A not-so-great escape: suicide in prison

Christian Brown is a newly qualified junior doctor with an interest in psychiatry and ethics. 

Early last month, Ariel Castro, convicted kidnapper, rapist, and murderer, used a bed sheet and a window-ledge to commit suicide in his prison cell. He was just four weeks into a life sentence. Recently on this blog, Rebecca Roache wrote a post about the possibility of enhancing prison sentences – today, I’d like to consider the right-to-die of inmates, and the role of medical professionals in their suicidal behaviour.

Inside the walls of our high security prisons, small numbers of prisoners face life-long sentences, deprived of all but the minimum of human contact, and confined for most of the day to their cells. Some people argue that it can be rational to commit suicide – for the purposes of this post, I’ll refer to suicidal acts which are voluntary, informed, and the individual shown to have mental capacity, as ‘rational suicide’. If one accepts this, it is hard to imagine a more subjectively powerful circumstance in which to kill oneself than at the outset of a life sentence. Indeed, suicide rates among prisoners are around six times higher than those of the general male population. Of course, a proportion of these cases will not meet the criteria for ‘rational suicide’, but let’s consider those that do.

The essence of the ‘right to die’ debate in general seems to be about the limits on circumstances in which it is ethically permissible to take one’s own life. At the uncontroversial end of the spectrum: consider a terminally ill great-grandfather, who’s lived life to the full, has made final contact with everyone he wishes to say goodbye to, and with the goal of ending his intolerable and intractable pain, chooses to self-administer a fatal dose of the analgesic, morphine.

On the other hand, there are a great many imaginable scenarios in which suicide could cause significant harm to others – let’s call these people ‘stakeholders’ in the life of the suicidal individual. Consider the effect of suicide on the young children of a single parent, or the depressed and unstable patients of a popular psychotherapist. In these cases, you might well argue that a fully informed, voluntary, and capacitous (i.e. fully aware of the consequences) decision to commit suicide, would be unethical.

So where do convicted criminals fit in? Who are the stakeholders, and what reasons could they have for wanting them alive? The most important players are probably: the convict themselves, the victim / family of the victim, relatives of the convict, and society at large. It is conceivable that the family of the victim may have found solace in the knowledge that the offender has been locked up and is now suffering. Indeed, one could contend that they are in a similarly ‘dependent’ situation on the life of the prisoner to that of the child on their mother, or the patient on their therapist.

But would this be a good enough reason to prevent a ‘lifer’ from killing themselves? I’m uncomfortable with the idea that satisfaction gained by the suffering of another is a ‘good’ justification for keeping them alive against their will. Of course, there’s the opposite situation in which stakeholders would rather the prisoner die – but this doesn’t go very far in justifying the ending of their life.

As a member of a medical team faced with suicidal inmates, I usually felt uneasy. The role of the doctor in prison seems to be to facilitate, or prolong the duration, of the patient’s suffering. It isn’t like treating the terminally ill in hospital – when we resuscitate someone who has cancer, perform palliative radiotherapy and administer analgesia and anti-sickness medication, we’re trying to remove the detrimental immediate effects of the illness, such that they can make the most of the rest of their lives. In prison, we are simply returning the patient to the condition which manifested itself in the ‘symptom’ of suicidal behaviour. There are no medical conditions in which the ideal end-point of the treatment is to re-establish the underlying pathology in this way. The role of doctors is often challenged by end of life issues, but in this instance, the function of care-giver, healer, or alleviator of suffering, seems to be detrimentally subverted. A case from 2002 illustrated a successful attempt by a prisoner to establish a do-not-resuscitate order, following a gruesome and sustained suicide attempt.

So far, I’ve considered situations in which we are faced with individuals who have already attempted suicide. However, there may be valid parallels to be drawn between the criteria we use to justify assisted dying in the context of terminal illness, and a hypothetical system for use with some prisoners. Let’s say we only consider convicts who can be shown (much like in capital cases) to be indisputably guilty of their crimes. Then we should ask whether they are likely to die in prison (i.e. whether there’s any chance of ‘recovery’), whether they have any evidence of mental illness / are fully capacitous, and whether their desire to end their life is sustained and consistent. The final point will encapsulate their subjective evaluation of dying versus to the life they expect to be able to lead.

Of course, the conclusions here only follow in a system where very long, or indefinitely long prison sentences exist, the acceptability of which warrant an altogether different discussion. The first point of call should be to try and make prison an environment which doesn’t lead to suicidal behaviour – a system in which death becomes the preferable option hardly screams ‘humane’. Saying this, there may be some minor practical benefits to the facilitation of ‘rational suicide’ in inmates – the financial cost of maintaining an individual who’ll never leave the justice system would be saved. But more importantly, for small numbers of convicts, an undignified and torturous existence serving a life of suicidal solitude could be avoided.