Terminally Ill Adults (End of Life) Bill Debate
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Lord Falconer of Thoroton
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Lord Falconer of Thoroton (Lab)
My Lords, first, I pay tribute to the noble Baroness, Lady Maclean, who referred to her own personal circumstances. Every one of us who have heard individual personal circumstances realises this is difficult to do, so I pay tribute to that and appreciate what she has done.
Secondly, I ask the Committee’s indulgence for 30 seconds to mention Mr Nathaniel Dye, who has been a campaigner for assisted dying and has been enormously helpful to me. He travelled through the whole process of this going through the Commons and the Lords. Tragically and suddenly, he died at the end of last month and today is his funeral. I know that his family, and everybody who knows him, would appreciate it if his involvement was recognised.
Lord Falconer of Thoroton (Lab)
Thirdly, I join with everybody in the Committee in deprecating vicious attacks on the noble Lord, Lord Sandhurst, and the noble Baroness, Lady Finlay. Any one of us who have been involved in this get vicious attacks outside. I agree with the noble Baroness, Lady Fox, when she says there is a slightly testy atmosphere from time to time in here. The best that we can do to try and fight off those attacks is to be as good-natured, funny and warm as we normally are. I am looking forward to the noble Lord, Lord Deben, being warm and funny again.
Fourthly, my Amendment 131A, which the noble Lord, Lord Harper, mentioned, would add that the Prime Minister is to consult the Welsh Ministers before making the appointment. I hope that nobody objects to that; it is what the Welsh Senedd effectively agreed by passing the LCM. When we come to that amendment, I will move it, as I detect no objections.
Finally, I am afraid I will not provide the noble Lord, Lord Moore of Etchingham, with any assistance in relation to the way he conducts himself in the Committee. He always conducts himself, if I may say so, with impeccable manners and courtesy. It is for each one of us to determine what is appropriate and what is not.
I will deal with the amendments quite quickly. They are all to deal with the voluntary assisted dying commissioner provided for in Clause 4. The voluntary assisted dying commissioner will be appointed by the Prime Minister. As my noble friend Lady Levitt, the Minister, has indicated, as long as that stays in, then it will be subject to an open appointment procedure involving an assessment panel.
The idea of the noble Lord, Lord Beith, is perfectly commendable: should a Select Committee look at the appointment? The way that would work in practice is that it would be for the Cabinet Office and the individual Select Committee to agree whether the appointment should be subject to a Select Committee procedure. I would be in favour of it. I do not think it is appropriate to put it into the Bill, but I can see real merit in it. Iwould not only have no objection to it, but I think it is a good idea.
Lord Harper (Con)
Given that the noble and learned Lord thinks it is a good idea and that part of the reason—I think the noble Lord, Lord Deben, touched on this—many of us have concerns is that so much of the detail of implementing this is not set out but left for decisions, what is his objection and rationale for not coming forward with an amendment and putting in the Bill so that it has to be done by a pre-appointment hearing rather than leaving it to a decision?
Lord Falconer of Thoroton (Lab)
With respect to the Select Committees in the other place, they should be consulted and decide whether they want it.
In the amendment from the noble Baroness, Lady Cass, she draws attention to the fact that the assisted dying commissioner has a function under the Bill. That function is to receive documents, make appointments to the assisted dying panels, make arrangements in relation to such panels—this means that he or she is responsible for making sure the process runs properly—and determining the applications for reconsideration of panel decisions. That means that, if a panel says no to an applicant who wants an assisted death, the voluntary assisted dying commissioner has the power under Clause 18 to say that another panel should look at it. He or she has that power in a semi-judicial function if there is an error of law in relation to it, so that is a function.
The commissioner also has a function to monitor the operation of this Act. If noble Lords go to Clause 49, they will see that he or she is given the power to make reports, give an annual report and identify things that may be of significance in relation to it. One should not confuse this role with monitoring, for example, the performance of doctors in relation to their role. I do not see the very specific functions and the obligation to monitor and give reports, as in any way in real conflict. I think they could be done by the same person, particularly if there is a deputy to be appointed as well. I note what the noble Baroness said, but I do not think it is necessary to make provision in the Bill for a separate role for somebody to do both. I have thought very carefully about it.
The noble and learned Lord, Lord Garnier, has been kind enough to indicate that he has had to leave, but I will deal with his point. He wants not the Prime Minister but the Lord Chancellor to make the appointment. The Prime Minister and the Lord Chancellor are both political appointments. We have chosen the Prime Minister because—even though I think there is practically nobody more important than the Lord Chancellor—the political world, for reasons I am completely unable to understand, regards the Prime Minister as more important. We have chosen the most important person in the Government to make the decision and, with the greatest respect to the noble and learned Lord, I do not think we should change that.
The noble Lord, Lord Weir, asked why we should have a judge. I am a great admirer of judges, and I declare an interest in that I am married to a judge. The reason why we have a judge is twofold. First, ex-members of the Supreme Court, the Court of Appeal or the High Court of England and Wales—it is England and Wales that we have in mind—have high standing. They are regarded as people of calibre, which is why they are put in. Secondly, one of the specific functions in the Bill is to consider whether the rejection by a panel is an error of law. That seems to us to be appropriate to be dealt with by somebody with high legal experience. Separately, the commissioner is somebody who has to issue rules and a process for dealing with it. That is the reason for doing that.
Lord Deben (Con)
If that is the argument the noble and learned Lord puts forward, with which I entirely agree, does it not lead him to understand that the proposal of the noble Lord who spoke unwillingly earlier, to put this back where it was in the first place—basically, under the control of judges—would be a very good thing to do? Why has he not accepted that most of us would be able to support that, and therefore we would cut down the time we are spending on dealing with the situation when it is not there? If it is necessary, as he says, why not do the whole hog?
Lord Falconer of Thoroton (Lab)
We have changed from a judge to a panel because, after considerable debate in the Commons, it was thought that having a legal person in the middle, a psychiatrist and a social worker gave greater reach and understanding of those issues. We debated that issue in full over a particularly long period of time on an earlier Friday. I am more than delighted to redebate it—however, I think that issue has been laid to rest. That does not mean one does not have to have a process whereby the doctors pass their findings to a panel, and that is the role, in part, of the assisted dying commissioner.
Lord Harries of Pentregarth (CB)
The noble and learned Lord talks about putting it to rest, but for many of us that issue is not at rest. I certainly supported the noble Lord’s Amendment 120, and I got the impression he was still thinking about its possible value—so, as far as many of us are concerned, it has not been put to rest.
Lord Falconer of Thoroton (Lab)
I was pretty clear in my remarks that I favoured the panel process. When I say that it has been laid to rest, I accept that the House may take a different view from me, which I would completely respect. To deal with that, obviously there would be a vote on Report when we would decide whether we wanted the panel or the court process. I hope the issue has been laid to rest, but if it has not and I lose, so be it. I earnestly hope that we get there and reach a decision in relation to it.
The noble Lord, Lord Moylan, would like to replace the word “principal” with the word “sole”. I make two points in relation to that. First, all the assisted dying commissioner can do is that which is prescribed in the Bill, because he or she is a creature of statute. Therefore, there is nothing more that he or she can do beyond that.
The word “principal” is used, not “sole”, because we do not want to get into a completely barren argument subsequently about whether something that the commissioner does as collateral to the principal functions is covered. That is why “principal” is used and why I would not be in favour of changing the wording of the Bill in relation to that.
Lord Moylan (Con)
That point seems to me to be covered by the general power of the assisted dying commissioner under Schedule 1 to do anything that is appropriate or necessary for carrying out his functions, so I do not think that is a reason for not using the word “sole” and giving some assurance to those of us who are concerned about creep.
Lord Falconer of Thoroton (Lab)
I think we will have to disagree on that. It is the normal way for that to be dealt with in drafting, so I am content with it. I am sorry to disagree with the noble Lord, but that is my view.
Amendments 135 and 436 from the noble Lord, Lord Frost, would place a duty on the assisted dying commissioner to check that all the paperwork is in order. Again, I have thought very carefully about that. The role of the commissioner, as far as the panel is concerned, is to pass the two reports on to the panel once he has received them from the doctor, for the panel then to consider whether that case is in order and meets the criteria—is the panel satisfied that there is no coercion and is it satisfied on capacity? I think it is neither appropriate nor necessary to add yet a further safeguard in that respect, because that is why the panel is there. It would lead to overlap and unnecessary delay without, in practice, any additional safeguard. The noble Lord, Lord Evans of Rainow, supported that. For the same reasons, I would reject his amendment.
The noble Baroness, Lady Finlay, made a point about conflicts of interest. There would obviously be a conflict of interest if the assisted dying commissioner had a financial or commercial interest in any sort of provider of assisted dying services. That would be covered by the principles to which the noble Baroness, Lady Levitt, referred in relation to the way in which the appointment would go. I completely agree with the point by the noble Baroness, Lady Finlay, but I do not think there is a need to put anything into the Bill in relation to it.
A number of noble Lords have referred to the risk of mission creep—the idea that an enthusiast or proponent of assisted dying would operate in an inappropriately biased way. All that the assisted dying commissioner can do is act in accordance with the terms of the Bill. As the noble Lord, Lord Carlile, said, if for example the commissioner stuffed a panel with people he knew would take a biased view, he would be acting both improperly and illegally under the terms of the Bill. As the noble Lord said—and I agree with this—Schedule 1 opens the door to every sort of judicial review if that were the position and people became concerned about it. That goes to the amendment from the noble Lord, Lord Wolfson, which would provide for complaints to be made to the Prime Minister. Of course you could make complaints to the Prime Minister, but you certainly would not need the Bill to make that possible; there would be political accountability for the conduct of the commissioner, because the Prime Minister has made the appointment. Equally, there would be legal accountability in the form to which the noble Lord, Lord Carlile, referred.
Lord Hamilton of Epsom (Con)
Given the noble and learned Lord’s encyclopaedic knowledge of the statute book, can he tell us what went wrong with the Abortion Bill, which morphed without parliamentary consent, much to the concern of its sponsor, Lord Steel.
Lord Falconer of Thoroton (Lab)
Would the noble Lord mind if I did not, as I think what one has to do is focus on this particular Bill?
Baroness O'Loan (CB)
It is all very well talking about access to judicial review when things go wrong, but the reality for the ordinary man in the street is that judicial review is largely out of the realm of possibility: it just costs too much. Therefore, we need to make sure that things are so laid down in the Bill that there do not have to be multiple requests for judicial review. For that reason, I ask the noble and learned Lord to consider this further.
Lord Falconer of Thoroton (Lab)
I could not agree more with the noble Baroness, Lady O’Loan. That is why, in addressing these issues, we have been very specific about what the voluntary assisted dying commissioner can do in both Clause 4 and the schedule. What is more, that is why we have such a limited panel that can be made for the voluntary assisted dying commissioner. It has to work, and that is why it has been drafted in this way. The noble Baroness is absolutely right that judicial review is an expensive process, and it provides a guardrail, but ultimately there must be sufficient detail in the Bill to give the public confidence that the system will work. That is why we have, for example, restricted it to a Supreme Court judge, a Court of Appeal judge or a High Court judge. We are absolutely on the same page on that.
I turn to the noble Lord, Lord Sandhurst. My understanding of his Amendment 430—although I may not be correct—is that, where the two doctors agree, the assisted dying commissioner, if he or she agrees, can then short-circuit the need to go to the panel. That is my understanding of the amendment, which is interesting. However, my anxiety is that we would then, in every single case, almost, be getting rid of the panel. The position would be that you only ever get to the panel if both doctors have agreed. The sponsors presented the Bill to this House on the basis that, in every case, the safeguard is—to shorten it—two doctors and a panel. So I respect the thinking, because it is trying to streamline the process, but I do not think that it is appropriate, and it would undermine the safeguards.
Lord Sandhurst (Con)
The noble and learned Lord is right. When I introduced the amendment, I did say that there might be problems with it, but I thought it was something that should be looked at.
Baroness Berridge (Con)
I am grateful to the noble and learned Lord for his realistic acceptance of the difficulty of judicial review as a remedy for many people. I would be grateful if he could also reflect on the situation with family members: if the panel approves assisted dying, their remedy to challenge that is judicial review. We heard evidence in the Select Committee, particularly from Sir Nick Mostyn, that that is just fine. Many of us, particularly myself, do not feel that it is satisfactory for family members to have to resort to judicial review if they have evidence, for instance, that there has been coercion. Will the noble and learned Lord reflect on that, which may avoid further amendments later down the line?
Lord Falconer of Thoroton (Lab)
I will certainly reflect on that, and may I express my gratitude to the noble Baroness, Lady Berridge, for facilitating the meeting with Professor Ruck Keene? It was incredibly helpful, and I genuinely appreciate it. Yes, I will reflect on what the noble Baroness said. I suspect there will be a similar answer to the one I gave to the noble Baroness, Lady O’Loan: we have to be as specific as we possibly can in the Bill, because judicial review is difficult for normal people, particularly in those circumstances. That is why, whether it is a court system or any other system, we must try to make this as clear as possible in the Bill.
Amendment 146, in the name of the noble Baroness, Lady O’Loan, says that the assisted dying commissioner should be able to investigate patterns. In particular, she cites what may happen in relation to care homes. I agree that the assisted dying commissioner should have that ability. He does have that ability under Clause 49(1)(a), (b) and (c); so, for example, if he is concerned about a pattern developing in care homes, he already has the power to monitor that.
The noble Lord, Lord Morrow, asked whether there should be a further Equality Act assessment. I dealt with that last time and said I had looked carefully at what the former commissioner had said and I did not think that a further impact assessment was appropriate, because, if you constantly make particular points that are covered in general, you are never going to get to an end of it. I do not think that the points the commissioner raised were ones that had not already been considered in the impact assessment.
Baroness O’Loan (CB)
I accept that there is a general power in Clause 49 to look at what is happening in relation to the regime, but I say again that there is an issue raised by Amendment 146 which definitely requires further consideration. I ask the noble and learned Lord to reflect again not just on the monitoring of delivery of the service, but on the arrangements for the delivery of the assisted dying process in care homes, where people are vulnerable, isolated and largely unsupported in many cases. There is a very serious problem, given the remarks of Age UK, care homes, et cetera.
Lord Falconer of Thoroton (Lab)
I will certainly reflect on it, but the issue of somebody who is isolated and alone in a care home is why there are five steps before you get to assisted dying, and the question is whether the sequence of doctor number 1, doctor number 2, doctor number 1 again, the panel, doctor number 1 again is a sufficient safeguard. My own view is that it is a sufficient safeguard and it is particularly focused on protecting the vulnerable.
Lord Falconer of Thoroton (Lab)
I should get on. I apologise, but the noble Baroness has had a very fair crack at that particular whip.
I come to the question of the noble Baroness, Lady Maclean, which is: should there be a register of the interests of the assisted dying commissioner? I understand what motivates that. I do not think that that is necessary because, as my noble friend Lady Levitt said, that is something that would be dealt with by the normal process governing conflicts of interest. There would not necessarily be a record of it, but it would be something that would have to be disclosed before a decision was made.
The noble Baroness, Lady Grey-Thompson, raised various issues in relation to the appointments process, but I hope that I have dealt with them by referring to the process that would apply. I think I have dealt with all the other points, including the point from the noble Earl, Lord Howe, about Amendment 913A.
Lord Harries of Pentregarth (CB)
I am still genuinely not quite clear who the noble and learned Lord thinks the commissioner, and indeed this whole process, is ultimately accountable to. With the rejection of the amendment from the noble Baroness, Lady Cass, and various others, I am trying to work out who ultimately is going to monitor this if there is public concern about the law being interpreted much too loosely, or things are going wrong. Who is going to keep a permanent eye on what is happening?
Lord Falconer of Thoroton (Lab)
The nature of the appointment is that it is an appointment by the Prime Minister. He is politically accountable for the appointment. The assisted dying commissioner, like so many other appointments made by a Minister, has legal duties, but, if you are looking for political accountability, it is the person who is responsible for his or her appointment. That is the way that public appointments operate.
Baroness Freeman of Steventon (CB)
I am sorry, but the noble and learned Lord has not addressed Amendment 144A.
Lord Falconer of Thoroton (Lab)
I apologise. The noble Baroness, Lady Freeman, emphasised in her Amendment 144A the importance of providing impersonalised information and assistance in relation to reaching a structured decision. She speaks from considerable experience, and I express my gratitude to her for talking to me about it and providing me with real assistance.
That would have to be dealt with by codes of practice issued by the Secretary of State under Clause 39. If there were problems—for example, the codes of practice were thought not to be adequate or were giving rise to problems—it would be for the assisted dying commissioner, under Clause 49(1), to report or indicate that something was wrong. The points the noble Baroness makes are important and I apologise for not dealing with them.
Baroness Coffey (Con)
The noble and learned Lord did not speak at all to his Amendment 480 in this group. Is he planning to address it later in group 3? I am conscious that he did not particularly address my amendments, but I assume it is because he disagrees with them, which I understand. However, Amendment 480 has not been talked about at all. It is okay if he wants to address it in group 3.
Baroness Cass (CB)
Long speeches are unpopular at the best of times, but particularly as I now stand between noble Lords and lunch, so I will try not to make one. It has been a very useful group. We have had a lot of discussion about the appointment process, transparency, conflict of interest and how we ensure public confidence in the commissioner. I think we have reached a conclusion on that—one which may not satisfy everybody, but we have come to a place on it.
Beyond that, a lot of the concern has been about things that fall through the cracks, such as my noble friend Lady Freeman’s concerns about patient information, data, risks and patterns in care homes, and family involvement, which is important. My reflection is that I accept the noble and learned Lord’s view that we do not need to separate a delivery and a monitoring role, but it still seems as if the assisted dying commissioner, even acting with the greatest integrity, needs eyes in the back of his or her head to pick up on issues such as local fluctuations or other aspects of concern. I look forward to hearing about other ways in which things are going to be monitored carefully, whether by the CQC or NHS England, as the noble and learned Lord suggested, so that we can be reassured on those matters. With that, I beg leave to withdraw Amendment 122.
“(3A) Before making an appointment under this section, the Prime Minister must consult the Welsh Ministers.”Member's explanatory statement
This amendment requires the Welsh Ministers to be consulted, before appointing a person as the Commissioner.
Lord Deben (Con)
My Lords, I did not intend to speak on this particular amendment until something happened at lunchtime. I have to apologise to the noble and learned Lord, because I am not sure that I can make a joke about it, as he has requested me to in any speech I make. The fact of the matter is that at lunchtime I discovered that my local health trust has withdrawn its payment to Marie Curie, which means that there will no longer be Marie Curie nurses helping people in the final months of their lives; that support has been withdrawn because of the tight budgets in the National Health Service. I am appalled that we are in that situation, but it reminds me very clearly of the fundamental problem of a single-issue Private Member’s Bill, because it asks us to consider something not as one of a series of priorities among which government has to make choices, but as something on its own. That inevitably is a real problem.
The second problem is that anyone who has been a Minister knows how the Treasury works. If you ask it to give you some money to spend and then say, “But we’re going to make these savings”, it always counts the spending and refuses to acknowledge the savings. That is a Treasury mechanism that we have all learned—and I see that a former Health Minister knows precisely what I mean.
The problem with this issue is precisely that: money will have to be spent, but the savings—let us leave aside whether this is a suitable balance—will certainly not be considered, which is why the Deputy Health Minister said there would have to be “reprioritisation”.
So I come to this Committee having been shocked at lunchtime. Perhaps the Chief Whip should not have allowed us off for lunch: then I would not have been able to see this. However, the truth is that I am shocked by the fact that one of the most important palliative care services is now going to be ceased for the part of the country in which I live. That therefore brings me back to the amendment. I think we have to say to ourselves, very clearly, that, if we are proposing to spend money on this, it is quite clear from the Government that that will mean “reprioritisation”, which actually means cutting other money in order to save enough to pay for this.
I hope the noble Baroness will not be upset by this, but I do not understand how the Government fail to do this: in all the advice they give us, they refuse to tell us how much they think this will cost. That is a duty of the Government. They should tell Parliament, if it is a Private Member’s Bill of this sort—I will give way.
Lord Falconer of Thoroton (Lab)
We produced an impact assessment of the Bill with detailed costings, provided by the health service, so to suggest to the Committee that the Government have not provided the costing is inaccurate.
Lord Deben (Con)
We have already told the noble and learned Lord what we think about the impact assessment. We have been asking for an updated impact assessment which takes into account the debates we have had and the assessments we have made. The Government have said they will not do that—that is what I am referring to. I want to see an absolutely up-to-date impact assessment based on the debates in which we have expressed and explained real issues which have not been raised before, so that we can, first, know how much it costs and, secondly, begin to ask ourselves, “Is this the priority?”
I will end on this. Is it a priority to provide people with the free chance to kill themselves and not provide people with Marie Curie nurses so they may live the end of their lives in a happier and better place? Anyone who suggests that we get that priority right by funding assisted suicide rather than Marie Curie nurses seems to me to be saying something that the public would not accept. One of the problems with this whole debate is that we have never been prepared to tell the public what the real effect of this is. Therefore, I very much support this amendment—not that I would normally support the kind of position my noble friend raises in his particular way, but he did it most elegantly. I support it entirely because, at long last, we are talking about the facts and what this really means for the people of Britain.
Baroness Levitt (Lab)
My Lords, I will speak only to the amendments about which the Government have significant operational workability concerns. Before I do so, I want to say a few words on the general points about funding raised by a number of noble Lords, including the noble Lord, Lord Harper, the noble Baronesses, Lady Fox and Lady Grey Thompson, and others.
I make it absolutely clear that I entirely understand the point that the noble Lord, Lord Deben, is making and why it might seem as though the choice is being restricted if you do not actually know the amounts involved, but I reiterate that it is for Parliament to decide whether this service should be provided and, if so, whether it should be publicly funded. If that decision is made, the Government will fund it. I am not evading the issue when I say that I simply cannot explain how that will be done, because that would be to put that ahead of Parliament’s own decision. We cannot possibly start, for example, putting aside a war chest for something that Parliament may decide that it does not want. As far as priorities are concerned, as I say, it is not a matter of evasion; it is a matter of principle.
It is also not right to assume that funding this, if that is the will of Parliament, will involve taking money away from other parts of the health service. That is not what the Government are saying; we are simply saying that the funding will be made available if that is what Parliament wants. My noble friend Lady Merron, the Health Minister, has written twice on this subject, and those letters are available in the Library for anybody who is interested. As for palliative care, there is an absolute commitment by the Government to increase funding for palliative care and make sure that palliative care is offered properly, irrespective of what happens in relation to this.
As for the noble Lord, Lord Deben, of course I am not upset by what he says about the impact assessment—as if I would ever be upset by anything that he says—but we are doing what is usual, which is to deliver the impact assessment at the outset and, as with other Bills, a further updated impact assessment will be provided following Royal Assent, if we get to that stage. There is a logic to this, because there are so many different elements to what has been debated in Committee that to provide a costing for each and every one would probably keep us here for as long as we are here debating all these amendments anyway. It simply cannot be done. It is not practical. I am not upset, but I am simply saying that we cannot do it and we will not do it until Royal Assent.
Turning to the amendments in the name of the noble Lord, Lord Moylan, these are collectively intended, as we have heard, to prevent the establishment and running of this service being publicly funded. Your Lordships may wish to note that, if passed, these amendments would create an internal inconsistency with Clause 41(5), which requires that the provision of voluntary assisted dying services must be provided free of charge.
Amendments 835 and 868, in the name of the noble Baroness, Lady Fraser, propose a delivery model whereby the Secretary of State must make regulations for the assisted dying service, which would be delivered only by private providers. The key workability risk here is that the new clause created by Amendment 835 would duplicate Clause 41, but with additional constraints, and that would create legal uncertainty, when the Act is looked at in the round, about the limits on the Government’s powers when commissioning a service. The Committee may also wish to note that this amendment may have implications for the devolution settlement, as Wales and the Welsh NHS trusts are implicitly included, which potentially constrains the powers for Wales in Clause 42.
Lord Falconer of Thoroton (Lab)
This group concerns the question of funding. First, the noble Lord, Lord Moylan, raised the question: should the people who benefit from this have to pay for it? Secondly, the amendments from the noble Baroness, Lady Fraser, raised the question of whether it should be free to the patient. Could it be provided by private providers? Separately, there were questions along the lines of: will this change the nature of the relationship between the doctor and the patient? Finally, there were questions over whether this might lead somebody to urge people to take an assisted death.
I start with the provisions of the Bill at the moment, which, subject to the amendments to Clause 41 that I propose, require that the integrated care board, or NHS England or the Secretary of State, commission the services. A separate provision, in Amendment 753A, makes provision that, in practice, they have to be free for the person getting them.
The principle that underlies that approach—my noble friend Lady Levitt is right and this is the choice that the Bill makes—is that it will be available free to somebody who wants it and who satisfies the conditions. The reason for that is that we do not want to create a two-tier system where you can have an assisted death only if you can afford to pay for it.
In evidence to the Commons Public Bill Committee, Dr Michael Mulholland, the honorary secretary of the Royal College of GPs, said:
“Whether it occurs in the NHS is not our decision, but we would be very concerned about health inequalities creeping into any part of the health service … If the Bill comes through, we will want to make sure that there is not a differential in who is able to access it”.—[Official Report, Commons, Terminally Ill Adults (End of Life) Bill Committee, 30/1/25; col. 278.]
The amendments of the noble Baroness, Lady Fraser, do not affect that. The amendments of the noble Lord, Lord Moylan, do, and it is for that reason that I oppose them.
I will first deal with the amendments of the noble Baroness, Lady Fraser, which would restrict the model that could be used to private providers only—albeit that she is not saying that it should not be free. I agree with what my noble friend Lady Levitt has said, to the effect that the way it is delivered should not be restricted. I would therefore not be in favour of the amendments of the noble Baroness, Lady Fraser, in that respect.
Lord Harper (Con)
Does the noble and learned Lord not see that the argument that he has just made in favour of having a fully funded assisted suicide service is exactly the mirror of the argument that I made on palliative care? The argument from the quotation that he gave is exactly the argument that I made. If you fully fund this proposal but you do not fully fund palliative care and make that universally available at high quality, you have an inequality where wealthier people can get palliative care and poorer people cannot. On previous occasions, the noble and learned Lord has made it quite clear that he is comfortable with those being reasons for people seeking an assisted death. I do not think that they are. You have to fund both services on an equal basis. Does he agree?
Lord Falconer of Thoroton (Lab)
The impact assessment suggests that in year 10, assuming the highest possible cost, it would cost £37 million in total to do assisted dying. This is not by reference to any savings and it includes not just the health elements but also the panel and the assisted dying commissioner. It is plain that palliative care should get as much funding as possible. It is patchy throughout the country and it needs more funding. For me, it is not right to delay the option of assisted dying, particularly when the amount of money that we are talking about to fund assisted dying is so much less than that amount of money, which I would fully support being provided as much as possible. I understand what the noble Lord, Lord Harper, is saying. I am fully behind him if he is saying, “Let’s all put our backs into getting as much money as possible for palliative care”. But I do not accept the argument that the inadequacy in some parts of the country of palliative care is a reason for delaying the assisted dying Bill.
Baroness Finlay of Llandaff (CB)
Just as a point of information, does the noble and learned Lord accept that there is evidence that if specialist palliative care was available across the country on an equal basis, that in itself would result in a saving of around £800 million a year, because patients would be getting better care and unnecessary investigations and so on would be avoided? So there is a cost transfer. The problem at the moment is that we have areas without services and therefore patients do not have choice. If we are talking about patient choice, there must be equipoise in that choice argument.
Lord Falconer of Thoroton (Lab)
I am absolutely sure that if there were proper specialist palliative care of the highest quality—we would hope that there would be—it would lead to savings. I honestly do not think that the £37 million cost is a reason for delaying this because it would in some way hold back the provision of better specialist palliative care, which is something that we are all in favour of.
Baroness O'Loan (CB)
I am concerned about the figure of £37 million being articulated as the absolute cost of this service. I find it somewhat difficult to believe that it could be the cost. If we have regard to the costs of similar public organisations that are already set up, the running costs alone run into millions. We are going to be talking about a national service for England and Wales that, presumably, will be provided in the patient’s location—the death will take place not where we want it but where they want it—and therefore there will be a lot of costs. I firmly believe that they have not been costed into the figures that the noble and learned Lord and the Minister have given us.
When I go shopping, I see whether I can afford what I want to buy. Yet we, as a Parliament, are being asked to decide whether we want to do this. One of the things that we should responsibly take into account is cost, otherwise we would not have had an impact assessment. We are being asked to consider it on the basis that it will cost £37 million and that that is peanuts—well, I wish I had £37 million pounds put into palliative care now. This is not an accurate figure.
This is the only point that I want to make. Can the noble and learned Lord put his hand on his heart and say to me that he really believes that this is what the service will cost, given the number of people who may avail of it and the number of safeguards that need to be introduced into the Bill because of its very significant flaws?
Lord Falconer of Thoroton (Lab)
First, I am grateful to the noble Baroness, Lady O’Loan, for her speech, rather than a question clarifying something. Secondly, as I have said, the figure of £37 million has been provided in the impact assessment for the 10th year. I note the points that the noble Baroness has made. Maybe the right course for her is to send a detailed letter raising the questions with the Department of Health and Social Care and the Ministry of Justice, because it is their assessment—and I do not dissent from it.
The Archbishop of York
I entirely accept that those who are proposing the Bill do not propose it for the reason of trying to save money. I also entirely accept the desire from everyone in this House for better-funded palliative care. However, I need something to be explained. Taken that palliative care is inadequate and underfunded, and taken that there are huge regional variations, what I do not understand is the noble and learned Lord’s confidence that this will not lead to coercion of vulnerable people in places where palliative care is not available and cannot be afforded, which will lead to unintended consequences. I entirely accept that he does not want those consequences either, but I ask him to give me some confidence, if he can, that this will not follow.
Lord Falconer of Thoroton (Lab)
I will try to give the most reverend Primate confidence. First, decisions about treatment at the moment frequently have to be made in the context of what everybody in this Committee would think was inadequate palliative care. There is scope for coercion there with no safeguards. Secondly, people have the ability to go abroad to get an assisted death, and there is scope for coercion there. In both those situations, there are no safeguards whatever. The landscape in which those choices are made, whether about continuing other treatment or about going to Switzerland, has absolutely no protections whatever. This Bill provides five levels of protection. I am completely satisfied that this is a safer system than the current law, and I very much hope that gives the most reverend Primate confidence that the Bill is the right thing to do.
On the funding of palliative care, I very much hope that the Government and other people will provide more money for palliative care. The experience in many countries is that the introduction of an assisted dying Bill leads to an increase in the amount of palliative care, because people debate and think about how you die. I hope those things put the most reverend Primate’s mind at rest. The risk for coercion is already there, and this provides safeguards. I hope the introduction of the Bill will produce more money for palliative care, but unfortunately I cannot give the most reverend Primate any guarantees of that.
Lord Moylan (Con)
My Lords, I shall be very brief. I am grateful to all the noble Lords who spoke in this short and valuable debate. I tabled these amendments in the first place to give the noble and learned Lord the opportunity to explain why this proposed service should be funded by the taxpayer—the unwilling taxpayer, it might be said, in the case of those who have a principled objection to it. I listened very carefully to what he said, and he gave one reason only: failure to make it available for free would contribute to an increase in health inequalities. That proposition rests entirely on the assumption that this is a health treatment. It is not; it is poisoning people. It is completely unpersuasive that this should be justified as contributing to health inequalities or otherwise. For that reason, I would certainly want to bring these amendments back on Report and invite the House to take the view that we should not fund this from public resources. In the meantime, however, I beg leave to withdraw the amendment.
Baroness Finlay of Llandaff (CB)
May I intervene on that, given that my amendment is being questioned? Let me explain. When looking after people who are parents, a conversation is often about what the children know. Telling the children about someone’s impending death is extremely difficult for most parents. Usually, it is because the person who is ill wishes to protect those children; they think that, by not telling them and preparing them, they are somehow protecting them. The way children are informed needs to be age appropriate and appropriate to where that child is.
I do not suggest in this amendment that it should be an agent of the state. The amendment refers to making
“adequate arrangements for another person”.
That could be anybody. It is about asking whether they have somebody who will inform those children—or not—about the death. As for bereavement support, it might simply be about telling them in person and letting them talk about it for an hour over a cup of tea, or it might be much longer, depending on the needs of the individual—because bereavement is a very individual thing as well.
I am concerned that we could legislate and somehow believe that, by someone having an assisted death, rather than a death for which there has been preparation, the impact on any children in a family will be less, because the evidence is that it will not.
Lord Falconer of Thoroton (Lab)
I do not know whether I am allowed to intervene, because I do not know whether the noble Baroness is intervening or speaking to her amendment.
Baroness Berridge (Con)
My Lords, I will speak to Amendment 462A in my name, which outlines that, before approving any application, the panel must be satisfied that the person requesting assistance has had the requisite assistance from the local authority in relation to the delivery of statutory services.
The amendment deals with the problem caused by the basic principles of the Bill, which is based on a very narrow concept of procedural autonomy. If it is only this that matters, then for the panel, as long as they can tick the boxes saying there is no coercion or pressure, and that the person has capacity et cetera, then the application is approved. It is approved under the current drafting of the Bill even if the panel believes and has evidence that the person is applying because, for instance, their housing is inadequate, the care package fell apart, they are actually grieving for other relatives or they are poor.
This amendment would mean that, before any such approval is made by the panel, it must be satisfied that the local authority has received a referral to look at the statutory provision of services for the person. In relation to this, I am grateful that the noble and learned Lord enjoyed his meeting with Professor Alex Ruck Keene, because he has put this a number of times in written and oral evidence about the concept of the panel and its powers, and it is worth quoting:
“You have to think … carefully about what purpose any … of this oversight is actually serving societally, if the oversight panel, whether that be a judge or a panel, cannot decline to approve an application if it considers that the reason the individual is seeking assistance in dying is because of service provision failures by the statutory bodies responsible for meeting their health and social care needs”.—[Official Report, Commons, Terminally Ill Adults (End of Life) Bill Committee, 28/1/25; col. 96.]
I know the noble and learned Lord has answered many questions and commented about the access to this service for the poor. This is a different question. I am not saying that poor people should not be able to apply. I distinguish that from a situation where the panel has concluded on the evidence that, although the person satisfies all the tests under the Act, the evidence is that they are before the panel because they are poor. There are many instances of this from other jurisdictions, for instance, particularly in relation to homelessness. People have come forward for MAID in Canada because they are homeless, which is available because it is not just for terminal illness in Canada.
In relation to the amendment, it may be that the drafting needs to be different; it might be that this needs to be done not just before the provision but can be twin tracked, so that you approve the application but at the same time make sure the local authority deals with the provision of services. I hope the noble and learned Lord will take seriously this additional power for the panel to ensure that people are there for the reason that they are exercising their autonomy in relation to the Act and not pressured because of lack of statutory services.
Lord Falconer of Thoroton (Lab)
The noble Baroness refers to it as an additional power but, as I understand the amendment, it says that this is an additional requirement for a certificate of eligibility.
Baroness Berridge (Con)
I am grateful to the noble and learned Lord. I accept that drafting changes might be needed between now—
Lord Falconer of Thoroton (Lab)
The noble Baroness says, “drafting changes”, but there is a fundamental difference between saying that this is an additional condition that the panel has to be satisfied of and giving it a power. I understand the noble Baroness’s amendment to be saying that an additional requirement needs to be satisfied.
Baroness Berridge (Con)
When I mention drafting changes, I mean in relation to the timing of this. As drafted, it would need to be done before the application is granted, and it may be that the requirement to go to the local authority could be at the same time as having approved it, not before. But, yes, this would be an additional requirement on the panel.
I hope the noble and learned Lord the sponsor or the noble Baroness, Lady Finlay, can help with my second point on the principle of the Bill. The noble Baroness, Lady Hayter, referred to the situation based on autonomy: the individual wants to do this and does not want to tell relatives. If we are strict purists about that—we had evidence on this at the Select Committee—then with this Bill there could be a situation where the first time anyone hears about the death is when the medical examiner telephones a relative.
I have tabled amendments in a different group on a requirement to nominate next of kin who are over the age of 18. I think it would be useful for the Committee to know what the situation is if someone acts completely autonomously like this and the body is there. Does the noble and learned Lord the sponsor need to bolt on a provision so that there is a public health burial? That is the continuation of the logic of this that you can do this alone, with no one in your life knowing about it. Therefore, to exercise that autonomy fully, there would need to be a public health burial, with everything done before anyone in the family knows. That is a conceptual difference. The noble and learned Lord and I spoke about this in a meeting in relation to what the law is, and it would be good for him to clarify the situation. Can the medical examiner not call anybody and go forward with a public health burial?
Lord Falconer of Thoroton (Lab)
The noble Baroness, Lady Lawlor, will know that there are quite a lot of cases at the moment where the first that somebody hears of the suicide of someone they love is when they are told about their death. I have two examples in mind. One is Mr Paul Blomfield, who described his father hanging himself and not involving him because he feared that he might be investigated by the police. The other is the wife of Stuart Broad’s father, Chris Broad, who hoarded pills and, as a result of her not wishing to involve her husband, the first he heard of it was when an email came through from her. What does the noble Baroness say to those people under the current law?
Baroness Lawlor (Con)
We are proposing and debating a piece of legislation at this moment. We are concerned about the safeguards in the current proposed piece of legislation. The noble Baroness, Lady Gray of Tottenham, has proposed that the reviewing panel must raise with the person considering assisted suicide whether they have discussed it with their nearest and dearest. That is a different matter from what the noble and learned Lord has raised. We are discussing a piece of proposed legislation and I am discussing an amendment proposed by another noble Lord.
It is very important for those on whom we have depended and may still depend that we form a society and, as human beings, give support and love to one another—a mother or father who wishes only to support their child, perhaps terminally ill, to live their life as best they can; a daughter, son or sibling supporting their loved parents, sister or brother; or a spouse or best friend.
I do not agree with the premise of the Bill that we are autonomous human beings to dispose of ourselves just as we wish. Whatever freedom we have as human beings is rooted in a network of social relations and responsibilities, especially to our kith and kin. We therefore need to do whatever is possible to ensure that a person’s ultimate decision to end their own life is taken within a familial and social context. This amendment, which I support, promotes that end.
Baroness Finlay of Llandaff (CB)
Perhaps the noble Baroness might be relieved to note that I do not intend to move my amendment. I would like to speak to it now, but I will not be moving it.
Routinely, when you go into hospital, you are asked who your next of kin is. That is a routine question and it is entered in your medical record. That person has no legal status in terms of making medical decisions, although they may be consulted if a best-interest decision has to be taken. However, if you die, that will be the person the ward will phone to say that you are dead and your body is going to be moved to the mortuary, and that is the contact number that will go to the medical examiner to phone you later, which I think is the point the noble Baroness, Lady Berridge, was trying to extract.
It was helpful that the noble and learned Lord, Lord Falconer, described the shock of discovery of a death that you did not know about. That shock has been described by relatives who suddenly discovered that their parent had died by some form of assisted suicide or euthanasia when they had not known about it beforehand. That is documented.
It is also worth remembering that there is no evidence that suicide rates fall when these types of assisted death services come into play, but there is evidence that when people get the care they need, suicidality—that is, thinking about ending your life early—falls. So people need to have care.
I shall speak to my amendments now.
Baroness Finlay of Llandaff (CB)
I have already spoken to Amendment 459 and am finishing off speaking to it.
I will move on to Amendments 475 and 939 in Schedule 2. There is concern over the operation of the panels and safeguarding responsibilities, just in terms of the information that comes forward. Someone with relevant information would be allowed to come forward to the panel with appropriate evidence and be afforded whistleblower protection, in the type of situation described by the noble Baroness, Lady Berger, where there is a new person on the scene who others may feel has malintent, for one reason or another.
In the Bill’s current model, medical assessments that have previously gone to the panel will not be monitored contemporaneously. They could be poorly reported, they will not be reviewed and this could hide errors, unconscious bias and discrimination. The role of the panel will be to issue a certificate. In Amendment 493, I have suggested that the certificate should have validity for six months and, in the event that the person has a longer prognosis—we have many examples of that—it is renewable rather than having to start the process again because they have outlived their prognosis.
However, the appeal mechanism to a panel seems to be one-sided. The person can appeal against a refusal to give them a certificate, but there does not seem to be a mechanism for appeal. My Amendment 499 seeks to allow information to be brought to the panel that it may not have known about when it gave a certificate. This may relate to domestic abuse that had been hidden, to coercion or pressure, to any information that the diagnosis may have been wrong, to recent emotional or psychological trauma, or to depression or metabolic disturbance which might have impaired capacity.
Amendment 932 is a very practical one concerning the provision and distribution of panels around England and Wales. It has not been made clear how many panels there would be or that there needs to be fair distribution. I have suggested a minimum of three per region in England and a minimum of three in Wales. For the geography, topography and population, I think three would work for Wales. However, areas of England with high population density, or very large rural areas, would probably need more to enable the panel to visit the patient face to face for an assessment. It is completely inappropriate to expect a patient to go to see a panel when they are already ill or to rely on remote consultation rather than having the ability for face-to-face discussion. Those face-to-face discussions must be subject to the confidentiality that you would expect in any medical consultation. I hope that we will not be suggesting that this would be publicly available.
I suggest that, as has been said, these panels came in two-thirds of the way through and a panel can take testimony from others. However, in terms of getting information about the person, as the Minister of State for Courts and Legal Services said in Committee on this Bill:
“It is not a court or a tribunal … They can make the request, but they cannot compel someone to attend”.—[Official Report, Commons, Terminally Ill Adults (End of Life) Bill Committee, 12/3/25; col. 1102.]
Lord Harper (Con)
That is very helpful. It enables me to make this point, because this is where we have a disagreement. It gives the sponsor of the Bill the opportunity to set out why the Bill is drafted as it is. I will set out why I think my noble friend’s amendment is broadly right, but perhaps there is a comparison with what we already do in similar cases. That may give the noble Lord, Lord Carlile, the opportunity—he may not wish to say so—for another “told you so” moment, as it is a judicial comparison.
The presumption in the Bill is that panels will do the referrals in public. There is a “subject to” on that: the chair of the panel can decide to do it in private if they feel that is appropriate. I accept that there is a balance to strike because, for obvious reasons, these panels are making decisions about personal, private matters. It is also right that there is some transparency. My noble friend Lord Jackson’s amendment would give quite a big window, 28 days, to publish the notice of the panel meeting. It would also include the name of the person.
The comparison I looked at, which I thought was a reasonable one, was what the Court of Protection does. It makes decision about sensitive financial and welfare matters. It used to be the case that the Court of Protection’s presumption was to sit in private and not hear cases in public. That has changed over time. The presumption now is that cases are heard in public. Again, my understanding is that there is the ability for the judge presiding on those cases to decide for them to be in private if that is felt necessary. Even when they are in private, I understand, members of the public can make applications to go and listen to those cases. I think that is all right and proper. That appears, I presume, to be where—the noble and learned Lord, Lord Falconer, is nodding.
Lord Falconer of Thoroton (Lab)
This is an important issue. Let me say what I think the purpose of this is, so that it can be properly debated. The norm for the panel—the noble Lord, Lord Harper, is right—is to sit in public, but it is such a thing that it should be determined by the patient. If the patient says that he or she wants it in private, and they very regularly will, the chair can say, “Okay, it’s in private”. The expectation is that it would normally be in private if the person asks. However, there is still a discretion for the chair. It is not like the Court of Protection where the judge is making a decision in a much wider public interest. The reason it is drafted like this is that there needs to be some transparency but, if the person wants it in private, they should generally be entitled to that because it is so personal.
Lord Harper (Con)
That is helpful in one sense because it is helpful to have fleshed out the noble and learned Lord’s intention. It is not helpful in the sense that he has made the Bill less attractive to me than I thought it was. I thought the presumption was more that it would be in public.
Lord Harper (Con)
I do. The reason why I partly agree with my noble friend Lord Jackson is that I had a look at what the Court of Protection does in terms of publicity—the bit that the noble Baroness, Lady Hayter, objected to. It publishes hearings in advance—not 28 days—but it does not publish the full name of the individual. It publishes initials and what the case is about: the broad category of the decision. That strikes me as quite a good balance, which provides transparency but maybe avoids people coming to “watch a spectacle”, to quote the concern of the noble Baroness, Lady Hayter.
However, there is some necessity for it to be in public. The reason for that is also set out in the Bill, which says the panels
“must hear from, and may question, the co-ordinating doctor … must (subject to subsection (6)) hear from … the person to whom the referral relates”.
At this point, I agree with the noble Baroness, Lady Berger. That should absolutely be a must; there should not be an exception. If it is the case, as I understand from the appearance of the noble Lord with me on a media programme, that the exception is designed for cases where the person’s medical situation is very severe, they should not necessarily have to come to the panel, but at least one member of the panel should absolutely still have to go and talk to them. It really should not be okay for the panel to authorise somebody to have an assisted suicide without ever having spoken to the person concerned.