LB v Croydon District Health Authority
| Jurisdiction | England & Wales |
| Judgment Date | 1995 |
| Date | 1995 |
| Court | Court of Appeal (Civil Division) |
NEILL, HOFFMANN AND HENRY, L JJ
Medical treatment – adult patient suffering from borderline personality disorder – symptoms including compulsion to self-harm – refusing food to punish herself – whether force feeding without patient's consent could be treatment within the meaning of s 63 of the Mental Health Act 1983.
The plaintiff, a woman aged 24, was sexually abused as a child by her grandfather and later by a lodger. At the age of 20 she began to show serious signs of mental disorder described as "borderline personality disorder coupled with post-traumatic stress disorder". The symptoms included depression and a compulsion to self-harm. The only known treatment was psychoanalytic psychotherapy.
In 1993 she was compulsorily detained under s 3 of the Mental Health Act 1983 and deprived of means of cutting or burning herself. She stopped eating until threatened with naso-gastric feeding. By May 1994 she had relapsed, weighed 32 kilos, and was given a life expectancy of two or three months. Once again tube feeding was threatened. She applied to the High Court for an injunction restraining the health authority from feeding her by tube without her consent. She also began eating again. But both she as plaintiff and the health authority as defendant wanted to know whether tube feeding would have been lawful. The Judge held that it was. The plaintiff appealed. A cross-appeal by the health authority as to the plaintiff's mental capacity did not fall to be dealt with.
Held – dismissing the appeal: An adult of full mental capacity could choose whether to eat or not. Even if refusal was tantamount to suicide, he could not be forced to eat or be forcibly fed. Against this, at common law, a patient who lacked the mental capacity to choose could be treated according to the doctor's clinical judgment of the patient's best interests. Nor, by s 63 of the Mental Health Act 1983, was the patient's consent required for "any medical treatment for the mental disorder" from which the patient was suffering. "Medical treatment" by virtue of s 145(1) of the 1983 Act included "nursing, care, habilitation and rehabilitation under medical supervision". By virtue of s 3(2)(b) a patient with a psychopathic disorder could not be detained unless the proposed treatment, taken as a whole, was likely to alleviate or prevent a deterioration of his condition. It did not follow that every act forming part of that treatment had, in itself, to be likely to alleviate or prevent deterioration of that disorder. Further, s 62 of the Mental Health Act 1983, dealing with emergencies, appeared to assume that treatment of symptoms, as opposed to the mental disorder itself, was a "form of medical treatment for mental disorder". Section 63 amply satisfied Article 8(2) of the European Convention on Human Rights which was
directed at the prevention of the exercise of arbitrary official power and requiring "interference with private life" to be in terms "sufficiently precise to enable the individual to foresee its consequences".
South West Hertfordshire Health Authority v KB[1994] 2 FCR 1051 approved. Re C (An Adult: Refusal of Treatment)[1994] 2 FCR 151 distinguished.
Decision of Thorpe, J [1995] 1 FCR 332 upheld in part.
Statutory provisions referred to:European Convention on Human Rights, Article 8.
Mental Health Act 1983, ss 3, 57, 58, 62, 63 and 145.
Cases referred to in judgment:C (An Adult: Refusal of Treatment), Re[1994] 2 FCR 151.
F v Riverside Mental Health NHS Trust[1994] 2 FCR 577.
Herczegfalvy v Austria (1992) 15 EHRR 437.
South West Hertfordshire Health Authority v KB[1994] 2 FCR 1051.
Richard Gordon, QC and Craig Barlow for the plaintiff.
Robert Francis, QC and Christopher Johnston for the health authority.
Gordon Murdoch as amicus curiae.
LORD JUSTICE HOFFMANN.Ms B is 24. As a child she was sexually abused, first by her grandfather and then by a man living as a lodger in her house. At the age of 20 she began to show serious symptoms of mental disorder. She was unable to resist trying to cause herself harm. At first this took the form of cutting or burning herself. In January 1991 she was admitted for the first time to a hospital for psychiatric assessment. The Judge found that she suffered from a psychopathic disorder known as borderline personality disorder coupled with post-traumatic stress disorder. The symptoms include depression and a compulsion to self-harm. The latter stems from an irrationally low regard for her own person. The only known treatment is psychoanalytic psychotherapy.
On 18 January 1993 Ms B was compulsorily detained under s 3 of the Mental Health Act 1983. She was kept under surveillance and deprived of the means of cutting or burning herself. So her urge to punish herself found a new outlet. She virtually stopped eating. In the course of 1993 her weight fell to a dangerous level. In the summer she had three sessions of psychotherapy but...
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