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Threats and offers in community mental healthcare
  1. Michael Dunn1,
  2. Daniel Maughan2,
  3. Tony Hope1,
  4. Krysia Canvin3,
  5. Jorun Rugkåsa3,
  6. Julia Sinclair4,
  7. Tom Burns3
  1. 1The Ethox Centre, University of Oxford, Oxford, UK
  2. 2Oxford Health NHS Foundation Trust, Oxford, UK
  3. 3Department of Psychiatry, University of Oxford, Oxford, UK
  4. 4School of Medicine, University of Southampton, Southampton, UK
  1. Correspondence to Dr Michael Dunn, The Ethox Centre, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK; michael.dunn{at}


Making threats and offers to patients is a strategy used in community mental healthcare to increase treatment adherence. In this paper, an ethical analysis of these types of proposal is presented. It is argued (1) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health because the nature of these duties will enable a threat to be differentiated from an offer, (2) that threatening to act in a way that would equate with a failure to uphold the requirements of these duties is wrong, irrespective of the benefit accrued through treatment adherence and (3) that making offers to patients raises a number of secondary ethical considerations that need to be judged on their own merit in the context of individual patient care. The paper concludes by considering the implications of these arguments, setting out a pathway designed to assist community mental healthcare practitioners to determine whether making a specific proposal to a patient is right or wrong.

  • Clinical ethics
  • competence/incompetence/attribute
  • mentally ill and disabled persons
  • sociology
  • psychiatry
  • medical ethics
  • resource allocation
  • substance abusers/users of controlled substances

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  • Funding NHS National Institute of Health Research (NIHR). Grant number RP-PG-0606-1006. The views expressed here are those of the authors and do not necessarily reflect those of the NIHR.

  • Competing interests None.

  • Patient consent The paper is theoretical and does not involve patients.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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