Namita Puran

Abstract

By using “Ulysses contracts”, a form of advance directive, mentally ill persons who are deemed to be competent and in remission, are able to give prior permission for treatment to be implemented at a later time when they are incompetent, uncooperative, and are refusing care. The benefits of Ulysses contracts are preventing relapses and sustaining good mental health. However, Ulysses contracts also raise a number of ethical questions, including the nature of patient autonomy, competency and how to handle refusal of treatment. This paper will discuss these three facets of the Ulysses contract.

Mary is a mother of two and a successful stockbroker. She is also a diagnosed schizophrenic. For her this presents few complications, if she stays on her treatment regimen. However, according to Buchanan and Brock (1989), due to the nature of the illness, schizophrenics will sometimes stop taking medication at perceived remission times. Mary does not realize, until it is too late, that her medications were in fact responsible for the remission. As a result Mary suffers a relapse, often showing symptoms, such as hearing voices and paranoia, that make her jobs as mother and stockbroker close to impossible to fulfill. She may even disappear and end up on the streets if her condition is not identified. After Mary is once again put on treatment she may be fine for long periods of times, until she stops taking her medication. Unfortunately, this cycle may repeat endlessly unless Mary’s inability to consistently follow a treatment regimen is resolved. Some psychiatrists would maintain that Mary’s free will, that is her autonomy as a person, allows her the right to refuse medication at all times, even when she is symptomatic. Yet others will contend that Mary should, for her own well being, submit herself to be willingly bound to treatment at a later date, even if she is not willing or able to follow treatment at that later date. In other words, she should consent to a Ulysses Contract.

The term “Ulysses Contract” is derived from the mythical example of Odysseus and the Sirens. In Book 12 of the Odyssey, the goddess Circe gives Odysseus the option to hear the beautiful but deadly Sirens. However, since their voices bewitch men into their lethal arms, Odysseus must allow his crew mates to bind him to the mast of their ship, while they themselves have their ears molded with wax. As Odysseus hears the Sirens’ song he begs his crew to release him from the mast. The sailors ignore his pleas and bind him tighter to the ship. After having rowed beyond the Sirens, the crew removes the wax from their ears and free a very grateful Odysseus. He was thankful that the crew heeded his rational wishes, rather than the irrational ones brought on by the trickery of the Sirens (Perseus Digital Library Project, 2004).
In modern terms, a Ulysses Contract allows a person, specifically a mentally ill patient, to give an advance directive as to future course of treatment. Odysseus’ crew was deaf to the requests of the bound Odysseus and heard only his unbound rational requests; psychiatrists are not as lucky in dealing with mentally ill patients. According to New York State Law via precedent of Schloendorff v. Society of New York Hospital, 1914, an adult patient has the right to refuse treatment at all times (Health Care Decision-making and Declarations in New York, 2004). The nature of the Ulysses contract contradicts this in that it declares the competent wishes of the patient to be the only ones that are followed.

This paper will explore the three main aspects of a Ulysses contract and its impact on patient autonomy via the classic example of Odysseus and the Sirens. The first issue examined will be the rationality of the contract in terms of prior informed consent of the patient. The second issue discussed will be the point during treatment at which Ulysses contracts may come into effect, that is when a patient is no longer deemed “competent.” Finally, the paper considers the options for enforcement of the Ulysses contract.

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