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Health: End-of-Life Care

Volume 705: debated on Tuesday 18 November 2008

asked Her Majesty’s Government whether the proposals in Dignity in Dying’s Charter for Dignity at the End of Life will be taken into account as they take forward their end-of-life care strategy.

The noble Lord said: I am pleased that we have the opportunity today for this short debate on this very important issue. I hope we will find time for longer debates in the next Session.

We exercise choices as we go through life; so why should we not do the same as we leave this life? Personal choice at the end of life is my theme today. I am a member of the British Humanist Association. I have no other relevant interest to declare. I support the policies of Dignity in Dying and I am grateful for the factual material that it has provided but the views that I express are entirely my own.

I begin by congratulating the Government on their end-of-life strategy document. It is a thorough and comprehensive piece of work that does the Government great credit. I like the way in which it builds on the Mental Capacity Act 2005, which gives statutory force to the right to refuse treatment by giving people more positive choices at the end of life. It is very much of a piece with the Government’s 2005 manifesto commitment to double the number of people with cancer who could be treated at home, which is what we know most of the public want.

The strategy, rightly in my view, identifies lack of open discussion between health and social care staff and those approaching the end of life as one of the key barriers to the delivery of good and dignified end-of-life care. That is why I welcome the commitment in the strategy that patients should have the chance to discuss personal needs and preferences with professionals and to have their preferences included in an end-of-life care plan. I assure noble Lords that I have my list of preferences ready for when my time comes. I also know that they may not count for much in the UK unless the care culture changes, more options are open to me and my legal rights are strengthened. That brings me to the Charter for Dignity at the End of Life produced by Dignity in Dying in June this year, for which I had the pleasure of providing the foreword.

Some critics of that document have, in my view rather foolishly, branded it as “A Deadly Charter”. Perhaps I may summarise for the Committee what the document actually calls for: first, giving everyone the opportunity to create an end-of-life care plan; secondly, placing a duty on healthcare professionals to consider that plan; thirdly, the Government promoting awareness of advance decisions by patients; fourthly, parliamentary approval to giving terminally ill, mentally competent people the option of an assisted death; fifthly, more resources to be made available for palliative care; sixthly, consistent palliative care commissioning to end the postcode lottery in provision; seventhly, better support for carers, including more access to respite care and stronger legal protection against employment discrimination; eighthly, specialist training for health and social care professionals on end-of-life issues; and, ninthly, better access to support services for bereaved people.

That hardly seems to me a charter of death. I hope that the opponents of any form of assisted dying will not rubbish everything that Dignity in Dying says or does. The organisation campaigned—courageously, in my view—for advance decisions, and has also campaigned for more resources for palliative care. There is no philosophical or practical reason why a person or organisation cannot be committed to both better palliative care and assisted dying within strict safeguards. That is certainly my position. Both options are part of a range of choices that should be available to us in a civilised society. It is worth bearing in mind that in those countries and jurisdictions where assisted dying has been legalised, palliative care has flourished and received extra investment.

I note, too, that the Government have produced a further consultation document, which provides for PCTs to demonstrate that they are aware of the views of their population with regard to the delivery of care at the end of life and that local population needs have been assessed. I welcome the fact that the Government are working on some outcome measures for these quality markers and that these could include “place of death” and surveys of bereaved relatives. This more informed approach will mean that policy making on end-of-life issues will be made less on the basis of ignorance and prejudice and more on the basis of solid and reliable information.

That brings me to the final part of my remarks, which relate to how we respond better to people's real preferences on end-of-life issues. The available evidence shows that the legislature in this country is significantly out of step with public views on assisted dying. Surveys—and I include in this the very reputable British Social Attitudes Survey 2007—consistently show that 80 per cent of the population support a change in the law so that a terminally ill, mentally competent person can have the option of an assisted death. Indeed, an ICM poll last month showed that 29 per cent of people think that assisted death is already legal in this country.

Both here and in the other place, parliamentarians seem to be in a diametrically opposite position on this issue to their constituents and fellow citizens. The Government have so far remained neutral on this issue. I do not doubt that my noble friend the Minister has the same brief on neutrality that used to be served up to me when I was a Health Minister, but I should like her and her colleagues to reflect on the fact that the situation is changing. International opinion is moving to where British public opinion has been for some time. Assisted dying laws are in place in the Netherlands, Belgium, Switzerland and Oregon state. Washington state has now voted in favour of an assisted dying law modelled on Oregon’s law. Luxembourg has just approved a new law. In France, President Sarkozy has ordered a study of possible amendments to the law—and the Spanish Minister of Justice is to study a possible law change.

Noble Lords will be relieved to know that I do not think that today is the occasion on which to deploy the arguments for a UK law change on assisted dying. However, I ask my noble friend and her colleagues to reflect on what is going on abroad on this issue and to consider the strong possibility that, the Government having produced this excellent end-of-life strategy, people may begin to take the Government seriously about choices at the end of life. They may even, dare I say, believe that one choice should be legally assisted dying for terminally ill and mentally competent people. We cannot have it all ways; if we have an end-of-life care strategy and we give people a chance to offer their views, we cannot always expect them to maintain the status quo in this area.

Finally, I ask my noble friend to consider commissioning an up-to-date authoritative study of UK public and medical opinion on the issue of assisted dying using a respected independent body and comparing this information with similar assessments of opinion in the United States and the EU jurisdictions that have already moved in the direction of assisted dying legislation. That would be a major service to parliamentarians and is something on which, in due course, I would welcome the views of the Government.

I, too, am extremely grateful to the noble Lord, Lord Warner, for introducing this all-too-important debate. We all acknowledge that Parliament has a duty to listen to the people whom it represents, thus I broadly welcome the Government’s end-of-life care strategy and the efforts of all the main parties to promote greater patient choice at the end of life.

Dignity in Dying commissioned an opinion to accompany its Charter for Dignity at the End of Life. It found that an overwhelming majority of the public believed that terminally ill people should be allowed to exercise choice over the care that they receive. Two-thirds of respondents said that they would be more likely to have a dignified death if they could discuss and record their wishes around end-of-life care and treatment. I hope that, if fully implemented, the end-of-life care strategy and the role of end-of-life care plans will go some way to meeting the public’s legitimate expectations of end-of-life care.

However, in one crucial regard Parliament is failing in its role to represent the will of the people. In 2006, an opinion poll conducted by YouGov found that 76 per cent of people believed that the law should change to allow terminally ill patients to receive a prescription from a doctor to end their suffering, subject to a range of safeguards. Another opinion poll, conducted by YouGov this year, again found that 76 per cent of people believed that terminally ill patients should be allowed medical assistance to die.

If we readily accept that people should have choice, control and access to services at the end of life, why is Parliament so reluctant to discuss this specific issue? Those who oppose assisted dying for the terminally ill insist that a change in the law poses a threat to vulnerable people. It is thus imperative that Parliament balances enacting the will of the people with ensuring their protection. When the law is changed, as I believe it will be—I repeat that it is critical to enact stringent safeguards to protect the vulnerable from abuse—it will be our responsibility to make sure that such a Bill is fit for the purpose. By calmly debating the safeguards needed, Parliament will enact a law which not only promotes greater choice at the end of life but provides greater protection for the vulnerable.

I accept that this is a difficult issue for many, but we have a responsibility to debate and resolve it. The current law on assisted suicide is nearly 50 years old. Society’s views have moved on, and Parliament should seek to reflect them. This has occurred in other contentious areas such as homosexuality, the death penalty and human embryology. In this contentious matter, let not bitterness and rancour pervade our debate, but rather let reason and understanding exist on both sides, at all times listening to the voice of the people whom we serve.

I declare an interest, having acted as amicus curiae in the Bland case and as counsel for the MND patient Annie Lindsell. I agree with the noble Lord, Lord Warner, and the noble Earl, Lord Arran, and I support the charter.

Reasonable legal certainty is especially important when a patient is suffering from a terminal illness and facing the prospect of severe suffering and indignity. Patients have the right to life; they also have the right to personal autonomy and to live and die with dignity. They and their doctors need to know what exceptions there are to the law of homicide which will enable a doctor, acting in accordance with the patient’s wishes and with the doctor’s judgment as to the appropriate medical treatment, to administer that treatment even though its probable effect will be to shorten the patient’s life.

There is a lack of certainty about the nature of the legal justification or excuse for what would otherwise be homicide, in relation to the medical treatment of the terminally ill. Where a doctor acts in good faith in accordance with what she considers to be responsible medical practice, with the aim of relieving pain or severe distress but with the foreseeable and probable consequence of shortening the patient’s life, the risk to the doctor is that the jury, as directed by the judge on currently declared principles, will impute the necessary specific intent to find them guilty of culpable homicide, and the judge will have to impose a mandatory sentence of life imprisonment. The absence of an adequate legal framework and the risk of prosecution under current law deter some doctors from treating their patients in accordance with those patients’ wishes.

The law should allow a doctor to have a defence to a prima facie case of murder based on foresight of consequences where the patient’s life is an intolerable burden to her, she is dying and the only humane treatment left is one that has death as its consequence. It should surely be a defence if the doctor satisfies the jury of three matters: first, the fact that she administered the treatment in good faith for the purpose of relieving her patient’s pain, suffering and severe distress; secondly, the fact that the treatment was given with the patient’s informed consent; and, thirdly, the fact that the treatment administered accorded with accepted medical practice. That approach avoids any artificial distortion of the well established legal concepts of causation and intention, and it provides much greater certainty than an approach based on the vague and confusing standard of primary and secondary intentions or double effect.

The time is overripe for Parliament to give terminally ill, mentally competent people the right to have an assisted death accompanied by stringent safeguards against abuse.

I support everything in the charter except, alas, one of its recommended measures—namely:

“Parliament must give terminally ill, mentally competent people the right to have an assisted death”.

I asked some of my medical colleagues to recall any episode or clinical story in which a patient recovered miraculously from a hopeless clinical situation. Most of them were able to remember someone who had recovered in spite of being beyond any expectation of life. What would happen to these recoverable cases if this law were adopted? Scientific progress continues to enable us to challenge human suffering from pain, breathlessness and such like, and there is much hope for even greater progress in this area.

I am a Muslim and in Islam, along with Judaism, Christianity and in fact many other non-Abrahamic religions, a physician has to render help, regardless of the patient’s financial ability and hopelessness due to disease. The physician, or anyone else, has no right whatever to terminate human life, and there is a very clear instruction in Islam, as in other religions, against taking your own life. Therefore, I suggest that the highly controversial proposal to ask Parliament to give terminally ill, mentally competent people the right to an assisted death be removed from the charter and submitted to the House, and it will then have my support and the support of many others in the House.

As it stands, the charter gives the impression that it is designed to introduce legalised euthanasia via Parliament under the cover of a package of harmless proposals relating to end-of-life care. This sort of tactic does its promoters no favours. If Parliament is to be asked to consider legalising euthanasia—and it rejected such a proposal decisively only two years ago—the agenda must be made completely clear.

I welcome this debate and I welcome much in the Dignity in Dying charter. I welcome the call for better resources for palliative care, the end of the postcode lottery in palliative care and improved support for carers. Better advice and counselling support for bereaved people is also greatly to be encouraged. The churches already contribute massively to this work. However, we cannot avoid the fact that these noble objectives are wrapped up in a package which, as its key objective, asserts the right of all to claim assistance in dying. To that end, we have already heard a great deal about choice and control. Choice and control are not bad things, of course, but they do not add up to a very rich anthropology. They point us to some important aspects of being human but they do not give us a rounded picture of how most people in total experience their lives.

Many of us, including most of us in your Lordships' House, are used to shaping our lives through the autonomous choices we make. But I ask noble Lords to reflect on the many people in the world and in this country whose experience of life is much more about being done unto, sometimes by those closest to them, and whose experience of professionals is not of jolly good folk, like you and me, but of remote, aloof and often faceless people who make decisions which may not immediately appear to reflect the client’s own interests. I ask noble Lords to consider whether a person whose life experience is not all about being in control and making free choices is likely to see the prospect of choosing the time of death as so great a boon as it may sound. For many—and I declare an interest as a parent of a Down’s syndrome child—the promise of more choice has so often turned out to mean pressure to choose that which suits others. People who have not led assertive lives, exercising their own choices, have often internalised the notion that others know best and end up valuing their own lives too cheaply. Are we to offer them the ultimate opportunity to give way to the will of those around them? I ask that in the context of requested legislation which, by definition, would involve the state in affirming the view of an individual life as intolerable and not worth living.

One of the prime functions of law is to protect the weak, so let us be very wary of a charter that imagines all human beings to be like us—confident, articulate and used to choosing the direction of our lives. For many others, choice is not always a promise—it can feel like a threat. Time and time again, history has shown that once a principle is breached, it becomes very hard to police the boundary.

The philosopher Alasdair MacIntyre describes human beings as dependent, rational animals. We are part of a greater creation; we have a unique capacity to reflect; but most of all, he says, the fundamental truth about being human is not that we are autonomous individuals but that we are dependent upon one another. Through good palliative care, our nature as dependent creatures can be given eloquent expression through the skill of the medical and nursing professions. The vision of our mutual dependency is surely better realised in a relationship dedicated to controlling pain and supporting life until death comes rather than the dry consumerist image of a medical profession part of whose job is to respond to a patient’s demand to die.

I thank my noble friend, as everyone else has, for securing this very timely debate. As I am sure the Government are aware, this is an issue of growing public as well as political concern. There are 22 noble Lords scheduled to speak, and this is the second parliamentary debate on this subject in as many weeks. A member of the judiciary recently called on Parliament to act to clarify the law on assisted suicide, and hardly a day passes when some aspect of end-of-life care and choices is not covered by the media. Personally, I very much welcome such open, lively discussion. Death, and how we die, have been taboo subjects in public policy for far too long, and the Government are to be warmly congratulated on the first official end-of-life strategy.

In this brief contribution, my purpose is to urge the Minister, as she takes forward the Government’s strategy, to broaden the terms of consultation specifically to include further work on the choice of assisted dying which is contained in the Dignity in Dying charter. The time has surely come when that choice for terminally ill and competent people must be responsibly considered.

I hope that the Minister will pay special attention to the suggestion of my noble friend Lord Warner that the Department of Health look closely at overseas experience. In my view, it is particularly important to examine the impact on palliative care in those jurisdictions where assisted dying is now legally permitted. The importance of extending good palliative care in this country is an ambition we all share, but the UK opponents of assisted dying often assert that professional good practice is threatened and palliative care services are undermined when the option of assisted dying is introduced.

My experience of hearing evidence to the Select Committee on the Bill of my noble friend Lord Joffe and visiting the American state of Oregon, where medically assisted suicide has been available for a decade, is that this is emphatically not the case. As the chief executive of the Oregon Hospice Association wrote recently in the Guardian:

“Palliative care in Oregon is ranked among the top 10 states … Hospice care … is provided by highly qualified, licensed, interdisciplinary teams of professionals … The team approach was established by one of our great heroes, Dame Cicely Saunders”.

Official Oregon figures show that the number of patients enrolled in hospice care when they died has more than doubled from 22 per cent to 57 per cent since the Death with Dignity Act was passed.

I hope the Government will accept that it is increasingly recognised that palliative care, however excellent, is not a universal panacea. There are and will always be a minority of terminally-ill competent people who would prefer to end their own lives. The empirical evidence from overseas now shows that this is a small and stable group; numbers do not shoot upwards in those places where assisted dying is a legal option. This is another area where the Government could helpfully undertake some modelling of possible demand if that choice was made available in this country.

I welcome this first-rate charter for end-of-life care and wholly agree with the sentiments expressed by the noble Lord, Lord Warner. It certainly reflects what people want at the end of life.

I am pleased to say that the medical profession, my own, as a whole seems to be changing at last to give greater respect to patients’ autonomous wishes. I have been heartened this week by the online poll conducted by the Student British Medical Journal in its survey “Should Doctors be Allowed to Help People Die?”. Yesterday, the last time I looked, the result of the 750 votes cast in the survey was 55 per cent yes, 45 per cent no. This is a significant improvement on what it would have been 10 years ago. It is a very heartening shift.

I wish to briefly address the issues raised by the right reverend Prelate the Bishop of Exeter about the vulnerable, particularly the mentally vulnerable. I speak as a psychiatrist who has worked most of my career with older people with mental disorders. I know that many are depressed at the end of life, and that there is a very high likelihood that if they are treated for that depression they will recover. It is important that, as the studies in Oregon show, one can assess clinical depression on a wide range of spectrum, from those who are mentally competent, understandable and have a not-treatable depressive response to those who have a treatable serious illness. It is not sufficient to give a person a one-off interview; you have to listen. Just as you would not take one blood test to diagnose diabetes, you would make a further assessment over a period of time. So it is with patients at the end of life.

We know from Battin’s studies published last year that, on the whole, over the past 10 years there has been no significant change in the number of people requesting death in other countries. It is a very small and containable group of people who seek an assisted death.

The Mental Capacity Act has had a positive impact on giving people greater choice to express in advance what they wish at the end of life. A change in the law to allow assisted dying would offer a much clearer framework for the protection of vulnerable people, including those who have lost capacity, those who are depressed and those who might be unduly influenced by others looking to their inheritance, among other things. Such a law would protect doctors. It would make clearer what they could and could not do and would immeasurably improve the trust that patients have in their doctors, knowing that their choices will be respected at the end of life.

Let there be no doubt whatever about the aims of those who are trumpeting this cause today. They have buried it in a whole lot of sensible goals which I cannot recall them ever mentioning before. When has the Voluntary Euthanasia Society, which was the previous version of Dignity in Dying, ever funded a hospice? Dame Cicely Saunders has been mentioned; she certainly did not support euthanasia. When has this society ever campaigned for accessing palliative care, more monetary help for carers or demanded that health and social care professionals should be trained to cope with spiritual support for patients?

Never before has there been a squeak of a suggestion that religion should be brought into this arena. Is this the road to Damascus? I do not think so. I do not think that, all of a sudden, the Voluntary Euthanasia Society has changed. It is trying to fool us. It is a bit like slipping a bottle of cyanide into a weekend shopping list and hoping that it will not be noticed among the Daz, eggs and vegetables. What we are actually talking about is encouraging people to kill themselves and, worse, opening the way for relatives to get elderly and sick people out of the way—which can be a boon, especially when they have money or property to leave. Make no mistake, it is very easy to give an old lady or old gentleman the impression that their continued existence leads to great problems and great expense for their sons and daughters. They love their relatives and they do not want to cause problems, either.

We also know that it is very costly and, heaven save us, that hospitals are severely hampered in meeting their all-important government targets when patients linger on in a bed for which there is a waiting list. “For goodness’ sake let us shoo them out of the way and into the graveyard or crematorium”. Terminally ill but mentally competent people will, if the true aims of the Voluntary Euthanasia Society are realised, submit themselves to a lethal injection or a fatal dose, when it is made clear to them in a subtle or direct way that it is time that they shuffled off this mortal coil for the general good. I cannot support this proposal, which worries me very much. This does not apply to every proposal in the paper but it applies the one that we should allow euthanasia.

This document contains a great deal that I agree with wholeheartedly. The Government worked for two years through various working groups and consulted widely on their excellent strategy for end-of-life care. These same ideas are presented as if they emanate from the voluntary euthanasia lobby, now known as Dignity in Dying. The document before us seems to be an attempt to import a very different additional proposal into the government strategy—that Parliament must give terminally ill, mentally competent people the right to an assisted death. I emphasise the word must because this is the only point in the charter that the voluntary euthanasia movement feels “must” be followed. That word alone shows that it is a key priority, but I cannot sign up to it.

Perhaps I may address the contents of the leaflet with which I agree. Carers and the bereaved need support. The Mental Capacity Act already requires professionals to take account of end-of-life care plans and preferred priorities for care documentation. Awareness of advance decisions is being actively promoted by the Government. Indeed, in 2001 I wrote an editorial calling for death plans. They did not, and do not, include euthanasia. Good care does not require the excuse of “double effect” to which the noble Lord, Lord Lester, alluded. Patients die of their disease and deserve good care and support, not shortcuts in care to end life. Good care is hard work.

Those who wrote this so-called charter seem remarkably ignorant of the increased resources that the Government are putting into end-of-life care. They seem unaware that a transparent formula for commissioning services is already being used in Wales; that carers are at the heart of many initiatives; that care and respite by Marie Curie nursing and others is cost-effective; that Dr Bee Wee has been appointed to develop the national training programme; and that communication skills training is already underway.

This charter masquerades behind the many years’ work of all those organisations that it alludes to as being supportive—clever wording indeed on page 6. It creates the impression that the hospice movement supports this charter. It certainly does not support item 5, which is the nub of the charter. Palliative care investment and education have increased around the world—not preferentially in countries that legalised euthanasia and assisted suicides, as has been asserted. In Oregon, one in six of those whose suicides were assisted had their depression missed by those assessing the request. The pro-euthanasia lobby’s approach in this document is reminiscent of Orwell’s 1984 and the Ministry of Truth.

So I ask the noble Lord whether this is an illusion. Are the people pictured next to the case vignettes the ones described in the document? Why is the euphemism “assisted death” used? Midwives assist at birth and palliative care assists at death; assistance is supportive help, not accelerating death or cutting life short by months or years. Why not be honest? What are the authors of this document frightened of? What they are really proposing is aiding and abetting suicide or giving doctors a therapeutic option of killing their patients. Palliative and other end-of-life care is being used like bubble-wrap around a sharp and dangerous object in an attempt to introduce assisted suicide by the back door.

I welcome the opportunity for another debate on this important subject. I also welcome the Government’s strategy.

I want to speak about the suggestion that assisting suicide should become lawful. I disagree fundamentally with my noble friend Lord Lester. His argument is for legalising precisely those hard cases that make bad law and which may indeed have the perverse effect of disadvantaging the very people he wishes to help. It is said that it is inappropriate to retain as an offence the assisting of something that is not unlawful—suicide—but do we not have to look at end of life with a quite different set of ethical values? If you assist a thief, the stolen goods can be returned. If you assist a suicide, only the body can be returned; there is no going back. At the moment we have a law that has a stern face and a kind heart with a discretion not to prosecute exercised sensitively. The existing law protects the vulnerable. The proposed law could well not protect the vulnerable in the same way and I believe that it would not.

The sort of legal certainty of a statutory kind espoused by my noble friend would lead to a prescriptive law. We do not have purposes for statutes in this country, we have very precise statutes. The result would be the perverse result of more prosecutions for murder and manslaughter in a situation where Government after Government still set their face against the removal of the mandatory life sentence for murder.

I have two further things to say for the future. The first is that I have read a lot—the noble Lord, Lord Joffe, and I should talk more and exchange fewer letters through the columns of the newspapers—about the influence of religion on this debate. I probably come at this debate from exactly the same point as the noble Lord, Lord Warner, in non-religious terms. However, I do not see the contribution of the right reverend Prelate the Bishop of Exeter, or of someone whom we already miss, the Bishop of St Albans, as being a contribution that has any less validity than that of those of us who are non-religious or humanists. Indeed, I say to those who say that this debate has been taken over by the religious that they are coming close to the sort of religious intolerance that I believe went out 100 years ago.

My final point is on where any Bill should occur. I simply challenge those who would wish to change the law to bring their Bill in the right place—where the law can be changed and where there can be a vote by democratically elected people on whether the law should be changed—and to bring it to your Lordships' House afterwards. This is plainly something that should now be considered, if at all, by a Bill in the House of Commons. It should not start next time in the House of Lords.

I, too, thank the noble Lord, Lord Warner, for raising this debate. Like others, I agree with a considerable amount in the charter but certainly cannot agree with assisted dying.

The Government’s own strategy document was published at about the same time, following extensive consultation. It is an excellent document. Indeed, I have described the strategy as,

“an overdue but welcome recognition that this branch of health care has been neglected and needs to be better resourced and coordinated”.

I reiterate that today.

By contrast, this charter from the voluntary euthanasia movement is a short document claiming to champion three,

“principles for dignity at the end of life”—

choice, access and control, which then appear as 10 recommendations for action. One of these, coming as it does from the Voluntary Euthanasia Society, now rebranded as Dignity in Dying, calls on Parliament to legalise euthanasia—or “assisted death”, as it is euphemistically put.

Yet the so-called principles for dignity at the end of life do not make reference to this—they talk coyly of “how I die” and,

“information on the choices for end of life care”.

The foreword by the noble Lord, Lord Warner, fails to make any mention whatever of assisted dying. This omission is truly extraordinary. It is hard to escape the impression, as one reads the charter, that there is a veritable elephant in the room—a presence which is obvious to anyone who reads it with a little care but about whose existence there is a good deal of embarrassment and reticence. It is pretty obvious what is going on.

By contrast, the Government’s own end-of-life care strategy takes a wise and statesmanlike approach to the topic. It is a true strategy for improved end-of-life quality of care and enhanced dignity, and it provides a specific and fair assurance on the euthanasia debate. It states:

“The strategy has been developed within the current legal framework. Whilst the debate about changing the law to allow euthanasia and assisted suicide will continue in this country and elsewhere, these issues are beyond the scope of this strategy”.

Indeed, not only is it beyond the scope of an end-of-life strategy but it is not a health issue at all. It is one of justice and human rights—the right to life. None of us can escape death but we must have the right to have healthcare provided free from the risk of coercion to suicide.

The Voluntary Euthanasia Society is trying, in my view, to piggyback the Department of Health’s strategy for care at the end of life as a mule for carrying its single-issue thinking into government policy. The Government should wisely smell a rat and resist that. Further attempts to change the law on assisted dying must be declared before Parliament for what they are. This is far too important an issue for sleight of hand and confusion.

I welcome this debate. I would certainly welcome a full debate in Parliament and a Bill because I support Dignity in Dying for a number of reasons.

Some time ago, I visited a friend of mine who had motor neurone disease. He was still able to communicate by typing. His family was gathered and I wondered why they were all there on that occasion. It turned out that they wanted to raise with me directly the issue that we are debating. They wanted to know what I would do and how I would vote in Parliament. When I asked my friend how he would like me to vote, he said that he would want me to support what Dignity in Dying is saying. The family had gathered there to lobby me. His wife said that, in her view, if a person in her husband’s position had one single thing to live for, they should stay alive. If they did not, they should seek a way out.

At the time, I asked myself what right I had to contradict that view. I thought to myself—as I still do—that I do not have the right to support something that imposes on others something that I would not want for myself. In other words, if I were in that unfortunate position, I would want the choice of ending, or being helped to end, my life. If I want that, what right do I have to deny it to anyone else?

I know that public opinion is on the side of the argument that I am putting forward, and I think that public opinion must count for something because some of the people, like my friend’s family, are seeing relatives, friends or loved ones move to the end of their life and they want to meet their wishes. Of course, the tragedy with some of these dreadful diseases is that at the point when people can make the choice easily—that is, when they can do something about it themselves—they are too well to want to end their lives, but when it comes to the point when they cannot do it themselves, they need help. Surely one is simply saying, “We don’t want you to have to make a decision against your life too early. If you can wait until nearer the time and you can be helped, then you have the right to end your life in that way”.

Finally, I understand that in the state of Oregon, where the palliative care is excellent, people use it more because they know that they have the option of being assisted in ending their life if that is what they want. Surely that is the way in which we should go forward. It is a human right which I support.

I feel the need to say a few words of warning to those people who want to make suicide easier. There are only a few people who want to be assisted to be killed, but there are thousands of vulnerable disabled people who fear that if the law is eased, their lives will be put at risk. Not long ago, a male nurse killed several patients recovering from operations in hospitals in Leeds. Medical and nursing staff have the opportunity to procure dangerous drugs which will kill patients.

I quote from the Independent:

“Some parents report that they avoid taking their disabled children to hospital, for fear that the attempts to resuscitate them that they wish for will not be made”.

It is felt that,

“the lives of disabled people are valued less than the lives of the typically abled”.

I know personally of young people who had been taken off their antidepressant drugs by their social workers. One threw himself over Beachy Head on a foggy day and the other, a young married woman, drove her car into a train. This subject is complex. The young rugby player, Daniel James, was one of the few who did not want to live, but I can assure your Lordships that, with the help that they need, many members of the Spinal Injuries Association, of which I am president, do splendid things and achieve good lives.

I wholeheartedly agree with the suggestion of better choice and better palliative care. At the moment, like so many aspects of healthcare, it is patchy across the country. My husband would have liked to die at home, but because the Sunday out-of-hours doctors said that they could not or would not set up a drip, he died in an A&E department. I am all for dignity, but not for killing.

The issue today is choice, and on one point we are all agreed: the need for palliative care. It should be available to all who want and need it. However, at present, some choices are legally available in the UK and others not. We have the right to choose to have life support withdrawn in certain circumstances and to receive painkillers that hasten death, but no right to receive help to commit suicide.

There is a certain logical inconsistency in the law as it stands. It is not clear, as the courts have pointed out. Many members of the public may find it difficult to understand why some choices are legal and others are not. Why is it morally and legally justified for a doctor to remove a ventilator or switch off a life support machine, but not to provide a lethal drug to a terminally ill person of sound mind?

The first is an act that intentionally and actively ends life. The second is an act that may or may not end life depending on whether the patient takes the drug—in Oregon, one-third of patients do not. The final decision is the patient’s. The reason that the first is moral and legal, and the second is immoral and illegal is not exactly clear.

When a doctor gives a large dose of morphine that will hasten death, it is legal if the intention is to relieve pain. However, the doctor knows that it is likely to cause death. Everyone knows that, in practice—certainly, in a large number of cases—he or she is doing it to ease death. We are all legally responsible for the consequences of our actions, and the doctor knows the consequences of his or her actions. Is there not a distinction without a difference between causing death to relieve pain and relieving pain in a way that will cause death?

Some may argue that the doctor cannot be sure that a very large dose of medicine will cause death, only that it is likely. But nor can a doctor who supplies the patient with a lethal drug be sure that it will cause death, because a patient may decide not to take it.

I hope that, whatever else our differences, we can all face the issues rationally, and avoid making distinctions which are confusing to the public and seem to have a basis neither in morality nor in common sense.

I want to add only a few words; I agree completely with much of what has been said.

I have worked with elderly people for slightly longer than 32 years. I know that, as they get older, many people think about how they are going to die and that many are very worried about the process of dying. They want to know where and how they are going to die; they want reassurance. I am afraid we also know that in this country there is widespread abuse of older people. It is tragic but we have to accept that it happens.

This charter and the Government’s strategy are extremely welcome. A huge amount in both is to be praised and taken up with enthusiasm. We have to insist on an acceptably high standard of care for people at the very end of life. This must mean that everyone dies well and that people of sound mind have their preferences taken into account. People want to die with dignity. At the moment, most people do not die where they want to die. I hope that the Government strategy and this charter will reverse that and make sure that they do.

I shall make only two more points. First, those who want to see, in exceptional circumstances, people openly being able to be helped to die are not seeking premature death for anyone; it should happen only at the very last stage of life when people are in intolerable pain. We are talking about extending the double effect to something which is clear and acceptable to everyone with all the safety measures built in—otherwise I would certainly have terrible doubts about ever introducing any legislation.

Secondly, we have to understand that we will be judged as a society on our ability to reassure and clarify for people what will happen to them if they find themselves in intolerable pain and losing their dignity at the end of life. As a society, we will be judged on that. I hope the Committee will consider carefully how this can best be done, taking into account the arguments about autonomy and control wherever that is appropriate and necessary for adults of competent mind.

Like other Members of the Committee, I welcome the Government’s end-of-life care strategy, addressing as it does one of the most difficult and sensitive issues of medical care. My interest in this issue stems from my involvement for many years as a UNISON official, which took me into a number of care homes and hospitals. During that time, I witnessed a wide variety of care, often delivered by committed health professionals working under considerable pressure. However, today I am not seeking to claim that I represent their collective views or interests; my comments come much more from a concerned observer with a massive respect for the profession but with a knowledge of how far we are from delivering the model of a good death that the strategy promotes.

It goes without saying that health and social care professionals are crucial to delivering high-quality care and greater choice at the end of life. However, it is also true that during the development of the end-of-life care strategy many people identified a lack of open discussion between staff and those approaching the end of life as one of the key barriers to the delivery of good end-of-life care. It is a sad fact that health and social care staff often find it hard to initiate discussions with people about the fact that they are nearing the end of their life. This makes it difficult or impossible to elicit people’s needs and preferences for care.

This lack of open discussion is particularly problematic in care homes, often due to inadequate training of care home staff, but poor communication regarding end-of-life issues between patients, family and staff is also a huge problem in acute hospitals. For example, the Healthcare Commission found that 54 per cent of all hospital complaints received in 2007 were regarding end-of-life care, and these complaints often related to poor communication.

So what needs to be done to improve the contribution of staff to end-of-life care? The new strategy rightly acknowledges that there are major deficiencies in the knowledge, skills, attitudes and behaviours of staff groups in frequent contact with those nearing the end of their lives. But before we focus in on the staff, we have to address the overriding issue that, as a society, we do not talk openly about death and dying. There will need to be a cultural and behavioural shift in attitudes if we are to deliver the open and honest discussion which will underpin an effective end-of-life care plan. This needs to be addressed by improving training and education for professional staff to help them to overcome those barriers. That is why I welcome Dignity in Dying’s charter, which calls for adequate training on end-of-life issues for health and social care professionals, including communications skills training.

Finally, and crucially, for health professionals to carry out their new responsibilities effectively, they must be given the tools to enable the terminally ill to exercise real choice over their care plan. This might include a wish not to have their life unnecessary prolonged and, in some cases, it may include a wish to be assisted to die. Regrettably, at the current time, staff embarking on these difficult and sensitive discussions risk leaving the patient feeling less, not more, empowered if they have to explain that some of those personal choices and preferences are simply not open to them.

In conclusion, I believe that the Dignity in Dying charter helps to fill the gaps in an otherwise admirable government strategy to improve end-of-life care, and I hope that the Minister will feel able to take on board its recommendations.

The noble Lord, Lord Warner, is asking the Government to take account of this charter in taking forward their end-of-life care strategy. I believe that the Government’s strategy is very important, and I looked at the charter with that in mind. Most of it seems fine to me; I believe that people should be encouraged to make plans for care at the end of life. Greater support should be given to those unsung heroes and heroines who care for people in the closing days of their lives, and I strongly support the giving of more resources for ensuring that our outstanding palliative care can be and is made available to everyone who needs it, irrespective of where they live. However, I am not at all happy with the proposal that assisted death—which I understand to mean assisted suicide—should be legalised and become part of the choice agenda.

Like many noble Lords, I have been watching the recent furore in the media on this subject. Those who want to see our laws change for terminally ill, mentally competent people tell us that there is no slippery slope of fear, yet, even as they say that, others are calling for people with dementia to be encouraged to regard themselves as a burden and to consider whether they ought to end their lives. We are told that legalised assisted suicide has proved to be without hazard in the American state of Oregon, yet only a week or two ago we heard of research published in the British Medical Journal indicating that as many as one in six of those who have committed suicide with lethal drugs from their doctors is suffering from treatable depression which has not been picked up. We know that depression can now be treated much more effectively than it has been in the past.

Although society treats attempted suicide with compassion, it rightly regards suicide as not to be encouraged, yet here we have a proposal that it should be facilitated for particular categories of people. This is a road along which we should not be going, and as long as this proposal remains part of the charter, I cannot support it. I hope that the Minister will be able to reassure us that the Government share this view.

This charter appeared at about the same time as the Government’s strategy on end-of-life care, which I welcome. So far as I can see, the Government’s strategy, with its emphasis on ensuring palliative care and more effective co-ordination among the many end-of-life care services, has rendered this charter redundant. I can only assume that the aim of the noble Lord, Lord Warner, is to focus on the one proposal in it which does not feature in the Government’s strategy—namely, that Parliament should legalise euthanasia. Let us be quite honest here: why is that proposal not proclaimed in the title of this debate?

The proposal is not only redundant, it is wholly inappropriate. The organisation that produced this charter, Dignity in Dying—although most of us know it better under its former name of the Voluntary Euthanasia Society—claims to be campaigning for greater dignity at the end of life. As a principle, I can most certainly agree with that: it is humanitarian and, indeed, desirable. However, along with many other people, I cannot accept that promoting dignity among people who are dying includes asking doctors to prescribe lethal drugs for them. That in certain circumstances can be a negation of a doctor’s role. In fact, I know of a Jewish doctor who refused, in illegal circumstances, to carry that out because he had experienced the same process in a concentration camp.

Many different kinds of experiences come to bear on this. For example, I believe that in the state of Oregon there is the phenomenon of doctor-shopping, in which a small number of doctors who do not normally write such prescriptions for people who are not their regular patients carry out this process when hunted out.

The proposal also flies in the face of society’s attitude to suicide. We have had contributions on that, and I do not think it appropriate to repeat them. There is certainly no place for suicide to be facilitated. Although one sympathises with people who find themselves in this position, there are many worse forms of suffering in society for which we would not countenance legalised suicide. I fear that it may be the influence of—shall we say?—relatives with other agendas who may be in a position to influence the situation. It is one thing to treat cases of suicide or attempted suicide compassionately but quite another to give them official blessing in the way that these people are suggesting. Therefore, I hope that the Minister will be able to reassure us that the Government will continue to keep “assisted death”, as the charter describes it, beyond the ambit of their end-of-life care strategy.

I declare a non-pecuniary interest as a patron of three hospices. I am much struck that we are meeting here in the Moses Room today under the painting of Moses bringing down the tablets of law to the Israelites. One of their clear injunctions is “Thou shalt not kill”. It seems to me that not only is that at the heart of all religious thinking on this issue but, as the noble Lord, Lord Carlile, said, many secularists also share that view. Indeed, the Hippocratic oath was based on the same principle.

When he gave evidence to the Select Committee that considered these issues, the noble Lord, Lord Joffe, very honestly said that he saw his Bill as the first stage. Perhaps the noble Baroness, Lady Warnock, gave us a glimpse a few weeks ago of what the following stages might be. In an article in the Times on 10 October, the noble Baroness is quoted as saying:

“If you’re demented, you’re wasting people’s lives—your family’s lives—and you’re wasting the resources of the NHS”.

There is a fundamental divide between those of us who measure life in terms of the right to life and the duty to protect life and those who measure life by its quality. From the hospice and palliative care movements, I see many of the things that the noble Lord, Lord Warner, aspires to and with which I would agree in nine of the 10 points in his charter. However, in this provision for assisted suicide, there is this fundamental divide.

To die with dignity we do not need doctors to kill us. I place rather more reliance on these age-old injunctions than I do on polls. Indeed, the Select Committee took exactly the same view. Having asked researchers to look at the value of opinion polls on issues of this kind, it said that they are,

“limited in value and cannot be accepted at face value as an authentic account of opinion within the United Kingdom. The subject matter is extremely complex and sensitive and therefore very challenging for anyone attempting to gain a meaningful understanding of opinion”.

I place more reliance on all the royal colleges, including the Royal College of Psychiatrists, and the British Medical Association, which remain opposed to any change in the law.

Mention has been made in our debates about the situation in the state of Oregon. I have one example—the case of Michael Freeland, who had a long history of depression and suicide attempts. Dr Gregory Hamilton, an Oregon psychiatrist, said that this man was not in pain because his pain was not treatable; he was in pain because nobody bothered. This was, commented Dr Hamilton,

“just one case among many”.

For me, the issue does not ultimately revolve around religious values but around public safety and the vulnerability of those who would no longer be protected should we change the law. I remind the Committee of the 1994 Select Committee, chaired by the noble Lord, Lord Walton of Detchant, which said that,

“dying is not only a personal or individual affair. The death of a person affects the lives of others, often in ways and to an extent which cannot be foreseen. We believe that the issue of euthanasia is one in which the interest of the individual cannot be separated from the interest of society as a whole”.

In other words, choice is not a trump card. Autonomy is not the only issue at stake here; the common good is at the heart of this equation as well.

We all welcome the Government’s paper on end-of-life care. I declare an interest in that I also support the Dignity in Dying charter.

I want to tell two brief stories of patients at the end of their lives. The first case is of a cancer patient who was refused surgery after attempts were made unsuccessfully to halt the tumour with chemotherapy. She decided, in consultation with her family, that she wanted to stay at home and receive palliative care. That was organised by the local hospice in conjunction with Macmillan nurses, and she received superb 24-hour care with the help of her family. That patient’s death was planned according to her wishes and, although painful at times—something about which she did not complain—was dignified; she had her way.

The second patient has a variant of motor neurone disease. Fully aware of the course of that disease, she discussed the manner of dying with her doctors a couple of years ago. Like many patients with neurological disease whom we read about in the press, the patient wanted to die at a time of her choosing because she did not want to have to go through the final stages of the disease—what we call the locked-in syndrome. Despite advance directives and discussions, she is now helpless, unable to speak, swallow or move. She still just about breathes, but her eyes say it all. I wish I could help her but I cannot.

Why do we treat these two patients differently? Some of us would like them to be treated equally. They both wanted to plan their own final days, and they both surely had a right to do so, but one achieved her plan and the other lives on unhappily.

Noble Lords have rightly pointed out the concerns that we would all have if doctor-assisted dying were allowed in this country. We are right to be worried. I shall not repeat the counter-arguments—the slippery slope and coercion by relatives. Even pressure on hospital beds has been mentioned. However, their fears have not materialised in the Netherlands or Oregon. In fact, palliative care in those countries has become more important and facilities have improved.

We all want to die well and, if possible, with dignity. We should not allow this for some patients and not for others. The patient must choose and we must help them with their choice.

I thank the noble Lord, Lord Warner, et al, for their charter, much of which I agree with. Enabling terminally ill patients to discuss their care, knowing that they have a right to refuse treatment, having effective advance directives, increasing resources for palliative care and emphasising the need for adequate respite care—all these recommendations are to be commended. They would do much to remove the fear of death and dying and the fear of unwanted medical treatment. The Voluntary Euthanasia Society—now Dignity in Dying—has every right to promote its views, but it really does not have a right to make statements such as the one made in another place, that doctors,

“administer pain relief in the absolute knowledge that their patient will die”.—[Official Report, Commons, 11/11/08; col. 234WH.]

That is not true. It is an insult and, what is more, shows a profound ignorance of the use of drugs.

The definition of a good drug such as a pain-relieving drug is that the dose required to relieve is a fraction of the dose required to kill. We doctors are often accused of being hypocritical in giving these drugs. Chemotherapeutic drugs are much more dangerous than pain-relieving drugs; does Dignity in Dying accuse oncologists of hypocrisy?

These recommendations are in operation in many places already. Where I part company with Dignity in Dying is on the issue of assisted suicide and euthanasia, which is what this charter is all about. One of its fund-raising letters speaks of a,

“ground-breaking campaign in Parliament on palliative care”,

which is needed,

“to keep the issue of assisted dying in the spotlight”.

The organisation goes on to say that this,

“is precisely how similar organisations in other countries prepared the ground before eventually succeeding in changing the law”,

to legalise euthanasia. Last month, another fund-raising letter stated that every day the organisation receives messages from people who are terminally ill but who are,

“people we are not allowed to help”.

Why would an organisation such as Dignity in Dying, which professes to campaign for hospice care, say that it is not allowed to help people? Because what it is not allowed to do is to help the terminally ill people kill themselves. That phrase, “not allowed to help”, reveals its one overriding objective—namely, the legalisation of euthanasia.

I congratulate the Government in that they have already rejected euthanasia in their own strategy for care at the end of life. Many people who would have obtained assistance in dying if it had been legal survived and are now very glad that their earlier wish to die was not granted. Alison Davis is a case in point; she is very grateful that assisted suicide remains illegal. When I spoke to her this past weekend, she wished me to repeat the evidence that she gave in 2004. Her serious illnesses rendered her permanently disabled and breathless. When she was diagnosed with a fatal illness 13 years ago, she decided that she had had enough and asked for euthanasia. When this was refused, she made three serious attempts on her life, but was rescued by her friends, who persuaded her that her life was worth living. She then established an orphanage in India—and these 13 years, she tells me, have been the happiest of her life. If euthanasia had been legal, she would have been deprived of the best 13 years of her life. She would like to know what the noble Lord, Lord Warner, et al, have to say about that.

First, I congratulate my noble friend on securing this debate, which has clearly struck a chord with other noble Lords and, hence, the extension of time. I congratulate noble Lords on their discipline in sticking to the time that they were allocated and succeeding incredibly well in making the points that they wished to make.

This is the first occasion on which we have had the opportunity to debate the Government’s end-of-life strategy since it was published in July this year. It is a matter that is clearly of great interest to all of us. It seems unlikely that I shall be able to address all the points that noble Lords made in my 12 minutes, but I shall do my best to cover those that seem pertinent to the question raised by my noble friend from the outset on how far the proposals from Dignity in Dying will be taken into account in the Government’s strategy.

The Government are committed to improving end-of-life care services for all. The end-of-life care strategy sets out a clear direction for the future development of services for adults and confirms our commitment to this important area of healthcare. I am grateful for the support expressed by noble Lords throughout this debate. The strategy was created after two years of discussion and debate with all those with an interest—patients and carers and their organisations, clinicians and nurses, families and many others, as was mentioned by the noble Baroness, Lady Finlay, and my noble friend Lord Warner. The strategy has benefited hugely from the care that went into it, and we are but at the beginning of its implementation.

Although my noble friend will be aware that the strategy has been developed within the current legal framework, he will be pleased to learn that many, but not quite all, of the proposals in Dignity in Dying’s A Charter for Dignity at the End of Life are compatible with the direction set out in the strategy. Seven of its 10 proposals are compatible, but we have difficulty with points 4, 5 and 8 for different reasons.

On point 4, the advance decisions, it is a matter of emphasis rather than disagreement. Point 8 raises an issue of resources which I shall address later in my remarks. On Point 5, which concerns assisted death, our reasons have been admirably illustrated today in what has been probably a 50-50 debate.

In line with the charter’s cause, the Government’s strategy covers the whole pathway of care for those at the end of life. It addresses the responsibilities of the NHS, local authorities, commissioners and the providers of services as well as the Department of Health. It deliberately does not include targets or recommendations, but does include helpful case studies and sets out measures that those bodies will wish to consider taking to improve end-of-life services. Importantly, it builds on and supports the visions for the end-of-life care developed by strategic health authorities as part of the NHS next stage review.

The strategy has been well received both within the NHS and the voluntary sector, including by Dignity in Dying. The measures set out in the strategy are based on what we heard from stakeholders and others as being needed to bring about real improvements in end-of-life care. They set out the key elements for the delivery of the high-quality care that we would wish all people to receive. Among these measures are, first, the need to ensure that all patients and carers have care plans to meet their needs, a point mentioned, for example, by the right reverend Prelate. An important component for care planning is advanced care plans, an element of which might be advanced decisions.

The second strand is to ensure that effective mechanisms are in place to facilitate co-ordination of care across all sectors and providers. We also need to ensure that the range of services, which people need to enable them to live and die at home, is available 24/7. For example, we need such key services as rapid response community nursing, and we need that care, if I may use jargon, to be seamless so that people do not experience the kind of situation faced by the noble Baroness, Lady Masham.

It is important that the needs and wishes of those who are dying are identified and addressed. Information on all relevant local services needs to be available to support those approaching the end of life and we also need to provide for the needs of the bereaved. For all of this to happen, all staff need to receive adequate and appropriate training and development, including training in the communication skills that are necessary to deal with those at the end of life, a matter outlined with great wisdom by the noble Baroness, Lady Greengross, and my noble friend Lady Jones.

In line with the NHS next stage review, PCTs are working with councils that have been asked to develop local strategic plans for end-of-life care. These will be based on the framework outlined in the strategy. In developing these plans, PCTs and local authorities will need to engage with all the relevant local provider organisations, partners, the public and families. We want to end the patchwork of uneven care.

The Government are committed to investing an additional £286 million in end-of-life services in the two years up to 2011 to support this important programme of work and to take forward a range of initiatives at a national level to help ensure that improvements are delivered in developing the tools to measure the quality of care received; developing workforce competences and training in end-of life care; and developing markers against which PCTs and providers can assess themselves, and indeed can be assessed by regulators. We are funding the new national end-of-life care programme to support the work being undertaken by strategic health authorities and PCTs, including the commissioning of end-of-life care services, and to share good practice.

Let me answer three specific points, which were raised during the course of the debate. On the issue raised by my noble friend, he will not be surprised that I will not be able to give him much satisfaction on his request.

This debate highlights people’s strong and opposing views on this issue. Some have deeply held convictions, religious or otherwise, about the sanctity of life. Some have been influenced by personal experience of caring for a terminally ill relative and wanting to end their suffering. Others are passionately convinced that they and others have the right to decide on the circumstances of their own deaths, and that those who help them, whether clinicians or relatives, to achieve this should not be vulnerable to prosecution. Some people can see compelling points on both sides of the argument and have not reached a firm view. This debate illustrates that completely.

We might also have to ask ourselves how we weigh up the views of particular groups. For example, how do we balance the views of the public with the views of health professionals or people who have direct relevant experience, or with the views of those who can only speculate about what their wishes may be in the future? There is no easy way to do this, and on behalf of the Government I can offer no answers. I remind Members of the Committee that the Government have no plans to change the law in this area and we have it made very clear that we take a neutral stance when others seek to change the law. This means not standing in the way of such a change, but not actively pursuing it. Equally, we have no plans at present to carry out any associated research in this area.

The noble Baroness, Lady Greengross, and others raised the issue of more specialists being required. We know that the majority of people would prefer to be cared for and to die at home. It is not practical that all such care be provided by specialist staff, and most care will continue to be delivered by GPs, district nurses, care home staff and other generalist staff. But to ensure that everyone has access to improved end-of-life care, it will be essential that health and social care staff at all levels have the necessary knowledge, skills and attitudes related to care for the dying. For this to happen, end-of-life care needs to be embedded in the training curriculum at all levels and for all staff groups, not just those specialising in end-of-life care. This is what we aim to do through the strategy.

The noble Baroness, Lady Tonge, and others raised the issue of advance decisions. The Government fully support the fundamental and important principle that everyone has the right to consent to or refuse treatment. The courts recognise that people have the right to make a decision in advance to refuse treatment if they lose capacity in the future. The Mental Capacity Act puts advance decisions to refuse treatment on a statutory footing and sets out the rules and safeguards governing advance decisions. We are quite clear that advance decisions are legally binding refusals of a particular treatment, and must be followed if they are valid and applicable. We believe that advance care plans and advance care decisions are appropriately addressed in the strategy.

In conclusion, we are only at the beginning of an important process of implementing the end-of-life care strategy. It will take time for many of the changes that we envisage to happen. However, we can confidently look forward to continuing improvements to end-of-life care services for all patients as a result of implementing this most important strategy.