INTRODUCTION AND HISTORICAL ASPECTS
Coercion in health care is well known and forced treatment against the patient’s will
is even more common in psychiatric care. In fact, psychiatry is the only discipline
where coercion in care can be legal and state-sanctioned. Although autonomous decision-making
is challenged because of the power relationship between the skilled practitioner and
the unskilled patient; this power gradient is even more intense in psychiatry because
of the nature of mental illness.[1] History is replete with examples of political
abuse of the power entrusted in physicians and more specifically, psychiatrists, as
seen during the Nazi rule and the Soviet regime when political dissidents were labeled
‘mentally ill’ and subjected to inhumane ‘treatments’. Coercion in psychiatric care
is seen in the form of involuntary admission, involuntary treatment, seclusion/restraint,
outpatient commitment, and in the Indian context, also includes surreptitious treatment.
Thus to say the least, discussing the controversies hovering coercion in psychiatric
care is of utmost importance and these controversies mainly center on the issues of
‘justification’ and ‘human rights’.
CONCEPTUAL ISSUES
Coercion and persuasion are closely linked, but are definitely different terms. Persuasion
is defined as the clinician’s aim ‘to utilize the patient’s reasoning ability to arrive
at a desired result’,[2] whereas, coercion occurs ‘when the doctor aims to manipulate
the patient by introducing extraneous elements which have the effect of undermining
the patient’s ability to reason’.[3]
The four basic ethical principles[2] 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. Although these are the guiding principles, it
is common in actual practice that these come in conflict with each other. The doctrine
of double effect states that an action producing both helpful and harmful effects
is not necessarily wrong. Although the deontological view states that right behavior
(respect for autonomy) is obligatory without regard for consequences, paternalism
is widely practiced in psychiatry. Paternalism is defined as 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.[2]
To promote individual autonomy and to encourage rational decision-making, the concept
of informed consent[4] was developed. Informed consent is built upon the elements
of information, decisional capacity, and voluntarism. 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. Competency assessment involves assessment of the mental ability to understand
the nature and consequences of a decision (includes benefits/risks of consenting as
well as refusing). Voluntarism[1] encompasses an individual’s ability to act in accordance
with one’s authentic sense of what is good, right, and best in light of one’s situation,
values, and prior history. Voluntarism further entails the capacity to make this choice
freely and in the absence of coercion.
PERCEPTION OF COERCION
It is widely believed by the providers that coercion is returned by patient’s subsequent
gratitude for the psychiatrist’s unilateral action; the so called ‘Thank you’ test.
A review by Katsakou et al.[5] found that between 33 and 81% of patients retrospectively
regard their involuntary admission as justified or the treatment as beneficial. However,
although some studies support this view others contest it. According to a study by
Eriksson and Westrin,[6] about two-thirds of the committed versus nearly one-third
of the voluntarily admitted patients reported the occurrence of coercive measures
during the index period of care. Almost half of the patients (51% of the committed
patients and 38% of the voluntarily admitted patients) stated at follow-up interviews
that, during the index period of care, they had been violated as a person. Even voluntarily
admitted patients often reported that they had been persuaded or pressurized by the
caretakers or professionals to seek help.[7] Approximately a third of the patients
who receives electroconvulsive therapy (ECT) perceive themselves to have been coerced
into having the treatment. Even when patients are not given ECT under compulsion,
they often feel that they did not freely give their consent.[8] The MacArthur Coercion
Study[9] found that some patients’ views about the need for hospitalization, however,
do change over time. Approximately half the patients who initially denied the need
for hospitalization acknowledge such a need in retrospect. The amount of coercion
that the individual experiences is strongly affected by the kind of pressures that
others apply on him; the use of ‘negative’ pressures (threats and force) engender
feelings of coercion; the use of ‘positive’ pressures (persuasion and inducements)
do not. It is also related to a patient’s belief about the justice of the process
by which he or she was admitted (procedural justice). That is, a patient’s beliefs
that others acted out of genuine concern, treated the patient respectfully and in
good faith, and afforded the patient a chance to tell his or her side of the story,
are associated with low levels of experienced coercion. This is true for both voluntary
and involuntary patients. Also, in a recent study,[10] when recruiting 115 patients
who lacked the capacity to make treatment decisions, it was found that most people
(83%) who regained the capacity following psychiatric treatment gave retrospective
approval, even if the initial treatment wishes were overridden. These findings were
similar in both informally and involuntarily admitted patients.
CLINICAL, LEGAL, AND ETHICAL CONTROVERSIES
For legal sanction of involuntary admission, two elements are required: presence of
a severe mental disorder that deprives the individual of the capacity to make treatment
decisions and the likelihood of harm to self or others. The latter is termed the ‘dangerousness
standard’. The Government has a duty toward every citizen, which includes ‘Police
power’, that is, protecting each citizen from another persons’ injurious actions,
and ‘Parens patriae power’, that is, the power and duty to protect individuals who
cannot do so themselves. However, the biggest legal controversy is that the Governments
also have a duty to protect the fundamental rights of any citizen, which includes
liberty, and this would be jeopardized by involuntary admission. Also, individuals
with mental illness are considered to have the capacity to consent to treatment including
ECT, unless evidence to the contrary is compelling. The presence of psychosis, irrational
thinking, or involuntary hospitalization does not in itself constitute proof of lack
of capacity.
Ethically, involuntary admission may be justified, as the principle of beneficence
directs physicians and others to care for individuals incapable of caring for themselves.
Moreover, the proponents claim that involuntary hospitalization may restore autonomy
to the mentally ill through treatment. However, this proposition lacks adequate evidence.
Also, involuntary hospitalization is considered a clear infringement of a person’s
autonomy and self-determination. In addition, the patient may have different belief
systems for causation and treatment, and involuntary treatment hampers the right to
refuse. The use of seclusion/restraint as a means of punishment or retribution for
agitated, demanding or disruptive patients; or for convenience of staff (including
standing or as-needed order) or as a substitute for treatment programs is absolutely
unethical. The Erwady tragedy[11] in which the chained inmates died due to fire in
a mental asylum in Tamil Nadu exemplifies the horrifying use of restraint.
Evidence has been gathered, which supports the clinical justification for involuntary
admission and treatment under specific circumstances and otherwise unavoidable situations.
Involuntary treatment was successful for patients with anorexia nervosa[12] and substance
abuse.[13] In light of compromised autonomy that individuals in the throes of addiction
exhibit, coercion may be necessary to initiate treatment, through an organized intervention
or other direct confrontation.[13] A review of 18 studies on the outcome of involuntary
hospital admissions demonstrated that most involuntarily admitted patients showed
substantial clinical improvement over time.[5] Acute involuntary hospitalization may
not be automatically associated with a higher risk for overall negative outcome.[14]
Seclusion/restraint may be beneficial as it prevents imminent harm to the patient
or other persons when other means of control are not effective or appropriate. Also,
association between perceived coercion at the time of hospital admission and patient
adherence to medication and other treatment after discharge is not always found. Although
some have proposed that coercive treatment can lead to the development of post traumatic
stress disorder among patients with schizophrenia, many have found that schizophrenic
and delusional symptoms are more traumatic than the coercive measures used to control
them. Nonetheless, most have warned about the risk of physical harm if patients are
not monitored adequately when under seclusion/restraint orders. Also, there has been
a shift in the dangerousness criteria from ‘hard’ to ‘soft’. ‘Arousing aggression’,
‘severe self-neglect,’ and ‘severe social breakdown’ are applied to psychotic patients
and these are cited as reasons for emergency involuntary admissions.
In terms of involuntary pharmacological treatment, depots are perceived as more coercive
than oral anti-psychotics and are associated with a relative lack of true autonomy.[15]
However, use of depot preparation is associated with enhanced compliance.[16]
In case of ECT, some strongly contend that true informed consent is ‘nonexistent,’
as the ‘harmful effects’ of this treatment are minimized in the informed consent process.
According to Andrade,[17] the risk-benefit ratio should be weighed for involuntary
use of ECT (with consent from surrogate decision-maker) based on efficacy, side effects,
and feasibility of other alternatives.
INDIAN PERSPECTIVE REGARDING COERCION IN PSYCHIATRIC CARE
Ethical issues
Few authors have tried to examine ethical issues in relation to psychiatric care in
India.[18] Individual autonomy is valued in Scandinavian, European, and American cultures,
but is not empowering for the traditional, family-centered societies in Indian, Arab,
African, and Japanese cultures. This difference may affect the use of involuntary
admission and informed consent, among other practices, in traditional versus Western
societies.[3
19] In addition, medical paternalism (‘the doctor knows the best’) is more acceptable
to the patient in these societies. However, that does not automatically and necessarily
imply the right of the treating agency to assume the role of a ‘do-gooder’ in the
form of involuntary treatment and coercion. Furthermore, with the rapidly changing
socioeconomic, cultural, and psychosocial profiles of the traditional rural-oriented
and family-centered societies of India and the Asian countries in general, it is all
the more important to be aware of the individual rights and preferences regarding
the necessity, mode, and venue of psychiatric treatment, along with those of the family
members.
Clinical issues
A recent study in Vellore, India[20] found that more than half of the patients were
not aware of the details of ECT, even at the end of the course, but were not unhappy
about receiving ECT. The relatives knew of its benefits and risks and felt that they
were offered a choice of treatment, but also admitted to feeling coerced.
In a study in an urban Indian population, families in half the cases of patient noncompliance
administered medication to them without the patients’ knowledge (surreptitious treatment),
under the supervision of the psychiatrist.[21] Thus, individual autonomy and independence
may not equally generalize to cultures where familial interdependence is stronger
and collective goals of the family are dominant. According to Srinivasan and Thara,[21]
principles of beneficence and utilitarianism are addressed here, as the treatment
helped many patients recover from the illness, enough to voluntarily participate in
further treatment, without many negative effects and at a low cost. Thus, they benefited
both financially and emotionally. However, the deception of concealed medicines involves
manipulation of persons – albeit for benevolent ends – which denies their dignity,
by depriving them of the right to know what is being done to their minds and bodies,
and also, their right to refuse is violated.
Although concealed medicines possibly have the advantage of avoiding physical harm
if a patient is expected to violently resist taking medicine, the dangers are ample,
including the possibility of serious side effects. Without informing their family
members, patients may consume other medications or psychoactive substances that interfere
with the therapeutic effects of the concealed medication or that are otherwise problematic.
Periodic monitoring would be difficult as patient co-operation for investigations
cannot be enlisted. Also, the actual motive of the family may be harmful to the patient.
Legal issues
Refusal to consent and incompetency to consent are both included in the section on
‘admission under special circumstances’ in the Mental Health Act (MHA) 1987, of India.[22]
It has been strongly criticized that ‘competence’ has not been defined in the purview
of the MHA.[23] In MHA, there is no separate provision for forced treatment. Involuntary
treatment thus is presumed to be subsumed under admission under special circumstances
and involuntary admission. As a ‘mentally ill’ person is defined as a person who needs
treatment because of his mental disorder, then it can be extrapolated that as per
Sections 19 and 20, it becomes the psychiatrist’s duty to treat the person. In other
words, the clauses of the Act do not make the situation any better or simpler. Specific
guidelines and criteria as to when and under what circumstances involuntary treatment
or admission is justified are woefully missing from the existing MHA.
The draft proposing amendments[24] in the MHA 1987, classifies admissions as being
‘independent’ where the person can decide for himself or herself, without support
or requires minimal support, and ‘supported’ admissions are where the persons needs
substantial or high support, approaching 100% support; although it remains vague about
provisions for assessing and implementing the same. Also, it mentions that high levels
of support bordering on 100% support are to be viewed as a temporary phenomena and
as soon as the person is judged to be able to make independent decisions, he or she
to be allowed to decide for himself or herself. This proposed provision may help to
strike a balance between beneficence and right to autonomy. The Indian Psychiatric
Society is currently in the process of finalizing its comments on the draft MHA amendment
document. Although premature to affirm at this moment, it is expected and desirable
that this consultative process would contribute to further improvement in the situation
as far as coercive practices in psychiatric care are concerned.
TENTATIVE ANSWER TO THE DILEMMAS
Although there are no easy answers (one would be surprised if there were any!), one
of the most crucial elements of current psychiatric care lies in the thorough assessment
of the capacity of decision-making and not a mere assumption of lack of capacity just
because the patient has a mental illness. The decision-making capacity can be improved
by improving the information through repeated disclosure of information, group sessions,
videotapes and computer programs, and involvement of family members. To the extent
possible, the patient (and family) should be involved or at least made aware of the
treatment and the targets to be achieved by it. The major instrument for achieving
this is communication: skilled communication that is two-way, open, repeated, empathic,
and accommodative. Along with communication, detailed documentation is necessary to
explain why a particular action (e.g., involuntary treatment or seclusion/restraint,
etc.) was felt necessary under the specific circumstances. Advanced planning for the
possibility of future incapacity, by use of joint crisis plans reduces compulsory
admissions and treatment in patients with severe mental illness, and may affect the
amount of perceived coercion. The doctrine of ‘least restrictive alternative’ (‘least’
in terms of modality, severity, and duration of the action taken) should be used.
Positive approaches, such as persuasion, should be the strategies of choice and negative
approaches, such as threats should be avoided. One should be explicit about what one
is doing and why, allow patients to tell their side of the story, and seriously consider
this information. The last, and possibly one of the most relevant dictums is discussion
among colleagues for the most acceptable approach. Finally, it is obvious that more
research is needed in this area, particularly from India and the other Asian and developing
countries. Such research needs to be not only service- and doctor-oriented, but also
patient- and society-oriented, so as to enable each side to hear the voice of the
other.