§ 2.56 p.m.
§ EARL JOWITT rose to move to resolve, That in the opinion of this House, in view of the apparent conflict of expert medical opinion on the banning of the manufacture of heroin in this country, the period of the present licences to manufacture should be extended pending the institution of further inquiries on this subject. The noble and learned Earl said: My Lords, I rise to move the Motion standing in my name on the Order Paper. I would say at the outset, to make it absolutely plain, that this is in no sense a Party question. So far as my own Party are concerned, I believe them to be divided. I do not know what their attitude would be; I have no authority to speak for them, and I have carefully abstained from any kind of lobbying, even amongst my own Party. I do know that my noble friend Lord Haden-Guest, at whose feet I have been accustomed to sit and learn on these matters, takes a strong view against the Motion; but apart from that, I do not know what view anybody takes. Therefore, I need hardly say that we have abstained from putting out any sort of Whip, even a one-line Whip, and I hope 11 and believe that the same applies to noble Lords on the other side of the House.
§ It is perhaps a pity that I should have had to put down this Motion. I confess that I felt that, if no one else put it down, this was a unique opportunity for assisting the Government—and I really mean that—by a pronouncement of this House on this difficult question. The Government, from the highest motives (I realise that to the full), have propounded this ban on the manufacture of heroin, and I think that an announcement by this House may help them to retrieve what I believe to be a mistake, and a grievous mistake. That pronouncement I accordingly intend to ask the House to make, unless the Government, at any stage of what I am going to say, interrupt me to say that, having regard to the considerations—some of which are completely novel—which I am putting forward, they realise that there is a case for further consideration; that they are prepared to give that further consideration, and that in the meantime they will continue the licences as they are at present. If they do feel inclined to make that pronouncement, then I hope that they will interrupt me at any stage in my speech, and I shall avoid the necessity of boring your Lordships with what I fear is going to be a rather long narration.
§ This is the first time in our history, so far as I know, that the medical profession are being prevented from using a drug which many of them—and I believe most of them—
§ EARL JOWITT
—consider to be indispensable in certain cases. Generally speaking, those are chronic cases in which other analgesics have failed to give satisfaction. I would briefly review the history. It started with a convention in July, 1941. In the old days of the League of Nations we all agreed that we would not allow the export of heroin save under stringent conditions, one of the conditions being that the export had to be addressed to the Government of the country to whom the export was being made. That convention was renewed in the days of the United Nations in 1946, and again in 1948. But I stress that the only conventions that there have ever been, and the only convention which exists to-day, are 12 conventions forbidding the export. There has never been a convention forbidding manufacture. I am going to give a colourless and, I hope, absolutely accurate and impartial short review of these circumstances.
In 1949, the British Medical Journal stated that pharmacological opinion held the view that the social dangers of heroin—that is, of course, the danger of addiction—overshadowed its therapeutic importance. Accordingly, in 1950, the monograph on heroin was deleted from the Pharmacopœia. So the matter remained until July 12, 1954, when the Eighteenth session of the Economic and Social Council of the United Nations passed a resolutionNoting that only seven members of the World Health Organisation are not in favour of the dispensability of heroin,and urging all Governments to prohibit the manufacture, import and export of heroin, save for scientific purposes. Incidentally, that meeting stressed the increase in the illicit use of narcotic drugs. When that resolution was passed in July, the Council of the British Medical Association passed a resolution, in reply to an inquiry from the World Medical Association:That the World Medical Association be informed that it is the duty of the Government to legislate against the misuse of heroin, but the medical profession should not in any way be deprived of the use of this or any other drug which may assist in the treatment of patients.Then, in December, 1954, after that resolution had been passed, the statutory committee was consulted by the Minister of Health and informed him—to use his own words—that it concurred with the Government's proposal to accept the resolution of the Economic and Social Council. That committee is a subcommittee of the Council, and was set up, under Section 2 of the National Health Act, 1947,To advise the Minister upon such general matters relating to the services provided under this Act or any services provided by local health authorities as the Council or the Minister may think fit relating to those services.The Council contain amongst their membership certain members of the B.M.A. who are appointed by the Minister after consultation with the B.M.A. But, as the Minister of Health made quite plain in a Written Answer in another place on December 5, "they serve in an 13 individual capacity." With the greatest respect to the noble Lord, Lord Mancroft, who made a statement on this matter the other day, to the effect that it was a matter of acute controversy as to whether the B.M.A. had ever been consulted, I would say that it is clear that the B.M.A. were never consulted at all before this ban was imposed. Although the President of the Royal College of Physicians is appointed eo nomine, it is a fact that the Royal College of Physicians have never been consulted and the Royal College of Surgeons have never been consulted. It would be most interesting to find out what the result would be if the Royal College of Physicians and the Royal College of Surgeons were consulted.
It is no part of my task to denigrate in any way the eminent members who work on this committee. As it has to advise the Minister on all the Services under the Health Act, from the top of one's head to the corn on one's foot, it is inevitable that it must be a very wide committee. It consists, for instance, of three medical officers of health, two psychiatrists, a pædiatrician, a radiotherapist, an orthopædic surgeon and one ophthalmologist—people who, I should imagine, in my ignorance, have very little to do or any knowledge whatever about the use of heroin. But it also includes among its members—and let it be quite plain that I am not going to indulge in any denigration—eminent people whose opinion on this question is of the greatest value. Anybody who has had the good fortune to have Sir Henry Cohen as his physician, as I have, will realise that he is one of the most outstanding figures in the medical profession. Then there is Sir Russell Brain, who I think at present is the President of the Royal College of Physicians, or has recently been President, a man whom I know and for whom I have the highest possible regard. But I say that this committee was the wrong body to consult.
What the Government should have done, I should have thought in a case of this sort, where for the first time it was proposed to ban a drug, was to appoint some high committee, comprising special people who have real knowledge of the use of this drug. If I may say so with the greatest respect, I think the committee failed in that they never revealed to the Minister chat there was a difference 14 of opinion in the medical profession. The Home Secretary has said, and said with some air of natural grievance, that it was not until April that letters appeared in the Press disapproving of the decision he had taken. I believe that the Minister of Health consulted the wrong committee, and I believe that he propounded to them the wrong question, though I am not quite certain what the question was.
The question which ought to have been propounded to a medical committee was simply this: Is there or is there not, in all cases, an adequate substitute for the use of heroin? That is a purely medical question on which other noble Lords and I, in the nature of things, can have no possible opinion. Instead of that, I infer (though I invite correction because it has never been expressly stated) that the question which was propounded was this: Do you agree with the Government's resolution to ban heroin? That is a mixed question. It is partly a medical question and partly a question calling for ministerial judgment, and involving an answer to the question whether our banning of the manufacture of heroin will have the slightest effect on the terrible problem of heroin addiction overseas.
I attach the greatest importance to the opinion of the British Medical Association: they represent, I suppose, 95 per cent. of the doctors in this country. After all, as I understand it (and I have given a great deal of thought and attention to this matter), if people are suffering from cancer, a terminal disease, in the terminal stages they are not in hospital, but are, sent home to die and are under the care of their local practitioner. Therefore, the opinion of these people is of the greatest value. Yet they were never consulted before this ban was imposed. Three members of the B.M.A. have, however, expressed in the Press—and the source of my information is mainly the Press—what operated on their minds when they went to that meeting and how they reacted. One of them is Dr. Wand, a general practitioner in Birmingham, who stated in The Times of May 27 that,He had gone to the meeting at which the matter was discussed with a firm opinion that a general practitioner should not have a drug taken from him which he wanted quite properly to use; but he had been convinced that the problem of addiction to heroin was serious and only to be solved by international action.15 Certainly, but by what international action? On that particular problem Doctor Wand is no better qualified than I am to express an opinion.
Doctor Gregg, who I think was a Chairman of the B.M.A., said this in The Times of June 4:I have to admit that in the discussion the dreadful picture of heroin addiction made such an impression on us that we did feel that the small sacrifice which might be involved in our forgoing having it at our disposal, was a very small sacrifice compared with the advantage that would come from heroin not being available.May I point out to Dr. Gregg that the small "sacrifice" is not a sacrifice which he is called upon to make, and that saying that heroin will not be available is completely to beg the question, because, in my opinion, the fact that you ban the licit manufacture of heroin increases enormously the danger that you may have what we have not had in this country, the illicit manufacture of heroin. Then Dr. Walker of Cambridge, in a letter to The Times of November 28, finished in this way:Should we join with other countries in banning the manufacture of heroin, or pursue our proud and selfish way alone?The alleviation of the pain of those dying of cancer who can get no other relief from other drugs can surely hardly be described as being "selfish."
On February 18, the Minister announced the Government decision to give effect to the ban. I quote the words of the Home Secretary:Accordingly the current licences"—they are yearly licences—for the manufacture of heroin under the Dangerous Drugs Act of 1951 which expire on the 31st December, 1955, will not be renewed.After that date licences will be granted only for the manufacture of such small quantities as may be required for purely scientific purposes. I come now to consider the Dangerous Drugs Act, 1951, and to a legal point. I may say at once that I feel rather like a shipwrecked mariner who at last reaches an island because, after being on this sea of medicine, about which I understand very little, I am now on the firm ground of law about which I understand something. I put this cautiously, but I do not think the Lord Chancellor will disagree with me when I say that there is very serious 16 ground for doubting whether the Minister has any right to use his powers under the Dangerous Drugs Act to ban the manufacture of heroin. This is a new point. I have brought it to the attention of Her Majesty's Government as early as I could. It needs careful consideration. It may well be that the Government will admit that and say that they would like further time within which to consider it. If they say that, may I say at once that I should not think any the less of them. The point has now been brought to their attention. It is manifestly a point which merits most serious consideration.
Let me put this legal point to your Lordships as simply as I can. It is doubtful whether the Home Secretary has any right to use this Act as a vehicle for bringing about this ban. Section 8 of the Act is in the simplest possible terms:It shall not be lawful for a person to import or bring into, or to export from, the United Kingdom a drug to which this Part of the Act applies"—and this Part of the Act applies, inter alia, to heroin. There you have a plain statement as curt as the Commandments: you must not import or export it without licence. Contrast that with the next section, Section 9, which deals with manufacture. Section 9 is manifestly contemplating that there will be a manufacture and it is giving, and properly giving, the Home Secretary power to control that manufacture. These are the words:For the purpose of preventing the improper use of the drugs to which this Part of the Act applies"—that is, including heroin—a Secretary of State may by regulations provide for controlling the manufacture"—of heroin—and in particular, but without prejudice to the generality of the foregoing power"—which is a power to control manufacture, the regulations may prohibit the manufacture of a drugexcept on premises licensed …Then paragraph (b) says that he may require the persons to be licensed. Paragraph (c) says that he may regulate the issue by medical practitioners of prescriptions containing the drug. Paragraph (d) says that he may require the persons engaged in the manufacture to keep books and return information.
So your Lordships will see that the granting of licences is an incident to the 17 general power of controlling the manufacture, and the power to control the manufacture is for the purpose of preventing the improper use of heroin. Doctors may be prevented from prescribing heroin and chemists may be prevented from dispensing it, and by those preventions, of course, it would be possible to take heroin off the market. But that method was not employed. A simpler method was employed. The Home Secretary, who obviously could not have had this point in mind and who was, as I think, advised unwisely on these matters, simply said this: "No particular individual can manufacture heroin unless he is licensed to do so. Therefore, if I announce in advance that I shall license nobody, I can indirectly ban the manufacture of herein." That is, of course, incidental, since this Part of the Act applies to all these other drugs—morphine, opium, cocaine and so on. He could, in that same way, indirectly ban the manufacture of any of them. If that is said to be a method controlling the manufacture to prevent its improper use, all I can ask is whether, if I were in charge of a horse, a dog or a child, and was told to control it, and I shot it through the heart, though it would lie still and give us no further trouble I should really be controlling it.
My mind went back to a somewhat similar case. As many of your Lordships will remember, when the Labour Government were in power, the House of Commons, against the advice of the Government of the day, passed a Bill which contained a clause doing away with judicial hanging. The Home Secretary of the day, Mr. Chuter Ede, announced that, that having happened, he was going thereafter to advise the Royal Prerogative of clemency in all cases. The late Lord Simon said this about it. I was Lord Chancellor and was in great difficulty about this matter, but I did the best I could to support my colleague the Home Secretary. This argument of Lord Simon, however, I found quite unanswerable. Let me read it to your Lordships [OFFICIAL REPORT, Vol. 156, col. 112]:I want to ask the noble Lord opposite"—who unhappily was I—a very simple question. Does he agree with me that when a discretion is granted to a person to decide a particular case, by reference to particular facts, such a person has no constitutional right to announce—and to 18 announce in advance—that, whatever may be the circumstances, in principle people are all to be treated in the same way? I never heard of such a thing. Many of your Lordships are practising justices. Whoever heard of justices in licensing sessions, who have a discretion to consider the circumstances as to whether they will grant a new licence or not, announce from the Bench through their chairman: 'It may be a convenience to everybody to know that we are never going to grant a new licence, whatever the circumstances.' Anybody who did that would be dealt with by the Lord Chief Justice in the Divisional Court within a week, and he would soon know the result. Where one is given a responsibility which one has to exercise in view of the circumstances of the particular occasion, one has no right whatever publicly to announce that one does not intend ever to exercise that discretion except in one way. Suppose that the Home Secretary instead of taking this course, had said: 'I shall announce that henceforth nobody will ever be reprieved.' What would happen then? The whole thing seems to me to raise a very serious Constitutional question.'The Lord Chief Justice who was there followed Lord Simon and said, after referring to the Bill of Rights [Col. 117]:… if this is not altering the law by administrative action, I do not know what is.My Lords, in this case the Home Secretary was advised to make an announcement:Accordingly, the current licences for the manufacture of heroin … which expire on the 1st December, 1955, will not be renewed.I imagine that to be absolutely wrong, ultra vires, outside his powers, and I beg the Government to consider this position. If this is going to be done for the first time, to ban a drug which many members of the medical profession think to be of the first importance, it ought to be done by a Bill and not by the indirect method of trying to use the Dangerous Drugs Act. I have been immersed in this question for the last few days. All I can say is that directly I discovered this point I acquainted the Lord Chancellor with it. I asked that the Opinion of learned counsel should be obtained. The Opinion of learned counsel was obtained, and it corroborates the view which I have ventilated to your Lordships. Directly that opinion was obtained, I took it upon myself to show the opinion to the Lord Chancellor. There is, therefore, grave doubt whether what has been done, in perfect good faith and with the best will in the world, has been done legally. That is a matter which I most humbly say that Her Majesty's Government would be welt advised to consider.
19 It does not, of course, follow that if the Home Secretary has gone outside the law inadvisedly he can necessarily be restrained by the courts. If what he has done had been done by a court of inferior jurisdiction I have no doubt whatever in saying that the remedy of mandamus would lie, and that any such proceeding by an inferior court would be quashed; but it does not necessarily follow that the same thing can be done with the Home Secretary. But if it cannot be done there is all the more reason (I am sure the Home Secretary would be the first to say this) why he should be scrupulously careful in not taking any step which in fact is outside the law. If it cannot be done, it is a very good matter to refer to the Committee on Ministerial Powers which is now sitting. Though I have given the Lord Chancellor all the notice I possibly could from the moment the matter came to my attention, the Government have had very little time to consider this legal point, and it would be perfectly natural, and nothing would be put against them, if they said that they would like further time to consider it. If they are going to say they would like further time to consider it, then of course it must be plainly understood that it is on the basis that in the meantime the manufacture of heroin should be allowed to go on, without prejudice, of course, to the possibility of their stopping it in future. Incidentally, if it does go on, then I should most humbly suggest to the Government that they should take the opportunity of further consultations with the medical profession. It is unfortunate that there should be a wide divergence of view on the part of the medical profession, and that it should have to come to us laymen, who can know little about it, to attempt to decide the point.
My Lords, I now leave my little rock in the middle of the ocean and I plunge into the medical details. I need hardly tell your Lordships that I have no sort of knowledge about this matter. I do not pretend to any knowledge, but I have derived information from eminent people whose word carries great weight, and I will try to reproduce their opinions. The first time I noticed anything about this subject at all was in a letter to The Times of May 18. I noticed that there were three members of the University College Medical School who expressed 20 strong opinion against the ban. That aroused my interest slightly, but I was not unduly disturbed. About a week later, there appeared in The Times a letter from Lord Horder, Sir John Conybeare and Sir Geoffrey Marshall—three names that even the layman knows. They wrote:No one disputes the value of heroin and its superiority in many cases over other narcotics, such as morphia. Before the Government take so drastic a step as to forbid the manufacture of a valuable and widely used drug surely the opinion of the Royal College of Physicians and perhaps that of other professional bodies should be asked. Heroin addiction in Great Britain is practically unknown and it is difficult to see why administrative action, taken without the advice or concurrence of representatives of the profession, should be allowed to hinder the relief of suffering.Then, on July 11, six months after the ban had been announced, the Home Secretary received a deputation from the B.M.A.; but, like Pharaoh of old, he had hardened his heart and declined to give way. It would have been so much better if he had seen the B.M.A. before he had made his pronouncement, as it is much more difficult to alter one's decision having once made it.
I will consider the B.M.A. and the general practitioner in a moment, but in the limited time at my disposal I thought I should try to ascertain the views of the great teaching hospitals in London. There are, I think, twelve such teaching hospitals. This is the result. These figures are really so striking that I think it would be utterly wrong for us, mere laymen who can have no knowledge, to go in a converse way. Guy's Hospital has unanimously passed a resolution against this ban—with this qualification: that so far as the Post-Graduate Medical School is concerned, they say they are not insisting on the use of heroin but they are protesting against the ban on the doctor's right to prescribe. They are quite agreeable to their name being used, with that qualification. That applies to the Post-Graduate Medical School at Guy's. The London Hospital, without qualification—wherever I quote hospitals I mean that the medical schools are unanimous: if there is a difference of opinion of course they do not express an opinion. So Guy's agree, with that qualification; London, St. Bartholomew's, Charing Cross, King's College, Hammersmith, St. Thomas's, St. Mary's, University College, the Royal Marsden (which 21 was previously the Cancer Hospital) and the Brompton. This is a terrific body of medical opinion. Who are we to speak against such opinion?
So far as quantity is concerned it is interesting to find this fact. I asked what quantity they used, because, if I understand it aright, this is a drug which one should use only in extreme circumstances after other drugs have been tried. Guy's Hospital, who are prominent in this controversy, use only 6 oz. a year, representing 20,000 doses. All these experts, who are reluctant to use this drug if there is a chance of other drugs being effective, have taken this line. I am particularly concerned with the views of the Royal Marsden (previously the Royal Cancer) Hospital and the Brompton Hospital. The views of the staff of the Royal Marsden were expressed in a letter to The Times newspaper on November 30 as follows:Many patients find the side effects of morphia intolerable. These are not experienced with heroin. For this reason we do not often prescribe morphia or any of its substitutes for the relief of pain in this hospital.They point out, as indeed is obvious, that in the terminal stage of an illness there is no question of addiction. A letter to The Times of November 28, written on behalf of hospitals for diseases of the chest, states that those hospitals feel thatit is essential that heroin should continue to be made available for their patients, especially for cancer of the lung.I do not want to bandy about great names, but Sir Cecil Wakeley, Vice-President of the Imperial Cancer Research Fund and of the British Empire Cancer Campaign has expressed his view. He thought that to impose the ban was both foolish and immoral. The anæsthetist in charge of the department of anæsthetics at St. Bartholomew's has said, after thirty-seven years' experience, that at least one person in five in intolerant to morphine, and that if one such person suffers an agonising pain, such as that due to an abdominal operation, there is no drug except heroin which will give real relief. He says thatHeroin is rather like a fire engine: you do not often want it, but when you do, You want it very badly.Sir Francis Walshe, President of the Royal College of Medicine, and Sir Reginald Watson-Jones have added their protests. I forbear to mention the name of one 22 noble Lord who has also protested; he sits in this House and will, I hope, be able to take part in this debate. Those are great names, though I hope that I have in no way denied that there are great names on the other side. I am not suggesting that all the light and learning are on one side; I merely suggest that medical opinion is deeply divided over this question.
When this ban was announced, the British Medical Association held a meeting on June 3 and passed, with practically no dissentients, this resolution:That this meeting protests against the threatened withdrawal of the most excellent sedative, heroin, and recommends that it should still be manufactured for use by medical practitioners but not exported.There were 450 people at the meeting and that resolution was carried almost unanimously. That is a matter of importance, as indicating the point of view of the general practitioners. As was asked in one of these letters, if the drug produces a condition of euphoria (which I suppose derives from the Greek word, meaning "bearing well") what does that matter in the case of terminal diseases? One doctor wrote to The Times newspaper asking whether the question of relief of burns had been considered. In some frightful cases of burns, heroin, and only heroin, can give relief from pain. We always hope that there will be no use of atomic weapons in this country, but is it wise at the present time to ban the use of heroin? In such an event we should want every ounce of heroin that we could possibly obtain.
I have said nothing from the patient's point of view, but I should like to refer to one letter to The Times newspaper of November 25, from a Mrs. Jean Loudon, who wrote as follows:This year I had the privilege of nursing my mother until she died, in full knowledge, of cancer. Although morphine and a heroin substitute were tried, only heroin effectively relieved her pain. If we deny heroin to those few who need it we shall make death and pain sadder arid more terrible than they already are.One gentleman, I believe a doctor, in a letter to the same newspaper told of someone suffering from a permanent colostomy, which entails violent attacks of colic. He said that the only drug which gives relief is heroin. All the other se-called substitutes have been tried, and none has been found to approach the 23 efficacy of heroin. He says of that particular patient:This poor soul is already morbidly apprehensive of the day when our stock of heroin having been used up, another attack is experienced.It has always been a mystery to me why the Church, of which I am a humble and unworthy member, always prays, in the Litany, against relief from sudden death. I believe that in many of these cases sudden death is a great mercy.
I hope I have established that in the opinion of a large and most influential body of doctors heroin cannot in all cases be dispensed with. I am advised that as a drug for relieving pain in terminal diseases, such as inoperable Lancer, particularly cancer of the lung, it is without any equal. Morphine is often, but not always, satisfactory—and in "morphine" I include all the other variants which the noble Lord, Lord Mancroft, mentioned in his Answer the other day. In some cases the use of morphine results in nausea and vomiting, which may be disastrous after an abdominal operation. Morphia, too, causes a rise in the pressure of bile in the main bile duct. After an operation for removal of the gall bladder this is obviously dangerous because it encourages leakage of the bile through the area of the bile duct, which has been stitched up. Heroin has not this action; pethidine has. Methadone has been proved, in clinical practice, to be a poor drug for relieving severe pain from any cause. The other purpose in using heroin, apart from that of relieving pain, is the suppression of cough. The cough of tracheitis, which often accompanies influenza, can be very distressing and often will not respond to codeine or other remedies. I have that from the very highest quarter.
The Minister of Health, in another place, was asked a straight question which ought to have been asked of the doctors but was not: whether, in relation to the stopping or alleviating of pain, there is any suitable substitute for heroin. The Answer was [OFFICIAL REPORT, Commons, Vol. 547, No. 68, col. 28]:All one can say on this matter, which is to some extent in dispute, is that we have taken the best medical advice we could find, and that this is the general opinion.24 In view of the facts I have given to your Lordships about the British Medical Association and the London hospitals I cannot imagine how the Minister came to say that "this is the general opinion." No person can deny that there is a risk of depriving those who are suffering pain and are intolerant of morphine from the relief which heroin could afford.
Lest I am too insular, bearing in mind that Professor Löffier of Switzerland was quoted the other day, may I quote somebody who is considered by doctors to be the greatest authority in Europe on this matter, Dr. Georges Brouet, Professor in the Faculty of Medicine in Paris and practitioner in hospitals there? His paper, which prayed for more careful and exceptional use of heroin, was published in the Bulletin on Narcotics, in which many of the reported lectures and speeches were in favour of the banning of these drugs. I think it is well worth while to read this to your Lordships because it is very authoritative. Doctor Brouet said:Only chronic complaints which have reached the terminal stage call for the use of heroin"—And he mentioned painful types of cancer—in which there is an invasion of the nervous system or metastasis of the bone which have failed to respond to any other form of therapeutic treatment.He went on:Heroin, especially by injection, may be useful as a last resort after the action of other analgesics has been exhausted. Its potent analgesic and tonic action can greatly alleviate the sufferings of the final weeks of a patient afflicted with cancer. Among the long diseases the last stages of pulmonary tuberculosis may require the use of heroin. When anti-tuberculosis treatment has met with failure after failure … and when the all too familiar picture of the consumptive who has reached the incurable stage of the disease becomes a reality, the physician should concentrate exclusively on relieving the patient.The relief of pain, Doctor Brouet stated,is an act of charity which the sufferer cannot be denied. During this final stage, heroin, by calming the distressing sensation of asphyxia, soothing the cough and leaving room for hope, can still be used as a valuable medicament which may succeed when all others have ceased to be effective.My Lords, that is a volume of testimony which any impartial person must admit is indeed formidable. What do we gain—or what does anyone gain—if we deliberately run this risk of depriving our doctors of the opportunity of using 25 this blessing? It may be right that those dying of cancer, or, if you will, that ten per cent. or twenty per cent. of those dying of cancer, should suffer agony which cannot be relieved after other drugs have been tried. But if you are going to incur that frightful, terrible responsibility you must show who is going to gain. You must establish something more substantial than a mere gesture of international solidarity.
Consider the facts. Consider the ease with which heroin can be prepared from morphine—and it is not proposed to ban morphine. Heroin can be prepared from morphine by the simple use of acetic anhydride. I am told, which is a common chemical not banned. Heroin can be made from morphine in a few hours over a kitchen stove by anyone with an elementary knowledge of chemistry. Are you quite sure you are doing the right thing? If you ban the licit supply of heroin, may you not bring about the illicit supply of heroin? In this country heroin addiction is almost negligible. We have some fifty-four heroin sufferers altogether. In the United States, the lowest figure of heroin addicts I have heard mentioned is 50,000, but I have also heard it put as high as 120,030. Incidentally, peihicline addiction in the United States is terrible. In a document which I have it is stated that in one hospital at Lexington, Kentucky, 457 pethidine addicts were treated in the three years from July, 1950. So do not think that by doing away with heroin and having pethidine in its stead you have solved your problem. No one has subgested that we should ban pethidine.
In 1953, which is the last year for which I have the figures, we manufactured 109 kilogrammes of heroin—about 220 lb. That is about 70 per cent. of the world's total. We consumed about 83 kilogrammes and we exported the balance of about 27 kilogrammes, and 23 kilogrammes of that went to Canada. That means that nearly all the balance went to Canada. There are said to be 5,000 narcotic addicts in Canada. Of course, all exports entail a danger of theft. But the Canadian Government in their Report to the Economic and Social Council in 1953 said this—this is the opinion of the Canadian Government:The abundant supply of illicit herein is in no way connected with the supplies legally imported. There has been a steady decrease 26 in the number of thefts from legitimate sources within recent years.The decrease in thefts of legal heroin was said to be due to the availability of illicit heroin, and to improved methods of control over legal supplies.
We want from the Government—if they are going on with this ban—some explanation as to how it is that banning the production of heroin in this country will assist the problem in the United States. I ant sorry to be so long but I would just like to give the House these figures. In the six years from 1946 to 1951 the total amount of illicit heroin seized in this country was 11 grammes—that is, in six years, 11 grammes only. Then in just one year, 1951, in the rest of Europe the total seizure amounted to 62,711 grammes. In North America in the same year total seizures amounted to 28,870 grammes. These figures are from the Bulletin on Narcotics, 1953. The Bulletin in a later issue stated thatTraffickers do not hesitate to set afoot clandestine production.My Lords, I am coming to the end of my remarks, but before doing so I should like to quote the view expressed by Doctor Berger, who is Consultant on Internal Medicine to the United States Public Health Service and President of the New York Medical Society. Two months ago, he said:It seems a shame that you in Britain who are held up as an example to the world on how to handle this problem are now about to go wrong and do what we did.Surely they have gone wrong. The manufacture of heroin was banned in the United States in the year 1924—that is, thirty-one years ago. And after thirty-one years the figures of addiction are alarming, and there is reason to fear that they are still increasing. Here we have not banned, but we control, and our addiction figures are negligible. Dame Rachel Crowdy-Thornhill, in a letter to The Times on December 5, 1955—she was for ten years head of the Department of the League of Nations which dealt with drug traffic—wrote:It was international control and not prohibition which lessened the illicit traffic in habit-forming drugs.What then should Her Majesty's Government do? I beg of them to postpone this ban for the time being. If they have prohibition of exports, they should certainly postpone the ban on manufacture, 27 and defer this matter. I think they have to do that, to consider the legal proposition, otherwise the whole thing is going to end up in a lot of litigation in the courts. Will you postpone it and consider constituting a special ad hoc committee of the most eminent doctors, who do know and who are concerned with this particular thing, to see whether you cannot resolve this conflict? Finally, I might add this. Doctor Trevan, a pharmacologist of the greatest repute in this country, and a Fellow of the Royal Society, has written to the British Medical Journal asking for a controlled clinical trial. He said it would be a difficult and protracted work,but the issue at stake, the relief of the agony of the dying, is so important that an attempt at a controlled trial should be made.I am sorry to have kept your Lordships so long, but as I feel this to be a matter of great importance, involving, as it does, the relief of the agony of the dying, I have felt it right to trouble your Lordships. Unless the Government can meet us by taking steps to announce that they will allow the manufacture of heroin to go on for the time being, I must ask your Lordships to divide on this Motion. I beg to move.
§ Moved, to resolve, That in the opinion of this House, in view of the apparent conflict of expert medical opinion on the banning of the manufacture of heroin in this country, the period of the present licences to manufacture should be extended pending the institution of further inquiries on this subject.—(Earl Jowitt.)
§ 3.50 p.m.
§ THE JOINT PARLIAMENTARY UNDER-SECRETARY OF STATE FOR THE HOME DEPARTMENT (LORD MANCROFT)
My Lords, I think it may be for the advantage of the House if I intervene at this point and try and put before your Lordships some of the considerations upon which the Government's decision to restrict the manufacture of heroin has been based. First, however, I should like to thank the noble and learned Earl, Lord Jowitt, for the calm, fair and dispassionate way in which he has put this matter before your Lordships. There is no need whatever for him to apologise for being a little longer than usual, because this is a difficult and complicated matter. I shall come at once to 28 the legal point which he has made. He described it as an island upon which he alighted with pleasure. The noble and learned Earl was good enough to give me as much notice of it as he possibly could, thereby spoiling my week-end. I can assure him that I found it a very uncomfortable island. We shall have to look at this point carefully. It is a difficult one, and I must say at once, in all frankness to the noble and learned Earl and to the House, that I think his point has more than considerable merit. My noble friend Lord Woolton will have more to say about that when he comes to wind up this debate.
As the noble and learned Earl has already told the House, addiction to heroin is not a serious problem in this country. There are only fifty-two addicts in England and Wales and two in Scotland, and so far as I am advised, there is, happily, no reason to think that addiction is becoming more serious. The system by which we control the manufacture, supply and possession, as well as the import and export, of drugs is one of the most successful in the world. There is not much illicit traffic in heroin in this country and there is no evidence that any substantial quantities of our supplies have found their way into the black market abroad. On the other hand, I readily agree that there are doctors—eminent doctors—who are sincerely convinced that heroin is essential to relieve the suffering of some of their patients, and they resent the fact that they may be deprived of it. However, I was glad to hear the noble and learned Earl admit that on the other side there are equally eminent and equally sincere doctors who disagree with that point of view. Why, then, your Lordships may ask—indeed, I have just been asked forcibly by the noble and learned Earl—have the Government decided to ban heroin? I must apologise if I traverse a little of the way that the noble and learned Earl has trod, but I want to give your Lordships as coherent and consecutive a picture and as clear evidence as I possibly can.
The Government's decision to restrict the import, export and manufacture of heroin was taken as a result of a resolution passed by the United Nations Economic and Social Council in July, 1954, a resolution to which the noble and learned Earl referred. I should like to quote a little more fully the text of this 29 resolution because I think it sets the initiation of the problem, so far as we are concerned as a Government, in the proper perspective. The resolution runs:The Economic and Social Council,Considering that in 1931 the Conference for the Limitation of the Manufacture of Narcotic Drugs recommended that Governments examine the possibility of abolishing or restricting the use of heroin and that the Committee of Experts of that Conference believed that heroin could be dispensed with entirely;Considering that the Sixth World Health Assembly expressed its conviction that heroin was not irreplaceable for medical practice, and passed a resolution recommending that member States not already having done so abolish the importation and manufacture of the drug;Noting that only seven out of 82-odd members of the World Health Organisation are not at the present time (that is, 1953) in favour of doing without heroin,This resolution states briefly the reasons which persuaded the United Nations and the expert bodies who advise them, after studying this question for very many years, to recommend that heroin should be banned. I should like to look at these reasons a little more fully and tell your Lordships how and why I think they particularly affect this country.
- 1. Urges all Governments to prohibit the manufacture, import and export of heroin, except for such small amounts as may be necessary for scientific put-poses only;
- 2. Requests the Secretary-General to communicate this resolution to all Governments for such action as they may be in a position to take."
Heroin is one of the most addicting drugs known and produces appalling changes in the individual, which progress faster than with any other drug. All the faculties of the mind are weakened, so that the addict rapidly becomes a mental and moral degenerate, and eventually, an animal. Whilst there is no serious addiction problem in this country, there is such a problem in ether countries. In Canada there are some 3,000 addicts, of whom over 2,000 are criminals. In Japan, I believe there are about 7,000 addicts. The figures for the United States are a little in doubt, but from 50,000 to 60,000 addicts is probably the, right figure.
It has been suggested that the banning of heroin in other countries has led to an increase in addiction there and may have the same result here. I have not been able to find much evidence to support this. The noble and learned Earl referred to America. Heroin was banned in 30 America in 1924, and after that date the number of addicts fell steadily until just after the war, when it started to go up again as a result of the large amount of heroin smuggled from Europe and the Near East; so that evidence at least is open to some doubt. The majority of these addicts use heroin which they get through the black market. This traffic is international and, as an example of its extent, your Lordships may remember that a few months ago three large seizures of heroin, amounting to over 80lb. of the drug—enough for nearly 2¼ million doses—were made in American and Canadian ports.
It is the considered view of all those countries which are struggling with this problem that the difficulty of controlling the illicit traffic is increased by the existence of lawful manufacture and trade, such as ours. More than fifty countries have already banned the use of heroin. In all these countries the doctors have found that there are satisfactory and effective substitutes for use in medical practice. Your Lordships will remember that I gave particulars of those substitutes to the House last Thursday. From none of these countries has there been, so far as I know, any suggestion or request from the doctors that they do need heroin after all—doctors who may originally have felt exactly the same doubts as some of our doctors feel to-day.
There are, then, five main reasons for advocating this restriction on heroin. First, heroin is one of the most dangerous drugs known and gives rise to an addiction problem of world-wide gravity. Secondly, heroin is easy to handle and easier to smuggle than opium, the place of which it is taking. It can be administered without any apparatus such as a hypodermic syringe. Incidentally, I do not think that it can be manufactured in the back kitchen quite so easily as the noble and learned Earl seems to think. Thirdly, the existence of a serious black market in heroin requires the taking of exceptional measures for its suppression. Fourthly, if the manufacture of heroin were made illegal, the task of suppressing the illicit traffic in the drug would be made much easier; and, lastly, less dangerous substitutes are now available.
§ EARL JOWITT
My Lords, why would the prevention of manufacture in this 31 country make it easier for the American authorities to deal with the illicit traffic in heroin?
§ LORD MANCROFT
The complete banning of the manufacture of heroin throughout the world is our ultimate object. Those countries wrestling with the problem believe that that would be facilitated by our acceding to the ban. As I have already told your Lordships, the expert and carefully considered medical advice given to the Government is that these substitutes are reliable, effective and equally beneficial. Without that assurance, of course, the Government would never have taken this decision. Most of the member countries of the United Nations have now agreed to ban heroin, and I think that only four countries still oppose the ban.
In recent years, the United Kingdom has been by far the largest manufacturer of heroin, manufacturing in 1953 (the last year for which figures of world production are available) 69 per cent. of the total world production. Since the beginning of the century this country has played an honourable and leading part in securing the adoption of international measures for the control of the illicit drug traffic. If we, the largest manufacturers and exporters of heroin, were not to agree to the United Nations request to ban it we should lay ourselves open to the charge that we were disregarding the fine example which we ourselves have set in the past and were obstructing international measures to stamp out the traffic in this most dangerous drug.
It has been suggested that the Government accepted the United Nations' resolution without giving the matter proper consideration and without proper consultation with the medical profession. This is the opposite of the truth. Let me remind your Lordships of the events leading up to the Government's decision—and the noble and learned Earl has touched on two or three of them. In March, 1950, the United Nations had stated that although twenty-four countries did not use heroin at all the figures of consumption had greatly increased in some other countries. The World Health Organisation then sent a circular letter to member States asking for the views of their Governments and the medical profession 32concerning the necessity for the use or the dispensability of heroin and the reasons therefor.A few months later, the then Minister of Health (Mr. Aneurin Bevan) asked his Standing Medical Advisory Committee to advise him whether, if an international agreement prohibiting the use of heroin were proposed, there was sufficient medical reason why the Government should not support the proposal.
Let me here say a word about this Standing Medical Advisory Committee. It has twenty-seven members who are appointed by the Minister after consultation with representative organisations. The members, as the noble and learned Earl said, quite correctly, serve in an individual capacity, and include the Presidents of the three Royal Colleges, the Chairman of the Council of the British Medical Association, the President of the General Medical Council, and the Chairman of the Council of the Society of Medical Officers of Health. At the relevant time there were, in all, three members of the Council of the B.M.A. sitting on the Advisory Committee and five general practitioners, whilst the majority of members were in active practice. I have taken the liberty of having the entire composition of the committee typed out, and I have put it in the Library in case your Lordships are interested to see exactly who was on the committee at that time. If you read it carefully your Lordships will observe that this committee includes the most eminent medical opinion in the country. My right honourable friend the Minister of Health is satisfied that this was without doubt the most suitable body to consult. Beyond holding a referendum of all the doctors in the country, not all of whom belong to the B.M.A., I suggest that my right honourable friend could hardly have taken more comprehensive advice.
The Standing Medical Advisory Committee then decided to consult the British Pharmacopœia Commission, who in their turn consulted a large number of bodies, including the Medical Research Council and, be it noted, the Science Committee of the B.M.A. So much for the suggestion that the B.M.A. were not "consulted in any way." The British Pharmacopœia Commission expressed the view that although heroin was still claimed by some practitioners to be of great value as a 33 sedative after operations and in inoperable malignant diseases, and to a lesser degree in severe coughing, the advantages so claimed did not outweigh the grave consequences of widespread addiction in certain countries. They said they were prepared to delete the monograph on heroin from the British Pharmacopœia if international agreement on prohibition were reached. The Standing Medical Advisory Committee agreed with the views of the British Pharmacopœia Commission and advised Mr. Bevan that it would be justifiable to prohibit the use of heroin in Britain if international agreement were reached to prohibit its manufacture and sale. The Scottish experts advised likewise.
In January, 1952, the World Heath Organisation reiterated its concern aboutThe continuing gravity of the heroin situation.Seeing that fifty countries had discontinued, or expressed a willingness to discontinue, the medical use of heroin, and feeling that the complete abolition of legally manufactured heroin would greatly facilitate the struggle against the illicit traffic in this drug, the World Health Organisation asked that a further approach should be made to countries which had not replied to earlier inquiries or which were not yet satisfied that it was possible to discontinue the medical use of heroin. In 1953 the World Health Organisation recommended that the few member States which had not already done so should prohibit the import and manufacture of the drug. In the 1953 edition of the British Pharmacopœia the monograph on heroin was omitted. In July, 1953, there appeared in the British Medical Journal (the journal of the B.M.A.) an article which clearly suggested that heroin was no longer indispensable. This article elicited one solitary letter of protest, from Dr. Douthwaite, who I readily admit has consistently opposed the restriction.
In July, 1954, the United Nations Economic and Social Council adopted the resolution which I quoted earlier urging all Governments to prohibit the manufacture, import and export of heroin except for such small amounts as might be necessary for scientific purposes. Then in December, 1954, the Minister of Health again consulted the Standing Medical Advisory Committee and asked for their views on the United Nations resolution. 34 The Standing Medical Advisory Committee considered the United Nations resolution and agreed with the Government's proposal to accept it. In view of the expert advice they had received I confirmed to your Lordships in April last the Government's decision that at the end of this year no further licences for the manufacture or export of heroin would be granted except for small quantities needed for scientific purposes, and that the present policy of not permitting imports would be continued. In all fairness, I do not see how Her Majesty's Government could possibly have taken any other decision.
In April this year, nearly five years after the matter had first been put before the medical profession, a number of letters began to appear in the medical and lay Press from doctors disapproving of the restriction. About the same time the noble Viscount, Lord Elibank, launched his campaign in your Lordships' House. On May 3 the B.M.A. revealed to the Ministry of Health for the first time that in the preceding November its Council had adopted, on the recommendation of the Science Committee (who appear by then to have changed their mind), the following resolution:That the World Medical Association be informed that it is the duty of the Government to legislate against misuse of heroin but the medical profession should not in any way be deprived of the me of this or any other drug which may assist in the treatment of patients.Whether that decision of the B.M.A.'s Council reflects the views of its 47,000 members in the United Kingdom more accurately than does the contrary opinion of its members on the Standing Medical Advisory Committee it is not for me to say.
Whilst it is true that members of the advisory bodies are appointed as individuals, and not as representatives of organisations to which they may belong or in which they hold office, there were in 1954, three members of the Council of the B.M.A. serving on the Standing Medical Advisory Committee. It is, to say the least, surprising that, when the Minister of Health asked for the Advisory Committee's advice in December, 1954. none of the members of the B.M.A. serving on the Advisory Committee objected to the proposal to ban heroin, despite the resolution against the ban passed by their own Association in the 35 previous month and the existence of which they never even revealed.
At the request of the B.M.A., the Home Secretary, the Minister of Health, the Joint Parliamentary Under-Secretary of State for Scotland and I received a deputation on July 11 and discussed the proposed ban very fully. The Home Secretary and his colleagues then gave the most frank consideration to the representations which the deputation had made. Therefore I can assure the noble and learned Earl that there was no question of "Pharaoh hardening his heart." My right honourable friends, thinking the matter over carefully, adhered to the advice which they had originally tendered to the Home Secretary, who informed the B.M.A. on October 17 that the decision must stand. On November 10, the Chairman of the Council of the B.M.A. wrote again to my right honourable friend the Home Secretary protesting against the ban and stating that the Council was convinced that he had been wrongly advised and that his decision was an unfortunate and regrettable one. In view of this and other protests against the ban, the Government gave further anxious and sympathetic considerations to this very complex problem, not forgetting the attitude and experience of other countries. The Government came to the conclusion, as I informed your Lordships a fortnight ago, that the proposed ban must stand.
I should like to make it clear that the ban on manufacture of heroin will not mean that supplies will cease as soon as the ban becomes effective. I believe that stocks of heroin are sufficient to last for two or three years at the present rate of consumption. Doctors and others who have authority to obtain dangerous drugs should therefore have no difficulty in obtaining supplies of heroin for some time to come. This interim period will give an opportunity for doctors to gain experience in the use of the alternative drugs with which they can in future treat their patients, and with the full effects of which they may not yet be wholly familiar. The Government naturally intend to keep the working of the restriction under constant and searching review, but they cannot go back on a decision which has only been confirmed after the most conscientious investigation—conscious of our duty to other civilized 36 countries and even more conscious of our duty towards a sick man in pain. I earnestly hope that your Lordships will see fit to endorse that decision.
§ 4.12 p.m.
§ LORD MORAN
My Lords, I feel that, before I turn to the medical aspects, which I am more competent to discuss than the legal ones, something ought to be said about the points raised by the noble and learned Earl. He said, for example, that the Central Health Services Council was the wrong body to consult because its composition, in his belief, was not suitable. Nevertheless, later he quoted the teaching hospitals as ammunition in favour of those who opposed this ban. But, surely, the medical committees of the teaching hospitals suffer from precisely the disadvantages that the Central Health Services Council does, in that every single medical committee has on it many members who have not personal experience of the use of heroin against pain—people like radiologists and the like. Therefore, if the Central Health Services Council is unsuitable because there are members on it who are not really accustomed to the treatment of pain, the same objection applies also to the teaching hospitals who have been quoted the other way. I should have thought that no body more suitable than the Central Health Services Council could be chosen. The members have behind them great corporations whom they can consult, not necessarily in an open debate, and they have many means of knowing what is the opinion of their colleges and the British Medical Association. It would be very difficult to think of any body that would be more suitable to give the Minister advice. Here let me say that I think the criticisms of the Minister have not been fair. He consulted the only body which is set up by Statute to advise him, and I do not think he could have done anything else. I consider he was wise to take the course that he did.
Another point brought forward by the noble and learned Earl was that members of the British Medical Association serve on the Central Health Services Council as what might be called private members. I think your Lordships ought to understand what the position is, whatever may be put down on paper. When I was a member of the Central Health Services Council it was because I was 37 President of the Royal College of Physicians. The moment I ceased to be President, at that moment I ceased to be a member of the Central Health Services Council; I was there ex officio. The same applies to the chairman of the British Medical Association Council; he is also ex officio. If there is any misunderstanding about the capacity in which members of my profession are on this Committee, I think it should be cleared up. I always understood, whatever was put on paper, that I was there as the representative of my College and I should have been reluctant to bring before that Council views which I thought were not in harmony with those who had elected me; and I am sure the Chairman of the Association felt the same. Why do I think that? Because when he found at a representative meeting that there was a majority against the ban, he promptly reconsidered his view. In fact, to put it briefly, he changed his mind. It seems to me that this is not merely a question of procedure. If the Minister consults his professional advisers, if he takes advice and then later some of them recant and take the opposite view, and whereas they who earlier supported the ban now lead a crusade against it, surely, here must be an end of all confidence between the Minister and his professional advisers. It is upon that smooth working between the two that so much of the efficiency of the Service depends.
But I am sure your Lordships are not primarily interested to-day in questions of procedure. As the noble and learned Earl has said, you want to know whether there is, or is not, an adequate substitute for heroin if it is banned. Let me say at once that it is obvious, from the division of medical opinion, how extraordinarily difficult it is to answer that question, and, bewildered as you must be by the division of medical opinion, you may clutch at what I might call a controlled inquiry which would settle the question once and for all. Your Lordships are familiar with the difficulties. Not only would you need to have an immense number of patients to make your answer statistically valid, but in every single case the doctor, as well as his patient, would have to be completely ignorant of which of the two tablets or the two rival drugs was being given. The difficulties seem great, but, realising the importance, 38 I went to the quarters which I think the Government might possibly consult, and asked their views. I would commit them to nothing because, lifter all, they had riot much time to consider the question. I was advised that one could compare morphine and heroin, but with great difficulty. Those who give morphia or morphine instead of heroin, now combine it with another drug so as to obtain a euphoric effect. The problem is, can you compare a combination of drugs with a drug like heroin? I am told that the difficulties in the way are almost insuperable. These difficulties are such that it would be almost impossible to devise, a trial which would lead to a satisfactory result, and I think anybody, without being a prophet, could say now that that result, whatever it was, would not be generally accepted.
As your Lordships know, pain is subjective; its measurement is extremely difficult. One man suffers from agony and the same pain in another is discomfort. I think this measurement of pain will always defy an inquiry of this kind. If that is true——and, of course, it is a matter of opinion; it cannot be asserted as a fact—then, naturally, one turns to individual judgments and asks whether they are likely to be more helpful. At once that raises the question: What is the scientific value of all these letters which have appeared in The Times? What are they doing? They are pronouncing what we already know—that heroin can be an extremely effective drug. So far as my inquiries have gone—and they have not gone very far—those who have written these letters have not had the opportunity to compare, or have not compared, the drugs in, the way that I have just mentioned—that is to say, compared heroin with a combination of drugs. If that is true, their observations are uncontrolled observations in the sense of an uncontrolled experiment. That is really very important, because it would mean that these letters from some of the most eminent men in my profession were satisfactory as giving an opinion upon the efficiency of heroin but were entirely unsatisfactory because they did not compare it with other combinations of drugs which since the war have multiplied and are much more efficient than ever before.
39 That is not the only difficulty when we are dealing with individual opinions. In the first place, I do not think any of your Lordships can have read some of the letters without feeling, quite naturally, that some of them were rather more emotional than scientific. That is inevitable. The man who is deprived of a drug which he believes is effective and which he wishes to use for his patients is naturally aggrieved. Further than that, he is even more aggrieved because he attributes this deprivation to the Minister of Health who, he thinks, should not interfere between him and his patient. Take that attitude of mind and add to it what I think your Lordships cannot possibly remove or ignore from these opinions—the question of the influence of habit. A consultant of my acquaintance, who was educated at a great London medical school, found, when he qualified and became a resident and a registrar, that the hospital's pharmacopœia contained a standard analgesic and a standard linctus, both containing heroin. He got into the way of prescribing these. Three to four years later, when he was elected to the staff of another teaching hospital, he found that their pharmacopœia did not contain any heroin prescription, and gradually he got out of the way of using it. He tells me that he has not used it for years. Your Lordships must not build too much on a single instance like that, but I think that habit plays a great part. Obviously, if we find a drug which does all we want we are inclined to go on using it, to the exclusion of all others.
I admit the weakness of these arguments; it is difficult to keep to the issue, because there are so many shades of the whole subject. But supposing I am right in thinking that a controlled inquiry will be very difficult, and that these expressions of opinion are not really a comparison of two drugs but a statement about one, does that mean that we are at the end of our tether? Is there nothing else that we can do? I do not think that is the position. There is a great deal of circumstantial evidence. There are fifty-four countries in which heroin is banned and where the doctors seem to get on quite well without using it. I suggest that to a certain extent it appears that the substitutes have been found satisfactory. One of those countries is the 40 United States of America. It is important that we should know as far as we can what is their experience.
An American physician, who was President of their College of Physicians and, later, President of the American Medical Association (which is their equivalent of the British Medical Association), and who is a highly respected figure of great experience in America, has sent me the following cable on this subject:American experience is nobody objects to ban on heroin except the addicts. Medical substitutes entirely satisfactory.That statement carries a certain amount of weight. It is from a man of judicial temperament who before he sent that message would consult other people; he would not do it on his own. He has been in a position there, as head of the American College of Physicians and later as President of their Medical Association, to gather opinions. He is at the end of his life. Therefore, I think that his opinion stands for something.
But, quite apart from this question of what different countries do, there are many hospitals where heroin is used sparingly. The noble and learned Earl, Lord Jowitt, has cited the case of teaching hospitals. I need not remind him, because he would know it much better than I do, that it is possible to address a question to a teaching hospital which really admits of only one answer. But if you were to ask any doctor, or, for instance, were to ask me whether I wanted any drug cut off, I should of course say "No." If, however, somebody took the trouble to inform me of the advantages of cutting it off and what might happen abroad, I might alter my opinion. Like the noble and learned Earl, I thought it important to find out the position of teaching hospitals, because they are the centres of inquiry and of enlightenment in our profession. Accordingly, I communicated with them all, though I received only ten answers. The average consumption of heroin in the year 1953 at those ten hospitals was 432 grains. It is a disputable point how much an addict takes. In general, it is said, the amount is from 15 to 20 grains; but if we assume that it is ten grains, that means that a teaching hospital with 500 to 600 patients uses in a year as much heroin as would keep an addict going from six to eight weeks. 41 Moreover, these quantities, small as they are, seem to be accounted for largely by one or two cases. One hospital, for instance, used 258 grains in one year. The next year the amount rose to 711 grains. Why? Entirely because of one case.
From all this, one fact stands out perfectly clearly; that is that the teaching hospitals use heroin extremely sparingly. Guy's Hospital has already been mentioned to-day, otherwise I should not have mentioned their figure, which arrived last night, and which shows that 2,800 grains were used, as has been stated. That is three times the amount that any other hospital has, but I think it only fair that it should be mentioned so that my "ten hospitals" figure may be corrected, for I have not included the figure from Guy's. Another hospital, a hospital for incurables (though it is not now called that) which deals with nothing but incurable diseases, and therefore largely with cancer, in the year 1953 used 14 grains.
In a debate at the Royal Society of Medicine on the treatment of inoperable cancer, heroin was not mentioned. There are important textbooks, some in the eleventh edition, in common use by students in which heroin is not mentioned at all. I cannot put aside and ignore this body of evidence of those who do not use heroin. I should entirely disagree with any suggestion that all these people, in all these countries and in all these important hospitals, are oblivious to the sufferings of their patients. I do not believe that they would do without heroin unless they were satisfied that it could be replaced adequately by some other substance. This circumstantial evidence—perhaps it might more correctly be called observational evidence—is significant. It is no more. In all that I am saying, I do not wish to speak with mere conviction than the facts allow. All these things are matters of opinion. We are on very difficult ground.
Then we come to another matter where really my opinion is of no value. Would this ban be effective or would it be useless? It is said, on the one hand, that heroin can be easily made from morphine—though I agree with the noble Lord who so ably put this case for the Government that it is not so easy as it sounds. First of all, it is necessary to get morphine. Again, I understand that 42 hardly any of the heroin in this country gets into the illicit market from which addicts get their supply. Moreover, in the United States, though the ban has been there since 1924, the number of addicts has gone up. On the other hand, on the other side, we have the World Health Organisation, with its enormous experience and its great body of experts, deliberately saying, "We shall get nowhere without a world ban." I must leave that aspect to others. The noble Viscount, Lord Waverley, who follows, will be able to deal with that much better than I can, and probably he will not draw the same conclusion. His experenee is much greater.
Finally, there is one point which The Times has called the most important point, and which I think does influence enormously the members of my profession—namely, did the Minister, advocating this ban to the Home Office, offend or not offend against the fundamental belief of the profession that no-one should interfere between a man and his patient; that no-one should prevent him from giving a drug which he thought would be efficient? That point needs to be considered dispassionately, without prejudice. There is not the slightest doubt that it is felt keenly in many quarters in the profession. It must be remembered, how-ever, that before the National Health Service Act came in doctors were individuals, and many of them came in reluctantly, dreading that their liberty would be curtailed. They became restless, and when this ban appeared they said, "This is the thin edge of the wedge. Where is it going to end?" I think that accounts for some of the depth of feeling which we have witnessed in this controversy.
Nobody would interfere between a patient and his doctor without some good reason, but, when that has been said, surely this freedom of the doctor can never be absolute. Supposing, for a moment, that the Government of this country decided to abandon the manufacture of atomic bombs, do your Lordships think that the country would tolerate a scientist who said, "I am going to make them in my laboratory in order to demonstrate the freedom of science"? Surely we must not push a principle beyond the point of common sense. It was well said in the Lancet that if there were 10 per cent. of addicts in this country there 43 would be little patience with a doctor who criticised the Minister of Health for promoting a ban. Surely the freedom of a doctor carries with it also responsibilities and some recognition of what is due to the community. I understand that, in the first instance, when the Minister went to the Central Health Services Council, he said to them, in effect, "I want to know whether this ban can be imposed without unnecessary suffering on the part of your patients. If it can, then I should like to help the World Health Organisation in their struggle with the tragedys"—and it is no less than that—" of drug addiction."
As I have already said, I am a doctor and am quite incapable of saying whether or not this ban is going to be effective. But, provided that the Government are satisfied on that point, I believe, after much thought, that your Lordships may be reassured that, if heroin is banned, adequate substitutes are available to take its place. In those circumstances, your Lordships may feel, on reflection—though I know the sense of the House is against me—that you can support the Government in their attempt to help the World Health Organisation. For centuries we in this country have lived an isolated, happy life, enjoying the benefits of national sovereignty. The hydrogen bomb put an end to that. We are faced in the future with grim alternatives. Anybody can see that there is no hope in the world unless there can be a measure of understanding amongst the nations, some degree of common action. I think it is because some of us feel that that is so important that we should like to see your Lordships to-day take a step towards that goal, and to make a contribution, however small, to what I know is the far-off ideal of the brotherhood of nations.
§ 4.35 p.m.
§ LORD WEBB-JOHNSON
My Lords, I find myself, not for the first time, in conflict of opinion with a brother member of my profession. The point with which I may bore your Lordships, but which I think is important, is whether the Minister of Health was right to use the Standing Advisory Committee as an advisory body in a question like this. I maintain that the Government have not yet had expert advice on the value of heroin as a therapeutic agent. In regard to propriety, I hope your Lordships will forgive 44 me for taking this opportunity to point out that, when this Committee was formed a most carefully drawn provision was included in the National Health Service Act to prevent the Central Council and the Advisory Committee from being used as supreme bodies for giving advice on medical matters. It was foreseen that the representative bodies of the profession might be short-circuited and ultimately superseded. Many safeguards against this danger are therefore to be found in the National Health Service Act.
It is laid down, for instance, that the duty of the Central Health Services Council shall beto advise the Minister upon such general matters relating to the services provided under this Act…Again, it was laid down that standing advisory committees could, by order, be constituted for the purpose of advising the Minister and the Central Council "on such of the services aforesaid." First, there was the Central Council itself; then there was the authority to establish standing advisory committees, and they were all for the purpose of "the services afore-said." Then it is said that it shall also be the duty of the standing advisory committeesto advise the Minister and the Central Council upon such matters relating to the services with which the committee are concerned, as they think fit and upon any questions referred to them by the Minister … relating to those services.While I am quoting from the Act, I venture to note that the Minister has described himself as having had laid upon him the comprehensive duty of providing health services for all the people in this country. He has the dutyto promote the establishment in England and Wales of a comprehensive health service.That is his job. Lastly, it is laid down in the First Schedule to the Act thatAny standing advisory committee may appoint such sub-committees, as they think fit, to consider and report upon questions referred to them … and any such … subcommittee may include persons who are not members of the … standing advisory committee.The machinery for the Central Council or Advisory Committee to obtain expert advice is there, but in regard to the value of heroin as a therapeutic agent it was not used. In my view, a question concerning such big issues ought to have been referred to representative bodies of the 45 profession. If the British Medical Association and the Royal Medical Colleges are to be supplanted, and if advice on medicine in general is to be sought from the Ministry's standing medical advisory committee, serious notice must be taken by the profession of the improper use of a committee set up under the National Health Service Act. Meantime, I suggest, such advice as has been given and received might be withdrawn until such time as consultations have been held with those who have had the necessary experience to qualify them to advise. In future, the Advisory Committee would be wise to refuse to advise on matters which ought to be referred to representative bodies of the profession, while in matters which quire expert investigation they should appoint a sub-committee to report. I urge that Her Majesty's Government should reconsider whether they shouldadhere firmly to the view that they took all the consultation that they properly should have taken.I feel convinced—and I believe I have shown—that proper advice was not taken.
What can be done if time is given? An intensive scientific study can be made of substitutes for heroin and of the clinical advantages claimed for the drug. Your Lordships would be wise to recall the words of the late Lord Rutherford in this House:Sound policy can only be formulated in the light of a knowledge of facts.Like most members of the Advisory Committee I have never used heroin. I start level with them; therefore I am riot in a position to give an opinion on the true value and advantages of heroin. But though I cannot judge its value from experience, I can be impressed by the testimony of the consultant staffs of the Brompton and London Chest hospitals and by the alarming and changing position in the incidence of cancer of the lung. I am also impressed by the testimony of numbers of general practitioners as to the value of heroin, where other drugs have failed, in easing the closing chapters of some incurable illnesses.
We in this country have been wonderfully successful in preventing addiction to habit-forming drugs. Let other coun- 46 tries follow our methods. Should not other countries sometimes follow Britain? Our methods have been successful both in our own country and through the licence exchange system which, according to Home Office reports, has continued to operate successfully. Above all, do not let us follow along the path of prohibition—a bad and dangerous way, the tragedy of which I saw with horror. We in this country are ready enough to accept controls when we see the need for them. I hope the noble Viscount, Lord Woolton, can now hear me well. He did not hesitate to change his plans when he was shown that there was danger in the method he was following—in milk zoning, for example. We are used to control by the Medical Research Council and gratefully take notice of the warnings of scientists, as in the case of penicillin, which, if given in inadequate doses, may give bacteria a chance of getting tolerant of it so that it becomes habit-forming. We accept the delay necessary for the careful investigation of reputed life-saving remedies before their general release. We are quite ready to accept the delay necessary for the careful investigation of the position in regard to heroin. Why not give time now in the case of heroin?
Get the facts from doctors, from sisters and nurses, those who hear the cries of distress during their lonely vigils, the still, but not quiet, watches of the night. Emotional, some may say. But is there any disgrace in pitying those in pain, those whom Kipling described as sufferingthe shameful nakedness of pain"?We may recall the last verse of his poem:Send here the bold, the seekers of the way—The passionless, the unshakable of soul,Who serve the inmost mysteries of man's clay,And ask no more than leave to make them whole.