Rotherham Metropolitan Borough Council v ZZ & Ors

When deciding whether life-sustaining treatment should be withheld from a child, the court must exercise its own independent and objective judgment. The child’s best interests are paramount and must be assessed broadly, including medical, emotional, sensory and welfare considerations. There is a strong presumption in favour of preserving life, but it is not absolute. The court must balance the advantages and burdens of providing or withholding treatment, including pain, suffering, quality of life, futility, burdensomeness and the prospects of recovery. The concept of intolerability is relevant but is not a separate or determinative test. The same best-interests approach applies to withholding and withdrawing treatment.

X was an infant diagnosed with severe, irreversible hydranencephaly. He had no prospect of developing higher brain functions and was suffering recurrent medical complications, including infection and seizures. The local authority applied under the inherent jurisdiction for declarations concerning resuscitation and escalation of treatment.

An earlier declaration had authorised life-sustaining treatment until further order. By the hearing, all parties supported replacing it with declarations that resuscitation and escalation to high dependency or intensive care, including artificial ventilation, would not be lawful or in X’s best interests, subject to clinicians providing treatment they considered at the time to be in his best interests.

1. Declarations granted. The court set aside the earlier declaration and declared that, subject to the qualification concerning clinicians’ contemporaneous best-interests judgment, it was lawful and in X’s best interests not to resuscitate him or escalate treatment to high dependency or intensive care, particularly artificial ventilation.
2. The governing question was X’s best interests. The court had to exercise an independent and objective judgment on all the evidence. Best interests were wider than medical interests and included relevant medical, emotional, sensory, psychological and welfare considerations. The views of clinicians, carers and parents were relevant only insofar as they illuminated X’s interests.
3. A strong presumption favoured preservation of life, but it was not absolute or necessarily decisive. The court had to balance the benefits and burdens of treatment and continued life, including pain, suffering, quality of life, the nature and prospects of treatment, futility, burdensomeness and the prospect of recovery.
4. There was no legal distinction between withholding and withdrawing life-sustaining treatment. The concept of intolerability could be a relevant factor, but it could not replace the comprehensive best-interests assessment or operate as a separate determinative test.
5. Applying those principles, X’s condition was permanent, irreversible and wholly untreatable. He had no prospect of developing higher functions, appeared capable of experiencing pain and discomfort, and was likely to suffer recurrent infection and seizures. Against the strong presumption in favour of life, the burdens and absence of meaningful benefit meant that withholding the specified treatment was in his best interests.