Select Committee on Assisted Dying for the Terminally Ill Bill First Report

CHAPTER 7: CONCLUSIONS

Introduction

234.  In the preceding chapters we have attempted to summarise the evidence which we have received on the theory and practice of assisted suicide and voluntary euthanasia, on the experience of other countries which have introduced legislation in this area and on the current state of public opinion in Britain.

235.  Our remit requires us to recommend whether Lord Joffe's Bill should proceed, with or without amendment, or not. It is clear to us that, with the likelihood of dissolution of Parliament in the near future, the Bill cannot be considered adequately in the present session due to shortage of Parliamentary time, and we therefore recognise that it cannot proceed. In these circumstances we consider that the appropriate course for us to take is to present a balanced account of the evidence which we have received; to recommend that an early opportunity should be sought for our report to be debated by the House; and to recommend also that, in the event that another bill dealing with this subject should be introduced into Parliament, it should, following a formal Second Reading, be sent to a Committee of the whole House for examination.

236.  In order to assist in these deliberations we draw attention to a number of issues which have emerged in the course of our inquiry and which we would wish to see considered carefully by the House in any debate on our report or by a Committee of the House on any successor bill. Some of the issues which we shall raise in this chapter refer to matters raised in evidence during the course of our inquiry, while others have been prompted by consideration of specific aspects of Lord Joffe's Bill.

Covert Euthanasia

237.  It has been suggested to us on a number of occasions that covert euthanasia already takes place both in this country and overseas and that the interests of patients and doctors would be better protected if this situation were to be recognised and legislation introduced to set out the precise limits of what is and is not acceptable. We have summarised the evidence which we have received on this subject in Paragraphs 76 to 79.

238.  So far as we are aware, there has been no reporting of any of these alleged crimes and malpractices either to the police or to the appropriate medical regulatory body—the General Medical Council (GMC). It may perhaps be argued that those who have alleged malpractice can have had no ulterior motive for doing so. We do however feel that it would be unsafe for us to assume that there has been no exaggeration or misunderstanding in any of these surveys. The Sunday Times article, for example, to which we have referred in Paragraph 77 makes allegations about the administration of diamorphine which suggest that what is being referred to here is the so-called double-effect principle, whereby patients close to death can receive, within both the law and the GMC's guidelines of clinical practice, dosages of analgesics which are designed to relieve their pain or other distress, which could in certain circumstances have the effect of hastening their deaths but which are not administered with that intention. In his evidence to us Lord Walton referred to "examples in the press of doctors saying that they have practised euthanasia". Lord Walton considered that "the very great majority of them have been practising double effect and not euthanasia. I think this is something which has been widely misconstrued" (Q 2051).

239.  While we are not able, for the reasons we have given, to accept as hard evidence the results of anonymous surveys or newspaper articles, this does not mean that we give no credence whatever to what they appear to be saying. Human experience shows that all laws are flouted to a greater or lesser extent, and we would be surprised if the law in this field were an exception. We recognise also the difficulties which medical practitioners may possibly feel about reporting malpractice on the part of colleagues, and this is certainly a factor to be taken into account. Bearing in mind however the trend towards death taking place in hospital rather than at home, the increasing prevalence of team-working in clinical care, the greater tendency for people to litigate where they suspect malpractice, and the potential for confusion with the legal administration of drugs to prevent restlessness and anxiety in the last hours of life, we would be surprised if covert euthanasia were being practised on anything like the scale which some of these surveys suggest.

A Question for Society as a Whole

240.  We have recorded in Chapter One our view that, at the end of the day and when all the expert evidence has been heard, the acceptability or otherwise of a change in the law is a matter for society as a whole to decide through its legislators in Parliament. We feel it necessary however to add two riders to this view. First, we have summarised in Chapter Six the results of a general survey which we commissioned of public opinion research during the last 10-20 years. This survey certainly suggests that there is a substantial majority of the public at large who would support a change in the law. The authors do however caution that the opinion polls which have been carried out on this subject tend to be "simple, direct questions placed without a proper explanatory context". It was also put to us by the BMA that such questions sometimes appear to suggest an either/or choice between intolerable suffering and an ending of a patient's life, whereas the reality—for example, with good palliative care—was rather different (Q 303). Parliament must obviously weigh public opinion very carefully in an issue of this nature. But we suggest that, as with other deeply controversial issues (such as, for example, capital punishment or immigration), it must also assess to what extent opinion research based on answers to questions placed with little surrounding context represents a sound basis for changing the law.

241.  Our second rider concerns the linkage between the general opinion of the public at large in this matter and the more specific views of professionals, such as doctors and nurses, who would be closely involved in the implementation of any change in the law. We are clear that Parliament's assessment of the balance of good and harm arising out of any future bill must be sovereign and that, if Parliament should decide that the law should be changed, it would be for the various professionals, subject to exercise of any conscience clause, to carry out its provisions. Having said that, we are also conscious that, while some medical bodies (such as the Royal Colleges of Physicians and of General Practitioners) have adopted a neutral stance on the underlying principle (though not the provisions) of Lord Joffe's Bill and while we have received evidence from some doctors who would favour a change in the law, other medical bodies, including the British Medical Association and the Royal College of Nursing, have voiced opposition

242.  It is in this context that the suggestion has been put to us by some of the witnesses whom we have heard that, if there should be a change in the law, its implementation should be placed outside the system of mainstream health care. We will not rehearse here the arguments for and against such an arrangement which have been put to us: they may be found in the accompanying volumes of our report—for example, in QQ 161, 324, 1123, 1196 and 2018—and they are summarised in Paragraphs 111 and 112 above. Here we would simply comment that assistance with the suicide of terminally ill people is not seen everywhere where it is practised as being necessarily an exclusive activity of the medical profession. Guidance issued by the Swiss Academy of Medical Sciences states that "assisted suicide is not part of a doctor's task, because this contradicts the aims of medicine. On the other hand, consideration of the patient's wishes is fundamental for the doctor-patient relationship". The guidance also states that "helping someone to commit suicide is not a punishable offence when it is done for unselfish reasons. This applies to everyone". As we have observed in Chapter Five, while a doctor's prescription is required in Switzerland in order to obtain lethal medication, this requirement reflects the need to control dangerous drugs. And it might also be argued that, if society wishes to legalise acts which run counter to accepted medical ethics, it would be wise to consider whether such acts might not be carried out by other means.

Assisted Suicide and Voluntary Euthanasia

243.  Lord Joffe's Bill seeks to legalise not only medical assistance with suicide but also, in cases where self-administration of lethal medication is not possible, voluntary euthanasia. We have visited two places—Oregon and The Netherlands—which have gone down different roads in this regard and which show widely different death rates from this source. In Oregon less than 1 in 700 deaths is currently attributable to assisted suicide, whereas in The Netherlands the figure is more than 1 in 40, less than 10% of which are from assisted suicide while over 90% are as a result of voluntary euthanasia. If the Oregon experience were to be replicated here, we might expect, on the basis of a simple pro rata calculation, around 650 deaths a year from assisted suicide for the United Kingdom as a whole. The Dutch experience, on the other hand, could lead to around 13,000 deaths a year, of which some 12,000 would result from voluntary euthanasia. Given the qualifying conditions in Lord Joffe's Bill, which are somewhat more restrictive than the Dutch Euthanasia Act, these latter figures probably overstate to some extent the numbers of likely deaths. And, as Lord Joffe proposed subsequently to tabling his Bill to restrict its geographical application to England and Wales only, the numbers (though not the proportions) would come down further. Nonetheless, the experience of other legislatures does suggest a strong linkage between the inclusion of voluntary euthanasia in assisted dying law and a significantly higher rate of take-up.

244.  There was general agreement among our witnesses that the number of people who might be regarded as serious about ending their lives, who are not psychiatrically ill and who are unlikely to be deflected from their purpose is very small indeed and comprises to a large extent terminally ill people who have strong personalities and a history of being in control of their lives and whose suffering derives more from the fact of their terminal illness and from the loss of control which this involves than from the symptoms of their disease. If therefore it should be accepted by the House that there is a case for such exceptional individuals to be afforded assistance to end their lives, consideration would need to be given to how the parameters of any new law could be set in such a way as to ensure that the take-up rate is limited to such people. In this context we cannot but observe an apparent link between the scope of assisted dying legislation in other countries and the incidence of deaths from this source in those places. The much smaller numbers of deaths in countries where only assisted suicide is legal suggests strongly that such a restriction, with its emphasis on the individual taking responsibility for the final stage of ending his or her life, has the effect of making those who are minded to end their lives think very carefully before taking action to give effect to their wishes.

245.  There are however other reasons why it might be considered that there is a case for any new bill to be narrower in scope than the present one. From the evidence we have received it is clear that, while there are indeed some doctors who support a change in the law, the medical profession as a whole is at best ambivalent on the subject and in many cases opposed. On the other hand, it appears that there would be rather less unhappiness about a law which is limited in its scope to assisted suicide. Dr Wilks referred to "an impression… that still a minority of doctors, but a larger number, would support a change in the law on physician-assisted suicide than would support a law on euthanasia". There was, he believed, "a feeling of comfort that there is a partnership involved between the doctor and the patient as opposed to the doctor being the agent"(Q 293). This endorses what we were told in Oregon—that any proposal to extend the ODDA into the field of euthanasia would encounter much greater opposition from the medical profession (Q 1048). It must also be the case that any blurring of the line between voluntary and involuntary assisted dying is likely to occur more easily with voluntary euthanasia than with assisted suicide.

246.  We therefore recommend that, if a successor bill should be introduced for consideration by Parliament, it should distinguish clearly between assisted suicide and voluntary euthanasia and thereby give the House the opportunity to address these two courses of action separately, as the considerations involved in each are very different. It would of course be necessary to take into account the situation of a small minority of terminally ill people, such as some with MND, who may be unable to administer to themselves prescribed lethal medication. According to Professor Timothy Quill of the University of Rochester, New York, this need not mean that no help can be given to patients in this position (Q 2123). And it was also pointed out to us by witnesses in Switzerland (QQ 2413-2421) that there are means by which physically incapacitated people can be enabled to administer lethal medication to themselves if they are determined to do so. The key issue however in our view is that responsibility for the ultimate act rests with the patient.

The Implementation of Assisted Suicide or Voluntary Euthanasia

247.  In his evidence to us Lord Joffe made clear that the primary aim of his Bill was to legalise assisted suicide and that, while it did provide also for voluntary euthanasia, this latter course would be authorised only where the patient was physically incapable of taking his or her own life with the medication supplied (Clause 1(2) and Q 70). Yet those clauses of his Bill (Clauses 5 and 7) which deal with the duties of the physician after an applicant has passed all the prescribed tests and made a written declaration that he or she wishes to die are unspecific about the actions which have to be taken by the doctor: they speak simply of the doctor "assisting the patient to die". This is in contrast to the detail which is included in those clauses of the Bill which are concerned with the making and assessing of applications and in those which deal with the paperwork following the patient's death.

248.  We therefore recommend that, should another bill be introduced into Parliament with the aim of legalising assisted suicide or voluntary euthanasia, it should spell out what a doctor may and may not do in circumstances where an applicant has met all the specified criteria and made a formal declaration. In the case of a provision seeking to legalise assisted suicide only, we would expect, for example, to see set out the procedures under which a prescription for lethal medication may be given and the necessary drugs obtained, along with the responsibilities, rights and immunities of the persons involved, such as doctors and pharmacists. In the case of a provision which sought to legalise also voluntary euthanasia, we would expect to see set out a detailed procedure for establishing whether a request fell within tightly-defined criteria for voluntary euthanasia rather than assisted suicide and, in the event that it did, for putting the necessary action into effect.

Qualifying Conditions

249.  Having addressed the scope of any future bill on this subject, it is necessary to consider the qualifying conditions for whatever it is proposed to legalise. Lord Joffe's Bill contains three key conditions—terminal illness, competence and unbearable suffering. In Chapter Four we have summarised the evidence which we have received on each of these conditions. Here we record some general conclusions.

250.  The root of the problem over linking assisted suicide or voluntary euthanasia with terminal illness lies in finding a formula for defining terminal illness in such a way as to ensure an appropriate degree of accuracy in diagnosing and forecasting the course of a patient's disease. Otherwise there is a risk that people who believe that they have a short time to live (or indeed that they are terminally ill at all) might be encouraged to end their lives on the basis of inaccurate prognoses or diagnoses. There is however clearly a difference between the popular view of terminal illness, which employs phrases like "three months to live", and the reality of clinical practice, in which prognosis is far from being an exact science and in which there can be wide variations from an overall norm.

251.  We recommend therefore that, if another bill along the lines of Lord Joffe's should be introduced into Parliament, consideration should be given to a definition of terminal illness which is based on the realities of clinical practice and is sufficiently precise in terms of the exception to the general law which it is proposing in order to ensure proper protection for those who may make use of it.

252.  The mental competence of an applicant for assisted suicide or voluntary euthanasia is a crucial condition. Lord Joffe's Bill defines competence as "having the capacity to make an informed decision". We would suggest however that any definition of competence needs to include two dimensions—that an applicant must be capable of understanding his or her situation and of reaching a reasoned decision without external pressure; and that it must be clear that an applicant's judgement is not temporarily clouded by psychological impairment which, as is frequently the case in people who are terminally ill, may be transient and treatable. We are reasonably comfortable with the thought that an assessing doctor should be able to spot cases where an applicant is non compos mentis, but we are less clear that cases of treatable depression or external pressure will be so readily apparent. The present Bill requires a psychiatric assessment only in cases where either of the two doctors involved has reason to believe that an applicant may not be competent. We have therefore considered whether given the importance of this condition being met such an assessment should not be mandatory in all cases.

253.  In doing so we have asked ourselves whether there is not, perhaps, an element of unwitting condescension in saying to someone who is suffering unbearably and has asked to have his or her life ended that he or she ought to be seen and assessed by a psychiatrist. Some might argue that depression is an occupational hazard of living for all of us and that we all take decisions at different stages of our life which may well be coloured, to a greater or lesser extent, by depression. Yet no one suggests to us psychiatric involvement. However, while it seems to us that this is a fair point to make in relation to life generally, we believe that the situation of someone who is seeking medical assistance with suicide or voluntary euthanasia is unique in that the act involved is one of the utmost gravity and, if implemented, irreversible. Society already makes strenuous efforts to frustrate attempted suicides on the basis that the person who has attempted to take his or her may well think better of it at a later date, and we have been told by a number of those who gave evidence to us that people who ask for assistance to die frequently change their minds either because they have received better palliative care or simply because they have re-assessed and come to terms with their situation.

254.  We therefore recommend that in the framing of any future bill consideration should be given to the inclusion of a requirement for any applicant for assistance with suicide or voluntary euthanasia to be given a psychiatric assessment in order both to confirm that the request is based on a reasoned decision and is free from external pressure and that the applicant is not suffering from a psychiatric or psychological disorder causing impaired judgement. In cases where such disorder was apparent, we would expect an applicant to be offered treatment. If a way could be found of confidently limiting applications to strong-minded individuals who are clear about what they want, such a requirement would be of less importance. Otherwise it would be necessary to weigh the inconvenience which a psychiatric assessment might cause to determined applicants against the need to protect less resolute persons from decisions arising from psychiatric disorder or external pressure.

255.  Lord Joffe's Bill includes the condition that an applicant must be suffering unbearably. This is undoubtedly the most difficult of the qualifying conditions to define. We are clear that there must be a filtering role for physicians who assess applications for assisted suicide or voluntary euthanasia in order to weed out situations which no reasonable person would regard as grounds for such action. We recognise however the very real difficulty which doctors might face in declining to accede to requests based on patients' subjective assessments of their own suffering or in satisfying themselves that such suffering derives from the presence of a terminal illness. It has also been suggested by some of our witnesses that there is an element of illogicality in allowing assisted suicide or voluntary euthanasia for patients whose medical state is such that they are likely to secure early release from their unbearable suffering by natural means while refusing it to others with chronic conditions whose suffering is likely to be more prolonged—or indeed to people, such a prisoners serving life sentences, who have no serious medical condition at all but who may nonetheless be suffering unbearably.

256.  An option which occurs to us is to make "unrelievable" or "intractable" rather than "unbearable" suffering or distress a condition of any future Bill. Such a definition would enable a more objective medical assessment to be made of a patient's suffering and should ensure that all available steps were taken to relieve distress before an application for assisted suicide or voluntary euthanasia could move forward. Consideration would need to be given to the position of individuals whose suffering was existential—i.e. deriving from feelings of loss of control or of self-worth—rather than a result of the symptoms of their terminal illness. This is the group of people, to whom we have drawn attention earlier in our report, who appear to have the most settled wish for their lives to be ended. A test of "unrelievable" suffering might ensure that an application would not be taken at face value but that action would be taken to attempt to relieve any suffering and that only in those cases where this was unsuccessful would assisted suicide or voluntary euthanasia be considered further. We recommend therefore that consideration should be given in any future bill to including a test of "unrelievable" or "intractable" in place of "unbearable" distress.

Palliative Care

257.  The current Bill seeks to make the provision of palliative care complementary to the opportunity to have assistance with suicide or voluntary euthanasia. It prescribes that "the attending physician shall ensure that a specialist in palliative care has attended the patient to discuss the option of palliative care" (Clause 3(1)). A number of our witnesses have described this as an unrealistic provision. We were told that "this requirement does not reflect the reality of specialist palliative care practice. Palliative care depends on continuity and relationship. It would not be possible to undertake a full and proper assessment of a patient's full palliative care needs in the time allowed for a short consultation"[77]. Expanding on this, Ms Vicky Robinson, a Nurse Consultant in palliative care at St Christopher's Hospice, asked whether the real purpose of Clause 3(1) of the Bill "is to complete a requirement for the process of attaining assisted dying or to assess how a person's suffering may be supported, and if possible relieved, through palliative care. If it is the former, it is not a palliative care assessment. If it is the latter, then assessment takes, at the very least, a week and, in proportion to the severity of the suffering experienced, may take months" (Q 354). Of course, the Bill does not prescribe an "assessment", but rather a discussion of "the option of palliative care".

258.  Lord Joffe suggested to us that for terminally ill people palliative care should be the first option and that assisted suicide or voluntary euthanasia should be considered only as a last resort (Q 70). We would support this view in the event that there were to be a change in the law. The problem is that not every terminally ill patient who is suffering will have access to good quality symptom control. In the words of Help the Hospices, "experience of pain control is radically different from the promise of pain control, and cessation is almost unimaginable if symptom control has been poor. On this view patients seeking assistance to die without having experienced good symptom control could not be deemed fully informed"[78]. Clearly therefore something more than a simple consultation with a palliative care doctor or nurse is needed if patients contemplating assisted suicide or voluntary euthanasia are to be able to make fully informed choices. The difficulty lies in the somewhat patchy availability of good quality palliative care. If however a future bill is to be able to claim with credibility that it is offering assistance with suicide or voluntary euthanasia as complementary rather than as an alternative to palliative care, it may need to find a way of resolving this dilemma.

Waiting Period

259.  The present Bill prescribes that a minimum a 14 days shall elapse between "the date on which the patient first informed the attending physician" of his or her wish for assisted suicide or euthanasia and the date on which one of these actions is taken (Clause 2(1)). Lord Joffe explained to us that the reason for starting the clock, so to speak, at the time of the request rather than at the signing of the declaration was concern "that, if there were so many steps (and we have already included a surprising number of safeguards), the patients will all have died before we get through them"(Q 70). Others expressed different concerns. The NCHSPCS considered that "it is possible that the period leading up to the signing of the declaration will become focused heavily on process, as the patient and his professional carers seek to ensure that the Bill's requirements have been complied with. Consideration should be given to whether there should be a waiting period after the declaration period has been signed, which would enable the patient to focus not on the process of qualifying for and making a declaration but on the decision whether then to proceed"[79].

260.  There is, of course, nothing to prevent an applicant doing just that under the present Bill. Once a declaration is signed, the applicant would be under no obligation to proceed with assisted suicide or euthanasia either at once or indeed at all. But there is, we feel, some force in the NCHSPCS's argument that, in the patient's own best interests, he or she should be prevented by law from acting without reflection—or even from feeling subconsciously that, having proceeded as far as the signing of a declaration and having put a number of people to a lot of trouble, he or she should not draw back. In the case of a bill seeking to legalise assisted suicide only, the need for a "cooling-off" period would seem less important, as the evidence we received in Oregon suggested that many of those who receive lethal prescriptions do not immediately ingest them but rather keep them as a form of insurance policy. In the case of voluntary euthanasia, however, consideration should be given to a pause before a patient makes his or her final decision on an irrevocable course of action. The length of such a pause would need to balance the need to avoid increased suffering for determined individuals against the desirability of providing time for reflection for the less resolute.

Responsibilities of Physicians

261.  We have already addressed (Paragraphs 247 to 248) the important need for explicit wording in any future bill to define precisely the actions which a doctor may or may not take after a patient has signed a declaration and requested assisted suicide or euthanasia. But it is necessary also to consider the position of doctors who have conscientious objections to assisted suicide or voluntary euthanasia. Clause 7 of the present Bill seeks to deal with this issue, providing as it does that "no person shall be under any duty… to participate in any diagnosis, treatment or other action… to which he has a conscientious objection" (Clause 7(1)) and that, if either an attending or consulting physician has such an objection when confronted with a patient who is seeking his services under the Bill, "he shall take appropriate steps to ensure that the patient is referred without delay" to an attending or consulting physician "who does not have such a conscientious objection" (Clause 7(2)(3)). We have already pointed out (Paragraph 32) that, in the light of concerns expressed by the Joint Committee on Human Rights[80] that Clauses 7(1) and 7(2) "give rise to a significant risk of violation of Article 9(1) of the ECHR", Lord Joffe has proposed to amend this section of his Bill in such a way as to remove the obligation on physicians with a conscientious objection to refer patients in the way proposed. We recommend that such an amendment should be reflected in any successor bill.

262.  Conscientious objections could however arise not only from doctors but also from other health care professionals, including nurses and pharmacists. The present Bill however is rather narrowly drawn on this point. We suggest therefore that any new bill should reflect, in addition to the revision of Clause 7 which Lord Joffe has proposed for his own Bill, the need to protect the interests of all members of the clinical team. In particular, it should seek to address such situations as that in which, for example, a nurse with conscientious objections is asked by a patient to raise with a doctor on his or her behalf a request for assisted suicide or voluntary euthanasia.

263.  It has also been drawn to our attention that care of the terminally ill is often carried out by multidisciplinary teams and that a number of doctors, nurses and other health care professionals could be involved, and might feel themselves implicated, in any action taken under the terms of the Bill to respond to a request for assisted suicide or euthanasia. Dr Vivienne Nathanson, for the BMA, told us that in many cases, such as, for example, in spinal injury cases, "you are not talking about one doctor, you are talking about teams of doctors, and I think there would be great difficulty in deciding who was, if you like, the primary care doctor and decision-maker, because the nature of these teams is that they work as equals" (Q 299). The GMC told us that its own guidance indicates that it should be clear at any one time who has responsibility for patient care (Q 339). It added that, while in theory this issue did not present insurmountable obstacles, the practical implications could be more complex (Q 340). Any new bill would therefore need to be drafted in such a way as to cater satisfactorily for such situations—for example, if the doctor with primary responsibility for a terminally ill patient wished to respond to a request for assisted suicide or voluntary euthanasia, where would that leave other members of the team who had conscientious objections?

Pain Relief

264.  The present Bill provides (Clause 15) that "a patient suffering from a terminal illness shall be entitled to request and receive such medication as may be necessary to keep him free as far as possible from pain and distress". This clause has attracted a good deal of criticism from witnesses. Lord Joffe told us that there were two reasons for its insertion into his Bill—that there was evidence that many patients do not get sufficient pain relief and that some doctors are reluctant to give increased doses of pain relief because of fear of prosecution (Q 70). He added that "it is only where a patient is suffering and either the GP or the hospital are not providing sufficient and adequate medication to control the pain that they would seek to invoke this right" (Q 157).

265.  The NCHSPCS commented that "the administration of pain relief is well-established in clinical practice and need have no bearing on or connection to PAD [physician-assisted dying]. It is unprecedented that a therapeutic course of action requires an act of legislation"[81]. Echoing this view, the BMA said that Section 15 of the Bill was "unnecessary and plays on public fears about the possibility of intolerable or unrelieved pain at the end of life"[82].

266.  There is also, it seems to us, a practical objection to what is being proposed here. In the event that a patient should exercise his or her right under this section, on what basis would he or she argue that the pain relief made available was insufficient? And on what basis would he or she demand the correct drugs or dosage? If it is envisaged that the basis of a claim under Clause 15 would be the patient's own perception of his or her pain, that would appear to be tantamount to authorising a patient to override the clinician's judgement. We cannot judge whether some doctors are currently acting in a niggardly manner with regard to pain relief, though the allegation does not sit easily alongside others which have been made (see Chapter Four) that many doctors are over-using pain relief. In fact, Lord Joffe has proposed to withdraw Clause 15 from his Bill, and we recommend that, if there should be a new bill seeking to legalise assisted suicide or voluntary euthanasia, it should not seek also to regulate pain relief.

In Conclusion

267.  The above are the principal concerns which have emerged in our inquiry both generally and in regard to the current Bill. A number of lesser, though nonetheless important, issues have also been raised, including the role of witnesses to declarations by patients, the provision of immunity from legal action to physicians and others who take action under the terms of the Bill and the role of the proposed monitoring commission. We do not rehearse them here because the Bill as it stands cannot proceed due to shortage of time.

268.  There have been differences of opinion among members of the committee on the relative importance of issues and on the interpretation of the evidence we have been given. In these circumstances we have agreed that the most appropriate way to proceed is to summarise, in as balanced a manner as possible, the evidence we have received on both the principles underlying the Bill and the practical implications which such legislation would have and to draw the attention of the House to a number of key issues arising from this which seem to us to be pertinent to the consideration of any future bill which might be brought forward on this subject. With this in mind we now submit our report.

Recommendations

269.  We recommend that:

(a)  an early opportunity should be taken for our report to be debated by the House in the next session of Parliament (Paragraph 235).

(b)  in the event that another bill of this nature should be introduced into Parliament, it should, following a formal Second Reading, be sent to a Committee of the whole House for examination (Paragraph 235).

(c)  any such bill should take account of the following considerations which have emerged in the course of our inquiry:

(i)  a clear distinction should be drawn in any future bill between assisted suicide and voluntary euthanasia in order to provide the House with an opportunity to consider carefully these two courses of action, and the different considerations which apply to them, and to reach a view on whether, if such a bill is to proceed, it should be limited to the one or the other or both (Paragraphs 243-246);

(ii)  any future bill should set out clearly the actions which a doctor may and may not take either in providing assistance with suicide or in administering voluntary euthanasia (Paragraphs 247-248);

(iii)  if a future bill should include terminal illness as a qualifying condition, this should be defined in such a way as to reflect the realities of clinical practice as regards accurate prognosis (Paragraphs 250-251);

(iv)  a definition of mental competence in any future bill should take into account the need to identify applicants suffering from psychological or psychiatric disorder as well as a need for mental capacity (Paragraphs 252-254);

(v)  consideration should be given in any future bill to including "unrelievable" or "intractable" suffering or distress rather than "unbearable" suffering as a criterion (Paragraphs 255-256);

(vi)  if a future bill is to claim with credibility that it is offering assistance with suicide or voluntary euthanasia as complementary rather than alternative to palliative care, it should consider how patients seeking to end their lives might experience such care before taking a final decision (Paragraphs 257-258);

(vii)  in setting a waiting period between an application for assisted suicide or voluntary euthanasia and the carrying out of such actions, any future bill should seek to balance the need to avoid increased suffering for determined applicants against the desirability of providing time for reflection for the less resolute. Such a waiting period is of less importance in the case of assisted suicide but needs to be considered carefully in the case of voluntary euthanasia (Paragraphs 259-260);

(viii)  any new bill should not place on a physician with conscientious objection the duty to refer an applicant for assisted suicide or voluntary euthanasia to another physician without such objection; it should provide adequate protection for all health care professionals who may be involved in any way in such an application; and it should ensure that the position of persons working in multi-disciplinary teams is adequately protected (Paragraphs 261-263);

(ix)  any new bill should not include provisions to govern the administration of pain relief by doctors (Paragraphs 264-266).

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77   See Volume II: Evidence, HL Paper 86-II, Page 135 Back

78   See Volume II: Evidence, HL Paper 86-II, Page 702 Back

79   See Volume II: Evidence, HL Paper 86-II, Page 133 Back

80   HL Paper 93 Paragraph 3.16 Back

81   See Volume II: Evidence, HL Paper 86-II, Page 133 Back

82   See Volume II: Evidence, HL Paper 86-II, Page 111 Back