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Mental Capacity Act 2005 v Mental Health Act 1983 as amended: Working in Collaboration or Opposition with regard to Capacity and Decision Making for individuals who are under the influence of Alcohol, | Joanne Howcroft - JDSupra
Mental Capacity Act 2005 v Mental Health Act 1983 as amended: Working in Collaboration or Opposition with regard to Capacity and Decision Making for individuals who are under the influence of Alcohol,
by Joanne Howcroft
The Mental Capacity Act introduced in 2005 and implemented in 2009 may have brought about many changes in the way in which statute is applied to ensure that people, who present a risk to themselves or others, can be managed, particularly when they have been assessed as lacking the capacity to make decisions about their care and/or treatment. This dissertation will explore the law surrounding the area of capacity, assessment, treatment and detention in the current climate and will also establish the difficulties of applying the law i.e. interpretation of statute and application of correct statute in situations where individuals have or are making unwise decisions . In doing this the dissertation will provide an insight into whether the Mental Health Act (MHA) 1983 and the Mental Capacity Act (MCA) 2005 work in collaboration or opposition in protecting indiviuals or others including the general public.
Download PDF 1 The University of Bolton LL.B (Hons) Mental Capacity Act 2005 v Mental Health Act 1983 as amended: Working in Collaboration or Opposition with regard to Capacity and Decision Making for individuals who are under the influence of Alcohol, Illicit Substances or make attempts to end their life. STUDENT: JOANNE HOWCROFT (0803776) PROJECT FOR HONOURS IN LAW TO BE SUBMITTED TO THE JUNE 2011 EXAMINATION BOARD SUPERVISOR: BRIAN JONES 2 Table of Contents TABLE OF CONTENTS .................................................................................................................. 2 TABLE OF CASES ............................................................................................................................... 3 TABLE OF STATUTES ....................................................................................................................... 3 INTRODUCTION ............................................................................................................................... 4 DEPRIVATION OF LIBERTY – WHAT DOES THIS MEAN? ................................................ 4 AN INTRODUCTION TO THE CURRENT PRACTICE IN MENTAL HEALTH ASSESSMENT OF CAPACITY AND DETENTION TO HOSPITAL ................................ 7 WHAT IS CAPACITY IN THE EYES OF THE LAW? ........................................................... 7 HOW IS APPLICATION FOR ASSESSMENT AND DETENTION MADE AND WHO IS RESPONSIBLE FOR THE APPLICATION? ...................................................................... 8 BIOMEDICAL ETHICS – BEST INTEREST ARGUMENTS ................................................ 12 THE IMPACT OF LEGISLATION ON THOSE WHO MAKE UNWISE DECISIONS WITH SPECIFIC REGARD TO ...................................................................................................15 BEHAVIOUR AND/OR PSYCHOSIS INDUCED BY: ALCOHOL USE /ILLICIT SUBSTANCE USE OR ATTEMPTS TO TAKE OWN LIFE ........................................................................... 15 Alcohol .............................................................................................................................................................. 15 Illicit Substance Use ................................................................................................................................... 18 Attempts to take on Life ............................................................................................................................ 18 CONCLUSION – PROTECTION OF INDIVIDUALS ............................................................22 BIBLIOGRAPHY .............................................................................................................................25 APPENDICES .................................................................................................................................28 APPENDIX I – TABLE 1 (ADULTS1 DRINKING MORE THAN RECOMMENDED DAILY LEVELS, BY GENDER AND SOCIO-ECONOMIC CLASSIFICATION2, 2004)........................ 28 APPENDIX II – TABLE 1.1 LIFETIME PREVALENCE (%) AND ODDS RATIO OF SUBSTANCE USE DISORDERS FOR VARIOUS DSM III PSYCHIATRIC DISORDERS ........ 29 APPENDIX III – TABLE 1.2 SUICIDES IN CONTACT WITH SERVICES IN THE 12 MONTHS BEFORE DEATH (ENGLAND AND WALES) ................................................................. 30 APPENDIX IV – ................................................................................................... 31 TABLE 1.3 ALL FORMAL DETENTIONS UNDER THE MENTAL HEALTH ACT IN NHS AND INDEPENDENT HOSPITALS, BY YEAR ........................................................................ 31 TABLE 1.4 ALL DETENTIONS UNDER THE MENTAL HEALTH ACT, ALL FACILITIES, BY YEAR ............................................................................................................................ 31 TABLE 1.5 USES OF SECTIONS 135 AND 136 – PLACE OF SAFETY, 2005/06 – 2009/10 ............................................................................................................................ 31 3 TABLE OF CASES A Local Authority v A (2010) 1549 EWHC (Fam) G v E and others (2010) 621 EWCA GJ v The Foundation Trust, PCT and The Secretary of State for Health [2009] EWHC 2972 HL v the United Kingdom [2004] All ER (d) 39 (Oct) Richard Rabone (In his own Right & as Personal Representative of the Estate of Melanie Rabone, Deceased), Gillian Rabone (In her own Right) v Pennine Care NHS Trust (2010) 698 EWCA (Civ) Savage v South Essex Partnership NHS Foundation Trust [2009] 1 All E 1053 TABLE OF STATUTES Mental Capacity Act 2005 Mental Health Act 1983 Mental Health Act 2007 Suicide Act 19614 INTRODUCTION The Mental Capacity Act introduced in 2005 and implemented in 2009 may have brought about many changes in the way in which statute is applied to ensure that people, who present a risk to themselves or others, can be managed, particularly when they have been assessed as lacking the capacity to make decisions about their care and/or treatment. This dissertation will explore the law surrounding the area of capacity, assessment, treatment and detention in the current climate and will also establish the difficulties of applying the law i.e. interpretation of statute and application of correct statute in situations where individuals have or are making unwise decisions1. In doing this the dissertation will provide an insight into whether the Mental Health Act (MHA) 1983 and the Mental Capacity Act (MCA) 2005 work in collaboration or opposition in protecting individuals or others including the general public. Deprivation of Liberty – What does this mean? People who lack capacity can be deprived of their liberty. Therefore a concern arises as to how or when a person can be legally deprived of their liberty, particularly when capacity is affected by negative lifestyle choices or unwise decisions2. Due to the complexity of Deprivation of Liberty (DoL) there does not appear to be a statutory definition. The case HL v the United Kingdom3 alternatively referred to as ‘The Bournewood Case’4, established the common law definition when the European Court of Human Rights (ECrtHR) ruled that: ‘The key factor in the present case is that the healthcare professionals treating and managing the applicant exercised complete and effective control over his care and movements’ and that ‘the applicant was under continuous supervision and control and was not free to leave’. 1 Mental Capacity Act (MCA) 2005 S1 (4) 2 MCA 2005 S1 (4) 3 [2004] All ER (d) 39 (Oct) 4 [1998] 1 All ER 634 5 The ‘Bournewood Case’ was a groundbreaking case for the area of protection of individuals when capacity to make decisions impacts on their liberty, and subsequently highlighted the need to protect against arbitrary detention of individuals. This case led to the introduction of The Mental Capacity Act (MCA) 2005, which introduced new DoL safeguards. The MCA was implemented in 2007; however, the safeguards only came into force in April 2009. Prior to this time there was no statutory procedure that could authorize deprivation of an individual’s liberty, particularly in the best interest of a person who appeared to lack capacity to make decisions. There were however procedures for detaining individuals in hospital when they were deemed as having a mental illness, for assessment and/or treatment i.e. The Mental Health Act 1983. The DoL safeguards5 require: ‘That a hospital or care home (a ‘managing authority’), must seek authorisation from a ‘supervisory body’ in order to be able to deprive someone who has a mental disorder as defined in statute6, and who lacks capacity to consent, of their liberty, within the meaning of Article 5 of the European Convention on Human Rights (ECHR)’.7 The aim of the safeguards provided for in the MCA 2005, are to protect vulnerable individuals, who are not detained under the MHA 1983, however their freedom may be restricted because they are unable to consent to care and treatment. Whilst it is considered as acceptable to deprive somebody of their liberty in sustaining life or carrying out an act if one reasonably believes that, he is preventing a serious deterioration to a person’s condition8, there are 5 MCA S42 6 Mental Health Act (MHA) 1983 7 Article 5 of Schedule 1 to the Human Rights Act 1998 provides: 'everyone has the right to liberty and security of person. No one shall be deprived of his liberty save in the following cases and in accordance with a procedure prescribed by law: ...(e) the lawful detention ... of persons of unsound mind ... 4 Everyone who is deprived of his liberty by arrest or detention shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful.' 8 MCA 2005 S[4B [(3-5) 6 restrictions in DoL where care and treatment is required. These restrictions and limitations appear to provide for those who are considered to require Mental Health Treatment, in situations where the condition may not be life threatening and there is not a requirement to sustain life, but treatment may be required to improve a condition. The MCA 2005 provides that all reasonable steps have been taken in ascertaining levels of capacity before DoL is applied9. The act of DoL must be proportionate to the fact that there is a likelihood of harm and must take into account the seriousness of the harm10. According to Richardson, 201011 there is much uncertainty surrounding the ‘precise factors, which will amount to deprivation of liberty’ as she believes that case law is inconsistent. This suggests that professionals, who are required to apply the MHA 1983 and MCA 2005, are likely to overcompensate in their application when addressing DoL to avoid legal redress. 9 MCA 2005 S5 (1-4) 10 MCA 2005 S6 (3) 11 Richardson, G. (2010). Mental capacity at the margin: the interface between two Acts. Medical Law Review . page 12 of 16. Accessed 12/07/2010 http://login.westlaw.co.uk 7 AN INTRODUCTION TO THE CURRENT PRACTICE IN MENTAL HEALTH ASSESSMENT OF CAPACITY AND DETENTION TO HOSPITAL What is capacity in the eyes of the law? A person is considered to lack capacity in the eyes of the law if they are ‘at the material time… unable to make a decision himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or the brain,’12 irrespective of whether the disturbance is temporary or permanent13. A person cannot be considered as lacking capacity purely because of their age or appearance14. Nor should an aspect of their behaviour lead others to make unjustified assumptions about his capacity.15 In making a decision a person is required to understand the information that is relevant, to be able to retain the information given to them, to weigh the information as part of the decision-making process and communicate his decision16. However, the fact that a person is unable to retain the information for a lengthy period solely should not be regarded as the inability to make a decision17, and it may be considered as unrealistic to require an individual to have the ability to foresee the consequences of an action18 in light of an unwise decision that has been made. According to Keywood, 201019, there is an immediate conflict between capacity and social care refusal. She identifies that service users are empowered to take responsibility whilst at the same time services are required to implement safeguards to protect service users from exploitation due to their vulnerability. Questions may subsequently be asked in how the conflict may be administered to ensure that actions in application of the statutes are considered as lawful. 12 MCA 2005 Part I S2 (1) 13 MCA 2005 Part I S2 (2) 14 MCA 2005 Part I S2 (3)(a) 15 MCA 2005 Part I S2 (3)(b) 16 MCA 2005 Part I S3 (1)(a-d) 17 MCA 2005 Part I S3 (3) 18 A Local Authority v A (2010) 1549 EWHC (Fam) 19 Keywood, K. (2010). Case Comment: Vulnerable adults, mental capacity and social care refusal. Medical Law Review . Accessed 12/07/2010 http://login.westlaw.co.uk 8 How is application for assessment and detention made and who is responsible for the application? It is common for people admitted to inpatient psychiatric wards to lack the capacity to make decisions relating to their treatment, particularly if the individual is suffering from illness such as mania, schizophrenia or having been detained using the MHA 198320. Scott, 200921, suggests that the MCA 2005 now stands alongside the MHA 1983, which is not considered as a capacity based statute. He further suggests that the MCA 2005 is a more appropriate statute to apply when there is a need to committ and treat patients where capacity appears to be an issue ensuring that the law is correctly applied. Subsequently this would imply that the consequence of correct application of statute would be that the aims of the safeguards will be realized and also resulting in compliance with the ECHR22. If a person requires admission to hospital for Assessment and/or Treatment; who was unwilling to be admitted informally; who are perceived as posing a risk to themselves and others, assessment may be made using the Mental Health Act (MHA) 1983. The MHA 1983 requires that application of the Act is only to be for mentally disordered23 individuals as defined within the statute. The MHA 198324, has changed the definition of mental disorder to ‘any disorder or disability of the mind,’ subsequently broadening the scope of the application of the statute, to a wider classification of individuals. By broadening the definition within the amended statute it was felt that there 20 Maudsley Hospital London. (2009). People admmitted to psychiatric hospitals commonly lack the mental capacity to make treatment decisions -Evidence based mental health. British Medical Journal – A study carried out by the Maudsley Hospital London between February 2006 and June 2007. 350 people that were consecutvely admitted to hospital were used in the research. 338 people where assessed with regard to capacity and 60% was the prevalence of those considered to be incapacitated to make decisions regarding treatment. 200 people were assessed using the McArthur Competence Assessment Tool and 138 were assessed by psychiatric trainees only without the tool being used. 21 Maudsley Hospital London. (2009). People admmitted to psychiatric hospitals commonly lack the mental capacity to make treatment decisions -Evidence based mental health. British Medical Journal . 22 Art 8 23 MHA 1983 Part I S1 (1) 24 Part I S1 (2) 9 would be a substantial decrease in the use of compulsory powers so long as there was a ‘well defined criteria in application’25. The Statute26 has also now included specific exclusions of those patients who present with ‘dependence on alcohol and drugs’ as these are not in themselves considered as a ‘disorder or disability of the mind,’ unless they are coupled with a concurrent mental disorder.27 One of the roles employed within Mental Health services currently is Accident and Emergency (A+E) Liaison. This role predominantly tends to be carried out by a Qualified Mental Health Nurse (QMHN). One of the responsibilities of the QMHN is to assess people who attend A+E that present with high-risk behaviours, such as wanting to commit suicide or have carried out acts to deliberately self-harm themselves. Those individuals who are presenting with behaviour that would suggest that they are experiencing a relapse from diagnosed mental illness28, requiring treatment may also be assessed. During the interview it may become apparent that the individual being assessed would benefit from treatment in hospital. In the first instance the individual would be offered admission on an informal basis, meaning that they have given their consent to the admission and then further provide ‘informed consent’ for subsequent treatment if this is required. If the patient is posing a risk to themselves and/or others29, they are considered as having a ‘disorder or disability of the mind’30, and if it is felt that hospital admission would benefit the individual for further assessment and/or treatment, but they will not consent to admission to hospital, the MHA 1983 Section 2 or 3 may be applied for compulsory detention if criteria of the statute are met. 25 Department of Health. (1999). Reform of the Mental health Act 1983. London: DoH. Page 3 26 MHA 1983 Part I S1 27 MHA 1983 Part I S1 [(3) 28 Identified within American Psychiatric Association. (1994). DSM-IV: Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington. 29 MHA 1983 Part I S3 (2)(c) 30 MHA 1983 Part I S1 (2) 10 If the QMHN feels the risks are high and the patient attempts to abscond from A+E without an assessment being carried out, a request may be made for an approved medical practitioner31 to attend and assess the individual resulting in a MHA application being made to detain the individual concerned32. In circumstances where the person is successful in absconding a request may be made for the police to carry out a welfare check on the individual. For the purpose of application of the MCA 2005 when capacity of an individual is in question and the person does not have a ‘disorder or disability of the mind’ as defined by statute33, the assessor must be a Medical Practitioner with a minimum qualification of 3 years post registration, and must have completed the Deprivation of Liberty Safeguards Mental Health Assessors training programme34. There may be also situations when people are brought to a place of safety (A+E) by the police35 when they have been found to be in a public place appearing to be suffering from a ‘mental disorder and to be in immediate need of care or control’36. The police, as with the assessments carried out by the QMHN, will need to apply the requirements of the statute to either further detain the person under a more appropriate section of the MHA or rescind the S13637. On occasions, due to the number of professionals required in the application of the MHA 1983, assessments can take several hours to co-ordinate. Consequently decisions have been made by Professionals to apply the MCA 2005 in holding a person in hospital until such a time as they can be assessed using the most appropriate statute, using the rationale that detention is ‘in the patients best interest’. It is the author’s experience that the police are the professionals that are more likely to use this practice, particularly at times where time constraints have been placed upon them from the senior 31 MHA 1983 Part II S12 32 MHA 1983 as amended 2007 Part II 33 MHA 1983 Part I S1 (2) 34 http://www.bma.org.uk/ethics/consent_and_capacity/mentalhealth0309.jsp 35 MHA 1983 as amended 2007 Part X S136 (2) 36 MHA 1983 as amended 2007 Part X S136 (1) 37 MHA 1983 as amended 2007 Part X S136 (2) 11 professionals within the police force. This would seem to support the argument that the MCA 2005 is a more appropriate statute to apply where capacity is concerned and individuals pose a risk to themselves or others. More recently the author has experienced practice whereby the police have transported an individual to a place of safety under MCA 2005 quoting Section 538, rather than applying the MHA 198339, again due to the time constraints placed upon them. This seems to suggest that the argument proposed by Keywood, 201040, that ‘professionals are reluctant to query capacity’ is not necessarily supported in circumstances where professionals such as the police are required to make decisions in the immediacy of their practice, with the desired outcome that the decisions made will have limited impact on their working time. One of the main concerns with this practice is that when an individual has been ‘delivered’ to A+E there are no powers to prevent them leaving again, as there would have been if the person had been brought to A+E under the provision of the MHA 198341. In the longer term this practice may impact upon the time constraints of the police when a welfare check is requested and the individual has left and is considered to be at risk to themselves and/or others, particularly if the individual avoids going to their normal place of residence. This raises fundamental questions in how the principles42 within the MCA 2005 are applied as was illustrated in the a recent case of GJ v The Foundation Trust, PCT and The Secretary of State for Health 43, in which it was stated obiter that ‘it would be unlawful for anyone to proceed on the basis that they can pick and choose between the two statutory regimes as they think fit…rendering one regime preferable to the other’44. More specifically giving the rationale for application of the MCA 2005 of time constraints of professionals i.e. police, nurses, medics etc as oppose to the protection of the 38(7)(b) 39 MHA 1983 S136 40 Keywood, K. (2010). Case Comment: Vulnerable adults, mental capacity and social care refusal. Medical Law Review . Page 3 41 S136 42 MCA 2005 Part I S1 (4 & 5) 43 [2009] EWHC 2972 44 GJ v The Foundation Trust, PCT and The Secretary of State for Health [2009] EWHC 2972 as per Charles J Para 59 12 needs of the individual being assessed. This argument seems to suggest that there is a potential currently for professionals to be acting unlawfully in their practice. In the protection of individual’s human rights a holistic assessment of capacity should be carried out encompassing many factors, rather than just the here and now. Biomedical Ethics – Best Interest arguments The MCA 2005 requires that an individual’s best interest be considered when a person is deemed to lack capacity45. This would suggest that even though a person lacks capacity the scope for consideration of other factors goes far deeper than just an assessment of whether or not they can make a decision, based on their understanding. The person that makes the assessment should take into consideration all the factors as required by the statute. It has been suggested further by Beauchamp & Childress, 200146, that those factors should include historical information, such as what the person would have wanted to happen prior to their capacity being affected, when they were able to make autonomous decisions i.e. their personal preferences, values and morals. Donnelly, 200947 suggests that the assessor should also consider whether or not the person lacking capacity is likely to regain capacity.48 Donnelly49 further implies that Autonomy is the essential principle within Advance Directives whereby a patient is provided with the opportunity to provide prior wishes regarding their future care and treatment when their capacity may be affected. These wishes include not only the right to refuse certain treatments but also the agreement to accept certain treatments for example Electro-Convulsive Therapy (ECT). 45 MCA 2005 S4 46 Beauchamp, T., & Childress, J. (2001). Principles of Biomedical Ethics (5 ed.). Oxford: OUP. Page 102 47 Donnelly, M. (2009). Best interests, patient participation and the Mental Capacity Act 2005. Medical Law Review : Accessed 12/07/2010 http://login.westlaw.co.uk 48 Autonomy is a fundamental principle identified under Article 8 of the ECHR. 49 Donnelly, M. (2009). Best interests, patient participation and the Mental Capacity Act 2005. Medical Law Review : Accessed 12/07/2010 http://login.westlaw.co.uk 13 It would be reasonable to assume that the above procedures should be simple to integrate into a mental health system, particularly since the introduction of Advance Directives. In Mental Health, individuals will have periods of time in which they have full insight into their illness, particularly during periods where they have recovered. At these times they will have the capacity to make decisions about their treatment options about times in the future where their insight may reduce during periods of relapse. Morrissey, 201050, appears to support the reasonable assumption, that people with mental health problems traditionally were not given the opportunity to be involved in decisions about their treatment, particularly when they have been in a crisis as this has been the point at which their capacity has been affected. She goes on further to say that the significance of prior autonomy is paramount in mental health practice where an individual’s level of insight fluctuates and the treatment they receive when they are unwell may be invasive. Morrissey’s view was reinforced with the introduction of the MHA 2007 whereby there are specific provisions made for ‘respect for a patients past and present wishes and feelings’51. The MCA 2005 permits an individual to make an advance decision whereby they can refuse treatment52. Having said this whilst there seems to be legislative cover for advance decisions the statutes53 conflict at times where public safety is involved as this appears to outweigh the autonomy of individuals54 as previously identified by Keywood, 2010. This consequently raises questions about individuals who present in situations where capacity issues may be considerably short term due to such things as substance induced psychosis or capacity issues. The associated risk behaviour that they present with, that may impact on their own safety or that 50 Morrissey, F. (2010). Advanced directives in mental health care: hearing the voice of the mentally ill. Medico-Legal Journal of Ireland : Accesses 12/07/2010 http://login.westlaw.co.uk 51 MHA 2007 S8 (2B) (A) 52 MCA 2005 S24 and S25 53 MCA 2005 and MHA 2007 54 MHA 2007 S8 (2B) (h and i) 14 of others, may be only present for a short period of time i.e. hours and minutes. There are also those who have been assessed as maintaining capacity and have made a conscious decision that they no longer want to live. Consequently it is possible therefore that statutes may be applied incorrectly and factors considered weighed inappropriately. 15 The Impact of legislation on those who make unwise decisions with specific regard to Behaviour and/or psychosis induced by: Alcohol Use /Illicit substance Use or Attempts to take own life Alcohol and substance use are major factors within the field of mental health practice.55 If there were a concurrent diagnosed mental illness this would be considered as a dual diagnosis. Where there is a dual diagnosis there would be a need to identify that illness is primary and which is secondary, meaning which illness presented first. According to Rassool, 200256, individuals who experience either substance use or alcohol use may present as also having cognitive impairment, which is likely to affect their ability to give ‘informed consent’. Informed consent has been defined as ‘the voluntary and continuing permission of the patient to receive a particular treatment, based on adequate knowledge of the purpose; nature; likely effects and risks of that treatment; including the likelihood of its success and any alternative to it.’57. Alcohol Alcohol use is a widely recognized form of social activity, and statistics (Appendix I – Table 1)58 suggest that adults regularly consume more than the recommended daily units of alcohol. Studies59 have also shown that alcohol use is more prevalent in men than in women, and is responsible for a large proportion of health care problems. 80% of men and 60% of women in developed countries drink alcohol at some time in their lives60. 55 See Mueser, K., Noordsy, D., Drake, R., & Fox, L. (2003). Integrated Treatment for Dual Diagnosis: A Guide to Effective Practice. New York: The Guildford Press; Rassool, H. (2002). Dual Diagnosis: Substance Misuse and Psychiatric Disorders. Blackwell Publishing Company; Rosenthal, R. (2003). Dual Diagnosis: Key Readings in Addiction Psuchiatry. New York: Brunner-Routledge. 56 Rassool, H. (2002). Dual Diagnosis: Substance Misuse and Psychiatric Disorders. Blackwell Publishing Company. Pages 39 – 40 57 Department of Health. (1993). Code of Practice of the Mental Health Act 1983. London. Para 15.12 (now Superseded by Department of Health. (2008). Revised Code of Practice of the Mental Health Act 1983. London.) 58 General Household Survey 2004, Office for National Statistics (ONS) 59 Schuckit, M. (2009). Alocohol use disorders. The Lancet , 373, 492 -501. 60 Teeson, M. (2006). Substance use, dependance and treatment seeking in the United States of America and Australia: A cross national comparison. Drug Alcohol Depend , 81, 149 -155. 16 Further studies have attempted to identify whether or not alcohol use affects mental health resulting in possible diagnosis of mental illness61. Findings62 have suggested that hazardous and dependent drinking were not associated with the onset of depression and anxiety at follow up, however binge drinking, at least on a monthly basis, was associated with an increase in anxiety and depression. Anxiety and depression were used as the main diagnostic tools as identified that individuals with significant psychiatric problems tend to display symptoms of both and subsequently may result in more than one psychiatric diagnosis i.e. Dual Diagnosis. This would seem to suggest that alcohol use therefore is unlikely to result in what may be considered as a concurrent mental disorder63, and therefore it may possible to argue that it would be unlawful to apply the MHA 1983 in transporting individuals to a place of safety64 or detaining individuals for assessment and/or treatment65. Having said this alcohol detoxification may pose an issue; it is possible for a person to suffer from Delirium Tremens (DT’s)66 in which they present with symptoms of psychosis such as various forms of hallucinations, without immediate insight during the detoxification process. The DT’s usually resolve within a period of hours to days (up to a period of 2-4 weeks) depending on the level of intoxification67. Therefore during this period there is a potential for a person’s capacity to be questioned. A problem arises when somebody is intoxicated, however does not exceed the level where they may present with DT’s upon detoxification, as it is likely that capacity may only be affected for a matter of hours rather than days. The MHA 1983 does not exclude disorders 61 Haynes, J. (2005). Alcohol Consumption as a risk factor for anxiety and depression. Results from the longitudinal follow-up of the National Psychiatric Morbidity Survey. British Journal of Psychiatry , 187, 544 -551. 62 Ibid 63 South London and Maudsley NHS Foundation Trust. (2010). The Maze: A Practical Guide to the Mental Health Act 1983 (Amended 2007). London. 64 MHA 1983 as amended 2007 Part X S136 (2) 65 MHA 1983 Part II S2 or S3 66 American Psychiatric Association. (1994). DSM-IV: Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington. Pages 129 -133 67 Ibid 17 of these kinds68 therefore in these situations it is possible that application would be lawful. An assessing practitioner records the alcohol readings. A Breathalyzer unit is used in which the individual is required to breathe into a machine, using a tube for several seconds. The Breathalyzer reads the amounts of alcohol per litre of breath. A reasonable assessment may be made of those individuals that blow a reading of the drink drive limit or below i.e. 0.35mg/L. Individuals who blow above this level are considered as intoxicated and therefore cannot be assessed until their level has reduced. The alcohol levels tend to reduce at a rate of 0.1mg/L each hour after final consumption. In the circumstances where the individual’s alcohol levels are excessive, they may be offered admission to a medical ward until such a time that their alcohol levels are within appropriate limits for assessment. If the person refuses and tries to leave hospital problems may arise as the police may be called to perform welfare checks as previously identified. Any other measure to try to prevent the individual from leaving could possibly be perceived as a ‘De Facto’ detention69. Could therefore the MCA 2005 be applied to deprive an individual of their liberty when their capacity is impaired due to alcohol or substance use? There are few cases, in which this has been explored within case law, and these, have been with regard to entering a contractual relationship. It was held in Gore v Gibson70 that a contract is not binding on a person that is so intoxicated that he does not know the consequences of his actions. Having said this, upon the intoxicated person sobering up the contract may then be considered binding71, subsequently making the contract voidable not void. In terms of assessment under the MCA 2005 for incapacity, it is therefore reasonable to assume that an individual may only be considered as lacking 68 See Department of Health. (2008). Revised Code of Practice of the Mental Health Act 1983. London. Para 3.11 69 See Fennell, 1998 70 (1845) 13 M & W 621; 153 ER 260 71 Matthews v Baxter (1873) LR 8 Ex 132 18 capacity whilst intoxicated. And capacity would resume at the point that the individual is no longer intoxicated unless there is an underlying condition that may affect capacity. It is possible therefore that if an individual’s alcohol reading was 0.55mg/L at the hospital, they abscond and it takes the police 2 hours to establish the whereabouts of the person, their alcohol level may be within appropriate levels and it is likely that they will have the capacity to make decisions regarding their care and treatment. Illicit Substance Use There are approximately 400,000 major drug users in the UK and it has been reported that there are only half of those who receive treatment72. It is likely that people with psychiatric disorders are more likely to also use substances than those that do not have a psychiatric disorder73 as illustrated in Appendix II – Table 1.174. It has also been suggested that the psychiatric diagnosis would be primary to the substance use in dual diagnosis75. This suggests that unlike alcohol there is on the balance of probability likely to be a concurrent mental disorder with substance users. This subsequently means that where an assessment is needed it may be more appropriate that the MHA 1983 S2 or S3 is used, however only if there is a concurrent mental disorder identified, for example drug induced psychosis76. However in both alcohol and illicit substance use the associated disorder may last only for a short time period, rendering the MCA 2005 as a more appropriate statute to detain an individual in maintaining their safety. Attempts to take on Life The ECHR77 underpins the ethical and moral principles of inviolability of human life78. In the wider arena where there has been a long-standing illness 72 http://lcjb.cjsonline.gov.uk/West%20Mercia/2522.html 73 Mueser, K., Noordsy, D., Drake, R., & Fox, L. (2003). Integrated Treatment for Dual Diagnosis: A Guide to Effective Practice. New York: The Guildford Press. Page 4-5 74 Mueser, K., Noordsy, D., Drake, R., & Fox, L. (2003). Integrated Treatment for Dual Diagnosis: A Guide to Effective Practice. New York: The Guildford Press. Page 5 75 See Rosenthal, 2003, chapter 3 76 American Psychiatric Association. (1994). DSM-IV: Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington. Page 310 -315 77 European Convention of Human Rights Art 8(1) 19 or medical condition, there should be a balance between a person’s autonomous decision to refuse life sustaining treatment and the government’s interest in preserving life. The MCA 200579 provides for appointment of Lasting Powers of Attorney, whom in theoretical terms are proxy decision makers for the individual. The decisions that they make concern individuals specified personal welfare80 and specified property and affairs81. It is possible to assume that enforcement of documents such as advance directives would be included in this power given to them. There has been academic opinion that would seem to suggest that this is not necessarily the case82. Where there are longer term illness decisions to be made about preservation of life, Samanta, 200983, suggests that it is likely that a court in assessing the proxy decision made by Lasting Power of Attorney against the Medical expertise, are likely to decide in the favour of the expertise of medics. Questions may be raised therefore in the situation where there are decisions to be made in the absence of advance directives, whereby an individual attempts to take their own life. Prior to 196184 it was considered a crime to committ suicide. Whilst there are provisions within the Suicide Act 1961 preventing others in assisting or encouraging suicide of another, there does not appear to be provision in the statute to consider the acts of omission in preventing another from committing suicide. On the other hand it is possible however for the court to make a 78 See Samanta, J. (2009). Lasting powers of attorney for healthcare under the Mental Capacity Act 2005: enhanced prospective self-determination for future incapacity or a simulacrum. Medical Law Review . Page 7 of 26 79 MCA 2005 Part 1 S9 80 MCA 2005 Part 1 S9 (1)(a) 81 MCA 2005 Part 1 S9 (1)(b) 82 Samanta, J. (2009). Lasting powers of attorney for healthcare under the Mental Capacity Act 2005: enhanced prospective self-determination for future incapacity or a simulacrum. Medical Law Review . 83 Samanta, J. (2009). Lasting powers of attorney for healthcare under the Mental Capacity Act 2005: enhanced prospective self-determination for future incapacity or a simulacrum. Medical Law Review . Page 19 of 26 84 Implementation of the amended Suicide Act 1961 20 declaration under MCA 2005 S15 (2) where a professional omits to act in such a situation where an individual is deemed to lack capacity85. The ECHR86 imposes an obligation on operational medical authorities to do everything that is reasonably expected of them to prevent a detained patient from committing suicide, however the same obligations are not required for informal patients87. A possible rationalle for this was stated obiter by Baker J88 in identifying that patients who are not detained may be considered as lower risk of suicide, and the obligations of the ECHR art 2, are general obligations therefore practices for informal patients as oppose to detained patients may differ. There is a possibility that where a qualified practitioner has made a mistake in the assessment there may be vicarious liability, which in theory could be dealt with under domestic law. Subsequently questions may be raised regarding the duty of care to members of the public who are not within an institutional setting, whether detained or informal; when they make a decision to end their life. It is possible that professions such as the Police may hold a duty of care in these situations and may therefore be required to apply statute in administering the duty of care. Much of the case law relates solely to the duty of care of officers when the individual commits suicide whilst in custody, and subsequently the duty of care arises from the obligations under the ECHR Art 2. However as previously identified, individuals who are suicidal may be found by the police in a public place, not whilst they are already in detention. The police have a tendency to offer to take these individuals to a place of safety for Care and Treatment. If the individual refuses then the officers make a decision as to whether or not the person can be detained and transported under statute89. 85 G v E and others (2010) 621 EWCA para 64 as per Baker J 86 ECHR Art 2 87 Savage v South Essex Partnership NHS Foundation Trust [2009] 1 All ER 1053 as per Jackson LJ Para 62 88 Savage v South Essex Partnership NHS Foundation Trust [2009] 1 All ER 1053 Para 50 89 Either MHA 1983 S136 or MCA 2005 S5 21 In applying the MCA 2005 there should be an appropriate assessment of the individuals capacity90. Application of the MHA 1983 requires the the person is suffering from a ‘mental disorder and to be in immediate need of care or control’91. In theory the individual who has capacity; does not have a mental disorder; is not posing a risk to others; should be within their right to make an autonomous decision to end their life, however in practice this is not the case as already identified services have a duty of care to preserve life. Between April 1996 and March 2000 there were reported to be 20,927 suicides92 in the England and Wales. These figures included verdicts of suicide, open verdict and deaths from undetermined cause. It has been acknowledged that the preventable suicides were those of individuals who suffer from a mental disorder and the less preventable ones were those who use alcohol and/or illicit substances93. It has been highlighted that the highest rates of suicide are amongst those who suffer from Affective Disorder, and people who use alcohol and illicit substances, whilst still reported as having committed suicide are amongst the lowest rates (APPENDIX III – Table 1.2)94. Despite this it is the authors experience that when individuals are detained and transported to A+E the rationale regularly provided by the professionals concerned, is that the ‘person has been found in unsafe circumstances e.g. carrying a knife, and because they are under the influence of alcohol or illicit substances they are going to kill themselves.’ This appears to contradict what the statistics suggest. 90 MCA 2005 S5 91 MHA 1983 S136 92 Department of Health. (2001). Safety First: Five Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. London: DoH. Page 16 -96 93 Department of Health. (2001). Safety First: Five Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. London: DoH. Page 37 94 Department of Health. (2001). Safety First: Five Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. London: DoH. Page 19 22 CONCLUSION – PROTECTION OF INDIVIDUALS The fact that alcohol, substances and attempts on own life are possible factors that need to be considered in both assessment under the MHA 1983 and MCA 2005 poses a problem within the current mental health practice. Quite often the individuals that present with suicidal thoughts or those that have deliberately self-harmed (DSH), may also be under the influence of alcohol and/or illicit substances, and their behaviour may be as a consequence of life style choices or them making unwise decisions. If an individual is under the influence of alcohol or illicit substances, an objective assessment cannot be carried out until these substances are out of the patients system, so that the assessment provides a true reflection of the reasons for the behaviour presented. As previously identified dependence on alcohol and drugs alone are not provided for in the MHA 1983, as they are not considered as a ‘disorder or disability of the mind’95. Therefore it is likely that unless there is a concurrent mental illness, application of the MHA 1983 in these circumstances may be considered as unlawful on the one hand, and lawful on the other, dependent on the nature and extent of the substance of choice and the extent and effect of its usage. With regard to the MCA 2005 the principles clearly state that an assessor cannot assume that an individual is incapacitated on the basis that they made unwise decisions96. Consequently it is possible that that alcohol and substance use if they are considered as a lifestyle choice rather than selfmedicating a mental disorder could be considered as an unwise decision. The MCA 200597 clearly identifies that the MHA 1983 is supreme when there is a need for an individual to provide consent to receive treatment or actually receive treatment for a mental disorder. Subsequently transportation of an individual by the police could be considered as inappropriate application of 95 MHA 1983 Part I S1 (2) 96 MCA 2005 S1 Part I S1 (4) 97 MCA 2005 S28 23 statute, particularly where MCA 200598 is referred to as authority. It is possible that application of the MHA 198399 may have been more appropriate. This would particularly apply in situations where Mental Health professionals request a welfare check by the police, on individual’s known to services. In conclusion it would seem that there is clear evidence to suggest that since the introduction of the MCA 2005 there are changes in the application of statute in ascertaining assessment and treatment of individuals, particularly where substance use impacts on a person’s decision-making capacity regarding care and treatment. The NHS Information Centre, Community and Mental Health Teams, 2010100, report that whilst there was only a 3.5% actual increase in detentions to hospital, there was over a 40% increase since 2008/2009 where the police used a place of safety at a hospital, and a comparable increase in those individuals whereby further detention was not required (Appendix IV – Table 1.3 and Table 1.4 and Table 1.5)101. In addressing attempts to take one’s own life with specific regard to making an unwise decision102, it would seem that this is a grey area. In the current law the application of the MHA1983, MCA 2005 and the Suicide Act 1961 may not apply as previously stated above, suggesting that this area alone may be a potential for law reform. The individual wishing to take his or her own life may not have a ‘disorder or disability of the mind’103; lack capacity or be assisted in any way to complete the act of suicide. It is possible that duty of care by professionals may be applied in application of the ECHR and Law of Tort, where there is a potential need to prevent an individual from taking their own life. 98 S5 99 S136 100 The NHS Information Centre, Community and Mental Health Teams. (2010). Inpatients formally detained in hospitals under the Mental Health Act 1983 and patients subject to supervised community treatment, Annual figures, England 2009/10. The Health and Social Care Information Centre. 101 The NHS Information Centre, Community and Mental Health Teams. (2010). Inpatients formally detained in hospitals under the Mental Health Act 1983 and patients subject to supervised community treatment, Annual figures, England 2009/10. The Health and Social Care Information Centre. Page 7, 8 and 11 102 MCA 2005 Part I S1 (4) 103 MHA 1983 Part I S1 (2) 24 With regard to practice, the MCA 2005 is considered as ‘new’ due to it’s relatively recent implementation. There is still research104 being carried out to explore the impact that the statute has had in regard to practice and specific diagnosis of mental illness. The MHA 1983 has been implemented for several years, and application of this depends on the interpretation of certain sections. It has been clear in practice experienced by the author that on many an occasion professionals applying the two statutes i.e. the police, do so on a cascaded verbal information, rather than formal training. This in itself poses a potential problem for the police if they inappropriately interpet statute in their practice, particularly given the fact that the MCA 2005 holds with it a potential for criminal liability105. Due to the relatively recent introduction of the MCA 2005 the author is of the opinion that interpretation and application of the statute by the Police, Nurses and Medical Professionals will improve, as further training is provided to them, and research and reviews are carried out on the impact of implementation. Furthermore there may be a potential in the future to consolidate the two statutes making it easier to apply when an individual may lack capacity and/or suffer from an disorder or disability of the mind. 104 For example see the ADE Project on Mental Capacity and Bipolar Disorder -The University of Nottingham. 105 MCA 2005 S5 (3) 25 Bibliography Allen, N. (2010). Case Comment: The Bournewood Gap (as amended). Medical Law Review . Allen, N. (2009). Taking Stock: The Mental Health & Mental Capacity reforms: the first year. The University of Manchester, School of Law. Manchester: Young Street Chambers. American Psychiatric Association. (1994). DSM-IV: Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington. Assessing mental capacity. (2008). Retrieved 2010 July from Community Care: http://www.commuintycare.co.uk/Atricles/2008/01/16/206974 Beauchamp, T., & Childress, J. (2001). Principles of Biomedical Ethics (5 ed.). Oxford: OUP. Bellhouse, J., Holland, A., Clare, I., & Gunn, M. (2001). Decision Making Capacity in adults: its assessment in clinical practice. Advances in Psychiatric Treatment , 7, 294 -301. Church, M., & Watts, S. (2007). Assessment of mental capacity: a flow chart guide. Psychiatric Bulletin , 31, 304 -307. Coats, T. (2006). Consent for emergency care research: the Mental Capacity Act 2005. Emergency Medicine Journal , 23 (12). Dawson, J. (2006). Mental health and incapacity legislation. British Journal of Psychiatry (189), 564-569. Department of Health. (1999). Reform of the Mental health Act 1983. London: DoH. Department of Health. (2008). Revised Code of Practice of the Mental Health Act 1983. London. Department of Health. (1999). Safer Services: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Wetherby: DoH. Department of Health. (2001). Safety First: Five Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. London: DoH. Donnelly, M. (2009). Best interests, patient participation and the Mental Capacity Act 2005. Medical Law Review . Eastman, N., & Peay, J. (1998). Bournewood: an indefensible gap in mental health law. BMJ . Fennell, P. (1998). Doctor Knows Best? Therapeutic Detention Under Common Law, The Mental Health Act and The European Convention. Medical Law Review , 6. Foster, C. (2010). Publication Review: Choosing Life, Choosing Death: The Tryanny of Autonomy in Medical Ethics and Law. Medical Law Review . Haynes, J. (2005). Alcohol Consumption as a risk factor for anxiety and depression. Results from the longitudinal follow-up of the National Psychiatric Morbidity Survey. British Journal of Psychiatry , 187, 544 -551. 26 Hewitt, D. (2007). Bournewouldn't. New Law Journal . Hill, D. (2009). Legislative Comment: The Hague Convention on the International Protection of Adults. International & Comparative Law Quarterly . Ho, V. (1995). Marginal Capacity: The Dilemmas Faced in Assessment and Declaration. Can Med Assoc J , 152 (2), 259-263. Jones, R. (2001). Mental Health Act Manual (7th ed.). London: Sweet and Maxwell Ltd. Keywood, K. (2010). Case Comment: Vulnerable adults, mental capacity and social care refusal. Medical Law Review . Lynch, T. (2008). The Mental Capacity Act 2: Patient advocacy and Ethics. Nursing Times , 104 (43), 26 -27. Marson, D., Savage, R., & Phillips, J. (2006). Financial Capacity in Persons with Schizophrenia and Serious Mental Illness: Clinical and Research Ethics Aspects. Schizophrenia Bulletin , 32 (1), 81-91. Maudsley Hospital London. (2009). People admmitted to psychiatric hospitals commonly lack the mental capacity to make treatment decisions -Evidence based mental health. British Medical Journal . Mental Health Act Commission. (2007). The scope of legal powers of coercion. From Parliament.uk: http://www.publications.parliament.uk/pa/cm200607/cmpublic/mental/memos/uc502 Moncrieff, J. (2003). The politics of a new Mental Health Act. British Journal of Psychiatry , 183, 8-9. Morrissey, F. (2010). Advanced directives in mental health care: hearing the voice of the mentally ill. Medico-Legal Journal of Ireland . Mueser, K., Noordsy, D., Drake, R., & Fox, L. (2003). Integrated Treatment for Dual Diagnosis: A Guide to Effective Practice. New York: The Guildford Press. Nine Years on, the Bournewood gap remains as wide as ever. (2006). Retrieved 2010 July from Community Care: http://www.communitycare.co.uk/Articles/2006/06/15/54558 Palin, A. (2010). Advising the Disabled: first principles: Part 1. Private Client Business . Palin, A. (2010). Advising the Disabled: Part 3: lasting powers of attorney, deputyship appointments, statutory wills and benefits. Private Client Business . R (on the application of MC (Algeria) v Secretary of State for the Home Department, 347 (EWCA Civ 2010). Rassool, H. (2002). Dual Diagnosis: Substance Misuse and Psychiatric Disorders. Blackwell Publishing Company. Richardson, G. (2010). Mental capacity at the margin: the interface between two Acts. Medical Law Review . 27 Rosenthal, R. (2003). Dual Diagnosis: Key Readings in Addiction Psuchiatry. New York: Brunner-Routledge. Samanta, J. (2009). Lasting powers of attorney for healthcare under the Mental Capacity Act 2005: enhanced prospective self-determination for future incapacity or a simulacrum. Medical Law Review . Scheepers, B. (2009). Personal injury law and severe head injury: helping millionaires to lead impoverished lives. Journal of Personal Injury Law . Schuckit, M. (2009). Alocohol use disorders. The Lancet , 373, 492 -501. Schwarts, D. A. (2010). Should Anti Psychotic Medication Be Legally Required? Kendra's Law. Retrieved 2010 July from MentalHelp.net: http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=37605 South London and Maudsley NHS Foundation Trust. (2010). The Maze: A Practical Guide to the Mental Health Act 1983 (Amended 2007). London. Teeson, M. (2006). Substance use, dependance and treatment seeking in the United States of America and Australia: A cross national comparison. Drug Alcohol Depend , 81, 149 -155. The Law Society. (2006). Mental Capacity Act Code of Practice: The Law Society's Comment to the Consultation. The Law Society. The Law Society. (2009). The Law Society response to the Office of the Public Guardian consultation: Reviewing the Mental Capacity Act 2005: Forms, supervision and fees. The Law Society. The NHS Information Centre, Community and Mental Health Teams. (2010). Inpatients formally detained in hospitals under the Mental Health Act 1983 and patients subject to supervised community treatment, Annual figures, England 2009/10. The Health and Social Care Information Centre. Thomas, S. &. (2000). A Casebook on Contract (11th ed.). Winterton, R. (2006). Explanatory Memorandum: The Mental Capacity Act 2005 (Independant Mental Capacity Advocates) (Expansion of Role) Regulations 2006: No. 2883. Department of Health. 28 APPENDICES APPENDIX I – Table 1 (Adults1 drinking more than recommended daily levels, by gender and socio-economic classification2, 2004) England Percentages All adults Men Women Drank more than 3/4 Units Managerial and professional 32 40 24 Large employers and higher managerial 35 42 27 Higher professional 31 36 24 Lower managerial and professional 32 41 24 Intermediate 30 41 21 Intermediate 31 43 23 Small employers/own account 30 39 19 Routine and manual 28 37 20 Lower supervisory and technical 31 38 23 Semi-routine 27 37 19 Routine 27 36 19 All adults3 30 39 22 Drank more than 6/8 units Managerial and professional 15 22 9 Large employers and higher managerial 16 24 9 Higher professional 13 18 8 Lower managerial and professional 16 24 9 Intermediate 15 23 9 Intermediate 15 24 9 Small employers/own account 16 23 8 Routine and manual 15 22 10 Lower supervisory and technical 16 23 10 Semi-routine 16 22 11 Routine 14 20 9 All adults3 15 22 9 Weighted bases (000's) Managerial and professional 13,957 6,721 7,234 Intermediate 6,576 3,076 3,500 Routine and manual 13,458 6,203 7,254 All adults3 34,908 16,372 18,536 Un-weighted bases Managerial and professional 5,143 2,450 2,693 Intermediate 2,280 1,053 1,227 Routine and manual 4,669 2,129 2,540 All adults3 12,387 5,748 6,639 1. Aged 16 and over. 2. Based on the current or last job of the household reference person 29 APPENDIX II – Table 1.1 Lifetime Prevalence (%) and Odds Ratio of Substance Use Disorders for Various DSM III Psychiatric Disorders APPENDIX III – Table 1.2 Suicides in contact with services in the 12 months before death (England and Wales) 30 APPENDIX IV – Table 1.3 All formal detentions under the Mental Health Act in NHS and independent hospitals, by year Table 1.4 All detentions under the Mental Health Act, all facilities, by year Table 1.5 Uses of sections 135 and 136 – place of safety, 2005/06 – 2009/10 31
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