Reflecting on the Reasons Pros and Cons Coercive Measures for Patients in Psychiatric and Somatic Care: The Role of Clinical Ethics Consultation. A Pilot Study

Abstract

Background and aim: Coercive measures in patient care have come under criticism leading to implement guidelines dedicated to the reduction of coercion. This development of bringing to light clinical ethics support is hoped to serve as a means of building up awareness and potentially reducing the use of coercion. This study explores the specific features of ethics consultation (EC) while dealing with coercion. Material and method: Basel EC documentation presents insight to all persons involved with a case. The EC database of two Basel university hospitals was developed on the grounds of systematic screening and categorization by two reviewers. One hundred fully documented EC cases databased from 2013 to 2016 were screened for the discussion of coercive measures (somatic hospital and psychiatry: 50% cases). Results: Twenty-four out of 100 EC cases addressed coercion in relation to a clinically relevant question, such as compulsory treatment (70.8%), involuntary committal (50%), or restricting liberty (16.6%). Only 58.3% of EC requests mentioned coercion as an ethical issue prior to the meeting. In no case was patient decisional capacity given, capacity was impaired (43.5%), not given (33.3%), or unclear (21.7%; one not available). Discussion: As clinical staff appears sensitive to perceiving ethical uncertainty or conflict, but less prepared to articulate ethical concern, EC meetings serve to “diagnose” and “solve” the ethical focus of the problem(s) presented in EC. Patient decisional incapacity proved to be an important part of reasoning, when discussing the principle of harm prevention. While professional judgment of capacity remains unsystematic, rationality or even ethicality of decision making will be hampered. The documented EC cases show a variety of decisions about whether or not coercion was actually applied. Ethical reasoning on the competing options seemed to be instrumental for an unprejudiced decision complying with the normative framework and for building a robust consensus. Conclusions: The recommendation is whether EC should be used as a standard practice whenever coercion is an issue—ideally before coercion is applied, or otherwise. Moreover, more efforts should be made toward early and professional assessment of patient capacity and advance care counseling including the offer of advance directives.

Clinical Ethics Support Services Are Not as Well-Established in Forensic Psychiatry as in General Psychiatry

“…Furthermore, hospitals without available CES structures more often indicated that they would require ethics support in moral value conflicts between team members, between people from different professions, and with relatives. This finding underlines the important role of CES in moral case deliberation in mental health care (8). Further support for the benefit and effectiveness of CES comes from the finding that only 26% of hospitals with active CES requested further resources for training in clinical ethics, whereas 71% of the hospitals without access to CES did.…”

“…The high frequency of requests regarding coercive medication and physical restraint might be interpreted as a consequence of the restrictive laws in Germany concerning forced medication in forensic and general psychiatry. According to the literature, however, coercive measures in general are among the most prominent moral conflicts handled in psychiatric ethics consultations (8,11,19). Requests for ethics consultation on seclusion and ethical/lawful conduct were more common in forensic psychiatry.…”

“…In Germany, the number of hospitals offering clinical ethics consultation has steadily increased in the last two decades (7). In psychiatry, however, structured ethics consultation has developed at a slower rate than in other medical disciplines, but it is considered to be relevant and helpful for moral case deliberation and an unprejudiced decision-making process (8)(9)(10). A study on clinical ethics consultations in Norway showed that 144 of 775 cases between 2003 and 2012 related to mental health and addiction treatment cases; among the most prominent ethical dilemmas were confidentiality and information (33 cases), drug dependency (27 cases), formal and informal coercion (23 cases), and competence to consent and patient autonomy (16 cases) (11).…”

Prevention and management of aggressive behaviour in patients at psychiatric hospitals: a document analysis of clinical practice guidelines in Hong Kong

“…Based on the ethical principles by Beauchamp and Childress (2013), Montaguti et al . (2019) have stated that it is quite simplistic to find sensible ethical reasoning for the use of seclusion and restraint in psychiatric care. For example, patient seclusion and restraint can be rationalized based on safety issues and patient beneficence; if a patient lacks decision‐making capacity, they may make decisions that may put the health and well‐being of themselves and others at risk.…”

Addressing harm in moral case deliberation: the views and experiences of facilitators

“…This differs from the four principles approach of Beauchamp and Childress including the non-maleficence principle 'one ought not to inflict evil or harm' [13], often used in Ethics Consultation. In Ethics Consultation harm is a topic of reflection in weighing up beneficial and nonbeneficial effects [14,15]. Doing so requires balancing the outcomes and choosing the best solution [16].…”