You don't in psychiatry

Dyer reports, “A new statutory right for patients to say in advance what treatments they would want to refuse if they later lose the capacity to take decisions came into force this week. Doctors will have to abide by the new advance decisions to refuse treatment (ADRTs) or risk criminal or civil proceedings in the courts.”¹ Alas, this is true only for medical patients. It is not true for mental health patients. Indeed, it cannot be true so long as we have special laws for such patients.

Dyer adds that “Patients will not be able to . . . require a doctor to do anything unlawful.” There is the rub. In psychiatry, procedures that incarcerated mental patients view as protection of their civil rights, psychiatrists regard as interference with their duty to protect patients and the public from the ravages of mental illness, an interpretation the courts uphold.

In short, the perceived moral-psychiatric need to prevent harm to self and others precludes the use of advance directives in psychiatry. Doctors and their patients ought to be aware of this limitation of advance directives.