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Ethical concerns about methods in psychiatry have been discussed for at least three centuries. 1 Methods used for controlling behaviour, such as seclusion and restraint, have been particularly questioned. 2 3 A consensus, concerning an optimal theoretical framework for ethical decision-making, has not yet been reached. 4 Until the 1960s mental health legislation reflected a paternalistic approach towards involuntary psychiatric treatment, including seclusion, and this was considered to be acceptable in the case of patients who were incompetent to decide. 5 In the last 40 years we have witnessed a development towards more patient autonomy in healthcare. 6 This has resulted in renewed discussions about the use of seclusion and restraint in psychiatry. 7 New legislation, recommendations and professional guidelines to control the use of coercive measures in psychiatry have since then emerged. 8 In recent literature many institutions, associations and hospitals have come up with programmes to reduce seclusion and restraint. 5 9 - 13 The reasons named to substantiate the need for reduction of seclusion and restraint are: respect for autonomy, human dignity and the net negative consequences in the sense of traumatic and harmful experiences during seclusion and restraint. At the same time coercion remained justified in certain circumstances in which patients are a danger to others or to themselves. 9 14 - 17 Some go further and committed themselves to eliminating the use of seclusion and restraint completely. 12 18 The contribution this paper wants to make is to discuss whether we can justify not using coercive measures at all, especially seclusion.
BACKGROUND
Definition and prevalence
There are a number of definitions for seclusion in the international literature. Lendemeijer has formulated the following definition after reviewing the literature on seclusion in psychiatry: "Locking a patient alone in a room for protection of the patient and his environment and in order to control problem behaviour and to enable nursing and treatment". 7 Patients can voluntarily choose to be secluded, however this paper will address involuntarily use of seclusion. The definition above implies that seclusion itself is not a form of treatment but an intervention to make treatment possible. Some people even see the use of seclusion and restraint as treatment failure. 11 12 Some articles do, however, describe therapeutic effects of seclusion;...