Alder Hey Children's NHS Foundation Trust v D & Ors

In determining a child’s best interests, the court must adopt an objective assessment from the child’s point of view and consider welfare in its widest sense. Preservation of life attracts very considerable weight, but the presumption is not irrebuttable. The court must balance the benefits and burdens of continued life-sustaining treatment, including the burdens arising from both the underlying condition and the treatment itself.

The analysis must remain individual and fact-sensitive. The court is not required to decide any wider philosophical question about the value or definition of life. A child’s awareness, capacity for pleasure, family relationships and inherent value may be relevant benefits, but may be outweighed by substantial and continuing suffering, treatment burdens and the absence of meaningful recovery.

The Trust sought declarations that it was in C’s best interests, aged 14, to withdraw mechanical ventilation and provide palliative care. C’s mother and Children’s Guardian supported the application. His father opposed it, arguing that C was not significantly cognitively impaired, that recovery remained possible, and alternatively seeking further independent evidence.

The court had previously adjourned the application to obtain independent expert opinions. Paediatric intensive-care and neurology experts subsequently concluded that C had no realistic prospect of meaningful neurological recovery, could not be discharged from intensive care, and would remain dependent on ventilation and extensive care. The central issue was whether the benefits of continuing life-sustaining treatment outweighed the burdens for C.

1. Best interests. The court concluded that continued life-sustaining treatment was not in C’s best interests. It declared that mechanical ventilation should be withdrawn, that C should receive palliative care, and that defined treatment limits should apply so that he should be allowed to die.
2. The preservation of life was given very considerable weight. It was a strong factor favouring continuation of ventilation, including in light of C’s religious background. That presumption was powerful but not irrebuttable.
3. The assessment required an objective decision from C’s point of view, with his welfare considered in the widest sense. The court had to balance the benefits and burdens of his life, including burdens arising from both his underlying illness and the intensive-care treatment required to sustain him.
4. Benefits included C’s awareness of, and pleasure and comfort derived from, his family. His life also had inherent value to his family. The court nevertheless found substantial burdens, including continuing pain and distress, invasive procedures, life in a noisy and intrusive intensive-care environment, complete dependence on others, and the prospect of an uncontrolled and frightening death from an intensive-care complication.
5. The medical evidence unanimously established that C had no realistic prospect of leaving intensive care or achieving meaningful recovery. His minimally conscious state and occasional flashes of pleasure did not outweigh the combined burdens of his condition and treatment.
6. The court declined to determine any wider philosophical question about what constitutes a life. The relevant question was what the particular life meant for C and whether it was in his best interests to continue the treatment regime.
7. The declarations were held compatible with C’s Article 2 right to life. Any interference with C’s and his parents’ Article 8 rights was necessary and lawful. Withdrawal was to take place in the intensive-care unit with palliative care and the presence of those who loved him.