In R. Bluhm & S. Tekin (eds.), The Bloomsbury Companion to Philosophy of Psychiatry. Bloomsbury. pp. 283-304 (2019)

Kelso Cratsley
American University
Across 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 are also 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 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.
Keywords coercion  psychiatry  mental health
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