher risk of injury than professional firefighters. A 2018 investigation by Time revealed that incarcerated firefighters are four times more likely to sustain cuts, bruises and broken bones, and eight times more likely to suffer from inhalation injuries, than professional firefighters working the same fires.³

Given these ethical concerns, we are compelled to reflect on the broader ethical issues surrounding incarcerated individuals, particularly the ethical dilemmas related to their medical treatment.

Legalities & Ethical Guidelines

The Eighth Amendment of the U.S. Constitution prohibits cruel and unusual punishment. In Farmer v. Brennan (1994), the U.S. Supreme Court ruled that prisons are required to provide adequate medical care for inmates under the Eighth Amendment. The Court emphasized that denying prisoners medical treatment could result in “pain and suffering which no one suggests would serve any penological purpose.”⁴

In 2017, the American Medical Association (AMA) released a Code of Ethics addressing healthcare for incarcerated individuals. This document highlights the unique challenges related to informed consent, respect for autonomy and the delivery of quality healthcare in correctional settings. The policies outlined aim to improve access to comprehensive physical and behavioral healthcare services throughout the incarceration process. Additionally, the guidelines emphasize how physicians providing court-ordered care for incarcerated patients can still honor the patients’ preferences and beliefs while ensuring autonomy and obtaining informed consent.⁵

In rheumatology, physicians face ethical challenges similar to those outlined by the AMA, but also encounter a range of issues specific to the specialty. This stems largely from the nature of rheumatic diseases, which often require long-term management with high-cost medications, frequent lab and image monitoring, and access to subspecialized care, often from a multidisciplinary approach. These challenges highlight the broader systemic issues in providing adequate healthcare for incarcerated individuals, underscoring the need for policy reforms that prioritize both medical necessity and ethical responsibility.