Steering clear of Akrasia: An integrative review of self‐binding Ulysses Contracts in clinical practice

• Published in: Bioethics 2023-09, Vol.37 (7), p.690-714
• Main Authors: Brenna, Connor T. A., Chen, Stacy S., Cho, Matthew, McCoy, Liam G., Das, Sunit
• Format: Article
• Language: English
• Subjects: Advance directives; Agreements; Autonomy; binding contract; Bioethics; Clinical decision making; Clinical medicine; Contracts; Decision making; Health care; Odysseus Transfer; Patients; Powers of attorney; psychiatric will; Ulysses Contract; Ulysses Pact; voluntary commitment contract
• ISSN: 0269-9702; 1467-8519
• DOI: 10.1111/bioe.13197

In many jurisdictions, legal frameworks afford patients the opportunity to make prospective medical decisions or to create directives that contain a special provision forfeiting their own ability to object to those decisions at a future time point, should they lose decision‐making capacity. These agreements have been described with widely varying nomenclatures, including Ulysses Contracts, Odysseus Transfers, Psychiatric Advance Directives with Ulysses Clauses, and Powers of Attorney with Special Provisions. As a consequence of this terminological heterogeneity, it is challenging for healthcare providers to understand the terms and uses of these agreements and for ethicists to engage with the nuances of clinical decision‐making with such unique provisions surrounding patient autonomy. In theory, prospective self‐binding agreements may safeguard patient's “authentic” wishes from future “inauthentic” changes of mind. In practice, it is unclear what may be comprised within these agreements or how—and to what effect—they are used. The primary focus of this integrative review is to curate the existing literature describing Ulysses Contracts (and analogous decisions) used in the clinical arena, in order to empirically synthesize their shared essence and provide insights into the traditional components of these agreements when used in practice, the requirements of their consent processes, and the outcomes of their utilization.