Self-binding directives in psychiatric practice: a systematic review of reasons

Lucy Stephenson; Astrid Gieselmann; Tania Gergel; Gareth Owen; Jakov Gather; Matthé Scholten

doi:10.1016/S2215-0366(23)00221-3

Self-binding directives in psychiatric practice: a systematic review of reasons

Lancet Psychiatry. 2023 Nov;10(11):887-895. doi: 10.1016/S2215-0366(23)00221-3. Epub 2023 Sep 12.

Authors

Lucy Stephenson¹, Astrid Gieselmann², Tania Gergel³, Gareth Owen³, Jakov Gather⁴, Matthé Scholten⁵

Affiliations

¹ Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. Electronic address: lucy.a.stephenson@kcl.ac.uk.
² Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany; Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany.
³ Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
⁴ Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany; Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany.
⁵ Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.

PMID: 37714174
DOI: 10.1016/S2215-0366(23)00221-3

Abstract

Self-binding directives (SBDs) are an ethically controversial type of advance decision making involving advance requests for involuntary treatment. This study systematically reviewed the academic literature on psychiatric SBDs to elucidate reasons for and against their use in psychiatric practice. Full-text articles were thematically analysed within the international, interdisciplinary authorship team to produce a hierarchy of reasons. We found 50 eligible articles. Reasons for SBD use were promoting service user autonomy, promoting wellbeing and reducing harm, improving relationships, justifying coercion, stakeholder support, and reducing coercion. Reasons against SBD use were diminishing service user autonomy, unmanageable implementation problems, difficulties with assessing mental capacity, challenging personal identity, legislative issues, and causing harm. A secondary finding was a clarified concept of capacity-sensitive SBDs. Future pilot implementation projects that operationalise the clarified definition of capacity-sensitive SBDs with safeguards around informed consent, capacity assessment, support for drafting, and independent review are required.

Publication types

Review