“‘In flowery meads the sportive Sirens play,
Touch the soft lyre, and tune the vocal lay;
Me, me alone, with fetters firmly bound,
The gods allow to hear the dangerous sound.
Hear and obey; if freedom I demand,
Be every fetter strain’d, be added band to band.’”
In the above, Odysseus addresses his crew as they approach the lair of the Sirens, hideous birdlike creatures whose seductive song drove hearers to madness. Odysseus, seeking to experience insanity without tempting death, developed a careful plan: tie me to the mast, fill your ears with beeswax, and don’t listen to a word I say until we safely traverse the island.
Psychiatry is unique within medicine as practitioners can deprive people of their civil rights. Every day, psychiatrists must carefully weigh patient safety against patient autonomy. For this reason, every psychiatric evaluation requires not merely clinical judgment, but also requires ethical discretion.
Odysseus’ careful planning as insanity loomed just on the horizon has, millennia later, served as a useful allegory for helping resolve these ethical quandaries. Over the past twenty years, thinkers have developed Psychiatric Advance Care Directives, colloquially referred to as “Ulysses Contracts,” for managing patients with episodic mental illness.
These documents are formulated during moments of good control of patients’ illness, when they have the capacity to reason through and articulate preferences regarding their psychiatric care. The terms of a Ulysses Contracts snap into effect when the patient, in the throes of decompensated illness, cannot longer offer safe, cogent plans regarding their care. The hope is that by soliciting the preferences of patients when they are well, psychiatrists can respect patients’ authentic, autonomous wishes when they are at their sickest. Like Odysseus giving instructions to his crew, these documents instruct psychiatrists how to manage a patient’s leave from reason congruent with their preferences as an autonomous person.
A turn to the Odyssey reinforces the key philosophical issues at play. As the epic describes it, Odysseus’ “soul takes wing to meet the heavenly strain” when hearing the Sirens’ call. Madness persisted “Till, dying off, the distant sounds decay/Then scudding swiftly from the dangerous ground/The deafen’d ear unlock’d, the chains unbound.”
Phenomenologically, there is often a marked difference between the patient who was admitted and the patient who is discharged. Those who have cared for psychotic patients have observed remarkable changes in mental status as they become stabilized. Over days, one palpably feels psychosis or suicidality recede, as an ocean tide. In many cases, patients cannot remember the extent of their dysfunction once they are recovered.
Should we recognize distinct selves, one sick, one well? From a philosophical perspective, an autonomy maximalist may contend psychiatrists should permit patients to engage in high-risk activity that may threaten their life. After all, it is the patient’s authentic choice and we must respect their choices. A psychiatrist would respond that due to the disease process at play—be it bipolar disorder, schizophrenia, major depressive disorder, etc.—the patient’s decision-making is not autonomous. A “sick self” making decisions. This “sick self” is not an autonomous self, for it is not free of entanglements, free of influences that compromise reasoning capacity. For that reason, a sick self’s preferences are not strictly authentic. While they are sick, these patients need someone to care for them until the autonomous self can be restored.
But imagine the perspective of an oarsman on the ship with beeswax in his ears. At what point should Odysseus—screaming and chained to the mast—have his orders followed again? How do we identify the point at which the “sick self” ends, and the “autonomous self” begins? The possibility of a self with some capacity being overruled by a self with putatively more capacity raises the specter of paternalism. Ethicists have justified this by reference to a spectrum of capacity. But tensions clearly linger.
Overall, psychiatrists daily navigate the Scylla of paternalism and the Charybdis of decompensated illness. It is not easy. It is harder still for patients experiencing mental illness, admitted to hospitals and treated against their will. Ulysses Contracts can be helpful in keeping a bearing, but they are no panacea. At bedrock, what may best help resolve ethical conflicts is leveraging the social bonds that envelop a patient. As Odysseus addressed his crew:
“‘O friends, oh ever partners of my woes,
Attend while I what Heaven foredooms disclose.
Hear all! Fate hangs o’er all; on you it lies
To live or perish! to be safe, be wise!'”
Psychiatrists, patients, and families must recognize that patients are not and should not be alone in their illness. Our collective social success or failure depend upon our partnership.
Image courtesy of Wiki Commons.
