The moral battleground of a prison psychiatrist

Objective Moral distress occurs when we know what the right thing to do is in accordance with our ethical principles and values, but institutional or other constraints make this difficult 1 . As psychiatrists and psychiatry trainees, we are asked to assume responsibilities and balance competing obligations to our patients, organisations, and the public. I offer a first-person narrative of the moral distress experienced by a prison psychiatrist. I hope it resonates with other psychiatrists and psychiatry trainees dedicated to addressing the moral challenges in mental health and inspires those to harness the moral courage to improve the broken systems in which we work. Conclusions Forensic psychiatrists who practice in the carceral system, a low resourced and punitive environment, encounter unique structural and institutional constraints on their moral judgement. These include the inequivalence of care, coercive practices, role conflicts, hierarchical power structures, and punitive laws. Such constraints on our moral agency invoke a complicity of wrongdoing and generate feelings of powerlessness where our moral intuitions are not heard or taken seriously. Moral distress is not unique to forensic psychiatry, but the sub-speciality is exemplary of the concept and offers fertile learning opportunities for other areas of psychiatric practice.