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 situations where people with mental disorders pose a substantial risk to themselves or others, they can, under certain legal conditions, be hospitalized and treated against their natural will in Germany and many other countries. When deciding whether to use coercive measures, various values are weighed against each other: the patient’s right to self-determination, their well-being, and the safety of the patient and third parties. In our project, we work with a broad definition of coercion, which also includes so-called informal coercion or psychological pressure. This involves using various communicative means, such as persuasion, interpersonal leverage, offers or threats, in an attempt to obtain the consent of those affected.

    This raises important conceptual and ethical as well as empirical questions, which are examined in more detail in various work packages in this project area:

    - In line with the methodological approach of the SALUS project, we start ‘bottom up’ by investigating the attitudes of different stakeholders towards coercion. The attitudes of people with mental disorders, their relatives, psychiatric professionals and the general population will be determined through both qualitative and quantitative methods.

    - Despite the central role of well-being in the justification of coercive measures, professionals and those people affected often have different perspectives on what is meant by the term ‘well-being’. In one subproject, we develop a concept of well-being that considers both subjective and objective aspects.

    - Risk assessment procedures have been developed to support psychiatric professionals in balancing self-determination and safety. We examine, inter alia, the justifiability of such safety-related considerations.

    - The concept and norms of coercion will be further analysed. Although basic philosophical approaches have proven fruitful in the analysis, psychiatry-specific requirements are often not adequately addressed in these approaches.

  1. Workstream II — Ethical challenges in forensic psychiatry

    Forensic psychiatric hospitals provide care for people with mental disorders who have committed a criminal offense but 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 the person committed and the security of society tends to be more pronounced in forensic settings.

    The law regulating forensic care in the German federal state of North Rhine-Westphalia and other federal states permits compulsory treatment in forensic psychiatric hospitals under certain legal conditions.

    We want to find out to what extent aspects of patient self-determination, well-being and safety play a role in the decision of psychiatric professionals and how the different values are weighed against each other in ethical decision-making.

  1. Workstream III — Improving the advance care planning process

    Mental health service users can state treatment preferences in psychiatric advance directives (PADs) for future mental health crises in which their decision-making capacity is impaired. Their primary goal is to preserve and strengthen patient autonomy; initial practical experience and scientific studies have also identified the improvement of the quality of subjective treatment and the therapeutic relationship as advantages. Furthermore, PADs can contribute to the reduction of coercive measures, compulsory treatment and involuntary commitment. The PADs have been legally binding in Germany since 2009. They also contribute to achieving the goals set out in the UN Convention on the Rights of Persons with Disabilities by promoting self-determination and equal treatment. In their PADs, service users typically document medication and hospitalization preferences, preferred types of treatment, relevant somatic comorbidities, contact people and instructions regarding the care of finances, dependants and pets.

    One service user talked about PADs in an interview study (Kim et al. 2007) 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.

    Despite a high level of interest in PADs among service users, the actual completion rates in Germany are low. This suggests that there are several barriers to PAD completion. One possible barrier could be the concern of some psychiatrists that the preferences documented might not be compatible with current practice standards or that patients could use them to reject any treatment, causing an increased risk of harm to self or others. Research has shown that these concerns are usually unfounded, particularly in the case of PADs created in collaboration with mental health professionals.

    The goal of this workstream is to contribute to the reduction of barriers to the widespread implementation of effective PADs. This includes, in particular, improving the quality of documents, proposing solutions to ethical dilemmas arising in the context of PADs, and promoting the transfer of perspectives and knowledge between researchers, practitioners and service users. The methods used include conceptual analyses, empirical research and systematic reviews.

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

    ‘Self-binding directives’ (SBDs) are a special type of advance directive that have been discussed rarely in German-speaking countries. The special feature of this directive is that it allows mental health service users to determine in advance for certain future situations when they wish other people (e.g. relatives or psychiatric professionals) to intervene in their actions.

    Such SBDs could be particularly relevant for people with bipolar disorder, as people with this mental disorder sometimes harm themselves during manic episodes or make decisions that they would not have wanted to make in this way during more stable phases (e.g. spending large sums of money). In such situations, some people with bipolar disorder may, in retrospect, wish that intervention had occurred earlier, if necessary even with the use of coercion.

    In this project area, we will investigate the views on SBDs of people with bipolar disorder, relatives and mental health professionals using interviews and a survey. We will compare the study results from Germany with experiences of our co-operation partners in Great Britain and the Netherlands – a country where SBDs are used based on an explicit legal regulation – and identify ethical challenges and opportunities for the implementation of SBDs in Germany.

    Co-operation partners in this project area are the department “Metamedica” at the VU Medical Centre in Amsterdam, the research group “Mental Health, Ethics and Law” at King’s College in London and the German Association for Bipolar Disorders (DGBS).

  1. Workstream V — Coercion and the COVID-19 pandemic

    Germany has been significantly affected by the SARS-CoV-2 coronavirus, and the measures and strategies to contain the pandemic have resulted in the restriction of the fundamental rights of the population (e.g. closure of schools, curfews). The COVID-19 pandemic has also had a significant impact on people receiving treatment in psychiatric hospitals. People committed against their will have been particularly affected.

    In this project area, we examine the ethical aspects of using restraint as a means of infection prevention and identify experiences and opinions of senior psychiatrists regarding changes in involuntary hospitalization during the COVID-19 pandemic.

  1. Workstream VI — Establishment of online ethics consultation in psychiatric hospitals

    Complex ethical conflicts often arise in the care of psychiatric patients, for example, regarding coercion and involuntary treatment. Psychiatric professionals, patients, relatives and legal guardians can benefit particularly from clinical ethics consultation in such situations. The case discussion is moderated by a trained ethics consultant. The people involved in the case first identify the ethical conflict and then, with the help of the ethics consultant, try to make an ethically well-founded decision for the further therapeutic approach. However, there are relevant challenges regarding the systematic implementation of clinical ethics consultation in the psychiatric field, and many hospitals do not yet have access to clinical ethics consultation. Online ethics consultation is expected to reach psychiatric hospitals without their own clinical ethics services and provide low-threshold access to assistance concerning ethical questions and conflicts.

    The aim of this research project is, therefore, together with various co-operation partners, to establish an offer of online ethics consultation in psychiatry and to evaluate its implementation. In this workstream, we will:

    1. develop a concept for online ethics consultation, including practically relevant strategies for data protection, technical and logistical implementation;

    2. implement online ethics consultation in co-operating clinics; and

    3. conduct quantitative and qualitative evaluation of online ethics consultation during and after implementation.

    In this way, we want to make clinical ethics consultation in psychiatry widely accessible, improve the quality of online ethics consultation in psychiatry, investigate the impact of participation in online ethics consultation on the ethical competence of participants and gather further insights into ethical conflicts in psychiatry.

  1. Workstream VII — Development of interdisciplinary clinical-ethical manuals

    In this project area, interdisciplinary clinical-ethical manuals will be developed with the involvement of relevant stakeholders, which will provide concrete recommendations for psychiatric practice based on the results from project areas I–VI.

    A first manual will provide concrete advice for ethical problems that frequently occur in daily psychiatric clinical practice. Clinical ethics consultation is very useful for the appropriate treatment of people with mental disorders as ethical questions and dilemmas are part of daily clinical practice. Nevertheless, an exhaustive systematic implementation of clinical ethics consultation has so far been missing.

    A second manual will contain recommendations for Advance Care Planning (ACP) in psychiatry. The ACP allows for the implementation of a mental health service users’ treatment preferences at a time when they are no longer capable of giving consent. It is characterized by its procedural accompaniment and support of patients in documenting their wishes for future treatment and ensuring the local structural conditions for its implementation. In psychiatric practice, systematic ACP is less established and is also handled very differently from region to region.

    Against this backdrop, the project aims at developing a standardized template of advance directives for the clinical manual on ACP. Additionally, a practical guideline with clinical examples for the implementation of ACP in daily clinical practice will be developed.

  1. Workstream VIII - Discrimination and epistemic injustice in mental health services

    People with mental illness are subject to structural discrimination. This can affect mental health care in different ways.

    Epistemic discrimination occurs when people are specifically harmed in their ability to produce and share knowledge, for example, when their testimonies are systematically given less credibility or when they are excluded from processes of knowledge production due to structural constraints. Such cases can also be described in terms of epistemic injustice. In this project area, we will address on a conceptual level the mechanisms by which people with mental illness are epistemically discriminated against and the implications this has for mental health care and research.

    In addition, people may have experiences of discrimination in mental health care settings. Experiences of discrimination depend on which other social categories (e.g. gender, class, race/ethnicity, sexuality) are assigned to a person, i.e. whether they are subject to multiple discrimination. Black feminist theorists have developed the theory of intersectionality to analyse complex systems and experiences of discrimination.

    In this project area, we cooperate with the project "INTERSECT -Heteronormativism, Racism, Classism, Ableism and Serious Mental Illness. An intersectional analysis of unequal treatment and discrimination in mental health care", which is being carried out at the LWL Clinic for Psychiatry, Psychotherapy and Preventive Medicine at the Ruhr University Bochum. The aim of the project is to use the concept of intersectionality for ethical considerations in mental health care and to gather the lived experience of discrimination within mental health care within an intersectional framework. Further information can be found at https://psychiatrie.lwl-uk-bochum.de/forschung-und-lehre/forschung/forschungsbereiche/ethik-in-der-psychiatrie.