The Law justifies the beating of a lunatic in such amanner as the circumstances may require. But aphysician who attends an asylum for insanity isunder an obligation of honour as well as of human-ity to secure to the unhappy sufferers committed tohis charge all the tenderness and indulgence com-patible with the steady and effectual government.And the straight waistcoat, with other improvementsin modern practice, now preclude the necessity ofcoercion by corporal punishment [1].

The exercise of coercion by psychiatrists in thecare of patients is of relevance in all areas of psychi-atric practice, but is particularly so in forensic psy-

chiatry. One poignant form of coercion is the use ofpotentially pathogenic interventions to preventsuicide by prisoners within the prison system.

Clarification of the moral boundaries between thejustified therapeutic use of coercion in the care ofpatients and the illegitimate abuse of power is a coretask for mental health professionals. At stake is thevery integrity of psychiatry as a discipline to whichindividuals suffering from mental illness, and societyas a whole, can look with trust and confidence.

The challenge to psychiatry

Clinicians in treating patients coercively confront aserious challenge regarding the abuse of power forthe purposes of control, punishment and even politi-cal tyranny.

Notable examples of the abuse of power in thehistory of psychiatry include the following: (i) coer-cive administration of psychotropic medication and

Ordinary article OA 635 EN

Ethical issues in the prevention of suicide in prison

Douglas Bell

O b j e c t i v e : The aim of this paper is to discuss ethical issues that arise in the care ofsuicidal patients within a prison context. Such a discussion provides a suitableframework for exploration of the broader question of how coercion may be exercisedby psychiatrists in a morally justifiable, as opposed to abusive, manner.M e t h o d : Literature relevant to the abuse of psychiatric power is reviewed. T h emeans for immediate containment of highly suicidal patients in certain prison con-texts is described and the paucity of relevant empirical research literature relating tothis is identified. A framework is proposed to assist clinicians in making an ethicalevaluation of coercive interventions that is applicable not only in the prevention ofprisoner suicide, but also in the practice of psychiatry as a whole.R e s u l t s : Due regard for the moral dimensions of the relationship between psychia-trist and prisoner has the potential to radically transform the way the exercise ofpower is subjectively experienced by each of them.C o n c l u s i o n : Coercion can be exercised by psychiatrists within an ethical frameworkwhich is not abusive. There will always be a risk that coercion will become anunhealthy habit of life within which the psychiatrist feels too comfortable.Key words: coercion, ethics, prisoner suicide, psychiatric abuse, strip cells.

Australian and New Zealand Journal of Psychiatry 1999; 33:723–728

Douglas Bell, Consultant Psychiatrist

Victorian Institute of Forensic Mental Health, PO Box 266,Rosanna, Victoria 3084, Australia

Received 6 November 1998; revised 5 May 1999; accepted 7 May1999.

724 PREVENTION OF SUICIDE IN PRISON

electroconvulsive therapy in the control of trouble-some prisoners [2]; (ii) prefrontal leucotomy of pris-oners, including remandees, for treatment of sociallydeviant behaviours such as psychosexual exhibition-ism and ‘antisocial pederasty’ by Bailey and col-leagues in Australia (Bailey subsequently becamenotorious for flagrant abuses associated with the useof deep sleep therapy at Chelmsford Private Hospital[3–6]); (iii) bribing of prisoners by offers of earlyrelease, especially in the USA, to participate in dan-gerous research (e.g. by becoming dependent onopiates) [7]; (iv) perverse misuse of psychiatry as aninstrument of the totalitarian communist State in theSoviet Union [8–11]; (v) complicity of psychiatristsin the atrocities of Nazism [12–14].

Foucault [15] has argued that psychiatrists arenecessarily enmeshed in a nexus of power over pris-oners in which they are by definition instruments ofcontrol and punishment by the State. For Foucault,psychiatry is not only open to abuse in individualcases by clinicians willing to subserve patient inter-ests 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 structuralpower relations between prison, psychiatry and pris-oners regardless of the motivation of individual prac-titioners. In tracing the evolution of judicialpunishment of criminals over the past 300 years, hemakes a simple but potent critique of psychiatry.

Formerly, judges would simply punish the crime,often in horrendously brutal ways. Over the past2 0 0 years, Foucault argues, judges have takenaccount of the characteristics of the individual crim-inal in determining sentences in addition to the crimeitself. Examples include sentences designed with atreatment or rehabilitative intent and judicial deci-sions exculpating responsibility for the offence onthe basis of insanity.

These developments could be viewed as reflectiveof a more humane, civilised society exercisinggreater leniency towards the criminal. Foucaultargues rather that they represent a pernicious exten-sion of the exercise of power by the State over theindividual. Now, not only is the body of the criminalcontrolled and punished by the State but so also is hismind and social identity. The criminal is not only tobe punished physically for crimes committed in thepast, but his future also is controlled by psycho-logical and social interventions aimed at reducing re-offending and transforming him into a law abidingcitizen.

The State has accepted the claim of practitioners of

new discourses such as psychiatry and psychology tohave scientific expertise in understanding andshaping the mind of the criminal. In so doing, it hasgranted them power in influencing penal interven-tions.

Against this background, there is a need for anethical framework in which coercion can be exer-cised by psychiatrists in a way which provides amoral bulwark, not only against the abuse of individ-ual patients but also against complicity with descentinto an abyss of sociopolitical tyranny. Such a need isparticularly urgent in situations where there is apotential conflict of interest between concern for theindividual patient’s mental health and the service ofthird agencies such as courts, parole boards, correc-tional or immigration authorities, insurance bodies,the military and so on. The question of suicide pre-vention in prison is an eminently suitable vehicle bywhich to achieve this aim.

Observation cells: ‘strip cells’/‘wetcells’/‘Muirhead cells’

Clinicians wanting to support suicidal prisonersface the dilemma of a very restricted range of thera-peutic options on account of the prison regime. Oneof the most basic restrictions is the inability to offerthe kind of psychological containment providedthrough the constant presence of a psychiatric nurseon a one-to-one basis. Access to clinical staff isseverely restricted in some maximum securityprisons by the practice of locking prisoners in theircells from 16:00 h in the afternoon until 07:00 h thenext morning. In some special purpose locations,especially those used for the purposes of punishment,or of containing individuals deemed to be at particu-larly high risk of violence to other inmates some pris-oners are confined in solitary cells for periods of upto 23 h per day.

In consequence, particularly given the high lethal-ity of hanging, at present there is no effective alter-native to emergency isolation in observation cells ifthe psychiatrist is convinced of the likelihood of asuicide attempt. Traditionally, observation cells usedfor the prevention of prisoner suicide were known as‘strip cells’, a reference to Spartan cells stripped ofall furnishings and in which normal clothes werereplaced by tear-proof clothing [16].

Following the Royal Commission into AboriginalDeaths in Custody in Australia [17], a new form ofobservation cell was designed, officially termed a‘Muirhead Cell’after Mr Justice Muirhead, the Chief

725D. BELL

Commissioner. Colloquially, it is referred to, at leastin Victoria, as a ‘wet cell’. The major features of aMuirhead Cell include: (i) preservation of the tradi-tional elements of a stripped cell with a tear-proofcanvas tunic instead of clothes, canvas blanket andmattress on the floor and a lack of any fittings whichmight suffice as a place for attachment of a noose;(ii) clear Perspex walls to allow observation from adistance; (iii) a television screen visible to the pris-oner through the Perspex wall for the purpose ofstimulation; (iv) a horizontal, 2-inch line paintedaround the walls at a certain height above the floor tofacilitate visual orientation; (v) a toilet bowl andwashbasin.

How pathogenic are observation cells? How effec-tive are they in preventing suicide? The author hasbeen unable to find any empirical research address-ing these questions. The most closely relatedresearch is that of the psychopathological effects ofsolitary confinement. A recent prospectiveNorwegian study of prisoners in solitary confinement[18] showed that the secluded prisoners had morehealth problems than prisoners serving less restric-tive sentences. The main symptoms were headache,bodily aches, anxiety and depression. These weregeneral prisoners secluded for prison managementreasons, not for purposes of suicide prevention. Thecomplaints tended to last for the whole period of soli-tary confinement and were difficult to treat while theprisoners remained secluded.

There are numerous references in the forensic liter-ature to a belief that observation cells are likely tocontribute substantially to prisoner turmoil anddespair [7,19,20]. Consider the example of a dys-phoric, impulsive young man with a history of pastsuicide attempts who is newly remanded for the firsttime in an overcrowded prison division where heencounters paranoid intimidating men standing overhim for cigarettes or sex. On being placed in anobservation cell, such an individual may well esca-late into having a profound sense of disempower-ment, fear and despair.

Most prisoners bitterly resent being placed in a wetcell and tend to regard it as a form of punishment.They are also aware that communication of suicidalintent runs the risk of being transferred to a wet cell.Unfortunately, situations arise where there seems nopractical alternative to emergency short-term place-ment in an observation cell if the prisoner’s safety isto be maximised. The decision of whether or not toplace a prisoner in an observation cell encapsulatesmany ethical issues confronting the psychiatrist who

exercises coercion not only in prison but in any clin-ical context.

It raises fundamental questions about personalidentity, freedom and responsibility for action andabout the relationship between the individual andsociety. The question of suicide provides a frame-work in which competing discourses about this rela-tionship can be explored. These include accountsbased on the analysis of power relations such as thatof Foucault and rights-based narratives emphasisingthe ‘right’ of the individual to dispose of his ownbody regardless of society’s claims [21]. Alongsidethese is another narrative which emphasises that thedespairing individual is a member of the humanfamily towards whom we as a community bear a col-lective responsibility.

Humans as relational beings: the ground ofethical discourse

It would be possible to construct a discourse onhuman society in which competing interests areresolved purely on the basis of the unbridled exerciseof power, such as in the totalitarian state. Ethicsarises where human beings resist such a discourse byappealing to certain qualities of human relationshipwhich constrain the exercise of power and which canonly be described in essentially moral terms.

Foucault [15] analyses the nexus of relationshipsbetween prisoner, prison and physician almost exclu-sively in terms of the distribution of power within thatnexus. He has virtually no regard for any moral dimen-sions to those relationships which might modify theanalysis based on power relations. It is the author’sbelief that such moral qualities have the potential toradically transform the nature of the power relation-ship itself and the way the exercise of power is expe-rienced by both psychiatrist and prisoner.

This notion receives support from a considerablebody of empirical research [22–28] in recent yearswhich has explored the moral themes identified bypatients in evaluating coercive intervention imposedon them within the context of involuntary civil com-mitment. Bennett and colleagues [29] at theMacArthur Foundation identified certain core themesas being critical determinants of whether patientsthemselves viewed coercive interventions on theirbehalf as morally justified. These themes consistedof patient inclusion within the decision-makingprocess, motivation of the coercing psychiatrist andgood faith.

Ethical action arises necessarily within at least two

726 PREVENTION OF SUICIDE IN PRISON

relational spheres. The first is what some theologianshave referred to as an ‘I-Thou’ relation [30]. This isthe encounter of one individual with another in whichthe other person is respected as an end in herself.This imposes a limit on what the individual can ethi-cally choose for herself, insofar as her action mustnot violate respect for the dignity of the other as afellow member of the human family. If such a limit islacking, then we are no longer speaking of ethicalaction but of the amoral exercise of power.

There is a fine line, in practice easily crossed,between the use of pathogenic interventions such aswet cells for the care and protection of vulnerablesuicidal prisoners, and the infliction of a humiliatingcruel procedure on them for the purpose primarily ofprotecting both our own and the prison’s reputationby seeking to prevent prisoner suicide at any cost.How can we refrain, in ethical terms, from crossingthis fine line?

This brings us to another relational sphere, that ofthe particular social world in which the individuallives with her society and culture, specific socialgroupings, historical context, physical environmentand so on. This world imposes a series of constraintsand demands on both the individual in herself and alsoon all persons involved in her particular ‘I-Thou’ r e l a-tionships. The individual in ethical terms stands some-where along a spectrum of acquiescence, compromiseor revolt against the world in which he lives. T h estance the individual takes within this world regardingthe way he relates to others has the potential for eitherperpetuating or transforming the quality of relation-ship which the surrounding ‘world’tends to impose.

The relationship between the prisoner and psychia-trist is an example par excellence of this. The psy-chiatrist, in relating to the prisoner as patient, is dailyconfronted by countless external physical remindersof the essentially coercive nature of the prison. Theseinclude the high security walls and razor wire, elec-tronically operated doors, prison officer and prisoneruniforms, security identification badges, musterparades and so on. The world of the prison coercivelyintrudes directly into the personal sphere of the clin-ician–prisoner/patient relationship, in ways whichthey are both more or less powerless to change.

Foucault’s [15] critique ignores another discoursein which the psychiatrist is situated and which ethi-cally constrains him, namely, the tradition of healeror physician. In addressing Foucault’s critique thequestion arises as to whether within this given coer-cive world of the prison it is possible for the clinicianand prisoner as patient to relate to one another in

their ‘I-Thou’ relationship in a way which somehowtransforms the way the coercion is experienced.

For example, the same coercive act of placing asuicidal prisoner in an observation cell in the face ofhis declared opposition to this may be experienceddifferently according to whether the clinician hasperformed her duties in a perfunctory or callous wayin contradistinction to the clinician who has given thepatient an opportunity to be heard and at least partic-ipate in the decision-making process, if not decide itsfinal outcome, and sought to communicate an aware-ness of the distress the action may cause.

In the former approach, the patient is treated prin-cipally as a means to an end, for example the endsboth of ensuring that the psychiatrist has fulfilled hisduty of care to prevent suicide and of being seen inthe Coroner’s Court to have done so. In the latter, thepatient is regarded as an end in himself whosewelfare is held to be of primary importance. Anapproach seeking to respect the dignity of the patientas an active agent in the process is much more likelyto foster at least some measure of trust and hope thatthe clinician is acting in good faith, motivated for thepatient’s own welfare. It will never be possible toprevent all suicides in prison. Respect for prisonerautonomy involves supporting the individual, who isoften poorly equipped psychologically to cope withthe rigours of prison life, in assuming a sense ofresponsibility for his own safety and in doing so pro-vides an opportunity for personal maturation. Thisinevitably involves an element of risk.

Observation cells are highly intrusive of the pris-oner’s privacy. They are not, however, suicide proof.Prisoners can still bang their heads on the concretewalls and floors. The canvas tunic currently in use inVictoria has been shown to be capable, by ingeniousconvoluted manipulation, of being used as a sus-pended noose. It would be possible for prison author-ities to propose that prisoners be stripped totallynaked, in full view of the officers responsible fortheir care, to prevent this. It is not hard to imaginehow much such a humiliating procedure is likely tofurther intensify prisoner despair. Here, the desiredend appears to be for the prison to prevent suicide atall cost, even at the expense of what might be legiti-mately condemned as torture of the individual it issupposed to be protecting. How far should psychiatrygo in colluding with this?

In addressing this question, the principle of respectfor autonomy must be counter-balanced in tensionwith another principle deriving from the ‘I-Thou’relational understanding of human existence I have

727D. BELL

argued previously. This is the principle of commu-nality or heteronomy [31], the governance of ourindividual conduct by others. Heteronomy is oneanswer to the rhetorical question asked in the ancienttale of Cain and Abel: ‘Am I my brother’s keeper?’All of us, by virtue of being members of humans o c i e t y, are subject heteronomously to demandsmade of us by others. Some heteronomous demandscarry strong moral force. One such demand is thebasic civil liberties tenet that I can only actautonomously insofar as I do not infringe on theautonomy of others.

Zifcak [32] is correct in lamenting that althoughthe civil liberties narrative is a strong basis for thecorrection of abuses of power, it cannot compel indi-viduals or communities to care. This requires anotherkind of heteronomous constraint.

With regard to suicide prevention, writing from atheological perspective, Best [33] argues: ‘Suicide inmost, if not all circumstances, reflects an incapacityof hope and trust. Most suicides flow from a loss ofthe vital ingredients of human life, hope and a sup-portive loving community…. Humans are notautonomous, independent of all limitation. Ratherthey are called upon to participate in an interdepen-dent unfolding drama in which there is the possibilityof a creative, organic interdependence…which ismeant to be trustworthy and essentially good’.

The psychiatrist is bound to the suicidal patient inan ‘I-Thou’relationship in which she views herself asheteronomously impelled to engage the despairingprisoner in a way which seeks to engender a sense ofhope, trust and self worth as a valued member ofhuman society. This may, on occasion, include a briefperiod of isolation in a wet cell to protect the patientfrom the consequences of his own despair.

Conclusion: a personal reflection

There is something profoundly repugnant abouthaving to place a suicidal prisoner in a wet cell, yet itis a practice which within the constraints of currentprison policy is simply unavoidable on occasion ifconcerns for patient safety are paramount. To abstainfrom any willingness to apply such coercive means inorder to preserve my own sense of being a benignfigure free from any association with the oppressivenature of the prison regime would be to abandon theprisoner/patient to the possibility of further despairand hopelessness. To lose the sense of repugnance atwhat isolation in a wet cell means for both the suicidalprisoner and myself as the one who initiates the inter-

vention would be to allow coercion to become a habitwithin which I feel aesthetically and morally at home,an ethically dangerous frame of mind to acquire.

Acknowledgements

The author would like to acknowledge the con-structive criticism of Paul Mullen on earlier drafts ofthis paper.

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