The High Court has ruled that an advance healthcare directive in which an anonymised woman refused all psychiatric medication was invalid because she lacked capacity when she signed it.
Mr Justice Dignam's judgment also provides guidance on when treatment may qualify as "life-sustaining" under the Assisted Decision-Making (Capacity) Act 2015, an issue which determines whether challenges to an advance directive belong in the High Court rather than the Circuit Court.
Ms M, a 45-year-old woman with a history of bipolar disorder, signed the directive on 6 November 2025. It stated that she did not want any psychiatric medication in any circumstances unless she later changed her mind, and that the refusal should apply even if her life was at risk.
She was involuntarily admitted to hospital on 24 December 2025 during what clinicians described as an acute manic episode. The HSE later sought court orders concerning psychiatric treatment and treatment for physical conditions including diabetes and high blood pressure.
Dignam J held that whether treatment is life-sustaining depends on the particular circumstances. The treatment must be intended to sustain life, and withholding it must create a real, proximate risk of death rather than a vague or general future risk.
On the medical evidence, the judge found that untreated mania, combined with Ms M's diabetes, high blood pressure, raised cholesterol and family history of heart disease, created a real cardiovascular risk. Psychiatric medication was therefore life-sustaining treatment in her particular circumstances.
The court also found that the statutory presumption that Ms M had capacity when she signed the directive had been rebutted. Evidence indicated that her mental health had deteriorated before November 2025 and that she was unable adequately to understand or use and weigh information relevant to refusing psychiatric treatment.
Ms M had been discharged from hospital before judgment. The court nevertheless determined the validity issue and declared the November 2025 directive invalid.