Manchester University NHS Foundation Trust v Mr Y & Ors
Summary
A 42-year-old man was found unresponsive, brought to A&E with multiple injuries, and had a seizure necessitating intensive care. There had been prior concerns that he was not taking his antipsychotic medication for paranoid schizophrenia and, after he stabilised and returned to the ward, he was detained under s.3 of the Mental Health Act 1983. A symptom of his mental health crisis was an inability to believe what his treating clinicians were telling him.
He required surgery to treat a fractured and dislocated left shoulder, which fell outside the scope of s.63 MHA 1983, and the relevant information for deciding the matter included:
- (a) the nature and purpose of the sole treatment option for his shoulder injury;
- (b) that there were risks to this treatment option;
- (c) the likely outcome or success of the treatment option;
- (d) the potential consequences if treatment was not provided.
He was experiencing psychotic delusional beliefs and thinking that resulted in him not believing the surgery was necessary to avoid future pain and the loss of function in his left arm. The evidence clearly demonstrated that he was unable to make the decision because of paranoid schizophrenia.
As to best interests, not having the surgery would put his independence at risk for he lived alone and travelled alone to London to meet his family. Such independence was a value which he prized, and it was right that significant weight was given to that value. His brother, himself a consultant orthopaedic surgeon, supported the surgery, as did his father. John McKendrick KC went on to observe:
45. Lady Hale in Aintree focussed the court on the need to understand that "[t]he purpose of the best interests test is to consider matters from the patient's point of view." As she goes on to say, values can account for what is 'right' for the patient. Both values and present wishes can furnish the court with the patient's point of view. At times they may be in conflict. In an appropriate context, the patient's history may paint a picture of who they are through their lived values, more accurately than their present day wishes. That is not to discount their wishes. Each part of the picture must be considered to focus the court, as accurately as possible, on the point of view of the subject of the proceedings. In the context of a patient with recurrent severe psychiatric ill-health, their ordinary day-to-day existence may permit the court an Each part of the picture must be considered to focus the court, as accurately as possible, on the point of view of the subject of the proceedings. In the context of a patient with recurrent severe psychiatric ill-health, their ordinary day-to-day existence may permit the court an understanding of who they are and what they might want with greater clarity than their recorded wishes at the moment of crisis from a hospital bed. Giving effect to Mr Y's value of independence more effectively respects his dignity and promotes his autonomy than seeking to follow his currently expressed wishes and feelings. This underlines the importance of all parties seeking to provide the court with evidence as to who P is, as Mr Edwards helpfully sought to do.
In conclusion, John McKendrick KC held that the surgery (including the potential need for sedative medication and restraint to administer general anaesthesia) was in the man’s best interests.
Comment
What is particularly interesting about this decision is the role of values in the best interests analysis. The patient’s present wishes and feelings opposed surgery, but the independence he valued so much favoured it. Reliably identifying someone’s lived values, particularly in an acute situation like here, may not always be easy but consulting with family members (and significant others) often provides an insight into what they might be. For those wanting to think more deeply about values, and how to bring them fully before the court, we recommend this video from the Judging Values Project.
