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Report No. 196

(10) Re C (adult: refusal of medical treatment, 1994 (1) All ER 819(Thorpe J) (14.10.93): C-Test:

A 68 year old male patient suffering from paranoid schizophrenia, developed gangrene in a foot during his confinement in a secure hospital while serving a 7-year term of imprisonment. He was removed to a general hospital where the consultant surgeon opined that if the leg below the knee was not amputated, the chances were 15% of survival and he would most likely die. C refused amputation.

A solicitor was called in the meantime, there was some improvement due to drugs, still the need for amputation due to fresh gangrene attack at a future date could not be ruled out. The hospital authorities moved the court for permission to amputate the leg below knee, contending that the decision of the patient refusing amputation was impaired by his mental illness and that he failed to appreciate the risk of death.

It was held that the High Court, in exercise of its inherent jurisdiction, could give directions by way of injunction/declaration in respect of an individual not capable of refusing/consenting to medical treatment (including future medical treatment). However, the question to be decided was whether it had been established that his capacity had been so reduced by his chronic mental illness and that he did not sufficiently understand the nature, purpose and effects of the preferred medical treatment.

That in turn depended upon whether he had comprehended and retained information as to the proposed treatment, had believed it and had weighed it in the balance when making a choice (known as C Test). This was the test of 'competency'.

Thorpe J described competency of patient as follows:

"I consider helpful Dr E's analysis of the decision-making process into three stages: first, comprehending and retaining treatment information, secondly, believing it and thirdly, weighing it in the balance to arrive at choice." (C-Test)

On facts, it was held that amputation should not be made, as his decision making was not so impaired by his schizophrenia. The presumption in favour of his right to self-determination was not displaced. Re T (adult: refusal of medical treatment) 1992 (4) All ER 649 and Airedale 1993 (1) All ER 821 (HL) were applied.



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