On 1 May 2014 Mr Justice Mostyn gave his judgment on an application brought by Mills & Reeve which had been described as a “terrible ethical dilemma”.

Some background

RC is aged 23 and diagnosed with a personality disorder. He was born into a Jehovah’s Witness family but not brought up in that faith after being taken into care when he was 4 years old. In August 2013 he embraced the Jehovah’s Witness faith while in prison.

On 1 February 2014, RC self-harmed by opening his brachial artery. This caused significant blood loss that was greater due to being prescribed warfarin for an earlier thrombosis. RC was transferred from prison to hospital where he refused a blood transfusion due to his faith. His haemoglobin fell to a life threatening level, but fortunately he survived.

RC was then transferred to a secure psychiatric hospital under the Mental Health Act 1983 (MHA). Measures were taken to prevent his self harm, including the use of a mechanical restraint belt and constant observations. When these measures were reduced, RC would try to self harm. At any point he could have suffered significant blood loss requiring a blood transfusion. On 4 April 2014, RC made an advance decision refusing blood products.

What does the law say?

Under section 63 MHA, medical treatment for a patient’s mental disorder can be imposed on them without their consent, even if they have the capacity to refuse it.

In this case, Mr Justice Mostyn found that:

  • The act of self harm was a symptom or manifestation of RC’s underlying personality disorder
  • A consequence of the self harm was bleeding from the wound which resulted in RC’s haemoglobin levels being lowered
  • Treating the haemoglobin with a blood transfusion was treatment of a symptom or manifestation of RC’s mental disorder which fell under section 63

He went on to find that RC had full capacity to refuse the administration of blood products, and his advance decision would be operative if he lost capacity.

The dilemma

This left the psychiatrist in the position where she had the power to impose a blood transfusion which could save RC’s life. However, she had some ethical difficulty in using the MHA to override RC’s capacitous religious wishes.

A declaration was sought that it was lawful for the psychiatrist not to use her power to treat the symptoms of RC’s mental disorder. Should the patient’s right to religion be respected? Or was the detaining authority under a duty to preserve his life? There had not been a case on these issues before.

The judgment

This was the first time that a full merits review of a decision not to treat under section 63 had been undertaken by the court. The judge said that: “where the approved clinician makes a decision not to impose treatment under section 63, and where the consequences of that decision may prove to be life-threatening, then the NHS trust in question would be well advised, as it has here, to apply to the High Court for declaratory relief.”

Mr Justice Mostyn concluded that the decision made by the psychiatrist was completely correct and it was lawful for those responsible for RC’s care to withhold a blood transfusion notwithstanding their power under section 63 MHA.