Treating children with severe medical problems

The case of Amber Hartland, a terminally ill six year old suffering from the rare genetic disorder infantile Tay-Sachs, raises again the difficulties involved in acting in a child's best interests when there is a difference of opinion as to what these best interests are.

Doctors looking after Amber thought she should not receive any further treatment if she required intensive care in the future. Amber had previously been treated for chest infections resulting from her Tay-Sachs.

When a doctor wishes to stop treating a young child, parents often agree with them that this is in the child's best interests. Sometimes, however, there is disagreement and the courts may become involved.

Doctors are under a duty to treat children in their care in accordance with a responsible body of medical opinion. However, they are not obliged to treat a child in a way that is against their ethical principles. Parents cannot demand that a doctor treats their child in a particular way if the doctor disagrees. This can lead to an impasse.

Court rulings

The court can be asked to step in to decide what is in the child's best interests. It makes its own decision, not always favouring the views of either party.A selection of cases, dealing with treatment decisions relating to children, have reached the news over the last few years and have highlighted this very issue. A review of these cases puts the Amber Hartland case into context.

The case of Re B [1981] led to the principle that life-saving treatment could be withheld from young children or that treatment could be ordered by the court as being in the particular child's best interests. In that case, the child's parents refused their consent for life-saving treatment for a child with Down's syndrome. The Court of Appeal ordered the treatment in the child's best interests, overruling the wishes of the parents.

In Re S [1993], a young child with leukaemia required a blood transfusion, but his parents refused on religious and safety grounds. Arguments put forward by the child's family that the transfusion could lead to relationship problems between the child and his family were dismissed. Even though a child's best interests encompass more than simply medical interests (and include a child's family life), the judge thought prolonging the child's life to be in his best interests.

Conflicting opinions

The courts do not always find that the child's best interests reflect those set out by the family or the medical profession. The courts look at the best interests of that child, at that time, and may find that the best interests of the child can best be served by an alternative course of action.

In An NHS Trust v B[2006], the judge refused the doctor's request to withdraw ventilation in a baby with spinal muscular atrophy who would only survive if kept on a ventilator. The judge also refused to order intensive treatment requested by the baby's parents. Here, the judge steered a middle way, retaining the best interests of the baby as his guide.

The very public case of Charlotte Wyatt (in which Mills and Reeve represented Portsmouth Hospitals trust), which was before the court on six occasions, over a period of years, showed clearly how difficult decisions about a child's best interests can be. Charlotte suffered from multiple medical problems that caused her pain and distress. Her parents, like Amber's parents, wanted Charlotte to be given treatment when the medical profession were overwhelmingly of the view that treatment was futile. On each occasion that the court met to decide what was in Charlotte's best interests, it reviewed her condition at that time, leading to decisions that varied from supporting the clinicians to supporting Charlotte's family. This is the correct way to deal with such cases and underlines the need to assess the child at that time and on an individual basis.

Cases such as that of Amber Hartland must be treated on their facts alone. These cases do not create precedents for use with other severely ill children when decisions need to be taken by the courts as to what is in their best interests.