Court of Protection: Anorexia nervosa is a condition which may render a patient without capacity to decide on treatment
27 August 2025
This judgment was handed down to parties via email at 3pm on 31st July 2025. A transparency order is in force. The judge has given leave for this version of the judgment to be published on condition that (irrespective of what is contained in the judgment) in any published version of the judgment the anonymity of Patricia must be strictly preserved.
Patricia’s Father & Ors v Patricia & Ors [2025] EWCOP 30 (T3)
This application was brought by the parents and aunt of a woman who has previously been anonymised to “Patricia”. Patricia, aged 25, had lived with anorexia nervosa since childhood, and was extremely malnourished with a BMI as low as 7, unable to walk unaided, and suffering severe complications like bed sores and osteoporosis. Diagnosed also with autism and pathological demand avoidance (PDA), Patricia’s condition was refractory despite years of efforts; she persistently refused to eat enough to sustain herself, though she voiced a desire to live and to travel. In 2023, the Court (Moor J) had ordered—after hearing her strongly expressed wishes—that Patricia should not be force-fed or receive medical treatment against her will, emphasising her autonomy in treatment decisions.
Throughout these proceedings Patricia was an in-patient at Norfolk and Norwich University Hospitals NHS Foundation Trust. She had said she wanted to go to a Specialist Eating Disorder Unit (SEDU) but when this case started she was not medically fit enough to go to one because of her low BMI and her lack of medical stability.
By the time of this application in 2025, Patricia’s parents and aunt, not parties to the 2023 orders, sought to revisit the matter, urgently applying to the Court of Protection as Patricia faced imminent discharge to a palliative setting, with the perception that she was nearing death. An extensive series of hearings unfolded, examining clinical feasibility, legal principles, and Patricia’s expressed preferences.
Her family sought to lift the previous orders preventing compulsory feeding, hoping a SEDU might accept her. The hospital was clear that they would not accommodate force feeding by nasogastric tube, unless there was a SEDU committed to providing the follow-on care which had to involve force feeding if necessary.
The clinical evidence was unanimous: leaving decisions to Patricia alone had not succeeded; her condition was worse despite small improvements during proceedings. Yet Patricia herself was unwaveringly opposed, describing force-feeding as traumatic and expressing PTSD from past attempts.
Issues before the Court
The question before Arbuthnot J was whether he could or should revisit the autonomy-based orders from 2023. In the event, he made a case management decision to deliver this judgment and not to await the availability of a bed at a SEDU. He had to consider new evidence, changed circumstances, and in particular, whether the earlier orders now constituted a barrier to potentially life-saving care.
The judge found that Patricia lacked capacity to make decisions about her treatment due to the direct cognitive effects of extreme anorexia:
“I heard unchallenged evidence that the brain shrinks as the AN takes hold. Patricia is at a very low weight indeed with a BMI of about nine: I heard evidence that this is likely amongst the lowest in the country. Her cognition is greatly affected by this disease. I find she lacks capacity to conduct litigation or make decisions in relation to her treatment for AN.”
Reasoning behind the decision
Arbuthnot J acknowledged the original 2023 judgments had rightly respected Patricia’s wishes at the time, but circumstances had markedly deteriorated; the hands-off approach had not worked, and Patricia was closer to death than ever. Key observations included the following:
“In 2025, it is undoubtedly the case that Patricia is much nearer to death than she was in 2023 and yet she does not want to die. It was her cognition caused by the AN in addition to her autism and PDA which have led to her refusal to take on the calories she needs to live. She said she wanted to be able to walk again and travel yet what was preventing her from doing this was her refusal to increase her BMI.” [para 166]
“The inability to accept that weight gain is essential for improved health can be the basis for detention and treatment under the Mental Health Act”.
Patricia’s parents’ evidence laid heavy with the judge.
“They were in an awful situation. They were desperate for their daughter to live. I had heard evidence that on occasions they interfered with Patricia’s treatment but they explained that they were being manipulated by Patricia on a regular basis. She would tell them she would stop eating if they did not do what she wanted. The degree of her control over them was shown by their evidence that when Patricia was in hospital, she told them what they could or could not buy for them to eat at home. I struggled to understand why they put up with this but it was because she was threatening them with stopping eating or “downing tools” (one of the expressions she uses with the court and others to get her own way).” [ para 104]
The Court of Protection exists to make decisions based on current best interests, which may change as circumstances change. The reasoning by the judge (Moor J) in the previous hearings regarding Patricia’s status were not wrong. He had made no error of law nor had he failed to take into account any factor relevant to best interests so that the best interests decision was wrong. Nevertheless, the Court had now heard evidence from a number of clinicians and experts or quasi experts, and should now consider the application afresh.
What the court could not anticipate is how Patricia would react to the decision of the court. Her thinking was “dominated by the AN… Her anorexic cognition has prevented her from understanding the link between living or even just being able to walk and the need to take on calories to give her the strength she needs. It is a complete block in her understanding caused either by AN or by her autism and PDA. She is a highly intelligent young woman yet she fails to accept the link between eating and living.
Leaving the orders in place had put an impossible burden on her.”
The evidence demonstrated that maintaining the autonomy-based orders denied Patricia access to treatment available to other anorexic patients, possibly sealing her fate. Her parents sought the lifting of the orders to enable active treatment. Clinicians recognised both the trauma that forced feeding would bring and the reality that past attempts had failed, but also noted that recovery was sometimes possible even in the direst circumstances. On balance, some felt that allowing compulsory treatment gave her at least a chance at survival, while respecting her wishes risked immediate death.
The Court of Protection’s Order
The Court was not being asked to consider what specific treatment the patient should receive in any SEDU and that question was to be left to the clinicians treating her. The judge’s view was that Patricia should have access to the treatment or lack of treatment that any other anorexic patient does. The court should not impose an order which would prevent her from having the treatment which may save her life when she wants to live.
It was within the Court’s power and Patricia’s best interests to revisit and rescind the previous autonomy-based orders. The ruling enabled clinicians in SEDUs to determine the appropriate treatment—including the possibility of compulsory feeding under the Mental Health Act—allowing Patricia the same options as other severely anorexic patients in the UK. This was not a mandate for force-feeding, but the removal of a judicial barrier so specialists could act as they judged fit.
Implications
The case is a powerful lesson about the law’s limits in safeguarding autonomy in cases of severe mental illness: rigid adherence may ultimately do harm, and prior judicial decisions must be kept under review. It underscores the difficulty of substituting best interests for personal wishes where capacity is clouded by illness, especially when the patient’s values and beliefs are formed by the very disorder the law seeks to treat. The decision also highlights resource constraints, disagreements among professionals, and the emotional turmoil for families and clinicians alike.
Patricia’s case illustrates that, in the unusual intersection of anorexia and legal incapacity, autonomy can become an illusory safeguard—sometimes requiring the court to step in and shift the balance toward minimally possible life-saving intervention. The decision is not a template for all similar cases but a reminder of the need for vigilance, flexibility, and humility in judicial orders concerning self-determination and life-sustaining treatment under the Mental Capacity Act.
As Alex Ruck Keene has commented in detail on this case in his Mental Capacity Law and Policy blog. “Clinically, it highlights deep and insufficiently understood splits amongst clinicians about how to respond to anorexia, especially in the context of resource limitations which appear (all too often) to cut off first line responses. And ethically it highlights how anorexia has an almost unique ability to render relationships – both familial and clinical – all but untenable: brought home vividly by the fact that name of the case suggests that Patricia’s father, mother and aunt are bringing a case against her.
The focus on ‘autonomy’, he continues, is “striking”, in this judgement and that of Moor J. “It is worth remembering that the word does not appear in the MCA 2005 itself; it is also worth remembering that it is a concept that frequently hinders more than it helps. As Swift J felt the need to point out in the Royal Bank of Scotland case, for instance, it is just as much a failure to respect autonomy not to interrogate evidence that the person may lack capacity to make a decision as it is to barge ahead and make decisions for them without establishing that they do, in fact, lack capacity to make the decision. It might be thought that (as with the term ‘dignity’) it would be sensible to strive to avoid making use of the term in decision-making in this context, at least without a very clear-eyed understanding of what exactly is being intended.”
