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The Duke of Norfolk: My Lords, perhaps I may say that the custom of the House is that if a noble Lord stands up to intervene, like the noble Lord, Lord Lester has just done, he should be allowed to speak.

Lord Williams of Mostyn: My Lords, I take that point. However, in fairness to the noble Lord, Lord McColl, he has only four minutes.

Lord Lester of Herne Hill: My Lords, such are the customs of the House that if I wish to ask a short question, it will not count against the noble Lord's four minutes. The noble Lord has, I think, impugned the integrity of those involved in the case. Is the noble Lord aware that at the conclusion of the case, when a costs order was sought against the doctor and the patient on the basis that the case should never have been brought, the president was so satisfied that it was properly founded that he did not even hear argument on the matter but rejected it? Was the noble Lord aware of that when he made those statements just now?

Lord McColl of Dulwich: No, my Lords, I was not aware of it. But I still think that there was no need at all to bring the case. And that is the view of a large number of people.

If one lesson has emerged from the Dutch experiment in recent years, it is that 1,022 patients were given euthanasia in one year without their specific permission. That is what will happen here. To change the law to allow intentional killing--to permit euthanasia, doctor-assisted suicide, mercy killing, or whatever it is called--can only result in the irretrievable breakdown of the relationship between the doctor and the patient. The law needs no change here.

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8.2 p.m.

The Lord Bishop of Southwell: My Lords, I am grateful to the noble Lord, Lord Lester of Herne Hill, for bringing this subject before your Lordships' House. It is one that needs to be revisited from time to time if only to remind us of the sanctity of life, given to us by God himself, and as such a gift to be revered and cherished. Furthermore, it provides the opportunity to reaffirm the position of the House of Bishops of the Church of England and the Roman Catholic Bishops' Conference of England and Wales, who in their joint submission to the Select Committee of your Lordships' House on Medical Ethics just four years ago stated:

    "Both Churches are resolutely opposed to the legalisation of euthanasia even though it may be put forward as a means of relieving suffering, shortening the anguish of families or friends, or saving scarce resources".

That stance is unchanged.

The Churches went on to say, however, that there is a proper distinction to be made between deliberate killing and the shortening of life through the administration of painkilling drugs. Neither of the Churches holds that a dying or seriously ill person should be kept alive by all possible means for as long as possible. There is a correct and fundamental distinction between that which is intended and that which is foreseen and not intended. This is not just a matter of semantics. Doctors have long recognised that the use of drugs in certain cases to relieve pain in terminally ill people has hastened death and the important consideration has always been the intention behind the administration of drugs. The primary intention is the relief of pain and suffering; the secondary consequence is an earlier death. If there were drugs available which relieved pain but did not hasten death, then those would, of course, be used in preference.

This principle, clarified by the Select Committee of your Lordships' House, was reiterated by Sir Stephen Brown, President of the Family Division, at the end of October in the distressing case of Miss Lindsell, suffering from motor neurone disease, to which the noble Lord, Lord Lester, referred. Although that was hailed as a victory for patients all over the country, it is surely clear that Sir Stephen's judgment was simply a restatement of the law as it already exists.

I submit that the current state of the criminal law and medical practice hold properly balanced a subject of deep medical and ethical significance. Those who become vulnerable through illness or disability deserve special care and protection, and adherence to this overriding principle provides a fundamental test as to what constitutes a civilised society and inevitably conflicts with those who believe in the right of individuals to exercise absolute personal autonomy.

I urge Her Majesty's Government to ensure that the necessary resources are available to all those who offer palliative care and also to the valued hospice movement which has enabled so many to die with dignity and brought real comfort to their families. As one Canadian report succinctly concluded:

    "We owe it to the dying to support and care for them as they pass through the valley of the shadow of death, and not to kill them".

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8.6 p.m.

Baroness Pitkeathley: My Lords, I want to begin my maiden speech with my most sincere thanks to noble Lords on all sides of the House for their kind welcome and their warm offers of help to me. However, I also want to take this opportunity to thank the House for its help and support over a number of years, and not just since I have been a Member of it. I refer to my relationship with the House in my role as chief executive of the Carers National Association. I have sat many hours below the Bar or in the Gallery or in committee rooms listening to debates and questions relating to carers' issues. I am very grateful for the understanding and support which the House has always shown to caring issues, and especially for the cross-party nature of that support. As I stand here this evening, I remember, above all, the wonderful contribution made to this issue by the noble Baroness, Nancy Seear, so much missed, I am sure, by your Lordships, by me personally, and by the carers movement in general, for her wisdom and her commitment to the carers' cause.

Given the tradition of the House that maiden speeches should be uncontroversial, your Lordships will not be surprised to know that I do not intend to address some of the more difficult issues that we are debating tonight. But neither will your Lordships be surprised to know that I want to make my remarks on carers and remind your Lordships that for every terminally ill person there is very likely to be a family member who is involved, who is concerned with and about the legal and medical decisions which are under consideration. These families, too, have needs which go beyond their need for support in the distressing circumstances in which they find themselves. They need communication and they need involvement.

The issue of communicating with relatives is, I know, a difficult one, surrounded as it is with issues of confidentiality and loyalty to the patient who is terminally ill. However, too many relatives complain of lack of information--information given too late or given in a form which is incomprehensible. This is particularly the case where the patient is being cared for in an institution which is not especially sensitive to the needs of the terminally ill. The hospice movement, which started in this country and is so admired throughout the world, has a proud record of taking a holistic view of the family when someone is dying, but we should remember that 50 per cent. of deaths take place in hospitals which may not be specialists in palliative care.

I am not necessarily suggesting that information is deliberately withheld--often such decisions are made from the very best of motives--but the result is that the carers often feel bewildered by medical processes and confused by their surroundings. This bewilderment and confusion may be conveyed to their dying relative and can be avoided by a few minutes of a doctor's or nurse's time taken to offer simple explanations and acknowledgement of the family's concerns. "I'd been married to him for 35 years", said one carer, "and nursed him for the last six, but I just didn't feel involved in his dying at all. All the doctors and nurses somehow took over and made me feel like a spectator".

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Families do not want to be spectators. They want guidance about how open they can be with their relative and they want guidance about the opportunities they should have to help patients talk through their own fears. Too often families feel that they have to be cheerful and pretend to be brave and strong and thus have no opportunity to share their sadness. People fear that death will be violent and traumatic since most of us have no experience of what death is like. As one widower said:

    "I didn't want the medical jargon--I just wanted to know how long she had and, most of all, would she be in pain and would I be able to cope".

We should not ignore the real fears which relatives have about how they themselves will cope with bereavement. Those fears are not confined to the emotional aspects of bereavement; the practicalities are important too, but what we must take most account of are the feelings between the terminally ill and their relatives.

Caring arises from a relationship. If you were not already in a relationship with someone, you would never become their carer. We all know that family relationships are very varied in their quality and their history. I would never suggest that they are all sweetness and light, but they are certainly often characterised by love and strong concepts of duty.

I beg your Lordships not to believe those who tell you that families do not care any more. Almost 7 million people in this country willingly take on the difficult task of caring for a relative and the way in which the end of that relationship is managed during a terminal illness is of vital importance. Surveys have shown that one of the major concerns of dying people is not the legal and medical issues--problematic though they are--but the overwhelming feelings of guilt they feel about being a burden to their caring relatives.

In conclusion, I am asking for involvement of relatives; not necessarily involvement in the very difficult decisions with which the debate is concerned but involvement in the sense that their feelings, their anxieties and their ability to contribute to a peaceful end of their relationships are borne in mind. If this is done, they can be seen as a resource for the hard-pressed professionals, not as a nuisance or as another problem to be dealt with. Above all, they can be a resource for the dying patient, enabling them to die peacefully and in the knowledge that these family relationships--which are, after all, the source of most caring in our society--are acknowledged and valued.

8.11 p.m.

Baroness Warnock: My Lords, I begin by congratulating the noble Baroness, Lady Pitkeathley, on, as one would expect, a most well informed maiden speech. I congratulate her also on her compassion and excellent delivery. I am sure that I speak for all noble Lords when I say that we hope to hear much more from her in the future.

In four minutes, I shall have to put my argument quickly but, speaking as a philosopher, one of the essential points here is to distinguish things that differ. The noble Lord, Lord Lester of Herne Hill, is not raising any general questions about euthanasia; nor about

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changing the law. He is simply seeking to clarify the specific way in which doctors and nurses may lawfully treat certain patients who are terminally ill and whose life in any case is certain to be short and is likely also to end in acute distress. I emphasise that word "distress" and the word "misery" because we are not speaking only about pain.

I emphasise the specific nature of the discussion because it is terribly easy to get carried away into suggestions that any possibly life-shortening procedure will start a descent down a slippery slope at the bottom of which lies the pit of putting to death those we think are not worth keeping alive. However, the slippery slope does not threaten us if what we are talking about is clarifying the right of the terminally ill to die peacefully.

My argument is that value judgments are involved here, on the part of the doctor, the patient and those who are caring for the patient. My hope is that the law should be so clarified that it will not seem to contradict or nullify such value judgments. The judgment involved is simply that to alleviate the patient's suffering is more important than to allow his life to continue for a few more days or weeks, whatever his suffering may be. What is at issue is not when, but how, the patient dies.

Part of the patient's suffering may well be the dread that he feels of dying by choking or by suffocation. As I know from personal and recent experience, a patient may be horrified by the thought of a particular manner of death even though he is stoical and realistic about the inevitability of death sooner rather than later. For such a patient, the reassurance from his doctor that that horrible death does not await him--that he, the doctor, will not allow it to happen--is an enormous relief and he can settle as calmly and as peacefully as his situation allows to face the short future.

It is important to recognise that the part of compassion here is to promise that the most horrible suffering will not occur. This entails that the doctor must claim to know both what the progress of the disease will bring if no extra steps are taken and that he is able to take such steps as will prevent what it is that the patient fears. I now believe that we ought to have it made clear for us that medical guidelines and prosecution policy will allow that such knowledge may be avowed by the doctor, and acted upon. I do not wish to see prolonged the use of the argument from double effect, but I do not have the time now to go into the details of that argument; nor do I want to go into the yet more shifty argument that the doctor does not actually know what will happen.

The point that I want to make crystal clear is that even if the doctor knows that the alleviating treatment will shorten the patient's life, if he judges that the alleviation of suffering is more important, he will not be liable to prosecution.

Finally, if that point can be clarified, I believe it to be of the utmost importance that the training of doctors should be a training in such compassion and that they should be taught that relieving suffering and fear are as important a part of their professional duty as prolonging life in the extreme situation of terminal illness. This would not be a licence for wholesale euthanasia; it

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would be to provide the possibility of the explicit judgment that peace and the absence of fear may be of more value than a day, a week or a month of mental and physical torture.

8.17 p.m.

Lord Swinfen: My Lords, I am neither a lawyer nor a doctor. In this matter I am a complete layman. However, as I understand the law, there does not appear to be any need for a change. I understand that a doctor may give whatever medication he genuinely believes is needed to relieve a patient's pain or suffering, even to the extent of sedation to keep the patient asleep. Provided that treatment of the patient is the doctor's intention and that it is in the patient's best interest, even if that treatment may shorten life, it is legally right and proper for the treatment to be given. When my time comes, I hope that no one will strive officiously to keep me alive, but will endeavour to reduce any pain that there might be at the time.

We all suffer pain from time to time, sometimes for long periods, and we recognise that pain is very tiring and that that fatigue of itself may well shorten life. The relief of pain in many cases will, I expect, give the patient a slightly longer and more comfortable life. Certainly, there will be a more dignified death.

I understand that although advances in pain relief have been dramatic in recent years, hospices have been accused of being able to help only 95 per cent. of patients suffering from pain. According to Dr. Robert Twycross, Macmillan Clinical Reader in Palliative Medicine at the University of Oxford, that is an inaccurate statement. Speaking in July this year he stated:

    "The bottom line is making the unbearable bearable, and this is readily achievable with skill, imagination and determination in approximately 95 per cent. of cases. In the remainder, approximately 5 per cent., it is much harder to achieve this goal, but that does not mean that the patient 'cannot be helped' or is not to be helped. In extreme situations, patients will receive sedation to keep them asleep, around the clock if necessary, in order to ease the intolerable physical and/or mental distress. No one need die in agony. It is not necessary to legalise mercy killing/euthanasia to make this claim [a] reality".

I have a feeling that those in favour of euthanasia tend to muddy the waters, and wish to muddy the waters, in order to obtain a change in the law. I hope that the Government will resist that and not make any change.

8.20 p.m.

Lord Stallard: My Lords, I too am grateful to the noble Lord, Lord Lester, for initiating this debate. I have relied very heavily on the report of the Committee on Medical Ethics of 1994. I am not an expert or a lawyer. I must rely on the expertise of the House, and there is none better. The noble Lord who initiated the debate seems to be unclear about the position. Lawyers do not appear to understand what ordinary laymen like myself have understood since the production of that report. Certainly, doctors are well aware of the findings of that report and what happens in practice.

I have visited hospitals and seen the practical outcome of the recommendations of that report of 1994. I have spoken to doctors and Macmillan nurses who work in

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hospitals. There is no lack of knowledge or understanding in the profession; nor is there any lack of knowledge in the hospice movement. Without doubt this country has the finest hospice movement in the world. In all of these cases I should like to see the Government provide greater support to spread this knowledge which is available to most people but apparently not to those in the legal profession where it is most necessary.

I agree with the point that has just been made by the noble Lord, Lord Swinfen. I do not know whether it is deliberate or whether it is part of a campaign, but there appears to be reliance on High Court cases to try to change the law, not through Parliament but through case law as has happened in the Netherlands. The results have been disastrous, not only for the law but for patients, their families and everyone concerned. I hope that we shall resist the temptation to go down that road.

I read this case from start to finish. The noble Lord who initiated the debate said that "we had won everything that we wanted". Those were his exact words. I did not understand it. What they had won was already there. The law is quite clear, and that court case proves it. The case collapsed because the Official Solicitor, the judge and everybody said that there was no need for a court ruling. They understood it. I do not know why the legal representatives of that poor, sad patient, for whom they had the greatest sympathy, did not understand it. Nor did the doctor understand it, if he is quoted correctly. Those of us who are interested in these matters understand it but we do not know why others cannot understand it. I hope that no positive move is made in the direction of building up case law to try to change the law on euthanasia rather than pursuing the parliamentary process. I hope that I am wrong but I have my suspicions that that is the case.

If there is lack of knowledge in this area I ask the Government to ensure that information is made available to everyone. That may well be done by improving the facilities available to the hospice movement, increasing the funding of GP services and the training of GPs to make them better informed than certainly one of them appears to be and improving the understanding of some in the legal profession. Have the Government any views on how those people can be made aware of what is already known to most others about help that can be given to many in dire circumstances at the moment? Patients, relatives and others who do not understand the position are being misled by others who should understand it. The Select Committee thoroughly examined all of these issues. I hope that the Government will reaffirm their confidence in the recommendations of that report and do what they can to publicise the results.

8.25 p.m.

Baroness Elles: My Lords, the House is indeed grateful to the noble Lord for giving it the opportunity to discuss this most crucial of issues--that of life and death--and to hear the views of the Government as they are now set out.

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As I understand it, the current state of the criminal law is contained in the judgment of Lord Devlin in the Adams case in 1957:

    "A doctor consents to do all that is proper and necessary to relieve pain"--

I stress the next words--

    "even if the measures might incidentally shorten life by hours or perhaps longer".

Forty years later--about three weeks ago--Dr. David Oliver, medical director of a hospice, emphasised in a letter to The Times of 11th November concerning the court case involving Annie Lindsell--whose name, very understandably, has been raised by most speakers--that it was standard practice in hospices and specialist palliative services and should be made available to any person with advanced motor neurone disease, cancer or other terminal illness to use carefully adjusted doses of morphine, diamorphine or other medicines to relieve pain, breathlessness or other symptoms. He pointed out that the average duration of the use of morphine at home for patients with motor neurone disease was 240 days, about two thirds of a year. The average duration of the use of diamorphine by injection was two days. One recognises the difference.

The conclusion of the Select Committee on Medical Ethics published in 1994 was that,

    "there should be no change in the law to permit euthanasia, nor the creation of a new offence of mercy killing".

Many noble Lords have already concurred with that conclusion.

However, the need for a new judicial forum to handle cases concerning medical treatment of incompetent patients is to be supported. I do not believe that other noble Lords have touched on this matter but it is a big subject. I believe that the point should be made in this debate. It was clear from the evidence received that there was a need for the removal of the mandatory life sentence for murder, particularly in those rare cases where, say, a relation had felt compelled to assist a patient to die other than a natural death. For instance, that relative could receive a suspended sentence. I believe that special care must be given to those cases. One cannot just write it off and say that the law is satisfactory. The law may be satisfactory but one must recognise that there are elements on the fringes of this debate which must be considered and dealt with.

The medical treatment of terminally ill patients has undergone fundamental change in recent years, even since 1994. First, it is no longer left solely to a doctor but includes the healthcare team and the patient who can consider the suitable and available options. That is very important. Secondly, the increase in methods of palliative treatment in the past 25 years, including advances in the application of medical technology in the past few years, has shown that as at 1994 under 1 per cent. of cases had not received relief from pain in the course of dying. A great tribute is due to Dame Cicely Saunders, a continuing provider of care, interest and concern. The many improvements in palliative care are due so much to her initiative.

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Proposals in the report, continued research, extension of the opportunity for palliative care from hospices to other hospitals throughout the land, and the possibility for doctors and healthcare staff to continue medical treatment needed for the relief of pain--all are proposals which have been encouraged and supported. I hope that the Government will be able to say some words in response. In conclusion, the task of the doctor is to cure and to care. That principle must remain paramount.

8.30 p.m.

Lord Alderdice: My Lords, I would like to express, as many others have done, my thanks to my noble friend Lord Lester of Herne Hill, for introducing this debate. In doing so he is reflecting a debate which is going on in the community at large. Some years ago, in an eminent book on medical ethics, a chapter was introduced with the comment that we are now in an age of anxiety so far as ethics are concerned. When it came to re-publication of the book some years later it was described not as an age of anxiety but as an age of ethical crisis. Whether one entirely subscribes to that or not, there can be little doubt that there has been a change in the situation.

I recall as a junior doctor finding myself on a number of occasions having to deal with these kinds of matters. After struggling with them and, often in collaboration with the patient, coming to a conclusion as to how we should act, I felt that I was doing the right thing. In most cases I believe that together we probably did do the right thing. In listening to the challenging and very distinguished maiden speech of the noble Baroness, Lady Pitkeathley, it seems to me that she has pointed out that there has been something of a change in development. For now, families, carers and the rest of the circle want to be involved in these matters, and there has been a development in the technology of the treatment such that we can extend life in a way in which it simply was not possible in the past.

It seems to me that in this context it is not sufficient to depend on legal and professional approaches of a previous generation. When I find many noble Lords saying that thus it has been and thus it should continue to be, it seems to me that what is being expressed is a deep sense of anxiety about the difficulties with which we must now necessarily struggle because of these new situations where patients and their relatives are no longer prepared merely to leave it in the hands of lawyers and the law or indeed in the hands of doctors and their art. They want to be involved and they want to struggle with the questions. I see this debate as part of our struggle as a society to deal with these new elements and developments, not elements to leave our principles behind but rather an opportunity to apply our fundamental principles in a new, changing and developing situation.

As we struggle to look at these things, it is not wise for us to polarise the debate into extreme positions, but rather to realise that it is rarely the more extreme positions that provide the difficulty. They are often the clearest. It is the more complex cases which often provide the greatest struggle and the greatest difficulty and problem in reaching a conclusion.

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It seems to me that this uncertainty in dealing with things is also leading to a problem in the community. While the family circle and patients want to be involved in the whole matter, they are complex issues and we all find them so. For example, some are finding the question of the involvement of medication such as morphine confusing. Realising the possibility of double effect, some are now beginning to request that morphine not be used, even though it may get rid of pain, as there is a fear about some of its other effects. It seems to me that this is an expression of people wanting to struggle with the difficulties but fearful because the knowledge is not entirely there and we have not found our way through to dealing with the complexity of these issues.

I do not wish to go on at length because many other and much more distinguished noble Lords have contributions to make much above what I have to say. It seems important to me that as we struggle to deal with these things we should not allow ourselves, in the anxiety of the problems with which we have to deal, to depend on the answers we gave in previous times when the profession of medicine simply stood on its dignity and was able to say, "I am doing a great thing and I should not have to explain myself to anyone else who knows less." The medical profession is struggling with these issues, working with patients and working with the family circle. Medical training now involves a greater degree of training and exploration of medical ethics in collaboration with philosophers, theologians and others in our medical schools. This is good because it is struggling with the difficult questions, but it does not mean that an answer is easily forthcoming. It places on all of us a bounden moral duty to continue to struggle with the increasingly difficult questions.

8.35 p.m.

Lord Hayhoe: My Lords, as many speeches have shown, this debate overlaps the debate on the Select Committee on Medical Ethics held on 9th May 1994. Just as the debate and the whole surrounds of that committee were subject to misinterpretation and misreporting in some areas, so I fear this debate may suffer in the same way. I was glad that the noble Baroness, Lady Warnock, made the point that she made at the beginning of her contribution.

I wish to say a word about palliative care because that is referred to in the Question. The best definition I have seen of that was given by the National Council for Hospice and Specialist Palliative Care Services to the Select Committee which said,

    "Palliative care: --affirms life and regards dying as a normal process; --neither hastens nor postpones death; --provides relief from pain and other distressing symptoms; --integrates the psychological and spiritual aspects of patient care; --offers a support system to help patients live as actively as possible until death; --offers a support system to help the family cope during the patient's illness and in their own bereavement".

I reaffirm those wise words and I hope that nothing is said, either in or about this debate, to detract from them.

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I am sorry that the sensible and responsible conclusions of that Select Committee, particularly its clear conclusion,

    "that there should be no change in the law to permit euthanasia"

are not more widely accepted throughout the country. But, alas, the euthanasia lobby rolls on and I would not be at all surprised if our debate today is muddled or misrepresented by supporters of euthanasia.

Another wise conclusion of the Select Committee on Medical Ethics was:

    "We strongly recommend the development and growth of palliative care services in hospices, in hospitals and in the community".

Let me declare an interest as a rather inactive president of Help the Hospices and immediately offer the warmest possible tribute to the Duchess of Norfolk who, by her efforts and example, has helped the hospice movement in our country become such a notable national achievement. We really do lead the world in this area. Perhaps my noble friend the Duke of Norfolk would tell his wife with what affection and admiration she is held by all of us who know of or have benefited from her work with Help the Hospices. Of course, none of us must ever forget the pioneering work of Dame Cicely Saunders, a truly wonderful lady, and all those who are participating in hospice work.

Euthanasia is the enemy of the hospice movement, as recent experience in Holland, referred to by my noble friend on the Front Bench, shows only too well. I am resolutely opposed to any change in the law to facilitate euthanasia. I would like to see a growing partnership, better training and closer co-operation between the voluntary hospice movement and the NHS, for in the long term that relationship will lead to steady improvements in palliative care, and as that improves so the demands for euthanasia will, I believe, reduce.

I hope that the noble Lord who introduced this Question tonight will endorse what the noble Baroness, Lady Warnock, said about this not being in any way a debate about euthanasia. It is on a fairly narrow legal point that he seemed to be raising these issues and I hope that it does not lead to any misunderstanding or muddle outside this House. Perhaps in his reply he could make that clear.

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