Portsmouth NHS Trust v Wyatt & Ors

In determining a child’s best interests, the court must adopt a broad welfare evaluation rather than a purely medical assessment. The sanctity of life creates a strong presumption in favour of treatment that prolongs life, but the presumption is rebuttable. Relevant considerations include the prospects and burdens of treatment, pain and suffering, quality of life, the possibility of a good death, and the child’s dignity. The views of parents must receive great respect, particularly because they know the child best, but the court retains final responsibility. The concept of a life being intolerable to the child is a useful guide in assessing best interests, not an additional or alternative legal test.

Portsmouth NHS Trust sought permission to withhold artificial ventilation and other aggressive treatment if Charlotte Wyatt, an extremely premature infant with profound neurological, respiratory and renal disabilities, deteriorated and required it. The parents wished treatment to be instituted, potentially following an elective tracheostomy, while the Guardian supported withholding invasive treatment if it became necessary. The central issue was whether further aggressive treatment would be in Charlotte’s best interests, having regard to her prospects of survival, pain, quality of life, dignity, the sanctity of life, and the views of her parents.

1. Best interests. The court’s responsibility was to decide what was in Charlotte’s best interests. That concept had to be interpreted generously and included medical, emotional and wider welfare considerations. The court was not confined to the medical evidence.
2. Relevant balance. The sanctity of life supported a strong presumption in favour of treatment which prolonged life, but the presumption was not irrebuttable. The court had to weigh the possible benefits of treatment against its risks, pain, suffering and effect on quality of life. A balance-sheet approach could assist, with necessary adjustments for a child and proper weight given to parental views.
3. Quality of life. The phrase “intolerable to that child” was a valuable guide in assessing best interests, but was not a gloss on, or supplementary test to, the best-interests test. The assessment had to be directed to the child’s experience, rather than the views of the judge, parents or clinicians.
4. Application. Charlotte had no effective sight, hearing or volition, could experience pain, and had no established capacity to experience pleasure. Her prospects of surviving a further year were minimal, and invasive treatment carried substantial burdens with little prospect of achieving more than a return to her existing condition. The court also treated the opportunity for comfort, parental contact and a peaceful death as relevant welfare benefits.
5. The parents’ genuine and carefully considered views were entitled to the greatest respect because they knew Charlotte best, but final responsibility rested with the court. Further aggressive treatment was not in Charlotte’s best interests. The relief granted was permissive: it authorised the treating doctors, if disagreement continued, not to arrange artificial ventilation or similar aggressive treatment. It did not compel them to withhold treatment or remove their responsibility to reassess the position as circumstances developed. The doctors were invited to reconsider elective tracheostomy as a possible palliative measure.