Psychiatric Advance Directives Under the Convention on the Rights of Persons With Disabilities: Why Advance Instructions Should Be Able to Override Current Preferences

Matthé Scholten; Astrid Gieselmann; Jakov Gather; Jochen Vollmann

doi:10.3389/fpsyt.2019.00631

Psychiatric Advance Directives Under the Convention on the Rights of Persons With Disabilities: Why Advance Instructions Should Be Able to Override Current Preferences

Front Psychiatry. 2019 Sep 11:10:631. doi: 10.3389/fpsyt.2019.00631. eCollection 2019.

Authors

Matthé Scholten¹, Astrid Gieselmann¹, Jakov Gather^{1

2}, Jochen Vollmann¹

Affiliations

¹ Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.
² Department of Psychiatry, Psychotherapy, and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany.

Abstract

Psychiatric advance directives (PADs) are documents by means of which mental health service users can make known their preferences regarding treatment in a future mental health crisis. Many states with explicit legal provisions for PADs have ratified the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). While important UN bodies consider PADs a useful tool to promote the autonomy of service users, we show that an authoritative interpretation of the CRPD by the Committee on the Rights of Persons with Disabilities has the adverse consequence of rendering PADs ineffective in situations where they could be of most use to service users. Based on two clinical vignettes, we demonstrate that reasonable clinical recommendations can be derived from a more realistic and flexible CRPD model. Concerns remain about the accountability of support persons who give effect to PADs. A model that combines supported decision making with competence assessment is able to address these concerns.

Keywords: United Nations Convention on the Rights of Persons with Disabilities; advance statements; competence; informed consent; mental capacity; psychiatric advance directives; substitute decision making; supported decision making.