When is treatment clinically appropriate? The Townsend v Epsom and St Helier NHS Trust controversy

The recent legal case of Townsend v Epsom and St Helier University Hospitals NHS Trust (2026) (Epsom) exposes a key ambiguity in medical ethical decision-making. In a controversial decision, the Court of Appeal held that a National Health Service (NHS) body cannot avoid best-interests scrutiny merely by labelling treatment as not ‘clinically appropriate’. This judgement potentially challenges a long-standing view that doctors are not obliged to provide treatment that they regard as clinically inappropriate. The Supreme Court will soon review whether the Court of Appeal’s approach in Epsom is legally correct. In this paper, we aim to provide ethical clarity to the underlying contested concept. We distinguish three categories of clinical appropriateness: scientific, welfare and resource. Welfare appropriateness asks whether the benefits of treatment outweigh its burdens. Scientific and resource appropriateness instead relate to whether the treatment has a plausible physiological basis and whether providing it would be a reasonable use of limited health resources. We propose a narrower concept of preference-insensitive clinical appropriateness to separate these limits from patient-relative welfare judgements. Applying this concept requires clinicians to identify whether a disputed treatment is being rejected based on evidence, fair resource allocation, or an assessment of the patient’s welfare and to make decisions appropriate to that reason. We address objections concerning scientific uncertainty, fair rationing and inequitable transfer to private care or overseas. We suggest several implications of our analysis that may apply regardless of which decision the Supreme Court reaches.