E v Northern Care Alliance NHS Foundation Trust

When considering medical treatment for a competent person under 18, the court retains power under its inherent jurisdiction to override that person’s decision. The court must establish the facts, decide whether immediate intervention is necessary, and then assess welfare from the young person’s perspective.

The welfare assessment balances preservation of life with personal autonomy. A competent young person’s decision carries increasing weight with age and maturity, but no presumption makes it legally determinative. A low probability of a medical crisis must be distinguished from the potentially grave consequences if it occurs. The court may authorise treatment where those consequences outweigh the immediate interference with autonomy, provided it gives proper weight to the person’s religious convictions and wider welfare.

Two competent young Jehovah’s Witnesses, aged 16 and 17, refused blood transfusions on religious grounds. In each case, a hospital trust sought a declaration under the inherent jurisdiction permitting transfusion if serious bleeding threatened death or grave injury and reasonable alternatives had failed.

Theis J made a declaration concerning E’s urgent appendectomy. Judd J made a 21-day declaration after F suffered a splenic injury carrying a risk of sudden haemorrhage. Neither young person ultimately required transfusion.

The appeals challenged the judges’ approach to welfare. The central issue was how the inherent jurisdiction should be exercised when a competent minor’s autonomous treatment decision conflicts with the preservation of life.

1. Appeals dismissed. The inherent jurisdiction extends to every person under 18. It permits the court to override the medical-treatment decision of a competent minor where an objective assessment shows that intervention is required in the minor’s best interests.

2. The court should proceed in three stages: establish the facts, decide whether intervention is presently necessary, and, if so, undertake the decisive welfare assessment. In considering necessity, the court may postpone its decision where a crisis may never arise and a fair and timely decision could realistically be obtained if it does.

3. Probability and consequence are distinct aspects of risk. A remote prospect of a medical crisis cannot be ignored where its occurrence may cause death or irreversible harm. The court must compare that possible future consequence with the certain present interference caused by provisionally overriding the young person’s decision.

4. The welfare assessment is individual and takes account of medical and non-medical considerations. In cases involving competent young people, the principal competing factors will commonly be preservation of life and personal autonomy. The importance of the young person’s decision increases with age and maturity, but welfare remains the overriding principle. The decision may predominate in the balance, yet it does not become legally determinative before adulthood.

5. The approach in Re W (A Minor) (Medical Treatment: Court’s Jurisdiction) [1993] Fam 64 remains good law. It recognises both the powerful importance of a competent young person’s decision and the court’s duty to intervene where refusal exposes that person to irreparable and disproportionate consequences. A properly conducted welfare assessment is compatible with articles 2, 3, 8 and 9 of the European Convention on Human Rights.

6. Generic lists derived from cases involving babies or persons lacking capacity may obscure the significance of a competent adolescent’s decision. Judges in such cases should focus on the factors that truly matter and direct themselves by reference to Re W and this decision.

7. Theis J had properly weighed E’s strongly held beliefs and the low probability but potentially fatal consequences of bleeding. Judd J was entitled to decide F’s case immediately because catastrophic haemorrhage might require surgery within an hour. Both judges were entitled to conclude that preservation of life should prevail if the contemplated danger arose.

1. Court of Appeal (Civil Division): Both appeals were dismissed. The declarations were upheld, although the court identified drafting errors in E’s order.
2. High Court (Family Division), Theis J: Declared that blood products could lawfully be administered to E during or following her appendectomy if clinically necessary. The written order incorrectly stated that E lacked capacity and failed fully to reflect the limits of the judgment.
3. High Court (Family Division), Judd J: Declared for 21 days that F could lawfully receive blood products in an emergency arising from his splenic injury after all reasonable alternatives had been considered and exhausted.
4. High Court (Family Division), Arbuthnot J: Refused the initial out-of-hours declaration concerning F as unnecessary, disproportionate and inappropriate, and continued the application for a fuller hearing.