Great Ormond Street Hospital for Children NHS Foundation Trust v ZG & Ors

In an application to withdraw life-sustaining treatment from a child, the court must determine the child’s best interests, treating welfare as paramount and considering the matter from the child’s assumed point of view. There is a strong but rebuttable presumption in favour of prolonging life. The court must balance all relevant benefits and burdens, including treatment that is intrusive or burdensome even where the child is unconscious and cannot experience pain. Where medical evidence establishes that there is no realistic prospect of recovery or meaningful benefit, the hope of a miracle cannot sustain the presumption in favour of continued treatment. The assessment remains fact-specific.

The Trust applied for declarations that continued life-sustaining treatment for MG, a young child with catastrophic and irreversible brain injury, was no longer in his best interests, was futile and burdensome, and could lawfully be withdrawn. MG required continuous mechanical ventilation, an external ventricular drain and intensive nursing care. His parents opposed the application, relying principally on their hope of recovery or a miracle. His court-appointed Guardian supported the Trust.

The court considered the medical evidence, the parents’ evidence and the Guardian’s report. The central issue was whether, applying the best-interests balancing exercise, the benefits of keeping MG alive outweighed the present and anticipated burdens of continued treatment.

1. Declarations granted. The court held that continued life-sustaining treatment was not in MG’s best interests, was futile and could lawfully be withdrawn.
2. The court adopted the five intellectual milestones identified in Re Fixler: the judge must decide the child’s best interests; welfare is paramount; the question must be considered from the child’s assumed point of view; there is a strong but rebuttable presumption in favour of prolonging life; and all relevant welfare factors must be balanced. The exercise is necessarily fact-specific.
3. Applying Aintree University Hospital NHS Foundation Trust v James and Re A (A Child), the focus was whether treatment was in MG’s best interests, considering his welfare in the widest sense, the nature and prospects of treatment, its likely outcome and his assumed attitude towards it.
4. The court accepted the unanimous medical evidence that MG had no consciousness, could not experience meaningful benefit from continued treatment and had no realistic prospect of neurological recovery. The possibility of a miracle, or that the medical evidence might prove wrong, could not justify continued treatment.
5. The benefits of continued treatment included prolonging life and enabling MG to remain the object of his family’s love. The burdens included invasive ventilation, tube feeding, suctioning, monitoring and the intensive-care environment. Those burdens remained legally relevant even though MG was unconscious and did not experience pain, although their weight was reduced by the absence of pain. Future burdens, including likely infection, respiratory deterioration, bone disease, fractures, renal stones and scoliosis, weighed heavily in the balance.
6. The presumption in favour of preserving life was rebutted. The court concluded that the treatment should not continue and made the declarations sought. Consequential arrangements were to include a palliative-care plan.