Liam Twomey (Wexford, Fine Gael)

I thank everybody who contributed, and I particularly thank the Minister, Deputy Reilly, for accepting the legislation. Some very thoughtful contributions were made during the debate.

We all believe in setting out the ethos we want in our health service, which is to become more patient-centred than doctor-centred. There have been significant changes in the past number of years that may be forgotten. The Irish Medical Council now has a lay majority and allied health care professionals, like social workers and physiotherapists, must now register, with people having the ability to make formal complaints in a way that would have individuals censured as a result of inappropriate action. The Mental Health Commission was set up on the back of the 2001 legislation. When the legislation was published I worked as a general practitioner, and people argued that it would not work and that people with serious mental health problems would be running around unable to get help. That turned out to be rubbish and the legislation and the Mental Health Commission has had a positive effect on mental patients. It is dealing with many difficulties that have become clear to mental health patients. That shows we have much work to do in fine-tuning that legislation, which is more than a decade old.

HIQA has been in place for five or six years and when it was established, people argued that it would add nothing to the health service. Nevertheless, Ms Tracey Cooper and her staff have been significant drivers in improving standards in the health service, which benefits patients. All of these changes are radically shaking up the status quo and how our health service is perceived. They are adding benefit for patients, which is what we should be about. We must constantly put the patient at the centre of what we do, and this legislation does that.

I will go further. We must push forward with a patient safety authority that could put the patient above everything else. Such an authority would be an overarching body that would incorporate the functions of the Mental Health Commission, HIQA, the Irish Medical Council and all the other agencies. When such a body is formed, we can really say that we are putting the patient at the centre of the Irish health care service.

Another major issue mentioned this morning is the definition of capacity. There are complex legal issues surrounding the term but the problem is similar to the example outlined by Deputy Stanton when he mentioned that 40% of patients do not quite understand their medical treatment. That is probably true and it can be difficult to grasp every word said by a doctor if a person is in need of serious surgery or is having a serious medical condition explained. That does not mean there is no capacity to decide treatment, and we may be too purist in our approach to capacity. One can understand enough to know what one needs, and we must look at the issue from that perspective.

If somebody is depressed when writing an advance health care directive, it may be darker than if it had been done when the person was in great form, but does that reduce the impact of the intent of the directive? It does not, as it relates specifically to that person. When we debate capacity, we must bear in mind that although capacity is different for everybody, people understand far more than we take for granted. We can make such issues a bit too complex.

The essence of this legislation is that a patient can decide his or her quality of life until its end. It is in the final days, weeks and months of life that a person would like to have most control. That is what the Bill is concerned with.

Deputy Kelleher referred to changes in health care and how they could impact on somebody with an advance health care directive. The directive can be changed at any stage. One can renounce it orally if one wishes. The lifespan of a patient diagnosed with dementia is only a few years. Medical technology does not improve that quickly but it reduces the complexity of procedures and enables them to be undertaken with more finesse. For instance, open heart surgery was the norm 20 years ago whereas nowadays it is done via angiogram. It is less stressful and easier on the patient undergoing the procedure. A person could write in his or her advance health care directive that he or she does not want to have major surgery carried out but that may not need to be applied given the changes that could have happened in the meantime because the procedure may be easier to carry out. That is a positive aspect to this. The Deputy could be adding complexity to an issue that is not complex. I am only bringing my own experiences to this. Some of the concerns he has raised do not exist. This proposals will be beneficial to patients in the long term.

I also do not accept his comments about people being put under duress. One can have one's full faculties and be put under duress by family members. That has nothing to do with an advance health care directive. If anything, such directives can protect people because they can draw one up when they are in a better frame of mind and that will kick into play when needed rather than them coming under duress from family members when they are vulnerable. I have never witnessed duress being applied regarding somebody's health. Such duress usually comes about when someone is drawing up a will, which entails handing over property or money to an individual.

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