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An abstract on morality of advanced directives

The most prominent are bipolar disorder and schizophrenia. People who suffer from bipolar disorder often can benefit from treatment and live a satisfying life.

An abstract on morality of advanced directives

However, even if the individual complies with the necessary lithium medication, a breakthrough of a manic condition cannot always be prevented. Some of these patients then refuse treatment or supervision because they lack insight into their actual condition. Consequently they may undertake actions that are harmful to themselves or others ie become extremely insulting to their neighbours, act sexually disinhibited, or embark on irresponsible financial transactions.

If not in the short run, in the long run this behaviour may be extremely destructive for individual self esteem, private and social relations, career opportunities, etc. However, in a number of cases these persons do not meet legal criteria for involuntary commitment or coercive treatment. Their actions may be harmful, but not extremely dangerous to themselves or others. This implies that their legal binding force in many jurisdictions is questionable or absent, unless specific legal provisions are made.

The use of Ulysses contracts also raises a number of ethical questions. One issue concerns their moral authority. On what grounds do they justify future interventions? A second issue relates to the notion of personal identity.

In what sense is the person who has formulated a Ulysses contract the same as the one to whom it later is applied? A third issue concerns the status of possible revocations of the advance directive during a crisis.

  1. They can assist the patient and their families to make a well judged end-of-life care decision and document their preferences. This gives importance to the ethical issue of autonomy surrounding end-of-life care preferences.
  2. Interpreting advance directives can be problematic at times, as when information is lacking, or when a strict reading of the document does not seem to make sense. Making Sense of Advance Directives.
  3. Such values, however, are themselves the product of deliberative processes of interaction between doctor and patient. Despite an advance directive requesting that treatment be provided, physicians may judge that treatment would be of little benefit to the patient in the given circumstances and unilaterally decide to withhold or withdraw treatment.
  4. Was it helpful in finding an acceptable way out of the problematic situation?

Normally, declarations for future treatment are supposed to be open to revision at any time. What is the moral status of a refusal of treatment, given an abstract on morality of advanced directives existence of an advance directive? A fourth issue is the risk of misuse and abuse: In this paper we discuss these issues from a narrative perspective.

We will regard advance directives as elements of an ongoing narrative in which patient and doctor try to make sense of and get a hold on the recurrent crises inherent in the patient's psychiatric condition. We argue that advance directives should be seen as part of a process of joint narrative work between patient and doctor. From this perspective it is possible to throw new light on the answers which thus far have been given in response to the ethical questions.

Such answers are commonly formulated within a principlist framework. They tend to focus upon patient autonomy in terms of informed decision making. We argue that patient autonomy should be regarded as part of a process of finding ways of living one's own life as a life which is always related to and sustained by others.

Thus, emphasis is put on processes of interaction as the context within which individual autonomy can flourish. We will show that many of the considerations put forward from a principlist point of view are relevant to the debate, but that their relevance can be enhanced if the intersubjective context of human life in general, and of psychiatric practice in particular, is taken into account. The common idea behind the use of advance directives is that they enable doctors to know the wishes of patients concerning what should be done in cases where treatment choices are to be considered and patients are no longer competent to express their views.

  • When a living will is ignored;
  • Also, physicians may give their own ethical principals priority when they conflict with patients wishes;
  • Even though we are discussing about patients right to autonomy we are talking about its limitations;
  • The time frame of preferences, dispositions, and the validity of advance directives for the mentally ill;
  • It does make sense, though, to be critical about its use, and to make sure that its primary aim is the patient's empowerment;
  • The living, of course.

The moral authority of advance directives can be based upon the principle of respect for patient autonomy.

Following the advance directive means acting in conformity with the patient's wishes. A foundation of their moral authority on respect for autonomy, however, requires more than just a referral to the patient's wishes.

In the first place, it refers to the values which the patient endorses. Advance directives are to be taken into consideration, because they express long-standing views on what is considered important in life. Secondly, advance directives are not simply orders to the doctor, they are part of a process of communication between doctor and patient about what courses of action are preferable within the the patient's life history.

Advance Directives

The communicative aspect of advance directives is clearly expressed in the widely shared view that they should not be considered as given, but must be discussed by doctor and patient. They should not replace deliberation about possible future changes in the patient's condition, but should rather elicit and guide communication about such topics.

In the case of Ulysses contracts, similar considerations apply. To have moral authority psychiatric advance directives must be the expression of the patient's values, developed in an intersubjective context of doctor-patient communication. Many authors emphasise that advance authorisation for future psychiatric care can only be valid if this expresses values which are crucial to the patient's life. The necessity of an intersubjective context of joint narrative work is hardly an explicit issue in the debate.

It can, however, be regarded as an implicit presupposition in many of the contributions.

Ethical Issues Surrounding End-of-Life Care: A Narrative Review

Typical examples are the alcoholist who is considering quitting drinking and the patient who suffers from bipolar disorder. A third way to conceptualise the notion of crucial values is to be found in the work of Gerald Dworkin. Narrative work Patient wishes in themselves are not decisive; some wishes have to be considered as more important than others. It takes a lot of work to make sure what wishes are the most important. It is not easy for the patient to formulate her wishes voluntarily, in a cool moment or through critical reflection.

Neither is it easy for the doctor to decide whether the wishes are based upon voluntariness, coolness or critical reflection. Such criteria are themselves part of a process of interpreting the wishes, a process which requires critical examination.

Voluntariness, coolness or critical reflection are possible arguments for the authority of certain wishes, but such arguments need to be investigated and discussed. The advance directive grows out of, and is itself the source for further, narrative work.

The need for a critical examination of both the patient's wishes and the way in which they are established implies that autonomy is not a given basis for the validity of psychiatric advance directives, but an issue which needs constant communicative work by patient and doctor.

The psychiatric patient is not a self-sufficient individual directing her own life. She is a person in distress, and in need of care. This is not only apparent when the patient is in crisis. The danger of future psychosis is always lingering, and induces the patient to seek help.

In discussing future treatment options, including a possible Ulysses contract, the patient tries to get a hold on her life. In discussing the future, the patient and the psychiatrist try to find ways to maintain and repair a world which is in need of joint caring activities.

How to counter the problem of personal identity? Some commentators challenge the moral authority of psychiatric advance directives from the perspective of a certain view of personal identity. The central challenge presented by the problem of personal identity is to articulate the conditions under which stages of a person's life are stages of the same person or, conversely, to articulate the circumstances which signal the development of a different person.

It may even be argued that under specific conditions a Ulysses contract is an instrument in the hands of the former self to enslave the later self of the person. Yet, by hypothesising two different personalities, the counterarguments in fact also assume a rigid notion of personal identity.

A narrative concept of identity does not imply that the person stays the same; neither does it entail an abstract on morality of advanced directives assumption that drastic psychological changes make it impossible to use the concept of identity any longer. From a narrative perspective, a person's identity is formed in stories, which both express and create the unity of a person's life. The Ulysses contract typically states what the patient wants to be done in case of crisis. This implies that she recognises that crises are part of her life, in that they have occured in the past, and are likely to occur again in the future.

The Ulysses contract acknowledges that drastic changes may take place, and claims that if such changes occur, specific forms of care are needed in order to make life livable.

The particular harms to be prevented by mental health treatment in accordance with such a contract would be those identified by the individual and her doctor. Finally, in the contract the patient and psychiatrist can agree prospectively what interventions are to be considered necessary and justified should these symptoms express themselves, even if the patient then refuses.

Thus, the change of identity is not denied, nor are the views of the person suffering a crisis declared to be irrelevant. The fundamental issue which is at stake is that the person needs help and support to keep a hold on life, especially but not exclusively during a period of crisis.

  • How Are Advance Directives Prepared?
  • It does make sense, though, to be critical about its use, and to make sure that its primary aim is the patient's empowerment;
  • An advance directive only comes into play if a person cannot communicate wishes because the person is permanently unconscious or mentally incapacitated;
  • Most contract proposals envision some third party involvement to ensure that the patient's best interests are served during negotiations as well as during the execution of the contract.

It refers to the wider notion of the life-story of the patient, a story which is constructed in interaction with others. The Ulysses contract does not imply that one phase of life a clear period is more important than another one a period of crisis. It rather entails the claim that the various phases should be taken seriously, and should be related to one another.

The phase of crisis should be dealt with in such a way that the consequences are not fatal. Yet, the procedure should be attuned to the actual crisis.

It should not be a plain denial of everything the person claims at that particular moment, but should be open to the meaning of the patient's utterances. A patient's expressed wishes during a period of crisis should not be accepted at face value, but neither should they be deemed totally irrelevant.

Rather they should be interpreted in the light of the patient's life-history, a history which is informed by narrative work between patient and doctor, including formerly discussed advance directives. How to deal with the right to refuse treatment? In many jurisdictions, the psychiatric patient has a legal right to refuse treatment. From a narrative perspective, the application of a Ulysses contract during a crisis requires narrative work from both patient and doctor.

  1. This is why when the family disagrees with the advance directive, the family's decisions usually win out. Psychiatric advance directives abstract psychiatric advance directives in particular—may also call into question the moral authority of a treatment.
  2. Both the young and the healthy express at least as much interest in planning as those older than 65 and those in fair to poor health p. Another common directive is naming a medical power of attorney sometimes called a health care proxy or agent.
  3. The paper concludes with recommendations to assist the professional nurse in dealing with issues related to honoring a patient's advance directive. The danger of future psychosis is always lingering, and induces the patient to seek help.
  4. These new medical treatments and technologies are increasing the number of people seeking long-term care.
  5. These procedural requirements are intended to prevent misuse and abuse of Ulysses contracts.

The document has to be interpreted, in order to establish whether, and if so, how it is to be applied. This means that the doctor cannot simply do what the form says; he will have to be responsive to the patient in a communicative way.

The advance directive requires narrative work, both during and after a crisis.

  • With these advances it has become possible to keep people in a vegetative state for almost unlimited periods of time;
  • On the whole the elderly, as well as others, welcome that development -- even if they fear some of its consequences;
  • They can guide the patients and their surrogates to make informed treatment preferences by providing them trustful information, appropriate prognosis and available options regarding the case specific treatment choices.

During the crisis, the doctor will have to try to persuade the patient to be compliant with the advance directive. This requires interaction and communication, ranging from persuasion to making decisions for the patient. Was the advance directive adequately applied? Was it helpful in finding an acceptable way out of the problematic situation? Is it still relevant, or should it be corrected or revoked? Both the application of the advance directive and the evaluation can be seen as a learning process in which patient and doctor can find out how to deal with possible future crises.

Morality of Advanced Directives

Being responsive to the patient during a crisis requires that refusals are taken seriously. This does not mean they are taken for granted as absolute infringements upon further interventions. But neither does it imply they can be simply overruled and regarded as totally irrelevant. The refusal has to be seen in the light of the former agreements between doctor and patient.

Given those agreements, it will have to be put into question. Yet, the refusal will always be different in some respects from what was previously expected. Such differences can only be taken into account if the refusal is regarded as an individual expression of the patient, which is in need of interpretation.

In order to interpret the refusal, one will have to admit the possibility that it may be more important than all formerly discussed arrangements.