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I welcome the general presumption in the Bill, as everyone has. Changing "incapacity" to "capacity" was significant. I have a particular concern about communication issues that I do not think has been aired during the debate. I address these comments to the House, but particularly to the Minister as I will not be applying to serve in Committee. These are particular issues that the Committee might want to consider.
I welcome parts of the Bill, especially the commitment to take every measure necessary to meet communication requirements. I am glad that the Government were able to publish the draft code of practice at a very early stage; I congratulate them on that. I have been able to look at it closely. I am glad that it is very much a draft. Looking at it from a Welsh point of viewthis Bill applies both to England and to Walesthere are glaring omissions in respect of a country that is officially and practically bilingual.
Hon. Members have referred to personal experiences, and I will refer briefly to the experience of my brother, who had a serious road traffic accident in 1972 and was in hospital for three years. Eventually he made a partial recovery, and he has subsequently had a very full life. The recovery of language after a head injury is a subtle and mysterious business. When my brother, who is trilingual, first recovered he spoke French, which was something of a problem in the emergency department of the Caernarfon and Anglesey hospital, as hon. Members can imagine. He moved on to speak English, which was no problem, and then Welsh, and essentially only Welsh, which was again something of a problem. My brother was communicating in the way that suited him, and it took a great deal of effort on the part of our parents, the five of his brothers and sisters and our cousins to talk to him continually, even when he was unconscious, to try to prompt him to start speaking. Initially, our communication with him was very slight, and as I said, it was in French.
Because of that experience, and having looked at the code of practice, I want to draw the Government's attention to some of its deficiencies and ask them to think again about the situation in Wales, at least, and possibly England, too, bearing in mind the ethnic minority population in both countries, many of whom
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are either bilingual or monoglot speakers of languages other than English. The situation in Wales is quite clear. There are 600,000 people who speak Welsh, and most of them also speak English. The Government's own figures show that there are 12,000 people who have learning difficulties. As 25 per cent. of the population speak Welsh, that means that there are 3,000 people with learning difficulties who speak Welsh, and because of their learning difficulties they are most likely to be monoglot Welsh speakers. Particular attention needs to be paid to their communication needs if they are to be able to express their wishes.
The Minister said that 7 per cent. of the population will at some point suffer manic depression, schizophrenia or severe clinical depression. If one applies that figure to the number of Welsh speakers, one finds that there are another 50,000 people who speak Welsh and, in most cases, English, who might need attention to be paid to their communication needs under the provisions of the Bill.
Mr. Boswell: The hon. Gentleman may know that I have an interest in that I am married to a Welsh lady, although she is not Welsh speaking. Does he agree that it is important that consideration is given to the particular needs of those in black and ethnic minority communities along exactly the lines that he is developing in relation to Welsh speakers?
Hywel Williams: There is certainly a congruence of requirements, and I thank the hon. Gentleman for his intervention. The only difference is that we have the Welsh Language Act 1993, which makes Welsh an official language, placing requirements on health and social services bodies when they are considering the provision of services in Wales.
To be fair, clause 3 notes that it must be ascertained whether the person understands the information relevant to the decision. There are points about communicating decisions, and clause 4(4) refers to encouraging the person to participate in any act or decision as fully as possible. All those points are well made and well taken, but what worries me is the presumption in the Bill that this is essentially an English speaking world with exceptions of people who cannot speak English, rather than the actual situation, which in Wales is that as well as people who cannot speak English, there are people who can speak English but would choose to speak Welsh.
I am worried that the model of language in the Bill is essentially a deficit model: it assumes an ability in English and then looks at special cases. That is why there is a reference to sign language and to the use of specialised skills in verbal and non-verbal communication. I do not think that Welsh speakers need specialised skills in verbal and non-verbal communication; what they need is practitioners who speak Welsh. The legislation must regard that as the norm; it must not make exceptions of people who have such communication needs. The deficit model is not what we need.
Language is referred to at various points in the Bill, but I want the Government to make more explicit references to Wales and the Welsh legislative context. We have the Welsh Language Act, which speaks of
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using Welsh and English on the basis of equality. Even the previous Welsh Language Act, the 1967 Act, spoke of anything done in Welsh being of the "like effect" as if it had been done in English. That is the normal situation that confronts my constituents. It is also the normal situation that confronts stroke patients and people who have temporary or permanent difficulty communicating. For example, stroke patients can recover language, and some people who were bilingual and perfectly capable of expressing their wishes in both Welsh and English suddenly find that they can communicate only in Welsh. A professional body of physiotherapists recently conducted a survey of people with restricted capacity: when the people were assessed in English, many were found to be incapable of expressing their wishes, but when they were assessed in Welsh, many of those were found to be perfectly capable of doing so, but only through the medium of the Welsh language.
I want assurances from the Government, either when the Minister winds up the debate or in writing, that the issues that I have raised will be examined in detail. Under clause 41(1), the Lord Chancellor is required to consult the National Assembly for Wales in respect of the code of practice. I ask that he be required also to consult the Welsh Language Board in respect not only of the code of practice, but of the entire Bill. Thus far, unfortunately, there has not been sufficient consultation of that sort. I hope that the Government will assure me that it will take place in future.
Dr. Richard Taylor (Wyre Forest) (Ind): It is a huge privilege to take part in this debate, which I think has shown the House in the best light. It has been a most sincere debate, with no hint of division along party lines, and we have heard heartfelt speeches, including from the hon. Members for Crosby (Mrs. Curtis-Thomas) and for Cannock Chase (Tony Wright).
Like all other hon. Members, I have received a few letters of support for the Bill and many letters expressing concern about issues including euthanasia, the validity of living wills, the definition of mental capacity, and the risks of conflict of interest. I promise not to go on too long, but I intend to discuss each of those issues.
The subject of euthanasia has been aired frequently. Most doctors vehemently oppose euthanasia, but they must continue to have protection in respect of giving pain relief to a terminally ill patient when such pain relief will almost inevitably shorten the patient's life and accelerate its ending. If that is not allowed, patient suffering will increase, even though the situation will become less common as the availability of specialist palliative care consultants and specialists in pain relief increases.
Turning to withdrawal of food and drink, 10 to 15 years ago that was a real problem, because it was incredibly difficult to keep people alive using intravenous and nasogastric drips. Now, with the ready availability of percutaneous intra-gastric feeding, which is so easy for the patient and can support life so easily, the major problem of providing food and drink has gone.
So we have to consider now just the underlying diagnosis of the patient. I am not altogether convinced by the many who have spoken so vehemently against the
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withdrawal of food and fluid that they are considering even any occasions when that is probably justified. Of course it is not justified in the case of someone who has a stroke, from which we have seen the most miraculous recoveries. It is not justified also in recovery from severe head injury. Again, we have all seen the most tremendous and dramatic recoveries from head injury.
I always think back to a patient who was riddled with cancer, bone secondaries, broken bones and pain. In those days it was impossible to control the pain without hefty doses of opiates, so that the patient was not really conscious of what was going on. In those circumstances it would not have been right to prolong life by keeping food and drink going. There are some rare circumstances when that is not justified.
I do not think that the Bill can provide guidance and legislation in all cases. The right hon. Member for Rother Valley (Mr. Barron) said that there had to be a certain amount of freedom for making individual decisions.
As for the validity of living wills, the hon. Member for Heywood and Middleton (Jim Dobbin) said that there would be no objection if such wills were made recently, were relevant to the current circumstances and there was no doubt about the person's mental capacity at the time. The hon. Member for Bolton, South-East (Dr. Iddon) suggested that such advance directives should be time-limited. That is an extremely sensible suggestion.
There is a strong argument that living wills should be advisory rather than mandatory. There are so many circumstances where things could have changed. Hon. Members have referred to the emergency situation when it will be incredibly difficult for doctors to ascertain whether there has been an advance directive. Perhaps when the electronic patient record comes in, things will be easier. For the moment, the process will be difficult and time-consuming.
It is usually obvious when someone is incapable of making decisions. I always remember having to speak to a court about a solicitor when the court was trying to imply that when he had driven all the way down the M1 in his Jaguar with no tyres and had all his breakfast down the front of his jacket he was capable of acting as a solicitor. The situation is usually obvious but it can be incredibly difficult.
In the journal of the Royal Society of Medicine, just this month, there is a comparison of assessment of mental capacity by medical teams and psychiatric teams. It is only a small comparison, but given 23 patients where there had been full assessments by both teams, in 19 they agreed, but in four they disagreed. That involved physicians and psychiatrists. As I have said, the assessment of mental capacity can be incredibly difficult.
Lastly, there are risks of conflicts of interest. The lasting power of attorney, as I think that it is written at the moment, appears at least to give rise to a potential conflict of interest from relatives. Research, too, provides the potential for a conflict of interest. The Royal College of Physicians' briefing paper states:
"A significant omission in the Bill, however, is a statement that the interests of the patient always prevail over those of science and society, such as can be found in the European Clinical Trials Directive or the World Medical Association Declaration of Helsinki."
I agree with the many people who have written to me and the many hon. Members on both sides of the House who have said that the Bill must make it clearer that it is not in any circumstances about euthanasia. Several hon. Members have implied that today's debate has made them change their mind. That is exactly what a debate should be about, yet it is incredibly rare for hon. Members to admit that that has happened. I have changed my mind. I was going to vote in favour of the Bill, because the idea behind it is absolutely right; it is the detail that is not. However, I am going to abstain because I regret to say that I was not convinced by the Minister's earlier comments that he was really going to take the concerns of hon. Members on board. I fear, having sat on a few Standing Committees, that changes made in Committee are usually very small and are usually dictated by the Government. I therefore appeal to the Minister to let the Standing Committee really debate the issues on non-party lines as the House has done this afternoon, so that we end up with a Bill that will tackle this extremely difficult issue without alienating a large proportion of the population.
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