Philosophy, Psychiatry, & Psychology

Savulescu and Dickenson present a timely consideration of expanding the use of advance directives into the field of mental illness. There has been little experience of this so far. Developments in the application of bioethics to medical practice can be slow to permeate into psychiatry even after they have been accepted into the mainstream of physical medicine. This is demonstrated by the Dr. Chabot case of “psychiatric euthanasia” in the Netherlands, a country where assisted suicide and euthanasia among the physically ill are now unexceptional. Perhaps bioethics permeates slowly into psychiatry because the added factor of mental disorder makes already difficult ethical dilemmas even more so. However, now that advance directives have an established validity in physical illness and are backed by a certain amount of case law, it is surely only a matter of time before their use in a mental health context is tested. As Savulescu and Dickenson relate, some writers have suggested that the advance directive could be used to provide a mechanism whereby persons suffering recurrent mental illness could consent to future psychiatric treatment should they again become unwell and incompetent again. If this is accepted, such patients must also similarly be able to refuse future treatment in the event they become incapacitated.

The present dispositional interpretation of advance directives states that such a directive represents not merely what course of action a patient preferred at some point in the past when the directive was formed (the past preferential model), but also what that patient can be assumed to continue to prefer (at least at some level) in the present, notwithstanding the fact that he or she may now be unable to formulate or express such a preference due to incompetence, or even, as may be the case in mental illness, that the patient contemporaneously expresses a different or conflicting preference. However, despite a long-standing disposition to act in a certain way, one can [End Page 255] never be sure that a person has not changed his or her mind. Therefore, taking the advance directive to be an indication of a person’s present preference is still only a “best guess” at what that person’s present preference is. In my view, therefore, the present dispositional interpretation represents a type of individualized substituted judgment based on what a person’s previously known dispositional preferences were, giving weight to the strength of these convictions (going to the trouble of issuing an advance directive is surely evidence of some strength of feeling on an issue), their endurance over time, and possibly the timeliness of the preference. I dispute the validity of temporal neutrality in this context. As time passes, one develops both experientially and psychologically, and thus it is only most recent preferences that are made on the basis of a person’s whole experience and understanding. My preferences and desires as an adolescent may well have been very different to my preferences and desires now. As Savulescu and Dickenson indicate, this present orientation is even more significant if an important event such as a serious mental or physical illness has intervened since the preference was expressed, as such an occurrence may well influence one’s views, and in particular the experience of the illness and its treatment may affect choices about preferred treatment of any subsequent illness or deterioration in health.

I will now turn to considering how the use of an advance directive representing present dispositional preferences might have affected the three cases from clinical psychiatric practice recently presented by Professor Hawton and myself in our paper “Suicide, Euthanasia and the Psychiatrist.”