Against Ulysses contracts for patients with borderline personality disorder

Abstract

Patients with borderline personality disorder (BPD) sometimes request to be admitted to hospital under compulsory care, often under the argument that they cannot trust their suicidal impulses if treated voluntarily. Thus, compulsory care is practised as a form of Ulysses contract in such situations. In this normative study we scrutinize the arguments commonly used in favour of such Ulysses contracts: (1) the patient lacking free will, (2) Ulysses contracts as self-paternalism, (3) the patient lacking decision competence, (4) Ulysses contracts as a defence of the authentic self, and (5) Ulysses contracts as a practical solution in emergency situations. In our study, we have accepted consequentialist considerations as well as considerations of autonomy. We conclude that compulsory care is not justified when there is a significant uncertainty of beneficial effects or uncertainty regarding the patient’s decision-making capacity. We have argued that such uncertainty is present regarding BPD patients. Hence, Ulysses contracts including compulsory care should not be used for this group of patients.

Is compulsory care ethically justified for patients with borderline personality disorder?

“…When BPD patients enter the emergency room, they are usually in crisis; emotionally upset and oftentimes ambivalent about the care offered. 2,63 Suicidal communication and self-harm behaviour (including self-cutting or intoxication with or without suicidal intent) are common. 13,15 If the patient is assessed as decision-incompetent, then compulsory care may of course apply, provided it is in the patient's best interest.…”

Hospital staff at most psychiatric clinics in Stockholm experience that patients who self-harm have too long hospital stays, with ensuing detrimental effects

“…However, the reasons for the patient's fragile appearance can be more complex than that. In borderline personality disorder, active passivity and regressive behaviour are common features [7,15,38], suggesting that the patient can appear as less able than she actually is. Reinforcing such traits by taking over agency from the patient, could have negative consequences for the patient's ability to manage her own emotions and adversities in the future [24].…”