I began synthesizing this theme issue and writing this letter amidst the reality of mandatory physical distancing, enforced mask wearing, and required sheltering in place. Force as a topic in health care took on new meanings during the 2020 COVID-19 pandemic, with society trying to balance public health obligations against individual liberties. Force in health care and public health is not new. Although public health measures apply and exert force differently than bodily applications of force through physical, chemical, or legal restraints on a patient’s liberty, both public and personal applications of force can be understood in terms of our intentions, our responsibilities as citizens and professionals to motivate common good, and our interest in protecting the most vulnerable among us.
Restraint use began hundreds of years ago to give officials legal authority to contain individuals thought to be disturbing the peace. Since then, policies and procedures have evolved; by the 1960s, movies like One Flew Over the Cuckoo’s Nest were bringing public attention to the use of physical and chemical restraints—specifically, in mental health care. The Joint Commission and the Centers for Medicare and Medicaid Services have since established guidelines for using restraints in clinical settings, which emphasize patients’ rights to be free from restraint or seclusion except in cases of endangerment to the patients themselves or to others.1,2
Using force is frequently justified in health care when the risk of harm is thought to be outweighed by potential benefits. Obtaining court approval (a legal means of force) for emergency electroconvulsive therapy in a psychotic patient with catatonia, for example, might be lifesaving. The hope that force of any kind might save patients’ lives, spare them injury, or spare them anguish is one reason why we even consider force as ethically justifiable and may be even the most compassionate thing professionals can do for patients in some circumstances. However, maximizing the chances for an intervention’s benefit while simultaneously minimizing the risk of adverse consequences isn’t easy and, in some cases, might not even be possible.
Clinicians are faced daily with situations like these, which necessitate rigorous contemplation of how best to balance patient and staff safety with patients’ human rights and dignity. Given that physical, pharmaceutical, or other means of force, even when justifiable, can undermine the therapeutic alliance in patient-clinician relationships,3,4 erode trust among patients,5,6 or exacerbate moral distress among staff,7,8,9 the clinical and ethical stakes are high.
Because of these stakes and the extreme vulnerability of patients with mental illnesses, this issue of the AMA Journal of Ethics critically investigates what it means to execute force in the most compassionate ways possible when, indeed, force is necessary. This issue brackets questions about when reasonable people disagree about the necessity of force and considers (1) the nature and scope of force’s utility in practice when force is generally agreed upon as justifiable and clinically necessary, (2) models for reducing iatrogenic trauma from justifiable and clinically indicated force in health care, and (3) what might constitute compassionate implementation of force protocols when force is justifiable and clinically necessary. Exploring ethical questions about events that necessitate using force might well prove invaluable not only for recognizing weakness in current force protocols and guidelines but also for gleaning further insights into how our actions can express compassion, even when they must be forceful.
- Masters KJ. Physical restraint: a historical review and current practice. Psychiatr Ann. 2017;47(1):52-55.
- Knox DK, Holloman GH Jr. Use and avoidance of seclusion and restraint: consensus statement of the American Association for Emergency Psychiatry Project Beta Seclusion and Restraint Workgroup. West J Emerg Med. 2012;13(1):35-40.
- Khatib A, Ibrahim M, Roe D. Re-building trust after physical restraint during involuntary psychiatric hospitalization. Arch Psychiatr Nurs. 2018;32(3):457-461.
Chieze M, Hurst S, Kaiser S, Sentissi O. Effects of seclusion and restraint in adult psychiatry: a systematic review. Front Psychiatry. 2019;10:491.
- Ray NK, Myers KJ, Rappaport ME. Patient perspectives on restraint and seclusion experiences: a survey of former patients of New York State psychiatric facilities. Psychiatr Rehabil J. 1996;20(1):11-18.
- Nyttingnes O, Ruud T, Rugkåsa J. “It’s unbelievably humiliating”—patients’ expressions of negative effects of coercion in mental health care. Int J Law Psychiatry. 2016;49(pt A):147-153.
- Vedana KGG, da Silva DM, Ventura CAA, et al. Physical and mechanical restraint in psychiatric units: perceptions and experiences of nursing staff. Arch Psychiatr Nurs. 2018;32(3):367-372.
- Preshaw DH, Brazil K, McLaughlin D, Frolic A. Ethical issues experienced by healthcare workers in nursing homes: literature review. Nurs Ethics. 2016;23(5):490-506.
- Guivarch J, Cano N. Use of restraint in psychiatry: feelings of caregivers and ethical perspectives. Usage de la contention en psychiatrie: vécu soignant et perspectives éthiques. Encephale. 2013;39(4):237-243.