A Local Health Board v Y (A Child) & Ors

When deciding whether to withhold or withdraw medical treatment from a child, the court must determine the child’s best interests from the child’s assumed point of view. There is a strong, but rebuttable, presumption in favour of prolonging life. The court must weigh the benefits and burdens of treatment, including pain, suffering, quality of life, the treatment’s prospects of success and its likely consequences. Welfare must be considered in the widest sense, including medical, emotional and other welfare factors. Treatment may properly be withheld or withdrawn where it would cause suffering without commensurate benefit.

The applicant Health Board sought declarations concerning the treatment of Y, a premature baby with extensive irreversible brain damage and recurrent cardiac arrests. The clinical team proposed extubation and withholding further cardiopulmonary resuscitation, re-intubation, ventilation, inotropes and other escalation of intensive care. Y’s parents initially opposed the proposal but, after obtaining independent expert evidence, agreed to it. Y’s guardian supported the application. The central issue was whether the proposed treatment plan was lawful and in Y’s best interests.

1. Jurisdiction and parental responsibility. Parents ordinarily have responsibility for the care and protection of their children, including power to consent to medical treatment. Where consent is absent or disputed, the High Court may exercise its inherent jurisdiction to make orders in the child’s best interests. A specific issue order may also be made under Children Act 1989, section 8.
2. Best-interests assessment. The court applied the principles stated in Re J (A Minor) (Wardship: Medical Treatment) [1991] Fam 33 and Wyatt v Portsmouth NHS Trust [2005] EWCA Civ 1181. The presumption in favour of prolonging life is strong but not irrebuttable. The court must balance all relevant factors, including the suffering caused by the child’s condition and by the proposed treatment, the treatment’s prospects of success, and the likely quality and duration of life.
3. Patient-centred welfare. Consistently with Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67, the assessment must consider welfare in the widest sense and must be conducted from the patient’s point of view. The court must consider the nature and consequences of treatment and, where relevant, the patient’s wishes and feelings.
4. Applying those principles, repeated CPR and further escalation of intensive care would expose Y to recurrent suffering without a realistic clinical benefit. The proposed plan, which preserved comfort care and existing treatment while withholding further escalation, was in his best interests. The court declared lawful and in Y’s best interests extubation at an appropriate clinical point, non-re-intubation if spontaneous respiration failed, and withholding CPR, ventilation and inotropes, subject to permitted stimulation.