Abstract
The Law justifies the beating of a lunatic in such a manner as the circumstances may require. But a physician who attends an asylum for insanity is under an obligation of honour as well as of humanity to secure to the unhappy sufferers committed to his charge all the tenderness and indulgence compatible with the steady and effectual government. And the straight waistcoat, with other improvements in modern practice, now preclude the necessity of coercion by corporal punishment [1].
The exercise of coercion by psychiatrists in the care of patients is of relevance in all areas of psychiatric practice, but is particularly so in forensic psychiatry. One poignant form of coercion is the use of potentially pathogenic interventions to prevent suicide by prisoners within the prison system.
Clarification of the moral boundaries between the justified therapeutic use of coercion in the care of patients and the illegitimate abuse of power is a core task for mental health professionals. At stake is the very integrity of psychiatry as a discipline to which individuals suffering from mental illness, and society as a whole, can look with trust and confidence.
The challenge to psychiatry
Clinicians in treating patients coercively confront a serious challenge regarding the abuse of power for the purposes of control, punishment and even political tyranny.
Notable examples of the abuse of power in the history of psychiatry include the following: (i) coercive administration of psychotropic medication and electroconvulsive therapy in the control of troublesome prisoners [2]; (ii) prefrontal leucotomy of prisoners, including remandees, for treatment of socially deviant behaviours such as psychosexual exhibitionism and ‘antisocial pederasty’ by Bailey and colleagues in Australia (Bailey subsequently became notorious for flagrant abuses associated with the use of deep sleep therapy at Chelmsford Private Hospital [3–6]); (iii) bribing of prisoners by offers of early release, especially in the USA, to participate in dangerous research (e.g. by becoming dependent on opiates) [7]; (iv) perverse misuse of psychiatry as an instrument of the totalitarian communist State in the Soviet Union [8–11]; (v) complicity of psychiatrists in the atrocities of Nazism [12–14].
Foucault [15] has argued that psychiatrists are necessarily enmeshed in a nexus of power over prisoners in which they are by definition instruments of control and punishment by the State. For Foucault, psychiatry is not only open to abuse in individual cases by clinicians willing to subserve patient interests to a wider social or political agenda but is also, when practiced within the criminal justice system, inherently abusive. This is by virtue of the structural power relations between prison, psychiatry and prisoners regardless of the motivation of individual practitioners. In tracing the evolution of judicial punishment of criminals over the past 300 years, he makes a simple but potent critique of psychiatry.
Formerly, judges would simply punish the crime, often in horrendously brutal ways. Over the past 200 years, Foucault argues, judges have taken account of the characteristics of the individual criminal in determining sentences in addition to the crime itself. Examples include sentences designed with a treatment or rehabilitative intent and judicial decisions exculpating responsibility for the offence on the basis of insanity.
These developments could be viewed as reflective of a more humane, civilised society exercising greater leniency towards the criminal. Foucault argues rather that they represent a pernicious extension of the exercise of power by the State over the individual. Now, not only is the body of the criminal controlled and punished by the State but so also is his mind and social identity. The criminal is not only to be punished physically for crimes committed in the past, but his future also is controlled by psychological and social interventions aimed at reducing reoffending and transforming him into a law abiding citizen.
The State has accepted the claim of practitioners of new discourses such as psychiatry and psychology to have scientific expertise in understanding and shaping the mind of the criminal. In so doing, it has granted them power in influencing penal interventions.
Against this background, there is a need for an ethical framework in which coercion can be exercised by psychiatrists in a way which provides a moral bulwark, not only against the abuse of individual patients but also against complicity with descent into an abyss of sociopolitical tyranny. Such a need is particularly urgent in situations where there is a potential conflict of interest between concern for the individual patient's mental health and the service of third agencies such as courts, parole boards, correctional or immigration authorities, insurance bodies, the military and so on. The question of suicide prevention in prison is an eminently suitable vehicle by which to achieve this aim.
Observation cells: ‘strip cells’/‘wet cells’/‘Muirhead cells’
Clinicians wanting to support suicidal prisoners face the dilemma of a very restricted range of therapeutic options on account of the prison regime. One of the most basic restrictions is the inability to offer the kind of psychological containment provided through the constant presence of a psychiatric nurse on a one-to-one basis. Access to clinical staff is severely restricted in some maximum security prisons by the practice of locking prisoners in their cells from 16:00 h in the afternoon until 07:00 h the next morning. In some special purpose locations, especially those used for the purposes of punishment, or of containing individuals deemed to be at particularly high risk of violence to other inmates some prisoners are confined in solitary cells for periods of up to 23 h per day.
In consequence, particularly given the high lethality of hanging, at present there is no effective alternative to emergency isolation in observation cells if the psychiatrist is convinced of the likelihood of a suicide attempt. Traditionally, observation cells used for the prevention of prisoner suicide were known as ‘strip cells’, a reference to Spartan cells stripped of all furnishings and in which normal clothes were replaced by tear-proof clothing [16].
Following the Royal Commission into Aboriginal Deaths in Custody in Australia [17], a new form of observation cell was designed, officially termed a ‘Muirhead Cell’ after Mr Justice Muirhead, the Chief Commissioner. Colloquially, it is referred to, at least in Victoria, as a ‘wet cell’. The major features of a Muirhead Cell include: (i) preservation of the traditional elements of a stripped cell with a tear-proof canvas tunic instead of clothes, canvas blanket and mattress on the floor and a lack of any fittings which might suffice as a place for attachment of a noose; (ii) clear Perspex walls to allow observation from a distance; (iii) a television screen visible to the prisoner through the Perspex wall for the purpose of stimulation; (iv) a horizontal, 2-inch line painted around the walls at a certain height above the floor to facilitate visual orientation; (v) a toilet bowl and washbasin.
How pathogenic are observation cells? How effective are they in preventing suicide? The author has been unable to find any empirical research addressing these questions. The most closely related research is that of the psychopathological effects of solitary confinement. A recent prospective Norwegian study of prisoners in solitary confinement [18] showed that the secluded prisoners had more health problems than prisoners serving less restrictive sentences. The main symptoms were headache, bodily aches, anxiety and depression. These were general prisoners secluded for prison management reasons, not for purposes of suicide prevention. The complaints tended to last for the whole period of solitary confinement and were difficult to treat while the prisoners remained secluded.
There are numerous references in the forensic literature to a belief that observation cells are likely to contribute substantially to prisoner turmoil and despair [7,19,20]. Consider the example of a dysphoric, impulsive young man with a history of past suicide attempts who is newly remanded for the first time in an overcrowded prison division where he encounters paranoid intimidating men standing over him for cigarettes or sex. On being placed in an observation cell, such an individual may well escalate into having a profound sense of disempowerment, fear and despair.
Most prisoners bitterly resent being placed in a wet cell and tend to regard it as a form of punishment. They are also aware that communication of suicidal intent runs the risk of being transferred to a wet cell. Unfortunately, situations arise where there seems no practical alternative to emergency short-term placement in an observation cell if the prisoner's safety is to be maximised. The decision of whether or not to place a prisoner in an observation cell encapsulates many ethical issues confronting the psychiatrist who exercises coercion not only in prison but in any clinical context.
It raises fundamental questions about personal identity, freedom and responsibility for action and about the relationship between the individual and society. The question of suicide provides a framework in which competing discourses about this relationship can be explored. These include accounts based on the analysis of power relations such as that of Foucault and rights-based narratives emphasising the ‘right’ of the individual to dispose of his own body regardless of society's claims [21]. Alongside these is another narrative which emphasises that the despairing individual is a member of the human family towards whom we as a community bear a collective responsibility.
Humans as relational beings: the ground of ethical discourse
It would be possible to construct a discourse on human society in which competing interests are resolved purely on the basis of the unbridled exercise of power, such as in the totalitarian state. Ethics arises where human beings resist such a discourse by appealing to certain qualities of human relationship which constrain the exercise of power and which can only be described in essentially moral terms.
Foucault [15] analyses the nexus of relationships between prisoner, prison and physician almost exclusively in terms of the distribution of power within that nexus. He has virtually no regard for any moral dimensions to those relationships which might modify the analysis based on power relations. It is the author's belief that such moral qualities have the potential to radically transform the nature of the power relationship itself and the way the exercise of power is experienced by both psychiatrist and prisoner.
This notion receives support from a considerable body of empirical research [22–28] in recent years which has explored the moral themes identified by patients in evaluating coercive intervention imposed on them within the context of involuntary civil commitment. Bennett and colleagues [29] at the MacArthur Foundation identified certain core themes as being critical determinants of whether patients themselves viewed coercive interventions on their behalf as morally justified. These themes consisted of patient inclusion within the decision-making process, motivation of the coercing psychiatrist and good faith.
Ethical action arises necessarily within at least two relational spheres. The first is what some theologians have referred to as an ‘I-Thou’ relation [30]. This is the encounter of one individual with another in which the other person is respected as an end in herself. This imposes a limit on what the individual can ethically choose for herself, insofar as her action must not violate respect for the dignity of the other as a fellow member of the human family. If such a limit is lacking, then we are no longer speaking of ethical action but of the amoral exercise of power.
There is a fine line, in practice easily crossed, between the use of pathogenic interventions such as wet cells for the care and protection of vulnerable suicidal prisoners, and the infliction of a humiliating cruel procedure on them for the purpose primarily of protecting both our own and the prison's reputation by seeking to prevent prisoner suicide at any cost. How can we refrain, in ethical terms, from crossing this fine line?
This brings us to another relational sphere, that of the particular social world in which the individual lives with her society and culture, specific social groupings, historical context, physical environment and so on. This world imposes a series of constraints and demands on both the individual in herself and also on all persons involved in her particular ‘I-Thou’ relationships. The individual in ethical terms stands somewhere along a spectrum of acquiescence, compromise or revolt against the world in which he lives. The stance the individual takes within this world regarding the way he relates to others has the potential for either perpetuating or transforming the quality of relationship which the surrounding ‘world’ tends to impose.
The relationship between the prisoner and psychiatrist is an example par excellence of this. The psychiatrist, in relating to the prisoner as patient, is daily confronted by countless external physical reminders of the essentially coercive nature of the prison. These include the high security walls and razor wire, electronically operated doors, prison officer and prisoner uniforms, security identification badges, muster parades and so on. The world of the prison coercively intrudes directly into the personal sphere of the clinician—prisoner/patient relationship, in ways which they are both more or less powerless to change.
Foucault's [15] critique ignores another discourse in which the psychiatrist is situated and which ethically constrains him, namely, the tradition of healer or physician. In addressing Foucault's critique the question arises as to whether within this given coercive world of the prison it is possible for the clinician and prisoner as patient to relate to one another in their ‘I-Thou’ relationship in a way which somehow transforms the way the coercion is experienced.
For example, the same coercive act of placing a suicidal prisoner in an observation cell in the face of his declared opposition to this may be experienced differently according to whether the clinician has performed her duties in a perfunctory or callous way in contradistinction to the clinician who has given the patient an opportunity to be heard and at least participate in the decision-making process, if not decide its final outcome, and sought to communicate an awareness of the distress the action may cause.
In the former approach, the patient is treated principally as a means to an end, for example the ends both of ensuring that the psychiatrist has fulfilled his duty of care to prevent suicide and of being seen in the Coroner's Court to have done so. In the latter, the patient is regarded as an end in himself whose welfare is held to be of primary importance. An approach seeking to respect the dignity of the patient as an active agent in the process is much more likely to foster at least some measure of trust and hope that the clinician is acting in good faith, motivated for the patient's own welfare. It will never be possible to prevent all suicides in prison. Respect for prisoner autonomy involves supporting the individual, who is often poorly equipped psychologically to cope with the rigours of prison life, in assuming a sense of responsibility for his own safety and in doing so provides an opportunity for personal maturation. This inevitably involves an element of risk.
Observation cells are highly intrusive of the prisoner's privacy. They are not, however, suicide proof. Prisoners can still bang their heads on the concrete walls and floors. The canvas tunic currently in use in Victoria has been shown to be capable, by ingenious convoluted manipulation, of being used as a suspended noose. It would be possible for prison authorities to propose that prisoners be stripped totally naked, in full view of the officers responsible for their care, to prevent this. It is not hard to imagine how much such a humiliating procedure is likely to further intensify prisoner despair. Here, the desired end appears to be for the prison to prevent suicide at all cost, even at the expense of what might be legitimately condemned as torture of the individual it is supposed to be protecting. How far should psychiatry go in colluding with this?
In addressing this question, the principle of respect for autonomy must be counter-balanced in tension with another principle deriving from the ‘I-Thou’ relational understanding of human existence I have argued previously. This is the principle of communality or heteronomy [31], the governance of our individual conduct by others. Heteronomy is one answer to the rhetorical question asked in the ancient tale of Cain and Abel: ‘Am I my brother's keeper?’ All of us, by virtue of being members of human society, are subject heteronomously to demands made of us by others. Some heteronomous demands carry strong moral force. One such demand is the basic civil liberties tenet that I can only act autonomously insofar as I do not infringe on the autonomy of others.
Zifcak [32] is correct in lamenting that although the civil liberties narrative is a strong basis for the correction of abuses of power, it cannot compel individuals or communities to care. This requires another kind of heteronomous constraint.
With regard to suicide prevention, writing from a theological perspective, Best [33] argues: ‘Suicide in most, if not all circumstances, reflects an incapacity of hope and trust. Most suicides flow from a loss of the vital ingredients of human life, hope and a supportive loving community…. Humans are not autonomous, independent of all limitation. Rather they are called upon to participate in an interdependent unfolding drama in which there is the possibility of a creative, organic interdependence…which is meant to be trustworthy and essentially good’.
The psychiatrist is bound to the suicidal patient in an ‘I-Thou’ relationship in which she views herself as heteronomously impelled to engage the despairing prisoner in a way which seeks to engender a sense of hope, trust and self worth as a valued member of human society. This may, on occasion, include a brief period of isolation in a wet cell to protect the patient from the consequences of his own despair.
Conclusion: a personal reflection
There is something profoundly repugnant about having to place a suicidal prisoner in a wet cell, yet it is a practice which within the constraints of current prison policy is simply unavoidable on occasion if concerns for patient safety are paramount. To abstain from any willingness to apply such coercive means in order to preserve my own sense of being a benign figure free from any association with the oppressive nature of the prison regime would be to abandon the prisoner/patient to the possibility of further despair and hopelessness. To lose the sense of repugnance at what isolation in a wet cell means for both the suicidal prisoner and myself as the one who initiates the intervention would be to allow coercion to become a habit within which I feel aesthetically and morally at home, an ethically dangerous frame of mind to acquire.
Footnotes
Acknowledgements
The author would like to acknowledge the constructive criticism of Paul Mullen on earlier drafts of this paper.