BAnEthical Perspective ± Compulsion and Autonomy
Harry Lesser
In mental health nursing the same issue dominates both legal and ethical dis-
cussions. This is the issue of the use of compulsion, whether in the form of
compulsory treatment or compulsory restraint: when, if ever, it should be used,
and what methods of compulsion should be employed. The crucial difference
ethically between mental and physical illnesses is that it is commonly held that
compulsory treatment can be justified only if a person's mental judgement is
impaired to such a degree that they lack the competence to decide for themselves
how they should be treated. This can arise in various ways ± with children, people
who are unconscious, people under the influence of drink or drugs ± but it can
arise from the illness itself only if the illness is a `mental illness' or has damaging
mental effects. Hence both legally and ethically, and with regard both to general
guidelines and to the treatment of individual people, decisions have to be made as
to when it is right to treat someone without their permission and/or against their
will. #These are different: an unconscious patient may be unable to give consent
but on recovering consciousness be very glad to have received treatment and not
feel they would have opposed it if they had been able to.)
These issues arise ethically at three points: there are ethical problems of how to
carry out the law as it stands, of assessing the law as it stands, and of assessing
proposed changes in the law as they arise. The first of these is perhaps the most
important in practice, but professional groups, such as nurses, can influence the
law; and in any case it is always important to consider the law from an ethical
standpoint, even if one has for the time being to accept it as being the law.
Accordingly, I will consider all three in turn.
9.11 The ethical use of compulsion
In considering all three, I shall assume that the shift in the way compulsion is
viewed morally, in theory if not always in practice, is a shift in the right direction. It
is nowadays widely agreed that in dealing with adults, even mentally disturbed
adults, the presumption should be that compulsion is to be avoided, and that it is