The Airedale NHS Trust v Bland [1993] case is crucial for law students studying medical law, particularly on ethical issues and legal precedents surrounding life-sustaining treatments. This landmark decision addressed whether it is lawful to discontinue treatment, including artificial nutrition and hydration, for a patient in a persistent vegetative state (PVS) without the possibility of recovery.

  • In the case of Airedale NHS Trust v Bland [1993] A.C. 789, it was held that since a persistently vegetative patient cannot give or withhold consent to treatment, it is for doctors to decide whether continuing treatment for such patients is in their best interests. It is never lawful to take active steps to cause or accelerate death, but in certain circumstances it is lawful to withhold life-sustaining treatment.

Facts of the Case Airedale NHS Trust v Bland

  • D, then aged 17, was seriously injured in the Hillsborough disaster. D suffered crushed and punctured lungs, interrupting the supply of oxygen to his brain.
  • D sustained catastrophic and irreversible brain damage, leaving him in a persistent vegetative state.
  • All medical opinions agreed that there was no hope of improvement in C’s condition or recovery. D had never indicated any wishes for when this scenario arose. His father gave evidence that D ‘would not want to be left like that.’
  • C, the authority responsible for C’s hospital, sought declarations that they could lawfully discontinue all of C’s life-sustaining treatment, only providing treatment to allow C to die peacefully with the least suffering.

Issues in Airedale NHS Trust v Bland

  • Was it lawful for D to withhold life-sustaining treatment from C when C could not give informed consent to do so?

Held by the House of Lords

  • Finding for D, that while doctors have a duty to act in the best interests of their patients, this does not necessarily require them to prolong life. Since there was no potential for improvement, C’s continuing treatment was not in his best interests. It was lawful for D to remove C’s feeding tube.

Lord Goff

  • The central issue in the present case is whether artificial feeding and antibiotic drugs may lawfully be withheld from an insensate patient with no hope of recovery when it is known that if that is done the patient will shortly thereafter die.
  • I start with the simple fact that, in law, C is still alive. It is true that his condition can be described as a living death; but he is nevertheless still alive. As a result of developments in modern medical technology, it has come to be accepted that death occurs when the brain, and in particular the brain stem, has been destroyed.
  • The principle of self-determination requires that respect must be given to the patient’s wishes. But in many cases, not only may the patient be in no condition to be able to say whether or not he consents, but he may have given no prior indication of his wishes with regard to it. The court cannot give consent on behalf of an adult patient who is incapable of himself deciding whether to consent.
  • “I am of the opinion that 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. It is scarcely consistent with the primacy given to the principle of self-determination in those cases in which the patient of sound mind has declined to give his consent, that the law should provide no means of enabling treatment to be withheld in appropriate circumstances where the patient is in no condition to indicate, if that was his wish, that he did not consent to it” [865A].
  • The law draws a distinction between cases in which doctors decide not to provide life-sustaining treatment to patients, and when they decide to actively bring a patient’s life to an end.
  • The former may be lawful, either because the doctor is giving effect to his patient’s wishes by withholding the treatment or care, or even in certain circumstances in which the patient is incapacitated from giving consent. But 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.
  • The doctor’s conduct in discontinuing life support can properly be categorised as an omission. It may be difficult to describe what the doctor actually does as an omission in fact. But discontinuation of life support is, for present purposes, no different from not initiating life support in the first place. The doctor is simply allowing his patient to die from his pre-existing condition. As a matter of general principle an omission will not be unlawful unless it constitutes a breach of duty to the patient.

Significance of the Case in Legal Development

Airedale NHS Trust v Bland significantly shaped the legal approach to medical treatment and patients’ rights:

  • Re F (Mental Patient: Sterilisation) [1990]: Highlighted the court’s authority in making decisions for incapacitated patients, a principle that was central in the Bland case.
  • Bolam v Friern Hospital Management Committee [1957]: Established the Bolam test, which assesses medical negligence based on standard practice, relevant to determining the standard of care in Bland.
  • Re J (A Minor) (Wardship: Medical Treatment) [1991]: Addressed the threshold for withdrawing treatment from minors, which parallels discussions in Bland about withdrawing life-sustaining treatment in terms of best interests.

Exam Questions and Answers

Below you will find answers to questions that are most commonly asked based on this case.

How does the decision in Bland interact with advancements in neurotechnology that might affect assessments of PVS?

The decision in Airedale NHS Trust v Bland discussed the withdrawal of life-sustaining treatment in patients diagnosed as being in a persistent vegetative state (PVS). Advances in neurotechnology, such as improved diagnostic tools that can better assess brain activity and potential consciousness, pose questions about the accuracy of PVS diagnoses. Such advancements could lead to legal challenges regarding the continued application of Bland’s principles, particularly when emerging tech might alter or refine a patient’s diagnosis.

What are the ethical implications of this ruling on current debates about euthanasia and physician-assisted suicide?

The Bland case indirectly influences the ongoing debates around euthanasia and physician-assisted suicide by establishing a legal framework for withdrawing life-sustaining treatment. This legal tolerance for allowing patients to die under specific circumstances contributes to broader ethical discussions about the right to die. The UK currently prohibits active euthanasia, but the principles discussed in Bland provide a foundation from which activists and legal experts debate potential law reforms.

In light of Bland, how have subsequent legal rulings addressed cases where patients have left advance directives?

Since the Bland decision, there has been an increased focus on the legal weight of advance directives in the UK. The Mental Capacity Act 2005 later codified the importance of respecting advance decisions, providing patients the right to refuse specific treatments in future circumstances where they might lack capacity. Subsequent cases continue to address complexities when interpreting these directives, especially when they conflict with clinicians’ views on the patient’s best interests. An example is the case of Re M (Withdrawal of Treatment: Advance Decision) [2011], where the court upheld an advance decision that conflicted with medical recommendations.