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An International Comparison of Psychiatric Advance Directive Policy: Across eleven jurisdictions and alongside advance directive policy

Overview

This research compares psychiatric advance directive (PAD) policies across eleven international jurisdictions with standard advance directives (AD). The study finds PADs are typically more strictly regulated and have weaker legal force than medical AD, with greater barriers to use and more conditions allowing override of patient preferences.

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Individual authors

Lead Authors:

  • Sophie Gloeckler - Institute for Biomedical Ethics and History of Medicine, University of Zürich, Switzerland
  • Matthé Scholten - Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Germany

Co-Authors:

  • Penelope Weller - Royal Melbourne Institute of Technology University, Australia
  • Alexander Ruck Keene - King's College London and 39 Essex Chambers, United Kingdom
  • Soumitra Pathare - Centre for Mental Health Law and Policy, Indian Law Society Law College, India
  • Ramya Pillutla - Centre for Mental Health Law and Policy, Indian Law Society Law College, India
  • Leticia Andorno - Institute for Biomedical Ethics and History of Medicine, University of Zürich, Switzerland

Senior Author:

  • Nikola Biller-Andorno (corresponding author) - Institute for Biomedical Ethics and History of Medicine, University of Zürich, Switzerland

Key insights

Key Insights

  1. Psychiatric directives face stricter regulation than medical advance directives globally

  2. Germany uniquely treats psychiatric and medical directives as legally equivalent

  3. Most jurisdictions allow overriding psychiatric preferences for emergency situations

  4. Northern Ireland and New South Wales lack legal psychiatric directive provisions

  5. Self-binding directives require stronger safeguards but enhance patient autonomy

  6. Capacity assessment requirements are often higher for psychiatric directives

  7. Treatment refusals in mental health face more restrictions than physical

  8. Policy differences may reflect unfair treatment of mental health patients

Did this resource draw on transformative evidence?

<p>This document was<strong> not</strong> based on experiential expertise from service users. It was a legal and policy analysis conducted by academic experts in law, clinical practice, and ethics. While the authors reference some studies that included service user perspectives (noting users prefer binding PADs), the methodology involved expert legal review of statutes across eleven jurisdictions, not direct experiential input from people with lived experience of psychiatric advance directives.</p>
<p>This document incorporated limited practice wisdom. While the research team included experts with "clinical, and ethics backgrounds," the methodology was primarily a legal analysis of statutes rather than systematic collection of clinical practice insights. The authors acknowledge this gap, calling for future research to examine "How do PAD tend to play out in practice" and what connections exist between policy and real-world implementation.</p>
<p>This document was primarily based on research insights but limited in evaluation. The authors conducted a systematic comparative legal analysis across eleven jurisdictions and extensively cited existing research literature on PAD effectiveness, user preferences, and outcomes. However, they acknowledge significant evaluation gaps, explicitly calling for future research to "compare the various impacts of these PAD policy choices" and evaluate how different policies perform in practice.</p>

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Categories

Resource type

Literature Review