A (A Child), Re

Life-sustaining treatment is lawful only if it is objectively in the child’s best interests. The assessment concerns the child’s welfare in its widest medical, social and psychological sense. It requires a weighted evaluation of the treatment’s burdens, prospects and likely outcome, while giving substantial but non-absolute weight to the preservation of life.

A balance sheet may assist, but it cannot replace evaluative judgment or obscure the relative weight of the factors. A possible modest improvement does not make withdrawal premature where the diagnosis and prognosis are clear, continued treatment offers no measurable benefit, and delay is likely to increase suffering. An appellate court should be slow to disturb a careful best-interests decision unless it is wrong.

A sustained catastrophic spinal and hypoxic brain injury left A, a young child, tetraplegic, minimally conscious, ventilator-dependent and unable to communicate. He had progressive cerebral atrophy, severely abnormal EEG findings, recurrent infections and no prospect of functional recovery. The medical evidence accepted that he might make only modest improvements in awareness, but the clinicians and children’s guardian considered that continued life-sustaining treatment was not in his best interests.

Mrs Justice Parker, sitting in the Family Division, declared that it was lawful and in A’s best interests to withdraw respiratory support and provide palliative treatment. A’s mother appealed, alleging error in the findings on pain, the best-interests balancing exercise and the protection of life. The central issue was whether the declaration should stand despite the possibility of limited future improvement.

1. Appeal dismissed. Lady Justice King, with whom Lord Justice McFarlane entirely agreed, held that the judge’s declaration should stand.

2. The governing question, drawn from Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67, was whether it was in A’s best interests to give the treatment. The assessment had to address his welfare in the widest sense. It was not confined to pain or to medical prognosis. The strong presumption in favour of life was relevant but not absolute.

3. The judge had permissibly preferred the evidence of the treating intensivist and one neurologist that the physical signs during airway suctioning were evidence of pain or discomfort. There was a reasonable range of professional opinion. Reading the judgment as a whole, the judge had not reversed the burden of proof and her finding was not plainly wrong.

4. The wider best-interests evaluation was also sound. A balance sheet was only an aide memoire, as explained in F (A Child) (International Relocation Cases) [2015] EWCA Civ 882; it could not displace an evaluative attribution of weight. The possibility of a modest increase in awareness did not outweigh the absence of measurable benefit from continued ventilation, the grave and progressive brain injury, and the likely increased burden of treatment. The case was not premature merely because A’s condition had not plateaued. The diagnosis and prognosis were clear, unlike the uncertainty discussed in the authorities relied on by the mother.

5. Even if A had been wholly free from pain, the judge’s conclusion would have been correct. Continued ventilation was futile except to maintain life, while A lacked the ability to derive benefit from it. Withdrawal of treatment other than palliative care was therefore in his best interests.

1. Court of Appeal (Civil Division): Dismissed the mother’s appeal and upheld the declaration: [2016] EWCA Civ 759.

2. High Court, Family Division: Mrs Justice Parker declared that withdrawal of respiratory support, with appropriate palliative care, was lawful and in A’s best interests (case reference FD16P00264).