Ethical deliberations about involuntary treatment

Ethical deliberations about involuntary treatment: interviews with Swedish psychiatrists Manne Sjöstrand1*, Lars Sandman2,3, Petter Karlsson5, Gert Helgesson5, Stefan Eriksson4 and Niklas Juth5

Abstract

Background: Involuntary treatment is a key issue in healthcare ethics. In this study, ethical issues relating to involuntary psychiatric treatment are investigated through interviews with Swedish psychiatrists.

Methods: In-depth interviews were conducted with eight Swedish psychiatrists, focusing on their experiences of and views on compulsory treatment. In relation to this, issues about patient autonomy were also discussed. The interviews were analysed using a descriptive qualitative approach.

Results: The answers focus on two main aspects of compulsory treatment. Firstly, deliberations about when and why it was justifiable to make a decision on involuntary treatment in a specific case. Here the cons and pros of ordering compulsory treatment were discussed, with particular emphasis on the consequences of providing treatment vs. refraining from ordering treatment. Secondly, a number of issues relating to background factors affecting decisions for or against involuntary treatment were also discussed. These included issues about the Swedish Mental Care Act, healthcare organisation and the care environment.

Conclusions: Involuntary treatment was generally seen as an unwanted exception to standard care. The respondents’ judgments about involuntary treatment were typically in line with Swedish law on the subject. However, it was also argued that the law leaves room for individual judgments when making decisions about involuntary treatment. Much of the reasoning focused on the consequences of ordering involuntary treatment, where risk of harm to the therapeutic alliance was weighed against the assumed good consequences of ensuring that patients received needed treatment. Cases concerning suicidal patients and psychotic patients who did not realise their need for care were typically held as paradigmatic examples of justified involuntary care. However, there was an ambivalence regarding the issue of suicide as it was also argued that risk of suicide in itself might not be sufficient for justified involuntary care. It was moreover argued that organisational factors sometimes led to decisions about compulsory treatment that could have been avoided, given a more patient-oriented healthcare organisation.

Keywords: Psychiatry, Bioethics, Personal autonomy, Paternalism, Coercion, Involuntary commitment

Background Whether it is justifiable to treat patients against their will and, if so, when, is a central question in medical eth- ics and law. Respect for autonomy is a central principle in contemporary healthcare ethics [1]. A common asser- tion is that respect for autonomy in healthcare implies, at a minimum, that patients should not be coerced or manipulated into treatment if they are capable of making

autonomous decisions about their care and treatment [2]. In recent bioethical debate, the idea that autonomy is something valuable that should be protected and pro- moted has become influential [3]. The idea is of particu- lar interest in the context of involuntary psychiatric treatment, where it can be argued that involuntary treat- ment could be justified in order to restore autonomy [4]. Laws on involuntary treatment in psychiatry typically

call for treatment of psychiatric disorders based on con- cerns relating to the severity of the patient’s condition, need for treatment, and danger to self or others [5–7]. Lack of decision-making capacity, which typically is

* Correspondence: manne.sjostrand@ki.se 1Stockholm Centre for Healthcare Ethics, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden and Center for Bioethics, Harvard Medical School, Boston, MA, USA Full list of author information is available at the end of the article

© 2015 Sjöstrand et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Ethical deliberations about involuntary treatment: interviews with Swedish psychiatrists Manne Sjöstrand1*, Lars Sandman2,3, Petter Karlsson5, Gert Helgesson5, Stefan Eriksson4 and Niklas Juth5

Abstract

Background: Involuntary treatment is a key issue in healthcare ethics. In this study, ethical issues relating to involuntary psychiatric treatment are investigated through interviews with Swedish psychiatrists.

Methods: In-depth interviews were conducted with eight Swedish psychiatrists, focusing on their experiences of and views on compulsory treatment. In relation to this, issues about patient autonomy were also discussed. The interviews were analysed using a descriptive qualitative approach.

Results: The answers focus on two main aspects of compulsory treatment. Firstly, deliberations about when and why it was justifiable to make a decision on involuntary treatment in a specific case. Here the cons and pros of ordering compulsory treatment were discussed, with particular emphasis on the consequences of providing treatment vs. refraining from ordering treatment. Secondly, a number of issues relating to background factors affecting decisions for or against involuntary treatment were also discussed. These included issues about the Swedish Mental Care Act, healthcare organisation and the care environment.

Conclusions: Involuntary treatment was generally seen as an unwanted exception to standard care. The respondents’ judgments about involuntary treatment were typically in line with Swedish law on the subject. However, it was also argued that the law leaves room for individual judgments when making decisions about involuntary treatment. Much of the reasoning focused on the consequences of ordering involuntary treatment, where risk of harm to the therapeutic alliance was weighed against the assumed good consequences of ensuring that patients received needed treatment. Cases concerning suicidal patients and psychotic patients who did not realise their need for care were typically held as paradigmatic examples of justified involuntary care. However, there was an ambivalence regarding the issue of suicide as it was also argued that risk of suicide in itself might not be sufficient for justified involuntary care. It was moreover argued that organisational factors sometimes led to decisions about compulsory treatment that could have been avoided, given a more patient-oriented healthcare organisation.

Keywords: Psychiatry, Bioethics, Personal autonomy, Paternalism, Coercion, Involuntary commitment

Background Whether it is justifiable to treat patients against their will and, if so, when, is a central question in medical eth- ics and law. Respect for autonomy is a central principle in contemporary healthcare ethics [1]. A common asser- tion is that respect for autonomy in healthcare implies, at a minimum, that patients should not be coerced or manipulated into treatment if they are capable of making

autonomous decisions about their care and treatment [2]. In recent bioethical debate, the idea that autonomy is something valuable that should be protected and pro- moted has become influential [3]. The idea is of particu- lar interest in the context of involuntary psychiatric treatment, where it can be argued that involuntary treat- ment could be justified in order to restore autonomy [4]. Laws on involuntary treatment in psychiatry typically

call for treatment of psychiatric disorders based on con- cerns relating to the severity of the patient’s condition, need for treatment, and danger to self or others [5–7]. Lack of decision-making capacity, which typically is

* Correspondence: manne.sjostrand@ki.se 1Stockholm Centre for Healthcare Ethics, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden and Center for Bioethics, Harvard Medical School, Boston, MA, USA Full list of author information is available at the end of the article

© 2015 Sjöstrand et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.