Refusal of medical treatment in a minor aged 16+: a reminder of the principles

New decision emphasises the overall evaluation of the best interests of a minor aged 16 who refused treatment for a life-threatening condition.

The applicant NHS Trust succeeded on its (without notice) application for the approval of a plan for the treatment of the respondent (B), aged 16, who had refused to accept treatment, namely insulin, for her diabetic ketoacidosis. The court decided that it was in B’s best interests to receive the proposed treatment, which if left untreated would lead to her death.

There was no evidence that B lacked capacity; her treating team were satisfied that she had good knowledge of her condition, and of the implications of not receiving insulin, namely the risk of death. However B wished to die.

B lived with her grandfather who was supportive of the decision to provide the treatment required to reverse her DKA.

The hospital’s medical evidence in support of its application stated that B had been persuaded to be admitted to hospital and to receive a cannula but she had refused insulin. The concern was that even if B were to agree to treatment, she may again refuse during the 48 hour period required for the administration of insulin.

B had a history of refusing to administer her insulin, resulting in in-patient care, but this was the most prolonged period of refusal and coupled with the most severe episode of DKA she had suffered.

A reminder of the principles

• The paramount consideration of the court is the best interests of the child. The role of the court when exercising its jurisdiction is to give or withhold consent to medical treatment in the best interests of the child.
• The starting point is to consider the matter from the assumed point of view of the patient: what is the patient’s attitude to treatment.
• Whether in the best interests of the child patient, a particular decision as to medical treatment should be taken.
• Best interests includes medical, emotional, sensory and instinctive considerations; the court must do the best it can to balance all the conflicting considerations in a particular case. The court is not bound to follow the clinical assessment of the doctors but must form its own view as to the child’s best interests.
• There is a strong presumption in favour of taking all steps to preserve life but the presumption is not irrebuttable.
• Each case is fact specific.
• The court must consider the nature of the medical treatment, including the likely outcome for the patient.
• There will be cases where it is not in the best interests of the child to subject him or her to treatment that will cause increased suffering and produce no commensurate benefit.
• The views and opinions of parents and doctors must be considered but “the court must also be mindful that the views of the parents may, understandably, be coloured by their own emotion or sentiment”.
• The view of the child must be considered and be given appropriate weight in light of the child’s age and understanding.

The court’s approach to its decision-making

A number of factors weighed in favour of the hospital’s application:

• Cogent evidence that B had developed DKA and there was no sign of improvement and the medical evidence was that her condition was “parlous” and if left untreated it would be fatal.
• The window for administering treatment to B is a “narrow one”.
• Strong presumption in favour of taking all steps to preserve life and that presumption is a “very compelling factor”.
• B’s grandfather was in favour of treatment.
• The treatment proposed by the NHS Trust represents that favoured by a consensus of medical opinion and the treatment proposed would be effective in ameliorating B’s DKA with it manifest benefits.

As to B’s stated wishes and feelings, the court noted that it is not mandated to accept the wishes and feelings of a competent child where to honour that would “result in manifest, and even fatal, harm to that child”.

Equally, the court also had regard to the fact that this was not the first time that B had refused treatment and that children sometimes “…seek, particularly during teenage years, to deal with the unremitting pressure of such a situation by seeking to exercise control of the seemingly uncontrollable in the only way available to them, namely refusing to co-operate with their treatment”. But within this context the court considered it significant that the B had already consented to admission to hospital, to a series of blood tests and to insertion of a cannula.

Medical treatment cases are difficult: do get in touch if you require support, we have a friendly expert team ready help.

Helen Burnell, Ruth Minnis and Jill Weston