C (A Child) (Life-saving Medical Treatment), Re

When parents and doctors disagree about life-saving treatment for a child who cannot decide, the court must determine whether the treatment is in the child’s best interests. The child’s welfare is paramount and must be assessed holistically, including medical, emotional, social and psychological considerations.

The court must consider the treatment’s nature, burdens and prospects of success, the likely outcome without treatment, the child’s assumed perspective, and the views of parents, doctors and other carers. There is a strong but rebuttable presumption in favour of preserving life. Parental, medical and assumed child views are important but none is determinative. Religious beliefs form part of the assessment, although care is needed before attributing religious beliefs to a very young child.

Hospital trusts applied under the inherent jurisdiction for declarations that a liver transplant was in the best interests of C, a 14-month-old child with hepatoblastoma, Beckwith-Wiedemann syndrome and cat-eye syndrome. The treating doctors considered transplantation the only available life-saving treatment. Without it, C was expected to die; with it, she had a substantial prospect of survival.

C’s parents opposed transplantation because of its burdens, risks, long-term immunosuppression and uncertain longer-term outcome. They also believed that God might heal her without treatment, although they had no religious objection to transplantation. C’s children’s guardian supported the medical recommendation. The central issue was whether transplantation was in C’s best interests.

1. Jurisdiction and governing test. The court had jurisdiction to make a best-interests declaration where a child could not decide and those with parental responsibility disagreed with the treating doctors. The question was whether the proposed treatment was in C’s best interests. The welfare checklist in Children Act 1989, s.1(3), did not strictly apply, but its factors were incorporated into the holistic assessment.
2. Best-interests assessment. The welfare of the child was paramount. The court had to consider medical, emotional, social and psychological welfare; the nature and burdens of treatment; its prospects of success; the likely outcome; the assumed attitude of the child; and the views of parents, doctors and others concerned with the child’s welfare. A strong presumption favoured preserving life, but it was rebuttable. No individual view was determinative.
3. Religious beliefs were relevant to the assessment. However, the court had to take care before attributing religious beliefs to a very young child who lacked understanding of such concepts.
4. On the evidence, transplantation was the only available treatment and without it C would virtually certainly die. Although transplantation involved substantial burdens and risks, its prospects of success were sufficiently high to justify proceeding. C had a good quality of life, and the adverse consequences of treatment did not outweigh the benefits of continued life.
5. The court therefore concluded that a liver transplant was very clearly in C’s best interests and granted the declarations sought.