Coercion in psychiatric care: Global and Indian perspective

Abstract

Byline: Ruchita. Shah, Debasish. Basu 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. [sup][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', [sup][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'. [sup][3] The four basic ethical principles [sup][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. [sup][2] To promote individual autonomy and to encourage rational decision-making, the concept of informed consent [sup][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 [sup][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. …