Re E (Medical treatment: Anorexia)

Factual and Procedural Background

A 32-year-old woman ("Plaintiff") suffers from extremely severe anorexia nervosa alongside other chronic health conditions. Her local authority applied urgently to the Court of Protection due to concerns about her imminent death caused by refusal to eat and minimal water intake. She was under palliative care in a community hospital aimed at providing comfort until death. A hearing was held with representation from the Official Solicitor, the Plaintiff's parents, the local authority, and the health authority. The court found that the Plaintiff lacked capacity to decide on life-sustaining treatment and ruled it was in her best interests to be forcibly fed despite her wishes. This decision followed extensive medical, familial, and legal consideration of her history, capacity, and treatment options.

Legal Issues Presented

1. Does the Plaintiff currently have the mental capacity to make decisions about her treatment?
2. If not, did she have capacity when making an advance decision in October 2011, and is that decision valid and applicable?
3. If the Plaintiff lacks capacity and has no valid advance decision, is it in her best interests to receive life-sustaining treatment through forcible feeding with associated measures?

Arguments of the Parties

Plaintiff's Parents' Arguments

• They are sceptical about further treatment success and do not want the Plaintiff to die but believe her wishes should be respected if treatment is unlikely to help.
• They emphasize the poor quality of life the Plaintiff has endured and question whether forced feeding would be appreciated in the long term.
• They advocate for the Plaintiff’s right to choose her own pathway, free from restraint and fear of enforced feeding, focusing on dignity and quality over quantity of life.
• They would support further intervention only if appropriate, long-term treatment for both anorexia and alcoholism with adequate funding and support were available.

Medical Staff and Health Authority Arguments

• Medical consultants expressed doubt about the benefits of further coercive treatment but acknowledged the difficulty and offered to support the court's decision.
• The health authority adopted a neutral stance, willing to fund treatment deemed in the Plaintiff’s best interests.

Official Solicitor's Arguments

• Initially, the expert advised against forcible feeding, but after reviewing records, recommended treatment as potentially beneficial and in the Plaintiff's best interests.
• Sought a court declaration that forcible feeding is in the Plaintiff’s best interests.

Local Authority's Arguments

• Initially neutral but ultimately supported the expert’s recommendation for forcible feeding.
• Did not call evidence but supported the treatment proposal.

Table of Precedents Cited

Court's Reasoning and Analysis

The court applied the Mental Capacity Act 2005 (MCA) framework, beginning with the presumption of capacity unless proven otherwise. It found that the Plaintiff lacks capacity due to her anorexia nervosa impairing her ability to weigh information relevant to treatment decisions, compounded by sedative medication and physical frailty. The court examined the validity of the Plaintiff’s advance decisions and concluded she lacked capacity at the time of signing the formal advance decision, rendering it invalid.

The court considered the best interests test under MCA s.4, balancing the Plaintiff's right to life against her personal autonomy and wishes. It acknowledged the Plaintiff’s clear and consistent refusal to eat, her complex medical and psychological condition, and the risks and burdens of forcible feeding. The court also considered the possibility of recovery and improved quality of life through treatment at a specialist hospital, noting the availability of resources and the potential for a 20-30% chance of recovery.

Respect for the Plaintiff’s autonomy was weighed against the fundamental right to life protected by Article 2 of the European Convention on Human Rights. The court found the forcible feeding would interfere with Articles 3 and 8 rights but that this interference was proportionate and necessary to protect life. The court emphasized the need for a realistic, individualized assessment informed by medical evidence and the Plaintiff’s circumstances, rejecting a mechanistic approach.

Ultimately, the court found the balance tipped in favor of life-preserving treatment, given the possibility of recovery and the absence of futility in treatment, despite the burdens and risks involved.

Holding and Implications

The court declared that the Plaintiff lacks capacity to make decisions about life-sustaining treatment and that it is lawful and in her best interests to be fed forcibly if necessary. The court held that the interference with her rights under Articles 3 and 8 ECHR is justified as proportionate and necessary to protect her right to life under Article 2.

The decision requires the provision of appropriate resources and treatment, including forcible feeding under medical supervision at a specialist hospital, with the expectation that this may improve her condition and possibly restore capacity. The ruling does not create new legal precedent but applies existing principles in a highly complex and individualized context. It underscores the court’s role in balancing autonomy and preservation of life in cases involving severe mental incapacity and life-sustaining treatment decisions.