Ryan J Dougherty

• Psychiatric services include various forms of treatment pressures that seek to influence or undermine the decisional autonomy of patients to gain compliance, including coercion. • The definition of coercion has evolved with time, and current debates concern whether nonthreatening treatment pressures (such as incentives) can be considered coercive. • The author proposes distinguishing between interpersonal coercion, which describes clinicians leveraging threats, and institutional coercion, which describes instances in which a patient’s ability to make choices is restricted by social systemic forces.

Background: This study examines the views of bioethicists in the US and Canada on incorporating social justice into their work and the field more broadly.Methods: Through an iterative process with leaders in bioethics, we created a survey and distributed it via bioethics listservs and individual emails.Results: Ultimately, we received responses from 355 bioethicists in the US and Canada. Respondents showed strong support for integrating social justice concerns, with 80% endorsing its inclusion in bioethics and 75% believing it should be a key aim of bioethics scholarship. However, engagement with specific social justice topics varied, and perceptions about institutional support for doing so were mixed. Early-career bioethicists were more likely to support integrating social justice into bioethics.Conclusion: Our findings highlight the importance of prioritizing social justice within bioethics and underscore the need for institutional support to advance these efforts.

In the wake of injustices in healthcare, the field of clinical ethics consultation would benefit from new methods that support ethicists in addressing the role of intersecting systems of oppression in healthcare decision-making.1 We argue for an expanded view of Delany and colleagues’ critical dialogue method to accomplish this by integrating a constructivist lens.2 By doing so, critical dialogue holds the potential to not only encourage a deeper examination of operating moral assumptions but also offers an important framework for examining how underlying social structures shape ethical reasoning in clinical cases.3 As a first step in consultation methods, ethicists are often encouraged to solicit the viewpoints of treatment teams. Taking a constructivist viewpoint, these encounters can reveal to ethicists the narratives that teams share, which are iteratively developed through patient and treatment team interactions, and play a central role in how teams interpret cases. Further, consider that concepts in clinical ethics cases can directly contribute to the characterisation of patients by treatment teams, such as decisional capacity or agreeableness to care. In this regard, how treatment teams frame ethical concerns is not necessarily a direct reflection of the core issues; rather, their interpretations are partially rooted in narratives about patients and the interpersonal dynamics through …

In mental health policy, a central ethical dilemma concerns involuntary outpatient commitment (OPC), which aims to treat vulnerable individuals with serious mental illness who decline services. The first concern regards whether coercive services undermine the quality of clinical interactions within treatment, particularly as it relates to psychiatric medication use. The second concern is the unexamined role that OPC, and coercive psychiatric programs more broadly, play in the broader landscape of social welfare policy. To examine these concerns, the purpose of this dissertation is to analyze how the management of psychiatric medications in involuntary outpatient services is undergirded by (a) provider and client interpretations of psychiatric medication effects and (b) moral discourses related to coercion and client autonomy. To achieve this aim, I examined data from a team-based ethnography that consisted of 1000 hours of participant observations and 56 semi-structured interviews with 20 clients, 21 providers, and 12 client family members with diverse backgrounds. I analyzed how medication compliance was discussed, monitored, and enforced in an involuntary outpatient program. My analysis demonstrates that medications were interpreted as a technology to control clinical symptoms (clinical control) though, particularly among clients, were also viewed as a method to control client mental experiences, behavioral expression, and autonomy (social control). Providers believed that medications were a necessary component of services (compulsory compliance) and could reduce client vulnerability to violence victimization and perpetration related to clinical symptoms (medicating vulnerability). To address client noncompliance, providers employed several strategies that I categorized as client manipulation. These strategies included providers, family members, and court officials strategizing ways to undermine client autonomy without clients’ knowledge (concealed collusion), deceiving clients into believing that medications were mandated when they were not (performing coercion), and minimizing the role of client consent and preferences in decision-making processes (circumventing consent). These findings demonstrate the pervasive role of manipulation to gain client medication compliance in OPC, which I named institutional coercion. They also highlight that the broader moral justifications for manipulating clients relate to their status as structurally vulnerable in their community settings and a growing relationship between the erosion of the welfare state and psychiatric coercion.

This article examines neuroleptics in relation to the histories of biopsychiatry and neoliberalism in the United States. Drawing from Foucault's concept of biopower, I contend that neuroleptics are socially constructed as a mechanism to address underlying biological illnesses in order to achieve neoliberal subjectivity for mad/disabled people. I then argue this biopsychiatric and neoliberal construct dominates services with the expressed goal of creating people who self‐govern their own drug consumption. This, however, contrasts with accounts that depict intersubjective balancing acts between treatment providers and mad/disabled people, who must incorporate the various effects of psychoactive drugs beyond measures of rehabilitation. In doing so, I advocate for new lines of psychological inquiry that critically examine the structural determinants of poverty and the underlying constructions of citizenship and wellness.

Recent global events demonstrate that analytical frameworks to aid professionals in healthcare ethics must consider the pervasive role of social structures in the emergence of bioethical issues. To address this, the authors propose a new sociologically informed approach to healthcare ethics that they term “social bioethics.” Their approach is animated by the interpretive social sciences to highlight how social structures operate vis-à-vis the everyday practices and moral reasoning of individuals, a phenomenon known as social discourse. As an exemplar, the authors use social bioethics to reframe common ethical issues in psychiatric services and discuss potential implications. Lastly, the authors discuss how social bioethics illuminates the ways healthcare ethics consultants in both policy and clinical decision-making participate in and shape broader social, political, and economic systems, which then cyclically informs the design and delivery of healthcare.