Ulysses Contracts in psychiatric care: helping patients to protect themselves from spiralling

Abstract

This paper presents four arguments in favour of respecting Ulysses Contracts in the case of individuals who suffer with severe chronic episodic mental illnesses, and who have experienced spiralling and relapse before. First, competence comes in degrees. As such, even if a person meets the usual standard for competence at the point when they wish to refuse treatment (time 2), they may still be less competent than they were when they signed the Ulysses Contract (time 1). As such, even if competent at time 1 and time 2, there can still be a disparity between the levels of competence at each time. Second, Ulysses Contracts are important to protect people’s most meaningful concerns. Third, on the approach defended, the restrictions to people’s liberty would be temporary, and would be consistent with soft paternalism, rather than hard paternalism: the contracts would be designed in such a way that individuals would be free to change their minds, and to change or cancel their Ulysses Contracts later. Finally, even if one rejects the equivalence thesis (the claim that allowing harm is as bad as doing harm), this is still consistent with the claim that, in particular cases, it can be as wrong to allow a harm as to do a harm. Nevertheless, controversies remain. This paper also highlights several safeguards to minimise risks. Ultimately, we argue that people who are vulnerable to spiralling deserve a way to protect their autonomy as far as possible, using Ulysses Contracts when necessary.

Reasons for endorsing or rejecting self-binding directives in bipolar disorder: a qualitative study of survey responses from UK service users

“…Some models view the self-binding directive as prioritising an individual's long-term values over those they hold when unwell; 1 some propose risk, not decision-making capacity, as the criterion for implementation; 22 and some adopt the idea that decision-making capacity varies by degrees, rather than there being a determinate threshold for implementation. 19 By contrast, most responses in our survey from service users with bipolar disorder, whether they individually endorsed or rejected the use of selfbinding directives, appeared to assume that impaired decision-making capacity for treatment was a prerequisite and the reason for implementation of a self-binding directive. Moreover, most of these responses appeared to imply the acceptance of the medicolegal notion of decision-making capacity as a threshold concept, when they presented distorted thinking as a distinct, determinate shift from healthy and unimpaired decision making.…”

“…Self-binding directives are conventionally justified in terms of minimising risk by ensuring swifter access to treatment. 1 , 2 , 3 , 5 , 17 , 18 , 19 However, the dominant justification given for the use of self-binding directives was the theme of distorted thinking when unwell and the resultant impairments of decision-making abilities, rather than risk avoidance. This dominance is all the more striking, given that all survey participants resided in countries where mental health laws are based on assessment of mental disorder and risk, rather than decision-making capacity.…”

Commitment devices: beyond the medical ethics of nudges

“…One might ask whether it is right to support A at t1 to make decisions which might prevent A at t2 from doing what he would otherwise choose. CDs offer a more complex version of so-called Ulysses contracts whereby somebody anticipates that they may wish to withhold consent to a given treatment at t2, but at t1 signs a contract overriding future capacitous refusal 33. CDs are less extreme, merely altering the future balance of incentives.…”

“…)34 While the CD adds a cost to flexibility, the CD may be worthwhile in order to prevent the harmful short-termism to which A(t2) is vulnerable. Moreover, while doctors may be colluding in helping A(t1) alter the choice architecture of A(t2), options are not restricted, they just become more expensive, unlike in Ulysses contracts 33. Within reason, the freedom to make binding decisions is an important part of autonomy because it enables complex identities and relationships in the pursuit of a greater range of goals.…”

Aktive Lebensbeendigung bei einer Patientin mit Alzheimer-Demenz in der Niederlanden: eine ethische Debatte – Kontra

“…Er zeigt auch, wohin die so starke und stetig zunehmende, von manchen als zuweilen einseitig empfundene Betonung des Patientenwillens als Richtlinie ärztlichen Handelns führen kann. In diesem Fall erweist sich die Patientenverfügung als wahrer "Odysseus-Kontrakt" [4], eine Festlegung, der man später nicht mehr entrinnen kann, selbst wenn die eigene Meinung sich geändert haben sollte. Aus den nachfolgend genannten Gründen halte ich das Vorgehen in dem geschilderten Fall, unabhängig von den rechtlichen Grundlagen, für medizinethisch sehr bedenklich:…”