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Baroness Andrews: Perhaps I may make my contribution at this stage. I shall be very brief. It has been some time since we were previously in Committee and I wish to restate the Government's position, which, as with all Private Member's Bills, is one of neutrality. Essentially, we are holding the ring.

As I understand it, the amendment seeks to make clear that no offence would be committed if a decision to withhold or withdraw sustenance was taken on the basis of the patient's own views or, where those views cannot be determined, the patient's best interests. We have stated at various stages of the Bill—certainly at Second Reading—that the Government believe it is important to maintain those principles in considering any change in the law. That is my major statement on this issue.

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However, I raise one point that the noble Baroness may wish to consider. Subsection (5) of the proposed new clause states that an offence would not be committed if,

    "The primary purpose of the withdrawing or withholding of sustenance is not to hasten or otherwise cause the death of the patient".

This suggests that it is possible to distinguish between the different purposes of a doctor in taking a decision to withhold or withdraw sustenance. I suggest that in practice this will create problems because of the difficulty in establishing what is a "primary purpose" when the outcome of a decision to withhold or withdraw sustenance will always be the same.

The amendment does not resolve that dilemma, which we have discussed in relation to other amendments at previous stages of the Bill. The withholding or withdrawal of sustenance will always lead to the patient's death. Therefore, in law, a doctor taking such a decision could under the Bill be held to have intended that death. The noble Baroness may wish to give further consideration to that part of her amendment.

Baroness Knight of Collingtree: The Committee will recall that the last Committee stage of the Bill—in fact, it would be equally as accurate to call it the first Committee stage of the Bill—went on much longer than the Government wished. They needed that time for important business of their own and, when I saw the agonised expression on the face of the noble Lord, Lord Grocott, I judged it wise to bring matters speedily to an end. In doing so, however, I made it very clear that I would return to the spirit of the amendment I had been moving at the end of that Committee stage. It was an amendment which sought to ensure that no offence would be committed if the patient asked or indicated that he or she did not wish to be fed by tube or PEG.

Members of the Committee will concede that I have listened with great care to everything that has been said. I have tried my utmost to meet all valid concerns, from whatever angle they came. To that end, I shall move an amendment on Report which I believe will meet the case, but it is rather different trying to meet other objections and concerns. I believe it will be a more straightforward and easy amendment than the one before us.

I am very troubled about subsection (2) of the new clause. I fear it would lead to great pressure being put on patients. If you are old, frail and ill, you have neither the stamina nor the courage to withstand pressure, especially from important people like doctors whom you believe are about one and a half steps down from the Almighty. You are a very easy target for those who, for one reason or another, prefer your space to your existence. There are many, many cases on record of families who will gain from a relative's death putting pressure on that person: "You really are a nuisance to everybody, you really are a burden, it's time you were gone". Or they use body language. If they are caring for a sick person, they put

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the food down as if it has been a wretched nuisance to prepare. There are other ways of making the poor sick person think that he or she really ought to quit this world. These pressures frighten me.

The words in subsection (2)(a), (b) and (c) would be an encouragement to exert pressure and get the patient believing he was useless and a trouble to everybody. For doctors, the prize would be a bed freed—that is a goal devoutly to be wished if you have a health authority trust and a government screaming for shorter waiting lists.

What the noble Baroness, Lady Finlay, told us is very enlightening, but I suggest that she described her intentions in her speech rather than in the wording of the amendment. So much of what she said I understand and agree with, but what she said is not what the amendment proposes, and that really worries me.

I am sure the noble Baroness meant subsection (2)(b) to apply to food being given artificially, but it appears to apply to all food. I could not help asking myself whether the noble Baroness was suggesting that people should sign a form to say they want to be fed before they are fed. People understand why they have to sign a form of consent if they are to have an operation or receive some other medical treatment. But do we want to send the message that people will not be fed in hospital unless they actually ask to be fed? I doubt it. But there is no doubt that the words imply precisely that. I tremble to think of the trouble and work—as well as the incredulity—that such a rule would cause.

I have no objection to subsection (3)(a), but I do not see any need for it. Listening to the noble Baroness, I can understand much more what she intends the amendment to do. But the amendment, in raw words, does not mean quite what she says it is intended to mean. Of course it would be reasonable and right to seek to avoid pain or to worsen illness. But a doctor would simply have to record in his notes on the case that the procedure would be harmful, and state why. I am told by lawyers—indeed, the noble Lord, Lord Carlile of Berriew, was absolutely clear on this at Second Reading—that the courts would understand that the evidence, if it ever got to that stage, of having a written note showing why food and water were withheld was X, Y or Z was a very good and sound reason.

Lord Clement-Jones: It would be helpful if the noble Baroness referenced some of her points against some of the guidance that is currently available. In her criticism of the amendment, she seems effectively to be saying that the current GMC guidance should be scrapped in many areas. I should like to quote one area which is pertinent to subsection (2) rather than (3), although quite a lot of the guidance is pertinent to subsection (3).

Paragraph 13 of the guidance deals with the guiding principles on consent:

    "Adult competent patients have the right to decide how much weight to attach to the benefits, burdens, risks, and the overall acceptability of any treatment. They have the right to refuse

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    treatment even where refusal may result in harm to themselves or in their own death, and doctors are legally bound to respect their decision".

It goes on:

    "it is essential that doctors ensure that those involved in making the decision—

about nutrition and hydration specifically—

    "are provided with clear and up to date information about what is known of the benefits, burdens and risks of providing nutrition and hydration through artificial means".

Those two points are absolutely four-square with the points that the noble Baroness, Lady Finlay, made. Much of the amendment is trying to read back into the Bill quite a lot of the safeguards that the GMC insists upon for medical practitioners. Those seem entirely reasonable. If there were time, I could take Members of the Committee through every aspect of the amendment and reference it to the GMC guidance. In that light, this seems an entirely reasonable amendment.

8 p.m.

Baroness Knight of Collingtree: I do not doubt for one moment that the GMC guidance, along with the BMA guidance, was well intentioned. I made it absolutely clear at Second Reading that I was worried that, notwithstanding all the words in both sets of guidance, patients were still being done to death—there is no doubt about that whatever—by starving them or having them die of thirst in our hospitals.

When doctors originally wrote to me after hearing that I was going to introduce this Bill and said that they had the guidance, my response was, "Then it is not working, because this is happening every single day in our hospitals". That is what made me introduce the Bill and that is what makes me proceed with it, with all might and main. I cannot bear what is going on in our hospitals. I shall come later to the fact that the BMA and all doctors had ample opportunity to respond to the allegations I made on Second Reading about patients dying in hospitals, and not a single one did so.

As I was saying, subsection (3)(b) and (c) worry me deeply. I hope there is no quarrel about food and water being essential for life. If you do not have them, you die. But they are not medicines to make you well. To be denied food and water because that will not cure disease, which is what the amendment is saying, would be extraordinary. Often, although not always, we feel quite good after an excellent meal, but we do not eat it to make us well. If patients are only to be fed if it improves their medical condition, which is what the amendment proposes, I have serious fears for the future of those hospitalised.

Subsection (4) proposes that no offence is committed if the intention of withholding food and water is to relieve suffering. I could agree, except that I have to be convinced that one relieves suffering by imposing it and starving people to death. How can one relieve suffering by starving them to death or having them die of thirst? I just do not understand. I am not saying that it is unreasonable to ask the question in the amendment. I am only saying, if it can be done in that

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way, please tell me how. How can it be right to put people to that length of suffering and say that it is saving them suffering? By all accounts, a lot of suffering is caused in the deaths that I describe, and there is no shadow of a doubt that dying of thirst is a ghastly way to die. How does such dreadful torture relieve suffering? I suppose one could drug them senseless, but there would be no observable suffering then either way.

Subsection (5) refers to the purpose of withholding sustenance. Surely, that would be set down in the patient's notes, which, as I have repeatedly said, will be very important. The whole point of the notes is that doctors should record precisely why food and water is withheld. If there is a sound reason which is stated clearly and would be recognised and understood, that should be put down. No such rules now exist. If doctors had to write their reasons, many patients would be saved much torment, because no doctor would then withhold sustenance without a good reason. Is that such an unreasonable thing to ask? If sustenance in hospitals is going to be withdrawn, there must be a clear and explained reason why.

The reasons for the exception in subsection (6) would also be set down in the notes. I hope that we can have an end to being told that doctors are too busy or have not the facilities to make proper notes. We are talking here about life and death. If people cannot make a note, or cannot be bothered to make a note, or do not have time to make a note about whether a patient is or is not being done to death in this way, then I despair—I really do.

Subsection (7) should not stand. When every patient is the responsibility of a named consultant, the situation is clear. If the consultant can, any old time he wants, go off early for any old reason and delegate his responsibility to any old doctor who happens to be passing—even a very junior one—it is making very light of a patient's life. The noble Baroness, Lady Finlay, would never do that, I know. If she were responsible for a patient, she would be there all the time. But the sad thing is that all doctors are not like the noble Baroness. That is what I am trying to counter in this Bill.

Senior doctors sometimes have to go off and do other things, because they are busy men, but they can and must always be contactable and responsible. We are not really playing a game of pass the parcel.

I was recently told that named doctors no longer take responsibility for individual patients. I rang a number of hospitals to check that, and so far I have not found one hospital where that was not the rule. The near universal response to my query was, "Of course someone takes responsibility, and that responsibility does not get farmed out or changed at will". I have tried to find as much evidence as I can of that. It may be that some hospitals that I have not contacted do that, but I do not believe that it is the general practice. For good reasons, a doctor or consultant—someone named and known—is responsible for each patient.

I have other concerns about this part of the amendment. Earlier, I stressed the dangers of allowing a relative or next of kin to say that sustenance should

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be withdrawn. In this part of the amendment, it is suggested that even a friend should say that. I listened to the noble Baroness very carefully, and she said that the proposal was for people who are incapable of making decisions for themselves. Forgive me, but that is not actually in the amendment, although I have no doubt that it is in the mind of the noble Baroness. The amendment could be taken to mean any patient—it does not say "incompetent".

I can envisage doctors taking a relative into a side room and saying, "Old Bill is a bit of a nuisance now, you know. He is 78 or 84 or something, and it's really time he went". Doctors might talk like that, with the patient never agreeing. I know that the noble Baroness does not want that, and I do not believe for a moment that she intended it, but that is what the amendment says. We must not forget that relatives often have reasons of financial gain to want the person dead.

On Second Reading I cited three cases of unwilling patients being deliberately starved to death in hospital. I spoke of a TV documentary that showed several more. My allegations were made here, in one of the most public places in which one could ever make an allegation, and reported all over the place to interested people. If they had been groundless, I would have expected an outcry from the BMA and letters from hospital doctors saying, "We never, ever do that. Patients who wish to live are never done to death in that manner". Not one single word have I received disputing my accounts.

I have had letters referring to the guidance, and my answer is that however good the guidance is, I am concerned with what is actually happening. The only letters that I have had have been from individual doctors saying, "Yes, you're quite right, it is going on, and it ought not to go on".

Many have seen these amendments before us as wrecking amendments, seeking to kill the Bill. However, I have listened to what the noble Baroness said, and I accept her word that that was not her intention. I find it difficult if not impossible to believe that she really wants the cruel, ghastly and indeed unlawful killings of sick people to continue. I am always ready to meet her at any time to discuss any suggestions for further amendments, which would meet her concerns and still safeguard patients. That is the one thing from which I will not move. I must pursue my aim of safeguarding people from being done to death when they do not wish it. I say that to any noble Lord who has reservations about the Bill. It is a vital matter. If we can get together on any disagreements and sort them out, and still proceed, I should be the first one through the door.

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