Self-binding directives in psychiatric practice: a systematic review of reasons

Lucy Stephenson, Gareth Owen, Tania Gergel, Gieselmann Astrid, Matthe Scholten, Gather Jakov

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Self-binding directives (SBDs) are an ethically controversial type of advance decision making involving advance requests for involuntary treatment. This study systematically reviewed the academic literature on psychiatric SBDs to elucidate reasons for and against their use in psychiatric practice. Full-text articles were thematically analysed within the international, interdisciplinary authorship team to produce a hierarchy of reasons. We found 50 eligible articles. Reasons for SBD use were promoting service user autonomy, promoting wellbeing and reducing harm, improving relationships, justifying coercion, stakeholder support, and reducing coercion. Reasons against SBD use were diminishing service user autonomy, unmanageable implementation problems, difficulties with assessing mental capacity, challenging personal identity, legislative issues, and causing harm. A secondary finding was a clarified concept of capacity-sensitive SBDs. Future pilot implementation projects that operationalise the clarified definition of capacity-sensitive SBDs with safeguards around informed consent, capacity assessment, support for drafting, and independent review are required.
Original languageEnglish
Pages (from-to)887-895
Number of pages9
JournalThe Lancet Psychiatry
Issue number11
Early online date12 Sept 2023
Publication statusPublished - Nov 2023


  • psychiatric advance directive, ethics, mental health, advance decision, advance choice, Ulysses contract


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