Assisted Dying Bill [HL]
Lord Berkeley of Knighton Excerpts(9 years, 5 months ago)
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Lord Cormack
My Lords, if we are to have this Bill, it is very important, as the noble and right reverend Lord said, that there should be confidence in it. I just want to address a few brief remarks to the amendment of my noble friend Lord Carlile of Berriew, to which the noble and right reverend Lord is also a signatory.
I remember as a young Member of Parliament in Staffordshire talking to a rural general practitioner who had been there for many years. He made the point to me—I have quoted it before—that a doctor can only truly know his patient if he knows him in his home as well as in the surgery. I know that things have changed a lot since then but I treasure my relationship with my general practitioner—it is one of the most important relationships that I have. I like to feel that I can talk uninhibitedly to him, and indeed I can.
It is very important that we avoid falling into a trap. Because of the widespread reluctance among the medical profession to support the Bill, we could fall into the trap of certain doctors being available for hire. That is the last thing that the noble and learned Lord, Lord Falconer, would want. I have never at any stage doubted for a single second his utter sincerity and his honourable motives. That should be taken as read throughout the House, and I believe that it is. However, where a large number of medical practitioners feel, for the best reasons of conscience, that they cannot sign up to this Bill, there will be a danger—I put it no higher than that but one has seen it in the field of abortion—that some doctors will in effect be for hire. That has to be guarded against and one of the best ways of doing so is to ensure that there is an amendment similar to that moved by my noble friend. I hope that, when he comes to respond, the noble and learned Lord, Lord Falconer, will accept that.
I have grave reservations about this Bill. I do not want the Bill but I understand why many do. Therefore, if it, or a Bill like it in the next Parliament, is to go on to the statute book, the safeguards must be real, comprehensive and absolute. If a doctor is to sign a document, that should happen only after lengthy conversations with the patient concerned—after a real discussion. I would like to feel that during that discussion the doctor, whatever his or her personal views, can play devil’s advocate and point out all aspects of this ultimate decision that the patient is on the verge of making. However, that can happen only if there is a real knowledge of the patient and a proper relationship between the doctor and the patient. Six months is a short enough time. I have been registered with my general practitioner for over 30 years. Many noble Lords will have had similar long relationships and others will have had shorter ones. But before you talk to a doctor you feel the need to know him, and he or she needs to know you. The amendment moved by my noble friend is modest but it helps to provide a safeguard which, if a Bill such as this is to go on to the statute book, we would all like to feel is in place.
Baroness Garden of Frognal
My Lords, the noble Baronesses, Lady Campbell, Lady Grey-Thompson and Lady Brinton, have been trying to speak for a while. I wonder if your Lordships would feel it appropriate if we heard from them now.
Lord Warner
The amendments would not deal with that matter. They would in many cases make it impossible for a terminally ill person who wanted to explore the issue of assisted dying to meet the requirements to have those conversations—let alone anything else—with a medical practitioner who was responsible for their care when they had moved house. I am not trying to make a wider point. I am on the narrow issue of the words in the amendments. I am with the noble Baroness, Lady Brinton, all the way on the impracticability of Amendment 13.
I move on to Amendments 20, 21 and 22 in this group. No one who supports the Bill is arguing that we expect doctors to have the gift of foresight about the length of time that someone will live for. I point out that the Bill uses a period which is commonly used in many other areas of public policy, not least in the area of welfare. If noble Lords read Section 82 of the Welfare Reform Act 2012, they will find a definition of terminal illness that is being applied by doctors day in and day out up and down the country—for those who are nerdy in these matters, it is on form DS 1500—to secure improvements in benefits because the person is terminally ill. Parliament, in the past couple of years, has passed legislation which sets out the terms of terminal illness, and doctors up and down the country are applying that legislation for the benefit of people with disabilities. The idea that the Bill is doing something different and novel in this area is, frankly, not true.
I also ask noble Lords to read the GMC guidance for doctors on issues such as end-of-life care and consent. In its admirable guidance, it is clear that there is a reasonable expectation that when a doctor thinks that someone may be terminally ill and may die before the end of 12 months, they may begin conversations with people. It is not unethical, it is not bad medical practice, where a doctor believes that someone may be terminally ill, not to do anything dramatic, but to begin to have a conversation with that person and their family. If you make it a shorter time for the person to have such conversations—six weeks, for example—all you are doing is putting enormous pressure on somebody who has had to come to terms with some catastrophic information about their life and circumstances. It would be inhumane, unfair and lacking in compassion to shorten the timescale within which doctors and their patients could have the conversations that they need to have.
I believe that the balance is struck right with the six-month term. In the United States, where assisted dying is legal, the bar has been set at six months and there is strong evidence to demonstrate that the model there works effectively and safely. Some very interesting work was done by a surgeon and public health researcher, Atul Gawande, who explains in his recent book Being Mortal: Medicine and What Matters in the End that survival statistics form a bell-shaped curve in which there are a small number of people who survive much longer than expected—the tail of the curve. He says:
“We have failed to prepare for the outcome that’s vastly more probable … we’ve built our medical system and culture around the long tail”,
of small numbers of cases. His view is supported by a number of pieces of research. I shall quote one that shows that fewer than one in four patients outlived the prognosis when their clinicians predicted survival for six months or less. In the great majority of cases, you could argue that the doctors have been optimistic about survivability rather than the other way around. Therefore, I think that my noble friend has struck the right balance in this area.
I shall mention one other bit of GMC advice, which relates to Amendment 20. The GMC is very clear to doctors, beyond doubt or peradventure, about the issue of patient consent. In my view, the amendment would be a breach of that advice. The advice is clear that even if the doctor disagrees with the patient’s decision their right to refuse a course of treatment is absolute and doctors are expected to respect that right. Following the GMC’s advice, I suggest that putting another impediment on doctors, as that amendment would, would be unfair to doctors.
Lord Berkeley of Knighton (CB)
My Lords, unlike the noble Lord, Lord Cormack, I have always welcomed and embraced the Bill, or certainly one very like it. One of the great qualities of your Lordships’ House is that, especially on an occasion like this, we listen to the arguments and are prepared to mould what we are trying to achieve. When I listened to Amendment 13 from the noble Lord, Lord Carlile, and especially Amendment 13A from the noble Baroness, Lady Finlay, I felt that they were reasonable. However, I have now heard the noble Baroness, Lady Brinton, and the noble Lord, Lord Warner, very eloquently saying why they are very worried about this issue so I am still slightly up in the air about it, although I think, with regard to Amendment 13A, that it is essential that these are “licensed” medical practitioners. The noble and learned Lord, Lord Falconer, is trying as hard as he can to go with the House and to take on things like this.
My point, and I shall make it extremely briefly, is about the six months’ terminal illness. I think that this is right, and I shall tell the House why. I have had lots of letters, as have many noble Lords, and there is something that they nearly all say. I had one this morning from someone who is 80, saying, “I don’t have a terminal disease but I do want to feel that I would have the option, if I became really ill, to talk this over with my doctor and work out a way of assuaging great pain and causing distress through that pain to my family. It might just be that I would talk to my doctor about having opiates that might repress the respiratory system”. Is that assisted suicide? I do not know. I certainly think that it is an option; frankly, very few doctors that I know deny that it has happened in their lives. They have treated people, especially in country practices where, as the noble Lord, Lord Carlile, has illustrated, they have known the patient for many years, even decades, and they ease them out of this life into the next one. It seems to me that this is the luxury that most human beings want to be afforded. I think that that is what the noble and learned Lord is trying to achieve, and on that basis I very strongly support him.
Lord Harries of Pentregarth
Would the noble Lord like to clarify what he means by that very ambiguous phrase about doctors easing patients out of this life? Does he mean the administration of pain-killing drugs, which might have the side-effect of slightly shortening life, or does he mean doctors deliberately administering an overdose in order to kill a person? Perhaps he could clarify what he means because he is making quite a bald claim about doctors’ practice.
Lord Berkeley of Knighton
As in so many things, there is a line here which is difficult to draw. However, doctors in this House have privately told me of occasions when they have treated people with appalling pain in a way that they knew was likely to finish their life. It is very hard to put it more precisely. They would not guarantee that it did because, as we have heard from the medical profession, nobody can guarantee anything. No doctor here can tell us when we are going to die; they can say only, “This is the likelihood”, so I cannot give the noble and right reverend Lord a definitive answer. Everybody keeps saying that we must have clarity but there is no clarity about dying or pain relief. That is the whole point of this. What I can say, which is germane to the argument at the moment, is that we need at least six months to be able to discuss these things calmly and give people the feeling that they can plan ahead. In fact, that should rule out the bronchial infections we have been talking about because they would not be considered part of the terminal disease. It is a question of planning and so many people have said, “I want this option at the end of my life”. Who are we to deny it?
Lord Blair of Boughton (CB)
My Lords, I declare an interest in that I was a member of the Commission on Assisted Dying, chaired by the noble and learned Lord, Lord Falconer. I want to respond to Amendments 17 and 21 by mentioning specifically that at the conclusion of the two years in which we heard evidence, our initial position was that this prognosis period should be 12 months. We based that on the GMC guidance to which the noble Lord, Lord Warner, has just referred. It was based on the time at which a doctor could begin to discuss end-of-life care with his or her patient. We decided to reduce the period to six months because we thought that this decision was even more dramatic than the 12-month position of possibly dying. Now that we are into six months, we are much closer.
With all respect, it seems that the noble Baroness, Lady Meacher, has made the right point in relation to these amendments. We are looking at this from the wrong end. As the noble Lord, Lord Berkeley, has just said, there is no certainty but this is aimed at those individuals who themselves believe, with mental capacity, that what lies ahead of them in suffering and indignity is unbearable to them. It may not be unbearable to somebody else but, for them, it is unbearable and they want to have a discussion. We have been told about people who are going to recover because a new treatment will appear. These are people of mental capacity who are making clear judgments. Is it very likely that those people, if they start to feel better, will say, “No, I still want to die because I decided that I wanted to a little while ago although I now feel better”? That is a completely nonsensical position.
There is one provision of this Bill that people do not seem to notice. In Oregon, when the decision is made, the medicine is handed to the patient and he or she wanders off and puts it in the cupboard. That is not the case in the Bill. The medicine, such as it is, will be in a pharmacy. It will not be released to the patient until everybody is absolutely clear that all the processes have been gone through and that the person still has a settled determination to end their own life. It will then be released to a medical practitioner or nurse and if that patient does not take it within 24 hours, it is not left in the house. It goes back to the pharmacy and the discussion starts again. These are reasonable provisions. There is the idea that we should tie it to the uncertainty of a medical prognosis. We have to have some limits but, after two years of deliberation and knowing the GMC guidelines, six months struck those of us in the commission as a reasonable compromise. I recommend it to the House.
Lord McColl of Dulwich
I thank the noble Lord for that intervention. I have been in practice for very many years and I still am. One of the things that always struck me was how wrong I was about trying to predict when a patient would die. I well remember a typical case of a lady who was only 28. She had inoperable cancer of her throat. She was in great distress, with pain and distressed breathing. I saw my job as a doctor to relieve all her symptoms, whatever the cost. I said to her, “If you like, I can put a needle into your vein and titrate you with heroin”. Heroin is a marvellous drug. You have to dilute it in a large volume and not use the small volumes in the ampoule, because if a gun goes off you might suddenly give them too much too quickly. I titrated her and asked her to tell me when all the symptoms had gone. Eventually she said, “Yes, that’s fine”. It was a huge dose of heroin. I had no problem about giving it. The strange thing was, not only did it not kill her, it gave her a new lease of life. It is unrelieved pain that is the killer.
Lord Berkeley of Knighton
The noble Lord said earlier that he gave his patient a huge dose of heroin. He used the words, “whatever the cost”. If it had killed her, would the noble Lord feel that he had assisted, maybe nobly, in her dying?
Lord McColl of Dulwich
The problem is that when you give these very powerful drugs, the symptoms are relieved but the patient is subject to the complications of being in bed for a long time, including clots in the veins of the legs. These may dislodge, go to the lungs and kill them, or they may develop pneumonia because their breathing is not quite as effective. Those are the complications but I resist the idea that I am deliberately killing them; I am deliberately relieving all their symptoms.
Female Genital Mutilation
Lord Berkeley of Knighton Excerpts(9 years, 6 months ago)
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Lord Berkeley of Knighton (CB)
My Lords, it is an honour to follow the noble Baroness, Lady Rendell of Babergh, who has espoused the cause of halting FGM for at least as many years as I have months. When I entered your Lordships’ House, I very much felt that I did so to represent music, culture and the arts, but what I discovered from listening to debates about FGM so appalled me that I became quite passionate in my own espousal of this cause. It is an appalling practice, and what really staggered me was that it is happening in Great Britain; I simply could not believe it. It is bad enough that it is happening in the way that it is in many countries—and I know that there are charities tackling that—but that this is going on in this country is completely staggering. I gather that some children are brought to this country to be subjected to FGM. Does the Minister have any figures not just on the people who live here who are being cut but on the ones who are possibly being brought here for that purpose? It would suggest that there is not a sufficient fear of the law.
When this issue was recently debated in your Lordships’ House, the noble Earl, Lord Howe, was asked about the discrepancy between this country and France, which the noble Baroness has just referred to. He said, with considerable justification, that France is a very different country from this one and that the idea of mandatory examination here would offend civil liberties and the mothers of young girls would be very upset. It is a fair point. I therefore undertook to ask several friends with young children how they would feel about it. Their initial response was exactly as the noble Earl predicted. However, when I said to them, “If the fact that you allowed your young child to be sensitively examined—however much you may baulk at it—saved five, 10, 20, 100 or who knows how many other children from being mutilated, would you feel differently?”. At which point they said, “If you put it like that, yes; I could not possibly refuse something that might save other children from this horrendous practice”.
I know that the Minister and everyone in his department and the Department of Health are very concerned about this—none of us doubt that. None of us wants to see this practice continue. We all think that it is barbaric. However, although progress is being made, we have not yet, as we have heard, obtained a conviction. I ask the Minister to consider—I use that word very carefully—mandatory targeted examination. If one is considering it one is not necessarily saying that it is going to happen, but the fact that the Government say that they may need to consider it would send a message to families who might be considering cutting their children. They might suddenly realise that they could be held to account. As far as I can see, this is a win-win situation for the Government. Even if it stopped a handful of children being cut, it would have achieved something.
I shall keep my speech very short because I have previously gone on and on about the barbarity of the practice. We do not need to hear those arguments again because we all share the same feelings about the practice. I simply ask whether the Minister will consider the possible mandatory targeted examination of children.
Criminal Justice and Courts Bill
Lord Berkeley of Knighton Excerpts(9 years, 6 months ago)
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Lord Berkeley of Knighton (CB)
I want to make one simple point. Even if the noble Lord is right that there are some cases of abuse—there are in every sphere of life including the police or indeed Parliament itself—is it not worth paying that price for the man in the street or the small community to feel that they have some way of redress against large institutions, government and big business? Many people feel it is their only way of making their point. We should not deprive them of it.
Lord Horam
That is precisely why, as I understand it, my noble friend is introducing in a later amendment a de minimis clause precisely designed to exempt small communities. When there is a project and neighbours perhaps contribute £100 or £150 each to object to it, that would be entirely legitimate and I would be wholly in favour of it. That would not be stopped by this precisely because the Government have recognised that point and in a later amendment are introducing a de minimis clause.
Lord Carlile of Berriew
The noble Lord, Lord Rooker, has, extremely uncharacteristically, if I may say so, missed the point. I am sure that it is my fault. We are talking about group actions that may involve a significant number of people—hundreds or thousands, maybe—to which a few individuals make a large contribution. They are making that contribution, often anonymously, to ensure that the matter is capable of going to judicial review for the reasons I gave earlier. We are not talking about 20% meaning that there are only five people involved in the action. We are talking about 20% of the funding that is collected, although there may be hundreds of people involved in the action.
Lord Berkeley of Knighton
My Lords, the noble Lord is quite right. In my experience—which I am sorry to say is rather larger than I would like—of local communities in mid-Wales fighting, for example, wind farms, a lot of households give a few pounds, but a judicial review becomes possible because one or two people who really do wish to remain anonymous give significantly more. Many of these people have been terrified by threats of being sued for costs. So I would implore the Minister to give as much clarity as possible on this point.
Assisted Dying Bill [HL]
Lord Berkeley of Knighton Excerpts(9 years, 11 months ago)
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Lord Berkeley of Knighton (CB)
My Lords, they said that this would probably be the hottest day of the year and, emotionally and intellectually, I think they were probably right. The noble Lord, Lord Alli, hit the nail on the head when he said that there are no absolute rights or wrongs in this; we all bring our own feelings to it and it is impossible to say something is absolutely right or absolutely wrong. The letters we have all received are so deeply moving and passionate about the perceived primacy of their position that I found them to make almost unbearable reading—particularly those, which in my case were in the majority, that recount the helplessness of watching a loved one die in agony. One farmer told me that if he allowed his animals to die in this way he would be locked up.
Consultants in palliative care, who have been very persuasive in what they have said, say that nobody should suffer in this day and age in that way. However, they still do: the evidence is there in the letters and is all too familiar to families up and down the land. As a young man, I worked for a while as a phlebotomist at St Bartholomew’s Hospital. It is strange to reflect that since those days, and in the aftermath of the appalling deeds of Harold Shipman, doctors have in many ways found themselves hamstrung in their dealings with the terminally ill and the dying. The days are gone when a country GP visiting a patient he or she has known for decades could quietly and gently ease them on their way. Perhaps some still do—I know many doctors who have done it. However, in curtailing the ability to carry out this compassionate care, through the forensic analysis of deaths, I believe we have created the need for the Bill of the noble and learned Lord, Lord Falconer.
We have heard very strong medical and legal arguments, which nobody of intellect could simply dismiss. I certainly do not and, rather, would love to see them used to improve the Bill, which I still support.
The church seems divided on this issue and rightly talks of the sanctity of life. There could be no greater subscriber to the sanctity of life than me, but surely part of that sanctity is constituted by—how can I put this?—a sacred stillness, a dignity, a precious humanity that is undone by rendering a dying human being into a screaming animal, a shadow of their former and real self, utterly deprived of the inalienable right of personal autonomy. Here we come to that great conundrum of faith. No one from the church or anywhere else has ever been able to explain to me how I should try to comprehend the notion that an all-seeing, all-merciful God would want this sort of terrible suffering to be endured rather than relieved.
A natural death is what we all hope for, and we would all like to think that, if needed, we would be given enough drugs to make us comfortable, but what if, to achieve that, a doctor prescribes so much morphine that it leads to depression of the respiratory system, bringing about death or, perhaps, the old man’s friend, pneumonia? My father, who had severe Alzheimer’s, got, as I prayed he would, pneumonia. I had months before asked the sister in charge that, should that be the case, please not to treat it with antibiotics. He slipped into a peaceful coma. Yet was I not in one sense part of an assisted death? Are we are not dealing in semantics in saying that a withdrawal of treatment is not actively bringing life to an end? Is this Bill not in a way simply spelling out, trying to clarify, the right of each and every one of us to have the final decision about our lives should disaster strike and to have as peaceful a death as possible?