Hemachandran & Anor v Thirumalesh & Anor

Factual and Procedural Background

The case concerns a 19-year-old young woman ("the Patient") born with a rare mitochondrial disorder known as Mitochondrial Depletion Syndrome RRM2B ("RRM2B"), a chronic degenerative disease with no known cure. She was admitted to intensive care following respiratory arrest caused by pneumonia and Covid-19. Over time, her condition deteriorated, leading the treating clinicians at Company A ("the Trust") to recommend a palliative care plan and withdrawal of life-sustaining treatment.

On 20 July 2023, the Trust applied to the Court of Protection for approval of a palliative care plan and withdrawal of life-sustaining treatment. The late Judge Roberts made a declaration on 7 August 2023 that the Patient lacked capacity to consent to or refuse medical treatment, including palliative care. A best interests hearing was scheduled but never took place because the Patient died 35 days later.

The Patient's parents appealed the declaration of incapacity after her death. Permission to appeal was granted, and the mental health charity MIND was permitted to intervene. The appeal challenged the finding that the Patient lacked capacity to make decisions about her medical treatment, particularly her wish to pursue experimental nucleoside therapy abroad and to "die trying to live."

Legal Issues Presented

1. Whether the Patient had capacity to make decisions regarding her medical treatment, including the choice to pursue experimental nucleoside therapy and refuse palliative care.
2. Whether the Patient’s inability or refusal to believe medical prognoses constituted a lack of capacity under the Mental Capacity Act 2005 (MCA), specifically under the functional and diagnostic tests.
3. The role and necessity of "belief" in the functional test for capacity under section 3(1) MCA.
4. Whether the judge erred by rejecting unanimous expert psychiatric evidence that the Patient had capacity.
5. Whether the judge’s approach complied with statutory principles and relevant case law regarding capacity assessments.

Arguments of the Parties

Appellant's Arguments (Parents)

• The judge erred in departing from unanimous psychiatric expert opinions that the Patient had capacity without adequate reasons.
• The judge wrongly treated non-expert clinical witness opinions as equivalent to expert opinions.
• The judge’s approach to the diagnostic test misapplied the requirement for a professional diagnosis of mental impairment.
• The judge improperly relied on disputed evidence about prognosis and treatment options outside the scope of the hearing.
• The judge erred in placing the functional test before the diagnostic test contrary to the MCA Code of Practice.
• The judge wrongly held that a lack of belief in medical prognosis equates to lack of capacity, despite the existence of a rational basis for that disbelief.

Respondent's Arguments (The Trust)

• The Patient lacked capacity because she did not "believe" or accept as true the objectively verifiable medical information relevant to her treatment decisions.
• This failure of belief rendered her unable to understand, use, or weigh the information as required under the functional test of capacity.
• The Patient’s refusal to accept the prognosis was delusional and therefore met the diagnostic test of impairment of mind.
• The judge’s reliance on the first psychiatric report was justified despite the later revised opinion.

Official Solicitor and MIND's Arguments

• Neither belief nor disbelief is determinative; a person may lack capacity if they do not believe relevant information but may also retain capacity despite disbelief.
• The statutory language of the MCA is complete and does not require an added gloss of "belief" as a separate element.
• The Patient’s decisions were consistent with autonomy and the presumption of capacity.

Table of Precedents Cited

Court's Reasoning and Analysis

The court analysed the capacity assessment under the two-stage test prescribed by the Mental Capacity Act 2005: first, the functional test under section 3(1) MCA, and second, the diagnostic test under section 2(1) MCA. The functional test requires a person to understand, retain, use or weigh relevant information, and communicate their decision. The diagnostic test requires that any inability to make a decision be caused by an impairment or disturbance of the mind or brain.

The Trust argued that the Patient's failure to believe the medical prognosis — specifically, her refusal to accept that she was dying and that experimental nucleoside therapy was unlikely to benefit her — meant she failed the functional test. The judge agreed, holding that belief was a necessary component of understanding under the functional test. This view was primarily based on pre-MCA case law and Munby J’s approach in Local Authority X v MM.

However, the appellate court found that the judge erred in treating the absence of belief as determinative of incapacity under the functional test. The court emphasised that the statutory language of the MCA does not require a separate element of belief; rather, lack of belief may be relevant but does not inevitably result in incapacity. The court preferred the approach in Re MB, which allows for a nuanced assessment where lack of belief may or may not amount to incapacity depending on the facts.

The court further held that the judge gave insufficient reasons for rejecting the unanimous expert psychiatric opinions (Dr Bagchi and Dr Mynors-Wallis) and the Official Solicitor’s endorsement that the Patient had capacity. The judge had relied on the first psychiatric report of Dr Mynors-Wallis, prepared without direct assessment of the Patient, while disregarding his second report after such assessment, which concluded the Patient had capacity.

The appellate court noted that the Patient was a fully conscious 19-year-old without mental illness or brain damage, communicating clearly and consistently expressing her wishes. The experts agreed she was making a capacitous, though unwise, decision. The court underscored the statutory presumption of capacity and the principle of autonomy, which requires significant justification before overriding a person’s expressed wishes.

Other grounds of appeal concerning the requirement for a professional diagnosis, the scope of evidence admitted, and the order of applying functional and diagnostic tests were dismissed, with the court affirming the primacy of statutory wording and Supreme Court authority in JB.

Holding and Implications

The appeal was ALLOWED on Grounds 1, 2, and 6, and DISMISSED on Grounds 3, 4, and 5.

The court set aside the declaration that the Patient lacked capacity to make decisions about her medical treatment. As a result, the statutory presumption of capacity applied, and the Patient is presumed to have had capacity at all times leading up to her death, including to refuse palliative care and to seek experimental treatment.

The decision reinforces the primacy of the presumption of capacity and the principle of autonomy under the Mental Capacity Act 2005. It clarifies that lack of belief in medical information alone does not necessarily establish incapacity, and courts must carefully consider expert evidence and provide clear reasoning when departing from unanimous expert opinions. No new precedent was established beyond affirming established statutory interpretation and case law principles.