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Incapacityandsexualrelationshipsintheelderly:balancingautonomyandprotectionAnitaMiller*IntroductionOlderpeopleenjoythesamefreedomasotheradultstoenterintorelationships,includingsexualrelationships.
However,thisexerciseofautonomyandself-determinationcanberegardedasproblematicwhenanolderpersonisperceivedtohavelostthecapacitytomakedecisionsaboutsexualrela-tions.
Whilethelawadoptsanapproachthatisdesignedtosupportincompetentadultstocontinuetomakedecisionstothegreatestextentpossible,1carersandfamilymemberscanbecomeconcernedaboutanincapacitatedolderpersonhav-ingsexualrelations.
2Thismaybebecauseoffearsofabuseorexploitation,orbecauseofsocialorfamilialstigmaaboutsex.
Wheretheolderpersonlivesinanagedresidentialcarefacility("resthome"3),carersorfamilymaycomplainaboutsexualrelationships,orevenaskstafftopreventsexualcontactfromoccurring.
Anecdotally,resthomesstrugglewiththevexedquestionofsexandincompetentadults.
Resthomeshaveanumberoflegalandprofessionalobligationstoprotectresidentsfromharm,4andalegaldutytoupholdresidents'rightstobetreatedwithrespect,tohavetheirprivacyrespected,andtoprovideservicesinamannerthatrecognisesdignityandindependence.
5Itisnotdifficulttoseehowthetensionbetweencarers'responsibilitiesandindividualautonomycouldresultintheerosionoftherighttoself-determination.
Withthistensioninmind,thisarticlediscussesconsentforsexualrelationsandthelawondeterminingcapacitytogivesuchconsent.
Itarguesthatthecontextinwhichdecisionsaboutsexualrelationsandcapacityassessmentsaremadeisrelevanttodeterminingcapacity.
Then,withaparticularfocusonthoseelderlypersonswithquestionableorfluctuat-ingcapacity,itexploreshowexpressedwishesaboutsexualrelationsmightestablishthenecessaryconsenttosexwhilealsobalancingtheneedtoprotectthoseinneedofprotection.
Aproposedmodelofstatutorysupporteddecision-makingandtheexistingframeworkforsubstituteddecision-makingarecanvassed,andadvocatedaslawfulmechanismstoupholdexpressedwisheswhilealsoallowingforriskassessmentandprotection.
Itthensuggeststhatmorecanandshouldbedonetoaddressquestionsaboutsexualrelationshipsintheelderly.
Advancedirectivesareencouragedasameanstoexpresshowapersonwantstoliveonceincapacitated,andtoinfluencedecisionsmadeafterincapacity.
Finally,itisrecom-mendedthatresthomesshoulddevelopindustryagreedguide-linesonsexualrelationsinresthomestoexpresslyguidestaff,individualsandfamiliesaboutsexinthatsetting,andtoaddressthedifficultquestionsthatcanarisewhenadultswhoareperceivedtolackcapacityentersexualrelationships.
ConsentandsexualrelationsItisawell-acceptedprinciplethatalladultsofsoundmindhavearighttodeterminewhatshouldbedonewiththeirownbody.
6Thus,subjecttotheboundsofthelaw,compe-tentadultshavethefreedomtochoosehowandwithwhomtheymightenterintosexualrelations.
7Consent,andthere-forethecapacitytomakeadecisiontohavesex,isanessentiallegalrequirementforsexualrelations.
Intheabsenceofconsent,sexualconnectionisacriminaloffence.
8Importantly,thecriminallawdeemsconsenttobeabsentincircumstanceswhereapersonis"affectedbyanintellec-tual,mental,orphysicalconditionorimpairmentofsuchanatureanddegreethatheorshecannotconsentorrefusetoconsenttotheactivity".
9CommentarytotheCrimesAct1961suggeststhat"priorconsentoranimplicationofcon-sentderivedfromthenatureandhistoryoftherelationshipandthesurroundingcircumstancesisnotrelevant".
10Thisindicatesthatamutuallyconsensualsexualrelationshippriortoincapacitywillnotoperateasadefence.
Itisalsoacriminaloffencetohave"exploitativesexualconnectionwithapersonwithasignificantimpairment",11beingaconditionthatsignificantlyimpairsthecapacitytounderstandthenatureortoforeseetheconsequencesofsexualconduct.
12InajudgmentonasimilarprovisioninEnglishlaw,13thecriminaljurisdictionoftheHouseofLordsmadeitclearthatcapacitytoconsentrelatestothespecificactofsexualtouching.
14However,notallsexualrelationsare(orshouldbe)viewedthroughthelensofthecriminallaw,whichisconcernedwithspecificallegedactsatapastpointintime.
ThelawoncapacitytoconsenttosexualrelationsInNewZealand,theProtectionofPersonalandPropertyRightsAct1988(PPPRA)providesalegalframeworkforprotectingandpromotingthepersonalrightsofthosenotabletomanagetheirownaffairs.
Itcreatesapresumptionofcompetencetomakedecisionsuntilthecontraryisproven.
15Rebuttingthepresumptionrequiresadeterminationthatapersonisnotcapableofunderstandingthenature,orfore-seeingtheconsequences,oftheirdecisions.
16Ingeneralterms,assessingcapacityunderthePPPRAinvolvesconsid-erationofanindividual'sabilitytocommunicatehisorherchoiceto:understandrelevantinformation;"appreciatethesituationanditsconsequences";andmanipulateinformation.
17NewZealandFamilyLawJournalSeptember2016190Applyingthestatutorytesttosexualrelationswouldlikelyinvolveanassessmentofaperson'sunderstandingofthesexactitself,therisksofsexuallytransmittedinfectionandpregnancy,andtheabilitytocommunicatethechoice(includ-ingthechoicetosayno).
Fortheolderadult,itisarguablethattheunderstandingofthesexactmayexistthroughpriorexperience,andforolderwomentheriskandimplicationsofpregnancyisremovedbymenopause.
Understandingtheriskofsexuallytransmitteddiseaseswould,however,remainarelevantmatter.
18Astounderstandingthe"situationanditsconsequences",someguidancemaybetakenfromcaselawconsideringthequestionofcapacitytoenterintomarriage.
19Thetestforcapacityformarriageinvolvesmorethanafunctionalassess-mentofthenatureoftheact:20…apersoncanbeperfectlywellawareofthenatureofmarriageandwhatitinvolves,yetlacktheintellectualcapacitytodecidewhetherornottomarryaparticularpersonortoresistadecisiontomarrythatperson.
Thereare,however,limitationswithacomparativeanalysisbetweenconsenttosexandconsenttomarriage.
Impor-tantly,marriageisnotsolelyconcernedwithsexualrelationsand,unlikemostsexualrelationships,itinvolvesapoten-tiallylong-lastinglegalrelationshipwithimplicationsforpropertyandinheritancerights.
Thatsaid,ifNewZealandcourtsadoptasimilarapproachaswithconsenttomarriage,capacityforsexualrelationswouldrequirebothafunctionalunderstandingofsexandanunderstandingofcircumstancesinwhichthesexualactmayoccur,includingtheidentityofthesexualpartner.
InEngland,thisso-called"situationspecific"capacitytoconsentisappliedinthecriminaljurisdiction,wheretheleadingdecisionputsitthisway:21…itisdifficulttothinkofanactivitywhichismorepersonandsituationspecificthansexualrelations.
Onedoesnotconsenttosexingeneral.
Oneconsentstothisactofsexwiththispersonatthistimeandinthisplace.
Autonomyentailsthefreedomandthecapacitytomakeachoiceofwhetherornottodoso.
Incontrast,theEnglishCourtofAppealhasconfirmedthatan"issuespecific,ratherthanpersonoreventspecific"22assessmentappliestosexualrelationsinthecontextoftheMentalCapacityAct2005(UK)(MCA),whichrelatestoadultswholackcapacityandwhichprovidesaframeworkforprotectingvulnerableadultsfromabuse,coercionandexploitation.
23Thus,itissufficientto"understandtherudi-mentsofthesexualact,[andtohave]abasicunderstandingofissuesofcontraceptionandtherisksofsexuallytransmit-teddisease".
24Inreachingthisview,theCourtofAppealendorsedtheneedforpragmaticlimitson"whatneedstobeenvisagedas'reasonablyforeseeableconsequences'",notingthat:25…theinformationtypically,andwestresstypically,regardedbypersonsoffullcapacityasrelevanttothedecisionwhethertoconsenttosexualrelationsisrelativelylimited.
Thetemptationtoexpandthatfieldofinformationinanattempttosimulatemorewidelyinformeddecision-makingislikelytoleadto…bothpaternalismandaderogationfrompersonalautonomy.
Accordingly,theEnglishCourtofAppealpurportstoupholdautonomybyjudginganotherwiseincompetentadult'scapac-ityforsexualrelationsagainsttherelativelylimitedquestionscompetentadultsmayaskthemselvesaboutsexualrelations.
Putanotherway,thethresholdisnotsohighastorequireadultswholackcapacityinotherrespectstodemonstrateananalysisofsexualrelationsthatwouldnotberequiredofcompetentothers.
AsoneEnglishcourtdescribedit,theprotectivepurposeoftheMCAisnottowrapapersonin"forensiccottonwool"buttoallowthemasfaraspossibletomakethesamemistakesthatothers"areatlibertytomakeandnotinfrequentlydo".
26This"desiretoavoidpaternalism,whilesupportingautonomy"hasbeencriticisedforoverlookingthefactthatthereislimited,ifany,evidenceaboutwhatconsiderationsarerel-evanttoacompetentperson'sdecisionaboutsexualrela-tions,andtheextenttowhichthisisdifferentforapersonwhoisundersomedisability.
27Thelowthresholdhasalsobeencriticisedforinterpretingautonomyassimplyallowingincompetentadultstohavesex,withoutproperregardtotheneedtoprotectthosewhoareatriskofabuse.
28Inparticular,asuggestionfromtheEnglishcourtsthatvettingsexualpartnerswouldbeunworkablehasbeencondemnedasincon-sistentwithaprotectiverole,29andbecauseitrisks"privi-legingadministrativeconvenienceovertheneedforatestwhichissensitiveto…thevulnerabilitiesofthose…whosecapacityisinquestion".
30Againstthis,itisarguablethatsettingcomprehensive(andmoresensitive)criteriaforassessingcapacityhasanumberofpossibledrawbacks,includingtheriskofplacingpeoplewithcertaindiagnoses(egdementia)intoacategorythatiseffectivelydeemedincapableofconsentingtosexualrelations.
Strict"personandevent"assessmentsmayalsobeinadequatetorecognisethatcapacitycanfluctuate,andthatpeoplewithvaryingdegreesofincapacitymayretaintheabilitytomakegenuinechoicesaboutenteringintosexualrelations.
Ascanbeseen,debateastotheappropriatemeasureofcapacityiscomplex,lackinginempiricalevidence,andstronglyinfluencedbythedifferingperspectivesofindividualautonomyandprotectiveinterests.
Whilesettingalow(iefunctionalunderstanding)thresholdforcapacitymayendorsesexualfreedom,italsocreatesariskofatleastsomeincidentsofnon-consensualsex.
Conversely,althoughahighthresholdmayprovideagreaterdegreeofprotectionbypotentiallyexcludingmoreindividualsfromsexualrelations,italsorisksbeingapaternalisticintrusionintoself-determination,evenintheabsenceofvulnerability.
Toattempttobalanceautonomyandprotection,itissuggestedthatanyassessmentofcapacityforsexualrelationsmustbeconsciousoftheneedtoprotectthose"whoselimitedcapacitypreventsthemfromappreciatingtherisks",31whilenotinterferingwithdecisionsunlessprotectionisobjec-tivelynecessary.
However,resthomes'(andothercarers')legalobligationsmayfavourprotectiveoutcomesthatpre-vent"detachedandobjective"capacityassessments.
32Althoughprotectionwillbeappropriateinsomecases,toavoidunnec-essarylimitsonautonomyitisimportantforthoseraisingquestionsaboutcapacitytoberequiredtogiveconsiderationtothewholecontextinwhichdecisionsaboutsexualrela-tions,andcapacityassessments,aremade.
CapacityassessmentsincontextThestartingpointisthatlossofcapacityisnotanormalpartofageing,andtherefore"oldage"(howeverdefined)isinsufficienttoestablishincapacity,orevenvulnerability.
33Thatsaid,dementiaisa"diseaseoftheageing"34thatNewZealandFamilyLawJournalSeptember2016191impactsonmemory,reasoningandlanguageskills.
35Whiledementiaaloneshouldnotbeenoughtoestablishincapacity,adiagnosisofdementia,includingtherateofcognitivedeclineandbehaviouralchangesoverthecourseofthedisease,mustberelevanttodeterminingcapacity.
Inaddi-tion,theextenttowhichdementiaiscoupledwithdisinhibitedsexualbehaviour,eitherininappropriatesettingsortowardsunwillingparticipants,willalsoberelevant.
36Thatis,observ-ablechangesinattitudeordesireforsexthatcanbeattrib-utedtodementiamayberelevanttothegenuinenessofaperson'schoice,theirvulnerability,andtherisktheyposetothemselvesorothers.
37Morebroadly,itisclearlyarguablethataperson'scapac-itytoconsenttosexualrelationsis"affectedbyrelationshipswithsexualpartners.
"38Therefore,assessingcapacitymustlogicallyinvolveconsiderationofthesexualrelationshipinquestion.
Thiscouldbeparticularlyrelevantinresthomes,whereresidentsmayhavelong-termrelationshipsthatremainimportantdespitecognitivedecline,orwhereresidentssim-plyseekcomfortandintimacyinwhathasbecometheir"home"environment.
Inotherwords,itmustberecognisedthathealthyrelationshipscanbeintegraltoaperson'swellbe-ing:"There'snothingaboutbeingcognitivelyimpairedthatmeansthatyouwouldn'tnecessarilyappreciatebeingcon-nectedwithotherpeoplethroughbothnonsexualmeansandsexualmeans".
39Considerationoftherelationalcontextshouldnotbeunderstoodasrequiringapersontobe(orintendingtobe)inastableorlong-termrelationshipinordertohavesexualrelations.
Instead,itissuggestedthat,foranaccuratepictureofcapacityforsexualrelations,considerationshouldbegiventoallthefactorsthatmayinfluencecapacity,includingthesexualpartner.
Whilescrutinising(intended)sexualpart-nersmayberegardedbysomeasanintrusionintoaperson'srighttoprivacy,suchaninquiryisnotnecessarilyananath-ematoautonomy.
Itisequallyarguablethatmakinganassessmentofrelationalfactorsactuallysupportsautono-mousdecision-making,whilealsoallowingforaproperassessmentofvulnerabilityandrisk.
40Inresthomes,askingresidentsaboutsexualrelationshipsisareasonablepartofdischargingtheobligationtoprotectthemfromharm.
Italsogoessomewaytosupportingaperson'sabilitytohavesexualrelationshipsinasafeandsupportiveenvironment.
Relationshipswithotherscanalsoprovideanotherwiseincapacitatedpersonwithsupportandguidancefordecision-making.
Autonomyhas"socialandrelationaldimensions"thatmayinfluencecapacity,andthereforeexamininghowanincompetentpersonutilisesotherstoassistwithdecision-makingisimportant.
41Inaddition,itmustbeacknowledgedthattheidentityofthepersonwhoundertakestheassessmentmayinfluenceitsoutcome,whetherforlackoftrustononehandorlackofknowledgeaboutthepersonconcernedontheother.
Likewise,capacityassessmentsshouldhaveregardtothefactorsthatmaytemporarilyaffectcapacity,suchastiredness,stressormedication,andshouldexpresslyrecognisethatcapacitymayfluctuateforthesereasons.
42WhilethecourtsexercisingpowersunderthePPPRAwillverylikelyconsiderthecontextforthedecision,aclearstatutoryrequirementtodosowouldprovidegreaterclarityforindividualsandresthomesabouthowcapacitywillbeassessed.
Therefore,itissuggestedthatrebuttingthepre-sumptionofcompetenceshouldexpresslyrequireconsider-ationofallthecircumstancesrelevanttothecapacitytomakethedecision.
ThiscouldbeachievedbyamendingthePPPRAtoreadthat"everypersonshallbepresumed,untilinallthecircumstancesrelevanttothedecisionthecontraryisproved,tohavethecapacity"(additionemphasised).
Itisnotedthatsucharequirementcouldwellsignalthatmerefunctionalunderstandingofsexisaninsufficientbasisforcapacity.
Inotherwords,anindividual'sfailuretoappreciatethesignificanceorimplicationsofaparticularsexualrela-tionshipcouldbefataltohisorherperceivedunderstandingofthenatureandconsequencesoftheirdecision.
Thatsaid,contextualmattersareequallyrelevanttoconsiderationofhowexpressedwishesforsexualrelationsmightbefacili-tated.
MakingdecisionsaboutsexualrelationsItisrecognisedthatincapacitycancreatesignificantvulner-abilityandexposepeopletoexploitation.
Forsomeincom-petentadultstherewillbenobasisonwhichexpressedwishesforsexualrelationscanbeupheld.
However,betweenobviouscompetenceandcompleteincapacityisagreyareaofquestionable(orfluctuating)capacity.
Thissectioniscon-cernedwithupholding,wherepossible,therightsofthoseolderadultswhoretainsomedegreeofcapacityformakingpersonalchoices.
AsnotedbytheformerHealthandDisabil-ityCommissioner(HDC):43…itdoesnotnecessarilyfollowfromthefactthatcon-sumersrequirecareandsupportinsomeareasoftheirlifethattheyarenotcapableofparticipatinginasexualrelationship,ormakingdecisionsabouttheirsexuality.
Tomakethisassumptionwhereitisnotappropriateplacesunnecessarylimitsonaconsumer'sindependence.
Studiessuggestthatsexcanremainanimportantpartofanelderlyperson'slife,andthatevenwithcognitivedeclineindividualsmayderive"emotionalpleasure…lifesatisfac-tion,confidenceandoverallpsychologicalhealth"fromsexualrelations.
44Thoseadultswithimpairedcapacityshouldnot,therefore,automaticallybedeprivedoftheopportunitytomaintainorenterintosexualrelations.
However,despitetheexistenceoflegislationintendedtopromoteandprotecttherightsofincompetentadults,NewZealandcourtshavenotyetbeenaskedtoconsideranotherwiseincompetentperson'scapacitytoconsenttosexualrelations.
Thatsaid,NewZealandlawdoesnotexpresslyrecognisea"right"tosex.
TheNewZealandBillofRightsAct1990(NZBORA)confirmstherighttoassociationandfreedomfromdiscrimination,45meaningthatindividualsenjoythefreedomtochoosewhomtheyassociatewith(includingthenatureofsuchrelationships46),andfreedomnottobedis-criminatedagainstbyvirtueoftheirageordisability.
47Onthefaceofit,theserightscouldpossiblyextendtosexualrelationships,althoughthishasnotbeentested.
TheNZBORAalsoaffirmsthatitdoesnotlimitany"existingrightorfreedom".
48Therefore,rightsexistingatcommonlawandinternationallawmayberelevanttosexual"rights".
TheInternationalCovenantonCivilandPoliticalRightsrequiressignatories(includingNewZealand)torecognisetherighttomarryandfoundafamily.
49Similarly,theEuro-peanConventiononHumanRightsrecognisestherighttorespectforprivateandfamilylife,andtomarryandfoundafamily.
50Atinternationallaw,theserightshavebeeninter-pretedasincludingthefreedomtoengageinsexualactivity"largelyfreefromstateinterference".
51However,whileNewZealandcourtshavepreviouslyexpressedaviewthatprotectionofprivateandfamilylifeisanimportantvalueinNewZealandNewZealandFamilyLawJournalSeptember2016192law,itisnotstrictlyrecognisedasajusticiablecommonlawrightinitself.
52Nevertheless,intheabsenceofdirectconsid-erationofsexualrightsinNewZealand,internationallawmaystillprovideanimportantbasisforanypurported"right"tosexualrelations.
AnothersourceofrightsistheCodeofHealthandDis-abilityServicesConsumers'Rights(CodeofRights).
TheCodeofRightsappliestotheprovisionofhealthanddisabil-ityservices,includingresthomecare.
Itcreatesrightstorespect,privacyandservicesthatrecognisedignityandinde-pendence.
53Wherearesthomeisregardedasaperson's"home",theserightscouldbeinterpretedasincludingthenecessaryprivacyforintimatecontact,oratleasttheoppor-tunityforintimacy,largelyfreefromintrusion.
Whilethereisscopefortheserightstoberelevanttosexualrelationships,therearenoHDCcasesthatprovideexamplesofindividualsseekingtoadvocatetheserightsasincludingsexualrela-tions.
54Whethersexualrelationscanbetranslatedintoa"right"thatisdeservingofpromotionorprotectionisunclear.
However,ifitisacceptedthatsexualrelationscanbeanimportantaspectofaperson'srelationships,wellbeingorwayoflife,andthatsuchdecisionsarealsointrinsicallylinkedtoprivacyandindependentchoice,thenitisarguablethatsexisamatterthatisworthyofcarefulconsiderationandpossiblyprotection,evenwhentherearequestionsaboutcapacity.
Whilethe"rights"focusofthePPPRAisintendedtofacilitateandsupportthesubjectperson,55itisevidentthatprotectionofthosewithlimitedcapacityisalsoanimportantaspectofthePPPRAjurisdiction.
56Withthisinmind,thewayinwhichapersonwhoisperceivedtolackcapacitymightbesupportedtogivevalidconsentforsexualrelations,andwhethersuchdecisionscanbemadeonhisorherbehalf,isexploredbelow.
Supporteddecision-makingSocialsupportscaninfluencecapacityandassistdecision-making,andthereforesupporteddecision-makingcanofferthosewithdiminishedordecliningcapacityanopportunitytoretainsomecontrolovertheirpersonalchoices.
Currently,theonlystatutorymodelfor"supporteddecision-making"inNewZealandistherequirementunderthePPPRAforwel-fareguardiansandthoseactingunderanenduringpowerofattorney(attorney)toconsultwithandencourageanincom-petentindividualtoactontheirownbehalf.
57However,thoseappointeddecision-makersalsohavearesponsibilitytoprotectthatperson'swelfare,andtheirdecisionwillultimatelyoverridethewishesofthepersonconcerned.
58Similarly,inexercisingjurisdictionunderthePPPRAacourtmust"enableorencourage"theexerciseofcapacity,butitcanstillmakedecisionsinthatperson'splace.
59Thus,these"supporteddecisions"aresimplyaprecursorto,orrelevantconsiderationfor,substituteddecisions.
Incontrast,inotherjurisdictionstherearelegalframe-worksforsupporteddecision-makingwherethereisnocorrespondingpowerofsubstituteddecision-making.
Toillustrate,since2000,Swedenhashadasystemofpersonalombudsmen,ausercontrolledservicefocusedonclient(notrelativeorauthority)priorities,wherebyskilledindividualsprovideindependentsupportforanincompetentclient'swishesinavarietyofmatters,includingsexuality.
60InCanada,supporteddecision-makinghasbeenexpresslyincludedinlegislationtogive"trustedfriendsandrelatives"legalstatusas"associatedecision-makers"toparticipateindiscussionswhenanimpairedadultismakingdecisions.
61Decisionsaremadewiththeassistanceoftheassociate,butnotbytheassociate,anddecisionsmadeorcommunicatedwithsuchassistancearebindingexcepttotheextentthatfraud,mis-representationorundueinfluenceexist.
62Supporteddecision-makingagreementsmaybeenteredintoifapersonunderstandsthenatureandtheeffectoftheagreement,whichsuggeststhatapersonwithpartialcapacitymayagreetosupportforidentifiedtypesofdecisions.
63Thosedecisionscouldreason-ablyincluderelationshipswithothers.
Closertohome,between2010–2012,SouthAustraliapilotedanon-statutorysupporteddecision-makingprojectinwhichincompetentadultsenteredsupportagreementsforassistancefromfriendsorfamilyfordecisionsaboutvariouslifechoices.
ThepilotwasrunbytheSouthAustralianOfficeofthePublicAdvocatethroughacommitteeappointedundertheGuardianshipandAdministrationAct1993,whichallowedthePublicAdvocatetosetupcommitteesforadviceonareasrelevanttoitsfunctions.
Theprojectfocusedonminimisingsubstituteddecision-makingbyusinglessrestrictive"sup-port"optionsforcognitivelyimpairedindividuals.
Overall,itdemonstratedtheviabilityofsupporteddecision-making,buthighlightedthe:requirementfortrainingandguidanceforsupporters;needformonitoringandoversightofsupportagree-mentstoensuretheyworkasintended;lackoflegalprotectionwithinformalsupportagree-ments;andabsenceofclarityaboutthe"boundariesandintersec-tions"betweensupporteddecision-makingandguardianship.
64Itisunclearwhethersupporteddecision-makinghasbeenusedtoassistwithdecisionsaboutenteringsexualrelation-ships.
WhiletheSwedishpersonalombudsmansystemhasbeenusedtoassistwithquestionsaboutsexuality,itisunclearwhethersexualityisusedtomeansexualidentityandorientation,orsexualrelationships,orboth.
However,theevaluationoftheSouthAustraliapilotfoundthatthemajor-ityofparticipantswantedtohavesupporttomakedecisionsaboutrelationships(althoughnotexpresslysexualrelation-ships).
65Althoughdiscussionsaboutsexualrelationsmightberegardedasintrusiveorembarrassing,thisassumptioncanbeanobstacletoaddressingquestionsofsexualhealthandwellbeingintheelderly.
66Inthecontextofmedicalcare,researchshowsthatolderindividualswanttobeaskedaboutsexualfunctionasawayofprovidinganopportunitytodiscussconcerns.
67Onthisbasis,withtherightsupporterinplace,acollaborativeandcompanionbasedsupporteddecision-makingprocessmayactuallylenditselftodecisionsaboutpersonalmatters,includingsex.
Inparticular,atrustedsup-portercouldbewellplacedtodiscussthebenefits,risks,andrelationship(s)inquestionandtherelevantoptionsforreach-ingadecision.
AnamendmenttothePPPRAthatcreatesresponsibilitiesandstandingforsupporterstoparticipateindecision-makingprocesseswouldprovidelegalrecognitionfortheimportantroleofsocialrelationshipstodecision-makingcapacity.
68Moreover,astatutoryframeworkcouldensurethatappropriateandenforceablesafeguardswereinplace.
Forexample,theremightbe:restrictionsonwhocouldbeappointed;69arequirementtoconsultwithorhaveasupporterpresentforspecificdecisions;NewZealandFamilyLawJournalSeptember2016193expressreferencetoinvalidatingdecisionsmadeunderduress;andacomplaintsprocessthatisaccessibletothesupportedadultandothersinterestedinthatperson'swelfare.
TheCanadianrequirementforsupporteddecisionstobetriedor"carefullyconsidered"70beforeguardianshipordersaremadewouldemphasisethevalueofsupporteddecision-makinginahierarchyofdecision-making.
Suchadirectionmightalsoprovideclarityastotherelationshipbetweensupporteddecision-makingandsubstituteddecision-making,andunderscorethefactthatsupporteddecisionsaremadeandcommunicatedwithassistance,butarenotthedecisionofthesupporter.
Tobalancetheneedforprotection,whererequired,statu-toryprovisionscouldpermitasupportertouseinformationobtainedinhisorherroletomakeanapplicationtothecourt,eitherforpersonalordersorguardianship.
71Toavoidunderminingthevoluntarilyagreedsupportrelationship,thecircumstancesinwhichthecourt'sinterventionmaybesoughtcouldbelimitedtothosewhere,objectively,theproposeddecisionplacestheindividualconcerned(orothers)atriskofharm.
Thismayprovideasupportedindividualwithsomeassurancethatitisonlywheretheyarereasonablyperceivedtobeatriskthattheirsupportermayseekthecourt'sinvolve-ment(andpossiblyasubstituteddecision).
Inthisway,supporteddecision-makingcouldlooktoupholdautonomywhilealsoquestioningcapacityandtheneedforprotection.
However,itmustberecognisedthatsupporterswillhavemindsoftheirown:"[i]tseemsdoubtfulthatsupporteddecisionscansomehowbecleansedofthepersonalityandvaluesofthesupportperson".
72Thiscouldhaveanumberofimplications,includingthepossibilitythatthewayinwhichoptionsandrisksaroundsexualrelationsareframedmay(evenunconsciously)beinfluencedbythesupporter'sviews.
This"undue"influencemayoverridetheexpressedwishesoftheindividual.
Anotherissueisthatthoseindividualswhoareisolatedorinconflictwithfamilymayhavedifficultyfindinganappropriatesupportperson.
Unlessadvocatesorothervolunteersarepreparedtoassist,themodelmayfavourthosewhoalreadyhavethesupporttheyneedfordecision-making.
Nevertheless,thesechallengesdonotnecessarilyunderminethesupportprinciple.
Withanappropriatestatu-toryframework,educationforindividualsandsupporters,andlegalprotectionsinplace,voluntarysupporteddecision-makingmightofferapersonwithprogressivelydecliningcapacityanintermediatestepbeforethepossibilityofmoreinterventionistsubstituteddecision-making.
Substituteddecision-makingSubstituteddecision-makingreferstolegallyenforceabledeci-sionsthataremadeonbehalfofanincompetentadult.
SubstituteddecisionsmaybemadebyawelfareguardianappointedunderthePPPRA(withrespecttoawhollyincom-petentadult),anattorneyappointedbyacompetentadult(andwhohasthepowertoactonlywhenthedonorwhollylackscapacityastopersonalcareandwelfare)orbythecourtexercisingpowerstomakepersonalordersunderthePPPRA.
73Substituteddecisionsmayfacilitateoroverridetheexpressedwishesoftheincompetentadult.
Exceptaslimitedbys18ofthePPPRA,asubstituteddecisionmadebyawelfareguard-ianorattorneyhasthesameeffectasifitwasmadebytheincompetentadult.
74UnlikeinEngland,75substituteddecisionstoconsenttosexualrelationsarenotexpresslyexcludedbythePPPRA.
Whilesubstituteddecisionsrelatingtomarriageandcivilunionsareexpresslyexcludedbys18(1)(a)ofthePPPRA,theserelationshipsanddecisionsarenotdirectlyanalogouswithsexualrelationsforthereasonsexplainedabove.
76Inparticular,sexualrelationsmayoccuroutsideoflegallyrecognisedrelationships.
Additionally,itisarguablethatsexualrela-tionscanreasonablyberegardedasapartofaperson'slivingarrangements,aboutwhichthereistheexpresspowertomakesubstituteddecisionsbywayofpersonalorder.
77Itisobservedthatawelfareguardianorattorneywithbroadorundefinedpowersastopersonalcareandwelfarecouldreasonablybeguidedastothescopeoftheirdecision-makingabilitybytherangeofpersonalordersavailableunderthePPPRA.
TheHighCourthasheldthatthephrase"livingarrange-ments"encompasses"allaspectsofthesubjectperson'senvironmentincludingwheretheylive…withwhomtheyhavecontact,andwhotheyarecaredby".
78Ordersencom-passing"alllivingarrangements"are,therefore,potentiallyverywide.
79TheHighCourthasupheldapersonalorderthatpermittedunsupervisedcontactbetweenanincompetentwomanandhermother,onthebasisthattheorderfacilitatedandpromotedher"rightstoafullfamilylife".
80Thisisjudicialrecognitionoftherighttoafamilylife(atleastinthePPPRAjurisdiction),whichatinternationallawhasbeeninterpretedasincludingthefreedomtoenterintosexualrelations.
81Ifitisacceptedthatsexualrelationsformarelevantaspectoflivingarrangements,thenitisnotincon-ceivablethat,ontherightfacts,substituteddecisionscouldextendtopermittingphysicalcontact,oratleastnotexclud-ingsuchcontact,withasexualpartnerina"home"environ-ment.
Welfareguardiansandattorneysconsideringsuchques-tionsmusthaveregardtoanindividual'sbestinterests:82Thepurposeofthebestintereststestistoconsidermattersfromthe[person's]pointofview.
Thatisnottosayhiswishesmustprevail…Butinsofarasitispossibletoascertainthe[person's]wishesandfeelings,hisbeliefsandvaluesorthethingswhichwereimportanttohim,itisthosewhichshouldbetakenintoaccountbecausetheyareacomponentinmakingthechoicewhichisrightforhimasanindividualhumanbeing.
Thus,subjectivewishesmustbeascertainedtotheextentthatthatispossible.
Welfareguardiansandattorneys,whoarecommonly(butnotexclusively)familymembers,mayhavesomeknowledgeofanindividual'srelationshipsandpre-incapacityvalues,behaviourorattitudetosexwhichcanguideanunderstandingofexpressedwishesastosexualrelations.
Inaddition,itislikelythatwelfareguardiansandattorneyswouldbeprovidedwithinformationfromothers,includingresthomestaffandsupporters(egifadopted,legallyrecognisedsupporteddecision-makers),astotherisksorbenefitsoftheproposedsexualcontact,therelationshipwiththesexualpartner,andthemattersdiscussedwiththeindi-vidualconcerned.
Itissuggestedthatthesecontextualfactorsarenotonlyrelevanttoquestionsofcapacitybutalsotodeterminingtheappropriatenessoffacilitatingexpressedwishes.
Itisalsosuggestedthattheconsultativeandencour-agementrequirementsforwelfareguardiansandattorneysindicatethatthelawacceptsthatevenwhollyincompetentadultsshouldretainsomeinfluenceoverdecisionsrelatingtotheircareandwelfare.
NewZealandFamilyLawJournalSeptember2016194Thereisnoobligationtoupholdincompetentlyexpressedwishes.
Welfareguardiansandattorneysalsohavearespon-sibilitytoconsideranincompetentperson'swelfare,whichmayrequiretakingstepstoprotectindividualsfromdeci-sionsthatplacethematriskofharm.
Whilethecourt'sobjectiveistomakethe"leastrestrictiveinterventionpos-sible",83ittoomustbemindfulofprotectingthosewhoselimitedcapacitymeanstheyarenotcapableofappreciatingrisk.
84However,itistritetoobservethattheoverlyprotec-tiveexerciseofpower,withoutgoodcause,mayunderminewhatcouldbesaidtobegenuinechoicesinthecircum-stances.
Inthefaceofanexpressedwishforsexualrelations,whichinitsparticularcontextpresentsnoobjectiveorreportedrisktotheindividual,thereistheoreticallynoreasonwhyasubstituteddecisioncouldnotbeacceptedasvalidconsent.
Whetherthis'thirdpartyconsent'tosexualrelationswouldsatisfythecriminallaw,andinparticulartheprovi-sionsintendedtoprotectimpairedpersonsfromsexualactiv-itywhichtheyaredeemedincapabletoconsentorrefuseconsentto,remainstobeseen.
85However,itisrelevantthatasubstituteddecisionhasthesamelegaleffectasitwouldhaveifithadbeenmadebythepersonconcerned,86andthatacourtordercanprovidelegallyeffective"consent"incircumstancesthatwouldotherwisebeanassault(egmedicaltreatment).
Assuch,itisarguablethatasubstituteddecisiontofacilitatethedesireofthesubjectpersondoesnotpermitnon-consensualsexbut,instead,confirmsconsentonbehalfofanotherwiseincompetentadult.
Substituteddecisionsaboutsexualrelationsmay,how-ever,beproblematicforotherreasons.
Forthedecision-maker,anyuncertaintywhatsoeverastotheappropriatenessoffacilitatingsexualrelationswillinevitably(andperhapsproperly)erronthesideofprotection.
Theimplicationsofadecisiontorefusesexualcontactcouldleadtopracticalenforcementdifficulties,whethermanagingtheexpectationsofthepersonwhosewisheshavebeenoverruledorphysicallypolicingandpreventingsexualcontact.
Thiscouldresultinintrusivemanagementstrategiesforresthomesrightlycon-cernedabouttheriskofcriminalliability.
87Forthepersonconcerned,substituteddecision-makingcarriestheriskthattheybecomesubjecttothemoraljudgementsofothers.
Whatthedecision-makerconsidersacceptablecouldbeinformedbyunfairorincorrectperceptionsthatelderlypersonsare"asexualanddisinterestedinsexorhypersexualtothepointofperversion".
88Thisriskmaybeparticularlystarkwhereaperson'spre-incapacityrelationshipsandvaluesareunknownornotfullytakenintoaccount.
Thelatteremphasisesthevalueofconversationsaboutsexualrelationstakingplacepriortoincapacity.
Itistheapparentlackoffocusonsuchconversationsthatiscentraltotheargumentthatmorecanandshouldbedonetoaddressthequestionofincapacityandsexualrelationsintheelderly.
WhatmorecanorshouldbedoneAspeopleagetheytendtomakedecisionsthatarefocusedontheendoftheirlife,suchasmakingawillorevenmakingprospectivedecisionsaboutmedicaltreatmentrelevanttotheendoflife.
However,itismuchlessclearwhethermany(ifany)peopleconsiderhowtheymightwanttoliveintheeventofincapacity,ortheimportancetothemofintimateorsexualrelationshipsinthosecircumstances.
Forsome,thismaybebecausethetopicistaboo.
Forothers,theimplicationsofincapacityandsexareunknownornotregardedassuffi-cientlyimportanttodiscussorplanfor.
Formost,itissuggested,thisisatopicthatissimplynotraisedwiththem,evenwhentheyenterresthomecare,possiblyforfearofcausingoffenceorembarrassment.
Therisksoffailingtoaddresssuchquestionsintheresthomecontextisillustratedbythecaseofa78yearoldUSmanchargedwith,andlateracquittedof,sexuallyabusinghiswifewhosufferedfromAlzheimer'sandlivedinaresthome.
89Thehusband'sprosecutionservedasa"wakeupcall"forresthomestobeexplicitwithpatientsandfamiliesaboutsex.
90ThismessageisequallyapplicabletoNewZealandresthomes,anditisrecommendedbelowthatindustryagreedguidelinesaboutsexualrelationshipsshouldbedeveloped.
The"wakeupcall"alsohighlightstheneedforolderadultsplanningfortheirlateryearstoconsiderwaysinwhichotherscanbemadeawareofallaspectsoftheirlifethatareimportanttothem,includingrelationshipswithothers.
Inthisrespect,anadvancedirectiveisonetoolworthyoffurtherconsideration.
AdvancedirectivesAnadvancedirectiveisamechanismtoexpresscompetentwishespriortoincapacity.
TheCodeofRightsaffirmstheabilitytomakeanadvancedirective,whetherinwritingororally,aboutpossiblefuturehealthcareprocedures.
91Sig-nificantly,avalidadvancedirectivecanprovidelawfuljusti-ficationnottoprovidelife-savingtreatmentwheresuchtreatmenthasbeenanticipatedandexpresslyrefusedbythe(now)incompetentperson.
Thisisconsistentwitheverycompetentadult'srighttorefusemedicaltreatment.
92Whileadvancedirectivesarecommonlyseenandusedinmedicaltreatment,thereisnologicalbasiswhyaformofadvancedirectivecouldnotbeusedtoexpresscompetentwishesaboutanydecisionthatmayariseintheeventofincapacity.
Inthisregard,itisrelevantthatadvancedirectivesareconsidereda"naturalextension"totheprinciplesofautonomyandrespectforautonomy.
93Anumberoffactorsareapplicabletothevalidityofanadvancedirective,includingthecircumstancesinwhichitismadeandwhenitismade;thatis,anadvancedirectivewillbecome"stale"withageandchangingcircumstances.
Advancedirectivesalsohavelimitations.
Clearly,anoraladvancedirectivewilllackforceunlessitisgivenwidelyandfre-quently.
Eveniftheadvancedirectiveisinwriting,thereisnocentralrepositoryforsuchdirectives,andthereforeunlessitsexistence(andlocation)ismadeknownpriortoincapacityitmayneverbetakenintoaccount.
Thesearefactorsthatrequirecarefulinquiry,particularlywhensomeoneentersresthomecare.
Anotherkeylimitationisthatwhileanadvancedirectivepurportstogivelegalforcetoanticipatorydecisions,statedpreferencesareunlikelytooverrideobligationstoprotectavulnerableadult.
Inparticular,ifthecontextdemonstratesvulnerabilityandtheneedforprotection,thatwillverylikelytakepriorityoverapreviouslyexpressedpreferenceforsexualcontact.
Inlightofthis,itseemsunlikelythatanadvancedirectivecouldgivevalidconsenttosexualrelationsatsomefuturepointintime.
Thatsaid,thereisstillvalueinacompetentadultprovidingwrittenguidanceonfuturedeci-sionsaffectingthewaytheywouldliketoliveifincapaci-tated.
Itisrelevantthatanattorney(andprobablyothers)mayhaveregardtoanadvancedirectivewhenmakingsub-stituteddecisions.
94Importantly,itisarguablethatcompe-tentlyexpressedwishesastosexualrelations,orcompetentassertionsrelevanttosexualvaluesandwellbeing,maybeNewZealandFamilyLawJournalSeptember2016195moreinfluentialthanalater,incompetent,expressionofwishes.
Forexample,a(written)statementcouldhelpfullyrecordtheexistenceofalongstanding,closeandlovingrelationship,andthedesiretocontinuewithintimatecontactfollowingincapacity.
Itcouldincludereferencetomutuallyacceptablesexualcontact,orrequestsforovernightstaysand/oradoublebed.
Equally,itcouldsimplyrecordthatphysicalrelationshipsand/orintimacyareimportanttothatperson'swellbeingoridentity.
Inthisway,anadvancedirec-tivecouldbeavaluablesourceofinformationforothersaboutpre-incapacitypreferences.
Onepossibleissuethatmightimpactontheuseofadvancedirectivesforthepurposesdescribedhereisthatthetermmaybeassociatedwithprospectivedecisionsaboutdying.
Thisisinconsistentwiththeintendedfocus,whichistoencourageprospectiveconsiderationofdecisionsaboutliv-ing.
Itissuggestedthatolderadultsmaybemoreinclinedtorecordtheirwishesas"livingchoices"ora"valueshis-tory",95anditisrecommendedthatthispositivelanguageisadoptedtopromotetheimportanceofdocumentingper-sonalchoices.
GuidanceforresthomesResthomeswillundoubtedlyencounterindividualswithdif-feringlevelsofcapacityandriskfactors.
Someindividualsenteringresthomecaremayhaveareducedphysicalabilitytocareforthemselves,butarecompetenttomakedecisionsaboutallaspectsoftheirlife.
Othersmayhavefluctuatingcapacity,inthattheyareabletomakedecisionsaboutday-to-daypersonalchoicesbutmightnothavecapacitytomakesignificantdecisions,forexampletosellproperty.
Someresidentswillbeadmittedtoresthomecarewithawelfareguardianorenduringpowerofattorneyinplacetomakesubstituteddecisionsontheirbehalf,inconsultationwiththem,whereasothersmaybeadmittedtoaresthomeduetoatotallossofcapacitywithnoformaldecision-makingmechanisminplace.
Whethercapacityispresent,questionable,orabsent,resthomeshavearesponsibilitytomanagethewellbeingoftheirresidents.
Therearecurrentlynonationalorindustry-wideagreedstandardsthatspecificallyaddressthemanagementofissues,orthedifficultquestions,aboutsexualrelationsinresthomes.
96Intheabsenceofsuchstandards,theonusrestsonindividualresthomestoensureresidentsreceiveservicesthatmeetindi-vidualneeds.
Whileresearchsuggeststhatsexandintimacycanremainimportantevenforincapacitatedelderly,"fewcarefacilitieshaveimplementedpoliciesor[staff]training"directedatsexualexpression.
97Intheabsenceofpolicies,managementstrategiesandstafftraining,itisarguablethatresthomesmightnotbemeetingresidents'individualneeds.
Thefirstopportunitytoensurethatdecisionsaccordwithresidents'needsisonadmission.
Itissuggestedthatresthomesneedtobeskilledandproactivetoincludediscussionaboutsexualrelationshipsaspartoftheadmissionprocess,perhapsaspartofrecordingaperson's"livingchoices"oradvancedirective.
Thiswillbeparticularlyimportantwheretheresidenthascapacityorpartialcapacityonadmission,asthiscouldrepresentthebestchancetounderstandtheirneedsbeforeanysignificantinca-pacityoccurs.
Theadmissionprocessmight,forexample,includequestionsaboutwhethertheresidenthasanycloserelationships,whetherheorsheissexuallyactive,andwhethertheywishtocontinuewithsexualactivity.
Theresidentshouldhaveachoiceaboutwhetherornottoanswer,althoughitwouldbehelpfultoexplainthattheirexpressedwishescouldbecomerelevantintheeventofincapacity.
Admissionis,however,justastartingpoint.
Anongoingprocessofevaluatingtheappropriatenessofsexualrelationsisrelevanttodischargingresthomes'obligationstoprotectindividualsfromharm.
Giventhepotentiallegalsignificanceforresthomesandindividuals,industry-wideagreedguide-linesspecificallyaddressingsexualrelationsarerecom-mended.
Anysuchguidelinesshouldbedraftedinconsultationwithotherrelevantagencies,includingtheHDCandorganisa-tionswithaninterestinageingandtherightsofolderpeople.
TheHDCcouldprovideinputintotheapplicabilityoftheCodeofRights,andtheviewsofelderlypersonscouldbeaneffectivecounterbalancetowhatmightbeanoverlyprotec-tivestartingpointbyresthomes.
Whileitisacceptedthatresthomesneedtobalanceindi-vidualfreedomalongsidetheirprotectiveresponsibilities,itissuggestedthattheguidelinesshouldstartwithapresump-tionofcompetence.
Staff(andfamily)shouldberemindednottomakeassumptionsaboutincapacityonthebasisofthelevelofsupportthatapersonneedsinotheraspectsofday-to-daylife,andtotakeanon-judgementalapproachtoproposedsexualactivity.
Likewise,guidelinesshouldensurethatstaffarealivetothepossibilitythatfamilyorcarersmaytrytoinfluenceresidentsnottohavesexualrelations,evenifthereisnobasisfortheobjection.
Guidelinesshouldencour-ageongoingdiscussionwithresidentsaboutsexualrelation-ships,including,whererelevant,askingthoseresidentswhoareknowntobesexuallyactivehowtheyfeelabouttheirrelationship.
Similarly,guidelinesshouldadvisestafftowatchforchangesinbehaviourafterintimatecontact,andtorecordanddiscusswithseniorstaffanyincidentsofconcernorunusualbehaviourrelevanttosexualactivity.
Itisanticipatedthatguidelineswouldbemostuseful,andperhapsmostinstructive,wherecompetenceisquestionableandtheappropriatemanagementresponsetothesexualcontactisuncertain.
Inthosecircumstances,guidelinesshouldrequire:considerationoffactorsthatcouldaffectcapacity(egadiagnosisofdementiaandthestageofthedisease);discussionabouttheresident'sunderstandingofthefunctionalaspectsandconsequencesofsexualactivityandtheirviewsoftherelationshipinquestion;anynon-verbalcuesindicatingconsent,andanypreviouslyexpressedwishes;what,ifany,supportstructuresorpersonsareusedbytheresident,andseekingthatsupportwhereappropri-ate;thecircumstancesinwhichanycapacityassessmenttakesplace(includinganyfactorsthatcouldtempo-rarilyaffectcapacity);andanyotherrelevantpersonstoconsultaboutthegenu-inenessoftheperson'schoice.
Theguidelinescouldsuggestspecificquestionstoassistwithdeterminingaperson'slevelofunderstanding.
Forexample,oneNewYorkresthomeasksitsstaffto"posequestionslike"whatwouldyoudoifyouwantedittostop".
98Appropri-atelyframedquestionscouldprovidepracticalassistanceforstaff.
Anyguidelinesshouldalsoexpresslyaddresspossiblesignsofvulnerability,exploitationorsexualassaultinrecog-nitionthatincapacitymaymakeelderlypeopleatriskofNewZealandFamilyLawJournalSeptember2016196sexualabuse.
Inadditiontoassessinganychangesinmood(beforeoraftersexualcontact),guidelinesmightrequirestafftobevigilantforanysignsofinappropriatepressureforsex;anyindicationsofdisinhibitedsexualbehaviour;andtotakeseriouslyanyreportsofsexuallyinappropriatebehaviour.
Staffshouldalsobemindfulthatduresscanvitiateconsent,andguidelinescouldsuggestcircumstancesinwhichitwillbeappropriatefordiscussionstotakeplacewithoutthesexualpartnerpresent.
Finally,guidelinescouldprovidedirectiononwheninterventionmightbenecessaryandpracticalman-agementtoolstopreventsexualcontactintheeventofincapacity.
ConclusionWhileincapacitymaymakeanolderpersonsusceptibletosexualabuseorexploitation,diminishedcapacitydoesnotalwaysequatetovulnerabilitythatshouldautomaticallyexcludeindividualsfromsexualrelations.
Insomecases,olderadultswithimpairedcapacitymayretaintheabilitytomakegenuinechoicesaboutsexualrelations,andthoserelationshipsmaybeimportanttomaintainingtheiroverallhealthandwellbeing.
Itisarguedthatthecontext,includingrelationshipswithothers,caninfluencecapacity.
Therefore,torespectautonomy,thoseraisingquestionsaboutcapacityforsexualrelationsshouldberequiredtoconsiderthewholecontextinwhichthe(proposed)sexualrelationsarise,andthecontextinwhichcapacityassessmentstakeplace.
Wherecapacityisinquestion,supporteddecision-makingandsubstituteddecision-makingareadvocatedaseffectiveoptionstosupportorfacilitatelegallyvaliddecisionsaboutsexualrelations.
Importantly,bothoptionscanallowforconcernedotherstoquestionthegenuinenessofchoice,toassessriskandvulnerabilityinthecircumstances,andtoseekprotectionwhereobjectivelynecessary.
Advancedirectives,or"livingchoices"areencouragedasatoolforindividualstoensurethattheirpre-incapacityvalues,relationshipsandpreferencesareknowntoothers.
Finally,whileresthomesseemtorecognisethecomplexi-tiesthatcanarisewithsexualrelationsintheresthomesetting,therehasbeennoindustryagreedresponseastohowthisshouldbemanaged.
However,resthomes'legalandprofessionalobligationsshouldbesufficientmotivationforthemtoadoptaproactiveapproachtodiscussingthistopicwithresidents(andintendedresidents),andforthedevelop-mentandimplementationofguidelinesonmanagingsexualrelations.
Guidelineswouldbeahelpful,openandtranspar-entresponsetotheissuesthatcanarise,andisonewaytoensurethataneffectivebalanceisstruckbetweenindividualautonomyandcarers'responsibilities.
Footnotes*.
Partner,Claro,Wellington.
ThisarticlewascompletedfortheElderLawcourseatVictoriaUniversityofWellington.
1.
ProtectionofPersonalandPropertyRightsAct1988,s8(b).
2.
"Incapacitated"and"incompetent"areusedinter-changeablyinthisarticle.
3.
Resthomeisusedheretorefertoagedresidentialcarefacilitiesthatprovide24hourcaregivercaretoresi-dents,andfacilitiesthatprovide24hourhospitallevelcare.
4.
Seeforexamplethelegaldutytoprotectvulnerableadultsfromriskofsexualassault,s195A(anoffencepunishablebyatermofimprisonmentnotexceeding10years).
5.
HealthandDisabilityCommissioner(CodeofHealthandDisabilityServicesConsumers'Rights)Regula-tions1996,Right1and3.
6.
SchloendorffvSocietyofNewYorkHospitals211NY125,105NE92(NY1914)at130,93.
7.
Theboundsofthelawarereferencetothefactthatsomesexualactsarecriminalacts,includingincestandsexualconnectionwithminors.
8.
CrimesAct,s128.
9.
CrimesAct,s128A(5).
10.
BruceRobertson(ed)AdamsonCriminalLaw(onlinelooseleafed,Brookers)at[CA128A.
05].
11.
CrimesAct,s138.
12.
CrimesAct,s138(6).
13.
SexualOffencesAct2003(UK),s30.
14.
RvCooper[2009]UKHL42,[2009]4AllER1033at[26].
15.
ProtectionofPersonalandPropertyRightsAct1988[PPPRA],s5.
16.
PPPRA,s5.
17.
SylviaBellandProfessorWarrenBrookbanks"Decision-MakingandtheProtectionofPersonalandPropertyRightsAct1988"inKateDiesfeldandIanMcIntosh(eds)ElderLawinNewZealand(ThomsonReuters,Wellington,2014)79at89,citingKRvMR[2004]2NZLR847(HC).
18.
Thereisevidenceofanincreasingprevalenceinsexu-allytransmittedinfectionsintheelderly.
SeeforexampleRobertaBilenchi,SaraPoggiali,ChiaraPisani,MarieleDePaola,RosannaSculco,LuciaAnnaDePadovaandMicheleFimiana"SexuallyTransmittedDiseasesinElderlyPeople:AnEpidemiologicalStudyinItaly"(2009)57JAmGeriatrSoc938.
19.
Forthepurposeofthisarticle,marriagemaybereadasincludingcivilunions.
20.
XvX(2000)19FRNZ544(FC)at[28].
TheCourtheld,at[76],that"MrX'sdisease,inallthesurround-ingcircumstancesincludinghisincreasingdependenceonMrsXandhisincreasingisolationfromhisownfamily,hadrobbedhimoftheabilitytomakethereasonedandinformeddecisionswhichwereaneces-saryprerequisiteofanagreementtomarryMrsX".
21.
Cooper,aboven14,at[27].
22.
IMvLM[2014]EWCACiv37at[79].
23.
IMvLM,aboven22.
24.
IMvLM,aboven22,at[18],citingthedecisionoftheCourtofProtection,whichwasupheld.
25.
IMvLM,aboven22at[80]and[82].
26.
IMvLM,aboven22,at[81]citingANHSTrustvP[2013]EWHC50(COP).
27.
RobinMackenzieandJohnWatts"Capacitytocon-senttosexreframed:IM,TZ(no2),theneedforanevidence-basedmodelofsexualdecision-makingandsocio-sexualcompetence"(2015)40IntJLawPsychia-try50at52–53.
28.
JonathanHerringandJesseWall"CapacitytoConsenttoSex"(2014)22MedLawRev620at629.
29.
HerringandWall,aboven28,at629.
30.
HerringandWall,aboven28.
31.
ReRMS[PPPR](1993)10FRNZ387(FC)at392.
NewZealandFamilyLawJournalSeptember201619732.
ALocalAuthorityvTZ(No2)[2014]EWHC973(COP)at[28].
33.
Forthisreasonalone,imposinganupperlimitfortheageofconsenttosexualrelationsmustberejected.
SeeforexampleStephanieLTang"When'yes'mightmean'no':standardizingstatecriteriatoevaluatethecapac-itytoconsenttosexualactivityforelderlywithneurocogni-tivedisorders"(2015)22ElderLJ449at478.
34.
MichaelBoyd,ChrisPerkinsandRodPerkins"Olderadulthealthissues:theemergingimplicationsinNewZealand"inKateDiesfeldandIanMcIntosh(eds)ElderLawinNewZealand(ThomsonReuters,Wellington,2014)59at65.
35.
MinistryofHealth"Dementia"(21June2015).
36.
SeeGabrieleCipriani,MartinaUlivi,SabrinaDanti,ClaudioLucettiandAngeloNuti"Sexualdisinhibi-tionsanddementia"(2016)16Psychogeriatrics145.
37.
SeeforexampleAReportbytheHealthandDisabilityCommissioner(Case04HDC07008)(2006)www.
hdc.
org.
nzhighlightingtherisksfacedbyvulnerableresthomeresidentstoincidentsofinappropriatesexualbehaviourbyaresidentwithdementia.
38.
LucySeries"Relationships,autonomyandlegalcapac-ity:mentalcapacityandsupportparadigms"(2015)40IntJL&Psychiatry80at82.
39.
SeeSarahKaplan"FormerIowalegislatorHenryRoyhons,78,foundnotguiltyofsexuallyabusingwifewithAlzheimers"TheWashingtonPost(onlineed,23April2015).
40.
Itisnotable,forexample,thatinIMvLMtheinitialapplicationhadbeenmadebyamalefriendoftheincapacitatedwomanwhowishedtohavesexwithher(andtheorderallowingcontacthadbeenappealedbythewoman'smother).
41.
Series,aboven38,at81.
42.
SeeforexampleMentalCapacityAct2005,s3(3):"Thefactthatapersonisabletoretaintheinformationrelevanttoadecisionforashortperiodonlydoesnotpreventhimfrombeingregardedasabletomakethedecision.
"43.
RonPatersonRelationshipsandRights—TheAppli-cationoftheCodeofRightstoConsumerswithIntel-lectualDisability(2009).
Whilethearticlerelatestoadultswithintellectualdisabilities,thecommentsareequallyapplicabletoelderlypersonswithimpairedcapacity.
44.
Tang,aboven33,at460.
45.
Sections17and19.
46.
Providedtheyarenotforacriminalpurpose.
SeeKerrvAttorney-General[1996]DCR951at958.
47.
HumanRightsAct1993,s21(1)(h)and(i).
48.
Section28.
49.
InternationalCovenantonCivilandPoliticalRights,Art23.
Article17recognisesthat"Nooneshallbesubjectedtoarbitraryorunlawfulinterferencewithhisprivacy,family,homeorcorrespondence…".
50.
EuropeanConventiononHumanRights,Art8and12.
51.
RichardGriffithandCassamTengnah"Assessingcapac-itytoconsenttosexualrelations:aguidefornurses"(2013)18BRJCommunityNurs198.
52.
SeeforexampleHeluvImmigrationandProtectionTribunal[2015]NZSC28,[2016]1NZLR298at[76].
53.
HealthandDisabilityCommissioner(CodeofHealthandDisabilityServicesConsumers'Rights)Regula-tions1996,Rights1and3.
54.
TheHealthandDisabilityCommissionermayinvesti-gateallegedbreachesoftheCodeofRightsandpublishopinionsastowhetherornotabreachhasoccurred.
55.
T-EvB[Contact][2009]NZFLR844(HC)at[18].
56.
RMS,aboven31.
57.
PPPRA,ss18(4),98A(3)and99A(1)(a).
58.
PPPRA,ss18(3)and98A(2).
59.
PPPRA,ss8(b)and10.
60.
MathsJesperson"ThePersonalOmbudsmanSysteminSweden"(paperpresentedtoLerSeminarioInternacionalsobreDiscapacidad,SaludMentalyCuidadoFacultaddeMedicina,UniversidaddeChile,Santiago,Chile,28March2015).
Notethatthepersonalombudsmansystemdevelopedoutofpsychiatricreformsin1995andgenerallyappliestoindividualswithmentalhealthissues.
61.
DecisionMaking,SupportandProtectiontoAdultsAct2003(Yukon,Canada),ss4and8.
62.
DecisionMaking,SupportandProtectiontoAdultsAct,s11.
63.
DecisionMaking,SupportandProtectiontoAdultsAct,s4.
64.
Mary-AnnDeMestre"Supporteddecisionmakingasanalternativetoguardianshiporders:TheSouthAus-traliantrial"(2014)8ElderLRev1at3.
65.
MargaretWallaceEvaluationoftheSupportedDecision-MakingProject(SouthAustralianOfficeofthePublicAdvocate,Report,November2012)at30.
66.
SharonHinchcliffandMerrynGott"Seekingmedicalhelpforsexualconcernsinmidandlaterlife:areviewoftheliterature"(2011)48JSexRes106at112.
67.
HinchliffandGott,aboven66,at114.
68.
TheCanadianmodelisworthyofcloseconsiderationshouldthisoptionbepursuedinNewZealand.
69.
SeeforexampleDecisionMaking,SupportandProtec-tiontoAdultsAct,s7(b)whichexpresslyexcludesapersonagainstwhomanorderhasbeenmadeunderFamilyViolenceProtectionlegislation,orwhoisthesubjectofanadultprotectionorderunderDecisionMaking,SupportandProtectiontoAdultsAct.
70.
DecisionMaking,SupportandProtectiontoAdultsAct,s2(d).
71.
SeeforexampleDecisionMaking,SupportandProtec-tiontoAdultsAct,s10(3)(c).
72.
Series,aboven38,at86.
73.
TheHighCourtexpresslyretainsitsinherentjurisdic-tion,includingparenspatriae,whichmaypermitittomakeorderswithrespecttoincompetentindividualswhoareunabletomakedecisionsforthemselves.
SeePPPRA,s114andJudicatureAct1908,s17.
74.
PPPRA,ss19and98(5).
75.
MentalCapacityAct,s27(1)(b).
76.
Thatis,marriageisnotsolelyconcernedwithsexualrelationsand,unlikemostsexualrelationships,itinvolvesapotentiallylong-lastinglegalrelationshipwithimpli-cationsforpropertyandinheritancerights.
77.
PPPRA,s10(1)(e).
78.
T-EvB,aboven55,at[22].
79.
T-EvB,aboven55,at[19].
80.
T-EvB,aboven55,at[26].
NewZealandFamilyLawJournalSeptember201619881.
WhilethisHighCourtdecisionpredatesSupremeCourtauthorityrejectingtheexistenceofarighttoaprivatelifeandfamilylifeinNewZealand(Helu,aboven52),itprovidessomeevidenceofacommonlawrighttoafamilylifeinNewZealandwhichmaybecomerelevantiforwhenarighttosexisdirectlyexaminedbyNewZealandcourts.
82.
AintreeUniversityHospitalsNHSFoundationTrustvJames[2013]UKSC67,[2014]1AllER573,[2014]AC591at[45].
83.
PPPRA,s8(a).
84.
RMS,aboven31.
85.
CrimesAct,s128A(5).
86.
PPPRA,ss19and98(5).
87.
CrimesAct,s195A.
88.
Tang,aboven33,at458.
89.
Kaplan,aboven39.
90.
TonyLeysandGrantRodgers"Rayhons:'truthfinallycameout'withnotguiltyverdict'"(22April2015)TheDesMoinesRegister.
91.
CodeofHealthandDisabilityServicesConsumers'Rights,cl4.
92.
NewZealandBillofRightsAct1990,s11.
93.
IrisReuvecamp"Advancingindividualautonomyinhealthcaredecisionmaking—theroleofadvancedirectives"(2015)NZLJ79.
94.
PPPRA,s99A(2).
95.
Theterm"valueshistory"istakenfromInésMariaBarrio-Cantalejo,AdoraciónMolina-Ruiz,PabloSimón-Lorda,CarmenCámara-Medina,IsabelToralLópez,MariadelMarRodríguezdelguilaandRosaMariaBailón-Gómez"Advancedirectivesandproxies'pre-dictionsaboutpatients'treatmentpreferences"(2009)16NursEthics93.
96.
NotethattheHealthandDisabilityServicesSectorStandards(particularlyNZS8134.
0:2008HealthandDisabilityServices(General)StandardandNZS8134.
1:2008HealthandDisabilityServices(Core)Standards),whichapplytoresthomes,refertosexualintimacyandexploi-tation,butdonotprovidepracticalguidanceonman-agingsexualrelationshipsinaresthomesetting.
97.
LaciCornelisonandGayleDoll"Managementofsexualexpressioninlong-termcare"(2013)53Gerontologist780.
98.
PamBelluck"Sex,dementiaandahusbandontrialatage78"(13April2015)TheNewYorkTimes.
NewZealandFamilyLawJournalSeptember2016199