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Ulysses Contracts in psychiatric care: helping patients to protect themselves from spiralling
  1. Harriet Standing1,
  2. Rob Lawlor2
  1. 1 Leeds Teaching Hospitals NHS Trust, Leeds, UK
  2. 2 Inter-Disciplinary Ethics Applied, University of Leeds, Leeds, UK
  1. Correspondence to Dr Rob Lawlor, Inter-Disciplinary Ethics Applied, University of Leeds, Leeds LS2 9JT, UK; r.s.lawlor{at}leeds.ac.uk

Abstract

This paper presents four arguments in favour of respecting Ulysses Contracts in the case of individuals who suffer with severe chronic episodic mental illnesses, and who have experienced spiralling and relapse before. First, competence comes in degrees. As such, even if a person meets the usual standard for competence at the point when they wish to refuse treatment (time 2), they may still be less competent than they were when they signed the Ulysses Contract (time 1). As such, even if competent at time 1 and time 2, there can still be a disparity between the levels of competence at each time. Second, Ulysses Contracts are important to protect people’s most meaningful concerns. Third, on the approach defended, the restrictions to people’s liberty would be temporary, and would be consistent with soft paternalism, rather than hard paternalism: the contracts would be designed in such a way that individuals would be free to change their minds, and to change or cancel their Ulysses Contracts later. Finally, even if one rejects the equivalence thesis (the claim that allowing harm is as bad as doing harm), this is still consistent with the claim that, in particular cases, it can be as wrong to allow a harm as to do a harm. Nevertheless, controversies remain. This paper also highlights several safeguards to minimise risks. Ultimately, we argue that people who are vulnerable to spiralling deserve a way to protect their autonomy as far as possible, using Ulysses Contracts when necessary.

  • autonomy
  • informed consent
  • mentally ill and disabled persons
  • philosophical ethics
  • psychiatry
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Footnotes

  • Contributors HS wrote the first (significantly longer) draft of this paper. RL then edited the paper, altered the structure, tweaked parts, and re-wrote some parts (particularly the sections "Competence" and "Interpreting the do no harm principle".) Ultimately, however, most of the key ideas were present in HS's original draft.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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