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House of Lords

Friday, 6th June 2003.

The House met at eleven of the clock: The LORD CHANCELLOR on the Woolsack.

Prayers—Read by the Lord Bishop of Chester.


Lord Grocott: My Lords, before we begin today's debate, I want to offer the House the usual arithmetic on the speakers' list. If everyone were able to restrict their speeches to six minutes, the House would rise at around 5.30 p.m. If they were to be able to restrict their speeches to around seven minutes, we would be about 50 minutes to an hour on from that—let us call it 6.30 p.m. Should they be 10 minutes, it would be 8.30 p.m., and I leave noble Lords to work out the arithmetic thereafter. I have had pressure from people asking me to point out that six-minute speeches would mean a 5.30 p.m. conclusion. Of course, the debate is not time-limited, and no one is in a position to impose anything.

A number of people have asked me to reiterate the requirement of the Companion that we always print at the start of the speakers' list, which is as follows:

    "Members who become aware in advance that they are unlikely to be able to stay until the end of the debate should remove their names from the list of speakers".

That is one reason why I thought it important to spell out the time scale.

Lord Cope of Berkeley: My Lords, in supporting the Captain of the Gentlemen-at-Arms in what he said, I should tell the House that my noble friends Lady Trumpington and Lord Elton have withdrawn their names from the speakers' list for exactly that reason.

Patient (Assisted Dying) Bill [HL]

11.7 a.m.

Lord Joffe: My Lords, I beg to move that this Bill be now read a second time. As the debate is expected to last for somewhere between seven and nine hours, I may have to slip out of the Chamber for a few minutes from time to time, but the noble Viscount, Lord Craigavon, has agreed to hold the brief in my absence. I must also apologise in advance for not setting a good example on time-keeping, in that I will speak for 20 minutes.

The Bill enables a competent adult who is suffering unbearably as a result of a terminal or a serious, incurable and progressive physical illness to receive medical help to die, at his own considered and persistent request. It also makes provision for a person suffering from such a condition to receive pain relief medication. At the outset, I would like to emphasise that central to the Bill are the following: a voluntary

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and persistent request by a competent adult to a doctor; unbearable suffering from a terminal or a serious incurable and progressive physical illness; and an informed decision by the patient, which he can withdraw at any stage.

I underline that the Bill does not cover assisted dying by relatives or friends, nor does it apply to incompetent individuals. Although it complies with the European Convention on Human Rights, it does not rely on it. Under the law as it stands, helping someone to die, even if that person is suffering unbearably from a terminal illness and has asked a doctor to help them to die, is a crime under either the common law or the Suicide Act 1961, which makes it an offence punishable by up to 14 years' imprisonment to aid or abet suicide.

The law has the following defects. It results in grievous, prolonged and unnecessary suffering to a significant number of patients, who are denied the right to remain in control of their lives until their death, and the right, as they see it, to die with dignity. It is ignored by many caring doctors who, moved by compassion, assist their patients to die, which results in grave risks to those doctors' careers, reputations and possibly freedom. It places patients at risk of making spontaneous and ill-informed decisions to end their lives. It influences patients with progressive physical diseases to end their lives earlier than they need to 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 in Zurich and perhaps elsewhere, without any safeguards.

The purpose of the Bill is to provide the solution to those disturbing consequences in a way which will not place vulnerable members of society at risk, nor compel doctors or other members of medical teams to participate in processes to which they have conscientious objections. The Bill seeks to achieve that purpose by changing the law so as to add to the freedom that patients already have to commit suicide, or to refuse medical treatment which could save their lives, the freedom to ask a doctor to bring their suffering to an end by assisting them to die at a time of their choosing. That is the single change proposed by the Bill. If during the debate other and better solutions emerge, I will welcome them and seek to amend the Bill to include them.

The case of Diane Pretty illustrates the unbearable suffering to which patients may be exposed, and why they may wish to end their suffering. I quote from the judgment of the noble and learned Lord, Lord Steyn, delivered on 29th November 2001:

    "She is paralysed from the neck downwards. She has virtually no decipherable speech. Her life expectancy is low. She has only months to live. Yet her intellect and her capacity to make decisions is unimpaired. She wishes to be spared the suffering and loss of dignity which is all that is left of her life for her. She wishes to control when and how she dies".

He went on to say that the disease deprived her of the opportunity to commit suicide and, accordingly, she wished that her husband should assist her to do so.

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The court, although sympathetic to Ms Pretty's predicament, found that under the law as it stands it could not come to her assistance. Similarly, an appeal to the European Court of Human Rights failed. Diane Pretty sought to have her husband assist her to end her life, whereas the Bill is limited to only assistance to die from doctors, which I know that Diane Pretty would have preferred if it had been lawful.

After returning from Strasbourg, Diane Pretty was admitted to the hospice that had cared for her previously. Although she was given excellent palliative care, she remained in considerable pain and distress until she died four weeks later, in the way she did not want. Last year, Reginald Crew, who also suffered from motor neurone disease, eventually reached a stage where he was paralysed from the neck downwards. The next inevitable stage in his illness was that he would lose the ability to communicate. Unable to face that inevitability, and unable to obtain help to die in the UK, he went to Zurich with his wife's assistance—although in so doing she exposed herself to a possible sentence of 14 years' imprisonment. With the minimum of safeguards, he was given a cocktail of drugs and died painlessly. Sadly, others have already followed him to Zurich and inevitably there will be more.

I do not wish to regale your Lordships with a catalogue of further tragic cases, but the Danny Bond case illustrates why it is necessary for the Bill to include cases of serious, incurable and progressive physical illnesses, in addition to terminal cases. Suffering from a bowel complaint from birth, Danny endured more than 300 operations and uncontrollable pain in the 21 years of his life. Unable to obtain assistance to die, after two failed suicide attempts, he starved himself to a harrowing death as his body disintegrated. I should add that Diane Pretty, Reginald Crew and Danny Bond all had palliative care and a loving, caring family, before they reached their decisions to seek to end their lives.

The law as it stands does not accord with the views of the overwhelming majority of the population. Public opinion surveys consistently show that more than 80 per cent of the public believe that the law should be changed to allow terminally ill people the right to receive medical help to die, if that is what they want. The case for a change in the law is based on personal autonomy—the right of each individual to decide for himself or herself how best he or she should lead their lives. However, there is one fundamental limitation to the autonomy of individuals when making a decision on their own life, which is that they must not in so doing indirectly harm other members of society. Recognising this, the Bill contains many safeguards to ensure that the vulnerable are protected.

Another important reason why legislation is required is that ending the lives of patients with, or indeed without, the consent of the patient already takes place on a considerable scale in the United Kingdom, despite the law. In 1996, a British Medical Association news review survey of more than 750 GPs and hospital doctors found that 3 per cent of the

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doctors had ended the life of a terminally ill patient where the patient had made a request for help to die. Other surveys show similar results.

It is impossible with any certainty to quantify the extent of doctors helping their patients to die with or without their consent, because the UK Government, unlike the Dutch and Belgium Governments, have refused to commission research into the subject. However, we know from a report in the Lancet in November 2000 that in Australia and Belgium, where, as in England, helping seriously ill patients to die even with their consent was a crime, such deaths accounted for in excess of 1 per cent of all deaths. Furthermore the percentage of deaths which were as a result of the patient's life being ended without their consent was in excess of 3 per cent in both those countries. Bearing in mind that similar methodologies were used and that standards of medicine in both these countries are not unlike those in the UK, it is reasonable to deduce that similar results may be found in the UK. If that were so, it could mean that as many as 8,000 patients each year were being assisted to die by doctors with the patient's consent, and, perhaps, 18,000 without their consent.

Despite many lives of patients being ended with or without their consent, there are only a handful of prosecutions each year. That demonstrates that there is a large gap between what the law says and what happens in practice. While there can only be speculation about the number of such cases, it is clear that such a practice should be properly controlled. Doctors will be protected by such controls from taking grave risks with their careers by following the processes contained in the Bill. Patients will be protected against rash and spontaneous decisions to end their lives.

In the past, it was accepted that the medical profession knew best, and it was left to the doctor to decide whether a patient's life should be ended. However, these days it is a decision that only the patient can make after considering the views and advice of the doctor. We must ensure that the patient's right to autonomy must not be defeated by the personal values and emotions of the particular doctors in whose care they are either fortunate or unfortunate enough to be. On the other hand, we naturally respect the deeply held convictions, beliefs, values and concerns of many members of the medical profession, and accordingly Clause 6 of the Bill contains a conscientious objection clause.

I shall touch on some of these concerns. Some believe in the sanctity of life and that only God who creates life can take it away. I respect the right of those who believe that personally to behave in accordance with their beliefs. However, I do not believe that they, who are in a small minority, should seek to impose their beliefs on the overwhelming majority who do not share them. Others rely on the "sanctity of life" principle as a basic tenet of our law. However, there are already several exceptions to that tenet, including the right to kill both the military and civilians in war—as we have seen recently; the right to kill in self-defence; the freedom to kill oneself; and the right of doctors to withdraw treatment from incompetent

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patients in hopeless cases. Yet others argue that good palliative care will control the pain and suffering of those dying so that everyone can die with dignity and without suffering. It is clear that quality palliative care—provided that it is available and often it is not—is preferred by the majority of patients.

But for others that is not the solution. It is important to appreciate that pain is not the main reason for most patients asking for help to die. The majority of such requests come from people who are suffering because they cannot bear the indignity of total dependence on others, of lying inert in their beds, possibly with tubes inserted into them, or of being doubly incontinent. Such people see no purpose in prolonging a life that has no quality, when all they have to look forward to is more hopeless suffering.

In that regard, it was acknowledged by the National Council for Hospices and Specialist Care Services, in its sensitive 1997 paper opposing euthanasia, that,

    "universal availability of excellent palliative care services will not and can never eliminate all rational and persistent requests for euthanasia".

Those requests come from patients who would prefer to be assisted to a gentle death and to be remembered by their loved ones as they were before the throes of death.

Another concern is that of the slippery slope—of the door being opened and assisted dying increasing rapidly and being extended to other areas such as people who are incompetent, those who are disabled and those who are mentally ill. In the Netherlands and Oregon, where assisted dying has been permitted for a considerable time, there is no evidence of a slippery slope, as confirmed by the third Remmelink report which came out just last week. Equally important, this Bill applies only to competent adults suffering unbearably from a terminal or incurable physical disease. It would require new legislation to enable any further extension to what is contained in the Bill. That would be a matter for future legislators.

The Government, despite the views of the overwhelming majority of the electorate, have so far evaded the issue of a change of law by relying on the findings of the Lords Select Committee on Medical Ethics published in 1994. It is now close to 10 years since the Select Committee began its deliberations on a wide range of issues of which the subject matter of this Bill was only one. A great deal has changed since that report. Patient assisted dying was legalised in Oregon five years ago and in Belgium last year. Surveys of UK doctors since the report show that a considerable number of doctors are helping their patients to die despite the law. And the system in the Netherlands which caused such concern to the Select Committee is now operating satisfactorily, although reporting by many doctors clearly needs to be improved. The system itself has the support of the overwhelming majority of the Dutch population and Dutch doctors as we found when we visited the Netherlands earlier this year.

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The Select Committee, in arriving at its decision, was rightly concerned about safeguards. Learning from that, the Bill includes a range of safeguards which I believe meet its concerns and which I shall now touch upon. The most important safeguard is that it is only a doctor who can assist a patient to die. Doctors are committed to saving life rather than ending life. There is almost nothing they desire less than to help their patient to die. So their starting point in considering a request to help a patient to die would instinctively be: what can we do to help the patient live? In that respect, I share the view, set out in paragraph 272 of the Select Committee report, that,

    "by virtue of their vocation, training and professional integrity they"—


    "may be expected to act with rectitude and compassion".

My Lords, allow me to explain the safeguard process to you. It begins with the patient requesting the doctor attending him to assist him to die. The patient must be over the age of 18, be competent and be suffering unbearably from a terminal or a serious, incurable and progressive illness. The doctor would then examine the patient and satisfy himself that those conditions were met. He would discuss with the patient his diagnosis and prognosis, and the alternatives including palliative and hospice care, and satisfy himself that the patient's request was not the result of external pressure.

A patient persisting with the request would be referred to a consultant physician who would independently go through the same process as the attending doctor. If either of the doctors has doubts about the competence of the patient, he must be referred to a psychiatrist. Before the patient can be helped to die, he must complete a statement confirming his request in the presence of two witnesses, one of whom must be a solicitor. That could be revoked at any time by the patient.

Before the request can actually be acted on, there is a waiting period of seven days where the illness is terminal, and 30 days where it is a physical, incurable and progressive illness. At the end of the period, if the patient still wants help to die, the doctor must discuss with him once more his decision, and again inform the patient of his right to revoke his request. Further safeguards require the attending doctor to recommend to the patient that he notifies his next of kin of his request. No member of the medical team or witnesses must have any financial interest in the patient's death. A further and final safeguard is the requirement of the attending doctor to document the process and send all the medical records to a special monitoring commission set up by the Secretary of State.

The Joint Committee on Human Rights, which considered the Bill in its seventh report, published on 21st March 2003, concluded:

    "In our view, the safeguards set out in the Patient (Assisted Dying) Bill would be adequate to protect the interests and rights of vulnerable patients. They would ensure that nobody could lawfully be subjected to assisted dying without his or her fully informed consent".

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As detailed Explanatory Notes are available in the Printed Paper Office and having already outlined the safeguards which are the essence of the Bill, and as time is moving on, I shall touch only briefly on two specific clauses. In relation to the schedule and Clause 3(2), the noble Lord, Lord Mishcon, has drawn to my attention that the responsibilities placed upon solicitors as witnesses are too widely drawn. I have undertaken to narrow those by amendment in Committee.

Clause 14 of the Bill entitles a patient to request and receive such medication as may be necessary to keep him free as far as possible from pain and distress. This provision is included for two reasons. First, there is much anecdotal and research evidence that many patients are not being given the drugs that would adequately control pain and suffering. Secondly, there are concerns that recent appeal court cases raise doubts about the lawfulness of doctors relying upon the doctrine of double effect, and suggest that doctors who foresee that their palliative care will shorten life may now prima facie be liable for murder.

In summary, we have laws in place which clearly are out of tune with the views of the majority of the population. They are laws which cause profound and unnecessary suffering to many people. They are laws which offend against the principle of autonomy. They are laws which place both patients and doctors at risk. Furthermore, they are laws which do not adequately prevent the offences they are intended to prevent. The purpose of this Bill is to change the law in the interests of patients, doctors and society as a whole. I commend it to the House.

Moved, That the Bill be now read a second time.—(Lord Joffe.)

11.27 a.m.

Baroness Howells of St. Davids: My Lords, I congratulate the noble Lord, Lord Joffe, for having instigated this debate and for the very feeling way in which he made his presentation. My postbag, like that of other noble Lords, has been bursting with letters on this matter. From the long list of speakers, there can be no doubt about the merits of the debate. The Bill is concerned with a very vulnerable phase in our life cycle—when one no longer has the will to live—and the desire for a change in the law to facilitate a termination. I understand those feelings.

I intend to speak purely from the perspective of a black person. That perspective is of one who is a participant but most often in the role of victim in that laws are made which are meant to serve the whole community but have a negative effect on those for whom it may be thought to be best. I make no claim to scientific objectivity or to any objectivity at all. As black people we are forced into a state of double consciousness, looking at ourselves through the eyes of others. I feel that the privilege of being in this House gives me the right to say what I am about to say.

My belief about the profound injustice that will result by introducing the Bill into law is based on the notion of institutional racism, which we all know

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pervades our society. Institutional racism reduces choice. When coupled with cuts in welfare and safety, that presents a dire view of the future. As the noble Lord, Lord Joffe, said, the proposals offer clear advantages for a very small segment of society, but their consequences for the black community are not pleasant to contemplate.

I believe that if the Bill were enacted it would undermine the financing and provision of proper geriatric and palliative care, and that the real victims would predominantly be the most disadvantaged members of society—black people. I truly fear that mistakes in the case of those people would rarely come to light and, even if they should, those mistakes could never be rectified and would merely join the ever increasing instances of deaths in custody and of those killed by a person or persons unknown.

Leaving aside that wrongful execution of an innocent man or woman cannot be reversed, a real fear is that any suffering patient who feels that he is a burden to carers or to society is particularly vulnerable under the Bill. The Bill strikes me as having too many practical limitations to be able to police the impossible boundaries of voluntary and involuntary euthanasia.

The definition proposed for an "irremediable condition" that is not likely to be cured by medicine is stated to be either a terminal or a serious condition. The term "serious condition" is dangerously wide in scope. What may be considered incurable today may be curable tomorrow. Many misdiagnosed black males find that natural medicine restores their systems to good health and they live productive lives to a ripe old age.

The duty on the attending and consulting physicians to police whether external pressure has been brought to bear comprises a tremendous task that requires more than mere medical ability. Add to that race and we are asking doctors to stray into areas of psychic abilities. For solicitors to decide whether the patient has understood the seriousness of the declaration is a life or death task they are not qualified to undertake.

There are too many unanswered questions. How much power is the monitoring body to have? How much funding will such a body receive? Will it be multiracial and multicultural? Is it possible to cover all diversity on such a committee? Is it possible to ensure that all acts of euthanasia will be truly voluntary and that liberalisation of the laws will not be abused? I do not think so.

Even if someone wants to die, that may well be due to undiagnosed mental health problems. With one in four of the UK population experiencing mental health problems in any single year, the danger cannot be underestimated. That figure is on the increase and I wonder how those undiagnosed people can be protected under the Bill. Are we asking the very same sick people who are contemplating suicide to declare that they are of sound mind? The liberalisation of drug laws and the research that suggests a direct link between the use of those drugs and mental illness does not sit comfortably with the arguments for assisted dying.

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It is the responsibility of government to place on the statute book suitable constraints in the law to allow justice to operate most fairly. Suicide in any form is devastating for the people left behind, and for government to support suicide would be devastating for us all.

11.34 a.m.

Lord St John of Fawsley: My Lords, it is a privilege to follow the noble Baroness, Lady Howells of St Davids. I did not think that anyone could raise a new point in this long-running debate but she has done so, and it is a point which must be considered in detail later in our proceedings.

It is a tribute to the importance of this subject that so many of your Lordships have put down their names to speak. I realise, however, that that means a constriction of time. This is not the moment to imitate St Patrick, who is alleged to have preached for three days and three nights without ceasing, although it is not said whether it was to the same audience. Nor is the example of my great predecessor as Master of Emmanuel, Lawrence Chadderton, one to be followed. Having preached for five hours he announced his intention of drawing his remarks to a close, whereupon the whole congregation rose and said, "For God's sake no sir, go on".

I thank the noble Lord, Lord Joffe, for giving us an opportunity to debate this issue in such a forum. I congratulate him on the restrained and irenic manner in which he spoke. This issue is of transcendent importance—life and death. Its end is just as important as its beginning. I remember when Cardinal Hume was abbot of Ampleforth a lady with boys attending the school congratulated him on preparing boys for life. He replied, "No, madam, we prepare our boys for death".

We do not want vituperation in this debate; we leave that to others. I hope that I may define my own position and declare my own interest, which is membership of the Catholic Church. Catholics have many different points of view on different issues and they have been frequently wrong on issues from the Fourth Crusade onwards. But there is one point of consensus on which we are all agreed and that is the sacredness of human life from conception to dissolution. I was impressed by the tribute paid by a non-Catholic MP to Cardinal Murphy-O'Connor when the latter addressed a meeting in Speaker's House. The MP thanked the cardinal for his witness on the value of life.

I describe myself as a liberal Catholic in the tradition of the great Lord Acton. I voted for all the historic reforms of the sixties with the single exception of abortion. I was one of a handful of Conservatives who voted against the Labour government's proposal to remove the rights of East African Indians to their full British passports. I therefore speak not, I think, from prejudice but from principle. I stress that the basis of a civilised society is to live together in peace and fraternity respecting certain moral values. You cannot separate morals and the law. "No bishop, no king"

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came to us in the 17th century, "no morality, no law" would be appropriate for us to reflect on in this. I hope, therefore, that we shall listen carefully to the leaders of the Churches and other communities on this issue.

But we cannot conclude tout court that if conduct is immoral, it therefore should be legislated against, and that is true of euthanasia. Its legitimacy has been discussed over the centuries but the contemporary debate has been stimulated by one of the great achievements of our age—the conquering of illness and disease so that life expectancy has been dramatically increased. This has been a substantial blessing. Life, after all, is an uncovenanted gift, and if one can extend its scope and span, the possibilities for happiness, achievement and service are proportionately increased. But one would be shallow indeed if one failed to see the very real problems that face us as a result of prolonging life. If people survive longer, many of them will do so in a state where their powers and faculties have wasted away, making it an existential question of whether life is still worth living.

Hence the Catholic Church has modified its position in two vital ways. Pius XII, in an address of 1957, drew the vital distinction between using ordinary and extraordinary means to prolong life, the first being obligatory and the second not. That answers some of the points made by the noble Lord, Lord Joffe. Lord Hordor made the same point even more succinctly:

    "The good doctor will be able to distinguish between prolonging life and prolonging the act of dying".

That is why the Royal College of Physicians and the BMA are so strongly opposed to the Bill.

The second modification is the principle of double effect. The Catholic Church makes a clear moral distinction between giving drugs to relieve pain, which may incidentally shorten life, and giving drugs with the intention of killing the patient. Those are two totally different situations.

There are many other practical considerations that we have to consider in this matter: self-deception and, above all, the state of mind of an old and sick person. Old people often feel that they may be a burden to their relations and once euthanasia is a possibility, they would be constantly wondering whether they should avail themselves of that option.

I conclude by repeating my belief that legalised euthanasia is a shortcut, offering facile solutions to problems of the highest complexity. Relief from physical pain is important to the dying. Even more important is the need to assuage the inner misery and loneliness of the dying patient. Dying people want more than anything else to avoid the sense of being written off. The final stage of an incurable illness can be a vital period of a person's life, reconciling him or her to life and death and giving an interior peace. To achieve that needs intense loving and tactful care and co-operation between relations and medical attendants. That painstaking, conscientious and constructive approach to the dying is more human and more compassionate than that of those who, however compassionate their motives, wish to snuff that life out.

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11.43 a.m.

Lord Lester of Herne Hill: My Lords, I, too, congratulate the noble Lord, Lord Joffe, on introducing this well-constructed Bill. My qualifications for speaking come from my professional experience as counsel in complicated and difficult cases such as those of Tony Bland and Annie Lindsell, which involved ethical questions about the law and medical practice in this area. I am also a member of the Joint Select Committee on Human Rights that, as your Lordships heard, has considered the Bill already.

Like all my noble friends on these Benches and indeed across the House, I am speaking in an entirely personal capacity and not in any party sense. There are divisions within and across all parties on these issues.

In view of the extreme propaganda and the overheated lobbying to which we have all been subjected in past weeks, I recall the wise words of a great American judge, who said

    "the spirit of liberty is the spirit that is not too sure that it is right".

That is an apt reminder of the need to avoid any excess of moral certitude or zealousness.

There is much more common ground than those who argue from dogmatic premises admit. We would all agree with the decision made by Parliament in the Suicide Act 1961 that suicide should no longer be a crime. Most of us would surely agree with the further decision made in that Act to retain the criminal offence of aiding or procuring suicide so as to protect the weak and vulnerable and deter the wrongdoer, even when the wrongdoer acts on what he or she thinks conscientiously to be right. We would surely all agree that terminally ill patients have the same rights to healthcare as any other group of patients, without discrimination on any ground, including race, gender, sexual orientation, disability or age. I say that particularly in light of the speech of the noble Baroness, Lady Howells.

We would all agree that a patient of sound mind should be able to refuse medical treatment even if that hastens death and that doctors and nurses should not be under any duty or coercive pressure to do anything to which they have a conscientious objection. We would all agree that the law should provide a clear and effective framework to prevent a slide towards involuntary euthanasia. And we would all agree that there must be effective safeguards against criminal wrongdoing and unethical medical practices.

The central question raised by the Bill is whether the law should be changed to enable a competent adult who is suffering unbearably as a result of a terminal or serious progressive physical illness to receive medical help to die at his or her own considered and persistent request. The answer to that question depends on answering some other questions. First, what is the current state of the law and is it clear? Secondly, what are the ethical issues that underpin the law? Thirdly, what is the nature and extent of the practical problems that the Bill seeks to tackle? Fourthly, are the Bill's safeguards adequate to prevent and deter abuse,

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whether by violating the patient's right to life, the personal autonomy of the patient, or the conscientious beliefs of the medical and nursing professions?

Reasonable legal certainty is especially important where a patient is suffering from a terminal illness and facing the prospect of experiencing severe suffering and indignity. Patients have the right to life. They also have the right to personal autonomy and to live and die with dignity. They and their doctors need to know what exception there is to the law of homicide, enabling a doctor, acting in accordance with the patient's wishes and the doctor's judgment as to the appropriate medical treatment, to administer that treatment, even though it is virtually certain that it will hasten the patient's death. Unless the criminal law and good medical practice are clear, conscientious doctors, seeking to act in the best interests of their patients, are left in a state of uncertainty, as are their patients.

Some matters are clear. There is no doubt that the intentional taking of life, albeit at the patient's request, or for a merciful motive, is unlawful. For a doctor to intervene actively to bring about a death is unlawful. Equally, a doctor who owes a duty of care to a patient and withdraws or withholds treatment without lawful excuse commits an unlawful act. It is also clear that a competent adult has the right to consent to or to decline medical treatment, even if the decision would result in the patient's death.

The problem with the existing state of the law is for the doctor to know what can lawfully be done to relieve suffering towards the end of a patient's life without fear of prosecution. One difficult problem concerns the relationship between intention and foresight in deciding whether a doctor has a criminal intent. In deciding whether there is the mental element necessary for murder, foresight of the consequences is evidence of the existence of a criminal intent. The greater the probability of death as a consequence, the more likely it is that it will be treated as having been foreseen and the greater the probability that it will be treated as having been intended.

As the noble Baroness, Lady Andrews, pointed out at Second Reading of the Patients' Protection Bill, in criminal law, when juries are asked to consider "intent", factors that they may be asked to take into account include the probability of the outcome and the extent to which that was appreciated by the defendant even if they were not the defendant's main intention. The noble Baroness said:

    "Therefore, if a doctor knew, as a virtual certainty, that withholding or withdrawing treatment"—

or, I would add, "giving treatment"—

    "even at the patient's request, would result in"—

or, I would add, "would hasten"—

    "the patient's death, the doctor could still be held to have positively intended the patient's death".—[Official Report, 12//3/03; col. 1433.]

When a doctor acts in accordance with what he considers to be responsible medical practice, with the aim of relieving pain or severe distress but with the virtually certain consequence of hastening the patient's death, the risk to the doctor is that the jury,

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as directed by the judge on currently declared legal principles, will impute the necessary specific intent to find the doctor guilty of murder, and the judge will have to impose a mandatory sentence of life imprisonment.

The humane Catholic theological doctrine of double effect, which has already been explained by the noble Lord, Lord St John of Fawsley, attempts to provide a justification for administering drugs that are necessary for the relief of a patient's pain or severe distress in the knowledge that a probable consequence is the shortening of the patient's life. The noble Baroness, Lady Warnock, whose speech I greatly look forward to, explained clearly the moral and logical difficulties of that doctrine. It is also problematic from a legal standpoint. Reference to double effect and primary intent does not explain the scope of the defence of lawful justification or excuse, and it risks confusing motive and intention. The present legal uncertainty is compounded by the absence of clear published guidance as to the policy of the prosecuting authorities.

The absence of a proper legal framework and the risk of prosecution undoubtedly deter some doctors from treating their patients in accordance with the patients' wishes and the doctors' conscientious beliefs. That is why, like the noble Lord, Lord Joffe, I believe that the time is ripe to give statutory authority to the administration of palliative care in limited circumstances, so that it is clear that doctors are entitled to do all that is proper and necessary to relieve pain and suffering and to permit a patient's life to end peacefully and with dignity, provided always that they comply with the rigorous safeguards set out in the Bill.

The 7th report of the Joint Select Committee on Human Rights, which is in the Printed Paper Office, explained the medical, legal and moral issues as we saw them, why we considered that the Bill as drafted is compatible with human rights and why we considered the safeguards to be adequate to avoid arbitrariness and protect vulnerable patients. As has been said, doctors and nurses must act only in accordance with their conscientious beliefs, and the Bill provides for that.

Given the many safeguards in the Bill, why has it aroused such passionate opposition from some quarters? I believe that the answer lies deep in the human condition and psyche. When they think about it, most people have a terror of death or at least a fear of dying. A Bill such as this compels us to contemplate our own death and whether we wish to be able to die with dignity and at a time of our choosing. Statements about the absolute sanctity of human life may involve an unconscious denial of death. This brave Bill does not deny the inevitability of death. It affirms the sanctity of life while acknowledging that there are other fundamental values that deserve our respect and compassion. I hope that the House will give the Bill a Second Reading.

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11.54 a.m.

Baroness Finlay of Llandaff: My Lords, this important debate is driven on all sides by compassion. I speak as a professor of palliative medicine and recently a visiting professor at Groningen University in Holland. However, I fear that the Bill is too broad and does not provide adequate safeguards. My remarks are based purely on my clinical practice.

The Bill fails to increase true patient choice and increases vulnerability of patients and the power of others over them. It requires unbearable suffering to persist, yet suffering cannot be objectively measured.

The Select Committee on Medical Ethics concluded, as has already been mentioned, that adequate safeguards around euthanasia and its oral form—assisted suicide—could not be put in place. One cannot have assisted suicide without also having euthanasia; when assisted suicide fails, someone has to rescue the patient who wakes up. All the evidence emerging from Holland, Belgium, Oregon and Australia supports the fact that one cannot have adequate safeguards. Involuntary and non-voluntary ending of patients' lives has increased and in Holland some now call for total deregulation. I find worrying the situation involving Dignitas in Switzerland.

The Long Title of the Bill makes provision for pain relief medication. However, good symptom control is legal. Morphine and similar drugs titrated up for pain control, and even sedatives in the terminal phase of illness, do not shorten life. There will always be a last dose but it is the disease that has killed the patient. One does not need to kill the patient to kill the pain. The Dutch use a barbiturate overdose, often combined with curare, to cause death, which results from not breathing, by asphyxia.

What is a serious incurable progressive physical illness? That includes almost any illness: diabetes, angina and emphysema to name but a few. However, prognosis prediction is notoriously difficult—at best, it is an inspired guess; it is not an exact science.

I fear that autonomy is illusory. Choice is influenced by one's understanding of the options and how they are put to one—it is not free. The Bill requires that patients are informed and understand the options. However, you do not know what something is until you experience it. Informing a patient of palliative care is inadequate. Many patients have been reluctant to go to a hospice yet are amazed how much their quality of life could improve and their despair be lifted. About 300,000 per annum who would benefit cannot access such care.

In 1990, a 35 year-old father of three was referred to me because his GP and two consultants said that they could not give him a lethal injection. He fitted all the criteria of the Bill completely. A malignant, incurable spinal tumour was making him paraplegic. Overwhelmingly distraught, with a prognosis of around three months, he could not enjoy his new baby. I saw him on Monday. He works from his wheelchair caring for his three children, because his beautiful wife

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died eight months ago of pancreatic cancer, glad now that no one could comply with his request, which was made in deepest despair.

Unbearable suffering is a totally subjective, multi-faceted experience. It cannot be defined, quantified or assessed. Clinical services should deal with physical problems but, even for that, care is sadly often inadequate. However, those who describe overwhelming suffering have major concerns in emotional, social and existential domains. That requires a different approach, and research into the support that people really need is in its infancy.

Insensitive, hurried care makes suffering massively worse. A desire for death seems to relate to fears about pain, future pain and suffering; fear that good care will not be available when needed; tragic experiences of inadequate, insensitive care; anger at loss of control as disease has snatched health and plans for the future; and social death when a person's role in life and relationships are lost as if they had already died. The Bill does not address temporary unbearable suffering. The desire for death is known to fluctuate with time. Persisting requests with good sensitive care are almost vanishingly rare.

No one wants to be a burden to those one loves. A sense of a duty to die is all too easy to create and all too difficult to detect. Some Dutch doctors describe being weary of pressure from families to end life. The Bill requires only a week's grace for the terminally ill and a month's for others.

A wish to die is a feature of untreated clinical depression. Depression, which is difficult to detect in the seriously ill, occurs in at least 20 per cent of cases, and a trial of antidepressants, which may be the only diagnostic test, will take two to six weeks to begin to have an effect. Patients are particularly sensitive to the tenor of care. They are greatly influenced by the way things are presented. Any clinician will find it easy to persuade patients to opt for one course of treatment or another. That is sad but true. Yet only 10 per cent of GPs in the UK have had formal teaching in palliation—a huge educational challenge. The power of the clinician cannot be underestimated.

Competence and capacity as regards major decisions are very difficult to assess, particularly in the very ill. No robust test exists. It has been estimated that at least 40 per cent of so-called informed decisions in routine care are woefully ill-informed.

Disabled people have grave concerns. In the words of Jane Campbell, their lives are viewed as,

    "less worthwhile, tragic, burdensome, and even desperate".

They need to be extraordinarily strong to resist this negativity. The Bill runs counter to all this House has done to promote disabled people as citizens of equal value.

A monitoring commission will be costly, yet looking at notes after the event will never detect subtle coercion, pressures or clinical errors. It will not assess the quality of information, how it was given or the quality of care given. The Bill will not increase patient choice and autonomy but will increase the power of

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doctors and the NHS. The right to be killed by a doctor and the right of a doctor to kill in the course of clinical practice are inextricably linked. Most doctors do not want a duty to consider killing.

The noble Lord, Lord Walton, regrets that he is unable to contribute today. His committee's report has stood the test of time; it is stronger than ever. Euthanasia, however seductive, is to be resisted.

12.2 p.m.

The Lord Bishop of Oxford: My Lords, first, I acknowledge that there are some really difficult cases which the Bill seeks to address: people in great distress physically and mentally, and none of us can be sure that if we were in that position we would not want to end our life. Secondly, I recognise that the Bill introduced by the noble Lord, Lord Joffe, has a number of important safeguards. Nevertheless, despite a profound sympathy with those in extreme distress and a respect for the noble Lord and the compassion that lies behind the Bill, I cannot support it.

I believe that to change the law in this way would make elderly, sick and other vulnerable people even more vulnerable and would totally change the relationship between physician and patient. The noble Baroness, Lady Finlay, stated that so powerfully and eloquently that in the interests of time I shall scrap the first two pages of my speech.

I want to concentrate on the much more testing aspect of this and argue that whatever the effects of changing the law, physician-assisted death is wrong. I take for granted that it is our human vocation to interact with and interfere and intervene in natural processes. It is our responsibility before God to plan the number of children we should have, to alleviate sickness, to improve our environment and to shape our future. So, the human mind naturally thinks, "Why stop there? We have been given control over so much of our lives should we not also take control of the moment of our death? Should we not respect human choice even at this point?"

But let us suppose that we are faced with a suicidal teenager. Do we accede to their request to kill themselves? We do not. We try to support them. We try to get them the medical help they need in order that they might live with a positive outlook on life. We do not accept that their stated desire to die is the overriding consideration. On the contrary, we override it by our desire that they should live.

Let us suppose, as the Bill envisages, that we are faced with a seriously ill, perhaps elderly person in distress who says that they no longer want to go on living. Suppose we accede to their request and arrange for them to die in the way envisaged by the Bill. I believe that that sends an implicit message to that person that, "Yes, you are a burden. Yes, your life no longer has any worth. Yes, you are no longer of value". It is to push them away from the here and now where they have a rightful claim on our care.

However much a person might protest and say, "I really do want to die", the message they receive by our acting on their request is that their life is no longer of

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value. To love someone sometimes means giving them what they say they want. Sometimes, however, it means refusing them what they say they want. In short, to love that distressed person, to show that they are still of worth in the here and now, means not doing what they say they want.

Palliative care has improved hugely since the pioneering days when St Christopher's Hospice was first founded. We know that the vast majority of patients can now be kept free from pain. We need to continue to do research on that. We need to ensure that all forms of palliative care conform to the highest in the country, which is now very good. When there is such care, as further research reveals, either patients do not ask for their lives to be ended or if they do they can be given the support which enables them to feel that their lives are, after all, still of value and worth.

At this point I should like to refer to the issue mentioned by the noble Lord, Lord Joffe, in his briefing paper; namely, that if the law allowed physician-assisted death, patients would feel much freer to talk about it. I wonder. I agree that creating a climate in which seriously sick or dying people can voice what they are feeling, including feelings of helplessness or that they wish they were dead, is a highly desirable goal. But if the law allowed physician-associated death I wonder whether people would not feel less easy about voicing such feelings for fear that, indeed, they might be acted on. For, of course, there would still be part of them, as there is in all of us, that would want to live.

What enables people to voice their feelings, including their sense of helplessness or despair, is good listening skills and good counselling techniques which, once again, one would look for as part of proper palliative care. Dr Tim Maughan, an oncologist, has said that most cancer patients go through a period of severe depression and in a small number of cases he has been asked by his patients to help them to end their lives. He then comments,

    "And yet, in each case, if you look with the patients at their situation, talk to them about their relationship with their families and friends, they come to regret making that request".

Many other examples from palliative care make the same point.

As has been mentioned, research shows that people who say they wish to die do so not so much from the pain as from the fear of losing their autonomy and becoming totally dependent on others. I respect that fear and certainly share it myself. But that highlights another crucial difference between what I consider to be a Christian understanding of what it means to be a human being and some current secular models.

Those secular models imply that we are autonomous individuals and that our real value lies in our ability to act and to choose. By contrast, the Christian understanding assumes that we are essentially not isolated individuals but persons in relationships. Indeed, we are persons only in and through our relationships with other persons. That means that our dependency on one another, just as much as our ability

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to act in support of one another, is part of our very humanity. A life that is dependent on others is not a wasted life. It is not a life without value or purpose.

Appropriate medical care, supported by the moral teaching of the Christian churches, urges that life does not have to be prolonged at all costs. Burdensome treatment which has no prospect of success can quite legitimately be refused. Necessary pain-reducing drugs can be administered even if the known effect is to shorten life. The process of dying can quite properly be left to take its course. But that is very different from deliberately taking steps to kill someone, even if they request it. All that moral theology was so clearly and eloquently outlined by the noble Lord, Lord St John of Fawsley. I wish that there was enough time to take up the arguments of the noble Lord, Lord Lester, which I believe to be seriously mistaken. I shall write to him on that point.

A few years ago a House of Lords Select Committee considered the subject. The Roman Catholic and Anglican churches submitted a joint statement. It stated:

    "Neither of our churches insist that a dying or seriously ill person should be kept alive by all possible means for as long as possible. On the other hand, we don't believe that the right to personal autonomy is absolute. It is valid only when it recognises other moral values, especially the respect due to human life as such, whether someone else's or one's own".

The Roman Catholic church and the Church of England are totally at one on this.

For the reasons I have suggested, to change the law in the way that the Bill suggests would have seriously deleterious consequences for all vulnerable people in our society. However, even apart from that, I suggest that assisted death is wrong in itself however compassionate the motive behind it might be. Other people, whatever state of mind they are in, and whatever they say, have a value in the here and now and they have a legitimate claim upon us. We should respond to that by continuing to care for them and by recognising that the condition of dependence, just as much as our ability to act and choose, is part and parcel of what it means to be a person in relation to other persons. I cannot support the Bill of the noble Lord, Lord Joffe.

12.11 p.m.

Baroness Jay of Paddington: My Lords, it is always very instructive to listen to the wise words of the right reverend Prelate, but I fear that on this occasion I am not able to agree with his conclusions. Perhaps, when he hears my remarks, he may wish to write to me as well as to the noble Lord, Lord Lester of Herne Hill.

Ten years ago I was privileged to be a member of your Lordships' Select Committee on Medical Ethics, which has been referred to by earlier speakers. As a junior Member of the House at that time it was a privilege to serve and particularly to be involved in the consensus report which was reached under the skilful chairmanship of the noble Lord, Lord Walton of Detchant. The overall consensus was that a legal right to request assistance in dying was a threat to society's

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prohibition of intentional killing, and that the interests of the individual could not be separated from those of society as a whole.

At the time the report was criticised in some quarters as being a little too cautious. Of course, with the benefit of hindsight, which I acknowledge, I now feel that I probably agree with that criticism. Even in the debate on the report in May 1994, I said that I felt that the committee had been too timid about advance directives. I suggested then that instead of simply commending the development of advanced directives, as we did—or "living wills" as they are sometimes called—we should have recommended giving them legal force, so that a person's explicit and definite wishes on how he wishes to be treated would be binding.

I realise that the question of advance directives is not immediately relevant to the Bill, but I use it as an illustration because it concerns the individual choice issue which I believe to lie at the heart of the debate. This is the area in which my tentative views of 10 years ago have strengthened.

Why have I altered my view? Partly because of the changes and improvements in medical practice that have occurred; partly because of the longer experience that we now have of assisted dying in other countries; and partly—and I think most importantly—because in our own society we have strengthened and statutorily codified our understanding of individual human rights.

I turn to the issue of the experience of other countries. This is clearly a matter which will be debated in detail by those who are very familiar with the circumstances in Holland, Belgium and other places. I do not intend to get involved in that detail for the purposes of trying to save a little time, but I simply say that in my observation of what is happening, I am not alarmed by my understanding.

On the question of developments in medical practice, I must emphasise that I am enormously supportive of the speciality of palliative care and of the hospice movement. As a health Minister in the last Parliament, I did what I could to support and extend the understanding and practice of those issues in the National Health Service and the voluntary sector. I think that a huge amount has been achieved by the practitioners of palliative care. I very much valued the authoritative contribution of the noble Baroness, Lady Finlay, who, as we all know, is a global expert on this matter. She and her colleagues have succeeded in enabling more people than ever before to have a better quality of life and ultimately to have what is described as a "good death".

So it may seem a paradox that I find these improvements sometimes contribute to my views on assisted dying. I wonder whether those who tend to see palliative care as a total panacea can recognise that for some people there are limitations to it, however widely spread and well practised. There are those, for example, who feel that pain control is not the answer to their situation. They would describe what they

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perceive as a drug-induced stupor as an inadequate life. Others of course suffer from intractable conditions where pain is not necessarily the most important issue. There are also some—and it would be foolish for us to ignore this—who simply feel that the natural span of their life has reached a conclusion because general debility has completely diminished their experience of life. That is where the issues of human rights and the role of individual autonomy in making decisions is fundamental. My view today is that the individual human right to choose should be paramount.

Personally, I must say that I do not have a religious faith that human life has a spiritual sanctity, but I do strongly believe that the unique value of each individual human life should be respected. In thinking about the implications of that belief I have been influenced by Professor Ronald Dworkin, the distinguished professor of jurisprudence who gave powerful evidence to the Select Committee 10 years ago and who has continued to think and to write about these matters both here and in the United States. In the 1994 report of our committee, he was quoted as saying:

    "I am in favour of choice because people disagree about what kind of death is meaningful for them. I, myself, believe what sort of a death is right for a particular person and gives the best meaning to that person's life, largely depends on how that life has been lived, and that the person who has lived it is in the best position to make that decision".

This is my position today. It is now important for those of us who support that area of choice to face the question: how does the possible legal validation of this individual human right conflict with the interests of society as a whole?

Although, as I have said, in the UK we have now enacted the Human Rights Act, very few of its provisions have been tested in case law. But the very existence of that Act has in my view changed the parameters of this kind of debate. In the United States, which is governed of course by its written constitution, the Supreme Court has already given opinions on those rights. One current Supreme Court judge said:

    "In my judgment . . . it is clear that [the states'] so-called 'unqualified interest in the preservation of human life' . . . is not itself sufficient to outweigh the interest in liberty that may justify the only possible means of preserving a dying patient's dignity and alleviating . . . intolerable suffering".

Beyond the jurisprudence we must also face the practical questions of how we might implement any legal right to choose an assisted death. I find extremely distasteful the recent examples referred to by the noble Lord, Lord Joffe, of British citizens travelling abroad in harrowing circumstances to fulfil their individual wishes.

However, we are all aware that there are very deep divisions in the medical profession in this country. I was encouraged by the recent human rights campaign newsletter which reported that 1,000 GPs had signed a declaration supporting the Bill of the noble Lord, Lord Joffe. But I am obviously also influenced by the helpful paper from the Royal College of Physicians which comes down against the Bill. However, the college in summary of its position states:

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    "It is, therefore, not enough to simply oppose the Bill without offering alternative suggestions. This is a problem that cannot be ignored, and it would be deeply unethical to walk away from it".

The royal college is right: none of us can walk away from these issues, some of which, I would assert, have altered in the past decade. My practical proposal, which I hope may be of interest both to the House and to the Government, is that we should set up a new Select Committee to look afresh at some of these matters. I feel that such a committee might be a very authoritative way of reviewing policy, and I have in mind the recent example of the widely praised deliberations and recommendations of your Lordships' Select Committee on stem cell research, which is another extremely controversial and sensitive matter.

So, in conclusion, I hope that whatever the fate of this legislation, the House may consider another committee inquiry as a longer-term way of examining some of these issues. In the mean time, I congratulate the noble Lord, Lord Joffe, on his wisdom and courage in introducing the Bill and hope it will make progress.

12.20 p.m.

Lord Phillips of Sudbury: My Lords, as others have done, I thank the noble Lord, Lord Joffe, most sincerely—this is not merely a formal expression of thanks—for all the work he has done, not just in enabling this debate but in the briefings he sent to all of us.

I—and others, I am sure—also want especially to thank the huge number of individuals and organisations for letters of great poignancy and insight and immense consideration which have helped me to reach my own tentative and stumbling view about the Bill. This is not a debate for experts. This is a classic issue for every man and every woman.

Each of us will bring to the debate our own experiences. Mine are as a general practitioner solicitor since 1957, which is when I first went into an office. One sees an awful lot as a general practitioner solicitor and quite a few duties are given to solicitors under the Bill. I also served a spell with the Samaritans for a few years. Obviously, there one witnesses a great deal of human distress—even to the point of people wanting to kill themselves. I also served as a coroner's officer—another interesting vantage point on the subject under debate. Indeed, my principal, my father, was the first—for many years, the only—coroner in Great Britain to be in favour of euthanasia. I did some work for Exit in its early days.

I have enormous compassion, as I know we all do, for those trapped in the situation where they cannot terminate their lives without getting others to help them, and where doing that, as has been explained, brings with it the risk—an attenuated risk, in fact, but nonetheless a theoretical risk—of those people being dragged before the criminal law.

Having said all that, hard cases make bad law. Where one proposes to introduce what on any reckoning would be a radical change in the law of the

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land, dealing with life and death at its most vulnerable point, one must make the case beyond any reasonable doubt. I do not believe that that has been done.

One illusion—held, if I may say so, especially by non-lawyers—is that the law can be a highly sensitive instrument that will reliably deliver the intent of those passing that law in circumstances as sensitive as those with which we are dealing. As an old lawyer, I must say that I have dying faith in the ability of the law to cope in that way. On the whole, micro-law is deluded law. Every year, we in this House put onto the statute book huge numbers of fantastically complicated laws, many of which will never see the real light of day—never be implemented—and many more of which, if implemented, will not be implemented in the way intended.

I must say that I get fed up with that most common error of reformers: to contrast the worst of the status quo with an assumption of perfection of the world that they are bringing into existence by legislation. In the Bill, we must decide which takes priority: allowing those suffering an "irremediable condition" and "unbearable suffering"—the two key tests—to have their lives terminated, under the Bill's protections, to which I shall return; or, on the other hand, prevention of abuses that will inevitably flow from the Bill, or any other Bill, and the unintended consequences of the Bill, which will also inevitably flow from it.

I happen to think that the status quo, for all that one can level criticisms at it and for all its defects, resting as it does on the honest ethical judgment of nurses and doctors throughout the land following accepted professional duties and well-established clinical practices, is a better guard against both abuse and abuse of the autonomy of those who are suffering, than the regime that would be created by the Bill.

To be fair to the noble Lord, Lord Joffe, he is in a classic dilemma. If one wants certainty, a Bill of this sort cannot possibly be sensitive enough to cover the myriad of different human predicaments involved. On the other hand, if one seeks to provide flexibility, as does the Bill, one swings to a position where ethical judgment has been replaced—or at least compromised—by detailed statutory provision but which, I believe, will still allow a great deal of abuse.

Anyone who deals with the vulnerable old in whatever capacity will surely recognise that the sort of rational assumptions that underlie many of the proposed protections of the Bill are worthless in real life if someone is lacking in confidence, totally emotionally dependent on a few people and at the mercy of those who are in a different state of mind and position.

We must also face the fact—I say this with reluctance and with the heavy caveat that I have the greatest possible respect for the medical profession as a whole—that the Bill will create a whole new breed of doctors and practices specialising in this class of medical business. It will be a bit like abortions. The protections will be circumvented and diluted with skill—that I promise. Let us not forget that it will be a profitable business. I fear that much of the subtle,

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calibrated attempt to pry into the minds and real intent of vulnerable people living in unbearable suffering will not work.

One of the key tests in the Bill is "irremediable condition", as is "unbearable suffering". "Irremediable condition" includes "serious physical illness". What is serious? That is a wonderfully rubbery word. "Incurable"? Many people are incurable. "Progressive physical illness"? Progressive is another liquid expression. What is meant by "unbearable suffering"? The Bill states that it is someone suffering,

    "by reason of pain or otherwise".

What does "or otherwise" mean? I can imagine doctors having many different views about what is "unbearable suffering" of a non-pain kind. It must then be suffering that could be ended by "a humane act". What is a humane act in such circumstances?

I say all this not to rubbish the Bill but out of a serious attempt to try to get across to those in the House who are not practising lawyers just how feeble a scheme of protection it will provide.

Beyond all that, we will be creating a new culture in which many vulnerable old people will feel themselves to be under pressure—a duty, even—to ask for a termination, whether or not they are actually subject to subtle or non-subtle pressure by relations or those who live in expectation of inheriting their estates. I can just imagine it—I have heard it. They will say, "Am I being selfish by hanging around? These huge nursing home bills are going out every week and my daughter is trying to get a mortgage to buy a house."

Those are all real, human, daily, pathetic pressures on people. It is idle for us to pretend that the Bill will not create a general context within which an unintended vulnerability will, I fear, in so many cases work to the precise reverse of the intentions of those who have advanced the Bill.

I conclude with a quote from the National Council for Hospice and Specialist Palliative Care Services and the Association of Palliative Medicine, which are basically the hospice movement umbrella bodies. They state:

    "Your Lordships need to be very clear that the passage of this bill in any form would change the face of medicine and a doctor's duty to care. It is a most serious and disturbing development in the authority of medicine and changes active killing as a fundamental harm to a potential benefit in clinical codes of conduct".

12.30 p.m.

Baroness Warnock: My Lords, there are three central reasons why I rise to support the Bill of my noble friend Lord Joffe. The first is that I entirely agree with the view put forward by the noble Lord, Lord Lester of Herne Hill, that we have come to a time, after many publicised cases, and many, for obvious reasons, less publicised, when we are in need of legislation in this area. We know that there are doctors who bravely but secretly promise their dying patients—I should point out that not all patients who are dying are also old and necessarily frail in any other

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sense except that they are dying—that they will not let them suffer a humiliating and protracted death. They keep this promise as best they can.

We no longer live in an age when doctors can safely make, or be sure of keeping, such promises. Most patients, for good or ill, die in hospital where the doctors are likely to be strangers to the patient and his family. Even if the doctor who knows the patient and his circumstances is still available, he is under the threat of exposure by those who are members of the team in charge of the dying patient.

It is time that the availability of assisted death, to a restricted and clearly circumscribed set of patients, should be brought into the open and be regulated so that those who, out of compassion, wish for such an outcome can bring it about without the threat of a murder charge. It is not for the medical profession alone to determine what may or may not be morally permissible in the matter of hastening the death of the terminally ill and acutely suffering. Since the law seems to hold that to hasten such a death is murder, and murder is a concept of law and not of morality alone, the law must be clarified. In my view, we should acknowledge the legitimacy of what surreptitiously and dangerously already happens. A law that decriminalised assisted death in certain clearly specified circumstances would safeguard the interests of patients who did not wish their death brought forward.

The limited scope of the present Bill, whether its limitations are exactly put forward or not, must be emphasised. Like the noble Baroness, Lady Jay, I, too, rely largely on the briefing of the Royal College of Physicians who, in opposing the Bill, noted that the goal of their opposition was not to use the slippery slope argument—of which your Lordships have heard something already and will doubtless hear more today. It states in its briefing that because of the humanity of the motive behind the Bill it is,

    "not appropriate to invoke the idea of the slippery slope".

Secondly, I believe that the arguments derived from religious beliefs should be kept to one side in this debate. Of course those who have beliefs derived from their religion or elsewhere, which would prohibit the legitimising of assisted death, should not be compelled either to accept such assistance or to proffer it. Nor do I deny for a moment that for many of us moral beliefs are deeply rooted in Christianity or some other religion. But it seems to me that the law should be based not on religious beliefs, but on a concept of morality separate from any particular religion. Of course I acknowledge that for many people their morality is derived from their religion. But for many, morality is essentially secular. It is this secular path that the law must follow.

In this particular case, it is the morality of compassion that must be paramount and dictate what the law should allow. I doubt whether anyone acquainted with the case of Diane Pretty would deny that compassion demanded that she should be assisted to die before she suffered the horrors that she so much feared. It was the law; it was theory; it was fear of the

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slippery slope; and it was the unwillingness of the medical profession to be bold enough to exercise that compassion—upon which, after all, the motive and the achievement of that profession is founded—that stood in her way.

My third reason is perhaps more personal. I know, as many in your Lordships' House know, that the terminally ill are obsessed with the question not whether a cure can be found for their condition, not even with the question when they will die, but with the question of how they will die. How can they face the deterioration—perhaps the inability to breathe, the total helplessness, or the humiliation—that will precede what they know to be their imminent death? We are here talking about the terminally ill.

If a doctor can promise them that it will not come to that and that they will not be allowed slowly to suffocate, for example, then so far from destroying their trust in doctors, it increases it. But if a doctor promises that and cannot fulfil his promise, that would indeed destroy trust. I am not impressed by those doctors who say,

    "We do not want this power".

Of course they may not: they have been trained in general to save life, not to hasten its end. Nowadays, they have been trained to assert the wonders of palliative medicine, making claims that so far are, alas, nowhere nearly justified. But I do not believe that the professional habits and ethos of the medical profession should outweigh what ought to be the basis of their relation with their patients; namely, compassion for the suffering. That is why I strongly support the Bill with all the restrictions and safeguards written into it. We have been reminded by the noble Lord, Lord Phillips, that hard cases make bad law. But that is a very easy and a very comforting generalisation. If the hard cases are relatively frequent and especially if, for the individuals affected, they are intolerably hard, perhaps it is time to revisit the law. Nor do I think that we should wait to do so until the probably distant time when palliative medicine is proved a success in every case.

12.37 p.m.

Lord Brennan: My Lords, the concept of illness and death in society, and when it comes to this legislature, should surely arouse us to discuss such concepts in a background of promoting trust, creating hope and arranging illness and the care of those who are dying for the common good. I profoundly disagree with this Bill because it does not achieve those objectives. Rather, perhaps unwittingly, it nurtures fear and is founded on despair. Those are strong words but I think that they need to be clearly said.

For the following reasons, I profoundly disagree with the Bill. First, it is against the common good. The phrase "personal choice" and the word "autonomy" mean nothing unless they are set into a social context. As we have just heard from the noble Baroness, Lady Finlay, in medical terms in the kind of cases that we are debating, the concept of autonomy is illusory. Indeed, the Bill, while proclaiming personal autonomy, is able

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to achieve its objective only by involving a third party—a doctor—to enable that personal autonomy to achieve the effect of its holder.

In law, human rights legislation has been referred to as changing the picture. I think not. The decision of the House of Lords in the Pretty case, and of the European Court of Human Rights, proclaimed the value and sanctity of human life and the protection of it under Article 2. It did not lessen it or seek to open the door for any radical change.

I hope that the House will forgive me for that short legal excursive, but autonomy must be put in its social context. So the closing question of my first point is this: is the exercise of personal choice, so as to enable yourself to be killed by a doctor, for the common good?

In 1994, after extensive research, the hearing of much evidence and, no doubt, very careful discussion with each other, a committee of this House regarded the present law as,

    "the cornerstone of law and of social relationships. It protects each one of us impartially, embodying the belief that all are equal. Dying is not only a personal or individual affair. The death of a person affects the lives of others, often in ways and to an extent which cannot be foreseen. We believe the issue of euthanasia is one in which the interest of the individual cannot be separated from the interests of society as a whole".

I note that two members of that committee, the noble Baroness, Lady Jay, and the noble Baroness, Lady Warnock, now hold different views. I hope that I have dealt with the concerns expressed by the noble Baroness, Lady Jay, about the impact of the Human Rights Act, but I propose to tease the noble Baroness, Lady Warnock, because I have here a report from the Daily Telegraph of January 2001 in which she is reported as saying that she is "terribly against . . . voluntary euthanasia". That merely illustrates that we can change our minds, but also that in the changing of them, we should examine carefully what we originally thought. What I read out of those original thoughts is, I suggest, compelling.

My second reason is that the Bill is legally unworkable. It is replete with safeguards and that very fact indicates the difficulty of legal protection. The Royal College of Physicians described the safeguards proposed as "grossly inadequate". The committee of 1994 felt that it was impossible safely to legislate in this area so as to introduce proper safeguards. A legal minefield that most definitely was. So I conclude that it is legally unworkable, no matter how well intentioned its drafting.

Thirdly, the Bill is medically unacceptable. As I have indicated to the House, it will not work unless it involves the active co-operation of a doctor. At present, as a layman and not a doctor, I cannot envisage how action under this Bill would stand easy beside the Hippocratic Oath or the Geneva and Helsinki Declarations, which are its modern form. But if the result is to create in the medical world death as a therapeutic option, which is what the Bill will result in, I suggest that that would mark a profound change in the doctor/patient relationship in this country.

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The change would be profound because the relationship is based on trust, the word I first mentioned, and it would be profound because medical treatment is much dependent on hope, the other word I mentioned. It is in the relationship of trust and hope between doctor and patient that this Bill encounters its most difficult obstacles. That may well explain why the Royal College of Physicians, the British Medical Association and a separate poll showed a majority of doctors against the Bill. The simple concept in medical terms for the public is—I shall put this very bluntly; it needs to be put—doctors are protectors of life, not agents of death.

My final reason is that the Bill is socially dangerous. The disabled, the elderly and the young, whoever the vulnerable person who may come under the Bill might be, self-evidently will be at a very parlous state of their life. I want to concentrate on the elderly. In 2000 in the United States, 29 per cent of the total cost of healthcare was expended on people in the last year of their lives. That is a huge social expenditure. Can it be argued plausibly that, if this Bill went on to the statute book, we would not face at least the risk that medical resources and the lack of them would become a very important factor in the decision-making that this legislation requires? How we care for the elderly is an extremely serious issue for us as a society.

In that regard, before I finish my remarks I should like to quote the words of the 1994 committee:

    "We believe that the message which society sends to vulnerable and disadvantaged people should not, however obliquely, encourage them to seek death, but should assure them of our care and support in life".

It would be a tragedy if a Bill such as this put that message at risk.

12.46 p.m.

Lord Patten: My Lords, I profoundly agree with the noble Lord, Lord Brennan, as much as I profoundly disagree with the Bill put forward by the noble Lord, Lord Joffe. But I very much welcome the opportunity which he has given the House to debate these important issues. I listened with great care to what he had to say in introducing his Bill.

In what I have to say, I shall take a leaf out of the book of the noble Baroness, Lady Howells, and say exactly what it is I think. She did that wonderfully well in her speech. What I say, however, will be mostly in the words of others and not in my own original compositions. I have always thought there is a number of serious sins that we in the speechifying classes can commit. Perhaps the worst of those is to cite with approval in support of a line of argument speeches made earlier by exactly the same speaker. Then, almost as bad in my book, is for the speaker to seek some convenient and transient support in the most recent leader on the subject in a newspaper. We should all remember what superficial creatures some, although not all, leader writers are as they face the exhausting task of turning out a rapid editorial of 400 or 500 words on their allotted subject in the brief period between tea and drinks.

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Not far behind both of those speechifying sins is to compose a speech that relies largely or wholly on letters that we might have received in order to provide both content and supposed authority to what we say in this House or in another place. I do not think that I ever did that in another place and I have never done it here, but today, for the first and I think the only time, I am going to break my duck. For just as I have never, ever been so forcibly struck by the strength of the arguments that I have received in correspondence as I have been by those standing against this Bill, so equally have I been overcome by what I have read and how it has been put in the correspondence that I have received. These arguments have been marshalled with greater coherence by most of my correspondents than I could manage myself, so I shall borrow some of their words with my thanks.

First, I express my thanks to Catherine Heckman, a nurse from Brentwood, who wrote on 2nd June saying:

    "This Bill undermines caring . . . It would be a great tragedy, and one that could never be rectified, if patients saw nurses as 'angels of death'".

Secondly, I should like to borrow the words of Jocelyn Cherry, a medical student at the University of Bristol School of Medicine, who wrote to me out of the blue on 19th May to say:

    "There are good treatments available for symptoms prompting euthanasia requests and we should be using them, offering our patients the best care possible, not killing them"—

and going on to opine—

    "Euthanasia seems to me to promote 'lazy medicine'".

Just so, my Lords.

I should now like to borrow some words from a couple of doctors who were kind enough to write. First I quote from Dr John Etherton, a general practitioner who wrote on 24th May stating that:

    "I did not spend 9 years of my life . . . training to be a GP . . . only to be told I can now legally kill my patients".

A professor of surgery, Professor Jonathan Shepherd, told me in a letter on the 20th May that,

    "adding the ability to kill people to treatment options would have a devastating effect on the doctor-patient relationship".

There we reach the nub, because there can be many arguments properly aired in this place by those with judicial, legal and ethical expertise greater than mine. Great subtleties of mind can be displayed before your Lordships. However, to ordinary people in the country at large they will rapidly divide up the doctors who treat them into those who will and those who will not. Local communities will rapidly recognise that there are doctors who are prepared to kill and those who are not. Public pressure would mount immediately if the Bill became law so that we would have to have a publicly available register of those doctors that would be prepared to kill. The noble Lord, Lord Phillips of Sudbury, was right in everything that he said. It would be otiose for me to add much to his excellent words, other than to say that we would have to have a list of one group of doctors who were devoted to ageless medical ethics, and a new group of those who would become, in effect, so-called vet doctors. They would be perfectly happy to be involved in the ending of human

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life, just as vets are very properly in their own profession involved in the handling of the end of animal existence, not animal life. There would be public disquiet from those of all ages, not just the most at-risk group, the elderly. We would have, in effect, two classes of doctors created in this country. There would also have to be separate training, perhaps in separate medical schools, for doctors who would and would not be prepared to exercise their right to kill.

I should like to pray in aid the words of a vet in support of that argument—Mrs Kate Wiltshire, who wrote on June 1st to me:

    "Although I routinely perform euthanasia on animals as part of my duties as a veterinary surgeon, I believe passionately that doctors should not be called upon to end human life".

She concluded:

    "If this Bill does become law, this country will become a very dangerous place for some of our most vulnerable members of society and it will make doctors the most dangerous people in it".

In addition, there have been many other letters and I shall trouble the House no more with quotations from them, except to say that a number have come from the self-declared elderly, or those who have written, from the evidence of their handwriting—one does not have to be an expert calligrapher to deduce from the evidence of their handwriting that they are probably elderly people—that they are fearful. I believe that as the Bill progresses through the House, and as the noble Lord, Lord Joffe, takes the Bill through the House, that level of fear and worry about the future will mount and, in ever-increasing numbers, people will feel concerned.

I am glad that the noble Lord has introduced the Bill. I thank him for doing so, but I hope that it makes no progress whatsoever.

12.54 p.m.

Lord Goodhart: My Lords, suicide used to be a crime. It meant that people who had tried and failed to commit suicide could be prosecuted for the attempt, and indeed sometimes they were prosecuted. As my noble friend Lord Lester of Herne Hill said, I do not believe that any of us would wish to go back to that situation.

Assisting someone else to commit suicide is another matter altogether. It remains a crime, and in my view rightly so. However, we are considering today not whether assisting someone else's suicide should cease altogether to be a crime, but whether there are exceptional circumstances in which that should not be a crime. Certainly assisting someone to commit suicide simply because they wish to die should not be lawful. A wish to die might result from clinical depression or other forms of mental disorder. In such a case a decision to commit suicide cannot be regarded as the decision of a rational mind, and should not be assisted. Some people might wish to die in the immediate aftermath of a catastrophic physical injury, for example tetraplegia. Many such people in time change their minds and are glad that they survived. I suspect that all of us on the speakers' list have received a

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number of moving letters from such people in the last few weeks. People in those circumstances should not be helped to commit suicide.

However, I believe that there are some circumstances in which a rational person can justifiably believe that suicide is the right option. That would be true of some people who were faced with an agonising or deeply degrading terminal illness. Even in those circumstances many people would wish to go on living for as long as possible. Some would not. There is the alternative of palliative care. Great advances in that have been made over the last few years and there will no doubt be more to come in the future. However, I doubt if palliative care will ever be able to provide the best answer for everyone.

Some people facing terminal illness can, and do, commit suicide without assistance. Some wish to, but cannot, because of physical incapacity or lack of access to the means of suicide. Should we allow them to be assisted to do what, if they were of physical capacity, they could do for themselves?

I recognise life as something of immense value. I cannot say that I regard life as a gift from God, because I do not have religious belief, but my view of life is not so very different from a religious belief. However, the time comes to some rational people when life becomes so burdened by suffering that that has no value to them and there is no prospect that it ever will have. For those people the greatest kindness is to help them to die, and that withholding that help is unkind. I do not believe that providing that help in strictly defined and limited circumstances, and with proper safeguards, should be a crime.

Providing that help should never be a duty. Many doctors have strong ethical objections to assisting suicide, and should never be required to assist their patient who asks to be assisted to commit suicide. However, all of us know that there are some doctors who are as far from Harold Shipman as could possibly be imagined, who do, and always have, helped patients to die at their request when those patients are in real distress. They do so at the risk to themselves of criminal prosecution and expulsion from their profession. They should not have to face that risk.

There must be safeguards and the Bill provides many. Changes or further safeguards might be needed. Now is not the time to go into that degree of detail because this is the Second Reading of the Bill which, we all realise, stands no chance of being enacted in the current Session. However, the Bill is a most valuable contribution to the debate. Speaking for myself, I would be happy with the proposal by the noble Baroness, Lady Jay, for a new Select Committee to enable the issues that were considered in 1994 to be looked at again 10 years later.

Sooner or later a successor to the Bill will be enacted and when that happens that will make a contribution to the relief of human suffering.

1 p.m.

Lord Alton of Liverpool: My Lords, the noble Lord, Lord Joffe, was good enough to say recently that we

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are usually on the same side of the argument. Although he knows that I am profoundly opposed to the underlying principles of the Bill, I commend the way in which he has introduced the arguments. At a number of meetings that we have jointly attended over the past few weeks, he has proved to be a very formidable and very honourable opponent. The tone of the debate in your Lordships' House today has done justice to the claim that we always make: that the House is able to debate issues of this importance in a sober way, which helps to give a lead to those who follow the proceedings of this place.

During meetings outside your Lordships' House and within its precincts, the arguments we have heard have been powerfully put by ethicists, medics and disabled people. I have been particularly struck by the views of doctors. The British Medical Association says that the Bill should be resisted. It states that,

    "there is consensus within the BMA that the law should not be changed to permit euthanasia or physician assisted suicide in the UK".

As we have heard, the BMA has been joined by the Royal College of Physicians, the Royal College of Anaesthetists and the Academy of Medical Royal Colleges in opposing my noble friend's Bill.

The Royal College of Physicians, which has been cited by the noble Baroness, Lady Jay, and by my noble friend Lady Warnock, has stated that the Bill is "potentially dangerous"; that it is "composed of two ill-fitting parts"; and that,

    "key terms in the Bill are worryingly vague . . . it could be extended to apply to a very large number of patients beyond those whom the sponsors had in mind when they proposed it".

Along with the Royal Colleges, the views of which we certainly should not simply dispose of, the hospice movement, to whom the noble Lord, Lord Phillips of Sudbury, referred earlier in a powerful speech, Help the Aged, Age Concern—from which I received a letter today signed by Gordon Lishman, its director— the Disability Rights Commission and an impressive array of religious leaders, including the most reverend Primate the Archbishop of Canterbury, the Archbishop of Westminster, the Chief Rabbi, Dr Jonathan Sacks, and the Islamic Medical Association have urged your Lordships to resist the Bill. I should say to my noble friend Lady Warnock that I do not believe that their views should any more be set aside merely because they are the views of religious leaders than the views of even the most eminent of our philosophers.

Nor should we discount the views of doctors. The most recent poll of doctors, carried out on 13th May this year, established that almost three out of four doctors—some 74 per cent—would refuse to perform assisted suicide if it were legalised: the very point which has been adumbrated so well today that they would not want to be turned into destroyers of life rather than remain the defenders of life that they have always been. A clear majority also considers that it would be impossible to set safe bounds to euthanasia.

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Not one single doctor involved in palliative care supported a change in the law. A significant majority supported both the BMA's position and the conclusions of your Lordships' Select Committee, which have been cited already. My noble friend Lord Walton of Detchant, who chaired that committee, still stands by its recommendations.

The arguments for and against euthanasia and assisted suicide were extensively considered by the Select Committee. Evidence, both oral and written, was taken from a host of witnesses representing a vast array of groups, charities, medical organisations and others. As we have heard today, the arguments have not really changed since then.

The committee's report unanimously recommended at paragraph 278 that,

    "There should be no change in law to permit euthanasia".

At paragraph 295 it stated:

    "We recommend no change in law on assisted suicide".

However, since that report the campaign by the international pro-euthanasia movement to change the law has intensified. Yet the arguments themselves have not changed. The conclusions of the Select Committee are as pertinent now as they were nine years ago. We ignore them at our peril. There is a danger that you set up new committees when you do not like the findings of previous committees. The arguments have not changed; all that has been stated in your Lordships' House is that the laws in Oregon, in Belgium and in Holland have been enacted. I shall return to that point a little later.

The members of the Select Committee recognised that society's prohibition of intentional killing,

    "is the cornerstone of law and of social relationships".

That leads me to a second area that I wish to cover: the wrongfulness of intentional killing.

The Select Committee correctly noted that the prohibition on intentional killing,

    "protects each one of us impartially, embodying the belief that all are equal".

It had no wish to see that protection diminished, hence its conclusion that the law should not be changed to permit euthanasia.

The Bill introduced by my noble friend seeks to abolish this "cornerstone of law and of social relationships". That would be highly dangerous. It would fatally corrupt the doctor-patient relationship, which is founded on trust, and doctors would become killers as well as carers. Euthanasia is not suicide. It requires a doctor to collaborate in an act of killing, and doctors are certainly not demanding that change. The recent poll of doctors found that very few patients requested euthanasia. In the comments accompanying the poll, doctors set out their reasons for not wanting that change.

It is widely acknowledged that rules in our moral code against actively causing the death of another person are not isolated fragments. They are threads in a fabric of rules that support respect for human life. The more threads we remove the weaker the fabric becomes. That led the Select Committee to insist that

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the prohibition on killing is at the centre of morality, providing the cornerstone of whatever rights an individual may have.

Nowadays we hear much talk of autonomy—a point raised during the debate—and the right to do with one's life as one chooses. "Autonomy" is one of the buzz words of the pro-euthanasia lobby and can clearly be seen in the wording of the Bill. However, autonomy is not an absolute right that each of us, as individuals, can exercise while living in our own little bubbles.

One cannot fail to be moved by the tragic cases we have heard about today. Those of us who oppose legalised killing recognise the suffering of patients with motor neurone disease and similarly debilitating diseases, and we acknowledge the anguish of the families who care for loved ones with those conditions. But again I recall the conclusions of the Select Committee that,

    "individual cases cannot reasonably establish the foundation of a policy (the legalization of euthanasia) which would have such serious and widespread repercussions. Moreover dying is not only a personal or individual affair. The death of a person affects the lives of others . . . We believe that the issue of euthanasia is one in which the interest of the individual cannot be separated from the interest of society as a whole".

Time is short but perhaps I may mention briefly the Dutch situation. My noble friend's strongest argument is that because the Dutch have legalised euthanasia we should do so too. The Dutch first decriminalised their laws; then enacted voluntary euthanasia; then permitted involuntary euthanasia; and now it has become so routine that many doctors do not even bother to report it.

I was in Holland last week when the Dutch Government officially reported that last year there were some 3,800 cases of euthanasia and that 900—one in four—were involuntary. So much for patient autonomy. Even more shocking, the Dutch Government also reported that in 2001,

    "just 54 per cent of such deaths were officially reported".

The research concluded that,

    "the low percentage of reported euthanasia deaths was because doctors wished to avoid the administrative hassle of reporting a euthanasia case and were concerned they might have breached the regulations".

So there we have it. We decriminalise; we move to voluntary euthanasia; we move on to involuntary euthanasia; and then, because it becomes so routine, we move on to non-reporting in some 50 per cent of cases.

In War and Peace Leo Tolstoy wrote that,

    "the great thing is to accept death and to welcome life".

All of us will have to one day accept death. What we should never accept is intentional killing other than for the requirements of justice. To do otherwise is unethical. It will destroy the doctor-patient relationship; increase the fear in our hospitals; create a subjective duty to die for the old; create a stigma for disabled people; and hinder progress in the palliative care that represents the real hope and comfort for the terminally ill and disabled. I hope your Lordships will resist the Bill.

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1.8 p.m.

Lord Patel: My Lords, I, too, thank the noble Lord, Lord Joffe, and congratulate him on introducing the Bill. I listened carefully to what he said today. We have had several discussions which have convinced me of his sincerity in wanting to help those facing death by bringing forward the Bill. He has no doubts about the rights of what the Bill proposes and his arguments are persuasive. However, persuasive though the arguments are, I have difficulty in accepting that voluntary euthanasia or patient-assisted dying should be made legal.

I have no problem in accepting patient autonomy. A competent patient, fully informed, choosing not to continue with treatment I find totally acceptable. Assisting death is different.

Primarily, as a doctor, my views reflect my training of treating and helping patients. If a cure cannot be achieved, we must help them cope with the illness and support and comfort them.

My own professional organisations are against the Bill, although there are a range of views expressed by individual doctors. Many feel that patient-assisted dying should be legally allowed. Opinion may be shifting, but the majority of doctors are still opposed to it.

The Bill produced some interesting debate in my own family of four doctors—one equivocally for, one against and two sitting on the fence and undecided. They were not the youngest, either.

Similar conversations with a group of medical friends—general practitioners and specialists—have been equally divided. While the medical professional organisations are against legalising voluntary euthanasia, a significant number of doctors accept that the practice of assisting the process of dying of suffering patients who are terminally ill from incurable disease goes on. In the United Kingdom, we do not have figures on the extent to which this happens and in what circumstances. I believe we need to know this, following structured research, before we move to legalising assisted dying.

It is this belief that such practice is widespread that makes many, professionals and public alike, seek a tight legal framework that will allow doctors to assist terminally ill patients to die with dignity. But it is the issue of making the remaining life of those facing death comfortable and bearable that concerns me most.

In my professional life, only on rare occasions have I had daily contact with patients facing death, for my work is at the other end of the spectrum of life. But I am impressed by the comments made and the concerns expressed about this Bill by those such as my noble friend Lady Finlay, who spoke so eloquently about constant and prolonged relationships with such patients.

On learning more about the debate that took place in the countries where voluntary euthanasia is legal, I found that one of the issues raised was the quality of care provided to the terminally ill. I believe this to be extremely important. At what point in time of the

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development of a country's health and social care services, particularly services for the vulnerable and terminally ill, would society have the confidence to make therapeutic death legal, because death was the only relief from pain and suffering that the service can offer?

Our services for the care of the terminally ill, sick, elderly and severely incapacitated are patchy in many places, and short of what would be considered even adequate, let alone good. Should we therefore not press for better provision of care of such patients? Other countries where such services are good have demonstrated less need for voluntary euthanasia. While recognising that public and medical opinion is shifting and accepting that the Bill provides for protection of vulnerable groups, I have concerns similar to those expressed by others about the definition and powers of regulation.

I cannot support the Bill in its present form, but I would support the suggestion of the noble Baroness, Lady Jay of Paddington, of setting up a special committee of the House to report in detail on all the issues.

1.14 p.m.

Lord Plant of Highfield: My Lords, when I was 34 years old I had a heart attack, and on being admitted to an intensive care ward I was asked for my religion. At the time I was rather high on an opiate that I had been given by my GP and I said that I was a Methuselist. The nurse, not unnaturally, looked puzzled and asked me what that was, and I said it was someone who believed in living as long as possible. Well, my Lords, I am no longer a Methuselist, and I support the principle behind the Bill of the noble Lord, Lord Joffe. I want to argue that we do not have the moral or empirical certainty to make it reasonable to deny assistance with dying for those who clearly want to end their lives because of the level of unrelievable suffering they endure.

I start with the idea that life has intrinsic value. I take this to mean that if it has intrinsic value it cannot be subordinated to some other value. Does this mean that all killing is wrong? If so, I can certainly respect it. Of course, it would rule out killing in war because the fact that those we kill are anonymous would be morally irrelevant if all life is of intrinsic value. It would also rule out capital punishment. To think that certain kinds of killing, whether in war or by capital punishment, are legitimate, is already to have moved away from the idea that life is intrinsically valuable and that all killing is wrong to the idea that the claim of life can be subordinated to other values—to national interest, or whatever, in the case of war, or justice in the case of capital punishment. Hence, most people, I think, believe that there are other values which have to be considered when thinking about the claimed intrinsic value of life. Most people believe that killing of some kinds can be justified. So the question is: can assisted dying be a form of justified killing?

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At the moment, we accept that for some people, their life—in the sense of their biological existence—does not have intrinsic value for them, and we accept that their life can be subordinated to another value held by that person. This is shown by the fact that suicide is no longer an offence and, in some recent cases, someone who has been kept alive mechanically can choose death by requesting that their mechanical aids be removed. This happened recently in a case judged by Dame Elizabeth Butler-Sloss. What is at stake here is the idea that the value of a life to the individual can be determined by that individual and therefore life and its value has to be seen in the context of the values and purposes entertained by that individual. In these legal contexts, we have already moved away from the idea that life is of intrinsic or absolute value.

The problem then arises: what about a person who wishes to die for the same reasons as those in the cases that I have mentioned where such dying is perfectly legal, but is physically unable to commit suicide because of disability or is not dependent on machinery which can be turned off as a withdrawal of treatment rather than active killing? Is there not an injustice in relation to such individuals?

Current opinion says no, for two broad reasons. The first reason is that we have a right to life that cannot or ought not to be alienated. It is worth pointing out that the cases I have mentioned already breach this principle, but let us look at it on its merits. In the western tradition of political and legal thought, rights are usually thought to be assigned in terms of either protecting the choice or autonomy of the right-holder or protecting some vital interest of such a person. If rights are there to protect autonomy, it is deeply paradoxical to prevent someone from doing what they autonomously want to do—namely, to die—and then justify this in terms of the right that is rooted in the idea of protecting autonomy. If the prohibition on dying is justified by the protection of autonomy, it is very paradoxical in that kind of case.

The second possibility is that rights protect basic interests, and one of these is life. The issue then arises of who is to determine these basic interests. Is it the person who has the interest, or are they to be defined by others? The pass has already been sold on this basis by the decriminalisation of suicide and also by the Butler-Sloss decision where the individual is given the opportunity to determine her interests and thus her rights rather than anyone else. So I do not think it is possible for this argument against assisted dying to go through on the basis of protecting rights.

It is argued that assisted dying is deeply immoral because it breaches the claimed categorical distinction between acts and omissions, between killing and letting die. Are we certain that there is a categorical difference? It is wrong, so it is said, actively to kill someone. But on the basis that there is a categorical distinction between acts and omissions, it is not morally wrong in the same sense to watch someone starve to death when one could give them food. I do not think this is a fanciful kind of case because it is arguable that the principle lies behind the policy

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adopted in some hospitals in the UK of the selective non-treatment of neonates who have multiple disabilities. The withholding of life-saving medication or the giving of analgesia which can suppress appetite so that food is not demanded by such neonates can lead them to die extremely protracted deaths.

How is that morally different from watching someone starve to death when one could feed that person? The answer given is that we are not responsible for the consequences of our omissions in the same way that we are for our actions. Is this true, however? The intention of the omission is to render the child dead; and that is its consequence. If that is so, if there is no difference between intention and consequence, how can there be a categorical moral difference between this series of omissions that leads to the child's death and giving the child a lethal injection, in the context of the selective non-treatment of neonates? As philosophers say, it is a distinction without a difference.

Let us take another case popularised by Professor Herbert Hart. The driver of a petrol tanker is hopelessly tangled up in the wreckage of a tanker after a crash. There is absolutely no hope of saving him before the tanker becomes engulfed in flames. He asks the paramedic who is tending him for a fatal injection so that he does not die an agonising death. Are we so sure that if the paramedic fails to act that is morally superior to giving that injection? My intuition is not that that is so clearly the moral thing to do: to leave the person to be burned to death.

I turn to the issue of double effect. The principle is often used by critics of assisted dying to justify what they take to be a more morally legitimate way of dealing with the kinds of cases with which the Bill proposes to deal. It is claimed that it is possible to provide sufficiently large doses of opiates to a patient with the primary purpose of relieving pain but with the foreseeable, albeit unintended, effect that the patient will be likely to die from either one such injection or as the consequence of a number of such injections. That is the principle of double effect: my intention is to relieve pain; the consequence is that the patient may die; I am not responsible for those indirect consequences.

I can fully understand why this doctrine is appealed to so frequently by doctors because it is a very consoling principle for the treatment of the terminally ill. I doubt, however, that it stands up to moral scrutiny. We can be, and frequently are, held to be morally responsible for the foreseeable as well as the intended consequences of our actions. For an experienced doctor it surely must be the case that a particular dosage of a drug will be likely to lead a patient to die; and, if so, this foreseeable consequence is also a matter of the doctor's moral responsibility.

The argument is resisted by those who want to hold to the principle of double effect by claiming that in fact the foreseeable consequences of giving opiates are not as certain as the argument suggests. It is argued that the way human beings respond to medicines is highly individualised and is, therefore, no basis for the claim that the death was a foreseeable consequence of

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opiates administration at a given level and, therefore, the doctor is not responsible for the foreseeable, albeit unintended, effects.

That argument has now been reversed, oddly enough, by the Association of Palliative Care, which claims that two papers give irrefutable grounds for thinking that opiates do not shorten life. Leaving aside the question whether two papers can irrefutably prove anything, it is odd that we are now told that there is absolute certainty about the effects of opiates—namely, that they do not shorten life—when it was argued previously as a way of avoiding the problem that I have posed regarding double effect that the effects of opiates were so individualised that one can never be certain what their effects would be. If my argument is right, the doctrine of double effect does not have the moral force that its defenders believe. I think, therefore, that we do not have the moral certainty to deny this option to people whose strong belief is that they need it.

1.24 p.m.

Lord Alexander of Weedon: My Lords, many of us, I think, will have witnessed the incurable illness accompanied by loss of personal control and autonomy, gradual failure of bodily function, with accompanying loss of dignity, of someone close and dear to us. All will, I think, agree that those experiences are harrowing for the carers, the family and all those who are not personally experiencing the much greater suffering of the person who is dying.

My personal experience included particularly the lingering and inexorable death from cancer of my younger brother. Bravely as he confronted his illness, he volunteered to me some weeks before his death that the quality of his life had incurably gone. Whether he would have wished to assist his own death, I simply do not know. But I do believe strongly that as a sentient, suffering human being he should have been allowed the right to choose. For me, as for the noble Baroness, Lady Jay, and the noble Lord, Lord Plant, an essential, fundamental issue in the Bill is the right to choice; or, as the noble Lord, Lord Joffe, put it so well in his opening address in words which I do not shrink to accept, the loss of personal autonomy.

Perhaps I may acknowledge that a substantial part, even the majority, of the medical profession is not in favour. But they will be free to exercise their choice to decline to assist. I particularly respect, too, the views of those who are concerned that pressure should not be put on sick patients to encourage them to seek prematurely their own death. I hope that it is reasonable to believe that many families and carers will wish to sustain and support those who are dear to them and encourage them to live. I also fully respect the fact that if the Bill is to make progress, exploration will be needed in careful and detailed terms of the effectiveness of the safeguards to prevent abuse.

I do not think that anyone could have listened to the speech of the noble Baroness, Lady Finlay, without feeling that those issues should be carefully explored. But I protest a little more when moral grounds, often

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backed by deeply held religious feelings, are prayed in aid by those who hold them strongly in order to deny others, who are themselves capable of making moral judgments, their right of choice. I do not believe that it is appropriate for those who hold those moral judgments to pray in aid the criminal law. Pray in aid, by all means if they can, their religion and the power of persuasion that goes with it. But do not pray in aid the criminal law against those who seek to make a responsible decision which is contrary to the morality of those who would continue to criminalise it.

I wish to express a few points from my standpoint as a lawyer. I do so with the preface that, as we have already seen in this House, lawyers can disagree on this as on so many issues. My starting point is the existing state of medical ethics as advised by the General Medical Council. As I understand it, it is sometimes permissible to withhold or withdraw medical treatment so as not to prolong life. This is a sensitive judgment. It is never lightly made. But in the event it is made in the best interests of the patient and is apparently morally acceptable. Yet where a patient is suffering from an incurable illness, and makes considered requests for assistance to die, it is still considered criminal and, presumably, morally offensive to respond to that request. I cannot make sense of that borderline in two views of morality, however many Popes may have supported it down the years. I also think that fine and different judgments on it are capable of being made by different people who wish to give effect to their own view of what morality should be.

My concerns about the present law go much further. My fundamental belief is that law should criminalise only acts that offend against public decency or order, or infringe or threaten the rights of others. There may be room, too, for rare cases where conduct is so outrageously offensive to all sense of propriety or moral values that it should be criminalised. However, patient-assisted dying falls miles outside any of those categories. So far as the polls help—public opinion matters—they have shown consistently that the majority of people consider that someone should be allowed a suitably safeguarded right of choice.

I am also comforted by the fact that the Bill would, according to the Joint Committee on Human Rights, be consistent with the Human Rights Act and the European convention. The authoritative French National Consultative Ethics Committee for Health and Life Sciences put the matter very well when it said in 2000:

    "It is never healthy for a society to experience situations where discrepancy between rules as they are laid down and real life is too glaring".

The report pointed out the dangers of both hypocrisy and concealment. As I see it, that is the reality on the existing state of the law. Relatives and doctors help terminally ill patients to die. They face potential charges of aiding and abetting suicide, manslaughter or even murder. The potential penalty for each is high, which no doubt explains why the view often seems to

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be taken that it is inappropriate to prosecute an act done with the best of motives and a strong moral belief that it is right.

For those who act in that way, there is already a difficult enough judgment to be taken without the fear of a serious criminal charge that may or may not be brought, based on criteria that lack clarity. I agree with the noble Lord, Lord Phillips of Sudbury, that hard cases may make bad law. However, hard cases are already making bad law where the existing law has fallen, with many people, into disrespect. What is left behind for those who currently have to decide to circumvent the law is fear, tension and uncertainty.

The Bill may or may not complete its progress through the House. If it does, it may or may not become law. The first Private Member's Bill to incorporate the European Convention on Human Rights was, after all, passed here some 30 years before it was belatedly introduced into our domestic law as one of the most admirable Acts of this Government. I hope that this Bill will do more than simply put down a marker for the future. I see strong arguments for giving it close further consideration.

My noble friend—my good friend—Lord Patten hoped that the Bill would make no further progress. I profoundly disagree. I hope that it will not be strangled at birth when so many people support it. I hope that those who are against it will have the courage to allow it to go forward to be further debated in Committee, or in Grand Committee as proposed by the noble Baroness, Lady Jay. Whether I am right or wrong in my own view—such views are very difficult to form—the fact that that view is shared and led by so many fine and thoughtful people should entitle the Bill to further consideration.

1.35 p.m.

Lord Taverne: My Lords, I regard it as a privilege to support the Bill, and commend the noble Lord, Lord Joffe, on the efforts that he has made, the courage that he has shown—he has certainly not made his life any easier by his proposals—and the eloquence with which he introduced it. I support the Bill because, if it were passed, it would make this country a more compassionate and civilised society.

The moral and legal arguments have been strongly advanced by a number of speakers, particularly the noble Lords, Lord Plant and Lord Alexander of Weedon. I want to concentrate on examining the Dutch experience, because there has been a great deal of focus on the Netherlands, which has led the way. I have read the recent Remmelink report—it is very recent indeed, having only just been published—which has some highly pertinent findings.

My first comment on comparisons with the Netherlands is that the medical profession in the UK, at least through its official organs, is opposed, although I am glad to see that the nurses' leader has come out in support of the Bill. Its objections certainly have to be taken seriously. Dutch doctors, who have experience of such a Bill, are overwhelmingly in favour. Is that because they are less compassionate? Of

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course not. The Netherlands has a great history of compassion in any number of fields. It is a very progressive country. They have experience of the regulatory system, and find that it has worked well. They have not found, as some noble Lords who have spoken feared, that doctor-patient relationships have fundamentally worsened.

It is important to mention that the survey was very carefully conducted. Interviews were carried out by trained doctors. Anonymity was assured. There was a great deal of cross-checking and, as the findings were very similar to earlier surveys, many of the findings seem to have considerable substance. More than 75 per cent of the doctors who were asked to give their views participated.

The survey's first and most important finding is that, contrary to what was feared by the noble Lord, Lord St John of Fawsley, there was no increase in euthanasia or physician-assisted suicide. The figures have remained steady, accounting for 2.7 per cent of deaths, with 2.5 per cent being cases of euthanasia and 0.2 per cent being assisted suicide. Only 40 per cent or so of requests were carried out, but that was partly because in half the cases the patient died before consent was given. In one fifth of the cases, requests were refused.

What is very important again, in view of the fears that many people have expressed, including the noble Lords, Lord Patel and Lord Brennan, and the right reverend Prelate the Bishop of Oxford, is that the survey found no pressure on vulnerable groups. I shall quote from the report, because the issue is vital. It stated:

    "There are no signs indicating an increase in life-terminating treatment among vulnerable patient groups".

That is a very important finding based on evidence gathered over a considerable number of years.

No shortage was found of palliative care. It has often been suggested that the reason for euthanasia is the absence of palliative care. In nine out of 10 cases, the families were completely satisfied with the palliative care available. There were only very few examples of euthanasia being provided in cases where people were simply tired of life. Indeed, in one case where that was the ground on which euthanasia was carried out, there was a public prosecution. It was in fact a prosecution for applying euthanasia to a Member of the Dutch Upper House, who expressed himself "tired of life". Clearly, he was not as stimulated by debates as are Members of this House.

I turn to the issue of non-voluntary euthanasia, which is the area of most concern, to which the noble Lord, Lord Alton, referred. The figures in the report—0.7 per cent of total deaths—were steady, with no evidence of any increase whatever. These were cases of people who were very close to death and did not give their consent because they could not communicate. Fifty per cent of them had already declared their wish to die, and in just about every case the family was very carefully consulted.

What is interesting about the cases of non-voluntary euthanasia is that the evidence shows that, when no legal euthanasia is possible, those cases are much more

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frequent. According to the research done on such cases, the incidence in Belgium was 3.2 per cent and in Australia 3.5 per cent, compared with 0.7 per cent in the Netherlands. Again, the noble Lord, Lord Joffe, referred to that figure in his speech.

Another grey area to which there has been a lot of reference is terminal sedation, or death accelerated by intensive treatment to combat pain, or death caused by withdrawal or withholding of treatment. That is a grey area, and an uncomfortable one. As the noble Baroness, Lady Warnock, and the noble Lord, Lord Plant, said, it is important that the law should be clarified in these cases. Those matters are all outside the Bill, but they are very common in this country. No information is available about them, but the Dutch are trying to find out as much information as possible, while other countries prefer to draw a veil over them. In that respect, the Dutch approach is healthy.

The conclusions of the Remmelink report, which I recommend every person concerned about this issue to read, are that there is no evidence whatever of a slippery slope. The regulatory system is working well, and it has overwhelming support from the Dutch population—85 per cent support it. It is also supported by the vast bulk of the medical profession. It was found that there was better regulation, an increase in the number of written wills and an increase in consultation with families and other doctors. There was much better control overall, and better reporting.

The noble Lord, Lord Alton, made great play of the fact that only 55 per cent of the cases were reported. Of course there was originally a reluctance to report, because there was still some possibility that if anything had not been carefully complied with there might be a prosecution. The figures are very significant: in 1991, when the first Remmelink report was issued, 18 per cent of cases were reported. In 1996, at the time of the second Remmelink report, 41 per cent of the cases were reported. The most recent figure, just published, is 54 per cent.

The Dutch experience is the best guide that we have on a number of issues raised in this debate. It does not dispose of the moral argument against the proposals, but it is highly relevant. There is often a reluctance in this country to learn from experience abroad, but the Dutch experience, as reported in the very careful Remmelink report, provides persuasive evidence in favour of the Bill presented by the noble Lord, Lord Joffe.

1.43 p.m.

Baroness Richardson of Calow: My Lords, I, too, am very grateful to the noble Lord, Lord Joffe, for introducing the Bill, although it gives me no pleasure at all to support it. I wish with all my heart that it were not necessary. I wish that we lived in the kind of society in which every person, no matter what their limitations or how ill or disabled they might be, was valued and could be of vital and contributory value to the life of the society.

It should be the birthright of every person in this society to have the right to holistic care on death, with the provision not only of pain relief but also of relief

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from mental, spiritual and emotional anguish. I wish that a loving network of family and friends was able to surround every person who comes to the end of their lives, giving such a generosity of care that there is never any doubt as to whether they are a burden. Because I am a Christian, I wish that every person here had a faith in a loving God within life, which was able to strengthen and comfort them during the process of dying and to offer hope of life beyond death. Life is not like that for many people, however. This is a Bill whose time has come. Perhaps in the interim, we may look for the kingdom of God on earth as a sign of hope for many.

I support the Bill for the following pragmatic reasons. I believe that assisted dying already happens, that it is piecemeal, secretive and unreported. I believe that the regulations in the Bill would prevent abuse and protect the vulnerable. On the biological and medical issue, I have heard many different opinions as to when life begins, whether it is at conception or birth or somewhere in between, when viable independent life is able to sustain authentic personhood. I believe that there is some uncertainty as to when authentic personhood is deemed to have come to an end. We are accustomed to the notion of "brain death" and we know when the body decays, but maybe there is a state in between those where the will to live has been eroded.

It is now legal to switch off artificial support systems, but some would argue that we should not interfere in the process of dying to hasten it. The most reverend Primate the Archbishop of Canterbury is quoted as saying that it would be,

    "an attempt to take possession of the future".

There seems to be no compunction about interfering in the process of dying in order to extend life beyond what might be termed natural death, sometimes by that means imposing lingering suffering on what might seem to be a rescued life. Life expectancy in the developed world has increased by leaps and bounds, but the death rate is still 100 per cent. A sister in a hospital once said to me, "To us every death is a failure". I do not believe that. A friend of mine who started a course of treatment was asked by the doctor, "Are we going here for quality of life or length of days?" If that question can be asked at the beginning of treatment and can determine the outcome, perhaps that question could be asked later on.

There is no doubt that palliative care can reduce pain and physical distress, but human suffering is much more complex than that. The fear of the process of dying is so great. The Bill is not really about causing death, as that is already being caused by the disease that is overtaking the person, but about shortening the dying process.

With some temerity, I want to offer insights from what I believe to be theology. In this, I recognise that I am going against a weight of theological opinion that has been expressed in many letters. I, too, believe in the sanctity of life, the will of God and the prohibition of killing, but there are other factors within theology that I will rehearse, with your Lordships' permission. Life

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is a gift that needs to be used creatively and to its full potential. Each life is unique, precious, to be valued and respected. Each person is given the responsibility to choose well and the freedom to choose less well. However, each life is not isolated; we are interdependent, and the choices that I make will affect others, while my choices are limited by the ones that they make.

The highest life in Christian understanding is to live for others within the common good. There is sufficient teaching in Christian thought about self-denial, which is not about mortifying the self but releasing gifts for others' benefit. I remember as a child being told the story of Titus Oates who, knowing that his death would happen but wanting to protect those he was with, walked out into the snow. I was encouraged to see that as a noble and heroic act. It is the same sort of concept of self-denial and self-offering for the benefit of others that sends young people to war.

I have no fear that there may be occasions under this legislation when people will wish for the benefit of others to offer their own death. The noble Lord, Lord Brennan, dares to mention medical resources. If I thought for one moment that I could offer the last fortnight of my life, perhaps in intensive care, in order to provide an extra nurse for the baby care unit where my grandson was, I would do it willingly and gladly and without any compunction at all.

Death may come as an enemy or as a friend. The will to live is very strong. Christian teaching says that while death is final, it is not the end of relationship with God. The Apostle Paul said:

    "for me to live is Christ, to die is gain".

For many, even Christians, the focus of hope changes from a life trapped in a dying body to a desire for release into fullness of life. I believe that that is to be respected. Many Christians would want to call on all the resources that their faith gives them to sustain life to the end, until they are able to hand it over into the hands of what they see to be a loving God. But we are not the majority in this country. For those without faith, can we in the name of our Christian conviction deny the final mercy of shortening the process of dying of a life that has become utterly wearisome and distasteful?

I support the Bill. I hope that it will go further. I think it needs to be strengthened. I would really love to see that every person who opts for this is given professional counselling as well as medical information. I would love to see residential homes included in the list of healthcare establishments. I also think that the conscience clause should be extended to all those in the healthcare team. If the Bill does not go further, I hope that it will have created a climate of debate within the country that will enable us really to discuss what is the quality of life and how as a society we can afford not to provide it for all our members.

1.53 p.m.

Lord Clarke of Hampstead: My Lords, like many other noble Lords I am grateful to the noble Lord, Lord Joffe, for the opportunity to discuss the Bill.

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However, I cannot say that I am pleased to be taking part in this Second Reading debate; in fact I am sad that we are having the debate at all. The option of ignoring the debate and keeping silent on the proposals was of course open to me and to other noble Lords who feel as I do. In my view, however, to stay silent would be to turn away from the responsibility that we all have—a responsibility that belongs to everyone regardless of whether they are a Member of this House. It is the responsibility to preserve the basic right to life.

We are being asked to consider proposals that would allow the precious gift of life to be taken away and the state to sanction the act of killing. In my view the House has a duty to uphold the principle that the state has a duty to protect all of its citizens. There should be no concession from this House or indeed from any other place to those who advocate removing the right to life or the state's duty to protect human life.

I cannot bring any new statistics or facts to the debate. I cannot claim expertise in the care of patients suffering from terminal illness or incurable disease. I cannot offer a legal view on the proposals; lawyers have already given those today. I can only approach the issue as a human being who has seen a fair share of what life is like for people at the end of life.

Like many other noble Lords I have received comments and information from lay people, doctors, professors and the views of highly respected representative bodies. It is abundantly clear from the many comments received from concerned lay and professional people that the people of this nation, especially those who would receive the right to end a human life, do not wish to see the provisions passed into legislation; quite the opposite.

It is helpful that so many doctors and medical organisations have given us their views. However, the views expressed in my postbag overwhelmingly oppose the Bill. Earlier, a noble Lord quoted from some of the letters he had received. I should like to quote just one, which expresses my feelings much more eloquently than I could do. This professor writes:

    "I am very concerned that patients will see themselves as a burden, to their families, or the Health Service, and will reluctantly ask for a way out to relieve the burden. There is clear evidence of this being an increasing trend both in the Netherlands and in Oregon. It is strange that in a country in which capital punishment is illegal because of the lack of certainty that we have in the process of law, that we consider the changing emotions of a vulnerable and dying patient a good justification for legal killing".

Later in the same letter there is a suggestion to which we would do well to listen. He said:

    "If Government wishes to do something to relieve the distress of those people who lose hope in the face of a terminal illness, the better way is to provide adequate funding to support and extend the excellent work of those in Palliative Medicine, a discipline founded and developed in the UK of which we should be justly proud".

We should be proud. We have a very good record in palliative care.

I am bound to say, however, that even if I had not received one letter or telephone call or had a single discussion on this subject I would still have come to the same conclusion. What is being proposed in the Bill is

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wrong. Those who support the idea that doctors should with certain conditions be granted the legal power to kill patients pray in aid the need to relieve the dreadful suffering so painfully endured by patients with a terminal or serious progressive illness. I am confident that every Member of this House would agree that there is a duty on all of us to do everything possible to relieve suffering and control pain. However, there is a world of difference between relieving pain and suffering and the deliberate taking of a life.

We are talking about introducing legislation that would allow killing. It is no good trying to dress it up as something else. It is no good trying to present it as anything other than killing a fellow human being. It would literally be granting a licence to kill.

This Second Reading debate has attracted a large number of speakers and I shall not take up much of your Lordships' time. To me, this question is not a matter of intellectual argument. It is not about setting out the criteria to be used to justify the act of killing. It is not about who can justify the final act. However many clauses the Bill contains, the question is both straightforward and fundamental—it is about right and wrong. It is about the right to life and the granting of a licence to end a life.

Just a few weeks ago my dear brother died after suffering for a considerable time from cancer. In his last few weeks he received care and dedicated attention from the doctors and nurses and from his loving family who made his final days as comfortable as possible. I thank God that there was no suggestion that he should have received anything but that devoted attention. If there were any procedural way in which this Bill could be brought to a peaceful and conclusive end today I would support such a move. I shall, whenever the opportunity arises, vote against this Bill. It is, as I have said, about right and wrong. There can be no doubt—to kill is wrong.

2 p.m.

Lord Mowbray and Stourton: My Lords, the noble Lord, Lord Clarke of Hampstead, has said almost everything that I wished to say. I completely agree with his views. My comments have also largely been covered by the noble Lord, Lord Phillips, who made many remarks that I should have liked to make, although I would not have expressed them half so well as he did. The noble Lords, Lord Brennan, Lord Patten and Lord Alton, also covered points that I wanted to make.

Noble Lords will gather that I shall not make a long speech, which is good from their point of view. It is also obvious that I speak from a deeply Christian angle. My beliefs are firm. I understand all the difficulties that the statement we are discussing could cause for lawyers and doctors. We all have our beliefs that we must accept.

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With the help of friends I have gathered together a few facts, most of which have already been mentioned. So far no speaker has mentioned Jennifer and Bob Stokes from Hertfordshire who killed themselves by drinking a lethal dose of sodium pentobarbital in an assisted suicide in Zurich, which has been much written about. Their family was appalled. According to the family, neither Mr nor Mrs Stokes was terminally ill, nor were they wheelchair users, and they were certainly not chronically depressed. If we were to allow such things to happen here, what an appalling state of affairs it would be. I hope that we in the United Kingdom shall not go down that road.

Many of the points that I had contemplated making were rather hit out of the field by the noble Lord, Lord Taverne. He hit sixes. I do not know whether his dates are different from mine. He said that his information was the most up to date. I shall not challenge him. In any case he cannot respond at the moment as he is not present.

According to the Bill, unbearable pain or suffering seems to be the hoop through which one has to jump for euthanasia to be acceptable to some. Yet, as Dr Andrew Lawson, a consultant in anaesthesia and pain management, recently pointed out in the Daily Telegraph, why is this so? The article states:

    "If I am allowed to die because I am in terrible pain, a situation that in any event should not happen, why cannot I be allowed to die because I do not wish to live? How much pain and of what kind do I have to have for it to be enough of a burden to be allowed to die? Surely it would be discriminatory to suggest that only in certain circumstances can euthanasia be allowed. One would in effect have to prove to someone else's satisfaction that one's quality of life was so bad. This would inevitably involve a subjective judgement which would diminish individual choice".

Euthanasia cannot be limited except by arbitrary and discriminatory regulations of the sort contained in the Patient (Assisted Dying) Bill.

One might be able to understand why the noble Lord, Lord Joffe, and his allies wish to see the introduction of state-sanctioned killing if there were no alternative. Thankfully, however, there is. Here in the United Kingdom we are fortunate enough to lead the world in the practice of palliative medicine. We owe an immense debit to individuals like Dame Cicely Saunders, founder of the hospice movement and president of St Christopher's Hospice in London. Our hospice movement coined the phrase "death with dignity" and it is a source of immense sadness and regret that that phrase has been hijacked by the pro-euthanasia lobby.

Dr Nigel Sykes, the current medical director of St Christopher's, recently addressed a meeting in Parliament on this Bill. He warned that there is the real concern that because killing is cheaper than caring, killing will become a frequently used "treatment". He could envisage a situation where people, not just old people, might feel that they had to pass a sort of "MoT" test and that if they failed, they would be "bumped off".

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Professor David Currow, Professor of Palliative and Supportive Services at Australia's Flinders University in Adelaide, also told a meeting in Parliament that,

    "Positive requests for euthanasia usually result from poor medical care",

and that when good palliative care is offered, there is a dramatic drop in requests.

It is instructive that an independent survey of doctors carried out by Opinion Research Business (ORB) and published on 13th May 2003 revealed that not one—I stress, not one—palliative care doctor who responded to the survey would practise either euthanasia or assisted suicide. I shall omit the next few sections of my notes as they have already been mentioned by the noble Lord, Lord Alton, and objected to by the noble Lord, Lord Taverne. I see no object in repeating their two arguments.

One case from the Netherlands is particularly disturbing. A Dutch GP, van Ooijen, was placed on trial because he had terminated the life of a nursing home patient at the request of the family rather than the patient. Van Ooijen was found guilty of murder, yet was not punished because he acted "with integrity". Experience in the Netherlands has demonstrated the impossibility of establishing an effective regulatory framework for assisted suicide and euthanasia.

Rather than introducing legislation of the type proposed by the noble Lord, Lord Joffe, our focus should be upon increased support of our marvellous hospice movement through greater funding and investment. Most doctors evidently support greater developments in both hospice and geriatric care. The ORB survey to which I referred earlier revealed that overall 66 per cent of doctors considered that the pressure for euthanasia would be lessened if there were more resources for the hospice movement. A majority of doctors (55 per cent) also felt that pressure would be reduced if greater resources were allocated to geriatric care.

I, too, have received an enormous amount of mail from all sorts of people, including from a religious leader. Archbishop Mario Conti, Archbishop of Glasgow, wrote:

    "We have a fine tradition in this country of curing the sick and caring for those who are terminally ill. This great tradition finds particular expression in the hospice movement. It is in improving and enlarging our hospices, not in practising euthanasia on the old, the vulnerable and the frail, that we advance as a civilised nation".

I think that we can all agree with that. If, as was reported last week, our hospices receive less than a third of their funding from government and have to rely upon charitable donations and lottery funding to provide care for the terminally ill, that is a scandal which must be swiftly remedied by the Government.

I regret that I cannot support the Bill introduced by the noble Lord, Lord Joffe, as noble Lords will understand, but I appreciate the considerable care with which he explained it to us.

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2.10 p.m.

Lord Russell-Johnston: My Lords, it was never my intention to make a long contribution to the debate, because I knew that the noble Lord, Lord Joffe, would—as indeed he did—set out the objectives of the Bill with clarity. I simply wish to affirm publicly my support for a proposition for a change in the law, which I, unlike the two noble Lords whom I follow, regard as benign, civilised and overdue.

Having listened carefully to all of the debate, I wish to make two brief points. Quoting from the speech of the noble Baroness, Lady Warnock, I agree that the Bill arises from "the morality of compassion". One must admit, however, that that is sometimes an untidy approach. Nevertheless, I have listened to the various legal objections—one lawyer said that it was "legally unworkable"; another said that it was "open to abuse" and that "hard cases make bad law". No one has ever demonstrated that to me, although it is frequently repeated. All the legal objectors ignored, as indeed did the noble Lord, Lord Mowbray and Stourton, the speech of the noble Lord, Lord Taverne, who indicated that the euthanasia legislation that is in place in the Netherlands is finding acceptability in the Dutch medical profession, to make no mention of the public at large. A detailed survey has been carried out.

It is nonsensical to suggest that the doctor-patient relationship, and all of the other forecasted social calamities which have been listed in often apocalyptic language, have made the Netherlands "a dangerous place for old people", which was the expression used by the correspondent of the noble Lord, Lord Patten, to describe Britain if the Bill were passed. The Netherlands has not become a dangerous place for old people. There is now a similar euthanasia law in Belgium. Similar arrangements exist in Switzerland. The contention that they are uncivilised, disorganised places is also nonsense. As the noble Lord, Lord Taverne, said, the Netherlands is one of the most progressive countries in Europe.

My second point is that I noticed that none of the critics of the Bill directly addressed the Diane Pretty experience. I have learnt from my correspondence, as, I am sure, have other noble Lords, that that experience is sadly but one of many.

The logic of the critics is nevertheless clear. When faced with the question of what they would do for Diane Pretty, their only logical answer is nothing. They might, like the noble Lord, Lord Alton, add that they feel extremely sorry for her, but they would not do anything for her in that circumstance. The Bill suggests a way forward that is legal and in a proper frame. We know that quite a number of mercy killings, as they are described, are carried out against the law in this country by doctors who are risking legal action because of their compassion for the patient. That is an unsatisfactory and unacceptable situation.

I shall make two final points. Among those active in opposing the Bill is a group called Pro-Life. Its name rather implies that, as I do not agree with them, I am pro-death. That is not the case. However, I cannot understand the attitude of those who for ideological or

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theological reasons are prepared to deny people such as Diane Pretty the right to end their misery by their own choice. They should have that right. Those who oppose the Bill are also denying choice. The maximisation of choice is one of the political and emotional imperatives in a civilised society. I recommend the Bill very strongly.

2.15 p.m.

Baroness Masham of Ilton: My Lords, I thank the noble Lord, Lord Joffe, for giving us the opportunity to discuss this very serious situation, which the Bill brings to your Lordships' House. A lobby outside this House passed a paper to me a few minutes ago, which reads:

    "Whilst the Lords take up time legislating our deaths, we demand that Parliament spends time legislating our freedom".

Many disabled people throughout the country feel threatened by the Bill.

What is more important than life and death? I do not believe that the majority of doctors want to be responsible for killing, but there are some people for whom the power of being able to do that gets the better of them.

It is not long since we saw the ease with which Doctor Shipman, a GP, got away with killing his patients on many occasions. When another doctor noticed that too many patients in the practice were dying, the police did not seem to act and more people died.

The Patient (Assisted Dying) Bill could make that sort of dreadful thing easier. More power has been given to primary healthcare, putting more pressure on the service.

My husband's aunt used to say that if she became incapacitated, she wanted to be put down, as might happen to an old dog, but when she contracted Alzheimer's, she stopped saying it. The Bill could open the way to making it even easier for the police to shrug off a death with, "It's the law anyway".

One of the Ten Commandments states: "Thou shalt not kill". If one believes in the sanctity of life, one cannot consider making the Bill law. We need the safeguard of not to kill in the difficult and complicated society in which we live. The Bill is a wake-up call that will alert many people to the pressures and inadequacies around us. I have a few questions for your Lordships to consider. Is there enough support and expertise in the homes of terminally ill and severely disabled people? Is there enough support for hospices? How much training for severe disability do doctors and nurses receive in their curriculum? What is the attitude of doctors to severely disabled people? The Bill could damage the relationship between doctor and patient.

I founded the Spinal Injuries Association and its members made me their life president. Many of our

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members are completely paralysed from the neck down. Our association's aim is to give them support and hope. I quote one of the members, Dr Ian Basnett:

    "I became quadriplegic following a sporting accident 17 years ago. I was ventilator-dependent for a while and at times said to people, 'I wish I was dead'. I am now extraordinarily glad no one acted on that and assisted suicide was not legal.

    I think the first difficulty I faced was the fact that like many people, I had a terrible negative image of disability. When you suddenly become severely disabled you still have that viewpoint. Before I was disabled, I was working as a junior doctor. That brought me into contact with disabled people and I remember clerking in a man with quadriplegia. My reaction was, how could anyone live like that? I said to my then girlfriend 'I'd rather be dead, if I couldn't play sport'".

How attitudes can change.

Certain pressures may well result from legislation on assisted suicide. Every older person who fears being a burden and every disabled person with an inadequate care package will have a shadow over them from the knowledge that the law thinks that it may be better if they were dead. Without the lives of disabled people being seen as having equal value, any attempt legally to sanction hastening our death will exacerbate a culture that fears incapacity so much that it wants to extinguish it.

Disabled people feel that the Bill is discriminatory. Non-disabled people who want to die are offered help to live as a first priority. There is no mention of counselling in the Bill. There is no mention of independent advocacy or help with communication. Not all physicians are expert in palliative care and pain control.

I am encouraged that the Royal College of Physicians has looked seriously at this matter. It said:

    "It is . . . not enough to simply oppose the Bill without offering alternative suggestions".

A medical student has written saying:

    "Voluntary euthanasia violates all historically accepted codes of medical ethics including the Hippocratic Oath, The Declaration of Geneva and the International Code of Medical Ethics".

She says that she does not wish to be made one of the most dangerous people in the UK with the power that the Bill would give her.

A group of Dutch doctors who visited the UK last weekend expressed concern that suicide was "spreading and spreading" in Holland and that suicide pills were now becoming freely available.

The Archbishop of Glasgow, whom I knew as a parish priest in Caithness a long time ago, wrote:

    "To take this step would be to open a very dangerous breach in the protective shield currently provided to the most vulnerable citizens by British law".

I agree with him.

2.23 p.m.

Baroness Pitkeathley: My Lords, I am a great admirer of the noble Lord, Lord Joffe. I was an admirer of his long before he came to your Lordships' House when, as head of a carers' charity, I benefited from his far-sighted and innovative approach to funding the work of charities. He is a man who thinks

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creatively and caringly. I know that he is motivated by the best of intentions in bringing this Bill before your Lordships' House. I am therefore particularly sorry that I must speak against the Bill.

Few people would argue against the view that they want to be able to die in a humane and dignified manner and above all free from pain. Those of us who have had near death experiences—I am sure I am not alone among speakers today when I say that I, with the unfailing support of my family, have faced the prospect of imminent death on more than one occasion—know the huge emotional stress of such experience for all those involved and the yearning for peace, tranquillity, freedom from pain and resolve of some kind from almost intolerable pressure. My personal experiences and those of my family have led me to provide a living will so that my children know my wishes and that if called upon again to make decisions about my life and death they would have something more than their instinct on which to rely. However, those personal instincts and personal safeguards are a very different matter from passing into legislation the right to assisted dying.

Let me emphasise two things at the outset. First, I absolutely acknowledge that this Bill is very limited in its provisions and that the noble Lord, Lord Joffe, and the draftsmen have been at pains to ensure as many safeguards as possible. My objections are therefore based on principle. There could be no Bill drafted which could overcome my objections to the principle of allowing assisted suicide and I do not think that that is inconsistent with my belief that individuals should have the right to end their lives if they are capable of doing so without assistance. It is the involvement of someone else—in this case, a medical practitioner—and of the danger of categorising assisted death almost as an alternative form of treatment to which I object.

From my work over many years with carers of those who are extremely ill or who have life-threatening illnesses, I have been witness to the appalling strain that is sometimes placed on carers and the guilt that they feel when they wish for relief by the death of the cared-for person, as they inevitably do from time to time. Carers have said to me time and again, "I wished for him to be out of pain and felt I could not go on any longer but I am so glad now that I did everything I could for him".

I know that the decision as set out in the Bill would be made by the patient and the medical practitioner together but it is impossible that the family—or at least the main carers—would not also be involved in some way. Carers feel enough guilt at the death of a loved one without another such decision or involvement being added to their burdens. I also feel that the involvement of a doctor could seriously undermine the relationship of trust which is necessary for the success of medical treatment. That, too, could have an effect on the future relationship of the family with the doctors concerned.

Of course, supporting families at this difficult time involves ensuring the provision of proper care and, above all, pain relief for the dying person so that the

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last days or weeks can be an experience to cherish rather than to dread. I feel, as other noble Lords have said, that we would be better advised setting up more hospices at home to provide care and support and counselling than legislating to offer alternatives. We should concentrate on alleviating pain, distress and suffering as we approach the end of life, not on ending the life itself. We have learned a great deal, I hope, from the hospice and palliative care movement.

The development of palliative care is advancing very rapidly. Pain and symptom control are unrecognisable now from what they were a few years ago and most people will now have had at least one experience of seeing a friend or relative die either in a hospice or with proper palliative care at home and know that it can be turned from a distressing experience for everyone concerned to as positive a one as possible.

I also have a major concern about the pressure which might be brought to bear upon those who are being cared for, or those who live independently but with profound disabilities. Legislation allowing assisted suicide, however tight the controls, always runs the danger of reinforcing negative stereotypes about the quality of life for those with a profound disability. Many of us say, as the noble Baroness, Lady Masham, reminded us, "I would rather be dead than live as a quadriplegic, or as someone with motor neurone disease". However, it is not for anyone else to make that judgment—only for disabled people themselves. I fear for the pressure—silent and covert pressure rather than public, of course—which could be brought to bear on someone who is very vulnerable.

Current coverage of the situation in countries in which assisted suicide is possible, about the speed with which decisions are taken and about the expectations which are very quickly established, does not make very comfortable reading, in my judgment. Many seriously ill or disabled people might feel pressure—real or imagined—to request an early death because they feel that that is what their families want. Given the reluctance—it is well documented—in our society to talk about death in an open way, I believe that that might well happen. I am the first to acknowledge that more help is needed by people and their families as death approaches but I believe that help should be given in the form of ensuring that sufficient palliative care is available and that enough counselling services are provided to the sufferer and his or her family to ensure that the right to a dignified and pain-free death is available to all without changing the law.

2.30 p.m.

Lord Laing of Dunphail: My Lords, I, too, thank the noble Lord, Lord Joffe, for introducing the Bill to this House. In supporting it I should declare an interest. I am a practising Christian and firmly believe in life after death. Remember the words,

    "This day you will be with me in paradise".

Our world is a very small part of the universe and while important to us, we should be aware of wider horizons and their implication for life after death.

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I have family experience of assisted dying. My father and one of my brothers both had incurable cancer and towards the end were, although this was not acknowledged, helped to "go" when the pain could no longer be properly controlled. It was certainly their wish to die with dignity and in their time, and they did. So, what we are debating today goes on, I suspect every day. The noble Lord, Lord Russell-Johnston, alluded to that, if I heard him correctly.

On the other hand my father-in-law, a Major-General aged 90, was blind, deaf and incontinent and had no interest or wish to remain alive but against family advice was given regular antibiotics whenever an infection occurred. To what purpose?

The Bill's objective is quite clear; to allow mainly elderly people to die with dignity and at a time of their choosing. That is the principal strategic purpose of the Bill. Surely it must be difficult if not irrational to condemn it. Strategy should never be confused with tactics. If the strategy can be agreed, the tactical element of providing safeguards to abuse becomes paramount. My wife and I have each made a living will, which state categorically that when we have no interest in living and are a bore to ourselves and our loved ones, we should not officiously be kept alive.

Which of us in the Chamber, if blind, deaf, incontinent and enfeebled in mind, would not prefer to be given the choice to say that enough is enough and a doctor or nurse be allowed to do the necessary for a quick and painless death. Of course, there have to be safeguards. The ones written into the Bill seem to me, as a non-lawyer, to be adequate. If not, it cannot be beyond the wit of man to devise additional safeguards without becoming hopelessly bureaucratic. I heard the comments of the noble Lord, Lord Phillips of Sudbury. I hope that his objection could be overcome. Special attention must also be given to the disabled, who are obviously a special case.

Now aged 80, I can think of nothing worse, after a very happy life and over 53 years married, with children and grandchildren all well and with my financial affairs in order, than to be kept alive against my will if I have a painful and incurable disease. While I have great admiration for the hospice movement, having lived an active and full life surrounded by a loving family, I want the right to bring my life to an end when the time comes in a manner and time which I choose.

To deny me the legal benefit of a painless and dignified death, putting an end to terminal indignities would seem to me to be a high degree of bureaucratic arrogance and morally questionable. Thousands of others must feel as I do and would expect their doctor, as I would mine, to achieve their wish when clearly stated and written.

2.34 p.m.

Baroness Thomas of Walliswood: My Lords, I welcome the Second Reading of this Bill. It allows us to discuss a very important matter which, as our e-mails and letters have shown, is of enormous concern to many people. My only doubt is whether this House

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will be able to give the attention to the later stages of the Bill which it deserves, given that we already have a very crowded timetable between now and the Summer Recess.

The first point I want to address concerns the argument put by a number of correspondents that suicide is wicked and against God's teaching and that therefore helping someone to commit suicide is equally wicked. I acknowledge the magnificent speech given by the noble Baroness, Lady Richardson of Calow, on that subject. I am not a lawyer, still less a moral philosopher or a theologian, but I take the view that the law in a secular society such as ours determines what we may or may not do, partly from custom, partly guided by the principles of human rights, and partly with reference to what is generally regarded by the citizen as ethically acceptable. There is certainly a good deal of evidence that the public support the sort of approach to this difficult subject which the Bill proposes.

Furthermore, the law has decided that suicide is not illegal, even if some people still regard it as wicked. My noble friend Lady Walmsley felt obliged to withdraw from today's debate because she cannot remain to the end. But it was she who helped me to clarify my own thinking in this area when she pointed out how strange it is that a person who is able to obtain the means to kill herself is not prevented from doing so by any legal threat, whereas someone who is too ill or weak to commit suicide may not have the help she needs to determine the time of her death without making her helper a criminal.

To put it as Lord Joffe did in his notable brief, giving the terminally ill patient the power to determine the time of his death with the assistance of another restores that sense of autonomy and control over his own life, the loss of which is a major determination of patient's wish to die.

My second point concerns the importance of having clarity in the law on this matter. One of the worst effects of the current situation is the anomalies it causes. It is not illegal to turn off the machines which are keeping alive an otherwise totally helpless and unconscious person. It is illegal to assist a competent adult to shorten her life or to die a peaceful death, even if she is only too aware of the pain, indignity and helplessness of her situation as a terminally ill person and of the likelihood of an extremely uncomfortable death.

Meanwhile, the evidence shows that some doctors do assist patients to die sooner and more comfortably than they otherwise might, despite knowing the risks they take. Very few are ever brought to court. I understand that in the appalling Shipman case, colleagues went to the police at a relatively early stage and expressed doubts about his treatment of patients but no action was taken. Perhaps if the law had been different, more precisely drafted along the lines suggested in the Bill and with a clearer delineation between what is and what is not acceptable practice,

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the police might have been more confident of carrying out at least preliminary investigations at an earlier stage.

Thirdly, I turn to the points made by many in their e-mails and letters that palliative care can deal with the problems of the terminally ill and that a dangerous practice that could end with the involuntary suicide—that is, murder—of the weak or disabled is therefore unnecessary. From reading the evidence provided to us, my conclusion is that even with the best of palliative care, death from a number of medical conditions can be intolerably painful, terribly traumatic or both.

The letter from a woman about her son who knew that he would choke to death but was unable to find anyone to help him avoid the ultimate struggle will not soon leave my mind. Hamlet describes death as that undiscovered country from whose bourne no traveller returns. If death is inevitable, if a dying patient asks for help to cross that frontier in peace and dignity who are we to deny what medical care can make possible? Why should we continue to criminalise those who would, as doctors, be willing to assist?

I am reassured that the safeguards in the Bill are sufficient to ensure that patients will not be helped to die against their will and that the Bill will not lead to the slippery slope that ends in the greedy individual or impatient society killing the weak or disabled for their own, not the sufferers', purposes.

Finally, I should add that I believe that there is much to be said for the idea of a living will to enable those threatened with mental incapacity at the end of their lives to determine the time and manner of their death. The Bill does not cover that issue; and I could support one that did.

Nevertheless, I intend to support the noble Lord, Lord Joffe, if he puts the Motion again at the end of the debate.

2.40 p.m.

Lord Beaumont of Whitley: My Lords, I speak from the mini Green Bench at the back of the Chamber. However, like other Members: I do not speak for my Party. My party, like all others, seems unable to make up its mind on the most important subject of all. It gets out of it by saying that these have become votes of conscience. It was my understanding that all Members of the two Chambers actually treated every vote as a vote of conscience. So I do not think that that is a very good escape route.

My second background is that I am a priest of the Church of England and one who has studied—and kept up-to-date with—theology the whole of my life. I have not come across any arguments that I regard as conclusive in saying that the freedom of choice which we are given in free will cannot be exercised in the matter of our deaths. That brought me to become chairman at one time of the Voluntary Euthanasia Society, or, as it was then rather I think better named, EXIT. It was going through a bad time. There were certain scandals. Therefore, I know all about the dangers and the problems. However, I became its

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chairman so it could publish a pamphlet giving people guidance as to how they could, if they had to, end their own lives. That I do not regret for one moment.

The right to commit suicide is not a crime. I have that right, although I hope and expect it will never come to that. However, if it did, I would want to do it with the help of my friends and relations without them running the danger of going to prison. I claim that right. I claim it for myself and, like I hope all your Lordships, what rights I claim for myself I would also wish to give to other people. It is for that reason that I believe we should give a Second Reading to the Bill. I agree that there are all kinds of issues that may need clearing up at later stages—the tactics, as was so recently well put, as opposed to the strategy. I am totally clear on the strategy. I support the Bill.

2.43 p.m.

Lord Ahmed: My Lords, this is one of the most difficult Bills for many of us who have very deep religious beliefs and moral values and who understand the social pressures for the terminally ill, the elderly and the disabled. It also has most serious and disturbing consequences for the authority of medical practitioners and changes active killing as a fundamental harm to a potential benefit and clinical codes of conduct.

While I believe that the motivation behind the Bill is deeply humane and has some support within our communities as well as in this House, the great majority of the British public and more than 70 per cent of doctors are against euthanasia and assisted suicide if—God forbid—this Bill becomes law.

This is the second time, after Section 28 of the Local Government Bill, that I have had so many letters, e-mails, and telephone calls advising me either to support or reject this Bill. Certainly an overwhelming majority has told me to oppose it on many different grounds. The great majority of those who have written to me have been professionals—doctors, nurses, practising Christians, and people of other faiths and no faith. I received only one letter from a Muslim urging me to oppose the Bill on the grounds of my religious beliefs.

Another reason why Muslims have not been writing to me over this religious and moral issue is that we have no choice in the matter. As Muslims, we believe that life is sacred and that only God, the creator of all, is the owner of life. Like all other Abrahamic faiths, we believe that only almighty God will decide about the life end of each one of us. No doctor, judge, MP, or Lord can give any ruling to end the life of any innocent human being. That is why in Islam and in all holy scriptures euthanasia and assisted suicide are prohibited. Furthermore, the concept of a right to die was overwhelmingly rejected by the British and European courts in the Diane Pretty case, which has been mentioned a few times earlier in the debate.

Two weeks ago my grandmother died at the ripe old age of over 100. She was able to look after herself until she was 95. However, there were occasions when she became ill, bedbound and dependent. One could argue

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that after the age of 90 she was suffering but had lived a good life, and, therefore, we could help her to end her life. However, thank God, we did not have any such law that allowed anyone to do that because Islam and other religions, as mentioned, encourage us to look after our elderly, to give them due respect, and to look after them during their illnesses. We would not have enjoyed the last 10 years of her life if the Bill had been part of our law.

In Chapter 17, verse 70, of the holy Koran, Allah says,

    "And indeed we have honoured the children of Adam and we have carried them on land and sea and provided them with lawful good things and have preferred them among many of those whom we have created".

I shall quote at least twice more from the Koran. The value of human beings is in Chapter 4. It says:

    "Do not kill yourselves, for verily Allah has been to you most merciful".

The principle of saving human life takes precedence over everything else. In Chapter 5, verse 32, the Koran states:

    "Because of that we ordained for the children of Israel if anyone killed a person not in the retaliation of murder, or [and] to spread mischief in the land—it would be as if he killed all mankind, and if anyone saved a life it would be as if he saved the life of all mankind".

That is why I believe 30,000 Muslim doctors and health professionals along with millions of British people would agree with me that life is precious and that, in spite of all the pain and suffering one experiences, only God can make the decision of cure or death. The Prophet Mohammed in his Hajj sermon said:

    "Your life and your property and your honour are sacred until you meet your Lord".

The National Council for Hospice and Specialist Palliative Care said that, "Euthanasia", once we accept it, is uncontrollable, for philosophical, logical and practical reasons rather than the slippery slopes of moral, laxity, or idleness. Patients will certainly die without and against their wishes if any such legislation is introduced. That will come out of what will be a doctor's revised duty to kill in situations of unbearable suffering or where they are seen to be acting in the patient's best interest, according to the redefinition of active killing as a potential clinical and societal good.

Even if we put aside religious faith-based arguments to oppose the Bill, and just look at morals and ethics, we can still come to the conclusion, as mentioned by the noble Baroness, Lady Masham, that the Hippocratic oath, the Declaration of Geneva and the International Code of Medical Ethics all state a value for human life. The duty of practising physicians is to make their priority the health and well-being of their patients and not their demise.

I am sure that many of your Lordships will quote from the International Code of Medical Ethics. It states:

    "A physician should always bear in mind the obligation of preserving human life".

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Those codes of medical ethics are as relevant to the medical world today as when they were first written. We learn from history and those documented oaths the significant words that doctors, nurses and medical staff learn. That is why I oppose the Bill.

With regret, I must tell the noble Lord, Lord Joffe, that if, later today, there is a vote to kill the Bill, I shall vote to do so.

2.50 p.m.

Lord Chalfont: My Lords, the noble Lord, Lord Ahmed, mentioned one of the phenomena which always accompany a Bill as controversial as this—namely, the emergence of a highly organised postal protest lobby. It has happened again in this case. I have received, as many of your Lordships will have received, a great volume of mail inviting me—in many cases almost instructing me—to oppose the Bill. Those letters were written to a clear brief provided by someone, often by people who had not read the Bill and had little idea what it was all about. The writers of the letters in many cases insisted that to oppose the Bill was the only possible course of action, and that to support it was cruel, immoral, or both.

Indeed, many of the letters contain phrases which do little to advance the cause of clear thinking: phrases such as "euthanasia is an act of violence", and "doctors will become licensed killers in a culture of mass murder". I often wonder whether the people who organise such postal propaganda campaigns realise how much they harm they do to their cause by alienating the very people whom they seek to influence. Of course, euthanasia is not an act of violence; it is a word with a clear Greek derivation and precise meaning. It means:

    "a quiet and easy death or the means of procuring it",

and anyone who reads the Bill carefully will see at once that those terms and others, such as "licensed killers" and "mass murder", have nothing whatever to do with what is proposed in the Bill.

My reply to the people who have written such letters has been one that I think would find a measure of agreement in your Lordships' House—namely, that I would listen carefully to the arguments on both sides before making up my mind. As we have heard today, there are powerful arguments, intellectually and morally respectable, on both sides of the debate.

I have no professional qualifications in the matter. My own brief contribution will deal with just one aspect of the problem. It is this: assisted dying is already a common occurrence in this country, despite it being against the law. A recent survey suggests that one in seven general practitioners in this country have helped patients to die at their request, even though that is a criminal offence, so there is a discrepancy between what the law says and how it is applied. In fact, in 1977, a survey of general practitioners revealed that nearly half of them had in one way or another eased a patient's death.

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In the current legal climate, the fact that there is no regulation regarding assisted dying leaves many genuinely vulnerable people unprotected. It would surely be better to have a clear and unambiguous legal framework to enable terminally ill people to be able to ask for medical help to die, within strict safeguards—I underline that—so that, as the noble Baroness, Lady Thomas of Walliswood, said, any instance of assisted dying outside the legislation could be dealt with consistently and severely.

One strong argument advanced by opponents of the Bill is that which is sometimes referred to as the "slippery slope"—that is, that such legislation might open the flood gates to abuse. In fact, I would advance the opposite argument, which is that the existence of carefully drafted legislation, embodying all the essential safeguards, would provide protection against abuse and what is sometimes called involuntary euthanasia.

The Bill has obviously been drafted with great care. It provides robust safeguards against abuse and carefully protects the doctor-patient relationship. I congratulate the noble Lord, Lord Joffe, both on the drafting of the Bill and on his courage in bringing this important issue into the realm of public debate, and I have no hesitation in asking the House to give it a Second Reading.

In conclusion, I return—perhaps vainly—to my proposition that this is an extremely important and profound problem, with respectable and sincerely held arguments on both sides. It should not be confused, as it has been by some lobbyists, by extreme and ill-considered language, or manipulated by unscrupulous propagandists.

2.56 p.m.

Lord Maginnis of Drumglass: My Lords, I am obliged from the outset to consider the context in which the Bill is set before us. It comes at a time when, here in the United Kingdom, it appears to be fashionable systematically to discard every accepted rule for living in a civilised society, and to replace them with a collective of legislation allegedly designed to promote human rights. I am ever being encouraged, in the furtherance of tolerance, human rights, liberty, freedom of the press, freedom of the individual, independence of the judiciary—and every other cliche to which so-called "modernists" appear to claim exclusive rights—that I have to accept changes of such magnitude.

I do not want by what I am saying to give the impression that I am some old fogey who cannot accept change or who has led a cloistered existence. In fact, this ex-rugby-playing schoolmaster, farmer, policeman, businessman, soldier and, latterly, elected politician, considers himself to be the very antithesis of cloistered. However, none of my encounters with life—and death—has prepared me for a situation where society is now invoked to abandon the accepted tenets by which I, for one, have tried to live for the past 65 years.

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Does not the Bill really mean that our society is expected to accept that deliberately killing another human being is, in certain circumstances, socially—indeed, morally—acceptable? That would be the thin end of the wedge and no one can even hazard a guess where it might end.

I voted in another place to abolish the death penalty for murderers. Many, like me, voted thus because of a religious conviction that God alone should be the arbiter when such a criminal is no longer a threat to society. But why should we have one opinion for the most base of individuals and another for the most vulnerable? Have religion and morality no longer a place in our consideration of what is beneficial?

On that point, having listened carefully to the caution from the noble Lord, Lord Alexander of Weedon, I felt that perhaps, if Jesus of Nazareth had been a lawyer, rather than a carpenter, I might have been able to claim more justification for my opinion. I wonder how we would vote if the Bill advocated that prisoners destined to spend, say, 30 or more years in prison should be allowed the option to be legally put to death. It could ultimately be argued that that would be one logical and reasonable development if we pass the Bill. Indeed, could not anyone at all, in the final analysis, assert "equal rights" to require the institutions of state to facilitate his killing?

Am I being ridiculously futuristic? I think not. Many, including doctors, who accepted the legalisation of abortion, with all the constraints and conditions that attached to the original Bill all those years ago, now live to regret the wholesale slaughter of unborn children—the majority for mere social convenience. What was intended and what resulted are now poles apart.

There is undoubtedly a dignity and sincerity attached to the plea where someone argues that, in one's final days, one would prefer to be helped out of this world rather than linger in a totally helpless and dependent condition. But, do we not all arrive in this world helpless and dependent? As there is no indignity in that, why should we imply that the state of being ill or elderly or both is different? And where might this Bill, in years to come, leave the child born and surviving in a profoundly disabled state—comparable, say, with a sufferer from motor neurone disease? Who will make the decision to kill the one that can never choose for himself?

Some of us are old enough to remember the social engineering philosophy of our enemies in the 1930s. This nation fought to destroy that evil. That, I fear, is the next logical question. May it not ultimately demand the same logical answer? I do not want to overlook what happens when logic outweighs morality.

Am I out of step? Perhaps I am in respect of the thought processes evident among some elements of society where, for example, the absence so far of weapons of mass destruction in Iraq is given greater consequence than mass graves with thousands of human remains of those who have been killed by the state. But, like many others where I live, for the past 30

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years I have walked daily, side by side, with cruel death. None can better understand the value of human life than I.

I have not spoken about the intolerable burden that this Bill would place on doctors or the anxiety that it would create for elderly who are content to meet God in His time. Suffice to say that virtually all of us who trust our physicians today would be deprived of that trust if our doctors' role was to be utterly ambiguous, as this Bill would permit.

I am not lacking sympathy with those who suffer either physically or mentally, but I have to conclude by asking why someone who would advocate his own killing by a doctor would not, before reaching a state of total disablement, take responsibility for that himself? No, I am not being callous, nor do I advocate suicide. If what I say offends anyone, it is simply that I am trying to illustrate how offensive is the reciprocal—that complete inequity and contradiction which would create a legal dilemma for some "healers" to become "killers". I implore your Lordships to join me in rejecting this Bill.

3.4 p.m.

Baroness Young of Old Scone: My Lords, I support this Bill which, in my view, is a rather modest step covering a very limited and defined set of circumstances. It is surrounded by careful safeguards, checks and balances against misuse. It meets a very real need by providing to a very defined category of patients an option to be helped to die when faced with unbearable suffering and the prospect of a ghastly death. I should stress that it is an option. Simply by passing this Bill we are not necessarily saying that everyone will be compelled to take that option. But it would be available and would extend the range of choices when facing a situation which I suspect many of us would dread to find ourselves tested by.

I commend the noble Lord, Lord Joffe. He has done a lovely job on this Bill with exquisite care; I believe that it is very effective. For 20 years I managed health services in both Scotland and England, including cancer care and palliative care services. In the past, I have had responsibility for two hospices. I, too, have seen patients in grave anxiety—indeed, in some cases in terror—about the manner of their dying.

Some of the debate today has promoted the view that improved palliative care will remove the need for assisted dying provisions. I do not believe this to be true for two reasons. First, even with palliative care, many conditions can mean a horrible death for patients. The terror of death can be dreadful, particularly when there is severe respiratory distress. Aside from that, we are far from having easy access to high quality palliative care for all. Therefore, we must continue campaigning for improved care, but that is not enough and never will be. We also need the provisions of this Bill. It is not about either palliative care or the ability to be helped to die, it is about having both of those options.

It is not just the actual way of dying that can be an abomination. Anticipation of a terrible death is a huge fear for many patients with progressive terminal

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disease. In particular, they feel loss of control and loss of autonomy. There have been some comments regarding autonomy today which I believe misunderstand quite how strong a desire this is in many people. Many of your Lordships will have been very much in control and in the driving seat throughout their lives. Imagine coming to a point at which one is no longer able to consider the choices and to make the decisions that need to be made.

This Bill provides a choice. It provides an ability for a patient in this circumstance to know that he or she can opt for being helped to die—even if they do not ultimately take that choice either because the palliative care is satisfactory or because some other circumstances change. But the comfort of knowing that, right to the end, one can be in the driving seat, is something from which people should not be barred.

Furthermore, I believe that this Bill sets a strict framework around assisted dying, which, as many of your Lordships have already commented, is happening at the moment without any adequate regulatory framework. I believe that the safeguards are strong. I was very impressed when talking to doctors who give independent second opinions under the Dutch system. They have a careful stepwise analysis of whether the patient and his circumstances meet the criteria for assisted dying. The analysis includes going very carefully—both with the patient and again with the medical practitioner—through the medical history and present condition of the patient and explores whether the suffering is really unbearable as judged by the doctor; that is, both actual suffering at that current time and future suffering.

As far as he is able, the doctor takes account of the personality of the patient, which can determine the ability to deal with suffering of a particular type, and the prognosis and progress over time. The doctor looks at environmental aspects: is the patient alone or does he have a supportive family and friends? He makes an assessment about mental status and considers whether this is truly a voluntary action and whether it is well considered. He ensures that it is not a whim in the face of a staggering and devastating diagnosis and that it is not driven as a result of the grief of family and friends. I believe that that account of the types of safeguards in this Bill is quite persuasive. Again, that analysis would fully confirm the decision ultimately made by the patient.

Lastly, the issue of the value of life has been raised many times. I cannot believe that others can cling to the value of a life when the patient him or herself no longer does so. The Bill is about extending common humanity to our fellow human beings. I recognise the proposition put forward by the noble Baroness, Lady Jay, to allow further discussion in a Select Committee. That may have to be the case, but I would regret it if we were to delay much longer on this. The Bill fulfils a need which is out there, but at the moment is being met under illegal circumstances. The Bill of my noble friend Lord Joffe is a modest and well-designed step. I hope that it will be taken further.

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3.10 p.m.

Lord Gray of Contin: My Lords, I am happy to follow the noble Baroness, with whose remarks I entirely agree. It is not an original thought, nor is it an unusual saying, that the only certain thing in life is death, but it certainly is a truism. The fortunate among us die peacefully while asleep. The less fortunate contract a disease with which their system or organs cannot cope and, like an ageing vehicle, they become too worn out to combat fatigue, while the truly unfortunate among us die of one of the more ghastly terminal complaints or physically punishing illnesses.

It is the last of those groups which gives the greatest cause for concern since all too frequently such diseases are accompanied by extreme pain, severe discomfort and often mental fatigue. Obviously those distressing features demand compassion and, wherever possible, co-operation from family, friends, medical staff and carers. It is with those thoughts in mind that the Patient (Assisted Dying) Bill has been fashioned. We are indebted to the noble Lord, Lord Joffe, for introducing this legislation, providing us with the opportunity of discussing it and, it is hoped, persuading Parliament that the passing of such a measure into law would be an act of compassion of the highest order.

Although there are many reasons why this Bill should be supported, there is one above all others; that is, whatever the present law may say, people are helped to die in this country. By far and away the best way of protecting the most vulnerable in society, and ensuring that assisted dying takes place only at the request of the terminally ill person, is to regulate assisted dying.

In my view, it is outrageous that doctors, driven by compassion and respecting the wish of their patients to end unbearable suffering, should, by co-operating, place themselves at risk of conviction. The noble Lord, Lord Joffe, has gone to great lengths in the very first clause of the Bill to provide detailed definitions. That is important, so that the status of physicians and of the individual patient is clearly defined and the meaning and wording of any declaration is fully understood.

The Bill has been drafted so as to be complementary to palliative care and is limited to competent adult patients with a terminal illness or with a progressive and serious physical illness. At this point I should like to put on the record that I am an active supporter of the hospice movement, and I pay tribute to the wonderful work it does—and would continue to do after the passing of this proposed legislation. Those safeguards also ensure that the vulnerable would not receive medical assistance to die as a result of outside pressures. It would be well nigh impossible for an adult to make a successful request without fulfilling all the specified criteria.

Since the Bill was published, and indeed for some time before, as have other noble Lords, I received a considerable number of letters in support of assisted dying. The Diane Pretty and Reginald Crew cases aroused a groundswell of indignation from the public that the wishes of those patients were ignored. People wrote giving examples of the suffering of their loved

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ones and some gave very moving accounts of their frustration and anger at not being able to assist in the dying process and of not being able to ensure that the wishes of their nearest and dearest were put into effect.

Dignity in death is something to which everyone is entitled, but there is precious little dignity in having to continue to suffer the pain, mental agony and the indignity of the loss of control of one's bodily functions, sometimes for a period of months or even years. "The right to choose" is an expression used loosely in many campaigns, but surely the right to choose to end the suffering caused by terminal illness is among the greatest of all rights.

Several of the letters I received described in detail the horrendous forms of suffering experienced by some patients, despite the fact that they were receiving professional nursing and caring of a very high order. Yet those patients felt that they had suffered as much as they could bear. They wanted to die in peace and without further delay. "Assisted dying" in this Bill means the painless "inducement of death". I must admit that I also received some letters asking me to oppose the Bill. While I respect the views held by those people, I cannot accept their reasoning. It was obvious that they had not had the opportunity to study the Bill, which goes to such lengths to protect the most vulnerable.

Throughout the past decade a variety of ways have been employed to assess public opinion on this subject. The questions asked in different polls have not always been identical, so it is difficult to draw exact comparisons or conclusions. What has become apparent, however, is that the public have become steadily more supportive of a change in the law to enable people to make a decision themselves about the timing of their death, should they succumb to the horrors of a terminal or progressive illness.

Since 1996, support has been continually in excess of 80 per cent. Within the medical profession itself opinion has moved considerably over the years. This year, Medix-UK, the leading medical research website, asked 1,000 doctors in a confidential survey: "Under what circumstances do you think physician-assisted suicide should be permitted?". Of the doctors surveyed, 55 per cent responded with, "Terminal illness with uncontrollable physical suffering", while only 39 per cent responded by saying, "Under no circumstances".

The results of research which has been carried out in the Netherlands and Belgium have already been referred to by other speakers, so I shall not weary the House by going over them again.

In conclusion, regulation, by its very nature, will encourage greater consultation between doctor and patient and an obligation to consider alternatives such as palliative care. But after all such alternatives have been considered by the doctor and the patient, and of course provided that the patient meets the requirements of the qualifying conditions outlined in Clauses 2, 3 and 4, then it must be the right of the patient to determine the timing of death; the right of the patient to choose, which is the very essence of this legislation. I strongly support the Bill.

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3.18 p.m.

Baroness Greengross: My Lords, I add my congratulations to my noble friend Lord Joffe, whom I respect and admire, in particular on the sincerity and compassion which has motivated him to introduce this Bill to your Lordships' House. I speak with some trepidation and have agonised somewhat about how I would address these issues, in part because I have immense respect for those whose beliefs draw them to the opposite conclusion of my own, but mostly because of the background of my working life. However, it is precisely because of that background that I support the Bill. I should like to add that I am not a member of the Voluntary Euthanasia Society.

Throughout almost all of my working life I have worked with, for and on behalf of older people and disabled people of all ages. I have campaigned and called for an end to the prejudice and discrimination which so often dogs their lives. I am deeply saddened that so many people who are disabled or old, and the organisations that represent them, have felt that the introduction of the Bill, if it were to become law, would lessen the value of their lives and would denigrate their lives further. It would be the absolute opposite if the Bill became law, and should not make them feel a greater burden or give them any more of those negative feelings that damage our society. The fact that such people are often subjected to discrimination and prejudice is a societal ill. I continue, and shall continue, to fight that, but that has nothing to do with the Bill, which is about terminally ill, suffering people who might be of any age or of any background and who are suffering from incurable and progressive illnesses or dying in much pain.

I believe passionately that all human life is of equal value. It does not matter whether a person is old, young, disabled or able-bodied. The matter is not for us to judge. Many of us know only too well that we can be inspired by the most severely disabled people whom we meet—perhaps more than anyone else in our lives. We all accept today that the responsibility of the doctor to his or her patient continues until the point of death and that that includes the process of dying. That responsibility does not end when no more effective treatment can be given. Modern medical practice and the enormous progress with palliative care in the hospice movement demonstrate how much can be done.

However, there is another side of modern medical practice that says that the patient must be at the centre of any decision-making and treatment. Any competent adult has a right to decide what treatment they should accept and be given—or not given. We must all ultimately make decisions about our own lives. Added to that we have to recognise that doctors have always helped people to die and still do in this country. They might be generous with drugs and the matter is part of their feelings of compassion and their medical professional judgment to the best of their ability to do the best they can for their patients. For some patients the issue is a lottery.

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Nowadays doctors who do show that compassion, and are willing to ease painful or difficult deaths, need protection in our much more open and litigious society—because of the increasingly rapid medical advances that are made all the time, which now change the state of people who can be kept alive. The current situation is also challenged by people who feel that they have to go overseas to seek to die in an unregulated manner—which, as the noble Baroness, Lady Finlay, has said, can sometimes go wrong.

There is a need for the Bill, which has careful safeguards built in; independent assessment, the exploration and the offer of alternatives to dying, including going into a hospice, having palliative care in another way and counselling—the availability of which must be improved. If the Bill became law there would be no point in offering people alternatives if those alternatives were not available. To comply with the law there would be an added spur to bring in more services, more palliative care and more hospice care, which is what most of us would like. Anybody feeling that they had to die because there was not enough care for them and they were too expensive for the state to support would be a terrible admission of failure on us as a society.

We also know that palliative care is not always totally successful, nor always appropriate in every case. I am an enormous fan of the hospice movement. Many people whom I have been privileged to know, including my own father, died in a hospice. I will always be grateful for the wonderful care that he received. The key point is that any adult who is mentally competent must retain the maximum autonomy to make the decision about their own life. If anybody feels that they need to die because pressure is put on them because they are a burden to society, that is a tragedy. Giving in to greedy grasping relatives is a tragedy. The noble Baroness, Lady Pitkeathley, knows more about carers than anyone else. We have to address the issue of carers who are driven to the point that they can no longer cope, or who put pressure on somebody they care for, or have had pressure put on them. I believe that the introduction of the Bill would make it inevitable that we improve the services that we give to people.

We are dealing with a form of reverse discrimination. As a competent adult, if my body functions, if my arms and legs work, if I decide to commit suicide—a tragedy for anybody, if after all the offers of alternatives, all the proposals that medical and care staff make to me, I want to end my life because I am terminally ill and I want to end it with dignity in the way I feel most appropriate, then if I am able to walk, move and reach those drugs, I can do it. If I am so disabled by my illness and I cannot reach those drugs then I cannot end my life. That is discrimination against disabled people that none of us should tolerate.

We must not muddle that central argument with any weakness in our system of care or in terribly discriminatory or prejudicial attitudes towards the most vulnerable people among whom we live. That is why I am unconvinced by slippery slope arguments.

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They relate again to social ill, not to the Bill, which is limited in its effect, applying only to people who are terminally ill or in terrible pain.

If the procedures for assisted dying were open and transparent, our services would have to be improved. The Bill has safeguards against poor care and the different arguments about being a burden. I know that the noble Lord, Lord Joffe, is willing to look again at those safeguards because I know, and I know that he thinks, that there may be areas that are still not completely covered. We need to make sure that those are improved. Whether the Bill becomes legislation or not, we are having an important debate. I hope that the Bill will reach Committee stage so that we might debate the provisions in detail and, where necessary, have the opportunity to improve it. I believe that the proposal of the noble Baroness, Lady Jay, for setting up a Select Committee is worth considering again. I hope that people in this House will support the Bill.

3.19 p.m.

The Lord Bishop of St Albans: My Lords, while I thank the noble Lord, Lord Joffe, for stimulating the debate and doing so with courage and compassion, nevertheless I believe that there are three twists of logic in the proposals before us that make me shudder with a kind of atavistic horror. I repeat that I have no doubt at all that the proposals have been created with the highest and most sincere of intentions. However, that makes the dangers that they carry even more troubling, if not frightening. I shall spell out the three twists in the moral logic.

The first concerns the concept of personal autonomy. We have heard many speeches this afternoon based upon that concept. I do not doubt that personal autonomy is a moral good, but that is not the only determinant of what constitutes our human meaning and purpose. My human meaning and purpose consists not only in exercising individual choice—but like all human beings I have to do that in a social context.

If I exercise personal freedoms regardless of the well-being of others, then I live in an amoral world of my own and would rightly be described as psychopathic. My human meaning—our human meaning—is partly constructed in relationships with others, which is why as human beings we give love the highest value. I would argue that the capacity to grow in understanding of myself and my relationships with others can and does go on developing right up until the moment of death.

When I was a parish priest I was for a while a part-time chaplain at a hospice. It was a privilege beyond description to share with others in caring for the dying and their families. We all know that hospices are places of profound peace, where some of the noblest and most precious aspects of our humanity are discovered and explored. They are places where daily miracles occur; where depths of love and truth, often neglected in our busy lives, can be encountered.

I recall a particular patient, an Austrian woman who for most of her life had lived entirely alone. She was formidably independent. I was sitting with her a

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day or two before her death when, looking around at her fellow patients, she said to me, "This is the best trade union I have ever been in". She said the words with a seraphic smile and with a quiet and astonished pride. Her understanding of herself in relation to others had simply been transformed. Two days later she died.

The Bill, in a justifiable attempt to give the highest value to personal autonomy—the right to choose and all of that—is in danger of denying one of the most significant truths about our humanity. We are not simply individuals; we are at our most human in relationship to and with others. No man is an island, not even in death. So by what authority and by what right do we in this House want to legislate to deny a fundamental truth of our humanity? I would humbly suggest that this is individualism pushed to a horrifying and giddy conclusion.

It seems to me that there are one or two other philosophical flaws floating around the debate. Perhaps I may draw attention to another before moving on. The ability to do something does not mean that I have the moral right to do it. I may wish in my worst moments to punch someone on the nose, but I do not have the moral right to do so. In some of the speeches in your Lordships' House there has been an unhelpful linkage between those who are said to be certain and the use of the word "zealotry". That is a shame and unhelpful.

A number of noble Lords have referred, in passing, to us living in a secular society. It is one of those phrases that goes unchallenged. I simply suggest, again in passing, that the most recent census figures would indicate that, yes, of course fewer people attend and practise their belief in specific religious buildings, but the levels of belief and spirituality in our nation are huge. To describe us as secular is simply not accurate.

The next twist in the logic concerns the word "compassion". I have heard many claim—I have heard many today claim—that euthanasia is compassionate, even merciful. But, as Professor Robin Gill has pointed out, the net result of introducing legislation on compassionate grounds is that we could—not necessarily would—create a society which is,

    "distinctly less compassionate. In such a society the elderly might feel pressured not to continue their lives at the expense of the young. The permanently disabled might feel the same. The health service might put less resources into palliative and geriatric care".

In the name of compassion the Bill could—not necessarily would—create a merciless society. If it could, then it might. Is it any wonder, therefore, that some of us might shudder at that prospect?

The third twist in the logic centres on the concept of dying with dignity. Of course we would all wish that for ourselves and for others, but our dignity, like our autonomy, is also built on trusting relationships. The relationship between doctor and patient, as many have said, has to be based on absolute trust, and only on absolute trust can dignity be assured. To achieve the goal of dignity which the Bill seeks could—not necessarily would—destroy the very trust which makes human dignity possible.

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The Bill, while claiming to uphold personal autonomy, may deny the very means by which true autonomy is discovered and exercised; claiming to uphold compassion, it could destroy compassion; claiming to uphold dignity, it could undermine it.

I believe, as a Christian, in the profound and inalienable sanctity of human life. I recognise that that is a view shared by some humanists and members of other faiths. I believe that our life is God-given and that the purpose of our lives is not terminated by death. But I humbly suggest that the Bill threatens all of us, believers and non-believers alike, because it could, by a terrible and frightening irony, destroy the very values it claims to uphold. I urge your Lordships not to allow the Bill to pass.

3.37 p.m.

Lord Turnberg: My Lords, I speak briefly today as a physician who practised in Salford and Manchester for most of my working life and as someone whose opinion, I freely admit, may be biased by the experience of caring for many patients who would come into the category of those we are considering today—that is, patients who are terminally ill or suffering from long-term incurable illness.

Anyone who has to care for such unfortunate people cannot fail to be emotionally affected by each and every one of those who face them so directly in this way. The desire to help alleviate their suffering is very strong indeed. So it is very easy for me to have considerable sympathy for the motives behind the Bill of the noble Lord, Lord Joffe, but I must strongly oppose the particular solution for relieving patients of their distress which the Bill proposes.

My objections are based on two rather practical reasons, neither of which have reliance on any religious or moral views that I may also hold. They are, first, the diversion of attention away from the need to provide good palliative care—an issue to which I shall turn in a moment—and, secondly, the distinct possibility of making mistakes about who would be killed in the process.

Care for patients coming towards the ends of their lives requires of their doctors and carers considerable sensitivity, compassion and understanding, as well as relief for symptoms causing their distress—and, of course, it requires much psychological and emotional support. It is sadly the case that these needs are not always met for all those who have them. Unfortunately, all too often we have inadequate facilities for palliative care and too few staff to provide all that is needed; and not all those who should be trained to deal with these patients receive training.

Compassion for the suffering cannot be legislated for. Where good palliative care services exist, they do a marvellous job. It is interesting that none of the doctors who work in such an environment felt that there was a need for assisted suicide and none would want to perform it. So I remain to be convinced that we are anywhere near exhausting the possibilities of what good care can provide before we take the ultimate alternative of terminating the life of the sufferer. The

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fact that there are failures in the current arrangements is an argument in favour of looking at the causes of failure, not substituting another solution. There is, of course, a distinction between respecting a competent patient's refusal of treatment and assisting that patient in suicide. There is also a distinction between assisted suicide and stopping futile and often uncomfortable treatment or the use of adequate pain and symptom relief. Those should be a normal part of the care patients deserve on the basis of careful judgment, after a thorough assessment of the particular patient's needs. Legislation would tread with heavy boots into this area.

So my main thesis is that patients should, by right, have access to the best sort of care available, and which can and does offer them what they need at these distressing times. Part of the reason why I am against offering to help a person's suicide is because it may divert the NHS from providing the best facilities possible and doctors from delivering the best care. That is quite apart from a whole series of reasons, which many others in this debate have described, about the uncertainties surrounding judgments which would have to be made about the nature of a patient's suffering, whether it is unbearable and unrelievable, whether a patient is depressed or of sound mind and, in particular, whether they are under pressure because they feel that they are a burden to themselves and others around them at a time when they are at their most vulnerable. The safeguards proposed in the Bill do not give me any confidence at all about that. I worry, too, about the impact of the Bill on the sensitive flower of the doctor-patient relationship.

So I believe that legislation is the wrong route, and while I welcome the attention that the Bill has drawn to the need for better care for the dying and the distressed, I cannot support it.

3.42 p.m.

Baroness Cumberlege: "I pledge myself and promise: that I will exercise the art and science of Medicine to the best of my powers and in accordance with the laws of honour and probity; that I will work for the benefit of all, whosoever shall seek my service, without distinction between great and small, rich and poor, youth and age or good and bad; that I will hold my knowledge in trust for the benefit of the common weal; that I will remember the example of my teachers who have given me this knowledge and give to those that follow me the gift of knowledge which I have myself received; and whatever I shall hear in the lives of others, so be it improper to disclose, that will I not disclose".

My Lords, on Sunday week, I will be taking the graduation ceremony of 190 newly qualified doctors—eager, excited, joyful young men and women who have spent either five or six exacting years studying to become members of the medical profession. They, together, will recite the pledge that I have just read.

These talented young people enter medicine to cure, care and treat, not to kill. In the pledge, they will promise to exercise the art and science of medicine. That is where the rub is. Medicine is not just a science, clear-cut and precise—it is also an art, an art which requires wisdom, judgment, compassion and courage.

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Aspiring doctors are taught how to treat, how to intervene, how to save life, but increasingly, through the new curriculum, they are taught ethics. Specifically, in year 1, they take part in an "end of life" seminar discussion. In year 3, they attend weekly seminars on issue such as end-of-life decision-making, the doctrine of double effect, consent to treatment, the ethics of physician-assisted suicide and euthanasia and comparisons of law and practice in different countries. In year 4, they have group discussions using demonstration and videotapes for feedback. They visit hospices and, with a family doctor or community nurse, they visit terminally ill patients at home. They discuss the role of the clinical team in managing patients with a terminal illness, and so on.

Only a few years ago, this would not have been commonplace. Death was considered a failure of modern medicine, but today's students are taught to recognise it as inevitable and to learn how to help patients and their relatives to come to terms with death and dying, how to manage the worst symptoms and how, as far as possible, to make the patient comfortable at the end. I think this is wholly encouraging for the future quality and access of palliative care.

Like many of your Lordships, I have been overwhelmed by the number of letters I have received from people on both sides of the debate. I am grateful for them. Like the noble Lord, Lord Alton, I have taken particular note of those from doctors, because the Bill seeks to put the responsibility on to them—in my view, unfairly. My noble friend Lord Patten mentioned the letter from Professor Jonathan Shepherd. I, too, read that letter and I thought it was extremely interesting because it is not from a palliative care physician but a surgeon in oral and maxillofacial surgery. He wrote, as my noble friend told us,

    "adding the ability to kill people . . . would have a devastating effect on the doctor-patient relationship.

But he also wrote:

    "Families are broken and fractured enough these days, without this threat of therapeutic termination of life of its most vulnerable members".

I agree with that. I do not want today's medical students to include in their learning an armoury of therapies, a battery of poisons and devices to end life. Neither do I want them to go out into the world in the knowledge that their motives are open to question, that the trust between doctor, patient and families—families under stress—is no longer taken for granted but is a variable commodity to be assessed and possibly negotiated.

The noble Lord, Lord Taverne, argued his case in favour of the Bill based on the Dutch experience. The evidence, of course, has been questioned by the noble Lord, Lord Alton. One has to see these surveys in the context of the country. We know that the palliative care service in Holland, Belgium and Switzerland does not match our own in its quality and comprehensiveness.

I share the concern of the medical profession in this country that giving doctors the power to end life would totally alter their relationship with patients and

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introduce a whole new dimension—that of fear. There would be fear that ending life was part of the legitimate therapeutic portfolio, fear that costly treatment at the end of life would be selfish and deny others treatment, fear that a responsible citizen should have a duty to exit prematurely. I am afraid the adage, "Where there's a will, there's a relation" is very often true. There would be fear that a responsible doctor should put scarce public resources before the needs of his or her patient.

Death is frightening enough without wondering whether your doctor is on your side. I want doctors always to put the patient first and to exercise Pare's dictum—cure sometimes, relieve often and comfort always. I appreciate that "comfort always" is commonly known as the double effect. It has been exercised for centuries and today it has been philosophically challenged by the noble Lord, Lord Plant, and one or two others. But for practical purposes, I find it acceptable, within the law, and a matter best discussed honestly and openly between the doctor, the patient and those nearest to the patient. Unlike the noble Lord, Lord Chalfont, I am comfortable with grey areas—I do not want the lawyers, the politicians, the Daily Mail and the rest of the world involved. For me, it is a private matter, a matter of trust between the individuals concerned.

Professor Sir Cyril Chantler, who pioneered the GMC guidelines on this subject, told me that if Parliament was intent on passing a law on assisted suicide, that is a matter for Parliament and politicians. But please, he said,

    "don't place a duty on me or my profession to be any part of it".

How deeply sad it would be if, on Sunday week, the 190 newly qualified doctors leaving St George's medical school had to alter their pledge and promise to accommodate assisted dying. It would undoubtedly diminish their total and unswerving commitment to care, treat and cure. So, while respecting the integrity of the noble Lord, Lord Joffe, I cannot support the Bill.

3.50 p.m.

Lord Neill of Bladen: My Lords, there has been a lot of public interest in the Bill. Mention has been made of the fact that we have received letters. Here and there, there has been a word of criticism from noble Lords. I hope that the message will not go out from this House that we do not want our future legislation to be the subject of intense public interest. It is highly desirable that it should be. I welcome the letters I have received from individuals and from societies. On balance, numerically I believe that they are in favour and would support the Bill but I have received them both ways. I welcome that degree of public interest.

Within your Lordships' House this matter has produced a fine degree of eloquence and strong opinions on moral and religious grounds. We have had extremely interesting speeches by those with medical qualifications. If one were taking an example of the value of this House, one would find it difficult to have a better example than the debate today.

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I make clear that I shall be an opponent of the Bill—I shall not touch the religious or moral ground—simply on the practical consequences. What would be the tendency of the Bill on society, doctors, the medical profession, young entrants to the professions, nurses, the hospice movement, families and vulnerable persons? My fear is summed up by a phrase from the eloquent speech by the noble Baroness, Lady Finlay, who said:

    "A sense of a duty to die is all too easy to create and all too difficult to detect".

My fear is that the enactment of the Bill will by itself create that sense of a duty to die in old and vulnerable people.

I am further worried that it will enable family pressures of one kind or another to be exerted on the vulnerable. I suppose that we have all spent time visiting geriatric hospitals. We all know case histories of divided families. I am afraid that this island is not inhabited by saints. One has families where an elderly person is in care or in a home that is costing a lot of money per week, per month, and per year. He may not be close at hand and has to be visited. That imposes a burden. Perhaps he is occupying what is considered to be a nice family house for one member of the family. One encounters cases—if noble Lords have not had experience of this they have led a fortunate life— where the elderly member of the family is regarded, frankly, as a nuisance. Of course, the elderly person cannot fail to become aware of the feeling—I think that the Bill by itself creates such a climate—that he is a nuisance and a burden. Many speakers have referred to the feeling on old people of being a burden. I believe that the Bill will give rise to pressures on people to accede to being put to death by this means, and going through the motions of this procedure.

Those pressures will be extraordinarily difficult to detect. In his carefully drawn Bill, the noble Lord, Lord Joffe, is very aware of the existence of this danger. In Clause 2(2) the attending physician has to have decided that the request is "not the result of external pressure". It is the family doctor, in effect, who forms that view. Along comes the consulting physician who I think we can reasonably assume knows in advance very little about the patient. He, too, has to reach the conclusion that the patient wishes to die and that that is not the result of external pressure. How a consulting physician can easily form that view is difficult to understand.

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