CWM TAF University v F

When deciding whether life-sustaining treatment should be withdrawn from a person lacking capacity, the question is whether continuing the treatment is in that person’s best interests. The court must consider welfare in the widest sense, including medical, social and psychological factors, the nature and burdens of treatment, its prospects of success, the likely outcome, the patient’s wishes, feelings, beliefs and values, and the views of those concerned with the patient’s welfare.

A strong presumption in favour of preserving life is not absolute. In a permanent vegetative state, where treatment has no therapeutic purpose and offers no prospect of recovery or awareness, the balance may fall entirely against continued treatment. Applications must ordinarily be supported by careful diagnosis and the structured assessments required by relevant clinical guidance.

The applicant sought declarations under section 15 of the Mental Capacity Act 2005 concerning F, an inpatient since 2007 following severe brain injury. The issues were whether F lacked capacity to decide about clinically assisted nutrition and hydration, and whether withdrawal of that treatment was lawful and in her best interests.

The court considered prolonged clinical and expert evidence diagnosing a permanent vegetative state, the views of F’s family and treating team, and shortcomings in compliance with relevant assessment guidance.

1. Declarations granted. F lacked capacity to make decisions about clinically assisted nutrition and hydration. It was lawful and in her best interests for that treatment to be withdrawn.
2. The court applied sections 2 and 3 of the Mental Capacity Act 2005. The evidence established that F could not understand, retain, use or weigh relevant information, or communicate a decision. There was no realistic prospect that she would regain capacity.
3. Under section 4, the decision concerned whether continuing life-sustaining treatment was in F’s best interests, rather than whether it was in her best interests to die. The court had to consider all relevant circumstances, including her past and present wishes and feelings, beliefs and values, the treatment’s invasiveness and prospects, its likely consequences, and the views of family, carers and clinicians.
4. The court followed the approach in Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67. Best interests is an individual and holistic test, not a merely medical test or an objective test based on what a reasonable patient would decide. The patient’s ascertainable wishes and values are important, but are not automatically determinative.
5. The strong presumption that it is in a person’s best interests to remain alive is not absolute. In a permanent vegetative state, where there is no awareness or prospect of recovery and treatment has no therapeutic purpose or benefit, continued life-sustaining treatment may properly be regarded as futile. A balance-sheet analysis is not necessarily required where all relevant factors fall on one side.
6. The Royal College of Physicians guidance should ordinarily be followed in applications of this kind. Applicants should provide reliable diagnosis, suitably trained assessors, structured assessments such as WHIM, SMART or CRSR, and appropriate best-interests evidence. Failure to do so may lead to summary rejection. Nevertheless, the deficiencies here did not prevent a safe conclusion because the prolonged observation, expert evidence and unanimous clinical opinion made the diagnosis sufficiently certain.
7. F had been in a permanent vegetative state for at least five years and probably eight. She had no awareness and no prospect of recovery or improvement. Continuing clinically assisted nutrition and hydration was futile and not in her best interests. The declarations were therefore made.

First-instance decision in the High Court (Family Division). No appellate history was stated.