Restricted accessCase reportFirst published online 2016-9
Two years of moral case deliberations on the use of coercion in mental health care: Which ethical challenges are being discussed by health care professionals?
Seven wards from three Norwegian mental health care institutions participated in a study in which regular ethics reflection groups focusing on coercion had been implemented and evaluated (2011–2015). This article presents (1) a thematic overview of the ethical challenges identified based on a systematic qualitative analyses of 161 ethics reflection groups and (2) some general observations on these ethical challenges.
Results
The ethical challenges are divided into four main thematic categories: (1) formal coercion, (2) informal coercion, (3) uncertainty related to the Norwegian legislation on coercion and (4) professional role and identity. Some ethical challenges did not fit into these categories. Only 36% of the ethical challenges were related to the use of formal coercion or the interpretation of the health law.
Conclusion
Even within coercion regulated by law, weighing different moral values remains important to reflect upon the appropriateness of the possible use of coercion.
LoremGFHemMHMolewijkB. Good coercion: Patients’ moral evaluation of coercion in mental health care. Int J Mental Health Nurs2015; 24: 231–240.
2.
VerkerkM. A care perspective on coercion and autonomy. Bioethics1999; 13: 358–368.
3.
WynnR. Staff’s attitudes to the use of restraint and seclusion in a Norwegian university psychiatric hospital. Nordic J Psychiatr2003; 57: 453–459.
4.
WynnR. Coercion in psychiatric care: Clinical, legal, and ethical controversies. Int J Psychiatr Clin Pract2006; 10: 247–251.
5.
LindMKaltiala-HeinoRSuominenT. Nurses’ ethical perceptions about coercion. J Psychiatr Ment Health Nurs2004; 11: 379–385.
6.
SjöstrandMHelgessonG. Coercive treatment and autonomy in psychiatry. Bioethics2008; 22: 113–120.
7.
HusumTLFinsetARuudT. The Staff Attitude to Coercion Scale (SACS): Reliability, validity and feasibility. Int J Law Psychiatr2008; 31: 417–422.
8.
HusumTLBjørngaardJHFinsetA. Staff attitudes and thoughts about the use of coercion in acute psychiatric wards. Social Psychiatr Psychiatr Epidemiol2011; 46: 893–901.
9.
LarsenIBTerkelsenTB. Coercion in a locked psychiatric ward: Perspectives of patients and staff. Nursing Ethics2014; 21: 426–436.
10.
SyseANilstunT. Ulike regler - lik lovforståelse?Om tvangsregulering og verdikonflikter i nordisk psykiatri. Tidsskrift for Rettsvitenskap1997, pp. 837–918.
11.
HøyerGKjellinLEngbergM. Paternalism and autonomy: A presentation of a Nordic study on the use of coercion in the mental health care system. Int J Law Psychiatr2002; 25: 93–108.
12.
HemMHElisabethGTonjeH. Ethical challenges when using coercion in mental healthcare: a systematic literature review. . Nurs Ethics. Epub ahead of print 1 March 2016. DOI: 10.1177/0969733016629770.
13.
LandeweerEGAbmaTAWiddershovenGA. Moral margins concerning the use of coercion in psychiatry. Nursing Ethics2011; 18: 304–316.
14.
Landeweer E. Moral dynamics in mental health care. Fostering reflection and change regarding coercion and restraint. PhD Thesis, Amsterdam, Free University Medical Centre (VUmc), EMGO+, 2013.
15.
MolewijkACAbmaTStolperM. Teaching ethics in the clinic: The theory and practice of moral case deliberation. J Med Ethics2008; 34: 120–124.
16.
MolewijkACVerkerkMMiliusH. Implementing moral case deliberation in a psychiatric hospital: process and outcome. Med Health Care Philos2008; 11: 43–56.
17.
MolewijkACZadelhoffELendemeijerB. Implementing moral case deliberation in Dutch health care: improving moral competency of professionals and quality of care. Bioethica Forum2008; 1: 57–65.
18.
VoskesYEvenblijKNoorthoornE. Moral case deliberation about coercion in psychiatry. Dilemmas, value and implementation. Psychiatr Prax2014; 41: 364–370.
19.
Voskes Y. No effect without ethics. Reduction of seclusion in psychiatry from a care ethical perspective. PhD Thesis, VUmc, EMGO+, Amsterdam, the Netherlands, 2015.
20.
Paulsrud Committee. Økt selvbestemmelse og rettssikkerhet: balansegangen mellom selvbestemmelsesrett og omsorgsans-var i psykisk helsevern. Utredning fra utvalg oppnevnt ved kongelig resolusjon 28. mai 2010: avgitt til Helse- og omsorgsdepartementet 17. juni 2011 [Increased self-determination and legal protection: the balance between theright to self-determination and responsibility for care in psychiatric health care: report from the committee appointed by the Royal decree of 28 May 2010: submitted to the Ministry of Health and Care Services 17 June 2011]. Oslo: Departementenes servicesenter, Informasjonsforvaltning, 2011, 407 pp.
21.
PET refers to the Norwegian words: ‘Psykiatri’, ‘Etikk’ and ‘Tvang’ (i.e. psychiatry, ethics and coercion).
22.
For example, a systematic literature review on ethical challenges related to coercion [12] and qualitative analyses of focus group interviews [23,24].
23.
HemMHMolewijkBNorvollR. Ethical challenges in connection with the use of coercion: a focus group study of health care personnel in mental health care. BMC Med Ethics2014; 15: 82–82.
24.
MolewijkBHemMHPedersenR. Dealing with ethical challenges: A focus group study with professionals in mental health care. BMC Med Ethics2015; 16: 4–4.
25.
For example, a systematic literature review on evaluation of clinical ethics support in mental health care [26].
26.
HemMHPedersenRMolewijkB. Evaluating clinical ethics support in mental healthcare – A systematic literature review. Nurs Ethics2015; 22: 452–466.
27.
For example, qualitative interviews with patients in mental health care regarding their view on coercion [28].
28.
NorvollRPedersenR. Exploring the views of people with mental health problems' on the concept of coercion: towards a broader socio-ethical perspective. Soc Sci Med2016; 156: 204–211.
29.
LillemoenLPedersenR. Ethics in municipal health services: working systematically with, and developing competence in ethics. Clinical Ethics2013; 8: 19–28.
30.
StolperMMolewijkBWiddershovenG. Learning by doing. Training health care professionals to become facilitator of moral case deliberation. HEC Forum2015; 27: 47–59.
31.
FørdeRPedersenR. Clinical ethics committees in Norway: What do they do, and does it make a difference?Cambridge Q Healthcare Ethics2011; 20: 389–395.
32.
LillemoenLPedersenR. Ethics reflection groups in community health services: an evaluation study. BMC Med Ethics2015; 16: 25–25. . DOI: 10.1186/s12910-015-0017-9.
33.
These results of the evaluation of the ERGs by the facilitator, including the evaluation of the ERGs by all participants, will be published elsewhere.
34.
MilesMHubermanAM. Qualitative Data Analysis. An Expanded Sourcebook, 2nd ed. Sage: London & Thousand Oaks, California, 1994.
35.
Engerdahl IS, Pedersen R and Molewijk B. Etiske utfordringer ved bruk av tvang i psykisk helsevern: Når lovverk møter praksis’ (Ethical challenges regarding the use of coercion in mental health care: when health law meets practice). Tidsskrift for Norsk psykologforening 2016; 53: 102–110..
Some ERGs were not (completely) registered by the ERG facilitators or some evaluation questionnaires were lost.
38.
OhYGastmansC. Moral distress experienced by nurses: A quantitative literature review. Nurs Ethics2015; 22: 15–31.
39.
AustinWJKaganLRanlkelM. The balancing act: psychiatrists’ experience of moral distress. Med Health Care Philos2008; 11: 89–97.
40.
AasenHS. Frivillighet, tvang og menneskeverd ved innleggelse i det psykiske helsevernet: Etiske og juridiske utfordringer. Tidsskrift for Norsk Psykologforening2009; 12: 1175–1181.
41.
SjøstrømS. Invocation of coercion context in compliance communication – power dynamics in psychiatric care. Int J Law Psychiatr2006; 29: 36–47.
