Joint Committee on the Draft Mental Incapacity Bill Written Evidence


76.Memorandum from Dr David Kingsley (MIB 731)

  I am responding to the inquiry into the proposed Mental Incapacity Bill in my capacity as a practising clinician and also as a doctor with an interest in Medical Ethics. I hold specialist registration in Psychiatry with the General Medical Council. Over the years I have worked in a number of clinical disciplines, my experience of which leads me to have some grave concerns about the Bill in its current form, which I will detail below.

1.  INTRODUCTION

  1.1  The need to provide improved decision-making structures and protection for those who lack the capacity to make decisions for themselves cannot be questioned. However, I believe that the proposals within this Draft Bill would do the opposite, in a similar way to proposals in the previous 1997 Green Paper "Who Decides", as I pointed out at the time (Kingsley 1999). The current proposals would disempower vulnerable people and make them prone to decisions being made on their behalf that they may neither agree with nor would be in their objective interests. Such decisions may include decisions about their very life or death. Furthermore, clinicians may actually be forced to act against their judgement of a patient' s best interests, in such a way as to cause the patient to be seriously harmed or killed. As such, this Bill would be more likely to do harm than good to vulnerable adults, and should have no place on the statute book of a democratic country that claims to wish to support and protect its vulnerable citizens.

2.  BEST INTERESTS

2.1  The "New" Medical Ethics

  2.1.1  It has been traditionally held in routine medical practice, as expressed in the Hippocratic Oath, that a doctor should always attempt to act in a patient's best interests. The Oath states, "I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion." Such an interest in doing what is "for the benefit of my patients" particularly applies to the treatment of those who are incapable of giving consent or of expressing their personal wishes in regard to the treatment they may receive. However, over recent times, a shift in ethical values within medicine and society has led to this principle being over-ridden. The most clear example of this is in regard to the acceptance of the practice of abortion within medical practice. This undermined the entire ethical basis of medicine up to this point. The maxim primum non nocere or "first do no harm" has been abandoned. Obstetricians who previously considered the lives of both of their patients equally (the unborn child and its mother) now willingly slay one patient (the incapable silent one) at the whim of the other. Human persons are now created for the prime purpose of experimentation and then murdered in embryological research. Embryos are discarded every day in IVF procedures as they are "not needed".

  2.1.2  In order to justify such practices, Medical Ethics have moved from absolutist positions such as that expressed in the Hippocratic Oath, where life is considered to be a basic good due to all, to more relativist utilitarian positions. It is now felt that not only the best interests of the patient should be considered, but the interests of society, relatives, doctors and other staff, society, finance, etc. One can easily see how such a shift leads to decisions being made that are clearly NOT in the patient's best interests.

  2.1.3  I believe that it is essential in this Bill to re-think the definition of "best interests". It is, of course, helpful to take into account the person's past and present wishes and feelings as well as those of their relatives or representatives. But these considerations should never override certain objective ethical principles as well as a clinician's judgement about the best assessment or treatment options available. Also, I strongly believe that it is never in a patient's best interests to be subject to any act or omission that has the direct intention of causing their death. This particularly applies (as I will mention below) to the withdrawal or withholding of food and fluid from a patient, which I believe is always unacceptable.

  2.1.4  The relevance of this massive shift in medical practice now influences many areas of clinical practice. For example, those with Learning Disability are often treated with disdain and receive poor medical care. I have personally had to fight for medical care for such people, when clinicians from other specialities have not seen their lives as of enough value to be worth treating with the same standard of care as their other patients. Moreover, people with Learning Disabilities are particularly vulnerable to being physically or sexually abused by others. It is now common practice for a person with Learning Disability who lacks the capacity to enter a sexual relationship, to be allowed to be sexually exploited by other patients (who may also have limited capacity). This is seen to be giving them their "rights"—but is actually allowing them to be abused. The only issue that is considered is to ensure that the patient is sterile—either by using injectable contraceptives or enforced sterilisation "in the patient's best interests". In my mind this is legally sanctioned sexual abuse, but it is now considered routine practice. I am somewhat encouraged to see in the Bill (Section 1, Para 26) that it is not considered possible to make a decision on behalf of an incapacitated person in regard to them having sexual relations. I hope that this will bring to an end the widespread practice I have mentioned of allowing people who do not have the capacity to make such decisions to be preyed upon sexually.

  2.1.5  Lord Mustill, a member of the 1993-94 House of Lords Committee on Medical Ethics and a member of the appellate committee that decided the case of Airedale NHS Trust versus Bland (1993) went so far as to suggest that Tony Bland, who was in a Persistent Vegetative State, had NO best interests because of the nature of his disability. This is a shocking statement and shows how far Medical Ethics have deteriorated to this point. PVS is a condition where much of the cerebral cortex is not functioning, but the brainstem, which controls basic functions of life, works fine—the patient's heart beats and lungs breathe quite normally. All that is required is that the patient be fed—no different from a newborn baby. And yet a senior Law Lord can say that such a person has NO rights. But then neither does a newborn baby up to the very minute of its birth in current legislation, so it is not hard to see how such a judgement could be made in the current climate. I have had to witness the delivery of a dead full-term baby whose mother had taken a train to London the day before for the baby to have potassium solution injected into its heart to kill it. The baby had some late-identified imperfection that led its mother to decide she would rather it died than lived. I find such practice sickening—it appears to me to have more in common with Nazi Germany than with a so-called democratic society that claims to wish to protect its citizens. I find it ironic in the extreme that we make such a fuss about the case of Harold Shipman, when I have colleagues who are mass murderers of unborn children and are sanctioned in their actions by government. It does not make me very proud to be a doctor.

2.2  Food and Fluid is Basic Care, not Medical Treatment

  2.2.1  Along with the change in ethical values, has come a change of language and meaning, in order to allow for practices to take place that would otherwise be inconceivable. A key manipulation of language took place within the Bland case, in regard to redefining food from basic care to medical treatment. In my view, this was an appalling decision, that gives doctors the power to choose who lives and who dies—because none of us, whether ill or not, will survive long if we are not fed or watered. I believe that there is a duty of care to ensure the provision of such care to all patients, irrespective of their mental capacity or physical condition. If it is not possible to provide nutrition and hydration by ordinary means, a doctor still has a duty to find a way of doing so even if a "medical procedure", such as the insertion of a PEG tube, is the only possible method. If a patient has the capacity to consent, then the initiation and ongoing use of artificial feeding requires consent, as would the "natural" feeding of a patient with a spoon or cup, if this were required. If a patient with the mental capacity to do so decided to refuse such care, it would constitute suicide; if the decision were made for him it would be murder. In the case of a patient without the capacity to consent, all should receive food and fluid, by whatever means are necessary as part of the basic care due to them.

  2.2.2  Obviously, if a patient is in the actual process of dying, the insertion or use of a tube during these hours may be intrusive and inappropriate. However, this could not be used as a valid reason for withholding food or fluids if the time taken to die was so long as to put the patient at risk of dehydration or starvation and the consequent suffering.

  2.2.3  I would argue that there is no ethical difference between "withholding" and "withdrawal" and would therefore state that there are no moral grounds for either withholding or withdrawing food or fluid, whatever means may be necessary to administer this care.

  2.2.4  Many people are dependent on artificial hydration and nutrition who are in little or no imminent danger of death from their medical condition. Patients in PVS fall into this category. I entirely reject the judgement in the Bland case, which I would maintain was not about "withdrawal of treatment" but about killing a man by omission of the food and fluid he needed to survive, leading to a barbaric death from dehydration and starvation. By omitting to feed a newborn baby one could kill it in a similar way, as it is completely dependent for its survival, and yet this would be considered infanticide. There is no philosophical difference between the two cases; only a difference in the language used which makes the first instance seem to be a compassionate treatment decision and the second, clearly murder.

  2.2.5  The fact that the withdrawal of food and fluid leads to such a slow and unpleasant death by dehydration and starvation, would appear to be, perversely, one of the reasons for the "pro-death" euthanasia lobby being so supportive of such withdrawals of food and fluids. The reason for this may be that they may then hold up such cases of unpleasant deaths as increased reason for legalising the possibility of putting these unfortunate people to death "humanely", by a "quick and painless" lethal injection. We must fight the possibility of this progression by strongly rejecting the necessity for any patient to die in this inhumane way, by having their basic human right to food and fluid withheld or withdrawn.

  2.2.6  In actual fact, the withholding or withdrawal of food and fluids sanctioned by the Law Lords in the Bland judgement already constitutes euthanasia, as defined as "the intentional killing by act or omission of a person whose life is felt not to be worth living".

  2.2.7  Many Health Professionals share this assertion that food and fluid should not be considered as medical treatment. Following the Bland judgement, the Royal College of Nursing (1993) said: "The RCN view differs from the judgement of the Law Lords in that nurses believe that to stop food and drink is a different issue from the decision to stop other forms of medical intervention". I believe that any planned legislation needs to reverse previous statements and clearly state the difference between food and fluid and other medical interventions, namely that food and fluid constitutes basic care. Statute law needs to overturn the Bland judgement in order that euthanasia by omission is once more outlawed in our country. Otherwise the outlook for the weakest and voiceless in our society can only get worse rather than better.

  2.2.8  The Human Rights Act (1998) also seriously contradicts the Bland judgement, and would be in opposition to the Mental Incapacity Act were it to come into force. Article 2 clearly asserts each human person's right to life and Article 3 protects against degrading or inhuman treatment. I find it hard to see how enshrining in law the right of doctors to starve patients to death (who otherwise would not be in a life-threatening condition) can be countenanced in the light of this Act.

  2.2.8  In summary, I believe that for the Mental Incapacity Act to provide any sure protection to vulnerable people, it is essential that the Act overturns recent case law by defining the provision (by whatever means are necessary) of food and fluid as basic care, not medical treatment, the withdrawal of which can never be justified, unless the person is close to the point of death and would not suffer the consequences of dehydration or starvation.

2.3  Importance of Accurate Diagnosis and Prognosis

  2.3.1  It is essential that patients in whom the withdrawal of treatment is being considered, have their diagnosis confirmed and a firm prognosis made. Where there is doubt regarding diagnosis or prognosis, as is often the case, no decision to withdraw or withhold treatment should be made. There will otherwise inevitably be patients who have the potential for recovery who do not receive the medical treatment they deserve.

  2.3.2  This issue applies particularly in regard to Persistent Vegetative State (PVS), which may be misdiagnosed, and the prognosis of which may be poorly judged. In all cases regular specialist assessment by Rehabilitation Neurologists and Neuropsychologists should take place to make a firm diagnosis and assess the possibility of specific functioning linked to tiny amounts of functioning cortex. These patients should not be treated in a District General Hospital, or even many Rehabilitation Units, as they should be placed in a unit where the timeframe can accommodate for the slow pace of recovery. In the Royal Hospital for Neurodisability in Putney, such a specialist unit, an element of recovery has been seen up to two and a half years after the onset of PVS and many have recovered up to a year after onset. As there is a 95 per cent five-year mortality for PVS, those not destined to recover will die a natural death soon enough. I repeat that it is never appropriate to kill these patients by withholding or withdrawing their food and drink, however administered, as this can never constitute medical treatment. It would, however, be reasonable after all hope of recovery had passed, to withhold aggressive treatment of intercurrent illnesses allowing a natural death to take place. It would be important for the Medical Visitors appointed by the Court of Protection to include specialists in Rehabilitation Neurology, in order that vulnerable patients (especially those suspected of being in PVS) are guaranteed adequate assessment and treatment, rather than inadequate management and premature death—as is often the case currently.

  2.3.3  It is important to stress that there are, of course, circumstances in which it is not appropriate officiously to strive to prolong life. Initially a full assessment of the patient, including second opinions where necessary, should take place in order to confirm the diagnosis, prognosis and possible treatment options. Where there are doubts regarding these elements, active treatment should not be withdrawn. Treatment should only ever be withdrawn inasmuch as it allows a patient who has a serious and irreversible condition to die a natural death. Palliative Care principles should guide such treatment as may be necessary to allow death to be as comfortable as is possible, without intentionally shortening life. Food and fluid should never be considered as medical treatment in this circumstance.

3.  ADVANCE DIRECTIVES AND STATEMENTS AND TREATMENT DECISIONS

3.1  Impossible to obtain truly informed consent

  3.1.1  I reject that Advance Directives have any moral or legal validity, irrespective of their content. Legislating for their use would be dangerous and would significantly reduce the protection offered to the most vulnerable. Valid consent or refusal to treatment is only possible when the patient has full knowledge of the condition from which he is suffering and the exact treatment being offered for this condition. Neither of these criteria can be fully met in an advance directive, therefore the documents can never be valid.

  3.1.2  I would go further and suggest that it is also essential for a patient to actually experience a situation to know how they feel about it and hence how they wish to be treated. It has been convincingly shown that the "well" choose differently from the "sick". Gardner et al. (1985) studied high tetraplegics who had been kept alive by artificial ventilation and found that of 21 asked, 18 would have chosen to be electively ventilated again, should the need arise. Two more were undecided. This response differs markedly from that which one would expect from the general population who might imagine themselves being in such a situation. Therefore, even if it were possible to provide the information required for informed consent in advance of the circumstances, it would still be impossible to consider such an advance decision as valid.

3.2  Clinical Implications of Advance Directives

  3.2.1  Even if a patient could (theoretically) validly refuse or consent to treatment in advance, there are further ramifications of advance directives. A doctor then has to act upon the directive, which may not be compatible with his ethical values or clinical judgement. His autonomy is thereby excluded entirely. He should not be bound to act entirely in accordance with this directive in spite of his own moral reservations or clinical opinion of the patient's "best interests" or prognosis at that time. At the very least, it is imperative that a conscience clause similar to that within the Abortion Act is added, in order that doctors who do not find it acceptable to kill patients by withdrawing their food and fluid may be able to opt out.

  3.2.2  The content of Advance Directives is also often faulty, with vague statements about the nature of conditions in which a patient may find themselves and the treatment they would want to receive or not receive. A typical form of words in Advance Directives refers to a medical state "which is likely to be irreversible". However, medical prognosis is somewhat on a par with weather forecasting in Britain—frequently right, but often hopelessly wrong. Many patients may end up not being treated for perfectly treatable conditions simply because they had unadvisedly signed an Advance Directive, leaving the clinician powerless to stop the patient dying a quite needless and/or unpleasant death. Vere (1984) summarises it well by suggesting that "A living will says, in effect, to a doctor: `If you could know what you don' t know, then I would like you to act as I believe you would were you to know it'.

  3.2.3  Medical science advances at an ever-increasing pace. New assessments and treatments become available all the time. However, if a patient has made a previous Advance Directive, they would be unable to revoke this (if they lack capacity) in order to receive a new treatment. The House of Lords select committee that reported in 1994 acknowledged this issue, saying that giving Advance Directives legal force would risk "depriving patients of the benefit of the doctor's professional expertise and of new treatments and procedures which may have become available since the Advance Directive was signed."

3.3  Advance Decisions and Mental Illness

  3.3.1  As a psychiatrist, I feel that one key issue is the distinction between a wish to die and a suicidal intention in the context of a mental illness. I am not sure that the distinction can be made. This has serious implications. Patients who are suffering from a severe mental illness (and hence lack the capacity to make the decision to die) may be given state sanction to kill themselves. Were this to be the case, they would be seriously let down by the health system that should be able to protect them from themselves until they are so recovered as to lose their suicidal intent.

  3.3.2  However, it is important to be aware that this issue does not simply relate to a small group of patients with primary psychiatric illness. Kathol and Wenzel (1992) found that among 128 patients admitted to a general medicine ward, one third of patients had major depression. This is not surprising—being physically unwell and in pain or discomfort can be a depressing experience for many people. Many such people may feel that life is not worth living any more. They may express such views openly. However, it is important to realise that such people may well be suffering from a Depressive Disorder that leads them to feel this way. What they need is treatment for their mental disorder in addition to their physical illness—not the offer of an Advance Directive that encourages their morbid wishes to be put into practice. It is likely that in most such cases, the patient's "suicidal" wishes will change following successful treatment.

3.4  Summary

  3.4.1  For the above reasons, I feel that it is essential that Advance Directives do not become legally binding upon doctors. I accept that a verbal or written statement of future wishes regarding treatment may be helpful in informing a doctor prior to a relevant treatment decision, as may the views of close relatives or friends of the patient. But the doctor must be able to make a final decision, made primarily in the patient's best interests, which incorporates his own view of the current clinical condition, the prognosis and the available treatment options. I would hence suggest that the Bill clearly rejects the legal validity of any Advance Directive.


4.  LASTING POWERS OF ATTORNEY AND THE COURT OF PROTECTION

4.1  Lasting Power of Attorney

  4.1.1  This power is currently a useful instrument to enable a trusted person, usually a relative, or occasionally a solicitor, to manage someone's day-to-day affairs when they become incapacitated, often due to a chronic illness such as Dementia. However, the proposal to extend such powers to health decisions changes the nature of the instrument entirely. To literally hand the power for a person's life or death to a relative (who may stand to gain considerably financially by the patient's demise) is a preposterous suggestion. A case of such a situation was that of Marjorie Nightbert in the US, in a nursing home after a stroke. The Court judged her "not mentally competent" to revoke the power of attorney given to her son, despite her having being heard to ask a nurse for something to eat. She was hence deprived of food and fluid leading to her death on April 6 1995.

4.2  The Court of Protection

  4.2.1  Similar to the situation with Lasting Power of Attorney, the Court of Protection currently has jurisdiction only in regard to financial decisions. It is planned in this legislation to transfer the current High Court jurisdiction over disputed decisions in healthcare cases to the Court of Protection. It is surely ironic that a so-called "Court of Protection" would potentially have as one of its central roles the condemnation to death of vulnerable patients by the withdrawal of their fluid and nutrition. Would judges who were opposed to medical murder in this way be given the option to withdraw from such a role?

5.  ECONOMIC AND EUGENIC CONSIDERATIONS

5.1  Economic Issues

  5.1.1  As I have mentioned, in contemporary medical ethics it is deemed necessary to consider not only the benefits and harms to the patient, but also those to others—including society as a whole. Western democracies are currently facing an impending economic crisis due to the aging population. Birth rates have steadily dropped over recent decades, to the point where the number of births has dropped below the necessary replacement level of 2.1 births per woman. The European Union as a whole has a 1.4 child per woman birth rate. In the UK the rate is 1.75. Alongside this, the number of people surviving to old age increases all the time. The economic burden to care for an ever-increasing number of elderly people is falling on ever fewer people of working age. Essentially, if western society is to avoid implosion and economic collapse over the next half century, there are two options. Either young people need to begin having more children, or the elderly need to be drastically reduced in number. I would argue that the former of these suggestions is the only serious potential solution—but unfortunately my view is not shared by contemporary society, where there is little sign that people are prepared to choose to welcome children into their families in greater numbers. Such factors as transient itinerant relationships, ever-increasing divorce rates and career-obsessed women fuel this situation. On the other hand, the possibility that significant numbers of older and handicapped people with chronic and expensive to treat illnesses could be removed from society could be seen as economically appealing by some. A bill such as the proposed Mental Incapacity Bill would do just this. It does not seem, then, too far fetched to suppose that one of the aims of this Bill might be to save the state money by killing many of its most chronic and expensive patients.

5.2  Eugenic Issues

  5.2.1  "Eugenics" is a term coined by Francis Galton, an English psychologist and half-cousin of Charles Darwin, late in the last century. He explained the term as the principle of encouraging better human stock to breed and discouraging the reproduction of less desirable stock, thereby improving the human race. This expanded Darwin's theory of natural selection into a concept of deliberate social intervention, which he held to be the logical application of evolution to the human race. Gobineau subsequently wrote that a fair-haired Arian race was the best human stock from which to breed. Shortly after this, these ideas were expanded further by a British-born German citizen named Houston Chamberlain, who upheld the German race to be the purest form of Arianism and regarded Jews and Afro-Caribbean people as inferior races. At the same time, eminent psychiatrists, aware of the heritability of many mental illnesses and the difficulties in treating them, turned to eugenics as a means of eliminating mental illnesses if they couldn't be cured. From this idea came the mental hygiene movement, founded amongst others by Sir Cyril Burt, who also founded MENSA, the high IQ group which also espouses eugenic principles. Prevention of the birth of the mentally ill was the prime aim. Laws began to be passed, including the UK Mental Deficiency Act of 1913, which segregated the mentally ill from the rest of the population. Other laws were planned for the sterilisation of the insane. The rise of the Nazi party in Germany allowed the mental hygiene movement a free hand. In 1931 the eugenicists hoodwinked the German public by campaigning for voluntary sterilisation. Within four months after the Nazis came to power in July 1933, a law allowing compulsory sterilisation of all suffering from hereditary disease was passed But the eugenicists had more in mind. They flooded Germany and England with propaganda campaigning for voluntary euthanasia. In 1938 Professor Werne Catel. a professor of Neurology and Psychiatry at the University of Leipzig, persuaded Hitler to authorise compulsory euthanasia in 1939 for inmates of Germany's mental institutions. 275,000 were killed. It wasn't until 1941 that the policy was also extended to Jews and other undesirables.

  5.2.2  After the war, the name of eugenics was so heavily associated with the Nazis that a whitewashing procedure began. Eugenicists began to infiltrate organisations as fifth columnists and set up ostensibly unrelated institutions. Among these institutions were the Voluntary Euthanasia Society, the Marie Stopes Memorial Foundation, the Family Planning Associations and the International Planned Parenthood Foundation. All of these organisations were supported by the Eugenics Society. It is time that we recognised that eugenics has made its comeback in the form of the abortion and family planning lobby, the euthanasia pressure groups as well as the current obsession with human genetics and weeding out the so-called "abnormal".

  5.2.3  More unborn children have died since the introduction of legal abortion than were ever killed by the Nazis. As I have mentioned it is now legal in Britain to murder a child up to the day of its birth if it is deemed to be less than perfect. We create human persons to experiment upon and then kill. We create embryos in order to choose the best ones to implant for IVF treatments and then we discard the rest. We now are prepared to starve vulnerable patients to death by denying them the food and water that all of us depend upon for our existence.

  5.2.4  My grandparents died in Bergen-Belsen concentration camp in 1945. My medical colleagues (eminent psychiatrists in particular) were the first to collaborate in the Nazi holocaust. In memory of my grandparents and in reparation for the disreputable history of my profession, I am not prepared to stand idly by and accept the current revival of eugenic killing that is taking over the practice of medicine in Britain. This Bill is a thinly veiled means of establishing in legal statute the extermination of the most vulnerable and least "valuable" members of our society. It cannot be left unopposed by those who value each human person, from their conception to their natural death, as having equal worth and dignity.

6.  SUMMARY OF MAJOR POINTS IN THIS SUBMISSION

  6.1.  The contemporary medical ethic has abandoned the Hippocratic tradition of medicine, where life was valued as an absolute good, and where any act or omission where the intention is to end life would be unacceptable. This is the moral context into which this Bill is inserted.

  6.2  The concept of "best interests" needs to be based on a sound medical ethic. Some objective principles need to be applied. It can never be in a patient's best interests to be killed by act or omission, especially by dehydration or starvation—a particularly unpleasant manner of death.

  6.3  Vulnerable patients need to be properly protected against acts against them that are not in their interests—such as the widespread practice of allowing learning disabled patients who lack capacity, to be preyed upon sexually, often by other patients. This abuse is compounded by enforced sterilisation or injectable contraception, which is also administered without consent.

  6.4  All patients, regardless of their disability, need to be considered as human persons of equal value and dignity. Lord Mustill's disgraceful statement in the Bland case that Anthony Bland had no best interests was tantamount to saying that he was not human. Such a eugenic attitude has no place in law-making in a democratic country. This Bill needs to counter such bigotry by offering true protection to all vulnerable people, no matter the level of their disabilities.

  6.5  For the Mental Incapacity Act to provide any sure protection to vulnerable people, it is essential that the Act overturns recent case law by defining the provision (by whatever means are necessary) of food and fluid as basic care, not medical treatment, the withdrawal of which can never be justified, unless the person is close to the point of death and would not suffer the consequences of dehydration or starvation.

  6.6  The Human Rights Act (1998) seriously contradicts the Bland judgement, and would be in opposition to the Mental Incapacity Act were it to come into force. Article 2 clearly asserts each human person's right to life and Article 3 protects against degrading or inhuman treatment. I find it hard to see how enshrining in law the right of doctors to starve patients to death (who otherwise would not be in a life-threatening condition) can be countenanced in the light of this Act.

  6.7  Advance Directives can never be valid, whatever their content, as it can never be possible for a patient to give informed consent unless they have full knowledge of the condition from which they are suffering and the exact treatment being offered for this condition. These conditions can only be adequately fulfilled at the time, not in advance. Moreover, it has been well demonstrated that the "well do not choose in the same way as the sick".

  6.8  The contents of an Advance Directive may not be compatible with a doctor's ethical values or clinical judgment. He should not be bound to act entirely in accordance with this directive in spite of his own moral reservations or clinical opinion of the patient's "best interests" or prognosis at that time. At the very least, a conscience clause, similar to that within the Abortion Act, should be added, in order that doctors who do not find it acceptable, for example, to kill patients by withdrawing their food and fluid, may be able to opt out.

  6.9  One third of medical inpatients have been found to suffer from Major Depression in addition to their physical condition. Many patients who may express wishes to die or make other Advance Directives may not be capable of making such decisions due to their mental states. Such patients require psychiatric assessment followed by treatment for any identified mental health problem, after which their "suicidal" wishes are likely to change.

  6.10  In a society with an aging population and an increasing financial burden on able people of working age, it is suspicious that a Bill should be suggested that would save the state money by sanctioning the killing of many of its most chronic and expensive patients.

  6.11  It should be recognised that eugenics has re-surfaced in the form of the abortion and family planning lobby, euthanasia pressure groups as well as the current obsession with human genetics and weeding out the so-called "abnormal". This Bill is a thinly veiled means of making legal the extermination of the most vulnerable and least "valuable" members of our society. It cannot be left unopposed by those who value each human person, from their conception to their natural death, as having equal worth and dignity.

REFERENCES

  Gardner BP, Theocleous F, Watt J W H, Krishnan K R. Ventilation or dignified death for patients with high tetraplegia. BMJ, 1985; 291: 1620-1622.

  House of Lords Judgement. Airedale NHS Trust v Bland. 4 February 1993.

  Kathol RG, Wenzel RP. Natural history of symptoms of depression and anxiety during inpatient treatment on general medicine wards. J Gen Intern Med. 1992; 7: 287-93.

  Kingsley DM. Mental Incapacity. Psychiatric Bulletin (1999); 23: 240.

  Report of the House of Lords Select Committee on Medical Ethics. 31 January 1994.

August 2003





 
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