PURAN, continued

RATIONALITY OF ULYSSES CONTRACTS

Informed Consent

Informed consent is seen as the first step in any medical trial or treatment. The lack of such a process of informed consent may lead to many human rights abuses. In Odysseus’ case, were the sailors to have bound him without his expressed consent to do so, it would have been a violation of his rights as an autonomous person. Indeed, such an action would not only harm him, but full disclosure may not have been given to Odysseus, thus invalidating the treatment (tying to the mast) as a whole. Further, Bernard (1927) indicates that this method is irrational in that no experiment should be performed on a patient that may be harmful to him, despite the benefits to humanity and medical science.

Bhutta (2004) further goes on to elucidate a plan for obtaining informed consent of the patient. The first step he outlines is discussing the possible treatment within the research team and any internal review board to assess rationality of the treatment. The next step would be to involve the patient in the discussion of the treatment options. After a “true understanding” is obtained from the patient, then and only then can the patient either choose to accept or reject the proposed treatment. Upon acceptance, a written, verbal, witnessed or recorded agreement is secured from the patient and medical official, and treatment will then be implemented.

According to the American Psychological Association (2002), informed consent exists merely between a patient and his or her physician. In order to obtain informed consent, the physician is required to disclose and discuss the diagnosis, the nature and purpose of the proposed treatment, the risks and benefits of the proposed treatment, any possible alternatives (and their risks and benefits) and finally, and perhaps most importantly in the case of mentally ill patients, the risks of not receiving treatment.

Although informed consent is usually assumed as valid for a patient who is competent, what is to be said of a mentally ill patient? Buchanan and Brock (1989) insist, “The informed consent doctrine requires the free and informed consent of a competent patient” (p. 26.) However, several studies on capacity to consent to psychiatric treatment among patients with mental illnesses like schizophrenia have been published. In Appelbaum and Grisso’s (1995) study, schizophrenic and non-symptomatic subjects’ ability to consent to psychiatric and medical treatments was measured. Participants’ abilities to meet the four legal standards of competency, (choice, understanding, appreciation and rational reasoning) were assessed using a MacArthur Competency Assessment Tool (MacCAT). The subjects with schizophrenia were shown to be unable to exercise decision-making capacity compared to other subjects, with the most difficulty occurring in the area of “understanding.”

Carpenter (2000) used a method of “enhanced informed consent” with the same MacCAT to assess decision making capacity in patients with schizophrenia. The schizophrenic group performed more poorly on the MacCAT than the non-symptomatic group, as was expected. However, a subset of patients with schizophrenia received an additional educational presentation consisting of reviewing the protocol, having questions answered, and working on a computer program designed to teach basic research concepts such as placebo, drug withdrawal, protocol and random assignment. The MacCAT was readministered after the educational presentation. The “understanding” scores of this subset of subjects with schizophrenia improved to the level of the non-symptomatic group. Thus, it can be concluded that informed consent from mentally ill patients is possible if reinforcements such as educational interventions are given to the patient.

IMPLEMENTING ULYSSES CONTRACTS

Analysis of Self: Past and Present

Some psychiatrists such as Dresser (1989) find the authority of Ulysses contracts to be questionable from the personal identity standpoint. The primary challenge presented by personal identity is the determination of when a person’s life stages are of the same person, or when the circumstances indicate development of a different person. As Parfit (1984), argues, psychological changes through time, as is seen in bipolar disorder and schizophrenia, raise questions about psychological continuity and connectedness between different stages in a person’s life, or the possibility that a different personality has emerged. Ricoeur (1986) even argues that under specific conditions a Ulysses contract is a method for the former self to enslave the later self of the person.
For one person to issue directives about what should happen to another person, Buchanan & Brock (1989) have asserted, even when that other person was housed in the same body, would be morally abhorrent and akin to slavery. They counter, however, that people who issue advance directives about their own future care before suffering these severe and irreversible dementias cannot be considered guilty of wrongfully enslaving another person because they cannot be considered to have become another person. Thus, the person who issued the advance directive no longer exists, but no further person has succeeded her. As a result, the issue of slavery of selves, as touted by Ricoeur (1986), becomes a non-issue.

One may further argue that a Ulysses contract underscores the unity of the patient’s life, and focuses not on individual selves, but on unifying the person’s wishes and goals as a whole. The Ulysses contract is usually put into effect when a person anticipates his or her life may be in crisis. The Ulysses contract does not imply that one phase of life (a clear period) is more important than another one (a period of crisis). It merely indicates that at these times of crisis, the patient still recognizes he or she is part of the whole person and thus this stage of life may be overcome in the future, hopefully with the treatment provided.

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