Mental health care often involves tension between two duties: respecting a person's autonomy and liberty and protecting the person or others from harm. Law and ethics set the limits of when care can be given without consent.

Ethical principles

Key concepts

• Mental illness does not equal incapacity. People with mental illness, including those admitted involuntarily, keep their civil rights (voting, marriage, contracts, religion, communication, humane treatment) unless a court rules otherwise.
• Decision-making capacity is a clinical judgment about a specific decision at a specific time. Competence is a legal determination made by a court; a person found incompetent may be assigned a guardian.
• Least restrictive environment: care should be delivered in the setting and manner that limits freedom as little as possible while keeping the person safe — community before hospital, open unit before locked unit, verbal de-escalation before medication, medication before restraint.

Assess and document

• Legal status (voluntary or involuntary) and what rights apply
• Decision-making capacity for each major decision
• Risk of harm to self, harm to others, or grave disability (inability to meet basic needs for food, clothing, shelter, safety)
• Presence of an advance directive (including a psychiatric advance directive), health care proxy, or guardian
• Understanding of rights, treatment, and consent
• Threats against identifiable people (duty to protect)

Rights of psychiatric clients (general US pattern; details vary by state)

• Right to treatment and to humane care in the least restrictive setting
• Right to refuse treatment, including medication, except in an emergency or after a legal process (court order or administrative review)
• Right to confidentiality and access to one's records (with some exceptions)
• Right to communicate (phone, mail, visitors) unless restricted for documented clinical reasons
• Right to legal counsel and hearings on involuntary commitment
• Right to be informed of rights on admission, in understandable language

Types of admission

Seclusion and restraint (US hospital rules — CMS Conditions of Participation)

• Used only to ensure the immediate physical safety of the client, staff, or others, when less restrictive interventions have failed; never for coercion, discipline, convenience, or retaliation
• Restraint = any manual method, physical or mechanical device, or drug used as a restriction (not a standard treatment dose) that limits movement; seclusion = involuntary confinement alone in a room the client is prevented from leaving
• Requires an order from a physician or other authorized licensed practitioner; never a standing or PRN order
• Orders for violent or self-destructive behavior are time-limited and may be renewed: 4 hours for adults 18 and older, 2 hours for ages 9–17, 1 hour for children under 9, up to 24 hours before the practitioner must see and assess the client in person
• Face-to-face evaluation within 1 hour of initiation by a physician, licensed practitioner, or specially trained registered nurse or physician assistant (who then consults the responsible practitioner)
• Use the least restrictive method and end at the earliest possible time, when the client meets release criteria, even if the order has not expired
• Continuous monitoring; simultaneous restraint and seclusion requires continuous in-person or audio-video monitoring
• Deaths associated with restraint or seclusion must be reported (CMS rules)
• The same principles apply in general hospital units (see Fundamentals restraint content): alternatives first, least restrictive, regular assessment of circulation and skin

Listed in priority order.

1. Safety with least restriction — use verbal de-escalation, reduced stimulation, choices, and voluntary time-out before seclusion or restraint
2. When restraint or seclusion is used
   • Obtain a timely order; follow agency and legal time limits
   • Continuously observe; monitor vital signs, airway and breathing (never restrain prone or with pressure on the back or neck), circulation and skin in restrained limbs, hydration, nutrition, toileting, and range of motion per policy
   • Explain the reason and the behavior needed for release; release as soon as criteria are met
   • Debrief the client and staff afterward to prevent recurrence
   • Document behavior, less restrictive measures tried, client response, monitoring, and release
3. Informed consent — confirm the client received information about purpose, risks, benefits, and alternatives, understood it, and agreed voluntarily; clients may withdraw consent
4. Protect confidentiality — share information only with those involved in care or as allowed by law; confirm identity and authorization before speaking with family
5. Duty to protect (Tarasoff) — report any threat against an identifiable person immediately to the treatment team and provider; document the client's words. Under the Tarasoff decision (California, 1976), a clinician who determines that a client poses a serious danger of violence to an identifiable victim must take reasonable steps to protect that person (warning the victim, notifying police, or hospitalizing). State laws vary (mandatory, permissive, or none)
6. Advocate — ensure clients know their rights, can contact attorneys and advocates, and have access to grievance processes
7. Report suspected child or elder abuse and unsafe or impaired practice by colleagues as required

Common legal risks (torts)

• Explain legal status, rights, and how to request discharge or a hearing
• Explain limits of confidentiality at the start of care
• Encourage psychiatric advance directives and naming a trusted person to help with decisions during a future crisis
• Inform clients about grievance and advocacy services

• People with mental illness keep civil rights; involuntary admission is not a finding of incompetence
• Capacity (clinical, decision-specific) vs. competence (legal, court-determined)
• Least restrictive intervention always; restraint is a last resort for immediate physical safety
• No PRN or standing orders for restraint or seclusion
• CMS order limits: 4 h adults, 2 h ages 9–17, 1 h under 9; renew up to 24 h; face-to-face within 1 hour
• Release restraints as soon as the client meets criteria; debrief afterward
• Involuntary criteria: danger to self, danger to others, grave disability
• Tarasoff: duty to protect an identifiable potential victim
• Forced treatment without authority = battery; unlawful detention = false imprisonment
• Clients may refuse medication except in emergencies or by legal process
• Informed consent requires information, understanding, capacity, and voluntariness