We often appeal to bioethical principles in ethical conflicts. Respect for autonomy is exemplified by informed consent and advance directive (AD) documents. In mental health we have to start from what the patients want and that they can participate in health decisions.1,2 Patients sometimes refuse effective treatments because they are not well informed. In that case, the professionals have the moral obligation to “make them autonomous and competent” by informing them. In cases of incompetence, the representative has to engage in a dialogue with the professionals so that the patient is respected, as far as possible.
In this dialogue, non-maleficence (the obligation to do no intentional harm) is also confirmed. We have to avoid violent behaviour through containment (pharmacological, mechanical, etc.). However, depriving someone, unjustifiably, from the right to autonomy also represents moral harm, as the individual is kept from carrying out his/her interests. In addition, harm is inflicted by unjustified paternalism that infantilises the patients, stigmatising them and discriminating against them. It is essential to seek their best interest. The AD brings positive repercussions in their recovery.3–7 Lastly, fair decisions can make it possible to save in health care expenses if the patients request that their lives not be prolonged beyond what is reasonable. Patients with dementia may fit this profile.
These principles are exemplified in the content and usefulness of the AD.
Wilder et al.8 and Srebnik et al.9 show that individuals with mental disorders accept neuromodulators and atypical antipsychotics better, refusing classic antipsychotics and lithium more frequently. Many professionals believe that the patients will reject all drugs; in fact, this does not generally occur.8 The reasons for drug refusal are: negative effects, feeling drugged and being incapable of carrying out activities of daily living.9
At any rate, freedom of choice in treatment and knowing its contraindications and the importance of continuing with it improve drug adherence; this in turn reduces the number of recurrences, because it represents a motivation for following the treatment.9 It is also a reason for choosing or refusing decisions about hospitalisation or contact persons for the patients while they are hospitalised.10
The use of an AD reduces coercive measures, as the medical team and the patient trust each other. In addition, establishing a proxy increases the possibilities of respecting the patient's desires and the individual will feel empowered by this.
Through all of this, we achieve respect for the individual (autonomy), we seek greater benefits (better drug compliance, etc.) and we avoid future harm (recurrences, coercive measures and so on). Freedom of choice in treatment can help to reduce the application of undesired treatments, and it is only fair that this should happen.