The Right to Refuse Medical Treatment

The law in British Columbia is clear that a mentally capable adult may refuse medical treatment, even if his doctors and family consider it to be in his best interests. The Supreme Court of Canada has recently said that the “right to refuse unwanted medical treatment is fundamental to a person’s dignity and autonomy.” There are a number of reasons why a patient may wish to reject his doctor’s recommended treatment: religious grounds, concern about side effects, or concern about risks. In fact, the law protects the right of a competent patient to make foolish decisions.

But what if the patient is mentally ill?

Professor Starson is not a college or university professor. He is a brilliant physicist who has published several papers in his field. Other physicists respect him, and refer to him as Professor Starson. He has also been diagnosed with bipolar disorder, and has been in and out of mental institutions in Canada and the United States. He was involuntarily committed to an institution in Ontario after he had uttered threats against others. He apparently suffers from delusions. He claims to be leading on the edge to build a starship, and that he is a world class skier and arm wrestler.

Professor Starson’s doctor prescribed various medications to alleviate his condition. The doctor is of the opinion that the medications might allow Professor Starson to function better outside of a mental institution and resume his scientific work, and that he would deteriorate without the medication.

The medication would slow down Professor Starson’s thinking. When Professor Starson had taken medications in the past, he found the side affects unbearable. His doctor was of the opinion that the new medications would not have as severe side affects as the medications Professor Starson had taken before. But Professor Starson was concerned that they would dull his thinking. For Professor Starson, the medication’s effects “would be worse than death for me, because I have always considered normal to be a term so boring it would be like death.”

Under the Ontario legislation (the Health Care Consent Act, 1996, S.O. 1996, c. 2, Sch. A) a patient has the right to refuse treatment if he has the ability “to understand the information that is relevant to making a decision about the treatment…and to appreciate the reasonably foreseeable consequences of a decision or lack of decision.” He must be able to understand the information, apply it to his circumstances, and weigh the risks and benefits of the proposed treatment.

A Consent and Capacity Board in Ontario determined that Professor Starson did not have the capacity to refuse treatment. However, the Ontario courts disagreed, and set aside the Board’s decision. The case went to the Supreme Court of Canda.

On June 6, 2003, the Supreme Court of Canada published its decision in Starson v. Swayze, 2003 SCC 32. In a 6 to 3 decision, the majority held that Professor Starson had the right to refuse the medication. According to the majority, although Professor Starson did not agree with the diagnosis of mental illness, he had a sufficient insight into his condition to have the ability to understand the relevant information. He knew that he was not normal, and that he had some problems. The majority also found that there was no basis for the Consent and Capacity Board’s finding that Professor Starson did not appreciate the consequences of refusing treatment.

In practice, it can be very difficult to determine if someone with a significant mental illness has the capacity to refuse treatment. All of the judges of the Supreme Court of Canada agreed on the legal principles to be applied, but three of them found on the evidence that Professor Starson did not have the capacity to refuse treatment.