R (on application of S) v. Louize Collins and Ors.

[1998] EWCH Admin 490
Download Judgment: English

A 36 weeks-pregnant woman, referred to as “MS”, sought care as a new patient at a local National Health Service (NHS) practice on 25th April 1996. She previously had not sought any ante-natal care. She was quickly diagnosed with pre-eclampsia, a condition threatening the life and health of both her and her baby. She rejected the advice given to her that she seek urgent attention and admission to a hospital for an induced delivery. She wanted the baby to be born naturally.

A social worker and two doctors saw her, and gave the same advice, which MS rejected again. The trio all viewed that MS’s mental state was affecting her decision making and was likely depressed due to financial, housing and relationship problems. The social worker, Louize Collins, applied for her admission under section 2 of the Mental Health Act 1983 (“the Act”) to Springfield Hospital, against MS’s will. Two doctors who saw MS signed the necessary documents to authorize the admission. After that, she was transferred against her will to Springfield Hospital.

Shortly thereafter, she was transferred against her will to St. George’s Hospital. The detention at St. George’s Hospital was not lawful, but no one appreciated this at the time. MS continued to refuse treatment and articulately wrote down her reasons for not accepting treatment. The hospital sought and received authorization to ignore MS’s consent from a Family Division judge. The hospital anaesthetized MS and delivered the baby by caesarean section. Initially the mother was very angry at the “physical assault” and rejected the baby, but then accepted the child. On 30th April, she was returned to Springfield Hospital. On 2nd May, her detention under the Act was terminated and she discharged herself from the hospital against medical advice. While she had been a patient, no specific treatment for mental illness had been prescribed. MS subsequently challenged essentially every step of what happened to her.

The Court made a major emphasis on the importance of autonomy. The Court noted that it was a foundation of English law, and society is to serve the individual and not visa-versa. The Court concluded that while pregnancy increases the personal responsibilities of a mother, it does not diminish her entitlement to decide whether or not to undergo medical treatment. The Court held that while the fetus is not a part of the mother like a leg, it is also not a separate person. The medical interests of the fetus cannot prevail over her rights. Any medical procedure constituted an infringement of the mother’s autonomy in the absence of consent or lawful justification.

The Court found that the Mental Health Act did not give lawful justification for the medical procedure. The Act provides a carefully structured scheme for when consent can be dispensed with, which MS did not fall within. The Court held that someone “detained under the Act for a mental disorder cannot be forced into medical procedures unconnected to that mental condition unless her capacity to consent to such treatment is diminished.” As MS had capacity, her consent was essential.

The Court held that the grounds for admission provided for in Section 2(2)(a) of the Act were not properly established. The Act requires that a patient be suffering from a mental disorder, and that detention must be related or linked to such a disorder. In this case, the social worker and the doctors did not separate the separate issues of a possible mental disorder with MS and the need for treatment arising from her pregnancy. The Court held the Springfield hospital faced no liability regarding MS’s detention as it acted in the face of a duly made application. All parties accepted that the detention in St. George’s court was unlawful due to an administrative error.

Even when his or her own life depends on receiving medical treatment, an adult of sound mind is entitled to refuse it. This reflects the autonomy of each individual and the right of self determination.” (Para. 45)

“There are occasions when an individual lacks the capacity to make decisions about whether or not to consent to treatment. This may arise when he is unconscious or suffering from mental disability. This question will have to be examined more closely in due course, but dealing with it generally for the moment, where the adult patient is disabled from giving consent the medical practitioners must act in his best interests, and if appropriate may carry out major invasive surgery without express consent.” (Para 49)

“In our judgment while pregnancy increases the personal responsibilities of a woman it does not diminish her entitlement to decide whether or not to undergo medical treatment. Although human, and protected by the law in a number of different ways set out in the judgment in Re MB, an unborn child is not a separate person from its mother. Its need for medical assistance does not prevail over her rights. She is entitled not to be forced to submit to an invasion of her body against her will, whether her own life or that of her unborn child depends on it. Her right is not reduced or diminished merely because her decision to exercise it may appear morally repugnant. The declaration in this case involved the removal of the baby from within the body of her mother under physical compulsion. Unless lawfully justified this constituted an infringement of the mother’s autonomy. Of themselves the perceived needs of the foetus did not provide the necessary justification.” (Para. 72)

“In the final analysis a woman detained under the Act for mental disorder cannot be forced into medical procedures unconnected with her mental condition unless her capacity to consent to such treatment is diminished. When she retains her capacity her consent remains an essential prerequisite, and whether she does, or not, must be decided on the basis of the evidence in each individual case, care being taken by those responsible for the detention of the patient, and indeed any court considering the problem, to ensure that the prohibited reasoning identified earlier in this judgment is avoided in relation to consent as it is with admission and detention under the Act.” (Para. 76)