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In conclusion, I believe that the Dignity in Dying charter helps to fill the gaps in an otherwise admirable government strategy to improve end-of-life care, and I hope that the Minister will feel able to take on board its recommendations.

4.25 pm

Baroness Howe of Idlicote: The noble Lord, Lord Warner, is asking the Government to take account of this charter in taking forward their end-of-life care strategy. I believe that the Government’s strategy is very important, and I looked at the charter with that in mind. Most of it seems fine to me; I believe that people should be encouraged to make plans for care at the end of life. Greater support should be given to those unsung heroes and heroines who care for people in the closing days of their lives, and I strongly support the giving of more resources for ensuring that our outstanding palliative care can be and is made available to everyone who needs it, irrespective of where they live. However, I am not at all happy with the proposal that assisted death—which I understand to mean assisted suicide—should be legalised and become part of the choice agenda.

Like many noble Lords, I have been watching the recent furore in the media on this subject. Those who want to see our laws change for terminally ill, mentally competent people tell us that there is no slippery slope of fear, yet, even as they say that, others are calling for people with dementia to be encouraged to regard themselves as a burden and to consider whether they ought to end their lives. We are told that legalised assisted suicide has proved to be without hazard in the American state of Oregon, yet only a week or two ago we heard of research published in the British Medical Journal indicating that as many as one in six of those

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who have committed suicide with lethal drugs from their doctors is suffering from treatable depression which has not been picked up. We know that depression can now be treated much more effectively than it has been in the past.

Although society treats attempted suicide with compassion, it rightly regards suicide as not to be encouraged, yet here we have a proposal that it should be facilitated for particular categories of people. This is a road along which we should not be going, and as long as this proposal remains part of the charter, I cannot support it. I hope that the Minister will be able to reassure us that the Government share this view.

4.28 pm

Lord Livsey of Talgarth: This charter appeared at about the same time as the Government’s strategy on end-of-life care, which I welcome. So far as I can see, the Government’s strategy, with its emphasis on ensuring palliative care and more effective co-ordination among the many end-of-life care services, has rendered this charter redundant. I can only assume that the aim of the noble Lord, Lord Warner, is to focus on the one proposal in it which does not feature in the Government’s strategy—namely, that Parliament should legalise euthanasia. Let us be quite honest here: why is that proposal not proclaimed in the title of this debate?

The proposal is not only redundant, it is wholly inappropriate. The organisation that produced this charter, Dignity in Dying—although most of us know it better under its former name of the Voluntary Euthanasia Society—claims to be campaigning for greater dignity at the end of life. As a principle, I can most certainly agree with that: it is humanitarian and, indeed, desirable. However, along with many other people, I cannot accept that promoting dignity among people who are dying includes asking doctors to prescribe lethal drugs for them. That in certain circumstances can be a negation of a doctor’s role. In fact, I know of a Jewish doctor who refused, in illegal circumstances, to carry that out because he had experienced the same process in a concentration camp.

Many different kinds of experiences come to bear on this. For example, I believe that in the state of Oregon there is the phenomenon of doctor-shopping, in which a small number of doctors who do not normally write such prescriptions for people who are not their regular patients carry out this process when hunted out.

The proposal also flies in the face of society’s attitude to suicide. We have had contributions on that, and I do not think it appropriate to repeat them. There is certainly no place for suicide to be facilitated. Although one sympathises with people who find themselves in this position, there are many worse forms of suffering in society for which we would not countenance legalised suicide. I fear that it may be the influence of—shall we say?—relatives with other agendas who may be in a position to influence the situation. It is one thing to treat cases of suicide or attempted suicide compassionately but quite another to give them official blessing in the way that these people are suggesting. Therefore, I hope that the Minister will be able to reassure us that

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the Government will continue to keep “assisted death”, as the charter describes it, beyond the ambit of their end-of-life care strategy.

4.31 pm

Lord Alton of Liverpool: I declare a non-pecuniary interest as a patron of three hospices. I am much struck that we are meeting here in the Moses Room today under the painting of Moses bringing down the tablets of law to the Israelites. One of their clear injunctions is “Thou shalt not kill”. It seems to me that not only is that at the heart of all religious thinking on this issue but, as the noble Lord, Lord Carlile, said, many secularists also share that view. Indeed, the Hippocratic oath was based on the same principle.

When he gave evidence to the Select Committee that considered these issues, the noble Lord, Lord Joffe, very honestly said that he saw his Bill as the first stage. Perhaps the noble Baroness, Lady Warnock, gave us a glimpse a few weeks ago of what the following stages might be. In an article in the Times on 10 October, the noble Baroness is quoted as saying:

“If you’re demented, you’re wasting people’s lives—your family’s lives—and you’re wasting the resources of the NHS”.

There is a fundamental divide between those of us who measure life in terms of the right to life and the duty to protect life and those who measure life by its quality. From the hospice and palliative care movements, I see many of the things that the noble Lord, Lord Warner, aspires to and with which I would agree in nine of the 10 points in his charter. However, in this provision for assisted suicide, there is this fundamental divide.

To die with dignity we do not need doctors to kill us. I place rather more reliance on these age-old injunctions than I do on polls. Indeed, the Select Committee took exactly the same view. Having asked researchers to look at the value of opinion polls on issues of this kind, it said that they are,

I place more reliance on all the royal colleges, including the Royal College of Psychiatrists, and the British Medical Association, which remain opposed to any change in the law.

Mention has been made in our debates about the situation in the state of Oregon. I have one example—the case of Michael Freeland, who had a long history of depression and suicide attempts. Dr Gregory Hamilton, an Oregon psychiatrist, said that this man was not in pain because his pain was not treatable; he was in pain because nobody bothered. This was, commented Dr Hamilton,

For me, the issue does not ultimately revolve around religious values but around public safety and the vulnerability of those who would no longer be protected should we change the law. I remind the Committee of the 1994 Select Committee, chaired by the noble Lord, Lord Walton of Detchant, which said that,



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In other words, choice is not a trump card. Autonomy is not the only issue at stake here; the common good is at the heart of this equation as well.

4.35 pm

Baroness Tonge: We all welcome the Government’s paper on end-of-life care. I declare an interest in that I also support the Dignity in Dying charter.

I want to tell two brief stories of patients at the end of their lives. The first case is of a cancer patient who was refused surgery after attempts were made unsuccessfully to halt the tumour with chemotherapy. She decided, in consultation with her family, that she wanted to stay at home and receive palliative care. That was organised by the local hospice in conjunction with Macmillan nurses, and she received superb 24-hour care with the help of her family. That patient’s death was planned according to her wishes and, although painful at times—something about which she did not complain—was dignified; she had her way.

The second patient has a variant of motor neurone disease. Fully aware of the course of that disease, she discussed the manner of dying with her doctors a couple of years ago. Like many patients with neurological disease whom we read about in the press, the patient wanted to die at a time of her choosing because she did not want to have to go through the final stages of the disease—what we call the locked-in syndrome. Despite advance directives and discussions, she is now helpless, unable to speak, swallow or move. She still just about breathes, but her eyes say it all. I wish I could help her but I cannot.

Why do we treat these two patients differently? Some of us would like them to be treated equally. They both wanted to plan their own final days, and they both surely had a right to do so, but one achieved her plan and the other lives on unhappily.

Noble Lords have rightly pointed out the concerns that we would all have if doctor-assisted dying were allowed in this country. We are right to be worried. I shall not repeat the counter-arguments—the slippery slope and coercion by relatives. Even pressure on hospital beds has been mentioned. However, their fears have not materialised in the Netherlands or Oregon. In fact, palliative care in those countries has become more important and facilities have improved.

We all want to die well and, if possible, with dignity. We should not allow this for some patients and not for others. The patient must choose and we must help them with their choice.

4.38 pm

Lord McColl of Dulwich: I thank the noble Lord, Lord Warner, et al, for their charter, much of which I agree with. Enabling terminally ill patients to discuss their care, knowing that they have a right to refuse treatment, having effective advance directives, increasing resources for palliative care and emphasising the need

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for adequate respite care—all these recommendations are to be commended. They would do much to remove the fear of death and dying and the fear of unwanted medical treatment. The Voluntary Euthanasia Society—now Dignity in Dying—has every right to promote its views, but it really does not have a right to make statements such as the one made in another place, that doctors,

That is not true. It is an insult and, what is more, shows a profound ignorance of the use of drugs.

The definition of a good drug such as a pain-relieving drug is that the dose required to relieve is a fraction of the dose required to kill. We doctors are often accused of being hypocritical in giving these drugs. Chemotherapeutic drugs are much more dangerous than pain-relieving drugs; does Dignity in Dying accuse oncologists of hypocrisy?

These recommendations are in operation in many places already. Where I part company with Dignity in Dying is on the issue of assisted suicide and euthanasia, which is what this charter is all about. One of its fund-raising letters speaks of a,

which is needed,

The organisation goes on to say that this,

to legalise euthanasia. Last month, another fund-raising letter stated that every day the organisation receives messages from people who are terminally ill but who are,

Why would an organisation such as Dignity in Dying, which professes to campaign for hospice care, say that it is not allowed to help people? Because what it is not allowed to do is to help the terminally ill people kill themselves. That phrase, “not allowed to help”, reveals its one overriding objective—namely, the legalisation of euthanasia.

I congratulate the Government in that they have already rejected euthanasia in their own strategy for care at the end of life. Many people who would have obtained assistance in dying if it had been legal survived and are now very glad that their earlier wish to die was not granted. Alison Davis is a case in point; she is very grateful that assisted suicide remains illegal. When I spoke to her this past weekend, she wished me to repeat the evidence that she gave in 2004. Her serious illnesses rendered her permanently disabled and breathless. When she was diagnosed with a fatal illness 13 years ago, she decided that she had had enough and asked for euthanasia. When this was refused, she made three serious attempts on her life, but was rescued by her friends, who persuaded her that her life was worth living. She then established an orphanage in India—and these 13 years, she tells me, have been the happiest of

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her life. If euthanasia had been legal, she would have been deprived of the best 13 years of her life. She would like to know what the noble Lord, Lord Warner, et al, have to say about that.

4.42 pm

Baroness Thornton: First, I congratulate my noble friend on securing this debate, which has clearly struck a chord with other noble Lords and, hence, the extension of time. I congratulate noble Lords on their discipline in sticking to the time that they were allocated and succeeding incredibly well in making the points that they wished to make.

This is the first occasion on which we have had the opportunity to debate the Government’s end-of-life strategy since it was published in July this year. It is a matter that is clearly of great interest to all of us. It seems unlikely that I shall be able to address all the points that noble Lords made in my 12 minutes, but I shall do my best to cover those that seem pertinent to the question raised by my noble friend from the outset on how far the proposals from Dignity in Dying will be taken into account in the Government’s strategy.

The Government are committed to improving end-of-life care services for all. The end-of-life care strategy sets out a clear direction for the future development of services for adults and confirms our commitment to this important area of healthcare. I am grateful for the support expressed by noble Lords throughout this debate. The strategy was created after two years of discussion and debate with all those with an interest—patients and carers and their organisations, clinicians and nurses, families and many others, as was mentioned by the noble Baroness, Lady Finlay, and my noble friend Lord Warner. The strategy has benefited hugely from the care that went into it, and we are but at the beginning of its implementation.

Although my noble friend will be aware that the strategy has been developed within the current legal framework, he will be pleased to learn that many, but not quite all, of the proposals in Dignity in Dying’s A Charter for Dignity at the End of Life are compatible with the direction set out in the strategy. Seven of its 10 proposals are compatible, but we have difficulty with points 4, 5 and 8 for different reasons.

On point 4, the advance decisions, it is a matter of emphasis rather than disagreement. Point 8 raises an issue of resources which I shall address later in my remarks. On Point 5, which concerns assisted death, our reasons have been admirably illustrated today in what has been probably a 50-50 debate.

In line with the charter’s cause, the Government’s strategy covers the whole pathway of care for those at the end of life. It addresses the responsibilities of the NHS, local authorities, commissioners and the providers of services as well as the Department of Health. It deliberately does not include targets or recommendations, but does include helpful case studies and sets out measures that those bodies will wish to consider taking to improve end-of-life services. Importantly, it builds on and supports the visions for the end-of-life care developed by strategic health authorities as part of the NHS next stage review.



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The strategy has been well received both within the NHS and the voluntary sector, including by Dignity in Dying. The measures set out in the strategy are based on what we heard from stakeholders and others as being needed to bring about real improvements in end-of-life care. They set out the key elements for the delivery of the high-quality care that we would wish all people to receive. Among these measures are, first, the need to ensure that all patients and carers have care plans to meet their needs, a point mentioned, for example, by the right reverend Prelate. An important component for care planning is advanced care plans, an element of which might be advanced decisions.

The second strand is to ensure that effective mechanisms are in place to facilitate co-ordination of care across all sectors and providers. We also need to ensure that the range of services, which people need to enable them to live and die at home, is available 24/7. For example, we need such key services as rapid response community nursing, and we need that care, if I may use jargon, to be seamless so that people do not experience the kind of situation faced by the noble Baroness, Lady Masham.

It is important that the needs and wishes of those who are dying are identified and addressed. Information on all relevant local services needs to be available to support those approaching the end of life and we also need to provide for the needs of the bereaved. For all of this to happen, all staff need to receive adequate and appropriate training and development, including training in the communication skills that are necessary to deal with those at the end of life, a matter outlined with great wisdom by the noble Baroness, Lady Greengross, and my noble friend Lady Jones.

In line with the NHS next stage review, PCTs are working with councils that have been asked to develop local strategic plans for end-of-life care. These will be based on the framework outlined in the strategy. In developing these plans, PCTs and local authorities will need to engage with all the relevant local provider organisations, partners, the public and families. We want to end the patchwork of uneven care.

The Government are committed to investing an additional £286 million in end-of-life services in the two years up to 2011 to support this important programme of work and to take forward a range of initiatives at a national level to help ensure that improvements are delivered in developing the tools to measure the quality of care received; developing workforce competences and training in end-of life care; and developing markers against which PCTs and providers can assess themselves, and indeed can be assessed by regulators. We are funding the new national end-of-life care programme to support the work being undertaken by strategic health authorities and PCTs, including the commissioning of end-of-life care services, and to share good practice.

Let me answer three specific points, which were raised during the course of the debate. On the issue raised by my noble friend, he will not be surprised that I will not be able to give him much satisfaction on his request.

This debate highlights people’s strong and opposing views on this issue. Some have deeply held convictions, religious or otherwise, about the sanctity of life. Some have been influenced by personal experience of caring

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for a terminally ill relative and wanting to end their suffering. Others are passionately convinced that they and others have the right to decide on the circumstances of their own deaths, and that those who help them, whether clinicians or relatives, to achieve this should not be vulnerable to prosecution. Some people can see compelling points on both sides of the argument and have not reached a firm view. This debate illustrates that completely.

We might also have to ask ourselves how we weigh up the views of particular groups. For example, how do we balance the views of the public with the views of health professionals or people who have direct relevant experience, or with the views of those who can only speculate about what their wishes may be in the future? There is no easy way to do this, and on behalf of the Government I can offer no answers. I remind Members of the Committee that the Government have no plans to change the law in this area and we have it made very clear that we take a neutral stance when others seek to change the law. This means not standing in the way of such a change, but not actively pursuing it. Equally, we have no plans at present to carry out any associated research in this area.

The noble Baroness, Lady Greengross, and others raised the issue of more specialists being required. We know that the majority of people would prefer to be cared for and to die at home. It is not practical that all such care be provided by specialist staff, and most care will continue to be delivered by GPs, district nurses, care home staff and other generalist staff. But to ensure that everyone has access to improved end-of-life care, it will be essential that health and social care staff at all levels have the necessary knowledge, skills and attitudes related to care for the dying. For this to happen, end-of-life care needs to be embedded in the training curriculum at all levels and for all staff groups, not just those specialising in end-of-life care. This is what we aim to do through the strategy.

The noble Baroness, Lady Tonge, and others raised the issue of advance decisions. The Government fully support the fundamental and important principle that everyone has the right to consent to or refuse treatment. The courts recognise that people have the right to make a decision in advance to refuse treatment if they lose capacity in the future. The Mental Capacity Act puts advance decisions to refuse treatment on a statutory footing and sets out the rules and safeguards governing advance decisions. We are quite clear that advance decisions are legally binding refusals of a particular treatment, and must be followed if they are valid and applicable. We believe that advance care plans and advance care decisions are appropriately addressed in the strategy.

In conclusion, we are only at the beginning of an important process of implementing the end-of-life care strategy. It will take time for many of the changes that we envisage to happen. However, we can confidently look forward to continuing improvements to end-of-life care services for all patients as a result of implementing this most important strategy.

The Deputy Chairman of Committees (Lord Haskel): The Committee stands adjourned until 5 pm.

[The Sitting was suspended from 4.53 to 5 pm.]


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