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Advance Directives in Mental HealthReview - Advance Directives in Mental Health
Theory, Practice and Ethics
by Jacqueline M. Atkinson
Jessica Kingsley, 2007
Review by Tony O'Brien, RN, MPhil
Jul 29th 2008 (Volume 12, Issue 31)

Since Thomas Szasz first suggested the notion of the 'psychiatric will' in 1968, various forms of expression of preferences for mental health care have developed. As Jacqueline Atkinson shows in this book, expressions of preference now take a wide variety of forms, from 'crisis cards' that simply inform caregivers, clinicians, and family members of individuals' choices should they become unwell, to 'Ulysses contracts' that attempt to bind a person to a particular course of action despite the preferences they might express at the time. In between are 'advance directives' and other forms of expressions of preference, with different degrees of legal authority, comprehensiveness and buy in from stakeholders. Since they were first mooted, advance directive have been the subject of varying levels of interest from service providers, and considerable academic interest at least from those working in this area. In this book Atkinson summarizes a good deal of the available literature, as well as exploring the philosophical and conceptual issues involved in advanced directives. These issues include the nature of identity, personhood, autonomy, responsibility and rationality. Advance Directives in Mental Health is a fine introduction to the area, as well as useful synopsis of the current state of theory and practice. It will be a valuable resource for clinicians, service users, family members and those planning and providing mental health services.

The book is divided into three sections, the first of which covers the history, development and legal context of advance directives, and their relationship to mental health legislation. In this section, and throughout the book, Atkinson draws on her knowledge of the Scottish mental health act which seems to be more enlightened than most. In addition to its set of principles and code of practice, the Scottish legislation makes provision for advance statements in a way that few jurisdictions do, if any. The middle section examines ideological issues, a term that serves to cover some complex philosophical problems posed by mental illness, competence, and consent or refusal of treatment in advance. These issues are not always addressed in the clinical literature on advance directives, which is the more impoverished for its lack of attention to some fundamental problems. The final section looks at the real world issues of researching advance directives, and applying them in clinical practice. Atkinson is well qualified to comment on the research in this area as she is one of the major contributors. The book ends with suggestions for the way forward in negotiating preferences in advance.

Advance Directives in Mental Health raises some important ethical and clinical problems. As is usual in this area, debate is framed in relation to autonomy and paternalism, but as Atkinson shows the issues cannot be reduced to a simple matter of ethical principle. If we respect autonomy, what of the agent's responsibility for the consequences of their decisions? Generally speaking this is not problematic, but if I decide to refuse medication and subsequently harm someone when unwell, how much responsibility do I carry for my decision to refuse? Atkinson points out that in the United Kingdom the limits of responsibility, and therefore freedom, are being debated in relation to smoking, a reminder that notions of freedom and responsibility are embedded within societal norms as much as in theoretical ethical frameworks. There is also an exploration of the insanity defense, especially the limits of mental illness as a defense where the offence results from a decision that can be considered within the person's control and for which they retain mens rea. Atkinson presents a series of vignettes which highlight criteria for judging responsibility. The issues are not settled, but Atkinson's exploration of them leaves readers better able to consider the complexity of such problems.

There are many take home messages in this book, and issues are explored with a clear sighted view of both the conceptual and practical problems involved in advance directives. Atknson is not an ideologue, although she clearly sees a place for advance directives in clinical care. It's hard to argue with that position in principle, but as Atkinson makes clear, there are numerous pragmatic problems that make advance directives difficult to implement successfully. They are suggested as an alternative to involuntary outpatient treatment, but an immediate problem is that in almost all cases an advance directive does not override mental health legislation. So even if negotiated with a clinical team, the preferences expressed in an advance directive may not hold sway. However as Atkinson makes clear throughout the book, like every clinical intervention, advance directives are more likely to be found useful by service users as well as clinicians if there is a commitment to work with them. It could perhaps be argued that this is no more than a good clinician should do: explore preferences, and undertake to honor those as much as possible. This is certainly a frequently made argument about involuntary outpatient treatment, that the legal contract is no more than a formalization of the clinician's (and service's) obligation to provide good clinical care.

One of the central issues in any advance directive program is support by those in positions to make a difference in its uptake. Some of the studies reported here show very low uptake, but an improvement when there are clear explanations and practical assistance provided. People who might be thought to be highly motivated to make advance directives do not always do so, preferring to see such issues as best left to clinicians. This is a phenomenon also observed in relation to coercive interventions, where service users do not always report a subjective sense of coercion even while subject to objectively coercive interventions such as civil commitment. This is especially so for those most at risk, vulnerable groups who may well be inured to coercion and accept it as a fact of life, or as a price to be paid for what should be theirs by right.

Advance Directives in Mental Health serves a useful function by exploring some of the conceptual issues that are taken for granted in clinical studies and research reports. Of course the discussion will have to be considered in the context of local service provision and legal frameworks; it is likely to be of more direct relevance to those in the United Kingdom than in other jurisdictions. However Advance Directives in Mental Health offers a useful overview of an important area of mental health care and is a valuable reference for clinicians, students, lawyers and those who work with service users and their families and carers. It is clearly written and well referenced, with the bibliography providing a rich source of original material.

© 2008 Tony O'Brien

Tony O'Brien, RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland, a.obrien@auckland.ac.nz


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