Walking the tightrope of best interests decision-making

Mr Justice MacDonald has recently given judgment on a case involving the withdrawal of life sustaining treatment and strongly held religious beliefs concerning the sanctity of life. These questions are one of the “hardest” of those that come before the family courts for determination.

The case of Alta Fixsler was brought by Manchester University NHS Foundation Trust who asked the High Court to declare that it would not be in the best interests of two-year old Alta to continue to receive life-sustaining treatment, and that it would be in her best interests for a palliative care regime to be implemented.

Alta suffered hypoxic ischaemic brain injury during her premature birth. Although she was successfully resuscitated, Alta continues to exhibit symptoms of a catastrophic brain injury, which will inevitably result in her death. Alta is currently a patient at the Paediatric Intensive Care Unit at the Royal Manchester Children’s Hospital receiving intensive life sustaining treatment.

The parents are Chassidic practising Jews and Israeli citizens. Alta’s parents emphasised in their evidence that being devout members of the Jewish faith meant that their faith was not simply a religion but also a way of life. The parents have sought and taken detailed rabbinical advice as to their religious duties and obligations in the context of Alta's medical situation. The parents opposed the application brought by the NHS Trust and instead sought to take Alta to Israel for continued treatment and the exploration of long-term ventilation at home in Israel in due course or, if the court concluded that it would be in Alta's best interests for life sustaining treatment to be withdrawn, for that step to be taken in Israel.

The judge heard evidence from Alta’s treating clinicians, medical experts, including the expert instructed on behalf of the parents, and each considered that it would be in Alta's best interests to withdraw life sustaining treatment and move her to a palliative care regime in circumstances where, even with the intensive care required to sustain long term ventilator support, Alta would never recover and would have a progression of increasingly debilitating symptoms.

Mr Justice MacDonald undertook a detailed review of the “best interests” test, the views of the parents and the role of ‘human dignity’ in the best interests decision in cases of this nature. Within this context, he rejected the parents’ submission that “the best interests decision-making process can and must be framed within the Jewish belief system” explaining that the Jewish belief system followed by the parents is “one factor” to be weighed in the balance by the court when reaching a best interests decision. Equally, Mr Justice MacDonald was not able to accept the submission that the assessment of Alta's perspective should start from the assumption that Alta would share the values of her parents, of her brother, and of her wider family and community.

In conclusion, and with immense sadness, Mr Justice MacDonald granted the Trust’s application for a declaration that it would not be in the best interests of Alta to continue to receive life sustaining treatment and that it would be in her best interests for a palliative care regime to be implemented.

You can read the judgment in Manchester University NHS Foundation Trust v Fixsler and others here.

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