Abstract
Psychiatric advance directives (PADs) are documents by means of which mental health service users can make known their preferences regarding treatment in a future mental health crisis. Many states with explicit legal provisions for PADs have ratified the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). While important UN bodies consider PADs a useful tool to promote the autonomy of service users, we show that an authoritative interpretation of the CRPD by the Committee on the Rights of Persons with Disabilities has the adverse consequence of rendering PADs ineffective in situations where they could be of most use to service users. Based on two clinical vignettes, we demonstrate that reasonable clinical recommendations can be derived from a more realistic and flexible CRPD model. Concerns remain about the accountability of support persons who give effect to PADs. A model that combines supported decision making with competence assessment is able to address these concerns.
Highlights
Psychiatric advance directives (PADs) are documents that enable mental health service users to make known their preferences regarding treatment in a future mental health crisis
We argue that the combined supported decision making model promotes service users’ goals in completing PADs, whereas the radical CRPD model renders PADs ineffective in cases where they could be of most use to service users
This paper focuses on the question whether the radical CRPD model promotes or impedes the realization of service users’ objectives in completing PADs
Summary
Psychiatric advance directives (PADs) are documents that enable mental health service users to make known their preferences regarding treatment in a future mental health crisis. Where in the Mental Capacity Act, the notion of best interest functions as an independent normative standard for substitute decision making and encompasses other items on the above list, here it is construed narrowly and functions as a source of evidence: if there is absolutely no information available about a person’s beliefs, values, and preferences and treatment cannot be postponed, as may happen in an emergency situation, providing treatment as medically indicated is most likely to be in accordance with what the person would have wanted had she been competent. The combined model is transparent because it makes explicit that service users decide for themselves and exercise their legal capacity as long as they are under a supported decision making arrangement and that substitute decision makers decide on behalf of service users under a substituted decision making arrangement
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