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ABSTRACT. Sometimes the mentally ill have sufficient mental capacity to refuse treatment competently, and others have a moral duty to respect their refusal. However, those with episodic mental disorders may wish to precommit themselves to treatment, using Ulysses contracts known as "mental health advance directives." How can health care providers justify enforcing such contracts over an agent's current, competent refusal? I argue that providers respect an agent's autonomy not retrospectively-by reference to his or her past wishes-and not merely synchronically-so that the agent gets what he or she wants right now-but diachronically and prospectively, acting so that the agent can shape his or her circumstances as the agent wishes over time, for the agent will experience the consequences of providers' actions over time. Mental health directives accomplish this, so they are a way of respecting the agent's autonomy even when providers override the agent's current competent refusal.
Some mental illnesses, such as bipolar disorder I or schizophrenia, are both episodic and treatable. Patients with bipolar disorder I, for example, occasionally become manic or depressed. During a manic episode, the patient may do things like insulting coworkers, making passes at attractive neighbors, or squandering money. Under American law, the mentally ill have the right to refuse treatment so long as they do not pose a serious risk of harm to themselves or others (Capron and Birnbaum 2005, pp. 20-103-20-107).1 This means that there are cases in which the mentally ill may refuse treatment during an episode, but later regret the consequences of, say, manic behavior. Half of all American states now have laws providing for "mental health advance directives," a kind of Ulysses contract for mental health care.2 People who execute a mental health directive are consenting to temporary treatment and hospitalization in advance, overriding their later refusal.
It is easy to justify coercing a patient who is not competent to refuse treatment, but arguably many people in a psychotic episode have sufficient mental capacity for a competent refusal, and health care providers have a moral duty to respect their refusal.3 How can one justify enforcing a Ulysses contract when Ulysses is competent to demand release? Two answers dominate the literature. First, some writers argue that all competent refusals must be respected and that Ulysses...