A.C. v Manitoba (Director of Child and Family Services),  2 SCR 181
This case addresses the issue of children directing their own medical treatment.
A.C. was a 14-year-old Jehovah’s Witness suffering from lower gastrointestinal bleeding caused by Crohn’s Disease. Although her doctor advised against it, as he believed that she was in imminent danger, A.C. signed an “advance medical directive” containing instructions not to be given blood under any circumstances.
A psychiatric evaluation revealed A.C. to be a “mature minor.” She was deemed mentally sound, demonstrated that she understood why a blood transfusion was the best course of treatment and did not fail to comprehend the consequences of her decision to refuse a transfusion. Despite the lawful advance medical directive however, the Director of Child and Family Services apprehended her as a “child in need of protection” and sought an order for treatment under ss. 25(8) and 25(9) of the Manitoba Child and Family Services Act. They read:
- 25(8). Subject to subsection (9), upon completion of a hearing, the court may authorize a medical examination or any medical or dental treatment that the court considers to be in the best interests of the child.
- 25(9). The court shall not make an order under subsection (8) with respect to a child who is 16 years of age or older without the child’s consent unless the court is satisfied that the child is unable
- (a) to understand the information that is relevant to making a decision to consent or not consent to the medical examination or the medical or dental treatment; or
- (b) to appreciate the reasonably foreseeable consequences of making a decision to consent or not consent to the medical examination or the medical or dental treatment.
The application judge granted the order because, according to the legislation, A.C. was she was not technically old enough to know what was or was not in her “best interest.”
A.C. and her parents appealed this order on the grounds the Manitoba Child and Family Services Act violates the Canadian Charter of Rights and Freedoms – more specifically Section 2(a) because A.C.’s right to practice her religion was contravened; Section 7 because the inability of children under 16 to determine their own capacity was an arbitrary restriction; and Section 15 because the Act is discriminatory against her age.
The main question in this case is whether ss. 25(8) and 25(9) are constitutional. Writing for the majority, Justice Abella claims that they are, but only if they are interpreted in a way that sufficiently respects an adolescent’s maturity and developing autonomy in a specific medical decision-making context.
Further, she states that competence is not merely possessing the capacity to make a decision, but it is determined by balancing many elements against one another including the adolescent’s ability to exercise mature and independent judgment, influence of family relationships or social affiliations as well as the existence of any emotional vulnerabilities.
When this standard is properly applied and takes into account a young person’s views in accordance with his or her maturity, it will create a situation where the law “is neither arbitrary, discriminatory, nor violative of religious freedom” (para 98).
In the dissent, Justice Binnie agreed with the majority but went even further. He stated that proof of capacity and maturity by way of the “best interest of the child” analysis, entitles a the young person to make the treatment decision, not just to have “input” into a judge’s consideration of what the judge believes to best (para 202). Under Justice Abella’s approach, the court still has the final say and may or may not give effect to the adolescent’s view.
In conclusion, the Supreme Court upheld the decision to dismiss A.C.’s appeal.
Although A.C. and her family technically lost the constitutional challenge, they did convince the most influential lawmakers in Canada that all adolescents under the age of 16 should have the right to demonstrate sufficient maturity for the purposes of directing their own medical treatment and have the decision respected.
Often referred to as “higher law,” natural law is believed to stem from an external, divine source that exists independently of humans, such as God or nature. As rational creatures, humans have access to such knowledge through the use of reason. Additionally, it is believed to be static and universal since the sources that inform it are considered unchanging and widespread.
According to Thomas Aquinas and other theorists of natural law, morality and law are inherently linked concepts that are indivisible from each other. Therefore, a law is obeyed for reasons of justice, fairness and morality. In this sense, natural law has a teleological purpose: the order and behavior of all individuals must be rationally and objectively directed toward the pursuit of common and moral good – not for the good of the sovereign. This is because the common good is the morally correct end for humanity. Furthermore, any law that does not have this function is no law at all and need not be followed.
Four elements of a valid law:
- 1. Must be directed to the common good (objective)
- 2. Must follow practical reason (reasonable steps leading to the common good)
- 3. Must be made by valid lawmaker (ruler within community, holds this position by way of the natural order)
- 4. Must be promulgated (public, written, proclaimed)
Application to A.C. v Manitoba
In assessing the validity ss. 25(8) and 25(9) of the Manitoba Child and Family Services Act, natural law theorists would agree with the majority that the common good of this legislation is to protect all children in the province under 16 years old who wish to direct their medical treatment. This law calls for a judge to balance what an adolescent wants against external factors including the desires of his or her family and doctor. A judge must be satisfied that the child understands his or her medical diagnosis, the consequences of his or her decision and was not influenced by other people. If the court is not satisfied, this law allows a court to act as a safeguard and change the proposed course of treatment so as to ensure the child’s safety. Therefore, ss. 25(8) and 25(9) shield children from harm even if they fail to recognize what is or could be harmful to them. According to the majority, this law is not directed to the benefit of one specific individual, rather it considers multiple interests in an attempt to uphold the common good of protecting children.
In contrast, the dissent argues that a child should be able to make the decision free from the input of a judge. Naturalists would disagree with this ruling and declare the legislation invalid because it goes against the common good. A law of this sort serves to grant individual autonomy.
This law and the majority ruling, naturalists would continue, is reasonable primarily because it limits the age of children in Manitoba who are eligible to make their own medical decisions to those 16 years old and up. While the majority ruled that this is a lenient restriction and courts should address maturity on a case-by-case basis, Thomas Aquinas would approve of the practical reason behind ss. 25(8) and 25(9) because it is in line with how the common good is reached.
The Manitoba Child and Family Services Act was created by government. While the provincial legislature does hold an authoritative position, natural law theorists would argue that it does not constitute a valid lawmaker because it is too concerned with democracy and fairness. This is evidenced by the fact that most members of the legislature are elected. According to naturalists, a valid lawmaker is a person or body that is naturally inclined to rule rather than be ruled, such as a king or queen.
Lastly, ss. 25(8) and 25(9) are part of a published provincial statute that is accessible to the public. Aquinas would assert that writing the law down and proclaiming its purpose to society compels each individual – particularly children and judges however – to follow it. If the legislation had not been pronounced, people in the province of Manitoba would not be compelled to comply with it because they would not be aware of it.
Based on this analysis, Aquinas and other natural law theorists would approve of the decision in this case and find that ss. 25(8) and 25(9) are valid laws.