Societies might fairly be judged based on how they treat their most vulnerable populations – those who are most prone to abuse, and least able to avoid or resist it. A proposed law in Singapore, the “Vulnerable Adults Bill”, aims to strengthen existing protections for such vulnerable individuals and facilitate their removal from abusive situations as needed. The Bill is under public consultation until August 23, with feedback on the Bill’s protections welcomed by the Ministry of Social and Family Development (MSF). And while the Bill focuses on the powers and duties of MSF officials, it has several implications for clinicians, nurses and other medical practitioners worth discussing.
The first main involvement of medical practitioners in the Bill is in assessment. The Bill grants MSF the power to appoint certain medical practitioners (or other qualified individuals) to assess (A) whether a vulnerable adult is facing “abuse, neglect, or self-abuse” (or history or risk thereof), and (B) whether the adult has the mental capacity to make decisions about their living conditions. (A) is necessary for the Bill’s provisions to be triggered in the first place – once abuse (or history/risk) has been detected, the Ministry then is granted the power to remove the individuals from their homes and relocate tpending court adjudication. It is not yet clear the circumstances under which medical professionals will be so appointed, but a possible context is when the at-risk individual is receiving medical home care or in a nursing home (although a conflict of interest may arise if healthcare workers are accused of abuse); alternatively, MSF could maintain a regular panel of medical assessors for purposes of evaluation.
The Bill is careful, though, to avoid removing vulnerable adults from home against their will. Such forced removal could constitute a further abuse on an already-disadvantaged and vulnerable group. And it is important to remember that many vulnerable adults have capacity to make many decisions, and those wishes should be respected. As such, consent is required for removal. The main exception is when the adult lacks the capacity (per the Mental Capacity Act) to consent to such a removal. Here, capacity is to be assessed by a medical practitioner.
Many vulnerable adults have an underlying medical condition, one which may in fact be the source of their vulnerability. The Bill’s purpose of protecting vulnerable adults would be subverted if removal and relocation to a temporary care facility caused bodily harm due to that condition. As such, the Bill (at section 11(2)) grants MSF the power to require medical care of vulnerable adults prior to removal and relocation. Again, consent is required for adults with capacity here. For those lacking capacity, care may be provided based on the best interests standard of the Mental Capacity Act. There is a further exception for consent concerning emergency care, presumably because consent cannot be reasonably obtained.
Interestingly, even if a deputy or donee has been appointed, their consent is not required for the medical care to take place (section 11(4)). This is in contrast to most contexts where, once deputies or donees have been appointed under the Mental Capacity Act, their consent is required for medical care (unless for life-sustaining treatment or to prevent serious deterioration). The reason for the Bill’s exception may be that the deputy or donee (likely a family member) could themselves be the perpetrator of abuse, and their refusal to consent to the medical treatment could be a tool to frustrate the purpose of the Bill, to protect vulnerable adults from such abuse.
Beyond implications for medical practitioners, a few aspects of the Bill are worth commenting on (I’ll be submitting some of these as comments on the Bill):
- “Vulnerable” is often meant broadly in the bioethics literature to refer to individuals who are comparatively limited in their ability to protect their own interests. In the Bill, however, it is defined more narrowly as incapable of preventing abuse, neglect or self-neglect. This makes sense as a limitation on the Bill’s intrusion into everyday family life.
- “Adult” is defined as above the age 18, unlike many other Singaporean laws (including the Mental Capacity Act) which takes the age of majority as 21. The precise reason for this difference is not immediately clear.
- Abuse includes detriments to “wellbeing”, which further includes harms to dignity. Being unclothed and visible to neighbours is given as an example of harm to dignity, but no broader definition is provided. This may lead to inconsistent evaluation by assessors with different values (e.g., is being prevented from working a harm to the dignity of work?)
- MSF is given the power to mandate temporary care relocation, and courts can mandate more permanent care provisions. However, the Bill does not specify who would pay for such care (the vulnerable adult’s CPF? This may further exacerbate harms to the vulnerable. The abuser? This might seem fair, but the Bill does not explicitly grant this power (and would likely need to). The government? More publicly-funded facilities may then be needed to ensure the law can be properly carried out).
- The conditions that trigger the Bill’s provisions includes “risk of abuse”, but such risk is never defined. All vulnerable adults are, by definition, at some risk of abuse; presumably “high risk” is meant, though clarification on this matter would be helpful.
- The Bill gives MSF full access to medical records in the course of investigation of a potentially abusive situation, overriding requirements of the Personal Data Protection Act in this context.
Have opinions of your own about the Bill? Be sure to submit your comments to MSF by the August 23 deadline!