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Baroness Neuberger: My Lords, it is impossible to make a proper winding-up speech after such a long debate with such excellent speeches. They have been absolutely in the tradition of this House, where passions have been running high but courtesy has nevertheless largely been shown, and even some humour. I, too, congratulate the noble and learned Lord, Lord Mackay of Clashfern, and his committee on their excellent report, and the noble Lord, Lord Joffe, on his Bill and the huge sincerity and unfailing courtesy with which he has brought it forward.

The Select Committee has produced an excellent report, and it has given us a way of taking forward some real concerns. We have heard compelling testimony about the unbearable nature of the suffering of some of those who are terminally ill, and who do not wish to choke to death or die in some other horrible circumstance. We know, from the committee's report and the evidence it heard, that there is a considerable body of opinion, in this House as elsewhere, that believes that people with such conditions should be able to ask for their doctors to help them to die, with all the safeguards discussed.

The committee looked closely at issues of patient autonomy, as has this debate, and examined the growing view that patients have the right to call the tune. This debate has also examined existential questions about the meaning of life, and about suffering as part of life. It has touched on questions of the doctor-patient relationship, and whether a change in legislation will damage that relationship—particularly that between older people and their general practitioners. We have also heard quite a lot about those "weasel words" the slippery slope, as the noble Lord, Lord Griffiths of Burry Port, put it, and the slippery slope argument, with evidence, particularly from the Netherlands, that euthanasia has not been wholly voluntary in all cases, as the noble Lord, Lord Tombs, reminded us.

We have heard that only some 54 per cent of euthanasias are reported to the authorities. In some of these cases, the evidence suggests that euthanasia includes neonates, people in comas and people with a mental illness. Most worryingly of all, according to Irene Keizer from the Dutch Ministry of Health,
 
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Welfare and Sport, 25 per cent are people who could have made a request but did not. Then we have had all this firmly rebutted, particularly by my noble friend Lord Taverne.

So where are we? In my view, the Select Committee was right to conclude that assisted suicide should be viewed separately from voluntary euthanasia. I was delighted to hear that the noble Lord, Lord Joffe, is minded to restrict a successor Bill, should there be one, to assisted suicide alone. There are clearly many among us, and I am one, who regard the killing of patients by their doctors, with intent to kill, despite its being at the patient's request, as wholly wrong. I agree completely with the noble Lord, Lord Walton of Detchant, on that.

Furthermore, many regard such killing as utterly incompatible, as do I, with the ethical principles and position of trust which doctors hold. Those who hold such a view would argue that, for societal and moral reasons—pace what the noble Baroness, Lady Hayman, has said, it is not only a religious view—even if a patient is utterly incapacitated by their disease and incapable of killing themselves, they should not be able to get someone else to kill them intentionally. That might be hard, but it may also be right for societal reasons. Unlike the noble Lord, Lord Plant of Highfield, I think there is a difference between commission and omission in these cases.

In the case of assisted suicide, however, the principles are different—even though, in the voluminous correspondence that we have all received, many seem not to think so. If individuals, understanding the consequences, take their own lives—particularly with the safeguards suggested in the original Bill of the noble Lord, Lord Joffe—then that is not unlawful killing committed by doctors or, indeed, nurses. It is arguable that doctors need not be a part of this other than for prescription purposes, as in Switzerland. The Select Committee wisely suggests 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".

In other words, outside the medical world, as the noble Lord, Lord Lucas, suggested. Two final points at this late hour. If a new Bill is to come before us that can ultimately be debated, as I hope, by a Committee of the whole House, it is important that such a Bill distinguishes not only between assisted suicide and voluntary euthanasia, but between physician-assisted suicide and other means. If doctors are to be involved, the Bill should make provision for them to opt in rather than out, as with other conscience issues. It also needs to make some provision for informing or discussing such issues with family members, as several people have suggested.

Secondly, with all the discussion we have had in this debate about palliative care, real measures need to be taken now for patients to experience good palliative care nationwide, whatever condition they are dying from. It is a disgrace that that is not yet the case, because otherwise people cannot make a real and informed decision.
 
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The Liberal Democrats' spring conference in March last year passed a motion in favour of assisted dying, but, your Lordships will be glad to hear, it left its parliamentarians free on conscience grounds. It is clear that we on these Benches are of mixed views, as is the whole House. Given the extraordinary attacks we have heard on my noble and real friends the right reverend Prelates opposite, I want to say my last bit as a rabbi. I come from what some say is the most life-affirming of all faiths, and we are a pretty life-affirming lot. Our toast when we drink is "lochaim"—not to health, but to life.

I am profoundly opposed to euthanasia. I am in no way convinced that medical involvement in suicide can be right. In a pluralist society, though, I do not necessarily believe that my view should stop all others—provided that doctors and nurses are not involved—and especially that it should stop those very few who genuinely find their pain unbearable, or, as the noble Lord, Lord Turnberg, puts it, "intractable". However, that should only be the case if there is a full and proper informed debate about the social change that might ensue, as the noble and right reverend Lord, Lord Habgood, has put it, and if the fears of those in hospices and the old and vulnerable are thoroughly dealt with, and those experiencing those fears reassured. It should be the case only if equal time is given to the issue of palliative care, and real investment is put into it, so that those hard and moving stories that we have heard today become a rarity, if not completely absent.

11.17 pm

Lord McColl of Dulwich: My Lords, I too pay tribute to the skill of the noble and learned Lord, Lord Mackay of Clashfern, whose wisdom and good humour have proved to be essential. In summing up from these Benches, I should say that the leader of our party, Michael Howard, is strongly opposed to the Bill, but of course there will be a free vote.

I have enjoyed the debate. As usual, I have learnt a great deal from your Lordships, and, as always, I appreciated the noble Lord, Lord Maginnis, putting things in perspective, especially at the very beginning and at the end of life. We doctors can be carried away with enthusiasm, like the paediatrician who said in a lecture, "The first few minutes of life are the most dangerous". An old man from the back shouted out, "The last few minutes are pretty dangerous, too".

My noble friend Lady Flather has invited me to mention my experiences in Holland to reinforce what the noble and right reverend Lord, Lord Habgood, said. I asked a Dutch doctor what it was like doing his first case of euthanasia. "Oh," he said, "we agonised all day. It was terrible". However, he said the second case was much easier, and the third—I quote—"was a piece of cake". That left us feeling cold.

When the noble Lord, Lord Joffe, introduced his Bill, he said that he recognised that it should not place vulnerable members of society at risk, nor compel doctors or other members of medical teams to
 
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participate in processes to which they have a conscientious objection. My fear is that the Bill will fail in both those respects. A Bill legalising euthanasia or assisted suicide would be a radical change in our law. The so-called safeguards are anything but safe. They are rather like banisters along the side of a high staircase that look fairly sturdy from a distance but give way when they are leant upon for support. As my noble friend Lady O'Cathain said, the risk of undiagnosed depression is very real and depression is common among the terminally ill. The risk of misdiagnosing terminal illness is also real. The Royal College of Pathologists told the committee that that sort of misdiagnosis occurred in about 5 per cent of cases. Yet, if a depressive illness goes untreated or a non-terminal illness is wrongly diagnosed, no one will ever know or be able to do anything about it, for the simple reason that the patient will be dead.

The Bill does not even require the physician who certifies that the patient complies with the safeguards to have any previous knowledge of the patient, nor does the Bill allow or require the physician to consult others who know the patient, such as his or her family. Then there is the danger that what appears to be a voluntary request to die is no such thing. If the Bill is passed, it will start a process over which we have no control and from which there will be no turning back. It is likely to cause a subtle change whereby it is expected of the elderly and vulnerable that they should opt for assisted death. The elderly and vulnerable should never have to justify their continued existence to others, nor should they have to justify their continued existence to themselves. How voluntary is a request that is made against a background of expectation created by the Bill, an expectation that the vulnerable will chose death over life?

The present law is not perfect, but it makes a clear distinction between the removal of treatment allowing nature to take its course on the one hand and the active commission of death on the other. The Bill removes the clear line and in its place introduces fuzzy lines that are arbitrary. As the noble Lord, Lord Phillips of Sudbury, asked, how does one objectively assess unbearable suffering? If it is a reason to end the life of people who are expected to die shortly, how long will it be before it is argued that it should be applied to others whose suffering can be expected to last longer? The new lines drawn by the Bill are liable to shift, as the noble Lord, Lord Turnberg, said.

The law as it stands does not allow the patient to demand medical treatment that his doctor does not regard as medically indicated, but the Bill creates two exceptions to that rule. Assistance with suicide and the lethal injection will become treatment options that the patient can demand and the doctor cannot refuse, provided that the checklist of so-called safeguards can be ticked.

It is no comfort to point to the conscience clause. At best, it will be divisive and, at worst, it will be ineffective in protecting would-be physicians who will probably opt out of geriatric care, just as those who rely on a similar clause in the Abortion Act have opted out of gynaecology. The noble Lord, Lord Neill of
 
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Bladen, speculated about the questions that would be asked of somebody applying for a job. How right he is; that is exactly what happened over the Abortion Act. The question that was asked of would-be obstetricians and gynaecologists by interviewing committees was whether the candidates would be prepared to take their share of abortions. If they said "Yes", they were considered for the appointment; but if they said, "Yes, I will act within the law", they would be excluded. Hundreds of midwives and obstetricians had to emigrate because they were discriminated against in that way.

Engineers are trained to design potentially lethal machines to fail to safety. For example, a thermostat that monitors the temperature on a heated oil tanker will be designed so that should it fail the heating element turns off, thus avoiding the possibility of overheating and explosion. The law as it stands now fails to safety. It errs on the side of prolonging life and protecting the vulnerable. For all its intended safeguards, the Bill will not fail to safety. The present law errs on the side of life; this Bill will err on the side of death.

Today the noble Lord, Lord Joffe, indicated that he proposed a new Bill that will relate to assisted suicide but not euthanasia. I fear that that revision is mere expediency. Imagine the reality. If I, as a doctor, place a lethal pill in a patient's hand and he swallows it, that would be legal; but if I place the pill on the patient's tongue a few inches away, that would be murder. One cannot make laws on that basis. The two acts are morally equivalent.

There have been several mentions of the double effect. It is important to stress that that is generally misunderstood. The medical profession has been accused of hypocrisy, and it is alleged that we give patients, say, heroin to relieve their symptoms but really what we are doing is killing them. People who make such criticisms are ignorant of the elements of pharmacology. The dose required to relieve a symptom is a fraction of the dose required to kill, which, after all, is the definition of a good drug. It is called the therapeutic index. What Cecily Saunders did so brilliantly was that she realized that the answer to relieving symptoms was to keep a constant level of drugs in the blood so that the patient was kept free of pain but was able to enjoy life; whereas in the old days we waited until patients got pain and then gave them a slug of heroin, which put them out for a while. When they surfaced and got the pain again, they would have another injection. That intermittent regime had its problems. So there is no hypocrisy at all.

When a patient comes into a hospice, it takes about 24 hours to settle the various doses of drugs to deal with the anxiety, to deal with the pain, and to deal with the breathlessness. Once the dose, say, of heroin has been fixed, it stays at that dose largely until the patient dies. So the idea that doctors are killing patients in this way is certainly not true.

Finally, I am glad that the noble and right reverend Lord, Lord Carey, stressed that religious views should not be excluded from the euthanasia debate. I have
 
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never tried to impose my Christian views, but what I have done on debates on euthanasia and in articles that I have written is to quote a TV programme shown on the much maligned BBC. It was called "Five Steps to Tyranny", and it brought together all the scientific and historical evidence that led to the conclusion that,

"we are all capable of doing the most appalling things to other people".

That was not a religious programme; it was a secular programme. The law is a great dam holding back the wildest excesses of the wild men, but it also holds back the potential for evil inherent in mankind. However careful and thoughtful the noble Lord, Lord Joffe, has been, many regard his Bill as a crack in the dam that could put in danger the elderly, the vulnerable and the dying: the very people most in need of protection.

11.30 pm

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