Assisted Dying Bill [HL]

Lord Avebury Excerpts

Friday 16th January 2015 Lords Chamber

[Lord Carlile of Berriew]

My Lords, I beg to move the amendment standing in my name and in the names of the noble Lord, Lord Darzi, and the noble and right reverend Lord, Lord Harries of Pentregarth. In relation to pre-emption, Amendment 13A is part of this group, and will be moved by the noble Baroness, Lady Finlay of Llandaff. It has the effect of amending the term “registered medical practitioners” to “licensed medical practitioners”. I make it clear at the outset that I have no objection whatever to that amendment being made. Indeed, I regard it as a helpful amendment to my amendment, for a reason that I shall now give.

As I understand the situation, a registered medical practitioner could be any medical practitioner who is on the register. I suppose that that is stating the obvious, but that could include, for example, a medical practitioner who is retired but who has chosen for one reason or another to remain on the register. It could include a registered practitioner who has not laid hands on a patient for a very long time. A licensed medical practitioner is one who is shown in the General Medical Council’s relevant documents to hold a particular expertise or expertises that are current. I am sure that the noble Baroness, Lady Finlay, will explain that more expertly than me in a little time.

I regard this group of amendments as extremely important, because they come at the gateway to assistance with suicide and assistance with dying that is provided for in this Bill. The gateway is diagnosis; nobody can go through that gateway unless they have been diagnosed as terminally ill—and what terminally ill means is defined.

I cite table 1 on page 7 of the Oregon’s Death with Dignity Act Annual Report for 2013. Its figures show that the median patient-physician relationship prior to assisted suicide in Oregon in 2013 was 12 weeks. That means that for the 752 people in Oregon recorded as dying using the Death with Dignity Act, half knew their doctor for 12 weeks or less.

I make no complaint about these issues if we are to have this Bill as an Act, but what are the issues that the diagnosing doctor or doctors are to certify themselves as satisfied about? First, it is that the person concerned has an inevitably progressive condition. That is quite a serious medical diagnosis, as is plain, to be determined at the date of the diagnosis. Secondly, it is that it cannot be reversed by treatment. In Clause 2(2), it is stated:

“Treatment which only relieves the symptoms of an inevitably progressive condition temporarily is not to be regarded as treatment which can reverse that condition”.

That is a very complex provision. The medical determination of whether medication or other treatment “only relieves the symptoms” is far from simple. How is one to judge whether it “only relieves the symptoms” or whether it provides some form of remission which goes rather further than only relieving the symptoms?

Then there is the provision in Clause 2(1)(b) that the person,

“is reasonably expected to die within six months”.

There was a discussion on Radio 4 this morning about the meaning of an expectation that someone will die within six months. This to a great extent is not science in the sense that no doctor, save in the most extreme circumstances, can predict when a person will die. Whether a person is potentially on the cusp of being expected to die within or around six months is certainly not something that I understand has ever been scientifically researched in full. Indeed, I recall in a debate some years ago a most compelling and memorable speech given by the noble Baroness, Lady Symons of Vernham Dean, in which she described exactly a circumstance in which it was predicted that someone extremely close to her would die within a very short time, and the person is still alive today. So this is very inexact medical science, and it is asking a great deal of doctors to make that kind of diagnosis.

What are the characteristics that might make that kind of diagnosis reliable and reasonable? I am sorry; I referred to my mother earlier and I am now going to refer to my father, who was a general practitioner in Burnley, Lancashire. One of my treasured possessions, which sits by my desk at home, is his last visiting book for the last year he was in medical practice. I spent much of my very happy childhood being given sweets by dear old ladies whom he visited on his rounds; it was one of the things that made me go on his rounds with him in his Austin A30. I reminded myself of what he used to do by looking at the book this morning. First, he used to visit his patients. I do not believe that anyone in my family has had a house call from their general practitioner in the 21st century, but it used to be very common. As I refreshed my memory this morning, I saw that he used to place his rounds in two columns: one was the calls that had been taken by the surgery—people who were ill and wanted the doctor to call—and the other was what he used to call, perhaps slightly unattractively, his “chronics”. His “chronics” were patients he visited on a periodic or regular basis. Some of them became friends to him and he knew all about their lives. He knew about the progress of their illness and about their domestic circumstances. He knew whether their children cared for them or took any interest in them. He knew whether they were poor or affluent and was able to ensure in the terms of those days that whatever statutory care was available was provided. In other words, he and doctors like him had a relatively intimate knowledge of their patients. When he met them in the streets of that great east Lancashire town, he could never remember who they were but he could always remember exactly what was wrong with them and members of their families. It is a bit like we lawyers remembering cases without necessarily being able to remember the names of those cases.

I know that it is dangerous to be nostalgic about medicine although, if we look at the state of the health service today, perhaps nostalgia is decent evidence, but when we look at the relationships that such doctors have with their patients, it is undoubtedly the case that they have, and had, a body of knowledge on which to base their diagnosis. We are not talking about diagnosing measles. We are not even talking about diagnosing some extremely unpleasant diseases; we are talking about diagnosing if and when someone is going to die.

My view, and that of the noble Lords who have also signed this amendment, and, I hope, of many others, is that nobody should go through the gateway of this Bill unless they have been seen by medical practitioners—I respectfully suggest to your Lordships that it should be no fewer than two—with at least one of them having had relevant care of that patient for at least six months, so that they have been able to build up a knowledge of that patient. It is difficult to imagine somebody with a terminal illness who has not had a relationship of six months with a doctor unless they have been involved in a trauma that has happened very recently.

[Lord Avebury (LD)]

Would my noble friend consider the case of patients with mesothelioma—perhaps we might hear also from my noble friend Lord Alton on that issue later—a disease that develops rapidly and which is normally fatal in a period of less than 12 months? Is it not probable that a patient who suddenly develops mesothelioma will not have been seen by a doctor for the period that the noble Lord requests?

[Lord Carlile of Berriew]

My noble friend, for whom I have the utmost admiration and with whom I have worked on many issues, I am afraid misses the point of what I am saying. I know the work that the noble Lord, Lord Alton, who was referred to, has done on mesothelioma. I absolutely applaud that work and I will give way to him in just a second when I have finished this paragraph. What I have in mind is that in a situation like that there will be not only the specialist who may be treating an issue that has arisen recently but a general practitioner who has had that patient on their books for a considerable time, who will have records that they can look at which give them that knowledge, and who will have seen the patient in the past. What I am seeking is exactly the combination between a licensed medical practitioner—I accept that they should be licensed—who has had some experience of dealing with the patient and a specialist who may be treating the symptoms of the particular illness.