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Scholten M, Efkemann SA, Faissner M, Finke M, Gather J, Gergel T, Gieselmann A, van der Ham L, Juckel G, van Melle L, Owen G, Potthoff S, Stephenson LA, Szmukler G, Vellinga A, Vollmann J, Voskes Y, Werning A, Widdershoven G. Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries. Eur Psychiatry 2023; 66:e48. [PMID: 37293987 PMCID: PMC10305757 DOI: 10.1192/j.eurpsy.2023.2421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/29/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs. AIMS This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders' views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom. METHOD Comparisons between the empirical findings were drawn using a structured expert consensus process. RESULTS Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals' confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns. CONCLUSIONS Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.
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Affiliation(s)
- Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Simone A. Efkemann
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Mirjam Faissner
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Marleen Finke
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Jakov Gather
- 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
| | - Tania Gergel
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Astrid Gieselmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Psychiatry and Psychotherapy, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Lia van der Ham
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Georg Juckel
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Laura van Melle
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- GGZ inGeest, Amsterdam, The Netherlands
| | - Gareth Owen
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sarah Potthoff
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Lucy A. Stephenson
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - George Szmukler
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | | | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Yolande Voskes
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anna Werning
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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