An NHS Foundation Trust v Kwame & Ors

In determining whether life-sustaining treatment should continue for a child, the court must decide the child’s objective best interests, with welfare as the paramount consideration. There is a strong but rebuttable presumption in favour of preserving life. The court must undertake an objective balancing exercise, considering medical, emotional, social and psychological welfare, the treatment’s burdens and prospects of success, the child’s likely wishes, and relevant family, religious and cultural factors. Parental wishes are not determinative, although parental views may illuminate the child’s welfare and relationships. Human dignity is also relevant. Treatment may lawfully be withdrawn where continued treatment confers no overall benefit and is contrary to the child’s best interests.

The applicant NHS Foundation Trust sought declarations concerning Kwame, a 16-year-old who had remained mechanically ventilated in paediatric intensive care for approximately 20 months following a hypoxic cardiac arrest and severe hypoxic brain injury.

The medical evidence was unanimous that Kwame had suffered profound, irreversible neurological injury, had no awareness or purposeful response, could not maintain his airway, and had no prospect of recovery or improvement. His mother did not oppose the application, the Children’s Guardian supported it, and his father wished him to be given more time in the hope of recovery or future medical developments.

The central issue was whether continued life-sustaining treatment, including mechanical ventilation, was in Kwame’s best interests.

The application was granted. The court declared that continued mechanical ventilation and further life-sustaining treatment were contrary to Kwame’s best interests, and that defined limits should be placed on treatment after withdrawal so that he could die with appropriate palliative care.

1. The governing question was Kwame’s objective best interests. His welfare was paramount, and the court had to consider his welfare in the widest sense, including medical, emotional, social and psychological factors. The assessment was individual and fact-sensitive.
2. A strong presumption existed in favour of preserving life, but it was not irrebuttable. The court had to balance the benefits and burdens of continued treatment objectively. The exercise was not mathematical.
3. The court considered the views of the doctors and parents. Parental wishes were not independently determinative, although parental views could have particular value because they might illuminate the child’s likely attitude and the quality of the child-parent relationship.
4. Kwame’s age, understanding, values and beliefs were relevant. His religious and cultural background had to be taken into account, but it did not carry pre-eminent weight. Human dignity was also a relevant aspect of the best-interests assessment.
5. The court accepted the unanimous medical evidence that Kwame’s injury was permanent, that he had no prospect of recovery, and that continued ventilation would involve increasing burdens, including difficult airway management, recurrent infection, physical deterioration and the risk of an unplanned and distressing death. Waiting for possible future medical developments was not a neutral course.
6. Although it was not possible to ascertain Kwame’s wishes, his values, prior character and likely attitude to his circumstances were relevant. The court concluded that continued treatment provided no sufficient benefit to outweigh its burdens and declared that withdrawal of ventilation was lawful and in his interests.