Airedale NHS Trust v Bland

Where a patient is irreversibly in a persistent vegetative state and continuation of invasive life-support (including artificial nutrition and hydration) confers no therapeutic benefit, doctors may lawfully discontinue such treatment if (a) continuing it is no longer in the patient's best interests and (b) the decision accords with responsible medical opinion; withdrawal in those circumstances is an omission, not an act of killing, and will not amount to murder. The Family Division should normally be asked for declaratory guidance in comparable cases.

The appellant is the Official Solicitor acting as guardian ad litem for Anthony Bland, who since the Hillsborough disaster has been in a persistent vegetative state (P.V.S.) with irreversible cortical destruction and no prospect of recovery. The Airedale N.H.S. Trust and the treating clinicians sought declarations from the Family Division that they could lawfully discontinue life-sustaining treatment, including artificial ventilation, nutrition and hydration. Sir Stephen Brown P granted the declarations on 19 November 1992. The Official Solicitor appealed to the Court of Appeal which dismissed the appeal on 9 December 1992. The Official Solicitor obtained leave and appealed to the House of Lords. The central legal issue was whether, and in what circumstances, withdrawal of artificial nutrition and related life-sustaining measures from a P.V.S. patient is lawful, and whether such withdrawal could amount to criminal homicide. The House of Lords was asked also whether court approval should be sought in similar future cases.

Overall disposition

1. The appeal is dismissed. The House of Lords upheld the declarations of the Family Division that, in the particular facts of this case, the Trust and responsible physicians may lawfully discontinue life-sustaining treatment (including artificial nutrition and hydration) and thereafter need not provide medical treatment except for palliative purposes ([1993] UKHL 17).

Key legal findings and reasoning

1. Legal character of artificial feeding: the court accepted that nutrition and hydration supplied by nasogastric tube constitute part of the patient's medical care and are properly characterised as medical treatment for present purposes. That characterisation is not determinative of the outcome but underscores that the measures form part of a therapeutic regime which may be assessed by clinicians ([1993] UKHL 17).
2. Best-interests principle governs treatment for incapacitated adults: where an adult patient lacks capacity no one may consent for him; treatment can be lawfully provided only if it is in the patient's best interests. Decisions to initiate, continue or discontinue treatment for such patients are to be made in accordance with responsible medical opinion applied to the patient's best interests (drawing on the approach in In re F. (Mental Patient: Sterilisation) [1990] 2 AC 1 and the Bolam standard) ([1993] UKHL 17).
3. Futility and best interests: where life-sustaining treatment confers no therapeutic benefit (is medically futile) and continuation serves no patient-centred objective, it is not necessarily in the patient's best interests to continue that treatment. In such circumstances discontinuance is lawful. In cases of extreme P.V.S. with no prospect of recovery the court accepted that continuing invasive measures may be futile and discontinuance may accord with the patient's best interests ([1993] UKHL 17).
4. Acts and omissions / criminal law: the House drew a crucial distinction between (a) positive acts intended to cause death (which remain unlawful and constitute euthanasia/possible murder) and (b) the omission to continue invasive treatment which the doctors are no longer under a duty to continue. Where no duty to continue exists because treatment is not in the patient's best interests, discontinuance is an omission and will not necessarily constitute murder or unlawful killing. The court held that discontinuance in the present case would not be criminal ([1993] UKHL 17).
5. Role of the court / procedure: because of the gravity and sensitivity of the decision and public concern the House endorsed the Family Division practice that, for the time being, applications for declaratory relief to authorise discontinuance in comparable cases should normally be made so as to protect patients, doctors and families and to provide public reassurance. The court envisaged that with experience the procedure might be refined ([1993] UKHL 17).

Practical conclusion and orders

The House dismissed the appeal and affirmed the declarations below that the Trust and attending doctors may lawfully discontinue life-sustaining treatment (including artificial nutrition and hydration) in Anthony Bland's case, and thereafter need not provide further medical treatment except for palliative purposes; there was liberty to apply in the event of material change. No order as to costs was made.

• Family Division (High Court): Declaration granted by Sir Stephen Brown P that the Trust and physicians may discontinue life-sustaining treatment including artificial nutrition and hydration (application issued by Airedale N.H.S. Trust) (19 November 1992) ([1993] UKHL 17 antecedent decision).
• Court of Appeal: Appeal by Official Solicitor dismissed (9 December 1992).
• House of Lords: Appeal dismissed and declarations upheld (4 February 1993) ([1993] UKHL 17).