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Front Psychiatry. 2021; 12: 790886. Published online 2021 Dec 14. doi: 10.3389/fpsyt.2021.790886 PMCID: PMC8712490 PMID: 34970171 Marie Chieze, 1 , * Christine Clavien, 2
Stefan Kaiser, 1 and Samia Hurst 2 Author information Article notes Copyright and License information PMC Disclaimer
Chieze M, Clavien C, Kaiser S, Hurst S. Coercive Measures in Psychiatry: A Review of Ethical Arguments. Front Psychiatry. 2021 Dec 14;12:790886. doi: 10.3389/fpsyt.2021.790886. PMID: 34970171; PMCID: PMC8712490.
Abstract Introduction: Coercion is frequent in clinical practice, particularly in psychiatry. Since it overrides some fundamental rights of patients (notably their liberty of movement and decision-making), adequate use of coercion requires legal and ethical justifications. In this article, we map out the ethical elements used in the literature to justify or reject the use of coercive measures limiting freedom of movement (seclusion, restraint, involuntary hospitalization) and highlight some important issues.
Methods: We conducted a narrative review of the literature by searching the PubMed, Embase, PsycINFO, Google Scholar and Cairn.info databases with the keywords “coercive/compulsory measures/care/treatment, coercion, seclusion, restraint, mental health, psychiatry, involuntary/compulsory hospitalization/admission, ethics, legitimacy.” We collected all ethically relevant elements used in the author's justifications for or against coercive measures limiting freedom of movement (e.g., values, rights, practical considerations, relevant feelings, expected attitudes, risks of side effects), and coded, and ordered them into categories.
Results: Some reasons provided in the literature are presented as justifying an absolute prohibition on coercion; they rely on the view that some fundamental rights, such as autonomy, are non-negotiable. Most ethically relevant elements, however, can be used in a balanced weighting of reasons to favor or reject coercive measures in certain circumstances. Professionals mostly agree that coercion is only legitimate in exceptional circumstances, when the infringement of some values (e.g., freedom of movement, short-term autonomy) is the only means to fulfill other, more important values and goals (e.g., patient's safety, the long-term rebuilding of patient's identity and autonomy). The results of evaluations vary according to which moral elements are prioritized over others. Moreover, we found numerous considerations (e.g., conditions, procedural values) for how to ensure that clinicians apply fair decision-making procedures related to coercion. Based on this analysis, we highlight vital topics that need further development.
Conclusion: Before using coercive measures limiting freedom of movement, clinicians should consider and weigh all ethically pertinent elements in the situation and actively search for alternatives that are more respectful of patient's well-being and rights. Coercive measures decided upon after a transparent, carefully balanced evaluation process are more likely to be adequate, understood, and accepted by patients and caregivers.
Introduction Coercive measures, defined as any measure applied “against the patient's will or in spite of his or her opposition” (1), are commonly used in clinical medical practice, particularly—but not exclusively—in psychiatry (2, 3). The definition of “coercive measures” is complex. These include formal coercion, such as actions limiting freedom of movement (restraint, seclusion), involuntary hospitalization, and forced treatment (4). Informal coercion is another part of the concept and includes any form of influence, pressure, or manipulation of the patient's decisions (5). Formal and informal coercion are conceived as a continuum ranging from persuasion, interpersonal leverage, inducements, and threats to compulsory treatment (5–7).
However, this distinction between formal and informal coercion may not be clear, and in practice, there are “gray areas” with sometimes unclear boundaries between a strong incentive and coercion (5, 6). Coercion is also defined according to the subjective perceptions of patients, caregivers, or other stakeholders (lawyers, relatives), which may differ from the objective measures used (8, 9). Different understandings of coercion have an impact on the care provided and are hence important to consider (10, 11). For instance, Trachsel et al. (12, 13) distinguished between curative and palliative psychiatric care based on the definition of palliative care given by the World Health Organization (WHO). From this perspective, the use of coercion may be legitimate or not, depending on whether it is used for a palliative or curative reason (7, 12). In addition, coercive measures with more serious consequences call for greater justifications (6, 12).
Coercive measures infringe on several fundamental rights based on ethical principles (autonomy, freedom of movement and will, bodily integrity). Fundamental rights are guaranteed by the Declaration of Human Rights, the European Convention on Human Rights and Bioethics (14, 15), the Convention on the Rights of Persons with Disabilities (CRPD) (16), and the laws of most countries (1, 17–19); they underpin professional guidelines such as the World Psychiatric Association's Madrid Declaration (20). Despite this, there are crucial variations across (and sometimes within) countries in local legal frameworks and in the ways in which coercion is applied (10, 11, 21).
Allowing coercion involves giving priority to some reasons and principles at the expanse of the fundamental rights and principles infringed by coercion (11, 22). This raises ethical questions about the primacy of the ethical principles used to legitimize coercive measures (4, 23) and about the way in which the principles ought to be properly “balanced” (12, 24, 25). This task is not easy as there is no consensus on the appropriate moral theory to apply (26, 27). For instance, the more we value the personhood of a disturbing patient, the greater the justification required to restrict his/her fundamental rights for the sake of protecting others (care providers, other patients, citizens) (6). Moral theories diverge in the comparative importance they place on different values (e.g., autonomy vs. liberty, community vs. individual rights vs. duties toward others or vs. community rights) (6, 26, 27).
Compared to the 18th century and to many contemporary states, modern Western societies tend to stress the importance of personhood, the individual's place in the community, and the development and prioritization of the principles of self-determination and autonomy (26, 28–30). This societal evolution has changed society's way of thinking about psychiatric care and the identity and vision of psychiatry as a discipline (26). Recent emphasis on the right to autonomy involves questioning the legitimacy of the paternalistic attitude that used to be the norm in medical care. Patient's best interests are increasingly taken as critical elements for deciding upon or justifying coercive measures (26, 28). Consequently, caregivers who assume that they know better than patients what is good for them tend to be considered authoritative and paternalistic. The risk of abuse of power associated with paternalism is now taken seriously (31, 32). The issue of paternalism is hotly debated in medical ethics (28, 33), especially in psychiatry (27, 34) and the context of coercive interventions (4, 6, 7, 35, 36).
Distinctions between strong/hard vs. weak/soft paternalism and social (for the good of the community) vs. medical (for the good of the individual) paternalism have been made (4, 7, 27, 28, 33, 34). Moreover, new approaches to ethics of care have emerged, such as relational ethics (37–39), which have helped people to reconsider the individual in a relational context within society. New concepts have appeared such as relational autonomy, which may help us to view coercion in a new light as a practice of care. Indeed, one may try to protect the patient by providing coercive treatment with the aim of facilitating the long-term recovery of autonomy, even if it implies a temporary override of the patient's self-determination (4, 26, 28, 37). This approach of coercion can be conceived of as soft paternalism (7, 40, 41).
Apart from the debates around medical paternalism, ethical discussions regarding the tensions between coercion and the respect of fundamental rights are understudied in psychiatry (4), which is paradoxical since limitations on one's freedom occur more often in medical (including psychiatric) contexts than in other civil or social areas (4, 9, 42). This infringement of freedom, present in coercive care, hinders patients from exercising their autonomy. The notion of autonomy is also complex and diversely understood in the literature, which may affect the evaluation of coercive measures. Studies often associate autonomy with decision-making capacity (4). However, this is not always the case.
Autonomy can also be understood as being able to make choices (even people with decision-making capacity might not be autonomous) and to realize one's priorities and values (23, 43, 44). It seems, therefore, that autonomy and decision-making capacity are interdependent but in a complex modality, depending on the individual's temporality and identity (45). This complex relationship between autonomy and decision-making capacity deserves an in-depth analysis (27, 34).
In practice, evaluating the acceptability of a coercive measure often implies evaluating the patients' decision-making capacity (DMC). DMC is an important element to take into account because it refers to the principle of autonomy, and coercions imply overriding patient's autonomy (37, 46–48). In some countries, the laws regulating coercion do not specifically refer to DMC, but in most countries and legal systems, one of the conditions for justifying coercion with a patient is his/her lack of DMC (26, 27, 34, 47). From a legal point of view, DMC involves patient's cognitive abilities (46) and is presumed to exist in adults (49–52). In case of doubt, its evaluation depends on the situation (intervention, time) and on the particular decision that the patient is expected to make (49, 53).
However, in detail, the way DMC is regulated differs across countries. In the US, the definition developed by Grisso and Appelbaum is widely used (54): DMC requires understanding, appreciation, reasoning, and making a choice (54–57). In Switzerland, DMC requires understanding (grasping the fundamental elements of the information relevant for a decision), evaluating information (assigning personal meaning to a situation in light of the options available), making a choice (deciding on the basis of the information available and one's own experience, motives and values), and expressing a decision (communicating and defending a choice) (58).
In England and Wales, DMC is regulated by the Mental Capacity Act (MCA) of 2005 and requires understanding, retaining, using or weighing information, as well as giving an option (49–51, 59–62). In this model, appreciating and reasoning (Grisso and Appelbaum) are replaced by using or weighing (51, 63–66), but it is not obvious that these terms are equivalent (51). Independent of the particular definition of DMC, a common controversy surrounds its evaluation for people suffering from mental disorders, whether they are decompensated or not (14–16, 31, 67).
Furthermore, the principles of “evidence-based medicine” require scientific evidence of the effectiveness of coercion. When a coercive measure is supposed to guarantee safety (to protect others from a patient's aggressive or disturbing behavior), evidence for risk reduction and forensic or social outcomes should be provided (68). Similarly, when a coercive measure is advocated as a way to treat a patient, it should be demonstrated that coercive measures benefit patients by contributing to their therapy or diagnosis in the short, medium, or long term (69).
Indeed, some coercive measures may facilitate the treatment of symptoms or allow for the precise and formal detection of a pathology. The implementation of coercion's efficacy in terms of diagnosis or therapy is much debated, and current scientific data are the subject of controversy (4, 21, 32, 70). From an ethical standpoint, the absence of scientific evidence of therapeutic effectiveness does not necessarily indicate that a type of therapy is illegitimate. This has been discussed in the literature (71) and in psychiatry (69), but little has been written about the particular case of coercion. It therefore seems worthwhile to more closely examine the ethical foundations of legitimate coercive measures.
Being able to justify a coercive measure is not only ethically significant; it also helps to alleviate tensions in clinical practice. Notably, it is critical to distinguish therapeutic and diagnostic goals from safety-based or protective goals (for the patient or others) and to recognize that the latter are not necessarily sufficient reasons to justify coercion. Conversely, safety and risk reduction may be conceived of as a means to achieve therapeutic goals because living in a safe environment favors individual reconstruction. This underlines the importance of thinking about coercion in the global context of long-term care. It would be interesting to see if professionals make these distinctions when discussing the adequacy of coercive measures.
In this article, we map out the ethical reasons used in the literature to assess coercive actions that impose limits to freedom of movement; that is, involuntary admission, seclusion, and restraint. To avoid covering an area that is too broad, we will exclude discussions related to informal coercion and coerced medication. We present the results of our literature search and of our qualitative analysis of the selected articles: We map out the ethical elements used in the literature to justify or reject the use of coercion. We then examine and weigh these elements, and address their relevance for assessing the acceptability of coercion in particular clinical settings. Finally, we highlight a series of important issues.
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