Assisted Dying Bill [HL]

Lord Winston Excerpts

Friday 16th January 2015 Lords Chamber

[Lord Pannick (CB)]

My Lords, that was a very powerful speech. The Bill as it stands seems to me to involve no lack of clarity whatever. Clause 1(1) is perfectly clear:

“A person who is terminally ill may request and lawfully be provided with assistance to end his or her own life”.

What does assistance mean? Clause 4(1) is perfectly clear:

“The attending doctor of a person who has made a valid declaration may prescribe medicines for that person to enable that person to end their own life”.

There is no lack of clarity there. We may disagree over whether this is a desirable or an undesirable Bill, but the idea that people in the country do not understand the issues because of the wording of the Bill is simply fanciful.

[Lord Winston (Lab)]

My Lords, with great respect to my noble friend Lord Pannick, I disagree, and totally agree with the noble Baroness, Lady O’Neill. There is another issue beyond clarity here. One of the issues that was raised at Second Reading and, I think, on the first day in Committee was the concept that fragile and possibly deranged, angry and distressed elderly people coming into hospital have of the nature of their status as patients. The use of the word “suicide” brings clarity for them, because it makes a very big difference to medical and nursing practitioners, who can quite clearly see that they will not be involved in a process of assisted dying. It is, effectively, suicide, and that limits any notion of how they might feel when they feel that somebody is not really worth supporting in hospital. This is a major problem and will become an increasing one. We see the increasing difficulties in the health service when dealing with cancer care at the moment and the provision of drugs. There will be pressures on budgets and increasing pressures on patients who will feel under pressure to take a decision that is not entirely theirs. I therefore support this amendment.

[Lord Mawson (CB)]

My Lords, I agree with the previous speaker. I do not believe there is clarity in the country about this matter at the moment. This is the first time I have spoken in Committee on the Bill, and I think I was the only person at Second Reading to draw attention to the practical implications of the Bill for modern multicultural Britain. Today in this country we are privileged to share our lives with virtually every nationality and culture on earth. This is a great privilege but also a considerable responsibility when it comes to the life and death issues captured in the Bill. It is from within this context, having spent the past 31 years working in the East End of London, that I speak today.

On an issue as sensitive and as important as the state helping people in modern Britain to sign their lives away, it is very important that the national debate about these matters is carried out as fairly and objectively as possible, so that British people can make balanced and informed judgments about these important matters that affect both them and members of their families. One of my primary concerns in speaking today is to ensure that the hard facts are all on the table and can be seen in the clear light of day. In that regard, the words we use in the Bill and what we mean by them really matters when we have to translate their meaning and purpose into the languages and dialects of every nationality on earth—but more of that later.

The Second Reading debate in your Lordships’ House and the first day in Committee demonstrated the House at its best and brought to the surface the very real, practical and complex issues for all to see, if only members of the public were allowed to both hear and see them. This House, packed as it is with so much experience and knowledge, is probably the only place in the country where a debate such as this can take place in a way that addresses the detail in all its glory.

That said, I have been concerned during the process of this debate in the country that some of our media, which have a responsibility to educate and inform the general public about all sides of this argument, have simply gone into campaigning mode. It would be interesting to ask how many of the journalists and commentators have actually read Lords Hansard and dug down into the issues with us, and then honestly and fairly communicated their findings. This issue sadly lends itself to lots of sentimental stories on all sides, but the hard realities are far less palatable in a media-driven age that skims across the surface of our lives.

I am concerned that much of our media are not covered with glory with regard to setting out clearly the complex choices and practical issues that need to be understood if members of the public are to seriously engage with the issues and make informed choices on this matter. I have tested this at home with members of my own family and got the sense, before they were encouraged to look further, that, for them, going for this injection would be a bit like going to the optician or dentist. Of course, the dentist analogy carries with it far more personal experience, I suspect, and fear.

There have been considerable sentimental stories about individuals in our media who, of course, have gone through terrible times, without the necessary balance given—

--- Later in debate ---

[Lord Dobbs]

The Bill is nothing to do with going off into a corner and getting someone to assist you in a death like that. This is a totally different legal and medical environment. We will all die.

[Lord Winston]

I am very grateful to the noble Lord, who has been constantly interrupted, for giving way yet again. Very briefly, does he not accept that many noble Lords have had well written letters from numerous people who are very confused about the nature of what is being proposed? That is one of the problems. Many of them with confused elderly relatives are worried that they are at risk. It is very clear that there needs to be the kind of clarity that the noble Baroness, Lady O’Neill, has talked about.

[Lord Dobbs]

That is precisely the sort of clarity that the proponents of the Bill wish to bring about. We are trying to change the law and any change in the law involves in the short term a degree of confusion. But once the Bill has been passed, as I know it will be eventually, I believe that the country will clearly understand what this is about. If we look at the way that this is being operated in other parts of the world, such as Oregon, there is no confusion.

--- Later in debate ---

[Baroness Finlay of Llandaff]

I am grateful to the noble Lord for that intervention. If they have been misinformed—it is not the diagnosis of the disease that is wrong but the prognosis—and they then take the lethal drugs, they are not there to outlive the wrong prognosis.

[Lord Winston]

I might be able to assist the noble Baroness’s arguments slightly. Is not the whole House aware of one of the most famous cases, the person accused of the Lockerbie bombing? He was examined by numerous doctors, in particular Karol Sikora, who is probably the leading cancer expert in the country, who, after great consideration, considered that this man had only three months to live. He was therefore allowed to leave the United Kingdom. In fact, I think he survived for either three or four years.

[Baroness Finlay of Llandaff]

I am grateful to the noble Lord for that illustration, which is very clear and well known to all Members of the House. It is for that type of reason that I have proposed the removal of the word “reasonably” from Clause 2(1)(b) of the noble and learned Lord’s Bill.

A number of clinicians have tried to predict prognosis—for instance, whether to take the risk of a heart or lung transplant, and when to introduce palliative care in non-cancer services for the frail elderly. However, they have found that they just cannot determine time. Prognostication is reasonably accurate on the population level but, as the noble Lord, Lord Winston, has just illustrated, it is not accurate at an individual level at all. It is no better than tossing a coin. Indeed, different studies have shown that a prognostication expecting someone to live for more than a year is not too awfully wrong. Similarly, expecting somebody to die within a month is more likely to be accurate than inaccurate. However, in the interval in between you honestly could toss a coin on it. It is for that reason that I suggested that, if the prognosis in the Bill really is to deal with those people who are distressed during their dying phase, the prognosis section should be shortened to six weeks.

There are other aspects to prognostication that I will point out to the noble and learned Lord, Lord Falconer. The national clinical director for end-of-life care told the commission that he chaired that predicting the course of a terminal illness is “fraught with difficulty”. In 2004 the RCGP made the same point to the Select Committee chaired by the noble and learned Lord, Lord Mackay:

“It is possible to give reasonably accurate prognoses of death within minutes, hours or a few days. When this stretches to months then the scope for error can extend into years”.

The Royal College of Physicians, giving similar evidence, said that,

“prognosticating may be better when somebody is within the last two or three weeks of their life … when they are six or eight months away from it, it is actually pretty desperately hopeless as an accurate factor”.

More recently, we have seen in the report from the inquiry into the Liverpool care pathway, chaired by the noble Baroness, Lady Neuberger, how prognoses of death within 48 hours have sometimes turned out to be wrong. The report called for further research into improving the accuracy of prognosis within the last weeks to days of life.

Yet, in the face of all this evidence, we are being asked to consider legalising assisted suicide or assisted dying for people with a prognosis of six months. The only conceivable explanation is that that is what Oregon’s assisted suicide law says. However, Oregon’s law has been shown to be fallible in the matter of prognosis. Oregon’s own data show that the time from the first request to death by whatever cause, whether through physician-assisted suicide or natural causes, ranges from 15 to 1,009 days, which is two years and nine months. Washington’s data show that, among those being given a prescription for lethal drugs and therefore expected to die within six months, the range was three to 150 weeks. I note that, in every year of that legislation since it has been passed, patients have lived well beyond 24 weeks or six months. The percentage ranges from 5% to 20% of a request for death.

The plain fact is that prognosis of “terminally ill” is highly unreliable over a range of six months. The DS 1500 has been used as a way to allow patients to access benefits rapidly, without having to go through assessment hoops. However, as those who have filled them out know only too often, it is only a guesstimate. Very often, patients vastly outlive the prognosis. We have had to have difficult conversations about how they should now go through the complete assessments. I tabled a Question to ask whether the Department for Work and Pensions collected data on the DS 1500. Unfortunately, it does not. It would be interesting to know for how many months that benefit had been drawn.

The plain fact is that this is unreliable. As a practitioner in the field, I can count the number of terminally ill people whom I have treated. I have not tallied them up among the thousands that I have looked after, but I could bore this House for weeks with the number of clinical stories of people who were expected to die within six months and who stayed alive for much longer. Those are the reasons behind these amendments. I hope that those who are arguing sincerely that the Bill aims to try to improve the dying process in those last days and weeks of life will seriously consider that they are asking people to make a prediction on which there really is not a scientifically accurate basis.