Read the full parliamentary debate at:
Also – see this BBC report of Belgium’s decision to euthanise children:
Extracts opposing assisted suicide and euthanasia follow:
12.11 pm Lord Alton of Liverpool (CB): My Lords, it is a particular pleasure for me both to thank the right reverend Prelate the Bishop of Sheffield for his thoughtful and poignant maiden speech, and to welcome him to your Lordships’ House. I see that, like Moses, he chose to read from a tablet. I am married to an Anglican whose father and grandfather were, for more than 60 and 50 years, Anglican priests, and there are eight ordained Anglican clergy crossing the generations on my wife’s side of the family. As an outsider, I have seen something of the extraordinary selflessness that characterises the men and women from whom the right reverend Prelate has been drawn. Steven Croft is a Yorkshireman who, after graduating from the University of Oxford, studied for the priesthood and obtained his doctorate at Durham. After serving in parishes and as a diocesan adviser in Wakefield, he returned to Durham with his family as warden of the university’s Cranmer Hall, St John’s College. This required him to lead the training of men and women for Church of England ministry. He thrived in his new responsibilities, wrote widely about his experiences as a parish priest and began to express increasing concern about the urgent need for the church to engage with a society that has been drifting spiritually but where the Christian faith is needed like never before. Shortly after Rowan Williams—now the noble and right reverend Lord, Lord Williams of Oystermouth—was appointed as the Archbishop of Canterbury, the right reverend Prelate became Archbishops’ Missioner and Fresh Expressions Team Leader. For four years he oversaw the emergence of Fresh Expressions, an initiative of the most reverend Primates the Archbishops of Canterbury and York, in conjunction with the Methodist Church. Fresh Expressions encourages and resources new ways for the church to engage with the world. The movement has resulted in thousands of new congregations being formed alongside more traditional churches. The right reverend Prelate is known as a very shrewd and strategic thinker. The energy and determination that he has brought to his work thus far will prepare him perfectly for his duties in your Lordships’ House. Sheffield is lucky to have him. I have no doubt that, as the years pass, we will hear many more thoughtful and challenging contributions to our proceedings, and I know that I speak for all sides of your Lordships’ House when I thank him again for making such an excellent start with his maiden speech. It was an illustrious English woman, a devout Anglican, Dame Cicely Saunders, whom I was fortunate to meet, who was the founder of the modern hospice movement in England. Dame Cicely trained as a nurse, a medical social worker and finally as a physician. Involved from 1948 onwards with the care of patients with terminal illness, she founded St Christopher’s Hospice in 1967 as the first hospice linking expert pain and symptom control, compassionate care, teaching and clinical research. St Christopher’s has been a pioneer in the field of palliative medicine, which is now established world wide. Like the late Lady Ryder of Warsaw, Sue Ryder, whose charity the noble Lord, Lord Dubs, referred to earlier, Dame Cicely was resolutely opposed to assisted suicide and euthanasia. She once said: “You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die”. In declaring a non-pecuniary interest as a patron of two hospices, I stand with the hospice movement, the disability rights groups and the British Medical Association in believing that we should never confuse the importance of providing end-of-life care with the legalisation of euthanasia. Were the law to change, we would see the emasculation of the hospice movement but we would also see a fundamental change in the relationship between doctors and their patients, especially the vulnerable. Nor does experience overseas, which has been referred to, encourage me to change my mind. We are told that in the US state of Oregon, one of the handful of places where these practices have been legalised, everything is fine and the law is working well. That is a highly questionable assertion. There is no audit system in place for Oregon’s law. It is totally dependent on the honest reporting of doctors. What we do know, from the annual statistical reports, is that the number of legal assisted deaths is rising year on year. In 2012, the number was nearly five times that in 1998, and the latest figure is the equivalent of between 1,100 and 1,200 such suicides per annum in England and Wales. It is claimed that the rising trend has levelled off. It has not. The official data show that the death rate from assisted suicide has increased by over 20% in the past five years. There is another reason for being cautious about Oregon. The latest report states that nearly half of those in Oregon who asked for lethal drugs with which to end their lives listed as a reason that they feared being or becoming a burden on their families. In today’s society, where we are living longer and where younger generations are often burdened with debt and other responsibilities, such fears are all too natural, and I fear that they will become even more so. For those reasons, I hope that we will resist the temptation to legalise something which on two occasions your Lordships have voted against. 12.16
Baroness Morris of Bolton (Con):
My Lords, we will all of us die one day, and how we die is as important as how we live. This is about the best possible care at the end of life, and the choices which that affords. I am grateful to the noble Lord, Lord Dubs, for giving us the opportunity to debate this important issue.
As a society, we are becoming personally less familiar with death. At one time, death was an integral part of life. Most deaths took place at home, with family present or nearby. My husband and I both come from large Irish Catholic families and it was the usual practice for your loved ones to be laid out at home for family and friends to pay their last respects before burial. However, with advances in medical science—advances for which we are all enormously grateful—death has increasingly become a clinical act that takes place in hospital, often after an emergency admission to an acute ward and, sadly, all too often in isolation. We have come to believe that medicine has the answer for everything.
We cannot recreate a society from another age, and each age must shape its own way. However, it is a fact, as the noble Lord, Lord Dubs, said, that when questioned, most people say that they would wish to die at home. We should strive to make that possible, wherever possible. That means greater investment in community care. It also means building on the investment which successive Governments have made in the development of specialist palliative care—an investment that has made this country a world leader in end-of-life care.
Those are the choices that I want to see embraced at the end of life. What I do not wish to see is the right to choose when to die, with assisted suicide enshrined in law as one of those choices for some people.
There is nothing more distressing than witnessing someone you love in pain and with little hope of recovery. I completely understand the honourable intentions of those who support a change in the law to license “assisted dying”. However, in reality that means licensing doctors to involve themselves in deliberately bringing about the deaths of some of their patients.
In the Bill of the noble and learned Lord, Lord Falconer, now before your Lordships’ House, responsibility for assisting suicide is placed on the shoulders of doctors. However, most doctors do not want that responsibility, and nor do their professional bodies. The Royal College of Physicians has stated explicitly that a doctor’s duty of care for patients,
“does not include being, in any way, part of their suicide”.
We need to remember that the law exists to protect us all—especially the more vulnerable among us. It is hard to imagine anyone more vulnerable than someone who is struggling to come to terms with their mortality and who is worried about the impact of their illness on those they love. The last thing they need is an invitation to take their own life. Instead they need and deserve our unfailing care and protection.
Lord Bishop of Sheffield:
My Lords, I must begin by thanking your Lordships for the warmth of welcome extended to me here. Thank you also to the staff for their guidance and help. I look forward very much to serving with you in this House and count it an immense privilege to be here.
It is particularly poignant for me to contribute to this debate on patient choice at the end of life as my own father is very seriously ill. Over the last few days I have been involved in a number of conversations with medical staff and my close family about the questions before us today. I am sure that these conversations are familiar to many noble Lords. The matters we debate are of profound importance to those who are near the end of their life, and to their wider families.
The diocese of Sheffield, where I now serve, covers most of south Yorkshire and parts of east Yorkshire. Its communities are vibrant, coherent, friendly and welcoming. Its manufacturing is alive and growing. There are vigorous partnerships between industry, civic life and the universities, including in the area of healthcare. Its people are deeply committed to their local institutions, including their National Health Service.
The city of Sheffield has this year embraced a new commitment to fairness and equality through its Fairness Commission and aims to become the fairest city in Britain in the coming years, including in equality of access to all forms of healthcare.
Like many others, I am grateful to those who have produced the independent review of the Liverpool care pathway. There is much in their report to be welcomed: the valuing of end-of-life care as a specific discipline, the move away from the language of pathway to a personal care plan, the greater shift to patient choice, and greater clarity in decision-making. Like others, I welcome particularly the continued valuing of the hospice movement. The greater shift to patient choice commended in the review does not, of course, include extending patient choice to physician-assisted suicide, something to which I remain opposed and which seems a very different kind of conversation.
I also welcome the work of the Leadership Alliance for the Care of Dying People, and in particular the collaborative partnership and way of working it has established between the medical profession, patients and their families. I note the sense of urgency among those involved in end-of-life care with whom I have spoken that proper provision should be in place soon in every place to replace the Liverpool care pathway, lest an imperfect system be made even worse by a period of uncertainty and confusion.
More Care, Less Pathway calls for a proper national conversation about death, which the Leadership Alliance is taking forward. This takes us to the heart of the issue. The death of someone we love, our own death, is far more than the cessation of life for medical reasons. Death is an existential event which raises and asks significant questions. Those questions are often suppressed, masked by humour or denied, but surface in times of vulnerability throughout our lives. What is it of the human person which endures? What light does death cast on the way in which we live? What is a good death? What does it mean to come to terms with our mortality and, from the Christian perspective, our vocation to eternity?
For all these reasons and more, the ministry of chaplains in our hospitals and hospices remains a vital part of end-of-life care. Chaplains are present to minister to those of all faiths and of none. They are drawn, of course, from every faith. They are present to offer spiritual support to the dying and to the bereaved, to patients and staff. They are a vital part of the team in end-of-life care as a specialist resource, as experts able to offer training to colleagues and as a point of referral in moments of crisis. I invite the Minister in the response to this debate both to affirm the key role of chaplains in this context and to ensure that the part they play is written clearly into the documents which will shape end-of-life care into the future.
I look forward very much to playing my part in the business of your Lordships’ House.
The Lord Bishop of Chester:
My Lords, I join other Members of the House in welcoming the reinforcements to the Bishops’ Benches. I will make three brief points in my contribution, the first of which does not have a direct connection with assisted suicide. We typically have long waiting lists today for transplantation surgery in this country, due to an absence of an adequate supply of donated organs. I hope that we will do as much as we can, and more, to encourage people to carry organ donation consent cards and to engender a culture in society in which transplantation and donation of organs are encouraged, especially for those whose death comes in an untimely and unchosen way. This is a matter of choice at the point of death, as are the things that we are discussing in the main part of this debate.
Some religious communities exhibit a particular reluctance to support organ donation, which often works to the disadvantage of the members of that community who are waiting for transplantation. For some time, efforts have been made to overcome this reluctance. Earlier this week, a new interfaith organ donation action plan was launched, backed by the NHS and with the active involvement of a number of churches including the Church of England. I mention this simply to underline that there are various issues connected with choice at the point of death beyond the main issue of today’s debate.
Turning to issues of choice in relation to assisted suicide, I acknowledge the strength of the momentum for legalising assisted suicide, which has been well illustrated in the contributions to the debate so far. I must acknowledge the state of public opinion on the matter, which I believe is likely to get stronger. For a society that has now embraced abortion by choice, the move to assisted suicide by choice might seem, in moral terms, rather a modest step. I am surprised that this connection is not made more often, although two noble Lords in today’s debate have acknowledged it and, in last week’s rat-a-tat-tat debate, the noble Baroness, Lady Hayter, made quite a lot of it, saying that the parallel between abortion and assisted suicide was connected by issues, as she put it, of common humanity. Whether one accepts that parallel or not, and whatever one makes of the parallel, I believe that the wider social context is crucial to our debates on this subject. Choice always has a context, and the context of our society has changed and is changing. I need to acknowledge that.
I remain personally opposed to the change in the law that is in the Bill of the noble and learned Lord, Lord Falconer. But the question with which I wrestle is: on what basis can I prevent others who take a different view from making their choices on the basis of a change in the law? It is a somewhat open question but I think I am still persuaded that in order to sustain justice for the vulnerable in our competitive and individualistic society—the context in which we are discussing this matter—there would have to be very powerful bulwarks in the law to prevent the exploitation of the weak and vulnerable.
Even with the safeguards in the draft Bill, changes in the law tend to create their own momentum, as has been well illustrated with what has happened with abortion. For me, that is where the problem will lie if a change in the law is based too much on the notions of choice and autonomy to which a number of noble Lords have referred very centrally. If you accept assisted suicide fundamentally on the basis of autonomous choice, how can you simply leave it to a very restricted group who are believed to be terminally ill? Logically, one day or another, sooner or later, it would have to be extended.
That leads me to my current conclusion: that the risks inherent in legalising assisted suicide still outweigh the benefits that might accrue.
Baroness Nicholson of Winterbourne (LD):
My Lords, I serve as a Member of this Chamber in the Parliamentary Assembly of the Council of Europe. It is in that context that I wish to draw noble Lords’ attention to the Council of Europe’s banning of euthanasia on 25 January 2012. As your Lordships of course know, Britain was one of the founder members of the Council of Europe and, in May 1990, we assisted through the treaty of London in forming the European Convention on Human Rights. Although that convention was misinterpreted when it was it put into law by the previous Labour Government, with Articles 6 and 8 distorted, we are none the less committed to it and continue to support it fully as a nation.
Nearly two years ago, on 25 January 2012, the Parliamentary Assembly of the Council of Europe adopted a resolution stating:
“Euthanasia … must always be prohibited”.
This articulates a strong principle for life and against euthanasia, given that, for the very first time, euthanasia was so clearly rejected by a major European political institution.
This was a third major victory for life and dignity of the weakest after the 2010 resolution of the Parliamentary Assembly that strengthened freedom of conscience for doctors and medical staff, and after the European Court of Human Rights asserted in 2011 that there was no right to euthanasia or assisted suicide under the European convention. The Council of Europe resolution, passed in January 2012, states in Article 5:
“Euthanasia, in the sense of the intentional killing by act or omission of a dependent human being for his or her alleged benefit, must always be prohibited”.
The resolution is entitled:
“Protecting human rights and dignity by taking into account previously expressed wishes of patients”,
and aims for a clarification of the principles that should govern the practice of “living wills” or “advance directives” in Europe. Patients should be permitted and encouraged to express in advance their wishes with regards to medical intervention and treatment in case a situation occurs in which they are no longer capable of doing so.
Given that divergent regulation in European countries and the abuse of so-called “living wills” or “advance directives” can provide a gateway for euthanasia or assisted suicide, there are growing concerns about the effective protection of human dignity at the end of life. Therefore, the Parliamentary Assembly judged it necessary to present clear guidelines to close the door to euthanasia, to the abuse of “living wills” and to surrogate decisions by recalling principles elaborated in previous documents such as the Oviedo Convention on Human Rights and Biomedicine. First and foremost, the Assembly sets the principle that,
“intentional killing … must always be prohibited”.
Secondly, an important amendment introduced by an Italian Member of the European Parliament, Luca Volontè, was adopted, so that Paragraph 7.8 states that,
“surrogate decisions that rely on general value judgements present in society should not be admissible and, in case of doubt, the decision must always be pro-life and the prolongation of life”.
With the adoption of this resolution, the Council of Europe placed the ball in the court of countries that permit euthanasia, such as the Netherlands and Belgium. Even if this resolution is not legally binding, these member states are expected to be aware of the standard set forth by the Parliamentary Assembly and to review their own legislation.
That draws my attention to the words of the noble Lord, Lord Joffe, in 2004, who said that his Assisted Dying for the Terminally Ill Bill was just a “first stage”. The slippery slope opens up there. In the Netherlands, euthanasia is permitted for children who are 12 years old; in Belgium the age is coming down to 12. Let us think of the burden that this would place on National Health Service, with at least 11,500 to 12,000 deaths being assisted, the mass of prohibitions that would surround that, the amount of debates and the enormity of transforming our National Health Service perhaps into a national death service. I strongly oppose.
Lord Rowe-Beddoe (CB):
My Lords, I, too, thank the noble Lord, Lord Dubs, for providing us with the opportunity to debate this topic. It is being proposed that the law should be changed to allow assisted suicide. This presupposes that there is agreement that the law as it stands is not adequate. What is being referred to by some noble Lords today would represent a major change to the criminal law. Parliament is being asked to agree that some people, namely doctors, should be licensed by law to involve themselves in deliberately bringing about the death of some others, namely people who are terminally ill. This, I propose, is no small adjustment; it is a major change of the law.
I suggest that if your Lordships’ House is to consider such a proposal seriously, it needs hard evidence that currently the law is not fit for purpose and if that is so, that which would be put in its place would be better and, above all, safer for us all. I do not believe that such evidence has been produced. All we hear are some honeyed words about the need to reduce suffering and some ill informed claims of what the law says and how it works.
For example, we are told that the law does not provide certainty as to whether a person who assists a suicide would be prosecuted. As citizens, we most certainly have the right to know what the law is. I submit that we do know. The law is clear: encouraging or assisting another person’s suicide is a criminal offence. Discretion is provided to the Director of Public Prosecutions to decide whether a prosecution is needed in the individual circumstances of any case. There is a published prosecution policy setting out how such decisions are reached and providing some of the circumstances which might incline the DPP to prosecute, or not to prosecute. This, however, is not sufficient for those who wish to see assisted suicide licensed by law.
A major complaint is that someone who breaks the law and assists a suicide does not have certainty as to whether the offence will be prosecuted. Certainty cannot be given as the outcome of a breach of the law will depend on the circumstances in which it was committed. To give assurance that a prosecution for assisted suicide would be in this or that circumstance would clearly amount to changing the law. Further, we are encouraged to believe that the law is cruel because of the maximum penalty that it holds in reserve— some 14 years. But no sooner do we work ourselves up on this issue than we are told that the law is not working properly because those who break it are not being prosecuted.
The reality, when the spin and fog is cleared away, is that we see a law with a stern face and an understanding heart. The penalties which the law holds in reserve are, I suggest, sufficient to make anyone minded to assist another person’s suicide think very carefully before proceeding. As a result, the offence is rare and the few cases that reach the DPP tend to be those where there has been serious soul-searching and genuinely compassionate assistance, perhaps somewhat reluctantly given. In such cases, the DPP is able to exercise the discretion that the law provides. I suggest that before there can be serious discussion of how the law should be changed by Parliament, we need clear and convincing evidence that it should be changed and that what would be put in its place would be better and safer—safer, that is, for us all. Until that evidence is submitted, we should return these proposals to the drawing board.
Lord Hylton (CB):
My Lords, today’s debate seems to be a dress rehearsal for the Second Reading of the Bill of the noble and learned Lord, Lord Falconer. However, I start from antiquity, where suicide was normal if someone suffered disgrace or their honour was seriously impugned. The Japanese samurai had a somewhat similar view. For the Jews, suicide largely fell under the command, “Thou shalt not kill”. For the western world, the Christian faith changed the earlier ways of thought. Shakespeare summed it up and gave a strong pro-life view in Act I of “Hamlet”:
“Or that the Everlasting had not fixed
His canon ’gainst self-slaughter”.
Islam is clearly opposed to euthanasia. Buddhists are doubtful about the rightness of suicide, emphasising the principle of not doing harm. Hinduism stresses Ahimsa, which is similar, and believes in Dharma, the accepting of moral duties. All faiths seek to minimise unnecessary suffering. Given the views of the great world religions, I conclude that humanists would be unwise to impose their genuine convictions on everyone else.
My second point comes from the old saying, “Hard cases make bad law”. We may be harrowed by individual cases of people suffering great pain, longing to die but perhaps too weak to kill themselves. Appeals to our compassion or to the principle of utility, however, should not be allowed to outweigh our duty to the common good of the great majority.
Changing the existing law would impose unnecessary burdens on a range of people. The handicapped or depressed will ask, “Am I a charge on society? Am I using resources that should be devoted to others? When will I reach the six-month point?”. Carers will wonder, “Should I speak to the declining person while they are still capable of deciding?” Temptations will face the beneficiaries of wills. Young people, perhaps aged 19 or 20, could make valid decisions, thus robbing their parents of precious time still together. Doctors and nurses also believe in preserving life rather than ending it. They have, and still seek, to provide a health service, not a death service. We should not add to their burdens but remember their Hippocratic oath.
I respect the deeply held convictions of those proposing change. Neither side will probably convince the other. Can we at least agree to work for a more co-operative and caring society where more people are enabled to die at home and fewer in the institutional surroundings of hospital wards? I believe that we should aim for all to be accompanied to a natural death in a familiar setting, with loved ones close at hand.
Lord McColl of Dulwich (Con):
My Lords, if it was possible to choose the occasion of one’s death by electing to be killed, it would create an escape route at the onset of an illness which, given time, would take away one’s independence and one’s mind. It would be an escape route from the fear of indignity and suffering. I understand that fear only too well. My wife, Jean, died last year having had dementia.
I have drawn two conclusions from my experience. First, it is imperative that we care for those who are suffering in this way and that we treat them with dignity. We need to create a society in which such care and treatment is the norm. I am so grateful to those of your Lordships and, especially, the doorkeepers and security officers who treated Jean with dignity and extended many kindnesses to her. It is so important to invest our time and resources to ensure that dementia patients receive proper care. Secondly, dependence is natural at certain stages in life. All of us were dependent on others at birth and for a considerable time thereafter. Dying is part of living and during that time we may be dependent on others. Why should that be a fearful thing? It is probably because our society prizes independence and schools us into it at an early age. We need to revisit this and to be educated to appreciate that dependence is no cause for shame.
The choice that I would like people to be able to make at the end of life is a choice to go on living in the assurance that they will be cared for with compassion and not ignored or regarded as a burden. All sides of this debate recognise that if assisted suicide is to be legal, there must be safeguards. Many of us believe that it is not possible to legislate for adequate safeguards. That aside, it is pertinent to ask whom the safeguards are intended to protect. It is sometimes assumed that it is only the would-be suicide who needs protection. Indeed, he or she does need protection, but society as a whole is also in need of protection from changes in the law which may have a deleterious effect.
There is a danger of confusing the role of the health professional and undermining the trust which exists between doctor and patient. At present, the health carer’s mandate is crystal clear. It is always to care and never to kill or assist in killing. One cures by treating the patient and eliminating the disease. Eliminating the patient is not treatment, no matter what the patient may request. Where one cannot cure, society should provide care. At present, the provision of adequate care is patchy and uncertain, and this needs to be addressed urgently.
If one was to legalise assisted suicide, one would be setting up independence as a quality whose worth is greater than life itself. What would such a society be saying to disabled people and the mentally ill? As the New York State Task Force on Life and the Law reported:
“The legalization of assisted suicide would itself send a message that suicide is a socially acceptable response to terminal or incurable disease. Some patients are likely to feel pressured to take this option, particularly those who feel obligated to relieve their loved ones of the burden of care. Those patients who do not want to commit suicide may feel obligated to justify their decision to continue living”.
While those who champion the legalisation of assisted suicide do so, I am sure, with the best of motives, I believe it to be a profound mistake. For these reasons and others, which time does not permit me to address, I believe that our energies and resources are best spent on improving the care that is available so that people can choose to go on living with confidence that they will not be neglected.
Baroness Hollins (CB):
My Lords, as the immediate past president of the BMA and chair of the BMA Board of Science, I remind your Lordships’ House that the BMA opposes all forms of assisted dying and believes that ongoing improvements in palliative care allow patients to die with dignity. The BMA respects the concept of individual autonomy and encourages patient choice about clinically appropriate treatments, but it believes there are limits to what people should be allowed to choose when their choice impacts on other people.
The Department of Health end-of-life care strategy says that more people are making choices about their care and treatment, but that too few health professionals yet know how to talk about death and dying. Can the Minister say what is being done about this? There is clearly still plenty of room for improvement.
Despite that, we can be rightly proud of our pioneering work to create and develop the specialty of palliative care. We are ahead of the curve, leading the global race. Dame Cecily Saunders, the founder of palliative medicine, left us an extraordinary legacy. As suggested by my noble friend Lord Alton, I agree that her legacy could be undone by the introduction of assisted suicide as a choice. Without strong advocacy, constraints on NHS funding could lead to more cuts being made to end-of-life care. Assisted suicide, instead of being an option, would be the cheaper alternative. We would be offered either/or—rather as in Oregon, where patients have to sign out of active treatment to access hospice support and where palliative care is not a clinical specialty. Since our healthcare system is more similar to that of the Netherlands than that of the USA, we should be studying practice there, with one in 34 deaths now being through euthanasia.
It could be argued that it would make economic sense both for families and for the nation. However, this is a policy change that would replace our traditional commitment and compassion to each other—“in sickness and in health”—with a greater value being placed on high-achieving, fit and healthy members of our communities. Instead, we could invest more in our pioneering palliative care services and sell them abroad. We could train overseas doctors and nurses. We could accelerate our search for a cure for dementia and other long-term conditions. Now that we have legally recognised parity between physical and mental health, we could become the most psychologically aware nation in the world, and bring our new learning about their interrelatedness to our understanding of death and dying, rather than continuing to deny it. Let us use our emotional intelligence here.
In response to the question of the noble Lord, Lord Joffe, it is usually unfinished business with family and friends that causes someone’s unbearable suffering, both mental and physical. People who have expressed a wish to die are now being publicly encouraged to commit to such a view to support the campaign by Dignity in Dying—which of course formerly had “euthanasia” in its title.
Certainty is difficult to commit to until you have the experience. Deciding is a process that unfolds and human beings have an extraordinary capacity to adapt. Help the Hospices told the Select Committee that informed choice means experience of palliative care, not just information about it. Let us show the world that our palliative care services put us ahead, not behind, those—only seven—jurisdictions which have chosen a cheap and unwise solution to the problem of death and dying and dependency.
The focus in the debate today has been more on a timetable for dying rather than coming to terms with leaving this life and what that will mean for the dying person and those left behind. Healthy adults are emotionally interdependent upon one another, and if we had time I would draw on psychoanalytic literature. Suffice it to say, the real issues at the end of life are the care and compassion that comes from being in a relationship with other people, including receiving more than giving, including becoming more dependent. I am talking about the love that endures rather than any physical inconvenience.
Emotional angst about unfinished business is better worked through than avoided through the mistakenly perceived control that comes with suicide. Dealing with unfinished business allows someone to let go of life and let go of suffering. Dealing with unfinished business is also better for those left behind, who will then live more peaceably when their loved one has gone.
Lord Harries of Pentregarth (CB):
My Lords, patient choice is a very great good and we ought to do all we can to encourage and enhance it. There are various ways in which we can do that. First, we can make it much more widely known that there is no moral obligation to go on receiving burdensome treatment when it is doing no good. There is no moral obligation to prolong life at all costs. That has always been the fundamental teaching of both the Roman Catholic Church and the Anglican Church. It is part of our culture and is quite properly reflected in all medical ethical codes.
I was very glad that the right reverend Prelate the Bishop of Sheffield, whom we congratulate on his maiden speech, spoke about the Liverpool care pathway. I myself was very privileged to be on the commission chaired by the noble Baroness, Lady Neuberger, and I examined very carefully the principles on which the Liverpool care pathway was set up, coming to the conclusion that they were fundamentally sound. The Liverpool care pathway was set up with good intentions, but it became bureaucratic and was not always administered well. I very much hope that our recommendations for the future, from pathway to personal care, will set good palliative care firmly in place in all our hospitals, not just in hospices.
There is another way in which personal choice can be enhanced and encouraged: by encouraging more people to sign up for advance directives. I know of somebody who is developing an interactive website to help people do that.
Patient choice is, therefore, a very great good. However, sometimes other goods override the good of patient choice. I will put before your Lordships three very simple and straightforward examples. First, a teenager in great despair pleads with you to help them end their life. Quite properly you override their choice because there is a greater good: the long-term well-being of that teenager. Somebody who is deeply depressed, who should be in a psychiatric hospital, resists going. They have to be sectioned, and sometimes drugs have to be administered to them so that they can be forcibly put into their hospital. Their choice is, quite properly, overridden. If a prisoner is in danger of suicide, they are put under “suicide watch”—a very careful watch has to be kept on them so that they do not commit suicide. Finally, the Samaritans organisation has saved hundreds of thousands of people.
I suggest by those examples that although patient choice is a good, it is not the only good, and that sometimes there is an overriding good. Those examples indicate that our society values human life at all times and in all circumstances. The noble Lord, Lord Taverne, said that the present law and DPP guidance are a mess and have been brought into disrepute. However, I suggest that where you have a very difficult situation, between lives that are unbearable and society’s desire to convey the message that lives at all times—even at the end of life—are of value, you are bound to get some kind of compromise like that. The DPP compromise is workable. It expresses society’s view that everybody’s life, even in extremis, is of value. The noble Lord, Lord Alton, quoted the words of Dame Cicely Saunders:
“You matter because you are you, and you matter to the end of your life”.
By having the law—which does express moral values—in place, that conveys society’s high estimate of every single human life.
Lord Singh of Wimbledon (CB):
My Lords, this debate takes us into new ethical territory with complex medical, legal and emotional implications. Rational discussion is made more difficult by a polarisation of attitudes and opinions. I saw something of this about 12 months ago when I attended a meeting of the All-Party Parliamentary Group on Assisted Dying. I raised some concerns and was made to feel that there was something wrong with my thinking if I could not immediately see the open-and-shut case for changing the existing law. I am also too aware of the opposite arguments, couched in religious terms, that life is a gift from God and we should never, ever, even think of curtailing it.
I served for some years as a member of the BMA Medical Ethics Committee and am well aware of major changes in society and bewildering advances in science and medicine that require us to constantly look anew at previously accepted views and attitudes. Sikhs accept that life is a gift of God to be cherished and preserved wherever possible, but we are also required to bear in mind the important Sikh teaching of compassion, dignity and care for the suffering. These two considerations are not necessarily incompatible. However, I am unhappy about a narrow focusing on individual autonomy to justify attitudes that clearly affect others. We have seen some of this today. We constantly hear the argument that we are all individuals and that our happiness and needs are all-important to the exclusion of our responsibility to others. I believe that this over-focusing on self, on me and my, is responsible for many of the ills in society today. For example, we are all aware that religious teachings suggest that marriage is a committed partnership for mutual care and support and for ensuring that children grow up as responsible adults. What I believe to be a short-sighted contemporary social attitude encourages us to believe that it is okay to look exclusively at our rights, without consideration of the effect on others. This focusing on individual needs rather than on the family as a whole is, at least in part, responsible for the growing increase in dysfunctional families, with children frequently ending up in what we euphemistically call care, or with them mirroring the narrow thinking of their parents. A person’s decision to end their own life has an effect on friends and, importantly, on the message it can give to wider society of trivialising life. We all have wider responsibilities in all that we do.
I shall pull together these different threads in rational and compassionate decision-making to arrive at the way forward. First, we should always respect the gift of life and question the concept of autonomy. Secondly, there are times when those in ill health feel that life is not really worth living but, within a short time, they often feel that it is not really that bad. It is worse for those who find themselves with severe disabilities but, as the Paralympics showed, despite such disabilities, it is often possible to live a meaningful life. Relatives and carers sometimes find looking after someone onerous, and they can inadvertently make their feelings known to those they are caring for, making them feel an unnecessary burden. Sadly, there are others who may have more mercenary motives. A seemingly hopeless situation today may not always remain so. Huge strides are constantly being made in combating previously incurable diseases, as well as in palliative care.
In summary, while we should always be on our guard against the notion of individual autonomy trivialising life, we need to recognise that, from an individual’s perspective, life can become pretty intolerable and there is an argument for helping to end it in strictly controlled circumstances. The danger is that, if we go down this path, it could itself be a slippery slope to trivialising life, altering the very ethos on which medical care is provided. I feel, on balance, that we should leave the law as it is.
Baroness Masham of Ilton (CB):
My Lords, I thank the noble Lord, Lord Dubs, for giving us the chance to discuss the final moments of life. End of life comes in so many ways; very often there is not the opportunity to have a choice. I was so pleased that Nelson Mandela, a remarkable person who had been ill with a chest infection and treated in hospital, went home, with medical help, and was able to die with his family around him. Seventy-three per cent of cancer patients would prefer to die in their own homes. However, only 29% of people with cancer are able to do so. Macmillan estimates that, in 2012, 36,000 cancer patients died in hospital who would have preferred to die at home.
My husband, who would have liked to die at home, died in an A&E department on a Sunday because the out-of-hours doctors would not come out on the Saturday and Sunday. On the Friday evening, when he became ill with a chest infection, which was serious as he had many medical conditions, the out-of-hours doctor came and prescribed a liquid antibiotic as my husband had a swallowing problem. However, I think that she wrote in the notes that he was not too bad. We had to drive for miles to find a supermarket with a pharmacy with the liquid antibiotic. This is the problem with rural healthcare; pharmacies and out-of-hours doctors are miles away. It is much easier to get an out-of-hours vet. With so many medical conditions it would be so much better if the people suffering from them had a copy of their own medical records. My husband died in a hospital 24 miles from home. The doctor could not get any records and had only the information that I could give him. My husband died in the presence of myself, a doctor and a very helpful and kind charge nurse. As it was classed as a sudden death, one had to wait for the police. The chaplain was late. So many people have a real fear that if a loved one goes into hospital they will be neglected.
During this year a young cousin of mine, aged seven, died of neuroblastoma after a two-year amazing battle with this aggressive childhood cancer. His parents did everything possible, including having him treated in America. He had a lovely thanksgiving service at York Minster, with all the children from his class and his headmistress attending. It is good for children to understand that death happens, and so much research is needed to make things better, but there needs to be ongoing support for those who are left behind.
We need mindfulness and compassion from those who have the responsibility of looking after patients at the end. Care for the dying must get better. Life and death are precious and sacred. Many vulnerable disabled people fear that they will be at risk of other people making decisions about their life and death if there is new legislation. It is dangerous as it could be a very slippery slope.
Lord Tombs (CB):
My Lords, I begin by apologising for my late arrival by a few minutes. I came rather a long way and the transport was not quite up to scratch.
I start by saying that I am opposed to assisted dying—as I think is well known—which has monopolised the discussion today, although the debate is rather wider than that and covers other aspects, which I would classify as assisted suicide. I do not think that we should place too much credence on reports of what happens in Oregon. There are good things about the system there and there are bad. One of the more worrying things is the number of fatal doses lying around that country in medicine cabinets, for which there seem to be no clear plans. That is a time bomb waiting to happen.
I think that the objections to assisted dying in particular, but also to assisted suicide, concern the vulnerability of ill people, old people, disabled people, and all sorts of people who require help—help which selfish people can consider a nuisance. My own experience, which is getting quite long now, is that the law is a very blunt instrument. It is designed as such because it has to be for the majority of people, quite rightly, because it is a societal invention and exists because of society. In doing so, it incorporates, because of pressure groups, so many exceptions or variations that it becomes almost impossible to administer.
Baroness Finlay of Llandaff (CB):
My Lords, this has been a double-sided debate. On the one hand, it is about improving services for people in their last months, weeks and days so they have real choices in care—to be home or in a hospice with their symptoms controlled at the medication level they wish, offered any helpful intervention without waiting, with personal care given with respect, time and as they want, and knowing that their family are properly supported.
On the other hand, some propose a licensing system for doctors to supply lethal drugs to patients to deliberately shorten the lives of those who are thought to be dying. That is totally different to providing pain relief while a person dies of their disease. Seale’s research showed that illegal action by doctors in Britain is rare or non-existent. This is not just about the complexities of an individual choosing to end his or her life. There are ramifications for others. It is a matter of both conscience and public safety. Others are directly involved in the suicide, and by normalising assisting suicide an attitudinal change occurs across society. Currently, doctors have a key role in preventing suicide; now they are being asked to go into reverse and facilitate it.
I am afraid that Oregon’s figures do not confirm safety but show an almost fivefold increase in the incidence of reported physician-assisted suicide. That would translate, as has been said, to about 1,200 assisted suicides each year in England and Wales. That means that in Oregon since 2008 there has been a 21% increase in physician-assisted suicide, from 19 to 24 cases per 10,000 deaths. Compare that with the UK, where currently fewer than 20 cases cross the DPP’s desk. Oregon has no audit system to shed light on what is happening there. The dynamic seems to have changed. The Bill of the noble and learned Lord, Lord Falconer, gives eligibility criteria, not safeguards. It seems to be looser than the Bill proposed by the noble Lord, Lord Joffe. The current proposal has no reporting and audit system to detect abuse. Indeed, in Oregon, it was only research that showed that one in six patients who ended their life by physician-assisted suicide had clinical depression that was undiagnosed and untreated. There are also reports of patients being offered not oncology treatment but physician-assisted suicide.
The inquiry by the noble Baroness, Lady Neuberger, into the Liverpool care pathway called for research to improve prognostic tools for the last weeks and days of life. We are very bad at prognosis. The Royal College of General Practitioners has said that we can,
“make reasonably accurate prognoses of death within minutes, hours or a few days. When this stretches to months, then the scope for error can extend into years”.
People are particularly vulnerable when very ill. On call last weekend, I was acutely aware how each patient hung on my every word and gesture, reading into it how I thought things were going. Behind each question was another. The GMC guidelines are absolutely clear—they enable in-depth discussions with patients about their dying or their fluctuating wish for death, and doctors are not frightened today of talking about death and dying. People fear being a burden on family, society or state, or being disempowered by the scandalous care that hits the headlines. The message that proponents portray is that for some the only way in which you have dignity when dying is by assisted suicide, that suffering is inevitable and pain often uncontrollable. That is deeply misleading and creates a great deal of anxiety.
Futile treatment is stopped because it is a burden not a benefit, not to bring about death. However, when a patient asks for help to end it all, the doctor can respond by processing the request at face value, which risks sending a subliminal message that the person would be better off dead; but when I ask, “What is making today so difficult?”, and, “What can I do, however small, to improve today?”, I give the message that, “You are worth me working hard for”. I have to redouble efforts, and rethink and reharness resources to meet the patient’s need to give true choice in care to the person.
A clinician cannot go in two directions at once by striving to improve quality of life and revise and review, while simultaneously booking an appointment for death. Physician-assisted suicide is being placed in the comfort zone of medicine, suggesting to society that it is some kind of therapy. We have heard euphemisms—assisted dying is not really assisted suicide or will not be extended to euthanasia, we have heard. Let us be clear: what is proposed is that Parliament should license an act that is otherwise regarded as criminal. As the Royal College of Physicians has said, a doctor’s duty of care to a patient,
“does not include being in any way part of their suicide”.
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