Report No. 196
(30) NHS Trust v. T 2004 EWHC 1279: (Justice Charles) (28th May 2004)
The hospital sought a declaratory relief in regard to Ms. T aged 37 years, who has borderline 'personality disorder'. She used to harm herself by cutting herself and blood-letting, resulting in fall of haemoglobin level and leading to chronic anemia. She frequently required blood transfusion supplemented by iron. She had taken such treatment for years. But on 28.1.2004, she executed an Advance Directive, (attested by a lawyer), giving various directions refusing blood transfusion 'unless when she is subject to compulsory treatment under the Mental Health Act, 1983'.
The reasons given by her were that she was not aware when she would cut herself and she felt blood was evil and the blood given to her mixes with hers and becomes evil and that would increase the danger of her committing acts of evil again. She stated she was mentally competent while writing the Advance Directive and she named her mental health lawyer, H and another social worker be told if she was admitted in hospital. If she lacked capacity, her lawyer should be consulted and he would speak for her in a crisis.
On 24.3.2004, the treating psychiatrist opined that she was unstable and that blood transfusion and iron were necessary. On 8.4.2004, the patient reached a collapsing state. On 9.4.2004, on the application of the hospital, Pauffley J, by her order, permitted blood transfusion, using minimum force. It was given and she recovered by 13.4.2004. On 16.4.2004, her solicitor wrote objecting to further blood transfusion.
After holding that under the new C.P.R. (Civil Procedure Rules), interim declarations can be given and referring to circumstances in which, in a given case, a declaration may be too premature having regard to the capacity of the patient at the moment or the lack of emergency, Charles J held that, on the medical evidence before him, the lady Ms. T lacked capacity when she signed the Advance Directive, that as in Re MB she was unable to weigh the relevant information and competing factors. Her position, at the present moment when she again refused, was no different.
Charles J then examined what was in her best interests. He quoted Munby J in A v. A. Health Authority 2002 (1) FLR 481 that an adult's best interests involve a welfare appraisal in the widest sense of taking into account, where appropriate, a wide range of ethical, social, moral, emotional and welfare considerations. Reference was made to similar views of the President Butler-Sloss LJ in Re A (medical treatment: male sterlization) 2000 (1) FLR 549.
He then quoted Thorpe LJ from Re A as to what is in best interests in the case of mental patients. The two reasons given by the patient in her advance directive that blood transfusion became a vicious circle and her blood was evil, could not be given weight. The 'potential gains' in the balance sheet were more than the losses, as enumerated by Thorpe L.J.
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