Joint Committee on the Draft Mental Incapacity Bill Written Evidence

66.Memorandum from Ms Teresa Lynch (MIB 409)

  1.  The government gives repeated assurances that it is opposed to euthanasia. However, euthanasia does and has included withholding or withdrawing tube-feeding with the intention of bringing about the patient's death since the early 1990s in this country. In addition, the Voluntary Euthanasia Society, whose aim is to establish the right to kill and be killed, has assisted the Government in its documentation relating to decisions required for treatment or lack of treatment for those patients who may or may not be at the end of life.

  2.  "Competence" is a dangerous word to employ in these situations. No right thinking individual would readily agree to death by starvation and dehydration. Proper informed consent is doubtful in situations where lay people are to be involved in such momentous decisions over life and death. It is surely not humane to put either "competent" or "incompetent" patients through such avoidable stress, where reasonable means can be employed to ensure best clinical care.

  3.  The British and European courts overwhelmingly rejected the concept of a "right to die" in the Dianne Pretty case. Patients in a vulnerable state will perhaps feel that euthanasia is the best option open to them, in particular, disabled people.

  4.  Financial expediency is never the answer to a "problem" of a vulnerable individual or any group considered to be economically or physically "non-viable". The increasingly-used term "bed-blockers" will become prime candidates for the abandonment of care.

  5.  Patient quality of life should not be considered on physical condition alone. Dignity, like autonomy, can only be generated by trusting relationships. The right to good clinical care is a paramount right of any patient, and the first responsibility of any individual, worthy of the name of Doctor, Nurse or Parliamentarian.

  6.  Lastly, in my professional opinion, the foreseeable implications of such a Bill are profound in relation to future motivation, recruitment and retention of both nurses and doctors. To my certain knowledge, the sinister encroachment of bad guidance on the duty of care is causing attrition rates in both professions, so long dedicated to the well-being of patients. Such a Bill if passed, in current form, will reflect both a total lack of compassion for people in need and respect for professional vocation, training and expertise.

  I hope these points may assist you in your deliberations.

Draft Mental Incapacity Bill submission: The Rights of nurses who may encounter distressing clinical directives in the work place

  The labour of nursing is acknowledged as comprising both physical and emotional elements to be part of their work. Recent national and professional guidance may now be an unforeseen pivotal factor in the attrition rates of nurses both prior to and post the nurse registration process.


  1.  What support will be available to nurses (and Doctors) who are unable to follow clinical directives which are incongruous with their own belief systems?

  2.  Nurse attrition rates: a frequent result of unresolved stress when attempting to work with repeated ethical conflict in the clinical area?


  Considerable changes in the training and expectation of nurses have occurred over time. These were designed, in part to manage the reduction in junior doctor hours, and would herald a new view of nursing among co-professionals.

  The climate in nursing in the UK is one of a developing autonomy with nurses taking on an increasing number of these expected developed roles. Progress is ongoing on the plan for nurses to be able to prescribe a more comprehensive range of medications than the current limited amount agreed by the Medical profession. Nurses are now able to be Consultant Nurse Specialists, Physician/Surgeon assistants and even take on the role of Endoscopist. To some extent these changes have increased the acceptance of nursing as a profession on a par with other University-based, professional training programmes. Closer links have evolved between the medical and nursing professions. Nurses are expected to take on the roles formerly within the province of junior medical staff. The profession of nursing is now linked increasingly to the responsibilities of Medicine.

  This technical aspect of the nurse's role expansion and the professional recognition has not always equated with the expected recognition in other more expressive areas of nurses' work which also involves close association in medical decision-making. Medical staff can now dictate a decision for withdrawing or withholding life-prolonging medical treatment (British Medical Association 1999). Such situations can distress many nurses, whose long-held wish, in most cases, would be to maintain their caring skills to meet the needs of their patients for both physical and psychological well-being.


  Care is perhaps the most basic element of a patient's treatment that a nurse can provide, yet it is the most essential.

  The term "Care" is derived from the Anglo-Saxon "to trouble oneself". This impulse, together with the desire for nurses to put the interests of others' good before their own, can be a clear declaration of a nurse's own ethical position.

  "The Essence of Care" Department of Health initiative was developed with the active participation of patients and their carers as well as hundreds of health professionals. It offers a practical toolkit to be used a part of quality improvement programmes. It will also become an integral part of clinical governance at local level.

  The eight areas addressed by "The Essence of Care" document are: privacy and dignity; nutrition; principles of self-care and record keeping; personal and oral hygiene; continence and bladder and bowel care; pressure ulcers; and the safety of clients with mental health needs. They are all seen as fundamental to achieving the basics of care. The "Essence of Care" defines patient-focussed best practice and then sets out the steps necessary to achieve the benchmark. Staff can use the pack to work with multi-disciplinary colleagues and patient representatives to consider how well they are performing in structuring the sharing of good practice within comparison groups and across an organisation. The clear role of nurses who wish to care for patients in line with such ideals can conflict with the professional views of others in certain clinical situations.


  A form for such caring impulses can be seen in the role of the nurse as Advocate. This role has been described as one of the most difficult a nurse has to face. Advocacy has been described as "not a slogan or a hobby, nor to be entered into by the faint-hearted" (Copp 1984). The advocate role, though not only expected of the nurse within the multidisciplinary team, can often be an inevitable result of the twenty four-hour responsibility of nurses for patient care.

  Patients' own Care plans were generated with the aim of giving individual patient care, and have been part of the nurse's care orientation and training for over thirty years in this country as in America.

  There are various reasons for the nurse finding difficulty in the role of advocate. Despite good approaches that have developed in multidisciplinary team work (particularly in the field of Gerontology). The Doctor is often the ultimate arbiter of any treatment plan.


  Recent Medical guidance has abrogated one of the historical functions of the nurse. Helping patients with their nutritional needs, whether involving assisted food and fluids, has always been an expected part of the total nursing care of patients.

  The original BMA guidance and the following guidance of the General Medical Council (2002), in relation to assisted food and fluid as "treatment" is opposed by many nurses, but application of such guidance, may become the norm in practice.

  The guidance from the BMA, was the result, in part of the notable case law in relation to the young man, Tony Bland, who was suffering from what is described as a "persistent vegetative state". This case elicited from one of the lawyers at the time, a warning that nurses involved in this case would have to cope with being expected to go against all their training preparation, but would need to realise that the agreed course of action, (discontinuation of the feeding programme), would be in the best interest of all concerned.


  Nurses are bound by their professional Code of Conduct. Their unchanging professional expectation is the clear duty of care, to safeguard the public and at all times to put their patients' interests and safety first (NMC 2002).

  Despite this Code, some nurses are placed in positions of conflict by the demands of other professionals, managers and contexts of employment which may clearly compromise their duty of care. Such situations can induce considerable stress for the nurse, who attempts to act as patient advocate and not least when threats of disciplinary action or suggestions that they are not coping, are employed against them.


  The National Framework for older people aims, among others, to make treatment decisions on the basis of clinical need, not age. The overall aim backed by £1.4 billion (invested every year by 2004) is better health and social care services for older people (DOH 2002). This move may prove beneficial to those who are supported at home by the Government's community care aims for older people. The number of people over 90 years of age will double in the next 25 years. There are examples of poor, unresponsive and insensitive treatment and sometimes, simply because of the age of patients. Denying access to services on the basis of age alone is not acceptable. The Government's drive to raise standards of care, particularly those relating to patient empowerment, is not restricted to the NHS and extends to the independent sector. The consultation document "For the Future" (DoH, 1999) epitomised the Government's commitment to establishing required standards for residential and nursing homes in recognition of the somewhat sketchy regulations set out in the Registered Homes Act (DoH, 1984).

  Another source of conflict (and confusion) for nurses, results when worthwhile initiatives, propelled by national directives can be seen to contradict other, more questionable directives.


  The Government, in October 1999, publiched its proposals to reform the law on mental incapacity, which have now been enshrined in its draft Mental Incapacity Bill (2002).

  By April 2002, draft "guidance" was issued by the Government on management of people unable to make decisions about their own treatment and care. The Government claim that it does not wish to introduce active euthanasia but is silent about euthanasia by neglect. It is moving ahead with plans that would introduce the routine denial of assisted nutrition and hydration, which could be labelled as passive euthanasia.

  This Bill applies to any adult who is mentally-incapacitated and will therefore affect every single person in this country, because everyone is vulnerable to accidents or illnesses that may cause mental incapacity. The Bill's radical proposals include using a system of living wills and unqualified, unaccountable attorneys to force doctors to withdrawing life-sustaining treatment and care (commonly understood to include also assisted food and fluid). If passed, the Bill will be the first comprehensive law in the world allowing euthanasia by neglect and may become a model for all common-law countries.

  This new draft guidance has been launched with the aid of the Voluntary Euthanasia Society and the clear aim is to allow the starvation and dehydration of incapacitated people. The guidance also recommends the use of the "living will" drawn up by the VES. No mention is made, however, of the known pitfalls of "Living Wills" or "Advanced Statement Refusals".

  This guidance will affect people able to feed themselves but who need considerable basic medical and nursing care, (eg elderly and or disabled people). In many cases these people will not die but become chronically-sick "bed-blockers" with little prospect of alternative accommodation in light of the many nursing home closures in recent years.

  The Mental Incapacity Bill could lead to a possible situation where one statement which request or agrees to a refusal of treatment would be all that is required to end that patient's life once the stage of mental incapacity is reached. For a doctor to continue to administer treatment (including assisted food and fluid) would be illegal.

  The nurse who cannot agree with some of the planned changes, and certain defeatist approaches to those most vulnerable, may feel compelled to leave his or her chosen profession. This may become the only possible course of action, if unsupported in the view that the duty of care should not be ignored devalued or interpreted with malice.

  Professionals, relatives and employers may argue that the expedient action or omission of care, which they may believe to be "in the best interests" of the patient, is also in line with a human right to "die with dignity".

  The nurse, who believes that human dignity is not contingent on physical condition but inherent to the individual, and like autonomy, is dependent on trusting relationships, may only experience the vision of patients in need, being abandoned by their carers.

  Nurses and Doctors also have human rights. The professions need to examine what impact on their mentors (and patients in turn), will result if these rights to practise within a vocational, caring perspective are denied.


  Department of Health (2002) National Service Frameworks for Older People Short summary, 22 April.

  Nursing and Midwifery Council (2002) Revised Nursing Code of Professional Conduct.

  Department of Health (2001) The Essence of Care. Patient-focussed benchmarking for health care Professionals. February.

  General Medical Council (2001) Withholding and Withdrawing Life-Prolonging treatment. (Draft) Guidance for Good Practice.

  Department of Health (1999) Consultation Document, "For the Future".

  British Medical Association (1999) Guidance on Withdrawing and Withholding Life-Prolonging Medical Treatment. BMJ Books.

  Department of Health (1999) Making Decisions: Helping people who have difficult decisions for themselves. HMSO.

  Smith P (1992) The emotional labour of nursing. Its impact on the interpersonal relations, management and the educational environment. MacMilan, Basingstoke.

  Cope LA (1986) The nurse as advocate for vulnerable persons. Journal of Advanced Nursing 1193): 255-63.

  Department of Health (1984) The Registered Homes Act.

August 2003

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