Should Medicine Face Up to Coercion?

SHOULD MEDICINE FACE UP TO COERCION? Under the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) Article 14, for people with disabilities receiving medical care, the article ensures that their rights are preserved, and they are not deprived of their liberty unlawfully or arbitrarily. In addition, Article 14 requires that people with disabilities receive reasonable accommodation, aiming to move away from coercive measures in treatment. In contrast to psychiatry, there is little discussion about using and reducing restraint in medicine. We suggest that medicine starts this discussion by developing and implementing effective restraint reduction strategies to improve patient and staff safety and reduce traumatization. COERCION IN MEDICINE The UNCRPD, Article 14 ensures that their rights are preserved and not deprived of their liberty unlawfully or arbitrarily for the person with disability.[1] This includes largely any coercive measures used in medicine, such as chemical, physical, mechanical, or psychological restraint, seclusion, and covert medication. The convention’s demands have caused widespread discussions within psychiatry about the use of restraint, but there has been almost complete silence within other medical specialties. This is surprising, given that coercion is common in medical wards where a large number of elderly patients get treated,[2] and restrained aggressive patients have worse outcomes than those not restrained.[3] A systematic review has shown that the prevalence of incapacity among medical patients is 34%.[4] This is understandable because many medical patients suffer from delirium, dementia, or other illnesses that can affect capacity. While coercion may occur in these contexts, it usually happens within treatment principles and values guiding medical practice. Notwithstanding benign intent when using coercive measures, we know that there is a relationship between aggression on staff and coercion use, and reducing aggression reduces coercion.[5] Data are available showing high levels of aggression on medical wards and in emergency departments (EDs) worldwide.[6] Studies in India[7] and other Asian countries suggest similar problems in medical wards in Asia,[8] indicating that it is not a culture-bound phenomenon. Surprisingly, few studies have investigated restraint prevalence in medical wards.[9] The dearth of data for medical settings, in contrast to psychiatric settings, shows a remarkable difference in our perception of where coercion happens and where it matters. However, this is in sharp contrast to the data showing that nonpsychiatric settings such as ED, psychogeriatric wards, ambulance services, and others are more at risk from aggression[10] and thus also the increased likelihood of using restraint. This lack of awareness of restraint within medicine happens in an environment of increasing attempts to fight the stigmatization of psychiatry, exemplifying that much more work needs to be done. Medical patients are also treated differently from psychiatric patients by the law, especially when it comes to coercion. As an example, a person with dementia who lacks capacity in an English medical hospital may be coerced under the Mental Capacity Act (2005) without any need to record and report figures regularly. In contrast, the same patient in a psychiatric hospital would have all their restraint episodes recorded in detail, analyzed, and reported periodically. Similarly in Sweden, a patient detained for a substance misuse problem under the Compulsory Psychiatric Care Act would have all their longer episodes of coercive measures recorded and reported immediately. The same patient could be detained in a medical ward under the Care of Substance Abusers (Special Provisions) Act, and their coercion would neither be defined by law nor is there a need to record or report it. In India, any patient restrained under the Mental Healthcare Act (2017) will have their restraint episode reported and monitored, whilst this does not happen to a patient restraint in a medical ward. In the USA, detailed data are available for restraint episodes in psychiatry but not in other fields of medicine.[11] These examples show that the same patient can have the same coercive experience. Still, they are perceived and recorded in substantially different ways, depending on whether they are in a medical or a psychiatric ward. We can only speculate what the reasons for this discrepancy might be. Still, it may be rooted in psychiatry’s history[12] and societal and professional stigma[13] against mental illness. Health-care providers are ethically and legally obliged to minimize harm and prioritize patient well-being, necessitating a reduction of coercion and restraint. However, we do not know its precise extent and character because there is no data on coercion in medical wards. This makes it difficult to engage staff in measures that would reduce coercion. It limits our possibilities to reflect upon what is reasonable and proportionate and what is not. By not reflecting on our practice, we may lose the opportunity to discuss when coercion may have been unnecessary, and chances to act in alternative ways are missed. This has the potential to harm patients and staff alike. There is good evidence that both staff and patients can get traumatized[14] and retraumatized by coercion. Injuries and even deaths have occurred. Staff can get injured and psychologically traumatized, particularly when coercion is done haphazardly and without prior training. Coercion reduction thus has the potential to improve staff safety, patient safety, and therapeutic relationships. CONCLUSION To get to a point where effective reduction management[15] can be implemented on medical wards with all the potential, we ought to look at a stepwise approach: The starting point may be acknowledging coercive measures on medical wards as coercion The next step would be to explore the character of coercion in any given local setting, examining the extent of coercion and which strategies for reduction may be particularly pertinent in that setting Solutions evaluated and implemented in psychiatric settings may be of help to develop measures relevant to medical wards Restraint reduction strategies are ratified and implemented.