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To deal with the next point made by the noble and learned Lord, Lord Mackay of Clashfern, I say that if the person changes their mind after making the declaration, of course they are entirely free to do so. Nothing in the amendment limits that in any way. The safeguard applies only to those who are terminally ill, have exercised free choice and wish to travel to a country where assisting suicide would be lawful. The question that I respectfully suggest should be asked and answered is: why is that not preferable to the present situation, where the loved ones of someone who wishes to end their life because they are terminally ill must risk prosecution, unless the Director of Public Prosecutions decides in that case that he will not prosecute? Why should the operation of the law have to depend on the DPP's discretion? The Court of Appeal indicated in the Purdy case that it is for Parliament, not the court, to answer those questions. If ever there were a case in which legislation needed to be reasonably clear, it is legislation of this kind, where one needs to know whether what one is doing is criminal.

I see the amendment as providing a safeguard that is now needed. A former client of mine-Annie Lindsell-had MND, did not wish to go into a hospice,

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did not wish to have a peg put in her throat towards the end of her life and wished to exercise her personal autonomy as a disabled person to die when she chose. Were she now alive, she would know that, under the amendment, if she wished to end her life and was totally paralysed and unable to exercise autonomy in any other way, she could go to Switzerland, accompanied by the magnificent two men who looked after her at the end of her life, and die with dignity.

I entirely understand the concern expressed by many-including the noble Baroness, Lady Campbell, who I am sure will wish to speak to the amendment-that the right of everyone to life is fundamental and that the disabled are as worthy in all respects of life and all that it means as someone who is not disabled. If I thought that the amendment would make the rights of the disabled less worthy of consideration than now, I would be totally opposed to it. Someone who is terminally ill with MND is disabled, in the sense that there will come a time when they are totally paralysed and unable to do anything for themselves. If they wish to end their life, that is a personal choice for them. The disabled should not be treated less favourably in their personal choice and autonomy than those who are not disabled. We can all go to Switzerland and kill ourselves if we wish to do so and, since the Suicide Act, we can all commit suicide in this country if we wish to do so, but those who cannot exercise personal autonomy in the end are the most seriously disabled who are terminally ill. They would get support from the amendment in knowing that, if they wished to exercise their personal choice, they could do so with their loved ones around them.

I regard the amendment as a humanitarian measure of a limited and moderate kind. It does not seek to do what the Bill of the noble Lord, Lord Joffe, did. I agree with the noble and learned Lord, Lord Falconer, that if it did something of that kind it would be a matter for full consultation and full debate. All that the amendment would do is provide a safeguard in a narrow set of circumstances.

Lord Walton of Detchant: In opposing the amendment, I speak as a doctor, a retired neurologist, and someone who in my professional life spent a great deal of my time looking after people with progressive neurological diseases and many individuals who were terminally ill. I must also remind the Committee that in 1992 and 1993 I had the privilege of chairing your Lordships' ad hoc Select Committee on Medical Ethics, which spent a full 12 months in detailed inquiry into issues relating to whether it would be appropriate to legalise physician-assisted suicide and voluntary euthanasia. I do not intend to go into details about that inquiry, except to say that we considered with great care submissions from many different quarters, including those who favoured the question of legalising assisted suicide. I fully appreciate that three members of the committee, which I was privileged to chair, have subsequently changed their minds. I know that they have supported the Falconer amendment, but I do not, for reasons that I should like to explain.

In that inquiry looking at the issue of people who were terminally ill from progressive and fatal diseases, we recognised that there was a principle that had been

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applied in many cases in the past by the medical profession and accepted by the legal profession-the principle of double effect. What double effect meant was that if, in order to relieve pain, distress and suffering it was necessary for doctors to give such doses of medication as may have the secondary consequence of shortening life, this was acceptable in law and in medical ethics, but the intention must not be to kill. Since that time, I wholly appreciate that a number of philosophers and doctors have regarded that principle as being hypocritical. Some have said that it is a fudge; nevertheless I still believe that it served the medical profession well over many years.

I recognise what the noble and learned Lord, Lord Falconer, said about his opinion to the effect that, at the moment, the law on this issue is being abused. I remind him that one of the issues that arose out of that inquiry-incidentally, our report was accepted by this House-related to an amendment, which had been tabled earlier on this Bill, about the law relating to the offence of murder. The Home Office reported to us 23 cases where a family member had administered a fatal dose of medication to an individual with terminal illness because of their belief that they were assisting that person and that their motives were merciful. In all but one of those 23 cases the law was, in a sense, not accepted because each one should have been accused of murder. However, in every case but one, the offence was changed to one of attempted murder or manslaughter, because everyone knew that the motive was merciful and that, in consequence, no jury would ever be likely to convict. It was for that reason that we recommended a change in the mandatory life sentence, but that is another issue entirely. However, the law was, in our opinion and at that time, being abused and not accepted.

I turn to the issue of assisted suicide. Ludwig Minelli, who runs Switzerland's suicide facility for overseas visitors, is something of a fanatic. He has made no secret of his view that suicide is a marvellous opportunity for a human being and that he regards safeguards as unnecessary. I believe that Parliament would be abdicating its responsibility for the safety of British citizens abroad if it were to pass this amendment. Look at the cases that have gone to Dignitas in Switzerland. They include individuals with cauda equina syndrome-weakness in the lower limbs-individuals with inclusion body myositis, and a whole series of people who have been put to death in that so-called clinic, which is not really a clinic, when there was no evidence that they were suffering from a terminal illness.

I turn to the point that the noble and learned Lord raised on safeguards and the issue of getting two medical practitioners to confirm that these individuals were of sound mind and could make this declaration. We all remember what happened to the Abortion Act as regards the requirement that two doctors should confirm that the individual was suffering from a disorder such that the continuation of the pregnancy should not be allowed. What about the qualifications of these doctors? Any regulation or law of that kind must surely prescribe in detail the nature of the medical people who would be called upon to certify these cases as being appropriate to travel abroad in company with a loved one.

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5.45 pm

Another issue came out of our report 17 years ago-I appreciate that in many respects the opinion of some Members of this House have changed and that the attitude of some members of the public may have changed. However, one of our major recommendations was that the facilities for palliative care for people in terminal illness should be vastly improved. Palliative care has changed out of all recognition. As a consequence of the law legalising euthanasia in the Netherlands, where we visited and saw that more than 1,000 people a year were being put to death by euthanasia when they were not capable of giving or withholding consent-the consent was given by others-there has been a decline in palliative care. In this country it has been extended considerably. Palliative care is provided not just by hospices but by doctors who are fully trained in general practice to administer palliative care. I believe that the situation is such that everyone in a terminal illness can be entitled to and can receive a quality of medical care to help them to die well.

I end with a quote from one of the papers I have received:

"If I were asked whether I would prefer to receive high quality palliative care in a terminal illness and would be enabled in the UK to die well, or whether I would rather go to Switzerland to be killed, I have no doubt which choice I would make".

Baroness Jay of Paddington: I, too, have signed the amendment and I had the privilege also of serving on the Select Committee chaired by the noble Lord, Lord Walton of Detchant. It was many years ago, as he reminded us. I say to him and to other Members of the Committee who raised some of the general points about palliative care and the Suicide Act in this country that, frankly, that is not what this amendment is about. It focuses exclusively on the particular circumstances of people who are terminally ill, who have mental capacity, and who have made a determined decision that they wish to travel abroad to have an assisted death.

The noble Lord, Lord Walton of Detchant, and others referred exclusively to the situation in Switzerland, but let us not forget that one could, for example-if one wished to-go to the Netherlands, Luxembourg, Belgium or, if one wished to make a long journey, Oregon or Washington State. Therefore, we are not in this amendment seeking to make judgments about a particular institution, which some noble Lords may feel has an unattractive presentation. That is not what this debate or this amendment is about. It is not about assisted suicide laws in this country. Frankly, it is not-except indirectly-about palliative care. I should also say, with great respect, although I took very clearly the points of the noble Lord, Lord Lester of Herne Hill, on disability, that it is not about disability. It is about a very narrow situation which my noble and learned friend Lord Falconer very adequately described in his introduction.

Taking the lay person's view on all of this, one is entitled to have as a citizen a clear view about whether one's individual conduct is criminal or not. In this respect, I refer the Committee to the point made by my noble and learned friend the Attorney-General in response to a previous amendment to the Bill. She said:

"One of the things that we aspire to achieve with these provisions"-

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that is, with the Bill-

That is precisely what my noble and learned friend's amendment is trying to achieve on a very narrow perspective. In supporting him, I should like not simply to reinforce that legal point, but to make a slightly more general, and perhaps more emotional, point about the nature of the people and their circumstances who would be affected-and, indeed, would be helped-if this amendment were agreed.

At Second Reading, I gave some examples of people who were faced with very agonising choices for their families and who would confront a situation whereby they could give one last act of loving kindness to a person who, as I said, is determined and of sound mind to travel abroad to somewhere where it is legal to get an assisted death. They can do that, but are then in the terrible situation that they may face prosecution. I mentioned people who defied the law to give that comfort and assistance. I mentioned those who felt terrible guilt for many years because they had been deterred from accompanying a loved one, and those who chose to keep their plans secret from a wider group. In one instance, a couple went to a place where they could effect a dignified death so that they would die together. In every circumstance, there was a clandestine nature to the activity and a sense that they were trying to keep something very quiet. I received a letter today from a woman with multiple sclerosis who said that she did not want to "sneak off" to another country to die earlier than she needed to. All of these people-and all of us who support the amendment-would like to see the desire expressed by the Attorney-General for clarity, certainty and consistency achieved by the amendment. That is what I would like to see.

The Lord Bishop of Exeter: With all due respect to the noble Baroness, I am not persuaded that this is a mere narrow and technical amendment. I see it as touching on concerns that ought to be at the heart of English law. I speak as the father of a 30 year-old woman with Down's syndrome. For much of her life, she and others like her have been the subject of countless government and other programmes, apparently intended to increase responsibility and choice. However, the lived experience of my daughter's life is that, for people like her, intention and reality often end up being far apart. With all respect to the noble and learned Lord, Lord Falconer, and the noble Lord, Lord Lester, speeches about freedom, choice and personal autonomy may be fine for those, including many of us in your Lordships' House, who are well educated, articulate and not totally economically dependent on others. We are used to shaping our lives through the autonomous choices that we make. However, I ask noble Lords to reflect for a moment on the many people, in this country and the world, whose experience of life is much more about being "done unto"-sometimes by those closest to them-and whose experience of professionals, including doctors, is not always of people of good faith, like you and me, but of remote, aloof and often faceless people who make decisions that may not immediately reflect, or appear to reflect, the client's interests or long-term needs.

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I ask noble Lords to consider whether a person whose life experience is not all about being in control and making free choices is likely to see any loosening of a law that is designed to protect the vulnerable from others and from themselves as being the compassionate liberalism that we are told it is intended to be. For too many, the promise of more choice has so often turned out to mean pressure to choose that which suits others. People who have not led assertive lives, exercising their own choices, have often internalised the notion that others know best. They end up valuing their own lives far too cheaply. Are we to offer them the ultimate opportunity to give way to the will of those around them? I ask this in the context of the amendment, which by definition would involve the state in affirming the view of an individual life as being, in at least some circumstances, intolerable and not worth living.

One of the prime functions of law is to protect the weak. So let us be very wary of any changes to the law that are based on an assumption that all human beings are like us: confident, articulate and used to choosing the direction of their lives. For many others, choice is not always a promise: it can feel like a threat. Time and again, history has shown that once a principle is breached it becomes very hard to police the boundary. That is my greatest worry about the amendment. Its apparent modest provision to provide support for those who have determined to seek assisted death abroad will, I am certain, despite all that has been said, come to constitute a legislative milestone on that slippery slope to introducing assisted suicide here in the UK by incremental degrees. My concern, on behalf of the most vulnerable, is that what is presented as an extension of "my right to choose" can too quickly become an option that I am pressurised, however subtly, to accept.

The philosopher, Alasdair MacIntyre, says that the fundamental truth about human beings is not that we are autonomous individuals, but that we are dependent on one another. Through good palliative care, our nature as dependent creatures can be given an eloquent expression through the skill of the medical and nursing professions. Most doctors, and the BMA, understand the provision of palliative care as central to their calling but are extremely wary of assisted dying. The vision of our mutual dependency is surely better realised in a relationship dedicated to controlling pain and supporting life until death comes, than in the dry, consumerist image of a medical profession part of whose job is to respond to a patient's demand to die.

So often this debate about assisted suicide is presented in terms of a conflict between warm compassion and cold dogma. But this is a false antithesis and far from the reality that the debate needs to be about. The real debate is about how a compassionate society discerns and enshrines in law what "compassionate" means for all its citizens, but particularly for the weak and vulnerable, with all the complex reality of their lives, and in a way that appears to reduce neither the value of individual human life, nor the mutual responsibility of us all.

This is a matter that deserves thorough debate and scrutiny in a substantive measure of its own. It is far too important to be dealt with in the loosely drawn amendment that it is now proposed to attach to this already broadly drawn Bill.

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Baroness Finlay of Llandaff: Last week, the BMA rejected the amendment's proposal, and also rejected supporting physician-assisted suicide generally. Why? Because it saw that this does not serve true choice in patient care. There are no safeguards of substance here. The two doctors have only to be registered-in other words, a year out of medical school. They need no training in the patient's condition, in assessing mental capacity or in detecting coercion. Each doctor has to do only a single assessment, which will inevitably miss some impairments in capacity and distorted thinking that may be fluctuant. The requirements would not have safeguarded the patients in the five cases highlighted by the noble and learned Lord, Lord Falconer, in his opening remarks.

This is a rubber-stamping exercise. The criteria are far less rigorous than those required for other serious assessments such as brain-stem death. What about the witness? Will they be a lawyer, or trained to detect coercion? How will the witness check the veracity of the doctors' statements? The declarations do not have to be formally registered with the Ministry of Justice; nor do they have a shelf life. There is no monitoring here, and the requirement that the patient has read or been informed of the contents of the doctors' certificates affords less protection than the informed consent required for major surgery.

Where will the registered medical practitioners come from? In Oregon, there is a culture of doctor-shopping. The pro-assisted-suicide organisations link patients to a compliant doctor. The Oregon health department's report showed that a tiny number of doctors provide all the lethal prescriptions. Such doctors from pro-assisted-suicide organisations are hardly going to be unbiased in their "in good faith" assessments. Let us not be fooled into thinking that a second, independent doctor is a rigorous check. I remind the Committee that Dr Shipman's cremation forms were all signed by doctors independent of him. That safeguard failed in several hundred cases. More than 90 per cent of doctors in palliative medicine in this country want nothing to do with this, as we work day in and day out with those with end-of-life diseases, on their management and care.

6 pm

The amendment certainly does not define terminal illness. Indeed, as stated, many of the Britons who have had assisted suicide at Dignitas were far from terminally ill. The definition which I used in my Palliative Care Bill related to an entitlement to care. If more than those who fitted the definition came within its ambit, they certainly would get more enhanced care than they were already receiving but that would not endanger the safety of anyone. They would simply receive that care and, subsequently, be discharged back to ordinary care.

Even when patients are thought by their doctors to be terminally ill, trying to predict time of death is notoriously inaccurate. In one in 20 post-mortems, misdiagnosis of a terminal illness has been shown to result in inappropriate treatment. I am afraid that I see enough patients every year who are thought to be terminally ill and dying to know that it is not easy to establish. Even, four years ago, when my mother was in a hospice, I and the doctors looking after her

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thought that she was within days of her death, but we were proved wrong. She lived to see her two great-grandsons born and now says that she has a great quality of life. I never believed that I would have my mother now.

Assisted suicide does not guarantee a peaceful death. There are well documented cases from Oregon, Switzerland and Holland of patients waking up again, some in overwhelming distress, hours or days after taking their lethal prescription. Once immunity from prosecution is granted, there is no check whatever. As care becomes more burdensome and family funds dwindle, why not encourage a patient to travel? Such pressure could be brought to bear by a family free from any worry that they might face a severe penalty. The amendment is an invitation to those whose wish for their relative to be put out of their misery may be dubious. Indeed, relatives often feel that a patient should be dead before a patient is ready to die, yet this amendment naively assumes that relatives never stand to gain anything by a foreshortened life.

Remember the Court of Appeal's judgment last November in the Purdy case which stated:

"Cases of assisted suicide ... vary hugely in their criminality ... not all cases of assisted suicide represent the final act or acts of love or the culmination of a lifelong loving relationship".

Only too often, patients feel that they cannot or should not go on. Improved care and dealing with their concerns results in them subsequently saying that they are glad that they are alive and that they never believed that they could have such good quality of life.

Some months ago, a man referred to me was adamant that he would travel to Dignitas but he wanted better pain control for the journey. His wife fully supported his decision and I felt that it was inevitable that he would go. Tentatively, I asked whether he had any unrealised dreams. He said that he had always wanted to go on a cruise but that that was now clearly out of the question. I suggested that we controlled his pain and got him on the QE2, where he had the time of his life. Eventually, months later, he died at home after a winter trip to the beach and an overly large helping of fish and chips. He never went to Switzerland and his wife is clear that neither of them would have missed the last months for the world. How hard his care was for us all. It was not easy but it would have been easy to have simply processed his request.

People change their minds. The law as it stands dissuades relatives from readily taking people to commit suicide. It dissuades clinicians from going for the easy option which would be to acquiesce to such requests. Make no mistake, coercion is very subtle. This amendment is no simple tidying up of the law; it would provide immunity from prosecution, irrespective of the subsequent events around the death.

Finally, which "country or territory" is referred to in the amendment? It actually means Dignitas in Switzerland because it provides suicide for non-Swiss nationals. Oregon and the Netherlands certainly do not take non-nationals for suicide and Belgium and Luxembourg are extremely reluctant to because they do not want the label of "death tourism" which has applied to Switzerland. Despite the media hype, the Swiss suicides referred to represent fewer than one out of every 50,000 British deaths.

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