Judge allows force feeding of mentally competent patient

BMJ 1994; 309 doi: (Published 30 July 1994) Cite this as: BMJ 1994;309:291
  1. C Dyer

    The Mental Health Act 1983 allows detained patients to be treated against their will even if they are mentally competent to refuse treatment and the treatment is against their best interests, a High Court judge ruled last week. Mr Justice Thorpe granted Croydon Health Authority a declaration that it could force feed a 24 year old detained patient suffering from borderline personality disorder.

    The judge made the declaration despite deciding that the patient was competent to refuse treatment and that force feeding would not be in her best interests “unless and until her physical state was so debilitated as to threaten her survival.” He said that it was “disquieting” that the act legalised what the common law would not.

    Lawyers for the patient, named only as Miss B, said that they would appeal. Her solicitor, Lucy Scott-Moncrieff, described the result as “a very sinister development,” adding: “It means that a doctor can give someone treatment for one condition which will make his or her underlying psychiatric condition worse.” Miss B's counsel, Richard Gordon QC, said: “This must be the first case ever where a patient has been declared to be competent and it's said to be contrary to the patient's best interests for the patient to be treated, yet the treatment is allowed to go ahead.”

    Miss B, detained in a locked ward at Warlingham Park Hospital near Croydon, was sexually abused by her grandfather from the age of 6 to the age of 10 and has a compulsion for self harm by burning with cigarettes, cutting herself, and - since these means were removed - limiting her food intake. She is receiving no psychotherapy or other treatment and sought a High Court declaration banning doctors from feeding her by nasogastric tube.

    Mr Justice Thorpe rejected her counsel's argument that nasogastric feeding was not treatment for mental disorder under the Mental Health Act. He was satisfied that she had the capacity in her present state to refuse artificial feeding. If he was wrong in that conclusion, he said, it would be necessary to consider whether such feeding was in her best interests. This should be assessed in accordance with acceptable medical practice. Force feeding would magnify her disorder and reduce the prognosis for the only recognised treatment, psychoanalytic psychotherapy. Miss B was driven to her current position by a restrictive caring regimen and the absence of any present or proposed treatment plan, the judge said. Had she received the treatment that her disorder required she might not be in her present conflict.

    The health authority had rejected advice from a psychiatrist with analytic training, brought into the case at the judge's request, that Miss B should be referred to a unit where she could receive psychotherapy. That seemed to approach the boundary at which the proposed medical treatment ceased to be acceptable. But the judge said that the effect of section 53 of the Mental Health Act was “to limit the autonomy of the detained patient whose capacity is unimpaired to treatments that are not related to the mental illness or disorder for which they are detained.”

    Granting the health authority a declaration that doctors could force feed the patient, he said that he had been tempted to require the authority to use its best endeavours to secure Miss B's admission to a specialist unit. But he accepted that since the authority sought no more than a declaration as to statutory rights it would not be appropriate to attach conditions.

    Paul Aitchison, unit general manager of Warlingham Park Hospital, said that he had not yet seen the judgment. “Our primary concern is to keep her alive against her wishes. We have considered treatment, but we're guided by medical staff and the consultant as to the timing and suitability of transfer.”

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