Coerced to autonomy

theoretical analysis of compulsory community care in Sweden

Abstract

In earlier research about compulsory community care, two contradictions related to the legisla-tion have been identified: First, compulsory community care (CCC) means both more and less autonomy for the patient. Second, it means that autonomous individuals are being coerced to autonomy. The aim of the article is to clarify the normative underpinning of the law in light of four perspectives on autonomy to that help understand the two contradictions. The first contradiction can be explained by the fact that the legislator operates with two dif-ferent definitions of autonomy: liberalistic and bioethical. In a liberalistic perspective, CCC res-tricts the right to autonomy. From a bioethical perspective, CCC potentially increases autonomy since it may enhance or protect the future autonomy of the patient. According to this perspective, other values, such as health and quality of life, can also warrant a restriction of autonomy. The second contradiction can be explained by how the legislator confuses procedural with substantial conceptions of autonomy. Since the patient is not assumed to be incompetent, the patient is assumed to have procedural autonomy. At the same time, whether or not the patient’s will is accepted depends on the eventual outcome of the patient’s choice. If the patient refuses care, her opinion is not presumed authentic, which is an expression of a substantive conception of autonomy. The coercive care provided is supposed to reinstall the patient’s substantive autonomy. When it comes to the practice of CCC, the patient is assumed to accept the coercive elements voluntarily. This means that the patient is also autonomous according to a substantive conception of autonomy. Since the objective of compulsory care is to enable the patient to accept care volun-tarily and thus restore his/her authentic opinion, the legal requisites for allowing and discharging from CCC are met at the same time. If compulsory community care is to be acceptable from a bioethical perspective, it must pro-vide the patient with actual benefits or more autonomy. There is no research evidence that com-pulsory community works. Accordingly, it is hard to identify what benefits CCC provide that can trump the autonomy of the patient.