The Scenario in Clinical Practice: Mental Capacity and Consent - Essay Example

Lecturer’s Submitted: Discussing a Dilemma from a Legal and Professional Viewpoint Adult: Refusal of Treatment) [1994] 1 WLR 290) Outline 1. Introduction (Re C (Adult: Refusal of Treatment) [1994] 1 WLR 290) 2. Legal Implications of the Case a. Define capacity in Law b. Define Consent in law c. Mental Capacity Act (MCA) i. Background of Mental Capacity Act ii. New Legislation under MCA (2005) iii. Principles of Mental Capacity Act (2005) d. Test of Legal Capacity e. Assessing Capacity f. Key Points about Mental Capacity Act (2005) g. UK Statutes of Law 3. Professional Implications of the Case a. Mental Capacity in Medical Profession b. Consent to Treatment c. Principles of Medical Laws d. Medical Principles 4. Conclusion Mental Capacity and Consent Scenario in Clinical Practice Alexander James is a 19 years old deaf teenager admitted in a mental institution for paranoid personality. Alexander was born deaf and abused by his siblings and friends because of his disability. He grew up believing that everyone is trying to plot a mischief against him. James’ parents admitted him in the mental institution because his paranoid disorder affected his academics, social life and relationships with other people. While at the mental institution, Alexander’s mental disorder intensified when he saw doctors communicating and laughing. He thought that they were laughing at his disability and were plotting to harmful activities against him with their medical practice. James became violent towards the mental health providers and other patients. He was sedated and kept in isolation while his mental health treatment began. During his treatment, James was diagnosed with early symptoms of leukemia. Doctors summoned his parents and informed him that immediate treatment would eliminate the cancer. However, James refused this treatment because he believed that God intentionally planned for his deafness and leukemia, which means that he wanted the cancer to take its own course. The doctors respected James wishes in the presence of an attorney and he received hospice care for the remaining months. In 1994 in England, a similar case of mental capacity and consent occurred when a 68 years old man refused treatment. The case is referred to as Re C (Adult: Refusal of Treatment) [1994] 1 WLR 290, where Mr. C was confined in a mental hospital because of a prolonged paranoid schizophrenia (Tan 4). He further explains that Mr. C had a gangrenous foot that threatened his wellbeing if untreated by amputation. However, Mr. C refused treatment and filed a case to deter doctors from amputating his foot in future. Justice Thorpe ruled in his favor because his delusions and mental illness did not affect his capacity to listen, understand and make solid judgments about his desires (Tan 4). Legal Implications of the Case In the case of James and the medical professionals in the mental institution, his wishes and beliefs were granted after a thorough consultation. Below is a discussion and analysis of the impact of James’ case on UK’s legal system. Capacity in Law Capacity is legally defined as individuals’ ability and freedom to make their own decisions or take necessary actions that will affect their own lives (Law 2). She further explains that the Law Commission of UK implemented a Mental Capacity Act that empowered and encouraged people to make their own decisions about important issues in their lives. Patients in the UK that refuse emergency treatment must be legally competent by exhibiting a high capacity. The wishes of these patients are respected after proving to the court that they have mental stability to reason clearly and deliberate (Buchanan 2). They should hold appropriate objectives and values concerning their refusal of treatment. The law requires patients that refuse emergency medical care to appreciate and acknowledge their current circumstances. Patients are required to understand the information presented by their doctors and finally communicate their desired choice, keeping in mind the consequences of their decisions (Buchanan 2). a. Consent in Law According to UK’s legal system, consent refers to a patient’s agreement to receive care from healthcare providers (Law 4). Consent is either orally through speech, non-verbally through body actions and gestures and finally in writing. The law insists on a valid consent that shows that the patient has legal competency to make his or her own decisions, equipped with detailed and extensive data from doctors about the health condition and make voluntary decisions that are not made under coercion or pressure (Gawthorpe 5). b. Mental Capacity Act i. Background of Mental Capacity Act Mental Capacity Act (MCA) is a legal framework that enables patients to make their own decisions. This Act allows personal attorneys to make decisions on behalf of clients who are 16 years and over in cases of learning disabilities, mental illnesses, dementia and temporary low capacity (Law 9). The MCA protects vulnerable adults and aids health professionals in adhering to the law. The Act also applies to health professionals such as psychiatrists, doctors, dentists, nurses and other social workers. This Act should be followed by hired assistants such as prisons officers, home care assistants, healthcare assistants and support workers. Law (11) explained that patients can also nominate legal decision-makers such as attorney under a legal system referred to as the Lasting Power of Attorney (LPA). The most recent Mental Capacity Act (2005) in UK was implemented in 2007 for adults who must make important decisions, doctors, attorneys and family members to make decisions on behalf of their patients who lack legal competence to make their own decisions. However, the revised MCA (2005) applies to patients in Wales and England only. Scotland uses a law called Adults with Incapacity (Scotland) Act 2000 while Northern Ireland is still governed by common law (Law 8). ii. New Legislation in Mental Capacity Act The court appoints Public Guardians who are given the tasks for registering, vetting and supervising LPAs (Law 13). The LPAs must work closely with Public Guardians to avoid abuse of power. Attorneys appointed by patients to present them before the court in decision-making about treatment can make their personal decisions. iii. Principles of Mental Capacity Act (2005) The first principle of the MCA (2005) deals with the presumption of patient’s capacity to make important decisions unless the court has proved using evidence that he or she lacks the capacity to reason and act wisely (Buchanan 8). The law requires doctors to respect the views of their patients before carrying out an extensive research to determine whether they are fit to make decisions. In the case of Mr. C who refused treatment, Justice Thorpe ruled in his favor because he observed and concluded that C could make sound decisions about refusal to accept treatment from his doctors. The second principle of MCA (2005) the law requires health professionals to refrain from administering treatment to patients who are unable to make clear decisions (Buchanan and Brock 34). The health professionals should seek legal assistance on the matter and only proceed in treating the patients when all these steps are unsuccessful. The third principle prevents health professionals from treating patients because of their low capacity and poor decisions (Buchanan 8). Health professionals will be held accountable for their actions of treating a patient that was unable to think clearly and made poor decisions. The law advocates for legal assistance from patient’s attorneys, family and friends who are legally appointed by the patient to make decisions. The fourth principle of the MCA (2005) puts the interest of the patient before the health professionals and attorneys (Law 45). This principle puts pressure on the decisions made by an attorney or doctors under this Act to be in the best interest of the patient. The last principle of MCA (2005) deals with making decisions under this Act that is least restrictive to the patient’s freedom and rights (Buchanan 10). c. Test of Legal Capacity The legal system in UK has designed a test that measures the capacity of patients before ruling out that they are incompetent to make their own decisions. There are two major steps involved in taking this test. The first stage is evaluating through tests whether the patient has an impairment of the brain or mind (Habiba 184). A disturbance to normal functioning of the brain can also be considered as a hindrance to clear reasoning. If the patient does not have an impairment of the brain or mind, he or she has the capacity stipulated by the Act to make sound judgments. However, if the patient has an impairment of the brain that affects the mind, he or she lacks capacity according to the Act and must appoint or allow the court to appoint a legal representative to make decisions on their behalf. Some of the brain impairment includes dementia, brain damage, learning disabilities, confusion, loss of consciousness, effects of drug and alcohol abuse, drowsiness and delirium. The second stage of the test is to find out whether the impairment affects the patient in making sound decisions about important issues (Habiba 186). In the case of Mr. C, Justice Thorpe determined that his mental illness did not affect his capacity. Mental Capacity Act (2005) gives a patient all the necessary support and practical help to allow them to make their own decisions. If these procedures fail, the courts appoint an attorney to make decisions on behalf of the patient concerning treatment consent or refusal. According to the MCA (2005), a patient lacks capacity when he or she cannot understand medical information presented by doctors, which is significant in making decisions. The patient lacks capacity when he or she is unable to retain the information, use information to make sound judgments and communicate their decisions. d. Assessing Capacity Mental capacity is a section of psychology that lacks measurement instruments or tools. Medical practitioners are unable to scientifically measure a patient’s mental capacity in a psychiatric institution of a medical facility (James 45). However, psychologists have found new ways to assess mental capacity of patients. The uses of cognitive and behavioral aspects of human nature improve the progress and evolution of psychology. Legal representatives use MCA (2005) to assess the capacity of individuals by checking whether the patient can comprehend information about his or her health. Patient who understands information has the ability to read, write and possess high concentration. In Mr. C’s case, he exhibited signs of retaining information by repeating and explaining the information. Justice Thorpe checked whether the Mr. C used the information to make sound decisions keeping in mind the consequences of treatment refusal. The last assessment is observing the response of the patient through speech, gestures (hand rising) and actions (blinking) that communicate the decisions made. Mr. C refused the treatment by filing the case to the High Court and defending his own mental capacity. e. Key Points about Mental Capacity Act (2005) Mental capacity ruling is tailored to meet the needs of individual patient in relation to the adverse condition that results from patient’s decisions (Marson et al. 667). Decision about a patient’s mental capacity is made by legal representatives who use the Act to protect the rights of patients. The MCA (2005) allows decisions to be made with limits. Examples of such cases arise from mental illnesses such as dementia and Alzheimers where patients can remember the information at one point then forget after sometime. The court appoints a legal assistant to enact and support a patient’s decisions. f. UK Statues of Law UK does not have statutes that relate to consent, but the Human Rights Act (1998) has legal consequences for professional healthcare law (Reese and Charlie 76). The first statute is Article 2, which is the protection of human life. This law comes first in the Human Rights Act because life has value. The doctors in the case of Mr. C acted on this first statute to protect life by considering the possibilities of amputating C’s leg to save his life. The second statute is Article 5, which portrays the right have freedom of choice and security (Tan 45). Mr. C used this statute in stating his decisions about his health. He exercised his freedom to decide whether to amputate his foot or use other methods of treatment regardless of the short chances of survival. The third statute that the doctors and Justice Thorpe adhered to is Article 8, which protects advocates for the respect of private life (Tan 47). Mr. C’s decisions were based on his own values and beliefs. The court and doctors respected C’s wishes after the case was ruled in his favor. The last statute is Article 9, which advocates for the freedom of cognitive conscience (Tan 49). Mr. C had a mental illness that distorted his reality to an ideal image of a famous doctor. Schizophrenia does not affect the reasoning and decision-making capabilities. Mr. C could listen and understand the information about his medical condition. He used his values to weigh the decisions and accept the consequences of his decisions. Justice Thorpe indicated that Mr. C’s mental condition has not affected his ability to understand information, retain it and make decisions while believing his decision was his preferred choice. Professional Medical Implications of the Case a. Mental Capacity in Medical Profession According to the guidelines of the British Medical Association (BMA), mental capacity applies to the ability to understand information and make a choice regarding the data (Buchanan 4). While legal definition of mental capacity allows a person to weigh options and make a choice, the medical definition of capacity means that patients must show the abilities of choosing the right treatment option. The British Medical Association proposes that a patient who is in grave danger and needs emergency medical attention should have a clear and outstanding mental capacity to save his or her own life (56). The first step into demonstrating mental capacity according to the British Medical Association is the ability to understand simple language used by doctors to explain the kind of treatment, its purpose in eliminating the illness, the environment of the treatment and the reasons why the health professionals are proposing the treatment. The next step that a patient should demonstrate to assess mental capacity according to the BMA is to understand the chief benefits of the treatment, risks associated and other treatment alternatives. The BMA requires that patients who have the mental capacity to understand in detail the consequences related to refusal of treatment. Health professionals propose treatments that suit each patient’s disease (59). Patients’ with high capacity should retain the above information for a long period and use it to make effective decisions. The last part of the British Medical Association guideline concerning mental capacity advises patients to make a free and informed choice (60). The doctors in Mr. C’s case followed the BMA guidelines and proposed leg amputation. b. Environment for Mental Capacity Assessment According to UK’s Medical Defense Union, the environment that medical professionals use in assessing mental capacity in patients who are required to consent to or refuse treatment must be have minimum anxiety and stress (par 8). A patient’s mental health is maintained for clear reasoning during decision-making. Medical professionals treat immediate causes of incapacity. Health professionals identify medications administered to their patients that might hinder the mental capacity. Communication is the most important part of assessing mental capacity. Doctors design communication techniques with patients that have physical disabilities, mental illnesses and learning disabilities. Health professionals adjust room temperature, facilitate comfort and minimize external distractions that may affect a patient’s ability to think clearly and make wise decisions. c. Consent to Treatment British Medical Association requires health professionals accept the consent in writing or oral from patients before performing any form of treatment (60). This law is important is maintaining a medical license because treating patients without their informed consent is using force, which is illegal and unethical. Treatment proposed by doctors might be beneficial to the patient, but the BMA guidelines deter doctors from administering treatment to their patients in the absence of an informed consent. The principles of consent in the medical professional include informed patients, voluntary actions and decisions and a continual discussion process in cases where the patients change their decisions (Palmer 99). In the case of Mr. C, the doctors did not over-step their boundaries by forcefully administering treatment without his consent. The doctors allowed him to exercise his legal rights in court and C won the case. d. Principles of Medical Laws i. Self-Determination Medical law advocates for consent and independence in making important decisions about allowing health professionals to administer treatment or refuse treatment. Adults who have the mental capacity to decide the course of their lives in relation to medical treatment should be respected and supported in their endeavors (Bunting 12). Self-determination protects and acknowledges a patient’s right and freedom to control his or her own life. The patient is also free from others undesired preferences and interferences concerning treatment. Values and cultural beliefs contribute to the overall decision made by a patient in relation to proposed treatment. Some cultures and religion do not advocate for blood transfusion while some people prefer the option of natural death rather than undergoing various treatments to prolong life. A patient’s freedom and the right to have informed choice against a form of treatment proposed by doctors is stronger than his right to choose the treatment (Bunting 13). Self-determination is stronger and relevant when patients refuse treatment. In the case of Mr. C, he refused the doctor’s proposed treatment of leg amputation and later filed a law suit against future treatment. C’s self-determination is manifested by his outstanding ability to choose alternative treatment method and refuse leg amputation while doctors estimated low chances of his survival. His main objective was to keep his leg and allow doctors to consider alternative methods of treatment. The health professionals in Mr. C’s hospital treated him without amputating his leg with the hope of their client changing his decisions in the future. However, C was determined to keep his leg and face the consequences of refusing the proposed treatment. Justice Thorpe considered C a person with a sound mind to make his own decisions, and his self-determination influenced the judge to rule in his favor. ii. Administering Proposed Treatment Doctors always defend their profession during conflicts of patient treatment. It can be argued that it is the ethical duty of doctors to administer their proposed treatment to their patients. This argument is in accordance with the Hippocratic Oath that doctors take. Health practitioners abide by this oath by providing appropriate treatments and giving good drugs to heal and prolong life while preventing deliberate harm towards their patients (Bunting 14). The duty of doctors to choose life over death should not be hindered or suppressed but elevated by the legal system. Instead of suing doctors for making the right choice in relation to a patient’s treatment, the law should be working towards making the doctors duty of saving lives a law in the UK. The role of choosing treatments for patients should not be done blindly but through guidance of set principles. In the case of Mr. C, his doctors wanted to perform the correct treatment to prolong his life. Their education and experience in the medical field proposes the sanctity of life rather than use alternative methods of treatment that shorten life. iii. Best Interests It is argued that doctors propose treatments that are in the best interests of their patients. Some health professionals administer treatment without the consent of a patient (Bunting 15). Cases occur when the patient lacks mental capacity to make his own decisions concerning the preferred mode of treatment or when the patient is in a critical medical condition that prevents him from consenting or refusing the proposed treatment. In the case of Mr. C refusal to treatment, his doctors wanted to administer treatment and make the decision in his behalf because they concluded that he was delusional and mentally unstable to make his own decisions. The most important aspect of Mr. C’s schizophrenia is his delusion of being a famous doctor that believed in alternative medicine. According to the doctors’ analysis, C’s delusions mislead him to believe that his proposed method was better than that of his doctors because he was the best doctor in the whole world. e. Medical Principles There are four medical principles that doctors and patients must abide to in the delivery and acceptance of healthcare services and products. The medical principles include honoring autonomy, justice, and beneficence (Selinger 30). i. Honoring Autonomy Autonomy is defined as self-rule or independence exercised by individuals to make decisions, perform actions and chooses their own preferences (Timothy 34). The medical field requires health professionals to respect and honor their patients’ autonomy in choosing their preferred treatments and drugs. The first implication of respecting patients’ autonomy is informing patients about treatments and asking for their consent before administering treatment. Exercising confidentiality in the medical field by keeping patients’ medical records in a safe place and not disclosing patients’ files to the public is an implication of honoring patients’ autonomy (Tan 40). Doctors use facts in making diagnosis and proposing appropriate treatment. Health professionals respect their patient’s independence to consent or refuse treatment according to the information given by doctors about the nature of diseases. Good communication is also an implication of honoring patients’ autonomy because patients reserve the freedom to make informed choices (Buchanan and Brock 89). In the case of Mr. C, his doctors not only respected his autonomy after the court ruled in his favor, but also gave him the facts about his disease and consequences of his decision. ii. Beneficence Beneficence is an act of generosity performed by individuals to benefits other people (Tan 42). These actions of generosity are either to remove and prevent harms or to improve the living standards of others. In the medical field, professional health practitioners exercise their generosity by helping their patients in providing necessary data about their conditions and appropriate treatment. There are two principle types of beneficence: ideal and obligatory. Ideal beneficence in the medical field is when a health practitioner attempts to help by benefiting his patients at all occasions. Some physicians practice this form of generosity because of their innate abilities to promote patients’ welfare and mentor their peers and subordinates. Obligatory beneficence is practiced by most medical professionals because they have a responsibility to care for and treat patients. Their obligation in the medical facilities is to remove and prevent harms and deliberate the possible gains against risks of a treatment plan. In the case of Mr. C, his doctors practiced obligatory beneficence when they informed him about the disease and possible benefits in amputating the leg to stop the spread of diseases. The doctors also advised C to make an appropriate decision to prevent harm and eliminate the risks associated with seeking alternative medical treatments. The decision made by Mr. C’s doctors before the law suit was to benefit C in prolonging his life and reducing the pain associated with a gangrenous foot. According to the British Medical Association, health professionals are required to give information that will lead to positive decision-making (59). Training in the medical profession impacts doctors with skills and abilities to remove and prevent harms by proposing effective treatment procedures. However, the doctor’s obligatory beneficence cannot abuse the patient’s right to have informed consent. iii. Non-maleficence Non-maleficence can be defined as doing no harm to other people (Tan 43). In the medical framework, health professionals are deterred from malevolent activities that cause injury, prolonged diseases and death. This medical principle has some limitations in relation to possible risks of some treatments and medicines administered to patients by doctors. Doctors choose specific treatments by checking whether the desired outcomes outweigh the risks. The British Medical Association has set guidelines that prevent health practitioners from using outdated and ineffective treatments (56). These poor treatment procedures not only offer risks without benefits but defy the Human Rights Act of protection of life. The only importance attached to this medical principle is when doctors use it to weigh against the benefits. Health professionals explain to their patients in detail about the possible risks associated with a treatment procedure against the benefits of the treatment. The patient is given information to make a decision whether the possible healthcare benefits balance the risks. In the case of Mr. C, the doctors used the information about his alternative treatment to indicate minimal chances of survival. The facts presented by the doctor showed that the risks of performing alternative procedure outweighed the risks. Doctors tried to treat Mr. C in accordance to his wishes with records of some success, but the overall health of C deteriorated. iv. Justice Justice in the medical field indicates fairness and moral obligation towards patients (Tan 48). Health professionals should fairly distribute scare medical resources to all patients. Doctors must learn how to administer treatment procedures that have clinical research data to patients with terminal illnesses. Allocating hospital beds in both private and open rooms should be fairly distributed among patients depending on the severity of their medical conditions. Another form of justice in the medical field is respecting other people’s values, rights and preferences. Medical professionals are coached and mentored to possess a high level of understanding when it applies to diversity in the health facility. The doctors should try to communicate with the patient to pass information and accept the patient’s preferences in accordance to law. Doctors should also adhere to standard laws that protect the lives of patients, treat patients after consenting and revising their treatment procedures in case of refusal to treatment. Justice in the medical institution requires physicians to respect their patients’ personal views on proposed treatments. Doctors must meet the demands of their patients in a timely fashion by providing equal health, maximize patient’s welfare and foster informed choice among patients. In the case of Mr. C who refused proposed treatment to amputate his leg, the doctors used fairness in respecting his wishes of seeking alternative treatment. Mr. C received justice from the legal system that ruled in his favor thus preventing his doctors from amputating his leg in future. This action was a morally accepted law that protected his personal choice, preferences and ability to exercise his freedom. Conclusion The case of Mr. C, a patient who needs the medical emergency of amputating his foot to prolong his life caused a dilemma in the medical and legal system in the UK. Mr. C filed a law suit to prevent the doctors from administering their proposed treatment method and Justice Thorpe ruled in favor of C. The legal system found out that Mr. C had a mental illness that left him delirious. He believed that he was a famous doctor, but his capacity to understand, reason and make choices was not impaired. The Judge ruled in favor of the patient stating that C knew and understood the information about his disease and the consequences of his decisions. The Mental Capacity Act (2005) was created to protect adults with mental, learning and physical disabilities by making informed choices on their behalf. The legal system in UK also assigned attorneys to represent patients that lack the mental capacity to make sound judgments. The statute law in UK protects human life, advocate for freedom of choices and preferences and require doctors to respect patients’ private lives. In accordance to the British Medical Association guidelines, Mr. C’s doctors followed the rule of giving information and receiving a response based on the information. The first regulation is protecting the life of a patient by explaining that the benefits of amputation outweigh the risks of alternative treatment methods. C’s doctors concluded that his schizophrenia affected his mental capacity, which allowed them to schedule a future date for leg amputation. However, after Justice Thorpe ruled in favor of Mr. C based on the legal definition and assessment of mental capacity, the doctors in the health facility respected C’s wished to receive alternative treatment in adherence to the principles of medical law. 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