Articoli di riviste sul tema "Enslaved persons, emancipation, united states"

This article explores the transition from enslavement to post-emancipation realities in the Muslim-majority societies of the Middle East and North Africa during the last stage of empire and the first phase of nation-building. The main argument is that within enslavement, there were gradations of bondage and servitude, not merely a dichotomy between free and enslaved. The various social positions occupied by the enslaved are best understood as points on a continuum of social, economic, and cultural realities. In turn, these were reproduced after emancipation in the successor states that emerged following the demise of the Ottoman and Qajar empires, the Sharifian state in Morocco, and the various principalities of the Arab/Persian Gulf. Hence, post-emancipation did not create equal citizenship for all freed persons, but rather the inequality within enslavement transitioned into the post-imperial societies of the Middle East and North Africa.

This essay presents an ecocritical analysis of Hannah Crafts's The Bondwoman's Narrative, the 1850s manuscript novel by a formerly-enslaved African American woman that was recovered by Henry Louis Gates in 2001. Examining Crafts's extensive engagement with Charles Dickens's Bleak House, it argues that Crafts's fictionalized narrative of enslavement and self-emancipation re-imagines a Victorian politics of environmental health as a critique of environmental racism. Showing how Crafts presents the material ecology of the plantation South as a site and vector of violence, it reads The Bondwoman's Narrative as resisting nineteenth-century scientific discourses of racialized immunity that sought to legitimize the systemic neglect of enslaved people in the antebellum United States.

In 2021, June 19 (Juneteenth) became a federal holiday commemorating the emancipation of enslaved people of African descent in the United States. Prior to Juneteenth gaining official status, January 1 (Emancipation Day) was the de facto national holiday on which African Americans celebrated the signing of the Emancipation Proclamation and the end of slavery. From 1863 until the late twentieth century, African Americans throughout the nation celebrated what the black-owned journal The Elevator called “the greatest event in the history of the Colored people of America.” While several scholarly works focus on Emancipation Day celebrations throughout the United States, these studies have largely ignored how black westerners celebrated what was essentially “independence day” for African Americans. This essay examines Emancipation Day celebrations in the African American communities of San Francisco, Sacramento, and Los Angeles. Emancipation Day celebrations illustrate how black Californians in the state’s largest African American communities used ritualized celebration and public dialogue to construct their new civic identities as free black men and women. Emancipation Day celebrations provided black Californians opportunities to testify to their aspirations as members of the American polity, and to their vision of themselves as upholders of liberty and beacons of freedom in post–Civil War America. Black Californians forthrightly used public commemorations of the signing of the Emancipation Proclamation to illustrate black community consciousness through the spirit of public festivals and civic celebrations, otherwise known as “public festive culture.” These public rituals did more than celebrate liberty: they legitimated black freedom and citizenship, honored the memory of Abraham Lincoln as God’s servant, and elaborated a political ethos powerful enough to unify African Americans as members of the American polity.

Gullah-Geechee is a creole culture that emerged among enslaved African Americans in the coastal Southeastern United States. Modern material expressions of this culture include a distinctive settlement type, the family compound, consisting of loosely clustered residences and outbuildings. The arrangement of these settlements resembles colonial slave quarters but differs from antebellum “slave rows.” Gullah-Geechee family compounds existed by the mid-20th century, but their origin, time depth, and evolution from linear quarters are unclear. Archaeological study of the Wilson–Miller plantation slave quarter near Savannah, occupied over most of the 19th Century, indicated that the Gullah-Geechee residential compound appeared soon after Emancipation. The study also suggested that communal outdoor space was important in maintaining cultural practices that were expressed in both colonial and post-Emancipation settlement patterns.

Abstract: This article illuminates a lesser-explored aspect of the United States as a “slaveholding republic.” Between 1816–1861, the U.S. Army relied on thousands of enslaved persons who served as officers' servants. In 1816, Congress authorized allowances, rations, and bonuses for officers' private servants while putting an end to the practice of soldiers serving as servants. This legislative move effectively subsidized and incentivized military slaveholding. The paper delves into the political circumstances and legislative maneuvers that led Congress to institutionalize military slavery, establishing mechanisms to sustain, fund, and expand the number of enslaved servants. Military slavery developed gradually with the foundation, bureaucratization, and professionalization of an American military peace establishment. It evolved from 1797 to 1816 through competing policy objectives, resulting in a long-lasting bureaucratic workaround euphemistically termed "servants not soldiers." Facing public criticism over officers’ abuse of soldiers’ labor, the army “outsourced” officers’ servants through a dual process of privatization and racialization, differentiating between “public” and “private” service, between free, white soldiers and enslaved, black servants. Though serving slaveholders’ interests, the adopted solution was a product of bureaucratic contingencies and ad-hoc decision-making and not a policy orchestrated by a cabal of enslavers. Interestingly, a basic question of reimbursement led somewhere unanticipated, ending in government-sponsored enslaved servitude. Acknowledging this contingency does not excuse the actions but underscores how slavery was often "solved" through institutional accommodation rather than political or moral opposition. Thus, slavery directly impacted the U.S. Army, a central national institution, altering the military system at its pivotal, formative moments.

Model systems enlightened by history that provide understanding and inform contemporary and future landscapes are needed. Through transdisciplinary collaboration, historic rice fields of the southeastern United States can be such models, providing insight into how human–ecological systems work. Rice culture in the United States began in the 1670s; was primarily successfully developed, managed, and driven by the labor of enslaved persons; and ended with the U.S. Civil War. During this time, wetlands were transformed into highly managed farming systems that left behind a system of land use legacies when abandoned after slavery. Historically accepted estimates range from 29,950 to 60,703 ha; however, using remotely sensed data (e.g., LiDAR) and expert opinion, we mapped 95,551 ha of historic rice fields in South Carolina, USA. After mapping, the rice fields’ current wetland and land cover characteristics were assessed. Understanding the geographic distribution and characteristics allows insight into the overall human and ecological costs of forced land use change that can inform future landscapes.

The emancipation of enslaved people after the Civil War dramatically altered the perception of immigrants in the United States. This paper explores legal and social changes that took place in America after the Reconstruction period and analyzes the effect of those changes by comparing the treatment of the Irish in the mid-19th century with that of immigrants who arrived later in the century. It focuses on three main topics: the evolution of immigration laws, the rising popularity of post-war pseudo-scientific theories on race in the late 19th century, and immigrant groups assimilation rates. The study demonstrates how these concepts are interrelated to illustrate the impact of the Civil War on immigration trends. It concentrates on Irish and Italian families since they share many traits: both groups came from poor, rural backgrounds, both took jobs away from Americans and lowered wages, both immigrant groups practiced Catholicism, and both came in waves from Europe. Despite these similarities, Italians, like Asian and Jewish immigrants fleeing their homelands between the 1880s and early 1900s, faced more virulent forms of nativism and more restrictions than Irish newcomers a few decades earlier, in part because of the 14th Amendments definition of birth-based citizenship and post-Reconstruction discrimination that was intended to subordinate newly freed African Americans.

The Transatlantic Slave trade began during the 15th century when Portugal and subsequently other European kingdoms were able to expand overseas and reach Africa. The Portuguese first began to kidnap people from the West Coast of Africa and took those that they enslaved to Europe. This saw a lot of African men and women transported to Europe and America to work on the huge plantations that the Whites owned. The transportation of these Africans exposed them to inhumane treatments which they faced even upon the arrival at their various destinations. The emancipation Proclamation signed on 1st January 1863 by the United States President Abraham Lincoln saw a legal stop to slave trade. However, the African Americans that had been taken to the United States and settled especially in the Southern region faced discrimination, segregation, violence and were denied civil rights through segregation laws such as the Jim Crow laws and lynching, based on the color of their skin. This forced them especially those that had acquired an education to rise up and speak against this treatment. They formed Civil Rights Movements to advocate for Black rights and equal treatment. These protracted movements, despite continued violence on Blacks, Culminated in Barack Obama being elected the first African American President of the United States of America. To cement the victory, he won a second term, which Donald Trump failed to obtain. This paper sought to critic the philosophies of Booker T. Washington in his civil rights movement, particularly his ideologies of integration, self-help, racial solidarity and accommodation as expressed in his speech, “the Atlanta Compromise,” and the impact this had on the political and civil rights arena for African Americans.

The Transatlantic Slave trade began during the 15th century when Portugal and subsequently other European kingdoms were able to expand overseas and reach Africa. The Portuguese first began to kidnap people from the West Coast of Africa and took those that they enslaved to Europe. This saw a lot of African men and women transported to Europe and America to work on the huge plantations that the Whites owned. The transportation of these Africans exposed them to inhumane treatments which they faced even upon the arrival at their various destinations. The emancipation Proclamation signed on 1st January 1863 by the United States President Abraham Lincoln saw a legal stop to slave trade. However, the African Americans that had been taken to the United States and settled especially in the Southern region faced discrimination, segregation, violence and were denied civil rights through segregation laws such as the Jim Crow laws and lynching, based on the color of their skin. This forced them especially those that had acquired an education to rise up and speak against this treatment. They formed Civil Rights Movements to advocate for Black rights and equal treatment. These protracted movements, despite continued violence on Blacks, Culminated in Barack Obama being elected the first African American President of the United States of America. To cement the victory, he won a second term, which Donald Trump failed to obtain. This paper sought to critic the philosophies of Booker T. Washington in his civil rights movement, particularly his ideologies of integration, self-help, racial solidarity and accommodation as expressed in his speech, “the Atlanta Compromise,” and the impact this had on the political and civil rights arena for African Americans.

In genealogy, tracing names and dates is often the initial goal, but, for many, desire soon turns to learning about the embodied lives of those who came before them. This type of texture is hard for any genealogist to locate, but excruciatingly hard for those seeking to trace family histories that include ancestors who were enslaved in the northern parts of the colonies that would become the United States. Often, records thin to nearly nothing and frame all lived experiences through the lens of an enslaver. This is true especially of public records, created, maintained, and curated by the state apparatus. By adhering to the proposition that even materials that do not immediately reveal much about Black life may be useful if we consider what is missing and left out, this article suggests that these types of documents might help breathe some fullness into the individual and collective lives of those Black ancestors whose humanity the state denied. Emerging from a larger project to locate stories and histories of Black residents of one of the first colonized spaces in British North America, this article focuses on the ways in which the publicly available Massachusetts pre-1850 Vital Records—which have specific “Negroes” sections—serve as an unexpected source of useful, if fragmentary, evidence of not only individual lives, but collective histories of the communities in which Black ancestors lived. Highlighting creative approaches to analyzing these particular vital records, and centering women’s lives throughout, this article demonstrates what is possible to learn about patterns of childbearing, relationships between and among enslaved persons owned by different families, the nature of religious lives or practices, relationships between enslavers and enslaved, and the movements, over time, of individuals and families. Alongside these possibilities, the violence, limitations, and challenges of the vital records are identified, including issues related to Afro-indigenous persons, the conflation of birth and baptismal records, and differential access to details of the lives of enslaved men vs. women.

Objective: Black/African American people have long reported high, albeit warranted, distrust of the US health care system (HCS); however, Blacks/African Americans are not a homogenous racial/ethnic group. Little in­formation is available on how the subgroup of Black Americans whose families suffered under US chattel slavery, here called De­scendants of Africans Enslaved in the United States (DAEUS), view health care institu­tions. We compared knowledge of unethical treatment and HCS distrust among DAEUS and non-DAEUS.Design and Setting: A cross-sectional random-digit dialing survey was adminis­tered in 2005 to Blacks/African Americans, aged 21-75 years, from the University of Pennsylvania Clinical Practices in Philadel­phia, Penn.Participants: Blacks/African Americans self-reported a family history of persons enslaved in the US (DAEUS) or no family history of persons enslaved in the US (non- DAEUS).Main Outcome Measures: HCS distrust was measured by a validated scale assessing perceptions of unethical experimentation and active or passive discrimination.Methods: We compared responses to the HCS distrust scale using Fisher’s exact and t-tests.Results: Of 89 respondents, 57% self-re­ported being DAEUS. A greater percentage of DAEUS reported knowledge of unethical treatment than non-DAEUS (56% vs 21%; P<.001), were significantly more likely to express distrust, and to endorse the pres­ence of covert (eg, insurance-based) than overt forms (eg, race-based) of discrimina­tion by the HCS.Conclusions: DAEUS express greater HCS distrust than non-DAEUS, patterned by awareness of unethical treatment and passive discrimination. Understanding how long-term exposure to US institutions influ­ences health is critical to resolving dispari­ties for all Black/African American groups. Rectifying past injustices through repara­tive institutional measures may improve DAEUS’ trust and engagement with the US HCS.Ethn Dis. 2021:31(3):417-424; doi:10.18865/ed.31.3.417

ABSTRACT This article provides a reading of Amiri Baraka’s play, Slave Ship: A Historical Pageant (1967) and Toni Morrison’s novel, Song of Solomon (1977). It argues that in both texts, written during the racial and political unrest of 1960s and 1970s United States, threats of violence and death toward Black individuals and communities allowed the formation of unique perspectives on life and death. Fundamentally, it was the belief that death is the beginning of life in another form, rather than its end. This belief and its corresponding ideas recall African worldviews and cultural philosophies, transported to the New World by enslaved Africans, which reject death as a state of powerlessness and hold that the dead, from the realms of the afterlife, have power to change the material world. When these ideas are articulated through Black nationalist discourses, death, and particularly suicide, is presented as a form of resistance. Specifically, self-inflicted death becomes a mean through which one contend for survival. The article argues that in their characterizations and various narrative strategies, both Morrison and Baraka interrogate the usefulness of these ideas by considering them as solutions to racialized injuries and injustices of post Emancipation Back American life.

Seventeenth-century reports of the suffering of European indentured servants and the fact that many were transported to Barbados against their wishes has led to a growing body of transatlantic popular literature, particularly dealing with the Irish. This literature claims the existence of “white slavery” in Barbados and, essentially, argues that the harsh labor conditions and sufferings of indentured servants were as bad as or even worse than that of enslaved Africans. Though not loudly and publicly proclaimed, for some present-day white Barbadians, as for some Irish and Irish-Americans, the “white slavery” narrative stresses a sense of shared victimization; this sentiment then serves to discredit calls for reparations from the descendants of enslaved Africans in the United States and the former British West Indies. This article provides a detailed examination of the sociolegal distinctions between servitude and slavery, and argues that it is misleading, if not erroneous, to apply the term “slave” to Irish and other indentured servants in early Barbados. While not denying the hardships suffered by indentured servants, referring to white servants as slaves deflects the experiences of millions of persons of African birth or descent. We systematically discuss what we believe are the major sociolegal differences and the implications of these differences between indentured servitude and the chattel slavery that uniquely applied to Africans and their descendants.

Abstract In this article we first trace the history of “management,” particularly in the United States, from the plantation to the factory to the corporation, with the intention of understanding and contextualizing “classroom management” in today‘s educational lexicon. To do so, we look at the intertwining history of racial knowledge and the management of enslaved persons; the subsequent development of scientific management; social efficiency educators‘ application of scientific management to education; and conceptions of classroom management in today‘s neoliberal environment, in which education is increasingly positioned as a consumer good subject to individual choice and competitive markets. We further look to examples from post- -colonial Africa to demonstrate the ways in which neocolonial forms of scientific management comingle and entwine with neoliberal policies and procedures. The global phenomenon of scientific management, rife with neoliberalism and racism, is finally examined in the context of (so-called) Culturally Responsive Classroom Management, a neoliberal project that claims to advocate social justice through the process of managing bodies in classrooms.

Abstract Lisa Bowens’s African American Readings of Paul provides a fascinating adventure for all those interested in reception history of Paul and/or the history of the Black Church in the United States. Although also engaging modern scholarship, Bowens allows the historic voices of the Black Church to speak for themselves, thus sometimes challenging paradigms established by earlier scholars working from more limited evidence. When enslaved persons read the Bible, they embraced its liberationist and justice-oriented principles, rescuing Paul from the counterreadings of the slaveholders. Bowens sympathetically highlights the spiritual experiences of historic African American readers, by which they appropriated Paul’s ethos more deeply. Applying the same principles, African American women recognized Paul’s appreciation for women ministry colleagues and so contextualized his apparent prohibitions of women in ministry. The figures treated in this book are of more than historical interest; they often provide models of faithful discipleship and faithful readings of Scripture for readers today.

Stories matter. They matter to those intent on maintaining structures of power and privilege, and to those being crushed by those structures. In the United States, the space to tell, and to hear, our stories has been expanding. This means that the histories and lived realities of those who have been excluded, particularly people of color, are seeping into mainstream discourse, into the books our children read, the movies and television shows they watch, and the many websites comprising social media. Critical race theory has played a role in this expansion. It insists that we recognize the legitimacy of the stories of those deemed “Other” because they have been erased or distorted beyond recognition in the dominant narrative. 3 Critical race theory has helped ensure that the legacies of genocide and broken treaties, of the cruelties imposed upon enslaved persons, of the forced inclusion and exclusion of those regarded simply as disposable labor, have worked their way into the realm of what can be talked about. Critical race scholars have exposed immigration injustices and called out xenophobia and Islamophobia. All this discomfits those who benefit, or believe they benefit, from the status quo.

This study investigated and established the specific features of the legal capacity of minors, as well as cases of granting them full civil legal capacity. The purpose of this study was to cover certain features of the implementation and protection of subjective civil rights of minors within their legal capacity, their emancipation and to develop specific proposals for improving the private law regulation of these relations. The study analysed the provisions of the current Ukrainian legislation on the legal regulation of relations on determining the scope of civil legal capacity of minors, as well as the legislative experience of foreign countries, in particular, France, Germany, Great Britain, the United States, etc. The authors of this study concluded that Ukrainian legislation is heterogeneous in nature, as well as that there are different legislative approaches to determining the age of majority of an individual, and to the scope of powers granted to minors. The study examined the foreign experience of legislative provision of minors with the opportunity to dispose of their property in case of their death, as well as the approach of the Ukrainian legislator in terms of governing these legal relations. Based on the analysis of Article 1234 of the Civil Code of Ukraine (hereinafter referred to as “the CCU”), the authors identified specific features of the right to make a will in terms of determining its subjects and concluded on the absence of legislative prohibition of making a will by a minor who has acquired full civil legal capacity in accordance with the procedure established by law. The position of scientists on the need for statutory consolidation of the ability of minors to make a will was supported, but with certain reservations conditioned by the provisions of the current civil legislation; the authors developed specific proposals for amendments to the CCU. It was concluded that a minor receives the status of a fully capable person in two ways – by granting and acquiring. At the same time, the granting of full civil legal capacity is interpreted as the adoption of an appropriate decision by the competent authority (in this case, the guardianship and custodianship authority or the court) provided the availability of grounds stipulated by law. Therewith, the acquisition of full civil legal capacity in the context of Part 2, Article 34 of the CCU is perceived as the result of independent performance of a legal action by a minor (in this case, marriage), which is stipulated by law and entails legal consequences in the form of obtaining full civil legal capacity without additional authorisation from other persons or the state

While we talk about Law as a profession, it is undoubtedly a vast area with innumerable persons contributing to it across the globe. It is also one of the most challenging professions for it encompasses tough thinking, analysing, reasoning, contemplating as a part of the process or for rendering advisory services, rule or policy making or simply when it comes to representing a client and arguing on behalf in a court of law. As per a report in the United States News’ List for the year 2016, the profession of a lawyer has been seen standing at the rank of 16 among the top 100 best paying jobs and the same stood at 71st rank across the world. Again, it not just the same being group as higher earning that makes it more attractive, the pride of the profession of law also entails the dynamic aspect of the job which is often reflected due to the emergence of several influential leaders of the world from the law background. Starting from the former President of USA, Barack Obama, Russia's President Vladimir Putin, Chinese Premier Li Keqiang, former US President Bill Clinton, former President of Russia, Dmitri Medvedev, managing director of International Monetary Fund (IMF), Christine Lagarde who are the contemporary world leaders worth mentioning to Karl Marx, Mahatma Gandhi and Nelson Mandela are the ones who had earned their highest degree in law and are the seasoned lawyers among others who passed their whole life in pursuit of emancipation of the human beings. Former President of Cuba, Fidel Castro and Former Prime Minister of Singapore, Lee Kuan Yew were also the law practitioners. The current paper is subdivided into various chapters which deals with the concept and development of legal profession, jurisprudential aspect, the role of lawyers in the Indian National Freedom Struggle Movement and their contribution towards nation building.

Abstract This article argues that American jurists fashioned new understandings about the capacity of states to legislate about marriage through regulating the intimate lives of enslaved and newly freed individuals. This article does so through analyzing the creation and impact of a little-studied 1809 law in New York that legalized the marriages of enslaved people—while individuals were still enslaved—as part of the state's process of gradual emancipation, which occurred from 1799 to 1827. In New York, by legalizing enslaved people's marriages, jurists privatized financial liabilities within soon-to-be freed families. The law stood at odds with national juridical understanding about marital regulation. Jurists in the early republic were uncertain about whether states could legislate about matrimony. Southern states after the Civil War then cited and replicated New York's logic in legislating to legalize the marriages of freedpeople, similarly privatizing financial claims within families. In the cases of both New York and national emancipation, jurists, in choosing privatization, foreclosed possibilities for a different or broader vision of state support for freedpeople, such as reparations. After making marital laws about slavery, both New York and Southern states created and/or tightened their marriage laws, further inscribing understandings of the marital family into American governance. This piece contributes to historiographies of slavery, the American state, and intimacy.

Contributing to the expanding examination of the accounting policies that facilitated slavery's persistence in the United States, this study examines the Gradual Abolition Act of 1804 of New Jersey, the last Northern state to emancipate enslaved humans. New Jersey's Act included a provision for payments to white ‘masters’ for the care of children born after the Act to mothers who were – and remained – enslaved. These payments were considered a form of ‘compensated abolition’ and were included in the Act because prior efforts to persuade enslavers in New Jersey to agree to an eventual end to human enslavement had failed. With a focus on the children in Montgomery Township, this article investigates how the State of New Jersey disbursed the funds for this provision, and expands on previous research on the role of accounting for slavery by examining the crucial role states – including Northern states that are often overlooked in studies of United States' slavery – played in perpetuating this brutal system.

The roots of white supremacy lie in the institution of negro slavery. From the 15th through the 19th century, white Europeans trafficked in abducted and enslaved Africans and justified the practice with excuses that seemed somehow to reconcile the injustice with their professed Christianity. The United States was neither the first nor the last nation to abolish slavery, but its proclaimed principles of freedom and equality were made ironic by the nation’s reluctance to extend recognition to all Americans. “Americans” is what Mrs. Child calls those fellow countrymen of African ancestry; citizenship and equality are what she proposed beyond simple abolition. While Mrs. Child expected the Appeal to offend and alienate a significant portion of her large audience, she wrote “it has been strongly impressed upon my mind that it was a duty to fulfil this task; and earthly considerations should never stifle the voice of conscience.” Thirty years before Abraham Lincoln’s Emanicipation Proclamation, she assembled the evidence for liberation and placed it before a large national audience. Her work helped push national emancipation into the mainstream, and her research supplied a generation of later essayists and pamphleteers with essential background for the continuing debate on the most vital issue in American history.

Photo by niu niu on Unsplash ABSTRACT Shackling prisoners has been implemented as standard procedure when transporting prisoners in labor and during childbirth. This procedure ensures the protection of both the public and healthcare workers. However, the act of shackling pregnant prisoners violates the principles of ethics that physicians are supposed to uphold. This paper will explore how shackling pregnant prisoners violates the principle of justice and beneficence, making the practice unethical. INTRODUCTION Some states allow shackling of incarcerated pregnant women during transport and while in the hospital for labor and delivery. Currently, only 22 states have legislation prohibiting the shackling of pregnant women.[1] Although many states have anti-shackling laws prohibiting restraints, these laws also contain an “extraordinary circumstances” loophole.[2] Under this exception, officers shackle prisoners if they pose a flight risk, have any history of violence, and are a threat to themselves or others.[3] Determining as to whether a prisoner is shackled is left solely to the correctional officer.[4] Yet even state restrictions on shackling are often disregarded. In shackling pregnant prisoners during childbirth, officers and institutions are interfering with the ability of incarcerated women to have safe childbirth experiences and fair treatment. Moreover, physicians cannot exercise various ethical duties as the law constrains them. In this article, I will discuss the physical and mental harms that result from the use of restraints under the backdrop of slavery and discrimination against women of color particularly. I argue that stereotypes feed into the phenomenon of shackling pregnant women, especially pregnant women of color. I further assert that shackling makes it difficult for medical professionals to be beneficent and promote justice. BACKGROUND Female incarceration rates in the United States have been fast growing since the 1980s.[5] With a 498 percent increase in the female incarceration population between 1981 and 2021, the rates of pregnancy and childbirth by incarcerated people have also climbed.[6],[7] In 2021, over 1.2 million women were incarcerated in the United States.[8] An estimated 55,000 pregnant women are admitted to jails each year.[9],[10] Many remain incarcerated throughout pregnancy and are transported to a hospital for labor and delivery. Although the exact number of restrained pregnant inmates is unclear, a study found that 83 percent of hospital prenatal nurses reported that their incarcerated patients were shackled.[11] I. Harms Caused by Shackling Shackling has caused many instances of physical and psychological harm. In the period before childbirth, shackled pregnant women are at high risk for falling.[12] The restraints shift pregnant women’s center of gravity, and wrist restraints prevent them from breaking a fall, increasing the risk of falling on their stomach and harming the fetus.[13] Another aspect inhibited by using restraints is testing and treating pregnancy complications. Delays in identifying and treating conditions such as hypertension, pre-eclampsia, appendicitis, kidney infection, preterm labor, and especially vaginal bleeding can threaten the lives of the mother and the fetus.[14] During labor and delivery, shackling prevents methods of alleviating severe labor pains and giving birth.[15] Usually, physicians recommend that women in labor walk or assume various positions to relieve labor pains and accelerate labor.[16] However, shackling prevents both solutions.[17] Shackling these women limits their mobility during labor, which may compromise the health of both the mother and the fetus.[18] Tracy Edwards, a former prisoner who filed a lawsuit for unlawful use of restraints during her pregnancy, was in labor for twelve hours. She was unable to move or adjust her position to lessen the pain and discomfort of labor.[19] The shackles also left the skin on her ankles red and bruised. Continued use of restraints also increases the risk of potentially life-threatening health issues associated with childbirth, such as blood clots.[20] It is imperative that pregnant women get treated rapidly, especially with the unpredictability of labor. Epidural administration can also become difficult, and in some cases, be denied due to the shackled woman’s inability to assume the proper position.[21] Time-sensitive medical care, including C-sections, could be delayed if permission from an officer is required, risking major health complications for both the fetus and the mother.[22] After childbirth, shackling impedes the recovery process. Shackling can result in post-delivery complications such as deep vein thrombosis.[23] Walking prevents such complications but is not an option for mothers shackled to their hospital beds.[24] Restraints also prevent bonding with the baby post-delivery and the safe handling of the baby while breast feeding.[25] The use of restraints can also result in psychological harm. Many prisoners feel as though care workers treat them like “animals,” with some women having multiple restraints at once— including ankles, wrists, and even waist restraints.[26] Benidalys Rivera describes the feeling of embarrassment as she was walking while handcuffed, with nurses and patients looking on, “Being in shackles, that make you be in stress…I about to have this baby, and I’m going to go back to jail. So it’s too much.”[27] Depression among pregnant prisoners is highly prevalent. The stress of imprisonment and the anticipation of being separated from their child is often overwhelming for these mothers.[28] The inhumane action has the potential to add more stress, anxiety, and sadness to the already emotionally demanding process of giving birth. Shackling pregnant prisoners displays indifference to the medical needs of the prisoner.[29] II. Safety as a Pretense While public safety is an argument for using shackles, several factors make escape or violence extremely unlikely and even impossible.[30] For example, administering epidural anesthesia causes numbness and eliminates flight risk.[31] Although cited as the main reason for using shackles, public safety is likely just an excuse and not the main motivator for shackling prisoners. I argue that underlying the shackling exemplifies the idea that these women should not have become pregnant. The shackling reflects a distinct discrimination: the lawmakers allowing it perhaps thought that people guilty of crimes would make bad mothers. Public safety is just a pretense. The language used to justify the use of restraint of Shawanna Nelson, the plaintiff in Nelson v. Correctional Medical Services, discussed below, included the word “aggressive.”[32] In her case, there was no evidence that she posed any danger or was objectively aggressive. Officer Turnesky, who supervised Nelson, testified that she never felt threatened by Nelson.[33] The lack of documented attempts of escape and violence from pregnant prisoners suggests that shackling for flight risk is a false pretense and perhaps merely based on stereotypes.[34] In 2011, an Amnesty International report noted that “Around the USA, it is common for restraints to be used on sick and pregnant incarcerated women when they are transported to and kept in hospital, regardless of whether they have a history of violence (which only a minority have) and regardless of whether they have ever absconded or attempted to escape (which few women have).”[35] In a 2020 survey of correctional officers in select midwestern prisons, 76 percent disagreed or strongly disagreed with restraining pregnant women during labor and delivery.[36] If a correctional officer shackles a pregnant prisoner, it is not because they pose a risk but because of a perception that they do. This mindset is attributed to select law enforcement, who have authority to use restraints.[37] In 2022, the Tennessee legislature passed a bill prohibiting the use of restraints on pregnant inmates. However, legislators amended the bill due to the Tennessee Sherriff Association’s belief that even pregnant inmates could pose a “threat.”[38] Subjecting all prisoners to the same “precautions” because a small percentage of individuals may pose such risks could reflect stereotyping or the assumption that all incarcerated people pose danger and flight risk. To quell the (unjustified) public safety concern, there are other options that do not cause physical or mental harm to pregnant women. For example, San Francisco General Hospital does not use shackles but has deputy sheriffs outside the pregnant women’s doors.[39] III. Historical Context and Race A. Slavery and Post-Civil War The treatment of female prisoners has striking similarities to that of enslaved women. Originally, shackling of female slaves was a mechanism of control and dehumanization.[40] This enabled physical and sexual abuses. During the process of intentionally dehumanizing slaves to facilitate subordination, slave owners stripped slave women of their feminine identity.[41] Slave women were unable to exhibit the Victorian model of “good mothering” and people thought they lacked maternal feelings for their children.[42] In turn, societal perception defeminized slave women, and barred them from utilizing the protections of womanhood and motherhood. During the post-Civil War era, black women were reversely depicted as sexually promiscuous and were arrested for prostitution more often than white women.[43] In turn, society excluded black women; they were seen as lacking what the “acceptable and good” women had.[44] Some argue that the historical act of labeling black women sexually deviant influences today’s perception of black women and may lead to labeling them bad mothers.[45] Over two-thirds of incarcerated women are women of color.[46] Many reports document sexual violence and misconduct against prisoners over the years.[47] Male guards have raped, sexually assaulted, and inappropriately touched female prisoners. Some attribute the physical abuse of black female prisoners to their being depicted or stereotyped as “aggressive, deviant, and domineering.”[48] Some expect black women to express stoicism and if they do not, people label them as dangerous, irresponsible, and aggressive.[49] The treatment of these prisoners mirrors the historical oppression endured by black women during and following the era of slavery. The act of shackling incarcerated pregnant women extends the inhumane treatment of these women from the prison setting into the hospital. One prisoner stated that during her thirty-hour labor, while being shackled, she “felt like a farm animal.”[50] Another pregnant prisoner describes her treatment by a guard stating: “a female guard grabbed me by the hair and was making me get up. She was screaming: ‘B***h, get up.’ Then she said, ‘That is what happens when you are a f***ing junkie. You shouldn’t be using drugs, or you wouldn’t be in here.”[51] Shackling goes beyond punishing by isolation from society – it is an additional punishment that is not justified. B. Reproductive Rights and “Bad Mothers” As with slaves not being seen as maternal, prisoners are not viewed as “real mothers.” A female prison guard said the following: “I’m a mother of two and I know what that impulse, that instinct, that mothering instinct feels like. It just takes over, you would never put your kids in harm’s way. . . . Women in here lack that. Something in their nature is not right, you know?”[52] This comment implies that incarcerated women lack maternal instinct. They are not in line with the standards of what society accepts as a “woman” and “mother” and are thought to have abandoned their roles as caretakers in pursuit of deviant behaviors. Without consideration of racial discrimination, poverty issues, trauma, and restricted access to the child right after delivery, these women are stereotyped as bad mothers simply because they are in prison. Reminiscent of the treatment of female black bodies post-civil war and the use of reproductive interventions (for example, Norplant and forced sterilization) in exchange for shorter sentences, I argue that shackles are a form of reproductive control. Justification for the use of shackles even includes their use as a “punitive instrument to remind the prisoner of their punishment.”[53] However, a prisoner’s pregnancy should have no relevance to their sentence.[54] Using shackles demonstrates to prisoners that society tolerates childbirth but does not support it.[55] The shackling is evidence that women are being punished “for bearing children, not for breaking the law.”[56] Physicians and healthcare workers, as a result, are responsible for providing care for the delivery and rectifying any physical problems associated with the restraints. The issues that arise from the use of restraints place physicians in a position more complex than they experience with regular healthy pregnancies. C. Discrimination In the case of Ferguson v. City of Charleston, a medical university subjected black woman to involuntary drug testing during pregnancy. In doing so, medical professionals collaborated with law enforcement to penalize black women for their use of drugs during pregnancy.[57] The Court held the drug tests were an unreasonable search and violated the Fourth Amendment. Ferguson v. City of Charleston further reveals an unjustified assumption: the medical and legal community seemed suspicious of black women and had perhaps predetermined them more likely to use drugs while pregnant. Their fitness to become mothers needed to be proven, while wealthy, white women were presumed fit.[58] The correctional community similarly denies pregnant prisoners’ medical attention. In the case of Staten v. Lackawanna County, an African American woman whose serious medical needs were treated indifferently by jail staff was forced to give birth in her cell.[59] This woman was punished for being pregnant in prison through the withholding of medical attention and empathy. IV. Failure to Follow Anti-Shackling Laws Despite 22 states having laws against shackling pregnant prisoners, officers do not always follow these laws. In 2015, the Correctional Association of New York reported that of the 27 women who gave birth under state custody, officers shackled 23 women in violation of the anti-shackling laws.[60] The lawyer of Tracy Edwards, an inmate who officers shackled unlawfully during her twelve-hour labor stated, “I don’t think we can assume that just because there’s a law passed, that’s automatically going to trickle down to the prison.”[61] Even with more restrictions on shackling, it may still occur, partly due to the stereotype that incarcerated women are aggressive and dangerous. V. Constitutionality The Eighth Amendment protects people from cruel and unusual punishment. In Brown vs. Plata, the court stated, “Prisoners retain the essence of human dignity inherent in all persons.”[62] In several cases, the legal community has held shackling to be unconstitutional as it violates the Eighth Amendment unless specifically justified. In the case of Nelson v. Correctional Medical Services, a pregnant woman was shackled for 12 hours of labor with a brief respite while she pushed, then re-shackled. The shackling caused her physical and emotional pain, including intense cramping that could not be relieved due to positioning and her inability to get up to use a toilet.[63] The court held that a clear security concern must justify shackling. The court cited a similar DC case and various precedents for using the Eighth Amendment to hold correctional facilities and hospitals accountable.[64] An Arkansas law similarly states that shackling must be justified by safety or risk of escape.[65] If the Thirteenth Amendment applied to those convicted of crimes, shackling pregnant incarcerated people would be unconstitutional under that amendment as well as the Eighth. In the Civil Rights Cases, Congress upheld the right “to enact all necessary and proper laws for the obliteration and prevention of slavery with all its badges and incidents.”[66] Section two of the Thirteenth Amendment condemns any trace or acts comparable to that of slavery. Shackling pregnant prisoners, stripping them of their dignity, and justification based on stereotypes all have origins in the treatment of black female slaves. Viewed through the lens of the Thirteenth Amendment, the act of shackling would be unconstitutional. Nonetheless, the Thirteenth Amendment explicitly excludes people convicted of a crime. VI. Justice As a result of the unconstitutional nature of shackling, physicians should have a legal obligation, in addition to their ethical duty, to protect their patients. The principle of justice requires physicians to take a stand against the discriminatory treatment of their patients, even under the eye of law enforcement.[67],[68] However, “badge and gun intimidation,” threats of noncompliance, and the fear of losing one’s license can impede a physician’s willingness to advocate for their patients. The American College of Obstetricians and Gynecologists (ACOG) finds the use of physical restraints interferes with the ability of clinicians to practice medicine safely.[69] ACOG, The American Medical Association, the National Commission on Correctional Health Care, and other organizations oppose using restraints on pregnant incarcerated people.[70] Yet, legislators can adopt shackling laws without consultation with physicians. The ACOG argues that “State legislators are taking it upon themselves to define complex medical concepts without reference to medical evidence. Some of the penalties [faced by OBGYNs] for violating these vague, unscientific laws include criminal sentences.”[71] Legislation that does not consider medical implications or discourages physicians’ input altogether is unjust. In nullifying the voice of a physician in matters pertaining to the patient’s treatment, physicians are prevented from fulfilling the principle of justice, making the act of shackling patients unethical. VII. Principle of Beneficence The principle of beneficence requires the prevention of harm, the removal of harm, and the promotion of good.[72] Beneficence demands the physician not only avoid harm but benefit patients and promote their welfare.[73] The American Board of Internal Medicine Foundation states that physicians must work with other professionals to increase patient safety and improve the quality of care.[74] In doing so, physicians can adequately treat patients with the goal of prevention and healing. It is difficult to do good when law enforcement imposes on doctors to work around shackles during labor and delivery. Law enforcement leaves physicians and healthcare workers responsible not only to provide care for the delivery, but also rectify any ailments associated with the restraints. The issues arising from using restraints place physicians in a position more complex than they experience with other pregnancies. Doctors cannot prevent the application of the shackles and can only request officers to take them off the patient.[75] Physicians who simply go along with shackling are arguably violating the principle of beneficence. However, for most, rather than violating the principle of beneficence overtly, physicians may simply have to compromise. Given the intricate nature of the situation, physicians are tasked with minimizing potential harm to the best of their abilities while adhering to legal obligations.[76] It is difficult to pin an ethics violation on the ones who do not like the shackles but are powerless to remove them. Some do argue that this inability causes physicians to violate the principle of beneficence.[77] However, promoting the well-being of their patients within the boundaries of the law limits their ability to exercise beneficence. For physicians to fulfill the principle of beneficence to the fullest capacity, they must have an influence on law. Protocols and assessments on flight risks made solely by the officers and law enforcement currently undermine the physician’s expertise. These decisions do not consider the health and well-being of the pregnant woman. As a result, law supersedes the influence of medicine and health care. CONCLUSION People expect physicians to uphold the four major principles of bioethics. However, their inability to override restraints compromises their ability to exercise beneficence. Although pledging to enforce these ethical principles, physicians have little opportunity to influence anti-shackling legislation. Instead of being included in conversations regarding medical complexities, legislation silences their voices. Policies must include the physician's voice as they affect their ability to treat patients. Officers should not dismiss a physician's request to remove shackles from a woman if they are causing health complications. A woman's labor should not harm her or her fetus because the officer will not remove her shackles.[78] A federal law could end shackling pregnant incarcerated people. Because other options are available to ensure the safety of the public and the prisoner, there is no ethical justification for shackling pregnant prisoners. An incarcerated person is a human being and must be treated with dignity and respect. To safeguard the well-being of incarcerated women and the public, it is essential for advocates of individual rights to join forces with medical professionals to establish an all-encompassing solution. - [1] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). Where does your state stand on shackling of Pregnant Incarcerated Women? Nursing for Women’s Health, 22(1), 17–23. https://doi.org/10.1016/j.nwh.2017.12.005 [2] S983A, 2015-2016 Regular Sessions (N.Y. 2015). https://legislation.nysenate.gov/pdf/bills/2015/S983A [3] Chris DiNardo, Pregnancy in Confinement, Anti-Shackling Laws and the “Extraordinary Circumstances” Loophole, 25 Duke Journal of Gender Law & Policy 271-295 (2018) https://scholarship.law.duke.edu/djglp/vol25/iss2/5 [4] Chris DiNardo (2018) [5] U.S. Bureau of Justice Statistics. 1980. " Prisoners in 1980 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/content/pub/pdf/p80.pdf). [6] U.S. Bureau of Justice Statistics. 2022. " Prisoners in 2021 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/p21st.pdf). [7] U.S. Bureau of Justice Statistics (1980) [8] Sufrin C, Jones RK, Mosher WD, Beal L. Pregnancy Prevalence and Outcomes in U.S. Jails. Obstet Gynecol. 2020;135(5):1177-1183. doi:10.1097/AOG.0000000000003834 [9] Kramer, C., Thomas, K., Patil, A., Hayes, C. M., & Sufrin, C. B. (2022). Shackling and pregnancy care policies in US prisons and jails. Maternal and Child Health Journal, 27(1), 186–196. https://doi.org/10.1007/s10995-022-03526-y [10] House, K. T., Kelley, S., Sontag, D. N., & King, L. P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.364 [11] Goshin, L. S., Sissoko, D. R., Neumann, G., Sufrin, C., & Byrnes, L. (2019). Perinatal nurses’ experiences with and knowledge of the care of incarcerated women during pregnancy and the postpartum period. Journal of Obstetric, Gynecologic &amp; Neonatal Nursing, 48(1), 27–36. https://doi.org/10.1016/j.jogn.2018.11.002 [12] Shackling and separation: Motherhood in prison. (2013). AMA Journal of Ethics, 15(9), 779–785. https://doi.org/10.1001/virtualmentor.2013.15.9.pfor2-1309 [13] King, L. (2018). Labor in chains: The shackling of pregnant inmates. Policy Perspectives, 25, 55–68. https://doi.org/10.4079/pp.v25i0.18348 [14] King, L. (2018). [15] AMA Journal of Ethics (2013) [16] Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews, (8). [17] Association of Women’s Health, Obstetric and Neonatal Nurses. (2011). AWHONN position statement: Shackling incarcerated pregnant women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(6), 817–818. doi:10.1111/j.1552-6909.2011.01300.x [18] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). Where does your state stand on shackling of Pregnant Incarcerated Women? Nursing for Women’s Health, 22(1), 17–23. https://doi.org/10.1016/j.nwh.2017.12.005 [19] Thompson, E. (2022, August 30). Woman sues NC state prison system for mistreatment while pregnant. North Carolina Health News. Retrieved March 12, 2023, from https://www.northcarolinahealthnews.org/2022/05/25/woman-sues-nc-state-prison-system-for-mistreatment-while-pregnant/ [20] CBS Interactive. (2019, March 13). Shackling pregnant inmates is still a practice in many states. CBS News. Retrieved March 12, 2023, from https://www.cbsnews.com/news/shackling-pregnant-inmates-is-still-a-practice-in-many-states/ [21] Griggs, Claire Louise. "Birthing Barbarism: The Unconstitutionality of Shackling Pregnant Prisoners." American University Journal of Gender Social Policy and Law 20, no. 1 (2011): 247-271. [22] American Civil Liberties Union. (2012, October 12). ACLU briefing paper: The shackling of pregnant women & girls in U.S ... American Civil Liberties Union (ACLU). https://www.aclu.org/wp-content/uploads/legal-documents/anti-shackling_briefing_paper_stand_alone.pdf [23] King.L (2018) [24] Griggs, Claire Louise (2011) [25] American Civil Liberties Union. (2012) [26] Clarke, J. G., & Simon, R. E. (2013). Shackling and separation: Motherhood in prison. AMA Journal of Ethics, 15(9), 779–785. https://doi.org/10.1001/virtualmentor.2013.15.9.pfor2-1309 [27] Berg, M. D. (2014, April 18). Pregnant prisoners are losing their shackles - The Boston Globe. BostonGlobe.com. Retrieved March 12, 2023, from https://www.bostonglobe.com/magazine/2014/04/18/taking-shackles-off-pregnant-prisoners/7t7r8yNBcegB8eEy1GqJwN/story.html [28] Levi, R., Kinakemakorn, N., Zohrabi, A., Afanasieff, E., & Edwards-Masuda, N. (2010). Creating the bad mother: How the U.S. approach to pregnancy in prisons violates the right to be a mother. UCLA Women's Law Journal, 18(1). https://doi.org/10.5070/l3181017816 [29] Chris DiNardo (2018) [30] Griggs, Claire Louise (2011). [31] Allen, J. E. (2010, October 21). Shackled: Women Behind Bars Deliver in Chains. ABC News. https://abcnews.go.com/Health/WomensHealth/pregnant-shackled-women-bars-deliver-chains/story?id=11933376&page=1 [32] Nelson v. Correctional, 533 F.3d 958 (8th Cir. 2009) [33] Nelson v. Correctional(2009) [34] House, K. T., Kelley, S., Sontag, D. N., & King, L. P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.364 [35] Amnesty International USA. (1999, March). “Not part of my sentence” Violations of the Human Rights of Women in Custody. Amnesty International USA. Retrieved March 12, 2023, from https://www.amnestyusa.org/reports/usa-not-part-of-my-sentence-violations-of-the-human-rights-of-women-in-custody/ [36] Pendleton, V., Saunders, J. B., & Shlafer, R. (2020). Corrections officers' knowledge and perspectives of maternal and child health policies and programs for pregnant women in prison. Health & justice, 8(1), 1. https://doi.org/10.1186/s40352-019-0102-0 [37] Elizabeth Alexander, Unshackling Shawanna: The Battle Over Chaining Women Prisoners during Labor and Delivery, 32 U. ARK. LITTLE ROCK L. REV. 435 (2010). Available at: https://lawrepository.ualr.edu/lawreview/vol32/iss4/1 [38] Hernandez, J. (2022, April 22). More states are restricting the shackling of pregnant inmates, but it still occurs. NPR. Retrieved March 12, 2023, from https://www.npr.org/2022/04/22/1093836514/shackle-pregnant-inmates-tennessee [39] Sufrin, C. (2012, June 24). End practice of shackling pregnant inmates. SFGATE. Retrieved March 12, 2023, from https://www.sfgate.com/opinion/openforum/article/End-practice-of-shackling-pregnant-inmates-3176987.php [40] Mullings, L. (1997). On our own terms: Race, class, and gender in the lives of African American women. Routledge [41] Ocen, Priscilla A., (2011). [42] Ladd-Taylor, M. (1998). "Bad" mothers: The politics of blame in Twentieth-century America. New York Univ. Press. [43] Hine, D. C. (1998). Hine Sight: Black women and the re-construction of American history. Indiana University Press. [44] Baldwin, L. (2019). Excluded from good motherhood and the impact of prison: Motherhood and Social Exclusion, 129–144. https://doi.org/10.2307/j.ctvk12qxr.13 [45] Ocen, Priscilla A., Punishing Pregnancy: Race, Incarceration, and the Shackling of Pregnant Prisoners (October 3, 2011). California Law Review, Vol. 100, 2012, Available at SSRN: https://ssrn.com/abstract=1937872 [46] Johnson, P. C. (2004). Inner lives: Voices of african american women in prison. New York University Press. [47] Thomas, D. Q. (1996). All too familiar: Sexual abuse of women in U.S. state prisons. Human Rights Watch. [48] Ocen, Priscilla A., (2011). [49] Ashley W. The angry black woman: the impact of pejorative stereotypes on psychotherapy with black women. Soc Work Public Health. 2014;29(1):27-34. doi: 10.1080/19371918.2011.619449. PMID: 24188294. [50] CBS Interactive. (2019, March 13). Shackling pregnant inmates is still a practice in many states. CBS News. Retrieved March 12, 2023, from https://www.cbsnews.com/news/shackling-pregnant-inmates-is-still-a-practice-in-many-states/ [51] Guardian News and Media. (2020, January 24). Pregnant and shackled: Why inmates are still giving birth cuffed and bound. The Guardian. Retrieved March 25, 2023, from https://www.theguardian.com/us-news/2020/jan/24/shackled-pregnant-women-prisoners-birth [52] Oparah, J. C. (2015). Birthing justice: Black women, pregnancy, and childbirth. Routledge. [53] Chris DiNardo (2018) [54] Griggs, Claire Louise (2011). [55] Chris DiNardo (2018) [56] Griggs, Claire Louise (2011). [57] Song, Ji Seon, Policing the Emergency Room (June 10, 2021). 134 Harvard Law Review 2646 (2021), Available at SSRN: https://ssrn.com/abstract=3864225 [58] Ocen, Priscilla A., (2011). [59] Staten v. Lackawanna Cnty., No. 4:07-CV-1329, 2008 WL 249988, at *2 (M.D. Pa. Jan. 29, 2008) [60] Lovett, K. (2018, April 9). Pregnant inmates at New York prisons will no longer be shackled under new law. New York Daily News. Retrieved March 12, 2023, from https://www.nydailynews.com/new-york/new-york-pregnant-inmates-no-longer-shackled-article-1.2474021 [61] Thompson, E. (2022, August 30). Woman sues NC state prison system for mistreatment while pregnant. North Carolina Health News. Retrieved March 12, 2023, from https://www.northcarolinahealthnews.org/2022/05/25/woman-sues-nc-state-prison-system-for-mistreatment-while-pregnant/ [62] Brown v. Plata, 563 U.S. 493 (2011) [63] Nelson v. Correctional Medical Serices, et al., Nelson v. Correctional Med. Servs, 583 F.3d 522 (8th Cir. 2009) [64] Nelson citing Women Prisoners of D.C. Dep't of Corr. v. District of Columbia, 877 F.Supp. 634, 668-69 (D.D.C. 1994), modified in part on other grounds, 899 F.Supp. 659 (D.D.C. 1995). [65] Ark. Dep't of Corr. Admin. Reg. 403 § V (1992) [66] Civil Rights Cases, 109 U.S. 3 (1883) [67] Physician charter. ABIM Foundation. (2022, October 18). Retrieved March 10, 2023, from https://abimfoundation.org/what-we-do/physician-charter#:~:text=Principle%20of%20social%20justice.&text=Physicians%20should%20work%20actively%20to,or%20any%20other%20social%20category. [68] Riddick FA Jr. The code of medical ethics of the american medical association. Ochsner J. 2003 Spring;5(2):6-10. PMID: 22826677; PMCID: PMC3399321. [69] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). Reproductive Health Care for Incarcerated Pregnant, Postpartum, and Nonpregnant Individuals: ACOG Committee Opinion, Number 830. Obstetrics and gynecology, 138(1), e24–e34. https://doi.org/10.1097/AOG.0000000000004429 [70] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). [71] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). [72] Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics. Oxford University Press. [73] Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119 [74] Medical professionalism in the new millennium: A physician charter. (2002). Annals of Internal Medicine, 136(3), 243. https://doi.org/10.7326/0003-4819-136-3-200202050-00012 [75] Allen, J. E. (2010, October 21). Shackled: Women Behind Bars Deliver in Chains. ABC News. https://abcnews.go.com/Health/WomensHealth/pregnant-shackled-women-bars-deliver-chains/story?id=11933376&page=1 [76] Jonsen, A. R. (2010). The Birth of Bioethics. Oxford University Press. [77] Beauchamp, T. L., & Childress, J. F. (2019). [78] Amnesty International USA. (1999, March). “Not part of my sentence” Violations of the Human Rights of Women in Custody. Amnesty International USA. Retrieved March 12, 2023, from https://www.amnestyusa.org/reports/usa-not-part-of-my-sentence-violations-of-the-human-rights-of-women-in-custody/

Photo by Sharon McCutcheon on Unsplash ABSTRACT COVID-19 highlighted a disproportionate impact upon marginalized communities that needs to be addressed. Specifically, a focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can provide this great benefit but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. INTRODUCTION COVID-19 disproportionately impacted communities of color and lower socioeconomic status, sparking political discussion about existing inequities in the US.[1] Some states amended their guidelines for allocating resources, including vaccines, to provide care for marginalized communities experiencing these inequities, but there has been no clear consensus on which guidelines states should amend or how they should be ethically grounded. In part, this is because traditional justice theories do not acknowledge the deep-seated institutional and interpersonal discrimination embedded in our medical system. Therefore, a revamped distributive justice approach that accounts for these shortcomings is needed to guide healthcare decision-making now and into the post-COVID era. BACKGROUND Three terms – health disparity, health inequities, and health equity – help frame the issue. A health disparity is defined as any difference between populations in terms of disease incidence or adverse health events, such as morbidity or mortality. In contrast, health inequities are health disparities due to avoidable systematic structures rooted in racial, social, and economic injustice.[2] For example, current data demonstrate that Black, Latino, Indigenous Americans, and those living in poverty suffer higher morbidity and mortality rates from COVID-19.[3] Finally, health equity is the opportunity for anyone to attain his or her full health potential without interference from systematic structures and factors that generate health inequities, including race, socioeconomic status, gender, ethnicity, religion, sexual orientation, or geography.[4] ANALYSIS Health inequities for people of color with COVID-19 have led to critiques of states that do not account for race in their resource allocation guidelines.[5] For example, the Massachusetts Department of Public Health revised its COVID-19 guidelines regarding resource allocation to patients with the best chance of short-term survival.[6] Critics have argued that this change addresses neither preexisting structural inequities nor provider bias that may have led to comorbidities and increased vulnerability to COVID-19. By failing to address race specifically, they argue the policy will perpetuate poorer outcomes in already marginalized groups. As the inequities in COVID-19 outcomes continue to be uncovered and the data continue to prove that marginalized communities suffered disproportionately, we, as healthcare providers, must reconsider our role in addressing the injustices. Our actions must be ethically grounded in the concept of justice. l. Primary Theories of Justice The principle of justice in medical ethics relates to how we ought to treat people and allocate resources. Multiple theories have emerged to explain how justice should be implemented, with three of the most prominent being egalitarianism, utilitarianism, and distributive. This paper argues that distributive justice is the best framework for remedying past actions and enacting systemic changes that may persistently prevent injustices. An egalitarian approach to justice states all individuals are equal and, therefore, should have identical access to resources. In the allocation of resources, an egalitarian approach would support a strict distribution of equal value regardless of one’s attributes or characteristics. Putting this theory into practice would place a premium on guidelines based upon first-come, first-served basis or random selection.[7] However, the egalitarian approach taken in the UK continues to worsen health inequities due to institutional and structural discrimination.[8] A utilitarian approach to justice emphasizes maximizing overall benefits and achieving the greatest good for the greatest number of people. When resources are limited, the utilitarian principle historically guides decision-making. In contrast to the egalitarian focus on equal distribution, utilitarianism focuses on managing distributions to maximize numerical outcomes. During the COVID-19 pandemic, guidelines for allocating resources had utilitarian goals like saving the most lives, which may prioritize the youthful and those deemed productive in society, followed by the elderly and the very ill. It is important to reconsider using utilitarian approaches as the default in the post-COVID healthcare community. These approaches fail to address past inequity, sacrificing the marginalized in their emphasis on the greatest amount of good rather than the type of good. Finally, a distributive approach to justice mandates resources should be allocated in a manner that does not infringe individual liberties to those with the greatest need. Proposed by John Rawls in a Theory of Justice, this approach requires accounting for societal inequality, a factor absent from egalitarianism and utilitarianism.[9] Naomi Zack elaborates how distributive justice can be applied to healthcare, outlining why racism is a social determinant of health that must be acknowledged and addressed.[10] Until there are parallel health opportunities and better alignment of outcomes among different social and racial groups, the underlying systemic social and economic variables that are driving the disparities must be fixed. As a society and as healthcare providers, we should be striving to address the factors that perpetuate health inequities. While genetics and other variables influence health, the data show proportionately more exposure, more cases, and more deaths in the Black American and Hispanic populations. Preexisting conditions and general health disparities are signs of health inequity that increased vulnerability. Distributive justice as a theoretical and applied framework can be applied to preventable conditions that increase vulnerability and can justify systemic changes to prevent further bias in the medical community. During a pandemic, egalitarian and utilitarian approaches to justice are prioritized by policymakers and health systems. Yet, as COVID-19 has demonstrated, they further perpetuate the death and morbidity of populations that face discrimination. These outcomes are due to policies and guidelines that overall benefit white communities over communities of color. Historically, US policy that looks to distribute resources equally (focusing on equal access instead of outcomes), in a color-blind manner, has further perpetuated poor outcomes for marginalized communities.[11] ll. Historical and Ongoing Disparities Across socio-demographic groups, the medical system exacerbates historical and current inequities. Members of marginalized races,[12] women,[13] LGBTQ people,[14] and poor people[15] experience trauma caused by discrimination, marginalization, and failure to access high-quality public and private goods. Through the unequal treatment of marginalized communities, these historic traumas continue. In the US, people of color do not receive equal and fair medical treatment. A meta-analysis found that Hispanics and Black Americans were significantly undertreated for pain compared to their white counterparts over the last 20 years.[16] This is partly due to provider bias. Through interviewing medical trainees, a study by the National Academy of Science found that half of medical students and residents harbored racist beliefs such as “Black people’s nerve endings are less sensitive than white people’s” or “Black people’s skin is thicker than white people’s skin.”[17] More than 3,000 Indigenous American women were coerced, threatened, and deliberately misinformed to ensure cooperation in forced sterilization.[18] Hispanic people have less support in seeking medical care, in receiving culturally appropriate care, and they suffer from the medical community’s lack of resources to address language barriers.[19] In the US, patients of different sexes do not receive the same quality of healthcare. Despite having greater health needs, middle-aged and older women are more likely to have fewer hospital stays and fewer physician visits compared to men of similar demographics and health risk profiles.[20] In the field of critical care, women are less likely to be admitted to the ICU, less likely to receive interventions such as mechanical ventilation, and more likely to die compared to their male ICU counterparts.[21] In the US, patients of different socioeconomic statuses do not receive the same quality of healthcare. Low-income patients are more likely to have higher rates of infant mortality, chronic disease, and a shorter life span.[22] This is partly due to the insurance-based discrimination in the medical community.[23] One in three deaths of those experiencing homelessness could have been prevented by timely and effective medical care. An individual experiencing homelessness has a life expectancy that is decades shorter than that of the average American.[24] lll. Action Needed: Policy Reform While steps need to be taken to provide equitable care in the current pandemic, including the allocation of vaccines, they may not address the historical failures of health policy, hospital policy, and clinical care to eliminate bias and ensure equal treatment of patients. According to an applied distributive justice framework, inequities must be corrected. Rather than focusing primarily on fair resource allocation, medicine must be actively anti-racist, anti-sexist, anti-transphobic, and anti-discriminatory. Evidence has shown that the health inequities caused by COVID-19 are smaller in regions that have addressed racial wealth gaps through forms of reparations.[25] Distributive justice calls for making up for the past using tools of allocation as well as tools to remedy persistent problems. For example, Brigham and Women’s Hospital in Boston, MA, began “Healing ARC,” a pilot initiative that involves acknowledgement, redress, and closure on an institutional level.[26] Acknowledgement entails informing patients about disparities at the hospital, claiming responsibility, and incorporating community ideas for redress. Redress involves a preferential admission option for Black and Hispanic patients to specialty services, especially cardiovascular services, rather than general medicine. Closure requires that community and patient stakeholders work together to ensure that a new system is in place that will continue to prioritize equity. Of note, redress could take the form of cash transfers, discounted or free care, taxes on nonprofit hospitals that exclude patients of color,[27] or race-explicit protocol changes (such as those being instituted by Brigham and Women’s Hospital that admit patients historically denied access to certain forms of medical care). In New York, for instance, the New York State Bar Association drafted the COVID-19 resolutions to ensure that emergency regulations and guidelines do not discriminate against communities of color, and even mandate that diverse patient populations be included in clinical trials.[28] Also, physicians must listen to individuals from marginalized communities to identify needs and ensure that community members take part in decision-making. The solution is not to simply build new health centers in communities of color, as this may lead to tiers of care. Rather, local communities should have a chance to impact existing hospital policy and should also use their political participation to further their healthcare interests. Distributive justice does not seek to disenfranchise groups that hold power in the system. It aims to transform the system so that those in power do not continue to obtain unfair benefits at the expense of others. The framework accounts for unjust historical oppression and current injustices in our system to provide equitable outcomes to all who access the system. In this vein, we can begin to address the flagrant disparities between communities that have always – and continue to – exist in healthcare today.[29] CONCLUSION As equality focuses on access, it currently fails to do justice. Instead of outcomes, it is time to focus on equity. A focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can gain traction in clinical decision-making guidelines and system-level reallocation of resources but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. 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