1. About the project

    Background

    In many jurisdictions, persons with mental disorders can be admitted to hospital and treated against their will in situations where they pose a risk to themselves or others. These justifications are often taken for granted.

    Mindful of Salus, the Roman goddess of well-being and security, the Bochum SALUS project will explore the nature and normative force of service user well-being and the security of third parties in the context of coercive interventions.

    Aims

    The Bochum SALUS project aims to determine under which conditions (if any) considerations of well-being and security can justify coercive interventions and to prevent potential conflicts between autonomy, well-being and security by integrating explicit consideration of the latter two values into the advance care planning process. In the course of the project, we will

    1. identify implications of recent autonomy-enhancing policy measures for the well-being of service users and the security of third parties;
    2. examine the attitudes of mental health professionals, service users and the general public toward coercive interventions in psychiatry;
    3. determine under which conditions, if any, involuntary interventions are morally justifiable;
    4. improve the quality of psychiatric advance directives by integrating an explicit consideration of issues surrounding well-being and security into the advance care planning process; and
    5. assess and evaluate the opportunities and challenges of self-binding directives and explore possibilities for implementation in Germany.

    Methods

    The SALUS project takes an innovative bottom-up approach in which conceptual and normative analyses are informed by, and closely interlinked with, qualitative and quantitative empirical research. The method at a project-level is reflective equilibrium. This method consists in a deliberative process of working up and down from considered judgments about specific cases to moral principles governing these cases.

    The project derives fundamental moral principles from legal documents and stakeholders’ attitudes and investigates considered judgments about individual cases by adopting an empirical bioethics approach. Empirical bioethics consists of the systematic study of stakeholders’ moral beliefs about bioethical issues by means of methods of the social sciences. The empirical bioethics branch will be operationalized using a mixed-method approach of qualitative and quantitative methods.

    Workstreams

    The questions of the SALUS project will be addressed in four workstreams, each encompassing various empirical, ethical and conceptual studies:

    I. Well-being, security and coercion in general psychiatry

    II. Ethical challenges in forensic psychiatry

    III. Improving the advance care planning process

    IV. Opportunities and challenges of self-binding directives

    Project structure

    SALUS is funded by the German Ministry for Education and Research (BMBF) as an independent research group in the field of ethical, legal and social aspects of modern life sciences. The research group builds a bridge between the Institute for Medical Ethics and History of Medicine of the Ruhr University Bochum and the Department of Psychiatry, Psychotherapy and Preventive Medicine at the LWL University Hospital of the Ruhr University Bochum.

    We are supported by national and international collaboration partners and advisory board members who are all leading experts in their field.

  1. Workstream I — Well-being, security and coercion in general psychiatry

    In many jurisdictions, persons with mental disorders can be admitted to hospital and treated against their will in situations where they pose a risk to themselves or others. Although many take these justifications for granted, there are many conceptual and ethical issues surrounding justifications of involuntary interventions based on the well-being of service users or the security of third parties.

    Whereas mental health professionals tend to define well-being objectively and equate it with medical health or remission of symptoms, service users often feel that the personal and social constituents of their well-being are neglected. Because of this, mental health professionals may be unable to justify involuntary interventions to those who are subject to them.

    While risk assessment tools are designed to help mental health professionals in making tradeoffs between autonomy and security, professionals often fail to appreciate the number of false positives such instruments yield (i.e., persons who are categorized as high risk but who will not harm others). Restrictions of liberty of persons who are categorized as high risk may thus be unjustifiable.

    In this large conceptual and ethical workstream, we aim to

    1. develop a conception of well-being in severe mental disorder that is able to mediate between staff and service user perspectives;
    2. determine under which conditions (if any) the current preferences of service users may be overridden to promote their own well-being;
    3. determine under which conditions (if any) the liberty of service users may be restricted to protect the interests of others.

    In accordance with the methodological approach of the SALUS project, we will start bottom-up by investigating the attitudes of service users, other stakeholders and the general public toward coercive interventions in psychiatry, employing both qualitative and quantitative empirical methods.

    For the purposes of this workstream, coercion is defined broadly, encompassing not only “formal” coercive interventions, such as involuntary admission and treatment, seclusion and mechanical restraint, but also treatment pressures such as persuasion, interpersonal leverage, inducements and threats. One thing we want to find out is which forms of treatment pressures service users experience and how they rank these treatment pressures in relation to each other and in relation to formal coercion. 

  1. Workstream II — Ethical challenges in forensic psychiatry

    Forensic psychiatric hospitals provide care for persons with mental disorders who have committed a criminal offense but who have been found to have either no or diminished responsibility for the offense on account of their mental disorder.

    Forensic hospitals have the dual task of providing care to patients and offering protection to society. Because of this, the conflict between the autonomy of persons with mental disorders and the security of society tends to be more pronounced in forensic settings.

    Under strict conditions, the law regulating forensic care in the German federal state North Rhine-Westphalia permits involuntary treatment with the aim of increasing the likelihood that a person can be discharged from the hospital and return to society. Similar provisions can be found in the laws other federal states.

    We want to find out how considerations of autonomy, well-being and security play a role and are weighed against each other in the decision-making process leading up to a decision to file an application for involuntary treatment.

    To this end, we will interview mental health professionals who played a role in the decision-making process before and three months after the court grants permission to proceed with involuntary treatment. The interview data will be complemented with from other sources, notably application forms and reports.

    Within this workstream, we closely cooperate with the forensic psychiatric hospitals Herne and Lippstadt. 

  1. Workstream III — Improving the advance care planning process

    Psychiatric advance directives (PADs) are documents by means of which mental health service users can make known their preferences regarding treatment in a future mental health crisis. PADs are legally binding in Germany since 2009.

    In their PADs, service users document preferences regarding medication, hospital admission, contact persons and care of finances, dependents or pets. PADs enable service users to remain in control of their life and treatment when in a mental health crisis. In an interview study (Kim et al. 2007), one service user expressed it as follows:

    “It’s probably one of the best things that’s come into mental health in a long time because it gives you rights, while you’re sound and while you know what’s best for you – and you’re the only person that knows what’s best for you deep down.”

    Although service users are highly interested in completing PADs, the actual completion rates are low. This suggests that there are several barriers to PAD completion. One of these barriers seems to be a concern among mental health professionals that treatment refusals documented in PADs may entail an increased risk of harm to self or others.

    In this workstream, we aim to improve the quality of psychiatric advance directives by integrating an explicit consideration of issues surrounding well-being and security into the advance care planning process. 

  1. Workstream IV — Opportunities and challenges of self-binding directives

    Self-binding directives (SBDs) are a special type of psychiatric advance directives by means of which service users can request involuntary interventions for a future mental health crisis. This instrument may especially be helpful for persons with bipolar disorder. During a manic episode, persons sometimes show types of risky behavior that they later regret (e.g., excessive spending) and at the same time refuse help offered by others – help they would have wanted to receive when looking back on the situation.

    In Germany, involuntary admission and treatment may be initiated only in order to avoid “a substantial damage to health.” As a result of this, persons who engage in excessive spending or other types of risky behavior during a manic episode may not qualify for involuntary admission and treatment. SBDs could give such persons the opportunity to plan the provision of involuntary care in such situations in advance.

    SBDs are a yet controversial. The Netherlands is the only country world-wide with explicit provisions for SBDs. In this workstream, we will

    1. explore the experiences with SBDs in the Netherlands;
    2. identify ethical risks and opportunities of SBDs; and
    3. explore the legal and practical limits for implementing SBDs in Germany.

    Within the workstream, we closely collaborate with the Department of Medical Humanities at VU Medical Center Amsterdam, the Mental Health, Ethics and Law research group at King’s College London and the German Association for Bipolar Disorders.