(‘‘Airedale NHS Trust v. Bland’’ 1993) on the interface between the two conflicting

principles of autonomy and preservation of life. It was accordingly ruled that the principle

of ‘‘best interests’’ was not applicable in cases where the patient had the mental capacity to

make relevant decisions about her medical treatment, and therefore, a doctor was under an

obligation to respect the wishes of the patient, even if it was plain to all parties, including

the patient, that death would ensue.

The approach to the issue on end of life adopted by the US courts is not entirely

dissimilar to the law in the UK (it is noted that although the House of Lords in Airedale

130 J Relig Health (2016) 55:119–134

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NHS Trust v Bland (‘‘Airedale NHS Trust v. Bland’’ 1993) declined to apply the test of

‘‘substituted judgment’’ used by the US courts in the case of an incapable patient, Lord

Hoffman at p. 857 noted that such principle, to the extent that it pays respects to what most

likely would have been the patient’s views, ‘‘may be subsumed within the English concept

of best interests’’). In the absence of the expressed wishes of a patient (be it in the form of

oral statements or advance directives), decisions are based on the patient’s presumed

wishes (Meisel 2008). This is known as the doctrine of ‘‘substituted judgement’’. Under

this doctrine, a surrogate appointed by a patient is legally authorised to make decisions on

behalf of the patient, or where there is no surrogate, the patient’s family members, based on

the patient’s values and beliefs. This practice marks the difference between the USA and

the UK positions; in the UK, it is not a legal requirement for relatives to assent on behalf of

a patient who is unable to give consent (per Lord Goff in Airedale NHS Trust v Bland

(‘‘Airedale NHS Trust v. Bland’’ 1993 at p. 872). Discussions with relatives are never-

theless of utmost value because they assist in providing indications about the patient’s own

attitudes and values concerning treatment (Kinsella and Booth 2007).

The prolific Florida case of Theresa Marie Schiavo (‘‘Schiavo ex rel. Schindler v.

Schiavo’’ 2005) is noteworthy not only to illustrate the application of the ‘‘substituted

judgement’’ test, but also due to the controversial intervention of the executive body and

conservative groups in the dispute surrounding her medical care, which attracted intense

media coverage. Theresa Schiavo was in a persistent vegetative state for 15 years, fol-

lowing a cardiac arrest. Although she suffered from irrevocable cerebral cortex, she was

able to breathe on her own and was kept alive through artificial nutrition and hydration

which was delivered by way of a tube implanted in her body. After having accepted the

grim medical prognosis that his wife’s incapacity was permanent, Michael Schiavo

attempted to seek the court’s permission for the removal of her feeding tube so that she

could die peacefully, stating that it would have been against Theresa’s wishes and values to

have her life prolonged in a vegetative state with no hope of recovery. Since The