Fluctuating capacity and advance decision-making in Bipolar Affective Disorder — Self-binding directives and self-determination

Abstract

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being ‘protected’ through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician–patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research.

How Situational Diagnosis Helps Disentangle Ethical and Psychological Features of Complex Cases

“…Severe mental illness, such as major depression, bipolar disorder, or schizophrenia, has been found to be associated with poor decision making [6]. And decision-making capacity can fluctuate in patients with bipolar disorder, being impaired when the patient is in a manic episode but returning with the patient's recuperation [7].…”

Ulysses in the United Kingdom: Difficulties with a capacity‐based justification for self‐binding in bipolar disorder

“…There has been a recent proposal in the United Kingdom for introduction of legally enforceable self‐binding directives for persons with bipolar affective disorder . Also known as a Ulysses contract, a self‐binding directive is a contract that a person may sign expressing her wish to be constrained at a later date if certain conditions are met.…”

“…Also known as a Ulysses contract, a self‐binding directive is a contract that a person may sign expressing her wish to be constrained at a later date if certain conditions are met. In the context of bipolar disorder, the idea is that a person with previous experience of mania enters into an agreement to be forcibly detained and treated if she relapses into mania, even if her manic self refuses detention and treatment at time of enforcement 1 [p95]. A manic episode consists of at least 1 week of abnormal and persistently elevated expansive or irritable mood and increased goal directed activity or energy.…”

“…Crucially, Gergel and Owen present a model of self‐binding directives which is rooted in presence or absence of decision‐making capacity for treatment 1 [p93]. Gergel and Owen point out that bipolar disorder is a condition which is associated with the full inter‐episodic recovery of decision‐making capacity for treatment 1 [p97, citing from empirical work by Owen et al] 4 [p119‐128].…”

“…Crucially, Gergel and Owen present a model of self‐binding directives which is rooted in presence or absence of decision‐making capacity for treatment 1 [p93]. Gergel and Owen point out that bipolar disorder is a condition which is associated with the full inter‐episodic recovery of decision‐making capacity for treatment 1 [p97, citing from empirical work by Owen et al] 4 [p119‐128]. Under their model a person with bipolar disorder, who is assessed to have capacity, may with free and informed consent, and the assistance of their clinical team, draw up a directive requesting that they be treated involuntarily if certain conditions are met 1 [p95‐96].…”