#1697 - Airedale Nhs Trust V Bland - Medical Law

Airedale NHS Trust v Bland [1993] AC 789

House of Lords

Held Lord Keith

• The object of medical treatment and care is to benefit the patient.

  • It may do so by taking steps to prevent the occurrence of illness, or, if an illness does occur, by taking steps towards curing it.

  • Where an illness or the effects of an injury cannot be cured, then efforts are directed towards preventing deterioration or relieving pain and suffering

• Given that existence in the persistent vegetative state is not a benefit to the patient, does 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, mean that treatment must be continued?

  • 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

  • The decision whether or not the continued treatment and care of a P.V.S. patient confers any benefit on him is essentially one for the practitioners in charge of his case.

    • The question is whether any decision that it does not and that the treatment and care should therefore be discontinued should as a matter of routine be brought before the Family Division for endorsement or the reverse.

Held Lord Goff

• I start with the simple fact that, in law, Anthony is still alive. It is true that his condition is such that it can be described as a living death;

  • but as a result of developments in modern medical technology, doctors no longer associate death exclusively with breathing and heart beat,

  • and it has come to be accepted that death occurs when the brain, and in particular the brain stem, has been destroyed

  • Here, the fundamental principle is the principle of the sanctity of human life - a principle long recognised not only in our own society but also in most, if not all, civilised societies throughout the modern world

    • But this principle, fundamental though it is, is not absolute. Indeed there are circumstances in which it is lawful to take another man's life, for example by a lawful act of self-defence

    • We are concerned with circumstances in which it may be lawful to withhold from a patient medical treatment or care by means of which his life may be prolonged.

      • But here too there is no absolute rule that the patient's life must be prolonged by such treatment or care, if available, regardless of the circumstances

• General Principles

  • First, it is established that the principle of self-determination requires that respect must be given to the wishes of the patient,

    • so that if an adult patient of sound mind refuses, however unreasonably, to consent to treatment or care by which his life would or might be prolonged,

      • the doctors responsible for his care must give effect to his wishes, even though they do not consider it to be in his best interests to do so.

  • But in many cases not only may the patient be in no condition to be able to say whether or not he consents to the relevant treatment or care, but also he may have given no prior indication of his wishes with regard to it

    • There is nevertheless no absolute obligation upon the doctor who has the patient in his care to prolong his life, regardless of the circumstances.

      • Indeed, it would be most startling, and could lead to the most adverse and cruel effects upon the patient, if any such absolute rule were held to exist.

• A distinction

  • In law there is a crucial distinction between cases in which a doctor decides not to provide, or to continue to provide, for his patient treatment or care which could or might prolong his life,

    • and those in which he decides, for example by administering a lethal drug, actively to bring his patient's life to an end.

      • It is not lawful for a doctor to administer a drug to his patient to bring about his death,

        • even though that course is prompted by a humanitarian desire to end his suffering, however great that suffering may be

    • It is true that the drawing of this distinction may lead to a charge of hypocrisy; because it can be asked why, if the doctor, by discontinuing treatment, is entitled in consequence to let his patient die,

      • it should not be lawful to put him out of his misery straight away, in a more humane manner, by a lethal injection, rather than let him linger on in pain until he dies.

        • But the law does not feel able to authorise euthanasia, even in circumstances such as these;

        • for once euthanasia is recognised as lawful in these circumstances, it is difficult to see any logical basis for excluding it in others

• So why?

  • At the heart of this distinction lies a theoretical question....