Relevant Regulations and Medical Treatment Methods

Laws related to inmate medical care are mostly stipulated in the "Prison Act" and the "Enforcement Rules of the Prison Act." Since the enactment of our country's Prison Act on January 19, 1946, it has only undergone one comprehensive amendment on December 25, 1954. Regarding provisions concerning medical care (Chapter 8, "Hygiene and Medical Treatment"), Article 51 was amended and promulgated only on July 28, 1993, and Article 58 was amended and promulgated on December 12, 1974, and May 26, 2010; all other provisions have remained unchanged since their enactment ^[1].

Viewed from the text of the provisions, the medical diagnosis and treatment methods available to inmates can be briefly classified as follows:

1. In-Prison Medical Care

   Article 51 of the Prison Act: "Inmates shall be given regular health checks and health checks based on actual needs, and infectious disease prevention measures such as vaccinations shall be implemented (Paragraph 1). Prisons shall hire medical personnel to assist in improving internal medical and health matters, and health authorities shall conduct regular supervision (Paragraph 2)."

2. Transfer to a Prison Hospital

   Article 54 of the Prison Act: "Those contracting acute illnesses shall be accommodated in an attached prison hospital (Paragraph 1). The prison hospital referred to in the preceding paragraph shall be separated from other buildings and necessary isolations shall be implemented according to the type of disease (Paragraph 2)."; Article 55 of the Prison Act: "Those contracting tuberculosis shall be transferred to a specially established tuberculosis prison; when there is no tuberculosis prison, they shall be separated and accommodated within a prison hospital."

   The "prison hospital" referred to in Article 54 of this Law mostly refers to medical units attached to ordinary prisons capable of handling acute and critical illnesses, such as the Taoyuan Branch of the Taiwan Taipei Prison and the Caotun Branch of the Taiwan Taichung Prison. Furthermore, the "tuberculosis prison" referred to in Article 55 means a specialized tuberculosis prison, currently established in the Taichung Prison. In cases of transfer to a prison hospital, because treatment is still received within the prison—unlike medical parole—the period during which treatment is received still counts as part of the execution of the sentence.

3. Self-Paid Medical Consultation

   Article 57 of the Prison Act: "When an inmate suffering from an illness requests self-paid medical consultation, the prison warden shall grant permission." According to the Implementation Guidelines for Self-Paid Medical Consultation for Inmates in Prisons, Detention Centers, and Prisons under the Ministry of Justice, inmates applying for self-paid medical consultation may apply for themselves or through their families to independently engage physicians at their own expense, or commission prisons, detention centers, or prisons to engage physicians to come to the prison, detention center, or prison for consultation and treatment. However, these implementation guidelines ceased to apply on January 1, 2011.

4. Medical Parole and Escorted Medical Treatment

   Article 58 of the Prison Act: "An inmate currently suffering from an illness who cannot receive appropriate medical treatment within the prison may, depending on the circumstances, report to the supervisory authority for permission for medical parole or transfer to a prison hospital or hospital (Paragraph 1). When the prison warden deems there are urgent circumstances, they may first execute the disposition of the preceding paragraph and then report to the supervisory authority for approval (Paragraph 2)." According to Article 73 of the Enforcement Rules of the Prison Act, medical parole shall be handled in accordance with the following regulations: The inmate shall detail their symptoms, the reasons why medical parole is necessary, the crime committed, the sentence, and the remaining sentence; attach a diagnosis certificate issued by a local public or private hospital within the most recent period; when the inmate is on medical parole, the warden shall regularly dispatch personnel to inspect them and maintain close contact with the hospital or local police authorities; and the prison shall fill out a monthly medical parole report table and report it to the Ministry of Justice for future reference ^[2].

In addition to the medical treatment methods prescribed by the provisions of the Prison Act above, since 1990, the Executive Yuan has required public hospitals to support medical services, and by 1994, it also required the Department of Health to assist prisons in establishing a health and medical care system. During the period before inmates were included in the National Health Insurance, to enhance the safety and convenience of medical treatment for prison inmates, the Ministry of Justice first launched the "Medical Zone Project," and with the approval of the Executive Yuan in 2000, established the "Pei-Te Hospital Attached to Taiwan Taichung Prison." Its operations were outsourced, managed by the medical team of China Medical University Hospital, a medical center-level teaching hospital. It is currently the only prison hospital in the country and was approved as a regional hospital by the Department of Health of the Executive Yuan in 2009. The specialized service scope includes eight sections: outpatient area, psychiatric ward, tuberculosis isolation area, hemodialysis center, critical care inpatient service area, male critical care ward, female critical care ward, and HIV-infected inmate accommodation area ^[3], serving as a stronghold for prison medical care in our country.

Furthermore, Article 10, Paragraph 1, Subparagraph 4, Item 3 of the National Health Insurance Act (i.e., the "Second-Generation NHI"), promulgated on January 26, 2011, and implemented on January 1, 2013, stipulates: "Those undergoing the execution of a sentence or receiving security dispositions or disciplinary confinement dispositions in correctional institutions. However, this does not apply to those whose sentence to be executed is two months or less, or those undergoing the execution of protective custody dispositions." This provision explicitly states that inmates with sentences of two months or more are also insured persons. From then on, inmates in correctional institutions were incorporated into the National Health Insurance system.

This systemic reform seemed to have significantly improved the medical rights and interests of inmates. However, because prison inmates have their personal freedom restricted due to criminal correction, while safeguarding the medical human rights of inmates, their medical treatment time and location are restricted due to security needs. Practical operational methods are as follows: In principle, inmates should prioritize seeking medical treatment in the outpatient clinics set up within the prison. If there is a necessity for referral, they shall then go to NHI-contracted medical institutions outside the prison for further examination or treatment through escorted medical visits outside the prison. Furthermore, based on security considerations, when hospitalized, they should prioritize admission to secured wards for treatment; when there is no secured ward, admission to an insured ward shall be the principle.

Moreover, according to Article 40, Paragraph 2 of the National Health Insurance Act: "The medical management measures for insured persons (i.e., inmates) regarding medical treatment procedures, medical consultation, provision methods of insured medical services, and other necessary medical matters shall be determined by the competent authority. For insured persons accommodated in correctional institutions, administrative measures concerning restrictions on their medical treatment time and location, as well as matters related to security escort, patient referral, and the provision methods of insured medical services, shall be jointly determined by the competent authority and the Ministry of Justice." Therefore, administrative measures concerning restrictions on medical treatment time and location, security escort, patient referral, and the provision methods of insured medical services are separately stipulated in more detail in the "Management Measures for Insured Persons Accommodated in Correctional Institutions Receiving Medical Treatment under the National Health Insurance" jointly enacted by the Department of Health and the Ministry of Justice ^[4].

Under the regulations of the Second-Generation NHI, medical service provision methods are in principle provided by NHI-contracted medical institutions, providing outpatient services within prisons through support, while the content of medical services (medical space and facilities, outpatient departments, session numbers and time slots, medical personnel, and regulations on time changes) varies according to the needs of each prison.

Current Status and Problems

Although under the current system inmates may join the National Health Insurance, which seemingly better satisfies human rights requirements from a legal perspective, after inmates join the National Health Insurance, problems may also arise, such as: "insufficient incentives to select medical institution physicians to visit and treat patients in prisons," "questioning the fairness of restricting inmates' medical treatment locations," "unceasing political lobbying and favors requested to transfer individuals to specific medical institutions," "frequent entry and exit of inmates, making agency manpower unable to bear the business of enrollment and withdrawal," "still unable to solve the problem of scarce medical resources at night and on holidays," "a sharp surge in demand for NHI premiums," "the general public's questioning of fairness and justice," and "difficulties in drug control, affecting security.">

The number of medical visits by prison inmates in 2011 was 1,189,640 visits, with internal medicine and family medicine accounting for a larger proportion (48.1% and 20.6% respectively, ROC Legal Statistics Yearbook, 2011 edition). After the implementation of the Second-Generation NHI, in 2015, a total of 51 correctional institutions nationwide cooperated with 100 neighboring NHI-contracted medical institutions, and the number of inmate medical visits in that year still reached as high as 862,122 visits. Despite the "support" of the Second-Generation NHI, correctional institution medical care, dealing with still as high as 860,000 visits, continues to face the following problems:

1. Medical Software and Hardware within Correctional Institutions Remain Insufficient

   Medical practices rely on software and hardware such as medical manpower, medical equipment, and medical supplies to maintain normal operations. Medical manpower includes physicians, nurses, and nurse practitioners. To soundly establish medical care within prisons and enable them to function, the primary goal is to have sufficient manpower. However, the number of physicians dedicated to in-prison medical care has been in a state of shortage for many years, preventing correctional medical work from proceeding smoothly. According to the 2007 statistical data of the Taoyuan Prison of the Agency of Corrections, Ministry of Justice, the staffing of the health section included 1 nurse practitioner (acting section chief), 1 administrative officer supported by the security section, and 1 contracted pharmacist, totaling 3 staff members. Calculated based on an average inmate population of 2,000, the ratio of staff to inmates was approximately 1:667, and the ratio of medical personnel to inmates was approximately 1:1000, which is much higher than the nationwide ratio of physicians to population of 1:620 in that year. By the end of 2015, there were only 75 physicians and other medical personnel (pharmacists, nursing personnel, laboratory personnel, clinical psychologists, etc.) in correctional institutions under the Ministry of Justice ^[5]; if distributed evenly among all prisons, each prison would have fewer than 5 medical personnel.

   Under such a current status, although after the implementation of the Second-Generation NHI, medical institutions dispatched physicians to visit and treat patients inside prisons, which could slightly meet the medical needs of inmates, given the current situation where the prison inmate population is aging and mostly suffers from chronic diseases ^[6], there remains a necessity to increase resident medical personnel ^[7].

   Regarding medical equipment and medical supplies, they include drugs and biological agents, medical consumables, and medical instruments for diagnosis and treatment. To ensure the completeness of the medical system within each correctional facility, the minimum standard is the sufficient supply of medical equipment and supplies. At present, except for general basic medical equipment, other more expensive equipment (such as CT scanners and dialysis machines) is generally lacking and equipment is too rudimentary in various prisons, which may severely undermine the effectiveness of prison medical care.

2. Procedures for Medical Parole and Escorted Medical Treatment Are Cumbersome and Have High Thresholds

   As mentioned above, the procedure for handling medical parole in our country requires attaching a diagnosis certificate and passing layers of reviews. According to the "Reference Standards for Review of Medical Parole by Correctional Institutions of the Agency of Corrections, Ministry of Justice," there are six conditions under which prisons may report to the Agency of Corrections to approve medical parole: "1. Suffering from a disease with a high fatality rate, expected to result in death in the short term. 2. Severe physical and mental disabilities, unable to self-care for daily life, and difficult to obtain appropriate care in prison. 3. Serious illness requiring long-term inpatient treatment outside the prison. 4. Severe physical disability requiring long-term rehabilitation outside the prison. 5. Complex, uncontrollable condition with a constant risk of death. 6. Suffering from a statutory infectious disease, making it difficult to properly isolate and treat in prison." Given the degree of cumdrance of procedures and the content of these reference standards, it is not difficult to imagine how high the threshold for medical parole is ^[8]. In circumstances where medical resources within prisons are insufficient and it is difficult to receive medical parole, the rights and interests of inmates inevitably suffer restrictions.

3. The Medical Competent Authority for Inmates Remains the Prison

   Whether in Taiwan or advanced countries such as Japan and the United States, the competent unit for prison medical care is the enforcement institution (prison). Such a system may cause the enforcement institution to use its left hand to maintain safety within the prison in the name of "security," while using its right hand to hire physicians in the name of "care" to evaluate medical care for inmates and judge whether medical parole is necessary. This practice is likely to cause many problems, such as physicians reporting inmates' medical conditions to the prison, creating tension in the doctor-patient relationship (foreign literature even uses expressions like "physicians are loyal servants of the prison security and escort section"); the maintenance of medical standards within prisons being solely self-sustained by the correctional institution, leaving it questionable whether the medical competent authority can intervene and investigate. Furthermore, after an inmate is released from prison, how medical consultation records should be preserved or where they need to be transferred to ensure the consistency of the inmate's medical care also warrants further review.

Conclusion

Medical treatment for inmate illnesses in our country's prisons remains restricted by insufficient medical equipment and manpower, failing to improve quality. Therefore, correctional institutions should coordinate with health authorities to increase the staffing quota of public hospital physicians across regions, and each correctional institution should have a hospital responsible for its medical care, establishing a complete medical defense system for correctional institutions as the most important current issue.

In addition, there is also a need to re-evaluate whether the entire correctional medical system is sound. However, if limited by the reality that policies are difficult to implement overnight, at least short-term, medium-term, and long-term goals must be established, with the ultimate goal of constructing a "social partnership network" capable of supporting correctional medical care. Taking inmates with psychiatric disorders as an example, psychiatric evaluation and related treatments within prisons, due to budget limitations and resource scarcity, should be reinforced by assistance from external medical manpower and material resources. Moreover, after such inmates are released from prison, the institutions that previously provided assistance within correctional institutions can continue to provide uninterrupted medical care, maintaining the consistency and continuity of treatment.

Currently, prison medical care has not yet reached the proper standard. In view of the medical deficiencies in prisons and detention centers causing significant impact on the rights and interests of inmates, the Control Yuan initiated an investigation into "Medical Deficiencies in Prisons and Detention Centers," which prompted the Agency of Corrections and the National Health Insurance Administration to jointly enact the "Operational Guidelines for the Provision of Medical Services to Correctional Institutions by the National Health Insurance" ^[9] to rationalize escorted medical treatments outside prisons for inmates. The NHIA also amended the "Medical Service Plan for Providing Insured Persons Accommodated in Correctional Institutions under the National Health Insurance" on January 23, 2014. If inmates are reluctant to seek medical treatment due to financial difficulties, correctional institutions have already assisted in referring them to social resources to help pay or provided medical subsidies in accordance with Article 5, Paragraph 1, Subparagraph 6 of the "Regulations on the Custody, Management, and Utilization of the Correctional Institution Operation Fund of the Ministry of Justice" so that they can smoothly use NHI medical care. The Ministry of Health and Welfare has also urged health bureaus of various county and city governments to inspect the inventory management of medicines and health materials in various correctional institutions every six months, and supervise the medical and health operations of correctional institutions, striving to protect the medical human rights of inmates ^[10]. However, whether this has achieved certain results still awaits subsequent follow-up.

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References and Further Reading

Notes