High Court vindicates hospital's action on transfusion

A LANDMARK High Court decision that the Coombe Women's Hospital acted lawfully in getting a court order allowing it give a necessary blood transfusion to a female member of the Jehovah's Witnesses faith against her wishes has set out guidelines for how hospitals, courts and the State might address similar future situations.

The case was the first time an Irish court was asked to decide in what circumstances a court may make an order authorising medical treatment for a competent adult who has refused such treatment.

The action arose after the hospital secured an emergency High Court order on September 21st, 2006, permitting it to administer a blood transfusion to the now 24- year-old Congolese woman, identified only as Ms K.

The hospital got the order on an ex parte basis (one side represented) after saying it feared the woman's life would be in danger were she not transfused. Ms K had earlier that day lost an estimated 80 per cent of her blood while giving birth to her first child, a boy, but refused the transfusion because of her religious beliefs.

In proceedings heard over 37 days before Ms Justice Mary Laffoy, the hospital argued it was entitled to seek the order and the court was entitled to grant it. Ms K rejected those claims, argued the order breached her rights and represented an assault on her person and also sought damages.

In her reserved 135-page decision, Ms Justice Laffoy granted a declaration that the hospital acted lawfully in sedating and transfusing Ms K, following the making of the September 21st order.

Because Ms K had initially told the hospital she was Roman Catholic and misrepresented other matters, the situation in which she was transfused against her wishes was, unfortunately, "of her own making", the judge remarked.

The core issue was whether the court was entitled to intervene and make the ex parte order authorising that Ms K, a competent adult, be transfused, notwithstanding that she had expressly refused a blood transfusion.

A valid refusal of treatment must be based on the appropriate treatment information, be made by a person with the necessary capacity, and must be voluntary, she said.

In this case, while Ms K's refusal was made on a voluntary basis and she had been given the appropriate treatment information by doctors, the refusal was not legally valid because she lacked the necessary capacity to make the decision.

The test for assessing capacity was whether a patient's cognitive ability was impaired to the extent they didn't sufficiently understand the nature, purpose and effect of the proffered treatment and the consequences of accepting or rejecting it in the context of the choices available.

Capacity also had to be decided on the basis of what was known to the hospital staff at the time about Ms K's condition and the fact the hospital was making its decision in an emergency situation.

The evidence showed the Master of the Coombe and other hospital personnel were "objectively justified" in doubting Ms K's capacity, the judge ruled. Remarks by Ms K that day to the effect her blood loss could be addressed by Coca-Cola, tomatoes, eggs and milk were "symptomatic of her lack of understanding of the gravity of her condition".

Ms K experienced a massive haemorrhage just before 10am and it was then staff learned she would not accept a blood transfusion. All the experts agreed the hospital had "superbly" managed the emergency that arose, and doctors were unanimous the appropriate treatment for her after the haemorrhage was a blood transfusion. The judge rejected as "fundamentally flawed" arguments by Ms K that, to justify the transfusion, the hospital had to show the threat to her life was such that her death was likely beyond reasonable doubt or, as an absolute minimum, probable. "Such a test would place an impossible burden on clinicians," she said.

Given her finding that the refusal was not legally valid, the judge said other issues, including the balancing of the rights of Ms K against those of her baby to be nurtured and reared by her mother, did not arise.