Medical Ethics Unpacked: Ethical Challenges of Carceral Healthcare

In the latest episode of Medical Ethics Unpacked, hosts Dominic Sisti, PhD, a bioethicist from Penn Medicine, and Steve Levine, MD, a psychiatrist from Compass Pathways, unpack the ethical and clinical challenges of carceral healthcare, a topic many clinicians encounter in practice but rarely receive formal training in. The discussion features Rose Onyeali, MD, clinical assistant professor at Penn Medicine, and Penn student Chinelo Osakwe, who collaborate on initiatives aimed at improving health education and advocacy for incarcerated populations.

The episode explores how incarceration, particularly solitary confinement, can have lasting physical, psychological, and neurological effects. Onyeali described how deprivation of movement, sunlight, and social interaction can accelerate both cognitive and physical decline among incarcerated individuals.

Osakwe, a neuroscience major planning to pursue medicine, highlighted the neurological implications of prolonged isolation. She explained that extended periods without social interaction can alter brain structure and function, contributing to chronic stress responses and long-term mental health consequences after individuals leave solitary confinement.

“Humans are inherently social primates,” Osakwe said. “Your amygdala gets a little bit bigger; your hippocampus gets a little bit smaller. All these little things that are happening, your fight or flight, your hypothalamus, it's running like crazy…and then you come out…but you're still kept from outside the world. It has a big impact. Something as small as brushing your teeth with your non-dominant hand…can break apart the overly structured carceral environment. You can make it a little challenge. 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. At the one hand, it's fun, it's a game, but on the other hand, it is literally good for your cognition.”

A major focus of the conversation is the rapidly aging prison population. Onyeali explained that correctional systems often classify individuals > 50 years as geriatric because incarceration accelerates aging and increases the prevalence of chronic disease and cognitive impairment. Yet clinicians working inside and outside correctional facilities may lack training to recognize conditions such as dementia in this population.

The episode also highlights systemic gaps in care for people transitioning out of incarceration. Even when individuals qualify for compassionate release or medical parole, many struggle to access housing, long-term care facilities, or coordinated medical follow-up. As Onyeali noted, “There's transition for people who…have drug issues or HIV, things of that nature…but there isn't a transition for especially the older adults with these chronic issues.”