Select Committee on Assisted Dying for the Terminally Ill Bill Minutes of Evidence

Examination of Witnesses (Questions 263 - 280)



  Q263  Chairman: Thank you very much for coming this afternoon. We are very sorry that our deliberations with the physicians and the general practitioners have slightly delayed our start but it is possible that the deliberations with physicians and the general practitioners has whetted our appetite to hear what you have to say. Please feel free to express your views within a reasonably limited time. The evidence is being transcribed, and so each witness will have an opportunity of correcting any mistakes that may happen in the transcript, although of course not altering the main thrust of your evidence. The intention is that you might wish to give us a short presentation, and then members of the committee will wish to ask you some questions.

  Ms Buchanan: Good afternoon. I am Maura Buchanan, Deputy President, Royal College of Nursing. With me is Carol Bannister, who is an adviser in our Professional Nursing Department. I am the Deputy President and have just been re-elected. I have been Deputy President for two years. My day job is as a senior nurse in the Oxford Radcliffe Trust. Clinically my background has been in neurosurgery, neurosurgical intensive care, general intensive care. Currently my position is senior nurse in a private patient unit which takes in virtually every type of patient you can imagine that comes through the Trust, many of whom are terminally ill, who have cancer and all sorts of other serious conditions. Ethics has been an interest of mine ever since I started nursing. I do have a Postgraduate Diploma in Health Law and Ethics. To put in summary the evidence that we have put to you in writing, I will highlight some of the points from the executive summary and maybe elaborate on them. There are some key concerns that we have around the Bill that we have summarised under some bullet points. We believe that more attention needs to be paid to the provision of high quality palliative care. That is and has been a key message from our members. By palliative care we do not just mean new structures, new hospices and new buildings. Palliative care is a philosophy. It is about key skills and knowledge that allow you to deliver that type of care. The Bill talks about unbearable suffering. That is a terribly subjective term and is different from pain. Pain control within the Bill is a totally unnecessary addition. We are entitled to give pain control, and indeed I would say that as a nurse or a doctor you are failing in your duty of care when you do not deliver pain control. We do not need laws to do it. We have the right to do that. There is a real danger in the Bill that it will change and undermine the nurse/patient relationship. It is a privilege to nurse patients. It is a privilege to be there at the end of their lives and to help families and support them and to work in the best interests of patients. We believe—and this is again the evidence from members—that patients trust nurses. The fear for nurses in this Bill is that that trusting relationship would be put at risk. The Bill would be unacceptable to many of our members on religious and moral grounds. We have not even started to consider in the Bill the religious and ethnic backgrounds that many of our nurses come from. Your Health Service, particularly in this part of England, is kept together because you have overseas nurses here. In my own Trust that is at least 30 per cent. Nursing homes will come to a standstill unless they can recruit people from overseas, and in fact they are bringing in nurses and using them as health care assistants. These nurses are from countries, mainly the Philippines and Kerala in India and some from Africa. A large majority of them come from countries where 90 per cent of the population are Roman Catholic. They would have huge problems working in any organisation that was delivering on this Bill. You cannot have conscientious objection when you work in this environment the way that you can for the Abortion Bill. You can choose not to work in a gynaecological unit, but people die everywhere in health care, so how will you take the nurses and look after them in a nursing home where the local GP comes in to practise euthanasia or, in a nicer phrase, hasten death? Who will counsel the nurses? How will we deal with them? They will not want to work there, so we will lose them. As a nurse I believe in the intrinsic value of human life. That is central to the code of nursing; it is central to our values. Some lives are not as valuable as others just because they are suffering? just because they are dying? The relief of suffering is what we are about; caring is what nurses are about. To come from the point of view that some lives are not worth living I am afraid is against the ethos of nursing. One of our great concerns is that the Bill would put pressure on vulnerable individuals. They might feel that they had to use the Bill when the cost of nursing home care started to eat away the family's inheritance. It would be easy to succumb to pressure and feel that you had to give up or feel that you were a burden when the family in today's world do not sit at home looking after mother or elderly relatives, because everybody has to work now to keep the mortgage going. This Bill is called the Assisted Dying Bill. That is a misnomer. I assist patients' dying. I assist them through a process. Dying is a process. It is the inevitable and inescapable process that results from living and that is what nurses do—assist the dying to have a pain-free, dignified death. This Bill is about assisted or hastened death. In talking about palliative care and relief of suffering I would add that there are other ways besides loading somebody up with morphine to relieve pain. My colleague, the President, has just helped open the new wing at Bart's for cancer patients and it has been her absolute ambition and drive to give complementary therapy as part of that unit. Indeed, she has raised the money for it. There is much more to be done to help relieve the pain and suffering that goes with dying. I have with me words that I think better express these sentiments than perhaps I can. They came from an elderly nurse who wrote a letter to me just last week and sent me some words from Dame Cecily Saunders, whom you will know was the founder of the hospice movement. In a previous paper that she delivered for the Templeton Prize she said, "We believe that euthanasia or assisted suicide is socially dangerous and a negative answer to a problem that should be tackled by other means, but we have a responsibility to work so that no-one should reach that desperate place where they felt they had to ask for that sad way out". I believe that is where we come from. There is a lot of mythology surrounding death. The proponents of this Bill would have you believe that dying absolutely requires you to be in pain and suffering. It is frightening people and they think that that is what is ahead of them. That is not the case. It is not the case when you have proper terminal care, proper palliative care with people who are caring for you and caring for your relatives. We are absolutely opposed to this Bill. It is not good for patients, it is not good for nurses, and it certainly is not good for the nurse/patient relationship or, in the long run, for the public.

  Ms Bannister: I just want to explain to you a little bit about the process that we undertook to arrive at our conclusions, to enable you to understand how the RCN has taken this fairly strong stance given that we know that there are nurses who hold different views from the one that we are expressing today. Certainly some of our members hold different views and it would be completely wrong of the RCN to say that we were completely overwhelmed by people opposed to the Bill. I have to say, though, that the overwhelming number of our members who contacted us—and I will deal with lobbying groups separately—were against this Bill for the reasons that Maura and our written submission describe. If you were to pin me down, as I suspect you might, and say, "What does that mean? How many are you talking about?", I would want to say to you that I do not think the number matters. I can give you that if you really want to push me on it, but I think what matters is the process that we undertook and how comprehensive that was in terms of enabling those people who wanted to say something to say it and also the balance of those for and those against. It is fair to say that this is the first time the RCN as a body representing nurses has gone very openly out to its membership on an issue as sensitive as this which causes very polarised views, and we have done it in a way that I think tries to embrace all the views of the membership. We used two or three of our main communication systems, including websites. We have a bulletin which goes out weekly to all our members and we expressed the view that we would like to hear from any member about what their thoughts were on the Bill. Also, because the RCN has specialist nursing groups within its structure, we wrote to each of those specialist nursing groups. They included groups that represent nurses in palliative care, nurses who work with older people, nurses that work with children. We targeted those particular groups to say, "What are your views?". The views that we are expressing therefore are coming from those places. They are coming from members directly who wrote in to us following our asking for views. They represent views that are from a group of members who work in particular areas of practice, such as palliative care. They also were, importantly, given to the leadership and governance part of the RCN. For our purposes, that includes the RCN General Secretary, Dr Beverley Malone, and her executive team, but also, more importantly, the governance committee of the RCN—the RCN Council, made up of RCN members. It is the RCN Council, along with the executive team of the RCN, that made the policy and the decision based upon our members' opinions. If we were to say what was the balance of opinion, we would say that approximately 70 per cent of our members were against the Bill and 30 per cent were for the Bill. We did a thematic analysis of what those members were saying, and if we look at those who were for the Bill the majority of those people were expressing concerns about the lack of palliative care. The overwhelming message was lack of palliative care.

  Q264  Lord Patel: Just before you we had evidence from the Royal College of Physicians and the Royal College of General Practitioners, and the Royal College of Physicians' evidence also included evidence from other colleges. Because of the difference of views expressed within their membership both of them and the other colleges took a stance of neutrality. You are not doing that, although you accept that there are differences of view in your College. Secondly, they made the point that this is an issue where society should have a voice and not necessarily the professions. What is your comment on that?

  Ms Buchanan: The issue is one for society to make decisions on, yes, as it is probably the biggest issue ethically in society today. No-one is forbidding someone to take their own life. The Suicide Act allows you to decide that you end your life, but you are asking professionals to take that life for them, so you cannot ignore their involvement. In the College we did open this up to views from the members and, as Carol has said, of those who were saying that it was probably OK to be pro this legislation, some had obviously thought very carefully through it but, for some, their comment was, as Carol said, built on bad experiences of patients in hospital where they felt, "I do not want to see that happen". Their argument was not really saying that this was a good way out. It was, "We cannot have our patients die in that way. We need to do something about it". What we as a College feel at this stage is that we cannot support nurses being involved in ending of life. That would be the wrong thing for the profession; it would be the wrong thing for the relationship of the profession with patients.

  Lord Taverne: Following up on that point, you have very eloquently expressed your own views, which are very similar to others we have heard expressed about the right to life, and you have clearly done as much as you can to consult your members on it. But just to go by the strength of reaction in terms of letters you get and protests you get seems on the face of it a rather poor guide. We have had a huge quantity of letters from people opposed to the Bill, and yet the opinion polls show that 82 per cent of people are in favour. I gather you have not conducted a MORI-type poll of your members, although there has been a poll by the Nursing Times which showed that two-thirds of United Kingdom nurses did in fact support the Bill. Do you not think that under these circumstances—

  Lord Carlile of Berriew: One third.

  Q265  Lord Taverne:— you should not take a stance as an organisation without conducting a proper poll of your members, which is an independent poll that does not reveal in any way any sort of prejudice on the part of the pollsters? Do you not think that is something you ought to do before you as a College take sides, unlike the College of Physicians and the College of General Practitioners?

  Ms Bannister: I think the point that you made right at the beginning was very well meant, that actually counting numbers is not necessarily the way to show leadership. I would, given time, be very interested in conducting a much more scientific poll than the Nursing Times could do. The Nursing Times has a readership of a particular group of people who may have a particular set of views, in the same way as the RCN may have a set of people who may have a particular set of views, in the same way as the Voluntary Euthanasia Society has people within it that have a particular set of views. I am not disputing those people's right to have those views. I would say that it would be really useful to have the time to have a much more structured look at what nurses are really saying. That is part of the reason why I would not particularly want you to have numbers of people we have canvassed, because it does not help. What we do know is the themes that have come through from the people that have corresponded and the leadership that is being shown by the Royal College of Nursing on this issue.

  Q266  Chairman: I think the membership of your College is of the order of 370,000?

  Ms Bannister: It is 377,000.

  Q267  Chairman: Do you know what the total size of the nursing profession in the United Kingdom is?

  Ms Buchanan: It is over 600,000 on the register but they are not all necessarily practising at the moment or in fact on the register. They are not even all in England. They may be on the register but elsewhere.

  Q268  Baroness Hayman: Could I ask you to reflect a little on the issue of patient autonomy, which has been a thread through the evidence and the argument that has been put to us? When you were speaking, there was a lot of emphasis put on appropriate palliative care and I wanted to ask you whether you believe, because it has been argued to us that this is not so, that if good palliative care was available to everyone this problem would completely disappear? It seems to be the experience of other jurisdictions that that is not so, that this is not always a failing of palliative care. It is the case that for some people loss of dignity, feelings of loss of support, whatever those feelings are, lead them to wish to end their life. You did envisage the possibility that those patients could commit suicide, and I recognise that there are a group of patients for whom suicide is not physically an option and they need assistance. But I wonder if you could just give me some thoughts on those sorts of issues, because it may well be that the suffering is existential and not simply an issue of pain, and I am not certain that is so easily resolved by improvements in palliative care.

  Ms Buchanan: There will be people who want that, but nothing that we could do as professionals would take away their wish to have their life come to an end. It is about control at the end of their life. It may be the same people who have control during their life and they want control of their death. When we go to Oregon, for example, where there is that option, in the 2003 report, a report that they are required to put down every year, something like 67 people had lethal prescriptions made up for them. The fact is that, out of 31,000 deaths in Oregon every year, around a tenth of 1 per cent actually choose death by this manner. Of the 67 that had prescriptions, 25 of them did not use them. The suggestion could be that they decided that it was enough to have the prescription, to have control or whatever. What I would ask is—is having a law to allow a tenth of 1 per cent of the dying population to have control of their lives sufficient reason to leave the other 99 per cent vulnerable? What we are saying is that those people who want control can often find other ways of having it. I think what people want is control of how they are treated at the end of their life, of treatment decisions. They do not want actively aggressive intervention when they say it is time to give up. As I said before, there are myths around the end of life and I think that is something that we have to address as well. Coming back to Lord Patel's question, nurses are part of the general public. They are exposed to the Nursing Times, if they choose to read it, they are exposed to Panorama or any other documentary that talks about it, so to look at a poll and take numbers and decide a majority or whatever is not necessarily a considered opinion on an issue, because not all nurses have been through any ethical training or think wider than the experiences they have had. What we are saying is that we looked at the issues that were being raised and that were important for us, what issues they were having to address in their daily lives with patients, and the issues that kept coming out were about end of life palliative care and support, support for the nurses as well as the families in being able to deliver pain control without fear and to have knowledge about how to relieve symptoms. We feel that the Bill would not protect vulnerable people and that is a fear that nurses have. We have taken our knowledge of what is going on out there and looked at the pros and cons of changing our opinion. It was not just about getting numbers in the results.

  Q269  Lord Turnberg: Coming back to this point about the numbers who fit into the category of wanting to die and have exhausted all other opportunities for relief and still wish to die, your concern was what impact it would have on the remainder of the population who were dying but did not want it who might be put in that position. If there were some sufficient safeguards against danger to that group but leaving this subset with access to this degree of autonomy, would that answer the problem?

  Ms Buchanan: In 1993-94 the Select Committee for Medical Ethics looked at this issue and the decision of the committee then was that the safeguards could not be put in place that would prevent abuse, that would prevent vulnerable people from coming to harm. At that time they felt there was no question of moving down the road for euthanasia to be legalised. I do not think things have changed and, in fact, I suspect have even more gone the other way perhaps. In a retrospective study of doctors in The Netherlands, despite not having had legislation until two years ago but a process that allowed them to report deaths, to have them scrutinised and not be prosecuted, when they retrospectively talked to the doctors, outside of that ruling they had gone ahead and helped people to die and did not report it. I do not believe that the safeguards are there. The Bill is quite narrowly focused on people who are terminally ill, within a few months of dying. There are a lot of people with neurodegenerative diseases who are nowhere near terminally ill but they can see the progression of the disease ahead, and I wonder when they would decide that they have got six months left to live—when would they become terminal? The disease is going towards a terminal conclusion but that might be a year or two years away. I think of Stephen Hawkins, the professor, who has Motor Neurone Disease; he has done amazing things with it, but if you give somebody a diagnosis of Motor Neurone Disease, for many and most, that is a diagnosis of a few years. When do you become terminal? There are not too many doctors who often get the exact number of weeks and months you have to live. I would also say that in Oregon it is the same issue, terminal illness. In fact, a large number of the people who had prescriptions were given them over nine months from the date at which they finally died, so the three months or six months or whatever time you put on it is not too precise. I would argue that you cannot put confines on it. People are acting outside the law in places that have laws, and in this country you may say that some people are already acting outside the law, and I do not believe it would stop them doing that just because you have a law that is slightly more narrowly-defined.

  Q270  Lord Turnberg: Certainly we are going to look at the evidence of experience in other countries, and there are obviously variable interpretations of that experience, and we hope to be able to tease that out. But do I take it that your view is that experience does not give you any confidence? Is that what you are saying?

  Ms Buchanan: Absolutely.

  Lord Turnberg: Thank you.

  Q271  Baroness Finlay of Llandaff: We have heard already from Lord Joffe himself that he views this Bill as part of an incremental process in terms of who would be eligible to have their life ended, and we heard from the College of Physicians this afternoon that there is a view that this could be viewed as a therapeutic option and, therefore, potentially as a therapeutic good. Within that context I wonder where you feel that nurses could be placed, given, as you have pointed out, the intimacy of the conversations that occur between patients and nurses that is very often at a much more comfortable level than it is between a patient and a doctor in our current health system? I was also interested in your figure that 30 per cent of nurses come from overseas, and perhaps I might return to that in just a moment. Perhaps if we can take one bit at a time.

  Ms Buchanan: Sorry, what was the start?

  Q272  Baroness Finlay of Llandaff: I was interested as to where you felt that nurses would be placed if this was a therapeutic option and was part of an incremental process in terms of the intimacy of conversations between nurses and patients?

  Ms Buchanan: I think that those words "part of an incremental process" give me the very reason why I think we are right, and I am even more concerned that we see it as part of an incremental process. Does that mean that today it is six months' terminal illness, competent patients, but tomorrow, as has been seen in The Netherlands, it is incompetent patients? There were quite a large number of babies, who obviously were not competent, put down, could I say, for reasons that they were disabled and their parents did not want a disabled child, and there is evidence of that. That fails me as a nurse, and I think most of my colleagues would support that. I have to say I found a lovely quote from, of all people, President Ronald Reagan, when he wrote in the American Human Life Review: "Regrettably we live at a time when some persons do not value human life, they want to pick and choose which individuals have value." That is what I would say this incremental drift would be—whom we see as whose life has no value at this stage; and I do believe that is the intent of the Bill—let us get this on the statute, and then we can start looking at who else. For example, somebody who has depression, and has had a bit of a bad life, they are competent. They are not necessarily incompetent with depression, but maybe we should let them go and help them on their way. It is proof for me that this is the wrong way. This is the door open to the most awful journey that I would not want to take as nurse.

  Ms Bannister: Can I say something in respect of your question around the comments that people make to us. Again, it was a very recurrent view of members that the compromising of the relationship between the nurse and the patient was very fundamentally risked here in relation to the trust, and that is a very clear theme that came through to us from our members. I have worked for the RCN for nine years, taking on board responses to all sorts of issues to do with government changes, government bills and so on. This is the only one that I have ever come across, as a policy and practice adviser, with people with serious stories to tell about their experience and their fears and real life stories, which is why we put some of those stories in our response, because they are very powerful. It was clear to me that nurses would feel very compromised in their relationship with the client in that position of trust, if they felt that the client thought they were party to a potential assisted death at some point. That was a strong feeling. I do not know whether that helps to answer your question?

  Q273  Lord Carlile of Berriew: I just wanted to ask one question. It is one, My Lord Chairman, concerned with the "lower issues" with which we are concerned. It is an employment rights issue. Clause 7 is a conscientious objection clause and I do take into account in my question a manuscript amendment that we saw at some stage from Lord Joffe. Neither the conscientious objection clause nor the manuscript amendment we have seen gives any right to a nurse to refuse to work as part of a team led by a doctor prepared to perform assisted death. Is that an acceptable position either to the Royal College of Nursing, or to any other representative body of which you are aware?

  Ms Buchanan: Absolutely not. If I could say on the second point, I was a bit concerned about it because I think it is fundamentally wrong—the conscientious objection.—It talks about "in accordance with the Act" or "to receive pain relief under section 15" as a conscientious objection. Nurses have no right to conscientiously object to giving pain relief—that clause is nonsense. We do not object to caring for people. You may disapprove of people's lives. You personally may not understand their life, but it is part of our code of conduct that we would never stop caring for people or delivering care. What you would have is that nurses would be so compromised in their own values that they would not go to work in these places, they would leave places. I am telling you the health service is held together by overseas nurses at the moment. They will go to America, because State after State is rejecting any attempts to introduce a Bill similar to Oregon. America is sitting there with a cheque book waiting for our nurses. We do not need another reason for them to go and that is exactly what will happen.

  Q274  Lord Joffe: It is clear what your views are, but I would like to come back to your members' views. Why did you not accept the invitation of the Committee to bring someone representing the views of what you consider to be a minority of the nurses to talk to us today?

  Ms Bannister: I am not sure that we received an invitation saying that. We were asked to come and present our evidence, which we have done. The decision-making about who would come was that we would have one member of staff who was involved in the process of collecting the data and theme-ing our evidence, and that would be me, and the Deputy President, who is on a number of our specialist ethics groups and is also a Council Member. I do not believe we were asked to do that.

  Q275  Chairman: I think you are right. I think what you were asked to do was to ensure your presentation included the description of the extent to which the views expressed were the views of the body as a whole and to what extent there was general dissent; and you have done that extremely clearly in my view.

  Ms Buchanan: My Lord Chairman, it is how we work altogether in the College. We look at issues and then we decide on policy. It would not be for us to set someone up in the minority view, to have to argue what is against what is now clear RCN policy. I think it would be unfair. We have considered the issues and this will be the RCN policy. While accepting that, members may have thought that they would rather it was otherwise.

  Chairman: You made it very plain that there are a number of people in the Royal College of Nursing who do not share the views you have expressed today. That was what we wanted to be made clear by the invitation to give evidence.

  Q276  Lord Joffe: With respect, that was not my understanding of what was agreed. Obviously, I accept the position. If we can come back to the numbers of members. Why I ask these questions is because I have been told that there is significant and possibly majority support for the Bill amongst nurses. Could you tell us a bit about the numbers? You have told us the percentages.

  Ms Bannister: Yes. I can come back and give you those numbers. As I said earlier, we did not feel it was particularly helpful to just use numbers because we were not counting responses in a scientific way; but, indeed, we can come back and, if it is possible, I will send a written note with those numbers. Certainly we were lobbied, Lord Joffe, significantly by lobby groups, and I think that I expected that to happen; and particularly there were "paid for inserts", that were run by the Nursing Times, which were about enabling those people who wished to to lobby both for and against the Bill. In fact, we received boxes of lobbying papers through that means, and we had some concerns about the Nursing Times entering into paid advertisements to lobby the Royal College of Nursing. But, then, that is politics and we understand that is going to happen, that is not a problem and we have heard those lobbyist messages. For our point of view, we are interested in what our verifiable members are saying to us and also what members of the public, who are going to be patients, are saying to us. We will come back to you with some figures if you would find that helpful.

  Q277  Lord Joffe: You understand it is part of this that you reject some of this, what you call, lobbying?

  Ms Bannister: I am not sure that I understand what "reject" means. We would not count boxes that arrived to us with cards as verifiable member returns from us. As I say, we were lobbied by different groups. We were lobbied by pro-groups and we were lobbied by for-groups. Therefore, to me that is lobbying. What we were trying to do at the Royal College of Nursing was to hear the members' voice and to "theme up" for you what our members were saying.

  Q278  Baroness Jay of Paddington: Following on from this point, you may think we are niggling about this, but I think that is the contrast we have between what you are saying and how you are saying it and the way in which the Royal College of Physicians and the Royal College of General Practitioners represented their position earlier this afternoon, which is, of course, as we all understand, about politics and lobbying, and it is all about verification or otherwise and mass card-sending et cetera. We have all been subject to that in our own eyes in many ways. I think it was Lord Taverne—or it may have been Lord Patel, forgive me if I have got it wrong—who asked at the beginning: would it not perhaps be more sensible, given the considerable difficulty that you have obviously had in getting an accurate picture, for you to present a neutral position in the way that the Academy of Medical Colleges did, and whether or not you felt you should have brought someone to represent the minority view? One of the ways in which the Academy did that, which I thought was very helpful, was that they had two presenters, both members of their Ethics Committee, who did take different views and very clearly identified when they were speaking from a personal position and when they were representing the view of the Academy. In retrospect, do you think that might have been more helpful to us?

  Ms Bannister: I think that if, I was asked to reflect what the experience of the RCN has been over this exercise, I would have to say that we can reflect to you what our members' opinions are. The overwhelming majority of our members' opinions are here. If we had had much more time, and we did not have sufficient time, to conduct an appropriate study which would have allowed us to have that sense of what members our doing—and we are not afraid of doing that, we could certainly do that. That would have been wonderful but, as it happened, we were left with a very short period of time in which to canvass views and opinions. I think we have used those views and opinions appropriately. Also, we have reflected the leadership of the RCN's views on what is currently RCN policy. We will continue to have debate and discussion on this. I have said that there are nurses who do not reflect that majority view. However, having been the person who analysed all of those responses, I know that even those that did not reflect that view, the majority of those people were talking about the weaknesses in palliative care services. The strength of our response, the experience of our response, is different from that which the physicians are getting.

  Q279  Baroness Hayman: Could I pick up on that very point because I do find it slightly concerning, I have to say, that there seems to be a gloss being put on some of the evidence that we have received and the interpretation that people were only saying that because they had had very bad experiences and had mentioned failures of palliative care—let us call it that, rather than failures of the existence of palliative care—but you were not subjecting to similar scrutiny the opinions that were in line with the view that you have given to us. So you were not doing an analysis of whether people already had a particular stance—ethical, religious or moral stance—that would take them in a particular direction, nor looking at their particular experiences which you referred to as having coloured their views. I think this makes one slightly uncomfortable and it is something that we are all coming back to. Certainly I find it perfectly acceptable for the leadership to say "This is our ethical position. We are the Council of the RCN and we are charged with doing that." But I must say I feel a slight discomfort about this interpretation of views, as indeed there seems to be some interpretation in your evidence of what patients really want, "Although they may say they want X, we know they actually want Y", and that seemed to me something, I may say, that was a theme that was coming through.

  Ms Bannister: I think that is a fair point to make. As I say, we are expressing what the leadership of the RCN believes to be the view and the voice of the RCN, which included hearing the predominant comments from our members to explain what our members are saying. All but the most rigorous scientific survey, which we have not had a chance to do in the time available, would have that problem. Someone has to sit down and make sense of viewpoints which are sometimes expressed in extremely emotional ways, and that is what we have tried to do.

  Ms Buchanan: Nor did we lay out the issues. We just said, "This Bill is coming before the Committee and we are asked to give evidence to it, would you like to comment?" We did not lay out, "Here is what might happen if there are changes" or any of the ethical dilemmas that might be raised by the Bill. It was purely and simply an invitation for members to just fire off. As I say, nurses, as is the case for many doctors, have not done ethics in their training, in their backgrounds, so necessarily thinking through the implications of their heartfelt response to something they have experienced and thinking "Oh, yes, that might be OK", we have to consider what would that mean for us as a profession. We have to take another view, and as an organisation we take the view that this is not good for the profession.

  Baroness Hayman: I understand that, but surely your caveat about not having explained the situation applies equally to people who say, "No, this would be a good idea." They have not had it laid out for them either. It affects both sides.

  Chairman: I understand that so far as numbers are concerned you did not really want to emphasise the actual numbers. But, if you want to give them to us later on, I am sure nobody will refuse to receive them.

  Q280  Baroness Finlay of Llandaff: Could I just return to the very practical issue about the role of a nurse to patient. If a patient says to you that they want to die, how do you, as a nurse, respond now? How would you, as a nurse, respond if there was a therapeutic option as outlined in the Bill?

  Ms Buchanan: It is a difficult question because I have to say that in 20 years no patient has ever said to me "I want you to help me die". It has not happened. I have nursed many patients and I have never had that, although I am sure that some of my colleagues have. I hope the care that I gave at the time meant they felt they were not suffering unbearably or whatever. I think my response would be to sit down and say, "Why do you feel this?" and have some dialogue and see who else could come to talk to them. I think that is the difficulty. How would somebody with religious principles faced with that question respond when they know there is an option and that option is against their beliefs? I have to say the Nursing Association of The Netherlands, because this has come up there and in the Council of Europe where the European nurses group sits on that, have currently advised their nurses to take no part in either passing on that request, in preparing the medicine or doing anything at all in relation to the current law in The Netherlands, because nowhere in that law is there any protection. Doctors are protected but nothing protects nurses. Their advice right now, until there is much clearer clarification, is that nurses back off and do nothing in relation to that. That would be the dilemma for me or any other nurse: what do you do if you have that on the statute and somebody asks that, because by implication you are passing on and fulfilling that wish. I believe that would be the reason that many nurses would go.

  Chairman: I said about an hour and we are at just about that. Thank you very much indeed for the help you have given the Committee and we thank the public who have come today. There will be a further sitting a week today.

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