Euthanasia

HC Deb 22 May 2002 vol 386 cc69-90WH

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Heppell]

9.30 am

Mr. David Amess (Southend, West)

I am delighted to have been given the opportunity to introduce a debate on such a crucial issue, but let there be no doubt that the hon. Member for Bolton, South-East (Dr. Iddon) has taken a clear lead in this area. He is undoubtedly responsible for bringing social care policies and euthanasia to the forefront of our debate, and I pay warm tribute to his work and action. I very much hope, Mr. Deputy Speaker, that he is able to catch your eye.

All Members of Parliament are sent here to legislate in a way that affects people's lives, so there can be no doubt that Members of Parliament believe that life is the most important matter that we have to consider. That said, for as long as I have been a Member there has been argument about the difficult subject of life itself. I particularly wanted to have the debate because there is an opportunity for Parliament to reclaim its power in this area. There is no doubt that, by stealth, decisions that affect all our lives are increasingly being taken outside Parliament, and I much regret that.

All Members of Parliament will have constituency cases involving loved ones who are injured in some way and then kept alive through food and fluid, but to start referring to food and fluid as medical treatment is absolutely crazy. Unless one eats and drinks, no matter what brain injury or illness one is suffering from, one cannot live. That is why I am concerned about the General Medical Council document, "Withholding and Withdrawing Life-Prolonging Treatment: Good Practice in Decision Making".

That publication is not good for patients or doctors. It contains a contradiction between the premise that it is unlawful and unethical intentionally to end a patient's life and the practice of deliberately withholding or withdrawing food and fluid from the non-dying when nursing or medical assistance is required. Such withdrawal could follow if the doctor judged the continuance of food and fluid to be of no benefit. However, as it would lead directly to a slow and painful death, it is hard to see how it might benefit the patient. Is someone to make the judgment that the patient's continuing life is of no benefit to them?

Ms Julia Drown (South Swindon)

Does the hon. Gentleman appreciate that in these days of medical advances, eating might sometimes be hard to describe as the same activity as being fed through a tube in the stomach? What is his view of someone in such a situation who has made a living will and has made it clear throughout their life that they would not want food and fluid to be given to them should they get into

such a situation? Does he believe that the medical establishment should override that patient's wishes, and possibly those of their family?

Mr. Amess

I certainly understand the first point. Later, I shall mention a constituency case in which a child goes to school normally and is fed through the stomach, without which the child would die. I am not dodging the issue of living wills; I shall come to it shortly.

Mrs. Marion Roe (Broxbourne)

I apologise to you, Mr. Deputy Speaker, and to hon. Members because other parliamentary duties mean that I am unable to stay for the whole debate.

I have a particular interest in this issue as chairman of the all-party parliamentary hospice group. Other hon. Members will share my great sympathy for Diane Pretty, who recently died, and for her family. It has been claimed that she experienced all of which she was most frightened—pain, breathlessness and choking—as she was dying. Does my hon. Friend agree that those claims have been contradicted by the Luton hospice, where she died and which I recently visited? Its announcement made it clear that her death was peaceful and painless, but the BBC in particular gave prominence to the former claims and said little about the hospice's statement.

Mr. Amess

I understand my hon. Friend's point, and I have been fully briefed by the Motor Neurone Disease Association. I do not wish to seem churlish, but I have made it clear to the association that the debate is not about the awful, tragic circumstances of Diane Pretty's death, and that I want to concentrate on general matters. That said, I know of my hon. Friend's work in support of the hospice movement. Dame Cicely Saunders is a marvellous woman whose work is experienced throughout the country. It allows people to die with dignity, and to be treated to the best standards.

I want to dwell on the withdrawal of food and fluids. The advice in the GMC document is that withdrawal should happen only if agreed to by a second doctor, but that puts doctors in an awful, invidious position. Doctors who do not go along with their team's decisions are told—the Minister will understand this—to report to their employers. Doctors already face challenges in the national health service, and this puts them in an even more difficult position.

To return to the issue that my hon. Friend perhaps wants me to discuss, the GMC document sits uncomfortably with article 2 of the European convention on human rights, which states: Everyone's right to life shall be protected by law. The fact that that means what it says has been reaffirmed by Mrs. Pretty's case. No one should be intentionally deprived of their life, least of all by doctors and by means of slow dehydration.

There is always pressure on the House, and it is clear from Hansard that we have not spent a huge amount of time discussing euthanasia. My hon. Friend the Member for Congleton (Mrs. Winterton) introduced a Bill in 2000, but there have been few big debates otherwise.

I am totally opposed to euthanasia, although some people might smile because they can think of a few individuals whom they would like to see off. The lead given since 1999 by the British Medical Association, and now by the GMC, means that judgments are being made for those who are not always in a position to make them for themselves.

As a result of the guidelines and the subsequent judgments, the treatment of some vulnerable patients has subtly changed. Organisations and individuals have inundated me with examples of what goes on in hospitals, and the hon. Member for Bolton, South-East will be familiar with them. I do not want the Minister to think, "My goodness, he's trying to undermine the national health service." I am simply saying that the debate has prompted umpteen relatives of loved ones to give me chapter and verse on what has happened in particular wards, although I am in no position to judge such things.

I pay tribute to Alert, which presents its argument peacefully, forcefully and constructively. In this week edition of The House Magazine, there is an advertisement for SOS-NHS Patients in Danger. The organisation claims that attempts to deprive elderly and vulnerable patients of food and water with the sole intention of causing their death is supported by a 2001 Government directive to doctors. The Minister may throw some light on how she regards that matter.

To describe food and fluid as medical treatment is to change the vocabulary, and it is beginning to affect attitudes among health care workers and to change the viewpoint from which important matters are handled. Total nursing care includes the administration of food and fluids by feeding through tubes, if necessary. I gave the hon. Member for South Swindon (Ms Drown) the example of a little boy being fed through a tube, and there are many more examples of that practice, which we all regard as wonderful, in fact.

Use of the naso-gastric tube has routinely involved nurses, although some patients have learned to use it by themselves. Stroke patients with swallowing difficulties have often left hospital with feeding tubes in situ until they can swallow again. Premature babies have been routinely fed through tubes until they can suckle. Other children, as I say, go to school wearing tubes.

As a result of what I consider to be an improper use of words, such methods are referred to in guidance documents as medical treatment or artificial hydration and nutrition. That is absolute nonsense. Where is the authority for that change of language? Parliament has never been given a real opportunity to consider the matter. If I have not simply been inundated with spoof calls, the practice seems to be occurring throughout the country. I often receive calls from relatives who have seen something happen that they think is wrong. The Minister has had a tough year, but will she consider giving us an opportunity to debate the repercussions of the directive, perhaps in the new Session when we have more time?

The change of language is already encompassed in an established framework of medical decision making. Thus, the necessities of life can be denied to dependent and vulnerable people on the basis that they are non-beneficial, unduly invasive or contrary to their supposed best interests. Who is going to make the decision? Will it be the two doctors or the relatives? The person is often unable to make the decision for himself or herself. That is a profound issue, which Parliament is entitled to debate, and Parliament can sometimes debate such subjects well. We need to hear the arguments for and against the practice.

The reasoning usually advanced for such fatal or lethal decisions is often based on the so-called quality of life considerations, as judged not by the patient, but by the health care team or relatives. Unfortunately, such people may not always have the best interests of the patient at heart. The quiet acceptance of futile case policies will put on a more formal basis decisions that are, in effect, about whether a person's life is worth continuing. What the goodness are we doing, coming to Parliament and making laws, if we cannot spend time considering such an important matter? We should debate the point at which relatives and doctors say, "We can't do that any more—that's it. Finito" Such decisions have been made without Parliament being given a proper opportunity to discuss the issue.

Those decisions would necessarily be subject to arbitrary and changing criteria, such as resource availability and burdens on others. Ultimately, with the pressures that the national health service is under, they would depend on utilitarian considerations. In view of those pressures, the Minister will understand what I am alluding to. We could end the sanctity of life principle under which, hitherto, all lives have been judged to be of equal value, and equal before the law. Many would add that they are equal in the eyes of God.

I am glad to see my hon. Friend the Member for Congleton in her place, because she introduced a Bill on the subject in 2000. I am sharing with the House my view that Parliament has not been allowed enough time to debate such an important and serious issue.

How can it ever be right to deprive a person who is not dying of the necessities of life? It is not acceptable that food and fluid should be described as medical treatment; that is absolute nonsense. Who has given people the authority to say that food and fluid is medical treatment? That is ridiculous. A further practice that occurs too often is the inappropriate and excessive use of sedatives, which render patients dependent and, often, unable to swallow.

We all know of the case of Tony Bland, the poor gentleman who was in a persistent vegetative state. I have dear friends whose son was knocked off a bike. He ended up in a vegetative state at the British Home and Hospital for Incurables, and I spent a great deal of time visiting him. I lived through that traumatic time with his loved ones and they wanted their son to be kept alive—that was their decision. At the risk of becoming boring, I must repeat that it is not acceptable to allow such decisions to be taken through a directive; it is wrong. Perhaps the Minister can provide clarification.

It was said that Mr. Bland's brain was dead. I have no expertise in such matters, but I am advised that at his autopsy it weighed 1,000 g and the normal weight of a brain is 1,400 g. It was certainly not a watery mass, as was stated at the time. The late Cardinal Hume, for whom I had the highest regard, tried to raise the matter

with the president of the family division, but he did not receive a satisfactory response. It is too late to argue about it, but the Bland judgment was desperately important.

Ms Drown

I am waiting for the hon. Gentleman to come to living wills. Perhaps Tony Bland should have made a living will, but he was too young to have thought about it. At the time of the case, all his relatives wanted to finish his life, although they had not done so initially. Does the hon. Gentleman believe that the wish of those relatives should have been overridden?

Mr. Amess

The hon. Lady is very sharp in not letting me get away with missing her point. Until Parliament has been given a proper opportunity to debate what is involved, I shall not be satisfied with living wills as I understand them. I have grave concerns.

I end with a plea to the Minister. She has a huge work load, and every issue that she is confronted with is the most important of that day, but we are talking about life. In hospitals throughout the country, people are lying in beds and the medical teams around them are faced with such decisions. It is not good enough that Parliament has not had the opportunity to debate who should be given the onerous task of deciding who should live and who should die. Giving a patient food and fluid is not medical treatment; it is what every human being is entitled to. I am totally opposed to euthanasia and I totally respect the sanctity of life. I hope that all hon. Members do so.

9.49 am

Dr. Brian Iddon (Bolton, South-East)

I am grateful to the hon. Member for Southend, West (Mr. Amess) for introducing this important debate. Many hon. Members are concerned that policy decisions in this area are being made outside the House. Although euthanasia, with all its ramifications, is a difficult subject, we should be debating it in both Houses of Parliament to try to reach a consensus.

Voluntary euthanasia—a third person ending the life of another with consent—has been legalised in some parts of the world, including the Netherlands and, last week, Belgium, as well as the state of Oregon in the United States. We are in danger of euthanasia creeping up on us without parliamentary decisions being made. I shall set out the legal background to the debate to show that the legal profession, aided by the medical profession, is driving policy in this area.

Bob Spink (Castle Point)

The hon. Gentleman is a member of the Science and Technology Committee. As I am sure he remembers, we took evidence from the former chairman of the Human Fertilisation and Embryology Authority only a few weeks ago. We discussed difficult issues of the beginning and end of life, and she informed the Committee that she thinks it right for decisions on such issues to be kept away from Parliament. She also said that, as emotive, complex and sensitive issues are involved, they are best decided by people other than politicians. She showed total contempt for the House and felt that we should be protected from having to make those difficult decisions, but people outside the House are in favour of the democratic process and they want those who are accountable to them to take the decisions. Does the hon. Gentleman recall that event?

Dr. Iddon

I do, and I agree with the hon. Gentleman that those decisions should be made by Parliament and that the debate should be held here.

Had I been an MP at the time, I would have supported the Suicide Act 1961, but there have been several landmark judgments since then. Reference has already been made to the 1993 Law Lords judgment in the Airedale NHS Trust v. Bland case. That was a critical moment in the history of the debate because, for the first time, doctors were given the legal ability to remove artificial feeding and hydration from patients.

Many doctors were worried about that judgment, and they lobbied the GMC and the BMA. The Government published several reports, and the Law Commission published a report in 1995. In October 1999, the Government's consultation resulted in the publication of "Making Decisions", and recent press reports emanating from the Lord Chancellor's office suggest that legislation is likely to be included in the Queen's Speech in November. In April, a consultation document on "Making Decisions"—it is extremely difficult to get hold of—was published. I should point out that euthanasia is a devolved issue, and legislation has been passed in Scotland, so the law in Scotland is already different from that in England and Wales.

Yesterday, the GMC put its draft document to the council for agreement. The BMA has been publishing guidelines, which are used in hospitals, without any reference to Parliament, or at least to the elected body of Parliament. It may have consulted the Government, but the rest of us certainly have not been consulted. As the hon. Member for Southend, West said, the important difference in the medical profession now—we cannot underline it enough—is that doctors regard artificial hydration and feeding as medical treatment. When that announcement was made, it really got up my nose. That is why I strongly supported the Winterton Bill in Parliament, which was unfortunately lost.

Following the Government's implementation of the Human Rights Act 1998 in October 2000 for use in the British courts, the BMA guidelines were revised, but they have not changed greatly. The Winterton Bill accepted the right of a patient with mental capacity not to accept treatment, particularly if it was burdensome, and we should underline that fact, too. Members of Parliament were divided on the issue then, just as they will be today. When the Bill was debated, I was rather surprised to find that Age Concern had lobbied against it, despite being worried about the appearance of terms such as "DNR" and "Do not ring 555" on patient notes. Hon. Members will remember the great publicity that that gained in the press.

Following the Bland judgment, a second landmark decision was made on 25 October 2000 by Dame Elizabeth Butler-Sloss, president of the family division of the High Court. It was about the lives of two women, Mrs. M, aged 49, and Mrs. H, aged 36, both said to have been in a permanent vegetative state, the former for more than three years and the latter for about nine months. The case of Mrs. M was non-urgent, as it was estimated that she could have lived for another 10 to 20 years. Those cases were brought to court to test whether the Human Rights Act had any bearing on the decision made in the Tony Bland case. Article 2 of the European convention on human rights, of course, refers to the right to life.

Amazingly, Dame Butler-Sloss ruled that the Human Rights Act had no effect on verdicts of that kind. That was an extremely important decision. I object not only to the decision, but to the fact that it was made by one person. I accept that she must have consulted, but she made the judgment in the name of only one person. Even the Pinochet case went first to three Law Lords and eventually to five, so why do we let one person in the family division make landmark judgments of that kind?

Dame Butler-Sloss has said some remarkable things since. For example, she believes that permanent vegetative state patients are insensate. Doctors are divided on that issue, but many believe that even patients in deep comas have sensations, so we would dispute her opinion. On 20 July 2000, she told the GMC: Hospitals may also need to consider the issue of resources, however distasteful that may seem, and consider whether resources should be directed to patients who have no hope of receiving any benefit from that treatment". That is an astonishing statement from someone who makes such landmark decisions.

This year, Dame Butler-Sloss handed down another landmark judgment in the case of a single middle-aged woman patient who has become known as Miss B and who had been kept alive for some time by ventilation. That judgment allowed a medical team to sedate the patient and turn off the ventilator. The patient has since died in another hospital, because the people in the first hospital, who saved Miss B's life, could not find it in themselves to turn off the ventilator. I think that Miss B had the right to ask for that ventilator to be turned off, and I have no objection to that landmark decision. Miss B was a thinking person; she was not in a coma and she had thought about the decision. To her, the ventilator had become burdensome. That was the point that I made about the Winterton Bill.

The Dutch Parliament legalised physician-assisted suicide and voluntary euthanasia in April 2000, and Belgium has followed suit. Since 1984, when voluntary euthanasia was decriminalised, there have been 50,000 such deaths in the Netherlands. Significantly, in one study, 85 per cent, of Dutch patients withdrew their request for euthanasia after receiving better symptom control.

I support the hospice movement, which does a great job. No matter how seriously ill a patient is, hospices have learned to cope and to relieve pain in some terrible circumstances. In Holland, some people carry passports to live, and the organisation Right to Life in Britain has proposed allowing people here to carry human rights cards, so that if they find themselves in such circumstances doctors will be aware of the patient's wishes.

The debate should be entitled "Futile care policies and euthanasia". 1 would like to discuss futile care policies—a euphemism for involuntary euthanasia. Futile care policies are implemented so quietly that no one knows their extent. Although a patient may want

life-sustaining treatment, if the doctor believes that their quality of life does not justify the cost of care in the health care system, he may refuse further treatment, other than comfort care.

Many hospitals in the United States of America have developed futile care policies designed to thwart legal action by the patient or their relatives. The Cambridge Review surveyed 26 Californian hospitals, 24 of which were found to have futile care policies. Only seven permitted patients or their representatives to make submissions before a decision is made to implement those policies.

Futile care policies are a descent from a health care system based on the Hippocratic oath and the Geneva declaration. They discriminate against the elderly, the chronically sick—dying or otherwise—and the disabled, who are expensive to care for. Do we want that sort of health care rationing in Britain? It has arrived.

A programme transmitted on 14 February 2002 by Channel 4 as part of its "Trust" series was filmed at Queen's hospital, Nottingham. It showed medical staff making subjective decisions about their elderly patients' quality of life that led to death by starvation and dehydration. Futile care policies now operate in the national health service in Britain. Who gave doctors the right to carry out futile care policies in this country? Doctors first sedate the patient so that they are unable to communicate or, usually, to swallow, as the swallowing reflex disappears. Opiates are usually used to sedate the patient, and they are left to starve to death or to dehydrate.

Angela Watkinson (Upminster)

One method by which such policies are implemented in geriatric wards in our national health hospitals is for someone to enter a ward of elderly and frail people who are lying in bed and unable to sit up unaided and to place food, such as bowls of soup, on tables over the bed. The patients are incapable of accessing that soup on their own, but 10 minutes later a different member of staff comes through the ward and says, "Oh, don't you want that?" and removes it. That is an insidious way to cut off food. Food is ostensibly provided, but it never—

Mr. Bill O'Brien (in the Chair)

Order. Interventions must be brief.

Dr. Iddon

I have some sympathy with that point of view, and I have seen that in action. However, I do not accuse national health service staff—auxiliaries and nurses—of carrying it out as a futile care policy. There are simply not enough people on the wards to sit with patients who need feeding one to one. Will the Minister comment on the view expressed by the hon. Member for Upminster (Angela Watkinson)?

We urgently need a full debate in the House, not merely a 90-minute debate in Westminster Hall. Although people take notice of such debates, they do not have the same impact as those in the main Chamber. I hope that the Minister agrees and that the Government enable us to have a much longer discussion. The subject was chosen by Mr. Speaker, and I am grateful to him for allowing us to discuss it.

Several hon. Members

rose—

Mr. Bill O'Brien (in the Chair)

Order. Four hon. Members wish to speak and we have 24 minutes left, so I would be grateful if Members show self-discipline and speak for only six minutes. I intend to call the winding-up speeches at 10.30.

10.5 am

Dr. John Pugh (Southport)

I must preface my remarks by saying that I am not a relative of anyone involved in unfortunate cases, such as those of Tony Bland and Diane Pretty. If I were, no doubt I would have other things to say. It is difficult to extrapolate from specific cases. I just want to submit a general argument against legislative or regulative change. We seem to fear that the law will be changed to allow medical practitioners or other people to assist a person to die—in other words, effectively to kill another individual under the remit of the national health service.

The matter raises the huge moral minefields of consent and intent. There will still be the issue of whether moral or social pressure has been brought to bear to secure consent. There will always be an argument about the state of mind of the person giving consent—both at the time that he agrees and when he is asked to reiterate that choice. At the point when euthanasia may be implemented or foreseen, the person may not be in a position to reiterate his initial choice or living will.

The issue of intent concerns whether the state should allow certain people, as a deliberate act of intent, to end a person's life. If those people are doctors, there will be conflict with the Hippocratic oath and the possible fear that such activity may be extended beyond cases when consent is given to other cases in which the person's condition is judged to be futile.

There are two arguments for change. First, there is a general argument that euthanasia would alleviate suffering. Secondly, euthanasia would allow the patient to choose the moment of his death. I shall deal with the second argument first. We all have the right to end our life. If the state tries to forbid us from so doing, it will be futile. However, that is not what we are discussing; the issue is whether someone else should assist in that process. That raises a nest of issues concerning who that person would be; with what authority he would act; how he would act and at what moment he would act. The state or medical practitioners do want to trespass in such a minefield without being aware of the dangers that they face.

I accept that the stronger argument in favour of euthanasia is based on the alleviation of suffering. The general view is that an easeful death is a good death, and I am sure that everyone in the Chamber agrees with that. We would all wish our loved ones to die an easeful death. There is a moral imperative to secure that, and few people deserve anything different. It is a known fact that methods of alleviating suffering can bring forward the moment of death and, by that, I do not mean the withdrawal of food and water. If engaged in seriously, the alleviation of suffering can shorten the period in which a person suffers and bring forward the moment of death.

There is a mediaeval principle called the double effect. If a medical practitioner engages in a form of medication that eases suffering and coincidentally brings forward the moment of death, that is a radically different choice from his deciding to terminate a person's life. In the

past, the Catholic Church supported therapeutic abortion, the object of which was to save a mother's life by removing the baby from her womb. The clear difference between that and abortion was that the object was not to end the baby's life. Were the baby to survive at the end of the process, everyone would be much happier.

If the possibility of an easeful death exists for individuals, why is there a need to change the medical role? Why is there a need to confront medical practitioners with awful medical dilemmas? My argument would fall absolutely if someone could prove that it is impossible to ease a death and forfend suffering—that medical science, even in its current advanced state, necessarily cannot avail dying people who are suffering intensely. I do not believe that. It is certainly untrue with regard to a few cases; I am thinking of a friend of mine who died of motor neurone disease.

If my argument is true with regard to a few cases, medical science can address them. Therefore, there is no need radically to change medical practice, the authority of medical practitioners and the nature of their task.

10.10 am

Mr. Kevin Barron (Rother Valley)

First, I declare an interest. I was appointed to the General Medical Council in October 1999, one of three Members of Parliament to be nominated lay members of that body. Therefore, I have been involved in the council's debate on the guidance. Indeed, the council discussed it again yesterday.

The document "Withholding and Withdrawing Life-Prolonging Treatment" is a good practice guide for decision makers in the clinical field. It is not about euthanasia. The guidance begins with a statement that euthanasia is against the law and the ethics of medicine. It is about making decisions when providing care at the end of people's lives. It does not provide answers; that is impossible, as every patient is an individual and their circumstances vary. It sets out a framework for decision making to guide clinicians in the field.

The GMC has consulted widely. A broad range of views were expressed to it, and it has carefully considered them. I first attended a GMC meeting in November 1999. It discussed the issue for the first time then, and one matter that it debated was whether guidelines should be sought, because it is clear that care for people in this state varies between hospitals. That cannot be denied, and the GMC, as the regulatory body for doctors, believed that it was its right and responsibility to provide guidelines, if at all possible.

Therefore, a working group of the standards committee was set up, and people from outside the GMC who have legal and other expertise were co-opted as members. The first draft of a report was produced 12 months later, in November 2000. In 2001, a written consultation was conducted for 10 weeks, between May and July. More than 730 responses were received from a wide range of organisations, and from many doctors and members of public. The process culminated in a consultation conference in London on 20 July 2001, and everyone with an interest in the issue was invited to attend.

Mrs. Ann Winterton (Congleton)

It sends shivers of fear down my spine when I am told that the great and the good consult and come forward with decisions, such as that made by the GMC. Does the right hon. Gentleman believe in the supremacy of Parliament? He is an experienced Member. Is he concerned that such decisions are being made outside the parliamentary and democratic system by people who ought not to be making them?

Mr. Barron

The GMC is a statutory body that was set up by Parliament to give advice to doctors. In part, it is self-regulating. However, I am a lay member, and there are 23 others. Parliament gives it the right to issue guidelines in this field. The people who have been leading in it, and those in the GMC who have been involved in drawing the guidelines up, are not members of the great and the good. The hon. Lady laughs, but those people deal with the matter almost daily in hospitals throughout the country. That is not being done by the great and the good sitting in London. The consultation process took place on the basis of trying to get advice from, and guidelines to, practitioners in the field who have to handle the situation.

We have obtained extensive legal advice from the Official Solicitor. When the guidance was discussed yesterday, several amendments from the Official Solicitor were made. The guidance states the principles established in the core guidance of good medical practice, which is effectively the clinician's bible, but it considers the primacy of patients' interests, respect for patients' autonomy and the duty to provide a good standard of practical care. It applies those principles in this difficult area of practice.

I do not think that anyone in this Room would disagree for one minute that the area in question is a difficult one for people to work in. The guidance cannot accord with all points of view, and I am sure that everyone in this Room accepts that. The GMC believes that the draft guidance reflects broad agreement so far established with the profession and the public on what can be regarded as good practice in decision making in this area.

My hon. Friend the Member for Bolton, South-East (Dr. Iddon) issued a press release on Monday, inviting the council to consider aspects of the issue. The council looked at those aspects. I want to go into one or two areas mentioned in Monday's press release that were also discussed. The first is whether artificial nutrition and hydration can be non-beneficial. In fact, the words "no benefit" were removed yesterday in drafting changes, and they will be replaced. I do not know exactly whether the phrase "net benefit" or other words were used at that time. Also, and it is right, fair and proper that people commented on it, the council said that it would reiterate the general guidance, in paragraph 55, on consulting the health care team, families and others. Our broader consultation will take place before decisions are taken on that.

Another part of Monday's press release was covered by Dr. Anthony Cole of the Medical Ethics Alliance. He was concerned about junior doctors, and said that those who could not in conscience agree to the withdrawal or withholding of food and fluid, should not have to take responsibility for finding another doctor to do what they could not do themselves. Should junior doctors have to find someone to cover for them if they withdraw from the care of a patient because of a conscientious objection? That is, I assume, what was alluded to on Monday. The council has agreed to introduce amendments to make it clear that it is the junior doctor's responsibility to inform the senior clinician responsible for the patient's care. The senior clinician must then make arrangements to find a replacement.

I shall briefly discuss advance directives, which were mentioned in my hon. Friend's press release by Dr. Jacqueline Laing. The issue is covered by the guidance in paragraphs 10, 28 and 39, as well as in the glossary that deals with advance directives and advance refusals of treatment. The council makes it clear that advance refusals are valid if they are clearly applicable to the patient's current circumstances and when there is no reason to believe that the patient has changed his or her mind. Paragraph 39 gives further guidance on taking into account advances in treatment made since the directive was issued.

After yesterday's debate, I took the issue up with Sir Cyril Chantler and Professor David Hatch, who have been leading on the guidance document in the GMC. To paraphrase what I believe to be the outcome of that, it is clear that someone who gave an advance directive years ago and who may have changed their mind should assume that they could and perhaps would have to go through that process again. That was not written on tablets of stone, but the gist of the discussion was that the GMC intends to issue guidelines to doctors working in the field.

Dr. Iddon

The point made by Dr. Jacqueline Laing at the Alert meeting on Monday, from which the press release emanated, is that people who make advance directives should be aware that they may put themselves in an even more difficult position by refusing treatment as a patient. In other words, they could become disabled by refusing treatment.

Mr. Barron

It is believed that the guidance that has been drawn up and that will, at some stage, be sent to all doctors—certainly those working in the field—takes everything into account. The advance directives, which I read yesterday, go into great detail, but I shall not bore the Chamber with that now. Doctors must have confidence that decisions made a long time ago still stand in all circumstances, however, although a decision made 10 years ago would not be ignored in a current situation. That is my understanding, although 10 years refers to my timetable, not that of others.

I shall finish, because we are pressed for time. I do not disagree that the House should discuss such matters, as it is for us to regulate doctors up and down the land who work in hospitals, primary care and so on. The House has given responsibility to the GMC, however, and in my view, based on the years that I have been a lay GMC member, it takes its responsibility seriously. It is clear that there are no guidelines in this sensitive area for people who work in our hospitals and other places, but we need guidance and a debate about it.

Let me emphasise that the GMC recognises that euthanasia is wrong and that it is against the law and medical ethics of this country. No one is saying that it should happen. At some stage, we in Parliament may be called on to pass laws on it, but that is not related to the guidance.

Mrs. Winterton

We all agree that euthanasia is illegal in this country, but is not it disingenuous for that organisation to say that? It advocates the withdrawal of food and fluids from certain patients. Is not that promoting euthanasia by stealth?

Mr. Bill O'Brien (in the Chair)

I trust that the right hon. Gentleman is bringing his comments to a close.

Mr. Barron

The answer to the hon. Lady's question, in all circumstances, is certainly not. I do not think that that is euthanasia by stealth. In some rare cancers, nutrition and hydration speed up the patient's metabolism, hastening death and increasing suffering. It is best that clinicians make the decisions in those cases, not us sitting here this morning.

10.22 am

Mr. Harold Best (Leeds, North-West)

I am fairly certain that everyone in the Chamber is, to say the least, well motivated, interested in the subject—it is an appropriate subject for the House to deal with—and eager to take decisions and come to conclusions that the freedom that allows us to gather here makes possible.

When I was very small, I went to the local cinema with my parents and we saw on the flickering black-and-white screen the smiling faces of children who were being carefully led off to be dispatched by a Nazi regime. They were people whom the doctors thought a waste of the state's resources. I remember my parents saying to me, "You must never forget this." I did not understand why, but they said that I would.

I began to understand what it meant. Culturally and racially, I am part Irish, part Catholic, part Church of England, mixed Methodist, part Jewish Russian immigrant. Any of those things could make one likely to be a target of someone who disapproves of one part or another of one's history or culture, and one can easily become the victim. People do not set out with malice aforethought; it is the way the machine rolls, and we should be careful that it does not become irresistible.

It is important that we in Parliament understand our role. My right hon. Friend the Member for Rother Valley (Mr. Barron) made a good argument, but I do not share his certainty in the GMC's capacity to make judgments— or in its right to make those judgments. Parliament is for ever changing, as are its ideological constructs, and whatever decisions Parliament took to empower the GMC to take decisions—decisions that are now being used to justify my right hon. Friend's observations—we may later wish to say that we were not right and that we should reconsider the matter. I believe that now is the time to do so.

The idea that the state should take on the role of moral guardian is interesting. In our lifetimes—at least, in mine—we have experienced not only Nazism but Stalinism, when the state did only what was in its own interests. I and others decided that we could not support that. Indeed, as a socialist it seemed to be an obscenity; it was nothing to do with the struggle of the people in whom I was interested. In my view, the state is not always benign.

We should acknowledge that individuals and families, too, are not always benign; for all kinds of reasons, they can be interested in the outcome of an illness, although for most, the outcome is a matter for sincere, deep regret. We are all familiar with our family doctors, but when they become involved in the care of someone who is terminally ill they will want to relieve pain and suffering. As the hon. Member for Southport (Dr. Pugh) said, it is generally accepted that the relief of pain can speed up the process of death, but there is a duty on all of us to ensure that suffering is minimised. The line that we draw between the relief of pain being appropriate and morally right and the fact that it may bring about a speedier death will therefore always be very narrow. The decision will always be burdensome, and it always involves the careful balancing of responsibilities.

The state and the judicial system together can make the ending of suffering lawful, and we might eventually want to subscribe to that case if it means simply a gentle release from pain. My fear is that if we empower people to take such decisions without their being constantly checked through the people's democratic involvement, we shall be leading ourselves into serious danger. We should bear in mind Churchill's observation. He said that when one first starts on the slippery slope, the downward descent is not too difficult or precipitous; when one begins to accelerate, however, one finds oneself on the way to this pit of hell—he was referring to the Nazi regime. We should be mindful of what steps we take, and we should be ever mindful of the need to review what we have done.

We must never repeat the horrors of the late 1930s and early 1940s, no matter how well motivated people say they are. If we reopen that door—if we revisit that period of horror—we shall have no one to blame but ourselves. Generations to come may well look back on us and ask, "Did they learn nothing from that period that they lived through? Are there no lessons that we can be sure of, ever? Does it have to be repeated over and over again?" I think that the idea of relief of suffering meets with the approval of everyone in this Chamber and in the House. However, we must be very mindful of what that could lead us to, and I am absolutely opposed to euthanasia.

Mr. Bill O'Brien (in the Chair)

I call Jim Dobbin. Two minutes.

10.30 am

Jim Dobbin (Heywood and Middleton)

Thank you, Mr. O'Brien, for allowing me to speak. It is an important time for this debate, because the House of Lords report on making decisions is out for consultation. I wanted to speak for more than two minutes on that, but it looks as though I am to be cut short. I do not want to spend so little time on that report—it is far too important for that—so I shall wait to hear what the Minister has to say. I hope that there will be an opportunity at a later date, if she would be so kind, for Parliament to debate this important issue properly.

10.31 am

Mr. Paul Burstow (Sutton and Cheam)

I am grateful to the hon. Member for Heywood and Middleton (Jim Dobbin) for giving us those two minutes back, because

the debate is important. I am also grateful to the hon. Member for Southend, West (Mr. Amess) for securing it. I understand that it has been sought for some time, and the luck of the draw led him rather than the hon. Member for Bolton, South-East (Dr. Iddon) to introduce it. The debate is timely, not least because the GMC considered these matters only yesterday.

The hon. Members for Southend, West and for Bolton, South-East are right to assert Parliament's right to debate and set the framework in which decisions on the care of people who lack the capacity to decide for themselves are made. That is very important, but I do not accept the criticism that is being laid at the door of the GMC for coming forward with guidance. The blame for that lies with the House and those who manage our business and set time aside for us to deliberate on such matters. We have not been given time to consider them, but we should be. That is the clearest and most powerful message that should come from the debate.

For Liberal Democrats, the moral, legal and ethical issues surrounding euthanasia are matters of conscience and therefore would be subject to a free vote, if there were ever such a vote in the House. I oppose the intentional taking of life, whether at the request of the individual or out of some sense of mercy. When the House considered the Medical Treatment (Prevention of Euthanasia) Bill in 2000, I voted for it on Second Reading to reaffirm my opposition to euthanasia. Several other Members voted for the principle of the Bill on that basis.

In preparing for the debate, I examined the report of the House of Lords Select Committee on Medical Ethics, which considered the issues carefully in 1994. It offers a clear view and I was particularly struck by paragraph 237 in part III, which sums up the Committee's recommendations: Ultimately, however, we do not believe that these arguments are sufficient reason to weaken society's prohibition of intentional killing. That prohibition is the cornerstone of law and social relationships. It protects each one of us impartially, embodying the belief that all are equal. We do not wish that protection to be diminished and we therefore recommend that there should be no change in the law to permit euthanasia. I support that view.

Policy and practice should rest on the foundation of respect for human rights—the right to autonomy, the right to be oneself—but as things stand, we are not all equal. The law denies legal rights to people who are judged by others to lack the mental capacity to make decisions for themselves. They are not only denied proper legal status as autonomous individuals in their own right, but many of them, in some areas of law, are simply ignored. There, they do not exist; they are non-people.

Who has the authority? How is capacity defined? How can people with mental or physical impairments be enabled to participate in decisions that affect their lives? The current all-or-nothing approach, whereby authority is passed to those claiming power of attorney or professionals giving medical or legal advice will not do. Common law recognises that third parties must act with a person's best interest in mind, but an incapacitated person's best interest is about more than managing money or rationing services to meet their care needs. It is about ensuring that they have a decent quality of life, can express their needs and emotions and are treated with respect.

I therefore regret that the publication of "Making Decisions" a few years ago has not led to a legislative debate or to decisions in the House. The Government have shied away from reform, despite promising legislation year after year. I am interested in the reading by the hon. Member for Bolton, South-East of the signals emanating from the Lord Chancellor's Department, because it contradicts what I have gleaned from Ministers in that Department. There seems to be a fear that reform of the law on mental incapacity will be hijacked and portrayed as a move down the road toward euthanasia. That fear is misplaced, but it is becoming an obstacle to legislating. It is appropriate for the House to make such legislation a candidate for pre-legislative scrutiny so that we can reach a broad consensus. We should take evidence and opinions from outside the House, and introduce an agreed Bill. I hope that the Minister discusses with her colleagues in the Lord Chancellor's Department the issues that have been raised today. In a way, a Minister from that Department should respond to the debate, because the issues are broader than health care.

Living wills, or advance directives, are one area of law that would benefit from being placed on a clear statutory footing. Although the courts have developed a body of case law that recognises the standing of such directives, I strongly believe that Parliament should provide a clear legal framework, with safeguards, in which people can exercise their right to give informed consent or to refuse treatment. Patients have the right to refuse treatment beforehand or at the time, if they have capacity, but no one has the right to require another person to assist with or to hasten their death.

When the House of Lords Select Committee on Medical Ethics considered euthanasia in 1994, it compared the UK and the Netherlands and found that there was almost no hospice movement in the Netherlands. Several Members have mentioned the movement, which plays an important part in our health care system. The development of the science of pain relief has made a real difference to the quality of life of thousands of terminally ill people. Quite simply, a hospice and good palliative care can make all the difference between a good death and a bad one, but what priority do the Government attach to the work of hospices? The independent charitable sector provides seven out of 10 in-patient hospice places. Over the past five years, state funding of hospice care has fallen from 35 to 28 per cent. What funding will be available in future? Hospices are already scaling back their activities and cutting the number of beds that they provide.

Extra Government funding to implement the cancer plan and to develop palliative care has not got to hospices, where it matters. They welcome the fact that the Government have made at least some concessions on NHS charges for ambulances, drugs, and laboratory and imaging services. Such charges are only the tip of the iceberg, however, and the payroll is the major cost for hospices. They must also compete with the NHS, and it would be useful if the Minister told us how the Government will help the hospice movement to bridge the ?60 million gap that confronts it.

The guiding principle for care policies must be the individual's best interests. Their right to decide should be paramount, but that does not confer a right to ask someone else to help them to die. I am concerned that the issue of incapacity remains unresolved in England and Wales. Legislation has been passed in Scotland, and it is for the Scottish Parliament to decide whether it is the right legislation. People in this country are left in limbo and denied the right to be treated as individuals. Law reform on capacity is an essential bulwark against any back-door moves towards euthanasia.

I hope that the Minister has heard loud and clear the message that Parliament should debate and decide on such matters. Time should be made available to allow us to do so thoughtfully, deliberatively and without taking the scaremongering tone that sometimes enters such debates. Today's, however, has been thoughtful, rather than scaremongering.

10.39 am

Tim Loughton (East Worthing and Shoreham)

We have had a good debate, but it has been a debate about a debate. We all agree that we need further discussion, and we have only scratched the surface. None the less, I congratulate my hon. Friend the Member for Southend, West (Mr. Amess) on securing the debate and the hon. Member for Bolton, South-East (Dr. Iddon) on putting him up to it. The subject is difficult to deal with. It is topical because of the cases of Diane Pretty and Miss B and because of the judgment by Dame Elizabeth Butler-Sloss, although this is the first time that I have heard her judgment compared to the General Pinochet case.

We have been debating problems of science and advances in medicine compared with matters of ethics and public conscience, in which Parliament has a vital role to play. However, as many Members said, the agenda seems to be moving ahead without proper parliamentary scrutiny. A theme common to all the contributions made this morning is that policy on euthanasia is moving ahead by stealth and that we in Parliament must reclaim that territory, because this is where the decisions should be made.

I congratulate my hon. Friend the Member for Congleton (Mrs. Winterton) on her attempts, whether one agrees with them or not, to bring the issue before Parliament in a private Member's Bill. Although that Bill failed, it was a good start to the process. She is sorry that she cannot be present for the winding-up speeches, but she has a dental appointment, which I hope will not be terminal.

As the hon. Member for Bolton, South-East said, the debate on euthanasia is taking place around the world. Holland became the first country to legalise euthanasia, the practice of giving terminally ill patients the right to end their lives. Doctors in Holland will no longer face prosecution under strict conditions, and regional review committees of legal, medical and ethical experts will carefully judge each patient's request.

As the hon. Gentleman said, Belgium has become the second country to allow euthanasia. There, patients who wish to end their lives must be conscious when the demand is made and must repeat their requests for euthanasia. They must be under constant and unbearable physical or psychological pain. There have been similar moves in South Korea, and the hon.

Gentleman mentioned Oregon and the changes made by the Scottish Parliament. The United Nations Human Rights Committee has taken a close interest in the moves in the Netherlands, criticising that country for its controversial new law. The committee rapporteur, Eckart Klein, said that the growing number of assisted suicides could lead to them becoming routine. The main worry is not only the actual practice, but also the fact that this new law could create precedents that dilute the importance and trivialise this act…The practitioner could become practically insensitive and the act trivialised. The committee is worried by figures supplied by that Government, which show that more than 2,000 cases of euthanasia were carried out last year. It is also concerned about reports that medical personnel have ended the lives of newborn handicapped babies.

The hon. Gentleman mentioned the human rights aspect and referred to the fact that many human rights tests did not apply or were found wanting in the case of Diane Pretty, and had other implications in the case of Miss B. He also mentioned futile care policies, and I remember the programme about the Queen's medical centre in Nottingham and the subjective judgments that were made. We must be aware of all that to have a say in what happens and to formulate a proper approach.

Dame Butler-Sloss's judgment has implications for hospital resources, which is a worrying aspect of the decisions that are being taken. The hon. Member for Leeds, North-West (Mr. Best) raised a similar point in his thoughtful contribution when he mentioned his lifelong memory of a film about children in Nazi Germany. The state has the power of life and death over its citizens, and as the hon. Gentleman said, it is not always used in a benign way. It certainly was not then.

There is great concern around the world about the developments that are taking place. The Conservative party remains opposed to euthanasia, as we said in our manifesto, although we recognise the right of patients to withdraw from treatment if they choose. Then the debate becomes complicated and fraught with problems of definition. As my hon. Friend the Member for Southend, West rightly said, there are concerns about the medicalisation of the vocabulary in this area, which is beginning to affect attitudes among health care workers.

Feeding is now referred to in guidance documents as medical treatment or artificial hydration and nutrition. The BMA guidance on withdrawing and withholding treatment in certain cases raises many questions. In June 2001, the BMA produced guidelines. Dr. Wilks of the BMA said: Our guidance on withdrawing and withholding treatment is intended to help doctors make compassionate decisions about treatment at the end of life for patients with no prospect of recovery. It is emphatically not about euthanasia, to which the BMA remains firmly opposed. He continued: The primary goal of medicine is to benefit the patient. If a medical treatment can no longer benefit the patient, then ethically, the doctor must start to consider whether it should be withdrawn. This must be done carefully and thoughtfully, in consultation with relatives, in close discussion with the whole team of people involved in the care of the patient". However, he added: We share the view of the courts that artificial nutrition and hydration is a part of medical treatment and could therefore potentially be withdrawn if it is not benefiting a patient. However we also recognise that not everyone shares this view and that special safeguards need to be taken in this difficult area of decision making. Absolutely right. That point was made by my hon. Friend the Member for Southend, West. We have heard about the experience of the right hon. Member for Rother Valley (Mr. Barron). The GMC plans to introduce guidelines outlining when it believes it right to withhold life-prolonging treatment. That will raise complex issues. The meeting yesterday to take legal advice was important in that process, but most people do not know about that. The GMC has, effectively, a licence from Parliament to get on with its duty. However, that does not mean that Parliament can abrogate its responsibility to be actively involved in making decisions and recommendations.

Mr. Barron

rose—

Tim Loughton

I shall carry on, if I may, because we are short of time.

It is right that medical professionals should tackle the issue, but Parliament needs to engage fully in the process, and, for the sake of clarity and consistency, to give strong guidance and validation to whatever position is agreed. We must then consider the huge moral minefield, which is how the hon. Member for Southport (Dr. Pugh) described definitions of stages of voluntary euthanasia, physician-assisted suicide, life-prolonging treatments and active and passive euthanasia. What is the difference between performing one act—for example, giving a lethal injection—with a particular outcome and failing to perform another, perhaps life-saving treatment, with an identical outcome?

The hon. Gentleman also mentioned the problems of social pressures being brought to bear on families to secure consent. People are made to feel that they are too much of a burden on their families. We dealt briefly—I shall not go into it in detail—with the difficult issue of advance directives or living wills. I agree that we need guidance from the Lord Chancellor's Department, but only after we have had a debate in Parliament. The Lord Chancellor must give a lead, but he should not issue contradictory or slightly insidious directives behind the scenes that nobody knows about.

The problem is increasing with the ageing of the population. In 1951, there were 300 people over the age of 100, most of them probably in Worthing. In 2031, it is expected that the monarch will send 36,000 telegrams. There are 1,162,000 people over the age of 85.1 conclude by looking on the bright side. My hon. Friend the Member for Broxbourne (Mrs. Roe) referred to her work with the all-party hospice group, there have been interesting developments in Holland on passports to live, which have been introduced as a reaction to some innovations there, and a number of people have changed their minds, as people do.

Advances in palliative care could eventually rule out one of the arguments made in favour of euthanasia— that it should be an option for patients whose quality of life is negligible. Whereas euthanasia aims to end suffering, palliative care aims to alleviate it. Specialists

working in the field say that modern palliative care is changing the face of medicine as it seeks to relieve the effects of illness rather than to cure the disease. If doctors could guarantee a high quality of life up to the moment of natural death, euthanasia campaigners would lose their central argument. The case of Diane Pretty was interesting, and I declare an interest as a patron of St. Barnabas Hospice (Worthing) Limited, which does fantastic work, as, I am sure, do the local hospices of many hon. Members.

I reiterate the questions to the Minister on the Government's commitment to increased funding for hospices, which have been particularly badly hit by national insurance increases. However, I appreciate that she has made some announcements about the standardisation of provision of free national health services to hospices. The subject is very difficult, but we should not duck it. Parliament must keep up with the scientists and medical professionals and must engage in a proper debate, otherwise we shall continue to have high-profile cases that cause enormous pain, anguish and confusion for individuals and their families and that leave doctors in difficult positions.

I hope that today's debate leads to a wider discussion of the more substantial basis of the subject, as the role of Parliament is to foster debate, make difficult decisions and give a lead. As my hon. Friend the Member for Southend, West said, Parliament has an opportunity to reclaim its power and to take the initiative on the matter. I hope that it does so.

10.49 am

The Parliamentary Under-Secretary of State for Health (Yvette Cooper)

I congratulate the hon. Member for Southend, West (Mr. Amess) on securing a debate on such an important subject, on which many in the House and throughout the country have strong views. The debate has been well-informed and expert, with speeches from my hon. Friend the Member for Bolton, South-East (Dr. Iddon), who has extensive interest in the subject and has studied it in great detail, and from my right hon. Friend the Member for Rother Valley (Mr. Barron), who has participated in many discussions with the General Medical Council and has considered the extensive consultation that it undertook.

Let us be clear from the beginning; euthanasia is illegal. The intentional taking of life, whether at the patient's request or from a merciful motive, is illegal in this country. The Government support that position and do not plan to change the law.

The legal position has been reinforced by the difficult case of Diane Pretty, which went to the European Court of Human Rights. United Kingdom court law was clear that there are no circumstances in which active intervention can be legitimately undertaken to bring about someone's death, even at that person's request. In 1993, the House of Lords Select Committee considered the matter in detail and decided against support for legalising euthanasia, for fear that vulnerable people might feel pressure, whether real or imagined, to request an early death.

None of that should detract from the real moral and ethical difficulties raised by the case of Diane Pretty. I am sure that all hon. Members would want to offer sympathies to her family and pay tribute to its bravery in

difficult circumstances. We should recognise that while many in this House and throughout the country consider the law too relaxed, others support the views of Diane Pretty, and other people who think like her, that the law should change in the other direction. The Government do not support changing the law, other than in particular areas of decision-making.

Hon. Members have raised a series of concerns, and I shall address as many as I can in the available time. The possibility that elderly people are receiving inadequate care is unacceptable in the national health service. We have drawn up a national service framework for older people to raise the quality of care, and made it clear that age discrimination is unacceptable in the NHS, but we should recognise the hard work of staff in the NHS who strive to provide the highest quality of care to elderly people in hospitals, the community and in nursing homes. It is also unacceptable to exclude from decisions on treatment those who are able to consent.

We strongly support, too, the work of hospices, which are world leaders in the provision of palliative care. Hospices are showing increases in their resources from the NHS and fund-raising, which is a good thing. We are increasing resources for hospices, and need to continue to do so.

Concerns were raised about the possibility of "euthanasia by stealth"—to quote some hon. Members. We should be clear that people have a right to refuse treatment; they may choose to have treatment withdrawn. My hon. Friend the Member for Bolton, South-East raised the case of Miss B, whose wish it was that her treatment, including being maintained on a ventilator, be withdrawn. The medical team considered that other options, such as rehabilitative treatment, should be pursued. Eventually, the case came to court. The court made it clear that under the law people have the right to consent to the giving or withholding of treatment, except in particular circumstances such as those set out in the Mental Health Act 1983. The law requires consent to be obtained from adults who are able to give that before the provision of medical treatment.

A health professional who gives treatment without consent could be guilty of both battery and negligence. If a patient has validly withdrawn consent to treatment, provision of such treatment against the patient's wishes constitutes a battery or, in more everyday terms, an assault. In the case of Miss B, the court decided that she was capable of making a fully informed decision on that issue. The underlying principle is that a competent adult has the right to consent to, or to decline, medical treatment, and can decline such treatment even if the decision would result in death.

More difficult questions arise if people are unable to consent or choose themselves. English law distinguishes between those who made their views clear when they had the capacity to do so and those who did not. The law provides that if an advance refusal is valid and applicable to the circumstances, it must be respected.

If people have not set out their views in an advance directive, the law provides that they must be treated in their best interests. Best interest should not be confused with purely medical interest because it represents a holistic view that takes account of people's wishes and preferences when they were competent, including their psychological health, their well-being, their quality of

life, and their medical condition. It should not be assumed that treatment is always in a person's best interest. Treatment itself can impose burdens through either the means of delivery, such as drips and tubes, or side effects.

Hon. Members mentioned the Tony Bland case, and in the judgment on the case in the House of Lords, Lord Goff stated: To presume that the incompetent person must always be subjected to what many rational and intelligent persons may decline is to downgrade the status of the incompetent person by placing a lesser value on his intrinsic worth and vitality. If treatment is not in the best interest of a person— perhaps because the burdens that it would impose outweigh the benefits that it could bring—it cannot be lawfully continued. Continuing such treatment would be an assault on the person. That is true even if the person would die from his or her underlying condition.

Hon. Members raised points about artificial nutrition and hydration. In the Tony Bland case, the court set out that artificial systems for delivering nutrition form part of the medical treatment or care of the patient. That reflects the fact that artificial systems can place burdens on patients and, as a result, patients in hospital sometimes try to pull such tubes out. Under current case law, if artificial nutrition and hydration is agreed to be not in the best interest of a patient, continuing that is unlawful. If any patient is capable of taking nutrition, withdrawal of fluids and food is illegal. However, it is important to understand the law on the subject.

I understand the concern that Parliament should discuss that matter, and I agree that it is important to have full discussions in debates such as this. Our unwritten constitution includes traditions of both case law and parliamentary sovereignty, and nothing is new about this issue compared with any other. Decisions on the best interest of a patient should be taken on an individual, rather than a parliamentary, basis. It would be wrong for Parliament to try to pronounce on the basis of individual cases. We should ask what is the right legal framework within which such individual decisions may be taken, whether they are taken by the patients themselves or, if patients are not capable of doing that, by health professionals in discussion with relatives or, if necessary, even by the courts.

Dr. Pugh

Will the Minister give way?

Yvette Cooper

Time is extremely tight, and I am trying to respond to final points. If I can give way, I shall.

The Government do not believe that there is a case for changing the law. The Lord Chancellor's Department set out points on "Making Decisions", and we shall legislate when parliamentary time permits. However, we do not think that it is necessary for Parliament to change the law on best interests, decision making and euthanasia. Clearly, there will be debate on the subject, but we should recognise that there is no consensus on an alternative to current law. There is no simple alternative that we can roll out to which Parliament will sign up. We need to follow the debate, which will continue. When necessary, the Government will consider issues raised, but this is a difficult subject, about which people will inevitably have very strong, conflicting views. I think that our legal framework strikes the right balance.