西方大多数法律制度允许非自愿治疗精神疾病,通常基于没有这种治疗的人将是一个危险的自己或他人。虽然历史上精神卫生法的管辖权一直是一个保护性的,它越来越受到民权和国际人权法的影响,享有自主权的价值和人身自由的权利。在这方面,已经形成的一个重要原则是,关于精神疾病治疗的决定必须是“限制性最小的替代方案”。这可能意味着,例如,支持一个人决定治疗他们的精神疾病,根据“支持决策”的演变实践,“这样他们的法律行为能力仍然得到承认。如果需要非自愿治疗,“限制最少”的方法要求最大程度地尊重个人的自由和完整性。《2016年精神卫生法》(“MHAQ”)规定,非自愿治疗的决策应最好按照其所谓的“限制性较小的方式”进行。\"然而,“限制性较小的方式”被定义为患者根据预先指令做出决策,以及替代决策者,包括非患者指定的律师或监护人,通常是家庭成员。MHAQ指出,这些安排与它所谓的“非自愿治疗和护理”有所区别,并优先考虑。“其中非自愿治疗的决定是由治疗团队做出的。然而,我们认为,这些安排实际上并不是对个人自主权的“限制较少”,而是不那么负责任的决策形式。根据非自愿治疗规定对待团队的决策需要更高的透明度和问责制。在澳大利亚各州,这些决定由专门组成的机构定期审查,独立的心理健康法庭。相比之下,在“限制较少的方式”下做出的治疗决定甚至没有被定义为构成非自愿治疗,并且超出了法庭的审查范围。在通过预先指令进行决策的情况下,我们承认,这被广泛认为是对一个人的法律行为能力和自主权的限制较少。然而,在这些情况下,在依据预先指示时,患者实际上可能拒绝治疗。这引发了严重的问题,即这种“自愿”入院和治疗是否不应该受到与非自愿入院和治疗相同的监督和问责。患者有权获得限制较少的决策形式,但是当他们被剥夺自由时,他们也有权获得法律规定的充分保障。MHAQ中的“限制较少的”一词在很大程度上是错误的和误导性的。在预先指令的情况下,它转移了人们对治疗的潜在限制性和缺乏问责制的注意力。更有问题的是,在限制较少的情况下,私人替代决策的特权忽略了个人和家庭领域内滥用和不当影响的真正风险。我们认为,MHAQ下的“限制较少的方式”是患者权利的倒退,因为它将权力转移给家庭,这是一种冒险的假设,即由这些受监督较少的个人做出决策更有可能维护人权。我们认为,这反映了前女权主义的假设,家庭,私人领域几乎总是安全的。这是一个有争议的假设,然而,这支撑了许多没有问题的思考和对支持决策的倡导。这个问题还突出了需要进一步阐明和讨论在非自愿治疗精神疾病的背景下限制性最低的手段。
Most legal systems in the West allow for involuntary treatment of mental illness, usually on the basis that without such treatment the person would be a danger to themselves or others. While historically the mental health law jurisdiction has been a protective one, it has become increasingly influenced by civil rights and international human rights law, which privilege the value of autonomy and the right to personal liberty.In this regard, an important principle that has developed is that decisions about treatment for mental illness must be the \"least restrictive alternative\" available. This may mean, for example, that a person is supported to make a decision on treatment for their mental illness, according to evolving practices of \"supported decision-making,\" so that their legal capacity is still recognized. If involuntary treatment is required, the \"least restrictive\" approach demands that the liberty and integrity of the person be respected to the greatest extent possible.The Mental Health Act 2016 (Qld) (\"MHAQ\") prescribes that decision-making on non-consensual treatment should preferably be done according to what it calls the \"less restrictive way.\" However, the \"less restrictive way\" is defined as decision-making by patients under advance directives, and also by substitute decision-makers, including by attorneys or guardians not appointed by the patient, usually a family member. The MHAQ states that these arrangements are distinguished from and prioritized over what it calls \"involuntary treatment and care,\" where the decision for non-consensual treatment is made by the treating team.However, we argue that these arrangements are not in fact \"less restrictive\" of the person\'s autonomy, but are less accountable forms of decision-making. Decision-making by treating teams under involuntary treatment provisions is subject to higher levels of transparency and accountability. In Australian states these decisions are reviewed regularly by a specially constituted, independent mental health tribunal. By contrast, treatment decisions made under the \"less restrictive way\" are not even defined as constituting involuntary treatment, and are outside the scope of the tribunal\'s review.In the
case of decision-making by advance directive, we acknowledge that this is widely considered to be \"less restrictive\" of a person\'s right to legal capacity and autonomy. However, in these cases, the patient may actually be refusing treatment at the time the advance directive is relied upon. This raises serious questions as to whether such \"voluntary\" admissions and treatment should not be subject to the same oversight and accountability as involuntary ones. Patients have a right to less restrictive forms of decision-making, but when deprived of their liberty, they also have a right to adequate safeguards established by law.The term \"less restrictive\" in the MHAQ is largely misplaced and misleading. In the
case of advance directives, it deflects attention from the potentially restrictive nature of the treatment and the lack of accountability. Even more problematically, the privileging of private substitute decision-making under the less restrictive way ignores the real risk of abuse and undue influence within the personal and family sphere. We argue that the \"less restrictive way\" under the MHAQ is a step backwards for the rights of patients, in that it shifts power to family on the risky assumption that decision-making by these less supervised individuals is more likely to uphold human rights. We believe that this reflects a pre-feminist assumption that the informal, family, private sphere is nearly always safe. This is a contentious assumption, which nevertheless underpins much unproblematized thinking and advocacy on supported decision-making. This issue also highlights the need for further elucidation and discussion on what least restrictive means in the context of involuntary treatment for mental illness.