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Member’s explanatory statement
The person’s decision must be taken devoid of encouragement to end their life from any other person and is compatible with the current Director of Public Prosecution guidelines on prosecution for assisting suicide.
Baroness Finlay of Llandaff (CB)
My Lords, we come to a key concern in this Bill—the very real risks of coercion and pressure to seek an assisted death. While the Bill acknowledges coercion, it does not fully address the dynamics of domestic abuse at the end of life nor the intersectional risks faced by women, those who are disabled, whether long-term or through illness, and those from ethnic minority backgrounds.
ONS data showed that, from March 2023 to March 2024, 2.3 million people over 16 were subject to domestic abuse. This equates to one in 20 of the population between 16 and 65 years old, yet only 45,000 of them in England and Wales are known to the police. In the older population, the incidence is even higher. Hourglass has estimated that one in five experiences some sort of abuse. Since the start of the Covid-19 pandemic, incidences of domestic abuse reported to third sector and statutory agencies have increased by over 60%. A systematic review by Michelle Myall and colleagues covering 2000 to 2021 found that the incidence of abuse increased in terminal illness. These results resonated with Jamilla Hussain’s findings in Bradford.
People with life-limiting illness experience a range of abusive behaviours in three broad categories: coercive and controlling behaviour, emotional and physical abuse and neglect, and financial abuse. Financial abuse is particularly rife in its many forms. Take the relative who goes to the cash machine for their relative who is ill and quietly pockets some of the cash or quietly steals valuables, or the family keen for their relative to die before a fixed-term life insurance runs out. Yes, I have seen it. They wanted a new car.
Emotional abuse includes telling the person that they are a burden—directly, or indirectly through conversations that are designed to be overheard by the person who is ill. Some are told that they are not dying quickly enough. Abuse affects treatment decisions and can lead to people missing out on curative treatment through making adverse decisions about their care. For some women, death is the only way out that they can see from their situation. It reflects the national data, where suicide is now the commonest cause of domestic abuse-related deaths.
The Oregon data shows that feeling a burden to family or carers has been stated as an end-of-life concern by over 47% of people having an assisted death. This was higher than the under 30% who cited inadequate pain control or concern about it as a reason. After the noble and learned Lord, Lord Falconer, gave evidence to the Select Committee, I rechecked the official reports. Oregon does not collect data to understand whether there have been problems with coercion or report on those who are turned down for lethal drugs.
This Bill has been publicised as being about pain but does not mention pain at all. Specialist palliative care can deal with pain. Detecting the coercive threats, humiliation and intimidation, which are usually subtle and consistently maintained out of sight of anyone in authority, is far harder. It is the complaints about the heating bills, family carers being fed up with having to prepare drinks and food, groaning when asked for something—there are so many ways to give the message that you are a nuisance and would be better off dead. Abuse impacts patients’ mental health and well-being and leads to feelings of loss of control, entrapment, powerlessness and depression.
However, health and care professionals lack confidence in identifying abuse. It is rarely detected by doctors. Why? Because dependence limits disclosure. Illness increases women’s dependence on the perpetrators, making disclosure harder in the last months, weeks and days of life, even when professionals ask directly. Disclosure requires time to build trust with the same professional, who understands how abuse presents at the end of life in different cultural contexts and who can offer practical support such as safe housing, financial help and, if needed, support for dependents. Without this, disclosure is too risky.
Most women in Dr Hussain’s group said that they would not dare to disclose abuse during an assisted dying assessment as currently set out. They felt that the process was too brief, too medicalised and too uncertain to guarantee their safety. I recall a patient whose pain was not controlled on 1,000 milligrams of morphine per day. After a few days in our hospice, she disclosed to a care assistant at night the years of worsening abuse that she had endured. Total distress from hidden abuse had given her total pain. Social work intervention and safeguarding in place was the solution. She went out to a new home needing only 60 milligrams a day.
Disclosure is more likely in a trusted relationship with someone whom the person can know, whom they can look in the eye, knowing that they will work hard to improve their situation. In today’s NHS, continuity of care is not the norm. It is fragmented, with inadequate transfer of information between sectors. Patients do not see the same person time and again, whether doctor, nurse or other professional. That is why it is essential that information is sought, from police callouts to a domestic disturbance, local authority records to reveal any safeguarding issues in the household, clinical teams who have been involved, social care, community carers and family members who may well be aware of abuse but had not known how to disclose it.
Another type of subtle subliminal pressure is also addressed in this group of amendments—that arising from whatever the doctor suggests. Under the Montgomery and McCulloch rulings, patients must be informed of all possible treatments which are appropriate to that condition. If a doctor says that there is also the option of an assisted death, the patient will hear that as, “I know what lies ahead for you and you should consider ending it now”. A Canadian lawyer told me of his friend who had a stroke. On being taken out of the ambulance, he was asked whether he wanted treatment or MAID—medical assistance in dying—Canada’s term for assisted death. He also told me of patients being repeatedly asked by different doctors in the hospital about MAID, and the corrosive effect that this has.
The amendment in the name of the noble Baroness, Lady Fox of Buckley, and others, is particularly important. It does not prevent conversations but it would stop subtle coercive influences from doctors, who may be under pressure, who may feel that they have to raise this—just as the problems of DNR orders arose during Covid—or with some of the abuses of medical power and inappropriate surgery that were in the headlines not that long ago. I beg to move.
Lord Hunt of Kings Heath (Lab)
My Lords, I have a few amendments in this group. My Amendment 118 seeks to introduce
“an independent financial review and background check on close relatives before eligibility can proceed. It aims to block eligibility where there is known financial abuse risk”.
My Amendment 462 aims
“to make coercion/financial abuse checking a shared statutory duty of both the Commissioner and the multidisciplinary Review Panel”.
The noble Baroness, Lady Finlay, has set out some of the issues and concerns about coercion, which I do not need to repeat. I am a long-standing supporter of Hourglass, an amazing organisation devoted to combating the abuse of older people. It is neutral on the Bill, but its chief executive said in evidence to the House of Commons that
“there is an epidemic of abuse against older people at the moment. Some of it is due to the economic climate that we are in, with people just wanting to have their inheritance now, and some of it is due to the fact that older people feel like a burden”.—[Official Report, Commons, Terminally Ill Adults (End of Life) Bill Committee, 29/1/25; col. 160.]
Lord Farmer (Con)
My Lords, I rise in support of Amendment 118 tabled by the noble Lord, Lord Hunt of Kings Heath, and I am introducing Amendments 118A and 118B which follow it. I also support Amendments 45, 46, 47, 49 and 58.
This is an atheist Bill that assumes there is nothing after death, which is not a neutral but an ideological position. To those without an active belief that there is something after death, I would say, “How can you be so sure?” What makes the point that it is an atheist Bill? It is that it desacralizes death and by so doing it opens the door to very many evils including coercion and pressure, the subject of this group. The Bill is coercive: it gives oxygen to dark thoughts which can loom especially large when our best days seem to lie behind us, and when we are no longer contributing to family and society in the way we once did. Culturally and societally, it encourages and influences them as much as any person referred to in Amendments 45 and 46. Two of my friends with terminal conditions both followed earlier stages of this Bill in the other place and told me the subject’s very airing made them feel that they were a burden. The message that legislation and policy should amplify is, “You will not walk the valley of the shadow of death on your own”. We should encourage people to make and keep those relationships that will carry them through life and through that dark valley.
Others might also have dug out the words of the Times columnist Matthew Parris, quoted in a debate on assisted suicide in the other place in April 2024. He said that although
“‘Your time is up’ will never be an order”
to the elderly, disabled, severely ill and the others to whom assisted suicide will, inevitably, be extended eventually, it
“may one day be the kind of unspoken hint that everybody understands. And that’s a good thing”.
As the right honourable Stephen Timms said in that debate:
“I cannot see that that would be a good thing. It seems to me that legalising assisted dying would impose a terrible dilemma on frail people, elderly people and others when they are at the most vulnerable point in their lives, especially on conscientious frail people who do not want to die but do not want to be a burden. I do not think that there is any way to avoid imposing that dilemma”.—[Official Report, Commons, 29/4/24; col. 18WH.]
We have heard from the noble Baroness, Lady Finlay, about the data from Oregon, where over half the people who have applied for assisted dying since 2017 did so not because they wanted to die but because they felt that they were a burden. Amendment 47 from the noble Baroness, Lady Coffey, would guard against this “internal coercion”, to use the Royal College of Psychiatrists’ phrase. Further, her Amendment 49 includes,
“body corporate, institution or organisation”,
alongside “person”, which would of course catch the Government themselves. Tragically, and I declare my interests as a Hampshire farmer, there are farmers who have committed suicide ahead of the imposition of the family farm tax, choosing to die early so their land is passed on intact. Law and policy starkly influence personal decisions, hence our responsibility as lawmakers to take these unforeseen consequences into account and not brush them aside.
In her Amendment 58, the noble Baroness, Lady Grey-Thompson, is right to focus on lack of care as a disadvantage that pressurises. If death looks as if it might be painful and protracted then going through it alone, unmissed and uncared for, is too terrible to contemplate, but surely we can do better than help someone act on that dread thought, “No one would miss me; no one cares”.
Amendments 118A and 118B, which are my amendments to Amendment 118 in my name and that of the noble Lord, Lord Hunt, would ensure that wills were scrutinised and the backgrounds of friends, as well as family, were not overlooked if sinister motives suggesting financial abuse were not assumed but at least considered. Legislating for motivation is notoriously difficult, because motives are private, subjective, and easy to disguise. Instead, assisted dying legislation must use clear, objective safeguards to remove the possibility of improper motives influencing the process.
As an aside, I am not sure the Bill prevents any doctors involved profiting from early death, but Dr Harold Shipman did of course inveigle himself into the wills of some of his victims, and that would also be a red flag if found in the commissioner’s checks on wills.
Therefore, I ask the noble and learned Lord, Lord Falconer, why the Bill does not do more to exclude anyone with a financial or personal interest, and by extension anyone who might have been under their influence. We cannot draft either for compassion or for malice, but we can protect applicants by making it clear from the outset that if anyone with suspect motives has any involvement, their application will fall.
Baroness Fox of Buckley (Non-Afl)
My Lords, I, by contrast, speak as an atheist and humanist, mainly to address my Amendment 45, which would add the word “encouraged” after “coerced”. I support the general theme of the other amendments in this group, which largely tackle the need to strengthen safeguards against patients being indirectly influenced into opting for assisted death—often coerced, in all but name. All these loopholes undermine any certainty that the “choice”, in inverted commas, is made autonomously.
My amendment, supported by the noble Lord, Lord Goodman of Wycombe, may appear to be a small change, as it would add just one word. But before anyone concludes that I am tabling trivial amendments to waste time, I note that, when dealing with a fundamental change in the state’s relationship with its citizens and the NHS’s relationship with patients, and life and death decisions, the specificity and appropriateness of the words in the changed law matter.
At present, the Bill requires doctors to ascertain only coercion or pressure. They are the only two words given in Clause 1; there is no duty even to probe or ask broader questions about more subtle, insidious influences that could affect a person’s decisions. I note that the concept of encouragement is not arbitrary; the encouragement of assistance in suicide is illegal under the Suicide Act but would not be in this Bill. Indeed, CPS policy guidance on prosecuting those who have assisted suicide acknowledges “encouraging”—it uses that word—the victim as a factor in favour of prosecution. It is also criminal to encourage a person to commit an offence under the Serious Crime Act. Therefore, the question is less about why I am bothering to table an amendment to add just one word; the question is why the sponsors of the Bill left out that word “encouragement”.
Adding the word “encouragement” would allow a shift in perception about what undue influence could look like. Even though there are real problems in spotting coercion or pressure—we have heard many examples of that—the concepts at least have a hard edge or overt sense, at least in everyday parlance, that you are talking about people doing something that they really did not want to do. You do not say, “I had a really lovely day today; my husband coerced and pressurised me into doing” something. There is a grey area of much more subtle intervention; an individual could motivate, lead on or nudge someone into opting for an assisted death, rather than making that person aware of all the ways that they might live out their limited time as comfortably as possible. This amendment is trying to get at that sort of encouragement.
As I explained at Second Reading, one of my big dreads is that, once assisted dying is normalised as a positive treatment option, that vibe shift will not be confined to medical scenarios. It can and will mean that it is popularised as a go-to option in broader society. Consider this scenario: you have just received the news that you have a terminal diagnosis and have about six months to live. You are frightened, shocked and seeking reassurance. It is a bleak time and you are depressed because you do not want to die.
But then a third party—a family, carer or friend to whom I ascribe no motivation—says, “Have you thought about asking your GP for an assisted death? I’ve been reading about it all over the place and you can do that now. At least that way you’d have dignity in dying. You know how much you hate hospitals and all those doctors fussing about you, and we all know that you are not good with pain. How would the kids cope with running around having to visit you when you’re in and out of hospital? Wouldn’t it be so lovely to choose when you go, then we could all be with you at the end?” All of this is said in soothing, kind tones. Therefore, you think, “Well, I really don’t want to die. My instincts are to
‘Rage, rage against the dying of the light’,
but I don’t want to be a nuisance either, and they know me so well. They know what I’m like and that I won’t cope. They have my best interests at heart, so I suppose so”. It does not sound exploitative or coercive, but it is an iron fist in a velvet glove.
We have some cultural reference points here. In discussions about how the Online Safety Act will tackle suicide sites, there is consensus about the problems of online influencers encouraging vulnerable people into believing that suicide is a positive way out of their suffering. There is widespread revulsion at those cajoling siren voices encouraging death as an attractive option. In that context, none of us concludes that this encouragement is not problematic because it is not explicitly coercive.
Baroness Ritchie of Downpatrick (Lab)
My Lords, I support the amendments to Clause 1 in this group. I speak in particular to Amendment 48 in my name. This seeks to strengthen the safeguards against someone being coerced into an assisted death by removing the words “by any other person” from Clause 1(2)(b). This would extend the notion of coercion by recognising that coercion or pressure can come from a multitude of places—an institution, a circumstance or another individual. I am sure there is agreement across your Lordships’ Committee that nobody should feel obliged to opt for an assisted death. This amendment aims to strengthen and clarify the eligibility criteria in the Bill in recognition that they are perhaps its most important safeguard.
I have deep concerns, as many of us do, about how we protect vulnerable people from unnecessary, unwanted death. I am especially anxious that we should be aware of the risk of coercion in all its forms, which is an issue that I raised during Second Reading. This includes somebody who feels coerced through a lack of real choice.
The National Audit Office’s recent report into the state of the palliative and end-of-life care sector is stark. As we know, funding is stretched and provision is disparate. As things stand, there is a lack of real choice for many people about the end of life. The knowledge of this could easily be internalised by people, leaving terminally ill patients in certain regions or who are part of particularly vulnerable marginalised populations feeling that they have no choice but assisted dying, whether or not another person is explicitly pushing this.
Therefore, my Amendment 48 seeks to ensure that such cases are not left out of the Bill’s definition of coercion. I ask my noble and learned friend Lord Falconer, in his summing up, to give consideration to this, so that it remains possible to detect and prevent any death that the person has not freely chosen.
Baroness Butler-Sloss (CB)
My Lords, I do not like this Bill, but I am here, like many other Members of this House, to agree on amendments that will make this a better Bill, and I hope it will be effective.
When my father died, the family nanny, who had also been his housekeeper, needed somewhere to live, and my brothers and I paid for her to live in a very nice care home, where she was entirely happy, until I went to see her. On each occasion, she said to me, “I shouldn’t be alive. I ought to die. It is not right that you and your brothers are having to pay for me”. I have this direct knowledge. She was perfectly happy when I was not there and, of course, we continued to look after her until she died.
But the Bill, once it is passed, is absolutely certain to be enlarged in all sorts of ways, as happened with other Bills in other countries once they became law. There are various reasons why it would be a good thing to enlarge it. For example, it seems to me bitterly unfair that those with locked-in syndromes such as motor neurone disease would be extremely unlikely to benefit from the Bill in the last six months, because many—those I have known—have been unable to do anything themselves in the last six months. The word “encouragement” is absolutely crucial. It does not have to be coercion. It does not have to be abuse. It could be nice people listening to a loved one and realising that they are saying, “I ought to die”, and consequently saying, “Yes, why not?” That would be extremely unjust.
Lord Pannick (CB)
My Lords, there is a profound irony in this group of amendments, because the Bill introduces far greater protection for vulnerable patients than exists under current law. Terminally ill people are currently vulnerable to all sorts of pressures from family members and others who may have their own agendas in seeking to persuade the patient not to continue with their treatment, to die or just to give up on life. The Bill introduces in statutory form a whole range of new statutory protections that simply do not exist in the standard cases of vulnerable people being encouraged not to continue with their treatment.
We see that in Clause 1(2), which summarises what the Act provides in some detail. Steps are to be taken, and they are taken under the Bill, to establish that the person concerned
“has a clear, settled and informed wish to end their own life, and … has made the decision that they wish to end their own life voluntarily and has not been coerced or pressured by any other person into making it”.
Those seem to me to be very strong and very appropriate protections. The idea that we should proscribe encouragement will inevitably lead to the family members and friends of the person concerned, the person in the terminally ill condition, being worried that, if they discuss this difficult, important subject with their loved one or friend, they will be vulnerable to all sorts of sanctions under the law. That, I would have thought, is the last thing that we want. The application of these principles—and they are the right principles in Clauses 1 and 2—will inevitably depend on the facts and the circumstances of the individual case, so I, for my part, do not see the need for any of these amendments.
Lord Deben (Con)
My Lords, I am not a lawyer, and it is dangerous to follow the noble Lord, Lord Pannick, but I think on this occasion he is mistaken. The fact that this kind of protection is not there until this Bill does not actually mean anything—perhaps it should have been there in any case—but, if we are going to have this protection, it needs to be proper protection.
I say to those who, at least today, live a privileged life that they ought to remember that there are many people in this country who, for the first time, are within touching distance of large sums of money, because the housing situation means that there are many old people who have houses of a value that those families have never seen ever before—grandma’s £200,000. I say to the noble Lord, Lord Pannick, that, as somebody who was a Member of Parliament for 40 years and works now in a community, that this is a very real fact, and we just have to accept that some people in this House are a long way away from those people. I was brought up in a slum parish by a clergyman. I have spent my life trying to deal with the very people we are talking about. I think these amendments are crucially important, because we are talking about circumstances which we are about to change deeply.
The fact is that the Bill itself changes the way in which we think about old age and infirmity. I desperately want people to know that they are always valuable and always got something to give, even at the end of life. This Bill removes that. If we are going to have it— I hope we will not, but if we are going to—we must make sure that people are protected not just from coercion but from encouragement, which I am afraid is sometimes driven by a sort of misunderstanding of what we can give. I can see people who will say, “You know that your grandson is in some real difficulty. You have a last opportunity to do something worthwhile. If you die now, your house will save his marriage, will save his firm and will look after his future”. That is what will happen. We, who are in happier circumstances, should just remember that we have a deep responsibility for those people.
Baroness O’Loan (CB)
My Lords, these amendments seek to prevent and/or identify coercive behaviours and pressure which may fall short of coercion, and situations in which vulnerable people may be encouraged to make what is actually an involuntary decision to end their own life that they would not otherwise have made. There is no definition of coercion or pressure in the Bill, although new offences are created by Clause 34. That is unfortunate.
Arrangements made did not enable the taking of evidence from those with disabilities until the recent Select Committee on the Bill. Liz Carr said in evidence to that committee:
“The absence of our … involvement has led to disability rights organisations making a formal complaint to the UN Convention on the Rights of Persons with Disabilities”.
That is very serious. We know that 40% of those who die by assisted dying in Canada have lived with disabilities.
Baroness Berridge (Con)
My Lords, I will speak to Amendment 48, to which I have added my name, and to my Amendment 846. I added my name to Amendment 48 to explore whether pressure can emanate from a non-human and non-corporate source. As I mentioned at Second Reading, so much pressure nowadays, particularly for young people, comes from the internet, video games, social networking, TikTok and influencers. It is not only the use by people of online devices as a mechanism to pressure another person; it can also be pressure from algorithms themselves, without a human intervening.
In addition to the two prosecutions of OpenAI for ChatGPT allegedly encouraging children to take their own lives, those with chronic illnesses have testified to me that when, for instance, Facebook realises from conversations that you have a chronic illness, it changes your feed from the promotion of group chats and adverts that are positive to negative content about your treatments, whether you can live with it, and even suggesting going to Switzerland. Is it the Bill sponsors’ intention that, when the medical practitioner is verifying under the terms of Clause 10(2)(h), it is not this type of pressure? Are the internet service providers covered by Clause 1, as there is no definition of “person” in the Bill? As I said in Committee, the Bill is designed for an analogue age and not one on the cusp of AI.
Turning to statutory guidance and Amendment 846, the next question is not who applies pressure but what we mean by “pressure”. The former Chief Coroner, Thomas Teague, came to our Select Committee and we asked whether we need to define pressure. He said:
“If it forms part of the ingredients of a statutory offence, then it might be necessary. Frankly, I’m not sure that it would because, for such a common word in the English language, the fundamental principle that lawyers apply is to take the dictionary definition”.
So, last night, I looked in Collins English Dictionary, which defines “pressure” as
“someone … trying to persuade or force”
someone to do something. What a low bar that is that has to be detected. It is a good job that the law will not be retrospective and that there is parliamentary privilege; otherwise, the attempts by the noble and Learned Lord, Lord Falconer, to try to persuade us of the merits of the assisted dying Bill might actually be covered by his own Bill.
I asked the noble and learned Lord in Select Committee whether a consultation is necessary when a new concept is introduced into criminal law. His reply was, “Sometimes yes, sometimes no”. I think that catching mere persuasion means that this is a “sometimes yes” moment, particularly—as has been outlined by the noble Baroness, Lady O’Loan—as this creates the basis for a criminal offence in Clause 34 that can mean imprisonment for life. The noble and learned Lord will not be surprised to hear that later in Committee we will return to his evidence to the Select Committee in relation to Clause 34.
In the Select Committee we asked various professionals what they thought “pressure” meant. Dr Suzy Lishman of the Royal College of Pathologists, who is opposed to the Bill, said:
“I would understand pressure to mean encouragement to go down a particular route, and coercion to involve some force or threat. I have had no training whatsoever in either of these”.
The Royal College of Psychiatrists’ Dr Annabel Price said:
“It would need to be differentiated from coercion in terms of its definition. Coercion would be the application of force, threat”—
Baroness Thornton (Lab)
I would like to ask the noble Baroness whether the Select Committee asked anybody who is terminally ill what they thought “persuasion” or “coercion” might mean?
Baroness Berridge (Con)
We covered that matter on the first day in Committee.
Baroness Thornton (Lab)
The noble Baroness is not answering my question. The truth is, of course, that the committee did not ask anybody who is terminally ill what their view was about any of this.
Baroness Berridge (Con)
I will just reply to the noble Baroness, then, that within the Bill that is not necessary. I have outlined Clause 10. This applies to the people who are verifying in the process, not to the individual. It was not in the Motion your Lordships’ House approved that that evidence should be taken.
To continue, Dr Annabel Price said:
“Pressure has a broader definition of perhaps strong encouragement, expectation or the worry of letting somebody down”.
The noble Lord, Lord Patel, joined in this mini focus group and asked:
“If I were to use the word ‘pressure’ and if I were to use the word ‘coercion’, how would you interpret the two?”
Professor Mumtaz Patel from the Royal College of Physicians—again opposed to the Bill—said, “It is grey”.
Amendment 846 also reflects the view of the Law Society, which is neutral on assisted dying but opposed to the Bill. Kirsty Stuart said:
“I think it is really difficult because there is not a definition at the moment … in the Bill”.
That is why Amendment 846 is based on the statutory guidance principle from the offence of coercion under the Serious Crime Act. I note that the Home Office has recently had to issue 91 pages of statutory guidance on that offence. It seems the courts are struggling with it.
Even if Thomas Teague is right that you look at the dictionary, are we talking about economic pressure, emotional pressure, financial pressure, spiritual pressure, reputational pressure, internalised or externalised pressure, or pressure of circumstances—for instance, no one provides you with a hospice bed? As Dr Suzanne Kite, from the Association for Palliative Medicine, said:
“We know that there are pressures of, ‘Can we afford the electricity for the oxygen supply?’ … Yes, these are issues”
that people face “on a daily basis”. The Bill is silent as to what kind of pressure is meant.
To move from individual sources of pressure, there can also be group sources of pressure. Alasdair Henderson, from the Equality and Human Rights Commission, spoke to the Select Committee about
“this wider issue of coercion or pressure at a societal level or an attitudinal level”
and
“the broader trends or cultural issues”.
He said that
“pressure is not always applied directly by another individual, but can result from attitudinal barriers, particularly around disability, and lack of services and support in society as a whole”.
Could pressure come from NICE refusing you, on value-for-money grounds, the drug that you think will wipe out your metastasised cancer? Indeed, the pressure could emanate from the Chancellor of the Exchequer in her Budget, or from the Secretary of State for Health and Social Care, to encourage vulnerable people to take assisted dying, a matter I put to the Government Minister, Stephen Kinnock.
Caroline Abrahams of Age UK said:
“The context again for this is a system in which adult safeguarding is under acute pressure because local government is under such acute pressure”.
The British Association of Social Workers also said that unless these statutory services
“are adequately resourced, that may bend people’s decision a certain way … much of social care is self-funded now. If you are poor and you cannot have access to those personal resources, even more pressure is applied to you”.
I look to the noble Lord, Lord Pannick: how does a medical practitioner sign to say that this kind of pressure—from culture, society or attitudes, or lack of statutory services—is not being put on the individual?
There was unanimity in the Select Committee when we started asking the professionals about training. I said that pressure
“is not defined in the Bill, so I am afraid I cannot help you. We have no definition in the Bill. You are going to need training, though, in pressure. Has any of you received any training like that?”
Professor Nicola Ranger from the Royal College of Nursing, Professor Mumtaz Patel of the Royal College of Physicians and Dr Michael Mulholland from the Royal College of GPs all said no. So we now have additional costs added to the Bill, because we have to devise training in pressure and deliver it to a whole raft of professionals, care staff, et cetera, so that they understand it, in particular bearing in mind the vulnerability to criminal prosecution that exists in Clause 34.
I am going to give the noble and learned Lord, Lord Falconer, this opportunity to shorten Committee proceedings. Deleting “pressure” from the Bill, when it has not been consulted on and has not been subject to pre-legislative scrutiny, would aid the Committee in evaluating the Bill.
Lord Carlile of Berriew (CB)
My Lords, in a group such as this, which has so many conceptual, linguistic and semantic alternatives on offer, it is very difficult to see how a Committee stage such as this is going to help very much in determining a final solution to the matters under consideration. Therefore, it could become very tempting to enter into the nice and easy solution suggested by my noble friend Lord Pannick, to the effect that the Bill is quite enough and provides sufficient protection. It is right to say that the Bill certainly seeks to provide sufficient protection, and I do not in any way attribute anything other than good motives to those who sponsor the Bill, in particular the noble and learned Lord, Lord Falconer.
Lord Evans of Rainow (Con)
My Lords, I rise to speak to Amendment 50 in my name and that of my noble friend Lord Goodman. It is a pleasure to follow the noble Lord, Lord Carlile. I would not describe him as a nasty lawyer at all. The noble Lord is a Burnley fan. I do not know any nasty Burnley fans, but I do know a lot of Arsenal fans. There is one thing I would say about some phraseology the noble Lord used early in his speech. He used the words “final solution”. I encourage the noble Lord to think of other phraseology to describe that.
I agree with a lot of what the noble Lord, Lord Carlile, said. I am grateful to my noble friend Lord Deben for following the noble Lord, Lord Pannick, because I, too, am not a lawyer, but like my noble friend, as a former Member of Parliament, I experienced lots of constituents who were under coercive control. Lots of MPs do surgeries for their communities and take on these cases. Not being a lawyer, as a layperson trying to fathom out coercive behaviour is notoriously difficult, and that is why I have come up with Amendment 50.
The existing language limits the coercion pressure bar to cases where it causes the person to make a decision, which creates evidential difficulties. This amendment excludes all cases of coercion and pressure without requiring finding out whether in fact it causes the person to make the decision to end their life. It is easier to see whether someone is being coerced or pressured than to know whether the coercion or pressure is the operable cause that leads a person into making the decision. A doctor should exclude all cases where a person is being coerced or pressured to make a declaration rather than engage in causation analysis. Similarly, offences ought to be focused on the wrongful act of coercing or pressurising regardless of the outcome.
At trial, the Crown, with plenty of resources, would have trouble proving that the coercion or pressure resulted in someone making the decision. How is a doctor on their own supposed to find out? Asking a patient is no help given that the frail or vulnerable person may not even know that they are pressurised or may have been intimidated by coercion. Doctors can see pressure from, say, the person accompanying the patient but cannot read the patient’s mind. This amendment would stop doctors being required to be detectives.
The closest analogy in existing law to this rule against coercion or pressure to do a potentially fatal action is Section 2 of the Suicide Act 1961, “Criminal liability for complicity in another’s suicide”. It does not require any attempt at suicide or even a decision to commit suicide and provides that
“D may commit an offence under this section whether or not a suicide, or an attempt at suicide, occurs”.
Section 184 of the Online Safety Act 2023 titled, “Offence of encouraging or assisting serious self-harm”, provides in subsection (5) that
“D may commit an offence under this section whether or not serious self-harm occurs”.
Compare also Section 65 of the Serious Crime Act 2007, which refers to pressurising someone to commit an offence and does not require the outcome be causative.
In recent years, the Crown Prosecution Service has pursued manslaughter charges against men who subject women to domestic abuse that is believed to have driven their suicide. These are criminal offences where there is a much higher bar to action, given that a person’s liberty is at stake. However, Clause 1 is addressing when civil authorities and doctors should draw the line at a patient’s autonomy. Why does the Bill have a higher standard? There is no statutory precedent for “pressured into making it”. The Government have claimed that the Online Safety Act 2023 and the Serious Crime Act 2007 are analogous, but the distinction is making the pressure all that is needed for an offence. Meanwhile the threshold for excluding a person in Clause 1 requires more than is necessary for a criminal offence under these Acts.
Without this amendment it would be lawful to progress a person towards an assisted death even though the person is living in a household where family members are actively making it difficult to live. All that is needed is to see that the person is not pressured or coerced into making the decision. The leading cause of death in domestic abuse victims is now suicide. We work to stop this, but this Bill is opening a door to help perpetrators. It is estimated that three women a week take their own lives. The Government view addressing this as a priority, and the CPS will now prosecute for manslaughter men whose abuse is seen to have contributed to the suicide of a woman. Those men have not had directly to coerce their partners into death, the facts of the abuse are sufficient pressure, but with assisted deaths there will be no coroner’s inquest to address foul play.
The UK leads the world in now recognising coercive control in law, but a regime of total control is poorly understood and insidious. As Cherryl Henry-Leach of Standing Together Against Domestic Abuse told the Lords Committee:
“Coercion is an incredibly complex phenomenon and by its very nature it is difficult to identify and respond to. A perpetrator of coercion will ensure that a person is dependent on them by isolating them from support, exploiting them and depriving them of their independence and autonomy to make decisions freely. As a result of this, we are extremely concerned ... When I think about pressure, I also am mindful of a pattern of coercive control that can be insidious and subversive. Pressure can be a tactic by a perpetrator to enforce a regime of coercive control. That is very complex and I get that, but it is important to be mindful that pressure can be a tool that indicates a pattern of coercive control”.
Studied neglect and coercion are naturally notoriously difficult to detect, and as it stands now, this Bill is a suicide charter. My amendment is intended to improve the Bill.
Baroness Hollins (CB)
My Lords, I have amendments in this group, and I have added my name to other amendments. I start by adding my support to Amendment 460, tabled by my noble friend Lady Finlay. Safeguarding measures are not optional; they are essential. To ensure that each individual requesting assisted dying is properly safeguarded, it is essential that all relevant information is gathered so that a full and thorough picture of their circumstances can be formed. We know that poor mental health, inadequate care support or unaddressed social vulnerabilities can profoundly affect a person’s decision-making and ultimately their capacity and understanding of an assisted death. When safeguarding is insufficient or overlooked, the risks of coercion, subtle pressure or abuse increase, and these are risks that may be difficult to detect or are deliberately concealed. This amendment seeks to ensure that such dangers are neither under-estimated nor ignored.
Baroness Coffey (Con)
I think the noble Baroness’s amendment about videoing affects Clause 25, which is considerably later, when the Act is about to happen. I wonder whether she would consider whether it should be done earlier in order to reduce that because, by the point of her amendment, the certificate of eligibility has already been issued. I would be interested to hear her thoughts on that and on whether video recording, as proposed in Amendment 612, should be considered at a much earlier stage.
Baroness Hollins (CB)
I thank the noble Baroness. I thought about that, and it could indeed be brought back in a different way later in the debate, but I feel that the prevention of coercion is really important, so thinking about it at this stage is really helpful.
Lord Winston (Lab)
My Lords, I want to ask this question of the noble Baroness, Lady Hollins, but it applies also to the noble Baroness, Lady Berridge: she mentioned various things that are cited as causing pressure, but does she not agree that being in palliative care also causes pressure?
Baroness Hollins (CB)
There is no suggestion in anything that I have said of imposing palliative care—none at all. I have listened to the debate, and I was not going to speak personally but I will now, since the noble Lord has challenged me on that. My husband was dying with motor neurone disease last year. He felt under immense pressure from this debate in the House of Commons, the other place. He found it very difficult. It made him ask questions, such as, “Am I still entitled to palliative care? Am I really entitled at a time when the NHS is so short of staff and short of time?” He worried about that, and I had to offer him a lot of reassurance so that he could make his own decision. He was not ready to die. The idea that offering palliative care applies pressure is really not to understand the whole nature of the dying process and the way in which, as we come to realise that our life is coming to an end, we need time to understand, reflect, heal and make sense. The pressure not to be a burden is huge, and the pressure of not having access to services that are in short supply is much worse.
Lord Winston (Lab)
I do not wish to extend this conversation but, given what the noble Baroness has said, can she explain why in Australia—I am sorry, in New Zealand—where there is very good palliative care, three-quarters of the people requesting assisted dying, something like 2,000 patients, had been in palliative care at the time of the request?
Baroness Hollins (CB)
My Lords, we are going to address palliative care in detail in a later group. We are going to make a distinction between palliative care of a general kind and specialist palliative care, and we are going to think about specialist palliative care at its best. Again, we hear day in, day out about how hospices are closing or having to make staff redundant— I think there is a hospice in Hertfordshire that is just starting its redundancy programme this week because it does not have the money to provide for people’s needs—yet we are relying on our hospices to provide that care, which is not sufficiently available.
When I asked my husband’s GP who was going to co-ordinate his care, because there were several different teams involved, said, “Oh, the hospice nurse will do that”. I thought: the hospice nurse or the community nurse who does not have access to all his notes and records? I was surprised that hospice nurses would take precedence over the GP and the district nurses. They did and they were brilliant but, golly, were they short-staffed.
Lord Griffiths of Burry Port (Lab)
My Lords, this has been an extraordinary and wide-ranging debate. I will limit myself, in a very short speech, to Amendment 3, which would take out the indefinite article and replace it with “an independent”. We have heard two poles of the considerations that are facing us. One is the need for autonomy for the person concerned—the person whose life is in danger and whose future we are considering—to make a choice with dignity and independence. Then there are the wide-ranging ways in which we have discussed coercion and pressure, which suggest that autonomy is not an easy thing to concentrate on. If there is this range of possible ways of expressing coercion, applying pressure or whatever it is, autonomy must be considered quite a difficult thing to achieve. I honestly believe that.
As I said at Second Reading, since the Enlighten-ment we have concentrated so heavily on the individual, but we need to rescue from that discussion of the individual the fact that we are individuals in community. From my experience as a Methodist minister—we are surrounded by people with all kinds of disciplines and experience—all I can say is that being with people, those who are clustered around the person who is to die, continuously from the time the news of an impending death is broken until the funeral, and indeed beyond the funeral, has made me aware of all kinds of pressures, subtle and otherwise.
I was taken by the list of possible pressures given by the noble Baroness, Lady Finlay, and the indirect or unthought-of ones: the groan, the body language and so on. What is more, the noble Baroness, Lady Thornton, asked whether witnesses were brought who were themselves facing an imminent death. I have sat with people facing an imminent death again and again, and I have heard them spell out both their hopes and their fears about their legacy, about someone who is whispering in their ear and about how it will play out among their children, who have quite different views between them. It is all indirect; it is real and contextual. Autonomy is a difficult thing to conceive of, and all these other indirect things need to be thought of very carefully indeed.
How many times have I counselled families for whom there was a rogue element who has fled the family home—for doing something or other years ago that was considered to be very nasty—on whether they should be brought into the picture about this imminent death, or invited to the funeral or beyond the funeral? They say, “Did we do the right thing?”, “How can we live with our conscience?” or “You shouldn’t have pushed me to say what I said”—all those things are said all the time.
Finally—I promised a short speech—just 16 years ago, I was diagnosed with a serious bowel cancer. After having very low blood levels and a total lack of energy, I was immediately rushed into hospital for a serious piece of surgery. It was a large tumour, and I had to face all kinds of things myself. As it happens, the letter that spelled out the seriousness and urgency of the case arrived when my wife, bless her, was with her mother, who was dying up in the Midlands, so I received it on my own. I cannot tell noble Lords what range of things my mind ranged over as I coped with that news: “How shall I tell?”, “Who will want to know?”, “Can I keep it secret?”, “What will the options be for me if I have this serious surgery?”, “Will I have to wear a colostomy bag?”, “Will I have to have invasive and extensive chemotherapy?”, and so on. It was surgery in the end and, mercifully, when we had the tests done and I went back later, they traced not an element of cancer in the rest of my body—and here I am to bore your Lordships with a five-minute speech all these years later. This is simply to say that the indirect subtlety—the stuff beyond the stuff you can be categorical about or put on a statutory basis—is what really comes into play when you are talking about the end of a life.
John Donne, long before the Enlightenment, reminded us that no man is an island—
“send not to know
For whom the bell tolls,
It tolls for thee”.
We are all caught up in this together. Somebody in the Times picked up a remark I had made casually to describe me. It was that I am now a semicolon on his way to his full stop.
The Lord Bishop of London
My Lords, I will speak particularly in support of Amendments 181, 45 to 49, 58 and 222. It is a privilege to follow the noble Baroness, Lady Hollins, and the noble Lord, Lord Griffiths, whom I thank for sharing their personal stories. They are a reminder to us that this debate touches some of the deepest things within us, and not only should we be kind to each other but we ought also to be kind to ourselves.
I declare my interests as set out in the register, and particularly that I am vice-president of Exeter Hospice Care, chair of the UK Commission on Bereavement, and patron of AtaLoss. Your Lordships will know that, however many amendments there are to this Bill, I do not feel it will ever be safe. But I want to speak on this group because I believe that these amendments are at the heart of the issue of motivation. I remain concerned about the fact that there is currently no real, deep investigation of the motivation for assisted dying.
Amendment 181 is critical for us in monitoring. Even if there were no further restriction on what the motivation is for assisted dying, just knowing and recording it is extremely important because it can give us understanding of why people choose assisted dying, especially if we are serious about properly funding the care and support for people who are dying.
If we are recording the reason why people choose assisted dying, this means that we can highlight reasons why people choose it that do not fall within the aim of this Bill. For example, there is currently no mechanism in the Bill to stop someone receiving an assisted death if they are in pain because they cannot access palliative care. I hope that all of us would believe that, if somebody in that stage of their life wants to live, they should have access to the palliative and social care support that they need.
Professor Katherine Sleeman, the Association for Palliative Medicine and the Royal College of Psychiatrists highlighted the importance of identifying and addressing unmet need. We have already heard about the pressure on our palliative care service. We know that only 30% of hospices are funded by the Government. We have begun to hear about the beds that are closing and the redundancy programmes that are in place. We also know that if hospices are only 30% funded through government funding, 70% comes through voluntary giving. That is unequal across the country, and therefore palliative care services in hospices in areas that are more deprived are likely not to be as good as those in areas where there is higher socioeconomic activity. It is important for us to begin to identify whether there are reasons for people accessing assisted dying that are not within the aim of this Bill. Therefore, asking this question of a person in the preliminary discussion is the bare minimum of what is needed here.
Amendments 45, 46, 47, 48, 49 and 58 all strike at what many other noble Lords have spoken about today: that pressure, coercion, influence, encouragement, whatever word is most legally appropriate, is subtle and complex. When asked about the meaning of pressure during the Select Committee, the Royal College of Psychiatrists cited
“expectation or the worry of letting someone down”.
In a sense, for me, that gets to the heart of why it is so important that we define these feelings and decide what we think about them. We have also heard not only how hard it is to define the term we want to use but how hard it is to spot it. We heard examples of how we are not spotting coercion already today.
We have also heard how hard it is to train. Certainly, one of my concerns in the discussion of the Bill so far has been that often our focus is on medical staff, but actually people spend much more time with support assistants, with nurses, with occupational therapists and a whole range of people, not just medical staff. Often, if somebody wants to talk about dying, it is not with the doctor but with the person who has spent more time with them, and that is a whole array of people. Therefore, training is much broader than I think we often see it.
It is also true that I suspect most of us at times feel obliged to, or a responsibility for, our family. There will be some point in our life, whether through illness or otherwise, when we have felt a burden to others. The reality is that our decisions do not live within a vacuum; they are shaped by the many currents of our life, which are different at different stages. I believe that the Bill’s supporters have decided that the policy intent is that, even if somebody chooses assisted death to save their family the cost of care, that is okay as long as it is their decision and free from coercion. Amendments 47, 48, 49 and 58 demonstrate why this is not okay. They get to the heart of how subtle coercion is. It is not just personal. As we have already heard, it can be society-wide. Discrimination in healthcare provision and failure to resource palliative care or adult social care adequately are examples of this. Indeed, describing indignity as the loss of physical function, or of incontinence, or the reliance on care, is another societal example of this. We need to remind ourselves that each person is of immeasurable value which cannot be diminished by illness, disability or care costs.
I turn finally to Amendment 222, in the name of the noble Baroness, Lady Hollins. Though we have been rightly focusing on the person at the centre of making a choice about their death, as we have heard, death affects so many more people than the person who has died. The National Bereavement Alliance has said that the needs of family members, including children, both before and after death, must be considered and met. We know that people who are bereaved unexpectedly are more likely to experience complex and prolonged grief, which is associated with worse physical and mental health, including suicidal ideation. The bereavement sector forum convened by AtaLoss highlighted the risk that the kind of grief associated with assisted death is very similar. It warned that the impact of failing to address it with the right support will bring costs not just on acute services and social care but on individual people.
That complex grief is also well documented in Canada. The Bill has encouraged helpful conversation about death and dying, but we must make sure that the Bill is clear on guidance and support for many families and friends who are involved with somebody who has requested assisted dying. The work of the UK Bereavement Commission highlighted that people still do not have access today to the bereavement support that they need, and there remains a lack of understanding of the cultural and faith considerations that many communities require for death. I hope that Amendment 222 will be an opportunity for us to be proactive about making sure that family, friends and loved ones can access the bereavement support they require.
Baroness Hayter of Kentish Town (Lab)
I think it might be appropriate to hear from somebody who is not against the Bill. We have heard endless interventions.
Lord Polak (Con)
My Lords, I want to respond to the noble Lord, Lord Griffiths, who is a member of the Labour Party. With respect, I would like the Committee to listen.
Lord in Waiting/Government Whip (Lord Lemos) (Lab)
Does my noble friend Lady Hayter want to make one point? Then we can hear from the noble Lord, Lord Polak.
Baroness Hayter of Kentish Town (Lab)
My one point is that it would very nice if somebody who supports the Bill could also have a hearing.
Lord Polak (Con)
It is a shame, because I have a particular and important point to raise in response to the noble Lord, Lord Griffiths.
Lord Polak (Con)
I will. I was given six months to live 37 years ago. I do not often share this personal issue. I stand here today as living proof that prognosis is not certainty. Estimates are sometimes wrong and sometimes wildly wrong. That experience shapes my approach to this legislation and underlines why safeguards matter so profoundly.
When I spoke at Second Reading, I made it clear that I was against the premise of the Bill, and that remains my conviction. However, if the House decides that the Bill should proceed, it must do so with the strongest possible protections, and I support many of the amendments that were mentioned, particularly Amendment 46 in the name of the noble Baroness, Lady Finlay.
In listening to the debate, I was particularly moved by the noble Lords, Lord Evans, Lord Carlile and Lord Deben, and by the noble Baroness, Lady Fox, on the issue of coercion and encouraging. I actually pay tribute to the noble and learned Lord, Lord Falconer, on this whole issue, which is so difficult. I understand. I think that he is plastering over gaping wounds in the Bill. In fact, I think he must have more plasters than my local pharmacy. I will return to this properly when I speak to my own amendments, but I want to say that this vital piece of legislation is not fit for purpose, no matter how many amendments or how many plasters. I think we need to look.
I shall end with just these words: when we debate matters of life and death, we do so with the utmost seriousness. I believe that those who brought forward the Bill are acting from the highest motives, and I respect that, but in moments such as these, I know the whole House feels the absence of the wise counsel of the late Lord Sacks. He reminded us that purity of motive does not guarantee rightness of outcome. Our responsibility here is clear: to ensure that the law we craft is robust, precise and overridingly safe.
Baroness Hayter of Kentish Town (Lab)
My Lords, this has been something of an unbalanced debate, so I hope it might be possible to hear from someone who supports the Bill. I was particularly anxious to come before the noble Lord, Lord Polak—for whom I have a lot of respect; we agree on many other issues—to respond very soon after the right reverend Prelate the Bishop of London. She was very honest when she said that she did not support the Bill, and I think she said that it was unamendable. Here we are, however, discussing amendments.
The noble Lord, Lord Carlile, spoke earlier about whether we should discuss a form of wording on which we could all agree. The question then would be: if we can agree a form of wording, would he then support the Bill? My feeling is that these amendments are not about making the Bill acceptable so that those putting them forward could then support it but are a way of trying to stop our discussion and proper scrutiny, because they do not want the Bill to go ahead.
Baroness Hayter of Kentish Town (Lab)
If I could just finish. It has been a long time in this debate without hearing from my side—I want to come on to something that the noble Lord, Lord Deben, said anyway.
The amendments to this Bill are about coercion or pressure. As stated by the noble Lord, Lord Pannick, the situation at the moment is that people can go to Dignitas without even proving to a doctor that they are dying, and without any check as to whether there is coercion or pressure, or whether someone is going to inherit their house. They can go, and that is the way they end their life, and they feel it is not worth living any longer. On the definition of coercion, are we really content with continuing the status quo where there is absolutely no check—from a psychiatrist, a social worker, a lawyer, or anyone else—on whether they have been coerced? That is the alternative: allowing the status quo to continue with no checks whatever.
We have to ask, therefore, whether these discussions about definition are really about that, or whether they are about trying to stop the Bill. Perhaps we could discuss whether those who want the wording changed would then support the Bill. If they would, let us get down to discussing that, but if they are never going to, they are wasting the time of those who want it to go through.
Baroness Hayter of Kentish Town (Lab)
I do not have to give way. I have been speaking for three minutes, and I have listened for some hours. I am sure the noble Lord can come back; it is Committee stage, so he can speak again.
People have talked personally. Both my parents died when I was a child. People know that one of them died tragically and very suddenly; the other did so in enormous pain at the end. As a child, I went through that, so I understand about bereavement and grief, and seeing someone die in great pain. We have all been through that, and some of us come to a different conclusion. We come to a conclusion that no matter how we define pressure or coercion—the discussions we are having—what we want is the ability to move forward and help those who want help to bring things forward a few days earlier. I do not know whether the noble Lord, Lord Deben, has been through probate when trying to sell a house, but for someone who is already dying and may be a month off, bringing it forward a month or a couple of weeks would not make that much difference. We are finding excuses.
I am sorry not to have given way, but I have listened for some hours, and it is only appropriate that someone who supports the Bill also gets the chance to speak today.
Baroness Hollins (CB)
Before the noble Baroness sits down, can I just ask which amendments she was speaking to, because this is Committee and not Second Reading? Every amendment that I have tabled is designed to make the Bill better and I feel quite concerned to be accused of time-wasting.
Baroness Hayter of Kentish Town (Lab)
I was talking to the debate on coercion, because there is no check on it for the existing way of ending one’s life early, which is to go to Dignitas. I was asking whether, if the Bill is changed in the way that, for example, the noble Lady, Lady Hollins, would like, she would then support it.
Baroness Butler-Sloss (CB)
My Lords, before the noble Baroness sits down, there are two separate situations here, and I wonder whether she agrees. One is that there are many of us who do not like the Bill, but there is a real probability that the Bill will pass, and if it passes, we want it better than it is at the moment. Consequently, we are not wasting time.
Baroness Hayter of Kentish Town (Lab)
I was not suggesting wasting time. I was asking whether, if these changes were agreed, people would then allow the Bill to proceed.
Lord Carlile of Berriew (CB)
Before the noble Baroness sits down, I have great admiration for her, but I and many others resent her waving her hands at us. The reason we wish to have the sorts of discussions that I was mentioning was so that, believe it or not, we can make a judgment as to whether we are prepared to support the Bill, or to be silent on whether we support the Bill, or to oppose it at Third Reading. It is unworthy of the noble Baroness to allege that all of us here who are expressing concerns are wasting time. It is not true, and it is what she said.
Baroness Hayter of Kentish Town (Lab)
I never said that about wasting time. The words did not come; I did not say them. I was asking whether the people who want a better definition will then be able to support the Bill.
Baroness Hayter of Kentish Town (Lab)
I hope that the right reverend Prelate is not going to push for a vote at Third Reading. The task for this House is scrutiny of the Bill both at this stage and on Report, and I hope that that is what we will do.
Lord Sandhurst (Con)
My Lords, I will not be long. I speak to Amendment 726, which, as those of you who get that far in the list of amendments will see from the explanatory statement, is one of a number of amendments that I have been prompted to put down by the Law Society. They are intended to make the Bill safer in operation.
I would also like the House to know that I speak free from religious belief, but I do speak as a world-weary lawyer with many years’ practice at the sharp end in both medical negligence matters and legal professional negligence matters. I am all too conscious of my own experience of having seen things go wrong even where the people concerned were decent, honest professionals. Some of them, of course, although professionals, were neither decent nor honest. I have also sat as a legal assessor for five years at the General Medical Council, and I appeared as counsel for a north-eastern NHS trust in a very messy inquiry about 20 years ago about the misdoings of a Doctor Neale, who had featured in a “Panorama” programme—some of you may know about that. I have seen things go wrong on the ground for the past 30 or 40 years of my life.
It is with that in mind that I put down, among others, Amendment 726 with the support of the Law Society. I stress that the Law Society is neutral in principle but has looked at this Bill with what can be described as lawyers’ eyes. Its amendment is designed to make the Bill safer and better in practice. This amendment would “require” and not just permit—that is the difference—the Secretary of State to issue a code of practice in connection with what we are concerned with today; that is, capacity and so on, and the absence of coercion. A code is necessary. In Clause 39 of the Bill, there is provision for other codes of practice to be made; this is simply to add an additional code.
I suggest that this is a perfectly safe, non-destructive amendment that would improve the Bill in respect of a very important practice. As we have heard, coercion—I use the word loosely to cover a wide range of subtle pressures—must be addressed, and it should come from the Secretary of State. The panels that will oversee all this will not be enough. This must come from the Government, looking at things carefully and putting down a code of practice which says: “This is how the panels must address this”. We cannot have a postcode lottery with a panel in one part of England adopting one approach and another adopting a much tougher approach. We need uniformity.
Lord Hay of Ballyore (DUP)
My Lords, I support Amendment 48 in the name of the noble Baroness, Lady Ritchie, which seeks to protect individuals from being pressurised into assisted death. As the Bill stands, references to coercion and pressure in Clause 1 are strictly related to coercion and pressure coming from “any other person”. Amendment 48 would remove these three words and broaden out the whole understanding of coercion to include more than just that which comes directly from other people.
Various forms of pressure and influence can arise very easily from various sources: institutions, the media and, of course, even oneself. Every week there are new headlines about hospices struggling for funding and the increasing costs of caring for an ageing society. The Pathfinders Neuromuscular Alliance shared a heartbreaking story in its written evidence to the Commons Bill Committee of a patient who was told by their GP:
“Have you got any idea how much you cost the NHS?”
What kind of influence will these stories have on someone who has the option of assisted death? There is currently no safeguard to protect patients from pressure to choose an assisted death because they feel like a burden on the NHS or their family, or are experiencing loneliness, depression and many other related issues.
This is not just my concern. Caroline Abrahams of Age UK said to the Select Committee:
“We worry about the lack of choice about whether you are going to get good social care or good end-of-life and palliative care … We worry about a sense that, over time, it can exacerbate a feeling that an older person’s life is not worth as much as a younger person’s”.
She spoke about
“how we could ensure that older people in particular do not feel under pressure to make a decision that is for reasons other than their own real choice”.
I remind the House that Dignity in Dying put pro-assisted suicide campaigning material in our Tube stations last year. While advertising for assisted dying will not be legal under this Bill, the promotion of this service by its supporters and its presence in our society, alongside all the problems that our NHS and hospices are facing, seriously risks sending a message to people at the end of their lives that our society is better off without them. If a patient was motivated towards assisted death for this reason, Amendment 48 would ensure that they were not eligible as a result.
I ask those supporting the Bill how they intend to safeguard those who feel like a burden, cannot access the palliative care they need and feel that they have no choice but to pursue an assisted death. What would we say to Professor Smith, who said in her evidence to the Select Committee that the key question was:
“Is the person trying to escape the abuse and feelings that they have been made to feel a burden or are they trying to escape the suffering of their illness? If we cannot answer that question, then we should be very concerned”?
If we start permitting assisted suicide because people feel that institutions and the media do not want them, leading them down a dark path in their heads towards that decision, we will have completely failed the most vulnerable in our community. I urge noble Lords to support Amendment 48, because we are dealing with a life and death situation.
Lord Rooker (Lab)
My Lords, in the circumstances, I do not feel that we can justify more than two hours on this group. I think we should move to wind up this debate.
Baroness Lawlor (Con)
My Lords, I support the amendments in this group. I am a research director at Politeia, a think tank that has commissioned a great deal of work from lawyers and academics, including on this subject, but I speak in my own capacity as a historian. I associate myself with the remarks of the noble Lord, Lord Griffiths of Burry Port, and the right reverend Prelate, who reminded us that we are part of a whole society and not just one person against another.
I support these amendments because they aim to tighten this Private Member’s Bill and prevent it being unsafe by prohibiting inducement to assisted suicide by those who, for whatever reason—we have heard about the reasons—seek to induce, encourage, advise or influence another to take his or her own life. My Amendment 57A would prohibit someone from planting the idea in the person’s head and getting them to consider suicide as an acceptable or even necessary course of action, so inducing them to choose an assisted suicide, which he or she might not otherwise have considered as an option. Given that the planting of such an idea could be done in a number of ways, directly or indirectly, under the Bill as it stands, and given the gravity and irrevocability of the decision to end your own life, the safeguard is needed.
Let me illustrate this with a possible conversation between someone suffering from cancer, whose diagnosis indicates that he or she has no more than six months to live and is in a state of shock and misery and depressed at the idea that nothing can be done, and a relative, friend or person such as a doctor, social carer, social services provider or someone else in a professional position. The person talks about the diagnosis and their feelings to the other party, who might reply: “Have you considered an assisted death?”, “I know someone who didn’t want to go through with the whole thing until the bitter end, and the doctor was very supportive” or “Others find it very helpful to plan an assisted death; it’s straightforward and can all be prepared for. The family can be with you at the time and you just doze off”. None of these possibilities is ruled out by the Bill as it stands—
Lord Pannick (CB)
What is the difference between that conversation and the conversation that happens every day, in tragic personal circumstances, where the relative or friend says to the dying person, “Have you considered giving up your chemotherapy”?
Baroness Lawlor (Con)
I thank the noble Lord for the intervention but, if he will permit me, I would like to finish. We can imagine many different sorts of conversation. If noble Lords would like to hear more examples, I am sure they will ask for them.
None of these possibilities is ruled out by the Bill as it stands. They would not be considered an instance of coercion or pressure. Nor will it be possible when this Bill becomes law to investigate with due legal process whether someone has been instrumental in inducing a person to assisted suicide, provided they are covered by the terms of the Bill. Clause 34 outlaws dishonesty, coercion and pressure, and Clause 35 the destruction of documentation or the falsification of what purports to be a declaration, but the Bill does not address other means of inducing someone to opt for assisted dying. Under Clause 32, criminal liability for providing assistance will be removed from the Suicide Act 1961; as will civil liability under Clause 33, which stipulates that
“providing assistance to a person to end their own life in accordance with this Act”
or assisting a person to end their life while performing a function under the Act does not of itself give rise to any civil liability.
Moreover, the Coroners and Justice Act 2009—the duty to investigate certain deaths—will be amended so that the reference to unnatural deaths does not include a death caused by the self-administration by the deceased of an approved substance within the meaning of this Bill. Similar changes will be made in respect of arrangements for medical certificates under the new regulations and for Schedule 1 on suspension of investigations. These changes mean that there will be no effective way of investigating improper behaviour after an assisted death has taken place. The Bill already, in effect, recognises this problem by making absence of coercion and pressure a condition for eligibility for someone to be given assistance to die under its provisions. It opens the possibility to object to an assisted suicide going forward on the grounds that the person about to die has been coerced or pressured.
Furthermore, Clause 10(2) gives the first doctor—the co-ordinating doctor—the duty of ascertaining that the person concerned has not been coerced or pressured. We have heard from the noble Baroness, Lady Finlay, and others who have great professional experience in looking after people with terminal and other grave illnesses how difficult it is to establish coercion. It is often very difficult to establish coercion. It is true that the Bill wants to establish coercion—or so it alleges—but, as has been argued, the grounds are too narrowly defined.
A person in a poor mental state, because of their terminal diagnosis, is especially likely to be open to suggestions from other people, especially figures of authority such as their doctor, or their own family, whom they want to believe are thinking only of them. If we want to be sure that the decision to have assistance to die is genuinely their own, it is not enough just to rule out coercion or pressure. We need also to outlaw subtler, more insidious, but no less effective forms of persuasion. There is a danger that, if the Bill includes, as it does now, just a prohibition on coercion and pressure, the inference will be drawn that any form of encouragement or inducement, so long as it is not coercion or pressure, is allowed. Surely that is not what the proponents of the Bill would want.
The noble and learned Lord the sponsor and his co-sponsor are putting forward the Bill under the banner of giving dying people more choice over what happens to them, and providing greater freedom. Surely, in pure consistency with this underlying purpose, they must be intent on ensuring that the irrevocable choice a person makes to undergo assisted suicide is genuinely that person’s free choice, and therefore must support the amendment I am proposing, and indeed the amendments that others are proposing.
I hope that we can go even further. If my amendment is adopted, a further provision could be added to Clause 10(2), making it the duty of the co-ordinating doctor to ascertain not just that there was not coercion or pressure but that the idea of assisted suicide was not suggested to the person by another party.
Baroness Grey-Thompson (CB)
My Lords, I have three amendments in this group—Amendments 52, 58 and 181—which seek to explore coercion and ensure that people are free from undue influence, including social, economic and care-related pressures—not only active coercion, which is very difficult to prove. These amendments also seek to understand the reasons why someone would choose to end their life, so that we can look at how we might improve further NHS services or use that in important debates on reforming the welfare system.
It was raised on the first day in Committee that definition is important, and I believe that much further work needs to be done on the definition of “pressure” and how it becomes a strict liability. However, we find that it is very hard to gather data. We have been told that there is no evidence of coercion in other countries, but Ellen Wiebe et al, in a paper on the reasons why people request assisted dying, highlighted some of these very important issues.
In 2018, Dr Wiebe’s team looked at 250 deaths in Canada and noted that data was collected differently across different jurisdictions. Of the 250 deaths, six charts had no reasons; 56 gave one reason; some of the charts gave three or four reasons, but only two reasons were coded. This does not show the whole picture of why people are choosing to end their life on top of having a terminal condition. Looking to other jurisdictions, in Belgium, legal requirements were more frequently not met in unreported cases of assisted dying than in reported cases, and we still do not really know how it is practised. In Oregon, the data and the records are destroyed a year after someone has died.
Admitting coercion is highly unlikely to occur, so that is why we need a robust process of identifying it so that it can be acted upon. I look forward to debates in other groups on the role of the coroner in this. It is hard to find studies on coercion—I spent a lot of time trying—but it is possible to find a huge number of individual cases. In Canada, Lisa Feldstein was with a patient when the patient was pushed towards assisted dying. The person who suggested it did not realise that Ms Feldstein was a lawyer. Heather Hancock, a woman with cerebral palsy, was told by medical professionals while she was in hospital that she was not living but merely existing. I wonder how that made her feel.
Again in Canada, slideshows of MAID have been shown to healthy patients, which would make you think as your condition deteriorates that you do not have any other options apart from ending your life. In Australia, in November this year, three people were arrested after a man was found dead with euthanasia drugs in his system, and the police believed he was part of a suicide encouragement ring. Ruth Posner ended her life abroad with her husband; a friend spoke publicly about Ruth’s emotionally controlling husband and did not believe it was a free choice. But the difficulty is that, once you are dead, it is really hard to prove. As the noble Baroness, Lady Berridge, raised, the Bill does not take into account the impact of social media.
In New Zealand, doctors are told to do their best to detect how pressure may be placed on a patient, but this is completely unclear as to their duties and does not stand as a safeguard. This is listed in the review of the End of Life Choice Act 2019 in the report published on 19 June this year. In Washington state, physicians are rarely there when lethal drugs are ingested, which makes it nearly impossible to ensure that the patient’s decision is free from last-minute coercion, impairment or doubt. In Holland, it was found that GPs in an interview study felt pressured by emotional blackmail, family influence, time constraints or systematic pressures when processing assisted dying requests. As mentioned before, real-world data from Oregon shows that the top reported reasons for assisted death are loss of autonomy, loss of enjoyable activities, loss of dignity and being a perceived burden—not uncontrolled pain, which is missing from the Bill.
At the Select Committee evidence sessions, the honourable Stephen Kinnock, the Minister for Care, was asked about protecting vulnerable people, but the panel has no power to ensure that unmet needs are supported, such as increased care hours, adaptive technology and palliative input. We should ensure that the law does not default to death as a substitute for deficient services, which is an ethical red line repeatedly emphasised by disability advocates and UN experts reviewing permissive regimes. Best practice guidance from jurisdictions with assisted dying frameworks highlights the importance of exploring whether enhanced external support might address these factors, and it should be the case that the approval process checks them.
What is presented as a voluntary choice may in fact be a choice made under hidden pressure. The Australian Care Alliance research shows that the training for voluntariness and assessing absence of coercion was a two minute and 10 second video, with slides that take approximately two minutes and 50 seconds to read. Qualitative reporting in Canada shows disabled applicants citing inadequate housing or lack of care rather than unmanageable pain.
Baroness Coffey (Con)
My Lords, I still have tabled amendments to speak to, but I will let the noble Baroness, Lady Rafferty, go first.
Baroness Rafferty (Lab)
I thank the noble Baroness so much. I speak as a nurse and a former president of the Royal College of Nursing. I thank the right reverend Prelate the Bishop of London for referring to the broader family of health practitioners who are impacted by the Bill.
I also note the comments made by the noble Baroness, Lady Berridge, about training. I wonder whether the noble Baroness is aware of the current intercollegiate guidance on safeguarding, which covers many of the types of abuse touched upon in our current debate. Secondly, does she agree that many of the scenarios that have been presented and portrayed in this debate could provide very helpful material for the training that would be provided were the Bill to be passed?
Lord Goodman of Wycombe (Con)
My Lords, I will be extremely brief. Rather than speak to my own Amendment 229, I simply suggest to the Committee that the bulk of the evidence we heard in the Select Committee suggests that the amendments that have been put forward and debated in this group are extremely important and essential. I will quote very briefly from the Select Committee’s report before sitting down. The Royal College of Psychiatrists said that every applicant should be
“holistically assessed at the stage of preliminary discussion, including for mental health need”.
Dr Luke Geoghegan, of the British Association of Social Workers, took the view that
“all applicants should have a safeguarding assessment”.
The British Geriatrics Society recommended in its evidence to us
“a requirement for all people requesting an assisted death to undergo a holistic assessment of needs”.
The next group of witnesses that produced a similar view was Standing Together Against Domestic Abuse, which called for a multidisciplinary assessment framework.
I could go on, but I recommend to the noble and learned Lord, Lord Falconer, when he replies to the debate, to take these points on. A central question in this debate, posed by the noble Lord, Lord Pannick, has been: are the protections in the Bill better than the protections we have at the moment? I suggest to the Committee that that is not the question. The question is not, are the protections better than those we have at the moment, but are they as good as they could be? The answer in many cases is that they are not, and I hope that the noble and learned Lord takes these points on board when he replies to the debate.
Lord Ashcombe (Con)
My Lords, I just want to raise one point. We have heard an awful lot today, but I very much support what my noble friend Lady Berridge and the noble Baroness, Lady Rafferty, have just said about training. I do not believe a doctor, or any form of medical practitioner, can spot coercion with one discussion. Training in this area is absolutely imperative to have any way of making it work reasonably. That has to be part of the overall solution to this problem.
I will just add that, while I support every one of these amendments to a greater or lesser extent, I hope that the noble and learned Lord, Lord Falconer, will consider them all very closely and not ignore them.
Baroness Coffey (Con)
My Lords, I have tabled Amendments 47 and 49. It should be no surprise to noble Lords that this group is going to take some time, because it is probably one of the most important elements of our consideration of the Bill.
I also gently point out that it feels like coercion is being applied, but I am not going to be bullied by people into not raising my concerns at this point. I point out that it is the Department of Health and Social Care that proposed the groupings, and I believe it was passed by the sponsor. Therefore, we have had over 18 amendments from 14 people grouped together. If the concern is that we are taking too long with big groups, that will actually encourage people like me to degroup even further. That is not necessarily fruitful in addressing some of the concerns of the Bill, when we need some joined-up conversations.
The noble Lord, Lord Pannick, and the noble Baroness, Lady Hayter, have talked about existing safeguards. There is an obvious one at the moment: it is against the law to help somebody to go to Dignitas. The person who wrote the guidelines on whether to press charges is of course now the Prime Minister. There are amendments made in Committee that reinstate the element of the DPP undertaking that.
In answer to questions that I tabled to the Government, the Justice Minister fortunately replied, basically indicating how many people had had proceedings against them. On average it was one a year for the last decade, and only two people have been convicted. But I am still waiting to hear about the arrests and charges made, never mind the proceedings. I will give an example. Sean Davison, who was in the papers in the summer, was arrested for helping 29 people take their own lives by going to Switzerland—not to Dignitas but to another place. This is the same man—he is well known—who had already been convicted of helping his own mother take her life, which was against the law, in a different country and jurisdiction. This is why I was interested in tabling questions: to understand what is actually going on.
The figures of people going to Switzerland are quite small—it is about 40 people. One of the things that worries me—and, I think, worries a lot of people—is how this whole situation could start to become commonplace. The Liverpool care pathway became commonplace—what a horrible way to die. I specifically mentioned at Second Reading that my greatest concern of all is indirect coercion. I appreciate that some other noble Lords have already spoken to this, so I hope to bring a slightly different angle with some of my concerns.
If I have time, I will try to explain why I strongly support several of the other words being used, particularly “encouragement”, which appeared in the speech by the noble Baroness, Lady Fox of Buckley, and got support in certain parts of the Committee. That is interesting, bearing in mind that the campaign group Dignity in Dying, anticipating the passage of the Bill, has now initiated a new element by creating a conversation guide on how to start to bring up assisted dying in conversations with people. Never mind the coercion that very obviously exists in the medical profession in trying to coerce people into “do not resuscitate” orders. That is already happening in our medical system today, which is why several Peers, I think, are generally worried.
Turning to my amendments, I will start with Amendment 49. As the proposer and sponsor of the Bill put forward, it started off as a judge-led process, which is why I support what the noble Lord, Lord Carlile of Berriew, seeks to do in amendments in later groups. We have a situation here where this is turning into a sort of commissioner/panel. We need to make sure that the legislation is as simple as possible to the ordinary man and woman on the street. I appreciate that there are some legal niceties about what the word “person” means in law—I believe it can mean almost anybody—but we need to be more explicit, which is why I have suggested talking about
“body corporate, institution or organisation”.
I hope that might start to cover some of the online issues that my noble friend Lady Berridge raised; I do not know whether the Online Safety Act can cover this.
I respect what some noble Lords may think: “What is she going on about? These people are dying anyway. We have the general approach of trying to prevent suicide, so what would be different in hastening that?” This is where I turn to Amendment 47, which talks about both external and internal coercion. We have had a considerable debate about external coercion, with some suggestions about that in the amendments, as well as, to some extent, the question of burden. It is that burden that genuinely worries me.
The evidence is clear. We have already heard of the 35% figure from, I think, Western Australia. Whether it is from Oregon, Canada, Western Australia or Washington, the jurisdictions that collect data on this issue show that between 35% and 59% of people cite being a burden. We then heard evidence given to the Commons from Professor Owen, who said that thinking about being a burden is
“an essential question. I work clinically in the over-65 age group, where there is a lot of terminal illness, some of it in the last six months. You have to understand the population … There can be a terminal illness, very typically with comorbidity. That comorbidity is often mental health comorbidity”.—[Official Report, Commons, Terminally Ill Adults (End of Life) Bill Committee, 30/1/25; col. 234.]
As Dr Price sensibly said, for somebody who has found out that they have a terminal illness and less than 12 months or six months to live, it would be surprising if there was not an element of depression at that point.
This is where we get into talking about burden. That is where a group already feels burdened, and some of that may be excessive. That is when you start to get into some of these interpersonal pressures. It is also where the impairments will start to interact and amplify each other, and that in itself can have an important consequence in terms of the functional ability of mental capacity. According to Professor Owen, outside the AD context, the Court of Protection itself has been struggling to recognise that. This is where trying to get some understanding of this is really important. But it is not, to the point from the noble Baroness, Lady Rafferty, somewhere where you can just have a ready-built training manual.
Lord Dodds of Duncairn (DUP)
Some noble Lords are becoming exasperated or resentful about the time that we are taking to consider these important amendments today. I say gently that, had some of these issues been dealt with in a different way in the other place, we would not have to spend the time we are spending in this House dealing with them. When we consider the number of days in Committee that we spend on important Bills that come before us—sometimes 11 or 12 days in Committee and another three, four or five days on Report—it is not unreasonable that we spend at least a few hours to consider matters of life and death.
These amendments relating to coercion are at the heart of some of the concerns that many people have about the Bill. Coercion is central to the concerns. We have heard about financial and emotional abuse, about external influences, people feeling a burden and wanting to relieve themselves of that burden. These are critical issues—they are real issues. Those of us who have served as Members of Parliament, who have worked in the community and who have dealt with real people in real communities understand and know the reality of what we are talking about.
It can be easy to dismiss these issues sometimes. We sometimes see people speak on television who are very strong and confident, with lots of family support and resources around them. But I was struck today by the words of the noble Lord, Lord Deben: we must speak up for the vulnerable. I came across many vulnerable people in my work as an MP in one of the most deprived areas of Belfast, and they suffered in great loneliness and financially straitened circumstances. They felt pressure in today’s environment, where suicide is something that people undergo. In this situation, will the safeguards being introduced be stronger than what we have today?
A new regime is being set up whereby, for the first time, the state and all its resources will be made available to assist another person to end their life. That is a very different set of circumstances. All the pressures and influences that vulnerable people come under today will be massively increased and amplified when this new law comes into place—if it does.
It is very important that we take the time to consider these matters. I support the amendments in this group, to a greater or lesser extent, and very much agree with the sentiments argued by the noble Baroness, Lady Fox, about encouragement. That is something that needs to be in the Bill if we are to provide all the necessary safeguards. Whether you are for the Bill or against it in principle, surely we need the most robust and strongest possible safeguards against coercion, pressure, encouragement or otherwise.
Baroness Blackstone (Lab)
We have given an enormous amount of time to looking at safeguards. The noble Lord just totally denied that and said that we have to begin all over again. We do not. This debate has regrettably been characterised by too few of the speakers giving any consideration at all to the important, tough safeguards already decided in the House of Commons. I will not go through them now, in the interests of time, because I that know my noble and learned friend Lord Falconer will, when he responds to this debate.
Captain of the King’s Bodyguard of the Yeomen of the Guard and Deputy Chief Whip (Baroness Wheeler) (Lab)
My Lords, we will hear from the noble Lord, Lord Shinkwin, and then the noble Baroness, Lady Cass.
Lord Shinkwin (Con)
My Lords, an enormous amount of time was given in the other place to blocking safeguards. I support the vital amendments in this group and thank all those who tabled them. It is a pleasure to follow the noble Lord, Lord Dodds of Duncairn, who made some incredibly important points about vulnerability. Some of us have been there. This is proper scrutiny; it is the House of Lords at its best. On whichever side of the divide we find ourselves on this Bill, we should all be very proud of that.
As someone who speaks from one patient’s perspective, I would never presume to know exactly how the pain another person experiences might feel to them as an individual. But I think that the sense of incredible loneliness, compounded by a sense of disorientation, are both parts of total pain, as defined by the pioneer of specialist palliative care, whom the noble Baroness, Lady Finlay of Llandaff, mentioned—Dame Cicely Saunders. That makes these amendments dealing with coercion and pressure crucial.
When I have been drowning in a pool of pain, the sides of which, in that moment, seemed so steep and slippery, I would have clutched at almost anything in an attempt to pull myself out. I appreciate how coercion and pressure are so nuanced and subtle and how much each of us in this House, at some point in our lives, may need to be protected from them. My noble friend Lady Coffey is absolutely right, in speaking to her Amendment 47, to mention the Royal College of Psychiatrists and, in her explanatory notes, its reference to the sense of being a burden as an internal coercion. I can testify from personal experience that in some cases the sense of being a burden, or the burden of pain, whether physical and or emotional, can be simply too great to bear on your own. This can be the most powerful and damaging form of coercion and perhaps the one from which we most need protection. We need to recognise that in the Bill.
I note that the Bill does not require any questions to be asked about why a person may wish to die. It is because Rebecca Paul’s Amendment 468 on precisely this issue was rejected in Committee in the other place that Amendment 3, moved by the noble Baroness, Lady Finlay of Llandaff, and Amendment 181, in the names of the noble Baronesses, Lady Grey-Thompson and Lady O’Loan, are so important. As the noble Baroness, Lady Ritchie, and the other sponsors of Amendment 48 have argued, we cannot divorce this internal coercion from the circumstances in which, for example, a disabled or older person might find themselves. We have to factor those in. It is not just coercion or pressure by any other person that may prove the tipping point.
I hope that your Lordships’ House will give very careful consideration to the amendments on financial pressures, such as Amendment 462, which I thank the noble Lord, Lord Hunt of Kings Heath, for tabling so ably. As we know, these pressures are exacerbated when a person is living with a disability.
In closing, I particularly welcome Amendment 846, tabled by my noble friend Lady Berridge, and Amendment 58, tabled by the noble Baroness, Lady Grey-Thompson, because the subtlety of pressure, particularly as it relates to disability, can definitely stem from cultural attitudes, whether institutional—for example, in terms of access to appropriate care—or societal. I give one example. I was laughed at in the street outside my home as recently as last weekend because of how I look as a result of my disability. That is not good for morale, to put it mildly.
It could be argued that mockery goes with the territory of being disabled, particularly when the anonymised vitriol on social media encourages teenagers, for example, to view disabled people as fair game. My question in relation to the Bill, and specifically Amendment 58, is, how can being subject to such prejudice not affect a person’s mental well-being or their sense of self-worth? How could such a structural disadvantage, in terms of the cumulative effect of being constantly exposed to such negative and discriminatory attitudes, not affect a person in a vulnerable situation who is considering assisted dying? It is inevitable, but how many non-disabled people factor that in?
Lord Goddard of Stockport (LD)
I have moved my seat. I wish to speak briefly as a member of the Select Committee who has not spoken.
Lord Goddard of Stockport (LD)
I moved from my position at the front, because there was a presumption that I was the Front-Bench spokesman trying to force something. I apologise; I was not. This House has a free vote, and nobody is whipped. I happened to be sitting on the Front Bench, and I have moved back; I understand the alarm I may have caused by standing up then, but I was not trying to derail the debate. I was just trying to be helpful, because lots of people have spoken, and I respect every single person who is doing so in the House—for and against. Within my own party we have the same difficulties.
It is about evidence. I want to help the House today, on the specific premise of coercion. Sir Max Hill, the former Director of Public Prosecution, said that
“throughout the time that I served as DPP … we did not have the coercion offences created by the Bill, which I suggest would be a significant advance, and nor did we have a legal system in which the investigation was taking place before the death. … The major advantage of the Bill, if I can put it that way, is that … scrutiny will be before death”.—[Official Report, Commons, Terminally Ill Adults (End of Life) Bill Committee, 28/1/25; col. 86.]
That comes to one of the points the noble Baroness, Lady Grey-Thompson, made—that when you are dead, it is too late to find out what has gone on.
In the other place, mandatory specific training on domestic violence, including coercive control and financial abuse, was introduced into the Bill and agreed through an amendment tabled by Jess Asato MP. Participating doctors and members of the multidisciplinary panel will have to undergo specific training in this area, as well as in assessing mental capacity. I believe there are now safeguards in the Bill—I think that was what the noble Lord, Lord Pannick, was alluding to.
It seems to me that we in the House think this is the first time this has ever happened, but the fact is that 300 million people across five continents have some form of assisted dying legislation. Not one of those countries has ever repealed it. It is right that we make it the safest and the best, and that the amendments be debated at length.
Noble Lords should forgive the cynicism of those who support the Bill—one Member said last week, causing some humour in the House, that they were sorry they came second to another Member in getting amendments down. This is not a competition; this is about getting the Bill right and fit for purpose.
I find it quite amusing when I see the noble Lords, Lord Pannick and Lord Carlile— it is worth the admission fee just to see the interaction. The points from the noble Lord, Lord Carlile, were right about trying to come to a conclusion and move forward. It is right that everybody speak, but that we speak to the amendments and try to get to a conclusion.
The noble Lord, Lord Dodds, is right: we should give it time. But we do not have time. We have four Fridays and no more. The Government have said they are not going to give way. If we do not finish the debate on these amendments, which are increasing every day—I believe we are up to 1,500 now—the Bill falls. Somebody—not me but someone else—might say, “Well, it is somebody’s objective that we run out of time; then we can stand here wringing our hands and say that we were just trying to make it the best Bill we could but we ran out of time and are very sorry”. That is not acceptable. Our role here is to ensure that legislation goes back to the other place, fit for purpose and the best we can make it. Somehow, we have to distil these amendments into something understandable.
Baroness O’Loan (CB)
I do not want to interrupt the noble Lord for very long. I just wanted to ask him this: is he aware that this House has the right to reject this Bill should it choose to do so? It is a Private Member’s Bill, and there are no conventions that apply in that situation. It is important that the House fulfils its scrutiny role. Another Bill could be brought forward that might be very different, but this is the Bill we are asked to debate, and we will debate it as best we can to improve it as best we can.
Lord Goddard of Stockport (LD)
And if we run out of time at the end of that, the Bill falls. Someone will say, “it is not our fault”, but it is our fault.
Lord Hunt of Kings Heath (Lab)
I thank the noble Lord for giving way, because he is clearly trying to be constructive in taking us forward. Is not the real problem that a Private Member’s Bill is just not suitable for this issue, which is so complex and sensitive? We should have had a royal commission; I believe the Commons should then have had a vote in principle; the Government should then have brought in draft legislation; it should have gone to pre-legislative scrutiny; and then both Houses could have dealt with the issue properly. This is the problem—not your Lordships, not the scrutiny we want to do, but the very fact that you cannot possibly bring in assisted dying through a Private Member’s Bill.
Lord Goddard of Stockport (LD)
Unfortunately, you can, because that is how this country works. It is called democracy. When 650 elected Members, representing 70 million people by a majority, send it to this House, we have a duty and the honour to treat that Bill with respect, not disdain, not threatening to derail it or run it out of time—
Lord Deben (Con)
Could I just put this to the noble Lord? He is suggesting this approach, however bad a Bill is, however many people are damaged by it, and whatever the mistakes in it. The Government say that, at the moment, the Bill is not suitable as legislation. We cannot go on discussing it until we get it right. As noble Lords know, I am not in favour of this Bill, but I am even more not in favour of a Bill that gets it wrong and does terrible damage. He surely is not saying that we should just pass anything and that that is okay, when we think of the people who are going to be damaged if we get it wrong.
Lord Goddard of Stockport (LD)
The noble Lord is on completely the other side of the argument, and I respect his views on that. This Bill has been scrutinised for over 100 hours in the other place. Evidence was taken from over 500 people. This is not just a piece of paper sent up here for us to determine.
Baroness Cass (CB)
Regardless of the amount of scrutiny, there are absolute conflicts between intent and delivery. The reason there cannot be trust in how we deliver this in real life is the very point made by the noble Baroness, Lady O’Loan, and the noble Lord, Lord Shinkwin: on the one hand, we are discussing the importance of coercion and of recognising it, yet it has been voted that you cannot ask the person why they want to die. I do not know how you can then possibly assess coercion. Unless you can hear from the person in their own words why they want an assisted death, you cannot even advise on symptom control, let alone on whether they have been coerced. There is the conflict between the intent on page one and what is expected in the delivery. If the Bill has arrived here with that level of conflict between what is on the first page and how it is expected to be delivered, then we change that; otherwise, it is not fit to pass through this House.
Lord Goddard of Stockport (LD)
I respectfully accept that position. The problem is that the more I speak, the more I will be intervened on, which is the opposite of what I am trying to do; I am trying to speed the process up.
All I am trying to say is that we all want the best Bill possible. I get that. If that cannot be managed, something else will have to happen. I was only trying to bring in the evidence of three former Directors of Public Prosecutions. One of them, because people had said, “We’ve had no real-life experience”, actually advanced to us, “I’ve got Parkinson’s disease and I’m going to die. I have a terminal illness”. He actually said that to the committee, and added that if the Bill passed he hoped to avail himself of it. That is just one little anecdote from probably the only person who gave evidence who actually has a condition, which he confirmed to us freely. He was not asked to do that.
All I am trying to do is balance the evidence, because a lot of people are quoting evidence. I want to try to redress that a bit and to gently move this on a bit quicker. I have completely failed, because I have been standing up for nine minutes. I apologise to the Committee for taking up too much time.
Baroness Berger (Lab)
I am very grateful to the noble Lord for giving way. I will make a point that has been raised on a number of occasions, about what happened in the other place and the number of hours that were dedicated to the Bill there. It is important to put on record that this House received a Bill that is very different from the Bill as it was first presented to the House of Commons. Many hours were taken up in the other place on a Bill that was completely altered. I will point to one particular issue. The process massively changed from a judge-led process to a panel. In fact, of the 91.5 hours of debate in Committee in the other place, 62 were on a Bill that still had the High Court process in it. So we have to reflect in our deliberations that many hours were rightly taken scrutinising the Bill in the other place, but we have now received it in a very different form.
Lord Goddard of Stockport (LD)
I accept the noble Baroness’s position. Perhaps a High Court judge might resolve the issue, then.
Lord Gove (Con)
My Lords, I support Amendment 52, in the name of the noble Baroness, Lady Grey-Thompson. I do so as the Government Chief Whip who helped ensure that the Serious Crime Act 2015 was placed on the statute book, and as the Justice Secretary who was responsible for some of its provisions thereafter.
I am hugely grateful to the noble Baroness for raising the vital question of domestic abuse and violence in the context of coercion. I do not believe that this has been suitably explored, canvassed or analysed before. I would be grateful for the reflections of the Bill’s sponsor on how we might protect some of the most vulnerable in our society.
I will respond very briefly to the point made by the noble Lord, Lord Pannick, who pointed out that there may well be inadequate protections for those people who are coerced or persuaded into declining treatment that might prolong their life at the end of their life. There may well be inadequate protection and a case for stronger protection but, as has been pointed out before, there is a world of difference between declining treatment that might preserve your life and having a lethal injection that will end your life. It is a point that the medical profession fully understands and one that should be firmly borne in mind.
Lord Pannick (CB)
This is at the heart of the Bill. Is there really such a profound difference between an individual being able to say, “I’m going to stop chemotherapy” or “I’m going to stop eating because my life is intolerable”, and that person saying to the doctor, “I wish to have a potion that will have the same result”? There is a difference, but the main difference is that the person can die with dignity.
Lord Gove (Con)
I think there is a profound difference, but the noble Lord has made his point and I shall allow others to judge whether the narrowness of the distinction that he draws is appropriate.
On the whole question of domestic violence, the legislation that was introduced in 2015 specifically introduced the idea of coercive and controlling behaviour as an aspect of domestic violence: the idea that domestic violence need not require physical harm. It was an advance in the law that was brought forward by my friend Robert Buckland in that legislation. It was absolutely vital and it made us a world-leading jurisdiction in recognising the danger of this particular type of abuse and violence.
Baroness Wheatcroft (CB)
The point that the noble Lord has just made—that people are committing suicide because they are in abusive relationships—is absolutely dreadful. But would he accept that there is more likelihood of their death being prevented under this Bill?
Lord Gove (Con)
I profoundly disagree with the noble Baroness on that, but I am grateful to her for making that point, and I am more grateful still to the noble Baroness, Lady Grey-Thompson, for raising this issue. It is precisely the nature of coercive and controlling behaviour within domestic settings, as part of domestic violence and abuse, that needs to be addressed in this legislation. I have an open mind as to how it might be, but it must be.
Lord McCrea of Magherafelt and Cookstown (DUP)
My Lords, I support the amendments in this group. They are important because, unlike the noble Baroness, Lady Hayter, I do not know what the outcome of this debate will be at the end. She might have some other knowledge of how this House will vote, but I certainly do not know the answer. Therefore, it is vital that we spend the time and debate these amendments, because words are important. If anyone ought to know the value of individual words, it is noble and learned Lords in this House, because many of them spend their lives arguing on the edge of a pin about particular words. As a matter of fact, they make a considerable amount of money out of arguing about single words. Words are important, so let us not try to pretend that words do not matter. Therefore, on “coercion”, “influenced” and “encouraged”, I believe that we need to get this right, because the Bill could pass this House.
I know that there are those who do want to shut down debate. I sat in the House of Commons on Wednesday at Prime Minister’s Questions. I noticed earlier today that for a considerable amount of this debate the person who raised it at Prime Minister’s Questions was sitting here. He is the right honourable Member for North West Hampshire. He has left his position on the Steps of the Throne, but he was here for a considerable amount of the debate. He was indignant and incensed that this House wants to look at and scrutinise this Bill because it was passed by the Commons. I was in the other House for 25 years, and I know that in those 25 years, under successive Governments, the other House got Bills wrong and had to change those Bills. I do not believe it is correct to suggest that just because the other Members have passed the Bill, somehow we must bow and surrender to their superior knowledge, and therefore I believe that we ought to spend time—
Lord Watts (Lab)
From the number of amendments here it is clear that this is about wrecking the Bill. It is not about improvements, it is about wrecking the Bill. I went through this with my late wife, who suffered a very long and painful death and wanted to have the opportunity of ending her life. If they wreck the Bill, Members should think about the thousands of other people who will go through that same process.
Lord McCrea of Magherafelt and Cookstown (DUP)
I do not believe that people are tabling amendments simply to wreck the Bill. That may be the noble Lord’s opinion, but he should remember that other people have different opinions. I respect the noble Lord’s opinion, but I hope that he will in turn respect my right to have an opinion. I believe that we must scrutinise this well. I noticed that the noble Baroness, Lady Hayter, objected to the fact that practically no one who supports the Bill has spoken. I know of no one supporting the Bill who has been stopped from speaking. They did not get up to speak, and therefore they were not stopped. If there are those who want to support this Bill and to get up to speak, they are free to do so. I certainly would like to hear their opinions just as well. I believe that I have an opinion that ought to be heard equally, as they have.
I come from a family that knows what the reality of suicide means and the heartbreak of suicide, where we examine and wonder whether something more could have been done before that person ended their own life in suicide. I know the pain of that and the loneliness that they went through. Therefore, I believe we must get this right.
In the domestic abuse and coercive and controlling behaviour context, a victim may, due to intimidation or trauma, deny that their actions are caused by wrongful coercion. Is the doctor supposed to be weighing the patient’s words against the very limited evidence that they can see in an examination room? Professor Jane Monckton-Smith OBE, professor of public protection at the University of Gloucestershire, emphasised in her testimony to the Select Committee the significant difficulties in relying solely on a person’s verbal denial of abuse when assessing coercion:
“I have worked in this area for a very long time. I have seen victims refuse medical help when they have been hit in the head with a hammer through fear. That is not an isolated example. If you speak to the other people here, I think they will probably agree with me. What I am saying is that coercive control is a serious social problem. It will impact on the people who are going to look to this Bill”.
Also in the Lords Select Committee evidence, Cherryl Henry-Leach of Standing Together Against Domestic Abuse warned
“the difficulty is the lack of insight into the impact of coercive control on somebody’s ability to make decisions, even though that has been enshrined in case law”.
I do not want to detain the Committee, but in over 50 years as a minister I have experienced people coming to the end of their life. I have been with them in their moments of their deepest pain, and, as a noble Lord said, was there with the families after the occasion, trying to minister to them. I also know what it is from my 25 years as a constituency Member of Parliament in the other House, and we should not close our minds to the fact that people can be coerced. Sometimes it is done very subtly and gently within family dynamics, and that is difficult for assessing doctors to detect in limited formal settings.
Therefore, I believe it is vital that the words put into this legislation, if it is passed, are the correct ones that cover all these possibilities. Remember, when the person takes that lethal injection or whatever potion they take, there is no return as far as this life is concerned, but they go to another.
Lord Blencathra (Con)
My Lords, I had intended to give my strong support to Amendments 3, 45 to 49, 52 and 58—a mere eight amendments out of the 21 in this massive group—but in the interests of time I will dump my notes on all those and speak merely to Amendment 58 in the name of my friend, the noble Baroness, Lady Grey-Thompson, who has made a crucial point with regard to that amendment.
Coercion and pressure do not always manifest themselves as direct, intentional acts by individuals. Instead, they can arise from broader and societal structures and conditions that constrain genuine choice. When a person facing terminal illness is subject to circumstances such as chronic poverty, social isolation or a systemic lack of quality healthcare, their options are severely limited. In such scenarios, the choice to pursue end-of-life options may not be a true expression of free will but rather the result of enduring disadvantage and unmet needs.
At Second Reading, my noble friend Lord Moylan made the telling point that many people contemplating suicide do not want to die; they just want their life circumstances to change for the better. Therefore, “structural disadvantage” refers to the social, economic and institutional barriers that systematically disadvantage certain groups. When terminally ill individuals lack access to palliative care, social support or financial resources, they may feel compelled to consider end-of-life options not out of genuine preference but because their suffering is exacerbated by these systemic failures.
Poverty is a profound social vulnerability. A terminally ill person living in poverty may fear becoming a burden to family or may lack the means to access pain relief, counselling or hospice care. The psychological and practical impact of poverty can create a sense of hopelessness, making the option of hastening death appear more acceptable or even inevitable. When systems persistently fail to address the needs of the most vulnerable, this neglect can be seen as a form of institutional or collective intent. Thus, the responsibility for coercion or pressure extends beyond individual actors to the structures that shape people’s lives and choices.
Many years ago, my illustrious predecessor in my constituency, the great Willie Whitelaw, said to me, “David, I was never interested in pensions until I turned 65”. The wonderful thing about this House of ours is that the average age in here is 71, I understand, and our average death age is 81. That, as we have heard from many noble Peers, gives us a unique insight into the sorts of infirmities that we and our close relatives suffer and the close experience of those near to us who have died from them.
We have heard from many noble Lords, including my noble friend Lord Polak and the noble Lord, Lord Griffiths, their experience of beating the odds because the prognosis was not right. I quoted in my Second Reading speech that Sir William Osler, the father of modern medicine, said, in about the 1890s:
“Medicine is a science of uncertainty and an art of probability”.
Because my noble friend Lady Berridge mentioned NICE, I am tempted to cite an example. I have experience of NICE. I am grateful to it in some ways and hate it in others. One of the side-effects of MS is that one’s feet feel nailed to the ground: they are as heavy as lead and do not move. Fifteen years ago, NICE approved an experimental drug call Fampridine. I was one of about 500 patients put on it at the National Hospital.
Fampridine is an absolutely miraculous drug. What does it do? You saw it in effect this morning. It helped me stagger from my chair to here. With assistance from my noble friends, I can manage to walk—not very fast—to the Dispatch Box. Every six months, I have to do a walking test. If my walking is not fast enough with the drug, they cut it off and I do not get it any more.
Lord Empey (UUP)
My Lords, there is one aspect of coercion that we have not so far discussed. It was mentioned tangentially by the noble Baroness, Lady Hollins. It is institutional coercion. As somebody who has unfortunately had to bring a loved one into hospital to be treated and discharged on a large number of occasions in recent years, I have become familiar with the process called “clerking”, where an individual is brought into the hospital, the paperwork obviously has to be brought to bear, the healthcare staff have to fill it in and so on.
If this legislation gets on to the statute book, in whatever form, it has to be translated into paper that the health service will have to deliver when a patient is brought into a hospital. We already have the “Do not resuscitate” aspect of an induction, and we will now have to have another set of paperwork. I have seen how it works frequently: the pressure that the staff are under from time to time, and the fact that the people coming and going and dealing with a patient are frequently different and they change at 8 am in the morning and 8 pm in the evening. That paperwork has to be done by an individual, sometimes a relatively junior member of staff, and all these things have to be translated into a box that has to be ticked.
How is that to be done? The actual process that one has to go through, particularly dealing with somebody who is seriously ill, is challenging in itself, and when you have to ask the person, “Do you want me to tick the box that says, ‘Do not resuscitate’?”, that is a big thing to do, and the person needs to be coherent, informed et cetera. We are moving things to a stage well beyond that.
I had the experience of being in a hospice and, while it was not an issue with pain that was the problem, when the consultant comes along and says to your loved one, “Have you considered the D-word?”, that sobers you up. Somebody who was perfect intellectually, who had the ability and the capability, shut down completely and could not cope with, “Have you considered the D-word?”. So, I say to noble Lords, these are emotional things, coercion is a very hard thing to define, but I have to say to the noble Lord, Lord Pannick, that the difference between his scenario and what we are facing is that the state is co-operating, providing the mechanism and delivering the mechanism for a person to end their life. That is the antithesis of what the medical profession and the National Health Service have stood for since its inception.
With regard to how we treat things in this House, when Bills come to us, of course we have a view on whether we are for them or against them. I remember when the Brexit legislation came before this House and I gently remind the noble Baroness, Lady Hayter, that she was not running to try to improve it so that she could get into the Content Lobby. It is the way things are. On an issue such as this, we have to be driven by our conscience, not by our parties or anything else, but let us remember that this will have to be translated into the room where the patient is sitting. What box is a junior nurse or a junior auxiliary going to be asked to tick? What is the question? Who is going to fill it out?
As the noble Lord, Lord Hunt of Kings Heath, said, if we had had a royal commission and a proper government Bill, we could have answered these questions, instead of having to sit here and go through the whole process again. I just ask the noble and learned Lord, Lord Falconer, to bear these things in mind. These are gaps in the system which the staff are going to have to face. There will be shifts coming on and there will be some members of those shifts who will refuse to participate. What kind of chaos is that going to create? These things need to be thought through and they are not thought through.
Baroness Hayter of Kentish Town (Lab)
I just remind the noble Lord, Lord Empey, that of course I did vote for the Brexit legislation and in fact led the Labour Party into the Lobby to support the final agreement on Brexit.
Lord Harper (Con)
My Lords, I support the thrust of the amendments in this group, but first, I want to say a word or two on one of the issues that has come up in this morning’s debate. I hope the Committee will indulge me if I just quote a few lines from yesterday’s maiden speech by the right reverend Prelate the Bishop of Chester. The House was a little less well-attended for the debate on the Sustainable Aviation Fuel Bill in which he spoke, but I thought his words yesterday, the ones I am going to read, are very relevant to the debate and the tone of it, so I hope the Committee will forgive me. He said that
“communication is a vital gift for those of us who nurture and curate community. In communication, we need to learn to speak and to listen. This is almost always done in person and directly. Indeed, I argue that one of our primary vocations in this noble House is to be with and to listen, for few disciplines are more vital in the search for wisdom—the search I so often witness in your Lordships’ House. The question for me is not so much how we can be great again, but how we can be kindly present. Greatness is great, but grace is greater”.—[Official Report, 20/11/25; col. 965.]
I think those were wise words. They moved me and I think they are relevant to how we conduct ourselves in this debate on these vital issues.
The noble Lord, Lord Carlile, referred to how useful this debate was, and I believe that it is vital. That is why I quoted those words from the right reverend Prelate. We have raised a range of issues, all connected to people’s capacity to make an informed choice. The point of the debate is for us all—but especially the Bill’s sponsor, the noble and learned Lord, Lord Falconer of Thoroton—to listen to the concerns that have been expressed. I agree with the noble Lord, Lord Carlile, that the noble and learned Lord will then have the opportunity to talk to noble Lords and to bring forward on Report amendments that deal with these issues.
Part of the problem here, and the reason there are many amendments on the Marshalled List and the debate will be lengthy—the noble Lord, Lord Watts, referred to that—is that the House of Commons spent, I think, 17 hours in Committee, focusing on just the first three clauses of this legislation because they are very important. That involved just 23 Members of Parliament. Almost all the proposals that we are discussing were brought up in the House of Commons, but almost all were rejected or disposed of. If some had been accepted and dealt with in the House of Commons, all we may have been doing here is tidying up some of the wording or improving the amendments. However, we have to address them from scratch because they were not dealt with in the House of Commons.
It is our job in the House of Lords to scrutinise legislation and to deal with the things that have not been dealt with. We do that on behalf of people— a number of today’s amendments deal with vulnerable people who do not have the same opportunities that we have. The one thing that we all have in common in this House is that we are all privileged. I am referring not to our material circumstances but to the fact that we have a voice. Many people in this country do not have a voice. Many of the people who have been touched on in these amendments—people of poor material circumstances; people undergoing coercive control, as my noble friend Lord Gove suggested; and people who have severe disabilities—have no one to speak for them. It is our responsibility and duty to make sure that we test these issues and make sure the Bill is as good as it can be.
The noble Baroness, Lady Hayter of Kentish Town, asked whether the noble Lord, Lord Carlile, would support the Bill if some of these things were dealt with. That is not really the question. I have been very clear that I do not support the change, and I will set out why in a moment in relation to one of the amendments. However, I have to confront the possibility that the Bill may become law; I will not find that welcome, but the noble Baroness will. If it becomes law, it is absolutely my responsibility—and the responsibility of everyone in this House—to make sure that the Bill has in it all the protections for vulnerable people. If we were to fail to do that, we would have failed the people of this country, whom we are supposed to support—that is our duty. There will be some people in this House who will, if the Bill is improved, support it; there are some who will not, but that is not the point. The point is to get the Bill in as good a shape as possible.
Let me now turn to the amendments. I will deal first with Amendment 45 on encouragement, so powerfully spoken to by the noble Baroness, Lady Fox of Buckley. The reason that word is important was demonstrated in the short debate between the noble Lords, Lord Pannick and Lord Carlile, on the present position. I hesitate, as a humble accountant, to trespass in the debate between those learned noble Lords, but I will make two points. First, there is a fundamental difference between someone refusing treatment or not having treatment and someone taking deliberate steps to kill themselves. Those are fundamentally different things, and trying to elide them is not helpful to the debate.
The noble Lord, Lord Pannick, talked about the status quo. As I understand it, the current position if you assist somebody to take their own life and the DPP investigates is that the guidance contains the concept of encouragement. There is a specific point, when the DPP is considering whether to prosecute you, about whether you have encouraged somebody to take their own life or tried to talk them out of it. If you have encouraged them not to take their own life but you have, none the less, assisted them, the current position is that that is treated much more favourably than if you had not tried to discourage them. That subtle position in the status quo is something we should maintain, because something very important will happen if this legislation passes, which is why I do not support it: it will, effectively, change society’s view of suicide. In some circumstances it will, effectively, support suicide where currently we do not. In those circumstances, the use of “encouraged” is vital. That is why I support the amendment.
Lord Dobbs (Con)
I will just follow up my noble friend’s remarks. He is a noble friend; I campaigned for him several times in his constituency when he was an MP, and I will remain a friend of his, I hope. I want very quickly to follow up on his remarks about what we might call the “Pannick paradox” between the decision to ask for an assisted death and the decision to refuse any further medication or help that will continue your life for a short time. My noble friend is right. They are not the same: a decision to ask for a death when you know that death is inevitable, and one simply to deny any further help or sustenance, with starving yourself to death the only way of achieving that end, are very different. The difference is that if someone is able to ask for a calm, assisted death, they will die with dignity and not in squalor, having forced the system to cut off any hope of further life. My noble friend knows that I do not agree with him on this, but I absolutely believe he is right in saying that there is a fundamental distinction. That is one reason why I support the Bill.
Baroness Berridge (Con)
It might help noble Lords to know that we are being followed on Twitter. This issue—I am aiming to save time—of the Pannick dilemma has been commented on by Philip Murray, who is a law lecturer at Robinson College in Cambridge. He said the following, and we may wish to seek his advice:
“I find it astonishing that various Lords”—
forgive me for the embarrassment—
“including those who should know better (Lord Pannick …), keep conflating withdrawal of treatment and assisted suicide. The act/omission distinction has underpinned morality and law for millennia”.
I hope that either of the noble Lords, Lord Pannick or Lord Dobbs, will reach out to this gentleman to aid all noble Lords so we will not spend any further time on that dilemma.
Lord Pannick (CB)
My Lords, may I just say that other views are available in the legal community, including among many distinguished judges who I will not name. There are many law reports that question this distinction, not least for the reasons that have just been given.
Lord Mackinlay of Richborough (Con)
My Lords, the debate on this matter this morning has been enlightening from all sides, with many with many distinctive speeches that will stay with me, including that of the noble Lord, Lord Griffiths, who brought a very personal account, though he is no longer in his place.
We are talking about concepts and words—whether it is encouragement, coercion or pressure. They are in a similar collective of words, and I worry that we are dancing with words a lot in this debate. The noble Lord, Lord Griffiths, brought the word “autonomy” to us this morning, which is very important. I know it has been described earlier in Committee and on the Floor here today. I would be significantly more encouraged and relieved if I could be absolutely sure that autonomy and freedom of action, freedom of movement, freedom of thought and of decision were clear, unambiguous and untainted. I cannot be assured by the Bill, as it stands, as it is weak on the coercion nature.
As I left the Chamber earlier—my wife had arrived— I thought back to the cases of Ruth Ellis and Derek Bentley, which were very significant as they stopped the death penalty in this country. It was a long time ago when the morality and thoughts of this country were in a very different place to today. One might talk about the deterrent effects of the death penalty—which is a whole different debate—but we were willing to put that aside because of the potential of getting things wrong, and we did not want miscarriages of justice. That was so powerful. However, here we are discussing this Bill with lots of suggestions on how we could strengthen the coercion measures and make sure that people are not being pushed towards an early death that they did not want. We are almost flippant about that because the unsaid words are, “They’re old and ill anyway, so they don’t really matter”.
In support of Amendment 58 in the name of the noble Baroness, Lady Grey-Thompson, my noble friend Lord Deben—with whom I do not always agree on everything—made a very powerful point. If you were to look at the bell curve of the wealth and status of us in this Committee, we are probably to the left of the public politically, but certainly to the right in terms of wealth and influence as a whole. There is a world of difference between how, if we were to face this, we would be treated—the voice we would have for ourselves and the way in which our families would know they have agency and power to speak—compared with others in society. It could be that the wealthy family would be in a different place, because they could afford the help at home and the support in a care home as necessary.
However, for those in the middle who perhaps have children who work away, which is increasingly likely in this country, the children are feeling guilty. There are lots of cases that have been talked about the real situation of how people feel. In cases of that type there may be no problem of wealth, but problems of support by children and others. The “I don’t want to be a burden” debate would be coming to the fore.
One of our Northern Ireland colleagues mentioned the issue of saying, “Do you know how much this costs the NHS?”. I will be exploring that in greater detail. I think Amendment 3 touched on having an independent person; I have laid amendments for another day examining whether the NHS should be part of this process at all.
I say to the noble Baroness, Lady Hayter, that I could be encouraged but I am not sure how we can overcome the facets and dimensions of autonomy and coercion, because people and families are complex. One’s situation in life is complex. Just as we were willing to change a major piece of criminal legislation on the back of two errors, we seem to be not so interested in looking after the vulnerable in this Bill. I wish I could advance an amendment that would satisfy me—a lot of these amendments would make me a little more satisfied—but, no matter what we do, I am tempted to follow the noble Lord, Lord Carlile, in saying that we need to look at this whole area of coercion and pressure all over again. It is absolutely apparent across this Committee that this is the sticking point for many of us, so please try to satisfy us.
Earl Howe (Con)
My Lords, in their various ways, the amendments in this group seek to protect those who are terminally ill from being coerced or pressured into a decision to seek an assisted death. One of the most worrying concerns that have been raised by opponents of this Bill is the risk of especially vulnerable people being encouraged or coerced into ending their own life. The noble Lord, Lord Dodds, was right about that. For that reason, I do not think the Committee should feel embarrassed about having spent the time on this debate that we have.
As has been pointed out, the Bill already seeks to cover the coercion issue in its existing drafting. However, given that it creates a totally new role for medical practitioners in a situation where a terminally ill person wishes to end their life, in my opinion noble Lords are surely right that a laser focus should be applied to delivering protections designed to prevent any such coercion or pressure.
As a number of speakers have pointed out, coercion can come from anywhere—family members, friends, neighbours, other trusted people in our lives or an institution—and it does not have to be overt. It can and often does take the subtlest of forms. The noble Baroness, Lady Finlay, and my noble friend Lord Deben vividly described situations of that nature. Of course, the vast majority of family and friends of someone suffering from a progressive terminal illness will act in good faith to support their loved one through what is in many if not most cases an incredibly difficult time. However, when framing legislation around a decision as momentous as whether to opt for an assisted death and, as the noble Lord, Lord Carlile, pointed out, human nature being what it is, it is doubly incumbent on us to look for ways of safeguarding those who might be most susceptible to external pressure.
Amendment 3 in the name of the noble Baroness, Lady Finlay of Llandaff, would state more clearly in the Bill that the decision to end one’s life must be made independently. I hope the noble and learned Lord, Lord Falconer, will look favourably on this amendment, as it seems to me in tune with the Bill’s aims and purpose.
The question, though, as posed by the noble Lord, Lord Pannick, is whether it is necessary. As far as I can see, in no part of the Bill is there any indication that where a person finds it difficult to make a decision about an assisted death, or where the possibility of an assisted death has not even entered their head, it would be appropriate for their thoughts to be influenced or guided by another individual. Indeed, the Bill contains specific prohibitions on advertisement and promotion, as well as the offences set out in Clause 34 in respect of inducing a person to seek an assisted death by dishonesty, coercion or pressure.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I thank all noble Lords who have spoken today for their contributions on these important issues. As I have already made clear, I will keep my comments limited to the amendments on which the Government have major legal, technical and/or operational workability concerns.
On that basis, I will speak about Amendments 118 and 118B. Amendment 118, tabled by my noble friend Lord Hunt, could prevent a person from accessing assistance where there is no clear connection between their individual circumstances and the crime that their close relative is under investigation for or has been convicted of, even if the said crime took place some years in the past. Amendment 118B, tabled by the noble Lord, Lord Farmer, would expand the meaning of “close relatives” to include “friends”. It is not clear who would determine the meaning of “friends” in this context. I should also say that disclosure of personal data engages Article 8 of the ECHR and is regulated by the principles set down in the Data Protection Act. Detailed financial assessment of those connected to a person seeking assistance is likely to interfere with the privacy of those individuals, particularly where there are no signs of coercion. The necessity of doing so is difficult to assess in the round rather than considering this on a case-by-case basis.
I turn to Amendments 222 and 612, in the name of the noble Baroness, Lady Hollins. Amendment 222 proposes a new clause to oblige the Secretary of State to provide specialist psychological assessment and support for persons considering an assisted death and their families. It would also oblige the Secretary of State to establish bereavement support services offering psychological support before an assisted death to all persons concerned. The Bill does not require families to know about an assisted death in advance, so requiring the offer of psychological services to them could create an undeliverable obligation on the Secretary of State.
Amendment 612 would mandate the video recording of a person being assisted to end their own life. The amendment would also require the person to confirm in the video recording their identity, their wish to die of their own free will, their capacity and that they are acting without persuasion or coercion. The amendment would require that this recording is sent to the coroner within 72 hours of death and it would create a regulation-making power for the Secretary of State concerning the practical arrangements for the recording, storing and transmission of the recordings. Requiring that a person’s death be video recorded where they did not wish the event to be recorded could risk being a significant intrusion into their family and private life under Article 8 of the ECHR. Since the Bill includes several safeguards, this intrusion is unlikely to be considered justified, and this amendment could also raise GDPR issues and concerns.
Amendment 460, in the name of the noble Baroness, Lady Finlay, specifies a range of actions the panel must take into account when considering a person’s psychosocial and safeguarding circumstances. It includes a requirement to offer immediate access to safe housing and financial support where abuse is disclosed. As the Bill is drafted, neither the panel nor the commissioner is provided with such a function and it is not clear how this would interact with local authority responsibility for housing provision.
As for the other amendments in this group where I make no detailed comments, although they may be deliverable, some would be challenging to implement. For example, Amendment 47 would require assessing doctors and the panel to assess a person’s state of mind or private thoughts. Amendment 58 would require an assessment of indirect structural disadvantage, including poverty or lack of care. Although I raise specific workability issues with only a small number of amendments in this group, noble Lords will be aware that the other amendments in this group have not had technical drafting support from officials. The issues raised by these other amendments are rightly a matter for noble Lords to consider and decide on, but I note that the way in which they are currently drafted means that they may not be fully workable, effective or enforceable.
Lord Falconer of Thoroton (Lab)
My Lords, in this debate we heard deeply personal information from the noble Lords, Lord Empey, Lord McCrea, Lord Watts, Lord Polak, Lord Griffiths, Lord Carlile of Berriew and Lord Shinkwin, and the noble Baronesses, Lady Hollins, Lady Hayter and Lady Grey-Thompson. I express my profound respect for people being willing to share in that way. I make it clear that in nothing that I say do I in any way intend to disrespect any of what must have been quite difficult statements to make. I really treasure many of the things that have been said, whether for or against the Bill.
As all noble Lords engaged in the debate know, at the heart of the Bill—there is no dispute about this—the decision to have an assisted death has to be where the patient, to quote the Bill,
“has a clear, settled and informed wish to end their own life, and … has made the decision that they wish to end their own life voluntarily and has not been coerced or pressured by any other person into making it”.
There is no dispute in the Committee that there have to be appropriate and sufficient safeguards to ensure that there is no coercion.
The current safeguards in the Bill are as follows: first, a doctor has to be satisfied that the person is not being coerced. Secondly, a second doctor has to be satisfied that the person is not being coerced. Thirdly, a panel has to assess that the person is not being coerced. Fourthly, the first doctor—after a period of reflection, in signing a second declaration by the patient—has to be satisfied again that the person is not being coerced. Finally, the doctor providing the assistance has to be at the last moment satisfied that the person is not being coerced.
The two doctors who give the certificate at the beginning must both have had specialist training in domestic abuse, including training on identifying coercive control and domestic abuse, and including identifying the effect of financial control. The panel considering the matter must consist of a psychiatrist, a social worker and a senior lawyer. If either of the two doctors have any doubt about the position in relation to capacity, they have to consult a psychiatrist. Anybody who by dishonesty, coercion or pressure induces the patient to either execute a declaration that they want an assisted death or take the assistance is guilty of a criminal offence. If all that the person does by dishonesty, coercion or pressure is to induce the person to execute a relevant document, the maximum sentence is 14 years. If, on the other hand, if they induce the person to take their own life, then the maximum sentence is life.
The question before the House in this debate is whether those protections are adequate to ensure that there is not coercion. I have before me a number of amendments. Amendment 3 is proposed by the noble Baroness, Lady Finlay: she would like “independent” to come before “decision”. I wholeheartedly agree with her that the decision must be independent, in the sense that it is a free decision made by the person, unpressured or coerced in the way that I have described. I am always influenced by what the noble Earl, Lord Howe, says in relation to that; he said, “Reassure us”. There is no dispute between me and the noble Baroness, Lady Finlay, that it has to be an independent decision. Is it clear enough in the Bill? With the deepest respect to both the noble Baroness, Lady Finlay, and the noble Earl, Lord Howe, I point out that it specifically says that the person should have
“made the decision that they wish to end their own life voluntarily and … not been coerced or pressured by any other person into making it”.
With respect, I say that it is clear enough on the face of the Bill.
I turn to Amendment 45, that of the noble Baroness, Lady Fox, which would insert “encouraged” in addition to “coerced” and “pressured”. I have thought very carefully about this, and I am against putting it in. The reason is that I see the reality: somebody who is thinking about an assisted death will want to talk frequently to those who love them. They may want to talk to the multidisciplinary team which is looking after them. Let us suppose somebody says, “I really, really want to go now. Should I take that opportunity?” If somebody says, “I encourage you to make the decision that is best for you,”, what the noble Baroness is proposing is that that becomes a criminal offence, potentially imprisonable for 14 years or for life. To me, that does not seem sensible.
I turn to Amendment 46. The noble Baroness, Lady Finlay, asks for “influenced” or “encouraged” to be added. I have dealt with “encouraged”. With regard to “influenced”, the multidisciplinary team or the person’s loved ones may well—with the best motives—influence somebody to go ahead with it. I do not criticise them for that if that is what the person wants and if it helps. It seems to me, again, wholly inappropriate to go beyond “coerced or pressured”.
On Amendment 47, the noble Baroness, Lady Coffey, suggests that it should be “external or internally” pressured that one is concerned with. We can understand external pressure—that is, somebody pressurising someone else to do it, and pressure carries with it an inappropriate degree of influence—but how does one in practice deal with an analysis of what would make me, for example, want my life to end? My noble friend Lady Merron also referred to that. The pain, the lack of dignity, the sense that I am not the person that I was in front of my own children is internal pressure. It might include me thinking, “I do not want to go on with this; in part, I’ve only got two or three weeks to live, and I want it to end”. The internal pressure is making me come to that conclusion. It is impossible to ask people, in particular the law enforcement authorities, to investigate what is going on in my mind. I have thought very carefully about that. I reassure the noble Lord, Lord Ashcombe, that I have given each of these amendments very careful thought, because they are important, but, again, I do not think that is a practical solution.
Baroness Berridge (Con)
My Lords, my name is on the amendment that the noble and learned Lord has just mentioned. This was also from Second Reading. There are loads of people signing forms saying that coercion or pressure has not happened. What is the situation with the internet? What is the situation for young people? We are failing young people if we do not make clear how that practitioner is going to know. Young people are pressured through non-human means nowadays.
Lord Falconer of Thoroton (Lab)
The Bill makes it absolutely clear that it must be your own decision. Let us suppose that your views of the world are affected by the internet and that you are ill and an organisation is urging you to commit suicide, that organisation should be liable if that happens.
In Amendment 49, the noble Baroness, Lady Coffey, wants “person” to include a body corporate or an organisation in relation to pressure. If an organisation or a body corporate is putting pressure on a group of people or on individuals and that makes them do it—this is putting it crudely, but if an organisation says, “Do have an assisted death; it is the right thing for everybody or for you”—that should be covered by the Bill. The noble Baroness adverted to how “person” can generally include both corporate person and human person, but I can talk to her separately about that to make sure that it is covered.
Baroness Fox of Buckley (Non-Afl)
Some clarification is needed in relation to a number of points that you have made. How does anybody know, how does the doctor know, whether any of these scenarios have happened? Is there anything in the Bill that makes the doctor ask and explore? The word I proposed was “encouragement”—that you would ask not just “Were you coerced or pressurised?” but “Were you encouraged?”—because it would develop a richer conversation. Is there anywhere in the Bill where all the things that you have just said—apologies; I should not have said “you” but “the noble and learned Lord”—can be fleshed out, discussed and teased out?
Maybe I have got this wrong, but at the moment as I understand it, you fill your form in, somebody might even ask “Were you coerced?” and you say no, and that is that, out the window and then, Bob’s your uncle, you are eligible and off you go. It does not matter how often that process happens. The noble and learned Lord spoke about “first doctor, second doctor”, but if they do not all explore it, how will we know whether it was anything other than a yes/no? The noble and learned Lord has given a very rich explanation of what could have happened, but the Bill does not allow us to find out whether any of that will have occurred before the assisted death is enacted.
Lord Falconer of Thoroton (Lab)
I do not feel insulted by being called “you”, but I do not think that the noble Baroness, Lady Fox, properly understands how the Bill operates. The two doctors and the panel have to be satisfied that the person is reaching a voluntary decision of their own, uncoerced and unpressured. Codes of practice will determine how that is done and, what is more, the panel with the three experts on it also has to be satisfied. The noble Baroness, Lady Fox, is saying that that is a tick-box exercise. With respect, no: this is obviously a very serious matter. I expect the doctors and the panel doing it to take it seriously.
Lord Mawson (CB)
My Lords, as the noble and learned Lord knows, I have spent a lot of my life working with people in housing estates in the East End of London. Research we did some years ago discovered that virtually every nation on earth is represented in the housing estates where I worked. I have spent a lot of my time, nearly 40 years, working with Bengali families. We know each other quite well, but do I really know what is going on in the minds of that community or with that single mother, trapped in a house, who does not speak English after all these years? The truth is that I do not. It is really difficult to know. In the same way, I find it difficult, as a Yorkshireman, to help southerners understand what is really going on in Yorkshire. Even though I have tried it many times, the quality of their fish and chips really does not cut it.
One of my problems with this overcertainty is that it feels like a very white, English conversation, when actually this country is a global community, with people from many different cultures, all over the world. What concerns me is the practicality of much of the discussion that I have listened to today, and I have no idea how you actually understand coercion or encouragement—I think that is a really important word—in practice. Having spent many years of my life with these people, I would not pretend to know what I was really hearing, at such a point, and what it meant for their life in practice.
Lord Falconer of Thoroton (Lab)
I completely agree that the noble Lord and I might well not understand what people from different cultures would say, but the two doctors and a panel would have to understand that sufficiently to reach a conclusion. If they do not, they cannot provide the satisfaction that is required by the Bill. The idea that the people who will make the Bill work are all from a particular class, demography and education is, with respect, wrong.
Lord Mawson (CB)
Will we have enough people from these different cultures with the skills and knowledge to enter into that kind of understanding, whether they are doctors or on the panels? It is really difficult to understand how that practical proposition will work in the real world—in the East End of London.
Lord Falconer of Thoroton (Lab)
That will very much depend upon the number of people who apply from particular groups, and I think one can be pretty sure, on the basis of the impact assessment, that there will be sufficient numbers.
Lord Falconer of Thoroton (Lab)
I think it would probably be sensible, unless the noble Lord has something to raise that we have not already dealt with, for me to make a bit of progress.
Lord Harper (Con)
It is directly relevant to the amendment that we are discussing, if the noble and learned Lord will forgive me. I am coming back to what the noble Lord, Lord Carlile, said about the point of the debate. I absolutely get that the noble and learned Lord is very certain about the quality of the Bill. He has set that out in his usual eloquent way. However, if he followed my injunction from the words of the right reverend Prelate the Bishop of Chester yesterday and if he has listened to this debate, he must recognise that that certainty is not shared by many Members of this Committee.
I hope the noble and learned Lord will forgive me if he was coming to this on later amendments, but he has in effect said that he is not persuaded by most of the amendments. If he does not accept that many noble Lords have concerns about the Bill and thinks it is basically fine as it is, I fear that—picking up the point made by the noble Baroness, Lady Hayter—many noble Lords who might have been persuaded to support it had it been improved will not now be persuaded. Is he prepared to listen and amend the Bill in any way at all?
Lord Falconer of Thoroton (Lab)
My Lords, first, I am sure that I will not be able to reach the high standard of the right reverend Prelate the Bishop of Chester, but I will try.
Secondly, I do not think I am rejecting the principle of many of the amendments. I am saying that—for example, in relation to an independent decision and to encouragement—the protection is there in practice. I also say to the noble Baroness, Lady Coffey, that her reference to organisations is something we could discuss. I think it may already be covered but let us discuss it.
The noble Lord, Lord Harper, is right: I am saying no to quite a lot of the amendments because, in my opinion, I do not think they are necessary and there is adequate protection. It does not mean I am not listening; but painful as it is, because I respect so many people who disagree with me, I do disagree with some people.
I am very conscious as well of what the Chief Medical Officer, Sir Chris Whitty, said, which is not to over-engineer this and make it a thicket people cannot get through. If you are serious about assisted dying, make sure it is genuinely accessible to people. I am trying to strike that balance.
Baroness Scotland of Asthal (Lab)
My Lords, I wonder if I might help my noble and learned friend on the concerns that clearly have been expressed. A number of noble Lords have been talking about what evidence there is. The concern was expressed in the last debate last Friday that if you are not going to have someone who has been intimately involved with the family or the person who is making the request, that becomes more difficult.
A number of suggestions have been made. For example, would it be possible to have a multidisciplinary assessment of need and coercion early, so that you could have the information? My noble and learned friend will know that when we make these multidisciplinary assessments, usually you hear from everyone—the social worker, the housing officer—just as we do for the multiagency risk assessment for domestic violence; and those domestic violence cases are really important. Will my noble and learned friend look again at how the Bill could make sure that the evidence upon which these decisions are going to be made is there?
Secondly, I will deal with the amendment from the noble Baroness, Lady Fox, on encouragement. My noble and learned friend will know—I disclosed this to the House, because, of course, I was the Attorney-General when the DPP’s guidelines were put out— that the whole purpose of looking at and assessing encouragement was to make sure that no one else had applied pressure. The word “encouragement” very much comes from the DPP’s guidelines, which has meant that since they came in, only four prosecutions have been made. They were made in relation to people who were identified as having participated in something which might have been homicide or manslaughter, and others were not prosecuted. I know that my noble and learned friend would think that entirely proper.
Will my noble and learned friend think again about looking at those issues to make sure, perhaps through regulations, that we can have that clarity, which might give reassurance to those who are desperately concerned about these issues?
Lord Falconer of Thoroton (Lab)
In relation to the multidisciplinary team, Amendment 222 from the noble Baroness, Lady Hollins, is a bit close to that but not quite there. On the question of encouragement, of course, the reason why the DPP’s guidelines refer to encouragement is that the criminal offence at the moment is encouraging suicide, and that deals with a completely different concept.
May I go on into Amendment 50—
Lord Ashcombe (Con)
I would like to go back to our noble colleague from Yorkshire—I am afraid I do not know the noble Lord’s name and I apologise. He talked about working in the communities in the East End. We are short of GPs as it is, and most of our GPs come from an Anglo-Saxon background still. The noble Lord referred to the fact that, having worked with this community for a very long time, he still could not necessarily read the situation. I wonder how we deal with that, because the GPs in that community may not have had the length of time that he had to assess these situations.
Lord Falconer of Thoroton (Lab)
I think I answered that; the noble Lord may not have been satisfied with my answer, but I did answer it by saying that people have to be satisfied that the decision is voluntary and without coercion. If they do not know, because they cannot read adequately the community, they could not be satisfied.
Baroness Coffey (Con)
The noble and learned Lord has just made a point about the risk of coercion and referred to a psychiatrist. It would be very helpful to understand what clause in the Bill he is referring to, because Clause 12(6)(b) is only about the capacity of the person; it is not talking about coercion. I am also conscious that capacity is on the balance of probabilities anyway. It would be useful to understand which clause he believes referral would be in, on the grounds of coercion.
Lord Falconer of Thoroton (Lab)
I will come to that in a moment, because I have to get through the amendments—we have to make progress a bit. However, I completely understand the question.
Amendment 50 is from the noble Lord, Lord Evans. He basically said that when anybody tries to behave badly, trying to coerce or pressure somebody into making the decision to have an assisted death, that should be sufficient to bar it for ever, even if it had no impact whatever in relation to it. I see the force of that; I think it would be a wrong amendment, for the following reasons. Somebody—a doctor—might go over the line, but it is absolutely clear that the person definitely wants an assisted death. I do not think they should be barred from doing that because they are concerned about what might happen to the doctor or to the person they love if it is absolutely clear that they have not been coerced or pressured into it.
On Amendment 52 from the noble Baroness, Lady Grey-Thompson, she is saying that somebody should not be subject to or at risk of coercive control. Everybody agrees that the person who is adopting the assisted death should not be subject to coercive control. If they are at risk, I would expect the two doctors and the panel to investigate that fully and, if they are not satisfied that the person is reaching a decision of their own, plainly an assisted death cannot go ahead. But I think we are all on the same page in that the risk has to be properly investigated and a conclusion reached.
Amendment 57A in the name of the noble Baroness, Lady Lawlor, says you should not be allowed to have an assisted death if someone has been
“prompted to consider ending their own life”—
presumably in the context of assisted death—by any professional person. Clause 5 leaves it to the judgment of the doctor as to whether they raise the question with the patient. If they raise it, they have to raise it under Clause 5 in the context of the treatment available to the patient and all other options available, including palliative care. I do not think that if a doctor, or indeed any other professional person, makes a judgment that it would be sensible to raise it, that should thereby debar the person from having an assisted death. The noble Baroness wants to intervene. By all means let us prolong the debate if it is a new point.
Baroness Lawlor (Con)
It is about the level of authority which the professional person, who is in a way a public servant, and the trust which one endows in one’s GP or family doctor. As we have heard today from other people who are medically qualified, that has great weight with the patient—I speak as someone who comes from a medical family. They constantly agonise about their prescriptions for patients and their emotional condition, and all that. But if one raises assisted dying with somebody who is terminally ill, the professional—the doctor, say—is planting the idea.
Lord Falconer of Thoroton (Lab)
I completely appreciate what the noble Baroness is saying. She is, in effect, repeating what she said with such force and articulateness before. My answer to that is that there will be some professional people, and Clause 5 recognises this, who think the person is saying, “I just can’t bear this, I want this to end”. Would it be inappropriate in those circumstances for a professional person, in the context of all the other options, to raise it? In my view, it would not be, and in my view, it would be completely wrong to say that if you did raise it in those circumstances, that person, the patient, would be barred from ever having an assisted death.
On Amendment 58, the lead amender—not every other amender—said that coercion or pressure should include
“intentional or indirect structural disadvantage including poverty or lack of care”.
We are all agreed that coercion and pressure on an individual by another individual is not to be allowed. Where the reason that you want an assisted death is because in your mind you are influenced by your circumstances—for example, because you are poor—should you be barred from having an assisted death because of your poverty? In my view, you should not be. What the two doctors on the panel have to be satisfied about is that it is your own decision.
Baroness Grey-Thompson (CB)
This partly follows on from the comments of the noble Baroness, Lady Fox. The noble and learned Lord mentioned in his previous answer to one of my amendments that the doctors would be able to investigate. I think many of us still do not understand how that investigation would take place. In terms of understanding the standard of proof, Minister Sarah Sackman in another place said it would be on a civil standard. So, in terms of balance of probability, is the noble and learned Lord saying that the doctor has to be only 51% certain that there is no coercion for the panel to carry on and for an assisted death to be granted?
Lord Falconer of Thoroton (Lab)
They have to be satisfied that the person is not being coerced. That means that they have to do the appropriate inquiries. If, for example, as the noble Lord was saying, they do not understand the community, then they cannot be satisfied. If, for example, they do not know enough about it, they cannot be satisfied. Every case will depend upon its individual circumstances. They will have to do what is required in relation to it.
Amendment 118, in the name of the noble Lord, Lord Hunt, proposes that if you have a close relative who has been convicted of fraud or you are living with somebody who has been convicted of fraud, there has to be an independent financial assessment. That means that if your child, grown up by this time, has committed a fraud, there has to be an independent financial assessment of your circumstances before you can have an assisted death. I am strongly against the idea that if a relative of yours committed such an offence, that would mean there would have to be a yet further layer that you have to go through. There are still all those protections.
Lord Falconer of Thoroton (Lab)
This is a new practice that every answer one gives, the person then responds by repeating their speech. So, if it is new, yes—
Lord Hunt of Kings Heath (Lab)
The Companion states that in Committee we are entitled to speak more than once, and I think it is more helpful to do it this way. I am the 11th amendment in this group that the noble and learned Lord has so eloquently dismissed so far, but I think he has about another 10 to go.
I want to make two points. First, does the noble and learned Lord not reflect, on all the concerns that have been expressed, that the Bill might have had a smoother passage if he had shown any disposition whatever to take any of these issues away and reflect on them before coming back on Report? Secondly, I mentioned the Human Tissue Authority legislation that provides some protection and investigation to make sure that a donor is not getting a financial reward. Will he at least look at that to see whether there is any way in which we could reflect that in this legislation?
Lord Falconer of Thoroton (Lab)
On my noble friend’s first question, I have not dismissed all the amendments; I have accepted that we should look at some of them, and very many of the ones I am not accepting are because they are already covered in the Bill. I am rejecting some of them on the basis that I do not think they are practical. When my noble friend talked about the donor, I think he was talking about, for example, somebody who may benefit from the will of the patient. Indeed, that was a point raised by the noble Lord, Lord Farmer. Very often, the person who most supports you in relation to this is the person you love most and who is going to benefit under your will. So, very frequently the person who has taken a loved one to Switzerland is the person who is then going to inherit under their will. That does not make them bad, and I would most certainly not exclude people who benefit from the will of the person who dies because they have helped them in this respect. It seems to me to not properly recognise the importance of human relations in relation to this.
I have dealt with the point of the noble Lord, Lord Farmer, about the will. His second point was that, if you had a friend who was convicted of a criminal offence involving financial fraud of some sort, you should not be able to have an assisted death unless there is an investigation of your financial position. Well, if I reject the point from my noble friend Lord Hunt in relation to a close relative or the person you speak with, then I think, for the reasons I have given, it also does not apply in relation to a friend.
In Amendment 181, the noble Baroness, Lady Grey-Thompson, proposes that the doctor must ask why and seek specific confirmation that a decision is not coerced. There is no specific requirement for that in the Bill: it is for the two doctors to determine what they think the right course is. If they felt that they could not reach a decision without asking why, or without asking, “Are you being coerced?”, they would have to ask that. But there is no prohibition. It is, as the noble Lord, Lord Pannick, said, a decision for the two doctors and the panel to decide, in each case, what is the best way to reach a conclusion as to whether this person is being coerced. That is the question that all these things are addressing.
Baroness Grey-Thompson (CB)
So, the two doctors could ask an entirely different set of questions to each person who is requesting to end their life?
Lord Falconer of Thoroton (Lab)
It will depend on the circumstances. If, for example, the doctor had a very severe doubt about whether somebody was being coerced, I would expect them to ask very many questions about their domestic circumstances. Suppose, however, it was somebody who was clearly not, on the face of it, at the slightest risk of coercion—a person of 60 in the full flush of his or her pomp, as it were—and who had said, right from the outset, “I can’t bear the thought of this illness”, and the idea that this person has been coerced is not really plausible, then I would expect the doctor to be asking different questions from the sorts of questions that they would be asking if the circumstances of somebody’s home life were completely different. It would obviously depend on what you knew as the doctor, or had found out as the panel, about the circumstances of the individual.
Baroness Royall of Blaisdon (Lab)
I apologise for interrupting my noble and learned friend, but I just point out that the BMA itself is very clear that the doctors should be able to make their own judgment in all these cases.
Lord Falconer of Thoroton (Lab)
As I understand it, Amendment 222, in the name of the noble Baroness, Lady Hollins, would establish a specialist service to provide psychological assessment and support and then bereavement support for those seeking an assisted death. My noble friend Lady Merron has indicated the difficulties in relation to that. On the question of a psychological assessment, the position is that some work has been done abroad in relation to this. California introduced, in addition to what was required by the law in a particular part of California, a psychiatric assessment for everyone who wanted an assisted death but concluded that that was not necessary because the numbers of psychiatric assessments were producing nothing. It was only where special requirements were required that suggested it was a good thing. So I respect the suggestion but I do not think it is necessary.
Baroness O’Loan (CB)
I have a very quick question. I cannot find in the Bill the powers that would allow the doctors to carry out the investigation to which the noble and learned Lord has repeatedly referred. If people do not co-operate, that is it.
Lord Falconer of Thoroton (Lab)
With the greatest respect, the noble Baroness has missed the point. If, for example, a person says to the doctor, “I’m not telling you things”, the doctor can never be satisfied. That is the protection.
Baroness Coffey (Con)
Would the noble and learned Lord write to me with the answer to the question I asked earlier?
Lord Falconer of Thoroton (Lab)
Of course, and I apologise for not answering it.
Lord Watts (Lab)
Can we perhaps shoot just one fox? There was a suggestion that there are not enough non-Anglo-Saxon GPs available to do this. I have just looked at the facts: 46% of GPs were born outside the UK and 25% of them are from Asia.
Lord Falconer of Thoroton (Lab)
I am very grateful to my noble friend for mentioning that, because that is what was being whispered to me but I did not have the statistics. I am very grateful to him for providing them.
Baroness Finlay of Llandaff (CB)
My Lords, this has clearly been a long debate, and I think for good reason. As one noble Lord said, coercion and pressure are a major concern for many people about the way the Bill is written. I will very briefly respond. I am well aware of the time, but a lot of points have been made. Noble Lords will all be relieved to know that I am not going to go through them all.
First, the word “encouragement” is taken from the Director of Public Prosecutions guidelines, and for good reason, because the Director of Public Prosecutions recognised the power of a person in authority over a person who is vulnerable. That is why it tends towards the prosecution of assistance coming from a person in authority. I would include doctors in that, but it was also thought to include prison staff, nurses and others employed in that role.
Lord Pannick (CB)
I am sorry to interrupt. There have been a number of references to the DPP’s guidelines. For accuracy, will the noble Baroness accept that paragraph 45.5 of the guidelines says:
“A prosecution is less likely to be required if … the actions of the suspect may be characterised as reluctant encouragement … in the face of a determined wish on the part of the victim to commit suicide”?
Baroness Finlay of Llandaff (CB)
For the sake of accuracy, I completely accept that. Perhaps the noble Lord might also see, while I am speaking, whether I am correct that the guidelines would tend towards prosecution if a person in authority was encouraging. That was my understanding.
I will raise a few points. The noble Lord, Lord Hunt, absolutely hit the nail on the head when he pointed out that, if we had had a royal commission and went through the processes and so on fully, we might be in a different place now. One of the big problems we have encountered in looking at this Bill is what has been deemed to be in or out of scope. If you do not have the services available, you do not have true choice. That is a real problem, yet those of us who have tried to table amendments to bring specialist palliative care provision into scope to match and stay parallel with any developments in assisted dying services have repeatedly been told—I have checked, and it is in the Companion that we cannot extend scope—that this was deemed out of scope. Therefore, we feel a bit stuck about how we can make sure that people get the services they need.
The Minister pointed out something in the Bill that has been a concern to a lot of us: that the family do not have to be informed. Behind that is the concern about grief. Let us take a 19 year-old with an osteosarcoma with metastases. The parents have been looking after him from childhood through to all his treatment, doing all they can to enhance his quality of life. He says that he now wants to go for an assisted death, and he does not want his parents told. The first thing that the parents hear is a phone call to say that he is now dead, having had lethal drugs. They may be aware of a whole lot of issues that have been going on in that 19 year-old’s life, which they would have shared with those involved in his care. This is pretty close to some patients whom I have looked after, because someone developing into an adult when terminally ill is very difficult, as are the transition issues.
There is another aspect to that. Having spoken to and heard from people who have a relative who has gone for euthanasia—it is usually euthanasia rather than assisted suicide—they often feel devastated that their love was not enough to support the person. They feel that they have failed, and they ask why they could not have helped the person find ways forward or access the services they need. I will quote from the commission chaired by the noble and learned Lord, Lord Falconer, with Demos, on the lack of services. It states:
“The Commission does not accept that any of these forms of pressure could be a legitimate motivation for a terminally ill individual to seek an assisted death. Therefore, it is essential that any future system should contain safeguards designed to ensure, as much as possible, that any decision to seek an assisted suicide is a genuinely voluntary and autonomous choice, not influenced by another person’s wishes, or by constrained social circumstances, such as lack of access to adequate end of life care and support”.
The motivation behind many of the amendments discussed today has been precisely to deal with that problem.
I will address two more things, beginning with the concept of how sure someone has to be. The civil standard of proof of 51% seems remarkably low when determining the eligibility of someone having lethal drugs. The implication in the debate in the other place was that the doctor should not ask the person, “Why is it that you want to end your life?” Yet in clinical practice, whenever patients say, “I’ve had enough; I do not want to go on”, you answer that with one question, another question and then another question. It feels like an onion: you take layer after layer off, and you find out what is happening. You find many remediable aspects to their situation—they might often seem trivial to some people, but they have been wearing the patient down.
I am horrified, frankly, whenever I hear of inadequate care and of people not getting the pain relief that they need. Morphine does not kill you; it is a good drug for pain relief, given appropriately in the right dose at the right time for the right reason. That is what prescribing analgesia is about. That is completely different to giving a massive overdose of lethal drugs—and, as we know, not all the ones in the world have been fully assessed.
Lord Watts (Lab)
Would the noble Baroness agree for one second that, even if someone has good hospice care and the best medications that they can, there are still patients who suffer and have pain before death, despite all the actions of the people who are trying to alleviate that?
Baroness Finlay of Llandaff (CB)
I thank the noble Lord for the intervention. Perhaps it might be helpful for us to have a conversation outside this Chamber. But I would just say that pain is complex. It is not only physical; it has multiple components. Of the patients I have had the most difficulty looking after, we discovered that there were very many issues in the psychosocial and emotional domain: things that had happened in the past, some of which we did not know about at the time. But I do not want to go off message from these amendments, which are really important.
These amendments were put down in good faith to address the concerns expressed all around the Committee. I am disappointed that we have not got to the point of saying that we will all sit down together. I think that those of us who have drafted amendments will sit down together and discuss how we should bring something back on Report to manage the situation that we highlighted today, which is a very profound concern over coercion, abuse and all the other factors that go along with that. Apart from that, I beg leave to withdraw the amendment.
Captain of the Honourable Corps of Gentlemen-at-Arms and Chief Whip (Lord Kennedy of Southwark) (Lab Co-op)
My Lords, we spent nearly four hours and 45 minutes on that group of amendments. I think this would be a convenient point to adjourn.