Justices rule on best interests test

The test in considering the best interests of a patient who lacks capacity is not an objective one, the Supreme Court has unanimously ruled in its first judgment on the Mental Capacity Act 2005.

In September 2012, Aintree University Hospitals NHS Foundation Trust sought declarations that it would be in David James’s best interests for specified treatments to be withheld from him in the event of a clinical deterioration. James’s family disagreed.

The Court of Protection found in favour of the family, holding that the Mental Capacity Act code of practice provision that withholding treatment may be in the patient’s best interests "where treatment is futile, overly burdensome to the patient or where there is no prospect of recovery” did not apply to treatments that could make James feel slightly better but not restore full health.

Giving the judgment of the Supreme Court in Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67, Lady Hale said the trial judge was correct to give great weight to James’s family life, and to hold that treatment was not “futile” if it gave the patient a quality of life that they would regard as worthwhile.

“Insofar as it is possible to ascertain the patient’s wishes and feelings, his beliefs and values or the things which were important to him, it is those which should be taken into account because they are a component in making the choice which is right for him as an individual human being,” she said.

The crucial question was whether administration of the life-sustaining treatment was lawful. That was decided by asking whether it was in the patient's best interests to have the treatment, not whether withdrawal of the treatment was in the patient's best interests. A holistic assessment of best interests had to be performed. 

Lady Hale said the Court of Appeal, which found in favour of the Trust, had been wrong to reject the Court of Protection’s approach and to hold that the test was an objective one, what the reasonable patient would think. However, by that time James’ health had deteriorated so it had reached the right decision for the wrong reasons.She said that although she might not have come to the same conclusion as the trial judge, that conclusion should not be altered by an appellate court.

James, a successful professional guitarist who once played with the Beatles, died 10 days after the Court of Appeal ruling.

Professor Mark Bellamy, president of the Intensive Care Society, which intervened in the case, said the Supreme Court had given a “helpful and very balanced judgment” which “adds clarity to this area of medicine”.