Against Ulysses contracts for patients with borderline personality disorder (original) (raw)
Related papers
Borderline personality disorder and the ethics of risk management
Nursing Ethics
Patients with borderline personality disorder are frequent users of inpatient mental health units, with inpatient crisis intervention often used based on the risk of suicide. However, this can present an ethical dilemma for nursing and medical staff, with these clinician responses shifting between the moral principles of beneficence and non-maleficence, dependent on the outcomes of the actions of containing or tolerating risk. This article examines the use of crisis intervention through moral duties, intentions and consequences, culminating in an action/consequence model of risk management, used to explore potential outcomes. This model may be useful in measuring adherence and violation of the principles of beneficence and non-maleficence and therefore an aid to clinical decision making.
Ulysses Contracts in psychiatric care: helping patients to protect themselves from spiralling
Journal of Medical Ethics
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 Contr...
Borderline Personality Disorder: Implications for Moral and Criminal Responsibility
There has been considerable controversy regarding the level of criminal responsibility in people diagnosed with Borderline Personality Disorder (BPD), with positions ranging from their having full responsibility to little or none. This paper defends the notion that BPD patients are morally---and legally responsible for any criminal acts they commit. Following Louis Charland and Carl Elliot, I argue that BPD is primarily a defect of character rather than a disease per se although “disease” cannot be totally eliminated as a factor for understanding the disorder. As such, the BPD person, all else being equal, knows right from wrong and has free choice regarding criminal behavior, and should therefore be held responsible for such behavior.
Psychiatric Services, 2014
Little is known about the crisis treatment preferences of people with borderline personality disorder. Clinicians may also question service users' ability to make considered decisions about their treatment when in crisis. Therefore, this qualitative study aimed to investigate crisis treatment preferences of a sample of community-dwelling adults with borderline personality disorder. Participants were 41 adults with borderline personality disorder who had created joint crisis plans during a randomized controlled trial. Data from all 41 joint crisis plans were analyzed iteratively via a thematic analysis framework. Participants gave clear statements in their crisis plans relating to the desire to recover from the crisis and to improve their social functioning. Key themes included the desire to be treated with dignity and respect and to receive emotional and practical support from clinicians. Many participants spoke of the importance of connecting with others during periods of crisis, but several reported a clear desire to be left alone during a future crisis. Other themes concerned preferences for specific treatment refusals during crises, including particular types of psychotropic medication and involuntary treatment. The variation of participants' preferences underscores the importance of developing individually tailored crisis plans for people with borderline personality disorder. The need to be treated with dignity and respect and to be given autonomy in decision making--also identified in global surveys of people with severe mental illness--is important to people with borderline personality disorder. Key messages for clinicians, service users, and policy makers, in addition to staff training issues, are discussed.
Risk of suicide is insufficient warrant for coercive treatment for mental illness
2013
"Mental health laws in many jurisdictions currently permit coercive treatment for persons with mental illness who are thought to be at risk of harm to themselves or others. These laws are often used to provide involun- tary treatment to persons who are thought to be at risk of suicide. In this article we argue that legislated coercive psychiatric treatment should not be triggered by an assess- ment of the likelihood of harm, including a likelihood of suicide, but should be available only where a person is found to lack capacity to make their own decisions about their own health risks, after appropriate support has been given. We suggest that current opposition to this approach may find its origin in factors including uncertainties about the idea of vulnerability and its relationship to capacity as well as tendency to minimise the real costs of psychiatric treatment and coercion against the aim of suicide prevention. Given the limits of suicide risk assessment, we argue that a public policy that allows involuntary preventative detention of competent persons thought to be at risk of suicide, places too great a burden on all persons living with mental illness to be justified. We suggest that we are better placed to serve the interests and respect the human rights of people with mental illness if we respect and support the right of persons to make decisions, rather than focussing on perceived vulnerabilities and calculations of suicide risk."
Rationality, diagnosis and patient autonomy in psychiatry
In Sadler et al. (eds.) Oxford Handbook of Psychiatric Ethics, Oxford University Press, 2014
In this chapter, our focus is the role played by notions of rationality in the diagnosis of mental disorders, and in the practice of overriding patient autonomy in psychiatry. We describe and evaluate different hypotheses concerning the relationship between rationality and diagnosis, raising questions about what features underpin psychiatric categories. These questions reinforce widely held concerns about the use of diagnosis as a justification for overriding autonomy, which have motivated a shift to mental incapacity as an alternative justification. However, this approach too has recently been criticized from a mental disability rights perspective. Our analysis of the relationship between mental capacity and rationality is used to illuminate these concerns, and to investigate further the relationship between rationality and psychiatric diagnosis.
Objective: In some Australian states clinicians and mental health tribunal members are already required to assess a person’s decision-making capacity before involuntary treatment can be applied. Professionals in other jurisdictions will likely soon be required to do the same as mental health law reform in most Australian jurisdictions makes the assess- ment of decision-making capacity a central component of the process of providing unconsented psychiatric treatment. We provide a guide to the legal issues around the capacity to refuse psychiatric treatment to assist with this task. Method: We review the legislation in the four Australian states most advanced in the mental health law reform pro- cess and use examples from clinical practice and the common law to describe how decision-making capacity should be assessed by these statutory standards. Results: Clinicians and tribunal members will primarily be required to judge whether a person with mental illness can understand the information relevant to the treatment decision and whether he or she can use or weigh that information to come to a decision. A person with a mental illness is presumed to have capacity, but that presumption can be rebut- ted. Capacity is specific to the decision at hand and cannot be determined by the nature of the decision made. Conclusions: The information provided should assist clinicians and tribunal members to make determinations of deci- sion-making capacity around treatment refusal in the context of mental illness.