An Ethical Analysis of the Application of Psychiatric Advance Directives in Treating Substance Use Disorder

Monica Gerrek, PhD – Department of Bioethics & Medical Humanities – Case Western Reserve University; Ben Schwan, PhD – Department of Bioethics & Medical Humanities – Case Western Reserve University

Abstract: Psychiatric advance directives (PADs) offer those suffering from a mental health condition the ability to indicate their medical preferences in periods of incapacitating psychiatric crises. However, despite substance use disorders (SUDs) classification in the DSM-V, PADs are not used to guide treatment in times of SUD crises. The reasons for this are unclear. As such, this future paper aims to examine the underpinnings of these directives and investigate their ethical application to treating addiction. Addiction, a condition characterized by impaired control and physiological effects that result in sustained use at great personal cost, threatens the two underpinnings of autonomy: authenticity and sovereignty. Similar to other DSM-V conditions, concerns over the ability to rule oneself according to fundamental values remain a hallmark of the condition. With PADs serving as a tool to specify treatment preferences during periods of incapacity, these documents seek to promote authenticity and sovereignty in directing future medical care. With the justification of PADs rooted in autonomy considerations, this piece underscores ethically relevant similarities between addiction and traditional psychiatric conditions that establish the application of these documents in treating SUD. As such, this presentation will explore the underpinnings of these advance directives and examine the fundamental moral considerations in the justification of PADs. We will then investigate the ethical application of PADs in treating addiction through a rigorous analysis of the contemporary approaches in treating mental health conditions and SUDs. Finally, we will argue for the application of these documents in treating addiction in times of SUD crises.

Keywords: Addiction, Authenticity, Advance Directives