Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online) doi:10.1111/dewb.

12137

BENEFICIAL COERCION IN PSYCHIATRIC CARE: INSIGHTS FROM AFRICAN

ETHICO-CULTURAL SYSTEM

CORNELIUS OLUKUNLE EWUOSO

Keywords
Coercion, ABSTRACT
Psychiatry, There is a ‘catch 22’ situation about applying coercion in psychiatric
African Ethical System, care. Autonomous choices undeniably are rights of patients. How-
mental illness, ever, emphasizing rights for a mentally-ill patient could jeopardize
Omo-olu-iwabi the chances of the patient receiving care or endanger the public.
Conversely, the beneficial effects of coercion are difficult to
predict.
Thus, applying coercion in psychiatric care requires delicate balanc-
ing of individual-rights, individual well-being and public safety, which
has not been achieved by current frameworks. Two current frame-
works may be distinguished: the civil liberty approach and the Stone
model. Both frameworks are restrictive, and not respectful of human
dignity. In a civil liberty approach, individuals who are severely men-
tally-ill but not dangerous would be denied care because they do
not meet the dangerousness threshold or because the use of coer-
cion will not lead to rebirthing of autonomy. This is unsatisfactory.
Albeit involuntary interventions such as talk therapies, peer-support
etc., may not always lead to rebirthing of autonomy or free patients
from mental illness; they can however help to maintain the dignity
of each mentally ill patient.
In place of these frameworks, this study proposes a new ethical frame-
work for applying coercion in psychiatric care that is respectful of human
dignity. Specifically, it draws on insights from the African ethico-cultural
system by using the Yoruba concept Omo-olu-iwabi to develop this new
framework. This way, the study shows that only a more respectful
approach for applying coercion in psychiatric care can lead to the careful
balancing of the competing interests of individual’s rights, individual’s well-
being and public safety.

INTRODUCTION
autonomy are contraries. Second, autonomous choices
The use of coercive measures in the care of mentally ill undeniably are rights of patients and they contribute to
raises a number of ethical issues. First, coercion and self-determination. But emphasizing rights for a mentally

Address for correspondence: Cornelius Olukunle Ewuoso, Center for Applied Ethics Department of Philosophy Stellenbosch University, Matieland 7602
South Africa. Email: ewuosocornelius@yahoo.com.
Conflict of interest statement: No conflicts declared.

© 2016 John Wiley & Sons Ltd

2 Cornelius Olukunle Ewuoso
ill patient could jeopardize the chances of the patient
receiving care.1,2
Hence, applying coercion in psychiatric care requires
delicate balancing – of individual rights, individual well-
being and public safety – which has not been achieved by
current frameworks. To bridge this gap, this study pro-
poses a new framework for applying coercion in psychi-
atric care. In the first section, I shall attempt a conceptual
clarification of coercion. This will be followed by an eval-
uation of existing models for applying the same, in the
care of the mentally ill. In the final analysis, I shall define
the new model for applying coercive measures, by appeal-
ing to the Yoruba communitarian concept of Omo-olu-
iwabi to balance the competing interests of individual’s
rights, public safety and appropriate care due to a mentally
ill patient. This model, I believe, will highlight and justify
grounds for coercive measures in psychiatric care.
CONCEPTUAL CLARIFICATION
There is no generally acceptable definition of coercion in
existing studies. Newton-Howes,3 for example, defined
‘coercion’ as a ‘a subjective state, within a patient, that is
reached after consideration of their environment and situa-
tion’; Weddershoven and Berghmans4 defined it as ‘a vio-
lation of a person’s freedom’. But what is clear from
existing definitions of coercion is that in every instance of
coercion, the coerced is made to act, by the coercer, in an
1
As is the case with several autonomy based laws in countries like
Netherlands, Germany and Austria. These laws often specify that ‘as long
as no others are harmed, individuals have sovereignty over themselves.
This begs the question; ‘do we need to wait until others are harmed before
providing treatment for individuals with mental disorder?’ Autonomy
viewed this way, implies a negative right since it sets limits for others; that
is, it articulates what others are not allowed to do. This conception as Jans-
sens and others rightly observed (2003; p. 454) has limited relevance for
care practice. Janssens MJ, Van Rooij MF, ten Have HA, Kortmann FA &
Van Wijmen FC. Pressure and coercion in the care for the addicted: ethical
perspectives. Journal of medical ethics 2004; 30: 453–8.
2
Furthermore, the beneficial effects of coercion are difficult to predict.
Empirical data are inclusive on the beneficial effect of coercion in psychi-
atric care. While some studies seem to support the truism that coercion
will lead to improved outcomes, other studies show no such association.
Equally, significant debate also exists amongst scholars on the inevitability
of coercion in psychiatric care (Steinert and colleagues, 2014); Dahm and
colleagues (2015); while some maintain that the use of coercive measure
is inevitable in psychiatric care, others disagree. However, scholars gener-
ally agree that the use of coercive measures in managing dangerous and
severely disturbing behaviour may become necessary at some point in the
care of the mentally behavior. When such time arises, how do we make
such use of coercive measure humane? This study will also attempt to
answer this question.
3
Newton-Howes G. Coercion in psychiatric care: where are we now, what
do we know, where do we go? The Psychiatrist 2010; 34: 217–220.; p.
217
4
Widdershoven G & Berghmans R. Coercion and pressure in psychiatry:
lessons from Ulysses. Journal of medical ethics 2007; 33: 560–3.; p. 561
involuntary manner. Thus, I define coercion, in this study,
as the practice of forcing the coercee to act in an involun-
tary manner. This definition, clearly distinguishes coercion
from persuasion, which is described by Shah and Basu5 as
the utilization of a patient’s reasoning ability to arrive at a
desired result. In coercion, the patient has no choice; and
is made to act against his/her will.
The different forms of coercive measure used in mental
health care include involuntary admission, involuntary
treatment, outpatient commitment, seclusion, mechanical
restraint, physical restraint and chemical restraint. There
are a number of reasons why coercion may be applied to
an individual, in general. Jimenez6 has provided a detailed
list, which includes the following:
 To prevent self-harm (including suicidal behaviour, cut-
ting or other parasuicidal acts, and behaviours that
threaten to interrupt medical treatments, such as
attempting to remove intravenous access lines or
mechanical ventilation tubes)
 To prevent violent behaviour/harm to others
 To prevent behaviours that threaten the therapeutic
milieu, such as uncontrollable screaming, damage to
property, fecal smearing, exposure of genitals, or mas-
turbating
 To prevent elopement/absconding
 To decrease stimulation
 To limit the physical agitation that may result from sev-
ere disorganization, intoxication, or other organic brain
syndromes or delirium states
 As a response to verbal threats
 To address patients’ refusal of medication
 As a consequence of breaking unit rules
 As part of a behavioural therapy program; or
 At the patient’s request.
Ethically, the principles of beneficence and non-malefi-
cence are often used to justify the use of coercion within
the mental health care system. Following these principles,
two common conditions for applying coercion in mental
health care include: the presence of a severe mental disor-
der that deprives the individual of the capacity to make
treatment decisions, and secondly, the likelihood of harm
to oneself or others.7
5
Shah R & Basu D. Coercion in psychiatric care: Global and Indian per-
spective. Indian journal of psychiatry 2010; 52: 203–6.; p. 203
6
Jimenez J. An Overview of Historical and Current Trends in the Use of
Mechanical Restraints in Psychiatric Settings. Mental Health Law and Pol-
icy 2012; 1: 15–34.; p. 25.
7
The Convention on Human Rights and Biomedicine issued by the com-
mittee of Ministers of the Council of Europe prohibits applying coercive
measure, that is involuntary treatment, in the interest of other people. The
convention allows coercive treatment only if, without such treatment seri-
ous harm is likely to result to the health of the patient. It is good to note
that not all norms allow coercive treatment in the interest of third parties.
Tannsjo T. The convention on human rights and biomedicine and the use
of coercion in psychiatry. Journal of medical ethics 2004; 30: 430-4.
© 2016 John Wiley & Sons Ltd
 Beneficial Coercion in Psychiatric Care
The ethical difficulty with the use of coercion in psychi-
atric care is that it brings into focus three principal consid-
erations, which must be carefully balanced. They include:
individual rights; health/safety of the mentally ill; and pub-
lic good. How do we balance these three considerations?
Two responses to this question can be contextualized – a
civil liberty approach and the Stone model.
CIVIL LIBERTY APPROACH AND
‘DANGEROUSNESS STANDARD’
The civil liberty approach is the basis of several State
laws, Mental Health Acts and Ethical Guidelines, regard-
ing the use of coercion in psychiatric care. A pivotal con-
dition in this approach is the dangerousness standard. In
some State laws such as Germany, the dangerousness stan-
dard is the only condition that justifies the use of coercion
in psychiatric care.8 The North Carolina civil commitment
statute considers an individual to constitute a danger to
himself/herself if there is probability of the individual suf-
fering serious physical debilitation unless adequate treat-
ment is given.9 There are other conditions that must be
satisfied before an individual may be civilly committed.
First, the danger must result from the mental disorder. Sec-
ond, the danger may be present or expected. With regard
to expected harm, there must be substantial evidence that
the individual who is coerced will likely do harm to some-
one or oneself. Finally, the use of coercion (involuntary
admission)10 is the means that takes the danger away. In
some State laws, the patient is to be discharged once the
danger has been removed.
Attention should be paid here to the distinction these
State laws make between involuntary admission and invol-
untary treatment. An individual is to be involuntarily
admitted only if he constitutes danger to himself and
others. If simple confinement is sufficient to diminish such
danger, involuntary treatment is impermissible. Dutch Law
encourages institutions to actively explore means11 of
8 12
Steinert T, Noorthoorn EO & Mulder CL. The Use of Coercive Interven-
tions in Mental Health Care in Germany and the Netherlands. A Compar-
ison of the Developments in Two Neighboring Countries. Front Public
Health 2014; 2, Zhang S, Mellsop G, Brink J & Wang X. Involuntary
admission and treatment of patients with mental disorder. Neuroscience
Bulletin 2015; 31: 99–112.
9
Habermeyer E, Rachvoll U, Felthous AR, Bukhanowsky AO & Gleyzer
R. 2008. Hospitalization and Civil Commitment of Individuals with Psy-
chopathic Disorders in Germany, Russia and the United States. In The
International Handbook of Psychopathic Disorders and the Law. John
Wiley & Sons, Ltd.
10
Some courts have granted legal order to restrain an individual at home,
if such measure can help overcome danger associated with the mental ill-
ness. Janssens, Van Rooij, ten Have, Kortmann & Van Wijmen.
11
In some situation, involuntary treatment may coincide with involuntary
admission. Detoxification, for example, automatically begins with admis-
sion of addicts
© 2016 John Wiley & Sons Ltd
3
averting the danger, without involuntary treatment. In
Dutch Law12, involuntary treatment is allowed; first, only
if this is the means of removing the danger; secondly, if
the individual is incapable13 of making this health decision
due to mental illness; and s/he constitutes danger to one-
self or others after admission – i.e inside the clinic.
Dutch Law on involuntary treatment is consistent with
the principle of least restrictive intervention proposed in
the Declaration of Hawaii14 (and updated by the Declara-
tion of Madrid). The declaration forbids involuntary treat-
ment unless withholding such treatment would endanger
the life of the patient and/or those surrounding him or her.
The dangerousness standard also appears to be the view
held by philosophers such as Hobbes and J.S Mill. In his
article On Liberty, J S Mill,15 for example, developed what
he called the harm principle, which holds that actions of
individuals should only be limited to prevent harm to other
individuals. According to him, 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.
However, there are ethical difficulties with the civil lib-
erty approach regarding the use of coercion in psychiatric
care. This model is too restrictive. In a civil liberty
approach, individuals who are severely mentally ill but not
dangerous would be denied care because they do not meet
the dangerousness threshold. There is something unethical
about abandoning a non-dangerous mentally ill individual
who needs care, but does not meet the conditions for
involuntary care. Critics of the civil liberty approach such
as Caplan16 also argue that a restrictive commitment crite-
rion (dangerousness standard) proposed by the civil liberty
model will further entrench the chaotic living conditions of
many mentally ill and contribute to widespread homeless-
ness among them. To overcome the weaknesses associated
with the civil liberty approach, the Stone model has been
proposed as a good alternative, which I examine in the
next section.
Salize JH, Drebing H & Peitz M. 2002. Compulsory Admission and
Involuntary Treatment of Mentally Ill Patients - Legislation and Practice in
EU-Member States. Central Institute of Mental Health, Steinert,
Noorthoorn & Mulder.
13
The test for determining competency involves the ability to comprehend
relevant information regarding proposed treatment options and alternatives.
This test, in most cases find all people, even people with severe mental ill-
ness, competent.
14
WHO. 2005. World Health Organization Resource Book on Mental
Health: Human Rights and Legislations. Freeman M, Pathare S, Drew N,
Funk M and Saraceno B, eds.
15
Mill JS. 2002. The Basic writings of John Stuart Mill : On liberty and
other writings. New York: Modern Library.; pp. 21ff
16
Caplan A. Denying autonomy in order to create it: the paradox of forc-
ing treatment upon addicts. Addiction 2008; 103: 1919–1921, Caplan AL.
Ethical issues surrounding forced, mandated, or coerced treatment. Journal
of substance abuse treatment 2006; 31: 117–20.
4 Cornelius Olukunle Ewuoso
STONE MODEL FOR APPLYING
COERCION
The Stone model is also known as the ‘Thank you The-
ory’, and is the most discussed model for applying coer-
cive measures in mental health care. Unlike the civil
liberty approach to the use of coercive measure in psychi-
atric care, the application of this model is not entirely
widespread. The American Psychiatric Association
approach to the use of coercion in psychiatric care is based
on this model. Alan Stone advanced this model in his
Book Mental Health and Law: A System in Transition. In
Stone’s17 view, ‘if the only persons committed are those
deemed to be dangerous, then we may end up releasing
those the system can treat, but are not dangerous’. In addi-
tion, Stone18 adds, it is doubtful whether psychiatrists pos-
sess the required expertise to make dangerousness
determination. According to Stone,19 ‘mentally ill patients
may need to be admitted involuntarily, for medical treat-
ment, even when they are not dangerous to themselves nor
to others; and might then thank those who forcibly com-
mitted them for insisting on treatment even against their
will’.
This position contrasts with the civil liberty model,
which insists that autonomous choices should be respected
and individuals who are not dangerous should not be
admitted against their will even when they are severely
mentally ill. Stone20 argues for two forms of commitment:
commitment for severely mentally ill, who act in a danger-
ous manner or have committed a crime; and commitment
for medical treatment for mentally ill but non-dangerous
individuals. Two powers of the State justify the use of
coercive measure(s) in both circumstances; the ‘State’s
police power’ – which is the protection of each citizen
from injurious actions of others – and ‘State’s parens
patriae power’ – which is the State’s power to protect
those who cannot protect themselves.21 Stone22 highlights
some conditions that must be satisfied before involuntary
treatment of non-dangerous but severely mentally ill
patients can take place. These conditions include:
 A reliable diagnosis of a severe mental disorder
 Major distress of the patient
 Availability of an effective treatment
 Patient’s incompetence to decide
17
Stone A. 1975. Mental Health and Law: A System in Transition. Rock-
ville, Maryland: National Institute of Mental Health.; p.37
18
Ibid.
19
Ibid.; p. 37
20
Ibid.; p. 37
21
I recognize that even the use of State power(s) to restrain an individual
from harming others, has its own ethical difficulties. Critics, for example,
may argue that the State has a duty to protect individual rights and liber-
ties, which are jeopardized by the use of coercive measure.
22
Stone.
 Reasonableness of applied treatment, which would be
accepted by a competent person
This model ensures that those severely mentally ill
patients, who do not meet the dangerousness criterion, but
require treatment, receive such treatment. An extension of
this model is the rehabilitation model advanced by
Caplan.23 In his rehabilitation model, Caplan24 argues that
‘mandating treatment, if it would restore individual’s free-
dom requisite for autonomy or self-determination, is not as
immoral as some may want us to believe. Contrarily, this
may be the right thing to do’. Involuntary treatment, such
as the use of relatively safe and effective drugs like nal-
trexone to free addicts from the coercive effects of addic-
tion, Caplan25 continues, should be mandated if it would
lead to rebirthing of autonomy26. Under both the Stone
and rehabilitation models, the moral basis for involuntary
treatment is the rebirthing of an individual’s autonomy.
The rehabilitation model, as well as the Stone model,
resolves the ethical difficulty associated with the civil lib-
erty approach but also raises new ones. I agree with both
models that involuntary treatment is not always immoral.
In this regard, these models present themselves as a ‘less’
restrictive approach to the use of coercion in psychiatric
care. But it is interesting that these models emphasize
(hope of) rebirthing of autonomy. If treatment, according
to them, will not lead to rebirthing of autonomy, it is
unethical to forcefully admit the mentally ill against their
will. Other forms of coercive interventions, such as talk
therapy for the actively suicidal that may also be beneficial
to mentally ill patients who do not meet the dangerousness
standard, are completely ignored by these models.
In addition, in both the Stone and rehabilitation models,
three classes of mentally ill patients will be involuntarily
committed/treated. They include:
 Mentally ill, dangerous and condition is treatable (civil
commitment)
 Mentally ill, dangerous, but condition not treatable
 Mentally ill, not dangerous but treatable
In both the Stone and rehabilitation models, with their
emphasis on rebirthing of autonomy and hope of recovery
through treatment, a number of non-dangerous mentally ill
23
Caplan, Caplan.
24
Caplan.; p. 1919
25
Ibid.; p. 1919
26
Caplan (2008; p. 1919) believes that addiction, like many other mental
illness, does not necessarily mean loss of competence. According to him,
to function as an addict, one should be able to remember complex infor-
mation and set goals. However, competency by itself, is not sufficient for
autonomy. In addition to competence, autonomy also requires freedom
coercion. Those who criticize involuntary treatment of addicts on the the
ground that addicts are not incompetent ignore the fact that while it could
be said that addicts are competent, their choices may not necessarily be
autonomous. If a drug can restore an individual’s autonomy, then mandat-
ing its use is not unethical.
© 2016 John Wiley & Sons Ltd
 Beneficial Coercion in Psychiatric Care
individuals, whose conditions have no known cure but
who could benefit from other forms of coercive measure
will be denied care because involuntary treatment will not
lead to rebirthing of autonomy in them. In addition, under
these models, continued hospitalization will also be ethi-
cally unjustifiable, when treatment has failed, including
physical restraint/seclusion, peer support and medication27
of individuals who are gravely disabled28,29 due to mental
disorder or chronic alcoholism. This is unsatisfactory.
Albeit such interventions may not always lead to rebirthing
of autonomy or free patients from mental illness; they can
however help to maintain the dignity of each mentally ill
patient. I argue that these models, albeit less restrictive, are
not respectful of the dignity of the human person, in the
mentally ill. We have a duty – as friends, family and even
as a State – to facilitate appropriate and respectful inter-
vention such as involuntary (and sometimes indefinite)
hospitalization, when a person we love can no longer care
for his/her basic needs due to severe mental illness; even
when such hospitalization will not lead to recovery.
Moreover, the paradox30 implied in the rehabilitation
model and ‘thank you’ theory in the Stone model, find lit-
tle support in empirical studies. In a study conducted by
Beck and Golowka31, only a minority of cases (of younger
patients with schizophrenia or affective disorders) fit into
the ‘thank you’ theory of Alan Stone. In place of both the
Stone and rehabilitation models, I propose a communitar-
ian model for applying coercive treatment in psychiatric
care. Specifically, I will draw insights from the African
ethico-sociological system by using the Yoruba (people of
South-West Nigeria) concept Omo-olu-iwabi. I believe that
this concept of person avoids the difficulties identified in
previous models, in a manner that balances the three
27
To manage symptoms
28
Grave disability is defined by the Welfare and Institutions code (section
5008, h;I;A), as a situation whereby an individual is unable to provide for
his/her basic personal needs, as a result of mental disorder. Some of these
needs may include food, clothing and shelter. Scholars are divided over
the whether individuals who are gravely disabled due to severe mental ill-
ness or chronic alcoholism constitute a danger to themselves and thus
qualify for civil commitment. Albeit there is no consensus on this issue, it
should noted that a majority believe that if gravely disabled individuals
constitute any danger to themselves, the danger is passive and not active.
Following this, a few States, such as North Carolina and Oregon, have
expanded behaviours which meet the dangerousness criteria to include
gravely disabled. J. Spensley & P.H. Werme. Conservatorship: An Invol-
untary Legal Status for `Gravely Disabled’ Mentally Disordered Persons.
Western Journal of Medicine 1979; 130: 476–484.
29
Stone and Rehabilitation models will consider California Conservator-
ship practice as ethically unjustifiable, since the practice involves prolong
care of individuals who are gravely disabled due to mental disorder or
chronic alcoholism. In these models, prolonged hospitalization of chroni
schizophrenic persons and individuals diagnosed with organic brain syn-
drome will also be considered ethically unjustifiable.
30
That is; infringing autonomy in order to create autonomy.
31
Beck JC & Golowka EA. A Study of Enforced Treatment in Relation
to Stone’s “Thank You” Theory. Behavioral Sciences & the Law 1988; 6:
559-566.; p. 564.
© 2016 John Wiley & Sons Ltd
5
competing considerations: individual rights; health/safety
of the mentally ill; and public good.
OMO-OLU-IWABI
Omo-olu-iwabi or Omoluabi is a Yoruba concept that is
used by the people of South-West Nigeria to explain the
core constitutive elements of personhood. This concept has
been extensively examined by several sociologists and
philosophers such as Akanbi and Jekayinfa (2016); Fayemi
(2009); Oluwole (2007); Oyeneye (1997) to mention a
few. However, no one has used this concept to develop a
model (communitarian model) for the care of psychiatric
patients. This is the first.
Translated literally, Omo-olu-iwabi is understood as omo
child; olu-iwabi chief of character. Omo-olu-iwabi therefore
implies a child begotten of excellent character. The term
contrasts Omokomo (worthless child) or omo la-san (carica-
ture person). To be described as an Omo-olu-iwabi in
Yoruba culture, a general description of personhood as
‘highly cultured’ or ‘well tutored’ is being elicited. Impor-
tant values incorporated in this concept include iteriba (re-
spect, which involves recognizing the rights of others);
Inurere (having good intentions towards others); Otito
(truth); and Iwarere (good character). The absence of these
important elements of Omo-olu-iwabi devalues personhood
in Yoruba thought.
The Yoruba people recognize that even sickness, espe-
cially mental illness, devalues personhood to the level of
eranko (an animal). In this regard, I agree with Fayemi32
(2009; p. 171), that the concept of Omo-olu-iwabi has bio-
logical, epistemological and ethical implications. To be
properly characterized as Omo-olu-iwabi in Yoruba cul-
ture, one must be well-behaved with evidential moral
uprightness that is demonstrated in private and public
actions; and good anatomical and psychological factors
necessary for being human. This characterization could be
applied at the individual or communal level. At the indi-
vidual level, Omo-olu-iwabi guarantees an individual’s
right to be respected and treated at all times in a humane
manner; and with dignity and respect for one’s personal
and bodily integrity. All invasive interventions are subject
to this fundamental requirement of protection of human
dignity.
In Yoruba culture, the core ethical value incorporated in
Omo-olu-iwabi is the community; working for a common/
social good. For this reason, Fayemi33 argues that in order
for an individual to realise the full potential of personhood,
s/he must be fully immersed in the life of the community.
32
Fayemi AK. Human Personality and the Yoruba Worldview: An
Ethico-Sociological Interpretation. Journal of Pan African Studies 2009; 2:
166–176.; p. 171.
33
Ibid.; p. 173.
6 Cornelius Olukunle Ewuoso
Against this background, Omo-olu-iwabi also fulfils a
communitarian function, since it incorporates central val-
ues of communitarian ethics such as communal responsi-
bilities, strong connections between people, sacrifice for
community good and reduced emphasis of selfish or radi-
cal individualism. In the Yoruba thought system, a person
is a person through other persons. In other words, individ-
uals are inextricably bound together with each other. What
affects the individual also affects the community and vice-
versa. When the individual is sick, the community is
affected. A community that does not protect the vulnera-
ble, care for the sick, protect individual good, and respect
individual rights, etc., devalues its personhood to the level
of an eranko through such neglect. In the same way, an
individual who does not seek or work for the community’s
good, risks compromising his/her own good and devaluing
himself/herself to the level of eranko.
Thus, at the community level, inter-dependence, recipro-
cal obligation, caring for others, sharing, social responsibil-
ities etc., are stressed. At this level, Omo-olu-iwabi
becomes a relational term, which grounds authentic per-
sonhood, as well as rightness of an action in the extent to
which it promotes harmonious relationships; ones in which
individuals identify with others and care for others well-
being and dignity. In this regard too, the communitarian
concept Omo-olu-iwabi also incorporates some elements of
ethics of care since it emphasizes inter-dependence, inter-
connectedness, care of other persons, etc. Within this
framework, non-consensual treatment, continued hospital-
ization and/or physical restraint of individuals who are
gravely disabled due to severe mental illness or chronic
alcoholism and in whom biological treatment has failed,
are not necessarily tyrannical, but are justified since such
coercive measures promote individual health by requiring
the community to actively work for the well-being of all.
Such (coercive) measures are equally respectful of human
dignity by prohibiting interference when individuals are
seen to be making an effort at seeking their own care.
Finally, such coercive measures facilitate public good by
ensuring that individuals who pose significant risk to
others are involuntarily constrained/confined. It is in this
regard – that is, through a more respectful approach for
applying coercion in psychiatric care – that Omo-olu-iwabi
balances the three competing interests: individual rights,
health/safety of mentally ill and public safety.
There is something unethical about abandoning a sick
member of the community whose autonomy and dignity
have been compromised due to severe mental illness or
chronic alcoholism. As a communitarian concept, Omo-ilu-
iwabi informs us that sickness, especially mental illness,
could happen to anyone. And the community/society has a
duty of care towards the sick (it is in this regard that this
communitarian model incorporates elements of ethics of
care). This may sometimes mean involuntary hospitaliza-
tion of individuals who are gravely disabled due to severe
mental illness or chronic alcoholism; even when they do
not constitute any real danger to the public/self or when
such hospitalization/treatment may not lead to rebirthing of
autonomy.
Critics may argue that this communitarian model will
escalate the use of coercive measure not only in the psy-
chiatry but in the healthcare system. This is not entirely
true. This model is proposed for the care of a particular
group of patients, mentally ill patients. And mental illness
is described by the World Health Organization (WHO) as
a broad range of disorders “with different symptoms. . .or
characterized by some combination of abnormal thoughts,
emotions, behaviour and relationships with others. Exam-
ples are schizophrenia, depression, intellectual disabilities
and disorders due to drug abuse”.34
In addition to the above, the ethical values incorporated
by this concept also act to limit interference that is possi-
ble in an individual’s life. Iteriba (respect), for example,
means that if a mentally ill individual is seen to be taking
care of himself/herself, coercive intervention will be uneth-
ical since it would be disrespectful of the individual’s
efforts. Methodologically therefore, coercive measures are
not to be applied when an individual is working hard at
preventing a devaluation of himself/herself to the level of
eranko. However, if a chronic addict has refused to check
himself/herself into a rehabilitation clinic, then society has
a duty to force him/her into rehabilitation. Parens Patriae
power of the State already justifies this form of interven-
tion. This use of coercion could also be premised on the
ethics of care, and is incorporated by the communitarian
concept Omo-olu-iwabi. At its core therefore, Omo-olu-
iwabi also enjoins us to be our brother’s keeper by ensur-
ing that the dignity of those who can no longer take care
of themselves or cannot make important healthcare deci-
sions or who has decided to devalue himself/herself to the
level of eranko, are maintained at all times. Hence, it is
hard to imagine how this model will lead to abuse, as crit-
ics may want to argue.
CONCLUSION
There is certainly a greater move towards reduction of the
use of coercion in the care of the mentally ill. However,
several scholars do believe that there may arrive a time
when the use of coercive measures may become necessary.
But how do we make such use humane? Current models –
civil liberty approach, Stone model, and rehabilitation
model – for applying coercion do not take human dignity
into consideration in their least/less restrictive frameworks
for applying coercion.
34
WHO. 2016. Mental Disorders. World Health Organization. Available
at: http://www.who.int/mediacentre/factsheets/fs396/en/ [Accessed 14 Nov
2016].
© 2016 John Wiley & Sons Ltd
 Beneficial Coercion in Psychiatric Care
These models mandate involuntary admission/hospital-
ization only when the individual constitutes a danger to
the public/self or when such involuntary admission and/or
treatment will lead to recovery or rebirthing of autonomy.
As I have demonstrated in this article, these models do not
accommodate those who do not meet these conditions –
that is, non-dangerous mentally ill individuals, whose con-
ditions have no known treatment. The question may be
asked: ‘Do we need to wait until others are harmed (or
until we are sure that hospitalization will lead to recovery)
before providing care for individuals with mental disor-
der?’ These models have limited relevance for care that is
due the human person in general.
The Yoruba concept of Omo-olu-iwabi overcomes this
difficulty by requiring care for all mentally disordered
patients who do not meet the conditions for involuntary
admission/treatment as highlighted by current models, but
can benefit from other forms of peer support or medica-
tion. It is this sense that this model will revolutionize care,
if it is adopted by national and international bodies, since
it will ensure that more humane, respectful and dignified
care is delivered in the psychiatry.
© 2016 John Wiley & Sons Ltd
7
Acknowledgement
This author greatly appreciates Dr Susan Hall of the Center for Applied
Ethics, Stellenbosch University, for her intelligent comments and insightful
contributions to the article.
Biography
Cornelius Olukunle Ewuoso was a recipient of the Santander/Ethics and
Society scholarship for Theories and Application from Fordham Univer-
sity; an international visiting fellow at the institute for Medical Ethics and
History of Medicine, Ruhr-Universitait, Bochum; a visiting scholar at the
Centre Biomedical Ethics and Law, Katholieke Universitet, Leuven and a
recipient of the Master of Science in Bioethics scholarship award of the
West African Bioethics Training Programs.
He currently teaches part-time at DOMUNI and the Dominican Institute,
Samonda, Ibadan, Nigeria. He has published articles with Ibadan Domini-
can Studies and in the Journal of Global Bioethics. Currently, he is
enrolled in the Centre for Applied Ethics, Department of Philosophy, Stel-
lenbosch University, Matieland, South Africa: for a PhD in Applied Ethics
with concentration in Bioethics. His PhD research is focussed on Informa-
tion management in Physician-patient consultative encounters.