Section 13 amends the 1983 Act to insert section 57A. This introduces new safeguards for patients who are refusing medical treatment either with capacity or competence at the time, or in a valid and applicable advance decision (which may be expressed as part of someone’s Advance Choice Document), or where treatment is in conflict with a decision made by a donee or deputy or the Court of Protection (see subsection (1)). These safeguards only apply to medical treatment for mental disorder falling in the scope of section 58, and those that may be specified in regulations made under section 58 subsection (1)(a). The intention of these new safeguards, particularly those that recognise well-established provisions that exist in the Mental Capacity Act 2005, is to strengthen the patient’s influence over their care and treatment, thereby further supporting the principle of choice and autonomy.
	Section 57A, subsection (3) sets out that, where section 57A applies, and the urgent circumstances under section 62 are not met, then the patient may not be given any forms of medical treatment unless there is a ‘compelling reason’ to give the treatment and a second opinion appointed doctor has provided certification. In this context, ‘compelling reason’ constitutes either that no other alternative forms of appropriate medical treatment are available for the patient’s mental disorder, or that alternative forms of appropriate medical treatment are available, but the patient has not consented, or they are in conflict with a valid and applicable advance decision, or a decision made by a donee or deputy or the Court of Protection (see subsection (4)). The intention of this part of the section is to ensure that the approved clinician gives proper consideration to all other avenues of medical treatment that they consider viable, with a view to finding a medication that the patient is content with (or is likely to be content with, where the patient lacks capacity or competence).
	Where the clinician in charge of the patient’s treatment considers that the ‘compelling reason’ test is met, a certificate provided by the second opinion appointed doctor must confirm the following in order for treatment to be given: that the treatment in question is appropriate (under the new definition of "appropriate medical treatment" in section 8); that the decision to give treatment was made by the approved clinician in line with the new duty to follow a clinical checklist under section 56A; and that in respect of any available alternative treatment either the patient has not given valid consent or that they appear to conflict with a valid and applicable advance decision or a decision made by a donee or deputy or the Court of Protection. It should be noted that, in line with current practice relating to section 58 certificates, the second opinion appointed doctor’s certificate may relate to a plan of treatment including one or more forms of treatment or classes or treatment. The exact contents of the certificate will depend on the nature of the patient’s refusal and wider circumstances. Subsection (5) further requires that the second opinion appointed doctor must consult two other people who have been professionally concerned with the patient’s medical treatment, as part of the certification process. These changes to the second opinion appointed doctor’s responsibilities enhance their role in enforcing new safeguards which support the principles of choice and autonomy and therapeutic benefit.
	This section requires that the approved clinician secures the second opinion appointed doctor’s certification before treatment is given. This is a significant change from previous legislation, which allows for the use of compulsory medication for a period of three months before assessment by a second opinion appointed doctor is required. By making it so that the second opinion appointed doctor’s certification is necessary before medication can be administered in the face of the patient’s refusal or the decision of a donee or deputy or the Court of Protection, the intention is that treating clinicians place more value on finding a medication that is acceptable to the patient. A potential result from this is that we see a reduction in the use of compulsory medical treatment where this is in conflict with a patient’s refusal and where there isn’t a good rationale for administering compulsory treatment, which we know has a negative impact on patient experience.
Treatment Section 13: Medicine etc.: treatment conflicting with a decision by or on behalf of a patient