Achieving Social Justice for Psychiatric Survivors: Capabilities and Advance Consent in Mental Health Law

《联合国残疾人权利公约》(CRPD)要求缔约国建立机制，支持精神疾病幸存者参与与健康有关的决定。心理健康治疗的事先同意是一种特殊类型的支持性决策，通过这种决策，一个人可以约束自己接受未来的治疗。事先同意可以适用于一个人被认为没有做出自己决定的精神能力或精神健康复发的情况。在精神健康方面引入事先同意的提议已经成为英格兰和威尔士立法者面临的当代和及时的挑战。2017年3月，法律委员会(英格兰和威尔士)发布了《精神能力和剥夺自由报告》，其中建议引入一项事先同意条款，允许一个人同意未来的治疗安排，否则就相当于剥夺自由。《精神上行为能力(修订)条例草案》并没有包括这类条文。在《精神健康法》的韦斯利审查(2018年12月)中，建议引入一份预先选择文件，该文件将允许精神疾病幸存者就未来的任何住院护理和治疗发表意见。韦斯利审查也考虑了事先同意入院的问题，但报告没有就这一问题提出明确的建议。因此，精神健康和精神能力法中提前决定的重大变化可能即将到来。到目前为止，由于缺乏经验证据，事先同意无法获得法定地位。随着事先同意在全球范围内获得势头，越来越多的国家，如印度、荷兰、德国和奥地利，制定了关于事先同意心理健康治疗的法律。司法管辖区以加拿大不列颠哥伦比亚省为例，我们发现自1996年以来，精神健康治疗一直可以事先征得同意。此外，加拿大是遵守《残疾人权利公约》最多的国家，这使它成为其他司法管辖区制定符合国际法的事先同意条款的一个有趣的例子。2018年，加拿大科学院理事会发表了一份关于死亡医疗援助事先请求的知识状况报告。该报告探讨了心理健康中的事先同意的运作方式，并建议该机制运作良好，不会造成任何问题。然而，人们承认，缺乏证据，需要进行定性研究，以更全面地了解事先同意是如何在实践中发挥作用的。本论文从概念上借鉴社会正义的能力方法，并通过进行关键的实证研究，解决了与事先同意有关的复杂的社会法律问题。为了评估事先同意在英国法律中的可取性、功能性和法律效力，本论文旨在利用在英格兰和威尔士对精神分裂症、双相情感障碍或临床抑郁症患者等精神幸存者进行的叙事和照片诱导访谈。然而，只有对不列颠哥伦比亚省现有制度的实证研究才能揭示事先同意是如何在实践中发挥作用的，并能够解决和缓解英格兰和威尔士的实证研究可能出现的差距/问题。因此，作为我博士学位的一部分，我打算在加拿大与制定或使用事先同意条款的精神幸存者进行海外实地调查。反过来，这篇论文以其迫切需要和新颖的方法来研究事先同意，将具有潜在的全球意义。

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) requires contracting states to create mechanisms that support and involve psychiatric survivors in health-related decisions. Advance consent to mental health treatment is a special type of supported decision-making by which a person binds themselves for the future treatment. Advance consent could apply in instances where a person is thought not to have mental capacity to make their own decisions or at the point of mental health relapse. Proposals to introduce advance consent in the mental health context have become a contemporary and timely challenge for law makers in England & Wales. In March 2017, the Law Commission (England & Wales) issued the Mental Capacity and Deprivation of Liberty report, where it recommended the introduction of an advance consent provision that would have allowed a person to consent to future treatment arrangements that would have otherwise amounted to a deprivation of liberty. No provision of this nature has been included in the Mental Capacity (Amendment) Bill. In the Wessely review of the Mental Health Act (December 2018), the introduction of an Advance Choice Document has been recommended, which would allow psychiatric survivors to voice their views about any future inpatient care and treatment. The question of advance consent to be admitted to hospital was also considered by the Wessely review, but the report stopped short of making firm recommendations on this issue. Significant changes to advance decisions in mental health and mental capacity law may, therefore, be forthcoming. A lack of empirical evidence thus far has prevented advance consent from being given statutory footing. As advance consent is gaining its momentum on the global scale more countries like India, Netherlands, Germany and Austria have developed their laws on advance consent to mental health treatment. Jurisdictions turn to the example of British Columbia, Canada where we find that advance consent to mental health treatment has been available since 1996. In addition, Canada is the most CRPD compliant country making it an interesting example for other jurisdiction to turn to in order to develop advance consent provisions compatible with international law. In 2018, the Council of Canadian Academies published a report on the State of Knowledge on Advance Requests for Medical Assistance in Dying. The report looks at the workings of advance consent in mental health and it is suggested that the mechanism is working well and is not causing any issues. However, it is admitted that the evidence is lacking and qualitative research is needed to create a more comprehensive picture of how advance consent is working in practice. This thesis addresses complex socio-legal questions pertinent to advance consent by conceptually drawing on the capabilities approach to social justice and by conducting crucial empirical research. To assess the desirability, functionality and legal effectiveness of advance consent in English law, this thesis aims to draw on narrative and photo-elicitation interviews conducted throughout England and Wales with psychiatric survivors like people with schizophrenia, bipolar disorder or clinical depression. However, only empirical research into the system available in British Columbia is capable of shedding light into how advance consent is working in practice and to address and mitigate gaps/issues that might emerge from empirical research in England & Wales. Thus, as part of my PhD, I intend to conduct overseas fieldwork in Canada with psychiatric survivors who made or used advance consent provisions. In turn, this thesis with its much needed and novel approach to the study of advance consent, will have a potential to be of global relevance.