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Potentially incapable patients objecting to treatment: doctors' powers and duties
Author(s) -
Dignam Paul
Publication year - 2014
Publication title -
medical journal of australia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.904
H-Index - 131
eISSN - 1326-5377
pISSN - 0025-729X
DOI - 10.5694/mja14.00552
Subject(s) - citation , mental health , service (business) , psychology , library science , medicine , psychiatry , computer science , business , marketing
TO THE EDITOR: Sadly, the case of “John”, who perhaps should have been detained earlier, is common.1 Mental health Acts seem to vary with the times, from the narrowness of legalistically defi ned “dangerousness” criteria to the vagaries of “care” criteria. Abuses and failures at each end repeatedly swing the pendulum back the other way. Some Australian legislation has been adjusted to bring it in line with United Nations recommendations, but those recommendations themselves have a history, being in part an over-reaction to historical abuses of psychiatry and detention around the world. They may not be quite right for us. Competence as a criterion is a potential solution to much of this2 but is problematic because of the level of sophistication required, particularly if the right to detain is extended — as it is in some jurisdictions — to all clinical staff. If in John’s case competence criteria had been legally available to the caseworker, would she have felt comfortable exercising them just because he seemed psychotic, when there didn’t seem to be any immediate danger? It is a big ask of relatively junior staff. Is it always appropriate to assume competence until proven otherwise — the legal principle? I would have thought that if a person acts in a way suffi ciently different to the way most people would in any situation, there should at least be doubt; and the more severe the potential consequences, the lower the threshold for intervention with a view to assessment of competence. It is on this basis that we intervene when the physically injured person places their health at risk by a refusal of treatment. Why would we not extend the same courtesy to the mentally unwell? We would do it with our neighbours or friends, surely! Eagle and Ryan3 provide a stepped approach to the management of some of these situations but could elaborate on the meaning of “detain”. If we are physically holding or medicating, against their will, a delirious patient who would otherwise be at risk, do we need to use one of the Acts (mental health, guardianship etc) in the various states, with all the inherent clumsiness that entails? Or is it enough that we document what we did and why, as part of the ordinary business of duty of care?