ONTARIO
SUPERIOR COURT OF JUSTICE
COURT FILE NO.: CV-15-288-AP
DATE: 2015 Oct 23
BETWEEN:
JUDY COLLEEN BROWN
Appellant
– and –
CINDY MOSER R.N.
Respondent
R. Michael Rodé, for the Appellant
Mark Handelman, for the Respondent
HEARD: October 14, 2015 at Kingston
Tranmer, J.
MENTAL CAPACITY APPEAL
[1] This is an Appeal from the decision of the Consent and Capacity Board finding Ms. Brown incapable with respect to admission to a care facility.
BACKGROUND
[2] Following a hearing before the Board on May 15, 2015, the Board found Ms. Brown to be incapable with respect to decisions relating to her admission to a care facility.
[3] The Record of Proceedings before the Board contains the Board's reasons for decision and copies of various clinical notes and assessments concerning Ms. Brown. Also, filed on the appeal, was the transcript of oral evidence heard by the Board during the hearing, namely, the testimony of the assessor, Ms. Brown's daughter and Ms. Brown.
ISSUES
[4] The appellant, Ms. Brown, submits that the Board erred in fact and in law in reaching its decision. In particular, the appellant submits that the evidence does not support a finding that Ms. Brown was unable to appreciate the reasonably foreseeable consequences of returning to her home alone. The appellant also submits that although the board articulated the proper legal test, it in fact applied the wrong test in the circumstances and instead considered what was in the best interests of Ms. Brown.
THE LAW
[5] The applicable legal principles are set out in the Supreme Court of Canada decision of Starson v. Swayze, 2003 SCC 32, [2003] 1 S.C.R. 722, in particular as follows:
75 The right to refuse unwanted medical treatment is fundamental to a person's dignity and autonomy. This right is equally important in the context of treatment for mental illness: see Fleming v. Reid (1991), 1991 2728 (ON CA), 4 O.R. (3d) 74 (C.A.), per Robins J.A., at p. 88:
Few medical procedures can be more intrusive than the forcible injection of powerful mind-altering drugs which are often accompanied by severe and sometimes irreversible adverse side effects.
Unwarranted findings of incapacity severely infringe upon a person's right to self-determination. Nevertheless, in some instances the well-being of patients who lack the capacity to make medical decisions depends upon state intervention: see E. (Mrs.) v. Eve, 1986 36 (SCC), [1986] 2 S.C.R. 388, at p. 426. The Act aims to balance these competing interests of liberty and welfare: see B. F. Hoffman, The Law of Consent to Treatment in Ontario (2nd ed. 1997), at p. 3. Neither party raised the constitutionality of the Act as an issue in this appeal.
76 The legislative mandate of the Board is to adjudicate solely upon a patient's capacity. The Board's conception of the patient's best interests is irrelevant to that determination. As the reviewing judge observed, "[a] competent patient has the absolute entitlement to make decisions that any reasonable person would deem foolish" (para. 13). This point was aptly stated by Quinn J. in Koch (Re) (1997), 1997 12138 (ON SC), 33 O.R. (3d) 485 (Gen. Div.), at p. 521:
The right knowingly to be foolish is not unimportant; the right to voluntarily assume risks is to be respected. The State has no business meddling with either. The dignity of the individual is at stake.
In this case, the only issue before the Board was whether Professor Starson was capable of making a decision on the suggested medical treatment. The wisdom of his decision has no bearing on this determination.
77 The law presumes a person is capable to decide to accept or reject medical treatment: s. 4(2) of the Act. At a capacity hearing, the onus is on the attending physician to prove that the patient is incapable. I agree with the Court of Appeal that proof is the civil standard of a balance of probabilities. As a result, patients with mental disorders are presumptively entitled to make their own treatment decisions. Professor D. N. Weisstub, in his Enquiry on Mental Competency: Final Report (1990), at p. 116 ("Weisstub Report"), notes the historical failure to respect this presumption:
The tendency to conflate mental illness with lack of capacity, which occurs to an even greater extent when involuntary commitment is involved, has deep historical roots, and even though changes have occurred in the law over the past twenty years, attitudes and beliefs have been slow to change. For this reason it is particularly important that autonomy and self determination be given priority when assessing individuals in this group.
The Board must avoid the error of equating the presence of a mental disorder with incapacity. Here, the respondent did not forfeit his right to self-determination upon admission to the psychiatric facility: see Fleming v. Reid, supra, at p. 86. The presumption of capacity can be displaced only by evidence that a patient lacks the requisite elements of capacity provided by the Act.
78 Section 4(1) of the Act describes these elements as follows:
A person is capable with respect to a treatment, admission to a care facility or a personal assistance service if the person is able to understand the information that is relevant to making a decision about the treatment, admission or personal assistance service, as the case may be, [page761] and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision.
Capacity involves two criteria. First, a person must be able to understand the information that is relevant to making a treatment decision. This requires the cognitive ability to process, retain and understand the relevant information. There is no doubt that the respondent satisfied this criterion. Second, a person must be able to appreciate the reasonably foreseeable consequences of the decision or lack of one. This requires the patient to be able to apply the relevant information to his or her circumstances, and to be able to weigh the foreseeable risks and benefits of a decision or lack thereof. The Board's finding of incapacity was based on their perception of Professor Starson's failure in this regard.
80 Secondly, the Act requires a patient to have the ability to appreciate the consequences of a decision. It does not require actual appreciation of those consequences. The distinction is subtle but important: see L. H. Roth, A. Meisel and C. W. Lidz, "Tests of Competency to Consent to Treatment" (1977), 134 Am. J. Psychiatry 279, at pp. 281-82, and Weisstub Report, supra, at p. 249 . In practice, the determination of capacity should begin with an inquiry into the patient's actual appreciation of the parameters of the decision being made: the nature and purpose of the proposed treatment; the foreseeable benefits and risks of treatment; the alternative courses of action available; and the expected consequences of not having the treatment. If the patient shows an appreciation of these parameters -- regardless of whether he weighs or values the information differently than the attending physician and disagrees with the treatment recommendation -- he has the ability to appreciate the decision he makes: see Roth, Meisel and Lidz, supra, at p. 281.
81 However, a patient's failure to demonstrate actual appreciation does not inexorably lead to a conclusion of incapacity. The patient's lack of appreciation may derive from causes that do not undermine his ability to appreciate consequences. For instance, a lack of appreciation may reflect the attending physician's failure to adequately inform the patient of the decision's consequences: see the Weisstub Report, supra, at p. 249. Accordingly, it is imperative that the Board inquire into the reasons for the patient's failure to appreciate consequences. A finding of incapacity is justified only if those reasons demonstrate that the patient's mental disorder prevents him [page763] from having the ability to appreciate the foreseeable consequences of the decision.
[6] The Ontario Court of Appeal has held that “The Board's application of the proper legal standard to the evidence before the Board is reviewable (by this Court) on a reasonableness standard.” “The reasonableness inquiry dictates respect for the expertise and advantaged position of the Board. It also, however, demands a somewhat probing examination of the reasons offered by the Board for its conclusion. That examination must ensure that the reasons taken as a whole provide a line of analysis, supported by the evidence that can reasonably justify the Board's conclusion.” (Giecewicz v. Hastings 2007 ONCA 890, para. 13). To the same effect is Starson, paras. 84-88.
ANALYSIS
[7] I have carefully reviewed the evidence before the Board and its reasons.
[8] The evidence supports the submission by the respondent before me that this is a case where Ms. Brown had the ability to appreciate the consequences which were reasonably foreseeable in January of 2015, when she consented to her admission to a care facility, but by the time of the hearing before the Board, she had lost that ability.
[9] In its reasons, the Board accurately recites the evidence before it, including in particular, at the bottom of page 4 and top of page 5, at the bottom of page 6 to halfway down page 7, at the top and bottom of page 8, at the bottom of page 9, throughout page 10, and the evidence of Ms. Brown and her daughter.
[10] The Board accurately recites the legal test to be applied by it, page 3, and specifically notes that it is not for the Board to base its decision on what is in the best interests of Ms. Brown, page 13.
[11] The Board found that the evidence failed to demonstrate that Ms. Brown was unable to understand the relevant information, the first prong of the legal test. That finding is not in dispute before me.
[12] I find that the Board’s conclusion,
The evidence shows clearly that JB is dependent on others for all her instrumental activities of daily living, and (despite her denials) I find as a fact that such assistance was being provided almost exclusively by her husband. The evidence is that her daughter also lent some support. If she were discharged to return home, she would be alone. Her husband would move out and her daughter would disengage. Whether community services could provide the assistance she would need (including maintenance of the residence) is highly problematic. However, she appears to have abandoned that as a possibility and talks about finding an apartment, decorating it, caring for it and doing some volunteer work. She proposes to file for divorce to obtain the means with which to pay for an apartment. If JB left the Hopsital in those circumstances, she would have no safe place to go. It was my opinion that, on a balance of probabilities, JB was unable to appreciate that such would be the consequences (and they are reasonably foreseeable) of a decision or lack of a decision regarding admission to a care facility.
is clearly supported by the evidence. I find that the Board's decision is reasonable in fact and in law. The Board applied the correct legal test.
[13] Following the oral hearing before me, I asked the parties for their written submissions with respect to the decision of this court in Saunders v. Bridgepoint, [2005] O.J. No. 5531 (Ont. S.C.J.). In particular, Justice Spies stated that “it is imperative that the board inquire into the reasons for the patient’s failure to appreciate consequences” (para. 148). She based her decision overturning the Board’s decision largely on the Board’s failure to make any inquiries into the reasons for Mr. Saunders’ alleged failure to appreciate the consequences of returning home (para. 164).
[14] I have received and read these further submissions from the parties.
[15] In the case of Ms. Brown, unlike Saunders, the Board found an inability to appreciate the consequences, not a failure to appreciate the consequences. It is in the latter case that Saunders stands for the proposition that the Board must inquire into the reasons for the actual failure to appreciate consequences. I agree with the submission of the respondent in the case of Ms. Brown that a “reason” for the actual failure to appreciate could well be the inability to appreciate. That is the finding made by the Board in the case of Ms. Brown. I find that it was not necessary for the Board in Ms. Brown’s case, to inquire into and determine the reason for the inability to appreciate. Saunders does not stand for such a proposition.
[16] For these reasons, this appeal is dismissed.
Honourable Justice Gary W. Tranmer
Released: October 23, 2015
COURT FILE NO.: CV-15-288-AP
DATE: 2015 Oct 23
ONTARIO
SUPERIOR COURT OF JUSTICE
BETWEEN:
JUDY COLLEEN BROWN
Appellant
– and –
CINDY MOSER R.N.
Respondent
Mental Capacity Appeal
Tranmer J.
Released: October 23, 2015