Ethical issues in the use of electronic monitoring (Global Positioning System ‘tracking’ technology) in forensic mental health settings

Abstract

Electronic monitoring (‘tracking’) of individuals has been used in the UK criminal justice system for over three decades, and its use is increasing. Electronic monitoring has more recently been implemented in forensic psychiatric services, which has generated considerable debate about the appropriateness of its use in clinical settings, and about legal and ethical concerns. The purpose of this article is to formally address the ethical issues that arise from using electronic monitoring in forensic psychiatry. These issues are considered using the Four Principles approach to medical ethics, namely autonomy, beneficence, non-maleficence, and justice. We conclude that by adopting a patient-centred approach, where informed consent is sought, and the patient's best interests remain central to the decision-making process, electronic monitoring is both ethical and justifiable. More robust studies are required to develop standardised clinical guidelines for the use of EM in forensic psychiatry, and to apply the theory of patient-centred, consent-driven care to practice.

Keywords

Forensic psychiatry medical ethics technology electronic monitoring leave violation medium security

Introduction

Electronic monitoring (EM), more colloquially referred to as ‘tracking’, or, erroneously, as ‘tagging’, has been used in the criminal justice system (CJS) for over 30 years. There, it serves as a means of enforcing conditions imposed by courts or prisons on offenders.^1,2 EM involves tracking the whereabouts of individuals using surveillance technologies. Initially, radio frequency (RF) technology was most commonly used; however, in recent times, Global Positioning System (GPS) technology has become the standard approach, given the greater flexibility it allows.^3–5 The rationale for use of EM in the CJS is to reduce recidivism, preventing rearrest and recall to prison, and to facilitate early release from prison.⁶ More recently, it has been trialled as a means of managing behaviour in prison leavers, serving as an alternative to prison recall.⁷ Tracking devices work by monitoring curfew requirements and/or the wearer's location to enforce predetermined restrictions related to the wearer's risk, including set exclusion zones.

Use of EM (especially GPS technology) in the UK CJS has increased steadily since its introduction in 1999.⁸ From March 2017 to September 2025, the number of individuals fitted with an EM device increased by 132% from 14,490 to 26,647.^9,¹⁰ Correspondingly, the effectiveness of EM has been increasingly called into question,^11,12 with many arguing that its increasing use is instead primarily motivated by political and commercial gain. Evidence for the impact of EM in the CJS on rates of recidivism is limited, with most studies failing to demonstrate a significant benefit. For instance, a systematic review carried out in 2005 ‘failed to find any convincing evidence that EM is superior to other prison diversion programs’.¹³ Similarly, a more recent meta-analysis (18 studies) found that the reduction in re-offending rates through using EM was not statistically significant.¹⁴

In stark contrast, a national cost–benefit analysis conducted in the USA demonstrated that EM could save over US$400 billion annually and prevent more than 780,000 crimes.¹⁵ In comparison to the estimated cost of implementation (∼US$37.9 billion), this estimate would strongly suggest that the benefits of EM outweigh the limitations. More recently, a group in Sweden showed that, as well as reducing criminal recidivism, EM also increases labour supply by preserving offenders’ attachments to the labour market, resulting in benefits for the wider economy.¹⁶ This is supported by a further study, which demonstrated that early release from prison with EM was associated with a decrease in NEET (not in employment, education, or training) status, especially for individuals with limited labour market attachment prior to incarceration.¹⁷ Together, this literature illustrates the importance of applying a wider perspective in consideration of the pros and cons of EM.

EM in forensic mental health services

EM has been used in healthcare settings for decades, primarily as a means of managing wandering in people with dementia,¹⁸ and increasingly in other settings, for instance, to monitor inhalation technique in patients with asthma.¹⁹ Following several incidents of patients violating leave permissions, EM was trialled in a forensic psychiatric unit in 2010.^20–22 The rationale was to reduce risks arising from leave from forensic hospitals, which is an essential step on the pathway towards discharge. Comparing leave granted and leave violation before the introduction of EM, and then at two follow-up periods in the succeeding two years, the total number of leave episodes increased by almost 60%, as did the ratio of unescorted to escorted leave, with the proportion of the former increasing from 28.1% to 60% after EM was in place.²³ A further study, in the same setting, compared average total cost per patient with and without EM, and found no significant difference in cost, providing cautious support for its use.²⁴

The implementation of EM in a forensic setting generated extensive debate, with many raising concerns about legal and ethical issues.^25,26 Since this time, while EM has not become a standardised or legally regulated practice amongst forensic psychiatric services, it has continued in forensic settings in the UK (though on making Freedom of Information requests to each MSU in the UK, of those that replied, only two units are currently using EM (personal correspondence)). At a global level, other countries that have trialled EM in forensic psychiatry include the Netherlands, Sweden, Poland, Canada, Australia, and New Zealand. As in the UK, its introduction triggered considerable debate in other countries. The Royal Australian and New Zealand College of Psychiatrists concluded that it is coercive and instead advocated for alternative methods of risk management.²⁷ Similarly, after commissioning three reports into the clinical and legal issues related to EM, the provincial government of Nova Scotia in Canada banned the practice.²⁸ In Europe, Poland uses EM following release from a forensic psychiatric hospital, which differs from Germany, Sweden, and the Netherlands, who instead rely on close supervision.²⁹ The use of EM continues to face criticism, with a recent qualitative study examining staff attitudes in a forensic MSU finding it was felt by some to be ‘invasive’, ‘overly restrictive’, and ‘excessively punitive’.³⁰

Legal issues relate to both mental health law and human rights and have been discussed in detail elsewhere.³¹ This article will focus specifically on ethical issues that arise from the use of EM in forensic psychiatry.

Ethical objections to EM

As well as concerns specific to use of EM in psychiatric settings, there are several ethical objections to the general use of EM. These primarily focus on concerns about privacy, autonomy and disproportionate punishment, with references to an ‘Orwellian society’, where people's lives are subject to totalitarian control and widespread surveillance, and where the line between incarceration and freedom is blurred.^32,33 Critics argue that EM shifts the burden of responsibility onto families and communities³⁴ and may exacerbate social inequalities by negatively affecting those who lack the resources to comply with requirements, that is, stable housing or access to electricity.^35,36 Furthermore, the collection, storage, and use of personal data is repeatedly highlighted as a concern,^37,38 undermining personal privacy and resulting in a form of ‘digital incarceration’.³⁹ These factors are all especially relevant to forensic populations, whose privacy and autonomy are already subject to extensive restrictions and monitoring. Similarly, concerns surrounding capacity in specific populations, including dementia,^40–42 are also applicable to forensic patients, who have disproportionate rates of cognitive impairment and early onset memory problems.^43–45

The ‘four principles’ approach in medical ethics

There is no standardised approach to ethical decision-making in clinical settings. One ethical approach with potential utility for clinical decision-making is the ‘Principlist’ approach.⁴⁶ This uses a framework of four universal and basic ethical principles: autonomy, nonmaleficence, beneficence, and justice. It was initially developed and introduced by Beauchamp and Childress⁴⁷ in their seminal work ‘Principles of Biomedical Ethics’, whose influence persists today. The principlist approach offers a structured and straightforward framework for addressing ethical issues in clinical settings, circumventing the need for formal or in-depth ethics training. It is therefore especially useful for individuals, such as clinicians, who are required to make difficult, often time-sensitive decisions. Accordingly, its utility for decision-making across forensic psychiatric services has been explored in some depth.^48–50 Proponents of this approach suggest that these four key principles in particular provide a basic common moral language and analytic framework that can be interculturally and internationally accepted, avoiding both moral relativism and moral imperialism.^51,52

Applying the four principles to EM in forensic psychiatry

1. Autonomy

Autonomy refers to an individual's right to make rational decisions and choices, capturing the moral requirement that each person should be allowed to exercise his or her capacity for self-determination.⁵³ It is the basis for informed consent, truth-telling, and confidentiality. In conflict with autonomy are the concepts of coercion and the nature of consent in psychiatry. These are complex issues, especially in secure forensic settings, where patients are legally obliged to stay. Coercive measures include formal coercion, such as actions limiting freedom of movement, as well as informal coercion through manipulation of a patient's decisions.⁵⁴ Determining what counts as coercion in psychiatry and if or when it is ever justifiable has been discussed extensively elsewhere.⁵⁵ Although, on the surface, coercion may be perceived straightforwardly as the antithesis of autonomy, there is a more subtle tension here, which lies in determining whether short-term restrictions on autonomy are ethically justified when they are framed as a pathway to greater long-term autonomy.

Considering coercion in the context of EM, professionals in favour of utilising EM in forensic psychiatry argue that (with the exception of high-risk patients requiring emergency hospital or court transfer) no patient is forced to wear a monitoring device without informed consent, therefore making it a justifiable intervention. The forensic unit that first implemented EM sought informed consent (both verbal and written) prior to any patient wearing a monitoring device for standard leave from hospital.⁵⁶ The decision to grant leave is made through careful clinical risk appraisal, with subsequent approval required from the Ministry of Justice in many cases. Consequentially, at baseline, patients have little autonomy in relation to decisions about leave. However, given the above study found that the use of EM resulted in more leave being given, it is arguable that EM could provide a means to enhance patients’ autonomy around decisions related to leave, as well as enabling greater freedom of movement. For many forensic patients, the alternative to EM, especially in the earlier stages of time in hospital, is escorted versus unescorted leave, or no leave at all, and therefore arguably a greater infringement on autonomy than use of EM.

Many have questioned the meaningfulness of consent to being monitored by EM. The key question may be framed as ‘Is abiding by the recommendations of the clinical team, in the knowledge that leave could be jeopardised by not doing so, true consent, or simply a form of coercion?’. If the latter is the case, EM would in reality be predominantly coercive, even if technically ‘consented’ to in a formal way. It also has the potential to jeopardise the therapeutic alliance by undermining the clinical team's trust in a patient to respect agreed parameters of leave, to reinforce paranoia and delusions about surveillance (see below), and to reduce an individual's sense of agency.

It is important to acknowledge that patients’ decisions are undoubtedly influenced by wanting to progress towards leave and ultimately discharge. Clinicians need to be aware that for many patients, there will likely be a degree of assent, whether this applies to taking medication, engaging in psychological therapies, or wearing a monitoring device. Assent is a further complex concept in applied ethics, and has been discussed extensively elsewhere.⁵⁷ In short, assent refers to an individual's broad agreement to engage in a particular process or procedure. It is often used in situations where the individual does not have the legal capacity to provide fully informed consent. In relation to EM, it may be that the term assent is more appropriate to the patient decision-making process, and this should be factored in to weighed decisions about the ethical basis of EM.

Confidentiality is another factor related to autonomy, and concerns about patient confidentiality in the context of EM have been highlighted. Following the introduction of GPS technology in healthcare, Michael et al.⁵⁸ raised important questions about the ownership of the data collected, for which no clear legislation exists, and the potential breach in patient confidentiality through the involvement of private sector companies. In forensic settings, there remains a lack of transparency about who has access to the data, how long the data is retained, and the extent it might be used for purposes beyond its original intention, such as by the CJS or third-party sharing.⁵⁹ Further, any forensic psychiatric patients who have spent years in institutional settings may understandably have limited technological literacy^60,61 and thus may not fully understand the implications of the collection of EM data. Taken together, these concerns emphasise the importance of clear and effective communication with patients about the implications of data collection using EM.

2. Beneficence

Beneficence refers to the obligation of clinicians to act for the benefit of their patients. Under this principle, decisions made in relation to patient care must always be made in the patient's best interests. This becomes complicated in forensic psychiatry, where there is an inherent conflict between the best interests of the patient and public protection.^62,63 Considering this conflict in the context of EM, it is important to establish the rationale for its use and who it benefits. As with many interventions in forensic services, there is a risk that the balance between patient benefit and public protection becomes lost. In the CJS, given that EM primarily serves as an alternative to incarceration, a punitive component to its use may be acceptable. Conversely, in forensic services, while protection of the public is a key consideration, the ostensible primary justification of EM is that it serves to enhance clinical progression and aid rehabilitation. In the study where EM was first introduced in a forensic setting, though preliminary in design, there was a reduction in episodes of leave violation with the use of EM.⁶⁴ This was only statistically significant for the second follow-up period, which the authors suggested was likely due to the scarcity of LV incidents and/or growing proficiency of clinical staff in targeting those patients most likely to benefit from EM.⁶⁵ Further studies, ideally prospectively designed, are required to establish clearer links between EM and its impact on leave.

A particular concern about EM is that it may become a tool at the disposal of forensic practitioners prone to overstepping the boundaries between clinician and ‘enforcer’. In such instances, there is a risk that EM would be unjustifiably used, or used for too long, in patients where therapeutic relationships are suboptimal, or where there are unjustified concerns about the nature of, or extent of risk, based on clinician and system biases. There is a distinct lack of validated tools to assess risks of granting leave in forensic services, and so there is a danger of a given patient being ‘doubly punished’ by both restricted access to leave, and subsequently restricted access to leave without EM. In contrast, proponents may again argue that EM may abate clinician concerns in relation to leave. This may expedite leave in those who are generally the most at risk of violating leave or inappropriate behaviour while on leave.

Opponents of the use of EM have also raised concerns about its long-term impact. Simpson and Penney⁶⁶ argue that EM simply delays reoffending as opposed to aiding rehabilitation. However, important distinctions between reoffending and rehabilitation need to be considered. Firstly, concerns about offending following a period of EM – after which a sense of false reassurance could take hold among clinicians – are valid. But, given that leave is broadly seen as having therapeutic benefits, it is also feasible that the risk of such offending would indeed be reduced at this stage, in which case EM would be seen to be a good example of ‘positive risk-taking’, with patient benefit. In contrast, if rates of offending transpire to be similar with or without the use of EM, this would have both ethical and cost implications for services. Secondly, it may be that EM has a positive impact in reducing offending, but no impact on clinical progress, in which case there is a still a net overall gain for both the patient and the service. Contrarily, it is also possible that EM may have a negative impact on wider clinical progress, for example, causing a deterioration in psychotic features in a patient who was not in fact ready to obtain leave. Reasons for this possible outcome are discussed further in section 3.

Further well-conducted research projects are required to clarify the impact of EM on offending and clinical trajectories, ideally over longer follow-up periods. In samples of prisoners, many of whom have similar clinical profiles to forensic inpatients, a meta-analysis of 18 studies demonstrated that the overall effect of EM on recidivism was favourable for certain offenders (sex offenders), at certain points in the criminal justice process (post-trial as an alternative to prison), and in combination with other conditions (such as geographical restrictions) and therapeutic components.⁶⁷ This emphasises the importance of a granular approach to examining these issues. It may be that there are positive effects of EM only in certain subgroups of patients, or only in specific circumstances, highlighting the importance of considering well-informed, individualised approaches in relation to EM.

3. Non-maleficence

In contrast to beneficence, which calls for physicians to actively seek good for their patients and promote their welfare, non-maleficence simply refers to the avoidance of harm. This requires clinicians to weigh up the advantages with the potential disadvantages of all interventions and treatments. The complexity in forensic psychiatry lies in: (a) whose judgement of the harm suffered should be prioritised – a violent patient may view the use of sedating drugs as unjustified, whereas staff would think the opposite – and (b) whose claim to protection is more important, which is to say that of the patient or the public. In the context of granting leave, for example, by not facilitating leave (where deemed appropriate following careful risk assessment) and therefore accelerating a patient's recovery, this could be viewed as detrimental to the patient and the clinical team failing to adhere to the principle of non-maleficence. However, it also raises the unavoidable question of whether it would be justified and the principle be upheld if the rationale for not permitting leave was one of public protection – that is, non-maleficence towards the public. In the context of a risk-averse culture, with genuine concerns about risk occasionally heightened by tragic outcomes, external pressures may unduly weigh decision-making in this direction.

Concerns have also been raised about the impact on the service user of wearing an EM device. These include symptom exacerbation, especially as delusions about surveillance are common amongst this population.⁶⁸ In a study focused on the mental health impacts of EM of migrants, those monitored described the feeling of being constantly watched and perceived as a ‘dangerous’ person in public spaces.⁶⁹ Careful monitoring of any impact of EM on clinical symptoms, especially in those with psychotic disorders, is likely to be an important factor in judicious use. Another major concern is the risk of increasing stigma. Stigma is already a significant problem for those engaged in forensic psychiatric services.⁷⁰ It leads to anger and alienation⁷¹ and has been shown to negatively impact treatment and recovery,⁷² in addition to overall care quality.⁷³ Use of EM in forensic patients results in patients potentially being subjected to two highly stigmatised labels; namely, mental illness and, due to the public understanding of electronic bracelets, that of a criminal history.⁷⁴ Therefore, visibility of any devices used is an important factor to consider. Electronic wrist bracelets, widely adopted by the public for exercise or health-related monitoring, are currently being trialled in some prisons, and their better wearability may resolve the issues discussed above.⁷⁵ Slimmer, lighter devices may be preferable, but would need to be designed according to security requirements and are likely to have cost implications. Studies assessing patient's experiences of wearing different EM devices whilst on leave would enable clinicians to better understand the implications of EM in relation to stigma and patient discomfort.

4. Justice

Justice refers to the fair and equitable treatment of individuals. In clinical settings, the relevant categories include, but are not limited to, distributive justice – the fair distribution of healthcare resources; rights-based justice – respect for people's rights and prohibition of discrimination; and legal justice – adhering to the law.

In the majority of medical specialities, justice is most often discussed in the context of resource allocation and access to healthcare. In forensic psychiatry, however, dilemmas arise in balancing competing claims to justice of patients, staff members, and the public when making clinical decisions.⁷⁶ Patients may perceive that an injustice is being done to them by being made subject to compulsory and/or coercive treatment, while staff may argue for justice in the form of protection from serious assaults, and members of the public may argue for justice in reduction of risk of wider offending. The challenge for the forensic psychiatrist lies in establishing whose claim for justice to prioritise, given their duty to third parties. Forensic psychiatrists have emphasised the role of justice in guiding ethical decision making, stating it to be the broadest and fairest principle for both patients and society.^77–79

In the context of EM, the principle of justice would require that:

EM should be applied without discrimination for race, gender, socioeconomic status, or psychiatric disorder.

Patients subjected to EM are not disproportionately burdened compared to others in similar circumstances.

The use of EM is proportionate to the risk posed and not overly restrictive.

With respect to (a), concerns have been voiced about the negative impact it may have on Black and Minority Ethnic groups, who are both overrepresented and have higher rates of being subject to restrictive practice.^80,81 If EM were to be disproportionately applied to these groups, it would risk compounding these factors. Furthermore, as monitoring devices have typically been designed for men, healthcare professionals need to be conscious of the fact that women may be affected differently.⁸² In the offender population, a study that analysed the experience of EM by sex found that, in comparison to men, women were less supported, and their relationships were negatively affected.⁸³ In another qualitative study exploring women's experiences of EM, devices were seen as particularly embarrassing to wear because they signified ‘male punishment’ and portrayed them as more serious offenders than they believed themselves to be.⁸⁴ Although women represent a minority in both forensic services and the CJS (about 6%–10%),⁸⁵ future studies should consider how experiences may vary by sex.

The fact that EM is neither legally regulated nor widespread in forensic services in the UK creates several challenges in relation to points (b) and (c) above. Exploring differences even between Medium Secure Units (MSUs) that have implemented EM (personal correspondence), there was a lack of any standardised process for making decisions, meaning that use of EM risks being subject to the ‘postcode lottery’ effect. A non-standardised approach risks inconsistencies and disparities in the use of EM, allowing prejudices and inaccurate impressions about risk unfairly influencing decisions. It also risks use of EM as a ‘blanket’ measure that loses sight of its role in safety and rehabilitation. Concerns about the inappropriate and/or unnecessary use, given the absence of guidelines, have been raised by staff in a service evaluation.⁸⁶ At the same time, there must be scope for decisions to be made as part of individualised care plans. Applying a decision-making tool that is too rigid risks limiting more targeted and effective use of EM as an intervention.

Challenges and limitations of the four principles approach

Given that; (i) ethical theories are often more complex and abstract than a framework, (ii) that a thorough understanding of each theory requires a similarly thorough understanding of the theories that conflict with it, and (iii) the use of EM is determined by often time-pressured clinicians without formal ethics training, we argue that principlism is the most appropriate framework for presenting the ethical issues associated with EM outlined in this article. However, the application of principlism can be challenging. This is due to potential conflicts between principles, the complexity of individual cases and the contexts to which they are applied, and the issue of balancing the rights of individuals with those of society, the latter of which is especially relevant in forensic psychiatry.

For instance, the lack of clear guidance about the weighting of the four principles presents an ethical dilemma. Beneficence is typically favoured as the main ethical underpinning in medicine, forming the basis of most medical codes of conduct. However, in prioritising one principle over the others, the role of the latter becomes ambiguous,⁸⁷ and can lead to widley divergent outcomes and interpretations.⁸⁸ Critics of principlism argue that rigidity of the framework fails to address the complexity of patient-clinician relationships, legal and moral dilemmas, and it may also fail to address the vulnerabilities of those involved in the CJS. Others suggest that, instead, a relational, contextual and more compassionate approach should be adopted in the context of ethical decision-making in forensic psychiatry.^89,90

The application of any ethical framework to guide ethical decision making comes with the disadvantage of lacking contextual sensitivity, which can result in oversimplifying what is, in fact, likely to be a complex situation, with ethical obligations possibly in conflict. Such situations, therefore, require careful reasoning towards arriving at a finely balanced judgement. By contrast, ethical theories, whether deontological, utilitarian, or virtue-based, for example, provide underlying, albeit conflicting, rationales for making ethical decisions based on a particular view about what does and does not take priority, morally speaking, and why. Although each is partisan, these theories have a deep, comprehensively thought out and well-defended justificatory basis. This means each is, or at least the defenders of each would say, amenable to application in many different scenarios, and will produce clear action-guiding conclusions and solutions to the dilemmas presented by those scenarios if the theory is properly applied.

Conclusions

The increasing use of EM in the CJS and healthcare settings, and its introduction into forensic psychiatry, presents significant ethical challenges. These concerns primarily focus on the justification for its use, the potential for coercion, and ensuring fairness and transparency in its application. In forensic psychiatry, where patients are legally required to stay, coercion and consent are especially complex issues. While EM can enhance autonomy by enabling leave and promoting rehabilitation, it also raises concerns about informed consent, confidentiality, and the impact on therapeutic relationships. We believe that increased emphasis should be placed on the use of EM as an adjunct to improve risk management strategies and ultimately patient outcomes. We argue against any use of EM as an undue restriction and against its use as any form of punishment. Further, robust data governance frameworks and transparent patient education are required to ensure EM is not coercive.

There is an ongoing need for robust, well-designed studies demonstrating the effectiveness of EM. Research involving patient groups is required to shed light on the experience of being monitored. Services and patients would benefit from clear policies that are well-informed and consistent at a service level, but allow for sufficient flexibility to apply to individualised therapeutic and risk management strategies. These would not only aid decision-makers, but also ensure their use is appropriate and judicial.

Overall, we advocate using EM in forensic psychiatry to contribute to structured reintegration into society while maintaining public safety, but call for implementation with strong ethical safeguards. The Four Principles approach allows for a pragmatic but theoretically sound basis for decision-making about the use of EM in forensic settings. We believe a code of ethics using this approach would have the most utility for forensic services, and the greatest potential benefit for patients.

Footnotes

ORCID iD

Georgia Ashworth

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Belur

Thornton

Tompson

, et al. A systematic review of the effectiveness of the electronic monitoring of offenders. J Crim Justice 2020; 68: 101686.

GOV.UK. Electronic monitoring in the Criminal Justice System; GOV.UK. Retrieved from: https://www.gov.uk/government/publications/electronic-monitoring-in-the-criminal-justice-system/electronic-monitoring-in-the-criminal-justice-system. 2023.

Bales

Mann

Blomberg

, et al. A quantitative and qualitative assessment of electronic monitoring. In: Report submitted to the Office of Justice Program, National Institute of Justice, US Department of Justice. Florida: The Florida State University, 2010.

Geoghegan

. Future of corrections: exploring the use of electronic monitoring. London, UK: Policy Exchange, 2012. Retrieved from: https://policyexchange.org.uk/publication/future-of-corrections-exploring-the-use-of-electronic-monitoring/.

GOV.UK. Equality impact assessment: Transition from radio frequency to GPS Electronic Monitoring Devices; GOV.UK. Retrieved from: https://www.gov.uk/government/publications/offender-management/equality-impact-assessment-transition-from-radio-frequency-to-gps-electronic-monitoring-devices. 2025.

Hucklesby

Holdsworth

. Electronic monitoring in England and Wales. Leeds: Centre for Criminal Justice Studies, University of Leeds, 2016, Retrieved from: https://emeu.leeds.ac.uk/wp-content/uploads/sites/87/2016/06/EMEU-EM-in-England-and-Wales_Briefing-report.pdf.

Davey

Yates

McAlonan

. Process evaluation of the electronic monitoring as licence variation project. London, UK: Ministry of Justice, 2025. Retrieved from: https://assets.publishing.service.gov.uk/media/67bdab3b44ceb49381213c26/process-evaluation-electronic-monitoring-licence-variation-project.pdf.

GOV.UK. Electronic Monitoring Statistics annual publication. GOV.UK. Retrieved from: https://www.gov.uk/government/statistics/electronic-monitoring-statistics-publication-september-2025. 2025.

Ibid.

10.

GOV.UK. Electronic Monitoring Statistics annual publication. GOV.UK. Retrieved from: https://www.gov.uk/government/statistics/electronic-monitoring-statistics-annual-publication-march-2024/electronic-monitoring-statistics-annual-publication-march-2024. 2024.

11.

Chalfin

McCrary

. Criminal deterrence: a review of the literature. J Econ Lit 2017; 55: 5–48.

12.

Farell

. Ankle tags and 24/7 surveillance – this is how the UK treats new migrants. The Guardian 2022, August 30. Retrieved from: https://www.theguardian.com/commentisfree/2022/aug/30/ankle-tags-24-7-surveillance-uk-new-migrants-immigration-rwanda.

13.

Renzema

Mayo-Wilson

. Can electronic monitoring reduce crime for moderate to high-risk offenders? J Exp Criminol 2005; 1: 215–237: p.231.

14.

Belur, et al. op. cit. note 1.

15.

Yeh

. Cost-benefit analysis of reducing crime through electronic monitoring of parolees and probationers. J Crim Justice 2010; 38: 1090–1096.

16.

Grenet

Grönqvist

Niknami

. The effects of electronic monitoring on offenders and their families. J Public Econ 2024; 230: 105051.

17.

Al Weswasi

. Effect of early prison release with electronic monitoring. J Crim Justice 2025; 97: 102379.

18.

Byard

Langlois

. Wandering dementia—a syndrome with forensic implications. J Forensic Sci 2018; 64: 443–445.

19.

Dierick

BJH

Achterbosch

Eikholt

, et al. Electronic monitoring with a digital smart spacer to support personalized inhaler use education in patients with asthma: the randomized controlled outerspace trial. Respir Med 2023; 218: 107376.

20.

Hearn

. Tracking patients on leave from a secure setting. Ment Health Pract 2013; 16: 17–21.

21.

Tully

Larkin

Fahy

. New technologies in the management of risk and violence in forensic settings. CNS Spectr 2015; 20: 287–294.

22.

Tully

Cullen

Hearn

, et al. Service evaluation of electronic monitoring (GPS tracking) in a medium secure forensic psychiatry setting. J Forens Psychiatry Psychol 2016; 27: 169–176.

23.

Ibid.

24.

Murphy

Potter

Tully

, et al. A cost comparison study of using global positioning system technology (electronic monitoring) in a medium secure forensic psychiatric service. J Forens Psychiatry Psychol 2017; 28: 57–69.

25.

Tully

Hearn

Fahy

. Author’s reply. British Journal of Psychiatry 2014; 205: 501–501.

26.

Watson

Madhani

Mysorekar

, et al. Electronic monitoring of forensic patients. Br J Psychiatry 2014; 205: 500–501.

27.

RANZCP. Electronic monitoring of people utilising forensic mental health services. Position Statement, The Royal Australian & New Zealand College of Psychiatrists. Retrieved from: https://www.ranzcp.org/clinical-guidelines-publications/clinical-guidelines-publications-library/electronic-monitoring-of-people-utilising-forensic-mental-health-services. 2018.

28.

Moulton

. Nova Scotia sets direction on GPS monitoring of patients. CMAJ 2015; 187: E232–E233.

29.

Jehle

J-M

Lewis

Nagtegaal

, et al. Dealing with dangerous offenders in Europe. A comparative study of provisions in England and Wales, Germany, the Netherlands, Poland and Sweden. Crim Law Forum 2021; 32: 181–245.

30.

Ashworth

Waldron

Kahai

. A service evaluation exploring staff perceptions about the use and impact of electronic monitoring (GPS tracking) in a medium secure forensic psychiatric unit. J Forens Psychiatry Psychol 2025; 36: 508–525.

31.

Malek

Hearn

Fahy

, et al. Legal and human rights issues in the use of electronic monitoring (using GPS “tracking” technology) in forensic mental health settings in the UK. Med Sci Law 2023; 63: 309–315.

32.

Nellis

. Surveillance and confinement: electronic monitoring and its ethical implications. Crim Justice Ethics 2009; 28: 207–222.

33.

Nellis

. Surveillance, power and everyday life: electronic monitoring and the ethics of control. In: Brown

(ed.) The Routledge international handbook of forensic psychology in secure settings. London, UK: Routledge, 2016, pp.362–375.

34.

Bales, et al. op. cit. note 3.

35.

Payne

Gainey

. Electronic monitoring: philosophical, systemic, and political issues . Crim Justice Policy Rev 2000; 11: 123–140.

36.

Travis

Western

Redburn

. The growth of incarceration in the United States: Exploring causes and consequences. Washington, DC: National Academies Press, 2014.

37.

Miller, Kevin. Total surveillance, big data, and predictive crime technology: privacy's perfect storm. J Technol Law Policy 2014; 19: Article 3.

38.

Nellis

. The ethics of GPS tracking. In: Standards and ethics in electronic monitoring: handbook for professionals responsible for the establishment and the use of electronic monitoring. Strasbourg: Council of Europe, 2015, pp.38–40.

39.

Weisburd

. Punitive surveillance. Va Law Rev 2022; 108: 147–221.

40.

Landau

Werner

. Ethical aspects of using GPS for tracking people with dementia: recommendations for practice. Int Psychogeriatr 2012; 24: 358–366.

41.

O’Neill

. Should patients with dementia who wander be electronically tagged? No. Br Med J 2013; 346: f3606.

42.

Yang

Kels

. Ethical considerations in electronic monitoring of the cognitively impaired. J Am Board Fam Med 2017; 30: 258–263.

43.

Cronje

H-M

Nixon

Rossell

. Exploring cognitive functioning among forensic mental health inpatients. Int J Forensic Ment Health 2024; 23: 217–228.

44.

Murphy

Mitchell

Vacher

, et al. Wechsler Adult Intelligence Scale full scale IQ of male admissions to a high secure psychiatric hospital over six decades. Int J Forensic Ment Health 2021; 20: 386–397.

45.

Shumlich

Reid

Hancock

, et al. Executive dysfunction in criminal populations: comparing forensic psychiatric patients and correctional offenders. Int J Forensic Ment Health 2019; 18: 243–259.

46.

Beauchamp

Rauprich

. Principlism. In: Have

(ed.) Encyclopedia of global bioethics. Cham: Springer, 2016, pp.2282–2293.

47.

Beauchamp

Childress

. Principles of Biomedical Ethics. New York, NY: Oxford University Press, 2019.

48.

Adshead

. Care or custody? Ethical dilemmas in forensic psychiatry. J Med Ethics 2000; 26: 302–304.

49.

Niveau

Welle

. Forensic psychiatry, one subspecialty with two ethics? A systematic review. BMC Med Ethics 2018; 19: 1–10.

50.

Sen

Gordon

Adshead

, et al. Ethical dilemmas in forensic psychiatry: two illustrative cases. J Med Ethics 2007; 33: 337–341.

51.

Beauchamp

Childress

. Principles of Biomedical Ethics Tom L. Beauchamp; James F. Childress. New York, NY: Oxford University Press, 1980.

52.

Gillon

. Ethics needs principles—four can encompass the rest—and respect for autonomy should be “first among equals”. J Med Ethics 2003; 29: 307–312.

53.

Varkey

. Principles of clinical ethics and their application to practice. Med Princ Pract 2020; 30: 17–28.

54.

Chieze

Clavien

Kaiser

, et al. Coercive measures in psychiatry: a review of ethical arguments. Front Psychiatry 2021; 12: 790886.

55.

McKeown

Mortimer

Manzini

, et al. Is coercion ever beneficent? Public health ethics in early intervention and prevention for mental health. Developments in Neuroethics and Bioethics 2019; 2: 45–68.

56.

Tully, et al. op. cit. note 22.

57.

Birchley

. Anything goes? Analyzing varied understandings of assent. Camb Q Healthc Ethics 2022; 32: 76–89.

58.

Michael

McNamee

Michael

. The emerging ethics of humancentric GPS tracking and monitoring. In: International conference on mobile business, 2006, pp.34–35.

59.

Kerasidou

. Data-driven research and healthcare: public trust, data governance and the NHS. BMC Med Ethics 2023; 24: 1–9.

60.

Kip

Sieverink

Van Germert-Pijnen

LJEWC

, et al. Integrating people, context, and technology in the implementation of a web-based intervention in Forensic Mental Health Care: mixed-methods study. J Med Internet Res 2020; 22: e16906.

61.

Richards

. The dangers of surveillance. Harv Law Rev 2013; 126: 1934–1965.

62.

McKeown, et al. op. cit. note 55.

63.

Szmukler

Appelbaum

. Treatment pressures, leverage, coercion, and compulsion in mental health care. J Ment Health 2008; 17: 233–244.

64.

Tully,

et al.

op. cit. note 22.

65.

Tully, et al. op. cit. note 22.

66.

Simpson

Penney

. Electronic monitoring of forensic patients. Br J Psychiatry 2014; 205: 500–500.

67.

Belur, et al. op. cit. note 1.

68.

Aminot

Ryan

Nijdam-Jones

. Delusion or conspiracy? How forensic mental health professionals differentiate delusional beliefs from extreme radicalized beliefs. Crim Justice Behav 2024; 51: 1548–1569.

69.

Bhatia

. Racial surveillance and the mental health impacts of electronic monitoring on migrants. Race Cl 2021; 62: 18–36.

70.

Vorstenbosch

Masoliver-Gallach

Escuder-Romeva

. Measuring professional stigma towards patients with a forensic mental health status: Protocol for a Delphi Consensus Study on the design of a questionnaire. BMJ Open 2022; 12: 1–8.

71.

Markham

. Stigmatization and marginalization of forensic psychiatric patients. Illness Crisis Loss 2024; 33: 613–635.

72.

Henderson

Noblett

Parke

, et al. Mental health-related stigma in health care and mental health-care settings. Lancet Psychiatry 2014; 1: 467–482.

73.

Knaak

Mantler

Szeto

. Mental illness-related stigma in healthcare. Healthc Manage Forum 2017; 30: 111–116.

74.

West

Yanos

Mulay

. Triple stigma of forensic psychiatric patients: mental illness, race, and criminal history. Int J Forensic Ment Health 2014; 13: 75–90.

75.

Lee

S-M

Lee

S-H

Park

. A multidimensional approach to wearability assessment of an electronic wrist bracelet for the criminal justice system. Fashion and Textiles 2022; 9: 1–10.

76.

Sen, et al. op. cit. note 50.

77.

Adshead

Sarkar

. Justice and welfare: two ethical paradigms in forensic psychiatry. Aust N Z J Psychiatry 2005; 39: 1011–1017.

78.

Adshead

. Three faces of justice: competing ethical paradigms in forensic psychiatry. Legal Criminol Psychol 2013; 19: 1–12.

79.

Sen, et al. op. cit. note 50.

80.

Payne-Gill

Whitfield

Beck

. The relationship between ethnic background and the use of restrictive practices to manage incidents of violence or aggression in psychiatric inpatient settings. Int J Ment Health Nurs 2021; 30: 1221–1233.

81.

Pedersen

Gildberg

Baker

, et al. Ethnic disparities in the use of restrictive practices in adult mental health inpatient settings: a scoping review. Soc Psychiatry Psychiatr Epidemiol 2022; 58: 505–522.

82.

Holdsworth

Hucklesby

. Designed for men, but also worn by women. Crim Justice Matters 2014; 95: 14–15.

83.

Maidment

. Toward a “woman-centered” approach to community-based corrections. Women Crim Justice 2002; 13: 47–68.

84.

Holdsworth

and Wincup E. Researching women’s experiences of electronic monitoring. In: Criminological Research: Understanding Qualitative Methods. London, UK: SAGE Publications Ltd, 2017, pp.147–156.

85.

De Vogel

Keulen de Vos

Leong

, et al. Working with women in Forensic Mental Health Care: Guidelines for Gender-responsive assessment and treatment. Int J Offender Ther Comp Criminol 2025; 69: 2165–2184.

86.

Ashworth, et al. op. cit. note 30.

87.

Adshead and Sarkar. op. cit. note 77.

88.

Huxtable

. For and against the four principles of biomedical ethics. Clin Ethics 2013; 8: 39–43.

89.

Adshead. op. cit. note 78.

90.

Austin

Goble

Kelecevic

. The ethics of forensic psychiatry: moving beyond principles to a relational ethics approach. J Forens Psychiatry Psychol 2009; 20: 835–850.

Ethical issues in the use of electronic monitoring (Global Positioning System ‘tracking’ technology) in forensic mental health settings – A four principles approach

Abstract

Keywords

Introduction

EM in forensic mental health services

Ethical objections to EM

The ‘four principles’ approach in medical ethics

Applying the four principles to EM in forensic psychiatry

1. Autonomy

2. Beneficence

3. Non-maleficence

4. Justice

Challenges and limitations of the four principles approach

Conclusions

Footnotes

ORCID iD

Funding

Declaration of conflicting interests

References