An NHS Trust v L & Ors (Rev 1)

Under the Mental Capacity Act 2005, the court must determine objectively what is in a person’s best interests by weighing all relevant circumstances. The person’s wishes, feelings, beliefs and values are important factors, but the exercise is not substituted judgment.

There is a powerful presumption in favour of preserving life, but it is rebuttable. The court cannot require clinicians to provide treatment contrary to their professional judgment. Where the evidence establishes that no clinically available treatment option exists, the court must not assume that it can create one. In any event, invasive resuscitation may properly be withheld where its burdens and risks decisively outweigh any realistic prospect of benefit.

An NHS Trust applied under the Mental Capacity Act 2005 for declarations that active resuscitation, ventilation and similar treatment would not be in the best interests of an adult patient, Mr L, if he suffered a further cardiac or respiratory arrest or serious deterioration.

Mr L lacked capacity after severe hypoxic brain injury and was in a minimally conscious state at a very low level. The Trust relied on consistent medical evidence that resuscitation was highly unlikely to succeed, would probably cause further neurological and physical deterioration, and would expose him to pain and distress without realistic benefit. His family sought all potentially life-sustaining treatment, relying on his religious beliefs, presumed wishes and the sanctity of life. The central issues were the proper best-interests evaluation and the extent to which the court could require treatment contrary to clinicians’ professional judgment.

1. Declarations granted. The court concluded that active resuscitation and analogous invasive treatment were not in Mr L’s best interests.

2. Sections 1(5) and 4 of the Mental Capacity Act 2005 require an independent, objective assessment of all relevant circumstances. The court must consider the patient’s ascertainable wishes, feelings, beliefs and values, and consult those interested in the patient’s welfare where practicable and appropriate. Those matters inform the decision but do not determine it by substituted judgment.

3. The sanctity of life creates a powerful but rebuttable presumption in favour of treatment capable of prolonging life. The court must balance the potential benefits of treatment against its burdens, risks, likely outcome, quality of life and effect on the patient’s dignity and suffering. An absolutist submission that all potentially life-sustaining treatment must be given was rejected.

4. Following Re J (A Minor)(Medical Treatment) and Re J (A Minor)(Child in Care: Medical Treatment), the court cannot directly or indirectly require a doctor to provide treatment contrary to the doctor’s professional judgment and duty to the patient. The court may disagree with medical evidence, including unanimous evidence, but must avoid placing clinicians in an impossible position.

5. In this context, the existence of actual treatment options is material. Options must be clinically available and must not require professionals to act contrary to their clinical judgment. The evidence did not establish any such option in this case. The court nevertheless undertook the balancing exercise because no party supported deciding the application solely on that basis.

6. The medical evidence was cogent and consistent. Resuscitation had a very low prospect of success and, if successful, was highly likely to cause further brain damage, physical deterioration and suffering, with no realistic prospect of meaningful benefit. Those factors substantially outweighed the patient’s age, stable condition, possible awareness, religious beliefs, presumed wishes, family views and the intrinsic value of life.