A former medical student who suffers from extremely severe anorexia can be force fed against her wishes, a high court judge has ruled.

The 32-year-old, who has other chronic health conditions, lacked capacity to make a decision about life-sustaining treatment, Mr Justice Peter Jackson found.

Those who knew her best, the court heard, believed she should be left alone to have a "dignified death", but the judge said the state was honour-bound to see her treatment through for the long term.

Doctors have had the power to force feed anorexic people, in order to prevent them starving themselves to death, since 1997 under guidance from the Mental Health Act commission.

Delivering his decision at the court of protection in London, the judge said it was a very difficult decision to make in a situation requiring "a balance to be struck between the weight objectively to be given to life on one hand and to personal independence on the other".

Her case, he said, had "raised for the first time in my experience the real possibility of life-sustaining treatment not being in the best interests of a person who, while lacking capacity, is fully aware of her situation".

"In the end, the presumption in favour of the preservation of life is not displaced," he declared, adding that "it is lawful and in her best interests for her to be fed, forcibly if necessary."

The resulting interference with the rights of the woman, who lives in Wales and cannot be named for legal reasons but is referred to as E, was "proportionate and necessary in order to protect her right to life".

It is extremely rare, though not unprecedented, for carers to resort to court orders enabling them to force feed anorexics. The court of protection deals with cases where individuals are having difficulty making decisions about their personal health, welfare or finances.

E's case came before the court last month when an urgent application was made by her local authority, which also cannot be identified, which was "concerned that her position should be investigated and protected".

The judge said of her: "E's death was imminent. She was refusing to eat and was taking only a small amount of water. She does not seek death, but above all she does not want to eat or to be fed.

"She sees her life as pointless and wants to be allowed to make her own choices, realising that refusal to eat must lead to her death."

Mr Justice Jackson added: "She was being looked after in a community hospital under a palliative care regime whose purpose was to allow her to die in comfort."

The former medical student, described as an "intelligent and charming person", who began to control her eating at the age of 11, has not taken solid food for more than a year and when her Body Mass Index (BMI) was last measured it was 11.3 - a healthy BMI is in the region of 20.

E, who has also abused alcohol since adolescence as a "means of escape", has an "obsessive fear of weight gain". She was "an adult with an entrenched history of acute difficulties".

The judge said: "For E, the compulsion to prevent calories entering her system has become the card that trumps all others. The need not to gain weight overpowers all other thoughts."

Explaining the reasons for his decision, the judge said: "At its simplest, the balance to be struck places the value of E's life in one scale and the value of her personal independence in the other, with these transcendent factors being weighed in the light of the reality of her actual situation."

He said: "In E's situation, any decision is a heavy one. The balancing exercise is not mechanistic, but intuitive, and there are weighty factors on each side of the scales.

"On one side, I have been struck by the fact that the people who know E best do not favour further treatment.

"They think that she has had enough and believe that her wishes should be respected. They believe she should be allowed a dignified death."

The judge said he acknowledged the significant risks involved in treatment, "not excepting a risk to life", the modest prospects of success, the "wholesale and prolonged invasion of E's privacy and self-determination that is proposed", the "high chance that, even if short-term progress can be made, long-term difficulties will remain" and accepted that a resumption of treatment "deprives E of an imminent and relatively peaceful death".

Against those "weighty factors", the judge said he placed E's life "in the other scale".

He said: "We only live once – we are born once and we die once – and the difference between life and death is the biggest difference we know.

"E is a special person, whose life is of value. She does not see it that way now, but she may in future."

The judge went on: "I would not overrule her wishes if further treatment was futile, but it is not. Although extremely burdensome to E, there is a possibility that it will succeed.

"Services and funding will now be provided that were not available before and it would not be right to turn down the final chance of helping this very vulnerable young woman."

As many as one in 200 women are affected by anorexia at some point in their lives. The condition most commonly develops among teenage girls. Around 5% of those affected die from complications caused by malnutrition.

© Guardian News and Media 2012

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