Around a dozen former healthcare professionals now sitting as MPs participated in the Marris Bill debate, with a number of speeches based on professional experience proving key
One of the most significant speeches made in the Marris Bill Second Reading debate was that of the Member for Bath, Ben Howlett, who was first elected to the House just four months earlier:
I must admit, Madam Deputy Speaker, that this will be a test of my oratory skills, as I have changed my speech three or four times based on some of the speeches that have been made and it is now unrecognisable. I admit that I came into the House thinking that I would support the Bill, but listening to the speeches made by other Members, particularly the hon. Member for Central Ayrshire (Dr Whitford) and my hon. Friend the Member for Totnes (Dr Wollaston), has completely changed my mind. I must say to those constituents who have got in touch with me on this issue over the past few weeks that listening to the arguments in this place has lain heavily on my shoulders.
My brother is a palliative care registrar. He wrote to me recently from New Zealand, saying that every time he is asked whether there is a way of speeding up the dying process the question normally comes from patients who have never seen a palliative care specialist. He normally says that he will help to improve the symptoms and the question of assisted suicide ends up dissipating.
After listening to the arguments made today by many people who are much more experienced in this field than I am, I have to say that I will oppose the Bill.
We reproduce below in full the speeches, cited by Mr Howlett, of GP Dr Sarah Wollaston and breast cancer surgeon Dr Phillippa Whitford (pictured above). Following these are extracts from nurse Nadine Dorries, GP Dr Liam Fox and nurse Maria Caulfield.
So many of us bring deeply personal perspectives to this debate. We also bring the voices of our constituents, and I thank everyone who has written in telling of their experiences both for and against.
I would like to add a clinical perspective. There are two conflicting principles here. There is the fundamental principle that doctors should do no harm—and this House must think very carefully before we remove that cornerstone of ethical medical practice—but that comes up against another very important principle: the principle of self-determination about which so many Members have spoken very powerfully. If we are to apply that principle, however, I ask where it will take us. If we are to argue that Diane Pretty, for example, had the right at a time of her choosing to end her life because of intolerable suffering—a quick death, without pain, at home, surrounded by her family—why should we deny that to somebody with mental capacity with locked-in syndrome such as Tony Nicklinson, or indeed a young man who has a high spinal injury?
Also, if we are to apply that principle further, what is intolerable suffering? Intolerable suffering is what is intolerable to us. We have seen that definition extend in Switzerland. Indeed, a British citizen—a retired nurse— took her life in Switzerland last year because she was afraid of getting old. We have seen the definition applied to people with depression, and in other countries to children. That starts to bleed into questions about capacity.
As a clinician, I have had the privilege to sit with many people at the end of their lives, and often people contemplate taking their life. People have asked me to help them do so. They do that because of fear or a deep depression, or sometimes a profound sense that they are a burden on their families. With time, I have seen many people come through that to find real meaning in their lives. We need to think very carefully before we take that away. Of course people say to me, "Who are you to say whether or not they should take that journey?"—or even whether they would come through that period, because some of course do not—but I say to the House that we have to consider the harms as well as the benefits.
We have to consider the impact on wider society, too. I believe it is inevitable that we would slide towards the Swiss position, and we must consider what message it would send to people if we say that it is all right in society to end one's life from fear of growing old. In Switzerland there is a high preponderance of people who live alone, who have been divorced, and who are women, and we have to think about why they have come to that position. What does it say if we have an attitudinal shift in our society, as I believe is inevitable, which changes the way we feel about the value of life? We have to consider not just the rights of the individual to self-determination, but the inevitable wider effects on society, and the pressure people will inevitably feel at the end of their life.
I hope that Members will look at the report on end-of-life care by the Health Committee, which I was privileged to Chair, and think again about how we can refocus on what the duties of a doctor should be. A doctor's duties should be to improve the quality at the end of life, not shorten it.
Let us look at how the House can work together to improve access to high-quality specialist palliative care, and how we can address variations in that access, and put the funding of our hospices on a long-term sustainable footing. I would like us to provide free social care at the end of life, so that more people can be at home surrounded by their loved ones in a place of their choosing if that is what they want.
I would also like us to bring forward discussions about dying, because there are many ways in which people can express their preferences at the end of life. Let us bring forward better care planning, bring forward those conversations, and bring forward access to specialist care, but please let us also consider the wider consequences and vote against this Bill.
I do not think anyone doubts the views that have made all of us give up a Friday to be here; everyone is here because they are concerned about the suffering of others and we want to alleviate it. We just do not agree about how we should go about it.
I believe that this is not just a tidying up of a small legal anomaly. It is, rather, a crossing of a Rubicon, as was mentioned earlier. It is changing and legalising the killing of one person by another, regardless of the reasons why we would want to carry that out.
The Bill's weaknesses have been mentioned, such as the problem of finding general practitioners who would write a report. In actual fact, quite a lot would be willing to do that, but not so many would be willing to be involved in the act of assisted suicide. Where would the independent expert be found? Some 96% of palliative care specialists are utterly against this Bill. They object to the name of it; they consider what they do is assisted dying, and what this is is assisted suicide.
I do not want to talk about the small print, however. That will be explored over the day. My objection is basically in principle. Many Members will be aware of my interest; as a breast cancer surgeon for 30 years, I have been involved in the journey to death of many patients, but as a doctor I have never considered that death was a good treatment for anything, no matter what was wrong with anyone.
People would choose such an option for lots of reasons: the fear of being a burden, the fear of dying, and most of all the fear of suffering. The responsibility to deal with that lies with us. Who is making them feel that they are a burden—is it their family or their friends, or is it society? Who is letting them down in their palliative care? It is us. As the hon. Member for Totnes (Dr Wollaston) mentioned, the services are patchy in some areas. Not everyone has access to palliative care, but I started out in 1982 when women did not know when they went into theatre that they had breast cancer because we did not have the ability to diagnose it. I worked for an eminent professor in Glasgow, and we lived in the ward in those days, and I watched patients come back from theatre having had the lump removed. If it was cancer their breast was removed, and that was it—no choice. They found out they had cancer by groping themselves on the trolley, because if they had a lot of bandages and a drip, that meant they had lost their breast and they had cancer.
Watching people die of cancer was awful at that time. They were cachectic, they were in pain, and we had very limited hospice and very little palliative care support in the hospital. But 30 years later that has changed. Whereas 40% of patients would live 10 years then, now 80% do so. Our patients know exactly what operation they are going in for. They have hours of discussion with us, and until a few years ago I would have been involved in their journey if that cancer came back, in their palliation and in their terminal care.
That journey can lead to a beautiful death. The event that had the biggest impact on me as a junior doctor was the death of a lady whom I had looked after for many months. When I came on to the ward that night, the nurses said, "I think Lizzie's going." She was curled up in her bed, obviously quite upset, and when I asked her what was wrong, she said she was frightened and she did not know what she had to do. I said, "You don't have to do anything. You just have to relax. You just have to let go." We had the family in. West of Scotland male is not good on emotion or openness, so I took her son in and I spoke to her again about what was happening to the point where he could tell her that he loved her and how much he was going to miss her. I went for my tea, and when I came back she was sitting up holding court with the whole lot of them. I thought, "Oh no, we've called it wrong", but she was gone in an hour, and it was beautiful. That made me commit to working with cancer patients. If I had not made it as a surgeon—which, as a woman at that time, I was told flatly that I would not—I would have gone into palliative care.
I have seen change in the journey for patients. We heard the hon. Member for Mid Bedfordshire (Nadine Dorries) describe the last two weeks of the life of her friend, and that is something that we see repeatedly—that the patient is ahead of the family. We are always utterly open with patients. We no longer have a situation in which a family member says, "Don't tell my mum. Tell me, but don't tell her." The patient will always know, because the fear is that when they see their death coming, they will know that everyone has lied to them and they will be on their own.
My job was not just to look after the patient; it was to look after the whole family. All these illnesses are diseases of the whole family, and we want the family to be left with the knowledge that they did everything they could and were able to express their love at the end of their loved one's life. Things have changed for cancer patients. I have not had a cancer patient ask me for a quick way out, an escape, for decades. We need to ensure that palliative care is offered to people with degenerative illnesses, of which we are all afraid.
When the public support this measure, they are not actually thinking about the last six months of a terminal illness; they are thinking about Alzheimer's, about motor neurone disease and about Parkinson's, none of which the Bill would address. It is therefore inevitable that this would migrate. As the hon. Member for Totnes said, we should support palliative care and we must ensure that it is available to people who are dying, regardless of their illness. We need to change our tone towards the people who live in our society, so that old and vulnerable people no longer feel that they should get out of the way.
All our horizons will narrow as we get older. Someone who was hill walking when they were 20 might not manage to do so when they are 80. I have seen patients who are grateful to be at home being wheeled out on to the patio in the sun and having a good blether with their son who has come home from London. They consider that a good day. We might consider it horrific, looking at it in advance, but when we get there we will have changed. We should support letting people live every day of their life until the end, and make sure that, as legislators, we provide the means for them to live and die with dignity and comfort. We should not say, "When you can't thole it, take the black capsule." We should vote for life and dignity, not for death.
In the 1980s, as a nurse, I had the privilege or the honour—I do not know the right word to use—to hold the hand of a young gay man when he was given a diagnosis of AIDS. It was not HIV, but AIDS—he was in a very bad way. He was given not six months, but 12 weeks. He is still alive today, as are so many of the other young men and women who were diagnosed at that time with HIV and AIDS and given fewer than six months to live.
Medical research ran ahead and found treatments for them to hold on to their lives for longer while even better treatments were developed. That race is still in progress: treatments are still being developed. We have now reached the point where somebody diagnosed with AIDS is far more likely to die of something else, but we would never have thought that in the 1980s. Many people present are probably thinking, "But this isn't the 1980s," but we did not know that AIDS was going to arrive in the 1980s and we do not know what is down the road, what new viral disease will land—it will probably be a virus, given the information we have—and what the AIDS of tomorrow will be. Six-month prognoses worry me, because no doctor can predict a life expectancy of six months.
I will use a personal case. Last August one of my closest friends visited her consultant after a series of tests had been ordered by her GP. At that meeting with the consultant, she was given 14 days to live. That was an accurate prognosis—it was accurate because it was 14 days. She went home, we got into bed and I spent 14 days on her bed. Her death was painless and peaceful; it was not for everybody around her, but it was for her, and those last 14 days were wonderful, until the very end when she was fast asleep and unaware. That is the beauty of palliative care today: no one needs to die a painful death. The combination of drugs that are administered to people in their final days ensure that they do not suffer pain.
The poison administered when someone makes the choice to take their own life, however, is not pleasant. They do not swallow a concoction of drugs and fall asleep. It is not a nice end. It is certainly not peaceful. They choke. It is not a good death. To people who argue that it is a good death, I say that it is not: it is painful and barbaric to die in that way.
I listened to the head of the hospice movement on Radio 4 this morning and I know of the fears and have read all the emails from people representing the hospice movement in my constituency. The hospice movement has very rightly highlighted that the pressure on people in hospices will shift over a period of time.
I want to make a final point. There are people all over the country who do not have a family member or relative as their next of kin. They do not have loved ones. For them, the next of kin is the state. It sends a shiver of fear down my spine to think that such a Bill might be legislated for and approved when so many people who are protected by the law may not have such protection in future because their next of kin is the state. When they feel that they are a burden or they feel under pressure, who will coerce them and who will feel the budgetary constraints involved in looking after them? I will end with that concern.
I want to make a few comments based on my experience as a doctor. Doctors can come under enormous pressure from relatives and from their own emotions to hasten the death of a patient whom they believe to be suffering too much. I worked in Glasgow Royal Infirmary during the early days of the marrow transplant programme. We had to give patients huge doses of sometimes very crude treatments, and when I was sitting with a young patient, there was very often a strong temptation to end their suffering. Some of them went on to survive, which is a lesson to doctors not to make judgments too hastily. I believe that anything that increases such pressures on doctors opens up an ethical trap that we do not want.
We already have laws relating to the concept of double effect. If a patient is suffering, we can give them medication whose primary aim is to alleviate their suffering, even though its effect will be to shorten their life. That is very different ethically and morally from giving a patient something that is primarily designed to kill them.
We need to understand that assisted dying can have an effect on the medical profession. Studies from the Netherlands and the United States on doctors who have performed or assisted at assisted suicides have shown that the medical professionals concerned had "high levels of emotional discomfort, distress and feelings of overwhelming burden".
However well-meaning the proponents of this Bill may be, they will open a Pandora's box that will fundamentally change who we are, how we are as a society, and how we relate to the medical profession. I believe that none of that will be to the benefit of future generations.
I come to this debate as a nurse with more than 20 years' experience in the NHS, most of which time was spent working in cancer care. I have looked after many patients with metastatic disease and many who needed end-of-life care. As a result, it has been my humble privilege to share the last few days, hours and minutes of many people's lives and, on numerous occasions, I have held the hand of someone as they have breathed their last.
Having experienced dying at first hand, I can say that death can be one of the most rewarding parts of life. It does not have to be as painful or distressing as the supporters of the Bill have described. The reason behind my positive experience of death is the availability of good palliative care, which tackles symptoms such as pain and enables people to have a good quality of life right up to the end. In the field of cancer care, we are fortunate to have access to some of the best palliative care in the world. However, many patients living with other illnesses are not so fortunate. Patients with cardiac failure, multiple sclerosis and Parkinson's—to name but a few—often have little or no access to palliative medicine, but instead of tackling the lack of palliative care, the Bill promotes assisted dying as a solution. Death today has become medicalised, and it is seen as a failure or as something to be feared instead of as a normal part of life. The reality is that a natural death can be a moving and peaceful experience for all involved.
Therefore, not only do I disagree with the rationale behind this Bill, but I have severe concerns about the lack of safeguards it contains. The first relates to its requirement to give someone a diagnosis of less than six months to live. It is almost impossible accurately to predict a person's prognosis in months. In my experience, that is not something a consultant would readily do, as someone's prognosis can vary greatly according to their disease, general health and response to treatment. This part of the Bill gives the false impression that having a terminal illness means life is over—nothing could be further from the truth.
If assisted dying becomes law, it will remove the incentive for science and medicine to find treatments for illnesses. Metastatic prostate cancer was a terminal illness 10 years ago but is now a chronic disease, whereby men, although not curable, are treatable and often die of other causes long before their prostate cancer ever becomes a problem. The same is true of metastatic breast cancer, with many women now able to live long and healthy lives even though they cannot be cured. HIV used to be a death sentence, but thanks to advances in medicine it is now a chronic illness that people live with, rather than die of. Would these treatments have been discovered if assisted dying had been legalised 10 or 20 years ago?
My third concern is that with so many doctors against legalising assisted dying—the Royal College of Surgeons, the British Medical Association, the Royal College of Physicians and the Association for Palliative Medicine are almost unanimous in their opposition—who will be left to assess the patients who wish to discuss assisted dying? The Bill requires both the attending doctor and the independent doctor to advise a patient on diagnosis, prognosis and treatment alternatives to assisted dying before giving consent. Most general doctors, however, would struggle to provide such specialist information. Are we certain that if we change the law, this will be carried out properly?
My final concern relates to the experience of places where assisted dying is already law. If the death rate in Oregon, where assisted dying is legal, were transposed to this country, 1,500 deaths a year would occur here from assisted dying. In Oregon, patients with lung cancer and prostate cancer are already being denied treatment on their state health insurance plan and are instead being offered assisted dying, as we have heard today. Is that what we want for patients in this country? Do we want them to be denied cancer treatment but offered assisted dying as an alternative?
Before we change the law to legalise assisted dying, we need to see serious evidence to prove, first, that the current law is not fit for purpose and, secondly, that what is being proposed would be better. On neither account has any convincing evidence been presented. Our current law is not perfect, but it does what it is designed to do: it holds penalties in reserve to deter malicious assistance, while allowing discretion not to prosecute, where appropriate. What is needed is not a change in the law, but better access to palliative care for all.