Lords Chamber
Friday 27th March 2026
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10:05
10:06
Lord Kennedy of Southwark (Labour)
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Lord Kennedy of Southwark (Labour)
>> My Lords, before we begin, I will make my usual brief remarks. Firstly, I reiterate our thanks on behalf of the whole House to all staff across the House for supporting this city. I cannot today do justice to the thanks that the staff of the House deserve, not only for today, but for all other days. Only in the last few days we've seen the care, kindness and dedication, the staff looking after members when they're taken ill. Yeah, yeah, this has been another long week and the recess is upon us.
I will not repeat everything I've said before at length, but I should, as usual, remind Labour Lord Stoneham key points. I will adjourn proceedings today at around 3 p.m. I hope we can conclude the group we are on, but when we finish. But if necessary, I'll adjourn the house during the middle of the group. The class will compile a list of all noble Lords in attendance at the beginning of. And the noble Lords will be able to check the table. Sure. Their name is properly registered.
Only those present start of the group can participate when the group resumes. My noble
I will not repeat everything I've said before at length, but I should, as usual, remind Labour Lord Stoneham key points. I will adjourn proceedings today at around 3 p.m. I hope we can conclude the group we are on, but when we finish. But if necessary, I'll adjourn the house during the middle of the group. The class will compile a list of all noble Lords in attendance at the beginning of. And the noble Lords will be able to check the table. Sure. Their name is properly registered.
Only those present start of the group can participate when the group resumes. My noble
10:07
Business of the House
Lord Kennedy of Southwark (Labour)
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Business of the House
Lord Kennedy of Southwark (Labour)
friend Lord Falconer of Thoroton has set a target for today's Committee stage. As I said before, Committee stage. As I said before, I hope that with discipline and usual courtesies, we may progress towards the target. There will be towards the target. There will be no lunch break, but kata facilities are open and the long room will stay open until the house rises. For general guidance on how noble Lords should conduct themselves, I highly recommend the companion. In highly recommend the companion.
In particular, paragraph 4.29 on page 60 and paragraph 8.81 and 8.82 on page one four, three. Finally, my Lords, as we start the Easter recess, as I did yesterday, I wish all noble Lords, staff and the House along with families and friends, a well deserved break over the Easter recess. Either myself or one of my colleagues will be back at 3 p.m. to adjourn the house and then, with everyone rested, we will be back on Monday the 13th of April for the final day and report of the English devolution Bill, with several divisions expected.
With that, I think we should move on to
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the business. My Lords, Baroness Campbell of Surbiton will be taking part remotely. I remind the committee remotely. I remind the committee that unless they are leading a group, remote speakers speak first after the mover of the lead after the mover of the lead amendment in a group and may therefore speak to other amendments in the group ahead of members who in the group ahead of members who tabled them in clause five. Amendment 189, the Baroness Fraser
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of Craigmaddie. My Lords, this group of
In particular, paragraph 4.29 on page 60 and paragraph 8.81 and 8.82 on page one four, three. Finally, my Lords, as we start the Easter recess, as I did yesterday, I wish all noble Lords, staff and the House along with families and friends, a well deserved break over the Easter recess. Either myself or one of my colleagues will be back at 3 p.m. to adjourn the house and then, with everyone rested, we will be back on Monday the 13th of April for the final day and report of the English devolution Bill, with several divisions expected.
With that, I think we should move on to
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the business. My Lords, Baroness Campbell of Surbiton will be taking part remotely. I remind the committee remotely. I remind the committee that unless they are leading a group, remote speakers speak first after the mover of the lead after the mover of the lead amendment in a group and may therefore speak to other amendments in the group ahead of members who in the group ahead of members who tabled them in clause five. Amendment 189, the Baroness Fraser
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of Craigmaddie. My Lords, this group of
10:08
Baroness Fraser of Craigmaddie (Conservative)
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Baroness Fraser of Craigmaddie (Conservative)
amendments seek to establish an opt in model for healthcare professionals, as explicitly professionals, as explicitly requested by the various royal colleges, including the Royal College of GPS, the Royal College of Psychiatrists, the Royal Pharmaceutical Society and the Royal College of Nursing. They seek to protect doctors and all healthcare professionals, not just with a vague, formal right to opt with a vague, formal right to opt out, but with a clear framework in which their rights are clear. My amendment 189, supported with many thanks by the noble Lord Carlile and the noble Baroness, Lady Lady O'loan seeks to strengthen the transparency of medical practitioners involved in delivering an assisted dying service by setting up a publicly available register of medical professionals who are willing and able to conduct preliminary discussions.
Now, whilst the bill's sponsors have confirmed that the bill is based on an opt in system. It is imperative that this opt in is explicitly referred to in the Bill to ensure participation is a positive choice, to avoid it being presumed or open to pressure that all professionals would participate unless they opt out. Now, in clause five, subsection six, it says that if a doctor is unwilling or unable or unwilling to participate, they must ensure the person is directed to where they can obtain information and have the preliminary discussion.
But, my Lords, where should that be? Would not a publicly available register be the perfect solution for the patient to seek out a medical professional on the register at their convenience? The noble and learned Lords amendments 42 and 42 three. Leave it to the Secretary of State to make provisions through regulation at some later date and 699A only covers coordinating and independent doctors, and only adds an opt in option to providing or participating in training. And I believe that this isn't good enough.
And I'm sure the noble Lord noble and learned Lord will also refer in his reply to clause 31, which I appreciate was expanded in the other place at Report stage. However, serious gaps remain, schedule three of the Bill may indeed provide for protection against detriment by incorporating existing employment rights, but this doesn't resolve the issue because it leaves individuals to resort to the tribunal system, a system that is already crowded and where the remedy is damages, not rehiring.
So potentially forcing individuals to have to choose between their conscience and their career. Now, we know that not all medical practitioners will want to participate in assisted dying. 45% of doctors in the BMA's 2020 study indicated they would not be willing to participate, with a further 19% undecided. It is my belief that a clear and public register of those professionals who do wish to participate would enhance transparency and enable everyone to know where they stand. Amendment 189 requires the Secretary of State to set up such a register, ensure there is a process to keep it updated and to make it publicly available.
A medical practitioner could only conduct preliminary discussions if they are in the register. My Lords concerns have been expressed that assisted dying will forever change the doctor patient relationship. Vulnerable patients would not be able to trust that clinicians had their best interests at heart. Such concerns illustrate the importance of ascertaining whether assisted dying is or is not to be considered a treatment, which amendments three, eight three and 657 in the names of the noble Baroness Cass and Fox are exploring.
But with amendment one, 89 patients would know if their GP was a willing participant, whether or not they wish to avail themselves of assisted dying, and presumably they could choose or not choose to register with such a practice. And patients would also know if their consultant or other medical professional had opted in, and thus providing a context for, say, discussions around future options. And it also protects to clinicians, protects clinicians who can point to the register if they wish to have nothing to do with assisted dying.
The BMA have advised that they are against the reintroduction of a requirement on doctors to refer patients, which would undo a change from refer to direct made in the other place. But I understand that not all royal colleges are at one. On this point, I take the point that my subsection nine in my amendment does read that a professional who is unwilling or unable to conduct the preliminary discussion must refer the person to the Register of Medical professionals, and I know that the BMA attached a specific meaning to the word refer, and as I am sure, the noble Lady.
The Minister will tell me in her reply, my amendment has not had the advantage of technical support in its drafting, and frankly, if the BMA would prefer the word direct, then I would be perfectly happy with that. But even if you remove the last clause, section nine of my amendment, the point remains, which is to set up a publicly available register for those who want to opt in. Such a register also has the advantage of being able to be tracked. We could review whether certain areas of the country were being better or worse served.
We could monitor the practice of doctors on the register to track concerns of doctor shopping, and we could analyse which professionals or specialisms are or are not participating in assisted dying. And all of this would assist with the regulation of assisted dying. My Lords, the bill is ambiguous about how far conscience protections actually extend. Amendment 673 in my name protects the rights of anyone involved in the care of someone who might want assisted dying to opt out of supporting that person to die.
We know that in practice, a much wider remit of health and care team members will be affected by supporting someone in an assisted death, not just the lead clinicians. The noble Baroness, Lady Watkins, reminded us last week of the multidisciplinary nature of support for the terminally ill people, and care workers in particular, are ignored in this bill. These health and care workers, whether they're registered or unregistered, should be able to refuse to participate if they wish to conscientiously object without penalty, and they should be afforded the same protections as lead clinicians.
Those of us who are following the debate in the Scottish Parliament last week will know that one of the reasons MSPs changed their minds was exactly because of the lack of clarity of the protections for conscientious objectors. Their ability to refuse to participate in assisted dying was not clear, and that Bill has now fallen. So can the noble and learned Lord, please confirm what is his response to the Royal College's call for an opt in system to be adopted? And how can he guarantee that no one will face legal or professional repercussions, including indirect ones, for refusing to participate in assisted dying? I beg to move the.
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Amendment. Proposed clause five, page three, line 30 leave out page three, line 30 leave out subsection six and insert the words as printed on the Marshalled List.
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as printed on the Marshalled List. My Lords, I have added my name to my noble birth. My noble friend. to my noble birth. My noble friend. Baroness Finlay amendment 190 and I have also supported amendments 268359383617 and 657 in this group. This basket of amendments as my noble as the noble Lady, Baroness Fraser said, seeks to ensure that no doctor or associated healthcare professional is under any pressure to participate in the process of assisted dying unless actively opting in to the process.
Amendment 190 provides an important safeguard against pressure on doctors by making it clear that the obligation to refer a patient to relevant information and another doctor applies only when the patient has specifically requested a preliminary discussion on assisted dying. It also ensures that doctors who do not wish to be involved are
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not required to take part beyond that point. My Lord's last summer I spent
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My Lord's last summer I spent six weeks in Saint Thomas's critical care after an accident at critical care after an accident at sea in the Bay of Biscay. I came home broken, bruised and in home broken, bruised and in terrible pain, but my salvation was the compassionate, dedicated team the compassionate, dedicated team of health professionals whose combined efforts brought me back to life and back to this chamber. This was what they were born to do. As ever, I took the opportunity to ask each person who came to my bedside what they thought of the bill and would they participate in its application should it become law.
Hand on heart. Not one doctor, nurse or allied professional said yes. What they did say was, it's
Now, whilst the bill's sponsors have confirmed that the bill is based on an opt in system. It is imperative that this opt in is explicitly referred to in the Bill to ensure participation is a positive choice, to avoid it being presumed or open to pressure that all professionals would participate unless they opt out. Now, in clause five, subsection six, it says that if a doctor is unwilling or unable or unwilling to participate, they must ensure the person is directed to where they can obtain information and have the preliminary discussion.
But, my Lords, where should that be? Would not a publicly available register be the perfect solution for the patient to seek out a medical professional on the register at their convenience? The noble and learned Lords amendments 42 and 42 three. Leave it to the Secretary of State to make provisions through regulation at some later date and 699A only covers coordinating and independent doctors, and only adds an opt in option to providing or participating in training. And I believe that this isn't good enough.
And I'm sure the noble Lord noble and learned Lord will also refer in his reply to clause 31, which I appreciate was expanded in the other place at Report stage. However, serious gaps remain, schedule three of the Bill may indeed provide for protection against detriment by incorporating existing employment rights, but this doesn't resolve the issue because it leaves individuals to resort to the tribunal system, a system that is already crowded and where the remedy is damages, not rehiring.
So potentially forcing individuals to have to choose between their conscience and their career. Now, we know that not all medical practitioners will want to participate in assisted dying. 45% of doctors in the BMA's 2020 study indicated they would not be willing to participate, with a further 19% undecided. It is my belief that a clear and public register of those professionals who do wish to participate would enhance transparency and enable everyone to know where they stand. Amendment 189 requires the Secretary of State to set up such a register, ensure there is a process to keep it updated and to make it publicly available.
A medical practitioner could only conduct preliminary discussions if they are in the register. My Lords concerns have been expressed that assisted dying will forever change the doctor patient relationship. Vulnerable patients would not be able to trust that clinicians had their best interests at heart. Such concerns illustrate the importance of ascertaining whether assisted dying is or is not to be considered a treatment, which amendments three, eight three and 657 in the names of the noble Baroness Cass and Fox are exploring.
But with amendment one, 89 patients would know if their GP was a willing participant, whether or not they wish to avail themselves of assisted dying, and presumably they could choose or not choose to register with such a practice. And patients would also know if their consultant or other medical professional had opted in, and thus providing a context for, say, discussions around future options. And it also protects to clinicians, protects clinicians who can point to the register if they wish to have nothing to do with assisted dying.
The BMA have advised that they are against the reintroduction of a requirement on doctors to refer patients, which would undo a change from refer to direct made in the other place. But I understand that not all royal colleges are at one. On this point, I take the point that my subsection nine in my amendment does read that a professional who is unwilling or unable to conduct the preliminary discussion must refer the person to the Register of Medical professionals, and I know that the BMA attached a specific meaning to the word refer, and as I am sure, the noble Lady.
The Minister will tell me in her reply, my amendment has not had the advantage of technical support in its drafting, and frankly, if the BMA would prefer the word direct, then I would be perfectly happy with that. But even if you remove the last clause, section nine of my amendment, the point remains, which is to set up a publicly available register for those who want to opt in. Such a register also has the advantage of being able to be tracked. We could review whether certain areas of the country were being better or worse served.
We could monitor the practice of doctors on the register to track concerns of doctor shopping, and we could analyse which professionals or specialisms are or are not participating in assisted dying. And all of this would assist with the regulation of assisted dying. My Lords, the bill is ambiguous about how far conscience protections actually extend. Amendment 673 in my name protects the rights of anyone involved in the care of someone who might want assisted dying to opt out of supporting that person to die.
We know that in practice, a much wider remit of health and care team members will be affected by supporting someone in an assisted death, not just the lead clinicians. The noble Baroness, Lady Watkins, reminded us last week of the multidisciplinary nature of support for the terminally ill people, and care workers in particular, are ignored in this bill. These health and care workers, whether they're registered or unregistered, should be able to refuse to participate if they wish to conscientiously object without penalty, and they should be afforded the same protections as lead clinicians.
Those of us who are following the debate in the Scottish Parliament last week will know that one of the reasons MSPs changed their minds was exactly because of the lack of clarity of the protections for conscientious objectors. Their ability to refuse to participate in assisted dying was not clear, and that Bill has now fallen. So can the noble and learned Lord, please confirm what is his response to the Royal College's call for an opt in system to be adopted? And how can he guarantee that no one will face legal or professional repercussions, including indirect ones, for refusing to participate in assisted dying? I beg to move the.
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Amendment. Proposed clause five, page three, line 30 leave out page three, line 30 leave out subsection six and insert the words as printed on the Marshalled List.
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as printed on the Marshalled List. My Lords, I have added my name to my noble birth. My noble friend. to my noble birth. My noble friend. Baroness Finlay amendment 190 and I have also supported amendments 268359383617 and 657 in this group. This basket of amendments as my noble as the noble Lady, Baroness Fraser said, seeks to ensure that no doctor or associated healthcare professional is under any pressure to participate in the process of assisted dying unless actively opting in to the process.
Amendment 190 provides an important safeguard against pressure on doctors by making it clear that the obligation to refer a patient to relevant information and another doctor applies only when the patient has specifically requested a preliminary discussion on assisted dying. It also ensures that doctors who do not wish to be involved are
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not required to take part beyond that point. My Lord's last summer I spent
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My Lord's last summer I spent six weeks in Saint Thomas's critical care after an accident at critical care after an accident at sea in the Bay of Biscay. I came home broken, bruised and in home broken, bruised and in terrible pain, but my salvation was the compassionate, dedicated team the compassionate, dedicated team of health professionals whose combined efforts brought me back to life and back to this chamber. This was what they were born to do. As ever, I took the opportunity to ask each person who came to my bedside what they thought of the bill and would they participate in its application should it become law.
Hand on heart. Not one doctor, nurse or allied professional said yes. What they did say was, it's
10:19
Baroness Campbell of Surbiton (Crossbench)
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Baroness Campbell of Surbiton (Crossbench)
not what I trained for years to do. My job satisfaction is making patients as comfortable as possible patients as comfortable as possible and supporting life, however long or short. I must admit, it made me or short. I must admit, it made me feel a great deal better and yes, safer, knowing they would go the safer, knowing they would go the extra mile to help me whilst in extra mile to help me whilst in their care. My Lords, we know that a number of the Royal Colleges have raised concerns about the pressures on healthcare professionals to clear hospital beds and meet treatment targets.
This, in turn may pressurise them to participate in the assisted dying process as a result. A subtle yet deadly form of unconscious coercion causing division within medical teams and undermining patient trust. This was clearly illustrated in the sobering BBC documentary Better Off Dead last year. Throughout our exchanges in this House, I've heard the term treatment option to describe assisted dying. It is not. Assisted dying as a treatment does not accord with the fundamental principles of medical practice.
Medical treatment is to alleviate symptoms and support life, however short, in the least distressing way possible. To do otherwise would fundamentally alter the nature of medical practice, shifting the focus from supporting life to suggesting its end, leaving patients feeling pressurised or fearful when seeking care. Amendments three, eight three and 657 in this group address this issue. The evidence is clear that without these amendments, we are in danger of travelling the same road as the Canadian legislation, a law which began as tightly drafted legislation but soon gave way to systemic pressures on healthcare professionals, many of whom see assisted dying as part of the end of life treatment.
Now, my Lords, we must not allow the introduction of assisted dying to disrupt the fundamental principles principles of healthcare. The opt in system proposed by Baroness Finlay Finlay and others in this group is not about protecting the rights of healthcare professionals. It is about preserving the very essence of patient care, the noble and learned Lord Faulks amendments fall short of addressing these concerns by limiting the statutory opt in solely to the bespoke training for coordinating doctors and independent doctors.
He leaves significant gaps in protection for the wider medical workforce. They are seen as too narrow and procedural to meet the fundamental concerns raised by the Royal College of General Practitioners
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and the Royal College of Psychiatrists. I urge your Lordship to support
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I urge your Lordship to support the amendments I refer to understand the Royal Colleges in understand the Royal Colleges in their call for a clear opt in system, a system which respects the system, a system which respects the rights and dignity of all healthcare professionals, providing healthcare professionals, providing them with a safe, ethical healthcare environment and protecting the integrity of their relationship with patients. Thank you.
This, in turn may pressurise them to participate in the assisted dying process as a result. A subtle yet deadly form of unconscious coercion causing division within medical teams and undermining patient trust. This was clearly illustrated in the sobering BBC documentary Better Off Dead last year. Throughout our exchanges in this House, I've heard the term treatment option to describe assisted dying. It is not. Assisted dying as a treatment does not accord with the fundamental principles of medical practice.
Medical treatment is to alleviate symptoms and support life, however short, in the least distressing way possible. To do otherwise would fundamentally alter the nature of medical practice, shifting the focus from supporting life to suggesting its end, leaving patients feeling pressurised or fearful when seeking care. Amendments three, eight three and 657 in this group address this issue. The evidence is clear that without these amendments, we are in danger of travelling the same road as the Canadian legislation, a law which began as tightly drafted legislation but soon gave way to systemic pressures on healthcare professionals, many of whom see assisted dying as part of the end of life treatment.
Now, my Lords, we must not allow the introduction of assisted dying to disrupt the fundamental principles principles of healthcare. The opt in system proposed by Baroness Finlay Finlay and others in this group is not about protecting the rights of healthcare professionals. It is about preserving the very essence of patient care, the noble and learned Lord Faulks amendments fall short of addressing these concerns by limiting the statutory opt in solely to the bespoke training for coordinating doctors and independent doctors.
He leaves significant gaps in protection for the wider medical workforce. They are seen as too narrow and procedural to meet the fundamental concerns raised by the Royal College of General Practitioners
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and the Royal College of Psychiatrists. I urge your Lordship to support
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I urge your Lordship to support the amendments I refer to understand the Royal Colleges in understand the Royal Colleges in their call for a clear opt in system, a system which respects the system, a system which respects the rights and dignity of all healthcare professionals, providing healthcare professionals, providing them with a safe, ethical healthcare environment and protecting the integrity of their relationship with patients. Thank you.
10:22
Baroness Finlay of Llandaff (Crossbench)
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Baroness Finlay of Llandaff (Crossbench)
Amendments 193268359617 and 660 in this group. The crux of this group is that assisting suicide is not a medical treatment, and products to bring about the death are not being used as medications, but in massive overdoses for their poisonous properties. The Human Medicines Regulations 2012 defines a medicinal product as a substance or combination of substances with properties of preventing or treating disease in human beings, or that may be used or administered to human beings to restore, correct or modify a physiological function by exerting a pharmacological, immunological or metabolic action, or in making a medical diagnosis.
The noble, my noble friend Baroness Campbell has described excellent care and complex care very well. After considering the issue about what is a medicine, let us consider treatment the Health and Social Care Act 2012 states the Comprehensive Health Service is designed to secure improvement in the physical and mental health of the people of England and in the prevention, diagnosis and treatment prevention, diagnosis and treatment of physical and mental illness. This is then embodied for patients in the NHS Constitution.
In debates to date, proponents have focussed on assisted dying as an existential choice, not a treatment. Canada considers it a treatment and the problems, as my noble friend Lady Campbell have explained, have emerged over time. But in Switzerland and Germany, it's fundamentally not a healthcare matter, and it's important to remember that outside life there is no health. So what are the role of doctors? The main conscience clause now, clause 31 was expanded at Report stage in the other place to include explicit carve outs to protect any person from a duty to participate in the provision of assistance in accordance with this act.
But I ask the noble and learned Lord, Lord Faulkner, how is this assistance defined and what are its boundaries? Is the assessment process for eligibility to lethal drugs, or is it only the provision of lethal drugs, or only actually helping the person to ingest the drugs, or setting up a delivery device for the lethal substance? Those boundaries are really important. Clause five of the six originally required doctors unwilling to conduct the preliminary discussion to refer a patient to another doctor who could conduct the discussion after objections from the medical organisations, this was changed to a duty to direct the person where they could find information.
Although the Royal College of Psychiatrists have said this may fail to adequately respect conscience, however, clause five still doesn't meet the requirement of expert medical bodies who request an opt in system. Amendment 268 states the coordinating doctor and in three five, nine the independent doctor. And in 617A substitute doctor have all explicitly opted in for these roles. Currently, freshly qualified medical graduates could act as coordinating doctors under my amendments. No one could be a coordinating doctor unless they had explicitly met training and competency requirements to be on a new, separate GMC register, eligibility for which would be would require specialist training and has, as has already been so well explained in the introduction of this group.
As has been said, the BMA, the Royal College of GPS both specifically requested an opt in system and the BMA requires an opt in model for doctors who opt in to provide assisted suicide to be able to choose which parts of the service they're willing to provide. Yesterday I had confirmation from the Royal College of General Practitioners that they strongly support my amendments 268359617 saying the College believes that any assisted dying provision must be separately funded and delivered through a distinct pathway, and that the college would support explicit clarification on the face of the bill.
To make it clear there is no expectation on any doctor, including GPS, to participate, and it is only those who positively choose to do so for an opt in who would have the training and participate. I note the amendment down in the name of the noble and learned Lord Dear Lord Falconer of Thoroton. That would make training the opt in, but it wouldn't deal with institutional expectations. And I'm uncertain how you. You may. If you can't be legally compelled to take the training.
But how you could, in the event, still be involved in the discussions or assessments, because it isn't clear that this amendment would mean that you should be on on the specialist register as explained. The only way to protect clinicians from detriment is by opt in. Evidence in the Other place from Canada suggests that physicians find it very hard to opt out, despite a right to describing how assisted dying has completely changed the practice of medicine in Canada. Doctors are expected to facilitate access to death if not willing to provide it themselves, even when a doctor knows reasonable options for care have not been provided.
And they went on to voice their concerns. And that's all in the written evidence. I've heard from Australian doctors who've been intimidated, even driven out of their job, for refusing involvement. Pressure does not only come in the professions, though. A recent study of Dutch GPS reported the majority of Dutch physicians feel pressured when dealing with the request for euthanasia or physician assisted suicide, particularly emotional blackmail. Control and direction by others. Doubts about fulfilling the criteria. Counter pressure by patient's relatives.
Time pressure around referred patients and organisational pressures. That creation of an expectation and of a culture of assisted death is why medical experts want a clear opt out system. OPT sorry, opt in. I beg your pardon? OPT in allows the NHS work to continue unhindered. Ensures patients seeking assisted suicide are seen by doctors who are fully trained in the process. The BMA survey has already referred to, has revealed that 6% of members of the Association for Palliative Medicine would be prepared to administer lethal drugs, but would opt in for staff and for and would risk an organisational exodus of staff.
Doctor Sara Cox, of the Association for Palliative Medicine, told the Other place in all evidence, for 43% of palliative medicine professionals say they would leave if assisted dying were made part of the organisation in which they work. And this leads on to another difficulty, which is the logistic workability of an opt out system. The bill's impact assessment working on the assumption of an opt out, notes that there is a high degree of uncertainty around the level of opt out in England and Wales.
Surveys conducted by Royal colleges and professional bodies suggested it could range from 35 to 76% for specific groups of staff. Consideration would need to be given to the impact of a high level of opt out on the workability of a national service model. My, my Lords, there are defects in the conscience provisions as written. Despite the amendment of the noble and learned Lord, Lord Faulkner. And I would suggest that any rewrite of this bill opt in, as required by the professional bodies, must be absolutely explicit.
And I would ask the noble Lord, Leonard noble and learned Lord, to explain why his amendment has come so late in the day, despite the fact that the evidence from the royal colleges was there from the beginning.
The noble, my noble friend Baroness Campbell has described excellent care and complex care very well. After considering the issue about what is a medicine, let us consider treatment the Health and Social Care Act 2012 states the Comprehensive Health Service is designed to secure improvement in the physical and mental health of the people of England and in the prevention, diagnosis and treatment prevention, diagnosis and treatment of physical and mental illness. This is then embodied for patients in the NHS Constitution.
In debates to date, proponents have focussed on assisted dying as an existential choice, not a treatment. Canada considers it a treatment and the problems, as my noble friend Lady Campbell have explained, have emerged over time. But in Switzerland and Germany, it's fundamentally not a healthcare matter, and it's important to remember that outside life there is no health. So what are the role of doctors? The main conscience clause now, clause 31 was expanded at Report stage in the other place to include explicit carve outs to protect any person from a duty to participate in the provision of assistance in accordance with this act.
But I ask the noble and learned Lord, Lord Faulkner, how is this assistance defined and what are its boundaries? Is the assessment process for eligibility to lethal drugs, or is it only the provision of lethal drugs, or only actually helping the person to ingest the drugs, or setting up a delivery device for the lethal substance? Those boundaries are really important. Clause five of the six originally required doctors unwilling to conduct the preliminary discussion to refer a patient to another doctor who could conduct the discussion after objections from the medical organisations, this was changed to a duty to direct the person where they could find information.
Although the Royal College of Psychiatrists have said this may fail to adequately respect conscience, however, clause five still doesn't meet the requirement of expert medical bodies who request an opt in system. Amendment 268 states the coordinating doctor and in three five, nine the independent doctor. And in 617A substitute doctor have all explicitly opted in for these roles. Currently, freshly qualified medical graduates could act as coordinating doctors under my amendments. No one could be a coordinating doctor unless they had explicitly met training and competency requirements to be on a new, separate GMC register, eligibility for which would be would require specialist training and has, as has already been so well explained in the introduction of this group.
As has been said, the BMA, the Royal College of GPS both specifically requested an opt in system and the BMA requires an opt in model for doctors who opt in to provide assisted suicide to be able to choose which parts of the service they're willing to provide. Yesterday I had confirmation from the Royal College of General Practitioners that they strongly support my amendments 268359617 saying the College believes that any assisted dying provision must be separately funded and delivered through a distinct pathway, and that the college would support explicit clarification on the face of the bill.
To make it clear there is no expectation on any doctor, including GPS, to participate, and it is only those who positively choose to do so for an opt in who would have the training and participate. I note the amendment down in the name of the noble and learned Lord Dear Lord Falconer of Thoroton. That would make training the opt in, but it wouldn't deal with institutional expectations. And I'm uncertain how you. You may. If you can't be legally compelled to take the training.
But how you could, in the event, still be involved in the discussions or assessments, because it isn't clear that this amendment would mean that you should be on on the specialist register as explained. The only way to protect clinicians from detriment is by opt in. Evidence in the Other place from Canada suggests that physicians find it very hard to opt out, despite a right to describing how assisted dying has completely changed the practice of medicine in Canada. Doctors are expected to facilitate access to death if not willing to provide it themselves, even when a doctor knows reasonable options for care have not been provided.
And they went on to voice their concerns. And that's all in the written evidence. I've heard from Australian doctors who've been intimidated, even driven out of their job, for refusing involvement. Pressure does not only come in the professions, though. A recent study of Dutch GPS reported the majority of Dutch physicians feel pressured when dealing with the request for euthanasia or physician assisted suicide, particularly emotional blackmail. Control and direction by others. Doubts about fulfilling the criteria. Counter pressure by patient's relatives.
Time pressure around referred patients and organisational pressures. That creation of an expectation and of a culture of assisted death is why medical experts want a clear opt out system. OPT sorry, opt in. I beg your pardon? OPT in allows the NHS work to continue unhindered. Ensures patients seeking assisted suicide are seen by doctors who are fully trained in the process. The BMA survey has already referred to, has revealed that 6% of members of the Association for Palliative Medicine would be prepared to administer lethal drugs, but would opt in for staff and for and would risk an organisational exodus of staff.
Doctor Sara Cox, of the Association for Palliative Medicine, told the Other place in all evidence, for 43% of palliative medicine professionals say they would leave if assisted dying were made part of the organisation in which they work. And this leads on to another difficulty, which is the logistic workability of an opt out system. The bill's impact assessment working on the assumption of an opt out, notes that there is a high degree of uncertainty around the level of opt out in England and Wales.
Surveys conducted by Royal colleges and professional bodies suggested it could range from 35 to 76% for specific groups of staff. Consideration would need to be given to the impact of a high level of opt out on the workability of a national service model. My, my Lords, there are defects in the conscience provisions as written. Despite the amendment of the noble and learned Lord, Lord Faulkner. And I would suggest that any rewrite of this bill opt in, as required by the professional bodies, must be absolutely explicit.
And I would ask the noble Lord, Leonard noble and learned Lord, to explain why his amendment has come so late in the day, despite the fact that the evidence from the royal colleges was there from the beginning.
10:31
Lord Carlile of Berriew (Crossbench)
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Lord Carlile of Berriew (Crossbench)
To speak. Signatory of Baroness >> To speak. Signatory of Baroness Fraser's amendment number 189, and I am strongly in favour of it, for reasons which I'll explain, I hope, briefly. I'm not a doctor, but I am a patient when I can't avoid it. And let's take an example which many of your Lordships House either have or will face when your eyesight begins to deteriorate, you go to the optician and the opposition says, well, I've examined your eyes. You've got the beginnings of a cataract, and you can make choice between either continuing with your spectacles as they are now, or you could go and have a cataract operation, which might even mean you don't have to wear spectacles ever again.
So what happens in order to decide which choice you make, you are sent to a specialist. Since the 1st of January 1997, there has been a GMC specialist register and it covers all sorts of specialities, including some which do not have the sort of high formality of gynaecology or obstetrics or orthopaedics. And it works very well. It's publicly accessible. It's just the sort of register that the noble Lady is referring to, although albeit as a specific one for this.
So when you face the choice of having less than six months to live and you want to or dying by assisted dying and you want to make your decision, you want to go to someone who has exactly the same sort of disciplinary approach as that specialist who would be advising me on my incipient cataract. And that is a specialism. And I cannot understand why there should be any other approach to this than having a specialist register, so that when you go and have that advice, you have it given clearly to you so that that's specialist, not any old general practitioner.
If I can forgive me, forgiven for using that phrase, I'm the son. I'm the son of a general practitioner who, by the way, was not any old general practitioner. But even the noble Baroness knows that the skills of general practitioners are not uniform and vary a good deal. And I think her surprise is falling from what I said. Now, as I say, that it's not a role of a general practitioner, it's a role of a specialist, and that specialist must be able to tell the patient, what are the options for their continuing with life, what palliative care is available, what caring systems are available if there are unable to do certain things?
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I'm very grateful to the noble Lord to give way for just a brief moment. It's the noble Lord, aware moment. It's the noble Lord, aware that virtually no specialism has 100% of those posts filled. In fact, 100% of those posts filled. In fact, in most cases in the UK. As you can check with the recent figures from the Department of Health that many the Department of Health that many specialists. Many specialisms are down to about 30% and there are many specialist areas which are not
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many specialist areas which are not covered by specialists at all in medicine. Well, I'm giving my. Answer to that is they jolly well should be. No, I don't see that. That is a point against the argument I'm making at all. I would say exactly what I'm saying in relation to any specialism, and it's a very simple point. Do I want someone knowledgeable to explain to me what palliative care is available to me or not? Or do I want it given by a generalist who may be extremely good, like the noble Lady Gerada, or maybe rather less good like one of her.
I used to be on the General Medical Council as a lay member. I have a disciplined, very large numbers of doctors as a result of that experience. And I think that having this specialist care is an absolute essential requirement of what we're discussing.
So what happens in order to decide which choice you make, you are sent to a specialist. Since the 1st of January 1997, there has been a GMC specialist register and it covers all sorts of specialities, including some which do not have the sort of high formality of gynaecology or obstetrics or orthopaedics. And it works very well. It's publicly accessible. It's just the sort of register that the noble Lady is referring to, although albeit as a specific one for this.
So when you face the choice of having less than six months to live and you want to or dying by assisted dying and you want to make your decision, you want to go to someone who has exactly the same sort of disciplinary approach as that specialist who would be advising me on my incipient cataract. And that is a specialism. And I cannot understand why there should be any other approach to this than having a specialist register, so that when you go and have that advice, you have it given clearly to you so that that's specialist, not any old general practitioner.
If I can forgive me, forgiven for using that phrase, I'm the son. I'm the son of a general practitioner who, by the way, was not any old general practitioner. But even the noble Baroness knows that the skills of general practitioners are not uniform and vary a good deal. And I think her surprise is falling from what I said. Now, as I say, that it's not a role of a general practitioner, it's a role of a specialist, and that specialist must be able to tell the patient, what are the options for their continuing with life, what palliative care is available, what caring systems are available if there are unable to do certain things?
**** Possible New Speaker ****
I'm very grateful to the noble Lord to give way for just a brief moment. It's the noble Lord, aware moment. It's the noble Lord, aware that virtually no specialism has 100% of those posts filled. In fact, 100% of those posts filled. In fact, in most cases in the UK. As you can check with the recent figures from the Department of Health that many the Department of Health that many specialists. Many specialisms are down to about 30% and there are many specialist areas which are not
**** Possible New Speaker ****
many specialist areas which are not covered by specialists at all in medicine. Well, I'm giving my. Answer to that is they jolly well should be. No, I don't see that. That is a point against the argument I'm making at all. I would say exactly what I'm saying in relation to any specialism, and it's a very simple point. Do I want someone knowledgeable to explain to me what palliative care is available to me or not? Or do I want it given by a generalist who may be extremely good, like the noble Lady Gerada, or maybe rather less good like one of her.
I used to be on the General Medical Council as a lay member. I have a disciplined, very large numbers of doctors as a result of that experience. And I think that having this specialist care is an absolute essential requirement of what we're discussing.
10:35
Baroness Gerada (Crossbench)
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Baroness Gerada (Crossbench)
My Lord, my Lord, my Lord, my Lord. First of all, many thanks for Lord. First of all, many thanks for the any old comment. I'm an any old general practitioner there. There are a few issues I would like to just pick up please. One is around the register being made publicly available. I certainly, absolutely, totally would not want my name on a publicly available register. As somebody who is provides the services of assisted dying. Not because. Not because I'm ashamed, but because of the hate mail that I would get.
And the and the the distress of which I already have. That does not mean that I'm against some form of register. Of course there can be. Just as there is for those doctors who do. Section 12 approvals under the Mental Health Act, and just as those doctors that do all sorts of issues. But to have a publicly available register, I think goes one too far. The second thing I would like to just pick up is around. The second issue I would like to put out is we are already getting confused, as I am about the opt in opt out.
And we saw that that earlier all doctors if this law, if this becomes law, must be trained in assisted dying, whatever that training compiled and the royal colleges will will determine that as all doctors are trained in termination of pregnancy, that they may then not deliver termination of pregnancy or may actually opt out of delivering any of the services is up to them. But all doctors must be competent in this area. I've been a GP now for nearly 40 years, and I've worked with doctors who do not want to get engaged at all in the delivery or any aspect of termination of pregnancy, but nevertheless, they're there to counsel their patients and then to direct them to a place of a doctor that is available and willing.
That is why they must all. And finally, I'd just like to pick up the point
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that was made by. Grateful to the the noble Lady.
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Grateful to the the noble Lady. I just wanted to ask her a question on her point about a publicly available register and that she available register and that she doesn't want one. Does she think that the patience of a general that the patience of a general practitioner have the right to know whether that general practitioner is willing to provide assisted
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is willing to provide assisted suicide services? Yes. I said before about using the word assisted suicide, but with respect to the. If this becomes available, patients that. This is going to be an unusual event that happens of patients wanting to have an assisted death. So we're not talking about hundreds of them. We're also within each local area, there will be available a list, I suspect, held at the local health authority or wherever it's going to be held, of those doctors who will be willing to participate.
And if any of you came to the event where we had the Australians coming over to say how it's done in their country, it's done by doctors of all professional groups because it's competence and capabilities, not the specialities of those doctors who wish to pursue the training in order to become competent at capable of doing this. So this is all feasible. We're not talking about me and my consulting room nipping off at lunchtime and administering assisted assisted death.
We're talking about a regulated system that will be properly managed with small numbers. So I hope that is the answer. By the way, I just wanted to pick up the last final point about the use of drugs and the use of drugs that are there to treat disease. Well, I'm sure my noble Lady will know with her expertise in palliative care at the end of life, we use drugs, sometimes an extraordinarily high doses that we know are going
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to accelerate death. Just before the noble Lady sits
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Just before the noble Lady sits down, I'd like to intervene on her comment about training, because, yes, everybody is trained in, for example, abortion as they go through medical school. But by the time you're practising clinically time you're practising clinically and you're on a specialist register, you are no longer keeping up to date with those skills at all. And your revalidation depends on you keeping up to date with those skills, which is the benefit of having a specialist register.
And if I might comment on her opening remarks about being worried about having hate mail, perhaps she might have some sympathy for those of us in palliative medicine who've been receiving a great deal of hate mail because we're known to be specialists in palliative medicine, and because we've been flagging up concerns over this bill. And as for the numbers, perhaps I would ask
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her. If I'm interfering. You can't intervene. Order, order!
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Can I see it? Baroness Finlay. But if you intervene, if you keep it short and the people kind of
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don't intervene on it, people are intervening. Repeatedly intervening on the different points. As for the numbers, the estimates based on the evidence from other countries suggests that the estimates in the impact assessment are very, very low. And actually, the demand for assisted suicide would be much higher. So it would come into the purview of a large number of clinicians. Hence the need for specialisation.
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I'm intervening if I thank you, some diffidence, my Lords. First of some diffidence, my Lords. First of all, to put on the record that this bill is abundantly clear that it is bill is abundantly clear that it is an opt in system. Clause 31 no obligation to provide assistance. No person is under any duty to participate in the provision of assistance in accordance with this act. No registered medical practitioner is any under any duty
And the and the the distress of which I already have. That does not mean that I'm against some form of register. Of course there can be. Just as there is for those doctors who do. Section 12 approvals under the Mental Health Act, and just as those doctors that do all sorts of issues. But to have a publicly available register, I think goes one too far. The second thing I would like to just pick up is around. The second issue I would like to put out is we are already getting confused, as I am about the opt in opt out.
And we saw that that earlier all doctors if this law, if this becomes law, must be trained in assisted dying, whatever that training compiled and the royal colleges will will determine that as all doctors are trained in termination of pregnancy, that they may then not deliver termination of pregnancy or may actually opt out of delivering any of the services is up to them. But all doctors must be competent in this area. I've been a GP now for nearly 40 years, and I've worked with doctors who do not want to get engaged at all in the delivery or any aspect of termination of pregnancy, but nevertheless, they're there to counsel their patients and then to direct them to a place of a doctor that is available and willing.
That is why they must all. And finally, I'd just like to pick up the point
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that was made by. Grateful to the the noble Lady.
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Grateful to the the noble Lady. I just wanted to ask her a question on her point about a publicly available register and that she available register and that she doesn't want one. Does she think that the patience of a general that the patience of a general practitioner have the right to know whether that general practitioner is willing to provide assisted
**** Possible New Speaker ****
is willing to provide assisted suicide services? Yes. I said before about using the word assisted suicide, but with respect to the. If this becomes available, patients that. This is going to be an unusual event that happens of patients wanting to have an assisted death. So we're not talking about hundreds of them. We're also within each local area, there will be available a list, I suspect, held at the local health authority or wherever it's going to be held, of those doctors who will be willing to participate.
And if any of you came to the event where we had the Australians coming over to say how it's done in their country, it's done by doctors of all professional groups because it's competence and capabilities, not the specialities of those doctors who wish to pursue the training in order to become competent at capable of doing this. So this is all feasible. We're not talking about me and my consulting room nipping off at lunchtime and administering assisted assisted death.
We're talking about a regulated system that will be properly managed with small numbers. So I hope that is the answer. By the way, I just wanted to pick up the last final point about the use of drugs and the use of drugs that are there to treat disease. Well, I'm sure my noble Lady will know with her expertise in palliative care at the end of life, we use drugs, sometimes an extraordinarily high doses that we know are going
**** Possible New Speaker ****
to accelerate death. Just before the noble Lady sits
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Just before the noble Lady sits down, I'd like to intervene on her comment about training, because, yes, everybody is trained in, for example, abortion as they go through medical school. But by the time you're practising clinically time you're practising clinically and you're on a specialist register, you are no longer keeping up to date with those skills at all. And your revalidation depends on you keeping up to date with those skills, which is the benefit of having a specialist register.
And if I might comment on her opening remarks about being worried about having hate mail, perhaps she might have some sympathy for those of us in palliative medicine who've been receiving a great deal of hate mail because we're known to be specialists in palliative medicine, and because we've been flagging up concerns over this bill. And as for the numbers, perhaps I would ask
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her. If I'm interfering. You can't intervene. Order, order!
**** Possible New Speaker ****
Can I see it? Baroness Finlay. But if you intervene, if you keep it short and the people kind of
**** Possible New Speaker ****
don't intervene on it, people are intervening. Repeatedly intervening on the different points. As for the numbers, the estimates based on the evidence from other countries suggests that the estimates in the impact assessment are very, very low. And actually, the demand for assisted suicide would be much higher. So it would come into the purview of a large number of clinicians. Hence the need for specialisation.
**** Possible New Speaker ****
I'm intervening if I thank you, some diffidence, my Lords. First of some diffidence, my Lords. First of all, to put on the record that this bill is abundantly clear that it is bill is abundantly clear that it is an opt in system. Clause 31 no obligation to provide assistance. No person is under any duty to participate in the provision of assistance in accordance with this act. No registered medical practitioner is any under any duty
10:41
Baroness Andrews (Labour)
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Baroness Andrews (Labour)
to become the coordinating Doctor. The independent doctor? No registered medical practitioner. I registered medical practitioner. I won't read the whole of the clause bylaws, but I do not understand why it is described by noble Lords in the way that the noble Lady does not opt out. Now, coming to the not opt out. Now, coming to the point of the register, we have heard over 13 days how important it heard over 13 days how important it is to listen to and consult medical practitioners at every stage of the Bill.
The proposition in a clause one, amendment 189 is that the register should be put on the face of the bill. It's a privilege to listen to the expertise of our noble friend, Lady Gerard. I would call her our noble friend, and she has expressed some very profound and very intimate reservations. But surely there will be provision, a due course for the discussion of how to register people who are willing to opt in, and to do that with a full consultation of all the medical professions, so that the concerns of the noble Lord Lord Carlile can be addressed.
But surely, my Lords, as with so much of the debate we are having, this is a matter for implementation. Let us get to the point where we can make the decision in principle, but let us make sure that in implementing it, we have it right and that must be done. I think with the full consultation of all the medical professionals. Yeah.
The proposition in a clause one, amendment 189 is that the register should be put on the face of the bill. It's a privilege to listen to the expertise of our noble friend, Lady Gerard. I would call her our noble friend, and she has expressed some very profound and very intimate reservations. But surely there will be provision, a due course for the discussion of how to register people who are willing to opt in, and to do that with a full consultation of all the medical professions, so that the concerns of the noble Lord Lord Carlile can be addressed.
But surely, my Lords, as with so much of the debate we are having, this is a matter for implementation. Let us get to the point where we can make the decision in principle, but let us make sure that in implementing it, we have it right and that must be done. I think with the full consultation of all the medical professionals. Yeah.
10:43
Baroness Cass (Crossbench)
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Baroness Cass (Crossbench)
Yes. my amendment three, eight, three and I so far limited my speeches within this bill to a maximum of 2 or 3 minutes. On this one occasion, I would like to take more time because this may be the only opportunity I have to discuss how we can integrate some of the approaches that have been put forward through the bill. Refraining, my noble friends, Baroness Hollins amendments on Multi-professional assessments up front and Stan part five and Baroness Finlay amendments on parallel care between assisted dying and the continuing care process.
And I believe what I have to say would vastly simplify things. So my amendment focuses on what professionals would be expected to do, who are opted in to work in an assisted dying service, and how it differs from what's expected of those who are not opted in. And specifically, I'd like to talk about two individuals who have completely different roles, a professional who's part of the treating team and so is not opted in, and a professional who is opted in as part of the assisted dying service.
So I just ask you to suspend belief and bear with me while I explain. And I believe we're all agreed on a few points. Firstly, that palliative care provision is inadequate and secondly, that services are often fragmented, with no one professional supporting someone at the end of life and helping them access all the help that they need. So let's walk through the patient journey, which I don't believe we have done in this House so far. And we start with the person who has just been given, rightly or wrongly, a six month prognosis.
There are many things they may wish to discuss and seek help with nursing care, access to financial support, pain management, or just someone to explain again what the consultant said about their terminal illness. Now, if they're lucky, they'll have an excellent general practice team who can help with all these things. But sadly, despite the wonderful primary care described by my noble friend Baroness Gerada, many do not have such a practice and my friend's husband died recently without being able to secure a single visit from anyone in their GP practice in the last nine months of their life.
In that scenario, what they need is a coordinating professional, but not one who is opted in to support their assisted death, but rather what it says on the can and coordinate their care and access to essential help. In this case, the coordinating professional who may be a nurse, a doctor or another healthcare professional would be part of the symptom management team within an ICU network. In fact, they may work across a number of GP practices and it would be their job to organise the Multi-professional assessments and support from relevant professionals, nurses, palliative care specialists, social workers, OTT services or maybe incontinence services.
Ideally, they would have palliative care training to the level of a GP or a nurse with a special interest and access to specialist care consultant, palliative care consultants as needed, and they assure that all the MDT assessments and information were written down or electronically available to the patient. So the patient is the master and owner of their information, and that individual would not need to be opted in because it's not their job to discuss assisted death. It's only their job to signpost the patient to somebody who can.
Now, let us suppose that the patient decides that they do want an assisted death. As I said before, they may talk to their GP, their priest, their partner, their children, but if they actually want concrete information about the practicalities, the best person to talk to will be somebody who knows about it and fully understands the process. And as my noble and learned friend Lord Carlile said, somebody who's specialist and this is where the opted in doctor comes in, who I'm going to call, don't shout at me, the independent doctor, because they're independent of the treating team, but they're part of the specialised assisted death team, and they make up a patient's locality.
Now, like any other patient, any other individual carrying out a specialised role. I agree they would have to be appropriately trained, and their job would then be to do what I set out in amendment 383. First, explain to the patient that this is not a treatment for their terminal illness, but a personal choice, and secondly, to ensure that they have fully understood the diagnosis, prognosis, treatment and palliative care options set out in the documents held by the patient. And I say check understanding, not assess for reasons I will come to.
And because all the patient, all the information would be there in their patient's hand, they would not need to go scurrying around trying to get hold of patient records or treating consultants, except in rare circumstances where something is not clear, and then their key task, the role for which they've been trained, would be to assess capacity, coercion and all the other aspects which we've discussed to ensure the decision is a clear and settled one. The person they may wish to talk to would be the coordinating professional of the GP had taken that role, then the GP, because that person would know the patient well and have information about family and personal circumstances and would be able to alert them to possible coercion.
Now my preference is that they would do this with another independent professional. And I say a professional because that may be a nurse or a social worker, because again, thinking of the patient doing it together and not sequentially would be much less burdensome for the patient. And additionally, when you do things together, I, for example, would often be looking at the face of the patient while the speech therapist was talking to them. The speech therapist would notice body language while I was talking to them.
So you get more information working together than you do sequentially. At that stage, there would be sufficient multidisciplinary involvement for the panel to only have two members, a lawyer of whatever qualification and another person. And then once the panel has signed off, it would be the role of the independent doctor to support the assisted death. If and when the person decides to go ahead. But meanwhile, that marvellous coordinating professional who so far missing from the system, will continue to provide support until such a time arrived.
Now, for the avoidance of doubt, let me explain why having an initial discussion doctor, a coordinating doctor and an independent doctor performing the duties set out in the bill panel work. Firstly, if the initial doctor initial discussion doctor is not the patient's GP because that GP opted out on conscientious grounds, then the Bill does not give any other doctor the right to access the hospital records or speak to the treating clinician, and that would introduce complex delays for the patient.
As far as I can see, the initial discussion adds a whole heap of complications and no real benefit. And that was why I supported Baroness Bull Hollins Part five. Secondly, more importantly, despite the assurance that the noble and learned Lord Alton gave last week that three different doctors would confirm the six month prognosis, the reality is that none of them can do that, and I acknowledge that the noble and learned Lord knows more about the law than I could ever learn in 20 lifetimes, but perhaps a bit less about medicine.
So if the oncology team has examined the patient's scans and determined that the tumour is no longer responding to the recent changes in chemotherapy and no options are left, no other doctor examining the patient with their bare hands is going to be able to confirm or refute that. And if the cardiologist has managed a patient with worsening heart failure over two years and sees that the symptoms are getting worse despite maximum doses of treatment, no other doctor is going to have a better feel for that patient's trajectory.
And unless these three doctors are trained in palliative care, none of them are going to be able to discuss the patient's palliative care options. So in summary, the best approach is for opted out professionals or those who are not opted in involved in the patient's care to advise on prognosis, treatment options and palliative care, and for the opted in professional to check that the patient has understood all this, to assess capacity and coercion and deal with matters related to assisted death.
And finally, by defining the roles and responsibilities as I have described, the process would involve a better use of staff time and, more importantly, be more supportive and less onerous for the patient. I would submit that at least part of the cost of coordinating professionals are already covered within the financial allocation of this bill, and any additional cost savings generated by simplifying the process while also making it safer and more patient centred, could be used to enhance palliative care. And to cheer you all up.
I have now also disposed of 37 amendments also disposed of 37 amendments forming the entirety of Group five.
And I believe what I have to say would vastly simplify things. So my amendment focuses on what professionals would be expected to do, who are opted in to work in an assisted dying service, and how it differs from what's expected of those who are not opted in. And specifically, I'd like to talk about two individuals who have completely different roles, a professional who's part of the treating team and so is not opted in, and a professional who is opted in as part of the assisted dying service.
So I just ask you to suspend belief and bear with me while I explain. And I believe we're all agreed on a few points. Firstly, that palliative care provision is inadequate and secondly, that services are often fragmented, with no one professional supporting someone at the end of life and helping them access all the help that they need. So let's walk through the patient journey, which I don't believe we have done in this House so far. And we start with the person who has just been given, rightly or wrongly, a six month prognosis.
There are many things they may wish to discuss and seek help with nursing care, access to financial support, pain management, or just someone to explain again what the consultant said about their terminal illness. Now, if they're lucky, they'll have an excellent general practice team who can help with all these things. But sadly, despite the wonderful primary care described by my noble friend Baroness Gerada, many do not have such a practice and my friend's husband died recently without being able to secure a single visit from anyone in their GP practice in the last nine months of their life.
In that scenario, what they need is a coordinating professional, but not one who is opted in to support their assisted death, but rather what it says on the can and coordinate their care and access to essential help. In this case, the coordinating professional who may be a nurse, a doctor or another healthcare professional would be part of the symptom management team within an ICU network. In fact, they may work across a number of GP practices and it would be their job to organise the Multi-professional assessments and support from relevant professionals, nurses, palliative care specialists, social workers, OTT services or maybe incontinence services.
Ideally, they would have palliative care training to the level of a GP or a nurse with a special interest and access to specialist care consultant, palliative care consultants as needed, and they assure that all the MDT assessments and information were written down or electronically available to the patient. So the patient is the master and owner of their information, and that individual would not need to be opted in because it's not their job to discuss assisted death. It's only their job to signpost the patient to somebody who can.
Now, let us suppose that the patient decides that they do want an assisted death. As I said before, they may talk to their GP, their priest, their partner, their children, but if they actually want concrete information about the practicalities, the best person to talk to will be somebody who knows about it and fully understands the process. And as my noble and learned friend Lord Carlile said, somebody who's specialist and this is where the opted in doctor comes in, who I'm going to call, don't shout at me, the independent doctor, because they're independent of the treating team, but they're part of the specialised assisted death team, and they make up a patient's locality.
Now, like any other patient, any other individual carrying out a specialised role. I agree they would have to be appropriately trained, and their job would then be to do what I set out in amendment 383. First, explain to the patient that this is not a treatment for their terminal illness, but a personal choice, and secondly, to ensure that they have fully understood the diagnosis, prognosis, treatment and palliative care options set out in the documents held by the patient. And I say check understanding, not assess for reasons I will come to.
And because all the patient, all the information would be there in their patient's hand, they would not need to go scurrying around trying to get hold of patient records or treating consultants, except in rare circumstances where something is not clear, and then their key task, the role for which they've been trained, would be to assess capacity, coercion and all the other aspects which we've discussed to ensure the decision is a clear and settled one. The person they may wish to talk to would be the coordinating professional of the GP had taken that role, then the GP, because that person would know the patient well and have information about family and personal circumstances and would be able to alert them to possible coercion.
Now my preference is that they would do this with another independent professional. And I say a professional because that may be a nurse or a social worker, because again, thinking of the patient doing it together and not sequentially would be much less burdensome for the patient. And additionally, when you do things together, I, for example, would often be looking at the face of the patient while the speech therapist was talking to them. The speech therapist would notice body language while I was talking to them.
So you get more information working together than you do sequentially. At that stage, there would be sufficient multidisciplinary involvement for the panel to only have two members, a lawyer of whatever qualification and another person. And then once the panel has signed off, it would be the role of the independent doctor to support the assisted death. If and when the person decides to go ahead. But meanwhile, that marvellous coordinating professional who so far missing from the system, will continue to provide support until such a time arrived.
Now, for the avoidance of doubt, let me explain why having an initial discussion doctor, a coordinating doctor and an independent doctor performing the duties set out in the bill panel work. Firstly, if the initial doctor initial discussion doctor is not the patient's GP because that GP opted out on conscientious grounds, then the Bill does not give any other doctor the right to access the hospital records or speak to the treating clinician, and that would introduce complex delays for the patient.
As far as I can see, the initial discussion adds a whole heap of complications and no real benefit. And that was why I supported Baroness Bull Hollins Part five. Secondly, more importantly, despite the assurance that the noble and learned Lord Alton gave last week that three different doctors would confirm the six month prognosis, the reality is that none of them can do that, and I acknowledge that the noble and learned Lord knows more about the law than I could ever learn in 20 lifetimes, but perhaps a bit less about medicine.
So if the oncology team has examined the patient's scans and determined that the tumour is no longer responding to the recent changes in chemotherapy and no options are left, no other doctor examining the patient with their bare hands is going to be able to confirm or refute that. And if the cardiologist has managed a patient with worsening heart failure over two years and sees that the symptoms are getting worse despite maximum doses of treatment, no other doctor is going to have a better feel for that patient's trajectory.
And unless these three doctors are trained in palliative care, none of them are going to be able to discuss the patient's palliative care options. So in summary, the best approach is for opted out professionals or those who are not opted in involved in the patient's care to advise on prognosis, treatment options and palliative care, and for the opted in professional to check that the patient has understood all this, to assess capacity and coercion and deal with matters related to assisted death.
And finally, by defining the roles and responsibilities as I have described, the process would involve a better use of staff time and, more importantly, be more supportive and less onerous for the patient. I would submit that at least part of the cost of coordinating professionals are already covered within the financial allocation of this bill, and any additional cost savings generated by simplifying the process while also making it safer and more patient centred, could be used to enhance palliative care. And to cheer you all up.
I have now also disposed of 37 amendments also disposed of 37 amendments forming the entirety of Group five.
10:52
Baroness Fox of Buckley (Non-affiliated)
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Baroness Fox of Buckley (Non-affiliated)
I would like to just thank the >> I would like to just thank the noble Lady Baroness Cass. That was totally compelling, and we're all totally compelling, and we're all going to have to read it and reread it, but I think gave us a real sense of what it would be like. Sometimes we are talking in the abstract anyway. In a more concrete sense, I think of this group of amendments as the workers rights group. And I, I think that we have to take seriously what's being asked of all the workers involved.
If the bill of this kind were to be passed, all sorts of workers associated with health and social care will be expected to deliver it. What happens if that goes against their conscience? That's why I added my name to amendments two, six, eight and 617 in the name of Baroness Finlay of Llandaff to make opt in for a doctor's explicit on the face of the bill, but also because I think it's important to extend any conscience protections to a wider range of workers who might not want to be involved in assisting in the death of others, I added mine.
I wished to have added my name, but. But there wasn't room for me to. Amendments 673 in the name of Baroness Fraser of Craigmaddie. I think it's really important that all workers should be free to refuse to participate without penalty. I've also tabled my own amendment six, five, seven. I'd like to thank Baroness Smith of Newnham and Baroness Eaton for supporting that. That is about proposing that the provision of assisted assisting in someone's death is not regarded as a medical treatment.
Now, we've heard excellent explanations of the problems with that in terms of existentially why it shouldn't be a medical treatment. And there are a range of ethical reasons for that. But the purpose, for the purposes of this group, the amendment is relevant, as if assisted dying is a medical treatment. This could have practical and regulatory pressure add pressure on particularly doctors in terms of their duties. It just seems to me that the aim of this group is quite straightforward, particularly in relation to opt in.
It's to ensure that no medical professional or related staff are forced to participate in assisted dying, or forced to undergo training in assisted dying against their will. And I know that supporters of the bill are keen fans of autonomy. So it seems to me that this group is indispensable because let's make this an autonomous, positive choice for those workers who are happy to take place, take part in the process. The noble Lady Baroness Andrews, has reassured us that in the Bill, there will be no pressure to participate.
Although I think in many workplaces, unless it's made explicit in terms of opt in, she will know that workplaces are not always places where workers rights are given full satisfaction, let us say. But anyway, as it happens, the noble and learned Lord Faulkner actually thinks that opt in should be on the face of the bill, because he emailed us in January to tell us that, saying, following conversation, extensive conversations with the BMA, I believe that explicitly including the words opt in on the face of the bill would provide greater reassurance to medical practitioners.
Well, I agree, I was a bit disappointed those amendments were not tabled more quickly, but they've now emerged. I'm glad to see that there's an explicit opt in provision, but I do think it's too narrow and too exclusively just confined to coordinating doctor, independent doctor and and so on, as explained so well by the noble Lady Baroness Finlay. This leaves out significant parts of the wider medical workforce. And I'm worried that for GPS, nurses and other frontline staff, they could still be mandated to participate in either assistance or training, regardless of their conscientious objection.
These concerns are not only about narrowly focusing on opt in only for the coordinating or independent doctor, but also we have to consider the dangers even of only considering opt in in relation to medical professionals. Baroness Fraser amendments 673 is a reminder not to leave out the plethora of stuff. You might well be asked to play a secondary role in assisted dying, such as those who work in care homes or prisons. Or what about the member of staff? Perhaps a porter who's asked to escort a patient to a room where an assisted death will take place? For goodness sake? Well, a bit of empathy might be helpful anyway.
Well, of course, our main focus is is understandably on doctors, even nurses. But we do need to be careful that we don't assume that those with medical degrees, the professionals, are entitled to a greater respect for their consciences than other relevant workers like porters. I've previously spoken about my qualms about the care sector being sidelined in discussions about the bill. Care England have complained that they've been under consulted, not least in the area of opt out, opt in the.
This matters in terms of the unintended consequences of the bill in care England's survey of its members, 24% of providers have said staffing would be very difficult because of the likelihood of conscientious objection speculating. If forced to comply, care staff will walk out. Imagine what a tragedy, unintended consequence that would be. Only 14% reported the staff would willingly participate in the procedure. 34% reported their staff would not be willing to participate at all. And in terms of what constitutes participation, the Royal College of Nursing has reminded us in written evidence to the Other place the need to consider administrative work.
Quote, protection should extend to indirect involvement, such as administrative tasks or referrals, to ensure that all professionals are supported in line with their personal and professional values. I now just want to reflect very briefly on the whole issue of training, which is so important in relation to these amendments. Practically everyone involved in providing medical or care services has to do manage, particularly medical services, have to do mandatory training units. Obviously they're studying at university, but there is, as we've heard, revalidation, there's CPD and so on.
But if a robust opt in conscience clause doesn't cover all such training, might those who try to opt out get a career limiting black mark against their name? Might those forces do such training fail if they don't endorse assisted dying as a medical treatment of merit, or receive professional sanctions if they give the wrong answers? So I'm looking for a guarantee from the noble and learned Lord, that no workers will face legal or professional repercussions, including indirect penalties of discrimination, for declining to participate in either training or the procedure on my amendment.
Six, five, seven. Despite the insistence when we discussed words last week that this is a change in criminal law, not a health bill, both the fact that the necessity to amend the constitution
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of the NHS and the huge changing expectation of medical ethics. Does not the.
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Does not the. Noble Navy find it very peculiar that people who are very, very keen that people who are very, very keen on employment rights in every other circumstance are not keen on employment rights in these circumstances and put their views circumstances and put their views on assisted suicide ahead of the rights of very ordinary workers. To
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say, I don't want to be part of it. Irony.
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Irony. Irony noted. Anyway. It is. She's making a point which.
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She's making a point which. Contradicts the words. Of the. Bill, as Baroness Andrews has has. Explained.
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Explained. Clause 31. One says in unambiguous terms no
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One says in unambiguous terms no person. I repeat, no person is under any duty, I repeat any duty to participate in the provision of assistance in accordance with this. We all agree with that. We all agree that employees, whatever their status, should be fully
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protected. And trade unions want better
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guarantees. And when we discuss the employment rights bill, sure. What further guarantees the noble Baroness and the noble Lord noble Baroness and the noble Lord have in mind? Because you will know from the bill that schedule three from the bill that schedule three amends the Employment Rights Act, 1996. It incorporates into anybody 1996. It incorporates into anybody who is being prejudiced against because they will not participate in a terminal illness. Things they given every single right under the Employee Employee Rights Act.
So first of all, the idea that they are not being given the same rights that everybody else is wrong. And secondly, I'm not quite sure what point the noble Baroness is making that there should be more rights.
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I sat for many hours through the Employment Rights Bill, and did say that there was a plethora of rights, that there was a plethora of rights, that we were overdoing it, and I was treated with some contempt. was treated with some contempt. Right. I've got to finish. The fear is that once assisted diet. Right, I'm moving on quickly. Once I'm moving on quickly. Once assisted dying is normalised as a medical treatment, health professionals will be obliged to professionals will be obliged to offer it as a medical treatment.
Even worse, under some obligation to explain this therapeutic option as part of their duty of care for eligible patients, they could be held negligent for not offering this treatment against their conscience, and that would seem to be the implications of case law in terms of the Montgomery ruling that ruled all reasonable therapeutic options needed to be presented to and discussed with patients. The
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worry here is that civil liability protections do not cover. The noble Lady to bring her
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remarks to an end. She's well over the ten minutes. This is meant to be a debate.
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This is meant to be a debate. I've taken a lot of opposition points. Let me finish. The worry is here that civil liability protections do not cover where a protections do not cover where a duty is owed to the patients. How can doctors who do not wish to offer or discuss assisted dying be sure they do not face liability for failing to comply with their alleged duty to raise treatments? When I've raised such concerns with supporters of the bill, I've been reassured that now that we have passed the Workers Rights Bill and there are parts in this bill too, there will be lots of protections and they point out that any.
If there are any problems, staff can always use employment tribunals if they feel they've been unfairly treated. Although, as I say, trade unions are quite keen on opt in. But as though those of us who sat through the hours and hours of deliberations. The Employment Rights Bill will know employment tribunals have huge year long, years long waiting lists, and also such tribunals put the burden on the employee to demonstrate and prove detrimental treatment, which seems completely unfair and it seems pertinent to note, as mentioned by the noble Lady Baroness Fraser, that as the remedy in employment cases is damages, not rehiring, this could lead to driving health and care workers out of the understaffed healthcare sector.
Not a good result. Finished to finish as the noble and learned Lord is a member of the party that rightly boasts of its commitment to workplace fairness and workers rights. I'm simply hoping that he'll be sympathetic to those amendments that very much put workers rights guaranteed centre stage in relation to assisted dying.
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It's not too much to ask. My Lord. I'm glad to.
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I'm glad to. Follow the noble Baroness Fox of Buckley because I did add my Buckley because I did add my signature to amendment 673 in the name of the noble Baroness Fraser, name of the noble Baroness Fraser, also signed by Lord Carlile and Lord Hunt of Kings Heath, allowing
If the bill of this kind were to be passed, all sorts of workers associated with health and social care will be expected to deliver it. What happens if that goes against their conscience? That's why I added my name to amendments two, six, eight and 617 in the name of Baroness Finlay of Llandaff to make opt in for a doctor's explicit on the face of the bill, but also because I think it's important to extend any conscience protections to a wider range of workers who might not want to be involved in assisting in the death of others, I added mine.
I wished to have added my name, but. But there wasn't room for me to. Amendments 673 in the name of Baroness Fraser of Craigmaddie. I think it's really important that all workers should be free to refuse to participate without penalty. I've also tabled my own amendment six, five, seven. I'd like to thank Baroness Smith of Newnham and Baroness Eaton for supporting that. That is about proposing that the provision of assisted assisting in someone's death is not regarded as a medical treatment.
Now, we've heard excellent explanations of the problems with that in terms of existentially why it shouldn't be a medical treatment. And there are a range of ethical reasons for that. But the purpose, for the purposes of this group, the amendment is relevant, as if assisted dying is a medical treatment. This could have practical and regulatory pressure add pressure on particularly doctors in terms of their duties. It just seems to me that the aim of this group is quite straightforward, particularly in relation to opt in.
It's to ensure that no medical professional or related staff are forced to participate in assisted dying, or forced to undergo training in assisted dying against their will. And I know that supporters of the bill are keen fans of autonomy. So it seems to me that this group is indispensable because let's make this an autonomous, positive choice for those workers who are happy to take place, take part in the process. The noble Lady Baroness Andrews, has reassured us that in the Bill, there will be no pressure to participate.
Although I think in many workplaces, unless it's made explicit in terms of opt in, she will know that workplaces are not always places where workers rights are given full satisfaction, let us say. But anyway, as it happens, the noble and learned Lord Faulkner actually thinks that opt in should be on the face of the bill, because he emailed us in January to tell us that, saying, following conversation, extensive conversations with the BMA, I believe that explicitly including the words opt in on the face of the bill would provide greater reassurance to medical practitioners.
Well, I agree, I was a bit disappointed those amendments were not tabled more quickly, but they've now emerged. I'm glad to see that there's an explicit opt in provision, but I do think it's too narrow and too exclusively just confined to coordinating doctor, independent doctor and and so on, as explained so well by the noble Lady Baroness Finlay. This leaves out significant parts of the wider medical workforce. And I'm worried that for GPS, nurses and other frontline staff, they could still be mandated to participate in either assistance or training, regardless of their conscientious objection.
These concerns are not only about narrowly focusing on opt in only for the coordinating or independent doctor, but also we have to consider the dangers even of only considering opt in in relation to medical professionals. Baroness Fraser amendments 673 is a reminder not to leave out the plethora of stuff. You might well be asked to play a secondary role in assisted dying, such as those who work in care homes or prisons. Or what about the member of staff? Perhaps a porter who's asked to escort a patient to a room where an assisted death will take place? For goodness sake? Well, a bit of empathy might be helpful anyway.
Well, of course, our main focus is is understandably on doctors, even nurses. But we do need to be careful that we don't assume that those with medical degrees, the professionals, are entitled to a greater respect for their consciences than other relevant workers like porters. I've previously spoken about my qualms about the care sector being sidelined in discussions about the bill. Care England have complained that they've been under consulted, not least in the area of opt out, opt in the.
This matters in terms of the unintended consequences of the bill in care England's survey of its members, 24% of providers have said staffing would be very difficult because of the likelihood of conscientious objection speculating. If forced to comply, care staff will walk out. Imagine what a tragedy, unintended consequence that would be. Only 14% reported the staff would willingly participate in the procedure. 34% reported their staff would not be willing to participate at all. And in terms of what constitutes participation, the Royal College of Nursing has reminded us in written evidence to the Other place the need to consider administrative work.
Quote, protection should extend to indirect involvement, such as administrative tasks or referrals, to ensure that all professionals are supported in line with their personal and professional values. I now just want to reflect very briefly on the whole issue of training, which is so important in relation to these amendments. Practically everyone involved in providing medical or care services has to do manage, particularly medical services, have to do mandatory training units. Obviously they're studying at university, but there is, as we've heard, revalidation, there's CPD and so on.
But if a robust opt in conscience clause doesn't cover all such training, might those who try to opt out get a career limiting black mark against their name? Might those forces do such training fail if they don't endorse assisted dying as a medical treatment of merit, or receive professional sanctions if they give the wrong answers? So I'm looking for a guarantee from the noble and learned Lord, that no workers will face legal or professional repercussions, including indirect penalties of discrimination, for declining to participate in either training or the procedure on my amendment.
Six, five, seven. Despite the insistence when we discussed words last week that this is a change in criminal law, not a health bill, both the fact that the necessity to amend the constitution
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of the NHS and the huge changing expectation of medical ethics. Does not the.
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Does not the. Noble Navy find it very peculiar that people who are very, very keen that people who are very, very keen on employment rights in every other circumstance are not keen on employment rights in these circumstances and put their views circumstances and put their views on assisted suicide ahead of the rights of very ordinary workers. To
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say, I don't want to be part of it. Irony.
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Irony. Irony noted. Anyway. It is. She's making a point which.
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She's making a point which. Contradicts the words. Of the. Bill, as Baroness Andrews has has. Explained.
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Explained. Clause 31. One says in unambiguous terms no
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One says in unambiguous terms no person. I repeat, no person is under any duty, I repeat any duty to participate in the provision of assistance in accordance with this. We all agree with that. We all agree that employees, whatever their status, should be fully
**** Possible New Speaker ****
protected. And trade unions want better
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guarantees. And when we discuss the employment rights bill, sure. What further guarantees the noble Baroness and the noble Lord noble Baroness and the noble Lord have in mind? Because you will know from the bill that schedule three from the bill that schedule three amends the Employment Rights Act, 1996. It incorporates into anybody 1996. It incorporates into anybody who is being prejudiced against because they will not participate in a terminal illness. Things they given every single right under the Employee Employee Rights Act.
So first of all, the idea that they are not being given the same rights that everybody else is wrong. And secondly, I'm not quite sure what point the noble Baroness is making that there should be more rights.
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I sat for many hours through the Employment Rights Bill, and did say that there was a plethora of rights, that there was a plethora of rights, that we were overdoing it, and I was treated with some contempt. was treated with some contempt. Right. I've got to finish. The fear is that once assisted diet. Right, I'm moving on quickly. Once I'm moving on quickly. Once assisted dying is normalised as a medical treatment, health professionals will be obliged to professionals will be obliged to offer it as a medical treatment.
Even worse, under some obligation to explain this therapeutic option as part of their duty of care for eligible patients, they could be held negligent for not offering this treatment against their conscience, and that would seem to be the implications of case law in terms of the Montgomery ruling that ruled all reasonable therapeutic options needed to be presented to and discussed with patients. The
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worry here is that civil liability protections do not cover. The noble Lady to bring her
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remarks to an end. She's well over the ten minutes. This is meant to be a debate.
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This is meant to be a debate. I've taken a lot of opposition points. Let me finish. The worry is here that civil liability protections do not cover where a protections do not cover where a duty is owed to the patients. How can doctors who do not wish to offer or discuss assisted dying be sure they do not face liability for failing to comply with their alleged duty to raise treatments? When I've raised such concerns with supporters of the bill, I've been reassured that now that we have passed the Workers Rights Bill and there are parts in this bill too, there will be lots of protections and they point out that any.
If there are any problems, staff can always use employment tribunals if they feel they've been unfairly treated. Although, as I say, trade unions are quite keen on opt in. But as though those of us who sat through the hours and hours of deliberations. The Employment Rights Bill will know employment tribunals have huge year long, years long waiting lists, and also such tribunals put the burden on the employee to demonstrate and prove detrimental treatment, which seems completely unfair and it seems pertinent to note, as mentioned by the noble Lady Baroness Fraser, that as the remedy in employment cases is damages, not rehiring, this could lead to driving health and care workers out of the understaffed healthcare sector.
Not a good result. Finished to finish as the noble and learned Lord is a member of the party that rightly boasts of its commitment to workplace fairness and workers rights. I'm simply hoping that he'll be sympathetic to those amendments that very much put workers rights guaranteed centre stage in relation to assisted dying.
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It's not too much to ask. My Lord. I'm glad to.
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I'm glad to. Follow the noble Baroness Fox of Buckley because I did add my Buckley because I did add my signature to amendment 673 in the name of the noble Baroness Fraser, name of the noble Baroness Fraser, also signed by Lord Carlile and Lord Hunt of Kings Heath, allowing
11:05
The Lord Bishop of Southwark (Bishops)
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The Lord Bishop of Southwark (Bishops)
Lord Hunt of Kings Heath, allowing for some reticence on the necessity of this amendment, I just wish to make two points. The bill allows an opt out for registered medical practitioners, a health professional, a social care professional or registered pharmacist. Administrative tasks are specifically not excluded. The bill defines health professionals as medical practitioners, pharmacists and nurses, but it does not define care professionals. This is a lacuna which will cause problems should this or any bill on this basis, pass your Lordships House.
Secondly, matters of acute conscience are not ready, are not restricted to the immediate preparation of a lethal dosage or the medical oversight of the procedure. There will be, for reasons of practicality, not least of cost pressure on all sorts of ancillary staff. As anyone in a health and care setting will attest to co-opt them, either directly or indirectly, into what becomes the final procedure. When the conscience of such an ancillary participant tells them they should have nothing to do with such a procedure.
Is it right, my Lords, that they should face sanction inhibition, or their careers of their careers, or even dismissal? I suggest not, and I hope that the House will support this amendment.
Secondly, matters of acute conscience are not ready, are not restricted to the immediate preparation of a lethal dosage or the medical oversight of the procedure. There will be, for reasons of practicality, not least of cost pressure on all sorts of ancillary staff. As anyone in a health and care setting will attest to co-opt them, either directly or indirectly, into what becomes the final procedure. When the conscience of such an ancillary participant tells them they should have nothing to do with such a procedure.
Is it right, my Lords, that they should face sanction inhibition, or their careers of their careers, or even dismissal? I suggest not, and I hope that the House will support this amendment.
11:07
Baroness O'Loan (Crossbench)
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Baroness O'Loan (Crossbench)
She starred in. >> Amendment six, six, eight and 672 and put my name to eight other amendments in this group, and I am amendments in this group, and I am supportive of other amendments, which I will explain. We are talking about how to protect the conscientious objections of doctors and other healthcare practitioners and others through an opt in system, which would allow doctors and others who are willing to engage in assisted suicide to register their position and thereby provide a framework by which their rights are clear and practitioners are not subject to organisational pressure to engage with elements of the process or indeed the whole process.
My Lords, we need to remember that medical practitioners need certainty about their legal and ethical obligations, especially when they're in a situation in which they may find themselves dealing with matters of life and death. In addition to this, my Lords, many of those who work in healthcare have religious beliefs which would preclude their engagement in facilitating others to kill themselves. Catholics, some other Christians, Muslims would be precluded from participation, yet may be prejudiced in their employment opportunities and prospects by this inability to engage.
It is important, therefore, that this factor is considered and any such consideration should surely lead inevitably to the acceptance that the only way that this can actually work is for people to opt in, rather than having to opt out. To that end, my Lord, I have tabled amendments six six, eight, which provides for a comprehensive conscience protection, allowing any person, not just a registered medical practitioner, to opt out of any activity which may facilitate assisted suicide, including any ancillary functions, and 670, which defines what might be might be said to to comprise assistance under the Bill.
Any aspect of assisted dying under or in connection with the provisions of this act, including, but not limited to, administrative and managerial tasks such as the allocation of duties. To carry out these tasks, the supervisors supervision of those to whom tasks are allocated, and accompanying, and monitoring a patient as they receive or after they have received the approved substance, the lethal drug. I also put my name to amendment 665, which states that no health or social care organisation, team or professional is required to or expected to participate in any part of the process of a person's request for an assisted death.
I put my name to amendment 660, which provides that involvement in assistance is wider than only the direct administration of lethal drugs, which clarifies the nature of what can be considered assistance under the. Under the act, I put my name to amendment 679, which is similar but more specific, and states that no company, charity or other organisation is under any duty to participate in, facilitate or permit on its premises. The provision of assistance under the act, no company, charity or other organisation shall be required as a condition of receiving funding or any other benefit from any public body to participate in, facilitate or permit on its premises.
The provision of assistance in accordance with the act. My Lord, this is fundamentally important to ensure that hospices, care homes, nursing homes and other similar organisations do not have to engage at all with the process of assisted suicide and it would also, I think, include prisons. I declare my interest as a trustee of a hospice. My Lords, there is a considerable fear that not providing explicitly to protect hospices in this way could lead to all sorts of difficulties. There's currently an expectation that hospices will provide care and support of many kinds, but.
And that they will not be involved in assisting people to kill themselves. To provide otherwise would change the whole ethos and purpose of a hospice. The amendment would ensure that no financial consequences can ensue from a hospice maintaining its traditional ethos and operations, and not engaging with assisted suicide. Amendment 770, which which we will debate later, would not provide that additional protection. The importance of this cannot be overestimated. Failure to protect hospices in this way may very well lead to closure of hospices.
At a time when there is a huge shortage of expert palliative care. As we've heard so often. My Lords, these amendments are all tabled to ensure absolute clarity for professionals and patients and to further define the nature of the protections which professionals will have under the law, should they not wish to become involved with assisted suicide. My Lords, very significant efficiencies will be created and many potential legal challenges could be avoided if there was absolute clarity about those professionals who wish to engage with assisted suicide and equal clarity that administrative and all other NHS staff cannot be required to engage with any aspect of assisted suicide.
As has been said, the Royal College of Nursing has stated that nursing staff should have should not have to actively choose to be involved, ensuring it's absolutely clear that nurses have the right to say, I want nothing to do with this. That is the language of the Royal College. The solution lies in the. In the establishment of publicly available registers of these professionals who do wish to be involved, and I support the establishment. Therefore, an opt in system and have their.
Put. Therefore, put my name to amendment 189, which requires the Secretary of State to establish and provide for the updating of a public register of registered medical professionals supported by the BMA and the Royal College of GPS, who are willing and able to conduct preliminary discussions. That's the first one. Preliminary discussions under subsection three of clause five and then amendment two, six eight provides that only doctors who have specifically opted in can become coordinating doctors, and only those who positively choose to do so would be able to do the training and participate.
Amendment 359 refers to the independent doctor under clause eight, who must also have explicitly opted in, and amendment 617 amends clause 26 two to provide that. Where a coordinating doctor authorises another doctor to carry out the duties and to provide the lethal drugs to enable a person to end their own life, that doctor must have expressly opted in to do so. I also appoint a support amendment 680, which provides for a specialist register for clinical psychologists who want to participate and to be operated by the Health and Care Professions Council.
And similarly, amendment 681, which requires a specialist register for assisted dying for pharmacists to be kept by the General Pharmaceutical Council. So providing for those who are not registered medical practitioners, etc. I want to go to training. The noble Lord, Lord Faulkner, has limited the statutory opt in language to the bespoke training for coordinating doctors and independent doctors. His amendments do not provide the system wide opt in protection that the Royal Colleges have requested. Consequently, doctors and GPS who do not wish to be coordinating doctors or independent doctors, nurses and other front line staff may be required to participate in basic or tier one training and participate in peripheral aspects of the process.
My Lord, it's important to say that it would not be cost effective to train every member of the National Health Service in the provision of assisted suicide if they're not going to engage with it. And we always have to remember that training. I'm not going to give away. Our noble Lady can come in later. And that training has to be repeated. It's not a one off, and there are huge costs of extractions of staff from the delivery of services when they have to do training.
If the noble and learned Lord is opposed to these amendments, what's his response to the arguments of the BMA and the GP that the Bill does not provide sufficient protections for practitioners? Does the noble and learned Lord think they're wrong if participation is opt out rather than opt in? It will become expected. Amendment 190, which provides for a doctoral only to be able to respond to a specific request from a patient. I also support my Lords. Significant issues would arise were assisted suicide to be regarded as a medical treatment.
For example, in some Canadian provinces, nurses must stay with the patient through all aspects of care except the direct administration of the lethal substance, and there a lot of them have to resign for reasons of conscience to resolve this problem. And we did see this in the abortion context here to resolve this problem. Amendment 657 provides that the provision of assistance under the act is not to be regarded as a medical treatment, at least if this amendment is accepted, doctors will be sure they will not be failing to comply with their duty to raise treatments and discussion with patients, and that no liability could arise from their not doing so.
My Lords, I commend these provisions to the House.
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Thank you. Can I just point out that we've heard it. Several times that the Royal College of GPS are in favour of a College of GPS are in favour of a publicly available register. To the best of my knowledge, and having just checked, the Royal College of just checked, the Royal College of GPS is not in favour of a publicly available register. They are in
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favour of opt in, but not of a publicly available register. I said I think it was an intervention.
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intervention. Intervention. My Lords, I said that there should be a publicly available register. I said that the Royal
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College of GPS were in favour of adopting. Know exactly.
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Know exactly. I just point to clarity. I sat and listened and I thought, should I intervene? You mentioned a should I intervene? You mentioned a number of faiths around the fact that people from those faiths don't believe in assisted dying, but believe in assisted dying, but people from those faiths also believe, don't believe in believe, don't believe in childbirth before marriage. But is there any evidence to suggest that people are opting out of midwifery because of that reason? Or is it just your opinion that people from those fears may not want to take part? Because I'm from one of those faiths, and when noble Lords may have heard that assisted dying might not be for me, but what's.
I'm not here to stop others, and I'm sure others in the medical profession might also share my views. Yeah.
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Sure of the logic of what the noble Lord is saying. And I do apologise to the House. I'm struggling slightly, but I think struggling slightly, but I think what I am saying is that there has to be a conscience clause that people of faith and we're talking about assisted dying here. We're about assisted dying here. We're not talking about anything else that people of faith must have the right. And I don't know, you know, how many faiths may be involved, but they must have the right not to go against their consciences.
It's go against their consciences. It's one of the human rights which we actually have. My Lords, my Lords, thank you very much.
My Lords, we need to remember that medical practitioners need certainty about their legal and ethical obligations, especially when they're in a situation in which they may find themselves dealing with matters of life and death. In addition to this, my Lords, many of those who work in healthcare have religious beliefs which would preclude their engagement in facilitating others to kill themselves. Catholics, some other Christians, Muslims would be precluded from participation, yet may be prejudiced in their employment opportunities and prospects by this inability to engage.
It is important, therefore, that this factor is considered and any such consideration should surely lead inevitably to the acceptance that the only way that this can actually work is for people to opt in, rather than having to opt out. To that end, my Lord, I have tabled amendments six six, eight, which provides for a comprehensive conscience protection, allowing any person, not just a registered medical practitioner, to opt out of any activity which may facilitate assisted suicide, including any ancillary functions, and 670, which defines what might be might be said to to comprise assistance under the Bill.
Any aspect of assisted dying under or in connection with the provisions of this act, including, but not limited to, administrative and managerial tasks such as the allocation of duties. To carry out these tasks, the supervisors supervision of those to whom tasks are allocated, and accompanying, and monitoring a patient as they receive or after they have received the approved substance, the lethal drug. I also put my name to amendment 665, which states that no health or social care organisation, team or professional is required to or expected to participate in any part of the process of a person's request for an assisted death.
I put my name to amendment 660, which provides that involvement in assistance is wider than only the direct administration of lethal drugs, which clarifies the nature of what can be considered assistance under the. Under the act, I put my name to amendment 679, which is similar but more specific, and states that no company, charity or other organisation is under any duty to participate in, facilitate or permit on its premises. The provision of assistance under the act, no company, charity or other organisation shall be required as a condition of receiving funding or any other benefit from any public body to participate in, facilitate or permit on its premises.
The provision of assistance in accordance with the act. My Lord, this is fundamentally important to ensure that hospices, care homes, nursing homes and other similar organisations do not have to engage at all with the process of assisted suicide and it would also, I think, include prisons. I declare my interest as a trustee of a hospice. My Lords, there is a considerable fear that not providing explicitly to protect hospices in this way could lead to all sorts of difficulties. There's currently an expectation that hospices will provide care and support of many kinds, but.
And that they will not be involved in assisting people to kill themselves. To provide otherwise would change the whole ethos and purpose of a hospice. The amendment would ensure that no financial consequences can ensue from a hospice maintaining its traditional ethos and operations, and not engaging with assisted suicide. Amendment 770, which which we will debate later, would not provide that additional protection. The importance of this cannot be overestimated. Failure to protect hospices in this way may very well lead to closure of hospices.
At a time when there is a huge shortage of expert palliative care. As we've heard so often. My Lords, these amendments are all tabled to ensure absolute clarity for professionals and patients and to further define the nature of the protections which professionals will have under the law, should they not wish to become involved with assisted suicide. My Lords, very significant efficiencies will be created and many potential legal challenges could be avoided if there was absolute clarity about those professionals who wish to engage with assisted suicide and equal clarity that administrative and all other NHS staff cannot be required to engage with any aspect of assisted suicide.
As has been said, the Royal College of Nursing has stated that nursing staff should have should not have to actively choose to be involved, ensuring it's absolutely clear that nurses have the right to say, I want nothing to do with this. That is the language of the Royal College. The solution lies in the. In the establishment of publicly available registers of these professionals who do wish to be involved, and I support the establishment. Therefore, an opt in system and have their.
Put. Therefore, put my name to amendment 189, which requires the Secretary of State to establish and provide for the updating of a public register of registered medical professionals supported by the BMA and the Royal College of GPS, who are willing and able to conduct preliminary discussions. That's the first one. Preliminary discussions under subsection three of clause five and then amendment two, six eight provides that only doctors who have specifically opted in can become coordinating doctors, and only those who positively choose to do so would be able to do the training and participate.
Amendment 359 refers to the independent doctor under clause eight, who must also have explicitly opted in, and amendment 617 amends clause 26 two to provide that. Where a coordinating doctor authorises another doctor to carry out the duties and to provide the lethal drugs to enable a person to end their own life, that doctor must have expressly opted in to do so. I also appoint a support amendment 680, which provides for a specialist register for clinical psychologists who want to participate and to be operated by the Health and Care Professions Council.
And similarly, amendment 681, which requires a specialist register for assisted dying for pharmacists to be kept by the General Pharmaceutical Council. So providing for those who are not registered medical practitioners, etc. I want to go to training. The noble Lord, Lord Faulkner, has limited the statutory opt in language to the bespoke training for coordinating doctors and independent doctors. His amendments do not provide the system wide opt in protection that the Royal Colleges have requested. Consequently, doctors and GPS who do not wish to be coordinating doctors or independent doctors, nurses and other front line staff may be required to participate in basic or tier one training and participate in peripheral aspects of the process.
My Lord, it's important to say that it would not be cost effective to train every member of the National Health Service in the provision of assisted suicide if they're not going to engage with it. And we always have to remember that training. I'm not going to give away. Our noble Lady can come in later. And that training has to be repeated. It's not a one off, and there are huge costs of extractions of staff from the delivery of services when they have to do training.
If the noble and learned Lord is opposed to these amendments, what's his response to the arguments of the BMA and the GP that the Bill does not provide sufficient protections for practitioners? Does the noble and learned Lord think they're wrong if participation is opt out rather than opt in? It will become expected. Amendment 190, which provides for a doctoral only to be able to respond to a specific request from a patient. I also support my Lords. Significant issues would arise were assisted suicide to be regarded as a medical treatment.
For example, in some Canadian provinces, nurses must stay with the patient through all aspects of care except the direct administration of the lethal substance, and there a lot of them have to resign for reasons of conscience to resolve this problem. And we did see this in the abortion context here to resolve this problem. Amendment 657 provides that the provision of assistance under the act is not to be regarded as a medical treatment, at least if this amendment is accepted, doctors will be sure they will not be failing to comply with their duty to raise treatments and discussion with patients, and that no liability could arise from their not doing so.
My Lords, I commend these provisions to the House.
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Thank you. Can I just point out that we've heard it. Several times that the Royal College of GPS are in favour of a College of GPS are in favour of a publicly available register. To the best of my knowledge, and having just checked, the Royal College of just checked, the Royal College of GPS is not in favour of a publicly available register. They are in
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favour of opt in, but not of a publicly available register. I said I think it was an intervention.
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intervention. Intervention. My Lords, I said that there should be a publicly available register. I said that the Royal
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College of GPS were in favour of adopting. Know exactly.
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Know exactly. I just point to clarity. I sat and listened and I thought, should I intervene? You mentioned a should I intervene? You mentioned a number of faiths around the fact that people from those faiths don't believe in assisted dying, but believe in assisted dying, but people from those faiths also believe, don't believe in believe, don't believe in childbirth before marriage. But is there any evidence to suggest that people are opting out of midwifery because of that reason? Or is it just your opinion that people from those fears may not want to take part? Because I'm from one of those faiths, and when noble Lords may have heard that assisted dying might not be for me, but what's.
I'm not here to stop others, and I'm sure others in the medical profession might also share my views. Yeah.
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Sure of the logic of what the noble Lord is saying. And I do apologise to the House. I'm struggling slightly, but I think struggling slightly, but I think what I am saying is that there has to be a conscience clause that people of faith and we're talking about assisted dying here. We're about assisted dying here. We're not talking about anything else that people of faith must have the right. And I don't know, you know, how many faiths may be involved, but they must have the right not to go against their consciences.
It's go against their consciences. It's one of the human rights which we actually have. My Lords, my Lords, thank you very much.
11:18
Baroness Watkins of Tavistock (Crossbench)
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Baroness Watkins of Tavistock (Crossbench)
My Lords. >> I just. >> Want to say that I'm broadly supportive of tightening the issue supportive of tightening the issue of ensuring that people's conscience and their beliefs are recognised, and that the people who are prepared to work with patients who, may I remind the House, are terminally ill adults and they are wanting an end of life story that is different to a full, extensive palliative care. And I am completely supportive, as is the Royal College of Nursing.
That full palliative care is what the majority of people will choose. However, I do think that there are a small proportion of people who would choose the the principles of this bill because of the nature of their particular illness or personal choice. I have talked before about the professions, all healthcare professionals responsibility to try and talk with patients about the choice that is available to them. But the thing that upset me most this morning is thinking about patients that I have worked with and done everything together with the multiple the multidisciplinary team to keep alive, who have then taken their own lives because of severe enduring mental illness.
And I really wish that we could stop referring to this as an assisted suicide bill. I think he's just terribly hard on people who have relatives and friends who have died through their own hand, usually in great distress, and the whole purpose of the bill we are talking about today is to reduce stress and distress for the small proportion of people who want this as an option. Yes.
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Lord Stern it's done. May I just ask her? I assume that she's aware ask her? I assume that she's aware that one of the reasons that we need to be absolutely specific about what we're doing is that 42% about what we're doing is that 42% of people think assisted dying is palliative care, and we need to make clear what we're talking about.
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I'm sorry. I do accept that. But I also
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I do accept that. But I also think there was quite a helpful article in one of the newspapers this week talking about using the term assisted death rather than assisted suicide, but I'm pleased that I've had the opportunity to say it in the chamber. My Lords. I will speak to. Well, I want first of all, I'd like to congratulate my noble friend Baroness Cass on her
That full palliative care is what the majority of people will choose. However, I do think that there are a small proportion of people who would choose the the principles of this bill because of the nature of their particular illness or personal choice. I have talked before about the professions, all healthcare professionals responsibility to try and talk with patients about the choice that is available to them. But the thing that upset me most this morning is thinking about patients that I have worked with and done everything together with the multiple the multidisciplinary team to keep alive, who have then taken their own lives because of severe enduring mental illness.
And I really wish that we could stop referring to this as an assisted suicide bill. I think he's just terribly hard on people who have relatives and friends who have died through their own hand, usually in great distress, and the whole purpose of the bill we are talking about today is to reduce stress and distress for the small proportion of people who want this as an option. Yes.
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Lord Stern it's done. May I just ask her? I assume that she's aware ask her? I assume that she's aware that one of the reasons that we need to be absolutely specific about what we're doing is that 42% about what we're doing is that 42% of people think assisted dying is palliative care, and we need to make clear what we're talking about.
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I'm sorry. I do accept that. But I also
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I do accept that. But I also think there was quite a helpful article in one of the newspapers this week talking about using the term assisted death rather than assisted suicide, but I'm pleased that I've had the opportunity to say it in the chamber. My Lords. I will speak to. Well, I want first of all, I'd like to congratulate my noble friend Baroness Cass on her
11:21
Baroness Hollins (Crossbench)
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Baroness Hollins (Crossbench)
excellent speech, but I'm going to speak to my amendment 667680681A and 848C, which seek to ensure that any healthcare professional who any healthcare professional who wishes to participate in assisted dying under this bill may do so only by formally and voluntarily only by formally and voluntarily choosing and training to work in this specialist area. In other words, by opting in and being entered on a register for assisted dying held by their regulatory body, I acknowledge that under the current bill, no person is under any duty to participate.
This is not enough. At the individual level, opting in requires an active and deliberate decision, whereas opting out relies on a pre-set default. The two are not ethically equivalent. Despite appearing similar, and an opt out system assumes that participation is expected unless an individual takes active steps to refuse, which is actually bureaucratically rather burdensome in the context of assisted dying. Making participation the default also risks signalling that it is an endorsed routine practice. Over time, this may shift social norms and create implicit pressure on those involved to participate.
Because of time constraints, I'm going to focus my remarks on amendments six, six, seven and 848C, which deal with doctors, but the principles apply to other healthcare professionals, including pharmacists and psychologists. So some noble Lords have focussed on the matter of conscience. This is important, but I suggest is not the only professional consideration here. If the Bill passes, assisting a person to end their life must not be regarded as part of every doctor's ordinary professional role. The Royal College of General Practitioners has expressed concerns about the Bill as drafted, and has emphasised that any assisted dying service should be separate from core general practice, both in structure and resourcing.
The college made clear that participation should be strictly opt in with no expectation placed on GPS or other healthcare professionals to take part, and one reason for their position is to ensure that core general practice and palliative care are not deprioritised, and that no additional demands are placed on already overstretched services. However, my amendments seek to ensure that if Parliament decides that doctors will be involved in implementing the bill, then doctors must choose to work in the service just as they choose other areas of medicine in which they wish to practice.
It follows that they must be adequately trained and registered to practice. OPT out systems are often justified on the basis that they increase participation. They work by setting a default position where individuals are included unless they take active steps to withdraw. And in practice, many people remain with that default, and it reflects a well-established behavioural tendency that people are more likely to stick with the preset option than to change it, even when there are alternatives. So as a result, uptake increases not because everyone has actively chosen to participate, but because fewer people opt out than would have opted in.
So making participation the default may increase uptake because it's expected. And in centralised healthcare systems such as the NHS, declining participation may carry subtle penalties. I want to illustrate this with the example of the Mental Health Act in principle. A clinician may object to compulsory detention or treatment of individuals who retain decision making capacity about their care. However, in practice, such a position may carry consequences for training and career progression. The Mental Health Act in England and Wales sets out the legal framework for compulsory detention, but does not impose a duty on individual doctors to participate.
For detection and treatment, a medical recommendation is required from an approved doctor. The approval framework defines which doctors are eligible to give such recommendations, but does not oblige them to do so in strict legal terms. There is no statutory duty compelling any psychiatrist to work within the Mental Health Act framework. Instead, the act requires that certain professionals are involved if detention occurs, but it does not compel any specific individual to act effectively. Participation operates as an opt in system.
A psychiatrist must apply for and maintain approval status to undertake this work. However, there's a clear distinction between legal obligation and professional and contractual expectations within the NHS. Many consultant psychiatrist roles include mental health act work in the job plan, and those taking up such posts are expected to hold relevant approval. If a psychiatrist accepts such a role, participation then becomes a contractual duty system. Therefore it's not. It's not coercive in a legal sense, but it becomes structurally coercive in a professional sense without any statutory compulsion.
The training pathway and the labour market strongly shape participation. This is even within an opt in system, and it raises the question of how much stronger these pressures may become under an opt out model proposed under the bill. Although I accept that it's been slightly modified potentially by the noble and learned Lords amendment, which I don't think goes far enough. My Lords, my amendments in this group also address the regulation of doctors who choose to participate. Just as every recognised medical speciality is regulated by the GMC, I believe assisted dying should be treated no differently.
It's a completely new area of practice, requiring its own defined set of skills, competencies and training standards that fall outside the remit of any existing speciality. So accordingly, my amendments and the amendment of the noble Lady Baroness Fraser propose the creation of a specialist register for assisted death, which would be publicly available. As with other speciality registers. Participating doctors would, of course, be required to hold both their primary speciality registration and this additional registration and dual speciality registration is well established within NHS practice.
It reflects a recognised training model in which clinicians develop advanced expertise across complementary domains to deliver specific, specific and often more complex interventions. Dual accreditation is typically used where clinical practice spans more than one domain, as is the case in assisted dying, where unmet palliative care needs must be addressed before death is considered. Therefore, this approach is entirely consistent with existing professional standards, and no clinician should take part in any aspect of the assisted dying process unless they are appropriately registered and regulated, requiring clinicians to specialise further reinforces that participation is genuinely opt in.
It would be difficult to argue that an individual was compelled to undertake specific training and accreditation, so this provides an additional safeguard. That involvement reflects a clear and deliberate professional choice. So, in conclusion, any involvement should be strictly opt in and sit outside. Routine professional responsibility. And registered with their respective regulatory bodies as providers of assisted death. And it supports a standalone, separately regulated system with participation limited to those who have actively chosen to be involved, have received appropriate training and are properly regulated.
Finally, personally, I hope that Parliament does not require doctors to participate in any way, and I support amendments to that effect as well.
This is not enough. At the individual level, opting in requires an active and deliberate decision, whereas opting out relies on a pre-set default. The two are not ethically equivalent. Despite appearing similar, and an opt out system assumes that participation is expected unless an individual takes active steps to refuse, which is actually bureaucratically rather burdensome in the context of assisted dying. Making participation the default also risks signalling that it is an endorsed routine practice. Over time, this may shift social norms and create implicit pressure on those involved to participate.
Because of time constraints, I'm going to focus my remarks on amendments six, six, seven and 848C, which deal with doctors, but the principles apply to other healthcare professionals, including pharmacists and psychologists. So some noble Lords have focussed on the matter of conscience. This is important, but I suggest is not the only professional consideration here. If the Bill passes, assisting a person to end their life must not be regarded as part of every doctor's ordinary professional role. The Royal College of General Practitioners has expressed concerns about the Bill as drafted, and has emphasised that any assisted dying service should be separate from core general practice, both in structure and resourcing.
The college made clear that participation should be strictly opt in with no expectation placed on GPS or other healthcare professionals to take part, and one reason for their position is to ensure that core general practice and palliative care are not deprioritised, and that no additional demands are placed on already overstretched services. However, my amendments seek to ensure that if Parliament decides that doctors will be involved in implementing the bill, then doctors must choose to work in the service just as they choose other areas of medicine in which they wish to practice.
It follows that they must be adequately trained and registered to practice. OPT out systems are often justified on the basis that they increase participation. They work by setting a default position where individuals are included unless they take active steps to withdraw. And in practice, many people remain with that default, and it reflects a well-established behavioural tendency that people are more likely to stick with the preset option than to change it, even when there are alternatives. So as a result, uptake increases not because everyone has actively chosen to participate, but because fewer people opt out than would have opted in.
So making participation the default may increase uptake because it's expected. And in centralised healthcare systems such as the NHS, declining participation may carry subtle penalties. I want to illustrate this with the example of the Mental Health Act in principle. A clinician may object to compulsory detention or treatment of individuals who retain decision making capacity about their care. However, in practice, such a position may carry consequences for training and career progression. The Mental Health Act in England and Wales sets out the legal framework for compulsory detention, but does not impose a duty on individual doctors to participate.
For detection and treatment, a medical recommendation is required from an approved doctor. The approval framework defines which doctors are eligible to give such recommendations, but does not oblige them to do so in strict legal terms. There is no statutory duty compelling any psychiatrist to work within the Mental Health Act framework. Instead, the act requires that certain professionals are involved if detention occurs, but it does not compel any specific individual to act effectively. Participation operates as an opt in system.
A psychiatrist must apply for and maintain approval status to undertake this work. However, there's a clear distinction between legal obligation and professional and contractual expectations within the NHS. Many consultant psychiatrist roles include mental health act work in the job plan, and those taking up such posts are expected to hold relevant approval. If a psychiatrist accepts such a role, participation then becomes a contractual duty system. Therefore it's not. It's not coercive in a legal sense, but it becomes structurally coercive in a professional sense without any statutory compulsion.
The training pathway and the labour market strongly shape participation. This is even within an opt in system, and it raises the question of how much stronger these pressures may become under an opt out model proposed under the bill. Although I accept that it's been slightly modified potentially by the noble and learned Lords amendment, which I don't think goes far enough. My Lords, my amendments in this group also address the regulation of doctors who choose to participate. Just as every recognised medical speciality is regulated by the GMC, I believe assisted dying should be treated no differently.
It's a completely new area of practice, requiring its own defined set of skills, competencies and training standards that fall outside the remit of any existing speciality. So accordingly, my amendments and the amendment of the noble Lady Baroness Fraser propose the creation of a specialist register for assisted death, which would be publicly available. As with other speciality registers. Participating doctors would, of course, be required to hold both their primary speciality registration and this additional registration and dual speciality registration is well established within NHS practice.
It reflects a recognised training model in which clinicians develop advanced expertise across complementary domains to deliver specific, specific and often more complex interventions. Dual accreditation is typically used where clinical practice spans more than one domain, as is the case in assisted dying, where unmet palliative care needs must be addressed before death is considered. Therefore, this approach is entirely consistent with existing professional standards, and no clinician should take part in any aspect of the assisted dying process unless they are appropriately registered and regulated, requiring clinicians to specialise further reinforces that participation is genuinely opt in.
It would be difficult to argue that an individual was compelled to undertake specific training and accreditation, so this provides an additional safeguard. That involvement reflects a clear and deliberate professional choice. So, in conclusion, any involvement should be strictly opt in and sit outside. Routine professional responsibility. And registered with their respective regulatory bodies as providers of assisted death. And it supports a standalone, separately regulated system with participation limited to those who have actively chosen to be involved, have received appropriate training and are properly regulated.
Finally, personally, I hope that Parliament does not require doctors to participate in any way, and I support amendments to that effect as well.
11:29
Baroness Blackstone (Labour)
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Baroness Blackstone (Labour)
Just ask the. >> Just ask the. >> Noble Lady Baroness Hollins why she has identified this small group she has identified this small group of specialists, and only then would she accept that the causes of dime. The causes of death are very wide, and many different specialists may have been involved in the treatment of a patient who wishes to end their death as. Bring on their deaths as soon as possible because of their huge suffering. So why why would we confine this, this form of treatment or the provision of this option for patients who are close to death, to only the small groups that she has identified here? Why would not general practitioners be included? Why would not neurologists be included? Why would not gastroenterologists be included? This seems to me to be an amendment that has been put in to narrow the number of medical practitioners who are able to support dying people in the way that those dying people wish, because they don't want to go on living any longer with the torment that they are suffering.
So I hope that the noble Lady will think again about this particular amendment, which seems to me unbelievably restrictive as far as
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the the inclusion of the medical profession is concerned. Lady may have misunderstood
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Lady may have misunderstood because I spoke about dual accreditation, which could apply to accreditation, which could apply to any doctor from any speciality who wished to obtain the necessary wished to obtain the necessary training and accreditation to be able to to to contribute in this particular in this particular issue.
So I hope that the noble Lady will think again about this particular amendment, which seems to me unbelievably restrictive as far as
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the the inclusion of the medical profession is concerned. Lady may have misunderstood
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Lady may have misunderstood because I spoke about dual accreditation, which could apply to accreditation, which could apply to any doctor from any speciality who wished to obtain the necessary wished to obtain the necessary training and accreditation to be able to to to contribute in this particular in this particular issue.
11:31
Baroness Berridge (Conservative)
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Baroness Berridge (Conservative)
Thank you. >> Thank you. >> Thank you. I'm grateful to the noble Lord. I've added my amendment, noble Lord. I've added my amendment, my name to amendments 359660665 and 681. As I believe these ensure the widest possible protection for those people who, due to issues of conscience, are not able to participate in assisted dying and I specifically use not able. This is a different concept to that underlying the bill of autonomy and choice. Not able in matters of conscience is something we haven't really considered in our law for a long time.
But if one casts one's mind to conscientious objection to war, to being involved in war, it is an important part of the rights of people to be able to say, I am not able to participate in that. Which is why, particularly when there was some comment about the role of the porter. Everybody has that right of conscience, not a choice, a conscience, and one only has to watch 24 hours in A&E to actually see that brief encounter with the porter, as an example, is such an important part of healthcare, and I think we need to remember that everyone has freedom of conscience, not choice.
Of course, if the bill provided the opt in system on the face of the bill, as my noble friend Lady Fraser mentioned, then the protections in these specific amendments would not be needed. And I'm afraid I address the noble and learned Lord Deben about pre-legislative scrutiny. I do admire the confidence with which he assures us, with Bill in hand, that this is all sorted out. But until I am satisfied that royal colleges, who are the people who are going to deliver this, are satisfied that the Bill.
Is that clear, then? I'm afraid these amendments do need to be considered. There are other jurisdictions where there are tighter protections for practitioners in Oregon. Even the medical practitioner does not have to participate, does not have to document requests or provide information. But the language in this bill is just unwilling or unable, which is a wider definition. And the noble Lady lady alone has mentioned the case from Scotland, where they considered the conscientious objection clause in the abortion Bill, which was found to actually only apply to direct participation, not the ancillary services which these various amendments are trying to secure for individuals and organisations.
And I note that I do anticipate that there will be GP surgeries who will opt out, because patients will just want to know that whoever they get at the surgery doesn't support this. But these amendments would cover the situations I have been concerned about, namely the Secretary of State, the Commissioners of Services for assisted dying. If this is going to be an NHS, NHS service and civil servants, I would be grateful to know from the noble Lady, the Minister, that she could confirm to us either today or on our final day of committee.
That's currently scheduled, that the civil servants in all government departments who have had to work on this bill have not been pressurised or or required to work on this bill. The bill may not yet be law, but I do think that it is a very best good employment practice to have not put any pressure or the other examples noble Lords have made that can be given to staff to make sure they participate. And finally, my Lords, in relation to the noble Lady, Lady Watkins point coroners still record verdicts of suicide.
The government still has a suicide prevention strategy. The bill in which we are amending is the criminal law, called the Suicide Act, 1961, and I. I do agree that we should act with compassion, but we do have to be legally correct about what we are doing. And there's potentially a wider issue there for the government to take away. If you want to change the name of legislation and change the name of strategy. But that's not for today. My Lords, my.
But if one casts one's mind to conscientious objection to war, to being involved in war, it is an important part of the rights of people to be able to say, I am not able to participate in that. Which is why, particularly when there was some comment about the role of the porter. Everybody has that right of conscience, not a choice, a conscience, and one only has to watch 24 hours in A&E to actually see that brief encounter with the porter, as an example, is such an important part of healthcare, and I think we need to remember that everyone has freedom of conscience, not choice.
Of course, if the bill provided the opt in system on the face of the bill, as my noble friend Lady Fraser mentioned, then the protections in these specific amendments would not be needed. And I'm afraid I address the noble and learned Lord Deben about pre-legislative scrutiny. I do admire the confidence with which he assures us, with Bill in hand, that this is all sorted out. But until I am satisfied that royal colleges, who are the people who are going to deliver this, are satisfied that the Bill.
Is that clear, then? I'm afraid these amendments do need to be considered. There are other jurisdictions where there are tighter protections for practitioners in Oregon. Even the medical practitioner does not have to participate, does not have to document requests or provide information. But the language in this bill is just unwilling or unable, which is a wider definition. And the noble Lady lady alone has mentioned the case from Scotland, where they considered the conscientious objection clause in the abortion Bill, which was found to actually only apply to direct participation, not the ancillary services which these various amendments are trying to secure for individuals and organisations.
And I note that I do anticipate that there will be GP surgeries who will opt out, because patients will just want to know that whoever they get at the surgery doesn't support this. But these amendments would cover the situations I have been concerned about, namely the Secretary of State, the Commissioners of Services for assisted dying. If this is going to be an NHS, NHS service and civil servants, I would be grateful to know from the noble Lady, the Minister, that she could confirm to us either today or on our final day of committee.
That's currently scheduled, that the civil servants in all government departments who have had to work on this bill have not been pressurised or or required to work on this bill. The bill may not yet be law, but I do think that it is a very best good employment practice to have not put any pressure or the other examples noble Lords have made that can be given to staff to make sure they participate. And finally, my Lords, in relation to the noble Lady, Lady Watkins point coroners still record verdicts of suicide.
The government still has a suicide prevention strategy. The bill in which we are amending is the criminal law, called the Suicide Act, 1961, and I. I do agree that we should act with compassion, but we do have to be legally correct about what we are doing. And there's potentially a wider issue there for the government to take away. If you want to change the name of legislation and change the name of strategy. But that's not for today. My Lords, my.
11:35
Lord Harries of Pentregarth (Crossbench)
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Lord Harries of Pentregarth (Crossbench)
Amendment for a. >> Little, because it's been such a privilege to listen and learn and try to clarify mind on the various amendments that we have had before amendments that we have had before us. And I do wish that some of our critics in the press would have been able to hear this morning, because the amendments this morning go to the very heart of the bill, and we've had the opportunity of hearing from people of different sides, of real expertise, expertise from Baroness Gerada, Baroness Hollins, Baroness O'Loan, Baroness Finlay and and so on.
It's been a huge privilege for those of us who are not medical in order to be able to clarify our minds on this issue. And I do hope that the noble and learned Lord Doyle will be able to address Baroness Cass point in particular, because she made points that I'd not heard before, and I don't know whether he'd heard them before, but she was claiming the bill, as we have it at the moment is not actually workable, and I very much hope that he will be able to address that point.
I just want to say three things very, very briefly. First of all, in relation to the noble Baroness Baroness Andrews, who suggested that actually the things we're talking about this morning should be left to the medical professions to actually regulate. But what we've been debating this morning as to whether we should have a public register or whether we should simply have an opt out clause, which everybody agrees with, of course, is not just simply a detailed regulation. With due respect, it actually goes to the very heart of the bill, which is something which actually Parliament has to make its mind about.
Secondly, in relation to the noble Baroness Prentis Grady, if I might say so, we listen to with great respect, towards the end of her speech, she mentioned the well known fact that a number of doctors, when patients come to the end of their life, are given very, very large doses of painkiller, which has the effect of shortening their life. This is, of course, very well known, but from an ethical point of view, there is a fundamental difference between depending on whether one is a utilitarian or a consequentialist on the one hand, or whether one believes that actually certain things are fundamentally wrong.
This has been mentioned 2 or 3 times in the debates over recent years. And for for the ethical tradition on which of this country is based in particularly the medical profession, there is a fundamental difference between administering a poison to kill someone and actually administering a large dose of painkilling drugs, which has the foreseen effect of also shortening their lives, which from a moral point of view is entirely legitimate. And finally, my Lords, in relation to the noble Baroness Baroness Watkins, on the question of language again, which has been mentioned another time, many of us don't like to confuse what we're debating with assisted dying.
We don't like that, but we do also respect what you say, that the language of suicide, of course, is is unpleasant and really not appropriate. So personally, I'd like just to use neutral language as possible and talk about people taking their own life, which seems to me that there's neutral language as we can get on this.
It's been a huge privilege for those of us who are not medical in order to be able to clarify our minds on this issue. And I do hope that the noble and learned Lord Doyle will be able to address Baroness Cass point in particular, because she made points that I'd not heard before, and I don't know whether he'd heard them before, but she was claiming the bill, as we have it at the moment is not actually workable, and I very much hope that he will be able to address that point.
I just want to say three things very, very briefly. First of all, in relation to the noble Baroness Baroness Andrews, who suggested that actually the things we're talking about this morning should be left to the medical professions to actually regulate. But what we've been debating this morning as to whether we should have a public register or whether we should simply have an opt out clause, which everybody agrees with, of course, is not just simply a detailed regulation. With due respect, it actually goes to the very heart of the bill, which is something which actually Parliament has to make its mind about.
Secondly, in relation to the noble Baroness Prentis Grady, if I might say so, we listen to with great respect, towards the end of her speech, she mentioned the well known fact that a number of doctors, when patients come to the end of their life, are given very, very large doses of painkiller, which has the effect of shortening their life. This is, of course, very well known, but from an ethical point of view, there is a fundamental difference between depending on whether one is a utilitarian or a consequentialist on the one hand, or whether one believes that actually certain things are fundamentally wrong.
This has been mentioned 2 or 3 times in the debates over recent years. And for for the ethical tradition on which of this country is based in particularly the medical profession, there is a fundamental difference between administering a poison to kill someone and actually administering a large dose of painkilling drugs, which has the foreseen effect of also shortening their lives, which from a moral point of view is entirely legitimate. And finally, my Lords, in relation to the noble Baroness Baroness Watkins, on the question of language again, which has been mentioned another time, many of us don't like to confuse what we're debating with assisted dying.
We don't like that, but we do also respect what you say, that the language of suicide, of course, is is unpleasant and really not appropriate. So personally, I'd like just to use neutral language as possible and talk about people taking their own life, which seems to me that there's neutral language as we can get on this.
11:38
Baroness Lawlor (Conservative)
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Baroness Lawlor (Conservative)
Introduce my amendment six six for it is designed not only to for it is designed not only to ensure that no medical professional is obliged to participate in training, but that in order to participate in training, a medical professional must give written consent. Professional training aims not only to show students how to apply their academic knowledge in practice, but how to approach their role in their chosen profession. The second element is two levels. There is the day to day one, as summed up by the Cambridge Clinical Course under the labels Communication Skills and Patient management.
How, for instance, to deal with a patient who insists, contrary to the evidence, that they have cancer. But there is a second higher level, an induction into the ethos of the profession. This level is of vital importance in training medical professionals because they are dealing with human beings. Throughout this Committee stage, one of the most powerful messages has been that each each individual is different, and that one of the most precious skills of doctors, nurses and other medical professionals is to be sensitive to these differences when applying medical science.
In a particular case, there is no simple blueprint or checklist to guide them. Rather, they need to be guided by other by the ethos of the profession into which their training has induced. Their. This is therefore a strong reason why this amendment seeks to ensure the training of health professionals related to an assisted suicide needs explicit consent from participants. It implies that training is treated as a separate activity. Training for. For this purposes of. This bill is treated as a separate activity within the course as a whole, requiring consent from the participants, and that there is neither compulsion nor pressure to participate it.
If assisting, assisting suicide or assisted death under this bill is presented in training as just another element, amongst others, of what health professionals do, the ethos will be drastically changed instead of one based on supporting the ill, the frail and the elderly, of seeing in every life one worth living and improving health, a new ethos will grow. At first, it will be one of moral equivalence between encouragement and help to live and encouragement and help to die, one in which there is no ethical basis for the profession.
But everything depends on the apparent preferences of the patient. But soon I fear it will develop into something more sinister, an ethos in which medical professionals are servants of the state, deciding for the common good as they believe who is to live and who is to die. A second reason for this amendment is the freedom of conscience, of medical and other healthcare professionals. To many, as has been mentioned, not just in this house. Baroness Sater.
I'm just finishing. I won't take interventions. Thank you. And a second reason for this amendment for written opt in for training for medical and other health and care professionals. Is that too many? Not just in this house but in society as a whole? Assisting suicide is deeply immoral, and it would be obnoxious to be training a have to train in practising it.
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My Lord, my Lord. I'll just. Check that I have understood her
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Check that I have understood her correctly when she said that the patient's preference should not prevail if they want an assisted prevail if they want an assisted death, but the doctor should decide. Does she mean that the doctor knows Does she mean that the doctor knows best? Is that what she meant?
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best? Is that what she meant? I thank the noble Lady for this. I'm talking about medical professionals and I'm also talking about the moral equivalence. Can you remind me where I exactly said
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that? I rise very briefly to speak to
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I rise very briefly to speak to amendment six, five seven in the name of the noble Lady Baroness Fox, name of the noble Lady Baroness Fox, to which I have added my name, and to support the amendments in the name of my noble friend Baroness name of my noble friend Baroness Finlay or the amendments 268359617
How, for instance, to deal with a patient who insists, contrary to the evidence, that they have cancer. But there is a second higher level, an induction into the ethos of the profession. This level is of vital importance in training medical professionals because they are dealing with human beings. Throughout this Committee stage, one of the most powerful messages has been that each each individual is different, and that one of the most precious skills of doctors, nurses and other medical professionals is to be sensitive to these differences when applying medical science.
In a particular case, there is no simple blueprint or checklist to guide them. Rather, they need to be guided by other by the ethos of the profession into which their training has induced. Their. This is therefore a strong reason why this amendment seeks to ensure the training of health professionals related to an assisted suicide needs explicit consent from participants. It implies that training is treated as a separate activity. Training for. For this purposes of. This bill is treated as a separate activity within the course as a whole, requiring consent from the participants, and that there is neither compulsion nor pressure to participate it.
If assisting, assisting suicide or assisted death under this bill is presented in training as just another element, amongst others, of what health professionals do, the ethos will be drastically changed instead of one based on supporting the ill, the frail and the elderly, of seeing in every life one worth living and improving health, a new ethos will grow. At first, it will be one of moral equivalence between encouragement and help to live and encouragement and help to die, one in which there is no ethical basis for the profession.
But everything depends on the apparent preferences of the patient. But soon I fear it will develop into something more sinister, an ethos in which medical professionals are servants of the state, deciding for the common good as they believe who is to live and who is to die. A second reason for this amendment is the freedom of conscience, of medical and other healthcare professionals. To many, as has been mentioned, not just in this house. Baroness Sater.
I'm just finishing. I won't take interventions. Thank you. And a second reason for this amendment for written opt in for training for medical and other health and care professionals. Is that too many? Not just in this house but in society as a whole? Assisting suicide is deeply immoral, and it would be obnoxious to be training a have to train in practising it.
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My Lord, my Lord. I'll just. Check that I have understood her
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Check that I have understood her correctly when she said that the patient's preference should not prevail if they want an assisted prevail if they want an assisted death, but the doctor should decide. Does she mean that the doctor knows Does she mean that the doctor knows best? Is that what she meant?
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best? Is that what she meant? I thank the noble Lady for this. I'm talking about medical professionals and I'm also talking about the moral equivalence. Can you remind me where I exactly said
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that? I rise very briefly to speak to
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I rise very briefly to speak to amendment six, five seven in the name of the noble Lady Baroness Fox, name of the noble Lady Baroness Fox, to which I have added my name, and to support the amendments in the name of my noble friend Baroness name of my noble friend Baroness Finlay or the amendments 268359617
11:44
Baroness Smith of Newnham (Liberal Democrat)
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Baroness Smith of Newnham (Liberal Democrat)
Finlay or the amendments 268359617 and the amendment in the noble. In the name of the noble Lady Baroness Cass and in particular, I think that the amendment from the noble Lady Baroness Cass in many ways picks up on the issue that's highlighted in six, five, seven to make explicit that an assisted death should not be seen as a form of treatment. And I think that was implicit in what the right reverend the Lord Harris was saying, that actually we have a situation where there is a difference between taking somebody off life support, giving them significant doses of pain relief at the end of life, and administering a dose of medicine that is intended to be fatal.
They are all slightly different, but I think the the wording in Roman numerals two of Baroness Cass amendment perhaps would also help us find a way across the aisles to deal with the concerns that Baroness Watkins raised, that those who are opposed to assisted dying tend to, say, assisted suicide. Many who are in favour say assisted dying. But the wording that Baroness Cass is used is to say that it's a personal choice to end their life, and I think that might be a way that we could at least think about finding a way forward.
But I have a few questions to ask the Minister and also the noble Lord, the sponsor of the bill, in intervening on the noble Lady Baroness Fox. Lord Faulkner rightly said that clause 31 already says there is no obligation to provide assistance, etc. and that picks up on the amendments of Lady O'loan as well, that to say no person is under any duty to participate in the provision of assistance. What I would be interested to understand is, in these circumstances, what should assistance be taken to mean? And that fits follows on from the points of noble Lady Baroness Berridge, who was asking about the roles of politicians and also civil servants, because most of the debate has been about what the medical profession, health workers, maybe even porters are being asked to do.
But clause four of the bill requires the Prime Minister to appoint a voluntary, voluntary assisted dying commissioner, and many of the clauses give sweeping powers to the Secretary of State. Does that mean that the Prime Minister and the Secretary of State, presumably for health, but possibly also the Justice Secretary and junior Ministers would be expected to engage with this legislation if passed, and that there wouldn't be a conscience clause for politicians and perhaps even civil servants, because that would seem to go against the norms of saying that there can be conscience clause clauses.
And I think it would be and I say this as a practising Catholic, unfortunate if Catholics and others of faith or people for whatever reason which may not be religious, felt that they couldn't support an assisted dying service.
They are all slightly different, but I think the the wording in Roman numerals two of Baroness Cass amendment perhaps would also help us find a way across the aisles to deal with the concerns that Baroness Watkins raised, that those who are opposed to assisted dying tend to, say, assisted suicide. Many who are in favour say assisted dying. But the wording that Baroness Cass is used is to say that it's a personal choice to end their life, and I think that might be a way that we could at least think about finding a way forward.
But I have a few questions to ask the Minister and also the noble Lord, the sponsor of the bill, in intervening on the noble Lady Baroness Fox. Lord Faulkner rightly said that clause 31 already says there is no obligation to provide assistance, etc. and that picks up on the amendments of Lady O'loan as well, that to say no person is under any duty to participate in the provision of assistance. What I would be interested to understand is, in these circumstances, what should assistance be taken to mean? And that fits follows on from the points of noble Lady Baroness Berridge, who was asking about the roles of politicians and also civil servants, because most of the debate has been about what the medical profession, health workers, maybe even porters are being asked to do.
But clause four of the bill requires the Prime Minister to appoint a voluntary, voluntary assisted dying commissioner, and many of the clauses give sweeping powers to the Secretary of State. Does that mean that the Prime Minister and the Secretary of State, presumably for health, but possibly also the Justice Secretary and junior Ministers would be expected to engage with this legislation if passed, and that there wouldn't be a conscience clause for politicians and perhaps even civil servants, because that would seem to go against the norms of saying that there can be conscience clause clauses.
And I think it would be and I say this as a practising Catholic, unfortunate if Catholics and others of faith or people for whatever reason which may not be religious, felt that they couldn't support an assisted dying service.
11:48
Lord Pannick (Crossbench)
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Lord Pannick (Crossbench)
Lord Roe I just want to respond, if I may, to Baroness Berridge on if I may, to Baroness Berridge on the importance of conscientious objection, because the strength of objection, because the strength of clause 31 and schedule three is that they are not confined to those who can show that they have a conscientious objection to assisted suicide. Any doctor, any other person who does not wish to assist has a legal right not to do so for any reason. Indeed, they don't have to give any reason.
This is the broadest possible protection and it is broader, let us not forget than the protection which Parliament included in the Abortion Act 1967, because under section four of the Abortion Act, the doctor or other person who does not wish to participate must not only have a conscientious objection, they must be able to prove that they have a conscientious objection if there's any issue about it. So Lord Falconer's bill includes the broadest possible protection, and my reaction to many of these amendments is the reaction I have had over 13 days to the amendments to this bill, which we have debated, whatever their intention, and I make no allegations about intentions, their effect will inevitably be unnecessarily to impede the ability of persons who are dying to receive the assistance
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that they so desperately want. After.
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After. I would like to thank. My Lord Sassoon. It was an intervention, but
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It was an intervention, but after another speech, I'm grateful for the clarity, but I. I draw for the clarity, but I. I draw attention to the fact that if that was a position that could have been put. If and can now still be put in put. If and can now still be put in a meeting with the various Royal colleges to assure them that the Bill does what the noble and learned Lord and the noble Lord Pannick says that it does, because we are faced with a situation where the practitioners are not satisfied and do not have the confidence that the noble Lord alludes, that the
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bill will give them the protection that they want. Don't. Of course, what we're not
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Don't. Of course, what we're not going to get to is any vote, any conclusion on on this bill which conclusion on on this bill which will enable Parliament to implement what is the view of the vast
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what is the view of the vast majority of people in this country. We could get to the front benches. Yes.
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Yes. Here, here. My Lords, I'm very. Except the spirit of the noble Lady, Baroness Butler-sloss. I shall be very brief.
This is the broadest possible protection and it is broader, let us not forget than the protection which Parliament included in the Abortion Act 1967, because under section four of the Abortion Act, the doctor or other person who does not wish to participate must not only have a conscientious objection, they must be able to prove that they have a conscientious objection if there's any issue about it. So Lord Falconer's bill includes the broadest possible protection, and my reaction to many of these amendments is the reaction I have had over 13 days to the amendments to this bill, which we have debated, whatever their intention, and I make no allegations about intentions, their effect will inevitably be unnecessarily to impede the ability of persons who are dying to receive the assistance
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that they so desperately want. After.
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After. I would like to thank. My Lord Sassoon. It was an intervention, but
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It was an intervention, but after another speech, I'm grateful for the clarity, but I. I draw for the clarity, but I. I draw attention to the fact that if that was a position that could have been put. If and can now still be put in put. If and can now still be put in a meeting with the various Royal colleges to assure them that the Bill does what the noble and learned Lord and the noble Lord Pannick says that it does, because we are faced with a situation where the practitioners are not satisfied and do not have the confidence that the noble Lord alludes, that the
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bill will give them the protection that they want. Don't. Of course, what we're not
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Don't. Of course, what we're not going to get to is any vote, any conclusion on on this bill which conclusion on on this bill which will enable Parliament to implement what is the view of the vast
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what is the view of the vast majority of people in this country. We could get to the front benches. Yes.
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Yes. Here, here. My Lords, I'm very. Except the spirit of the noble Lady, Baroness Butler-sloss. I shall be very brief.
11:50
Lord Moore of Etchingham (Non-affiliated)
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Lord Moore of Etchingham (Non-affiliated)
The. I just want to come back to the. In support of the Baroness, noble Baroness Lady Fraser of noble Baroness Lady Fraser of Craigmaddie, in her amendment about the register, and I do understand we're trying. One of the things we're trying. One of the things we're trying to do is, of course, protect professionals in this grouping. And therefore many of us will be very sympathetic to what will be very sympathetic to what the noble Baroness Gerada said about receiving hate mail if there about receiving hate mail if there were a register.
But I'm afraid that I think in modern times, everyone in public positions has to face the disagreeable fact of hate mail. It's a feature of social media, and we cannot prevent. We cannot, therefore close down the openness that we want to have in many aspects. And I'm thinking about this in relation to the patient here of the benefit to the patient of this register. It's very important that for the medical profession as well, but it's also very important for the patient, I think, for a wider reason.
First of all, the reason, obviously, is that you want to find someone who who will do this for you, who will assist in your taking your own life. But also, as these debates so often show, there is a big moral gulf, unfortunately, between those who support and those who oppose this bill. And if you think of a patient, particularly perhaps an elderly patient, someone with a serious illness and therefore eligible for the bill, they it's important that they do know what type of a doctor they are dealing with in a wider field of care.
I. I think, for example, suppose I had to find a doctor for my aged mother who is absolutely determined to live to be 100 and is in fact the only woman woman I know who lies about her age upwards. She. I know that she would not want to go to a doctor who was a doctor who provided assisted dying, so it seems pretty. And I think that's a understandable thing, because behind all of this is a very different view about what life and death is.
And therefore a patient would need to know that. And I think that's a very good reason for supporting the amendment of the noble Baroness.
But I'm afraid that I think in modern times, everyone in public positions has to face the disagreeable fact of hate mail. It's a feature of social media, and we cannot prevent. We cannot, therefore close down the openness that we want to have in many aspects. And I'm thinking about this in relation to the patient here of the benefit to the patient of this register. It's very important that for the medical profession as well, but it's also very important for the patient, I think, for a wider reason.
First of all, the reason, obviously, is that you want to find someone who who will do this for you, who will assist in your taking your own life. But also, as these debates so often show, there is a big moral gulf, unfortunately, between those who support and those who oppose this bill. And if you think of a patient, particularly perhaps an elderly patient, someone with a serious illness and therefore eligible for the bill, they it's important that they do know what type of a doctor they are dealing with in a wider field of care.
I. I think, for example, suppose I had to find a doctor for my aged mother who is absolutely determined to live to be 100 and is in fact the only woman woman I know who lies about her age upwards. She. I know that she would not want to go to a doctor who was a doctor who provided assisted dying, so it seems pretty. And I think that's a understandable thing, because behind all of this is a very different view about what life and death is.
And therefore a patient would need to know that. And I think that's a very good reason for supporting the amendment of the noble Baroness.
11:53
Lord Stevens of Birmingham (Crossbench)
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Lord Stevens of Birmingham (Crossbench)
Yeah. >> Being equivalently. concise. >> I do think.
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It's important to connect amendment 657, which specifies that assisted dying would not be regarded as a medical treatment. regarded as a medical treatment. With the debate we've had on the broader conscience protections that the bill needs to include. And the reason for that is not just that regarding assisted dying as a treatment is a conceptual error. As Wittgenstein pointed out, death is not an event in life. Instead, what we're talking about is a personal existential choice. It is in no sense a treatment.
But the bill is silent on that question and the reason why, in the real world, that matters, as Baroness Fox and others have pointed out, is because notwithstanding the employment protections that are based in the included in the bill, nevertheless, the professional duties on a doctor are potentially in play if assisted dying is determined to be a treatment, it will give rise to questions of the obligations on a doctor to raise assisted dying as a possibility, even if that doctor has not, is in conscience not wanting to participate.
It will give rise to consent questions. McCulloch tests. And so we've talked previously. It will give rise to negligence questions from surviving members of the family. So it is important that we put this beyond doubt. And given the desire, understandably, of the House to move, move on to the next group. I just commend to fellow noble Lords the article by Professor Gareth Owen, Alex Keen and Catherine Sleeman in the BMJ of the 9th of June last year, which sets this all up beautifully. The conclusion being, quote, statutory ambiguity serves neither professionals providing assisted dying nor patients requesting it.
Parliamentarians must consider this question. That's what we're doing. Amendment 657 puts it beyond doubt. I would hope that the noble Lord, the sponsor, will accept it.
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It's important to connect amendment 657, which specifies that assisted dying would not be regarded as a medical treatment. regarded as a medical treatment. With the debate we've had on the broader conscience protections that the bill needs to include. And the reason for that is not just that regarding assisted dying as a treatment is a conceptual error. As Wittgenstein pointed out, death is not an event in life. Instead, what we're talking about is a personal existential choice. It is in no sense a treatment.
But the bill is silent on that question and the reason why, in the real world, that matters, as Baroness Fox and others have pointed out, is because notwithstanding the employment protections that are based in the included in the bill, nevertheless, the professional duties on a doctor are potentially in play if assisted dying is determined to be a treatment, it will give rise to questions of the obligations on a doctor to raise assisted dying as a possibility, even if that doctor has not, is in conscience not wanting to participate.
It will give rise to consent questions. McCulloch tests. And so we've talked previously. It will give rise to negligence questions from surviving members of the family. So it is important that we put this beyond doubt. And given the desire, understandably, of the House to move, move on to the next group. I just commend to fellow noble Lords the article by Professor Gareth Owen, Alex Keen and Catherine Sleeman in the BMJ of the 9th of June last year, which sets this all up beautifully. The conclusion being, quote, statutory ambiguity serves neither professionals providing assisted dying nor patients requesting it.
Parliamentarians must consider this question. That's what we're doing. Amendment 657 puts it beyond doubt. I would hope that the noble Lord, the sponsor, will accept it.
11:55
Baroness Grey-Thompson (Crossbench)
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Baroness Grey-Thompson (Crossbench)
Yeah. >> Baroness Greenfield Lords, I have. My Lords, I have two amendments in this group six, seven, amendments in this group six, seven, three A and 679673A6. A medical practitioner who has opted into the process can at any time choose to opt out. And six, seven, nine introduces a new clause. I'd like to start today with a number of questions. The noble and learned Lord. So in letters to peers on the 28th of January, the noble and learned Lord said it had very productive discussions with Hospice UK around institutional protections and that he would be able to table amendments as soon as possible.
I think three amendments have been tabled, but I'm not actually sure that they solved the problem that we're trying to, because there's no requirement to keep any training up to date. There's no nothing in there about revalidation, and there's no requirement for being trained and up to date to enter the assisted suicide process. So could the noble and learned Lord give us an update on his statement that he's working with officials to address how Hospice UK concerns might be addressed? Does the noble and learned Lord accept the red line for many care homes is that they're not willing to tolerate this process on their premises.
And the hon. Member for Batley and Spen, another place, resisted a blanket institutional opt out, arguing that it could lead to stress and distress for terminally ill patients if they're forced to move out of there, and I quote, so-called home on their final day. But what about the stress and distress of those that share the home with them? Should it take place on the premises? And does the noble and learned Lord accept that it will be very difficult to extricate care home staff from involvement with assisted suicide to take place on the premises, for example, organising appointments to connected to the provision of assisted dying, assisting in the organisation and sending of documentation connected to the provision of it or accommodating the doctor who must remain with, although not necessarily in the same room as the resident until they die.
And does the noble and learned Lord and the noble Lady, the Minister, recognise the seriousness of the situation with hospices to feel forced to close, and that it could cost around £8.4 billion a year to the public purse. In the group of amendments we've been debating this afternoon. This morning still, it was kind of very interesting talking about the number that may need to be trained, but if the equality impact assessment is anywhere near correct and year one suggests it might be somewhere between 2 and 273 doctors, sorry, patients and 1078 and year ten.
It could be 1737 up to 7598. This doesn't kind of sit alongside with a 310,000 people who accessed hospice care last year. So if there's no expectation for an overwhelming demand of numbers for people to end their lives. So why is there need for a mass enrolment? There might be, you know, a number of different reasons that organisations with principal opposition might be want to be exempted. Freedom of association for charities and law, legal rights of choice, of place of care for patients, cost to the public purse, freedom of religion and belief in law and public benefit of faith based charities.
But my Lords, I believe we have a currently a fragile workforce. In 2020 for the Royal College of General Practitioners surveyed GPS and 42% said they're unlikely to be working as a GP in the next five years. And this brings us back to actually the number of people that we may need to have trained. And I am concerned, whatever we think that the bill says, I don't think the bill is clear enough. But also I don't think we can underestimate the pressure that a doctor or medical practitioner may choose to opt out.
But if they're working in an organisation that feels very strongly that this process should take place on the premises, someone's career might be in jeopardy if they're not willing to sign up to it. The noble Lady Baroness Fox raised issues around something like a porter we haven't discussed in this group. What about prison officers? We've discussed prisoners in previous groups, but I think there's another group of individuals, not just doctors, that might want to exercise a conscience clause.
It might be administrators as much as anybody else who works in the system. My noble friend Baroness Watkins of Tavistock, I think, rightly said that many people would choose to have excellent palliative care. The reality is, and we've discussed this before, it is a postcode lottery, and I think it's a great shame that as part of this bill, we weren't able to discuss the provision of palliative care, that it was ruled out of scope because I think that would have given many of us a level of assurance and reassurance if we could have debated that at the same time.
And, my Lords, I think we should challenge the notion that assisted suicide in a care home would just be a private act taking place similar to a person's own home, as if no one else in the care home would be involved. My Lords, they would be. And I think we do look to other jurisdictions. The Commons Public Bill committee was told about the fate of Irene Thomas Hospice in British Columbia. It was known as a sanctuary for dying people who did not want to be in a setting offering assisted dying.
But the province adopted a policy that required hospices to provide assisted dying if they had over 50% funded beds, and hospice board voted not to offer this. It's 1.5 million CAD of public funding was cut, its clinical staff were laid off, and it was taken over by the regional health authority. Voices from the sector within the UK. Saint Gemma's Hospice in Leeds warned if compliance with assisted dying provision becomes a condition for NHS funding, institutions like Saint Gemma's may have no alternative but to cease operations entirely.
Dan Hayes, of the Order of Saint John's Care Trust, argued that in a care home, there is no way in which a professional could be fully separated from assisted dying because the magnitude of the event would affect the entire atmosphere of the communal living space. We also haven't in this group discussed the impact it might have on pharmacists, and I don't believe that they are adequately protected in this group. It's unclear what doctors medical practitioners can actually opt out of. It's unclear provision of assistance, what it means, whether that's opting out of the conversation or the whole process.
And I think the Royal College of GPS. GPS have been really clear. They believe that this bill is inadequate. My Lords, I believe it's a deeply flawed bill, economically risky, and it fails to safeguard the rights of organisations and individuals who want a conscientiously object.
I think three amendments have been tabled, but I'm not actually sure that they solved the problem that we're trying to, because there's no requirement to keep any training up to date. There's no nothing in there about revalidation, and there's no requirement for being trained and up to date to enter the assisted suicide process. So could the noble and learned Lord give us an update on his statement that he's working with officials to address how Hospice UK concerns might be addressed? Does the noble and learned Lord accept the red line for many care homes is that they're not willing to tolerate this process on their premises.
And the hon. Member for Batley and Spen, another place, resisted a blanket institutional opt out, arguing that it could lead to stress and distress for terminally ill patients if they're forced to move out of there, and I quote, so-called home on their final day. But what about the stress and distress of those that share the home with them? Should it take place on the premises? And does the noble and learned Lord accept that it will be very difficult to extricate care home staff from involvement with assisted suicide to take place on the premises, for example, organising appointments to connected to the provision of assisted dying, assisting in the organisation and sending of documentation connected to the provision of it or accommodating the doctor who must remain with, although not necessarily in the same room as the resident until they die.
And does the noble and learned Lord and the noble Lady, the Minister, recognise the seriousness of the situation with hospices to feel forced to close, and that it could cost around £8.4 billion a year to the public purse. In the group of amendments we've been debating this afternoon. This morning still, it was kind of very interesting talking about the number that may need to be trained, but if the equality impact assessment is anywhere near correct and year one suggests it might be somewhere between 2 and 273 doctors, sorry, patients and 1078 and year ten.
It could be 1737 up to 7598. This doesn't kind of sit alongside with a 310,000 people who accessed hospice care last year. So if there's no expectation for an overwhelming demand of numbers for people to end their lives. So why is there need for a mass enrolment? There might be, you know, a number of different reasons that organisations with principal opposition might be want to be exempted. Freedom of association for charities and law, legal rights of choice, of place of care for patients, cost to the public purse, freedom of religion and belief in law and public benefit of faith based charities.
But my Lords, I believe we have a currently a fragile workforce. In 2020 for the Royal College of General Practitioners surveyed GPS and 42% said they're unlikely to be working as a GP in the next five years. And this brings us back to actually the number of people that we may need to have trained. And I am concerned, whatever we think that the bill says, I don't think the bill is clear enough. But also I don't think we can underestimate the pressure that a doctor or medical practitioner may choose to opt out.
But if they're working in an organisation that feels very strongly that this process should take place on the premises, someone's career might be in jeopardy if they're not willing to sign up to it. The noble Lady Baroness Fox raised issues around something like a porter we haven't discussed in this group. What about prison officers? We've discussed prisoners in previous groups, but I think there's another group of individuals, not just doctors, that might want to exercise a conscience clause.
It might be administrators as much as anybody else who works in the system. My noble friend Baroness Watkins of Tavistock, I think, rightly said that many people would choose to have excellent palliative care. The reality is, and we've discussed this before, it is a postcode lottery, and I think it's a great shame that as part of this bill, we weren't able to discuss the provision of palliative care, that it was ruled out of scope because I think that would have given many of us a level of assurance and reassurance if we could have debated that at the same time.
And, my Lords, I think we should challenge the notion that assisted suicide in a care home would just be a private act taking place similar to a person's own home, as if no one else in the care home would be involved. My Lords, they would be. And I think we do look to other jurisdictions. The Commons Public Bill committee was told about the fate of Irene Thomas Hospice in British Columbia. It was known as a sanctuary for dying people who did not want to be in a setting offering assisted dying.
But the province adopted a policy that required hospices to provide assisted dying if they had over 50% funded beds, and hospice board voted not to offer this. It's 1.5 million CAD of public funding was cut, its clinical staff were laid off, and it was taken over by the regional health authority. Voices from the sector within the UK. Saint Gemma's Hospice in Leeds warned if compliance with assisted dying provision becomes a condition for NHS funding, institutions like Saint Gemma's may have no alternative but to cease operations entirely.
Dan Hayes, of the Order of Saint John's Care Trust, argued that in a care home, there is no way in which a professional could be fully separated from assisted dying because the magnitude of the event would affect the entire atmosphere of the communal living space. We also haven't in this group discussed the impact it might have on pharmacists, and I don't believe that they are adequately protected in this group. It's unclear what doctors medical practitioners can actually opt out of. It's unclear provision of assistance, what it means, whether that's opting out of the conversation or the whole process.
And I think the Royal College of GPS. GPS have been really clear. They believe that this bill is inadequate. My Lords, I believe it's a deeply flawed bill, economically risky, and it fails to safeguard the rights of organisations and individuals who want a conscientiously object.
12:02
Lord McCrea of Magherafelt and Cookstown (Democratic Unionist Party)
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Lord McCrea of Magherafelt and Cookstown (Democratic Unionist Party)
En bloc. >> En bloc. >> I rise to speak to the main theme of these. This group, but theme of these. This group, but particularly to the amendment 679 in the name of the noble Baroness Baroness Grey-Thompson, which I Baroness Grey-Thompson, which I believe is essential if we are to safeguard the valuable work of faith based hospices and care homes, along with other institutions which have a conscientious objection to assisted suicide. And can I say to noble Lords that I do speak as a member of a family that have a loved one's more than one who have committed suicide, and I know the pain of what that word entails and means.
But the particular part of the amendment, six, seven, nine, no company, charity or other organisation shall be required as a condition of receiving funding or any other benefit from any public body to participate in, facilitate or permit on its premises. The provision of assistance in accordance with this act. I am seriously concerned that even after 13 days of consideration in this place, we have still not truly appreciated the scale of the crisis facing the care sector. Should this bill fail to provide sufficient protection for conscientious objection.
Now the noble and learned Lord indicated in January that he had discussions with Hospice UK on this matter, but this only scratches the surface of the consultation which ought to take place. A Care England survey from Autumn last year found that 84% of care providers have not been consulted on the bill or its implications. This has caused particular concern within the care sector. But returning to my point, in lieu of clear protections, it is clear the sector stands on the brink.
We cannot ignore the fact that for many hospices and care home provision of assisted suicide on their premises is a red line that they will not cross. The Mission Care is a Christian charity providing nursing and residential care in five homes across London and south east England. Aidan O'Neill QC recently warned on their behalf that should such charities be required as a matter of law to allow for the provision of euthanasia or assisted suicide for residents within their care, then they would no longer be able to operate in the sector.
Then, Mr. O'Neill warns. Could this? This, Mr. Need warns, could participate a crisis in terms of local authority provision for care homes. Now, given the report from the Commons Public Accounts Committee just a couple of weeks ago, which found that, and I quote the NHS is a. Is at risk of losing the huge value it gains from independent hospices. Beyond the provision of statutory palliative and end of life care. End quote. It is quite shocking that we are risking active withdrawal from the sector in terms of adult social care services.
It has been estimated that faith based organisations account for 10 to 15% of provision in the United Kingdom. This accounts for around 192,000 people. Should such organisations feel the need to withdraw, then it has been estimated that it could cost 8.4 billion annually for the state. Where to fully absorb that course, that cost. But it's not simply the money, my Lords. It is also the special approach to care that will be lost. Just to focus on Christian care homes.
Not because I believe they're the only group of people who recognise the inherent dignity of human life and are at risk. Under this bill. I believe we all, deep down in our conscience, recognise that being is more important than having. But because as a Christian Minister for over 15 years, 50 years, I've been able to see firsthand the distinctive benefits of what these Christian care homes can offer and what I. And what I therefore believe is under threat by this bill.
Does it take just one example of a special approach. In addition to the skills of medics and nurses, Christian care homes and hospices often provide the support on on site chaplains and carers to treat. And I quote the whole person in response to the total pain of dying. They can also offer a community which, contrary to our modern tendency to pretend death doesn't exist. They recognise that it does as a part of the human condition. For we all must needs die, and it is appointed unto men once to die.
And of course, to continue that verse. It says, and after this the judgement. It is my time as a Minister which has struck me in visiting such care homes is that for many it is much more than just the person's own home, not simply a room within a facility. It's a family which is embracing the ethos set by the home, can support one another in prayer and worship, and through investing in one another's lives. Openness in conversation about death can be just one part of that, meaning there's not an issue left exclusively to the person's individual room.
That is why I struggle with the government's argument against care home opt outs. The argument runs that institutional updates can infringe article eight rights of the individual to choose to die in their home. It has been said that would lead to stress and distress for terminally ill patients if they were forced to move. But I think this fundamentally fails to recognise the community aspect of life within many care homes, which is predicated upon the protection of the ethos.
In other words, we also must ask about the stress and distress that could be caused to other residents within the care home should things happen that fail to align with our values they have signed up for. After all, in a way, it is their home too. To put it bluntly, my Lord, many residents would feel a violation of the place they have chosen to be in if an assisted suicide were to take place, many may have exercised their right under the Health and Social Care Act 2012 and NHS Constitution to actively choose a faith based place of care because it aligns with our values and do not wish to be in an environment where assisted suicide is practised.
And what about the impact on care staff? I think it is vital that we appreciate that for many staff working in the care sector, it is not just a job, it's a vocation. It's their life's calling. Many indeed offer their services free of charge. We should not just suppose that it is as simple as walking away and getting another job. Again, to speak from the perspective of many Christian carers, not because the same depth of feeling is not true of others, but because as a Christian community is my community, I can relate to the depths of feeling.
For many Christian carers, this is not a peripheral issue to their faith, their desire to care and bestow dignity through understanding, support and relationship is driven by their belief that God is inviting man into a special relationship with him through the giving of His Son, and has bestowed the ultimate meaning and dignity upon life, which they must model in their respect, care and giving of themselves for others. In other words, it is rooted in the very heart of their Christian faith.
I leave with this, recognising that this is not a perspective that many noble Lords may share, because I think it is my. It is vital that in discussing conscientious protection, conscience protection, that we realise just how closely this issue draws to many people's central identity and their expression of it. I appreciate in closing that the noble and learned Lord, the sponsor of this bill, Lord Porter, may say that he very much respects those
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convictions, And that is precisely why he has put protections in the bill so that put protections in the bill so that they can opt out of the most direct aspects of it. But in closing, I do aspects of it. But in closing, I do have to question whether the current provisions are anywhere near sufficient. I do not believe near sufficient. I do not believe they are. Does noble and learned Lord, that it will be very difficult to extricate care home staff from involvement, where assisted suicide to take place on their premises, for example, organising appointments connected to the provision of assisted dying, assisting in the organisation, sending of documentation connected with the provision of assisted dying or accommodating the doctor who must remain with, although not necessarily in the same room as the resident until they die.
For many, given the centrality of this issue to their identity, these two are tasks that may. They may feel unable to perform. And so I say, without an explicit provision, giving care homes, especially Christian care homes, the option or faith care homes, the option to not allow assisted suicide on their
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premises. I do fear we will see an exodus from that sector. The noble Lord.
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The noble Lord. Sits down. Could I just ask. Him if my. Noble friend. Were to. Introduce into the bill the provisions.
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That the noble. Lord wishes, would he then be in favour of such a bill?
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favour of such a bill? Well, I think the noble Lady will be under no illusion. I am personally against the Bill, because I do not believe it. But if there is a Bill, we have got to have every protection in it. That's a completely different thing. And therefore to suggest, because I am personally opposed to it, that as far as they protect, there should be no protection. I believe that every protection, if it were to pass, then I do believe we have to have a proper protection for people who have got a faith.
But the particular part of the amendment, six, seven, nine, no company, charity or other organisation shall be required as a condition of receiving funding or any other benefit from any public body to participate in, facilitate or permit on its premises. The provision of assistance in accordance with this act. I am seriously concerned that even after 13 days of consideration in this place, we have still not truly appreciated the scale of the crisis facing the care sector. Should this bill fail to provide sufficient protection for conscientious objection.
Now the noble and learned Lord indicated in January that he had discussions with Hospice UK on this matter, but this only scratches the surface of the consultation which ought to take place. A Care England survey from Autumn last year found that 84% of care providers have not been consulted on the bill or its implications. This has caused particular concern within the care sector. But returning to my point, in lieu of clear protections, it is clear the sector stands on the brink.
We cannot ignore the fact that for many hospices and care home provision of assisted suicide on their premises is a red line that they will not cross. The Mission Care is a Christian charity providing nursing and residential care in five homes across London and south east England. Aidan O'Neill QC recently warned on their behalf that should such charities be required as a matter of law to allow for the provision of euthanasia or assisted suicide for residents within their care, then they would no longer be able to operate in the sector.
Then, Mr. O'Neill warns. Could this? This, Mr. Need warns, could participate a crisis in terms of local authority provision for care homes. Now, given the report from the Commons Public Accounts Committee just a couple of weeks ago, which found that, and I quote the NHS is a. Is at risk of losing the huge value it gains from independent hospices. Beyond the provision of statutory palliative and end of life care. End quote. It is quite shocking that we are risking active withdrawal from the sector in terms of adult social care services.
It has been estimated that faith based organisations account for 10 to 15% of provision in the United Kingdom. This accounts for around 192,000 people. Should such organisations feel the need to withdraw, then it has been estimated that it could cost 8.4 billion annually for the state. Where to fully absorb that course, that cost. But it's not simply the money, my Lords. It is also the special approach to care that will be lost. Just to focus on Christian care homes.
Not because I believe they're the only group of people who recognise the inherent dignity of human life and are at risk. Under this bill. I believe we all, deep down in our conscience, recognise that being is more important than having. But because as a Christian Minister for over 15 years, 50 years, I've been able to see firsthand the distinctive benefits of what these Christian care homes can offer and what I. And what I therefore believe is under threat by this bill.
Does it take just one example of a special approach. In addition to the skills of medics and nurses, Christian care homes and hospices often provide the support on on site chaplains and carers to treat. And I quote the whole person in response to the total pain of dying. They can also offer a community which, contrary to our modern tendency to pretend death doesn't exist. They recognise that it does as a part of the human condition. For we all must needs die, and it is appointed unto men once to die.
And of course, to continue that verse. It says, and after this the judgement. It is my time as a Minister which has struck me in visiting such care homes is that for many it is much more than just the person's own home, not simply a room within a facility. It's a family which is embracing the ethos set by the home, can support one another in prayer and worship, and through investing in one another's lives. Openness in conversation about death can be just one part of that, meaning there's not an issue left exclusively to the person's individual room.
That is why I struggle with the government's argument against care home opt outs. The argument runs that institutional updates can infringe article eight rights of the individual to choose to die in their home. It has been said that would lead to stress and distress for terminally ill patients if they were forced to move. But I think this fundamentally fails to recognise the community aspect of life within many care homes, which is predicated upon the protection of the ethos.
In other words, we also must ask about the stress and distress that could be caused to other residents within the care home should things happen that fail to align with our values they have signed up for. After all, in a way, it is their home too. To put it bluntly, my Lord, many residents would feel a violation of the place they have chosen to be in if an assisted suicide were to take place, many may have exercised their right under the Health and Social Care Act 2012 and NHS Constitution to actively choose a faith based place of care because it aligns with our values and do not wish to be in an environment where assisted suicide is practised.
And what about the impact on care staff? I think it is vital that we appreciate that for many staff working in the care sector, it is not just a job, it's a vocation. It's their life's calling. Many indeed offer their services free of charge. We should not just suppose that it is as simple as walking away and getting another job. Again, to speak from the perspective of many Christian carers, not because the same depth of feeling is not true of others, but because as a Christian community is my community, I can relate to the depths of feeling.
For many Christian carers, this is not a peripheral issue to their faith, their desire to care and bestow dignity through understanding, support and relationship is driven by their belief that God is inviting man into a special relationship with him through the giving of His Son, and has bestowed the ultimate meaning and dignity upon life, which they must model in their respect, care and giving of themselves for others. In other words, it is rooted in the very heart of their Christian faith.
I leave with this, recognising that this is not a perspective that many noble Lords may share, because I think it is my. It is vital that in discussing conscientious protection, conscience protection, that we realise just how closely this issue draws to many people's central identity and their expression of it. I appreciate in closing that the noble and learned Lord, the sponsor of this bill, Lord Porter, may say that he very much respects those
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convictions, And that is precisely why he has put protections in the bill so that put protections in the bill so that they can opt out of the most direct aspects of it. But in closing, I do aspects of it. But in closing, I do have to question whether the current provisions are anywhere near sufficient. I do not believe near sufficient. I do not believe they are. Does noble and learned Lord, that it will be very difficult to extricate care home staff from involvement, where assisted suicide to take place on their premises, for example, organising appointments connected to the provision of assisted dying, assisting in the organisation, sending of documentation connected with the provision of assisted dying or accommodating the doctor who must remain with, although not necessarily in the same room as the resident until they die.
For many, given the centrality of this issue to their identity, these two are tasks that may. They may feel unable to perform. And so I say, without an explicit provision, giving care homes, especially Christian care homes, the option or faith care homes, the option to not allow assisted suicide on their
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premises. I do fear we will see an exodus from that sector. The noble Lord.
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The noble Lord. Sits down. Could I just ask. Him if my. Noble friend. Were to. Introduce into the bill the provisions.
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That the noble. Lord wishes, would he then be in favour of such a bill?
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favour of such a bill? Well, I think the noble Lady will be under no illusion. I am personally against the Bill, because I do not believe it. But if there is a Bill, we have got to have every protection in it. That's a completely different thing. And therefore to suggest, because I am personally opposed to it, that as far as they protect, there should be no protection. I believe that every protection, if it were to pass, then I do believe we have to have a proper protection for people who have got a faith.
12:13
Baroness Scotland of Asthal (Labour)
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Baroness Scotland of Asthal (Labour)
Hear, hear. Lord. >> Hear, hear. Lord. >> I rise, not least because. >> I think it is very important for
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I think it is very important for us to just take a moment to understand the importance of this debate. And I rise in particular to address the matters raised by the noble Lord Lord Pannick, because I too have sat through all the sessions and noble Lords will know that I have spoken rarely. But my conclusion is different from that of the noble Lord Lord Pannick, because I think there is a huge benefit in listening. Listening to all sides of this debate, and I have been moved by the speeches of my noble friends who have supported this bill, and I've also been moved by the speeches of those who have not.
But the essence of this issue in relation to opting in is very important. And I have benefited, and I want to agree with what the noble, the right reverend Prelate, the Bishop Harris, Lord Harris said in relation to the extraordinary contribution made by those who are specialists in this area, not least Baroness Cass. My Lords. It is agreed. And what this House has been marvellous about is finding agreement. We are all agreed, it seems to me, including my noble and learned friend, Lord Falconer of Thoroton, that this has to be an opt in and not an opt out.
And so what we're debating is how do we make sure that that which we all aspire is actually delivered in the bill? And I wonder whether the noble Lord has had an opportunity noble and learned Lord Feldman opportunity to look at the simple form formation that was adopted in Jersey and in the Isle of Man, which puts beyond doubt the question of the opt in. And if I may just remind the noble Lord what it says, because it deals with two things the opt in and the need for a register, says all professionals working in the assisted dying service, which would mean everybody must opt in to doing so and must be placed on the Jersey Assisted Dying Service Register.
It's the same as the Isle of Man. I know the noble Lord has adopted the configuration of the Canadian model, but may I ask him whether he would consider whether, in order to give clarity to everyone, we could adopt very simple language which would put beyond doubt that we're talking about all those who are going to participate in this service of what whichever discipline would have to opt in. And maybe that would take the sting out of much of this debate.
Because I must say to your Lordships, this has been one of the most painful bills I've ever had the privilege to listen to because of the pain I've heard on all sides of this House. And if there's one thing this house has been traditionally good at is listening to each other, reducing the level of pain and actually being loving. And one of the things that's hurt is that this bill has trespassed and hurt in a way that none of us ever intended, none of us would ever want.
And I want us just to remember that we actually like each other a lot.
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I think it is very important for us to just take a moment to understand the importance of this debate. And I rise in particular to address the matters raised by the noble Lord Lord Pannick, because I too have sat through all the sessions and noble Lords will know that I have spoken rarely. But my conclusion is different from that of the noble Lord Lord Pannick, because I think there is a huge benefit in listening. Listening to all sides of this debate, and I have been moved by the speeches of my noble friends who have supported this bill, and I've also been moved by the speeches of those who have not.
But the essence of this issue in relation to opting in is very important. And I have benefited, and I want to agree with what the noble, the right reverend Prelate, the Bishop Harris, Lord Harris said in relation to the extraordinary contribution made by those who are specialists in this area, not least Baroness Cass. My Lords. It is agreed. And what this House has been marvellous about is finding agreement. We are all agreed, it seems to me, including my noble and learned friend, Lord Falconer of Thoroton, that this has to be an opt in and not an opt out.
And so what we're debating is how do we make sure that that which we all aspire is actually delivered in the bill? And I wonder whether the noble Lord has had an opportunity noble and learned Lord Feldman opportunity to look at the simple form formation that was adopted in Jersey and in the Isle of Man, which puts beyond doubt the question of the opt in. And if I may just remind the noble Lord what it says, because it deals with two things the opt in and the need for a register, says all professionals working in the assisted dying service, which would mean everybody must opt in to doing so and must be placed on the Jersey Assisted Dying Service Register.
It's the same as the Isle of Man. I know the noble Lord has adopted the configuration of the Canadian model, but may I ask him whether he would consider whether, in order to give clarity to everyone, we could adopt very simple language which would put beyond doubt that we're talking about all those who are going to participate in this service of what whichever discipline would have to opt in. And maybe that would take the sting out of much of this debate.
Because I must say to your Lordships, this has been one of the most painful bills I've ever had the privilege to listen to because of the pain I've heard on all sides of this House. And if there's one thing this house has been traditionally good at is listening to each other, reducing the level of pain and actually being loving. And one of the things that's hurt is that this bill has trespassed and hurt in a way that none of us ever intended, none of us would ever want.
And I want us just to remember that we actually like each other a lot.
12:17
Baroness Coffey (Conservative)
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Baroness Coffey (Conservative)
Which strongly supports the amendment one six, nine, two, six amendment one six, nine, two, six eight and 657. In my discussions with a variety of doctors with a variety of doctors representatives, very clearly two issues came out straight away. They volunteered it. I didn't ask it. volunteered it. I didn't ask it. And it was about this must shift to being an opt in. And as it stands, it still definitely feels like an opt out process in this legislation. The other thing they were absolutely clear about is that this should not in any way be considered a treatment, because it's not.
And I don't need to repeat some of the arguments that have already been well articulated by the noble Lord Lord Stevens of Birmingham and others. And in terms of support, the 169I think it is sensible to have a register. The noble Lord Lord Moore of Etchingham explained one of the reasons why. But I think it's just for straightforwardness, so that people who are considering this potential approach could do that. And while I disagree with the BMA and we're not discussing the clauses today about removing whether things can be raised by judgement, I do think it would be helpful in to give confidence actually in this process.
Now, the questions that I've got are principally for the sponsor and the Minister, and I'm conscious of the noble Baroness. Lady Blake knows that I value her very much, but I appreciate she's not the policy Minister. So if she doesn't have the answers today, I'd be more than happy to receive a letter in this regard from the relevant Minister. But I wanted to just talk through some of the amendments that noble and learned Lord Falconer has tabled, 42 and 43. There are there are other groups later where I think we're discussing replacement of doctors.
So I'm just trying to get a sense of why that's. It doesn't matter whether it's in this group or not. It is. But why he feels the need to do that. I think one of my broader concerns more generally is six six, nine A is that I think the I appreciate the noble Lord is trying to address a challenge that's been made, but it still doesn't feel either it's gone far enough or it's almost tipping it the other way. If we consider the impact assessment of the government suggests that even by year ten, fewer than 8000 people as opposed, may have taken advantage of this bill.
That contrasts significantly to Marie Curie's figures that over 300,000 people engage with hospice care and palliative care every year. So it does feel and part of the debate we were going earlier almost suggested that doctors should do it unless they choose not to, and I strongly believe we should do it the other way. And that's where some of the amendments in this bill lend itself to that. In effect, opt in register and then get the necessary training to provide this this approach.
I do think it's fair to say that schedule three is comprehensive. But again, sometimes when you're relying on aspects, you often which you end up becoming a minority. That in itself can bring coercion to perhaps go against one's own personal views. Now, a few weeks ago, we did get into the whole issue of providing treatments and the legal ruling that led to the GMC changing its guidance, which was deemed enough. Well, actually, the GMC has just published new draft guidance tackling issues to do with personal beliefs and the like.
And in particular, I'm just concerned that if this does end up through, unless we're not explicit on the face of the bill, that this is not a treatment and all the forward then implications as a consequence, that it's not there, we may end up with a lot of case law, a lot of rulings, which also, though it's I think it's point 23 of the guidance, the draft guidance the GMC has put forward, which suggests basically, if there's no alternative, you're going to have to do this.
You're going to have to offer it whether you like it or not. That's what it's more or less saying. So it'd be useful to hear from the Minister what discussions they've had with the GMC in considering that particular approach in the guidance, because I think it is relevant to our consideration of the bill in terms of the other aspect, is section sorry, amendment 888, tabled by the noble and learned Lord. This extends clause 31 to all everybody in Scotland. Now, I'd already had an amendment which I didn't talk to because eight, eight, eight was in this group, which is just trying to understand whether it was the government, whether it's the sponsors who had already started to expand a series of primary legislation issues, I guess, to practitioners in other, other countries, of which the bill really generally does not apply.
Now, we did have a debate a while ago about section 30 order, which is now somewhat redundant given the decision by the Scottish Parliament not to proceed with the Bill that they were considering. But I just wanted to get a sense from the government of where they are with. I thought that issues that are proposed in section eight, eight eight would actually have been covered by section 104 order if the Scottish Parliament had decided. So I wanted to just get a sense and understanding behind the reasons for tabling this.
If it's going further and trying to bring things like the Scottish medical profession into providing potentially services in this country, I think that opens up a whole new chapter of consideration. So it's in asking these questions. I'm just trying to get deepen my understanding and get clarification, both from the sponsor and from the
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Minister. And my. Lords, I want to just cover a couple of points and reflect on couple of points and reflect on also what the noble and learned Lady Baroness Scotland said about. Lady Baroness Scotland said about. Actually, there is a. Despite the debate, there's quite a sense, I think, on which people have agreed think, on which people have agreed that this should be an opt in process rather than an opt out one. The problem is, the way the bill is drafted doesn't make that clear.
And that's not just my view, but as we've heard, and I won't go into it in great detail because many people have said so. That isn't the view of many of those who are going to be involved in delivering this service. The Royal College of GPS thinks that there should be register and a more explicit opt in system. Some of the other royal colleges do too, and I think somebody else said that the Royal College of Nursing thinks it should be very clear that no one should be forced to participate.
Of course,
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I'll give way to Noble and learned. Lord Gerard made it clear that the Royal College of GPS were not the Royal College of GPS were not in favour of a register. They may well be in favour of an opt in process, but not a register.
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process, but not a register. She said they weren't in favour of a public register and I didn't say that they were so, but that's a say that they were so, but that's a helpful clarification that the House has now been able to hear. The problem, though, as I said, is how the bill is drafted and the. There's a couple of points. First of all, I'm strongly in support of amendment 657 that assisted dying is not to be regarded as a medical treatment.
And as I said, I don't need to set out the details. Why I think the noble Lord Lord Stevens did that admirably. What I would ask the sponsor of the bill, the Noble and learned Will Falconer, is because I don't I don't think I forgive me if he has said this on a previous occasion. I don't think he has this. Does he regard the provision of assisted suicide as a medical treatment or not? If he does regard it as a medical treatment, then that would be clear.
I wouldn't agree with that, but it would it would, I think, make it more important that we change the
And I don't need to repeat some of the arguments that have already been well articulated by the noble Lord Lord Stevens of Birmingham and others. And in terms of support, the 169I think it is sensible to have a register. The noble Lord Lord Moore of Etchingham explained one of the reasons why. But I think it's just for straightforwardness, so that people who are considering this potential approach could do that. And while I disagree with the BMA and we're not discussing the clauses today about removing whether things can be raised by judgement, I do think it would be helpful in to give confidence actually in this process.
Now, the questions that I've got are principally for the sponsor and the Minister, and I'm conscious of the noble Baroness. Lady Blake knows that I value her very much, but I appreciate she's not the policy Minister. So if she doesn't have the answers today, I'd be more than happy to receive a letter in this regard from the relevant Minister. But I wanted to just talk through some of the amendments that noble and learned Lord Falconer has tabled, 42 and 43. There are there are other groups later where I think we're discussing replacement of doctors.
So I'm just trying to get a sense of why that's. It doesn't matter whether it's in this group or not. It is. But why he feels the need to do that. I think one of my broader concerns more generally is six six, nine A is that I think the I appreciate the noble Lord is trying to address a challenge that's been made, but it still doesn't feel either it's gone far enough or it's almost tipping it the other way. If we consider the impact assessment of the government suggests that even by year ten, fewer than 8000 people as opposed, may have taken advantage of this bill.
That contrasts significantly to Marie Curie's figures that over 300,000 people engage with hospice care and palliative care every year. So it does feel and part of the debate we were going earlier almost suggested that doctors should do it unless they choose not to, and I strongly believe we should do it the other way. And that's where some of the amendments in this bill lend itself to that. In effect, opt in register and then get the necessary training to provide this this approach.
I do think it's fair to say that schedule three is comprehensive. But again, sometimes when you're relying on aspects, you often which you end up becoming a minority. That in itself can bring coercion to perhaps go against one's own personal views. Now, a few weeks ago, we did get into the whole issue of providing treatments and the legal ruling that led to the GMC changing its guidance, which was deemed enough. Well, actually, the GMC has just published new draft guidance tackling issues to do with personal beliefs and the like.
And in particular, I'm just concerned that if this does end up through, unless we're not explicit on the face of the bill, that this is not a treatment and all the forward then implications as a consequence, that it's not there, we may end up with a lot of case law, a lot of rulings, which also, though it's I think it's point 23 of the guidance, the draft guidance the GMC has put forward, which suggests basically, if there's no alternative, you're going to have to do this.
You're going to have to offer it whether you like it or not. That's what it's more or less saying. So it'd be useful to hear from the Minister what discussions they've had with the GMC in considering that particular approach in the guidance, because I think it is relevant to our consideration of the bill in terms of the other aspect, is section sorry, amendment 888, tabled by the noble and learned Lord. This extends clause 31 to all everybody in Scotland. Now, I'd already had an amendment which I didn't talk to because eight, eight, eight was in this group, which is just trying to understand whether it was the government, whether it's the sponsors who had already started to expand a series of primary legislation issues, I guess, to practitioners in other, other countries, of which the bill really generally does not apply.
Now, we did have a debate a while ago about section 30 order, which is now somewhat redundant given the decision by the Scottish Parliament not to proceed with the Bill that they were considering. But I just wanted to get a sense from the government of where they are with. I thought that issues that are proposed in section eight, eight eight would actually have been covered by section 104 order if the Scottish Parliament had decided. So I wanted to just get a sense and understanding behind the reasons for tabling this.
If it's going further and trying to bring things like the Scottish medical profession into providing potentially services in this country, I think that opens up a whole new chapter of consideration. So it's in asking these questions. I'm just trying to get deepen my understanding and get clarification, both from the sponsor and from the
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Minister. And my. Lords, I want to just cover a couple of points and reflect on couple of points and reflect on also what the noble and learned Lady Baroness Scotland said about. Lady Baroness Scotland said about. Actually, there is a. Despite the debate, there's quite a sense, I think, on which people have agreed think, on which people have agreed that this should be an opt in process rather than an opt out one. The problem is, the way the bill is drafted doesn't make that clear.
And that's not just my view, but as we've heard, and I won't go into it in great detail because many people have said so. That isn't the view of many of those who are going to be involved in delivering this service. The Royal College of GPS thinks that there should be register and a more explicit opt in system. Some of the other royal colleges do too, and I think somebody else said that the Royal College of Nursing thinks it should be very clear that no one should be forced to participate.
Of course,
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I'll give way to Noble and learned. Lord Gerard made it clear that the Royal College of GPS were not the Royal College of GPS were not in favour of a register. They may well be in favour of an opt in process, but not a register.
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process, but not a register. She said they weren't in favour of a public register and I didn't say that they were so, but that's a say that they were so, but that's a helpful clarification that the House has now been able to hear. The problem, though, as I said, is how the bill is drafted and the. There's a couple of points. First of all, I'm strongly in support of amendment 657 that assisted dying is not to be regarded as a medical treatment.
And as I said, I don't need to set out the details. Why I think the noble Lord Lord Stevens did that admirably. What I would ask the sponsor of the bill, the Noble and learned Will Falconer, is because I don't I don't think I forgive me if he has said this on a previous occasion. I don't think he has this. Does he regard the provision of assisted suicide as a medical treatment or not? If he does regard it as a medical treatment, then that would be clear.
I wouldn't agree with that, but it would it would, I think, make it more important that we change the
12:25
Lord Harper (Conservative)
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Lord Harper (Conservative)
bill to make it clear it isn't. If he doesn't think it's a medical treatment, then I can't see any objection to accepting this amendment and making that clear. Now, this isn't just dancing on the head of a pin. It's really head of a pin. It's really important because for this to be opt in, not opt out, everyone opt in, not opt out, everyone involved has to be clear about their responsibilities now in the bill. And this was one of the bits bill.
And this was one of the bits that was read out by the noble Lady Baroness Andrews in clause 31 one, it says no person is under any duty to participate in the provision of assistance in accordance with this act. Now, there's two problems with that. First of all, they may not be under a duty according to the the bill. But the problem is, as the noble Lord Lord Stevens has said, if if this is regarded. If the provision of assisted suicide is regarded as medical treatment, then particularly.
Medical professionals have a whole range of other professional and legal duties that they have to undertake. And the problem is, they may not be compelled by this bill to participate in providing assisted suicide, but some of their other medical their other legal duties may force them to do so if it's regarded as a medical treatment. And it would be helpful, I think, to to clear that up, of course,
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I'll give way to the noble Lord. Amazed to hear that clause five
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Amazed to hear that clause five one says no registered medical practitioner is under any duty to raise the subject of the provision raise the subject of the provision of assistance in accordance with this act with a person. So that would mean as a matter of law, would mean as a matter of law, there is never a duty to raise it. If you go to clause 31, it says If you go to clause 31, it says sorry, no registered medical practitioner is under any duty to become the coordinating doctor or the independent doctor.
There could not be. Take it from me, greater legal clarity that there is no legal obligation either to raise it or to participate in it, and whether it is a treatment or not, which is a most interesting philosophical and I'm not I'm not underplaying that issue. The reason the terms of the bill are so absolutely clear is that so? Not so that no doctor could be in any doubt whatsoever that they're under no legal duty.
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The problem is, I don't think it's that clear. And it isn't just me. That's not clear. If it were me. That's not clear. If it were that clear, then the Royal College is that think that it should be made clearer. Wouldn't think that. made clearer. Wouldn't think that. And the problem is, I don't know. Hang on. Let me let me just finish the point. And also, with respect, the point. And also, with respect, people on my side of the debate keep being told off for speaking at length.
Now, there's a choice here. length. Now, there's a choice here. I want to try and make my remarks brief, but if I'm going to take lengthy interventions from the noble and learned Lord, which I'm quite happy to, then I don't expect to be shouted at if I end up going over the time limit. So people
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can't have it both ways. I am delighted to take his intervention. I never make long interventions.
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I never make long interventions. The complaint about the doctors is they want an opt in, not an opt out. Their complaint is not that it is Their complaint is not that it is not clear enough that they're under no duty to give advice, and no duty
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to be a doctor under the act. The noble and learned Lady Baroness Cox said there was a great deal of agreement in the House that deal of agreement in the House that there should be an opt in system, and the noble and learned Lord is nodding his assent to that. Now, if it were the case that the bill as drafted delivered that, then the royal colleges that say they want an opt in system would be presumably content with the bill as drafted.
They are not. They want it to be changed to deliver that opt in system.
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I completely. Accept the point about opt in. The point I am pressing him on is the point about pressing him on is the point about could there be a doubt that you were under a duty to read it? And I'm saying there is absolutely no I'm saying there is absolutely no doubt on the bill that no doctor is under a duty to be the doctor under under a duty to be the doctor under the bill, or to raise it under the bill.
The question about opt in, everybody except there should be opt in. And I put a provision in in
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opt in. And I put a provision in in my amendments to that effect. I'm very clear that the bill does not create a duty for people to participate. The problem is, if there are other statutes and other responsibilities that medical professionals have, and then there is a lack of clarity. And it doesn't matter whether the noble and only Lord thinks so. If the medical professionals who are having to make judgements think it's not clear, then that is the problem and it should be put beyond doubt.
That is the only point I am making. The second point comes down to the the register and the noble Lady Gerada didn't answer my question that I put to her. She gave a long answer, but it wasn't the answer to my question. It was an answer to a different question that I hadn't asked. And I'm grateful that she's just come back into the chamber. I asked her if she thought that a patient of a general practitioner had the right to know whether that general practitioner supported the provision of assisted suicide.
Now, the reason why that's important. It's not just a piece of nosiness. It's because, as we know from earlier debates, the bill prohibits a medical professional raising this issue unprompted with a child, but they are able to raise it unprompted with an adult. And it's perfectly reasonable for a patient of a GP to want to know that if they were to become at a point where assisted suicide might be raised with them, they would rather have a GP that didn't. And the reason why this is important is as soon as you say that a patient has a right to know this information and the GP tells them that information can then be in the public domain, and I just think it's better if we just have a sensible system that's transparent and we have a register, and then people are very clear about it.
And I think the noble Lord Moore made the point that in the modern world, you have to have transparency. We deal with the way people behave with other aspects of the criminal law. It's not right, and it would be unlawful for people to harass or to step over what is reasonable in the way they treated a general practitioner, just as it is in the way they treat members of Parliament or other people in professional life. And there are aspects of the law that can deal with that, and that's how you deal with it.
That's not an excuse to keep this information secret, and I think people do have a right to know whether somebody is willing to participate in this sort of activity. The final point I wanted to make is about extending to everyone in the process. There's a lack of clarity about what provision of assistance means, whether that simply means the provision of the poisons that are to end life, or whether it means every aspect of the process. And I have to say, I was very disappointed.
I don't know who said it, but when the noble Lady Baroness Fox referred to a porter being very uncomfortable and not wanting to participate in this process, somebody shouted out who it was, for goodness sake. I thought that was appalling. A porter in the health service has exactly the same right to not participate in this process as a doctor, and they should have the same right to object to this and have to opt into it as anybody else. And I think expecting a particularly junior members of staff to have to use the employment tribunal system and to defend themselves if they are put under pressure to participate in this isn't the right way to deal with it.
So I think an explicit opt in system for every single person in the system, I think, is the right way to go. And I strongly support the amendment, which makes it clear and puts beyond doubt. This is not a medical treatment, because I think that then deals with the other duties that may fall upon medical professionals in the National Health Service.
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Just give a clarification. Apologies. I've just been in contact with all the senior officers or most of the senior officers or most of the senior officers at the Rcgp Royal College of General Practitioners. To the best of their knowledge, they have best of their knowledge, they have not called for a register publicly or otherwise. So, to the best of my knowledge and the best of their knowledge, the Royal College of GPS just put on the record, have not called for a register.
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called for a register. I'm grateful to the noble Lady. I said they were in favour of an opt in system. I didn't say they'd call for a register. I want a register and I support the amendments that say we should have one. And I think, as Lord Moore put, that it should be a public register. And I think in essence, even if you didn't have a public register, as soon as people asked their GPS and other medical professionals what their view is, that information in the modern world will become public.
So it would be much better to actually have a proper, well-managed system that was published. And then everyone would be very clear about where people were on this and will be able to access the relevant medical them.
And this was one of the bits that was read out by the noble Lady Baroness Andrews in clause 31 one, it says no person is under any duty to participate in the provision of assistance in accordance with this act. Now, there's two problems with that. First of all, they may not be under a duty according to the the bill. But the problem is, as the noble Lord Lord Stevens has said, if if this is regarded. If the provision of assisted suicide is regarded as medical treatment, then particularly.
Medical professionals have a whole range of other professional and legal duties that they have to undertake. And the problem is, they may not be compelled by this bill to participate in providing assisted suicide, but some of their other medical their other legal duties may force them to do so if it's regarded as a medical treatment. And it would be helpful, I think, to to clear that up, of course,
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I'll give way to the noble Lord. Amazed to hear that clause five
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Amazed to hear that clause five one says no registered medical practitioner is under any duty to raise the subject of the provision raise the subject of the provision of assistance in accordance with this act with a person. So that would mean as a matter of law, would mean as a matter of law, there is never a duty to raise it. If you go to clause 31, it says If you go to clause 31, it says sorry, no registered medical practitioner is under any duty to become the coordinating doctor or the independent doctor.
There could not be. Take it from me, greater legal clarity that there is no legal obligation either to raise it or to participate in it, and whether it is a treatment or not, which is a most interesting philosophical and I'm not I'm not underplaying that issue. The reason the terms of the bill are so absolutely clear is that so? Not so that no doctor could be in any doubt whatsoever that they're under no legal duty.
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The problem is, I don't think it's that clear. And it isn't just me. That's not clear. If it were me. That's not clear. If it were that clear, then the Royal College is that think that it should be made clearer. Wouldn't think that. made clearer. Wouldn't think that. And the problem is, I don't know. Hang on. Let me let me just finish the point. And also, with respect, the point. And also, with respect, people on my side of the debate keep being told off for speaking at length.
Now, there's a choice here. length. Now, there's a choice here. I want to try and make my remarks brief, but if I'm going to take lengthy interventions from the noble and learned Lord, which I'm quite happy to, then I don't expect to be shouted at if I end up going over the time limit. So people
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can't have it both ways. I am delighted to take his intervention. I never make long interventions.
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I never make long interventions. The complaint about the doctors is they want an opt in, not an opt out. Their complaint is not that it is Their complaint is not that it is not clear enough that they're under no duty to give advice, and no duty
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to be a doctor under the act. The noble and learned Lady Baroness Cox said there was a great deal of agreement in the House that deal of agreement in the House that there should be an opt in system, and the noble and learned Lord is nodding his assent to that. Now, if it were the case that the bill as drafted delivered that, then the royal colleges that say they want an opt in system would be presumably content with the bill as drafted.
They are not. They want it to be changed to deliver that opt in system.
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I completely. Accept the point about opt in. The point I am pressing him on is the point about pressing him on is the point about could there be a doubt that you were under a duty to read it? And I'm saying there is absolutely no I'm saying there is absolutely no doubt on the bill that no doctor is under a duty to be the doctor under under a duty to be the doctor under the bill, or to raise it under the bill.
The question about opt in, everybody except there should be opt in. And I put a provision in in
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opt in. And I put a provision in in my amendments to that effect. I'm very clear that the bill does not create a duty for people to participate. The problem is, if there are other statutes and other responsibilities that medical professionals have, and then there is a lack of clarity. And it doesn't matter whether the noble and only Lord thinks so. If the medical professionals who are having to make judgements think it's not clear, then that is the problem and it should be put beyond doubt.
That is the only point I am making. The second point comes down to the the register and the noble Lady Gerada didn't answer my question that I put to her. She gave a long answer, but it wasn't the answer to my question. It was an answer to a different question that I hadn't asked. And I'm grateful that she's just come back into the chamber. I asked her if she thought that a patient of a general practitioner had the right to know whether that general practitioner supported the provision of assisted suicide.
Now, the reason why that's important. It's not just a piece of nosiness. It's because, as we know from earlier debates, the bill prohibits a medical professional raising this issue unprompted with a child, but they are able to raise it unprompted with an adult. And it's perfectly reasonable for a patient of a GP to want to know that if they were to become at a point where assisted suicide might be raised with them, they would rather have a GP that didn't. And the reason why this is important is as soon as you say that a patient has a right to know this information and the GP tells them that information can then be in the public domain, and I just think it's better if we just have a sensible system that's transparent and we have a register, and then people are very clear about it.
And I think the noble Lord Moore made the point that in the modern world, you have to have transparency. We deal with the way people behave with other aspects of the criminal law. It's not right, and it would be unlawful for people to harass or to step over what is reasonable in the way they treated a general practitioner, just as it is in the way they treat members of Parliament or other people in professional life. And there are aspects of the law that can deal with that, and that's how you deal with it.
That's not an excuse to keep this information secret, and I think people do have a right to know whether somebody is willing to participate in this sort of activity. The final point I wanted to make is about extending to everyone in the process. There's a lack of clarity about what provision of assistance means, whether that simply means the provision of the poisons that are to end life, or whether it means every aspect of the process. And I have to say, I was very disappointed.
I don't know who said it, but when the noble Lady Baroness Fox referred to a porter being very uncomfortable and not wanting to participate in this process, somebody shouted out who it was, for goodness sake. I thought that was appalling. A porter in the health service has exactly the same right to not participate in this process as a doctor, and they should have the same right to object to this and have to opt into it as anybody else. And I think expecting a particularly junior members of staff to have to use the employment tribunal system and to defend themselves if they are put under pressure to participate in this isn't the right way to deal with it.
So I think an explicit opt in system for every single person in the system, I think, is the right way to go. And I strongly support the amendment, which makes it clear and puts beyond doubt. This is not a medical treatment, because I think that then deals with the other duties that may fall upon medical professionals in the National Health Service.
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Just give a clarification. Apologies. I've just been in contact with all the senior officers or most of the senior officers or most of the senior officers at the Rcgp Royal College of General Practitioners. To the best of their knowledge, they have best of their knowledge, they have not called for a register publicly or otherwise. So, to the best of my knowledge and the best of their knowledge, the Royal College of GPS just put on the record, have not called for a register.
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called for a register. I'm grateful to the noble Lady. I said they were in favour of an opt in system. I didn't say they'd call for a register. I want a register and I support the amendments that say we should have one. And I think, as Lord Moore put, that it should be a public register. And I think in essence, even if you didn't have a public register, as soon as people asked their GPS and other medical professionals what their view is, that information in the modern world will become public.
So it would be much better to actually have a proper, well-managed system that was published. And then everyone would be very clear about where people were on this and will be able to access the relevant medical them.
12:34
Baroness Blake of Leeds (Labour)
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Baroness Blake of Leeds (Labour)
Apologies. >> I was taken by surprise by the lack of the front bench opposite, lack of the front bench opposite, but can I start by thanking noble Lords, of course, for another important debate on opting into and out of providing assistance in various functions under the Bill? As I've already made clear, I will keep my comments limited to amendments on which the government has made major legal, technical or operational workability concerns. I first turn to amendment 189, tabled by the noble Lady Baroness Fraser.
This amendment may give rise to article eight issues as publishing a register of professionals willing to participate in voluntary assisted dying could expose those individuals to intrusion or a risk to personal safety. Amendment 657, tabled by Baroness Fox, seeks to specify that provision of assistance under the act is not to be regarded as medical treatment. The government has made no decisions on what a service delivery model would look like. The House may wish to note that this amendment may impact the possible service models for voluntary assisted dying.
By limiting what the government can achieve through clause 41 regulations, clause 41 currently enables the government to make amendments to legislation, including the NHS act 2006, to ensure that assisted dying could be delivered as part of the health service, which may require amending or modifying definitions of treatment to include assisted dying. Amendment 664, tabled by the noble Lady Baroness Lawlor, would allow health and social care professionals to opt out of all training in relation to the bill.
It would. Oh.
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I'm sorry to interrupt the noble of the Minister, but grateful for her for allowing me to do so. I her for allowing me to do so. I just wanted to make sure that I'd understood correctly what she'd understood correctly what she'd just said. So I think she just said that at the moment the NHS wouldn't that at the moment the NHS wouldn't be able to deliver this service unless there were some amendments made to make it clear that this was made to make it clear that this was indeed a medical treatment, and it would therefore be necessary to make those amendments and to explicitly define it as a medical treatment.
And I just wanted to make to just check I had understood her, because if that is what she's saying, then it does open up the very complex and difficult issues that the noble Lord Lord Stevens so
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ably set out a short while ago. Just to confirm that it's a.
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Just to confirm that it's a. It's may require that the response It's may require that the response I wish to give to him. But again, it's again, it's pushing the limits it's again, it's pushing the limits of, of, of what I am able to say at this point in terms of future
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policy. OK. Thank you. Except, as my noble friend Lady Kofi said, that I accept that the Minister isn't the doesn't have the policy responsibility here, so I, I absolutely not going to press her for an answer now, but I think it would be helpful if we were to get a written response from the policy Minister. Just clarifying this point about whether it would be necessary to amend the law so that it was explicitly a medical treatment for the NHS to be able to provide this service.
I think that would be helpful, but I absolutely
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not going to press her on this. That would be most unfair. Well, I'm certainly quite happy
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Well, I'm certainly quite happy to take his comments to my noble friend Baroness Merron and see if friend Baroness Merron and see if if it is appropriate for her to respond in the way that the noble Lord suggests. Can I start again on Lord suggests. Can I start again on my paragraph with regard to the noble Lady Baroness Lawlor? Her amendment would allow health and social care professionals to opt out of all training in relation to the Bill. It would require that where a health and social care professional agrees to training, written consent must be given.
The amendment also creates an obligation to provide official guidance on training in relation to the bill on the day it receives Royal Assent, the requirement to publish official guidance on the Day of Royal Assent may be unachievable, given the work on implementation that must be undertaken before such guidance can be published. It is also unclear how this interacts with other requirements in the Bill, such as the duty to consult various persons before any guidance is issued. Moving to amendment six, six, seven and 848 see table by the noble Lady Baroness Hollins amendment 667A would require the Secretary of State to make regulations to provide for a specialist register of assisted death practitioners and the.
The criteria for entry in that register, as the government would only begin work on regulations once the Bill had received Royal Assent. The requirement to make regulations within one one month of the day on which this act is passed may be unworkable. In addition, significant policy work would be required to understand what, especially speciality for assisted dying would look like. Amendment A4 848C would additionally prevent registered medical practitioners from performing functions under the bill if they were not included on the GMC specialist Register with a primary speciality in geriatric medicine, palliative medicine, medical oncology or clinical oncology.
And I think my noble friend Baroness Blackstone was was linking to this point. The effect of this amendment would be to exclude clinicians who may have relevant, relevant experience and qualifications. This may limit the government's ability to design an optimal service. Moving now to amendment six, eight one and eight six for. Tabled by the noble Lord, Lord Goodman, these amendments give rise to two key workability issues. First, they duplicate matters largely covered in clause 31 and schedule three of the bill.
Secondly, amendment 681 introduces a complete right to conscientiously object to taking part in the provisions of assistance. This conflicts with clause 31 seven, which contains a small number of duties that cannot be opted out of. For example, recording cancellation. The cancellation of a of a first declaration or passing on or recording information about a person in their medical records, which may be relevant to their eligibility for assisted dying. If a person is able to opt out of participating in any aspects of the bill without any exceptions, this may render the bill unworkable.
Turning now to amendment six, six eight and 670, tabled by the noble Lady Baroness O'Loan. Amendment 668 replaces registered medical practitioner with person in clause 31 three. This would widen the provision so that individuals with express statutory duties in the Bill would not be obliged to perform any function under the Bill. This would include, for example, the Secretary of State, Welsh Ministers, the assisted dying commissioner and members of an assisted dying panel. Allowing opt outs for these roles could make the bill unworkable.
Amendment 670 also provides an opt out in relation to ancillary functions, such as administrative tasks or supervision of staff. This could broaden the range of activities that a person can refuse to carry out, and could give rise to significant operational issues. Lastly, I turn to amendment 679, tabled by the noble Lady Baroness Grey-Thompson. This amendment could limit the places where assistance could be provided. It could, for example, preclude access to an assisted death for those residing within some private hospices or care homes.
The House may wish to note that this amendment may result in inconsistent treatment for patients when seeking to access an assisted death, and could give rise to article eight hr issues, unless a reasonable and objective justification were provided. As noble Lords will be aware. Other amendments in this group have not had technical drafting, support from officials and of course, the issues raised by these other amendments are rightly matters for noble Lords to consider. Finally, to respond to the direct question from the noble Baroness, Lady Baroness Berridge.
No civil servant working on this bill was put under any pressure to work on on the bill, and responding to the noble Lady Baroness Miller policy decisions regarding opt outs within the bill are for the sponsor. However, once legislation is passed, the government as a whole is expected to implement it. If an individual had an objection to working on assisted dying policy due to a personal conscience, objection issues would be handled case by case through discussion. And finally, again, turning to the noble Lady Baroness Grey-Thompson, if the bill passes, any service model would be developed with stakeholders.
The bill, as drafted, does not require care homes or hospices to provide assisted dying, nor does it specify funding arrangements or penalties for opting not to do so. The government has a continued commitment to high quality palliative care and end of life care for all, regardless of assisted dying provision. With regards to the noble Lady Baroness Coffey, as I have said before, the purpose of amendments tabled by the sponsor is for the sponsor to respond to. However, I will of course write on the other very specific questions asked.
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Broken down by the government in saying that the proposals in these saying that the proposals in these amendments would limit the ability to design an optimum service in to design an optimum service in relation to the bill. In in relation to considering the system in the Netherlands of the skin doctors who are the second opinion doctors who have specific training doctors who have specific training and are indeed specifically listed as being able to provide that information.
And that is in a nation where the number of euthanasias is very much higher than suggested in the impact assessment. So it would seem that having a separate group separately trained, separately listed, who are deemed to be specialising in. Part of this does seem to work in the Netherlands, and I would be interested to know what assessment the government made of that in formulating their response to this
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group of amendments, could I? I can't answer that specific
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I can't answer that specific question. I'm not sure it would be appropriate for me to do so. But we appropriate for me to do so. But we note the comments that she's made.
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note the comments that she's made. Could Noble and learned friend love sometimes overstates it, I have to say, but I think we should have to say, but I think we should do our best to try and cooperate and reach agreements. And secondly, I'd like to express my gratitude to the House for all the opportunities they have given me to listen over the last 15 days and two more days
This amendment may give rise to article eight issues as publishing a register of professionals willing to participate in voluntary assisted dying could expose those individuals to intrusion or a risk to personal safety. Amendment 657, tabled by Baroness Fox, seeks to specify that provision of assistance under the act is not to be regarded as medical treatment. The government has made no decisions on what a service delivery model would look like. The House may wish to note that this amendment may impact the possible service models for voluntary assisted dying.
By limiting what the government can achieve through clause 41 regulations, clause 41 currently enables the government to make amendments to legislation, including the NHS act 2006, to ensure that assisted dying could be delivered as part of the health service, which may require amending or modifying definitions of treatment to include assisted dying. Amendment 664, tabled by the noble Lady Baroness Lawlor, would allow health and social care professionals to opt out of all training in relation to the bill.
It would. Oh.
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I'm sorry to interrupt the noble of the Minister, but grateful for her for allowing me to do so. I her for allowing me to do so. I just wanted to make sure that I'd understood correctly what she'd understood correctly what she'd just said. So I think she just said that at the moment the NHS wouldn't that at the moment the NHS wouldn't be able to deliver this service unless there were some amendments made to make it clear that this was made to make it clear that this was indeed a medical treatment, and it would therefore be necessary to make those amendments and to explicitly define it as a medical treatment.
And I just wanted to make to just check I had understood her, because if that is what she's saying, then it does open up the very complex and difficult issues that the noble Lord Lord Stevens so
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ably set out a short while ago. Just to confirm that it's a.
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Just to confirm that it's a. It's may require that the response It's may require that the response I wish to give to him. But again, it's again, it's pushing the limits it's again, it's pushing the limits of, of, of what I am able to say at this point in terms of future
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policy. OK. Thank you. Except, as my noble friend Lady Kofi said, that I accept that the Minister isn't the doesn't have the policy responsibility here, so I, I absolutely not going to press her for an answer now, but I think it would be helpful if we were to get a written response from the policy Minister. Just clarifying this point about whether it would be necessary to amend the law so that it was explicitly a medical treatment for the NHS to be able to provide this service.
I think that would be helpful, but I absolutely
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not going to press her on this. That would be most unfair. Well, I'm certainly quite happy
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Well, I'm certainly quite happy to take his comments to my noble friend Baroness Merron and see if friend Baroness Merron and see if if it is appropriate for her to respond in the way that the noble Lord suggests. Can I start again on Lord suggests. Can I start again on my paragraph with regard to the noble Lady Baroness Lawlor? Her amendment would allow health and social care professionals to opt out of all training in relation to the Bill. It would require that where a health and social care professional agrees to training, written consent must be given.
The amendment also creates an obligation to provide official guidance on training in relation to the bill on the day it receives Royal Assent, the requirement to publish official guidance on the Day of Royal Assent may be unachievable, given the work on implementation that must be undertaken before such guidance can be published. It is also unclear how this interacts with other requirements in the Bill, such as the duty to consult various persons before any guidance is issued. Moving to amendment six, six, seven and 848 see table by the noble Lady Baroness Hollins amendment 667A would require the Secretary of State to make regulations to provide for a specialist register of assisted death practitioners and the.
The criteria for entry in that register, as the government would only begin work on regulations once the Bill had received Royal Assent. The requirement to make regulations within one one month of the day on which this act is passed may be unworkable. In addition, significant policy work would be required to understand what, especially speciality for assisted dying would look like. Amendment A4 848C would additionally prevent registered medical practitioners from performing functions under the bill if they were not included on the GMC specialist Register with a primary speciality in geriatric medicine, palliative medicine, medical oncology or clinical oncology.
And I think my noble friend Baroness Blackstone was was linking to this point. The effect of this amendment would be to exclude clinicians who may have relevant, relevant experience and qualifications. This may limit the government's ability to design an optimal service. Moving now to amendment six, eight one and eight six for. Tabled by the noble Lord, Lord Goodman, these amendments give rise to two key workability issues. First, they duplicate matters largely covered in clause 31 and schedule three of the bill.
Secondly, amendment 681 introduces a complete right to conscientiously object to taking part in the provisions of assistance. This conflicts with clause 31 seven, which contains a small number of duties that cannot be opted out of. For example, recording cancellation. The cancellation of a of a first declaration or passing on or recording information about a person in their medical records, which may be relevant to their eligibility for assisted dying. If a person is able to opt out of participating in any aspects of the bill without any exceptions, this may render the bill unworkable.
Turning now to amendment six, six eight and 670, tabled by the noble Lady Baroness O'Loan. Amendment 668 replaces registered medical practitioner with person in clause 31 three. This would widen the provision so that individuals with express statutory duties in the Bill would not be obliged to perform any function under the Bill. This would include, for example, the Secretary of State, Welsh Ministers, the assisted dying commissioner and members of an assisted dying panel. Allowing opt outs for these roles could make the bill unworkable.
Amendment 670 also provides an opt out in relation to ancillary functions, such as administrative tasks or supervision of staff. This could broaden the range of activities that a person can refuse to carry out, and could give rise to significant operational issues. Lastly, I turn to amendment 679, tabled by the noble Lady Baroness Grey-Thompson. This amendment could limit the places where assistance could be provided. It could, for example, preclude access to an assisted death for those residing within some private hospices or care homes.
The House may wish to note that this amendment may result in inconsistent treatment for patients when seeking to access an assisted death, and could give rise to article eight hr issues, unless a reasonable and objective justification were provided. As noble Lords will be aware. Other amendments in this group have not had technical drafting, support from officials and of course, the issues raised by these other amendments are rightly matters for noble Lords to consider. Finally, to respond to the direct question from the noble Baroness, Lady Baroness Berridge.
No civil servant working on this bill was put under any pressure to work on on the bill, and responding to the noble Lady Baroness Miller policy decisions regarding opt outs within the bill are for the sponsor. However, once legislation is passed, the government as a whole is expected to implement it. If an individual had an objection to working on assisted dying policy due to a personal conscience, objection issues would be handled case by case through discussion. And finally, again, turning to the noble Lady Baroness Grey-Thompson, if the bill passes, any service model would be developed with stakeholders.
The bill, as drafted, does not require care homes or hospices to provide assisted dying, nor does it specify funding arrangements or penalties for opting not to do so. The government has a continued commitment to high quality palliative care and end of life care for all, regardless of assisted dying provision. With regards to the noble Lady Baroness Coffey, as I have said before, the purpose of amendments tabled by the sponsor is for the sponsor to respond to. However, I will of course write on the other very specific questions asked.
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Broken down by the government in saying that the proposals in these saying that the proposals in these amendments would limit the ability to design an optimum service in to design an optimum service in relation to the bill. In in relation to considering the system in the Netherlands of the skin doctors who are the second opinion doctors who have specific training doctors who have specific training and are indeed specifically listed as being able to provide that information.
And that is in a nation where the number of euthanasias is very much higher than suggested in the impact assessment. So it would seem that having a separate group separately trained, separately listed, who are deemed to be specialising in. Part of this does seem to work in the Netherlands, and I would be interested to know what assessment the government made of that in formulating their response to this
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group of amendments, could I? I can't answer that specific
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I can't answer that specific question. I'm not sure it would be appropriate for me to do so. But we appropriate for me to do so. But we note the comments that she's made.
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note the comments that she's made. Could Noble and learned friend love sometimes overstates it, I have to say, but I think we should have to say, but I think we should do our best to try and cooperate and reach agreements. And secondly, I'd like to express my gratitude to the House for all the opportunities they have given me to listen over the last 15 days and two more days
12:47
Lord Falconer of Thoroton (Labour)
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Lord Falconer of Thoroton (Labour)
to come. Can I deal with the the issues that have been raised under four particular headings? First of four particular headings? First of all, is this an opt in or opt out system? And if it is not an opt in system, do we need to change it to system, do we need to change it to make it one? Secondly, is the width of the opt out in section 31 and section five wide enough? Thirdly, section five wide enough? Thirdly, what should we do about the noble Baroness Baroness Fraser and others? Suggestion of a register and Suggestion of a register and fourthly, Baroness Cass suggestion, which I think was significant and we should think about and see whether it's it's it's workable in a variety of ways.
First of all, is it not in or an opt out system? I've spoken to a lot of people in relation to this, in particular the BMA. They are unhappy in the bill in its current draft, is adequately clear that it is an opt in system. So, in accordance with the wishes of the BMA and after very considerable discussions with them in amendment six, 69A, we have included in the Bill by way of an amendment, a requirement that everybody who has the specialist training, which is a necessary requirement before you can participate as a doctor in under the scheme, has opted in to the specialist training.
The BMA were very clear and I accept this. That opt in should be on the face of the Bill so that there can be no doubt about that. So we have done that and I hope that everybody will agree with that. Secondly, the
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width or otherwise. Lord, I don't quite understand
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Lord, I don't quite understand then why I received a letter dated the 26th of March, which is just this week from the Royal College of General Practitioners, requesting explicit clarification on the face of the bill to make clear that there is no expectation of any there is no expectation of any doctor, including GPS. And I wonder then whether there were discussions with them and whether comments that
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they made had been rejected. There's a difference between, on
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There's a difference between, on the one hand, expectations and on the other opt in. We take the view the other opt in. We take the view after discussions with the BMA, that opt in is sufficient to make clear that you've actively got to clear that you've actively got to take a step before you are required to participate. The fact that to participate. The fact that you've got to opt in means there is no expectation one way or the other, that you've got to opt in.
So I take the view that that is an adequate response. I don't know whether or not the general. The Royal College of General Practitioners have had a chance to look at our amendments, but I suspect they will be adequate in relation to that point. Could I go on from there to clause? Sorry.
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This really is the most important point. There are elements of the delivery of health service, of the delivery of health service, which require an ability to which require an ability to understand what it is that a doctor is doing and what his views are. To have doctors opting in, we will not have doctors opting in, we will not know which doctors have opted in. They will not know which doctors have opted in. They may wish to do have opted in.
They may wish to do the training and then after not to participate in the process. That may change their views and therefore I think it's not sufficient to make a clause which says A69A does that doctors will opt in and therefore that deals with the problem of opting in because it doesn't. I think the reality is we actually do need. With great respect to the noble and learned Lord Moore, we do need a specific provision for opt in in
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the bill, as suggested by the noble Baroness. A specific provision for opt in.
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A specific provision for opt in. I'm not quite sure what the noble Baroness is saying. It is absolutely clear that that is the absolutely clear that that is the position. Can we move on to the next one, which is the width of the next one, which is the width of the the the opt out, which is clause five and clause 31 as far as clause five and clause 31 as far as clause five is concerned, as I indicated to you, I think it was the noble Lord, Lord Harper.
No registered medical practitioner is under any duty to raise the subject of the provision of assistance in accordance with this act, with the person. Now, a number of laws include. The noble Lord Lord Stevens has made the point, and he's referred to the professor and other articles about the problem. We have approached the question of whether it's a treatment or not on the basis of what provides a practical answer to doctors and medical professionals. If you say it's not a treatment, I don't see why that would necessarily obviate the need.
If you're worried about doctors or health professionals having in particular circumstances to raise it, the key thing for the doctor to know is there can be no legal duty on him or her ever to raise it, or ever to become a participant in the system. I was thinking, what more could wait, wait, let me finish. Let me finish, let me finish. What more could one do to give protection to doctors beyond saying no duty ever to raise it, no duty to participate? I
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couldn't think of what wording there could be. Thank you, Lord, for giving away.
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Thank you, Lord, for giving away. One answer would be simply to put on the face of the bill that this is not a treatment, in which case is not a treatment, in which case all of the other consequences wouldn't arise. But the question the question, just to clarify, is he saying then that if assisted he saying then that if assisted dying is deemed to be a treatment? Nevertheless, his bill overrides the duties on a doctor affirmed by the Supreme Court in July 2023? In
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the McCulloch case, yes. Yes, there can be no duty to
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Yes, there can be no duty to raise a question of assisted dying if an Act of Parliament says there is no duty to raise it and it does is no duty to raise it and it does not override. Sorry, that's the case. The Montgomery case, the the case. The Montgomery case, the the normal negligence cases do not in any way lurk in the underground any way lurk in the underground waiting to, as it were, stop this. It's absolutely plain that the effect of this provision and the provision in clause 31 is that if you didn't raise it, there could be no legal kickback of any sort, and that is why put it in like that.
And that is why putting in the words it's not a treatment would
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not be sufficient. Sorry. I entirely agree with what the
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I entirely agree with what the noble Lord Lord Stevens of Birmingham was just saying. But I think we just heard from the Minister that one of the possible implications of the bill is that in implications of the bill is that in clause 41 for they would need to adapt the NHS act 2006 in order to adapt the NHS act 2006 in order to bring this service into the scope of what the NHS act says is the role of the National Health Service, and potentially, if I understood the Minister's wording correctly, by bringing assisted dying within the context of treatment under the NHS act 2006, seems to me this is entirely the wrong thing to do.
Rather than amending the NHS act to say that the NHS is going to provide this service, but it doesn't provide any form, any part of the comprehensive service the NHS provides for promoting the improvement of people's physical and mental well-being. And it seems to me how the bill, how this bill would be interpreted into the responsibilities of the NHS. As the noble Lord Lord Stevens told us on a previous day, is a very important question to which the sponsor of the bill is not yet giving us an answer.
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Discussed this before, and the noble Lord Lord Stevens is noble Lord Lord Stevens is absolutely right. He's referring to the 2006. It might be a act, not your act, but the one before it. And it. And it basically says words to the effect. The obligation of the National Health Service is to provide treatment and care. And then there's a question as to whether or not that includes whether or not that includes assisted dying, which is unresolved. But if if it is to be provided in the NHS, then it's got to be there has to be some amendment to that particular bill because it or that act as it refers to the basic constitutional point that is of little assistance to a doctor who needs to know whether or not he could be in breach of any legal duty by not providing assisted dying.
That is the key question that is raised, and that question is unequivocally answered by clause five, clause 31.
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Is, is that the doctor's duty is to present a patient with all the possible treatments that they could have. And if they didn't, if they have. And if they didn't, if they kind of refused to mention chemotherapy or they refused to say, you can take this painkiller, this you can take this painkiller, this would be a negligent doctor. And you could imagine them getting you could imagine them getting struck off. Now, if assisted dying becomes a medical treatment, then regardless of conscience clauses, a doctor would be under duty to offer it as a treatment.
And if they didn't, they would be potentially in breach of their medical role as a doctor and also be open to civil liability. Those of us who are concerned about that doctor's conscience is saying, can you? You can't just keep saying, I've said opt in. It's fine. Stop worrying. We've said that your duties are fine. If it's a medical treatment, their duty will be to offer it. And nothing you say here will cancel that. And they could lose their professional reputation job and end
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up in the courts. That's what we're worried about. I see that the noble Baroness
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I see that the noble Baroness put it brilliantly. Of course it is. Here's a here's a range of Here's a here's a range of treatments. Or delete the word treatment. Here's a range of things that can be done. One of them is assisted dying. The worry that the noble Baroness expresses is if it's noble Baroness expresses is if it's a thing that can be done using it neutrally. If you don't tell the patient that you could be negligent or in some way in problems.
That is why, whether it is a treatment or not, we have dealt unequivocally with the problem by saying you're never under a duty to. It is not to be treated as in the same category as the other sorts of treatment, for example, chemotherapy. So we the the you did it. Sorry. I apologise for calling you. You, the noble Baroness Baroness Fox expressed the problem exactly. We have addressed the problem. You may not like the answer, but as far as the doctors are concerned, they have complete clarity and complete protection.
Could I move on from from from the. It is an opt in or an opt out. And we've we've made it into an opt in subject to the amendment being accepted. The next is the width of the opt out. In clause 31. I've read five one. Never obliged to raise it. Then if you go to clause 31. And again, I'm sorry to weary noble Lords with this, but we've looked at this a bit already. No person, not just a medical professional, no person is under any duty to participate in the provision of assistance in accordance with the act.
That means that no person is under a duty to do the things referred to in clause 26. No registered doctor is under any duty to become the coordinating doctor or the independent doctor. No doctor other than the coordinating doctor or the independent doctor is under any duty to perform any function in connection with the act. No healthcare professional or social care professional is obliged to respond to any request for information in connection with assisted death. No registered pharmacist or registered pharmacy technician is under any duty to participate in relation to the supply of an approved substance.
Now, these are wide protections, but they are not empty protections. Can I just finish? They are not empty protections. They are protections which have the support of the full panoply of schedule three of the Employment Rights Act, 1996. So. So although the noble Baroness Burt Baroness Fox fluctuated between their saying there are too many protections and too few protections in the course of this, this this bill, the absolute maximum number of legal protections is provided to anybody who, because they will not do an assisted death or participate in it, or even will participate in it, they are entitled to all the protections against discrimination that is given to all the protected characteristics.
Now, this is a clause that is wider for all the reasons that the noble Lord Lord Pannick said. Then the Abortion Act. I notice that the noble Baroness Baroness Berridge and the noble Lord, Lord Goodman, have put their name down to incorporating into this bill the same provision as the one in the Abortion Act. And it's narrower because you have to establish a conscientious objection in relation to abortion. Whereas here, if you say no for any reason whatsoever, then that no has to be respected and the law is not interested in whether your objection is conscientious or not, it can, of course, be conscientious if you want, but there is no problem about trying to establish that the noble Lord Wood.
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Very grateful to the noble and learned Lord, I listened, given I'd raised the concern, and he took raised the concern, and he took care and trouble in responding to it, I listened very carefully to it, I listened very carefully to what he said. The problem is what he said about not no one being forced to participate in the. In forced to participate in the. In the steps set out in clause 26 and the steps set out in clause 26 and all of the other provisions actually doesn't cover to pick the noble Lady Baroness Fox example, it wouldn't cover the porter who is being asked to take the patient to the room in which they were to be assisted in ending their life, and if that porter were to say, I don't wish to do that because I don't wish to help this person end their life.
Actually, there's nothing in what he said that would provide them with any protection, which is why there are many of us that don't think this provision is wide enough. And actually, the unfortunate thing is it probably provides quite a lot of protection to the more senior people in this process the doctor, the medical professionals. But actually it fails to provide protection to the more junior people in involved in this process. Those without medical qualifications, the porters, the administrative staff, the cleaners, the other people who work in a healthcare setting.
They don't appear to be protected at all.
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For example, the porter, the porter cannot be required to be in the room or helping in. I said clause 26, I meant clause 25, and I apologise for that which is in relation to the provision of assistance. But but take take you assistance. But but take take you given an example of a of a cleaner. There are many, many other examples of administrative staff in a hospital. For example, the sponsors of the bill have taken the view of the bill have taken the view that there shouldn't be a conscience clause in relation to, for example, a cleaner in relation to it, or somebody doing ordinary administrative tasks, because you've got to make these institutions run properly.
What there should be an absolute bar on is either being a doctor, participating in the process, or being actually involved in the process of providing the lethal drugs under clause 25. Now, we've drawn the line there, and it's for the House to decide whether they think the line is in the right place. Could I go on to the can I go on for a bit? Actually, I think I think I think no, I'll come back at the end if there's time. But let's keep going next.
The the register. What the the the the the noble Baroness Baroness phrases amendment 189 is, I think, trying to do two things. One, it is trying to have some sort of opt in process because it says if you're a registered medical professionals who are unwilling or unable to conduct preliminary discussions are not required to join the register under subsection six. That's her. That's her sub eight in amendment 189. And I think I think that's not really an opt in.
That's a you're not required to join. I think my conversations, in particular with the BMA, make it clear they want the words you've got to opt in in. So I'm not sure that that bit as far as opt in opt out quite gets it as far as the other point is concerned, the register it might be in time that there should be a register. I am very strongly not in favour of putting a register on the face of the Bill. Let the Secretary of State and the medical profession say if that's an appropriate thing to do.
I don't think it goes to the fundaments of the bill. And although I am struck by the noble Lord, Lord Moore's robustness on behalf of doctors, I do not think without there being further consultation after the implementation period has gone through, that one should willy nilly put onto a public register the names of people either willing and therefore some people who are not willing to do assisted dying into a public domain without having a bit more knowledge about what the effect might be in relation to that.
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My my noble friend in the amendment that started this group amendment that started this group is looking for who it is that one goes to in order to provide the goes to in order to provide the necessary assistance to a person. If that original conversation is not something the doctor wants to not something the doctor wants to pursue themselves. All of the doctors are supposed to have training and they opt in to the training and they opt in to the training.
But how do we know who they are if we don't have a register?
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The precise knowledge of who does it, where the list is kept, who registers with whom? For who registers with whom? For example, do they register with the commissioner? That is about detailed implementation, and I am. detailed implementation, and I am. I am very strongly that we should. Of the view that we should not try to get into the nitty gritty in to get into the nitty gritty in relation to that on the face of the Bill. So I recognise the purpose for which the Baroness and I for which the Baroness and I understand he's on his feet.
Could you just give me a few minutes? I understand why the Baroness Fraser has put this onto the face of the bill, but I hope she will understand why. First of all, in relation to opt in. I'm not sure it quite gets there. And secondly, in relation to register, I am not in favour of it at the moment. The
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noble Lord Lord Deben. To help the noble Lord. For this reason I'm concerned about the. I'm reason I'm concerned about the. I'm concerned about the. The person who wishes to avail themselves of this wishes to avail themselves of this bill. And I don't understand how bill. And I don't understand how you do that effectively unless you can look at a list and get the person you want. I really am concerned that those of us who want real protection mustn't overcomplicate this bill, even if we are against it.
So this is why I'm really, genuinely saying to him, if you don't have a list, I don't understand how somebody can, with ease and confidence, take part in something I don't like, but which, if it were the law, would be available. And that's what I'm very concerned about. If there isn't a list, it's a great deal of obfuscation, and it does seem to me that it should be part of the policy of those presenting this bill to expect a list.
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Yeah, yeah. I'm very grateful to the noble Lord for his assistance in relation to this matter. As far as as far as. I am concerned, precisely how one I am concerned, precisely how one identifies who is available to do it is something that should be worked out in the implementation, worked out in the implementation, because it goes to publicity, it goes to what's the most convenient way of doing it. And I do not think way of doing it.
And I do not think normally or sensibly this should be on the face of the bill. Could I end with the Baroness Cass? The Baroness Cass is proposing is, first of all, that in the course of the conversation which is referred to in clause 12, you should say this is your own choice. I think that's that's not necessary or appropriate, where one of the things that the two doctors and the panel have got to be satisfied of is the fact that this is a clear, the written record, which is in effect, the written record of the multidisciplinary team.
And if it's available, they should definitely do that. But I don't think that will be available in every case. One hopes that it is, but I can't be sure that it would be. And that shouldn't be a bar to doing it. I see the force of saying do it together. The two doctors. But my anxiety about that is if you're looking for genuine safeguards, you've got to have a position where the two doctors who are reaching a view that the conditions are satisfied have done it independently of each other, so I can see the convenience of it.
But I think it's got to be done separately rather than together. And I've had the benefit of discussing with Baroness Cass many of the ideas that she's put forward, which I have found incredibly helpful. And one of the one of the one of the insights that Baroness Cass has given, which I find very helpful, is in reality, this is going to have to be, in effect, some sort of specialist service if you want somebody to help you in relation to this.
It's got to be somebody who has expertise in doing it. But that insight does not mean it's got to be completely separate from all the other care that you are being provided with. And in particular, you will frequently, when you are dying, have a variety of specialists who are helping you, who are part of the team that is helping you. And if assisted dying is what you want, then I don't think you should feel that. You've got to be completely separated from the rest of the team that's looking after you.
Can I raise one other
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point and make sure you. Respond to that? I haven't actually. Said that they can't.
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Said that they can't. Be part of the team. And it's likely. That the the person who is covering a particular area or locality will be known to the team and known to the palliative care and known to the palliative care services. And, you know, maybe, well, one would hope not as familiar as other specialists just familiar as other specialists just by virtue of the fact that we're, we're, we are anticipating smaller numbers, but it's just that they are a separate individual who comes
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in like, you know, a cardiologist. I'm sorry if I said they were part of the I mean, what I was part of the I mean, what I was getting at and I stand corrected was you shouldn't feel you've got to separate yourself in order. If I to separate yourself in order. If I want to have an assisted death and I want to have it at home, I still want to think that the people who want to think that the people who are caring me, caring for me up until it happens, are still going to be available to me because it
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would matter to me quite a lot. I suspect. That they would. That's that's the point of it, that you're coordinating professional, as I described them, would be with you throughout. And so and and from the time you start engaging with the specialist assisted dying doctor, they would be. So you might want to check in with one or the other, depending on whether you want your symptoms addressed or whether you want to have another discussion about really, you know, what the process is going to be like of
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having an assisted death. Sure. Sorry. My six, six, four, given the
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My six, six, four, given the Noble and learned, Lord Horam insists that no person would be under any duty to perform or under any duty to perform or provide for an act in under this provide for an act in under this measure, it. Will that apply to participation in training? Because participation in training? Because that is training rather than a duty to do something.
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Opt in to training in the consequence of my amendment. Therefore, there can be no duty to participate. I don't think it's participate. I don't think it's necessary to say that on the face of the bill. Could I deal with one other point, which is the point other point, which is the point made by the noble and learned Lord? Not learned the noble Lord Lord McCrea, who is not in his place. He can I just deal with that? First, he raised the point about care he raised the point about care homes and hospices and other institutions.
I have had, along with the sponsor of the bill in the Commons, very considerable conversations with Hospice UK. Their anxiety is that if they say no institutionally to assisted dying, could that affect their entitlement in various ways to funding, particularly from the state? And I'm I'm alive to that concern. And I think we should deal with that on the face of the bill. And I've been working on trying to do that. I should make it clear it is only limited to hospices, and it may, when one looked at it, be limited only to private hospices, not to NHS hospices.
But that is the area we are looking at and it requires work being done to it. But the point that was being made has got validity, not in relation to care homes I don't think, but in
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relation to hospices. The noble Lord Lord Harper. And this will be my last one, I
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And this will be my last one, I promise. I just wanted to press him a bit on the exchange we had earlier. He confirmed that in earlier. He confirmed that in clause 31, the duty not to participate is in the provision of assistance, and I'd been unclear about the definition of provision of assistance. And the noble and learned Lord confirmed that that learned Lord confirmed that that meant the title that the steps set out in clause 25. He corrected himself, which is titled Provision of Assistance, which is the.
The end point of this process. The the provision of the substances, the poisons that are going to end someone's life. So I think he confirmed, and I just want to make sure I'm absolutely clear. So I don't misrepresent him. That means that it would not be open to the porter, for example, who didn't want to take the person to the room in which the substances were going to be administered. It wouldn't be open to that Porter to say they had an objection to this process, and to not carry that out.
They would not be able to use the provisions in this act. They would not have the protections. And I don't think that is right. And if the noble Lady, the noble and learned Lady, Baroness Scotland, I think, correctly interpreted the mood of the House as that we do think people should have those protections and have to opt in. That should apply to everybody, not just those at the top of the tree. It should apply to everyone involved in the process, including more junior members of staff who will find it harder to enforce their rights.
As far as.
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The 31 is concerned, one is no person not restricted to doctors is person not restricted to doctors is under any duty to participate in the provision of assistance, which is clause 25 two. No registered is clause 25 two. No registered medical practitioner has to be a coordinating doctor or an independent doctor. Three no registered medical practitioner registered medical practitioner other than the coordinating doctor or the independent doctor, is under any duty to perform any function any duty to perform any function under or in connection with this act.
So I think I have set out what my position is in relation to it, including in relation to the Porter example. I don't think I should go further than that.
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I hesitated, I wanted to come in on top of that because I'm not clear what the position is over clear what the position is over care assistance. People who are involved in intimate care of involved in intimate care of patients, because in Australia in particular, there have been problems where the staff, such as problems where the staff, such as the care assistants who are not the qualified nurses, feel that they qualified nurses, feel that they are somehow providing the patient with their last breath, with their last meal, and it feels to them as if they are having to prepare somebody effectively for their execution, for their end of their life.
Now, that might sound shocking in the way that it's expressed, but that's how it was relayed to me. And that similarly, staff who are preparing a meal, which turns out to be the last meal for that person, can also find that very difficult and very distressing. But if I've heard the noble and learned Lord Knight, those staff have no ability to have any conscience objection whatsoever. And effectively they are being treated as people who just have to operate in their job, like it or
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leave it. Is that correct. In that language? Not at all. But if suppose you were a care assistant giving somebody a bath assistant giving somebody a bath before the provision of assistance, then there's no conscience clause in relation to that. And I'm not sure what the noble Baroness Cass suggesting that if you're caring for somebody who, you know, subsequently is going to have an assisted death, whether there's some point at which you would be entitled to say, as a care assistant, I'm not going to provide assistance to that person, because I find the issue of providing assistance contrary to my conscience.
As far as the the the bill is concerned, it's the every person, doctor or not, that would include the care assistant is under no duty to provide to participate in the provision of assistance in relation to the provision of the substance under clause 25. Back from that, the person doesn't have
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the protection. If I could. Just clarify, the noble and
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Just clarify, the noble and learned Lord Moore is not allowing a provision here to say that. For a provision here to say that. For instance, if you have strong feelings that you would be able to feelings that you would be able to ask to not be rostered to work on that shift or on that day or in that situation, and you would be able to move to another place. Because one of the solutions in some places has been that when there is going to be an assisted death scheduled, the members of staff who don't want to work that day have a right to be rostered off
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in terms of being able to assert their conscience. The position is that if you're
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The position is that if you're on the roster, there was a risk that you would be actually in the that you would be actually in the room and assisting in relation to the provision of assistance. And of course, it would be sensible not to be rostered on that day, and I hope be rostered on that day, and I hope that would be the sort of solution that people would be looking for.
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that people would be looking for. Six, six, nine, eight, if you please, your amendment 669A69A yeah. Your amendment sorry, 6698 and refers to section eight seven, 11 nine and 26 two. But that is only for medical practitioners. It's not for other medical professionals. And it's for that reason. I brought my amendment six, six, four so that my amendment six, six, four so that anybody could opt out to opt in to training for this, not just the medical practitioners, which I'm very glad to see.
Your amendment
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exempts. It's the others. Baroness Lawlor is right that the opt in provision that I've the opt in provision that I've introduced is only in relation to the doctors. And the reason it's only in relation to the doctors is only in relation to the doctors is because it's the doctors that are because it's the doctors that are given the particular role under the bill. So what this is doing is saying you need to be trained saying you need to be trained before you can do particular functions under the bill.
That's why there needs to be an opt in equally in relation to others. There is a no detriment clause. If you say you will not participate and depending on who you are, you can participate. If you're any person not in the provision of the assistance. And as you as as you go wider, you've got wider protections. If you're, for example, a doctor or
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a healthcare professional. Somebody who is employed by an
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Somebody who is employed by an agency or an agency nurse, they may not have the whole provision of the text in front of them, and they may text in front of them, and they may not be encouraged to look into the exemptions for conscientious or other reasons about which we've other reasons about which we've heard. And it's for that reason, if it's on the face of the bill that anybody involved in the medical or anybody involved in the medical or social care for frail people should have the right should be know that they are entitled under law to opt
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out of such training. Well, I. Think I think we know the differences between us. I've set out what my position is. I'm
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out what my position is. I'm grateful to you for setting it out again. Thank you. What the noble and learned Lord
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What the noble and learned Lord said in response to the noble Lady, Lady Finley, that that would be a sensible solution. But that is a sensible solution. But that is a different language to having a legally enforceable right to say to legally enforceable right to say to your employer, I do not want to be rostered on that day. So is that the correct position as I understand it? And could the noble and learned Lord concede that actually these problems exist from the fundamental pillar of the bill, which is you can base this on the notion of of autonomy, which is based on choice and conscience is a different concept to that.
And
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that's why we're in these difficulties. Honestly, don't think that these
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Honestly, don't think that these are difficulties. I do think there is absolute clarity in the bill as is absolute clarity in the bill as to what the legal position is, and to what the legal position is, and it is a very, very wide exception, and it is more than sufficient to give protection to people who do give protection to people who do not want to participate in the provision of assistance under the bill and the pushing it wider and wider simply gives rise to uncertainty.
The key thing is there should be certainty and sufficient width, and I believe that is what
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caused 31 has done. (422) 423-9888. It's possible he could do that in another group at a could do that in another group at a later date, but I just wanted to clarify whether he would make sure he does that.
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he does that. Or 4422 and 423 is creating a regulatory power to allow regulatory power to allow coordinating doctors or independent doctors when they step down in certain circumstances, not to have to give notice, for example, if to give notice, for example, if they're too ill. So it's a
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practical drafting change. I think everyone. Right.
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Right. Who's actually answering my
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Who's actually answering my questions on amendment 679. Well, I think the noble and learned Lord Moore suggested that there might be a differentiation between NHS a differentiation between NHS providers and private providers in the hospice sector. So does the noble and learned Lord see a noble and learned Lord see a scenario where people may feel reluctant or frightened to enter into an NHS hospice, because it may have to be provided there? And will this not put more pressure on private providers? And the noble Lord has rejected many of our amendments, arguing they're not necessary because there should be totally equal access to the process.
But isn't this going to create a two tier system where those who don't want to discuss assisted suicide and might be able to afford a private provider, will actually be able to stay away from any discussions where someone who has
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no money or less money will be forced to go into NHS provision. No.
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No. I do not think it will. And the reason I do not think that it will reason I do not think that it will is because the nature of the safeguards in relation to everybody safeguards in relation to everybody are such that the idea that a assisted death is going to be forced on people is wrong.
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forced on people is wrong. One last thing. I just want to clarification. When the noble and learned Lord talked about hospices, he said in a slightly confusing way that didn't necessarily refer to care homes. I am concerned about care homes, which are run by organisations for for whom this is unacceptable. Are they going to be protected to be able to say that from the beginning? So anybody going into care home of that kind
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knows precisely the terms under which that care home is run. First of.
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First of. All, the only organisational exception that I'm thinking about, because the exceptions in clause one, sorry, clause 31 are for individuals. The only individuals. The only organisational ones that I'm contemplating are ones in relation to hospices, not in relation to
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care homes. On that topic. That's a very important point that the noble and learned laws just made. So to clarify, what he's saying is that 30 clause 30 1AB would not apply in hospices. In other words, at the moment, as drafted, the bill would prevent a hospice as an employer from restricting, say, doctors who were working for that hospice from also participating in assisted dying. If the hospice wanted, as a matter of philosophy or ethos to say, we don't want to be part of that, is he saying that they would have an opt out from 31 A8B? I'm not.
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Sure I understood the question. If the question is, can a hospice opt out from the opt out? The opt out from the opt out? The answer is not can the hospice have a separate opt out? That may be the
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a separate opt out? That may be the position, but I need to consider how to do that. So just to clarify, I think 30
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So just to clarify, I think 30 18B prevents hospice as an employer from restricting its employees from from restricting its employees from participating in assisted dying if they do it somewhere else. Is he saying that he is willing to change
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that? What I what I am thinking about is a provision that says if as a is a provision that says if as a hospice, you say you don't want to provide it, you should not suffer various sorts of institutional various sorts of institutional detriment. That's what I'm interested in. So I'm not saying anything about clause 31 because
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anything about clause 31 because I'm not understanding your question. But that's what I'm thinking about, to be clear. OK, so I think what follows from
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OK, so I think what follows from that is then he is accepting the position that hospices will not be in a position to restrict their employees from participating in assisted dying. If they're doing that somewhere other than in the
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hospice. That's correct. My Lords. I.
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I. I have to thank all noble Lords for this extremely interesting debate and long debate. I don't think I can possibly sum up in any better way than the noble and learned Lady Baroness Cox did, and learned Lady Baroness Cox did, and I felt that she summed up very brilliantly the issues that have been raised during the last 3.5 hours, but I'm going to quickly come back to the noble and learned Lord Dear sponsor.
He posed for responses. One, we've all seemed to be coalescing around that this bill should have an opt in on the face of it. And the noble and learned Lord has given us six, six, nine a. As his response. And. And I think the mood of the House, if I may say, is that that is, is not sufficient. And the mood of the Royal Colleges seems to be. That is not sufficient. So the second point was, is it wide enough? And the resounding answer seems to be no.
We've had a. There is no practical. And I'm sorry I always come back to practicalities in this bill because, you know, it's fine to sort of refer to to the clauses, but but the idea of what's going to happen, how are people going to take these words and implement them? How would you say no? And I am thinking about a busy ward where somebody is, is wanting to, to, to participate in, in assisted assisted dying requests in process and somebody doesn't want to participate.
And they might fear that speaking up at that point might, you know, it might be seen as obstructive, it might harm their chances of promotion. They might not have the confidence to speak up to their superiors. And it wouldn't be a very healthy work dynamic. So there's nothing in this bill that allows for that person to, to, to, to have to say, I didn't opt into this. An opt in system would, you know, would make it all agreed if things would be known about before there's a crisis and people would have the right and there would be a mechanism to change their minds.
And I'm afraid that's where six, six, nine A fails because how can you opt out later? Where's the provision for that? The third point was about the register, which I want to thank the noble Lord Moore for his fantastic support. But the question about where does someone go if the participating doctor doesn't want to participate, where
First of all, is it not in or an opt out system? I've spoken to a lot of people in relation to this, in particular the BMA. They are unhappy in the bill in its current draft, is adequately clear that it is an opt in system. So, in accordance with the wishes of the BMA and after very considerable discussions with them in amendment six, 69A, we have included in the Bill by way of an amendment, a requirement that everybody who has the specialist training, which is a necessary requirement before you can participate as a doctor in under the scheme, has opted in to the specialist training.
The BMA were very clear and I accept this. That opt in should be on the face of the Bill so that there can be no doubt about that. So we have done that and I hope that everybody will agree with that. Secondly, the
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width or otherwise. Lord, I don't quite understand
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Lord, I don't quite understand then why I received a letter dated the 26th of March, which is just this week from the Royal College of General Practitioners, requesting explicit clarification on the face of the bill to make clear that there is no expectation of any there is no expectation of any doctor, including GPS. And I wonder then whether there were discussions with them and whether comments that
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they made had been rejected. There's a difference between, on
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There's a difference between, on the one hand, expectations and on the other opt in. We take the view the other opt in. We take the view after discussions with the BMA, that opt in is sufficient to make clear that you've actively got to clear that you've actively got to take a step before you are required to participate. The fact that to participate. The fact that you've got to opt in means there is no expectation one way or the other, that you've got to opt in.
So I take the view that that is an adequate response. I don't know whether or not the general. The Royal College of General Practitioners have had a chance to look at our amendments, but I suspect they will be adequate in relation to that point. Could I go on from there to clause? Sorry.
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This really is the most important point. There are elements of the delivery of health service, of the delivery of health service, which require an ability to which require an ability to understand what it is that a doctor is doing and what his views are. To have doctors opting in, we will not have doctors opting in, we will not know which doctors have opted in. They will not know which doctors have opted in. They may wish to do have opted in.
They may wish to do the training and then after not to participate in the process. That may change their views and therefore I think it's not sufficient to make a clause which says A69A does that doctors will opt in and therefore that deals with the problem of opting in because it doesn't. I think the reality is we actually do need. With great respect to the noble and learned Lord Moore, we do need a specific provision for opt in in
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the bill, as suggested by the noble Baroness. A specific provision for opt in.
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A specific provision for opt in. I'm not quite sure what the noble Baroness is saying. It is absolutely clear that that is the absolutely clear that that is the position. Can we move on to the next one, which is the width of the next one, which is the width of the the the opt out, which is clause five and clause 31 as far as clause five and clause 31 as far as clause five is concerned, as I indicated to you, I think it was the noble Lord, Lord Harper.
No registered medical practitioner is under any duty to raise the subject of the provision of assistance in accordance with this act, with the person. Now, a number of laws include. The noble Lord Lord Stevens has made the point, and he's referred to the professor and other articles about the problem. We have approached the question of whether it's a treatment or not on the basis of what provides a practical answer to doctors and medical professionals. If you say it's not a treatment, I don't see why that would necessarily obviate the need.
If you're worried about doctors or health professionals having in particular circumstances to raise it, the key thing for the doctor to know is there can be no legal duty on him or her ever to raise it, or ever to become a participant in the system. I was thinking, what more could wait, wait, let me finish. Let me finish, let me finish. What more could one do to give protection to doctors beyond saying no duty ever to raise it, no duty to participate? I
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couldn't think of what wording there could be. Thank you, Lord, for giving away.
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Thank you, Lord, for giving away. One answer would be simply to put on the face of the bill that this is not a treatment, in which case is not a treatment, in which case all of the other consequences wouldn't arise. But the question the question, just to clarify, is he saying then that if assisted he saying then that if assisted dying is deemed to be a treatment? Nevertheless, his bill overrides the duties on a doctor affirmed by the Supreme Court in July 2023? In
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the McCulloch case, yes. Yes, there can be no duty to
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Yes, there can be no duty to raise a question of assisted dying if an Act of Parliament says there is no duty to raise it and it does is no duty to raise it and it does not override. Sorry, that's the case. The Montgomery case, the the case. The Montgomery case, the the normal negligence cases do not in any way lurk in the underground any way lurk in the underground waiting to, as it were, stop this. It's absolutely plain that the effect of this provision and the provision in clause 31 is that if you didn't raise it, there could be no legal kickback of any sort, and that is why put it in like that.
And that is why putting in the words it's not a treatment would
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not be sufficient. Sorry. I entirely agree with what the
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I entirely agree with what the noble Lord Lord Stevens of Birmingham was just saying. But I think we just heard from the Minister that one of the possible implications of the bill is that in implications of the bill is that in clause 41 for they would need to adapt the NHS act 2006 in order to adapt the NHS act 2006 in order to bring this service into the scope of what the NHS act says is the role of the National Health Service, and potentially, if I understood the Minister's wording correctly, by bringing assisted dying within the context of treatment under the NHS act 2006, seems to me this is entirely the wrong thing to do.
Rather than amending the NHS act to say that the NHS is going to provide this service, but it doesn't provide any form, any part of the comprehensive service the NHS provides for promoting the improvement of people's physical and mental well-being. And it seems to me how the bill, how this bill would be interpreted into the responsibilities of the NHS. As the noble Lord Lord Stevens told us on a previous day, is a very important question to which the sponsor of the bill is not yet giving us an answer.
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Discussed this before, and the noble Lord Lord Stevens is noble Lord Lord Stevens is absolutely right. He's referring to the 2006. It might be a act, not your act, but the one before it. And it. And it basically says words to the effect. The obligation of the National Health Service is to provide treatment and care. And then there's a question as to whether or not that includes whether or not that includes assisted dying, which is unresolved. But if if it is to be provided in the NHS, then it's got to be there has to be some amendment to that particular bill because it or that act as it refers to the basic constitutional point that is of little assistance to a doctor who needs to know whether or not he could be in breach of any legal duty by not providing assisted dying.
That is the key question that is raised, and that question is unequivocally answered by clause five, clause 31.
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Is, is that the doctor's duty is to present a patient with all the possible treatments that they could have. And if they didn't, if they have. And if they didn't, if they kind of refused to mention chemotherapy or they refused to say, you can take this painkiller, this you can take this painkiller, this would be a negligent doctor. And you could imagine them getting you could imagine them getting struck off. Now, if assisted dying becomes a medical treatment, then regardless of conscience clauses, a doctor would be under duty to offer it as a treatment.
And if they didn't, they would be potentially in breach of their medical role as a doctor and also be open to civil liability. Those of us who are concerned about that doctor's conscience is saying, can you? You can't just keep saying, I've said opt in. It's fine. Stop worrying. We've said that your duties are fine. If it's a medical treatment, their duty will be to offer it. And nothing you say here will cancel that. And they could lose their professional reputation job and end
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up in the courts. That's what we're worried about. I see that the noble Baroness
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I see that the noble Baroness put it brilliantly. Of course it is. Here's a here's a range of Here's a here's a range of treatments. Or delete the word treatment. Here's a range of things that can be done. One of them is assisted dying. The worry that the noble Baroness expresses is if it's noble Baroness expresses is if it's a thing that can be done using it neutrally. If you don't tell the patient that you could be negligent or in some way in problems.
That is why, whether it is a treatment or not, we have dealt unequivocally with the problem by saying you're never under a duty to. It is not to be treated as in the same category as the other sorts of treatment, for example, chemotherapy. So we the the you did it. Sorry. I apologise for calling you. You, the noble Baroness Baroness Fox expressed the problem exactly. We have addressed the problem. You may not like the answer, but as far as the doctors are concerned, they have complete clarity and complete protection.
Could I move on from from from the. It is an opt in or an opt out. And we've we've made it into an opt in subject to the amendment being accepted. The next is the width of the opt out. In clause 31. I've read five one. Never obliged to raise it. Then if you go to clause 31. And again, I'm sorry to weary noble Lords with this, but we've looked at this a bit already. No person, not just a medical professional, no person is under any duty to participate in the provision of assistance in accordance with the act.
That means that no person is under a duty to do the things referred to in clause 26. No registered doctor is under any duty to become the coordinating doctor or the independent doctor. No doctor other than the coordinating doctor or the independent doctor is under any duty to perform any function in connection with the act. No healthcare professional or social care professional is obliged to respond to any request for information in connection with assisted death. No registered pharmacist or registered pharmacy technician is under any duty to participate in relation to the supply of an approved substance.
Now, these are wide protections, but they are not empty protections. Can I just finish? They are not empty protections. They are protections which have the support of the full panoply of schedule three of the Employment Rights Act, 1996. So. So although the noble Baroness Burt Baroness Fox fluctuated between their saying there are too many protections and too few protections in the course of this, this this bill, the absolute maximum number of legal protections is provided to anybody who, because they will not do an assisted death or participate in it, or even will participate in it, they are entitled to all the protections against discrimination that is given to all the protected characteristics.
Now, this is a clause that is wider for all the reasons that the noble Lord Lord Pannick said. Then the Abortion Act. I notice that the noble Baroness Baroness Berridge and the noble Lord, Lord Goodman, have put their name down to incorporating into this bill the same provision as the one in the Abortion Act. And it's narrower because you have to establish a conscientious objection in relation to abortion. Whereas here, if you say no for any reason whatsoever, then that no has to be respected and the law is not interested in whether your objection is conscientious or not, it can, of course, be conscientious if you want, but there is no problem about trying to establish that the noble Lord Wood.
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Very grateful to the noble and learned Lord, I listened, given I'd raised the concern, and he took raised the concern, and he took care and trouble in responding to it, I listened very carefully to it, I listened very carefully to what he said. The problem is what he said about not no one being forced to participate in the. In forced to participate in the. In the steps set out in clause 26 and the steps set out in clause 26 and all of the other provisions actually doesn't cover to pick the noble Lady Baroness Fox example, it wouldn't cover the porter who is being asked to take the patient to the room in which they were to be assisted in ending their life, and if that porter were to say, I don't wish to do that because I don't wish to help this person end their life.
Actually, there's nothing in what he said that would provide them with any protection, which is why there are many of us that don't think this provision is wide enough. And actually, the unfortunate thing is it probably provides quite a lot of protection to the more senior people in this process the doctor, the medical professionals. But actually it fails to provide protection to the more junior people in involved in this process. Those without medical qualifications, the porters, the administrative staff, the cleaners, the other people who work in a healthcare setting.
They don't appear to be protected at all.
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For example, the porter, the porter cannot be required to be in the room or helping in. I said clause 26, I meant clause 25, and I apologise for that which is in relation to the provision of assistance. But but take take you assistance. But but take take you given an example of a of a cleaner. There are many, many other examples of administrative staff in a hospital. For example, the sponsors of the bill have taken the view of the bill have taken the view that there shouldn't be a conscience clause in relation to, for example, a cleaner in relation to it, or somebody doing ordinary administrative tasks, because you've got to make these institutions run properly.
What there should be an absolute bar on is either being a doctor, participating in the process, or being actually involved in the process of providing the lethal drugs under clause 25. Now, we've drawn the line there, and it's for the House to decide whether they think the line is in the right place. Could I go on to the can I go on for a bit? Actually, I think I think I think no, I'll come back at the end if there's time. But let's keep going next.
The the register. What the the the the the noble Baroness Baroness phrases amendment 189 is, I think, trying to do two things. One, it is trying to have some sort of opt in process because it says if you're a registered medical professionals who are unwilling or unable to conduct preliminary discussions are not required to join the register under subsection six. That's her. That's her sub eight in amendment 189. And I think I think that's not really an opt in.
That's a you're not required to join. I think my conversations, in particular with the BMA, make it clear they want the words you've got to opt in in. So I'm not sure that that bit as far as opt in opt out quite gets it as far as the other point is concerned, the register it might be in time that there should be a register. I am very strongly not in favour of putting a register on the face of the Bill. Let the Secretary of State and the medical profession say if that's an appropriate thing to do.
I don't think it goes to the fundaments of the bill. And although I am struck by the noble Lord, Lord Moore's robustness on behalf of doctors, I do not think without there being further consultation after the implementation period has gone through, that one should willy nilly put onto a public register the names of people either willing and therefore some people who are not willing to do assisted dying into a public domain without having a bit more knowledge about what the effect might be in relation to that.
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My my noble friend in the amendment that started this group amendment that started this group is looking for who it is that one goes to in order to provide the goes to in order to provide the necessary assistance to a person. If that original conversation is not something the doctor wants to not something the doctor wants to pursue themselves. All of the doctors are supposed to have training and they opt in to the training and they opt in to the training.
But how do we know who they are if we don't have a register?
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The precise knowledge of who does it, where the list is kept, who registers with whom? For who registers with whom? For example, do they register with the commissioner? That is about detailed implementation, and I am. detailed implementation, and I am. I am very strongly that we should. Of the view that we should not try to get into the nitty gritty in to get into the nitty gritty in relation to that on the face of the Bill. So I recognise the purpose for which the Baroness and I for which the Baroness and I understand he's on his feet.
Could you just give me a few minutes? I understand why the Baroness Fraser has put this onto the face of the bill, but I hope she will understand why. First of all, in relation to opt in. I'm not sure it quite gets there. And secondly, in relation to register, I am not in favour of it at the moment. The
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noble Lord Lord Deben. To help the noble Lord. For this reason I'm concerned about the. I'm reason I'm concerned about the. I'm concerned about the. The person who wishes to avail themselves of this wishes to avail themselves of this bill. And I don't understand how bill. And I don't understand how you do that effectively unless you can look at a list and get the person you want. I really am concerned that those of us who want real protection mustn't overcomplicate this bill, even if we are against it.
So this is why I'm really, genuinely saying to him, if you don't have a list, I don't understand how somebody can, with ease and confidence, take part in something I don't like, but which, if it were the law, would be available. And that's what I'm very concerned about. If there isn't a list, it's a great deal of obfuscation, and it does seem to me that it should be part of the policy of those presenting this bill to expect a list.
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Yeah, yeah. I'm very grateful to the noble Lord for his assistance in relation to this matter. As far as as far as. I am concerned, precisely how one I am concerned, precisely how one identifies who is available to do it is something that should be worked out in the implementation, worked out in the implementation, because it goes to publicity, it goes to what's the most convenient way of doing it. And I do not think way of doing it.
And I do not think normally or sensibly this should be on the face of the bill. Could I end with the Baroness Cass? The Baroness Cass is proposing is, first of all, that in the course of the conversation which is referred to in clause 12, you should say this is your own choice. I think that's that's not necessary or appropriate, where one of the things that the two doctors and the panel have got to be satisfied of is the fact that this is a clear, the written record, which is in effect, the written record of the multidisciplinary team.
And if it's available, they should definitely do that. But I don't think that will be available in every case. One hopes that it is, but I can't be sure that it would be. And that shouldn't be a bar to doing it. I see the force of saying do it together. The two doctors. But my anxiety about that is if you're looking for genuine safeguards, you've got to have a position where the two doctors who are reaching a view that the conditions are satisfied have done it independently of each other, so I can see the convenience of it.
But I think it's got to be done separately rather than together. And I've had the benefit of discussing with Baroness Cass many of the ideas that she's put forward, which I have found incredibly helpful. And one of the one of the one of the insights that Baroness Cass has given, which I find very helpful, is in reality, this is going to have to be, in effect, some sort of specialist service if you want somebody to help you in relation to this.
It's got to be somebody who has expertise in doing it. But that insight does not mean it's got to be completely separate from all the other care that you are being provided with. And in particular, you will frequently, when you are dying, have a variety of specialists who are helping you, who are part of the team that is helping you. And if assisted dying is what you want, then I don't think you should feel that. You've got to be completely separated from the rest of the team that's looking after you.
Can I raise one other
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point and make sure you. Respond to that? I haven't actually. Said that they can't.
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Said that they can't. Be part of the team. And it's likely. That the the person who is covering a particular area or locality will be known to the team and known to the palliative care and known to the palliative care services. And, you know, maybe, well, one would hope not as familiar as other specialists just familiar as other specialists just by virtue of the fact that we're, we're, we are anticipating smaller numbers, but it's just that they are a separate individual who comes
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in like, you know, a cardiologist. I'm sorry if I said they were part of the I mean, what I was part of the I mean, what I was getting at and I stand corrected was you shouldn't feel you've got to separate yourself in order. If I to separate yourself in order. If I want to have an assisted death and I want to have it at home, I still want to think that the people who want to think that the people who are caring me, caring for me up until it happens, are still going to be available to me because it
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would matter to me quite a lot. I suspect. That they would. That's that's the point of it, that you're coordinating professional, as I described them, would be with you throughout. And so and and from the time you start engaging with the specialist assisted dying doctor, they would be. So you might want to check in with one or the other, depending on whether you want your symptoms addressed or whether you want to have another discussion about really, you know, what the process is going to be like of
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having an assisted death. Sure. Sorry. My six, six, four, given the
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My six, six, four, given the Noble and learned, Lord Horam insists that no person would be under any duty to perform or under any duty to perform or provide for an act in under this provide for an act in under this measure, it. Will that apply to participation in training? Because participation in training? Because that is training rather than a duty to do something.
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Opt in to training in the consequence of my amendment. Therefore, there can be no duty to participate. I don't think it's participate. I don't think it's necessary to say that on the face of the bill. Could I deal with one other point, which is the point other point, which is the point made by the noble and learned Lord? Not learned the noble Lord Lord McCrea, who is not in his place. He can I just deal with that? First, he raised the point about care he raised the point about care homes and hospices and other institutions.
I have had, along with the sponsor of the bill in the Commons, very considerable conversations with Hospice UK. Their anxiety is that if they say no institutionally to assisted dying, could that affect their entitlement in various ways to funding, particularly from the state? And I'm I'm alive to that concern. And I think we should deal with that on the face of the bill. And I've been working on trying to do that. I should make it clear it is only limited to hospices, and it may, when one looked at it, be limited only to private hospices, not to NHS hospices.
But that is the area we are looking at and it requires work being done to it. But the point that was being made has got validity, not in relation to care homes I don't think, but in
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relation to hospices. The noble Lord Lord Harper. And this will be my last one, I
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And this will be my last one, I promise. I just wanted to press him a bit on the exchange we had earlier. He confirmed that in earlier. He confirmed that in clause 31, the duty not to participate is in the provision of assistance, and I'd been unclear about the definition of provision of assistance. And the noble and learned Lord confirmed that that learned Lord confirmed that that meant the title that the steps set out in clause 25. He corrected himself, which is titled Provision of Assistance, which is the.
The end point of this process. The the provision of the substances, the poisons that are going to end someone's life. So I think he confirmed, and I just want to make sure I'm absolutely clear. So I don't misrepresent him. That means that it would not be open to the porter, for example, who didn't want to take the person to the room in which the substances were going to be administered. It wouldn't be open to that Porter to say they had an objection to this process, and to not carry that out.
They would not be able to use the provisions in this act. They would not have the protections. And I don't think that is right. And if the noble Lady, the noble and learned Lady, Baroness Scotland, I think, correctly interpreted the mood of the House as that we do think people should have those protections and have to opt in. That should apply to everybody, not just those at the top of the tree. It should apply to everyone involved in the process, including more junior members of staff who will find it harder to enforce their rights.
As far as.
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The 31 is concerned, one is no person not restricted to doctors is person not restricted to doctors is under any duty to participate in the provision of assistance, which is clause 25 two. No registered is clause 25 two. No registered medical practitioner has to be a coordinating doctor or an independent doctor. Three no registered medical practitioner registered medical practitioner other than the coordinating doctor or the independent doctor, is under any duty to perform any function any duty to perform any function under or in connection with this act.
So I think I have set out what my position is in relation to it, including in relation to the Porter example. I don't think I should go further than that.
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I hesitated, I wanted to come in on top of that because I'm not clear what the position is over clear what the position is over care assistance. People who are involved in intimate care of involved in intimate care of patients, because in Australia in particular, there have been problems where the staff, such as problems where the staff, such as the care assistants who are not the qualified nurses, feel that they qualified nurses, feel that they are somehow providing the patient with their last breath, with their last meal, and it feels to them as if they are having to prepare somebody effectively for their execution, for their end of their life.
Now, that might sound shocking in the way that it's expressed, but that's how it was relayed to me. And that similarly, staff who are preparing a meal, which turns out to be the last meal for that person, can also find that very difficult and very distressing. But if I've heard the noble and learned Lord Knight, those staff have no ability to have any conscience objection whatsoever. And effectively they are being treated as people who just have to operate in their job, like it or
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leave it. Is that correct. In that language? Not at all. But if suppose you were a care assistant giving somebody a bath assistant giving somebody a bath before the provision of assistance, then there's no conscience clause in relation to that. And I'm not sure what the noble Baroness Cass suggesting that if you're caring for somebody who, you know, subsequently is going to have an assisted death, whether there's some point at which you would be entitled to say, as a care assistant, I'm not going to provide assistance to that person, because I find the issue of providing assistance contrary to my conscience.
As far as the the the bill is concerned, it's the every person, doctor or not, that would include the care assistant is under no duty to provide to participate in the provision of assistance in relation to the provision of the substance under clause 25. Back from that, the person doesn't have
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the protection. If I could. Just clarify, the noble and
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Just clarify, the noble and learned Lord Moore is not allowing a provision here to say that. For a provision here to say that. For instance, if you have strong feelings that you would be able to feelings that you would be able to ask to not be rostered to work on that shift or on that day or in that situation, and you would be able to move to another place. Because one of the solutions in some places has been that when there is going to be an assisted death scheduled, the members of staff who don't want to work that day have a right to be rostered off
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in terms of being able to assert their conscience. The position is that if you're
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The position is that if you're on the roster, there was a risk that you would be actually in the that you would be actually in the room and assisting in relation to the provision of assistance. And of course, it would be sensible not to be rostered on that day, and I hope be rostered on that day, and I hope that would be the sort of solution that people would be looking for.
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that people would be looking for. Six, six, nine, eight, if you please, your amendment 669A69A yeah. Your amendment sorry, 6698 and refers to section eight seven, 11 nine and 26 two. But that is only for medical practitioners. It's not for other medical professionals. And it's for that reason. I brought my amendment six, six, four so that my amendment six, six, four so that anybody could opt out to opt in to training for this, not just the medical practitioners, which I'm very glad to see.
Your amendment
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exempts. It's the others. Baroness Lawlor is right that the opt in provision that I've the opt in provision that I've introduced is only in relation to the doctors. And the reason it's only in relation to the doctors is only in relation to the doctors is because it's the doctors that are because it's the doctors that are given the particular role under the bill. So what this is doing is saying you need to be trained saying you need to be trained before you can do particular functions under the bill.
That's why there needs to be an opt in equally in relation to others. There is a no detriment clause. If you say you will not participate and depending on who you are, you can participate. If you're any person not in the provision of the assistance. And as you as as you go wider, you've got wider protections. If you're, for example, a doctor or
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a healthcare professional. Somebody who is employed by an
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Somebody who is employed by an agency or an agency nurse, they may not have the whole provision of the text in front of them, and they may text in front of them, and they may not be encouraged to look into the exemptions for conscientious or other reasons about which we've other reasons about which we've heard. And it's for that reason, if it's on the face of the bill that anybody involved in the medical or anybody involved in the medical or social care for frail people should have the right should be know that they are entitled under law to opt
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out of such training. Well, I. Think I think we know the differences between us. I've set out what my position is. I'm
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out what my position is. I'm grateful to you for setting it out again. Thank you. What the noble and learned Lord
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What the noble and learned Lord said in response to the noble Lady, Lady Finley, that that would be a sensible solution. But that is a sensible solution. But that is a different language to having a legally enforceable right to say to legally enforceable right to say to your employer, I do not want to be rostered on that day. So is that the correct position as I understand it? And could the noble and learned Lord concede that actually these problems exist from the fundamental pillar of the bill, which is you can base this on the notion of of autonomy, which is based on choice and conscience is a different concept to that.
And
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that's why we're in these difficulties. Honestly, don't think that these
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Honestly, don't think that these are difficulties. I do think there is absolute clarity in the bill as is absolute clarity in the bill as to what the legal position is, and to what the legal position is, and it is a very, very wide exception, and it is more than sufficient to give protection to people who do give protection to people who do not want to participate in the provision of assistance under the bill and the pushing it wider and wider simply gives rise to uncertainty.
The key thing is there should be certainty and sufficient width, and I believe that is what
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caused 31 has done. (422) 423-9888. It's possible he could do that in another group at a could do that in another group at a later date, but I just wanted to clarify whether he would make sure he does that.
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he does that. Or 4422 and 423 is creating a regulatory power to allow regulatory power to allow coordinating doctors or independent doctors when they step down in certain circumstances, not to have to give notice, for example, if to give notice, for example, if they're too ill. So it's a
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practical drafting change. I think everyone. Right.
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Right. Who's actually answering my
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Who's actually answering my questions on amendment 679. Well, I think the noble and learned Lord Moore suggested that there might be a differentiation between NHS a differentiation between NHS providers and private providers in the hospice sector. So does the noble and learned Lord see a noble and learned Lord see a scenario where people may feel reluctant or frightened to enter into an NHS hospice, because it may have to be provided there? And will this not put more pressure on private providers? And the noble Lord has rejected many of our amendments, arguing they're not necessary because there should be totally equal access to the process.
But isn't this going to create a two tier system where those who don't want to discuss assisted suicide and might be able to afford a private provider, will actually be able to stay away from any discussions where someone who has
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no money or less money will be forced to go into NHS provision. No.
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No. I do not think it will. And the reason I do not think that it will reason I do not think that it will is because the nature of the safeguards in relation to everybody safeguards in relation to everybody are such that the idea that a assisted death is going to be forced on people is wrong.
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forced on people is wrong. One last thing. I just want to clarification. When the noble and learned Lord talked about hospices, he said in a slightly confusing way that didn't necessarily refer to care homes. I am concerned about care homes, which are run by organisations for for whom this is unacceptable. Are they going to be protected to be able to say that from the beginning? So anybody going into care home of that kind
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knows precisely the terms under which that care home is run. First of.
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First of. All, the only organisational exception that I'm thinking about, because the exceptions in clause one, sorry, clause 31 are for individuals. The only individuals. The only organisational ones that I'm contemplating are ones in relation to hospices, not in relation to
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care homes. On that topic. That's a very important point that the noble and learned laws just made. So to clarify, what he's saying is that 30 clause 30 1AB would not apply in hospices. In other words, at the moment, as drafted, the bill would prevent a hospice as an employer from restricting, say, doctors who were working for that hospice from also participating in assisted dying. If the hospice wanted, as a matter of philosophy or ethos to say, we don't want to be part of that, is he saying that they would have an opt out from 31 A8B? I'm not.
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Sure I understood the question. If the question is, can a hospice opt out from the opt out? The opt out from the opt out? The answer is not can the hospice have a separate opt out? That may be the
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a separate opt out? That may be the position, but I need to consider how to do that. So just to clarify, I think 30
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So just to clarify, I think 30 18B prevents hospice as an employer from restricting its employees from from restricting its employees from participating in assisted dying if they do it somewhere else. Is he saying that he is willing to change
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that? What I what I am thinking about is a provision that says if as a is a provision that says if as a hospice, you say you don't want to provide it, you should not suffer various sorts of institutional various sorts of institutional detriment. That's what I'm interested in. So I'm not saying anything about clause 31 because
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anything about clause 31 because I'm not understanding your question. But that's what I'm thinking about, to be clear. OK, so I think what follows from
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OK, so I think what follows from that is then he is accepting the position that hospices will not be in a position to restrict their employees from participating in assisted dying. If they're doing that somewhere other than in the
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hospice. That's correct. My Lords. I.
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I. I have to thank all noble Lords for this extremely interesting debate and long debate. I don't think I can possibly sum up in any better way than the noble and learned Lady Baroness Cox did, and learned Lady Baroness Cox did, and I felt that she summed up very brilliantly the issues that have been raised during the last 3.5 hours, but I'm going to quickly come back to the noble and learned Lord Dear sponsor.
He posed for responses. One, we've all seemed to be coalescing around that this bill should have an opt in on the face of it. And the noble and learned Lord has given us six, six, nine a. As his response. And. And I think the mood of the House, if I may say, is that that is, is not sufficient. And the mood of the Royal Colleges seems to be. That is not sufficient. So the second point was, is it wide enough? And the resounding answer seems to be no.
We've had a. There is no practical. And I'm sorry I always come back to practicalities in this bill because, you know, it's fine to sort of refer to to the clauses, but but the idea of what's going to happen, how are people going to take these words and implement them? How would you say no? And I am thinking about a busy ward where somebody is, is wanting to, to, to participate in, in assisted assisted dying requests in process and somebody doesn't want to participate.
And they might fear that speaking up at that point might, you know, it might be seen as obstructive, it might harm their chances of promotion. They might not have the confidence to speak up to their superiors. And it wouldn't be a very healthy work dynamic. So there's nothing in this bill that allows for that person to, to, to, to have to say, I didn't opt into this. An opt in system would, you know, would make it all agreed if things would be known about before there's a crisis and people would have the right and there would be a mechanism to change their minds.
And I'm afraid that's where six, six, nine A fails because how can you opt out later? Where's the provision for that? The third point was about the register, which I want to thank the noble Lord Moore for his fantastic support. But the question about where does someone go if the participating doctor doesn't want to participate, where
13:31
Baroness Fraser of Craigmaddie (Conservative)
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Baroness Fraser of Craigmaddie (Conservative)
do they go? How do we know where, where, where they could go? And I'm where, where they could go? And I'm going to take a because the noble and learned Lord Wood suggested that there might be a register at some point in the future. So I'm going to take that as a it's not a going to take that as a it's not a bad idea. And, and, and I it really bothers me that if we're not going to do it because it might be public, to do it because it might be public, then what are we saying about this? The services in this bill, you know, if the public are going to throw brickbats at people for delivering this service, then, you know, as I think the noble Lord, Lord Harper, said, you know, there are other criminal places to to come back at them.
But but there are lots of things that that medical professionals have registered for. The noble Lord and Lady Lord Carlile was talking about registers of specialists. I mean, every single registered professional is on a is on a publicly available. You can look it up. So it bothers me if we're not going to do something just because we are concerned about the response to the public. And finally, workability and may I pay huge tribute to the noble Baroness, Lady Cass, for bringing us back to the patient's journey.
I think it's been a real flaw of the 13 days of our debate, that this is possibly the first time we've actually walked through the patient's journey through this process. And I think, I mean, the idea of a coordinating professional, I have no idea how legally it actually would fit in, but it is a lovely idea. And I think, you know, understanding what the patient's ability to to go through this process is, is very, very important. It just strikes me that the people that are asking for clearer protections, the people that are asking for clearer opt ins and clearer understandings of what we should actually do, and not the lawyers who are all pointing to employment law.
And that's fine. But that takes us to tribunals. And it takes us to, you know, settlements and people having to choose between their career and and their conscience. The people that are asking for it are the health and care and medical professionals and hospital porters and people like that, who will actually have to deliver the service. And I think there is broad support for tightening of the conscience clauses. And I urge the noble and learned Lord, if he's thinking about hospices, you know, he can think about some of these.
And please, will he tighten it up? I beg to with you.
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Are we withdrawing that? Is it your Lordships pleasure that this your Lordships pleasure that this amendment be withdrawn? Amendment by leave withdrawn. Amendment 190 Baroness Finlay not moved. Baroness Finlay not moved. Amendment 191. Lord Frost not moved. Amendment 191. Lord Frost not moved. Thank you. Amendment 192. Baroness Finlay not moved. We now turn to amendment 193. My Lords. Lord Shinkwin will be taking part remotely. I invite the noble Lord to move his amendment in clause five, amendment 193 Lord Shinkwin.
But but there are lots of things that that medical professionals have registered for. The noble Lord and Lady Lord Carlile was talking about registers of specialists. I mean, every single registered professional is on a is on a publicly available. You can look it up. So it bothers me if we're not going to do something just because we are concerned about the response to the public. And finally, workability and may I pay huge tribute to the noble Baroness, Lady Cass, for bringing us back to the patient's journey.
I think it's been a real flaw of the 13 days of our debate, that this is possibly the first time we've actually walked through the patient's journey through this process. And I think, I mean, the idea of a coordinating professional, I have no idea how legally it actually would fit in, but it is a lovely idea. And I think, you know, understanding what the patient's ability to to go through this process is, is very, very important. It just strikes me that the people that are asking for clearer protections, the people that are asking for clearer opt ins and clearer understandings of what we should actually do, and not the lawyers who are all pointing to employment law.
And that's fine. But that takes us to tribunals. And it takes us to, you know, settlements and people having to choose between their career and and their conscience. The people that are asking for it are the health and care and medical professionals and hospital porters and people like that, who will actually have to deliver the service. And I think there is broad support for tightening of the conscience clauses. And I urge the noble and learned Lord, if he's thinking about hospices, you know, he can think about some of these.
And please, will he tighten it up? I beg to with you.
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Are we withdrawing that? Is it your Lordships pleasure that this your Lordships pleasure that this amendment be withdrawn? Amendment by leave withdrawn. Amendment 190 Baroness Finlay not moved. Baroness Finlay not moved. Amendment 191. Lord Frost not moved. Amendment 191. Lord Frost not moved. Thank you. Amendment 192. Baroness Finlay not moved. We now turn to amendment 193. My Lords. Lord Shinkwin will be taking part remotely. I invite the noble Lord to move his amendment in clause five, amendment 193 Lord Shinkwin.
13:34
Lord Shinkwin (Conservative)
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Lord Shinkwin (Conservative)
Myinbox. I managed to speak to amendment 193 in my name, which I amendment 193 in my name, which I should make clear at the outset I don't intend to move. I also support the other amendments in this group and look forward to learning and to listening, as I'm sure the noble and learned Lord does before I wind up at the end of the debate on the strip, my Lord, the modest and reasonable nature of my amendment 103 belies its significance.
It is crucial to ensuring transparency and thus trust the trust of the patients, their families, the medical profession in the widest sense, any relevant legal and regulatory bodies, and, of course, the public. In practical terms, the amendment would require that if a registered medical practitioner or other health professional raises the subject of the provision of assistance in accordance with this act with a person, or if a person raises the subject with a registered medical practitioner or other health professional, it must be considered a preliminary discussion and the discussion must be recorded.
This is therefore very much a to be or not to be amendment, because the noble and learned Lord Forbes response to it will show whether he wants the assisted dying regime that his bill would create to operate transparently or in the shadows. Whether he recognises that transparency is crucial to engendering at least a modicum of trust in the assisted dying process he's proposing, or whether he has something to hide and would much rather plough on.
Regardless, as a lifelong NHS patient who receives a copy of any post appointment letter sent by my orthopaedic surgeon to my GP, as a matter of course, I find the idea not just positively Neanderthal but also pretty sinister, that such a pivotal exchange as a preliminary discussion about assisted dying would not be recorded in a way that explicitly involves the patient. Often becomes essential. As well as touring, and would implicitly multiply beyond a practitioner, beyond the person's GP practice.
To quote the bill. And surely it begs the question as to why any registered medical practitioner or other health professional involved, or indeed the patient would not want for there to be a record of what was said. And furthermore, for that to be made available to both the patients and appropriate stakeholders such as, but not only their GP within the set time frame as provided by amendments in this group, which other noble members will speak to.
My Lords, most sought by Kim Leadbeater in the Other place that this Bill provides for the safest assisted dying regime in the world. I beg to differ, but it's good to know nonetheless that she acknowledges the need for the question of its safety to be addressed. This amendment does exactly that. Its sole purpose is to improve safety. At its heart is the recognition that it's vital to have a written record of the preliminary discussion in the way that my amendment provides, because it acts as a legal gateway to the assisted dying process and provides a permanent trail of evidence for a decision that is final and irreversible.
Maintaining a robust written record of the preliminary discussion and ensuring it is completed and circulated promptly is therefore a fundamental safeguard required to ensure the transparency, accountability and clinical safety of the assisted dying process. Without such a record, the preliminary discussion will always be regarded as having been conducted properly, making it impossible, in fact, to regulate the process. So it's not good enough for the Noble and learned law to point to clauses seven, nine, ten, and 11.
As if to say, what's the problem? Not least because as an amendment in the other place, which explicitly required the doctor to and I quote, record and document the discussion and the information provided. End of quote. And if a copy of the report directly to the patient was not included in Kim Leadbeater new clause seven on reporting, not least because. It did me, of course, the noble and learned Lord may rely on clause 44 and say that the Secretary of State would have the power to require this.
However, that wouldn't put on the face of the bill that there should be a record of the preliminary discussion that sets a minimum standard format or required level of detail for its contents. So to state would have the power to require this according to the bill. But I draw members attention to the recommendation of the delegated Powers and Regulatory Reform Committee's recommendation, which signalled that this was inadequate, and instead that the bill should be amended to explicitly clarify, and I quote, what type of event or other information must be notified or the principles underlying notification indicates on the face of primary legislation.
That is what this amendment does. My Lords, in closing, I would simply highlight that my amendment and the others in this group seek to address what is already, sadly, a known problem in other jurisdictions, including in Canada and in Australia, resulting in disciplinary action and official findings of non-compliance. My Lords, let us learn from them and let us pay heed to the evidence given to the Bill. Select Committee by Doctor Michael Mulholland, Honorary Secretary of the Royal College of General Practitioners, who said, and I quote, if you are having assisted dying conversations, you would want to make sure it was recorded at every point that people were thinking about this on the way through.
End of quote. Indeed. Why would you not? I hope the noble and learned Lords will accept my amendments. I beg to move.
It is crucial to ensuring transparency and thus trust the trust of the patients, their families, the medical profession in the widest sense, any relevant legal and regulatory bodies, and, of course, the public. In practical terms, the amendment would require that if a registered medical practitioner or other health professional raises the subject of the provision of assistance in accordance with this act with a person, or if a person raises the subject with a registered medical practitioner or other health professional, it must be considered a preliminary discussion and the discussion must be recorded.
This is therefore very much a to be or not to be amendment, because the noble and learned Lord Forbes response to it will show whether he wants the assisted dying regime that his bill would create to operate transparently or in the shadows. Whether he recognises that transparency is crucial to engendering at least a modicum of trust in the assisted dying process he's proposing, or whether he has something to hide and would much rather plough on.
Regardless, as a lifelong NHS patient who receives a copy of any post appointment letter sent by my orthopaedic surgeon to my GP, as a matter of course, I find the idea not just positively Neanderthal but also pretty sinister, that such a pivotal exchange as a preliminary discussion about assisted dying would not be recorded in a way that explicitly involves the patient. Often becomes essential. As well as touring, and would implicitly multiply beyond a practitioner, beyond the person's GP practice.
To quote the bill. And surely it begs the question as to why any registered medical practitioner or other health professional involved, or indeed the patient would not want for there to be a record of what was said. And furthermore, for that to be made available to both the patients and appropriate stakeholders such as, but not only their GP within the set time frame as provided by amendments in this group, which other noble members will speak to.
My Lords, most sought by Kim Leadbeater in the Other place that this Bill provides for the safest assisted dying regime in the world. I beg to differ, but it's good to know nonetheless that she acknowledges the need for the question of its safety to be addressed. This amendment does exactly that. Its sole purpose is to improve safety. At its heart is the recognition that it's vital to have a written record of the preliminary discussion in the way that my amendment provides, because it acts as a legal gateway to the assisted dying process and provides a permanent trail of evidence for a decision that is final and irreversible.
Maintaining a robust written record of the preliminary discussion and ensuring it is completed and circulated promptly is therefore a fundamental safeguard required to ensure the transparency, accountability and clinical safety of the assisted dying process. Without such a record, the preliminary discussion will always be regarded as having been conducted properly, making it impossible, in fact, to regulate the process. So it's not good enough for the Noble and learned law to point to clauses seven, nine, ten, and 11.
As if to say, what's the problem? Not least because as an amendment in the other place, which explicitly required the doctor to and I quote, record and document the discussion and the information provided. End of quote. And if a copy of the report directly to the patient was not included in Kim Leadbeater new clause seven on reporting, not least because. It did me, of course, the noble and learned Lord may rely on clause 44 and say that the Secretary of State would have the power to require this.
However, that wouldn't put on the face of the bill that there should be a record of the preliminary discussion that sets a minimum standard format or required level of detail for its contents. So to state would have the power to require this according to the bill. But I draw members attention to the recommendation of the delegated Powers and Regulatory Reform Committee's recommendation, which signalled that this was inadequate, and instead that the bill should be amended to explicitly clarify, and I quote, what type of event or other information must be notified or the principles underlying notification indicates on the face of primary legislation.
That is what this amendment does. My Lords, in closing, I would simply highlight that my amendment and the others in this group seek to address what is already, sadly, a known problem in other jurisdictions, including in Canada and in Australia, resulting in disciplinary action and official findings of non-compliance. My Lords, let us learn from them and let us pay heed to the evidence given to the Bill. Select Committee by Doctor Michael Mulholland, Honorary Secretary of the Royal College of General Practitioners, who said, and I quote, if you are having assisted dying conversations, you would want to make sure it was recorded at every point that people were thinking about this on the way through.
End of quote. Indeed. Why would you not? I hope the noble and learned Lords will accept my amendments. I beg to move.
13:43
Baroness Hollins (Crossbench)
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Baroness Hollins (Crossbench)
Amendment proposed in clause five, page three, line 34. At the five, page three, line 34. At the end, insert the words printed on the Marshalled List.
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the Marshalled List. I commend the important speech of the noble Lord Lord Shinkwin. Decisions at the end of life are complex, and a single conversation simply isn't enough to capture someone's physical condition, their mental state, and their own personal and familial family circumstances. Attempting to record such a complex conversation is quite a daunting prospect, and requiring a preliminary step also adds an unnecessary layer of stress before a proper evaluation can even begin. Both clauses five and seven add more steps, but not more safeguards.
The key protections in this bill checking capacity, ensuring the decision is genuinely voluntary, identifying any coercion can and would be addressed within a multidisciplinary specialist assessment and as it stands, requiring a preliminary discussion and recording it adequately risks duplication whilst also causing unnecessary delay at a time when time is of the essence. Instead, a multidisciplinary panel would provide a specialist provide a full and balanced assessment from the outset. And of course, it would be properly documented. Noble Lords tabled amendments in earlier clauses proposing panel based, evidence led decision making that draws on the skills of multiple professionals and in-depth assessments and multidisciplinary panels, as recommended by Medical Royal Colleges, would allow each person to be assessed appropriately and holistically.
This isn't about adding obstacles, it's about removing unnecessary steps whilst strengthening safeguards, and by going straight to a comprehensive specialist assessment, we make the process both more efficient and more responsible. Lord Stephen more responsible. Lord Stephen would not then be required.
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the Marshalled List. I commend the important speech of the noble Lord Lord Shinkwin. Decisions at the end of life are complex, and a single conversation simply isn't enough to capture someone's physical condition, their mental state, and their own personal and familial family circumstances. Attempting to record such a complex conversation is quite a daunting prospect, and requiring a preliminary step also adds an unnecessary layer of stress before a proper evaluation can even begin. Both clauses five and seven add more steps, but not more safeguards.
The key protections in this bill checking capacity, ensuring the decision is genuinely voluntary, identifying any coercion can and would be addressed within a multidisciplinary specialist assessment and as it stands, requiring a preliminary discussion and recording it adequately risks duplication whilst also causing unnecessary delay at a time when time is of the essence. Instead, a multidisciplinary panel would provide a specialist provide a full and balanced assessment from the outset. And of course, it would be properly documented. Noble Lords tabled amendments in earlier clauses proposing panel based, evidence led decision making that draws on the skills of multiple professionals and in-depth assessments and multidisciplinary panels, as recommended by Medical Royal Colleges, would allow each person to be assessed appropriately and holistically.
This isn't about adding obstacles, it's about removing unnecessary steps whilst strengthening safeguards, and by going straight to a comprehensive specialist assessment, we make the process both more efficient and more responsible. Lord Stephen more responsible. Lord Stephen would not then be required.
13:45
Baroness Grey-Thompson (Crossbench)
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Baroness Grey-Thompson (Crossbench)
I have. >> 12 amendments in this group, and I'm going to speak also to two for one, which is in the next group, which actually probably fits better which actually probably fits better in this one, because it's about the time period for recording information. My Lords, as soon as possible, I think appears eight times in this bill in terms of recording information. And I believe that that is a little bit too vague. It feels like a non-binding term without a strict or official definition, and it makes me think of the parliamentary term soon, which is often used by government Ministers to suggest something may be coming soon, next week, next month or possibly never.
And I think about this process in what might be a busy hospital. It's not only important to gather data correctly, but I think it's important to record it accurately and at pace and the lack of a precise time frame feels like we're giving busy staff just too much flexibility, and it might end up slipping down the list of the things that they need to do when there's a lot of call on their time. And I also think it's about providing and recording information that can be open to scrutiny, because I think the phrase could be used to deflect an immediate challenge or an urgent question, or to be able to follow up in an appropriate way.
My amendment. 214 I do expect there to be some pushback on that, and being told that I'm being overly prescriptive, but I do think it's important to understand why the person wants to enter this process, and whether there are other events or family issues or anything that could possibly impact it. Lack of health and social care, for one, I do have other amendments on support which have been discussed in in other groups. 214 A is about having a witness present, someone who can record the conversation.
My noble friend Baroness Cass, in the earlier group talked about the importance of having a person there, someone who could watch facial expressions, someone who could take the mood of the room, could possibly look out for coercion. And actually, it allows the person who's doing the initial recording to actually listen to what the person is saying, rather than necessarily having to sit and record every part of the conversation. 217 to 18 are all about recording in a timely manner to sorry, five, six, two, five, six three and 564 is about how we record the cancellation of the process.
And I was very interested with Lord Wolfson of Tredegar's amendments, which looked at recording the cancellation immediately. I think that's actually a better version than the one that I had, because I think if someone decides to stop the process, actually, everybody needs to know that straight away rather than maybe something getting lost in reporting or somebody, a medical practitioner, a doctor, assuming that the person still wants assisted dying. I also think it's really important to record how many times somebody may have entered and dropped out of the process that is in another group, but that's also to check that someone is not being guided by mental health issues, suicide ideation, pressure.
I do think these things are important because we do need a minimum standard, and I think doctors and patients need to know what to expect from each other. The Delegated Powers Committee, when looking at this bill, did say that it lacked definition. There was lots of unknown information being recorded. And I think we also have to think about non-compliance. I don't think when I've read the bill many times, I don't think there's enough in there about what happens if this information is not reported correctly.
You know, we know in Oregon, which has been mentioned many times, that about 70% of information is not recorded, recorded on the paperwork. So we don't know if people are having a good death or not. And, you know, the Delegated Powers Committee did recommend that this bill needed amendments. And I think that sort of timely reporting of information avoids any sanitation of the notes. And, you know, it's very easy to forget or I do all the time. I scribble notes and come back to it even a day later and can't necessarily read what I've written.
So, you know, this is really crucial stuff to, to actually how the process work. And I also think it should be there to protect the clinician. And this is where the complication of this bill, you know, I've got 13 amendments I'm talking to now, which actually I'm asking for very little change in the bill, but the bill has to be amended in so many different ways. And this group actually fits with the previous group as well, because the hon. Member of Batley and Spen, Miss Ledbetter, said in another place, you know, agree that under the provision of the bill, the doctor would have a duty to lay out the options available to the patient if they meet the eligibility criteria.
That's the whole purpose of the bill, end quote. But that's why it's so important that the information is recorded properly. And I was talking my one of my passholders, Doctor David Prosser, is a specialist in forensic psychiatry working within NHS Secure Services and His Majesty's Prisons. We've spent a lot of time discussing the bill and talking to a doctor who could be at the very sharpest end of this. His view that, you know, doctor needs to be very clear, has to have very clear criteria in which the assessment is made and also to in order to achieve operational consistency and quality, because what we don't want is in different hospitals, different areas, the information being recorded in a different way.
And if I just look at, you know, a small business, they have to provide more documentation to HMRC than potentially a doctor working in this area. And these amendments are not to overcomplicate the process. But actually, I think contemporary concept, contemporaneous documentation is, is really important. And this also fits into how the commissioner might oversee the compliance of the process if the records are all kept in a different way. And so in previous groups, and when we're debating face to face discussions, the noble and learned Lord Hall Faulkner said, and I quote, is wrong and dangerous to use as soon as practicable in that situation.
So I would ask the Noble and learned, Lord, why is it OK to use it when we're talking about recording data?
**** Possible New Speaker ****
I rise to speak to the amendments in my group. In this amendments in my group. In this group, they aim to tighten the recording rules under clause seven, recording rules under clause seven, but make them even tighter than the noble Baroness who's whose remarks I was very grateful for. The noble Baroness has proposed a seven day Baroness has proposed a seven day limit. I would propose that where the discussion is with the practitioner in the patient's own GP practice, the record of the relevant discussions and assessment is written and saved on the same day online and in other cases the practitioner must within a week submit the record to the patient's medical practice.
Excuse me and to the commissioner. This also. They also require that the practice includes, at that day in the patient's online records, they impose similar tight time limits for the submission of the coordinating doctor's assessment. My Lord speed in recording discussions is of the essence. My experience as a historian, often working with hundreds of documents for over a period of a week in history or even a day, and suggests, and these are government documents of the private records of officials and politicians were.
Speed is important. My work suggests that every hour that passes between a conversation and the record of it brings a loss in accuracy, accuracy and nuance. In the matter of deciding to take your own life, it is particularly important that the record is as accurate and precise as possible. The same day requirement should make for greater accuracy, including details that might otherwise be lost if more time elapses, even insignificant details can turn out to be important.
By contrast, allowing a period of time. As. As in the bill, as soon as practicable to elapse will tend to mean details can be blurred into a general pattern a doctor may form as a result of having seen a number of patients seeking an assisted death. The individual nature of the case may be lost. A report written up and submitted the same day is likely to is less likely to be affected by hindsight, or a desire to tailor the report to ensure that the practitioner will not be held responsible should a breach occur.
These amendments in my name leave the medical practitioner the choice of writing a handwritten note at the time, or just after the appointment, or immediately then, or keying it in later that day into the computer. Although it may be argued that a doctor needs a longer period to see to the paperwork, or that the medical practitioner should be allowed more individual choice about how they handle the recording, the obligation for speed and a formal process is imposed by these amendments, and it's justified since a person's life is at stake.
And I think about this process in what might be a busy hospital. It's not only important to gather data correctly, but I think it's important to record it accurately and at pace and the lack of a precise time frame feels like we're giving busy staff just too much flexibility, and it might end up slipping down the list of the things that they need to do when there's a lot of call on their time. And I also think it's about providing and recording information that can be open to scrutiny, because I think the phrase could be used to deflect an immediate challenge or an urgent question, or to be able to follow up in an appropriate way.
My amendment. 214 I do expect there to be some pushback on that, and being told that I'm being overly prescriptive, but I do think it's important to understand why the person wants to enter this process, and whether there are other events or family issues or anything that could possibly impact it. Lack of health and social care, for one, I do have other amendments on support which have been discussed in in other groups. 214 A is about having a witness present, someone who can record the conversation.
My noble friend Baroness Cass, in the earlier group talked about the importance of having a person there, someone who could watch facial expressions, someone who could take the mood of the room, could possibly look out for coercion. And actually, it allows the person who's doing the initial recording to actually listen to what the person is saying, rather than necessarily having to sit and record every part of the conversation. 217 to 18 are all about recording in a timely manner to sorry, five, six, two, five, six three and 564 is about how we record the cancellation of the process.
And I was very interested with Lord Wolfson of Tredegar's amendments, which looked at recording the cancellation immediately. I think that's actually a better version than the one that I had, because I think if someone decides to stop the process, actually, everybody needs to know that straight away rather than maybe something getting lost in reporting or somebody, a medical practitioner, a doctor, assuming that the person still wants assisted dying. I also think it's really important to record how many times somebody may have entered and dropped out of the process that is in another group, but that's also to check that someone is not being guided by mental health issues, suicide ideation, pressure.
I do think these things are important because we do need a minimum standard, and I think doctors and patients need to know what to expect from each other. The Delegated Powers Committee, when looking at this bill, did say that it lacked definition. There was lots of unknown information being recorded. And I think we also have to think about non-compliance. I don't think when I've read the bill many times, I don't think there's enough in there about what happens if this information is not reported correctly.
You know, we know in Oregon, which has been mentioned many times, that about 70% of information is not recorded, recorded on the paperwork. So we don't know if people are having a good death or not. And, you know, the Delegated Powers Committee did recommend that this bill needed amendments. And I think that sort of timely reporting of information avoids any sanitation of the notes. And, you know, it's very easy to forget or I do all the time. I scribble notes and come back to it even a day later and can't necessarily read what I've written.
So, you know, this is really crucial stuff to, to actually how the process work. And I also think it should be there to protect the clinician. And this is where the complication of this bill, you know, I've got 13 amendments I'm talking to now, which actually I'm asking for very little change in the bill, but the bill has to be amended in so many different ways. And this group actually fits with the previous group as well, because the hon. Member of Batley and Spen, Miss Ledbetter, said in another place, you know, agree that under the provision of the bill, the doctor would have a duty to lay out the options available to the patient if they meet the eligibility criteria.
That's the whole purpose of the bill, end quote. But that's why it's so important that the information is recorded properly. And I was talking my one of my passholders, Doctor David Prosser, is a specialist in forensic psychiatry working within NHS Secure Services and His Majesty's Prisons. We've spent a lot of time discussing the bill and talking to a doctor who could be at the very sharpest end of this. His view that, you know, doctor needs to be very clear, has to have very clear criteria in which the assessment is made and also to in order to achieve operational consistency and quality, because what we don't want is in different hospitals, different areas, the information being recorded in a different way.
And if I just look at, you know, a small business, they have to provide more documentation to HMRC than potentially a doctor working in this area. And these amendments are not to overcomplicate the process. But actually, I think contemporary concept, contemporaneous documentation is, is really important. And this also fits into how the commissioner might oversee the compliance of the process if the records are all kept in a different way. And so in previous groups, and when we're debating face to face discussions, the noble and learned Lord Hall Faulkner said, and I quote, is wrong and dangerous to use as soon as practicable in that situation.
So I would ask the Noble and learned, Lord, why is it OK to use it when we're talking about recording data?
**** Possible New Speaker ****
I rise to speak to the amendments in my group. In this amendments in my group. In this group, they aim to tighten the recording rules under clause seven, recording rules under clause seven, but make them even tighter than the noble Baroness who's whose remarks I was very grateful for. The noble Baroness has proposed a seven day Baroness has proposed a seven day limit. I would propose that where the discussion is with the practitioner in the patient's own GP practice, the record of the relevant discussions and assessment is written and saved on the same day online and in other cases the practitioner must within a week submit the record to the patient's medical practice.
Excuse me and to the commissioner. This also. They also require that the practice includes, at that day in the patient's online records, they impose similar tight time limits for the submission of the coordinating doctor's assessment. My Lord speed in recording discussions is of the essence. My experience as a historian, often working with hundreds of documents for over a period of a week in history or even a day, and suggests, and these are government documents of the private records of officials and politicians were.
Speed is important. My work suggests that every hour that passes between a conversation and the record of it brings a loss in accuracy, accuracy and nuance. In the matter of deciding to take your own life, it is particularly important that the record is as accurate and precise as possible. The same day requirement should make for greater accuracy, including details that might otherwise be lost if more time elapses, even insignificant details can turn out to be important.
By contrast, allowing a period of time. As. As in the bill, as soon as practicable to elapse will tend to mean details can be blurred into a general pattern a doctor may form as a result of having seen a number of patients seeking an assisted death. The individual nature of the case may be lost. A report written up and submitted the same day is likely to is less likely to be affected by hindsight, or a desire to tailor the report to ensure that the practitioner will not be held responsible should a breach occur.
These amendments in my name leave the medical practitioner the choice of writing a handwritten note at the time, or just after the appointment, or immediately then, or keying it in later that day into the computer. Although it may be argued that a doctor needs a longer period to see to the paperwork, or that the medical practitioner should be allowed more individual choice about how they handle the recording, the obligation for speed and a formal process is imposed by these amendments, and it's justified since a person's life is at stake.
13:56
Lord Jackson of Peterborough (Conservative)
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Lord Jackson of Peterborough (Conservative)
I rise to support the amendment >> I rise to support the amendment in the name of my noble friend Lord Shinkwin, and the amendments moved Shinkwin, and the amendments moved by my other noble friends and others. Verbal volant, Scripta others. Verbal volant, Scripta Manet. Spoken words fly away. Written words remain. My Lords, there is a reason that other noble Lords have pressed this specific issue about the collection of data and how specific that data is, and I'm just going to make a broad reference to the experience in other jurisdiction, because without a record, the preliminary discussion will always be regarded as having been conducted properly.
Making it impossible to regulate the process. My Lords, in Australia, we have already seen VAD documentation failures serious enough to trigger disciplinary action and official findings of non-compliance, including unsigned and backdated declarations in Victoria. Witnessing errors, late submission of mandatory forms and hundreds of timeliness related form issues identified in Western Australia. In Victoria, specifically, non-compliant cases included witnessing and late form problems. In the last annual report, Victoria said one case was non-compliant because of an error in which witnessing the contact person appointment form.
Six more cases were non-compliant because forms were submitted late, including first assessment, consulting, assessment and practitioner administration forms. The board also said a data audit had to identify historic cases where first assessment forms had been started, but never submitted specifically to improve data integrity and reporting. The issues and problems are even more significant and egregious in Canada. Paul. Documentation. There were reports of, quote, incomplete assessments, recurrent and excessive delays in reporting, frequent errors and missing information, a lack of evidence on safeguards.
Doctor Yarrow Cotellic, a Canadian academic, noted that despite federal regulations mandated data collection, there is no publicly, quote, no publicly accessible evidence that the eligibility criteria and safeguards prescribed by law were respected unquote, and refusals not being tracked. The Canadian system does not require doctors to formally document their refusals, making it difficult to assess patterns of approval, bias or doctor shopping. And back in Australia, former attorney General for Victoria Robert Clarke described the oversight structure as, quote, hear no evil, see no evil, speak no evil, unquote.
He testified that the regulator simply checks if paperwork is signed rather than auditing actual compliance. In one case where a doctor falsely certified a patient's signature, the regulator merely asked for the missing signature. Instead of investigating the breach. Now, I'm not saying that that is likely to happen, but it's much less likely to happen. My Lords, and even the noble and learned Lord, the sponsor will agree if we have tight wording in the on the face of the Bill which are contained in these amendments, and for those reasons I strongly support the amendment of my noble friend Lord Shinkwin and others.
Making it impossible to regulate the process. My Lords, in Australia, we have already seen VAD documentation failures serious enough to trigger disciplinary action and official findings of non-compliance, including unsigned and backdated declarations in Victoria. Witnessing errors, late submission of mandatory forms and hundreds of timeliness related form issues identified in Western Australia. In Victoria, specifically, non-compliant cases included witnessing and late form problems. In the last annual report, Victoria said one case was non-compliant because of an error in which witnessing the contact person appointment form.
Six more cases were non-compliant because forms were submitted late, including first assessment, consulting, assessment and practitioner administration forms. The board also said a data audit had to identify historic cases where first assessment forms had been started, but never submitted specifically to improve data integrity and reporting. The issues and problems are even more significant and egregious in Canada. Paul. Documentation. There were reports of, quote, incomplete assessments, recurrent and excessive delays in reporting, frequent errors and missing information, a lack of evidence on safeguards.
Doctor Yarrow Cotellic, a Canadian academic, noted that despite federal regulations mandated data collection, there is no publicly, quote, no publicly accessible evidence that the eligibility criteria and safeguards prescribed by law were respected unquote, and refusals not being tracked. The Canadian system does not require doctors to formally document their refusals, making it difficult to assess patterns of approval, bias or doctor shopping. And back in Australia, former attorney General for Victoria Robert Clarke described the oversight structure as, quote, hear no evil, see no evil, speak no evil, unquote.
He testified that the regulator simply checks if paperwork is signed rather than auditing actual compliance. In one case where a doctor falsely certified a patient's signature, the regulator merely asked for the missing signature. Instead of investigating the breach. Now, I'm not saying that that is likely to happen, but it's much less likely to happen. My Lords, and even the noble and learned Lord, the sponsor will agree if we have tight wording in the on the face of the Bill which are contained in these amendments, and for those reasons I strongly support the amendment of my noble friend Lord Shinkwin and others.
14:00
Baroness Murphy (Crossbench)
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Baroness Murphy (Crossbench)
I just want to comment on some of these earlier amendments, particularly the noble Lord Shinkwin. I think actually the Shinkwin. I think actually the noble Lady Finley, I can't remember who's the week before or the week before that, but has reminded us that people who are terminally ill or have discovered that they are very ill and likely to die, have a range of things they want to talk about. Almost always, it will go through their head at some stage as to whether or not they could opt out in some way, whether it's legal or illegal.
That is the way it is, and they will often want to discuss that. But that is not quite what the preliminary discussion for the purposes of this bill is, which is a rather more formal discussion covering a number of. I think there's half a dozen things in the act which the preliminary discussion must cover, and that's not quite the same as this very early recording that is being proposed. For any old discussion that takes place, of course, there will be multiple things that get covered in between a doctor, nurse, between the nurse and the patient, between the patient and his doctor about what they're feeling and what they want.
But it's when it comes down to something which is considered sincerely held, then it is at that point, the preliminary legal discussion comes in as the first discussion to record. A lot of these discussions will be recorded in the medical notes. My experience of actually reading many medical notices. We don't cover what you'd like them to, but in this occasion they often will. But nevertheless, it's not quite the same as what is proposed in this bill. So I would urge people to concentrate on what is actually recorded in this bill as having to be recorded for that preliminary discussion, because that does cover a huge amount more than is being proposed in some of these
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amendments. I just. Wonder if the noble Lady would
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Wonder if the noble Lady would agree with me in the light of the fact that she said that this would be a formal discussion, that if we be a formal discussion, that if we are sticking with the principle of choice and autonomy and accurate information, that it becomes even more important that the patient is more important that the patient is given as fast as possible. A comprehensive copy of that discussion, and that it isn't just left filed in a medical record, but that it should be given to the patient for them to look at and reflect on.
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Well, I don't know about what the noble Baroness discussions with her patients are like, but I remember mine very well. And actually there's a lot of issues. There's a lot of discussion that goes on between a doctor and a goes on between a doctor and a patient, which does not get formally recorded, but is part of the everyday conversation of a consultation. And I think we must recognise, as the noble Lady Fraser recognise, as the noble Lady Fraser this morning was urging us to do, is to get back to the realistic issues about what patients want, what they talk about, and I think it is important that we remember what this bill is about.
It's about trying to do something with what we have in normal day to day medical practice. It is not about imposing something else on what is ordinary day to day practice. Until such time as people have expressed, probably repeatedly, a settled wish that they wished to go down this route and are terminally ill. Then the proper discussion kicks in. Then they need all that information. How much of it is provided to them in written form? How much is provided to them already? I would say as a judgement between the doctor and the nurse and the medical team, the multiple disciplinary team who are looking after them.
That is the way it is, and they will often want to discuss that. But that is not quite what the preliminary discussion for the purposes of this bill is, which is a rather more formal discussion covering a number of. I think there's half a dozen things in the act which the preliminary discussion must cover, and that's not quite the same as this very early recording that is being proposed. For any old discussion that takes place, of course, there will be multiple things that get covered in between a doctor, nurse, between the nurse and the patient, between the patient and his doctor about what they're feeling and what they want.
But it's when it comes down to something which is considered sincerely held, then it is at that point, the preliminary legal discussion comes in as the first discussion to record. A lot of these discussions will be recorded in the medical notes. My experience of actually reading many medical notices. We don't cover what you'd like them to, but in this occasion they often will. But nevertheless, it's not quite the same as what is proposed in this bill. So I would urge people to concentrate on what is actually recorded in this bill as having to be recorded for that preliminary discussion, because that does cover a huge amount more than is being proposed in some of these
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amendments. I just. Wonder if the noble Lady would
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Wonder if the noble Lady would agree with me in the light of the fact that she said that this would be a formal discussion, that if we be a formal discussion, that if we are sticking with the principle of choice and autonomy and accurate information, that it becomes even more important that the patient is more important that the patient is given as fast as possible. A comprehensive copy of that discussion, and that it isn't just left filed in a medical record, but that it should be given to the patient for them to look at and reflect on.
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Well, I don't know about what the noble Baroness discussions with her patients are like, but I remember mine very well. And actually there's a lot of issues. There's a lot of discussion that goes on between a doctor and a goes on between a doctor and a patient, which does not get formally recorded, but is part of the everyday conversation of a consultation. And I think we must recognise, as the noble Lady Fraser recognise, as the noble Lady Fraser this morning was urging us to do, is to get back to the realistic issues about what patients want, what they talk about, and I think it is important that we remember what this bill is about.
It's about trying to do something with what we have in normal day to day medical practice. It is not about imposing something else on what is ordinary day to day practice. Until such time as people have expressed, probably repeatedly, a settled wish that they wished to go down this route and are terminally ill. Then the proper discussion kicks in. Then they need all that information. How much of it is provided to them in written form? How much is provided to them already? I would say as a judgement between the doctor and the nurse and the medical team, the multiple disciplinary team who are looking after them.
14:04
Lord Rook (Labour)
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Lord Rook (Labour)
I thank. >> The noble Baroness, and it's a helpful segue to the amendments that I rise to speak to, which are very much about the first formal very much about the first formal conversation that takes place between a medical practitioner and a patient who is interested in a patient who is interested in exploring the potential of an assisted death. My Lord, I rise to speak to amendments two and three and two, one six in my name. Like others, I'm really grateful for the work that has gone on to strengthen the bill and the decision to record the preliminary discussion is, I think, significant and important.
That said, there remains, in my opinion, a serious gap because while records must be made at the moment, the commissioner who is responsible for the oversight of this system does not have access or visibility to these records. I recognise we are close to recess. I don't wish to lead noble Lords minds astray to their their tube journey home, but my amendments are an attempt to mind the gap that has been created here, and I hope, in fact, they go a bit further and maybe fill the gap by simply making available these written records of the preliminary discussion to the Commissioner.
I believe oversight becomes evidence based, rather than simply allowing regulators to assume the best. This preliminary discussion is the gateway moment in what will be, for some, their final journey. In that moment, a doctor has first sight of the patient's capacity. In that consultation, the patient first hears their full range of options, and in that encounter, there may be the first warning signs of other problems. For instance, evidence of coercion or distress, because, rightly, this conversation will go on in private.
The written record of the doctor is the only durable account of what is likely to be a determinative discussion. And as it stands, that account is not available to the scrutinising body, the very mechanism charged with monitoring the system. Now, this raises two questions for me. First, to my noble Lord and my, my, my noble and learned friend Lord Falconer of Thoroton. If informed consent is the ethical foundation of this legislation, how is this meaningfully verified by the Commissioner? If the primary record of what was explained, asked and understood is not available to them? Without that record, it is not possible, in my opinion, for a commissioner to verify consent.
Rather, they simply take it on trust. And secondly, a question to my noble friend, the Minister how does His Majesty's Government expect the Commissioner to investigate concerns or ensure compliance within the safeguards of this bill, if they are not entitled to see the contemporaneous written record of the very discussion that initiated the process. My Lords, we're all agreed on the need for safety, and if these services aren't sufficiently regulated, I fear they may not be sufficiently safe. A regulator who cannot see the record cannot regulate the system.
A commissioner who only can examine summaries cannot give the system a complete bill of health. And there are wider implications, too. If a family raises concerns about coercion, what is the evidential basis for any investigation? If a clinician is accused of misconduct, what information do they have by which to defend themselves? And if Parliament or the public wish to understand how this law is operating, where is the underlying data that can provide the detail and confidence they seek? My Lords, we have sadly seen what happens when regulators do not have sufficient sight of the systems they oversee.
In 2005 to 2009, there were serious failings in Stafford Hospital widespread, widespread patient harm and avoidable deaths. And despite multiple regulatory bodies, including the Healthcare Commission, the mid staffs problems were not identified or acted upon in time. Why? Because regulators relied on aggregated data targets and self-reporting. Because regulators lacked access to and failed to interrogate evidence because regulators did not have full visibility of serious warning signs and complaints. The lessons learned from missteps help us to think about how we might mind and fill the gap in this legislation.
Compliance without visibility is not protection, and this is precisely what we need to guard against here. From a practical perspective, these amendments are straightforward. They do not impose a new burden on the doctors. The record is already required. They do ensure that the record is shared with the commissioner, who is already acting as the regulating authority. They align responsibility with capability, visibility with compliance, and safety with oversight. My Lords, my Lords, in all legislation, let alone a bill as consequential as this.
We want services that can be trusted and for that we need systems that can be scrutinised. My Lords are regulator who cannot scrutinise the record, cannot regulate the system. These simple amendments simply correct that and I commend them to the House. Yes.
That said, there remains, in my opinion, a serious gap because while records must be made at the moment, the commissioner who is responsible for the oversight of this system does not have access or visibility to these records. I recognise we are close to recess. I don't wish to lead noble Lords minds astray to their their tube journey home, but my amendments are an attempt to mind the gap that has been created here, and I hope, in fact, they go a bit further and maybe fill the gap by simply making available these written records of the preliminary discussion to the Commissioner.
I believe oversight becomes evidence based, rather than simply allowing regulators to assume the best. This preliminary discussion is the gateway moment in what will be, for some, their final journey. In that moment, a doctor has first sight of the patient's capacity. In that consultation, the patient first hears their full range of options, and in that encounter, there may be the first warning signs of other problems. For instance, evidence of coercion or distress, because, rightly, this conversation will go on in private.
The written record of the doctor is the only durable account of what is likely to be a determinative discussion. And as it stands, that account is not available to the scrutinising body, the very mechanism charged with monitoring the system. Now, this raises two questions for me. First, to my noble Lord and my, my, my noble and learned friend Lord Falconer of Thoroton. If informed consent is the ethical foundation of this legislation, how is this meaningfully verified by the Commissioner? If the primary record of what was explained, asked and understood is not available to them? Without that record, it is not possible, in my opinion, for a commissioner to verify consent.
Rather, they simply take it on trust. And secondly, a question to my noble friend, the Minister how does His Majesty's Government expect the Commissioner to investigate concerns or ensure compliance within the safeguards of this bill, if they are not entitled to see the contemporaneous written record of the very discussion that initiated the process. My Lords, we're all agreed on the need for safety, and if these services aren't sufficiently regulated, I fear they may not be sufficiently safe. A regulator who cannot see the record cannot regulate the system.
A commissioner who only can examine summaries cannot give the system a complete bill of health. And there are wider implications, too. If a family raises concerns about coercion, what is the evidential basis for any investigation? If a clinician is accused of misconduct, what information do they have by which to defend themselves? And if Parliament or the public wish to understand how this law is operating, where is the underlying data that can provide the detail and confidence they seek? My Lords, we have sadly seen what happens when regulators do not have sufficient sight of the systems they oversee.
In 2005 to 2009, there were serious failings in Stafford Hospital widespread, widespread patient harm and avoidable deaths. And despite multiple regulatory bodies, including the Healthcare Commission, the mid staffs problems were not identified or acted upon in time. Why? Because regulators relied on aggregated data targets and self-reporting. Because regulators lacked access to and failed to interrogate evidence because regulators did not have full visibility of serious warning signs and complaints. The lessons learned from missteps help us to think about how we might mind and fill the gap in this legislation.
Compliance without visibility is not protection, and this is precisely what we need to guard against here. From a practical perspective, these amendments are straightforward. They do not impose a new burden on the doctors. The record is already required. They do ensure that the record is shared with the commissioner, who is already acting as the regulating authority. They align responsibility with capability, visibility with compliance, and safety with oversight. My Lords, my Lords, in all legislation, let alone a bill as consequential as this.
We want services that can be trusted and for that we need systems that can be scrutinised. My Lords are regulator who cannot scrutinise the record, cannot regulate the system. These simple amendments simply correct that and I commend them to the House. Yes.
14:10
Lord Empey (Ulster Unionist Party)
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Lord Empey (Ulster Unionist Party)
My Lords, at our last meeting >> My Lords, at our last meeting last Friday, we were talking about communication difficulties, whether that was through hearing language, etc. and in that context, I think etc. and in that context, I think the amendments and Lord Rook is done as a service by making it simple and clear. The reason why this is important is that the bill is basically a series of stages, and what happens at stage one needs to be people in stage two needs to know what has occurred, etc.
and down the line. And the oversight to be effective has to be made available. And the reason I raise this, I'm not a medical person, although I do have a family member who's a medical professional, but I've seen at first hand how things can change in a hospital setting where a patient may be in one condition one day and a different condition the next. And the reason why I think this reporting and the availability of the records are so important in assessing how safe the process is.
And the reason I raise this is, by definition, a person who's in hospital is probably going to be receiving medication or in fact, multiple medications. And what you can have happen is you can get drug induced psychosis, delirium, hallucinatory states. These are temporary and reversible conditions. But delirium is a bit like a thief in the night. It creeps up on announced it's there one minute and it's gone the next. And unless people have a consistent record of what the patient has been responding, and how is that patient is assessed and that is passed down the line from one stage to another.
It is going to be extremely difficult to see if these things have been occurring. I mean, delirium is caused and can be caused by the reaction of an individual to various medications that they're receiving. It's sudden and a temporary state of acute confusion and altered mental function. It can develop in hours. It can involve impairing impaired attention, disorientation, hallucinations, rapid shifts between agitation and lethargy, inability to concentrate, emotional swings and distorted thinking. It is therefore my view that having a record and Baroness Grey-Thompson said, perhaps, sir, Amendment 2014 was over.
Prescriptive, perhaps. Let's not argue about the minutiae, but the principle is that the material needs to be available not only to the professionals who are dealing with each stage, but it needs somebody to be safe, as Lord Rook has just told us, has to have oversight, has to have the information available. And when we have these conditions, which bearing in mind, setting aside all the heavy duty communication issues we discussed last week, because a patient is in a hospital, the chances are those patients are receiving significant amounts of very strong medication.
And I've seen it with my own eyes. It can induce a situation of delirium like that and it can go away. It's temporary. So the mood of person is in a, say, the initial stage. That person might be in a different condition at the next stage. People have to see that. People have to know that, and it has to be recorded, because this is just not any old thing. This is a decision to end a life. And I think having some fundamental safety mechanisms available, the records have to be kept, but they have to be shared.
And I think if the analysis that Roderic has just given about the mid staff situation, there have sadly been others subsequent to that, they're not an unusual occurrence. So anything we can do to alleviate that problem, to minimise that problem, let's do it. I don't see any reason why not, but I just draw the attention of members to the fact that these conditions occur in in the hospital. Almost by definition, because of the receipt of the patient of very powerful medications.
So therefore, seeing the condition that might a person might be in that initial stage. And bearing in mind I referred to the fact that one of the conditions is distorted thinking. So let's make it safe. Let's ensure the records are kept and distributed, and that those who need to see them get to see them.
and down the line. And the oversight to be effective has to be made available. And the reason I raise this, I'm not a medical person, although I do have a family member who's a medical professional, but I've seen at first hand how things can change in a hospital setting where a patient may be in one condition one day and a different condition the next. And the reason why I think this reporting and the availability of the records are so important in assessing how safe the process is.
And the reason I raise this is, by definition, a person who's in hospital is probably going to be receiving medication or in fact, multiple medications. And what you can have happen is you can get drug induced psychosis, delirium, hallucinatory states. These are temporary and reversible conditions. But delirium is a bit like a thief in the night. It creeps up on announced it's there one minute and it's gone the next. And unless people have a consistent record of what the patient has been responding, and how is that patient is assessed and that is passed down the line from one stage to another.
It is going to be extremely difficult to see if these things have been occurring. I mean, delirium is caused and can be caused by the reaction of an individual to various medications that they're receiving. It's sudden and a temporary state of acute confusion and altered mental function. It can develop in hours. It can involve impairing impaired attention, disorientation, hallucinations, rapid shifts between agitation and lethargy, inability to concentrate, emotional swings and distorted thinking. It is therefore my view that having a record and Baroness Grey-Thompson said, perhaps, sir, Amendment 2014 was over.
Prescriptive, perhaps. Let's not argue about the minutiae, but the principle is that the material needs to be available not only to the professionals who are dealing with each stage, but it needs somebody to be safe, as Lord Rook has just told us, has to have oversight, has to have the information available. And when we have these conditions, which bearing in mind, setting aside all the heavy duty communication issues we discussed last week, because a patient is in a hospital, the chances are those patients are receiving significant amounts of very strong medication.
And I've seen it with my own eyes. It can induce a situation of delirium like that and it can go away. It's temporary. So the mood of person is in a, say, the initial stage. That person might be in a different condition at the next stage. People have to see that. People have to know that, and it has to be recorded, because this is just not any old thing. This is a decision to end a life. And I think having some fundamental safety mechanisms available, the records have to be kept, but they have to be shared.
And I think if the analysis that Roderic has just given about the mid staff situation, there have sadly been others subsequent to that, they're not an unusual occurrence. So anything we can do to alleviate that problem, to minimise that problem, let's do it. I don't see any reason why not, but I just draw the attention of members to the fact that these conditions occur in in the hospital. Almost by definition, because of the receipt of the patient of very powerful medications.
So therefore, seeing the condition that might a person might be in that initial stage. And bearing in mind I referred to the fact that one of the conditions is distorted thinking. So let's make it safe. Let's ensure the records are kept and distributed, and that those who need to see them get to see them.
14:15
Baroness Keeley (Labour)
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Baroness Keeley (Labour)
Making it safe. I rise to speak to my amendment 219, which would open an extra channel of communication. It requires the person's GP to disclose relevant information about the person's information about the person's eligibility for assisted dying. That information would be disclosed first to the doctor who conducts first to the doctor who conducts the preliminary discussion. Second to the coordinating doctor making the assessment. And third, if the GP believes the person may not be eligible to the commission. The principle behind this amendment is a simple one the doctors, the panel.
They need to be as informed as possible about the applicant and their circumstances. A GP may well have crucial information and at the moment the Bill does not give a clear opportunity for that information to be shared. The GP's only role in the bill, as has been said previously, is to receive notifications. As my noble and learned friend Lord Falconer put it, the GP in the structure of the Bill is not somebody who has to be involved. The GP is somebody who is receiving information, but this seems to be a missed opportunity.
It is not hard to think of cases where a GP might have relevant knowledge. There are instances of fluctuating capacity where GP might well know more about the person and their mental capacity than the assessing doctors and the panel. There are cases of coercion where the assessing doctors might miss the signs, and where there is doubt over the person's illness and their six month prognosis. The GPS input could be essential. The bill does require the accessing doctor to make such inquiries of professionals who are providing, or have recently provided health or social care to the person, as the assessing doctor considers appropriate.
But that's quite a broad provision. Crucially, it's a one way process to the assessing doctor can make an inquiry with the person's GP. The GP is then not supposed to offer helpful information unless they are specifically asked for it, and that seems an obvious gap. In a previous group, we discussed amendments which would give a greater role to the GP, but those amendments were then criticised as unrealistic. This amendment, by contrast, makes a small change which would enhance the protections already in the bill.
My Lords, the report of the Demos Commission, chaired by my noble and learned friend, said a key element in the assisted dying regime was a doctor who, where possible, knows the person well. That doctor could be the patient's general practitioner. The bill does not guarantee that, but my amendment ensures that if the GP does have significant first hand knowledge, that knowledge will be taken into account and not overlooked. You.
They need to be as informed as possible about the applicant and their circumstances. A GP may well have crucial information and at the moment the Bill does not give a clear opportunity for that information to be shared. The GP's only role in the bill, as has been said previously, is to receive notifications. As my noble and learned friend Lord Falconer put it, the GP in the structure of the Bill is not somebody who has to be involved. The GP is somebody who is receiving information, but this seems to be a missed opportunity.
It is not hard to think of cases where a GP might have relevant knowledge. There are instances of fluctuating capacity where GP might well know more about the person and their mental capacity than the assessing doctors and the panel. There are cases of coercion where the assessing doctors might miss the signs, and where there is doubt over the person's illness and their six month prognosis. The GPS input could be essential. The bill does require the accessing doctor to make such inquiries of professionals who are providing, or have recently provided health or social care to the person, as the assessing doctor considers appropriate.
But that's quite a broad provision. Crucially, it's a one way process to the assessing doctor can make an inquiry with the person's GP. The GP is then not supposed to offer helpful information unless they are specifically asked for it, and that seems an obvious gap. In a previous group, we discussed amendments which would give a greater role to the GP, but those amendments were then criticised as unrealistic. This amendment, by contrast, makes a small change which would enhance the protections already in the bill.
My Lords, the report of the Demos Commission, chaired by my noble and learned friend, said a key element in the assisted dying regime was a doctor who, where possible, knows the person well. That doctor could be the patient's general practitioner. The bill does not guarantee that, but my amendment ensures that if the GP does have significant first hand knowledge, that knowledge will be taken into account and not overlooked. You.
14:18
Lord Harper (Conservative)
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Lord Harper (Conservative)
Can be very brief. I just want to speak to the two amendments that I tabled in this group three, five, I tabled in this group three, five, four A and 432A, which are both about making sure that relevant information from the preliminary information from the preliminary discussion are made available to the commissioner and the panel. And the reason why I can be brief is because they're very similar in what they're trying to achieve to those amendments tabled by Lord Rook.
And he set out very clearly the rationale for doing so. So I can simply agree with what he said in terms of the support for my two amendments. I would just briefly like to comment on Lord Shinkwin and Baroness Grey-Thompson. The theme behind all of them is to ensure that there's a timeliness in reporting and sufficient clarity about what is recorded, to give people confidence that the process has been carried out properly. The noble and learned Lords, Lord Falconer, has been very clear about, in the way he set it out, that there's a clear process setter in the bill, but it's very important, I think, to give people confidence that it is documented both comprehensively and on a timely basis.
And there's clearly a debate that can be had about the being too specific about the time frame or what's recorded. But I think ensuring that there is sufficient detail and it's done sufficiently quickly is very important. And I commend those other amendments to
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your Lordships' House as well. My Lords, I hope the House will
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My Lords, I hope the House will forgive me if, for brevity, I focus on the few amendments I have tabled on the few amendments I have tabled in my own name in this group. As in my own name in this group. As the committee will have heard, many of the amendments relate to the
And he set out very clearly the rationale for doing so. So I can simply agree with what he said in terms of the support for my two amendments. I would just briefly like to comment on Lord Shinkwin and Baroness Grey-Thompson. The theme behind all of them is to ensure that there's a timeliness in reporting and sufficient clarity about what is recorded, to give people confidence that the process has been carried out properly. The noble and learned Lords, Lord Falconer, has been very clear about, in the way he set it out, that there's a clear process setter in the bill, but it's very important, I think, to give people confidence that it is documented both comprehensively and on a timely basis.
And there's clearly a debate that can be had about the being too specific about the time frame or what's recorded. But I think ensuring that there is sufficient detail and it's done sufficiently quickly is very important. And I commend those other amendments to
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your Lordships' House as well. My Lords, I hope the House will
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My Lords, I hope the House will forgive me if, for brevity, I focus on the few amendments I have tabled on the few amendments I have tabled in my own name in this group. As in my own name in this group. As the committee will have heard, many of the amendments relate to the
14:19
Lord Wolfson of Tredegar (Conservative)
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Lord Wolfson of Tredegar (Conservative)
of the amendments relate to the preliminary discussion or to recording general medical information as the patient progresses through the procedure. But as indicated by the noble Lady Baroness Grey-Thompson, I'm grateful to her for her kind words. My amendments focus on a particular issue, which I think is very important. My amendments five, six, two, A, five, 63A and 564A all seek to probe the circumstances in which it would be appropriate for a patient's decision to cancel their first or second declaration, not to be recorded immediately.
And I do think there is a point of principle here that while I can understand there can be a genuine debate about whether a decision to initiate the procedure should be recorded and if so, how quickly it should be recorded. I am concerned that a decision to pull out, which is what a decision to cancel, is, whether after the first or second declaration should not be left sort of hanging there. I don't understand why that should only be recorded as soon as practicable and not immediately, as the noble and learned Lord Roe will be aware, for the benefit of the committee immediately.
In English, law generally means forthwith. It means as quickly as possible. You're not going to be in breach of the statute if you do not record it within 3.5 seconds. The courts will always take circumstances and context into account, but immediately gives that sense of urgency, which I would suggest is very important. I think it is particularly important, and this is why I put the amendments down in the context. When somebody is cancelling, I is pulling out because we must not have any risk whatsoever that somebody, another medical practitioner or other healthcare professional might think that the person is, so to speak, still in the system, when in fact they have cancelled their first or second declaration.
I would also point out, without getting too much into the the threshing through the undergrowth on a Friday afternoon, but it always is Friday afternoon for this bill, and this is particularly important in clause 24 three, sorry, 24 three. And let me explain why 24 two deals. When the notice or indication is given to a registered medical practitioner with the person's GP practice, and immediately there, I would suggest, is appropriate for the reasons I've just given.
It's all the more important in 24 three, when the registered medical practitioner to whom the notice or indication of cancellation is given is not within the practice. The problem there, as drafted, is that you have two as reasonably as soon as reasonably practicable, the first one must notify the practice as soon as reasonably practicable, and then the practitioner notified must as soon as reasonably practicable, or as soon as practicable, record the declaration. Now that doubling seems to me to be problematic as well, and I would suggest that immediately in this circumstance ought to be the key test.
So I would invite the noble Leonard, Lord Lord Falconer of Thoroton, when he replies to explain whether he believes, as I do, that the failure to record a declaration cancellation immediately might result in harm coming to a patient, and if not by way of my amendment, how do we mitigate that risk? So far as the noble Lady the Minister is concerned, this does go. I would suggest to the point which we are repeatedly told by the Ministers on duty is the focus of the government's position, which is whether this is workable or practicable.
Has the government looked at whether immediate recording is practicable, and if so, and even if not, I for one will be interested in knowing the Minister's thoughts and the government's position on that point.
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My Lord. Can I start by thanking noble Lords for an important and noble Lords for an important and thoughtful debate this afternoon? As I've already made clear, I will As I've already made clear, I will keep my detailed comments limited to amendments on which the government has major legal, government has major legal, technical or operational workability concerns. I was first
And I do think there is a point of principle here that while I can understand there can be a genuine debate about whether a decision to initiate the procedure should be recorded and if so, how quickly it should be recorded. I am concerned that a decision to pull out, which is what a decision to cancel, is, whether after the first or second declaration should not be left sort of hanging there. I don't understand why that should only be recorded as soon as practicable and not immediately, as the noble and learned Lord Roe will be aware, for the benefit of the committee immediately.
In English, law generally means forthwith. It means as quickly as possible. You're not going to be in breach of the statute if you do not record it within 3.5 seconds. The courts will always take circumstances and context into account, but immediately gives that sense of urgency, which I would suggest is very important. I think it is particularly important, and this is why I put the amendments down in the context. When somebody is cancelling, I is pulling out because we must not have any risk whatsoever that somebody, another medical practitioner or other healthcare professional might think that the person is, so to speak, still in the system, when in fact they have cancelled their first or second declaration.
I would also point out, without getting too much into the the threshing through the undergrowth on a Friday afternoon, but it always is Friday afternoon for this bill, and this is particularly important in clause 24 three, sorry, 24 three. And let me explain why 24 two deals. When the notice or indication is given to a registered medical practitioner with the person's GP practice, and immediately there, I would suggest, is appropriate for the reasons I've just given.
It's all the more important in 24 three, when the registered medical practitioner to whom the notice or indication of cancellation is given is not within the practice. The problem there, as drafted, is that you have two as reasonably as soon as reasonably practicable, the first one must notify the practice as soon as reasonably practicable, and then the practitioner notified must as soon as reasonably practicable, or as soon as practicable, record the declaration. Now that doubling seems to me to be problematic as well, and I would suggest that immediately in this circumstance ought to be the key test.
So I would invite the noble Leonard, Lord Lord Falconer of Thoroton, when he replies to explain whether he believes, as I do, that the failure to record a declaration cancellation immediately might result in harm coming to a patient, and if not by way of my amendment, how do we mitigate that risk? So far as the noble Lady the Minister is concerned, this does go. I would suggest to the point which we are repeatedly told by the Ministers on duty is the focus of the government's position, which is whether this is workable or practicable.
Has the government looked at whether immediate recording is practicable, and if so, and even if not, I for one will be interested in knowing the Minister's thoughts and the government's position on that point.
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My Lord. Can I start by thanking noble Lords for an important and noble Lords for an important and thoughtful debate this afternoon? As I've already made clear, I will As I've already made clear, I will keep my detailed comments limited to amendments on which the government has major legal, government has major legal, technical or operational workability concerns. I was first
14:25
Baroness Blake of Leeds (Labour)
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Baroness Blake of Leeds (Labour)
speak to amendments 2121 2215 2172 1821 457557558559562563 and 564. Tabled by the noble Lady Baroness Grey-Thompson these amendments introduce specified time limits for when duties in the Bill must be under undertaken. Similarly, amendments. 212A212B215A217A218A218. B320. C three. 321. A tabled by the noble Lady Baroness Lawlor. Specify a time frame by which records of a person's preliminary discussion and first assessment must be recorded in the medical notes as drafted.
The bill requires this information to be recorded as soon as practicable, as the government has not developed a service delivery model, I cannot confirm that the timelines proposed in these amendments are workable amendments which change the duty to record information from as soon as practicable to within 24 hours, or to require the coordinating doctor to make a report the same day they see the person may result in a duty that is difficult or impossible to discharge. As drafted, these amendments may increase the risk of practitioners facing legal or professional action, for example, if they fail to comply with this mandatory duty due to being sick or on leave, the amendments do not afford any discretion or flexibility.
Amendments 219 tabled by my noble friend Baroness Keeley, would require a registered medical practitioner with the person's GP practice to disclose any information in their possession, which may affect the person's eligibility for an assisted death. They must disclose this information to the practitioner conducting the preliminary discussion, and this information must be taken into account by the coordinating doctor when undertaking the first assessment. Subsection five of the amendment requires a registered medical practitioner with the person's GP practice to notify the commissioner if they have reasonable grounds to believe that an individual does not meet the eligibility requirements for an assisted death.
The amendment is not clear on a number of key details, such as who in the GP practice is subject to these obligations when the information must be sent, how the information is to get to the Coordinating Doctor for the first assessment, whether it is continuing a continuing or a one off obligation, and how the duty is intend to operate with clause 31. This duty may also mandate information sharing with the Commissioner in relation to people who are considered by a registered medical practitioner within a GP practice to not be suitable for an assisted death, even if the person in question is not actively seeking an assisted death under the.
The bill, with reference to the question from my noble friend Lord Rook, the. The. His question about whether the powers in the bill are sufficient for the Commissioner, or whether further powers should be granted, is one for Parliament to decide in the eventuality. Finally, amendment 561, tabled by the noble Lady Baroness Grey-Thompson amends clause 24 to require any preliminary discussion, first discussion and second declaration to be recorded in a person's medical records, including the reason for not continuing to the next stage.
It is not clear who must undertake these duties, or what happens if the person seeking assistance does not give a reason for why they do not wish to proceed. Where legislation seeks to impose a duty, it must specify who that duty is placed on. This is particularly important given that an intentional or reckless failure to comply with the duty under clause 24 is a criminal offence. This amendment would require further policy and legal work to clarify the intent and ensure the drafting is workable, with reference to the noble and learned Lord Wolfson amendment 562, A, five, 63A and 564A do not have major workability concerns.
Noble Lords will be aware that other amendments in this group have not had technical drafting support from officials. The issues raised by these amendments are rightly a matter for noble Lords to consider and decide, but I would note that the way they are currently drafted means they may not be fully workable, effective or enforceable.
The bill requires this information to be recorded as soon as practicable, as the government has not developed a service delivery model, I cannot confirm that the timelines proposed in these amendments are workable amendments which change the duty to record information from as soon as practicable to within 24 hours, or to require the coordinating doctor to make a report the same day they see the person may result in a duty that is difficult or impossible to discharge. As drafted, these amendments may increase the risk of practitioners facing legal or professional action, for example, if they fail to comply with this mandatory duty due to being sick or on leave, the amendments do not afford any discretion or flexibility.
Amendments 219 tabled by my noble friend Baroness Keeley, would require a registered medical practitioner with the person's GP practice to disclose any information in their possession, which may affect the person's eligibility for an assisted death. They must disclose this information to the practitioner conducting the preliminary discussion, and this information must be taken into account by the coordinating doctor when undertaking the first assessment. Subsection five of the amendment requires a registered medical practitioner with the person's GP practice to notify the commissioner if they have reasonable grounds to believe that an individual does not meet the eligibility requirements for an assisted death.
The amendment is not clear on a number of key details, such as who in the GP practice is subject to these obligations when the information must be sent, how the information is to get to the Coordinating Doctor for the first assessment, whether it is continuing a continuing or a one off obligation, and how the duty is intend to operate with clause 31. This duty may also mandate information sharing with the Commissioner in relation to people who are considered by a registered medical practitioner within a GP practice to not be suitable for an assisted death, even if the person in question is not actively seeking an assisted death under the.
The bill, with reference to the question from my noble friend Lord Rook, the. The. His question about whether the powers in the bill are sufficient for the Commissioner, or whether further powers should be granted, is one for Parliament to decide in the eventuality. Finally, amendment 561, tabled by the noble Lady Baroness Grey-Thompson amends clause 24 to require any preliminary discussion, first discussion and second declaration to be recorded in a person's medical records, including the reason for not continuing to the next stage.
It is not clear who must undertake these duties, or what happens if the person seeking assistance does not give a reason for why they do not wish to proceed. Where legislation seeks to impose a duty, it must specify who that duty is placed on. This is particularly important given that an intentional or reckless failure to comply with the duty under clause 24 is a criminal offence. This amendment would require further policy and legal work to clarify the intent and ensure the drafting is workable, with reference to the noble and learned Lord Wolfson amendment 562, A, five, 63A and 564A do not have major workability concerns.
Noble Lords will be aware that other amendments in this group have not had technical drafting support from officials. The issues raised by these amendments are rightly a matter for noble Lords to consider and decide, but I would note that the way they are currently drafted means they may not be fully workable, effective or enforceable.
14:30
Lord Falconer of Thoroton (Labour)
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Lord Falconer of Thoroton (Labour)
These amendments. Concern the. >> And the timing. >> Of recording, not just the preliminary discussion, but also preliminary discussion, but also cancellations, and they also raise obligations on the part of GPS to provide information. And they also provide information. And they also provide the need to give the commissioner material so that he can properly continue his or perform his functions as a effectively a regulator of the process. Could I just adopt what the noble Baroness Baroness Murphy said? And there needs to be some degree of understanding about clause five.
Clause five is a requirement that has to be gone through before one can have an assisted death. The effect of clause five is that it has to be a preliminary discussion. The preliminary discussion requires a doctor to go through with the patient, their diagnosis and prognosis, any treatment available in the likely effect of it, and all appropriate palliative hospice or other care, including symptom management and psychological psychological support, and offer to refer them to palliative care person so that the person before they embark on this has a balanced view about what their options are before they embark on the process of an assisted death, which means going through the safeguards.
And what's more, the bill currently requires that the record of that conversation is recorded as soon as practicable by the person with whom the patient has had that requirement. Now that's the framework within which one looks at these. The first proposal is from Baron Lord Shinkwin, the noble Lord Lord Shinkwin, who proposes that any conversation that a patient has with any doctor, whether the doctor raises an assisted death or they raise an assisted death, should be treated as a preliminary discussion of the sort that I've just described, and that discussion must be recorded.
I understand why the noble Lord has put that in, but I don't think it's either appropriate or practical. The reason there is a preliminary discussion requirement and the requirement that preliminary discussion be recorded, is that a safeguard, it shouldn't stop any patient having a conversation, formal or informal, with their doctor, in which they raise issues about their care and, for example, they might want to raise. Well, tell me what you know about assisted dying. Or have you ever seen one? If you have that conversation, I think it should be recorded, but it doesn't make it a preliminary discussion.
And it can be before the process has started. So although I understand why the noble Lord Lord Shinkwin has put the amendment down, I'm not minded to accept it because I don't think it's either necessary or appropriate or practical. The noble Baroness Baroness Grey-Thompson and the noble Baroness Baroness Lawlor wished in primarily in relation to the preliminary discussion, but also in relation to other areas, to, say, reduce the words as, as, as soon as reasonably practicable to either immediately 24 hours, record straight away, seven days, etc.
subject to the question of cancellation, where I think there's an. I think there's a different case. I'm not in favour of changing the words as soon as reasonably practicable. It seems to me that's the appropriate test for your recording. Something that goes on as soon as reasonably practical has to be looked at against the the framework. It's just not appropriate, it seems to me, to to change that, where we're dealing with doctors who will have other pressures on them. But I completely underline the importance of there being a record, hence the requirement for it be done as soon as it needs to be practical.
The noble Baroness Baroness Keeley amendment, what what she is suggesting is that a GP has got to give information to. I think it's one or other of the assessing doctors, though it's also the. I assume it applies right across the board, not just the preliminary doctor, but the assessing doctor as the noble Baroness Baroness Lawlor knows. In relation to clause 12, there is a requirement on both the independent and the. Coordinating Doctor to examine the person and their records.
Make such inquiries of professionals who are providing or have recently provided health or social care to the person, as the assessing doctor considers appropriate. And I've also put an amendment down which reflects discussions that we've had earlier, which suggests that both those doctors should also talk to the multidisciplinary team in who's responsible for the care of the doctor, to ensure that they get the full amount of information available. I completely accept the underlying principle behind the noble Baroness Bi Baroness Keeley amendment, but I think that those steps which are mandated are probably enough.
The noble, the noble Lord Lord Rook and the noble Lord, Lord Harper, both want there to be a specific requirement on the preliminary discussion record to be given to the. To the Commissioner, noble Lords will know that clause 44 of the Bill I just refer to. It allows the Secretary of State to make regulations requiring that any doctor involved to notify the Commissioner of any part that they play and any information that they play that noble Lords will know under clause 49 that the Commissioner is under an obligation to monitor the operation of the act, and noble Lords will know that that, Commissioner is effectively.
The obligations of confidence don't apply when providing information to the Commissioner. Now, I think those provisions are sufficient. I don't think it is necessary at all unreasonable for the proposal that the noble Lord Lord Harper, the noble Lord Lord Rook, has made. But it may well be that the right approach for the Commissioner to take is to decide which documentation he wants to have on a habitual basis, because I completely accept what the Commission, what Lord Rook noble Lord Northbrook and the noble Lord, Lord Harper, are saying, which is the Commission has got to be in a position to perform his regulatory function.
But I think it's probably for him to decide what documentation should come to him habitually. So I don't think it's appropriate to amend the bill in that respect. I finally, the point made by the noble Lord Lord Wolfson and the noble Baroness Baroness Grey-Thompson, and I note that the noble Baroness Parminter said there are no workability, I am. I am struck by the argument that they both made, which is. This is obviously so important that if you give a cancellation to avoid any problem, then you should probably notify immediately.
And I thought that the noble Lord Lord Wolfson made a good point when he said there's a two stage process before you get to it. So I think I should consider that. I think that's an important amendment.
Clause five is a requirement that has to be gone through before one can have an assisted death. The effect of clause five is that it has to be a preliminary discussion. The preliminary discussion requires a doctor to go through with the patient, their diagnosis and prognosis, any treatment available in the likely effect of it, and all appropriate palliative hospice or other care, including symptom management and psychological psychological support, and offer to refer them to palliative care person so that the person before they embark on this has a balanced view about what their options are before they embark on the process of an assisted death, which means going through the safeguards.
And what's more, the bill currently requires that the record of that conversation is recorded as soon as practicable by the person with whom the patient has had that requirement. Now that's the framework within which one looks at these. The first proposal is from Baron Lord Shinkwin, the noble Lord Lord Shinkwin, who proposes that any conversation that a patient has with any doctor, whether the doctor raises an assisted death or they raise an assisted death, should be treated as a preliminary discussion of the sort that I've just described, and that discussion must be recorded.
I understand why the noble Lord has put that in, but I don't think it's either appropriate or practical. The reason there is a preliminary discussion requirement and the requirement that preliminary discussion be recorded, is that a safeguard, it shouldn't stop any patient having a conversation, formal or informal, with their doctor, in which they raise issues about their care and, for example, they might want to raise. Well, tell me what you know about assisted dying. Or have you ever seen one? If you have that conversation, I think it should be recorded, but it doesn't make it a preliminary discussion.
And it can be before the process has started. So although I understand why the noble Lord Lord Shinkwin has put the amendment down, I'm not minded to accept it because I don't think it's either necessary or appropriate or practical. The noble Baroness Baroness Grey-Thompson and the noble Baroness Baroness Lawlor wished in primarily in relation to the preliminary discussion, but also in relation to other areas, to, say, reduce the words as, as, as soon as reasonably practicable to either immediately 24 hours, record straight away, seven days, etc.
subject to the question of cancellation, where I think there's an. I think there's a different case. I'm not in favour of changing the words as soon as reasonably practicable. It seems to me that's the appropriate test for your recording. Something that goes on as soon as reasonably practical has to be looked at against the the framework. It's just not appropriate, it seems to me, to to change that, where we're dealing with doctors who will have other pressures on them. But I completely underline the importance of there being a record, hence the requirement for it be done as soon as it needs to be practical.
The noble Baroness Baroness Keeley amendment, what what she is suggesting is that a GP has got to give information to. I think it's one or other of the assessing doctors, though it's also the. I assume it applies right across the board, not just the preliminary doctor, but the assessing doctor as the noble Baroness Baroness Lawlor knows. In relation to clause 12, there is a requirement on both the independent and the. Coordinating Doctor to examine the person and their records.
Make such inquiries of professionals who are providing or have recently provided health or social care to the person, as the assessing doctor considers appropriate. And I've also put an amendment down which reflects discussions that we've had earlier, which suggests that both those doctors should also talk to the multidisciplinary team in who's responsible for the care of the doctor, to ensure that they get the full amount of information available. I completely accept the underlying principle behind the noble Baroness Bi Baroness Keeley amendment, but I think that those steps which are mandated are probably enough.
The noble, the noble Lord Lord Rook and the noble Lord, Lord Harper, both want there to be a specific requirement on the preliminary discussion record to be given to the. To the Commissioner, noble Lords will know that clause 44 of the Bill I just refer to. It allows the Secretary of State to make regulations requiring that any doctor involved to notify the Commissioner of any part that they play and any information that they play that noble Lords will know under clause 49 that the Commissioner is under an obligation to monitor the operation of the act, and noble Lords will know that that, Commissioner is effectively.
The obligations of confidence don't apply when providing information to the Commissioner. Now, I think those provisions are sufficient. I don't think it is necessary at all unreasonable for the proposal that the noble Lord Lord Harper, the noble Lord Lord Rook, has made. But it may well be that the right approach for the Commissioner to take is to decide which documentation he wants to have on a habitual basis, because I completely accept what the Commission, what Lord Rook noble Lord Northbrook and the noble Lord, Lord Harper, are saying, which is the Commission has got to be in a position to perform his regulatory function.
But I think it's probably for him to decide what documentation should come to him habitually. So I don't think it's appropriate to amend the bill in that respect. I finally, the point made by the noble Lord Lord Wolfson and the noble Baroness Baroness Grey-Thompson, and I note that the noble Baroness Parminter said there are no workability, I am. I am struck by the argument that they both made, which is. This is obviously so important that if you give a cancellation to avoid any problem, then you should probably notify immediately.
And I thought that the noble Lord Lord Wolfson made a good point when he said there's a two stage process before you get to it. So I think I should consider that. I think that's an important amendment.
14:38
Lord Shinkwin (Conservative)
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Lord Shinkwin (Conservative)
My Lords, I remind the committee that Lord Shinkwin is taking part remotely, and I invite noble Lord to reply to the debate. >> My Lords, I'm mindful that noble
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My Lords, I'm mindful that noble members will be counting down the minutes to the start of a minutes to the start of a well-earned Easter recess, so my remarks are short on time. My votes. I hope I will be forgiven if I don't refer to individual contributions. But I was struck by the strong consensus that was provided by the amendments in this group is crucial, not just to engendering trust in the system, but also for providing for patient safety, especially as conditions towards the end of life will fluctuate, particularly in the case of delirium.
So I thank members for their contributions. And while I disagree with the Noble and learned law that it is not appropriate to retort any discussions about assisted dying, I believe keeping records on assisted dying is vital. I feel I must thank him for something he said unto me today. 13 on the 20th of March, which makes the case for my amendment 103 and the other amendments in the group. Perfectly noble members may report that the noble and learned Lord Moore caused the House to be convulsed in laughter by a trip he made.
When my noble friend Lord Frost appeared in the chamber after my noble friend Lord Gove had moved Lord Frost amendments in his unavoidable absence, I told him to. Parliament live, and the transcript that goes with Parliament live at approximately 4:10 p.m. on the 20th of March. But noble and learned Lord quipped on seeing Lord Frost returning to the chamber, and I quote, so sorry. He perhaps shouldn't have bothered. It was brilliant for a number of reasons for its timing, its spontaneity and particularly its piercing, if inadvertent honesty.
I was correct for Noble and learned Lordships phrase brilliantly. That is, in the two sensible words, in terms of shining a light on something. His overall approach to dealing with 14 days of dismissing amendment after amendment and allowing dignity in dying, and other supporters of the bill to denigrate noble members carefully considered and well intentioned attempts to mitigate the worst dangers posed by this bill. Notable members to be forgiven for asking why this is relevant to today's consideration of amendments.
The reason my vote is this the amendments were discussing highlight the need for rigorous recordkeeping at the preliminary discussion phase and indeed beyond. Throughout the assisted dying process. Yet noble members may be interested to know that despite it being clearly captured on Parliament life both on screen and in the accompanying transcripts, as I've already mentioned, there is no rattles over noble and learned Lord Stirrup in Hansard. My vote. I mean, no criticism of our wonderful Hansard team, but I find it rather odd that the official record should be inaccurate in this specific respect.
I therefore hope it helps the House and also the noble and learned laws that his significant remarks to my noble friend Lord Frost. Sorry, perhaps he shouldn't have bothered are now on the record in Hansard. The fact that they were admitted surely provides compelling evidence in support of rigorous recordkeeping, as provided for by amendment 193 and the other amendments in this group. My Lords, I hope we can all accept that there is no such thing as too much transparency when it comes to matters of life and death that we are discussing in relation to this bill, and in closing, to my entire room doors, as my mother, friend Baroness.
Grows out of it, the remarks of the noble Baroness, Lady Scotland, that we all write each other a lot and wish all noble members a very happy Easter.
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The noble Lord wishes to withdraw his amendment. Yes, yes. Not rude.
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Not rude. Is it your Lordships pleasure that this amendment be withdrawn? Amendment is by leave withdrawn.
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Amendment is by leave withdrawn. Amendment 194. Lord Shinkwin not moved. Not moved 195.
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Not moved 195. Lord Frost not moved 196. Lord Frost not moved 197. Lord Frost not moved 198. Lord Frost not moved 199 not moved 200. Baroness Grey-Thompson not moved 202. Sorry. Of course. Oh yeah. Question is that clause stand part of the bill as many of that financial content not content. The contents have it. Clause two 200 B Lord Weir of Ballyholme not moved 200 C Baroness Berridge not moved a two 201 Baroness Finlay of Llandaff not moved 202 Baroness Goudie not moved.
Amendment 204. Baroness Lawlor not not moved. 205 Baroness Monckton of Dallington forest not moved. Therefore. 200 200 and 208 Baroness Goudie not moved. Not moved to. Not 2207 was a was an amendment to. 205 thank you. Amendment 209 Baroness Goudie not moved. 210 Lord Rook not moved. 211 Lord Rook not moved. The question is that clause 610 part of the bill as many of that opinion's content contrary not content contents have it.
Amendment 212 Baroness Grey-Thompson not moved 200 202 a Baroness Lawlor not not moved 212B Baroness Lawlor not moved 213 Lord Brooke not Lord Rook not moved 214 Baroness Grey-Thompson not moved 214A2145 Paris Thompson not moved 215A Baroness Lawlor not moved to one six. Lord Rook not moved 217 Baroness Grey-Thompson not not moved 217A Baroness Lawlor not moved 218 Baroness Grey-Thompson not moved 218A Baroness Lawlor not moved. 218B Baroness Lawlor not moved 219 Baroness Keeley not moved.
220 Baroness Foster of Oxton not moved. Not moved. Question is that clause seven part of the Bill? As many of that opinion content contrary, not content. The contents have it. amendment 221 Baroness Hollins not moved 224. Baroness Hollins not moved sorry. 222222 not Hollins not moved sorry. 222222 not amendment 223 Lord Birt not moved. Therefore. Therefore. Therefore two two. Therefore, we have come to. OK.
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My Lords, I beg to move that the House be resumed. Question is that the House be resumed. As many as that opinion shall say content contrary, not content. I think the contents have
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it. My Lords, before I adjourn the House. My wish. All noble Lords, clerks and doorkeepers are very wonderful. Recess. And with that, my Lords, I beg to move that the House do now adjourn. House do now adjourn.
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My Lords, I'm mindful that noble members will be counting down the minutes to the start of a minutes to the start of a well-earned Easter recess, so my remarks are short on time. My votes. I hope I will be forgiven if I don't refer to individual contributions. But I was struck by the strong consensus that was provided by the amendments in this group is crucial, not just to engendering trust in the system, but also for providing for patient safety, especially as conditions towards the end of life will fluctuate, particularly in the case of delirium.
So I thank members for their contributions. And while I disagree with the Noble and learned law that it is not appropriate to retort any discussions about assisted dying, I believe keeping records on assisted dying is vital. I feel I must thank him for something he said unto me today. 13 on the 20th of March, which makes the case for my amendment 103 and the other amendments in the group. Perfectly noble members may report that the noble and learned Lord Moore caused the House to be convulsed in laughter by a trip he made.
When my noble friend Lord Frost appeared in the chamber after my noble friend Lord Gove had moved Lord Frost amendments in his unavoidable absence, I told him to. Parliament live, and the transcript that goes with Parliament live at approximately 4:10 p.m. on the 20th of March. But noble and learned Lord quipped on seeing Lord Frost returning to the chamber, and I quote, so sorry. He perhaps shouldn't have bothered. It was brilliant for a number of reasons for its timing, its spontaneity and particularly its piercing, if inadvertent honesty.
I was correct for Noble and learned Lordships phrase brilliantly. That is, in the two sensible words, in terms of shining a light on something. His overall approach to dealing with 14 days of dismissing amendment after amendment and allowing dignity in dying, and other supporters of the bill to denigrate noble members carefully considered and well intentioned attempts to mitigate the worst dangers posed by this bill. Notable members to be forgiven for asking why this is relevant to today's consideration of amendments.
The reason my vote is this the amendments were discussing highlight the need for rigorous recordkeeping at the preliminary discussion phase and indeed beyond. Throughout the assisted dying process. Yet noble members may be interested to know that despite it being clearly captured on Parliament life both on screen and in the accompanying transcripts, as I've already mentioned, there is no rattles over noble and learned Lord Stirrup in Hansard. My vote. I mean, no criticism of our wonderful Hansard team, but I find it rather odd that the official record should be inaccurate in this specific respect.
I therefore hope it helps the House and also the noble and learned laws that his significant remarks to my noble friend Lord Frost. Sorry, perhaps he shouldn't have bothered are now on the record in Hansard. The fact that they were admitted surely provides compelling evidence in support of rigorous recordkeeping, as provided for by amendment 193 and the other amendments in this group. My Lords, I hope we can all accept that there is no such thing as too much transparency when it comes to matters of life and death that we are discussing in relation to this bill, and in closing, to my entire room doors, as my mother, friend Baroness.
Grows out of it, the remarks of the noble Baroness, Lady Scotland, that we all write each other a lot and wish all noble members a very happy Easter.
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The noble Lord wishes to withdraw his amendment. Yes, yes. Not rude.
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Not rude. Is it your Lordships pleasure that this amendment be withdrawn? Amendment is by leave withdrawn.
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Amendment is by leave withdrawn. Amendment 194. Lord Shinkwin not moved. Not moved 195.
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Not moved 195. Lord Frost not moved 196. Lord Frost not moved 197. Lord Frost not moved 198. Lord Frost not moved 199 not moved 200. Baroness Grey-Thompson not moved 202. Sorry. Of course. Oh yeah. Question is that clause stand part of the bill as many of that financial content not content. The contents have it. Clause two 200 B Lord Weir of Ballyholme not moved 200 C Baroness Berridge not moved a two 201 Baroness Finlay of Llandaff not moved 202 Baroness Goudie not moved.
Amendment 204. Baroness Lawlor not not moved. 205 Baroness Monckton of Dallington forest not moved. Therefore. 200 200 and 208 Baroness Goudie not moved. Not moved to. Not 2207 was a was an amendment to. 205 thank you. Amendment 209 Baroness Goudie not moved. 210 Lord Rook not moved. 211 Lord Rook not moved. The question is that clause 610 part of the bill as many of that opinion's content contrary not content contents have it.
Amendment 212 Baroness Grey-Thompson not moved 200 202 a Baroness Lawlor not not moved 212B Baroness Lawlor not moved 213 Lord Brooke not Lord Rook not moved 214 Baroness Grey-Thompson not moved 214A2145 Paris Thompson not moved 215A Baroness Lawlor not moved to one six. Lord Rook not moved 217 Baroness Grey-Thompson not not moved 217A Baroness Lawlor not moved 218 Baroness Grey-Thompson not moved 218A Baroness Lawlor not moved. 218B Baroness Lawlor not moved 219 Baroness Keeley not moved.
220 Baroness Foster of Oxton not moved. Not moved. Question is that clause seven part of the Bill? As many of that opinion content contrary, not content. The contents have it. amendment 221 Baroness Hollins not moved 224. Baroness Hollins not moved sorry. 222222 not Hollins not moved sorry. 222222 not amendment 223 Lord Birt not moved. Therefore. Therefore. Therefore two two. Therefore, we have come to. OK.
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My Lords, I beg to move that the House be resumed. Question is that the House be resumed. As many as that opinion shall say content contrary, not content. I think the contents have
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it. My Lords, before I adjourn the House. My wish. All noble Lords, clerks and doorkeepers are very wonderful. Recess. And with that, my Lords, I beg to move that the House do now adjourn. House do now adjourn.