T (A Minor)

When the 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 of the balance of advantage and disadvantage. It must give due weight to a devoted and responsible parent’s view, but parental reasonableness is not the test and cannot determine the outcome. Medical prognosis is important, but the court must also consider pain, suffering, quality of life, the treatment’s demands, the carer’s confidence and commitment, and practical consequences for the family. Life-prolonging treatment attracts a very strong but rebuttable presumption. On unusual facts, compelling treatment without the primary carer’s support was not in the child’s best interests.

C. was an infant suffering from biliary atresia. Medical evidence was unanimous that, without a liver transplant, he would die within months, and that transplantation offered good prospects of success. His devoted and medically experienced parents refused consent because of the burdens, risks and long-term consequences of the treatment.

The local authority obtained leave under Children Act 1989, section 100(3), and invoked the High Court’s inherent jurisdiction. Connell J held that transplantation was in C.’s best interests, authorised it despite the mother’s refusal, and ordered the child’s return to England. The appeal concerned whether the judge had applied the correct welfare test and whether the court should compel treatment in circumstances where the primary carer lacked confidence in it.

The appeal was allowed unanimously. Butler-Sloss LJ gave the leading judgment, with Waite LJ agreeing and Roch LJ agreeing while giving additional reasons. The three questions posed by the local authority were answered in the negative, and the orders made by Connell J were set aside.

1. Governing principle. The welfare of the child is the paramount consideration when the inherent jurisdiction is exercised. The court must make its own independent and objective assessment. A devoted and responsible parent’s view must receive respect and due weight, but the court may reach a different conclusion and override it.
2. Parental reasonableness. The judge erred by treating the reasonableness of the mother’s refusal as the central issue. The adoption-law concept of a range of reasonable parental decisions has no place in this welfare jurisdiction. The relevant question is the child’s welfare, not whether the parent’s decision is reasonable or unreasonable.
3. Balancing exercise. The court must balance the advantages and disadvantages of the proposed treatment. There is a very strong, but rebuttable, presumption in favour of a course that prolongs life. That presumption is not conclusive. The court must consider expected quality of life, pain and suffering with and without treatment, and the burdens and risks of treatment. Prolonging life is not the sole objective.
4. Parental commitment and practical consequences. Medical evidence of likely surgical success does not exhaust the welfare inquiry. The court must consider the primary carer’s confidence in and commitment to the treatment, particularly where complex surgery requires years of specialist care. Such commitment may have clinical importance and may affect the child’s subsequent welfare. The consequences of return from abroad, family separation, accommodation, hospital cooperation and possible further treatment were relevant, though not individually decisive.
5. On the unusual facts, compelling the mother to present C. for transplantation and provide long-term care while believing the treatment was wrong created grave risks for the child. The broader welfare balance therefore favoured leaving future treatment in the hands of the devoted parents.

• Court of Appeal (Civil Division): appeal allowed; the three questions were answered in the negative and the High Court orders were set aside.
• High Court of Justice, Family Division (Connell J, 17 September 1996): held that transplantation was in C.’s best interests, authorised surgery despite the mother’s refusal, and ordered the child’s return to England.
• High Court (Hollis J, 27 August 1996): granted the local authority leave to commence proceedings under Children Act 1989, section 100(3).