Abstract

Across many parts of the health sector there is increased recognition of the ethical significance of interventions that constrain or coerce. Much of the recent interest stems from debates in public health over the use of quarantines and active monitoring in response to epidemics, as well as the manipulation of information in the service of health promotion (or ‘nudges’). But perhaps the area in which these issues remain most pressing is mental health, where the spectre of involuntary treatment has always loomed large. Indeed, there are good reasons to think of psychiatry as ethically exceptional given its broader role as social and legal arbiter. This is compounded by the fact that mental health treatment has other special features that can serve as potential entry points for more subtle forms of pressure and influence. These include the relative cognitive and emotional vulnerability of patients, the highly confidential information involved, and the importance of the therapeutic relationship. Thus the field of mental health needs to grapple with a range of closely related issues concerning the ethics of influence. In this chapter I explore several, with a primary focus on clinical concerns, although implications for research ethics will also be touched on. Discussion of treatment pressure has traditionally focused on ‘coercion,’ or, very roughly, the use of threats or force to get someone to do something they otherwise would not. Here I follow suit, beginning with discussion of its conceptual standing alongside other categories of influence, including manipulation and persuasion. As it stands, there is nothing close to a consensus on these matters. But a relatively broad, rough and ready understanding of coercion is available and can be useful for ethical deliberation. Or so I suggest here. Interestingly enough, there is also a growing body of empirical literature on coercion in psychiatry, including research on the use of coercive measures such as hospitalization, physical restraint, and forced medication, as well as the construct of ‘perceived coercion,’ which tracks patients’ experiences of treatment pressure. I briefly describe several key findings and their relation to recent recommendations to reduce coercion. Building on all of this, I then take up the normative questions directly, by way of evaluating a recently proposed framework for the ethical analysis of influence. Based on some of the considerations covered in earlier sections, and consistent with this proposal, I recommend that mental health continue to direct its ethical attention to coercion and related questions concerning autonomy, capacity, and consent familiar from debates over involuntary treatment. However, I also suggest that recent findings underscore the importance of more subtle forms of influence better captured by the categories of manipulation and persuasion. At the core of these matters are questions about the nature of relationships – between patients, practitioners, family members, and even with broader social norms – and the ways in which information is framed and processed. At the very least, the ethics of persuasion in mental health are far from straightforward given disparities in authority and capacity. What’s more, as in recent debates in public health, mental health may also need to attend to the ways in which the manipulation of information can effectively bypass rational assessment.