“Prison should not actually do things that are knowingly going to make people worse,” replied Hank Greely when asked about the ethical issues of solitary confinement. Greely, who is director of the Center for Law and the Biosciences at Stanford University, pointed out that the United States houses 25 percent of the world’s prison population. “So in that sense,” he quipped, “we’re number one!” Sitting alongside a panel of experts, Greely was one of three speakers to open up the discussion of mental health and safety for prison inmates at the annual International Neuroethics Society (INS) meeting.
The panel addressed prison system policy in the U.S., as well as the world’s growing mental health crisis. Alan Leshner, chief executive officer emeritus of the American Association for the Advancement of Science (AAAS) and a Dana Alliance member, introduced the topic as a “criminal-justice issue, a human-rights issue, and a neuroethics issue of the highest order.” The prevalence of mental illness in criminal justice is tremendous, he added, and rhetorically asked if it can be seen as a direct consequence of incarceration.
Each speaker explored the topic from their area of expertise, which made for an engaging and educational session. Joining Greely and Leshner on stage was James Blair, chief of the Unit of Affective Cognitive Neuroscience at the National Institute for Mental Health and James Giordano, chief of the neuroethics studies program of the Pellegrino Center for Clinical Bioethics, as well as senior science advisory fellow at the Pentagon.
Even though prisoners are among the only people in the U.S. with a right to healthcare, the extent of quality is extraordinarily low, said Greely, adding that part of the problem with our staggering incarceration rate arose when we began de-institutionalizing mental institutions in the 1950s and re-institutionalized patients into prisons. Although the Supreme Court laid out standards in the 1990s for mandatory treatment, he believes that further reform is necessary. “Are we making people mentally ill in prison? Yes, I’m afraid we are,” he added.
Many questions have been raised about the types of treatment offered and their long-term effects (e.g. deep brain stimulation, psychosurgery). Currently, nine states require a procedure Greely referred to as “chemical castration” for male sex offenders, one that involves a type of birth control pill that blocks testosterone and affects the reproductive system and the brain. Some argue that this forced method of treatment can be considered “cruel and unusual punishment” and leads to other kinds of health problems.
Blair looked specifically at the behaviors synonymous with psychiatric disorder and the mechanisms that put patients at further risk. He explained that there are two types of aggression: reactive and instrumental. Reactive aggression is threat-induced and can be associated with a variety of conditions, such as depression and bipolar disorder. He described instrumental aggression as “goal-directed” and more closely associated with psychopathy.
In addition to aggression, Blair focused on empathy in the amygdala, a part of the brain associated with our emotions and motivations. Recent data examined this region’s level of response to the distress of others as a way of predicting that participant’s level of instrumental aggression. When it comes to rage, he said, a healthy brain will choose a non-antisocial way of dealing with situations. He added that schizophrenic and autistic patients who display antisocial behavior along with psychopathic traits show this same type of dysfunction in the amygdala.
Prisoners represent a very vulnerable part of the population, Giordano explained, because they have special needs. He introduced a host of questions that he said are necessary to consider when it comes to the discussion of “solving the problem” of pervasive mental illness in prison (e.g. Who makes the final decisions? Who pays? What are the risks involved?). In tow with Leshner’s introduction, Giordano noted that in order to make a decision that is as ethical as it is effective, it will take “pragmatism, precautionary views, and prudent practice.” He related the solution with wisdom that his father, who was an engineer, imparted on him as a child: “Measure twice, cut once.” As it relates to incarceration and mental health, Giordano said, we need to measure the brain, science, and neuroethics.
Greely said he believed that a possible reason people don’t address the topic frequently enough is because “it’s too depressing,” and a solution has yet to emerge. “I’m worried there aren’t really good answers. The best thing we can do is get better treatments for mental illness.” While he acknowledged that prisoners would likely be among the last to receive innovative treatments, Greely suggested improvements to delivery and funding. New money isn’t likely to come in, he said; but current funds can be better directed. “All in all, pressure should be kept up to try to improve what is a shameful state of American prisons,” Greely concluded. “Can we fix it? I don’t know. But it’s important that we begin to try.”
– Seimi Rurup