Reports of children participating in hunger strikes while detained in offshore detention centres raise interrelated ethical issues and recognizable challenges for the medical decision-makers at these sites. A composite case study, informed by reports in the public domain, is employed to explore the unique challenges of consent and decision-making in these circumstances and the perennial issues inherent in adolescents’ developing capacity and autonomy. We present an amalgamated case of a fourteen-year-old adolescent who refused to consent to medical reversal of her (...) hunger strike protest. The medical team became the final arbiter when her parents, who were also in detention, could not agree with each other even after mediation. The case explores the complexity of evaluating the adolescent’s capacity to provide informed consent while influenced by the opinions of co-detainees in this extreme setting. We argue that the parents and the child had compromised decisional capacity due to the effects of detention. The challenges to the medical team are recognized and discussed. The team members faced a difficult dilemma and considered the competing values of the multiple cultural and ethical factors. Each team member integrated his or her own roles, duties, and discipline-specific professional guidelines with the primary goal of mitigating potential harms. (shrink)

Reflecting on Smith (2021) in this issue, this commentary extends our consideration of issues in carceral health and questions the dehumanizing language we sometimes use—including in public health and public health ethics—to talk about persons held in incarceration. Even the language we use for the carceral system itself (such as ‘criminal justice system’) is fraught: it casts a laudatory light on the system and papers over its role in compounding racial health inequities and in sustaining colonialism. A host of issues (...) call out for ethical analysis, using lenses that can encompass the tensions and contradictions experienced by people within the system who deliver healthcare and those within the system trying to access that care. Beyond access to health care (promotion, prevention, treatment and palliation), the societal commitment to dealing with social issues by depriving people of many key social determinants of health is at the heart of many of these tensions and contradictions. (shrink)

Australian immigration detention has been called state sanctioned abuse, cruel and degrading and likened to torture. Clinicians have long worked both within the system providing healthcare and outside of it advocating for broader social and political change. It has now been over 25 years and little, if anything, has changed. The government has continued to consolidate power to enforce these policies and has continued to attempt to silence dissent. It was in this context that a boycott was raised as a (...) possible course of action. Despite discussions among the healthcare community about the merits of such action, a number of questions have been overlooked. In this article, I will examine whether a boycott is both ethical and feasible. Taking into account the costs and benefits of current engagement and the potential impact of a boycott, more specifically the potential it has to further harm those detained, I conclude that under current circumstance a boycott cannot be justified. This however does not mean that a boycott should be dismissed completely or that the status quo should be accepted. I discuss potential ways forward for those seeking change. (shrink)

There are few issues that have been as vexing for the Australian healthcare community as the Australian governments policy of mandatory, indefinite, immigration detention. While many concepts have been used to begin to describe the many dilemmas faced by healthcare professionals and their resolution, they are limited, perhaps most fundamentally by the fact that immigration detention is antithetical to health and wellbeing. Furthermore, and while most advice recognises that the abolition of detention is the only option in overcoming these issues, (...) it provides little guidance on how action within detention could contribute to this. Drawing on the work of political theorists and the broader sociological literature, we will introduce and apply a form of action that has not yet been considered for healthcare workers within detention, resistance. We will draw on several examples from the literature to show how everyday resistance could be enacted in healthcare and immigration detention settings. We argue that the concept of resistance has several conceptual and practical advantages over much existing guidance for healthcare workers in these environments, namely that it politicises care and has synergies with other efforts aimed at the abolition of detention. We also offer some reflections on the justifiability of such action, arguing that it is largely consistent with the existing guidance produced by all major healthcare bodies in Australia. (shrink)

Australian immigration detention has received persistent criticism since its introduction almost 25 years ago. With the recent introduction of offshore processing, these criticisms have intensified. Riots, violence, self-harm, abuse and devastating mental health outcomes are all now well documented, along with a number of deaths. Clinicians have played a central role working in these environments, faced with the overarching issue of delivering healthcare while facilitating an abusive and harmful system. Since the re-introduction of offshore processing a number of authors have (...) begun to discuss the possibility of a boycott. While taking such action may lead to change, further discussion is needed, not only in relation to the impact of a boycott, but whether it is possible for clinicians to engage with this system in more productive, ethical ways. This article utilises a framework proposed by Lepora and Goodin that provides a structured approach to examine complicity and seeks to explore how clinicians have engaged with Australian immigration detention and ultimately whether they should continue to do so. (shrink)

Australian immigration detention has been called state sanctioned abuse and a crime against humanity. The Australian healthcare community has been closely involved with these policies, calling for their reform and working within detention centres to provide healthcare. As well as having a devastating impact on health, immigration detention changes the scope and nature of healthcare, with its delivery described as a Sisyphean task. In this article I will explore the guidance that is available to clinicians who work within detention centres (...) and argue that codes, guidelines and positions statements provide little help in relation to ethical decision making. First I will outline guidance that can be found in codes of ethics and position statements, focusing on particularly relevant principles, such as advocacy, clinical independence and the clinicians’ relationship to human rights. I will then highlight the disparity between this guidance and the delivery of healthcare within detention by drawing on the testimony of clinicians who formerly worked in these environments. While this disparity should be cause for alarm and at a minimum call into question how codes and positions statements are being used, there are more fundamental reasons why codes and position statements fail to provide guidance in these circumstances. I will outline a more general criticism of codes of ethics and use this to suggest a way forward, including looking beyond codes and position statements to guide action within Australian immigration detention. (shrink)

Australian immigration detention has been called state sanctioned abuse and a crime against humanity. The Australian healthcare community has been closely involved with these policies, calling for their reform and working within detention centres to provide healthcare. As well as having a devastating impact on health, immigration detention changes the scope and nature of healthcare, with its delivery described as a Sisyphean task. In this article I will explore the guidance that is available to clinicians who work within detention centres (...) and argue that codes, guidelines and positions statements provide little help in relation to ethical decision making. First I will outline guidance that can be found in codes of ethics and position statements, focusing on particularly relevant principles, such as advocacy, clinical independence and the clinicians’ relationship to human rights. I will then highlight the disparity between this guidance and the delivery of healthcare within detention by drawing on the testimony of clinicians who formerly worked in these environments. While this disparity should be cause for alarm and at a minimum call into question how codes and positions statements are being used, there are more fundamental reasons why codes and position statements fail to provide guidance in these circumstances. I will outline a more general criticism of codes of ethics and use this to suggest a way forward, including looking beyond codes and position statements to guide action within Australian immigration detention. (shrink)