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Tvingad till autonomi: en teoretisk analys av öppen psykiatrisk tvångsvård i Sverige
Umeå University, Faculty of Social Sciences, Department of Social Work.
(Swedish)Manuscript (preprint) (Other academic)
Abstract [sv]

Utifrån tidigare forskning om öppen psykiatrisk tvångsvård har två paradoxer i förhållande till lagstiftningen identifierats: Öppen psykiatrisk tvångsvård (ÖPT) innebär både mer och mindre autonomi för patienten. ÖPT innebär att autonoma individer tvångsvårdas till autonomi. Syftet med artikeln att tydliggöra vilka normativa ställningstaganden som ligger till grund för tvångsvårdsformen genom att de två paradoxerna belyses utifrån fyra perspektiv på autonomi.

Den första paradoxen förklaras genom att lagstiftaren förhåller sig till både en liberal och en medicinsk-etisk autonomidefinition. I ett liberalt perspektiv är öppen tvångsvård en inskränkning av individens rätt till frihet. I ett medicinsk-etiskt perspektiv kan öppen tvångsvård öka autonomi genom att det ökar eller skyddar patientens autonomi i framtiden. I ett medicinsk-etiskt perspektiv kan andra värden, som hälsa och livskvalitet, också motivera inskränkningar i patientens autonomi.

Den andra paradoxen kan förklaras genom att lagstiftaren blandar proceduriella och substantiella rekvisit för autonomi. Patienten förutsätts vara autonom enligt proceduriella rekvisit eftersom patienten inte anses vara beslutsoförmögen. Samtidigt är utfallet av patientens val avgörande för om det respekteras. Om patienten vill avstå vård förutsätts detta inte vara patientens autentiska önskan, vilket är ett uttryck för en substantiell syn på autonomi. Vården ska istället återge patienten dess substantiella autonomi. Vid ÖPT förutsätts patientens i praktiken frivilligt medverka till vården. Det betyder att patienten uppfyller även autenticitetsrekvisiten. Men eftersom syftet med tvångsvården är att återupprätta just den autentiska viljan genom att patienten blir i stånd att frivilligt ta emot tvångsvård är autonomikraven för öppen tvångsvård uppfyllda samtidigt som autonomikraven för vårdens upphörande också är uppfyllda.

Om ÖPT ska kunna motiveras utifrån ett medicinskt-etiskt perspektiv krävs att tvångsvården faktiskt ger mer autonomi senare eller andra vinster. I dagsläget finns inget vetenskapligt stöd för att tvångsvårdsformen fungerar. Mot denna bakgrund är det svårt att se vilket värde som tillförs som väger tyngre än patientens autonomi.

Abstract [en]

In earlier research about compulsory community care, two contradictions related to the legislation have been identified: First, compulsory community care (CCC) means both more and less autonomy for the patient. Second, it means that autonomous individuals are being coerced to autonomy. The aim of the article is to clarify the normative underpinning of the law in light of four perspectives of autonomy to that help understand the two contradictions.

The first contradiction can be explained by the fact that the legislator operates with two different definitions of autonomy: liberalistic and bioethical. In a liberalistic perspective, CCC restricts the right to autonomy. From a bioethical perspective, CCC potentially increases autonomy since it may enhance or protect the future autonomy of the patient. According to this perspective, other values, like health and quality of life, can also motivate restriction of autonomy.

The second contradiction can be explained by how the legislator confuses procedural with substantial conceptions of autonomy. Since the patient is not assumed to be incompetent, the patient is assumed to have procedural autonomy. At the same time, whether or not the patient’s will is accepted depends on the eventual outcome of the patient’s choice. If the patient refuses care, her opinion is not presumed authentic, which is an expression of a substantive conception of autonomy. The coercive care provided is supposed to re-install the patient’s substantive autonomy. When it comes to the practice of CCC, the patient is assumed to voluntarily accept the coercive elements. This means that the patient is also autonomous according to a substantive conception of autonomy. Since the objective of compulsory care is to enable the patient to accept care voluntarily and thus restoring her/his authentic opinion, the legal requisites for allowing and discharging from CCC are met at the same time.

If compulsory community care is to be acceptable from a bioethical perspective, it must provide the patient with actual benefits or more autonomy. There is no research evidence that compulsory community works. Accordingly, it is hard to identify what benefits CCC provide that can trump the autonomy of the patient.

National Category
Social Work
Identifiers
URN: urn:nbn:se:umu:diva-146888OAI: oai:DiVA.org:umu-146888DiVA, id: diva2:1199750
Available from: 2018-04-22 Created: 2018-04-22 Last updated: 2018-06-09
In thesis
1. Tvångsvård i frihet: tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård
Open this publication in new window or tab >>Tvångsvård i frihet: tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård
2018 (Swedish)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[en]
Coercion in freedom : genesis, implementation, and legal rights in compulsory community care
Abstract [en]

This thesis aims to analyze compulsory community care (CCC) as a social and normative practice in different contexts in the Swedish welfare system. The research questions are:

- How can the motives to introduce CCC in Sweden and other Western countries be understood?

- What happens in and between psychiatric and social service organizations when CCC is implemented?

- How are the legal rights of patients protected and what forms of social control of patients is discernible in written court decisions regarding CCC?

- What normative positions regarding autonomy is the CCC legislation based on?

- How can CCC be understood from steering, historic and power perspectives?

The four first research questions corresponds to the four research studies included in the thesis and the fifth question relates to the material as a whole.

The empirical material for the first study mainly consists of documents from the parliamentary process. For the second study, 15 interviews with employees in psychiatric and social services were conducted. For the third study, all written court decisions over a 6 month period (N=541) were investigated. In the fourth study, the analysis is primarily based on the current legislation and its history.

Community care has already taken over most tasks of the old institutions. With the adoption of CCC, even the coercive measures are now formally found in community settings. CCC was adopted despite lack of evidence supporting its effectiveness. Although the policy process started in the aftermath of high-profile crimes, the government bill was focused on integration and rehabilitation with the stated intention to reduce coercive powers. While CCC entails an actual expansion of coercive powers, those coercive elements are downplayed in the bill. CCC allows for preventative restrictions on non-violent civilly committed patients. The CCC example shows that political steering is not something that automatically restricts discretion over the medical profession. Earlier political steering strategies had failed to reduce the excessive clinical use of use of temporary leave. The introduction of CCC meant that politicians adapted legislation to previously undesired practices.

In psychiatric and social services, CCC is materialized as a physical object in the coordinated care plan. The interviewees talked about the template form for the coordinated care plan as almost synonymous with CCC. It helped clarify responsibilities and facilitated coordination between the organizations. These changes extended even beyond services for the targeted patients under CCC. The requirement of a coordinated care plan thus served as a political steering strategy for enhancing collaboration.

In the written court decisions about CCC we found deficiencies in procedural fairness in all four requirements for a fair trial that were investigated: transparency, clarity, consistency and impartiality. For example, more than 99 % of the decisions were made in favor of the claims of treating psychiatrist and a substantial minority of courts routinely delegated decision-making authority to treating psychiatrists. The special provisions often involved surveillance controlling techniques. The control is mostly physical, because of the unique role of medication, but also spatial and temporal. Even though no formal coercive measures are allowed, the special provisions as controlling measures seem to have real impact on patients. CCC may therefore be understood as disciplinary power.

A legal requisite for coercive care is that the patient oppose care. However, in practice it is assumed that a patient under CCC will accept the coercive elements (i.e. special provisions). The legal requisites for allowing and discharging from CCC are thus met at the same time. Restrictions of patient autonomy in the legislation is often motivated in terms of enhanced autonomy in the future, for example through avoiding relapse. Another rationale for the restriction of autonomy is to safeguard the health and quality of life of patients. There is no research evidence that compulsory community works. Accordingly, it is hard to identify what benefits CCC provide that can trump the autonomy of the patient.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2018. p. 94
Series
Studier i socialt arbete vid Umeå universitet : avhandlings- och skriftserie, ISSN 0283-300X ; 90
Keywords
compulsory community care, community treatment orders, mental health policy, policy implementation, patient rights, social control, court rulings, autonomy
National Category
Social Work
Identifiers
urn:nbn:se:umu:diva-146889 (URN)978-91-7601-886-6 (ISBN)
Public defence
2018-05-18, Hörsal B, Samhällsvetarhuset, Umeå, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2018-04-25 Created: 2018-04-22 Last updated: 2018-06-09Bibliographically approved

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