Mr Speaker, Sir, we have taken a long time to prepare the proposals in the White Paper. It is a complex problem. We have a good system. We have to be careful to make things better, and not unintentionally make things worse. The situation today is that we are delivering high quality, affordable, universal health care to Singaporeans, all of them. What we are worried about are long term trends, because our population is ageing and also because all the developed countries have run into trouble with health care, and we do not want to follow their example. The perception of the public is not quite the same. Most Singaporeans, 80%, agree that we have a good health care system. But many of them, as many as 40%, are concerned that they personally cannot afford health care cost. So our problem in this situation is to institute controls on the health care system so that it will operate properly over the long term. Secondly, to reassure Singaporeans that their health care needs are being looked after. The White Paper explains our approach. I will highlight three points. Firstly, we rely on competition to promote efficiency and to improve service. Secondly, the Government will intervene in the health care market in order to remedy market failures in health care. Thirdly, we will emphasise personal responsibility for health. We would intervene in the health care market by limiting cost and by ensuring that people can afford to pay. We control the supply of doctors, of beds, and of specialists. We moderate demand by defining a basic health care package. We moderate demand by depending on savings instead of on taxes, and on third party insurance. We control the operations of the subvented hospitals, the restructured hospitals. We tell them how to structure their wards, what they can put into their wards, what equipment they can buy, overall how much they can charge. This is not to tie their hands down but to set the parameters and the framework within which they can operate efficiently and flexibly, and compete with one another, and give good service to Singaporeans. It is a formalisation and elaboration of what we have been doing. It is an approach which has provided Singaporeans with affordable good health care. The Cost Review Committee went into this at some length. We debated its Report a few weeks ago and Members will remember that the Committee confirmed that health care in Singapore is affordable. It is not for free, unlike in some other countries. But all those systems which provide health care for free are in difficulty. The British with their National Health System, Canadians with a single buyer, namely, the Government, the French with national health, and China, which used to go on the principle of need, now goes on the principle of the person benefiting pay, as they say in Chinese [ ] shou hui zhe jiao fei (the person who benefits, he pays). We pay in Singapore, but we enjoy better health care by paying than citizens of these other countries do for free. Mr Low Thia Khiang and the other Opposition MPs have made a great to-do about health care being unaffordable and people are being alarmed. How it is possible to die but not possible to get ill in Singapore. I ask a simple direct question: how many actual cases have they come across of patients who have been denied health care because they have no money? How many MP's letters have they written on behalf of desperate constituents asking for waivers of charges? They have been in Parliament now for two years and how many letters have they written. I asked the Ministry of Health. They did not take very long to compile the answer. They should have a copy with them. Number of requests: Mr Chiam See Tong, 1991, one appeal for downgrading, approved. 1992, nil. 1993, nil. Mr Ling How Doong, 1992, one appeal for waiver. They classified it as a subsidised patient. 1993, one case. Financial assistance at Kandang Kerbau Hospital. Instalment plan arranged. Mr Low Thia Khiang, 1992, one appeal for free treatment, approved. 1993, one allegation that he was charged a huge consultation fee at SGH and asked why he was made to pay cash before admission and so forth. Investigation was carried out. It turned out that he did not pay cash. He paid with Medisave and he was never sent to SGH. The person concerned withdrew his letter of complaint and apologised to the Hospital for the false allegation. That is the complete list, Mr Speaker, unless, of course, there are some items which I have left out which the Opposition MPs will no doubt point out promptly if they exist. I am sorry. I forgot to read one more - Mr Cheo Chai Chen. 1992, nil; 1933; nil. I hasten to add, Mr Speaker, that I am in no way doubting that the MPs have been carrying out their duties to the best of their ability, and conscientiously. Indeed, I am quite sure that they have worked very hard in order to find cases like these to embarrass the Government. All the more, this list proves how few there are. So, where is the problem? Rationally, we have no problem with access to health care. But we do have difficulty reassuring people that in fact there are no problems. Health care is a human problem. We are dealing with human lives. Patients and families are agitated and distraught, very worried, frightened, and doctors are also human. They err. They make mistakes from time to time and they respond to financial incentives and pressures, like all the rest of us. Therefore, our system must allow for these human frailties. It should support and help patients and doctors to make rational decisions in their long-term best interest. It should not put too much burden on the doctors or on the patients to be super-human in their detachment or in their infallibility. The system must support them. You cannot assume that he is rational, he is logical, he is informed, he will judge, and he will answer completely for the consequences of his decisions. Thirdly, the system should discourage doctors from over-servicing patients, whether it is to earn fees or whether it is to practise defensive medicine, just in case the patient sues them, let them order the tests, even if they are not essential. Some people have argued that because medicine is a human problem, we cannot treat the health care system coldly and we should not do cost-benefit calculations of how to treat as many patients as possible for as little cost as possible. They are wrong. I give you an analogy. If I am sick and worried, do I want a doctor who is so sorry for me that he also becomes agitated and overwrought and excited? Or do I want a doctor who is cool and dispassionate, sympathises but retains his professional distance and makes a sober judgement of what is in my best interest? I think I know what to choose, and I think when we design a health care system, we have to choose the same approach. One day we may be patients, but today we have to be the doctors. Our resources are always finite. We can deploy the resources which are available for health care in different ways, but one way or another, they are finite and limited. We can put them here or there, or half here and half there, but not all here and also all there. And you can spend more by taking away from some other place, as some MPs have suggested. But, ultimately, it is finite. Because it is finite, in health care, like in other areas of public policy, for every decision we make there is an opportunity cost. What is an opportunity cost? It is what you gave up by choosing to do one course of action instead of another one. For example, if the top surgeon in Singapore spends his time operating on routine cases (piles and appendectomies, for example), then he will have to do fewer of the complex cases which really genuinely require his unique skills. Another example. Every patient who stays every day in an ICU, there is an opportunity cost. He is potentially depriving another patient of one-day stay in the ICU, and that other patient, paying or not paying, may well have a better chance of recovering and getting better from the ICU stay than the first one. So, all right, we spend more on ICU beds. There is an opportunity cost because, then, we will spend less on preventive health care, on primary health care, on the areas which can catch diseases early and cut down on the need for ICU beds. We do not have enough doctors? We produce more doctors and surgeons and specialists. We can do that. Then we will have fewer entrepreneurs, managers, Permanent Secretaries, MPs, Ministers. Or we can, as Dr Soin has suggested, spend more on health care overall. Then we will have less for education, for housing, for defence, for raising the standard of living of people, which, in fact, is more important than spending money on hospitals for improving their health. Different ways of allocating resources lead to different outcomes. We cannot avoid the responsibility of having to judge which of these outcomes we prefer. We cannot avoid deciding how much overall to spend on health care, and having decided on that, which areas of health care should get more resources, and which areas less. Because a great deal is at stake, especially human lives, therefore, all the more we have to approach the problem rationally, to make sure that no money is wasted, and to make sure that we focus our efforts on areas which do the most good. The economists would coldly call it "rationing". To the laymen, the word "rationing" has a negative tone. It is something unpleasant. But one way or another, allocation, prioritising, is not avoidable. We can allocate in different ways: by price, like they do in America. You do not pay, you do not get. By queuing, like under the National Health Service in Britain. You take your number, you wait your turn. Your turn may be in three years' time. If before then you have died, hard luck. You can allocate by medical need. Let the doctors and the hospitals decide. This person is worth treating, he is young, he has got a family; that person is not, he is old, his chances of recovery are not good. Or we can allocate by merit, and decide who has contributed to society more, who has made more effort to look after himself, maybe who has donated blood and, therefore, is deserving of being treated first. Or we can refuse to do any of these, in which case, we will still be allocating, but we will do so arbitrarily, as the haphazard outcome of uncoordinated decisions and choices. There is no logical escape from these possibilities. How do we do it in Singapore? We use a combination of methods. Firstly, we use price. We charge patients instead of providing health care for free, firstly, to prevent excessive demand from developing; and, secondly, to allocate non-basic health care. So you want what is more than basic, you pay. Even basic, you pay some, so that if you do not need it, please do not come and queue up. Secondly, we allocate by medical need. We define a basic health care package, and we subsidise it heavily, and we make it available to everybody. Thirdly, we allocate by merit. Those who have taken responsibility for their own health, for example, they have accumulated their Medisave, they have participated in MediShield, they are living healthy lifestyles, they should enjoy priority in getting Government help. Some people wish there was no need to prioritise, and that we could provide all the health care we wish to everyone who needs it or wants it. But in the real world, this is impossible. And in any case, limiting the amount of health care is not necessarily a bad thing, because more medical care does not always mean better medical care. If you look at different developed countries, you will find, depending on their systems, on their incentives, and on their habits and culture of the doctors, enormous variations in the degree to which patients are operated upon. I have circulated a list - I think you have it with you - to give some examples. Consultations with doctors (GPs and specialists) - in Germany, 10 per year; in UK, 5 per year. Hospital admission - Germany, 19 per thousand population; UK, 13. Acute hospital length of stay - Germany, 12; UK, 8; US, 7. Rate of surgical operations - US, 91 per thousand; Japan, 22 (four times). Yet the Japanese live longer than the Americans. Maybe because they are cut up, that is normal. Coronary bypass operations - US, 60 per 100,000; UK, 6. Hysterectomies (removal of wombs from women) - US and Denmark, 7 out of 10 women have hysterectomies. Seven out of 10! UK - 2 out of 10. You mean to say the Americans are three times healthier than British women? Here is what the experts themselves say about these developed countries: "Coronary bypass surgery is performed 300,000 times per year in the United States and accounts for about $1 of every $50 spent on healthcare. But a study by the Rand Corporation a few years ago found that more than 40% of such operations did very little, if anything, for the patients. ... American doctors performed open-heart surgery 2.6 times as often as Canadian doctors and 4.4 times as often as German doctors." Another opinion: "In the US, the long-standing problem of over-treatment, particularly in surgery, persists. A 1988 study by the Albert Einstein Medical Centre found high rates of pacemaker implantation without medical indication ... [that means, there were no medical reasons for doing it, but it was done] 44% were definitely indicated, 36% were possibly indicated and 20% not indicated. ... ... New research at the RAND Corporation found high rates of inappropriate coronary artery bypass surgery, gastrointestinal endoscopy [that means, putting a tube in to see what is going on inside] and carotid endarectomy [that means, drilling a hole in the carotid artery and cleaning out the inside, like a pumper]. On review by a physician panel, the study found that 32% of the carotid endarectomy procedures were performed for equivocal reasons [one-third], and 32% for inappropriate reasons [another one-third]. The study found that after the procedure, 9.8% of patients had a major complication defined as stroke with residual deficit at the time of hospital discharge or death within 30 days of surgery." Anybody wants more health care in Singapore, I will offer him or her a free carotid endarectomy. In medicine, we cannot depend solely on patients' perception of need, or on what the patients want. The patients are not in a position to decide. They ask for drugs and procedures not because they understand what will really help them, but because they have heard about them, or read about them, or saw it on TV, or heard from friends, and hope desperately that it may do them some good. I know this from personal experience. When I had chemotherapy last year, I appeared on TV and some people saw I was carrying the portable chemotherapy pumps. My doctors tell me that after that, they have no difficulties persuading any of their patients to use pumps. They explained to the patients, and the patients said, "Ah yes! Same like BG Lee." They take it, in fact, they have to order more pumps. I give you another example - Traditional Chinese medicines. A lot of people have asked me, or if they do not ask me, they ask my wife quietly, what Chinese medicines is BG Lee taking. We tell them truthfully, "No. I am not taking any." But if it became known that I was taking a particular set of herbs, you can be sure that those herbs are quickly going to become hot selling items and will soon be promoted as "BG Lee's medicine". My point is not that Traditional Chinese medicine is no good because I believe there is a great deal of folk wisdom in Traditional Chinese medicine, and there is a lot that Western medicine does not understand. My point simply is that patients make these decisions not based on real scientific or medical knowledge or any understanding of what is necessary, but on faith and hope, which is often misplaced. The public also get worried because they do not understand how the health care system works, what provisions we have made, how they can benefit from it by making wise individual choices for themselves. Should they go to C, B2, B1, community hospital, polyclinic, or see a specialist? It is complicated, and it leads to alarm. One common misconception they have, and which I think some MPs share, is that restructured hospitals raise medical costs. Actually, restructured hospitals provide better medical services and better value for money for the patient than Government hospitals. Because the Government hospitals are subject to the very complicated constraints of belonging to the civil service, 30,000 employees, and you are 500. You want to change rules, you want to change salaries, you want to change terms, you want to hire somebody on a different contract, you have to clear it with PSD, PSC. So many relativities have to be reconciled, it is very difficult to work. If you are a restructured hospital, you are the Chief Executive Officer, you decide. You have a budget, you operate, you pay, we will control the bottom line. We give you the subvention, you provide the service. I went to Woodbridge Hospital a few weeks ago - brand new buildings, $200 million spent, we opened the hospital. New hardware, same software. It is a Government hospital. So I asked whether they had any problems being a Government hospital. They were a bit reluctant to speak but, eventually, we got the story out of the patient. Yes, they had problems. They want to pay special allowances for the nurses who work in Woodbridge Hospital because it is a tough job. You are working with patients not quite right in the mind, long hours, you have to cheer them, you have to wash them, you have to look after them, and you are at risk of being assaulted by them, because some of them are violent. They cannot get an allowance because it will raise questions of relativity. They want to create new grades of staff. They need male nurses to deal with male patients. They cannot get. So they said, "All right, we will get wardens." Civil service said, "We never heard of wardens." It cannot be done. They want to recruit other staff, therapy aides, technicians to run the estate, estate management. You get nowhere. You spend all your time arguing, paperwork, instead of treating patients. And it is not because the civil servants in charge of personnel are unreasonable. It is just a very rigid and difficult-to-operate system. So what is the solution? The solution is to restructure Woodbridge Hospital into a proper autonomous hospital. Let it run independently, give it the same subsidies which it should now have and let it do what it needs to do, and not be tied down by the rest of the civil service. I told the Minister this, he said, "After the next Budget." But I said, "Start studying now!" It has to be done, and we have to explain it to the population. They have to understand because, otherwise, you are just making things worse. One day, there will be a disaster because hospitals are not properly manned. We have a Commission of Inquiry and then we will make it autonomous. I think that is too late. The third reason patients do not fully see things dispassionately is because they and their families are emotionally involved. They are frightened and confused. They may have gone through a traumatic experience, family member may have died, shocked, or they themselves may nearly have died. And it is a well-established phenomenon that families and patients, having gone through such traumatic experiences, are often not reliable witnesses, or judges, of what went right, or what went wrong. It is not reasonable to expect it. You just have to allow for it. It is not to blame anybody who says this. But it is a fact of life which we must make allowance for when we try to manage the health care system. And if you react to emotional sentiments expressed without getting behind that, to the truth, then we will do the wrong thing. This is the reason why it is important to continuously educate the public about health care, to clear their misconceptions, and prevent them from being unnecessarily alarmed, not least by people who are deliberately out to alarm them. The media play an exceptionally important role. They have got to report medical news responsibly and extra carefully. They should not raise excessive expectations with reports of sensational new procedures or drugs. Each time, there is a story in the newspaper about a new procedure, new drug, new treatment, the patient goes to the doctor the next day, carrying his press cutting, asking for the same. And I have three examples here. First example, Straits Times of 25th August about the cancer centre. It is a neutral story, but in the middle it said that research has shown that combining three main therapies of surgery, chemotherapy and radiation can offer a better chance of survival than surgery alone. So all the patients who have been operated on, and not yet given radiotherapy and chemotherapy, came to ask, not knowing that it depends on the type of cancer, the stage of the cancer, the assessment. You may make things better, or you may make things worse. Second example, more recent, Straits Times of 24th September, about cardiomyoplasty. This is an operation to cut the muscle from the back, wrap it around the heart, train it to pulsate like the heart and give the patient, with a bad heart, a new lease of life. The story says, "For one patient here, the countdown to death has stopped." They must have a secret. They have done one operation here, paid for by Mount Elizabeth Hospital. But cardiomyoplasty is not suitable for all heart patients. Thus the need for heart transplants would remain. Immediately patients came to ask this. It is an experimental procedure but expectations and hopes were raised. Most recently, last Friday's New Paper "Family liver transplant here soon". This was drawn to my attention by the Vice-Chancellor. It is a story about a surgeon about to carry out live donor liver transplant from a family member to a child. You cut part of the liver and you donate it across, because it is very hard to get donors for livers. Experimental leading edge technique. I asked MOH what this was about. MOH's reply is that the report was totally unjustified. Gleneagles Hospital has not applied to MOH for permission to carry out live donor liver transplants. The Administrator of Gleneagles Hospital has confirmed that the Hospital has no plans to set up any liver centre next year and it has not authorised the doctor concerned, a certain Dr Tan Kai Chah, a Malaysian working in England, to make such a statement on their behalf. And furthermore, Dr Tan has not anywhere in his application for registration or correspondence with the Ministry of Health mentioned his intention to do liver transplants from live donors. MOH considers liver transplants using living related donors to be an unproven procedure, and it will not authorise such operations in Singapore until they have been generally accepted and validated. So you may sell a newspaper but think how many hopes you have raised and dashed in vain. It is not the end of the story. MOH will follow up and make sure it does not happen. The media have got to cooperate. They also must make an effort to explain to the public how the system works. One positive example of this is the way the Straits Times serialised the White Paper, over several days, with pictures, explanations, captions, side stories, and interviews to get people to understand. It is not easy because people only read when they get sick. But it is natural. All the more we have to do it, again and again because each new generation must be educated. They are fresh. Thirdly, the media should be careful in investigating and reporting individual patient's complaints that their cases have been mishandled by their doctors or by the hospitals. They have to be careful because of the factor which I mentioned earlier, namely, that if you ask the patient, you get a story, if you investigate, you often get a different story. I am not asking them not to report at all, but they have to be very cautious in doing so, because by publishing an exaggerated or inaccurate story, they will very easily generate additional unnecessary alarm among the public who are in no position to judge the accuracy or the plausibility of the stories. Firstly, they do not know the facts. Secondly, they are not doctors. So great caution is called for. I am not saying that the health care system is perfect, or that doctors never make mistakes. Doctors are human and, occasionally, they will make mistakes. Hospitals handle thousands of patients a day and once in a while, they will slip up. Not everybody is a senior most physician, some are housemen, some are trainee nurses. They are learning on the jobs, sometimes errors occur. Even the best doctors, confronted with a difficult case, will sometimes make the wrong diagnosis or will decide on a course of action which subsequently turns out badly. When you see the top surgeon, or the top doctor, you are not betting on a 100% outcome. You are lucky if you are betting on a 70% or 80% outcome. And if it turns out tail instead of head, you have to accept that the doctor has done his best job, unless there are overwhelming reasons to believe that he has done you in. Sometimes, the errors will lead to unnecessary procedures. Patients did not have appendicitis, you cut out his appendix. No harm done. Other areas will lead to deaths of patients. This is a regrettable but unavoidable fact of life. We can minimise it but, like traffic accidents, you cannot eliminate it. You take appendicitis cases. Every now and then, there is a story in the newspaper. In the early stages, my doctors tell me appendix cases are very difficult to differentiate from other sorts of problems. You may have gastroenteritis, you may have some other abdominal problem, generalised pain, and there is no way you can tell for sure. All you can do is wait and see, and as the disease develops, if it is appendicitis, it will show itself. If you want to see the doctor once and have him be sure that he does not leave a bad appendix there, then you must be prepared to see the doctor and have lots of good appendixes taken out because the doctor just wants to be safe. In the case of an appendix, there is no harm. I can think of a lot of other parts of the body where you would mind very much. But it is a real problem. You can either misdiagnose by not recognising something which is there, or you can misdiagnose by thinking that something is there, which is not. I give you another example, viral myocarditis. Once in a while, a national serviceman, or a school boy, running drops dead. Viral myocarditis, what is that? It is the inflammation of the lining of the heart. What does it look like? It looks exactly like flu. Thousands of boys and girls and national servicemen have flu. One or two have viral myocarditis. Are you going to say that all flu cases will be given 10 days MC, rest in barracks? Or can we find some way to be cautious but discriminate, if possible, and in the end, you still have to run some risks that one or two may turn out tails? There is no clear-cut way to distinguish. You can have the best doctor in the world. He cannot tell the difference except wait and see. So we have to accept that mistakes will take place. But there are certain things which we can do. Firstly, we can keep mistakes to a minimum by maintaining high standards, have good well-trained doctors. Where we find bad ones, weed them out. Secondly, you must establish procedures of review and checking, so that when a doctor makes a mistake, it is discovered as soon as possible. If a doctor sees a person with a tender belly and suspects appendicitis, he should say, "Wait. If it persists, come back and I will see you again." Somebody else will see you. He can check, he can find out. You would not die but just live with the discomfort and the unease. It will be seen to. The situation will develop. Thirdly, have standard treatment protocols so that less is left to chance. Doctors make judgments. But many cases follow patterns and a protocol will guide the doctor. In this situation, have an X-ray. In that situation, dispense with an X-ray. In this situation, have a catscan. In that situation, it is better to call a specialist. It is not a cast-iron rule but it sets guidelines which, I think, simplifies a doctor's job. Finally, we need to have a system where patients' complaints are properly investigated so that mistakes are not covered up. But if there are any shortcomings, they are put right. And if anybody has been negligent or irresponsible, that is discovered and disciplinary action is taken. There are formal procedures for doing this. In a serious case, the Ministry of Health will convene a Committee of Inquiry. A formal board will sit as a committee. Senior doctors, including doctors from other hospitals, will look into the case, how was it handled, was anybody negligent, could something have been done better, could this mistake be avoided in future? And the Ministry of Health, I have discussed this with them, has agreed that not only will they have Government doctors serve on the Committee of Inquiry but they will also have private doctors who have established themselves serve on the Committee of Inquiry so that people can see visibly that the system is not covering up. We must find doctors who are incompetent or irresponsible and punish them. But we must be careful not to punish doctors who have made honest mistakes, because if we do that we are going to frighten all the doctors, demoralise them, and encourage them to practise defensive medicine. He does not need this, but it will look good at the Committee of Inquiry. So a balance has to be struck and we should be careful not to generate public hysteria. When people say, "I have had a bad experience. I will never visit the hospital again.", we can sympathise, but I do not think we can agree. In medicine, we are dealing with human lives. Doctors cannot cure all patients, or keep us alive forever. Their aim should be to allow as many of us as possible to live out our normal lifespans while enjoying a high quality of life. That is why the White Paper contains the explicit statement that the basic health care package does not include "extravagant efforts to keep gravely ill patients alive regardless of quality of life or prospects for recovery". I drafted that. I suggested to the Chairman that it be put into the White Paper because I think it is an important issue which should be brought out into the open. It is a sensitive issue, but it is one which we will increasingly have to face as medical science progresses and as our population ages. You look at the US experience. One-third of their medical expenditure takes place in the last year of the patient's life. They spend 14% of GDP. For the last year of the patient's life, that is 4% of GDP. They have Medicare which is state payment for the old. Most of it is spent for the last phase of terminal illness. Patient is dying, spend more money. 21% during the last six months, most of it in the last 30 days. I read you a quotation from the Economist, 28th April 1984. It is out of date but the problem has got worse, not better. "Last year [1983] Medicare alone paid out around US$15 billion - more than the whole national income of Bangladesh - on care of terminally ill Americans in their last six months of life. Although third-party insurance makes it profitable for a doctor to pump the finest medications into an unprotesting near-corpse, there is no evidence that this extended the average such patient's life by more than a few harrowing days. For each day that it did, it will have raised the national health bill by nearly another US$100 million." Our experience is not as extreme but similar: 80% of a person's hospitalisation expenses over his lifetime occur during the last two years of his life. In response to these trends, in the developed countries, people, especially those who have incurable diseases like cancer, are increasingly making "living wills". They specify the conditions under which they do not wish to be given medical treatment. Let me die. For example, if my heart stops, do I want to be revived? If I am unconscious, incapacitated, comatose, do I want to be kept alive with ventilation, with intravenous feeding? They are doing this voluntarily, not to save money, but to die with dignity. Lianhe Zaobao carried a report a few days ago. President Clinton said he himself was willing to sign a living well and make its contents public. The President gets free health care. He is prepared to sign a living will and he said: "I think families should think about living wills and should have them." The M D Anderson Cancer Centre is in Houston. It is one of the best cancer centres in America. Some of you may have heard of it. I was there last year. It actively encourages patients to make living wills. Once a patient is diagnosed as having cancer, the Centre will hold counselling sessions to explain to the patient what is likely to happen, advise the patient in his own best interest, better think of eventualities. When I was there, there were posters on the corridors and in the waiting rooms. While you are waiting to see the doctor, read the poster, memento mori; remember, you must die. And the poster reminds the patient to make living wills if they have not yet done so. Do not leave it until it is too late. Many countries have enacted legislation to validate "living wills" to enable doctors to carry out the wishes of comatose patients. Thirty-six states in the United States have legislation. The State of Victoria in Australia also has legislation. Britain is also considering a Bill to legalise "living wills". This year, the British House of Lords held that it was lawful to withdraw medical treatment and support for a patient in a vegetative state, which would result in his being allowed to die. This is a problem which arises not only when patients have to worry about how they themselves are going to be treated. Some of the most agonizing situations arise when people have to decide for children who are gravely ill. I circulated three examples, just chosen at random. The first is the International Herald Tribune, 26th October 1993. 2-year old Baby K, or just over a year old, born without a brain, permanently unconscious without any ability to see, hear or feel. The mother insisted against the judgment of doctors and the hospital ethics committee that the baby be kept alive with a ventilator. The hospital went to court to find out if it had to continue offering life-sustaining treatment. The lower court said it did. It described the baby as a disabled baby. It has got no brain, just brain stem so it can breathe. Disabled baby. Who is to pay? Yesterday's Straits Times. This is the opposite. The mother wants to let nature take its course, the school objects. 12-year old daughter with cerebral palsy and progressive scoliosis. Scoliosis is a lateral curvature of the spine. This is progressive scoliosis. So it is slowly crushing her vital organs. She is going to die. The mother made a request to the teachers that if the girl collapses during class, they should not try to revive her but only make the little girl comfortable. In other words, Do Not Resuscitate (DNR). The school refused to observe this request. They went to the school board. The school board ruled and upheld the mother. The mother said she consulted a paediatrician and three medical specialists before making the request. Today's Straits Times, British girl, 5-year old, two multiple transplant operations. The first in June last year, new liver and new bowels. Paid for by public donations and Saudi Arabia's King Fahd. Failed. Transplant again. This time, six organs - liver, bowels, stomach, pancreas, kidneys, intestines. 15-hour operation eight weeks ago. The child has now died. Patient paid o350,000 ($805,000). Doctors said she did not die in vain. I quote the chairman of the local health authority: "New frontiers in medicine can bring sadness as well as success." Such cases happen from time to time in Singapore. We do not have generous donors like this, but the same human problem arises. It is heartbreaking to watch a child suffer and die from an incurable illness. But it is even more heartbreaking to raise false hopes in the family, torture the child with high-tech medicine and with repeated operations until at last he or she dies. Singapore doctors have lived with this problem for a very long time. Just like doctors elsewhere, they do their best to make sensible decisions but they prefer not to be exposed to the glare of publicity. You may have read the report in the Life section of the Straits Times a few weeks ago. They interviewed five doctors who all explained why this was a necessary part of medical practice, but none of them wanted to be named except the medical doctor in Toa Payoh Hospital. The problem will grow and it cannot just be left to doctors. Therefore, the White Paper has brought this matter out into the open. It says no more than what doctors and hospitals have always been doing. Where exactly to draw the line is not just a medical decision, but it is one which will reflect social and ethical values. Therefore, it is right that it be made by an ethics committee and all hospitals in Singapore have set up an ethics committee to deal with these issues. The exact limits will shift with time but the need to draw the line will never go away. So far, I have focused on what we can do as a Government and as a society to look after our health care system. But we must not neglect individual responsibility which is one of the key principles in the White Paper. Some MPs have questioned this. Mr Low Thia Khiang, for example. They argued that once a person is ill, it is the Government's responsibility to look after him, meaning, of course, the Government must pay for his treatment. They are completely wrong. It is the responsibility of each of us to keep fit, live healthy lifestyles, avoid risky activities. You keep fit, you reduce the chance of heart disease. You stay fit and trim, you not only reduce the chance of heart diseases but also the risk of diabetes. You avoid unsafe sex, you minimise the risk of AIDS. People who do not take these precautions are imposing a burden on the rest of society when they fall ill. Even cancer, which accounts for one-quarter of deaths in Singapore, is amenable to how people act and what they do. Smokers get lung cancer. If you do not want lung cancer, do not smoke. If you eat more high fat diet you increase the risk of colorectal cancer and breast cancer. You go sun-tanning recklessly, you increase the risk of skin cancer. So it depends on what you do. After a person has got cancer, very often the chances of his being treated successfully depend on how early he can discover it and do something about it. The most important determinant of the prognosis, of the outlook, for many types of cancer, is what stage is it. First question. Is it early, is it intermediate, is it late? There are elaborate systems of classifying cancer by stage. That determines your chances. For example, colorectal cancer. In Singapore, most cases present very late, "present" means the cases are shown to the doctors long after the warning signs have appeared. There is a system called Duke's classification - Duke A, Duke B, Duke C, Duke D. Duke A is earliest and Duke D is latest. In Singapore, one-third of colorectal cancers are Duke D when they are diagnosed. That means incurable. Only 8% are Duke A. Duke A means surgery alone can achieve nearly 100% cure. So by the time the patient goes to see the doctor, it is months, maybe years, after the symptoms have appeared and the patient knows something has gone wrong, but he is risking his life. Breast cancer, the same thing. The earlier you are treated the better your chances are. My doctors tell me that we have a particular problem with Malay female patients with breast cancer because somehow they present very late. There is a lump, they leave it, maybe they are embarrassed. By the time they see the doctor it is very advanced and there is nothing much the doctor can do. So the way to bring down cancer death rate in Singapore is not to spend another few percent of GDP on medicine, like Dr Soin suggested. It is to educate the public to see the doctors early, and not to invest in high-tech treatments for advanced cases of cancer. We have got to get people to take personal responsibility for their health. In Britain, they are talking about giving smokers and drinkers bottom priority. This is not only because they do not deserve to be treated, but also because even if you treat them, if they continue smoking and drinking, their chances of benefitting from the treatment are poor. That is why in Singapore we have said that, for personal responsibility, Medifund will give priority to people who have conscientiously contributed to Medisave and who have participated in MediShield. I think we should go one step further and say people who live healthy lifestyles should have priority. Doctor advises you not to smoke, you smoke. When you get lung cancer, you then say, "C class cannot find, go to B2, please waive charges." Should we? Is it right? We have a good health care system. High quality medical services are available to all, at affordable prices. The total cost of the medical services to the country is low. We are proud that it only costs 3% of the GDP. That does not mean we must spend more. That means we are getting value for money. The results, if we measure it in terms of standard indicators, life expectancy and infant mortality, are good. Of course, not everybody is happy with the system. But then as one health care economist said to me, when you study this subject, after a while, you will conclude that there is a theorem that every country in the world is unhappy with its health care system and it does not matter what system it has. It will be unhappy. So I would say to those who are unhappy: where would you prefer to live? Where else? You want to go to America? 14% of GDP on health care. If you have money, the best available, it is outstanding, best in the world; if you have no money, 30 million Americans have no health insurance. Or you can go to Canada, it is for free. You just pay 50% of your income in taxes upfront. Or you can go to Japan, it is not very expensive. You can live quite long, but the hospitals are dumps, deliberately so, spartan and ill-equipped, to keep cost down and discourage people from using them. We are not badly off in Singapore. Let us improve on our health care system progressively. Let us install safeguards now which will contain health costs and keep the services affordable to all. I think, Mr Speaker, the proposals in this White Paper will help us to do that. [Applause.]