Clinical, Ethical Impacts of Solitary Confinement on Health

In this episode of Medical Ethics Unpacked, hosts Dominic Sisti, PhD, of Penn Medicine and Steve Levine, MD, of Compass Pathways, joined by Rose Onyeali, MD, clinical assistant professor at Penn Medicine, and Penn student Chinelo Osakwe, examine the psychological and physiological impact of solitary confinement among incarcerated populations.

The full episode can be viewed here.

This Q&A captures a segment of the conversation focusing on the clinical and ethical implications of isolation in correctional settings. Onyeali describes how prolonged confinement can disrupt circadian rhythms, limit mobility, and restrict access to sunlight and social interaction, which are factors that may accelerate physical decline and worsen cognitive health. The discussion also highlights efforts to support cognitive resilience inside correctional environments, including simple occupational strategies aimed at maintaining mental engagement.

Beyond the clinical effects, the exchange also explores the ethical tensions clinicians may face when providing care within the carceral system. As Sisti notes, research links time spent in solitary confinement with greater risks of suicide and adverse mental health outcomes after release. This raises questions about how physicians balance patient advocacy with the structural realities of correctional healthcare.

Sisti: Tell us more about what solitary confinement can do to an individual, both emotionally and psychologically, but also physically. When you talk about dementia, accelerated aging, what do we know from the evidence?

Onyeali: I always try to explain, even to residents, every solitary confinement is different. I know the hospital is not solitary confinement, but we even notice, even with younger people, or even people who are older, they lose track of time just being in the hospital. So, imagine solitary confinement. Your time is now warped. In the hospital, you're being forced to sit still. I [have to] remind [residents] that being in the hospital for five days in the bed, automatically your lung volumes are changed. Physically, that's impacting you.

You have the deprivation mentally, but you also have physical impacts of not being able to move and things of that nature. And then…everyone talks about race like it's more a Black issue. I call it everybody's issue, because…more than 50% of white people are inside prisons and jails.

It's pretty crazy to me, but [the] reality of it is, Black Americans…need vitamin D. We saw [during] COVID… [inmates would] get an hour outside…. [With] solitary confinement, you get nothing outside. Those are big impacts.

We tried to use occupational therapy to give the men ideas and ways of keeping their minds active. Not even just solitary confinement, [but] being inside the prison still has big cognitive effects.

Osakwe: When the occupational therapist came…the men are kind of just like, what is that going to do for me? When they think medicine, they think [of] health, they think [of] your heart. They think their lungs and things like that. But I was like, ‘No, you guys need to listen. These things are helpful for even us outside, but something as small as brushing your teeth with your non-dominant hand that can break apart the overly structured carceral environment.’ You can make it a little challenge.

With people who are in here, you know, ask, ‘Oh, how many days have you been doing it? And if you haven't been doing it…. It’s a little game now, and it's something that won't get you in trouble, won't get you put in the hole, or get your privileges revoked, because you're not doing anything outside of the structure. But at the same time, that's [a] way for you to self-advocate for yourself. On the one hand, it's fun, it's a game, but on the other hand, it is literally good for your cognition.

Sisti: I recently read a paper that indicated that anyone who's ever spent time in the hole in solitary has had [a] significantly higher risk of suicide, even in re-entry. Most of the world considers solitary confinement torture, right? It's banned in most countries, most developed nations. It does seem like we have a major problem on our hands, from an ethics perspective and from a clinical perspective.

How do you, Rose, as a doctor, deal with this conflict between being a caregiver for folks inside, and also do you ever feel like you're part of the problem when you're helping somebody adapt to solitary [confinement]? How do you navigate this issue of being part of the jail system but also an advocate for your individual patient?

Onyeali: I don't work completely inside with the medical team. Unfortunately, we have done our best to separate ourselves from the medical team inside, just because that's the way that the Department of Corrections has it.

One thing that we have tried to definitely do [is]…bringing in providers from outside to see what it's like inside and trying to make providers who come inside with us [to] go outside and express a lot of those issues to other residents, other trainees. One thing that we've noticed, even before I did this, was that when we talk to trainees and people who are in medicine, a lot of them don't realize that they're dealing with people who are formerly incarcerated almost every day. I don't know if you know this stat, [but] 1 out of 35 people in Philadelphia are under supervision, and what we mean by that is they're either incarcerated, or they are on parole or probation. That’s 1 out of 35 adults, so we encounter them in our day-to-day. Philadelphia is one of the most incarcerated cities in the world.

Dr. Eberly is…a cardiologist at Penn just released a paper about the effects of supervision, and how it actually affects your health worse than being inside… the health outcomes are worse if you look at all the supervision. That's another area that medicine research hasn't done much on.

One thing that I do to make myself feel less helpless….as a provider or a human being is doing this program. I've been recruited to doing more evaluations inside the prison due to [an 2018 ACLU] lawsuit in Pennsylvania … a lot of people don't realize that the ACLU has won a lawsuit about [the > 100] men that were on death row put in solitary. Now, [with] that lawsuit, they're actually starting to act on it.