Tuesday, June 19, 2012

Global Philosophies on Justice

A few weeks ago, I received my rotation calendar for my intern year. Every three months for the next two years, I will switch back and forth between family medicine and psychiatry rotations, since I am in a program to become board certified in both of these specialties. Anyway, I noticed that in December of this year I will be doing a month of psychiatry at our county jail. In this rotation and others in "forensic psychiatry", as it is known, I will perform psychiatric evaluations of inmates, be a member of the "expert witness" team at trials and propose/implement treatment plans for inmates with mental illness.

I think that my impending up-close involvement in the justice system is one reason that I have lately become more attentive to the system as a whole. One article in CNN today caught my eye for this reason(click here to view). The article highlights the looming implementation of a recently passed law in South Korea which allows the "chemical castration" of convicted serial rapists. At first, I was put off by this notion, but I find that my opinions are changing the more I think about it.

I wish to clarify that in tentatively supporting this idea, I am decidedly not echoing the boorish rants in the comments section below that article. Those comments, crassly suggesting that a serial rapist "deserves" only physical castration, exemplify the very American justice philosophy of revenge. From what I have noticed, the American justice system seems to place a large emphasis on punishment, and the general public seems to think that even the harsh prison sentences and the executions that still do happen in the U.S. are not severe enough to sufficiently punish inmates for their crimes.

In contrast, the South Korean law seems to actually be an attempt to decrease the risk of repeat offense. "Chemical castration", as the article describes it, involves a mandatory injection of some compound (I won't speculate here what the compound might be) which would theoretically decrease the sex drive of the convict, but that is all. Those sentenced under this law would stay under close scrutiny for three years and receive treatment for up to 15 years. As I think about it, in the United States we already use antipsychotic or sedative medications for violent inmates even if they do not consent to treatment. Are sexual offenses all that different? I haven't thoroughly thought through the potential implications of such a move, but it doesn't seem like an unethical leap.

And after all, shouldn't our focus as a society be on rehabilitating criminals with intent to reintegrate them into the fabric of our society, rather than retaining our current system which encourages repeat offenders and establishes a rather large population of citizens who cycle in and out of prison for life? To take an extreme example of a rehabilitation-based system, consider the example of Norway. Last month, I was reading this article about the "World's nicest prison", located on an island off the coast of Norway. I encourage you to read the well-written, if lengthy, composition. It details the Norwegian judicial philosophy, including their short prison sentences and emphasis on teaching convicts how to return as productive members of society, and providing those opportunities.

Such a system doesn't leave the vengeful with much satisfaction, but I ask you to consider, should our focus be on making ourselves feel better about the proper retaliation against an offense, or should our focus rather be on reducing the "recidivism" rate, or risk of repeat offense after a criminal is released? Say what you will about the Norwegian system, the numbers don't lie. The Norwegian recidivism rate at 3 years out is 16-20%. In the U.S.? It's 43-50%. Food for thought.

NOTE: I greatly appreciates responses/discussion, but please keep it civil. Thank you.


  1. Your latest post is quite thought-provoking. It is also one of your best written yet. Although our world views are usually aligned, I have to emphatically disagree with you that chemical castration is an ethical solution. I consider it to be cruel and unusual punishment, a potential vehicle to various health problems, as well as a violation of the Fourteenth Amendment.

    As quoted from Wikipedia, "the actual effect of the procedure falls disproportionately upon men." Some may argue that men are disproportionately sex offenders in society, thus justifying the amendment violation. However, holes in this argument become glaringly apparent when one considers the fact that men are disproportionately in the majority in a number of categories.

    Rape is an evil, and to do so to children is an even worse monstrosity. Nonetheless, I cannot condone chemically altering or disfiguring any human being for their actions without their consent. I think we both feel that most crimes, serious or petty, are psychologically grounded. As a consequence, we must strive to fix the root of the problem instead of being quick-triggered to kill it. You cleverly allude to this in your discussion of the rehabilitation and reintegration of criminals back into society.

  2. Lobotomist,

    As usual, your comments are thought-provoking themselves and much aprpeciated. I do want to respond to what you said about "chemical castration", however. I think one of the problems with the treatment is pure semantics. "Castration" is a charged word that can evoke some powerful emotion. The treatment involves no more than the administration of a hormone, usually medroxyprogesterone acetate (or MPA- the active ingredient in the contraceptive shot Depo-Provera), with the intent to decrease sexual urges.

    Stigma aside, I'll grant you that a court-ordered medication administration is somewhat troubling. Regardless, the current situation in many of the United States and elsewhere is that administration of this medication is a requirement for the parole of certain sex offenders. Let me propose an alternative to this, which you may agree with, and perhaps could eventually replace the current legislation.

    My only concern with the laws as they are, is that the court orders a specific treatment for a psychiatric diagnosis, thus taking the role of treatment management out of the hands of physicians and putting it in the hands of the court. I would rather see something less specific. My proposal would be that, in order to be eligible for parole, repeat sex offenders must agree to see a psychiatrist on an ongoing basis and be compliant with the recommendations of that physician. Those treatment options certainly could include sex drive-lowering medications, but this puts management decisions back into the context of the relationship between patient and physician, where it ought to be.

    What are your thoughts?

  3. I also feel as if I should mention that, in the course of mulling this over, I discussed the topic with some of the attending psychiatrists at my institution. In addition to helping me formulate my above thoughts, they did mention to me that in their experience, patients who suffer from pedophilia and other paraphilias are almost always amenable to taking medications which lower their sex drive. I'll grant that this evidence is anecdotal, but I still found it worthwhile.

  4. In regards to your first paragraph, thank you for clarifying the procedure further. Although I understood what chemical castration is about(as I hinted in my previous comment, "...I cannot condone chemically altering or disfiguring any human being for their actions without their consent"), I appreciated your explanation of MPA.

    I like your proposal. I'm shocked that parolee's are not already required to routinely see a psychiatrist! How about we also ask repeat sex offenders to consent to MPA injections in order to be paroled instead of enforcing its administration? This is assuming that the court will not have a higher authority over the physician in the future (a possible issue you should lobby against perhaps?).

    I am also surprised to hear that some patients are amendable to taking medications to lower their sex drive. This goes against a recent statement made in an article on the Sandusky trial, where someone(either a psychiatrist or lawyer well experienced with convicted pedophiles) shared that these patients nearly always believe they did nothing wrong in hindsight.

    Interesting topic Dr. Gibson, thank you for starting the conversation!

  5. Good post, good questions.

    I think the choice you present us of satisfying our need for vengeance or reducing recidivism might be misleading. Deterrence might be another consideration which needs to be included among the possible options or factors to balance. Additionally, punishment might be distinct from vengeance -- punishment as a component of justice is different from a desire for personal vengeance. Also, I'm not sure if you are intending to make such a argument, but using reduced recidivism rates to argue for a rehabilitative or therapeutic theory of criminal justice risks circularity. The acceptance of recidivism rates as a valid measure of the performance of a criminal justice system presupposes that rehabilitation or the prevention of future offenses by the same person is the purpose of criminal justice -- which is precisely the proposition under consideration for which recidivism rates are being presented as evidence. Again, you did not explicitly make this argument, I simply wanted to warn of the potential for circularity.

    A few things from the Bastoy article also raised some questions:

    "This prison, he says, gives them a chance to see they have worth, "to discover, 'I'm not such a bad guy.' "
    In locked-down prisons, inmates are treated "like animals or robots," he said..."

    The example prisoner strangled his girlfriend; the other criminal mentioned shot 77 people. If these are not bad guys, then they are at least guys that do bad things. But the only way to avoid the conclusion they are bad guys is if those bad things were beyond their control or somehow caused by forces external to their volition ("Man is born free, yet he is everywhere in chains"). Since the philosophy behind this prison presupposes they are not bad guys, it must also assume these bad things were beyond their control or they are somehow not responsible. This denial of free agency seems to border on treating people like robots in the manner they accuse locked-down prisons of doing.

    "Many, however, don't want to leave. If they tried and failed, they would be forced to go to a higher-security prison and could have their sentences extended."

    Isn't this an example of the punishment mentality this prison was built to combat? Why would the threat of punishment of going to a lock-down prison be necessary if the idea of punishment for wrongdoing is itself wrongheaded?

    "Think of prison like parenting and it starts to make sense, said Mark A.R. Kleiman, a professor of public policy at UCLA..."

    How does this endorsement of paternalism interact with the principles of medical ethics you've studied?

  6. At the risk of arguing too much in my own voice, some comments from a British prison doctor seemed relevant to this discussion. These excerpts are from "Life at the Bottom" by Theodore Dalrymple, a collection of essays from a former prison doctor working at a poor, inner-city hospital in Britain.

    "Not long after academic criminologists propounded the theory that recidivists were addicted to crime (bolstering their theories with impressive diagrams of neural circuits in the brain to prove it), a car thief of limited intelligence and less education asked me for treatment of his addiction to stealing cars—failing receipt of which, of course, he felt morally justified in continuing to relieve car owners of their property... Is it surprising that recidivist burglars and car thieves now ask for therapy for their addiction, secure in the knowledge that no such therapy can or will be forthcoming, thereby justifying the continuation of their habit?"

    "Both parts of this message are welcome to my patients in the prison: that they are ill and in need of treatment, and that imprisonment is not only pointless but cruel and morally unjustified—less justified, indeed, than their crimes. After all, the judges who sentence them to imprisonment cannot exculpate themselves by virtue of their dysfunctional brains. No wonder that each week prisoners tell me, “Prison’s no good to me, doctor; prison’s not what I need.” I ask them what they do need, then. Help, treatment, therapy."

    "The creation of a universal disposition to do good, and not the creation of fear of the consequences of doing evil, was what was needed to extirpate crime. Not surprisingly, these were glad tidings to those tempted by the life of crime and demoralizing ones to those who upheld the law."

    Sorry for the long reply, but the issues you raised deserved more than a cursory response. =)