The case of M could establish very dangerous precedents that would place the lives of many sick and disabled people in danger

The case of M, a woman who suffered severe brain damage as a result of encephalitis in 2003, has just had its third day of hearings before Justice Baker (pictured) in the Court of Protection.

M's sister and partner want artificial nutrition and hydration to be removed with the explicit intention of ending her life. But the Official Solicitor is opposing them.

Under precedent established by the Bland judgement in 1993 it is now possible to make an application to the Court of Protection to withdraw artificial nutrition and hydration (food and fluids) from patients who are in permanent vegetative state (PVS). These patients are judged on the basis of clinical tests to have no awareness.

People with PVS are severely brain-damaged but not imminently dying and so they take usually between ten days to three weeks to die from dehydration. Thus far 43 have died in this way after court rulings.

M, however, is not in PVS but rather is in a ‘minimally conscious state’, meaning that she does have some degree of awareness; in effect she is in the next level up from PVS. She is not on a ventilator. But as she cannot eat or drink she does receive food and water through a thin feeding tube.

The case is hugely significant because of the British legal principle of ‘precedent’. This means that the principles established by this court ruling will be applicable in similar cases and will only be able to be overturned by a higher court, in this case either the Court of Appeal or the Supreme Court.

The Bland case in 1993 established legal principles which have now been given full statutory force in the Mental Capacity Act 2005. These included the principle that artificial nutrition and hydration constitutes ‘medical treatment’ that can be withdrawn if it is judged to be in a patient’s ‘best interests’ to do so. This highly controversial judgement has thereby enabled withdrawal of nutrition and hydration from PVS patients with the intention that they die – a situation that does not exist in most other European countries. Some have called it ‘euthanasia by omission’ or ‘euthanasia by the back door’.

If Justice Baker rules that M’s life can be ended, the arguments he uses in his judgement will have a crucial bearing on future similar cases. But the arguments currently being used by M’s sister and partner and their lawyers in the case actually equally apply to many people who are neither in PVS nor minimally conscious state.

In fact most are not arguments at all, but rather slogans, euphemisms or clichés. Let us consider some of them as reported in the Daily Mail today.

1. M’s younger sister broke down in tears on Monday as she told the Court of Protection she wanted to ‘end her suffering’.

But in what way is M actually suffering? And if she is minimally conscious how can we tell? If she is hardly aware then this cannot be mental suffering. And if it is physical suffering (eg. pain, nausea, thirst, hunger) then surely it can be ended without killing her - in the same way that we would end similar suffering in any other person - with pain relief, fluids, nutrition etc.

2. Vikram Sachdeva, for the relatives, says M's family felt that she would not want to live a life 'dependent on others'.

Are we saying that all people who do not wish to be dependent and cannot fend for themselves should be starved and dehydrated to death? And if she is minimally conscious how do we know what she actually wants?

3. M's sister - referred to as B - previously has told the court: 'She cannot enjoy a drink, a cup of tea or anything. She has got no pleasures in life.’

How do we know that she not able to experience pleasure? Her nurses claim that she smiles. And does not being able to ‘enjoy a cup of tea’ mean that life is no longer worth living? And are we saying that all people who say they have no pleasure in life and want to die for any reason should be able to end their lives?

4. 'Just a daily routine of being taken out of bed, put in a chair and put back in bed. Shower, doubly incontinent. It is just awful. It's not life. It's existence.’

Are we saying that having a worthwhile life means being able to walk and being continent? Are we saying that one person can decide whether or not another person’s life is worthwhile?

5. ‘And I know she would not want that.'

Perhaps she may have expressed this view in the past but if she is minimally conscious then how do we know that this is her view now? And even if it was does this mean that others thereby have a responsibility to end her life? And why should M's sister be able to make this sort of decision?

6. 'I am just looking for a peaceful end for my sister. I know she would not want to carry on living like this.’

We all wish a peaceful end but is dying from dehydration and starvation peaceful? And why can’t a natural death be made peaceful with good palliative care?

7. ‘I cannot bear the thought she is going to live X amount of years in this state. It is cruel. There is no point to it and she would say exactly the same.'

Who is really suffering here? Is it M who we are told in minimally conscious and aware of very little? Or is it really her sister and partner who ‘cannot bear the thought she is going to live X amount of years in this state. Whose suffering are we really talking about relieving here? And are we saying that we should be able to end one person’s life because someone else can’t bear to see them this way?

8. Mr Justice Baker... said that it is a 'unique case' that raises 'very important issues of principle'.

Can Justice Baker really be serious? Yes indeed it certainly raises very important issues of principle. But the key thing about this case is precisely that it is not unique - there are thousands of other cases in Britain which raise similar issues about dependence, suffering, meaning, being a burden etc - which is precisely why this judgement could be so far reaching, of such public importance and potentially so dangerous.

The point is that the above arguments all apply equally to many people who are not minimally conscious, and therein lies the problem. If any of them are accepted as a justification for ending this woman’s life, then it will create a legal precedent for them to be employed as a justification for ending the lives of others who are the next step up from minimal awareness, and so on. Better not to go there.

My position is really very simple – people who are severely brain-damaged, but not imminently dying, should be given nutrition, hydration, symptom relief and warm human interaction until the day that they die peacefully and naturally. We don’t kill them either by giving them lethal injections or dehydrating them to death and we ensure that there is adequate legal protection in place so that no one who has an interest in their deaths, whether financial or emotional or to get rid of an unwelcome care burden, should be able to exploit or harm them in any way.

We will all be watching Justice Baker very carefully because whatever he decides will have repercussions for many more people than Ms B, for better or for worse.

Wonderful testimony – ‘the whole rollercoaster ride had been worth every bump, just to be able to hold my tiny son’

I mentioned earlier this week the wonderful story of a woman who resisted pressure to have an abortion when her baby was discovered to have a tumour in her heart. Her daughter is now 19 months old and doing well.

Babies with serious disabilities don’t always have such good outcomes however. But even when there is no real hope of survival love and hope do not have to die.

There is an amazing testimony in the British Medical Journal today titled ‘Destined to Die’ about an Australian woman, Pauline Thiele, who discovered her baby was affected by Trisomy 18 or Edwards’ syndrome.

Edwards’ syndrome is a complex chromosomal disorder, in which there is an extra 18th chromosome. Children with this disorder have limited capacity for survival, and severe developmental delay is usual in survivors. Most children end up dying very early in life, usually of cardiac or respiratory failure.

Pauline’s description of her reaction in hearing the diagnosis is gut wrenching:

‘My world felt like it had been turned upside down and I listened in stunned silence as he tentatively told me that our 18 week old baby was not going to live. Any glimmer of hope that I had been holding onto disappeared. The weekend was tumultuous and I struggled with the realisation that the dream of raising this child would never happen.’

But when the baby moved she said she ‘knew that I loved this little one and would not take his or her life with a termination.’

Although some of her family’s initial reactions were not helpful she was supported by her mother and four friends. However, apart from a supportive GP, the lack of understanding she received from other doctors made things very difficult.

‘Without any referral to genetic counselling or paediatrics my decisions were based solely on information retrieved from the internet and I was left feeling abandoned by the medical profession.’

Eventually she tracked down four American paediatricians via the internet who provided her information by email. Later she discovered a local paediatrician and palliative medicine specialist who offered to support her through the birth. But then movements stopped at 36 weeks and it confirmed that her baby’s heart had stopped beating.

‘With a midwife’s firm guidance Liam was born quickly. Tenderly I held my son and realised that the whole rollercoaster ride had been worth every bump, just to be able to hold my tiny son. After delivery our paediatrician entered the room and cradled my son tenderly, gently patting him on the bottom. Watching this interaction, I felt my heart swell with love for my son and in gratitude to this man for the fight that he had fought. Conversing easily, the paediatrician commented, “If a baby can know stress in utero then surely it can know love. Liam knew that he was loved.” These words made the whole experience worth the heartache—just for my son to know that he was loved.’

General Medical Council and Medical Defence Union endorse 'tactful' offers of prayer by GPs

The GP magazine Pulse reports in an exclusive this week on new guidance from the Medical Defence Union saying that GPs can pray with their patients as long as they ensure patients are ‘receptive' to the offer.

The guidance quotes a letter from Jane O'Brien, GMC Assistant Director for Standards and Fitness to Practise, published in the Daily Telegraph in 2009 suggesting that a ‘tactful' offer to pray could be appropriate. O’Brien’s letter in full read as follows:

‘Nothing in the GMC's guidance Personal Beliefs and Medical Practice (2008) precludes doctors from praying with their patients. It says that the focus must be on a patient's needs and wishes. Any offer to pray should follow on from a discussion which establishes that the patient might be receptive. It must be tactful, so that the patient can decline without embarrassment – because, while some may welcome the suggestion, others may regard it as inappropriate.’

Although Pulse does not mention it this guidance from the MDU is not actually breaking new ground. Their last guidance in 2009 made the same points and quoted the same letter.

The development is highly significant in that it follows a statement by the GMC’s Chief Executive Niall Dickson who in a recent Radio Four interview confirmed the appropriateness of sensitive faith discussions with patients.

Dickson amplified his comments further this week. ‘Conversations about faith should not be a starting point. Doctors can however sensitively explore whether a patient may wish to discuss their own faith when it is appropriate to their care and then provide spiritual support if this is what the patient wants.’

Clare Gerada, Chair of the Royal College of General Practitioners, largest Royal College in UK, with 44000 members, tweeted on the new guidance that it was ‘good that sense is prevailing at last’. Other high profile doctors have also recently endorsed the importance of spiritual care.

Professor Mike Richards, national clinical director for cancer and end-of-life care, said at the launch of the new RCGP end of life charter that it was important that patients at the end of their lives should be offered spiritual support from GPs if they wanted it. He added that studies in other countries, such as Canada, had shown that spiritual assistance – such as that provided by hospital chaplains – was very valuable.

And RCGP clinical champion for end-of-life care Professor Keri Thomas said that spiritual care was 'essential' for end-of-life care.

The latest advice follows the case of Dr Richard Scott, who made national headlines in May when he said he would formally reject an official warning from the GMC for discussing his faith with a patient. Dr Scott told Pulse he received, and rejected, the official warning this week, and now ‘fully expects' to face a public hearing. I have previously argued that the GMC had overreacted in this case by jumping to conclusions without a proper investigation on the basis of a complaint from the patient’s relative.

Pressure is now intensifying on the GMC to offer more definitive guidance on the issue. Dr Andrew Freeman, a GP in Mossley, Greater Manchester, is reported by Pulse as calling for greater clarity: ‘The guidance isn't clear enough. We are told to judge the patient's receptiveness to religion, but in the Dr Scott case it was not the patient, but their family, that took exception. If GPs are given better guidance and more help where to draw the line, it will improve care for patients, their relatives and doctors.'

The current GMC guidance gives considerable latitude for faith discussions. It recognises that ‘all doctors have personal beliefs which affect their day-to-day practice’ and that these principles apply to all doctors whatever their political, religious or moral beliefs. It emphasises that ‘personal beliefs and values, and cultural and religious practices are central to the lives of doctors and patients’ (p4); that ‘patients’ personal beliefs may be fundamental to their sense of well-being and could help them to cope with pain or other negative aspects of illness or treatment.’ (p5) and that ‘discussing personal beliefs may, when approached sensitively, help you to work in partnership with patients to address their particular treatment needs.’ (p9)

Faith discussions are not normally part of the consultation, but there are occasions when they were appropriate. The World Health Organisation’s definition of health includes physical, mental, social and spiritual dimensions and part of practising whole-person medicine means addressing all issues that have a bearing on a person’s health.

Let’s pray that the GMC handles Dr Scott’s case wisely and let’s continue to encourage Christian doctors to practise medicine that addresses the needs of the whole person, to take opportunities to address spiritual issues impacting on health, and to share their faith sensitively when it is appropriate to do so.

Unity's outpourings on abortion are symptoms of deep-seated anxiety

Back in April I blogged that the Royal College of Psychiatrists’ review of the relationship between abortion and mental health had resulted in a comprehensive 120-page consultation document that was ‘worthy of serious study and measured response’.

The Christian Medical Fellowship accordingly put together a working group of academic psychiatrists and gynaecologists to participate along these lines.

After several weeks of conference calls and wide discussion CMF produced a detailed, balanced and carefully researched submission which they both submitted to the RC Psych and also published on their website along with a summary of the main points and a two page statement outlining their conclusions.

CMF concluded that, whereas there was much to commend in the RC Psych consultation paper, they still had concerns about some inaccuracies, lack of transparency and overconfident conclusions.

I was therefore intrigued to hear that someone had described the CMF submission as ‘a pile of tendentious and ill-informed crap’.

Naturally I sought to find out ‘who and why?’ I was not surprised to discover that the comments originated in 4,365 word rambling post on a website called ‘Ministry of Truth’ written by none other than our old friend, the infamous pseudonymous Liberal Conspiracy troll-blogger ‘Unity’ (pictured), whose unsurpassed powers of analysis I have drawn attention to previously on this site.

The normal way to respond to public consultations on important subjects is to make a formal submission to the body carrying out the review. Unity’s approach, by contrast, is to ignore the review process and seek to discredit the responses of those who have taken the trouble to engage through the proper channels.

So true to form, rather than participating in the consultation as a serious stakeholder, Unity has instead bleated his thoughts into the blogosphere and then tweeted his bleats to his small band of supporters. These are tactics similar to those of the playground bully who, rather than engaging in constructive debate, shouts obscenities from a corner of the playground to impress his fellow thugs and then sniggers and titters about how clever he is, whilst all the time wearing a paper bag over his head so that no one can actually ascertain his real identity.

My initial inclination, was therefore simply to ignore Unity’s ramblings, but I then felt It was better to make some comment just in case people, without knowledge of the subject matter, might conclude from the sheer length of Unity’s post that he/she had landed a successful punch or two.

I have dismissed any thought of doing a detailed line by line rebuttal. I have too much of a life to spend time on mindless tit for tat and I didn’t want to risk legitimising Unity’s rather intemperate and vitriolic ramblings by paying them more attention than they deserved.

So instead I have opted to respond briefly to two of Unity’s more serious points and suggest that those who are interested in contributing to the debate in an informed way examine the CMF submission, summary document and statement for themselves.

First, Unity claims that the CMF is wrong to suggest there is insufficient transparency in the RC Psych’s selection, exclusion and rating of research papers, and instead asserts that the methodology section in the consultation document contains all the elements one would expect from a rigorously conducted systematic review.

However, there is actually no publication of the data extraction tool used by the review group, nor is there an appendix with the data extraction table which summarizes the data that has been extracted, nor is there a table showing how the criteria for the quality items for each paper were scored and how the overall score was derived. But all of these are actually common practice in Cochrane Reviews published in the Cochrane Library and are in fact required in order to understand the final conclusions drawn by the review team. The methods may be accurately described in the review document (as Unity correctly asserts) but the selection process is not made clear. Decisions for judgments made regarding a source of bias have to be made explicit.

Second, Unity takes issue with CMF’s suggestion that, given the limitations in the current data, other methods to seek the views and experiences of those involved in the care of women who have had an abortion should be considered as a valid source of evidence. He/she complains, ¬ somewhat absurdly, ¬that qualitative studies almost always provide no usable evidence for a review of this kind.

However, the inclusion of qualitative data, particularly in evaluating complex health care issues is of increasing importance to policy makers and health care professionals. The Cochrane Collaboration and leading academics such as Tricia Greenhalgh, Andrew Booth, Geoff Wong and Jennie Popay are developing ways of incorporating and synthesizing qualitative data in systematic reviews. It is simply naive to dismiss the rigorously collected narrative data qualitative that researchers can bring to an understanding of such an issue.

As far as I am aware Unity has not sent in a response to the RCPsych review committee himself/herself (or at least not published one). One would have expected that someone who claims to understand the data and research so well would have put his/her own response - and indeed credentials (and even perhaps his/her real name!) - into both the public domain and to the RCPsych. This raises questions about how willing Unity is to have his/her own responses objectively evaluated. He/she is apparently more adept at throwing stones than building anything of worth him/herself.

CMF has invested time into producing a balanced, informed and fair critique of the RC Psych review and submitted it formally. This is the correct way to respond to official consultations.

Unity’s outpourings are symptoms of a deep anxiety about the fact that the pro-abortion lobby is steadily losing ground as a result of growing public disquiet about abortion numbers and a growing evidence-base about the adverse effects of abortion on the mental and physical health of women. I would recommend taking a detour around them rather than attempting to wade through them.

Meanwhile, CMF’s submission to the RC Psych consultation remains in the public domain and is offered as a serious response to serious debate.

A life precious to God – how to cope when you find your unborn baby has special needs

There is a deeply heart-warming story in the Daily Mail today titled, ‘Doctors told us to abort our little girl as she wouldn't survive birth - but our little fighter has flourished’

When an ultrasound scan showed ‘a massive tumour covering the entire left chamber of her heart that was restricting blood flow’ Charley-Marie Skinner's parents Heather and Andy were informed that there was little chance she would survive her birth and were advised to have an abortion.

They refused and were glad that they held their ground.

Now Charley-Marie (pictured) is nineteen months old and thriving – and if she does eventually deteriorate and require surgery the tumour may well be operable.

I have lost count of the number of times I have heard stories like this. Why is it that the medical profession responds in this knee-jerk fashion recommending abortion for disabilities we would make every effort to treat or correct in a baby after birth?

Why are not more parents given the opportunity, with proper support, to see their babies’ births through? Why is it that offering surgery, other treatment, or if relevant terminal care, to disabled, sick or dying babies seems no longer to be regarded as a serious option?

Why has our society instead reached the conclusion that these most vulnerable members of the human race, because they are disabled, sick or dying, have lives that are somehow not worth living? That they are, in other words, better off dead?

Recently released abortion statistics revealed that between 2002 and 2010 there were 17,983 terminations in Britain on the grounds that there was a ‘substantial risk’ that the babies would be ‘seriously handicapped’ — known as Ground E abortions. The overwhelming majority of these ‘abnormalities’ were compatible with life outside the womb.

Of the 17,983, a total of 1,189 babies were aborted after 24 weeks, the accepted age of viability, after which there must be such a serious risk for an abortion to be legal if the mother is not in danger.

A few years ago we carried in the CMF Student journal Nucleus, the story of a baby whose parents opted to love and care for her even though she had abnormalities that were not compatible with life outside the womb.

But they still went through with it and gave her all the love and care they could in the few hours their daughter Jennifer had with them.

I’d thoroughly recommend reading their testimony, ‘A life precious to God’.

The author Karen Palmer, a Christian psychiatrist, makes a powerful case for choosing to give birth to a disabled baby rather than having it aborted.

All pastors and prospective parents should read this, lest they are ever called to advise or cope with the arrival of a little one with extra special needs.

I leave the closing comments to Karen (but do please read her whole story):

Why did it happen? I don't believe that we can always know the reason God allows these things to happen. There's a spiritual battle going on and often the devil appears to have his way. What we do know is that God our loving Father, cushioned us and sustained us with his grace. It wasn't him who hurt us - he hurt with us.

What did we learn? We learned that God is intimately involved with us and with a tiny baby. We learned that even such a tiny, damaged life is precious to him. We learned better how to care for each other and our parents and friends. Our church learned how to care for us. We saw that terminating a pregnancy where there is an abnormality denies the parents and wider family the opportunity to grieve and remember a real and valuable member of that family. We learned that God answers prayer.

After Jennifer's death, a steadfast friend said that when Jennifer arrived in heaven there would be great rejoicing and celebration because of all she achieved in her short life. I dream that when I arrive there people will say 'Ah! You're Jennifer's mother' and I'll be so proud!

Martin Pistorius – an inspiring story about faith, hope and love through ‘locked in syndrome’

The Sunday Times today tells the story of Martin Pistorius, a South African man who ended up paralysed and comatose following a throat infection at the age of 12. His awareness began to improve four years later and by the age of 19 had fully returned.

However it was a further five years before a therapist noticed that he was trying to communicate. The penny eventually dropped that he had been aware of everything going on around him for almost ten years whilst everybody had assumed he was unconscious.

Now, ten years later aged 36, he is married and runs a computer business despite being still in a wheel chair with limited limb movement and using computerised speech.

I see that the Daily Mail actually ran the story over a week ago (I missed it at the time) and there is a powerful review by Dominic Lawson of his autobiography, ‘Ghost Boy’ in the Sunday Times today.

I’d highly recommend reading all these accounts if you can access them (you need a subscription for the Sunday Times).

One of the most striking aspects of the story to me was the extreme range of attitudes in the people who cared for him. Lawson writes:

‘He learns that… nurses can be monsters as well as saints. In the latter category there is Virna, who with aromatic oils tirelessly massages away the muscular knots in his inert frame and talks to him lovingly all the while. At the other end of the moral spectrum, a carer addresses him as “piece of shit”, feeds him so brutally he vomits, and then shovels the sick back down his throat. A nurse at the same clinic gives him a bath-time enema so forcefully he bleeds, and then dips a toothbrush into the cloudy water before wiping his teeth with it. Yet another would make sure that she could be alone with him, and then uses his body as a tool for her solitary pleasure, before “wiping herself off on me”.’

‘Locked-in syndrome’ is a rare neurological disorder characterized by complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement. It may result from traumatic brain injury, diseases of the circulatory system, diseases that destroy the myelin sheath surrounding nerve cells, or medication overdose.

Individuals with locked-in syndrome are conscious and can think and reason, but are unable to speak or move. The disorder leaves individuals completely mute and paralyzed. Communication may be possible with blinking eye movements. While in rare cases some patients may regain certain functions, the chances for motor recovery are usually very limited.

There have been some inspiring stories of people with locked in syndrome rising above their disabilities and regaining some function – including the recent British cases of Kate Allatt, Graham Miles and Nikki Kenward.

But the account that made the condition famous was that of Jean-Dominique Bauby, the French editor of Elle magazine, who suffered a severe stroke, from which he never recovered.

Aided by a therapist he learnt to communicate by blinking his left eye, the only part of his body that wasn’t paralysed. He described his experiences in the book he ‘dictated’ letter by letter, ‘The Diving Bell and the Butterfly’, which was later made into a 2007 film of the same name. He died three days after the book was published in 1997.

If you haven’t seen the film I would thoroughly recommend it. I was particularly struck by the way Bauby, after being initially suicidal, was able to find meaning and purpose in the face of immense suffering and to value what function he had left. He said the two things that his condition could not take away for him, were his memory and his imagination.

I once had the privilege of spending half an hour with Matt Hampson (pictured), a Leicester rugby player, who ended up permanently paralysed from the neck down and on a ventilator after a scrum collapsed, but now runs a charity to support people who are, in his own words, ‘less fortunate than himself’. ‘I don’t think about what I can’t do. I think about what I can do’, he told me. ‘I can still talk and feel, and I can still smell a steak cooking on the barbecue. And when I dream at night I can still play rugby.’

After you have spent time in the company of such people, you wonder how you can justify complaining about anything ever again.

Many naturally assume that people who suffer from such devastating conditions must necessarily end up in deep despair but given the right support and encouragement, it is remarkable what the human spirit is capable of.

For Pistorius, Bauby and Hampson, loving relationships which helped to sustain them through the hard times, were crucial in their ability eventually to find hope in the midst of their suffering.

Pistorius says of his wife, Joanna, that ‘it was she who has taught me to understand the true meaning of the Bible passage we were having read at the service: “There are three things that will endure – faith, hope and love – and the greatest of these is love.” My life has encompassed all three and I know the greatest of all is indeed love, in all its forms. I’d experienced it as a boy and man, as a son, brother, grandson and friend, I’d seen it between others and I know it could sustain us through the darkest of times.’

It is perhaps somewhat ironic that Pistorius’ case is being highlighted just a day before the Court of Protection reviews the case of Ms M, a woman in her 50s suffering from ‘minimally conscious state’ which she contracted after a bout of encephalitis. M’s mother wants to remove her feeding tube in order that she can be starved and dehydrated to death.

Italy joins Bulgaria and France in blocking euthanasia legislation as new withdrawal of treatment case is about to be heard in Britain

Earlier this year I reported that France, Australia, Scotland, Israel and Canada had recently blocked legislation to allow euthanasia or assisted suicide.

Last week the Bulgarian parliament Health Committee overwhelmingly rejected a bill to legalize euthanasia and the State of Oregon (where assisted suicide has been legal since 1997) passed a law making it illegal to sell, produce or distribute suicide Kits.

Today Lifesite News has reported on a vote in the lower house of Italy’s parliament to prohibit the starvation and dehydration of patients in a move that is seen as a response to the killing of Eluana Englaro in 2009.

In a 278-205 vote recorded in secret, the Italian Chamber of Deputies voted to approve the bill, which prohibits ‘all forms of euthanasia and all forms of assistance or aid for suicide.’

The law provides for the creation of Anticipated Declarations of Treatment (DAT), which are also known as ‘Living Wills.’ DATs will allow patients who are unconscious or otherwise unable to communicate to refuse treatments that are ‘disproportionate or experimental.’

However, under the bill the withholding of food and fluids is prohibited in all circumstances. It states that nutrition and hydration ‘cannot be the object of the DAT’ and ‘must be maintained until the end of life, with the exception of cases in which the same proves to be no more efficacious in providing the patient in the terminal phase with the nutritional factors necessary for the essential physiological functioning of the body.’

The measure now goes to the Senate, where it is also expected to be approved.

The bill originated in late 2008, while Eluana Englaro, a 38 year old woman in a ‘vegetative state’ but otherwise in perfect health, was being starved and dehydrated to death by decision of her father. It was introduced after the nation’s Supreme Court allowed the killing to proceed. Englaro died after four days without food or water after the nation’s president refused to sign the anti-euthanasia.

In Britain, since the Tony Bland judgement in 1993, the courts have allowed applications in Britain to remove nutrition and hydration from patients suffering from ‘permanent vegetative state' (PVS).

But the Italian move comes just days before an application to the Court of Protection in Britain to withdraw nutrition and hydration from a woman in a ‘minimally conscious state’.

The case poses a major threat to disabled people and if successful will take Britain several more steps down the slippery slope towards legalizing full-blown euthanasia - way beyond Italy.