The pros and cons of ordering involuntary treatment
In the first section, the respondents' reasoning regarding the pros and cons of ordering involuntary treatment are presented (Table 1).
Fulfilling the patients’ need of care
The most important reason stated for ordering involuntary treatment was the patients’ perceived need of care and treatment. Firstly, this was seen as necessary in cases where patients refused care and there was a risk of suicide. Secondly, involuntary treatment was seen as justified in cases where seriously ill patients refused treatment that was seen as essential for improving their condition, both psychiatric and somatic. Thirdly, also protection from social harms was seen as a viable reason for involuntary treatment.
Preventing suicide
Risk of suicide was generally raised as a major factor when deciding about compulsory treatment. One of the respondents recalled a case where a patient with a complicated background, but no established psychiatric diagnosis, had issued a suicide threat in a letter to his counsellor. When they met, the patient was calm and did not display any severe psychiatric symptoms.
And this was one of the hardest cases. Because here is a person who at first sight seems just like anyone else. But who I know has this background and had expressed suicidal thoughts in this letter. […] After much hesitation I made the decision about involuntary admission after all. It was hard, but with this suicide business…
-Specialist in psychiatry, female.
Another respondent told of a case in which he had respected a patient’s rejection of medical treatment for a depression. When asked what could have changed his mind so that he instead would have decided to admit the patient involuntarily, he replied:
If she had planned a suicide attempt later the same week, then I couldn’t have waited.
-Resident in psychiatry, male.
Providing necessary psychiatric treatment
The other typical example of involuntary treatment being considered justified was when patients rejected a treatment deemed necessary. The typical example concerned patients with psychotic disorders.
There are many people whose apartments may be in total disarray and everything is messed up, but whom you do not see as mentally disordered. But if you have a chronically psychotic patient in that situation, then it is a sign that things are pretty serious. He cannot manage his everyday life anymore, and that is a sign that he needs care.
-Specialist in psychiatry, male.
One respondent argued that it is sometimes necessary to give treatment involuntarily in order to show the patients that their condition can improve through medication.
And you see that you have to medicate, at least in order to show that you can stop this. That, at least, you make some effort so that the person will not lose their entire life.
-Specialist in psychiatry, female.
Ensuring treatment of somatic disorders
One more reason mentioned was need of care for somatic conditions. Here it was argued that patients with psychiatric disorders who mismanaged their somatic disorder could be involuntarily admitted to treat their somatic disorders.
Then, if he [the patient] has a serious psychiatric disorder and doesn’t understand the seriousness of his somatic condition, I think that you have the right to breach his autonomy.
-Specialist in psychiatry, male.
This, however, was seen as controversial and, in line with the law, typically only seen as justifiable in severe cases.
But, I also realise that… well… that you are on thin ice, and well exactly… Where should you draw the line? Should you, like, be able to treat high blood pressure coercively? And that is something I perhaps wouldn’t consider right.
-Resident in psychiatry, female.
Protecting patients from social harms
Another example mentioned in the interviews was to protect patients with acute psychiatric disorders from social harms, such as ruined relationships or financial problems. The typical case concerned patients in manic episodes.
Absolutely, in a manic episode… Yes, yes. To protect them from themselves. […] I don’t find that very complicated because they can ruin so much for themselves and those who are close to them.
-Resident in psychiatry, female.
Promoting autonomy
Another category of reasons for accepting involuntary treatment was that of promoting the patient’s autonomy. Instances concern restoring the patient’s autonomous ability, promoting well-founded decisions, and acting in accordance with what was presumed as the patient’s true will.
Restoring autonomous ability
Paradoxical as it may seem, autonomy was mentioned as a possible justification for compulsory treatment. The issue was raised in various circumstances, the main reason being treatment of psychotic episodes that were seen as detrimental to autonomy.
…well, you could really argue that sometimes when you make decisions about involuntary treatment, at the end of the day it’s about restoring the patient’s autonomy.
-Specialist in psychiatry, male.
More specifically, improving decision-making capacity was mentioned:
But the solution is then to treat the psychiatric disorder so that they are able to understand what their best interest is. Or to optimise their decision-making capacity so that they can make a decision.
-Resident in psychiatry, female.
Promoting well-reasoned decisions
Issues relating to autonomy were also mentioned in relation to preventing patients from impulsive actions that might be detrimental to reasoned long-term goals.
It could be about giving time. For an important decision, like a suicide or so, so that you can make that decision after more reasoning.
-Resident in psychiatry, male.
Respecting the patient’s presumed will
Several respondents brought up the idea that consent to treatment may be presumed despite the patient’s refusal. One idea was that even though a patient might reject treatment, this rejection would not be representative of the patient’s ‘true’ will, i.e. what the patient would prefer if not afflicted.
It could be anything from a patient with psychosis who has a completely different apprehension of the world and does not, at the moment, want medicine. However, I know that when he is better, he will want it, because he wants to be well and get out of this.
-Specialist in psychiatry, female.
One respondent expressed this in terms of what the patient would want, if they possessed adequate cognitive abilities.
No, I act in accordance with what I believe [the patient] would want if he had the time and the intellectual and emotional ability to reflect on his situation. Presumed consent.
-Specialist in psychiatry, male.
Safeguarding third party interests
A third category of reasons was reasons relating to third-party interests. This included both preventing danger to others (beside the patient) and relieving relatives of responsibility.
Preventing harm to others
One aspect raised by some respondents was danger of harm to others, which was considered a major reason for decisions in favour of involuntary treatment. The examples given all referred to patients with psychotic symptoms. One respondent talked about a psychotic patient who had tried to set fire to her apartment.
She doesn’t let healthcare personnel in and she doesn’t let social workers in. And maybe she needs another place to live according to me – in order to minimise the risk of relapse into this kind of serious criminality and danger to others.
-Specialist in psychiatry, female.
Relieving relatives of responsibility
One respondent mentioned the interests of patients’ relatives as a relevant factor regarding decisions about compulsory treatment. He argued that relatives should not be left with the responsibility of caring for seriously ill or suicidal patients, since they would lay so much blame on themselves if the patient were to harm him- or herself.
If you are that worried about a patient. And think that she is, is suicidal or…psychotic so that she doesn’t know what she’s doing. Then… then it would not be ethically justifiable to impose that [responsibility] on the relatives.
-Resident in psychiatry, male.
Reasons against involuntary treatment
A number of situations were described where one or more of the above mentioned reasons for ordering involuntary treatment were present, but where contra reasons could still make the psychiatrist refrain from deciding in favour of involuntary admission.
Involuntary treatment as an unwanted exception
One general assertion was that involuntary treatment was problematic and constituted an unwanted exception to standard care.
Treatment against the will of the patient…I mean that should be seen as a real exception.
-Resident in psychiatry, male.
Avoiding disruption of trust
The main reason against compulsory treatment mentioned was typically the risk of the patient–physician alliance being harmed and patients losing confidence in the psychiatric services if a decision about compulsory treatment were to be made. This was stated as a reason for not ordering involuntary treatment, also in situations where legal criteria would be fulfilled.
…in the long run there will be a better alliance, she will maintain her trust in psychiatric care, which is the only institution in society that [will be able to] help her if she has a serious mood disorder.
-Resident in psychiatry, male.
Avoiding direct harms of coercion
The reasons against compulsory treatment were often described in terms of harms or negative outcomes of the treatment. The harm could be directly related to limiting patient’s freedom or to the physical coercion that it may involve.
I wouldn’t say that the problem with mandatory treatment is something abstract. It is that it can be so brutal.
-Specialist in psychiatry, male.
Infringements of patients’ freedom were seen as a direct harm to be avoided if possible.
It can really be traumatic for someone to be admitted… 24 h… in a [psychiatric] ward when they don’t want to be.
-Specialist in psychiatry, female.
Respecting self-determination within limits
As noted, autonomy was used as a reason for involuntary admittance and treatment. However, in discussions about involuntary treatment, respect for self-determination was also mentioned as a reason for not ordering involuntary treatment when patients refused care. Respect for self-determination was typically the default position in cases where the immediate risk of harm was seen as low. One respondent told about a case of a patient with bipolar disorder who, after a manic episode, refused treatment with Lithium.
And that is so frustrating because you know that he would probably do so much better, but he refuses. And so we talked about it a lot and […] He had his reasons for this. And who am I to know better than him?
-Resident in psychiatry, female
However, it was acknowledged, if the condition were to deteriorate, (involuntary) treatment would still be an option. Another respondent told of a case where she had been consulted as an expert by the court. The patient was diagnosed with bipolar disorder and was deemed to be in a manic state, however the respondent did not agree with the assessment of the attending psychiatrist.
Then it was better [for the patient] to make these decisions himself, so that he could take the consequences, not blame it on us for locking him up and stopping him… I think he needed to feel that he could take responsibility himself.
- Specialist in psychiatry, female.
Accepting the possibility of rational suicides
As already noted, suicide prevention was mentioned as a major reason for involuntary psychiatric treatment. However, it was also argued that not all possible cases of suicide should be seen as cases for psychiatric care. When asked directly, respondents agreed that so-called ‘rational suicides’ might occur although there were different assertions regarding how common they are. Such suicides were often described as a means of escaping somatic conditions.
I think that it could be about somatic conditions. Where you may be suffering, you are in terrible pain; you see that your level of functioning is deteriorating. And you don’t have any other way out.
-Specialist in psychiatry, female
However, it was also argued that psychiatrists should be cautious.
I think that if as a psychiatrist or physician you are to judge whether there are rational reasons, you are into something that is pretty dangerous and hard to tell for any outside person.
-Specialist in psychiatry, male.
One respondent specifically asserted the right of psychiatric patients to make decisions about when and how to end their lives. The respondent raised this argument in relation to a case where a patient with a psychiatric disorder and a debilitating and painful physical condition had contemplated going abroad in order to complete a physician-assisted suicide.
And in these discussions, people have hesitated whether to allow patients with serious psychiatric disorders to make decisions about this. And I do not think that should be a hindrance, it should rather be a right.
-Specialist in psychiatry, female.
Circumstances affecting decisions about involuntary treatment
The second section of categories concerns the circumstances in which decisions about compulsory psychiatric treatment are made.
The patient’s social circumstances
It was argued that the patient’s social circumstances, e.g. social network and economical situation, also could influence whether an involuntary admission was deemed necessary.
For instance, I do believe that it [involuntary admission] is more common among people who do not have that much resources and…relatives that take care of them….
-Resident in psychiatry, male.
Legal influence
The relationship between ethics and the law was described in two ways. The law set a basic framework for the ethical deliberations and was often commended by the respondents; however, it was also seen as something open to interpretations by the psychiatrists.
Legal demands
Several respondents acknowledged that the law heavily influenced their ethical deliberations. Mostly, the law was seen as commendable, but some of the respondents were also critical of ethical issues often being treated as mere legal issues.
It becomes so easy to conflate ethics and the law. When you work so much with it. You get used to … to think according to the law.
-Resident in psychiatry, male.
Interpreting the law
However, respondents also acknowledged that the law in itself was not very clear and that in most situations it left room for personal judgments and choices between different alternatives.
Like I said before: first you think about it ethically: should you try to save her? And if you decide that you will try, then you will have to use the law the way you can.
-Resident in psychiatry, male.
Another respondent argued similarly that whether or not it was possible to admit a patient involuntarily depended on how the physician chose to present the patient’s symptoms in the involuntary treatment order. In the case discussed by the respondent, the respondent believed that there was a risk of the patient harming herself if she were not admitted. The patient, however, did not accept to stay at the ward.
And I think that the first criterion is not really satisfied. That there is a serious psychiatric disorder. […] But, anyway I chose to order involuntary treatment. I was thinking that I would be able to get the criterion fulfilled anyway.
-Resident in psychiatry, male.
The possibility of informal coercion
In some cases the patient refused or was reluctant to accept care, but a formal decision about involuntary treatment was deemed inappropriate or not possible. Here, there was a ‘grey zone’ between persuasion and manipulation that could be used to make the patient accept treatment and this functioned as an alternative to formal coercion.
Restricting options
One respondent argued that, particularly in somatic care, one way to achieve this was to restrict information about alternatives.
You don’t create that many alternatives for the patient. [You say] ‘This is…we have to give you this.’ You behave in a way that does not give the patient any alternatives.
-Specialist in psychiatry, male.
Using the law to make the patient accept “voluntary” treatment
Another way to make the patient comply was to merely introduce the possibility of coercive treatment. One respondent gave an example of how this might be carried out:
Maybe you can put it this way: I have… I am worried about you, and so I am considering whether to order involuntary treatment if you do not agree to be admitted voluntarily.
-Specialist in psychiatry, female.
Healthcare deficiencies
The functioning of health care also influences decision-making regarding involuntary treatment according to the respondents. Here it was argued that decisions about compulsory treatment were made that could have been avoided in a more well-functioning healthcare organisation.
Inadequate care environment
It was argued that the atmosphere in the clinical ward affected how patients behaved and how they were treated. This included features such as presence of other distressed patients, attitude and behaviour of the staff and whether or not patients knew the staff from before.
I think that just coming in to a psychiatric emergency ward creates a number of incentives for coercive measures that would not exist in a calmer and friendlier atmosphere, where the patients know the staff.
-Specialist in psychiatry, male.
It was also argued that the need for coercive interventions varied from one ward to another, depending on the staff and their approach to the patients.
For instance, the amount of coercive measures varies, depending on what nurse works there. And that depends on…how you treat the patients.
-Resident in psychiatry, male.
Inadequate resources
When physicians were not able to give patients appointments for return visits, coercive measures were deemed more likely.
And then it feels like you are using mandatory treatment in order to… make sure the patient gets appropriate follow-up.
-Resident in psychiatry, male.