Retirement of a Member: Lord Hodgson of Astley Abbotts
The Senior Deputy Speaker (Lord Gardiner of Kimble)
My Lords, I should like to notify the House of the retirement, with effect from today, of the noble Lord, Lord Hodgson of Astley Abbotts, pursuant to Section 1 of the House of Lords Reform Act 2014. On behalf of the House, I thank the noble Lord for his much-valued service to the House.
Space Industry (Indemnities) Bill
(1 day, 16 hours ago)
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Baroness Anelay of St Johns (Con)
My Lords, I congratulate John Grady MP, who introduced the Bill in the House of Commons, where he secured all-party support. I thank all those who supported the Bill in this House as it made its way through Second Reading. Every Member who participated at Second Reading supported the Bill.
I am also grateful to the Minister for responding in constructive detail both during the debate itself and subsequently in a letter to all Second Reading participants, in which he answered the detailed questions posed by my noble friend Lord Moylan, the opposition transport spokesman. The Minister’s hard-working experts, who may well be in the Box today, no doubt had an expert hand in that.
The Bill amends the Space Industry Act 2018 to provide legislative certainty that spaceflight operators will not face unlimited liability when operating from the UK. As a consequence, the Bill should strengthen investment in the UK’s space sector, which is important for both the economic growth and the defence of the United Kingdom. I beg to move.
Viscount Stansgate (Lab)
My Lords, I will not detain the House, because, as we all know, there is important business ahead. However, I congratulate and thank the noble Baroness, Lady Anelay, for her work on the Bill and for having brought it to the stage where it is poised on the brink of the statute book. As someone who, in the past, has piloted a Private Member’s Bill through to its final stages, I know very well that the Private Members’ Bill procedure can indeed change the law of this country.
The Bill literally changes one word, from “may” to “must”. As a member of your Lordships’ UK Engagement with Space Committee—I am not here to talk about our report, Act Now or Lose Out, interesting though it was—I believe that the Bill will unlock investment and a space economy for the future. The UK could be well placed to play an active part in that. I thank all those involved and wish this Bill very well in the future.
Lord Moylan (Con)
My Lords, this is the second Bill this week that, in effect, transfers risk or cost away from private investors to the taxpayer or the fare payer, to help put Britain on the path to industrial success in the future. I say to the Minister, who supports the Bill, that this is a long way from the days of the railways, when private money without government support and without any transfer of risk—and sometimes with private investors losing their funds—built our great railway network. However, it turns out that this is necessary for our success in space and so we support the Bill and congratulate my noble friend Lady Anelay of St Johns on bringing it forward and to a successful conclusion. Like her, I thank not only the Minister for his friendly and open engagement but his civil servants, who have been supportive in this process.
The Minister of State, Department for Transport (Lord Hendy of Richmond Hill) (Lab)
My Lords, I thank all noble Lords for their contributions to and support for the Bill. I offer particular thanks to the noble Baroness, Lady Anelay, for steering the Bill through this House and to John Grady for bringing forward this short but important Bill in the other place.
The Government recognise that the question of liability and insurance is of utmost concern to the space sector, given the value that the industry places on having legislative certainty on this matter and the concerns that it has raised about the use of the word “may” in Section 12(2) of the Space Industry Act. I am therefore grateful to the noble Baroness for the Bill, which, by amending Section 12(2), will meet a key request from the sector.
Arrangement of Business
Captain of the Honourable Corps of Gentlemen-at-Arms and Chief Whip (Lord Kennedy of Southwark) (Lab Co-op)
My Lords, before we move on to the fourth day of Committee, I will make a statement about proceedings, as I did on the previous three sitting Fridays. I hope again that this will help planning and is in line with how business has proceeded previously.
First, it is important to thank the staff of the House—those on duty today in their various roles and those who have been working in preparation for today’s proceedings. The whole House greatly values their work and we thank them for what they do.
The Government Whips’ Office has circulated the updated groupings list. As previously, my noble and learned friend Lord Falconer of Thoroton has set a proposed target for today’s debate. As was the case in previous weeks, I expect the House to rise at a convenient point around 3 pm. In line with usual procedures and the Companion, we maintain the typical flexibility to rise slightly before or beyond that point to include the group we are debating. As we have considered only six groups of amendments in three days of Committee, we should be looking to make considerably more progress today. Ultimately, this remains in the hands of the House and not in mine, in my role as Government Chief Whip. I expect to return to the Dispatch Box this afternoon, between 2.30 pm and 3 pm, to advise the House further.
I want to make a few other points before we again begin Committee stage of the Bill. In doing so, I fully accept that not everything I say is accepted by the whole House, but I ask noble Lords to accept that my intentions are good—it is to show the House in the best light and enable the House to deliver effective scrutiny of the important issues before us.
Many times, before this Dispatch Box as Government Chief Whip and from the Dispatch Box opposite, as Opposition Chief Whip, I have made reference to the Companion. Following its guidance is of great assistance to the House and to all noble Lords in undertaking our important work every day. I make that same point today. Following the advice of the Companion would help us all to have a better debate and proceedings today. In that light, it is important to remind ourselves that this is Committee. Noble Lords should address their remarks to the amendments under consideration and not make long, Second Reading speeches, going way beyond the substance of the amendment that is being debated. This is all set out in the Companion on page 143, 8.81.
Also, we do not accept interventions on interventions. That is not the House of Lords way. Please refrain from attempting to do this. I have asked the Government Whip on the Bench to intervene to stop this practice if it begins. If any noble Lord makes an intervention, I refer them to the Companion, specifically page 60, 4.29, which makes it clear that interventions should be a brief question of clarification only and not another speech.
When pressing or withdrawing amendments, noble Lords should be brief. This is set out in the Companion on page 143, 8.82. I expect, as I believe all noble Lords do, that despite sincerely held views and differences of opinion, we will always conduct ourselves with courtesy and respect for one another and show the public watching our debate the House of Lords in the best possible light. So, as I have said before, please refrain from doing anything that would bring that into question.
As I have said previously, the acoustics are excellent in this Chamber and the microphones are very sensitive. Noble Lords should not be holding conversations in the Chamber or making remarks that they would not like to be broadcast live. If you wish to speak to another noble Lord, please retire to the Prince’s Chamber, the Royal Gallery, the Peers’ Lobby, the Long Room or the Peers’ Guest Room and then return when your conversation has ended. These are good places to have conversations and I regularly use them on other days.
After every sitting Friday’s debate on the Bill, I have noble Lords with very different views contacting me in the proceeding days, expressing their frustration with other noble Lords sitting near them who seem to talk constantly, to the annoyance and inconvenience of others. I ask noble Lords to please bear this in mind. As I have said, noble Lords should have their conversations outside the Chamber.
This is a Private Member’s Bill. The noble Lord in charge of the Bill is my noble and learned friend Lord Falconer of Thoroton. It is not a government Bill and the Ministers on the Front Bench are not in charge of the Bill. It is not a government Bill and it will not become a government Bill. The Government remain neutral. That position is not going to change. I have said it time and time again; this will not change.
Having made those remarks, which are said to assist the House, we should now move on to debate the issues of substance before us.
Baroness Hayman (CB)
My Lords, very briefly, I am extremely grateful to the Chief Whip for what he has said. Enforcing the Companion is obviously a prime responsibility of the Whip, the Front Bench and the Government Whips, but it extends further. Would he confirm that any of the Whips can intervene and point out when the Companion is not being adhered to and that that applies to any Member of the House as well?
Lord Kennedy of Southwark (Lab Co-op)
When the noble Baroness spoke, I remembered the Countess of Mar, who would regularly get up and correct noble Lords when they were getting things wrong. The noble Baroness is absolutely right. We should all follow the Companion. We are all responsible. We are a self-regulating House and we should do that to ensure that we have good and seamless debates and make good progress.
Terminally Ill Adults (End of Life) Bill
(1 day, 16 hours ago)
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“(ca) has not, for at least 12 months ending with the date of the first declaration, been deprived of their liberty under section 4A (restriction on deprivation of liberty) or 4B (deprivation of liberty necessary for life-sustaining treatment etc) of the Mental Capacity Act 2005, and”Member’s explanatory statement
This amendment would ensure that someone who so lacks capacity in one area as to be currently or recently deprived of liberty will not be found to have capacity for the decision to seek assistance to end their own life, which is otherwise a legal possibility under the Mental Capacity Act 2005’s approach to capacity.
Baroness Finlay of Llandaff (CB)
My Lords, Amendments 16 and 114 propose that anyone who is currently, or was in the year preceding their first declaration, deprived of liberty under the Mental Capacity Act will be considered to lack capacity for the decision to seek an assisted death. Amendments 16A and 114A extend this to those on whom an application has been made but not necessarily completed. Given the data, there is good reason why these amendments from the noble Baroness, Lady Keeley, should be considered.
Section 4 of the Mental Capacity Act 2005 requires that decisions made on behalf of individuals who lack capacity are made in their best interests and with the least restriction of freedom. This amendment can only probe the eligibility assessment process because we are at a transition point from the overloaded deprivation of liberty safeguards system possibly to liberty protection safeguards. Implementation of the 2019 Mental Capacity (Amendment) Act, with the concomitant refresh of the MCA code to incorporate liberty protection safeguards guidance, is planned for early next year, but no firm date has been set.
Deprivation of liberty safeguards authorise arrangements that restrict liberty in hospitals and care homes for those aged 18 or over when necessary for care and safety in their best interest and there is no other way to look after them. A standard authorisation under Section 4A can be given by a local authority, valid for up to one year, to a hospital or care home after a series of six assessments within a 21-day period. Section 4B allows for an urgent, seven-day deprivation of liberty, renewable once, to sustain life or for vital acts pending a Court of Protection decision or while the standard process is under way.
Urgent DoLS applications arise from acute crises. In 2023-24, 58% of applications were urgent. Temporary incapacity in acute hospital settings is often due to acute delirium in cardiovascular events, infection or medication effects. Of course, when a person improved and regained capacity, the DoLS became inapplicable.
However, the system is completely overloaded. There were over 334,000 applications in England alone in 2023-24, taking an average of 144 days for assessment. Only 44% were fully assessed and only 19% were completed within the required statutory 21 days. This goes to the heart of the problem. As local authority records are not integrated with health records, neither the panel nor the assessing doctors in the Bill will always have details of applications and outcomes. Different medical record systems exist in different trusts. Access to GP records is variable, absent or very limited, because some GP practices have not signed to give trusts access to their GP records. There is no access to social care clinical information systems, no information sharing between social care and medical records, and no access to the details of safeguarding information held by local authorities.
Although police call-outs may trigger the GP being notified that a call-out has occurred, no details are given, meaning there is no access to police records of what went on. Even when psychiatry services ask, such information is not readily given from the police national computer network. We will discuss later whether a panel can access this information, as it may be a clear pointer to domestic abuse.
Without a requirement to even interview the family, how will anyone know what has gone on? Hence the amendment. The very fact that an impairment of capacity serious enough to precipitate a DoLS application has occurred should act as a yellow flag when eligibility is being assessed.
Although the numbers are relatively small, the 2023-24 data shows that 3% of fully assessed DoLS applications were rejected. However, it is noticeable that half were due to a change in circumstance and a fifth because the criteria were not fulfilled. I expect to be told that this amendment, intended to protect vulnerable adults, has adverse implications for individuals with temporary hospital-related incapacity, potentially restricting autonomy because they had had a previous episode of seriously impaired capacity. However, individuals with irreversible conditions, such as advanced dementia or lifelong severe cognitive impairment, may remain ineligible long term, which aligns with this safeguard’s intent.
I am grateful to my noble and learned friend Lady Butler-Sloss and my noble friend Lady O’Loan, who have supported this amendment, and to the noble Baroness, Lady Keeley, whose amendment to my amendment intends to increase safety by capturing the larger number comprising 56% of applications that had not been completed.
I anticipate that the Minister will say that this amendment poses legal difficulties for those who lack capacity when it was temporary but serious enough to prompt DoLS, as it creates a statutory presumption rather than case-by-case assessment for anyone with a DoLS or LPS history. I hope therefore that this short debate will mean that a previous impairment of capacity will act as a yellow flag: an indicator that risk may be elevated when an application is assessed.
It is known that an episode of impaired capacity serious enough to trigger restricted liberty can signal further episodes of delirium in over a fifth of people, or be the first pointer to dementia. I hope this will encourage recognition by the noble and learned Lord, Lord Falconer, of the need to re-examine the balance of safety in cases where unrecognised indications of impaired decision-making could all too easily lead to an excess of poor assessments and inappropriate assisted deaths. I beg to move.
Amendment 16A (to Amendment 16)
Baroness Berger
Member’s explanatory statement
This amendment would ensure that someone who so lacks capacity in one area that an application has been made to deprive them of their liberty will not be found to have capacity for the decision to seek assistance to end their own life, which is otherwise a legal possibility under the Mental Capacity Act 2005’s approach to capacity.
Baroness Berger (Lab)
My Lords, Amendments 16A and 114A, which were tabled by the noble Baroness, Lady Keeley, address the fact that for the last 10 years there has been a substantial backlog of applications for deprivation of liberty safeguards assessments. This backlog grew after there was a Supreme Court ruling in 2014 on Cheshire West. Following that ruling in 2014, the criteria for what constituted a deprivation of liberty assessment led to a surge in applications for DoLS assessments. Back in 2013-14, there were around 13,000 assessments. This grew to over 332,000 applications in 2023-24.
The last reported backlog of deprivation of liberty safeguards assessments back in October of this year was more than 123,000 applications. That is more than 123,000 cases where a person so lacks capacity in one area that an application for a deprivation of liberty safeguards assessment has been made, but our overstretched social workers and local authorities have not been able to process it.
I hope we can all agree that people whose incapacity to make basic decisions is so severe that they are deprived of their liberty, or for whom an application has been made for the deprivation of their liberty, are the most vulnerable members of society, and that the protection of people who lack capacity is a solemn duty. The state looks after their interests because they cannot.
Amendments 16, 16A, 114 and 114A provide a fundamental safeguard to protect this group by excluding them from making a life-and-death decision, both when they have been deprived of their liberty in the last 12 months or—as these amendments particularly seek to achieve—while they are waiting for the assessment to be made to deprive them of their liberty.
In conclusion, while considering these amendments, and in addition to addressing the delays outlined by the noble Baroness, Lady Finlay, we might also reflect that our current social care workforce has struggled so much with the backlog of assessments, as I have described, that the last Government were not able to implement the changes to the deprivation of liberty safeguards assessments contained in the Mental Capacity (Amendment) Act 2019. It is worth pointing out that the Bill seeks to create a new and additional role for social workers on the panels, and in that context, I hope noble Lords will consider these amendments.
Baroness Butler-Sloss (CB)
My Lords, for the reasons given by the noble Baronesses, Lady Finlay and the Lady Berger, I support all these amendments.
Perhaps your Lordships, and particularly the Whips, will forgive me if, very briefly, I go slightly wider. I am one of the oldest Members of this House. I do not like the Bill but I am here, like other noble Lords, to try to make it work. It needs scrutiny and improvement. However, we must get it to Third Reading. If we do not, there is a very real danger that the reputation of this House, which not only I but all your Lordships care about deeply, will be irreparably eroded.
This morning I listened to the “Today” programme. I agree with every word of what the noble Baroness, Lady Grey-Thompson, said, but there was a perception that we are being unreasonable. What we can do, perhaps, is not expect to be entitled, exercise self-restraint, deal with the amendments relatively briefly, and not make a point if someone has already spoken on the point you were going to make. We really must get to Third Reading. Forgive me for saying all that.
Lord Falconer of Thoroton (Lab)
My Lords, I will act immediately on the words of the noble and learned Baroness, Lady Butler-Sloss, and respond briefly to what the noble Baroness, Lady Finlay, and my noble friend Lady Berger said. Basically, they are referring to the problem of people who lack capacity and who have had their liberty deprived because their lack of capacity is so severe that they cannot be trusted to be free. That normally takes place in the setting of a hospital or a care home, but it can also take place in the setting of a private home; that is where the Cheshire East cases come into play.
The noble Baroness, Lady Finlay, said that this should be a yellow flag. If your lack of capacity is so serious that your liberty is taken away, it indicates that something is seriously wrong. The principle of the Mental Capacity Act 2005 is that capacity should be looked at on a case-by-case basis. There will be cases where someone’s liberty is taken away where they would not necessarily lack capacity in relation to very serious issues.
I should have declared this before. Apart from my receiving money from Mr Bernard Lewis to pay for an assistant and having Dignity in Dying pay for the publication of some printing that went to Peers, my wife was, until very recently, a designated family judge and sat in the Court of Protection. I should disclose that.
Among the sorts of case that come before the courts —they will come before the courts, not a local authority—are those of people who desperately do not want to leave their home. Eventually, they will have to have an order from the Court of Protection, meaning that they have to leave; this is sometimes accompanied by a deprivation of liberty order. Many of those people, even though they are moved somewhere else, would still have the capacity to make a decision in relation to assisted dying.
How do we deal with the perfectly legitimate points made by the noble Baroness, Lady Finlay? I have had the opportunity to discuss this with the noble Baroness; I thank her for that. The answer is that there should be some form of enhanced protection to deal with what she says is a yellow flag. I suggest to the Committee that I speak to those Peers who are interested—including my noble friend Lady Berger and the noble Baroness, Lady Keeley, who sadly cannot be here today—to see what form that enhanced protection could take.
I hope that in the light of what I have indicated, we can move on to the next amendment.
Baroness Hollins (CB)
My Lords, I would like to comment on this group in response to what the noble and learned Lord, Lord Falconer, has just said.
In its recent briefing for Peers, the Royal College of Psychiatrists gave its view:
“Assessors should be required to take all practicable steps to work with professionals involved in a person’s health and social care, and to talk to a relative, carer or nominated friend, including by accessing medical notes from both primary and secondary care”.
It expressed concern that
“a consideration of suicide protection duties are being bypassed by the Bill in its current form”
due to unmet need not being formally assessed. A previous DoLS is relevant to consideration of current capacity to decide to end one’s life. What would be the mechanism for reliably ensuring information that there has been a DoLS before it gets to the assessors and the panel?
Having mentioned the Royal College of Psychiatrists, I would like to make a short statement. The college has asked me to respond to the allegations about its leadership made by the noble Baroness, Lady Murphy, on 14 November, our first day in Committee. The president of the college, Dr Lade Smith, wrote to the noble Baroness asking her to withdraw her allegations, as they are inaccurate. But although the noble Baroness was present in the Chamber the following week, no clarification was provided. As a past president myself, I beg leave to set the record straight.
The college’s recommendations on the Bill are, in fact, based on 18 months’ consideration by a cross-college working group involving membership surveys, debate with members on proposals before other jurisdictions, and discussions with colleagues in other jurisdictions where assisted dying is practised. The president is clear that Dr Annabel Price, the appointed college lead for the Bill, has accurately represented its views when giving formal evidence to both Houses. With the Bill before the Lords, the Royal College of Psychiatrists is focusing on how to make it safer for people with mental health needs and learning disability needs, and better aligned with the responsibilities of psychiatrists. I feel that, in the light of the discussion on DoLS, this is an appropriate statement to make.
Baroness O’Loan (CB)
My Lords, I have put my name to Amendment 16. I also support Amendments 16A, 114 and 114A because the very general definition in Clause 1 of a terminally ill adult who has the capacity to take their own life does not contain any consideration of those who have been deprived of their liberty under Section 4 of the Mental Capacity Act. It is an unfortunate reality that many of those detained in hospitals or care homes are detained because they lack the capacity to make a decision about their own care or treatment. As the noble Baroness, Lady Finlay, said, in such circumstances it is surely axiomatic that there should be careful consideration of cases involving individuals subject to a DoLS.
As the noble and learned Lord, Lord Falconer, said, even assessing the capacity of someone with dementia or another neurological condition, for example, can be profoundly difficult. This is not just because of the frequent fluctuation of both capacity and the extent to which any identified capacity enables the making of a particular decision; a medical practitioner or social worker who meets a person for the first time may be misled as to the capacity they actually have. As the Royal College of Psychiatrists noted in its written evidence,
“an assessment of a person’s mental capacity to decide to end their own life is an entirely different and more complex determination requiring a higher level of understanding”
than in other assessments of capacity.
In the 1997 case of Re MB, the noble and learned Baroness, Lady Butler-Sloss, said:
“The graver the consequences of the decision, the commensurately greater the level of competence required to take the decision”.
Capacity assessment is not a precise science. The unique context of this Bill makes taking a cautious approach appropriate. It is common sense that there is a likely correlation between incapacity in one area, so extreme that the state must deprive the person of their liberty, and incapacity to decide whether to end one’s own life. People whose incapacity for basic decisions is so severe that they are deprived of their liberty are the most vulnerable members of society.
I want to give your Lordships a brief example. I was aware of a woman in her late 80s who had been assessed and was subject to a DoLS. She objected to it and appealed against it. Intellectually, she was enormously able, possessed of considerable social skills despite her dementia. She was able to persuade those dealing with her appeal that she had capacity despite the very real concerns of her family, who knew the extent of her incapacity. The DoLS was lifted and she went back to her own home. Shortly afterwards, she was found playing golf in the road in her pyjamas at two o’clock in the morning. She was going to the supermarket at 4 am. She was leaving the door unlocked all night for her husband and cooking his dinner every night; he had died some 20 years previously.
That lady was my mother. She certainly would not have understood a suggestion that she should opt for an assisted death. The DoLS was subsequently reinstated. This is not an unusual situation. If the noble and learned Lord, Lord Falconer, rejects these amendments, how does he consider that such vulnerable individuals can be protected from making this final decision, although they may not understand exactly what they are doing?
Baroness Royall of Blaisdon (Lab)
My Lords, forgive me. What the noble Baroness is saying is extremely interesting, but the noble and learned Lord, Lord Falconer, has already said that he will seek a meeting with the noble Baroness, Lady Finlay, and all other noble Lords who are interested in this. He is not rejecting the amendments; he is willing to enter into a discussion.
Baroness O’Loan (CB)
I thank the noble Baroness for that helpful intervention, but we do not know what the outcome of that meeting will be. I think I have the right to make my remarks.
Baroness Berridge (Con)
My Lords, I will speak to the amendments in this group. I did not table one in my name about a group of people who are also subject to deprivation of liberty safeguards. I am pleased to hear the noble and learned Lord repeat his offer of a meeting, which was made last Friday. I was disappointed not to receive an invitation to a group meeting to discuss the various groups of vulnerable people who may need additional conditions. Had there been such a meeting, I would not be taking up time today or on the later group, where I had offered to withdraw amendments had a meeting taken place.
There is another group of people under deprivation of liberty safeguards who are not under the Mental Capacity Act. These are young people who are under the High Court jurisdiction of deprivation of liberty safeguards—called High Court DoLS. I thank the President of the Family Division for ensuring that there is research available on this group and the Children’s Commissioner, who has visited very many of them. Those young people are so troubled that their liberty needs to be restricted, but they cannot currently be detained under Section 25 of the Children Act in a secure children’s home. That was for a variety of reasons. One was that we ran out of places, but another was that some of them were in such a situation that they could not even bear a communal secure environment like that.
I did not table an amendment also because under the Children’s Wellbeing and Schools Bill these young people will possibly be brought under the statutory jurisdiction of the Children Act, though it would not be all of them. There were 1,280 applications made last year, and around 90% of them were granted, so this is not, as was originally envisaged, a handful of young people. Are any of those young people also ill? Are noble Lords content that at 18 years and one day old they should have assisted suicide raised with them? Are they also happy that if a child has been under mental health treatment but is also physically ill, at 18 years and one day they come under the jurisdiction of this Bill? The same applies to those detained in a young offender institution. Sadly, due to the Private Member’s Bill process, I do not believe that there has been any consultation, a White Paper or pre-legislative scrutiny to flush out the details and data that we need to properly legislate.
I am grateful to the Children’s Commissioner for attending the Select Committee, but I was surprised that the Public Bill Committee in the House of Commons did not hear from her.
In addition to the issue of those who are 18 years old and one day, some of whom are still under the jurisdiction of the Children’s Commissioner until they are 25 and under the jurisdiction of the local authority, it is not wrong to say that there will be enormous societal change that affects children. I would be grateful to know, whether now or in the meeting that the noble and learned Lord has promised, whether he is aware of this group of children and what meetings he has had to establish how many would be affected at 18 years old, how many are in this group and how they can be protected by additional conditions and safeguards.
Lord Harper (Con)
My Lords, the noble and learned Lord, Lord Falconer, gave a very welcome response to the opening speech of the noble Baroness, Lady Finlay. He set out a range of protections that there may be. Once he has had those conversations, if he is persuaded that there need to be some protections, will he be prepared to table his own amendments on Report to put those protections and assurances in the legislation, or will he do what the Delegated Powers Committee referred to as disguise legislation, which is only putting it in codes of practice and guidance?
I think it would be widely agreed that if we are going to have those protections, it is better that they are in the Bill. They then cannot be watered down and can be properly enforced. Could he indicate that to all noble Lords after he has had those conversations with those who are interested? The disadvantage of having private meetings is that you are not able to tell other people. If the noble and learned Lord wants proceedings to go faster and to table his own amendments on Report and prevent the need for other people to do so, can he indicate that, once he has had those conversations, he would be willing bring forward those amendments and put those protections in the legislation. I am sure that would be most welcome. If he could indicate his thinking on that today, that would be of help to the House.
Lord Kamall (Con)
As I set out last week and will repeat if noble Lords will forgive me, I completely agree with what the Government Chief Whip said about noble Lords ensuring that they speak to the amendments and do not give Second Reading speeches, but, at the same time, I think it is important that all noble Lords who want to speak to an amendment are given the opportunity to do so.
I thank the noble Baroness, Lady Finlay of Llandaff, for her amendment in this group. It seeks to ensure that someone who currently is or has recently been deprived of their liberty will not be eligible under the Act. This amendment refers to the Mental Capacity Act 2005, which is also the Act underpinning capacity for the purposes of this Bill. I appreciate the underlying logic behind the amendment, which has opened up a valuable discussion of who exactly should have access to assisted dying services. I am sure that all noble Lords would agree, whatever their position, that there should be robust provisions and safeguards in the Bill and that it should be available only to those who are suffering from terminal illnesses who are of sound mind, so that we do not inadvertently open it up to those with issues related to their capacity.
I am also grateful to the noble Baroness, Lady Berger, for her contribution in place of the noble Baroness, Lady Keeley. It is very important that, given the backlog in the system, not just those who have DoLS but those who have made an application for DoLS are deemed not to have capacity when seeking to end their lives. It would be very interesting to hear the Government’s perspective on this and that of the noble and learned Lord.
These questions all fundamentally ask whether the Bill is right to use the Mental Capacity Act 2005 as the basis for defining capacity. I am very grateful to the noble and learned Lord, Lord Falconer of Thoroton, for offering to meet those who have tabled these amendments. That is very constructive and helpful and should be acknowledged. I also look forward to hearing the noble and learned Lord’s responses to some of the issues that have been raised.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I am grateful to noble Lords for their contributions on this group. To echo the comments of my noble friend the Chief Whip, the Government remain neutral on the principle of assisted dying and on the passage of this Bill. Whether the law in this area should change is a matter for Parliament. As before, any comments that I make will focus on amendments where the Government have major legal, technical or operational workability concerns.
This group relates to deprivation of liberty and eligibility for seeking an assisted death. I thank the noble Baroness, Lady Finlay, and my noble friend Baroness Keeley for tabling the amendments in this group. Amendments 16 and 114, tabled by the noble Baroness, Lady Finlay, seek to prevent individuals who have been deprived of their liberty within the last 12 months under the Mental Capacity Act being eligible for an assisted death. In the case of Amendments 16A and 114A, tabled by my noble friend Lady Keeley, someone would be ineligible as a result of an application for deprivation of liberty having been made, irrespective of the outcome of that application.
Noble Lords may wish to consider that the amendments would introduce a departure from the Mental Capacity Act framework by linking a lack of capacity in one area—capacity to consent to care and treatment arrangements that amount to confinement—to lack of capacity in another area, that being capacity to make the decision to end one’s life. Amendments 16A and 114A go further and would make a person ineligible on the basis that only an application for deprivation of liberty had been made. This may result in a situation where the application was unwarranted, but that person would still be ineligible for assisted death.
Regarding the European Convention on Human Rights—
Lord Scriven (LD)
I want to ask what the Government’s view is. This actually changes the whole basis of the Mental Capacity Act. The Mental Capacity Act concerns existing capacity. These amendments move into retrospective or future capacity, which is completely incompatible with the Mental Capacity Act. Do the Government have any views about that significant change of capacity and the test of the capacity of an individual?
Baroness Merron (Lab)
I hope that the comments I have made already indicate where we are concerned, rather than going into further areas, but I would be very happy to look at the noble Lord’s point.
I also wish to raise points relating to the European Convention on Human Rights. As before, these are potential risks that I am raising to inform noble Lords’ decision-making, but I wish to be clear that the underlying policies are rightly a matter for Parliament. Noble Lords may wish to note the requirement for an objective, proportionate and reasonable justification to treat those who have previously lacked capacity in a different context differently from others who have not. Noble Lords may also wish to consider whether there is justification for different treatment where an application for deprivation of liberty has been made, but not necessarily completed or approved. In the absence of justifications that are sufficient to persuade a court, the amendments may conflict with ECHR obligations, specifically Article 14 on the prohibition of discrimination, when read with Article 8.
I confirm to noble Lords that, if a court finds that primary legislation is incompatible, it may make a declaration of incompatibility. This does not invalidate legislation. As is usual, the Government would then consider—
Lord Harper (Con)
I am grateful to the Minister for making that point, which I think was the question I asked last time. This is very relevant to the question that I posed to the noble and learned Lord, Lord Falconer. It is very important that we put protections in the legislation, so that they are not subsequently unpicked, whether by domestic courts or the European Court of Human Rights. If they are only in a code of practice or guidance, it would not provide protection against those legal challenges. Will the Minister just confirm that what I have said is correct?
Baroness Merron (Lab)
I am sure that my noble and learned friend will comment on the noble Lord’s points, but the point I wished to make, which might be helpful, is that it is usual practice for the Government to consider and address these matters. Noble Lords are aware that there is a range of ways of dealing with that: by amending primary legislation, through a remedial order or by a declaration of incompatibility. That is the usual practice.
Lord Pannick (CB)
On human rights law, does the Minister agree that, if Parliament forms a considered judgment that there is a basis for a differentiation in this context or any other, it is most unlikely that a court is going to intervene on the sensitive subjects of social policy that we are concerned with here?
Baroness Merron (Lab)
I hear the noble Lord, but my role today, as I am sure he understands, is to advise your Lordships on the risks as we see them and for noble Lords to decide how they wish to interpret them with regard to these amendments. But I am grateful for the point that the noble Lord makes.
Noble Lords may wish to note that these amendments would lead to different treatments for those detained under the Mental Health Act from those detained under the Mental Capacity Act. Only those detained under the Mental Capacity Act would be excluded from assisted dying. Noble Lords may wish to consider whether this is justifiable, given that the criteria for detention under both Acts are similar. The decision on which Act to use is largely a matter of professional discretion. Operationally, these amendments could also create confusion for practitioners, because they depart from the principle that capacity assessments are decision- and time-specific, so additional guidance and training would be needed.
Finally, as noble Lords will be aware, these amendments have not had technical drafting support from officials, which means that they may not be fully workable, effective or enforceable in the way that they are currently drafted. However, the issues raised are rightly a matter for noble Lords to consider and decide.
Baroness Berridge (Con)
I have heard this outline of the Government’s position. Am I correct in understanding that the Government have no position on ensuring that the Bill is safe for vulnerable groups of people?
Lord Kamall (Con)
The question that a number of noble Lords are concerned about, when discussing this amendment, is that the Mental Capacity Act was passed in 2005. Of course, the guidance has been updated, but it might be helpful to those in the Committee who are concerned that this Act is 20 years out of date to talk about any guidance that has been updated, so that it is not seen as out of date—if that makes sense. This is just to clarify that we are not dealing with an Act that was set in stone in 2005, as things have changed since then.
Baroness Merron (Lab)
I am grateful to the noble Lord and feel that this would probably be a very appropriate point to move on to my noble and learned friend.
Lord Falconer of Thoroton (Lab)
I will just pick up what the noble Lord, Lord Kamall, is saying. I think he is saying that the Act has been updated over the years and that people have taken account of improvements. He is absolutely right; from my own knowledge of the working of the Act, he makes an absolutely valid point.
I repeat what I said earlier—that we need to discuss this. I will deal with the interventions after I have given my response.
First, the noble Baroness, Lady O’Loan, is right in identifying the risks that arise. That is why I think that the noble Baroness, Lady Finlay, is right that we need to build in some form of enhanced protection.
As far as the intervention from the noble Baroness, Lady Berridge, is concerned, this amendment is limited to DoLS under the Mental Capacity Act; it does not include any exercise of the inherent jurisdiction of the courts on somebody whose liberty has been taken away. The noble Baroness is very welcome to come and discuss that with us, and I will give her notice of any meeting that we have.
As far as the noble Lord, Lord Harper, is concerned, how one provides effective protection depends first on the discussions that take place. I would envisage tabling an amendment on this or maybe agreeing that somebody else tables one. I cannot tell noble Lords the extent to which it will involve the Minister having powers, but it is something that we will discuss.
The points that the Minister, my noble friend Lady Merron, made about discrimination relate to people who have had a deprivation of liberty order in the past, or even those who have one now, who will be excluded altogether from the right to assisted dying. The nature of the Mental Capacity Act is that this should be done on a case-by-case basis. I am proposing that we discuss how to provide enhanced protection rather than excluding.
In the light of what I have said, I hope that the noble Baroness, Lady Finlay, and the noble Baroness, Baroness Berger, on behalf of the noble Baroness, Lady Keeley, feel able to withdraw their amendments.
Lord Harper (Con)
I agree with the noble Lord, Lord Pannick, that a court is unlikely to interfere with important social and economic policy that has been decided by Parliament. That rather reinforces the point that I made about why it is important that these protections are included in the legislation.
Baroness Finlay of Llandaff (CB)
My Lords, I am grateful to those who have contributed to this discussion. I made it clear at the beginning that I was probing. I am particularly grateful to the noble Baroness, Lady Hollins, for pointing out that one of the difficulties for assessors is in knowing how reliable the information that they can access is. It seems that we need a way to make sure that people who could be particularly at risk have an enhanced level of assessment for the protections relevant to them.
I am sorry; should I not be speaking now?
Lord Falconer of Thoroton (Lab)
I apologise to the noble Baroness. I was being told by the Whips that my noble friend Lady Berger has to withdraw her amendment first. I apologise for the discourtesy.
Baroness Finlay of Llandaff (CB)
That is fine; I was hoping to sum up, and then I would willingly hand over to the noble Baroness, Lady Berger, to withdraw the amendment. I think that we need to make sure that the face of the Bill makes it clear that there is a level of particularly enhanced assessment for several groups of people—this will be only one group—who are, for whatever reason, particularly vulnerable. I hope that the number of meetings that we have will include everybody who has a concern over this, going forward to Report stage. It is of concern that the code of practice for the Mental Capacity Act has still not finished being updated. I hope that we will see an updated version next year, because the one currently in place is, in some ways, a little bit out of date, given the modern world we live in. With all that, if the noble Baroness would like to withdraw her amendment, I will be delighted to withdraw mine.
Baroness Berger (Lab)
My Lords, just in advance of withdrawing the amendments, I would like to put on record the magnitude of this issue. In the last recorded year, there were 141,925 people who had the deprivation of liberty safeguards—DoLS—standard authorisations granted, and only 3% of the applications that were fully assessed and completed were not granted; 97% of applications were granted. I have listened very closely to what my noble and learned friend said and I look forward to the meetings that we will have, further to our deliberations today. On that basis, I withdraw my amendment.
Member’s explanatory statement
This is a probing amendment to establish whether it is intended to exclude from the scope of the Bill residents of border areas of England who are registered with a general medical practice in Scotland.
Baroness Fraser of Craigmaddie (Con)
My Lords, I rise to speak to Amendments 17 and 309A in the name of the noble Lord, Lord Beith, which I have supported. The noble Lord sends his sincere apologies that he cannot be here today. I will also speak to Amendment 62 in my name. I thank the noble and learned Lord, Lord Falconer, for his discussions with both the noble Lord and me on how this Bill affects Scotland.
These are probing amendments. They seek to establish the scope of the Bill, firstly with regard to residents of England who may find themselves availing of Scottish health services. Amendments 17 and 309A remove an anomaly in the Bill under which some residents in England close to the Scottish border will be excluded from its scope because they are registered with a Scottish GP. This is relatively common in border areas, as it may be that a Scottish GP is closer than the nearest English practice, or it may reflect a desire to stay with the same practice after moving house. The BMA has identified cross-jurisdiction protection for doctors supporting their patients in shared-care arrangements across borders as a gap in this Bill that it would like to see addressed in Committee. The Scottish Ambulance Service has also requested further clarity on what paramedics should do or not do across border areas. How does the noble and learned Lord plan to address these issues?
My Amendment 62 is about whether the remit of the Bill extends, perhaps unwittingly, to Scottish doctors, as it probes whether any Scottish GP, whether or not you are registered with them, can undertake preliminary discussions. The Amendment refers to Clause 3, referred to on page 1 of the Bill, and the steps taken under Clauses 8, 10, 11 and 19. Clause 8 refers to the preliminary discussion, the initial request for assistance and the first declaration that is done by the terminally ill person who, under subsection (3)(a), must be in England and Wales, but Clauses 10 and 11 are about the role of doctors. My reading of Clause 1(3), which was inserted in the other place, is that the steps in Clauses 8, 10, 11 and 19 must be taken when the terminally ill person is in England or Wales, but the steps in Clauses 10 and 11 are to be taken only by doctors in England and Wales—not Clause 8, the initial request for assistance, or Clause 19, the confirmation of the request for assistance, or second declaration. They could be undertaken by any GP and, as such, the Bill as it stands would permit discussions to be undertaken by GPs in Scotland even though they would not be regulated under the Bill. Is this what the sponsors of the Bill intended?
I believe there would be a number of consequential issues that might need to be addressed, depending on the territorial extent of the Bill. For example, can the noble and learned Lord say whether the recording required of the preliminary discussion in Clause 7 would work for Scottish GPs? Given the very separate record keeping of NHS Scotland and NHS England, which he and I have discussed, the considerable challenges of cross-border data sharing in the context of health, particularly in primary care, and the separate Scottish legal context, where does that leave the offence of destruction of documentation in Clauses 35 and 36 if the preliminary discussion is undertaken by a Scottish GP? If the intention is that Scottish GPs can undertake these discussions, can I ask the sponsors to clarify this for the record? If this is not the intention, can the noble and learned Lord consider whether the territorial extent needs to be clarified in other areas of the Bill? If it is not the intention, does the noble and learned Lord consider that further amendments need to be tabled to ensure that this loophole is closed? Perhaps he could take us through the provisions relating to Scotland in this response and clarify.
I believe that, when parts of the Bill were extended to Scotland on Report, the sponsor did not have time to explain why they were needed or what they did. The honourable Member for Glasgow West asked whether the Bill’s sponsors had had any conversations with Scotland’s Lord Advocate and the Scottish Government, and the honourable Member for Spen Valley was only able to confirm that she had taken legal advice from government officials to ensure that devolution is respected. She stated that conversations had already started and would continue where legislation that affects other jurisdictions needs to be amended. Could the Minister confirm for us what guidance the Government have provided regarding the provisions relating to Scotland and their necessity?
As this House is well aware, the Scottish Parliament is currently going through its own stages on an assisted dying Private Member’s Bill in Holyrood, so we are facing the very real possibility of a two-tier system in Britain, which the former Prime Minister Gordon Brown has highlighted as being extremely concerning. There is currently a sharp divide between what has been proposed for Scotland and what we have before us here. The amendments in this group do not affect in any way what happens in Scotland, but, like the former Prime Minister, I am very concerned that we could find ourselves in a situation where people are moving between the two jurisdictions. At the very least, I would have expected there to be intensive consultation between the two Parliaments.
The Scottish Cabinet Secretary for Health has written a number of letters to the lead committee on assisted dying in the Scottish Parliament, in which he acknowledges that the Scottish and UK Government officials must continue to hold discussions on the legislative competence issues. Is the Minister able to say more about these discussions? Are they confined to legislative competence or do they extend to issues such as delivery timescales, the regulatory framework of medical practitioners across the UK and the intention to give Scottish Ministers the authority to determine approved substances to use, all of which Mr Gray has highlighted as concerns and are indicative of the problems of having potentially different systems north and south of the border?
In conclusion, it seems to me that matters are moving and changing at pace, both with additions to this Bill and the Scottish Bill. If things are done piecemeal or with haste, we are in danger of assisted dying becoming another deposit return scheme—although you cannot return from being dead. The deposit return scheme was an example of the two Parliaments wanting to implement something that needed careful consultation and co-operation across the UK, legislating separately, both totally within their devolved areas but, in the case of Scotland, ending up with a Bill that could not be implemented because of the cross-border issues that had not been fully acknowledged and addressed. Addressing these issues and getting clear answers from the Bill’s sponsors and the Minister are what this group of amendments is about, and I believe they are essential. I beg to move.
Lord Shinkwin (Con)
My Lords, I rise to speak to Amendment 17, particularly in relation to the Scottish Ambulance Service, which my noble friend Lady Fraser of Craigmaddie mentioned briefly in her speech. I do so as someone who can remember just about all my journeys in ambulances—some in agony after a fracture, some with the blue light flashing, others more sedate. What marked them all was a sense that, however much pain I was in, I was none the less safe. The ambulance crew were in control of the situation, caring, competent and consistently professional. That is my abiding memory based on first-hand experience.
I am concerned, as I understand the Scottish Ambulance Service is, that there is currently no guidance on this specific issue even though its absence has significant practical implications. Simply put, from a frequent ambulance traveller’s perspective, without this amendment ambulance crews and other healthcare professionals might well not feel fully in control of the situation. That is just not where you want to be as a potential patient needing urgent emergency care.
Surely, emergency services operating across the Scotland-England boundary not only need but deserve clear guidance. For example, what exactly is a paramedic meant to do if they are called out because an assisted death has gone badly wrong, leaving the individual seriously injured but very much alive, which of course can happen and indeed has happened on occasion in other jurisdictions where such legislation has been implemented? It does happen, yet the Bill, as far as I can see, is silent on this point, which is not much use to a paramedic desperately wanting to provide care when an emergency response is requested due to complications such as choking or vomiting.
I am not aware of this having been covered in the impact assessment, or of John Grady having received an answer when he raised this very issue on Report in the other place. So, I would be very grateful if the Minister could share with the House in her closing remarks what work has been done by the Government to evaluate and address such an important cross-border issue.
The Lord Bishop of Norwich
My Lords, I support Amendments 17 and 309A, proposed by the noble Lord, Lord Beith, and so ably explained by the noble Baroness, Lady Fraser. I declare an interest, in that my wife is a GP and a medical examiner—so the Bill has had much discussion at home.
Having spent 10 years living in Northumberland, and having friends who live along the Scottish border, I know that many of those living sufficiently close to the border have chosen very deliberately to be registered with a Scottish GP because they then receive free prescriptions. This raises a number of questions for the noble and learned Lord.
Let us say that you live on the English side of the border, at Cornhill-on-Tweed, and your GP is in Coldstream. The sense of continuity of care that GPs give to their patients is vital to that GP-patient relationship. Indeed, this House was reminded of that yesterday in the excellent maiden speech of the noble Baroness, Lady Gerada:
“That continuity, seeing lives unfold across time, gives general practice its unique moral and social power. It allows us to see people as whole human beings, not as isolated organs or diagnoses”.—[Official Report, 11/12/25; col. 370.]
In supporting this probing amendment, I am interested to discover more about how that continuity of care that is so essential in primary health care can be continued.
Lord Harper (Con)
My Lords, this is a very sensible group of probing amendments, and it is a pleasure to follow the right reverend Prelate. I will speak to them because the issues raised in this group concerning the difference between where somebody resides and where their GP is registered are exactly analogous to the situation regarding England and Wales, which I raised in an earlier group but have not received a satisfactory answer to.
I will remind the noble and learned Lord of the situation and he can, I hope, respond in a positive way. There are two issues, one of which is the difference between where you reside and where your GP is registered. There are a significant number of people living along the England-Scotland border and the England-Wales border whose place of residence is not the same as where their GP is registered. Therefore, it is very important that the legislation makes it clear that the rules through which you access assisted suicide are governed by where you live, not where your GP is registered. That is important for the reasons my noble friend Lady Fraser set out—in England and Scotland there will potentially be very different legal situations.
As we know from the earlier debate, although the Bill covers England and Wales, the rules governing the detail of how an assisted suicide service will work in Wales will be set by the Welsh Senedd, not the UK Parliament. Therefore, it is important that the Welsh rules apply only to people in Wales, who are governed by a body that is democratically accountable to them, not to people who live in England; otherwise, there would be a massive democratic deficit. It is very important that the noble and learned Lord is clear about how that is going to work.
Secondly, I think the noble and learned Lord said in response to our debate on England and Wales that he and the honourable Member for Spen Valley had had some detailed discussions with the devolved Governments. However, I was not clear from his responses whether those discussions had covered this point. Obviously, they need to take account of the views of not only the devolved Governments but the UK Government—which, for these purposes is actually only the English Government. We need to understand how this is going to work in practice.
As I have said, and in conclusion, this must be got right now, in primary legislation. If we do not get it right now, somebody will have to spend months and years clearing up the mess afterwards, which is one of the things that I had to do when I was the Member of Parliament for the Forest of Dean to deal with the cross-border issues that had not been properly thought through then. This is a valuable set of amendments. I was pleased that that the noble and learned Lord acknowledged, I think last week when the noble Lord, Lord Beith, spoke about this briefly, that these are valid issues that need proper answers. I look forward to hearing them now.
Lord Deben (Con)
Could I be vulgarly practical about this, because of a point the noble Baroness mentioned, which is the parallelism with the deposit return scheme that got into terrible trouble? I declare an interest as chairman of Valpak. We had to work through that, so it is burnt into me how extremely damaging it was because it was not decided beforehand. I know that we are talking about much greater issues here but, as I hope the noble and learned Lord will accept, this is a really serious issue; it brought about enormous cost and a vast misunderstanding, and it ended up destroying what the Scottish Government wanted to do. It is a very dangerous precedent. I am sure that the noble and learned Lord will want to make absolutely sure that we do not have a repetition of something that cost vast sums of money, in both the private and public sectors, and that has undermined an important measure ever since.
Earl Howe (Con)
My Lords, this group of amendments covers two distinct but connected questions. The first question, posed by Amendment 17, is, in my judgment, a very helpful one, because the answer will clarify the role—or lack of role—played by a person’s GP in the process being pursued by that person in seeking an assisted death. It seems to me, from reading the Bill’s provisions, that the involvement of a person’s GP in that process, although very likely, is not legally necessary provided that the patient fulfils all the conditions set out in Clause 1(1). Clarification from the noble and learned Lord would be very helpful.
The second question, posed by my noble friend Lady Fraser’s Amendment 62, is also one that I hope can be answered very simply by the noble and learned Lord. Am I correct that it is implicit in Clause 5 that the preliminary discussion between the patient and the registered medical practitioner need not involve a doctor physically situated in England and Wales and need not be face to face? Equally, am I correct that it is unnecessary to state in Clause 1(3)(b) that the steps set out in Clauses 8 and 19 must be taken
“by persons in England or Wales”,
because Clauses 8 and 19 already explicitly provide for this?
Baroness Merron (Lab)
My Lords, I thank noble Lords for their contributions to this debate. As I have said, I will keep my comments limited to the amendments on which the Government have major legal, technical or operational workability concerns.
On Amendments 17 and 309A, in the name of the noble Lord, Lord Beith, and introduced by the noble Baroness, Lady Fraser, Amendment 17 is a probing amendment that seeks to establish whether people who are registered with a GP in Scotland but live in England would be excluded from eligibility for an assisted death under the Bill. Noble Lords may wish to note that Amendment 17 would have limited effect as it amends only Clause 1, which is largely descriptive. Without further amendments to Clauses 10 and 17, which contain duties to assess eligibility criteria, Amendment 17 would not impact those criteria and would introduce conflicting provisions.
Amendment 309A would amend the corresponding eligibility criteria in Clause 10 to include a person registered as a patient with a general medical practice in England, Wales or Scotland. It would not amend Clause 17, which contains the assessment by the panel. Therefore, Amendments 17 and 309A would require further consequential amendments to ensure that the Bill is coherent. This would include amendments to ensure that data recording obligations and the associated criminal offences apply to Scottish GPs. These consequential amendments would likely require consultation with the Scottish Government, as the noble Baroness, Lady Fraser, referred to, in line with the guidance for Private Members’ Bills.
I thank the noble Baroness, Lady Fraser, for tabling Amendment 62. The purpose of this amendment is to establish why the Bill requires only the actions set out in Clauses 10 and 11 to be undertaken by people in England or Wales, and not the preliminary discussion under Clause 5. Our understanding is that the reference to the preliminary discussion in Clause 5 is not mentioned in Clause 1(3) because Clause 5(3) already requires that a person wanting to have a preliminary discussion must be in England and Wales. Amendment 62 would require steps under Clauses 8 and 19 to be taken by persons in England or Wales. As drafted, the Bill requires that most of the steps in Clauses 8, 10, 11 and 19 will already have to take place in England and Wales.
In addition, Amendment 62 would have the effect that, when the Secretary of State makes regulations under Clause 19, the Secretary of State must be in England and Wales at the moment they sign the regulations. This could lead to the regulations being improperly made and challenged should the Secretary of State not physically be in England or Wales at the time of signing the regulations. This raises a practical issue of workability, as I am sure the noble Baroness understands.
On the points raised by the noble Baroness, Lady Fraser, and the noble Lord, Lord Shinkwin, relating to Scotland and guidance that the Government have provided to the sponsor, as I am sure noble Lords will understand, and I have reiterated, we are providing technical and workability support to the sponsor on devolution issues, including those that have been raised. This is an evolving situation that will continue throughout the passage of the Bill.
Lord Falconer of Thoroton (Lab)
I am grateful to everybody who has taken part in this short debate. I pay particular tribute to the noble Baroness, Lady Fraser of Craigmaddie, who discussed the issues with me yesterday and was incredibly clear in the way that she raised them today. She also raised the concerns of the noble Lord, Lord Beith.
I will deal with three issues: first, where the GP practice has to be to satisfy the eligibility requirements; secondly, whether the Clause 5 conversation has to take place with an England and Wales GP, or whether it can take place with a Scottish GP; and thirdly, how we will deal with the clashes between Scotland and England. I am aware, because the noble Baroness, Lady Fraser of Craigmaddie, told me about it, of the deposit return scheme and how that went wrong. I am conscious of that as an issue.
First, the noble Lord, Lord Beith, asks with his amendment whether the GP to whom you have to be a member of the practice can be in Scotland. The answer is no under the Bill at the moment. The Bill is clear that you have to be in a GP’s practice in England or Wales. Everybody has said to me that it is perfectly normal for a person living in England in the border areas to have a GP in Scotland, and asked why cannot we change the Bill to say that your GP could be in Scotland, because that reflects how people actually live.
I am sympathetic to that, but the noble Baroness, Lady Fraser of Craigmaddie, legitimately points out that, if that happened, I would need to make various other changes. For example—and the noble Baroness made this point—under Clause 7, where there is a preliminary discussion it has to be sent to the GP, and the GP has to keep a proper record of it. How can I enforce that unless I expand the provisions of the Bill to allow Scottish enforcement, for which I would need Scottish agreement? My view in relation to the point made by the noble Lord, Lord Beith, is: let us see whether we can make it work, but it will require discussions with Scotland.
Baroness Fraser of Craigmaddie (Con)
I thank all noble Lords who have taken part in this short debate, and I thank the Minister for her words. We all want to ensure that the Bill is coherent. We all appreciate that it is an evolving situation and that there might be consequential things that need to happen down the line. I just fear that the interactions with Scotland seem to have been very hastily done. We had our debate on Wales on the first day in Committee but I feel that Scotland is different, both with health and justice being devolved and with the fact that there is a Bill going through the Scottish Parliament at the moment.
I have the permission of the noble Lord, Lord Beith, to withdraw his amendment. On the assurance that we can continue to monitor this evolving situation to ensure that things are indeed coherent, I beg leave to withdraw the amendment.
Lord Rook
Member’s explanatory statement
This provides a simple way to check one of the aspects of ordinary residency required in paragraph (c), and ensures the person in question has been receiving medical care within the jurisdiction prior to making the request.
Lord Rook (Lab)
My Lords, my Amendment 19 would add a modest but important safeguard to Clause 1 by ensuring that a person seeking an assisted death has been registered with a GP practice in England or Wales for at least 12 months and has had at least two contacts with that practice in that period, whether in person, remotely or through a home visit. These are minimal thresholds. They do not obstruct genuine applicants. They would simply ensure that before someone seeks the assistance of the state in ending their life, there is at least some continuity of care—the importance of which the right revered Prelate the Bishop of Norwich has already stressed this morning.
To this end, a real relationship with the primary care system is important and prevents a terminal decision becoming subject only to a paper exercise. The Bill already requires 12 months of ordinary residence, but ordinary residence, as we discussed on the last day in Committee, can be, legally speaking, a somewhat elastic concept. A single GP registration can in practice be little more than having your name down on a list. The Government’s own equality impact assessment notes that access to GP services is uneven, that continuity of care is declining, and that patients in deprived or rural areas often struggle to obtain timely appointments.
The independent investigation into the NHS by the noble Lord, Lord Darzi, discovered that more than 1,300 GP practices have closed since 2015, while the average full-time GP now has responsibility for more than 2,200 patients. In such a landscape, it is simply unrealistic to assume that every person approaching the end of life will have a meaningful GP relationship, without a safeguard such as the one I propose in this amendment.
This amendment would give the residency requirement real substance. Twelve months of registration and two GP contacts would not create a barrier but would provide a more objective basis for assessing doctors to know that the person has not merely appeared in the system at a moment of crisis. The amendment would also increase the chance that some medical history exists. Notes of previous consultations, indications of distress, relevant family context and prior diagnoses are all crucial in understanding whether a wish to die is stable or situational.
This matters because, as we have discussed already and at some length, the Bill places extraordinary weight on two clinicians making difficult judgments about a prognosis, about mental state and about possible coercion. Clause 12 allows them to seek information from the person’s GP, but this safeguard works only if a relationship with that GP actually exists.
As a number of noble Lords have mentioned, this House has been served well by the Bill’s own Select Committee. In that, your Lordships heard repeatedly that continuity of care is one of the most reliable protections against misjudging capacity or missing signs of procedure. Dr Michael Mulholland of the RCGP stressed that continuity is not a luxury but central to safe clinical judgment. Professor Katherine Sleeman explained that earlier access to palliative care often changes patients’ perception of their suffering, which again relies on a clinician who knows the patient. Without any medical history or any prior interactions with clinicians, life and death decisions are being made without the proper safeguards. This is not safe for patients, and it is not safe for, or fair to, doctors.
We also heard extensive evidence on access difficulties. Caroline Abrahams of Age UK told the Select Committee that the single biggest practical improvement that older people want is simply being able to see their GP. Many cannot. She noted that significant numbers of older people near the end of life have no contact at all with their GP, not because they do not want it but because the system does not provide it. A report cited in the equality impact assessment on the Bill found that two in three older people in Wales struggle even to make suitable appointments. If access to GP care is already fragile, the Bill must not assume a relationship that does not exist.
There is also the risk, recognised multiple times already in Committee, of doctor shopping. We see it in pain management, in cosmetic procedures, even in end-of-life discussions. When someone is desperate, frightened or grieving, they will simply go from clinician to clinician until they find the answer that they feel they want and need. Expert witnesses, including psychiatrists and geriatricians, told the Select Committee that major emotional shifts commonly occur around diagnosis, around transitions in care or around family crises. These are precisely the moments when a single assessment by an unfamiliar doctor is most likely to misread a temporary situational wish to die as a settled and autonomous choice.
International evidence reinforces the point. Australian states, often cited as models, have tightened their systems after discovering patterns of people travelling to access assisted dying without any real connection to local health services. Canadian doctors regularly highlight the difficulty of assessing capacity and voluntariness when clinicians had no longitudinal knowledge of the patient, contributing to public concern over several high-profile cases.
We need not make those mistakes. The DHSC and MoJ impact assessments underline that assisted deaths must be documented and monitored and that clinicians require access to historical records to make safe judgments. But the true quality and veracity of these records relies on real and consistent engagement with a primary care provider. The Select Committee also heard from social workers and safeguarding experts, who emphasised that subtle coercion is almost impossible to detect in a single clinical encounter.
Lord Winston (Lab)
I am grateful to the noble Lord for giving way. I just wonder what he feels a GP should do in the circumstance in which he does not approve of assisted dying? Does the noble Lord feel that that is a problem?
Lord Rook (Lab)
With the greatest respect, that is not the conversation I am trying to have here. The conversation is about the necessity that someone who is going through the process has continuity of care and a relationship with that GP. We are suggesting that someone who is after a state-assisted end-of-life process should have the opportunity to see that GP on a number of occasions so that their judgment can be made in the context of continuity of care, not in one appointment.
To pick up the noble Lord’s questions, this amendment would not block access. It would not frustrate autonomy. It would simply ensure that assisted dying does not begin from nowhere. It grounds a grave decision in a minimal but essential relationship with the health service that is charged with safeguarding the person in question. Supporting autonomy requires a supportive context. It requires knowing whether a request reflects a settled conviction, a moment of despair, untreated depression or pressure that the patient feels unable to articulate. These things cannot be reliably assessed in isolation. Above all, care is relational. If Parliament is to contemplate legislation under which the state may participate in deliberately ending life, the very least we must insist on is that such decisions take place within the context of real and primary medical relationships, not on the periphery of the system.
This amendment would strengthen residency safeguards, improve the evidential foundation for clinicians, reduce the risk of doctor shopping and respect the seriousness of what the Bill proposes by rooting it in genuine and consistent care. I commend the amendment to the Committee.
Baroness Jay of Paddington (Lab)
Can I ask the noble Lord, having cited the doctor Michael Mulholland as a great authority in relation to his evidence to the Select Committee, whether he also accepts what Dr Mulholland said to the Select Committee? He said:
“As GPs, we are very used to providing holistic care and trying to understand where the patient is coming to us from in lots of situations”.
Lord Rook (Lab)
I absolutely agree with that. The reason why the doctor is able to do that is because he gives consistency and continuity of care. He does not see patients on one occasion on one big issue, but is able to travel with them in a longitudinal relationship, and that gives him the ability to make those decisions.
Baroness Gerada (CB)
As a GP, I understand the sentiment behind this amendment and the power of continuity; in fact, it was what my maiden speech was about yesterday. But modern general practice works in multidisciplinary teams. We have nurse prescribers, pharmacists and physician associates. We also work with other team members, especially with those at the end of their life, such as palliative care teams and oncology teams. While I understand the need to have a GP involved, I think it is rather reductive. We deliver continuity in today’s world through our medical record, which is a complete record of the individual from cradle to grave. I would say it is with the primary healthcare team that the individual has a relationship rather than with an individual.
On a point of clarification, the average patient over the age of 75 consults their GP team—the primary healthcare team—around 10 times per year, so I do not recognise the figure that most elderly people at the end of their life have no access to the GP. We reach out to our elderly patients and we try to deliver the best possible care we can to them, especially when they are approaching the end of their life.
Baroness O'Loan (CB)
My Lords, I tabled Amendment 20 and I have put my name to Amendment 220, in the name of the noble Baroness, Lady Foster, who is not able to be here today. I am sympathetic to Amendments 21 and 29 and to the process devised by the noble Baroness, Lady Lawlor, in her Amendments 30B, 265A and 443A.
A huge range of clauses—Clauses 7, 8, 10, 12, 15, 19, 20, 23, 24, 28, 29 and 30—refer to the applicant’s GP practice and the importance of keeping a GP informed. Clause 12(2)(f) includes a provision for the assessing doctor to recommend that the applicant informs their GP practice. These amendments also refer to the very relevant information that may be available from those who are close to the person seeking assisted death.
There is an assumption that the GP knows the patient and that the patient has an ongoing supportive relationship with the UK GP practice. Notwithstanding what the noble Baroness, Lady Gerada, has just said, that is no longer the case for many people. Many patients now see different clinicians on each visit. Locum and temporary staffing arrangements reduce the possibility of a GP being familiar with the patient’s condition or with the context in which they live. Home visits have almost disappeared. People in need of care often have to go to A&E, since doctors no longer visit as they once did. A major theme in UK and international data on GPs is declining continuity of care, particularly where people live in poverty or deprived areas. The Government’s equality impact assessment notes that such people experience “poorer quality healthcare”. They
“have a higher patient to GP ratio … have worse continuity of care”
and
“are more likely to struggle with navigating the healthcare system”.
Amendment 20 in my name would provide that it is not enough to be registered with the GP, but that there must be an established relationship between the GP and the patient. The GP must be able to certify that they have good knowledge of their personal circumstances, having seen the patient at least four times in the year and made at least one home visit in the last 12 months. As I said, the reality today is that many sick and elderly people do not have the relationship they might like with their GP; it is a thing of the past. Moreover, when a person moves into a residential or nursing home, they are often required to change to the GP who attends that facility and who may only have seen them on a few occasions, if at all. A GP who does not know a patient may not have the ability to make the necessary assessment.
The Select Committee heard evidence highlighting the very real inherent difficulties in detecting coercion, pressure and complex capacity issues. Making someone feel that they are a burden does not normally happen by direct coercion but is more likely to occur over a period of time. The National Care Forum stated:
“Our members are concerned that some of the people they support may sadly already see themselves as a burden. This can be financial, or just because they are now reliant on those who once relied on them. The concern is that this makes them vulnerable to deciding for this reason alone, or as a result of exploitation”.
Dr Annabel Price of the Royal College of Psychiatrists said in her evidence that coercion
“is everybody’s business. It is an area that is difficult to rule out confidently”.
It needs to be thought about throughout the process, not just at the scrutiny at the end of the panel. Professor Patel, president of the Royal College of Physicians, said in his evidence:
“Involvement of family within decision-making is important … I feel that the complex decision-making is hard. It has to be shared”.
Amendment 220 would provide a mechanism to allow GPs to consult with those who have a close interest in the applicant’s welfare when there are concerns about safeguarding capacity and undue influence. Such concerns, regrettably, often arise. Family members and close contacts may possess information which could be vital for a robust assessment and which is otherwise unavailable to the assessing medical practitioner.
Professor Katherine Sleeman said that
“complex capacity assessments do conventionally require triangulation, with input and information from the family”.
This amendment would allow access to professional records, including police and local authority records. Medical practitioners may be unaware, for example, of existing domestic abuse situations which have been reported to the police but have not made their way back to the doctor, where you have got a patient or an elderly person.
It should never be the case that the first time that somebody finds out that a family member has been granted a request for assisted dying is when they are asked to go to the mortuary to view the body. Anybody with any experience of the situation in which a person dies by suicide will know the terrible shock and trauma which ensue for surviving family and members. The reality is that, by extending the concept of autonomy to this extent, there can be a terrible impact on the ability to function of those who love the person who has died. Autonomy in this context can cause serious medical problems for those who are left behind. Autonomy, to the extent provided for in the Bill, does not ensure sufficient protection for a vulnerable—
Baroness Hayter of Kentish Town (Lab)
Does the noble Baroness accept—because she has been quoting some of the evidence given to the Select Committee of which I was a member—that the committee was not able to hear either from people who were dying or indeed from the families who had been through what she is talking about? That was absent; we lost that. On the particular point she raises about the first time a family may know about it, might she also reflect that the evidence was that most families try to discourage somebody from taking their own life rather than the other way round?
Baroness O’Loan (CB)
My Lords, I thank the noble Baroness for her intervention. It is of course the case that the Select Committee was very truncated in its ability to hear evidence. That was a decision of the House and, although we would have preferred to hear evidence from others, it was not possible.
Lord Markham (Con)
I just say, if I may, as a member of the Select Committee, that it was decision by the Select Committee not to hear from terminally ill people. It was not to do with the time available; it was to do with the majority of the committee being opposed to hearing from terminally ill people.
Baroness O’Loan (CB)
I cannot comment on the deliberations of the committee. I think there are others here who possibly can.
Baroness Berger (Lab)
My Lords, for the record, I inform the Committee that there was only one vote taken in the Select Committee. The vote was on whether the committee should receive written evidence; that vote was taken and the committee did not receive written evidence, which is a great shame because we would have heard from so many groups that people are raising in their contributions today. So, for the record, there was only one vote taken. There were many witnesses whom people on all sides wished to hear from. There was a deep regret that we were truncated and had only those three weeks to have those 13 panel sessions. If we had had more time, we would have been able to hear from many other groups. Again, for the record, only one vote was taken, which was not to take written evidence.
Baroness O’Loan (CB)
I thank the noble Baroness for her intervention, which is very helpful. All I was trying to say is that we are aware of many situations in which people are subject to coercion and where there are financial and other interests that cause people to be subject to pressure or to think that perhaps they are a burden. The autonomy which currently exists in the Bill in terms of decision-making, where there is no provision for access to police and medical records, does not ensure sufficient protection for a vulnerable individual who is making an application for assisted death. That is why these amendments are important, so that the GP who is faced with dealing with the situation and all those involved can have access to other documents.
Baroness Butler-Sloss (CB)
My Lords, I am currently a patient, in a very minor way, at an excellent medical practice where the nurses know me well. There are five GPs; I have met two of them briefly, but they do not really know me. I have huge sympathy with these amendments, but I think this is unrealistic. Over the years that I have been at this excellent practice, I have never got to know a GP, certainly to an extent of more than twice. Since there are five, and I am extremely well looked after, I do not see any problem with it. However, the idea that you should know your GP, or rather that your GP should know you—I just do not think that happens across the country. Going by what the noble Baroness, Lady Gerada, said, that is the reality.
Baroness O’Loan (CB)
My Lords, could the noble and learned Baroness possibly accept that there are situations in which patients either cannot get access to GPs or, when they do get access to GPs, have GPs with huge patient loads, which means that they cannot see the patients? While she may be in the privileged position of having five GPs, many doctors’ practices do not have that number, and people quite simply do not get access to the doctor. I am not fabricating anything as I say this, and I ask her to reflect on the fact that it is established in the Government’s equality impact assessment that there are problems with access.
Baroness Butler-Sloss (CB)
Yes, I entirely agree. That is the basis of what I am saying. I think it would be admirable if anyone who was seeking assisted dying in fact had the opportunity to be known by the local GP. All I am saying is that, yes, I am lucky, but I do not actually know my GPs. Of course, I accept what the noble Baroness, Lady O’Loan, says: there are many people who never meet their GPs and never have access. That is why it seems to me that what is required cannot be achieved. That is all I am saying.
Baroness Coffey (Con)
My Lords, should we not hear from the noble Lords who have tabled the amendments before we—
Baroness in Waiting/Government Whip (Baroness Anderson of Stoke-on-Trent) (Lab)
My Lords, can we follow the normal courtesies of the House, please? As the noble Baroness was not here at the beginning of this group of amendments, she cannot participate on this group of amendments. I urge noble Lords to take note of where we were and move forward.
Lord Winston (Lab)
My Lords, the noble Baroness, Lady O’Loan, in fact destroys her own argument, because access to GPs, unfortunately, is still a major problem. In that respect, I greatly congratulate the noble Baroness, Lady Gerada, who gave a fantastic maiden speech yesterday explaining the role of the GP and the ideal situation. The fact is, in this Chamber, there will be a number of people who, quite rightly, absolutely deplore or disagree with assisted dying, as they have every right to do.
It is also true that, in my practice many years ago, I saw patients who had requested termination of pregnancy—certainly, in more than one case. However, there is one particular patient who I remember very clearly. Several years after the Abortion Act had been agreed to and had started, I saw a patient who came into the hospital having been refused referral by a GP because he disapproved, as he was entitled to do, of abortion. She did not get a further referral. She went to an illegal practitioner in the East End of London and ended up with infection of the uterus and was in bed for several weeks with septicaemia. She did not die, but her laparotomy required her uterus, tubes and most of her pelvis to be removed. That is the risk. It is always going to be the case that individual GPs have the absolute right to decide how they might handle a particular difficult ethical issue. Of course, the problem here is that these vary from patient to patient; we have to understand that, and simply relying on the GP in this way seems to me to be deeply flawed.
Baroness O’Loan (CB)
My Lords, it is very regrettable that the noble Lord had a patient in an abortion situation. We are not, in this group, discussing the doctor’s wishes or otherwise and his views about abortion. I ask the Minister, because I can hear mutterings here, what provision says that you cannot intervene in a debate where you have not been present, perhaps, at the very first moment of the debate? What is the section in the Companion that provides for that?
Baroness Fox of Buckley (Non-Afl)
My Lords, returning to the amendments that we are discussing, I want to commend the sponsors of the Bill in the sense that, when I read the Bill, multiples clauses referred to the applicant’s GP. There is an assumption, however, of an ongoing relationship with that GP. If there is not, we can come back to that. I had assumed that there is an ongoing relationship. The noble Lord, Lord Rook, has raised some of the real challenges to why that might not be realistic.
The problem is that, if there is no assumption of an ongoing relationship but simply a visit to a GP, it seems to me completely meaningless. You go in for a 10-minute meeting with a GP, which is transient and patchy at best, as they are unlikely to be able to make any clinical assessment of great merit. The noble and learned Baroness, Lady Butler-Sloss, referred to the real-life situation of not seeing a GP but how pleasant it was.
Baroness O'Loan (CB)
I remind the noble Baroness that we are talking about people who are terminally ill, not the general population.
Baroness Fox of Buckley (Non-Afl)
I will just finish, because it relates to this. I appreciate that, once given a terminal diagnosis, that might be true, but not necessarily. That is the honest reality of the situation.
We have a moral dilemma here. GPs are being called on as though they are important to this Bill, but if they are just passing and you do not have continuity of care, they are actually being treated with contempt. On the other hand, in truth, the demand that you have to have continuity of care before you can ever be offered assisted dying seems unrealistic in today’s modern health service.
Baroness Lawlor (Con)
My Lords, I will speak to Amendments 30B, 220 and 265A in my name. They share the aim of other amendments in this group to ensure that the GP knows and has looked after the person who wants to end his or her life, but go beyond them in proposing the extent and length of the relationship needed and in requiring a letter from the GP to provide important additional safeguards. I will explain the amendments.
First, I propose that the patient be known personally to a doctor for two years through having been seen for at least six appointments. Secondly, I propose that the doctor submits a letter to the assessment panel on the patient’s physical and mental health during that period, and a prognosis. Thirdly, I stress that the doctor, as we see their involvement in this Bill, may be the patient’s GP, but that is not required; the doctor may be the first doctor, but, given Clause 11(8), this is unlikely, and it will probably not be the second doctor. The important point is that a medically qualified practitioner knows the patient over time and can write an assessment for them.
Why does this matter? Advocates of and those concerned about the current arrangements in the Bill want adequate safeguards. We all do. We want to protect the weak, the elderly and people with physical or mental health conditions from being influenced, pressured or coerced into wanting to end their own life. But if the request for assisted suicide can be accepted without a doctor who knows the patient personally over time, there will be no such safeguards. “Knows” does not mean a fleeting acquaintance but a professional knowledge of the patient built up over years. That is the aim of my amendments. By contrast—
Lord Pannick (CB)
What happens if my doctor retires and I therefore have not had a doctor who knows me for two years? Am I to be denied access to the provisions under this Bill?
Baroness Lawlor (Con)
I thank the noble Lord. I hope to come to deal with that question.
By contrast, all the Bill requires is the involvement of two doctors, neither of whom needs to be at the practice where the patient is registered or even has to have had prior knowledge of them before the process begins. Under the Bill as it stands, there is no connection between a doctor who knows the patient well and the process that leads to the assisted suicide. The other amendments in this group go some way to mitigating this, but it matters that there is a guaranteed role in the process for the doctor who may have known the patient.
The Bill recognises that the patient’s GP may not wish, as a matter of conscience, to be involved in the process, but that does not mean that they or another doctor who knows the patient should not submit a letter to the process of the assessment panel as one of a number of documents seen by the multidisciplinary panel, which would be part of the public record of the assisted suicide. It will be in a different format—neither a checklist nor compiled from the hasty notes that GPs are obliged to write that they squeeze in between their 10-minute appointments.
I turn to possible objections to these two-pronged amendments. First, the requirement that the same doctor has seen the patient six times over two years to allow adequate safeguards may be thought too much. Anything less would hardly amount to knowing the patient, the condition and their state of physical and mental health. It is feasible. Some evidence suggests that, on average, in 2018-19 patients had 3.3 face-to-face consultations per year with their GP, and 8.7 when every sort of consultation was taken into account. This data has not necessarily changed over the 20-year period of the study. Other data puts the face-to-face consultations lower, at 2.6, but these are averages. Very seriously ill people will have had far more consultations.
Moreover, only face-to-face consultations, when the patient is physically with the doctor, give a good idea of physical and mental conditions as they develop. If the Bill is so amended, in answer to some problems that have been raised, it might encourage more face-to-face GP consultations with seriously ill patients. If there is a seriously ill patient and the GP retires, they might like to leave a letter providing the evidence over the period they saw them before they retire. But there will always be objections—
Baroness Lawlor (Con)
These things can happen, but we should have a process or an alternative mechanism. I am not going to deal with exceptional cases. My GP is still in situ, and I can see my GP when I want to; other practices could aim to do the same thing. We have very great demands on the practice in Cambridge, with many students registering.
Baroness Wheatcroft (CB)
Can the noble Baroness tell the Committee whether she actually listened to what the GP in our midst said about how practices work?
Baroness Lawlor (Con)
I thank the noble Baroness for her question, but I would like to press on. There are other GPs who want to see the same patients; they want to build up the patient relationship over time because they say it makes for better diagnosis, care and treatment for their patients. We should not put up with the worst-case scenarios simply because it does not happen or because we think a multi-doctor practice works well. It may work well in some cases, but there is no replacement for knowledge of a patient over time.
The letter gives the multidisciplinary panel an assessment of the patient’s illness and state of mind by someone who knows them. If anything raises suspicion that there has been pressure or that the patient is not in a state of mind to make the decision, the panel can investigate further. Moreover, unlike the other matters and activities in the process, the letter is not a matter of ticking boxes. The demand is for something that doctors are used to doing; to write a coherent letter about one of their patients is something that requires thought and careful concern for the individual case. It is standard practice in referring a patient to a consultant for specialist care where there are letters passed to and from. Doctors and consultants write letters.
If the Bill is to have real safeguards in the form of coherent and analytical evidence from a doctor who has known a patient over time, such amendments are needed. I ask the sponsor of the Bill to require it.
Lord Deben (Con)
My Lords, we are supposed to be making the Bill more practical; it does not make it more practical to ask for something that is manifestly impossible. I could not demand assisted dying, because I have not seen my registered practitioner in Suffolk for many years. I do not have a particular practitioner because that is not how the local system works. We are not in a sensible position if that is what we are going to ask for.
But the noble Lord, Lord Rook, has an important point that I do not want us to lose because of the suggestion that all people have the kind of National Health Service that we would all wish to be the case. We have to take his point rather differently. I was surprised that the noble Lord, Lord Winston, suggested that the proposition is that the general practitioner or the team—in normal circumstances it is the team—could in some way stop the application.
The point is—and I ask the Committee to think about this seriously—that if someone has a general practitioner, it is important that the GP and his or her team are informed of the request in case they are able to contribute to a sensible decision. The fact that this is assumed in the Bill, as was put forward by the noble Baroness, Lady Fox, does not prevent us insisting that they should at least have the opportunity. If we do that, we will be doing a very valuable thing.
Lord Scriven (LD)
It is not an assumption. It is in the Bill that if the co-ordinating doctor is not the GP of the person seeking the assisted death, under Clause 10(3)(b)(ii) the co-ordinating doctor has to write to the GP practice to make it aware of the request.
Lord Deben (Con)
I agree with that, but the point of the amendment from the noble Lord, Lord Rook, is to tie together a period of someone being in the National Health Service. I agreed with the comments made by the lawyers about “normally resident”, rather than other words. The noble and learned Lord who introduced the Bill might consider that this amendment will give some confidence to those who had a concern because it means that “normally resident” has been underlined by the fact that someone has in fact been in a general practice of the National Health Service. I cannot see that it does any harm, given that there is a year in any case. It underlines what the noble Lord reminded us of: the idea that this should be a part of the normal way in which people are dealt with.
I do not like the Bill very much, but it is our job to make it work. To do that, it is more valuable to fix it within the National Health Service as we have it, rather than trying to invent a service that we might well like to have—and I am old enough to remember when we did have it. Let us not pretend, when things are not as they ought to be.
Baroness Gerada (CB)
My Lords, if a patient is at the end of their life in any practice in the NHS, that patient will be discussed at a multidisciplinary team meeting. The patient will be put on an end-of-life pathway and will have a named clinician within the practice to do their care. This would include assisted dying. There is absolutely no way that a patient, unless in an extraordinary situation—and I take the point about Wales, which has a desperate problem with GPs—would not be cared for in that way. That is how our contract is; that is how we want to care for our patients. We would code it on the notes so that every single person consulting with that patient would know that this patient was an assisted dying choice, and they would get the care that I have just described.
With respect to the arbitrary 12 months or 24 months, many patients choose to move at the end of their life. They choose to move to the place where their loved ones are. Many choose to do something such as go abroad to the countries that they may have come from and come back right towards the end of their life. To put in an arbitrary barrier of 12 or 24 months is not putting the patient first; it is putting an arbitrary time limit first.
Baroness Falkner of Margravine (CB)
My Lords, I wonder whether the Minister in winding up could advise us what the Companion says about Peers making speeches on the same amendment over several points of the passage of that amendment.
It is a pleasure to follow the noble Lord, Lord Deben, speaking to the amendment from the noble Lord, Lord Rook. There is a lacuna in Clause 1(1)(d), which, by requiring registration with a GP, does not cover the practical point of what happens to people who have lost contact with their GP. They may have lost contact for no other reason than being so ill, perhaps with cancer as that is the main illness that people who might be seeking assisted dying have, that they have been taken into private care—those who are lucky enough.
An increasing proportion of the population of the United Kingdom now uses private care, not least because employers provide it as part of a package. So, coming to continuity of care, if we must have the light-touch amendment of the noble Lord, Lord Rook, in the Bill, to clarify and strengthen Clause 1(1)(d), I will share with the Committee very briefly a practical experience of what it means to have advanced cancer and the interaction with the GP. My GP practice, having failed to diagnose me over six months, as I mentioned in my Second Reading speech, slipped away the moment I engaged with private care, although every single consultation with a private practitioner is sent to the GP. Nevertheless, between 30 August 2024, when I was first diagnosed, and late this September, I had no contact whatever with my GP practice. I was finally invited to come in and was told I had fallen between the cracks—it must have been a pretty large crack to have lasted 14 months.
I noticed in the equality impact assessment that 66% of the people who sought assisted dying in the two jurisdictions quoted were people who had cancer. My question to the noble and learned Lord when he winds up on this debate is therefore, what consideration has been given, in having Clause 1(1)(d) in the Bill, as to the relationship of the private oncologist who is treating that patient with the local GP, given that terminally ill people in significant enough numbers that we need to be conscious about them in the Bill may well have been—shall I say—passed on from the GP?
As a final point, once I had the diagnosis, I had the experience of requesting treatment at my local—within a walkable distance—leading cancer teaching hospital in the United Kingdom. When I rang about that after the diagnosis, I was told by my GP, “They won’t take you, because now you’ve gone private”. I leave that for noble Lords to reflect on.
Lord Blencathra (Con)
Before we move to the rest of the debate, could we please give way to those noble Lords who have tabled amendments? I would like to hear what they have to say.
Baroness Grey-Thompson (CB)
My Lords, I will speak to Amendment 21, tabled in my name, from personal experience. The richness of the debate today shows that, even in your Lordships’ Chamber, we all have completely different experiences of how we access a GP practice.
I tabled this amendment partly from personal experience, trying to look at how we provide continuous care to a patient. As for my own experience, I am disabled, not sick, but I have had some very interesting experiences of interacting with doctors. Fairly recently, I was asked by a doctor how I caught spina bifida and had to explain to him that it was congenital. As for my husband’s experience of the healthcare system, he had a spinal cord injury in 1984 and, at a recent visit, was continually asked whether it was in 1884 that he had his accident—I know he looks good for his age, but not that good. This is not to be flippant, which I have been accused of before. It is actually to try to ensure that we have proper continuity of care for a person who wishes to end their life.
My amendment is also grounded in coercion detection and the limitations of any capacity assessment. When I tabled it, I was thinking that perhaps a GP could provide extra knowledge to contribute to the decision that was made. But then I heard of the experience of my noble friend Lady Falkner, which is absolutely appalling. It shows that there is far more work we need to do, not just on the National Health Service but on making sure we provide the right care. The noble Lord, Lord Deben, talked about the NHS we wish to have. Well, this might be a chance to think about the NHS we wish to have.
I take this opportunity to welcome my new noble friend Lady Gerada and the experience she brings to the Chamber. I have to say that it has left me slightly more confused. I have amendments on data recording, which we will be debating later. Her comments show that data recording and sharing is really important. The part I got a bit confused about was that, if there is a named clinician as part of that process, does that not ultimately feed in to the points that have been made today? I would welcome the chance to discuss that with her outside the Chamber.
Continuity of care is really important, and how it relates to improved patient outcomes. In 2012, 56.7% of patients had a preferred GP, but that is declining. There is a link between your preferred GP and being able to access that GP. The decline has happened regardless of baseline continuity, rural or urban location or level of deprivation. Providing a better experience to patients will make those final weeks and months better for them. The Royal College of General Practitioners published excellent work in 2021 on why the patient’s relationship with their general practitioner is so important. Research on coercion and undue influence demonstrates that standard capacity assessments, while necessary, are not currently sufficient to identify subtle forms of coercion. That is why I tabled an amendment.
In response to the comments of my noble friend Lord Pannick, about what happens if a GP dies, I am happy to be corrected, but I thought the provision in the Bill about your doctor dying would cover a general practitioner as well as any other doctor involved in the process.
What we are talking about here are really complex decisions. Consulting an established GP or GP practice might mean that they possess the nuanced knowledge which would help somebody make a choice. The requirement that GPs confirm that they have a good understanding of the individual’s personal circumstances represents, to me, a better form of safeguard, ensuring that this knowledge actually exists. We cannot assume anything during this process. The assessment should provide abuse detection capacity unavailable in other types of consultations. For individuals whose care is family dependent, the home visit element—which I had, not so long ago—can play an important part in identifying coercion. If the debate has raised nothing else today, it is that this is a really complicated issue which needs much further work.
Lord Markham (Con)
My Lords, perhaps I may just ask a question on that. Everyone believes a GP should be able to conscientiously object. But, in all of this, I have not heard an answer to what happens in that circumstance. Surely, we need a circumstance, as happens today, involving a team-based approach, as the noble Baroness, Lady Gerada, said. Otherwise, you could have formed a great relationship with a GP who then conscientiously objects—which we think is absolutely suitable—withdraws himself or herself from the situation and can no longer take part in it. Surely a team-based approach is the better approach.
Baroness Grey-Thompson (CB)
The comments made by my noble friend Lady Gerada explaining the team-based approach seem very sensible in terms of providing that continuity of care. I am very lucky that I see the same GP every time I go; it is interesting to understand that not everybody experiences that. I am not absolutely welded to it being a single GP. For me, it is about ensuring that we have continuity of care and the right support for an individual, and doing it in the right way that enables them to make the best choice, while not experiencing any coercion in making that decision. The more frequent contact means that a GP or a practice may be able to understand some of the really difficult family complications that we absolutely know go on.
Many noble colleagues who worked on the then Domestic Abuse Bill will see that coercion can be very subtle and understated and happens in numerous different ways. We have a duty to make this Bill the safest Bill in the world. The noble and learned Lord will say that it is. We slightly disagree on it being the safest Bill in the world, but we have a duty to make it safer.
Baroness Finlay of Llandaff (CB)
My Lords, I shall speak to my Amendment 26 in this group. It is important to remember that Clause 1(1)(d) of the Bill simply states
“is registered as a patient with a general medical practice in England or Wales”.
It does not require anything more than that. I will explain why I have tabled an amendment looking at a home visit, because, as my noble friend Lady Gerada has said, patients will be looked after by many different members of a primary care team but will be legally listed and registered with the named GP, because that is how the funding flows to the practice for care delivery. We must not confuse the two, and the notes held in the practice are important.
The person may actually be receiving most of their care in secondary or tertiary care, as the noble Baroness, Lady Falkner of Margravine, has pointed out, but if this qualifying condition is to have any meaning, there must be substance in it, with a clinical record that can be drawn down in assessment. That does not mean that the GP has to have anything to do with providing an assisted death, but it seems sensible that the clinical record, which will have the record from previous GP practices if the patient moves, can be drawn down.
Data suggests there has been a fall in home visit rates over time. Most home visits undertaken by primary care team members are indeed to people who are seriously ill. The data shows that in October 2025 there were over 462 home visits by GPs, which comprised about 1.7% of all face-to-face consultations registered by a practice that month, or 1.1% of all contacts. While that percentage may seem low, particularly as care moves into the community, it is important to remember that the pressures on primary care teams have increased, with more listed patients per GP and more complexity. In addition, there is less continuity of care, with patients often seen by several different doctors in a practice, and different members of the team. During a hospital stay, patients are likely to encounter, on average, 18 to 27 different healthcare professionals. All those conversations and details should be entered in the hospital record, but they may not be well entered, and the information sent to the GP after admission may be a rather simplistic summary about more of the physical aspects but not necessarily psychosocial details that may be recorded somewhere in the depth of a hospital record.
Why does all this matter? It is because the living conditions and atmosphere in a home reveal an enormous amount about pressures and influences on a person who is ill in a way that is never ascertained in the consulting room. The well-groomed patient’s home can reveal overcrowding and poverty, where others in the household are dismissive or even verbally abusive in front of the healthcare professionals who visit. For most patients, a home visit can allow the person the confidence on their own territory to talk about their hopes and fears in depth, and about why they seek an assisted death. They are not intimidated by the hospital or GP venue, knowing that other patients are waiting outside and aware that others may notice that they have been crying when they leave through a crowded waiting room.
In evidence to the Select Committee, we heard from the Royal College of General Practitioners, of which I declare I am a fellow, that any assisted dying service should be seen as a stand-alone, specialised service that GPs and other healthcare professionals may opt in to provide. They stated that it is neither appropriate nor practical for this to be deemed core GP work, and they do not want any blurring of lines with the palliative care that they provide, which has already been described by my noble friend Lady Gerada. That position was confirmed in a motion at the RCGP Council last week. The GPs were clear in evidence to the Select Committee that they have no spare capacity in the working day to take on additional duties related to providing an assisted death. For some, a lifetime of 10-minute contacts will have built long-term relationships, but that does not apply to everyone.
As the Bill does not require any inquiry of the family about the person’s circumstances, the clinical record from the GP practice about a home visit may be the most revealing way to ascertain the true situation and decrease the risk of coercion being missed, as my noble friend Lady Grey-Thompson has referred to. The GP record must be available to whoever is undertaking the assessment and assisted death service provision.
In terms of ability to see the GP, I support the evidence that we heard from Caroline Abrahams of Age UK, who said that older people often report that better access to a GP would make a huge difference to their world, and that two in three struggle to make appointments or communicate with their GP. Sadly, I am afraid the evidence in Wales is that in 2023 two-thirds of patients said to the Older People’s Commissioner for Wales that they had difficulty in getting an appointment, and that had gone up from one-third in 2022.
The Demos commission report, which was led by the noble and learned Lord, Lord Falconer, found that a doctor supporting the person and their family
“are the key elements that … should be included in any future framework for assisted dying”.
So I ask him: is that the reason why the requirement to be registered with the GP is included as a qualifying condition? Perhaps he could clarify a bit further.
The noble and learned Lord’s commission report envisaged that the assessing doctor would know the patient well and have an established relationship. In his “Newsnight” interview, he also confirmed that if the patient was young, it would be a sensible investigation for family members such as the parents to be interviewed if that young person was asking for an assisted death. Does he recognise the importance of putting some kind of stable primary care relationship at the heart of information that is available about the circumstances of the patient?
Lord Falconer of Thoroton (Lab)
It might help the House if I answer those questions, because they are rather at the centre of the debate. Before I get there, I should say that, in the view of the sponsors, the requirement to be registered with a GP practice reflects the reality, which is that in some cases you will have a relationship with your GP but in other cases you will not, despite your best efforts to do so. The reason for the relationship with the GP’s practice was that it provides a central place for records to be kept. The noble Baroness, Lady Fox, rightly identified myriad references in the Bill to GP practices, and noble Lords will see that it is informing the GP of every step that is taken. As ever, though, the noble and learned Baroness, Lady Butler-Sloss, puts her finger on it: you cannot possibly rely on people having an established relationship with their GP, and that is not the protection.
The point made by the noble Baroness, Lady Gerada, seems to be key, and it is reflected in what the noble Baroness, Lady Finlay, has said. The people looking after you are those who should be putting their input into what the right course is. The wrong answer to this is ludicrous hurdles that you have to get over. I do not call the speech of the noble Baroness, Lady Lawlor, ludicrous, and I unreservedly withdraw that in relation to her, but having to have seen your GP six times in the previous years is not the way to deal with it. Surely the way to deal with it is to put in the Bill—and I am more than willing to discuss how we do that—how the multidisciplinary team, which might be GPs, oncologists, nurses, physiotherapists or social workers but it might not, get to have some input into it.
What I am taking away from this debate is this: do not think about the GP being able to provide it, because they will in some cases, but they will not in others. Think instead about how you get the multidisciplinary team who are looking after the patient who wants an assisted death to give the appropriate input. Again, the right course is to talk to the people who have some expertise in relation to this and think how we build that into the Bill. It is not in the Bill at the moment, but I think we can put it in.
Baroness Finlay of Llandaff (CB)
Can the noble and learned Lord clarify whether he would consider amending the Bill to ensure that information is sought from those who have provided care to the patient during the course of the serious life-limiting illness that has led them to request an assisted death, whether that is from primary care, a hospital or a private sector provider? Would that also include information from members of the family, as he suggested in the Demos commission, when the person is young and when there are circumstances that would be particularly pertinent?
Lord Falconer of Thoroton (Lab)
Yes, we should get the information from those responsible for the care of the individual in a health sense. However, I am not willing to commit myself to that in relation to the family. The person making the decision should think, “What should we do about the family?”—but what if the patient has not seen their family for a long time or are at odds with particular family members? I believe that it should be done very much on a case-by-case basis.
Baroness Lawlor (Con)
My Lords, the noble and learned Lord thought that it was ludicrous that a patient would see the same doctor. Is it ludicrous, in his view, that, on average, 3.5% of consultations between a patient and a doctor are face to face? Is it ludicrous that we should expect those consultations to be with the same doctor?
Baroness in Waiting/Government Whip (Baroness Anderson of Stoke-on-Trent) (Lab)
I am sure that my noble and learned friend will respond to that in the debate, but the noble Baroness has just intervened on an intervention. The Chief Whip made clear reference to that earlier.
Baroness Hollins (CB)
My Lords, I welcome the comments from the noble and learned Lord. General practice is very different today from when I practised as a GP earlier in my career; it was certainly not as part of a multidisciplinary team.
I added my name to the very reasonable Amendment 21 tabled by my noble friend Lady Grey-Thompson. The debate has not been about whether assisted dying should be part of a GP’s role; it has, very helpfully, focused on the importance of continuity of care and accurate records.
I congratulate my noble friend Lady Gerada on her first contribution in Committee; she is correct that GPs now work as part of a multidisciplinary team. I think that patients accept that, but they also expect that a doctor is ultimately responsible for their care when they are seriously ill. Perhaps Amendment 21 could meet the noble and learned Lord’s requirements if it were amended to refer to the medical practice rather than to the general practitioner.
Lord Empey (UUP)
My Lords, in my opinion, these amendments are really about safety, but we have turned the debate into a generalised whinge-fest about the shortcomings of the National Health Service, and we are all aware that there are many.
However, from recent personal experience, I accept what the noble Baroness, Lady Gerada, said. I am fortunate that we have a local health centre; it has four floors and four practices—a separate practice on each floor—each with multiple members within them, who come and go. In general, if somebody is seriously ill, we are fortunate in that we would be able to have established contact with more than one team member.
However, the noble and learned Lord, Lord Falconer, said that he wanted the GPs mentioned to be a central point for the records. Here we come to an entirely different issue. I have seen records that include what the GP practice puts in, as well as discharge letters from the various hospitals people have been in. Those discharge letters are written by F1 doctors—which is the most junior doctor grade—who have just come out of university. Sitting there late at night, writing these discharge letters is regarded as one of the worst things a doctor has to do. I have seen serious mistakes in those letters, even regarding one of the problems the patient had. Getting those records changed is very difficult. The making of decisions on the future of an individual on the basis of a record that might be totally wrong or misleading is the reason why we need additional protections. It is only common sense, because we humans are all frail and we make mistakes. We write and say mistakes. We overlook things.
Lord Blencathra (Con)
My Lords, I did not speak last Friday, and this is the only group to which I intend to speak today. I could have spoken to the last group, as my former constituency abutted the Scottish border of Dumfries and Galloway and a mere 85 yards across the River Sark was Gretna. I was aware of our glorious 600-year history of border-raiding for cattle and women—in that order—and now it seems we can add free prescriptions to the list as well.
These amendments would strengthen the safeguards with a demonstrable, ongoing clinical relationship with a GP, reducing risk of error, coercion and administrative confusion, while supporting clinical judgment and the continuity of care. Requiring 12 months’ registration plus a minimum number of in-person contacts gives a straightforward verifiable test of recent clinical involvement. We need robust, practical safeguards and clear eligibility checks. These are essential to protect vulnerable people by evidencing local care and oversight. A sustained relationship with a local GP who has seen the patient helps ensure that the patient is informed and is acting voluntarily and free from subtle pressure. The GP’s direct knowledge of the patient’s circumstances is therefore a critical safeguard rather than a bureaucratic hurdle.
The big issue, which has already been raised today, is: who sees the same GP twice these days? I am very lucky, and perhaps some other noble Lords are as well, in that there are superb multi-disciplinary GP practices in Cumbria. I almost always see the same GP, and we can email as well. In fact, in 40 years of living that constituency, I have only ever had two GPs. However, that is not the national picture. Many patients see a different GP every time they visit. Therefore, for this part of the Bill to work, it cannot be any old GP from a practice; it has to be a GP who has treated the patient personally on a few occasions or over a period of time.
Yesterday, I had the wonderful privilege of hearing in this House from a GP who satisfied all the criteria of these amendments thanks to her deep knowledge of her patients. I was later able to congratulate the noble Baroness, Lady Gerada, a former president of the Royal College of General Practitioners, on her excellent maiden speech. I am delighted to see her here today. I understand that this morning, she was doing the day job, treating her patients in her constituency.
I know that the noble Baroness is in favour of assisted dying, but what she said in one part of her speech yesterday was directly relevant to these amendments. The noble Baroness—I am rather vexed at the right reverend Prelate the Bishop of Norwich, who stole these lines earlier this morning—said:
“I became a GP in Kennington, and I have lived and worked in the community I serve ever since … My very first patient was a young woman who suffered a stillbirth. Decades later, I look after her children and now their children too. That continuity, seeing lives unfold across time, gives general practice its unique moral and social power. It allows us to see people as whole human beings, not as isolated organs or diagnoses. We are interpreters of experience, translators of suffering and witnesses to change”.—[Official Report, 11/12/25; col. 370.]
That is exactly the sort of GP I trust to make a decision on whether a person has a confirmed wish to opt for assisted dying—not just any general practitioner, who may never have met the patient before and has just 10 minutes to form an opinion.
I would love to find a way to include that magnificent sentence about continuity and seeing lives unfold over time giving general practice its unique moral and social power; I would love to see whether we could incorporate it into the Bill, because it sets the right moral climate.
As I say, I have a GP. However, for those millions of people who are not so lucky, these amendments would balance safeguards with practicality. Setting a modest minimum of contacts is proportionate. It is enough to demonstrate an established relationship without imposing unrealistic burdens on patients or practices.
Many noble Lords have spoken of multidisciplinary teams. Can the noble Baroness tell me—indeed, can anyone tell me—how many of all the GPs in this country are still single-practice doctors? A Google search suggests that it is around 63%. That seems terribly high; there must be more multidisciplinary teams than that. There are still an awful lot of single-practice GPs. On the rare occasion when I have not seen my own GP, the other GP has had a look at the computer and read all my clinical notes. However, he does not really know who I am; perhaps that is just his good fortune.
These amendments would support patient safety and public trust in any assisted dying regime. It needs to be visible and enforceable, and it needs to have enforceable safeguards. Clinicians must be able to attest to a patient’s circumstances. I support these amendments.
May I say to the noble and learned Lord, Lord Falconer of Thoroton, that I was dismayed to read some very hostile comments about noble Lords and noble Baronesses in the weekend press? The complaint was that some Peers had tabled a large number of amendments, and that that was somehow wrong. If they were the only Peers who spoke to them, that criticism would be valid, but those noble Lords and noble Baronesses, as professionals and experts, tabled amendments to which many of us wanted to speak. We left them to do it because those Peers have experience; scores of Peers have spoken to their amendments, so they were not abusing the House. I am absolutely certain that the noble and learned Lord was not behind that bad-mouthing, because he is a gentleman as well as a Peer, but some supporters of this Bill are trying to drown out and close down any proper scrutiny in the Lords.
Lastly, I remind the noble and learned Lord and the Committee that Dignity in Dying’s website boasts that the Bill had 29 Committee sittings in the Commons and over 90 hours of consideration. Since the Bill has come to us from the Commons, we have heard devastating criticisms of it from the Constitution Committee, the Delegated Powers Committee and experts giving evidence to the noble Baroness’s Bill Committee. Today, we are on only our fourth sitting, after, I think, 18 hours of debate. So I say this to the noble and learned Lord: please tell some of the others to call off the attack dogs because this House is doing its proper job.
Lord McCrea of Magherafelt and Cookstown (DUP)
My Lords, like many noble Lords, I grew up at a time when the family doctor was looked upon as a family friend who could always be depended on whenever you were ill or in a time of crisis. Unfortunately, that is not the situation today. There is a major problem across the United Kingdom: patients desiring to see a GP find themselves sitting on the telephone and ringing the surgery 120 times, perhaps, but still not getting through to someone and giving up at the end of it. That is the reality of the situation in many places.
I am sorry that the noble Lord, Lord Pannick, is not here. He posed a question to the noble Baroness, Lady Lawlor, concerning what happens if your GP retires. Let me give my small experience. My GP was in his late 50s. He was an excellent GP. During Covid, unlike many other practices, he still allowed patients to come to his surgery. Whenever elderly patients could not come, he went out to their houses and visited them in their own homes—unlike many other practices and GPs. Unfortunately, he got cancer and, in his late 50s, just recently, he passed away.
We were left with a practice in our town with several thousands of patients but nobody to take it over. So what happened to us? Our GP died, and so, without any consultation whatever, we were all farmed out to seven or eight practices around the countryside, some of them not even close—just to whoever would take us. It is unrealistic to imagine that somehow a new doctor would have any knowledge of the pressures, the problems or the complex challenges that his new patient was facing; he would not have any continuity of care whatever.
It was even worse than that, because it was several months before the notes went to the next practice that you were farmed out to. You were allotted a practice but the notes concerning any illnesses of the patients did not immediately follow; it was several months before they arrived. What has been suggested in these amendments today strengthens safeguards. Therefore, they are worthy of the support of noble Lords in this House.
Lord Sentamu (CB)
My Lords, I agree with the noble and learned Lord about why we are focused on GP practices, because they are the hub of information. Since I arrived in this country, I have had a lot of treatment for all kinds of conditions—I am one of those people—and all the national insurance I have been paying has being paid back to me about a hundred times, so I am a walking miracle.
An amazing thing happened to me recently. When my anaemia was so high—I did not think I would survive it—I went to see a consultant in Newcastle hospital and he called up my records from 1975. It was amazing that, apart from one GP who did not keep the record properly, he had it all; therefore, I was able to get proper treatment. Friends, the record keeping on health in this country—even if some do not do it well —really is amazing. The records are very clear. The GPs who are good will always keep up their information, which is digitalised so that they can send it quickly.
Therefore, for me, the whole picture is not just the GP doing it but GP practices, which are the hub from which a lot of information about anybody can be gathered. You sever that and put it somewhere else, and you may not actually get it. I have every confidence that in my GP practice at the moment, which has nine doctors, they will have access to that information.
I therefore think that noble Lords should stick with what is in the Bill about the GP, because it is the information that you want to get, and you get it now and I am amazed. I am therefore very thankful for the care that I have received and the records that speak about my journey, and I want to thank all those who have been involved in my health.
Baroness Blackstone (Lab)
My Lords, I wonder whether we can now hear from the Front Benches. We have had a long discussion about these issues and have moved into the danger of repetition. We have already had a response from the sponsor of the Bill too, so I think it is now the turn of the Front Benches.
Lord Harper (Con)
My Lords, I will raise some new points that have not yet been raised in the debate—looking at the Companion, as the Government Chief Whip instructed, I have every right to do so. My noble friend Lord Blencathra made some very good points. I have been here for every minute of the debate on the Bill, and I have listened with care and courtesy to every noble Lord, whether they were making points I agreed with or disagreed with, and I expect the same courtesy to be afforded to every Member of this House.
I agree with the sentiment of these amendments. It has been a very valuable debate, because there has been a general sense in the Committee about the importance—
Baroness Winterton of Doncaster (Lab)
My Lords, the noble Lord and I go back a long way. I certainly appreciate what he just said, but I ask him whether he agrees with the noble and learned Baroness, Lady Butler-Sloss, that it is important that the Bill gets to Report and that the House has the time to consider it then and not only in Committee.
Lord Harper (Con)
I am trying to make some comments on the amendments. Let me do that and then, if I have time—I am very careful to keep my remarks to less than 10 minutes, which is the guidance in the Companion—I will address the noble Baroness’s points. She is right that, when I was Government Chief Whip, she was my opposition and we had a very good working relationship, which I want to continue in this House.
What has come out of the debate is a general view from everybody, whatever their view on the Bill, about the importance of the relationship that people have with their general practitioner, whether it is an individual or, as the noble Baroness, Lady Gerada, said, a multidisciplinary practice. That is a very important point. The amendments that have been tabled to Clause 1 are about the eligibility criteria for whether someone is able to make a request for an assisted death.
The flaw in the amendments—I support the idea behind them, but I do not support them—is that they do not make an appreciable difference to the safeguards in the Bill. When the noble and learned Lord, Lord Falconer of Thoroton, made some remarks in this debate, he put his finger on it: there is no requirement in the Bill for the GP or the team at the GP practice to be the doctor who makes the assessment about whether the person has the capability to make this decision or not. That, as was said by the noble Lord, Lord Scriven, is the role of the co-ordinating doctor, who does not need to have any relationship with the patient at all.
When the noble and learned Lord, Lord Falconer, looked at this issue before, there was a report from the Demos assisted dying commission, which the noble and learned Lord chaired. Its recommendations recognised the need for
“a doctor who … knows the person well and supports the person and their family”.
The report also said that that doctor who knows the person can better assess whether the request to die is a cry for help, a sign of poor care or a result of coercion, and that
“if an assisted death was to go ahead, the first doctor should be responsible for arranging support for the patient and their family during and after the assisted death”.
It envisaged that
“the first doctor would have a greater level of involvement”
and
“an established relationship with the person requesting this assistance, and be familiar with their personal history and family context”.
That seemed to be the general view of all of the noble Lords who have spoken.
The problem is that there is no requirement in the Bill before us for the GP or multidisciplinary practice to be the co-ordinating doctor or even to be consulted before the co-ordinating doctor makes the first assessment. It is absolutely true, as the noble Lord, Lord Scriven, said, that, when the co-ordinating doctor has made the assessment, he or she has to send that to the GP practice. However, as the Bill is drafted at the moment, the role of the GP practice is to act as a postbox, log the report—I see the noble and learned Lord, Lord Falconer of Thoroton, nodding—and pop it on somebody’s medical records. There is no requirement or duty on that GP practice to read the report, to make an assessment of the decision of the person with whom they have a relationship to die or to do anything about it at all. That is the flaw in this.
The problem with the amendments on the eligibility criteria that we are considering is that, if they were all adopted—this is an administrative point—they would not ensure that that knowledgeable individual or practice with whom the patient has a relationship has any role whatever in making this important decision, involving the family or consulting anybody at all. That is the flaw.
This has been a valuable debate because I think it has demonstrated—and I think the noble and learned Lord, Lord Falconer, recognised in his earlier comments —that there was value in that relationship, and I am not surprised by that, given the conclusions that the commission he chaired came to, but the problem is that that is not reflected in the Bill at all.
If I may, I will conclude on this point before I address the remarks of the noble Baroness, Lady Winterton. Why we have these debates, and the reason for hearing from noble Lords with opinions, is because it highlights the flaws that exist in the Bill. The point of this process is that that then enables the sponsor of the Bill and all noble Lords to listen carefully to the debate and to bring forward improvements on Report.
I hope that, in his response, the noble and learned Lord, Lord Falconer, will draw on the concerns that have been highlighted and can indicate his approach. If he is minded to bring forward amendments that deal with some of these things, that clearly means that other people do not need to. If he indicates he is not minded to do that, then other noble Lords can bring forward amendments to deal with it, which can then be debated and voted on at Report stage. That is the point of our process and why we debate these things in the Chamber: so that everybody can hear the debate and the points. It is a better way of improving the legislation than having lots of private discussions to which most of us are not party.
What I would say to the noble Baroness, Lady Winterton—
Lord Scriven (LD)
My Lords, I think there is a misconception by the noble Lord on how modern general practice works through the electronic patient record. If the report goes to a GP, like any report does, it is clinically coded, and there would be a flag on the patient’s electronic patient record that would indicate to the GP and anyone in that practice that an assisted death had been requested through the co-ordinating doctor. It would not, to use the noble Lord’s words, just be postboxed; it would be automatically registered on the electronic patient record, and a flag would come up for anyone in the GP practice to see what was happening.
Lord Harper (Con)
That is a very helpful intervention, and I absolutely accept that. I understand that that is the way it works. Certainly, with the way the NHS works now, you can go on to the NHS app, which many noble Lords may use, access your own patient record and see all those various notifications registered. He is absolutely right that a flag would be raised; the problem is that there is no requirement in the way the Bill is drafted at the moment for that GP practice to do anything as a result of that flag being raised—none at all. I think there should be. We can come on to that, as we progress through the Bill, when we get to Clause 10. That is the point I was trying to raise.
I do not want to go over my time, but I will deal briefly with the points by the noble Baroness, Lady Winterton. I agree with her. It is right that the House scrutinises the Bill properly. If you look at the number of days of debate in the House of Commons, I think there were 11 days in Committee. If you look at the normal way this House conducts itself—because we tend to do a more detailed level of scrutiny than the House of Commons—you would expect, as a rule of thumb, about 16 days of debate in Committee; then we normally have 50% of that on Report and at Third Reading. I do not disagree with her. It may be that this Bill requires more time, and that is clearly a discussion for the sponsor to have with the Government Chief Whip about making that time available. But I think the wrong response is for us to not do our jobs properly, not scrutinise the Bill and not make sure that it is a properly fit piece of legislation to get on to the statute book. That would be the wrong response. If we were to do that, we would be failing in our duty to legislate properly for the people of this country.
The Lord Bishop of Gloucester
My Lords, I will speak to these amendments because I want to make a new point. A very vulnerable population that we must continue to remember is the prison population. Although we will deal with the prison population more fully in the group coming up, we must remember that this Bill currently does not exclude prisoners from being eligible. That means we must consider how each issue is likely to play out in a prison setting.
As we have heard extensively, these amendments deal with two main issues: first, access to primary care; and, secondly, how well that primary care physician knows the details of your medical history. The first is very closely related to inequalities and making sure that those who have worse access to care are not more likely to choose assisted dying. The prison population are therefore a key group that must be considered, since their health and access to healthcare are worse than that of the general population. That is evidenced by the recently published report by the Chief Medical Officer.
That report also highlights access to healthcare for those in prison. There is no automatic or compulsory enrolment of prisoners into primary care on the prison estate. Over 20% of the prison population do not complete registration on arrival. For those who do, the service is often slow or inaccessible. According to the Nacro report on physical health in prison, two in five prisoners waited for a month or longer for a GP appointment and one in 13 never got one. According to the Chief Medical Officer’s report, one in three prisoners does not have their full electronic health record available to prison healthcare staff. These are not just statistics. When I visit and talk with prisoners about their well-being and purpose, access to healthcare is always spoken about.
Briefly, I do not believe that the issue of how well a primary care physician knows your medical history has been sufficiently considered from a prison context. If a GP may be the person to conduct a preliminary discussion to consider a person’s application for an assisted death, how will they do that safely with incomplete information about their patient’s health record? We must question eligibility along these lines. Before we talk about the next group of amendments, I hope that there will be important safeguards for prisoners on the issues raised in this group.
Earl Howe (Con)
My Lords, the noble and learned Lord has already been very helpful in the undertakings and clarificatory comments that he made earlier in the debate, so I shall be very brief. In following up those comments, I will return to the question that I raised on the previous group. The Bill seems consciously to steer clear of insisting that a person’s GP must always be involved in the process being pursued by that person in seeking an assisted death, other than the GP having a duty to note in the patient record that the preliminary discussion has taken place. The entire process, in other words, could be conducted by the patient in conjunction with hospital-based medical consultants.
Do I understand correctly that the noble and learned Lord is willing to look closely at ways of making sure, by whatever means, that the crucial judgments made by clinicians about a patient’s capacity, about coercion and about that person’s settled wish to end their life are firmly and soundly based? The route to achieving that may well be the GP practice and the multidisciplinary team within it, but, as we have heard, that source of information may not be practical or useful in every case. Will the noble and learned Lord therefore ensure that he will consider more generally in the round possible safeguards that will forestall the possibility of superficial or cursory assessments being made—especially, perhaps, assessments by hospital consultants, who may have enjoyed only a brief acquaintance with the patient?
Baroness Merron (Lab)
My Lords, I thank noble Lords for their contributions on proposed safeguards relating to general practice. I will keep my comments limited to the amendments on which the Government have major legal, technical or operational workability concerns. On that basis, I draw noble Lords’ attention to the operational workability concerns in relation to Amendments 19, 20, 21, 29, 30B, 265A and 443A.
Baroness Lawlor (Con)
I beg the Minister’s pardon but she is referring to my Amendments 30B, 265A and 443A, not those of the noble Baroness, Lady Hollins.
Baroness Merron (Lab)
I am most apologetic and grateful for the clarification. I hope that the noble Baroness, Lady Hollins, will forgive me, too.
I will continue. The GP must also have seen them at least six times in face-to-face appointments during those two years. Noble Lords may wish to note that these amendments introduce requirements that may result in people seeking GP appointments that are not clinically necessary. This may have an impact on wider access to GP services. Noble Lords may also wish to note that, even if a person has seen their GP the required number of times over the two-year period, their GP could still refuse to provide the explanatory letter, as they are not under any duty to participate in the provision of assistance, as per Clause 31. This would result in the person being unable to access an assisted death.
Lastly, Amendment 220, tabled by the noble Baroness, Lady Foster, seeks to add an additional step in the assisted dying process. It would not be a compulsory step; therefore, it would not have a major impact or be unworkable. However, this amendment has not had technical drafting support from officials and, although the issues raised are rightly a matter for noble Lords to consider and decide, would likely require further consideration in order to be made fully workable, effective or enforceable.
Baroness Lawlor (Con)
If there are on average 3.5 consultations a year face to face, with calls and so on bringing it up to 8.7, it would not necessarily make for additional unnecessary appointments for a person with such a condition. That is my first clarification. My second is about a letter being required and the doctor concerned not wanting to assist in the process. The letter is not about the process. The letter would go into the person’s history over the two years they have been consulting the doctor. It has nothing to do with the process of seeking an assisted death.
Baroness Merron (Lab)
Acknowledging that the amendments that I was referring to were tabled by the noble Baroness, Lady Lawlor, I have nothing to add to the points that I have already made, other than to say that the noble Baroness used the word “average” and therefore there is a question about workability. Therefore, our interpretations on the noble Baroness’s second point do differ.
Lord Falconer of Thoroton (Lab)
My Lords, I indicated my position in my intervention. I will summarise my understanding of the amendment, what my response is and next steps. All the amendments in this group seek a requirement in addition to having a GP before you can have an assisted death. My noble friend Lord Rook suggests having a GP for at least 12 months and having seen him twice before the first declaration. The noble Baronesses, Lady O’Loan and Lady Grey-Thompson, refer to having an “established relationship” with a GP. The noble Baroness, Lady Finlay, refers to one consultation and a home visit before the application. The noble Baroness, Lady Lawlor, refers to a two-year relationship, an average number of visits face to face and then a letter that relates to the medical condition, the treatment and the state of mind of the patient.
As I have indicated, the GP, in the structure of the Bill, is not somebody who has to be involved. The noble Earl, Lord Howe, encapsulated perfectly that the GP is somebody who is receiving information. All these provisions for making it necessary to have a better relationship with your GP than just having a GP do not touch the safeguards. Quite separately from that, I support what the noble Lord, Lord Deben, and the noble and learned Baroness, Lady Butler-Sloss, said. These provisions have an air of utter unreality if you are saying that a condition of an assisted death is a particular relationship with a particular GP. I do not think that any of these safeguards work or reflect the current drafting of the Bill.
It is clear from listening to the debate that people who are concerned with the care should form a basis for the decision. It may not necessarily be making the decision—a lot of people would say that they should not be making the approval—but their input is vital. That was the insight of the noble Baroness, Lady Gerada, which was very much reflected around the Committee. I am willing and keen to reflect that insight in the Bill. But the route is not through newness in relation to the GP. It is reflecting the proposition that the multidisciplinary team dealing with the patient must have some input. I do not know whether that satisfies the question asked by the noble Earl, Lord Howe, but that is the purpose of what I am taking away from this very valuable debate.
As for the right reverend Prelate the Bishop of Gloucester, we are going to speak about prisoners on the next group. Can I reserve my position in relation to prisoners to avoid there being too much duplication?
In those circumstances, I invite the noble Lords not to press their amendments.
Lord Rook (Lab)
I thank noble Lords for their patience, passion and seriousness in scrutinising this part of the Bill.
My Amendment 19, which started this debate, possibly needs some clarification. Forgive me, as one who is still becoming accustomed to your Lordships’ House, if I should have intervened earlier on this. I am very grateful to the noble Baroness, Lady Gerada, for her remarks. I had the privilege of working with her in a previous life and saw her brilliant healthcare and the provision of many experts—not just healthcare professionals but the wider community—in seeking people’s health and well-being. Her best-case scenario is what we would like to see in all end-of-life care and in assisted dying.
However, to speak to the comments by the noble and learned Baroness, Lady Butler-Sloss, and the noble Lord, Lord Pannick, my amendment is not seeking for a patient to have to see the same GP twice. That is not the amendment that we are trying to make here. We are asking that someone should be registered in a practice for a year and see a GP twice in that year.
I am very grateful to the noble Baroness, Lady Hollins, for her view that this could mean a wider team engagement—it might not be just the GP. I am saying not that it has to be the same GP twice but that a person has to engage with a GP twice in that stage. If any one of us in this Committee, or any one of our loved ones, were facing a serious medical condition right now, I think we would all have the reasonable expectation that in the next 12 months we might see a GP at our practice. Given the importance of this legislation and just what it will do for the state’s relationship to life and the NHS’s relationship to life, someone who is critically facing the end of life and requesting an assisted death should also be afforded the opportunity to see a GP twice in that period.
Dr Michael Mulholland has been quoted a number of times from his remarks to the Select Committee. I will finish with a quote from him. He said:
“We need to be sure that these things are checked on many levels. It is not at a single time and point where you tick something”.
I am grateful to the noble and learned Lord, Lord Falconer of Thoroton, for his willingness to consider this issue. I look forward to seeing how these concerns and conversations might be expressed and reflected in the Bill. With that, I beg leave to withdraw the amendment in my name.
Baroness Grey-Thompson
“(e) is not a serving prisoner, and(f) is not detained by a hospital order,”
Baroness Grey-Thompson (CB)
My Lords, I will speak to Amendments 22, 24, 30C, 308, 347 and 458. I tabled these amendments after looking at data from other jurisdictions and listening to debates in another place. These amendments are probing. I want to be clear that they are here to invite debate not on the death penalty, abortion rights or who can become pregnant but merely on the groups and how they are impacted by the Bill.
With regard to my amendments on prisoners, those on remand and defendants on bail, there could be seen to be a conflict between prisoners’ rights to autonomy and the state’s duty to administer punishment. I was privileged to visit a young offender institution recently with the Duke of Edinburgh’s Award, which I chair. It is always very interesting to visit prisoners in young offender institutions and see the life that they live. UK staff are trained to spot prisoners who are at risk of bullying, suicide or self-harm. But I would like to understand—including in the context of what the right reverend Prelate the Bishop of Gloucester raised about prisoners’ access to primary care—how this would work in practice and which doctors would be allowed to have a conversation with prisoners.
Those deprived of liberty can be very vulnerable and prone to suicide. As we have heard, they could also experience a lack of care and palliative care. Yoann Della Croce argues that while prisoners in Switzerland should have the same level of care as the general population, assisted dying is a liberty that should not be extended to prisoners.
There are many international examples. Peter Vogt, a prisoner with kidney and heart disease in Switzerland, applied for euthanasia in 2023 due to physical and mental suffering, citing a life of “vegetating behind walls”. As of August 2020, three prisoners in Canadian federal prisons had received MAID. The process for these cases is complex, involving unique barriers such as bureaucratic hurdles and concerns about voluntariness and confidentiality in correctional settings.
This issue is not without controversy. Quadriplegic Marin Eugen Sabau requested euthanasia in 2022 after being shot and paralysed by police while being arrested. Due to the Spanish Government’s wording of the assistive Bill around incurable and unbearable permanent conditions, he was successful in requesting euthanasia. After initiating procedures in July 2022, and approval by the guarantee and evaluation commission of Catalonia, the process was suspended as a result of private and public prosecutors filing several appeals. Despite this, these were dismissed and the man’s euthanasia was carried out a month later.
In Belgium, Frank Van Den Bleeken asked for approval for euthanasia. It was initially granted, but the decision was later reversed. Similarly, in 2018, a Swiss inmate made a request to die through the EXIT society, because of an incurable lung disease and mental illness, arguing that refusing him access to assistance constituted psychological torture.
Lord Farmer (Con)
My Lords, in giving support to Amendment 22, tabled by the noble Baroness, Lady Grey-Thompson, I will also speak to Amendment 30C in my name and hers. These amendments would prevent serving prisoners—those on a hospital order and remanded— and bail defendants accessing legally assisted suicide.
This group is about people in vulnerable categories having access to assisted suicide, but it must be said that anyone with a terminal illness is, by virtue of that, in a vulnerable group. I frequently came across that word in relation to female offenders when I was asked by the previous Government to chair a review on how to strengthen their family and other relationships to prevent reoffending and intergenerational crime. Hence, it seemed very important to define it. From the Latin vulnerabilis, it means wounding or being susceptible to physical harm or damage and emotional injury, especially in being easily hurt and subject to attack.
We can argue about relative vulnerability, but my now rather extensive experience of visiting men’s and women’s prisons has brought home to me that many male prisoners and men on remand are also highly vulnerable, for similar reasons to women. Without excusing criminality and overstating causality, I know that a very large proportion have had multiple adverse childhood experiences. Three-quarters of boys in the youth estate grew up with only one parent, typically an overworked mother, and one-quarter of adult prisoners spent time in local authority care. I know that adversity can develop a deep seam of resilience in a young person or adult, but research shows that it is far less likely to happen without healthy supportive relationships. This is the very ingredient lacking in the lives of very many of those sitting in our prisons. A conservative estimate is that around half of prisoners do not receive visits from anybody outside.
Few of us can imagine the despair that settles in when people enter prison: the inner turmoil and the sense that their life has been ruined. Those on remand can feel stuck in limbo for months, given the severe backlogs in our criminal courts. Sentenced prisoners at least have some certainty. Detention in prison is the punishment, and the state has a duty of care while people are detained, which is why levels of self-inflicted death are of such concern to the Prison Service. The suicide rate for prisoners on remand is approximately 1.8 deaths per 1,000 prisoners, while the rate for sentenced prisoners is less than half of that—approximately 0.8 deaths per 1,000 prisoners. My review team worked out that the cost of the inquiry that followed each suicide was around £2 million in 2017’s money. In 2024, people on remand accounted for about 34% of all self-inflicted deaths in custody, despite being 20% of the population.
Noble Lords might ask: what does that have to do with assisted suicide? The duty of care we owe to remand and sentence prisoners should disallow a death sentence being carried out when they are already far more likely to be in the frame of mind that says that they just want to end it all when a terminal illness is diagnosed. We have an ageing prison population, and one that is full of historical sex offenders. That is the compassionate reason. We should be able to promise them excellent palliative care and not play into an understandably exaggerated desire to end it all quickly on their terms—their last act of control in a life that has spiralled out of control.
But there is a more hard-edged reason: compassion to victims. We do not want sentenced prisoners or people remanded in custody while awaiting trial to have access to assisted suicide to avoid justice. Jeffrey Epstein was officially ruled to have died by suicide in his cell while awaiting trial. There is also the famous case of Goering after the Nuremberg trials. Conspiracies abound, but the principle remains that, if terminally ill adults know they can be assisted with their suicide, this implies a possible moral hazard if the cost of committing a crime is dramatically lowered.
Baroness O'Loan (CB)
My Lords, I have put my name to Amendments 22 and 24 in the name of the noble Baroness, Lady Grey-Thompson, and support the other amendments in this group, which relate to the fact that prisoners, people detained under a hospital order, homeless people and those who are pregnant require special care because of their situations.
Suicidal ideation and depression as a result of incarceration, with limited ability to access outside resources due to imprisonment, are very common among prisoners. One study found that 61% of elderly male prisoners had a mental disorder. Primary care mental health services are still being developed in prisons to provide for conditions such as depression, anxiety, post-traumatic stress disorder and learning disabilities. That vulnerability, combined with a terminal illness and probable lack of access to good palliative care, means that their welfare is a special responsibility of the state. Special arrangements must be made to ensure that they do not feel they have no option other than to opt for assisted death.
Suicidal ideation is also very common among the homeless. The noble Lord, Lord Bird, recently spoke eloquently in your Lordships’ House about the problem of poverty, which so often results in homelessness and the hopelessness which accompanies poverty. Solutions to things such as poverty and homelessness should not involve offering people assisted death rather than a home, possibly in sheltered accommodation, in which they may be able to flourish.
The noble Baroness, Lady Grey-Thompson, spoke eloquently about pregnancy. I want to add just a couple of things. Pregnancy is not an illness, but pregnant women are at a higher risk of mental illness. The Maternal Mental Health Alliance reported that at least one in five women develops a mental illness during pregnancy or within the first years after having a baby and that maternal death due to mental health problems is increasing and suicide remains the leading cause of death in the first year after birth.
Baroness Berger (Lab)
I declare an interest as chair of the Maternal Mental Health Alliance. The figures have been updated; currently, one in four women experiences a mental health condition in the perinatal period, either during pregnancy or in the two years after birth.
Baroness O'Loan (CB)
I thank the noble Baroness for her intervention. I also want to raise the risk of domestic abuse, which is much higher during pregnancy. The Maternal Mental Health Alliance says that up to 30% of domestic abuse cases begin during pregnancy.
Ending someone’s life with lethal drugs while they are pregnant raises additional layers of moral, legal and medical concern—for example, consent, the viability of the baby, conflicts of interest, et cetera. Pregnancy causes drugs to be processed differently. The rate of absorption is affected by physiological changes. That could mean a slower or more prolonged death from the approved substances for both mother and child. Women are particularly vulnerable, and the safeguards just do not seem to be in the Bill at present.
The amendments from the noble Baroness, Lady Berridge, in this group relate also to those up to the age of 25 who have an EHCP, which may be provided to vulnerable children, including those with special educational needs and mental health concerns.
Finally, the noble Baroness, Lady Hollins, has told us that young people with complex needs may be at a higher risk of internalising negative societal values about their disabilities. The National Down Syndrome Policy Group states that people with learning disabilities can be highly suggestible and prone to acquiescence bias, agreeing with authority figures to please them.
There may also be diagnostic overshadowing, the risk that a young person’s desire to die might be as a consequence. In this context, a young person with an EHCP, for example, might request assisted dying not because their condition is intolerable but because the social care and support legally promised to them has failed to materialise, making their daily life situation unbearable. That could be misinterpreted by clinicians as a rational choice due to their disability. It is therefore the case that special provisions, such as those identified in these amendments, are necessary to ensure proper support, and that the various vulnerable groups of people do not feel that they have no choice.
Baroness Fox of Buckley (Non-Afl)
My Lords, I want to speak specifically to Amendment 22, about why prisoners should not be eligible for assisted dying. The amendments from the noble Lord, Lord Farmer, are also pertinent here.
The right reverend Prelate the Bishop of Gloucester raised the real and specific safeguard issues from the lack of medical records of prisoners, and I am sure we will hear more about the problems of medical care for prisoners. The terrible terminal diagnosis that one might get as a prisoner would be particularly frightening, I would think, because of the lack of medical care.
That is actually not my concern. Regardless of where one stands on assisted dying in general, I really hope that, when it comes to this Bill, noble Lords will consider the very particular circumstances of those incarcerated by the state. I hope the sponsors of the Bill will still be open to excluding prisoners and keeping them out of the Bill, on the basis, if nothing else, of their lack of autonomy.
I have to confess that I was rather taken aback when I heard Minister Stephen Kinnock in the other place state that excluding prisoners from this Bill would lead to a difference in treatment between prisoners and non-prisoners, an inequality, citing Article 8, private life, and Article 14, discrimination, of the ECHR. He noted that differential treatment would require objective and reasonable justification. It seems a bit shocking to me to have to explain this to a Minister, but my objective and reasonable justification is that, if you are in prison, you do not have the same rights as if you are not in prison. I did not make that up—although I know the Sentencing Bill has gone a bit liberal.
Actually, I think that, you know, you are deprived of your liberty. Many of the arguments made by the advocates of the Bill about autonomy and giving people choice towards the end of life, in particular circumstances —which I completely understand, philosophically and politically—are entirely appropriate for free people. But when you are not free and do not have autonomy, it brings with it a whole new range of ethical dilemmas.
The purpose of prison is, as I have said, to suspend certain rights from people to protect the public, to ensure deterrence and to uphold a sense of justice in society—I could go on. When the state has deprived an individual of so much autonomy, for all the criminal justice reasons we know, offering the option of an assisted death does not increase their autonomy in a meaningful way. It is saying, “Oh, well, we’re giving them choice”—but their real choice would be being able to leave. In other words, we have limited their choices.
Why does this matter? It is because, when the state decides to deprive somebody of their liberty, it is a very serious decision. For me, it is the worst possible punishment you could give: you are limited in being free, which I obviously consider to be very important. Prisoners, inevitably, are depressed: and often they are vulnerable in the first place. That is why they are prone to suicidal ideation.
Those of us who have had the privilege of doing some work with prisoners will know that we spend a lot of time tackling self-harm, with people hating themselves and the circumstances they are in. We do a lot of work on that. I and many others have worked on IPP prisoners, who are, ridiculously unfairly, still in prison indefinitely based on an abolished sentence, often for minor breaches of the law in the past. It is always shocking when you hear of another IPP prisoner who has taken their life. It is particularly horrible, as many noble Lords here have articulated far better than I can, because it is almost like it is on the state’s conscience. That is the reason why coroners make such a fuss about it. Those prisoners should not be there; they are in prison because the state made a mistake with the sentencing regime that it will not resolve and then they take their life. The state is somehow implicated in those suicides and we make a particular point of that.
Those of us who have worked in prisons will also know that suicide prevention is something we take very seriously. It does not matter how heinous the prisoner’s crime is. They could be a child abuser, a rapist or a murderer, but, if there is even a hint that they might commit suicide, there is suicide watch. We do all sorts of suicide prevention. The reason is that, as a humane society, we do not think that people should be allowed to take their own life, if at all possible. We have suicide watch in prison because the state has somebody incarcerated. Therefore, as a humane society, you take seriously not letting them kill themselves: otherwise, you could just say, “Carry on boys, it doesn’t matter”. We do not do that because we think that we have to protect those prisoners in the state’s care.
Right, I will finish. Letting prisoners have access to and be eligible for assisted death would be very close to reckless state abandonment of those prisoners to something very deeply dark. Philosophically, if a penal sentence in Britain ends up with the state effectively putting a prisoner to death via lethal drugs—I do not want to go on, but that is what would have to happen: they would be locked up in a prison, in the state’s care, the state would then make them eligible to ask for assisted dying, with limited autonomy, and would then hand them lethal drugs—that is far too like capital punishment, which I have long opposed and do not approve of. Therefore, even if you do not agree with me on the rest of the Bill being a completely difficult challenge to humanity, which I think it is, I none the less suggest that, if we pass it, we should absolutely exempt prisoners from it.
Lord Moore of Etchingham (Non-Afl)
My Lords, I support these amendments, particularly those relating to prisoners and, indeed, what the noble Baroness, Lady Fox, so eloquently expressed. Just before I do, I will also support something that the noble Lord, Lord Blencathra, who is now not in his place, said earlier, when he complained about some of the exterior noise around those of us who are debating this Bill.
I declare an interest as a general practitioner, not of medicine but of journalism. I know very well what happens and how to recognise when we are being pushed to do a story. In the past two weeks, all the British media have been pressed very hard by lobbyists in favour of this Bill to produce a series of highly contentious arguments that attack anybody who tries to debate the Bill fully. This is very much at odds with the spirit of legislation of this sort, and with what the noble and learned Lord, Lord Falconer, keeps trying to do. He says at the end of each group what a valuable debate it has been. He does not say, “What a waste of time this debate has been”; he says it has been valuable, which it has been. I have learned a lot today, for example, about GPs and their difficulties, and we are learning more about prisoners. There was a virulent article in the Times by Nicholas Boles, who was an informal—
Lord Winston (Lab)
Forgive me. What the noble Lord is saying is very interesting, but could he possibly keep to the amendment? The amendments are quite tricky and really do need discussion.
Lord Moore of Etchingham (Non-Afl)
I am grateful to the noble Lord. As I said, I will come on to the amendment soon, but I want to emphasise this point because I think that it matters a lot in this debate and will matter in the coming weeks. A particularly virulent article in the Times, written by Nicholas Boles—he was, until recently, an informal adviser to the Prime Minister—put these arguments in a way that was quite inappropriate for the type of discussion on a conscience issue that we are having.
On prisoners, I want very much to pursue the point about autonomy, which is absolutely right. It goes to the heart of this Bill, because the Bill’s supporters are those who give precedence to autonomy over all other things. The people who are more questioning of the Bill do not necessarily do that—at least, they think that there are many qualifications to the right of autonomy.
As the noble Baroness, Lady Fox, pointed out so eloquently, this issue very much applies to prisoners, who have a double loss of autonomy in prisons. First, their autonomy has been taken away from them by the decision of the state, as expressed in the quaint phrase “at His Majesty’s pleasure”; it is not “at the prisoner’s pleasure” but “at His Majesty’s pleasure”, which is an expression of the power of the state and the prisoner’s loss of autonomy. Secondly, prisoners lose autonomy in another way because of their vulnerability and the situation they are in.
The point I wish to add to this argument is to do with the Government, rather than the movers of the Bill, although it affects them, of course. In evidence to the Select Committee, the relevant Minister at the Ministry of Justice, Sarah Sackman, said that, as far as the Government are concerned:
“The policy choice that the option of a voluntary assisted death be extended to those in prison is just that. It is a policy choice on which the Government are neutral”.
I do not understand how the Government can be neutral on a matter that is entirely within their purview, and I would like to hear what the Minister has to say about that.
Baroness Berridge (Con)
My Lords, I will speak to Amendments 30A and 119A in my name, which relate to children and young people who are under an EHCP. I offered to withdraw these two amendments in order to shorten proceedings; by putting that on the record, I will shorten the meeting offered by the noble and learned Lord, Lord Falconer, but not necessarily these proceedings.
I am grateful to my noble friend Lady Coffey for spotting a typo in Amendment 119A—ECHP instead of EHCP. Please may we not create any more quangos with that combination of letters?
The Select Committee heard from Dame Rachel de Souza, the Children’s Commissioner for England, about the basic policy reason behind some vulnerable adolescents and those with additional needs being under her jurisdiction until they are 25: they need the extra support to transition into adulthood. Amendment 30A would remove all young people under an EHCP from the Bill; Amendment 119A on this policy ground would mean them falling under the Act, but with additional conditions. Such an issue may be additional subject matter for the promised meeting. Would these be the right conditions, were we to accept Amendment 119A?
The Children’s Commissioner’s jurisdiction also covers anyone under the age of 25 who has ever been in care. She has a specific responsibility for children up to the age of 25 who have an EHCP. I note that, in law, it is not 18 for all purposes. You cannot adopt children until you are 21. So, at the moment, the Bill does not produce a cliff edge at the age of 18.
Some of the young people on EHCPs may lack capacity and are, therefore, outside the scope of the Bill. As the noble Baroness, Lady Hollins—she is no longer in her place—has often said, assessing the capacity of people with learning disabilities is a complex matter. However, many young people are on an EHCP because of other additional needs or considerable childhood traumas; they will have capacity and will, therefore, come under this Bill. It is again relevant to think of them at 18 years and one day old, and with a life-limiting condition. Sadly, due to the lack of the usual pre-legislative processes of consultation, a White Paper and scrutiny, we are without the data on these vulnerable groups showing how many in the EHCP or under High Court DoLS also have life-limiting conditions. That data would give us an idea as to the priority of conditions for different groups.
In the Select Committee, Ken Ross of the Down’s Syndrome Association stated that people with Down’s syndrome cannot always fully comprehend complex decisions and have very suggestible minds. This is why there are additional safeguards in the EHCP, but if they have capacity, they are under the Bill currently without any additional safeguards.
Again, due to the process of the Private Member’s Bill, it is not clear how this legislation sits with other legislation and safeguards. Has the Bill been considered by the Department for Education, which has responsibility for children under the 1989 Act? Has the noble and learned Lord met with those Ministers? For instance, just to give an array of possible problems, in many cases local authorities legally still have a role for those under an EHCP after the age of 18. How will that fit with the processes outlined for assisted dying? Will there be a clash of decision-making from the EHCP special educational needs panel and the TIA panel?
What legal authority does the local authority have on safeguarding grounds to intervene in the panel’s process for a young adult on an EHCP if it disagrees with the assessment by the panel that the young person is making the request for assisted dying due to peer pressure or, as Ken Ross suggested, an enhanced susceptibility to pressure from white coat syndrome for those with Down’s syndrome? Is it mandatory for the TIA panel to get information from the SEND panel? Can the SEND panel appeal the decision to grant assisted dying? It seems not, so the family and the local authority will be left with the expensive and difficult remedy of judicial review.
Has the noble and learned Lord considered the evidence from the British Association of Social Workers? It states that the panel needs the power to do its own safeguarding assessments, or the power to close a case a local authority is seized of under Section 42 of the Care Act 2014. Otherwise, assisted dying could be granted and there could still be an open safeguarding case at the local authority unless the panel has the power to investigate and close it. These issues would have been flagged on a government write-round or during proper pre-legislative scrutiny. I am disappointed at the lack of meetings so far, as we need a proper process to consider the position of many vulnerable 18 year-olds on the day after their 18th birthday.
Bearing in mind Amendment 22, which the noble Baroness, Lady Grey-Thompson, mentioned, I wonder whether she, the noble and learned Lord or the Minister are aware of whether the policy decisions made for pregnant women in other jurisdictions are based on policy alone or on clinical evidence. If there is clinical evidence that drugs can promote and induce labour, is that why other jurisdictions have taken pregnant women out? That is relevant, because I have amendments later in the Bill about warning relatives of complications, especially if there is going to be a person under 18 present while assisted dying is being given.
Finally, on the points raised at the start of the proceedings by the noble and learned Baroness, Lady Butler-Sloss, I did not have the benefit of listening to the “Today” programme, but we are dealing with so many groups of vulnerable people. That is because of the lack of pre-legislative steps that we usually have. Groups would have been consulted and there would have been a White Paper. I have been exchanging optimistic emails with the noble Lord, Lord Carlile, but for me personally it is an open question, bearing in mind the lack of pre-legislative scrutiny, whether the Private Member’s Bill process actually fix that.
I know that the noble and learned Baroness worked with the noble Baroness and that she is very fair-minded, but I have had cause to look at the evidence from the Jersey States Assembly, a small Parliament. It was drawn to our attention in the Select Committee by Alex Ruck Keene KC that some instructions went to 200 pages, so I asked the Library to do some research and the Jersey parliament’s process is gold-plated. Not only that, but its website is much easier to use than parliament.uk and one can look at the process and timetable from 2021. When the States Assembly approved what it was going to do, the Executive—the Minister for Health and Social Affairs—gave drafting instructions to parliamentary counsel. To write a piece of legislation fit for purpose, they ran to 201 pages. We say that we are the mother of Parliaments in the Commonwealth context, but that is the way to legislate. I keep open in my conscience whether this process can fix the problems with the Bill which are such that none of the royal colleges is currently supporting it.
The Lord Bishop of Gloucester
My Lords, I speak to Amendment 22 in the name of the noble Baroness, Lady Grey-Thompson, to which I have also added my name. I declare my interest as Anglican Bishop to prisons in England and Wales.
There are many reasons why I believe that assisted dying may not be a fair choice for the general population, as things stand, but today I am shining a spotlight, as has already been said, on the prison population. I do not think that there has been enough attention in the debate so far on how the Bill would function for those in prison. I do not apologise for having spoken about prisons in the previous group, because this Amendment 22 is about excluding prisoners from the Bill, but the previous group of amendments assumed that prisoners would still be in the Bill. Therefore, we still need to look through that lens when we are discussing issues about GPs and medical records.
The prison population is in worse health than the general population. We have heard that. However, the reports from both the Health and Social Care Select Committee in the other place and the Chief Medical Officer paint a more concerning picture than that. Age-related illnesses, dependency and frailty can begin at an earlier age than in the general population. The prison population is ageing faster, and when I am visiting prisons I never cease to be shocked by the number of extremely elderly and frail people in prison. In most places, the prison system is not able to meet their needs properly—and that is not to criticise the prison staff, who are doing their best.
Nacro reported that, in 2019-20, people in prison missed 42% of scheduled hospital appointments. The Health and Social Care Select Committee goes as far as to say that
“so-called natural cause deaths, the highest cause of mortality in prison, too often reflect serious lapses in care”.
As has been said by the noble Lord, Lord Farmer, there is a lack of palliative and end-of-life care in prisons and, although there are some examples of excellent practice, action to improve this is voluntary and not supported by the commissioning of services.
Noble Lords may well say that prisoners should have equal access to care under the law, including assisted dying but, as has already been said, they do not currently have equal access to care. For me, this is not simply about the prison system and healthcare; it is about the perspectives and sense of well-being among those in prison. I will not rehearse everything that has already been said, but will just reiterate that the prison population experience high levels of hopelessness. We have frequently and rightly spoken about IPP prisoners in this House.
Again and again as I visit prisons, I hear about and see evidence of the high levels of self-harm in our prisons; it is particularly high in the female estate. Self-inflicted deaths in prison are predicted to continue to rise disproportionately compared to the general growth of the prison population. We need to be cognisant of the fact that, during the special Select Committee on the Bill, the Royal College of Psychiatrists talked about how a person’s wish to hasten their death can be impacted by what their life is like.
Although compassionate release is an option, it is rarely taken up. Crucially, according to Macmillan Cancer Support’s A Guide for Prisoners at the End of Life, it also requires a three-month prognosis. How does that interact with the Bill?
Lord Carter of Haslemere (CB)
My Lords, I want to make a very brief intervention in relation to the prison population. It is only the second time I have spoken on the Bill. I declare an interest as a trustee of the Prison Reform Trust.
The suicide rate among male prisoners is four times as high as that of the general population. In the year to 2024, 89 male prisoners committed suicide. The Prison Service has a duty of care towards the prison population to protect them from committing suicide—to stop it. The Government run the Prison Service, so they must have a view on what to do about a prisoner whose suicide the Prison Service has correctly thwarted under its duty of care but who then requests an assisted death under the Bill. How will the Government balance those two conflicting things?
That is my short intervention—to ask that question. I wholly support all the comments made by the noble Baroness, Lady Fox, the noble Lords, Lord Moore and Lord Farmer, the right reverend Prelate the Bishop of Gloucester, and others on this crucial issue. I am genuinely interested to know what the noble and learned Lord, Lord Falconer, makes of this dilemma for the Prison Service and the Government.
Lord Deben (Con)
My Lords, the moments in the Bill that most concern me are when it gets nearest to saving money. There are several occasions on which that appears to be the case, particularly when talking about people for whom many have no sympathy at all, and when you are talking about a service in which we all know we are failing. It cannot be true that any Member of this House believes that our prisons are as they should be. Yet we imprison more and more people. We imprison twice as many people as the French or the Germans. I still do not understand why we cannot take this seriously, but we still go on doing it.
First, can one really think that someone in prison circumstances finds it possible to make the same kind of decision as people who are not? Just simply, those circumstances are the pressures, the crowding and the fact that you are not in any company that you would have chosen. I do not believe that those are the circumstances in which the Bill’s proponents meant for decisions of the sort we are talking about to be made.
The second issue is: what about the pressures there? We have been talking about the concerns of those who find themselves under pressure. Do we really believe that there will not be many prisoners for whom the whole issue will be presented as, “You will be better off and we will be better off if you make this decision”?
The third issue is surely this: we know that prisoners have much worse healthcare than people outside prison. Therefore, the fact that they are told that they have but six months to live is much more difficult than it would be if they were in normal circumstances. I put it no more sharply than that, but it does seem to be true.
Fourthly, earlier on, we were talking very strongly about the difficulty that the Government are willing to fund this when they are not funding palliative care for very large numbers of people in the country. I therefore come back to my deep concern that it will become so much easier for people to die than to continue.
The right reverend Prelate, whose experience is remarkable and whom I admire enormously for her work in the prisons, has reminded us of how old the prison population is and how much older it is becoming. I just do not think that those of us in this House who really believe that our major job in this Bill is to protect the vulnerable can possibly agree that people in prison should be included under the Bill. We should take them out.
Lord Markham (Con)
May I just offer a different perspective on this? It has been an interesting debate. One of the main reasons I am supportive of assisted dying is kindness—kindness to the people who are scared about the inevitable end of their life and kindness in that they face a lot of pain. They see assisted dying as a way of relieving themselves from that pain.
In this debate, are we saying that people in prison are not deserving of that kindness? People in prison have been deprived of their liberty because of the crimes they committed, and that is the punishment that they have been given in the face of the law. That is the debt being paid to society. But are we saying at the same time that they do not deserve the same kindness that we would give to others and that they should face pain because they are in prison, whereas others should not? That is my perspective on this.
Baroness Finlay of Llandaff (CB)
My Lords, I put a question to the noble Lord who has just spoken. I am really concerned—
Lord Falconer of Thoroton (Lab)
The noble Baroness is intervening on somebody who made an intervention on somebody else. We got a very severe talking to about that before, so I do not think that is allowed.
Lord Deben (Con)
I did not realise that the noble Lord was intervening on me, but I will just say that, for me, it is very difficult to have that argument. Kindness is absolutely the central point of everything that I believe in, so I am very vulnerable to that question. But the truth is, the Bill does not talk about pain at all. There is nothing in the Bill about pain. This is about a totally different circumstance. One of the problems in the country as a whole is that many people who support the Bill do so because they think it is about pain.
We could have a Bill about pain, but then we would come back to the point made by the noble Baroness, Lady Berridge, that that is not what the Bill should have been. The Government should have said that they would give a free vote on a government Bill on this subject, rather than slipping it in in a wholly different way.
However, we are faced with what we have, and in that case it does not seem kind to say to people who are under all sorts of pressures and who are particularly vulnerable that this is a choice they should make. If we want kindness, we should be saying to the Government, “Get the Bill withdrawn and introduce a government Bill that is properly thought through where we can have the real debate that the public as a whole want us to have. You can still have a free vote”, but it should never have been put through in this way.
Lord Markham (Con)
If I may respond on the pain point, I have spoken to lots of people who are terminally ill and heard their evidence. Again, I recommend that as many people as possible hear them because they have heartwarming stories. For them—not all the time, but a lot of the time—it is because they want to have that choice at the end so they do not have to face that pain. That is a key reason for them. The Bill says that you have to be within six months of the end of your life, but then you have the choice within that. For some people, the thought of that pain, and the experience of that pain, is the real reason why they want an assisted death. My point is that I believe prisoners should have exactly that same right so that they have the possibility to avoid that pain.
Baroness Gray of Tottenham (Lab)
My Lords, I support Amendments 308 and 347 regarding the availability of assisted dying services to people who are homeless.
The intention and the fundamental principle behind the Bill are that terminally ill individuals are able to exercise their autonomy and end their lives on their terms and at a time of their choosing. But, as many noble Lords have articulated during the passage of the Bill, that is a vision of autonomy that simply does not exist for far too many people. We do not live in a society where everyone is equally able to make decisions without being constrained by external influences, whether that is in the form of other people or simply follows from one’s own life circumstances. Indeed, the noble Baroness, Lady Grey-Thompson, has highlighted the ways in which society does not always afford even her that degree of autonomy despite her extraordinary career and achievements, from physical obstacles that prevent her having equal access to the public transport that is supposed to serve everyone to people who are not disabled telling her that, were they in her position, they would not keep on going.
Not only are people who are homeless by definition cut off from and invisible to key public services, including healthcare, but they often have complex further needs, such as abusive relationships, poor mental health and addiction. How can we imagine that they will not be at risk of being offered an assisted death simply because those needs are judged too hard to meet, or because someone else has decided that their lives are not worth while? We have seen that happen in jurisdictions such as Canada, where the parameters for an assisted death were widened soon after the law was passed, and we duly saw examples of individuals dying by Medicaid explicitly because they were affected by isolation and homelessness. Yes, the Bill differs from the law in Canada in that it requires a terminal diagnosis, but as soon as that threshold is crossed there is nothing in the Bill that would stop a person accessing an assisted death for reasons that were nothing to do with their illness but simply because they had been too worn down for too long by problems that could have been solved with the right care, attention and funding.
This year, Crisis and Pathway reported that almost 80% of health professionals say that homeless people are discharged from hospital with unmet health needs, and 92% of homeless people find mental health care difficult to access. The average age of death is 46 for a homeless man and just 42 for a homeless woman. Their circumstances deprive them of autonomy because they remove meaningful choice. That applies just as much to the gravely ill person sleeping rough or isolated in temporary accommodation as it does to the one who cannot afford proper palliative care at the end of life.
While I have other reservations about the Bill and the pressuring effect it will have on disadvantaged groups, I am especially concerned that we are looking to introduce it at a time when the cost of living means that homelessness has reached critical levels throughout the UK. Only yesterday, the Government published a national plan to end homelessness, and I commend my colleagues in the Government on that, but there are some shocking statistics in that plan about the numbers who are homeless. It paints a picture of utter despair and isolation for some of the most vulnerable in our society. It is wholly impossible to justify leaving out safeguards that would prevent homeless people being coerced into an assisted death, whether through abuse, absence of choice or simply their despair. I urge noble Lords to support Amendments 308 and 347.
Baroness Monckton of Dallington Forest (Con)
My Lords, I rise very briefly to support my noble friend Lady Berridge’s Amendment 30A on EHCPs, and I declare my interest as founder of a special educational needs college. All our students have EHCPs, and all of them, in their various ways, are vulnerable. What I have learned in the years that I have been campaigning for people with learning disabilities is that they are always at the bottom of the heap when it comes to making legislation. I can only think that, once again, in drafting this Bill, this cohort has been forgotten. People with an EHCP should not be included in the Bill.
Baroness Stroud (Con)
My Lords, I support Amendments 22, 308 and 347, tabled by the noble Baroness, Lady Grey-Thompson. Amendment 22 rightly seeks to exclude serving prisoners and those detained by a hospital order from accessing assisted dying under the Bill. As we have heard, the Bill speaks the language of choice, autonomy and settled intention, yet this group are, in effect, the group least likely to have choice, autonomy and settled intention. Nevertheless, these are men and women living in overcrowded, often violent environments, cut off from family contact and support networks, access to services and meaningful work—those things that provide a context for someone’s life. Many are traumatised, mentally ill or struggling with addiction.
Prisoners, as we know, are an exceptionally vulnerable population. In a report published in July this year, the Prison Advice and Care Trust—PACT—warned of the mounting mental health crisis in prisons, where mental ill health is the norm and not the exception. It goes on to note that rates of self-harm in prisons have more than trebled in the last decade, from nearly 26,000 in 2014 to just over 79,000 in 2024, and reflects that recent data shows that, among prisoners, 56% of men and 74% of women report having mental health problems. In the year to June 2025, government statistics show that there were 86 self-inflicted deaths per 1,000 prisoners.
Behind these statistics lies a culture that breeds hopelessness. It is into this context that we are proposing to make serving prisoners eligible for an assisted death. I am deeply concerned that, terminal illness aside, if you design a scheme in which a person’s own sense of despair may well be a key trigger, and there is no requirement for asking someone what their motivation is for engaging in this act, those who feel most hopeless will be the most susceptible. By any objective measure, prisoners are perhaps among the most hopeless within our society.
I note that in response to a question during the Select Committee evidence sessions, the Minister of State for Courts and Legal Services, Sarah Sackman KC, MP, commented that, as we have already heard, this is a policy choice on which “the Government is neutral”. But she went on to say that much will depend on its interaction
“with the wider prison regime and some of the challenges that lie therein”,
and that there would be a need to ensure that the Bill operates in a way that
“does not lead to abuse or is not misused”.
I would like to learn from the noble and learned Lord, Lord Falconer, precisely how he intends to ensure that this is not misused within the prison system.
I wonder whether the Minister and indeed the noble and learned Lord have considered the 2021 Hospice UK report Dying Behind Bars. The authors note that
“up to 90% of older incarcerated people have at least one moderate or severe health condition, with over half having three or more”.
I have great sympathy for the comments made by the noble Baroness, Lady Fox; clearly, the state has already taken from these individuals their liberty as a punishment to protect the public. The state is of course also responsible for the delivery of healthcare within prisons. In such an imbalanced power dynamic where the state has such overwhelming power, the shift this legislation represents as drafted, whereby the state may say to a prisoner who otherwise meets the eligibility criteria, “We will help you die”, is a profound challenge. I am concerned that if we fail to exclude prisoners from the remit of the Bill, we risk undermining the comprehensive suicide prevention programmes operating in our prisons.
Providing access to assisted dying in prison sends a chilling message that where the state has failed to provide adequate care, resources or meaningful autonomy, its final offer is death, which is why I support this amendment. I am conscious of time, though, so will speak only briefly in support of Amendments 308 and 347 in the name of the noble Baroness, Lady Grey-Thompson.
Noble Lords will perhaps be aware that I ran community projects for homeless people for the better part of two decades. I will not repeat what others have said, but the complexity of the lives of people who are homeless cannot be overstated, and I am deeply concerned that the Bill fails to account for their specific needs and risk factors. People experiencing homelessness already face significant obstacles to accessing the healthcare they need. The NICE guidelines for integrated health and social care for people experiencing homelessness note:
“Barriers to access and engagement with preventive, primary care and social care services can mean that problems remain untreated until they become very severe and complex”.
It seems entirely reasonable to reflect the complexity of the lives of people experiencing homelessness, as the amendments in the name of the noble Baroness aim to do.
I accept that the legislation is based upon the premise of autonomy, but autonomy is not absolute, and we do not live as isolated individuals. It is reasonable and appropriate to ensure that this legislation is as safe as possible, with vulnerable populations in mind. To that end, I also strongly support Amendments 308 and 347.
Captain of the Honourable Corps of Gentlemen-at-Arms and Chief Whip (Lord Kennedy of Southwark) (Lab Co-op)
My Lords, before we proceed, I will just say that we are getting to the point where we should begin to think about Front-Bench replies to this group of amendments so we can finish at around 3 pm. I do not want to break mid-group because that, of course, is very difficult for the House, Members and the clerks, as it will have to be recorded. Perhaps your Lordships can just bear that in mind, as I am conscious that the time now is nearly 2.40 pm.
Baroness Butler-Sloss (CB)
My Lords, I want to make a practical point. It is obvious that this will be the first Act in relation to assisted dying. Clearly, it is unjust because it does not deal with people with motor neurone disease and so on. Why does the House not accept that the issue of prisoners should be in the next Bill and not the present one?
Lord Shinkwin (Con)
My Lords, I will keep my remarks very brief. I rise to speak in support of Amendments 30A and 119A in the name of my noble friend Lady Berridge. I thank her most sincerely for tabling them and thank my noble friend Lady Monckton for her supportive remarks. Disabled people and people with Down’s syndrome should know that this House would never treat them as bottom of the heap.
Given the evidence provided to the Select Committee by the National Down Syndrome Policy Group, the question to my mind is not so much why we would want, but why would we not want to support the provisions in these amendments? We are talking about vulnerable young adults who deserve and need extra protection on account of their disability. I say that as a disabled person who has been involved in championing disability rights for almost 30 years. Such protection as would be afforded by these amendments is neither patronising nor discriminatory. On the contrary, it is our duty to strike the correct balance between rights and protection. I believe these amendments do so.
Lord Mackinlay of Richborough (Con)
My Lords, I will speak for just a couple of seconds as I am very mindful of time. I support Amendments 24 and 458 in the name of the noble Baroness, Lady Grey-Thompson. We have had very little debate about the issue of pregnancy. I am quite shocked by that, given that there are administrations around the world with many years of experience, such as Oregon, which had similar legislation in 1997, and Belgium, which had it in 2002. They considered the issue of pregnancy during these very delicate discussions on assisted dying.
I am somewhat disappointed and concerned that the noble and learned Lord, Lord Falconer, has not addressed this, and I really hope that this can be addressed on Report. There is a world of difference between a very early pregnancy and a baby close to full term, which is reflected in our Abortion Act. May I therefore give the noble and learned Lord some advice? When this does come back on Report, the issue of pregnancy should be addressed, as it has been in other jurisdictions.
Lord Winston (Lab)
My Lords, as Amendment 24 has been tabled and pregnancy has been spoken about, I now feel that I ought to just make one point very quickly. The noble Baroness, Lady Grey-Thompson, quite rightly presented a lot of statistics about cancer, but that she did not address the issue of cancers of the pregnancy itself. That is a serious issue. Choriocarcinoma, for example, is a fatal disease; it is rapidly metastatic, can cause issues all over the body and is not easily treatable. It could easily be that somebody who was pregnant with that, who would test pregnant with that condition, would be eligible. I therefore ask the noble Baroness to consider not pressing her amendment and to reconsider the wording of it, because I do not think that it would be an acceptable amendment later on. Both early in pregnancy and in late pregnancy, this would be a real risk.
Lord Mackinlay of Richborough (Con)
I will just come back on that, if I may. I would also say that the wording in the amendments in the name of the noble Baroness, Lady Grey-Thompson, is insufficient, because it is a far more complex issue than that. As I said, there is a world of difference between a very early embryo in the first few weeks and a close to full-term pregnancy. I certainly hope that this Committee would agree that point.
Baroness Coffey (Con)
My Lords, I really had hoped that we would get to the next group but, as it is clear that we will not, I will raise a couple of points and some questions. The increasing number of older prisoners has already been mentioned. This is largely driven by sexual offences, particularly those of historical sexual abuse. While we of course need to treat people appropriately, I suggest that, wrongly, the majority of the public would not care if sexual abuse offenders or murderers killed themselves. It is, however, our duty as stewards of the Crown to consider these matters carefully.
It so happens that, in the next group, we would have got to a particular situation about halting treatment, or what could happen as a result of halting treatment. There are situations in Australia where prisoners who have been diagnosed with cancer have then declined treatment and have been able to take up assisted dying. One thing that is happening is the rise in prisons of natural deaths. In the 12 months to September 2025, there were 221, and that is with the Ministry of Justice not even knowing and waiting for further information. That is a significant increase from 123 in 2010, which reflects the older age.
It is important that we have compassion, so it is surprising to me that there has been a yearly average of only 9.5 early releases of prisoners on compassionate grounds over the last 15 years. There was just one in 2022, seven in 2023 and no figures yet for 2024. The policy framework is deliberately sparing. Meanwhile, a legal ruling earlier this year allowed an applicant, Mr Khan, out. It is worth considering—it may not be possible at this stage in the response by the Minister or the sponsor—and thinking ahead to Report. Where are we going with this? It should not just be that the ECHR does not allow this.
Lord Kamall (Con)
I have never been so popular; it will not last, I know.
I thank the noble Baroness, Lady Grey-Thompson, for her amendments. I pay tribute to her for her sincere and long-standing commitment to protecting the most vulnerable in society. If we cast our minds back to Second Reading, many of the contributions made and concerns raised were regarding those who are the most vulnerable in our society. I remember at Second Reading being particularly touched by the words of the noble Lord, Lord Rees—he is not in his place now—who raised concerns about the vulnerability of some ethnic-minority communities, particularly those from disadvantaged communities as well.
Let us quickly rush through some of the points. On Amendment 22, which would make prisoners ineligible for end-of-life services as envisaged by the Bill, I completely understand the underlying principle. Many have spoken, rightly, about the vulnerability of prisoners. While for some it might seem wrong, as the noble Lord, Lord Farmer, has suggested, that a prisoner who has a terminal illness may have a way of cutting short their sentence by means of this Bill, as my noble friend Lady Coffey alluded to, others may say “Good riddance”. I also recognise the argument that prisoners with a terminal illness should be treated with the same compassion and care at the end of their lives as other terminally ill people subject to the Bill, as my noble friend Lord Markham recognised.
We also have to recognise some of the concerns over moral hazard. I do not know how large the incidence of this would be. Would it really encourage those who are terminally ill to commit crime? No studies have been done, but I am open to that concern. There is also the idea about higher levels of suicidal ideation, as raised by the noble Baroness, Lady Fox. These are really important points that we have to take account of.
The right reverend Prelate and my noble friend Lord Deben spoke about the pressure of reducing the prison population, while the noble Lord, Lord Carter, spoke about the higher rate of suicide among male prisoners. These are all reflections that should give us cause for concern, and things we should take account of as we consider what we will do between Committee and Report.
I thank the noble Baroness, Lady Grey-Thompson, for raising the issue of those who are pregnant. As the noble Baroness said, this was not debated in the other place, so I am grateful that the noble Baroness was able to give us the opportunity to debate it. I am also grateful to the noble Baroness, Lady Berger, for sharing statistics about expectant mothers. It was important that we heard those stats. I cannot begin to imagine the difficulty an individual in those circumstances may face. I understand the concern that it does not seem right that the safety of an unborn child may be endangered under the provisions in the Bill. I also understand that there might be precedence in other legislation. I wonder what the noble and learned Lord’s reflections on that are, given his expertise.
I note the amendment tabled by the noble Lord, Lord Farmer, on access to this for those who are awaiting trial. Once again, I would be very interested in the noble and learned Lord’s legal experience on whether that seems relevant and should be within this Bill. During the debates on the Mental Health Bill, my noble friend Lady Berridge was assiduous in spotting gaps in legislation or inconsistencies between different Acts. My noble friend has done the same thing here by raising concerns over the vulnerability of those with education, health and care plans. I think this needs further consideration.
I also thank the noble Baroness, Lady Grey-Thompson, for her amendments relating to those who are homeless or who live in insecure and temporary accommodation. I welcome the experience of the noble Baroness, Lady Gray. I still remember a conversation I had with one homeless charity that we are all one or two unlucky events or bad decisions away from homelessness. I heard from homeless people who told me that they had a great job and a great family life and that everything was going their way. They lost their job, which then led to them losing their marriage. After incidents of sofa surfing and testing the patience of their friends, they ended up homeless. It could happen to anyone. It is important that we do not dismiss the homeless as people who cannot be bothered or are idle. It could happen to anyone. Any noble Lords who have met those in homeless communities will know that some people had been incredibly successful but, after two or three bad decisions or unlucky things that happened in their life, they suddenly found themselves homeless. They are also judged by the way they look when they are homeless.
I remind all noble Lords that the Bill relates only to those who are suffering from a terminal illness and those who have been given an expectation that they will not live for longer than six months. We have to be very careful that, although we have sympathy for the homeless and prisoners, the Bill relates only to those who have a terminal illness. I know there are concerns that the Bill may be widened beyond that, but that is the debate at this stage. We should be quite clear that we are focusing on those with a terminal illness. So, much like on the question of prisoners and others, I recognise the arguments on all sides, but this is an opportune moment, not only because of time but because of the noble and learned Lord’s legal experience, to hear his reflections—after the Minister, obviously.
Baroness Merron (Lab)
I am most grateful.
My Lords, I thank all noble Lords for their contributions to the debate on this group. As is my consistent introduction, my remarks will focus only on issues where the Government have major legal, technical or operational workability concerns. Many of the points that follow relate to the European Convention on Human Rights. These are risks that I am raising to inform noble Lords’ decision-making, as I said on the first group. I wish to be clear that the underlying policies are a matter for Parliament. I say to noble Lords who referred to my ministerial colleagues in the other place that it is the role of Ministers, whether in your Lordships’ House or in the other place, to flag the risks to the Bill, including potential legal challenges. As I said, policy decisions remain a matter for the sponsors. Decisions in this regard rest with Parliament.
I begin with Amendment 22, tabled by the noble Baroness, Lady Grey-Thompson, and Amendment 30C, tabled by the noble Lord, Lord Farmer. These amendments would make prisoners, a defendant on remand, a defendant on bail or those detained by a hospital order ineligible for assisted dying services, even if they have a terminal illness and meet all other criteria. Aside from the right to liberty—Article 5—the ECHR requires that prisoners, a defendant on remand or a defendant on bail should have the same rights as those who are not. The rights engaged by this amendment are Article 8 on the right to respect for private and family life and Article 14 on prohibition of discrimination. Noble Lords may wish to note the risk that making these groups ineligible for assisted dying would, on the face of it, lead to a difference in treatment, which would need to be objectively and reasonably justified in order to comply with ECHR obligations.
Likewise, making ineligible hospital in-patients who are under a hospital order would lead to a difference in treatment. Without sufficient justification for the discriminatory treatment, this may be a breach of the ECHR, which could lead the courts to issue a declaration of incompatibility.
The noble Baroness, Lady Grey-Thompson, has also tabled Amendments 24, 458, 308 and 347. The purpose of Amendments 24 and 458 is to exclude those who are pregnant from accessing assisted dying, while that of Amendments 308 and 347 is to make persons who are homeless, or living in supported or temporary accommodation, ineligible for assisted dying services. As I have previously noted, the reasons for this difference in treatment would need to be adequately justified to avoid the risk of a successful challenge under the ECHR.
Baroness Stroud (Con)
Can the Minister give her perspective on whether the arguments laid out today would be justifiable as reasons for a different form of treatment between the two categories: prisoners and non-prisoners?
Baroness Merron (Lab)
It is important I reclarify that that is a policy decision. What I am doing with your Lordships’ Committee is advising on risks, to assist noble Lords to make their decision regarding this policy.
Amendments 30A and 119A, tabled by the noble Baroness, Lady Berridge, would exclude any person with an education, health and care plan from being eligible for an assisted death, except in cases provided for in regulations made by the Secretary of State. As drafted, these amendments could impose unclear and potentially undeliverable legal duties on the Secretary of State and are potentially not aligned with how EHCPs work in practice or in law. The amendments give rise to a number of unresolved operational questions that do not work with other provisions of the Bill and they are not drafted with sufficient specificity. That could lead to confusion for those interpreting the legislation and unintended outcomes.
Baroness Berridge (Con)
We are about to have a meeting to outline special additional conditions, so can I clarify that the Minister is not saying that that is not possible and just that the particular conditions outlined in Amendment 119A are not possible?
Baroness Merron (Lab)
First, I am referring to the amendments before us. Secondly, I am advising on risk and workability, again for the assistance of your Lordships’ Committee, which, as is correct and proper, will make the decision.
These amendments appear to treat people with EHCPs differently from those who do not have them. This could give rise to potential incompatibility with Article 14 of the ECHR, when read with Article 8, and would require reasonable justification for differential treatment.
Finally, as noble Lords will be aware, the amendments in this group have not had technical drafting support from officials, so the way they are drafted means that they may not be fully workable, effective or enforceable. However, as I have said, the issues raised are rightly a matter for noble Lords to consider and decide.
Lord Carter of Haslemere (CB)
My Lords, the Minister referred to a number of articles of the ECHR, but she has not referred to Article 2, which is the duty on a state to protect life. That is why the courts have imposed a duty of care on the Prison Service and the Government to protect prisoners from committing suicide. My question goes back to what I said earlier: how do the Government reconcile that duty with a vulnerable prisoner applying for an assisted death? How does that square with the duty under Article 2 and the duty of care to prisoners?
Baroness Merron (Lab)
I refer the noble Lord to the provisions within the Bill. His earlier question was very much about policy. I am sure that my noble and learned friend will also refer to this, but this is a matter of policy and therefore it is for Parliament to decide.
Lord Falconer of Thoroton (Lab)
I am obliged to noble Lords for all their questions. I will deal with the four issues that this group raises: prisoners, pregnant women, homeless people and those who are the subject of an education, health and care plan.
Turning first to prisoners, I declare my interest as chair of a prison charity, Liberty Kitchen. I have been involved in prison issues for a very long time; indeed, I was once the Minister responsible for prisons. When I was in that role, every time a prisoner committed suicide, it was deemed a failure of the Prison Service and something that we took incredibly seriously.
As far as prisoners are concerned, I will make two points. First, this is about people who are terminally ill and have six months or less to live. The question that the sponsors address is whether prisoners should be treated differently from the rest of the population. The posit is: if you are a prisoner and get a terminal illness, is the condition of the prison so terrible that you should never allow a prisoner ever to have that right?
Lord Farmer (Con)
I thank the noble and learned Lord for giving way. I will comment on the other side of the argument, which is the moral hazard. This could be an extreme case, but I will give the example of somebody who has lung cancer and has within a year to live. They also have some very difficult relationships and have wanted to get rid of a certain person for a long time. If they get rid of them, they will be sent to prison but will be within having six months to live and can have an assisted death, which takes away from the victim, the victim’s family and others any concern that justice is done. By giving them an assisted suicide, justice would not be done in that case.
Lord Falconer of Thoroton (Lab)
I am not quite sure I understand the point. If the position is that I have six months to live and I want to kill somebody, which appears to be the example given, I am entitled to an assisted death whether I am in prison or not. It would probably take six months before the trial took place anyway. I am not quite sure what is the moral hazard that the noble Lord, Lord Farmer, has in mind, because the right to an assisted death would be there inside or outside of prison. So, I do not see what benefit would be obtained by excluding it from somebody in prison.
Lord Farmer (Con)
If I may try and answer that, the moral hazard is that the victim would have seen a criminal convicted, but the criminal would not serve the sentence given to them by the courts and would instead have an easy way out. You could say that he has six months to live, but as we know, in many cases —Esther Rantzen, for instance, is one of them—it can go on for years. To end his punishment would not give justice to the victim—that is the point I am making.
Lord Falconer of Thoroton (Lab)
It is just such an obscure proposition that we should not determine our policy in relation to it.
Moving on to pregnant women, the amendments say that no pregnant woman should have the right to an assisted death and that everybody who wants an assisted death must have a pregnancy test. The noble Baroness, Lady Grey-Thompson, made it clear that the second was a probing amendment and not a serious proposition. In relation to pregnant women, I completely accept what is being said, particularly by my noble friend Lady Berger, about what the statistics show. Again, safeguards can adequately deal with this and I am not in favour of any change in relation to it. We should remember that what we are dealing with here is somebody who has only six months to live. Homeless people—
Lord Mackinlay of Richborough (Con)
There is a big issue here. Other states around the world which have had assisted dying for some time have differences of view. In Oregon, which has had assisted dying since 1997, there is a requirement to keep the mother alive for as long as possible, particularly when there is a viable foetus. The Netherlands takes a completely different view, with foeticide—where the foetus must be terminated by one means or another, often by intracardial injection of potassium chloride—before the mother can be euthanised.
At which end of the scale does the noble and learned Lord prefer these things? The royal colleges are against this whole system, yet we will be relying on them to fill in the gaps in this legislation. It is incumbent upon us to fill in those gaps for them, because they are not keen on this.
Lord Falconer of Thoroton (Lab)
The noble Lord puts it accurately. Some countries have taken one view and other countries have taken another. It is clear from the choice that I am supporting that we take the view that pregnancy should not be a bar to it, though inevitably, as the noble Baroness, Lady Grey-Thompson, said, there should be questions in relation to appropriate people, whether they are pregnant or not, which may have an effect on the result. On the more detailed questions, based on what I am saying, they would not arise in the Bill.
Going on to the third category, homeless people, again with six months to live or less, will very frequently, as my noble friend Lady Gray said, have complex needs and complex lives. I am very strongly against that right to an assisted death being taken away from them, but the safeguards will apply, to be sure that it is their clear and settled view and not the product of coercion.
Finally, the noble Baroness, Lady Berridge, raised the education, health and care plan. The range of people with an EHCP is very wide, as everybody knows. I am again very against excluding everybody from the significant provisions of the Bill, because the protections are there. They can go up to the age of 25 and, as I indicated last Friday, for people aged 25 and under we should think of whether there should be enhanced protection. That would include everybody up to the age of 25, including those under an education, health and care plan. In the light of those indications, I hope—
Lord Harries of Pentregarth (CB)
My Lords, I spoke at Second Reading but have not yet intervened in Committee. I have the greatest respect for the noble and learned Lord. However, would he not agree that there is a special vulnerability about all the categories that we have been discussing this afternoon? Are there any provisions that he can build into the Bill to address this? If you took a homeless person who only had six months to live and said, “Come and live in a five-star hotel and have good palliative care”, would they then still choose an assisted death? If you took somebody out of prison who had only six months to live and said, “We’re giving you early release, you can live in a five-star hotel with good palliative care”, would they still choose an assisted death? There is a particular vulnerability about these people. It is no good simply talking about their rights. They do have their rights, but they are vulnerable. I hope that the noble and learned Lord might be able to build something into the Bill to protect these categories of people.
Lord Falconer of Thoroton (Lab)
I completely accept that there are vulnerabilities in these groups. The question is whether we should exclude everybody within those groups from this right. Should we exclude every single homeless person or prisoner? We can disagree on this, but I am saying that I do not think that is right because the protections are sufficient.
Finally, the noble Lord, Lord Carter of Haslemere, asked how we deliver our Article 2 duty to protect people from death when they are in prison and we are offering them an assisted death. We are protecting them through the detailed safeguards there are before the individual prisoner is entitled to have an assisted death. In my view, that will be an adequate protection and give adequate effect to Article 2. In light of my remarks, I hope the noble Baroness will feel able to withdraw her amendment.
Baroness Grey-Thompson (CB)
My Lords, I thank all noble Lords for this thoughtful and considered debate. As ever in your Lordships’ Chamber, the debate did not go quite the way I was expecting. This has been quite a catch-all group trying to cover a number of very complicated issues. I thank the noble Lord, Lord Kamall, for summing up. I will not seek to sum up all the contributions, but I will pick up a few points.
The noble Baroness, Lady Berridge, asked me about pregnancy. There is very little data on the numbers and one of the challenges is that recording and reporting are very different in different jurisdictions. In somewhere such as Oregon, where the data is destroyed a year after death, it is hard to follow up and interrogate the information. Many jurisdictions around the world do not require a pregnancy test, but that puts a lot more pressure on doctors as it is then up to them to assume or guess whether or not a woman is pregnant. Whether she is showing or not, do they accept the request for assisted dying? It is really worrying for those doctors, because if it is later found out that the woman was pregnant in jurisdictions where there is a penalty for the doctors, they might find themselves less likely to want to carry out an assisted death.
Lord Winston (Lab)
Does the noble Baroness not accept that there are certain cancers that will give a positive pregnancy test and also be killing the patient, in a very serious condition?
Baroness Grey-Thompson (CB)
I thank the noble Lord; I will cover that later in my summing up, if that is okay, but I will come to back it. What happens in other jurisdictions makes it really difficult for doctors, which means that we need clarity in this Bill about what would happen in those situations.
Many noble Lords discussed the vulnerability of prisoners. This debate has shown that it is not that simple. I have visited many prisons and young offender institutions over the years and they are all very different places. I have met many people who have hope and some who do not. The noble Lord, Lord Deben, articulated my thoughts on the circumstances in which prisoners find themselves very well.
I debated long and hard whether to use this example. The noble Lord, Lord Farmer, talked about moral hazard. There is the case in Australia of Daniel Hume, who was six years into a 30-year sentence for paedophilia. He had a terminal condition and exercised his right to die. His daughter said that she and other victims felt robbed by him being able to access assisted dying. This highlights the complexity of the issues we are dealing with. I hope I am a kind person—I believe in rehabilitation for prisoners—but these are not easy things that we are trying to sort out or get to the bottom of. I have very complicated views on all these issues, as I know many noble Lords do. It is absolutely something that we have to come back to.
I was probably expecting the answer from the Minister on Articles 8 and 14. I am not convinced that we have Article 2 quite right. I thank the noble Lord, Lord Winston, for his intervention and I would be very happy to take his advice. I tried to keep my opening speech very close to 10 minutes, rather than the 15 minutes I am allowed, so there are lots of areas I was unable to discuss in my opening speech. I accept what the noble Lord said—he has far more experience of pregnancy than I do—but that just throws another complication into the mix in respect of what we are trying to sort out. I will welcome his advice on rewording my amendments, should I choose to come back with them.
I would like to thank the noble and learned Lord, as well as the honourable Member for Batley and Spen, who I am meeting next week to discuss some of my amendments. I hope that we can get a bit more clarity in that meeting on the amendments we are discussing. I thank the noble Lord, Lord Mackinlay, for his intervention. I think there is a line—I am sorry, I am jumping back to pregnancy—when it comes to what we do and at what point we do it. I believe that the noble and learned Lord and I have agreed to disagree on the safeguards in the Bill.
I would like to make a correction. I am serious about my amendments, although I could have worded them better. I did not intend for men to have a pregnancy test, and I did not intend to get into a debate about age and the pregnancy test. The reason why I tabled the amendment on a pregnancy test was to allow women to understand all the implications of what they are getting into and to be able to make a choice. They may or may not choose to do something differently with that information.
I thank all noble Lords who have contributed to the debate this afternoon. With that in mind, I beg leave to withdraw my amendment.
Lord Kennedy of Southwark (Lab Co-op)
My Lords, we have completed four groups of amendments today, which in my opinion is still slow progress. It means that, in four days of Committee, we have completed only 10 groups of amendments. Before we return to Committee in the new year, I think that all noble Lords should reflect on that fact.
The one thing I have achieved today is a run on copies of the Companion. There are now only two copies left in the Printed Paper Office. I draw to the attention of the House page 15, pararaph1.54, which makes clear that:
“The House does not recognise points of order”.
We are a self-regulating House. This is the reason why we say “My Lords” in the House and do not address either the noble Lord on the Woolsack or the noble Lord at the Table. Being a self-regulating House is something we all treasure, but it does call for some self-regulation by all noble Lords.
I will talk again next week to the usual channels. I will also email all noble Lords, to their parliamentary email accounts, with the various references, relevant paragraphs and page numbers. I can recommend chapter 8 as very good festive season reading.
Lord Bassam of Brighton (Lab)
I want to ask a question about timing. I have read that, somehow, in the calculation of time allocated for Committee, it is expected that we would have one and a half times the number of Committee hours on a Bill than the other place. My understanding when I was in the usual channels was that we tried to provide, roughly speaking, the same number of Committee hours in your Lordships’ House as they do in another place. I wonder whether the noble Lord could clarify that point.
Lord Kennedy of Southwark (Lab Co-op)
I can confirm that I had never heard of the one and a half days figure until I saw the letter that arrived yesterday. We are a self-regulating House. There is no formal algorithm that we use for Committee days. I talk to the usual channels to try to get agreement on the number of Committee days; sometimes I am successful, and sometimes not. There is no formula or algorithm that we use, so I do not recognise the one and a half days comment that was made in the letter circulated yesterday.