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NEWS: Clare Dyer Patients win right to have their advance decisions honoured BMJ 2007; 335: 688-b-689-b [Full text]

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Psychiatric Advance Directive

Thomas Szasz   (23 October 2007)

Psychiatric Advance Directive 23 October 2007
Thomas Szasz, Emeritus professor of psychiatry, SUNY Upstate Medical University, Syracuse, NY Home. 4739 Limberlost Lane, Manlius, NY 13104 Send response to journal: Re: Psychiatric Advance Directive	Clare 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." Alas, this is true only for medical patients. It is not true mental 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 1982, I proposed a "psychiatric will" for mental patients who wish to reject coerced hospitalization and other coerced psychiatric interventions. This proposal has been consistently opposed by American psychiatrists. Paul S. Appelbaum, a leading American forensic psychiatrist, warned: "One of the earliest proponents of advance directives, Thomas Szasz ... suggested that people with mental disorders use advance directives to preclude future treatment, especially treatment with medications. As Szasz saw it, if advance directives represented the unalterable choices of competent patients, there would be no way to override the preferences embodied in the directives. This suggestion raised the prospect of a class of patients who would be permanently untreatable, even if they later became psychotic and were hospitalized involuntarily." In short, the perceived moral-psychiatric need to prevent harm to self and others precludes the use of advance directives in psychiatry. Physicians and their patients ought to be aware of this limitation of advance directives. Thomas Szasz, M.D. Professor emeritus of psychiatry SUNY Upstate Medical University, Syracuse, New York 13210 tszasz@aol.com 1. Dyer C. Patients win right to have their advance decisions honoured by medical staff. BMJ 2007; 335: 688-89. 2. Szasz T. The psychiatric will: a new mechanism for protecting persons against "psychosis" and psychiatry. Amer Psychol 1982;37: 762-70. 3. Chodoff P and Peele R. The psychiatric will of Dr. Szasz. Hastings Cent Rep 1983; 13: 11-13. 4. Appelbaum P S. Psychiatric advance directives and the treatment of committed patients. Psychiat Serv 2004; 55:751-63. Competing interests: None declared