The medical ethics of hospitalizing inmates with severe mental illness

Abstract

Summary Medical ethics principles of beneficence towards patients, including primacy of patient welfare and promoting access to medical care, favor the hospitalization of severely mentally ill inmates whose condition would require such level and quality of treatment were they not incarcerated. Today, more for fiscal concerns than for liberty interests of patients, hospitalization is removed from the spectrum of mental health services afforded to mentally ill persons behind bars. The most serious ethical challenge for correctional psychiatrists in the United States today is providing hospital care for inmates in need of this level of services. Hospitalization of the most severely psychotic inmate whose condition is deteriorating is frustrated by four barriers: the need for an adversarial hearing for legal approval to transfer the inmate; a shortage of hospital beds creating inhumanely long delays even for legally approved transfers; administrative decisions to categorically deny hospital admission for inmates regardless how psychotic who are not first adjudicated incompetent to stand trial or not guilty by reason of insanity, and mental health professionals relinquishing the effort to hospitalize inmates in need of intensive psychiatric care and turning to partial solutions which ultimately provide policy makers and administrators with excuses for denial of proper care. It is this last barrier, the indifference and acquiescence of mental health professionals themselves to the withdrawal of hospital services, that should be of greatest ethical concern. This creates a challenge for correctional medical and mental health providers who must make a difficult choice regarding the clinically and ethically proper treatment of the most severely disturbed inmates. Options include: redirect efforts towards inmates who can be treated properly without hospital transfer, resign from employment in correctional health care, incorporate hospital methods, specifically enforced medication, into the non-medical correctional facility, and with creativity and determination strive to effect changes that will provide hospital care for the few but most seriously disturbed inmates who are in need of this level of treatment. This article examines the merits of each of these four approaches within a framework of medical ethics, and concludes that the fourth option is the most ethically defensible.