A blog from the Centre for Research Ethics & Bioethics (CRB)

Author: niklasjuth

How should coercive care be regulated within somatic healthcare?

Coercive measures against patients are regularly used in healthcare outside of psychiatry, for example in neurosurgical care. Examples of such measures are belting, boxing gloves, holding patients down, forced medication and hidden medication. It is mostly nurses who carry out these coercive measures. The most common motive for forcing patients is to protect them from harming themselves or others: patients may be confused or aggressive and try to pull out vital ports for intravenous drug administration or abuse staff, often without understanding what they are doing themselves. Because the staff act in a legal and moral gray zone, they often feel moral stress exercising coercion.

How can we regulate coercive care in a way that balances ethically relevant considerations about the measures, so that staff no longer have to act in a gray zone?

Different countries have chosen different paths to regulate coercive care within somatic healthcare. In Sweden, it is in principle illegal to use all forms of coercion without the support of compulsory psychiatric care. An overarching problem in the regulation of coercive care is to ensure that patients with reduced decision-making capacity receive the care they need and at the same time ensure that patients with a sufficient degree of decision-making capacity are not forced into care they do not want. In an article in the Journal of Medical Ethics, Amina Guenna Holmgren and I and two co-authors try to sort out these difficulties. Arguments about justice, trust in healthcare, minimizing harm and respect for autonomy are made for and against different national regulations. We conclude that a regulation that includes an assessment of the patients’ decision-making capacity and takes the patient’s best interests into account is preferable, in contrast to regulations based on psychiatric diagnoses or regulations where there are no legal possibilities to practice coercive care at all within somatic care.

If you want to take a closer look at our reasoning regarding the regulation of restraint in somatic healthcare and evaluate our proposal, you will find the article here: Restraint in somatic healthcare: how should it be regulated?

Niklas Juth

Written by

Niklas Juth, Professor of Clinical Medical Ethics at the Centre for Research Ethics & Bioethics (CRB)

Guenna Holmgren A, von Vogelsang A, Lindblad A, Niklas Juth. Restraint in somatic healthcare: how should it be regulated? Journal of Medical Ethics. Published Online First: 18 October 2023. doi: 10.1136/jme-2023-109240

This post in Swedish

Thinking about law

What does it mean to prioritize patients according to severity?

How should patients be prioritized in health care? In many countries’ regulations, the answer to this question is formulated in terms of severity: the more severe the illness of a patient is, the higher the patient should be prioritized. Although other things may matter for health care priorities, such as cost-effectiveness, severity should be at least one of the criteria. But what makes an illness more severe than another? How should we compare patients in terms of severity?

A recently launched research project tries to tackle these issues. The project is a collaboration between CRB and The National Centre for Priorities in Health in Sweden at Linköping University. The issue of morally sound priority setting in health care is increasingly important and pressing, not least because of the continuing development of new treatments. We can do more for patients today than ever before, but these treatments compete for the limited resources of health care.

The purpose of the project is to make the vague and contested notion of severity more normatively robust and precise by investigating moral issues related to severity. If the concept of severity is to provide valid reasons for prioritization, we must first examine what we should mean by the concept in the context of disease and health care. For instance, there are different ideas about why severity should matter in health care priorities. One idea is that being more severely ill means being worse off than others and that this inequality is something bad. Another idea is that we have stronger reasons to help people the worse off they are, that is, some idea about the moral weight of evil. These different ideas have different implications for which patients to treat first.

There are also different notions about what features of a patient or illness makes that patient more severely ill. It could be quality of life, functioning, existential suffering, or length of life. A common intuition is that an illness with a prognosis of one year survival is more severe when it affects a 20-year old person than an 80-year old person, but that there is no difference in severity when the same illness affects people only ten years apart, say a 40-year old compared to a 50-year old. Together with Borgar Jølstad, I have investigated if this intuition holds up for closer scrutiny. Our conclusion is that it is doubtful. Read our article here: Age and Illness Severity: A Case of Irrelevant Utilities?

The project also looks into economic and legal issues. One economic issue is how different notions of severity affect the total health we can get out of the health care system with a limited budget. Legally, the issue is to what extent different notions of severity are compatible with existing regulations.

This was just a brief presentation of the new project. More posts on specific issues will come when we publish our studies in journals. Hopefully we can soon propose some well-argued answers on how to prioritize patients according to severity. If you want to know more about our basic perspective on some of the issues that will be investigated further, you can read this article: Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda.

Niklas Juth

Written by

Niklas Juth, Professor of Clinical Medical Ethics at the Centre for Research Ethics & Bioethics (CRB)

Jølstad, B., & Juth, N. (2022). Age and Illness Severity: A Case of Irrelevant Utilities? Utilitas, 34(2), 209-224. doi:10.1017/S0953820822000024

Barra, M., Broqvist, M., Gustavsson, E. et al. Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda. Health Care Analysis 28, 25–44 (2020). https://doi.org/10.1007/s10728-019-00371-z

This post in Swedish

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