Is Capacity Enough? How Much Coercion Is Appropriate in C-L Psychiatry? A Bioethics SIG-sponsored Symposium

Consultation-Liaison (C-L) psychiatrists are widely considered experts in determining decision-making capacity (DMC). While these determinations often result in binary outcomes (i.e., a patient does or does not have capacity), the reality of clinical practice is far more ambiguous and complex. DMC is the foundation for informed consent, a crucial but neglected element of which is the absence of undue coercion. Yet, C-L psychiatrists are often in treatment situations where coercion has become accepted and even expected. Regardless of the potential benefit, the underlying clinical and ethical harm that may come from coercion is often inadequately assessed. However, a consequentialist approach recognizes that failure to utilize clinically indicated and ethically justifiable coercion may cause more harm than good. Similarly, the opposing deontological position, in which coercion is always viewed as inappropriate no matter what the outcome as it removes the patient’s choice, may undermine the patient’s best interest and other important public health principles.



This Bioethics SIG sponsored symposium will explore types of coercion C-L psychiatrists commonly encounter in practice and consider how coercion can both positively and negatively impact patients, the healthcare system, and society as a whole. We will examine issues of healthcare disparities for patients with serious mental illness (SMI) who, despite retaining DMC, often experience coercion. Recommendations will be provided to empower psychiatrists to approach the fundamental tensions between respecting autonomy and an individual’s pursuit of self-actualization versus adapting a more paternalistic approach in the name of beneficence. Ultimately, we will address the question: Is coercion ever ethically justifiable and if so, who has the right to impose it and under what conditions?



Dr. Mazur will introduce key concepts in the study of DMC and coercion and analyze these situations from the perspective of several major ethical theories. A powerful case will be presented to bring these abstract models to life.



Dr. Schreiber will discuss cognitively impaired patients, including those with traumatic brain injury, dementia, and intellectual disabilities, for whom capacity is often limited. The subtleties of DMC and methods of coercion commonly used to encourage these patients to participate in their personal care, medical treatment, or mental healthcare will be explored.



Dr. McFarland will present timely research on DMC assessments of hospitalized patients with SMI and cancer and will question whether the relational approach to DMC evaluations is adequate for these patients.



Dr. Geppert will discuss the relative neglect of the capacity for voluntarism in DMC assessments and how reliance on cognitive domains has supported ethically problematic uses of coercion. She will offer suggestions for how the evaluation of voluntarism can lead to a more nuanced and comprehensive evaluation of DMC that promotes the authentic values of the patient while also safeguarding their well-being.