Doncaster & Bassetlaw Hospitals NHS Trust & Anor v C

An adult patient with mental illness has an absolute right to refuse medical treatment if mentally competent, even where the refusal appears irrational. Capacity depends on whether an impairment or disturbance of mental functioning prevents the patient from understanding and retaining material information, or from using and weighing it in reaching the decision. Where the patient lacks capacity, the court may authorise treatment if it is in the patient’s best interests. The court authorised a CT scan under general anaesthesia because the medical evidence established that the scan was necessary to assess a probable renal malignancy and determine appropriate treatment.

Two NHS Trusts applied for a declaration that they could administer a general anaesthetic to C, an elderly woman detained under the Mental Health Act 1983, so that a CT scan could be performed against her wishes. An ultrasound scan had indicated a probable malignant tumour in her left kidney. C had paranoid schizophrenia, lacked insight into her illness and was unable to understand or weigh the medical information relevant to decisions about her physical health.

The Official Solicitor, acting as C’s guardian, did not oppose the application after considering the medical evidence. The central issues were whether C lacked capacity to decide about the scan and whether the scan, including any necessary restraint and general anaesthesia, was in her best interests.

1. Capacity and refusal. A mentally competent adult has an absolute right to refuse medical treatment, whether the decision is rational or irrational. The court relied on St Georges Health Care NHS Trust v S (1998) 3 AER 673 for that principle.
2. Test for incapacity. Applying the formulation in Re MB (An Adult) (Medical Treatment) FCR 1997 Vol II, a patient lacks capacity where an impairment or disturbance of mental functioning makes the patient unable to comprehend and retain material information, or unable to use and weigh that information in reaching a decision. The court also referred to Re C (1994) 2 FCR 151 concerning the effect of a disorder that stifles belief in information presented to the patient.
3. Application. C’s delusions and lack of insight meant that she did not believe the medical advice about her kidney and could not weigh the benefits and risks of the available options. The court accepted the psychiatric evidence and found that she lacked capacity to decide about the treatment.
4. Best interests and safeguards. The medical evidence established that the CT scan was essential to stage the suspected tumour and determine appropriate treatment. The court was satisfied that it was in C’s best interests and that the proposed anaesthesia and restraint arrangements protected her human rights.
5. Order. The court gave the Trusts permission to carry out the CT scan in the terms of the agreed order.