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Lord Guthrie of Craigiebank: My Lords, I belonged for 44 years to one of the professions that see death at first hand more often than others. Like doctors, soldiers cannot afford to marginalise death as something that does not impinge on their life. I make that point because I know that that attitude exists in a large part of our society and because I am afraid that, if we are not careful, we might be tempted to focus on the more comfortable philosophical side of the subject and to neglect the hard realities.
Let us start with one of those hard realities: many people in this country die in pain or with other distressing symptoms of terminal illness. That is one argument advanced to legalise voluntary euthanasia, but we need, first, to ask why it is that, in this day and age when medicine has made such great strides, people are still dying in pain. The Select Committee answered the question. Its report records that Britain is a world leader in the science of effective palliative care. So why are people dying in pain? The answer has nothing to do with medical science. It is because too few doctors and nurses in the National Health Service have been given core training in the techniques of alleviating pain and other symptoms of terminal illness; because there is a large shortfall in the number of palliative care
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consultants; because hospitals other than those that are specialist do not have the resources to treat the dying effectively and sympathetically away from the bustle of mainstream general wards; and—last but by no means least—because we do not make supporting hospices and providing proper care for people to die at home enough of a national priority.
I do not envy the task of the resource allocators in the Department of Health. The essential problem that they face is that patients have ever-increasing expectations of curative treatments while the cost of such treatments rises rapidly. National health—like national defence, with which I have been closely associated—is an area where we could spend almost limitless sums of money to good effect. But the budgetary line must be drawn somewhere, and available resources must be allocated according to a system of priorities. Surely, therefore, with demographic changes taking place, that is an area of medicine that deserves a much higher priority. It is the failure of successive governments of all parties to do that that has fuelled the demands of the pro-euthanasia lobby and which, if we are not careful, will lead us into the error of killing the patient instead of the pain. Moreover, unlike expensive new treatments, such as cardiac surgery, palliative care is relatively low-cost. A substantial injection of funds into that branch of medicine would therefore benefit far more people than some of the projects that hit the headlines but actually benefit relatively small numbers of patients—what we used to call, when I was concerned with resource allocation in the Ministry of Defence, getting more bang for your buck. We should remember that we may all need palliative care at some point.
I now turn to another hard reality. We are told that the demand is for assisted suicide or voluntary euthanasia, so why should not those who want to do that be able to do it while those who do not want it can stay as they are? That notion—that all that you have to do is to draft a law and that is what will happen on the ground—is naive in the extreme. All laws are evaded or broken, and it is simply irresponsible to ignore the potential for abuse or elastic interpretation of what the law says. The Select Committee on Medical Ethics concluded unanimously 10 years ago that it was not possible to set secure limits on voluntary euthanasia and that,
"It would be next to impossible to ensure that all acts of euthanasia were truly voluntary, and that any liberalisation of the law was not abused".
The latest Select Committee's report is full of warnings about that: about the silent, and often internal, pressures on dying people to avoid being a burden on their children; about incremental creep in the law; about the margins of error in terminal prognosis; about the near impossibility of defining unbearable suffering or mental competence; and about what has happened in other countries that have legalised such acts.
In Holland, the Select Committee tells us, one in every 38 deaths is the result of either legal or illegal euthanasia. The Dutch sister of our Voluntary
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Euthanasia Society, known as the NVVE, has secured the legalisation of euthanasia. The chairman of the NVVE's medical committee told the committee that his organisation's next goal was legalising euthanasia for people with dementia. After achieving that, he said, the ultimate goal was legalisation of what is known in Holland as the "end-of-life pill". Today, we have heard people say that there is no such slippery slope, but how else could it be described? I understand that now the Dutch Parliament is about to have euthanasia of children—the so-called Gröningen protocol—laid before it.
Another Dutch pro-euthanasia witness put it another way:
"However, the patients need the doctors because we have to access the medication . . . Eventually maybe they can decide for themselves and have the possibility to do so without consulting a doctor".
Although we are talking here of euthanasia to relieve the suffering of terminal illness, the Dutch experience seems to be moving towards death on demand. If we once embark on that road, the pressures to go further will grow. Although I respect the compassionate motives of those who advocate a change in the law, I look at the way that the campaigning organisations behave once they have a foot in the door. Did not the noble Lord, Lord Joffe, himself tell the committee that his recent Bill might be just "the first stage"?
My advice to your Lordships, therefore, is to think carefully before taking the leap in the dark that some Members of the House suggest. Remember that we know how to deal with the pain and distress of terminal illness. It is tragic that it is not available to all, through the misallocation of National Health Service resources. Be warned of what has happened elsewhere.
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Lord Turnberg: My Lords, there were of course, as we have heard, very strongly held views on both sides of the argument in our committee, on which I was privileged to sit. Yet the report which was produced sets out the issues far more clearly than I ever expected, or even hoped for. That, of course, is largely due to the masterly work of our chairman, the noble and learned Lord, Lord Mackay of Clashfern—a remarkable achievement.
I start by expressing enormous sympathy for the view that patients suffering unbearably from a terminal illness who ask to be relieved of their misery should be helped in whatever way is possible. I imagine that very few doctors are unmoved by the patient who says "Help me out of my misery".
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My anxieties reside elsewhere, however: in how it might be possible to avoid the unintended consequences of a Bill which allowed us to help patients to commit suicide. Even in a largely secular society, where the views of the main orthodox faiths on the essential sanctity of life above all else may not hold sway, there remain major practical problems.
Much was made in the evidence before us of the need to preserve the patient's autonomy; that is, every patient's wishes should be acceded to wherever that is possible. Where a patient insists on being helped to die, they should be so assisted. However, a patient's autonomy cannot be absolute. We have to consider the downside of our acceding to that patient's autonomy where others may suffer. It cannot be absolute autonomy where others are involved. The benefits to the individual are rather clearer than the risks to others.
It is here that I worry about patients who may feel a sense of obligation or coercion to go along the route to assisted suicide. They may feel that they are an increasing burden upon their families and carers, or a drain on their resources, or a continuing cost to the National Health Service. As they sense they are going to die anyway, why not have themselves removed from this life? It is a sense of burden to others, rather than unbearable suffering, which encourages them along this route. That this is a realistic burden was emphasised to our committee by a group of disabled people who felt very vulnerable indeed. So a Bill designed to help one group of patients might open a door to harm others.
Then there is the whole set of problems about definition of words, such as "unbearable" suffering—incidentally, I am much more attracted to the alternatives of "intractable" or "unrelievable" suffering, which suggest that at least an effort has been made to relieve it—or the word "terminal". Can we say with any degree of certainty that someone will be dead within six months, as has been suggested in the Bill? Predictions of that type are very insecure. Why, indeed, do we not refer to three or 12 months? Why do we need to have any time limit at all if someone is suffering unbearably? The illogicality of restricting assisted suicide to the terminally ill will, I fear, soon send us down that route.
I ought to say a brief word about the position of doctors in all of this. It seems clear from surveys that many—probably most—doctors would be unwilling to take part in assisted suicide. This means that only a subset would be involved in prescribing the fatal doses. Patients would have to be referred to such doctors, who may find themselves specialising in this type of practice. It is quite unclear what elderly or vulnerable patients might feel about doctors who have in their therapeutic repertoire the possibility of helping them to die. Who knows what might happen to the doctor-patient relationship?
Finally, I want to say a word or two about experience that was gained abroad, in Holland, Oregon and Switzerland. Some members of the committee gained confidence from what we heard
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there. I, on the other hand, was not reassured at all. In Holland, as we have heard, about one in 40 of all deaths is apparently due to euthanasia or assisted suicide, while in Oregon it is only one in 700. I think Holland goes too far, as many have suggested. In Oregon there are a number of complicating factors, not least the medical insurance payment business; that is, payment for palliative or hospice care that is limited to six months, when a renewal of cover has to be negotiated. What sort of pressure might that exert on vulnerable patients and their families?
I have every sympathy with the need to alleviate suffering, and we should do everything we can. I fully understand the reasons for assisted suicide in principle, but my fear is that in framing a law that allows it to happen, we will be placing some patients in a difficult dilemma, and they could be harmed in a singularly irrevocable way.
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