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

Byline: Alok. Sarin Poised as we are, with the new Mental Health Care Bill very much on the cards and waiting to go Parliament, it may be wise to reflect on at least some of the provisions of the Bill which may not have received the thought or consideration that they have deserved. While much has been written about how the 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 the planned introduction of the use of advance directives in psychiatry. An advance directive is a mandate that specifies a person's preferences for treatment, should s/he lose the capacity to make treatment decisions in the 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 the use of the 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 the use of the advance directive in terminal illness is rather straightforward, as the expression of intent for a time when the 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 the expressed intent may actually be saying completely the opposite. It is an attempt to reconcile the facts of patient autonomy and choice, with the 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] the influential and vocal critic of psychiatry, the advance directive was the proverbial "olive branch" to psychiatry. It offered a means of breaking the logjam that often appeared when somebody who was diagnosed as violent or psychotic and deemed to be in need of treatment by the medical 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, the position on the one hand is that since the advance directive gave the user of the system autonomy, it is unquestionably a good idea. The counter position is that both conceptually and practically there are many difficulties with the use of advance directives, which have not been adequately thought about. In a well-argued article, Szasz recognizes the inherent differences between the positions of those who accept the reality of mental illness as a medical reality and those who view this as a form of myth and metaphor - an individual dealing with unacceptable circumstance - as a moral, not a medical issue. Identifying these as the "medical protectionistic" positions as opposed to the "voluntaristic," he recognizes the fact that as the two groups speak different languages, a meeting ground appears impossible. He also accepts the fact that this may not be a situation that is easily amenable to "therapy by the judiciary. " To circumvent this, he offered the "psychiatric will" as the 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, the use of a novel tool, "the Ulysses clause," was suggested. Based on the tale of Ulysses, who asks his crew to bind him to the mast of his ship as he sails past the isle of the sirens so that he can both listen to the song and not run his ship aground, the clause says that the person may mandate treatment for anticipated "incompetence. " On the other hand, the advance directive may actually say that the person, if he ever were to be diagnosed as "psychotic," would wish that he not be treated. So, the situation is that what was offered by Szasz as a seemingly irrefutable argument for reconciliation actually depends on the world view that the individual espouses. …