Abstract
Coercive hospitalization or coercive treatment of psychiatric patients – both not uncommon even today – often get justified by their potential of benefitting the patients themselves. This paper develops some general and some psychiatry-specific deliberations with regard to the ethical legitimacy of such paternalistically motivated interventions.
The author, opting for a broad concept of paternalism, argues that in the context of medicine only “soft” paternalism could be ethically justified. The two conditions under which she would attest such legitimacy, i.e. relevant deficits of patient autonomy and the intervention’s potential for subjective patient benefit, first get discussed in more general terms. Thereafter, some programmatic ideas are presented about how to spell out in a systematic and coherent way the ethical justification for (very limited) psychiatric coercion.
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Notes
- 1.
This article takes up a project that I had the opportunity to pursue years ago at the University of Zurich when working for the chair of philosophy with Anton Leist.
- 2.
Feinberg himself later changed the terminology without substantial changes: “Strong” paternalism became “hard” paternalism and “weak” became “soft” paternalism. But the standard nomenclature leans towards the original terms (Beauchamp 1995). Incidentally, Feinberg believes that the weak version should not even be called paternalism at all.
- 3.
Yet here we would have to ask whether, for instance, a requirement to wear a helmet falls under the concept of paternalism, if such a rule consequently results in a situation wherein many people do not even develop a preference for driving a motorcycle without helmet. We have to broaden the definition so that bans to further the well-being of affected parties can also be counted as paternalistic if they prevent the development of respective preferences.
- 4.
Admittedly some authors deem Ulysses contracts to be strongly paternalistic and criticize them accordingly; see Spellecy (2003).
- 5.
The following is a significant simplification of the detailed account in Faden and Beauchamp (1986), ch. 7–10, or Beauchamp and Childress (2009), ch. 4. I believe the simplification is still true to the core of the original thoughts. For instance the mentioned authors list seven elements for a valid consent of patients, yet some of them can be seen, I believe, as either preconditions of the three main requirements (e.g. “information and “advice” as preconditions of understanding) or as specific descriptions of actions (“deciding” and “authorizing”).
- 6.
Regarding the thresholds there are certainly various standards; cf. Helmchen (1996).
- 7.
An important question in this context, which cannot be treated here, concerns the sliding-scale conception of competency: According to this conception the requirements for decisional autonomy have to be more demanding in congruence with increased risk of harm. This position has many supporters, e.g. (Drane 1985; Wilks 1997). For a critical assessment see Demarco (2002).
- 8.
This must not be understood in a strictly chronological way: Often judgments regarding competency are made during patient briefing.
- 9.
They are rather balancing acts between mistakes due to ignorance vs. excessive demands on patients and doctors, or else between a decision by third parties vs. leaving patients on their own.
- 10.
The subjectivism about values, on which this position bases, cannot here be justified in its own right.
- 11.
By way of example, in Germany psychiatric sections and treatment are, according to the “law regarding support and security measures in case of mental illness” (Gesetz über Hilfe und Schutzmaßnahmen bei psychischen Krankheiten), only legal if due to mental illness or disability a patient poses a “present and significant threat for themselves or others” or if there is a danger of suffering serious health-related harm. Involuntary hospitalization is only allowed if limited in time and under court supervision. Coercive treatment may only be performed if the patient lacks capacity to consent or on the basis of consent of a person authorized by the patient or of a legal guardian (Dressing 2004; Koch et al. 1996).
- 12.
- 13.
This is accommodated in Germany, Switzerland, and the USA (but not in all European countries; see Lauter 1996) by clearly distinguishing between legal capacity and (the less demanding concept of) capacity to consent to treatment.
- 14.
Yet it is generally admitted that there is a need for further psychopathological research in this area (see also Helmchen and Lauter 1995).
- 15.
Müller (2005) contains evidence that at least in singular cases legal guardians and courts end up with highly problematic decisions.
- 16.
This paper was originally published in Jahrbuch für Wissenschaft und Ethik 14, 2009, 107–127. Translated from German by Andrew Fassett.
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Schöne-Seifert, B. (2015). Paternalism: Its Ethical Justification in Medicine and Psychiatry. In: Schramme, T. (eds) New Perspectives on Paternalism and Health Care. Library of Ethics and Applied Philosophy, vol 35. Springer, Cham. https://doi.org/10.1007/978-3-319-17960-5_10
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