The Health Service Executive has asked the High Court to decide that an advanced healthcare directive made by a woman with a serious mental illness that opposed her being treated with “any type” of psychiatric medication is not valid.
The Advanced Healthcare Directive (AHD), made last year under the Assisted Decision-Making Capacity Act 2015 shortly before the woman was admitted to a psychiatric unit, is not valid because the woman lacked capacity to make it, the court was told on Friday.
The AHD “cannot trump the preservation of life”, said senior counsel Patricia Hill, for the HSE. The evidence is that psychotropic medication, when considered in the context of the woman’s mental illness, her physical health conditions and family medical history, amounts to “life-sustaining” treatment.
All those factors mean a risk to the woman’s life if she is not treated with the medications, counsel said.
The woman’s treating psychiatrist, and an independent psychiatrist who interviewed her earlier this month at the request of her court-appointed guardian, both took the view she probably lacked capacity when she made the AHD, the court heard.
The middle-aged woman, with a history of mental illness over 20 years, has for some months been an involuntary patient under the Mental Health Act in a psychiatric unit and is being treated with psychotropic medication.
A core issue before Judge Conor Dignam is whether, in light of the woman’s AHD, the psychotropic treatment is permissible.
The case, to which the Mental Health Commission is a notice party, raises significant issues about the interaction of mental health legislation and the 2015 Act and has potentially far-reaching implications.
The court heard the legal compellability of an AHD depends on what provision of the Mental Health Act under which a person is involuntarily detained. The provision under which they are detained depends on the level of risk they are deemed to pose to themselves and others.
If detained as high risk, an AHD does not have to be complied with. Because treatment can alleviate the level of risk and lead to involuntary detention under another provision, an AHD may have to be complied with.
That situation can result in an “endless cycle”, Hill said.
Speaking via video-link, the woman said she believed she is not being given the same treatment choices as a non-psychiatric patient.
When on psychiatric medication in the past, she experienced huge weight gain and high blood pressure and came off tablets “bit by bit”. She was waiting for “an opportunity” like the AHD provided, she said.
The tablets she is currently taking do not appear to affect her blood pressure and she believed, if she came off them, she would be “in here forever”. When she was involuntarily detained last year, she did not feel she was that unwell and believed she had the right “to be as unwell as I want to be”.
The woman’s treating psychiatrist said her physical and mental condition has improved but, if her medication stopped now, she would relapse “in a matter of days”, would become more manic and hostile, and her physical health would also deteriorate. Her treatment would need to continue for perhaps two months, she said.
An issue arose at the outset of Friday’s hearing over whether, in light of a provision of the 2015 Act, the media could attend and report on it.
The HSE, the woman’s guardian, and the woman herself, did not object to the media reporting the proceedings but senior counsel Shane Murphy, for the commission, said the 2015 Act mandated a hearing in private.
Dignam decided, “on balance”, the media could report on the basis nothing should be published that could identify the woman, hospital or doctors involved. The case, he said, deals with the exercise of power by public authorities, potentially raises public interest points, may impose treatment on a person, and the person most directly affected did not object to reporting of it.
The hearing continues on Monday.