Nottinghamshire Healthcare NHS Foundation Trust v MC

An adult with decision-making capacity ordinarily has the right to refuse medical treatment, even where refusal may lead to death. Detention does not remove that right. Section 63 of the Mental Health Act 1983 may nevertheless authorise treatment without consent where treatment for a physical condition is sufficiently connected with, and directed at alleviating or preventing worsening of, a mental disorder or its symptoms or manifestations. Whether that connection exists is fact-specific and depends heavily on properly tested psychiatric evidence. A responsible clinician may lawfully decide not to impose treatment by force where the proposed restraint would be clinically dangerous, counterproductive or inconsistent with the capacitous patient’s wishes. The court may grant declaratory relief concerning that decision.

Nottinghamshire Healthcare NHS Foundation Trust applied under the inherent jurisdiction for declarations concerning the treatment of MC, a restricted patient detained under sections 37/41 of the Mental Health Act 1983. MC had type 1 diabetes and serious complications, hypertension and peripheral vascular disease. He had capacity to decide about his treatment but refused much of the recommended physical healthcare. The Trust contended that his refusal and the resulting physical complications were manifestations of severe personality disorder, bringing treatment within section 63. It sought a declaration that clinicians could lawfully refrain from using force, even if that led to serious deterioration or premature death. The central issues were whether the treatment fell within section 63, whether MC had capacity, and whether non-forcible treatment was lawful and in his best interests.

1. MC had capacity to litigate and to make decisions about his physical health treatment. The fact that his decisions were unwise did not establish incapacity, consistently with section 1(4) of the Mental Capacity Act 2005.

2. An adult with capacity may refuse life-saving treatment, however unwise the refusal may be. The right of bodily self-determination applies equally to a detained person. Doctors are neither entitled nor obliged to provide treatment contrary to that refusal, subject to any applicable statutory power.

3. Section 63 of the Mental Health Act 1983 operates, through section 145, only where the treatment is for the mental disorder from which the patient suffers, including treatment directed at alleviating or preventing worsening of the disorder or one or more of its symptoms or manifestations. Treatment for a physical condition may fall within section 63 where the physical condition or the patient’s refusal of treatment is sufficiently connected with the mental disorder.

4. The determination is fact-specific. The court placed substantial weight on the psychiatric evidence. On the evidence, MC’s approach to healthcare, including his overriding need for control, distrust and confrontational functioning, was rooted in severe personality disorder. His serious diabetic complications and the inconsistent engagement with treatment were therefore manifestations of that disorder, and the proposed treatment fell within section 63.

5. The declaration sought was granted. It was lawful for MC’s treating clinicians not to use physical, chemical or mechanical restraint to provide treatment for his physical health needs, even though non-treatment might result in serious deterioration or premature death. The declaration did not concern treatment immediately necessary to save life in an emergency, when clinicians would exercise their clinical judgment under Part 4 of the Mental Health Act 1983.