Can we justify eliminating coercive measures in psychiatry?

Abstract

The practice of coercive measures in psychiatry is controversial. Although some have suggested that it may be acceptable if patients are a danger to others or to themselves, others committed themselves to eliminate it. Ethical, legal and clinical considerations become more complex when the mental incapacity is temporary and when the coercive measures serve to restore autonomy. We discuss these issues, addressing the conflict between autonomy and beneficence/non-maleficence, human dignity, the experiences of patients and the effects of coercive measures. We argue that an appeal to respect autonomy and/or human dignity cannot be a sufficient reason to reject coercive measures. All together, these ethical aspects can be used both to support and to reject a non-seclusion approach. The total lack of controlled trials about the beneficial effects of coercive measures in different populations however, argues against the use of coercive measures.

Prevalence and correlates of seclusion and restraint use in children and adolescents: a systematic review

“…SRU are an infringement on the patients" rights and other research has indicated that SRU can lead to severe consequences, both psychological and physical [5,22,26,27,29]. Authors argue that in specific situations and for specific indications SRU cannot be avoided, but advocate for the implementation of strict guidelines about its use, the possible indications and close monitoring during SRU.…”

“…Seclusion and restraint use (SRU) is a frequent intervention in psychiatric settings [1,2,29,30,34]. The literature prior to the year 2000 reports rates ranging from 28% to 60% [1,4,10,15,23].…”

“…In addition, SRU can have severe 4 consequences. SRU are not only traumatic for the individual (including a reactivation of prior trauma experiences), but they can also lead to serious physical side-effects such as asphyxia, aspiration, blunt trauma to the chest, thrombosis and mortality [5,22,27,29]. A study of Nunno et al found 45 fatalities between 1993 and 2003 in child and adolescent psychiatric facilities related to restraints [26].…”

Contentions mécaniques en psychiatrie : étude phénoménologique de l’expérience vécue du personnel infirmier

“…Dans un premier temps, l'utilisation de mesures coercitives présente un dilemme éthique dans la mesure où elle brime l'autonomie du patient (Bloch & Green, 2006;Katsakou & Priebe, 2007;O'Brien & Golding, 2003;Prinsen & van Delden, 2009;Wynn, 2006). Comme le consentement du patient n'est pas requis en situation d'urgence, soit lorsque la sécurité du patient ou d'autrui est menacée (OIIO, 2009), la majeure partie des interventions restrictives se déroulent dans un contexte où les droits du patient -c'est-à-dire autonomie, liberté de choix, consentement éclairé -se heurtent aux principes de liberté d'autrui et de non-malfaisance.…”

Directions for Future Patient-Centered and Comparative Effectiveness Research for People With Serious Mental Illness

“…102 The ethics of these practices have been questioned, as has their legality, therapeutic value, and effectiveness. 74,103 Muralidharan and Fenton 104 reviewed the effectiveness of nonpharmacological forms of containment-including special observation, locked units and rooms, deescalation, and behavioral contracts-and concluded that there was insufficient evidence to support these practices. Prinsen and van Delden 74(p72) conclude: "It is very hard to argue that seclusion is the appropriate measure to control these circumstances [violence and aggression] when there are no data to support this.…”