Coercive tactics and ethics

I have a bit of an ethical dilemma. Imagine, if you would, a female patient with severe and enduring mental health problems. The main issue is her thought disorder. She also has physical health problems that require regular treatments. Her delusional beliefs are that she will get better without any treatment. She has been assessed as having no capacity. She is now refusing treatment and her mental state has deteriorated even more. She does like to utilise an E-vape regularly during the day and it seems to be her only enjoyment at the minute. Now, the question is, would it be coercive to withhold the E-vape until she accepted her medication?

Yes, it would. You’d be withholding the vape in order to coerce her to take medication.

And on what basis would it be lawful ?

Unlikely she lacks capacity to decide whether to vape, so what business is it of anyone else to decide whether she can do so ?

If it’s her vape, what right would you have to take it off her, or prevent her accessing it ?

If it’s not her vape, or she’s detained under the MHA, easier to see how it might be lawful. But to me it still seems tantamount to punishment for not following doctor’s orders, which isn’t an attractive proposition.

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Completely agree. HRA article 5 may not be absolute but evidenced based decision making & application of MHA or MCA need for DOLS is. In other words, imposing a restriction that Joe Public would consider unreasonable needs scrutiny & justification.

So. Hypothetically speaking, what’s the difference between using restraint to give an injection? She has been on Section 3 for many years. The physical condition could endanger her life.

Legally, the difference seems to be that there’s likely to be a clear basis for the restraint and injection, whereas for this it’s far less clear how the law would permit it. Even when the end is justified, the law doesn’t give care blanche to use any means to get there.

Ethically, perhaps the difference is that the restraint in the injection case isn’t being used in order to cause distress (even though it may have that effect). Here, however, the purpose of withholding the vape would be to cause distress, in order to coerce her into accepting treatment. And the distress would be caused even if it didn’t achieve that end.

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Both would or should achieve the same outcome and reestablish a more stable mental state. Scenario 1. A patient has been refusing medication and becoming more and more disturbed. It is decided to prescribe I/M medication, using restraint if necessary. This works and the patient is reestablished on regular medication. Scenario 2. A patient has been refusing medication and becoming more and more disturbed. The patient is told that they should take their medication before having their E-vape. The patient agrees and shortly afterwards her mental state improves.

Are both scenarios ethical?

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I’m no ethicist (or health professional), but I suspect it’s impossible to give a definitive answer, certainly in the hypothetical.

Some people, of course, would argue that both are equally unethical as a matter of principle, while in practice I doubt either would get anyone hauled before their professional regulator.

Unethical acts can have good outcomes. So the fact that both might achieve the same desirable outcome can’t be determinative by itself.

Both approaches raise ethical issues. But personally I see more problems with the incentive/blackmail option, because it’s less certain to achieve the intended outcome (whilst guaranteed to cause some unhappiness) and is arguably more restrictive of the person’s autonomy - because if successful it forces them to take treatment and denies them the pleasure of vaping. Others would no doubt disagree.

I am just trying to understand if social norms or the concept of what is acceptable here because in my field the dilemmas present themselves all the time. It seem totally acceptable and justifiable for 3 or 4 people to hold down a person to be injected. Even just the option of this given to the person (‘patient’) that may be a threat surely? And, would be coercive.

I agree it’s all coercion.

That’s largely what the Mental Health Act is for. To force people to have treatment. Some people would say it’s unethical for that very reason. But their view has yet to become the orthodoxy. Some people might equally argue it is illogical to have a law to force people to have mental health treatment, but not physical treatment. But our society, and our law, have (rightly or wrongly) long tended to see the two as different.

The Mental Capacity Act isn’t meant to be about coercion - although in certain circumstances it permits things which are coercive provided they are in a person’s best interests.

You can’t use coercion to obtain consent - because compliance obtained by coercion isn’t true consent.

But where consent isn’t an issue - either because the MHA dispenses with the need for it, or because a person lacks the relevant capacity - some form of coercion may well be legally and ethically justifiable and appropriate.

But that doesn’t make all forms of coercion equally acceptable. Some are basically always unacceptable - in this country, at least, you’d never succeed in justifying waterboarding a patient to make them take their medicine, or threatening to kill their dog, for example. But inevitably there will always be a large grey area where choices have to be made, governed by legal principles (eg least restriction in the MCA), ethical conventions (eg what the professional consensus deems acceptable) and personal ethical intuitions.

Apologies if I am missing your point completely.

No. You’re not missing the point. I was just wondering what others philosophic viewpoints were.

Interesting thread discussion; the only issue with answering is that once we leave the ‘safe harbour’ of the law, the consideration of what is right or wrong - or what is ethical - lies within each individual

I sometimes feel, that even though their perception of reality is ‘different to social norms’, their distress is nonetheless real to them. Our reality is also, it can be argued, an hallucination created by our brains from electrical input from our senses. The goal is to their perception of reality to be more like ‘the norm’ so that they do not present a danger to themselves or others essentially.
‘Best practice’ could be said to be a general consensus of is and is not acceptable. But, what if the application of ‘best practices’ could be seen by the individual as very distressing? Let’s not forget, their perception is as real to them as ours is to ourselves due to the lack of any insight.

What is interesting is the idea of law - one is using physical force to get a patient to act in the way they want - the other a psychological approach.

From what I can gather having worked in hospitals both are readily used in wards to make patients adhere to what they deem as the ‘norm’ in behaviour. And both are clearly unethical.

The only difference is that one is recognised as by law as a legal act to violate a patient’s human rights. Whereas the other is not - therefore would constitute essentially as abuse. When in reality - using physical force is as good as assault and battery. Maybe people need to come with better ideas to treat patients who are needing treatment?

Good point. Rather than a change in behaviour, I was questioning the ethical nature in the shorter term to facilitate a return to a more stable mental state so the person could make a more informed decision.

I think if the patient has ability to listen and understand then I feel communication is still a viable option. If the patient is clearly oblivious and acting in a way that puts them and others at risk (exhibiting physical wild movements) then well trained/controlled force is necessary to restrain them.

Another option rather than taking away something from the patient - an incentive could be used - like a treat if they do as instructed?

For example: if you take the medication - I will give you a vape of your choice or I will give you two vapes.