Ethics of Coercive Treatment and Misuse of Psychiatry

Why should a person not have the right to refuse treatment—and the right to remain ill? Nobody would be forced to accept a diabetes diet, drugs for increased blood pressure, or chemotherapy or surgery for cancer, even if there was a considerable risk of deterioration of health or even death. Then why should a person with schizophrenia or mania be forced to take medication against his or her will? Psychiatrists who say that such coercion is appropriate should provide good reasons in order to respond to the harsh criticism that has been voiced in many countries and with increasing frequency since ratification of the United Nations Convention on the Rights of Persons With Disabilities (UN-CRPD). This convention has been ratified by 160 countries worldwide, not including the United States.

Even though the U.S. Senate refused to ratify the UN-CRPD in 2012, the United States has been viewed from a European perspective as a model in realizing the rights of persons with disabilities for many years. In many European countries, the convention has had considerable impact in various areas of society, particularly in education systems. In regard to psychiatric services, articles 12 (equal recognition before the law), 14 (liberty and security of the person), and 15 (freedom from torture and inhuman or degrading treatment or punishment) are particularly important. Essentially, the UN-CRPD does not address the construct of impaired capacity, but it also does not mention any special groups of people with disabilities, such as people with mental disabilities. Whether or not a person with a mental disorder is considered as disabled is not important, because the convention specifies only rights that should be valid for all humans.

Although the UN-CRPD represents a logical next step in a series of human rights declarations since 1948, a more radical and specific interpretation was presented in 2013 by the Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1) and by general comments in 2014 (2). In these documents, it is argued that article 12 recognizes that all persons enjoy “legal capacity” in all aspects of life on an “equal basis with others.” Therefore, the “medical necessity doctrine” and the “best interest doctrine” are denied; coercive treatment is linked to torture, with a demand for abolishment of any coercive measures. The documents recommend that national policies should ban any coercive treatment and that all laws or policies related to “substituted decision making” should be replaced with “supported decision making” options. The above positions pose a challenge for medical ethics, in which the concept of impaired capacity plays a central role in decisions made against a patient’s will. In this Open Forum, I primarily address the issue of involuntary treatment, which for the past 30 years has been separated from involuntary detention in legal frameworks in most developed countries, including the United States. I also discuss some consequences regarding involuntary detention.

Principle-Based Ethics

Principle-based ethics is now the most common approach in medical ethics. On the basis of an analysis of all historical approaches in medical ethics, Beauchamp and Childress (3) identified four equivalent principles: respect for the patient’s autonomy, beneficence, nonmaleficence, and justice. With respect to patient autonomy and therapy, the gold standard is the concept of “informed consent.” The physician’s duty is to enable an autonomous decision by the patient, based on free will and in full knowledge of beneficial and potential adverse aspects of the suggested therapy, ideally consenting in shared decision making. There is evidence that shared decision making is as possible in psychiatry as it is in any other medical disciplines (4). However, ethical principles are sometimes in conflict, rendering decisions about ethically appropriate actions difficult, particularly when, in the view of others, the patient’s expressed intentions seem unreasonable and in contradiction to his or her best interest. The use of coercion in such cases by definition violates the principle of autonomy. Furthermore, coercive treatment can impose harm on the patient because of short-term and long-term medication side effects and psychological distress. Therefore, the use of coercion can be justified only if the principles of beneficence (acting in the patient’s best interest), nonmaleficence, or justice are in strong contradiction to the patient’s expressed will and if convincing observations indicate that the patient’s autonomy is severely undermined.

For example, consider the typical case of Anna, an 85-year-old female patient with acute inflammation of the gall bladder who has consented to cholecystectomy after being given comprehensive information. In a delirious state after the surgery, she wants to remove infusions with antibiotics (which she calls poison) and go home, saying that she has to go to work and that she is currently in a “madhouse” with malevolent people around her. Most people would conclude that it would not be right to let Anna go home, because doing so would lead to a deleterious outcome. The key aspect of this scenario is that the patient is suffering not only from a somatic disease but also from a mental state (delirium) that impairs her ability to make free decisions, which may or may not be reasonable and in her best interest. However, there are good reasons to assume that the patient would consent to the continuation of treatment in her best interest if she was not delirious and that she will later approve the decision. In this case, principle-based ethics can justify a limited amount of coercion, and the justification does not depend on whether the patient is treated on a psychiatric or surgical unit.

However, it is more difficult to determine whether the same is true for Thomas, a 27-year-old man who has discontinued his antipsychotic medication after several psychotic episodes and now hears commanding voices, acts in a strange manner, and strongly rejects any suggestion that he resume taking medication. In considering the four principles, we are confronted with new and challenging questions.

Autonomy, Insight, and Capacity to Consent

The ethical concept of capacity to consent differs from legal competence. Capacity to consent is always related to a concrete situation. Patients must be able to understand relevant information, relate that information to their personal situation, and make a balanced decision (5). Many instruments have been developed to assess capacity, and it is well known that clinicians tend to overestimate their patients’ capacity (6). In most European countries, however, such instruments are considered to be inappropriate and are not used in practice. Assessment of capacity is viewed as a complex idiographic, empathic procedure that should take into account the patient’s cognitive capacity, emotional and psychopathological features, history, and personality.

A patient like Thomas may understand that there is a disorder called “psychosis” that can be successfully treated in many cases with dopamine receptor–blocking agents but may deny that he suffers from such a state himself. Being unable to relate relevant information to his own situation, this patient would not be able to make a balanced decision. At the same time, this patient may well understand that he suffers from pneumonia and needs treatment. Therefore, from an ethical point of view, he would be able to consent to therapy with antibiotics but not to therapy with antipsychotics. However, it might be possible, with repeated reasoning and kind persuasion, to improve his insight. Only if these efforts fail might it be justified to allow another person (an authorized relative, a guardian, or a judge—or a combination of these individuals on the basis of legal requirements) to decide on antipsychotic treatment. This should happen according to a defined and fair procedure, taking into account the patient’s previously expressed values and preferences. However, allowing a doctor to make the decision alone would not be justified, except in an emergency.

With regard to impaired capacity, the position of medical ethics seems to be in contradiction to the UN-CRPD and to the U.N. committee that developed the convention. Recently, prominent psychiatrists have expressed a view strongly opposing the UN-CRPD (7), and the lack of participation of psychiatric experts in its development has been recognized as an important omission (8). However, I suggest that views of medical ethics and the UN-CRPD can be reconciled to a considerable degree. From both perspectives, it is obvious that the presence of a mental disorder alone cannot justify overriding a patient’s will; only an impairment, for whatever reason, of his or her capacity to consent can justify this action. And even in such a case, medical ethics and the UN-CRPD would require the use of any supports to allow the patient to make an informed decision and would also require that the individual’s previously expressed preferences be taken into account, if applicable. Recently, the concept of “decision assistance” has been developed in medical ethics, which is well in line with UN-CRPD recommendations to replace substituted decision making with supported decision-making options (9).

Beneficence, or Acting in a Patient’s Best Interest

In international statements and guidelines, there is a high level of consensus that only severe danger to a patient’s health or life can justify the use of coercion. However, it may be difficult to reach a consensus on what constitutes a severe danger. In the case of Anna, it is obvious that a disruption of treatment would pose serious threats to her physical health and might endanger her life. In the case of Thomas, ethical assessment is more difficult. He hears voices, but so do some people who are not ill. He has delusions, but some patients do not suffer from their delusions and some people in the general population also have bizarre ideas that can result in danger to themselves or to others, but they are not forced to take medication. If Thomas had a serious somatic disease, his discontinuing treatment would pose an obvious danger to his health—for example, if he had diabetes and stopped taking insulin because of delusions of being healed by God. More frequently, however, Thomas and patients like him are not in immediate danger in terms of their physical health nor are they suicidal, but they are expected to neglect themselves badly and to lose jobs, homes, and friends as a result of their psychotic state. They are also in danger of losing their social integration and social inclusion, which are important aspects of health, according to the definition of the World Health Organization. This psychosocial aspect of health is of paramount importance, particularly for vulnerable individuals like Thomas.

Dangerous Behavior Against Others

If interventions that restrict freedom, such as prolonged involuntary inpatient treatment, seclusion, or even detention in forensic psychiatric units, become necessary as a result of dangerousness or dangerous behavior, psychosocial health is likely to deteriorate severely. Preventing such outcomes can also be considered as acting in the interest of a patient’s health. Thus treatment against Thomas’s will could be justified as being in his best interest if the goal is to prevent long-term restriction of his liberty and if such restriction is not simply a theoretical possibility. Prevention of this kind of individual harm is the ethical reasoning that justifies coercive treatment in some cases of dangerous behavior in the absence of mental capacity. Treatment—in contrast to detention, seclusion, or restraint—can improve the state that caused the dangerous behavior. Involuntary treatment is thus justified by improvement of the patient’s health, not by danger to others. As in the case of any citizen, dangerous behavior against others justifies restriction of freedom, but it does not justify involuntary treatment by a physician. Resorting to involuntary treatment would be a violation of the UN-CRPD, and this highlights the fact that people with mental disorders are subject to a different kind of coercion than others.

Nonmaleficence, or Avoiding Harm

Avoiding harm is the counterpart of doing good for a patient. Ethical considerations have to take into account the abundant body of conflicting evidence related to antipsychotic treatment along with the patient’s individual attitudes and previous experiences with treatment. Although short-term coercive treatment in emergencies might be considered to pose fewer ethical conflicts than long-term coercive treatment, antipsychotic treatment is believed to be necessary for the long term in many cases. Therefore, side effects weigh much more heavily in long-term treatment than in acute treatment. Only some treated patients achieve remission and recovery, and involuntary treatment can be experienced as traumatizing. Many patients discontinue treatment after an episode of coercive treatment, and the public’s focus on the severe and persistent deleterious side effects of antipsychotic drugs is increasing. Any evidence that new drugs are more effective and have fewer side effects would probably have a significant impact on ethical judgments regarding coercive medication. But withholding treatment can also cause harm, as can detaining the patient in a criminal justice setting. Involuntary detention for a short period provides an opportunity for assessing a patient’s mental state and mental capacity and offering treatment options.

Justice

When patients like Thomas refuse treatment, psychiatric hospitals may benefit. When such patients are not admitted, it is probably beneficial for the ward atmosphere: an open ward policy can be maintained, ward statistics on the use of coercion may look better, and stigma related to the institution may be reduced. However, allowing the patient to refuse treatment means that individuals with particularly severe illness are left untreated, which could be considered a violation of the principle of justice. Detaining a patient involuntarily in a psychiatric hospital without any treatment requires financial and human resources that might be better used for patients willing to receive treatment. On the other hand, coercive interventions—and particularly coercive treatment—cannot be justified if these interventions result from an inappropriate lack of resources, such as staff, space, and time. When there is no clear evidence that patients with psychotic or any other mental symptoms have an impaired capacity to consent or impaired responsibility for their actions, subjecting them to coercive treatment would not be fair, just as it would not be fair to coercively treat other people without mental illness who act dangerously and are considered responsible for their actions. In this respect, the ethical perspective of psychiatrists is in agreement with the UN-CRPD.

Consequences

Some consequences can also be drawn from this ethical analysis with respect to clinical practice and legislation, and these consequences can be considered as applicable in all countries. First, coercive treatment can be ethically justified in a very limited number of cases as a last resort and under strict conditions. The individuals in these cases can be found in psychiatric service settings and in nursing homes that care for patients with primary diagnoses of mental disorders. But patients with secondary psychiatric disorders can also be found in general medical hospitals. Therefore, appropriate legislation should not be restricted to psychiatric service settings (10).

Second, some consequences apply to the practice of involuntary outpatient treatment, which is legal in several countries. Involuntary outpatient treatment was introduced primarily to ensure antipsychotic maintenance therapy, preferably with depot antipsychotics, for people with poor insight into illness and treatment and frequent relapses (11). With antipsychotic treatment, a considerable portion of these individuals recover and regain capacity to consent. Even though many psychiatrists would consider it undesirable to allow these patients to discontinue medication, from an ethical perspective the patients must be allowed to do so. This also applies to former forensic patients who have been discharged on the condition that they continue taking medication; however, those who choose to discontinue would face the consequence of hospital readmission. This is in line with Goldman’s (12) suggestion that decisions about involuntary commitment should be based on a capacity criterion, not on an illness or dangerousness criterion.

Third, coercive treatment can be justified as being in the interest of the patient according to his or her presumed values and preferences, not as being in the interest of others. This is important for treatment of people with impaired responsibility due to mental illness and dangerous behavior against others. If dangerous behaviors are expected to give rise to loss of freedom and social exclusion, providing treatment that is expected to prevent these outcomes and improve the illness is in the patient’s interest. However, using treatment options such as psychoactive drugs only for purposes of behavior control and without therapeutic intent is unethical and a misuse of psychiatry. Mental health professionals should abstain from such practices.

Fourth, in mental health legislation, the need to meet the mental illness criterion as the basis for restricting a person’s freedom and using coercion is misleading, as claimed in comments about the UN-CRPD and also from the ethical viewpoint of psychiatrists. The mental illness criterion should be replaced by a capacity criterion, allowing short-term detention for purposes of assessment in cases of uncertainty. A mental disorder is a necessary but not a sufficient prerequisite for impairment of capacity, because having a mental disorder does not automatically lead to lack of capacity and responsibility. A person with intact capacity and responsibility should never be subjected to coercive treatment, regardless of whether he or she has a psychiatric diagnosis, and should never be detained in psychiatric institutions without treatment options, except for short periods with the purpose of assessment. The mental disorder criterion can be seen as inappropriately medicalizing social problems by labeling them as psychiatric disorders and ascribing control functions beyond medical treatment to psychiatric services. These issues underlie the many controversies and distrust that have separated psychiatry from other medical disciplines worldwide.