Table 1.
Ethical elements used in the literature to discuss the acceptability of coercion, classified under different levels of families (thematic groups).
| Group level 1: Broad families of ethical elements | Group level 2: Families of ethical elements | Group level 3: Ethical elements |
|---|---|---|
| Non-negotiable rejection | ||
| Non-negotiable respect for fundamental rights | Infringement of fundamental, non-negotiable rights | Coercion is an infringement of fundamental rights (freedom of movement and will, autonomy, bodily integrity), to be respected above all (1, 4, 9, 17, 18, 32, 42, 72–80) |
| Respect for human dignity | Dignity to be respected, not compatible with coercion (29, 30, 72, 81) | |
| Respect for moral values | Respect for autonomy | Autonomy as an intrinsic human value, to be respected at all costs (4, 17, 29–31, 72, 73, 76, 82, 83) |
| Respect for bodily integrity | Violating integrity is prohibited if decision-making capacity is present (1, 17, 73) | |
| Coercion prohibited if decision-making capacity is present (1, 4, 17, 31, 74) | ||
| Ontology of (a) mental disorder(s) | Mental disorder does not exist; hence, there is no legitimacy for the use of coercion (76, 82, 84, 85) | |
| Acceptability under conditions | ||
| Elements in favor of coercion | ||
| Prioritized moral values | Autonomy | Absence of contradiction between autonomy and coercion (86) |
| Autonomy to be considered when coercing (1, 9, 86, 87) | ||
| Respect for autonomy not absolute (32) | ||
| Supported autonomy (4) | ||
| Coercion of autonomous patients (1, 17, 77) | ||
| Integrity | Avoid damage to integrity if coercion is used (87, 88) | |
| Coercion is possible, but integrity may not be violated if autonomy is present (1, 17) | ||
| Respect for dignity | Dignity to be respected, even if patient is coerced (1, 9, 42, 73, 74, 87, 88) | |
| Coercion can bring a greater perception of dignity (4, 29, 81, 87, 89) | ||
| Dignity as an outcome of coercion assessments (32, 90) | ||
| Benevolence | Institutions and their measures are beneficial (1, 9, 41, 42, 77, 87, 88) | |
| Coercion is necessary if there is no other possibility of respecting benevolence (1, 4, 9, 17, 18, 31, 41, 42, 47, 68, 77, 81, 88) | ||
| Coercion is needed to protect the patient's interests (paternalism) (4, 9, 18, 29, 31, 32, 36, 40, 42, 47, 48, 73, 75, 77, 80, 86, 87, 89, 91) | ||
| The relational nature of the person allows one to intervene in his/her life (4, 39, 82) | ||
| Non-maleficence | Coercion is needed if there is no other possibility to respect non-maleficence (1, 4, 17, 31, 42, 77, 81) | |
| Coercion as an alternative to the occurrence of other damage or harm (1, 4, 9, 18, 29, 47, 73–75, 81, 88, 89, 92, 93) | ||
| Not using coercion would be non-assistance to a person in danger (17, 72, 86, 91, 94, 95) | ||
| Less frequent coercion for non-maleficent purposes (17) | ||
| Justice/fairness | Coercion for society's protection and well-being (9, 31, 72) | |
| Coercion to regulate with justice and fairness (1, 9, 11, 32, 77, 87) | ||
| Individual rights are to be balanced with the common good (74, 81, 91) | ||
| Coercion: Little reference to justice (4) | ||
| Safety | Safety of others (1, 4, 9, 31, 42, 47, 72–74, 81, 88, 89, 91, 93, 96, 97) | |
| Patient safety (4, 9, 25, 42, 72, 73, 81, 86–89, 91, 93, 98–102) | ||
| Community well-being | Community primacy (good of the many) (1, 29, 42, 72, 73, 81, 103) | |
| Authorized infringement of rights | Overriding fundamental rights and freedoms | Overstepping is allowed under certain circumstances (1, 9, 17, 29, 30, 77, 80, 95) |
| Restrictions on freedom to be adapted to the need for treatment (42, 47, 80, 104) | ||
| Dichotomous approach: Rights are respected or not (29) | ||
| Necessary coercion | Unavoidable coercion (1, 9, 17, 42, 73, 88, 93, 96, 105, 106) | |
| To consider coercion as unethical is too simplistic (9, 17, 32, 73) | ||
| Coercion as naturally present | Coercion is present in daily life (77, 87) | |
| Coercion is present in daily clinical practice (87) | ||
| Coercion is common in psychiatry (9, 32, 42, 75, 91) | ||
| Legal basis and official recommendations | Legislative norms regulate coercion (1, 4, 9, 17, 22, 37, 41, 42, 47, 73–75, 107, 108) | |
| Legal standards take the principle of autonomy into account (9, 32, 86) | ||
| Guidelines are based on scientific evidence and ethical outcomes (32, 109) | ||
| Factors influencing the justification of the infringement of rights | Dichotomous approach: Coercion is ethical (or not) (29) | |
| The conception of freedom changes the justification (74, 77) | ||
| Limits to the authorization of coercion | Fundamental rights to be respected, even under coercion (9, 42) | |
| Coercion requires ethical justification (1, 17, 31, 78, 110, 111) | ||
| Relational factors to consider | Physician's responsibility | Moral and legal responsibility toward the patient (9, 29, 42, 91, 95, 112) |
| Duty of care (25, 99, 103) | ||
| Necessary moral and professional qualities (4, 26, 32, 74, 87) | ||
| Avoid role-based conflicts (1, 38, 86) | ||
| Patient-caregiver interactions | Patient-caregiver relationship (1, 4, 9, 29, 32, 74, 82, 86–89) | |
| Communication (1, 4, 9, 74, 87, 88, 112–117) | ||
| Caregiver competence (1, 4, 9, 32, 72, 74, 87) | ||
| Debriefing in anticipation of the future (72, 74, 117) | ||
| Lack of health care personnel (72, 89, 93, 109) | ||
| Place of relatives | Relatives to be involved in decisions (1, 4, 11, 87) | |
| Coercion when relatives are exhausted or overwhelmed (1, 9, 29, 86, 91) | ||
| Beneficial, subjective perceptions | Of caregivers (4, 9, 29, 72–74, 93) | |
| Of patients (1, 4, 9, 29, 72, 74, 75, 87, 89, 116) | ||
| Elements against coercion | ||
| Respect for fundamental rights | Infringement of fundamental rights | Rights are to be respected, but can be overstepped in certain circumstances (31, 77, 81, 118) |
| Respect for human dignity | Risk of losing dignity with coercion (72, 87, 89, 90, 93) | |
| Respect for bodily integrity | Coercion as a violation of integrity (73) | |
| Respect for moral values | Respect for autonomy | Coercion affects autonomy (4, 17, 31, 74, 77) |
| Respecting autonomy allows one to decrease coercion (4, 31, 77, 100) | ||
| Autonomy to be respected unless there is danger or decision-making incapacity (1, 9, 18, 25, 31, 73, 81, 82, 103, 104, 112, 119–122) | ||
| A mental disorder does not imply a lack of autonomy (4, 9, 24, 31, 32, 76) | ||
| Benevolence | Coercion is contrary to the patient's interests (4, 31) | |
| Unjustifiable paternalism (4, 9, 29, 31, 32, 73, 76, 91, 104, 123, 124) | ||
| Benevolence often comes first in psychiatry, but is not enough (9, 29, 31, 76, 82) | ||
| Non-maleficence | Coercion is contrary to the principle of non-maleficence (32, 72, 125) | |
| Prevention of damage in advance is not justifiable (9, 73) | ||
| Safety | Unjustifiable coercion for safety (72, 126) | |
| Institutionalization for safety is not justifiable (9, 17) | ||
| Other elements weighing against coercion | Punitive coercion is unacceptable | Punitive use of coercion (4, 42, 73, 92) |
| Punitive perception of coercion (4, 31, 74, 89, 93, 102) | ||
| Difference between punishment and care (18, 32, 82, 126) | ||
| Abuse of power (4, 31, 72, 81, 87, 92) | ||
| Global process | Coercion prevents an increase in self-esteem and a sense of identity (31, 72) | |
| No proven efficacy (4, 17, 18, 31, 72, 75, 76, 82, 100, 126) | ||
| The interests of others are put before the patient's interests | Anticipation/comfort of caregivers (1, 9, 31, 73, 89, 93) | |
| Safety of others is important (6, 9, 18, 40, 42, 73, 76, 89, 127, 128) | ||
| Relatives involved in coercion-related decisions (1, 89, 93) | ||
| Adverse effects of coercion | Negative and traumatic experiences (1, 4, 31, 72, 74, 89, 93, 96, 103, 129–131) | |
| Risk or aggravation of somatic disorders (4, 17, 31, 75, 87, 89, 92, 93, 125, 130) | ||
| Personality changes (4, 18) | ||
| Coercion can impair decision-making capacity (4) | ||
| Informal coercion | Informal coercion to be considered as coercion in its own right, therefore to be justified (1, 9, 31) | |
| Informal coercion leaves the patient in a position of no choice (4, 9, 75) | ||
| Formal coercion | More serious consequences require more justification than informal coercion (4, 6, 77) | |
| Banalization (1, 38, 87) | ||
| Elements of inadmissibility of the justification of coercion | Decision-making capacity | Decision-making incapacity is not sufficient to justify coercion (1, 17, 31, 77, 123) |
| Ontology of (a) mental disorder(s) | A mental disorder does not justify coercion (1, 9, 24) | |
| Identical mental and somatic disorders (18, 32) | ||
| Preventing coercion | Alternatives (125) | Coercion not as the first phase of treatment (72) |
| Prevention, de-escalation, communication (4, 17, 18, 109, 117) | ||
| Recovery and advance directives (18, 32) | ||
| Relational factors to consider | Need for clearer recommendations to respect the patient | Respect for the patient's rights (25, 32, 42) |
| Research to be pursued (11, 18, 32, 86, 105, 132) | ||
| Hospital discharge: The gray area of no choice (9, 32) | ||
| Place of psychiatry and psychiatrists | The only discipline where treatment can be provided against the patient's will, so be careful (42, 72, 76) | |
| Psychiatry is caught between different norms (social, legal, medical), so there are tensions and pressures to be aware of for an ethical decision (26, 42, 87, 91, 110, 123) | ||
| Patient-caregiver relationship | Coercion alters the therapeutic relationship (4, 17, 31, 72, 120, 130) | |
| Coercion is used to avoid caregiver involvement (72, 89) | ||
| A strong relationship can reduce coercion (4, 10, 32, 93) | ||
| Caregiver competence | Lack of ability to assess dangerousness (81) | |
| Problem evaluating decision-making capacity (4, 9) | ||
| Subjective perceptions of caregivers | Negative emotions and guilt (4, 17, 74, 87, 89, 93, 132) | |
| Ambivalent feelings to be analyzed for a patient-centered decision, not the caregiver's self-interest (32, 74) | ||
| Coercion as the omnipotence of caregivers (1, 72, 73) | ||
| Other people's eyes (4, 73) | ||
| Subjective perceptions of patients | Negative experiences of coercion (4, 31, 72, 74, 75, 89, 93, 117, 120) | |
| Subjective perceptions may differ from objective measures, to be considered for the care and support of the patient (9, 75) | ||
| Principle of the least restrictive measure not applicable because assessment is subjective (74, 133) | ||
| Decision-making procedures for clinicians | ||
| Conditions for the fair application of coercion | Principles of proportionality and necessity (1, 17, 42, 47, 74, 81, 88, 93, 112) | |
| Principle of subsidiarity | Coercion as a last resort (1, 17, 26, 72, 75, 89, 91, 105, 134) | |
| Least restrictive method (1, 4, 9, 31, 41, 81, 93, 102, 135) | ||
| Choice of method with the best or least negative consequences (29, 74, 77, 81, 136) | ||
| Non-cumulative (but alternative) measures of coercion (1, 17, 81, 88, 93) | ||
| Necessary (but not sufficient) conditions | Severe mental disorder (1, 4, 9, 17, 18, 29, 32, 47, 74, 75, 77, 81, 86, 88, 91) | |
| Decision-making incapacity (1, 4, 9, 10, 17, 18, 29–32, 74, 75, 77, 81, 86, 89, 91, 105, 137) | ||
| Danger to oneself or others: the right to protection (1, 4, 9, 10, 17, 18, 29, 42, 73–75, 77, 81, 86–89, 91, 105, 113, 115, 134) | ||
| Need for care: the right to treatment (1, 4, 7, 9, 17, 18, 29, 31, 42, 47, 72, 74, 80, 81, 86–88, 91, 92, 94, 105, 124, 137, 138) | ||
| Emergency (1, 17, 18, 42, 81, 87, 91, 105) | ||
| Agitation/violence (1, 17, 73, 81, 89, 91–93, 98, 105, 113, 114, 134) | ||
| Justification according to the overall process of care in which the measure fits | Efficiency (1, 4, 9, 10, 17, 18, 29, 31, 32, 72–75, 77, 81, 86–89, 92, 93, 98, 105, 139) | |
| Coercion as a care setting (4, 9, 17, 72, 73, 77, 81, 91–93, 135, 139) | ||
| Recovery of autonomy, relational autonomy (4, 9, 17, 26, 37–39, 74, 77, 81, 87, 106, 114) | ||
| Post-acceptance (29, 77, 81) | ||
| Distinction between punishment and care (1, 18, 74) | ||
| Level of justification required | Degree of the coercion continuum (1, 4, 9, 29, 31, 77, 81, 87, 92) | |
| Degree of influence (4, 29) | ||
| Informal coercion to avoid formal coercion (4, 9, 31, 74, 77, 87) | ||
| Formal coercion varies (42, 47, 75) | ||
| Proper evaluation criteria | Evaluation according to dichotomous criteria (29) | |
| Individual assessment (1, 31, 42, 47, 74) | ||
| Decision-making capacity assessment (1, 4, 9, 29, 72, 77, 86, 91) | ||
| Intervention assessment (17, 74, 116, 118) | ||
| Assessment of future danger (4, 9, 29, 72, 73, 77, 91) | ||
| Evaluation of the lifting of the measure (1, 47, 73, 81, 87) | ||
| Assessor competencies (1, 29, 74, 87, 115) | ||
| Conflicting standards | According to the moral weight at stake (1, 4, 9, 17, 32, 42, 73, 74, 77, 81, 87, 88, 91, 136, 140) | |
| Autonomy–safety (1, 4, 9, 32, 42, 74, 87, 91, 93, 97) | ||
| Benevolence–autonomy (1, 4, 7, 17, 26, 29, 31, 42, 48, 74, 87–89, 91, 93, 136, 137, 140) | ||
| Non-maleficence-autonomy (1, 4, 17, 42, 74, 88, 91) | ||
| Beneficence–non-maleficence (4, 87) | ||
| Benevolence–safety of others (18, 40, 42, 73, 127, 128) | ||
| Benevolence–equity (4, 9) | ||
| Risk of abuse of power (4, 31, 74, 87, 130) | ||
| Choice of measure | Balance of benefits and adverse effects (17, 74, 101) | |
| Internal caregiver conflicts (4, 7, 25, 42, 74, 89, 93) | ||
| Value conflicts for relatives (87, 89, 91, 93) | ||
| Evaluation | Patient refusal does not imply decision-making incapacity (1, 9, 17, 24, 29, 31, 74, 77, 87, 91) | |
| Mental disorder does not imply decision-making incapacity (1, 4, 9, 18, 31, 75, 77, 81, 86) | ||
| Evaluation paradoxes | Choice between moral values (4, 87) | |
| Patients say what caregivers want to hear (29) | ||