High Court allows Jehovah's Witness minor's refusal of blood transfusion to protect bodily integrity and life.

THE HIGH COURT

WARDS OF COURT

[2026] IEHC 134

[WOC 11903]

IN THE MATTER OF E AND IN THE MATTER OF A MINOR AGED 16 AND IN THE MATTER OF A BLOOD TRANSFUSION TO WHICH THE MINOR OBJECTS AND HER PARENTS DO NOT CONSENT

RESPONDENT

Ex Tempore Ruling of Mr. Justice Mark Heslin delivered on the 13th day of February 2026

Introduction

1. I would like to express my thanks to counsel for the H.S.E, Ms. Hill S.C. and Mr. O'Connell B.L.; to Mr. Ó’Muircheartaigh B.L. for the Guardian ad Litem, Ms. Quinn; and to [E]’s loving parents Mr. [F] and Ms. [G] who have participated on-line. Throughout this ruling, I will refer to [E] as ‘the minor’ in circumstances where she is someone under the age of 18.

Parental views

2. I am going to begin with the position articulated so clearly by her parents, through her father, which, in summary, is to say: we love our daughter, we want what's best for her, she is someone who has been taking her own decisions for some time, her current pregnancy illustrates that. They are of the Jehovah's Witness faith and they hope their daughter will be or will become such. They support their daughter, and they want to honour her wishes, and, in the manner I will come to, they are not in a position to give parental consent to the treatment sought in this application.

Affidavits

3. Next, I want to turn to the facts which emerged from the evidence, in circumstances where I have a number of sworn affidavits before me. An affidavit is, of course, a statement of facts sworn to be correct and affidavits have been proffered by Ms. Katherine Kelleher, solicitor for the applicant and by Dr. [H], consultant gynaecologist and obstetrician and clinical director of the relevant hospital. I will presently come to other affidavits, in particular, an affidavit of service as well as an affidavit by Ms. Seona Ní Mhurchú, solicitor for the Guardian ad Litem, exhibiting Ms. Quinn’s report.

The facts

4. Summarising the facts, the minor is 16 and a female who is 37 weeks pregnant. She was admitted to a certain hospital on 8 February 2026 presenting with reduced foetal movement and this was for a third time over the course of her pregnancy. The minor has purported to execute an Advance Healthcare Directive under part 8 of the Assisted Decision Making (Capacity) Act 2015, (the “2015 Act”) and, by doing so, she has expressed the wish not to receive a blood transfusion in all situations, even a life-threatening situation.

The minor’s view

5. During consultations on 5 and 6 February 2026, the minor repeatedly informed her treating consultant obstetrician and gynaecologist, Dr. [H], that she does not wish to receive any blood transfusion of red blood cells under any circumstances, including, in the event of any major haemorrhage before, during, or after delivery of her baby, and even if refusal of a blood transfusion could result in her death.

Parental support

6. In the manner I have touched on, her father supports the minor’s wish not to receive a blood transfusion and in circumstances where he is joined on-line by the minor’s loving mother, I take it that this represents the joint view of [E]’s parents. The minor’s wish to refuse a blood transfusion and parental support for that decision is a based on religious beliefs.

Medical opinion

7. Dr. [H] prepared a report of 10 February 2026 and I have a carefully considered its contents. Dr. [H] reports that a risk of haemorrhage exists at all stages of pregnancy, i.e. prior to, during, and after delivery. As well as explaining the circumstances in which a haemorrhage can arise and the risks flowing from that, Dr. [H] makes clear that: “in any case of significant blood loss a blood transfusion may be required in order to save the life of the patient and to restore their health”.

Risks facing the minor

8. Speaking directly to the minor’s risk of haemorrhage, Dr. [H] reports that: “Even in an uncomplicated first pregnancy a haemorrhage can occur unpredictably with a rapid progression. The refusal of red blood cells may result in a volume of blood loss that would otherwise be survivable, leading to the minor's death”. Dr. [H] goes on to state that: “Where this is the minor's first pregnancy, the minor is more likely than a person with prior deliveries to have a prolonged labour perineal trauma or a retained placenta or products all of which create an increased risk of haemorrhage”. Furthermore Dr. [H] makes clear that “Adolescent pregnancies are associated with higher risk of complications such as anaemia and hypertensive disorders with an associated increased risk of postpartum haemorrhage”. Dr. [H] confirms that “A massive obstetric haemorrhage is a time critical life-threatening emergency that can occur suddenly and progress rapidly leading to acute loss of circulating blood and reduced oxygen delivery to vital organs requiring intensive intervention”.

9. The applicant has exhibited a copy of a document entitled “Care Plan for Women in Labour Refusing a Blood Transfusion”. In the manner Dr. [H] make clear, none of the measures detailed in that report treat acute massive bleeding. As section 5 of Dr. [H]’s report she states: “Once heavy bleeding is identified, immediate treatment is required immediately, including prompt escalation and initiation of major haemorrhage protocol”, and she goes on to say: “if bleeding is ongoing or severe, transfusion of red cells and other blood components may be required urgently as part of resuscitation and delay in administering definitive haemorrhage control and/or transfusion significantly increases the risk of cardiac arrest, multiorgan failure and death”.

10. Dr. [H] also confirms that there may be some circumstances in which it may be possible to stabilise a patient following significant obstetric blood loss without the need for a blood transfusion. Nevertheless, she goes on to note that: “If there is major blood loss or ongoing haemodynamic instability, severe anaemia or coagulopathy, there is a materially increased risk that such measures will be insufficient”. My understanding of the phrase “haemodynamic instability” is insufficient blood flow in the body. My understanding of “coagulopathy” is impairment of the body’s ability to form clots leading to excessive bleeding.

11. Regarding the risks to a patient of not receiving a blood transfusion where one is required due to significant blood loss, Dr. [H] confirms that a failure to receive treatment carries a material risk of “irreversible organ damage and death”. Dr. [H] also makes clear that while there are risks associated with blood transfusion, these are mitigated through strict identity procedures, testing, monitoring and adherence to protocols and these material risks, as she makes clear, will always be weighed against the risk of untreated major blood loss.

Time-critical life-threatening emergency

12. Ms. Hill has opened further extracts from Dr. [H]’s evidence and, at the risk of repetition, the following evidence seem to me to be particularly relevant, given (i) the potential risks facing the minor which the treatment at issue is designed to address, as well as (ii) the minor’s own suggestions regarding an alternative. At para. 12 of her affidavit, Dr. [H] avers:

“A massive obstetric haemorrhage is a time-critical life-threatening emergency that can occur suddenly and progress rapidly leading to acute loss of circulating blood and reduced oxygen delivery to vital organs, requiring intensive intervention even if severe bleeding is brought under control. Severe anaemia and tissue hypoxia can result in serious injury and multiorgan failure. From the time a major haemorrhage occurs treatment must be commenced within an extremely short period, measured in minutes, in which case there would not be sufficient time to make an application to the court in those specific circumstances even on a most urgent ex parte basis.”

“Cell salvage”

13. Later, at para. 14, and speaking directly to a suggestion made by the minor, Dr. [H] avers:

“Whereas the minor has indicated that she is willing to permit cell salvage where her own red blood cells are recovered and transfused into her circulatory system, closed loop cell salvage is not a straightforward procedure and is one that is typically considered where there is controlled or limited bleeding including, for example, in a planned surgical procedure. In the context of obstetrics there is certainly no guarantee that self-salvage will be available and/or suitable to address urgent uncontrolled and/or substantial blood loss. In many ways a blood transfusion is a last resort to save the life of a patient or prevent serious injury to their vital organs.”

Last resort

14. The phrase “last resort” has been used more than once in today's application. At the very outset, it was confirmed by the H.S.E., through Ms. Hill, that the proposed treatment would be very much as a last resort, only.

The current position summarised

15. Dr. [H] concludes her 11 February affidavit by making the following averments at paras. 24 and 25. In many ways they encapsulate the significant risk, including to the minor’s very life, which the treatment at issue in the present application concerns, and I quote:

“I say that the minor is a 16-year-old girl who is expected to experience the onset of labour shortly and on the basis of religious belief has purported to make a decision that she will refuse any red blood cell transfusion even in the event that her life is at risk due to a massive blood haemorrhage before, during, or after her anticipated delivery of her baby. Where clinically required, blood transfusion is in a very real sense a measure of last resort to preserve the life of a patient, to prevent irreversible damage to vital organs, and restore their health following major blood loss. Were the minor to require a blood transfusion and not receive it, it is a real prospect that the other treatments available will not be sufficient where they are not a replacement for blood transfusion as a result whereof an otherwise survivable event could become terminal.

Whereas the minor does appear to understand the nature and purpose of a blood transfusion and the consequences of not receiving one where it is required, in my opinion her judgment is clouded by her religious beliefs such that she is unable to truly weigh the information provided to make a valid decision. Furthermore, her decision-making may be influenced by an overly simplistic view of the practicality of alternatives including cell salvage which are by no means guaranteed to be available, and if so, adequate to prevent her death or serious injury in the event of a massive haemorrhage.” (emphasis added)

No parental consent

16. I referred earlier to an affidavit of service, from which it is clear that the minor's parents were served, on 11 February, and, as I have noted, they are a participating on-line today. In the manner they have confirmed today, through the minor’s loving father, there is no change in their stance with respect to the issues ‘at play’ and there is no parental consent being provided. That is by no means a criticism, but it is a relevant fact.

Guardian ad Litem

17. In her role as the minor’s Guardian ad Litem, Ms. Claire Quinn met with the minor by appointment yesterday, 12 February. I very carefully considered her report, which Mr. O’Muircheartaigh spoke to in his very helpful submission. To have the clearest understanding of the minor's views and the relevant views of others I propose to touch briefly on certain aspects of the reporting by Ms. Quinn.

Core principle

18. Among the matters which Ms. Quinn and the minor discussed was the question of the minor's religion. At para. 3.5 of her report, Ms. Quinn put things as follows: “[E] said she is not strongly into her religion at the moment, she has chosen not to be baptised even though some of her friends have been as she does not feel ready for that. She feels her religion stands by her, but just at the moment she is not overly into her religion”. Regarding why the minor feels so strongly about the blood transfusion refusal, the Guardian ad Litem reports: “[E]” said that this is one aspect of her religion that she has always had a strong view about and generally within the religion it is a core principle”.

Treatment decision

19. Regarding the treatment in question the minor confirmed to Ms. Quinn that if the decision was taken out of her hands it would be easier, but she would still feel guilty about it. The minor said it would not feel right in her body but someone else making the decision would be easier. Ms. Quinn asked [E] if her parents ceased their belief in their religion today or moved away from her, would she still hold this view in relation to the blood transfusion? She confirmed to the guardian that she would and that her parents are not pressurising her to take this stance. However, the minor stated that she is not taking this view in relation to a blood transfusion for her unborn baby, she is satisfied for her baby to receive blood if necessary. With regard to her engagement with the minor's father, Ms. Quinn reports that he confirmed his position is to support his daughter in whatever her views are. He does share her views about refusing a blood transfusion but indicated he just wants to support his daughter's views.

Last resort

20. Ms. Quinn also spoke with [E]’s consultant, Dr. [H], who confirmed that any decision to undertake a blood transfusion would be a matter of last resort and that all other possible suitable interventions would be taken first. When speaking both to the minor and her father, Ms. Quinn reiterated the consultant’s view in that regard and it was reported by Ms. Quinn that this a could be stated in court, as it has been. This is something which did seem to bring some comfort. Mr. O’Muircheartaigh has very helpfully and appropriately opened [E]'s views in her own voice, as quoted at section 4.1 of Ms. Quinn's report in the form of a letter to this Court.

Guardian’s view

21. In relation to the guardian’s independent view, the following extracts from Ms. Quinn’s report encapsulate her independent professional opinion: “This guardian came away from the meeting with [E] believing that the Court must step in and take this massive pressure of making this decision away from this vulnerable teen”, later stating:

“In addition to [E]'s own obvious vulnerability as a teenager over and above those of a typical teenager, this guardian has no hesitation in supporting the application for wardship in the context of having the utmost respect for [E]'s religion. The Court is sending [E] a message that her life is worth saving above all else. [E] said that if she made the decision she would regret it for the rest of life but indicated that if others made the decision it might make things easier. The guardian shared with [E] at the end of the interview that I would be supporting the wardship application.” (emphasis added)

Orders sought

22. Having set out the facts which emerge from the evidence before me, I am now moving to a discussion of the issues, grateful to Ms. Hill and Mr O'Connell for their written submissions which were very helpful. As touched on with reference to the motion, the H.S.E. is seeking an order authorising the provision to the minor of all appropriate medical treatment and ancillary procedures including blood transfusion and clotting agents. That is “the treatment”, and that's what I mean when I refer to treatment, provided always that such treatment is in the clinical judgment of the minor’s treating consultant namely Dr. [H] or their deputy to be appropriate and, in the minor’s best interests. In addition, the H.S.E. is seeking an order authorising the hospital and its servants or agents, in the event of complications arising from the treatment, to take all reasonable steps necessary and clinically or medically indicated to treat such complications.

Issue before the Court

23. The issue before this Court, therefore, concerns the decision by the minor, supported by her father, to refuse a blood transfusion in all circumstances, even if such a refusal could result in her death or multi-organ failure or serious and permanent injury. That is what I mean when referring to “the decision” to refuse treatment made by the minor and supported by her father. As I say, that

decision has not been countermanded by any different decision made by the minor’s parents, today.

Advance Healthcare Directive

24. I now turn to the significance of the Advance Healthcare Directive (“AHD”). While the minor has executed one expressing the decision, that is not determinative of the question before me. That is because to be valid, as a matter of law, someone making an AHD must be over the age of 18. In that regard, section 84 subsection 1 of the 2015 Act specifies that someone must have “attained the age of 18” as well as referencing the need for them to be someone with capacity to make an Advance Healthcare Directive and I will touch on the question of capacity again, presently.

Refusal -vconsent

25. The issue before the Court concerns refusal, and I emphasise refusal of treatment. Therefore, section 23 of the Non-fatal Offences Against the Person Act, 1997, which deals with consent to treatment by someone over the age of 16, cannot provide an answer in the present case. In that regard I am also grateful to Ms. Hill and Mr. O’Connor who direct my attention to In RE XY; HSE v. JM and RP [2013] IEHC 12, [2013] 1 IR 574 at 58, a decision in which Mr. Justice Birmingham drew a distinction between consent to, as opposed to refusal of, treatment.

Constitutional rights

26. It is plain that there are a number of constitutionally-protected rights at play in the current situation, for example, the right to profess religion; the right to bodily integrity; the right of equal access to necessary care; the right to life; family rights; and the rights of the child.

Art. 42A

27. Article 42A presumes that a child's bests interests are normally served within the family, which is recognised as the primary and natural care-giver. Given that Article 42A 2.1 rights are engaged, the question for this Court is whether the decision is prejudicial to the minor’s safety or welfare such that this this Court should make the order sought by the H.S.E., namely, to give substitute consent, notwithstanding the stance adopted by the minor and in the absence of consent by her parents, who love and support her.

“JJ”

28. The evidence before me is to the effect that the minor ordinarily lives at home with her parents, and is someone who shares their faith. Her father shares the minor’s views, namely, to refuse a blood transfusion even if necessary to save life, whilst emphasising that he simply wants to support his daughter. Even though on the evidence, and absent even hearing from the minor’s loving parents, it was safe to infer that, should the treatment become medically necessary there will be a refusal to provide parental consent consistent, of course, with supporting the minor’s decisionmaking, it has been made explicit that no parental consent is forthcoming. I am guided in today’s consideration by the decision of the Supreme Court In the matter of JJ [2022] 3 IR 1 (“JJ”), and on my reading of JJ, the proper approach for this Court is to decide whether there is “clear and convincing evidence that the decision of the parents is one which prejudicially affects the health and welfare of the child to such an extent that the decision of the parents can properly be described as a failure of parental duty to the child in question” and that is to quote directly from para. 176 of JJ.

“parental failure”

29. I want to make very clear, especially for the benefit of the minor’s loving parents, that the phrase “parental failure” as employed in JJ may well be difficult to hear, but two important points deserve emphasis.

Legal meaning

30. The first is that the phrase has a specific legal meaning which is very different to its commonsense meaning, in other words, there can be a finding of parental failure in the JJ sense even if the parents are entirely loving, attentive, supportive of their child, and sincere in their views and there is nothing to suggest that the position is otherwise in this application. Indeed, as made clear in para. 134 of JJ, parental failure is assessed with reference to the adverse impact on a minor, not the motivation or reasoning of parents, and that holds true regardless of how loving and sincere the parents may be.

Single decision

31. The second point to emphasise is that this Court is concerned today with only a single discrete decision, out of a myriad of decisions which parents may make in respect of a minor. Indeed, JJ makes explicit that: “The failure under Article 42A 1.2 can be a failure in one single respect and not amount to a persistent failure tantamount to abandonment of the parental role” and that is a direct quote from para. 135 of JJ.

Increased risk

32. It is also important to note that while Dr. [I], consultant psychiatrist, reports that the minor denied any specific worries or anxieties regarding the delivery of her baby, the uncontroverted medical evidence provided by Dr. [H] establishes that, not only does the minor face risk of haemorrhage at all stages of her pregnancy, she is at increased risk given that this is her first pregnancy, as a consequence of that she is more likely than someone who has given birth before to have prolonged labour, perineal trauma or retained placenta or products all of which create an increased risk of haemorrhage. Moreover, because adolescent pregnancies are associated with high rates of complications, she is also in a position where she has an increased risk of postpartum haemorrhage.

Due weight

33. I want to make clear that I am giving due weight to the views expressed by the minor and I am doing so because she is plainly over the age of 16 and, as such, is a maturing adolescent who is approaching adulthood. She is also facing the prospect of becoming a parent, herself. Furthermore, her views appear to reflect a sincerely-held religious belief in a faith which she shares with her parents. However, in considering those views two other factors seem to me to be relevant.

Lack of capacity

34. First, I have medical evidence before me which casts doubt on the capacity of the minor to make the decision to refuse treatment, in light of what Dr. [H] considers to be the minor's inability “to truly weigh the information provided, to make a valid decision”. As Ms. Hill has rightly submitted, the ability to weigh up information is one of the four essential aspects of functional capacity, the other three being, of course, to understand the information, to retain information long enough to make a decision and fourthly, to communicate information. However, an inability to weigh up information ‘robs’ some of functional capacity to make a decision.

Easing a burden

35. The second relevant factor is that, whilst the minor expresses very clearly her wish not to receive a blood transfusion, even to save her life, she has also made clear that if this decision was taken out of her hands it would be easier. In other words, she has already contemplated the possibility that someone else might make the decision for her. I am entitled to infer from the evidence that, were this to happen, it would ease a burden which is currently oppressing this minor.

Avoidable death

36. Giving all due weight to the views of the minor, reflecting those of her father, if the minor were to sustain significant blood loss, a transfusion may be required to save her life and restore her health. The risk to the minor of not receiving a blood transfusion, where one is medically required due to significant blood loss, includes irreversible organ damage and death. Indeed, failure to provide the minor with the treatment in respect of which the H.S.E. seeks orders in this application could result in the death of a young person which would be otherwise avoidable.

Best interests

37. In light of the evidence which I have attempted to summarise, I take the view that the treatment in question is manifestly in the minor’s best interests. Therefore, this Court is dealing with a situation where a decision by the minor, supported by her parents, is in conflict with the minor’s best interests when viewed objectively.

Prejudice to the minor’s safety and welfare

38. A consideration of best interests is not the end of the analysis because such a finding is not, of itself, a sufficient justification for court intervention. However, guided by JJ, I also take the view that, given the serious risks identified in uncontroverted medical evidence, including risks to the very life of the minor, despite having given due weight to the views which she has articulated, and which are supported by her father, I am satisfied that the Court does have in this particular situation clear and convincing evidence before it that the decision to refuse the treatment in question prejudices the minor’s safety and welfare to such an extent that the test for court intervention as outlined in JJ has been met.

Override

39. In short, the inability on the part of the minor’s parents, for sincere reasons, to consent to the relevant treatment, can be considered parental failure in the sense used in JJ. This is not for a moment to discount, disrespect, or discard sincerely-held views based on religious belief. Rather, it is to say that, having carefully considered the entirety of the evidence, I am satisfied that this is a situation where it is appropriate to override the single, discrete, decision to refuse treatment. Put simply, unless this Court takes that view and overrides this specific decision, it could result in the tragic and needless death of the minor, or her serious and irreversible injury.

Future oriented

40. In the exhibited report of Dr. [I], dated 9 February, it stated that minor “presented as future oriented”; expressed she is looking forward to the birth of her baby boy; has chosen a name for him; and plans to breastfeed. It is also clear from the evidence that the minor’s parents are hoping for a bright future for their daughter and her baby. I say this in circumstances where the minor’s father confirmed to Ms. Quinn that she and the baby can live with them after the birth, also indicating to Ms. Quinn that he finds the minor’s boyfriend supportive to his daughter.

41. I mention the foregoing because if this Court were not to override this discrete decision to refuse treatment, the effect could be to deprive the minor and those who love her of the very future which the minor is focused on.

The minor wardship jurisdiction

42. As made very clear in JJ, where minor wardship proceedings have been commenced - and they have certainly been in this case - this Court can make orders under that minor wardship jurisdiction without a minor being admitted into minor wardship, and that is the position here. Therefore, in the present case, this Court is doing no less but no more than exercising its minor wardship jurisdiction to override a single decision; in other words, to provide consent on behalf of the minor to treatment which her parents are not in a position to give consent to.

Faith

43. If it is not already obvious from what I have said, I want to emphasise that this application has nothing to do with the love and care of parents for a child. Doubtless the minor’s parents love their daughter dearly and nothing in this ruling is intended to suggest otherwise. One can well imagine how enormously difficult it must be for a person of faith who finds themselves unable to consent to particular treatment for their child by reasons of sincerely-held religious beliefs.

Balancing of rights

44. That brings me to the final aspect of this ruling, namely, to repeat that it is one which involves the consideration of a range of constitutional guaranteed rights, including, the right to profess faith. However, I am satisfied that the making of the orders sought by the applicant, today, represents the appropriate outcome of a careful balancing of various, and sometimes competing, constitutionally-protected rights. To look at it otherwise, a refusal by this Court to permit a blood transfusion in the event that one was clinical necessary as a last resort would constitute a clear failure to vindicate this minor’s right to bodily integrity and right to life.

45. To echo a submission made earlier, the right to life is on ‘top’ of the ‘pyramid’ of rights and it is very much through that ‘lens’ that I hope the minor can see the outcome of today’s application, echoing the contents of the guardian’s analysis, based on her discussions with [E]. Put otherwise, this Court cannot countenance otherwise avoidable serious injury, including multi-organ failure and/or death, to this already vulnerable minor.

Proportionality

46. Speaking to the question of proportionality, I am also satisfied that making the orders sought by the applicant today goes as far as but no further than is necessary to vindicate the minor’s rights, in particular, her rights to life and to bodily integrity and, therefore, it is in my view a proportionate intervention by the Court.

47. Again, and perhaps for the benefit of not only the minor but her parents, this is not a question of [E] being taking into minor wardship. Not at all. There is simply an overriding of a particular discrete decision. This is substitute consent being given by the Court.

48. I propose to adjourn the minor wardship summons to a future date, exactly as Ms. Hill suggested. That is because it is unnecessary, and it would be disproportionate, to do otherwise.

Some comfort

49. To draw this ruling to a conclusion, I am hoping that the minor will take some comfort from the fact that this Court has taken the making of this decision ‘out of her hands’. I also hope that the minor, and possibly her parents, will take comfort from the fact that it was confirmed in writing and in open court today by the H.S.E. through their senior counsel, Ms. Hill, that (i) a blood transfusion would be a matter of last resort only; and (ii) that all other options would be pursued first.

50. Finally, I want to express the sincere hope that the birth of [E]’s child will go well, without any of the risks manifesting or any need for treatment arising. I want to wish the minor and all who love her, in particular her parents, as well as her supportive boyfriend, the very best.

51. This is my ruling on today’s application and the reasons for it.