Refusing Care: Forced Treatment and the Use of Psychiatric Advance Directives

Abstract

ABSTRACT This article discusses recommendations regarding forced treatment proposed in Refusing Care: Forced Treatment and the Rights of the Mentally Ill (2002). Two of these recommendations are discussed. First, the work proposes that on a first, serious psychotic break individuals should be committable under lesser standards than ordinary civil commitment standards (likewise for involuntary medication). Each element of this recommendation is discussed: Why the break should be psychotic, why it should be a first–and only a first–break, and why it should be serious. In addition, certain counterweights are raised and answered–e.g., will this proposal discourage voluntary admissions? The second recommendation is that after a first psychotic break, patients should self-bind (i.e., give an advance directive) to care under similar circumstances as in the case of the first break–or self-bind to no treatment undertaken for the patients' own benefit. The use of self-binding in this context is discussed, in addition to some puzzles concerning its use. Most important, what we should do if a patient self-binds to no treatment, and then, when impaired, says he or she wants treatment? The last part of the article discusses practical dimensions of the recommendations proposed, e.g., how do we ensure that advance directives are truly voluntary?