A right of appeal under Ontario's Health Care Consent Act: a paper victory is no victory at all.

• Author: Greenberg, Jaclyn

Ontario's Health Care Consent Act enshrines robust procedural protections for people entering the mental health system. One such protection is the automatic right of appeal from a Consent and Capacity Board decision under section 80 of the Act. In tandem with section 18, which states that treatment cannot commence pending final disposition, section 80 ensures that a person's rights to self-determination and bodily integrity are respected. When an individual is found incapable to consent to or refuse treatment and involuntarily hospitalized, they have the right to have the Board review the findings, which is done expeditiously and with the person represented by counsel. However, the process of appealing the Board's confirmation of the findings unleashes a host of complications: the patient-appellant's inability to retain counsel, the hospital's inability to take steps to improve the mental condition that necessitated the finding of incapacity and involuntary status in the first place, and most notably, the indeterminate suspension of the patient-appellant's liberty. In upholding the rights to self-determination and bodily integrity, section 80 leaves a person with little else.

In tracing the problem, as originally outlined by Justice Brown of the Ontario Superior Court of Justice, the author argues that section 80 is more harmful than it is helpful. History proves the necessity for the right to review but a distinction ought to be made between the right to review and the automatic right to appeal. The former guards against abuse of the authority granted by the legislation, while the latter provides legal protection that affords no practical benefit to the individual patient-appellant. The paper discusses Brown J.'s efforts to establish a case management system for CCB appeals, and reviews four cases in light of such efforts. The author relies on the results of these cases and the annual statistics of CCB appeals to argue that efforts to correct the disparity between the way the law is supposed to work and the way it actually works are misplaced. Rather than treat the problem as one of funding issues and the role of counsel, the author suggests amending section 80 so that the automatic right be replaced by leave to appeal. This would place the burden on the justice system, and ensure that a right introduced to safeguard a person's well-being does not eclipse the very thing it seeks to protect.

La Loi sur le consentement aux soins de sante de l'Ontario prevoit de solides protections procedurales pour les personnes qui font affaire au systeme juridique en matiere de sante mentale. Entre autres protections, on note le droit d'appel automatique d'une decision rendue par la Commission de revision du consentement et de la capacite (la Commission) en vertu de l'article 80 de la Loi. Combine avec l'article 18, qui interdit de commencer un traitement dans l'attente d'une decision, l'article 80 garantit que les droits d'une personne a l'autodetermination et a son integrite physique seront respectes. Lorsqu'une personne est jugee incapable de donner son consentement ou refuse un traitement et qu'elle est hospitalisee contre son gre, elle est autorisee a faire reviser cette decision par la Commission, selon un procede accelere et dans l'interet de la personne representee par un conseiller juridique par l'entremise de l'Aide juridique. Le processus d'appel de la decision rendue par la Commission en vue de maintenir la conclusion entraine cependant toutes sortes de complications : l'incapacite du patient-appelant a engager les services d'un avocat, l'incapacite de l'hopital a prendre les mesures adequates pour ameliorer la condition mentale a l'origine de la conclusion d'incapacite et du statut involontaire en premier lieu et plus particulierement, la suspension pour une duree indeterminee de la liberte du patient-appelant. En confirmant les droits d'une personne a l'autodetermination et a son integrite physique, l'article 80 laisse finalement peu de chose a cette personne.

En exposant ce probleme, comme l'avait a l'origine souligne le juge Brown de la Cour superieure de justice de l'Ontario, l'auteur fait observer que l'article 80 est davantage source de problemes que de solutions. L'histoire nous a certes demontre la necessite de conferer le droit de faire reviser une decision, mais il faudrait etablir une distinction entre ce droit et le droit d'appel automatique. Le premier ayant pour objectif de se premunir contre l'abus du pouvoir octroye par la legislation, tandis que le deuxieme confere une protection juridique qui n'accorde aucun avantage concret a la personne en tant que patient-appelant. Dans ce texte, on discute des efforts du juge Brown en vue de creer un systeme de gestion des cas pour les appels de la Commission et dans cette optique, il passe quatre causes en revue. En se fondant sur les conclusions de ces causes et les statistiques annuelles des appels de la Commission, l'auteur soutient que les efforts deployes pour corriger la disparite entre la maniere dont la loi est censee s'appliquer et la facon dont elle fonctionne dans les faits sont malavises. L'auteur preconise de modifier l'article 80 de facon a remplacer le droit d'appel automatique par un systeme d'autorisation d'interjeter appel plutot que de traiter le probleme comme etant lie au financement et au role du conseiller juridique, comme c'est le cas actuellement. Ce faisant, on placerait le fardeau sur le systeme de justice et on veillerait ainsi a ce qu'un droit instaure en vue d'assurer le bien-etre d'une personne n'ait pas pour effet d'eclipser ce que l'on cherche justement a proteger.

Table of Contents I. INTRODUCTION II. THE RIGHT TO REVIEW A. From Parens Patriae to Rights-Based Legalism B. The Right to Review: A Human Right C. Ontario's Statutory Landscape D. Section 80: The Automatic Right of Appeal III. REALITY ON THE GROUND A. The "Warehousing" Effect B. Call for Case Management C. Many Appeals Reflect One Story: Appellants Languish, Only to Have Appeal Dismissed IV. CONCLUSION 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. (1)

Justice Major in Starson v Swayze

1. INTRODUCTION

   In 2007, the Chief Justice of the Supreme Court of Canada, Beverley McLachlin, delivered a speech on the challenges the Canadian justice system faces in building a truly just society. (2) The Chief Justice identified four challenges that threaten the courts' ability to provide a just and efficacious process: access to justice; lengthy trials; delays in the justice system; and dealing with deeply rooted, endemic social problems. (3) For mental health consumers--individuals who live with mental illness and who become entangled in the justice system in either civil or forensic contexts--three of the four challenges identified are everyday realities. The Chief Justice told her audience, "[t]he most advanced justice system in the world is a failure if it does not provide justice to the people it is meant to serve." (4) The question mental health advocates and practitioners struggle to answer is: what does justice for mental health consumers look like?

   Currently, Canada's answer has been to move away from a best interests-based reliance on professional discretion towards a rights-based approach. (5) No longer does a clinician have unfettered discretion when it comes to providing treatment to a mental health consumer who appears to need outside intervention. This article focuses on Ontario mental health law, which has legislated many significant and robust safeguards and procedural protections to ensure that a mental health consumer's liberty, autonomy and integrity are not only respected but prioritized. (6) The law requires, for instance, that in order to admit a person involuntarily to hospital, he or she must be suffering from a mental condition that is likely to result in harm to himself or herself or others. (7) The "dangerousness" criteria are considered to be an objective threshold by which a person's right to liberty can be suspended. (8) Whereas it was once commonplace to simply commit someone when it was believed to be necessary, and the rights of people with mental illnesses were moot, today the law says that the rights of the individual take precedence. Unless those rights are respected insofar as the legal protections demand, no rights-suspending intervention is permitted.

   The problem is that there are gaps between the law in theory and the law in practice. (9) One such gap has come to light in section 80 of the Health Care Consent Act, 1996 (HCCA). (10) This provision establishes a comprehensive appeals process from the Consent and Capacity Board (CCB or the Board), one of Ontario's mental health tribunals. (11) The CCB reviews clinicians' determinations that limit the rights of their patients in a civil context. Section 80 enshrines many of the rights articulated in international treaties, jurisprudence and mental health law theory, namely the right to have a finding made against a person reviewed by an independent body and the right to an expeditious review. The problem lies not in the ideas, but in their execution. When mental health consumers appeal decisions from the CCB, most often they are unable to secure counsel and their mental states are such that they are unable to move their appeals forward on their own; their treatments cannot commence pending final disposition, and they are left, in effect, in limbo. The rights of the individual are upheld, but blindly. The right to self-determination is respected but at the expense of one's liberty. The rationale behind re-orienting the law from a professional discretion-based model to a legalism-based approach was to guard against injustice. Considering that justice is not merely a legal concept, but a...