By Michael T. Puerini, MD, CCHP-A, and Dean Rieger, MD, MPH, CCHP
Posted on September 29, 2010 – A 30-year-old man with known paranoid schizophrenia is incarcerated after being found guilty of murdering his family. While in jail, he murdered a security officer with a shank that he bought from another inmate. He refused to take his meds and was placed in an isolation cell, where he lived for six months while awaiting trial. His mental condition, which initially showed paranoia and mild auditory hallucinations, deteriorated. Forced psychotropic meds by injection were initiated, with partial results. He still was paranoid and hallucinatory, although clearly improved. He received a lengthy sentence and was remanded to the state institution. There, he did not follow instructions, had repeated rules infractions, and was seen by security as a danger and a risk to the safety of the institution. He remained in isolation in the supermax section of the prison. His institution psychiatrist sees him and changes his injectable medication with little improvement. The psychiatrist wonders if there might be further improvement with socialization, group and milieu therapies. He suggests this form of treatment with a trial out of isolation to the institution security officials, appealing the negative decision to the warden. The psychiatrist’s opinion is rejected based on safety concerns, and the patient continues in indefinite isolation confinement in the supermax.
In this case, principles of medical autonomy are superceded by the institution’s perceived duty to use best judgment to maintain a secure environment in the institution. The human right to safety of other inmates and security officers are deemed more essential than the rights of the patient in question. The psychiatrist has behaved ethically by being her patient’s advocate. In this case, principles of beneficence and nonmalfeasance give way to ensuring a safe environment for others in the prison.
The question remains: How can clinicians balance their ethical duties against the safety values of the institution? Isolation, solitary confinement and various forms of restraint are commonly used as the way to deal with difficult or dangerous prisoners in lock ups, sometimes for extended periods of time. Commonly enough, these prisoners have serious mental illness. It has been proposed that prolonged isolation of those with serious mental illness is cruel and unusual punishment, and that physicians and medical groups should speak out more forcefully against the practice1.
In order to formulate policy, physician groups should recognize that, on the ground, we do not occupy a black and white world. We must develop definitions for terms such as prolonged isolation and severe mental illness. We must propose tenable solutions for the ethical dilemmas that face clinicians and administrators inside correctional institutions across America. If jails and prisons are the New Asylums, we must formulate effective balanced policies that address these dilemmas. Arbitrary thinking and rigid policies probably will not work.
Dr. Puerini is the Chief Medical Officer for the Oregon State Correctional Insitution in Salem, Oregon. Dr. Rieger is the Corporate Medical Director for Correct Care Solutions in Nashville, Tennessee. Readers may contact the authors at mike.t.puerini@doc.state.or and drieger@correctcaresolutions.com.
References
1. Metzner, Jeffrey L. and Fellner, Jamie, Esq. Solitary Confinement and Mental Illness in U.S. Prisons: A Challenge for Medical Ethics. Journal of the American Academy of Psychiatry and the Law. 2010; 38: 104-108.
