Decriminalizing Medicine: Ending Punitive Practices in Health Care
In this article, PRH fellow Dr. Meera and PRH community members Megan and MaryBeth examine how punitive health care practices deepen harm and argue that abolitionist, harm-reduction care creates a future grounded in dignity and liberation.
As providers in health care and street-based spaces who are also involved with community organizing, we often witness how oppressive systems of power such as racism, capitalism, cis-heteropatriarchy and white supremacy actively and disproportionately harm structurally marginalized individuals and communities.
We have seen how providers and health care institutions participate in the criminalization of care and in the expansion of the surveillance and carceral state, policing the bodies of people and parents with substance use disorder. Instead of focusing on the oppressive structures, trauma, and structural harm that contribute to substance use, individuals are often blamed for their substance use and are labeled as undeserving, as failures, and as criminals. In doing so, providers and institutions are deflecting attention from the intersecting systems of oppression that justify their continued presence and their authority over patients’ lives. Support and care in these health care spaces often reinforce notions of surveillance, control, and punishment rather than abolition, harm reduction, and liberation, imposing insurmountable barriers to care that further harm individuals and communities.
We have participated in the care of many people who do not present to care until later in pregnancy out of fear of being forcibly separated from their child given a history of substance use and prior involvement with the “child welfare” or “family policing” system, as well as patients who present for abortion care whose decision was partly influenced by health care providers telling them that they cannot parent with substance use. These patients and their stories have taught us the importance of dismantling systems of punishment and surveillance that aim to control the bodies of patients often without their fully informed consent. This demands of us to radically reimagine care that centers liberation and self-determination, and which is life affirming. It is possible to support people on their terms and with their consent, and doing so requires our commitment and our creativity.
These patients and their stories have taught us the importance of dismantling systems of punishment and surveillance that aim to control the bodies of patients often without their fully informed consent.
Abolition is a praxis centered on dismantling the intersecting systems of oppression that enforce principles of carcerality and punishment while simultaneously reimagining and building systems that are structurally supportive, affirming, and liberatory. The criminalization of substance use and the surveillance and policing of patients with substance use disorder happens through nonconsensual urine drug tests and reporting to the family policing system in health care. Decriminalization requires an abolitionist approach that moves away from individualizing blame on the victims of the state-sanctioned violence and harm enacted by systems of racial capitalism. Instead, we name the manifestations of this system – poverty, trauma, and houselessness – while moving towards systems centering the humanity and collective liberation of marginalized communities.
Harm reduction offers an approach to care that prioritizes the autonomy and dignity of the patient. It focuses on mitigating the impact of drug-related harm rather than reduction in substance use, allowing for a space to reimagine what person-defined safety and care can look like for patients and communities. Through harm reduction we can co-create spaces and support systems that allow people with substance use disorder to parent rather than separate families.
Harm reduction offers an approach to care that prioritizes the autonomy and dignity of the patient.
As providers, we see how paternalistic systems of oppression and state-sanctioned violence are both inscribed on the bodies of individuals and impact the autonomy and self-determination of people making decisions about their reproduction. The stories and journeys of the people whose care we have been involved in and our work with community organizations holds us accountable to dismantle the systems enacting harm against people through policing, surveillance, and control. We must also build structures that prioritize self-determination, autonomy, affirmation, justice, and consensual support.
As we continue to learn how to operationalize these principles in practice, we have discovered a few ways to start restructuring care. First, recognize that people who use substances may have different goals around parenting/family planning, and it is our role to walk alongside them whether that is in the direction of reduction, cessation, or episodically neither / both. Instead of focusing on only reducing substance use, we can focus on ways to facilitate safer substance use with practices like needle exchanges, offering fentanyl test strips, free naloxone access, buddy systems, creating safety plans with patients around safe use, ensuring safe storage of substances, universal housing, access to primary care and mental health care, and universal child care access. It is important to know the policies that both do and do not exist in your state and institution around urine drug testing and mandatory reporting to reduce the surveillance of bodies and forcing involvement of the family policing system.
Additionally, we must be cognizant of and transparent in what we do (and do not) document in a person’s chart. Stigmatizing and derogatory language is harmful to patients because it colors how they are seen by other providers when they access care in the future. It is also important to think about the need for and documentation of urine drug tests and to shift away from punitive and non-consensual approaches. We should move towards patient centered care that offers agency to the patient and will not be used against them in seeking care and treatment.
It is essential for providers to surrender our unearned power and authority and take our cues from individuals with direct experience.
Finally, it is essential for providers to organize beyond the silos of gate-kept medicalized spaces, surrender our unearned power and authority as providers to the most marginalized, and take our cues from the work of individuals with direct experience and community organizations to transform both our practice and praxis of care. It is important to also acknowledge that the current capitalistic model of the delivery of health care with its focus on number of patients and revenue often does not allow adequate time to practice abolition and harm reduction and thus also requires revamping and restructuring.
We can co-create a world in which individuals and communities have the tools and power to live joyful, loving, and dignified lives and make decisions about their lives and bodies that are free of coercion from oppressive systems and state-sanctioned violence. We look forward to joining with you in this work.