Psychiatric advance directives: reconciling autonomy and non-consensual treatment

Abstract

This paper examines the potential for advance directives to be used by people with mental illness. Also known as a ‘living will’, an advance directive enables a competent person to make decisions about future treatment, anticipating a time when they may become incompetent to make such decisions. In Englishlaw, if “clearly established” and “applicable to the circumstances”, an advance directive assumesthe same statusas contemporaneous decisions made by a competent adult. A psychiatric advance directive, anticipating relapse of a psychosis, develops the concept of the living will. We argue it could reconcile two apparently contradictory themes in the current practice of psychiatry - on the one hand, the call to provide for non-consensual treatment outside hospital, and on the other, the promotion of patient autonomy.

Mandated Community Treatment: Beyond Outpatient Commitment

“…Yet there are a number of indications that mandated treatment is expanding at a rapid pace, not just in the United States but throughout the world (59). If mental health law and policy are to incorporate-or repudiate-some or all of these types of leverage, an evidence-based approach must rapidly come to replace the ideologic posturing that currently characterizes the field.…”

Care and compulsion in community psychiatric treatment

“…In the current political environment, little enthusiasm has been generated for alternatives to involuntary outpatient treatment, such as advanced directives (Halpern & Szmukler, 1997), the use of crisis cards and joint crisis plans (Sutherby & Szmukler, 1998), stimulating case management efforts, mobilising supportive resources and improving individual compliance. Under current UK legislation clinicians already have considerable powers in compulsory community treatment, albeit for a limited period and with the requirement of compulsory admission to initiate it.…”

Least restrictive alternative – advance statements and the new mental health legislation

“…Refusing medication may result in increased hospital stay, as described in relation to advance directives (Halpern & Szmukler, 1997). How far, however, is it appropriate to impose restrictive choices on a patient because of lack of resources or political inability to deliver choices?…”

“…Although the use of advance statements/agreements will be influenced by ethics, resources (Halpern & Szmukler, 1997) and legal implications (Dawson et al, 2001), there does appear, however, to be a growing commitment to them, as evidenced by the mental health law reviews in the UK. A recent New York State initiative, which is spending US$1 million on an education campaign advising how to complete a mental health advance directive (Monahan et al, 2001), demonstrates a commitment to them in a country from which, for better or worse, many social policy initiatives are imported into the UK.…”