Unqualified patient autonomy harms the heart of medicine

At a resumed inquest in October, the Coroner ruled that doctors at the Norfolk and Norwich University Hospital had acted correctly in not giving any lifesaving treatment to 26 year old Kerrie Wooltorton when she was admitted in 2007 having suicidally ingested antifreeze. (1) It appears that she had done this up to nine times previously, accepting lifesaving treatment on every occasion, and this history might have been due to her 'untreatable' emotionally unstable personality disorder. (2) On this occasion, a few days before her death she had drafted an advance statement indicating she did not wish to be treated if the same circumstances arose in the future. They did. She drank antifreeze again, called an ambulance, was taken to hospital, and while conscious and said to be with full capacity consistently refused lifesaving treatment. (She called the ambulance because she did not want to die alone and wanted comfort measures only.)

October's publicity caused outcry, with most people's intuitions being that this was not what medicine is about; that attempts should have been made to save her. At first the case was seen to concern advance directives, given (mistakenly in CMF's view) full legal force in the Mental Capacity Act 2005. Health Secretary Andy Burnham said that the case took the law into 'new territory' which he did not believe had been intended by Parliament. (3) However, as Sheila McLean argues (2) it was the consistent, contemporaneous refusal with capacity of lifesaving treatment that meant the doctors, after consultation and with legal advice, were right to let her die.

That conclusion about capacity has since been challenged by two consultant forensic psychiatrists who state that 'depression and emotionally unstable personality disorder are mental disorders, which often impair a person's cognition and emotional health'. (4) Arguing that she could have been detained compulsorily and treated, they make the further point that, with a few exceptions, 'the Mental Health Act 1983 “trumps” the Mental Capacity Act 2005'.

The legal and ethical debate will doubtless continue, but even if the doctors acted correctly within the letter of the law, most have concluded they missed the spirit of it. The ideology of unqualified patient autonomy harms the heart of medicine.

References

1. news.bbc.co.uk/1/hi/england/norfolk/8284728.stm
2. McLean S. Live and let die. BMJ;339:b4112
3. Bingham J. Living wills law could be 'revisited' after Kerrie Wooltorton suicide case – Andy Burnham. Daily Telegraph 4 October 2009
4. Bashir F, Crawford M. Autonomy or life saving treatment for the mentally vulnerable? BMJ 2009;339:b4400

Article written by Andrew Fergusson

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