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Twenty years ago, English courts were twice faced with the dilemma of needle phobia; both cases relating to women who had consented to urgent caesarean section and explicitly wanted their babies to be born safely. In one, L was in full term obstructed labour; whilst MB had a footling breach presentation in a 33 week baby.
Neither woman would consent to the venous cannulation required for the anticipated anaesthesia, because they were both terrified by the prospect of an injection. In the first case, the judge ruled that L had demonstrated capacity to consent for the operation. But he found that her extreme needle phobia amounted to an involuntary compulsion, disabling her from weighing and balancing treatment information, and thus removing her capacity to refuse the procedure. Her phobia compelled L ‘with such force that her own life would be in serious peril’. Accordingly, he declared that it was lawful for L to be cannulated, since in her (temporarily) incapacitated state, safe delivery of her baby was in her best interests.
In the case of MB, on similar facts, a High Court judge again declared that it would be lawful to compel her to have the treatment required for a safe delivery. An appeal was immediately launched, but the Court of Appeal dismissed this in the early hours of the following morning. The Court started by reminding itself that a person with capacity is entitled to make a decision for religious or other reasons, for rational or irrational reasons, or for no reasons at all, irrespective of the consequences. Irrationality was described in stark and memorable terms;‘A decision so outrageous in its defiance of logic or of accepted moral standards that no sensible person who had applied his mind to the question to be decided could have arrived at it’
The Court of Appeal accepted that panic, irrationality and indecisiveness may be symptoms of incapacity, but made it clear that by themselves, these do not amount to a loss of capacity (as today is defined by the Mental Capacity Act 2005). The Court reiterated the proposition that needle phobia amounts to an involuntary compulsion, asserting that ‘…temporary factors, such as confusion, shock, fatigue, pain or drugs, or panic induced by fear might erode or destroy capacity’. It emphasised that careful examination of the evidence was required before concluding whether fear had destroyed capacity; as opposed to being a reason for capacitous refusal. Applying these principles to MB’s facts, it was held that she had lost her capacity because her needle phobia had dominated her thinking.
Adults with capacity have dominion over their decision-making for consent to any intervention. It is only in extraordinary circumstances that this principle can be challenged. Nevertheless, most clinicians will see needle phobia in their career. In elective or urgent circumstances, it should be possible to anticipate the destruction of the patient’s capacity due to fear, and negotiate a solution prior to the start of the intervention.
In emergencies, it would be rare for needle phobia to have an opportunity to erode the patient’s capacity to consent for treatment. Most patients are usually very unwell in the prelude to their emergency intervention. The illness itself may have rendered them incapacitated; or at the very least, the severity of their plight prior to surgery or other procedure may overshadow the panic that the prospect of cannulation might induce in less onerous circumstances. Should needle phobia stand in the way of emergency treatment in a patient who otherwise has capacity, it would seem likely that a telephone application to the High Court at any time of the day or night will produce a similar result to that in these two obstetric cases.