Court authorised life-saving surgery to remove gastric band against wishes of woman

Seán McCárthaigh

The High Court authorised the HSE to arrange life-saving surgery on a woman against her wishes last month after she repeatedly refused to have an operation to remove on a gastric band that had become dangerously restrictive of food passing into her stomach.

A newly published ruling shows Judge Barry O’Donnell issued orders permitting the HSE to carry out invasive medical procedures that it considered urgent on foot of concerns raised by her doctors.

The court heard the woman suffered from a serious eating disorder and required surgery to remove a gastric band that had been in place for about 10 years as well as a period of postoperative care in a specialised unit to help her deal with the potential for some rapid weight gain which she was likely to find very distressing.

Lawyers for the HSE claimed the continued presence of the gastric band was unsuitable when the woman had an eating disorder.

They said the gastric band was also too tight and causing her malnutrition from very little food passing into her stomach.

The HSE said the gastric band had already caused damage to the woman’s oesophagus and stomach and risked causing further harm including potentially fatal damage.

Judge O’Donnell directed that no details of the case should be published which could identify the woman, her doctors or the hospital.

The court heard that the woman who is in her 30s is intelligent, employed and lives a fully independent life.

The judge heard there was unanimous clinical evidence including from an independent expert that the woman did not have the legal capacity to make decisions about the removal of the gastric band.

However, the woman made it very clear in direct evidence that she did not wish to undergo the procedure.

The woman, who has a background history of recent trauma, also voiced concerns about the impact of hospitalisation on her employment, finances and professional qualifications.

She acknowledged the bona fides of her doctors but expressed a preference for a slower and less invasive way of addressing her difficulties.

A consultant psychiatrist for the HSE, identified only as Dr M, said the woman, who had problems with her weight since her teenage years, had a terror of weight gain to the point that she was jeopardising her long-term physical health.

Dr M gave evidence that although the woman did not want the surgery or treatment, a point had been reached where they were largely unavoidable and “robust intervention” was required.

He told the court that while she was consuming up to 16,000 calories per day, approximately 90% of her food intake was not being absorbed and she was being treated for anaemia.

An independent psychiatrist retained by the woman’s guardian ad litem (independent advocate) agreed there was an urgent need for the procedure.

He claimed her extreme fear of weight gain had primacy over any other aspect of her life including her survival.

A bariatric surgeon, Prof H, who was due to carry out the surgery, observed there was a risk that blood supply to the woman’s stomach could be compromised by a tight gastric band.

Prof H explained that this increased the risk of a hole in the stomach, which would be a life-threatening emergency.

She outlined how a barium swallow study showed nothing had passed through the gastric band after 11 minutes, which she described as “highly abnormal".

The court heard the woman’s oesophagus was significantly dilated at almost four times its normal diameter and at risk of rupture, particularly in case of forced vomiting.

Prof H said there was a risk the patient would develop pseudoachalasia – a movement disorder of the oesophagus – which poses difficulty swallowing and would affect her nourishment and quality of life.

She claimed there was a risk of the woman developing a rare condition of a gastric or oesophageal perforation which carries a mortality rate of 30 per cent but 100 per cent if not treated within 48 hours.

Prof H estimated the risk for the patient at 3-5 per cent which she claimed was 3 to 5 times that of the general population.

In his ruling, Judge O’Donnell said he was very impressed with the woman’s “genuine and heartfelt” approach to her situation and acknowledged her “reasonable” concerns about practical matters such as ability to pay her rent.

The judge noted she did not want the band removed entirely and did not think it was dangerous.

However, he said it was striking that the psychiatric evidence in the case was unanimous about her inability to weigh clinical evidence in the balance.

“The fear of weight gain amounts to an overwhelming factor that outweighs all other concerns,” the judge observed.

He ruled that the woman suffers from Other Specified Feeding or Eating Disorder – a recognised condition – which requires treatment.

Judge O’Donnell said the woman attaches “disproportionate and overwhelming weight to the need to avoid any weight gain”, but there was compelling and uncontroverted evidence that she was facing a substantial health risk, including death, by retaining the gastric band.

The judge said he was satisfied the proposed surgery and postoperative treatment was proportionate and necessary, despite the fact her wishes and objections were “reasonable, heartfelt and presented clearly”.

He stressed that the more intrusive orders relating to the potential use of restraint should only be utilised as a last resort and every effort should be made to get the woman’s cooperation before the powers of the court’s orders were used.