# Whose voice is heard? Mental health professionals’ involvement, epistemic injustice, and the ethics of psychiatric advance directives

## TL;DR

The paper explores how mental health professionals can ethically support women in creating psychiatric advance directives without undermining their autonomy.

## Contribution

It introduces a novel ethical framework combining clinician-patient relationship models and epistemic justice to guide professionals in supporting psychiatric advance directives.

## Key findings

- Mental health professionals may unintentionally exert undue influence when assisting in drafting psychiatric advance directives.
- Ethically sensitive facilitation can transform psychiatric advance directives into spaces of epistemic repair.
- Training and institutional frameworks are essential to empower professionals to act as agents of ethical and epistemic justice.

## Abstract

Women living with mental health conditions, neurodevelopmental disorders, or other forms of psychosocial disabilities are disproportionately exposed to coercive practices, structural stigma, and epistemic marginalization. Psychiatric advance directives (PADs) have been proposed as tools to promote autonomy and reduce coercion, yet their implementation in practice remains complex. When a mental health professional is designated to support the person in drafting the directive, they may face specific ethical challenges, including the risk of exerting undue influence on the person’s choices. This mini review offers a critical synthesis of theoretical and ethical frameworks to clarify mental health professionals’ roles in facilitating PADs. Drawing on the four models of the clinician–patient relationship developed by Emanuel and Emanuel, and Fricker’s concept of epistemic injustice, we analyze how relational dynamics influence the drafting process. These models provide a useful framework to conceptualize the mental health professional’s role within an alliance aimed at support in restoring agency, trust, and recognition. This analysis highlights how ethically sensitive facilitation may transform PADs into spaces of epistemic repair, ensuring that mental health professionals’ involvement respects women’s autonomy and lived experiences instead of inadvertently reproducing existing power imbalances. This synthesis contributes to socio-political and clinical debates on PADs, care ethics, and health equity, emphasizing the need to recognize and value experiential knowledge. It also underscores the importance of training and having institutional frameworks that empower mental health professionals, particularly nurses, to act as agents of ethical and epistemic justice in supporting the drafting of PADs.