Current law 276 Other jurisdictions 283 Community ... · 13.16 VCAT has the power to consent to any...

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13Chapter 13Medical treatment

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CONTENTSIntroduction� 276

Current�law� 276

Other�jurisdictions� 283

Community�responses� 285

The�Commission’s�views�and�conclusions� 290

Victorian Law Reform Commission – Guardianship: Final Report 24276

13Chapter 13 Medical treatment

INTROduCTION13.1 Inthischapter,theCommissionmakesrecommendationsforreformofthelaw

concerningauthorisationofmedicaltreatmentforpeoplewithimpaireddecision-makingcapacity.

13.2 Thecurrentlawiscomplex,largelybecauseitissometimesnecessarytoconsideranumberofoverlappingstatutesaswellasthecommonlawinordertodeterminethelegalrulesthatapplywhenapersonisunabletomaketheirowndecisionsaboutmedicaltreatment.

13.3 Thischapterdealswiththesubstitutedecision-makingarrangementsformedicaltreatmentintheGuardianship and Administration Act 1986(Vic)(G&AAct)andtheMedical Treatment Act1988(Vic)thatapplytoalladultswhoareunabletomaketheirowndecisionsaboutmedicaltreatment.InChapters23and24,weconsidertheDisability Act 2006(Vic) andthe Mental Health Act 1986(Vic),whichalsodealwithsubstitutedconsentformedicaltreatmentforpeoplewithimpairedcapacityduetoparticulardisabilities.ThelawgoverningsubstituteconsentforparticipationinmedicalresearchproceduresisconsideredinChapter14.

13.4 Thereappearstobeawidespreadlackofunderstandingabouthowthelawregulatesmedicaltreatmentforpeoplewholackcapacitytomaketheirowndecisions,perhapsbecauseofitscomplexity.TheCommission’srecommendationsaimtosimplifythelawandtoimprovecommunityunderstandingofitsoperation.

13.5 Thischaptercontainsrecommendationsthatseektoachievethefollowingoutcomes:

• streamliningthelawregulatingpersonalappointmentsofsubstitutedecisionmakersformedicaltreatmentbyreplacingthetwoexistingmechanismswithonenewprocess

• improvingtheprocedureofautomaticallyappointingapersontobecomethesubstitutedecisionmakerformedicaltreatmentwhenthereisnopersonalguardianwiththepowertomakethesedecisions

• providingappropriateexternalauthorisationofimportantmedicaltreatmentdecisionsbymakingthePublicAdvocatethesubstitutedecisionmakeroflastresortinsomeinstances.

CuRRENT Law13.6 Thecommonlawsupportstherightofalladultswithcapacitytomakedecisions

aboutwhathappenstotheirbodies.Thismeansthatitisunlawfulforanymedicalpractitionertotreatanadultwithouttheirconsent,‘exceptincasesofemergencyornecessity’.1Thecommonlawdoesnototherwisecaterforpeoplewhoareunabletomaketheirownmedicaltreatmentdecisions,becauseitdoesnotallowanadulttoauthorisetreatmentforanotheradultinanycircumstances.2

13.7 InVictoria,thecommonlawrulesconcerningmedicaltreatmenthavebeensupplementedbytwopiecesoflegislationthatallowpeopletomakearrangementsformedicaltreatmentdecisionswhentheyareunabletomaketheirowndecisions.Thislegislationwasfirstpassedinthe1980sandsubsequentlybroadenedbyamendmentinthe1990s.

1 Rogers v Whitaker(1992)175CLR479,489.2 SeeBernadetteRichards,‘GeneralPrinciplesofConsenttoMedicalTreatment’inBenWhite,FionaMcDonaldandLindyWillmott(eds),

Health Law in Australia(LawbookCo,2010)93–111.

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13.8 Since1986,theG&AActhaspermittedatribunaltoappointaguardiantomakemedicaltreatmentdecisionsforapersonwithimpaireddecision-makingcapacity.Since1988,theMedicalTreatmentAct,whichsoughttoclarifythecommonlawrightofpeopletorefusemedicaltreatment,hasallowedapersonwithcapacitytogiveawrittendirectionaboutrefusaloftreatmentthat,insomecircumstances,continuestooperatewhenthepersonnolongerhasthecapacitytomaketheirowntreatmentdecisions.

13.9 TheMedicalTreatmentActwasamendedin1990toallowapersonwithcapacitytoappointanagenttomakemedicaltreatmentdecisionsforthem—includingrefusaloftreatment—shouldtheylosecapacityinthefuture.3

13.10 In1999,theG&AAct wasamendedtoallow:

• apersonwithcapacitytoappointanenduringguardiantomakedecisionsforthemiftheylosecapacity,includingdecisionsaboutmedicaltreatment,and

• apersontobeautomaticallyappointedbyoperationofthelegislation,withouttheneedforanytribunalappointment,withauthoritytoconsenttomedicaltreatmentonbehalfofapersonwhoisunabletoconsentthemselves.Thesubstitutedecisionmakerisreferredtointhelegislationasthe‘personresponsible’andtheprocessisreferredtointhischapterasan‘automaticappointment’ora‘statutoryappointment’.

13.11 Bothpiecesoflegislationrespondedtotheneedsofmedicalpractitionersandthecommunityforclearerallocationoflegalresponsibilityformedicaltreatmentdecisions.TheMedicalTreatmentActsoughttoprovidegreaterclarityandsecurityaboutpotentiallylife-endingwithdrawaloftreatment,whilethe‘automaticappointment’amendmentstotheG&AActsoughttoestablishanefficientmeansofobtainingconsenttotreatpatientswholackedcapacitytomaketheirowndecisions.4

13.12 ThewayinwhichthesetwoActsoperatetogetherisnotclearbecauseMedicalTreatmentActagentsandenduringguardiansappointedundertheG&AActhaveverysimilarroles.WhiletheMedicalTreatmentActwasinitiallyconcernedwithendofliferefusaloftreatment,the1990amendmentappearstopermitapersonwithcapacitytoappointanagenttomakedecisionsaboutanymedicaltreatment.Anenduringguardiancanalsobegivenauthoritytomakeanymedicaltreatmentdecisionsforapersonwhoisunabletodoso,otherthandecisionsabout‘specialprocedures’,whichmustbemadebytheVictorianCivilandAdministrativeTribunal(VCAT).5

ThE GuaRdIaNShIp aNd admINISTRaTION aCT 1986 (VIC)

Substitute decision makers13.13 TheG&AActauthorisessixdifferentsubstitutedecisionmakerstomakesome

decisions,insomecircumstances,foranadultwhois‘incapableofgivingconsent’6to‘medicalordentaltreatment’.7Theyare:

• aguardianappointedbyVCATwithpowertomakemedicaltreatmentdecisions

• anenduringguardianappointedbythepersonconcernedwithpowertomakemedicaltreatmentdecisions

3 Thesearetheprovisionsforappointmentofanenduringpowerofattorney(medicaltreatment):seeMedical Treatment Act 1988 (Vic)s5A.4 TherehadbeenalargenumberofapplicationstoVCATforrelativelyminorprocedures.SeeVictoria,Parliamentary Debates,Legislative

Assembly,22April1999,594–5(MarieTehan).5 SeeGuardianship and Administration Act 1986(Vic)pt4Adiv4.6 Thistermisdefinedins36oftheGuardianship and Administration Act 1986 (1986).7 Thistermisdefinedins3oftheGuardianship and Administration Act 1986(Vic).Foreaseofdiscussion,theterm‘medicaltreatment’isused

throughoutthischaptertoincludewhatisdescribedinpart4AoftheActas‘medicalordentaltreatment’.


13Chapter 13 Medical treatment• apersonwhoisautomaticallyappointedbyoperationofthelegislationasa

personresponsiblewithpowertoconsenttosomeformsofmedicaltreatment

• VCAT,whichcanmakedecisionsaboutanymedicaltreatment,8includingaspecialprocedure

• a‘registeredpractitioner’,9whocanmakedecisionsaboutanymedicaltreatment,includingaspecialprocedure,whenthepractitionerhasreasonablegroundsforbelievingthatthetreatmentis‘necessary,asamatterofurgency’10

• a‘registeredpractitioner’,whocanmakedecisionsaboutanymedicaltreatmentotherthanaspecialprocedure,whenthepractitionerhasbeenunabletoobtainconsentfromapersonresponsiblefortheproposedmedicaltreatmentwhichthepractitionerbelievestobeinthebestinterestsofthepersonconcernedandappropriatenoticehasbeengiventothePublicAdvocate.11

powers of guardians13.14 Theextentofaguardian’sauthoritytomakedecisionsconcerningmedicaltreatment

dependsonthepowersgiventotheguardianbyVCAT,orthepowersgiventoanenduringguardianbyadonor.Aguardiancanbegiventhepowertomakeanymedicaltreatmentdecisionsthattherepresentedpersoncouldmakeotherthanconsentingtoaspecialprocedure.Aguardianappointedtomakehealthcaredecisionsusuallyhasthepowertoconsenttoanymedicaltreatmentofferedbyaregisteredpractitioner,aswellasthepowertorefuseordeclineanytreatment.

VCaT’s powers13.15 VCAThasthepowertomakedecisionsaboutallformsofmedicaltreatment,

includingspecialprocedures,foranadultwhoisunabletomaketheirowndecisions.Specialproceduresaredefinedaspermanentsterilisations,abortions,andremovalofnon-regenerativetissuefordonation,aswellasanyotherproceduresnamedinregulations.12OnlyVCATcanprovidesubstituteconsentforaspecialprocedure.13

13.16 VCAThasthepowertoconsenttoanymedicaltreatment(orspecialprocedure)offeredbyaregisteredpractitioner,aswellasthepowertorefuseordeclineanytreatment(orspecialprocedure).14

powers of the person responsible13.17 Section37oftheG&AActcontainsahierarchyofpeoplewhoarepermittedby

section39oftheActtoconsentto‘medical(ordental)treatment’foranadultwhoisincapableofdoingsowhenthereisnoguardianwiththepowertomakethesedecisions.TheseautomaticappointmentprovisionsoverlapwiththosepartsoftheActthatpermitaguardiantobegiventhepowertomakemedicaltreatmentdecisions,becauseguardiansareincludedinthelistofpeoplewhoareeligibletobeapersonresponsible.

13.18 Thefirstpersononthelistwhoisavailable,willingandabletoactisthepersonresponsible,whohastheauthoritytoconsenttoorwithholdconsenttotheproposedmedicaltreatment.Thesection37listis:

8 VCATcanalsoappointanotherpersontomakethesedecisions:Guardianship and Administration Act 1986(Vic)s42N(6).9 Thistermisdefinedins3oftheGuardianship and Administration Act 1986(Vic)andincludesregisteredmedicalanddentalpractitioners.10 Thisconceptisexplainedfurtherins42A(1)oftheGuardianship and Administration Act 1986(Vic).11 Guardianship and Administration Act 1986(Vic)ss42Kand42L.12 Ibids3.Therearecurrentlynoadditionalspecialproceduressetoutinregulations.13 Guardianship and Administration Act 1986(Vic)pt4Adiv4.14 Ibidss39,42N.

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• anagentwithanenduringpowerofattorney(medicaltreatment)appointedbythepatientundertheMedicalTreatmentAct15

• apersonspecificallyappointedbyVCATtomakedecisionsabouttheproposedtreatment

• apersonappointedbyVCATunderaguardianshiporderthatincludesauthoritytomakedecisionsabouttheproposedtreatment

• aguardianwithenduringpowerofguardianshipappointedbythepatientandwhoseappointmentincludesauthoritytomakedecisionsabouttheproposedtreatment

• apersonappointedinwritingbythepatientwithauthoritytomakedecisionsabouttheproposedtreatment

• thepatient’sspouseordomesticpartner

• thepatient’sprimarycarer

• thepatient’s‘nearestrelative’.16

13.19 Ifthereisnopersonresponsibleavailable,orthemedicalpractitionercannotfindoutwhothepersonresponsibleis,thenthepractitionercanmakethedecisiontocarryoutthetreatmentwithoutconsent,providingtheyfollowcertainprocedures,whichareexplainedbelow.17

The types of treatment covered13.20 ‘Medicaltreatment’isdefinedbroadlybytheG&AActtoincludeanymedical

treatment‘normallycarriedoutby,orunder,thesupervisionofaregisteredpractitioner’.18‘Dentaltreatment’issimilarlydefined.19Thedefinitionalsoexpresslyexcludesanumberofmattersincluding:

• a‘specialprocedure’

• a‘medicalresearchprocedure’

• non-intrusiveexaminationsmadefordiagnosticpurposes

• first-aidtreatment

• administrationofpharmaceuticaldrugsaccordingtoprescriptionor,ifitisadrugforwhichaprescriptionisnotrequired,accordingtothemanufacturer’sinstructions

• anythingelsesetoutinregulations.20

Consenting to a medical procedure13.21 Thepersonresponsiblemustactinaperson’sbest interestswhendecidingwhether

toconsenttomedicaltreatment.TheG&AActrequiresthepersonresponsibletoconsiderarangeofmatterswhenmakingthis‘bestinterests’determination.Thosemattersare:

• thewishesofthepatient,asfarastheycanbeascertained

15 TheauthorityofanagentappointedundertheMedical Treatment Act 1988(Vic)isdiscussedbelow.16 Nearestrelativeisdefinedins3oftheGuardianship and Administration Act 1986(Vic)asthespouseordomesticpartneroftheperson,or

ifthepersondoesnothaveaspouseordomesticpartner,thefirstlistedinthefollowinghierarchywhoisovertheageof18years(withtheeldestmemberofeachcategorygivenpriority):sonordaughter;fatherormother;brotherorsister;grandfatherorgrandmother;grandsonorgranddaughter;uncleoraunt;nepheworniece.

17 Guardianship and Administration Act 1986(Vic)s42K.18 Ibids3.19 Ibids3.20 Therearecurrentlynoadditionalexclusionsinregulations.


13Chapter 13 Medical treatment• thewishesofanynearestrelativeoranyotherfamilymembersofthepatient

• theconsequencestothepatientifthetreatmentisnotcarriedout

• anyalternativetreatmentavailable

• thenatureanddegreeofanysignificantrisksassociatedwiththetreatmentoranyalternativetreatment

• whetherthetreatmentistobecarriedoutonlyforthepurposesofpromotingandmaintainingthehealthandwellbeingofthepatient

• anyothermattersprescribedbytheregulations.21

13.22 Additionalmatterscanberelevantifthepatientislikelytobeabletomaketheirowndecisionwithinareasonabletime.Ifthepatientobjectstoanearestrelativebeinginvolvedinthedecision,thepersonresponsibleisnotrequiredtotakethatrelative’swishesintoaccount.22Inaddition,thepersonresponsiblecannotgiveconsentatallunless:

• themedicalpractitionerstatesinwritingthattheybelieveafurtherdelayincarryingoutthetreatmentwouldresultinasignificantdeteriorationofthepatient’scondition,and

• thereisnoreasontobelievethattreatmentwouldbeagainsttheperson’swishes.23

13.23 Ifthepersonresponsibleconsentstomedicaltreatment,thatconsenthasthesamelegaleffectasifthepatienthadconsentedtothetreatmentwiththecapacitytodoso.24

withholding consent and refusing treatment13.24 Thepowersofapersonresponsibledifferfromthoseofamedicalagentunderthe

MedicalTreatmentActoraguardianwithbroadmedicaltreatmentpowers,becauseamedicalagentandaguardianmaymakeafinalandbindingdecisiontorefusetreatmentfortherepresentedperson.Apersonresponsiblecanonlyconsentorwithholdconsenttotheproposedtreatment.

13.25 Part4AoftheG&AActdoesnotdealexpresslywithsubstituterefusaloftreatmentforapersonwithimpaireddecision-makingcapacity.WhiletheActgivesthepersonresponsiblethepowertoconsenttomedicalordentaltreatment,italsorecognisesthatconsentmaybewithheld,becauseitpermitsamedicalpractitionertoproceedwithtreatmentinsomecircumstanceswherethepersonresponsibledoesnotconsent.25Thismeansthatifpersonresponsiblewithholdsconsent,itwillnotalwaysamounttoarefusaloftreatment.ThishasledtoconsiderableconfusionaboutthedifferencebetweenwithholdingconsentundertheG&AActandrefusingtreatmentundertheMedicalTreatmentAct.

Carrying out medical treatment without consentEmergencies13.26 TheG&AActauthorisesaregisteredpractitionertoperformmedicaltreatment

withoutconsentinanemergency.Anemergencyexistswhentheprocedureisnecessary:

21 Guardianship and Administration Act 1986(Vic)s38(1).Therearecurrentlynoadditionalmattersprescribedbyregulation.22 Guardianship and Administration Act 1986(Vic)s38(2).23 Ibids42HA(2).24 Ibids40.25 Ibids42L.

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• tosavethepatient’slife

• topreventseriousdamagetothepatient’shealth,or

• topreventthepatientfromsufferingorcontinuingtosuffersignificantpainordistress.26

13.27 Whilethereisalsoacommonlawpowertoperformmedicaltreatmentwithoutconsentinanemergency,27thisstatutorypowerisprobablymoreextensivethantheauthoritygiventomedicalpractitionersbythecommonlaw.28

When the person responsible is unavailable or withholds consent13.28 Ifamedicalpractitionerisunabletoidentifyorcontactthepersonresponsible,they

maystillcarryoutamedicaltreatmentprocedureiftheybelievethatthetreatmentisinthebestinterestsofthepatientandtheygivenoticetothePublicAdvocate.29

13.29 Ifthepersonresponsibleiscontactedbutwithholdsconsenttothemedicaltreatment,themedicalpractitionercanstillproceedwiththetreatment,iftheybelieveitisinthepatient’sbestintereststodosoandtheyadviseboththepersonresponsibleandthePublicAdvocateoftheirintentiontoproceedwiththetreatment.30ThemedicalpractitionercannotproceedwiththetreatmentuntilthepersonresponsiblehasbeengivenatleastsevendaystoapplytoVCATtochallengethatdecision.31VCAThasbroadpowerstomakeordersitbelievesareinthebestinterestsofthepatient.32

ThE mEdICaL TREaTmENT aCT 1988 (VIC)13.30 TheMedicalTreatmentAct originallysoughttoclarifythecommonlawrightofpeople

torefusemedicaltreatment.The1990amendment33thatpermitsapersontoappointanagentasasubstitutedecisionmakerappearstoallowthepersontoauthorisetheagenttomakeanydecisionsthatthepersoncouldmakeaboutanymedicaltreatmentwhenthepersonisincapableofmakingtheirowndecisions.34

Who can consent to or refuse treatment13.31 Threegroupsofpeoplecanmakedecisionsaboutmedicaltreatmentunderthe

MedicalTreatmentAct.Theyare:

• patients themselves,iftheyhavethecapacitytoso35

• agentsappointedbyanenduringpowerofattorney(medicaltreatment)36

• guardians appointed by VCAT,whereVCAThasincludedthepowertomakedecisionsaboutmedicaltreatmentintheguardianshiporder.37

13.32 Apersonwithcapacitytomaketheirowntreatmentdecisionsmayappointanagent‘tomakedecisionsaboutmedicaltreatment’38forthemiftheybecome‘incompetent’.39Theappointmentismadebyusinganenduringpowerofattorney

26 Ibids42A(1).27 Rogers v Whitaker(1992)175CLR479,489.28 SeeRichards,‘GeneralPrinciplesofConsenttoMedicalTreatment’,aboven2,108–10.29 Guardianship and Administration Act 1986(Vic)s42K.30 Ibids42L.31 Ibids42L(2)(a).32 Ibids42N(6).33 Medical Treatment (Enduring Powers of Attorney) Act1990(Vic).34 Seesection5AandSchedule2totheMedical Treatment Act 1988(Vic).While‘medicaltreatment’whenusedinsection5AandSchedule2

mustmean‘medicaltreatment’asdefinedinsection3ofthatAct,thatstatutorydefinitionappearstobemuchbroaderthanthedefinitionof‘medicaltreatment’insection3oftheGuardianship and Administration Act 1986 (Vic).

35 Medical Treatment Act 1988(Vic)s5.36 Ibidss5A(1)(a)(aa).37 Ibids5A(1)(b).TheMedicalTreatmentActdoesnotrefertopersonallyappointedenduringguardians.38 Medical Treatment Act 1988(Vic)s5A(2)(a),sch2[2].39 Ibids5A(2)(b).


13Chapter 13 Medical treatment(medicaltreatment).Thereferenceto‘decisions’inthelegislation40suggeststhattheagenthasthepowertoconsenttoandrefusemedicaltreatmentwhentheappointmentisoperative.

The types of treatment covered13.33 TheMedicalTreatmentActcontainsaverybroaddefinitionof‘medicaltreatment’,

describingitasthecarryingoutofanoperation,theadministrationofadrugorotherlikesubstance,oranyothermedicalprocedure.Itexpresslyexcludespalliativecare.41

13.34 Thedistinctionbetweenmedicaltreatmentandpalliativecarehasbeenamatterofsomecontroversy,despitethefactthattheMedicalTreatmentActcontainsdefinitionsofbothterms.42In2003,JusticeMorrisoftheVictorianSupremeCourtfoundthatartificialnutritionandhydrationviapercutaneousendoscopicgastronomy(PEG)wasmedicaltreatmentratherthanpalliativecare.43Thisfindingpermittedaguardianwithpowerstomakedecisionsaboutaperson’smedicaltreatmenttorefusePEGforarepresentedpersonbyrelyingupontherefusaloftreatmentprovisionsoftheMedicalTreatmentAct.

13.35 TheCommissionseesnoneedtorevisitthemeaningofthesetermsintheMedicalTreatmentAct.Thematterisbestlefttothecourtsfordecisiononacase-by-casebasis.TheCommissionalsonotesthatthetermsofreferenceprovidethat‘issuesassociatedwithendoflifedecisions,beyondthosecurrentlydealtwithbytheMedical Treatment Act 1988,arenotwithinthescopeofthereview’.

The procedure for refusing medical treatment13.36 Anagentorguardianmustbeinformedaboutapatient’scurrentconditionbefore

theycanrefusemedicaltreatmentonthepatient’sbehalf.Theremustbesufficientinformationaswouldallowthepatienttomaketheirowndecisionaboutwhethertorefusethetreatment.44Theagentorguardiancanrefusetreatmentifitwouldcauseunreasonabledistresstothepatientoriftherearereasonablegroundsforbelievingthatthepatientwouldconsiderthetreatmentunwarrantediftheywereabletomakethedecisionthemselves.45

13.37 Whenanagentorguardiandecidestorefusetreatmentonbehalfofapatient,itisnecessarytocompletea‘refusal of treatment certificate’.46Thiscertificaterequirestheagentorguardiantodeclarethat:

• theyareauthorisedtomakemedicaltreatmentdecisionsforthepatient

• thepatientisatleast18yearsold

• theyhavebeeninformedaboutthepatient’scondition

• theyunderstandthisinformation

• theybelievethatthepatientwouldnotwantthetreatmenttobeadministered.47

13.38 Twowitnessesmustcertifythattheyaresatisfiedthattheagentorguardianhasbeeninformedabout,andunderstands,thepatient’sconditiontotheextentthatwouldbesufficientifthepatientwereabletomaketheirowndecision.Oneofthesetwopeoplemustbearegisteredmedicalpractitioner.48

40 Ibids5A(2)(a).41 Ibids3.42 Ibiddefinespalliativecareasincluding‘theprovisionofmedicalproceduresforthereliefofpain,sufferinganddiscomfort;orthereasonable

provisionoffoodandwater’.43 Re BWV; Ex Parte Gardner(2003)7VR487,504–5.44 Medical Treatment Act 1988(Vic)s5B(1).45 Ibids5B(2).46 Ibids5B(3).47 Ibidsch3.48 Ibid.

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Consenting to medical treatment13.39 TheMedicalTreatmentActdoesnotsetoutanyprocedureforanagenttofollow

whenconsentingtomedicaltreatment.

Carrying out medical treatment when there is a refusal of treatment certificate13.40 Ifanagentorguardianhascompletedarefusaloftreatmentcertificate,theMedical

TreatmentActonlyallowsmedicaltreatmenttobeundertakenifthepoweroftheagentorguardianissuspendedorrevokedbyVCAT.49AnypersonwhohasaspecialinterestintheaffairsofthepatientcanapplytoVCATforthistohappen.50VCATmaysuspendorrevokethepower,orrevokethecertificateitself,ifitissatisfiedthatitwouldnotbeinthepatient’sbestinterestsfortherefusaloftreatmenttocontinue,orfortheagenttocontinuetoholdthepower.51

OThER juRISdICTIONS13.41 AllotherAustralianjurisdictions,excepttheNorthernTerritory,havelegislationsimilar

totheG&AActthatprovidesforautomaticappointeestomakemedicaltreatmentdecisionsforadultswithimpaireddecision-makingcapacity.Itisinstructivetoconsidersomeoftheimportantpointsofdifference.

dISTINCTION bETwEEN mINOR aNd majOR TREaTmENT fOR ThE puRpOSES Of CONSENT13.42 InNewSouthWales,asinVictoria,adoctormaycarryoutamedicaltreatment

procedurewithouttheconsentofthepersonresponsibleiftheyareunabletoidentifyorcontactthepersonresponsible.InNewSouthWales,thiscanhappenonlyiftheprocedurefitstheAct’sdefinitionofminortreatment.52Majortreatmentwouldrequireaguardiantobeappointed,oranapplicationtothetribunalforitsconsent.Minortreatmentisanytreatment,otherthanspecialtreatmentorclinicaltrials,notdefinedbyregulationasbeingmajortreatment.53

13.43 TheNewSouthWalesregulationsdescribemajortreatmentas:

• injectionoflong-actinghormonesforcontraceptionorregulatingmenstruation

• administeringadrugofaddiction

• administeringageneralanaestheticor,insomecases,asedative

• anytreatmenttoeliminatemenstruation

• certaintreatmentsthataffectthecentralnervoussystem

• treatmentsthathaveahighlevelofriskinrelationtodeath,braindamage,paralysis,scarring,distress,prolongedrecovery,etc.

• anytestforHIV.54

13.44 InQueensland,minoranduncontroversialtreatmentmaybecarriedoutwithoutconsent,aslongasthehealthpractitionerbelievesitwillpromotethepatient’shealthandwellbeingandthattherearenoobjectionstoit.TheActdoesnotactuallydefine‘minoranduncontroversial’treatment,leavingthismattertobedeterminedonacase-by-casebasis.55

49 Ibids5D.Otherwisethemedicalpractitionermaycommittheoffenceofmedicaltrespass:ats6.50 ThePublicAdvocateandtheagentoranalternateagentmayalsoapply:Medical Treatment Act 1988(Vic)5C(2).51 Medical Treatment Act 1988(Vic)ss5C(3).52 Guardianship Act 1987(NSW)s37.53 Ibids33.54 Guardianship Regulation 2005(NSW)reg10.55 Guardianship and Administration Act 2000(Qld)s64.



pRINCIpLES TO GuIdE dECISION makERS13.45 TheAustralianCapitalTerritorylegislationincludesprinciplesthatguidethedecisions

madebyanysubstitutedecisionmaker—anydecisionaboutmedicaltreatmentmustbemadeaccordingtothoseprinciples.56TheQueenslandActcomplementsitsbroaddecision-makingprincipleswithspecifichealthcareprinciples.57

pROVISION Of INfORmaTION13.46 TheAustralianCapitalTerritorylegislationalsoincludesaprovisionrequiringhealth

professionalstogivecertaininformationtoa‘healthattorney’,whoistheAustralianCapitalTerritoryequivalentofapersonresponsible.58TheActalsorequiresahealthprofessionaltoinformthePublicAdvocateifahealthattorneyisconsentingtoaparticularmedicaltreatmentprocedureforaperiodlongerthansixmonths.59

auTOmaTIC appOINTmENTS Of SubSTITuTE dECISION makERS13.47 NewSouthWaleswasthefirstAustralianjurisdictiontorespondtotheproblems

associatedwithsubstitutedconsentformedicaltreatmentbyestablishingaschemeforautomaticstatutoryappointmentsofsubstitutedecisionmakers.60Otherjurisdictionsquicklyfollowed,andnowVictoria,theAustralianCapitalTerritory,61SouthAustralia,62Queensland63andTasmania64alldealwithautomaticappointmentofsubstitutedecisionmakersformedicaltreatmentinlegislationbroadlysimilartothatoperatinginNewSouthWales.

13.48 InQueensland,apersonknownasthe‘statutoryhealthattorney’isautomaticallyappointedtomakedecisionsabouthealthcaremattersifnoonehasbeenappointedundertheGuardianship and Administration Act 2000(Qld)tomakehealthcaredecisions.Healthcaremattersmustfirstbedealtwithaccordingtoanyhealthdirectivemadebythepersonconcerned,thenbyanyguardianappointedbythetribunal,andthenbyanyenduringappointmentmadebytheperson.Ifnoneoftheseappointmentshasbeenmade,the‘statutoryhealthattorney’appointedunderthePowers of Attorney Act 1998 (Qld)becomesthedecisionmaker.

13.49 Thelegislationsetsoutahierarchyofpeoplewhocanbethe‘statutoryhealthattorney’,beingfirstthespouseoftheperson,thentheirunpaidcarer,thentheirclosefriendorrelativeandthen,finally,ifnoneofthosepeopleareavailable,theQueenslandAdultGuardian.65

13.50 Inallofthesejurisdictions,otherthanQueensland,automaticappointeescanonlymakedecisionsaboutmedicaltreatment.InQueensland,admissiontosomenursingfacilitiesisincludedinthelistofhealthcaredecisionstowhichastatutoryhealthattorneycanconsent.66

alberta, Canada13.51 WhilealloftheAustralianjurisdictionshavesomekindof‘standinglist’ofautomatic

appointees,theCanadianprovinceofAlbertatakesadifferentapproach,permittingamedicalpractitionertochoosewhotheappropriatedecisionmakershouldbe.

56 Guardianship and Management of Property Act 1991 (ACT)s32E.57 Guardianship and Administration Act 2000(Qld)sch1.58 Guardianship and Management of Property Act 1991 (ACT)s32G.59 Ibids32J.60 See Guardianship Act 1987(NSW)s33A.61 SeeGuardianship and Management of Property Act 1991(ACT)pt2A.62 SeeGuardianship and Administration Act 1993(SA)s59.63 SeeGuardianship and Administration Act 2000(Qld)s66andPowers of Attorney Act 1998(Qld)s63.64 SeeGuardianship and Administration Act 1995(Tas)s39.65 Powers of Attorney Act 1998 (Qld)s63.66 Guardianship and Administration Act 2000(Qld)sch2s5.

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InAlberta,a‘specificdecisionmaker’isauthorisedtomakevarioushealthcaredecisions.Thispersonisarelativechosenbythehealthcareproviderapplyingcriteriasetoutinthelegislation.67

Tribunal reviews13.52 EachAustralianjurisdictionwithanautomaticappointmentssystemprovidesforsome

limitedtribunalreviewofthewayinwhichthepowersareexercisedinaparticularcase.InQueensland,theactualappointmentcanbereviewed,68whileinNewSouthWales,asinVictoria,69atribunalcanbeaskedtoconsenttotreatmentthatthepersonresponsiblehasrefusedtoauthorise.70

COmmuNITy RESpONSES13.53 Intheconsultationpaper,theCommissionidentifiedanumberofreformproposals

thatsoughttosimplifythelawgoverningsubstitutedecisionmakingformedicaltreatmentforpeoplewithimpairedcapacity.

haRmONISaTION Of ThE G&a aCT aNd ThE mEdICaL TREaTmENT aCT13.54 AnimportantoptionwastheproposaltoharmonisetheG&AActandtheMedical

TreatmentActtoovercometheconfusioncausedbyhavingtwoActsthatallowapersontomaketwodifferentappointmentsofasubstitutedecisionmakerwithmedicaltreatmentpowers.TheCommissionsuggestedthatMedicalTreatmentActagentsandenduringguardianswithmedicaltreatmentpowersshouldmergewithinanew,singlepersonalappointmentofapersontomakesubstitutemedicaltreatmentdecisions.

13.55 WediscusscommunityresponsestothatideainChapter10andtheCommission’srecommendationtocombinethoseappointments.Weconsiderthatrecommendationinmoredetaillaterinthischapter.InChapter17,theCommissionrecommendsnewprinciplestoguidesubstitutedecisionmakers.Laterinthischapter,wealsoconsideradditionalprinciplesthatshouldguidemedicaltreatmentdecisions.

auTOmaTIC appOINTmENTS—ThE pERSON RESpONSIbLE13.56 TheCommissionalsoproposedreformoftheautomaticappointmentsschemeinthe

G&AAct.Intheconsultationpaper,theCommissionnotedtheapparentwidespreadlackofawarenessoftheautomaticappointmentprocessandtheroleofthepersonresponsible.

13.57 TheCommissionproposedretainingthe‘personresponsible’hierarchybutsuggestedchangestoclarifytheroleandresponsibilitiesoftheposition.

The person responsible hierarchy13.58 Communityresponsesandsubmissionsweregenerallysupportiveofthecurrent

‘personresponsible’hierarchyandthecurrentAct’sprovisions,71althoughsomepeoplevoicedconcernsaboutlackofawarenessofthesystembymembersofthecommunityandbymedicalpractitioners.72Otherresponsespointedtothelimitedoversightoftheframeworkandalackofunderstandingbythepersonresponsibleabouttheirrole.73

67 Adult Guardianship and Trusteeship Act,SA2008,cA-4.2,s89(1).68 Powers of Attorney Act 1998(Qld)s113.69 Guardianship and Administration Act 1986 (Vic)s42N(6).70 Guardianship and Administration Act 1987(NSW)s44.71 SubmissionsCP19(OfficeofthePublicAdvocate),CP27(CatholicArchdioceseofMelbourne),CP44(LeadershipPlus),CP59(Carers

Victoria),CP71(SeniorRightsVictoria).72 SubmissionCP68(AustralianNursingFederation),CP73(VictoriaLegalAid).73 SubmissionCP19(OfficeofthePublicAdvocate),CP65(CouncilontheAgeingVictoria).


13Chapter 13 Medical treatment13.59 TheVictorianEqualOpportunityandHumanRightsCommissionadvocatedchanges

tothecurrenthierarchy,arguingthatallpersonalappointmentsshouldprecedeVCATappointments.74

13.60 Therewereconcernsexpressedaboutthehierarchy’slackofculturalvariabilityandthefactthatitautomaticallyfavourstheoldestpersoninanycategorywhendeterminingtheidentityofthenearestrelative.TheCatholicArchdioceseofMelbournenotedthatthepersonresponsiblemightnotalwaysbethemostappropriateindividualinthecircumstancestomakeadecision.75Thesubmissionconceded,however,thatalegislativeschemeforautomaticdecisionmakerscannotcapturetherangeofpersonalandculturalfactorsthatmakeoneperson,ratherthananother,amoresuitablesubstitutedecisionmaker.76

Scrutiny of automatic appointees13.61 Initsconsultationpaper,theCommissionaskedwhethernewguardianshiplegislation

shouldprovideforenhancedscrutinyofdecisionsofautomaticappointeesbyuseofpracticessuchasrandomauditingbythePublicAdvocateofdecisionsby‘personsresponsible’.

13.62 Thereweremixedresponsestotheproposal.Varioussubmissionsthoughtthatthecurrentprovision,whichpermitsanapplicationtoVCATconcerningaperson’sbestinterestsinthecontextofproposedtreatment,wasadequate.77

13.63 ThePublicAdvocatepointedoutthattheabilitytoapplytoVCATtoremovethe‘personresponsible’israrelyexerciseddespiteseriousdoubtsaboutthewaythatsomeoneismakingdecisions.78

dEfINITION Of mEdICaL TREaTmENT13.64 Intheconsultationpaper,theCommissionproposedexpandingthedefinitionof

‘medicaltreatment’intheG&AActbecauseofconcernsthatitexcludedproceduresforwhichpriorconsentwouldberequiredwhendealingwithapersonwithcapacity.TheCommissionnotedthatbroadeningthedefinitionwouldmeanthatpeopleconnectedtothepersonwithimpairedcapacityratherthanhealthprofessionalswouldberesponsibleformoresubstitutehealthcaredecisionsthaniscurrentlythecase.

13.65 Therewasbroadsupportforwideningthedefinitiontoencompassabroaderrangeoftreatmentsthatfallwithinordinaryperceptionsofmedicaltreatment.Onesubmissioncommentedthatabroaderdefinitionwouldbeconsistent‘withtheincreasingtrendforhealthprofessionalsotherthandoctorstoprovidehealthcare’.79Therangeofavailablehealthcareservicesismuchbroaderthanthatcurrentlycoveredbythedefinitionof‘medicaltreatment’intheG&AAct,andincludesalternativemedicinesandparamedicalservices.

13.66 ThePublicAdvocatesuggestedbroadeningthedefinitiontoincludetheadministrationofpharmaceuticaldrugsaswellasparamedicalandcomplementarymedicalprocedures,whilealsomakingitconsistentwiththedefinitionof‘medicaltreatment’inboththe MedicalTreatmentActandtheMentalHealthAct.80Themostsignificantofthesedifferences,asnotedabove,istheMedicalTreatmentAct’sexclusionof

74 SubmissionCP66(VictorianEqualOpportunityandHumanRightsCommission).75 SubmissionCP27(CatholicArchdioceseofMelbourne).76 Ibid.77 SubmissionCP22(Alzheimer’sAustraliaVictoria),CP27(CatholicArchdioceseofMelbourne),CP59(CarersVictoria),CP73(VictoriaLegal

Aid).78 SubmissionCP19(OfficeofthePublicAdvocate).79 SubmissionCP63(Shin-NingThen,ProfLindyWillmott&AssocProfBenWhite(QUT)).80 SubmissionCP19(OfficeofthePublicAdvocate).

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palliativecarefromitsdefinitionofmedicaltreatment.81ThePublicAdvocatealsosuggestedthatlegislationshouldlistexamplesoftreatmentsthatfallwithinthenewdefinition.82

13.67 Theinclusionoftheadministrationof‘medication’withinthedefinition,asisthecaseinNewSouthWales,wasstronglysupportedbymostsubmissionsthatcommentedonthisissue,includingthePublicAdvocate,EpworthHealthCareandtheCatholicArchdiocese.83

13.68 ThePublicAdvocatepointedoutthatcurrentpracticemakesiteasytoprovidestandardmedicationswherepractitionerscannotobtainconsentfromthepersonresponsible.84However,thePublicAdvocatealsopointedoutthatadministeringcertaindrugsisnotalwaysasimpleanduncontroversialprocedure.ItcanamounttotreatmentthathasmoresignificantconsequencesthansometreatmentscurrentlyregulatedbytheAct,suchaswhenthereareadverseeffectsfromtheadministrationofadrug.85

13.69 Severalsubmissionsexpressedconcernabouttheuseofbehaviourmodifyingdrugs.TheAMAnotedthattheAct’scurrentexclusionofpharmaceuticaldrugsfromitsdefinitionofmedicaltreatmenthasallowedtheexcessiveuseofbehaviourmodifyingdrugsinagedcarefacilities,becauseconsentfortheiradministrationisnotrequired.86AsubmissionbyDrMichaelMurrayarguedthat‘thisisanareasubjecttosignificantabusewithregularfailuretoconsult’.87

13.70 RespectingPatients’Choicesdidnotsupportexpandingthedefinitionofmedicaltreatmenttoincludetheprovisionof‘medication’.Theybelievethatexpandingthedefinitiontoencompasspharmaceuticalswouldmakethetreatmentofpatientsunabletoconsenttooralmedication‘verydifficult’.88

13.71 Broadeningthedefinitionofmedicaltreatmenttoincludecomplementaryandparamedicalprocedureswaswidelysupported.89

mINOR mEdICaL pROCEduRES13.72 IntheconsultationpapertheCommissionalsoaskedwhetheramedicalpractitioner

shouldberequiredtoobtainformalconsentfromthepatientorthepersonresponsibleforminoranduncontroversialmedicaltreatment.

13.73 Thereformoptionpresentedintheconsultationpaperwouldallowmedicalpractitionerstoperformminorprocedureswithoutconsent,subjecttosatisfyingcertainproceduralconditionsthatmightinclude:notifyingVCAT;seekingasecondmedicalopinion;orrecordinginthepatient’sfilethedecisiontoperformtheprocedurewithoutconsentandthereasonsfordoingthis.

13.74 Twoapproachesfordistinguishingbetween‘minor’and‘major’treatmentwerediscussedintheconsultationpaper:

• theNewSouthWalesapproach,whichdefinesmajortreatmentandprovidesthatminortreatmentisthatwhichisnotmajortreatment

81 Medical Treatment Act 1988(Vic)s3.82 SubmissionCP19(OfficeofthePublicAdvocate).83 Ibid,CP20(EpworthHealthCare),CP27(CatholicArchdioceseofMelbourne)andCP69(AustralianMedicalAssociation(Victoria)).84 SubmissionCP19(OfficeofthePublicAdvocate).85 Ibid.86 ConsultationwiththeAustralianMedicalAssociationVictoriaLimited(18May2011).87 SubmissionCP47(DrMichaelMurray).88 SubmissionCP49(RespectingPatientChoicesProgram—AustinHealth).89 Fore.g.,submissionCP19(OfficeofthePublicAdvocate),CP20(EpworthHealthCare),CP24(AutismVictoria),CP33(EasternHealth),

CP59(CarersVictoria),CP68(AustralianNursingFederation)andCP75(FederationofCommunityLegalCentres).


13Chapter 13 Medical treatment• theQueenslandapproach,whichrefersto,butdoesnotdefine,‘minorand

uncontroversial’treatmentandprovidesexamplesofproceduresthatmayfallintothiscategory.Twoexamplesaregiven:theadministrationofanantibioticrequiringaprescriptionandtheadministrationofatetanusinjection.90Ahealthcarepractitionermustalsobesatisfiedthatthetreatmentwillpromotethehealthandwellbeingofthepatientandthattherearenoobjectionstoit.91

13.75 WhilesomesubmissionsadvocatedadoptingtheNewSouthWalesorQueenslandapproaches,92othershighlighteddefinitionalproblemsandthepotentialforabuseinremovingthesafeguardofconsentforminorprocedures.93SeniorsRightsVictoriasupportedtheQueenslandapproach.94

13.76 ThesubmissionbymembersoftheHealthLawResearchProgramattheQUTFacultyofLawsuggestedthat‘minoranduncontroversial’shouldbe‘narrowlydefined’.95Theydoubtedwhetherproceduralsafeguardssuggestedintheconsultationpaperwouldbeeffectivebecausethereisnooversightofthesedecisions.96

13.77 ThePublicAdvocatesupportedpermitting‘minoranduncontroversial’treatmenttoproceedwithoutconsent.97ThePublicAdvocatefavouredtheNewSouthWalesdefinitionalapproach,whichdefines‘majortreatment’.98Asasafeguard,thePublicAdvocaterecommendedthatpractitionersobtainasecondopinion,notedonthepatient’smedicalrecordandverifiedbythatpractitioner’ssignature.99

13.78 EpworthHealthCareagreedthat‘minor’proceduresshouldnotrequireconsentiftheproceduralconditionsoutlinedintheconsultationpaperaresatisfied.100

13.79 Otherhealthbodiesweregenerallysupportivebutuncertainabouthowtodifferentiatebetween‘minor’andotherformsoftreatment.TheRoyalDistrictNursingServicefavoureditinprinciple,butsaidthattheyneededtoconsiderhowthetwoconceptscouldbedistinguishedinpractice.101

13.80 VictoriaLegalAidandtheVictorianEqualOpportunityandHumanRightsCommission(thecommission)didnotsupportthisproposal.VictoriaLegalAidarguedthatalesserstandardshouldnotapplytoindividualswithdiminishedcapacity.102Thecommissionhighlightedthepracticalproblemofdrawingadistinctionbetween‘minor’andotherformsoftreatment.However,thecommission’smainobjectionwasthattheproposalhadthepotentialtoleadtohumanrightsabuses.103Thecommissionarguedthat‘thecurrentsituationallowingsubstituteconsenttomedicaltreatmentisalreadyfraughtwithhumanrightsimplicationsthatrequirestrictsafeguardstopreventabuse’.104Accordingly,thecommissioncontendedthatwhereapersonreceivingtreatmentisunabletoconsent,liftingtherequirementforconsentbyasubstitutedecisionmakerunacceptablyinfringesacorehumanrightenshrinedintheCharter of Human Rights and Responsibilities Act 2006(Vic)(theCharter).105

90 Guardianship and Administration Act 2000(Qld)s64(1).91 Ibid.92 Foreg,SubmissionsCP19(OfficeofthePublicAdvocate),andCP63(Shin-NingThen,ProfLindyWillmott&AssocProfBenWhite(QUT)).93 SubmissionCP35(UrsulaSmith),CP56(DisabilityDiscriminationLegalService),CP73(VictoriaLegalAid)andCP75(Federationof

CommunityLegalCentres(Victoria)).94 SubmissionCP71(SeniorsRightsVictoria).95 SubmissionCP63(Shin-NingThen,ProfLindyWillmott&AssocProfBenWhite(QUT)).96 Ibid.97 SubmissionCP19(OfficeofthePublicAdvocate).98 Ibid.99 Ibid.100 SubmissionCP20(EpworthHealthCare).101 ConsultationwithRoyalDistrictNursingService(9March2011).102 SubmissionCP73(VictoriaLegalAid).103 SubmissionCP66(VictorianEqualOpportunityandHumanRightsCommission).104 Ibid.105 Ibid.

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13.81 Somesubmissionshighlightedthefactthatindividualsunderstandandexperiencemedicaltreatmentdifferently.Alzheimer’sAustralia(Victoria)saidthattreatmentsareneverinsignificantforindividualswhoareweakandlackcapacity.106AutismVictoriasaidthatapersonlivingwiththeconditionmaybecomedistressedbecausetheydonotcomprehend‘thedifferenceorconsequenceofaprocedurewhetherminorornot’.107

SpECIfIC pRINCIpLES fOR mEdICaL dECISION makERS13.82 Intheconsultationpaper,theCommissionproposedthatautomaticappointeesshould

adoptasubstitutedjudgmentapproachtomedicaldecisionmakingbyseekingtomakedecisionsthatthepersonwouldmakethemselves,iftheyhadcapacitytodoso.TheCommissionnotedthatthisapproachdiffersfromtheexisting‘bestinterests’standardbecauseitfocusesonthelikelywishesoftherepresentedperson.WediscussthisapproachtodecisionmakingmoregenerallyinChapter17.Inthatchapter,theCommissionrecommendsthatdecisionmakersshouldmakedecisionsthatpromotethepersonalandsocialwellbeingofthepersontheyarerepresenting.Thisapproachinvolvesaconsiderationofsubstitutedjudgmentprinciples.

13.83 MostresponsestotheconsultationpapersupportedasubstitutedjudgmentapproachtodecisionmakingalthoughthesubmissionfromAlzheimer’sAustralia(Victoria)pointedoutthedifficultyindeterminingwhatshouldhappenwhenthesubstitutedecisionmakerfacesamedicaltreatmentdecisionthattherepresentedpersonhadnotconsideredwhentheyhadcapacity.108

13.84 ThePublicAdvocatesuggestedthatthepatient’spersonalandsocialwellbeingshouldbethekeyguide.Itwasnotedthattheprincipleofsubstitutedjudgmentisimportantbutshouldnotbetheonlyfactorthatthepersonresponsiblereliesupontomakeadecision.109ThePublicAdvocatesupportedageneralsetofprinciplestoassistdecisionmakersinalltypesofdecisions,andtheinclusionofadditionalprinciplestoguidedecisionmakersinrelationtomedicaltreatment.110

13.85 TheAdHocInterfaithCommitteeandtheCatholicArchdioceseofMelbournearguedthatbestinterestsshouldberetainedastheguidingprincipleforhealthdecisions.111Theyarguedthatthisapproachbestservespeoplewithdisabilities,andthattherearesignificantrisksassociatedwiththeproposaltomakesubstitutedjudgmenttheparamountconsideration.112

SpECIaL mEdICaL pROCEduRES fOR mINORS13.86 ThePublicAdvocatebelievesthatguardianshipprovisionsconcerningmedical

treatment113shouldapplytoallpeoplewithdisabilities,notjustthoseovertheageof18.114Currently,theFamilyCourtmakesmedicaltreatmentdecisionsforchildrenthatarebeyondparentalcapacity.115ThePublicAdvocatenotedthesedecisionsareoften‘ethicallycomplex’.Itquestionedtheappropriatenessofthesedecisionsbeing

106 SubmissionCP22(Alzheimer’sAustraliaVic).107 SubmissionCP24(AutismVictoria).108 SubmissionCP22(Alzheimer’sAustraliaVic).109 SubmissionCP19(OfficeofthePublicAdvocate).110 Ibid.111 SubmissionsCP27(CatholicArchdioceseofMelbourne)andCP52(AdHocInterfaithCommittee).112 Ibid.113 Guardianship and Administration Act 1986(Vic)pt4A.114 SubmissionCP19(OfficeofthePublicAdvocate).115 Department of Health & Community Services v JMB and SMB (Marion’s Case)(1992)175CLR218ruledthatconsenttocertainmedical

proceduresfallsoutsideparentalauthority. Marion’s Caseinvolvedtheproposedsterilisation,forreasonsnotbasedonmedicalnecessity,ofayoungwomanwithanintellectualdisability.AsFehlbergandBehrensnote,thejudgmenthad‘threekeyfeatures’:thesterilisationprocedurewassignificantandirreversible;thelikelihoodthatparentsmisjudgetheirchild’spresentandfutureabilitytoconsentand‘bestinterests’;andthe‘consequencesofawrongdecisionareparticularlygrave’:BelindaFehlbergandJulietBehrens,Australian Family Law: The Contemporary Context(OxfordUniversityPress,2008)261,quoting(‘Marion’s Case)(1992)175CLR218,250.


13Chapter 13 Medical treatmentdeterminedintheFamilyCourtbecauseoftheadversarialnatureofthatCourtandtheprohibitivecostsofFamilyCourtapplications.116

13.87 ThePublicAdvocatearguedthat,insomecircumstances,VCATwouldbeamoreappropriatebodytomakethesedecisionsforchildrenwithadisabilitythantheFamilyCourt.117ItwasarguedthatVCATisbettersuitedtomakesuchdecisionsbecauseitis‘anaccessibleandinquisitorialforum’withexperienceinhearingcasesconcerningmedicaltreatmentofadults.118ThePublicAdvocatesuggestedthatVCATshouldbeabletomakemedicaldecisionsconcerningchildren.119ThiswouldresultinVCAThavingsharedjurisdictionwiththeFamilyCourttoconsenttospecialproceduresforchildrenwithdisabilities.

13.88 TheCommissiondoesnotbelievethatitisconstitutionallypossibletoimplementthePublicAdvocate’ssuggestion,becausetheVictorianParliamentreferreditsrelevantlegislativepowerstotheCommonwealthin1986.120EvenifitwerepossiblefortheVictorianParliamenttolegislateaboutthismatter,itwouldbeunnecessarilyconfusingforaCommonwealthcourtandaVictoriantribunaltohaveconcurrentjurisdictioninrelationtocomplexmedicaltreatmentissuesthatoftenrequirequickandfinaldecisions.

ThE COmmISSION’S VIEwS aNd CONCLuSIONSa NEw pERSONaL appOINTmENT fOR mEdICaL dECISION makING13.89 TheCommissionbelievesthatitisimportanttostreamlinethelawregulatingpersonal

appointmentsofsubstitutedecisionmakersformedicaltreatmentbyreplacingthetwoexistingmechanismswithanew,simpleprocess.Itisunhelpfultohavetwomechanisms—anagentappointedundertheMedicalTreatmentActandanenduringguardianwithmedicaltreatmentpowersappointedundertheG&AAct—forpersonallyappointingapersontomakemedicaltreatmentdecisionsfortheprincipalwhentheyareunabletomaketheirowndecisions.

13.90 TheCommissionrecommendsthatnewguardianshiplegislationshouldcontainonlyonemechanismforpersonallyappointingasubstitutedecisionmakerformedicaltreatment.Thisproposalwouldeffectivelymergethetwocurrentpersonalappointmentsofsubstitutedecisionmakersformedicaltreatment.

13.91 Theproposednewenduringpersonalguardian,discussedinChapter10,wouldbecomethesolenewmechanismforpersonallyappointingamedicalsubstitutedecisionmaker.Thepersonwhomakestheappointmentwoulddeterminetheextentofthepowersgiventotheirenduringpersonalguardian,whichcouldincludetheendoflifedecision-makingpowersthatmaybegiventoanagentappointedundertheMedicalTreatmentAct.Thisstepwouldbeamatterofchoiceforthepersonwhomakestheappointment.

13.92 Nousefulpurposeisservedbyretainingtwostatutorymechanismsforpersonallyappointingasubstitutedecisionmakertomakedecisionsaboutmedicaltreatment.Giventheneedforcertaintyabouttheextentofasubstitutedecisionmaker’spowerswhenmakingendoflifedecisions,newguardianshiplegislationshouldcontainprovisionsthatmirrortheexistingsectionsoftheMedicalTreatmentActthatpermitagentsandguardianstomakerefusaloftreatmentcertificates.121

116 SubmissionCP19(OfficeofthePublicAdvocate).117 SubmissionsIP8(OfficeofthePublicAdvocate)andCP19(OfficeofthePublicAdvocate).118 SubmissionCP19(OfficeofthePublicAdvocate).119 Ibid.SeealsoOfficeofthePublicAdvocate(Victoria),What Role Should VCAT have for Persons Under the Age of 18 Years?(June2010),4

<http://www.publicadvocate.vic.gov.au/file/file/Research/Discussion/2010/VCAT%20age%20criteria.doc>.120 Commonwealth Powers (Family Law – Children) Act 1986(Vic).121 Medical Treatment Act 1988(Vic)ss5A–5F.

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13.93 WhilethisrecommendationwouldcausethosesectionsintheMedicalTreatmentActthatconcernsubstitutedecisionmakerstoberemovedandfoldedintonewguardianshiplegislation,theremainingsectionsshouldberetainedbecausetheyestablishausefulprocessbywhichapersoncangivedirectionsaboutunwantedmedicaltreatment.

13.94 Toavoiddoubt,itwouldalsobehelpfulfornewlegislationtoprovidethatVCATcanappointapersonalguardianwiththepowertomakedecisionsaboutanyhealthcaremattersthattherepresentedpersoncouldmakeadecisionabout,otherthanspecialprocedures.

13.95 Newguardianshiplegislationshouldalsomakeitpossibleforapersonwhocompletesarefusaloftreatmentcertificate—whetherasaprincipalorasanenduringpersonalguardianwiththepowertodoso—tofilethatcertificatewiththeRegistrarofBirths,DeathsandMarriagesforinclusionintheonlineregisterthatisdescribedinChapter16.

RECOmmENdaTIONSA new personal appointment for medical decision making

199.Newguardianshiplegislationshouldpermitapersontoappointanenduringpersonalguardiantomakedecisionsabouthealthcaremattersforthemwhentheydonothavethecapacitytomaketheirownhealthcaredecisions,includingthepowertocompletearefusaloftreatmentcertificateinthemannerinwhichthisstepcanbetakenbyanagentappointedundertheMedical Treatment Act 1988(Vic).

200.NewguardianshiplegislationshouldintegratetheprovisionsintheMedical Treatment Act 1988(Vic)concerningtheappointmentofanagenttomakemedicaltreatmentdecisionsforapersonwholackscapacitywiththeprovisionsinthenewlegislationconcerninghealthdecision-makingpowersthatcanbegiventoanenduringpersonalguardian.

201.IftheprovisionsintheMedical Treatment Act 1988(Vic)concerningtheappointmentandpowersofanagentarefullyintegratedwithprovisionsinnewguardianshiplegislationconcerningtheappointmentandpowersofanenduringpersonalguardian,theprovisionsoftheMedicalTreatmentActconcerningtheappointmentofanagentshouldberepealedinsofarastheyapplytoappointmentsmadefromthedateofthecommencementofnewguardianshiplegislation.

202.Itshouldbepossibleforthetribunaltoappointapersonalguardianwiththepowertomakedecisionsabouthealthcaremattersforapersonwhodoesnothavethecapacitytomaketheirownhealthcaredecisions.

203.ItshouldbepossibleforapersonwhomakesarefusaloftreatmentcertificateforthemselvesinaccordancewiththeprovisionsoftheMedical Treatment Act 1988(Vic),oranenduringpersonalguardianwiththepowertomakearefusaloftreatmentcertificatefortheprincipal,tofilethatcertificatewiththeRegistrarofBirths,DeathsandMarriagesforinclusionintheonlineregister.



auTOmaTIC appOINTmENTS13.96 WhiletheCommissionrecommendsretentionofthestatutoryschemeofautomatically

appointingapersontomakemedicaltreatmentdecisionsforapersonwhoisunabletomaketheirowndecisions,itproposesanumberofimprovements.

health decision makers13.97 Thenameofthepersonwhoisautomaticallyappointedtomaketreatmentdecisions

byvirtueoftheirrelationshiptothepersonwholackscapacitytomaketheirowndecisionsshouldbechangedbecausethecurrentterm—‘personresponsible’—isnotwidelyknownorunderstood.TheCommissionrecommendsthatthispersonshouldbereferredtoasthe‘healthdecisionmaker’becausethistermclearlydescribesthenatureoftherole.

Guardians distinguished from health decision makers13.98 Theautomaticappointmentschemeformedicaltreatmentdecisionsshouldbeclearly

distinguishedfrompersonalguardianswiththepowertomakemedicaltreatmentdecisions.

13.99 TheG&AActdoesnoteffectivelydifferentiateaguardianwithmedicaltreatmentpowersfromapersonwhoisautomaticallyappointedasapersonresponsible,becauseitincludesguardianswithinthehierarchyofpeoplewhocanbethe‘personresponsible’.Thisunnecessarystepappearstolimitthepowersofaguardianwhoactsasapersonresponsible,becauseapersonresponsibleisonlypermittedtoconsenttotreatmentorwithholdconsent.Incontrast,aguardianwithmedicaltreatmentpowerscanconsenttotreatmentorrefusetreatmentfortherepresentedpersonwhenactingasaguardian.ItisunlikelythatthiswastheintendedoutcomewhenguardiansandMedicalTreatmentActagentswereincludedinthelistofpeoplewhocouldbeapersonresponsible.

13.100 TheCommissionbelievesthatifsomeonehasappointedapersonalguardianwiththepowertomakemedicaltreatmentdecisions,orifVCAThasmadesuchanappointment,thepersonalguardianshouldbethefirstpersonwhoisaskedtomakedecisionsforapersonwhoisunabletomaketheirowndecisions.Thispersonshouldactasapersonalguardianwhentheymakethesedecisionsandnotasastatutory‘healthdecisionmaker’.

13.101 Theautomaticappointmentschemeshouldonlyoperatewhenthereisnopersonalguardianwiththeappropriatepowersorwhenthatpersonisnotavailabletomakethenecessarytreatmentdecisions.Theautomaticappointmentschemeshouldnotincludeapersonalguardianamongthehierarchyofsubstitutedecisionmakers,becauseapersonalguardianwiththeappropriatepowersisalreadyauthorisedtomakemedicaltreatmentdecisions.Theautomaticappointmentschemeisadefaultmechanismforappointingasubstitutedecisionmakerwhenthereisnoonewiththeauthoritytomakethedecisioninquestion.

RECOmmENdaTIONAutomatic appointment of a health decision maker

204.Newguardianshiplegislationshouldprovidefortheautomatic(statutory)appointmentofasubstitutedecisionmaker—tobeknownasahealthdecisionmaker—tomakemedicaltreatmentdecisionsforapersonwholacksthecapacitytomaketheirowndecisionsandwhodoesnothaveanenduringpersonalguardianorapersonalguardianwiththepowertomakethosedecisionsforthem.

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The powers of guardians and health decision makers13.102 Thedifferencebetweenthemedicaltreatmentpowersofapersonalguardianand

thoseofahealthdecisionmakershouldbeclearlyexplainedinnewlegislation.Undercurrentlaw,theextentofaguardian’spowersdiffersfromthoseofapersonresponsiblewhenmakingmedicaltreatmentdecisionsforapersonwhoisunabletomaketheirowndecisions.WhilethedraftingoftheG&AActgeneratessomeconfusion,122aguardianwithhealthcarepowershasthepowertomakeanymedicaltreatmentdecisionthattherepresentedpersoncanmake,otherthanconsentingtoaspecialprocedure.Asanadulthasacommonlawrighttorefuseanymedicaltreatment,123aguardianwithappropriatepowersmustalsohavetheauthoritytorefusetreatmentonbehalfoftherepresentedperson.

13.103 TheCommissionrecommendsthatnewguardianshiplegislationshouldclearlyindicatethatapersonalguardianwiththepowertomakehealthcareormedicaltreatmentdecisionshastheauthoritytoconsenttoanytreatmentortorefusethattreatment.AnypersonwhosoughttochallengearefusaloftreatmentwoulddosobyaskingVCATtoconsiderwhetherthepersonalguardianshouldretainauthoritytomakesomeorallmedicaltreatmentdecisionsfortherepresentedperson.

13.104 UndertheG&AAct,a‘personresponsible’hasthepowertoconsenttoanymedicaltreatmentfortherepresentedperson,otherthanaspecialprocedure.124Thepersonresponsiblealsohasthepowertowithholdconsenttoanymedicaltreatment.Withholdingconsentdoesnotconstituterefusaloftreatment,becausetheregisteredpractitionerispermittedtoproceedwiththetreatmentifthepersonresponsibleandthePublicAdvocatehavebeengivenanopportunitytoapplytoVCATforadeterminationaboutwhatshouldhappeninthecircumstancesandtheydeclinetotakethisstepwithinadesignatedperiod.125

13.105 Therearegoodpolicyreasonsfordistinguishingbetweenthepowersofanenduringguardianandahealthdecisionmakertoactinawaythatcausesarepresentedpersonnottoreceivetreatmentrecommendedbyaregisteredpractitioner.PersonalguardiansarepeoplewhohavebeenchosenbythepersonconcernedorVCATtomakeimportantdecisionsforthatperson.Itisappropriatethattheyhavethepowertomakeanydecisionsthattherepresentedpersoncouldmakeinthecircumstances.Healthdecisionmakersareautomaticordefaultappointees—theyarechosenbecauseoftheirrelationshiptothepersonconcernedratherthanfollowinganindividualdeterminationoftheirsuitabilitytomakemedicaltreatmentdecisions.Itisappropriatethatthesepeoplehavemorelimitedpowersthanpersonalguardians.

13.106 TheCommissionrecommendsthatahealthdecisionmakershouldhavesimilarpowerstothoseofapersonresponsible—thepowertoconsenttoorwithholdconsenttoanymedicaltreatmentotherthanaspecialprocedure.NewguardianshiplegislationshouldalsocontainaprocesssimilartothatintheG&AActthatpermitsaregisteredpractitionertoproceedwhenconsenthasbeenwithheldafterthehealthdecisionmakerandthePublicAdvocatehavebeengivenareasonableopportunitytoseekarulingfromVCATabouttheproposedtreatment.

122 Theformsetoutinsch4oftheG&AActforusewhenappointinganenduringguardianreferstoapower‘toconsenttoanyhealthcarethatisinmybestinterests’andsubsequentlyrefersinanotetothepowerofanenduringguardian‘toconsentorwithholdconsenttomedicalordentaltreatment’.Thiswordingisunfortunatebecauseadecisionaboutmedicaltreatmentcouldbeapositivedecisiontorefusethattreatmentratherthananequivocaldecisiontowithholdconsent.

123 LoaneSkene,Law and Medical Practice: Rights, Duties, Claims and Defences(LexisNexisButterworths,3rded,2008)329.124 Guardianship and Administration Act 1986(Vic)s39(1)(b).125 Ibids42L.



RECOmmENdaTIONSThe powers of guardians and health decision makers

205.Newguardianshiplegislationshouldclearlyindicatethatapersonalguardianwiththepowertomakehealthcareormedicaltreatmentdecisionshasthepowertoconsenttoorrefuseany‘medicaltreatment’,otherthana‘specialprocedure’,fortherepresentedpersonwhenthatpersonlacksthecapacitytomaketheirowndecisionaboutthematter.

206.Ahealthdecisionmakershouldbepermittedtoconsentorwithholdconsenttoany‘medicaltreatment’,otherthana‘specialprocedure’,fortherepresentedpersonwhenthatpersonlacksthecapacitytomaketheirowndecisionaboutthematter.

207.Newguardianshiplegislationshouldcontainaprocesssimilartothatsetoutinsections42L,42Mand42NoftheGuardianship and Administration Act 1986(Vic),whichpermitsaregisteredpractitionertoproceedwithtreatmentwhenconsenthasbeenwithheldbythehealthdecisionmakerafterthehealthdecisionmakerandthePublicAdvocatehavebeengivenareasonableopportunitytoseekarulingfromthetribunalabouttheproposedtreatment.

hierarchy of health decision makers13.107 TheCommissionrecommendsretentionofthepersonresponsiblehierarchyinthe

G&AActsubjecttotwochanges.First,forthereasonsjustgiven,thehierarchyshouldnotincludeanenduringpersonalguardianoraguardianappointedbyVCATwithmedicaltreatmentpowersbecausetheautomaticprocessshouldonlycomeintoeffectwhenthereisnopersonalguardianwithauthoritytomakemedicaltreatmentdecisions.

13.108 Secondly,inChapter9,theCommissionproposedtheintroductionofanewjointdecision-makingarrangementknownasa‘co-decisionmakingorder’.Insomecircumstances,apersonwithimpaireddecision-makingabilitywhohasaco-decisionmakerinrelationtomedicaltreatmentmaylosetheabilitytoparticipateinthosedecisions.Inthissituation,theco-decisionmakershouldbecomethehealthdecisionmaker.

13.109 TheCommissionacknowledgesthattheprocessofchoosingamedicalsubstitutedecisionmakerforapersonbyuseofastatutoryautomaticappointmentsystemisnotwithoutitsflaws.Apersonwhoisautomaticallyappointedtomakedecisionsforanotherisnotrequiredtomeetthesuitabilityrequirementsinsections23and47oftheG&AActthatVCATmustconsiderbeforeitmakesanappointment.Additionally,thispersonmightnotbetheonewhowouldhavebeenchosentoactinthisrolebythepersonwhoisunabletomaketheirownmedicaltreatmentdecisions.

13.110 Differentcultureshavedifferentconceptsoftheroleoffamily,andsometimestheirbroadercommunity,indecisionmaking.Someculturesaremoreinclinedtorecognisemultipledecisionmakersandextendedfamily,whilesomehavearoleforcommunityelders.Intheconsultationpaper,theCommissionacknowledgedthechallengeofdesigningasystemthatcanadapttodifferentculturalcircumstancesandyetremainworkableforthirdparties,suchasmedicalpractitioners,whooftenneedtoidentifyasubstitutedecisionmakerquickly.

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13.111 Theautomaticappointmentschemegivesstatutoryrecognitiontothelongstandingpracticeofaskingaperson’snextofkintomakemedicaltreatmentdecisionswhentheyareunabletodoso.Whiletheentireprocess,andparticularlythedefinitionof‘nearestrelative’,126isopentocriticism,theschemeisaworkable,yetimperfect,meansofseekingauthorisationtotreatapersonwhoisincapableofmakingtheirowndecisionaboutthematterwhenitisnotpracticaltoconductahearingtodecidewhothemostappropriatepersonistomakethedecisionsinquestion.

RECOmmENdaTIONHierarchy of health decision makers

208.Thehierarchyofstatutorilyappointedhealthdecisionmakersinnewguardianshiplegislationshouldbe:

(a) thepatient’sco-decisionmakerwithauthorityinrelationtomedicaltreatmentdecisions

(b) thepatient’sspouseordomesticpartner

(c) thepatient’sprimarycarer

(d) thepatient’snearestrelative.

The public advocate as decision maker of last resort13.112 TheCommissionrecommendsthatthePublicAdvocateshouldbecomethedecision

makeroflastresortwhenthereisnopersonalguardianwithmedicaltreatmentpowersorahealthdecisionmakerwhoisavailabletomakeadecisionabout‘significanttreatment’forapersonwhoisunabletomaketheirowndecision.ThisproposalmirrorsthepositioninQueensland,wheretheAdultGuardianisthehealthdecisionmakeroflastresort.127

13.113 Thecurrentsystemofpermittingaregisteredpractitionertoproceedintheabsenceofconsent,ifthepractitionerhasmadereasonableeffortstolocateasubstitutedecisionmakerandifthepractitionernotifiesthePublicAdvocateofanintentiontoproceedwithoutconsent,128doesnotappeartooperatesuccessfully.ItseemsthatthePublicAdvocatereceivesrelativelyfewnotices,perhapsbecausetheprocessistimeconsumingandnotwidelyknown.

13.114 Itisimportantthatsignificantmedicalproceduresareauthorisedbysomeonewhoisresponsibleforthewellbeingofthepersonconcernedandwhoisnotdirectlyinvolved,eitherprofessionallyorfinancially,intheadministrationofthoseprocedures.Itisalsoimportantthatthisprocessofexternalauthorisationisrestrictedtosignificantmedicalproceduresandthathealthprofessionalsareabletoadministerroutinetreatmenttoapersonwhoisunabletomaketheirowndecisions,withouttheneedforexternalauthorisationorunhelpfulreportingrequirements.

13.115 ThePublicAdvocate’sroleasthedecisionmakeroflastresortshouldbelimitedtothosemattersthatconstitute‘significantprocedures’,becauseoftheneedtoensurethatthePublicAdvocate’sresourcesandthetimeofhealthprofessionalsisexpendedwisely.Thedistinctionbetween‘significantprocedures’and‘routineprocedures’isdiscussedbelow.

126 Guardianship and Administration Act 1986(Vic)s3.127 Powers of Attorney Act 1998 (Qld)s63.128 Guardianship and Administration Act 1986(Vic)s42K.



RECOmmENdaTIONThe Public Advocate as decision maker of last resort

209.ThePublicAdvocateshouldbepermittedtoconsenttoorrefuseany‘medicaltreatment’,whichis‘significanttreatment’,forapersonwhodoesnothavethecapacitytoconsenttothattreatmentandwhodoesnothaveapersonalguardianwiththerelevantpowers,orahealthdecisionmaker,toactastheperson’ssubstitutedecisionmaker.

definition of medical treatment13.116 TheCommissionrecommendschangestothestatutorydescriptionoftherangeof

medicaltreatmentthatrequirestheconsentofasubstitutedecisionmakerifapersonisunabletoconsenttotheirownmedicaltreatment.TheCommissionbelievesthatthestatutorydefinitionofmedicaltreatmentshouldbeexpandedtoincludesomemedicalproceduresthatarecurrentlyexcluded.Itshouldalsobedividedintotwocategories—’significantprocedures’and‘routineprocedures’—forthepurposesofdeterminingtheprocessestofollowwhenthereisnopersonalguardianorhealthdecisionmakertomakedecisionsforapersonwhoisunabletoconsenttotheirownmedicaltreatment.

13.117 TheCommissionbelievesthatthestatutorydefinitionofmedicaltreatmentshouldencompasstheadministrationofprescriptionpharmaceuticaldrugs.Allpharmaceuticaldrugs—prescriptionandnon-prescriptiondrugs—areexpresslyexcludedfromthecurrentdefinitionofmedicaltreatmentintheG&AAct.129Thismeansthat,inpractice,prescriptiondrugsareoftengiventoapersonwhoisunabletoconsenttotheirownmedicaltreatmentwithoutanyauthorisationbyaguardianorapersonresponsible.

13.118 Thecurrentdefinitionisalsolimitedto‘medicaltreatment’or‘dentaltreatment’.Whilethesetermsarenotdefinedexhaustively,theyarelimitedtotreatmentcarriedout‘byorunderthesupervisionofaregisteredpractitioner’.Thisprobablymeansthatintrusivetreatmentscarriedoutbyalliedhealthprofessionals,whichmighttechnicallyconstituteanassaultifperformedwithoutconsent,donotfallwithintheauthorisationpowersofapersonresponsible.

13.119 TheCommissionbelievesthatthestatutorydefinitionofmedicaltreatmentshouldalsobeexpandedtoincludeproceduresperformedbyalliedhealthprofessionalswhichareintrusiveandwhichwouldconstituteanassaultintheabsenceofconsent.

13.120 Therewaswidespreadsupportforincludingtheadministrationofpharmaceuticaldrugswithinthestatutorydefinitionofmedicaltreatment.Theadministrationofsomeprescriptiondrugsmaybeassignificantandintrusiveforapersonasothermedicaltreatmentproceduresthatfallwithinthestatutorydefinition.Somepeopleexpressedconcernabouttheliberaluseofpsychotropicmedicationinsomeagedcarefacilitieswithoutanyauthorisationbyaguardianorpersonresponsible.Itisappropriatethatsubstitutedecisionmakersmaketheseimportanthealthcaredecisions.

13.121 Theadministrationofnon-prescriptionmedicationseemslessproblematic.Itappearssufficienttorelyonnormalcareprinciplesforensuringthatthosemedicationsarenotmisusedoroverusedbypeoplewhoareunabletomaketheirowndecisions.TheCommissionbelievesthatthenewdefinitionofmedicaltreatmentshouldspecificallyexcludemedicationthatcanbeobtainedwithoutaprescriptionandisnormallyself-administered,provideditisadministeredinaccordancewiththemanufacturer’sinstructions.ThisapproachistakeninQueenslandguardianshiplegislation.

129 Ibids3.

297

RECOmmENdaTIONDefinition of medical treatment

210.Newguardianshiplegislationshouldcontainadefinitionof‘medicaltreatment’thatisinsimilartermstothedefinitionof‘medicalordentaltreatment’insection3oftheGuardianship and Administration Act 1986(Vic)exceptasfollows:

(a) Theadministrationofpharmaceuticaldrugsforwhichaprescriptionisrequiredshouldfallwithinthedefinition.

(b) Paramedicalandalliedhealthprocedureswhichinvolveatouchingoftheperson’sbodyandwhichareintrusiveshouldfallwithinthedefinition.

Significant and routine medical procedures13.122 Asnotedearlier,thecurrentsystemofpermittingaregisteredpractitionerto

administermedicaltreatmentintheabsenceofconsent,ifthepractitionerhasmadereasonableeffortstolocateasubstitutedecisionmakerandifthepractitionernotifiesthePublicAdvocateofanintentiontoproceedwithoutconsent,130isunwieldyandshouldnotberetainedinnewguardianshiplegislation.

13.123 TheCommissionproposesthatthePublicAdvocateshouldbecomethedecisionmakeroflastresortwhenthetreatmentinquestionis’significant’.Whenthetreatmentinquestionis’routine’,thehealthprofessionalconcernedshouldbepermittedtoproceedintheabsenceofanyauthorisation,ifappropriatenotesaremadeofunsuccessfulattemptstolocateapersonalguardianorhealthdecisionmakerforsubstituteconsent.

13.124 Itisnoteasytodeviseprincipledandpracticaldefinitionsof‘significant’and’routine’medicaltreatment.TheCommissionbelievesthatatwo-stepprocessisrequired.Newguardianshiplegislationshoulddefinetheconceptsinbroadterms,withtheirpracticalmeaningamplifiedbyguidelinespreparedbythePublicAdvocateinconjunctionwithrelevantprofessionalbodiesandinterestgroups.

13.125 Animportantprincipletobearinmindwhenseekingtodefine‘significanttreatment’isthatpeoplewhoareunabletoconsenttotheirowntreatmentshouldbedealtwithinthesameway,wheneverpossible,aspeoplewhoareabletoconsenttotheirowntreatment.Ifahealthprofessionalwouldordinarilyseekspecificconsenttoperformingaparticularprocedurefromapersonwithcapacitytoconsenttotheirowntreatment,thisprocedureshouldpresumptivelybe‘significanttreatment’thatrequiresexternalauthorisationwhenperformeduponapersonwhoisunabletoconsent.

13.126 Anotherimportantprincipletobearinmindissubjectiveassessmentofthesignificanceofsomeprocedures.Whilesomemedicalanddentalproceduresmightberoutinefromaprofessionalperspective,thedegreeofintrusionormomentarypainthatpeoplemightexperiencecouldcausethemtoregardtheprocedureassignificant.

13.127 TheCommissionsuggeststhatthefollowingmattersshouldfallwithinthestatutorydefinitionof‘significanttreatment’:

• ‘significantdegreeofbodilyintrusion’,whichmayincludeinternalandintimateexaminations

• ‘significantrisk’tothepatient,includingtreatmentsthatmayresultinsomeseriousbodilydamage

130 Ibids42K.


13Chapter 13 Medical treatment• ‘significantlynegativesideeffects’,includingtheadministrationofpharmaceutical

drugswithseriousadverseeffects

• ‘significantdistress’,includingthedistressapersonmayfeelwhentheyareabouttoreceiveaninjectionoraparticulartreatmentthatisknowntocausethemfearandanxiety.

13.128 Thestatutorydefinitionof‘significanttreatment’shouldbecomplementedbyguidelinespreparedbythePublicAdvocateinconsultationwithprofessionalassociationsandgroupsthatrepresenttheinterestsofconsumersofhealthservices.Theguidelinesshouldindicate,withreasonableprecision,theproceduresthatfallwithintheconceptof‘significanttreatment’orforwhichthePublicAdvocateisthedecisionmakeroflastresort.

13.129 TheCommissionproposesthataregisteredpractitionershouldbeauthorisedtoperforma‘routineprocedure’onapersonwhoisunabletoconsentandwhodoesnothaveapersonalguardianorhealthdecisionmakertoprovidesubstituteconsent,ifreasonableattemptshavebeenmadetolocatesuchapersonandnotesarekeptofthestepstaken.ThisrecommendationwouldovercomethecurrentrequirementthataregisteredpractitionernotifythePublicAdvocateinwritingoftheirintenttoperformtreatmentuponapersonwhoisunabletoconsentandwhodoesnothavealocatablesubstitutedecisionmaker.

13.130 TheCommissionrecommendsthatregisteredpractitionersshouldberequiredtotakereasonablestepstolocateapersonalguardianorhealthdecisionmakerbeforetheyareauthorisedtoperformaroutineprocedureonapersonwhoisunabletoconsenttothatprocedure.

13.131 Thisrequirementwouldnotaffecttheabilityofaregisteredpractitionertoperformanynecessarytreatmentinanemergency,becausetheCommissionproposesthattheexistingemergencytreatmentpowersintheG&AAct131shouldbereproducedinnewguardianshiplegislation.

RECOmmENdaTIONSSignificant and routine medical procedures

211.Newguardianshiplegislationshoulddefine‘significanttreatment’asamedicalordentalprocedure,otherthananemergencyprocedureoraspecialprocedurethat:

(a) involvesasignificantdegreeofbodilyinvasion,or

(b) involvesasignificantrisktothepatient,or

(c) islikelytohavesignificantlynegativeorunpleasantsideeffectsforthepatient,or

(d) islikelytoresultinsignificantdistressforthepatient,and

(e) wouldordinarilycauseamedicalpractitionertoseekspecificconsentfromapersonwithcapacitybeforeproceeding.

Guidelines to be developed by the Public Advocate

212.ThePublicAdvocateshoulddevelopandpublishguidelinesinconsultationwithrelevantprofessionalbodiesandotherinterestedorganisationstoassistregisteredpractitionerswhendeterminingwhetheraparticularprocedureis‘significanttreatment’.

131 Ibids42A.

299

Definition of routine treatment

213.Newguardianshiplegislationshoulddefine‘routinetreatment’asamedicalordentalprocedurethatisnotan‘emergencyprocedure’,a‘significantprocedure’ora‘specialprocedure’.

Consent to a significant medical treatment

214.Newguardianshiplegislationshouldprovidethatifapersonisunabletoconsentto‘significanttreatment‘,theregisteredpractitionermayundertakethatprocedureonlywiththeconsentof:

(a) apersonalguardianwiththepowertomakedecisionsaboutthematter,orifthereisnosuchpersonorthatpersoncannotbereasonablylocated

(b) ahealthdecisionmaker,orifthereisnosuchpersonorthatpersoncannotbereasonablylocated

(c) thePublicAdvocate.

Consent to a routine medical treatment

215.Newguardianshiplegislationshouldprovidethatifapersonisunabletoconsenttoa‘routineprocedure’,theregisteredpractitionermayundertakethatprocedure:

(a) withtheconsentofapersonalguardianwiththepowertomakedecisionsaboutthematter,orifthereisnosuchpersonorthatpersoncannotbereasonablylocated

(b) withtheconsentofahealthdecisionmaker,orifthereisnosuchpersonorthatpersoncannotbereasonablylocated

(c) intheabsenceofconsentiftheregisteredpractitionerhastakenreasonablestepstolocateapersonalguardianorahealthdecisionmakerandtheregisteredpractitionerbelievesthetreatmentwillpromotethepersonalandsocialwellbeingofthepersonconcerned.

216.Newguardianshiplegislationshouldrequirearegisteredpractitionerwhoperformsa‘routineprocedure’uponapersonintheabsenceofconsenttomakenotesinthatperson’sfileofattemptsmadetolocateanypersonalguardianorhealthdecisionmaker.

addITIONaL CONSIdERaTIONS TO GuIdE mEdICaL dECISION makING13.132 InChapter6,theCommissionrecommendsthatallpeoplewhohavediscretionary

powersundernewguardianshiplegislationshouldbeguidedbystatutoryprincipleswhenexercisingthosepowers.

13.133 TheCommissionbelievesthatthereisvalueinlistingadditionalconsiderationstoguidepersonalguardiansandhealthdecisionmakerswhenmakingmedicaltreatmentdecisionsforanotherperson.ManyoftheseconsiderationsaredrawnfromtheexistingprovisionsoftheG&AAct.



RECOmmENdaTIONAdditional considerations for personal guardians and health decision makers

217.Newguardianshiplegislationshouldcontainalistofmattersforpersonalguardiansandhealthdecisionmakerstoconsiderwhenmakingmedicaltreatmentdecisionsforarepresentedperson.Thoseconsiderationsare:

(a) anyinstructionaldirectivepreparedbytherepresentedperson

(b) whethertherepresentedpersonislikelytobeabletomakeadecisionaboutthetreatmentthemselveswithinareasonabletime,andtheeffectontheperson’sconditionofwaitingforthepersontomakethedecisionthemselves

(c) theextenttowhichtheproposedtreatmentislikelytobeofbenefittotheperson

(d) theextenttowhichtheproposedtreatmentislikelytocausedistresstotheperson

(e) alternativetreatmentsavailable,andtheextenttowhichthesearelikelytobenefitthepatientortocausedistresstotheperson

(f) otherlikelyrisksassociatedwiththeproposedtreatment,oranyalternativetreatmentsavailable,fortheperson.

EmERGENCy pROCEduRES13.134 TheG&AActauthorisesaregisteredpractitionertoundertakeanyformofmedical

treatmentwithoutconsentwhereitis‘necessary,asamatterofurgency’to‘savethepatient’slife’,‘preventseriousdamagetothepatient’shealth’,or‘preventthepatientfromsufferingorcontinuingtosuffersignificantpainordistress’.132Thisauthorityappearstobebroaderthanthecommonlawpowertoprovidetreatmentwithoutconsent‘incasesofemergencyornecessity’.133Itisunclearwhetherthecommonlawpowerextendstotreatmentgivenwithoutconsentto‘preventseriousdamagetothepatient’shealth’or‘preventsignificantpainordistress’.134Aregisteredpractitionerwhoreliesuponthisauthorityingoodfaithisnotliableforanycriminal,civilorprofessionalconsequencesthatmightotherwiseresultfromtreatingapatientwithoutconsent.135

13.135 TheCommissiondidnotreceiveanysuggestionstochangetheemergencytreatmentpowersintheG&AActanditisunawareofanycircumstancesinwhichtheextentofthispowerhasbeencontentious.TheCommissionbelievesthatsection42AoftheG&AActcontainsafairandreasonabledescriptionofthosecircumstancesinwhicharegisteredpractitionershouldhavetheauthoritytotreatanypersonwithoutconsent.Thissectionshouldberetainedinnewlegislation.

132 Ibids42A(1).133 Rogers v Whitaker(1992)175CLR479,489.134 SeeSkene,Law and Medical Practice,aboven123,113–14foradiscussionoftherelevantcaselaw.135 Guardianship and Administration Act 1986(Vic)s42A(2).

301

RECOmmENdaTIONEmergency procedures

218.Newguardianshiplegislationshouldcontinuetoauthorisea‘registeredpractitioner’toperform‘medicaltreatment’uponapersonwhodoesnothavethecapacitytoconsenttothattreatmentinemergencies.Section42AoftheGuardianship and Administration Act 1986(Vic)shouldbereproducedinnewlegislation.

SpECIaL pROCEduRES13.136 OnlyVCATcanauthorisea‘specialprocedure’forapersonwhoisunabletomake

theirowndecisionsaboutmedicaltreatment.136ApersoncannotauthoriseanenduringguardianoranagentappointedundertheMedicalTreatmentActtoconsenttoaspecialprocedureforthem.VCATcannotappointaguardiantomakeadecisionaboutaspecialprocedureanditisbeyondthepowerofapersonresponsibletoconsenttoaspecialprocedure.

13.137 Specialproceduresaremedicalprocedureswithpermanentconsequences.Atpresentthreeproceduresareincludedwithinthestatutorydefinitionofaspecialprocedure.Theyare:

• permanentsterilisations

• abortions

• removaloftissueforthepurposeofdonationtoanotherperson.137

13.138 Itissoundpolicytorequireanindependent,experttribunaltodecidewhetherapersonwhoisunabletomaketheirownmedicaltreatmentdecisionsshouldhaveamedicalprocedurethathassignificant,irreversibleconsequences.TheCommissionbelievesthatthe‘specialprocedure’processshouldberetainedinnewguardianshiplegislation.TheCommissionseesnoneedtorecommendthatanyproceduresbeaddedtoorremovedfromtheexistinglistofspecialprocedures.

RECOmmENdaTIONSpecial procedures

219.NewguardianshiplegislationshouldcontinuetorequireVCATauthorisationbeforea‘specialprocedure’canbeperformeduponapersonwholacksthecapacitytoconsenttothatprocedure.

136 Ibids39(1)(a).137 Ibids3.Therearecurrentlynoadditionalspecialproceduressetoutinregulations.

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