Airedale NHS Trust v Bland [1993] UKHL 17 (04 February 1993)

A victim of the Hillsborough disaster, Anthony Bland, was left in a persistent vegetative state. The House of Lords ruled it was lawful for doctors to withdraw his life-sustaining artificial nutrition and hydration, as continuing treatment was not in his best interests.

Facts

Anthony Bland was a 17-year-old football supporter who suffered severe hypoxic brain damage during the 1989 Hillsborough Stadium disaster, crushing his chest and causing his lungs to collapse. This left him in a condition known as a persistent vegetative state (PVS). He was not ‘brain dead’ as his brain stem continued to function, and he could breathe unaided. However, his cerebral cortex was destroyed, leaving him with no awareness of self or his surroundings, and no prospect of recovery. His life was sustained solely by artificial nutrition and hydration provided through a nasogastric tube. After three and a half years, the Airedale NHS Trust, with the full support of his family, applied to the court for a declaration that they could lawfully discontinue all life-sustaining treatment, including the artificial feeding, which would inevitably lead to his death.

Issues

The central legal issue before the House of Lords was whether the discontinuance of life-sustaining treatment (specifically, artificial nutrition and hydration) from a patient in a PVS constituted a lawful act or an unlawful killing (murder). This required the court to address several key questions:

• Is the withdrawal of treatment a positive act of killing or a lawful omission?
• What is the extent of a doctor’s duty to provide care to a patient who cannot consent?
• How should the ‘best interests’ of a patient who is permanently insensate and has no hope of recovery be determined?
• Is there a legally significant distinction between withdrawing life-sustaining treatment and actively causing death (euthanasia)?

Judgment

The House of Lords unanimously dismissed the appeal, affirming the decisions of the lower courts. They declared that it would be lawful for the doctors to withdraw the life-sustaining treatment. The judgment established that while the sanctity of life is a fundamental principle, it is not absolute.

The Nature of the Act: Omission, Not Act

The court characterised the proposed course of action as an omission rather than a positive act. Lord Goff of Chieveley explained that discontinuing the treatment was letting the patient die from his existing injuries. The cause of death would be the underlying pathology that prevented him from being able to swallow, not the doctor’s action.

“But the doctor’s conduct is to be differentiated from that of, for example, an interloper who maliciously switches off a life support machine, because in the case of the doctor, he is acting in the context of the doctor/patient relationship, and the question is whether he is in breach of his duty to his patient.”

Duty of Care and Best Interests

Their Lordships reasoned that a doctor’s duty is to act in the best interests of the patient. While treatment that sustains life is prima facie in a patient’s best interests, this does not apply if the treatment is futile and confers no benefit. In the case of a PVS patient with no hope of recovery, continued existence was not considered a benefit. Therefore, the duty to provide treatment ceased.

Lord Goff articulated the crucial question:

“The question is not whether it is in the best interests of the patient that he should die. The question is whether it is in the best interests of the patient that his life should be prolonged by the continuance of this form of medical treatment or care.”

Since the treatment was deemed futile and burdensome (in terms of the indignity of the condition), with no countervailing benefit to the patient, it was no longer in his best interests to continue it. The court concluded that the principle of the sanctity of life was not violated by ceasing treatment that had become futile. Lord Browne-Wilkinson stressed that such decisions should not be taken lightly and required a court declaration for the protection of all involved.

Implications

The decision in Airedale NHS Trust v Bland created a crucial legal precedent in English medical law. It confirmed that it is lawful for doctors to withdraw life-sustaining treatment from patients in a PVS, provided that an application is first made to the courts for a declaration that such a course of action is in the patient’s best interests. The ruling carefully distinguished this lawful omission from the unlawful positive act of euthanasia or mercy killing, which remains illegal. It firmly established the ‘best interests’ test as the determinative factor in such cases and cemented the role of the judiciary in overseeing the most difficult end-of-life decisions, providing legal protection to medical professionals and ensuring a public and transparent process.

Verdict: The appeal was dismissed. The court granted the declaration that the Airedale NHS Trust could lawfully discontinue all life-sustaining treatment and medical support measures for Anthony Bland.

Source: Airedale NHS Trust v Bland [1993] UKHL 17 (04 February 1993)