Reducing Coercion in Psychiatric Care

REF 2021: Reducing Coercion in Psychiatric Care

Psychiatric practice has been riddled with ethical dilemmas for decades. One particularly challenging issue is how to care for patients that are not always fully capable to make their own choices or provide consent to treatment. The impact case study bears evidence of the contribution philosophical thinking can provide to improve psychiatric practice. Philosophy helps getting a clearer grasp of the underlying conceptual landscape and relevant ethical concerns, especially as regards individual autonomy and influences on will formation. Professor Schramme's work in the philosophy and ethics of psychiatry has informed and influenced both public debate and the medical guidance in Germany, leading to a significant reduction of coercive care in psychiatric consultations, which directly affects over 800,000 cases per year.

The Challenge

Philosophical thinking is not usually seen as contributing to the solution of actual social problems. Philosophers are often considered to sit in an ivory tower, contemplating but not acting in the real world. The main challenge for philosophers is therefore to confront and change this stereotype. This can only be achieved by an accommodating and collegial research environment. Luckily, psychiatrists have for a long time been interested in collaboration with philosophers. After all, psychiatry and philosophy share a main focus on the mind and its performance.

Research Action

Schramme has analysed forms of "interactive paternalism". Interactive paternalism concerns how the formation of individual choice and the will of patients may be unduly influenced without using threats or force, despite the intention of benefitting them. This is particularly pertinent to psychiatric contexts, where patients often struggle to develop and maintain their own will. Schramme's analysis of such cases makes visible morally problematic types of interpersonal interactions that are usually overlooked, because patients actually consent to treatment. 

Working in Partnerships

Schramme has been appointed to several different Task Forces of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN), the leading professional organisation in Germany with around 10,000 members. One of these Task Forces examined the ethics of coercion in psychiatric practice. Their report, co-authored by Schramme, highlighted the requirement to respect patients' self-determination. It was one of the main driving forces of the new 2018 DGPPN Guidelines on Avoidance of Coercion, which brought a sea change in the regulation of psychiatric care. 

Outputs and Outcomes

Germany is currently undergoing legal reform, including landmark rulings of the German Federal Constitutional Court. The German Ethics Council was commissioned by the German parliament to write a report to inform the legislature, the general public and professional services about facts and ethical concerns regarding "Benevolent Coercion – Tensions between Welfare and Autonomy in Professional Caring Relationships". This report was informed by Schramme's invited expert statement during a public hearing of the Council in 2017, which was held in preparation of the report. All these advancements evidence a change in the social, ethical and legal assessment of coercion, which has vexed psychiatry for a very long time. Similar developments are underway in other countries as well, including the UK.