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Psychiatric advance directives: reconciling autonomy and non-consensual treatment

Trinity Hall, Cambridge CB2 1TJ

George Szmukler, Consultant Psychiatrist^*

Bethlem and Maudsley NHS Trust, Maudsley Hospital, Denmark Hill, London SE5 8AZ

^* Correspondence

This paper examines the potential for advance directives to be used by people with mental illness. Also known as a ‘living will’, an advance directive enables a competent person to make decisions about future treatment, anticipating a time when they may become incompetent to make such decisions. In English law, if "clearly established" and "applicable to the circumstances", an advance directive assumes the same status as contemporaneous decisions made by a competent adult. A psychiatric advance directive, anticipating relapse of a psychosis, develops the concept of the living will. We argue if could reconcile two apparently contradictory themes in the current practice of psychiatry — on the one hand, the call to provide for non-consensual treatment outside hospital, and on the other, the promotion of patient autonomy.

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