Criteria For Involuntary Admission Research Articles

Risk for Self-Harm or Harm to Others: Definition and Assessment of Dangerousness

The Mental Health Act of 1995 was fully revised on May 29, 2016, and implemented on May 30, 2017, under the name of the Mental Health Promotion and Mental Health Service Support Act (Mental Health Welfare Act). The act newly defined mentally ill people as those with significant limitations in independent daily life and reduced their classification based on severity. Before the revision, patients could be admitted to the hospital if satisfied with the risk of self-injury or harm to others or the need for treatment. The self-injury and harm to others risk criteria for involuntary admission is based on the idea of respecting patients’ right to self-determination. However, predicting future risks can be challenging, and the situation at the time of judgment should be considered. This study aims to examine the administrative and legal interpretation of the self-injury or harm to others risk for involuntary admission, review definitions and evaluations of the risk of self-harm in various areas, and suggest improvements for mental health policies or guidelines.

England's rate of involuntary psychiatric admission is double that of the Republic of Ireland: Why? A consideration of some possible causes.

Involuntary psychiatric admission or 'sectioning' is a serious event with clear implications for the right to liberty, among other rights. Rates of involuntary admission vary considerably across jurisdictions. The rate of involuntary admission in England is approximately double that in the Republic of Ireland. Why? This paper examines potential explanations for this difference, including the prevalence of mental disorder in the two jurisdictions, factors relating to mental health legislation, differing levels of police involvement in care-pathways, funding and resources, and attitudes to risk among the public and professionals. Overall, it appears that the relatively high rate of involuntary admission in England might be attributable to the role of perceived risk in shaping mental health law in England but not Ireland, the broader definition of 'mental disorder' in the Mental Health Act, 1983 in England, broader legal criteria for involuntary admission in the 1983 Act, differences in the operational definitions of 'voluntary patient' between the two jurisdictions and, possibly, increased involvement of police in pathways to care in England and differences in relation to different ethnic groups. The relatively higher number of inpatient beds in England could be a cause or a consequence of higher rates of involuntary admission. Future research could usefully focus on other factors that are also likely relevant: issues relating to social care, substance misuse, availability of alternative treatment options in the community and various other factors that are, as yet, unknown. The potential impact of risk aversion among mental health professionals and others merits particular attention.

Changing patterns and influencing factors of involuntary admissions following the implementation of China\u2019s mental health law: A 4-year longitudinal investigation

Involuntary admission (IA) is limited to particular situations in mental health laws to protect patients from unnecessary coercion. China’s first national mental health law has been in effect since 2013; however, the status of IA has not been sufficiently explored. To explore the changing patterns of IA since the clinical application of the IA criteria specified in the new law, an investigation of IA status was undertaken in 14 periods (each period lasting for one month from 05/2013 to 05/2017) in the tertiary specialized psychiatric hospital in Shanghai. The socio-demographic and clinical characteristics of 3733 patients were collected. The differences among IA rates in different periods were compared, and the characteristics of patients who were and were not involuntarily admitted were analysed. Multiple logistic regression analysis was used to clarify the independent variables of IA. The IA rate dramatically decreased after the implementation of the new law, while the overall trend gradually increased. The implementation of the IA risk criteria is effective, but IA is still common in China. The medical factors influencing IA following the implementation of the new law are similar to those in previous studies at home and abroad. Non-medical factors might be the main causes of the high IA rates in Chinese psychiatric institutions.

Commentary: The Implementation of China's Mental Health Law-Defined Risk Criteria for Involuntary Admission: A National Cross-Sectional Study of Involuntarily Hospitalized Patients

Objective: Involuntary admission is one of the most controversial issues in psychiatry in China. This study aimed to examine the implementation of the new risk criteria for involuntary admission, as defined by the new Mental Health Law (MHL), in major psychiatric hospitals; and to explore factors associated with the implementation. Method: We selected 32 psychiatric hospitals in 29 provincial capital cities in mainland China. We included all involuntarily admitted psychiatric inpatients who were discharged from December 25 to 27, 2017. Patients' demographic and clinical data and reasons for admission were retrieved. Hospitals' information was also collected. Multilevel logistic regression was applied to explore factors associated with the implementation. Results: We collected valid data from 814 inpatients. Rates of risk criteria implementation ranged from 7.9 to 88.5% in these hospitals. Only 369 inpatients (45.3%) met the MHL-defined risk criteria. Overall, between 62.2 and 78.5% of the variance in risk criteria implementation was at the patient level, and between 21.5 and 37.8% of the variance was at the hospital level. Patients with higher Global Assessment of Functioning (GAF) scores at admission were less likely to meet the risk criteria (OR 1.02, 95% CI 1.01-1.03). No statistically significant association was found between risk criteria implementation and other patient level or hospital level factors. Conclusion: Our findings show the implementation rate of the MHL's risk criteria overall was low, with only 45.3% of involuntary admissions meeting the MHL-defined criteria. This suggests that some patients' civil rights might have been violated.

The Implementation of China's Mental Health Law-Defined Risk Criteria for Involuntary Admission: A National Cross-Sectional Study of Involuntarily Hospitalized Patients.

Objective: Involuntary admission is one of the most controversial issues in psychiatry in China. This study aimed to examine the implementation of the new risk criteria for involuntary admission, as defined by the new Mental Health Law (MHL), in major psychiatric hospitals; and to explore factors associated with the implementation.Method: We selected 32 psychiatric hospitals in 29 provincial capital cities in mainland China. We included all involuntarily admitted psychiatric inpatients who were discharged from December 25 to 27, 2017. Patients' demographic and clinical data and reasons for admission were retrieved. Hospitals' information was also collected. Multilevel logistic regression was applied to explore factors associated with the implementation.Results: We collected valid data from 814 inpatients. Rates of risk criteria implementation ranged from 7.9 to 88.5% in these hospitals. Only 369 inpatients (45.3%) met the MHL-defined risk criteria. Overall, between 62.2 and 78.5% of the variance in risk criteria implementation was at the patient level, and between 21.5 and 37.8% of the variance was at the hospital level. Patients with higher Global Assessment of Functioning (GAF) scores at admission were less likely to meet the risk criteria (OR 1.02, 95% CI 1.01–1.03). No statistically significant association was found between risk criteria implementation and other patient level or hospital level factors.Conclusion: Our findings show the implementation rate of the MHL's risk criteria overall was low, with only 45.3% of involuntary admissions meeting the MHL-defined criteria. This suggests that some patients' civil rights might have been violated.

Compliance with the criteria of involuntary admission in China's Mental Health Law: a national cross-sectional study of patients admitted to hospital involuntarily

BackgroundChina's Mental Health Law was implemented in 2013 to provide a legal foundation to protect patients' rights and provide involuntary treatment for patients at high risk of suicide or self-injury, or of harming others, or both. However, the law has not been thoroughly examined since its implementation. This study aimed to examine compliance of major psychiatric hospitals in China with the criteria of involuntary admission defined in the Mental Health Law. MethodsAs part of a national survey, we collected data from discharged inpatients from 32 tertiary psychiatric hospitals across all 31 provinces of China. We manually retrieved patients' admission information from discharge medical records, and calculated the proportion of the patients who met the criteria of involuntary admission. FindingsWe included data from 1663 (93%) of 1780 discharged inpatients from all hospitals. 814 (49%) of 1663 patients were admitted to hospital involuntarily. 369 (45%) of these 814 patients were admitted because of risks of suicide or self-injury, or of harming others, or both, as defined in the Mental Health Law. Among the 369 patients, 85 (23%) had risk of suicide or self-injury, 310 (84%) had risk of harming others, and 26 (7%) had both. The rest of the patients who were admitted involuntarily, although needing treatment, did not meet the Mental Health Law-defined criteria for involuntary admission. InterpretationThe number of involuntary admissions in major psychiatric hospitals in China is high. Fewer than half of the patients who were admitted involuntarily met the criteria for involuntary admission, as defined by the Mental Health Law. Psychiatric hospitals and clinicians need to be mindful of balancing the safety of patients or others and avoiding the unnecessary restriction of patients' freedom. FundingBeijing Medical and Health Foundation.

Does Involuntary Admission With Bipolar Disorder Differ From Involuntary Admission With Schizophrenia and Related Disorders? A Report From the Dublin Involuntary Admission Study (DIAS).

While involuntary psychiatric admission and treatment are common, little is known about what impact different diagnoses have on specific features of involuntary admission and on how involuntary status is terminated (eg, by psychiatrists or tribunals, which are independent, court-like bodies reviewing involuntary admissions). We studied 2940 admissions, 423 (14.4%) of which were involuntary, at 3 psychiatry units covering a population of 552,019 individuals in Dublin, Ireland. Involuntary patients were more likely than voluntary patients to be male and unmarried. The median length of stay for involuntary patients was 27 days compared with 10 days for voluntary patients (P<0.001). Schizophrenia (and related disorders, including schizoaffective disorder) and bipolar disorder accounted for 58.6% and 17.3% of involuntary admissions, respectively, compared with 20.1% and 12.4% of voluntary admissions (P<0.001). Psychiatrists revoked the majority of involuntary orders for both patients with bipolar disorder (85.3%) and those with schizophrenia (and related disorders) (86.6%); in contrast, tribunals did not revoke any involuntary admission orders for patients with bipolar disorder and revoked orders for 3.8% of patients with schizophrenia (and related disorders) (P=0.034). On the basis of multivariable testing, increased age among patients with bipolar disorder was the only characteristic among those studied (sex, age, marital status, occupation, involuntary admission criteria, length of stay, method of involuntary order revocation, location) that independently distinguished involuntary patients with bipolar disorder from those with schizophrenia (and related disorders) (P=0.028). Involuntary admission of patients with bipolar disorder is similar in most respects to that of patients with schizophrenia (and related disorders). Consequently, it is important that measures aimed at reducing the need for involuntary admission (eg, patient advance statements/advance directives) are implemented equally across all diagnostic groups associated with involuntary care.

How involuntary admission might have been avoided: An interview study of referring general practitioners

IntroductionThe legal criteria for involuntary admission in Norway are that the patient has a serious psychiatric disorder (i.e. psychosis) and is in need of admission to secure needed treatment or that there is a risk of danger. While there have been some studies focusing on coercion in hospitals, less is known about the processes leading up to involuntary admission and the reasoning of referring doctors. In Norway, it is primarily general practitioners (GPs) that refer patients.AimsTo study which factors that GPs who had recently referred patients to involuntary admission thought might have made their latest referral unnecessary.MethodsSeventy-four GPs were interviewed by phone. They had all recently referred patients involuntarily to a major Norwegian university psychiatric hospital. One central question concerned how their latest involuntary referral might have been avoided.ResultsThese are the main factors that the GPs thought could have been of importance in avoiding involuntary referral of their patients:– that the patient took the prescribed medication (28%);– that they personally had the opportunity to closely follow up the patient in the following days (22%);– that other health care staff could follow up the patient closely in the patient's own home (i.e. home care nursing, etc.) (19%);– that a family member of the patient could help the patient (8%).ConclusionsThe GPs suggested that an increased availability of resources and more assistance from other parts of the health service were some of the factors that could be of importance in reducing involuntary admissions.

Exploring and explaining involuntary care: The relationship between psychiatric admission status, gender and other demographic and clinical variables

Involuntary admission and treatment are features of psychiatric care in many countries, but the relationship between involuntary status and gender (among other factors) is not clear. We examined demographic and diagnostic factors associated with involuntary admission in a general adult psychiatry service in a deprived area of Dublin's north inner-city over a 7-year period (2008 to 2014 inclusive). Over this period, there were 1099 admissions, yielding an annual admission rate of 504.8 admissions per 100,000 population per year. When adjusted for deprivation, this rate (387.7) was lower than the national rate (413.9). Consistent with other inner-city areas in Dublin, 14.1% of admissions were involuntary, yielding an involuntary admission rate of 71.2 per 100,000 population per year (deprivation-adjusted rate: 54.8), which is higher than the national rate (39.4). After controlling for age, occupation, marital status and diagnosis, the only independent predictors of admission status were place of origin (p<0.001) and male gender (p=0.001). These findings are consistent with studies showing associations between male gender and involuntary status in the United States, New Zealand, Netherlands, Norway, Belgium, France, and Luxembourg. In contrast, female gender is associated with involuntary status in Switzerland, Brazil, and China. These cross-national differences are likely related to differing legal traditions and different criteria for involuntary admission, possibly related to varying emphases placed on “dangerousness” as a mandatory criterion for involuntary hospitalization. This merits further, cross-national study.

Clinically Significant Differences among Canadian Mental Health Acts: 2016.

Objectives:First, to highlight the major differences among mental health acts in different Canadian jurisdictions as they relate to involuntary admission criteria, treatment authorization, review and appeal procedures, and conditional leave and community treatment orders. Second, to analyze the impact of these differences on the care that individuals with mental illness receive.Method:We examined the mental health act provisions of all Canadian jurisdictions to determine how the clinical management of a typical case would differ among jurisdictions. We used a statement of principles for mental health legislation endorsed by the Canadian Psychiatric Association to guide the analysis. We confirmed interpretation of each act and its implementation through key informant contact in each province and territory.Results:We found clinically significant differences among the provinces and territories on all major components of their mental health acts.Conclusion:Provisions that prevent patients receiving appropriat...

Involuntary psychiatric admission: The referring general practitioners’ assessment of patients’ dangerousness and need for psychiatric hospital treatment

Background: In Norway, GPs may decide to refer patients to involuntary psychiatric treatment. Internationally, there has been a discussion regarding criteria for involuntary admission. In Norway and in other countries where the treatment criterion is still used, some have suggested its removal. Aims: To examine which legal criteria GPs used to refer patients to involuntary admission, whether they had thought about using a different criterion, and on which information they based their decision. Methods: A total of 74 doctors who had referred patients to involuntary admission at one major Norwegian psychiatric hospital participated in semi-structured interviews. Results: In total, 38% (28) had applied the danger criterion only and 23% (17) had applied the treatment criterion only; 32% (24) had applied both criteria, while 7% (5) did not answer this question; 74% (55) said that they could not have chosen a different criterion; 45% (33) had based their decision on events/behaviour prior to and during the consultation, 43% (32) on events prior to the consultation only, and 8% (6) on information obtained during the consultation only; 4% (3) did not answer this question. None had used tools to aid in the assessment of danger. Clinical implications: The danger criterion was frequently used by the referring GPs. It is unclear how a removal of the treatment criterion from Norwegian legislation might impact clinical practice. Conclusions: While the danger criterion was applied by a majority, the treatment criterion was also chosen by many and was of importance to the doctors’ reasoning regarding referrals to involuntary admission. Most thought they could not have chosen a different criterion.

Interpretations of legal criteria for involuntary psychiatric admission: a qualitative analysis

BackgroundThe use of involuntary admission in psychiatry may be necessary to enable treatment and prevent harm, yet remains controversial. Mental health laws in high-income countries typically permit coercive treatment of persons with mental disorders to restore health or prevent future harm. Criteria intended to regulate practice leave scope for discretion. The values and beliefs of staff may become a determinating factor for decisions. Previous research has only to a limited degree addressed how legal criteria for involuntary psychiatric admission are interpreted by clinical decision-makers. We examined clinicians’ interpretations of criteria for involuntary admission under the Norwegian Mental Health Care Act. This act applies a status approach, whereby involuntary admission can be used at the presence of mental disorder and need for treatment or perceived risk to the patient or others. Further, best interest assessments carry a large justificatory burden and open for a range of extra-legislative factors to be considered.MethodsDeductive thematic analysis was used. Three ideal types of attitudes-to-coercion were developed, denoted paternalistic, deliberative and interpretive. Semi-structured, in-depth interviews with 10 Norwegian clinicians with experience from admissions to psychiatric care were carried out. Data was fit into the preconceived analytical frame. We hypothesised that the data would mirror the recent shift from paternalism towards a more human rights focused approach in modern mental health care.ResultsThe paternalistic perspective was, however, clearly expressed in the data. Involuntary admission was considered to be in the patient’s best interest, and patients suffering from serious mental disorder were assumed to lack decision-making capacity. In addition to assessment of need, outcome effectiveness and risk of harm, extra-legislative factors such as patients’ functioning, experience, resistance, networks, and follow-up options were told to influence decisions. Variation in how these multiple factors were taken into consideration was found. Some of the participants’ statements could be attributed to the deliberative perspective, most of which concerned participants’ beliefs about an ideal decision-making situation.ConclusionsOur data suggest how a deliberative-oriented ideal of reasoning about legal criteria for involuntary admission lapses into paternalism in clinical decision-making. Supplementary professional guidelines should be developed.

Short-Term Hospitalization Underlies the Similarity between Involuntarily and Voluntarily Admitted Patients: A One-Year Cohort Study

ABSTRACTThis study compared individuals admitted to a psychiatric hospital under a civil involuntary commitment order (IA) and patients admitted voluntarily (VA) using a one-year, shortest-stay cohort. Data were collected for 439 patients consecutively admitted to a university-affiliated Mental Health Center from March 1, 2012, to February 28, 2013, and discharged within seven days (one-year, shortest-stay cohort). A cross-sectional comparison between IA (n = 106) and VA (n = 333) groups was conducted. Mean length-of-stay was found to be slightly longer (4.7 ± 1.7 days) for the IA group compared to the VA group (3.8 ± 1.9 days; p = 0.019). Both IA and VA groups were similar regarding age, gender, marital status, age of onset, illness duration, and diagnosis. An acute psychotic state as reason for admission was observed 3.4 times more (p < 0.001) for IA compared to VA, whereas suicidal thought (p = 0.002), major depressive episode (p < 0.001), and hallucinations (p = 0.014) were found less frequently among IA patients. About one quarter of the patients (26.6 percent) in the study cohort were discharged for lack of adequate reason to remain hospitalized. There were no significant differences between IA and VA inpatients. The shortest length of stay underlies the similarity between involuntarily and voluntarily admitted patients. The obtained data point toward the need for more accurate assessment of the criteria for involuntary admission.

China’s New Mental Health Law: Reframing Involuntary Treatment

China’s New Mental Health Law: Reframing Involuntary Treatment

Involuntary treatment in Europe

Involuntary treatment is burdened by the lack of evidence. One of the challenges is the difference in practice across borders in Europe. While reviewing the current literature, a proposal of monitoring guidelines is discussed. The field is characterized by a small number of dedicated researchers. A study of violence in first-episode psychosis shows that differences in criteria for involuntary admission lead to different prognosis for the patients. The most recent contributions from the cross-national EUNOMIA study point to great variation across countries, regarding frequencies of involuntary admission as well as outcome. The EUNOMIA study provides suggestions for good quality in involuntary admission. A Cochrane review has examined the evidence of involuntary community treatment compared with standard treatment. The effectiveness of involuntary community treatment is limited. The review concludes that the benefits for a small number of patients are outweighed by the high numbers needed to treat in terms of avoided re-admission. Despite pioneering work, involuntary treatment is still caught up in tradition. There is a lack of standard and proof of effectiveness. A proposal of monitoring guidelines for involuntary measures is a first step to improve the situation.

Mental health legislation needs to point to the future.

The forum article by Professor Xie[1] raises the broad issue of whether mental health legislation in China needs to respond to the existing realities of the community mental health services system. Given the lack of community mental health resources in China, the burden of caring for persons with mental illnesses has traditionally been borne by families and by psychiatric hospitals. As China introduces its first national mental health legislation the concern is that it is premature to introduce legislative changes that the current community mental health service system is ill-prepared to implement. Professor Xie suggests that the extent and direction of the change to current practices proposed in the mental health legislation could have a negative impact on access to much needed services because it raises the threshold for involuntary treatment too high and increases the opportunities for challenging the decision to admit and treat. In our view there are two issues which need to be considered separately – the criteria for involuntary admission and treatment, and who is authorized to decide whether or not the criteria are met.

ECP05-02 - Coercive measures and legal aspects

In detail two issues will be addressedThe analysis of standardized reports on the national legal situations on involuntary admission to psychiatric hospitals. This work revealed major cross-national differences, e.g. for basic conditions as well as for additional criteria for involuntary admission, time periods for making decisions, the association between involuntary placement and treatment, patients’ rights to register complaints, roles of relatives, and safeguard procedures of these processes.One of the clinical results (established by the assessment of 2326 legally involuntary patients) was that in the different countries, between 39% and 71% of the patients found the admission right after one month, and between 46% and 86% after three months. Female patients, those living alone and those with a diagnosis of schizophrenia had more negative views. Adjusting for confounding factors, differences between countries were significant. The presentation will outline that a potential explanation of these differences is the extent to which national mental health legislation protects the rights and interests of the patients concerned.Thus, the important, but complex link between coercive measures and legal aspects will be demonstrated. Further, the discussion section of this presentation will focus on legal issues which could be (cross-nationally) harmonized in the sensitive field of coercive treatment.

Book Review: Mental Health Law: Canadian Mental Health Law and Policy: Second Edition

Mental Health Law Canadian Mental Health Law and Policy: Second Edition John E Gray, Margaret A Shone, Peter F Liddle. Markham (ON): LexisNexis Canada Ine; 2008. 490 p. Can$ 165.00 Reviewer rating: Good This book is the second edition of a book that was highly regarded when first published in 2000. It is a comprehensive review and analysis of mental health legislation in Canada updated to reflect the many changes that have occurred in the intervening years. All the major issues in the framing of mental health legislation are discussed, and for the most part it is balanced and dispassionate, in an area that has been prone to much polarization and political wrangling. This book deals with all aspects of the law and mental disorder. It is comprehensive and scholarly, with copious references and appendices. The 3 authors are, respectively, a psychologist with experience in hospital management, a lawyer with long experience in mental health law, and a psychiatrist with forensic experience and much practical clinical knowledge. The first 4 chapters describe the current mental health legislation in Canada with its recent history and the psychiatric classification of mental disorders and their modern treatment - all primarily from a legal perspective. The next 5 chapters discuss issues that have been controversial in the past 5 decades, and that successive revisions to the legislation have tried to address. These include criteria and procedures for involuntary admission, psychiatric treatment authorization and refusal including consent and capacity, assisted community treatment, and rights and safeguards for patients, including those contained in the Charter of Rights and Freedoms. Chapter 1 0 discusses mandated services and attempts to develop Comprehensive Mental Health Legislation (CMHL) on a national level. Chapter 1 1 discusses mental disorder and the Criminal Code of Canada. Chapter 12 sums up the arguments made earlier and makes recommendations for a national approach to CMHL. They assert that there is at least some level of agreement about criteria for involuntary admission, rights, and safeguards for patients, and increasing recognition of the need for assertive community treatment. Areas of disagreement include the authorization of treatment in people who meet the criteria for involuntary admission but give competent refusal to all treatment. This is an issue that has remained very controversial and which different jurisdictions in Canada have handled differently. The civil libertarian view is that imposing treatment on an involuntary patient who does not or cannot give consent is an abuse of human rights. There have been several well-known court cases on this issue. Often the courts have decided in favour of authorizing treatment but sometimes they have not. In either case, the protracted process has meant that these people remain incarcerated for long periods without the treatment that would shorten their period of illness. …

Australian and Canadian Mental Health Acts Compared

The main objective of this paper is to compare the mental health Acts of the eight Australian jurisdictions and the 13 Canadian jurisdictions on three major issues: involuntary admission criteria, treatment authorization/consent and compulsory treatment in the community, in the light of international trends towards patients' rights. The legislation was examined against the background of rights instruments such as the Canadian Charter of Rights and Freedoms and the United Nations Convention on the Rights of Persons with Disabilities. It was found that some Canadian involuntary admission criteria require the likelihood of bodily harm whereas all Australian Acts have broad harm and deterioration criteria. Unlike all Australian jurisdictions, some Canadian jurisdictions allow for the refusal of treatment that may be required for discharge. In addition, Canadian community treatment orders are much more restrictive than in Australia because they require a person to have considerable previous hospitalization despite meeting the committal criteria. Australian jurisdictions can use community treatment orders as a least restrictive alternative to inpatient status without prior hospitalization. The paper concludes that there are significant philosophical differences regarding the purpose of involuntary admission between Australian and some Canadian jurisdictions where treatment refusal is possible. Australian mental health Acts have a relatively stronger 'treatment' focus than some Canadian Acts. The apparently stronger 'rights' focus of some Canadian laws (such as the permission of treatment refusal) can paradoxically result in a denial of liberty rights. The way in which the relevant legislation is shaped in both countries will increasingly be affected by international trends towards the rights of individuals with disabilities.

Mental Health Acts in Canada

There are 12 different Mental Health Acts (MHAs) in Canada, all of which provide for the involuntary confinement of the mentally disordered to protect both them from themselves and others from them. The Acts differ in many ways, but three issues stand out above all: (1) involuntary admission criteria, (2) the right to refuse treatment, and (3) who has the authority to authorize treatment. I first describe how the MHAs differ on these issues. I then take up the methodological question of how to select or construct a MHA from the many, all of which have something to be said for them. Finally, I apply this test to the three main issues in dispute and identify which solutions would be in an ideal MHA. My aim in this last is not to settle the issues but to engage with them and so deepen our understanding of what is at stake.