On psychiatric wills and the Ulysses clause: The advance directive in psychiatry

Abstract

Byline: Alok. Sarin Poised as we are, with new Mental Health Care Bill very much on cards and waiting to go Parliament, it may be wise to reflect on at least some of provisions of Bill which may not have received thought or consideration that they have deserved. While much has been written about how proposed legislation is different, and what this difference entails, some aspects of this I would think are worthy of a larger discussion. One such provision is planned introduction of use of advance directives in psychiatry. An advance directive is a mandate that specifies a person's preferences for treatment, should s/he lose capacity to make treatment decisions in future. The use of advance directives in terminal illness has been in place for some time, but its use in psychiatry is a rather recent phenomenon. Any reflection on use of advance directive in psychiatry raises some rather interesting issues. This also remains an area on which there remains paucity of both literature and of discussion despite some existing reviews. [sup][1],[2],[3] The first issue is that while use of advance directive in terminal illness is rather straightforward, as expression of intent for a time when individual may be incapable of expressing intent, in psychiatry this is different. It is an expression of intent of expected treatment for a time when expressed intent may actually be saying completely opposite. It is an attempt to reconcile facts of patient autonomy and choice, with possibility of involuntary treatment that has been agreed upon in advance. It is thus an attempt to reconcile seemingly irreconcilable issues, namely, those of choice and involuntarity. Proposed first by Thomas Szasz, [sup][4] influential and vocal critic of psychiatry, advance directive was proverbial to psychiatry. It offered a means of breaking logjam that often appeared when somebody who was diagnosed as violent or psychotic and deemed to be in need of treatment by profession refused it. It was originally hailed by both activists and professionals alike, but has subsequently been characterized by a rather dichotomous and often contentious debate. So, position on one hand is that since advance directive gave user of system autonomy, it is unquestionably a good idea. The counter position is that both conceptually and practically there are many difficulties with use of advance directives, which have not been adequately thought about. In a well-argued article, Szasz recognizes inherent differences between positions of those who accept reality of mental illness as a reality and those who view this as a form of myth and metaphor - an individual dealing with unacceptable circumstance - as a moral, not a issue. Identifying these as medical protectionistic positions as opposed to voluntaristic, he recognizes fact that as two groups speak different languages, a meeting ground appears impossible. He also accepts fact that this may not be a situation that is easily amenable to therapy by judiciary. To circumvent this, he offered psychiatric will as olive branch to psychiatry, where a person, in times of competence, may mandate a directive for treatment if he were ever to become psychotic. For this, use of a novel tool, the Ulysses clause, was suggested. Based on tale of Ulysses, who asks his crew to bind him to mast of his ship as he sails past isle of sirens so that he can both listen to song and not run his ship aground, clause says that person may mandate treatment for anticipated incompetence. On other hand, advance directive may actually say that person, if he ever were to be diagnosed as psychotic, would wish that he not be treated. So, situation is that what was offered by Szasz as a seemingly irrefutable argument for reconciliation actually depends on world view that individual espouses. …