Withdrawal of life-sustaining treatment from a patient in a minimally conscious state.

This column reports on a recent decision, the first in England in which a court was asked to authorise the withdrawal of artificial nutrition and hydration from a patient in a "minimally conscious state". Since the seminal decision in 1993 in Airedale NHS Trust v Bland [1993] AC 789, in which the House of Lords authorised withdrawal of artificial nutrition and hydration from a patient in a persistent vegetative state, the relatively new diagnosis of a "minimally conscious state" has been recognised. In deciding whether it was in the patient's best interests that artificial nutrition and hydration be withdrawn and withheld, the court made a key legal determination, with precedential effect, as to whether the so-called "balance sheet" approach to determining a patient's best interests, as opposed to the (discredited) "futility" principle, applies to a patient in a minimally conscious state. The merit of the former approach is that it forces explicit consideration of quality-of-life assessments in favour of and against withdrawing life-sustaining treatment. A significant pitfall of the English position, as it is currently developing, is the premium it places on accurate diagnosis, whether of vegetative state or minimally conscious state. These issues will have to be faced sooner or later by Australasian courts.