Health Care Ethics USA Archives

While over 40 states have passed laws that restrict the use of restraints during the birthing process for patients coming from carceral settings, the practice of using technologies such as handcuffs, leg restraints and belly chains to restrain patients coming from carceral settings is still occurring, even in states with anti- shackling laws.¹ This can be due to exceptions written into anti-shackling laws that allow prison and jail staff to make determinations of whether or not a patient is deemed as a "threat to public safety" or at risk of escape, as well as pre-existing hospital policies that require patients coming from carceral settings to be shackled upon arrival to the hospital.²

House, et al. have argued that commonly cited safety concerns that are used to justify the continued practice of shackling of patients coming from carceral settings to give birth in a hospital are unpersuasive for the following reasons:

"(1) physical demands of labor and delivery make escape extremely unlikely,

(2) no pregnant or laboring incarcerated individual has ever been documented as having escaped a hospital, and

(3) most women experiencing incarceration 'are not violent offenders, so restraining them to prevent attacks on workers is largely unnecessary.'"³

Moreover, the practice of shackling while giving birth can also put patients at risk for physical harm. Shackling has been shown to put patients at a higher risk of physical complications such as placental abruption, maternal hemorrhage, and stillbirth as well as psychological harms, which is particularly troubling given the disproportionately high rates of post-traumatic stress disorder within the population of incarcerated women.⁴ The practice of shackling also disproportionately impacts Black women, given that Black women are incarcerated at a rate that is three times higher than White women.⁵ For these reasons and more, shackling patients coming from carceral settings during the process of giving birth should be considered an inhumane and unsafe practice that contributes to unjust health inequities for a patient population that is incredibly vulnerable.

Catholic ethicists have a unique responsibility to help ensure that restraints are not used for pregnant and laboring patients coming from carceral settings. This responsibility stems from Catholic social teaching regarding the social responsibility of Catholic health care services. We have identified four directives from the Ethical and Religious Directives for Catholic Health Care Services that support the claim that ethicists working within Catholic health care institutions have a responsibility to support these efforts to respect the dignity of patients coming from carceral settings through ensuring that restraints are not used while a patient is giving birth.

Directive 3: "In accordance with its mission, Catholic health care should distinguish itself by service to and advocacy for those people whose social condition puts them at the margins of our society and makes them particularly vulnerable to discrimination"

Directive 5: "Catholic health care services must adopt these Directives as policy, require adherence to them within the institution as a condition for medical privileges and employment, and provide appropriate instruction regarding the Directives for administration, medical and nursing staff, and other personnel"

Directive 23: "The inherent dignity of the human person must be respected and protected regardless of the nature of the person's health problem or social status"

Directive 33: "The well-being of the whole person must be taken into account in deciding about any therapeutic intervention or the use of technology"⁶

Individuals coming from carceral settings are certainly "people whose social condition puts them at the margin of our society" and require our advocacy and support to ensure that the care that they receive in Catholic health care settings is free of discrimination and undue harm, while protecting their inherent human dignity. Ending the use of restraints, which is a dangerous practice without medical benefit or factually-grounded reasons for implementation, is a way in which Catholic health care institutions can embody their social responsibility and protect the dignity of a highly vulnerable patient population.

Given that restraints are still often used in hospitals located in states in which there are anti-shackling laws, ethicists working within Catholic health care institutions can support anti-shackling efforts through participating in the development of policies, providing education, and facilitating communication efforts between health care caregivers and employees coming from carceral settings when issues of safety arise. For ethicists working in Catholic health care institutions, we offer the following recommendations:

1. Review your hospital's policies regarding patients delivering who are coming from carceral settings. Consider the following when reviewing and updating policies: "Organizational policies should comply with applicable federal and state law, be concise and easily readable, use language that reinforces all patients' personhood and dignity, and limit exceptions in accordance with 3 features of model policy:

1. A pregnant patient in any stage of delivery may not be placed in restraints at any time.
2. A patient in postdelivery recuperation shall not be placed in restraints, except under extraordinary circumstances (ie, the patient presents immediate, serious threat to self or others or presents immediate, credible risk of escape that cannot be curtailed by other measures). If clinicians determine that restraints must be used, restraints shall be the least restrictive and most reasonable available.
3. Leg or waist restraints shall not be used on a pregnant or postpartum patient"⁷

2. Provide education to caregivers regarding:

1. hospital policies.
2. any exceptions included in state laws, as well as how to approach discussions about those exceptions.
3. how to communicate with prison or jail staff who may accompany patients to Labor & Delivery units.

By creating hospital policies that are aligned with dignity-enhancing, medically-indicated best practices, and equipping hospital employees with the education and resources to support the implementation of hospital policies, ethicists working in Catholic health care institutions can do their part to ensure that pregnant and laboring patients coming from carceral settings receive the safe, respectful care that they and their babies deserve.

KAYLA TABARI RN, MBE
Clinical Ethicist Providence
Portland, Oregon

ELIZABETH BALSKUS, PHD
Clinical Ethicist and Educator Providence
Portland, Oregon

ENDNOTES

1. "A Call to Stop Shackling Incarcerated Patients Seeking Health Care," American Public Health Association - For science. For action. For health., accessed March 12, 2025, https://www.apha.org/policies-and-advocacy/public-health- policy-statements/policy-database/2024/01/16/shackling- incarcerated-patients.
2. "A Call to Stop Shackling Incarcerated Patients Seeking Health Care," American Public Health Association - For science. For action. For health., accessed March 12, 2025, https://www.apha.org/policies-and-advocacy/public-health- policy-statements/policy-database/2024/01/16/shackling- incarcerated-patients.
3. House, et al. "Ending Restraint of Incarcerated Individuals Giving Birth," AMA Journal of Ethics 23, no. 4 (April 1, 2021), https://doi.org/10.1001/amajethics.2021.364.
4. 1. Veronica Brawley and Emma Kurnat-Thoma, "Use of Shackles on Incarcerated Pregnant Women," Journal of Obstetric, Gynecologic & Neonatal Nursing 53, no. 1 (January 2024): 79–91, https://doi.org/10.1016/j.jogn.2023.09.005.
5. House, Kayla, et al. "Ending Restraint of Incarcerated Individuals Giving Birth." 365.
6. ethical-religious-directives-catholic-health-service-sixth- edition-2016-06.pdf
7. House, et al. "Ending Restraint of Incarcerated Individuals Giving Birth," AMA Journal of Ethics 23, no. 4 (April 1, 2021), https://doi.org/10.1001/amajethics.2021.366.

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