We are delighted to announce the details of a fascinating workshop taking place on 29-30 August 2022 in Molyvos, Greece. This international workshop aims to explore the relationship between freedom and proportionality, bringing together human rights law doctrine and philosophical theorising.
It will do so by pursuing two main themes:
Is there a morally valuable – albeit overridable – freedom to engage in potentially harmful behaviour or should the concept of freedom be inherently limited by the reasonable interests of others?
Is the proportionality test, as applied in human rights law, committed to a particular philosophical conception of freedom? If so, is that conception morally justified?
Underlying these abstract questions are urgent issues of practice about the balance between the individual and society, the correct interpretation and application of rights, and the role of courts and other state institutions in their protection. For example, the relationship between freedom and proportionality is at the heart of controversies over the lawfulness of government measures aiming to tackle the COVID-19 pandemic such as restrictions of movement and economic activity and compulsory vaccinations.
The issue is typically framed in terms of the proportionality between the public benefit of these measures and the intensity of the interference with human rights. However, for many scholars, this framing is deeply problematic. It assumes that such restrictions amount to losses of valuable rights, which must be offset by an overriding public benefit. But, so the argument goes, we do not have even a prima facie right to be a public threat e.g. by carrying a contagious virus. To think otherwise is to assume a highly individualistic and antisocial notion of personal freedom. And yet arguably this assumption underpins the proportionality doctrine, inasmuch as claimants must clear a relatively easy hurdle to establish that a restriction amounts to a prima facie interference with their human rights. As a result, almost any activity or personal preference, however harmful, triggers a proportionality assessment.
By ensuring that proportionality best reflects moral notions of freedom, we vindicate it and guide its use towards the optimal results. The workshop has this dual aim, to elucidate legal doctrine through sustained theoretical scrutiny and improve it, so that it can successfully address contemporary challenges in human rights law.
The workshop is hybrid. Most of the speakers will meet in Molyvos (Greece), the hometown of Stavros Tsakyrakis, who spearheaded the aforementioned line of attack against proportionality. But the proceedings will also be accessible via a Zoom webinar that is open to everyone. The workshop’s programme and registration details can be found below:
Fundamental disagreements between healthcare professionals and family members about the life and death of loved ones are, thankfully, relatively rare. It is even rarer for those disagreements to be resolved through the courts. The Archie Battersbee case has, however, brought this issue to the fore in recent weeks. For his family, their fight on his behalf was played out on the media stage at every turn. It ended in the 12-year-old boy’s death in hospital on 6 August 2022, a devastating outcome for his family. This followed several hearings culminating in an appeal to move him to a hospice being refused by the courts.
Others have already commented on the legal issues arising from that case, centring mainly on the best interests of the child. While we are sympathetic to the view previously put forward by others such as Dominic Wilkinson, and Cressida Auckland and Imogen Goold, of an alternative to the use of the best interests test in cases like these, for example the use of a significant harm threshold, that substantive legal discussion is not the aim of this piece.
Instead, our aim here is to consider whether, when these disputes do arise, there might be better ways to resolve them than going through the courts. For many, the court process is expensive, time-consuming, adversarial and, psychologically and physically exhausting. It is also uncertain, because the parties on both sides of the conflict must await an outcome determined by a third party, the court.
As a result, it has been suggested that mediation might be a better way of approaching these issues when they first arise, not least by Mr Justice Francis in the Charlie Gard case, who remarked that the case was calling out for mediation:
‘I recognise, of course, that negotiating issues such as the life or death of a child seems impossible and often will be. However, it is my clear view that mediation should be attempted in all cases such as this one even if all that it does is achieve a greater understanding by the parties of each other’s positions‘.
Para. 20
Yet despite increasing emphasis on mediation in other broadly similar areas, including family law and clinical negligence, there is limited evidence about its use in medical treatment cases. Furthermore, in medical treatment disputes the aims of the mediation might not be, as they are often in these other areas, settlement rates and cost savings; mediation may require a different approach that instead prioritises the experiences of participants and the potential for a therapeutic outcome.
The use of mediation to resolve medical treatment disputes is the focus of a research project led by Dr. Jaime Lindsey with consultancy from Margaret Doyle and Sarah Barclay, funded by an ESRC New Investigator Grant. This research will consider whether there are any therapeutic, or healing, benefits of using mediation to resolve disputes that arise from health and care contexts, as well as considering the ways in which mediation could become more therapeutic as an intervention.
The research seeks to test, empirically, the various claims about mediation through qualitative analysis of mediation in medical treatment disputes, covering cases involving children (similar to those involving Charlie Gard and Archie Battersbee, for example) and cases involving adults under the Mental Capacity Act 2005 (similar to cases such as that of Aintree v James as well as wider health and care decisions). How best to resolve these disputes was also the topic of a project led by the Nuffield Council on Bioethics – Disagreements in the Care of Critically Ill Children – and is being looked at by the UK government, which in the Health and Social Care Act 2022 committed to undertaking a review into how to resolve disagreements in the care of critically ill children and to report within one year.
What is Mediation and Why Might it Help?
Mediation is one type of ‘alternative dispute resolution’ (‘ADR’), which is generally seen as more informal and flexible than court proceedings and has several perceived benefits for those who take part. For example, it can improve communication between parties, enable individuals to feel heard as participants and increase the speed of resolution. It also tends to be less costly than court proceedings and can take place in parallel, meaning that no delay is needed should those involved not reach agreement at mediation. However, cases involving medical treatment disputes, especially involving children, are highly emotive, often involve life and death issues and have evident power imbalances between family members and healthcare professionals, meaning that mediation is not always seen as appropriate. Furthermore, for mediation to work, all parties must voluntarily agree to its use, which is not always possible.
Despite the drawbacks, mediation might help family members come to terms with the issues at the heart of the dispute and help healthcare professionals fully understand family members’ perspectives. The realisation as a parent that you are not legally the final decision maker for your own child can be shocking and lead to a feeling of powerlessness in the interactions with healthcare professionals. It can take time and careful discussion to digest the realities when faced with your seriously unwell or dying child.
Conversely, healthcare professionals may benefit from hearing directly from the family, in a neutral venue, over a period of time, away from the realities of the hospital ward. For both parties, then, mediation might provide an opportunity to hear from and be heard, in a way that is not possible in the ordinary course of the provision of healthcare.
Yet mediation is not a cure-all to the difficulties that arise in these disputes, and it should not be discussed as such. Nor should it be seen as a route to compromise, something neither party in medical treatment disputes could countenance when issues of life and death are at stake.
In such contexts, the ‘stereotypical image of a mediated settlement model, often characterised in terms of a confidential carve-up borne of an unseemly horse-trade, need not apply. Mediation is a flexible tool, in which the ground rules and outcomes can be dictated by the nature of the dispute and the priorities of the parties.’[1] Unlike in clinical negligence disputes, the remedy sought in medical treatment cases is not a financial settlement, requiring a different ‘sensibility’ of mediation than that commonly used in civil and commercial claims.
One of the concerns, raised by Supperstone et al and other public lawyers, is the confidentiality of mediation when used in disputes with a wider public interest. It is important to draw a distinction between the confidentiality of the mediation discussion and the confidentiality of any agreed outcome. The former is the default position for most mediations, to allow for frank and honest exchange between the parties. The latter, however, is for the parties to agree, and in mediations involving a wider public interest, the parties can agree on a shared public statement on the mediation outcome.
Mediation in medical treatment disputes should be seen as providing a much-needed neutral space for careful discussion between parents and family members and the healthcare professionals, mediated by an independent and highly skilled facilitator. Working with the parties, the mediator tailors all aspects of the mediation process to the needs of all those involved and ensures each voice is heard. Getting the appropriate people to the mediation is important so that questions can be answered, interests explored and, where appropriate, consensual agreements reached on ways forward.
Mediations are often highly emotive meetings, and no more so than in this context. Crucially, any outcomes are ones the parties themselves have decided on, and in that way they are active participants reaching collective decisions. Where the parties in dispute must maintain an ongoing working relationship, this can be invaluable.
What’s the Evidence?
Despite the perceived benefits of mediation and the wide-ranging evidence from other fields, there is currently only limited evidence about its use to resolve medical treatment disputes. There is some evidence about mediation’s use in the linked areas of resolving paediatric conflict, adult care mediation and an interview study with participants in mental capacity law mediations, see Reimagining the Court of Protection: Access to Justice in Mental Capacity Law. Otherwise, the data on mediation’s use is incomplete.
As part of our current research on medical treatment mediation, we will be conducting direct observations of mediations, as well as interviewing and surveying mediation participants. Our research will provide much-needed evidence as to whether mediation does provide a more therapeutic way of resolving medical treatment disputes, and if so, in what ways.
What Next?
The discussion about how best to resolve disputes between healthcare professionals and families will no doubt continue, with some advocating for greater parental rights and others maintaining that the current law is well suited to resolving these matters. What is clear, however, is that the legal process can reinforce disagreement and entrench positions.
Perhaps a different way of approaching healthcare conflict is required – one which values giving all parties the time and space to engage in early communication and to seek agreement on their own terms, with a neutral third party guiding them.
Yet the risks in using mediation are numerous: it is relatively empirically untested as a way of resolving these cases specifically (although the evidence is strong in other fields); it may lead to the interests of one of the parties being prioritised over the other’s; it may cause delay and lead to prolonged suffering for the patient; it may be felt by families that mediation is used merely to persuade them into agreement with the healthcare professionals; it may fail to prioritise the voice of the patient herself.
Using mediation to resolve these cases will not be a panacea. However, its potential is worth considering, and we aim to shine a light on it as a tool for helping to resolve these difficult cases in a more therapeutic way.
If you would like to know more about our research project looking at the use of mediation in medical treatment disputes, please contact Dr Jaime Lindsey, the Principal Investigator, at j.t.lindsey@essex.ac.uk.
[1] M. Supperstone, D. Stilitz and C. Sheldon, ‘ADR and Public Law’, (2006) Public Law Summer, 299-319, p. 313.
Legal aid, as we know it today, is a relatively recent institutional development, but the concept is old. From the Court of Requests in Tudor and early Stuart times to the pro bono advice offered by the Poor Man’s Lawyers Movement, the idea that everyone is entitled to some form of legal advice and support has been present in the United Kingdom for a long time.
However, legal aid as charity did little to help those unable to pay for legal counsel (it was, after all, mostly restricted to pre-trial advice) or to level the legal playing field, as the courts continued to be part of the modus vivendi of the aristocracy. Due to strong opposition to the idea that everyone should be entitled to legal aid (mainly for fear of encouraging people to be litigious), some of the first formal policies were, perhaps inevitably, heavily moralized. For example, the Poor Prisoners Defence Act 1903 included provisions for legal aid for prisoners who had a defence.
The end of World War II led to the foundation of legal aid roughly as we know it today. Since then, several reforms have attempted to manage both the volume and the cost of legal aid, with the post-1986 cuts being the first concentrated effort to reduce the budget. In April 2013, the Legal Aid, Sentencing and Punishment of Offenders Act 2012 (LASPO) introduced further cuts, which heavily affected several areas of litigation and excluded most private family law cases from the scope of legal aid.
LASPO and the Right to Legal Aid
LASPO’s explicit goal was to save money and family law was one of its main targets. While public law proceedings and the representation of children generally remained in scope, private family law was the reform’s main ‘victim’. Most private family law cases, including procedures as common and stressful as divorce and child contact, became ineligible for legal aid. Cases involving children or finance remain in scope only where there are issues concerning domestic violence or child abuse and specific evidence is provided (the evidence-related requirements relaxed in 2018). The Ministry of Justice expected that this new policy would also discourage litigation on private family problems, which could be resolved out of court. Apparently, the idea that people become unreasonably or excessively litigious if legal support is readily available still survives.
One possible concern with this blanket approach is that the exclusion of entire areas of law seems arbitrary and irreconcilable with the very raison d’ être of legal aid. Even where alternative means of dispute resolution (such as mediation) are available, some of these cases may inevitably end up in court. Furthermore, mediation itself requires legal support and, as we will see, there is evidence that people need to be advised by a lawyer that it is an available option. The problem, therefore, with the removal of almost the entire area of private family law from civil legal aid is that this policy choice may restrict access to justice for many people, without consideration for their needs and circumstances.
The idea that access to civil legal aid is inherently linked with effective access to justice is part of the European legal tradition. Article 47 of the European Charter of Fundamental Rights 2000 illustrates the point: ‘Legal aid shall be made available to those who lack sufficient resources in so far as such aid is necessary to ensure effective access to justice.’ However, there is no universal or unconditional right to legal aid, especially with regard to civil law cases. While efficient access to justice remains important for the European Court of Human Rights (‘the Court’), it has been ruled that Article 6 § 1 does not imply that the State must provide free legal aid for every dispute relating to a ‘civil right’ (Airey v. Ireland, § 26). The crucial question is whether the lack of legal aid would deprive the applicant of a fair hearing and the answer depends on the specific circumstances of the case (Airey v. Ireland, § 26; Steel and Morris v. the United Kingdom, § 61; McVicar v. the United Kingdom, § 48).
The Court has identified a set of criteria for assessing the states’ obligation to make legal aid available in non-criminal proceedings. These are: the importance of what is at stake for the applicant (Steel and Morris v. the United Kingdom, § 61; P., C. and S. v. the United Kingdom, § 100); the complexity of the relevant law or procedure (Airey v. Ireland, § 24); the applicant’s capacity to represent him/herself effectively (McVicar v. the United Kingdom, §§ 48-62; Steel and Morris v. the United Kingdom, § 61); and the existence of a statutory requirement to have legal representation (Airey v. Ireland, § 26; Gnahoré v. France, § 41). Two further criteria have emerged in the Court’s case law regarding the conditions attached to legal aid: the financial situation of the litigant; and the prospects of success in the proceedings (Steel and Morris v. the United Kingdom, § 62).
LASPO and Access to Justice: the Project’s Findings
The question that naturally emerges from these general remarks is whether LASPO was successful in saving money without ignoring the above criteria and restricting access to justice for many people who require legal aid to effectively exercise this right. In a research project funded by the British Academy, Theodoros Alysandratos, Mariol Jonuzaj and I looked at the effect of LASPO on family law cases, hoping to shed some light on these issues.
First, we find that legal aid funding started to drop in the first financial quarter of 2014 and kept on falling for the next two years. At the end of this period, funding had dropped by 35% relative to the amount approved before the fall started.
Legal Aid by Financial Year and Financial Quarter. The image illustrates the percentage change on a year-to-year basis (from the project’s findings)
Then, we observe that the number of funded cases started to drop in the first financial quarter of 2012 and continued for 3 years. At the end of this period about 60-65% fewer cases were being funded. The discrepancy in the timing of the effects between funding and funded cases can likely be attributed to the disbursement of commitments prior to LASPO coming into effect.
Volume by Financial Year and Financial Quarter. The image illustrates the percentage change on a year-to-year basis (from the project’s findings)
In terms of saving money, the case of private family law reveals that the LASPO had an immediate effect. Whether this effect was sustained in the years that followed remains to be seen. The same applies to the number of cases that received legal aid, since it also dropped significantly in the years immediately following LASPO. This means that, at least for a certain period of time, a considerable number of people was denied access to legal aid for private family law cases (with the exceptions noted in the introductory paragraph), regardless of their financial situation and/or ability to secure some kind of legal advice, let alone representation.
Did this lead to an increase in the number of cases going to mediation or the number of Mediation Information and Assessment Meetings (MIAMs)? According to the post-legislative memorandum released by the Ministry of Justice in 2017, this was certainly not the case, presumably because it is only after receiving legal advice that most people see mediation as an option. In fact, before LASPO came into force, 4 out of 5 cases that ended up in MIAMs were referrals from legally aided solicitors. To make things worse, the Legal Aid Agency reported in 2017 that only 61% of completed mediations were successful (slightly down from the 68% reported for 2013-2014).
This evidence suggests that, as far as legal aid is concerned, many people in England and Wales are experiencing a return to a pre-World War II world. Their chances of securing free legal advice and representation are very slim, as their only avenue is to contact organisations with already limited resources, such as Citizens Advice and Family First. University Law Clinics also shoulder some of the burden, but they cannot offer legal representation. In a sense, civil legal aid is to an extent seen, once again after almost a century, as a form of charity.
However, as lawyers realised at the time, charity is not enough to ensure effective access to justice for all. As one of the founders of the Poor Man’s Lawyers Movement observed more than 120 years ago, extensive lack of free access to legal advice and representation for those who most need them makes the rule of law ‘an anaemic attenuated make-believe which we flash in the eyes of the poor as justice’.
Essex Law Research Blog 