Against Ulysses contracts for patients with borderline personality disorder
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SCIENTIFIC CONTRIBUTION
Against Ulysses contracts for patients with borderline personality disorder Antoinette Lundahl1 · Gert Helgesson2 · Niklas Juth2
© The Author(s) 2020
Abstract Patients with borderline personality disorder (BPD) sometimes request to be admitted to hospital under compulsory care, often under the argument that they cannot trust their suicidal impulses if treated voluntarily. Thus, compulsory care is practised as a form of Ulysses contract in such situations. In this normative study we scrutinize the arguments commonly used in favour of such Ulysses contracts: (1) the patient lacking free will, (2) Ulysses contracts as self-paternalism, (3) the patient lacking decision competence, (4) Ulysses contracts as a defence of the authentic self, and (5) Ulysses contracts as a practical solution in emergency situations. In our study, we have accepted consequentialist considerations as well as considerations of autonomy. We conclude that compulsory care is not justified when there is a significant uncertainty of beneficial effects or uncertainty regarding the patient’s decision-making capacity. We have argued that such uncertainty is present regarding BPD patients. Hence, Ulysses contracts including compulsory care should not be used for this group of patients. Keywords Ulysses contract · Borderline personality disorder · Autonomy · Authenticity · Decision competence · Ethics · Psychiatry
Introduction Patients with borderline personality disorder (BPD) often raise distress and concern among caregivers in psychiatry (Linehan 1993; Lundahl et al. 2018). Borderline patients often experience relentless crises and display rapid changes in emotions and attitudes, due to the low tolerance for adverse situations and inner unpleasant emotions, which are characteristics of the disorder (Linehan 1993; American Psychiatric Association 2013). Moreover, suicidal and selfdestructive behaviour is typically used as a means of regulating emotions and communicating inner discomfort (Linehan 1993; Black et al. 2004; Brown et al. 2002). Inpatient care * Antoinette Lundahl [email protected] Gert Helgesson [email protected] Niklas Juth [email protected] 1
Norra Stockholms Psykiatri, S:t Görans Sjukhus, 112 81 Stockholm, Sweden
Stockholm Centre for Healthcare Ethics (CHE), Karolinska Institutet, LIME, 171 77 Stockholm, Sweden
2
is commonly applied due to suicidal behaviour, but experience has shown uncertain or even negative effects of such measures when it comes to preventing suicide and selfharm (Paris 2004; Krawitz et al. 2004; National Institute for Health and Care Excellence 2009). Therefore, inpatient care for longer than a few days has been advised against in several clinical guidelines (National Institute for Health and Care Excellence 2009; Australian Government, National Health and Medical Research Council 2012). Compulsory care, even during a crisis, is also advised against since it may inadvertently undermine the patient’s capacity to care for herself (National Institute for Health and Care
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