• Nuala B Kane.
• Department of Psychological Medicine, King's College Hospital, South London and Maudsley NHS Foundation Trust, London, UK.
• J Eval Clin Pract. 2017 Oct 1; 23 (5): 103810441038-1044.

AbstractThere has been a recent proposal by Gergel and Owen for introduction of legally enforceable self-binding directives for persons with bipolar affective disorder in the United Kingdom. The model is rooted in presence or absence of decision-making capacity, and the notion of capacity used is an expansion of the usual notion of capacity, in that it is individualized and diachronic. In this article, I argue that an individualized notion of capacity either lacks a coherent foundation or exposes itself to a situation where epistemological error results in a double standard or unjustified enforcement of the directive. I also raise concern that the diachronic notion of capacity leads to an authenticity type account, which fails to incorporate differences in individual prognosis. I then present a rough sketch of an alternative account, more in keeping with current mental health legislation, which uses an individualized notion of "risk to self" to justify self-binding directives in bipolar disorder.© 2017 John Wiley & Sons, Ltd.

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