Thursday, 6 November 2014

Anorexia: To Treat or Let Die? The Case of Ms.X

This very recent Judgment on a rather unusual, and I think, contentious case was published on 8th October 2014.

Ms.X has a 14 year history of severe anorexia nervosa, complicated by also having alcohol dependence syndrome which had caused chronic and irreversible cirrhosis of the liver. She has had many spells as an inpatient detained under the MHA when she has had forced refeeding. She currently has a BMI of less than 13.

The Judge states:
“The purpose of re-feeding an anorexic patient is to keep that patient alive whilst psychotherapy, talking therapies, can be facilitated in an endeavour to investigate and treat the underlying anorexia; this has been shown over many years not to work for Ms X.  So it is that the medical professionals firmly believe that not only would in-patient treatment once again involve painful, invasive and wholly unwelcome procedures for Ms X, but it would be pointless in terms of achieving long-term treatment, and would be likely in their view to intensify her consumption of alcohol on discharge from hospital, thereby actually increasing her mortality, and accelerating her demise.  As it is, the doctors opine that her life expectancy is measured in months.”

As a consequence of this poor prognosis, Ms.X’s mental health trust went to the Court of Protection to obtain the following declarations:

“i) It is not in Ms X's best interests to be subject to further compulsory detention and treatment of her anorexia nervosa, whether under the Mental Health Act 1983 or otherwise, notwithstanding that such treatment may prolong her life.
ii) It is in her best interests, and shall be lawful, for her treating clinicians not to provide Ms X with nutrition and hydration with which she does not comply.”

The medical evidence indicates that Ms.X suffered extensive childhood trauma. Both her eating disorder, and her dependence on alcohol, probably arose as coping strategies to deal with these early traumatic life events. The evidence submitted to the Court states that she is extremely resistant to the idea of any psychological talking therapy, and that as soon as she is not detained in hospital, her drinking and eating behaviours recommence.

All the medical evidence obtained by the Judge came to the same conclusion: that is was no longer in the patient’s best interests to be forced to undertake medical treatment, even if that treatment was intended to prolong life.

The Judge referred to a 2013 Supreme court case, Aintree University Hospital NHS FoundationTrust v James, and quoted Baroness Hale as saying: "The starting point is a strong presumption that it is in a person's best interests to stay alive … this is not absolute. There are cases where it will not be in a patient's best interests to receive life-sustaining treatment”.

Applying that principle, the Judge concluded in this case: “I have reached the clear conclusion that I should not compel treatment for Ms X's anorexia.”

What are we to make of this?

I certainly have severe concerns about the implications of this judgment, not just for Ms.X, but for others with chronic and difficult to treat mental disorders.
The case referred to in this judgment concerned a man, Mr James. He had developed an infection which was complicated by chronic pulmonary disease, an acute kidney injury and persistent low blood pressure. He was placed on a ventilator, and over a period of months had a stroke and recurrent infections.

Mr. James was essentially terminally ill. He had serious and untreatable medical conditions, and ongoing treatment would only serve to prolong life at the expense of quality of life.
Ms.X, on the other hand, although suffering from serious physical health problems, had a mental disorder, and it was this mental disorder that was the driving force behind her poor physical health.
A couple of years ago the Court of Protection considered another case involving a woman with anorexia nervosa. This was the case of E.

E had a Body Mass Index of less than 12. She was in a palliative care setting and was refusing to eat. She had a very long history of anorexia, and had had been subject to many treatment regimes over that time, with little or no success. She was at the point of death. The essential decision the Judge had to make was whether or not further life saving treatment against her will was in her best interests.

It was presented to the Judge that, although past treatment had failed, there was a prospect that long term treatment for her eating disorder and other underlying conditions had some prospect of success. The Judge concluded in this case:

“The competing factors are, in my judgment, almost exactly in equilibrium, but having considered them as carefully as I am able, I find that the balance tips slowly but unmistakably in the direction of life-preserving treatment. In the end, the presumption in favour of the preservation of life is not displaced.
I declare that E lacks capacity to make decisions about life-sustaining treatment, and that it is lawful and in her best interests for her to be fed, forcibly if necessary. I find that the resulting interference with E’s rights under Articles 8 and 3 is proportionate and necessary in order to protect her right to life under Article 2.”

Both these women had anorexia nervosa with very low body weight. While Ms X also had alcohol dependency problems, I don’t think these cases are sufficiently different in their nature to warrant the different conclusions reached: Ms.X was essentially to be allowed to die from the medical consequences of her mental disorder, while E would be forcibly fed if necessary in order to protect her life.

I have often written on this blog about the use of the MHA to save life, in cases of anorexia nervosa and with other mental disorders. Whether a patient lacks capacity or not, I still incline to the view that, at least in the case of people with mental disorder, legal powers should be used to save and prolong life, not to facilitate the ending of life.


  1. E had had indifferent and patchy support from overburdened and largely non-specialist services. Perhaps with X the view was that treatment had had a fair trial? Only saying: I share your deep concern about this. Where would we be in a few years if the boiled down received wisdom version of this judgement was that professionals were allowed to abet service users with complex needs putting themselves out of the misery of frustrated professionals?

  2. Terrified, - so now it is OK to let people with mental illness die. No one knows what might change her sitiuation if she is given life saving treatment. It is certain that without it she will die and the State will have removed any opportunity for her to stay alive. As a carer of relatives with mental illnesses there are so many barriers to effective treatment, it is made very clear that it is all about cost. When you already feel worthless and want to die, now you are told that the State agrees. Where is the protection for severely ill people?.

  3. I agree, this is very worrying, though unfortunately not the first case like this. A similar decision was made in Re L; the NHS Trust v L (2012). I think it says more about the attitudes of professionals than the patient. Chronic patients are hard and frustrating to treat... shove them all into palliative care and assuage your guilt by pretending it's in their best interests. Commissioners would love it - save money and improve throughput... I don't believe anybody should be written off like this. I've known people more physically unwell than X who've gone on to make a 'full' recovery (Conversely, people at higher weights and shorter duration of illness have died). Death can be very enticing when you're in the depths of mental illness, death from starvation can be a romanticised goal when you are anorexic. Knowing that professionals might condone these wishes, which are ultimately part and parcel of a mental illness, sets a dangerous precedent.

  4. I have a couple of issues with your conclusions and the comments here. This is described as a unique case, and it is. This balances the treatment for a mental disorder with the potential for continued/accelerated damage to the liver. This does not strike me as a sudden change to allow people who have mental health problems to die because clinicians agree with them if they want to die. This is clearly a matter where the current treatment methods for one problem might exacerbate another problem and where death can result from both problems. It doesn't appear to be about powers ending life, but as clearly indicated in the judgement summary that it may prolong life.

  5. Anonymous 1.

    Finally caught up with the judgment, which neatly explains the difference in outcome from the re: E case thus: [an expert in treating eating disorder] 'considered that "treatment which might return E to relatively normal life is available but has not so far been tried, and that she should receive it" (§38 ibid.). There was a specialist eating disorders unit prepared to undertake the treatment. In this case, Ms X has been successfully treated in the past, but has then relapsed; there is no untried treatment in this case – all treatments have been offered and failed.'

    1. I have of course read, and commented on, both cases. My basic stance remains that there may be cases in which it is appropriate to condone assistance with dying -- but only in cases of chronic and/or terminal physical illness, and not where the physical health problems arise from mental disorder. One should strive to treat and resolve the mental disorder, in order to facilitate the recovery from the physical disorder.