SM (A Ward of Court) [2025] IEHC 717: Best Interests, Dignified Death and the Role of Medical Ethics in Withdrawing Life‑Sustaining Treatment

This commentary analyses the ex tempore judgment of Barniville P in SM (A Ward of Court) [2025] IEHC 717, an urgent end‑of‑life decision concerning the withdrawal of life‑sustaining treatment from an adult ward of court following devastating hypoxic brain injury. The decision re‑affirms and operationalises the “best interests” test derived from Re a Ward of Court (withholding medical treatment) (No. 2) [1996] 2 IR 79 and integrates the Medical Council’s 2024 Guide to Professional Conduct and Ethics into the legal analysis, with a strong emphasis on the constitutional right to a dignified death.

1. Introduction

The case concerns an urgent application by the Health Service Executive (HSE) in respect of a 51‑year‑old woman, “SM”, who had long been a ward of court due to a mild intellectual disability and an emotionally unstable personality disorder. In late November 2025 she suffered a prolonged cardiac arrest, resulting in a catastrophic hypoxic brain injury. Ten days later, she remained deeply comatose with no measurable brain activity and no prospect of recovery.

Because SM was a ward of court, the clinicians and the HSE could not unilaterally withdraw life‑sustaining treatment. Instead, they were required to seek directions from the High Court exercising its wardship jurisdiction. The application, heard urgently by the President of the High Court (Barniville P), sought:

Orders permitting the withdrawal of life‑sustaining treatment;
Cessation of active supportive care; and
Authorisation to change SM’s care to palliative care only.

The central legal issue was whether, in light of the undisputed medical evidence and within the constitutional framework (including the right to life), it was in SM’s best interests that life‑sustaining treatment be withdrawn and her care be confined to palliative measures.

The judgment sits within a line of Irish authorities on end‑of‑life decision‑making, most notably Re a Ward of Court (No. 2), but is significant as a contemporary, urgent application of those principles to an adult ward in ICU, expressly anchored in the 2024 edition of the Medical Council’s ethical Guide and with strong emphasis on the right to dignity and a “dignified death”.

2. Summary of the Judgment

2.1 Factual background

SM, aged 51, had mild intellectual disability and an emotionally unstable personality disorder and had been a ward of court since February 2023 (para. 2).
She had been living successfully in a residential placement outside Dublin for several years.
On 4 November 2025 she was admitted to St Vincent’s University Hospital with respiratory problems and discharged on 21 November (para. 3).
On 25 November 2025 she suffered a cardiac arrest at her placement; CPR was performed for approximately 53 minutes before transfer to hospital (para. 3).
Diagnostic tests revealed bilateral pulmonary emboli which may have triggered the arrest and she suffered a further cardiac arrest in hospital (para. 3).
She was admitted to ICU, treated with ventilation, nasogastric feeding, cardiovascular support and other invasive supports (paras. 3, 7).

Within ten days, a comprehensive battery of tests (EEG, somatosensory evoked potentials, CT imaging) revealed a “devastating severe hypoxic brain injury” (para. 4), diffuse brain swelling, absence of electrical brain activity, and bilaterally absent somatosensory evoked potentials. The medical consensus was that:

The injury was permanent;
SM would never recover or regain consciousness; and
Active supportive care could only prolong the inevitable outcome—her death (paras. 4, 6, 8).

2.2 Evidence before the Court

The Court received evidence from two consultant intensivists at St Vincent’s University Hospital:

Dr Andrew Westbrook – the treating consultant since 1 December 2025, who gave reports and oral evidence.
Dr Fiona Roberts – independently retained by SM’s independent solicitor to provide a second opinion; she provided a written report and was available to give evidence, though ultimately not called (para. 5).

Both intensivists were in complete agreement that:

There was no realistic prospect that SM would regain consciousness;
Continuing active supportive treatment was medically futile;
Further treatment posed risks of additional cardiac arrests and serious infections (para. 6); and
SM’s care should ethically and clinically be changed from active supportive care to palliative care (paras. 6, 8–9).

The independent solicitor, Mr John Neville (acting also for the General Solicitor, SM’s committee in wardship), tested the evidence, sought an independent medical opinion (Dr Roberts), and consulted SM’s family—particularly her mother. SM’s mother supported the application and expressed gratitude for the care provided (para. 10).

2.3 Legal test applied

The President emphasised that the ultimate legal test was whether the orders sought were in SM’s best interests (para. 11), to be assessed:

Within the constitutional framework – including SM’s rights to life, bodily integrity, privacy and self‑determination, and her right to refuse medical treatment (para. 11); and
Having regard to the leading authority Re a Ward of Court (withholding medical treatment) (No. 2) [1996] 2 IR 79 and to In the matter of C.F. [2023] IEHC 321 (para. 12).

Barniville P stressed that none of SM’s constitutional rights were diminished by her wardship status; rather, because she was a ward, the Court was obliged to decide on her behalf what course of action was in her best interests (para. 11).

2.4 Decision and orders

Having considered the evidence and submissions from counsel, the Court concluded, without any doubt, that:

Continuing active, invasive, life‑sustaining measures would confer no benefit on SM;
Such measures would merely prolong the inevitable (death) and deny her a dignified death (paras. 7, 12);
In her best interests, life‑sustaining treatment should be withdrawn and her care limited to palliative measures (para. 13).

The President therefore:

Granted liberty to issue the Notice of Motion and made it immediately returnable, reflecting the urgency (para. 15);
Made an anonymity order under s. 27 of the Civil Law (Miscellaneous Provisions) Act 2008, prohibiting publication of any material likely to identify SM as a person with a medical condition (para. 15);
Made the substantive orders sought:
- Permitting withdrawal of life‑sustaining treatment;
- Directing cessation of active supportive care; and
- Authorising the switch to palliative care (para. 15);
Ordered that Mr Neville’s costs be discharged by the HSE in the usual terms, and granted liberty to apply (para. 15).

In a postscript, the Court recorded that SM had subsequently passed away and offered condolences to her family, friends, carers and loved ones (para. 17).

3. Detailed Analysis

3.1 Factual and procedural matrix

The judgment highlights the characteristic features of an urgent ICU end‑of‑life application in the wardship context:

Extreme urgency: the application was heard approximately ten days after the cardiac arrest, during a rapidly evolving critical care situation (paras. 1, 4).
Complex medical picture: prolonged cardiac arrest, bilateral pulmonary emboli, severe hypoxic brain injury with no electrical activity, absent somatosensory potentials and diffuse brain swelling (para. 4).
Wardship overlay: because SM was a ward of court, major decisions about life‑sustaining treatment required High Court approval; clinicians could not rely solely on clinical discretion.
Independent legal and medical input: the ward’s independent solicitor instructed an independent intensivist (Dr Roberts), and full engagement took place with SM’s family (para. 10).

Procedurally, the Court:

Granted liberty to issue a Notice of Motion and made it immediately returnable (para. 15), showing how wardship procedures can be fast‑tracked for urgent medical decisions.
Sat as the Wards of Court list of the High Court, with the President—who knew SM’s case from previous reviews—hearing the application (para. 2).

This context is important because it shows that although the decision has profound ethical and constitutional dimensions, it was taken in a pragmatic, clinically urgent setting. The Court balanced the need for speed with a robust evidential basis (two intensivists, independent solicitor, family consultation).

3.2 Legal framework: rights and best interests

At the heart of the judgment is the articulation of the best interests test and its constitutional anchoring. Paragraph 11 is pivotal:

“The ultimate legal test I have to apply in considering and determining this application is – what is in the best interests of Ms SM? I obviously have to consider the various constitutional rights that are engaged, including her constitutional right to life, in respect of which there is normally a presumption that all steps be taken to preserve life, her right to bodily integrity, her right to privacy, including self-determination, and her right to refuse medical care or treatment. None of these personal rights are diminished or extinguished by virtue of Ms SM’s status as a ward of court.”

This passage encapsulates several core principles:

Best interests as the governing test: For an incapacitated ward, the court must determine what is in her best interests, having regard to her rights and the evidence.
Constitutional rights remain intact: Wardship does not strip an individual of constitutional rights; it simply transfers the decision‑making locus to the court, which must exercise it in the ward’s interests.
Presumption in favour of preserving life: There is “normally” such a presumption – but it is not absolute; it can be displaced where treatment is futile and inconsistent with dignity.
Right to refuse treatment: Although SM cannot exercise this personally, her right “to refuse medical care or treatment” remains relevant; the court must not authorise treatment that would be contrary to that right in substance.

These threads are drawn directly from Re a Ward of Court (No. 2), where the Supreme Court held that withdrawal of artificial nutrition and hydration from a ward in a persistent vegetative state could be lawful when in the ward’s best interests, and where it stressed both the right to life and the right to die a natural death with dignity.

3.3 Precedents cited

3.3.1 Re a Ward of Court (withholding medical treatment) (No. 2) [1996] 2 IR 79

The President expressly identifies this case as the leading authority (para. 12). While the present judgment does not rehearse the full reasoning of the Supreme Court, it clearly relies on the following key aspects of Re a Ward of Court:

The High Court, in wardship, has jurisdiction to authorise the withholding or withdrawal of medical treatment, including artificial nutrition and hydration, when it is in the ward’s best interests.
The ward’s constitutional rights—especially the right to life (Article 40.3.2°), bodily integrity, privacy and dignity—must be considered holistically.
The right to life does not oblige the State (or courts) to insist upon treatment that is futile, burdensome or no longer in the ward’s best interests.
The ward has a right to die a natural death with dignity; prolonging biological existence by artificial means when there is no hope of meaningful recovery can be inconsistent with that right.

Barniville P draws particularly on the idea that, in cases of catastrophic and irreversible incapacity, the court’s role is to determine whether continued treatment serves any benefit for the patient or simply extends the dying process. In SM, the Court emphasises:

“…the evidence is very clear that no interventions now will lead to a positive benefit or outcome for Ms SM. She would simply be left in a position where she would be having all these active and invasive interventions with no positive benefit or result and which will only serve to prolong the inevitable, her death.” (para. 12)

This echoes the language and approach of Re a Ward of Court, and confirms that twenty‑nine years later it still provides the principal constitutional template for such decisions.

3.3.2 In the matter of C.F. [2023] IEHC 321 (Barniville P)

The President also cites his own earlier decision in In the matter of C.F. [2023] IEHC 321 (para. 12). The current judgment does not detail the facts of C.F., but by referencing it “see also: In the matter of C.F.” immediately after Re a Ward of Court, Barniville P signals that:

C.F. applied the Re a Ward of Court principles in a more recent context dealing with serious medical decision‑making for a person lacking capacity; and
The approach there (balancing constitutional rights, medical evidence and best interests) is being replicated and reaffirmed here.

Doctrinally, the reference to C.F. reinforces that:

The best‑interests test is now well‑entrenched in High Court practice;
The methodology—careful evidence, independent representation, and structured rights‑based analysis—is consistent across different medical scenarios.

In this way, SM is not a radical departure but a careful, pragmatic application of settled principles to a tragic factual matrix, with updated reference to current ethical guidance.

3.4 The Court’s legal reasoning

3.4.1 Unanimous, unchallenged medical evidence

The Court places considerable weight on the unanimity and robustness of the medical evidence:

All “conceivable tests” had been carried out (para. 4);
All pointed to a “devastating severe hypoxic brain injury” that was permanent (para. 4);
Two consultant intensivists (treating and independent) reached the same conclusion (paras. 5–6, 9);
There was no contrary medical opinion.

The President underlines that SM had “no prospect of a positive outcome” and “will never recover and will never regain consciousness” (paras. 4, 6). On this medical foundation, the legal question is not finely balanced: the evidence “all points one way” (para. 8).

3.4.2 Ethical dimension and the Medical Council’s Guide

A striking feature of the reasoning is the reliance on the Guide to Professional Conduct and Ethics for Registered Medical Practitioners (9th ed., 2024) (para. 7). Paragraph 46.4 of the Guide (quoted in the judgment) provides that a doctor should not start or continue treatment, including resuscitation or medically delivered nutrition and hydration, if the doctor considers the treatment:

“unlikely to work”;
“might cause the patient more harm than benefit”; or
“is likely to cause the patient pain, discomfort or distress that will outweigh the benefits.”

Barniville P uses this ethical framework to reinforce the conclusion that continuing invasive measures with no prospect of benefit is not merely clinically pointless but ethically problematic. He notes that such treatment is:

“very active and invasive” (para. 7);
ethically questionable when it cannot produce a positive outcome; and
potentially denies SM “a dignified death” (para. 7).

This dovetails with the constitutional right to dignity and the idea, long recognised in Irish law, that the right to life does not entail a duty to accept futile or overly burdensome treatment. The integration of the 2024 Guide into the legal reasoning effectively updates the court’s understanding of what professional, ethical medical practice requires in end‑of‑life scenarios.

3.4.3 Best interests and the right to a dignified death

The President’s reasoning on best interests synthesises:

SM’s constitutional rights (life, bodily integrity, privacy, self‑determination, refusal of treatment);
The medical prognosis (no recovery, no consciousness, inevitable death);
The ethical duties of clinicians (to avoid futile, harmful or distressing treatment); and
The practical consequences of continuing treatment (prolonging the dying process without benefit).

In particular, the Court emphasises the right to dignity:

“The Court must take into account all of the rights involved here, including Ms SM’s right to dignity in circumstances where the evidence is very clear that no interventions now will lead to a positive benefit or outcome for Ms SM. She would simply be left in a position where she would be having all these active and invasive interventions with no positive benefit or result and which will only serve to prolong the inevitable, her death.” (para. 12)

This passage shows how “best interests” is not a purely medical assessment; it is a composite of legal rights, ethical standards, clinical evidence and humane considerations. Continuation of invasive treatment is characterised as:

Contrary to SM’s dignity;
Not in her best interests;
Inconsistent with the ethical obligations in the Medical Council’s Guide.

3.4.4 The continuing force of the presumption in favour of life

The judgment does not dilute the importance of the constitutional right to life. The President acknowledges that there is “normally a presumption that all steps be taken to preserve life” (para. 11). However:

This presumption operates within a broader framework of rights;
It can be rebutted where the only effect of treatment is to prolong dying with no benefit;
In such circumstances, respecting life may require not insisting on futile interventions.

This is consistent with Re a Ward of Court and with subsequent Irish and international jurisprudence: the right to life does not mandate the deployment of every possible medical technology regardless of benefit or burden.

3.5 Procedural and evidential safeguards

The judgment also illustrates the safeguards that characterise serious medical decision‑making in wardship:

Independent legal representation: SM was represented by Mr John Neville, an independent solicitor who has acted for her for years and also for the General Solicitor as committee (para. 5, 10). His role included:
- Testing and challenging the evidence where appropriate (para. 10);
- Seeking an independent medical opinion (Dr Roberts) (para. 10);
- Engaging with SM’s family, especially her mother (para. 10).
Independent medical opinion: The Court did not rely solely on the treating team; it had an independent intensivist report aligned with the treating doctor’s conclusions (paras. 5, 9).
Family engagement and support: SM’s mother was informed, aware of the application, and supportive of the course proposed (para. 10). While not determinative, this family consensus supports the conclusion that the orders are in SM’s interests.

The President expressly notes that Mr Neville “has taken all steps that could, I think, be reasonably taken to test and challenge the evidence” (para. 10), confirming that this was not a rubber‑stamping exercise but a carefully scrutinised application.

3.6 Role of the Medical Council’s 2024 Guide: legal and ethical convergence

Paragraph 7 is particularly important in illustrating how professional ethical standards and legal standards are converging in Irish end‑of‑life law. The Court:

Explicitly references the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (9th ed., 2024);
Quotes paragraph 46.4, which prohibits starting or continuing treatment that is futile, harmful or disproportionately distressing relative to its benefits;
Uses that ethical guidance to characterise ongoing invasive treatment as ethically problematic and legally relevant.

This has at least three implications:

Normative benchmark: Courts may increasingly treat the Guide as articulating the standards by which clinicians’ decisions in end‑of‑life cases are to be judged.
Support for withdrawal decisions: Where clinicians, relying on the Guide, conclude that treatment is futile or harmful, the courts are likely to give significant weight to that assessment.
Dignity and proportionality: The Guide reinforces a proportional approach to treatment—legal analysis now explicitly integrates this ethical proportionality when assessing best interests.

3.7 Anonymity and confidentiality: s. 27 Civil Law (Miscellaneous Provisions) Act 2008

The Court made an order under s. 27 of the 2008 Act, prohibiting publication or broadcast of any matter “which would, or which would be likely to, identify the Respondent as a person with a medical condition” (para. 15). This provision:

Is often used to protect privacy in sensitive medical, family and professional regulation cases;
Reflects the constitutional right to privacy and dignity, as acknowledged by the President in his rights analysis (para. 11);
Ensures that public understanding of the law can develop (through judgment publication) without compromising the individual’s confidentiality.

The use of this power in SM is routine yet significant: it underscores that the protection of the ward’s privacy and dignity is not only substantive (in the medical decision itself) but also procedural (in public reporting).

3.8 Impact and significance

While SM (A Ward of Court) does not announce a wholly new legal principle, it has clear significance in several respects:

3.8.1 Contemporary reaffirmation of Re a Ward of Court

The decision:

Restates that Re a Ward of Court remains the core authority on withholding or withdrawing treatment from wards;
Shows how its principles are applied in the highly technical ICU environment of 2025, with modern diagnostic tools and ethical guidelines;
Confirms that withdrawal of treatment, when futile, is legally and constitutionally permissible and can be required by best interests.

3.8.2 Integration of professional ethics into judicial reasoning

By foregrounding the 2024 Medical Council Guide, the judgment:

Signals that updated professional ethical standards are not peripheral but central to the court’s view of what is reasonable, lawful clinical practice;
Gives clinicians reassurance that decisions made in accordance with the Guide—particularly regarding futility—will be strongly supported judicially;
Aligns legal and ethical understandings of “dignified death” and non‑beneficial treatment.

3.8.3 Clarifying the best‑interests test for wards in ICU

The case gives practical content to the best‑interests test in end‑of‑life ICU care:

Where there is clear, unanimous evidence that:
- The patient will never regain consciousness;
- There is no prospect of positive outcome;
- Continuing treatment merely prolongs the dying process;
it is in the ward’s best interests to discontinue active life‑sustaining measures.
The court will be reassured by:
- Independent medical opinion;
- Independent legal representation;
- Consultation and agreement from close family.

In this sense, SM is a strong precedent for the proposition that in catastrophic, irreversible brain injury cases concerning wards of court, the High Court will respond swiftly and authorise withdrawal of treatment where the evidence is clear and the procedural safeguards are in place.

3.8.4 Ongoing wardship practice in a changing capacity law landscape

Although the judgment does not expressly address the broader reforms under the Assisted Decision‑Making (Capacity) Act 2015, it shows that:

For existing wards, the traditional wardship jurisdiction remains the forum for major medical decisions;
Courts continue to emphasise that wardship is protective, not rights‑stripping; all constitutional rights remain fully engaged (para. 11);
The best‑interests standard is applied in a nuanced, rights‑respecting manner, consistent with contemporary understandings of dignity and autonomy.

4. Complex Concepts Simplified

4.1 Ward of court

A “ward of court” is a person whom the High Court has found to lack capacity to manage his or her own affairs (personal, financial or both). The Court then assumes responsibility for major decisions about that person’s welfare and estate, usually acting through a committee (here, the General Solicitor). The ward retains all constitutional rights, but the Court exercises decision‑making power in their best interests.

4.2 Best interests

“Best interests” is not a mere medical label; it includes:

Clinical considerations (prognosis, benefit/burden of treatment);
Legal rights (life, bodily integrity, dignity, privacy, autonomy);
Ethical standards (as reflected in the Medical Council Guide);
Personal circumstances and values (so far as they can be known);
Views of family and carers (not decisive, but relevant).

In practice, best interests means: What course of action respects the person’s rights and welfare, avoids unnecessary suffering, and accords with humane and ethical medical care?

4.3 Life‑sustaining treatment vs. palliative care

Life‑sustaining treatment includes interventions like mechanical ventilation, artificial feeding (e.g. via nasogastric tube), and strong cardiovascular support that are intended to keep a person alive who would otherwise die.
Active supportive care (as used in the judgment) refers to such active medical interventions aimed at sustaining life or organ function.
Palliative care focuses on comfort, pain relief and symptom management rather than cure or life prolongation. It aims to ensure that a person’s remaining life is as comfortable and dignified as possible.

In SM, the switch from active supportive care to palliative care meant:

Stopping invasive, non‑beneficial measures intended to prolong life;
Continuing (and not diminishing) pain relief, comfort measures and supportive, compassionate care (para. 14).

4.4 Hypoxic brain injury and prognosis

A hypoxic brain injury occurs when the brain is deprived of oxygen for a significant period, for example during a prolonged cardiac arrest. If severe and prolonged, it can cause catastrophic, irreversible brain damage.

Key tests mentioned in the judgment include:

Electroencephalogram (EEG): Records electrical activity in the brain; here, it showed no activity (para. 4).
Somatosensory evoked potentials: Measure the brain’s response to peripheral nerve stimulation; “bilaterally absent” means both sides of the brain show no response (para. 4), an extremely poor prognostic sign.
CT scan: Imaging showed diffuse swelling and early crowding of the brain stem (para. 4), consistent with severe, diffuse injury.

In legal terms, this medical evidence was crucial in establishing that further treatment could not change the outcome—death was inevitable and consciousness would not return.

4.5 Ex tempore judgment

An ex tempore judgment is delivered orally by the judge at the end of the hearing, rather than being reserved for a later written decision. It is often used in urgent cases, such as critical medical applications, to provide an immediate, authoritative decision. The text we have is a written record of that oral judgment.

4.6 Section 27 Civil Law (Miscellaneous Provisions) Act 2008

Section 27 allows the court to restrict publication or broadcast of information that would identify a party to civil proceedings as a person with a medical condition. It is designed to protect privacy in sensitive cases. In SM, it ensured that while the legal principles could be reported, SM herself would remain unidentifiable in public reporting (para. 15).

5. Conclusion

SM (A Ward of Court) [2025] IEHC 717 is a clear and humane application of established Irish law on the withdrawal of life‑sustaining treatment from incapacitated adults. It:

Reaffirms that the central legal test is the ward’s best interests, assessed in light of their full suite of constitutional rights;
Confirms that wardship does not diminish those rights; it transfers decision‑making to the court, which must act protectively and respectfully;
Illustrates how courts rely on robust, unanimous medical evidence and independent expert opinion in catastrophic brain injury cases;
Integrates the 2024 Medical Council Guide into the legal analysis, especially the prohibition on futile or harmful treatment in paragraph 46.4;
Emphasises the ward’s right to a dignified death and rejects the idea that invasive, non‑beneficial treatment should be continued merely to defer the inevitable;
Shows the importance of procedural safeguards—independent legal representation, independent medical review, and family engagement—in such grave decisions.

The decision does not create a new legal doctrine but consolidates and updates existing principles. Its enduring value lies in demonstrating, in a modern ICU context, how Irish courts will balance the presumption in favour of preserving life with the realities of medical futility, the demands of dignity, and the ethical responsibilities of clinicians. For future end‑of‑life cases involving wards of court, SM will stand as a practical, rights‑based example of lawful and compassionate withdrawal of life‑sustaining treatment.