Ethics in carceral mental health

Abstract It remains an extraordinary commentary on the state of mental health that the largest mental health institutions in the United States are jails and prisons. Ethical dilemmas arise when working as a psychiatrist in a jail or prison, and many are unique to the carceral setting. Obligations to the law, professional standards, the patient, the community, and public health require a complex appreciation of competing values. Integration of all these values into a humanistic vision of professionalism means advocating for clinical values, recognizing influences that marginalize individuals and groups, and opposing mistreatment. Making the limits of confidentiality clear is a time-honored element of the informed consent process and need not be diluted in the carceral system. Honoring clear boundaries between treatment and forensic evaluation remains imperative: Confidentiality warnings and access to counsel cannot be one-off affairs that do not account for the cognitive, educational, cultural, and mental health vulnerabilities of the patient in a carceral setting. Prioritizing values like care, confidentiality, dignity, trust, and transparency that are vulnerable to economic and political constraints and delivering clear descriptions of procedural requirements are the lessons of research and commentary that support the incarcerated individual’s perspective and can lead to more collaboration and less violence. This chapter expands upon these critical issues of mental health treatment in carceral institutions.