Factual and Procedural Background
This case concerns an individual ("C") who, following an attempted suicide by paracetamol overdose, suffered severe liver and kidney injuries requiring renal dialysis, a life-saving treatment. C refuses to consent to further dialysis, supported by her family, particularly her two elder daughters. The treating clinicians, represented by a hospital trust ("the Trust"), applied to the court under the Mental Capacity Act 2005 for declarations that C lacks capacity to make medical decisions regarding dialysis and for authority to administer treatment, including restraint if necessary.
The court heard evidence from multiple psychiatrists, medical experts, C's family, and the Official Solicitor. After a detailed hearing, the court determined that C has capacity to decide whether to accept dialysis and dismissed the Trust's application. A reporting restriction protects C's identity and details of the medical professionals involved.
Legal Issues Presented
- Does C have the mental capacity to decide whether or not to consent to life-saving renal dialysis treatment?
- If C lacks capacity, whether the Trust is authorised under the Mental Capacity Act 2005 to provide treatment and take necessary measures to enforce it.
Arguments of the Parties
Trust's Arguments
- C lacks capacity under section 3(1)(c) of the Mental Capacity Act 2005 because she is unable to use and weigh relevant information about her prognosis and treatment.
- C demonstrates an inability to believe in or contemplate a future including recovery, influenced by a diagnosed personality disorder.
- The refusal to accept dialysis is not a capacitous decision but the product of impaired cognition and rigid, black-and-white thinking.
- The Trust relies on expert psychiatric opinions diagnosing histrionic and narcissistic personality disorders causing this incapacity.
Official Solicitor's Arguments
- C does have capacity to refuse treatment, having considered and weighed her prognosis and chosen to give it no weight based on her values and beliefs.
- The apparent rigidity in C's thinking reflects a reasoned decision within her personal outlook, not incapacity.
- The Trust cannot establish a causal link between any inability to use and weigh information and a personality disorder, as the inability may stem from C's belief system or character.
Family's Arguments
- C's daughters agree that C has capacity to make the decision to refuse dialysis.
- C has made a clear, reasoned decision consistent with her long-held values prioritising appearance, lifestyle, and autonomy.
- The Trust applies too high a standard of capacity, demanding a "balanced, nuanced" weighing of prognosis that is not required by law.
- The inability to use and weigh information, if found, is not causally linked to a personality disorder but rather to C's belief system and character.
Table of Precedents Cited
| Precedent |
Rule or Principle Cited For |
Application by the Court |
| Re T (Adult: Refusal of Treatment) [1993] Fam 95 |
Established absolute right of capacitous adult to refuse medical treatment, even life-saving. |
Supported the principle that C, if capacitous, has the right to refuse dialysis despite fatal consequences. |
| PH v A Local Authority [2011] EWHC 1704 (COP) |
Set out the burden and standard of proof for lack of capacity; importance of objective assessment of capacity. |
Guided the court in assessing all evidence and applying the balance of probabilities standard. |
| KK v STC and Others [2012] EWHC 2136 (COP) |
Confirmed burden of proof and approach to capacity assessments. |
Reinforced the court's approach to the burden and standard of proof. |
| PC v City of York Council [2014] 2 WLR 1 |
Capacity is decision-specific and assessed at the time the decision is needed. |
Supported assessing C's capacity specifically regarding dialysis consent. |
| Heart of England NHS Foundation Trust v JB [2014] EWHC 342 (COP) |
Warned against equating unwise decisions with incapacity; the decision's outcome is irrelevant to capacity. |
Informed the court that C's refusal, though unwise, does not imply incapacity. |
| R v Cooper [2009] 1 WLR 1786 |
Outcome of decision is irrelevant to capacity assessment. |
Supported the principle that refusal of life-saving treatment does not alone indicate incapacity. |
| York City Council v C [2014] 2 WLR 1 |
Clarified the relationship between diagnostic and functional tests for capacity under the Mental Capacity Act 2005. |
Guided the court in applying the diagnostic and functional tests in correct sequence. |
| PCT v P, AH and The Local Authority [2009] COPLR Con Vol 956 |
Defined "use and weigh" as the capacity to engage in the decision-making process and relate parts of the argument. |
Used to evaluate whether C could use and weigh information relevant to dialysis decision. |
| CC v KK and STCC [2012] EWHC 2136 (COP) |
Capacity to use and weigh information need only apply to salient factors, not every detail. |
Supported the court's finding that C may weigh some information but not all and still have capacity. |
| Re SB (A Patient: Capacity to Consent to Termination) [2013] EWHC 1417 (COP) |
Capacity decision is a judgment for the court; expert evidence is important but not determinative. |
Informed the court's approach to weighing expert psychiatric opinions versus other evidence. |
| Oldham MBC v GW and PW [2007] EWHC 136 (Fam) |
Recognised potential lack of objectivity in professional assessments due to protective instincts. |
Highlighted need for detached and objective capacity assessment in vulnerable adults. |
Court's Reasoning and Analysis
The court applied the Mental Capacity Act 2005, focusing on the 'functional test' under section 3(1) and the 'diagnostic test' under section 2(1). The Trust conceded that C could understand, retain, and communicate information but argued she could not use and weigh relevant information due to a personality disorder impairing her mind.
The court carefully examined the evidence, including psychiatric reports, medical records, family statements, and the Official Solicitor's observations. It noted that while two psychiatrists found incapacity based on inability to use and weigh information, an independent psychiatrist and other evidence suggested C had capacity.
The court found that C had repeatedly acknowledged her prognosis, including the life-saving nature of dialysis and the risk of death without it. Although C often rejected or gave no weight to this prognosis, the court concluded this reflected a reasoned decision consistent with her personal values rather than an inability to use and weigh information.
The court emphasized that making an unwise decision, including refusing life-saving treatment, does not equate to incapacity. It rejected the Trust’s argument that C’s decision was the product of impaired cognition due to a personality disorder, noting the evidence was inconclusive and that the inability to use and weigh information could equally be attributed to C’s belief system or character.
Given the balance of probabilities standard, the court determined that the Trust failed to prove C lacked capacity. It also noted the importance of considering the entire evidential context, including medical records showing C's understanding and weighing of information, and the absence of uniformly positive prognosis information, which contextualized C’s responses.
Holding and Implications
The court's final decision is DISMISSED of the Trust's application for declarations that C lacks capacity and for authority to administer treatment without consent.
As a result, C retains the legal right to refuse life-saving dialysis treatment despite the fatal consequences. The court recognized the gravity of this decision but reaffirmed the principle that a capacitous adult has sovereignty over their own body and mind, including the right to refuse treatment.
The judgment does not set new legal precedent but reinforces established principles regarding capacity assessments and respect for personal autonomy in medical treatment decisions. The treating medical team remains entitled to continue to engage with C and offer treatment, but cannot override her capacitous refusal.