Terminally Ill Adults (End of Life) Bill

Lord Markham Excerpts

Committee stage
Friday 13th March 2026 Lords Chamber

These amendments would create a clear, streamlined service with greater transparency and clear, defined oversight that is more easily monitored. They have been written to respond to requests from the Royal College of GPs, the Royal College of Physicians, the Royal College of Psychiatrists and the Association for Palliative Medicine that an assisted death service must be a separate service. They respond to the call for a recognition that multidisciplinary input into assessment and good governance are essential and that an assisted death is not a medical treatment. They are based on more than 20 years’ work by clinicians and academics who have not been opposed to assisted dying but recognise the dangers of a system that can easily expand to have all the complications and escalation that we have seen, for example, in Canada. These amendments are designed to provide coherence. I beg to move.

[Lord Markham (Con)]

As requested, I was waiting until the noble Baroness had moved her amendment—

[The Deputy Chairman of Committees (Viscount Stansgate) (Lab)]

The noble Baroness has moved her amendment.

[Lord Markham (Con)]

I was trying to respond to the noble Baroness’s request not to be intervened on during her speech, but I have some questions on what she was talking about. I am now concerned that she will not have the opportunity to answer them.

[Noble Lords]

She will.

[Lord Markham (Con)]

I thank noble Lords. I totally appreciate that the noble Baroness’s intention in all this is to try to make the process as robust as possible and she gave a very moving example of why she believes in it. But surely the people best placed to give evidence and understand the situation or the capacity of the person involved—their circumstances and whether there is any coercion—are the very people who she is suggesting should not be part of that panel, namely the health professionals and doctors involved. I am trying to understand why the noble Baroness would not want to involve those professionals who are closest to the case.

[Baroness Finlay of Llandaff (CB)]

Unfortunately, I am not sure that the noble Lord heard me right. The panels that we discussed previously did not include the treating clinicians—they were to look at the evidence brought to them. In the panel structure that I am proposing, the panel would have access to all the patient’s notes—with their permission—all their investigations, the full assessment of capacity and all other aspects that would be happening in routine practice during the patient’s care.

Concerns over the patient’s family and behaviours during the course of their illness would be documented in the clinical record, along with the criteria on which the diagnosis was made, and that clinical record would be available to the panel. That is why I have suggested that there needs to be an expert with knowledge of the specific disease afflicting the person who is seeking an assisted death. There are many rare conditions in medicine; common things occur commonly, but rare things are not that uncommon, and it is quite common for there to be a misdiagnosis that may lead to the patient making a decision based on the fallacy that they have an illness they may even have been treated for. We heard evidence in a previous Select Committee that, at post-mortem, around 5% of people are found to have died of something different from what had been recorded on the death certificate, suggesting that misdiagnosis is, sadly, not a very rare occurrence.

[Lord Markham (Con)]

I was specifically referring to:

“The person’s health or social care professional cannot participate in any part of the assessment for a person’s request of an assisted death”.


That is the point I am trying to understand. Yes, unfortunately there are cases of misdiagnosis—the 5% that noble Baroness mentioned—but 95% of the time these people are the best qualified to make an assessment, so I am trying to understand why we would not want them involved.

[Baroness Finlay of Llandaff (CB)]

They will not be involved in the judgment as to whether the person is eligible for lethal drugs; they are providing their clinical expertise and knowledge. It is the panel who, separately, independently and through a process that can be completely scrutinised and documented, would make that assessment. That would mean that the patient’s care could not be contaminated by pressures causing the doctor to be burnt out, financial pressures on the system in which that patient is being treated, or even administrative pressures, such as the patient’s discharge becoming difficult and the hospital needing beds because patients are being treated in corridors—which we know is happening all the time. It provides separation and a degree of clarity over the assessment and judgment.

--- Later in debate ---

[Lord Deben (Con)]

The proposal here is not isolating them in all the things that matter; it is doing something quite different. It is saying that those who are looking after them continue to look after them and give the information that is necessary for those who will make judgments to make those judgments. It is making a distinction between care—that is, the people we are talking about—and a decision about life and death. That decision should not be made by the people who are looking after them, but the people who are looking after them should provide information to those who are making an objective decision. That is why putting carefulness at the heart of what we do, and putting the rest to one side, is a proper way of dealing with it.

[Lord Markham (Con)]

The noble Lord was at pains to say that he felt that assisted dying was somehow not a compassionate part of care, but will he accept that, for some people, it is the true definition of compassion? Noble Lords have heard me say on many occasions that, when my mother was terminally ill and it was suggested that we might help her take an earlier train home, that was absolutely the compassionate thing, which she and others wanted. For all the supporters of assisted dying in this House and in this country, which is about 70% of people of every religion and including those with a disability—every group we talk about—it is because they believe that that is the most compassionate thing they can do: to give the person the autonomy of their own choice of how they want to end their suffering.

[Lord Deben (Con)]

One problem with using the word “compassionate” is that it is a mechanism for suggesting that one’s own answers to these issues are compassionate and other people’s are not. I happen to think that the most compassionate way of dealing with this is, first, to have a society in which we have palliative care of the highest standard for everybody. Then, if you have that, it may be that some would believe that it would be better for them to make a choice to kill themselves. This is what we are debating: not the principle but how you do this. I have given a clear statement of what my principled views are, but I am talking now about the facts of this issue. First, you have to show that you have proper palliative care. Secondly, you have to accept that there will be, in accordance with the Bill, the opportunity for people to decide. Who should make that decision? The problem is that, if you have proper palliative care, that will continue—or it ought to continue. All the information that those people have should be given to the people who are making that decision.

My noble friend is absolutely right: there are those who feel that this is a compassionate answer. I suggest that, if they feel that, the opportunity to make that choice should not be in the hands of people who are actually looking after them. I have tried to explain that, first, it makes many people more frightened of hospitals; secondly, it confuses their relationship with doctors; and, thirdly, it is very difficult to see that all those people who are looking after people will want to be involved in this. Fourthly, this begins to get closer to what the people who support the Bill demand should be carried through. We are trying to find an answer and, if the sponsors of the Bill do not like this particular answer, perhaps they can come forward with a proper programme for how to do this, instead of leaving it to the vagueness which our own Select Committee said was unacceptable.

Terminally Ill Adults (End of Life) Bill

Lord Markham Excerpts

Committee stage
Friday 27th February 2026 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I have two amendments in this group. Amendment 139 simply requires the commissioner to report to Parliament, and in Amendment 913 I have tried to ensure the independence and freedom from bias of the commissioner and staff. The voluntary assisted dying commissioner, as the public figurehead of an assisted death regime, must be free from any whiff of conflict of interest or perceived bias.

Conflicts of interest can be direct, such as the commissioner having shares in a provider of assisted deaths, when increased deaths are profitable. However, as NHS England’s standards of business conduct point out, perceived conflicts of interest can also present problems, and all interests must be declared. NHS England’s policy states:

“Officers should be mindful of any situation where relationships may give rise to a perception that a loyalty, credit, or responsibility is owed to another person or body”.


It goes on to say that

“previous employment with an employer which directly or indirectly provides services or products”

could be seen to be an influential factor.

The noble Lord, Lord Weir, has addressed the functions of the commissioner; I will not repeat what he said, but I will add a few points. Appointments to panels must not be biased to those sympathetic to assisted death, and they must also avoid those who have publicly expressed some scepticism. The commissioner is to review appeals, and bias can creep in here. Failure to follow statutory safeguards could be viewed leniently, and we have already heard examples of that from the noble Lord, Lord Frost. Highlighting failures in panels would reflect badly on the commissioner who had appointed them. In reviewing and reporting on the operation, the whole regime could skew reporting, because it is not clear which stakeholder groups will be consulted, or which data will be collected and what will be omitted—again, that could leave room for bias.

The amendment simply embodies the principle set out in the Cabinet Office’s Governance Code on Public Appointments that there should be

“no conflicts of interest that would call into question their ability to perform the role”.

Can the Minister confirm that these standards would be adhered to in any appointment? The governance code states that many conflicts of interest could be satisfactorily resolved and mitigated, giving the Prime Minister much discretion. Could a mitigation allow an assisted suicide organisation’s patron to serve as the commissioner? This is not purely hypothetical. In Belgium, the joint head of the Federal Commission for the Control and Evaluation of Euthanasia was one of the leading proponents of the 2002 law there. Since then, it has euthanised more than 100 patients and become something of a celebrity. That reputation has caused controversy. We have already heard about underreporting—

[Lord Markham (Con)]

Is there not a critical difference, when we talk about conflicts of interest, in that, in this case, this will be law—something that has been passed by Parliament? I do not believe that, in any public appointment, being supportive of a law of the land is deemed to be a conflict of interest.

[Baroness Finlay of Llandaff (CB)]

The point that I was trying to make, and I am sorry if I have not expressed it properly, is that there is a huge amount of discretion here and the commissioner will be the person who appoints the panels. In a way, by assessing the work of the panels, the commissioner will be marking his or her own homework. That does not provide the independence that one would require.

If I may go on, we heard too in our Select Committee hearing, which the noble Lord was present at, about problems that have occurred in New Zealand. These need to be taken as a warning: we must ensure that there is independent transparency and lack of bias in the commission, through statutory safeguards, to avoid the failures that occurred in other countries. In the case of Mortier v Belgium, the European court—

--- Later in debate ---

[Baroness Fox of Buckley (Non-Afl)]

I think that is self-evidently true in the real world, if I can put it that way.

I note that the present Prime Minister is himself personally not neutral. As we now well know, he promised Esther Rantzen that assisted dying would be made legal, although that was not a promise made to the British electorate or in the manifesto, but it was certainly made in public with much singing and dancing. Would the Prime Minister’s personal views influence whom he chose as a commissioner? Noble Lords might think that is far too cynical and I am being grubby—that is fair enough. However, I want to know if there is anything in the Bill that guards against such grubby behaviour, because if anyone thinks there is no grubby behaviour in politics, they need to get out more. If the commissioner is perceived—

[Lord Markham (Con)]

If I may intervene again, let me say that this is a post which will happen only if the law has been passed by Parliament. I am not aware—but perhaps the noble Baroness can help me—if there is any other public appointment process which says that someone cannot be in favour of the law that they will be in charge of implementing. Is the noble Baroness aware of any others for which that is the case, or is she saying that this should be the only example in which someone cannot be in favour of the law of the land and the job that they have been appointed to do?

[Baroness Fox of Buckley (Non-Afl)]

I should clarify that I do not anticipate that those who have reservations about assisted dying will be queuing up to be the commissioner. I am not at all arguing that the commissioner could not be an enthusiast, but what happens if they become an activist and an advocate for it, and mission creep follows? That is very different. It is fine if it is somebody who says they voted for it—somebody in this Committee might well be that person, and they might have disagreed with me. How do you stop someone if they say, “Great, I am the commissioner. I am now in charge of monitoring this”, and so on? We have heard good examples so I will not repeat them.

Sorry, I am not sure if the noble Lord, Lord Moylan, wants to intervene, but I am trying to finish.

--- Later in debate ---

[Baroness Finlay of Llandaff (CB)]

My Lords, I added my name in support of Amendment 827, although I also support the amendments that make it clear that the delivery of the service must not be provided by the NHS, an NHS trust or any body or any agency holding itself out to be part of the NHS, as in Amendment 835 from the noble Baroness, Lady Fraser of Craigmaddie.

The amendment to which I added my name would allow a collaborative funding model for the service to be developed, based on a means-tested formula, for those who are able to pay adequately and would otherwise have paid the fees charged by Dignitas in Switzerland, whose accounts are not open for examination. The collaborative funding model could be based in part on the principles behind co-operatives. The accounts of a collaborative scheme would need to be completely open to public scrutiny. Co-operative funding models leverage shared ownership, democratic control and member investment to finance enterprises, prioritising community benefit over profit maximisation. The shared ownership would relate to those who use the service, with levels set depending on the aspects that they access, because some might access information only and others might access the whole process.

There are five interconnected component parts to a co-operative model. First, the policy and regulatory framework defined by government would give proportionate oversight and regulation. Secondly, it would ensure adequate training across the whole system. Thirdly, the clearly defined market environment would be restricted to the provision of an assisted death service. Fourthly, the culture of the co-operative collaborative would be shaped by those wishing to avail themselves of an assisted death without jeopardising their ability to access clinical care and without jeopardising the clinical care of others through the diversion of NHS funds. This could involve crowdfunding and allow specific donations in memoriam and so on.

The fifth component relates to networks of knowledge exchange to inform the criteria used in the financial assessment, based on needs. The Bill is based on the principle of choice, and that principle could run to the funding as well. People may choose to have a slightly less extravagant funeral and pay into a collaborative system, allowing others who would not be able to afford a fancy funeral to still access the service even if they could not pay for the components of the service. After all, we have people who pay high rates of tax, such as council tax, to fund our public services, equally benefiting those who are in a much lower financial bracket.

Overall, these amendments are important because they would ensure that NHS funding is not eroded. We hear consistently about NHS deficits in all parts of the system. The palliative care and hospice sector is withering under extreme financial pressures since it has no secure rolling contracts for the services it delivers. Pressures on commissioners are already resulting in difficult decisions. There is no spare money to pay for an assisted death service.

The noble and learned Lord, Lord Falconer, has tabled amendments that would require ICBs to commission this service, but the Minister has admitted that the funding will come from reprioritisation of existing budgets. How will the ICB balance its legal obligation to meet the palliative care needs of its population with the provision of an assisted death service? The noble and learned Lord’s Amendment 749B would mandate the provision of assisted deaths by ICBs, meaning that they will be fully funded by the NHS—in contrast to hospices, which are heavily reliant on donations for a major portion of their funding.

I hate to suggest it, but sometimes this looks like a way to save money. Each assisted death has been estimated to cost around £2,000 yet would save about £13,000, four months of healthcare costs, giving a net saving of £11,000 overall. The money has to be found from somewhere. At the moment, there is a serious risk of clinical services being eroded to fund the multiple payments that will need to be made to the different professionals involved; that will become particularly important when we looked at funding it in a devolved model.

[Lord Markham (Con)]

I am a bit confused. I think I heard from the noble Baroness a concern that savings of £13,000 a week would be generated if assisted dying happened. I then heard her say afterwards that there would be costs on other people. Obviously, she cannot have it each way. A few times I have heard people asking, “Where’s the money coming from?”, and other people saying, “There’s an incentive because there’s a saving in it”. Can the noble Baroness clarify that, please?

[Baroness Finlay of Llandaff (CB)]

I thank the noble Lord for asking for the clarification. I did not say a week; I said four months. Actually, with the severe deficit that we—

[Lord Markham (Con)]

I believe the noble Baroness’s general point was that there is a danger because savings would be made from an assisted death. On the other hand, she asks where the costs are going to come from. I am just wondering which she believes: that there will be savings or that there will be additional costs.

[Baroness Finlay of Llandaff (CB)]

My concern is that if you take money out of a healthcare budget that is already in deficit, you will end up with an incentive for people to go down the road of saving money by working towards promoting assisted deaths for patients for whom additional care would mean them no longer feeling in despair in any way and having their quality of life returned to them. The NHS budget appears to be in such a difficult and parlous state that we have to be very careful that we do not spend NHS money on what is not a healthcare treatment.

--- Later in debate ---

The amendments from my noble friend Lord Moylan raised important questions. I want to hear from the Minister about funding palliative care in full—if the Government think that assisted suicide should be funded in full, palliative care should be funded in an equal way—and from the sponsor about the risk of setting up a structure where you incentivise the health service to push people towards assisted suicide rather than providing proper healthcare. The latter is a question properly directed at the sponsor rather than the Minister.

[Lord Markham (Con)]

I let my noble friend finish but I just want to give a bit of my own experience as a former Health Minister. I think we would all agree that clinicians always look at what is the best outcome for their patients, regardless of cost. I want to put very clearly here today that, although I am sure it is not anyone’s intention to suggest that clinicians will somehow be incentivised to push one course of treatment, be it assisted dying or another, for reasons of cost, all our experiences of the health service are that clinicians will always put the welfare of their patient first and that financial considerations do not come into it.

[Lord Hamilton of Epsom (Con)]

I wish I could agree with my noble friend Lord Markham, but at the end of the day we have a National Health Service and it has to make choices, and we know that the National Health Service is desperately short of money. If it can save money by making sure that people go for assisted dying, I am sure it will do that, on the basis that then it could keep other people alive. Those are the invidious choices that the National Health Service has to make. I always assumed—I will give way in a minute—that, for the proposers of the Bill, one of their reasons was that they wanted to save money. I agree that the money concerned would not be very big, but at the end of the day there is an incentive to save money by ensuring that people opt for assisted dying, thereby saving the National Health Service money. I give way to the noble Baroness.

Terminally Ill Adults (End of Life) Bill

Lord Markham Excerpts

Committee stage
Friday 9th January 2026 Lords Chamber

[Lord Markham (Con)]

My Lords, I have found this debate to be very helpful, because we all of course want the safest processes possible in all of this. It is clear that we are all reaching to try and find a way that we think will work. To a certain degree, it is all down to whether the best way to do this is through a multidisciplinary panel or a judge-led court process.

The example that the noble Lord, Lord Carlile, gave in terms of life support is quite illustrative, because life support decisions are made by medical professionals. In the vast majority of those cases, they then go through on the basis of that professional advice. It is only in the edge cases or serious cases where there is an appeal process that the family can take to court.

On this proposed process, there is a multidisciplinary panel, very well described by the noble Lord, Lord Pannick, which includes a psychiatrist, social worker and judge—the professionals in this particular area—who will be very well placed to reach a decision in a similar way to life support decisions for which, in the vast majority of cases, everyone is happy that it is the safest and right decision. There is also the oversight role of the commissioner, who is of course a judge in this process and, rather like the example of the life support case, has the ability to oversee and review that case where there are serious concerns. The life support example is a very good one here, given that we are trying to adopt a similar process in the multidisciplinary panel with the oversight of the commissioner.

On a way forward, it may be for the noble and learned Lord, Lord Falconer, and the noble Lord, Lord Carlile, to discuss how those cases can interact. Where the multidisciplinary panel might need oversight, the concern is how that can be triggered and how that can be worked out in terms of the commissioners. We have a framework there that, like the life support example, can get the best of both worlds. That could prove a constructive way forward.

[Baroness Hayter of Kentish Town (Lab)]

I will take the advice of the noble and learned Baroness, Lady Butler-Sloss, and now get rid of what I was going to say, because the noble Lord, Lord Markham, has said most of it. I now have only three points to add, so I thank the noble Lord for that.

First, the big discussion is on whether it should be a court or panel. The reasons for the panel have been put, so I do not need to repeat that. The only thing I would say is that when this was discussed in the Commons, it was not about the capacity of the courts that made them make the change to a panel but about the advice they got that this would be a much better, holistic and patient-focused way of doing it. In fact, making sure that that bit was added was very much welcomed by the British Association of Social Workers and the Association of Palliative Care Social Workers.

Secondly, the mention just now of legal aid says it all. Surely, we do not want this to be an adversarial process. It should not be argued in front of a court that way. I want to be very brief, because I am taking the advice of the noble and learned Baroness to be very brief, but we want this to be a conscientious decision and not one that is adversarial, which is why I think the panel would be so much better.

Lastly, this is not a life-or-death issue, because these people are dying. We are discussing only when they die, not whether. That is different from deciding that a baby will die who was not going to die anyway, or even someone in a permanent vegetative state. That is why I really do not agree that it is right to use the word “suicide”, rather than “assisted dying”. People are dying, and this is the issue of when they die and not whether.