Parfitt v Guy's and St Thomas' Children's NHS Foundation Trust & Anor

When a court determines whether life-sustaining treatment should continue for a child, the child’s best interests are assessed objectively and in the widest sense. Welfare and best interests are synonymous. The court must balance all medical and non-medical considerations, while giving considerable but not decisive weight to preserving life.

Unconsciousness and an inability to feel pain do not preclude physical harm. Loss of function and the burdens of intensive or invasive treatment may therefore be considered. Potential benefits from family life and home care must also be evaluated, even where the child lacks awareness.

Parents’ views may carry substantial or even decisive weight where viable options are finely balanced. They do not create a presumption in favour of the parental choice. The court must independently select the course serving the child’s best interests.

A five-year-old child had suffered catastrophic and irreversible brain damage and was in a persistent vegetative state. She lacked conscious awareness, could not breathe independently and required intensive mechanical ventilation and frequent specialist intervention. The NHS trust sought declarations permitting withdrawal of life-sustaining treatment. Her mother proposed a trial of portable ventilation, followed if successful by a prolonged transition to home care.

Poole J concluded that continued ventilation, whether in intensive care or at home, would prolong burdens without sufficient benefit. He also found that the prospects of achieving home care were remote. He declared that a tracheostomy should not be performed, ventilation could lawfully be withdrawn, and defined limits could be placed on subsequent treatment.

The mother appealed on grounds concerning unconscious harm, non-medical benefits, the weight given to parental views, and the assessment of the proposed ventilation trial and additional expert evidence. The central question was whether the judge’s best-interests decision was wrong.

1. Disposition. Permission to appeal was refused on grounds one, three and four. Permission was granted on ground two, but that ground and the appeal were dismissed. The judge was entitled to declare that withdrawal of life-sustaining treatment was lawful and in the child’s best interests.

2. A best-interests assessment requires an independent and objective judgment focused on the child. Welfare must be considered in its widest sense and includes medical, emotional, social, psychological and other relevant interests. A strong presumption favours preserving life, but it is neither absolute nor determinative. The assessment remains a fact-specific balance of benefits and burdens.

3. The proposition that an unconscious person cannot suffer physical harm was plainly wrong. The absence of pain is different from the absence of harm. Profound loss of function, diminished quality of life and repeated invasive interventions may burden a person despite the absence of conscious awareness. A contrary rule would unjustifiably exclude significant aspects of the child’s condition and treatment from the required broad assessment.

4. The judge had not excluded possible non-medical benefits from home care. He separately assessed continued intensive-care ventilation and the proposed pathway towards home ventilation. He recognised that care by a loving family at home is generally in a young child’s interests, but was entitled to find those potential benefits outweighed. The proposed process would take at least six months, had only a remote prospect of reaching home care, would continue intensive treatment, and would not improve the child’s neurological condition. The terms “welfare” and “best interests” are substantially synonymous; the judge’s occasional distinction between them did not affect his conclusions.

5. Parental views must receive careful consideration and may be highly influential where viable treatment options are genuinely balanced. They do not introduce a preliminary filter or preference. The court must examine each realistic option from the child’s perspective, and the child’s best interests ultimately prevail even over the views of thoughtful and devoted parents. The judge had carefully considered and appropriately weighted the mother’s views.

6. The judge properly considered the suggested modifications to the ventilation regime and was not required to make detailed directions about medical management. His refusal to admit a fourth expert report served after the evidence had closed was within his case-management powers. The report concerned matters which he was entitled to regard as non-central.

7. The possible role of dignity in treatment-withdrawal cases was left open. No party challenged the judge’s decision not to adopt an objective concept of dignity, and resolving its wider doctrinal role was unnecessary.

1. Court of Appeal (Civil Division): In [2021] EWCA Civ 362, permission to appeal was refused on grounds one, three and four. Permission was granted on ground two, but the appeal on that ground was dismissed.
2. High Court, Family Division: Poole J declared that it was lawful and in the child’s best interests not to provide a tracheostomy, to withdraw mechanical ventilation, and to impose defined limits on treatment following withdrawal. No citation for that judgment was stated.