Baroness Grey-Thompson:

Moved by Baroness Grey-Thompson

149: Clause 5, page 3, line 5, at end insert—“(A1) No registered medical practitioner may raise the subject of provision of assistance—(a) within 48 hours of a terminal diagnosis;(b) until a multi-agency assessment to identify the patient’s current support needs since diagnosis has occurred;(c) unless the necessary steps have been taken to meet the needs of the individual and both the assessment of and support for this is fully funded.”

My Lords, the purpose of my amendments in this group is to ensure that all patients’ needs are taken into account and support is given so that people have a genuine choice. I am delighted that my noble friend Lady Campbell of Surbiton will speak to this group. Amendment 149 would ensure that the subject of assisted suicide is not raised within 48 hours of a terminal diagnosis. Perhaps this should be considered a cooling-off period. I have been with someone when they received a devastating diagnosis that they were dreading. They had not considered assisted suicide, but neither of us heard much after initially being told.

This is about a timing issue that could be seen to be a power imbalance or an implied endorsement. Options need to be very carefully discussed. If discussed straight away, treatments might seem so awful that assisted suicide is considered the best option. It might be quicker or easier to talk about this than a complex set of treatment options. To give patients choice, a multi-agency team assessment should take place to identify current support needs and ensure that steps are being taken to meet those needs.

This amendment would also offer some protection to doctors. If the conversation is discretionary, there may be a difficult legal dilemma: if it is raised at the initial consultation, it might be seen to be implicit coercion, but if doctors fail to raise it, that might be considered blocking access. There was a case in South Australia, mentioned in the Voluntary Assisted Dying (Voluntary Assisted Dying Board Annual Report 2022-23). Siblings said that, when they were with their relation, who was given VAD, it was the only time that doctors had shown empathy or understanding. The Medical Defence Union, which supports 200,000 healthcare professionals, is deeply concerned about the appropriate time to raise the subject.

This leads us into a grey area of suicide ideation. We fund suicide prevention; we do as much as we can to prevent someone dying by suicide. This Bill could lead to unforeseen consequences. As previously debated, it does not guarantee a quick or painless death, and if this process exists, the rate of suicide may even rise, as has happened in Australia in the over-65 age group.

There is also an assumption that if a terminal diagnosis is given, the process will be entered into, which might not be the case. ONS data from 2022 shows that people with terminal conditions can feel suicidal. One year after diagnosis for low-survival cancers or COPD, the suicide rate for patients was 2.4 times higher than the suicide rate for the matched controls. One year after diagnosis for chronic ischemic heart conditions, the suicide rate for patients was nearly two times higher than for the matched controls.

In oral evidence, Dr Price said that, of those who would qualify under the Bill,

“around 20% will have diagnosable depression, around 10% will have a wish to hasten death, and around 4% will have a more persistent wish to hasten death

She added:

“Those who had a wish to hasten death were 18 times more likely to also feel suicidal”.—[Official Report, Commons, Terminally Ill Adults (End of Life) Bill Committee 30/1/25; col. 276.]

The Royal College of Psychiatrists has raised issues, stating that doctors do not know how to assess the presence of depression. In a large-scale survey of professionals in England and Wales, co-authored by Professor Gareth Owen in 2021, only 6.9% of non-psychiatric doctors rated themselves as assessing capacity “very well”. When Fazilet Hadi from Disability Rights UK gave evidence, she said:

“We often find that doctors, because they cannot treat or cure us, do devalue our lives”.—[Official Report, Commons, Terminally Ill Adults (End of Life) Bill Committee 29/1/25; col. 180.]

She was referring to disabled people.

The VAD review board of the Australian state of Victoria says that doctor initiation might be the reason for increased take-up. Previously, there was a prohibition on doctors raising it, but that gagging Clause has now been removed. A JAMA Psychiatry paper from 2019 also highlighted the heightened risk during the first week after diagnosis. It said:

“Clinically, our results identify specific cancers associated with significantly elevated risk of suicide”.

The combined literature suggests that the first week after diagnosis has the highest risk for suicide, and it falls thereafter. It therefore makes sense that those who have received a shock terminal diagnosis are most vulnerable and suggestible and may have low self-worth. Macmillan Cancer Support recommends a holistic needs assessment as part of cancer care. The Bill will be better for having this assessment built in and will lead to more patient-centred care. It is impossible to have true agency when only one realistic choice is offered. That is why it is crucial that the patient’s current support needs are identified after diagnosis.

I strongly support Amendment 155 in the name of the noble Baroness, Lady Keeley. I feel very strongly that patients should be able to discuss their diagnosis and treatment with no fear of potentially being encouraged or having this process suggested to them.

On Amendment 176, we have covered complications before. The noble and learned Lord said in the Chamber that a discussion should take place before the first set of drugs are taken, and, if they do not work, the patient can choose to take a second dose of poison. But what is there to protect the doctor? Will the wishes be written down or witnessed? What should the doctors do if the drugs do not work? Should the doctor have a second dose with them? Will it be a doctor or, perhaps, a physician assistant? Is euthanasia the next step? It could be seen to be the next logical step in expansion. If one or two bad deaths are recorded, we might be told that we need to be more compassionate, and this is the best way to go.

In Hawaii, a doctor allegedly completed the death of a patient after the woman began choking; it was reported in the Honolulu Star-Advertiser. That doctor was charged with second-degree murder. Legally, a patient needs to know the effect of the drugs. Clause 12(2) refers to the need to discuss the complications, but we cannot play down the risks. Data from Oregon from between 2012 and 2022 showed a complication rate of 11%. In the Netherlands, in one-third of cases it takes up to 30 hours for a patient to die. As I have said before, assisted suicide is often represented as painless and quick, allowing for a calm and meaningful goodbye, but the reality from cases around the world shows that it can be far from this. The case of Kurt from Colorado has been raised previously by my noble friend Lady Finlay.

There has been much said in this Chamber about the importance of words, and I strongly believe that the word treatment does not cover what we are talking about. Using “treatment” to mean a lethal mixture of drugs intended to end life is clearly an attempt to soften the blow of reality. That is why people are not aware of the frequency of complications, and of the need to know the wishes of the patient in the event of complications.

My Amendment 200 is very similar to Amendment 149— it just seeks to amend a different part of the Bill. Briefly, I will talk to Amendment 200A and the unique context around the preliminary discussion, because failure to comply with regulations is appropriately treated as misconduct and subject to existing disciplinary procedures. I know that the noble and learned Lord is not keen to ask someone why they would want an assisted suicide, but I think the question should be asked. People do not need to answer, but we need to ask, to understand the process and look at whether there are other ways that we can improve our health service.

In Victoria, in 2023, the reasons for accessing VAD were not recorded, so the nature and source of the suffering—which is a clear criterion for access to VAD—is not known. This information could help us improve legislation in the future, or close gaps. The impact evaluation of VAD is undertaken by researchers funded by time-competitive grants, which means the results can be piecemeal and the data not always accurate. In 2023-24, 10 doctors with the highest VAD caseloads consulted on 55% of all VAD cases. In Australia, the VAD substance is often taken in the absence of a health professional, and there are no specific requirements or procedures for gathering or publishing information, including on whether complications have occurred.

Turning to my Amendments 207 and 207A, I have previously quoted Tommy Jessop and his concerns for people with Down syndrome. People with Down syndrome put great store in people in positions of trust around them, and the Learning From Lives and Deaths report that was published in January 2026 discussed some of the challenges. The proportion of deaths of people with learning disabilities classified as avoidable was 40.2% in 2023; it was 21.8% for the general population in 2022, so the figure is almost double. That demonstrates that there are problems in healthcare for people with learning disabilities. Some 72.7% of adults with learning disabilities who died in 2023 were reported to have received the reasonable adjustments they required when they accessed care, but conversely, 27.3% were reported to have needed at least one reasonable adjustment that they were not provided with.

There are already deficiencies in our system, and disabled people are discouraged by ableist attitudes in our culture. In 2024, Autism Alliance UK reported that 91% of autistic people feel that society does not accept them, or only sometimes accepts them. That is the reason why my amendments would widen the definition, so that we should be looking to support from a “guardian, or independent person”. Many families are loving and caring, but we have to recognise that some are not, and we should ensure that people have the right protection and support around them. I beg to move.

My Lords, I will speak to my Amendment in this group, Amendment 200B. It would insert a new Clause to say that care professionals are not permitted to raise the subject of assistance. For the avoidance of doubt, the proposed new clause says that anyone who is engaged in patient care may not

“raise, suggest, encourage or initiate consideration of the subject of the provision of assistance under this Act”.

There are four main reasons why I have tabled this amendment. First, it would give clarity and absolute legal certainty to those in the medical profession and to care professionals regarding the initiation of discussion of the subject. We know that other parts of the Bill set out a clear position on what actions will be taken by medical professionals when it comes to the administration of the assisted death, but it is important that we have a clear legal position when it comes to the front end of the process. That is not simply to give assurance that there is clarity in the law; I think it would give comfort and certainty to anyone who is involved in the care profession. If I were a care professional, I would want to know with certainty what I am entitled to do and not entitled to do. My amendment would give a level of support to those people.

Secondly, the amendment is very much in the spirit of trying to create a distinction between healthcare and the provision of assisted death. A concern has been raised on a number of occasions in this Committee about the extent to which assisted death will alter the perception of the National Health Service and its mission statement. This amendment in and of itself would not solve all those problems, but at least it would go some way to having a level of protection for the National Health Service, which is very much the jewel in the crown of this society. It was created through probably the most significant legislation that a Labour Government ever put through, and it is important that we look at the implications of this.

I remember remarks being made on an earlier group by the noble Lord, Lord Empey, who said that moving outside the bubble of this Chamber we have to work out how people on the ground will perceive the existence of assisted dying, particularly if it is located in the health service. There is a fear that the perception out there will be that someone going to their doctor might be steered in the direction of an assisted death—or will they be receiving care? Because in our society there is word of mouth, that is a real danger for health provision. Having that distinction is important.

Thirdly, this is one of a number of amendments required to this Bill to provide some level of safeguard to try to address the concerns of the many disabled groups out there. It is no surprise, and people need to think about this, that among the dozens upon dozens of groups representing the disabled there is not a single one in support of this legislation. There are widespread fears and concerns.

Quite often, when we are talking about provisions for the disabled, there will be honeyed words in this Chamber, but there is a danger that the concerns of the disabled will be treated in a certain blasé fashion. It is difficult for any of us to put ourselves into the minds of those with severe disabilities. If you are disabled, particularly if you have a visible disability, the world looks at and treats you differently, and it speaks to you differently. As many noble Lords will know, in the past three years, due to a partial disability, sometimes I can walk about without any aid but, if I am going any distance, I have to use an electric wheelchair—it is electric because I do not have the same level of fitness as the noble Baroness, Lady Grey-Thompson. I see that members of the public look at me and perceive me differently when I am in a wheelchair from when I am not.

As an aside, last summer, whenever we had one of those days, which are rare in this country, of warm sunshine, and I was out and about in a pair of sunglasses, I got pitying looks from some people, as if they were thinking, “Look at that poor man. Not only is he disabled and in a wheelchair but he is obviously blind as well”—though that might have been more of a commentary on my wheelchair driving.

The reality is that there are deep fears and concerns out there among disabled people. One of the biggest concerns that many of us have with this Bill is around the issue of coercion. It is not simply about the clear-cut form of coercion of family members pushing a person into an assisted death; it can be a much more subtle process. The concern is that disabled people will be made to feel a burden and that the only route out for them is an assisted death. Further, if they feel that they are getting suggestions or if it is being raised in conversations with medical professionals, that puts an additional pressure on them, particularly so for those with suicidal ideation. Picking up remarks and suggestions can lead people down a path along which they do not have to go.

Finally, the key reason for this is that it preserves the idea of autonomy. Initially, one of the key principles of the Bill was to deal with the situation of pain and suffering, and there have been well-rehearsed arguments about why that has disappeared completely from it. For the proponents of the Bill, the key argument, the golden thread that has run through it, is the autonomy of the individual. If we are genuinely to respect the autonomy of the individual, the initiation of any process of assisted death has to come from that person. That is not simply protection against coercion: it is to ensure that it is not initiated or suggested by others. I look forward to the response of the Bill’s sponsor in relation to this, perhaps more in hope than expectation, given some of the responses, but I look forward to the rest of the debate.

Before anybody else intervenes, I should have said at the beginning of this group of amendments that the noble Baroness, Lady Campbell of Surbiton, and the noble Lord, Lord Shinkwin, will be taking part remotely. I apologise to both of them for forgetting that at the beginning. The noble Lord, Lord Shinkwin, is taking part remotely and I invite him to speak.

My Lords, Amendments 162, 194 and 858 are in my name, and I should make clear that I do not intend to move them. Amendment 162 proposes that, where a person has Down syndrome or a learning disability, a registered medical practitioner must not initiate, suggest or raise the matter of assisted dying with that person. This is consistent with two findings of a new poll by Whitestone Insight, to which my noble friend Lord Harper referred in the previous group. It shows, first, that 84% of people believe that assisted dying should be initiated only by the patient, and that figure rises to 91% among people aged over 75. It also shows that 86% of people support additional safeguards for people with Down syndrome, autism and learning disabilities.

Ken Ross of the National Down Syndrome Policy Group told the Select Committee on the Bill that

“those with learning disabilities may place great weight on a doctor’s suggestion and be unduly influenced towards choosing an assisted death”.

He added:

“The acquiescence bias risk from people with Down syndrome is extraordinary”.

We have talked extensively about the huge risks of coercion caused by this poorly drafted and unsafe Bill. As our forensic scrutiny has highlighted, these cannot be overstated for some of the most vulnerable members of our society, including people with Down syndrome or learning disabilities.

The noble and learned Lord has complained about the number of amendments that have been tabled, but, bizarrely, he did so without any acknowledgement that this reflects the very poor state of this unsafe Bill when it came to your Lordships’ House. It is regrettable that the noble and learned Lord, in his consistently dismissive responses, is sabotaging noble Lords’ carefully considered and reasonable attempts to mitigate the worst effects of his badly drafted Bill. That is the purpose of Amendment 162 and its consequential Amendments 858 and 194, none of which I would have needed to table if the Bill were safe. Amendments 194 and 200A, in the name of my noble friend Lady Maclean of Redditch, who cannot be present today, would require the Secretary of State, by regulations, to make provision about the training, qualifications and experience that a registered medical practitioner must have if they are to exercise their professional judgment under Sections 2 and 3.

At the moment, despite the sensitivity of these conversations, not least with people who, because of Down syndrome, are predisposed to agree with what they are told and are unable to compute the gravity or finality of the choice of an assisted death, and the fact that a conversation is the first step on the pathway to end that person’s life with lethal drugs—despite all this, there are no minimum requirements for training or experience. In such a situation, where the Bill grants every doctor legal protection if they exercise their professional judgment to discuss assisted death with a person, is it not essential that there are minimum requirements to qualify for this protection?

Surely, the question is how they could not need minimum training or experience to deal with such delicate and sensitive situations, especially those involving people with Down syndrome and learning disabilities? I cannot understand how anyone could think that they do not, unless there is another agenda at play that prioritises, over everything else, making access to an assisted death as easy as possible, and thus unencumbered by safeguards such as those my amendments would provide, in particular to those with Down syndrome or learning disabilities, because these disabilities would place them in an invidiously vulnerable situation

Mr Ross told the Select Committee that such training should be mandatory. He also cited a shocking statistic which underlines the point made earlier by the noble Baroness, Lady Grey-Thompson, about the extent of existing discriminatory outcomes in evidence of health inequalities, which was revised only two months ago in a corrected version of the 2025 LeDeR report. The statistic is that just over 40% of people with learning disabilities die from avoidable causes—and that is now, without the Bill. We may consider how much worse the Bill would make that deeply unsettling statistic.

Mr Ross also told the Select Committee:

“There is a real fear among the people with Down syndrome I have spoken to that this Bill will further target their lives”.

Is the noble and learned Lord really going to ignore their fear? I have to say, that is not the Labour Party that I, and many other disabled people, know and respect.

While dismissing the case I made in Committee on 6 February relating to people with congenital lifelong conditions such as mine, the noble and learned Lord expressed sympathy and referred to my “fate”—which is a bit ominous, although perhaps inadvertently accurate in the context of this Bill. I dare say I should be grateful for such touching thoughtfulness, although I am not sure his sympathy would afford either me or, in relation to these amendments, a person with Down syndrome or a learning disability any protection from the deadly provisions of this deeply flawed Bill.

In closing, I readily acknowledge that translating warm words of sympathy into effective safeguards might defeat even the most able of advocates; perhaps, therefore, I could offer a more practical solution in the form of these amendments. I hope the noble and learned Lord will accept them.

My Lords, I have added my name to Amendment 149 in the name of my noble friend Lady Grey-Thompson. I also support the principle underpinning Amendments 150, 151 and 154, all of which aim to prevent a medical practitioner initiating discussions on assisted dying under Clause 5 of the Bill.

Like the noble Lord, Lord Shinkwin, I thoroughly agree that doctors must not be permitted to initiate conversations about assisted dying to patients. Let me tell your Lordships why. Doing so would breach their fundamental duty of care to their patients at the very point when the patient may well be at their most fragile—newly diagnosed and frightened about what the future holds. It would not be a neutral clinical act but an Intervention laden with power, meaning and consequence. The very suggestion of assisted death from a doctor at such times risks being heard not as an option but as a judgment.

Not long ago, during the scariest time of the Covid-19 pandemic, disabled people were contacted by their GPs to ask them to allow permission for DNR notices to be placed on their medical records should they be hospitalised after contracting the virus. Disabled people were horrified; many contacted me and other parliamentarians to know why they were being treated differently from non-disabled people. They said that it felt as though catching Covid would be a death sentence. Thankfully, the Secretary of State for Health rectified the issue, reminding doctors that their actions were in contravention of the Equality Act and the Human Rights Act, but the damage was already done. Disabled people who relied on their doctors for their health and well-being felt betrayed and unworthy of life-saving treatment.

If a medical practitioner raises the possibility of an assisted death, the patient’s feeling of security and trust will be damaged in the same way as during the pandemic. Your Lordships have often heard me say that I count my blessings every day because my doctors support and celebrate my life, however ill I become. I feel secure knowing that they will do their absolute best, however grim my prognosis may be. Reliance on that assurance is critical to the well-being of patients, especially those with long-term disabilities.

If assisted dying is to become an option, it must be one that is strictly patient-initiated, tightly defined and clearly demarcated from ordinary clinical care. It must sit within a system that prioritises palliative care, practical support and the affirmation of life; otherwise, it will be seen as the simplest and most straightforward option for the patient, their family and friends, the NHS and society as a whole.

The doctor-patient relationship is inherently unequal, and never more so than after a terminal or life-limiting diagnosis. When a doctor introduces the possibility of assisted dying, however delicately phrased, it carries weight. For many patients, particularly those who already feel themselves to be burdensome, costly or devalued, the message risks being internalised as a subtle signal that their lives are no longer worth living.

We must also confront the reality of acute vulnerability. A diagnosis of serious illness often brings shock, despair and temporary suicidal thoughts—feelings that, with time, treatment and compassionate support, frequently pass. This is why I support my noble friend Lady Grey-Thompson in her Amendment 149, which seeks to address this. Depression, unmanaged pain, fear and loneliness are not unusual bedfellows for people with a terminal diagnosis. Medical practitioners are not specialists in disentangling these states.

If we are serious about safeguarding autonomy, our first duty is to ensure that people are offered care, hope and practical support, not an expedited exit at a time when they feel most afraid. I therefore hope the noble and learned Lord will recognise this and come back with his own amendments on Report, to ensure that the subject of assisted dying is raised only by the patient and never by a medical practitioner. I would be very pleased to meet him between now and Report to explain further why this is so essential for the legislation to be safe in practice.

It is with some trepidation that I speak, since I realise how passionately the previous speakers think about what they have said. The first small point I want to make is that the noble Baroness, Lady Campbell, referred to Report—we are not going to have a Report stage, because we have taken so long in dealing with all the many, many amendments that have been tabled.

Leaving that on one side, we have to realise that doctors’ main objective is to try to alleviate suffering. This is what those of us backing the Bill believe it does: it will alleviate suffering—sometimes terrible suffering—and torment by allowing people to choose the time of their death when they are already dying. We must not forget this. If we accept that this is the role of doctors, that this is what they try to do in their professional work, we must allow them to discuss at an appropriate point, in their judgment, all the possible options that are available to the dying person. If the Bill were enacted, one of the options would be an assisted death if they had reached that point. So to say that a doctor in a close relationship with his or her patient would be unable to raise this as a possible option would be entirely wrong.

I advise everybody, if they have not done so already, to look at what the BMA says about this. It has specifically briefed against prohibiting doctors from initiating discussion about assisted dying under the Bill, warning that it will be detrimental to patient care. I accept this piece of advice from the BMA. It is a view that many doctors, and some in this Chamber, too, would actually adhere to and agree with.

I very much hope that this group of amendments will not be accepted. It does not mean that at the end the patient is not the one who makes the decision about whether to request an assisted death—of course he or she does. But it just becomes one of the options that is available to them, and that is an option I believe we should allow them to be aware of.

My Lords, I will speak to my Amendment 151, which is supported by the noble Lord, Lord Carlile, and the noble Baronesses, Lady Fox and Lady Hollins. It was also referred to approvingly by the noble Baroness, Lady Campbell, in her earlier remarks. My amendment would prohibit medical professionals from raising assisted dying as an option, unless explicitly requested by the patient.

I will be very brief in introducing this amendment, by pointing out to the Committee that it goes to the heart of a juxtaposition suggested by the Bill. On the one hand, we have an increasingly large, frail, vulnerable, often elderly population, who may not have the full autonomy that the sponsor of the Bill suggests. On the other hand, we have a National Health Service that, by the nature of events, is almost always underfunded and feels that it will be underfunded. If you put those two things together, there will be an inevitable pressure to cut costs and present the cheaper option to the patient who is seeking guidance.

I have carefully read the sponsor’s words in Clause 5 and it is true that, on paper, the patient must be offered the option of palliative care as well as that of an assisted death. However, in these circumstances of financial restriction, I am concerned about the patient being steered in a certain direction. I will not regale the Committee with horror stories from abroad, usually from Canada, about precisely this taking place. Were I to do that, the sponsor of the Bill and others would, quite rightly, point out that there are safeguards in the Bill that are not present in Canada. I would point out in return that safeguards can be whittled away over time. In making that point, I mean nothing to the detriment of the sponsor of the Bill; I am sure that he does not mean it to happen but, over time, people can make amendments and changes to legislation.

I will step back from this amendment and look at it in this way. I believe that assisted dying is intrinsically problematic and, if the Bill ever got further, I would vote against it at Third Reading. However, my concern while we are here is to improve the Bill. If we are to have such a Bill, I want it to be in the best—I should say the least bad—condition possible. Noble Lords know that nothing in the amendment would alter the basic architecture and structure of what the sponsor of the Bill has proposed—in relation to the first doctor, the second doctor, the panel, proxies, the regime for regulating substances or any of that. The amendment would do nothing whatever to prevent anyone seeking an assisted death. All it would do is to prevent a medical professional raising it.

Therefore, I suggest to the noble and learned Lord the sponsor that, if he wants to make some progress with the Bill, he might accept this amendment or one of the many others in this group to a similar end. I look forward to hearing him when he replies but, whether he does accept it or not, this amendment would write a safeguard into the Bill that is not there, and I commend it to the Committee.

I congratulate the noble Lord because, although I disagreed with his conclusions, in just three minutes and 35 seconds he managed to summarise brilliantly the arguments both ways and the evidence.

My Lords, I will add a word to follow my noble friend Lord Goodman’s Amendment 151, in proposing my Amendment 153A. This goes further to stipulate that a medical practitioner may not raise the subject with the patient

“unless the person has raised it first during an in-person appointment requested specifically for that purpose”.

We have spoken today about the position of trust that the doctor enjoys. He or she is trusted by the patient and by our society, and is paid for by the taxpayer who trusts him or her. That trust is breached if the position is used not for the treatment of a patient’s symptoms, to help manage them or to benefit the patient, but to suggest that the patient should instead consider killing themselves.

A doctor who is trusted to find the best medical treatment for, say, pneumonia, blood pressure or heart disease becomes an agent who leads to the medicalised death for the patient with a poison that is self-administered, as if it were just an ordinary curative medicine. Moreover, as the Bill stands, the requirement to discuss possible side-effects and complications, which we know happens in other jurisdictions, is not there. Perhaps we might also consider why doctors are in this position of trust. It is because they have special knowledge, not only of medicine and its treatment, but of access to medications. They are especially trusted when the patient is very ill, very frail or terminally ill and perhaps already feeling a burden to those who are looking after them. If we permit the doctor to raise the subject of assisted dying to those who are so suffering, we leave the door wide open to the abuse of power. It need not be deliberate abuse. The doctor may only be raising a possibility—

Is the noble Baroness, Lady Lawlor, aware that, of all the countries in Europe, it is the Netherlands where doctors are most trusted? We should consider what their legislation is and how close, often, the relationship is between the doctor and the patient who is in receipt of assisted death. I am not advocating their legislation, but I note that, of all the countries that have assisted dying, the doctors are most trusted in the Netherlands.

I thank the noble Baroness for that, but I point out that the Netherlands has many significant problems to do with various aspects of its legalisation of certain medical actions and operations. I will not go into them, but other countries are suffering from a fallout of what is happening, especially those on a rail service from Amsterdam.

If we leave the door wide open, it can happen. A doctor may only be raising the possibility, but a patient may be more swayed by a doctor’s opinion than their own. Indeed, where no pressure is intended, the pressure may be there none the less. The position of trust can therefore survive only if the doctor recognises that their normal role is limited to supporting the health of the living, helping the patient to live life as fully as possible by managing an illness or its symptoms or coping through the ups and downs of treatment. Participating in assisting suicide, for those doctors who agree to do so, is an extraordinary non-doctorly role that they should enter into only at the self-initiated request of the patient.

My Lords, I have found some of this discussion quite difficult to compute with my own very limited—non-doctor—experience of end-of-life care and relatives who have been dying. The noble Baroness, Lady Lawlor, spoke as if there was a very binary Division between assisted dying care and palliative care. Yet the cases that I have been involved with and seen very closely have been of people very definitely frail and at the end of their lives, and where the range of options they wanted to talk about were not simply pain relief. This whole time, no one has mentioned the right of people to exercise autonomy, to stop eating and starve themselves to death. Does the doctor not consider what happens in those circumstances and talk about options then? There is the option, of course, to turn off life support. There is the option—which my mother chose—to refuse any blood transfusions. Doctors talked her through how that would reduce her life expectancy.

My Lords, I will speak to Amendments 150, 156, 166 and 205, to which I have put my name, and in support of other amendments in the group.

As drafted, the Bill would permit a discussion about assisted dying with the patient before any requirement to discuss expert palliative care. The noble Baroness, Lady Blackstone, said that it would be irresponsible not to allow this. In Australia and New Zealand, doctors are not permitted to initiate such discussions.

As drafted—

Doctors in Australia are now allowed to do so. The law has been changed there.

I accept the noble Baroness’s Intervention, but they certainly thought it was a bad idea, and there is further discussion in South Australia about the issue.

If I may go on: as drafted, the Bill will permit discussion about assisted dying before discussion about palliative care. It would come as something of a shock—

I think the position was that there was an Act in Victoria, Australia. After the five-year review of the operation of the Act, the Government recommended that the prohibition on raising it be removed as it was found to be impeding access and undermining patient-centred care. The Royal Australian College of GPs welcomed the recommendation as a sensible step and the law was changed.

I accept that, no problem.

It would come as a shock if a doctor came to one’s bedside and said, “In these circumstances, you may wish to consider an assisted death”. Experience would tell us that a patient might not hear much more of any discussions about treatment and palliative care, given the shock and their already vulnerable state.

Can the Minister explain why the Bill is drafted as it is in this context, permitting a discussion about assisted dying without requiring a previous discussion about palliative care? Can the noble and learned Lord, Lord Falconer, assure your Lordships that there will be a genuine choice?

The noble Baroness will know that Clause 5 specifically says that if a registered medical practitioner raises the question of assisted death, he

“must explain to and discuss with that person … all appropriate palliative, hospice or other care” that is available. It says:

“Accordingly, such a preliminary discussion may not be conducted in isolation” of, among other things, palliative care. I am not sure of the basis on which the noble Baroness is saying that that should come before rather than at the same time.

I am saying that it should come before, because Clause 5, as drafted and as the noble and learned Lord read it out to the Committee, says it is to be part of a discussion about assisted death. I suggest to the Committee that if a doctor mentions assisted death, that will focus one’s mind in a way that may cause distress, shock and all sorts of things.

There is another problem: the issue of the doctor raising the issue despite the fact that the patient has given no indication that he wants to talk about it. The Bill is said to be a matter of autonomy, but it cannot be denied that there is an unequal relationship between the patient and the doctor. Doctors are perceived as knowing and acting in the interests of the patient. Under the constitution of the National Health Service, it is provided:

“It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives”.

Even where a patient may have autonomy, were a doctor to initiate a discussion about assisted dying, he or she would fundamentally undermine patient autonomy. Offering assisted suicide is not the same as offering palliative care, cancer treatment or any other care. These are all directed to the treatment of a living person. Assisted suicide is about killing the person.

When doctors raise assisted suicide or assisted dying, patients may interpret this as an implicit recommendation or, indeed, a judgment about the value of their life, not a neutral option. That undermines agency. A choice influenced by authority, fear or deference is not a free choice. There is a huge risk of a doctor exercising undue influence and exposing patients to pressure at the most vulnerable point in their lives. I heard the noble and learned Lord, Lord Falconer, acknowledge that doctors hold exceptional authority over patients. He should reflect on that.

The solution to these problems, as in Amendments 150, 151 and 154, is to amend Clause 5 to provide that there would be no discussion with the patient until the patient says that they want the discussion. Amendment 156 would delete Clause 5(2) and is consistent with the other amendments. Amendments 159 and 160 would clarify the meaning of the Bill to state specifically what is to be discussed: the death of the person sitting or lying in a bed before the doctor, not any other matter. All these amendments would bring clarity and additional protection.

Amendments 157 and 164 would protect the patient even further by providing that, where a person has told their GP they do not want a discussion about assisted dying, this should be recorded in their notes. That should provide an audit trail of the wish of the patient. This must then be complied with by any registered medical practitioner.

Another problem is that, as drafted, the Bill will allow any doctor to raise assisted dying with any patient, regardless of whether they are under their care at the time or whether, for example, a locum doctor has temporary care of a patient, even for one day. The solution suggested in Amendments 155 to 157 would preclude any doctor from raising the issue with a patient who has previously considered assisted dying and rejected it or who has opted out. Further amendments would ensure that doctors would be legally permitted to raise assisted dying only with people who are genuinely under their care, not with any person they encounter. The solution offered in Amendment 158 would require that the doctor must have known the patient for six months.

Can the noble and learned Lord confirm that the provision currently in Clause 5 allows any doctor to raise the option of ending the patient’s life if they feel it is appropriate to do so in their professional judgment? Can he also confirm that, as drafted, the Bill is not limited to the patient’s GP or treating consultant specialist and that there are no restrictions on the settings in which a doctor might do this, or in whose presence they might do this? Allowing any—

Am I right in understanding that the noble Baroness’s amendments are designed to achieve a situation where someone experiences and receives the best palliative care before the discussion takes place? Otherwise, as the most reverend Primate the Archbishop of Canterbury has said, any choice that you exercise could be illusory, unless you are in that situation.

I thank the noble Baroness for her helpful Intervention.

There is a further problem. As drafted, there is nothing to prevent any other health professional—a nurse, health visitor or physio—raising assisted dying with a patient. Sometimes, patients form stronger relationships with these people than with doctors because they see more of them. It is essential, therefore, that there is no possibility of a warm-up conversation being initiated by a professional to ease the ground for the doctor when he wants to make his approach. It may be said that this would not happen, but we have seen ample evidence of situations in which cost savings to be secured by freeing up beds and ending treatment are regarded as justification for assisted death. We have, of course, seen situations in which a person who has suffered an amputation or has a terminal cancer seeks a wheelchair and is told the waiting list is two years, but that assisted dying can be provided tomorrow. Any situation in which assisted dying is discussed for the first time must be strictly patient initiated, tightly confined and take place through a clearly defined process.

Amendment 205, to which I put my name, as well as Amendments 207 and 207A and other amendments in the group, would prevent any discussion about assisted suicide with a person who has a learning difficulty or autism without a family member, guardian or independent person present. The effect of this would be to do what all professionals and caring organisations do when dealing with or engaging with people with such disabilities. I also support Amendments 317, 346, 457 and 512 in this group, which seek to protect those who experience feelings of suicidal ideation, which may be transient.

What about the doctors? The MDU, which represents over 200,000 healthcare professionals, is deeply concerned about the proposals in the Bill. The MDU points out that the position whereby doctors are not required to raise this but are still permitted to do so is the worst of both worlds for doctors because they would be liable to complaints in either situation. If the doctor does not raise it, a complaint can be made against them for not having done so; if they do raise it, a complaint can be made against them. As the MDU points out:

“Such proceedings can take a vast toll on doctors. The time taken; the emotional toll; the procedural concerns. This cannot be overstated”.

This is one of the many unintended consequences emanating from this Clause as drafted. The clause requires substantial amendment to make it safe.

There seems to me to be a whole range of circumstances that you would want a doctor to be able to talk to the patient about. It is not simply, “We can offer you a way”, and they only talk to you and say, “This is the palliative care available, and only if you have heard that, seen it and chosen from it can we then talk to you about something different, which is assisting your death”. It seems to me—

As I understand it, the noble Baroness is talking about various possible options. Would she think it a good idea if the doctor were free to advise the patient to stop eating?

It is very important that the doctor should listen to the wishes of the patient. I certainly think that a doctor should not be able to force-feed a patient in those circumstances.

My Amendment 169 is a very modest one. It simply proposes that, if the Bill proceeds, before any doctor raises the possibility of assisted dying, the patient should first receive a psychological assessment from an appropriately qualified specialist. This is not an onerous hurdle but a basic and sensible safeguard.

As many noble Lords have said, when people are approaching the end of their life, they are often in a very vulnerable state. Feelings of sadness, anxiety or despair are not unusual and even the most resilient of individuals is affected. That vulnerability can become much more acute when patients are told that they have a terminal illness and perhaps only six months to live. Such news can be profoundly shocking and can often trigger despair and even suicidal thoughts.

The evidence reflects this reality. Research drawing on data from the Office for National Statistics, King’s College London and the University of Manchester shows that the risk of suicide rises significantly in the first six months after diagnosis. In other words, the period immediately following diagnosis is often when patients are at their most fragile psychologically. This is precisely why we must proceed with great care.

Before introducing the possibility of assisted dying, it seems only prudent to understand the patient’s mental state. Without a proper psychological assessment, we cannot know whether patients are coping as well as they appear to be or whether they may be struggling with depression and even suicidal thoughts. Studies suggest that from 20% up to 40% of patients with advanced cancer experience clinical depression. Dr Rachel Clarke, a palliative care physician, warned the Commons Public Bill Committee exactly about this situation, saying that raising the question of assisted dying can unintentionally place pressure on a vulnerable patient.

Autonomy is often far more fragile and complex than we assume. When someone has just received devastating news, even a carefully framed question may be interpreted in ways that we never intended. Both the Royal College of Physicians and the Royal College of Psychiatrists, as well as palliative care and disability groups, have warned that vulnerable patients are not adequately protected by the Bill as it currently stands.

Ordinary doctors are not usually trained to make complex psychological assessments. According to the Government’s own impact assessment, doctors involved in these early conversations may receive as little as 90 minutes of e-learning and one hour of an online interactive session. Surely that is unlikely to equip them to recognise subtle depressions or suicidal feelings in patients who are already known to be at great risk.

My son is a consultant physician at the largest psychiatric hospital in Berlin. For many years he has worked on the front line treating patients in acute crises and teaching junior doctors how to recognise mental illness. His view is very clear: depression can be remarkably easy to miss if you are not a specialist.

We assume that every human has free will, but this will be impeded by severe depression. People suffering from severe depression may appear calm, rational and composed—they may even seem cheerful—yet internally they may be struggling with profound hopelessness and suicidal thoughts that impair their judgment and decision-making. Research published in the Lancet has shown that general practitioners detect depression in only 50% of cases. This is not a criticism of them. It simply reflects the fact that recognising depression, especially in people with a serious physical illness, requires time, training and specialist experience. In the context of assisted dying, this matters enormously. A misdiagnosis is not a harmless mistake. It can have fatal consequences for a patient whose suicidal thoughts might be treatable and whose desire to die may have been only temporary.

For that reason, many psychiatrists across the United Kingdom and Europe believe that a specialist psychological assessment should come at the very beginning of the process. It is a careful, humane and responsible safeguard that ensures that a request for assisted dying reflects a settled decision, not untreated despair at a moment of profound vulnerability. If we fail to make that assessment first, we risk confusing a treatable cry for help with a settled and autonomous decision to die. To proceed without that knowledge is unfair, unethical and legally questionable, as many noble Lords have said before me. The noble Baroness, Lady Finlay, one of the most authoritative medical voices in the Lords, has warned:

“Without proper psychiatric assessment, a request to die may reflect treatable depression rather than a settled wish to end life”.

I very much hope that the noble and learned Lord, Lord Falconer, will take into account these worries and accept my amendment.

My Lords, I have tabled four amendments towards the end of this group, Amendments 317, 346, 457 and 512, which are in identical terms. They are designed to ensure that a person seeking a state-assisted death is not acting out of a temporary feeling of fear, panic or anxiety in relation to their diagnosis and prognosis. I am grateful for the support of the noble Baroness, Lady Fox, and the noble Lord, Lord Farmer. I can testify that when a person is told that they have a terminal illness with only a year or so at best to live, it is difficult to think rationally. It does not occur to you that it will often be a wholly inaccurate prognosis or that specialist palliative care can deal with most pain. My amendments therefore seek to ensure that the assessing doctors are satisfied that a person seeking a state-assisted death is not acting from such feelings of panic.

The noble and learned Lord the sponsor may say in response that the Bill already requires the doctor to ascertain whether the person has a “clear, settled” wish to end their life. However, it seems to me that a person can have such a clear and settled wish as a temporary result of fear, panic or anxiety. These amendments seek to raise the threshold at which an assessing doctor can be satisfied that the person has such a clear and settled wish.

It is at moments like that, when people are at their most vulnerable, that great care needs to be taken to ensure that they do not opt to go down a path which, on deeper and longer reflection, they might decide is wholly unnecessary or inappropriate for them. Yes, in theory they can change their mind later, but many people might feel reluctant, for all sorts of reasons, to reverse their decision once they are on that track, so the initial discussions with the assessing doctor are critically important.

A full specialist palliative care assessment, which was in an Amendment I previously tabled in Committee that was rejected by the noble and learned Lord the sponsor, would help to ensure that they are not acting out of despair, fear, anxiety or panic, since it would put a pause on the whole process and ensure that their wish to end their life was properly informed, as required by the Bill. Both these sorts of amendments strike me as obviously desirable in a Bill of this nature, and I urge the noble and learned Lord the sponsor to avoid the need to have to bring them back on Report.

My Lords, Amendments 158 and 163 are in my name. I will speak also to Amendments 157 and 164, in the name of my noble friend Lord Ahmad, who cannot be with us here today. Amendment 157 in my noble friend’s name

“seeks to ensure that a doctor may not raise assisted suicide with a patient who has ‘opted-out”’.

The statement on Amendment 158 in my name says:

“The Bill appears to permit any doctor to raise ending a patient’s life, even if they have no prior relationship with the patient. This amendment specifies that a preliminary discussion can only take place with a registered medical practitioner who has known the patient for a minimum of six months”.

Amendment 164 in my noble friend’s name would insert:

“If a person has informed their general practitioner that they do not wish to discuss the subject of the provision of assistance in accordance with this Act, that fact must be added to their medical records, and a registered medical practitioner must not discuss it with them”.

In his observations on the previous group, the noble Lord, Lord Deben, made a powerful point. He said that, based on his experience as a Constituency MP, many members of the public are worried by doctors and hospitals, so when we debate medical issues in this House and put legislation on the statute book, it worries very great numbers of the population. It reminded me of my grandmother, who died 10 years ago. She lived until she was 97, but she had a theory that if you went into hospital, you did not come out alive. When I went to see her in East Cheshire Hospice—an outstanding hospice—at the age of 97, she grabbed hold of my arm and said, “What did I tell you? They’re trying to kill me. Get me out of this place”. But she died a very dignified death.

It was similar with my 90 year-old mother. There was an outstanding family GP service that knew our family, and we knew the GPs. There was good service from the local NHS, outstanding palliative care and, again, the outstanding East Cheshire Hospice. The glue that helped my family members to have a dignified death was that of a loving family. On a previous day in our debates, the noble Lord, Lord Harper, made a powerful point: it is okay if you have a loving family network around you to take care of you and think of your interests when interacting with doctors and hospitals. But he then referred to those people who are poor, lonely and ill, and without the loving network around them to look after them.

A recent case happened that was very close to your Lordships’ House. A noble friend was admitted to a regional general hospital with sepsis: a very ill friend indeed. One issue that the noble Lord, Lord Goodman, mentioned was about the NHS and the pressures on it, whether through funding or at times of stress, such as when the junior doctors are on strike. An assessment was made that my noble friend needed to be operated on urgently—a life-saving operation—but, because of the junior doctors’ strike, they were unable to get the necessary staffing for the operation, so the decision was made that they could not operate on my noble friend. My noble friend’s daughter was distraught, as you can imagine, so she contacted the Whips’ Office and asked whether they could help.

Your Lordships’ House is full of eminent clinicians. A Member of your Lordships’ House was able to find a crew that could operate on my noble friend in London. All they had to do was extract her from the NHS hospital in the regions and bring her down to the private hospital in London, which was duly done. However, they could not operate on my noble friend because she was dehydrated. The decision had been made in that regional hospital to not continue with food and liquids. The good news is that, when she was rehydrated, they operated. I am very happy to say that my noble friend made a full recovery and to this day makes a huge contribution to this House from our front bench.

What has that got to do with this Bill? Well, the danger of this system is that it would permit any doctor to raise ending the patient’s life and does not require other options to be provided. The doctor need have no knowledge of the patient, further intensifying the risk of quick judgments, bias or dismissiveness. NHS failure or strikes meant that no other options were available in this instance on the NHS. The doctor had no knowledge of the patient. All that the doctor saw was a frail old lady, perhaps coming to the end of her life, who was in fact a Government Minister. In their judgment, with all the biases that are part of human nature, would they have said the same thing, that they could not get the operating team together, if it was a child with sepsis? Would they not have moved heaven and earth to make that operation happen? The doctors proposed that the only way forward was dehydration and to let my noble friend die. In their professional judgment, that was the best option because the doctor did not know who the patient was.

Only the massive advocacy of a powerful network of noble Lords and noble friends managed to save my noble friend’s life. However, the Bill would allow very similar situations: options constrained by NHS failure, government decisions not to fund treatment or just logistics. Any doctor could raise the option, explain that nothing else can be done and ask immediately whether they want to sign the declaration for the first assessment, or arrange for someone else to. They would put them on the conveyor belt to the second assessment seven days later, which would be followed immediately by the panel, with the reflection period reduced to 48 hours. That is a timeline of just nine days to save your loved one, who has been told that there is no other option.

My Lords, I would like to clarify something that the noble and learned Lord, Lord Falconer, said in response to my statement that assisted dying was not something that doctors could suggest in Australia. The website of the Department of Health, Victoria, states:

“It is against the law for a medical or other health practitioner to suggest voluntary assisted dying as an end of life option to one of their patients. A medical practitioner cannot talk about voluntary assisted dying unless a person asks them about it first”.

If I can take noble Lords to New Zealand—

Before the noble Baroness references New Zealand, I was saying that that was the position. There was then a five-year review in Victoria and the law was changed.

It has not changed on the Government’s contemporaneous website. If I go to New Zealand, it says that the doctor cannot advise or discuss assisted dying with you unless you ask for it first. Those are both government websites today. I accept that there may be changes due and that they may come, but they are not there, as far as I can see.

My Lords, when a doctor, the very person entrusted to preserve life and relieve suffering, raises the possibility of assisted dying, it is no longer a neutral act. For some people, particularly those who are depressed, isolated or overwhelmed, the mere introduction of the possibility of an assisted death risks planting the idea that this course is rational or even expected. In an inherently unequal doctor-patient relationship, suggestion is easily perceived as a recommendation.

There is no requirement for an independent advocate—somebody to sit beside the patient and help them process and grasp what is being said. We are leaving some of the most consequential conversations a person can ever have to take place in isolation, within an asymmetrical, authoritarian relationship. There is no requirement for the discussion to take place with someone with specialist expertise. A “registered medical practitioner” could be a locum doctor who the patient has never met before, a foundation-year doctor in their early years of practice, or someone with no training in palliative care or experience of autism or learning disabilities, and yet they are the people who may introduce a conversation that could seriously alter the trajectory of a life.

No clinician should be allowed to initiate such a conversation; it should arise only if a patient independently raises it themselves, and even then the doctor’s role should be limited to acknowledging the request and directing the patient to an independent body while remaining firmly focused on diagnosis, treatment and the provision of appropriate and timely palliative care, as needed. Assisted dying must not be presented as an equivalent option alongside treatment, support and comfort. To do so risks the medical service being seen as one that no longer values preserving and improving life but rather one that enables the end of life.

The Royal College of GPs has stated that the role of a GP should be limited to signposting patients to a designated specialist service if, and only if, the patient raises the subject. This week, the Royal College of Psychiatrists wrote to me expressing its continuing concern. Its view is that

“all applicants should receive a holistic, multidisciplinary assessment at the preliminary discussion stage, including for mental health needs”; in other words, something much more like the multidisciplinary panel proposed by my noble friend Lady Finlay in the previous group. I therefore suggest that Clause 5, and, in consequence, Clause 6, should not stand part of the Bill.

My Lords, Amendment 205 is in my name, as well as those of the noble Lord, Lord Carlile, and the noble Baroness, Lady O’Loan. I declare an interest as founder of Team Domenica, and as the mother of a young woman with Down syndrome. As several of my points have already been covered by other noble Lords, I will be brief.

My amendment is simple and proportionate. It reflects the concern I raised at Second Reading: it is incomprehensible that people with learning disabilities will not be allowed a family member or, in the absence of a family member, a learning disability nurse or qualified practitioner to be with them when a doctor initiates the conversation about assisted suicide. People with learning disabilities may chronologically be adults, but many are still children who lack understanding of abstract principles. It is true that Clause 5(2) specifies that a doctor must exercise

“their professional judgement to decide if, and when, it is appropriate to discuss” assisted suicide, but I am not satisfied that that provision is sufficiently strong. My amendment would provide an additional layer of protection for this vulnerable group, many of whom have a limited understanding of the concept of death and dying and would therefore be panicked and frightened. This combination of fear and lack of understanding would be, emotionally, absolutely devastating.

As we have heard, there is also—I see this in my own daughter—a desire to please, which is a way of seeking to belong. My daughter is also terrified of doctors, hospitals, dentists and anything medical. I dare not imagine what it would be like for anyone with a learning disability to be in a situation of having a conversation about killing themselves, probably in front of a doctor who they may never have even met, without a family member present. Yes, the Bill requires that there is mental capacity and a clear, settled and informed wish to die, but assessing capacity for people with learning difficulties is complicated on so many levels. I cannot begin to imagine how it would be done. Would it be through an easy-read leaflet with diagrams? It does not even bear thinking about.

I acknowledge—I know that this will come up—that not all families are perfect and that malign family dynamics are a reality, but I suggest that the greater threat would come from a process that fails to accommodate the specific vulnerabilities of people with learning disabilities. I find this lack of understanding extraordinary, but then, people with learning disabilities are so often ignored and forgotten. As my noble friend Lord Harper has already pointed out, during Covid, people with learning disabilities had “do not resuscitate” notices put at the end of their beds. Then came the clinical frailty scale, with nine categories going from category 1, meaning “fit”, to category 9, meaning “terminally ill”. The guidance was to deny those in categories 7 to 9 life-saving treatment. My daughter fell into category 7; thank God we did not have to send her to hospital when she got Covid.

In the Bill, this discrimination may be about saving money. The Government’s own impact assessment has revealed a saving of £2,323 if an independent advocate is not used. It is easy to work out cost, but it is much harder to measure the value of a human life.

Before I end, I thank all the parents who have written to me about the Bill. Some of them have said that they are too scared to die themselves because they do not know what on earth would happen to their adult children. These are parents who have spent a lifetime fighting. One mother wrote to me, as she digested the implications of the Bill for her own child, saying, “Sometimes, it’s easier to cry about the small things”.

My daughter has taught me a different way of looking at the world. She has taught me to live more fully and to be courageous. She has given me the strength to fight for people with learning disabilities so that they are not defined by being different. Their story is our story. We have a shared humanity and an absolute duty of care for this most vulnerable group, from the beginning of their lives to the end. It is on their behalf that I stand in your Lordships’ House and ask noble Lords to support my amendment.

My Lords, Amendments 154, 210 and 211 are in my name. I also support my noble friend Lady Goudie’s Amendments 202, 208 and 209; she is unable to be in her place today. I will endeavour to be brief. Together, these amendments address two questions that I believe unite noble Lords across the House: how we can protect vulnerable people from coercion; and how we can safeguard young people.

On preventing coercion, Amendment 154 would establish a simple but essential safeguard: that assisted dying should be patient-initiated, so a doctor or other health professional should not raise the subject unless the patient has done so first. The proposed legislation rests heavily on patient choice and the absence of coercion or pressure. If freedom from pressure is the legal foundation of the Bill, the design of the process must minimise avoidable influence. Dr Matthew Doré of the Association for Palliative Medicine cautioned the Commons Committee that, if clinicians introduce the subject of assisted dying, vulnerable patients may reasonably perceive that as an endorsement or even a recommendation, particularly given the power imbalance that is already in place.

We have rightly heard how much agency and patient choice play a role in these debates, but, if an assisted death is truly a matter of patient choice, why allow the authority figure in the room to introduce the option? The Bill already makes it clear that there is no duty on doctors to raise assisted dying. If there is no duty and preventing coercion is central, why not make that safeguard explicit in the Bill? I ask my noble and learned friend Lord Falconer of Thoroton this: if the Bill’s case rests on patient choice and the absence of pressure, why resist the clear rule that this conversation must always be initiated by the patient themselves?

Secondly, Amendments 210 and 211, on protecting young people, seek to strengthen safeguards where young people are concerned. I have previously supported amendments proposing that we raise the minimum age for assisted dying to 25, based on neuroscientific evidence that the brain continues to develop into the mid-20s. However, if that is not possible, it is essential that Clause 6 protects younger people. Clause 6 prohibits raising assisted dying with a person under 18, and that is welcome, but what happens if that is breached? Amendment 210 would provide that such a breach must be referred to the General Medical Council. Without consequence, a statutory prohibition risks becoming merely symbolic. Statutory prohibitions normally carry consequence, and clarity here would protect both the patient and the clinician.

Supporters of the Bill may suggest that existing professional regulation covers this. If that is so, placing referral clearly in the Bill should pose no difficulty and would increase clarity and safety. What enforcement mechanism will operate if Clause 6 is breached? What sanction will follow if a clinician fails to uphold this safeguard?

Amendment 211 addresses a different scenario, where a minor raises assisted dying themself. The Bill is silent about what must follow, yet silence in safeguarding creates inconsistency and risk. Dr Annabel Price told the Commons Public Bill Committee that around 20% of those who might qualify under the Bill could have diagnosable depression, and that those expressing a wish to hasten their death are far more likely to feel suicidal. Professor Louis Appleby’s work likewise shows that suicidal risk can spike in the immediate aftermath of a serious diagnosis before stabilising with support.

It is a tragic fact in our country that suicide is now one of the leading causes of death for young people. When a child expresses a wish to die, our national response is about safeguarding, compassion, referral, care and support. My amendment therefore seeks to provide clarity for clinicians: if a minor raises assisted dying, the doctor must refuse to discuss it, beyond explaining that the person is ineligible; the interaction must be recorded; and the young person must be referred for mental health support. In other words, when a minor expresses a wish to die, we should treat that not merely as an inquiry about their eligibility but as a serious safeguarding event.

Finally, I support the amendments tabled by my noble friend Lady Goudie. Amendment 202 would ensure that prohibition applies not merely to raising assisted dying but to discussing it. Without that clarification, the boundary risks becoming semantic rather than substantive. Amendment 208 would make it clear that the protection applies even if a child initiates the conversation—vulnerability does not disappear simply because the young person speaks first. Amendment 209 recognises that influence comes not only from clinicians; adults in positions of authority—guardians, carers and educators—all carry significant weight, and safeguarding must be consistent across all those parties. If we accept that minors are vulnerable to influence, why confine the prohibition to clinicians alone?

I close by saying that, through all these different amendments, there is a single thread. If this truly is to be a safe Bill, the final legislation must minimise coercion and protect the vulnerable. Above all, it must fulfil the commitment of its sponsors; namely, to ensure that a citizen’s decision to choose an assisted death is always voluntary and that the state’s obligation to safeguard the most vulnerable is always upheld. I commend these amendments to the Committee.

My Lords, probing Amendment 200C, in my name, would prohibit people from raising with children assistance in taking your own life, and deals with the method by which the issue of assisted dying can be raised with someone under 18. It particularly should not be raised online. The amendment seeks to extend Clause 6.

I first note my support for Amendment 210, just outlined by the noble Lord, Lord Rook, on the consequences for breaching Clause 6. Further, I wish to support Amendments 157 and 164, in the name of my noble friend Lord Ahmad and spoken to by my noble friend Lord Evans. It is entirely sensible to enable people to opt out of being offered such an assisted suicide service.

The Bill seems to have no limit, nor is it probably possible to place a limit, on the number of times assisted suicide could be raised with a patient, so it is surely consistent with autonomy to give the patient the right to opt out. One need think only of a GP surgery, and the number of GPs or nurses you see. If each of those people raises it with you, that could possibly even border on harassment. Conceptually, it is an extension of the freedom of conscience that we give to organisations and clinicians to opt out of the service. I hate to think that even dealing with a GP surgery could perhaps become part of Patchs.

This leads me on to the means by which issues can be raised, which has radically changed, and why my amendment includes online. I am grateful to the noble and learned Lord for filing comprehensive amendments in relation to advertising, but the issue of raising it with someone under the age of 18 is different. I would like assurance from the noble and learned Lord that this use of social media—for instance, someone sending a TikTok or something like that about assisted suicide—is covered by Clause 6.

That example may seem straightforward, but, once again, it brings into focus the analogue nature of the Bill. If ChatGPT, for instance, in response to a question which it mishears, tells someone under the age of 18 all about assisted dying in the Bill, is that covered by the amendments on the prohibition of advertising that the noble and learned Lord has raised? Could a bot or algorithm operate without direct human Intervention and raise with a child the issue of assisted dying?

Noble Lords will be aware—the noble Baroness, Lady Berger, has spoken much on this—of the cases that are currently being taken against ChatGPT, in which OpenAI is the litigant. It is being sued for giving suicidal information to young people, who have, incredibly sadly, acted on that information. Has the noble and learned Lord spoken with technology experts about the Bill to ensure that all of these situations have been fully considered? By my reading, I do not believe that they are covered by the prohibition on advertising. As I say, advertising and raising it with someone seem to be two different concepts.

I used the word “person” in the amendment, not just “healthcare professional”, as there are numerous situations and relationships where children might have assisted dying raised with them—obviously that includes at school or college. Does the noble and learned Lord envisage that there will be guidance in this regard, and which one of the many delegated powers would be used under the Bill? What about youth groups, faith groups, sports clubs, carers or school transport? Parents need to know who is allowed to raise this potentially life and death issue with their children.

Assisted dying law will shape how children understand the value placed on life, disability and dependence. Vulnerable children may internalise the message that society is more willing to facilitate their death rather than fund their long-term care and inclusion. The concern of parents and carers around how this issue is raised with children could make the issue of PHSE teaching—namely, sex education—in schools look uncontroversial.

Although the scope of the amendment is wide—as I have said, it is probing—at least it is clear, whereas, alas, Clauses 6 and 56 are not. The phrase “No health professional” is in the title of Clause 6. It then uses the phrase:

“No registered medical practitioner or other health professional” within the clause. This is a mixture of the definition of health professional in Clause 56. Usually, when you have an interpretation clause stating a definition such as “health professional”, you would then expect that term to appear consistently within the Bill. Nowadays, all you have to do is Ctrl+F to find every example to ensure that there is consistency throughout the legislation. Due to this mix of use of terminology, are physios or OTs included in these definitions and therefore within Clause 6? Although I accept that Clause 6 was added in the Commons, I am disappointed that the noble and learned Lord, the sponsor, has not got ahead of the curve here and laid his own amendment.

Finally, can we have clarification on whether the registered medical practitioner in Clause 5 can be a private GP or healthcare professional? People may have a financial interest as we believe there can be private providers of assisted dying services. It may be that I am correct in that understanding, and I presume the noble and learned Lord, Lord Falconer, will want to ensure that there is no conflict of interest or incentive in the matter. It is possible that the matter has been covered in the developments under the law since the medical devices report. However, due to the lack of pre-legislative scrutiny, it is not clear and I would be grateful if the noble and learned Lord could clarify that.

My Lords, I will speak to my Amendment 155, which is different to the amendments in the name of the noble Lord, Lord Ahmad, on patients who opt out. My amendment ensures that when a person has previously cancelled the process of obtaining assisted dying—having considered it as an option and then rejected it—they can continue to discuss their terminal illness freely with their medical practitioner without being pressed to reconsider assistance to end their life.

As we are hearing, we have had a great deal of evidence on this issue. In its written evidence, the Association for Palliative Medicine of Great Britain and Ireland observed:

“Doctors influence decisions made by their patients in conscious and unconscious ways and are themselves shaped by their personal and professional life experiences … if the patient clearly rejects AD, they may suspect that other treatments suggested by this doctor are driven by an agenda to shorten their lives or may otherwise result in this. This could lead to patients opting not to engage with palliative care or to the loss of trust in a medical practitioner or in the medical profession at a crucial time in people’s lives”.

There is a clear danger here. If a patient has already considered and rejected assisted dying and their doctor raises it again, it may appear as though the doctor is pursuing an agenda to shorten that person’s life. That risk to trust at the very moment when trust is most needed should not be created by the legislation before us.

I also want to refer to evidence given to the Commons by Dr Vicki Ibbett, an NHS specialty doctor in psychiatry with extensive professional and personal experience of suicidal ideation. She expressed serious concerns about the impact of the Bill on suicide prevention work and highlighted that the voices of people with lived experience of suicidal ideation were not heard in oral evidence sessions. Speaking about terminally ill people who may experience thoughts of not wanting to be alive, Dr Ibbett wrote:

“Thoughts of wanting to die have a known association with being given a cancer diagnosis and learning of being terminally ill … Suicidal ideation may have arisen as part of the response to a new diagnosis with a terminal prognosis. It may, therefore, be part of an ‘adjustment reaction’. Adjustment Disorder often settles without professional Intervention. If it persists additional support may be beneficial. Assisted suicide should not be facilitated”.

My Amendment 155 therefore seeks to ensure that a doctor may not raise assisted dying with a patient whose medical records show they have previously cancelled a first or second declaration. When somebody has already walked back from that decision, the law should protect them from renewed pressure, intentional or not.

Finally, I will quote from a recent article by Jim McManus, national director of health and wellbeing at Public Health Wales, writing in a personal capacity. He wrote that

“no end-of-life decision happens in a vacuum. Choices are shaped by many things, and sometimes these are inequality, unmet need, patchy palliative care, and the grinding pressures of an overstretched NHS … People expressing a wish to die may be experiencing treatable depression, loneliness, or feelings of being a burden. The Royal College of Psychiatrists has raised concerns that the Bill’s safeguards are insufficient to protect people in exactly these vulnerable states”.

Amendment 155 is a small but vital safeguard, ensuring that when someone has stepped back from assisted dying, their decision is respected. At such a vulnerable moment, no patient should face renewed pressure; our priority must be to protect, trust and uphold compassionate, high-quality care at the end of life.

My Lords, what influenced me to look positively at a number of amendments in this group, and to table Amendment 150, was that some jurisdictions with assisted dying legislation explicitly prohibit doctors from initiating assisted dying discussions. I know that there was a bit of a row earlier about Australia, South Australia and New Zealand, but the truth is that people who have this legislation thought it was important to say that if a doctor raised this with the patient, it would breach professional misconduct. In fact, South Australia even used the wording “must not … suggest”. That is quite hard.

However, it is very interesting that this group of amendments holds importance for all of us. In other words, it cannot be assumed to be either filibustering or messing around, because we are citing places that have assisted dying, and they think that this is a very good and important safeguard—or that it is at least worth debating.

One reason they do that is the issue of autonomy, which I know is very close to the noble and learned Lord. The concern is that, if a doctor initiates discussions about assisted dying, it undermines the very principle of the Bill’s supporters, which is to ensure that the decision regarding assistance to end your own life is yours taken freely; it is patient-initiated. I was rather surprised to hear the noble Baroness, Lady Blackstone, cite the BMA. What happened to the patient-centric approach? We now have the BMA versus the patient. If a patient wants an assisted death, good—well, not good, but they can initiate the discussion and raise it themselves, if they want to; it is an autonomous decision.

We have to be honest about something that is not discussed enough: the fact that, socially and culturally, there is an imbalance of power in a doctor-patient relationship. In this House, because we are surrounded by many brilliant medical experts and because we are all peers—and Peers—we sometimes do not hold back from challenging each other. We are all equals. I do not know about other noble Lords, but when I go to the doctor as a patient, I suddenly become a quivering wreck. I very much feel the less-equal partner, like millions of people. The noble Lord, Lord Deben, made the point that people are frightened of doctors. I do not think it is that; I think it is a kind of old-fashioned deference and awe. It is a relationship of dependence. After all, you are seeing the doctor because you are ill—in this instance, terminally ill—and when you are very poorly, your sense of agency is at its weakest; you feel fragile and vulnerable. That is one reason why I added my name to the important amendments in the name of the noble Lord, Lord Carter of Haslemere. We look to the doctor as an expert, on whom we are dependent for treatment, advice, expertise and help. That awards considerable moral social authority to the doctor and considerable influence over an ill person’s medical decisions.

Therefore, if a doctor raises assisted dying, patients might interpret that as an implicit recommendation about, for example, what they face in handling the illness. Is it a suggestion that the suffering will be intolerable? It might even be a comment on the value of someone’s life at that point. As the noble Baroness, Lady Campbell of Surbiton, explained, patients could well hear this as something like: “You’re better off dead”. That may be the worst-case scenario, but it might even be heard as, “We recommend it”. If you go to the doctor and they say, “Have you thought about assisted dying?”, you will think, “Oh my goodness, they’re recommending it”. It is certainly not an impartial Intervention, because doctors typically do not suggest causes of action that they believe to be harmful. If it were raised, we would understandably assume that it was a suggestion in our best interest, and that causes real problems.

That is true in general, but, as the noble Baroness, Lady Monckton of Dallington Forest, so movingly, passionately and powerfully put it, people who have Down syndrome often want to keep people happy. What if they hear that suggestion? I am putting this very badly, but it is an abomination that it should even be there on the possibility list. I would like to hear the noble and learned Lord at least concede that point, if nothing else today. That would be worth coming for.

It was so moving to hear the contribution from the noble Baroness, Lady Monckton, and the points that others made about the words that people may hear, including people with learning disabilities. I was reflecting on the evidence we heard at the Select Committee from the National Down Syndrome Policy Group. It is not just the words that people may hear; it is also what they see in front of them. In particular, what was really striking—I had not thought about this—was that even the uniform of the doctor who is having that conversation could suggest a position of authority that someone with a learning disability should show acquiescence to. I thought that was something for us to consider in the light of all these important amendments.

That is very helpful. When I see a uniform, I get a bit quivery as well—

Noble Lords:

Oh!

We are obviously at that time of day.

As we have gathered, I do not want doctors to initiate raising assisted dying as a healthcare option at all but, if they do, I do not want there to be any linguistic whitewashing. Sarah Wootton, the chief executive of Dignity in Dying, wrote in her book Last Rights:

“We have to move away from idealised, sanitised, nursery-rhyme accounts of what death can be…towards truthful”,

no-BS—I have abbreviated that—and

“plain-spoken explanations of what could happen”.

Surely these words, which are very powerful, should also apply to conversations about assisted dying or assisted suicide. Let us ensure that, if a doctor is to raise it with patients, there is no attempt to hide behind idealised and sanitised nursery-rhyme accounts of what assisted death would be like.

That is why I was particularly keen to emulate this no-BS approach, which is why I added my name to Amendment 160 in the name of the noble Baroness, Lady Lawlor. This would ensure that, in any discussion that a doctor initiates, they make it clear what is being suggested—namely, that this about ending a person’s life. If a doctor said to you, “Would you like a dignified death?”, that might sound very appealing, but if they say, “Would you like me to give you a lethal drug that means that you can take your own life?”, it might suddenly feel a bit different. We genuinely need to say what we are talking about. A similar concern is raised in Amendment 167 by the noble Baroness, Lady Fraser of Craigmaddie. The doctor must not hide behind opaque language and euphemism that avoids spelling out clearly what they are suggesting and offering, from the first preliminary step to the ending of a patient’s life by, as I said, basically helping them take their own life.

My final point is that we are saving the doctors here. Doctors starting to suggest that you can end people’s lives will completely change the relationship between doctors and patients. You are forcing a doctor to think, “Is it in the best interest of this patient to die, with my help, through the ingestion of a lethal substance?” That must mess up the mind of a doctor, who is trained to keep life going as much as possible. It would erode trust in healthcare relationships moving forward because if, for example, your doctor suggested assisted dying and you said no, you would then have to go back and face the same doctor. I am not entirely convinced that I would be confident enough in the medical practitioner who had told me I would be better off dead to ask, “Can you help me extend my life a bit longer?” I might want to doctor-shop, as they say.

I am perhaps imagining the noble Baroness, Lady Fox, as a quivering wreck. If that is how she feels, you can imagine what it is like for most of us when we face our doctors, so the point was made very strongly.

There are so many good amendments here and I cannot possibly refer to all of them, but I want to drive home, by force of comparison, a point that arises from two things that were said—one by the noble Lord, Lord Rook, and one by the noble Baroness, Lady Hollins, who is no longer in her place. The noble Lord, Lord Rook, said that there is no duty under the Bill to raise assisted dying, which is obviously true. It is very important to pursue what that implies.

The noble Baroness, Lady Hollins, said that by raising assisted dying a doctor is not performing a neutral act, so the question we have to ask is what is going on when a doctor proposes assisted dying. I am saying that if it is not a neutral act it is an ideological act, and that is not something appropriate for a professional.

I shall draw a comparison that will illustrate that point. The Government keep promising to introduce a Bill to ban conversion therapy—and I think that they will do so. The objection to conversion therapy is that it is a form of coercion of the weak and of exploitation, forcing an ideology on people that is considered to be wrong and exploiting their feeling of weakness. That is the danger we face here. Many noble Lords will object, of course—and they will be right—that conversion therapists are quacks whereas doctors are real doctors. In my view, that makes it even more important that the doctors stick to their professional obligations and do not start advocating things they happen to believe are right. If we think about it that way, we will see just how important these amendments are.

My Lords, I rise to speak to a couple of amendments that I have in this group. I start by responding to what the noble Lord, Lord Moore of Etchingham, has just said. I think that he misconceives his opponents—indeed, if I may say so, our opponents. They do not regard the offer of assisted suicide as an ideological act but simply as the offer of a different medical treatment, and this is one of the great divides between us. There are those of us who will not accept that offering to kill somebody or assist them in killing themselves can constitute a medical treatment. I say that purely as a preliminary and without relevance to what I am coming to, which is Amendment 166, which I shall speak to briefly.

This is a minor and technical amendment. It arises from the fact that the Bill, because it has this elaborate bureaucratic process, creates lots of decision points; if you made a decision map, it would be very complicated as you passed down through it. There is one here in Clause 5 that needs correcting or improving. It says in subsection (3):

“Where a person in England or Wales indicates to a registered medical practitioner their wish to seek assistance to end their own life in accordance with this Act, the registered medical practitioner may (but is not required to) conduct a preliminary discussion”.

Now a “preliminary discussion” is a technical term in the Bill. It is a key that opens up the path to assisted suicide—it is not just any old discussion that happens to come early, but a technical term. The registered medical practitioner may at that point have the preliminary discussion, but they do not have to; but subsection (6) makes clear what they do have to do, which is to refer somebody to a place where they can get information about how they can have a preliminary discussion.

My point is that the person making the inquiry about assisted suicide does not actually have to be ill. They might be asking—and quite wrongly asking—about ending their life, without coming within the scope of the Bill at all. I suggest that to avoid the poor doctor being driven off on these two impossible and irrelevant courses, we add to subsection (3), after the words “in England or Wales”,

“who has been diagnosed with a terminal illness”.

I should have thought that the noble and learned Lord would be willing to add that in the interests of clarity, to try to straighten out some of the complexities that the Bill, through its complications, has created.

Amendment 152 would do something that many other amendments in this group seek to do: it would prohibit a doctor or another health professional from initiating a discussion about assisted suicide. So many speeches have been made already about why this is a valuable thing to do that I am not going to attempt to repeat them. Indeed, even the story about my late father that I was going to tell noble Lords has been trumped by the very moving stories from my noble friend Lord Evans of Rainow about his mother and grandmother. Everything that I wanted to say has been said.

The only thing I can say is that in Canada, doctors regard it as a professional obligation to raise assisted suicide, because it is regarded as a medical treatment. There is the possibility that, lying in your hospital bed and having just received a terminal diagnosis, four or five different doctors walk into the room in the course of the day, each one of them suggesting assisted suicide. Morecambe and Wise would have made a fantastic sketch out of it, when you think about it. That at least we could avoid if we had an amendment that prohibited them from doing so quite explicitly.

What I have learned from the debate is that there is a divide. There are confident people, who are confident that they can make their own decisions, that they will be in charge of events and that they can choose their own end, exercising their autonomy at a time that is suitable for them. Those of us on the other side want to give a voice to, we would say, the great mass of people, who—if not necessarily quivering wrecks when they go to their doctor but, as my noble friend Lord Deben said—are frightened of the doctor, have some awe of the doctor, tend to give what might be excessive respect to what the doctor says and find themselves being driven in a certain direction and not necessarily the one they would autonomously choose.

Ultimately, if we ever get to a vote on the Bill, that is the choice. The House has to decide which side it wants to be on—that small number who are confident or the very large number who are not confident about themselves when faced with medical issues?

Finally, the noble Baroness, Lady Hayman, spoke as if there was not already at least 3,000 years of philosophy and moral theology devoted to the difficult issues she raised. We know that nobody is obliged to accept medication that keeps them alive artificially if they decide that it is not the right thing for them. Nobody is obliged to accept more blood transfusions that—

I am grateful to the noble Lord. I was trying particularly to get to the point of the doctor’s role. I understand what he says, and he is quite right. I was trying to advocate that doctors should be able to have conversations with their patients about care, not just medical treatment—which is the phrase he was using before—to look holistically at what that dying person wants and needs, and be able to respond to their desire not to have any more pain, drugs or treatment. The doctor should be able to talk freely about all those options. In my view of the world, that would include assisted dying, but there is a spectrum.

There is, indeed, a spectrum, and the doctor should be able to speak. As I say, there have been 3,000 years of thought given to this. What has resulted from that is a firm conviction that, while some medications that do you good may also do harm—and the doctor has to make careful judgments about that—the active killing of a patient, the actual administration of substances with a view solely to bringing about death, is morally abhorrent.

It may not be morally abhorrent to the noble Baroness, but she has to understand the novelty of this and the violence that she is doing to our inherited moral framework when she—

My Lords—

Let me finish. The noble Baroness puts that forward and says that, to her, it is simply one option. It is not one option; it crosses a line.

My Lords, “morally abhorrent” is quite distressing. I am a doctor; I have been a doctor for 50 years and have worked with dying people quite regularly in hospital, particularly in general hospitals. I find the notion that doctors all find this abhorrent is utterly wrong. We know that at least half support the principles of the Bill and can recognise that it is something that they would like to support. I am not talking about the medical royal colleges; they take one line—in fact, most of them are neutral about the principle. The reality is not as the noble Lord, Lord Moylan, describes. Certainly, I do not feel the way he does. I find it very offensive when somebody says that it is morally abhorrent. It is not morally abhorrent to help people when they are desperately suffering and to respond during a conversation to what they are talking about and what they are asking for.

My Lords, if I may briefly answer that, I am saying that we have 3,000 years of a moral framework in which it is morally abhorrent. I am not here primarily to protect the sensitivities and feelings of doctors. I am saying what a violent novelty this is that we are embarking upon if we go down this route.

My Lords, there are a number of key objectives outlined in the amendments that we have been discussing for some time now, which are worthy of our most serious consideration. I suppose that the burden of the Amendment is that doctors should be prohibited from initiating discussions about assisted dying because, if they were permitted to do so, it would fundamentally undermine the long-established patient-doctor contract and could expose vulnerable patients to undue pressure or influence at a time when they are fragile—at a fragile moment in their lives.

The raising of the issue of assisted dying surely must be strictly initiated by a patient and any discussion of the issue must be embedded in a manner that prioritises palliative or other support care over death. If doctors were permitted to initiate the issue of assisted dying, patients could rightly interpret this as an implicit recommendation on behalf of the medical profession and it could be seen as a choice influenced by authority, or even fear, and not a free choice. It must be acknowledged that, within society, doctors have an exceptional moral and social authority. A person who feels vulnerable, marginalised or devalued can easily be susceptible to pressure and influence if the recommendation or initiation of the issue of assisted dying comes from their doctor.

The moment of diagnosis of a terminal or life-limiting illness is an earth-shattering moment for most people within society. As a Minister of religion for over 50 years, I have been with thousands of such people, who, when they have received the diagnosis that they have a terminal illness, feel shattered and absolutely broken. I can tell noble Lords that that leads to a multiplicity of emotions. I have also had many loved ones and friends who have faced that moment. The immediate shock of hearing those words can turn into depression and, even for a period, it can turn into suicidal thoughts and a feeling of “It’s all over anyhow; therefore, let me get out”.

However, we all know from personal experience—or many of us certainly know—that these thoughts at that earth-shattering moment can dissolve over time, whenever people are surrounded with love, aided by a loving conversation or their personal faith, or supported within the family or the community context. Indeed, the initial devastation I have seen turns dramatically into a quiet confidence: into a determination to fight for life and to live a fulfilling life, even though the person is in the midst of adversity. That is something to be cherished and praised. At the moment of despair, when a terminal diagnosis is given, how improper it would be for any doctor to raise or to suggest assisted dying as a more sympathetic way out of their pain or a free exit from life.

Sadly, the personal and deep doctor-patient relationship is no longer the reality that it used to be, and in multi-doctor practices, you may never see the same doctor again for months or even years. They do not really know you as they used to know you. To pretend that somehow it is the old way is not reality—it is living in a different world. Therefore, often no personal knowledge of that patient is held by a particular doctor. Any deep understanding of their mental health, their family life context, or societal or financial pressures that that person may be experiencing is negligible, yet it is the moment of crisis in a life.

During previous debates, some noble Lords and Baronesses have been rebuked for using the term “assisted suicide” instead of “assisted dying”. But does “assisted dying” terminology not mask the reality of what we are discussing? Normalising discussions about ending life before the natural-appointed, or God-appointed, time surely risks reframing suicide as a legitimate medical response to pain or distress, which is outside the scope of the Bill—at least, that is what we are told.

Allowing but not requiring doctors to raise assisted dying with their patient gives me no comfort, as I feel that it would lead to medical professionals being open to criticism or challenge. It will no doubt lead to inconsistency among professionals. Will patients seek to move from one general practice to another because the doctor they are moving to supports them in assisted dying? Will they have to move because their GP has a sincerely held conviction about the sanctity of life and will not participate in the practice of assisting a person to die?

A doctor permitted to discuss assisted dying with a patient surely cannot be just any registered medical practitioner. For clarification, I ask the noble and learned Lord, Lord Falconer, to confirm that the provision in Clause 5 is not limited to the patient’s GP, and that treating consultants, specialists or doctors who have a minimal relationship with the patient or none are not restricted from giving this advice. Can he also confirm that there are no restrictions on the setting in which a doctor might give this advice—a hospital ward, an out-patient clinic or elsewhere?

If so, how is it professional that someone with little or no knowledge of the patient’s history, mental state, et cetera, who has no care relationship with that person, is permitted to raise ending their life? The doctor involved is not required to be caring for the person, but their knowledge can be based on a glance at their chart, a computer screen or their appearance. Surely that is not thoughtful or caring for a health service.

Dr Neil Shastri-Hurst MP, in the Public Bill Committee, said:

“The reality of clinical practice is that there are consultations within consultations” and that the Committee needs to trust

“in the judgment of clinicians, who know their patients well”.

One final thing concerns discrimination against disabled groups. Fazilet Hadi of Disability Rights UK said:

“We often find that doctors, because they cannot treat or cure us, do devalue our lives. We have had disabled people who have actually had it suggested to them or their families that their lives are expendable, when actually those people have got a lot of years to give. We also know that when you—”

Order.

I am finishing with this quotation, and it is just a couple of sentences:

“We also know that when you acquire disability, which most people do … it is absolutely frightening … If doctors are not on our side because they are thinking, ‘Should we mention the fact that they could have an assisted death?’, that poses a big cultural issue for the NHS, but also for us having confidence in the NHS”.

My Lords, I will speak to the probing Amendment 161 in my name. It asks the simple but profoundly important question of whether registered medical practitioners should be granted a blanket legal protection to raise the possibility of ending any person’s life or whether that protection should be carefully and responsibly limited to patients already in their care.

At the heart of this debate lies the issue of safety and trust. The relationship between a patient and their doctor is not a casual exchange. I hope it is a deeply personal, often vulnerable, bond built on confidence, continuity and professional responsibility. When someone receives a terminal diagnosis, they are not merely confronting medical facts; they are confronting fear, uncertainty and the fragility of their remaining time. In that moment, words matter immensely. To grant blanket legal protection to any registered medical practitioner, regardless of whether they have an established clinical relationship with the individual, risks undermining that trust. It risks introducing the possibility that a suggestion about ending life could come from a professional who does not know the patient’s history, values, mental state, family circumstances or vulnerabilities.

Amendment 161 does not seek to obstruct lawful medical practice or to deny terminally ill adults the autonomy that the Bill intends to provide. Rather, it seeks to ensure that conversations about assisted dying occur in the right context, within a relationship in which the doctor knows the patient, understands their condition and is responsible for their ongoing care.

We must consider the subtle power imbalance inherent in clinical settings. A doctor’s words carry authority. Look at the effect they have on the noble Baroness, Lady Fox, at times. For a patient who is elderly, disabled, isolated or feeling like a burden, even a carefully phrased suggestion can carry unintended weight. If such a conversation is initiated by a practitioner with no established duty of care, we risk normalising a culture in which ending life becomes a broadly available option rather than a carefully safeguarded patient-led request.

Limiting legal protection to practitioners involved in a patient’s care and case strengthens safeguards. It ensures that any discussion arises from clinical knowledge, not abstract eligibility; it reinforces accountability; it reduces the risk of inappropriate suggestion; and it protects vulnerable people feeling steered towards a decision at a moment of profound weakness.

Autonomy is meaningful only when it is protected from subtle coercion, even unintentional coercion. By supporting Amendment 161, we are not diminishing choice: we are strengthening the ethical framework in which that choice is exercised. In matters of life and death, precision, boundaries and safeguards matter. Amendment 161 offers a proportionate, reasonable and ethically sound safeguard. It preserves trust in the medical profession, protects vulnerable patients and ensures that, if such conversations occur, they do so within the context of established clinical responsibility. For those reasons, I urge the Committee seriously to consider the intent and spirit behind Amendment 161.

My Lords, I say to the noble Baroness, Lady Fox, that my mother held doctors in great esteem and reverence until the day that I and my rowdy friends qualified, and then the whole mystique was exploded overnight.

My serious point is that I am still mystified by Clause 5, because it remains completely unclear who is having this preliminary discussion. Even if we safeguard against the doctor raising the subject of assisted dying without it being initiated by the patient, none the less this clause is still opaque about who this person is. If, fortuitously, the patient has a good relationship with their GP and is able to raise the matter and have a full discussion, they may be able to cover all the things that are listed in this clause—diagnosis, prognosis, palliative care, hospice, available treatments and so on—but, if it is not their GP, who is the medical practitioner supposed to direct them to? Unlike the co-ordinating doctor and the independent doctor, they do not have the right written into the Bill to access the patient’s records or make inquiries of the person who is looking after them, so I am unclear about how they are supposed to discharge all these duties.

Also, it does not reflect reality. If somebody is starting to think about possibly seeking an assisted death, they may ask their GP about one part, their priest about another aspect, their next of kin about another aspect, and they will gradually form a view. But to lay it down in statute seems to be putting an additional hurdle in the patient’s way. Surely, at the time when they want to ask about the detail of assisted death, what it might entail and its feasibility, the person to seek advice from is the co-ordinating doctor or the first doctor within the voluntary assisted dying service, who will have had the training and will have some knowledge to be able to say with confidence what the individual should expect. So I strongly support my noble friend Lady Hollins’s view that Clause 5 should not stand part of the Bill, because it seems to be a complete muddle that we have been discussing various aspects of for some time now.

My Lords, I think the debate that we have had for the last two and a half hours shows this House in a very positive light. It goes to the very essence of what some of us who are sceptical about the Bill believe to be the most crucial issue: how the Bill will impact the most vulnerable people in society. I say in passing how moved I was by the wonderfully powerful and emotional speech from my noble friend Lady Monckton, as well as by my noble friend Lord Shinkwin’s speech on his Amendment.

Noble Lords might ask a rhetorical question: why are we spending so much time on this particular group? I will offer an anecdote to your Lordships on why it is important that we have spent this time talking about people with disabilities and learning disabilities, and particularly people with Down syndrome. In the summer of 2024, my 91 year-old father was admitted to Peterborough hospital and spent a number of hours in what is euphemistically called “ambulatory care”—which is the back of an ambulance—before being able to access a trolley for a number of hours. As it happens, he was terminally ill. He died a few weeks later from bladder cancer that had metastasised to the rest of his body, but he did not have a diagnosis of terminal illness.

When I reached the hospital, his belongings were adjacent to where he was. At the bottom of the Sainsbury’s carrier bag that held all his personal belongings was a “Do not resuscitate” form that had been filled in. In fact, I think it was what they call—again, euphemistically—a “respect form”. It had been countersigned by a doctor without any discussion with myself or my two brothers. As your Lordships know, none of us are shrinking violets. My brother is a decorated police officer and my other brother is a world-leading scientist and a professor of psychology. We are all quite smart people, but this form had been completed without any discussion with the family.

Indeed, it was alleged that my father had had capacity to sign that form and had agreed to it being countersigned by a doctor. That was a very significant development. I found myself having to front up a difficult conversation with the clinicians in accident and emergency and the geriatrician who was on duty that day. I thought to myself: what if my father had a learning disability? What if he could not read or write properly? What if he was anxious about dealing with bureaucracy and professional people? I thought about how much more difficult it would have been if he did not have a family: if he had not had three sons watching out for him and protecting his interests. How much difficulty would there have been in him challenging the professional bona fides and authority of a clinician—a medic who is well educated and articulate and knows their profession.

I posit that that is the reason we have spent so much time debating these issues. It is not for people such as my father, who, as I say, was terminally ill, but for the many people who have great difficulty: people who are already in a position where they are sad, lonely, depressed, bereft and distraught after a diagnosis of a terminal illness. Those people need assistance in primary legislation to protect their interests, because otherwise no one else will look out for them. That is not to say that those doctors were in breach of the Hippocratic oath, or that they were not compassionate, empathetic, caring and feeling for my father and many thousands of other people in similar situations, particularly old people. Nevertheless, they are busy and stressed and that form was filled in in good faith.

In the modern NHS—not the NHS of five, 10 or 20 years ago—a patient can be in the back of an ambulance for hours outside the hospital, and then be put in a corridor before they get to a ward; and they might see a consultant on the ward round only once or twice a week for a few minutes, if they are lucky, and may not see the same consultant again for weeks. That fundamental change in the nature of our health service over recent years, with the huge additional pressure and demand, makes these protections all the more important.

As usual, the noble Lord makes a very apposite point and reinforces my arguments.

Time is pressing, so if I can beg the indulgence of your Lordships’ House, I will just develop slightly my support for the points that my noble friend Lord Shinkwin made at the beginning of this debate. The danger that terminally ill patients, accustomed to trusting medics who care for them, will sense that they should do what their doctor is telling them when they are only suggesting the option of assisted suicide is greatly heightened where, for instance, learning disabilities are in the mix. My noble friend made reference to Ken Ross of the National Down Syndrome Policy Group, who was quite right when he said:

“People with Down syndrome have a very complex and unique speech and communication profile. They are highly suggestible. Even someone wearing a uniform could suggest a position of authority to them and something they should show acquiescence to. The acquiescence bias risk from people with Down syndrome is extraordinary.”

This was mentioned by my noble friend.

“They could have a seeded view around what they think that person wants to hear and talk about without fully understanding the position”.

I assume that by “a seeded view”, Mr Ross means that the idea is planted in their mind, by a doctor mentioning assisted suicide, that this is what that doctor would prefer. Others, more expert, might put me right.

Other similar points were made by my noble friend Lady Monckton, in her superb speech, about the dangers of someone such as her daughter Domenica, who has Down syndrome, being advised by a doctor new to her that a terminal condition might mean it is best to have her life ended—without any legal obligation to discuss this with parents, other family members or someone independent, as the amendments from the noble Baroness, Lady Grey-Thompson, propose. As she said, fear, terror and a total lack of comprehension would sit alongside her daughter’s highly suggestible disposition.

The Commons, in fairness, did ensure that the Bill now has extra safeguards for those with learning disabilities, but these are focused on training and an advocate from the first declaration—far further down the road than the preliminary discussion. Actually, the experience in Australia is that training around the specific bespoke issue of coercion is very limited, and that needs to be looked at. Perhaps the noble and learned Lord will address that in his concluding remarks. This is when framing effects will occur and will be the starting point for vulnerable people misunderstanding the options or feeling pressure. By the time an advocate is in place, the person they are working for might have a fixed idea, which the advocate will not want to ride roughshod over. Clause 5 therefore needs strengthening to address this inconsistency, which is a key concern of experts in learning difficulties.

Hence the question that some noble Lords may be asking, about the need for prohibition, particularly where Down syndrome and learning disabilities are in play, because these might be the patients most likely to provoke cost concerns but least likely to discern that this motivation, not their best interest, is the main reason for raising the possibility of assisted suicide. I have to say that that would be a minority of cases, and I am not making that point about the vast Majority of clinicians.

In conclusion, it is for these reasons that I strongly support Amendment 162 and others in this group.

My Lords, I have two amendments in this group. We have heard a lot of comments about the real world and what is actually going on now, today, out there in healthcare. It will be very interesting to hear how the noble and learned Lord, Lord Falconer, responds to all the criticisms and to the way the inherent dangers in Clause 5 have been highlighted.

My Amendment 201 concerns children. A little boy with advanced malignancies said to me, “I'm going to die when my goldfish dies”. He went on to talk through what he wanted when he was dying and how he would play football in heaven with another boy who had died recently. Not long after, his goldfish was found floating. My strenuous attempts to resuscitate his goldfish failed, and he gently died soon after.

That was some years ago. Today, children live off the internet, not just off what they hear from other children. They know about the debate on this Bill—some raise it in “Learn with the Lord” sessions. If a child is asking questions about this, they must be able to express their fears if they are already ill. They often speak with remarkable frankness. Children’s awareness is phenomenal. They deserve gentle, honest planning of their care that also explains why they are ineligible for assisted suicide. Hence my wording, but the wording of the noble Lord, Lord Rook, provides much clearer guidelines for clinicians involved, to allow them to listen but in no way to hint that the child will be eligible.

Assisted suicide is not a medical treatment. It falls outside McCulloch and Montgomery rulings, hence my Amendment 159. As has been said, if a doctor raises assisted death unprompted, the implication is that this is something you should consider—a tacit implication that this might be your best option. Addressing the comments by the noble Baroness, Lady Hayman, it is a doctor’s duty of care to sensitively explore with open questions and careful listening, to discuss whatever the person wishes to discuss at their initiation. That is patient autonomy and control. Mencap, the Association for Palliative Medicine and the Royal College of Psychiatrists have all warned how patients’ trust gives doctors a dangerous ability to steer decisions if the suggestion comes from the doctor.

Listening with undivided attention is crucial in gentle, honest communication in the face of patients’ anguish. Patients hang on to our every word, so suggesting it as an option signposts them in that direction. It abandons suicide prevention duties under the Mental Health Act and the state’s duty under Article 2 of the European Convention on Human Rights. The amendments overall have a common theme of making the autonomy of the patient paramount in these discussions, their being able to raise assisted death in their own time, at their own pace and at their instigation. I hope these amendments will be taken heed of.

My Lords, I thank my noble friends Lord Jackson and Lady Monckton—whose speech was quite spectacular—for raising the example of DNRs. It is very good example when we are talking about who can raise assisted dying in preliminary discussions.

I want to give a very brief illustration. When my father was in hospital, five different medical professionals came into his room and took us, his family, aside, to get him signed up to a DNR. He did not really want that. It might have philosophically been the right medical thing to do, but he was not in the right place. He did not want to be asked, and certainly not five times by five different medical professionals. It left a rather bitter taste in our mouths, because when we were able quietly, as a family, to have that discussion with him, he did have a DNR. We were fortunate to have that time, rather than him having something put at the end of his bed with the Sainsbury’s bag.

This group of amendments is really important. They are all similar, saying that we need some guidance on who can raise the discussion and under what circumstances. If we really believe that patient autonomy is important, then something should come from this group of amendments and be in the Bill.

My Lords, briefly, Clause 6 standing part has been opposed by my noble friend Lord Moylan because of other aspects of amendments he has tabled. I very much support Clause 6 staying in the Bill: it was the one Amendment on Report in the Commons where there was a significant Majority in favour. In particular, I found it astonishing that anyone could even consider raising this with a child: it disappointed me that the sponsor of the Bill in the Commons voted against that amendment, but I am relieved it got through. It is also worth pointing out to the Committee that there is slightly different wording between Clause 6 and Clause 5(1), which my noble friend Lord Moylan’s Amendment 152 addresses by making sure “other health professional” is included, not just “medical practitioner”.

I have also seen multiple times what my noble friend Lady Fraser has just referred to. It is very irritating, especially when somebody is being taken home to die, if, against their wishes, DNR had been put in place by medical practitioners and then had to be rescinded. It is somewhat frustrating in that regard.

My noble friend Lord Goodman was succinct; I think that is partly the training of a journalist, or it might have been two years of quiet contemplation when he considered his vocation in an abbey on the Isle of Wight.

I want to briefly raise one point: the noble Baroness, Lady Blackstone, referred to the BMA. I am conscious that it is a trade union for doctors and does a lot of work on their behalf, but it is not a clinical body. However, the BMA pointed out its concerns that, without it, there would be uncertainty and legal risks for doctors. The BMA went into more detail on that in its evidence. In contrast, the Medical Defence Union’s written evidence to the Commons Select Committee—by the way, the MDU is an organisation that specialises in providing indemnity and other legal issues regarding doctors—came up with a different thing. It said:

“The MDU is concerned that the legislation, as … drafted … leaves doctors who do raise it at greater risk of a complaint”,

and then subsequent legal things.

So, as has also been pointed out, at what point would this ever be raised? I support more generally the approach and understand that, if a doctor is asked about this, of course that should be open to a response, unless they do not wish to do so, and part of Clause 5 covers that. But, overall, that initiation should not be in the hands of the medical practitioner, and we will come on later in further clauses to debate the recording of such discussions.

My Lords, I shall focus my remarks on two points. One is that I thought the speech of my noble friend Lady Monckton of Dallington Forest was very powerful. I strongly support what she said about proper safeguards for people with learning disabilities and she has an Amendment which deals with that. But I really want to test the thinking here, because there is a view, and this is where I settled, on whether medical professionals should be able to raise things proactively.

What I was thinking through—I would be interested in what the noble and learned Lord, Lord Falconer, thinks—is that the Bill is obviously about, first, legalising assistance to help someone take their own life, but it is also about putting a process in place, and those are two separate things. I was also thinking about the thing that is currently lawful, which is that someone is able to take their own life if they do not require assistance. I do not know whether it is just me but, if you were diagnosed with a terminal illness and suggested to a medical practitioner that you were thinking of taking your own life if the Bill were not in force, as far as I understand it—there are many in this House who can correct me—the medical practitioner has a duty under various existing suicide prevention strategies to take steps to try to prevent you taking your own life. They are absolutely not supposed to help you; they are supposed to try to stop you, up to and including using provisions in the Mental Health Act.

Therefore, it would be extraordinary if, in enabling assistance to be provided, we were to permit medical professionals to raise proactively the subject of someone taking their own life when that had not been raised by the person themselves. That seems to me to be the more consistent approach; otherwise, we will have a very strange approach whereby a medical professional will be able to raise proactively with somebody, using the provisions in the Bill—should it become law—providing them with medical assistance to end their own life.

I think I am right in understanding that we still would not find that appropriate, under the suicide prevention strategies and duties that exist for medical professionals. I do not think that the noble and learned Lord is suggesting this—he will be able to say so when he winds up—and I do not think that anyone is suggesting that it would be appropriate for a medical practitioner to suggest proactively that someone ends their own life, without assistance, by going off and doing it themselves. The noble and learned Lord is nodding his assent to that proposition.

There is a reason why I raise this issue. It has been raised before; my noble friend Lady Berridge and other noble Lords have raised it. I do not think that we have ever had a clear answer on how we can reconcile the provisions of the Bill on assisted suicide with the long-standing and important duties of not only medical professionals but many other professionals, under both this Government and previous ones, including via suicide prevention strategies. We must resolve this issue; otherwise, we will—my noble friend Lady Coffey set this out when she quoted the Medical Defence Union—be putting the professionals whom we would ask to implement this measure, were the Bill to become law, in an invidious position. We would be giving them conflicting legal and professional duties, which we would then expect them to reconcile at considerable risk to themselves.

The cleanest way of doing this would be to say that such professionals may respond to the patient only when the patient themselves raises this issue. If a patient goes to their medical professional and asks them a question, it is reasonable to expect that expert to answer it in some way, either by responding to the content of the question or by directing the patient to somewhere they can get that information. It would be not helpful if that expert were to refuse to engage, because that would simply drive the person away to some other forum—often a dangerous online forum, as my noble friend Lady Berridge said. It is not appropriate for these professionals to raise this issue proactively.

As I have said, this also raises the issue of what we expect of medical professionals, in terms of people who want to take their own lives without assistance, and what they should do in those circumstances. I still do not understand how we are reconciling those two things. I do not understand how a medical professional can have a duty to prevent someone taking their own life in other circumstances but be expected to facilitate such a thing in these circumstances. I still do not understand how we are reconciling that in a moral, professional or legal context, so I would be grateful if the noble and learned Lord could set out how he will reconcile these things when he responds to this excellent and very helpful group of amendments.

My Lords, the sheer number of amendments from noble Lords on all sides of the Committee that are seeking to prevent medical practitioners initiating a conversation about assisted dying with a patient demonstrates how strongly noble Lords feel about this issue. As a minimum, it is clear that many noble Lords do not feel that the Bill’s current drafting is sufficient. Although we have heard some counter-arguments during the debate, it is now incumbent on the noble and learned Lord, Lord Falconer, to set out in some detail his reasons for allowing registered medical practitioners to initiate these discussions.

Following on from that, there was one particularly moving contribution to this debate: the speech from my noble friend Lady Monckton. The case she made from her own family perspective in support of my noble friend Lord Shinkwin’s Amendment 162—to prohibit the topic of assisted dying being raised with someone with Down syndrome or a learning disability—was one I found especially powerful. I hope that the noble and learned Lord, Lord Falconer, will acknowledge that this is a particularly sensitive aspect of the issue which needs to be addressed.

There are two additional issues I should like to pick up. I was particularly interested in the amendment tabled by the noble Baroness, Lady Grey-Thompson, which requires a minimum 48-hour delay between diagnosis and any conversation about assisted dying. Given the shock that a patient will feel when receiving a diagnosis that could make them eligible under the Bill, it seems right and appropriate that they be given the space and time to process the news before facing the question of potentially ending their own life. Is the noble and learned Lord, Lord Falconer, willing to consider how that degree of sensitivity might be incorporated into the Bill—or, failing that, into guidance—to ensure that patients who receive some of the worst news they will ever hear do not immediately feel the need to address a choice as momentous and emotive as whether they wish to end their own life?

Finally, the amendments in respect of persons aged under 18 are worthy of the noble and learned Lord’s careful consideration. The Bill is designed to create a legal right for those aged over 18, not for children, so surely it follows that its provisions should not be raised with children. I therefore hope the noble and learned Lord will carefully consider the protections for children that the Bill could usefully incorporate.

My Lords, I thank all noble Lords who have contributed to this very important debate. As usual, I will limit my comments to amendments on which the Government have major legal, technical or operational workability concerns.

To begin, key concepts in Amendment 149, moved by the noble Baroness, Lady Grey-Thompson, are unclear. It will therefore be difficult to assess whether the duties have been discharged. For example, it is not clear who must co-ordinate and undertake the suggested multiagency assessment of support needs and who is responsible for ensuring that those needs are fully funded, so it may be impossible to demonstrate that these criteria have been met.

Amendment 152, tabled by the noble Lord, Lord Moylan, seeks to prohibit registered medical practitioners or any other health professionals from raising the subject of provision of assistance under the Bill. If passed, this would be inconsistent with the discretion currently afforded to the registered medical practitioner in Clause 5(2), which makes it clear that a registered medical practitioner may exercise

“their professional judgement to decide if, and when, it is appropriate to discuss the matter”.

This amendment would therefore create conflicting duties and may lead to confusion about whether a registered medical practitioner can raise the issue of assisted dying.

Briefly, as it is of no interest to other Members of the Committee, but it is surprising that, with all the legal advice offered to her, the noble Baroness has not noticed that there is a consequential Amendment in my name in the same group—which I referred to—which deletes subsection (2), since I too have spotted that there is an inconsistency and I have dealt with it.

I thank the noble Lord for his comments. It is still worth raising these matters in this context to avoid any confusion.

Amendment 162, tabled by the noble Lord, Lord Shinkwin, would mean that a registered medical practitioner could not raise assisted dying with any person with a learning disability, including people with Down syndrome, unless they raise the subject themselves. This restriction would apply to all persons with a learning disability, including where the person has the capacity to make a decision to end their own life.

The purpose of Amendments 205, 207 and 207A, tabled by the noble Baronesses, Lady Monckton and Lady Grey-Thompson, appears to be to prevent a healthcare professional raising the subject of the provision of assistance with a person who has a learning disability or autism, unless that person has a family member, independent person or guardian present. Under Amendment 207A, both a family member and an independent person would need to be present. These amendments do not draw any distinction between varying levels of individual need. As drafted, a registered medical practitioner would be required to establish in all cases that the person does not have autism or a learning disability before raising the subject of an assisted death, unless a family member or independent person is present.

Amendment 200C, tabled by the noble Baroness, Lady Berridge, would mean that no person could raise the provision of assistance with those under the age of 18, whether online or otherwise. Amendment 209, tabled by my noble friend Lady Goudie, prohibits any adult with a duty of care or responsibility for a person under 18, including but not limited to guardians, social workers, educators or carers, from raising the subject of assisted dying “with such a person”. These amendments would be extremely difficult to enforce, due to their breadth and ambiguity. They may, for example, prohibit parents or guardians from discussing the broad issue of assisted dying with their children.

Finally, I bring to noble Lords’ attention that amendments discussed here, including Amendments 149, 162, 200C, 205, 207, 207A and 209, could give rise to legal challenge on ECHR grounds, in particular challenges brought under Articles 8, 10 and 14. These amendments would require reasonable and objective justification to comply with ECHR obligations.

I make no comment on the other amendments in this group. However, as noble Lords will be aware, the amendments have not had technical drafting support from officials. Therefore, further revision and corresponding amendments may be needed to provide consistent and coherent terminology throughout the Bill.

My Lords, for the benefit of the Committee, I will let noble Lords know that when we have heard from my noble and learned friend Lord Falconer of Thoroton, I intend to bring the Committee to a conclusion. It would be wiser to wait to start the next group next week, rather than to get half way through it and have all the problems about who was or was not here, and so on. If colleagues are thinking ahead to the next group, it will not be called until next week.

My Lords, I pay tribute to the noble Lord, Lord Jackson of Peterborough, for telling us about the circumstances of his father’s DNR, to the noble Lord, Lord Evans of Rainow, for telling us about the circumstances of the deaths of his mother and his grandmother, and the noble Baroness, Lady Fraser of Craigmaddie, for telling us about the circumstances in which her father became ill.

I also pay an especial tribute to the noble Baroness, Lady Monckton of Dallington Forest, whose speech was incredibly powerful and moving, and obviously requires a detailed answer from me in policy terms, about people who have learning disabilities and what may happen to them. It also has relevance not just for those whose parents are still alive, but much more significantly, for when their parents are gone. There therefore needs to be a solution beyond simply ensuring that a family member is there. I pay tribute to the influential nature of the speech that the noble Baroness made in relation to this. Whatever happens to this Bill—and I very much hope it becomes law—what she said will, I am absolutely sure, have an influence on its terms, and we should respect that.

There are three categories that I need to deal with in relation to this. First, what is the position in relation to people who do not have a disability? Secondly, what is the position for those who do have a disability? Thirdly, what is the position for children?

First, for those without a disability, the Bill currently prescribes that no registered medical practitioner is under any duty to raise with anybody the subject of the provision of assistance in accordance with this Act, but nothing prevents a registered medical practitioner exercising their professional judgment to decide if and when it is appropriate to discuss the matter with such a person. Clause 5(5) provides, in relation to this preliminary discussion, that they cannot just raise assisted dying—it has to be in the context of the illness, the prognosis, the treatment and the palliative care. The Bill specifically identifies that it cannot be conducted in isolation from an explanation of the illness, the treatment options available or the palliative care available.

The consequence of that requirement is that no doctor can comply with this provision without knowing the full details of the patient’s position, their condition or prognosis or the available palliative care. The doctor who does it must be in possession of that material. In addition, because this is a legal requirement, you can raise it, as a doctor, only in that context; namely, you have to provide the whole context. There will have to be guidance, and I am absolutely sure that there will be guidance from the GMC and, if he chooses to do so, from the Secretary of State issuing a code of practice, making it clear that such a preliminary discussion can take place only in that context. The material saying that a random doctor could give this is completely wrong; it would be breaking the law if they did. The circumstances are as I have described them.

If you ban a doctor equipped with all this knowledge about the patient and under the legal requirement from having to put the whole picture to the patient, you end up in a situation with, as it were, only those who know about it being able to access it. As the state of Victoria discovered after its five-year review, restricting any doctor from raising it, unless it is raised by somebody who knows about it already, had detrimental impacts on access in relation to it and was unfair to groups of patients. That is why, in the state of Victoria, they passed an Act in November—I am sorry that the noble Baroness, Lady O’Loan, is not in her place for this. That Act has not come into effect; it will come into effect in 2027, and it gets rid of the gag.

This was thought about in great detail and, in my view, the correct policy was reached; in relation to somebody without any sort of disability, it is right that you should leave it to the doctors, for the reasons I have given. I very much hope that my explanation of how it operates in practice shows that it means that it cannot be a random doctor. Again, I do not think that any change is required, having listened very carefully in relation to people without a disability.

I am still not sure what a person is supposed to do if they cannot access a doctor who is in possession of the full information. If the GP, for example, has a conscientious objection, that potentially puts a hurdle in that will stop them being able to move on to the next stage—they will have to cast around to find a doctor who can have that full discussion. I would have thought that the proponents of the Bill would not want that to happen.

I completely understand what the noble Baroness is saying. Suppose you cannot find a doctor with that information about you—the noble Baroness, Lady Cass, is not talking about the sorts of cases that many noble Lords were talking about, where, by raising it, you are leading to a situation where somebody might be persuaded when they otherwise would not—the answer would be that you would have to consent to all your records being given to a doctor with whom you could have the conversation.

Noble Lords should remember that Clause 5(6) says:

“A registered medical practitioner who is unwilling or unable to conduct the preliminary discussion mentioned under subsection (3) is not required to refer the person to another medical practitioner but must ensure that the person is directed to where they can obtain information and have the preliminary discussion”.

So you can get assistance from a doctor who is not willing to have the discussion. The noble Baroness is absolutely right that, in order to have the discussion, the doctor has to have all the information I referred to. If no doctor in possession of that is willing then you will have to consent to it being given to somebody else—and a patient can consent to their records being given to another doctor.

I turn to the position for those with a disability and, in particular, will deal with the point so powerfully raised by the noble Baroness, Lady Monckton. My Amendment 548A would require that anybody providing a relevant activity under the Bill—new subsection (8) defines “relevant activity” as including “conducting a preliminary discussion”—must not carry out that relevant activity unless the person seeking assistance has an “independent advocate”.

The amendment says that

“‘qualifying person’ means … a person with a mental disorder (as defined by section 1(2) of the Mental Health Act 1983) … a person who (in the absence of support) would experience substantial difficulty in doing one or more of the following … understanding relevant information … retaining that information … using or weighing that information as part of the process of making relevant decisions, or … communicating their views, wishes or feelings”.

Where there is to be a preliminary discussion, the person has to be accompanied by an independent advocate, unless—this is in new subsection (3) to be inserted by the amendment—the person

“seeking assistance informs the relevant person that they do not want an independent advocate, or … where the relevant activity is conducting a preliminary discussion, the person seeking assistance informs the relevant person that they are content for the preliminary discussion to be conducted without them having an independent advocate”.

What the sponsor of the Bill is aiming at there is as follows. If there is any question about one’s ability to process information—what the noble Baroness, Lady Monckton, said about the suggestibility of people with Down syndrome is incredibly resonant—I would envisage the position to be that you have to have an independent advocate but you may not need to have one if it is known to the doctor, or if it becomes apparent, that a family member would be adequate. That would be a reason for not having an independent advocate. But, if there is no family member—for example, if the person suffering from a disability has no parents, siblings or whatever—there has to be an independent advocate.

It may be that the area I should focus on in the amendment on independent advocates is this: you can say no to the need for an independent advocate, maybe because you have nobody else, but is that too risky? I need to consider that, given the point on suggestibility raised by the noble Baroness, Lady Monckton, and Mr Ross of the Down syndrome advisory policy group, whom I have discussed that with.

The points made about people with a learning disability are, I hope, addressed in my amendments on an independent advocate. Ultimately, where there may be no family, the independent advocate has to be the rock-bottom protection.

I move on from that to children. I remind noble Lords that, as the noble Baroness, Lady Coffey, made clear, Clause 6 says:

“No registered medical practitioner or other health professional shall raise the subject of the provision of assistance in accordance with this Act with a person under the age of 18”.

It cannot be raised, and I completely stand by that. What happens if it or something like it is raised by a person who is under 18? I found what the noble Baroness, Lady Finlay, said, to be resonant and insightful. You have to deal with it in a sensible way. You cannot just say, “I’m afraid I can’t talk about that. That’s the end of it”. You have to treat the person with a degree of maturity.

The noble Baroness, Lady Finlay, supported Amendment 211, in the name of the noble Lord, Lord Rook, which says:

“If a person under the age of 18 raises the subject of the provision of assistance under this Act, the medical practitioner must refuse to discuss the subject and shall inform the person that such assistance is not available to individuals under the age of 18”.

I am sure that the medical practitioner should say that it is not available to persons under the age of 18, but I am not sure that it would be wise for the Bill to prescribe that no further discussion is appropriate—particularly for 17 year-olds, who are often quite perceptive. The idea that you cannot have any discussion about this is just not practical or sensible and it would drive people to other sources, which may be more dangerous.

I will press the noble and learned Lord on that point. The ability for medical professionals to discuss this with patients is prescribed in the first part of Clause 5, but only

“in accordance with this Act”.

If you were a medical professional and a child raised this with you, and you started discussing it, would you not be obliged, under your legal and professional suicide prevention duties to that child, to take steps to protect them? Under the Bill, they would not be eligible to have an assisted suicide. I do not understand this—and the noble and learned Lord has not answered my question about what happens with adults—but if a child goes to a medical professional and starts suggesting that they want to end their life, that medical professional is under a clear duty to take steps to protect the life of that child and even to take steps to force that to be the case. Unless I am missing something, nothing in the Bill will change the legal and professional duties on that medical professional.

The noble Lord is right. The point I was making was that, if it is raised, it is not sensible to just close down the discussion altogether. There has to be an informed discussion, which is completely consistent with the duties that the noble Lord referred to. The idea that there cannot be any discussion about it, which is what I think the Amendment in the name of the noble Lord, Lord Rook, says, is, in my submission, neither practical nor wise. It is for the doctor to decide how to deal with it, of course in the context that the noble Lord mentioned.

Finally, if the Bill passes, Parliament will have decided that the option of an assisted death for those who are terminally ill is an appropriate option. It may well have come to that conclusion because it thinks that it is a compassionate option to give people, as has occurred in so many other countries in the world. Once Parliament has said that that is the position, those people who are in a position to access assisted dying should be given appropriate assistance to do so. That is why, in my view, it is perfectly acceptable for it to be discussed by doctors as an option for people who are terminally ill, because they will look to those who are caring for them for assistance to determine how their life ends. I am not sure whether the noble Lord, Lord Moylan, was saying this, but I do not believe that adopting that option is morally abhorrent.

I will press the noble and learned Lord because I genuinely want to understand what is going to happen. This is quite a big deal for the health service and other professionals in this area. When, under the Suicide Act, which the Bill amends, somebody trying to take their own life stopped being a criminal offence, we did not suddenly say that we thought that was an acceptable thing for them to do; we recognised that making it a criminal offence did not make a lot of sense. Therefore, just because we make assisted suicide lawful—getting assistance to take your own life—in itself that does not change the suicide prevention duties.

I want to understand, if the Bill were to become law, what steps the Government would have to take on the legal duties that medical professionals have under the suicide prevention duty and their professional duties; otherwise, I do not think we are being very consistent here. I do not want medical professionals, who we are asking to do this work, to be conflicted or to think they are at risk. Organisations such as the Medical Defence Union think we are in great danger of putting those medical professionals in that invidious position, and the noble and learned Lord has not really answered my question satisfactorily—or certainly not to my satisfaction.

The point of this part of the Bill is that it is a legitimate option. If the noble Lord is saying that because we have suicide prevention policies in other areas, we should still treat it as something that we should not in any way encourage or help people to access if that is what they want, that is wrong. The true position is that, once it becomes an option, subject to the safeguards being gone through, it is something that people should know about and make their own judgment about.

I do not think we have fully understood these two categories. I was grateful to the noble and learned Lord for the meeting with Professor Ruck Keene. It is clear, particularly when you are talking about the Mental Health Act, when there are two different statutes you can choose from, that we need to be clearer about that for clinicians. So, unfortunately, even at this late stage, I am afraid I will have to lay some amendments so that we can really talk about this in detail, because it is a matter of concern, particularly to psychiatrists.

On the points I have made about children, I accept the point from the Minister that the probing Amendment is probably too wide. However, we have not even had the comments on the categories of people who can now raise this with children, such as schools, et cetera. I also raised the point—I am grateful that the noble Lord, Lord Tarassenko, is now in his place—that I believe we also now have this gap with regard to what advertising prohibits. You have medical practitioners unable to raise it with under-18s, but then you have a whole wealth of technology in between that, which can, as we know, even with a mistaken question, raise this issue with under-18s. What does the noble and learned Lord envisage will happen in those scenarios, which are at the moment subject to legal cases in other jurisdictions?

A whole range of issues is covered to a large extent by the Online Safety Act in relation to the promotion of suicide, particularly to young people. That, in a way, is a separate issue from this issue. I fully encourage and support all attempts to try to reduce the risks to young people, but I am afraid that the Bill cannot take that on, on its own.

My Lords, I thank all those who have contributed to the debate on this group of amendments on raising AS in conversation and preliminary discussion, including training.

I thank the Minister for her response to my amendments. However, given the government response and the question about funding, it lays open the bigger question of the whole Bill that many of us are grappling with: who pays for this and what that final bill may be.

The debate has gone in a slightly different direction from what I expected. It is interesting that the noble and learned Lord, Lord Falconer, differentiated in his response between non-disabled and disabled people. Independent advocates will come up in a later group, but I think it is really important that it is understood, as part of this group, when we are talking about learning disabilities, that it may be very difficult for someone with a learning disability to understand what an independent advocate is and what their role is. They may say that they do not need it but not really understand what they are saying yes or no to. We will cover that next week.

I am slightly worried that there may or may not be guidance from the GMC and/or the Secretary of State. I will be very interested to discuss that with the noble and learned Lord away from this Chamber. This is where we probably disagree. Those who support this Bill will talk about Victoria and say that it gives greater access; I say it is a slippery slope and that it is making it easier for a wider group of people to enter this process. We have covered in previous amendments the use of language. “Person with a disability” is not used in the Equality Act. I had hoped, through my contributions to previous debates, that there was some understanding of it and why organisations of and for disabled people are worried about this Bill. It is not just about the contents of the Bill; it is about the language of the Bill. Organisations of and for disabled people use the social model. I will not go through that again, but the language they choose to use is “disabled people”.

The noble Lord, Lord Weir, has apologised for having to leave, but he raised the issue of how disabled people are treated. I am going to raise a difficult question, not to anyone in particular but to the whole Chamber. It is rhetorical. How many in your Lordships’ Chamber have ever felt sorry for me because I am a wheelchair user? My previous career as an athlete negated some of that feeling because, if you like sport, competing for Great Britain is a privilege: of course it is. In my second career, however, I consider the way that I am treated every single week. I am a long way from my sporting career now but, if I am rushing to a meeting, I luckily do not hear “It is not a race” too often these days. I know: I am not in my racing chair and I am not wearing Lycra. I am not sure sometimes, when people say this, whether they think they are being kind, sweet or funny. I did not have a traumatic or dramatic accident; I was a wheelchair user from a very young age. There were a few points in my life when I had three spinal surgeries and experienced terrible pain, but I am healthy.

The noble Lord, Lord Weir, raised the different views that doctors have of people. I have said before that my husband had a traumatic accident at 21. He broke his back and spent nine months in hospital. Many people assumed that it irreparably changed his life. It did not. He went on to complete his PhD. He changed sports; he went from cycling to wheelchair racing and he met me. But the way that he was and is treated is very different depending on whether he is walking with his crutches or is occasionally using a wheelchair. If he is walking, people like to think that he has had a skiing accident or something quite cool but, when he is in his wheelchair, people talk down to him. His colleagues have completely forgotten that he has a PhD and have talked to him differently.

He had a stroke in 2020 and I was really worried about him going into hospital because I was not sure of the outcome. I had calls with doctors telling me about the impact of the stroke. The noble and learned Lord talks about doctors needing to know all the information. It was really clear in his patient notes that he had a spinal cord injury, but the doctors rang to tell me that both of his legs were really badly affected, and I was saying, “Well, that would be the spinal cord injury”. They then told me that his grip strength was really good. Well, 30 years of doing wheelchair racing and cycling and walking with crutches would make that happen; they had no idea what his grip strength was like before he had the stroke. So the information they were giving both of us was not very helpful at all.

All our experience of healthcare is very different. I had a doctor in a spinal unit ask me, “How did you catch spina bifida?” I laughed. I have been asked it several times. I think the first time was when I was in my early 20s, and I said I had caught it with a butterfly net—humour does not always go down very well, either in the Chamber or outside. I was really shocked that a doctor in a spinal unit was asking me how I caught a congenital disability. Because of my scoliosis, my internal organs are all in rather strange places in my body. Every time I go to the hospital for a kidney scan, I am asked, “Do you have one kidney?” I say, “I have two kidneys; look at the notes”. “Are you sure?” “Yes. I haven’t had an operation to remove one of my kidneys”. Every time you are measuring what you say because you do not want to offend doctors and you do not want to be rude or flippant. I sit there and say, “I have two kidneys. My right kidney is somewhere up under my arm”. “It can’t be there”. “Look at my notes”. Eventually, they find my kidney somewhere up underneath my right arm.

This is the frustration that disabled people feel. It is lovely to say that doctors will read all the notes and understand them, but actually something as basic as “I have two kidneys” is often misunderstood. So I challenge your Lordships’ Chamber. Have you ever pitied me? Do you think I am brave? Do you ever think, “Well, at least it’s not me?” Am I brave as a wheelchair user or brave because I was an athlete? How many people consider that, because of my impairment, I suffer? I apologise for sighing when the noble and learned Lord talked about the suffering of disabled people. My phone started pinging. I cannot read out any of the responses or the messages I have had on that, as all the language is unparliamentary. This is why disabled people are scared. The assumption is that we suffer. I do not suffer.

Disabled people are worried. That is why they are fighting this Bill. It is not kind, it is not sweet, it is not being understanding, it is not being compassionate. We are constantly having to try to fit into a version, an idea, of what non-disabled people think of us. If we dare challenge that, we have a chip on our shoulder, and we are one of those funny disabled people who just do not understand that we are meant to deal with people being kind to us. We have to deal with being patted on the head, literally and figuratively. It once happened to me in this building. It was a Peer who did it to me. I was with colleague who was a wheelchair user and we were chatting about a Bill that we were working on. The Peer came up to us and said, “Are you having a nice time?”—in that tone. We said, “Yes, actually, we’re debating the Bill that we’re working on at the moment”. The Peer ruffled my hair. This is patronising. This is ableist. It is not kind. How does the noble and learned Lord assume that people like me “suffer”? I am really squeamish about the word. So many people are frightened because of the assumptions that are constantly made. I want to take my challenge further. How do you see disabled people who might be on the streets? Are we deserving and undeserving disabled people? That happens between Paralympians and non-Paralympians.

My noble friend Lady Campbell of Surbiton talked about DNRs being put on healthy disabled people. By virtue of how people who speak remotely are able to contribute, my noble friend and the noble Lord, Lord Shinkwin, were not able to come back into the debate. My noble friend wanted to make it clear that she has to rely on doctors for everything in terms of her well-being. We put huge trust in those people. My noble friend has been in hospital many times, and it is important to listen to her experience of what it is like. I will keep raising this in terms of how I am able to contribute in debates. I can sit in one place—well, three places—in the Chamber. I cannot sit with my colleagues. Those speaking remotely cannot come back and ask questions. There was one time in the time that I have been here when five wheelchair users wanted to speak in a debate. We had to tag-team in and out of the Chamber. How many other noble colleagues have had to do that?

My noble friend Lady Campbell wanted to reiterate the unequal nature of the system. She also wanted to draw attention to a BMA survey looking at doctors and medical students who are disabled or have long-term health conditions. It was published on 3 December 2025. The author, Natasha Wilcock, is deaf. It raised the ableism that exists in that profession. The assumption is that the barriers are from patients, but actually there are deep-rooted issues in the experience of doctors who are disabled. A huge amount of prejudice comes from other doctors.

The noble Lord, Lord Shinkwin, again, was not able to come back in, but he wanted to raise a couple of points. He asked me to say that the noble and learned Lord did not answer any of his questions and that he would be happy if he could write to him.

If you treat your disabled colleagues with prejudice and contempt—sorry, I am again referring to the BMA survey—how do doctors treat disabled patients? The equity of treatment of staff and of patients is inextricably linked.

We have talked before about how anybody who has a terminal condition is disabled, but you do not have to be disabled—it does not work the other way around. But the Department for Work and Pensions frequently links sick and disabled. Again, this is why disabled people are worried. We have to question our own biases in the Chamber and the biases of the system that disabled people will be going into. Groups of and for disabled people are not reassured by the words of the noble and learned Lord, Lord Falconer.

Like others, I thank the noble Baroness, Lady Monckton, for her speech. It is not easy to stand up and talk about something so personal. As a daughter and a mother, I find talking about my parents much easier than talking about my daughter. How can we live in a world where somebody with Down syndrome gets a clinical frailty scale of 7? What is going on with that? How can we live in a world where people are frightened to go to hospital because of what the doctor is going to say to them?

I was contacted by a friend, who is a scooter user and also has a clinical frailty scale of 7. They thought their scale was 3. They were shocked when they were told that that was their level. They contribute massively towards society. My friend said that he thought his life had value, but suddenly, a process is telling you that you have no value. He said that it makes you feel a bit rubbish when you realise that the Government value your life as a 7, not a 3. He also went on to say that he feels that if assisted suicide existed, he would be in big trouble.

My noble friend Lady Murphy is not in her place, so I will follow up outside on what she said about the percentage of doctors who support this.

In February 2025, in the Royal College of GPs’ polling, only 33.7% said that they would support the principle of assisted dying, and 47.6% said that they would oppose it. It is worth noting that surveys by the Pharmaceutical Journal revealed that while 54% of pharmacists support the principle of assisted suicide, this dropped to 38% when asked about the Bill.

I am conscious of time, but there is a lot to cover in this group.

The noble Baronesses, Lady Blackstone, Lady Fox and Lady Coffey, talked about the BMA, and that is an interesting point. It gave two reasons in its written evidence. The first was that it was likely to be detrimental to patient care and the second was that it would also create uncertainty and legal risks for doctors. That goes a little bit further than the noble Baroness, Lady Blackstone, said.

I have covered the gagging Clause.

We still have not got to the bottom of the definition of medical personnel, which was raised by the noble Baroness, Lady Berridge, and my noble friend Lady Cass.

Ultimately, terminal diagnosis has a significant pressure on someone’s mental health. Currently, suicidal thoughts are given protection or support. The UK national lead on suicide prevention, Professor Louis Appleby, in research with palliative care expert Katherine Sleeman, raises that increase in suicidal risk. Dr Jamilla Hussain, in committee evidence, said that palliative care staff experience racism and patients from ethnic minorities experience worse outcomes in healthcare.

The timing of this discussion is very important, as is how it is raised and the words that are used. While this has been a really interesting debate, we still have not got to the bottom of many issues that these amendments address. But at this stage, I beg leave to withdraw my Amendment.

Amendment 149 withdrawn.

Amendments 150 to 164 not moved.

House resumed.

House adjourned at 5.35 pm.