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The Evolution of Prisons and Penality in the Former Soviet Union - Articles (2)

Between Autonomy and Dependency: Medical Professionals in the Modern Russian Penal System

Kseniia Runova

Abstract

In Russian prisons, the issue of the quality of healthcare relates to the position of doctors within the penal system. Doctors are subordinated to the Ministry of Justice in which the prison service is also located, and not to the Ministry of Health. In 2014, as a result of reform to the prison system, prison medical personnel ceased to be subject to the authority of the prisons in which they worked. However, in practice the autonomization of prison service medical professionals has not happened. The purpose of this study is to explore this contradiction and clearly delineate the position of medical professionals in Russian prisons through the application of theoretical concepts of professional autonomy and dual loyalty to qualitative data collected from those inside the system.

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Index terms

Countries :

Russia

Research Fields :

Law, Prison studies
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Full text

  • 1 In the Russian penal system, the number of prisoners dramatically increased from 700 thousand to 10 (...)
  • 2 In remand centers average space being 1,7m2, in some other facilities this number was 0, 5 m2 durin (...)
  • 3 Death rate among prisoners dramatically increased between 1991 and 1997. (A. Bobrik, op. cit. p. 39

1After the dissolution of the USSR, the Russian penal system was in a state of decline: remand prisons and some correctional facilities were overcrowded1, the average space per prisoner was under 4 metressquared2, there was a lack of food for inmates, and poor living conditions prevailed. Medical assistance in prisons left much to be desired3. According to long-term workers in the system, staff were working under extremely difficult conditions, as there was a shortage of employees, and they were poorly paid. Furthermore, the human rights of prisoners were violated, and their punishment too often was disproportionately severe.

  • 4 Konseptsiia razvitiia ugolovno-ispolnitel'noi sistemy Rossiiskoi Federatsii do 2020 goda. Utverzhde (...)
  • 5 K. Runova, “Resotsializatsiia v mestakh lisheniia svobody v Rossii”. Centre for strategic research. (...)

2Currently, reforms are being made to the Federal Penitentiary Service (hereafter: the FPR) over the period between 2010 and 20204. The main reform areas are an alignment of the penal system with international standards and the humanization and individualization of penal institutions. The successful implementation of this reform is being hampered by the fact that the prison system still primarily performs the function of punishment. The resocialization of offenders is not a priority for prison authorities and employees5.

  • 6 A. Lehtmets, J. Pont, Prison Health care and medical ethics: a manual for health-care workers and o (...)

3Prison reform includes the transformation of the organization of prison healthcare. This aspect of the reform is the focus of the present article. In terms of international standards, the European Court of Human Rights has repeatedly found that the low level of health services in the Russian penal system are inhuman or degrading6.

  • 7 G. Niveau, “Relevance and Limits of the Principle of “Equivalence of Care” in Prison Medicine”, Jou (...)
  • 8 W. Bretschneider, B. S. Elger, op. cit. pp. 319-332.

4Researchers of penal healthcare have developed the principle of equivalence when considering medical assistance in jails. This principle is that a healthcare system for prisoners must operate and be measured by the same indicators as broader public health7. Prisoners’ lack of access to choose a doctor, unwanted interventions into a doctor’s professional practice, and additional gatekeepers to medical assistance such as guards and prison officers create unequal healthcare access and provision for prisoners when considered against the general population8.

  • 9 D. Moran, J. Pallot, L. Piacentini, “The Geography of Crime and Punishment in the Russian Federatio (...)

5In Russia, all prison medical infrastructure is separate from public healthcare due to special security rules. The Russian penal system has its own medical professionals, hospitals, laboratories specifically made for prisoners. In every correctional facility and remand prison there is an infirmary. However, organizing hospitalization of prisoners is extremely difficult, because it is impossible to establish the necessary medical infrastructure in every prison with all the required medical equipment and medical specialists. Additionally, the fact that Russia has inherited its penal estate from the USSR, so that facilities are often located in small towns and villages throughout the country, causes problems for the recruitment of medical personnel and the transportation of sick prisoners9.

  • 10 United Nations Office on Drugs and Crime, World Health Organization (Regional Office for Europe), G (...)

6Another organizational factor that influences the Russian prison medical system is the less than powerful position of medical professionals in comparison to prison officers. Formally, healthcare workers are not subject to prison authorities. During the present reform a new separate medical chain of command was established inside the penal system. However, in practice, doctors continue to work in conditions of informal subordination to the prison administrations of the facilities in which they work. According to the World Health Organization, prison healthcare must be independent from the penal system, and prison medicine is supposed to be a part of the public system of healthcare in order to avoid the involvement of doctors in a conflict of loyalties between prison authorities and the professional community and patients10.

  • 11 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, "Organization models of health care servi (...)

7In a number of European countries medical services are not a part of the penal system, but a part of the ordinary health system, for instance, in France, some cantons of Switzerland (among them Geneva), Scotland and some others. However, prison medicine in the Netherlands, Belgium and some German-speaking Cantons of Switzerland is a part of the penal system. In these regions, prison medical professionals are subject to the administration of correctional estates. This restricts the professional independence of physician and nurses. As a result, it is difficult to follow the principle of equivalence in these systems11.

8Russian penal medicine is discussed in public discourse in the context of cruel treatment and poor living conditions in prisons. Participants of discussions on the topic are mostly human rights defenders and journalists. However, in both public and scientific discussion, there is no systematic qualitative analysis of the organization of prison medicine and the position of medical personnel within the prison system. This article is intended as one step in creating such an analysis.

9For this paper, twenty-four interviews with prison doctors, correctional officers, representatives of the prison administration, former prisoners and with human rights defenders were conducted and analyzed. Also, examination of both Russian and international rules about prison health care was conducted. The purpose of these interviews was to understand the relational dynamics that influence the work of doctors in Russian prisons and impact their professional autonomy.

  • 12 E. Goffman, The Characteristics of total institutions in Symposium on Preventive and Social Psychia (...)
  • 13 E. Freidson, Professionalism: the third logic, Chicago: The University of Chicago Press, 2001.
  • 14 A. Giddens, op. cit.
  • 15 J. R. Williams, “Dual loyalties: How to resolve ethical conflict”, South African Journal of Bioethi (...)

10The paper inductively worked through these interviews and worked up a conceptual framework for understanding the narratives provided by the prison workers, NGO representatives and former prisoners. The framework is based on Erving Goffman’s notion of total institutions. This, among other things, maintains that medical professionals cannot be independent from other professional groups in penal institutions12. I further consider the concept of professional autonomy as developed by Eliot Freidson13. Following Freidson, I consider the interaction between doctors and other professional groups in a total institution as a power struggle which is defined by the use of resources to defend group interests14. The other crucial notion for this research is the phenomenon of dual loyalty which appears in situations when doctors are under pressure from the state or under extreme conditions, and doctors are compelled to balance between the contradictory interests of patients and political authority15. The paper is structured as follows: I firstly consider the formal position of doctors in Russian prisons, before looking at how this formal position is compromised informally. After describing more thoroughly the data, I then utilize the interviews to provide a bottom up account of these informal processes arguing that doctors experience dual loyalty that ties them in to the total institution despite limited powers of contestation and increased oversight by civilian bodies.

The Formal Position of Doctors across "Regimes" in Russian Prisons

  • 16 P. 2 Prikaz Minzdravsotsrazvitiia RF N 640, Miniusta RF N 190 ot 17.10.2005 (s izm. ot 06.06.2014) (...)
  • 17 All citizens of Russia use the mandatory health insurance which is free to them and includes basic (...)

11In Russia, convicted offenders who are sentenced to deprivation of freedom, lose certain rights, but their right to medical assistance is preserved. Prisoners cannot choose a hospital or certain medical services. They can receive additional medicines from relatives only on the prescription of a prison doctor. Prisoners have the right to use mandatory health insurance (obiazatel'noe meditsinskoe strakhovanie), but they do not have the right to use voluntary health insurance (dobrovolʹnoe meditsinskoe strakhovanie)16, and their opportunities to use additional medical paid services or to choose a doctor or medical organization are restricted. Therefore, they can only agree to or reject the services, which are offered by the FPS17.

  • 18 V. V. Solomentsev, “O probleme v nomenklature meditsinskikh uchrezhdenii ugolovno-ispolnitel'noi si (...)

12The FPS medical professionals as well as other penal staff are subordinate to the Ministry of Justice, thus prison medicine is not a part of public health services. Instead, there is a medical substructure in the FPS called the “department of healthcare”. On the regional level this department consists of penal medical clinics (mediko-sanitanaia chastʹ) (hereafter medical clinics). These medical clinics are separate legal entities. All prison health care workers are accountable to a clinic that is subordinate to the regional prison authority. These penal service clinics have a dual reporting line to both the department of health care of the FPS and to the heads of the regional prison authority. Medical professionals were fully taken out of the formal competences of any individual prison administration by 201418 (cf. Annex 1). Thus, formally, they constitute a separate group in any penal facility, but on a higher level they are subject to the regional prison service.

13The position of medical workers in the Russian penal system has an important feature. Some prison doctors are “attested” employees as well as being correctional officers. “Attested” workers hold a military rank. According to respondents, roughly 30% of medical workers in the Prison Service are “attested” and 70% are “non-attested” or independent contractors. Many of these medical workers are retired officers who were “attested” employees before. Medical management consists only of essentially uniformed medical workers. That means that all heads of prison medical units, heads of departments in prison hospitals, chief physicians and employers of clinics are law enforcement officers. Medical management takes responsibility for establishing relations with prison staff and contacting the prison administration. Importantly, “attested” employees spend more time at work every day than “non-attested”. Besides, “attested” employees receive additional social benefits which they are afraid to lose. As a result, their professional position is not independent of the prison administration. At the same time, social benefits are one of the few things that attract workers to this system; a shortage of medical staff is caused by the low status of this professional position. Frequently, medical professionals admit that they took a job in a jail due to the higher salary than in a civilian hospital, or because they have a rare specialization (for instance, TB doctor or Infectious Disease Specialist), and they could not find any other suitable workplace in their small towns.

  • 19 Strict regime and general regime colonies are not too much deferent. Strict regime implies more che (...)

14In the Russian penal system, there is a wide variety of security categories, or «regimes» that apply to penal institutions for male and female adult prisoners. The basis for the court to appoint prisoners to one or another category is the heinousness of the committed offence. In addition, the court considers whether an accused person committed a crime for the first time, or whether it is a repeat offence. In every correctional facility, there is an infirmary with in-patient beds. The organization of healthcare depends on the type of facility. There is a certain pattern: the stricter the discipline in a facility is, the higher is the intensity of interaction between medical professionals and correctional officers. In stricter regimes, healthcare is less available than in establishments where living conditions for prisoners are more lenient. It is easiest to get into an infirmary in colonies for men or women where convicts can move freely without escort: general regime colonies, and strict regime colonies19. In these types of facilities, inmates are put in communal barracks where 80 to 100 prisoners live in one room. In such colonies, an inmate can address a prison officer to make an appointment with a doctor. After that, an inmate will visit the infirmary and wait with other prisoners in a corridor. A prison officer must be present in the corridor of the infirmary to keep order. In addition, there are video cameras installed in the corridors, and sometimes in the medical rooms.

  • 20 Shtrafnoi-izoliator (SHIZO) and pomeshchenie kamernogo tipa (PKT) – small punishment cells for pris (...)
  • 21 Prikaz Minzdravsotsrazvitiia RF N 640, Miniusta RF N 190. Op. cit. Art. 50-52

15In some penal institutions, it is a lot harder to get into an infirmary. This applies to establishments where inmates live in cells and do not have the opportunity to move within the territory of the establishment without escort: prisons, remand centres (SIZO), special regime colonies, and punishments cells (SHIZO, PKT20). In such facilities, a guard must escort every prisoner to an infirmary for security reasons. Prison authorities do not provide many staff to escort prisoners to the medical unit due to shortages. The easiest way to get to a physician in prisons is to do this during the morning round. Representatives of all departments of a prison establishment attend this procedure, including a physician. If inmates have complaints about their health, they can say that they would like to see a doctor, and a prison officer has to put it on record21.

16Medical correctional facilities (lechebno-ispravitelʹnoe uchrezhdeniia or LIU) are a special type of penal institution. Prisoners are transferred to these institutions when doctors find that the inmates suffer from infectious disease, alcohol or drug addiction. The majority of medical prison establishments are built for people with tuberculosis. In such facilities, more attention is paid to treatment than in other prison establishments, but discipline is also important for the prisoners’ life.

  • 22 Prikaz Minzdravsotsrazvitiia RF N 640, Miniusta RF N 190. Op. cit. Art. 132.

17In most prisons and penal colonies, there is a paramedic, a therapist, and a psychiatrist. There may also be a dentist. If prisoners need a special kind of medical care that the prison medical workers cannot provide him or her with, the guards transport inmates to prison hospitals or medical correctional facilities, where guards and prison officers work, and where other living conditions – which the FPS has to provide in accordance with court decisions – are set up for the prisoners. There are cases when the nearest prison hospital is located in another city or even in another region. In such situations, the process of transportation takes a long time. To speed up the process of hospitalization, the FPS concludes contracts with civilian hospitals. However, the organization of prisoners’ healthcare in such hospitals requires the constant presence of guards, because such hospitals are not equipped for prisoners22. Under conditions of prison staff shortages, guards’ long-term stay with inmates at civilian hospitals becomes problematic.

  • 23 Art. 16. Federal'nyi zakon “Ob obshchestvennom kontrole za Obespecheniem Prav Cheloveka v Mestakh P (...)

18One of the aims of the prison reform is to enhance the transparency of the penal system. Information about the living conditions of prisoners, about cases of abuse of authority by prison employees and about unsatisfactory healthcare is supposed to be widely available to the general public. The public monitoring commissions or PMCs (Obshchestvennye Nabliudatel'nye Komissii) were established for this purpose. According to the law, members of these commissions have the exclusive right to visit any facility in which people are in custody without special permission and check conditions of prisoners23. Candidates for members of PMCs are nominated by NGOs and approved by Public Chambers – the institution consisting of social activists.

19Russian doctors in prisons are "attested" workers often with law enforcement backgrounds working across a range of different penal institutions graded by ‘regime’. However, doctors are formally independent from the prisons they work in and according to the law are accountable through mechanisms of civilian oversight. In practice though, doctors in Russian prisons have to work within total institutions that compromise their independence. I now turn to theorising how doctors’ professional autonomy is practically restricted.

Compromising the Position of Doctors in Russian Prisons

  • 24 E. Goffman, op. cit. pp. 312-338.

20The conceptual framework of this research is based on the notion of the total institution first conceptualized by Erving Goffman. Total institutions are characterized by a lack of transparency and strict regulation of prisoners' life. Also, order in a total institution influences the lives of staff members. A total institution has to comply with humane standards such as adequate health care. However, these standards always will only play a secondary role in comparison to the goals of discipline and security24. As a result of liberalizing prison reforms in some countries, prisons are less than total, but, in Russia, penal institutions have retained many of the characteristic features identified by Goffman.

  • 25 J. Jacob, D. Holmes, “The Culture of Fear: Expanding the Concept of Risk in Forensic Psychiatric Nu (...)

21The staff and the administration of total institutions reinforce the atmosphere of danger and suspicion, especially in facilities for people who have broken the law or social norms, as in the case of prisons and mental hospitals. Cultures of fear and risk are prominent. In prisons and camps, the function of crime prevention is prioritised in comparison with other functions, the function of healthcare in particular is left behind25.

  • 26 I. Y. Sun, H. E. Sung, D. C. Chu “Collateral Gains from the military? A Cross-national Analysis of (...)

22The Russian penal system has the characteristics of two types of total institutions: the prison and the army. The main features of social organization in military institutions are a rigid hierarchical structure, and special disciplinary rules. The army is characterized by authoritarianism (discipline and subordination), hypermasculinity, formalism (ceremonial display and etiquette), a siege mentality, that is, institutional solidarity and separation from other communities26.

  • 27 E. Freidson, 2001, ibid. p. 127
  • 28 E. Freidson, 2001, ibid. p. 134
  • 29 J. R. Williams, “Dual loyalties: How to resolve ethical conflict”, South African Journal of Bioethi (...)
  • 30 E. Freidson, 2001, op. cit. pp. 129-132.
  • 31 N.N. Sawicki, “Doctors, discipline, and the death penalty: professional implications of safe harbor (...)
  • 32 J. D. Jacob, “Understanding the Domestic Rupture in Forensic Psychiatric Nursing Practice”, Journal (...)

23Doctors in total institutions are a group of professionals. Eliot Freidson, a researcher in the area of the sociology of profession, considered two principal features which any professional group seeks to possess: the monopoly on certain work and decision-making autonomy. Besides this, at some stage of development, a professional community elaborates a code of ethics for all the members of this group27. Frequently, according to Freidson, the state prevents professionalization in an effort to turn professionals into government agents or even instruments for the state’s goals. The state not only limits professional autonomy but also organizes professional activity, providing the basic legislative framework for doctors’ work28. Medical professionals face a dilemma: to follow the interests of patients and to seek independence from the government, or to serve the state. There is an ethical problem, namely, dual loyalty which is the range of interests from those of the patient to those of the government and state institutions. Doctors’ loyalty to a government works to the detriment of their duty of care to patients29. Freidson also noted that sufficiently frequent restrictions on doctors’ professional autonomy by the state are connected to declining ethical standards30. When a doctor becomes a part of a state organization, ethical norms are often questioned, and, occasionally, physicians violate rules because they do not want to go against established order in a given facility. A case in point is the participation of American doctors in the administration of the death penalty31. The other example of dual loyalty in total institutions comes from research about forensic psychiatric nurses. The conclusion is that they play a dual role: caring about patients, while at the same time controlling them like guards. In conditions of dual loyalty and a culture of fear nurses continue to care about patients, but, simultaneously, they start to mistrust patients and control them32.

  • 33 E. Freidson, Profession of Medicine: a Study of the Sociology of Applied Knowledge, Chicago, New Yo (...)
  • 34 E. Freidson, 1988, op.cit. p. 143.

24A professional community seeks autonomy from the state, but ‘on the ground’, professional autonomy is reflected in employees performing organizational functions independently. Eliot Freidson, thus, writes that autonomy, on the one hand, includes control over the terms of work (economic, organizational, social). On the other hand, autonomy includes control over the content of work, that is, the technical aspects of doctors' activity (a diagnosis, a treatment and so on)33. There is a conflict between the organizational and the technical field in a hospital. While medical staff and the administration of a hospital perform organizational functions, doctors treat patients. The conflict is manifested as a struggle for control because a lack of control over the organizational part of work restricts the autonomy and self-regulation of the medical profession34.

  • 35 R. Roth, “Obstructing justice: prisons as barriers to medical care for pregnant women”, UCLA women' (...)

25Doctors’ professional autonomy is further restricted when prison officers become middlemen and women between doctors and patients. That means that inmates are forced to address the prison staff when they need healthcare, and then prison officers decide to take a prisoner to the doctor or not. One researcher of human rights in female prisons, Rachel Roth, considers this gatekeeper system as one of the most serious problems in female prisons in the USA. As an illustration, in 1998 in one of the female prisons in Colorado, a guard did not escort a pregnant woman to an infirmary, because he was busy counting the inmates. Meanwhile, the woman had contractions. It was only the third guard she addressed that helped her by escorting her to a nurse after more than 7 hours35.

  • 36 A. Giddens, op.cit. p. 16.
  • 37 A. L. Strauss, S. Fegerhaugh, B. Suczek, C. Weiner, Social organization of medical work, London: Tr (...)

26Interaction between doctors, prison officers, and the administration of prison can be considered in terms of a power struggle. A power struggle implies a struggle for some resources of power – instruments, that are essential for the constant reproduction of these power relations. The strongest group possesses the greatest power resources, but weaker groups also can have some resources which give members of these groups opportunities to affect the decisions of dominant groups. Anthony Giddens called the power of such weak groups the dialectic of control36. In practice groups of workers in a total institution not only compete, but also negotiate order to resolve disputes37. In the case of healthcare, this negotiation of order means that medical professionals cannot take decisions within their competence independently. In this way they partly lose their professional autonomy and must constantly struggle to expand it. I will demonstrate how these theoretical issues of dual loyalties in a total institution play out in the case of Russia. Before I turn to this, I provide some more detail as to the data the rest of the paper is based on.

Data Collection Methods

  • 38 A paramedic (dentist; feldsher) – a medical worker graduated 46-month medical training. Paramedics (...)

27Twenty four semi-structured interviews were collected between January 2017 and July 2018. I interviewed prison healthcare professionals, doctors who held administrative positions in prison clinics or hospitals, doctors who work in the medical clinics, prison officers, and the head of a correctional colony. One of the prison officers was a former employee, but he kept in touch with current officers. Almost all the respondents among employees of the penal system are “attested”. Most of the “non-attested” doctors among respondents are retired military personnel. There are also interviews that were conducted with human rights defenders. One of the human rights defenders was an employee of an NGO, the other four represented the PMC. There are former convicts and a formerly accused person who was in custody in a pre-trial detention centre among respondents as well. In total, among respondents, there are 12 prison medical workers (2 paramedics, 10 medical specialists38), 5 other employees of the Prison Service, 3 former prisoners (one of the human rights defenders is a former prisoner), and 5 human rights defenders. Among respondents, there are 9 women and 15 men aged from 24 to 55 years.

28Almost all respondents among doctors have experience in civilian medicine. However, 8 medical workers spent more time in the penal system than in civilian medical facilities. Seven of them have 7 or more years of experience of work in the penal system. Such permanence is connected with an “attested” status which gives them an opportunity to get early retirement and other social guarantees.

29The length of the interviews varied from 27 minutes to 2 hours 30 minutes. There were face-to-face interviews and Skype interviews. Most of the doctors were interviewed in a room where only other prison doctors were present but no guards. Other face-to-face interviews were held in the workplaces of respondents or in cafes.

30All doctors and three employees of the penal system, including the head of a prison colony, were from a federal region with a population of more than 1 million people. Almost all of these respondentrespondents were from small towns. The rest of the respondents were from different regions. Because of the extremely difficult access to this sociological field, a sufficient number of respondents cannot be found in only one region. I do not divulge the names of the regions to maintain the anonymity of respondents.

31I used the method of maximum variation sampling. Respondents were from different types of penal institutions. Different factors affect the position of doctors in a prison: from informal relationships between doctors, prison officers and the head of a prison to the location of a given prison itself. In addition to that, in one correctional facility there can be varying regimes for different categories of inmates. The respondents in this research are from male facilities (general regime colonies, strict regime colonies, special regime colonies, prisons), general regime colonies for women and remand prisons (SIZO), medical correctional facilities and prison hospitals. Due to the diversity of institutions in our sample, we can draw conclusions about the common features of the organization of prison medical care and the position of doctors in different types of jails.

  • 39 B. G. Glaser, Theoretical Sensitivity: Advances in the Methodology of Grounded Theory, Mill Valley (...)

32The interviews were transcribed in Russian. Then the grounded theory of Barney Glaser was applied to analyse the interviews, in particular, open and selective coding was used39. For coding, the program Atlas.ti was used. In each interview, I highlighted pieces of text which equated to a certain code. Then the individual codes were combined into families of codes. Finally, pieces of text with the same family label from different texts were compared with each other.

33These data have some restrictions. The Russian penal system is a rather challenging sociological field because of prison employees’ distrust of journalists, human rights defenders and researchers. Workers in the penal system do not see a big difference between them. Doctors face extremely sensitive ethical problems. Doctors and prison officers can hide or omit information about conflicts with other employees or actions that are not in conformity with the law, as this information could possibly cause damage to their career. These restrictions were partially overcome, as data triangulation was used: not only doctors were interviewed but also correctional officers, human rights defenders and others. This allowed me to create a more complete and reliable picture.

34The interviewer was not involved in respondents' work and they know that the interviewer is a researcher. Access to prison doctors was implemented with a key respondent, who was a colleague of the doctors, this enabled the establishment of trust. In cases of other prison employees and former prisoners, the interviewer shared mutual acquaintances with them. This also increased confidence between the researcher and respondents.

The System of "Give-and-Take"

35The relationship between doctors and prison officers is one of the main factors affecting medical professional autonomy in the modern Russian penal system. The data from the interviews shows that medical professionals and prison officers believe that doctors can work without obstacles only if they have informal agreements with non-medical personnel. Doctors claim that both professional groups are seeking to reconcile the function of controlling and punishing the inmates and taking care of their healthcare. Most often, respondents from among the doctors mentioned "a system of give-and-take". Prison officers also noted that they work and cooperate with medical workers in this system.

36Doctor respondents noted that they possess some power such as their skills and competencies. These allow them to avoid conflicts with prison staff because the latter cannot work without the exclusive knowledge and skills of medical professionals:

There are never any conflicts because they [correctional officers] need us, too. […] When new prisoners come, a medical professional is needed. […] When a shift of officers on duty changes, they need a doctor (Mikhail, a doctor in the prison hospital and in the corrective colony).

  • 40 A. Giddens, op. cit. p.16.

37This quotation show examples of Giddens’ dialectic of control40: doctors as a weaker professional group, in comparison with prison officers, possess a certain power. Prison officers also recognize doctors’ influence because of the specific functions that non-medical personnel cannot perform. At the same time, correctional officers as a stronger professional group than doctors, in conditions of a staff shortage, are forced to decide who from among prisoners will receive medical treatment, and who will not:

[…] If there is regime activity that includes the participation of all the staff members, I cannot quit everything and bring a person for some kind of injection. Why else does a doctor needs an inmate? […] I think he can take a pill of Validol later during the day. […] Then again, I try to ask doctors, talk with them: "let’s not transfer 23 people because we have no opportunity to do so, but we will try to transfer as much as possible. Let me see which prisoners you really need urgently. We will transfer the rest tomorrow" (the former prison officer in the remand prison, Iuri)

38Iuri’s words illustrate that because of lack of time personnel in remand prisons need to choose between providing medical treatment and participating in the activities associated with security. Most frequently, prison officers opt to prioritise their main work responsibilities which do not include medical assistance. Yuri in the quote above underestimates the need for medical assistance implying that injections or pills are not a valid reason to spend their time escorting prisoners to an infirmary. However, the correctional officer said that he tried to negotiate with a doctor, to give the doctor the opportunity to choose those most in need for medical treatment.

39The respondents mentioned not only the agreements reached on equal terms between medical professionals and prison officers, but also the pressure originating from the prison officers. In some interviews, both with prison officers and doctors, I found clear messages about prison officers’ influence on medical professional activity. As an illustration, a prison officer who works in a large regional prison hospital talks about such kind of interactions between doctors and patients:

If I am not satisfied with the bad behaviour or such like of an inmate, I can make an arrangement with a doctor to treat this person as soon as possible, and, god willing, let him go home (Ivan, a prison officer in a prison hospital)

  • 41 The order of the Ministry of Justice of the Russian Federation “Ob Utverzhdenii Pravil Vnutrennego (...)

40In this quotation, the officer admits that he can speed up the process of treatment, or, conversely, stop it for an inmate who breaks the rules of the establishment. In this case, the employee’s acts would violate the law that forbids releasing patients from prison hospitals prematurely in cases when they break a hospital’s rules. Patients can be released only according to medical grounds41.

41In the two citations above, the prison officers declare that they can negotiate with doctors implying healthcare professionals’ active participation in this process. However, the question is to what extent the doctors’ role is active. Yuri underestimates the value of medical procedures whilst Ivan says he can “make an arrangement” without reference to the medical professional, thus denying the active role of a doctor in these informal agreements.

42Prison officers, according to doctors, do not dive into the niceties of diagnosis and treatment. They are interested in how one or another diagnosis can affect their part of work with an inmate. If they are not satisfied with these effects, they try to influence the doctors. For instance, if a prison officer decides to punish an inmate, but a legal basis cannot be found for this, then the prison officer or the prison’s director asks a doctor to find medical grounds for the punishment:

For example, if they need to lock a man up for operational reasons […] to forbid meeting his relatives or going outside of prison, [prison officers] often push medical professionals to find medical grounds, that is, to push them towards forgery, shall we say. If a health care professional refuses to meet me halfway […], he can be pressurized by the prison officers. (Anton, the deputy head of the medical clinic)

43According to the respondent, this «administrative pressure» may consist of slowing down the doctor's work, for example, because a doctor cannot move without officer escort within the facility and cannot leave the facility without officers’ participation.

44In terms of interaction between doctors and the management of the penal institution, doctors note that despite a new organizational structure, they are forced to continue addressing the prison’s governor because he possesses the material and administrative resources for their work. Prison medical professionals do not control the space of the infirmary and medical facilities. As an illustration, prisoners can be sent to the infirmary, LIU or a hospital without any medical reasons. This may be related to corruption or the privileged position of some inmates, because in infirmaries and in hospitals there are better living conditions, than in ordinary colonies and jails. Also, prison authorities hide some prisoners in infirmaries to secure them from violence from other inmates. Finally, in some cases, a transfer to another facility, including LIU and prison hospitals, may play a disciplinary role, as especially severe living conditions are created in such institutions.

45In describing the disparity in power, there are some exceptions when doctors really succeed in their struggle for professional autonomy. However, such examples are mainly related to high-ranking doctors. It is likely that, in the case of ordinary medical workers the struggle is less successful in the face of powerful officers and prison administrations.

Safeguarding Medical Confidentiality

  • 42 St. 13. Federal'nyi zakon ot 21.11.2011 N 323-FZ (red. ot 29.07.2017) "Ob osnovakh okhrany zdorov'i (...)
  • 43 St. 13.14 Kodeks Rossiiskoj Federatsii ob administrativnykh pravonarusheniiah ot 30.12.2001 N 195-F (...)
  • 44 St. 137 ch. 2. Ugolovnogo kodeksa Rossiiskoi Federatsii.

46One of the most important medical professionals' ethical principles is safeguarding medical confidentiality. This ethical standard directly affects the issue of trust in relations between patients and doctors. According to the law, personal health information should not be disclosed. However, these data can be submitted to the bodies of the penal system as a response to a formal request42. The violation of medical confidentiality by a healthcare professional is an administrative offence43 and, in some cases, a criminal offence44.

  • 45 A. Lehtmets, J. Pont, op. cit. pp. 12-13.

47The Committee for the Prevention of Torture of the Council of Europe recommends against there being a prison officer being present during a medical examination, the transfer of medications by non-medical personnel in unsealed envelops and the use of CCTV in infirmaries. Such practices are a violation of medical confidentiality. In addition, the gatekeeper system, whereby prisoner patients have to apply to non-medical personnel for permission to visit an infirmary, is condemned as a violation of medical confidentiality, because of the danger that they might be coerced into disclosing their health problems45. All these issues have been reported in the Russian prison system.

  • 46 A. Lehtmets, J. Pont, ibid. p. 13

48In Russia, occasionally, prisoners resist the guard’s presence during medical examinations and they also complain about cameras in medical rooms. A solution to this problem could be non-medical - a call system - in infirmaries46. However, correctional officers interviewed claimed that security would be compromised. In general, the interviewed healthcare workers did not comment negatively on prison officers’ presence during medical examinations or on cameras in infirmaries, as they believed these to be necessary security measures. This attitude demonstrates the prioritization of a culture of fear over security and the secondary role of medical ethics and prisoners' human rights in prisons. This is despite the fact that doctors said that their fear of being attacked by prisoners has weakened when they got used to working in prison. In addition, among the prisoners, violence against doctors is discouraged, as they help prisoners.

Doctors' Strategies in Situations of Cruel Treatment in Prisons

  • 47 According to human rights defenders and former prisoners, prison officers rarely commit violence th (...)
  • 48 Art. 42. European Prison Rules, Council of Europe & Committee of Ministers, Strasbourg, 2006 [onlin (...)

49A separate important problem emerges in this system of “give-and-take” between medical staff and guards. This is the problem of cruel treatment of prisoners by prison officers in conditions of doctors’ double loyalty. The important role of the medical staff in preventing cruelty and torture towards prisoners by prison staff is reflected in international ethical codes. There is a simple line of reasoning: if a doctor reports all a prisoners’ injuries even in the cases when injuries were inflicted by staff, such incidents will become less frequent because members of staff will know that they cannot escape responsibility47. If prison doctors observe any signs that prison staff is involved in violence against inmates, or a prisoner declares that the actions of somebody from the prison staff is related to inmates’ injuries, medical professionals should report this information to the authorities48. In the Russian penal system, firstly, the doctors must inform the facility’s Operations Department, which is responsible for internal security and for investigating crimes including alleged cases of abuse of authority by prison officers.

50The doctors interviewed mostly concurred that when inmates are injured, healthcare professionals make a record of the patient’s claims. The Operations Department has to be informed both when a patient says that he or she has been injured, and when a patient is supected of attemtping to conceal the nature of his or her injuries. Patients can claim that they fell over or that they self-harmed due to a fear of reprisals. Some doctors said that in many cases they, as professionals, have the skills to understand how an inmate was injured – whether it was an accident, self-harm or violence. As an illustration, when a prisoner visits a doctor with a black eye, it is most likely violence.

  • 49 Some Russian mass media and NGOs claim about participation of medical staff in cruel treatment and (...)

51Most of the doctors said in the interviews that they always follow the rules described above49. However, a few respondents from among the doctors said that occasionally they do not follow the formal procedure. For instance, a respondent who has been working in the prison establishment for men for 15 years said that sometimes, when patients blame prison officers for violence, she breaks official rules and ethical standards. She admitted that prison officers had asked her to change the medical record of a prisoner in order to avoid punishment. Not only abusers themselves but also, according to the respondent, their immediate superior can address a doctor with such a request. Besides, in some cases, doctors decide to write a false diagnosis without being asked:

For instance, they [staff] hit him in the jaw, I made an X-ray: he had a fracture. And I did not record "a fracture". I even wrote another diagnosis myself. […] Then, there was another in the punishment cell (SHIZO). He had signed his name in the appointment list, I came: his front teeth, I saw, they were healthy, but they were blackened, that is, they had been hit, but history does not know how exactly: did he hit himself or was he hit. He said that he was hit. I did not make the records according to his claims that he was hit. […] He was a rogue: someone who ignores the rules, forever in a punishment cell. (Natalia, a physician in the corrective colony)

52There are two groups of interest in this narrative. The first group consists of the prison officers, who have to oversee discipline and punish when somebody refuses to follow the rules. The second group is inmates who want to receive healthcare. The physician decides not to record possible violence from prison staff because she believes that the harsh actions from prison staff are justified. She supports the decisions of the prison officer.

53In this research, there is insufficient data to say that all prison doctors in Russia choose the same strategy. However, this example shows that in such ethically ambiguous and even illegal situations a doctor can act as a proxy prison officer in the interest of the total institution. The doctor Natalia faced a situation of dual loyalty when she is asked to make a choice between two sides. It must be noted that the doctor picked the side of the prison officers without any pressure from them but because of solidarity with them.

54In these types of situations, when a doctor's professional ethical norms conflict with the interest of correctional officers the main strategies of doctors were identified. . The first doctor's strategy is the normative strategy: here the doctor operates independently from correctional officers and the authorities of a prison and provides a real diagnosis and the necessary treatment. In fact, in circumstances of serious restrictions of medical autonomy, this strategy can be seen as a form of contestation of the prisons' authority and power. The second strategy is group solidarity: the doctor protects the interest of the institution and prison staff and they flout the interest of patients. In cases of using this strategy, as described above, doctors flouted their professional ethics. Finally, the third strategy is subordination: doctors are forced to violate some ethical norms or even laws under pressure from correctional officers and prison authorities. Correctional officers and doctors do not talk about this strategy directly, but it is clear from their interviews that it has to be considered alongside the other options.

Relationships between Prison Doctors and Human Rights Defenders

55The emergence of public monitoring commissions (PMC) and non-governmental non-profit organizations for human rights have become a challenge for workers of the FPS in recent years as they are no longer able to hide information about the inner life of prisons as they did in the past. Furthermore, human rights defenders identify themselves as auditors of these facilities. Official and unofficial monitors can report violations to supervisory authorities or to the press and this can lead to investigations of malfeasance and serious punishments for prison workers and authorities.

56Prison doctors often communicate with human rights defenders, as the biggest share of inmates’ complaints to them considers prison healthcare. Doctors say that human rights defenders waste doctors’ time, and they cannot help healthcare professionals and inmates. Furthermore, according to doctors, human rights defenders’ demands of prison medical staff are impracticable in many cases. Doctors note that through these claims, human rights defenders devalue medical professional work:

But yes, we, of course, really irritate doctors, and conversations can end by the prison doctors saying: "How many people did you help? I have helped so many people, […] but you have not helped anyone" (Lilia, member of a PMC)

57Human rights defenders constitute a supervisory body. This leads to a situation in which doctors see them as opponents. Therefore, health care professionals fight against them in order to protect their professional group and the penal system as a whole:

We [health workers] and they [human rights defenders] are on the opposite sides of the line. We protect ourselves and our doctors, but they are trying to demonstrate that the doctors are always wrong. It turns out that we are on the same side as the entire penal system … we protect all our staff from all these [pause] observers (Maria, doctor in a prison medical clinic).

58Doctors and prison officers believe that human rights defenders financially profit from the difficult situations of prisoners and their relatives. In addition, both doctors and prison officers suspect human rights defenders of working in the interest of the criminal underworld and getting money from criminals. Likewise, human rights defenders are hostile to prison doctors. Human rights defenders argue that health care professionals are loyal to the penal system more than to patients. This is exemplified by doctors’ malfeasances and hiding violations against inmates. Furthermore, human rights defenders had a perception of heartless doctors who believe that they have to provide medical treatment only when a patient may die. However, according to human rights defenders, the doctors are not the only ones to blame. The penal system’s organizational structure is at fault too as it creates a fear among doctors that they may lose their job together with their social benefits if they do not follow formal and informal rules.

59It must be noted that human rights defenders gave examples of their communication with good doctors who try to make every effort in order to help patients under prison conditions. Moreover, sometimes such doctors come into conflict with prison authorities for saving medical professional autonomy. The share of doctors who try to be independent of correctional officers and the prison administration, balancing their loyalty to the system and to their patients, cannot be estimated. However, the examples above clearly show the conflict and duality between these loyalties.

Conclusion

60In the Russian penal system doctors' professional autonomy is significantly restricted. Despite the fact that the recent prison reform has given some official independence from the prison authorities to medical professionals, doctors continue to depend on the prison administration and non-medical personnel in places of incarceration. One of the most important limitations of doctors' professional autonomy in Russian jails is the system of gatekeepers: prison officers become the mediators between a patient and a doctor. Prison officers are able to rank inmates in accordance with their need for healthcare. This is an example of a layperson’s intervention in medical professional activity. This is contrary to the principle of equivalence of medical care where prisoners receive the same healthcare as the broader public.

61Prison officers are a significantly more powerful group than medical personnel. Members of this group are able not only to ask doctors to do their bidding, but also are able to put pressure on them. However, doctors do not obey prison officers fully due to professional exclusive and essential medical skills and competencies in the context of the penal system. This circumstance allows doctors to achieve some of their own goals.

62Doctors, especially “attested” ones, do not antagonise or breach the total institution. In the modern Russian penal system, doctors follow the interests of prison officers which contradict the interests of inmates in many cases. A culture of fear is present, where security is perceived as the supreme value. Additionally, prison doctors pursue the interests of the total institution, as they seek to save jobs which give them socio-economic stability. All these factors create a problem of dual loyalty. Despite this problem, prison doctors deem that medical professional ethics and sympathy to patients are integral parts of their professional self-identification. Doctors struggle to give patients the possibility to have better treatment and to be transferred to hospitals when they need it.

63A high degree of solidarity in a total institution does not allow doctors to cooperate with human rights defenders. In general, prison officers’ and doctors’ narratives about human rights defenders have the same negative connotation. Nobody from among the employees of the penal system sees any opportunities for cooperation with human rights defenders.

  • 50 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, "Organization models of health care servi (...)
  • 51 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, op. cit. p. 19.
  • 52 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, op. cit., p. 19.
  • 53 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, op. cit., p. 19.
  • 54 B. S. Elger “Towards Equivalent Health Care of Prisoners: European Soft Law and Public Health Polic (...)
  • 55 B. S. Elger Prison medicine, public health policy and ethics: the Geneva experience, Swiss Medica (...)

64With regard to further reform of penal healthcare, Russia could look abroad at different models. It should be noted that the Russian system of managing penal healthcare is far from unique. In the Netherlands, the Ministry for Justice, DJI (Dienst Justitiele Inrichtingen), includes medical service for prisoners, and medical personnel work for this Department as civil servants. The manager of an infirmary in a prison is responsible to the governor of the facility50. In France, on the contrary, medical units are completely subordinate to the Ministry of Health since 1994. Every prison has a medical unit (USMP and SMPR) which is responsible to a neighbouring civilian hospital. If USMP or SMPR cannot help inmates, the inmates are hospitalized in the civilian hospital. Medical professionals work in hospitals and in corrective facilities simultaneously. Formally, doctors and nurses are fully independent51. Thus, in France, on weekends, when physicians and nurses do not work, prison officers give an inmate a phone to speak with a doctor, and then a doctor gives instructions a prison officer52. A similar system exists in Geneva: prison infirmaries are subject to the University Hospital of Geneva under control of the cantonal department of health53. Due to doctor independence, in Geneva, medical confidentiality is strictly observed, prison doctors do not transfer medical information to prison officers. They only can be briefed on conditions which must be created for prisoners because of their state of health and safety rules for staff54 though inmates even here continue to complain about disclosure of medical information, in particular, because prison officers attend medical examinations55.

65The problems of the Russian penal healthcare system highlighted in this paper suggests that doctors should be made more independent from the prison system and become part of public health as it is in France or Geneva. As a result, prisoners would get high-quality medical treatment. The number of cases of cruel treatment from correctional officers would be expected to decrease in such a scenario because medical professionals would not be afraid to report it. However, such a reform would impose high costs on the Ministry of Health due to the need for additional infrastructure in civilian hospitals and training for the current medical staff in prisons. Current “attested” doctors would be disadvantaged because they would lose significant social guarantees. The Ministry of Health should create for them equivalent conditions as they have in the penal system in order to prevent the dismissal of a great number of workers.

66This research is a pilot and the data could not give comprehensive information on prison medicine in Russia. However, the paper gives a preliminary qualitative examination that builds on the very little information about this topic in social scientific study. The data obtained in the course of this study may be the basis for future more detailed qualitative and quantitative studies about Russian prisons.

  • 56 This structure does not include hospitals and other facilities for prison staff.

Organizational structure of the department of healthcare of the Russian penal system56

Organizational structure of the department of healthcare of the Russian penal system56

Source: see, “Structure of FPSR”, Federal Penitentiary Service of Russia, 2017. URL: http://fsin.su/​eng/​structure/​

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Appendix

Annex 1 - Organizational structure of the department of healthcare of the Russian penal system

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Notes

1 In the Russian penal system, the number of prisoners dramatically increased from 700 thousand to 1060 thousand between 1992 and 2000. After that, the number of inmates has been declining. The prison population had fallen to 600.8 thousand by 1 March 2018 (Russian Federation, World Prison Brief [online], connection on 2 February 2019. URL: http://www.prisonstudies.org/country/russian-federation).

2 In remand centers average space being 1,7m2, in some other facilities this number was 0, 5 m2 during the 1990s. (A. Bobrik, K. Danishevski, K. Eroshina, M. McKee, "Prison health in Russia: the larger picture", Journal of public health policy, Vol. 26, # 1, fall 2005, pp. 30-59.)

3 Death rate among prisoners dramatically increased between 1991 and 1997. (A. Bobrik, op. cit. p. 39)

4 Konseptsiia razvitiia ugolovno-ispolnitel'noi sistemy Rossiiskoi Federatsii do 2020 goda. Utverzhden rasporiazheniem Pravitel'stva Rossiiskoi Federatsii ot 14.10.2010. № 1772-r.

5 K. Runova, “Resotsializatsiia v mestakh lisheniia svobody v Rossii”. Centre for strategic research. 2018 [online]. Connection on 2 February 2019. URL: https://www.csr.ru/wp-content/uploads/2018/06/Resocializaciya_in_Russia_Internet-kopiya.pdf

6 A. Lehtmets, J. Pont, Prison Health care and medical ethics: a manual for health-care workers and other prison staff with responsibility for prisoners’ well-being, Council of Europe, Strasbourg, 2014, p. 5

7 G. Niveau, “Relevance and Limits of the Principle of “Equivalence of Care” in Prison Medicine”, Journal of Medical Ethics, Vol. 33, # 10, 2007, pp. 610-613; R. Lines, “From Equivalence of Standards to Equivalence of Objectives: The Entitlement of Prisoners to Healthcare Standards Higher than Those Outside Prisons”, International Journal of Prisoner Health, Vol. 2, # 4, 2006, pp. 269-280; W. Bretschneider, B.S. Elger, “Expert Perspectives on Western European Prison Health Services: Do Ageing Prisoners Receive Equivalent Care?”, Journal of Bioethical Inquiry, Vol. 11, # 3, 2014, pp. 319-332.

8 W. Bretschneider, B. S. Elger, op. cit. pp. 319-332.

9 D. Moran, J. Pallot, L. Piacentini, “The Geography of Crime and Punishment in the Russian Federation”, Eurasian Geography and Economics, Vol. 52, # 1, 2011, pp. 79-104.

10 United Nations Office on Drugs and Crime, World Health Organization (Regional Office for Europe), Good Governance for Prison Health in the 21st Century. A Policy Brief on the Organization of Prison Health, 2013 [online], connection on 2 February 2019. URL: http://www.euro.who.int/__data/assets/pdf_file/0017/231506/Good-governance-for-prison-health-in-the-21st-century.pdf?ua=1

11 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, "Organization models of health care services in prisons in four countries", Health Services Research (HSR) Brussels: Belgian Health Care Knowledge Centre (KCE), 2017.

12 E. Goffman, The Characteristics of total institutions in Symposium on Preventive and Social Psychiatry, Walter Reed Army Institute of Research, Washington, 1957, pp. 312-338.

13 E. Freidson, Professionalism: the third logic, Chicago: The University of Chicago Press, 2001.

14 A. Giddens, op. cit.

15 J. R. Williams, “Dual loyalties: How to resolve ethical conflict”, South African Journal of Bioethics and Law, Vol. 2, # 1, 2009, pp. 8-11.

16 P. 2 Prikaz Minzdravsotsrazvitiia RF N 640, Miniusta RF N 190 ot 17.10.2005 (s izm. ot 06.06.2014) "O Poriadke organizatsii meditsinskoi pomoshchi litsam, otbyvaiushchim nakazanie v mestakh lisheniia svobody i zakliuchennym pod strazhu" (Zaregistrirovano v Miniuste RF 01.11.2005 N 7133).

17 All citizens of Russia use the mandatory health insurance which is free to them and includes basic health services. The voluntary health insurance is a paid service for people. This insurance includes not only basic services, but also a number of additional health services.

18 V. V. Solomentsev, “O probleme v nomenklature meditsinskikh uchrezhdenii ugolovno-ispolnitel'noi sistemy Ministerstva iustitsii Rossii”, Meditsinskoe obrazovanie v Sibiri, № 2, 2014.

19 Strict regime and general regime colonies are not too much deferent. Strict regime implies more checks and searches, more strict punishments for violation of prison rules (this largely depends on the administration's policy), less meetings with relatives and packages with food.

20 Shtrafnoi-izoliator (SHIZO) and pomeshchenie kamernogo tipa (PKT) – small punishment cells for prisoners, who have violated prison rules, in corrective colonies and prisons. Prisoners are limited to parcels, telephone conversations and meetings with relatives.

21 Prikaz Minzdravsotsrazvitiia RF N 640, Miniusta RF N 190. Op. cit. Art. 50-52

22 Prikaz Minzdravsotsrazvitiia RF N 640, Miniusta RF N 190. Op. cit. Art. 132.

23 Art. 16. Federal'nyi zakon “Ob obshchestvennom kontrole za Obespecheniem Prav Cheloveka v Mestakh Prinuditel'nogo Soderzhaniia i o Sodeistvii Litsam Nakhodiashchimsia v Mestakh Prinuditel'nogo Soderzhanii” N 76-ФЗ. 2008.

24 E. Goffman, op. cit. pp. 312-338.

25 J. Jacob, D. Holmes, “The Culture of Fear: Expanding the Concept of Risk in Forensic Psychiatric Nursing”, International Journal of Culture and Mental Health, Vol 4, # 2, 2011, pp. 106-115

26 I. Y. Sun, H. E. Sung, D. C. Chu “Collateral Gains from the military? A Cross-national Analysis of the Armed Forces–crime Relationship”, International journal of offender therapy and comparative criminology, Vol 51, # 5, 2007, pp. 599-614.

27 E. Freidson, 2001, ibid. p. 127

28 E. Freidson, 2001, ibid. p. 134

29 J. R. Williams, “Dual loyalties: How to resolve ethical conflict”, South African Journal of Bioethics and Law, Vol. 2, # 1, 2009.

30 E. Freidson, 2001, op. cit. pp. 129-132.

31 N.N. Sawicki, “Doctors, discipline, and the death penalty: professional implications of safe harbor policies”, Yale law & Policy review, Vol. 27, # 1, 2008, pp. 107-172.

32 J. D. Jacob, “Understanding the Domestic Rupture in Forensic Psychiatric Nursing Practice”, Journal of Correctional Health Care, Vol. 20, # 1, 2013, pp. 45-58; J. D. Jacob, D. Holmes, “The culture of fear: expanding the concept of risk in forensic psychiatric nursing”, International Journal of Culture and Mental Health, Vol. 4, # 2, 2011, pp. 106-115.

33 E. Freidson, Profession of Medicine: a Study of the Sociology of Applied Knowledge, Chicago, New York: The University of Chicago Press, 1988, pp. 359-362.

34 E. Freidson, 1988, op.cit. p. 143.

35 R. Roth, “Obstructing justice: prisons as barriers to medical care for pregnant women”, UCLA women's law journal, Vol. 18, # 1, 2010, pp. 79-104.

36 A. Giddens, op.cit. p. 16.

37 A. L. Strauss, S. Fegerhaugh, B. Suczek, C. Weiner, Social organization of medical work, London: Transaction Publishers, 1997, pp. 27-28.

38 A paramedic (dentist; feldsher) – a medical worker graduated 46-month medical training. Paramedics are middle level of medical personnel with higher professional competence then nurses but lower then medical specialists. А medical specialist (eye doctor, gynaecologist ets) – a doctor graduated from 6-years training in medical school and one-or two-years additional training (internship or residency) where they enter after a High school.

39 B. G. Glaser, Theoretical Sensitivity: Advances in the Methodology of Grounded Theory, Mill Valley (CA): Sociology Press, 1978.

40 A. Giddens, op. cit. p.16.

41 The order of the Ministry of Justice of the Russian Federation “Ob Utverzhdenii Pravil Vnutrennego Rasporiadka”, №295, 2016.

42 St. 13. Federal'nyi zakon ot 21.11.2011 N 323-FZ (red. ot 29.07.2017) "Ob osnovakh okhrany zdorov'ia grazhdan v Rossiiskoi Federatsii».

43 St. 13.14 Kodeks Rossiiskoj Federatsii ob administrativnykh pravonarusheniiah ot 30.12.2001 N 195-FZ (red. ot 23.04.2018) (s izm. i dop., vstup. v silu s 14.05.2018).

44 St. 137 ch. 2. Ugolovnogo kodeksa Rossiiskoi Federatsii.

45 A. Lehtmets, J. Pont, op. cit. pp. 12-13.

46 A. Lehtmets, J. Pont, ibid. p. 13

47 According to human rights defenders and former prisoners, prison officers rarely commit violence themselves against inmates. Instead, workers of a prison establishment often ask other prisoners to do the officers’ "dirty work". Such situations must be recorded by a doctor and investigated.

48 Art. 42. European Prison Rules, Council of Europe & Committee of Ministers, Strasbourg, 2006 [online], connection on 4 February 2019. URL: https://rm.coe.int/european-prison-rules-978-92-871-5982-3/16806ab9ae.

49 Some Russian mass media and NGOs claim about participation of medical staff in cruel treatment and tortures. Data we have does not allow to validate that such practice is regular. Only one doctor among respondentrespondents said that she made a false diagnosis. Human rights defenders also do not assert that medical staff intentionally try to deteriorate the health status of inmates.

50 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, "Organization models of health care services in prisons in four countries". Health Services Research (HSR) Brussels: Belgian Health Care Knowledge Centre (KCE), 2017, pp. 120-123.

51 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, op. cit. p. 19.

52 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, op. cit., p. 19.

53 Ch. Dubois, S. Linchet, C. Mahieu, J. Reynaert, P. Seron, op. cit., p. 19.

54 B. S. Elger “Towards Equivalent Health Care of Prisoners: European Soft Law and Public Health Policy in Geneva”, Journal of Public Health Policy, Vol. 29, # 2, 2008, pp. 192-206.

55 B. S. Elger Prison medicine, public health policy and ethics: the Geneva experience, Swiss Medical Weekly, 141, w13273, 2011.

56 This structure does not include hospitals and other facilities for prison staff.

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List of illustrations

Title Organizational structure of the department of healthcare of the Russian penal system56
Caption Source: see, “Structure of FPSR”, Federal Penitentiary Service of Russia, 2017. URL: http://fsin.su/​eng/​structure/​
URL http://journals.openedition.org/pipss/docannexe/image/5022/img-1.png
File image/png, 139k
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References

Electronic reference

Kseniia Runova, « Between Autonomy and Dependency: Medical Professionals in the Modern Russian Penal System », The Journal of Power Institutions in Post-Soviet Societies [Online], Issue 19 | 2018, Online since 12 June 2019, connection on 18 November 2019. URL : http://journals.openedition.org/pipss/5022 ; DOI : 10.4000/pipss.5022

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About the author

Kseniia Runova

European University at Saint-Petersburg

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Copyright

CC BY-NC-ND 2.0

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