MB, Re

Factual and Procedural Background

This appeal originated from an application by a health authority seeking a High Court declaration that it would be lawful for a consultant gynaecologist to perform a caesarian section on a young woman, the Patient, who was 40 weeks pregnant and admitted to the hospital on 14th February. The initial declarations were granted by Judge Hollis on 18th February, following which the Patient appealed. The appeal was heard the same night and dismissed, with reasons reserved and later provided.

The Patient, approximately 23 years old and mother of one child, had a history of refusing blood samples due to needle phobia and missed several ante-natal appointments. The foetus was diagnosed with a footling breech presentation, a condition with a significant risk (estimated at 50%) of serious harm or death to the foetus if delivered vaginally. Medical advice recommended delivery by caesarian section, which the Patient initially consented to but repeatedly refused the necessary anaesthetic procedures involving needles due to her phobia.

Despite multiple attempts to proceed with the operation, the Patient's needle phobia led to cancellations of the procedure. The hospital sought urgent court intervention to authorize the operation and the use of reasonable force if necessary. Following the court's declarations, the Patient eventually consented and the operation was successfully performed, resulting in the birth of a healthy child.

Psychiatric evidence was provided by a consultant psychiatrist who assessed the Patient as understanding the need for the operation but found that her needle phobia caused temporary incapacity to consent at critical moments due to panic. The judge granted declarations authorizing the medical treatment, including the use of reasonable force, if necessary.

Legal Issues Presented

1. Whether the Patient lacked the capacity to consent to or refuse the proposed medical treatment due to needle phobia.
2. Whether the proposed caesarian section treatment was in the Patient's best interests.
3. Whether it was lawful to use reasonable force to administer medical treatment to a mentally incompetent patient.
4. Whether the court may take into account the interests of the unborn child when authorising medical intervention against the Patient's refusal.

Arguments of the Parties

Appellant's Arguments

• The judge erred in finding that the Patient lacked capacity to consent or refuse treatment.
• The judge failed to make an explicit finding on what constituted the Patient's best interests.
• The evidence did not establish that the proposed treatment was in the Patient's best interests.
• It is unlawful at common law to use force on a mentally incompetent patient to impose medical treatment.
• The cause of the Patient's disability (needle phobia) should be examined carefully to determine if it justifies removal of autonomy.
• There was sufficient time for a thorough investigation of the Patient's capacity prior to court intervention.

Respondent's Arguments

• The Patient was temporarily incapacitated by panic induced by needle phobia, preventing informed consent at critical moments.
• The caesarian section was in the Patient's best interests, given the significant risk of death or serious harm to the foetus and potential harm to the Patient.
• Reasonable force may be lawfully used to administer treatment when a patient lacks capacity and the treatment is in their best interests.
• The court does not have jurisdiction to consider the interests of the unborn child in balancing against the competent Patient's refusal.

Amicus Curiae's Role

• The Official Solicitor acted as Amicus Curiae, providing independent assistance to the court.

Table of Precedents Cited

Court's Reasoning and Analysis

The court began by affirming the fundamental legal principle that physically invasive medical treatment without consent constitutes assault unless exceptions apply, such as emergency treatment in the patient's best interests where capacity is lacking.

The court applied established tests for capacity, notably from Re T and Re C, focusing on whether the Patient could understand, retain, believe, and weigh the information relevant to the decision. The court acknowledged that capacity is decision-specific and commensurate with the gravity of the decision.

Evidence showed that while the Patient initially consented to the caesarian section, her needle phobia caused panic and temporary incapacity at critical moments, rendering her unable to make a rational decision regarding anaesthesia involving needles. This temporary impairment of mental functioning justified the court's finding that she lacked capacity at those moments.

The court found that the proposed treatment was in the Patient's best interests, supported by psychiatric evidence indicating significant risk of long-term harm if the operation was not performed and minimal risk of lasting harm from the procedure. The court emphasized that best interests encompass more than medical considerations, including the Patient's expressed wishes and circumstances.

Regarding the use of reasonable force, the court held that if a patient lacks capacity and treatment is in their best interests, reasonable force may be lawfully used to administer treatment. The extent of force must be judged case-by-case by medical professionals.

The court rejected the argument that it could balance the interests of the unborn child against the competent Patient's refusal. It reaffirmed that English law does not recognize the foetus as having separate legal rights prior to birth and that the Patient's autonomy cannot be overridden on that basis.

The court reviewed relevant statutory provisions and international human rights jurisprudence, concluding that the current state of English law prioritizes the competent patient's autonomy and does not grant the foetus independent rights to justify intervention.

Finally, the court provided procedural guidance emphasizing early identification of capacity issues, representation of the Patient, involvement of the Official Solicitor, and the desirability of inter partes hearings with psychiatric evidence where possible.

Holding and Implications

The appeal was dismissed.

The court held that the Patient temporarily lacked the capacity to consent to or refuse medical treatment due to needle phobia-induced panic, justifying the lawfulness of the caesarian section and related medical interventions without her valid consent at critical moments. The use of reasonable force to administer treatment was lawful in these circumstances.

The court confirmed that a competent adult has an absolute right to refuse medical treatment for any reason, and the interests of the unborn child cannot be taken into account to override this autonomy. This decision reinforces the principle of patient autonomy and clarifies the limited circumstances under which courts may authorize treatment without consent.

No new precedent was established beyond affirming and applying existing legal principles. The direct effect is to uphold the lawfulness of court-ordered medical intervention where a patient lacks capacity temporarily due to phobia-induced panic, and to reject legal recognition of foetal rights to override competent maternal decisions.