Saturday, July 15, 2006

Ethics, Shmethics

Someone asked me an interesting question last night. He asked, "So, do you think it's appropriate to work in an environment that you think is so inadequate that you can't give even minimally adequate care?"

It wasn't the first time that someone suggested to me that correctional work was unethical. Many years ago when I first started working in prison a colleague of mine said to me, "Surely, you're not working there." He was implying that to work inside a correctional facility was equivalent to participating in punishment. Fortunately, times have changed.

In 1988 the American Psychiatric Association published a position statement on psychiatric services in jails and prisons, and this is what it said:

"Psychiatrists should take a leadership role administratively as well as clinically...the APA calls on its members to participate in the care and treatment of the mentally ill in jails and prisons, for without an increased commitment and involvement of its membership in providing services to the mentally ill in jails and prisons, position statements such as this will be meaningless. The breadth and depth of these problems demand much more."
Correctional experience is now mandatory in some situations. In the 1990's forensic psychiatry was recognized as an official medical subspecialty. The American Council for Graduate Medical Education (ACGME), the organization which accredits forensic psychiatry training programs, requires that all forensic psychiatry fellows have a minimum of six months experience working with inmates in a correctional facility. Child psychiatry fellowships also require forensic experience, which in some programs may involve work in juvenile correctional facilities.

Correctional psychiatry bears similarities to the newly developed field of disaster psychiatry. Disaster psychiatry developed as a result of the September 11th terrorist attack and other subsequent tragedies. It is based on the idea that when the health care need is urgent you treat the patient where you find them. The correctional environment may not be optimal or ideal, but it is no worse than caring for victims at the scene of a car accident or treating wounded soldiers on the battlefield. Or, for that matter, treating hurricane victims. In the latest issue of BrainWise, the newsletter put out by the Johns Hopkins Department of Psychiatry, Dr. Michael Kaminsky vividly described his experience providing mental health care in central Louisiana following Katrina:
"In one way, Katrina was paradise. No billing, no medical forms. We became super efficient. We just did what was needed. And we loved it."
They treated 45 patients in two days, many of them suffering from complicated major mental illnesses. And talk about an inadequate work environment---their clinic was an elementary school cafeteria with sheets draped over the windows for privacy. Surely this was not an environment that was adequate for providing mental health care. Surely, he didn't work there.

But fortunately, he did. Ethics, shmethics.