Chieze Marie, Clavien Christine, Kaiser Stefan, Hurst Samia
Adult Psychiatry Service, Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland.
iEH2-Institute of Ethics History Humanities, University of Geneva, Geneva, Switzerland.
Front Psychiatry. 2021 Dec 14;12:790886. doi: 10.3389/fpsyt.2021.790886. eCollection 2021.
Coercion is frequent in clinical practice, particularly in psychiatry. Since it overrides some fundamental rights of patients (notably their liberty of movement and decision-making), adequate use of coercion requires legal and ethical justifications. In this article, we map out the ethical elements used in the literature to justify or reject the use of coercive measures limiting freedom of movement (seclusion, restraint, involuntary hospitalization) and highlight some important issues. We conducted a narrative review of the literature by searching the PubMed, Embase, PsycINFO, Google Scholar and Cairn.info databases with the keywords "coercive/compulsory measures/care/treatment, coercion, seclusion, restraint, mental health, psychiatry, involuntary/compulsory hospitalization/admission, ethics, legitimacy." We collected all ethically relevant elements used in the author's justifications for or against coercive measures limiting freedom of movement (e.g., values, rights, practical considerations, relevant feelings, expected attitudes, risks of side effects), and coded, and ordered them into categories. Some reasons provided in the literature are presented as justifying an absolute prohibition on coercion; they rely on the view that some fundamental rights, such as autonomy, are non-negotiable. Most ethically relevant elements, however, can be used in a balanced weighting of reasons to favor or reject coercive measures in certain circumstances. Professionals mostly agree that coercion is only legitimate in exceptional circumstances, when the infringement of some values (e.g., freedom of movement, short-term autonomy) is the only means to fulfill other, more important values and goals (e.g., patient's safety, the long-term rebuilding of patient's identity and autonomy). The results of evaluations vary according to which moral elements are prioritized over others. Moreover, we found numerous considerations (e.g., conditions, procedural values) for how to ensure that clinicians apply fair decision-making procedures related to coercion. Based on this analysis, we highlight vital topics that need further development. Before using coercive measures limiting freedom of movement, clinicians should consider and weigh all ethically pertinent elements in the situation and actively search for alternatives that are more respectful of patient's well-being and rights. Coercive measures decided upon after a transparent, carefully balanced evaluation process are more likely to be adequate, understood, and accepted by patients and caregivers.
强制手段在临床实践中很常见，尤其是在精神病学领域。由于它凌驾于患者的一些基本权利之上（特别是他们的行动自由和决策权），因此，合理使用强制手段需要法律和伦理依据。在本文中，我们梳理了文献中用于证明或反对使用限制行动自由的强制手段（隔离、约束、非自愿住院）的伦理要素，并突出了一些重要问题。我们通过在PubMed、Embase、PsycINFO、谷歌学术和Cairn.info数据库中搜索关键词“强制/强制措施/护理/治疗、强制、隔离、约束、心理健康、精神病学、非自愿/强制住院/入院、伦理、合法性”，对文献进行了叙述性综述。我们收集了作者在支持或反对限制行动自由的强制手段时所使用的所有伦理相关要素（如价值观、权利、实际考量、相关感受、预期态度、副作用风险），并进行编码，然后将它们分类整理。文献中提出的一些理由被视为支持绝对禁止强制手段；这些理由基于某些基本权利（如自主性）不可协商的观点。然而，大多数伦理相关要素可用于在特定情况下对支持或反对强制手段的理由进行权衡。专业人士大多认同，只有在特殊情况下，当侵犯某些价值观（如行动自由、短期自主性）是实现其他更重要的价值观和目标（如患者安全、患者身份和自主性的长期重建）的唯一手段时，强制手段才是合理的。评估结果因优先考虑的道德要素不同而有所差异。此外，我们发现了许多关于如何确保临床医生应用与强制手段相关的公平决策程序的考量因素（如条件、程序价值观）。基于这一分析，我们突出了需要进一步探讨的重要议题。在使用限制行动自由的强制手段之前，临床医生应考虑并权衡该情况下所有伦理相关要素，并积极寻找更尊重患者福祉和权利的替代方案。经过透明且审慎权衡的评估过程后决定的强制手段更有可能是恰当的，并且能被患者及其护理人员理解和接受。
