Bland,courts have struggled to fit the clinical aspects of cases into the guidelines'
framework. In Frenchay NHS Trustv. S41994), the Court of Appeal heard
arguments questioning the PVS diagnosis of the 24 year old male patient, who had
suffered acute and extreme brain damage after taking a drug overdose. The nurses
on the health care team were convinced that S seemed to suffer, and medical
reports recorded what appeared to be voluntary and volitional behaviour.
Attempts at rehabilitation had been made for two years, which called into question
the confidence with which PVS had been diagnosed in the first place. Although
there was no doubt among the judges that the decision to allow S to die promoted
his best interests, it is clear from this case that PVS guidelines need not always be
strictly adhered to. It is worth noting that the trigger for referring the case to court
was the dislodging of S's feeding tube.
More recently, in the case ofRe D medical treatment)41997), a hospital trust
applied for a declaration that artificial nutrition and hydration could be withdrawn
from a patient who did not exhibit all the diagnostic criteria normally associated
with PVS. A year before the High Court hearing, D had been diagnosed as being in
vegetative state with remote prospect of recovery. A PVS diagnosis followed in
December 1996. However, D's condition did not fit that paragraph ofThe Per-
manent Vegetative Statewhich requires that there should be no nystagmus in
response to ice water caloric testing and that the patient should not be able to track
moving objects with the eyes or show a menace' response. Some limited pathways between the cerebral hemispheres and the brain stem had apparently continued to function and it was argued on D's behalf that this gave her an interest in being kept alive. The judge, however, could findno evidence of any meaningful life what-
soever', the medical evidence having established that D had no feelings, no hearing
and could not see. As it was not in the patient's best interests to be kept alive, he
granted the declaration sought by the NHS Trust.
It is now clear that the withholding of treatment from PVS patients is not deemed
to infringe Article 2 of the European Convention on Human Rights which protects
people's right to life. In the cases ofNHS Trust Av.M42000) andNHSTrust Bv.H
42000), decided in October 2000, the High Court ruled that treatment may cease
where, as in PVS cases, there is no positive obligation to prolong life. The court
issued declarations that artificial nutrition and hydration could lawfully be with-
drawn from two female patients in PVS.
10.4.5 Borderline cases
Where there is evidence of a real possibility that meaningful life continues for the
patient, cessation of treatment 4which according toBland, includes artificial
nutrition and hydration) would obviously be harder to justify than it is in the PVS
cases. Health care teams and the courts would have to balance factors similar to
those taken account of in children cases at present 4see section 10.1.2 earlier in
this chapter).
Some insight is provided by the case ofRe R adult: medical treatment)41996). R,
at 23, was described as operating cognitively and neurologically at the level of a
newborn infant. He also suffered poor physical health, including recurrent chest
infections and ulceration of the oesophagus. The High Court decided that
The Critically Ill Patient 207