In the presentation of results, we will first describe ethical challenges which seem to occur across various wards and services, related to different types of coercion. Afterwards, we will show how certain challenges are context specific.
What is coercion and how is it done
Defining coercion is in itself ethically challenging since it has consequences for how the power of health care professionals is recognized and exercised. Defining and recognizing coercion has to do with being morally sensitive and reflective. Several participants reflected on how to understand what coercion actually is. They tended to think of coercion as a broad phenomenon covering many aspects, and they referred to both formal and informal coercion. For instance, one person from an acute ward said:
I have always thought of coercion as involving the big offences, and I have really discovered that coercion is as much a part of the everyday routines, but they are much more difficult to detect.
In order to further reflect upon what coercion is, some contrasted it to the concept of freedom. They stated that we are not entirely free in the way we lead our lives. Being members of society, we have to adjust to regulations and prohibitions, we have obligations at work and in our families and networks, and we react very differently to such “restraints”. Furthermore, some saw the power they have to define what the patients are allowed to do, as ethically challenging. It requires sensitivity and reflectivity which several of our participants talked about.
In interview after interview, they said that it is ethically important how coercion is carried out. It tended to make an essential difference whether coercion was done with a caring and friendly attitude or not, with concern and explanations or not. The way you express yourself, “how you coerce”, as one participant said, is essential to how patients experience the action, whether they feel that their dignity is respected or not. Approaching each patient in an individualised manner seemed to be crucial:
For some … to be admitted here, everything is coercion. To hear keys jingle is the equivalent of the exercise of power. How to tap on the door, right? Do you ask to come in? How to behave? For some, none of what is going on is coercion, while for others everything is coercion.
There is a different and paradoxical kind of ethical challenge that also comes up in the interviews - that challenges common conceptions of coercion - namely that there are patients who request or insist on compulsory admission in the emergency ward, or ask to be put in belts. For example, they may be threatening to commit suicide:
They pull the suicidal card, or they escalate self-harm and do what they need to do in order to be admitted. The ethical dilemma is: should we take care of them on the acute ward or motivate them to take responsibility and offer them help on a lower level (than the acute ward level)?
Coercion as ‘opportunity’ – formal coercion and conflicting values
For the participants, it seems to be ethically challenging to apply coercion, or their ‘license to coerce’, in good ways. On the one hand, they recognize the opportunities that coercion gives. On the other hand, they are aware of the possibilities for abuse. In two of the interviews (psychogeriatric unit and sub-acute unit), participants said that applying coercion may sometimes be necessary ‘to come into position’ to help a patient. Coercion is the tool that gives the staff the responsibility, possibility, and duty to do good for the patient (beneficence), which is sometimes seen as more important than safeguarding the patient’s autonomy. Another participant (from a psychogeriatric unit) presented the same ethical challenge – the dilemma between paternalism and neglect:
They may say in The Times today that ’old, defenseless woman was removed from her home by force’ or it could be written in The Observer that ’an old lady is perishing in her home and nobody interferes’.
Participants from rehabilitation departments talked about how difficult it can be to support patient autonomy in cases where they have worked intensively for months with patients suffering from both substance abuse and severe mental illness. An example could be when they have been holding back information about the patient having received a considerable amount of money in their bank account (for instance from the tax authorities). The reason for not informing them about this is that they assume that the patient would buy drugs. Consequently, the positive results of months of intensive treatment and care could be destroyed in a very short time. The ethical challenge they face, is how far they can go in utilizing the opportunity to hold back information in connection with coercion – in the name of preventing harm - when this, at the same time, compromises patient autonomy to such a large degree.
The ethical challenges which have been presented so far focus on consequences for individual patients. Yet, another kind of ethical challenge is described by an employee in an acute ward. He is concerned with the relationship between the patient’s right to autonomy, and the protection of both the population and the employees:
It is a dilemma that we are expected to safeguard the patient’s right to autonomy while at the same time the safety of the general public must be respected. We need to think about our employees, they too are entitled to be protected.
The perspective of society is introduced here, and as an ethical challenge the protection of society is quite different from the focus on beneficence and autonomy for individual patients.
‘Coercive culture’ in mental health care
By focusing on ethics and coercion in mental health care, we also should be aware of the potentially infringing culture. One participant put it this way:
Even if you do not think about it, there is a tendency in our attitude that ‘I have and you have not, I can leave at 3 pm., you have to stay. I go to the mountains on Friday at 3 pm., ha-ha, you get pizza or porridge tomorrow. We are employees. We wear private clothes, but we also wear id-cards and alarms, we have keys, it is all visible, it is right there, all the time.
The distinction between ‘us and them’ is emphasised by several participants, and some points at the possibility of infringement due to the fundamental asymmetry of power between patients and staff. However, others argued that it is also possible that a culture characterised by asymmetry between patients and staff can uphold dignity by safeguarding the patient’s need to be dependent and receive help. These participants underscored the necessity of being aware of aspects of the culture that can degrade patients and pose a threat to their dignity. As an employee at a mental health district office put it:
It is hard to foster cooperation when the patient only sees you as an abuser.
To exercise care and coercion in a ‘good’ way is challenging since the culture in the mental health field tends to be ‘coercive’.
A different issue mentioned in the focus group interviews is that how coercive routines are actually carried out may vary a lot:
Many of our routines are in themselves limitations to patient autonomy, to be allowed to go outside the ward or not, monitoring, safety procedures, rounds, confiscation of cell phones. The routines and decisions, which are part of everyday life on the ward, are followed up/practiced very differently by the staff.
Another participant (physician) in the same department said:
We find on our rounds between the different wards that coercion is implemented very differently.
Yet, another also talked about
… how coercion is exercised, it could be very different. What kind of vocabulary do you use, how do you relate to the patients, what kind of attitude do you have?
Informal coercion – relationships and cooperation
Coercion may occur in conflict situations where there might be a weak or non-existing alliance between staff and patient, and where there may be disagreement concerning the participation of the patient in the daily routines:
… we have discussions about this, how long should people be allowed to stay in bed; where, when should we interfere, what do we do?
Informal coercion related to the use of smart phones with internet connection is a topic that comes up several times in the interviews:
It is a real ethical challenge because we set limits for one patient. If we don’t, we risk that pictures taken in the ward can compromise another patient.
Another example of informal, ‘grey-zone’ or ‘fuzzy’ coercion is related to the dosing of forced medication:
… there has been a decision on compulsory drug treatment, and yet you provide such a low dosage that the hospital stay lasts much longer than necessary.
That is, one does not want to give a higher dosage, e.g. to prevent disturbing side-effects. However, this may be more negative because the involuntary hospital admission may last longer.
Context dependent ethical challenges
As mentioned above, some of the ethical challenges seemed to be dependent upon the context. Such ethical challenges will be presented in the following.
The adolescent ward faces specific ethical challenges due to the age of their patients and the laws related to age. Parents are supposed to consent on behalf of their children until they are 16 years of age. However, parents do not always know what they agree to:
When the consent from the parents is valid, they are ‘inside’ and begin to influence what is going on. However, to be parents in all this, what are they actually influencing? How many parents have insight into what they are agreeing to when hospitalising their youth? It is not easy. Among other things, in relation to forced tube feeding, it is a major intervention they are involved in and saying ‘yes’ to.
The employees of the adolescent psychiatric department also talk a lot about the difference between the youth being under or over 16 years of age. When the youth turns 16, s/he has reached the legal age, and parents, with some exceptions, are not entitled to insight into the treatment if the patient refuses. This situation is ethically challenging since the health professionals move from including the parents in the treatment the one day to not be allowed to include them the next day. The youth is still the same person with the same needs and challenges. They are still as dependent upon their parents, and usually still live with them. The parents are still supposed to be responsible for their kids, but now without being informed about key aspects of their mental health. It sometimes feels morally wrong to the professionals to exclude the parents.
Employees also described how they exercise coercion or pressure through the parents. An example was when they had asked a father to make sure that his hospitalised son went to bed, something they knew his son refused to do. Other times, parents invade their children and the staff feel they have to protect the patient.
Yet another case they talked about was where the youth had seriously and repeatedly assaulted his parents, something the staff had to stop by force. They also described how they intervene when parents – suffering from guilt towards their kids - smuggle in food and such, and thereby contribute to sabotaging the treatment program. This, among other things, includes the expectation that the patients participate in the daily activities on the ward, like common meals. Several employees also talked about forced tube feeding of adolescents with severe anorexia, which they describe as especially challenging since they have to keep the patient physically fixed.
Several participants described ethically challenging situations where they manipulate elderly patients through their way of talking to them, for instance in cases where patients say they want to go home. One referred to a patient who said that
… he would like ‘to leave the ship’. So I said, ‘Boy, that’s okay, but first we need to find a place for you to stay and that will probably take some time’. So he agreed to that. ‘Okay’. I mean, we talk to patients that way a lot. The result in this case was that the patient has volunteered to be coercively admitted!
The participants problematised the fact that they are not completely honest in the way they talk to the patients. They express themselves in this way to ensure that their assessment about what is in the best interest of the patient is followed through.
A common ethical challenge they face in the outpatient clinic is to observe the patients becoming more and more ill, but refusing to be hospitalised or receive any medical treatment. The health care personnel think that they should wait until the patient is sick enough to be legally committed. The family of the mentally ill person may disagree:
They wanted us to intervene earlier. They wished that they had not had to see how sick their loved one ‘had to become’ before we intervened.
This is a painful ethical challenge for health care professionals. However, they also described how they use the time when coercive measures are not yet taken to build trust and safety in the relationship with the patient, which is important for cooperation in the future, also if coercion is finally needed.
Participants from rehabilitation units presented ethical challenges regarding giving back autonomy to the patient. They described how they spend month after month treating patients – as a rule involuntarily admitted and often medicated against their will – and the patients make huge progress. When the patient’s condition is improving there comes a time when they no longer can be involuntarily admitted. The health care personnel know that the patient might want to quit treatment once the coercive measures are suspended. They also know that the effect of the therapeutic endeavors might be spoiled after a very short time if the patient for instance goes back to drug abuse.
A common ethical challenge in the acute wards concerns the urgency and seriousness of the situations. For example, the health professionals described ethical challenges regarding coercion and suicidal patients. One moral question they face is when to let the suicidal patient take back some degree of control of his/her own life? One employee puts the dilemma this way:
So, where is the boundary between what should be the patient’s responsibility in relation to their own lives and what are our responsibilities? Where do these lines cross, for example the extent to which one should dare to give back responsibility to the patient? A while ago, we admitted a young girl who was suicidal. She was in the emergency room for quite some time. She did not want to be admitted. We had discussions with her parents. Her mum was in despair, and finally we decided to let her go. Afterwards, there were a number of suicide attempts and she was brought to the hospital by air ambulance several times. She is ok now, but it is like … these are tough choices. At some point you have to take a chance. But when? What are the consequences? In the worst case, they might die.
As we see here, it is often not obvious what the best option is, and this may lead to disagreement between staff members about whether or not to take over the responsibility, which, in turn, causes inconsistent use of coercion. Sometimes it is the patient’s relatives that are the ones to most strongly oppose giving back some responsibility to the patient.