Coercive Measures in Psychiatry: A Review of Ethical Arguments

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.

Regulatory issues and law enforcement practice of using coercive measures, such as isolation and involuntary hospitalization on epidemiological grounds

The article examines the possibility of applying compulsory hospitalization and isolation to persons infected with the coronavirus, and to persons who have been in contact with the former. There are two mechanisms of coercion: coercive measures and mandatory measures. A distinction is made between the concepts of hospitalization and isolation, and legal subjects of the relevant legal relations are analyzed. The scientific and theoretical provisions of the article are illustrated by the author using the example of Russian legislation (codes and other federal laws, bylaws of the Ministry of Health of the Russian Federation and Rospotrebnadzor, relating to both substantive law and procedural law), as well as practice that has developed or is only emerging in domestic courts. At the end of the article, the existing regulatory problems, in particular conflicting regulation, are described and some solutions are proposed.

Do no harm in due process – a historical analysis of social determinates of institutionalization in the USA

Involuntary hospitalization has been a fundamental function of psychiatric care for mentally ill persons in the USA for centuries. Procedural and judicial practices of inpatient psychiatric treatment and civil commitment in the USA have served as a by-product of socio-political pressures that demanded constant reform throughout history. The origin of modern commitment laws can best be understood through the lens of cultural paradigms that led to their creation and these suggest caution for future legislative amendments.

Continuity of antipsychotic medication use among migrant and Finnish-born populations with a psychotic disorder: a register-based study

Background Higher incidence of psychotic disorders and underuse of mental health services have been reported among many migrant populations. This study examines the initiation and continuity of antipsychotic treatment among migrants and non-migrants with a non-affective psychosis during a new treatment episode. Methods This study is based on a nationwide sample of migrants and Finnish-born controls. Participants who were diagnosed with a psychotic disorder in 2011–2014 were identified from the Care Register for Health Care (n = 1693). Information on purchases of antipsychotic drugs in 2011–2015 was collected from the National Prescription Register. The duration of antipsychotic treatment since diagnosis was estimated using the PRE2DUP model. Cox regression analysis was used to study factors that are associated with discontinuing the use of medication. Results There were fewer initiators of antipsychotic treatment after being diagnosed with psychosis among migrants (68.1%) than among Finnish-born patients (73.6%). After controlling for sociodemographic background and factors related to the type of disorder and treatment, migrants were more likely to discontinue medication (adjusted hazard ratio 1.28, 95% confidence interval 1.08–1.52). The risk of discontinuation was highest among migrants from North Africa and the Middle East and Sub-Saharan Africa and among recent migrants. Non-use of antipsychotic treatment before being diagnosed with psychosis, involuntary hospitalization and diagnosis other than schizophrenia were associated with earlier discontinuation both among migrants and non-migrants. Conclusions Migrants with a psychotic disorder are less likely to continue antipsychotic treatment than non-migrants. The needs of migrant patients have to be addressed to improve adherence.

Factors associated with involuntary psychiatric hospitalization in Portugal

Background Identifying which factors contribute to involuntary psychiatric hospitalization may support initiatives to reduce its frequency. This study examines the sociodemographic, clinical, and contextual factors associated with involuntary hospitalization of patients from five Portuguese psychiatric departments in 2002, 2007 and 2012. Methods Data from all admissions were extracted from clinical files. A Poisson generalized linear model estimated the association between the number of involuntary hospitalizations per patient in one year and sociodemographic, clinical, and contextual factors. Results An increment of involuntary hospitalizations was associated with male gender [exp($$\widehat{\upbeta }$$ β ^ ) = 1.31; 95%CI 1.06–1.62, p < 0.05], having secondary and higher education [exp($$\widehat{\upbeta }$$ β ^ ) = 1.45; 95%CI 1.05–2.01, p < 0.05, and exp($$\widehat{\upbeta }$$ β ^ ) = 1.89; 95%CI 1.38–2.60, p < 0.001, respectively], a psychiatric diagnosis of psychosis [exp($$\widehat{\upbeta }$$ β ^ ) = 2.02; 95%CI 1.59–2.59, p < 0.001], and being admitted in 2007 and in 2012 [exp($$\widehat{\upbeta }$$ β ^ ) = 1.61; 95%CI 1.21–2.16, p < 0.01, and exp($$\widehat{\upbeta }$$ β ^ ) = 1.73; 95%CI 1.31–2.32, p < 0.001, respectively]. A decrease in involuntary hospitalizations was associated with being married/cohabitating [exp($$\widehat{\upbeta }$$ β ^ ) = 0.74; 95%CI 0.56–0.99, p < 0.05], having experienced a suicide attempt [exp($$\widehat{\upbeta }$$ β ^ ) = 0.26; 95%CI 0.15–0.42, p < 0.001], and belonging to the catchment area of three of the psychiatric services evaluated [exp($$\widehat{\upbeta }$$ β ^ ) = 0.65; 95%CI 0.49–0.86, p < 0.01, exp($$\widehat{\upbeta }$$ β ^ ) = 0.67; 95%CI 0.49–0.90, p < 0.01, and exp($$\widehat{\upbeta }$$ β ^ ) = 0.67; 95%CI 0.46–0.96, p < 0.05 for Hospital de Magalhães Lemos, Centro Hospitalar Psiquiátrico de Lisboa and Unidade Local de Saúde do Baixo Alentejo, respectively]. Conclusions The findings suggest that involuntary psychiatric hospitalizations in Portugal are associated with several sociodemographic, clinical, and contextual factors. This information may help identify high-risk patients and inform the development of better-targeted preventive interventions to reduce these hospitalizations.

Involuntary psychiatric hospitalization among migrants in Italy: A matched sample study

Background: Immigrants in Europe appear to be at higher risk of psychiatric coercive interventions. Involuntary psychiatric hospitalization poses significant ethical and clinical challenges. Nonetheless, reasons for migration and other risk factors for involuntary treatment were rarely addressed in previous studies. The aims of this study are to clarify whether immigrant patients with acute mental disorders are at higher risk to be involuntarily admitted to hospital and to explore clinical and migratory factors associated with involuntary treatment. Methods: In this cross-sectional matched sample study, we compared the rates of involuntary treatment in a sample of first-generation immigrants admitted in a Psychiatric Intensive Care Unit of a large metropolitan academic hospital to their age-, gender-, and psychiatric diagnosis-matched native counterparts. Clinical, sociodemographic, and migratory variables were collected. The Brief Psychiatric Rating Scale-expanded (BPRS-E) and the Clinical Global Impression-Severity (CGI-S) scale were administered. McNemar test was used for paired categorical variables and a binary logistic regression analysis was performed. Results: A total of 234 patients were included in the analysis. Involuntary treatment rates were significantly higher in immigrants as compared to their matched natives (32% vs. 24% respectively; p < .001). Among immigrants, involuntary hospitalization was found to be more frequent in those patients whose length of stay in Italy was less than 2 years (OR = 4.2, 95% CI [1.4–12.7]). Conclusion: Recently arrived immigrants appear to be at higher risk of involuntary admission. Since coercive interventions can be traumatic and negatively affect outcomes, strategies to prevent this phenomenon are needed.

Involuntary hospitalization

The chapter outlines a series of arguments designed to answer possibly the most important ethical question in psychiatry: under what circumstances, if any, is it ethically justifiable to treat people with clinical features of mental illness, despite their objection? We argue that involuntary inpatient treatment is ethically justified, but only in circumstances where: the objection to treatment was made without decision-making capacity; there is no reason to believe that the person would have objected had he or she been competent; the treatment will protect the person from serious harms (when balancing these with any harms associated with the treatment); and involuntary treatment represents the avenue for protection least restrictive of the person’s freedom. Having established a model for ethically justified involuntary inpatient psychiatric treatment, we examine how it can be applied to two real-world cases.

Factors Associated With Involuntary Psychiatric Hospitalization in Portugal

BackgroundIdentifying which factors contribute to involuntary psychiatric hospitalization may support initiatives to reduce its frequency. This study examines the sociodemographic, clinical, and contextual factors associated with involuntary hospitalization of patients from five Portuguese psychiatric departments in 2002, 2007 and 2012.MethodsData from all admissions were extracted from clinical files. A Poisson generalized linear model estimated the association between the number of involuntary hospitalizations per patient in one year and sociodemographic, clinical, and contextual factors.ResultsMale gender [exp(β̂) = 1.31; 95%CI:1.06-1.62, p<0.05], having secondary and higher education [exp(β̂) = 1.45; 95%CI:1.05-2.01, p<0.05, and exp(β̂) = 1.89; 95%CI:1.38-2.60, p<0.001, respectively], a psychiatric diagnosis of psychosis [exp(β̂) = 2.02; 95%CI:1.59-2.59, p<0.001], and being admitted in 2007 and in 2012 [exp(β̂) = 1.61; 95%CI:1.21-2.16, p<0.01, and exp(β̂) = 1.73; 95%CI:1.31-2.32, p<0.001, respectively] were associated with an increment of involuntary hospitalizations. Being married/cohabitating [exp(β̂) = 0.74; 95%CI:0.56-0.99, p<0.05], having experienced a suicide attempt [exp(β̂) = 0.26; 95%CI:0.15-0.42, p<0.001], and belonging to the catchment area of three of the psychiatric units evaluated [exp(n) =0.65; 95%CI:0.49-0.86, p<0.01, exp(β̂) = 0.67; 95%CI:0.49-0.90, p<0.01, and exp(β̂) = 0.67; 95%CI:0.46-0.96, p<0.05 for Hospital de Magalhães Lemos, Centro Hospitalar Psiquiátrico de Lisboa and Unidade Local de Saúde do Baixo Alentejo, respectively] were associated with a decrease in involuntary hospitalizations.ConclusionsThe findings suggest that involuntary psychiatric hospitalizations in Portugal are associated with sociodemographic, clinical, and contextual factors. This information may help to recognize high-risk patients, and to inform the development of better-targeted preventive interventions to reduce these hospitalizations.

Patient Protection and Paternalism in Psychotherapy

This chapter provides a synthetic overview of the ethics of paternalism in psychotherapy with a focus on involuntary hospitalization to protect patients from self-harm. Paternalism entails the intentional overriding of someone’s preferences or actions on grounds of beneficence and nonmaleficence. After the emergence of autonomy in medical ethics, paternalism is generally considered prima facie wrong, as it infringes on patient autonomy, trust, and right to informed consent. In particular, the use of paternalism in psychotherapy raises a host of complex and delicate ethical issues due to the nature of the therapeutic relationship and the difficulty to assess the autonomy of the person who will supposedly benefit from the paternalistic intervention.