Patients discharging themselves from care in the hospital against medical advice in Singapore, as in elsewhere, is not an infrequent occurrence. In patients assessed as lacking the mental capacity to make treatment decisions, the health care team decides on the basis of best interests, and this may include forced custody to facilitate treatment. However, depriving people of their liberty may involve the use of restraints and should only be justified under very exceptional circumstances of best interests.

In this presentation, I shall examine how clinicians can reconcile the conflict that arises from their wanting to treat patients whose capacity to decide on treatment is questionable, whilst having to manage patients’ adamant demands for voluntary discharge. I shall do this by analyzing two case studies, in which the final decision of acquiescing to a voluntary discharge is contrasted with one of not acquiescing, together with the attendant implications for treatment.

I propose a triad of factors to be at the apex of considerations when contemplating the abrogation of the rights of patients to voluntary discharge and impliedly, treatment refusal in the name of best interests under the Mental Capacity Act Singapore: (i) nature of harm and response needed, (ii) restraint considerations and (iii) support of family, when family involvement is available. By doing this, the approach of best interests, often considered as subjective, can be improved for certainty and consistency, in such analogous cases.

The UN Convention on the Rights of People with Disabilities, with the focus on ‘wills and preferences’ and legal agency is also relevant to the discussion. Some of the challenges this poses to the above approach of substitute decision making will also be discussed.