Background
MM, a 45-year-old woman with bipolar disorder, executed an advance healthcare directive on 6 November 2025 stating that she did not want psychiatric medication in any circumstances, even if refusing it placed her life at risk. After she stopped taking prescribed medication, she experienced an acute manic episode and was involuntarily admitted under the Mental Health Act 2001 in December 2025. She also declined medication and monitoring for diabetes, hypertension and high cholesterol.
The HSE sought declarations concerning MM’s capacity and the directive’s validity and applicability, together with authority to provide psychiatric and physical healthcare. The High Court made interlocutory orders permitting treatment while the proceedings were pending. MM was discharged after the substantive hearing, but the Court proceeded to decide jurisdiction and the directive’s validity because the directive remained in existence, the dispute could recur urgently, and the statutory issues had broader public importance.
The Court’s Holding
Mr. Justice Dignam held that whether treatment is “life-sustaining treatment” under the Assisted Decision-Making (Capacity) Act 2015 depends on the circumstances existing when treatment is proposed. In MM’s particular condition when the application came before the Court, psychiatric medication qualified as life-sustaining treatment. The application therefore fell within the High Court’s jurisdiction under section 89(2) of the 2015 Act.
The Court further held that a directive-maker’s lack of capacity when making an advance healthcare directive is a ground on which the directive may be declared invalid under section 89. Applying the statutory functional test and presumption of capacity, the Court found that the presumption had been rebutted: MM lacked the ability to understand, use and weigh the information relevant to the decision when she executed the directive. It therefore declared the 6 November 2025 directive invalid.
Because MM had been discharged and the directive was invalid, the Court did not decide whether it had been applicable, whether the Mental Health Act independently authorised treatment of her physical conditions, or what effect a valid refusal of psychiatric medication would have had on her continued involuntary detention.
Key Takeaways
- Whether psychiatric medication is life-sustaining treatment is context-specific; it was life-sustaining in MM’s circumstances when the proceedings began.
- Lack of capacity at the time an advance healthcare directive is made can support a declaration under section 89 of the 2015 Act that the directive is invalid.
- The statutory presumption of capacity requires evidence addressing the person’s functional ability to understand, retain, use or weigh relevant information, and communicate the decision.
Why It Matters
The judgment provides guidance on Ireland’s relatively new statutory regime for advance healthcare directives, particularly the division of jurisdiction between the Circuit Court and High Court. Its context-sensitive treatment of the phrase “life-sustaining treatment” also affects whether interim treatment may be provided while the High Court determines a directive’s validity or applicability.
The decision does not establish that psychiatric medication is invariably life-sustaining, nor does it resolve the scope of authority under the Mental Health Act 2001 to treat unrelated physical conditions. Those questions remain dependent on the facts or await fuller determination in a suitable case.