P.P. v. Health Service Executive

[2014] IEHC 622
Download Judgment: English
Country: Ireland
Region: Europe
Year: 2014
Court: High Court of Ireland

The plaintiff, P.P., was the father of N.P., a pregnant woman who was admitted to the defendant hospital situated outside Dublin after experiencing severe headache and nausea. Two days later of being admitted, N.P. suffered a fall and was found unresponsive. She was later transferred to a Hospital in Dublin who advised the plaintiff that there shouldn’t be an attempt at resuscitation in the event of her suffering a cardiac arrest. A few days later, she was declared brain dead. Five days after this declaration, N.P. was transferred back into the care of the defendant hospital where, against her family’s wishes, she was supported and maintained by mechanical ventilation, fed by nasogastric tube and was given heavy doses of medication for a number of conditions including pneumonia, fungal infections and high blood sugar. N.P.’s parents and partner wanted these life support machines to be turned off and N.P.’s two children did not even recognise her when they visited her and were extremely troubled by her appearance. The respondent hospital, however intended to maintain this treatment regime for the duration of the pregnancy of N.P.

The plaintiff approached the court praying for life support to be turned off. He contended that the prolonged somatic support of N.P. amounted to unreasonable and “experimental” treatment and the respondent hospital had no proper basis or ethical principles in medical science to do so. He stated that the hospital medical staff had told him that for legal reasons they were constrained to put his daughter on life support because her unborn child still had a heartbeat. However, the plaintiff wanted her daughter to have a dignified death and be put to rest. The central issue in the case was whether right to life of unborn child should prevail over mother’s personal right to a dignified death.

Applicable law in this case is Article 40.3.3 of the Irish Constitution which reads as: “The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.”

The High Court of Ireland in favour of the plaintiff held that the life support should be switched off as it was in the best interest of the unborn child. The chances of foetus being born alive were infinitesimal and in such circumstances, the woman’s right to dignity in her death and her family’s wishes could take precedence.

The Court held that the ‘plain and ordinary meaning’ of Article 40.3.3 was to protect an unborn child’s right to life beyond situations in which abortion was invoked. The Court held that the State has the obligation to defend and vindicate that right “as far as practicable” and this should be taken to mean that the Court should not “make orders which are futile, impractical or ineffective.”

The Court relied on previous judgments to determine the appropriate extent to which it was appropriate to vindicate such rights of the unborn child. It was clear from In re a Ward of Court (withholding medical treatment) (No. 2) [1996] 2 I.R. 79, that a person’s right to life, although ranking first in the hierarchy of personal rights, was not absolute, and respecting a person’s death could be regarded as an aspect of respecting life. In Airedale NHS Trust v Bland [1993] AC 789, Lord Browne Wilkinson had acknowledged that there came a time when the continuation of life support ceased to be in the patient’s best interests and began to constitute battery and trespass to the person. In Re A (a Minor) [1993] 1 Med L Rev 98, Johnson J had declared it contrary to the interests of a brain-dead child for his body “to be subjected to the continuing indignity [of life support”. In a case involving the exercise of his ‘parens patriae’ jurisdiction over a ward in connection with the proposed withdrawal of life support, the President of the High Court would invoke the “best interests principle” articulated in SR (a Ward of Court) [2012] 1 IR 305. This involved considering what the ward’s subjective views of his quality of life would be if he were able to make a sound judgment. The Court’s vindication of the unborn child’s right to life therefore involved an enquiry into the “practicality and utility of continuing life support measures”.

The Court held that since the child was in the womb of a mother who had died, such an environment would be unsafe, unstable and it was ‘failing at an alarming rate’ for the child. The court relied on the expert evidence which stated that the child had no realistic prospect of being born alive and, the future only involved distress and death. Given that the treatment could not be justified as being in the best interests of the child and the treatment being continued at a great cost, the Court ordered discontinuation of the somatic treatment to the mother.

“It is the view of the Court that, while the ordinary common understanding of what in context was involved in the referendum which led to the present wording of Article 40.3.3…in its plain and ordinary meaning may also be seen as acknowledging in simple terms the right to life of the unborn which the State, as far as practicable, shall by its laws defend and vindicate. This does not mean that the Court discounts or disregards the mother’s right to retain in death her dignity with proper respect for her autonomy with due regard to the grief and sorrow of her loved ones and their wishes. The Court therefore is unimpressed with any suggestion that considerations of the dignity of the mother are not engaged once she has passed away.” (page 11)

 “However, when the mother who dies is bearing an unborn child at the time of her death, the rights of that child, who is living, and whose interests are not necessarily inimical to those just expressed, must prevail over the feelings of grief and respect for a mother who is no longer living…The question then becomes one of how far the Court should go in terms of trying to vindicate that right in the particular circumstances which arise here.” (page 12)

 “This unfortunate unborn has suffered the dreadful fate of being present in the womb of a mother who has died, and in which the environment is neither safe nor stable, and which is failing at an alarming rate. We accept the evidence of the medical witnesses that…in this case there is no real prospect of maintaining stability in the uterine environment, having regard to the degree of infection, the fluctuating temperatures in the body of the mother, the difficulty in maintaining a safe blood pressure and the amount of toxic medication being administered to the mother which is not licensed for pregnancy. The somatic support being provided to the mother is being maintained at hugely destructive cost to both her remains and to the feelings and sensitivities of her family and loved ones.” (page 14)