Airedale NHS Trust v. Bland

[1993] 1 ALL ER 821
Download Judgment: English

Mr. Bland was in the care of the health authority, and had been in a persistent vegetative state for three and a half years due to a severe crushed chest injury, which had caused devastating and permanent damage to the higher functions of his brain. He was being fed artificially by a tube inserted through his nose into his stomach. Although his respiration and digestion was unaided, he could not smell, see, hear, talk, move involuntarily or feel pain. All of the doctors who had examined him felt that there was no possible chance of recovery from such a condition and that it would be in his best interests to stop the artificial feeding and allow him to die with dignity and without pain or distress. His family was also supportive of this decision.

The health authority applied to the court for declarations that it and the responsible physicians could lawfully discontinue all life-sustaining treatment and medical support measures designed to keep Mr. Bland alive in his existing persistent vegetative state. The sought declarations included declarations permitting the termination of ventilation, nutrition and hydration by artificial means and declarations permitting the cessation of medical treatment, except for treatment with the sole purpose of enabling Mr. Bland to die peacefully.

At trial, the judge granted a declaration stating that it would be lawful to discontinue artificial feeding to Anthony Bland. The Official Solicitor unsuccessfully appealed to the Court of Appeal. The Official Solicitor then appealed to the House of Lords, arguing that withdrawal of life support would be not only a breach of the doctors’ duty of care towards their patient, but also a criminal act.

The Court held that given the particulars of this case, the withdrawal of life support by the health authority would not be a breach of its duty of care or a criminal act. A doctor who had in his care a patient who was incapable of deciding whether or not to consent to treatment was under no absolute obligation to prolong the patient’s life. Medical treatment, including artificial feeding and the administration of drugs, could lawfully be withheld from a patient with no hope of recovery when it was known that the patient would shortly thereafter die, as long as responsible and competent medical opinion was that continued medical treatment would not be in the patient’s best interests because continuing treatment would be futile and would not confer any benefit.

Furthermore, ending life support by withdrawing artificial feeding or other means of support was not a criminal act. If continuing an intrusive life support system was not in the patient’s best interests, the doctor was no longer under a duty to maintain the patient’s life. Instead, the doctor was simply allowing his patient to die of his pre-existing condition. The patient’s death would be regarded in law as exclusively caused by the injury or disease to which his condition was attributable. In light of Mr. Bland’s condition, the declaration had been properly granted. The appeal was dismissed.

“Given that existence in the persistent vegetative state is not a benefit to the patient, it remains to consider whether the principle of the sanctity of life, which it is the concern of the state, and the judiciary as one of the arms of the state, to maintain, requires this House to hold that the judgment of the Court of Appeal was incorrect. In my opinion it does not. The principle is not an absolute one. It does not compel a medical practitioner on pain of criminal sanctions to treat a patient, who will die if he does not, contrary to the express wishes of the patient. It does not authorise forcible feeding of prisoners on hunger strike. It does not compel the temporary keeping alive of patients who are terminally ill where to do so would merely prolong their suffering. On the other hand it forbids the taking of active measures to cut short the life of a terminally ill patient. In my judgment it does no violence to the principle to hold that it is lawful to cease to give medical treatment and care to a PVS patient who has been in that state for over three years, considering that to do so involves invasive manipulation of the patient's body to which he has not consented and which confers no benefit upon him.” 1 All ER p. 861.

“The real answer to the Official Solicitor, as your Lordships are already agreed, is that his argument starts from the fallacious premiss, which can be taken as correct in ordinary doctor-patient relationships, namely that feeding in order to sustain life is necessarily for the benefit of the patient. But in the prevailing circumstances the opposite view is overwhelmingly held by the doctors and the validity of that view has been accepted by the courts below. The doctors consider that in the patient's best interests they ought not to feed him and the law, as applied by your Lordships, has gone further by saying that they are not entitled to feed him without his consent, which cannot be obtained. So the theory of the 'duty to feed' is founded on a misapprehension and the Official Solicitor's argument leads to a legally erroneous conclusion. Even though the intention to bring about the patient's death is there, there is no proposed guilty act because, if it is not in the interests of an insentient patient to continue the life-supporting care and treatment, the doctor would be acting unlawfully if he continued the care and treatment and would perform no guilty act by discontinuing.” 1 All ER pp. 876-877.

“In these circumstances, it is perfectly reasonable for the responsible doctors to conclude that there is no affirmative benefit to Anthony Bland in continuing the invasive medical procedures necessary to sustain his life. Having so concluded, they are neither entitled nor under a duty to continue such medical care. Therefore they will not be guilty of murder if they discontinue such care.” 1 All ER pp. 884.