Nottinghamshire Healthcare NHS Trust v RC [2014] EWCOP 1317

RC was 23 and had been diagnosed with antisocial and emotionally unstable personality disorders. He had a repeated history of grave self-harm. In August 2013, whilst serving a prison sentence for sexual assault, he became a Jehovah’s Witness. In February 2014 he slashed the major artery in his arm and was admitted to a secure psychiatric hospital, where he repeatedly attempted to re-open the wound. He later refused to consent to blood transfusions on religious grounds, and in April 2014 he signed an advance decision which affirmed his refusal. This advance decision was found to be compliant with ss. 24-26 of the Mental Capacity Act 2005 (‘MCA’).

The NHS Trust sought the following three declarations from the Court of Protection:

1.       RC had the capacity to refuse blood transfusions and to self-harm;

2.       the advance decision was  valid and operative if RC was to become incapable of issuing a decision to refuse treatment; and

3.       the treating physician’s decision not to impose a blood transfusion was lawful.

Regarding the first declaration, Dr S (the treating clinician) and Dr Latham (an independent forensic psychiatrist) made written reports which were unanimous that RC had full capacity to refuse blood products. The reports outlined that RC’s refusal derived almost exclusively from his religious faith, whilst holding that RC had full capacity to enter into the advance decision. The reports also concluded that RC’s decision to adopt the religion of the Jehovah’s Witnesses was made with full capacity. Further, the reports agreed that whilst RC on occasions did harm himself with full capacity, that on other occasions (particularly at times of severe emotional distress) it was likely that he did so without the capacity to choose to self-harm. Dr Latham argued that the only possible question here related to whether RC was able to weigh information in the balance, stating that RC’s ‘ability to weigh the risks of refusing blood against his religious beliefs [was] difficult to describe because his religious beliefs effectively create[d], in his mind (and others) an absolute prohibition on blood products and so there [was] relatively little ‘weighing’ when it [came] to this decision’. The Court therefore concluded that the test of capacity was to be applied very cautiously and carefully when religious beliefs were in play, and that it would be an extreme example of the application of the law of unintended consequences if an iron tenet of an accepted religion gave rise to questions of capacity under the MCA. Therefore little emphasis was placed on the fact that a tenet of RC’s religious faith prevented him from weighing the advantages of a blood transfusion if his medical circumstances had indicated that one was necessary. The Court, by agreeing with the expert evidence above, found that RC had full capacity to refuse the administration of blood products.

In relation to the second declaration, the Court held that the question here related to the following formal requirements contained within the MCA:

–          that the signature was made or acknowledged in the presence of a witness (section 25(6)(c));

–          that the witness signed it in the patient’s presence (section 25(6)(d));

–          that it was not withdrawn when P had capacity (section 24(2)(a));

–          that there was no subsequent lasting power of attorney that covered the same matter (section 24(2)(b)); and

–          that the patient had not acted inconsistently with the advance decision (section 24(2)(c)).

After Dr S had informed the Court in her oral evidence that she saw RC and the witness sign the advance decision in each other’s presence, they held that all the formal requirements to the advance decision were satisfied. The Court further concluded that RC had full capacity when he executed the document, drawing again on the reports submitted by Dr S and Dr Latham which held that RC had full capacity to enter into the advance decision. Therefore the advance decision was operative.

Finally, regarding the third declaration, the Court found that the decision made by Dr S to not impose a blood transfusion was lawful. The Court held that it would be an abuse of power in such circumstances even to think about imposing a blood transfusion on RC having regard to the findings made which indicated that RC did have capacity to refuse blood products and that the advance decision was operative. The Court held that to impose a blood transfusion would be a denial of a most basic freedom. Therefore the Court concluded that the decision of Dr S was lawful, and that it was lawful for those responsible for the medical care of RC to withhold any treatment that involved the transfusion into him of blood or primary blood components, notwithstanding the existence of powers under section 63 of the Mental Health Act 1983.

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