An NHS Trust v C NHS Trust & Ors

In determining medical treatment for a child, the court’s paramount consideration is the child’s best interests. The assessment is broad and fact-specific. It includes the child’s wishes and understanding, the views of parents and clinicians, the nature and prospects of treatment, likely suffering, quality of life and the strong presumption in favour of preserving life.

A child under 16 may be Gillick competent to consent to treatment, but that competence does not prevent the court from authorising treatment contrary to the child’s wishes where this is in the child’s best interests. The court must exercise its own independent judgment. It may authorise treatment without the consent of the child or parent where necessary, while requiring appropriate respect for their views.

The applicant NHS Trust sought declarations that it was lawful and in the best interests of CX, aged 14, to receive blood and blood products as part of intensive chemotherapy and stem-cell treatment for recurrent stage 4 lymphatic cancer.

CX and his mother were Jehovah’s Witnesses and opposed blood transfusions for religious reasons, although they accepted other aspects of the proposed treatment. The medical evidence was that chemotherapy could not safely proceed without the possibility of blood-product support. The central issues were whether CX was Gillick competent and, if so, whether the court should nevertheless authorise the proposed treatment in his best interests.

1. Best interests. The court’s task was to give or withhold consent to medical treatment by applying its own independent and objective judgment. Best interests had to be understood in the widest sense and assessed by balancing all relevant medical, emotional, sensory, instinctive and other considerations. The court was not bound by the clinicians’ assessment, although their evidence was highly material. The child’s and parents’ views had to be considered, with appropriate weight given to the child’s age and understanding.
2. Gillick competence. Applying Gillick v West Norfolk and Wisbech Area Health Authority [1986] AC 112 and Re R (A Minor)(Wardship: Consent to Treatment) [1992] Fam 11; [1992] 1 FLR 224, CX was Gillick competent to decide whether to undergo the proposed treatment. He understood its essential nature and consequences, despite lacking professional knowledge of the underlying medical science.
3. Competence did not determine the outcome. Following the analysis in Re R (A Minor)(Wardship: Consent to Treatment), the court retained power to override a competent child’s decision where this was required by the child’s best interests.
4. The treatment was potentially life-saving and there was no viable alternative to chemotherapy. The evidence established that chemotherapy could not safely be delivered without access to haemoglobin, platelets and other blood products. Without treatment, CX’s cancer was likely to progress and prove fatal. The likely distress caused by overriding his religious objections was outweighed by the commensurate and potentially life-saving benefit of treatment.
5. The court therefore declared that it was lawful and in CX’s best interests to receive blood and blood products as part of the treatment plan. The Trust could commence treatment immediately and administer blood products without consent where no reasonable alternative existed. It was expected to reduce their use to the lowest level necessary to keep CX safe.