In re T (adult: refusal of medical treatment)

[1992] 4 All ER 649, CA
Download Judgment: English

This case dealt with the right to choose how to live, specifically regarding the right to refuse a blood transfusion. Miss T had been raised by her mother, a Jehovah’s witness, but was never baptized into the faith and had told her boyfriend and father that she was not a Jehovah’s Witness. She was 34 weeks pregnant when she was admitted to a hospital for pneumonia and when her condition worsened the decision was made for her to have a Cesarean section. Numerous times while she was at the hospital she had stated that she would not consent to a blood transfusion, but the validity of that refusal was questioned because she had been on heavy medication when expressing her refusal to the transfusion and because her refusals came directly after conversations with her mother (posing the risk of undue influence). After the Cesaerian section was performed, Miss T was in need of a blood transfusion, but the anesthetist did not proceed because she had expressed wishes against the procedure.

Miss T’s father and brother went to the court, seeking an order that would allow the transfusion. From the testimony of her doctor, Judge Ward found that the transfusion could be legally administered, even despite Miss T’s lack of consent, because she had not been fully competent at time of her refusals and the transfusion was in her best interest. The transfusion was then administered.

After the transfusion the matter was again brought before Judge Ward, who found that while Miss T had been competent enough to refuse treatment, the scope of that refusal did not extend to circumstances where her life would be forfeited if she did not under go treatment. The lower court held that Miss T had neither consented nor refused and, as she could no longer do either, the doctors could treat her situation as an emergency and administer treatment as the felt met her best interests.

The case was then appealed to the court of appeals, civil division.

The Court upheld the lower court’s decision that it was lawful for the hospital to have administered the blood transfusion, noting that there was enough to evidence to justify the conclusion that Miss T was not in a physical or mental condition to consent and that her mother had unduly influenced her decision to refuse a blood transfusion.

The Court then went on to consider, generally, the principles by which hospitals should judge this situation in the future and concluded that:

  1. Every adult has the prima facie right and capacity to refuse medical treatment, even where such refusal has dire health consequences;
  2. The presumption of such capacity can be rebutted in certain circumstances (long-term mental incapacity, unconsciousness, under influence of fatigue, drugs, etc.);
  3. Where the adult patient does not have capacity to decide, the doctors should treat him in the manner they consider to be in his best interests;
  4.  Doctors must consider whether a patient’s capacity at the time of refusal was reduced below the level required for an important decision;
  5. Doctors may also need to consider whether the patient’s refusal was vitiated due to undue influence on the patient by others. In determining such issue, doctor’s should consider the relationship of the influencer to the patient;
  6. Doctors must consider the scope and basis of the refusal to ensure that it was intended to apply to, and based on the assumptions which, match the actuality of the patient’s situation;
  7. Refusal Forms should clarify the consequences of refusal to the patient; and
  8. Where there is doubt as to a purported refusal and failure to treat the patient would lead to irreparable health damage, doctors should apply to courts for assistance.

Lord Butler-Sloss agreed with decision to uphold the lower court’s decision, but emphasized that in his opinion the lower court did not sufficiently take into account the degree of undue influence of Miss T’s mother, noting that “an  influence may be subtle, insidious, pervasive and where religious beliefs are involved especially powerful. It may also be powerful between close relatives where one may be in a dominant position vis-à-vis the other.”[p.667]

Lord Staughton also agreed with the decision to uphold the lower court’s decision but explored in greater detail three reasons (undue influence, consent or refusal made without reference to the relevant circumstance, incapacity) where consent or refusal of consent may be inoperative in law.

“This situation gives rise to a conflict between two interests, that of the patient and that of the society in which he lives. The patient's interest consists of his right to self-determination—his right to live his own life how he wishes, even if it will damage his health or lead to his premature death. Society's interest is in upholding the concept that all human life is sacred and that it should be preserved if at all possible. It is well established that in the ultimate the right of the individual is paramount. But this merely shifts the problem where the conflict occurs and calls for a very careful examination of whether, and if so the way in which, the individual is exercising that right. In case of doubt, that doubt falls to be resolved in favour of the preservation of life, for if the individual is to override the public interest he must do so in clear terms.” [p.661]

“If there is a distinction between failure to consent and a refusal of consent, it is because a refusal can take the form of a declaration of intention never to consent in the future or never to consent in some future circumstances.”[p. 661]

“What matters is that the doctors should consider whether at that time he had a capacity which was commensurate with the gravity of the decision which he purported to make. The more serious the decision, the greater the capacity required. ”[p. 661]

“If the doctors consider that the patient had the capacity to decide and has exercised his right to do so, they still have to consider what was the true scope and basis of that decision.. what they can do is consider whether at the time the decision was made it was intended by the patient to apply in the changed situation.”[p.663]

“...the patient’s right of choice exists whether the reasons for making that choice are rational, irrational, unknown or even non-existent”[p. 662]