By Mirjam Faissner and Esther Braun.
William is a Black student with chronic schizophrenia under voluntary treatment in a German psychiatric hospital. The night before his death, William experiences a mental health crisis: he is screaming loudly, shadow boxing, lashing out. The doctors on the ward judge him to be a danger to himself and others. William is offered calming medication, which he refuses. The next morning, William leaves the ward to smoke a cigarette and sits on a bench outside the hospital entrance. Three guards approach him to accompany him back to the ward. As William refuses, the security guards use force. Later, several witnesses will report that the security men were brutal, sitting on him three at a time, and restraining him in prone position. William loses consciousness, is reanimated and dies in the ICU 5 days later.
The case is not fictional: William Tonou-Mbobda died on April 26, 2019 in the Medical Center Hamburg-Eppendorf, Germany. The attending physician and three security staff members were investigated on charges of bodily injury resulting in death. In 2021, one and a half years after William Tonou-Mbobda’s death, the public prosecutor’s office dropped the investigation, stating that there was no indication of either racist motives or an excessive use of violence by the security guards. A coalition of self-organized groups including Black Community Hamburg are still fighting the discontinuation of the criminal investigation today.
On August 8, 2022, Mouhamed Lamine Dramé was shot in Dortmund, Germany by a police officer with a machine gun. The 16-year-old refugee from Senegal had been in psychiatric care just days before. On the day of his death, a social worker had called the police after Mouhamed Lamine Dramé had exhibited suicidal behavior, holding a knife and stating his intention to end his life. It was later stated that police were unable to communicate with him. After pepper spray and tasers were used, one officer hit Mouhamed Lamine Dramé with four shots. He died in the hospital shortly afterwards. Five of the twelve police officers involved in the operation are now facing criminal charges.
The cases of William Tonou-Mbobda and Mouhamed Lamine Dramé are different in many ways. What the two cases have in common is that they both died in contact with German institutions, both had mental health struggles and were experiencing acute psychological distress, both died while seeking mental health support, and both were male, young and Black.
In recent years, psychiatry has increasingly confronted its racist past and present. Empirical studies demonstrate the disproportionate use of coercive measures against Black people. They are more than twice as likely to be compulsorily admitted to psychiatry than White people and are at a significantly higher risk of being restrained while hospitalized. Such coercive measures have potentially severe consequences for people with mental illness, including psychological trauma, the possible loss of trust in the mental healthcare system, physical injury and death. As a consequence, the use of any coercive measure requires thorough ethical justification.
In our recent article, we examine the standard justification for coercion in psychiatric ethics in the context of structural racism. As two White female medical ethicists, our initial motivation to investigate the relationship between structural racism and coercion stems from our experiences during medical training. In this context, we have witnessed both everyday instances of racism as well as institutional racism embedded in psychiatric practices. These experiences have shaped our belief that psychiatric ethics needs to provide discrimination-critical tools for ethical analyses.
In our article, we attempt to contribute to this task by showing the limits of the standard ethical framework used to justify coercion in mental healthcare when it is applied to cases shaped by structural racism. We first show that the standard ethical criteria used to assess instances of coercion are susceptible to racist biases. Second, we argue that the standard framework fails on a more fundamental level because it ignores how structural racism may lead to situations in which coercion is used. We argue that mental health ethics must begin to systematically take structural discrimination into account – starting by, for example, integrating the contributions already made by Black bioethics. Our article aims to provide a starting point for a debate on context-sensitive and discrimination-critical conceptual tools within mental health ethics.
 We capitalize the term “Black” to highlight that it refers to a social position and to acknowledge its use as a political self-identification. We choose to also capitalize “White” to highlight White as a social position and avoid framing Whiteness as a neutral standard.
Authors: Mirjam Faissner and Esther Braun
MF: Department of Psychiatry, Psychotherapy and Preventive Medicine, Ruhr University Bochum, Bochum, Germany; Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
EB: Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
Competing interests: None declared.