Special considerations in forensic psychiatry

Abstract

Coercion is one of the major ethical issues in psychiatry. Seclusion, isolation, physical or mechanical restraint and especially forced medication have been debated fiercely between patient’s rights activists, psychiatrists, philosophers, politicians and even courts. Forensic psychiatry was not much involved in this debate for many years. Coercion was part of the toolkit applied with the understanding that the patients in forensic psychiatry were hospitalised involuntarily, that these patients were considered to be dangerous and treatment, hospitalisation and avoiding criminal or violent recidivism with or without or against their will was the job of the staff of forensic hospitals. This has changed dramatically in the last few years, when, e.g. the Committee on Bioethics (CDBI) of the Council of Europe or the Convention on the Rights of Persons with Disabilities (CRPD) started to advocate a guarantee of human rights for the mentally ill even if they had committed crimes. Different national and international courts have ruled that that the basic human rights principles (rule of law, proportionality, legal certainty, subsidiarity) are to be applied in forensic psychiatry as well as in other medical specialties. In Germany, the consequence of such a ruling was that involuntary treatment was not possible for a while, because there were no legal provisions for it in the laws. The legal abolition or at least severe restriction of coerced medication led to a severe deterioration in some patients. The current situation forces us to rethink the ethical principles of coercive measures and their practical application within the framework of international conventions and national laws and to advise law makers and courts accordingly. The author advocates soft paternalism as a guiding principle for dealing with these issues.