E (A Child : Medical Treatment)

In determining a child’s best interests, the court must adopt a holistic welfare appraisal. Relevant considerations may extend beyond narrowly medical matters to emotional, psychological, social, familial and developmental consequences.

Where treatment is not clinically urgent, its benefits are substantially personal or social, and the decision can safely be deferred, the court should generally leave it to the child’s long-term parents or carers. It is wrong in principle for a judge to assume a decision which is better made by those who will undertake the child’s day-to-day care.

E, a young child in foster care, suffered a severe head injury requiring a decompressive craniectomy. The issue was whether he should undergo a cranioplasty, whether the operation should be deferred, or whether the court should leave the decision to his future long-term carers.

The medical evidence identified significant operative risks and no immediate clinical need for surgery. The principal benefits were described as cosmetic and psychological, including possible effects on social interaction and carers. The central issue was whether the court should decide the treatment question immediately or defer it.

1. The court’s task was to evaluate E’s best interests judicially. That required a holistic welfare appraisal, not an assessment confined to medical risks and benefits. The approach in Re G (Education: Religious Upbringing) [2012] EWCA Civ 1233, [2013] 1 FLR 677 was applied.
2. The relevant factors included the greater risks of cranioplasty compared with leaving E in a normal family environment without a plate; the principally cosmetic and psychological nature of the benefits; the absence of clinical urgency; the increasing marginality of the benefit if surgery were delayed for several years; the likely identification of E’s long-term carers within months; and the potential effect of making a significant non-urgent decision before those carers were identified.
3. The decision was principally one for E’s parents or carers, rather than for doctors. There was no universal or dogmatic answer. E’s long-term carers would be better placed than the judge to assess the personal, emotional and practical consequences of surgery.
4. Although courts may become involved in medical treatment decisions when parents cannot agree or prefer to leave an agonising decision to a judge, there was no such necessity here. The discussion of that point referred to In re Jake (A Child) [2015] EWHC 2442 (Fam).
5. Because the decision could safely be deferred and there was no immediate medical need, it would be wrong in principle for the court to arrogate the decision to itself. The court therefore declined to make any order.

Not stated in the judgment.