Terminally Ill Adults (End of Life) Bill

Lord Rook Excerpts

2nd reading
Friday 19th September 2025 Lords Chamber

[Lord Rook (Lab)]

My Lords, I am grateful to all noble Lords for the sincerity and seriousness of the debate over these two days. It has been illuminating and moving to hear so many family stories and personal testimonies. I note my interest as a carer for my father, Roy, who suffers with dementia.

This time tomorrow, my dad will knock on the door of the care office in his supported living complex to address an issue of singular importance: whether his choice has been registered for the 4 pm fish supper. Dad will have already made this trip four or five times, and Dawn, his ever-kind and patient carer, will smile and affirm once again that he has chosen haddock and chips and paid his £7 bill. My dad will beam back and say, “Thank you. I’ll see you soon”. This will indeed be true; in the hours that follow he will return many times to ask the same question.

I do not make light of my father’s condition: all carers know that we see many dark moments, and some of the lighter moments give us a degree of hope and happiness. But the truth is that my dad’s life is immeasurably improved by the fact that he lives in a loving environment with tailored medical support, endless activity and entertainment and an astonishing team with almost infinite capacity for kindness and compassion. Despite his diminishing and terminal condition, he has a good standard of living. Why? Because he can afford it.

We have heard a great deal about choice in this debate. I believe choice is a good thing; hence my concern, in assessing this legislation, is for those who have less choice than us—those who, unlike my father, cannot subsidise their own care in the final season of life. The most disadvantaged members of our communities already suffer increased mortality rates and the pronounced effects of health inequalities. They find it hard to see a GP, they wait longer for treatment and they struggle to navigate complex health systems. We have heard it said over and over: the NHS is currently able to support only 30% of the palliative care costs of our country. I simply cannot see how the introduction of this legislation will not pressurise those who, unlike my father, are without access to first-rate care and cannot afford to supplement what the NHS struggles to provide, to turn to assisted dying, not as their first choice but as their last and final option.

Noble Lords sceptical of this point should pay attention to states that have gone this way before. In Canada, increasing numbers of patients, many of them disabled, are being driven in the direction of assisted dying, due to poverty and a lack of ability to fund their own care. In Victoria, Australia, Robert Clark, the former Attorney-General, has said that disadvantaged patients are likely seeking assisted dying precisely because of the problems in accessing adequate care. The same is true in the United States. In Washington, the proportion of people choosing assisted dying because of concerns about their finances has risen fivefold, from 2% to 10% of cases. In Oregon, the percentage of patients choosing this route because they fear becoming a burden to their family has climbed from 13% to 52%.

In scrutinising the Bill, I hope that we will learn from these countries and take a different course. Where my own choice is concerned, I have chosen to support my noble friend Lady Berger’s intervention and her proposal to convene a Select Committee. I hope that this will give us an opportunity to listen carefully to voices that have not been heard as much as they should have in the procedures, processes and legislation before us. I look forward to working with noble Lords in Committee for as long as it takes to ensure that we can give a good end for all.

Terminally Ill Adults (End of Life) Bill

Lord Rook Excerpts

Committee stage
Friday 14th November 2025 Lords Chamber

[Lord Ashcombe (Con)]

My Lords, I speak definitely not as a lawyer or as part of the medical profession in any way. It appears to me that the Mental Capacity Act uses the balance of probabilities when making a decision, rather than “beyond reasonable doubt” as, in my understanding, the criminal court does. For such a definite decision as whether to end your life, the balance of probabilities is insufficient. Therefore, is the current definition of capacity in the Act sufficient for this job? I suspect not. Is “ability” the right word? I am not sure. Somewhere along this line, to the point made by my noble friend Lord Deben, there is an answer, and maybe two words is right.

[Lord Rook (Lab)]

My Lords, I will keep this brief. I was not going to share this at this point because it is quite personal and because it takes a lot for me to counter the noble Baroness, Lady Andrews, for whom I have huge respect. She was the first person to invite me to the House of Lords for tea, many years ago. I do not doubt that the Mental Capacity Act has been a huge advance in how we deal with these issues.

I accept that the noble and learned Baroness, Lady Butler-Sloss, is probably one of the few people in this place to make judgments in the courts and the Court of Appeal on mental capacity. I suspect that more of us have had to go through the process of helping a loved one through a mental capacity assessment, although I suspect that number is also still low. My father has dementia. I have had to support him through a mental capacity assessment. No matter how clear the Act or various legislations or definitions may be on paper, it is extremely difficult at times to take someone through that process. All he had to do was prove that he had capacity to instruct a solicitor, a decision far less serious and far less terminal than the one we are discussing today.

If you assessed my father’s capacity, you would find—on the comments made by the noble Baroness, Lady Hollins, about literacy and numeracy—that my father has near-perfect literacy and numeracy. We have had comments about executive function. You would find that he has near-perfect capacity for executive function to make important decisions. You would also find that he has virtually no short-term memory. He is more than capable of making a decision, but that decision is gone in 30 seconds—sometimes sooner. If you apply that to this situation, he would be able to make a decision but would not know about it at the point that decision was acted upon.

Returning to the comment from the noble and learned Baroness, Lady Butler-Sloss, about whether it is capacity or ability, I pick up on the comments from the other side of the Committee recently. There is not enough, in the way we judge capacity at the moment, to make this practicable and desirable. We certainly need more. I am not sure whether it is “ability”, but what we have at the moment is not enough to deal with this in practice.

[Lord Harper (Con)]

My Lords, I have listened carefully to the debate. The noble Baroness, Lady Finlay, has done the Committee a service in tabling this amendment. It has enabled us to think in advance of the debate that we will have when we get to Clause 3 on the existing wording in the Bill about the Mental Capacity Act. Some of those issues came out in the debate that we have just had. It has been helpful to cue that up.

I want to comment on a couple of issues following on from the comments made by the noble Lord, Lord Deben. Two different things are being talked about with capacity and ability. I listened carefully to the comments of the noble Lords, Lord Pannick and Lord Scriven. There is a clear mental capacity test. But as others have said—I will not repeat the quote—experts in assessing capacity from the Royal College of Psychiatrists think that this decision was not thought about when the test was designed and that it is not an adequate test. I will not labour the point now, but we should think about whether we need a new test or, as the noble Lord, Lord Deben, said, an additive process where we take the Mental Capacity Act test and add something to it. There are amendments on both of those—a new test or adding things to it.

That comes to the point that the noble Lord, Lord Scriven, made. Of course, it is true that people make life and death decisions about medical treatment and about whether to refuse medical treatment. But there is a qualitative difference between refusing medical treatment, even if the consequence of refusing that medical treatment will be to hasten the end of your life, and to make a decision for active steps to be taken to administer substances to you which will end your life. They are very different things, and they are treated differently in the law. Perhaps that is the reason why we have had that slight cross-purpose. We need to be very precise about our language when we come to have that debate on capacity. I think that that would be helpful. That is all I will say about that at this point. I suspect that we will have a very extensive debate on Clause 3.

I think that the noble Baroness, Lady Finlay, was getting at something a little wider, which was not just about the capability of the individual to make a decision—that is the capacity piece. It was also about both the information they are furnished with and whether they have all the information at their disposal to be able to exercise their capacity to make a decision. It is not just about whether the information is available but whether the services are available that make that a truly proper, informed decision. Clearly, she has enormous expertise in palliative care.

Whether that palliative care is available in practice is incredibly important. Somebody could have capacity, and we could judge that they do. I listened very carefully to what the noble Baroness, Lady Andrews, said, with her expertise on the Mental Capacity Act, and I listened carefully to my noble friend Lady Browning about the importance of recognising how it works in practice, but it is also about whether those services are available. You could have the capacity and a lot of information provided to you, but if the palliative care services are not available to you, you do not have the ability to make a meaningful choice about whether you wish to end your life. I think that is what the noble Baroness, Lady Finlay, was getting at in that wider use of the word “ability” on top of capacity.

When we get to Clause 3 and the amendments to it, one of the things we should think about is whether we accept that the Mental Capacity Act is a good basis. As people on both sides of the argument have said, it is a tried and tested situation. As we heard earlier, it has been tested in court, up to and including the Supreme Court. We should think about whether we want to replace that with a completely new test or whether we actually stick with the Mental Capacity Act and perhaps have some additions to it, which recognise that it is a qualitatively different decision from whether you are having medical treatment or not. That is the essence of it.

In the place it is in the Bill, just accepting the word “ability” probably is not the right thing to do. We want that wider debate. But the noble Baroness, Lady Finlay, has done us a service in flagging up some of the issues that we can now think about in advance of the debate on Clause 3.

Terminally Ill Adults (End of Life) Bill

Lord Rook Excerpts

Committee stage
Friday 12th December 2025 Lords Chamber

Moved by

[Lord Rook]

19: Clause 1, page 1, line 12, at end insert “and has been so registered for at least 12 months ending with the date of the first declaration, during which time the person has been seen by a general practitioner at said practice (in appointment, consultation, or home visit) at least twice”
Member’s explanatory statement
This provides a simple way to check one of the aspects of ordinary residency required in paragraph (c), and ensures the person in question has been receiving medical care within the jurisdiction prior to making the request.

[Lord Rook (Lab)]

My Lords, my Amendment 19 would add a modest but important safeguard to Clause 1 by ensuring that a person seeking an assisted death has been registered with a GP practice in England or Wales for at least 12 months and has had at least two contacts with that practice in that period, whether in person, remotely or through a home visit. These are minimal thresholds. They do not obstruct genuine applicants. They would simply ensure that before someone seeks the assistance of the state in ending their life, there is at least some continuity of care—the importance of which the right revered Prelate the Bishop of Norwich has already stressed this morning.

To this end, a real relationship with the primary care system is important and prevents a terminal decision becoming subject only to a paper exercise. The Bill already requires 12 months of ordinary residence, but ordinary residence, as we discussed on the last day in Committee, can be, legally speaking, a somewhat elastic concept. A single GP registration can in practice be little more than having your name down on a list. The Government’s own equality impact assessment notes that access to GP services is uneven, that continuity of care is declining, and that patients in deprived or rural areas often struggle to obtain timely appointments.

The independent investigation into the NHS by the noble Lord, Lord Darzi, discovered that more than 1,300 GP practices have closed since 2015, while the average full-time GP now has responsibility for more than 2,200 patients. In such a landscape, it is simply unrealistic to assume that every person approaching the end of life will have a meaningful GP relationship, without a safeguard such as the one I propose in this amendment.

This amendment would give the residency requirement real substance. Twelve months of registration and two GP contacts would not create a barrier but would provide a more objective basis for assessing doctors to know that the person has not merely appeared in the system at a moment of crisis. The amendment would also increase the chance that some medical history exists. Notes of previous consultations, indications of distress, relevant family context and prior diagnoses are all crucial in understanding whether a wish to die is stable or situational.

This matters because, as we have discussed already and at some length, the Bill places extraordinary weight on two clinicians making difficult judgments about a prognosis, about mental state and about possible coercion. Clause 12 allows them to seek information from the person’s GP, but this safeguard works only if a relationship with that GP actually exists.

As a number of noble Lords have mentioned, this House has been served well by the Bill’s own Select Committee. In that, your Lordships heard repeatedly that continuity of care is one of the most reliable protections against misjudging capacity or missing signs of procedure. Dr Michael Mulholland of the RCGP stressed that continuity is not a luxury but central to safe clinical judgment. Professor Katherine Sleeman explained that earlier access to palliative care often changes patients’ perception of their suffering, which again relies on a clinician who knows the patient. Without any medical history or any prior interactions with clinicians, life and death decisions are being made without the proper safeguards. This is not safe for patients, and it is not safe for, or fair to, doctors.

We also heard extensive evidence on access difficulties. Caroline Abrahams of Age UK told the Select Committee that the single biggest practical improvement that older people want is simply being able to see their GP. Many cannot. She noted that significant numbers of older people near the end of life have no contact at all with their GP, not because they do not want it but because the system does not provide it. A report cited in the equality impact assessment on the Bill found that two in three older people in Wales struggle even to make suitable appointments. If access to GP care is already fragile, the Bill must not assume a relationship that does not exist.

There is also the risk, recognised multiple times already in Committee, of doctor shopping. We see it in pain management, in cosmetic procedures, even in end-of-life discussions. When someone is desperate, frightened or grieving, they will simply go from clinician to clinician until they find the answer that they feel they want and need. Expert witnesses, including psychiatrists and geriatricians, told the Select Committee that major emotional shifts commonly occur around diagnosis, around transitions in care or around family crises. These are precisely the moments when a single assessment by an unfamiliar doctor is most likely to misread a temporary situational wish to die as a settled and autonomous choice.

International evidence reinforces the point. Australian states, often cited as models, have tightened their systems after discovering patterns of people travelling to access assisted dying without any real connection to local health services. Canadian doctors regularly highlight the difficulty of assessing capacity and voluntariness when clinicians had no longitudinal knowledge of the patient, contributing to public concern over several high-profile cases.

We need not make those mistakes. The DHSC and MoJ impact assessments underline that assisted deaths must be documented and monitored and that clinicians require access to historical records to make safe judgments. But the true quality and veracity of these records relies on real and consistent engagement with a primary care provider. The Select Committee also heard from social workers and safeguarding experts, who emphasised that subtle coercion is almost impossible to detect in a single clinical encounter.

[Lord Winston (Lab)]

I am grateful to the noble Lord for giving way. I just wonder what he feels a GP should do in the circumstance in which he does not approve of assisted dying? Does the noble Lord feel that that is a problem?

[Lord Rook (Lab)]

With the greatest respect, that is not the conversation I am trying to have here. The conversation is about the necessity that someone who is going through the process has continuity of care and a relationship with that GP. We are suggesting that someone who is after a state-assisted end-of-life process should have the opportunity to see that GP on a number of occasions so that their judgment can be made in the context of continuity of care, not in one appointment.

To pick up the noble Lord’s questions, this amendment would not block access. It would not frustrate autonomy. It would simply ensure that assisted dying does not begin from nowhere. It grounds a grave decision in a minimal but essential relationship with the health service that is charged with safeguarding the person in question. Supporting autonomy requires a supportive context. It requires knowing whether a request reflects a settled conviction, a moment of despair, untreated depression or pressure that the patient feels unable to articulate. These things cannot be reliably assessed in isolation. Above all, care is relational. If Parliament is to contemplate legislation under which the state may participate in deliberately ending life, the very least we must insist on is that such decisions take place within the context of real and primary medical relationships, not on the periphery of the system.

This amendment would strengthen residency safeguards, improve the evidential foundation for clinicians, reduce the risk of doctor shopping and respect the seriousness of what the Bill proposes by rooting it in genuine and consistent care. I commend the amendment to the Committee.

[Baroness Jay of Paddington (Lab)]

Can I ask the noble Lord, having cited the doctor Michael Mulholland as a great authority in relation to his evidence to the Select Committee, whether he also accepts what Dr Mulholland said to the Select Committee? He said:

“As GPs, we are very used to providing holistic care and trying to understand where the patient is coming to us from in lots of situations”.

[Lord Rook (Lab)]

I absolutely agree with that. The reason why the doctor is able to do that is because he gives consistency and continuity of care. He does not see patients on one occasion on one big issue, but is able to travel with them in a longitudinal relationship, and that gives him the ability to make those decisions.

[Baroness Gerada (CB)]

As a GP, I understand the sentiment behind this amendment and the power of continuity; in fact, it was what my maiden speech was about yesterday. But modern general practice works in multidisciplinary teams. We have nurse prescribers, pharmacists and physician associates. We also work with other team members, especially with those at the end of their life, such as palliative care teams and oncology teams. While I understand the need to have a GP involved, I think it is rather reductive. We deliver continuity in today’s world through our medical record, which is a complete record of the individual from cradle to grave. I would say it is with the primary healthcare team that the individual has a relationship rather than with an individual.

On a point of clarification, the average patient over the age of 75 consults their GP team—the primary healthcare team—around 10 times per year, so I do not recognise the figure that most elderly people at the end of their life have no access to the GP. We reach out to our elderly patients and we try to deliver the best possible care we can to them, especially when they are approaching the end of their life.

--- Later in debate ---

[Lord Falconer of Thoroton (Lab)]

My Lords, I indicated my position in my intervention. I will summarise my understanding of the amendment, what my response is and next steps. All the amendments in this group seek a requirement in addition to having a GP before you can have an assisted death. My noble friend Lord Rook suggests having a GP for at least 12 months and having seen him twice before the first declaration. The noble Baronesses, Lady O’Loan and Lady Grey-Thompson, refer to having an “established relationship” with a GP. The noble Baroness, Lady Finlay, refers to one consultation and a home visit before the application. The noble Baroness, Lady Lawlor, refers to a two-year relationship, an average number of visits face to face and then a letter that relates to the medical condition, the treatment and the state of mind of the patient.

As I have indicated, the GP, in the structure of the Bill, is not somebody who has to be involved. The noble Earl, Lord Howe, encapsulated perfectly that the GP is somebody who is receiving information. All these provisions for making it necessary to have a better relationship with your GP than just having a GP do not touch the safeguards. Quite separately from that, I support what the noble Lord, Lord Deben, and the noble and learned Baroness, Lady Butler-Sloss, said. These provisions have an air of utter unreality if you are saying that a condition of an assisted death is a particular relationship with a particular GP. I do not think that any of these safeguards work or reflect the current drafting of the Bill.

It is clear from listening to the debate that people who are concerned with the care should form a basis for the decision. It may not necessarily be making the decision—a lot of people would say that they should not be making the approval—but their input is vital. That was the insight of the noble Baroness, Lady Gerada, which was very much reflected around the Committee. I am willing and keen to reflect that insight in the Bill. But the route is not through newness in relation to the GP. It is reflecting the proposition that the multidisciplinary team dealing with the patient must have some input. I do not know whether that satisfies the question asked by the noble Earl, Lord Howe, but that is the purpose of what I am taking away from this very valuable debate.

As for the right reverend Prelate the Bishop of Gloucester, we are going to speak about prisoners on the next group. Can I reserve my position in relation to prisoners to avoid there being too much duplication?

In those circumstances, I invite the noble Lords not to press their amendments.

[Lord Rook (Lab)]

I thank noble Lords for their patience, passion and seriousness in scrutinising this part of the Bill.

My Amendment 19, which started this debate, possibly needs some clarification. Forgive me, as one who is still becoming accustomed to your Lordships’ House, if I should have intervened earlier on this. I am very grateful to the noble Baroness, Lady Gerada, for her remarks. I had the privilege of working with her in a previous life and saw her brilliant healthcare and the provision of many experts—not just healthcare professionals but the wider community—in seeking people’s health and well-being. Her best-case scenario is what we would like to see in all end-of-life care and in assisted dying.

However, to speak to the comments by the noble and learned Baroness, Lady Butler-Sloss, and the noble Lord, Lord Pannick, my amendment is not seeking for a patient to have to see the same GP twice. That is not the amendment that we are trying to make here. We are asking that someone should be registered in a practice for a year and see a GP twice in that year.

I am very grateful to the noble Baroness, Lady Hollins, for her view that this could mean a wider team engagement—it might not be just the GP. I am saying not that it has to be the same GP twice but that a person has to engage with a GP twice in that stage. If any one of us in this Committee, or any one of our loved ones, were facing a serious medical condition right now, I think we would all have the reasonable expectation that in the next 12 months we might see a GP at our practice. Given the importance of this legislation and just what it will do for the state’s relationship to life and the NHS’s relationship to life, someone who is critically facing the end of life and requesting an assisted death should also be afforded the opportunity to see a GP twice in that period.

Dr Michael Mulholland has been quoted a number of times from his remarks to the Select Committee. I will finish with a quote from him. He said:

“We need to be sure that these things are checked on many levels. It is not at a single time and point where you tick something”.


I am grateful to the noble and learned Lord, Lord Falconer of Thoroton, for his willingness to consider this issue. I look forward to seeing how these concerns and conversations might be expressed and reflected in the Bill. With that, I beg leave to withdraw the amendment in my name.

Amendment 19 withdrawn.