Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries – Scholten, M., et al (2023)

2023 | Advance Directives | Output
30 Jun, 2023

Matthé Scholten, Simone A. Efkemann, Mirjam Faissner, Marleen Finke, Jakov Gather, Tania Gergel, Astrid Gieselmann, Lia van der Ham, Georg Juckel, Laura van Melle, Gareth Owen, Sarah Potthoff, Lucy Stephenson, George Szmukler, Astrid Vellinga, Jochen Vollmann, Yolande Voskes, Anna Werning and Guy Widdershoven

European Psychiatry, 66(1), e48, 1–6, https://doi.org/10.1192/j.eurpsy.2023.2421


Background. 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.
Aims. 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.
Method. Comparisons between the empirical findings were drawn using a structured expert
consensus process.

Results. Findings converged on many points. Perceived opportunities of SBDs include promo-
tion 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 interpret-
ation, 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disappointment due to noncompliance, and outdated content.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.
Conclusions. Stakeholders tend to see the implementation of SBDs as ethically desirable,
provided that the associated challenges are addressed.