Coercion in Psychiatry

1. COERCION
IN PSYCHIATRY
Consultant In-Charge: Dr Nitin B Raut
SR Moderator: Dr Harneet Kaur
Presenter: Dr Nitin Kumar

2. OUTLINE
 Introduction
 History (Erwadi)
 Ethical Aspects
 Legal Aspects (MHCA)
 Research Aspects
 Training Aspects
 Patients and Care Givers Perception
 Assessment of coercion
 Future Directions
 Conclusion
 References

3. INTRODUCTION
 Definition (In General English)
 the use of force to persuade someone to do something that they
are unwilling to do. (Oxford Dict)
 Definition (In Psychiatry)
 ‘when the doctor aims to manipulate the patient by introducing
extraneous elements which have the effect of undermining the patient’s
ability to reason’(Okasha 2001)

4. o Definition (In Psychiatry)
 “an act of violence that results in, or is likely to result in,
physical, sexual, economical or psychological harm or suffering
to person with mental illness, including threats of such acts,
coercion or arbitrary deprivation of liberty, whether occurring in
public or in private life”. (Mysore)
 Coercion is defined as “any action or threat of actions which
compels the patient to behave in a manner inconsistent with his
or her own wishes.” (Raveesh 2016 IJP)

5. INFORMAL COERCIONS
 Persuasion
 Persuasion: Persuasion is defined as the clinician’s aim ‘to utilize the patient’s
reasoning ability to arrive at a desired result’, (Beauchamp T, Childress J. New York:
Oxford University Press; 1994. Principles of Biomedical Ethics)
 Interpersonal leverage
 The clinician uses the personal relationship with the patient to influence the
decision-making process, leveraging the emotional dependency the patient may
have on the clinician. (Szmukler G, Appelbaum PS, 2008)
 Inducement
 The clinician suggests that the patient will receive additional support or services
if they agree to participate in the suggested course of treatment. (Szmukler G,
Appelbaum PS, 2008)

6.  Threat
 The clinician suggests that services or support will be withdrawn if the
patient does not comply with treatment; the clinician may also mention
that the use of involuntary hospitalization will be considered
(Szmukler G, Appelbaum PS, 2008)
 Paternalism
 The intentional overriding of one person’s known preferences or actions by
another person, where the person who overrides justifies the action by the goal
of benefiting or avoiding harm to the person whose preferences or actions are
overridden.
(Beauchamp T, Childress J. New York: Oxford University Press; 1994. Principles of Biomedical Ethics)
 Cheating
 to give medicine without the patient being aware of it
(pelto 2019)

7.  History
 Coercion in its various guises has always been central to
psychiatry, a legacy of its institutional origins.
(Sashidharan 2017)
 Tended to deny that people with mental health conditions
have the capacity to decide whether to accept or refuse
treatment.
 Examples of political abuse of the power entrusted in
physicians in Nazi rule
 By psychiatrists as seen during the Nazi rule and the Soviet
regime when political dissidents were labeled ‘mentally ill’
and subjected to inhumane ‘treatments’

8.  The underlying belief is that people with psychosocial
disabilities lack the intellectual capacity to make decisions for
themselves, which can engender a destructive cycle of
marginalization and abuse
(Drew N, Funk M, Tang S, Lamichhane J, Chavez E, Katontoka S, et al. Human rights violations of
people with mental and psychosocial disabilities: an unresolved global crisis. Lancet. 2011 Nov
5)

9.  Coercion in Psychiatric Care is seen in form of
 involuntary admission
 involuntary treatment
 Seclusion
 restraint
 outpatient commitment
 surreptitious treatment. (in the Indian context)
(Mysore)

10. ONE OF THE MAJOR ETHICAL DILEMMAS
CONFRONTING
PSYCHIATRY IS DEALING WITH FREEDOM
AND COERCION
(Lie´geois A, 2005)

11.  There is vicious circle caused by a coercion based mental health
approach.
 Lack of community-based, voluntary mental healthcare services
result in even more coercion and deprivation of liberty.
 What coercion in mental health ultimately does is to silence and
isolate those who are already suffering from mental illness
 There is not enough scientific evidence to prove the usefulness of
coercion in reducing harm, whereas there is abundant evidence for
the harm – and sometimes irreparable harm – that involuntary
placement and treatment can cause for patients
(Parliamentary Assembly of the Council of Europe Debate on “Ending coercion in mental
health: the need for a human rights-based approach” Strasbourg, 26 June 2019)

12.  Principle Of Autonomy is breached by Involuntary
treatment or admission. the acceptability and quality of
any form of coercive mental health care has been
questioned.
 Right To Equality is also affected by coercive practices
because they deny that everyone has an equal capacity to
make decisions about their own well being.
 The Right To Inclusion in the community is violated by
coercive practices that can result in institutionalization or
in another form of marginalization
(WHO policy and Practice 2019)
PRINCIPLE AND RIGHT VIOLATION IN COERCION

13. COERCION AND ETHICS
 The four basic ethical principles that dictate professional behavior are:
 (a) Respect for autonomy: this includes components of liberty or
independence from controlling influences and agencies or the capacity for
intentional action;
 (b) Beneficence: it refers to a moral obligation to act for the benefit of others
 (c) Nonmaleficence: this simply means ‘First do no harm’; and
 (d) Justice: it refers to the fair and equitable distribution of treatment
resources
(Beauchamp T, Childress J. New York: Oxford University Press; 1994. Principles of Biomedical Ethics)

14.  The “doctrine of double effect” states that an action producing
both helpful and harmful effects is not necessarily wrong. (2010
coercion)
On contrary
 the “Deontological” view states that right behavior (respect for
autonomy) is obligatory without regard for consequences.(2010
coercion)

15.  For Protection of Individual autonomy concept of Informed
Consent was developed. Informed consent is built upon the
elements of information, decisional capacity, and
voluntarism.[PubMed: 9812106]
Where
 Decisional capacity or competency, in turn, comprises of the ability
to communicate, understand, and logically work with information
and to appreciate the meaning of a decision within the context of
one’s life.

16. COERCION AND CONVENTION ON HUMAN RIGHTS
AND BIOMEDICINE
 Four instances in which the use of coercion can be justified as
per Convention on human rights and biomedicine
1. The representative can consent to coercive measures when the patient
lacks the capacity to consent and when these measures are for the
patient’s direct benefit.
2. ‘‘a person who has a mental disorder of a serious nature may be subjected,
without his or her consent, to an intervention aimed at treating his or her
mental disorder only where, without such treatment, serious harm is
likely to result to his or her health’’
(Committee of Ministers of the Council of Europe. Convention on human rights and biomedicine. Brussels: Council of
Europe, 1996.)

17. 3. ‘‘when because of an emergency situation the appropriate
consent cannot be obtained, any medically necessary
intervention may be carried out immediately for the benefit of the
health of the individual concerned’’
4. When a patient is a ‘‘possible source of serious harm to
others’’, he or she may be ‘‘subjected to a measure of
confinement or treatment without his or her consent’’, and this ‘‘in
order to protect other’s people’s rights and freedom’’.
(Committee of Ministers of the Council of Europe. Convention on human rights and biomedicine. Brussels: Council
of Europe, 1996.)
COERCION AND CONVENTION ON HUMAN RIGHTS
AND BIOMEDICINE (CONT.)

18. COERCION AND UNITED NATIONS REPORT
 Coercion and United Nations Report
 “It is therefore important to clarify that treatment
provided in violation of the terms of the Convention on
the Rights of Persons with Disabilities – either through
coercion or discrimination – cannot be legitimate or
justified under the medical necessity doctrine.”
 It Propose that there should be no coercion under
any circumstances.
(Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or
punishment, Juan E. Méndez 2013)

19. DIFFERENT MODEL OF PSYCHIATRIC CARE
 THE GROUNDS FOR COERCIVE TREATMENT
 Need Model
(Tannsjo T. Coercive care: the ethics of choice in health and medicine. London and New York: Routledge,
1999.)
 Life Rescue Model
 Incompetency Model
 Full Responsibility Model
(Tannsjo 2004)

20.  Need Model
 This model takes advantage of all the scope for coercion
allowed by the convention.
 Assumes all people suffering from a mental illness, who need
medical treatment for it , and who don’t assent to the
treatment should be coercively treated.
(Tannsjo 1999)

21.  Life Rescue Model
 Only people who suffer from mental illness, who need medical
treatment for it, whose lives are put at risk if they are not
treated, and who do not assent to the treatment, should be
coercively confined and treated for their illness.
(Tannsjo 2004)

22.  Incompetency Model
 only people who suffer from mental illness, who need medical
treatment for it, who are not capable of making an
autonomous decision about their medical needs, and who do
not assent to the treatment, should be coercively treated for
their illness.
 coercion against competent patients may mean that the
general trust in the health care system withers
(Tannsjo 2004)

23.  Full Responsibility Model
 If a patient is incompetent, they should be coercively treated,
on the presumption that this is what they would have asked
for, had they been able to make an autonomous and well
informed request.
 If patient influenced by their mental illness, commit crimes. If
we are not allowed to treat people for their mental disorder on
the grounds that they are dangerous to others?
 Hold them responsible when they have committed a crime,
and sentence them to jail.
 Of course, if they have a mental disorder for which there is a
cure , they should be offered this cure on a voluntary basis
(they should be taken out of jail to receive the treatment and
then returned to prison when the cure has been finalized).
(Tannsjo 2004)

24.  Substitute decision-making led to abuses, ranging from methods to
suppress political dissent to the sexual and physical abuse of mental health
service users in the custody of psychiatrists. Substitute decision-making is
inconsistent with the right to equal recognition before the law.
V/S
 Supported decision-making, whereby the necessary accommodations are
made (and support provided) to ensure that individuals can express their
own will and preferences.
 In rare instances in which individuals may be unable to do so, practitioners and other
officials should make every effort to arrive at the most accurate interpretation of the
individual’s will and preferences.
The Convention on the Rights of Persons with Disabilities, 2007,

25. FUTURE DIRECTIONS
 Many basic research questions seemed to be
inadequately addressed, such as the long-term
effects of involuntary treatment.

26. CONCLUSION

27. REFERENCES