Miss B: Case is a warning to doctors not to act unlawfully

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Hospitals that allow doctors to deny patients the right to refuse treatment will face huge legal bills if the cases end up in court, lawyers and right-to-die groups warned yesterday.

Hospitals that allow doctors to deny patients the right to refuse treatment will face huge legal bills if the cases end up in court, lawyers and right-to-die groups warned yesterday.

Medical and legal experts agreed that if hospital rules had been followed correctly, the case of Miss B would never have come before the High Court in the first place.

In yesterday's ruling, Dame Elizabeth Butler-Sloss said the doctors were guilty of "unlawful trespass" against Miss B and awarded her £100 nominal damages as well as £55,000 in agreed costs.

Deborah Annetts, a solicitor and director of the Voluntary Euthanasia Society, said Dame Elizabeth's judgment had showed the law was clear and that, by spelling out the financial costs in this case, the judge had sent a "warning shot across the bows" of other hospital trusts that do not follow established medical guidelines.

Miss B's solicitor, Francis Swaine, said: "This case is really about choice and the ruling is a confirmation of the right of all patients with capacity, however severely disabled, to be able to choose whether to accept medical treatment or to refuse it."

Medical experts said it has been clear for at least a decade, both legally and ethically, that patients who are mentally competent have a right to refuse treatment and doctors may not impose it, even where it is in the patient's best interests.

Dr Michael Wilks, chairman of the BMA's ethics committee, said: "This is another example of how we can be caught out by the long standing practice of doing things that we think are entirely in the interests of patients and then finding out with a sense of shock that this isn't always shared by our patients."

"This is a wake-up call to the profession to think what do we really mean by patient autonomy and a competent refusal of treatment. We haven't got our heads round that and it is a problem I suspect these doctors [caring for Miss B] have fallen foul of. There was no malign motive, just a desire to do their best and it is very difficult when the patients says 'That's what you think, doctor, but I want something else'." He added: "It is unfortunate it had to go as far as this. I think the vast majority of doctors would feel discomfort that it went this far. One would hope cases like this could be decided by careful thought and discussion."

Guidelines on withdrawal of treatment issued by the British Medical Association in 1999 spelt out when treatment could be stopped and made it clear a patient's right to refuse treatment could not be overruled.

Dr Anthony Cole, chairman of the Medical Ethics Alliance, an anti-euthanasia group, said it was wrong to regard the case as a "right to die" decision.

"The judge has upheld the right to refuse treatment. This has long been the situation of English law. The use of pro-euthanasia slogans such as 'right to die' or 'death with dignity' is worrying." Dr Cole, a consultant paediatrician and a member of the Guild of Catholic Doctors, said there was a crucial difference between the case of Miss B and that of patients such as the Hillsborough victim Tony Bland, who was allowed to die after the withdrawal of tube feeding and hydration.

Withdrawing food and water was a failure to provide "basic care", while ventilation - the issue at the heart of Miss B's case - was regarded as medical treatment, he said. He added he was unaware of any case like Miss B's where it was the patient themselves applying to the court, rather than a relative.

Patients groups welcomed the decision. Roger Goss, director of Patient Concern, said: "Patients must be allowed to decide what makes an acceptable quality of life. It is their experience. They know how they actually feel, their beliefs, values and priorities. Doctors are good judges of patients' best medical interests. But that is only a part of what is involved in deciding whether life is worth living.

"Unfortunately, medical staff may presume the right to play God. Some doctors seem to find rejection of what they have to offer a personal affront. They talk and think in terms of "managing" patients. They forget that they are above all a caring profession. This means accepting competent patients' right to choose what treatment they are willing to accept and complying with Advance Directives (Living Wills)."

Dr Jonathan Romain, of the Reform Synagogues of Great Britain, said the case was a "double landmark". He said: "First, it allows the patient rather than the doctors to be the instigator of the decision to end artificial life support. Second, the case extends the previous yardstick - judged when a person was brain dead - to when a person is 'brain alive' but 'body dead'.

"This could place enormous responsibility on future paralysis victims, and safeguards need to be put in place to prevent them feeling pressurised by doctors or relatives to withdraw life-support systems against their will." But he welcomed yesterday's ruling on Miss B as "the right decision" in a "desperately sad case".

Shami Chakrabarti of the civil rights group ,Liberty, said: "We very much welcome the decision which reinforces the principle that adults of sound mind are able to take decisions for themselves, including the decision to die."

But other groups including those which campaign against euthanasia said the ruling placed the doctor-patient relationship at risk.

Andy Berry of the anti-euthanasia group, Alert, said: "I am surprised and appalled that the health authority are not going to appeal this decision.

"I'm very concerned about the implications for all disabled people. I'm sure Miss B could enjoy life with appropriate support and I'm very sorry she has chosen to refuse rehabilitation.

"My one primary message would be to emphasise the importance of providing the best possible support to people in her position."

The Society for the Protection of Unborn Children added its voice to the debate. A spokesman said: "We are profoundly concerned because the legal issues raised by this case weren't properly aired in the legal hearings."