Background Self-binding directives (SBDs) are psychiatric advance directives that include the possibility for service users to consent in advance to compulsory care in future mental health crises. Legal provisions for SBDs exist in the Netherlands since 2008 and were updated in 2020. While ethicists and legal scholars have identified several benefits and risks of SBDs, few data on stakeholder perspectives on SBDs are available. Aims The aim of the study was to identify opportunities and challenges of SBDs perceived by stakeholders (...) who have personal or professional experience with legally enforceable SBDs. Methods Data collection was carried out in the Netherlands from February 2020 to October 2021 by means of semi-structured interviews. Participants were selected through purposive sampling and snowball methods. Interviews were conducted with mental health service users (n = 7), professionals (n = 13), and an expert on SBD policy (n = 1), resulting in a total number of 21 interviews. The data were analyzed thematically. Results Perceived benefits of SBDs included increased autonomy, improvement of the therapeutic relationship, possibility of early intervention and prevention of harm, prevention of compulsory care, reduction of the duration of compulsory care and recovery, mitigation of negative experiences around compulsory care, and guidance for professionals in providing compulsory care. Perceived risks included infeasibility of SBD instructions, difficulty in decision-making around SBD activation, limited accessibility of SBDs, disappointment of service users due to non-compliance with SBDs, and limited evaluation and updating of SBD content. Barriers to SBD completion included lack of knowledge of SBDs among professionals, lack of motivation or insight among service users, and lack of professional support for SBD completion. Facilitators of SBD completion and activation included support for SBD completion, involvement of relatives and peer experts, specification of SBD content, and evaluation of compulsory care and SBD content. The new legal framework was regarded as having both positive and negative effects on SBD implementation. Conclusions Stakeholders who have personal or professional experience with legally enforceable SBDs perceive SBDs as having important benefits and tend not to articulate the fundamental ethical concerns about SBDs which can be found in the ethics and legal literature. Instead, they perceive ethical and practical challenges that can be addressed through the implementation of suitable safeguards. (shrink)

Definition of the problem “Ulysses contracts” are advance directives by means of which a patient authorizes compulsory treatment for a phase of a temporary inhibition of competence. Ethical discussion of Ulysses contracts usually focuses on the question of the “moral authority” or the “binding force” of Ulysses contracts, i.e., of whether Ulysses contracts should be honored or whether the competent patient’s prospective wishes for compulsory treatment are overridden by the patient’s actual preferences in the situation of treatment. Arguments In this (...) contribution, I argue that, even if the Ulysses contract undoubtedly applies to the actual situation, there may be reasons for not acting upon it. The main argument is that acting in conformity to a Ulysses contract may be justified but nevertheless wrong. After some terminological clarifications, I argue that Ulysses contracts justify the use of compulsory treatment but do not necessarily make it the right course of action. They authorize physicians to act in accordance with the patient’s advance directive and, thereby, protect them from blame and sanctions in case they administer compulsory treatment. Whether compulsory treatment is right or wrong, however, hinges on whether the patient retrospectively consents to it. It may be the case that administering compulsory treatment in conformity to the Ulysses contract is justified but turns out to be wrong if the patient does not retrospectively consent to it. It may also be the case that not obeying the Ulysses contract turns out to be right if the patient retrospectively consents to not following it. Conclusion In view of this, I conclude that Ulysses contracts should not be seen as morally binding and that they should not be made legally binding. They are not normatively on par with other advance directives that relate to, for example, states of dementia. (shrink)

Commitment devices (CDs) can help people overcome self-control problems to act on their plans and preferences. In these arrangements, people willingly make one of their options worse in order to change their own future behaviour, often by setting aside a sum of money that they will forfeit it if they fail to complete the planned action. Such applications of behavioural science have been used to help people stick to healthier lifestyle choices, overcome addictions and adhere to medication; they are acceptable (...) to many patients and even relatively small sums can be effective. Some authors have objected to the use of nudges in healthcare. Engelen has listed nine potential objections to nudges in relation to means (why nudge rather than persuade?), ends (what action is being promoted?) and agents (who is nudging whom?). These objections are shown to lack force in the context of CDs. Instead, an analysis specific to the ethical issues in CDs is employed. CDs exclude certain groups including so-called ‘naifs’ and risk increasing health inequality. CDs may promote the wrong behaviour and people might legitimately change their minds. Intermediaries might encounter perverse incentives. Approaches to overcoming these problems are described and eight key ethical considerations for those considering implementing CDs in the future are described. Altogether this paper illustrates the advantages of appraising the ethics of behavioural science in medicine on a case-by-case basis. (shrink)