“He certainly wouldn't want to be left like he is. I would feel that he should be removed and the family feel the same. I was angry when the advice from the coroner was received. I can see no point whatsoever in continuing treatment.”
“What is the diagnosis? This can be confidently answered that on the basis of history, physical and neurological examination supplemented by laboratory data, this is a classical example of the persistent vegetative state.”
“I am confident that from my knowledge of other patients, neurophysiology, previous cases from the literature and from animal experimentation that the patient has no awareness nor can he suffer pain or experience pleasure. Further the prospect of improvement can also confidently be answered since based on what we know of the degree of damage to his brain, the comparison of his case with those recorded in the literature (particularly considering the nature of his damage and the duration of his illness) and the type of systems and signs he exhibits, there is no hint or hope or any prospect of improvement. In my opinion artificial feeding and hydration, constitutes ‘medical treatment.’ If a patient were to be admitted under my care and was for one reason or another unable to feed himself, the setting up of a nasogastric tube for feeding and hydration would constitute beyond any measure of doubt ‘medical treatment’ as opposed to normal feeding.”
“Very impressed by the recommendation of the British Medical Association, that is to say in respect of the consultation and treatment of patients in the persistent vegetative state. In particular the recommendation that where the diagnosis had been well established and the differential diagnosis had been ruled out and all the necessary laboratory tests done then the prognosis could confidently be given as zero if after one year there was no sign of improvement.”
“I regard him as being in a persistent vegetative state. He is the most severe case I have seen and I do not consider Tony Bland will make any recovery whatsoever. If the regime continues as at present he is likely to survive a few years, not more than five, because he is prone to infections.”
“The use of the equipment might be thought to be medical treatment but not the supply of food which is a basic human requirement.”
“Moreover, it seems to me of first importance that the common law should be readily intelligible to and applicable by all those who undertake the care of persons lacking the capacity to consent to treatment. It would be intolerable for members of the medical, nursing and other professions devoted to the care of the sick that, in caring for those lacking the capacity to consent to treatment they should be put in the dilemma that, if they administer the treatment which they believe to be in the patient's best interests, acting with due skill and care, they run the risk of being held guilty of trespass to the person, but if they withhold that treatment, they may be in breach of a duty of care owed to the patient. If those who undertake responsibility for the care of incompetent or unconscious patients administer curative or prophylactic treatment which they believe to be appropriate to the patient's existing condition of disease, injury or bodily malfunction or susceptibility to such a condition in the future, the lawfulness of that treatment should be judged by one standard, not two. It follows that if the professionals in question have acted with due skill and care, judged by the well known test laid down in Bolam v. Friern Hospital Management Committee [1957] 1 W.L.R. 582, they should be immune from liability and trespass just as they are immune from liability in negligence.”
“cutting the thread of life.”
“This brings me face to face with the problem of formulating the critical equation. In truth it cannot be done with mathematical or any precision. There is without doubt a very strong presumption in favour of a course of action which will prolong life, but, even excepting the ‘cabbage’ case to which special considerations may well apply, it is not irrebuttable. As this court recognised in In re B. (A Minor) (Wardship: Medical Treatment) [1981] 1 W.L.R. 1421, account has to be taken of the pain and suffering and quality of life which the child will experience if life is prolonged. Account has also to be taken of the pain and suffering involved in the proposed treatment itself.”
“But in the end there will be cases in which the answer must be that it is not in the interests of the child to subject it to treatment which will cause increased suffering and produce no commensurate benefit, giving the fullest possible weight to the child's, and mankinds, desire to survive.”
“Guardians of patient in persistent vegetative state brought declaratory judgment action seeking judicial sanction of their wish to terminate artificial hydration and nutrition for patient. The Circuit Court, Jasper County, Probate Division, Charles E. Teel Junior J. directed state employees to cause request of guardians to be carried out. Appeal was taken. The Missouri Supreme Court reversed (1988) 760 S.W.2d 408. Certiorari was granted. The Supreme Court, Chief Justice Rehnquist, held that: (1) the United States constitution did not forbid Missouri from requiring that clear and convincing evidence of an incompetent's wishes to the withdrawal of life sustaining treatment; (2) state Supreme Court did not commit constitutional error in concluding that evidence adduced at trial did not amount to clear and convincing evidence of patient's desire to cease hydration and nutrition; and (3) due process did not require State to accept substituted judgment of close family members absent substantial proof that their views reflected those of the patient.”
“Medical advances have altered the physiological conditions of death in ways that may be alarming: highly invasive treatment may perpetuate human existence through a merger of body and machine that some might reasonably regard as an insult to life rather than as its continuation. But those same advances, and the reorganisation of medical care accompanying the new science and technology, have also transformed the political and social conditions of death: people are less likely to die at home, and more likely to die in relatively public places such as hospitals or nursing homes. Ultimate questions that might once have been dealt with in intimacy by a family and its physician have now become the concern of institutions.”
“But for patients like Nancy Cruzan, who have no consciousness and no chance of recovery, there is a serious question as to whether the mere persistence of their bodies is ‘life,’ as that word is commonly understood … The State's unflagging determination to perpetuate Nancy Cruzan's physical existence is comprehensible only as an effort to define life's meaning, not as an attempt to preserve its sanctity.”
“In any event, absent some theological abstraction, the idea of life is not conceived separately from the idea of a living person.”
“He certainly wouldn't want to be left like that.”
“(1) … lawfully discontinue all life-sustaining treatment and medical support measures designed to keep [Mr. Bland] alive in his existing persistent vegetative state including the termination of ventilation nutrition and hydration by artificial means; and
“(2) … lawfully discontinue and thereafter need not furnish medical treatment to [Mr. Bland] except for the sole purpose of enabling [Mr. Bland] to end his life and die peacefully with the greatest dignity and the least of pain suffering and distress.”
“In my view, doctors have a lawful excuse to discontinue ventilation when there is no medical justification for continuing that form of medical assistance. To require the administration of a life support system when such a system has no further medical function or purpose and serves only to defer the death of the patient is to confound the purpose of medicine. In such circumstances, the continuation of the artificial ventilation may be lawful, but that does not make it unlawful to discontinue it if the discontinuance accords with good medical practice.”
“The point, for present purposes is, as I apprehend it, that a doctor acting in good faith and in accordance with good medical practice is not under a duty to render life support necessary to prolong life if that is, in his or her judgment, contrary to the best interests of the patient.”
“Medical science and technology has advanced for a fundamental purpose; the purpose of benefiting the life and health of those who turn to medicine to be healed. It surely was never intended that it be used to prolong biological life in patients bereft of the prospect of returning to an even limited exercise of human life. Nothing in the inherent purpose of these scientific advances can require doctors to treat the dying as if they were curable. Natural death has not lost its meaning or significance. It may be deferred, but it need not be postponed indefinitely. Nor, surely, was modern medical science ever developed to be used inhumanely. To do so is not consistent with its fundamental purpose. Take the case of a man riddled with cancer, in constant agony, and facing imminent death. Is he to be placed upon a respirator? On the contrary, it has been generally accepted that doctors may seek to alleviate a patient's terminal pain and suffering even though the treatment may at the same time possibly accelerate the patient's death. As I perceive it, what is involved is not just medical treatment, but medical treatment in accordance with the doctor's best judgment as to what is in the best interests of his or her patient. They remain responsible for the kind and extent of the treatment administered and, ultimately, for its duration. In exercising their best judgment in this regard it is crucial for the patient and in the overall interests of society that they should not be inhibited by considerations pertinent to their own self-interest in avoiding criminal sanctions. Their judgment must be a genuinely independent judgment as to what will best serve the well-being of their dying patients. Conscientious doctors will undoubtedly continue to strive with dedication to preserve and promote the life and health of their patients. That is their primary mission. But with a patient such as Mr. L., where ‘life’ is being prolonged for no therapeutic or medical purpose or, in other words, death is merely being deferred, the doctor is not under a duty to avert that death at all costs. If, in his judgment, the proper medical practice would be to discontinue the life support system, and that would be in the best interests of his patient, he may do so subject to adhering to a procedure which provides a safeguard against the possibility of individual error.”
“At this stage, it may be useful to summarize the tentative conclusions which the Commission has reached to date. These conclusions are as follows: (1) the law should recognize the competent patient's wishes and respect them as regards the cessation or non-initiation of treatment; (2) the law should clearly state that a physician acts legally when he decides to terminate or not to initiate treatment which is useless or which no longer offers reasonable hope, unless the patient has expressed his wishes to the contrary; (3) the law should recognize that the prolonging of life is not an absolute value in itself and that therefore a physician does not act illegally when he fails to take measures to achieve this end, if these measures are useless or contrary to the patient's wishes or interests; (4) the law should recognize that a physician who continues to treat a patient against his wishes is subject to the provisions of the Criminal Code; (5) the law should recognize that the incapacity of a person to express his wishes is not a sufficient reason to oblige a physician to administer useless treatment for the purpose of prolonging his life; (6) the law should recognize that in the case of an unconscious or incompetent patient, a physician incurs no criminal responsibility by terminating treatment which has become useless.”
“a physician should not incur any criminal liability if he decides to discontinue or not initiate treatment for an incompetent person, when that treatment is no longer therapeutically useful and is not in the person's best interest.”
“feeding/gastrostomy tubes for nutrition and hydration are medical treatments and are warranted only when they make possible a decent life in which the patient can reasonably be thought to have a continued interest … There is no justification for continuing medical intervention in such a state and the working party feels that the individual concerned is most appropriately treated as an incompetent patient with a terminal condition.”
“The decision on life and death must and does remain in other hands. What doctors and the court have to decide is whether, in the best interests of the child patient, a particular decision as to medical treatment should be taken which as a side effect will render death more or less likely. This is not a matter of semantics. It is fundamental. At the other end of the age spectrum, the use of drugs to reduce pain will often be fully justified, notwithstanding that this will hasten the moment of death. What can never be justified is the use of drugs or surgical procedures with the primary purpose of doing so.”
“This brings me face to face with the problem of formulating the critical equation. In truth it cannot be done with mathematical or any precision. There is without doubt a very strong presumption in favour of a course of action which will prolong life, but even excepting the ‘cabbage’ case to which special considerations may well apply, it is not irrebuttable.”
“Once the absolute test is rejected, the proper criteria must be a matter of degree.”
“Clearly, a decision to focus exclusively on pain as the single criterion ignores and devalues other important ideals regarding life and death. Consequently, a pain standard cannot serve as an indirect proxy for additional and significant concerns that bear on the decision to forego life-prolonging treatments.”
“But Nancy Cruzan's interest in life, no less than any other person, includes an interest in how she will be thought of after her death by those whose opinions mattered to her. There can be no doubt that her life made her dear to her family, and to others. How she dies will affect how that life is remembered.”
“The medical and nursing treatment of individuals in extremis and suffering from these conditions entails the constant and extensive handling and manipulation of the body. At some point, such a course of treatment upon the insensate patient is bound to touch the sensibilities of even the most detached observer. Eventually, pervasive bodily intrusions, even for the best of motives, will arouse feelings akin to humiliation and mortification for the helpless patient. When cherished values of human dignity and personal privacy, which belong to every person living or dying, are sufficiently transgressed by what is being done to the individual, we should be ready to say: enough.”
“Based upon such factors it should be possible to structure critical treatment decisions that are reliable, understandable and acceptable.”
“values of human dignity and personal privacy …. Human dignity and personal privacy belong to every person, whether living or dying. Yet, the sheer invasiveness of the treatment and the manipulation of the human body which it entails, the pitiful and humiliating helplessness of the patient's state, and the degradation and dissolution of all bodily functions invoke these values; …”
“The world that we encounter in ordinary experience is one in which we are faced with choices between ends equally ultimate, and claims equally absolute, the realisation of some of which must inevitably involve the sacrifice of others … The knowledge that it is not merely in practice but in principle impossible to reach clear-cut and certain answers, even in an ideal world of wholly good and rational men and wholly clear ideas — may madden those who seek for final solutions and single, all-embracing systems, guaranteed to be eternal. Nevertheless it is a conclusion that cannot be escaped by those who, with Kant, have learnt the truth that out of the crooked timber of humanity no straight thing was ever made:” see Two Concepts of Liberty (1969), at pp. 168, 170.
“the physician should and may do nothing else but preserve life. Whether it is valuable or not, that is none of his business. If he once commits such considerations to influence his actions, the doctor will be the most dangerous man in the state:”
“What would the patient have decided in the circumstances:”
“that despite the inability of the defendant to consent thereto the plaintiff and the responsible attending physicians: (1) may lawfully discontinue all life-sustaining treatment and medical supportive measures designed to keep the defendant alive in his existing persistent vegetative state including the termination of ventilation nutrition and hydration by artificial means; and (2) may lawfully discontinue and thereafter need not furnish medical treatment to the defendant except for the sole purpose of enabling him to end his life and die peacefully with the greatest dignity and the least of pain suffering and distress; …”
“Mr. Anthony David Bland, then aged 17ä, went to the Hillsborough ground on15 April 1989 to support the Liverpool Football Club. In the course of the disaster which occurred on that day, his lungs were crushed and punctured and the supply of oxygen to his brain was interrupted. As a result, he suffered catastrophic and irreversible damage to the higher centres of the brain. The condition from which he suffers, and has suffered since April 1989, is known as a persistent vegetative state (‘P.V.S.’). P.V.S. is a recognised medical condition quite distinct from other conditions sometimes known as ‘irreversible coma,’ ‘the Guillain-Barre syndrome,’ ‘the locked-in syndrome’ and ‘brain death.’ Its distinguishing characteristics are that the brain stem remains alive and functioning while the cortex of the brain loses its function and activity. Thus the P.V.S. patient continues to breathe unaided and his digestion continues to function. But although his eyes are open, he cannot see. He cannot hear. Although capable of reflex movement, particularly in response to painful stimuli, the patient is incapable of voluntary movement and can feel no pain. He cannot taste or smell. He cannot speak or communicate in any way. He has no cognitive function and can thus feel no emotion, whether pleasure or distress. The absence of cerebral function is not a matter of surmise; it can be scientifically demonstrated. The space which the brain should occupy is full of watery fluid. The medical witnesses in this case include some of the outstanding authorities in the country on this condition. All are agreed on the diagnosis. All are agreed on the prognosis also: there is no hope of any improvement or recovery. One witness of great experience described Mr. Bland as the worst P.V.S. case he had ever seen.
“Mr. Bland lies in bed in the Airedale General Hospital, his eyes open, his mind vacant, his limbs crooked and taut. He cannot swallow, and so cannot be spoon-fed without a high risk that food will be inhaled into the lung. He is fed by means of a tube, threaded through the nose and down into the stomach, through which liquefied food is mechanically pumped. His bowels are evacuated by enema. His bladder is drained by catheter. He has been subject to repeated bouts of infection affecting his urinary tract and chest, which have been treated with antibiotics. Drugs have also been administered to reduce salivation, to reduce muscle tone and severe sweating and to encourage gastric emptying. A tracheostomy tube has been inserted and removed. Genito-urinary problems have required surgical intervention. A patient in this condition requires very skilled nursing and close medical attention if he is to survive. The Airedale National Health Service Trust have, it is agreed, provided both to Mr. Bland. Introduction of the nasogastric tube is itself a task of some delicacy even in an insensate patient. Thereafter it must be monitored to ensure it has not become dislodged and to control inflammation, irritation and infection to which it may give rise. The catheter must be monitored: it may cause infection (and has repeatedly done so); it has had to be resited, in an operation performed without anaesthetic. The mouth and other parts of the body must be constantly tended. The patient must be repeatedly moved to avoid pressure sores. Without skilled nursing and close medical attention a P.V.S. patient will quickly succumb to infection. With such care, a young and otherwise healthy patient may live for many years.
“At no time before the disaster did Mr. Bland give any indication of his wishes should he find himself in such a condition. It is not a topic most adolescents address. After careful thought his family agreed that the feeding tube should be removed and felt that this was what Mr. Bland would have wanted. His father said of his son in evidence:
‘He certainly wouldn't want to be left like that.’
“To presume that the incompetent person must always be subjected to what many rational and intelligent persons may decline is to downgrade the status of the incompetent person by placing a lesser value on his intrinsic human worth and vitality.”
“I consider the correct approach is for the court to judge the quality of life the child would have to endure if given the treatment and decide whether in all the circumstances such a life would be so afflicted as to be intolerable to that child.”
“This was in my respectful view a wise ruling, directed to the protection of patients, the protection of doctors, the reassurance of patients' families and the reassurance of the public. The practice proposed seems to me desirable. It may very well be that with the passage of time a body of experience and practice will build up which will obviate the need for application in every case, but for the time being I am satisfied that the practice which the President described should be followed.”
“Yes, I understand the point, now that you have explained it to me. There is no duty, or indeed right to feed, when feeding is not in the best interests of the patient. But the real reason for withdrawing feeding is that the doctors consider that it would be in the patient's best interests for him to be allowed to die. (I also know that the same result could be achieved, if not so quickly, by allowing the patient's next infection to go untreated, but that is not just the point which we have been discussing here.) The solution here seems to me to introduce what lawyers call a distinction without a difference: the intention is to terminate life, but the acceptable way of doing it is to discontinue a regime which the law has said that the doctors have no duty or even right to continue. And, incidentally, In re F. (not that I would venture to query your reliance on that authority) was not concerned with matters of life and death at all. So might it not be suggested, no doubt quite wrongly, that this case is, in effect if not in law, an example of euthanasia in action? I can of course appreciate the arguments in a case like this, for indirectly terminating the patient's life and I believe that very many of my friends would be in favour of what is now proposed, but equally there must be many people who, from conviction or simply by virtue of their conventional upbringing, are unconvinced that someone who can be kept alive should be allowed to die.”
“(1) lawfully discontinue all life-sustaining treatment and medical support measures designed to keep [Mr. Bland] alive in his existing persistent vegetative state including the termination of ventilation, nutrition and hydration by artificial means; and (2) lawfully discontinue and thereafter need not furnish medical treatment to [Mr. Bland] except for the sole purpose of enabling [Mr. Bland] to end his life and die peacefully with the greatest dignity and the least of pain, suffering and distress.”