ADVANCE MEDICAL DIRECTIVE BILL (As reported from Select Committee)

Order for Third Reading read. 4.53 pm

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

Sir, the Select Committee on the Advance Medical Directive (AMD) Bill received 14 written submissions. The Committee heard oral representation from 12 persons in respect of six of the written submissions. The Committee's Report has been circulated to Members of the House.

Most of the points raised in the submissions are already catered for in the Bill presented earlier to Parliament. These include safeguards against euthanasia, the proper certification of terminal illness and the rights of patients who have not made directives.

I wish to take this opportunity to reiterate three important points concerning the AMD. First, the purpose of the AMD is to allow the patient to make a choice in advance and not have the dying process prolonged by extraordinary life-sustaining treatment if he becomes terminally ill and mentally incompetent. While this is the patient's own decision, we will encourage the involvement of family members in the decision-making process and will emphasise this point in our public education programme.

Second, the AMD is only applicable when the patient is "terminally ill". It applies only to those who are already in the process of dying and no longer able to decide for themselves. No one can force a patient to accept medical treatment against his wishes. All the AMD does is to enable him to express his wishes in advance while he is still mentally competent. Therefore, the concern that the directive may be used by some individuals to commit suicide is unwarranted. Notwithstanding this, the Bill clearly states that it does not condone nor authorise abetment of suicide, mercy killing or euthanasia. Sufficient safeguards have been incorporated into the Bill to prevent such abuses.

Third, the directive does not affect the right of a patient who is mentally competent to make decisions concerning his own medical treatment. As long as the patient is able to express his wishes, doctors will act according to them whether or not he has made an AMD. For those who do not wish to make a directive, the current practice will continue when they become terminally ill and mentally incompetent. Doctors will then make decisions in consultation with family members.

Sir, I will now highlight the substantive amendments recommended by the Select Committee.

Witnessing the making of a Directive

One representor asked whether the two witnesses required for the making of the directive should be present at the same time.

The Select Committee felt that this had to be so logically, but to put it beyond doubt, the Bill has been amended to make this requirement clear.

Revocation of a Directive

One representor commented that the requirement to have two witnesses for the revocation might not be necessary. This could result in a delay if one witness failed to report the revocation to the Registrar.

The Committee agreed with the representor that the revocation of the directive should be made easy so that, if there is any doubt, we err on the side of prolonging life. The Bill has thus been amended to allow revocation with one witness, provided that the witness informs the Registrar in writing. Of course, the patient should also notify the Registrar if he is able to do so.

As a counter-balance to the above amendment which makes revocation easier, a related amendment is made to give greater certainty to the medical practitioner who has to decide whether to act on a directive.

Medical Practitioners' involvement in the Directive

The Committee shared the concern raised by some representors that the Bill did not explicitly exclude medical practitioners who might benefit from the death of the patient.

The Bill has thus been amended to state that doctors who may benefit from the death of the patient will be excluded from being involved in the certification of terminal illness and in the execution of the directive.

Offence in causing another to make a Directive

One representor pointed out that irresponsible family members might be able to pressure an elderly patient to make a directive without actually committing any offence under clause 14(1).

The Committee shared the representor's concern and decided to amend the Bill to widen the scope of clause 14(1) to make it an offence to obtain a directive by "unconscionable conduct".

Information concerning the patient's making of a Directive

Finally, it was pointed out by one representor that clause 15(3), requiring doctors to keep all information relating to the patient's making of a directive confidential, might hinder the doctor from counselling family members when the patient has already been determined to be terminally ill under clause 9.

The Committee agreed that counselling family members is important when the directive is being executed. The Bill has been amended accordingly to allow doctors to divulge information about the patient's AMD to family members once the patient has been determined to be terminally ill under clause 9.

Sir, the Ministry of Health will conduct a public education programme on various aspects of the AMD. We will involve civic organisations and community leaders. Doctors and relevant health care workers, in particular, will be trained on what their responsibilities are, and what advice they should give to their patients.

Sir, I beg to move.

Question proposed.

Mr Loh Meng See (Kampong Glam GRC): Sir, I wish to commend the Minister for Health and his Ministry officials for the painstaking effort in bringing this Advance Medical Directive Bill through the various stages of consultation. For a subject as important as this, the process of consultation and feedback has been worthwhile. The National Medical Ethics Committee did very good work. The views and comments of the various professional bodies and religious organisations were considered and incorporated into the Bill.

By committing the AMD Bill to a Select Committee, it allowed for further opportunity to the members of the public to submit their views. The AMD Bill was further amended. It shows that the Government listens to good and constructive suggestions.

I am satisfied that we have done all we could in giving legal effect for advance directive to medical practitioners against artificial prolongation of the dying process. The terminally ill patients are allowed to die peacefully and with dignity.

I accept the Minister's view that the AMD will in fact make euthanasia less likely as it removes the ambiguity in the medical care of the terminally-ill patients.

In the United States, two federal appeal courts recently lifted bans on physician-assisted suicide. This has led to the tormenting question in the minds of the Americans as to whether the right to die has become a duty to die.

We are clear that we are not heading this treacherous route. We will not be subjecting our citizens with this tormenting question. Singaporeans, especially the elderly sick, need not feel that they better choose a quick death because they impose financial and emotional burden on their families and society.

I am pleased that the assertion of patient autonomy has been moderated. We are discerning enough to appreciate the importance of the involvement of family members prior to making the decision to sign the AMD. We recognise that any serious sickness of a family member affects everyone in the family.

Sir, there are two areas which I hope the Ministry will be vigilant and will monitor the situation closely. For the country's psychological defence, our people must be inculcated with a strong will to face any crisis and be prepared to fight to save dear lives for the sake of family and country. There should not be any let-up in maintaining the high threshold of pain of our people to compete and in achieving better quality of life for our citizens.

Any attempt to coerce the elderly patient to sign the AMD which is illegal should be acted upon quickly to nip the problem in the bud.

I hope that with this AMD, a step forward is taken to forge the doctor-patient relationship and the concept of the family doctor will be an established practice in Singapore.

Sir, I support the Bill.

Dr Kanwaljit Soin: Mr Deputy Speaker, Sir, like most other medical practitioners, I have tussled with questions of life and death many times in my work. When the AMD legislation became an issue in Singapore, the question of life and death became more urgent and vexing for many of us.

It is vexing because the field of medical science is inexact and rapidly changing with few fixed sign posts. This applies especially to the condition pertaining to the end of life. I therefore would like to outline some problems of putting a grey area of medicine into black and white legislation.

There are different ways of meeting death with dignity. If we choose the AMD way, then we must be cognizant of the medical, legal and philosophical mines and pitfalls of this route. If we respect the human determination to live and the principle of fighting death to the last gasp, then we must be aware of the implications of this legislation and the message it sends to society.

Sir, from my knowledge of the private health sector, the need for the Advance Medical Directive Bill to be pushed is not pressing as the artificial prolongation of the process of dying is not a big problem. There is good communication and trust between doctors and patient's relatives. If a doctor thinks that the case for a particular patient is hopeless, the relatives usually take the doctor's advice and discontinue heroic medical measures or do not even have these measures instituted in the first place. For those few relatives who want extraordinary life-sustaining treatment to continue, then nearly always, after a week or so, they ask the doctor for a re-evaluation of the patient's condition. If the prognosis remains grim, then the relatives will take the doctor's advice of discontinuing the treatment. During this week or two, the futility of the process helps relatives to accept the impending death of the loved one.

I know that we are going to have an increasingly aged population but we are not Australia or the USA where medico-legal problems abound and where doctors and hospitals have to protect themselves from being sued. We are Singapore and problems in this area have not arisen.

Another factor to consider is that the concept of an informed consent is integral to the signing of a living will or an advance medical directive. In Singapore, this issue of informed consent has not been developed sufficiently. In the local context, patients often leave many medical and surgical decisions to their doctors who take this responsibility and make decisions for patients as best as they can. Are we going to allow this to happen also in the case of the signing of an advance medical directive, and leaving it more to the doctors' discretion? Because, in my opinion, Sir, the issue of informed consent is crucial in the signing of an advance medical directive.

I think that in Singapore we have to develop this concept and culture of an informed consent much more before we push advance medical directives.

Now, Sir, I would like to address some provisions in the Bill.

(1) Definition of "terminal illness" -- according to the Bill, there are two limbs to the definition. One limb defines it thus, "death would within reasonable medical judgment be imminent regardless of the application of extraordinary life-sustaining treatment."

If we take this definition, then there is little point in having a statute permitting withdrawal of such procedures if death is imminent even with the full application of extraordinary life-sustaining treatment.

The other limb of the definition says, and I quote, "the application of extraordinary life-sustaining treatment would only serve to postpone the moment of death of the patient" -- this contradicts the first limb which says that death is imminent even with the application of life-sustaining treatment. How can we reconcile limb (a) and limb (b) when they both have to be necessary conditions for defining terminal illness?

Also, the definition in the second limb, that is, it only postpones the moment of death, makes the provision too broad, if taken literally -- most medical interventions serve only to postpone the moment of death, even in an otherwise healthy patient.

The definitions in the Bill of "extraordinary life-sustaining treatment" and "terminal illness" are problematic in that they are tautological -- "terminal illness" is defined with respect to "extraordinary life-sustaining treatment" and vice versa.

Hence, we can see that there are problems in drafting legislation of this sort in general terms. It requires interpretation to determine whether the patient's condition warrants its implementation. The interpretation has to be made by the doctors. Therefore, although in general terms, legislation for advance medical directives may seem appropriate, we must not forget that the devil is in the details. The legislation when enacted will have to be fleshed out in its many details and innumerable problems will arise. Therefore, I would like to request the Minister not to push this legislation too quickly and too far, but let us take our time, see what are the problems that arise in other countries, and then implement it slowly.

Mr Cheo Chai Chen (Nee Soon Central): ( In Mandarin): Mr Deputy Speaker, Sir, life is a very remarkable phenomenon, a masterpiece by mother nature. So we must treasure our lives and try our very best to extend the existence of life. However, the Advance Medical Directive Bill contradicts this philosophy. But, in order to lighten the mental stress and financial burden of members of the patient's family, there are some merits in this Bill.

Although careful consideration has been given to the various aspects covered by the provisions under this Bill, there is always a possibility of human error and the question of integrity of the decision-making specialists that may result in the patient concerned losing the chance of extending his life. Therefore, the Government should pay special attention to this.

On the other hand, I hope that the Government will make a study on whether the passage of this Bill will provide the opportunity and make it more convenient for unscrupulous people and unethical medical officers to engage in illegal trafficking or sale of human organs.

We have heard, from time to time, of incidents of dead people coming back to life again. With rapid advancement of medical sciences today, if life can be extended, there is always a possibility that there may be some kind of cure for the patient later on. Moreover, whether the patient has a chance of recovery or not is a decision that no one can be absolutely sure about. In the long run, the Advance Medical Directive Bill may give rise to some undesirable consequences.

Mr Deputy Speaker, Sir, because the various provisions in the Bill have been considered very carefully, I do not object to the Bill being passed in this House to become law. But I would like to give my personal views on the recommendations of the Select Committee on this Bill. I think a number of recommendations made by the Select Committee are all very good. However, there is one point where the original provision required two witnesses to be present for a person to revoke his Advance Medical Directive, but the Select Committee recommended that it be amended to only one witness being required. I think this amendment is not necessary because if a dispute arises as a result of the revocation of the Advance Medical Directive, the presence of two witnesses will make it easier and fairer to settle the dispute.

Dr Michael Lim Chun Leng (Cheng San GRC): Mr Deputy Speaker, Sir, the Advance Medical Directive Bill is timely -- it seeks to lay down the ground rules on the artificial prolongation of the dying process in a terminally-ill patient. With the advances in science, many in the lay public believe that doctors can do wonders and expect all sorts of extraordinary measures to be taken, even though there is no hope at all. The end result is the same -- the patient will eventually die. However, the bill will be enormous. Doctors have always erred on the side of safety and if there is any doubt that life can be prolonged, they will always continue with measures which they think will prolong life. And I think no member of the public need worry that doctors will err on the other side and shorten life unnecessarily. The Bill has also been very carefully scrutinised by Singaporeans from various walks of life and the Select Committee has also gone through it with a fine tooth-comb.

However, the success of a piece of legislation depends not only on how well it has been crafted but also in its implementation. The legislation has focused mainly on the rights and protection of the patient which it should rightly do so. However, ultimately, the success of the Bill will require support of the medical professionals who are intimately involved in the implementation of the Bill.

In implementing the Bill, the process of administering the Bill should not be burdensome and create more difficulties for medical practitioners whose main aim is to practise good rational medicine.

The involvement of more doctors in the process of determining what situation constitutes a terminally-ill condition will mean that doctors who were not involved in the medical care of the patient will also be involved in the decision-making process. This can sometimes be rather difficult. Furthermore, if the opinions differ, the patient is referred to a committee of three specialists who will then make the decision. Good medical decisions cannot be made solely by sitting on a table and examining the case-notes alone. Will the Ministry ensure that the appointed specialists from the panel be present together to review every patient at the bedside when the situation arises?

One of the major concerns of this legislation is that it has opened the medical profession to the possibility of a fine and/or conviction, as stated in clause 15. Prior to this, a decision on the care of terminally-ill patients would have been purely a medical one made in consultation with the family and the patient with no legal sword of Damocles hanging over their heads.

I think that the law must distinguish between divulging this information for dishonest intentions and not punish medical practitioners who may divulge this information unwittingly with no ill intent. Although there are some safeguards in subsection 2, nevertheless, we have placed upon them this potential threat. Any court action can result in dire consequences for any medical professional. In the administration of this Bill, I would urge the Ministry to exercise due care and concern so that medical practitioners do not get excessively burdened. If this act becomes too burdensome, many medical practitioners will register themselves as objectors and the advance medical directive may become an act which may not be acted upon. This will defeat the purpose of the Bill.

In conclusion, I support the Bill but I urge the Ministry to give due consideration to the points highlighted.

Mr John De Payva (Nominated Member): Mr Deputy Speaker, Sir, I am against mercy killing. Doctors have no right to hasten the death of any individual whatever the circumstances. But the Bill before us does not sanction mercy killing. It merely provides for a person to give advance notice to doctors not to prolong his life by artificial means. This I can support.

Only last week, I heard over the BBC a sad episode. It concerned a woman in coma for four years. Finally, a court in Scotland allowed the doctors to take her life. Of course, the woman's husband was sad. But, at the same time, he was relieved that her agony was over.

We have made tremendous progress in medical science but we cannot put off death. When the time comes, it is better to let a person to die naturally rather than keep him alive through artificial means. The question is at what point the doctor sees life-supporting operations. The Bill is quite explicit on this matter. The decision whether to let the patient die is taken off the hands of the doctor responsible for the treatment. Two other doctors must agree that the patient is terminally ill. If the doctor in charge is not a specialist, then the other two doctors must themselves be specialists. If the doctor in charge is a specialist, one of the other two doctors must be a specialist. If there is no unanimity, the issue has to be referred to a committee of three specialists and, here again, the principle of unanimity is preserved.

I am satisfied that every precaution will be taken before the extraordinary life-supporting processes are switched off. Medical treatment is costly. Keeping a person alive through extraordinary means is even more costly. It is also agonising to close relatives of the patient as well as to doctors and nurses. But decisions on whether to let a person go cannot be based on cost. They must be based on medical and moral grounds. I have stated earlier that doctors have no right to hasten the death of a patient. Let me add that doctors have no right either to prolong the life of a patient needlessly. What do I mean when I say "needlessly"? This would involve the use of high-tech machines to keep a patient alive for a prolonged period when it would be much more humane to let him die naturally.

The critical issue is whether there is a chance of recovery. If there is, then doctors must do everything possible to save the patient. But if there is no chance of recovery, the decent thing is to let nature take its course. Once the Bill is passed, it is up to each of us to make that critical decision whether to make an advance medical directive. All those 21 years and above are entitled to make such directives provided they are of sound mind. There is also provision for a person to revoke such directives.

Once a person makes an advance medical directive, who else should be told of this decision? According to the Bill, the directive would be kept confidential and made known only to such person as he may authorise in writing. The directive will be made known to the doctor responsible for treatment only if such a certificate has been forwarded to the Registrar of the Advance Medical Directives. I do not know why it is necessary for the advance medical directive to remain confidential. Decisions of this sort are taken only after familial consultations. I would urge that such decisions be taken when people are in the pink of health, not when they are about to go for major surgeries. If family members are aware of the directive, they can better understand decisions taken by doctors on whether or not to switch off the extraordinary life-supporting processes.

Should family doctors be informed of the advance medical directive? I would say, yes. But chances are that it is not family doctors who will make the life-and-death decision. Chances are it will be the doctors in hospitals. As such, it would help if the family doctor is involved, at some point in time, in the decision-making process. Perhaps, the Bill could be further amended to bring the family doctor into the picture, assuming that the doctor treating the patient in hospital is a specialist. Then he should refer his decision on the nature of terminal illness to another specialist and to the family doctor. If, on the other hand, the hospital doctor is not a specialist, then his decision should be referred to two specialists plus the family doctor. So at the point when a person signs his advance medical directive, he should also state who his family doctor is. There must also be provision for a person to change his family doctor.

Sir, I support the Advance Medical Directive Bill.

Mr Imram bin Mohamed (Nominated Member): Mr Deputy Speaker, Sir, I would like to highlight an anomaly between the AMD Bill and the Human Organs Transplant Act (HOTA). To ensure proper protection of the patient, the AMD Bill stipulates that three doctors are required to certify a patient to be terminally ill before his extraordinary life-sustaining treatment can be stopped. HOTA, on the other hand, requires only two doctors to certify a patient to have suffered irreversible cessation of all functions of the brain before his organs can be removed. This difference in certification level between the two Acts is incongruous in certain circumstances where the Acts overlap.

One may say that the AMD Bill deals with terminally ill patients who are still alive, whilst HOTA deals with those who are brain dead. So there is no comparison. This is generally true. However, a terminally ill patient is not necessarily always still alive. The patient could be brain dead. If I may quote Dr Tan Kee Guan, a Medical Director at Ang Mo Kio Community Hospital, who, in his written representation to the Select Committee on the AMD Bill, said, and I quote:

"Terminal illness -- a rather straight forward explanation for those with advanced cancer and brain dead." Terminal illness can also be the result of a serious accident where the patient suffers severe brain injuries.

Members may remember when Dr Tan Cheng Bock vividly presented three scenarios of typical AMD cases at the Second Reading of the AMD Bill last December. Incidentally, two of his three scenarios also depicted the terminally ill patients as being brain dead which support Dr Tan Kee Guan's description of terminal illness. But I would like to specifically refer to his third scenario in which he portrayed an accident victim, a young man of 20 years old, being rushed into the hospital following a traffic accident. He had sustained serious head injuries and stayed in the Intensive Care Unit. His condition deteriorated and he became brain dead. This is a situation in which the AMD Act and HOTA clearly overlap. For such a patient, three doctors in one case, or two in the other, would need to certify him brain dead before the life support equipment, or his organs, could be removed under the respective Acts. It is inconceivable in such a case for the AMD Act and HOTA to have different standards for certifying a common condition. Moreover, if the patient is covered under both the AMD Act and HOTA, the hospital will be left in a quandary as to which Act takes precedence and, consequently, which procedure to follow.

It is also anomalous that the patient is given lesser protection under HOTA where, unlike the AMD Act, the removal of organs follows the pronouncement by the doctor and therefore ought to have a protection level no less stringent than that of the AMD Act.

Sir, I have no qualms with the AMD Bill in principle. But the passing of the Bill today will create the anomalous situation which I have just described. This is not desirable. The Minister for Health had previously said that there was no urgency in legislating this Bill. I would, therefore, ask the Minister to defer the passage of this Bill until the differences with HOTA have been resolved.

Sir, before I conclude, I would like to seek clarification from the Minister for the rationale for having a two-tier system of six doctors to certify terminal cases. Some statements in the Minutes of Evidence of the Select Committee Report appeared to suggest that having the second panel of doctors would increase safeguards for patients against possible error of judgment by doctors.

The Minister for Health had also expressed a similar view during the Second Reading of the Bill. He has said of the two-tier certification process, "Where there is any doubt, this procedure will ensure that we err on the side of life." But does having another level of judgment really increase safeguards? Does it err on the side of life? I think not. It actually does the opposite. This is because the second panel of three specialists is only convened when there is no unanimity among the first group. When the first three doctors disagree, this decision would allow the patient to live except that it could be reversed by a higher committee of three other doctors. Thus, the more levels you have, the greater the possibility of the patient being condemned. I wish to ask the Minister whether it would be better to have just one panel of three specialists which includes the patient's doctor if he qualifies to make the judgment. If the doctors agree unanimously, the AMD will be carried out. If any one of the doctors disagrees, the patient continues to receive life-sustaining treatment. This will ensure the quality of judgment that we seek to provide and yet err on the side of life.

BG George Yong-Boon Yeo: Mr Deputy Speaker, Sir, I would like to thank Members who have just spoken for their comments, for their thoughtful suggestions, for their concerns and for some moving, inspiring words about the nature of life and the problem of crossing this twilight zone between life and death. I thank Mr Loh Meng See for his kind words concerning the process with which we brought this Bill into its Third reading. We have deliberately taken our time, spent almost two years now on it from the beginning, making sure that all sectors of our society were consulted. Many views were tossed up, considered and incorporated, where possible.

Dr Soin asked whether we could not make the definitions clearer. If the definitions could be made clearer, there would not have been the need for this Bill. Does the Bill create grey areas where there were none? It does not, because the grey areas exist as a condition of life. Every day it is being faced by doctors in hospitals. Every day family members, doctors and specialists have to make decisions. Very often, imperfect decisions. Very often, without consensus. Very often, resulting in recriminations years after the patient had passed away.

What we are trying to do here is to allow those who feel strongly about their own wishes to state them in advance so that doctors and family members will know when the time comes. And this, in fact, removes the heavy burden from those who would otherwise have to make the decision anyway in this grey area. It is not something which can be solved by words.

Dr Soin said that definitions are tautological. They are not tautological. They are subjective. They are subjective precisely because this is an area in which we cannot escape from human beings having to apply their minds and their hearts and exercising human judgment and human wisdom. There is no way by which the words can be so cunningly redrafted that all of us can then say, "All right, let the words decide for us." That is not possible. And yet we know that decisions have to be made.

Take, for example, a patient in the final stage of cancer suddenly having a heart attack. The doctors have to decide. Do you try to resuscitate the patient? All right, you resuscitate. The heart pumps again and the patient lives on for a few more days, maybe for a few more weeks. Is this what the patient would have wanted? Is this what family members want? Is this what doctors would have prescribed? Or a patient has an infection, dying from pneumonia. And today, with medical technology, with antibiotics, you can treat the pneumonia and keep the patient living for a few more days. As medical technology advances, there are all kinds of new methods that you can introduce to stretch out the dying process. Is it natural?

Today, between doctors and family members, usually they can come to a decision, to a consensus. But as our population becomes more educated, I think they will become more litigious. And once a few doctors are sued in court for not doing enough, very quickly all doctors will keep on treating till the family members say no. And are we sure that family members can agree among themselves? Brothers, sisters, in-laws involved in a decision, very often it is very complicated. The result is tremendous stress for everyone. So if the person himself says, "Look, let me give my input so that you don't have to worry.", I think that is a great help. But, of course, if you as a patient decide, "No, I will leave it to my wife. I will leave it to my son. I will leave it to my doctor.", so be it.

There is no intention whatsoever to conduct a campaign to promote the AMD. That is not the intention. The intention is to have it available for those who feel that they want it. And we will have a programme to educate all our doctors, health care practitioners and members of the public to know what it is about, so that they can make a choice.

Dr Soin asked whether most people understand the concept of informed consent. They may not. And if they do not, they should not do the AMD. But if they understand what informed consent is and they decide to have it, I do not think it is for us to deny them this facility, which is why I am not in favor of further postponing this legislation. But we are not pushing it and I respect the comments made by many Members here that we should not rush into the implementation without due regard for the details. And as Dr Soin said, the devil may well be in the details, and I think she is right there. I am particularly appreciative of the views expressed by Dr Michael Lim and Dr Kanwaljit Soin who are themselves medical practitioners, advising me to watch the implementation and not to make it burdensome. In implementing it, we should not create new problems for ourselves which defeats the original purpose of the legislation. So we will try to create something which is the least burdensome to doctors and health care practitioners, something which can be widely understood by all, but something which in the end relies on common sense and human wisdom.

Mr Cheo Chai Chen supported the legislation. But he mentioned that we should not reduce the number of witnesses from two to one in respect of the revocation of the AMD. I think Mr Cheo misunderstood what was intended. We are not reducing the number of witnesses required before we pull the plug. We are saying that if a patient decides to revoke his AMD, there need only be one witness. Because it may be a few minutes or a few hours of consciousness in between critical periods when a patient has changed his mind, and only one person may be there. That one person should be good enough. This matter was discussed at the Select Committee and we decided, "Look, that is right. If the patient has indicated any change of mind, accept it." I think that is fairer to him.

Dr Michael Lim suggested that the panel of specialists, in the event that this matter could not be decided by the lower committee, if it goes up to the panel of three specialists, should not just make a decision on the basis of case sheets and case notes but go down to the bedside to look at the patient themselves. I will take up his point. I think here what we seek is not a rigid administrative procedure but good medical practice. In other words, if doctors in the committee cannot decide, there must be good reasons why they cannot decide. If the panel feels that they have got to go down to assess the situation for themselves, then they should go down. But I do not think that we should prescribe it in law.

As to whether doctors who unthinkingly and without malice divulging information being hauled to the Medical Council or to court for infringement, I think here we will apply common sense. The purpose here is not to make life difficult for doctors but to help them help the patients they are looking after.

Mr John De Payva asked why is there a need for confidentiality. I think it is important to have some safeguards on confidentiality because the fact of an AMD itself may change the way doctors treat their patients. There is that possibility. The Medical Ethics Committee, which first looked at this matter, discussed it fully this was discussed by the Health Ministry also and we decided that, like the making of a will by a human being, the contents of the will, if it is to be divulged, should be divulged by the patient himself and not by those who are custodians of that will. Because we do not know whether he wants others to know. And in the case of doctors who are treating him, it may affect their decisions. But if the patient himself decides to inform his wife, his relatives, his friends, his doctors, it is perfectly in order, because that is the patient's own judgment. But the law should protect him in the event that he wishes to have confidentiality.

In the case of spouses and immediate family members, indeed, we are going to recommend that in all cases, the AMD be made in consultation with family members. But however you consult, in the end, it is your own decision. The family doctor ought to be one of the witnesses, but we cannot be sure that the family doctor is the best doctor in every case. Because depending on the person, he may or may not have a family doctor. He may have a family doctor in name, but he may not be the family doctor he goes to all the time. Sometimes he goes to see his company doctors, sometimes he goes to a polyclinic. Sometimes for different conditions, he sees different specialists in hospitals. So it is very difficult for us to put in the Bill a special place for the family doctor. But in all cases where a GP is recommended, it is the family doctor who should be there, because he would know the patient and his family the most. And that point would be taken into account when we implement this Bill and conduct our education programme.

Mr Imram raised what he felt to be an inconsistency between the number of two doctors required to certify brain death under the Human Organs Transplant Act (HOTA) and the three doctors necessary to certify terminal illness. In the case of HOTA, brain death is defined as death. It is only for HOTA. It is not for all the other statutes. As I mentioned earlier in this House, at some point in time, we will have to resolve what is the position of brain death in our law. In fact, brain death is the most conclusive definition of death, much more than the heart stopping. To certify brain death, the issue arises when you keep the heart pumping artificially, but in fact the brain is dead. Then you got to certify that the patient is in fact brain dead before you can then switch off the heart/lung machine to stop the heart from pumping. The procedures are quite complicated. It involves checking the cornea, pouring cold water into the ear canal, a series of seven tests which are very technical in nature. These are not subjective. These are objective criteria to determine brain death, internationally accepted, which is why there is no need to have more than two doctors to do it.

In the case of AMD, we are not certifying death. We are certifying terminal illness and that inherently is a more subjective view, which is why three doctors are required. It may well be that the patient is already brain dead and has made an AMD, and the three doctors decide that he is already brain dead. Therefore, he is already terminally ill and therefore they can switch off the heart/lung machine. But for most cases of terminal illness, it is not so straightforward and therefore three doctors are required.

Mr Imram also asked what happens if someone comes under both HOTA and has made an AMD. So we have, for example, a case of someone involved in a traffic accident and therefore coming under the ambit of HOTA, assuming he has not opted out, and let us say he has also made an AMD. If he is already brain dead, then he is defined as dead under HOTA and the issue of AMD does not then arise. In other words, in the case of someone being covered by both, then HOTA comes first because he is by definition already dead, and therefore the AMD does not arise.

Mr Imram also asked whether it is necessary to have this two-tier system, that the more tiers you have the more you condemn a person to death. I think that is turning things the wrong way round. We must not forget that a person who has made an AMD has made a serious decision that he does not want the dying process to be prolonged when he is terminally ill. So we should respect that wish. If a lower committee of doctors cannot decide, we are submitting it to a higher committee in order to be doubly sure that we are acceding to his wish, and that we are not at all condemning him.

Sir, I believe I have answered the main issues raised by Members. As I said earlier, we have taken a long time to discuss all aspects of the Bill, turn it around, look at it front side, back side. The problem is now implementation and I fully respect the concerns of Members that good implementation is very important and I assure Members that we will not take this lightly and that in our education programme and in the development of administrative procedures, we will try to anticipate all problems, gain some experiences as we go along, make a review after a year, make adjustments if necessary, come back to this House if necessary, so that what we have is something which is a facility some of us can resort to with a certain peace of mind if we feel that it is good for us and for our family.

Question put, and agreed to.

Bill accordingly read a Third time and passed.