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Informed Consent - the Basis of Treatment

© Ian Chovil

In my last column I discussed the current debate of individual freedom to be ill and the obligation of government to ensure public safety. I said I would discuss informed consent this article, because informed consent forms the basis of all medical treatment in North America. I must apologize that I am only somewhat familiar with the laws of Ontario and although I hope this column has a wider application, I don't know how relevant it would be for people in other jurisdictions. The treatment of mental illness in Ontario is governed by three interdependent acts:

• The Health Care Consent Act
• The Substitute Decisions Act
• The Mental Health Act

All acts, forms, and fact sheets concerning this legislation is available at the Ontario Ministry of Health web site, "http://www.gov.on.ca/health/". Essentially there is no treatment, and no admission to hospital or care facility without informed consent, except in an emergency. Consent is not just cooperation, valid and informed consent must be given. Consent requires that a person has the capacity to understand the consequences of their decision. Where an individual is considered incapable of informed consent, a substitute decision maker gives consent. Those are usually the next of kin, but there is a rank order of substitute decision makers who are called when incapacity is determined and a treatment decision must be made.

Essentially the Health Care Consent Act allows emergency treatment for any illness except a mental illness, in which case the reader is referred to the Mental Health Act. The Mental Health Act uses a threshold of dangerousness to commit a person to a hospital for observation and assessment. There is nothing in the Mental Health Act about treatment per se. Its primary focus is public safety. It is not a crime to be crazy in other words, but when there is evidence of dangerousness and self harm, people will be taken by police to hospital.

An individual suspected or known to have a mental illness who is threatening someone or actively suicidal is brought by police to a physician, usually at the emergency ward of the local hospital to determine if they should be hospitalized on a Form 1. If in the physicians opinion the individual is at risk the signed Form One allows detention in a locked unit for 72 hours for assessment. Once that assessment has been done and if incapacity is evident then substitute decision makers will be called. Doctors in the psychiatric ward or hospital can treat emergencies, but that is usually only a one time dose of medication. Once the Form One has expired the physician can place the individual on a Form 3, which lasts two weeks and can be renewed indefinitely or something to that effect. The individual has no review process available to them for a Form One but can appeal to a Review Board for most other actions they do not themselves agree to.

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