Is it ever acceptable for the government to coerce someone into receiving healthcare? Is it acceptable for healthcare professionals to do so? Equally important, if an individual is coerced to do something including, for example, consenting to treatment, does the coercion invalidate responsibility for the act? Are prisoners and other institutionalized persons able to freely decide whether to enroll as subjects in experiments, or should they be seen as coerced, and, if so, does that invalidate their consent? Is paying research subjects to participate in research acceptable, or is that practice coercive?
These questions are basic to many of the ethical dilemmas faced in healthcare and healthcare research. To answer them, it is necessary to answer a number of more general questions. What is coercion? Are coercive acts ever morally legitimate? If so, how can they be distinguished from illegitimate coercion? Are there types of coercive acts that are always illegitimate, or do their moral natures vary with the context in which they occur? This entry aims to answer these and other related questions. A clear definition of coercion is a mandatory first step.
What Is Coercion?
In their 4th edition of Principles of Biomedical Ethics, published in 1994, Tom L. Beauchamp and James F. Childress provided a definition of coercion that is consistent with common usage: "Coercion … occurs if and only if one person intentionally uses a credible and severe threat of harm or force to control another" (Beauchamp and Childress, p.164). This definition has three critical elements: a person acting intentionally, a threat of harm, and an effort to control another. Perhaps the prototype of this image of coercion is the robber who approaches a victim and says, "Your money or your life." Note that the robber is not forcing the victim to hand over the money. The victim still has options, but the robber has manipulated the options in such a manner that most people would agree to hand over the money.
If Beauchamp and Childress's definition is correct, most constraints on freedom should not be thought of as coercion. In their definition only other people can coerce. Someone who lacks resources should not be thought of as being coerced by the lack of resources. The poor are not coerced into homelessness no matter how much their situation may be out of their control. A nation that lacks oil is not coerced into trading with a country that has oil simply because of its need. Similarly, an environment, such as a prison, cannot be thought to be coercive. Thus the regulatory restrictions on research with prisoners cannot be justified by limitations on coercion.
Similarly, threats are a fundamental feature of this definition; other pressures do not produce coercion. This position is controversial. In his 1986 volume, Harm to Self, Joel Feinberg, like Beauchamp and Childress, used the term compulsion rather than coercion to refer to the actual use of force, because compulsion reduces options and coercion only changes the attractiveness of the options. Michael D. Bayles, like others, however, did not consider this distinction important (Bayles).
Force is not the only type of pressure that is sometimes included in coercion. Positive pressures such as inducements and persuasion may be seen as "excessive." Many commentators on research ethics have suggested that excessive inducements may well constitute a form of coercion (Macklin; Levine; Ackerman; Dickert and Grady). For example, in his 1986 book, Ethics and the Regulation of Clinical Research, Robert J. Levine suggested that almost all bioethics support this view. The U.S. Food and Drug Administration's (FDA) information sheets require institutional review boards to ensure that payments not be "unduly influential" (FDA). Indeed, Neal Dickert and Christine Grady suggested in a 1999 article that whether or not a payment is unduly influential is largely determined by the strategy used to establish the amounts to be paid. Several others, including Beauchamp and Childress and Robert Nozick (1969), exclude positive incentives from the concept of coercion.
It should also follow from Beauchamp and Childress's definition that if the threatener has no intention of controlling the behavior of the other party, there is no coercion. Thus a physician who tells an individual seeking help for what might be a gunshot wound that he must report any gunshot wounds to the authorities is not coercing the potential patient, because there is no attempt to alter that person's behavior.
The question of coercion can be stated as follows: If A proposes to do something to B , what are the conditions that make the act coercive or not? Several commentators have suggested that the relevant question is whether the proposed act leaves B better off or worse off. If better off, it is a legitimate offer; if worse off, it is coercive (Zimmerman). Nevertheless, this does not entirely solve the problem. Consider a physician who tells a sick patient that she will provide treatment but only with the payment of $100 (or some other reasonable fee). This is an entirely reasonable offer and not coercive at all. If, however, the patient belongs to an HMO to which the physician belongs and which forbids this sort of co-pay, this "offer" might be coercive. Put more generally, whether an act is a legitimate offer or coercion depends on the right of the offerer to make the offer.
Such problems can be handled better by what Alan Wertheimer, in his 1987 book, Coercion called a "moralized theory" of coercion. Wertheimer objected to views suggesting that what is coercive can be determined simply by looking at the pressure applied to the individual. In his view, coercion is an inherently moralized judgment. One cannot determine whether or not an act is coercive except on the basis of understanding the normative context of the actions. Wertheimer argued that coercion judgments come down to whether the possible coercer has the right to make the proposal and whether the possible coercee has the obligation to resist it.
Coercion and Autonomy
The view in Western culture that coercion is a bad thing reflects a deep commitment to the principle of autonomy. Starting with the German philosopher Immanuel Kant (1724–1804) and his 1785 work, Groundwork of the Metaphysics of Morals, secular ethics has taken the respect for the autonomous actions of others as a primary point of orientation. In this context, coercion is wrong because it interferes with autonomy. Thus the nineteenth-century English philosopher and economist John Stuart Mill argued in On Liberty (1859) that there were inherent limitations on the power that the state or other authorities should exercise over individuals:
[T]he sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number, is self-protection.… the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. (Mill, p. 494)
Although this often quoted passage seems to prohibit many coercive actions that Western society accepts routinely today, it is worth noting that Mill made exceptions for children and for adults not of sound mind. His vision of autonomy is so rationalistic that there appears to be no basis for respecting the autonomy of those who are lacking in reasoning ability.
Is Coercion Always Wrong?
At least in the context of Western values, it is hard to defend coercive behaviors per se. Nonetheless, there are many examples of coercive behaviors that are generally accepted. Indeed, political scientists general acknowledge that the governmental monopoly on the use of force is a fundamental feature of civil order. The ability of the authorities to threaten the use of force seems essential. There are innumerable examples, both in and out of medicine, in which coercion is accepted. The courts routinely tell people who are thought to have a mental illness that they can either take their prescribed medicine or be involuntarily committed to a hospital. In this case, the courts are still consistent with Mill's viewpoint. But when parents are told that if they want their children to attend public schools, the children must have certain vaccinations, this appears to go beyond Mill's limits on coercion.
The viewpoint that coercion is sometimes justified is referred to as paternalism. Here the authority, be it the state or the medical professional, justifies the use of threats and force based on the best interests of the individual. Although few ethicists have expressly focused on justifying paternalism per se, there has been considerable discussion of the circumstances under which paternalism might be acceptable.
Feinberg (1971) distinguished between weak paternalism and strong paternalism. The former depends for its legitimacy on an individual's compromised ability to decide, based on, for example, the influence of psychotropic drugs, some forms of mental illness, severe acute pain, or acute neurological injuries. Strong paternalism, by contrast, justifies actions that are simply intended to benefit a competent rational individual who is, in the view of the paternalist, making the wrong decision. Strong paternalism may take the form of either restricting what is disclosed to an individual or simply overriding the person's autonomous choices.
Empirical Findings: The Example of Psychiatric Admission
Empirical data cannot resolve ethical issues, but experience in bioethics has shown that ethical issues often look quite different when they are embedded in complex situations. Likewise, empirical data can render problematic assumptions about the nature of the ethical decisions that occur in healthcare contexts.
There have not been very many efforts to study coercion in healthcare. The exception is psychiatric care. There has been considerable research into coercion in psychiatric admissions and in other aspects of psychiatric care that are mandated by courts or other legally constituted authorities. Precisely because such situations use the coercive power of the state and yet occur within the context of medical care, they have been of special interest to ethicists and policymakers. For this reason, research on coercion in psychiatry can also be helpful in understanding some of the general issues concerning coercion in healthcare.
Research on coercion in psychiatry was relatively unorganized until the MacArthur Foundation funded a series of studies in the 1990s. These studies contributed a number of important empirical findings, but their most important contribution was to create a measure of perceived coercion that has been widely adopted and that has allowed comparisons across international boundaries and among different types of psychiatric care. It is important to recognize, however, that this scale measures perceived coercion and that it is based on an understanding of coercion as a restriction on the ability to make decisions for oneself (Gardner et al., 1993).
Among its findings, the MacArthur group reported several that have important implications for understanding coercion in healthcare. First, there is surprising agreement among the participants in hospitalization decisions (patients, family, and clinicians) about what happened (Hoge et al., 1998; Lidz et al., 1998). The differences are in how the events are evaluated. Thus the different participants often disagreed about the level of coercion even when they agreed about the acts involved.
Perhaps the most surprising MacArthur finding was that being legally involuntarily committed is not necessarily perceived by patients as coercive. Indeed, almost a third of the people who were legally committed reported that they did not feel coerced. Conversely, more than 10 percent of those who were admitted "voluntarily" felt coerced (Hoge et al., 1997). These finding have been confirmed by other investigators (Nicholson, Ekenstam, and Norwood; Hiday et al.). Similar findings have been found in different countries (McKenna, Simpson, and Laidlaw), in involuntary outpatient treatment (Swartz et al.), and in drug treatment (Wild, Newton-Taylor, and Alletto).
Perhaps the most interesting of the MacArthur group's findings involved the issue of moralized versus nonmoralized concepts of coercion. In a 1993 study, Nancy S. Bennett and her colleagues examined the transcripts of interviews with admitted patients and noted that the patients' descriptions of their experiences with admission and their perceptions of coercion appeared to be substantially related to their perception of what came to be called procedural justice. This concept included the sense that patients had a chance to express their own thoughts on the hospitalization, that they were listened to, and that the motives of others involved in the hospitalization decision were benign (Bennett et al.). Subsequent follow-up studies, both from the MacArthur group (Lidz et al., 1995) and others (Hiday et al.), showed that both procedural justice and what the researchers called negative pressures (force and threats) were strongly related to perceived coercion but that "positive pressures" such as inducements were not.
Coercion may be defined in a purely behavioral manner as the use of a threat to control the behavior of another. Other thinkers have argued that coercion is inherently a moralized judgment that can be understood only in the normative context in which it is made. From this perspective, there can be no such thing as approved coercion. Indeed, coercion is almost universally condemned in the abstract, but there are many instances in which actions that fit behavioral definitions of coercion are approved. The empirical studies of coercion appear to support a view of coercion that involves both behavioral and moral components. There appears to be little empirical support, however, for the idea that offers or other inducements are experienced as coercive.
charles w. lidz
SEE ALSO: Authority in Religious Traditions; Autonomy; Behaviorism; Behavior Modification Therapies; Conscience; Conscience, Rights of; Ethics; Informed Consent; Paternalism; Psychosurgery, Medical and Historical Aspects of; Public Health
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Bayles, Michael D. 1972. In Coercion, ed. J. Roland Pennock and John W. Chapman. Chicago: Aldine Atherton.
Bennett, Nancy S.; Lidz, Charles W.; Monahan, John; et al. 1993. "Inclusion, Motivation, and Good Faith: The Morality of Coercion in Mental Hospital Admission." Behavioral Sciences and the Law 11(3): 295–306.
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J. A. Cannon
The intimidation of a victim to compel the individual to do some act against his or her will by the use of psychological pressure, physical force, or threats. The crime of intentionally and unlawfully restraining another's freedom by threatening to commit a crime, accusing the victim of a crime, disclosing any secret that would seriously impair the victim's reputation in the community, or by performing or refusing to perform an official action lawfully requested by the victim, or by causing an official to do so.
A defense asserted in a criminal prosecution that a person who committed a crime did not do so of his or her own free will, but only because the individual was compelled by another through the use of physical force or threat of immediate serious bodily injury or death.
In the laws governing wills, coercion is present when a testator is forced by another to make provisions in his or her will that he or she otherwise would not make if permitted to act according to free choice. It is an element of both duress and undue influence, two ways in which a testator is deprived of his or her free choice in making the will. If coercion is established in a proceeding to admit a will to probate, the document will be denied probate, thereby becoming void; and the property of the decedent will be distributed pursuant to the laws of descent and distribution.
Coercion, as an element of duress, is grounds for seeking the rescission or cancellation of a contract or deed. When one party to an instrument is forced against his or her will to agree to its terms the document can be declared void by a court. A marriage may be annulled or a separation or divorce granted on the grounds of coercion.
The coercion of small businesses by a cartel to fix prices of particular items supplied to them is a violation of antitrust laws, which are intended to prevent the restraint of competition in commerce. Laws regulating labor-management relations are violated by coercion when the employer coerces employees not to join a labor union or when a union representative pressures, uses physical force, or threatens an employee into joining the union.
Coercion is recognized as a defense in prosecutions for crimes other than murder. If an accused can establish that he or she committed a crime as a result of the coercion imposed by another the defendant will be acquitted on the charge as a matter of law. He or she will not be excused for the crime if there was only fear of minor physical injury, damage to reputation, or property loss. The person who coerces another to commit a crime is guilty of the crime committed. The coercer can also be prosecuted for the separate crime of coercion.
Coercion by law is the rendition of a judgment or a decree by a court, tax assessment board, or other quasi-judicial body for an amount of money presently due that mandates the sale of property owned by the defendant to pay the judgment.