EDITORIAL REVIEW

Mental illness and informed consent: seeking an empirically derived understanding of voluntarism
Laura Weiss Roberts
Department of Psychiatry, Institute for Ethics, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA Correspondence to Laura Roberts MD, Professor and Vice Chair, Department of Psychiatry, UNMHSC Institute for Ethics, MSC09 5030, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA Tel: +1 505 272 3867; fax: +1 505 272 4569; e-mail: lroberts@salud.unm.edu Current Opinion in Psychiatry 2003, 16:543545
# 2003 Lippincott Williams & Wilkins 0951-7367

process, and mental status measures. Many participants did not initially perceive signicant coercive pressures across two different settings (one involving a mental health court, the other a conventional misdemeanor court arrangement), but many also did not indicate awareness of what choices and rights they actually had. The individuals in the mental health court were more positive about the judicial process and emotional impact of the hearing than were comparison participants who underwent conventional court procedures. Also related to forensic populations, Rigg [6] administered a survey and interview to 30 inmates participating in a sex offender treatment program in Canada to explore perceptions of coercion and treatment motivation. Respondents in this study indicated experiencing low levels of treatment coercion, although length of incarceration and chronological age positively correlated with perceived degree of coercion in the sex offender treatment process. Enhanced opportunities to move to less restrictive settings or to become eligible for parole due to participation in treatment were viewed as positive motivation, not as coercive external pressure, in this study. This result, related to the interface of internal and external pressures inuencing ones subjective sense of voluntarism and coercion, merits further study. In a third subpopulation, Gudjonsson et al. [7] examined the effects of alcohol withdrawal in 127 individuals undergoing detoxication with respect to psychological state, including mental status, suggestibility, confabulation, anxiety, and other measures. The authors concluded that alcohol withdrawal heightens suggestibility and interferes with an individuals ability to cope with interrogative pressure. Similar empirical work is presently underway examining the extent of voluntarism and decisional capacities of schizophrenia and dementia research participants that is certain to yield important ndings that may help determine diagnosis and staterelated vulnerability of ill persons and help build better attuned ethical safeguards. A suite of empirical studies published recently examined ethically important aspects of involuntary hospitalization of persons with mental illness highlighting distinct perspectives and methodological approaches. Zinkler and Priebe [8] performed a review of available studies on involuntary admission (detention) of mentally ill
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Informed consent is a practice of legal and ethical signicance for persons living with mental illness [1,2]. It helps to translate the preferences and rights of autonomous persons into concrete decisions. Informed consent may occur in the context of a therapeutic relationship that is dedicated to fostering the health and best interests of the ill individual, respectfully, benecently, and faithfully. Informed consent may also occur in relation to a research participation decision; in this context, it serves as a safeguard to ensure that the individual truly understands and freely undertakes the special task of furthering a valuable scientic endeavor, which may or may not bring some personal benet. In both clinical and research situations, informed consent has been conceptualized as having three core components: information, decisional capacity, and voluntarism (Fig. 1). Over four decades, there have been extensive efforts to understand consent processes, giving emphasis to information-related and decisional capacity considerations [3]. In this time, relatively little attention has been given to the cardinal element of voluntarism, dened minimally as the expression of authentic choice in the absence of coercion [2]. The past year, however, has witnessed the emergence of a handful of promising evidence-based papers seeking to present a more nuanced, substantive understanding of voluntarism, which is at the heart of the informed consent process. Intriguing data-driven projects have focused on special issues related to voluntarism in subpopulations with mental illness or addictions. Poythress et al. [5], for example, performed a study involving 222 adult court defendants with known mental health issues in Florida, USA, assessing perceived coercion, perceived procedural justice, the emotional impact of the legal hearing
DOI: 10.1097/01.yco.0000087262.35258.f6

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Figure 1. Elements of informed consent

Informed consent Nature of decision Nature of relationship Voluntarism Information Developmental Dialogue/process Illness-related Rationale Psychological/cultural Risks/benefits and likelihood Contextual factors Alternatives Future choices Decisional capacity Communication Understanding Reasoning Appreciation [Adapted from 4]

tic methodological approaches, and they yield inconclusive and uncertain results [5,6,10,21]. They raise many more scientic and ethics questions than they immediately resolve. For example, is a self-report scale the best way to measure coercive pressure? Furthermore, how does one ethically obtain informed consent from a person with overlapping sources of vulnerability (e.g. an ethnic minority who is imprisoned or institutionalized and is also suffering from mental illness) for a study ironically about voluntarism and coercion in the context of informed consent? Nevertheless, evidence-based studies permit us to systematically characterize the diverse experiences of people who live out the personal consequences of clinical care practices, public policy initiatives, and societal attitudes. This is important to our fulllment of the ethical principles of Respect for Persons and Justice. It is also valuable in determining whether we are actually doing what we think we are doing in our efforts to safeguard ill individuals [22,23]. In addition, empirical studies highlight what may be critical conceptual lacunae, such as the ironic situation illustrated in different ways by both Poythress et al. and Rigg in which one does not perceive coercion because one does not imagine even the existence of choice [5,6]. These authors also offer evidence about disease processes and critical time periods that may represent heightened vulnerability (or strength) in the context of serious illness [7,24,25]. This information may be used to construct targets of opportunity for the development of interventions that seek to enhance the autonomy of ill individuals [26]. Taken together with rigorous scholarship of many forms and derived from many sources, empirical work represents an important tool in enhancing our understanding of mental illness and informed consent and its subtlest components.

persons across Europe up to 1999, revealing nearly 20fold variations in rates across different countries at different times. This work suggests that hospitalization patterns are inuenced by societal, policy, and attitudinal inuences that may be distinguished from basic clinical phenomena associated with mental illness. In an attitude-based study, Lauber et al. [9] performed a telephone survey with 1737 individuals in Switzerland, nding more than 70% supported involuntary or compulsory hospitalization of mentally ill persons who are acutely ill or potentially dangerous. Ironically, respondents with positive prior experiences with the eld of psychiatry, as well as those with negative stereotypes toward mental illness, were supportive of the practice of compulsory admission. Finally, Papageorgiou et al. [10] studied the impact of advance directives for psychiatric treatment upon compulsory readmission by performing a randomized, controlled trial involving 156 mentally ill inpatients. One year after discharge, no difference was found in the numbers of involuntary or voluntary readmissions, inpatient length-of-stay, or satisfaction measures across the control group and the group that had participated in psychiatric advance directive intervention. This prospective study giving a null result suggests the value of obtaining formal outcomes data prior to broad scale introduction of certain ethics safeguard practices. A substantive empirical literature on informed consent across the age spectrum in mental health care and research in the context of other physical illnesses and addictive disorders is now emerging internationally [11 16]. This work holds great promise, but the projects described here also illustrate several challenges in this eld [1720]. The studies employ disparate, opportunis-

Acknowledgements
The author gratefully acknowledges support from the National Institute of Mental Illness in the form of a Career Development Award (1K02MH01918) and from the National Institute on Drug Abuse (1R01DA13139).

References
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