Terminally Ill Adults (End of Life) Bill (Twenty-sixth sitting)

(Limited Text - Ministerial Extracts only)

Committee stage
Wednesday 19th March 2025 Public Bill Committees

[Lewis Atkinson]

My instinct is that it would not. If the Bill becomes law, it would be a lawful choice. The hon. Gentleman may not characterise it as healthcare, but it would be part of healthcare and end-of-life services. We would not accept such stipulations on other healthcare services. I can see a sketch that some may choose to draw; someone mentioned housing supported by a religious institution. The reality is that people do not go out of their way to offend, and they try to live in harmony with those around them. If people are clear that they might actively explore assisted dying as an option, they will not choose to spend their last days in a community where others are ideologically opposed to their choice; it would be uncomfortable for the individual. They would, however, have the legal right to do so.

[Kit Malthouse (North West Hampshire) (Con)]

Having also thought about this overnight, I think there is a freedom-of-association argument. If it were a Roman Catholic organisation designed just for Roman Catholics to live in, such as a home for retired priests, or if it were a Jewish organisation just for Jewish residents, I could see that, but that is not a service that is generally on offer to the public. My concern is whether we could see a situation in which the board of trustees of Hampshire hospitals foundation trust has a majority of people who have a strong religious conviction, and they vote that the service shall not be provided across the three hospitals that the trust manages. If the provision is drawn tightly and the freedom-of-association argument could be made, I could see it. Having said that, there is no institutional objection power in law for abortion: people just do not offer it because they do not have the staff to offer it. It feels to me as though that is what the hon. Gentleman is pointing to.

[Lewis Atkinson]

That is entirely right. The response of public bodies such as NHS trusts is a slightly different issue. I would not want to speak for the Government or imagine what the Secretary of State might say, but it would be inconceivable to me for a quasi-independent public body to decide, on a vote on principle by some local governors, not to offer citizens choices that have been enshrined in law. That is a slightly different point, but I am grateful to the right hon. Gentleman.

The hon. Member for East Wiltshire suggested yesterday that if someone chooses to have an assisted death, everyone in the care home or wherever would be part of it. That fundamentally misunderstands the point; I will go for “misunderstands” rather than doubting his intentions, but some would see it as scaremongering. No one is asking for the right to do it in a communal area, where staff or neighbours are forced to observe or participate in any way. Where people live in their own home, they should have rights and dignity at the end of life, whether that is in a care home or in a private residence. We cannot deny them the choice to access end-of-life options, as set out in the Bill. I therefore cannot support new clause 22.

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Our conversations throughout this debate have been very much about “autonomy, autonomy, autonomy”, but what about those people who want autonomy over how to run their businesses, whether that is from a religious perspective, from an ethical perspective or, for a charity, from a fundraising perspective? It is the month of Ramadan, and one of the obligations on me as a Muslim—one of my five pillars—is giving zakat, which is charity. There is a very clear outline of where zakat can go and what needs it meets, such as educational or other purposes. There are different kinds of charity that I can give for other purposes, but they are specified.

[Kit Malthouse]

This is obviously a difficult and sensitive area, but does the hon. Lady think, for example, that a women’s refuge run by a Catholic foundation should be allowed to evict a woman who wants or has an abortion?

[Naz Shah]

I absolutely do not think that, because her abortion rights are set out in law. However, I also think that when that woman is going into a refuge, that refuge will make it clear that she may choose not to. It is about empowering both sides.

I am grateful for the right hon. Member’s intervention, but let us follow that argument. Let us say that somebody wants to pursue assisted death, and they want to go into a place, but they are informed that that organisation does not want to provide or has not signed up to providing an assisted death. It comes back to the issue that my hon. Friend the Member for Sunderland Central rightly raised, which is that people do not deliberately go out looking to offend people. If we were in that space—I cannot imagine being there, but I am trying to understand it—would we want to access that service, because its religious belief differs from assisted dying as a principle?

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[Danny Kruger]

There is much to get into, and I will try to respond a bit more when I speak again. I do not want to revisit the whole question of palliative care but, on the scenario set out by the hon. Member for Penistone and Stocksbridge, the strong advice that I have received from palliative care professionals is that it is not accurate to say that somebody’s pain cannot be palliated. It might well be that there is a difficulty with particular opioids, but there are other palliative care options available to everybody. No palliative care doctor ever says that there is nothing they can do.

[Kit Malthouse]

She said exactly that.

[Danny Kruger]

Well, we have been over the whole question of palliative care and alternatives to assisted suicide; nevertheless, I wanted to challenge that scenario.

On the suggestion that there is a comparison with an abortion service no one is suggesting that a woman who goes into a refuge, discovers she is pregnant and wants to have a termination is somehow obliged to have it on the premises of the refuge, which does not believe in abortion. That is not a scenario that could happen, because that is not how abortion operates. What we are suggesting is that somebody who arrives in a care home or hospice that does not want to facilitate assisted suicide would not be able to receive such assistance there. There is no objection to their believing in or desiring an assisted suicide; the point is to protect the institution.

I recognise the difficulty with the specific case the hon. Member for Penistone and Stocksbridge raised. Nevertheless, the alternative is to have blanket permission for any resident of any care home or hospice to insist that they can receive an assisted death in that home or hospice, despite what the rest of that community and the management might want. Indeed, the patient might have signed a contract specifying that they will not seek an assisted death in that home or hospice. There is much more to discuss, but I hope that that is helpful for the hon. Lady.

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[Naz Shah]

My hon. Friend is absolutely right that we need to clarify this.

To sum up, this comes back to some of the questions I have for the Minister, and I wonder whether he can answer some of them. I say that especially because the Committee has had lots of debates on amendments tabled by the Government via my hon. Friend the Member for Spen Valley giving the Secretary of State statutory duties. Perhaps the Secretary of State will be able to clarify this issue and make it watertight using regulations.

Have we had an assessment of what the impact would be on the provision of healthcare if assisted death were permitted in either a hospice or care home, and is the Minister happy to share that assessment with the Committee? For example, if palliative care specialists are saying, “X amount of people would no longer want to be involved, so there is a real risk of an exodus of specialists from hospices,” we need to know whether there has been an assessment of that. Perhaps the Government can help us to understand that real concern from palliative care specialists.

Given that the Minister mentioned his visit to a hospice this week, has he had any discussions with Care England care homes about allowing this process to happen in care homes themselves? How have the concerns of clinical staff about allowing an assisted death in their healthcare facility been assessed, and have those concerns been put to him? How many staff have indicated that they would need to leave the NHS, care providers or hospices if an assisted death were mandated on their premises?

Coming back to beliefs, there is also the element of charitable bodies. Have we spoken to the Charity Commission about the impact on those bodies if they were pressured by the Bill into changing their charitable aims? Would they be protected from providing assisted death because of their charitable aims?

For me, this debate has raised more questions than answers, and there is much more discussion to be had. I am happy to listen to the hon. Member for East Wiltshire, as I can then intervene and probe further.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship this morning, Ms McVey, even though it is a little later than originally planned.

Amendment 480 is intended to extend the category of those protected from being obligated to participate in the provision of assisted dying under clause 23 from registered medical practitioners, registered nurses and registered pharmacists or pharmacy technicians to all individuals. The amendment also seeks to clarify what an individual can refuse to do under clause 23(1), by setting out a non-exhaustive list of activities under the Bill that an individual would not be obligated to participate in. The amendment also specifies that the ability not to participate in the provision of assisted dying does not override any duty to signpost someone to information about assisted dying; to perform clerical, secretarial or ancillary acts; or to perform life-saving acts or grave injury-saving acts.

The amendment would introduce significant legal uncertainty and may mean that a person who had opted in to providing services under the Bill could refuse to continue to do so or could use clause 23 as a justification not to perform their duties as described in the Bill. For example, they may use the amendment as justification for not checking eligibility criteria, discussing prognosis or palliative care options, or performing other requirements under the Bill.

Amendment 480 may also conflict with other provisions. It states:

“no individual is under any duty…to be involved, directly or indirectly, in the provision of assistance”,

in accordance with the Bill. That may, for example, mean that although doctors are required under the Bill to notify a cancellation, they would be allowed to refuse to do things under the Bill, even if they have opted in to providing assisted dying services. It is not clear which provision would take precedence, which could allow the doctor to decline to notify a cancellation, by arguing that they are relying on clause 23(1).

Amendment 483 is intended to extend

“the range of activities which medical practitioners and other healthcare providers are not under an obligation to provide to include activities closely related to the provision of assistance”

under clause 23(1).

Amendment 484 is intended to expand the protection from being subject to a detriment by an employer at clause 23(2), to include where a registered medical practitioner or health professional refuses to participate in activity closely related to the provision of assistance. The term,

“activity closely related to the provision of assistance”,

is not defined, and that could create uncertainty as to what types of activity it is intended to cover.

The Bill does not, as currently drafted, specify where the provision of assistance may or may not take place. Amendment 441 would prevent there being any obligation on a care home or hospice regulated by the Care Quality Commission or Care Inspectorate Wales to permit the provision of assistance to be carried out on their premises. The effect of the amendment may be to limit the places where assistance could be provided. It may thereby reduce access to an assisted death for those residing within a care home or hospice, if a care home or hospice did not wish to allow an assisted death to be provided on its premises. The amendment could preclude some people from accessing services under the Bill if they were near the end of life and leaving their usual place of residence was therefore impeded. It may result in inconsistent treatment for patients when seeking to access an assisted death. That could potentially engage a person’s rights under article 8 of the ECHR—the right to respect for private and family life.

Amendment 481 has two parts. The first aims to ensure that employees cannot participate in the assisted dying process in the course of their employment if their employer has chosen not to participate in assisted dying. The effect of the amendment could be to limit the places where assistance would be provided, and it may result in inconsistent treatment for patients when seeking to access an assisted death. That could engage a person’s rights under article 8 of the ECHR—the right to respect for private and family life.

The explanatory notes suggest that the second part of the amendment seeks to ensure that employers require employees to provide or not provide assisted dying under schedule 9 of the Equality Act 2010. That schedule enables an employer to specify that having a protected characteristic is a requirement of a job when having that characteristic is crucial to the post and a proportionate means of achieving a legitimate aim. The ability to specify occupational requirements is conferred by schedule 9 of the Equality Act, and reference to it in this amendment would not have any additional effect.

The purpose of new clause 22 is to provide that the owners or occupiers of a premises would not be obligated to permit the self-administration of an approved substance on their premises. This right to refuse would not extend to a person who has an interest in the land but who is not occupying or operating on those premises, such as a landlord. It is unclear if the term “premises” would apply to a residential property, care home or hospice. As a result, the amendment may mean that someone who is terminally ill and is residing in, for example, a care home or a hospice could be required to leave that care home or hospice in order to receive assistance under the Bill if the care home or hospice owner did not wish to allow assisted dying on their premises. That could engage a person’s rights under article 8 of the ECHR—the right to respect for private and family life.

[Jack Abbott]

Another example raised by the hon. Member for East Wiltshire was about hospitals under certain trusts—because of the word “premises”. In the Government’s view, would hospitals and other such facilities beyond hospices and care homes also be included within this new clause?

[Stephen Kinnock]

As I was saying, the scope of the term “premises” is unclear. Is it residential property, care home, hospice or indeed hospital? That is one of the challenges with the drafting of the amendment: the scope and definition of the term is not clear.

[Danny Kruger]

We are going to get to the question of the NHS provision, but, surely, if it is the decision of Parliament and the Secretary of State that assisted suicide should be provided through the NHS, then that is what will happen. It might be that there are some trusts that will have some sort of autonomy—to the extent that they can decline to deliver certain services—but, if this is a healthcare treatment that is regulated in that way and if it is to be set out as something that shall be provided by the NHS, surely hospitals will not be in a position to decline to deliver, if they are indeed NHS hospitals. The purpose of these amendments is to protect private and charitable providers. Does the Minister agree?

[Stephen Kinnock]

I agree with the sentiment of the hon. Gentleman’s intervention. The challenge is that the way in which the amendment is drafted could well lead to unintended consequences, because the scope is not clear. If we are not clear what the scope is, it could potentially be exponential.

New clause 23 would prevent regulated care homes and hospices from facing any detrimental consequences for not providing or permitting assistance in accordance with the Bill. This also means that their funding must not be conditional on them providing or permitting such assistance to take place on their premises. As a result, a person who is terminally ill and is residing in a care home or hospice could be asked or required to leave that care home or hospice in order to receive assistance under the Bill, if that care home or hospice provider does not wish to allow assisted dying on their premises.

In such circumstances, the care home or hospice provider would not be able to be placed in any detriment as a result of any action or decision taken. This could engage a person’s right under article 8 of the ECHR. Further, public authorities would not be able to persuade care homes or hospices to provide or permit assistance to take place on their premises by offering additional funding if they agreed to do so. Equally, if a public authority gave funding to care homes or hospice providers in recognition of their agreement to provide or permit assisted dying on their premises, and that provider later decided not to provide or permit the assistance, and spent the funding on other matters, the public authority would not be able to recover the funding if it were given unconditionally.

Clause 23 sets out that no registered medical practitioner or other health professional would be under any duty to participate in the provision of assistance in accordance with the Bill. It also sets out that employees cannot be subject to any detriment by their employer for exercising their right to either participate or not participate in the provision of assistance in accordance with the Bill. Further amendment to the clause will be required on Report to ensure that the opt-out in clause 23(1) and the employment protections in clause 23(2) work effectively alongside the duties imposed on health professionals in other provisions of the Bill as amended in Committee.

I hope those observations were helpful.

[Kim Leadbeater (Spen Valley) (Lab)]

Thank you for stepping into the breach this morning, Ms McVey.

Clause 23 provides that there will be no obligation on medical practitioners and health professionals to provide assistance as set out in the assisted dying process. We know doctors and other health professionals hold a variety of views on assisted dying. A significant number are in support of what this Bill sets out to do, and the experience from other jurisdictions is that that number increases once it is seen to be working safely and effectively in practice. Others, of course, would object to being involved at any stage and I am very respectful of that. The Bill is about giving terminally ill people choice and autonomy, but it is absolutely right that the principle of autonomy is extended to registered medical practitioners, health professionals and others.

As such, I turn to amendment 480. I agree with the intention behind the amendment—nobody should have a duty to be involved with the provision of assistance in accordance with the legislation—and I think there is consensus across the Committee on that.

However, I am concerned about the drafting of the amendment, the lack of clarity around being directly or indirectly in the provision of assistance, and the framing of the selective list of activities. I fear that the amendment could have unintended consequences and an impact on continuity of care, and I take on board the Minister’s comments about the significant legal uncertainty that that would create. I therefore cannot support the amendment as drafted but, as I have said, I am happy to work with the hon. Member for East Wiltshire to consider an alternative amendment that would better achieve the aim of ensuring that no one has an obligation to take part in the assisted dying process.

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[Kim Leadbeater]

The hon. Gentleman makes a good point, and I am aware of the Minister’s comments. This will be part of the discussion as we take it forward. That is why this debate is really powerful.

In their written evidence, the trustees at Willow Burn hospice, based in the UK, told us:

“Our Mission is to deliver hospice care of the highest standard to our patients and those important to them...We also believe that we should support and enable people to make the choices that matter to them.”

They said they had not decided their position on assisted dying and remained

“open minded about possible future actions. We believe this stance is in the best interests of patients and their families and reflects the wishes of our community.”

I welcome that open-minded approach and their commitment

“to put care, compassion and dignity at the heart of everything”

they do. Contrary to what the hon. Member East Wiltshire has said, the picture is not black and white. I agree with my hon. Friend the Member for Ipswich in that regard.

Colleagues may remember the evidence given to the Committee by the CEO of Hospice UK, Toby Porter. He clarified for us that institutions do not function in the same way as individuals when it comes to conscience-influencing decisions. He told us:

“There is this idea that your individual opinion guides everything, but with a hospice charity the opposite is true. As many Members will know because of their own work as trustees, the trustees and leadership of a hospice team are required to put personal opinion and interest to one side and always act in the best interest of the charity’s beneficiaries, who are the population.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 195, Q255.]

It is also important to remember that international experience shows that up to 30% to 40% of patients who sign up to the assisted dying process ultimately do not access it. Palliative care may meet their needs, or they may simply change their mind. However, we also know that the reassurance and comfort that the choice of an assisted death provides alongside other treatment and care is really important to them, and I do not believe that reassurance should be denied to some people because of the institution they happen to be in.

[Kit Malthouse]

The hon. Lady is outlining the issues very effectively. No one, of course, is saying that anybody who works at the hospice that may object has to participate. It may say, “No one here will assist.” We have talked about the importance of place. To a certain extent, I have a right as a tenant in a place where I am resident. It seems that my hon. Friend the Member for East Wiltshire is proposing actively to prevent someone from being able to access this in a place that they choose. That feels to me the wrong balance. I wonder whether that is broadly where she is heading.

[Kim Leadbeater]

The right hon. Gentleman makes an important point. The word that we have used a lot—maybe not enough in some respects—is choice. That is important for individuals, but it is important for institutions as well. Putting an institutional opt-out in the Bill would risk creating confusion and distress for patients and their loved ones, and indeed for staff and volunteers.

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[Kit Malthouse]

To clarify my remarks, I was not necessarily saying that they should have the right to deny, but by default they would if they were, in effect, a closed community that was discriminating in favour of like-minded individuals—a home for retired Catholic priests, for example. By default it would be someone who was unlikely to offer those services. The other point to ask is: if I am in a hospice, in my bed at the last with visitors coming to see me, and one of those visitors is the doctor who is coming to administer to me, I am not quite sure how that would be prevented, unless people are willing for there to be a wrestling match at the door of my room.

[Danny Kruger]

Under the terms of amendment 441, the owners of the premises would be entitled to deny access to anyone who is seeking to deliver an assisted dying service on their premises. They would be entitled to prevent that from happening, yes. Obviously, that is an extremely unlikely scenario; nevertheless, it is one that I think we need to contemplate.

I thank my right hon. Friend the Member for North West Hampshire for his clarification. I had understood that he had acknowledged that it would be appropriate for the management of a Catholic care home to specify that there shall be no assisted dying on the premises, but he is suggesting that it would be illegal or inappropriate for the management to make that stipulation; it just would not happen organically, because no one would want that in that place. I regret that, because I think it should be appropriate for the management of a place—not in some sort of vindictive mission to deny people a particular right or service—to convey to everyone else who lives there that this is, as it were, a safe space in which there will not be state-assisted suicide. I think that is a reasonable hope and expectation that many residents will want when they live in a certain place.

Once this becomes normalised, once it becomes 5% or 10% of deaths, as happens in parts of Canada—if this becomes a normal and standard way to die—I think many people will not want to live in communities in which that practice takes place. I am afraid that we will find a demarcation, a bifurcation in society, for those who do not want to live in an assisted suicide community. It would be appropriate for them to have the option of going to live in a place where they know that will not be taking place.

I concede, by the way, that for many of the institutions that we are imagining here, these shared communities, it would be perfectly appropriate and understandable for it to be an option for residents. Let us think about the different sorts of places we are talking about. The Duchess of Somerset almshouse in my constituency—the sort of place we have in Wiltshire—is a lovely place, beautiful. It has lots of Liberal Democrat voters in it, which I know because I knocked on all their doors—unfortunately, the wrong sort of Liberal Democrat. I can imagine many of them supporting the right in their home, behind their own front door—which they have there—to have an assisted death, and I am sure that the other residents of that place would concede that that is appropriate.

In other places in my constituency, however, a hospice being the most obvious one, neither the management nor the other residents would be comfortable—in fact, they would be extremely uncomfortable—with the sense that assisted suicide might be practised in the next-door room. Whether it is performed, as it were, by the hospice staff, or merely facilitated by them—it would be extraordinary were it somehow to take place without the facilitation of the staff who managed the facility and look after the patients—for it to take place on some sort of parallel track would be an extreme imposition on that hospice and its management. It would be extremely disquieting for everyone else who lives and works in that place. I therefore think it is an appropriate consideration to give such places the right, at a management level, to opt out.

I also want to express my deep concern about what we heard from the Minister—his suggestion that we should not give either individuals or institutions the absolute right to opt out of the facilitation of assisted suicide because we think the European convention on human rights might challenge that. He suggested that a court in this country or Strasbourg would overrule a decision or would negate this law, or challenge it, if we passed it with these amendments to protect hospices and individuals. We would then have a court citing international law in an attempt to overturn this law. I am very concerned about that in terms of both parliamentary sovereignty and the Government’s position. Surely, if the Government think this is the right thing to do, we should do it even if we fear an ECHR challenge. This is a craven submission to a lawmaking body that is not sovereign in our country and would be only advisory. I regret what the Minister for Care said and hope that the Justice Minister can clarify that the Government would not concede an ECHR challenge if Parliament decides to insist on individuals’ rights to decline to participate in assisted suicide.

In response to my challenges on that point, the hon. Member for Spen Valley suggested that it would be an interesting topic for a future conversation. This is the moment to have that conversation. We are deciding on amendments now that will insist on people’s right to decline to take part in assisted death. There will be no further opportunity to insist that people have that right to opt out except on Report, which will be a limited opportunity.

Yesterday, the hon. Member for Luton South and South Bedfordshire made an interesting point that had not occurred to me—whether a husband living with his wife in their own shared home could legitimately deny her the right to assisted suicide in their home. It is a very good challenge. It is certainly not the policy intention, as I am sure the hon. Lady appreciates, to enable one partner to deny the other the right to assisted suicide in their shared home. I ask her to accept that that is not the intention. The purpose of the amendment is to give an occupier the right to refuse assisted dying.

With the hon. Lady’s permission, given that this clause will be voted on only next week, I propose tabling an amendment that would address her concern. I am happy to work with her or the Government to get to the point where we are satisfied that that concern has been addressed, because she is absolutely right: in someone’s own home, their partner or the person who shares the home with them should not be allowed to deny them.

We have hashed out the question about protected beliefs in relation to amendment 481, so I will move on.

[Kit Malthouse]

I am wondering about the difference between my own home with my partner, and my care home with lots of people that may or may not be strangers, and why I should have the right in one but not in the other.

[Danny Kruger]

I hope my right hon. Friend will understand that there is a difference between occupying one’s own home and living in a community under conditions set by somebody else, which is what happens if someone lives in a care home. There are terms and conditions. People have to comply with the rules of the place and have obligations to their fellow residents. In someone’s own home, whether they are living with a partner or not, they have absolute rights. That is the difference. If someone signs up to live in a care home, they have to follow the rules of the place, just like in a hotel. In someone’s own home, they can do what they like, as I am sure my right hon. Friend does.