Select Committee on Assisted Dying for the Terminally Ill Bill Minutes of Evidence

Examination of Witnesses (Questions 1905 - 1919)



  Q1905  Chairman: Good morning. Those of you who are kind enough to appear this morning as witnesses are doing so in a purely professional capacity—that is to say, not as representing any organisation. Professor Tallis has been here before representing an organisation and he is now here as an individual, perhaps with more freedom to express a view than otherwise he would have had. I want to be clear that all of you are representing no persons other than yourselves in the evidence you are giving here. That of course gives a degree of freedom possibly which otherwise people would not feel they have when they are within the constraints of representing an organisation. The evidence and help you give us will be noted and transcribed. You will have an opportunity of checking the transcript. The transcript will be appended to our report and, although this is a public session and what you say is public, the transcript of it will become public when we present our report to the House which we hope to do in due course. Baroness Greengross, are you going to begin?

Baroness Greengross: I am going to start, if I may my Lord Chairman, by thanking you and the Committee for inviting us here. I have been asked to respond first simply because I think I am more used to being here than my colleagues. It is a great honour to come and give evidence to you. If I may, I will just introduce my colleagues. Professor Raymond Tallis is a geriatrician and is here as a geriatrician in a personal capacity. Dr David Cole is a consultant oncologist based in Oxford. Dr Carole Dacombe is medical director of St Peter's Hospice in Bristol. Dr Georg Bosshard is an expert in assisted dying in Switzerland. I am not going to waste time by speaking now. I will come in, if I may, a little at the end and we will start with very brief introductions, if that is convenient to you.

  Q1906  Chairman: Please.

  Professor Tallis: I am very grateful for this opportunity to make a second appearance before the Committee. As Lord Mackay said, I am not representing the Royal College of Physicians and I am no longer chair of the Royal College Committee on Ethical Issues and Medicine. I am speaking in an entirely personal capacity as a geriatrician. I have been professor of geriatric medicine in the University of Manchester since 1987 and an honorary consultant physician in health care of the elderly since 1982. I am in support of Lord Joffe's Bill in its present form but in these brief opening remarks I am not going to set out my general reasons for this. Instead, I want to address specific concerns that have been raised with respect to older people. The first is that older people will be particularly vulnerable if the Bill is enacted because they may feel under pressure not to be a burden to others. This view was expressed in the presentation to this Committee by the British Geriatric Society which stated that older people are often unduly influenced by their families and carers who will not necessarily have the older person's wellbeing at heart. Little evidence for this claim was offered and in contrast it seems to me there is abundant evidence to the contrary from countries where assisted dying has been legalised. Firstly, the average age at which people receive assisted dying is younger than the average age of those dying without assistance. In Holland, for example, people over 80 are less likely to receive assisted dying. The data from Oregon are compelling. Whereas the average age of patients in hospice care is 83, the average age of that small minority—I think it was 0.14 per cent in Oregon—who have assisted dying is 71. In another Oregon study, patients who chose assisted dying were also younger, their median age 64, than patients who voluntarily refused food and fluids as a way of hastening death, their median age being 74. This, to me as a geriatrician, makes clinical sense. One would anticipate for biological reasons that the older the age of death the less need in general there is likely to be for assisted dying. Younger people die harder than very old people. The major factor determining whether a patient receives assisted dying is, as the literature shows us, the condition from which they are suffering, not their age. Patients with the relatively rare motor neurone disease are 25 times more likely to use assisted dying than patients with chronic respiratory disease, a particularly common cause of death in old people.

  Q1907  Chairman: Where does this come from?

  Professor Tallis: The Oregon Department of Human Science, publication 2004. I am happy to provide all the references. The Oregon experience also shows that a successful request for assisted dying is associated with an assertive rather than a compliant individual and usually from a higher socio-economic class. As for external pressures from, for example, family members, these tend to be negative pressures. In Oregon, 25 per cent of terminally ill patients who were planning to have an assisted death modified or delayed their plans at the family's request, even when this prolonged their suffering. The second concern is that the Bill might undermine the confidence older people have in their doctors and indeed in the entire health care system. International experience suggests the opposite. Trust in doctors is highest overall in Holland out of 11 European countries and a full and frank discussion about end of life management which is necessary for respecting the patient's autonomy is greatly appreciated. A recent survey of six European countries indicated that this was best carried out in Holland. In a YouGov poll at the end of last year in the UK, 83 per cent of people said they would trust their doctor more or the same if the Bill became law and, most pertinently, this percentage was slightly higher in older than in younger adults. In general, older people seem to be more frightened of unbearable suffering protracted as a result of injudicious medical intervention than of being killed against their will. This is reflected of course in the current debate around living wills which will enable people to specify in advance the limits to life prolonging or invasive medical treatment. The fear of medical intervention incidentally is entirely rational. I have, for example, witnessed or been aware of many inappropriate efforts at cardiopulmonary resuscitation simply because doctors do not know when to stop or are afraid to do so for fear of being accused of not trying too hard. In the light of all this, it is hardly surprising that support for euthanasia or for this Bill does not decline significantly with age. Whereas there is 82 per cent support in the general population, there is 78 per cent support in people over 65. This very small difference is accounted for by the influence of religious beliefs which increase with age. The data I have cited are unexpected only if one takes a rather patronising attitude to older people and assumes that they are vulnerable to suggestion and do not know their own minds. I am not aware of any evidence that increasing age is automatically associated with a decline in assertiveness over things that matter, as anyone who wants to impose upon an old person an arrangement they object to will discover. Indeed, the written response from Help the Aged on the Assisted Dying Bill emphasises that the desire to retain control, autonomy and choice in daily life is strong amongst people of all ages. Speaking as a geriatrician, I would be very sorry if the care of older people facing death proved to be the last bastion of unreconstructed paternalism in UK medicine.

  Dr Cole: I am a consultant in clinical oncology. That is the practice of chemotherapy and radiotherapy in cancer patients. I have been a consultant since 1990 predominantly working at the Oxford Radcliffe Trust but also with quite a big district hospital practice in Swindon. I am chairman of the Thames Valley Cancer Network Urological Specialist Group. I have been programme director for training in oncology in the Oxford Deanery for quite a number of years. I have come into this via Lord Joffe. One of my colleagues in the hospital known to Lord Joffe asked me to offer an opinion about this Bill. I have not previously had a major interest in this topic. I would not claim specialist knowledge of the subject, except in the sense that it applies to my clinical practice. I do not have a strong personal view in the matter. My involvement is as a day to day doctor, providing cancer care and frequently therefore having to deal with end of life issues. In my own practice, I would roughly estimate that 100 to 200 of my patients die every year. I am not there at the end in all cases by any means but I do have a very extensive experience of managing, talking and communicating with dying patients. I do not have detailed records of numbers of patients who have discussed a wish to choose the time that they die, but I would estimate that perhaps one patient per year, in my experience. I get involved in a detailed discussion with about whether they might possibly want to avail themselves of what they would call euthanasia as a generic term for this subject—not that we think it is a good term. Choice of the time of death is a better way to describe this issue. I would emphasise that being an oncologist I do not really feel competent to advise about non-cancer patients. I would not want to start talking about patients with heart disease, chronic pulmonary disease or motor neurone disease. That is not my area of competence. From time to time, I have been involved in these discussions with patients and I feel my contribution to this debate is not to express my own opinion but to express their opinion. I am, if you like, an advocate on their behalf expressing the wish that could not be met in their case, that is to choose the time that they die, somewhat sooner than they would do naturally. I have over the last few months reviewed quite a lot of literature pertaining to this subject but I have only come to this subject fairly recently. I have a very strong sympathy for the few patients who do wish to die at a time of their choice, but there are implications for other patients as well, the large majority of patients who do not wish to die at a particular time and who wish to allow the disease to take its natural course. Considering this issue, those who do not want that choice are an important and very numerous group. This is not an issue about whether people are going to die of cancer or not; it is more a question of allowing patients the opportunity to choose when they would like to die. This is usually or almost exclusively when anti-cancer treatment has become ineffective and, in my experience, their health is deteriorating and their life expectancy is of the order of one to two months or so, perhaps nearer one month than two. Reference has been made to patients with a prognosis of six months or so. It has clearly been shown that the reliability of predicting prognosis deteriorates with the longer time to death and I would be reluctant to invoke this kind of legislation for people where one really did not have a good idea as to how long they had to live. These patients of mine who are failing with conventional oncology treatment are also moving into the realm of palliative care. For many of these patients, we share their care with the palliative medicine team. That becomes, in a lot of patients, a transition over a period of time from predominantly anti-cancer treatment to predominantly symptom control. I think the assessment of these patients by clinical oncologists, by palliative care specialists, is one that takes place over quite a long period of time and I would be quite concerned if this Bill allowed for, say, a single consultation with a patient with advanced cancer by a palliative care physician as part of the authorisation process. Palliative care provides its service in a multidisciplinary fashion over quite a period of time and it may not be appropriate for that to be provided by, say, a single or a small number of consultations. For this Bill to be successful, it would be very important for palliative care to be broadly speaking in favour of the measure and that is one of the concerns that I have. The other thing I have been asked to say something about in particular is actual assessment of prognosis at the end of life. I have alluded to the fact that the longer you have to live the more difficult it is for doctors to make that prediction. I would feel much happier predicting prognosis in patients who have one or two months to live and the data rather supports that, as I think you will have seen. As clinical oncologists, we use the World Health Organisation performance scale in making judgments about prognosis. This is a widely used international scale from nought to five. Nought is perfectly well, perfectly functioning; five is dead and there are grades in between. Grade four is that patient who is predominantly in bed or probably exclusively in bed or perhaps in a chair, unable to move independently, unable to get to the lavatory, unable to feed himself or herself, unable to wash, so somebody who has become entirely dependent on nursing care. I am not particularly talking about those who have physical symptoms and hopefully not those who have psychological symptoms. I would hope those could be successfully addressed by expert palliative care. I think there is a group of patients who continue to have intractable distress, despite the input from expert palliative medicine, expert general practitioners etc. That small group of patients who continue to suffer intractable distress may express a wish to choose the time at which they want to die. I would feel extremely sympathetic to that view. I have a number of cases—one particularly about six months ago—where this was the situation. I did not withdraw from the discussion but I continued the support of that patient to try to deal with these difficult issues but of course I was unable to meet her wishes. In a sense, it is on behalf of that patient and others like her that I am here today.

  Q1908  Chairman: You mentioned the World Health Organisation scale from nought to five and you said four was the description you gave us. How does that link to the prognosis of life?

  Dr Cole: I have not seen much of the hard evidence behind this. It is used in clinical practice and proves to be a reliable scale to predict prognosis.

  Q1909  Chairman: Does that mean that if it was four in the scale you would expect death within two months or so at the most?

  Dr Cole: I would not be as categorical as that but it provides a good guide. I am excluding patients who are perhaps performance status four by virtue of toxicity from treatment or reactions to medication that can be dealt with or uncontrolled symptoms. I am talking about patients who are deteriorating because of their progressive cancer.

  Q1910  Chairman: The four would be the one that would give you a pretty accurate idea?

  Dr Cole: I would feel confident in predicting a very limited prognosis in a patient who was performance status four. There are performance status three patients who are perhaps confined to bed or chair more than 50 per cent of the time and have some degree of independence, but also quite a lot of dependence. If they are moving fairly swiftly, within a week or two, into performance status four, they are also a subgroup for whom this legislation might be appropriate in my view. Others have used more complex scales. The Karnovsky scale is well known. A five or six point scale is more easily usable in practice and I do not know many colleagues who use the Karnovsky scale in daily practice.

  Q1911  Baroness Jay of Paddington: Dr Cole, you are talking specifically about oncology, are you not? For example, you could easily have someone in status four, as you have described it, suffering from dementia for a very long period of time. It is important that we recognise that.

  Dr Cole: Oncology, yes.

  Q1912  Chairman: All your evidence is in the area of oncology.

  Dr Cole: Absolutely.

  Dr Dacombe: I am Carole Dacombe, here as the medical director of St Peter's Hospice. As I believe that I am here to represent myself as an experienced grass roots practitioner in palliative care, I think it is important that I explain something about the service that I now work in and my own experience and history that have brought me to this position. I want to explain that St Peter's Hospice is a community based hospice offering a wide range of specialist palliative care services to all of the wider Bristol area. That gives us a catchment population of approximately a million. Within that area, we see patients right across the board within that population. That means people from a wide variety of faith or non-faith and cultural backgrounds. We do not only become involved with cancer patients; we also have patients with a range of other non-malignant, incurable, progressive diseases referred to our services. The services are run as a community based project. We have specialist community nurses who visit patients in their own homes so we are not simply a building orientated service. The visits to those patients in the community by specialist nurses are backed up by myself and a wide range of colleagues from a multitude of disciplines within our team. We offer domiciliary visits to patients by both senior medical clinicians and other disciplines, as well as the opportunity to see patients on an outpatient basis and to offer them support on both our major sites, one in the north of the city and one in the south, in a day hospice environment or indeed by admission to our inpatient unit facilities for assisting patients through times of crisis, be those physical symptom control crises, psychosocial crises or need for respite on the part of the patient and their family.

  Q1913  Chairman: Are there similar facilities at north and south sites?

  Dr Dacombe: Exactly so. That is the service I am involved with and within that service my own role is that of a senior clinician but also an individual who has executive responsibilities for the running of the service and also somebody who has people management responsibilities within our wider medical team, which means I am responsible for managing our team of doctors, our occupational therapists, physiotherapists, pharmacists and complementary therapists. I am involved in a wide range of our work. As an individual, my background is that I have been a doctor for 28 years. After working in a number of junior hospital posts, many of which are particularly relevant to discussions about palliative care, because I worked in oncology, neurology, haematology and care of the elderly before completing training to work in general practice, I then worked as a principal in general practice for over nine years before moving into specialist palliative care. Within general practice, I obviously was involved in the provision of generalist palliative care and developed further my interest in that area. I then moved into working at the hospice and I have worked at the hospice now for 14½ years. It is on the basis of that experience that I believe I am here as a grass roots practitioner with that experience. There are two points that I would like to make in this introduction. First, I want to totally and passionately endorse all the previous remarks that have been made here and indeed outside this Committee regarding the issue of there being a deficit of care in this country. There is undoubtedly a deficit of care and it is across the board in many areas of the delivery of health and social care to our population. There is in particular a deficit of palliative care. It is an indictment on our society that the vast majority of specialist palliative care in this country are still delivered by and funded by the charitable sector. That point needs to be made and cannot be made too often, particularly as there are multiple references to palliative care within this Bill that you are considering. The second point I wanted to make was that throughout those years of my experience I wish to acknowledge to you that I have consistently and persistently encountered a small number of patients who, despite the whole range of services that have been offered to them, both at generalist and specialist palliative care level, have felt a need to express a wish to see their life ended. That has been a consistent part of my experience. These people do tend in my experience to demonstrate some of the common characteristics that I know have been described to you before by previous witnesses both in this country and elsewhere. They often are people who have a long life history of seeking control over their own destiny, of wishing to plan their lives for themselves. They often are people who, despite having explored various faith structures or spiritual concepts that some of us find are a great help and support to us in life, have either rejected them or have failed to find in them sufficient solace and support to see them through the final stages of whatever illness it is that they are dealing with. They do make these requests. Given that it is a fact that unfortunately we have no living experts in dying as we will only, all of us, ever do it once and our patients have only ever done it once and are no longer her to tell us what it felt like, if I truly believe in the principles by which we work in palliative care which are to respect our patients, to respect their need for respect, for dignity and choice, I need to be prepared to listen to patients who wish to request. I need to acknowledge that I have heard those requests here today.

  Dr Bosshard: My name is Georg Bosshard. I am a physician from Switzerland. In our country, we speak German, French and Italian but not English so if I am struggling sometimes with the language I apologise. My basic training is as a general practitioner and in legal medicine. I am working in the Institute of Legal Medicine in Zurich and today there we have to investigate on the spot, every week, one or two cases of assisted suicide. During the last few years, I have carried out research on the one hand on end of life practices in different European countries and, on the other hand, about the specific situation of assisted suicide in Switzerland. I am also a member of the Swiss Academy of Medical Sciences and I have been involved in the reformulation of their guidelines on the care of patients at the end of life. Today, the academy has something that we could call a neutral stance. The academy says it is not a physician's task to assist in suicide but if an individual physician decides to assist an individual patient this decision has to be respected. The academy also provides some safeguards that have to be met in such cases. Today, there is a quite well established practice of assisted suicide in Switzerland for a very small number of people, about 200 persons every year. There is broad public and political support. There are only very few people challenging the basic legal fact that in Switzerland assistance in suicide without motives of self-interest is not illegal. You might be more familiar with the situation in Oregon and the Netherlands than in Switzerland so I would like to stress three issues that in my opinion are crucial to the legislation in Switzerland or to the system we have in Switzerland. Firstly, the practice in Switzerland is restricted to assisted suicide but this term is defined more broadly than in Oregon. In exceptional cases, it is also allowed to use drips or gastric tubes and this is assisted suicide because the patient has to start the infusion as the last step of the action leading to death. So, considering the action itself, no patients are excluded from the practice. Even people with an advanced stage of motor neurone disease, usually or always can have the assistance. On the other hand, no physician in Switzerland has to kill his patient. The second issue that seems important to me is that of the preconditions. The law does not restrict assisted suicide to the terminally ill. Practice shows that around 80 per cent of the people who died from assisted suicide were fatally ill. There are some people in Switzerland striving to restrict the practice to terminally ill people but they are a minority. The last point is the responsibility for the assistance. In Switzerland, not only the doctors but also members of right to die societies are responsible for the assistance. In many cases, this can be a relief for the physician involved and for the rest it is very important that as much responsibility as possible is kept with the patient anyway. Once the barbiturates are prescribed, the patient can decide independently from his physician where and when and if at all he wants to die.

  Baroness Greengross: I did submit written evidence to the select committee. I am the only non-medic I think in this group of people and I speak as somebody who has worked and still works for about 30 years with older people fighting for them to be treated as adults, however frail they are and however vulnerable they are and fighting for them and all of us as we get older to have a better quality of life. "Life" is the important word there. We now live in an atmosphere when a lot of current and previous legislation is leading to greater autonomy and, in my experience, that is what most older people want: control, dignity and autonomy with regard to their lives. Autonomy is different from independence. You can be very dependent and you can still retain autonomy over decisions. That is terribly important to people. We are talking about people who are very vulnerable but who are mentally competent. In my view, mentally competent people who are dying should retain control for as long as possible over what happens to them. The dying process, again through a lot of experience, is what frightens people much more than death itself. There is a great deal of fear about how this is going to happen and we do live in a country where a lot of issues relating to this process are fudged. They are not clear, open and transparent. It would be of enormous help to many people to have permission to talk about these issues more openly with their family and their doctors. This Bill would encourage that. It took me a very long time to come to the decision I have about supporting this issue and this Bill. It is a very limited Bill, limited to a small group of people who are close to death. We heard very movingly about the circumstances where this Bill would apply. Very importantly as far as I am concerned, the Bill would make it easier for palliative care to be available to everybody who needs it because built into the Bill is the necessity to offer it. Palliative care practitioners would need to be partners if this Bill became law because you cannot offer a service to people if it is not available. Should it become law, it would immediately have that knock-on effect to make that available to the people who at the moment do not have access to it. The fact that it is limited to people in the very last stages of life is important. I know there is an enormous amount of worry about slippery slopes. The slippery slope argument applies to a huge amount of our legislation. There is always the possibility of it being abused. There is always the possibility of it spreading into areas where it is taken to extremes and these are dangerous. Controls and restrictions and regulation are always needed to stop legislation going wrong and in this case it is very important that those take place. This is extremely limited. We also know that this would lead I think to better care and it would also avoid a possible breach of the European Convention on Human Rights through loss of dignity caused by intractable pain. It is very much in line with a lot of thinking about compassion and humanitarian care across Europe. More people die at home, which is what older people on the whole want to do, in countries where assisted dying for terminally ill people is allowed than do in countries where it is not. It is very important because the whole thrust of this Bill would be for more openness, more transparency, more possibility of getting things right for people. We do know that, with all respect to people's particular religious views and views on ethics who oppose this Bill, the vast majority of the public when asked about it want this control over the dying process. I believe that the dying process is an essential part of life. Openness is very important. Stringent safeguards are hugely important. If there are areas where greater safeguards are needed, I would be the first to say they should be built in. We all want absolute safeguards from this Bill being open to abuse in any way. It would increase the ability to communicate openly with doctors. This is something that a lot of older people cannot do. People are terribly frightened of complaining about anything to do with health because a lot of very old people are still very grateful that there is an NHS at all and many are frightened of the repercussions that follow if they do complain. We have to bear that in mind. We have a very compliant older population. Above all, the criminal law in this area could, if this Bill was introduced as law, be more consistent and more rigorously applied where at the moment it is not. I think that legalising this might stop the abuse that we know takes place at the moment. There is abuse. We also know that many doctors take huge risks in helping people to die because their conscience says they must but they are open to prosecution. This leads to my most important point which is that under English law people have a right to commit suicide. It is a tragedy if anybody commits suicide for the reason that they have been pressured into doing so, that they have been told they are a burden, that they are misused by grasping relatives or whatever. We know that this is a tragedy. We know it happens. It does not happen, I hope, too often but it does happen. If somebody is severely disabled and they need help, they do not have the same rights therefore as an able bodied person because an able bodied person can commit suicide. It is not a crime. We are in fact, although the disability lobby does not always agree with this point, discriminating against people who are disabled because they do not have the same rights as able bodied people in this country. If somebody makes a rational decision that they want to end their suffering only a little bit before it would automatically end, it is our humanitarian duty as people who are carers, doctors, nurses and family members, with our loved ones, to enable them to retain their dignity and die in the way they wish to die. Above all, with so much in the way of medical advances and increased longevity, we have to pay attention to the people who place a greater emphasis on the quality of their life as it draws to an end than merely on promoting that life for another very short period, be it days or weeks, in a way they do not wish.

  Q1914  Baroness Thomas of Walliswood: Thank you very much for all your evidence which I thought was extremely interesting. I would like to ask a question addressed to the doctors present. We have had a great deal of evidence from people as to the potential ill effect of this legislation upon the doctor/patient relationship. It has been very frequently deposited before us as evidence. In Holland when we were there we asked doctors what they felt and how they regarded their own practice on those occasions, which I think we all agree are probably quite rare, when they do what the law permits them to do. They all said they did not really like it but one or two of them said, "But it is the last thing I can do for my patient." Can I ask the doctors here where they fall in that spectrum and how they feel the doctor/patient relationship in this country in particular will be affected by a change in legislation?

  Professor Tallis: First of all, it would be a harrowing experience for doctors but being a doctor is often a harrowing experience. It is part of the burden of being a physician or whatever. That in itself seems to me to be not an argument against the Bill. In terms of the overall impact of the doctor/patient relationship, in a sense this is an empirical question and one has to look elsewhere for data. I am enormously impressed -- it is one of the reasons I changed my mind about the Bill, partly because the Bill itself changed—by the positive impact it had on the doctor/patient relationship and also more widely upon the kind of thing that Sally has been talking about which is transparent end of life decision making, because we do other harrowing things. For example, the decision to withdraw treatment which can have ultimately the same impact. The knowledge that this takes place in a much more transparent context I think can only make doctor/patient relationships better and doctors feel better about themselves. It illustrates a general principle that this Bill, although it will only be applied to a very small number of people, may have a much wider knock-on effect. For example, picking up Carole's point about the inadequacy of palliative care services, wherever I have looked at the literature, it has been a major driver to improving palliative care services. I feel it can have only a beneficial effect on how doctors feel about themselves and their role and about the doctor/patient relationship both individually and more largely in society as a whole.

  Q1915  Lord McColl of Dulwich: On the doctor/patient relationship, a lot of old people are now worried that when the doctor comes, is he coming to help them or to do something else. Could we get round this difficulty by precluding doctors and nurses from taking any part in this at all? This is not a new suggestion. It was considered in Switzerland. It does seem to me to have quite an attraction and indeed, if any doctor was against this, one might look at him askance. Why would he want to take part in it if there were other people who were able to do it?

  Dr Dacombe: Could I respond firstly to Baroness Thomas who was seeking an answer to her question from all the doctors on the panel? I would endorse much of what Professor Tallis has already said. I would like to make the point that there is a sense in which, were there to be a Bill in place that offered legislative support to assisted dying, it could give a completion to the discussions between doctors and patients around this area which I have already alluded to and do occur and which in a sense are incomplete because they can only go so far as to be the patient expressing that wish and, ultimately, the doctor saying, "But there is no structure in which that can happen." It does not necessarily have to mean that, as I know has been discussed in previous sessions, that same doctor who is having that discussion ultimately carries out the act. For there to be the knowledge that the process is available to the patient could enhance the length, depth and scope of the conversation that takes place.

  Professor Tallis: There is a particular premise, Lord McColl, in your question. There is not any evidence, even in the post-Shipman era, that there is distrust of doctors. In the YouGov poll I referred to in my opening comments, there was no suggestion that patients, including older patients, would trust physicians less if they knew that part of the therapeutic alliance included assisted dying. There is no evidence of that, in so far as we can get evidence on these things. For that reason, I would be very sorry if assisted dying was something that was made separate as opposed to the whole care of the patient and preferably it should involve the doctors and nurses who had been caring for the patient earlier on. It is very important as part of the overall therapeutic alliance, which is a phrase I am sure you have heard a lot.

  Dr Bosshard: In the first place, you mentioned elderly people being afraid that they are not sure what is the motive of the doctor visiting them, whether he has come to kill them or not.

  Q1916  Lord McColl of Dulwich: There are old people who have expressed this.

  Dr Bosshard: This, to me, seems to be exaggerated. I am not aware of such patients in Switzerland. In terms of the role of the doctor, you cannot regulate assisted dying without doctors but you can keep that involvement to a minimum, and I would say this was the aim of the Swiss regulation.

  Q1917  Bishop of St Albans: The first question relates to some work done by Professor Nicholas Kristakis at Harvard on what he calls collateral health effects. This is the BMJ, July 2004. No one could have done more than Lady Greengross for whom I have the highest respect in caring for and putting the needs of elderly people absolutely firmly and centrally on our map in this country. It has been wonderful. One of the arguments for those who look at collateral health effects as opposed to arguments on personal autonomy is that there could be very significant social effects from such legislation going through. I think you would know, Professor Tallis, anecdotally and objectively, that when elderly people are moved from one ward to another or one hospital to another incidence of death goes up. Professor Tallis in particular, could you speculate on what you think the collateral health effects might be particularly upon elderly people should such legislation go forward?

  Professor Tallis: My own feeling is the collateral effects would be beneficial, precisely for the kind of reasons that Sally and Carole referred to. There would be much more transparency in the kind of decision making towards the end of life—for example, withdrawing treatment which may have the same outcome as assisted dying. This seems to me an empirical question again, so far as I can read the literature, because I have not been to the Netherlands, there are empirical data to support that. The knowledge also that there is this available will support and help a much greater number of people than the number of people who simply avail themselves of assisted dying. I am very impressed, for example, by the data from Oregon—I may need to correct this—where a very small proportion of people who request assisted dying and even go through the process of having it agreed do not avail themselves of it. I think that is another potential benefit.

  Q1918  Bishop of St Albans: I think you are saying that you think this would have no impact at all on the way the general public regard the value and worth of older people. It would only have a positive outcome. Is that what you are saying?

  Professor Tallis: I think so. The data, such as they are—and they are always going to be interpreted in many ways—suggest even counter intuitively the very positive effects that exist in such a Bill in places like Oregon and the Netherlands. It is for those very specific, positive effects that I am in support of it.

  Baroness Greengross: I wondered if I might come back to Lord McColl because I am horrified that there are elderly people who are worried now about whether the doctor is coming to care for them or to kill them. That is absolutely dreadful and terrible. It would seem to me that this Bill makes that much less likely because the doctor is going to be honest and say, "I am here to look after you but if you want to talk to me at a future time about your impending death we can be open. We can discuss it and there is not this lack of clarity about what my role as the doctor is or your role as the patient." To open this up and be clear is what is needed because it is appalling if people are scared of doctors. We must avoid that at all costs.

  Q1919  Lord McColl of Dulwich: Would you object if doctors and nurses were precluded from this activity? It would clarify without any doubt at all what the roles were.

  Baroness Greengross: Speaking personally, I have a doctor I trust. I would rather, if I got to this stage, he was involved in some way. Hopefully, I could take the prescription myself but if I could not I trust the doctor and I would want him to be the person who was there, in some way involved. Caring for someone is caring right until they take their last breath. I would hope that we could have those trusting relationships and that openness could only be of benefit.

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