Ethics

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7. Use of restraint to provide treatment

Can doctors restrain children or young people to provide treatment against their wishes?

Once a decision has been made that it is lawful and ethically acceptable to override a refusal of treatment (see Card 4 on consent and refusal), in principle there cannot be an absolute prohibition on the use of force to carry it out. However, doctors must look at the patient’s overall interests, and whether imposing treatment is a proportionate interference given the expected benefits.

 

What factors should be taken into account when considering the use of restraint?

Doctors should consider if imposing treatment could damage the young person’s current and future relationships with health care providers and undermine trust in the medical profession. It is important for young people to understand that restraint of any form in order to provide treatment is used only as a matter of last resort and not until other options for treatment have been explored.

The child and the family must be offered continual support and information throughout the period of treatment.

If, after spending as much time as is practicable, it is impossible to persuade a child to cooperate with essential treatment, the clinician in charge of the patient’s care may decide that restraint is appropriate.

The following points are relevant to any action taken:

  • Restraint should be used only when it is necessary to give essential treatment or to prevent a child from significantly injuring himself or herself or others.
  • The effect should be to provide an overall benefit to the child and in some cases the harms associated with the use of restraint may outweigh the benefits expected from treatment.
  • Restraint is an act of care and control, not punishment, and should be administered with due respect.
  • Unless life prolonging or other crucial treatment is immediately necessary, legal advice should be sought when treatment involves restraint or detention to override the views of a competent young person, even if the law allows doctors to proceed on the basis of parental consent.
  • All steps should be taken to anticipate the need for restraint and to prepare the child, his or her family, and staff.
  • Wherever possible, the members of the health care team involved should have an established relationship with the child and should explain what is being done and why.
  • Treatment plans should include safeguards to ensure that restraint is the minimum necessary, that it is for the minimum period necessary to achieve the clinical aim, and that both the child and the parents have been informed what will happen and why restraint is necessary.
  • Restraint should usually be used only in the presence of other staff, who can act as assistants and witnesses.
  • Any use of restraint should be recorded in the medical records. These issues are an appropriate subject for clinical audit.

 

Who is responsible for the decision to use restraint?

Members of the health team should be given an opportunity to express their views and to participate in decision-making, although ultimate responsibility rests with the clinician in charge of care. All staff require support, and must not be asked to be involved in restraining a child without proper training.

 

Can children and young people be detained to provide medical treatment?

Detaining children for the purpose of providing medical treatment raises serious legal issues.

Legal advice is essential before children are detained outwith the provisions of mental health legislation, and court approval will be necessary. A court asked to rule on such an issue is required to have regard to the young person’s rights under the Human Rights Act 1998, and whether, in the circumstances, detention is compatible with these. For example, the right not to be subjected to inhuman or degrading treatment (Article 3), the right to liberty and security (Article 5), and the right to a fair hearing (Article 6).

 

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Card 7: Use of restraint to provide treatment (PDF)