Background: Informal coercion, that is, situations where caregivers use subtle coercive measures to impose their will on patients, is common in adult psychiatric inpatient care. It has been described as ‘a necessary evil’, confronting nurses with an ethical dilemma where they need to balance between a wish to do good, and the risk of violating patients’ dignity and autonomy. Aim: To describe nurses’ experiences of being involved in informal coercion in adult psychiatric inpatient care. Research design: (...) The study has a qualitative, inductive design. Participants and research context: Semi-structured interviews with 10 Swedish psychiatric nurses were analysed with qualitative content analysis. Ethical considerations: The study was performed in accordance with the Declaration of Helsinki. In line with the Swedish Ethical Review Act, it was also subject to ethical procedures at the university. Findings: Four domains comprise informal coercion as a process over time. These domains contain 11 categories focusing on different experiences involved in the process: Striving to connect, involving others, adjusting to the caring culture, dealing with laws, justifying coercion, waiting for the patient, persuading the patient, negotiating with the patient, using professional power, scrutinizing one’s actions and learning together. Discussion: Informal coercion is associated with moral stress as nurses might find themselves torn between a wish to do good for the patient, general practices and ‘house rules’ in the caring culture. In addition, nurses need to be aware of the asymmetry of the caring relationship, in order to avoid compliance becoming a consequence of patients subordinating to nurse power, rather than a result of mutual understanding. Reflections are thus necessary through the process to promote mutual learning and to avoid violations of patients’ dignity and autonomy. Conclusion: If there is a need for coercion, that is, if the coercion is found to be an ‘unpleasant good’, rather than ‘necessary evil’ considering the consequences for the patient, it should be subject to reflecting and learning together with the patient. (shrink)

This article discusses under what circumstances patients who are suffering from senile dementia or mental retardation should be submitted to coercive care, who should decide about this kind of coercion, and in what legal framework it should take place. A distinction is drawn between modest (i.e. of moderate degree) and meddlesome coercion. The use of modest coercion is defended. It is argued that medical personnel ought to decide exclusively about the use of modest coercion. However, no (...) law should render legitimate the use of even modest coercion. It is conceded that to prohibit the use of a kind of coercion that is expected to take place is hypocrisy. It is argued that this is, however, an acceptable form of hypocrisy. (shrink)

Informal coercive tactics play an important role in maintaining political and social order in authoritarian regimes today, a fact variously attributed to the state’s incapacity to monopolize coercive force and to the strategic concealment of repression from international society. Studying the coercive tactics used by the Chinese government, this article directs attention to how state institutions and strategies create incentives for state agents to delegate coercion to third parties. In particular, this article recognizes the importance of Chinese leaders’ (...) traditional preference to rely on third parties rather than formal state force for social control, and also the impressive improvements in the institutionalization of state coercion after the start of extensive legal reforms in the late 1970s. More important, however, is the multilayered and decentralized state structure that creates tight constraints on local officials and therefore motivates them to use informal coercion. The state structure in China is conducive to informal coercion in two ways. First, when local officials pursue local or private interests that diverge from central interests, informal coercion helps them overcome procedural barriers and avoid scrutiny from above. Second, although central and other upper authorities tend to restrict local officials’ use of force, they often exert considerable pressure on local authorities to fulfill various tasks that require strong coercion. Such conflicting or unfunded mandates have frequently prompted the use of informal coercive tactics. This study highlights the difficulty of holding local government officials accountable with formal institutions in China. (shrink)

Treatment pressures are communicative strategies that mental health professionals use to influence the decision-making of mental health service users and improve their adherence to recommended treatment. Szmukler and Appelbaum describe a spectrum of treatment pressures, which encompasses persuasion, interpersonal leverage, offers and threats, arguing that only a particular type of threat amounts to informal coercion. We contend that this account of informal coercion is insufficiently sensitive to context and fails to recognize the fundamental power imbalance in (...) mental healthcare. Based on a set of counterexamples, we argue that what makes a proposal coercive is not whether service users will actually be made worse off if they reject the proposal, but rather whether they have the justified belief that this is the case. Whether this belief is justified depends on the presence of certain contextual factors, such as strong dependency on professionals and the salient possibility of formal coercion. (shrink)

According to what Douglas calls ‘the consent requirement’, neuro-correctives can only permissibly be provided with the valid consent of the offender who will undergo the intervention. Some of those who endorse the consent requirement have claimed that even though the requirement prohibits the imposition of mandatory neurocorrectives on criminal offenders, it may yet be permissible to offer offenders the opportunity to consent to undergoing such an intervention, in return for a reduction to their penal sentence. I call this the neurocorrective (...) offer. In this chapter I consider the coercion-based objection to the neurocorrective offer, which claims that offenders cannot provide valid consent to undergoing a neurocorrective on the basis of this offer because it is inherently coercive. Having outlined early formulations of this argument, I point out that there are in fact two different versions of this objection, which appeal to different understandings of the concepts of coercion, consent and voluntariness. (shrink)

Using payment to recruit research subjects is a common practice, but it raises ethical concerns that coercion or undue inducement could potentially compromise participants’ informed consent. This is the first national study to explore the attitudes of IRB members and other human subjects protection professionals concerning whether payment of research participants constitutes coercion or undue influence, and if so, why. The majority of respondents expressed concern that payment of any amount might influence a participant’s decisions or behaviors regarding (...) research participation. Respondents expressed greater acceptance of payment as reimbursement or compensation than as an incentive to participate in research, and most agreed that subjects are coerced if the offer of payment makes them participate when they otherwise would not or when the offer of payment causes them to feel that they have no reasonable alternative but to participate . Views about undue influence were similar. We conclude that human subjects protection professionals hold expansive and inconsistent views about coercion and undue influence that may interfere with the recruitment of research participants and impede valuable research. (shrink)

Whether intended or not, conceptions of informed consent are often rooted in archetypal notions of the researcher and prospective study participant. The former is assumed problematically to be a disinterested yet humanitarian individual who is well trained to conduct robust science. The latter is often characterized as being motivated by some altruistic notions about the contribution to science and society they are making even as they seek some personal benefit from the research. Cast in a dyad, the researcher has the (...) responsibility to inform the participant thoroughly about the purpose of the research, the risks and benefits of participation, and any alternatives to research available, as well as the .. (shrink)

Michael Blake’s excellent book 'Justice and Foreign Policy' makes an important contribution to the ongoing debates about the kinds of values that should inform the foreign policy of liberal states. In this paper I evaluate his defence of the view that egalitarianism applies within the state but not globally. I discuss two arguments he gives for this claim - one appealing to the material preconditions of democracy and the other grounded in a duty to justify coercive power. I argue that (...) neither argument succeeds. I then identify a general problem with his approach. If states adopted Blake’s principles for their foreign policy we would have a much better world than currently exists. But it would not – I submit - be a fair world. (shrink)

Feminist legal scholarship has questioned the usefulness of non-consent as a criterion for rape. Under conditions of generalized sexual oppression, consent may not be an adequate for absence of coercion. I defend this argument and propose that rape law reform can be usefully informed by state protection of workers in the capitalist labor market, where it is assumed that the parties occupy an unequal bargaining position.

The law of armed conflict prevents the coerced extraction of information from Prisoners of War (PoWs). We claim, however, that the letter of that law involves too broad a concept of coercion. On a natural reading, there is a sense in which any extraction of information—by any method—is coercive. We respect the notion that PoWs ought not be treated poorly, but we argue “coercion” should not be understood so broadly. With respect to its use in international law, we (...) favor a moralized notion of “coercion,” as opposed to a non-moralized one. We explain what this means, and argue why this is a better reading of the law. We think a moralized notion of coercion is more intuitive, is more in line with both actual practice and the intent of the framers of international law, and has practical benefits as well. (shrink)

Against the libertarian view, this essay argues that coercion aimed at bringing about a more equal distribution across persons can be morally acceptable. Informal social norms might lead toward equality (or another social justice goal) without coercion. If coercion were unnecessary, it would be morally undesirable. A consequentialist integration of social norms and principles of social justice is proposed. The proposal is provided with a preliminary defense against the non-consequentialist egalitarianism of G.A. Cohen and against liberal (...) criticisms directed against the common ground that Cohen and the proposed consequentialist egalitarianism occupy. Key Words: distributive justice • consequentialism • Lockean rights • prioritarianism • social norms • incentives. (shrink)

Background While community engagement is increasingly promoted in global health research to improve ethical research practice, it can sometimes coerce participation and thereby compromise ethical research. This paper seeks to discuss some of the ethical issues arising from community engagement in a low resource setting. Methods A qualitative study design focusing on the engagement activities of three biomedical research projects as ethnographic case studies was used to gain in-depth understanding of community engagement as experienced by multiple stakeholders in Malawi. Data (...) was collected through participant observation, 43 In-depth interviews and 17 focus group discussions with community leaders, research staff, community members and research participants. Thematic analysis was used to analyse and interpret the findings. Results The results showed that structural coercion arose due to an interplay of factors pertaining to social-economic context, study design and power relations among research stakeholders. The involvement of community leaders, government stakeholders, and power inequalities among research stakeholders affected some participants’ ability to make autonomous decisions about research participation. These results have been presented under the themes of perception of research as development, research participants’ motivation to access individual benefits, the power of vernacular translations to influence research participation, and coercive power of leaders. Conclusion The study identified ethical issues in community engagement practices pertaining to structural coercion. We conclude that community engagement alone did not address underlying structural inequalities to ensure adequate protection of communities. These results raise important questions on how to balance between engaging communities to improve research participation and ensure that informed consent is voluntarily given. (shrink)

BackgroundThe need for an ethical debate about the use of coercion in intensive care units (ICU) may not be as obvious as in other areas of medicine, such as psychiatry. Coercive measures are often necessary to treat critically ill patients in the ICU. It is nevertheless important to keep these measures to a minimum in order to respect the dignity of patients and the cohesion of the clinical team. A deeper understanding of what patients and their relatives perceive during (...) their ICU stay will shed different light on intensive care management. Patients' experiences of loss of control, dependency and abandonment may lead to a new approach towards a broader approach to the concept of coercion in intensive care. The aim of our research is to explore the experiences of patients and relatives in the ICU and to determine when it might be possible to reduce feelings and memories of coercion.MethodsWe conducted and analysed 29 semi-structured interviews with patients and relatives who had been in the ICU a few months previously. Following a coding and categorisation process in MAXQDA™, a rigorous qualitative methodology was used to identify themes relevant to our research.ResultsFive main themes emerged: memory issues; interviewees’ experiences of restricting measures and coercive treatment; patients’ negative perception of situational and relational dependency with the risk of informal coercion; patients’ perceptions of good care in a context of perceived dependency; progression from perception of coercion and dependency to respect for the person. All patients were grateful to have survived. However, coercion in the form of restraint, restriction of movement, and coercive treatment in the ICU was also acknowledged by patients and relatives. These included elements of informal coercion beyond restraints, such as a perceived negative sense of dependence, surrender, and asymmetrical interaction between the patient and health providers.ConclusionsTo capture the full range of patients' experiences of coercion, it is necessary to expand the concept of coercion to include less obvious forms of informal coercion that may occur in dependency situations. This will help identify solutions to avoid or reduce negative recollections that may persist long after discharge and negatively affect the patients' quality of life. (shrink)

Background: Coercion can cause harm to both the patient and the patient’s family. Few studies have examined how the coercive treatment of a close relative might affect young next-of-kin. Research questions: We aimed to investigate the views and experiences of health professionals being responsible for supporting young next-of-kin to patients in mental health care in relation to the needs of these young next-of-kin in coercive situations and to identify ethical challenges. Research design: We conducted a qualitative study based on (...) semistructured, focus group interviews and an individual interview. Participants and research context: We held three focus group interviews with six to seven children-responsible staff in each group and one individual interview with a family therapist. The participants were recruited from three hospital trusts in the eastern part of Norway. Ethical considerations: The study was approved by the National Data Protection Official for Research and based on informed consent and confidentiality. Findings: Coercion was not a theme among the participants in relation to their work with young next-of-kin, and there was much uncertainty related to whether these young people need special support to deal with the coercive treatment of their close relative. Despite the uncertainty, the study indicated a need for more information and emotional support among the youth. Discussion: Few studies have addressed the potential impact of coercive treatment of a close family member on young next-of-kin. The findings were consistent with existing research but highlighted disagreement and uncertainty among the children-responsible staff about to what extent the young next-of-kin should visit and whether they should enter the ward unit or not. We identified ethical challenges for the children-responsible staff related to the principle of not inflicting harm. Conclusion: From the perspective of children-responsible staff, it appears that the coercive treatment of a close family member entails a need for extra support of young relatives both in relation to information and the facilitation of visits, but more systematic knowledge about these issues is needed. (shrink)

Background: Studies have demonstrated the extensive use of coercion in Norwegian nursing homes, which represents ethical, professional as well as legal challenges to the staff. We have, however, limited knowledge of the experiences and views of nursing home patients and their relatives. Objectives: The aim of this study is to explore the perspectives of nursing home patients and next of kin on the use of coercion; are there situations where the use of coercion can be defended, and (...) if so, under which circumstances? Methods: The data are based on individual interviews with 35 patients living in six nursing homes and seven focus group interviews with 60 relatives. Ethical considerations: Participation was based on written informed consent, and the study was approved by the Regional Committees for Medical and Health Research Ethics. Results: More than half of the patients and the majority of the relatives accepted the use of coercion, trusting the staff to act in the patient’s best interest. However, the acceptance of coercion is strongly related to the patients’ lack of understanding, to prevent health risks and to preserve the patient’s dignity. Conclusion: The majority of nursing home patients and relatives accepted the use of coercion in specific situations, while at the same time they emphasised the need to try alternative strategies first. There is still a need for good qualitative research on the use of coercion in nursing homes, especially with a closer focus on the perspectives and experiences of nursing home patients. (shrink)

The debate concerning whether to legalize and regulate the global market in human organs is hindered by a lack of adequate bioethical language. The author argues that the preferential option for the poor, a theological category, can provide the grounding for an inductive moral epistemology adequate for reforming the use of culturally Western bioethical language. He proposes that the traditional, Western concept of bioethical coercion ought to be modified and expanded because the conditions of the market system, as viewed (...) from the perspective of organ vendors systemically deprived of access to sufficient resources, are sufficiently exploitative as to diminish the possibility of these vendors giving informed consent. Moreover, empirical studies conducted by professionals in medicine, sociology, psychiatry, economics, and medical anthropology continue to contribute support to the growing interdisciplinary consensus that functionally coercive structural factors exert the most significant influence upon a vendor's decision to sell an organ within any market, regardless of legality or degree of regulation. Therefore any proposal to legalize and regulate the organ market remains patently unethical because doing so would likely function to constrain further the agency of poor potential vendors. (shrink)

Claims about coercion play a significant role in some of the most important questions in political philosophy: most ordinary citizens as well as philosophers think that the exercise of power by the state and other political institutions is coercive, and as such requires special justification. Political philosophy, it has been assumed, must assess both the truth of that claim and its relevance for whether or not states, in general, can be justified. Whether the state is always or necessarily coercive (...) is a central question in the philosophy of law. Under what conditions a state exercising coercive power can be justified is the question that informs all major works in the social contract tradition since Thomas Hobbes's Leviathan. (shrink)

Some libertarians argue that informed consent alone makes transactions in the labour market morally justified. In contrast, some of their critics claim that such an act of consent is no guarantee against coercion. To know whether agreements are voluntary, we need to assess the quality of the offers or the prevailing background conditions. ISCT theorists argue that it is imperative to take social norms into account when evaluating the labour market. We present a novel framework for moral assessment in (...) the labour market, which takes consent, background conditions and norms into account, but which mainly focuses on the offers and demands made. Consent renders a transaction legitimate in the same way we regard a fair election legitimate even if we object to its outcome. For offers to be substantially justified, exploitation must be avoided and offers must give expression to the value of community. Only then they are morally justified. (shrink)

Increasingly, mental health social workers in the United Kingdom and elsewhere in the world are employing coercive interventions with clients. This paper explores this trend in the context of community-based settings, using national and international research literature on this subject. It begins with a discussion about the complex, contested nature of ideas on coercion. The authors then explore debates about how coercion is perceived and applied in practice. They choose two forms of coercion?informal types of leverage, (...) and the legally mandated use of Community Treatment Orders?to highlight the range of ethical problems and dilemmas that confront practitioners in this field. The authors conclude by developing a tentative, explanatory model to explain how and why mental health social workers should consider a more holistic, situated approach to help deal with ethical concerns about the use of coercion. (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)

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)

John Rawls argued in A Theory of Justice that “justice as fairness…is likely to have greater stability than the traditional alternatives since it is more in line with the principles of moral psychology”. In support, he presented a psychology of moral development that was informed by a comprehensive liberalism. In Political Liberalism, Rawls confessed that the argument was “unrealistic and must be recast”. Rawls, however, never provided a psychology of moral development informed by a specifically political liberalism, leaving it at (...) a disadvantage with respect to comprehensive liberalism itself. I argue that no coherent account is available. But, because Rawls’s Liberal Principle of Legitimacy, along with its implied stricture against “indoctrination in the pejorative sense,” is a creature of ideal rather than non-ideal theory, the deficiency is far less significant than many would assume. In non-ideal circumstances -- such as ours -- political liberalism does not disallow, and in fact requires, compulsory, free early education informed by the best available comprehensive liberal philosophy. (shrink)

John Rawls argued in A Theory of Justice that ‘justice as fairness … is likely to have greater stability than the traditional alternatives since it is more in line with the principles of moral psychology'. In support, he presented a psychology of moral development that was informed by a comprehensive liberalism. In Political Liberalism, Rawls confessed that the argument was 'unrealistic and must be recast'. Rawls, however, never provided a psychology of moral development informed by a specifically political liberalism, leaving (...) it at a disadvantage with respect to comprehensive liberalism itself. I argue that no coherent account is available. But, because Rawls’s Liberal Principle of Legitimacy, along with its implied stricture against 'indoctrination in the pejorative sense', is a creature of ideal rather than non-ideal theory, the deficiency is far less significant than many would assume. (shrink)

In communities of user-generated content, systems for the management of content and/or their contributors are usually accepted without much protest. Not so, however, in the case of Wikipedia, in which the proposal to introduce a system of review for new edits (in order to counter vandalism) led to heated discussions. This debate is analysed, and arguments of both supporters and opponents (of English, German and French tongue) are extracted from Wikipedian archives. In order to better understand this division of the (...) minds, an analogy is drawn with theories of bureaucracy as developed for real-life organizations. From these it transpires that bureaucratic rules may be perceived as springing from either a control logic or an enabling logic. In Wikipedia, then, both perceptions were at work, depending on the underlying views of participants. Wikipedians either rejected the proposed scheme (because it is antithetical to their conception of Wikipedia as a community) or endorsed it (because it is consonant with their conception of Wikipedia as an organization with clearly defined boundaries). Are other open-content communities susceptible to the same kind of ‘essential contestation’? (shrink)

Given that the concept of coercion remains a central concern for bioethics, Quigley's (Monash Bioethics Rev 32:141–158, 2014) recent article provides a helpful analysis of its frequent misapplication in debates over the use of ‘nudges’. In this commentary I present a generally sympathetic response to Quigley’s argument while also raising several issues that are important for the larger debates about nudges and coercion. I focus on several closely related topics, including the definition of coercion, the role of (...) empirical research, and the normative concerns at the core of these disputes. I suggest that while a degree of precision is certainly required when deploying the relevant concepts, perhaps informed by empirical data, we need to continue to push these debates towards more pressing normative considerations. (shrink)

While sexual violence should not be the prerequisite for legal abortion, expanding definitions of abuse to include reproductive coercion can open avenues of access to abortion following the Dobbs decision. Understanding the increased danger and compounding challenges of intimate partner violence can inform legislative initiatives, healthcare responses, and movements for reproductive justice.

Background Seven wards from three Norwegian mental health care institutions participated in a study in which regular ethics reflection groups focusing on coercion had been implemented and evaluated. This article presents a thematic overview of the ethical challenges identified based on a systematic qualitative analyses of 161 ethics reflection groups and some general observations on these ethical challenges. Results The ethical challenges are divided into four main thematic categories: formal coercion, informal coercion, uncertainty related to the (...) Norwegian legislation on coercion and professional role and identity. Some ethical challenges did not fit into these categories. Only 36% of the ethical challenges were related to the use of formal coercion or the interpretation of the health law. Conclusion Even within coercion regulated by law, weighing different moral values remains important to reflect upon the appropriateness of the possible use of coercion. (shrink)

The author congratulates Dr Brian Hurwitz, who recently reported the successful “intimidation” of an elderly competent widow into accepting badly needed therapy for a huge ulcerated carcinoma. He reports approvingly of the Israeli Patients' Rights Law, enacted in 1996, which demands detailed informed consent from competent patients before permitting treatment. But the law also provides an escape clause which permits coercing a competent patient into accepting life-saving therapy if an ethics committee feels that if treatment is imposed the patient will (...) give his/her consent retroactively. He suggests this approach as an appropriate middle road between overbearing paternalism and untrammelled autonomy. (shrink)

We describe the informed consent procedures in a research clinic in Santiago, Chile, and a qualitative study that evaluated these procedures. The recruitment process involves information, counseling and screening of volunteers, and three or four visits to the clinic. The study explored the decision‐making process of women participating in contraceptive trials through 36 interviews. Women understood the research as experimentation or progress. The decision to participate was facilitated by the information provided; time to consider it and to discuss it with (...) partners or relatives; and perceived benefits such as quality of care, non‐cost provision of methods and medical care. For some women, participation was an opportunity to express altruism. The main obstacles for participation were perceived side effects or risks. The final risk‐benefit balance was strongly influenced by women’s needs. Women perceived that the consent form benefited the clinic, proving that participants had made a free decision, and benefited the volunteers by warranting their right to free medical care. The most important problem detected was occasional misunderstanding of the information given on the form. We concluded that a full decision‐making process enhances women’s ability to exercise their right to choose, and assures research institutions that trials are conducted without coercion and that the participants are committed to the study. Researchers have the responsibility of conducting this process. (shrink)

Introduction Scholars have debated how to define coercion and undue influence, but how institutional review boards (IRBs) view and make decisions about these issues in actual cases has not been explored. Methods I contacted the leadership of 60 US IRBs (every fourth one in the list of the top 240 institutions by National Institutes of Health funding), and interviewed 39 IRB leaders or administrators from 34 of these institutions (response rate=55%), and 7 members. Results IRBs wrestled with defining of (...) ‘coercion’ and ‘undue inducement’, most notably in deciding about participant compensation. IRBs often use these terms synonymously and define undue inducement in varying ways, often wrestling with these issues, relying on ‘gut feelings’, and seeking compromises. Ambiguities arose, partly reflecting underlying tensions: whether subjects should ‘get paid’ versus ‘volunteer’ (ie, whether subjects should be motivated by compensation vs altruism), and whether subjects should be paid differently based on income, given possible resultant selection bias. Lack of consistent standards emerged between and even on single IRBs. Questions arose concerning certain aspects and types of studies; for example, how to view and weigh providing free care in research, whether and how recruitment flyers should mention compensation, and how to avoid coercion in paediatric, developing world, or students research. Conclusions These data, the first to probe qualitatively how IRBs view and approach questions about coercion, undue influence and participant compensation, and to examine how IRBs have reviewed actual cases, reveal several critical ambiguities and dilemmas, and have vital implications for future practice, education, policy and research. (shrink)

Increasingly, bioethicists defend informed consent as a safeguard for trust in caretakers and medical institutions. This paper discusses an ‘ideal type’ of that move. What I call the trust-promotion argument for informed consent states:1. Social trust, especially trust in caretakers and medical institutions, is necessary so that, for example, people seek medical advice, comply with it, and participate in medical research.2. Therefore, it is usually wrong to jeopardise that trust.3. Coercion, deception, manipulation and other violations of standard informed consent (...) requirements seriously jeopardise that trust.4. Thus, standard informed consent requirements are justified.This article describes the initial promise of this argument, then identifies challenges to it. As I show, the value of trust fails to account for some commonsense intuitions about informed consent. We should revise the argument, commonsense morality, or both. (shrink)

Coercion in mental health care gives rise to many ethical challenges. Many countries have recently implemented state policy programs or development projects aiming to reduce coercive practices and improve their quality. Few studies have explored the possible role of ethics in such initiatives. This study adds to this subject by exploring health professionals’ descriptions of their ethical challenges and strategies in everyday life to ensure morally justified coercion and best practices. Seven semi-structured telephone interviews were carried out in (...) 2012 with key informants in charge of central development projects and quality-assurance work in mental health services in Norway. No facilities used formal clinical ethics support. However, the informants described five areas in which ethics was of importance: moral concerns as implicit parts of local quality improvement initiatives; moral uneasiness and idealism as a motivational source of change; creating a normative basis for development work; value-based leadership; and increased staff reflexivity on coercive practices. The study shows that coercion entails both individual and institutional ethical aspects. Thus, various kinds of moral deliberation and ethics support could contribute to addressing coercion challenges by offering more systematic ways of dealing with moral concerns. However, more strategic use of implicit and institutional ethics is also needed. (shrink)

Research protocols are joining the list of inclusion criteria for signing informed consent. This may be due to conceptual confusion, intent to manipulate the subject, or even discrimination and coercion. This article reviews the basic concepts of inclusion criteria and analyzes the negative consequences of reducing a person’s voluntary participation in research and the process of informed consent to merely signing a document that is likened, in turn, to a criterion for recruiting subjects.

In psychiatry, caregivers try to get free and informed consent of patients, but often feel required to restrict freedom and to use coercion. The present article develops ethical advice given by an Ethics Committee for Mental Health Care. The advice recommends an ethical ideal of shared deliberation, consisting of information, motivation, consensus and evaluation. For the exceptional use of coercion, the advice develops three criteria, namely incapacity to deliberate, threat of serious harm and proportionality between harm and (...) class='Hi'>coercion.The article also discusses the viewpoints of the ethical advice and of the European Convention on Human Rights and Biomedicine: is the advice in agreement with the Convention and can the advice refine the guidelines of the Convention for the particular context of psychiatry? Although the Convention emphasises the autonomy of the individual patient, whereas the advice focuses on the relationships between the partners involved, the advice enjoys a complementary and supportive function in the application of the Convention. (shrink)

The very existence of society depends on the ability of its members to influence formatively the beliefs, desires, and actions of their fellows. In every sphere of social life, powerful human agents (whether individuals or institutions) tend to use coercion as a favorite shortcut to achieving their aims without taking into consideration the non-violent alternatives or the negative (unintended) consequences of their actions. This propensity for coercion is manifested in the doxastic sphere by attempts to shape people’s beliefs (...) (and doubts) while ignoring the essential characteristics of these doxastic states. I argue that evidential persuasion is a better route to influence people’s beliefs than doxastic coercion. Doxastic coercion perverts the belief-forming mechanism and undermines the epistemic and moral faculties both of coercers and coercees. It succeeds sporadically and on short-term. Moreover, its pseudo doxastic effects tend to disappear once the use of force ceases. In contrast to doxastic coercion, evidential persuasion produces lasting correct beliefs in accordance with proper standards of evidence. It helps people to reach the highest possible standards of rationality and morality. Evidential persuasion is based on the principles of symmetry and reciprocity in that it asks all persuaders to use for changing the beliefs of others only those means they used in forming their own beliefs respecting the freedom of will and assuming the standard of rationality. The arguments in favor of evidential persuasion have a firm theoretical basis that includes a conceptual clarification of the essential traits of beliefs. Belief is treated as a hypercomplex system governed by Leibniz’s law of continuity and the principle of self-organization. It appears to be a mixture consisting of a personal propositional attitude and physical objects and processes. The conceptual framework also includes a typology of believers according to the standards of evidence they assume. In this context, I present a weak version of Clifford’ ethical imperative. In the section dedicated to the prerequisites for changing beliefs, I show how doxastic agents can infuse premeditated or planned changes in the flow of endogenous changes in order to shape certain beliefs in certain desired forms. The possibility of changing some beliefs in a planned manner is correlated with a feedback doxastic (macro-mechanism) that produces a reaction when it is triggered by a stimulus. In relation with the two routes to influence beliefs, a response mechanism is worth taking into consideration – a mechanism governed to a significant extent by human conscience and human will, that appears to be complex, acquired, relatively detached from visceral or autonomic information processing, and highly variable in reactions. Knowing increasingly better this doxastic mechanism, we increase our chances to use evidential persuasion as an effective (although not time-efficient) method to mold people’s beliefs. (shrink)

Ethical codes help guide the methods of research that involves samples gathered from ?at-risk? populations. The current article reviews general as well as specific ethical principles related to gathering informed consent from partner violent offenders mandated to outpatient treatment, a group that may be at increased risk of unintentional coercion in behavioral sciences research due to court mandates that require outpatient treatment without the ethical protections imbued upon prison populations. Recommendations are advanced to improve the process of informed consent (...) within this special population and data supporting the utility of the recommendations in a sample 70 partner violent offenders are provided. Data demonstrate that participants were capable of comprehending all essential elements of consent. (shrink)

We describe the informed consent procedures in a research clinic in Santiago, Chile, and a qualitative study that evaluated these procedures. The recruitment process involves information, counseling and screening of volunteers, and three or four visits to the clinic. The study explored the decision‐making process of women participating in contraceptive trials through 36 interviews. Women understood the research as experimentation or progress. The decision to participate was facilitated by the information provided; time to consider it and to discuss it with (...) partners or relatives; and perceived benefits such as quality of care, non‐cost provision of methods and medical care. For some women, participation was an opportunity to express altruism. The main obstacles for participation were perceived side effects or risks. The final risk‐benefit balance was strongly influenced by women’s needs. Women perceived that the consent form benefited the clinic, proving that participants had made a free decision, and benefited the volunteers by warranting their right to free medical care. The most important problem detected was occasional misunderstanding of the information given on the form. We concluded that a full decision‐making process enhances women’s ability to exercise their right to choose, and assures research institutions that trials are conducted without coercion and that the participants are committed to the study. Researchers have the responsibility of conducting this process. (shrink)

This paper critically discusses an argument that is sometimes pressed into service in the ethical debate about the use of assisted reproduction. The argument runs roughly as follows: we should prevent women from using assisted reproduction techniques, because women who want to use the technology have been socially coerced into desiring children - and indeed have thereby been harmed by the patriarchal society in which they live. I call this the argument from coercion. Having clarified this argument, I conclude (...) that although it addresses important issues, it is highly problematic for the following reasons. First, if women are being coerced to desire to use AR, we should eradicate the coercive elements in pro-natalist ideology, not access to AR. Second, the argument seems to have the absurd implication that we should prevent all woman, whether fertile or not, to try to have children. Third, it seems probable that women's welfare will be greater if we let well informed and decision-competent women decide for themselves whether they want to use AR. (shrink)

Many accounts of informed consent in medical ethics claim that it is valuable because it supports individual autonomy. Unfortunately there are many distinct conceptions of individual autonomy, and their ethical importance varies. A better reason for taking informed consent seriously is that it provides assurance that patients and others are neither deceived nor coerced. Present debates about the relative importance of generic and specific consent do not address this issue squarely. Consent is a propositional attitude, so intransitive: complete, wholly specific (...) consent is an illusion. Since the point of consent procedures is to limit deception and coercion, they should be designed to give patients and others control over the amount of information they receive and opportunity to rescind consent already given. (shrink)

BackgroundNorway has extensive and detailed legal requirements and guidelines concerning involvement of next of kin during involuntary hospital treatment of seriously mentally ill patients. However, we have little knowledge about what happens in practice. This study explores NOK’s views and experiences of involvement during involuntary hospitalisation in Norway.MethodsWe performed qualitative interviews-focus groups and individual-with 36 adult NOK to adults and adolescents who had been involuntarily admitted once or several times. The semi-structured interview guide included questions on experiences with and views (...) on involvement during serious mental illness and coercion.ResultsMost of the NOK were heavily involved in the patient’s life and illness. Their conceptions of involvement during mental illness and coercion, included many important aspects adding to the traditional focus on substitute decision-making. The overall impression was, with a few exceptions, that the NOK had experienced lack of involvement or had negative experiences as NOK in their encounters with the health services. Not being seen and acknowledged as important caregivers and co sufferers were experienced as offensive and could add to their feelings of guilt. Lack of involvement had as a consequence that vital patient information which the NOK possessed was not shared with the patient’s therapists.ConclusionsDespite public initiatives to improve the involvement of NOK, the NOK in our study felt neglected, unappreciated and dismissed. The paper discusses possible reasons for the gap between public policies and practice which deserve more attention: 1. A strong and not always correct focus on legal matters. 2. Little emphasis on the role of NOK in professional ethics. 3. The organisation of health services and resource constraints. 4. A conservative culture regarding the role of next of kin in mental health care. Acknowledging these reasons may be helpful to understand deficient involvement of the NOK in voluntary mental health services. (shrink)

Argumentation theory has much to offer our understanding of the doctor-patient relationship as it plays out in the context of seeking and obtaining consent to treatment. In order to harness the power of argumentation theory in this regard, I argue, it is necessary to take into account insights from the legal and bioethical dimensions of informed consent, and in particular to account for features of the interaction that make it psychologically complex: that there is a fundamental asymmetry of authority, power (...) and expertise between doctor and patient; that, given the potential for coercion, it is a challenge to preserve the interactive balance presumed by the requirement of informed consent; and finally that the necessary condition that patients be ‘competent to consent’ may undermine the requirement of respecting patient autonomy. I argue argumentation theory has the resources to deal with these challenges and expand our knowledge, and appreciation, of the informed consent interaction in health care. Keywords: argumentation theory, informed consent, doctor-patient interaction, competency to consent, autonomy, medical paternalism. (shrink)

The biblical healings by Jesus and the primitive Church, the liturgical development of the Roman Rite of Exorcism, and the current practice of exorcists reflect a relationship between exorcism and the medical healing arts. Since mutuality characterizes all healer–sufferer interactions, informed consent is a central concept in physician–patient and exorcist–energumen relationships. Informed consent requires adequate information, decision-maker competence, and freedom from coercion. The determination of freedom from coercion is a particular challenge in exorcism, and guidelines for its assess­ment (...) are discussed. While proxy decision making in medical care is generally driven by concerns over competence, foreseeable periods of demonic coercion will necessitate establishing proxies in exorcism. This places a moral duty on the exorcist to establish a substitute decision maker even in cases where the energumen would be considered competent. Discussion of this need through the process of informed consent builds the trust necessary for mutual decision making. (shrink)

Evidence shows that during birth women frequently experience unconsented care, coercion, and a loss of autonomy. For many countries, this contradicts both the law and medical ethics guidelines, which emphasize that competent and fully informed women’s autonomy must always be respected. To better understand this discordance, we empirically describe perinatal maternity care providers’ and women’s moral deliberation surrounding coercive measures during birth. Data were obtained from 1-on-1 interviews with providers (N = 15) and women (N = 14), and a (...) survey of women (N = 118). Analyses focused on an in-depth exploration of responses to a question on the permissibility of coercion in birth whose wording was borrowed from a Swiss medical-ethical guideline. Reasons for and against a principle permissibility of coercive measures in birth were grouped into clusters of reasons to build a coherent explanatory framework. Factors considered morally relevant when deliberating on coercion included women’s decisional capacity, beneficence/non-maleficence, authority through knowledge on the part of providers, flaws of the medical system, or the imperative to protect the most vulnerable. Also, we identified various misconceptions, such as the conviction that a pathological birth can justify coercion or that fetal rights can justifiably infringe on women’s autonomy. Information and education on the issue of coercion in birth are urgently needed to enable women to fully exercise their reproductive autonomy, to prevent long-term adverse health outcomes of women and children, and to reconcile the medical vigilance which has lead to a reduction of perinatal morbidity and mortality with women’s enfranchisement in their own care. (shrink)

We examined the efficacy of including a research intermediary (RI) during the consent process in reducing participants' perceptions of coercion to enroll in a research study. Eighty-four drug court clients being recruited into an ongoing study were randomized to receive a standard informed consent process alone (standard condition) or with an RI (intermediary condition). Before obtaining consent, RIs met with clients individually to discuss remaining concerns. Findings provided preliminary evidence that RIs reduced client perceptions that their participation might influence (...) how clinical and judicial staff view them. This suggests that using RIs may improve participant autonomy in clinical studies. (shrink)

The application of genetic technologies in China, especially in the area of prenatal genetic testing, is rapidly increasing in China. In the wealthy regions of China, prenatal genetic testing is already very widely adopted. We argue that the government should actively promote prenatal genetic testing to the poor areas of the country. In fact, the government should prioritize resources first to make prenatal genetic testing a standard routine care with an opt-out model in these area. Healthcare professions would be required (...) to inform pregnant women about the availability of genetic testing and provide free testing on a routine basis unless the parents choose not to do so. We argue that this proposal will allow parents to make a more informed decision about their reproductive choices. Secondarily, this proposal will attract more healthcare professionals and other healthcare resources to improve the healthcare infrastructures in the less-developed regions of the country. This will help to reduce the inequity of accessing healthcare services between in different regions of China. We further argue that this policy proposal is not practicing eugenics. (shrink)

BackgroundResearchers conducting community-based participatory action research (CBPAR) in highly collectivistic and socioeconomically disadvantaged community settings in sub-Saharan Africa are confronted with the distinctive challenge of balancing universal ethical standards with local standards, where traditional customs or beliefs may conflict with regulatory requirements and ethical guidelines underlying the informed consent (IC) process. The unique ethnic, socioeconomic, and cultural diversities in these settings have important implications for the IC process, such as individual decisional autonomy, beneficence, confidentiality, and signing the IC document.Main textDrawing (...) on insights and field observations from conducting CBPARs across several rural, highly communal, low literate, and low-income communities in Ghana, we discuss some theoretical, ethico-cultural, and methodological challenges associated with applying the universal, Western individualistic cultural value-laden IC process in sub-Saharan Africa. By citing field situations, we discuss how local cultural customs and the socioeconomic adversities prevalent in these settings can influence (and disrupt) the information disclosure process, individual decisional authority for consent, and voluntariness. We review the theoretical assumptions of the Declaration of Helsinki’s statement on IC and discuss its limitations as an ultimate guide for the conduct of social science research in the highly communal African context. We argue that the IC process in these settings should include strategies directed at preventing deception and coercion, in addition to ensuring respect for individual autonomy. We urge Universities, research institutions, and institutional review boards in Africa to design and promote the use of context-appropriate ethical IC guidelines that take into consideration both the local customs and traditional practices of the people as well as the scientific principles underpinning the universal IC standards.ConclusionWe recommend that, rather than adopt a universal one-size-fits-all IC approach, researchers working in the rural, highly collectivistic, low literate, socioeconomically disadvantaged settings of sub-Saharan Africa should deeply consider the roles and influence of cultural values and traditional practices on the IC and the research process. We encourage researchers to collaborate with target communities and stakeholders in the design and implementation of context-appropriate IC to prevent ethics dumping and safeguard the integrity of the research process. (shrink)

Some are concerned about the possibility that offering money for research participation can constitute coercion or undue influence capable of distorting the judgment of potential research subjects and compromising the voluntariness of their informed consent. The author recognizes that more often than not there are multiple influences leading to decisions, including decisions about research participation. The concept of undue influence is explored, as well as the question of whether or not there is something uniquely distorting about money as opposed (...) to a chance for treatment or medical care. An amount of money that is not excessive and is calculated on the basis of time or contribution may, rather than constitute an undue inducement, be an indication of respect for the time and contribution that research subjects make. (shrink)