Cardiff and Vale University Local Health Board v SR & Ors

In disputes about life-sustaining treatment for a child who cannot decide, the court must determine the child’s best interests objectively. The child’s welfare is paramount and must be assessed holistically, including medical, emotional, social and other welfare considerations. There is a strong but rebuttable presumption in favour of preserving life. Parents’ views, religious beliefs and family-life interests require respectful consideration, but they are not determinative. Treatment may be burdensome even where pain is unlikely or unproved. Physical harm from medical intervention may therefore form part of the balancing exercise. The court need not wait for foreseeable complications to become acute where treatment cannot improve or arrest a fatal and irreversible condition. The declarations sought were made and palliative care approved.

The applicant health board sought declarations concerning the withdrawal of life-sustaining treatment from TR, a young child with Leigh syndrome, irreversible brain damage and no realistic prospect of recovery or independent breathing.

The treating clinicians and independent experts considered that continued ventilation and associated treatment provided no appreciable benefit and imposed physiological burdens. TR’s parents opposed withdrawal. They relied on their observations of apparent responsiveness, their desire for further time with their son, and their Islamic faith. The children’s guardian supported withdrawal.

The central issue was whether continuing life-sustaining treatment was in TR’s best interests.

1. Best-interests jurisdiction and test. The court had jurisdiction to make declarations concerning medical treatment where a child cannot decide and there is disagreement between clinicians and those with parental responsibility. TR’s welfare was the paramount consideration. The court had to conduct an objective, holistic assessment of his medical, emotional and other welfare interests. A strong presumption favoured preserving life, but it was rebuttable.
2. The court considered the views of the doctors, parents and guardian. The parents’ views and religious beliefs, including the impact of withdrawal on their family life and faith, were important but not determinative. The analysis had to be from the assumed point of view of the child, with all relevant factors weighed in a non-mathematical balancing exercise.
3. The judge accepted the consistent expert evidence that TR had irreversible brain damage, no cognitive awareness, no prospect of recovery or independent breathing, and was in the terminal phase of a fatal disease. Apparent changes or isolated responses did not establish meaningful awareness or improvement when viewed against the wider neurological picture.
4. Treatment could be burdensome even though TR was unlikely to experience pain. The court identified foreseeable physiological burdens, including pneumonia, worsening respiratory failure, osteopenia, pathological fractures, renal stones, scoliosis, progressive gut failure, seizures, infection and sepsis. It was unnecessary to wait for those burdens to manifest or become acute where treatment could not alleviate or halt the disease.
5. Balancing the irreversible condition and treatment burdens against the parents’ genuinely held views, religious beliefs and family-life interests, continued life-sustaining treatment was not in TR’s best interests. The declarations sought by the applicant were made, with a view to approving an updated palliative-care plan. The judge declined to give separate procedural guidance because it would distract from the welfare determination.