In re T (Adult: Refusal of Treatment)

A capable adult has an absolute right to accept or refuse medical treatment, even where refusal is irrational or risks death. Capacity is presumed, but may be impaired by illness, pain, fatigue, shock or drugs. The capacity required must be commensurate with the gravity of the decision.

A refusal is effective only if it represents the patient’s independent will and covers the circumstances which arise. Undue influence, material misinformation or a false underlying assumption may make it ineffective. Where an incapacitated patient has made no effective decision, doctors may provide treatment which their clinical judgment considers necessary in the patient’s best interests.

An adult patient, who was seriously ill and receiving narcotic medication, stated that she did not want a blood transfusion and signed a refusal form. She later became unconscious and required blood products. Her father and partner sought urgent judicial assistance.

Ward J initially authorised transfusion and, following a full hearing, declared that further transfusion would be lawful. He found that the patient had possessed capacity and had expressed a valid refusal, but that the refusal did not extend to the life-threatening emergency which subsequently arose.

The patient, acting through the Official Solicitor, appealed. The central questions were whether she had capacity, whether her mother’s influence had overborne her independent will, and whether the refusal covered the circumstances in which transfusion became necessary.

1. Appeal dismissed unanimously. The Court of Appeal affirmed Ward J’s declaration that administering blood to the patient was lawful. Lord Donaldson MR delivered the leading judgment. Butler-Sloss LJ agreed with his general propositions, and all three members of the court concluded that there had been no effective refusal applicable to the emergency.

2. A mentally capable adult has an absolute right to accept or refuse treatment, even where the choice is irrational or may cause death. Treatment without consent, or contrary to a valid refusal, is a trespass to the person and may be criminal. The right recognised in Sidaway v Board of Governors of the Bethlem Royal Hospital and Maudsley Hospital [1985] AC 871 therefore requires careful examination of whether a choice was truly made and what it covered.

3. Capacity is presumed in an adult but may be rebutted. Temporary confusion, severe pain, fatigue, shock, illness or medication may reduce capacity. Per Lord Donaldson MR, capacity must be commensurate with the gravity of the decision: the more serious its consequences, the greater the capacity required. The evidence would have justified finding that the patient’s illness, pain, medication and condition prevented a binding decision, although the court did not need to displace Ward J’s factual finding.

4. A refusal must represent the patient’s own decision. Persuasion is permissible, however strong, provided it does not overbear independent judgment. The patient’s vulnerability, the strength of the persuader’s relationship and the potentially compelling character of religious influence are relevant. Butler-Sloss LJ considered that the mother’s influence, operating upon a seriously weakened patient, vitiated the apparent refusal.

5. The refusal must also be construed according to its true scope and basis. Doctors may ask whether it was intended to govern the circumstances which actually arose and whether it depended upon an assumption later shown to be false. They may not substitute speculation that the patient would have changed her mind. Here the patient had not been confronted with the life-threatening consequences and had been reassured, incorrectly, about alternatives. Her refusal did not cover the emergency.

6. Where an incapacitated patient has made no effective decision, the principle of necessity described in In re F (Mental Patient: Sterilisation) [1990] 2 AC 1 permits and requires doctors to act in accordance with reasonable clinical judgment of the patient’s best interests. The doctors were therefore justified in administering blood.

7. Failure to provide appropriately full information may sound in negligence but does not by itself invalidate consent or refusal. Material misinformation, or withholding information which the patient expressly or impliedly seeks, may do so. In urgent cases involving danger to life or irreparable harm, hospitals with real doubt about a refusal should seek an immediate judicial declaration.

1. Court of Appeal: The appeal was dismissed unanimously. Ward J’s declaration that administration of blood would be lawful was affirmed. Leave to appeal to the House of Lords was granted.

2. High Court, Family Division: Ward J first authorised urgent transfusion on an interlocutory application. After a full hearing, he found that the patient’s refusal did not extend to the life-threatening emergency and declared that transfusion in her best interests would be lawful.