Terminally Ill Patients: Medication (Hansard, 3 July 1997)

§ Lord Ashley of Stoke
asked Her Majesty's Government:
Whether they will clarify and explain the law regarding the administration of drugs to relieve the pain and distress suffered by terminally ill patients.

§ The Minister of State, Department of Health (Baroness Jay of Paddington)
My Lords, the Government recognise that this is an extremely difficult ethical and legal question. With the forgiveness of the House, I shall answer the Question in a little more detail than I would normally hope to do. We are very sensitive to the needs of people who are terminally ill and to the concerns of their families. We recognise that there are differing views about the range of responses that should be available in some cases. Wherever possible, patients should have a choice of treatments and care. However, the law does not permit euthanasia but recognises that sometimes the level of medication required to control the overall symptoms may shorten the patient's life. Provided that the primary intention in administering the 299 medication is the relief of pain and suffering and not the deliberate shortening of the patient's life, then this is lawful. In forming a judgment about treatment, the doctor will assess the overall symptom control, the views of the patient if those are known, any relevant advance refusal of treatment, and, of course, the best interests of the patient.
We have no plans to legalise euthanasia but will follow very carefully developments relating to the care of terminally ill people as well as the strong public debate that surrounds these very difficult issues.

§ Lord Ashley of Stoke
My Lords, I warmly appreciate that comprehensive and very specific reply. Is my noble friend aware of the assessment by Dr. Finlay, a professor of palliative medicine, that up to 30,000 cancer patients die each year in unnecessary distress as a result of the reluctance of their doctors to use morphine? That is indefensible. Will the Government consider changing the law so that, instead of doctors being permitted to prescribe drugs of their own free will for terminally ill patients who are in intolerable pain, they are required to do so if that is the wish of the patient?

§ Baroness Jay of Paddington
My Lords, it is worth reminding my noble friend that the development of palliative care has done much to change our attitude to death and the process of dying, teaching health professionals that death is not a failure. With appropriate palliative care, pain can be greatly reduced and people can be helped to cope with it. We are committed to expanding palliative care for the dying in all settings, not merely in the hospice movement. It is our policy that all patients needing these services should have access to them and we are seeking to encourage their provision throughout the NHS. As my noble friend will be aware, if an advance directive about the withdrawal of treatment is given by a patient and is accepted as being valid at a time when that treatment is under question, then it will be accepted by the medical profession.

§ The Duke of Norfolk
My Lords, are the Government aware that within the hospice movement people can die without pain? My wife is intimately concerned with this. For those who enter a hospice, with the administration of drugs, there is no pain at all. Hospitals are not quite so up-to-date in this matter. Secondly, are the Government aware that in my faith, which is the Christian faith, and in the Jewish, Mohammedan and no doubt other faiths—to all those of us who believe in religion—the idea of euthanasia is totally repugnant?

§ Baroness Jay of Paddington
My Lords, I am grateful to the noble Duke for reminding us of the extraordinarily good work done by the hospice movement and by all of those involved with palliative care. The NHS and the Government will continue to work very closely with the movement. In fact, I have had a very successful personal meeting with the executive director, Mrs. Gaffin, within the past few 300 weeks. I accept that those who are fortunate enough to have that kind of care have a great deal of pain eased. As the noble Duke said, it may even cease. Unfortunately, that is not the experience of everyone facing terminal illness. It is that difficulty that we seek to address.

Viscount Tonypandy
My Lords, is the Minister aware that the country is in very great debt to Professor Finlay. At a hospice in Cardiff it has been proved that people can die without pain. However, if patients believe that a doctor has the right to make up his mind rather than theirs, then there will be fear. Does the Minister agree that those who suffer terminal illness above all want to make up their own mind and not have it made up for them by anyone else?

§ Baroness Jay of Paddington
My Lords, I welcome the noble Viscount's comments. I am very happy to see him in his place making a contribution to this important debate. The points he makes are exactly those about the ability of people to control their own lives and to understand the treatment they are given. That is why there is a role for the advance directive whereby people can, if possible, say how they would like to be treated at a later stage in their life.

§ Lord Molloy
My Lords, will my noble friend consider the possibility of her department getting in touch with the appropriate department of the Royal British Legion which recognises that this issue concerns ex-servicemen and women who have been badly wounded serving their nation? Noble Lords laugh. I must tell the party opposite that I do not find this a humorous matter. Will my noble friend give the issue the serious consideration that it justly deserves?

§ Baroness Jay of Paddington
My Lords, I am grateful to my noble friend for drawing attention to this particular group who have a special interest in the matter. I assure him that the Department of Health will consult as widely as it normally does on this and other difficult issues.

§ Lord Lester of Herne Hill
My Lords, does the Minister agree that there is one awkward area of ambiguity, namely, the meaning of "suffering" or "distress" as distinct from pain? Does she further agree that the Walton Committee on medical ethics recommended that doctors should be able to relieve severe distress as well as pain but that there is no lawful authority establishing that that is what doctors can do using the principle of double effect? Is that not a serious gap in our understanding of the law?

§ Baroness Jay of Paddington
My Lords, having been a member of the committee chaired by the noble Lord, Lord Walton, I remember our long consideration of that issue. Perhaps I may draw the noble Lord's attention to the judgment made in the case of Dr. Cox,
301 who was charged with manslaughter in relation to a case of this kind. The judge, summing up the evidence, said: If a doctor genuinely believes that a certain course is beneficial to his patient, either therapeutically or analgesically, then even though he recognises that that course carries with it a risk to life, he is fully entitled, nonetheless to pursue it".

§ Lord St. John of Fawsley
My Lords, perhaps I may congratulate the Minister on her brilliant encapsulation of the law on this difficult subject. Does she agree that there is guidance for the medical profession in the wise words of the late Lord Horder? He said that the good doctor is able to distinguish between prolonging life and prolonging the act of dying.

§ Baroness Jay of Paddington
My Lords, I am grateful for the noble Lord's kind words. That thought is expressed exactly in the whole consideration of the double effect, described by the noble Lord, which is considered to be relevant to the practice of medicine in this field.

§ Lord Jenkins of Putney
My Lords, is my noble friend aware that there is a case for clarifying the law, having regard to the movement of public opinion on the matter? Will she look into the subject again, with the idea of making it possible for a doctor to act in accordance with the patient's desire and the doctor's own judgment of what is right without the doctor risking the possibility of being charged with murder?

§ Baroness Jay of Paddington
My Lords, perhaps my noble friend will forgive me for saying that I believe that I dealt with that point in the question about the law relating to advance directives. The problem involves those who may be mentally incapable at the time when the necessary decisions are taken. I know that my noble and learned friend the Lord Chancellor is looking at the report of the Law Commission which raises difficult additional problems about the law.

§ Baroness Cumberlege
My Lords, does the noble Baroness agree that some of the greatest skills and best expertise on pain control for dying people is exercised by Macmillan and terminal care nurses? If so, will she honour our commitment to introduce nurse prescribing nationwide next year, especially when evaluations of the pilot scheme show it to be popular with patients, good for nurses, efficacious and cost effective?

§ Baroness Jay of Paddington
My Lords, I believe that that is slightly wide of the Question on the Order Paper. However, I am delighted to respond. I spoke at the national rally of the Macmillan nurses last week and I am glad to say that I was well received by them. They seem to feel that the present Government are fulfilling their responsibilities for that important movement.
Nurse prescribing, as the noble Baroness will know, was referred to a national piloting scheme in April. We shall take a decision when the results are known.