Terminally Ill Adults (End of Life) Bill
Debate between Baroness Watkins of Tavistock and Baroness Hollins
Baroness Watkins of Tavistock (CB)
I accept that. There was a helpful article in one of the newspapers this week talking about using the term “assisted death” rather than “assisted suicide”. I am pleased that I have had the opportunity to say it in the Chamber.
Baroness Hollins (CB)
My Lords, I congratulate my noble friend Lady Cass on her excellent speech. I am going to speak to my Amendments 667A, 680, 681A and 848C which seek to ensure that any healthcare professional who wishes to participate in assisted dying under this Bill may do so 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 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 preset default. The two are not ethically equivalent, despite appearing similar. An opt-out system assumes that participation is expected unless an individual takes active steps to refuse, which is bureaucratically burdensome. In the context of assisted dying, making participation the default 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 am going to focus my remarks on Amendments 667A and 848C, which deal with doctors, but the principles apply to other healthcare professionals, including pharmacists and psychologists.
Some noble Lords have focused on the matter of conscience. This is important, but I suggest that it 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 in both 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. One reason for its 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.
My amendments seek to ensure that, if Parliament decides that doctors will be involved in implementing the Bill, doctors must choose to work in the service, just as they choose other areas of medicine in which they wish to practise. It follows that they must be adequately trained and registered to practise. 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. In practice, many people remain with that default. It reflects a well established behavioural tendency that people are more likely to stick with the pre-set option than to change it, even when there are alternatives. As a result, uptake increases not because everyone has actively chosen to participate but because fewer people opt out than would have opted in. Making participation the default may increase uptake because it is expected.
In centralised healthcare systems such as the NHS, declining participation may carry subtle penalties. I will illustrate this with the example of the Mental Health Act. In principle, a clinician may object to the 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 detention 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, as psychiatrists must apply for and maintain approval status to undertake this work.
However, there is 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. Therefore, the system is 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 within an opt-in system, and it raises the question of how much stronger these pressures may become under the opt-out model proposed in the Bill. I accept that it has potentially been slightly modified by the noble and learned Lord’s amendment, but I do not think it goes far enough.
My amendments in this group address the regulation of doctors who choose to participate. Just as every recognised medical specialty is regulated by the GMC, I believe assisted dying should be treated no differently. It is 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 specialty. Accordingly, my amendments and the amendment tabled by the noble Baroness, Lady Fraser, propose the creation of a specialist register for assisted death, which would be publicly available as with other specialty registers. Participating doctors would be required to hold both their primary specialty registration and this additional registration.
Dual specialty 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 and often more complex interventions. Dual accreditation is typically used where clinical practice spans more than one domain, as is the case with 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. This would provide an additional safeguard that involvement reflects a clear and deliberate professional choice.
Any involvement should be strictly opt-in and sit outside routine professional responsibility. All those who chose to participate should be registered with their respective regulatory bodies as providers of assisted death. This supports a stand-alone, 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 the amendments to that effect as well.