JJ, R (on the application of) v Spectrum Community Health CIC

A competent person may choose whether to accept or refuse medical treatment, including treatment carrying a risk of death. That autonomy does not entitle the person to require a medical professional to provide treatment which the professional rationally considers clinically contraindicated or adverse to the patient’s clinical needs. Where feeding depends on carers, the patient’s autonomy must be considered alongside the carers’ professional autonomy and exposure to legal or regulatory consequences. In exceptional circumstances, dietary choice may engage Article 8, but interference may be lawful and proportionate to protect health and the rights and freedoms of others. A civil court should not declare in advance that conduct causing future, fact-sensitive harm will be criminally or regulatorily lawful.

The claimant was a profoundly disabled prisoner who was quadriplegic, dependent on the defendant’s staff for feeding, and assessed as being at high risk of choking, aspiration and re-feeding syndrome. He had capacity and wished to choose food outside the recommended Level 6 soft and bite-sized diet. The defendant refused to provide food which its clinical advisers regarded as presenting an elevated risk.

The claimant sought judicial review and declarations concerning autonomy, rationality, Article 8 of the ECHR and discrimination under the Equality Act 2010. The central questions were whether the defendant was legally obliged to give effect to the claimant’s dietary choices and whether the requested declarations should be made.

1. Claim dismissed. The claimant had capacity to choose what he wished to eat, including an unwise choice. That did not require the defendant to execute the choice.
2. Feeding constituted medical treatment. Once a patient is accepted for treatment, medical staff owe a positive common-law duty of care, including reasonable steps to keep the patient alive. That duty does not override a competent refusal of treatment. Conversely, autonomy does not entitle a patient to insist on a treatment which the professional considers clinically contraindicated or adverse to the patient’s clinical needs. The defendant had rationally reached that conclusion on appropriate expert evidence.
3. The defendant was not required to find another professional willing to administer treatment which it considered adverse to the claimant’s clinical needs. The court rejected the wider submission based on Ms B.
4. Reeves did not establish a general duty to prevent a prisoner from undertaking any activity which might cause harm. Its unusual duty concerned the risk of criminal or regulatory action; the court declined to determine future liability in unknown circumstances.
5. Although the claimant’s food choice engaged Article 8 in the exceptional circumstances, the interference was in accordance with law and proportionate. It pursued protection of the claimant’s health and protection of the defendant and its staff.
6. The Equality Act 2010 claims failed. The defendant had not unlawfully discriminated or failed to make reasonable adjustments, and permission was refused for the unpleaded section 15 claim.