A.C. v. Manitoba

[2009] 2 R.C.S.; 2009 SCC 30
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A.C., a child and a Jehovah’s Witness, suffered from Crohn’s disease. She had signed an advance medical affidavit containing her instructions not to be given blood under any circumstances. At the age of 14, she was admitted to hospital and refused to consent to the receipt of blood. The Director of Child and Family Services sought a treatment order from the court under s 25(8) of the Manitoba Child and Family Services Act (“Act”), by which the court could authorize treatment that it considered to be in the child’s best interests. Section 25(9) of the Act presumed that the best interests of a child 16 or over will be most effectively promoted by allowing the child’s views to be determinative, unless it could be shown that the child did not understand the decision or appreciate its consequences. Where the child is under 16, however, no such presumption existed.

The applications ordered that A.C. receive blood. A.C. and her parents appealed the order arguing that the Act was unconstitutional and breached A.C.’s rights under sections 2(a),[1]  7[2]  and 15(1)[3]  of the Canadian Charter of Rights and Freedoms. The Court of Appeal rejected the appeal. A.C. appealed to the Supreme Court.

[Adapted from INTERIGHTS summary, with permission]

The Supreme Court dismissed A.C.'s appeal, holding the following:

(1) The question was whether the statutory scheme struck a constitutional balance between what the law has consistently seen as an individual’s fundamental right to autonomous decision making in connection with his or her body and the law’s equally persistent attempts to protect vulnerable children from harm.

(2) At common law, adults are presumptively entitled to direct the course of their own medical treatment and generally must give their ‘informed consent’ before treatment occurs, although this presumption of capacity can be rebutted by evidence to the contrary. A competent adult can therefore reject specific treatment or all treatment, although there is a specific exception to this principle in the case of emergencies.

(3) The latitude accorded to adults at common law to decide their own medical treatment had historically narrowed dramatically when applied to children. However the common law has more recently abandoned the assumption that all minors lack decisional capacity and replaced it with a general recognition that children are entitled to a degree of decision-making autonomy that is reflective of their evolving intelligence and understanding. This is known as the common law ‘mature minor’ doctrine (Gillick v West Norfolk and Wisbech Area Health Authority [1985] 3 All ER 402 considered). However, the court retains the right to intervene if thought necessary in the best interests of the child (Re W (a minor) (medical treatment) [1992] 4 All ER 627 and various Canadian and Australian jurisprudence considered).

(4) There is no simple and straightforward means of definitively evaluating – or discounting – the myriad of subtle factors that may affect an adolescent’s ability to make mature, stable and independent choices in the medical treatment context (academic, legal and social scientific literature considered).

(5) There is considerable support for the notion that while many adolescents may have the technical ability to make complex decisions, this does not always mean they will have the necessary maturity and independence of judgment to make truly autonomous choices. Clearly the factors that may affect an adolescent’s ability to exercise independent, mature judgment in making maximally autonomous choices are numerous, complex and difficult to enumerate with any precision.

(6) The application of an objective ‘best interests’ standard to infants and very young children is uncontroversial. Mature adolescents, on the other hand, have strong claims to autonomy, but these claims exist in tension with a protective duty on the part of the state that is also justified.

(7) The more a court is satisfied that a child is capable of making a mature, independent decision on his or her own behalf, the greater the weight that will be given to his or her views when a court is exercising its discretion under s 25(8) of the Act. Such a scrutiny will require an individualised assessment.

(8) Such a robust conception of the ‘best interests of the child’ standard is also consistent with international instruments to which Canada is a signatory, including the Convention on the Rights of the Child.

(9) When the ‘best interests’ standard is applied in a way that takes into increasingly serious account the young person’s views in accordance with his or her maturity in a given treatment case, the legislative scheme created by sections 25(8) and 25(9) of the Child and Family Services Act is neither arbitrary, discriminatory, nor violative of religious freedom.

On the other hand, the dissent argued that Section 25 of the Act was unconstitutional because it prevented a person under 16 from establishing that he or she understood the medical condition and consequences of refusing treatment, and should therefore have the right to refuse treatment whether or not the applications judge considers such refusal to be in the young person’s best interests, just as was the case with A.C., a ‘mature minor.'

[Adapted from INTERIGHTS summary, with permission]

"Interpreting the best interests standard so that a young person is afforded a degree of bodily autonomy and integrity commensurate with his or her ability to exercise mature, independent judgment navigates the tension between an adolescent’s increasing entitlement to autonomy as he or she matures and society’s interest in ensuring that young people who are vulnerable are protected from harm. This brings the 'best interests' standard in s. 25(8) in line with the evolution of the common law and with international principles, and strikes an appropriate balance between achieving the protective legislative goal while at the same time respecting the right of mature adolescents to participate meaningfully in decisions relating to their medical treatment." Page 186.

[Dissent] "Forced medical procedures must be one of the most egregious violations of a person’s physical and psychological integrity. The state’s interest in ensuring judicial control over the medical treatment of 'immature' minors ceases to exist where a 'mature' minor under 16 demonstrates the lack of need for any such overriding state control. In such cases, the legitimate object and basis of state intervention in the life of the young person has, by reason of the judge’s finding of maturity, disappeared. Whether judges, doctors and hospital authorities agree or disagree with C’s objection, the decision belongs to her, as the Charter is not just about the freedom to make the wise and correct choice; it also gives her the individual autonomy and the religious freedom to refuse forced medical treatment, even where her life or death hangs in the balance, regardless of what the judge thinks is in her best interest." Page 188.

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