Restraint has been used within health care settings for many centuries. Initially physical restraint was the method of choice, in present times. Within critical care units PR and chemical rest...

This study aimed to clarify the coping strategies of nurses working in general wards who face the ethical dilemma of restraining older people with dementia. The participants were 272 nurses working in general wards in the Kansai region of Japan. Coping strategies were measured using a questionnaire consisting of 16 items. A low score of 1—4 points suggested good coping strategies. Factors were difficult to interpret for three of the 16 coping items identified; these items were therefore deleted. Eleven of (...) the remaining 13 items were used for analysis. An explanatory factor analysis revealed three factors concerning coping with ethical dilemma: (1) self-initiated positive cognition and action; (2) negative cognition and action; and (3) choosing not to act, or maintaining the status quo. These findings highlight the need for programs that could disseminate effective coping strategies among nurses faced with the ethical dilemma of restraining older people with dementia. (shrink)

Restraint has recently become an important legal and clinical issue in England and Wales with the introduction of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards introduced by the Mental Health Act 2007. The requirements of these two new pieces of legislation are complex, and therefore pose major challenges to the provision of high quality and patient-centred care, support and treatment in a range of health and social care settings. In this paper, the legal and ethical aspects (...) of physical restraint in an acute medical care environment are considered, and practical guidance is provided to individuals adopting methods of restraint to care for general hospital patients. Aspects of the Introduction below are written in the first person to reflect the personal experiences of the lead author. (shrink)

This article focuses on the reasons for using physical restraints, their prevalence and nurses’ experiences of their use. The data were collected by means of a questionnaire from nurses, trained nurse’s aids and auxiliary staff ( n = 173) in seven Swiss nursing homes. The results showed that physical restraints are used in nursing units, the mean number of restrained residents in each being 3.7 (SD 3.9). However, nursing staff did not necessarily understand and consider the (...) term ‘restraint’ as a restrictive device in its negative sense. The most common reasons indicated for the use of restraint were related to the protection and safety of the residents themselves, the prevention of disturbance of other residents, and the residents’ restlessness and aggressiveness. As for the reasons related to staffing, reference was made to understaffing, a lack of competence on the part of nurses, and the demands of residents, their next of kin and doctors. It was not common practice to inform the elderly residents that they would be restrained, and therefore they were not always aware of what was happening to them and why. Twenty-nine per cent of the respondents reported that the flexibility of their work was affected by the use of physical restraint. (shrink)

Background Physical restraints are routinely employed to ensure patient safety in Japanese acute care. Little is known about nursing students' perspectives and how they begin to question their value and knowledge in the face of restraint experiences in clinical practice. Objective To investigate nursing students’ questions about patient restraints and how they understand the ethics of the use of restraints in nursing. Research design Qualitative descriptive research using narrative analysis. Participants and research context Experiential data were (...) generated and thematically analyzed from semi-structured interviews with 16 nursing students who had completed their bachelor’s degree program requirements. Ethical considerations The study was approved by academic and clinical ethics agencies. Participants provided written informed consent. Results Physical restraints were encountered in 16 incidents, 3 with children and 13 with older patients with dementia. Students struggled to comprehend the policies and protocols of restraint use and worried their use was primarily for security rather than therapeutic purposes. Five themes were identified: (1). Questioning the tension between person-centered care, patient autonomy, and restraints, (2). Questioning the nature of restraints in which participants analyzed the policies and protocols around restraint use, (3). Questioning the professional nursing self whereby students reflected on how restraint use challenged their nursing values, and (4). Questioning professional nursing practice, in which students explored how restraints fit within a nursing perspective and positioned themselves as patient advocates. Students encountering physical restraints should ask questions based on values of patient-centeredness, autonomy, and advocacy. There is a need for education that facilitates reflection and questioning so that it informs students’ ethical thinking which may enhance nurse advocacy to reduce restraint use. Conclusions Restraints provide contexts in which students must face tensions between nursing values and clinical reality. Further research on nursing education strategies within non-psychiatric settings is needed to reduce physical restraints. (shrink)

This article focuses on the reasons for using physical restraints, their prevalence and nurses’ experiences of their use. The data were collected by means of a questionnaire from nurses, trained nurse’s aids and auxiliary staff (n = 173) in seven Swiss nursing homes. The results showed that physical restraints are used in nursing units, the mean number of restrained residents in each being 3.7 (SD 3.9). However, nursing staff did not necessarily understand and consider the term (...) ‘restraint’ as a restrictive device in its negative sense. The most common reasons indicated for the use of restraint were related to the protection and safety of the residents themselves, the prevention of disturbance of other residents, and the residents’ restlessness and aggressiveness. As for the reasons related to staffing, reference was made to understaffing, a lack of competence on the part of nurses, and the demands of residents, their next of kin and doctors. It was not common practice to inform the elderly residents that they would be restrained, and therefore they were not always aware of what was happening to them and why. Twenty-nine per cent of the respondents reported that the flexibility of their work was affected by the use of physical restraint. (shrink)

The ethics of physical restraint in the Emergency Department has always been an emotive and controversial issue. Recently a vanguard of advocacy groups and regulatory agencies have...

This article gives a brief overview of the state of the art concerning physical restraint use among older persons in nursing homes. Within this context we identify some essential values and norms that must be observed in an ethical evaluation of physical restraint. These values and norms provide the ethical foundation for a number of concrete recommendations that could give clinical and ethical support to caregivers when they make decisions about physical restraint. Respect for the autonomy and (...) overall wellbeing of older persons, a proportional assessment of the advantages and disadvantages, a priority focus on the alternatives to physical restraint, individualised care, interdisciplinary decision making, and an institutional policy are the central points that make it possible to deal responsibly with the use of physical restraint for older persons in nursing homes. (shrink)

This study reviews the ethical dilemmas of nursing staff about using restraints on patients suffering from dementia in two types of health care settings in Israel: internal medicine wards of three general hospitals; and psychogeriatric wards of three nursing homes. The nurses’ level of knowledge about the Patient’s Rights Law, the Israeli Code of Ethics, and the guidelines on restraints was analysed. The purposes of restraints were defined as beneficial to: (1) the patient; (2) other patients; or (...) (3) the institution. The concept was evaluated in a realistic situation (expressing views of daily practice) and in an idealistic situation (expressing personal and professional beliefs and values). It was shown that nurses in internal medicine wards of general hospitals agreed more with the use of restraints than those in psychogeriatric wards in nursing homes. Differences were more pronounced when restraints were beneficial to the institution. In addition, nurses working in psychogeriatric wards of nursing homes had more knowledge about the guidelines on restraints and were less inclined than their counterparts to agree with the use of restraints for the benefit of other patients or the institution. (shrink)

In their practice, nurses make daily decisions that are ethically informed. An ethical decision is the result of a complex reasoning process based on knowledge and experience and driven by ethical values. Especially in acute elderly care and more specifically decisions concerning the use of physical restraint require a thoughtful deliberation of the different values at stake. Qualitative evidence concerning nurses’ decision-making in cases of physical restraint provided important insights in the complexity of decision-making as a trajectory. However (...) a nuanced and refined understanding of the reasoning process in terms of ethical values is still lacking. A qualitative interview design, inspired by the Grounded Theory approach, was carried out to explore nurses’ reasoning process in terms of ethical values. We interviewed 21 acute geriatric nurses from 12 hospitals in different regions in Flanders, Belgium in the period October 2009–April 2011. The Qualitative Analysis Guide of Leuven was used to analyse interview data. Nurses’ decision-making is characterized as an ethical deliberation process where different values are identified and where the process of balancing these values forms the essence of ethical deliberation. Ethical decision-making in cases of physical restraint implies that nurses have to choose which values receive priority in the process, which entails that not all values can be respected to the same degree. As a result, decision making can be experienced as difficult, even as a dilemma. Driven by the overwhelming goal of protecting physical integrity, nurses took into account the values of dignity and justice more implicitly and less dominantly. (shrink)

Background: Physical restraint is among the commonly used methods for ensuring patient safety in intensive care units. However, nurses usually experience ethical dilemmas over using physical restraint because they need to weigh patient autonomy against patient safety. Aim: The aim of this study was to explore factors behind ethical dilemmas for critical care nurses over using physical restraint for patients. Design: This is a qualitative study using conventional content analysis approach, as suggested by Graneheim and Lundman, to (...) analyze the data. Methods: Seventeen critical care nurses were purposefully recruited from the four intensive care units in Tehran, Iran. Data were collected through in-depth semi-structured interviews and were concurrently analyzed through conventional content analysis as suggested by Graneheim and Lundman. Ethical consideration: This study was approved by the Ethics Committee of Iran University of Medical Sciences, Tehran, Iran with the code: IR.IUMS.REC.1397.795. Before interviews, participants were provided with explanations about the aim of the study, the confidentiality of the data, their freedom to participate, and the right to withdraw the study, and their free access to the study findings. Finally, their consents were obtained, and interviews were started. Results: Factors behind ethical dilemmas for critical care nurses over using physical restraint were categorized into three main categories, namely the outcomes of using physical restraint, the outcomes of not using physical restraint, and emotional distress for nurses. The outcomes of using physical restraint were categorized into the three subcategories of ensuring patient safety, physical damage to patients, and mental damage to the patient. The outcomes of not using physical restraint fell into two subcategories, namely the risks associated with not using physical restraint and legal problems for nurses. Finally, the two subcategories of the emotional distress for nurses main category were nurses’ negative feelings about restraint use and uncertainty over the decision on physical restraint use. Conclusion: Decision-making for restraint use is often associated with ethical dilemmas, because nurses need to weight the outcomes of its use against the outcomes of not using it and also consider patient safety and autonomy. Health authorities are recommended to develop clear evidence-based guidelines for restraint use and develop and implement educational and counseling programs for nurses on the principles of ethical nursing practice, patient rights, physical restraint guidelines and protocols, and management of emotional, ethical, and legal problems associated with physical restraint use. (shrink)

Background:There is controversy concerning the use of physical restraint. Despite this controversy, some nurses still consider the application of physical restraint unavoidable for some of their clients.Aim:Identify the perceptions and practice of physical restraint in China.Research design:This was a descriptive study that combined qualitative interviews with a quantitative cross-sectional survey.Participants:A total of 18 nurses were interviewed and 330 nurses were surveyed.Ethical considerations:Approval of the study was obtained from the hospital ethics committee. Permission to conduct the study was (...) obtained from the director of nursing. Participants were assured that their participation is voluntary.Results:Physical restraint was commonly used to protect patients’ safety. Naturally, intensive care unit nurses used physical restraint much more frequently than general medical/surgical ward nurses ( p < 0.01). In addition, night shift nurses tended to use physical restraint more frequently.Conclusion:Nursing managers should be aware of the role nurses play in the use of physical restraint. In-service training regarding the proper use of physical restraint should be strengthened and nurse staffing levels should be improved in order to minimize the use of physical restraint in China. (shrink)

Crutchfield and Redinger argue that consciousness-altering chemical restraints are less “liberty-intrusive” (or as we will sometimes put it, just less “intrusive”) than physical restraints. Physica...

Despite moves to enhance the autonomy of clients of health care services, the use of a variety of physical restraints on the freedom of movement of frail, elderly patients continues in nursing homes. This paper confronts the use of restraints on two grounds. First, it challenges the assumption that use of restraints is necessary to protect the welfare of frail, elderly patients by drawing on a range of data indicating the limited efficacy of restraints. Secondly, (...) it argues that the duty to respect individual autonomy extends to a duty to respect the autonomy of patients who are elderly, frail and living in nursing homes. (shrink)

The practice of medicine frequently involves the unconsented restriction of liberty. The reasons for unilateral liberty restrictions are typically that being confined, strapped down, or sedated are necessary to prevent the person from harming themselves or others. In this paper, we target the ethics of chemical restraints, which are medications that are used to intentionally restrict the mental states associated with the unwanted behaviors, and are typically not specifically indicated for the condition for which the patient is being treated. (...) Specifically, we aim to identify the conditions under which chemical restraints are ethically permissible. It is wrong to assume that what is morally true of physical restraints is also true of chemical restraints. Our aim is thus to identify the conditions under which chemical restraints are permissible while distinguishing these conditions from those of the application of physical restraints. (shrink)

Jesus embodies for the Christian the model of true service, which should be discernibly distinct from secular service. Even for non-Christian services, the Church offers relevant models and teaching. Contemporary service structures often lose sight of the dignity of served and server, and have grown dependent upon technology and technique, straying outside the realm of relationality. An example of this within certain service fields is reliance on physical and mechanical restraints to restrict movement, causing harm to recipients and (...) to the relationship between server and served. Such techniques overshadow the nature of Christian service, which is personal, relational, and communal. Catholic social doctrine, and many personalist frameworks, build on the pillars of dignity, responsibility, and subsidiarity. Rules alone will not be protective against service-mediated harm; however, principled servers can protect vulnerable people, particularly when guided by a concern for the common good, fraternity and solidarity. (shrink)

The use of four-point physical restraints has long been controversial in psychiatry. But the most common objections against these restraints hinges on the idea that they would be imposed against patients. In light of the trend towards giving patients access to Advance Directives, why not allow patients to use such legal documents to arrange for restraints being used against them? Patients might do this if they feared an inability to make competent decisions in the future. Proper (...) oversight over the requests and the restraint-use would help psychiatric patients plan for their own care. Clearly, not all patients would qualify for such an expansion of their autonomy. Many would be unable to give adequately informed consent. Still, for the patients who could consent, being able to draw up such a “Ulysses Contract” could provide an improved balance of risks and benefits. (shrink)

The use of four-point physical restraints has long been controversial in psychiatry. But the most common objections against these restraints hinges on the idea that they would be imposed against patients. In light of the trend towards giving patients access to Advance Directives, why not allow patients to use such legal documents to arrange for restraints being used against them? Patients might do this if they feared an inability to make competent decisions in the future. Proper (...) oversight over the requests and the restraint-use would help psychiatric patients plan for their own care. Clearly, not all patients would qualify for such an expansion of their autonomy. Many would be unable to give adequately informed consent. Still, for the patients who could consent, being able to draw up such a “Ulysses Contract” could provide an improved balance of risks and benefits. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Rhetoric 36.1 (2003) 39-47 [Access article in PDF] Restraint and Emotion in Cicero's De Oratore Per Fjelstad In De Oratore Cicero has the revered orator Crassus ask, "Who then is the man who gives people a thrill? whom do they stare at in amazement when he speaks? who is interrupted by applause? who is thought to be so to say a god among men?" (1942a, III.53). Crassus, (...) who is asking his companions to think about emotional energy in speech, goes on, "It is those whose speeches are clear, explicit, and full, perspicuous in matter and language, and who in actual delivery achieve a sort of rhythm and cadence—that is, whose style I call 'ornate'."Several things are striking about the passage. First, it resolves its inquiry by invoking the concept of ornatus, a word widely used to translate the Greek idea of kosmos (DiLorenzo 1978). Cicero thus refers to a quality that joins the ideas of cosmic order, physical beauty, and earthly power. Second, the passage is delivered in the midst of Crassus's discussion of the fourth rhetorical canon, that referring to the elaboration of ideas in language, of selecting levels of style and modes of verbal embellishment. Third, the passage ranges across the entire field of rhetorical art, at least as indexed by the scope of the canons. The performative quality directly under discussion, that which gives people a thrill—initially associated with the Theophrastian virtues of style that Crassus has been enumerating, that is, clarity and explicitness—quickly is expanded to include copiousness of invention, perspicuity of language, and energetic beauty in delivery. Cicero's Crassus thus discusses a performative dynamic that appears to govern rhetoric as a whole.As the other characters in the dialogue discuss this quality of speech, which engages listeners emotionally and transforms their experience of the present, they bound beyond the preliminary categories of their analysis and describe a power of speech that is aesthetic and philosophical. As the [End Page 39] narrator of this dialogue, Cicero eventually associates the possibility of emotional transformation with a quality of performance we might identify as graceful or urbane. Cicero suggests that performative style can rise above particular details, conventions, and rules of standard rhetorical instruction. Ornate speech is, in sum, emotionally transformative. In detail, however, how does Cicero theorize this grand ability? What goals, resources, or models does he invoke?This essay argues that Cicero's theory of ornatus insists an orator display emotions relevant to the performance while responding to the need of listeners to hear emotional expression against a backdrop of relative calm. In developing this analysis, I claim that the dialogic format of De Oratore allows insight to emerge from juxtaposed perspectives, that Cicero's ideal of ornatus contains a limiting threshold for performative exuberance, and that his examples of emotional engagement illustrate the importance of context and aesthetic restraint. Theoretical tensions as sources for synthetic insight Theoretical tensions in Cicero's De Oratore are instructive. While Cicero's effort to reconcile Isocratean practice with Aristotelian teleology ultimately makes for a rough fit, the juxtaposition of those understandings within the dialogue also generates new insight, even about limits for rhetorical theory itself. Referring to this mode of theorizing as "ironic eloquence," Michael Leff holds that "through this merger of theory and practice, the rival conceptions of oratory as systematic art and oratory as synthetic practice coalesce within the text, the two perspectives interacting to produce a development that incorporates both" (1986, 323).A similar theoretical tension can be observed in De Oratore regarding the prospects and significance of emotional engagement in oratorical performance. In discussing the practices of emotional oratory Cicero draws on three distinct intellectual sources: a quasi-enthymematic model of emotional engagement, in which an orator need not share or display the sought-after emotional response; a mimetic theory of theatrical performance (that is, a typology of tonal and gestural "moods"); and a latent theory of "authenticity," according to which that which is being theatrically displayed is not "fakely" fictional, but somehow genuine.The conflicting theories suggest... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Rhetoric 36.1 (2003) 39-47 [Access article in PDF] Restraint and Emotion in Cicero's De Oratore Per Fjelstad In De Oratore Cicero has the revered orator Crassus ask, "Who then is the man who gives people a thrill? whom do they stare at in amazement when he speaks? who is interrupted by applause? who is thought to be so to say a god among men?" (1942a, III.53). Crassus, (...) who is asking his companions to think about emotional energy in speech, goes on, "It is those whose speeches are clear, explicit, and full, perspicuous in matter and language, and who in actual delivery achieve a sort of rhythm and cadence—that is, whose style I call 'ornate'."Several things are striking about the passage. First, it resolves its inquiry by invoking the concept of ornatus, a word widely used to translate the Greek idea of kosmos (DiLorenzo 1978). Cicero thus refers to a quality that joins the ideas of cosmic order, physical beauty, and earthly power. Second, the passage is delivered in the midst of Crassus's discussion of the fourth rhetorical canon, that referring to the elaboration of ideas in language, of selecting levels of style and modes of verbal embellishment. Third, the passage ranges across the entire field of rhetorical art, at least as indexed by the scope of the canons. The performative quality directly under discussion, that which gives people a thrill—initially associated with the Theophrastian virtues of style that Crassus has been enumerating, that is, clarity and explicitness—quickly is expanded to include copiousness of invention, perspicuity of language, and energetic beauty in delivery. Cicero's Crassus thus discusses a performative dynamic that appears to govern rhetoric as a whole.As the other characters in the dialogue discuss this quality of speech, which engages listeners emotionally and transforms their experience of the present, they bound beyond the preliminary categories of their analysis and describe a power of speech that is aesthetic and philosophical. As the [End Page 39] narrator of this dialogue, Cicero eventually associates the possibility of emotional transformation with a quality of performance we might identify as graceful or urbane. Cicero suggests that performative style can rise above particular details, conventions, and rules of standard rhetorical instruction. Ornate speech is, in sum, emotionally transformative. In detail, however, how does Cicero theorize this grand ability? What goals, resources, or models does he invoke?This essay argues that Cicero's theory of ornatus insists an orator display emotions relevant to the performance while responding to the need of listeners to hear emotional expression against a backdrop of relative calm. In developing this analysis, I claim that the dialogic format of De Oratore allows insight to emerge from juxtaposed perspectives, that Cicero's ideal of ornatus contains a limiting threshold for performative exuberance, and that his examples of emotional engagement illustrate the importance of context and aesthetic restraint. Theoretical tensions as sources for synthetic insight Theoretical tensions in Cicero's De Oratore are instructive. While Cicero's effort to reconcile Isocratean practice with Aristotelian teleology ultimately makes for a rough fit, the juxtaposition of those understandings within the dialogue also generates new insight, even about limits for rhetorical theory itself. Referring to this mode of theorizing as "ironic eloquence," Michael Leff holds that "through this merger of theory and practice, the rival conceptions of oratory as systematic art and oratory as synthetic practice coalesce within the text, the two perspectives interacting to produce a development that incorporates both" (1986, 323).A similar theoretical tension can be observed in De Oratore regarding the prospects and significance of emotional engagement in oratorical performance. In discussing the practices of emotional oratory Cicero draws on three distinct intellectual sources: a quasi-enthymematic model of emotional engagement, in which an orator need not share or display the sought-after emotional response; a mimetic theory of theatrical performance (that is, a typology of tonal and gestural "moods"); and a latent theory of "authenticity," according to which that which is being theatrically displayed is not "fakely" fictional, but somehow genuine.The conflicting theories suggest... (shrink)

Despite the lack of evidence for their effectiveness, the use of physical restraints for patients is widespread. The best ethical justification for restraining patients is that it prevents them from harming themselves. We argue that even if the empirical evidence supported their effectiveness in achieving this aim, their use would nevertheless be unethical, so long as well known exceptions to informed consent fail to apply. Specifically, we argue that ethically justifiable restraint use demands certain necessary and sufficient conditions. (...) These conditions are that the physician obtain informed consent for their application, that their application be medically appropriate, and that restraints be the least liberty-restricting way of achieving the intended benefit. It is a further question whether their application is ever medically appropriate, given the dearth of evidence for their effectiveness. (shrink)

A programme of research into conflict (e.g. violence, absconding, medication refusal) and containment (e.g. seclusion, special observation, physical restraint) in inpatient psychiatry has been under way at City University, London, UK, for the past 10 years. Recent research findings, plus the challenges posed by ongoing projects, have made apparent the need for greater clarity about the overarching concepts of ‘conflict’ and ‘containment’. This paper pulls together research findings pertaining to this issue, and conducts a reasoned analysis of what common (...) characteristics might underlie ‘conflict’ and ‘containment’. It is concluded that these are patient threats to safety, and the staff maintenance of safety. Details are presented on the inclusions and exclusions that follow from taking such a position, and potential definitions offered. On the grounds of this conceptual analysis, plus evidence for moderate degrees of statistical association between behaviours and events in each domain, it is concluded that it is legitimate to conduct analyses at the level of total conflict and containment rates, as well as at the level of individual types of behaviours and events (e.g. verbal abuse, sedation). Some of the mathematical difficulties in the analysis of total conflict and containment are addressed, and results of a weighting exercise presented. This exercise challenges our perception of the severity of some containment measures that are becoming more commonly used in acute psychiatry. (shrink)

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. (shrink)

Christian Non-Resistance (1846) is the major philosophical statement by the nineteenth-century theorist of nonviolence, Adin Ballou. Ballou argued that the Biblical injunction "resist not evil" should be understood as "resist not personal injury with personal injury." While prohibiting the injury of any person under any provocation whatsoever, Ballou taught that Christians have a duty to resist, oppose, or prevent evil by all uninjurious means, including the use of "uninjurious benevolent force." He believed that this would allow a community to adopt (...) non-resistant principles while still maintaining public safety and order. Once dismissed as a relic of the naive and sentimental optimism of pre-Civil War America, Christian Non-Resistance is now recognized as an important contribution to the theory of nonviolent resistance. Ballou's combination of the utmost moral resistance to evil with the uninjurious physical restraint of evildoers provides a conceptually simple, flexible approach to the problem of resisting evil without becoming evil oneself. This edition contains the essay "Christian Non-Resistance in Extreme Cases" (1860), in which Ballou takes up a type of challenge often put to pacifists: "Suppose a robber attacks you in some lonely place on the highway? Suppose you and your family are attacked by a gang who design to commit rape, robbery and murder? How can the downtrodden peoples of the earth ever gain their liberty without fighting to the death against their tyrants?"". (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumThe Self-Fulfilling Prophecy of Police BrutalityKathryn Petrozzo (bio)In their timely and pressing piece, Arjun Byju and Phoebe Friesen explore the contentious diagnosis of excited delirium; a syndrome characterized by erratic, aggressive, and “delusional” behavior (2023). Overwhelmingly, this term is used when individuals come in contact with police and/or first responders. Although much attention has been given to debating whether or not this is a “real” diagnosis, the authors (...) want to shift the focus to examining the work that excited delirium is doing in the world, as well as the underlying beliefs guiding it that are perpetuating substantial harm. Drawing significantly on the work of Ian Hacking (1998, 2006) and Sherene Razack (2015), Byju and Friesen explore what kinds of people are being made up by the label of “excited delirium” and the subsequent dehumanization that perpetuates violence towards those in this grouping.Despite the lack of an agreed upon definition, excited delirium tends to frequently group together young Black men and other marginalized people of color, who have a psychiatric history, and those who have taken or are suspected to have taken drugs (Byju & Friezen, 2023). As this is “observed” when individuals come into contact with law enforcement and/or first responders, those who are presumed to be suffering from excited delirium are typically met with physical restraints (chokeholds, hogties, etc.), forced injections of sedatives, and/or taser guns. The violent reactions are often justified not only by this “diagnosis,” but the employment of racial stereotypes; notably, the notion that Black bodies as being less susceptible to pain. As the authors aptly put it:This kind of symptom language helps make up the novel category of a person who suffers from excited delirium: a crazed and inhumane monster, a golem that must be met with unrelenting and superordinate force, who is fated, regardless of interventions, to die a spontaneous death. This paradox, that those with excited delirium are supposedly both too strong and too weak, is at the core of the illness narrative.(2023)It is evident that this label is reinforcing the combination of two harmful stereotypes: the notion that those suffering from severe mental illness occupy a space that is “less than fully human,” and racist stereotyping of Black bodies “superseding human strength.” This perpetuates total dehumanization of the individual, where it is then justified to invoke brutal tactics, as well as signal [End Page 357] to the greater community this is how individuals with mental illnesses and/or belonging to a particular racial group (chiefly, Black men), should be treated. This is despite the fact that those suffering from mental illnesses are significantly more likely to be victims of violent crimes, Black Americans are 3.2 times more likely to be murdered by police, and convergence of these factors (being Black and living with a mental illness) increases likelihood of such fatal interactions (Schwartz & Jahn 2020; Shadravan, Edwards, & Vinson 2021; Stuart, 2003).Although I am in wholehearted support of their account, I take issue with the authors’ conceptualization of excited delirium as non-falsifiable, as well as the notion that diseases, generally, are falsifiable. In an attempt to further criticize the utilization of excited delirium, Byju and Friesen call upon Karl Popper’s falsifiability criterion as a measure for what constitutes as scientific; arguing that excited delirium is not a legitimate scientific concept as it is impossible to falsify. First, I am not convinced that excited delirium is in principle non-falsifiable; as the way in which it’s conceptualized actually appears to be falsifiable. The authors point out that external factors, such as tasing and violent restraints, are clearly the causal explanation, which should in fact, lead one to reject the hypothesis of an excited delirium diagnosis. However, in practice, those who are seeking to exonerate the police/first responders responsible for these deaths, are not accepting this evidence leading them to reject the excited delirium diagnosis, but rather, are crafting an incorrect causal narrative. This is deeply problematic, but it does not necessarily render excited delirium as non-falsifiable. More broadly, I am concerned with the reliance on the falsifiability criterion, which has been widely criticized in the... (shrink)

Those whom the gods wish to destroy, they first make mad, says a Nigerian proverb. These words of wisdom re-echo in traditional approaches to mental health ethics in sub-Saharan Africa. Among many cultures in Nigeria, it is customary to subject persons with mental health illness, especially those who present with violent behavior, to physical restraint and beatings. The belief is that such subjugation could restore mental health in the early stages of madness. Physical restraint and beatings only form (...) a part of the healing process, as it also has communitarian cum spiritual aspects. The healing process is carried out by family members or community, who share in the life of the mentally ill person. Their... (shrink)

_Covert treatment raises a number of ethical and practical issues in psychiatry. Viewpoints differ from the standpoint of psychiatrists, caregivers, ethicists, lawyers, neighbours, human rights activists and patients. There is little systematic research data on its use but it is quite certain that there is relatively widespread use. The veil of secrecy around the procedure is due to fear of professional censure. Whenever there is a veil of secrecy around anything, which is aided and abetted by vociferous opposition from some (...) sections of society, the result is one of two: 1) either the activity goes underground or 2) it is reluctantly discarded, although most of those who used it earlier knew it was needed. Covert treatment has the dubious distinction of suffering both such secrecy and disapproval. Covert treatment has a number of advantages and disadvantages in psychotic disorders. The advantages are that it helps solve practical clinical problems; prevents delays in starting treatment, which is associated with clinical risks and substantial costs; prevents risk of self-destructive behaviour and/or physical assault by patient; prevents relapse; and prevents demoralization of staff. The disadvantages are that it maybe used with malafide intent by caregivers with or without the complicity of psychiatrists; it may be used to force conformity in dissenters; and the clinician may land himself in legal tangles even with its legitimate use. In addition, it may prevent insight, encourage denial, promote unhealthy practices in the treating staff and prevent understanding of why noncompliance occurs in the first place. Some support its use in dementia and learning disorders but oppose it in schizophrenia. The main reason is that uncooperative patients of schizophrenia (and related psychoses) are considered to be those who refuse treatment but retain capacity; while in dementia and severe learning disorder, uncooperative patients are those who lack capacity. This paper disputes this contention by arguing that although uncooperative patients of schizophrenia (and related psychoses) apparently retain capacity, it is limited, in fact distorted, since they lack insight. It presents the concept of insight-unconsciousness in a patient of psychosis. Just as an unconscious patient has to be given covert medical/surgical treatment, similarly an insight-unconscious patient with one of the different psychoses (in the acute phase or otherwise) may also have to be given covert treatment till he regains at least partial insight. It helps control psychotic symptoms and assists the patient in regaining enough insight to realize he needs treatment. Another argument against covert treatment is that people with schizophrenia have the capacity to learn and therefore can learn that they are required to take medications, but if medications are given covertly it may well fuel their paranoia. However, it should be noted that the patient who has lack of insight cannot learn unless he regains that insight, and he may need covert treatment to facilitate this process. Covert treatment can fuel the paranoia, true, but it can also control the psychotic symptoms sufficiently so that regular treatment can be initiated. In a patient who refuses to accept that he is sick and when involuntary commitment is not an option to be considered, covert treatment is the only option, apart from physical restraint. Ultimately, a choice has to be made between a larger beneficence (control of symptoms and start of therapy) and a smaller malevolence (necessary therapy, but without the patient's knowledge and consent). A number of practical clinical scenarios are outlined wherein the psychiatrist should adopt covert treatment in the best interests of the patient. Ethical issues of autonomy, power, secrecy and malafide intent arise; each of these can be countered only by non-malfeasance (above all, do no harm) under the overarch of beneficence (even above that, dare to care). An advance directive with health care proxy that sanctions covert treatment is presented. Questions raised by the practical clinical scenarios are then answered. The conclusions are as follows: covert treatment, i.e, temporary treatment without knowledge and consent, is seldom needed or justified. But, where needed, it remains an essential weapon in the psychiatrist's armamentarium: to be used cautiously but without guilt or fear of censure. However, the psychiatrist must use it very judiciously, in the rarest of rare cases, provided: i) he is firmly convinced that it is needed for the welfare of the patient; ii) it is the only option available to tide over a crisis; iii) continuing efforts are made to try and get the patient into regular psychiatric care; iv) the psychiatrist makes it clear that its use is only as a stop-gap; v) he is always alert to the chances of malevolence inherent in such a process and keeps away from conniving or associating with anything even remotely suspicious; and vi) he takes due precautions to ensure that he does not land into legal tangles later. The need of the hour is to explore in greater detail the need and justification for covert treatment, to lay out clear and firm parameters for its legitimate use, follow it up with standard literature and, finally, to establish clinical practice guidelines by unconflicted authors. The term "covert treatment" is preferable to "surreptitious prescribing"; they should not be used synonymously, the latter term being reserved for those cases where there is malafide intent._. (shrink)

Little is known about the views of mothers when their children are invited to participate in randomized clinical trials (RCTs) investigating medicines and/or invasive procedures. Our goal was to understand mothers’ perceptions of the processes of informed consent and randomization in a RCT that divided uncooperative children into three intervention groups (physical restraint, sedation, and general anesthesia) for dental rehabilitation.

This book explores the religious experiences of two notable figures who endured severe trials under authoritarian regimes: Bediuzzaman Said Nursi (1877–1960) within the Islamic tradition, and Aleksander Solzhenitsyn (1918–2008) within the Russian Orthodox Christian tradition. Against the tumultuous backdrop of the twentieth century’s spiritual, social, political, and intellectual upheavals, both Nursi and Solzhenitsyn grappled with immense hardships because of their beliefs. Despite immense tribulations, both individuals demonstrated unwavering faith and resilience in the face of adversity, continuing their scholarly and literary (...) activities. The current study centers on the dichotomy of spiritual confinement and expansiveness, illustrating how people can experience spiritual distress even without physical restraints. It explores the historical and conceptual aspects of imprisonment within Christian and Muslim perspectives, explores the reasons for Nursi and Solzhenitsyn's incarceration, examines their coping mechanisms in the face of hardship, and underscores the role of faith and spirituality. The author integrates personal experiences, particularly his own incarceration during the aftermath of the 2016 Turkish staged coup attempt, within the context of the narratives of Nursi and Solzhenitsyn. The book addresses court proceedings, release, departure from Turkey, and resettlement in Australia. Throughout, the author draws parallels between their own observations and those of Nursi and Solzhenitsyn, contributing to the broader discourse on individual spirituality and collective consciousness. The book offers insights into spiritual resilience in the face of adversity, utilizing the lives of these figures to illuminate shared human experiences. A unique collation of personal narration and scholarly reflection, it is relevant to academics and students in history, political science, sociology, Islamic and Middle Eastern studies, and to social scientists researching the phenomenon of exile and prison in different countries across the world. It also speaks to the work of activists and policymakers in human rights. (shrink)

While a standard procedure in mental health internment facilities, physical restraint, as an extreme form of coercion in mental health, has been claimed to be abolished. Three sorts of arguments have been provided: an argument from dignity, and argument from informed consent, and a consequentialism argument. In this chapter we discuss these arguments and conclude that these arguments are not decisive to completely ban such forms of coercion. Restraint, in particular, may be justified in exceptional circumstances, where an imminent (...) risk for the personal integrity of anybody involved, including the person with the mental health problem. However, this sort of case is infrequent, while restraint is often the first option. This conclusion also suggests that much can be done to prevent reaching such extreme circumstances where coercion may be the only option. The discussion also clarifies how coercion should be carried out, when justified, making it supervised and as short as possible. (shrink)

The use of restraints on psychiatric patients has long been criticized, and the need for self-restraint of professionals in response to new technologies has been documented from the nineteenth century. Since the middle ages, when leprosy disappeared from civilized society, individuals with a “deranged mind” came to occupy the public space of outcast once reserved for the leper. This diminished social status conflicts with the ethical precept of respect for all patients and the need for humane treatment within the (...) clinical care setting. Psychiatric patients may be presented as a physically dangerous presence in clinical care facilities. New technologies may seem to offer a solution to the problem of balancing the safety of staff with the ethical requirement to treat patients with respect and attention to their medical needs. The Taser, promoted as a safe method of law enforcement, has received notoriety in at least one case involving restraint of psychiatric patients. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hume Studies Volume XXIV, Number 1, April 1998, pp. 53-70 Hume on Justice to Animals, Indians and Women ARTHUR KUFLIK I. The Circumstances of Humean Justice For Hume, the virtue of justice is its "usefulness" to the support of society.1 To help prove this point, he guides us through a series of imaginative thought-experiments. Suppose that resources were infinitely available or that human beings were generous and kind without (...) limit: in such unusual circumstances, nobody would have even "dreamed of" the various property restrictions associated with justice. If the supposition seems too fanciful, the same point can be illustrated, at least to some extent, by special real-life circumstances as well: e.g., by the way that air or water or land go unregulated in those places where they are super-abundant or the way in which the line between what is "mine" and "thine" blurs in loving families or between intimate friends. Moving to the opposite extreme: suppose that resources were so scarce as to render it impossible for most people (regardless of their cooperative exertions) even to subsist. Or suppose that people were not merely limited in their benevolent concern but "perfectly malicious"! Once again, there would be little or no point to the observance of rules of justice. On Hume's account, such rules define a scheme of social cooperation. But by hypothesis, extreme scarcity makes even well-meaning cooperative effort unproductive. Extreme villainy makes it pointlessly dangerous. Indeed, in a world wholly villainous, just cooperative schemes would be altogether impossible. Arthur Kuflik is at the Department of Philosophy, The University of Vermont, 70 South Williams Street, Burlington, Vermont 05401-3404 USA. email: [email protected] 54 Arthur Kuflik What can we conclude? There is a range of circumstances within which schemes of justice make sense: (1) moderate scarcity (resources are adequate to sustain people, but not so extensive that everyone could have as much as might be desired); and (2) limited benevolence (people are neither saintly nor satanic; though clearly concerned about themselves, they are not incapable of caring about what happens to others). John Rawls has dubbed these conditions "the Humean circumstances of justice."2 Hume wants us to notice that they are the very conditions under which justice is both practically possible and socially necessary. Fortunately, they are also the conditions that most commonly prevail. ("The common situation of society is a medium amidst all these extremes" [EPM 188].) II. A More Puzzling Thought-experiment Suppose we grant that the foundation of justice is its usefulness to society. This raises a certain worry: aren't there groups whose members ought to be treated justly even though "society" could flourish just as well if they weren't? (Another way to put the point is to ask: just who are the members of "society"?) This very issue underlies one more puzzling, and even disturbing, Humean thought-experiment: Were there a species of creatures intermingled with men, which, though rational, were possessed of such inferior strength, both of body and mind, that they were incapable of all resistance, and could never, upon the highest provocation, make us feel the effects of their resentment; the necessary consequence, I think, is that we should be bound by the laws of humanity to give gentle usage to these creatures, but should not, properly speaking, lie under any restraint of justice with regard to them, nor could they possess any right or property, exclusive of such arbitrary lords. Our intercourse with them could not be called society, which supposes a degree of equality; but absolute command on one side, and servile obedience on the other.... And as no inconvenience ever results from the exercise of a power, so firmly established in nature, the restraints of justice and property, being totally useless, would never have place in so unequal a confederacy. (EPM 190-191) What can we learn from this thought-experiment? What insight into justice do we gain by imagining a "species of creatures intermingled" among us who, though endowed with some ability to think and to reason, are: (i) greatly inferior to us both physically and mentally; (ii) "incapable of all resistance" to our provocations; and... (shrink)

One approach to the analysis of ethical dilemmas in medical practice uses the “four principles plus scope” approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: (...) the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles. (shrink)

ABSTRACTThe growing reliance on Unmanned Aerial Vehicles in armed conflict raises important questions regarding our conception of both war and the warrior’s place within it. This includes the question of whether the degree to which UAVs mitigate physical risk has imperilled the ethical status of the operator. For those that view this tension as resolvable, reference is frequently made to the eventual acceptance of previous categories of “unfair” weaponry. This article engages with this historical context, identifying the role of (...) physical risk within the historical and contemporary warrior ethos. It first outlines that exposure to personal, physical risk has long been regarded as a crucial element in the ethos-based conception of legitimate violence in war. As will be further shown, however, the warrior ethos is an evolving framework, one that increasingly considers factors such as restraint and professionalism in determining ethical status. The adaptive quality of this ethos is a key explanatory fa... (shrink)

If one can judge a society by how it treats its prisoners, one can surely judge a society by how it treats cognitively- and learning-impaired children. In the United States children with physical and cognitive impairments are subjected to higher rates of corporal punishment than are non-disabled children. Children with disabilities make up just over 13% of the student population in the U.S. yet make up over 18% of those children who receive corporal punishment. Autistic children are among the (...) most likely to receive corporal punishment. -/- Although they may deny or redescribe particular instances of corporal punishment or their use of restraints, educators defend such actions as legitimate punishment. In this paper, I assess the logic underlying the use of restraints and corporal punishment on autistic children by educators. The rationalizations for the corporal punishment or restraint of autistics stems from the educator’s desire to control the autistic children so as to end typical autistic behaviors such as rocking, repetitive verbalizations, or “flapping” but also the autistic child’s non-affective responses such as not appearing to feel remorse or shame or the absence of a verbal acknowledgement of remorse or shame. The educators assume that the autistic’s failure to exhibit the desired responses is evidence of the autistic’s moral incorrigibility and is, therefore, evidence of the appropriateness of corporal punishment. But this assumption of the incorrigibility of the autistic child is questionable. -/- Indeed accepting this incorrigibility assumption reveals two important problems. First, instructors using physical punishment on autistic children do not understand autism. Second, they are not working with a tenable conception of punishment. Any action undertaken to induce socially acceptable behaviors (whether it be the end of autistic acts or responses such as remorse) is to fail to understand what the legitimate punishment of children is about. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumWhat’s Psychiatry Got to do With It?Paul B. Lieberman, MDIf in life we are surrounded by death, so too in the health of our intellect by madness.—WittgensteinDelirium is a medical syndrome defined as “a relatively acute decline in cognition that fluctuates over hours or days” whose primary manifestation is a deficit of attention. It is common, estimated to occur in 10% to more than 50% of hospitalized patients, (...) with higher prevalence rates among people in nursing homes and at the end of life. It is often fatal, with a mortality rate in the hospital estimated to be 25% to 33%. Caused by a wide variety of conditions and frequently difficult to diagnose, it lacks characteristic postmortem pathology (Josephson & Miller 2018)‘Excited delirium,’ as Byju and Friesen forcefully argue (Byju & Friesen, 2023), is, if nothing else, an excuse. The ‘diagnosis’ has not been empirically validated and remains controversial (American Psychiatric Association, 2020). And while delirium is usually treated by internists and emergency medicine physicians, psychiatrists should also be concerned about the misuse of a putative medical diagnosis and join actively in discussion about it. For one thing, patients mis-diagnosed with this condition, as Byju and Friesen’s examples suggest, may actually have another psychiatric condition and, so, be people for whose safety we should advocate. Moreover, the kinds of police interventions which Byju and Friesen document as involving excited delirium also befall patients with other psychiatric problems in whom the issue of delirium does not arise.There are at least two broad ways in which psychiatrists are qualified and obligated to engage with this issue. As physicians, we should join our medical colleagues in carefully but persistently telling the scientific, medical truth. As psychiatrists, we should bring psychiatric knowledge into the discussion, for example, by explaining what can happen when people who do not, apparently, have a diagnosable mental disorder interact under stress with other people who, apparently, do.Delirium is a clinical diagnosis, made when characteristic signs and symptoms are present which should not be made ‘by exclusion’ when, as may happen, other causes are not found. There is no evidence of delirium in any of the three clinical descriptions Byju and Friesen provide. Perhaps such evidence exists which is not in their brief reports, but these three people appear to have had, either, another psychiatric condition, such as psychosis or drug intoxication, or perhaps no [End Page 353] diagnosis at all. Psychiatrists are particularly wellpositioned to make this point since patients with mental health problems are often misdiagnosed when they seek medical attention and are told, and treated as if, “it’s all (“just”!) psychological.”Excited delirium, if it exists, is fatal in 10% of cases (Gonin, Beysard, Hersin, & Carron, 2018) and, although this is lower than the rate for delirium in general, it is still high. Medical personnel must be available to evaluate and ensure the safety of patients in custody.The potential conflict between protecting the patient and protecting the public should not be overstated. Although physical trauma and excessive administration of medications, including ketamine 500 mg IV (Orhurhu, Vashicht, Claus, & Cohen, 2023) can be lethal, mechanical restraint by itself is not (Chieze et al., 2019; Gleerup et al., 2019): something else is necessary, such as asphyxiation (Evans, Wood, & Lambert, 2003). Nor is restraint necessary in many cases in which ‘de-escalation’ techniques can be equally effective (Garriga et al., 2016; Fernández-Costa, 2020). Perhaps these points are best made by law enforcement leaders—and they have been—but psychiatrists can add that safe management of potential violence can be provided for agitated people with psychiatric conditions.Although it is not clear what kind of strength ‘superhuman’ strength might be (certainly not medical), relative imperviousness to pain is clinically described. Its locus classicus is Beecher’s observation, during World War II, that injured soldiers awaiting return home from the front, required lower than usual doses of analgesics (Beecher, 1946). And it’s a common experience, scientifically confirmed, that physical trauma may not become painful until sometime after the injury (Melzack, Wall, & Ty, 1982). But pain is a warning. Its absence is not a license, but a caution... (shrink)