Baroness Hollins
Main Page: Baroness Hollins (Crossbench - Life peer)(1 day, 13 hours ago)
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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.
Baroness Blackstone (Lab)
My Lords, I ask the noble Baroness, Lady Hollins, why she has identified this small group of specialists, and only them. Does she accept that the causes of death are very wide, and that many different specialists may have been involved in the treatment of a patient who wishes to bring on their death as soon as possible because of their huge suffering? So why would we confine this form of treatment, or the provision of this option, for patients who are close to death to only the small groups she has identified here? Why would general practitioners, neurologists or gastroenterologists not be included?
Baroness Hollins (CB)
The noble Baroness may have misunderstood. I spoke about dual accreditation, which could apply to any doctor from any specialty who wished to obtain the necessary training and accreditation to be able to contribute on this issue.
Lord Shinkwin (Con) [V]
My Lords, I make it clear at the outset that I do not intend to press my Amendment 193. I also support the other amendments in this group and look forward to learning and listening, as I am sure the noble and learned Lord does, before I wind up at the end of the debate on this group.
The modest and reasonable nature of my Amendment 193 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:
“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’s response to it will show whether he wants the assisted dying regime that his Bill would create to operate transparently or in the shadows. It will show whether he recognises that transparency is crucial to engendering at least a modicum of trust in the assisted dying process he proposes, 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 it not just positively Neanderthal but 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 after the conversation as well as during it—and that it would implicitly not apply beyond a practitioner from the “person’s GP practice”, to quote the Bill. Surely this begs the question of why any registered medical practitioner or other health professional involved—or indeed the patient—would not want there to be a record of what was said and, furthermore, for that to be made available to both the patient and appropriate stakeholders, such as but not only their GP, within the set timeframe, as provided by amendments in this group that other noble Lords will speak to.
We are assured 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 is good to know none the less that she acknowledges the need for the question of its safety to be addressed. This amendment would do exactly that: its sole purpose is to improve safety. At its heart is the recognition that it is vital to have a written record of the preliminary discussion in the way that my amendment provides, because it would act as a legal gateway to the assisted dying process and provide 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 effect, to regulate the process. So it is not good enough for the noble and learned Lord to point to Clauses 7, 9, 10, and 11 as if to say, “What’s the problem?”, not least because Anna Dixon’s amendment in the other place—which explicitly required a doctor to
“record and document the discussion and the information provided”
and give a copy of the record directly to the patient—was not included in Kim Leadbeater’s new Clause 7 on recording.
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 would not put in the Bill that there should be a record of the preliminary discussion or set a minimum standard format or a required level of detail for its contents. The Secretary of State would have the power to require this, according to the Bill, but I draw noble Members’ attention to the Delegated Powers and Regulatory Reform Committee’s recommendation which signalled that this was inadequate. It recommended, instead, that the Bill should be amended to explicitly clarify
“what type of event or other information must be notified or the principles underlying notification”
in primary legislation. That is what this amendment seeks to do.
In closing, I 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 Canada and Australia, resulting in disciplinary action and official findings of non-compliance. Let us learn from them and pay heed to the evidence given to the Bill Select Committee by Dr Michael Mulholland, honorary secretary of the Royal College of General Practitioners. He said:
“If you were 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”.
Indeed. Why would you not? I hope the noble and learned Lord will accept my amendment. I beg to move.
Baroness Hollins (CB)
My Lords, I commend the important speech of the noble Lord, Lord Shinkwin. Decisions at the end of life are complex, and a single conversation simply is not enough to capture someone’s physical condition, mental state, and personal and family circumstances. Attempting to record such a complex conversation is quite a daunting prospect.
Requiring a preliminary step also adds an unnecessary layer of stress before a proper evaluation can even begin. Both Clauses 5 and 7 add more steps but not more safeguards. The key protections in this Bill—checking capacity, ensuring that decisions are genuinely voluntary and identifying any coercion—can and would be addressed within a multidisciplinary specialist assessment. As it stands, requiring a preliminary discussion and recording it adequately risks duplication while causing unnecessary delay, when time is of the essence. Instead, a specialist multidisciplinary panel would provide a full and balanced assessment from the outset, and of course it would be properly documented.