Assisted Dying for the Terminally Ill Bill [HL]

My Lords, I beg to move that this Bill be now read a second time. The Bill follows previous Bills of the same nature brought forward in 2003, 2004 and 2005. None was proceeded with in order to allow a Select Committee, chaired by the noble and learned Lord, Lord Mackay of Clashfern, to consider the issues. The committee took evidence over nine months in the United Kingdom, the state of Oregon in the USA, the Netherlands and Switzerland and reported in April last year. After the Take Note debate on the Committee’s report, I introduced this Bill, which had its First Reading on 9 November last year. The Bill is modelled on the Oregon Death with Dignity Act, which has been in force in Oregon for eight years and has operated satisfactorily with no credible evidence of abuse. I am pleased to be in a position to say that the Bill is supported by a majority of the members of the Select Committee, including two former Ministers of Health. The Bill would allow a doctor, at the persistent and informed request of a terminally ill patient who has capacity and is suffering unbearably, to prescribe medication for self-administration by the patient in order to end his suffering by ending his life. To judge from the many letters I have received from opponents of the Bill—some adorned with swastikas, and with many references to the Holocaust—it is clear that there has been much misrepresentation about what the Bill permits and much ignorance about what it does not permit. There appears to be a belief among some of those opposing the Bill that it allows doctors arbitrarily to kill terminally ill patients; that it applies to patients without mental capacity—Alzheimer’s being frequently quoted; that the Bill and its supporters are opposed to palliative care; and that it applies to all patients rather than only to terminally ill patients. Nothing could be further from the truth. The current law has the following defects. It results in unnecessary suffering by a significant number of terminally ill patients who are denied the right to end their suffering by ending their lives and the right, as they see it, to die with dignity. It is ignored by some caring doctors who, from time to time, moved by compassion, accede to persistent requests by suffering patients to end their lives. That results in grave risks to those doctors’ careers, reputations and possibly freedom. It is also ignored by loved ones who face a terrible emotional burden when helping with such a request. It places patients at risk of making spontaneous and ill-formed decisions to end their lives. It influences patients with progressive physical diseases to end their lives earlier than they need to, such as Dr Turner, because they fear that at a later stage they may not be physically able to do that. Finally, it results in patients leaving the United Kingdom to die lonely deaths at Dignitas in Zurich, without any legislative safeguards whatever. The Select Committee unanimously concluded in its report that there is a small but significant number of determined patients, generally having strong personalities and a history of being in control, who are unlikely to be deflected from their wish to end their lives by more or better palliative care. As a result of our current laws, these dying patients are forced to suffer therapy against their wishes. Under the law as it stands, helping someone to die, even if that person is suffering unbearably from a terminal illness and has asked the doctor to help him to die, is a crime and is punishable under the common law of murder or the Suicide Act 1961 by a mandatory life sentence, for murder, or by up to 14 years’ imprisonment for aiding or abetting suicide. However, we know that, despite the law, there is a number of patients whose caring doctors assist them to end their lives. Professor Clive Seal of Brunel University, in a study this year, concluded that such cases may amount to a little more than 900 deaths in England and Wales. In the eyes of the law, those compassionate doctors are murderers. In considering whether the law should be changed, regard must be had to a key unanimous finding of the Select Committee that:"““While the most careful account must be taken of expert evidence, at the end of the day, the acceptability of assisted suicide is an issue for society to decide upon through its legislators in Parliament””." Let us start with the experts. There is a strong division among them. For example, the Royal College of Physicians was in favour of neutrality when it gave evidence to the committee but later, after a consultation process, decided to oppose the Bill. The British Medical Association was against the Bill when it gave evidence, but subsequently changed to a position of neutrality. The Royal College of Nurses was against the Bill, but a survey in the Nursing Times found 60 per cent of nurses in favour of the law being changed. As for society, which is the really important matter, public opinion polls over 25 years consistently show that between 71 per cent and 87 per cent—the latter, incidentally, emerging in a poll in the Daily Telegraph—of society supports assisted dying. Marketing Research Services reviewed the surveys for the Select Committee and concluded that they did not form a very useful guide to public support for legislative change, but recognised an apparent groundswell of public agreement for euthanasia that it felt could not be dismissed. My noble friend Lord Moser, who is widely recognised as a leading expert on such surveys, reviewed the same surveys and will outline his conclusions later in the debate. If your Lordships, like me, have been inundated with letters opposing the Bill, you may have thought, ““Perhaps public opinion is against the Bill””. Public opinion surveys show conclusively that that is not the case. The letters come from some of the relatively small number of deeply committed Christian worshippers and are the result of a massive political campaign by the Churches, led by the Catholic Archbishop of Cardiff, which included the dissemination of 500,000 leaflets or DVDs asking recipients, among other things, to write to Peers and MPs to express their opposition to the Bill. The irony is that research and public opinion surveys, including a 2004 NOP survey, have found that about 80 per cent of Christians of all denominations support assisted dying—a disparity on which right reverend Prelates may wish to comment. It is also a source of comfort when receiving those letters that only 1 or 2 per cent, I should imagine, of the 500,000 have responded. The principle underpinning the Bill is one of personal autonomy—the right of each individual to decide for himself or herself how best he or she should lead his or her life. In the NHS, it is called patient choice and is a fundamental principle. It allows patients to request their doctors to desist from further life-sustaining treatment so as to allow them to die, but does not include the right to ask them for assistance to die by prescribing appropriate medication. To many, the distinction between those two cases is invisible. Central to the Bill is that it applies only to terminally ill adult patients who have capacity. An informed decision must be made by the patient. Self-administration by the patient is essential. There is a conscientious objection clause for all health professionals. Voluntary euthanasia and mercy killing are not permitted. More than 20 interrelated safeguards ensure that vulnerable members of society are not put at risk. The process begins with an adult patient requesting a doctor in writing to assist him to die. As I said, there is then an array of safeguards to be traversed, as set out clearly in the Bill and the Explanatory Notes, including examination by and consultation with two independent doctors, one of whom must be a consultant; a reference, where capacity is in doubt, to a psychiatrist; a consultation with a palliative care specialist; and, finally, if the patient persists, a declaration asking to be assisted to die signed before two witnesses, one of whom must be a solicitor or public notary. Only then, and after a minimum of 14 days have elapsed since the initial written request, may the doctor prescribe the medication, after advising the patient once more of his right to revoke the declaration. It is then for the patient to decide when and if to ingest the medication. If he decides to take the medication, the prescribed documentation must be sent to a special monitoring commission set up by the Secretary of State. The committee estimated that if the Oregon experience was replicated here, we might expect 650 deaths in England and Wales out of the 500,000 or so annual deaths. The committee also received evidence that many patients do not take the medication, but that it gives them great reassurance to know that it is available in case they require it. The Bill is very different from the legislation in the Netherlands, which is far more widely drafted; allows voluntary euthanasia; and is not restricted to competent and terminally ill adult patients. Accordingly, the evidence of some developments in the Netherlands is of little relevance to the Bill. On the recommendations in the Select Committee’s report, paragraph 269(b) contains a procedural recommendation that if another Bill of the nature of the previous Bill was introduced, it should, following a formal Second Reading, be sent to a Committee of the Whole House for examination. However, the Bill’s opponents have refused to follow this recommendation, which is why we are here today on this sunny Friday. We have carefully considered the remaining recommendations, all but two of which have been incorporated fully or partially into the Bill. Two recommendations are, however, so contrary to the concept of personal autonomy that we cannot accept them: in paragraph 269(c)(v), ““unrelievable”” or ““intractable”” suffering is preferred to ““unbearable”” suffering; and paragraph 269(c)(vi) proposes that the patient must actually experience palliative care before taking a final decision. As these do not relate to the principles of the Bill, we naturally expect to debate them fully in Committee. I shall now address some of the concerns raised by the Bill’s opponents, all of which are speculation about what might happen, and which can be tested only by reference to the experience of countries where assisted dying is lawful, after making due allowance for differences in culture. It was for this reason that the Select Committee visited Oregon, the Netherlands and Switzerland. I will touch briefly on some of these concerns. We naturally respect the deeply held convictions of all those who share a concern about the sanctity of life. The Bill does not seek to interfere in any way with the belief and conduct of those who oppose it, but I question the right of those who object on faith grounds to seek to impose their beliefs on those who do not share them—the overwhelming majority of society. There are two components to the slippery slope argument. One is that, by starting with a small number of deaths, assisted dying will gain momentum until the number has multiplied many times over. In Oregon, out of approximately 30,000 deaths each year, there were only 38 assisted dying deaths in 2002, 42 in 2003, 37 in 2004, and 38 in 2005. Nothing could demonstrate more clearly that there has been no slippery slope in Oregon. As the Bill remains comparable to, but with even more safeguards than, the Oregon legislation, there is no reason to fear that there will be a slippery slope over here. The second component of the slippery slope argument is the fear that the limits of the Bill will be tested in practice so that more and more patients are brought within its remit. This has not happened in eight years in Oregon, and there is no sign of it happening. All the committee and all the supporters of the Bill strongly support the provision of more and better palliative care. On our visit to Oregon, it was reassuring to note that palliative care has flourished there since the introduction of assisted dying legislation. The number of patients who use hospices increased from 2,000 in 1988 to 15,000 in 2005 and, according to the evidence that we have received, the expansion was probably accelerated by the legislation, rather than the reverse. There is no reason to believe that palliative care will not significantly increase and improve if the Government provide the necessary funding. Lack of funding, not the introduction of assisted dying, will be the constraint on development. The potential danger of assisted dying to vulnerable members of society has simply not emerged in Oregon. There is no credible evidence of any abuse; Ann Jackson, director of the Oregon Hospice Association, confirmed this to Members of both Houses only last month. As for the concern about decreasing trust in doctors, if between 71 per cent and 80 per cent of the public are in favour of assisted dying, it is difficult to follow the argument that they should lose trust in their doctors for doing what they are actually in favour of. A YouGov survey in November 2004 found that 83 per cent of patients would trust their doctors the same or more if there were assisted dying legislation. It will be clear to the House that the coverage of the present Bill is more tightly drawn and restrictive than the earlier Bill considered by the Select Committee, dealing as it does only with assisted dying and explicitly excluding any form of euthanasia, whether voluntary or otherwise. So in some ways it is climbing up the slope rather than descending down it. In that context, I shall make my personal position clear. When I gave evidence to the Select Committee about the original Bill, I expressed my personal conviction, which was honestly held at the time, that I would welcome a widening of the scope of the legislation. I no longer hold that view. One of the advantages of the Select Committee process was the opportunity to see different regimes in operation, and to hear a wealth of evidence from those who have thought deeply about the issues and are intimately involved in them. At the end of the process, it is now my firm view that the extent of legislative change that I put before the House today, which we shall now contemplate and should broadly welcome, will have the most advantage and carry the least risk. I would not support further extension into the field of euthanasia, or support assisted dying for patients who are not terminally ill. Others, of course, may have different views, but after three years of legislative effort on the subject, I have no intention of pursuing this issue beyond the ambit of the present Bill. As detailed Explanatory Notes have been made available in the Printed Paper Office, and as I have already outlined the key provisions of the Bill, I shall touch only briefly on two specific issues, the first of which is Clause 1(a)(ii), which authorises assisted dying. The great majority of patients will end their lives by orally ingesting the prescribed medication, but provision is made in this paragraph for the small number of patients—we estimate perhaps 5 per cent—who are unable to swallow, such as some motor neurone disease patients, to be provided with the necessary means for them to end their lives. The clause would enable the patient to self-administer by, for example, pouring the medication into their feeding tube. The key point about self-administration, as set out in paragraph 246 of the Select Committee’s report, is that responsibility for the ultimate act rests with the patient. I give early notice of two amendments to the clause which I propose to move in Committee. These were drawn to my attention by opponents of the Bill, for which I thank them. I now realise that, by including ““or appropriate”” after ““impossible””, I have opened up the possibility of the doctor interpreting the provision of means exception too widely, and I intend to seek to delete the words ““or appropriate””. To set the matter beyond any possible doubt, I also intend to include an explicit prohibition against ending a patient’s life by lethal injection or act of euthanasia. I also draw attention to Clause 14(2)(d), which would enable the Secretary of State to provide a code of practice for the guidance of doctors and others acting in accordance with the Act. This code would cover, inter alia, the prescription, dispensing and control of the medication and the provision of the means of self-administration. In conclusion, I would underline that the Bill is modelled on the Oregon legislation, which has been operating satisfactorily for eight years. The noble Earl, Lord Arran, who visited Oregon as a member of the Select Committee, will be dealing in detail with the evidence given in Oregon. As a caring society, we cannot sit back and complacently accept that terminally ill patients who are suffering unbearably should simply continue to suffer for the good of society as a whole. We must find a solution to the unbearable suffering of patients whose needs cannot be met by palliative care. The Bill provides that solution, in the absence of any other, and, based on the successful model in Oregon, we can move forward on this sensitive matter with confidence, secure in the knowledge that the Bill would not impose anything on anyone; it merely provides an additional end-of-life option for terminally ill patients, which they are free to accept or reject as they, and only they, decide. I commend the Bill to the House. Moved, That the Bill be now read a second time.—(Lord Joffe.)