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452 AICHER
important to acknowledge this difference. Second, I will turn to the bioethical principle of
autonomy and the concept of voluntary informed consent insofar as it relates to the debate
surrounding PADs. Finally, I will focus on the problem of (surrogate) decision-making in case
of mentally ill patients and the moral authority of PADs.
2. PADs and End-of-Life Advance Directives
Although advance directives for the terminally ill are in some respects similar to advance
directives in mental health, there are also several differences that have to be acknowledged.
While both instruments are designed to foster patient autonomy, psychiatric patients often
have a different appearance from other patients. Most of them are conscious, physically able
to express a will, able to give consent or to refuse treatment and not terminally ill. They are
often faced with coercion, prevented from harming themselves (i.e. protected) as well as
restrained from acting in certain ways. Their freedom of action and will is restricted by
external and internal (medication, delusions) forces. They are temporarily (or in random
cases permanently) in a difficult mental state. The question is not how they want to die or if
they desire artificial life extension. It is not about euthanasia, neither active nor passive.
Instead, as Backlar claims, “advance directive[s] for end-of-life decisions and an advance
directive for psychiatric treatment are similar kettles which contain quite different fish.” 6
One of the main differences between PADs and medical advance directives which has been
neglected in the research literature, stems from the knowledge and experience that the
psychiatric patients has about her disorder. Psychiatric advance directives are usually written
after a mental crisis has already occurred. They do not emerge “out of the blue”. Instead the
patient who suffers from mental illness learns from what he experienced during past crisis
and she decides how she wants to be treated in the future when another crisis occurs that
results in her being no longer competent to make medical decisions for herself. Furthermore,
mental diseases are often chronic. As Lidz et al. found out by participant observation, people
who suffer from serious chronic diseases are very interested in active participation when it
comes to treatment decisions, since they
cannot so easily give up responsibility for their treatment, deny the reality or
seriousness of their illness, and wait to be cured. To do so mean giving up
responsibility for larger parts of their life while waiting for something that will probably
never come. 7
The Scottish psychologist Jacqueline Atkinson who wrote a book on Advance directives in
Mental Health in 2007 summarizes the concept of (P)ADs as follows: “At its simplest, the
concept of an advance directive is that, when well (capable/ competent), a person indicates
what they want to happen to them when they are ill and, crucially, not capable of making that
decision for themselves”. 8 Thereby she argues that the most important distinction regarding
the structure of PADs is between “opt-in” and “opt-out”. To be more precisely: It is possible
for mental health patients to exercise precedent autonomy either by giving voluntary
informed consent 9 or by refusing treatment in advance. Thereby it is of utmost importance
that advance directives are formulated by competent agents who are able to give their
consent 10 since otherwise the authority of advance directives is questionable from the outset.
In addition to that, the directive only comes into effect when the patient is no longer capable
6
Backlar 1997, p. 261.
7
Lidz et al. 2012, p. 305.
8
Atkinson 2007, p. 39.
9
See: Helmchen 2010, pp. 209-226.
10
See: Vollmann 2008.