Mental health treatment, capacity and consent

 

Whether a person is a compulsory patient or not, psychiatrists and other clinicians must seek their informed consent before any treatment can be given. Prescribing a particular psychiatric medication, providing psychological treatment or even making significant changes to a person’s dose of antipsychotic medication could all be individual treatment decisions requiring consent.

Requirements of the Mental Health Act 2014

Consistent with the focus on individualised treatment, including for compulsory patients, the MHA 2014 sets out explicit obligations on public mental health services and psychiatrists when making decisions about mental health treatment, even when a person is already a compulsory patient.

Treatment for mental illness

“Treatment” for mental illness is defined at section 6 to mean things “done to the person in the course of the exercise of professional skills:

i to remedy the mental illness; or

ii to alleviate the symptoms and reduce the ill effects of the mental illness.” [emphasis added].

This definition is narrower than the previous definition. An intervention that reduces the ill effects of a person’s mental illness without also alleviating the symptoms would no longer meet the definition of treatment. Detention in hospital in and of itself for example does not meet this definition since it cannot be said to alleviate symptoms of the illness, nor remedy it. It is also hard to see how other interventions, such as monitoring and supervision of medication by staff, alone would constitute “treatment” under this definition.

Capacity and informed consent

Psychiatrists and other clinicians must seek a person’s informed consent before treatment can be given under the MHA 2014 (s 70(1)).

A key change in the MHA 2014 is the fact that, irrespective of whether the person is a compulsory patient or not, they are presumed to have capacity to make their own decisions about treatment (s 70(2)). The presumption should only be displaced by cogent evidence that the person does not have capacity to make that particular decision.

Given that capacity is decision-specific, for each treatment the starting point should be a presumption of capacity. If a person agrees with the proposed treatment, then it could be argued they can provide informed consent. So a person might be on a compulsory order and giving informed consent to some aspects of their treatment, but not others.

The test for capacity to provide informed consent is outlined at section 68(1). It requires that the person:

a understands the information they are given, relevant to the decision;

b is able to remember the relevant information;

c is able to use or weigh that information; and

d is able to communicate the decision in some way.

Capacity is decision-specific and may change over time. To give effect to this, psychiatrists should seek a person’s informed consent for each treatment decision that needs to be made. Incapacity should not be assumed based only on the person’s age, appearance, condition or behaviour or the fact their decision could be considered unwise. Furthermore, the assessment of a person’s capacity (or rather, incapacity) should be conducted at a time and in an environment where it can be most accurately assessed (s 68(2)).

The meaning of informed consent is outlined at section 69(1), which states a person gives informed consent if they:

a have capacity to give informed consent (see s 68(1));

b have been given adequate information to enable them to make an informed decision;

c have been given a reasonable opportunity to make the decision;

d has given consent freely without undue pressure or coercion; and

e has not withdrawn consent or indicated an intention to withdraw it.

“Adequate information” involves an explanation of the proposed treatment and the type, method and likely duration of the treatment, an explanation of its advantages and disadvantages, any discomfort, risks and common or expected side effects and an explanation of any beneficial alternatives reasonably available, including their advantages and disadvantages (s 69(2)).

A person will have been given a “reasonable opportunity” to make the decision if they have been given: a reasonable period of time to consider the issues; an opportunity to discuss them with the doctor or treating team who is proposing the treatment; a reasonable amount of support to make the decision; and a reasonable opportunity to get advice or assistance (s 69(3)).

The interpretation of these provisions and the scope of the obligations on psychiatrists will no doubt be tested and clarified with the operation of the new MHA 2014. Consumers who are concerned they were not given sufficient information or opportunity or support to make their own decisions can make a complaint to the Mental Health Complaints Commissioner. If the person is a compulsory patient, an application for revocation of the order may be appropriate.

Treatment decisions where a person does not have the capacity to – or does not – consent to treatment

If the person does not have the capacity to give informed consent or has capacity but does not give informed consent (i.e. is refusing), the authorised psychiatrist is then empowered to make a treatment decision for the person only if they are satisfied that there is no less restrictive way for the person to be treated other than the treatment proposed (s 71(3)).

“Treatment decision” is not defined, but arguably, it refers to any decision to provide compulsory treatment. For example, prescribing a particular psychiatric medication, providing psychological treatment or even making significant changes to a person’s dose of antipsychotic medication could all be individual treatment decisions.

In determining whether the treatment the psychiatrist proposes is “least restrictive”, they must have regard to a range of factors at section 71(4) including, importantly, the person’s views and preferences about their treatment and any beneficial alternative treatments that are reasonably available. If the person is happy to take alternative medication, then it may be possible to argue the person should receive that treatment as a voluntary patient. If not, the person can only receive compulsory treatment if they are a compulsory patient.