Limitations to the Scope and Binding Force of Advance Directives: The Conflict Between Compulsory Treatment and the Right to Self-Determination

Abstract

Advance planning for people with mental illness involves allowing competent individuals to specify their treatment preferences in advance of future incapacity. Supporters of advance planning argue that it can enhance autonomy and allow people to participate in their future treatment decisions, allowing patients and clinicians to engage in a constructive approach to treatment planning, while opponents claim that advance directives are problematic both legally and ethically and not workable in practice. To argue that advance directives are useful in psychiatry means being clear about what they are intended to achieve and thus what outcome measures might be appropriate. Outcome measures may best be suggested by both the type of advance directive involved and the philosophy behind it. Autonomy and empowerment, for example, would be best assessed by asking patients whether having the plan had made them feel more involved or in control when detained or admitted. Where compulsory detention or treatment is needed, questions arise as to how to balance a patient’s right to autonomy and self-determination with a physician’s duty of care. There is undoubtedly an inherent conflict and a balance to be struck between the two. The main issues that arise relate to the capacity of an individual to make an advance directive, when a directive is written and what it actually contains.