One of the primary implications of the growth in aged prisoners is that many of these inmates are developing age-related impairments, such as dementia. In fact, aging prisoners may be more likely than the non-incarcerated population to develop dementia. As Ben-Moshe (2014a) succinctly states, “Prison is disabling.” In regards to dementia specifically, Belluck (2012) notes, “Prisoners appear more prone to dementia than the general population because they often have more risk factors: limited education, hypertension, diabetes, smoking, depression, substance abuse, even head injuries from fights and other violence” (para 7). Although statistics are not readily available on how many prisoners in the United States have dementia, Kingston, Le Mesurier, Yarston, Wardle, and Heath (2011) found that psychiatric disorders and cognitive impairments are unrecognized and undertreated for older adults in prisons. Furthermore, Maschi et al. (2012) reported that, based on a review of 10 published studies on incarcerated older adults with dementia, 1% to 44% of older prisoners have dementia, depending on the size of the correctional institution. This situation raises many ethical issues. One of the primary concerns is how the U.S. Prison System – and American society – should care for incarcerated people with dementia. Specifically, should people with dementia be cared for in prison? If so, what should this care look like? If not, should they be released and cared for in community contexts? This blogpost attempts to begin to answer these questions, with the hope of starting a dialogue about this important, although often overlooked, ethical and social issue.
My Approach to these Questions
The Ethical Principle of Justice
- that those who commit certain kinds of wrongful acts, paradigmatically serious crimes, morally deserve to suffer a proportionate punishment;
- that it is intrinsically morally good...if some legitimate punisher gives them the punishment they deserve;
- that it is morally impermissible intentionally to punish the innocent or to inflict disproportionately large punishments on wrongdoers. (p. 1)
Justice in Medical Care for Incarcerated Older Adults with Dementia
Prisons are not generally equipped to deal with infirm or disabled people…existing prison health systems are experiencing difficulties with their ability to [prioritize] beds, which are primarily intended for prisoners with acute medical needs…there is also strain on staff, as corrections officers are generally trained to manage inmate behavior, not to [recognize] and attend to the symptoms of dementia. (p. 16)
The lack of appropriate treatment and services violates the Eighth Amendment of the U.S. Constitution, as well as the principle of retributive justice, which both state that unusual, cruel, or disproportionately large punishments are inappropriate or immoral. Maschi et al. (2012) state:
The United States Supreme Court has held that deliberate indifference to a prisoner’s serious illness constitutes cruel and unusual punishment in violation of the Eighth Amendment (Estelle v. Gamble, 1976). The Court states in its opinion: “denial of medical care may result in pain and suffering which no one suggests would service any penological purpose.” (p. 445).
Providing Care in Prison
If prisons are to provide care for people with dementia, major changes and innovative programs are required.
One such program is the Gold Coats, at the California Men's Colony, which pairs aged prisoners with dementia with other prisoners who provide support and care (Belluck 2012; Hodel & Sánchez, 2012).
The Gold Coats are so named because they wear distinctive gold coats in place of the standard prison uniform. The types of support and care the Gold Coats provide include: showering, shaving, eating, toileting, and changing adult diapers. They also protect the prisoners with dementia and ensure that other inmates do not bully, abuse, or victimize them.
The program has been somewhat controversial because many of the Gold Coats have been convicted of murder or similarly violent offenses. However, the Gold Coats are providing assistance that the prison could not otherwise provide, and many of the Gold Coats report finding great meaning in their work. They were trained by the Alzheimer's Association and given a thick manual on dementia. As a result, the Gold Coats know more about dementia than the prison staff, and are thus better able to meet the unique needs of their fellow prisoners with dementia.
Providing Care in the Community
Keeping many of these older [people] locked away has little effect on public safety…[Many] older prisoners are in for nonviolent offenses such as drug possession and property crimes. What’s more, crime data shows that people are extremely unlikely to commit serious offenses once they hit 50. (p. 14).
Yet another issue related to the release of prisoners with dementia is the type of care they receive in the community. Due to their impairment, prisoners with dementia cannot be released without a plan for their care in place. “Simply pushing them out the prison door will be tantamount to a death sentence” (Ridgeway, 2013, p. 14). In some cases, families may be well equipped to provide care for a person with dementia. However, other prisoners with dementia may be from families that are no longer present in their lives, or may not have the resources to care for them. For example, in the case of one of the prisoners with dementia at the California Men’s Colony who is being cared for by the Gold Coats program, prison officials asked the family if they would like to have the prisoner with dementia paroled. The family declined, with one family member stating, “To be honest, the care he’s receiving in prison, we could not match” (Belluck, 2012, para 55). Although this is an exceptional case given this prison’s innovative program, it still points to the issue that our society needs to invest more in caring for people with dementia in the community.
However, community care or nursing home care is typically still cheaper than caring for a person with dementia in prison and also places the person with dementia in an environment better suited to their needs with access to appropriately trained caregivers. Caring for a person with dementia in prison can cost over $100,000 annually (Ridgeway, 2013), while long-term care services in a nursing home cost on average $78,110 annually (Alzheimer’s Association, 2014). Community supports, such as home health aides, personal care assistants, and adult day care services, are even more affordable and also allow the person with dementia to continue living in a community. Thus, the State may be able to provide better care for the person with dementia and still save money by partially or fully financing community care or nursing home care in certain cases, such as when there is no family involved in the prisoner with dementia’s life, or the family cannot provide care due to economic restraints.
It is important to note that it is rare in Disability Studies to advocate for nursing home placement for people with disabilities. However, I am arguing that, in this specific case, nursing home placement would be better than prison. Community living would still be ideal, but supports for people with dementia to live in community settings would need to be in place.
For instance, my favorite option for community living currently is to expand the concept of dementia villages. Dementia villages are designed to provide care and support for people with dementia in community settings, without placing them in locked wards of institutions like nursing homes. As a result, people with dementia can still experience privacy and autonomy. Furthermore, these villages have facilities (e.g., bars, restaurants, theatre) that can be used by people in neighboring communities, which means that people with dementia in these villages are not segregated from society. Ben-Moshe (2014b) highlights villages in Norway for people with disabilities that are similar to dementia villages as a way to avoid institutionalization/incarceration, and so dementia villages would be a viable (albeit presently expensive) solution.
- Alzheimer’s Association. (2014). Planning for care costs. Retrieved from: http://www.alz.org/care/alzheimers-dementia-common-costs.asp
- American Civil Liberties Union. (2011). Combating mass incarceration: The facts. Retrieved from: https://www.aclu.org/combating-mass-incarceration-facts-0
- American Civil Liberties Union. (2012). Releasing low-risk elderly prisoners would save billions of dollars while protecting public safety, ACLU report finds. Retrieved from: https://www.aclu.org/prisoners-rights/releasing-low-risk-elderly-prisoners-would-save-billions-dollars-while-protecting
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- Hodel, B., & Sánchez, H. G. (2012). The special needs program for inmate-patients with dementia (SNPID): A psychosocial program provided in the prison system. Dementia, 12(5), 654-660.
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- Maschi, T., Kwak, J., Ko, E., & Morrissey, M. B. (2012). Forget me not: Dementia in prison. The Gerontologist, 52(4), 441-451.
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