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The value of life in English law: revered but not sacred?

Published online by Cambridge University Press:  02 January 2018

Rob Heywood*
UEA Law School
Alexandra Mullock*
University of Manchester
Rob Heywood, Professor of Medical Law, Deputy Head of School, UEA Law School, Earlham Hall, University of East Anglia, Norwich NR4 4TJ, UK. Email: Alexandra Mullock, Senior Lecturer in Law, University of Manchester, School of Law, Williamson Building, Oxford Road, Manchester M13 9PL, UK. Email:
Rob Heywood, Professor of Medical Law, Deputy Head of School, UEA Law School, Earlham Hall, University of East Anglia, Norwich NR4 4TJ, UK. Email: Alexandra Mullock, Senior Lecturer in Law, University of Manchester, School of Law, Williamson Building, Oxford Road, Manchester M13 9PL, UK. Email:
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Terms such as sanctity and inviolability have failed to provide a legally coherent or ethically sound principle upon which to determine the scope of the intrinsic value of life against extrinsic, quality-of-life considerations in a medical context. In their recent work, Margaret Brazier and Suzanne Ost introduce a new term, reverence for life, which they suggest may be more appropriate when attempting to navigate the murky waters of the meaning of life and the value that should be attached to it. They suggest that reverence should be utilised as an alternative that better reflects the nuances and the realities of the dilemma. This paper explores the existing difficulties before considering how the principle of reverence might provide a principled compromise over when the presumption in favour of preserving life should be rebutted.

Research Article
Legal Studies , Volume 36 , Issue 4 , December 2016 , pp. 658 - 682
Creative Commons
Creative Common License - CCCreative Common License - BY
Legal Studies: The Journal of the Society of Legal Scholars published by John Wiley & Sons Ltd on behalf of Society of Legal Scholars This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.(
© 2016 The Authors



This longer paper was adapted and developed from a short chapter originally published in an edited book: C Stanton et al (eds) Pioneering Healthcare Law: Essays in Honour of Margaret Brazier (London: Routledge, 2016). The work for this paper was supported by the Wellcome Trust [108858/Z/15/Z].


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6. Ibid.

7. ‘End-of-life law’ encompasses both criminal and medical law principles. See Coggon, J ‘Assisted dying and the context of debate: “medical law” versus “end-of-life law” (2010) 18 Med L Rev 541.CrossRefGoogle Scholar

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9. Brazier and Ost, above n 4, pp 90–91.

10. Ibid.

11. In terms of the literature, see in particular Williams, above n 1. The sanctity of human life is discussed at length in the House of Lords’ decision in Bland, above n 8. More recently, see the judgment of Lord Neuberger in Nicklinson, above n 8, at [90]–[98].

12. Brazier and Ost, above n 4, pp 83–84.

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14. Keown, above n 1, p 4.

15. Williams, above n 1.

16. Keown, above n 1, at 5–22.

17. Ibid, at 13–16, 332–335.

18. Ibid, at 12.

19. Brazier and Ost, above n 4, p 89.

20. Keown, above n 1, p 12.

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34. Schweitzer, above n 32, p 31.

35. Ibid.

36. Ibid.

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39. Brazier and Ost, above n 4, p 89.

40. Ibid. The authors simply state that it will become ‘apparent’ that they do not intend to use the phrase in the same way as Schweitzer.

41. Brazier and Ost, above n 4, p 90.

42. Ibid.

43. See Barsam, above n 37, p 30. See also Schweitzer, above n 33, p 237.

44. See Barsam, ibid, p 40.

45. Brazier and Ost, above n 4, p 90.

46. Ibid, p 91.

47. For an alternative and interesting discussion, see Huxtable, R Law, Ethics and Compromise at the Limits of Life: to Treat or Not to Treat? (London: Routledge, 2013).Google Scholar

48. Bland, above n 8. For a general critique, see Keown, above n 1.

49. Airedale NHS Trust v Bland (1992) WL 896030; (1992) 142 NLJ 1755, per Hoffmann LJ (as he then was).

50. Keown, above n 1, p 340.

51. Bland, above n 8.

52. This approach is actually advocated by Keown, above n 1.

53. W v M; Aintree, above n 8.

54. See discussion above at pp 6–8. In particular, see Doyal, LDignity in dying should include the legalisation of non-voluntary euthanasia’ (2006) 1 Clin Ethics 65 CrossRefGoogle Scholar; Singer, above n 26.

55. Indeed, this would seem to be a key reason as to why Brazier and Ost have sought to develop their reverence for life argument.

56. Brazier and Ost, above n 4, at 90–91.

57. Pretty, Purdy and Nicklinson, above n 8.

58. W v M; Aintree; Nicklinson, above n 8.

59. Ibid.

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61. Section 4(6) of the Mental Capacity Act 2005 requires the decision maker to ‘consider, as far as reasonably ascertainable, the person's past and present wishes and feelings … and the beliefs and values that would be likely to influence his decision …’

62. Mental Capacity Act 2005 s 4(7). For an interesting discussion, see Halliday, S, Kitzinger, C and Kitzinger, JLaw in everyday life and death: a socio-legal study of chronic disorders of consciousness’ (2015) 35(1) Legal Stud 5574.CrossRefGoogle Scholar

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64. Kitzinger, C and Kitzinger, JThe “window of opportunity” for death after severe brain injury: family experiences’ (2013) 35 Sociol Health & Illness 1095.CrossRefGoogle ScholarPubMed

65. The treatment in question was not ANH but invasive support for circulatory problems, renal replacement therapy and CPR (in the event of cardiac arrest).

66. Aintree [2012] EWHC 3524 COP.

67. Aintree [2013] EWCA Civ 65.

68. Lord Neuberger, Lady Hale, Lord Clarke, Lord Carnwath and Lord Hughes.

69. Aintree, above n 8, at [35].

70. Ibid, at [45]. This supports the decision in R (Burke) v General Medical Council [2005] EWCA Civ 1003 CA.

71. Substituted judgment is employed in some US jurisdictions. See In re Quinlan (1976) 355 A.2d 647; Cruzan v Director Missouri Department of Health (1990) 110 S Ct 2841 (USA Supreme Court).

72. M v N, above n 8.

73. Per Hayden J in M v N, above n 8, at [74].

74. Per Hayden J in M v N, above n 8, at [75].

75. For another recent case in which significant emphasis was placed on the subjective position of the patient, see Wye Valley NHS Trust v B [2015] EWCOP 60; [2015] COPLR 843.

76. This is especially pertinent in the light of the UN Convention for the Rights of People with Disability (UNCRPD), Art 12. This provision seeks to promote a ‘supported decision-making' scheme for those who lack capacity, which creates a tension if the patient seems to prefer a course of action that is not in his medical best interests. Also, if the patient is unable to communicate or indicate any preference, it would appear to be effectively impossible to achieve ‘supported decision-making’.

77. Heywood, RMoving on from Bland: the evolution of the law and minimally conscious patients’ (2014) 22(4) Med L Rev 548571.CrossRefGoogle ScholarPubMed

78. [2014] EWCOP 16.

79. Ibid, at [29]–[33].

80. Sheffield Teaching Hospital NHS Trust v TH and TR [2014] EWCOP 4.

81. Ibid, at [55].

82. See Nicklinson, Pretty and Purdy, above n 8.

83. Lady Hale and Lord Kerr.

84. See the judgments of Lord Neuberger, Lord Wilson and Lord Mance.

85. See eg Haas v Switzerland (2011) 53 EHRR 33; Koch v Germany (2013) 56 EHRR 6; and Gross v Switzerland (2014) 58 EHRR 7.

86. Nicklinson, above n 8, at [90].

87. Ibid, at [94].

88. See B v NHS Hospital Trust [2002] EWHC 429 (Fam); [2002] 2 All ER 449.

89. Nicklinson, above n 8, at [302]–[304]; and Bland, above n 8.

90. See Nicklinson, above n 8. Lord Kerr agreed with Neuberger regarding the logic of using the sanctity argument to prevent those who need assistance while those able to act independently are not prevented [358].

91. Purdy, above n 8.

92. Nicklinson, above n 8, at [96].

93. Ibid.

94. Ibid, at [108].

95. Ibid, at [209].

96. Ibid, at [311].

97. Ibid.

98. Purdy, above n 8.

99. Ibid, at [68].

100. Ibid, at [66].

101. Ibid, at [68].

102. The Assisted Dying (No. 2) Bill, MP Rob Marris’ private member's bill – which, like the recent HL Bill (below) sought to legalise physician-assisted suicide (PAS) for terminally ill, mentally competent people expected to die naturally within 6 months – was defeated at second reading on 11 September 2015.

103. House of Lords Bill (24 (2013), 6 (2014)). The Bill reached Committee Stage before parliamentary time elapsed; however, it is significant that some of the debates reflected an appreciation of the judgment in Nicklinson.

104. See Hansard HL Deb, vol 756, cols 1851–1898, 7 November 2014; and cols 1001–1047, 16 January 2015.

105. B v NHS Trust, above n 88.

106. See eg Mason, JK and Laurie, GT Mason and McCall Smith's Law and Medical Ethics (Oxford: Oxford University Press, 9th edn, 2013) p 549 CrossRefGoogle Scholar; and Orentlicher, DThe alleged distinction between euthanasia and the withdrawal of life-sustaining treatment: conceptually incoherent and impossible to maintain’ (2012) 1998 U Ill L Rev 837.Google ScholarPubMed

107. Mental Capacity Act 2005, s 4(6)(a)–(c).

108. Bland, above n 8, at 866.

109. See eg Kass, LRDeath with dignity and the sanctity of life’ in Kogan, BS (ed) A Time to be Born and a Time to Die: the Ethics of Choice (New York: Aldine de Gruyter, 1991) p 117 Google Scholar; Macklin, RDignity is a useless concept: it means no more than respect for persons or their autonomy’ (2003) 327(7429) Br Med J 1419 CrossRefGoogle Scholar; Schroeder, DDignity: Two riddles and four concepts’ (2008) 17(2), Camb Q Healthcare Ethics 230 CrossRefGoogle ScholarPubMed; Dworkin, G The Theory and Practice of Autonomy (Cambridge: Cambridge University Press, 1988)CrossRefGoogle Scholar; O'Neill, O Autonomy and Trust in Bioethics (Cambridge: Cambridge University Press, 2002)CrossRefGoogle Scholar; McLean, S Assisted Dying: Reflections on the Need for Law Reform (London: Routledge, 2007).Google Scholar

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112. Above n 8.

113. Dignity in Dying, see (accessed 14 February 2016).

114. See eg Fischer, S et al ‘Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians’ (2009) 139 Swiss Med Weekly 333 Google ScholarPubMed; Ruijs, CDM et al ‘Unbearable suffering and requests for euthanasia prospectively studied in end-of-life cancer patients in primary care’ (2014) 13(1) BMC Palliative Care 62.CrossRefGoogle ScholarPubMed

115. For two interesting decisions that illustrate the extent to which the criminal law permits autonomous choice in relation to certain activities, but not others, see R v Wilson [1997] QB 47; R v Brown and Others [1994] 1 AC 212.

116. Nicklinson, above n 8, at [314].

117. Ibid.

118. See eg the British Medical Association's Policy on assisted dying, available at (accessed 14 February 2016), and Assisted Dying for the Terminally Ill Committee Assisted Dying for the Terminally Ill Bill tteeics/bma-po (2005) at 42.

119. For a discussion, see Huxtable, R and Mullock, AVoices of discontent? Conscience, compromise and assisted dying’ (2015) 23 Med L Rev 242.CrossRefGoogle ScholarPubMed

120. Fischer et al, above n 114, at 333; Ruijs et al, above n 113.

121. Brazier and Ost, above n 4, p 83.

122. Price, DMy view of the sanctity of life: a rebuttal of John Keown's critique’ (2007) 27 Legal Stud 549.CrossRefGoogle Scholar

123. Montgomery v Lanarkshire Health Board [2015] UKSC 11; [2015] AC 1430.