Airedale NHS Trust v Bland

The House of Lords held that, on the facts of this case, it was lawful for treating clinicians and the hospital authority to discontinue life-sustaining medical treatment (including artificial nutrition and hydration) for a patient who had been in a persistent vegetative state (P.V.S.) for a prolonged period with no prospect of recovery. The court treated nasogastric feeding as part of medical treatment and applied the established principle that where an adult patient lacks capacity the provision or withdrawal of medical treatment is to be judged by reference to the patient's best interests. The court emphasised the legal distinction between an active step intended to cause death (euthanasia), which remains unlawful, and discontinuance of treatment which allows the underlying condition to cause death. The court also recommended that, for the protection of patients, families and clinicians, applications for declarations in similar and grave cases should ordinarily be brought to the Family Division of the High Court with the Official Solicitor as guardian ad litem.

This appeal concerned an originating summons brought by the Airedale National Health Service Trust seeking declarations that it would be lawful to discontinue life-sustaining treatment (including ventilation, nutrition and hydration by artificial means) for Anthony Bland, who had been in a persistent vegetative state since the Hillsborough disaster and for whom there was unanimous medical opinion of no prospect of recovery.

Background and procedural posture:

• Anthony Bland, then a minor at the time of injury, sustained catastrophic hypoxic brain damage at Hillsborough (15 April 1989) and had been insensate with irrecoverable cortical damage for over three years. He was maintained by artificial feeding (nasogastric tube), catheter care and other life-supporting measures.
• The Airedale NHS Trust, with the agreement of the treating clinicians and the patient's family, applied to the Family Division for declaratory relief that the proposed discontinuance of life-sustaining treatment and thereafter provision of only palliative measures would be lawful.
• The Official Solicitor acted as guardian ad litem for Anthony Bland and opposed the declarations on criminal law and other grounds. The President of the Family Division (Sir Stephen Brown P.) granted the declarations on 19 November 1992; the Official Solicitor appealed and the Court of Appeal dismissed the appeal (9 December 1992). The Official Solicitor appealed to the House of Lords which heard the case and dismissed the appeal on 4 February 1993.

Nature of the claim / relief sought: declarations that the Trust and responsible physicians may lawfully discontinue all life-sustaining treatment and medical support measures (including artificial nutrition and hydration) and thereafter provide only treatment for the purpose of enabling a peaceful death.

Issues framed by the court:

• Whether artificial nutrition and hydration by nasogastric tube constitutes medical treatment.
• Whether, and in what circumstances, a doctor may lawfully discontinue life-sustaining medical treatment for an adult patient who lacks capacity.
• Whether discontinuance in such circumstances would amount to criminal homicide (murder or manslaughter) or a civil wrong.
• What procedural safeguards (if any) should apply to similar future cases.

Reasoning and conclusions:

• The court accepted the unanimous medical evidence that Mr Bland was in irreversible P.V.S. with no prospect of recovery and that nasogastric feeding and associated care form part of medical treatment/care.
• Relying on the legal principles in In re F. and established common-law doctrine, the court held that where an adult lacks capacity the standard for providing or withholding treatment is the patient's best interests. That assessment may include broader considerations (dignity, invasiveness of treatment, family interests) and is not confined to pain or suffering alone.
• The court distinguished active euthanasia (deliberate acts to cause death) — which remains unlawful — from discontinuance of medically provided life support where the treatment is futile; discontinuance, when in accordance with responsible medical opinion and the patient's best interests, does not constitute murder because it is not an unlawful act or omission within the meaning of the criminal law.
• The court recommended that, as a safeguard and public reassurance, declarations by the Family Division should be sought in similar cases and that the Official Solicitor should act as guardian ad litem to ensure full investigation of facts.

Appeal dismissed. The House held that on the facts (irreversible persistent vegetative state, no prospect of recovery, unanimous responsible medical opinion that feeding and other life-sustaining measures were futile and not in the patient's best interests) it is lawful for clinicians to discontinue life-sustaining medical treatment including artificial nutrition and hydration. The court treated artificial feeding as medical treatment, distinguished discontinuance from active euthanasia, and recommended Family Division applications with the Official Solicitor as guardian ad litem as an appropriate safeguard.

Originating summons in the Family Division (High Court) — declaration granted by Sir Stephen Brown P (19 November 1992); appeal to the Court of Appeal — appeal dismissed (9 December 1992); appeal to the House of Lords — appeal dismissed [1993] UKHL 17 (4 February 1993).