Influence and coercion: relational and rights-based ethical approaches to forced psychiatric treatment

The dominant rights-based approach to the ethics of coercion in psychiatric treatment guides clinicians in deciding whether treatment should be compelled or the patient's autonomy respected, but provides no guidance across the remaining broad continuum of influence that clinicians exert with patients. The assumptions of the rights-based approach lead to three dichotomous decisions: (1) 'Is the treatment voluntary?'; (2) 'Is the patient competent?' and (3) 'Are the consequence of no treatment dangerous?'. The assumptions of a relational approach lead to ethical guidance across the full range in the intensity and types of influence which may be ethically justified or required in psychiatric treatment. These assumptions are: (1) influence is inherent in the clinical relationship; (2) the relevant factors are continuous and (3) all decisions are subjective. While the rights-approach emphasizes defining competence and developing techniques to predict future patient dangerousness, the relational approach emphasizes patient-clinician responsibilities in ethical relationships and understanding all factors which legitimately bear on the use of influence. An initial list of such factors is offered.