Assisted Dying Bill [HL]
Lord Ribeiro Excerpts(10 years, 1 month ago)
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Lord Ribeiro (Con)
My Lords, I should like to speak as we have heard many noble Lords speaking but we have not heard from the medical profession. Noble Lords will have heard that the majority of doctors are not supportive of being involved in the decision-making process. The reason is very clear. I, as a surgeon, on more than one occasion had to deal with children and adults—but children particularly—whose parents were Jehovah’s Witnesses. If an operation was needed that required transfusion there was a dilemma between my opinion that surgery and transfusion were necessary to save that child’s life and the parents’ decision that under no circumstances was a transfusion to be given.
What has made life easier for doctors is that we can now go for a judicial decision, made by the judges as to what should happen. That happens when, as was mentioned earlier, you have to divide a Siamese twin, to which the noble Lord, Lord Pannick, referred, or when you have to switch off the machine. These are important life and death decisions. Surgeons have always been referred to as people who play God and carry out life and death decisions, but the fact is that this is a situation in which they feel comforted that the decision is taken outwith their domain and taken by the judiciary. The same principles apply here, in this case.
I am slightly varied in terms of whether I support the noble Lord, Lord Pannick, or the noble Lord, Lord Carlile, but, in either case, doctors should be as far removed from decision-making as possible. If it is decided that assisted suicide should then happen, the mechanism and how it is done and whether it involves the medical profession is something to which we can then apply our minds. But the initial decision must be underpinned by the judiciary.
Baroness Finlay of Llandaff (CB)
My Lords, as another doctor I follow the noble Lord, Lord Ribeiro, who has explained so clearly why doctors do not feel that they should be involved in this. Indeed, my feeling is that the noble Lord, Lord Pannick, has made a very important first step, but I worry that his amendment does not go far enough. For that reason, the amendment tabled by the noble Lord, Lord Carlile, about which we will hear more in further groupings, is the way forward.
I reassure all Members of this House that compassion is at the heart of those who do not support this Bill. My objection is on public safety to protect those who are vulnerable. I declare an interest, having looked after these patients for more than a quarter of a century. I have looked after thousands of people—I have had hundreds of conversations with people who wanted their lives to end. Then we have done things, and they have not persisted with those requests.
I address very briefly the issue of finance. Please do not forget that many people who are dying are already reliant on charitable funds of different sorts to support them. I do not believe that it is beyond the wit of our society to find a way of having pooled funding that can be drawn on to support the fees for a legal process where it is absolutely right to go through one, and society deems that it is. It is dangerous to have the illusion that money would get in the way.
I address a couple of points that have already been raised in the previous excellent and outstanding debates, when examples were given of poor pain control. As a clinician, I was horrified at the bad care. There is no excuse for not redoubling efforts to relieve symptoms or to withhold analgesia from someone who needs it; even if you know that you are taking a risk and you are clear with it, there is absolutely no excuse, and our law does not require doctors to withhold all efforts to relieve distress. But doctors have to look after patients, and we are often in a difficult situation.
The noble Baroness, Lady Mallalieu, laid out very clearly the problem of coercion and coercive pressures, and I completely agree with her. There are external pressures, and pressures now coming from healthcare. Sadly, it is true that not all doctors are good doctors. At a meeting this week, we heard from the CQC that 2% to 3% of general practices will probably have to go into special measures and that 20% to 30% are below substandard. Yet the Bill without these amendments leaves decision-making in the hands of people—we know not what. We will go on to address all the inadequacies in the Bill.
There are families where there is carer fatigue—they are worn down. I have had families refuse to take patients home because they are fed up with their relative. That is a really difficult conversation to have with anybody. Indeed, I have had relatives pressurise me to give something to end a life and get it all over with—yet the patient has not wanted their life to be ended. As I have already explained to your Lordships, I discovered later, after the birthday of one female patient, that it was her fixed-term life insurance policy running out that drove the request to push up the drugs. After her birthday, they did not get the extra money and they visited less. I am afraid that I was taken in before I knew that, and I have been taken in time and again—because, while most parents love their children, sadly, not all children love their parents. It is difficult to detect coercive pressures, but then there is also the selflessness that patients may feel when they know that they are imposing a burden on their family.
Let me give a cogent example. I was asked to see a man by a GP who said that the man was a clear case for euthanasia or assisted suicide but that he could not give him a lethal injection. That was the only reason the GP was referring him. The consultant surgeon, oncologist and GP all thought that the man had a life expectancy of three months. His wife had just given birth to their third child. There was a small baby there. I went straight out and I was there until 11 o’clock that night. The distress was overwhelming. Weeks later, the distress was calming down. Much later, when I had conversations with that man, he said that the pain had been overwhelming and the prospect of becoming paraplegic and wheelchair-bound was overwhelming and terrifying but that also at the back of his mind he wondered how his lovely, beautiful postnatal wife could cope with their three children, particularly the new baby, and look after him as well. He felt that it might be best for everybody if he was not there. I spoke to him this morning. He said that I could relate his story. He can see the dangers of what is proposed because he lived way beyond three months. We will discuss prognosis and the difficulty of determining who is terminally ill later.
However, if the court were to receive evidence from experts, not the doctors described in the Bill, and assessment of capacity were done properly by experts, the court could make a balanced decision and that would not contaminate the way that clinicians behave. It would not put clinicians under a lot of pressures which are difficult to untangle and it would maintain their prime duty to relieve the distress of the patient in front of them, and to help the family and carers cope and redouble their efforts when they fail. It is for that reason that I think the Bill is wholly inadequate without such a control.
Medical Innovation Bill [HL]
Lord Ribeiro Excerpts(10 years, 6 months ago)
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Lord Ribeiro (Con)
My Lords, I am pleased to follow the noble Lord, Lord Winston, who is an acknowledged innovator outwith the accepted norm. I welcome the introduction of this Bill, which has generated much interest and debate following the recent NHS consultation—based, I might add, on an earlier iteration of the Bill. The Bill we are discussing today is simple and easy to implement, if confined to hospital practice involving surgery and interventional procedures. The terms “treatments” in Clause 1(3)(e) and “treatment” in Clause 1(4)(b) open this up to all treatments provided, whether in the regulated area of the NHS and private hospitals or the unregulated area of the cosmetic industry, where unqualified practitioners may undertake Botox treatments for cosmetic purposes.
During the early stages of the Bill I met my noble friend Lord Saatchi with colleagues from the Pelican Cancer Foundation, a cancer charity, to explain some of the barriers to innovation that we had experienced. These have been mirrored by Sir Robert Francis and were identified earlier by the noble Baroness, Lady Bakewell: bureaucracy, scarcity of resources and ethical reservations. We stressed the importance of keeping patients at the centre of the decision-making process and providing them with as much information as possible on, for example, the number of patients who had previously received the procedure or treatment; the percentage cure rate of the treatment; the likely impact of side effects and an obligation to explain the impact of those side effects to the patients. These are all encapsulated in Clause 1(3)(c) and (e). The Medical Defence Union and others feel that Clause 1(3)(e) is unnecessary, given the current use of Clause 1(3)(d), which deals with informed consent.
Informed consent is even more important when dealing with new and untried techniques. The practice of medicine is regulated through numerous guidelines, guidance, protocols and pathways which must be followed to ensure the safe delivery of care. Many of these did not exist when I began my surgical career and I was free to innovate in the best interests of my patients, usually after joint consultation and agreement. This is not the case for surgeons today. The advent of laparoscopic cholecystectomy, or keyhole removal of the gall bladder, is a case in point. In 1989, a French gynaecologist removed the gall bladder of a patient while carrying out a routine gynaecological operation. As we heard earlier, gynaecologists have been rummaging around in the stomach with their little telescopes for an awfully long time. This ushered in a new era of surgery, which challenged the gold standard of open surgery for gallstones that had held for 100 years.
However, the freedom to undertake such operations without any oversight came at a price to some of the patients involved, who developed unnecessary complications. At the time, I set up a national register to collect data on laparoscopic cholecystectomy, from which we published reports of complications to warn colleagues of the hazards of these new procedures. It is an innovation which would be impossible to introduce today and many of us would be considered mavericks for carrying it out.
The Royal College of Surgeons and the Government established a minimal access training unit to teach the new procedure and, in 1996, introduced a safety and efficacy register for new interventional procedures, called SERNIP. The register accumulated a list of new procedures and allocated each to a category, signifying its perceived degree of safety and efficacy, but it had no legal power and so its effects were limited. It was taken up by NICE in 2002 and remains within its remit. If the Bill is adopted, it would be essential to have a national register with legal powers to log and follow up with patients. I am delighted to hear that Oxford University has agreed to undertake this.
One way to ensure the Bill’s stated aim—that it,
“allows the test of whether innovation is negligent to be applied at the time when the doctor is deciding to innovate”,—
is to provide access to expert independent advice, particularly when the multidisciplinary team or the body of one’s peers fails to sanction the procedure being proposed. The invited review mechanism deployed by the Royal College of Surgeons to assess failing surgical departments in the NHS at the request of a trust board could act as a blueprint for such independent advice, providing two experts from relevant specialties to review the case for innovation, one from the Royal College and the other from the specialty association or society. This is no different from requesting a second opinion—something we all find valuable and which reassures patients that a body of opinion agrees with your proposals for treatment. The situation becomes more complicated, however, when the practitioner does not have a responsible officer, an MDT, a clinical director, a medical director or a chief executive to consult and, as in the case of the NHS, to approve the introduction of a new technique or procedure.
The overarching umbrella of protection—some may say “bureaucracy”—is not available to non-NHS practitioners, some of whom are not medically qualified but undertake cosmetic procedures in the private sector. Some, for financial gain, may work out of their own clinics or hospitals. How can we ensure that the treatment they provide is covered by the Bill? Will they also be free to innovate? The answer is yes, because they do already. Some end up creating problems and facing negligence charges, but they would not enjoy the protection that the Bill provides. This is something that we must look at carefully. When we talk about cancer, it is very easy to talk about innovation and freeing people from the shackles that bureaucracy provides because we all want the best for our patients, particularly when we are dealing with cancer. However, the use of the term “treatment” opens up the Bill to a wide area that will need to be covered. That is the only area that I have reservations about; otherwise, I am in support.
Tobacco: Smuggling
Lord Ribeiro Excerpts(12 years, 8 months ago)
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Lord Sassoon
My Lords, I can point to the success over the past decade of HMRC in particular, helped by the contribution of the UKBA, and it will be the same people, however configured, carrying on. As I have explained, money has been specifically targeted. As my noble friend also indicates, under the World Health Organisation there is a legally binding international treaty, which will also contribute to the further drive in this area.
Lord Ribeiro
My Lords, I congratulate the Government on their plain packaging campaign, which aims to reduce smoking by the young. Will the Minister confirm that the identification codes on packets of cigarettes make it easier to identify contraband products and thus remove them from this country?
Lord Sassoon
My Lords, on plain packaging, it is important to recognise that this is an open consultation on which the Government do not have a view. The contributions we are getting are important and helpful to that ongoing consultation.