Manchester University NHS Foundation Trust v Fixsler & Ors

In a dispute concerning life-sustaining treatment for a child lacking capacity, the court must make its own objective assessment of the child’s best interests in the widest sense. There is a strong but rebuttable presumption in favour of preserving life. It may be outweighed where treatment imposes substantial pain and other burdens without commensurate benefit or prospect of recovery.

Religious, cultural and ethical beliefs are important factors in the assessment. They do not replace the secular best-interests test, and the court should not assume that a child shares family values without evidence. A proposed transfer abroad must itself be shown to promote the child’s best interests; it will not be permitted where it adds pain without medical benefit or frustrates a best-interests decision.

The NHS trust sought declarations that continued ventilation and other life-sustaining treatment for Alta Fixsler should cease and that palliative care should be provided. It also sought a specific issue order under section 8 of the Children Act 1989.

Alta had sustained a catastrophic hypoxic ischaemic brain injury at birth. She had no conscious awareness, no prospect of recovery, and depended on ventilation, tube feeding and extensive care. Her parents opposed withdrawal on religious grounds and sought her transfer to Israel, either for continued treatment or for withdrawal there.

The central issues were whether Alta experienced pain, whether continued treatment was in her best interests, and whether either proposed transfer to Israel served those interests.

1. The Trust’s application was granted. The court declared that continued life-sustaining treatment was not in Alta’s best interests and that a palliative-care regime should be implemented.

2. Applying the established best-interests approach, including In Re J (A Minor)(Wardship: Medical Treatment) [1991] Fam 33 and Aintree University Hospital NHS Trust v James [2013] UKSC 67, the court made an independent and objective assessment from Alta’s assumed perspective. The assessment encompassed medical, emotional, sensory and instinctive considerations. Although there was a strong presumption in favour of preserving life, it was rebuttable where treatment’s burdens outweighed its benefits.

3. On the balance of probabilities, Alta consistently experienced spasms when handled for care and treatment. The court accepted the neurological and clinical evidence that relevant pain pathways remained partly functional and that Alta experienced pain, notwithstanding her lack of conscious awareness or cognitive understanding. That pain was a substantial burden, likely to increase as her condition deteriorated. Continued ventilation, feeding and associated intervention would not improve her condition or offer recovery, but would maintain her in a state of profound impairment and recurrent pain.

4. The parents’ Orthodox Jewish beliefs, their wish to preserve Alta’s life, and the cultural and spiritual significance of Israel were treated with respect and included in the best-interests balance. They did not frame or displace the governing secular test. Nor could the court assume that Alta would share those beliefs, since she had never developed knowledge or understanding of them. Any Article 9 interests under the ECHR could be limited where inconsistent with Alta’s welfare.

5. Transfer to Israel for continued treatment was contrary to Alta’s best interests. The proposal lacked sufficient detail, offered no medical benefit, and would expose her to further pain and risk. Transfer for withdrawal was also refused: it would add pain without benefit, there was no evidence that withdrawal would be authorised in Israel, and delay would prolong Alta’s suffering. A short period was allowed for appropriate end-of-life planning and for the parents to be involved.

not stated in the judgment.