Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.
Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany.
Eur Psychiatry. 2023 Jun 9;66(1):e48. doi: 10.1192/j.eurpsy.2023.2421.
Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs.
This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders' views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom.
Comparisons between the empirical findings were drawn using a structured expert consensus process.
Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals' confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns.
Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.
自我约束指令（SBD）是一种精神科预先指示，其中包括一项条款，即心理健康服务使用者事先同意在特定条件下非自愿住院和治疗。医学伦理学家和法律学者确定了 SBD 的各种潜在好处，但也提出了伦理问题。直到最近，人们对利益相关者对 SBD 的机会和挑战的看法知之甚少。
本文旨在通过比较德国、荷兰和英国最近关于利益相关者对 SBD 的机会和挑战的观点的实证发现，促进 SBD 的国际交流。
使用结构化专家共识过程对实证发现进行比较。
研究结果在许多方面趋同。SBD 的预期机会包括促进自主性、避免个人定义的伤害、早期干预、缩短住院时间、改善治疗关系、让信任的人参与、避免非自愿住院、处理创伤、减少非自愿治疗的污名化、增加专业人员的信心和减轻代理决策者的负担。预期的挑战包括缺乏意识和知识、缺乏支持、不当影响、危机期间无法获得、跨机构协调不足、解释问题、能力评估困难、治疗灵活性受限、资源稀缺、因不遵守而失望以及内容过时。利益相关者往往关注实际挑战，而不太关注基本的伦理问题。
利益相关者倾向于认为实施 SBD 在道德上是可取的，前提是解决相关挑战。
