Intended for healthcare professionals

Opinion

An ethicist’s view on the Archie Battersbee case: a bad situation made worse

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1980 (Published 09 August 2022) Cite this as: BMJ 2022;378:o1980
  1. Daniel Sokol, medical ethicist and barrister
  1. London
  1. Follow Daniel on Twitter @DanielSokol9

For weeks, the details of the Archie Battersbee case have filled the pages of newspapers and social media. Archie was a 12 year old boy who was found, on 7 April 2022, severely brain damaged from what is believed to have been a self-inflicted injury inspired by an online challenge.

His case was heart wrenching. A young child, his whole life ahead of him, was fit and healthy one moment and neurologically devastated the next. The photographs of a lively Archie only deepened the sense of loss. Few people, thankfully, will plumb such depths of despair, but for those with children it is an ever present fear.

The decision to withdraw life support was a grave one, as it led to Archie’s death, but the enormity of a decision’s consequences does not render it ethically complex. All of the judges and clinicians who examined the case agreed on the morally correct course of action.

Ethically, the case was simple. Archie was dying, kept alive artificially by technology. There was no prospect of recovery. The clinicians believed that he experienced neither joy nor pain. There was no medical benefit to be gained from continuing to keep him from dying, nor any likelihood of future benefit. Prolonging treatment merely stretched out the process of dying. That said, it is understandable that parents would fight mightily to keep their child alive. It is a natural instinct, even if it no longer makes sense logically and ethically.

Withdrawing treatment allowed him to succumb to his underlying disease. It was not cruel but compassionate. It was not a burden but a release.

Chris Hadfield, former commander of the International Space Station, once said, “In the astronaut business, we have a saying, which is: ‘There is no problem so bad you can’t make it worse.’”1 Archie’s case illustrates this. The original tragedy—Archie’s dreadful injury and subsequent medical condition—was then followed by further ordeals for all concerned. The repeated rounds of legal challenges, virtually all unsuccessful, will doubtless have taken their toll on Archie’s parents. In these desperate circumstances, parents will want to be with their child, not in court surrounded by lawyers or in countless conferences with their legal team, giving instructions on next steps.

The treating clinicians—forced to treat a child in a manner contrary to what they believed was right and subject to constant criticism, even abuse, in the press and social media—have surely suffered from moral distress. By the end of the saga, trust between the parents and carers was gone.

The NHS trust, treading on eggshells while trying to avoid offence and reputational damage, must look back on this episode with a mixture of relief that the case is over and dread of another similar one. The legal costs alone must have reached hundreds of thousands of pounds. The increased levels of security have added to the bill: at one point there were reportedly eight security guards around Archie’s room. In the future, that dread of another case could translate into a tactical decision by the NHS to respect the views of relatives even when these are harmful to the patient.

The practical consequences of this case, aside from the psychological toll on the parents and staff, the loss of trust, the financial cost, and the dangerous precedent, meant that Archie’s death was drawn out by weeks. Surely no one would want to survive in that condition, awkwardly balancing between the world of the living and the dead with no chance of survival? It was a tragic situation made worse.

Archie’s parents have called for a change in the way cases such as Archie’s are handled. Could this very public dispute have been prevented? Some have suggested mediation. It was offered to the family, and they declined. The relatives reportedly changed their mind about mediation after getting legal advice, but by then it was too late.2 Perhaps providing relatives with funded, independent legal advice at an early stage would help. Lawyers can offer a more impartial perspective to families who are losing trust in hospital staff, providing much needed guidance and reassurance. In 2019 I recounted such an example in The BMJ.3

Archie’s case was not reviewed by a hospital ethics committee but by a “rapid case review group,” without involvement of the parents. Maybe a full ethics committee, well constituted and considering the views and values of the parents, would have altered the course of events. Maybe a skilled clinical ethicist, rather than a more daunting institutional committee, could have gained the trust of the family early on, managed expectations, and avoided the subsequent conflict between the healthcare team and the parents.

No one can possibly know, but these cases are so damaging to all concerned that every reasonable option is worth exploring.

Footnotes

  • Daniel Sokol is a medical ethicist and barrister. He is the author of Tough Choices: Stories from the Front Line of Medical Ethics (Book Guild, 2018)

  • Competing interests: None declared.

  • Provenance and peer review: Commissioned, not peer reviewed.

References

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