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