A Local Authority v E

English Medical Law

A Local Authority v E
Image: ‘Woman in Foetal Position’ by Unknown Artist

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The struggle for autonomy amidst the pain of abuse, is central to a case involving the wishes of a patient with a debilitating illness, and the requisite obligations of the State. By balancing the safeguarding nature of the Mental Capacity Act 2005 with Convention rights, it is left to the courts to determine which argument offers the greatest reasoning.

After experiencing years of intense sexual abuse during the formative years of her childhood, the patient in question became prisoner to her manifestations of trauma, through increased dependency on alcohol and medically prescribed opiates. The prologue is one of repeated lapses of overall function, underpinned by contrasting highs of academic achievement that defied her emotional scars; but through time, the former overshadowed the applicants deliberate plans for happiness, in the form of chronic anorexia nervosa.

Following hospitalisation on numerous occasions through dangerously low body weight, and a number of therapeutic approaches proving collectively unsuccessful, it was decided by the applicant to submit advanced decisions surrounding life sustaining procedures, where her health suffered to the point of imminent death; only to then provide paradoxical statements portraying her deep conviction to regain a life of meaning that had once been enjoyed. This cyclical existence placed prolonged stress upon the applicant’s health, and that of her parents and appointed specialists, who had all extended themselves beyond any obligation to keep what was considered an engaging, and yet tormented, woman alive.

Several years of medical intervention provided little to no lasting results, and so it was largely accepted that after a year of no real calorific ingestion, the patient had made clear her decision to refuse food, and that in light of her last advanced decision, she wished to remain in palliative care until the date of her impending death. When her BMI (body mass index) then reached a potentially fatal level, it was with the concerns of those assigned her care, that the matter went before the Court of Protection, in the aim of determining if (i) the patient lacked mental capacity at the time her last advanced decision was made, and (ii) whether it was in her best interests to cease intervention, and leave her to die with dignity, or resort to long-term invasive nasogastric treatment to restore her BMI to that where therapeutic rehabilitation could again recommence.

Art.2 of the Human Rights Act 1998 (Right to life) determines that the State is under a duty to protect the individual right to life, and yet art.3 (Prohibition of torture) serves to prevent any inhuman or degrading treatment, which in this case, the proposed medical programme would, by all accounts, place unreasonably high levels of physical and emotional stress upon the patient; in part as the result of years of previous treatments producing a ravaged immune system with weakened bones mass. However, art.5 (Right to liberty and security) and art.8 (Right to respect for private and family life) both enforced the applicant’s right to die with dignity, in a manner that suited both herself and her family.

In light of her advanced decision, the contradiction of mental capacity while suffering from an eating disorder, allowed s.3(1) of the Mental Capacity Act 2005 to question if the cessation of ingestion can validate the supposition that a person can understand and evaluate, information as part of a decision making process, when they are consciously killing themselves, despite knowing the consequences of that action. For that reason, it was then argued that any suggestion that the advanced directive was undertaken while compos mentis, failed when an irrational request serves only to end a life and not preserve it.

With full appreciation of the medical evidence and lengthy testimony of all parties (aside from the patient whose heath was too critical for an appearance), it was concluded that in spite of the discouraging background to both the applicant’s childhood experiences and the endemic frustrations of anorexia, there remained a concept and hope, that at the age of thirty-two, it was not too late to rule out any meaningful recovery, nor the chance for the applicant to resume the full life she had once, if only briefly, created. For those reasons, the applicant was deemed lacking mental capacity at the execution of her advanced decision, that forcible restitution was in her best interests, and that such action failed to interfere with the rights presented.

Key Citations

“[I]t is artificial to treat the various forms of intervention involved in forcible feeding individually. They are all central to or supportive of a single purpose. I therefore find that E lacks capacity to accept or refuse treatment in relation to any interventions that are necessary in conjunction with forcible feeding.”

“E’s actual behaviour in refusing food has been entirely consistent with her decision and I would have been reluctant to conclude that her decision was undermined by trusting statements about what are bound to be deeply mixed feelings.”

“For present purposes, I find nothing in E’s statements to indicate a belief that, if she were well, she would not want efforts to be made to save her.”

“[T]he balance to be struck places the value of E’s life in one scale and the value of her personal independence in the other, with these transcendent factors being weighed in the light of the reality of her actual situation.”

“If taken too far, the argument that everything that can be done must be done carries the risk of discrimination against incapacitated persons by depriving them of options that are available to the capacitous…”

Author: Neil Egan-Ronayne

Author, publisher and foodie...

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