Court Removes Direction to Force Feed Anorexia Nervosa Patient

The High Court discontinued its order which had previously authorised the force feeding for a woman suffering from severe treatment-resistant Anorexia Nervosa (AN) for more than 25 years. Ms Justice Hyland based her reasoning on the best interests test in Re a Ward of Court (No.2)[1]. The judge also considered evidence from the patient’s treating doctors that continuing coercive treatment would be traumatic and not without inherent risks.

Background

The woman in her 40s had a 25 year history of severe treatment-resistant AN. She had been hospitalised regularly due to acute medical issues and only partially complied with recommended care plans often discharging herself against medical advice.

In November 2019 her condition deteriorated and she refused nasogastric (NG) feeding. When she sought to be discharged from hospital, the HSE successfully applied to the High Court for orders to detain and coercively treat her as she lacked capacity to make treatment decisions due to the severity of her condition. In January 2020, she was made a Ward of Court and the Court became responsible for making decisions relating to her healthcare needs.

A further court order was then made permitting the patient’s transfer to a specialist treatment facility in the UK where her condition stabilised after seven months of intensive treatment which included NG feeding. On her return, a further order was granted in September 2020 authorising treatment in the community which allowed for her admission and detention in hospital, if deemed necessary. This order also provided for coercive NG feeding where necessary.

The woman, however, expressed strong opposition to any form of coercive treatment and it was later ordered by the court that if she was admitted to hospital against her wishes, her clinicians did not have authority to use forced feeding without obtaining express consent from the court.

Over the course of 2021, attitudes towards the effectiveness of coercive feeding began to change generally in the medical community. In April 2021, following a further hospital admission, the patient’s treating psychiatrist decided that coercive admission to hospital caused her extreme distress and was not in her best interest. The court authorised her discharge for treatment in the community. It subsequently removed the mechanism to allow her to be admitted to hospital involuntarily.

When matters returned to court in December 2021, this woman had not been fully compliant with her treatment plan, had severely low body weight, chronic malnutrition and many related medical conditions. The HSE sought to lift remaining court orders authorising coercive treatment on the basis this would not only be traumatic but in her case would carry its own medical risks. It was proposed instead only to provide care, in her best interests that she agreed to. Without her agreement, life-saving treatment would not be provided.

The Decision

Ms Justice Hyland noted the decision of the President of the High Court in A v Hickey[2]. In that case, the President observed “the general rule in relation to medical treatment is that the consent of the patient is required”. However, in cases where the patient lacked capacity and “where it is the court that has to give substituted consent” this must be decided on well established principles. These principles include in particular “the sanctity of life, which gives rise to a strong but, in recognition of the right to die a natural death, a rebuttable presumption in favour of sustaining life prolonging treatment”.

The court also noted the Supreme Court decision in the JJ case[3] that in circumstances involving withholding of life sustaining treatment “the legal issue is not whether the patient or the patient’s family consents to the course proposed by the doctors, but rather whether it is lawful for the doctors to do so; i.e., whether the judgment is one to which they can properly come”. The Supreme Court noted that in cases where consent was not possible, it was “prudent to seek confirmation, if necessary from a court” that withdrawal of treatment was permissible.

In deciding that substituted consent should be given, the court followed the best interest test set out by the Supreme Court in Re a Ward of Court (No.2)[4]. This test considered a range of factors such as the woman’s current condition and medical treatment, the degree of bodily invasion, the treatment involved, her life history, prognosis, medical evidence and her constitutional rights.

Given her long standing medical condition of AN, her absolute opposition to NG feeding and the pessimism of her doctors for recovery, the court concluded it was in her best interest to agree to the approach proposed by the HSE. The Court stressed its decision was “very much informed” by the length of time over which she has suffered from AN and a “very different view might be taken…. where the duration of the illness was shorter and/or the person was younger”.

Key message from this case

This case suggests the Courts are open to limiting or discontinuing the use of coercive treatment in cases where there is a lengthy history of severe illness even though this may result in a person’s death.

For more information on the application of this judgment and its wider impact on future cases, contact a member of our Medical Law team.

The content of this article is provided for information purposes only and does not constitute legal or other advice.

[1] Re a Ward of Court (No. 2) [1996] 2 IR 79.

[2] A v Hickey & Ors [2021] IEHC 318.

[3] In the Matter of JJ [2021] IESC 1.

[4] Re a Ward of Court (No. 2) [1996] 2 IR 79.