There had been two major changes in the situation since the first hearing a week ago. Firstly, SM’s baby was now in the breech position. Secondly, as expressed by Mr Justice Holman, the Trust was now “not necessarily resistant to doing some form of spinal anaesthesia on the day if that is her express preference and she is cooperative”.
Mr Justice Hayden is well-known (and celebrated) for his robust defence of autonomy and self-determination. And yet in this instance I got the impression that, faced with a decision about a pregnant woman, his protective instincts had (temporarily) overwhelmed him. I am relieved that he adjourned the hearing rather than precipitously (in my view) declaring SM to lack capacity and making a premature decision about her best interests.
The right of a capacitous pregnant person to make their own medical decisions unfettered by any consideration for the life or health of the foetus they carry has been enshrined unequivocally in UK law. As Judge LJ emphasised in the Court of Appeal in St George’s NHS Trust v S, pregnancy does not reduce a competent patient’s right to make decisions about their medical treatment, and a capacitous pregnant patient therefore has the right to make a medical decision that might cause death or serious injury to the foetus, however repugnant such a decision might seem to onlookers.
There was no evidence before the court about the extent to which mothers with agoraphobia (or other conditions) are in fact resistant to obtaining medical intervention in the midst of labour if advised that it is necessary to ensure the safety of themselves or their baby. In so many of the cases about mode of delivery that come before the court, the concern of the health professionals is that there will be lack of compliance in labour. Yet in most cases, the babies are born without resort to force or the authority of the court order.
Specialist perinatal mental health midwives (as well as consultant midwives who have a remit for perinatal mental health) are frequently involved in complex birth planning for women with significant mental health disorders. We have experience of creating individualised birth plans for women with severe anxiety, obsessive-compulsive disorder, post-traumatic stress disorder and psychotic illness, as well as agoraphobia. Our experience is that in all these cases, there were safe and happy outcomes – without recourse to court orders or forced hospital transfer.
At the conclusion of a three-day hearing, Mr Justice Holman declared that P lacked capacity to make the relevant decisions and ordered that it was lawful and in her best interests for medical staff to transfer her to hospital a few days before her estimated due date, and for medical professionals to offer her a choice of induction of labour or Caesarean Section in hospital.