The principle of informed consent is basic to medical practice. It requires that the patient be informed of the reasons for the proposed intervention, including medication, the expected outcome and any and all potential adverse reactions. As has been pointed out many times, informed consent – and informed refusal – does not consist merely of the signing of a form but the discussion between patient and physician. In the UK, USA and Canada, the right of informed refusal is well established but there persists a misunderstanding of the role of competence. The Supreme Court of Canada, in Starson v. Swayze [2003], 1 allows informed refusal of medications even by a patient with a diagnosed psychiatric disorder. The presiding judge stated that:
‘The HCCA [Health Care Consent Act] confronts the difficult problem of when a mentally ill person may refuse treatment. The problem is difficult because it sets in opposition fundamental values which we hold dear.
The first is the value of autonomy – the ability of each person to control his or her body and consequently, to decide what medical treatment he or she will receive. The second value is effective medical treatment – that people who are ill should receive treatment and that illness itself should not deprive an individual of the ability to live a full and complete life. A third value – societal protection – comes into play in some cases of mental illness. Where the mentally ill person poses a threat of injury to other people or to him- or herself, it may be justified to impose hospitalization […] The right to refuse unwanted medical treatment is fundamental to a person's dignity and autonomy. This right is equally important in the context of treatment for mental illness […] Few medical procedures can be more intrusive than the forcible injection of powerful mind-altering drugs which are often accompanied by severe and sometimes irreversible adverse side effects […] a competent patient has the absolute entitlement to make decisions that any reasonable person would deem foolish […] The right knowingly to be foolish is not unimportant; the right to voluntarily assume risks is to be respected. The State has no business meddling with either. The dignity of the individual is at stake. […] In this case, the only issue before the Board was whether Professor Starson was capable of making a decision on the suggested medical treatment. The wisdom of his decision has no bearing on this determination […] The Board must avoid the error of equating the presence of a mental disorder with incapacity. Here, the respondent did not forfeit his right to self-determination upon admission to the psychiatric facility […] The reviewing judge properly held that the Board's finding of incapacity was unreasonable, and that the Board misapplied the statutory test for capacity. There is no basis to find that either of the courts below erred on the evidentiary issues that were raised by the appellant. Accordingly, I would dismiss the appeal.’
The patient was granted the right to refuse medications and seek psychotherapy.
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