Current Ethical Challenges in Prison Psychiatry in England and Wales

Abstract

As has been reported for most European countries (Salize et al. 2007), the prison population in England and Wales has increased dramatically in the last decade and currently stands at 85,117 (Ministry of Justice 2010b). Consequently, the number of mentally disordered offenders (MDOs) incarcerated within the prison system has also risen. At the same time, we have seen enormous changes in both the legal and policy context and the organisation of prison health care. Changes in criminal law have demonstrated a shift from a retributive to a preventive detention model leading to an increase in longer and indeterminate sentences (Völlm 2009). Policy developments have placed more emphasis on the treatment and management of personality disordered offenders both in prison and in psychiatric settings (National Institute of Mental Health for England 2003). The organisation of prison health care has recently undergone a major transformation owing to the move of ministerial responsibility from the Home Office (now Ministry of Justice) to the Ministry of Health in 2006. These changes have added additional ethical challenges to those inherent in working in a prison environment. This chapter describes the legal context of psychiatric care for MDOs in England and Wales, the different settings in which such care is provided, the organisation of the prison system and of healthcare provision within prisons as well as the main ethical challenges mental health care practitioners working in prisons face. We will consider ethical challenges encountered through recent legal and policy developments, those related to working in a custodial setting, challenges associated with providing healthcare to mentally disordered prisoners and specific ethical issues such as food refusal.