Abstract
The patient's decision-making abilities are often altered in psychiatric disorders. The legal framework of psychiatric advance directives (PADs) has been made to provide care to patients in these situations while respecting their free and informed consent. The implementation of artificial intelligence (AI) within Clinical Decision Support Systems (CDSS) may result in improvements for complex decisions that are often made in situations covered by PADs. Still, it raises theoretical and ethical issues this paper aims to address. First, it goes through every level of possible intervention of AI in the PAD drafting process, beginning with what data sources it could access and if its data processing competencies should be limited, then treating of the opportune moments it should be used and its place in the contractual relationship between each party (patient, caregivers, and trusted person). Second, it focuses on ethical principles and how these principles, whether they are medical principles (autonomy, beneficence, non-maleficence, justice) applied to AI or AI principles (loyalty and vigilance) applied to medicine, should be taken into account in the future of the PAD drafting process. Some general guidelines are proposed in conclusion: AI must remain a decision support system as a partner of each party of the PAD contract; patients should be able to choose a personalized type of AI intervention or no AI intervention at all; they should stay informed, i.e., understand the functioning and relevance of AI thanks to educational programs; finally, a committee should be created for ensuring the principle of vigilance by auditing these new tools in terms of successes, failures, security, and relevance.
Highlights
The issue of complex decisions, as is often the case in situations covered by Psychiatric Advance Directives (PADs), raises the question of the impact of a nonhuman making decision: such a decision proposed by a nonhuman entity appears to be safer, more rational than that of a human because it is based on a very large amount of data and algorithms with few margins of error
For PADs, particular attention should be paid to the way in which data are used: explanations to patients of the issues and rights, patients must give their free and informed consent to the use that can be made of their data, what data they wish to have added to a knowledge database or not, and how they can exercise the right to withdraw
Some professionals are still skeptical about the introduction of a crisis plan [16]: doubts about the relevance of this crisis plan, addition of documents to be taken into account, lack of consideration of the crisis plan by the teams, etc
Summary
Psychiatric disorders are often characterized by a high rate of relapse, during which the patient’s decision-making abilities are altered and may result in psychiatric admissions, often involuntarily. PADs may reduce negative coercive treatment experiences and stigma [15] and is a strong enhancer of therapeutic relationship [16] This “Advance Statement” refers to the possibility of identifying prodromal signs of relapse and proposing early personalized interventions. CDSS enhanced with AI could make compulsory admissions more efficient to provide appropriate psychiatric care [4] In addition to these data, the increase in the use of mobile and chatbots applications (providing exchange, therapeutic exercises) creates sources of declarative data on the patient’s condition that are interesting to better understand what the person is experiencing in their daily lives, to anticipate relapses, and to better treat such disorders. This combination of tools could be useful and could facilitate PAD completion as peers and caregivers already do [18]
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