Coercion and undue influence in decisions to participate in psychiatric research – conceptual issues

The essential elements of informed consent to research include the provision of relevant information to a person who is competent to make a decision, and who is situated so as to be able to do so voluntarily. The nature of the requirement of voluntariness has been resistant to exploration. Concerns about voluntariness are usually invoked under the rubrics of coercion or undue influence. Coercion can be conceptualized as the use of morally unjustified threats to bring a person to consent to research participation. Undue influence in the research context typically involves the use of affirmative inducements to persuade a person to ignore what would otherwise be their preferences regarding research participation. Talcott Parsons noted four means by which influence may be exercised, involving respectively the use of appeals to shared goals, inducement, persuasion, and power. In the context of human subjects research, evocation of shared goals may be manifest by appeals to altruism; inducement by offers to provide incentives; persuasion by the application of interpersonal pressure or by an exhortation to self-interest; and power by the issuance of threats. Appeals to altruism, if honestly framed, are unlikely ever to constitute illegitimate constraints on choice, but the other categories can be more problematic. A final component of this conceptualization of voluntariness is the recognition that constraints on decision-making can be actual or perceived. Actual offers, pressure, or threats reflect the behavior of other people who are trying to affect the subject's decision. However, there is often a dichotomy between the behaviors of others and a subject's perception of those behaviors. Hence, both actual and perceived constraint are relevant. Perceptions are the mediating variable between behaviors of others and their impact on subjects' decisions; this approach has proven fruitful in studies of voluntariness in other contexts

Harnessing the power of fusion? A valiant but flawed effort to obviate the need for a distinct mental health law

When it comes to involuntary interventions, the notion that people with mental disorders should be treated identically to persons with general medical disorders has an undoubted appeal. As Dawson and Szmukler have argued previously, principles of fairness and non-discrimination would appear to be well served by basing involuntary hospitalization and treatment in both contexts on incapacity to provide consent. In this commentary, I take note of some of the intellectual forebears of the Szmukler, Daw, and Dawson proposal, and ask why – despite the formidable intellects that have lined up behind similar approaches in the past – they have not been adopted. I also consider some aspects of the current proposal itself, including the unresolved tensions between equal and differential treatment of persons with mental disorders, and the potential practical consequences, especially for persons with general medical disorders. I conclude that the rationale for fusing two disparate bodies of law may itself be irremediably flawed, and the undesirable consequences significant. 

Balancing autonomy and beneficence at the time of psychiatric discharge

As in much of the world, mental health law in Israel has evolved over the past half-century toward greater protection of patients’ liberty and an increased emphasis on due process. Part of that process in Israel involved taking decisions about prolonged involuntary hospitalization out of the hands of treating psychiatrists and turning them over to independent review panels. Argo and colleagues examined outcomes of discharge decisions made by these panels compared with treating psychiatrists. In this brief commentary, we describe related trends in mental health law in other countries, especially the U.S., consider countervailing perspectives on the role of review panels, and suggest how the Argo et al. study might be followed up with additional research

Ultra-bright source of polarization-entangled photons

Using the process of spontaneous parametric down conversion in a novel two-crystal geometry, one can generate a source of polarization-entangled photon pairs which is orders of magnitude brighter than previous sources. We have measured a high level of entanglement between photons emitted over a relatively large collection angle, and over a 10-nm bandwidth. As a demonstration of the source intensity, we obtained a 242-$\sigma$ violation of Bell's inequalities in less than three minutes.Comment: 4 pages, 5 encapsulated Postscript figures. To appear in Physical Review A (Rapid Communication

The Capacity to Vote of Persons With Alzheimer’s Disease

OBJECTIVE: The right to vote can be abrogated when persons become incompetent to cast a ballot. This applies particularly to people with Alzheimer’s disease, who at some point will lose capacity. A 2001 federal court decision offered the first clear criteria (“Doe voting capacity standard”) for determining voting competence, focused on understanding the nature and effect of voting and on the ability to choose. This article explores how persons with Alzheimer’s disease perform on these criteria. METHOD: The Doe standard was operationalized in a brief questionnaire, along with measures of appreciation and reasoning about voting choices. Performance was assessed in 33 patients attending an Alzheimer’s disease clinic and was related to dementia severity and demographic characteristics. RESULTS: The interview questions were scored with high reliability. Performance on the Doe questions, along with appreciation and reasoning, correlated strongly with Mini-Mental State Examination (MMSE) scores. Patients with very mild to mild Alzheimer’s disease generally retained adequate ability to vote, and most persons with severe Alzheimer’s disease did not. Performance was highly variable among persons with moderate Alzheimer’s disease. The desire to vote was a poor predictor of voting capacity. CONCLUSIONS: The capacity to vote, as embodied in the Doe voting capacity standard, can be measured simply and reliably. Structured assessment is particularly likely to be useful for people with moderate Alzheimer’s disease, whose performance cannot be predicted from MMSE scores alone. This approach can ensure retention of voting rights by capable persons and exclusion of clearly impaired persons from the voting booth

Ethical and Practical Issues in Video Surveillance of Psychiatric Units

Objectives: Video surveillance is used in inpatient psychiatry in many countries and institutions. However, its use varies considerably because of a lack of research, discussion, and agreement on best practice. This review provides an overview of current issues in the use of video surveillance in psychiatry, with a focus on ethical questions and their practical implications. Methods: A narrative review of literature on video surveillance in psychiatry was conducted. References were identified through searches of PubMed, CINAHL, MEDLINE, PsycINFO, and Google Scholar for articles published before December 2018. Sixteen articles in English and German were reviewed. Results: The ethical challenges and practical implications differ between surveillance of public spaces versus private areas, such as bedrooms or seclusion rooms. The most common reason for video surveillance was to increase security and safety. However, empirical evidence suggests that it is not useful in increasing security of shared spaces on psychiatric wards. Some evidence exists for clinical benefits of video surveillance in private spaces (e.g., allowing patients to sleep undisturbed). Video surveillance can increase patients’ choices regarding monitoring options. The main ethical conflict lies in balancing patients’ autonomy and privacy versus patient and staff security and safety. Conclusions: Whether video monitoring is used in the most effective and ethical manner needs to be reconsidered. Available evidence does not support its use as a security measure. More research is needed to evaluate the benefits, risks, and best practices of using video monitoring for patient observation, with consideration given to increasing the role of patient consent

Is assertive community treatment coercive?

Background: Assertive community treatment (ACT) has become one of the cornerstones of care for people with serious mental illnesses. ACT is usually conceptualized as incorporating a multidisciplinary team approach, active and persistent attempts to engage clients, direct provision of comprehensive health and social care, and in-vivo and out-of-hours working. In addition, the service is ongoing, not time-limited, and has a low practitioner-to-client ratio (usually 1:10). However, ACT is not without its critics, many of them focused on the use of "coercive" techniques with ACT patients 12. At one end of the spectrum are those opponents of ACT who contend, "ACT is largely a euphemistic label for coercion." Despite substantial interest in the coercive aspects of ACT, no studies have focused specifically on understanding the phenomenology of the use and experience of leverage in ACT. Methods: Staff and patients of 4 ACT teams in Manhattan were recruited to participate in focus groups exploring their experiences with and opinions about the use of leverage in ACT. A total of 21 patients and 24 staff members participated with group size ranging from 10 to 12 members. Results: With only one exception, patients said uniformly that they did not believe that their ACT team was coercive or went too far in pressuring them to comply with treatment. ACT staff seemed more aware of the dangers of engaging in coercive behavior. Hence, they indicated a need to "keep each other in check." Conclusion: This preliminary series of focus groups with patients and staff members of ACT programs revealed little evidence from either set of participants of significant use of leverage or perceptions of coercion. Instead both patients and staff reported that supporting patients and building relationships with them were the preferred mechanisms for promoting treatment goals. This study suggests that ACT is not an intrinsically coercive model for the delivery of mental health services