key: cord-0850555-0hnf1kfa
authors: Gunn, Michelle A; McDonald, Fiona J
title: COVID‐19, rationing and the right to health: can patients bring legal actions if they are denied access to care?
date: 2021-02-22
journal: Med J Aust
DOI: 10.5694/mja2.50952
sha: 3ad2160d8f837772d94ec9f4963269f742d9b975
doc_id: 850555
cord_uid: 0hnf1kfa

nan

COVID-19, rationing and the right to health: can patients bring legal actions if they are denied access to care?

There is little legal recourse in Australia for someone who is denied care on resource grounds, particularly in the context of a pandemic A s health providers worldwide respond to the coronavirus disease 2019 (COVID-19) pandemic, clinicians and communities are asking questions about who will be given access to scarce health care resources. While resource allocation decision-making frameworks have been developed, or adapted, to govern the unprecedented impacts of the pandemic, access to health care may, now and in the future, be restricted in ways previously unimaginable. While the broader community may accept the need for rationing, individuals denied COVID-19 or other care might look to the law to protect their interests. Clinicians may have questions about any legal consequences of denying patients access to health services. This article explores the nature of health rights in Australia and the difficulties in bringing legal cases that challenge resource allocation decisions during a pandemic or its aftermath.

The right to health is central to the work of the United Nations and lies at the core of the 1948 Universal Declaration of Human Rights and other international human rights instruments. 1 Article 12(1) of the International Covenant on Economic, Social and Cultural Rights (the Covenant) states that: "The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health". 2 Australia is a signatory to the Covenant and all Australian jurisdictions have anti-discrimination laws 3 which prevent discrimination when accessing health services (a negative right to health). However, a positive expression of the right to health (an obligation to provide access) has not been directly incorporated into domestic law, except in a limited fashion in Queensland. 4 In contrast, in countries such as South Africa and Canada there are constitutional rights to health, and legislative ones exist in countries such as Israel and New Zealand. 5 Commonwealth legislation does not explicitly enshrine a positive right to health as envisaged by the Covenant. The Australian Government argues that international obligations are maintained through laws funding access to health services. 6 While the World Health Organization acknowledges that the provision of universal health coverage is the practical expression of the right to health, it is not the same as creating an actual right. 7 An individual having access to a range of health services does not guarantee them any specific service or treatment, especially in situations of scarcity.

Three Australian jurisdictions have introduced human rights legislation: Queensland, Victoria and the Australian Capital Territory. The legislation in Victoria 8 and the ACT 9 is much the same, in that they have a limited right to health arising from a right to life. This legislation does not compel providers to actually provide particular services. 10 This is unlikely to be effective in resource allocation matters, as in other jurisdictions this type of right has been found to be limited, especially in cases where the treatment is considered futile, ineffective or not in accordance with clinical guidelines.

In Queensland, there is an explicit right to health, albeit a limited one. The Human Rights Act 2019 (Qld) contains a right to health services, defined as "Every person has the right to access health services without discrimination", and states that "A person must not be refused emergency medical treatment that is immediately necessary to save the person's life or to prevent serious impairment to the person". 4 While these provisions are a first for an Australian jurisdiction, the rights found in the Covenant are only partially put into effect, as the right to health is confined to emergency medical treatment. While these provisions may ensure access to emergency care, they are unlikely to oblige a provider to provide ongoing treatment as may be required to treat COVID-19, or other conditions which have waiting lists. It is also uncertain how this right intersects with the common law, which has established that a doctor is not under a legal duty to provide treatment that will not benefit the patient or is not in the patient's best interest, which may be relevant in the COVID-19 pandemic context. 11 The limited nature of these rights may be attributed to human rights legislation in Australia being designed to hold public authorities to a high standard of human rights, not to create mechanisms for legal action by individuals to uphold those rights. The respective jurisdictional Human Rights Commissions, which address the majority of cases under this legislation, do not have the power to compel public authorities to provide particular treatments or invalidate legislation, and as such may only declare that legislation or a decision is inconsistent with human rights. In cases related to the allocation of health resources, the public authority may only be required to remake the 

Whether a COVID-19 or other rationing decision could be the subject of a negligence claim is dependent on state and territory civil liability legislation.

While wording differs between the jurisdictions, civil liability legislation holds that if a professional can find another professional that would have undertaken the same acts, negligence cannot be established. For example, the relevant Queensland legislation states:

A professional does not breach a duty arising from the provision of a professional service if it is established that the professional acted in a way that (at the time the service was provided) was widely accepted by peer professional opinion by a significant number of respected practitioners in the field as competent professional practice. 12 This makes it unlikely that a negligence claim for a resource allocation matter, in a pandemic or because of it, would be successful if clinicians or independent experts are required to limit service provision using a broadly agreed upon guideline, such as the ANZICS guidance on complex decision making during the COVID-19 pandemic. 13 Further, the limited nature of public resources and inevitable requirement of public health services to ration is recognised in civil liability legislation, with the resource decisions of public authorities not open to challenge in the context of negligence claims. 14 The nature of COVID-19 and any resource allocation in response, makes it unlikely that a resource allocation decision would attract civil liability. Additionally, emergency and disaster management legislation may also apply if a state of emergency has been declared. For example, in New South Wales, if resource allocation decisions were made during a declared state of emergency, legal proceedings could not be brought against anyone acting pursuant to the powers under that legislation whose actions or omissions were undertaken in good faith. 15

Satisfactory resolution of a COVID-19 or other rationing decision through an administrative law process is influenced by the limited nature of judicial review processes and remedies available. Administrative law is concerned with the procedural rather than substantive matter of a decision, which means that it is only concerned with the way the decision was made, not the actual outcome. This is because the role of the court is not to determine the merits of a decision of another branch of government, but rather to establish whether the decision maker had the power to make the decision; whether they made that decision lawfully; and whether they considered all relevant information to ensure that decision-making power has been exercised appropriately. In relation to decisions to deny access to resources during the COVID-19 pandemic, or in its aftermath, at best an individual would only have an entitlement to a fair decision-making process, not a right to a particular health care treatment as such.

Whether a COVID-19 or other rationing decision could be satisfactorily resolved through a health care complaints process is limited by the nature and purpose of this type of legislation. Although all Australian jurisdictions have legislated systems dealing with complaints about the provision of health services, they do not necessarily provide avenues to challenge rationing decisions. While these systems seek to uphold patient's rights, such as those outlined in the Australian Charter of Healthcare Rights (https://www.safet yandq uality.gov.au/consu mers/worki ng-your-healt hcare -provi der/austr alian -chart er-healt hcare -rights), legally enforceable rights are not created. This is because the intent of this type of legislation is, among other things, to create a procedural framework to resolve complaints in the most efficient manner possible, not to create a mechanism for pursuit of claims against health providers, public or private. 14 While a complaint about a resource allocation decision can be made to a health complaints body, it is likely that the broader context of a pandemic, resource constraints and policies would limit any recourse.

The COVID-19 pandemic has raised questions about how scarce resources should be allocated, and the complexities of balancing ethical perspectives and future health care realities. It has also raised concerns about the legal consequences of making these decisions. Unlike many other countries, Australia does not have a constitutionally or legislatively protected right to health. A review of available legal avenues shows that there is little legal recourse in Australia for someone who is denied care on resource grounds, especially if there is a broad consensus of professional opinion that it is necessary in a situation of a pandemic or its fiscally challenged aftermath.

Universal Declaration on Human Rights

Anti-Discrimination Act 1992 (NT)

The right to health at the public/private divide: a global comparative study

Review of Australia's fourth periodic report on the implementation of the International Covenant on Economic Social and Cultural Rights

Anchoring universal health coverage in the right to health: what difference would it make? Geneva: WHO

R (on the application of Rogers) v Swindon NHS Primary Care Trust

Australian and New Zealand Intensive Care Society. Guiding principles for complex decision making during pandemic COVID-19

Guidi ng-Princ iples

Vic); Health Care Complaints Act 1993 (NSW)

Health and Community Services Complaints Act 1998 (NT); Health Complaints Act