Involuntary psychiatric hospitalization of children and adolescents in Northern Greece: Retrospective epidemiological study and related ethical issues.

The aim of the present study was to investigate epidemiological data on involuntary hospitalization of underage patients in psychiatric settings and illustrate the related ethical issues. The medical records of 131 involuntary psychiatric admissions of children and adolescents ordered by public prosecutor between 2005 and 2014 were examined carefully. The examined variables involved the place of origin, the place of residence of minors after discharge, the length of stay in hospitals, the discharge diagnosis, the rate at which the minors were introduced to police and other authorities before their hospitalization, and the results of the neuropsychological assessment (WISC II). Data were analyzed by SPSS (Statistical Package for the Social Sciences). The mean age of the minors was 14.19 years (Male: Female ratio; 1.6:1). First, a high rate of incidences of compulsory admissions was found [5-year period (2005-2009):(2010-2014) ratio; 1:1.85] most likely due to organizational factors, which, however, could have been avoided in a more patient-oriented healthcare system. It is most likely that the criteria used for making decisions in favor of compulsory admissions were disproportionately (unduly) broad. In parallel, it was observed that, during 2010-2014, despite the increase in the rate of the prosecutor's orders, there was a decrease in the duration of coercive hospitalization of minors in psychiatric departments of hospitals in comparison to the period 2005-2009 [5-year period duration of hospitalization (2005-2009):(2010-2014) ratio; 2.33:1]. Furthermore, family was found likely to wield considerable influence on the decision-making for compulsory admissions. In addition, the effectiveness of a compulsory hospitalization of minors in a child and adolescent psychiatry department was found largely dependent on the type of the underlying mental health problem. In that respect, low rates of recidivism (7.6%) indicated that the measure of involuntary hospitalization was necessary and effective. It was also observed that the short-term removal of the minor from the family environment was a potentially relieving strategy for both the child and the family apart from the need for therapeutic intervention. The paper concludes by highlighting the role of a multi-stakeholder decision-making process (which entails shared decision-making as an integral component of providing mental healthcare to minors) in facilitating a decision about involuntary psychiatric hospitalization that is proportional and respectful to patient autonomy.

Achieving Safe, Effective, and Compassionate Quarantine or Isolation of Older Adults With Dementia in Nursing Homes.

Nursing homes are facing the rapid spread of COVID-19 among residents and staff and are at the centre of the public health emergency due to the COVID-19 pandemic. As policy changes and interventions designed to support nursing homes are put into place, there are barriers to implementing a fundamental, highly effective element of infection control, namely the isolation of suspected or confirmed cases. Many nursing home residents have dementia, associated with impairments in memory, language, insight, and judgment that impact their ability to understand and appreciate the necessity of isolation and to voluntarily comply with isolation procedures. While there is a clear ethical and legal basis for the involuntary confinement of people with dementia, the potential for unintended harm with these interventions is high, and there is little guidance for nursing homes on how to isolate safely, while maintaining the human dignity and personhood of the individual with dementia. In this commentary, we discuss strategies for effective, safe, and compassionate isolation care planning, and present a case vignette of a person with dementia who is placed in quarantine on a dementia unit.

An Ethicolegal Analysis of Involuntary Treatment for Opioid Use Disorders.

Supply-side interventions such as prescription drug monitoring programs, "pill mill" laws, and dispensing limits have done little to quell the burgeoning opioid crisis. An increasingly popular demand-side alternative to these measures - now adopted by 38 jurisdictions in the USA and 7 provinces in Canada - is court-mandated involuntary commitment and treatment. In Massachusetts, for example, Part I, Chapter 123, Section 35 of the state's General Laws allows physicians, spouses, relatives, and police officers to petition a court to involuntarily commit and treat a person whose alcohol or drug abuse poses a likelihood of serious harm. This paper explores the ethical underpinnings of this law as a case study for others. First, we highlight the procedural and substantive standards of Section 35 and evaluate the application of the law in practice, including the frequency with which it has been invoked and outcomes. We then use this background to inform an ethical critique of the law. Specifically, we argue that the infringement of autonomy and privacy associated with involuntary intervention under Section 35 is not currently justified on the grounds of a lack of evidenced benefits and a risk of significant of harm. Further ethical concerns also arise from a lack of standard of care provided under the Section 35 pathway. Based on this analysis, we advance four recommendations for change to mitigate these ethical shortcomings.

Reweighing the Ethical Tradeoffs in the Involuntary Hospitalization of Suicidal Patients.

Suicide is the 10th leading cause of death in the United States and the second cause of death among those ages 15-24 years. The current standard of care for suicidality management often involves an involuntary hospitalization deemed necessary by the attending psychiatrist. The purpose of this article is to reexamine the ethical tradeoffs inherent in the current practice of involuntary psychiatric hospitalization for suicidal patients, calling attention to the often-neglected harms inherent in this practice and proposing a path for future research. With accumulating evidence of the harms inherent in civil commitment, we propose that the relative value of this intervention needs to be reevaluated and more efficacious alternatives researched. Three arguments are presented: (1) that inadequate attention has been given to the harms resulting from the use of coercion and the loss of autonomy, (2) that inadequate evidence exists that involuntary hospitalization is an effective method to reduce deaths by suicide, and (3) that some suicidal patients may benefit more from therapeutic interventions that maximize and support autonomy and personal responsibility. Considering this evidence, we argue for a policy that limits the coercive hospitalization of suicidal individuals to those who lack decision-making capacity.

Coercion in psychiatry: is it right to involuntarily treat inpatients with capacity?

Psychiatric inpatients with capacity may be treated paternalistically under the Mental Health Act 1983. This violates bodily autonomy and causes potentially significant harm to health and moral status, both of which may be long-lasting. I suggest that such harms may extend to killing moral persons through the impact of psychotropic drugs on psychological connectedness. Unsurprisingly, existing legislation is overwhelmingly disliked by psychiatric inpatients, the majority of whom have capacity. I present four arguments for involuntary treatment: individual safety, public safety, authentic wishes and protection of autonomy. I explore these through a case study: a patient with schizophrenia admitted to a psychiatric hospital under the Mental Health Act 1983 after an episode of self-poisoning. Through its discussion of preventative detention, the public safety argument articulates the (un)ethical underpinnings of the current position in English law. Ultimately, none of the four arguments are cogent-all fail to justify the current legal discrimination faced by psychiatric inpatients. I conclude against any use of involuntary treatment in psychiatric inpatients with capacity, endorsing the fusion approach where only psychiatric patients lacking capacity may be treated involuntarily.

Do Community Treatment Orders in Psychiatry Stand Up to Principalism: Considerations Reflected through the Prism of the Convention on the Rights of Persons with Disabilities.

Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.

The Role of Civil Commitment in the Opioid Crisis.

This article seeks to shed light on civil commitment in the context of the opioid crisis, to sketch the existing legal landscape surrounding civil commitment, and to illustrate the relevant medical, ethical, and legal concerns that policymakers must take into account as they struggle to find appropriate responses to the crisis.

Beneficial Coercion in Psychiatric Care: Insights from African Ethico-Cultural System.

There is a 'catch 22' situation about applying coercion in psychiatric care. Autonomous choices undeniably are rights of patients. However, emphasizing rights for a mentally-ill patient could jeopardize the chances of the patient receiving care or endanger the public. Conversely, the beneficial effects of coercion are difficult to predict. Thus, applying coercion in psychiatric care requires delicate balancing of individual-rights, individual well-being and public safety, which has not been achieved by current frameworks. Two current frameworks may be distinguished: the civil liberty approach and the Stone model. Both frameworks are restrictive, and not respectful of human dignity. In a civil liberty approach, individuals who are severely mentally-ill but not dangerous would be denied care because they do not meet the dangerousness threshold or because the use of coercion will not lead to rebirthing of autonomy. This is unsatisfactory. Albeit involuntary interventions such as talk therapies, peer-support etc., may not always lead to rebirthing of autonomy or free patients from mental illness; they can however help to maintain the dignity of each mentally ill patient. In place of these frameworks, this study proposes a new ethical framework for applying coercion in psychiatric care that is respectful of human dignity. Specifically, it draws on insights from the African ethico-cultural system by using the Yoruba concept Omo-olu-iwabi to develop this new framework. This way, the study shows that only a more respectful approach for applying coercion in psychiatric care can lead to the careful balancing of the competing interests of individual's rights, individual's well-being and public safety.

Una visión más realista de la Convención sobre los derechos de las personas con discapacidad / A realistic view of the Convention on the Rights of Persons with Disabilities / Uma visão mais realista da Convenção sobre os direitos das pessoas com deficiência

En este artículo analizamos de manera crítica la Convención sobre los derechos de las personas con discapacidad. Una visión más realista puede ser llevada a cabo cuando se aplica a personas con enfermedad mental. Dos situaciones clínicas serán revisadas a la luz de la Convención: el consentimiento informado y las decisiones por representación. Bajo esta interpretación se propone que la aplicación de la Convención en salud mental respetará satisfactoriamente los derechos humanos de las personas con discapacidad.

In this article, we critically analyze the Convention on the Rights of Persons with Disabilities. A realistic view should be taken into account when the text is applied in persons with mental illness. Two clinical situations will be revised in light of the Convention: informed consent and substitute decision-making. This interpretation states that the application of the Convention in Mental Health will respect satisfactory human rights of persons with disability.

Neste artigo analisamos criticamente a Convenção sobre os direitos das pessoas com deficiência. Uma visão mais realista pode ser feita quando se aplica a pessoas com doença mental. Duas situações clínicas serão revistas à luz da Convenção: o consentimento informado e decisões pela representação. Sob esta interpretação, propõe-se que a implementação da Convenção em Saúde mental respeitará satisfatoriamente os direitos humanos das pessoas com deficiência.