The use of leverage in community mental health: ethical guidance for practitioners.
BACKGROUND
Leverage is a particular type of treatment pressure that is used within community mental health services to increase patients' adherence to treatment. Because leverage involves practitioners making proposals that attempt to influence patients' behaviours and choices, the use of leverage raises ethical issues.


OBJECTIVE
To provide guidance that can assist practitioners in making judgements about whether it is ethically acceptable to use leverage in a particular clinical context.


METHODS
Methods of ethical analysis.


RESULTS
Four ethical duties relevant to making such judgements are outlined. These four duties are (1) benefitting the individual patient, (2) benefitting other individuals, (3) treating patients fairly and (4) respecting patients' autonomy. The practical requirements that follow from each of these duties are considered in detail. It is argued that practitioners should determine whether the use of leverage will mean that care is provided in ways that are consistent with the requirements of these four duties, regardless of whether the patient accepts or rejects the terms of the proposal made.


CONCLUSIONS
Particular attention must be paid to determine how the requirements of the four duties should be applied in each specific treatment scenario, and in making careful judgements when these duties pull in opposing directions.
The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK michael.dunn@ethox.ox.ac.uk.
Michael
M
Dunn
Department of Psychiatry, University of Southampton, Southampton, UK.
Julia M A
JM
Sinclair
Department of Psychiatry, University of Oxford, Oxford, UK.
Krysia J
KJ
Canvin
Department of Psychiatry, University of Oxford, Oxford, UK Health Services Research Unit, Akershus University Hospital, Oslo, Norway.
Jorun
J
Rugkåsa
Department of Psychiatry, University of Oxford, Oxford, UK.
Tom
T
Burns
D003068:Coercion; D003156:Community Mental Health Services / Q000941:ethics* / Q000379:methods; D006801:Humans; D001523:Mental Disorders / Q000523:psychology / Q000628:therapy; D010349:Patient Compliance; D026684:Personal Autonomy; D012941:Social Responsibility
Leverage; coercion; community mental health; ethics; treatment pressures