PURAN, continued

Patient Competency

In the myth of Odysseus and the Sirens it was clear that the unbound Odysseus was completely competent in issuing his directives, and the bound Odysseus was under the influence of the Sirens and thus incompetent to issue directions to his crew. However, this clear dichotomy is hardly the case with of modern makers of Ulysses contracts. While the Patient Self Determination Act of 1991 indicates that a federally funded hospital must inform patients of their rights to create an advance directive, it says nothing of what the level of decision making capacity the undertaker must have (or have lost) to implement their prescribed Ulysses contract (Watson, 2001). It is unfortunate, but Ulysses contracts cannot be worded to take effect just when, according to this standard, “incompetence” is determined.
Additional complexities arise in judging competence. While the victims of degenerative diseases like Alzheimer’s may show a shifting pattern of competence, rather than a slow and inexorable decline, they all eventually reach a degree of incompetence that is definitive. In contrast, psychiatric patients may never exhibit clear and indisputable competence on the one hand, or unmistakable incompetence, on the other. These cases pose an additional problem for whatever standard of competence is chosen. Psychiatric patients are grouped in the sphere between competence and incompetence, but they cross and recross the disputed boundaries with the varying relapses and remissions. Week by week, even, in some cases, day by day, these patients’ level of competence shifts. In order to put into practice a policy of honoring advance directives just when or until competence is achieved, a degree of stasis greater than possibly achievable is required.

Application of any standard of competence in psychiatric settings, then, is likely to be particularly difficult. A related point, as noted by Carpenter (2000), is that too often the autonomy and rationality of mental patients are assessed against the higher standard of autonomy and rationality construed as ideals instead of against the measured autonomy and rationality of the same patient during different stages of treatment.

It is clear that there must be formal standards of competence. The least rigorous of these standards require only that the patient be able to focus on the decision’s outcome in light of what other rationally deemed persons would see as the outcome. That is, by discontinuing treatment, the patient can realize they may never attain the level of mental health they once had (Appelbaum & Roth, 1981). Other standards emphasize the process by which the decision is reached, and the level of competence exhibited in the patient’s understanding and reasoning capacities. That is, the patient understands that discontinuing treatment is not wise, regardless of the conclusion, even if that conclusion is that treatment is liable to make him or her sicker, or even that he or she may not be sick in the first place (Hackler, 1989). As a middle-of-the-road solution, Buchanan and Brock (1989) have proposed that patient competence be understood and assessed in terms of three abilities: understanding the relevant options, understanding the relevant consequences for the patient’s life in each of the relevant options, and evaluating the consequences of the various options by relating them to his or her values (p. 49). Focused on the patient’s decision-making process rather than upon the outcome of that process, this standard falls midway between the other standards and would seem to be the wisest choice in terms of judging competency.

ENFORCING ULYSSES CONTRACTS

Right to Refuse Treatment

In many states, such as New York, the psychiatric patient has a legal right to refuse treatment. Ulysses contracts undermine this right because the prior consent leads to the possible overruling of a later refusal of commitment or treatment (Radden, 1988). The issue then becomes, what justification can be given for overruling future refusals of treatment solely on the basis of the past authorization?

Proponents of Ulysses contracts argue that an overruling of a refusal of treatment can be justified if the patient has become incompetent (Brock, 1993). The notion of incompetence enables the doctor to raise doubts about the refusal, and not to give in automatically. For example, if a schizophrenic patient similar to Mary were to feel as if she were no longer ill yet clearly showed symptoms such a paranoia, it is evident that this would show incompetence. In this case, the patient’s doctor would undoubtedly medicate despite the patient’s objections that she was no longer suffering from schizophrenia.

According to Spellecy (2003), the application of a Ulysses contract during a refusal time, requires the doctor to interpret the Ulysses contract in an adaptive way. That is, the doctor must be able to adequately persuade the patient to be compliant with his or her written Ulysses contract. If this were not possible, a possible reevaluation in terms of adequacy and relevancy of the Ulysses contract must occur. For example, a very successful bipolar writer finds that when she is in her manic phase she is very productive, but she also has a son whom she must care for. She deems that her son is more important to her than her career. As a result, she enters into a Ulysses contract with her psychiatrist to stay on her treatment regimen. However, a month later her son is tragically killed in an accident. At this point, the Ulysses contract becomes a liability to her career. In this case, the writer and her psychiatrist would most likely choose to invalidate her Ulysses contract (Moody, 1992). Analogously, this would be as if the Sirens no longer presented a threat to Odysseus, and he longer had a young son and beautiful wife at home in Ithaca. If the Sirens represented the only joy Odysseus could possibly have in his life, it is possible that his shipmates might have considered untying him from the mast. Thus, a justification for overruling or upholding refusals can always be found in a specific declaration in the past, but only in the process of constant reevaluation of the patient’s social, emotional and mental status.

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