C (Baby: Withdrawal of Medical Treatment), Re

A strong presumption exists that preserving life is in a person's best interests, but it is not absolute. Life-sustaining treatment may lawfully be withdrawn where, viewed from the patient's perspective, its burdens substantially outweigh its benefits. The court must determine best interests, having regard to medical and non-medical considerations, the views of parents and doctors, and the child's quality of life. In cases involving children, the assessment must focus on the child's experience rather than the interests or perceptions of adults. Where continued treatment offers only prolongation of life through burdensome intervention and no realistic prospect of benefit, withdrawal may be authorised, with appropriate palliative care.

The Trust applied for authority to withdraw respiratory support from an eight-month-old child who had suffered severe and irreversible hypoxic-ischaemic brain injury at birth. She required continuous mechanical ventilation, tube feeding and extensive medical intervention, and showed no meaningful interaction with her surroundings. Her parents wished treatment to continue and opposed the proposed plan, but did not participate meaningfully in the proceedings. The Children's Guardian supported withdrawal on the basis that the burdens of treatment outweighed its benefits. The central issue was whether withdrawal of respiratory support accorded with the child's best interests, notwithstanding the likelihood that she would die.

1. The application was granted. It was lawful and in the child's best interests to withdraw all respiratory support under the proposed staged treatment plan, even though withdrawal was likely to result in death.

2. The court began with the strong presumption that it is in a person's best interests to remain alive. That presumption is not absolute. The authorities, including In Re J (A Minor) (Wardship: Medical Treatment) [1991] Fam 33 and Aintree University Hospitals NHS Foundation Trust v James [2014] AC 591, establish that life-sustaining treatment may cease where it is no longer in the patient's best interests.

3. The court adopted and applied the ten propositions identified by Holman J in An NHS Trust v MB [2006] EWHC 507 (Fam). The ultimate decision belongs to the court, not to the parents or doctors. Medical evidence is important, but the best-interests assessment includes all relevant circumstances.

4. In assessing quality of life, the court must consider matters from the child's perspective. Here, continued treatment prolonged life only through intensive intervention. The burdens included pain, distress, repeated invasive procedures and the absence of any realistic capacity to experience pleasure or other benefit from continued life. Those burdens substantially outweighed the benefits.

5. The parents' wishes were considered with care but could not prevail over the course that was in the child's best interests. The order permitted staged withdrawal, with pain relief, sedation and nursing care to minimise distress. Discharge to a hospice was permitted only if agreed by the Trust, the parents and an identified hospice, and the treatment plan was not to be deferred for more than 14 days while reasonable attempts were made to reach agreement.