The role of medical personnel in places of detention 87 the main task of the prison administration is detention where investigation, execution of sentence, safety and security and social rehabilitation are regulated by strict penitentiary laws, whereas the tasks of healthcare providers are maintenance of health, prevention of health disorders, detection and treatment of health disorders and individual care of patients according to medical ethics, which, in comparison to ‘hard’ penitentiary law is often regarded as ‘soft’ law. — As a consequence, healthcare ethics can and do come into conflict with prison realities: Confidentiality, privacy and patients’ consent, which are all fundamental aspects of medical care, conflict with principles of custody such as ‘security and safety first’. Access to and equivalence of quality of medical care is often hampered by a lack of resources, overcrowding and understaffing. The professional independence of the healthcare workers employed and paid by the prison administration is restricted or regarded as restricted. The importance of prison health and prisoners’ health as set out by WHO in the Moscow Declaration 2003 has yet to gain public recognition and support. Preventive healthcare is a difficult task in prison, i.e. an environment that is pathogenic in itself: The risk of a number of diseases among prisoners (mental disorders, suicide, tuberculosis, hepatitis B and C, HIV/ AIDS, drug misuse and dependency) can be caused by imprisonment itself or increased by it. Concepts of health promotion, such as assuming self-responsibility for health, are hindered in an environment of deprivation of autonomy and self-determination. Planning of aftercare or through-care is difficult due to the organisational separation of prisons from the general community. The sole task of healthcare workers is the health and well-being of the inmates. — Prison inmates who cannot choose their doctor may find it difficult to trust a physician who is employed or contracted by the administration. They may question the doctor’s confidentiality, professional independence and qualification. Healthcare staff are likewise challenged by the peculiarities of providing healthcare in prison, such as how to manage confidentiality, privacy and patients’ consent in prison and detention centres, the paradigm of ‘total institutions’.5 Obtaining the inmates’ trust, balancing professional relationships with inmates and custodial staff, coping with pressures and expectations from inmates and the prison administrations while maintaining professional independence are among the greatest demands put on healthcare professionals working in prisons. Prison governors and custodial staff may have their own perspectives on the physician’s role regarding safety and security, and on healthcare expenses. They may question whether medical confidentiality, patients’ consent and the doctor’s professional independence are compatible with safety and security in prison. They may ask prison physicians to certify inmates as fit for disciplinary punishment or ask for the doctor’s support during intimate body searches and drug testing. In addition, they may question expensive medical care costs within paltry prison budgets. 5 Goffman E: Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Garden City, N. Y.: Anchor books, 1961