Point blank refusal of treatment due to a mental illness can be a major problem.

South African law provides protection here for the affected patient including that the individual may have to be treated against his will. However, this is generally regarded as an extreme measure and is only considered a last resort. All attempts must be made to convince the patient of the seriousness of his illness and the need for treatment.

In the absence of a mental illness, refusal of treatment is regarded as a choice. Patients may refuse treatment, which will lead to a deterioration of their medical condition. An example is a patient with terminal cancer who decides against chemotherapy and radiation therapy. The condition will deteriorate faster and even cause death earlier, but it is the patient’s right of choice to follow this path. However, if for instance, this patient has severe depression then the patient’s ability to optimally decide for himself may be affected and the opinion of a psychiatrist should be obtained.

South African law stipulates the process for committing the patient to a mental institution for treatment against his wishes (also called compulsory or certified admission). The patient must:

 
• have a mental illness  
• be a danger to himself or to others  
• refuse treatment.

The first step
The first step is for family or friends to complete an affidavit, which is called “Application for a Reception Order”. In this affidavit the family member or friend must indicate why he is of the opinion that the patient suffers from a mental illness and that the patient refuses treatment. This is a sworn statement and must be signed by a Commissioner of Oaths. The form for completion of the affidavit is available from the Police, Magistrate’s Office, and some hospitals.

The second step
On completion of this affidavit the Police have to assist the family so that the patient can be taken to a District Surgeon for completion of a medical certificate. In the medical certificate the District Surgeon states how he examined the patient and also provides a provisional diagnosis of mental illness. The Mental Health Act requires assessment by two District Surgeons, but if only one is available then that would suffice.

Finally
The third and last step is for the Magistrate to issue a reception order. In this order the Magistrate instructs the Police to take the patient to a designated mental health hospital. At the mental health hospital the patient will be seen by a doctor on admission. If the patient suffers from a major medical illness then the doctor may refer the patient to a general hospital, otherwise the patient is admitted. Treatment may now be given against the patient’s wishes.

The above process for the application of a reception order is described under the Mental Health Act of 1973. A new mental health act is being written and this will change the whole process. Patients can appeal to the process of involuntary treatment. Their mental health status is also regularly reviewed by doctors to ensure that they are de-certified as soon as they are healthy.

The Mental Health Act also provides for urgent (after hours) admissions to a psychiatric hospital. The “Application for a Reception Order” affidavit has to be completed and also the medical certificate. No Magistrate’s order is required and the patient can be admitted to a psychiatric hospital. Within 48 hours another medical certificate has to be completed and then a Magistrate’s order.