An NHS Trust v MB

In a medical-treatment dispute concerning a child without capacity, the court must independently determine the child’s objective best interests under Children Act 1989, section 1. Best interests include medical, sensory, emotional and instinctive considerations. There is a strong but rebuttable presumption in favour of preserving life.

Withholding and withdrawing life-sustaining treatment are legally equivalent. The court must balance the child’s present benefits from life against treatment burdens and any inevitable, rapid deterioration. A child’s sensory awareness, assumed cognition and valuable family relationships may be real benefits even where the child can no longer communicate them. Painful escalation of treatment may properly be withheld although continuing ventilation remains in the child’s best interests.

An NHS Trust sought declarations that it was lawful and in MB’s best interests to withdraw continuous invasive ventilation from him, notwithstanding his parents’ opposition. MB, aged 18 months, had the most severe form of type 1 spinal muscular atrophy. He was conscious, assumed to have normal cognition, unable to breathe unaided, and subject to frequent invasive care.

The parents opposed withdrawal and sought a declaration permitting a tracheostomy for long-term ventilation. The central issue was whether MB’s current and predicted treatment burdens outweighed the benefits he continued to derive from life, including sensory experience and his relationship with his family.

1. The Trust’s application was refused insofar as it sought withdrawal of ventilation. The court held that it was not presently in MB’s best interests to discontinue ventilation, which would cause his immediate death. The parents’ cross-application for a tracheostomy declaration was dismissed.

2. Applying section 1 of the Children Act 1989, Holman J held that the court must make an independent and objective best-interests decision. The assessment is broad. It includes medical evidence, pain and suffering, sensory and emotional experience, the instinct to survive, and the value to the child of relationships with family. The parents’ views were important evidence but their wishes were not determinative.

3. There was a strong, though rebuttable, presumption in favour of prolonging life, consistently with Re J (A minor) (wardship: medical treatment) [1991] Fam 33. Following Airedale NHS Trust v Bland [1993] AC 789, the court held that the same best-interests test governs both withholding and withdrawing life support.

4. The court accepted that MB endured near-continuous discomfort, distress and occasional pain, and that his deterioration was inevitable and relevant to the balance. However, it had to assume normal age-appropriate cognition. MB could hear, see to some degree and feel touch. He continued to obtain real, precious benefits from sensory experience and close, sustained contact with his parents and siblings. Those benefits were not presently outweighed by the burdens of continuing ventilation and its necessary routine care.

5. The court nevertheless declared it lawful and in MB’s best interests to withhold cardiopulmonary resuscitation and related monitoring, intravenous antibiotics and blood sampling. Those treatments would entail further invasive pain when death was near and were not justified. The declaration was permissive only: it did not prevent clinicians from giving treatment if they considered it appropriate at the time.

6. The decision was expressly fact-specific and required continuing review as MB’s condition deteriorated.

not stated in the judgment.