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The Substitute Decisions Act (the Act) is an act of the Legislative Assembly of Ontario in Ontario, Canada. It establishes the legal criteria determining when a person has the ability to make decisions that are fundamental to his/her well-being. The ability to make these types of decisions is termed capacity and the decisions are termed consent. Capacity establishes the legal right to consent to or refuse medical treatment, choose housing arrangements and manage one's money. However, there are different tests for capacity that vary according to the type of decisions that must be made. In some instances, capacity will exist for people who do not have full capacity in the common sense understanding of the concept.
Capacity is presumed under the Act if the person is over 18 for management of property or 16 for personal care decisions. This means that before a person's right to make decisions for him/herself is removed it must be proven that they do not have capacity. Incapacity is the term for a person who cannot make these decisions.
In terms of personal care, incapacity is defined as not being able to "understand information that is relevant to making a decision concerning his or her own health care, nutrition, shelter, clothing, hygiene or safety, or is not able to appreciate the reasonably foreseeable consequences of a decision or lack of decision." The key concepts are understanding information about a condition and appreciating the results of treatment options, including refusing treatment.
In terms of managing one's property, incapacity is similarly defined as being unable to "understand information that is relevant to making a decision in the management of his or her property, or is not able to appreciate the reasonably foreseeable consequences of a decision or lack of decision."
If a person is found to be incapable they will have a substitute decision-maker appointed for them. A substitute decision-maker may be a family member, non-family members are exceptionally rare. The Office of the Public Guardian and Trustee may also be appointed to this role.
Whoever is appointed to make decisions for an incapable person is expected to make them in keeping with the same principles of the legislation, understanding the relevant information and appreciating the consequences of decisions. Decisions should also incorporate what can be reasonably known about the person's likely opinions, including preferences and cultural attitudes. A substitute decision-maker can be replaced if they are found to be not meeting their obligations.
Under the Act, incapacity can only be determined by a formal assessment. However, a person has the right to refuse to be assessed. To ensure that this right is upheld, an assessor, prior to beginning an assessment must tell the person being assessed what they are doing, what is its purpose, what impact their finding will have and that the person being assessed has the right to refuse. If a person refuses to an assessment it cannot be conducted.
There are limits to a person's right to refuse an assessment. A Court may order an assessment of a person's capacity against their will if it determines that there are reasonable grounds to suspect that the person does not have capacity.
The Capacity Assessment Office maintains a limited register of Capacity Assessors, who must be licensed physicians, psychologists, registered nurses, registered social workers or occupational therapists. [1] Assessors must also hold liability insurance for up to $1,000,000, successfully complete a training course with the Capacity Assessment Office and complete ongoing continuing education. The Capacity Assessment Office does not make specific referrals, but they will provide the names of several Assessors based on a client's needs and location.
Assessments aim to answer the question of whether a person has capacity in keeping with the legislation. Exactly what methods they will use often depends on the skill set of the specific Assessor and the nature of the problem that they face. In other words, an assessment should always be comprehensive enough to understand a person's ability to make decisions for him/herself, but the decision may require only limited capacity. In this case, it can occur that a person who does not have full cognitive ability can still have capacity to make important decisions.
In Ontario, the Office of the Ministry of the Attorney General oversees the Capacity Assessment Office. [2] The Capacity Assessment Office ensures that only licensed Capacity Assessors are allowed to conduct capacity assessments and can assist members of the public in finding Capacity Assessors.
When a person has been found to be incapable the Office of the Public Guardian and Trustee [3] can be appointed to manage their property, which includes their money, real estate, investments, bank accounts, and vehicles.
A person who has been found incapable with respect to property management can appeal their finding before the Consent and Capacity Board. [4] This Board is Composed of public and professional members and will review the history of a person's finding of incapacity and any history since that time. Reviews are permitted on a more frequent basis when incapacity is first determined and then become more periodic once a set period of time has elapsed. A person is always eligible to have their capacity reviewed.
Public versions of the reasons for decisions of the Consent and Capacity Board are published through CanLII and available in a searchable format [5] on the CanLII website, but only the signed original in the Board file serves as the official version of the reasons for decisions. [6]
Since only regulated professionals are allowed to conduct capacity assessments, a person who believes that they have been treated unfairly by their assessor can lodge a complaint at the assessor's respective self-governing regulatory body. The self-governing bodies are: the College of Physicians and Surgeons of Ontario; the College of Psychologists of Ontario; The Colleges of Nurses of Ontario; [7] The College of Social Workers and Social Service Workers [8] and The Occupational Therapists College of Ontario. [9] In addition, if a person feels that their lawyer has acted in a way that has caused them harm, they can contact the Law Society of Ontario.
There is a danger that assessors will not be fully objective in certain circumstances. This conduct is most often associated with a professional who believes that his/her referral source will provide future business on the basis of receiving a predetermining finding. This type of misconduct can have serious negative impacts for a client. If a person who is capable is labelled as incapable their rights will be severely violated without just cause. On the other hand, a person who is incapable and is found capable is at risk of causing harm to him/herself or others.
It is a danger for people who are found incapable that they will be put into circumstances that steadily erode their independence. Careful attention must be devoted to ensuring that the extents of incapacity, as well as existing capacities, are appreciated and balanced so that a person can be independent to the greatest extent possible.
It is also a concern on the part of many people found incapable, their family and patient advocates that careful attention is given to ensuring that treatments do not cause further incapacity. This concern has particular bearing for psychotropic medication and other treatments that affect the brain.
A person who loses the right to make decisions on their behalf is exceptionally vulnerable to many types of exploitation. A common form of exploitation is the expropriation of money for purposes that do not benefit the patient and are often clearly fraudulent. This type of exploitation can be perpetrated by a substitute decision-maker, an employee of the Office of the Public Guardian and Trustee, a lawyer representing the client or an employee in an institution.
Other types of exploitation can include abuse and neglect.
There are times when the family or friends of a person, or their community as a whole, may believe that a person needs access to care that they are unwilling or unable to provide to themselves. On the other hand, many of these types of decisions are the most fundamentally personal and private decisions that a person will ever make. There is a conflict of interest in that the community's reasons for wanting a course of action to be imposed on a person are not necessarily the same as that person's, yet he/she is the one who will be required to make the change.
A power of attorney (POA) or letter of attorney is a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter. The person authorizing the other to act is the principal, grantor, or donor. The one authorized to act is the agent, attorney, or in some common law jurisdictions, the attorney-in-fact.
An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In the U.S. it has a legal status in itself, whereas in some countries it is legally persuasive without being a legal document.
Legal capacity is a quality denoting either the legal aptitude of a person to have rights and liabilities, or altogether the personhood itself in regard to an entity other than a natural person.
Forensic psychiatry is a subspeciality of psychiatry and is related to criminology. It encompasses the interface between law and psychiatry. According to the American Academy of Psychiatry and the Law, it is defined as "a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory, or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment." A forensic psychiatrist provides services – such as determination of competency to stand trial – to a court of law to facilitate the adjudicative process and provide treatment, such as medications and psychotherapy, to criminals.
A legal guardian is a person who has been appointed by a court or otherwise has the legal authority to make decisions relevant to the personal and property interests of another person who is deemed incompetent, called a ward. For example, a legal guardian might be granted the authority to make decisions regarding a ward's housing or medical care or manage the ward's finances. Guardianship is most appropriate when an alleged ward is functionally incapacitated, meaning they have a lagging skill critical to performing certain tasks, such as making important life decisions. Guardianship intends to serve as a safeguard to protect the ward.
In United States and Canadian law, competence concerns the mental capacity of an individual to participate in legal proceedings or transactions, and the mental condition a person must have to be responsible for his or her decisions or acts. Competence is an attribute that is decision-specific. Depending on various factors which typically revolve around mental function integrity, an individual may or may not be competent to make a particular medical decision, a particular contractual agreement, to execute an effective deed to real property, or to execute a will having certain terms.
The Mental Health Act is an Ontario law that regulates the administration of mental health care in the province. The main purpose of the legislation is to regulate the involuntary admission of people into a psychiatric hospital. Since the changes brought about in 2000 under Bill 68, the Act allows for a community treatment order by the attending physician. This order is intended to provide comprehensive treatment outside of a psychiatric facility.
The Mental Capacity Act 2005 is an Act of the Parliament of the United Kingdom applying to England and Wales. Its primary purpose is to provide a legal framework for acting and making decisions on behalf of adults who lack the capacity to make particular decisions for themselves.
The Guardianship Tribunal of New South Wales, a former specialist disability tribunal of the Government of New South Wales for people with cognitive incapacity, or disability operated between 1989 and 2013. The Tribunal was superseded by the New South Wales Civil and Administrative Tribunal (NCAT) which came into effect from 1 January 2014. Its functions now operate within a divisional context in the NCAT.
Starson v Swayze, 2003 SCC 32, [2003] 1 S.C.R. 722 was an important case at the Supreme Court of Canada that considered the legal requirements for determining if a person is capable of making decisions regarding their medical treatment.
A surrogate decision maker, also known as a health care proxy or as agents, is an advocate for incompetent patients. If a patient is unable to make decisions for themselves about personal care, a surrogate agent must make decisions for them. If there is a durable power of attorney for health care, the agent appointed by that document is authorized to make health care decisions within the scope of authority granted by the document. If people have court-appointed guardians with authority to make health care decisions, the guardian is the authorized surrogate.
The Human Rights Tribunal of Ontario is an administrative tribunal in Ontario, Canada that hears and determines applications brought under the Ontario Human Rights Code, the provincial statute that sets out human or civil rights in Ontario prohibiting discrimination on the basis of a number of grounds in certain social areas. It is one of the 13 adjudicative tribunals overseen by the Ministry of the Attorney General that make up Tribunals Ontario. Any person who believes they have been discriminated against under the Human Rights Code may bring an application to the Tribunal.
Lasting powers of attorney (LPAs) in English law were created under the Mental Capacity Act 2005, and came into effect on 1 October 2007. The LPA replaced the former enduring powers of attorney (EPA) which were narrower in scope. Their purpose is to meet the needs of those who can see a time when they will lack capacity to look after their own affairs. There are two types of LPA: health and welfare, and property and financial affairs; either or both may be created. The LPA allows them to make appropriate arrangements for family members or trusted friends to be authorised to make decisions on their behalf. The LPA is created and registered with the Office of the Public Guardian (OPG), an executive agency of the Ministry of Justice of the United Kingdom.
The Health Care Consent Act (HCCA) is an Ontario law concerned with the capacity to consent to treatment and admission to care facilities.. As of 2 August 2023 on a date to be named by proclamation of the Lieutenant Governor, the act will apply to confining in a care facility.
The Work Capability Assessment (WCA) is used by the British Government's Department for Work and Pensions (DWP) to decide whether and to what extent welfare benefit claimants are capable of doing work or work-related activities. The outcome of the assessment also determines whether claimants are entitled to "new style" Employment and Support Allowance (ESA) and potentially additional elements of Universal Credit (UC).
A mental health tribunal is a specialist tribunal (hearing) empowered by law to adjudicate disputes about mental health treatment and detention, primarily by conducting independent reviews of patients diagnosed with mental disorders who are detained in psychiatric hospitals, or under outpatient commitment, and who may be subject to involuntary treatment.
Insolvency in South African law refers to a status of diminished legal capacity imposed by the courts on persons who are unable to pay their debts, or whose liabilities exceed their assets. The insolvent's diminished legal capacity entails deprivation of certain of his important legal capacities and rights, in the interests of protecting other persons, primarily the general body of existing creditors, but also prospective creditors. Insolvency is also of benefit to the insolvent, in that it grants him relief in certain respects.
Advance care planning is a process that enables individuals to make plans about their future health care. Advance care plans provide direction to healthcare professionals when a person is not in a position to make and/or communicate their own healthcare choices. Advance care planning is applicable to adults at all stages of life. Participation in advance care planning has been shown to reduce stress and anxiety for patients and their families, and lead to improvements in end of life care. Older adults are more directly concerned as they may experience a situation where advance care planning can be useful. However, a minority use them. A research conducted in Switzerland with people aged 71 to 80 showed that better knowledge on advance care planning dispositions could improve the perception older people have of them. Communication on dispositions should take into account individual knowledge levels and address commonly enunciated barriers that seem to diminish with increased knowledge.
In the law of England and Wales, best interest decisions are decisions made on behalf of people who do not have mental capacity to make them for themselves at the time the decision needs to be taken. Someone who has the capacity to make a decision is said to be "capacitous". Since 2007, there has been a dedicated court with jurisdiction over mental capacity: the Court of Protection, although it mostly deals with adults. Most applications to make decisions on behalf of a child are still dealt with by the Family Court.
Legal capacity is the ability of an individual to transact with others. It should be distinguished from consent, where the individual with capacity, agrees for another to commit an act involving the consenter, such as consent to sexual relations under the Sexual Offences (Scotland) Act 2009.