In re T (A Minor) (Wardship: Medical Treatment)

When the court’s inherent jurisdiction is invoked to decide whether a child should receive medical treatment, the child’s welfare is paramount. The court must make an independent and objective assessment and may override even a reasonable parental decision.

Parental views nevertheless carry substantial weight. Where treatment requires major surgery and prolonged care, the court must consider the consequences of compelling an opposed parent to provide essential continuing support. A very strong presumption favours life-prolonging treatment, but it is rebuttable. The court must balance the treatment’s benefits against its pain, risks, effect on quality of life, practical implementation and the clinical consequences of absent parental commitment.

A young child suffered from a fatal liver defect. Without transplantation he was expected to die within 12 to 18 months. Three specialist doctors agreed that transplantation offered good prospects and was clinically in his best interests. His medically trained parents refused consent after considering the surgery, continuing treatment and its effect on their child.

The local authority obtained leave under Section 100(3) of the Children Act 1989 to invoke the High Court’s inherent jurisdiction. Connell J authorised the operation, notwithstanding the mother’s refusal, and ordered her to return with the child from abroad.

The mother appealed. The central issue was whether the judge had properly assessed the child’s welfare by treating the reasonableness of the parental decision as a central consideration, and whether the Court of Appeal should authorise transplantation after undertaking the required welfare balance itself.

1. Appeal allowed unanimously. Lady Justice Butler-Sloss delivered the leading judgment. Waite and Roch LJJ delivered concurring judgments. The High Court’s orders were set aside, and the three questions concerning the desirability of transplantation, authority to operate without parental consent and the child’s return to England were answered in the negative.

2. The child’s welfare was the paramount consideration. Once the inherent jurisdiction was invoked, the court had to exercise its own independent and objective judgment. The parents’ consent or refusal was an important factor, but their decision was not determinative. The court could override even a decision reasonably made by devoted and responsible parents. The approach in Re Z [1996] 2 WLR 88 was incompatible with any protected band of reasonable parental decisions.

3. The judge had misdirected himself by assessing the reasonableness of the mother’s refusal principally against the unanimous clinical evidence. That approach prevented him from giving proper weight to the broader consequences of transplantation. The inquiry could not be reduced to weighing medical advice against parental reasonableness.

4. A very strong presumption favoured treatment which would prolong life, but it was not irrebuttable. The court had to balance the expected benefit against pain, suffering, quality of life and the burdens of the treatment. Life prolongation was not the court’s sole objective.

5. On the unusual facts, the mother’s committed participation was clinically important to successful postoperative treatment and long-term care. The court therefore had to consider the consequences of compelling her to undertake years of care for treatment which she believed was contrary to her child’s interests. It also had to consider disruption of the family abroad, uncertainty about which medical team would operate without consent, and possible future transplantation.

6. Waite LJ emphasised that every case depended on its facts. The greater the legitimate scope for disagreement between responsible parents and the court, the more readily the court might recognise that a child’s interests ordinarily include difficult decisions being taken by the parent entrusted with care. Roch LJ additionally regarded the parents’ views as clinically significant because unwilling participation diminished the prospects of a successful outcome.

7. After conducting the welfare balance afresh, the court concluded that transplantation and a compulsory return to England were not in the child’s best interests. Future treatment was left to the parents.

1. Court of Appeal: Allowed the mother’s appeal unanimously, set aside Connell J’s orders and answered the local authority’s three questions in the negative. Leave to appeal to the House of Lords was refused.
2. High Court, Family Division: Connell J held that transplantation was in the child’s best interests, authorised surgery despite the mother’s refusal and directed the child’s return to the jurisdiction. The judge granted leave to appeal.
3. High Court, Family Division: Hollis J granted the local authority leave under Section 100(3) of the Children Act 1989 to commence proceedings under the inherent jurisdiction.