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.

中文翻译：

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精神卫生法中的“限制最少”或“限制较少”是什么意思？澳大利亚昆士兰州的矛盾与混乱

西方的大多数法律体系都允许对精神疾病进行非自愿治疗，通常是因为如果不进行这种治疗，患者就会对自己或他人构成危险。虽然从历史上看，精神卫生法管辖权一直是一种保护性管辖权，但它越来越受到公民权利和国际人权法的影响，这些法优先考虑自主的价值和个人自由权。在这方面，已经制定了一项重要原则关于精神疾病治疗的决定必须是可用的“限制最少的替代方案”。例如，这可能意味着，根据不断发展的“支持决策”实践，支持一个人做出治疗其精神疾病的决定，以便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 年精神健康法》（昆士兰州）（“MHAQ”）规定，非自愿治疗的决策双方同意的治疗最好按照所谓的“限制较少的方式”进行。然而，“限制较少的方式”被定义为患者根据预先指示做出的决定，也可以由替代决策者做出决定，包括非患者指定的律师或监护人（通常是家庭成员）。 MHAQ 指出，这些安排有别于所谓的“非自愿治疗和护理”，并优先于“非自愿治疗和护理”，即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“不那么重要”。 “限制”个人的自主权，但属于不太负责任的决策形式。根据非自愿治疗规定，治疗团队的决策需要更高程度的透明度和问责制。在澳大利亚各州，这些决定由专门成立的独立精神健康法庭定期审查。相比之下，在“限制较少的方式”下做出的治疗决定甚至不被定义为构成非自愿治疗，并且不在仲裁庭的审查范围之内。在通过预先指示做出决定的情况下，我们承认这被广泛考虑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，患者在依赖预先指示时实际上可能拒绝治疗。这就提出了一个严重的问题：这种“自愿”入院和治疗是否不应受到与非自愿入院和治疗相同的监督和问责。患者有权获得限制性较小的决策形式，但当被剥夺自由时，他们也有权获得法律规定的充分保障。MHAQ 中的“限制性较小”一词在很大程度上是错误的和误导性的。如果是预先指示，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。更成问题的是，以限制较少的方式赋予私人替代决策特权，忽视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”对于患者的权利来说是一种倒退，因为它将权力转移给家庭，这是基于一个危险的假设，即这些受到较少监督的个人的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，即非正式的、家庭的、私人的领域几乎总是安全的。这是一个有争议的假设，但它支撑了许多毫无问题的思考和支持性决策的倡导。这个问题还强调需要进一步阐明和讨论精神疾病非自愿治疗背景下限制最少的含义。