Intended for healthcare professionals

Head To Head Maudsley Debate

Should people with mental illness be able to commit themselves to future involuntary treatment?

BMJ 2023; 383 doi: (Published 15 November 2023) Cite this as: BMJ 2023;383:p2287
  1. Tania Gergel, director of research1, honorary senior research fellow2,
  2. Allen Frances, professor and chair emeritus3,
  3. Arun Chopra, executive medical director4,
  4. Theo Van Willigenburg, research fellow5
  1. 1Bipolar UK
  2. 2Division of Psychiatry, University College London
  3. 3Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine, Duke University, North Carolina
  4. 4Mental Welfare Commission for Scotland
  5. 5Faculty of Religion and Theology, Vrije Universiteit Amsterdam (VU Amsterdam)
  1. Correspondence to: T Gergel tania.gergel{at}, A Chopra arun.chopra2{at}

Self-binding directives, which allow people with mental illness to dictate a compulsory treatment for themselves in the event of a future episode, could give them a degree of control and safety in decision making, say Tania Gergel and Allen Frances. But Arun Chopra and Theo Van Willigenburg argue that this takes advance planning too far and could worsen inequalities

Yes—Tania Gergel and Allen Frances

Many people with severe episodic mental illness, such as bipolar disorder, know from past experience that their illness may well expose them to risk during future severe episodes in a way that they won’t be able to control at that point. They may also recognise the likelihood that they’ll resist treatment during such episodes—even though this is when treatment is most desperately needed.

These people understand, when they’re well, the potentially catastrophic consequences of remaining untreated, even including risk to their lives given the high risk of suicide, particularly during the most severe depressive or “mixed” episodes of bipolar disorder. A self-binding directive (SBD) could provide them with a greater degree of control and safety for their future, by allowing those who wish to do so to explain how illness and risk manifest for them and to request treatment during the most severe phases of illness, even if they don’t consent when a future episode occurs.

Common concerns

SBDs are a form of advance request. They are not legally binding and would never lead to a clinician being forced to prescribe a treatment that went against their own clinical judgment. They are not “directives” in the sense of people receiving unnecessary or avoidable involuntary treatment or hospital admission. Rather, they harness the expertise of all stakeholders drawn from previous episodes, allowing clear indicators to be given for treatment and assessment, ensuring that treatment would be imposed only if the necessary clinical and …

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