Coercive measures, defined as any measure applied “against the patient's will or in spite of his or her opposition” (1), are commonly used in clinical medical practice, particularly—but not exclusively—in psychiatry (2, 3). The definition of “coercive measures” is complex. These include formal coercion, such as actions limiting freedom of movement (restraint, seclusion), involuntary hospitalization, and forced treatment (4). Informal coercion is another part of the concept and includes any form of influence, pressure, or manipulation of the patient's decisions (5). Formal and informal coercion are conceived as a continuum ranging from persuasion, interpersonal leverage, inducements, and threats to compulsory treatment (5–7). However, this distinction between formal and informal coercion may not be clear, and in practice, there are “gray areas” with sometimes unclear boundaries between a strong incentive and coercion (5, 6). Coercion is also defined according to the subjective perceptions of patients, caregivers, or other stakeholders (lawyers, relatives), which may differ from the objective measures used (8, 9). Different understandings of coercion have an impact on the care provided and are hence important to consider (10, 11). For instance, Trachsel et al. (12, 13) distinguished between curative and palliative psychiatric care based on the definition of palliative care given by the World Health Organization (WHO). From this perspective, the use of coercion may be legitimate or not, depending on whether it is used for a palliative or curative reason (7, 12). In addition, coercive measures with more serious consequences call for greater justifications (6, 12).

Coercive measures infringe on several fundamental rights based on ethical principles (autonomy, freedom of movement and will, bodily integrity). Fundamental rights are guaranteed by the Declaration of Human Rights, the European Convention on Human Rights and Bioethics (14, 15), the Convention on the Rights of Persons with Disabilities (CRPD) (16), and the laws of most countries (1, 17–19); they underpin professional guidelines such as the World Psychiatric Association's Madrid Declaration (20). Despite this, there are crucial variations across (and sometimes within) countries in local legal frameworks and in the ways in which coercion is applied (10, 11, 21).

Allowing coercion involves giving priority to some reasons and principles at the expanse of the fundamental rights and principles infringed by coercion (11, 22). This raises ethical questions about the primacy of the ethical principles used to legitimize coercive measures (4, 23) and about the way in which the principles ought to be properly “balanced” (12, 24, 25). This task is not easy as there is no consensus on the appropriate moral theory to apply (26, 27). For instance, the more we value the personhood of a disturbing patient, the greater the justification required to restrict his/her fundamental rights for the sake of protecting others (care providers, other patients, citizens) (6). Moral theories diverge in the comparative importance they place on different values (e.g., autonomy vs. liberty, community vs. individual rights vs. duties toward others or vs. community rights) (6, 26, 27).

Compared to the 18^th century and to many contemporary states, modern Western societies tend to stress the importance of personhood, the individual's place in the community, and the development and prioritization of the principles of self-determination and autonomy (26, 28–30). This societal evolution has changed society's way of thinking about psychiatric care and the identity and vision of psychiatry as a discipline (26). Recent emphasis on the right to autonomy involves questioning the legitimacy of the paternalistic attitude that used to be the norm in medical care. Patient's best interests are increasingly taken as critical elements for deciding upon or justifying coercive measures (26, 28). Consequently, caregivers who assume that they know better than patients what is good for them tend to be considered authoritative and paternalistic. The risk of abuse of power associated with paternalism is now taken seriously (31, 32). The issue of paternalism is hotly debated in medical ethics (28, 33), especially in psychiatry (27, 34) and the context of coercive interventions (4, 6, 7, 35, 36). Distinctions between strong/hard vs. weak/soft paternalism and social (for the good of the community) vs. medical (for the good of the individual) paternalism have been made (4, 7, 27, 28, 33, 34). Moreover, new approaches to ethics of care have emerged, such as relational ethics (37–39), which have helped people to reconsider the individual in a relational context within society. New concepts have appeared such as relational autonomy, which may help us to view coercion in a new light as a practice of care. Indeed, one may try to protect the patient by providing coercive treatment with the aim of facilitating the long-term recovery of autonomy, even if it implies a temporary override of the patient's self-determination (4, 26, 28, 37). This approach of coercion can be conceived of as soft paternalism (7, 40, 41).

Apart from the debates around medical paternalism, ethical discussions regarding the tensions between coercion and the respect of fundamental rights are understudied in psychiatry (4), which is paradoxical since limitations on one's freedom occur more often in medical (including psychiatric) contexts than in other civil or social areas (4, 9, 42). This infringement of freedom, present in coercive care, hinders patients from exercising their autonomy. The notion of autonomy is also complex and diversely understood in the literature, which may affect the evaluation of coercive measures. Studies often associate autonomy with decision-making capacity (4). However, this is not always the case. Autonomy can also be understood as being able to make choices (even people with decision-making capacity might not be autonomous) and to realize one's priorities and values (23, 43, 44). It seems, therefore, that autonomy and decision-making capacity are interdependent but in a complex modality, depending on the individual's temporality and identity (45). This complex relationship between autonomy and decision-making capacity deserves an in-depth analysis (27, 34).

In practice, evaluating the acceptability of a coercive measure often implies evaluating the patients' decision-making capacity (DMC). DMC is an important element to take into account because it refers to the principle of autonomy, and coercions imply overriding patient's autonomy (37, 46–48). In some countries, the laws regulating coercion do not specifically refer to DMC, but in most countries and legal systems, one of the conditions for justifying coercion with a patient is his/her lack of DMC (26, 27, 34, 47). From a legal point of view, DMC involves patient's cognitive abilities (46) and is presumed to exist in adults (49–52). In case of doubt, its evaluation depends on the situation (intervention, time) and on the particular decision that the patient is expected to make (49, 53). However, in detail, the way DMC is regulated differs across countries. In the US, the definition developed by Grisso and Appelbaum is widely used (54): DMC requires understanding, appreciation, reasoning, and making a choice (54–57). In Switzerland, DMC requires understanding (grasping the fundamental elements of the information relevant for a decision), evaluating information (assigning personal meaning to a situation in light of the options available), making a choice (deciding on the basis of the information available and one's own experience, motives and values), and expressing a decision (communicating and defending a choice) (58). In England and Wales, DMC is regulated by the Mental Capacity Act (MCA) of 2005 and requires understanding, retaining, using or weighing information, as well as giving an option (49–51, 59–62). In this model, appreciating and reasoning (Grisso and Appelbaum) are replaced by using or weighing (51, 63–66), but it is not obvious that these terms are equivalent (51). Independent of the particular definition of DMC, a common controversy surrounds its evaluation for people suffering from mental disorders, whether they are decompensated or not (14–16, 31, 67).

Furthermore, the principles of “evidence-based medicine” require scientific evidence of the effectiveness of coercion. When a coercive measure is supposed to guarantee safety (to protect others from a patient's aggressive or disturbing behavior), evidence for risk reduction and forensic or social outcomes should be provided (68). Similarly, when a coercive measure is advocated as a way to treat a patient, it should be demonstrated that coercive measures benefit patients by contributing to their therapy or diagnosis in the short, medium, or long term (69). Indeed, some coercive measures may facilitate the treatment of symptoms or allow for the precise and formal detection of a pathology. The implementation of coercion's efficacy in terms of diagnosis or therapy is much debated, and current scientific data are the subject of controversy (4, 21, 32, 70). From an ethical standpoint, the absence of scientific evidence of therapeutic effectiveness does not necessarily indicate that a type of therapy is illegitimate. This has been discussed in the literature (71) and in psychiatry (69), but little has been written about the particular case of coercion. It therefore seems worthwhile to more closely examine the ethical foundations of legitimate coercive measures.

Being able to justify a coercive measure is not only ethically significant; it also helps to alleviate tensions in clinical practice. Notably, it is critical to distinguish therapeutic and diagnostic goals from safety-based or protective goals (for the patient or others) and to recognize that the latter are not necessarily sufficient reasons to justify coercion. Conversely, safety and risk reduction may be conceived of as a means to achieve therapeutic goals because living in a safe environment favors individual reconstruction. This underlines the importance of thinking about coercion in the global context of long-term care. It would be interesting to see if professionals make these distinctions when discussing the adequacy of coercive measures.

In this article, we map out the ethical reasons used in the literature to assess coercive actions that impose limits to freedom of movement; that is, involuntary admission, seclusion, and restraint. To avoid covering an area that is too broad, we will exclude discussions related to informal coercion and coerced medication. We present the results of our literature search and of our qualitative analysis of the selected articles: We map out the ethical elements used in the literature to justify or reject the use of coercion. We then examine and weigh these elements, and address their relevance for assessing the acceptability of coercion in particular clinical settings. Finally, we highlight a series of important issues.

Our analysis revealed relevant ethical elements (e.g., rights, values, practical considerations, the feelings of the actors involved, risks of side effects) in the literature for establishing the adequacy of coercion. Among these elements, some tip the balance against the indication for coercion, while others tip the balance in favor of an exceptional indication for coercion. This means that for each case of coercion, we should weigh the appropriate elements.

Our results imply that the main justifications for or against the use of coercion vary according to the moral elements defended (mostly principles such as autonomy, integrity, dignity, beneficence, non-maleficence, equity, and safety) and the relative weight given to them. In the literature, some authors especially stress certain elements (e.g., autonomy) over others (e.g., safety), while some ignore arguably germane elements in their assessment (e.g., patient's need/right to treatment or to protection in crisis situations).

We found strong agreement on the idea that coercive measures should only be used in exceptional circumstances and that in each unique case, they should be legitimized by a fair balance of reasons given the legislation, official recommendations, and all ethical elements pertinent to the situation.

Some authors defend the view of an absolute prohibition on coercion, but this is due to an exclusive focus on fundamental rights that are described as non-negotiable (e.g., the duty to respect autonomy in all circumstances). Most authors recognize that even fundamental rights such as autonomy and self-determination may be infringed upon in exceptional clinical situations. However, this can only be done when all other alternatives that are more respectful of the patient's rights have failed and when coercion helps to achieve the greater good (e.g., cases of immediate risk to the patient or others). The fact that coercion is always presented as a rare option of last resort (often in urgent situations) and that it needs to be thoroughly justified underlines how much importance authors give to patient's autonomy and self-determination. However, we found substantial variability in the evaluation of available alternatives. In some cases, authors do not mention relevant ethical elements in their evaluation. For instance, they may refer autonomy and safety but not benevolence, non-maleficence, or justice (9), or the absolute respect of fundamental rights but not the problem of managing a potential risk to others (31, 72, 73). Justice is often an underevaluated principle in studies on coercion (4). In other cases, they diverge on which ethical element should be prioritized or on how much weight should be attributed to a given element.

Based on the retrieved literature, we propose examining several recurrent points of reflection: the use of different argumentative strategies in the literature; the different categories of models used to assess the adequacy of coercive measures; the need to clarify certain concepts used in psychiatric practice; an analysis of whether there are circumstances or limits beyond which coercion is not acceptable or proportionate; and the importance of considering the manner and means in which coercion is applied. Finally, we propose discussing the use of coercive measures limiting freedom of movement in the context of relational ethics of care through the concepts of relational autonomy and interpersonal relationships.

First, in the retrieved literature, different argumentation strategies legitimize the use of coercion. Many ethical reasons are formulated according to a modality of exception. Coercive measures are considered fundamentally prohibited, but their use may be tolerated in exceptional circumstances detailed in laws, conventions, and national or cantonal regulations. Scientific evidence for the therapeutic effectiveness of coercive measures is highly polemical (70). Their justification and acceptance for use based on recommendations of good practice are most often rooted in expert consensus (32). Another argumentation modality found in the selected articles is the tendency to justify one's action a posteriori based on observed consequences. For example, by justifying the measure by the patient's later subjective reaction (improvement of symptoms; recognition a posteriori of the need for the measure; positive emotions reported) or that of the caregiver (exculpation by justifying the measure via the absence of alternatives to coercion; certainty that otherwise there would have been a dangerous act for the patient or others; that leaving the patient without care would have been deleterious for the latter in the future) (4, 9, 29, 73–75). A third argumentative strategy found in the literature is that of discrediting a posteriori the choice to use coercion by considering that the caregiver lacked competence and misused his/her authority (9, 81). This is an external judgment without necessarily understanding all the issues at stake in real situations, which would require a more detailed analysis of the issues facing the caregiver, who has to make the decision. These argumentation strategies reflect the way in which the authors weigh the various ethical elements at stake.

We would like to highlight one particularly relevant analysis proposed by Torbjörn Tännsjö. In an effort to group argumentative elements together, he worked out four different theoretical models that can be used to assess the adequacy of coercive measures (18, 81, 86). The identified models differ regarding the ethical elements they prioritize:

A third interesting point to note is the need, reported by several authors, to clarify concepts used in psychiatric contexts (4, 9, 82). Indeed, we found great disparities in the definitions in the literature, and sometimes, the definitions proposed are unclear (21). For example, coercion is defined according to a dichotomous modality, either as emanating from an external authority or by the limits that one can impose on oneself internally (29, 77); in contrast, it is sometimes defined as a continuum with different degrees of intensity and constraints on freedom (1, 4, 31, 81). Most commonly, a distinction is made between formal, informal, and subjective coercion (4, 17, 77). Other notions need to be clarified for better psychiatric practice, such as person (4, 81, 82), identity (77), freedom (1, 32, 74, 77), or integrity (9, 75). The relevance of using the concept of “dignity” is a matter of debate (90, 142, 143). Regarding coercion, its definition includes the notion of paternalism, which has a pejorative connotation in the common sense, while being understood in a more nuanced way by some authors; “soft paternalism” is seen as a way to take care of patients with mental disorders, at least when the aim is to restore their autonomy (75). While it is important to clarify concepts, the plethora of existing definitions may lead to confusion and misinterpretation. In the domain of psychiatry, more collective work is needed to unify the terminology and concepts used in relation to coercion.

Assuming that coercion can be justified in some circumstances (e.g., when it is the only way to fulfill a fundamental value or right) (9, 17, 42), a crucial question is to identify whether there are limits above which coercion is not proportionate or circumstances in which coercion is not acceptable. Some authors argue that some forms of violations are prohibited whatever other value they may fulfill. For instance, it is never permitted to violate the physical integrity of a competent person (1), to torture a person, or to impose inhuman or degrading treatment (144, 145). The latter risk is the most common in psychiatry. For instance, if a caregiver actually intended to harm, humiliate, or punish a patient with coercive measures, this could not be justified by referring to therapeutic benefits. Clinical settings, however, are full of gray areas of which it is important to be aware. This reflection highlights the relevance and difficulty of virtue ethics: Caregiver's intentions, personality, and responsibility matter when we evaluate the acceptability of a coercive measure (32).

Further, the manner and means of coercion need to be considered while evaluating its adequacy. Even in the case of a purpose that is considered legitimate (e.g., ensuring the safety of, and protecting, the patient or others), the way in which coercion is employed might make it unacceptable. Legislation and professional recommendations provide clear, useful safeguards. There is less ethical conflict about how coercion should be used compared to when it is indicated to use it. Nevertheless, clear, uncontroversial instructions on how to utilize coercion do not alleviate the urgency of developing alternative strategies designed to reduce the use of coercion in the first place (de-escalation techniques, advance directives, a Joint Crisis Plan, a trialogue) (21, 146–148).

Finally, one of the most common arguments in the literature is that the patient's autonomy is a critical element in evaluating the justification of coercive measures limiting freedom of movement (4, 86, 87). Some authors go further: Based on the concept of relational autonomy and on the theory of the social construction of the individual through interpersonal ties, one might perceive coercion as a constructive component of a more global process of the recovery of autonomy (4, 9, 17, 26, 37–39, 74, 77, 81, 87, 106, 114). Rethinking coercion within the relational ethics of care may open up new perspectives on care. This is a promising avenue for future studies.

MC helped to develop the research question and strategies, collect and analyze the data, and to edit the main part of the manuscript. SH supervised the project's progress and helped to develop the research question and strategies. SK and CC helped to analyze the data and to build the discussion. All authors contributed to the writing of the manuscript and agreed approved of the final version.

This narrative review is part of a research program investigating seclusion and restraint reduction, with funding from the University Hospital of Geneva.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.