ADVANCE MEDICAL DIRECTIVE BILL

Order for Second Reading read. 2.00 pm

The Minister for Health (BG George Yong-Boon Yeo): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

Rapidly advancing medical technology presents human societies with new moral challenges. Today, modern medical technology is able to sustain essential physiological functions and technically prolong life in the final stages of terminal illness. Sometimes, it does no more than prolong the process of dying.

The choice of treatment alternatives to doctors and patients will widen in the future. But we must all still die. Whatever new technology may bring forth, we will still have to make difficult choices either on our own behalf or on behalf of others in the last days of life. Medical technology is after all only our servant, and not our master.

When the patient is of sound mind, when he is compos mentis, he decides for himself. He may consult, he may be advised, but the decision is his. Under common law, he is autonomous. The problem arises when the patient is no longer able to decide for himself. Today, when this happens, the doctor will consult with the family who will be asked to make a decision on behalf of the patient. When the decision involves withholding or withdrawing extraordinary life-sustaining treatment, it places a heavy burden on family members. The experience varies. Some families will decide firmly one way or another. Many families become divided. Sometimes to avoid making such a decision, the family may leave the decision to the doctor who then decides according to his professional judgment and personal conscience.

Let me illustrate some of the dilemmas with the example of a person dying from terminal cancer with no reasonable hope of recovery. Because the patient's body is weak, his heart may stop beating. Should the doctor try to resuscitate? And if so, how often? Or if the dying cancer patient is suffering from pneumonia which in fact is the way death naturally takes its course, should the doctor prescribe expensive antibiotics which may clear the immediate infection but leave the underlying condition unchanged? Of if the patient is in severe pain, should morphine be given when that morphine may itself reduce the body's will to live?

These are difficult decisions to make. They are not only medical decisions, they are also moral decisions. Doctors may not be prepared to make such decisions on behalf of families, especially when they are liable to be sued. As Singaporeans become more educated and aware of the medical alternatives available, civil suits will become more common and doctors may become more inclined to do the safe thing from a legal point of view, than to do the right thing from a professional or a moral standpoint.

If the patient, while he is compos mentis, has clearly made known his wishes in full knowledge of the alternatives, the decision becomes much easier on both family members and doctors. And this is the purpose of the Advance Medical Directive (AMD) - to allow the patient to make his wishes known in advance clearly and unambiguously. The AMD will remove any doubt as to the patient's own preferences.

The AMD is based on the principle of patient autonomy. Under common law, every patient has the right to decide whether to accept or reject the treatment that is offered to him by a doctor, and this is also the position of all the major religions. The AMD allows him to make and register that decision in advance so that his wish can guide his treatment when he is unconscious or no longer of sound mind.

As the AMD touches on life and death, we must take into account the views of all segments of our multi-cultural and multi-religious society. It is for this reason that the National Medical Ethics Committee (NMEC) conducted wide-ranging consultations with all the major religious groups in Singapore before submitting its report. After consultations with 24 religious and professional organisations, the NMEC has published a report recommending the legislation of AMDs. The Ministry of Health has accepted the report and taken all their recommendations into consideration when drafting the Advance Medical Directive Bill.

Let me now highlight the main features of the Bill. The Bill allows a person of sound mind who has attained the age of 21 years and who desires not to be subjected to extraordinary life-sustaining treatment when he is suffering from a terminal illness to make an AMD on a prescribed form. The making of an AMD is entirely voluntary. Any person who by deception, fraud or undue influence causes a person to make an AMD will be guilty of an offence under the Act. The penalty for such an offence is a fine not exceeding $10,000 or imprisonment for a term not exceeding three years or both.

The making of an AMD must be witnessed by two persons of at least 21 years old, one of whom must be a doctor, preferably the patient's family or regular doctor. To prevent coercion and conflict of interests, witnesses must not be persons who stand to benefit from the death of the patient. While this will exclude immediate family members as witnesses, we will encourage every person making an AMD to discuss his decision with his family so that they are aware of his wishes. The doctor who is a witness will be required to explain to the patient on the medical implications of making an AMD, and preferably in the presence of family members. The making of an AMD should not be kept a secret from immediate family members.

The AMD only applies to the specific clinical condition of "terminal illness" as defined in the Bill. "Terminal illness" is defined as a condition that is incurable, with no reasonable prospect of recovery and where death is imminent, whether or not extraordinary life-sustaining treatment is provided, and where such treatment will only postpone the moment of death. Certification of "terminal illness" is strictly controlled by a process requiring unanimous agreement by three doctors, two of whom must be specialists. If there is no unanimity, a committee of three specialists drawn from an independent panel of specialists established by the Ministry of Health for this purpose will be consulted. Unless the decision of this committee is unanimous, the patient will not be certified to be terminally ill and the AMD will not take effect. This comprehensive procedure will ensure that an AMD will only take effect after due professional consideration has been given to the clinical condition, the diagnosis and the prognosis. Where there is any doubt, this procedure will ensure that we err on the side of life.

The Bill provides for a central register of AMDs to be established and maintained by the Ministry. All AMDs must be registered in the register which shall be kept confidential. Access to the register will be strictly controlled. This is to ensure that the existence of an AMD is never allowed to influence medical treatment decisions before the patient is certified to be terminally ill. Under the Bill, it will be an offence for any person to require or prohibit the making of an AMD as a condition for receiving medical services or for being insured. It will also be an offence for a doctor or hospital to ask a patient about the existence of an AMD or about his intention to make an AMD.

Those who have made AMDs must of course be allowed to change their minds. The Bill therefore provides for easy revocation made orally, in writing or in any other way. The revocation can be made at any time so long as it is witnessed by two persons. In other words, we deliberately make it easier for an AMD to be revoked than for it to be made. This is better than the alternative of making the directive valid for only a fixed period of time and requiring it to be renewed periodically.

In the NMEC's dialogue with professional medical bodies, the need for a conscientious objector clause was raised. The Bill provides for doctors and those who work for them to register their conscientious objections to the AMD. Doctors who are conscientious objectors are excluded from participating as witnesses to the making of AMDs and from the certification of terminal illnesses.

Let me now address three specific concerns that have been raised. The first concern has been that legislation for AMDs is the first step down the "slippery slope of euthanasia". Let me state clearly and categorically that the Ministry of Health, the NMEC and the medical profession in general are all opposed to euthanasia. And this position is fully reflected in the Bill. Clause 17(1) of the Bill states that nothing in the Act "shall authorise an act that causes or accelerates death as distinct from an act that permits the dying process to take its natural course". To remove any doubt whatsoever, clause 17(2) of the Bill declares that "nothing in this Act shall condone, authorise or approve abetment of suicide, mercy killing or euthanasia". Abetment of suicide, mercy killing and euthanasia will thus remain as criminal offences punishable under our Penal Code.

The provisions of the Bill also ensure that the AMD cannot be used indirectly to allow an act of mercy killing or euthanasia. The definitions of "terminal illness" and "extraordinary life-sustaining treatment" are specific and do not allow any flexibility of interpretation to include mercy killing. The Bill also ensures that even when an AMD has taken effect, palliative care including the provision of food and water must still continue. In fact, we have deliberately discarded the term "Living Will" because of its association with the euthanasia movement.

There are some who argue that the very act of legislating AMDs makes legal euthanasia more likely in the future. I do not agree. Legislation is the prerogative of Parliament. We cannot predetermine what the Parliament of tomorrow will legislate. In our democratic system, we have the right and the responsibility to elect those who will protect our best interests. Reflecting the majority view of Singaporeans today, the Advance Medical Directive Bill is unambiguous about our opposition to euthanasia. By itself, the Bill does not make legal euthanasia more or less likely in the future. Indeed, it could well be argued that once AMD legislation is in place, legal euthanasia will become less likely because a major area of ambiguity has been removed.

The second concern is that we are introducing AMDs to reduce healthcare costs. The two are not directly related. Whether or not we have AMDs, the decision whether or not to make use of extraordinary life-sustaining treatment must still be made either by the patient himself, his family members or by doctors. No individual, no family, no society can escape having to weigh the competing claims of young and old, or the healthy versus the sick, and of the living versus the dying. We do not want healthcare costs to become a crushing burden on our society regardless of how that burden is apportioned among the State, employers, families and individuals. We do this by striking a good balance between market pricing and subsidies, and by controlling the introduction of medical technologies that are not proven to be cost-effective. AMDs are an entirely separate matter. No one can be forced to make an AMD. If an individual chooses to make an AMD, it is his own decision. AMDs may well have the effect of lowering healthcare costs to the individual and his family, and even the State too if the patient is subsidised, but that is not the purpose of introducing it. AMDs will, however, reduce the need and the cost of medical litigation.

The third concern that has been expressed is that while the principle of the AMD is acceptable, there is no need for legislation at this point in time. In fact, the legal position concerning the withholding or withdrawing of extraordinary life-sustaining treatment is not clear in Singapore today. In the absence of legislation, we make the assumption that the broad principles of common law will apply, including English common law. In an area that is culturally sensitive, this uncertainty is not desirable. Having Parliament legislate will remove any ambiguity as to the scope and legal effect of AMDs. More importantly, legislation ensures that what is acceptable to us is consistent with our own social consensus and beliefs and not dependent on decisions made in other jurisdictions.

Even in the UK, the thinking on the need for legislation has changed. The British Medical Association which earlier opposed separate legislation for advance medical directives has since recommended in January 1994 that it favours the concept of limited legislation. More recently, the Law Commission of the United Kingdom in its publication Mental Incapacity released in March 1995 endorsed the principle of "advance statements about health" which are in fact advance medical directives and recommends supporting legislation to remove any ambiguity in the law. In Singapore, the need for legislation has been supported by both the Academy of Law and the Law Society. Legislation for AMDs is not new and already exists in one form or another in Australia, Canada and the USA. We have studied carefully the legislation in these jurisdictions and have used their experiences to guide us in the drafting of our Bill.

Some have also argued that there is no need for legislation today because the clinical situations for which AMDs apply are not many. That is not an argument against legislation because the need already exists. It is a facility which should be made available to those who wish to take on the moral burden of making their own decisions. We must also prepare for the future. With the speed at which medical technology is advancing, there will be more ways for the dying process to be prolonged by extraordinary life-sustaining means. Our population is also ageing rapidly. The incidence of cancers, strokes and other chronic degenerative diseases will rise. We can therefore expect more Singaporeans wanting to make AMDs in the next 20 to 30 years.

However, I agree that we should not rush to legislate. Indeed, the NMEC was meticulous in its study and consultations, and took over a year to submit its report. Even so, I propose to refer this Bill to a Select Committee to ensure that all views are taken into account in the final legislation.

Sir, I beg to move.

Question proposed.

Mr Loh Meng See (Kampong Glam GRC): Mr Speaker, Sir, I wish to commend the Minister and his Health Ministry officials for their painstaking and unhurried approach in introducing the Advance Medical Directive legislation to Singapore. The Minister has just confirmed that this Bill will be sent to a Select Committee.

A lot of work on the Advance Medical Directive has been done by the National Medical Ethics Committee. The Committee has put up an excellent report reflecting the views and incorporating the suggestions of various professional bodies and religious organisations.

The Advance Medical Directive Bill before Parliament contains provisions that no right thinking Singaporean can reject outright. This is because no Singaporean is compelled to sign the AMD if he does not wish to do so. It is voluntary and not compulsory. It is an enabling Act, when passed, made available to anyone who wishes to take advantage of it.

Yet, as the Minister has alluded to earlier, questions are still being asked as to whether we are too hasty in wanting to pass the law on Advance Medical Directive in Singapore. It has been said that there is no conclusive evidence to show that AMD provides real value and benefits to society. We should instead find improved ways to deal with the problems associated with the care and treatment of terminally ill patients without having to resort to passing the Advance Medical Directive law.

Some feel that the present arrangement where the doctor, patient and family members make the decision collectively is better and more helpful in dealing with terminally ill patients. Our doctors are competent and altruistic enough to help decide for the good of the patients and their families.

Sir, the main argument for wanting to have legislation on Advance Medical Directive is to remove the uncertainty and to clarify what are permissible and what are not permissible in achieving the high standards of medical practice and to incorporate safeguards against abuse.

However, this may introduce rigidity and take away the flexibility and discretion available to doctors in dealing with matters relating to their specialty. As much as the Minister has argued that in fact it has allowed the doctors to handle the situation better, I wish to suggest that there is also the other side because of the very wide spectrum of age group and the diseases and injuries involved. So there is that much you can legislate. There may be other conditions that discretion and flexibility may still be permitted.

Sir, the principle of personal autonomy is the basis for advance medical directive. I am afraid that the over-emphasis on this aspect of personal autonomy is something that I am uncomfortable about. It is questioned whether personal autonomy is really a good thing for someone deciding in advance an unknown future medical condition. In the future, there may be the advancement in technology and discovery of new drugs to treat the medical condition which today is deemed to be terminal. I think experience shows that some of the conditions are curable today but 10 to 20 years ago it was not possible. But I am very happy that the Minister has clarified just now that though the personal autonomy allows a person to sign the AMD, he should openly discuss and consult with the family members. This is because on reading the Bill, I have the impression that the person can actually hide the AMD from the next-of-kins and he is not obliged to discuss it with his family members. I think the remark made by the Minister that a person should not keep it a secret from his family members is a very important point, because on reading the Bill, it actually allows a person to keep mum and not tell anyone. It is the family members who are likely to be affected most when one of its members is afflicted with a critical medical condition and he needs urgent medical attention and treatment.

It is important because in Singapore we stress the family to be the building block of our society and nation, and we should not allow the principle of self-determination to be over-exerted. If that is the case, we run the risk of members of the family pulling themselves apart. This would not be healthy because it would upset family cohesion and kinship ties and it may lead to a less united and less strong country. This is something that I hope we will want to emphasise. As much as possible, we should encourage family consultation. Though we are allowed personal autonomy to sign the AMD, family consultation should be encouraged.

One thing good that comes out from the AMD legislation would be that it has already created sufficient awareness and our people will be prepared for the eventuality if they have to decide when confronted with a terminally ill condition. It will also help those who may not have made up their minds earlier to decide at the critical stage whether to proceed with extraordinary life-sustaining treatment.

Terminal illness not only strikes with a bout of sickness but comes suddenly when met with an unexpected nasty accident. It is tricky for doctors who have to deal with accidents and emergencies. Quick decisions have to be made by the doctors who sometimes have no time or opportunity to consult the family members but to attend to the emergency out of necessity.

For the patient who has signed the advance medical directive without informing the parents or spouse, one can imagine the shock of the aggrieved parents or spouse who might want to override the AMD already signed. There must be avenues and mechanism available to deal with conflicts of this nature. We know clearly that the law does not allow overriding, but when confronted with a situation of an emergency, it is going to be very difficult for the doctors to handle. I think some mechanism and avenues must be found to anticipate this difficulty in the hospital setting.

Though the Minister has explained that revalidation of the AMD is not as good as the provision for revocation, my concern is that we have allowed young adults above the age of 21 years to sign the advance medical directive and they go through different phases of life. They may not remember whether they have signed one or not. I think this question of validity ought to be considered again at the Select Committee and whether a revocation is still a preferred method to revalidation. I am more concerned about the younger adults than anybody else.

Sir, the Bill defines quite clearly the nature of terminal illness. But it does not provide the time frame to specify how imminent is imminent. Is it a month, a few days, when? I know it is not easy, but it is difficult for an ordinary person to understand that you are terminally ill but you do not know how long the patient would last and what constitutes terminal illness.

The other difficulty that I have is that though we have taken the trouble to define terminal illness, we should also try to define what is meant by "mental incompetence". We presume that it is easy to define mental incompetence, but it is important because here the assessment of mental incompetence really triggers the operation of the advance medical directive. So I would suggest that this assessment of mental incompetence be considered carefully because it is only when the two conditions of terminal illness and mental incompetence must come together before the AMD can come into effect.

My worry is really the larger question on the long term effect of AMD on our society and whether this will inevitably evolve a new mindset on our people. For example, what would be our attitude towards the elderly in our society, and even what our own elderly will think about themselves? That growing old is being useless and it is better to die than be a burden to the children and grandchildren. If our people lack the will to live on and endure pain and suffering, will it lead us to become a soft people? We know that for us to excel, we often need to overcome the pain threshold to test our limits. I know that we would not allow that to happen, but we must make sure that it will not be allowed to happen. Because without pain and suffering, how are we to know and appreciate the joys and pleasures of the good and healthy lives that we are having? I mean you need the contrast. Without the contrast, it is always difficult to compare.

Sir, the other question is, once the Bill is passed, how would the Government measure the success of implementing such a law. Does the Government measure its success by having the majority of adult Singaporeans signing the AMD? Do our civil servants embark on an intensive campaign to bring in the numbers?

The form and manner of public education programmes should be handled sensitively with the view to prepare our people and facilitating the process in decision-making. We only need to help Singaporeans make up their minds to decide with confidence and be comfortable in the decision that will be best for themselves and their families.

Sir, I am happy to support the Bill and for it to be committed to a Select Committee. I support the principle and spirit behind the AMD, but I hope that we would recognise the possible pitfalls and find ways to overcome the negative effects, if any, of AMD. 2.30 pm

Dr Tan Cheng Bock (Ayer Rajah): Mr Speaker, Sir, I rise to support this Bill. However, Sir, the concerns of the medical practitioners and other Singaporeans must be well addressed in the AMD. To do this, I would like to draw yourself, Mr Speaker, Sir, and Members of this House into the actual working of a hospital set-up and how this Bill will apply to those who have to execute the directive and the safeguards in the Bill to prevent abuse. I would illustrate through three case scenarios.

The first case scenario: a man with terminal cancer enters the hospital; he is conscious, extremely weak; he needs a Ryle's tube for feeding, a drip for intravenous feeding and medication. The doctor assesses his condition and concludes that he is terminally ill. This man has a registered directive.

The second scenario: a young man of 38 years old is brought in unconscious. His family informs the doctor he has hypertension or high blood pressure. He is put into intensive care unit with all the life-support systems in place. His consciousness lapses further and the doctor thinks he has no chance of surviving. The patient takes a turn for the worse. His brain tracing is flat but continues breathing through a ventilator. His heart stops but is revived by a heart machine. He is fed by a tube, the Ryle's tube. His relative wants the tubes to be removed, but he has no registered directive.

The third scenario: an accident victim, a young man of 20 years old, rushed into the hospital following a road traffic accident. He has sustained serious head injuries and stays in the intensive care unit. His condition deteriorates and he becomes brain dead. The doctor continues to keep him alive, in spite of his brain tracing being flat. His parents want to donate his organs for transplant. He is a minor and he cannot sign a directive.

In all, Mr Speaker, the three cases illustrate three different scenarios for the executors of the advance medical directive. The Bill has laid down a set of procedures for them, especially the doctors on the case, to follow. And a doctor, for example, cannot ask if the patient has a directive. It is stated clearly in the Bill. He must provide good medical care to all, including life-support systems, if necessary. However, if the condition of the patient deteriorates to an extent he cannot survive with all the life-support systems, he must carefully assess if that patient is terminally ill before invoking the AMD. And to do this, again he follows a set of procedures spelt out in the Bill, and this is important, to assure all those who have signed up. The doctor in charge, for example, checks with the Registrar of the Advance Medical Directive Board as to whether the patient has registered under the AMD. And if informed that he has, he discusses with two other specialists to confirm his findings. And if they agree, he then gets a written confirmation from the Registrar of AMD and then proceeds to execute the registered directive. He need not provide the patient with extraordinary health support systems, like the ventilator or the heart machine. However, in case of doubt, he and the two colleagues of his have to seek a third opinion of an independent panel of three specialists who must unanimously agree that the patient is terminally ill with no prospects of recovering. The safeguards are more than adequate.

Mr Speaker, Sir, let me come back to the three scenarios I painted. I want to try to apply the AMD Bill, as it stands, on the three cases in more detail. Case one, the terminally ill cancer patient with a AMD. This scenario is straightforward and where procedures are adhered to, there should be no problem. Case two, the young hypertensive with a stroke, who is brought into the hospital in a coma, but his condition later deteriorates and he is brain dead. He has no registered directive. The relatives request to pull the plug, but the doctor will not, because he cannot do so. No new directive can be entertained, and this is stated very clearly in clause 5 of the Bill. In the present situation, as mentioned by the Minister earlier, in the absence of this AMD Bill, relatives, upon the advice of the doctors, can request for the plug to be pulled and the doctors can oblige.

Mr Speaker, Sir, when a person is brain dead, he can be kept alive for weeks, months, or even for years. I recall the case of Karen Quinlan who was kept alive for years. Eventually her father sought a court order to have the life-support systems removed.

Mr Speaker, Sir, it is sad to cite money as one of the reasons for having to pull the plug on those who are brain dead. But I do not want to pretend that this will not be the reason for some cases. Having said that, the irony here is that we are actually forced to artificially prolong the dying process in the second and the third case scenarios, contrary to the aims of this Bill. The rigidity of the rule in clause 5 which forbids anyone to act without a registered directive must be tempered by giving parents or next-of-kin some say. I will come to clause 5 again when I discuss in more detail the third scenario.

Case three, as I mentioned earlier, is of a young man, 20 years old, who develops terminal illness as a result of his head injuries. He has no directive and, in fact, he cannot sign a directive - he is a minor. The problem arises when his parents want to will his organs for transplant. I could have gone along with this Bill without much reservation, had I not read of the death of Wah Liang, the comedian who died tragically in a road traffic accident. His parents gave consent to allow his organs for transplant. It suddenly dawned on me that had Wah Liang not given a registered directive, his life-support systems could not be switched off. Under the AMD Bill, his parents could not be in a position to permit the donation of his organs to save several other human lives.

Mr Speaker, Sir, I refer you again to this clause of the Bill which states in no uncertain terms that no one can act on an unregistered directive. This very clause has made the Bill very restrictive. It excludes those below 21 years old and those who are of unsound mind. Sir, you must keep in mind that AMD is an opt-in legislation. You must ensure that should you desire to be caught by the AMD Bill, that means, you want to be in this Bill, you have to take steps to register your directive with the Registrar before any doctor or doctors would act on your directive. And this is where I cannot reconcile the AMD with the Human Organ Transplant Act.

Let me explain. The Human Organ Transplant Act is an opt-out legislation. In other words, no active steps need to be taken to be caught by the Act. Unless otherwise indicated by default, one is caught by the Act. Its coverage is therefore very extensive. Many may fall under this Act because they are either unaware of this or they may be indifferent or may even find it too troublesome to take the time to sign the release form. For these and other reasons, many Singaporeans may also not register under the AMD and thus not come under its umbrella, having not opted in. The AMD thus lacks the extensive coverage of the Human Organ Transplant Act, because the AMD excludes a large section of the population, namely, the under-21s, and precludes their parents, guardians, from making any decision on their behalf. And because no directive can be made, no doctor can act. Therein lies the conflict between the AMD and the Human Organ Transplant Act. To me, this is an example of how a good piece of well-written, well-intentioned legislation can be done in by another equally well-written, well-intentioned piece of legislation, that is, the new Advance Medical Directive Act has rendered the Human Organ Transplant Act inoperational for this group of people. This will affect organ donations as most of such organs are obtained from young accident victims. Furthermore, Singapore parents have no choice but to continue to provide the life-support systems to those young terminally injured accident patients who cannot sign up.

Therefore, may I request the Minister to review this clause carefully to allow parents to have a say in the event of those not having registered under the AMD as they will be responsible for the health bill eventually. If, however, there is difficulty in amending this clause, may I suggest that we amend the Human Organ Transplant Act to make the Human Organ Transplant Act operational for those who have not or cannot sign on the AMD. This way, we tidy the two Acts to operate together.

Mr Speaker, Sir, the three cases that I have mentioned show that the Bill has set out clear guidelines and procedures for the doctor and his colleagues to follow when confirming terminal illness. I am satisfied with the assurances given to those who sign up and their relatives that due diligence will be practised when confirming terminal illness. However, the Bill is not so clear in the definition of "extraordinary life-sustaining treatment" which the Bill defines, and I quote, "any medical procedure or measure which, when administered to a terminally ill patient, will only prolong the process of dying when death is imminent, but excludes palliative care". What is "any medical procedure or measure"? This is the question that many doctors, and even lay people, ask. Does tube feeding at the first case of a cancer patient or intravenous feeding in the second case of a hypertensive patient fall into this definition? I think the medical profession needs further guidelines on this. Having said that, no doctor will stop providing palliative care to the terminally ill in order to alleviate his pain and suffering. Clause 11 of the Bill is very clear on this.

The Bill is also clear that treatment must be given first and that it is an offence to enquire whether a directive has been made. This is again reassuring for Singaporeans who sign up and is again spelt out clearly in clause 15.

In all my years of experience in medical practice, the doctor has always been most reluctant to pull the plug. Times, unfortunately, have changed. Doctors are no longer in charge of hospital administration and policy. Hospital culture and hospital philosophy have changed. Medicine has been called an industry. I am thus glad that clause 15 was inserted because there is a temptation for hospitals to prolong those who have no directives.

Finally, Mr Speaker, Sir, we must assure our people that the Advance Medical Directive Bill does not force Singaporeans to sign. It is voluntary. It is not mercy killing. It is not euthanasia. In fact, it is to safeguard against this. It is very clearly spelt out in the Bill. However, it gives the legal framework for doctors and Singaporeans to operate. To make sure the Bill is fully understood and accepted, I am sure the Ministry of Health must have plans to embark on a big public education exercise after the passage of this Bill.

Mr Speaker, Sir, I support the Bill which, I think, must be referred to a Select Committee for fine-tuning.

Encik Harun bin A. Ghani (Hong Kah GRC): ( In Malay): Mr Speaker, Sir, thank you for allowing me to participate in the debate on the Advance Medical Directive Bill.

After reading the Report of the National Medical Ethics Committee which studied the issues pertaining to this Bill, I am happy with the Report and I fully support this Bill.

In fact, the Fatwa Committee of the Muslim Religious Council of Singapore had discussed this matter on 25th August 1994 and they had agreed with the following matters, and I quote,

`Islam allows anyone with sound mind to make a will or advance medical directive stating that he does not want or refuse to accept any treatment to prolong his life when his illness is incurable and terminal and that there is no hope of him to continue living. This is allowed because a patient who is terminally ill cannot live longer and is prepared to endure the suffering and wants to die peacefully and calmly. This is because he believes that his destiny is in the hands of God and the time has come for him to go and that he will die.'

Mr Speaker, Sir, it can be said that all Muslims want to be at the bedside of their loved ones who are dying. They believe that they can teach the dying loved ones to repeat the two Islamic declarations of faith. Therefore, many Malays or Muslims prefer to bring home their terminally ill loved ones who have no hope of living as they prefer that they die at home rather than in hospital. At home, he will be at the bedside with members of his family who will say prayers for him.

In principle, this Bill is proactive, that is, it is aimed at underlining the action that can be taken or done by an individual to overcome the critical moment when facing death, and also to make arrangement with his next-of-kin to face with his critical situation. This will erase any misunderstanding which may arise when he is facing the final moment of his life.

In fact, the advance medical directive is not euthanasia, or mercy killing, or determining one's death on the ground of mercy. Euthanasia is an action carried out deliberately on a person who is terminally ill so as to cause death immediately. Euthanasia is just like committing suicide which is prohibited by most religions. I oppose euthanasia because it is against the principles of my religion.

The advance medical directive actually allows an individual to leave a will to his next-of-kin to let him die peacefully. His next-of-kin does not have to do anything or take any action merely to prolong his life.

Mr Speaker, Sir, I support this Bill because an individual is given the freedom and the right to determine his own destiny while he is in a critical moment of death. The individual is free to make the said advance medical directive at the time of his good health and after having all the information about his own self and his family condition. No other person can force him to make an advance medical directive. In fact, if there is an element of force or fraud, the said advance medical directive can be abrogated and the offender can be charged and sentenced according to the provisions in the Bill. Although the said individual has made his advance medical directive, he is still free to withdraw and cancel the said medical directive at any time.

The principle of individual freedom, which is the essence of this Bill, indicates that the Government has no intention to force anyone to be subservient in all the decisions that have been made by the Government. Therefore, in my opinion, this Bill is not contrary to any religious belief even though there are still some feelings of doubt about the real interpretation of the advance medical directive which is almost equivalent to euthanasia.

Mr Speaker, Sir, I would also like to call upon the Government to ensure that all provisions of the law are made to prevent any mischief or misuse by persons responsible for the implementation of the advance medical directive. In this matter, I support the move to have a certification which should be signed by three medical experts. These experts should confirm that the patient is suffering from a terminal illness and cannot be cured with modern medicine according to the current knowledge of the medical experts. Only then, the life supporting machine or equipment can be dismantled. But I would like to call upon the authorities that efforts to give medical care to the patient in an appropriate way should continue until he draws his last breath.

Mr Speaker, Sir, for those who are not yet convinced, I would like to call upon the Government to educate them about the benefits of this Bill. What I mean is that the Ministry of Health should provide more information through the mass media, including video tapes, and if this is still inadequate, then I agree with the proposal by the Minister for Health who has proposed that the Bill be sent to a Select Committee so that more organisations, especially individuals who are familiar with their own religious beliefs, would come forward to give their views because this is a sensitive matter. To me, the more information and inputs we get from them, the better it is for us so that those who have understood the latest development in the medical field will understand and realise the importance of introducing this Bill.

Mr Speaker, Sir, I support the Bill.

Dr Lee Tsao Yuan: Mr Speaker, Sir, the Advance Medical Directive Bill is a pragmatic response to a very difficult and sensitive issue. There are a number of advantages to the Bill.

First, it is not only entirely voluntary but it is also an opt-in system, not an opt-out system. If a person wants to make a directive, then he or she has to make the effort to do so. This is much better than an opt-out system when AMDs are presumed to be in effect unless a person chooses otherwise.

Second, the legislation provides the individual with a choice, the choice of not wanting to prolong his or her life when he or she is terminally ill and incapable of making such a decision. The current practice is that this decision is made by the doctor and the family members who may or may not make a decision in line with the patient's wishes. The patient may not have wanted to have his life artificially prolonged, thus causing more physical, emotional and financial stress on his family. However, his family members may not be able to make the decision to switch off the life support system and thus the treatment continues. Some people, especially older ones, live in fear of being a burden on their family in precisely such instances. The availability of an AMD would reduce this fear.

These are powerful and valid arguments for the enactment of AMD legislation. I can see that there is a point at which life need not be artificially prolonged. Life need not be preserved at all costs and in all circumstances and, in particular, there are advantages of not prolonging a living death by artificial means. However, there are a number of issues which the Bill, in its present form, leaves unresolved. In my view, the nub of the issue is not whether there should or should not be legislation but whether the legislation provides for sufficient safeguards to prevent abuse of the AMD.

I see the need for more safeguards where three issues are concerned. The first issue is the determination of terminal illness. As far as I understand, no medical practitioner, no matter how expert, can determine for sure with 100% certainty that an illness is incurable and will shortly result in death. There are enough documented cases of what can be called miraculous healing, that not even a panel of experts can definitively say that there is no prospect of recovery.

The definition of terminal illness in the Bill, therefore, is that of no reasonable prospect of recovery and that death would, within reasonable medical judgment, be imminent. What is reasonable in this case? What if a wrong prognosis is made? And why is it that the three medical practitioners or the Committee of three specialists are absolved not only from civil and criminal liability but even from discipline for professional misconduct in making this literally life or death decision? And, similarly, for a person who gives effect to the directive in the absence of knowledge of revocation or intended revocation of the directive when such care is taken to maintain the registry. Knowing the pain and suffering which the patient and his family members have to go through, do these provisions build in an unconscious bias to broaden the definition of terminal illness?

While I understand the need for protection for medical practitioners, as no one can definitively pronounce illness as terminal, a distinction surely can be made between civil and criminal censure on the one hand and professional review and discipline on the other. Instead of blanket immunity, isn't there room for the professional body to deal with cases of gross misconduct in this case? A related question is: suppose a patient has made an AMD and has been diagnosed as terminally ill, when should the treatment be withdrawn - three months, a week, a day? Is there a time limit? Who makes the decision as to timing? The Bill is silent on this issue.

The second issue concerns whether the existence of AMD legislation changes doctors' behaviour for patients who have not made AMDs. At present, without legislation, decisions are already being made whether to artificially prolong life or not for terminally ill patients. Doctors and family members exercise considerable flexibility on a discretionary case-by-case basis. Life support systems are being switched off for some terminally ill patients. Would AMD legislation actually limit doctors' choices, in the sense that the decision becomes: for patients with AMDs, withdraw treatment; for patients with no AMDs, therefore, continue treatment? In other words, does the very existence of legislation alter the basis of decision making for patients without AMDs? Similarly, for society as a whole, would AMD legislation change attitudes towards a greater intolerance of terminal illness?

Mr Loh Meng See has raised concerns regarding the long-term effects on society and I share his concerns. Pressures could arise in favour of making AMDs, especially since life-sustaining treatment could be very expensive, not to mention the emotional stress borne by the family. I recall that there was a time when eyebrows were raised when a couple had more than two children because it was not socially correct. Similarly, will there come a time when it would not be socially correct not to have an AMD? I believe that this choice is an entirely individual matter to be made after much thought and consideration. Legislation is only the beginning of the process. I would suggest that special attention be given to extensive public education as to what an AMD is and the benefits and cost of making one. This suggestion has already been made previously.

A third issue is whether the AMD Bill could eventually lead to the legalisation of euthanasia. I must state here that I am against euthanasia. At present, euthanasia is an offence under the law. I must also emphasise that the Bill per se has nothing to do with euthanasia. However, if individual self-determination forms the basis for the AMD, then it is not that difficult to take this principle one step further to allow an individual the right to die. In 10 or 20 years' time, when the proportion of the aged rises in Singapore, pressures might mount for the logical progression from not wanting life-sustaining treatment to wanting to die rather than face suffering and pain. These pressures are already present in some developed countries today. The Minister has just given the assurance that the Ministry is against euthanasia and that the Bill itself does not permit euthanasia. I would be more assured if I knew for sure that the Minister would still be the Minister for Health in 20-30 years' time. As such, my concern is that there are insufficient safeguards to prevent a slide from an AMD into the legalisation of euthanasia, perhaps not now, not this generation, but in the future.

Let me conclude by saying that I support the broad thrust and direction of the Bill. There are instances where life need not be artificially prolonged and the Advance Medical Directive Bill makes that personal choice legal. However, I think that the Bill in its present form allows for too many questions and loopholes to be satisfactory. In particular, there need to be more safeguards built in to prevent abuse and to address the three issues that I have outlined. I would further suggest that there be a review of the AMD scheme after one year to fine-tune its efficacy in actual practice.

Sir, I support the Bill provided that it goes to a Select Committee.

Mr Speaker: Order. I suspend the Sitting and will take the Chair again at 3.30 pm. Sitting accordingly suspended at 3.05 pm until 3.30 pm.

Sitting resumed at 3.30 pm