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