Tony Bland
Encyclopedia
Anthony David Bland (21 September 1970 - 3 March 1993) was a supporter of Liverpool F.C.
injured in the Hillsborough disaster
. He suffered severe brain damage that left him in a persistent vegetative state
whereby the hospital, with the support of his parents, applied for a court order allowing him to 'die with dignity'. As a result he became the first patient in English
legal history to be allowed to die by the courts through the withdrawal of life-prolonging treatment. The relevant case was Airedale NHS Trust v. Bland (1993) AC 789 HL.
's Hillsborough
football ground for an FA Cup
semi-final between Liverpool
and Nottingham Forest
on 15 April 1989. During the game, a crush behind the Liverpool goal ensued due to, as it was later discovered, the police losing control of the situation outside the ground. A crush had formed at the outer gates, and the Liverpool fans were eventually let in through a side gate by order of Chief Superintendent Duckenfield. However, he neglected to close the tunnel access first and thousands more Liverpool fans were sent down this tunnel into pens 3 and 4 which were already overcrowded due to the failure of police officers and club stewards to direct the fans to the appropriate areas. This resulted in fatal consequences. Although Bland survived the initial crush when still only 18 years old, he had suffered severe injuries and eventually became the disaster's 96th victim on 3 March 1993, aged 22. He never regained consciousness and a legal ruling allowed doctors to withdraw his treatment after all concerned were able to conclude that there was no reasonable possibility that his condition would improve and this was the best possible option.
(PVS).
He was transferred to the care of Dr J. G. Howe FRCP., a consultant geriatrician (and neurologist) at the Airedale General Hospital
. Dr Howe had some experience in treating those with PVS. Several attempts were made by Dr Howe and his team, along with Bland's father, sister and mother, to try to elicit some response from him and for some signs of interaction. However, all attempts failed. He showed no sign of being aware of anything that took place around him.
EEG
and CT scans revealed that whilst the brain stem
remained intact, there was no cortical activity. Indeed, scans subsequently shown to the court showed far more 'space than substance in the relevant part of Anthony Bland's brain'. His body was being kept alive by artificial nutrition, hydration and excellent nursing. But to all intents and purposes the person who was Anthony Bland was gone and there was no reasonable possibility of recovery.
complicated by intestinal obstruction which, if left untreated without surgery, would be fatal. The parents felt that it would be in the child's best interests if she were left to die. This was a decision upheld by Lord Justice Dunn at first instance, who lauded the parents' decision as being 'an entirely reasonable one'.
The matter reached the Court of Appeal who overturned the decision. Any such decision had to be made in the best interests of the child and that the prognosis was that the child would have a reasonable quality of life. However, in other cases, for example Re C (a minor) (wardship: medical treatment) [1989] 2 All ER 782 and Re J (a minor) (wardship: medical treatment) [1990] 3 All ER 930, this test has been used to determine that doctors can choose not to treat or provide life prolonging treatment.
of high repute and impeccable professional integrity, wrote in his notes that the 'Parents do not wish it to survive. Nursing care only.' The baby died 69 hours later. Dr Arthur was charged with murder.
During the trial the defence provided evidence that the child was not physically healthy. As a result the charge was reduced to attempted murder and Dr Arthur was acquitted.
This demonstrates that a doctor who deliberately withdrew life-prolonging treatment under any circumstances, and where the patient subsequently dies, could be charged with murder. There was a subtle exception. If a patient suffered complications but the doctors felt that it would serve no purpose to apply additional treatments, such as antibiotics to fight infection, as might happen in a case of P.V.S. and the patient subsequently dies as a result of the complication then they were not liable under the criminal law. Theoretically, however, they could still find themselves being sued in negligence by the family of the deceased.
In August 1989, Dr Howe contacted Dr Popper, the [Sheffield] coroner, who was both legally and medically qualified. He informed Dr Popper of the 'plan to withdraw all treatment including artificial nutrition and hydration'. This decision had been taken following full consultation with the family and in accordance with their wishes. Dr Howe reflects:
The Coroner advised Dr Howe to contact his medical defence society and the Regional Health Authority and copied his letter to the Chief Constable of the West Midlands Police (the investigating force), the local regional Health Authority solicitor and Dr Howe's medical defence society. The following day Dr Howe was visited by the police and told that if he 'withdrew treatment and Tony dies, I would be charged with murder' (for a full, personal account see: Howe 2006).
Following the obtaining of the legal advice, which concurred with that of the coroner, the Airedale National Health Service Trust, with the support of Bland's family and Dr Howe, made an application to court to withdraw all life-prolonging treatment. As Bland was unable to speak for himself and was, for legal purposes, deemed an incompetent, the Official Solicitor was assigned as his guardian ad litem. The Official Solicitor
opposed the Trust's application because if the Trust were allowed to pursue the actions proposed by Dr. Howe, it would amount in law to the crime of murder
.
This declaration, apart from the latter part of the declaration (which was deemed inappropriate), was granted. The court considered that it was in the patient's best interests for treatment to be withheld and that its discontinuance was in accordance with good medical practice.
Acting on Anthony Bland's behalf, the Official Solicitor appealed this decision.
who, along with Professor Fred Plum
, coined the term 'persistent vegetative state' in 1972. Professor Jennett expressed the very strong view that it would be in accordance with good medical practice in the case of Anthony Bland to withdraw the nasogastric artificial feeding. He considered that there was no benefit to continue with the treatment as there was no prospect of recovery of cognitive function.
Other experts in the field of neurology gave evidence. Amongst those was Professor Peter O'Behan who examined Bland on behalf of the Official Solicitor. Like the experts who gave evidence for the Airedale Trust, Prof. O'Behan's evidence was extremely pessimistic. The depth of the hopelessness of Tony Bland's condition is summed up as much in his evidence as in anyone else's where he stated:
This case is another which delegated to the Bolam standard. This was a test introduced by the courts in Bolam v Friern Hospital Management Committee [1957] 1 W.L.R 582. The essence of the Bolam standard is such as to remove liability from medical staff if the treatment they have provided to a patient under the particular circumstances would have been followed by a responsible body of medical personnel, exercising due skill and care in the process. Under Bolam, a doctor need only show that he was following an accepted medical practice - even if that practice was only followed by a minority of medical professionals. This was one of the arguments put forward on behalf of Dr. Howe; that it would be intolerable if Dr. Howe was charged with murder for following what he submitted to be generally regarded as good medical practice.
Liverpool F.C.
Liverpool Football Club is an English Premier League football club based in Liverpool, Merseyside. Liverpool has won eighteen League titles, second most in English football, seven FA Cups and a record seven League Cups...
injured in the Hillsborough disaster
Hillsborough disaster
The Hillsborough disaster was a human crush that occurred on 15 April 1989 at Hillsborough, a football stadium, the home of Sheffield Wednesday F.C. in Sheffield, England, resulting in the deaths of 96 people, and 766 being injured, all fans of Liverpool F.C....
. He suffered severe brain damage that left him in a persistent vegetative state
Persistent vegetative state
A persistent vegetative state is a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness. It is a diagnosis of some uncertainty in that it deals with a syndrome. After four weeks in a vegetative state , the patient is...
whereby the hospital, with the support of his parents, applied for a court order allowing him to 'die with dignity'. As a result he became the first patient in English
England
England is a country that is part of the United Kingdom. It shares land borders with Scotland to the north and Wales to the west; the Irish Sea is to the north west, the Celtic Sea to the south west, with the North Sea to the east and the English Channel to the south separating it from continental...
legal history to be allowed to die by the courts through the withdrawal of life-prolonging treatment. The relevant case was Airedale NHS Trust v. Bland (1993) AC 789 HL.
The Hillsborough Disaster
Bland was an avid Liverpool supporter who travelled with two friends to Sheffield WednesdaySheffield Wednesday F.C.
Sheffield Wednesday Football Club are a football club based in Sheffield, South Yorkshire, England, who are currently competing in the Football League One in the 2011-12 season, in England. Sheffield Wednesday are one of the oldest professional clubs in the world and the fourth oldest in the...
's Hillsborough
Hillsborough Stadium
Hillsborough Stadium is the home of Sheffield Wednesday football club, Sheffield, England. Football has been played at the ground since it was opened on 2 September 1899, when Wednesday moved from their original ground at Olive Grove. Today it is a 39,812 capacity all-seater stadium, making it the...
football ground for an FA Cup
FA Cup
The Football Association Challenge Cup, commonly known as the FA Cup, is a knockout cup competition in English football and is the oldest association football competition in the world. The "FA Cup" is run by and named after The Football Association and usually refers to the English men's...
semi-final between Liverpool
Liverpool F.C.
Liverpool Football Club is an English Premier League football club based in Liverpool, Merseyside. Liverpool has won eighteen League titles, second most in English football, seven FA Cups and a record seven League Cups...
and Nottingham Forest
Nottingham Forest F.C.
Nottingham Forest Football Club is an English Association Football club based in West Bridgford, Nottingham, that plays in the Football League Championship...
on 15 April 1989. During the game, a crush behind the Liverpool goal ensued due to, as it was later discovered, the police losing control of the situation outside the ground. A crush had formed at the outer gates, and the Liverpool fans were eventually let in through a side gate by order of Chief Superintendent Duckenfield. However, he neglected to close the tunnel access first and thousands more Liverpool fans were sent down this tunnel into pens 3 and 4 which were already overcrowded due to the failure of police officers and club stewards to direct the fans to the appropriate areas. This resulted in fatal consequences. Although Bland survived the initial crush when still only 18 years old, he had suffered severe injuries and eventually became the disaster's 96th victim on 3 March 1993, aged 22. He never regained consciousness and a legal ruling allowed doctors to withdraw his treatment after all concerned were able to conclude that there was no reasonable possibility that his condition would improve and this was the best possible option.
The injuries and prognosis
Bland suffered serious injuries in the crush at the Leppings Lane terrace. He suffered crushed ribs and two punctured lungs, causing an interruption in the supply of oxygen to his brain. As a result, he sustained catastrophic and irreversible damage to the higher centres of the brain, which had left him in a Persistent Vegetative StatePersistent vegetative state
A persistent vegetative state is a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness. It is a diagnosis of some uncertainty in that it deals with a syndrome. After four weeks in a vegetative state , the patient is...
(PVS).
He was transferred to the care of Dr J. G. Howe FRCP., a consultant geriatrician (and neurologist) at the Airedale General Hospital
Airedale General Hospital
Airedale General Hospital is an NHS district General Hospital based in Steeton with Eastburn, West Yorkshire, England and is operated by the Airedale NHS Trust...
. Dr Howe had some experience in treating those with PVS. Several attempts were made by Dr Howe and his team, along with Bland's father, sister and mother, to try to elicit some response from him and for some signs of interaction. However, all attempts failed. He showed no sign of being aware of anything that took place around him.
EEG
EEG
EEG commonly refers to electroencephalography, a measurement of the electrical activity of the brain.EEG may also refer to:* Emperor Entertainment Group, a Hong Kong-based entertainment company...
and CT scans revealed that whilst the brain stem
Brain stem
In vertebrate anatomy the brainstem is the posterior part of the brain, adjoining and structurally continuous with the spinal cord. The brain stem provides the main motor and sensory innervation to the face and neck via the cranial nerves...
remained intact, there was no cortical activity. Indeed, scans subsequently shown to the court showed far more 'space than substance in the relevant part of Anthony Bland's brain'. His body was being kept alive by artificial nutrition, hydration and excellent nursing. But to all intents and purposes the person who was Anthony Bland was gone and there was no reasonable possibility of recovery.
Selective non-treatment of newborn babies
Prior to Bland, English case law on the non-treatment of patients was restricted to newborn babies. There have been several recorded cases of handicapped neonates being 'allowed to die'. A leading case was that of Re B (a minor) [1990] 3 All ER 927. That case involved a baby with Down SyndromeDown syndrome
Down syndrome, or Down's syndrome, trisomy 21, is a chromosomal condition caused by the presence of all or part of an extra 21st chromosome. It is named after John Langdon Down, the British physician who described the syndrome in 1866. The condition was clinically described earlier in the 19th...
complicated by intestinal obstruction which, if left untreated without surgery, would be fatal. The parents felt that it would be in the child's best interests if she were left to die. This was a decision upheld by Lord Justice Dunn at first instance, who lauded the parents' decision as being 'an entirely reasonable one'.
The matter reached the Court of Appeal who overturned the decision. Any such decision had to be made in the best interests of the child and that the prognosis was that the child would have a reasonable quality of life. However, in other cases, for example Re C (a minor) (wardship: medical treatment) [1989] 2 All ER 782 and Re J (a minor) (wardship: medical treatment) [1990] 3 All ER 930, this test has been used to determine that doctors can choose not to treat or provide life prolonging treatment.
Doctor's potential liability
In R v Arthur (1981) 12 BMLR 1 a baby was born with uncomplicated Down Syndrome and was rejected by the parents. Dr Arthur, a paediatricianPediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
of high repute and impeccable professional integrity, wrote in his notes that the 'Parents do not wish it to survive. Nursing care only.' The baby died 69 hours later. Dr Arthur was charged with murder.
During the trial the defence provided evidence that the child was not physically healthy. As a result the charge was reduced to attempted murder and Dr Arthur was acquitted.
This demonstrates that a doctor who deliberately withdrew life-prolonging treatment under any circumstances, and where the patient subsequently dies, could be charged with murder. There was a subtle exception. If a patient suffered complications but the doctors felt that it would serve no purpose to apply additional treatments, such as antibiotics to fight infection, as might happen in a case of P.V.S. and the patient subsequently dies as a result of the complication then they were not liable under the criminal law. Theoretically, however, they could still find themselves being sued in negligence by the family of the deceased.
In August 1989, Dr Howe contacted Dr Popper, the [Sheffield] coroner, who was both legally and medically qualified. He informed Dr Popper of the 'plan to withdraw all treatment including artificial nutrition and hydration'. This decision had been taken following full consultation with the family and in accordance with their wishes. Dr Howe reflects:
The Coroner advised Dr Howe to contact his medical defence society and the Regional Health Authority and copied his letter to the Chief Constable of the West Midlands Police (the investigating force), the local regional Health Authority solicitor and Dr Howe's medical defence society. The following day Dr Howe was visited by the police and told that if he 'withdrew treatment and Tony dies, I would be charged with murder' (for a full, personal account see: Howe 2006).
Following the obtaining of the legal advice, which concurred with that of the coroner, the Airedale National Health Service Trust, with the support of Bland's family and Dr Howe, made an application to court to withdraw all life-prolonging treatment. As Bland was unable to speak for himself and was, for legal purposes, deemed an incompetent, the Official Solicitor was assigned as his guardian ad litem. The Official Solicitor
Official Solicitor
The Office of the Official Solicitor is a part of the Ministry of Justice of the Government of the United Kingdom. The Official Solicitor acts for people who, because they lack mental capacity and cannot properly manage their own affairs, are unable to represent themselves and no other suitable...
opposed the Trust's application because if the Trust were allowed to pursue the actions proposed by Dr. Howe, it would amount in law to the crime of murder
Murder
Murder is the unlawful killing, with malice aforethought, of another human being, and generally this state of mind distinguishes murder from other forms of unlawful homicide...
.
First instance
Airedale NHS Trust applied to the courts for a declaration to the effect that:- they might lawfully discontinue all life-sustaining treatment and medical support measures, including ventilation, nutrition and hydration by artificial means
- any subsequent treatment given should be for the sole purpose of enabling him to end his life in dignity and free from pain and suffering
- if death should then occur, its cause should be attributed to the natural and other causes of his present state
- and that none of those concerned should, as a result, be subject to any criminal or civil liability.
This declaration, apart from the latter part of the declaration (which was deemed inappropriate), was granted. The court considered that it was in the patient's best interests for treatment to be withheld and that its discontinuance was in accordance with good medical practice.
Acting on Anthony Bland's behalf, the Official Solicitor appealed this decision.
Expert evidence
Such was the importance of the case, and the obvious legal ramifications, it attracted a number of expert witnesses to give evidence. These included Professor Bryan JennettBryan Jennett
Bryan Jennett was a pioneering Professor of Neurosurgery who established Glasgow as a world centre in the speciality and made major advances in the care and management of patients...
who, along with Professor Fred Plum
Fred Plum
Fred Plum was an American neurologist who developed the terms"persistent vegetative state" and "locked-in syndrome" as part of his continuing research on consciousness and comas and care of the comatose....
, coined the term 'persistent vegetative state' in 1972. Professor Jennett expressed the very strong view that it would be in accordance with good medical practice in the case of Anthony Bland to withdraw the nasogastric artificial feeding. He considered that there was no benefit to continue with the treatment as there was no prospect of recovery of cognitive function.
Other experts in the field of neurology gave evidence. Amongst those was Professor Peter O'Behan who examined Bland on behalf of the Official Solicitor. Like the experts who gave evidence for the Airedale Trust, Prof. O'Behan's evidence was extremely pessimistic. The depth of the hopelessness of Tony Bland's condition is summed up as much in his evidence as in anyone else's where he stated:
The House of Lords
The Court of Appeal decision was appealed to the Judicial Committee of the House of Lords. Each of the five judges who heard the case delivered a lengthy opinion on 4 February 1993. Each dismissed the appeal.Moral and legal issues
The case brought up a number of moral and legal issues. As a result, the number of previous cases referred to is extensive.This case is another which delegated to the Bolam standard. This was a test introduced by the courts in Bolam v Friern Hospital Management Committee [1957] 1 W.L.R 582. The essence of the Bolam standard is such as to remove liability from medical staff if the treatment they have provided to a patient under the particular circumstances would have been followed by a responsible body of medical personnel, exercising due skill and care in the process. Under Bolam, a doctor need only show that he was following an accepted medical practice - even if that practice was only followed by a minority of medical professionals. This was one of the arguments put forward on behalf of Dr. Howe; that it would be intolerable if Dr. Howe was charged with murder for following what he submitted to be generally regarded as good medical practice.