Terminally Ill Adults (End of Life) Bill

Danny Kruger Excerpts

2nd reading
Friday 29th November 2024 Commons Chamber

[Danny Kruger (East Wiltshire) (Con)]

I think you indicated that I could speak for a little longer than eight minutes, Mr Speaker.

[Mr Speaker]

Yes.

[Danny Kruger]

Thank you very much. I do not want to have too much grumbling at the eight-minute moment. I will take my 15 minutes, with time for interventions.

I start by paying tribute to the hon. Member for Spen Valley (Kim Leadbeater) for her very powerful speech and the way in which she has led this campaign—with great respect, sensitivity and, to use a contested word, dignity. She and I knew each other before we were MPs, when we both worked in the charity sector. I like and admire her greatly, and I know that we have more in common than might appear today.

All of us in this House have this in common: we all share a deep concern about the experience of people dying or fearing death, pain and suffering. I bear heavily on my conscience the people whose lives will be prolonged beyond their wishes if I get my way and this Bill is defeated today. I will not disregard those people or minimise their anxiety. We will hear those voices in today’s debate—we have heard many of them already—speaking through hon. Members in what I know will be very moving speeches.

If I voted for this Bill, I would have on my conscience many more people whose voices we cannot hear—the people who would be vulnerable as a consequence of the huge changes that this Bill would introduce in our society and in the NHS. My view is that if we get our broken palliative care system right and our wonderful hospices properly funded, we can do so much more for all the people who we will hear about today, using modern pain relief and therapies to help everybody die with a minimum of suffering when the time comes. We will not be able to do that if we introduce this new option; instead, we will expose many more people to harm.

I will go through the Bill in a moment, but first I will say a word about process, in response to the points made by the hon. Member for Spen Valley. This Bill is simply too big for the time that it has been given, and I implore hon. Members not to hide behind the fiction that it can be amended substantially in Committee and in its later stages. The remaining stages of a private Member’s Bill are for minor tweaks, not the kind of wholesale restructuring that we would need if we were ever to make this Bill safe. Members who vote for the Bill today must be prepared to see it become law largely unamended. I suggest that if they have any doubts, the only responsible choice is to vote no, and let the advocates of assisted dying bring back a better Bill at another time.

[Alistair Strathern (Hitchin) (Lab)]

I deeply appreciate the respectful way in which the hon. Gentleman is making his point, but I stand before him not sure of how any colleague in this Chamber cannot have doubts whichever way they are voting today. It feels like there are two necessary harms that we are all forced to weigh up. If the hon. Gentleman is so certain that doubt should push people one way, I am deeply intrigued to hear why that is, when it is very clear that many people will continue to suffer unnecessarily if we reject this Bill.

[Danny Kruger]

I recognise that there are very many doubts on each side, and I fully respect the arguments that have been made by the hon. Member for Spen Valley. Of course this is a finely balanced debate, but the point about process is that this Bill is too flawed; there is too much to do to it to address in Committee. By all means, let us have this debate, but let us have that before a Bill of this magnitude is brought forward, The consideration of the Bill should be much more comprehensive.

[Andrew George (St Ives) (LD)]

Contrary to what the media are saying, today’s decision is not about bringing this Bill into law; it is about allowing it to go to the next stage. People may have misgivings, but the hon. Gentleman is making the assumption that the Bill cannot be corrected or amended in order to make it palatable to people who have doubts. We all have doubts, but surely today’s vote is simply to let it go to the next stage. The final decision on Third Reading is the critical one in deciding whether the Bill goes into law.

[Danny Kruger]

I think I have made the point that this Bill is too comprehensive and there is too much in it to address through the process of a private Member’s Bill. If the hon. Gentleman has serious concerns about aspects of the Bill that he would not be prepared to see come into law, he should not be supporting it today.

Let me explain the concerns about the Bill that I think are too comprehensive to be dealt with in Committee. I recognise how hard the hon. Member for Spen Valley has worked to try to ensure that it is safe, but I do not believe it is, for the following reasons. Let us start at the beginning. The process starts with a conversation between a patient and a medical practitioner—not necessarily a doctor; just a medic of some sort, unspecified at this stage. If the patient tells their ordinary family doctor that they want an assisted death, the doctor is obliged to either explain how it works or pass them on to someone who will do it—which is probably what will happen, by the way. The likelihood is that we would see a new branch of medicine spring up, like the medics I met in Canada.

[Kevin McKenna]

Will the hon. Member give way?

[Danny Kruger]

I will in a moment.

These medics I met in Canada are specialists in assisted death and personally kill hundreds of patients a year in their special clinics. [Interruption.] If hon. Members have difficulty with the language, then I wonder what they are doing here. This is what we are talking about. I met doctors for whom this is their profession and their job, and they are proud to do it.

[Lewis Atkinson (Sunderland Central) (Lab)]

Will the hon. Member give way?

[Danny Kruger]

I will give way to the other hon. Gentleman.

[Kevin McKenna]

I want to be very clear that “medical practitioner” is a synonym for doctor—not nurse, pharmacist, dentist or any other practitioner. To be a doctor is to be a practitioner of medicine. We need to be very clear on this. There is lots of law and regulation on this, and I believe that what the hon. Member said is incorrect.

[Danny Kruger]

What the Bill actually says is that a doctor means

“a registered medical practitioner…who has such training, qualifications and experience as the Secretary of State may specify by regulations”.

Obviously they are some sort of regulated medic—I recognise that—but they are not necessarily a doctor. We will find out. I recognise that they will have professional qualifications, but it is not clear what those are going to be because it is not in the Bill.

[Gavin Robinson (Belfast East) (DUP)]

I commend the hon. Gentleman for the way in which he is engaging in this discussion, in the same spirit as the hon. Member for Spen Valley (Kim Leadbeater). We often hear that one of the safeguards associated with the Bill is that medical practitioners would be involved and that a diagnosis of a terminal illness, with six months or less to live, would be required. Does the hon. Gentleman accept that medicine is not an exact science? It is the science of uncertainty blended with the art of probability. There is no exactitude in this. No court will second-guess medical opinion; it will simply look at process.

[Danny Kruger]

I entirely agree with the right hon. Gentleman; he is absolutely right. I am afraid that the definition of terminal illness is in a sense the essential flaw in the Bill, but I will come on to that.

Going back to the conversation that the patient has with the medical practitioner, the crucial point is that the conversation does not need to be started by the patient, according to the Bill. It could be started by the medic—any medic—perhaps in hospital, who could make the suggestion of an assisted death to a patient who has never raised the issue themselves, whose family have never suggested it and whose own doctor does not think it is the right thing to do. And so the idea is planted.

Then, for whatever reason—and, by the way, there is no need ever to give a reason—the patient says that they want to proceed with an assisted death. They sign a declaration, or rather somebody else can sign it for them. It could be any professional, someone they do not know—maybe a new medical practitioner. A total stranger can do all the paperwork on their behalf. That is what the clause about the proxy entails. Then these two medical practitioners make their assessment.

[Paula Barker (Liverpool Wavertree) (Lab)]

I urge the hon. Member to check the wording of the Bill, because if somebody signs as a proxy, they have to have known the individual for two years, and would simply be signing to say that they agree with the patient who wishes to go forward with assisted dying.

[Danny Kruger]

I do not have time to check the Bill now, but from my memory it refers to someone who has known the patient for two years or someone of good standing in the community, which could be some sort of professional who is not known to them at all. Someone can quickly check the Bill, but my understanding is that it could be a total stranger to them.

[Jim Allister (North Antrim) (TUV)]

Is the matter not very clear? Clause 15(5) states:

“In this section “proxy” means—

(a) a person who has known the person making the declaration personally for at least 2 years, or

(b) a person who is of good standing in the community.”

So there is no protection such as that which is pretended by the supporters of the Bill.

[Danny Kruger]

I am grateful for that intervention.

The assessments have to determine whether the patient is terminally ill, whether they have mental capacity to make the decision, and then whether they have been coerced or pressured into the decision. In many ways the whole issue turns on the question of whether someone is terminally ill. I am afraid that it is a term of great elasticity, almost to the point of meaninglessness. It is well known, as the right hon. Member for Belfast East (Gavin Robinson) said earlier, that it is impossible for doctors to predict with any accuracy that somebody will die within six months. It is a purely subjective judgment, made in this case by a doctor whose job will be approving assisted deaths. They simply have to determine not whether it is reasonably certain that death will occur, but that it can be reasonably expected—in other words, that it is possible.

[Simon Hoare]

The thrust of the Bill, as I understand it, is to ease suffering and pain in a patient who has a diagnosis and will die of the condition that has been diagnosed. But that right could only be exercised within a six-month period, and the pain and discomfort could last a lot longer than that. Has my hon. Friend heard—because I have not—what the importance of six months is? Why not eight, 10 or 12? What would stop people challenging it on the grounds that the dam has been breached, the six months is entirely arbitrary and it could, and indeed should, be extended by negative resolution in a statutory instrument?

[Danny Kruger]

My hon. Friend makes the right point, and I am afraid to say that is absolutely the case. The six-month cut-off is completely arbitrary and impossible to determine. It is a line in the sand, and of course it could be challenged, as so much of the Bill could be challenged, on human rights grounds. Every one of the safeguards that has been introduced by the hon. Member for Spen Valley would in fact be a barrier and a discrimination against the new human right that has been awarded to one group but should of course be awarded to all—if the point is conceded in this way.

[Melanie Ward]

Earlier this week, colleagues and I met two eminent doctors who were former presidents of the Association for Palliative Medicine, and they raised serious concerns about the Bill, including that the doctor or medical practitioner who makes the assessment need never have met the person they are assessing, or been involved in their care at all. What does the hon. Gentleman make of that?

[Danny Kruger]

The hon. Lady makes a very important point. I will not get into the question of public opinion and the polling, because it is so contested, but there is clear evidence that the doctors who work with the dying—the palliative care professionals—are opposed to a change in the law by a great majority. They see the damage that it would do to the palliative care profession and services, and they see the danger for vulnerable patients.

[Wera Hobhouse]

I appreciate that the hon. Gentleman talks to us as a medical professional and we need to listen to his views. But is it not true that any medical assessment is an approximation; something that cannot be said for certain? For this decision too, we cannot be 100% certain, but that is life. We cannot make legislation that is 100% good because at some point we have to make a decision, on balance, whether something has merit or not. For that reason, we should vote for the Bill.

[Danny Kruger]

I am grateful to the hon. Lady, especially for promoting me to the status of doctor; I am actually a charity worker and political hack by background. It is good of her to credit me with those skills—perhaps I should set myself up as a medical practitioner. She is right that medics and indeed judges have to make difficult judgments all the time. I think it would be very dangerous and inappropriate to give them the power to do so in this case.

The whole question of the six-month cut-off is very important. I acknowledge all the points that have been made, but there is another problem with the definition of terminal illness. Almost anybody with a serious illness or disability could fit the definition. I recognise that these are not the cases that the hon. Member for Spen Valley has in mind—of course they are not—but that is the problem with the Bill. All that someone needs to do to qualify for an assisted death—for the definition of terminal illness—is refuse treatment, such as insulin if the person is diabetic. In the case of eating disorders, a topic on which I have worked with the hon. Member for Bath (Wera Hobhouse), a person just needs to refuse food. The evidence from jurisdictions around the world, and our own jurisprudence, shows that that would be enough to qualify someone for an assisted death.

[Lewis Atkinson]

Does the hon. Gentleman accept that every day in the NHS patients refuse treatment, and indeed food, and that there is currently legal oversight in respect of coercion and other such matters? Would the Bill not strengthen protections in those areas?

--- Later in debate ---

[Danny Kruger]

I am perplexed by that argument. The suggestion that there may be coercion—of course there will be—and abuse, and all sorts of injustices that take place in the current system, does not strike me as an argument for regulating and licensing assisted suicide. If we have concerns about practice in the NHS, let us deal with that. Let us not license suicide—and, by the way, evidence from around the world shows that that increases suicide in the general population. Suicide is contagious. For instance, Oregon is often pointed to as an example. The incidence of suicide, outside assisted suicide laws, has risen by a third there since it was legalised. There would be enormous contagious effects were we to regulate and license it in this way.

[Richard Tice (Boston and Skegness) (Reform)]

The hon. Gentleman is making an excellent case for the Bill to be passed today. What he is actually saying is that there are specifics that require debate, analysis and discussion in great detail in Committee—that is the whole point of it. If it is not dealt with properly in Committee, it will not pass Third Reading. He is suggesting that because he does not like those specifics, we cannot discuss the Bill in any detail.

[Danny Kruger]

I am sure that the hon. Member for Spen Valley is delighted to have the support of the hon. Gentleman. I refer him to the point that I was making: this is an inappropriate process.

[Sir John Hayes (South Holland and The Deepings) (Con)]

My hon. Friend is making a superb speech, as I expected him to do. On the issue of process, I say this to the hon. Member for Boston and Skegness (Richard Tice), my constituency neighbour: as he will know, I have introduced some very serious Bills, including the one that became the Investigatory Powers Act 2016. It was preceded by three independent reports and pre-legislative cross-party scrutiny by both Houses, which happened before the Committee stage. The point is that that process should take place before Second Reading, not after.

[Danny Kruger]

I am grateful to my right hon. Friend. I will now run through the process before taking any more interventions.

As I have explained, pretty much anybody with a serious illness or disability could work out how to qualify for an assisted death under the Bill. Members may think that far-fetched, but it is what happens everywhere that assisted suicide is legal, including in Oregon.

[Cat Eccles (Stourbridge) (Lab)]

On a point of order, Mr Speaker. The hon. Gentleman is using incorrect language. It is not suicide. That is offensive. I ask him please to correct his language.

[Mr Speaker]

That is not a point of order.

[Danny Kruger]

I am sorry if offence is given, but the fact is that the value of having a Bill in black and white is seeing what the law really is. What the Bill would do is amend the Suicide Act 1961. It would allow people to assist with a suicide for the first time. I respect the hon. Lady’s concern, but I am afraid we do need to use the proper language here.

The Bill’s scope is very broad. Members who think that assisted suicide for people with anorexia or other conditions that would not be regarded as terminal could not happen here should consider the young people in the UK today who are given a diagnosis of terminal anorexia and put on a palliative care pathway—essentially, assigned to death. Of course these are extreme cases—

[Wera Hobhouse]

rose—

[Danny Kruger]

I am not going to give way again.

There are a great many of these cases, I am afraid, and I mention them to show how wide open the Bill is. [Interruption.]

[Mr Speaker]

Order. May I ask the hon. Member for Bath (Wera Hobhouse) to keep a little calmer? She has intervened twice already, and plenty of other Members who also need to be heard.

[Danny Kruger]

I think particularly of disabled people, many of whom require constant treatment to stay alive. All, immediately and by definition, will be eligible under the terms of the Bill for a state-sponsored death. I refer Members to the Equality and Human Rights Commission, which has made the point that the line between disability and terminal illness is very blurred. That is why the Bill’s title is, in fact, so dangerous.

[Mary Kelly Foy (City of Durham) (Lab)]

rose—

[Danny Kruger]

I will make a little progress.

The second question that medical practitioners have to answer is about mental capacity, and here again is a great vagueness. How do they judge if someone is in their right mind when they are asking for help to kill themselves? The Bill says that the definition of capacity is based on the Mental Capacity Act 2005, but that Act is deliberately expansive. It explicitly assumes capacity in the patient, so having acute depression is no bar to being judged to have capacity under the Act. Being suicidal is no bar under the Act, so the capacity test is no bar at all.

Finally, there is the question of coercion. Is the patient asking for an assisted death because of pressure from someone else? There are two glaring problems here. The first is that the process does not even attempt to answer the question properly. There is no investigation, no requirement for medics to interview friends and family, and no need for a psychiatrist or family doctor to be consulted. The medics just need to satisfy themselves—who knows how?—that, to the best of their knowledge, the person has not been pressured.

The second problem with the coercion test is that it focuses on only one type of coercion—the less likely type. The bigger danger is not other people pressuring someone to do this; it is that they pressure themselves—hon. Members have made this point. The Bill has nothing to say on that. Internal pressure is absolutely fine. If you feel worthless or a burden to others, if the NHS will not offer you the treatment you need, if the local authority will not make the adjustments you need to your home, if you have to wait too long for a hospital appointment, or if you want to die because you think the system has failed you, that is absolutely fine.

[Several hon. Members rose—]

[Danny Kruger]

I will get to the end of my speech.

That is the medical stage, and I will jump straight to the judicial stage. The medical practitioners sign it off, and then the judge has to confirm all the same tests. Of course, many eminent judges have made the point that it will overwhelm the family courts if the test were applied properly, but it will not be applied properly, because the Bill assumes that judges will fulfil a new inquisitorial role and actually look into cases as investigators, which is entirely unknown in English common law. But the Bill will not require any actual investigation.

There is no requirement for a judge even to meet the applicant. They simply have to have a phone call, or maybe it will be an email, from one of the medics. That is it. That is the inquiry. On that basis, the judge must decide whether it is more likely than not that there has been external pressure. After the judge approves it—they are required to approve it, unless they can find evidence of external coercion—we go to “the final act”, as the Bill says, where a junior colleague, as a medical practitioner, oversees your death by pills or lethal injection.

And here is the last thing that the Bill does or does not do. There is no requirement at any stage of the process—at either the medical or the judicial stage—for anyone to tell the patient’s next of kin, their wider family or even their GP that the NHS and the judicial system are working in secret to bring about the death of their loved one, maybe their father or their daughter. I say again that these are not the cases that the Bill was designed for, but they are directly in scope, and it is going to take more than a tweak in Committee to get them out.

Is this what is meant by having choice at the end of life? Let us talk about choice. I am often accused of wanting to impose my view on others—that point was made earlier. People say, “If you don’t approve of assisted death, don’t have one, but don’t deprive me of the choice.” In fact, the evidence is that, with this new option and the comparative loss of investment and innovation in palliative care, real choice will narrow. There is a broader point to make about choice, which is that no man or woman is an island. Just as every person’s death, even a good death, diminishes us all, so we will all be involved and affected if we make this change.

The Bill will not just create a new option for a few and leave everyone else unaffected; it will impose this new reality on every person towards the end of their life, on everyone who could be thought to be near death, and on their families—the option of assisted suicide, the obligation to have a conversation around the bedside or whispered in the corridor, “Is it time?” It will change life and death for everyone.

I am very aware of the terrible plight of the people who are begging us for this new law. I think we can do better for them than they fear, but we also need to think in real human terms about what the effect will be on the choices of other people, and I do not mean the people who are used to getting their way. I am talking about the people who lack agency, the people who know what it is to be excluded from power and to have decisions made for them by bigwigs in distant offices who speak a language they do not understand—the sort of people who the hon. Member for Spen Valley and I both know from our previous charity work, and who we all know from our constituency work. They are not the people who write to us campaigning for a change in the law, but the people who come to our surgeries with their lives in tatters, or who the police or social workers tell us about—the people with complex needs. What are the safeguards for them?

Let me tell the House: we are the safeguard—this place; this Parliament; you and me. We are the people who protect the most vulnerable in society from harm, yet we stand on the brink of abandoning that role. The Rubicon was a very small stream, but on the other side lies a very different world—a worse world, with a very different idea of human value. The idea that our individual worth lies in our utility, valuable only for so long as we are useful—not a burden, not a cost, not making a mess. Let us not be the Parliament that authorises that idea.

I mentioned at the start of my speech the voices of those we cannot hear: the frail and elderly and the disabled. As we are surrounded by such a cloud of witnesses, let us do better than this Bill. Let today be not a vote for despair, but the start of a proper debate about dying well, in which we have a better idea than a state suicide service. Let us have a debate in which we remember that we have intrinsic value; that real choice and autonomy means having access to the best care possible and the fullest control over what happens to us while we live; and that true dignity consists in being cared for to the end.

[Several hon. Members rose—]

Terminally Ill Adults (End of Life) Bill (First sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 21st January 2025 Public Bill Committees

[Kim Leadbeater (Spen Valley) (Lab)]

I beg to move,

That the Committee do sit in private to consider matters relating to the sittings motion.

It is a pleasure to serve under your chairmanship, Sir Roger, and to be here for the first formal meeting of the Terminally Ill Adults (End of Life) Bill Committee. Ahead of the oral evidence sessions next week and the line-by-line scrutiny thereafter, we have two jobs to do this afternoon. One is to confirm the sitting times for the Committee and the other is to confirm the witnesses for oral evidence. Following discussions, I have taken the decision to have some of our sitting today in private. That is normal procedure for discussing witnesses and I think it is the right way to proceed, given that some of those discussions will probably involve conversations about the suitability of witnesses who are not here to speak for themselves. It would be inappropriate to discuss named individuals in such a way. Transparency is of course very important, but so is respecting individuals’ privacy. I hope that is clear to colleagues and to others.

I appreciate that members of the Committee and those viewing our proceedings may wish to know about the purpose and effect of this motion. Most Public Bill Committees are subject to programming, and the Programming Sub-Committee would discuss in private which witnesses to hear from. Similarly, Select Committees discuss in private which witnesses they will hear evidence from. Out of respect for the named individuals that we may call to hear evidence from, I propose that we discuss them informally in private. Once that informal discussion has concluded, the Committee will move back into a public session to formally consider the sittings motion. Any Member who wished to speak about the motion publicly or move an amendment would then be able to do so.

[Danny Kruger (East Wiltshire) (Con)]

It is a pleasure to serve under your chairmanship, Sir Roger. I look forward very much to the process of this Committee and to working with hon. Members to do what we can to ensure that a good Bill is presented back to the House.

I very much respect the points made by the hon. Member for Spen Valley. Nevertheless, I do have some real objections to the motion, which I encourage Members to oppose. The fact is that this debate was due to be held in public—in fact, people have travelled here in the expectation that they would be able to attend and observe our debate on the sittings motion—but last night, for reasons we do not fully understand, a decision was clearly made to table a motion that we sit in private. I would be grateful to understand why that decision was made so late.

My general point is that there is a clear public interest case. The public should understand why witnesses have been chosen and why other people have not, and if there are concerns about the witnesses, they should be aired publicly. This is the only time that the public are being consulted—that experts from outside Parliament have a chance to contribute to our deliberations. I fail to understand why those discussions cannot be held in public. The only argument that I can imagine—and the hon. Member for Spen Valley made it—is that Members might for some reason be uncivil or speak disrespectfully about potential witnesses, which I do not for a moment believe. I am sure that you, Sir Roger, or the other Chairs will keep us in order throughout our proceedings.

We are here to talk about the overall balance and particular qualifications of the witness list. Looking at the witness list that was presented this morning by the hon. Lady, I have very serious concerns, which should be aired publicly, about the list. It includes eight witnesses from foreign jurisdictions, who are being called to give evidence from abroad; all are supporters of assisted dying in their jurisdictions. There are no people speaking against the operations of assisted dying laws internationally. There are nine lawyers on the list—all of them, with the exception of three who appear to be neutral, in favour of a change in the law. There is not a single lawyer against this Bill. Sir James Munby was suggested, but I understand he has been removed. There might be a perfectly good reason for that, but he has spoken against the Bill.

There is nobody on the list from deaf or disabled people’s organisations, but the UN convention on the rights of persons with disabilities recognises the importance of engaging with such organisations in laws of this nature. With the exception of Dr Jamilla Hussain, there is no one on the witness list who can speak to the equality impacts of assisted dying.

[Dr Simon Opher (Stroud) (Lab)]

rose—

[The Chair]

Order. I appreciate that the hon. Member for East Wiltshire, and indeed all members of the Committee, received the final version of these documents fairly late in the day, and I am not unsympathetic to hearing what any Member wishes to say, but now the hon. Gentleman is going rather further down the brief than he is probably entitled to. The motion on the amendment paper is very narrow. The Question is, quite simply, that the Committee should sit in private.

[Danny Kruger]

I understand, Sir Roger, and I accept your reprimand. I was trying to make the case that it should be acceptable for these arguments to be heard in public, but I take your point.

Let me address the specifics of the motion that we sit in private. The point has been made that it is appropriate and, in fact, common for Committees to consider sittings motions privately. In fact, Public Bill Committees that consider private Members’ Bills do not sit in private to consider a sittings motion. That should be the starting point. Members may claim—I think the hon. Member for Spen Valley did—that sitting in private is like a Programming Sub-Committee on a Government Bill, but it is not. Government Bills have a sittings motion that is agreed in the usual channels, between the Whips of each side, and often that does happen privately. The way it works then is that both sides suggest witnesses and agree to them. Those decisions then go to the Programming Sub-Committee, which usually takes a couple of minutes to rubber-stamp them. Then, crucially, the sittings motion goes to the whole Committee, which has the opportunity to discuss what was decided in the Programming Sub-Committee. That is the opportunity for public consideration of the schedule of witnesses in a Government Bill, as set out by the Programming Sub-Committee.

It has also been suggested that the proposal to sit in private today is rather like the private pre-meet that happens before particular evidence sessions, which I am sure we will do when we proceed to take evidence; we will have little private meetings to discuss which Members go in which order and who will ask each question. I fully accept that that is perfectly appropriate for a private discussion, but that is not what this sitting is. Today, we are discussing exactly who we are going to call and the overall timetable for our work. This is much bigger than a discussion about who is going to ask which questions. It is about who the witnesses are going to be.

In the very limited number of private Members’ Bills since 2010 that have had a large number—five or more—sittings, the sittings motions were debated in public. That is the way it works. I could list a whole load, but I will not bother the Committee with that detail. The fact is that we have had no discussion through the usual channels; there are no usual channels in a private Member’s Bill. Everybody in the Committee was invited to submit suggestions to the hon. Member for Spen Valley, which we all did, and we appreciated that invitation. She then made her choice. There was no discussion about who the witnesses should be. It was just a decision made by the hon. Member.

A list was informally communicated last week, which we also appreciated, although it was different from the list before us now. We did not have full advance notice of this list, which we only received at 10 o’clock this morning. It was not tabled in advance and was not on the amendment paper, so we had no opportunity to prepare amendments to the schedule of witnesses or to the timetable that we are discussing. We can table manuscript amendments—and that needs to happen—but the situation still procedurally disadvantages those of us who have concerns about the Bill. Last night, I and colleagues tabled a sittings motion, which I hope we will have the opportunity to debate, in the absence of one from the hon. Member for Spen Valley.

I am afraid that this issue reflects a general concern I have about the process, which is why it is so important that we debate the witness list before a public audience.

--- Later in debate ---

[The Chair]

Order.

[Danny Kruger]

I look forward to the opportunity to discuss the sittings motion, which I hope we can do publicly. On a general point about process, the Bill was written by a campaign group.

[Kim Leadbeater]

That is not true.

[Danny Kruger]

Well, it had a significant input.

[Kim Leadbeater]

On a point of order, Sir Roger. That is categorically not true. The Bill was written with senior legislative expertise, along with myself as a sitting Member of Parliament and with esteemed colleagues. I take that point of offence quite personally.

[Danny Kruger]

Well, I hope that the hon. Member—

[The Chair]

Order. A point of order has been raised; I had better reply to it—if only to say that it is not a matter for the Chair.

[Danny Kruger]

I apologise, Sir Roger, and I apologise to the hon. Lady for causing offence. I hope she will not be offended when points are made that she disagrees with.

[Kim Leadbeater]

It is a matter of fact.

[Danny Kruger]

I am happy to withdraw the suggestion that the Bill was written by a campaign group, on the basis of the hon. Lady’s assurance that it was written by herself. I hope it is not the case that there was significant input from campaigners. I do not see why there should not have been; I just mention it because the Bill came to us with no formal consultation. There was no impact assessment—

[Kim Leadbeater]

On a point of order, Sir Roger. Surely we are having a conversation about whether we sit in private or not. Can we keep to that matter?

[The Chair]

Forgive me: I am in the Chair and I will decide—but the hon. Lady is absolutely correct. Once again, I am afraid that the hon. Member for East Wiltshire is straying very wide of the motion on the amendment paper. I would be grateful if he would now come to his conclusion so we can start to move forward.

[Danny Kruger]

I absolutely will. In fact, I will finish there. The points I have been trying to make are simply in the light of the fact that if the hon. Lady’s motion is accepted, the public will no longer have the opportunity to hear any of our points on the sittings motion—on the process that we will be decide on.

[Kim Leadbeater]

On a point of order, Sir Roger. That, again, is factually incorrect. We have already said that there will be a private sitting for conversations about individual witnesses, including some that the hon. Gentleman has already started talking about, and then we will open again to the public so that everybody can hear the Committee’s conversations.

--- Later in debate ---

[The Chair]

Order. Once again, that is not strictly a matter for the Chair, so it is therefore not a point of order, although it is now a matter of record. We are going to spend quite a lot of time together and it would be helpful if, reflecting the tone of the debate that took place on the Floor of the House, we were civil and courteous to each other and that the debate was conducted throughout not only these proceedings, but right throughout the entire Committee stage, with customary candour and decency. If we can manage that, accepting that these are highly divisive issues and that strong feelings are held on both sides of the argument, we might just end up with a conclusion that would satisfy most, if not all, people.

[Danny Kruger]

I genuinely do not want to cause any distress or offence to the hon. Member for Spen Valley. I simply am doing my job, which is to represent my genuine concerns about the process that we are deciding on today. I think it is not appropriate to sit private, and I do not believe it is the case that we will have the opportunity to discuss in public the sittings motion. We are deciding that in private, according to her intention. There is not going to be the chance to debate publicly the list of witnesses or the timetable that we are to follow. So be it. If hon. Members in the Committee want to proceed down that line, that is what we will do. I look forward to that discussion, which I am sure we will have courteously, but I encourage hon. Members to vote against the motion.

[Lewis Atkinson (Sunderland Central) (Lab)]

I, like you, Sir Roger, hope that we can spend the next five or six weeks in the spirit of collaboration and that we do not get bogged down in procedural wrangling. We need to work across the Committee to get the best procedure we can.

The hon. Member for East Wiltshire made several points, including the precedent for private Members’ Bills. The relevant point here is that this private Member’s Bill is unique already by the fact that the lead Member, my hon. Friend the Member for Spen Valley, has agreed to take evidence—unlike in any other private Member’s Bill. Therefore, in some cases there may be a need to discuss the sensitivity of individual witnesses’ availability and personal circumstances. We cannot agree as a Committee just by calling witnesses in the abstract. We have to agree—as is outlined by my hon. Friend’s motion and indeed by the alternative motion in the name of the hon. Member for East Wiltshire—for them to attend at a specific time and at a specific place. I gently say to the hon. Gentleman that the Committee would do well to have a conversation in private about the individual availability and suitability of some witnesses.

The motion set out on the amendment paper to sit in private is to consider

“matters related to the sittings motion”,

not the sittings motion itself. My hon. Friend the Member for Spen Valley has clearly indicated that we will return to sit in public for the formal proceedings, which I support. That means that the hon. Member for East Wiltshire and any others who wish to place on record their observations can do so then. In the same way that the hon. Gentleman acknowledges happens in Select Committees and other forums where there is discussion about witnesses, how to call them and so on, I suggest that we spend a little bit of time in private to do so too, before agreeing—I hope with a level of consensus across this Committee—to return in public and to operate in public scrutiny as the hon. Gentleman suggests is appropriate.

I support the motion to sit in private for the consideration of these specific matters in initial discussion and then I support returning to public, as my hon. Friend the Member for Spen Valley has indicated, so that we can be subject to the right public scrutiny for the decisions that we make today.

--- Later in debate ---

[Naz Shah]

On amendment (b), given the issue we are considering, I think it is important that the Royal College of Psychiatrists is involved. One thing that is very important to me is the issue of coercion, and the royal college would be able to shed light on that. One of the many reasons advanced for giving the Bill its Second Reading was that we would have further debate, and the royal college would add value to that.

On amendment (c), Dr Ramona Coelho is a physician with well-founded concerns about the operation of the law in Canada. She is a member of the Ontario Medical Assistance in Dying Death Review Committee, and she gave evidence to the Scottish Parliament Committee that considered the Assisted Dying for Terminally Ill Adults (Scotland) Bill.

On amendment (d), Ellen Clifford is co-ordinator of the UK Deaf and Disabled People’s Monitoring Coalition, and she has a key role in advocating for people with disabilities.

[Danny Kruger]

I want to speak in support of the proposed addition of Ellen Clifford. Last week, she won a High Court case against the previous Government for their consultation on benefits reform, so she is no friend of my party, but she is a powerful advocate on behalf of disabled people, and she represents the deaf and disabled people’s organisations that are so important in informing the Government on the implementation of policy that affects disabled people. I recognise that the hon. Lady has included some representatives of the disabled community, but I suggest that there would be particular value in hearing from Ms Clifford because of her role as the co-ordinator of the monitoring coalition of all these deaf and disabled people’s organisations across the country. She is the best person to advise the Committee on the operation of the Bill.

[The Chair]

Order. Before we proceed any further, let me say that the hon. Gentleman was in order, because I allowed him to speak, but it would be unhelpful if we started to cherry-pick amendments while going through them. Let the hon. Member for Bradford West speak to them—they are being taken together—and then any hon. Member who wishes to comment on any or all of them will have the opportunity to do so. Otherwise, we will have a very piecemeal approach.

--- Later in debate ---

[Naz Shah]

Thank you, Sir Roger.

[Danny Kruger]

I want to make a general point in support of the hon. Lady’s suggestions.

[The Chair]

No, I am sorry. Please let the hon. Lady finish her speech.

--- Later in debate ---

[Kit Malthouse]

I will just finish, if I may. Our Bill is built on a very different legal framework from Canada’s. Drawing legislative parallels between the two seems like a cul-de-sac, not least because, as the hon. Lady will know, the legal framework in Canada is dictated by the charter of rights and freedoms, effectively a constitution, which has been used there to widen the scope of the law. Canada started from a very different place as well, so I am not totally convinced.

What the hon. Member for Spen Valley has tried to do with the list is to find overseas territories that are analogous to our own and have adopted a model similar to ours. We are therefore trying to learn lessons from the process of debate and legislative procedure that they went through—either to learn from them or to learn from their mistakes. For example, knocking out the Member of Parliament from Australia would be a mistake, not least because Australia has been through a number of iterations with its law. Most of Australia has a bar on doctor initiation of the conversation. The medical profession think that that is a big negative in Australia, as I understand it, so I would like to understand why, politically and in legislation, it was felt that that was needed or helpful, and why it was imposed.

On the other amendments, the hon. Member for Bradford West is making a value judgment about comparative expertise between Amanda Ward and whoever she wants to propose instead—Philip Murray. I do not know why she is making that value judgment, but as far as I can see, the names were properly submitted in the process. The hon. Lady obviously had the chance to submit names during the process. For better or worse, as she may see fit, the hon. Member for Spen Valley has come up with a list that is a compromise. That is not to say that the hon. Member for Bradford West cannot arrange briefings with any of these experts outside the formal process, for Members to attend should they so wish, or that she cannot seek advice from them during the process of the Bill.

My primary concern about the amendments is that we are opening up a whole area of debate where we could all have gone with our suggestions. I would rather stick with the list that we have, because I fear that the hon. Member for Bradford West is doubling up and making value judgments about expertise that are not necessarily warranted.

[Danny Kruger]

All the names that the hon. Member for Bradford West has suggested were indeed submitted, I believe, to the hon. Member for Spen Valley ahead of the deadline that she put to us at the end of last month.

[Kim Leadbeater]

On a point of order, Sir Roger. All those names were not submitted.

[Danny Kruger]

The hon. Lady can feel free to intervene on me without troubling the Chair. I stand corrected if that is the case. We only received the final list this morning. It was necessary to make alternative suggestions ahead of that, which was done. I am now supporting the hon. Member for Bradford West in making suggestions for slight adjustments, as she suggests is all that is appropriate at this point. The list is unbalanced. I had to do a very quick analysis, and of the almost 60 names that have been put to us, 38 of them are in favour of the Bill and the principle of assisted dying, whereas there are only 20 who are opposed. There is an inherent imbalance there. It is only a quick analysis that has been done, and we will be able to do more of that subsequent to this sitting, but that is my impression.

--- Later in debate ---

[Dr Opher]

The Bill as proposed is extremely similar to the Australian law, but it is not similar to Canadian law. Therefore, I do not see that bringing Canadian expertise into the Committee is of any use at all. I also back the right hon. Member for North West Hampshire when he said that in almost all situations we are just replacing one expert for another, so the only contentious bit is whether we have people from Australia in support of or against assisted dying.

A split of 38 to 20, with the other witnesses being neutral, is appropriate and actually reflects the vote in the House. I do not see that as a disadvantage. Are the witnesses really going to change what we are saying? We need to listen to them and learn from them, but having some of them against assisted dying is enough to give us due discipline and ensure we listen to exactly what the problems might be, so I disagree with the hon. Member for East Wiltshire.

[Danny Kruger]

Very quickly, let me say that 38 to 20—two to one—was not the split that happened on Second Reading. There was a much more finely balanced position in the House. I accept that the hon. Gentleman does not want to hear from Canada and I do not blame him—people who are in favour of the Bill are desperate to keep Canada out of it. Okay—let us look at Australia. There are many people in Australia—MPs included, if we could hear from politicians—who continue to profoundly oppose the Bill on the grounds that it is not working, it is dangerous and it is being expanded. Let us hear some alternative views if we are interested in foreign experience.

[Several hon. Members rose—]

--- Later in debate ---

[Danny Kruger]

I think Baroness Hale has been knocked off the list. Am I right? I do not think we are going to have the huge pleasure of hearing from Baroness Hale.

[Jake Richards]

Well, we have had lots of lists, but Lord Sumption and Lord Neuberger are giving evidence, I believe; Lord Sumption is, anyway. These things can be tested and challenged, so the notion that we need to have others is slightly absurd. We have the law lecturer from Cambridge University as well.

Terminally Ill Adults (End of Life) Bill (Second sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[Kit Malthouse]

Q In the run-up to Second Reading, we heard from some of the overseas experience that where there was effectively a gag clause on doctors, it was proving to be extremely difficult, and the medical profession felt that that was a big barrier to discharging its duties. Would you recognise that?

Dr Green: Indeed. I believe that in New Zealand—and I think in the state of Victoria, but I would need to check that—there have been official reviews that have identified those concerns, and they are looking to review the legislation.

[Danny Kruger (East Wiltshire) (Con)]

Q It is noteworthy that in Australia and New Zealand, palliative care professionals are very keen on retaining that safeguard, to ensure that it is not suggested to patients that they might have an assisted death unless they have brought it up themselves.

I would like a quick clarification from Dr Green. In terms of the survey, my understanding is that the British Medical Association’s official position is to be neutral. The majority in favour of neutrality—moving away from an opposed position—were junior doctors and those not working with the elderly and the dying, whereas the great majority of doctors who work in palliative care and work with dying people remain firmly opposed to a change in the law. Is that your understanding?

Dr Green: There were some variations between specialities; that is true, but within all specialities, there was a wide variety of opinion. It is that wide variety of opinion that the BMA has based its policy on.

[Danny Kruger]

Q I understand—thank you.

I have a question for you, Dr Green, on the delivery of the service if it is brought into law. Is it your understanding that the Bill mandates the NHS to provide an assisted dying service? I appreciate that it is not clear in the Bill. Nevertheless, it does authorise the Government to pay for it and it establishes this right. My question to you is this: is this a medical procedure that we are proposing to legalise, and should the NHS provide it? If the answer is yes, should that be a separate service within the NHS or should it just be part of general practice?

Dr Green: We have not taken a view as to whether it should be inside or outside the NHS. That is not for us to take. We do believe that it should not be any part of any doctor’s normal job to provide assisted dying. In other words, it should be set up through a separate service with a degree of separation.

We believe that is important for patients, because it would reassure patients who may be anxious about the service that it would not just be part of their normal care. It would reassure patients that the service they were going into had proper quality and proper audit attached to it. It would reassure doctors, because doctors who did not want to have any part would not feel that it was part of their normal job, whereas the doctors who wanted to go ahead would be assured of having support, emotional support and proper training. Also, it should, hopefully, reassure the providers, who would then be assured that it would not be expected of them just as part of their normal duty. We believe a degree of separation is very important.

[Danny Kruger]

Q What are the implications for resources? I appreciate that that is your view, and I recognise that it makes very good sense. Are you concerned about the resourcing of that service, in terms of whether there might be implications for other parts of the NHS if it was to be a separate service?

Dr Green: I think we are always concerned about resourcing, and I can only back up what Dr Whitty said about the importance of palliative care.

[Danny Kruger]

Q Mark, I have a question about the end, or “the final act” as I think it is called in the Bill. Do you think there needs to be more specific guidance in the Bill about what should happen in the case of complications—if the death is taking a long time? It can take up to an hour quite commonly in other countries. There may be complications. Again, that happens. What would happen if a doctor were to intervene to genuinely assist the patient to die, if something was going wrong? Are you worried about the legal implications for doctors in those circumstances?

Mark Swindells: I would agree with you that there certainly needs to be really clear guidance for doctors on that scenario. We have not taken a view on whether that needs to be in the Bill, in regulation or in the statutory code of practice. What I would say is that we would be willing to participate in the setting of that. It would be very important to listen to the view of doctors and indeed patients who might be interested in taking such a course of action, to understand their issues.

[Danny Kruger]

Q Very quickly on that last point, it is not totally clear what kind of medical professional would be in attendance at the end. Do you think it should be a fully trained doctor? Should there be some separate professional in that role? How should that work?

Mark Swindells: I am not trying to duck the question, but because we do not take a general view on whether the Bill should pass or not, we have not taken an established view on the delivery mechanism for it.

[Lewis Atkinson]

Q I want to cover two areas. I will start with the current law. I am interested in the position that doctors are currently in, both regulatorily and around the current law. The Suicide Act 1961 and so on clearly prohibit this. A number of us have heard from families who have gone to Switzerland, and so on, and who have returned and had a conversation with their family doctor around the death of a loved one. There have been incidents in which people have attempted to take their own lives, given that there is no current assisted dying provision. Could you say a little about the dilemmas facing doctors on the current law as it stands?

Mark Swindells: We do get inquiries from doctors who are concerned that they are doing the right thing when it might become apparent to them that a patient wants to travel overseas to access assisted dying. We have taken legal advice, and on that basis, we guide doctors that it is permissible for them to provide the existing medical records to that patient, as you might under a subject access request, but to be really cautious about going any further in terms of recommending that or assisting the process more than that. That is based on our understanding of the existing law in the Suicide Act.

Dr Green: Of course, that leads to a further issue. As we heard from Dr Whitty today, this measure may progress at a different speed in Scotland and England and Wales. We also have the Crown dependencies, which are some way further ahead than the mainland Governments on it. That raises an issue for doctors who work in England and Wales but treat patients in the Crown dependencies. We would want clarity about the legal situation regarding a doctor in Liverpool who is treating a patient in the Isle of Man, should the law allow assisted dying in the Isle of Man.

--- Later in debate ---

[Kit Malthouse]

Q Professor, I want to test a little further the notion of a separate organisation that you mentioned. I can understand a separate discipline emerging, acquired by training, which is what happens in palliative care at the moment. We heard from previous witnesses that simplicity in safeguards is key, and in particular from the CMO that we have to avoid the last 6 months of someone’s life being a bureaucratic nightmare. At the moment, within palliative care and palliative nursing generally, you are already dealing with patients who are electing to refuse treatment, food and water, or are supporting patients following an advance directive. If you are supporting people in those circumstances as they move towards their death, do you think that it could be absorbed within the current functions, rather than having a separate organisation?

Professor Ranger: It is difficult. If I am honest, we have probably not explored that enough within our thinking as a college. We know what we would not want to see, which is a situation where there is an expectation that it becomes part of a pathway. It has got to be something you actively seek and opt into. I think how that is administered probably requires more thought, if I am honest, but I would not want to see it becoming an expectation of a pathway, because then the pressure on the individual may change. That is something we need to safeguard against.

I am worried that we should not make it so bureaucratic for the individual that it becomes impossible to have their autonomy respected, but how that happens is something that needs further exploration. We would fully support making it as clear and unbureaucratic for the person as humanly possible. But we would not want to see it as a sort of pathway within our current setting, because there could then be a sense that this is something that is externally influenced rather than being something that someone actively seeks for their autonomy.

[Danny Kruger]

Q You have done this very powerful report, the “Last Shift”, and talked about the moral injuries—a very powerful phrase—felt by nurses in the light of shortages in care in the NHS and social care. What should a nurse, or indeed any health professional, do in circumstances where a patient is requesting assisted dying and qualifies for it, when that professional thinks that what they really need is palliative care, but that is not available because of the shortages in the palliative care system?

Professor Ranger: It is difficult, but in my experience there are ways to try and get people palliative care, whether that is, as was said earlier, via other organisations outside the NHS and within hospice care. There are ways through the current routes to get people the care that they need.

[Danny Kruger]

Q Just to be clear, do you think it is possible for every patient who needs it to get the palliative care that they should have?

Professor Ranger: I do not think it is as good as it needs to be. We know that it is sometimes hard for people to access care. We know the struggles regarding hospices. We know far too many people die in hospital. We know there are real challenges in social care and the health service. I cannot say it is not without challenge.

[Danny Kruger]

Q So somebody could request assisted dying because of the absence of adequate palliative care.

Professor Ranger: When you put it like that, it could be possible, but we would want to strive to have a system that does not leave anyone in distress.

[Danny Kruger]

Q Indeed. Lastly, I am very interested in your suggestions about a separate service and about the importance of protecting the rights of professionals who do not want to be involved. I was very conscious of the plight of care home workers in the pandemic, and I regretted my vote to mandate the vaccine to them.

Do you think—I cannot decide for myself what the answer is—it should be possible for a care home director to exempt their whole service, that care home and the people who work in that care home, from being involved in assisted dying? That is where people live, after all. If somebody is having it there, it could affect the entire atmosphere of the place, and the work that all of the people there have to do. Do you think they should be protected as an organisation?

Professor Ranger: Particularly for nursing homes, I think that would be difficult. How and where people end their life probably needs further thought and further explanation. There is something about being really clear— if you are the leader of that nursing home, we would have to explore your ability to be able to advocate for the care that you want to be able to give in that nursing home. All of these practical things need further exploration.

It is difficult, because for someone who wants to end their life, if that is their home, they may want to be there. It is all of these practical things that probably need further thought and exploration, because I think it could be argued either way.

[The Chair]

Q We have about 40 seconds left, so I do not think we will get in another question. Glyn, do you want to add anything to any of the points?

Glyn Berry: I do not think so. I think that the last question around care homes was a really good one. I am already thinking about the implications for registrations with the Care Quality Commission and what that would mean in terms of the process and the protection of staff, residents and families. It is a really helpful question to think about.

Terminally Ill Adults (End of Life) Bill (Third sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[Dr Simon Opher (Stroud) (Lab)]

Q Thank you for all giving up your time, with your very high level of palliative care expertise and experience. I am a practising GP, and GPs and district nurses do a lot of palliative care with a lot of advice from you people. I have also noticed that, even with the absolute best quality palliative care, some people have still talked to me about an assisted death, or shortening their death. I would like to hear your comments. Is this more about autonomy than symptom control?

Dr Clarke: I absolutely agree that in a small number of cases, palliative care at the highest level cannot eradicate all suffering, and cannot prevent a person from wishing to end their life and have assistance in ending their life. That is absolutely the case; I would say that it happens surprisingly uncommonly, in my experience, but it does happen.

Autonomy is the crux of the issue for me, because autonomy is predicated on having meaningful choices. Can you actually choose option a or option b? Let us say that option a is high-quality not just palliative care, but medical care in general—district nursing care or social care, for example. If that is not available to you, you are potentially being pushed towards “choosing” option b—the route of assisted dying—not freely and not autonomously, but because option a has been denied to you by real-world failures. We all know about those real-world conditions—we are all familiar with the latest winter crisis, where patients have been dying on trolleys in corridors, etc—that are preventing the actual option of a death in which dignity, comfort and even moments of joy can be maintained right up until the end of life, when that patient is getting the high-quality palliative NHS and social care that they need.

That is the crux of the issue. If you do not have that as a real option for patients, we can say that they are choosing autonomously assisted dying, but actually society is coercing them into that so-called choice because it is not funding the care that makes them feel as though life is worth living. That is why I think many of my colleagues are so concerned about legal change now. It is not because of an opposition to assisted dying in principle. It is because the real-world conditions of the NHS today are such that people’s suffering means that occasionally they will beg me to end their life, and I know that that begging comes not from the cancer, for example, per se, but because they have been at home not getting any adequate pain relief. Once you start to provide proper palliative care, very often that changes.

[Danny Kruger (East Wiltshire) (Con)]

Q I will ask you one quick question, Dr Cox. Dr Clarke said that the capacity assessment was poorly conducted. Do you think that the threshold is appropriate, using the Mental Capacity Act 2005? Assuming that we could conduct these assessments adequately, do you think that the threshold is safe?

Dr Cox: I and my colleagues have concerns about the safeguards in the Bill. It is not just the capacity assessment; we also acknowledge that prognosis is incredibly difficult to assess accurately. I would say that you cannot always identify coercion. You can identify it when it is very obvious and extreme, but when it is very subtle, we cannot always identify it. After the event, there is nobody to tell us about coercion, so it is very difficult to monitor.

The other thing that concerns me is that we are putting all these assessments on the shoulders of two doctors individually, followed up by a High Court judge. In any other clinical practice, when we are making very serious decisions, we know that shared decisions are much better quality, much more robust and much safer. In clinical practice, we make all these decisions in multi-professional teams. I would never make these decisions independently of my team, because the perspective they bring can help me to understand things that I am not seeing.

The thing that I am really concerned about is how it is possible for these doctors, even with training, to have a good understanding of all illnesses in order that they can identify prognosis—neurological, cancer and every other. How is it possible for them to really understand capacity when capacity is not an absolute; it does change and it is very complex to assess? How is it possible for them to see all cases of coercion, which can be invisible?

In addition to that, are those doctors going to be looking out for opportunities to refer to palliative care when they see somebody who has suffering that could be addressed and may change their mind? Are they looking out for untreated depression? We know that treatment of depression can result in people changing their minds about wanting to die. It is a lot to ask these individual doctors to do, and that really concerns me.

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

Q I want to pursue that point a little with you, Dr Cox. My understanding is that your profession is already taking these decisions, or supporting patients to take these decisions—for example, the withdrawal of ventilation for an MND patient towards the end, or if I decide to decline treatment or food and water to end my life as quickly as I can. Presumably, you already have guidelines or training about assessing coercion and capacity in those circumstances. I think in some—for example, advance directives—you are legally obliged to comply with a patient’s wishes. Are those guidelines and safeguards broadly translatable across into what, from my point of view, is another choice that a patient may make to end their life?

Dr Cox: There are two differences that I would identify. The examples you give are of somebody who may be naturally dying and is being kept alive, so the difference is that you are withdrawing a treatment; you are not intentionally killing them. This is the first difference with assisted dying.

The second difference, I would say, is that you are absolutely right that we do make those decisions with patients—with their families, if they wish—but in a multi-professional team. I would almost never make those decisions as an individual doctor without the support of my colleagues, for several reasons. First, as I have said already, that makes for much better decisions—they are safer and more robust. Secondly, the moral distress associated with these decisions is much less if you share them. That is also a worry for me—what happens to the moral distress of the co-ordinating doctor and the other assessing doctor? They are carrying a lot of moral distress. My understanding is that a very small percentage of doctors will want to engage with this—maybe 1% or 2% of all doctors will want to be in those assessing positions. They are carrying a lot of that distress because they will be doing a lot of assessing.

--- Later in debate ---

[The Chair]

Order. I said earlier that this is not a dialogue. Address your comments to the Chair, and I will decide who speaks and when. I do not wish to be rude, but everybody’s got to have their fair share.

Sir Nicholas Mostyn: I do not know if you have seen Sir Stephen Sedley’s memo, which came today. He has suggested that the Official Solicitor should be the checker of these facts, which seems a sensible idea. The Official Solicitor would be able to recruit more staff to do this. It would not be nearly as expensive as High Court judges, and it would be an efficient way of dealing with the problem. The advantage of the Spanish system is that you have a qualified doctor as well as a lawyer doing the checking. Remember—a High Court judge is not going to be a qualified doctor. That is a significant advantage in my opinion.

[Danny Kruger]

Q I have a quick question for each of you. Sir Max, as you point out, the Bill does not repeal the ban on assisted suicide. It would still be illegal to assist someone to go to Switzerland. Alex Goodman KC, giving an opinion on behalf of Dignity in Dying, the campaign group that champions the Bill, thinks it is more likely that there would be prosecutions for people who assist their relatives to go to Switzerland once this Bill is passed. Do you share that view?

Sir Max Hill: I am not sure about that. I would always default to the code for Crown prosecutors and the two tests that the prosecution must go through, regardless of the crime that is being investigated. The evidential stage test sets out what it is necessary to be able to prove—some people say to a reasonable level—to afford a reasonable prospect of conviction. One can well imagine that, in Dignitas cases, that hurdle or test is often satisfied. It was often satisfied in the cases that I considered, and could often be satisfied in the future, but the evidential stage test being satisfied does not always mean that a prosecution results. That is because prosecutors must then go to the public interest stage and consider the non-exhaustive list of factors that are set out in the public interest stage test together with other policy, which, in this area of law, has developed since the legal case of Purdy in 2009.

In common with many other forms of crime, there are some legal policy considerations that a prosecutor is entitled to consider. They start at the very obvious—for example, what is the age of the suspect? Here, one is not thinking about the deceased who has gone to Dignitas. What is the age of the suspect? What are their characteristics? Have they ever committed a criminal offence before? What is their proximity to the case? What motivation did they have, emotional or otherwise, to lend assistance that technically means they have committed the offence?

I am going through that because, as I said, a proportion of the cases I considered were Dignitas cases, and it was often at the public interest stage that I determined that a public prosecution was not necessary. That is because, after full investigation, it transpired that the surviving relative had acted wholly out of compassion and, may I say, love for the deceased and was not seeking any gain for themselves—far from there being any dishonesty before or after the fact. That would still remain the case. It does not follow that, were this Bill to pass and were people then to take elderly relatives to Dignitas, they would necessarily face prosecution, but the premise of your question is “Could they?” and the answer to that is yes.

[Danny Kruger]

Q Sir Nicholas, do you want to comment? I have another question for you as well, but is it the case that prosecutions will be more likely? Maybe you disagree.

Sir Nicholas Mostyn: I do not agree.

[Danny Kruger]

Q You do not agree. In that case, this Bill would be worse for somebody with your condition because it does not address your condition and it would put your relatives at greater risk if they did assist you—but you do not think there is a danger of prosecution.

Sir Nicholas Mostyn: I think it is unlikely. I am sorry for interrupting you. I always used to say, “Don’t interrupt”, so I am sorry about that.

I fear that I will be one of the people, referred to by the lady who asked the first question, who has to go to Dignitas—frankly, I could afford to do that—because the Bill is not ever going to provide an assisted death for me. I will not be graphic about what the advanced stages of Parkinson’s are like, but the medical Members among you will be able to describe what is likely—not definitely; I do not want to say definitely—to await me. I am choosing my words carefully. It is either going to be a poor death here or to go somewhere like Dignitas. If my children took me as far as Calais, and then helped me after Calais—assistance only applies to within the jurisdiction—and drove me on to Zurich, I would be extremely surprised if any prosecution ensued.

[Danny Kruger]

Q I wanted to follow up further, but because time is tight I will jump to Mr Ruck Keene. Can you explain a little bit about your concerns about the Mental Capacity Act and its interaction with the Bill? Do you think the threshold of capacity, as set out, is adequate?

Alex Ruck Keene: I think there are two different questions. First, is any idea of capacity sufficient at all? I think that is an existential question that I am just going to park. Turning to the Mental Capacity Act itself, it is important to understand that there are three different bits of that Act in play. We have a set of principles: the presumption of capacity; the presumption that you have to provide all practicable support before you find someone to lack capacity; and the idea that you cannot, just because a decision seems unwise, say that someone lacks capacity. Then we have a functional aspect—in other words, can you understand, can you retain, can you use and weigh the relevant information, and can you communicate that decision? We also have what some people call the diagnostic element—in other words, is there an impairment or disturbance in the functioning of the mind or brain?

These are the three separate things, all of which we make work—more or less—in everyday practice. I say “more or less”, because yesterday I was on the advisory group for a project funded by the National Institute for Health and Care Research, which was funded in 2022 to try and increase the quality of mental capacity assessments in healthcare settings. We need to be under no illusions about how well we are doing it at the moment, but we make it work, more or less.

The Mental Capacity Act works more or less in the healthcare context, because every time we reach the view that someone cannot make a decision, we have an alternative—we can think about best interests. What we are asking the idea of mental capacity to do here is different, because there is no suggestion that, if you cannot support someone to make a decision, you will ever make a best interest decision in their name to assist death. It is also not obvious that the idea of a presumption of capacity should apply. If I doubt that you have capacity to make the decision to take your own life, or end your life, but I cannot prove it, is it logical or are we required to proceed on the basis that you do? Also, it is not immediately obvious that it is right that the diagnostic test applies in this context. In other words, I think you cannot understand the information, but I cannot prove the reason that you cannot understand it is that you have an impairment or disturbance. That is where my concern came in when I was explaining it in my written evidence.

I want to be absolutely and totally crystal clear: as far as I am concerned, at this stage, this is policy development. I am so glad that evidence is being taken and the public is thinking about this, but a Bill of this nature needs to be drafted by the Office of the Parliamentary Counsel. I am really trying to get across the policy line, which to me is about what doctors need to be interrogating—or anyone else, as I would love it if other people were involved—is, can the person understand the information? Can they retain it? Can they use and weigh it? Can they communicate their decision? If they cannot, we do not need to start mucking around with, “Why not?” It is just that they cannot, and that is the central idea of capacity. It is the functional idea, but it is tooled for use in the Bill rather than, as it stands at the moment, just being cross-referred out to the Mental Capacity Act, raising a whole series of additional complexities.

My only other observation is that I spend an awful lot of my life trying to improve Mental Capacity Act practice more broadly. I would be massively concerned were a knock-on effect of the Bill’s seeking to deal with a very specific group of people to be that it starts inadvertently—it would be inadvertent—interfering with how we think about healthcare decision making more broadly in the context of those people with impaired decision-making capacity. It is an insulation point, a making sure you have the right tools for the job point, and a not having a knock-on effect on thinking about things more broadly point. Sorry for the long answer.

[The Chair]

I will move on to Sojan Joseph, but perhaps you can pick this up. We have eight people wanting to ask questions and half an hour, tops.

--- Later in debate ---

[Stephen Kinnock]

Dr Spielvogel, I do not know whether you have anything new to add to that. If not, that is fine.

Dr Spielvogel: Without repeating anything that Dr Kaan said, I was just going to say that in addition to my assisted dying hat, I am also the programme director for the family medicine residency programme, so my main job is actually training young physicians who are becoming what you would call GPs.

We have instituted curricula as part of our residency programme here to train interested physicians in learning how to do assisted dying. We go through a whole process for that, including lectures, them shadowing me and me shadowing them, listening in on their conversations, giving them pointers and walking them through the steps of the process. They then do this with multiple patients through the course of their residency, so when they graduate, they feel confident in being able to offer this care. As with most medical training, this should be included in that part of the training process. All the other things, such as pathways in continuing medical education, are very important for physicians out there in practice who want to start doing this, but really getting this into medical training at its roots is vital for normalising the practice.

Speaking of which, something else I have heard a lot is that this might be distressing to physicians, or that physicians would not want to offer this care. I would like to say that 80% of our residents on our programme opt to receive this training. When we did a study on this of graduates from our programme who were continuing to offer assisted dying, 70% of the surveyed residents said that their assisted dying work was more rewarding to them than the rest of their primary care work—70% said that it was more rewarding.

I want to come back to the notion that physicians would feel burdened or that this would be some sort of psychological negative to physicians practising it, because it is actually quite rewarding work. It has led me to be a better physician to all my patients because it has helped me with having these difficult end-of-life conversations with them. That was a bit of a twofer, sorry—I added that on there.

[Danny Kruger]

Q I have four very quick questions. I would be grateful if you could try to answer them quickly, because we have to let everybody else in before the end of the session. Dr Spielvogel, I was struck by you saying that nine out of 10 patients to whom you have suggested this option were not aware of it. How many people who did not know about it before and to whom you might have suggested assisted dying as an option do you think have taken it up? How many people do you think benefited from you telling them about the option?

Dr Spielvogel: A lot. I have actually been quite surprised. Everybody is different. This is the whole point: different people have different goals, objectives and values. I have mentioned it to people who say, “No, I would never do that,” and I never bring it up to them again.

[Danny Kruger]

Sorry, but how many do you think?

[The Chair]

Order. Do not interrupt the witness, please. Let him finish. You can then come back in with a question.

[Danny Kruger]

I apologise.

Dr Spielvogel: No problem. To answer your question more directly, I have had several people over the past couple of years who had no idea that it was an option and said, “That’s what I want to do.” They then went through the process with me.

[Danny Kruger]

Q Thank you very much. I was also concerned by what you said about what you called family coercion, which is people trying to stop their relatives taking this option. Do you think we can do anything to prevent that happening?

Dr Spielvogel: Yes. I think it could be made into a misdemeanour, a felony or whatever the equivalent is over there—sorry, I do not have the terminology. You could make it illegal to interfere with a patient’s right to make this choice. We stopped short of that in our most recent addendum to our law here, but I think that was a lost opportunity.

[Danny Kruger]

Q I will just jump straight to my final question. Dr Kaan, you said that you felt that people who felt they might be a burden were exercising their autonomy, and it was a perfectly appropriate reason to seek an assisted death. Is that right, and do you think there is anything more we should do to make it easier for people to access this right? Do you think they should be asserting anything other than their wish to do so?

Dr Kaan: You characterised it correctly in that I think that for people who have capacity, and who are making the decision to have this as an option, a part of their reasoning is that they want to save their family from an onerous caregiving experience. I think that is their right and it is part of their value system.

Of course, if that is the only reason, we are going to be exploring that. As Dr Spielvogel has said, that is a red flag. We are going to be exploring that, and exploring whether acceptable alternatives exist and what are the resources that the person may not be aware of. That is always part of the discussion. These discussions are always broad and multifactorial. But I think it is appropriate and okay for somebody to say, “I do not want my family to experience what I myself had to experience when I was caregiving for my elderly parents with dementia.” I have heard that many, many times. I do think people who have capacity should have their autonomy respected, in terms of the values that are driving them to make this decision.

We always want to work towards improving the social support for caregiving that exists in our society. There is certainly a lack of it here in the US, and probably there in the UK as well. Hand in hand with allowing people to make an informed decision about the option of having an assisted death, you should also be a strong advocate for social support and caregiving services at the end of life, because those really are important and needed.

[Naz Shah]

Q Dr Spielvogel, there is a Bill in California, SB 1196, which was introduced on 24 February 2024. It proposes, first, to remove the six-month terminal illness prognosis and allow requests from those with a “grievous and irremediable” disease causing unbearable suffering; secondly, to allow dementia patients to request assisted suicide if two doctors deem them to have capacity; thirdly, to allow self-administration of lethal drugs via intravenous injection; and, fourthly, to eliminate the sunset clause in the current law. Do you know what the status of that Bill is? Is it still live? It suggests a significant broadening of the law, which would have similarities to that in Canada, and it would seem to reinforce the slippery slope argument.

Dr Spielvogel: That is a good question. I do not know the specific status of the Bill, but I would assume that it has itself undergone an assisted death at this point. That Bill is not really being supported by any of our advocacy groups or, by and large, the physicians who perform assisted dying, because it is, as you mentioned, very broad and not aligned with how we feel standard practice is going and where we would want it to go. That Bill did not receive support from many of us.

--- Later in debate ---

[The Chair]

Order. I am sorry; I hope this does not sound rude, Dr Kaan —regrettably, there are procedures in Parliament that require me to do this—but we have come to the end of the allotted time for the Committee to ask questions. I thank the witnesses Dr Spielvogel and Dr Kaan for your contributions and time. This was very valuable.

Thank you to our witnesses and for all the contributions, and for your forbearance on this very sensitive subject.

[Danny Kruger]

On a point of order, Mr Dowd. I wonder, given the fact that we have had so many really helpful conversations and questions but not enough time for everybody to ask everything they wanted, whether it would be appropriate for Members who want to write to witnesses to ask for follow-up information or further questions could do so through the Committee, rather than us all deluging the witnesses with our own messages, some of which will duplicate each other. I appreciate that there is a capacity question for the Clerks, but it might be appropriate to ask the Speaker for a bit more resource to enable that to happen. I think that the hon. Member for Spen Valley broadly supports the idea; I do not know if others do, as well.

[The Chair]

Let us be clear. Witnesses can submit written evidence until the Committee reports to the House. It is open to Members to individually write to witnesses and invite them to give written evidence, if they so wish. My advice to the hon. Member is that if he wishes to look at this in a more formal way or through a more formal mechanism, he is to speak to the Committee Clerks, because it is beyond my remit.

We now come to motions (a) to (d) amending the sittings resolution tabled by the Member in charge. I have selected the amendment tabled to motion (a) and will group all four motions and the amendment for debate. I will first call Kim Leadbeater to move motion (a), then Naz Shah to move the amendment. The scope of the debate is all four motions and the amendment.

Terminally Ill Adults (End of Life) Bill (Fifth sitting)

Danny Kruger Excerpts

Committee stage
Wednesday 29th January 2025 Public Bill Committees

[Kit Malthouse]

Q We have heard from earlier witnesses, particularly from other jurisdictions, that training is the key. Is it therefore your view that in guidelines, for example, specific training in this area could be effective?

Richard Robinson: We take calls from professionals all the time, and we give training all the time. Safeguarding older people requires specialist training—it is a specialist issue—and although it may not be a solution, it is certainly on the pathway. We would also like to see refresher training built in. Any kind of amendment that includes training—not just on the medical side, but for anyone involved in decision making, like the judiciary—would be a real step forward.

[Danny Kruger (East Wiltshire) (Con)]

Are we asking one question each, Mr Dowd, or may I ask two if I am quick?

[The Chair]

If you are quick.

[Danny Kruger]

Q Professor House, in Oregon, which partly inspired this Bill, I understand that there is an expectation—in fact, a requirement—that there be a psychological assessment if the assessing doctor thinks that a mental health condition, depression or other issue might be present. Do you think that that would be appropriate? Do you think that it would be a helpful safeguard to insist on a psychological evaluation?

Professor House: I do, although I do not think it is enough. Perhaps I could say a little about assessment more generally, and where that fits in.

With my background, I am familiar with meeting people who have a severe and life-limiting physical illness and say that they want to end their life. In the assessment, the starting point is trying to understand why. That can mean circumstances—external factors. Some of those have been aired during the public debate about all this. They include things like limitation of available resources, symptom control, poor housing and financial insecurity. There is also the question of the baleful influence of third parties. There are then the internal factors that we could call something like state of mind—feelings of personal worthlessness or burdensomeness, loneliness and isolation.

When we put those two together, that is what people mean when they talk about psychosocial assessment: “psycho”, the inner state, and “social”, the external circumstances. Part of it is psychological. These ideas of burdensomeness and worthlessness, for example, come very often with low mood—indeed, chronic physical pain is often exacerbated by the presence of low mood—so you would certainly wish to have a psychological component to the assessment. It goes rather beyond identifying and diagnosing mental illness, as I hope is clear from what I have said about the sorts of psychological factors you would be looking for. Does that answer your question?

[Danny Kruger]

Yes, thank you. So we need it anyway: in all cases, there should be a psychological assessment as part of the process.

Professor House: As part of the assessment, yes.

[Danny Kruger]

Q Mr Robinson, I want to come back to the question of coercion. We heard from advocates of assisted dying laws elsewhere that there is hardly any evidence of cases of coercion in this service overseas, and yet you are reporting—and we absolutely believe you, because we see evidence of it—that there is a chronic problem of elder abuse in our country. Presumably there is in every country. How do we square this? Is it that elder abuse does not apply in the context of assisted suicide in other jurisdictions, or is it just not being picked up?

Richard Robinson: I think there is a fundamental misunderstanding around what the abuse of older people is, and that has been borne out by a number of research papers that we have written, some working with YouGov, for example. Likewise, as I said, it is also a question of understanding what coercion is and getting the older person to open up, to help them to understand and to trust the person they are talking to.

We fully believe that there is nowhere near enough training and understanding across the medical profession and the judiciary around understanding the signs of abuse or coercion. Even though we completely welcome the new law on coercive control in the Domestic Abuse Act 2021, we have not seen a significant change. If anything, we as a charity believe that there is an epidemic of abuse against older people at the moment. Some of it is due to the economic climate that we are in, with people just wanting to have their inheritance now, and some of it is due to the fact that older people feel like a burden. You mentioned Oregon: of course, there is also the statistic that 48% of people who went down the assisted dying route in Oregon cited being a burden as part of their decision-making process.

I think that the abuse of older people in this country is vastly underplayed. I have mentioned the 75,000 impacts that we see and the 2.6 million people affected by it, but we have to fight for headlines and for understanding in every sector of society. It is seen as a minority issue, and it is really not. It is not a niche issue, and it is growing.

That does not mean that we as a charity are against the assisted dying Bill. If anything, we are pushing towards a safer ageing society. We would like to see a safer ageing society by 2050, and we believe that older people as a demographic should have an independent choice of what they want to do. That fits within our safer ageing society viewpoint. However, safeguarding is at the very heart of this. Until society can take the safeguarding of older people more seriously and look at training around abuse in the same way as with other forms of abuse and neglect, there is a much broader question to be asked.

[Sarah Olney (Richmond Park) (LD)]

Q Professor House, concerns have been expressed in written evidence that an assisted dying Bill of this sort is incompatible with wider policy around reducing suicide or suicide prevention measures. Do you think that it is possible to implement effective policies to reduce suicide rates, while having an assisted dying Bill at the same time?

Professor House: It is a challenging question, isn’t it? A lot of it is based on interpretation of far-from-definitive evidence. A starter would be to observe that we would have to change our national suicide prevention strategy, because at the moment it includes identifying suicidal thoughts in people with severe physical illness as something that merits intervention, and the intervention is not an intervention to help people proceed to suicide. So the answer to your question, to some extent, is “Yes, it is going to change our approach to suicide prevention.”

The wider question is whether it will change both the medical approach and society’s approach to suicide prevention in general if we start saying, “We don’t like suicide and we want to do something about it, except in some groups of people.” You may know that Professor Louis Appleby in Manchester, who leads the national confidential inquiry into suicide, is concerned about that. The best I can say on the international evidence is that there is no evidence that introducing this sort of legislation reduces what we might call unassisted suicides.

--- Later in debate ---

[Dr Tidball]

Q With respect, my question was about whether you think that, should the Bill go through Parliament, there should be some kind of body, possibly an advisory council, that disabled people in particular should be involved with. Your other point speaks to some evidence that we heard yesterday and earlier about the anchoring, where there is assisted dying in the legal system, of the quality and level of provision of palliative care. I would be grateful if you could speak to the point of my original question, which was about the need for some kind of advisory body that includes disabled people, should the Bill pass.

Baroness Falkner: Had there been a Public Bill consultation on the Bill, you would have heard from the different players that need to be consulted. We do not have an opinion on the kind of advisory body, because we would find it difficult to see where it would fit in with the provisions of this particular Bill, but a public consultation in advance of the Bill being written would have been the way to deal with that.

[Danny Kruger]

Q Dr Graham, on the points about article 14, I very much appreciate and welcome your belief in parliamentary sovereignty, and the suggestion that the courts should listen to Parliament—most of us agree with you on that—but it is a big hope. They do have the opportunity, and have demonstrated their power, to object to statute on the basis of the ECHR. As you said, they could allow assisted dying, and indeed discrimination within an assisted dying law, if there was some justification for it.

You are presumably aware of Lord Neuberger’s judgment in the Nicklinson case. He said that there was

“significantly more justification in assisting people to die”

who have long-term chronic conditions and are going to suffer for years than for people who are on the verge of death. I also point out Lord Bingham’s judgment in the Pretty case, which suggested there would be discrimination against people who are unable to perform the final act themselves. Surely, then, there is a very strong case to be made under the ECHR that the Bill would be discriminatory. I would value your response on that, and maybe from Lord Sumption too, if he wants to come in.

My second question is to you both, on article 2. If it were to be allowed, the safeguards that would be required —I shall quote from the Mortier case, which you know well—would be that

“medical professionals are complying with the free, informed, explicit and unambiguous decision of their patients”

without pressure and abuse. Do you therefore accept that this comes down not just to the safeguards in theory, but to how they actually operate in practice? We have heard very serious concerns on that front. Are you confident that the courts would allow this? That is, of course, assuming this is an NHS service, because it could be that they decide it should not be.

Dr Graham: The takeaway message from cases like Nicklinson and others, both at the domestic level and the European level, is that this is a decision for politicians and a decision for Parliament—you mentioned the sovereignty of Parliament—regardless of what Lord Bingham and Lord Neuberger might think personally about or, I suppose, obiter about the relationship between discrimination law and the provisions that were looked at in those cases. For the reasons that I set out earlier, on the justification question, judges in our jurisdiction are heavily deferential towards the decision of our elected Parliament. In any future challenge, and there probably will be a challenge—we do not know, but there is nothing to stop someone from bringing one—the courts will adopt the same line of thinking.

I agree with you completely that the theory and the practice must both be taken into account when assessing whether there are adequate safeguards for the purpose of article 2. All I want to note is that in the Mortier case, which you mentioned—in which the Belgian legislation and its compatibility with article 2 were challenged before the Strasbourg Court—the Court found that there were sufficient safeguards in that legislation. That is despite the fact that if we put the Belgian legislation that the Court was looking at and this piece of legislation side by side, this legislation contains, at least in theory, more and stronger safeguards.

The Belgian legislation did not have a waiting period; did not require judicial approval; was not restricted to a terminal illness; and was not restricted to adults only. Yet the European Court said that there were sufficient safeguards for the purposes of article 2. At least from a precedent-based perspective, I think there is a strong argument for saying yes, the Bill complies with both article 14 and with article 2.

Lord Sumption: I have read Dr Graham’s evidence, and obviously have listened to him this afternoon. I agree with it in its entirety. Dr Graham points out the additional layer of safeguarding in the form of clause 12, but I do not understand him to be suggesting that without clause 12 the Act, if the Bill became an Act, would be defective on human rights grounds.

I also agree with Dr Graham on the question of the likely approach of the courts. The courts would be dealing with legislation that reflected a balance between two very powerful but contradictory moral instincts, both of them fundamental to our legal and social culture. That is not a context in which the courts are going to feel that they ought to be putting their own oar in.

I would also point out that, since the Nicklinson case, there have been a number of decisions of the Supreme Court—two in particular: the Shamima Begum case and the Child Poverty Action Group case on the two-child limit—in which the Supreme Court has expressly said that in issues of this kind, the courts should not devise policies of their own, independent of policies that can be discerned in parliamentary legislation. It is therefore even less likely now that the courts would intervene on human rights grounds than it was at the time of Nicklinson.

[Tom Gordon]

Q My questions are to Dr Graham and Lord Sumption. The Bill, in its current form, has several opportunities for confirming capacity and whether the people who want to take up assisted dying have the capacity to do so; there are a number of safeguards and steps within it. That is more than is typically required for any other end-of-life decisions. I wondered whether you would comment on that. Is the Bill safe enough in its current form? If not, what other steps could be added?

Dr Graham: The only thing I would feel comfortable saying is that, yes, I agree with you that the Bill does contain further safeguards, more safeguards, than some of the other legislation in European countries. The legislation in those countries has been held to be compatible with the right to life and with other rights under the European convention. From a pure human rights perspective, which is all I feel qualified to comment on, I think you are on very safe ground.

Lord Sumption: I take exactly the same view. We must all be conscious of the fact that coercion, even when it is overtly applied, is extraordinarily difficult to detect: the kind that Baroness Falkner described a few moments ago as the subtle pressures that old and disabled people—in fact, people who are very sick generally—will feel without the need for any pressure. That spontaneous feeling of pressure is, I would have thought, practically impossible to detect. We have to live with the limitations of what human beings can do. In the end, I have come down in favour of the principle behind the Bill, but I regard it as an extremely difficult balance to draw—notably, for that reason.

--- Later in debate ---

[The Chair]

This will be the last question for today.

[Danny Kruger]

Q Okay, very quickly, from what we have heard from you today, it is clear that the interface of assisted suicide, palliative care and NHS care generally in social care and hospices is really problematic and complicated. If we are going to do this, should we not just take it out of healthcare altogether? Would you not feel safer and happier if this was something done in independent clinics and not part of hospice care or the NHS, so that GPs would not have to recommend it?

Toby Porter: There are certainly many people on hospice boards and in hospice leadership and medical teams who will find it very overwhelming to deal with the complexity of exactly how they position themselves and their service. They would be balancing obligations towards a community who might be in favour with the duty of care towards a clinical workforce who might be against, because of the risks that I spelled out. Obviously one choice facing members is that you remove it from the health and care system, and therefore those operational dilemmas are removed from individual institutions. Then the onus is on you to define how a service that would sit outside the national health system would operate.

But I think it is important to counter that by saying that hospices evolved out of the community. They exist because communities wanted better deaths. In the end, it is the job of institutions to evolve to fit the values and laws of society as they evolve, rather than vice versa. If, as Professor Whitty said yesterday, it is the will of society, expressed through yourselves, that this change takes place and is delivered as part of the health and social care system, then I have no doubt that the wonderful resources that exist in the governance and staffing of the hospice sector will be deployed to find a way that tries to mitigate those risks and do their best for their supporters, and in particular patients and staff.

[The Chair]

That brings us to the end of the time allotted for the Committee to ask questions. I would like to thank our witnesses on behalf of the Committee for their evidence. Witnesses can, if they want, follow up in writing. We are more than happy to hear anything else they have to say.

Ordered, That further consideration be now adjourned. —(Kit Malthouse.)

Terminally Ill Adults (End of Life) Bill (Fourth sitting)

Danny Kruger Excerpts

Committee stage
Wednesday 29th January 2025 Public Bill Committees

[Stephen Kinnock]

Thank you very much for that very comprehensive answer. Is there anything that our other guests would like to add?

Dr Mewett: As I was on the very first implementation taskforce, running blind, I probably could not add much more, except to say that it can be done. One has to focus on the readiness of practitioners, the readiness of health services, the readiness of the population and a whole range of other issues, including the pharmacy service. We have a state-wide care navigator service, which assists patients and doctors in the space. We had to set up a lot of services, and that gave us the time to do so. It was very successful and very challenging, but fortunately we did not have covid in our way.

[Danny Kruger (East Wiltshire) (Con)]

Q I am very grateful for your evidence; it is really useful. I want to state, for the record and for information, that we have before us today three professionals from Australia, all of whom support the laws in that country, and that we heard yesterday from two American doctors, who were also supportive of assisted suicide laws, even though in both countries there are many doctors who oppose what is happening. I regret that we are not hearing evidence from them, but it is very helpful to have your input.

Dr Fellingham, I was interested in your point about the distinction between the Australian model and the model in Canada and elsewhere. You are suggesting that most people who seek assisted death do so for what I think you called “existential reasons”. It is certainly not because of an absence of care, although we do see evidence of that in many countries. Can you expand on why you think it is so important that we have the terminally ill definition in the Bill, rather than recognising pain and suffering as the reason for seeking assisted dying, when I think most of the public who support a change in the law do so because they recognise that many people would naturally want to avoid pain and suffering? Yesterday, we heard from people who said that that is the right reason and that we should write that into the law. Why should we not do that?

Dr Fellingham: That is a very good question and I am grateful that you have asked it. We absolutely have to keep at front and centre that pain and suffering are primary drivers for people seeking access to relief of suffering, whether that is at the end of life or in any interaction that they have with healthcare providers. I speak to remind you that these laws apply to terminally ill people, because I feel that that is a lot easier for us to understand and get our heads around, but it does not detract from the fact that suffering can be a feature of non-terminal illnesses. There are people who can suffer terribly for very long periods of time—dementia being a clear example, but one that would be incredibly challenging to legislate for at this early stage.

What is interesting about the parallels you draw between pain and suffering is that it is a quite common conception that pain is suffering and suffering is pain, and that people seek access to relief of suffering at the end of life because it is the physical symptoms that are the most debilitating. Of course, the physical symptoms can be horrendous—pain, nausea, vomiting, anorexia; there are a multitude—but they are symptoms that we tend to be really quite good at treating. We have a whole range of medications in our palliative care spectrum that are very good at treating those physical symptoms, so it is quite rare that people prioritise those when thinking about this.

But suffering is subjective and it is context-dependent. What suffering is to me might be completely different from what it is to you, even if we are suffering from what looks to be, from the outside, the same disease. Suffering and distress—the thing that makes us human: the existential overlay of our own interaction with the world and how that is impacted by our disease process—is an incredibly personal journey and one that is extremely challenging to palliate, and it is very, very distressing for patients, their families and their practitioners if we cannot support people who are suffering at the end of life. Does that answer your question?

[Danny Kruger]

Q It does, very helpfully. Can I come back to you quickly? You point out that to suffer is essentially a subjective experience, so it is very difficult for somebody from the outside to determine whether somebody else is suffering to a certain threshold. By that reasoning, it should simply be the case that people who feel that they are suffering intolerably should be eligible. Why do you not think that that is what we should have in the law?

Dr Fellingham: In our law, in Western Australia, one of our eligibility criteria is that a person is suffering intolerably, in a manner that they consider intolerable, and that we have taken all reasonable steps to alleviate. The important thing about suffering is that it is a personal experience. It is not mine to judge as a clinician; it is mine to delicately and expertly tease out of a patient and to attempt to mitigate and treat to the best of my ability. Yes, suffering absolutely is what the patient says it is, and these laws are designed to honour individual patients who are dying. They are not designed for us as practitioners or clinicians looking in from the outside; they are designed to be supportive of an individual patient’s illness journey, and only they can know what the experience of that is.

Dr McLaren: It is a very good question, Mr Kruger. I think one of the distinctions is where the point of hope is and where the point of no return may be for that suffering. If you were to say that patients or people may apply for this or self-confess suffering in the absence of an end-of-life condition, that leads to questions about whether it applies to a 21-year-old with a decompensated mood disorder that could be treated or improved. When we are talking about patients within the last six months of their life, that suffering is very hard to come back from in the time that is given to them. It is about that recognition of the point of difference between hope for the future and a different type of hope—hope for improvement in symptoms or control of the situation, but not for physical improvement or a return to normal function or living. That is the real difference between legislating purely on the basis of suffering, versus in the context of suffering that will not get significantly better.

The point is that the line must be drawn somewhere. We have seen patients who have been ineligible under our laws where we have found immense suffering, and that is a difficult space to navigate in its own right, but those cases are going to happen regardless of where the line is drawn, and it needs to be in a place where people are comfortable to navigate on one side or the other. That is where the clinical education comes into the process, in terms of how we best manage that, recognise the suffering in the individual, try to make things better and work hand in hand with palliative care and other colleagues to try to improve symptoms for the patients who are not eligible under these laws.

Dr Mewett: As a palliative care physician, I spend all my professional life addressing people’s suffering in the context of an advanced, progressing, incurable illness. Palliative care, of course, approaches that from a range of different angles. I see VAD—assisted dying, voluntary —as an end-of-life choice among a range of end-of-life choices that people may or may not make. A minority of our patients will take that choice and have some control. They require and should have excellent palliative care up to the time that they die, whichever way they decide to die.

I think we should understand that despite the best palliative care in the world, there are still patients who suffer uncontrollably, unremittingly and intolerably. I believe that it is that small minority of patients who should have a legal option to take control of that stage when it is irreparable. It is not incompatible with palliative care; it is part of palliative care and an end-of-life choice, and not the philosophy of care that palliative care is.

--- Later in debate ---

[Kim Leadbeater]

Q Thank you for coming to give evidence this morning—it is incredibly helpful. I am going to come back to clause 2 of the Bill, which concerns the definition of terminal illness. I am very clear on who the Bill is aimed at helping and who it is not aimed at involving. The definition says that the person has to have

“an inevitably progressive illness, disease or medical condition which cannot be reversed by treatment”.

It also says, for the avoidance of doubt, that this cannot be “a mental disorder” or “a disability”. I hear your concerns, and I want to support you and work with you on this. I am keen to know: what else do you want to see in the Bill that would reassure you that this is not about disabled people or people with mental disorders?

Dr Griffiths: I am conscious of time, so I will be very quick. My first point would be, why would you stick it at six months then? Why not have it at seven days, for example, as a way to take out our concerns? If you are talking about prognosis, let us go back to Chelsea’s point and the point that I made before. My condition is a neuromuscular condition. I have had meetings with clinicians where some have referred to it as a terminal illness, some have referred to it as a life-limiting condition, and others have referred to it as a progressive condition. The articulation of the ideas and the ways in which we think about conditions show the complexity of the issue. We are talking about terminal illness, and people who are terminally ill do constitute disabled people under the Equality Act, so you cannot make the distinction.

If you want to be quite proactive about it, then why not reduce the prognosis timeframe and make it as short as possible to take out the concerns about prognosis, and the concerns around whether individuals are going to live longer or could be facilitated access to alternative treatments to prolong life? I do not understand why we are fixated on a six-month prognosis because, as we have seen in other countries, as soon as you pass the legislation on six months, you will have individuals who say, “Why not seven months? Why not five months?” You will have campaigners who will say, “This does not include me and I have been campaigning for this.” There will be pressure to change and Governments will change. There is no guarantee that you can make that the eligibility criteria will be fixed.

[Danny Kruger]

Q I want to give Professor Shakespeare the chance to respond to the point that we have heard. I am interested in whether you recognise that many disabled people—in fact, not just disabled people, but anybody who declines treatment that keeps them alive—would qualify as terminally ill under the terms of the Bill? What protections we could give to prevent that?

Professor Shakespeare: First of all, a terminal illness is defined as a “condition which cannot be reversed by treatment” I know that that does not mean a cure; you are not aiming at a cure—but it says, “cannot be reversed”. Surely that would not include things like HIV and diabetes because they can be reversed. They cannot be cured; they are still there, but they can be reversed with insulin, antiretrovirals or whatever.

I think, yes, terminally ill people are disabled people almost always, but that does not mean that all disabled people are terminally ill. Even if you have a disease or a condition—like Miro does or like other people do—that will probably result in your death eventually, you are not going to die tomorrow or in six months. You may die in 16 years or whatever. It is very difficult to define terminal illness, and that is why six months, I think, is used in this Bill.

Very recently, my aunt died. She was unconscious for the last month or so of having cancer and then she finally died. She would not have been able to express her will and her preference to have assisted dying, even if she wanted it. Therefore, I think six months when you can have capacity, you can anticipate, you know you are going to die but you want to have control in the manner of your death, is more useful than seven days or less, when you might be unconscious and you might not be able to express a will or preference.

[The Chair]

I call Simon Opher.

Terminally Ill Adults (End of Life) Bill (Sixth sitting)

Danny Kruger Excerpts

Committee stage
Thursday 30th January 2025 Public Bill Committees

[Dr Neil Shastri-Hurst (Solihull West and Shirley) (Con)]

Q I will direct this question initially to Mr Greenwich. The issue of coercion has been a significant concern to many in the debate. In line with the New South Wales legislation, the Bill as proposed does not provide a definition of coercion, either explicitly or by reference to other legislation. Have you found that to pose a difficulty in your jurisdiction?

Alex Greenwich: In New South Wales, our legislation deals with and goes through coercion in quite some detail, with pathways to assess it. It deals specifically, for example, with a situation in which someone is under coercion from a person who is a beneficiary of their will; obviously, the person seeking voluntary assisted dying then becomes ineligible. In the space of coercion, that is a key part of the training for a doctor who will be a consulting or co-ordinating practitioner. We have made it a criminal offence in New South Wales, and indeed our board will report on it and on whether eligibility for access to voluntary assisted dying has been denied to someone. Our most recent report indicates that it has.

The overwhelming experience is that having voluntary assisted dying in place is itself a safeguard from coercion for people with a terminal illness. If someone wants to end their life quickly, voluntary assisted dying through a regulated process is not the option that they are going to take. Someone engaging in voluntary assisted dying will be assessed against coercion and against decision-making capacity, and will have to make sure it is an enduring decision.

When we talk about coercion, and the concern that people may currently have in the UK about people with a terminal illness feeling in any way coerced, the experience in New South Wales and elsewhere in Australia is that voluntary assisted dying has provided a safeguard in that regard. Our legislation, the training and the reporting is very clear on that.

[Danny Kruger (East Wiltshire) (Con)]

Q Can I have one minute with Dr Furst and one minute with Mr Greenwich? Dr Furst, I have had a look at the reports of the South Australia Voluntary Assisted Dying Review Board, and I can find no data on referrals for additional assessments of eligibility or decision-making capacity, or reasons why people were considered ineligible. There is no provision for reporting on complications, the time between the administration of the drugs and loss of consciousness, or the time between the administration of the drugs and death, and as we have heard there is no requirement for a doctor to be present. I do not understand how you can say that there is no evidence of coercion, issues around capacity or complications at the death, because you clearly do not collect the evidence on those things.

Dr Furst: I do not think that is the case. We are seeking out from relatives—within a month, normally—around any complications. As I said, we are also informally speaking to the nurse practitioners who are on site, but I do not think that that has been published as part of our state report. In terms of coercion, I would say that it is much more likely that patients are being coerced into invasive and intensive treatments, like cancer treatments such as chemotherapy, than being coerced into voluntary assisted dying.

[Danny Kruger]

Q Okay. Thank you very much for that.

Mr Greenwich, you said a couple of things. You said that voluntary assisted dying supports palliative care in terms of funding. I read that although New South Wales committed to spending an extra 743 million Australian dollars on palliative care, in fact the budget was cut by 249 million Australian dollars in 2023; at the same time, New South Wales allocated 97 million Australian dollars in new funding to assisted dying. I do not understand how you think that palliative care benefited from this introduction.

You talked about suicide prevention. The fact is that unassisted suicide rises in states that have assisted suicide laws, because suicide is contagious. It is too early to tell what is happening in New South Wales, but in recent years in Victoria unassisted suicide rose by 50%, while in New South Wales, before it had this law, it stayed the same. Again, I do not understand how you think that this helps with suicide.

We have just heard about the so-called safeguards and we heard yesterday from Australian colleagues. Do you agree that the safeguards that were introduced were in fact impediments to access and that it would be the right thing to do to remove them?

Alex Greenwich: I will try in the time to answer all three of those questions and I am happy to provide more information on notice as well.

On the palliative care funding, it is accurate that New South Wales had a record boost in palliative care funding. Not all of that could be expended as the workforce was being trained up, but that commitment from all sides of our Parliament is there. You can always seek to improve palliative care funding; that in no way should be competing at all with voluntary assisted dying.

When it comes to the question of suicide, as I addressed in my opening statement, voluntary assisted dying is a form of suicide prevention. If someone wishes to end their life, voluntary assisted dying is not the process they are going to take. It is a process that provides a safeguard to ensure that people are getting full information on palliative care and getting social supports.

In terms of the safeguards in our legislation and being proposed in your legislation, it is really important that you have in your head and in your heart the experience of a person with a terminal illness who is going to have a cruel and painful death. We are talking about people who are dying and who want to have a death better than their terminal illness would otherwise provide them with. We are talking about a small cohort to whom we in New South Wales sought to give peace, dignity and control. We are really proud that we did.

[The Chair]

I remind colleagues to stay within scope of the Bill, please.

Terminally Ill Adults (End of Life) Bill (Seventh sitting)

Danny Kruger Excerpts

Committee stage
Thursday 30th January 2025 Public Bill Committees

[The Chair]

It is one question, one answer. I call Danny Kruger.

[Danny Kruger (East Wiltshire) (Con)]

Q Professor Hoyano, what do you think about the indemnity against civil liability in the Bill? Do you think it is appropriate to indemnify all doctors, even if they have made a woefully bad diagnosis, botched a prescription or, in some cases, actually caused some harm? Do you think it is appropriate that they be excluded from civil liability?

Professor Hoyano: I always have a problem when tort liability is ruled out by legislation. I think that the accountability of medical professionals, and indeed all medical practitioners in private practice, lies at the heart of how our national health service works, so I have a difficulty with that. I would have to ask Ms Leadbeater whether this is correct, but perhaps the intention was to ensure that members of the family who, for example, were against assisted dying in principle, would not be able to bring an action that could be vexatious against a doctor who had complied with the legislation and should therefore not be troubled with that type of litigation. It might be that that provision could be refined.

[Lewis Atkinson (Sunderland Central) (Lab)]

Q Professor Hoyano, the Bill would establish offences relating to coercion, pressure and so on. In the processes set out, there are a number of checkpoints, for want of a better term, at which a person seeking assisted dying may talk to doctors or others. What are your observations on how the criminal construct of offences is linked to the different opportunities for an individual seeking assisted dying to have conversations? In your view, is it likely to lead to the identification of those offences? How does that contrast with some of the considerations at the moment, where people are withdrawing treatment in a life or death situation, for example?

Professor Hoyano: It is interesting that a number of Members of Parliament who are practising physicians pointed out in the debate that they have to evaluate freedom of decision making and absence of coercion in many different medical contexts. I point particularly to the withdrawal of medical treatment at the request of the patient, even if that will inevitably lead to death. It is considered to be a fundamental human right that lies at the heart of medical law that a patient has personal autonomy to decide what to do with their body and whether or not to accept medical treatment, provided that they have the capacity to do so and are acting without coercion from external sources. Doctors have to make those assessments all the time.

I suggest that it is perhaps a convenient fallacy to say that pulling the plug on a respirator or stopping artificial nutrition and hydration is a negative act, whereas giving a patient a syringe to end their own life is a positive act. I realise that with the Tony Bland case it was convenient to say that, but there is no doubt that most people on the street would say that pulling the plug on a respirator is a positive act, and yet doctors and nurses are required to do that every day in the NHS, because that is the patient’s autonomy. If there is any question about either coercion or capacity, the Court of Protection steps in and has the jurisdiction to make those decisions.

The Court of Protection should, I believe, be the court that is supervising this, not the High Court. Three levels of judges sit in the Court of Protection; I suggest that a High Court judge be specified, which would mean a statutory amendment to extend the jurisdiction of the Court of Protection. The Court of Protection makes decisions every day on whether a patient has the mental capacity to make decisions about their own medical treatment. It is accustomed to doing that, and one aspect of that analysis is whether the patient is being coerced externally.

Generally speaking, when a patient says, “I don’t want to be on a respirator any longer; I know I’m going to die,” we do not ask questions. As I understand it, it is not part of the protocol to say, “Are you doing this because you are worried about being a burden on the NHS?”, because their personal autonomy is the overriding principle governing medical decision making in relation to the patient. I hope that that answers your question.

--- Later in debate ---

[The Chair]

Time allows us to ask more questions. Three people have indicated that they wish to come in. I will start with Danny Kruger.

[Danny Kruger]

Q It is great to hear about the case for common law over the Human Rights Act. Yesterday we heard about parliamentary sovereignty. This is a tremendous process we are having here.

Professor Hoyano said that the person in the street would not see the difference between a patient requesting to die by the withdrawal of treatment versus the active administration of fatal drugs, whereas I think you said, Professor Owen, that you did see a profound difference between that decision on the part of the patient and also, presumably, the act on the part of the medical professional, in the case of either the withdrawal of treatment or the administration of fatal medication. You said that you would be happy to draw that out; could you do so?

Professor Owen: Yes. I am happy to try now, but also to do it further with some written submissions if that would be helpful, because it is such an important point. First, for the man on the street, or the person on the bus, one thing to remember—this comes out in the public opinion polling—is that when you ask about assisted dying, some people think that that is access to palliative care. There is a degree of misconceptions that are out there in the public that are important to bear in mind.

On the distinction between the decision around the refusal of life-sustaining treatment and the decision regarding assisted dying, what are the similarities? Well, they are both about life and death. What are the differences? One is a refusal; one is a request. One is traditionally considered to be about bodily integrity—it is the so-called shield of the person, or the patient, against the intervention on the body that is being made by the medical profession. You are giving the patient an important right, which is a shield-like right. That contrasts with a request for assisted dying, which is a request. You are involving other people in an act that is an act of ending one’s life. That is not something that the medical profession has been comfortable with, going back thousands of years.

So you can discern a number of differences. Could you reduce those differences to one thing and one thing only, and be particularly precise about it? Probably not. I think you are talking about differences that cluster and group, and which we overall accept as a difference of kind.

The other issue here that is important is intention. When you are assessing somebody’s decision to refuse a life-sustaining treatment, the doctor there does not have the intention to end a person’s life. That would be a concerning intention were it there—and sometimes it is looked for, actually, if it is disputed. But of course, when a doctor is involved with a process where somebody is seeking assistance in the ending of their life, it is quite difficult to say that the doctor does not have an intention to end life.

One could go on with a discussion of the differences, but the similarity is that we are talking about life and death.

[Kim Leadbeater]

Q This has been an incredibly helpful panel, so thank you for all your expertise.

Let me come back to the content of the Bill, and to some of your points, Professor Owen. In terms of capacity and coercion, I think we are absolutely having these really important conversations. What concerns me a little bit, though, is whether we are saying we are not confident that two doctors, potentially a psychiatrist and an oncologist, and a judge can make assessments of capacity and coercion between them. What does that mean for things that are happening at the moment? We have talked about the withdrawal of end of life treatment and those things; those assessments must be being done now, all the time, but at the moment there is no legal framework around that. Surely, putting a legal framework around that and having all those multidisciplinary people involved has got to be a positive thing. Professor Hoyano, I would appreciate your thoughts on that.

Professor Hoyano: As I say, whereas I completely respect Professor Owen’s expertise in this as a psychiatrist, for me as a lawyer the question of capacity is a yes or no, necessarily. But capacity is always determined by the Court of Protection in respect of the decision that must be made by the person concerned: do they have the capacity to do it?

When we are talking about a determination of capacity, and also about coercion—which of course is part of capacity in a sense, because capacity is the autonomy of decision making—you are going to be having a very focused inquiry. It is not an inquiry into whether a person has capacity to manage their financial affairs. I probably do not have that capacity, but on something like this I would have capacity. It is important to recognise that it is a yes or no question, which the law has to draw and does draw, depending on the expertise of psychiatrists like Professor Owen, but also forming its own judgment from its own experience, which is why I think the Court of Protection really is the place where this should be.

There is one aspect of the Bill that worries me a lot, and that is the number of people who will be excluded by the provision that the medication must be self-administered. This would mean that Tony Nicklinson, who went all the way to the House of Lords to try to get the right to die, could not have it under this Bill, because he was paralysed. He was a tetraplegic, basically—he was paralysed from the neck down, with limited movement of his head, from a stroke. He lived for seven years with that condition and he would not have been able to self-administer. In fact, when he was denied by the House of Lords—anyone who has seen the Channel 4 programme will have watched him wail in despair—he refused all nutrition and hydration from that point until he died. That was the death he did not want, and I think we need to recognise that there are problems like that. In 2023 in Canada, across the entire country, only five patients opted to self-administer the medication—only five. Even when patients were capable of doing it, they wanted the doctor to do it instead, so let us remember that as well, please.

Dr Ward: Can I make a quick point about self-administration? This is something that in Scotland we looked into in great detail. In Scotland, we chose self-administration specifically because it does not just include ingestion or swallowing. There is a range of ways in which you can self-administer the medication, and I am happy to provide that information to the Committee if that would be helpful.

--- Later in debate ---

[Lewis Atkinson]

Q Dr Richards, in the light of your research, could you say a little bit more about the weight that individuals dying place on the importance of autonomy and how that is weighed up against other considerations around safeguarding and so on?

Dr Richards: There are two things that I would like to say about this. The first is that it is individually specific, which probably will not come as a shock to you. The evidence shows that the people who request assisted dying are people who have a particular preference for control in their life, and they have had this preference across their life, so it is part of their identity. In that sense, it is a personal preference as opposed to a deficit in palliative care, which is what we hear a lot about.

The second thing is that, with regards to autonomy, proponents of assisted dying are very keen to emphasise that this is an autonomous decision, which it is, and would have to be by virtue of the law. However, that does not mean that families, loved ones and close social relations are not really embedded in that decision making. It is important to think of autonomy as relational rather than as an isolated making a decision not in relation to others. It is also important to think about the impacts on the family when you are thinking about the guidelines that would go along with any legislation.

[Danny Kruger]

Q This is a question for Claire Williams. It was interesting that you said you were not aware of what drugs might be used in assisted dying. We obviously do not yet know what will be proposed here if we pass this law. There are lots of different combinations of drugs used in other jurisdictions, and we do not know much about them. I think that is fair to say.

What we do know is that there is a combination. In two thirds of deaths in Belgium, I think, and in the United States, where I have visited, the first drug that is used is an anaesthetic, and then there is a paralysing agent. A paralytic drug is introduced, which often gives the impression that the patient is having a peaceful death, but we do not actually know what is going on beneath the surface. I am afraid to say that, from studies into people who have been on death row who have been legally executed, there is often evidence of brain trauma. Can you speak to this at all? We know that in a minority of cases real complications occur—it often takes a very long time for the patient to die, and there is vomiting and all sorts of distress. How can we improve what we know about the actual process of dying, and how can we reduce these terrible complications?

Claire Williams: I can only apologise, because I am here to give evidence about a model for collective decision making rather than about my experience with regard to these drugs. As you say, the potential side effects and prolonged deaths are something we will need to consider for these cases. We need to take evidence from other countries that have had this experiences. Apologies, but I cannot comment on this particular aspect.

[Kit Malthouse]

Q My question is to Dr Richards. Obviously health service medics are dealing with end-of-life situations at the moment—they are withdrawing treatment or declining to give treatment if they think it is futile. In those circumstances there are a set of safeguards. How do those safeguards compare with the safeguards in the Bill? From your research, do you think there is any adjustment required to the safeguards we have at the moment?

Dr Richards: Assisted dying is quite categorically different from the end-of-life scenarios you are talking about there, so you would expect a very different set of safeguards. It is a misunderstanding to think that assisted dying is of a piece with other life-ending decisions. It is really something quite different and requires a different framework.

--- Later in debate ---

[The Chair]

Order. One question, one answer. I call Danny Kruger.

[Danny Kruger]

Q Professor Preston, I wonder what you think about this idea of a panel instead of the High Court judge. A lot of Members who voted for the Bill on Second Reading did so partly on the basis that there would be that judicial stage. Although we can all recognise the value of having more expertise involved, the role of the judge is essentially adversarial in principle, and the public would expect it to be. They would be hearing arguments and taking evidence. Do you think that the Bill would be safe without that? Secondly, do you not agree that, as we heard earlier from a law professor, the right of appeal should be in both directions? There should be the right of appeal against an approval as well as against a denial?

Professor Preston: I think we suggested a panel. I submitted some evidence after the last Select Committee inquiry about a panel that could operate outside. Lots of the reasons I gave were about helping to navigate, helping to identify doctors and helping to support people who feel vulnerable within the NHS.

What increasingly came out from the idea of a judge is the question of what exactly their role is and the fact that there is no right of appeal. However, if you had a panel, that would give a much more thorough understanding of what is happening. The additional safeguard is that the panel could say there needs to be a palliative care consultation. You would have to be sure the doctors who are doing it are, based on their register, qualified to have a palliative care conversation so that all options have been explored.

My fear is about if we do not specify what training is or what these people’s expertise is. Most doctors do not know too much about palliative care or what the options are. You do not need to see a palliative care doctor, as a palliative care nurse can talk you through it, but the additional power of that panel is that it could be answerable to the court or some other sort of assisted dying tribunal.

[Lewis Atkinson]

Q I have a question for Dr Richards. I note from your biography that you have done work studying the phenomenon of old age rational suicide. I noted your comments before about research suggesting that people who seek assisted death have got particular, strong preferences for control and agency at the end of life. We know there are around 650 people with terminal illnesses who take their own lives every year at the moment. I wonder, particularly given your work on old age suicide, what would be your assessment on how assisted dying becoming an option here in the UK might affect those statistics.

Dr Richards: The Bill covers terminal illness only. It includes people with six months left to live, so it would not include the phenomenon of old age rational suicide, which is where you want to end your own life for reasons of the accumulated losses of old age, or because you feel you have lived a completed life. This really relates to people who are in what is called the fourth age of life. It is a social and cultural phenomenon that there are people in the fourth age of life who want to wrap things up on their own terms, but this is a separate phenomenon to people who are in a natural dying phase of life and want to accelerate that. It is different.

After you legalise assisted dying for terminally ill people, you will still get older people taking their own life. The highest demographic for completed suicides is people over the age of 70. It is a phenomenon around the world, but it is a qualitatively different phenomenon to people in a natural dying phase. If we look at the data on who requests assisted dying, it is people who want control and agency, and they may even have thought about it as a mode of dying that they want to access before they even had a terminal illness. They might have always imagined that, but that is in conjunction with various forms of suffering that they will be experiencing. It is not just personal preference; they are also suffering, and suffering is very multi-faceted and multi-dimensional at end of life. It has various different components, not just physical.

--- Later in debate ---

[Rachel Hopkins]

Q Thank you all for sharing your family stories today. It is really moving. Julie, I want to ask about your experience in Spain and how you found that particular process in comparison with what we have in the Bill. How did it work? What was positive or difficult for you?

Julie Thienpont: Guido had decided right from the word go, even before he got sick, that that was the way he would want to end his life, if there was a possibility of it. He was from Belgium originally, so he expressed a wish that if ever he needed it, he would like to go back there.

The law in Spain is very similar to the Bill, which I have read through countless times. There are a lot of similarities. There were very rigorous checks. It involved much paperwork, counselling and family liaison. The difference was that it went before a board, so it was a panel that would allow or not allow the decision—it was not decided in a court. That would be the main difference, but the process was rigorous. It was slightly difficult for me, because although I can speak Spanish, the terminology was frequently more difficult, so they very kindly translated for me. They explained everything: what would happen and how it would happen, if it happened. It was a big celebration for Guy when he was actually granted this. They also told us that he could change his mind after he had made the decision, should he wish to. He did once. It was me who asked him to do that, because I did not feel he was sick enough, which sounds a bit silly, I know.

He was an intensely private person. The palliative care in the part of Spain where we were is excellent, but it was quite irrelevant for him because he had already expressed that he wanted to die at home. We lived up a mountain; we were quite remote. Being such a private person, he never wanted to be in a situation where somebody else had to see him in any vulnerable situations, especially with personal hygiene and so on—even me, although I was able to help him in many ways. I had to do a lot of procedures for him, after being trained to do so, but he was more than happy with the situation of having assisted dying once it was granted. He did not need any other sort of care, although we still had a nurse coming every few days and the family doctor came up at least once a week. That does not sound much, but he did not want her any more often than that.

[Danny Kruger]

Q This is a question for Mr Malone. May I say how greatly I sympathise with what you have been through? I am very sorry to be fighting against you in this matter. I really can imagine how that feels. Thank you for what you said. I just want to ask about your sister’s experience. On the eligibility question, is it your belief that she would have qualified for an assisted death under the Bill, with the six-month terminal illness criterion? To follow up on that, do you think we should expand the scope to include people with motor neurone disease who might not fall within the six months?

Pat Malone: She would not qualify, because there was no telling how long she would live as a live brain in a dead body, as she said. It could have been months or even years, so she would not qualify in any case under this Bill. However, you have moved mountains to get to this point, so the last thing in the world I want to do is pile more requirements on the Bill. I would like to see some stuff stripped out of it, actually, to make it easier, but I am not going to ask for that because we desperately need to get away from the status quo. This Bill gets us away from the status quo.

[Naz Shah]

Q Thank you very much for coming today and sharing your stories. I have two questions. Julie, you said that you had family liaison and counselling. How long did that go on for? This Bill does not have that requirement, so do you think it is something that we should put in it?

Julie Thienpont: Maybe I said “counselling”, but it was not a session of counselling. It was somebody asking my opinion to check that I was 100% behind Guy. His son also did that by proxy—via us—because he was in a different part of Spain. They wanted to ensure that he had talked it over with family members. It was not hastened along, because he had been given a short life span, so it did not take terribly long. He had to wait about three weeks before the initial ball started rolling, and then two weeks later a family doctor and nurses from the hospital came round for form filling, reading through, translating and signatures, and again another two weeks after that. Each time, I believe it went before a panel. We did not, but the paperwork had to go before a panel. They were left in no uncertain terms that that was the way he wanted to end his life.

It was a very peaceful, serene and beautiful death, as opposed to what it would have been like. He was able to speak to his relatives in Australia, his brothers in Belgium and other family members, and I was able to hold his hand. Guy had always been a bit of an old cowboy, and he always said that he wanted to die with his boots on. I am proud to say that that is what he did. At the end, we were holding hands, and I said to him, “Don’t be afraid.” He said, “I’m not afraid,” and he winked at me just before he closed his eyes.

On the process, perhaps I should have said that it was intravenous, so he had a drip in each arm. It was quite a quick process—maybe 10 to 15 minutes, which I thought was quite quick—but we had had lots of time that morning, you know. It was a beautiful end—the wink especially. I am left with very good memories of such a peaceful death, which was going to happen regardless. He was at peace with it, so that helped me.

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[The Chair]

As we have time, I call Danny Kruger.

[Danny Kruger]

Q Following straight on from that, do you imagine it to be an NHS-funded service if it is outside core general practice? If so, what might the implications be for resourcing, assuming that it was funded out of general NHS resources? In the practical terms of the Bill, what do you think of the provision that the co-ordinating doctor must remain present with the person until they die, bearing in mind that that might take some hours? I am interested in your view on the implications for resourcing the service.

Dr Mulholland: Fortunately, that is not the RCGP’s bit, but I think we would be very much concerned. In our principles, we were clear that we thought that there should be no reduction in core services in general practice, nor should there be any reduction, if the Bill goes through, in funding to palliative care services, which we know are often struggling as well. This should therefore be additionally funded. Whether it occurs in the NHS is not our decision, but we would be very concerned about health inequalities creeping into any part of the health service. We are aware of the differential that occurs in lots of things—life expectancy has come out again in recent reports between different parts of the country and people who live with different levels of poverty. If the Bill comes through, we will want to make sure that there is not a differential in who is able to access it. Whether that says that it should be NHS or private I am not sure, but that needs to be considered as part of whatever comes out of this.

[Dr Opher]

Q I would like to go back to the point about depression, because it is common. In the general population, 20% are on antidepressants—on SSRIs. GPs diagnose the vast majority of depressions. Dr Mulholland, what are your thoughts on whether checking for demonstrable depression should be a standard part of the assessment before you refer people into the service? The idea of getting a psychiatrist who wanted assisted dying to see every case, given how difficult it is to see a psychiatrist in the NHS at present, would really limit the service.

Dr Mulholland: We see a lot of people with mood disorders of different types and of different severities. Many people with depression who are treated with antidepressants carry out full-functioning jobs and lives because of the treatment that they have and because their depression is not of that severity. If someone had very severe depression and we were accessing our psychiatric colleagues, that would be a different decision, and perhaps it is not something that would happen at that point. Most people with depression, anxiety and other mental health problems would have capacity, because we would presume it under the Mental Capacity Act, so it is not necessarily an obstruction to people being referred for anything.

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[Sarah Sackman]

Further to that point of order, Mrs Harris. I want to clarify the Government’s position. As the Committee knows, the Government are neutral on the Bill, but once the Committee has concluded its work and prior to Report, we are committed to publishing the ECHR memorandum, a delegated powers memorandum, the economic impact assessment that was committed to during the money resolution debate, and an assessment of the equalities impact of the Bill. In terms of the timing, it is necessary that the impacts that are assessed be of the Bill as it is brought forward. If the Bill is liable to change via amendments proposed by members of this Committee, it is important that we know what it is that we are assessing the impact of. That is why the proposed timing is to publish the impact assessment at that stage. The point is that before Members of the House come to a vote on Report and Third Reading, they will all have before them the impact assessment in respect of equalities and all those other aspects of the Bill.

[Danny Kruger]

On a point of order, Mrs Harris.

[The Chair]

I am going to proceed now. I thank the hon. Member for Bexleyheath and Crayford for notice of his point of order. I am sure that the Member in charge and the Government have heard his points. If he wishes to look at procedural options, he should consult the Clerks in the Public Bill Office.

That brings us to the end of today’s sitting. The Committee will meet at 9.25 am on Tuesday 11 February to begin line-by-line consideration.

Ordered, That further consideration be now adjourned. —(Bambos Charalambous.)

Terminally Ill Adults (End of Life) Bill (Eighth sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[The Chair]

As I expressed before, it is for the Committee to decide. Should Members feel they have not had enough time, it is for the Committee to raise a point on that. Should people wish to have an adjourn, they could move that and the Committee would vote on it.

[Danny Kruger (East Wiltshire) (Con)]

Further to those points of order, Ms McVey. I am grateful for your guidance, and I acknowledge your point that normal process is being followed in this Committee.

Nevertheless, further to the points made by hon. Members, last night we heard through the media that a very substantial change to the Bill will be introduced. We have not yet seen those amendments proposed by the hon. Member for Spen Valley, but we look forward to doing so. This goes to the same point: we are being asked to start line-by-line scrutiny today of a Bill with a huge amount of evidence that we have not yet been able to digest. Furthermore, substantial changes to the Bill that we voted on at Second Reading are being tabled. I appreciate that the process allows amendments to be tabled at any time through the course of the Bill as long as the clause is still ahead. Nevertheless, I value your guidance on whether it might be appropriate to seek an Adjournment so that we can consider the additional evidence, but also allow the hon. Member for Spen Valley to table her amendments, which change the whole scope of the Bill as voted on at Second Reading.

[The Chair]

I thank the hon. Member for his point of order. As I said, the Committee would have to move and vote on an Adjournment. These are significant points of concern and alteration for the Bill, but that is for the Committee to decide.

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[Kim Leadbeater]

It is a great pleasure to serve under your chairship, Ms McVey, in this very important stage in the consideration and detailed scrutiny of the Bill.

We are discussing assisted dying for terminally ill adults who have a clear, settled and informed wish to end their own life, and who have not been subjected to coercion or pressure from anybody else to do so. These are very serious matters and deserve serious consideration, which is why I was determined that this Bill should have an unprecedented level of scrutiny. We have heard from a range of over 50 witnesses with differing views on the Bill and have received written evidence from many, many more.

I am grateful to everyone who has contributed in such a thoughtful and constructive way. It has been widely remarked—and I wholeheartedly agree—that the Second Reading debate on 29 November last year, when the House approved the principle of the Bill by a majority of 55, showed Parliament at its best. I hope and believe that this Committee, as it goes through the Bill line by line, will do so in the same considered, respectful and measured manner.

[Danny Kruger]

I completely endorse that last point made by the hon. Lady. Does she remember how many Members on Second Reading—including, I think, herself—made reference to the judicial stage of the process and specifically to the High Court judge? Over 60 colleagues have stated on the record that they voted for the Bill on Second Reading because of that safeguard. Does she acknowledge that point?

[Kim Leadbeater]

I do acknowledge that point—absolutely, as I have acknowledged, the role of a High Court judge is really important in this process. That role will remain with the amendment I have tabled. It will also take account of the very clear evidence we received during the oral evidence sessions from psychiatrists, social workers and other professionals who feel that they have an important role to play in this process. Indeed, I heard the hon. Gentleman say he agreed with that on the radio this morning. It is very important that we hear from those experts. There is no point in having witnesses if we do not listen to what they have to say.

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[Sarah Olney]

That is an absolutely relevant point. The Mental Capacity Act was not drafted in anticipation of it ever being used for this kind of scenario. Therefore, it is really incumbent upon us to weigh very carefully whether the Mental Capacity Act is the right way of assessing people’s ability to make this decision. As I was saying, it includes the presumption of capacity, and for a decision to end one’s life, an assumption of capacity to make that decision is a low bar, and we have lots of evidence.

[Danny Kruger]

I am interested in that point about the Mental Capacity Act not having been written with the Bill in mind. That is absolutely true for the minds of its framers and the Parliament that passed it at the time. It is worth noting, however, that we can see from the accounts and records of the Voluntary Euthanasia Society, which became Dignity in Dying a few years later, that it was lobbying at the time covertly—or behind the scenes—for the Mental Capacity Act to be framed in exactly that way. The Voluntary Euthanasia Society was very conscious that, when the time came to pass the law for assisted suicide, it would be very helpful to have a capacity Act on the statute book that had this very low bar. The society was delighted when the Act was passed in the way that it was, and it boasted at the time of the influence it had had on the Act.

[Sarah Olney]

That is a very interesting intervention. I cannot comment on that because I have no knowledge of how the Mental Capacity Act was drafted or the evidence that was taken.

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[Sarah Olney]

If I may say so, the hon. Gentleman’s intervention precisely illustrates what other hon. Members were raising as points of order earlier. How can we properly scrutinise the legislation when new amendments are being tabled at the last minute that potentially change the entire nature of the legislation that we are attempting to scrutinise? It is very difficult then to speak about the amendments that have already been tabled.

[Danny Kruger]

Further to that point, the hon. Lady responded to the hon. Member for Stroud, who suggested that a doctor must refer to a psychiatrist in the event of concern over capacity. There is no such obligation in the Bill. There is the opportunity to do so—the second doctor may do so, if they choose—but there is no such obligation. That is something that we could definitely improve.

The hon. Member for Stroud, who is a GP, says that it is always obvious to him when there are issues about capacity. I assume he might think the same about coercion. I wonder if the hon. Lady is aware that one in six older people are subject to abuse—elder abuse. Does she think that the hon. Member for Stroud always spots the one in six of his older patients who are subject to abuse?

[The Chair]

Order. I remind everybody to stay within the scope of what we are talking about, which is capacity.

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[Danny Kruger]

Will the hon. Lady give way?

[Dr Tidball]

I will give way to the hon. Member for Richmond Park, who asked first.

[Dr Tidball]

I am grateful to the hon. Lady for making that statement. That is not the assumption. As I will say later, the term “ableism” is very much grounded in a deficit model of disability, which assumes that somebody is not capable of doing something themselves—for instance, making important decisions—whereas the Mental Capacity Act starts from a different perspective: it presumes that the person will have the ability to do something until proven otherwise. That is why I feel that the concept of ability does not align well with what is needed in understanding and providing autonomy to people making very difficult decisions at the end of their lives.

[Danny Kruger]

The hon. Lady accurately quoted clause 2(3) about a person not being considered to be terminally ill “by reason only” of having a mental disorder or a disability. That word “only” is very important, as she acknowledged. Does she recognise that that explicitly allows for somebody whose judgment might be impaired by a mental disorder still to be eligible for an assisted death, because they would still be judged to have capacity under the terms of the Mental Capacity Act? That term “only” is in fact not a safeguard; it is an access to an assisted death for somebody with impaired judgment.

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[Dr Neil Shastri-Hurst (Solihull West and Shirley) (Con)]

I thank the hon. Member for Richmond Park for tabling the amendments. Fundamentally, I do not agree with them, but I am grateful for her good intentions. I understand the concerns that she has raised, and she makes an eloquent argument, but I fundamentally disagree.

In my view, the amendments would only lead to abandoning the well-established principles codified within the Mental Capacity Act. They would introduce a degree of woolliness and legal uncertainty by introducing of a new term that is, as yet, undefined. That would make the operability of the Bill so much harder and would move us away from the Mental Capacity Act, which has a heritage of some 20 years and is already well established in the use of advance directives around organ transplantation, the withdrawal of treatment and the decision to undergo major operations that can have life-changing or life-limiting consequences.

[Danny Kruger]

My hon. Friend says that the term “ability” is not yet defined, but it is set out quite clearly in new clause 1, tabled by the hon. Member for Richmond Park. It simply says:

“The person is to be considered as having the ability to make a decision to request assistance to end their life if they can fully understand, use and weigh the relevant information”.

It uses the language of the Mental Capacity Act on understanding and weighing information. The key distinction is that it does not allow for impaired judgment; it requires somebody fully to understand the information in front of them. It is very straightforward, and I do not think that it would be difficult to apply. Does my hon. Friend recognise that the terms are pretty clearly laid out?

[Dr Shastri-Hurst]

My hon. Friend makes incisive points clearly and concisely, as always, but I cannot agree. This is a short clause that is dealing with a hugely complicated issue that is presently codified within the Mental Capacity Act, which runs to some 183 pages. I do not think that it is as simple as saying that the new clause deals with the issue.

There is also the two-stage test, which determines both the functional ability to make the decision and whether that decision is impaired in any way. It would be an oversimplification to suggest that the provision as drafted would deal with those issues in a satisfactory way that would provide confidence not only—although most importantly—to those who are making a decision around an assisted death, but to the medical practitioners who are part of the process and the courts, which will have to grapple with the issues that will inevitably arise from a new definition.

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[Dr Shastri-Hurst]

The hon. Member makes an interesting point, which I had already considered; in fact, I have tabled a new clause that would address it. It is not grouped with the amendments now before the Committee, but I will touch on it, if I may.

There is an argument that, if an individual with an advance directive has gone through the two-stage test in the Bill and then loses capacity, the advance directive should hold weight. My new clause 6 would deal with that point. Sections 27 to 29 of the Mental Capacity Act deal with exclusions from advance directives, including issues around voting rights, marriage rights and Mental Health Act implications. There may be a mechanism, for example, to exclude an advance directive that deals with assisted death, either through the Bill or through an amendment to the Mental Capacity Act. But I do not disagree with the hon. Lady; she raises an interesting point.

[Danny Kruger]

Is my hon. Friend suggesting—I think his new clause makes it clear, and I think my right hon. Friend the Member for North West Hampshire is making the same point—that it is inappropriate for an advance directive to authorise an assisted death? The Mental Capacity Act authorises somebody to decline treatment at a future point, so my hon. Friend is acknowledging that there is a difference between the principle of declining treatment and the principle of requesting an assisted death. Given his new clause, I do not imagine that my hon. Friend thinks that we should have advance directives that authorise an assisted death. If he acknowledges that, he must recognise that there is a distinction between declining treatment and requesting an assisted death.

[Dr Shastri-Hurst]

My hon. Friend makes a valid point. I have concerns about public confidence in the Bill without that additional safeguard, as this is such a consequential decision, but of course any advance directive would be predicated on having gone through those two stages first before capacity is lost. I feel that on this occasion additional tightening is necessary so that the public can be confident that a robust process has been gone through.

The MCA is a tried and tested piece of legislation used by practitioners up and down the country. The hon. Member for Stroud uses it every day in his practice; I have to say that I did not, but I was not consenting patients for surgery every day. Every time I did so, however, I had those conversations. Capacity lies on a spectrum: if I am doing major abdominal surgery, the level of capacity required to make a decision will be much greater than if I am removing a small bump or lump on an arm.

As well as having been tried and tested by medical practitioners, the MCA has been tested in the courts, as the hon. Member for Penistone and Stocksbridge said. It has been right up to the highest court in this land, it has been robustly tested and it has been found to be good legislation. The risk we now face is that it will be replaced not only with a new legal concept, but with an entirely different process for assessing capacity in this setting. Although there may be good intentions to improve the system, that will only add to the folly of it and overcomplicate the issue.

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[Dr Shastri-Hurst]

The hon. Member is right: there is a huge spectrum of patients when dealing with these complex issues, and it would be absolute nonsense to arbitrarily say that anybody with depression is unable to make an informed decision on any issue. There are individuals who have mild depression—indeed, I suspect that most people with a terminal diagnosis would have some form of depression or reactive disorder, whether formally diagnosed or not, because of their circumstances. That does not mean that they are unable to make a rational, informed decision; we have to look at each patient individually. The Act is a tried and tested piece of legislation that doctors up and down the country use every day. Doctors over the road in St Tommy’s will be using it at this very moment, and they are adept at knowing and sensing when they need to escalate, whether by getting the opinion of a psychologist or a psychiatrist, because they have concerns about underlying issues. The Act is a robust piece of legislation, and we should be using it to enhance this Bill, not introducing further complexity, which will only put us into a quagmire of uncertainty.

[Danny Kruger]

My hon. Friend does not want uncertainty, so perhaps he could answer this question very directly: would he be content to see somebody who is depressed, and indeed suicidal, successfully apply for an assisted death?

[Dr Shastri-Hurst]

My hon. Friend puts it with his usual candour. He asked a straight question, so I will give him a straight answer: I think there is a difference between somebody who is depressed and somebody who is depressed and suicidal. I have no personal moral objections if someone who has a terminal illness, who suffers from depression and who has capacity as set out through the two-stage test in the Mental Capacity Act, ultimately wishes to end their life because of their terminal diagnosis. If they are doing it because they are suicidal as a consequence of their depression, that is a different and distinct issue. We are talking about individuals who want to end their life because of their terminal diagnosis, not because of their mental disorder.

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[Daniel Francis]

I welcome that commitment and look forward to that discussion in due course.

Dr Hussain went on to say:

“Ultimately, I do not think the Mental Capacity Act and safeguarding training are fit for purpose.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 199, Q260.]

Professor Owen said:

“That conveys questionable confidence in the consent processes, of which mental capacity is part, in relation to the decision to end one’s life. It is significant evidence about the confidence that is out there among experienced practitioners.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 228, Q290.]

Dr Price said:

“I…refer back to Professor Gareth Owen’s oral submission, thinking about the purpose that the Mental Capacity Act was drawn up for and the fact that decisions about the ending of life were not one of the originally designed functions of it. We would need to think carefully about how that would then translate into a decision that was specifically about the capacity to end one’s life.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 268, Q349.]

[Danny Kruger]

I note the point about training, and of course we would all welcome the strongest possible training. As the hon. Gentleman implies, nobody has yet used the Mental Capacity Act to assess somebody for an assisted death; it would be completely uncharted territory for the whole system, including anybody providing training. How does he imagine that training might be designed to allow for the Mental Capacity Act to be applied in this case, when it would be completely novel?

[Daniel Francis]

As I say, I am not an expert on this matter from a legal or medical background, but those are the concerns that have driven me to the place that I am in.

Dan Scorer, from Mencap—as my hon. Friend the Member for Spen Valley knows, I was adamant that Mencap would give evidence to us—said:

“building on the previous question about the adequacy of the Mental Capacity Act, there is a question about the adequacy of training, awareness and compliance with that Act now.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 269, Q350.]

He clearly cited what many people know occurred during covid, with “do not resuscitate” orders and decisions being made on people’s behalf. That is what has driven me to this place, and that is why I will support the amendment. I also have further amendments on this issue later on down the line.

I completely understand what my hon. Friend the Member for Spen Valley said about training in relation to these decisions and scenarios. At the end of life, people should have autonomy and choice, but if that comes at the price of one person, in a borderline capacity decision that is made on their behalf, it will be one death too many.

[Danny Kruger]

It is a great pleasure to follow the hon. Member for Bexleyheath and Crayford, and I pay tribute to his powerful speech. I wish more people on our side of the debate and on the Committee had medical backgrounds, but I am glad that we have someone who has such direct personal experience of supporting people with learning disabilities. I am grateful to the hon. Gentleman for everything he said and I entirely agree with it.

I want to speak in support of new clause 1, tabled by the hon. Member for Richmond Park, to replace the use of the Mental Capacity Act with a new ability test. This goes to the heart of the Bill: it is absolutely crucial. Clause 3, which her new clause would replace, is in a sense the essence of the Bill. It is the shortest clause, but perhaps the most important one, because it determines the means by which somebody will be assessed to be capable of making this decision. It is a very important protection—and, at its simplest, this is a very confusing and complicated area. I will no doubt confuse myself in the course of my speech, but I have a simple observation to make, which the hon. Lady also made very well. We are dealing with the issue of impaired judgment; currently, under the Mental Capacity Act, it will be possible, through the terms of this Bill, for somebody whose judgment is impaired by virtue of a mental disability or mental illness to successfully apply for an assisted death. I do not think that is what the public want and I do not think it is what the House of Commons voted for. I think it is a misunderstanding of the principle of the Bill, which did win support on Second Reading.

The simple fact is that somebody’s judgment can be impaired under the Mental Capacity Act, but they could still have capacity. We have repeatedly heard points made about how the Mental Capacity Act applies in the normal conduct of life for disabled people—for people with mental disabilities. For instance, people can be anorexic, depressed or suicidal, and of course they can still consent to all sorts of decisions that affect their life, including medical treatments. A person can consent to have surgery on a broken leg while depressed; there is no difficulty whatever with that and of course that is appropriate. That is rightly the basis on which we currently judge capacity.

New clause 1 would build on the terms of the Mental Capacity Act. It would add to the principles of autonomy and of people being able to understand, use and weigh the relevant information. As I said in an intervention, the key point is that using this new test of ability would ensure that the person was fully able to do those things—fully able to understand, use and weigh the relevant information. In the case of impaired ability, they would not be considered to pass the test.

We hear a lot that this is the toughest Bill in the world, with the highest safeguards. It is worth pointing out that in Oregon, which this Bill is largely inspired by, there is an impaired judgment test. There is a capacity test similar to that in the Mental Capacity Act, but people are also required to demonstrate that there is no impaired judgment, and that is exactly what the hon. Lady is seeking to achieve. Her new clause would build on the terms of the Mental Capacity Act with these key principles about understanding information, but would ensure that it was a full understanding, with no impairment. It would strengthen the Bill without complicating it. In fact, it would significantly simplify it, because at the moment—this is the substantial issue with the application of the Mental Capacity Act—a huge complication is involved when we go into the forest of the MCA and try to apply it in these terms. When we try to navigate our way through the MCA in pursuit of an assisted dying application, there is a whole series of complications.

I will cite some of the evidence that we received. The Royal College of Psychiatrists, which we heard from, stated in its written evidence:

“It is the RCPsych’s view that the MCA is not sufficient for the purposes of this Bill.”

We also had evidence from King’s College London’s Complex Life and Death Decisions group, which is a group of world-leading professionals working on issues relating to the end of life. They say that use of the MCA for assisted suicide would be “an entirely novel test”. I note that the hon. Member for Penistone and Stocksbridge—and I think my hon. Friend the Member for Solihull West and Shirley—made the point that an “ability” test would be a novel term. I acknowledge that the term “ability” is not currently set out or recognised in law in the same way that capacity is, but as I said, it is clearly defined in new clause 1, as tabled by the hon. Member for Richmond Park. Of course it is going to be novel—we are talking about something that is entirely novel. Assisted suicide is a new measure that is being introduced, so of course we have to have a new measure by which we define who is appropriate.

[Bambos Charalambous (Southgate and Wood Green) (Lab)]

I am reading the text of new clause 1, and it is remarkably similar to the text of section 3(1) of the Mental Capacity Act, which says,

“For the purposes of section 2, a person is unable to make a decision for himself if he is unable—

to understand the information relevant to the decision,

to retain that information,

to use or weigh that information as part of the process of making the decision”.

It is not a novel concept—that wording is virtually the same as in new clause 1. I do not see why we need to have the new clause or the new definition, as it is already present in the Mental Capacity Act.

[Danny Kruger]

The hon. Gentleman’s intervention helps me to explain my point more clearly, which is that the new clause tabled by the hon. Member for Richmond Park builds on the terms of the Mental Capacity Act. It recognises the value of the terms, which have been well established in case law through the MCA—the ability to understand, use and weigh the relevant information.

The key difference is the word “fully”. The case law around the MCA allows for somebody to be deemed capacitous even though their judgment might be impaired. What is proposed in the new clause is the closing of that lacuna, so that it would not be possible for someone to get an assisted death if their judgment was impaired. That is the key difference.

It is also important to exclude the MCA because of the thicket of complications that it would entail. We have heard about the importance of simplification. A much simpler and better way to do the entirely novel thing that we are proposing, which is to authorise assisted suicide by the state, is to have a new definition.

[Kim Leadbeater]

Will the hon. Gentleman give way?

[Danny Kruger]

The hon. Lady does not like my terminology.

[Kim Leadbeater]

I do struggle with that terminology. This is not assisted suicide by the state. The state is not involved. It is the person making an autonomous decision based on their choice at the end of life. I will say on the record that the term “suicide” is not accurate for the cases we are talking about. The people we are dealing with are not suicidal. They very much want to live; they do not want to die, but they are dying. It is important that we have that on the record.

[Danny Kruger]

I think it is totally valid for us to have this argument about terminology periodically. I will repeat the point that we have made before, which is that we are actually amending the Suicide Act 1961—or rather, we are disapplying that Act—in the process set out in the hon. Lady’s Bill. There is no getting away from the fact that we are talking about assisting suicide. I am afraid that I will continue to use the term, and I hope the hon. Lady will forgive me for that.

I am arguing that the MCA is a complicating factor in the process that is being proposed for the Bill; it makes things much more difficult and complicated. The point has already been made—the hon. Member for Richmond Park put it very well—that, in the case for the MCA, a lot of weight is being put on the evidence from Sir Chris Whitty, suggesting that the MCA works very well. I point out that Sir Chris made a significant mistake in his evidence, when he said that

“the more serious the decision, the greater the level of capacity that someone needs to have.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 30, Q3.]

There is no such requirement in the Mental Capacity Act. Of course, we would hope that doctors would take a serious decision more seriously than a trivial one, but there is no such requirement. I cite Alex Ruck Keene KC, who wrote to the hon. Member for Richmond Park after his evidence session; with the greatest of respect to Chris Whitty, the fact that he got that wrong does not inspire confidence in his comments that the Mental Capacity Act is well understood by doctors throughout the country. I very much echo that. We have had so much evidence on how the Mental Capacity Act does not work well in practice that I think it was regrettable for the chief medical to have made the Panglossian observation that every doctor interprets it in exactly the same way and it works perfectly everywhere.

The Mental Capacity Act does not detect coercion. We will discuss coercion more in subsequent debates, but that Act is certainly not the safeguard against it. Professor House made some comments to us about Down’s syndrome and about diagnostic overshadowing. That is a very important concept. I am afraid to say that it is frequently the case, regarding people with severe disabilities, that capacity—or, indeed, incapacity—is not correctly observed because the medical professional will not see beyond the more presenting of their conditions. Observing capacity in someone who does have disabilities is often mistaken; it is harder than it is regarding other people.

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[Lewis Atkinson (Sunderland Central) (Lab)]

Can I clarify what the hon. Member is proposing by introducing a separate test for people accessing assisted dying? Say an individual is on a respirator at the end of their life. Under what the hon. Member is proposing, if they said, “Please turn this respirator off; I want to die”, he thinks that it is appropriate for capacity to be assessed under the Mental Capacity Act 2005, but somehow he thinks that that person should have a different legal test if they said, “I want to take a drug to end my life,” knowing full well that they would have exactly the same result.

[Danny Kruger]

The simple answer is yes, I do. I think it is a causatively different decision. In fact, this whole Bill entails causative differences between those decisions. I will come to that point more in a moment.

Professor Owen made an important point to us regarding capacity. He said:

“You might be talking about a kind of cognitive impairment that has not reached the threshold for a diagnosis of dementia; you might be talking about a kind of mood problem or an anxiety problem that is sub-clinical; or you might be talking about a level of intelligence that is not clinically a learning disability.”

He talked about

“pressure within a family, let us say, which is often not malign in its intentions, but it exists.”

and about situations

“where there is an impairment and also an interpersonal pressure”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 234, Q297.]

Although we are not talking at this point explicitly about coercion and family pressure, the issues around capacity and coercion are nevertheless intertwined, and it is often very difficult for doctors to determine what is really going on. Again, the challenges around capacity are intense.

The point has been made by hon. Members that under clause 9(3)(b), if the second doctor in the process is in doubt about capacity, they “may” refer the person to a psychiatrist, but the clause in fact refers to “a registered medical practitioner” who “has experience of” the assessment of capacity—so not a psychiatrist, but just someone who has experience, whatever that means, of the assessment of capacity. It is not totally obvious what that means. Amendment 365 has been tabled overnight by the hon. Member for Bath (Wera Hobhouse) which would mean that both the first and second doctor, and indeed the court, if we are allowed to have a court process, “must”—not “may”— refer the person to a psychiatrist. That is not just if they are concerned about capacity, by the way. The court, or whoever it is, must conclude that there is no

“impairment of judgment arising from a mental disorder or other condition”.

I very much welcome that amendment and I hope that we will pass that in due course.

[Kim Leadbeater]

On that point about clause 9(3)(b), as I think was mentioned earlier, an amendment has been tabled by the hon. Member for St Albans (Daisy Cooper)—an amendment that I would support and I hope the Committee will—that would indeed turn the “may” to a “must”, so that there has to be a referral to a psychiatrist if there is any doubt from either of those doctors.

[Danny Kruger]

That is excellent news. For the first time so far in the course of this debate, we have a strengthening of the Bill from the hon. Member. That is great news—we can chalk that up as a victory, and as good sense breaking out. I am grateful for that. Let’s see what more we can achieve.

The point that I want to make is that we are in the foothills of understanding the effects of depression, cognitive impairment and social pressure on the decision to end life. That is a point made strongly by a series of witnesses to us in both oral and written evidence: we are still very much in the early stages of understanding how capacity interacts with mental illness, disability and coercion. Then, into the mists of vagueness, we are proposing to insert this single clunking, clumsy question: “Is there evidence of incapacity?” I strongly suggest that the abuse of the Mental Capacity Act that we are seeing here is not a way of simplifying the process of ensuring that there are a small number of strong safeguards; it is a great complication of the process and introduces more complexity, as we see from the many additional things that clinicians should consider. That is in direct contradiction to the principle of the Mental Capacity Act, which simply asks the question: “Is there capacity?”

The point has been made that there is more to the Mental Capacity Act than simply the question of capacity. There are concepts of best interests and supporting decision making. As the hon. Member for Penistone and Stocksbridge suggested, it is a cumulative process. The Mental Capacity Act entails not only the question of capacity but the consideration of best interests and whether we are supporting the decision making of an individual. I am not sure how those terms apply in a situation of assisted dying. It is not similar or comparable to the sorts of decisions that the MCA is intended to apply to.

[Lewis Atkinson]

This touches on some of the evidence given by Mr Ruck Keene, particularly around the best interests decision. From my reading of this legislation, it is very clear that there is no possibility for someone to make a decision on behalf of or in the best interests of anyone else. As the hon. Member for Solihull West and Shirley mentioned earlier, there are a number of exclusions in the Mental Capacity Act. For example, someone is not able to make a best interests decision on someone getting married or adopting. Does the hon. Member agree that in order to have a guarantee, without any doubt, on the best interests point, an amendment could be included to clarify that nothing in the MCA would allow a best interests decision under this legislation?

[Danny Kruger]

That is absolutely right. I do not think best interests can apply in this case. That is why the Mental Capacity Act is being abused. As the hon. Member for Penistone and Stocksbridge said, it is supposed to be cumulative. We are supposed to consider all aspects of the Mental Capacity Act, and best interests should be part of a consideration—but how on earth does one make a best interests decision about somebody deciding to commit suicide? The hon. Gentleman is right that best interests are excluded in the Bill, so the Mental Capacity Act is not being used, except for this most basic, low-level bar to cross, which is the capacity decision.

[Dr Tidball]

For clarity, I agree with my hon. Friend the Member for Sunderland Central on what would strengthen the Bill. The exceptions only apply where the right and proper Mental Capacity Act process has been gone through and the person doing that assessment has arrived at the point that that person does not have capacity. It is only in that very narrow set of circumstances where they have determined that the person before them does not have capacity to make the decision at hand that they then go to the second look at whether making such a decision would be in the individual’s best interest. The specific exclusions listed in the MCA only apply in that stage.

What my hon. Friend the Member for Sunderland Central is suggesting is that we table an amendment that would add to the list of specific exclusions; that would further strengthen the two stages. First, there would be the full Mental Capacity Act tests that may determine that the person does not have capacity. Such an amendment would give us belt and braces in circumstances where the person does not have capacity. Under the Bill currently, the person would fall out of scope and not be able to seek assistance if it had been determined that they did not have capacity. A belt-and-braces approach would make sure that there is no circumstance in which it could be determined by a medical practitioner or any other that it was in their best interests to follow this course of action.

Under the Bill as currently drafted, those people who have not got capacity as a result of the Mental Capacity Act would not be able to have access to the provisions in the Bill. My hon. Friend the Member for Sunderland Central suggests that we augment that even further so that there can be no doubt that, where it has been determined that the person does not have capacity, following the Mental Capacity Act, we should also add a very clear exception—

Terminally Ill Adults (End of Life) Bill (Ninth sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[The Chair]

Members may remove their jackets if they wish to do so. I reiterate the instruction—you will note that it is an instruction, not a request—that Members address one another through the Chair and do not, therefore, use the expression “you” when speaking. I understand we had a slight problem with that this morning.

I remind the Committee that with amendment 34 we are discussing the following:

Amendment 36, in clause 7, page 4, line 7, leave out “capacity” and insert “the ability”.

This amendment is consequential on Amendment 34 and NC1.

Amendment 37, in clause 8, page 4, line 34, leave out “capacity” and insert “the ability”.

This amendment is consequential on Amendment 34 and NC1.

Amendment 38, in clause 9, page 6, line 27, leave out “capacity” and insert “ability”.

This amendment is consequential on Amendment 34 and NC1.

Amendment 202, in clause 9, page 6, line 31, leave out “capability” and insert “capacity”.

This amendment corrects a typographical error.

Amendment 39, in clause 9, page 6, line 31, leave out “capability” and insert “ability”.

This amendment is consequential on Amendment 34 and NC1.

Amendment 40, in clause 12, page 8, line 2, leave out “capacity” and insert “the ability”.

This amendment is consequential on Amendment 34 and NC1.

Amendment 41, in clause 13, page 9, line 31, leave out “capacity” and insert “ability”.

This amendment is consequential on Amendment 34 and NC1.

Amendment 42, in clause 18, page 12, line 23, leave out “capacity” and insert “the ability”.

This amendment is consequential on Amendment 34 and NC1.

Amendment 43, in clause 30, page 18, line 16, leave out “capacity” and insert “the ability”.

This amendment is consequential on Amendment 34 and NC1.

Amendment 44, in clause 40, page 23, line 26, leave out from “capacity” and insert “ability”.

This amendment is consequential on Amendment 34 and NC1.

New clause 1—Ability to make decision—

“The person is to be considered as having the ability to make a decision to request assistance to end their life if they can fully understand, use and weigh the relevant information in accordance with regulations made by the Secretary of State under affirmative resolution.”

This new clause defines the concept of ability which is intended to replace the concept of capacity. This new clause is intended to replace Clause 3.

Amendment 45, in schedule 2, page 26, line 36, leave out “capacity” and insert

“the ability to make a decision”.

Amendment 46, in schedule 3, page 28, line 1, leave out “capacity” and insert

“the ability to make a decision”.

Amendment 47, in schedule 5, page 30, line 14, leave out “capacity” and insert

“the ability to make a decision”.

[Danny Kruger (East Wiltshire) (Con)]

Before the break, the hon. Member for Penistone and Stocksbridge gave a helpful account of the operation of the Mental Capacity Act 2005, with particular reference to the concept of “best interests” that applies in that Act. She explained that the best interests consideration kicks in only once the capacity test has been failed—once it has been concluded that someone does not have capacity. Therefore, there would be no best interests consideration in the case of assisted dying. Either a person has capacity and that is that—a rather low bar, which is, as we have discussed, appropriate for buying a cup of coffee, is got over, and they are off to the assisted dying commission, or whatever process we eventually try to set up—or they do not have capacity and are ejected from the system, and there is no best interests consideration.

I reference that because my whole point is that the Bill does not use the Mental Capacity Act; it just uses the definition of capacity that is in it, and that definition is very weak. It is designed to assume capacity in the patient and, as we discussed earlier today, it can include somebody who has impaired judgment—they could be depressed or even suicidal. Indeed, my hon. Friend the Member for Solihull West and Shirley said earlier, very honestly, that he would be content with somebody who had depression accessing assisted suicide, as would be possible under the legislation.

The point is that once the test of capacity has been passed, there is no best interests consideration. It is a great abuse of the Mental Capacity Act, the whole purpose of which is concern for the vulnerable, for that purpose to be ignored once the usefulness of the Act has been fulfilled. This Bill does violence to the Mental Capacity Act in using it for this purpose. The fact is that that Act was designed for the opposite situation: to protect people from having things done to them.

I will conclude shortly, Sir Roger, but that brings me to the point we have discussed at length already today: the crucial question of whether the decision to have an assisted death is different from the decision to decline or to cease treatment. I start by pointing out that case law specifies that to decline treatment is not to commit suicide —I recognise that the hon. Member for Spen Valley does not like the term suicide, and I apologise, but we are using legal terms here. The fact is that there is a distinction in law between the act of suicide and the decision to decline treatment.

I refer in particular to the famous case of Airedale NHS Trust v. Bland in 1993, and quote Lord Goff, of the House of Lords, who said that

“in cases of this kind, there is no question of the patient having committed suicide, nor therefore of the doctor having aided or abetted him in doing so. It is simply that the patient has, as he is entitled to do, declined to consent to treatment which might or would have the effect of prolonging his life, and the doctor has, in accordance with his duty, complied with his patient’s wishes.”

I also quote Sir Thomas Bingham, as he then was, who said that in the case of Tony Bland it was plainly not suicide, and that

“it was not the discontinuance of artificial feeding but the patient’s condition and its underlying cause which caused his death”.

In the withdrawal of treatment, it is not the act of withdrawing treatment that kills someone, but their disease, or the condition they have, whereas in assisted suicide it is the act that kills them. That is a crucial distinction, and that distinction is apparent. We heard it this morning in remarks from my hon. Friend the Member for Solihull West and Shirley and my right hon. Friend the Member for North West Hampshire, and I think from the hon. Member for Spen Valley, who pointed out that there is a difference between the two cases, as is evident with respect to advanced directives that allow for the withdrawal of treatment. They do not allow for the active administration of treatment; they allow for the withdrawal of treatment. They would not allow for assisted dying, as the hon. Member for Luton South and South Bedfordshire accurately said.

This goes to the heart of the matter. There is a difference between being left alone and demanding that something is done to us. The state protects our right to be left alone. It does not yet give us the right to have something done to us simply because we asked for it.

[Rachel Hopkins (Luton South and South Bedfordshire) (Lab)]

The proposal in the Bill is not about someone doing something to someone: it is about self-administration and someone being able to do something to themselves. The point is about the choice to do that.

[Danny Kruger]

I recognise that, and that the Bill makes a distinction in respect of euthanasia or physician-assisted suicide, which would be the doctor doing it to us. The Bill specifies that the drugs must be self-administered. I do not understand the logic of that distinction, but I recognise that there is an attempt to make the Bill more palatable and that the distinction has been preserved. Nevertheless, the Bill would enable a doctor to prescribe lethal drugs with the purpose of ending a life. That is an act that is performed: a person is prescribed drugs to end their life. Whether they take the pills or press the syringe themselves, the act has been performed, and the prescribed drugs kill the person.

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

My hon. Friend will recall the evidence from Professor Hoyano, who said she could not legally see the distinction between a doctor handing the pills to somebody to take themselves and the doctor pulling the plug out of the wall to turn off the ventilator or whatever machine might be keeping the person alive. Both of them are an act by a doctor at the request of the patient to foreshorten their death and avoid whatever they contemplate at the end.

I realise we are dealing with semantics here. We might have an irreconcilable difference about such an act, but I have to say that from the point of view of a patient—the person approaching their death—those two acts seem to be broadly the same. In both circumstances I am requesting that a doctor do something to hasten my death, because I do not wish to continue living in the circumstances presented to me.

[Danny Kruger]

My right hon. Friend articulates the point well. I do not think it is a semantic decision: there is a real distinction. The fact is that unplugging the ventilator leads to death, but what kills the patient is not the administration of any treatment or drugs that have been provided. The patient dies naturally, whereas the administration of drugs designed to kill them is a qualitatively different event. I agree that of course the ultimate effect is the same, but the act that is performed is qualitatively different, and indeed the intention of the doctor is different.

[Kit Malthouse]

Forgive me, but surely the whole point of what we are trying to do here is to give people the opportunity to avoid the natural death that is presented to them. We hear again and again, and we heard it from the families who gave evidence, that people profoundly wished to avoid their natural end because it was going to be degrading, unpleasant and profoundly painful on every level. That is the whole purpose of the act. To say that we should avoid that issue seems to me to negate our whole reason for being here.

[Danny Kruger]

We are trying to avoid suffering, pain and bad deaths. We all share that view. Indeed, later amendments look explicitly at the purpose of an assisted death and the question of the avoidance of pain. I am simply making the important distinction between the decision to withdraw treatment and the decision to administer fatal drugs, which, as I say, are qualitatively different—different in principle and different in practice.

[Kim Leadbeater (Spen Valley) (Lab)]

To build on the point made by the right hon. Member for North West Hampshire, this is the heart of the issue. You are right that they are slightly different things.

[Kim Leadbeater]

Sorry, Sir Roger. The hon. Member is correct. It gets to the heart of whether we think this is the right thing to do. The Bill Committee’s job is to put that decision back to the House. It is not for us to decide today; it is for us to have the discussion about how we can improve the Bill and send it back to the House.

The hon. Member is absolutely right to say that it gets to the heart of the issue. I think dying people should be given that choice. In the same way that they are given the choice to have treatment withdrawn or the machine turned off, they should be given the choice to take control and to have the autonomy and dignity that assisted death will provide.

[Danny Kruger]

The hon. Lady has expressed very well her whole purpose for the Bill. In a sense, all the debates we are having about safeguards, protections, process and eligibility are secondary to her purpose, which is to give autonomy to patients. One has to ask about the purpose of the safeguards, particularly the one on people having to administer the drugs themselves. In all jurisdictions where physician-assisted suicide is legal, that is the option that people overwhelmingly opt for—I certainly would if I were in that situation.

The hon. Lady is right, and that is what she is trying to do: she simply wants the Bill to go through. I take strong issue with her implied point that our purpose here is simply to work out the Bill’s implementation. We are looking at each clause, line by line, to decide whether it is safe or not. As she said herself at the time, the decision on Second Reading was a vote in principle to continue the discussion, which is what we are doing now. We are closely and minutely examining whether every clause is safe.

[Kim Leadbeater]

On that point, it is not an either/or. It is not just about passing legislation that improves choice and gives autonomy and dignity to dying people, and indeed fixes the current failings of the law as it stands, as we have discussed in great detail. It is about providing safeguards that make sure that is done safely, securely and robustly, and that address the issues and concerns we are discussing. It is not an either/or and it is important to make that distinction.

[Juliet Campbell (Broxtowe) (Lab)]

rose—

[Danny Kruger]

I am happy to give way to the hon. Lady.

[The Chair]

Order. You cannot intervene on an intervention. Let us be absolutely clear about that. The hon. Lady was intervening on the hon. Gentleman who has the floor. If he now wishes to give way, he may do so.

[Danny Kruger]

If the hon. Lady would like to intervene on me, I would be happy to give way.

[Juliet Campbell]

To go back to the amendment, we were talking about the Mental Capacity Act. The use of that Act must be drawn into question, because it was never intended as legislation for assisted dying. Much of what has been said in favour of using the MCA relates to it being tried and tested, and people understanding it, and the idea that to use anything else would make life complicated for professionals who use it as part of their day-to-day activities when assessing capacity.

On the surface, those reasons seem reasonable, and it is an easy option. However, if the MCA does not meet the threshold of meeting the needs of everyone, convenience should not be the deciding factor. Convenience cannot be considered as a sufficient reason to use the MCA as a fundamental element of the Bill. The assisted dying Bill in itself is enough reason to have an alternative measure to determine an individual’s eligibility to be considered for assisted dying.

[The Chair]

Order. I am going to have to draw the hon. Lady to order. An intervention is an intervention. I accept that we have slightly more flexibility in Committee than we do on the Floor of the House, but the hon Lady, and indeed all hon. Members, have to understand that speeches are speeches and interventions are interventions. That said, it is the job of the Chair to make absolutely certain that every Member has the right and the opportunity to speak. If the hon. Lady wishes to make a speech, that is entirely within her right: all she has to do is indicate to the Chair that she would like to be called and she will get called.

[Danny Kruger]

I am grateful to the hon. Lady; her points are absolutely right. Even if the House concludes that the overall principle is right, as the hon. Member for Spen Valley suggested, if it is not possible to do it safely, we should not do it at all. My great concern is that proceeding with the use of the Mental Capacity Act as it currently stands in the Bill will make the Bill dangerous.

Let me conclude my point about the difference between assisted dying and the withdrawing of treatment. To decline treatment is to assent to nature; it is to let one’s body do what it will. To commit suicide is to contradict nature; it is to do something to one’s body that interrupts its own plans. I recognise that the outcome is the same —it is death—but we are considering the process of decision making in the clause, and the decision is fundamentally different.

--- Later in debate ---

[Naz Shah]

My hon. Friend is not wrong, in so far as there can be two truths. There is a truth, for me, that the Mental Capacity Act does not deliver what we need it to deliver, and that is the concern we have heard from people who have given us evidence. We have not talked about the word “ability”—as hon. Members have pointed out, it is not set out in law—so there is a conversation to be had.

As my hon. Friend the Member for Spen Valley, the promoter of the Bill, clearly stated, this is about strengthening the Bill and bringing the best Bill to Parliament to give people a choice. That is what this is about.

[Danny Kruger]

The hon. Member is making such an important speech, and I am very grateful to her. This is a crucial discussion. The hon. Member for Ipswich suggested that the amendment would make things worse because it would apply a new test.

[Jack Abbott]

I was just following the argument.

[Danny Kruger]

I respect that. The hon. Gentleman is suggesting that there would be a new test, but it is for a new situation. I want to alert the Committee to the purpose behind this amendment. I understand that we are in a slightly polarised discussion. The hon. Member for Bradford West and I both voted against the Bill on Second Reading, and it is not likely that we will ever support it. Nevertheless, I encourage hon. Members to consider that the amendment, which was tabled by the hon. Member for Richmond Park, who is not opposed to assisted dying in principle, is genuinely trying to ensure that the Bill is as safe as it can be. All that has been proposed, as the hon. Member for Bradford West suggests, is a strengthening and a recognition of the importance of the principles of the Mental Capacity Act, without the—

--- Later in debate ---

On resuming—

[Danny Kruger]

I will conclude my intervention very quickly. I fear that I may have mischaracterised the hon. Member for Bradford West when I said that she is opposed to the Bill in principle; in fact, I do not think that is the case. I am not sure what the difference is between opposition in principle and opposition to the detail, but I recognise that she is certainly not opposed to the Bill in principle, so I apologise to her.

Does the hon. Lady agree that the Bill would take a great leap in the dark by legalising assisted dying? At the moment, that leap lands on the uneven ground of the Mental Capacity Act. Does she agree that, if we want to do this properly, we should prepare a solid, cushioned, safe landing space that is appropriate for the Bill, rather than the inappropriate mess that the Mental Capacity Act would induce?

[Naz Shah]

I am grateful to the hon. Gentleman for his correction. To clarify, I do not think anybody in this House disagrees in principle with the idea of not letting people suffer. I am very much about principle, and I came to this Committee very much in that spirit. When I was asked to join this Committee, I had to sleep on it, and I now realise why.

I am grateful for the interventions from my hon. Friends the Members for Rother Valley and for Ipswich. There are a couple of things that are important for us to understand. The Mental Capacity Act has not been tried in any of the other jurisdictions across the world on which we are basing this law, so we cannot make a comparison.

On the issue of whether it is either/or—whether it is the Mental Capacity Act or the word “ability”—the Secretary of State has the power to change that. If we are to be true to the spirit in which we have come to this debate to make the Bill as safe as possible, given that so many psychiatrists and experts have said that they are not convinced that the Mental Capacity Act is fit for purpose in this regard, surely it is incumbent on us to make that case.

--- Later in debate ---

[Kit Malthouse]

If the hon. Lady goes to column 277 of Hansard from that oral evidence session, Dr Price said:

“You are equating a refusal of treatment, in capacity terms, to hastening death by assisted dying. If those two things are equated, in terms of the gravity and the quality of the decision, the Mental Capacity Act may well be sufficient, but there are differences. There are differences in the information that the person would need and what they would need to understand.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 277, Q361.]

It is clear what Dr Price said. To be honest, the question was partly prompted as we had become a little confused, because the whole practice of psychiatry in the UK is founded on the Act at the moment. She seemed to be implying that somehow the entire practice of psychiatry in the UK was on unstable ground—and I do not think anybody is claiming that.

[Danny Kruger]

rose—

[Naz Shah]

I will take this intervention and then address both points.

--- Later in debate ---

[Danny Kruger]

It is interesting that my right hon. Friend the Member for North West Hampshire has cited that, and I will look at Hansard. However, what I just heard him say, quoting the doctor from the Royal College, was that if we equate the gravity of the cases, it would be appropriate. That is the equivalent of saying that if the two cases are the same, the mechanism can be the same.

Crucially, I do not believe that the Royal College does equate the gravity of the two cases. Its written evidence states that while

“a person’s capacity to decide treatment can be reliably assessed, an assessment of a person’s mental capacity to decide to end their own life is an entirely different and more complex determination requiring a higher level of understanding.”

It regards the two cases as different in principle and therefore requiring different tests.

--- Later in debate ---

[Stephen Kinnock]

I thank the right hon. Member for her intervention. We have had a conversation about the need to ensure that the impact assessment has a clear and specific focus on the impact in Wales. I can absolutely assure her that either there will be a separate impact assessment for Wales, or we will ensure that the impact assessment that we produce is absolutely clear in terms of the impact that it will have in Wales; it will be one of those two.

Personally, I am agnostic as to which of those it is. It is simply a question of what works best given the highly integrated nature of the conversation because the criminal justice aspects of it are a reserved competence, while health and care are a devolved competence. What is the best way to present that—having a single document or two separate documents? I am not entirely clear, but I have undertaken to check the matter with officials. I will get back to the right hon. Lady as soon as possible on that point.

[Danny Kruger]

I am very puzzled, on two grounds. The first is about the impact assessment. I simply do not understand the argument that the Government have to wait until the end of the Committee stage before they can have a view on the Bill and present it for Report. The fact is that the Bill could change again on Report, and the impact assessment would have to be updated further. Why on earth do we not have an impact assessment, which could advise the members of the Committee and the Government themselves on the appropriateness of the measures?

That brings me to my second point of confusion: I simply do not understand what on earth the Minister means when he says that he is neutral about the clauses. He has just given the view, from his position, that he objects to the amendment and that he supports the use of the Mental Capacity Act. He is basing his view— I had understood that, as a neutral member of the Committee, he was not going to express one—on something. What is he basing it on? Secondly, how can he express a view when he is supposed to be neutral?

--- Later in debate ---

Division 2

Question accordingly negatived.

Ayes: 8

---

Labour: 5
Conservative: 2
Liberal Democrat: 1

Noes: 15

---

Labour: 10
Liberal Democrat: 2
Conservative: 2
Plaid Cymru: 1

[Danny Kruger]

On a point of order, Sir Roger. I wonder whether you can advise me. I am perplexed about the position of the Government Ministers. It is an absolute pleasure to have them here, but I am confused by this Jekyll and Hyde character. They seem to have two personalities on the Committee, voting as private Members but speaking as Ministers. I wonder whether there is any precedent for that in any private Member’s Bill, or indeed any Bill, and whether Parliament admits the split personas that they have.

I totally understand the rationale for having Government Ministers here. It makes me query the whole concept of this being entirely a private Member’s Bill, but I recognise the role of the Government in it. However, if the Government want Ministers present at this Committee, there are Standing Orders that enable Law Officers to attend in their official capacity but not vote. That seems to me to be the appropriate way in which Ministers should be represented here. If they want to speak on the appropriateness of particular measures in terms of Government policy and applicability, that is perfectly appropriate, but I do not understand why they are also voting on this amendment in their capacity as private Members. I wonder whether you can advise me, Sir Roger.

[The Chair]

Happily, that is not a matter for the Chair. However, let me make it clear that the two Ministers present are members of the Committee in their own right as Members of Parliament and are therefore permitted to speak and vote, as are all other Committee members. Were any Minister to feel that there was a conflict between their personal view and the view that the Government wish to express, my understanding is that that would be a matter for discussion between that Minister and the Government. More than that I am afraid I cannot offer.

--- Later in debate ---

[The Chair]

We will take it when we get to it. Thank you for raising that point, because this is a learning process for a lot of people. We decide on the amendment that is moved; we will then decide on any further amendments, if any Member wishes to propose them, in the order in which they appear in the Bill. In this case, that is not yet.

[Danny Kruger]

I beg to move amendment 353, in clause 1, page 1, line 12, at end insert

“, and

(e) is not a prisoner”.

This amendment makes prisoners ineligible for assisted dying.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 356, in clause 1, page 1, line 12, at end insert

“, and

(e) is not homeless within the meaning of section 175 of the Housing Act 1996 (Homelessness and threatened homelessness).”

Amendment 354, in clause 7, page 4, line 12, at end insert—

“(ea) is not a prisoner,”.

This amendment is consequential on Amendment 353.

Amendment 357, in clause 7, page 4, line 12, at end insert—

“(ea) is not homeless within the meaning of section 175 of the Housing Act 1996 (Homelessness and threatened homelessness).”

This amendment is consequential on Amendment 356.

Amendment 355, in clause 12, page 8, line 9, at end insert—

“(fa) the person is not a prisoner”.

This amendment is consequential on Amendment 353.

Amendment 358, in clause 12, page 8, line 9, at end insert—

“(fa) the person is not homeless within the meaning of section 175 of the Housing Act 1996 (Homelessness and threatened homelessness).”

This amendment is consequential on Amendment 356.

[Danny Kruger]

Me again, I’m afraid. The amendments in my name would exclude from eligibility people who are in prison and people who are classified as homeless. In this debate and in our evidence sessions, we have heard it said quite a lot that most people who opt for an assisted death in countries that have it are advantaged—they are middle-class, in our idiom—but the plan is to offer it to everybody; it would be a universal right. My amendments would address some of the most disadvantaged people in our country.

I have had a very privileged life, but for 20 years I have run a charity working in London prisons; I spent about 10 years as full-time chief executive and have spent another 10 years as chairman. I have known hundreds of prisoners and ex-offenders, and I still do. Although I firmly believe in criminal justice—indeed, I think we need to be tougher on certain categories of offender—I recognise from my personal experience the dignity in all prisoners and the absolute necessity of respecting their dignity. In fact, I once wrote a speech for a Conservative leader of yesteryear that made some of those points and got headlined “Hug a hoodie”.

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[Kim Leadbeater]

Did the polling ask people’s view on whether terminally ill homeless people should have access to assisted dying, or on whether it should be offered to homeless people just for being homeless? That would seem very strange.

[Danny Kruger]

The hon. Lady might well be right. I totally take that point. I dare say it is people who are homeless. I think the question put was, “Should those who are homeless simply be able to ask for assisted dying?” People in this country say no. In Canada, asked the same question, a quarter of people say yes. The effect of the law has been to institute this principle of assisted dying being an acceptable choice under any circumstances, which is indeed, I am afraid, what happens.

I will end with a powerful quote from Fazilet Hadi, who spoke to us representing disabled people. She said:

“This Bill is not an abstract exercise; it will land in a society that is rife with inequality.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 185, Q242.]

She said that the society the Bill will land in is the thing that needs to change, not the Bill. She thinks we need to change our society before we do anything like introducing assisted dying. I agree.

[Kit Malthouse]

I should start by recognising that my hon. Friend the Member for East Wiltshire, who is my constituency neighbour, has devoted much of his adult life to public service. He should know that I have always admired him for that, and particularly for his work with the vulnerable and underprivileged in prisons. As he knows, I have spent much of my time in politics working with a similar population, so, like him, I understand their particular vulnerabilities. However, I oppose his amendments, and I hope he will bear with me while I enumerate why.

I believe that there are some definitional problems with the amendments, as well as some quite serious moral and ethical problems, and they compound into a practical difficulty. The first definitional one is who exactly my hon. Friend means by “prisoners”. As he knows, not all prisoners are the same. Would he seek to deny assisted dying to prisoners on remand who have yet to be found guilty of a crime but are being held in advance of the criminal justice process? Would he deny assisted dying—which will be available to everybody else if the Bill passes—to people who are held in prison for not paying their council tax, for example, or for contempt of court? There is a variety of vulnerability in the criminal justice system, and prisoners are inside for different lengths of time and in different institutions. Quite a lot of white-collar criminals go to open prisons, for example. Would he seek to deny them?

To me, if my hon. Friend’s objective is to protect vulnerable prisoners, the definition that he is using is far too wide. There are many people who may well find themselves in extremis while they are in prison and are likely to be released at some point, after a short sentence or because of the nature of their sentence, who would therefore have their ability to access assisted dying foreshortened.

Similarly, when my hon. Friend speaks of homeless people and uses the definition in the Housing Act 1996, I think he actually means rough sleepers. The definition of homelessness that he referred to includes people who are staying with friends, people who are moving between homes and people who are likely to become homeless at some point in the future. It is a very wide definition, which covers a large number of people, some of whom would not necessarily be classified as vulnerable and may well be assessed as perfectly capable and have the capacity to make this decision. So my first point is that there is a definitional problem with the broad terms that my hon. Friend has chosen.

[Danny Kruger]

I accept those points. Nevertheless, the Bill itself has broad definitions and large exclusions—people who have more than a six-month prognosis, and so on. The Bill, I am afraid, operates in pretty broad brush strokes in order to try to defend large categories of people, so I think it is appropriate to exclude all people who are currently incarcerated—people who are in prison—whatever the reason or the length of their sentence, until they are released, and then they can start the process if they wish to and if they qualify.

On homelessness, yes, we should use the official definition of homelessness, which basically means “in precarious housing”. The purpose of the Bill is to enable people who have full autonomy to make a decision in their own best interest. I think it is legitimate to ask whether people who are living in insecure accommodation, whose lives are in flux, who are experiencing extreme precariousness in their lives, should meet the appropriate criteria for autonomy that we wish to set out.

[Kit Malthouse]

I was about to come on to the fact that those questions would indeed be asked through the assessment that takes place. As my hon. Friend knows—we have had a long discussion about it—the Mental Capacity Act relies to a certain extent on context to assess capacity.

Turning to my hon. Friend’s point on prisoners, this may come as a surprise to him, but some people who are held on remand are found innocent and are released from prison. During their period on remand, which could be quite lengthy, they would be denied access to something they would not otherwise be denied access to.

[Danny Kruger]

My objection is not on the basis of criminality, innocence or guilt. I would not deny criminals this right because they are criminals. I would deny them what I regard as a dangerous opportunity because they are vulnerable. Whether guilty or not, whether they are on remand or not, they are in an equally precarious position and equally vulnerable, and that is why they should be excluded.

[Kit Malthouse]

I understand my hon. Friend’s point, but we are talking about people who do not have much time. We have to remember throughout this debate that we are talking about people who have limited time; they have been diagnosed, and their prognosis is six months or less. In fact, the experience from overseas is that quite a lot of people come to assisted dying beyond six months. We are operating on the basis that suddenly everybody at six months decides they are going to apply for it. Quite a lot apply with just days or weeks to go; time is therefore important to them, and so it should be to us. I am concerned that the definitions interfere with that.

Secondly, there is a distinct moral issue about the denial of services, particularly medical services, to groups of individuals based on their circumstances. We do not currently do that. We do not deny medical services to prisoners because they are prisoners. We believe it is a sign of a civilised society that they access the same healthcare as everybody else through our national health service. The same is true of those homeless groups. That includes allowing them to make the kind of decisions that we have talked about in the previous debate: decisions about life-threatening surgery and about the continuation of their life. It is certainly the case, as my hon. Friend will know from his work in prisons, that a number of prisons have developed hospice facilities within the prison to deal with end-of-life issues. Indeed those that do not have hospice care work closely with NHS palliative care outside and very often bring in specialists to deal with end-of-life issues in the prison.

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[Kit Malthouse]

I would certainly concede that; absolutely, I agree. The whole purpose of the safeguards in the Bill is to protect those who would be vulnerable, to ensure they have the capacity to make the decisions they want to make, and to ensure that they are making them for the right reasons. However, I think a lot of people would find it unfair and immoral that they were excluded not because of their own sense of themselves and their ability and capacity but simply because of their circumstances. As I am trying to point out, those who are homeless or prisoners in the widest definition of those words can find their circumstances changing quite significantly within the timeframe of six months. Given that they have only got six months under this Bill, we should not interfere with that and say, “Well, you are in; you are out.”

This may seem like a narrow example, but imagine that somebody diagnosed with a progressive disease were to commit a criminal act and end up going to prison, and during their time in prison, they reach the six-month period. Are they to be denied assisted dying if it is available to everybody else in the population? To me, that would not seem morally right, particularly given that we have a duty to deliver, and we do deliver, end-of-life services to them in the prison to help them cope with those circumstances. As my hon. Friend will know, there are charities which provide end-of-life care in prison as well.

[Danny Kruger]

In the circumstances my right hon. Friend is describing, the prisoner would be eligible for the compassionate release scheme.

[Kit Malthouse]

They would, yes.

[Danny Kruger]

That is what I hope would happen if it was necessary for the prisoner to be released in order to avail himself of opportunities on the outside. If he is terminally ill, that is what should happen.

[Kit Malthouse]

I am very pleased my hon. Friend raised that issue, because I was about to come to the practical difficulties that this presents, for exactly that reason. As he rightly pointed out, for a large number of prisoners, subject to assessment of the safety of the public, if they contract a terminal disease in prison, as they reach the end of their life, they qualify for compassionate early release. Often, that is within weeks of their death—naturally, as one would expect. It is carefully reviewed by prison governors and, I think, has to be signed off by the Secretary of State, as a final control. The problem with denying them the services while they are in prison is that if they are eventually compassionately released, they may have only a matter of weeks or days to go through what will be quite an onerous process to avoid a horrible death.

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[Danny Kruger]

rose—

[Kim Leadbeater]

rose—

[Naz Shah]

I give way to the hon. Gentleman first.

[Danny Kruger]

On the point of legality, of course a law could be challenged under the European convention on human rights, but Parliament is sovereign. If Parliament decides to exclude a particular category, we in this place have to take this enormous responsibility—we make the law in this country.

[Naz Shah]

I give way to my hon. Friend.

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[Naz Shah]

I do not have any comparable situations; this is uncharted territory.

[Danny Kruger]

Prisoners are denied their liberty, not just their vote. They are treated as a single class of people who the state has specific responsibilities for, because it essentially owns them for the time that they are incarcerated. Prisoners have particular protections, but they are also denied a whole range of human rights and opportunities that the rest of society can have. It is not inappropriate to treat prisoners as a distinct class of people to whom the state has a specific responsibility.

[Naz Shah]

The hon. Gentleman clearly has more recent experience of prisons than I have—thankfully. In closing, I will be supporting his amendments to protect people who are vulnerable in prison and people who are homeless.

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[Stephen Kinnock]

I apologise; I think I misunderstood the intervention of my hon. Friend the Member for Bradford West, so my comments were not clear. I meant the treatment of this matter under the law. As I said, the justification test requires that the treatment in question is a proportionate means of achieving a legitimate aim. That means the way in which the matter is treated under the law. That is what I meant; I think we got our wires crossed.

Finally, let me address amendments 356, 357 and 358, whose purpose is to exclude those who are homeless within the meaning of section 175 of the Housing Act 1996 from the definition of a “terminally ill person”. The effect of amendment 356 would be to amend the definition of a “terminally ill person”, as set out in clause 1 of the Bill, to expressly exclude a person who, notwithstanding that they met all the other requirements set out in paragraphs (a) to (d) of subsection (1), was homeless within the meaning of section 175 of the Housing Act 1996.

Amendments 357 and 358 seek to make consequential amendments to clause 7 on the first doctor’s assessment and clause 12 on court approval. These amendments would require the co-ordinating doctor and the court to be satisfied that, in their opinion, the person was not homeless within the meaning of section 175 of the Housing Act 1996 before making their statement or declaration to allow the person to proceed to the next stage of the assisted dying process.

Article 14 states that the rights set out in the ECHR should be secured for everyone without discrimination on any ground. This amendment engages article 8 on the right to respect for private and family life. Making those who are homeless ineligible for assisted dying would lead to a difference in treatment that will need to be objectively and reasonably justified. The justification test requires that the treatment in question is a proportionate means of achieving a legitimate aim.

I hope these observations may be helpful to Members in considering these amendments and making a determination about who should be eligible for accessing assisted dying services, should the Bill pass.

[Danny Kruger]

What an interesting debate—I am grateful to all hon. Members who participated.

I am interested in what the Minister was saying about the ECHR. Notwithstanding my general point about the sovereignty of Parliament, when Lord Sumption gave evidence to the Committee two weeks ago, he stressed the wide margin of appreciation given to member states on the ECHR. Does the Minister think that that will apply in this case to ensure that the British Parliament could vote to exclude these categories of people? If his view is that the Bill could be subject to challenges on discrimination grounds, however, particularly under article 14, I think we will have a lot of problems in applying the Bill. I wonder whether, in due course, we will be able to tease out how the ECHR will intersect with the Bill.

As the Minister says, the crucial point is that any discrimination must be justified on the basis of achieving a legitimate and proportionate aim. My suggestion is that there is an absolutely legitimate aim, and that this is a proportionate means of achieving it.

The debate got quite philosophical, which I found very interesting. I observe that my constituency neighbour, esteemed colleague and great Conservative, my right hon. Friend the Member for North West Hampshire, has a vision of our particular political creed that is entirely individualistic. He stresses the absolute importance of individual autonomy, treating everybody as an individual without reference to the context in which they live. I suggest to him, and to the Committee, that our freedom and autonomy depend on our relationships. Our autonomy proceeds from our socialisation. We do not emerge fully formed into the world with all our values and attributes; we acquire them by virtue of the people around us.

The crucial thing about the prison experience is that it disrupts the relationships that can make an individual genuinely free. Homelessness does likewise, and it sets up all sorts of new relationships and new socialisations that can often be very negative.

[Kit Malthouse]

I am grateful for my hon. Friend’s kind words, but he will know that the foundation of our beliefs stretches from Magna Carta through to Mill and is based on a legal notion that I am to a certain extent my own island—that I have autonomy over myself. From habeas corpus to making decisions about my own medical treatment, I should have rights. That is not to say that my decision-making capacity should not be assessed within the context in which I live.

What I was trying to communicate to my hon. Friend and his supporters in respect of this amendment is that I think it profoundly wrong to paint all prisoners with the same brush and see them as a homogeneous whole, rather than seeing them for the individuals they are, specifically when they are taking a very individual, personal and private decision about their own life and death.

[Danny Kruger]

I trace our liberties to an evolution of British law, and of English law, that recognises the essential nature of our individuality as being socialised. We belong to one another and we derive our freedom from other people. Our autonomy, Magna Carta and all the liberties of the individual proceed from that. None of us, no man, is an island. That is what I suggest to my right hon. Friend. His point was about treating everybody as solitary individuals, making independent private decisions. That is not the way any of us operate; it is certainly not the way people in the most vulnerable circumstances operate. What actually happens is that we are heavily influenced by the people around us, by our circumstances and by the choices before us.

To descend from the abstract, let us consider an actual case, albeit a hypothetical one. Someone is in prison. They have committed some crime, or they have not committed a crime but have been remanded. Their whole family life has been smashed to pieces over the years, or just recently. They then get the terrible diagnosis of a terminal illness. A doctor says to them, because they are allowed to do so under the Bill, “You know, one of your options is an assisted death.” I think that that would be incredibly influential, to the point of serious concern, for those of us who know how vulnerable people in prison are. The same applies to people living on the streets, the people my right hon. Friend was describing.

[Sean Woodcock]

I believe that what the hon. Member has just espoused, and what has prompted this amendment, is the sort of thing that would have come out if we had had an impact assessment. If this were a Government Bill, some sort of consultation would have flagged up the potential issues ahead of the next stage. I believe that that is the exercise in which he is engaged. We have been promised a Bill with the strongest possible safeguards. He comes from a position similar to mine, which is that there is no stronger safeguard than preventing people from having assisted dying. I believe—I am happy to be corrected—that what he is trying to do in the absence of that is flag up potential issues that mean that more safeguards are needed than are being offered in this Bill. Is he prepared to comment on that?

[Danny Kruger]

The hon. Gentleman is absolutely right. Once again, it is a shame that we are feeling our way in the absence of that assessment. Nevertheless, I think we all have experience and we can draw on the evidence. The hon. Member for Bradford West made a very powerful point, and she was absolutely right. I spoke earlier about the evidence on suicide among the male prison population; I have experience of working with women in prison as well. There is a genuine danger of chronic, almost epidemic, self-harm among the female prison population. Likewise—this is a fact that we need to bear in mind throughout the debate—suicide is itself contagious. That is why it is so important to discuss it in a responsible way. The option—I use the term advisedly—of assisted suicide is itself dangerous in the context of a prison population in which these ideas are contagious.

My right hon. Friend the Member for North West Hampshire talks about the need to assess each case on its own merits, individually. I recognise that, and in principle of course that is what we should be doing. Nevertheless, that assumes that the safeguards in the Bill are adequate to the challenge of dealing with people in such particularly vulnerable circumstances. I am concerned that they are not adequate anyway. I believe very strongly that they are not appropriate to people in these circumstances and that therefore it is appropriate to have what he calls a blanket ban.

As I said in an intervention earlier, we have to treat particular classes of people in the same way. We do that all the time, with respect specifically to the prison population. The fact is that we have to draw the line somewhere. We are drawing the line in all sorts of places in this Bill—around the age limit and around diagnosis and prognosis. I think it would be very appropriate, given the extreme vulnerability of these populations, to draw it around them and protect them from the vulnerabilities and dangers that I think all Members recognise might apply in certain circumstances. They will apply in heightened likelihood to these populations.

I do not propose to press these amendments to a vote, but I am grateful to hon. Members for the points that they have made, and I hope that the concerns have been noted. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment made: 179, in clause 1, page 1, line 13, after “provided” insert “in England or Wales”.—(Kim Leadbeater.)

This amendment limits the assistance that may be provided in accordance with the Bill to assistance in England or Wales.

[Juliet Campbell]

I beg to move amendment 109, in clause 1, page 1, line 17, after first “and” insert “demonstrably”.

This amendment reflects the changes in Amendments 110 to 112 that change the requirement from having to establish that a person who wishes to end their own life under the Act has clear, settled and informed wish, to a clear, settled and demonstrably informed wish.

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[Stephen Kinnock]

The amendments in the name of my hon. Friend the Member for Broxtowe relate to an individual who seeks to access assisted dying services demonstrating their wish to end their own life and demonstrating their understanding of the process by which that happens. To support the Committee’s deliberations, I will briefly summarise the Government’s analysis of the effect of the amendments.

Amendments 109, 110 and 111 would modify the requirement that the co-ordinating doctor and the independent doctor must undertake an assessment to ascertain whether, in their opinion, the person has a clear, settled and informed wish to end their own life. That would be amended to require the person to have a clear, settled and demonstrably informed wish. The term “demonstrably” would not provide further practical guidance beyond the words already in the Bill and could create uncertainty as to what constitutes being demonstrably informed.

I turn to amendment 112. Clause 9 currently provides that the co-ordinating and independent doctors must explain and discuss a number of matters with the person being assessed. These matters are set out in clause 9(2)(b), (c) and (d). In the interests of time, I will not go through each of those matters, but they include an explanation and discussion of the person’s diagnosis and prognosis, any treatment available and the likely effect of it, and the further steps that must be taken before assistance can lawfully be provided to the person under the Act.

The amendment would create an additional requirement for the co-ordinating and independent doctors. It would require them both to be satisfied that, in their opinion, the person seeking assistance has demonstrated their understanding of the matters that have been discussed under clause 9(2)(b), (c) and (d). The amendment does not specify in any further detail what the doctors would be required to look for to satisfy themselves that a person has demonstrated their understanding. That would be left to their professional judgment, with training, support and guidance, as with other concepts in the Bill. The amendment would leave it to the co-ordinating and independent doctor’s professional judgment to determine what “demonstrated their understanding” looked like in respect of each individual person.

I hope that those observations are helpful to the Committee.

[Danny Kruger]

I have just a few points to make. I very much applaud the hon. Member for Broxtowe for her amendment, which would genuinely—demonstrably, I might say—strengthen the Bill. It does not seem in any sense hostile to the principle or purpose of the Bill; it supports it.

To make a gentle criticism, I think that there is a concern about the lack, throughout the Bill, of a proper trail of documentary evidence following the applicant through the process. For example, the two conversations with the doctor would take place behind closed doors, and no record of their discussion would be made. I do not think that conducive to trust. There is no way to assess whether the safeguards are actually in operation.

[Kit Malthouse]

I am afraid that that is not actually correct. If my hon. Friend is willing to look at my amendments—I appreciate that he might not have got to them yet—he will see that one of them would require the doctor to produce a report on their assessment of the patient. Obviously a two-way declaration would also be required that the conversation pursuant to clause 4(4) has taken place and that in the doctor’s view the person is in possession of all the facts that they need in order to make the judgment that we are asking them to make. That detail and documentation will be inserted into the Bill if my amendment is agreed to.

[Danny Kruger]

I am grateful to my right hon. Friend. I particularly applaud his amendment’s aspiration to ensure that the doctors’ conversations are properly recorded.

[Kim Leadbeater]

Further to the comment from the right hon. Member for North West Hampshire, all of that will obviously be recorded on the patient’s medical records as well. The idea that it is not being recorded is just not correct.

[Danny Kruger]

The decisions will be recorded, but the conversations that the hon. Lady stipulates should take place under the Bill need further recording, in my view, with further evidence of what was discussed in order to ensure that the safeguards have been properly applied. I also point out that for the chief medical officer to effectively carry out the review under clause 34, they must have evidence available, not just a few schedules that have been signed off.

Likewise, I am glad to say that the opportunity remains for a legal appeal, in so far as we still have a judicial process, but I am concerned that the lack of any documentary evidence makes the application difficult for any external party or the Court of Appeal to review. Currently, there is a great paucity of information that the High Court judge considering the application can request. I think it is important that the High Court judge—or, indeed, the panel, if we move to that approach—should have access to a much fuller range of documentation to ensure that the process has been properly followed.

[Tom Gordon]

The hon. Member makes a valid point about ensuring that there is documentary evidence. Does he not feel that that will be covered at a later point in the Bill when we debate the amendments on training, and specifically on ensuring a coherent way in which all the doctors and people in the process set about recording?

[Danny Kruger]

The hon. Gentleman is a great stickler for doing things in the right order. I am grateful to him for calling us to order on that point again. I dare say that he is absolutely right. All these issues are rather interwoven through the Bill.

I will finish on a point about the role of the Court of Appeal. A rejected application—although not an approved application, I am sorry to say—can be appealed under clause 12. For the Court of Appeal’s review to be substantive, it must surely be able to review the evidence as fully as possible on what happened throughout the terminally ill person’s application.

[Juliet Campbell]

I still think that it is important to add “demonstrably”. The word should be included; I do not see that it would create any additional confusion. The right hon. Member for North West Hampshire said that he had tabled some amendments later on in the Bill. However, that is later on. Putting in “demonstrably” here would strengthen his proposal.

Terminally Ill Adults (End of Life) Bill (Tenth sitting)

Danny Kruger Excerpts

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[Rebecca Paul]

I completely agree. The hon. Member has made some powerful points over the course of this Committee. The reality of the matter is, like the hon. Lady said, this has not really been considered fully until recent times. I think we are now all much more aware of the coercion and pressure that goes on. It is only right, when we are making this decision now, to be fully aware of that and have our eyes wide open to the realities.

At the end of the day, we are not legislating for when it works perfectly for that ideal candidate who absolutely wants to do this for all the right reasons and they are in pain, which is exactly what the Bill is designed for. We are legislating for that big group of people who are vulnerable, and who it may not work for. That is a much bigger group. We heard compelling evidence from Dr Jamilla Hussain, which really impacted me, about this big group of vulnerable people who could be detrimentally impacted. We must make legislation for the group that could be negatively impacted. They should be our focus.

[Danny Kruger (East Wiltshire) (Con)]

I am very struck by that last point. Does my hon. Friend agree that the purposes of these amendments build on the principle of the Bill? The Bill recognises the existence of vulnerable groups and attempts to introduce safeguards. It is not a free-for-all. The absolute purpose of the Bill is to ensure that vulnerable groups are protected.

My hon. Friend’s amendments support the principle of the Bill, which says that encouraging suicide remains illegal. By implication of the Bill, to encourage people to take an assisted suicide should be illegal too. My hon. Friend is actually building on the principle of the hon. Member for Spen Valley’s Bill, and I hope the Committee will not regard these amendments as in any way harmful to its purpose or as an attempt to make it more impractical in operation. They would make the Bill clearer. To the point made by the hon. Member for Spen Valley about overcomplicating things—I think the complications exist in the current text of the Bill, whereas my hon. Friend the Member for Reigate would be clarifying its purpose.

[Rebecca Paul]

My hon. Friend makes the point powerfully. I say to everyone in this Committee—we had this discussion yesterday—that I am not opposed in principle to the concept of assisted dying, but I see my role here as to protect the vulnerable. That is what I am trying to do, and I know everyone here wants to do exactly that. I cannot really see any downside to these amendments. Why would the Committee not want them included, if we want to protect the most vulnerable? Yes, it may put a bit more onus on clinicians, because they would need to look for a lower level of coercion. But that is absolutely right—of course they should have to do that. We are talking about assisted death. It is really important that we have a higher level of consideration.

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[Rebecca Paul]

My interpretation is that it would not.

[Danny Kruger]

What the hon. Member for Luton South and South Bedfordshire said is not the case at all. What the Bill would do is to exempt people who go under this new procedure from the operation of the Suicide Act. It would not create some new category of person; the law would just operate in a different way. I recognise that she is saying that, in her mind, there is a difference between somebody who is dying who has an assisted death and somebody who is healthy who commits suicide, but that is a completely arbitrary distinction in reality. Many people who have terrible diagnoses kill themselves, even though one might say that they are not actually dying and they could be treated. Should that person qualify?

Entering into the mind of someone who wants to take their own life is an absolute impossibility, and that is the whole problem with this Bill: we are trying to create distinctions that are impossible to police properly. It goes to the point of my right hon. Friend the Member for North West Hampshire about trying to police private conversations. That is what this Bill entails. We are inviting the state to intrude, in an absolutely impossible way, on what is going on in people’s minds. To go back to the point made by the hon. Member for Luton South and South Bedfordshire, there is no clear distinction between somebody who would choose assisted dying through a doctor’s prescription and one who would choose to take their own life without assistance. It is not possible to draw that distinction. In fact, we have seen so many times that people who might want to kill themselves one month change their mind a month later. I am afraid that this is the challenge with the whole Bill.

[Rebecca Paul]

I support my hon. Friend’s comments. Outside of this place, I speak about this topic in a manner that is as sensitive as possible. When we are talking about the legislative changes that are needed to this Bill and how it interacts with other legislation, I will use the correct legal terminology, because I think it is really important that we do that.

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[Rebecca Paul]

I thank the hon. Member for that intervention. I think the point on probate is right; it is commonly used there, but it is not just used in that situation. My understanding is that, when it comes to decisions by clinicians with regard to withdrawing life-sustaining treatment, undue influence is one of the considerations.

[Danny Kruger]

Just to amplify that point, my hon. Friend is absolutely right. In the “Re T” case, the Court of Appeal judged that undue influence should be taken into account in medical decisions, so that is an existing principle in law. It feels totally appropriate to bring that in here, seeing as, as we have discussed, the principle already exists that it is wrong to encourage suicide, and that it is possible to have undue influence without coercion or pressure being present. To address the point made by the hon. Member for Spen Valley, I do not think those terms are adequate to include undue influence; undue influence can exist even when there is no evidence of coercion.

[Rebecca Paul]

I thank my hon. Friend for that intervention. The point that I would make is about an example that we talked about a lot yesterday, so I know that it resonates for many on the Committee. If someone is making a decision and a treatment is being withdrawn, or life support is being turned off, undue influence is already one of the things they consider, so when we are considering assisted death, surely, in order to be consistent, we would apply undue influence to that as well, rather than having a lower level. Why would we have a lower threshold for assisted dying compared with withdrawal of treatment?

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[Rebecca Paul]

It is reassuring to hear that I am not the only one worried about this, so I thank the hon. Lady for that.

[Danny Kruger]

I understood the Minister to say that the judge needs clarity when they come to adjudicate on a case. We have heard through the media, although an amendment has not yet been tabled, that a judge will not oversee the process. Does my hon. Friend share my concern that we are setting up a legal system that will not provide proper legal oversight of the proposed measures?

[Rebecca Paul]

My hon. Friend’s point goes to the heart of the case, and to the point that I made earlier: it is extremely difficult when the Bill is a moving feast. We are tabling amendments to the Bill as drafted, but if substantial changes are made, that will impact some of what we did earlier.

[Rebecca Paul]

I thank the hon. Member for sharing her view on that.

[Danny Kruger]

This is a very helpful conversation, and I am grateful to my hon. Friend for allowing all these interventions. It is right that there would be a judge in the event of a criminal offence. We are trying to ensure that we do not get to that point by insisting that in the early stages of the process, when a doctor makes their assessment—indeed, when a judge makes their assessment, if there is still that judicial stage, as we hope there will be—they are required to ensure that there has not been undue influence. It is important that, at that early stage, they are asked to check not just whether there has been coercion. I hear what the Minister says about the concept of undue influence hopefully somehow being incorporated in the definition of coercion or pressure, but we need to ensure that that test is applied at a very early stage. The first people who discuss the matter with the patient should ensure that there has been no undue influence, which by the way is about much more than outright coercion; it is about an imbalance of power in the relational dynamics within families, which as we all know can be very complicated. That is what necessitates the amendment.

--- Later in debate ---

[Jake Richards]

The issue I have is that if we open the door to all different types of terminology, it will never end. The law is best served when it is clear, simple and straightforward.

[Danny Kruger]

Will the hon. Gentleman give way?

[Jake Richards]

Let me just make this key point. Members have raised the case of Re T. I must admit that I do not know that case, but I believe it is a 1992 Court of Appeal case about a refusal of treatment, so it is 33 years old. The law has moved on. As the Minister said earlier, the terminology of coercion and pressure is much more modern, and is used in legislation that has been drafted in the last decade, rather than the Suicide Act drafted in the 1950s and that Court of Appeal case from the early 1990s.

Last night, I briefly went back to my law books—I sound like I am really missing my old job—and looked into where the concept of coercion is used across different jurisdictions and areas. This is what I read: “Coercion is a phenomenon the courts have experience of handling. Generally, coercion as a concept in our law involves applying pressure, whether physical, psychological or moral, to force someone to act against their free will or better judgment. This pressure can manifest in various forms, such as threats of intimidation and undue influence, and is recognised across criminal, family, consumer and contract law.” It is used in forced marriage legislation. It is used in criminal legislation. Case law has made it very clear that coercion is used interchangeably with duress, defined as a constraint on a person’s choice.

I feel that we are dancing on the head of a pin. The law has been drafted by one of the most senior parliamentary draftspeople. The Government Minister has confirmed that the Ministry of Justice deems this to be a sensible course of action if this legislation is to proceed.

--- Later in debate ---

[Jake Richards]

Yes. As I say, the amendments are perfectly reasonable; it is sensible to raise them and it is good that we are having this conversation. I have looked into this carefully and I take it seriously. I feel that the square is squared—or the circle goes all the way round, to mix my metaphors—but that does not mean that we should not look into this further when we get to the relevant clauses.

[Danny Kruger]

I am worried about the constant suggestion that we look at these issues later. The fact is that we do not know what the Bill will look like later. We do not know what amendments will be tabled or what will be agreed. It is always possible to revisit amendments that have been passed in the earlier stages if subsequent amendments make them otiose. The point is that we should not pass this opportunity to strengthen the Bill if we can.

On the point that the hon. Member for Rother Valley was discussing with my hon. Friend the Member for Reigate about the Suicide Act explicitly referring to pressure as a subset, as it were, of encouragement, that Act specifies that encouragement is the general, catch-all term and includes pressure. I think the hon. Gentleman is suggesting, and other hon. Members have suggested, that it is the other way round: that coercion or pressure somehow include encouragement. Surely encouragement is the broader term—it exists in the current law on suicide. What is the problem with using that term in addition to coercion and pressure, consistent with existing law? It is a broader and more sufficient term.

[Jake Richards]

On the first point, in fairness, the hon. Member for Reigate was talking about a clause that we are going to consider and the link between two different criminal offences in the 1961 Act and clause 26 of the Bill.

On the second point, the Bill—to coin a political phrase—needs to be fit for the future. The language used in legislation over the last decade when we are considering coercion—I use that word automatically because that is the language we use now—is much more appropriate than “encouragement”, which is slightly archaic, to be honest. Perhaps we need to look at the Suicide Act as well—although not in this parliamentary term; that is for the second term. [Laughter.] I have nothing further to add.

--- Later in debate ---

[Juliet Campbell]

I absolutely agree that we do not want people not to understand what the Bill allows them to do or not do. We spoke earlier about making the Bill simple enough for professionals to understand so that they know how to deal with particular instances, but it is not here to make life easy for professionals; it is here to ensure that anyone who is vulnerable—anyone who has six months to live, or for whatever other reason—is protected.

A continuous theme of our debates and all our conversations is that we must make safeguarding as tight as possible so that people are protected. I believe it is not too much to ask to include those additional words to ensure that the wording is as tight as possible and protects the people who need our protection every single day.

[Danny Kruger]

It is a pleasure to follow the hon. Lady. May I say how much I agree with what she has been saying and the purpose of her amendments, which I will be supporting if we get the chance, as I will the amendments in the name of my hon. Friend the Member for Reigate?

I do not want to repeat what I said yesterday, but my general point is that we make decisions in a context. We are directly influenced by the people around us. I want to highlight the very powerful phrase that my hon. Friend used. She said that love can shroud decision making, and the influence and pressure that is applied to us can be shrouded in love.

Professor House, who gave evidence to us, talked about the enmeshment of people’s decision making with the influence of their loved ones and people around them. The fact is—hon. Members have made this point—that power dynamics in families are complicated, and where there is an imbalance of power, there is risk. The Bill implicitly acknowledges that through the safeguards that it attempts to create, but I do not think they are strong enough.

I know that my right hon. Friend the Member for North West Hampshire is concerned that strengthening the Bill in this way will create an opposite risk, which is that a family member who was behaving perfectly properly could somehow be dragged into a prosecution, or that the application would be denied on the basis of a reasonable conversation that had taken place between loved ones—“My darling, do you think I should do this?” It is a lovely fictional conversation, a sweet exchange between a loving couple, but saying to somebody that you agree with the decision they have made and that you would support it, or that you are content with it or understand it, is not the same as undue influence—it is not even the same as encouragement. It is similar to the debate we will be having in due course about the role of the doctor making an overt suggestion of an assisted death, rather than consenting to a suggestion that has been made by the patient.

[Kit Malthouse]

My hon. Friend is asserting that those two things are different, but obviously, those assertions would be tested in court. If a person were to appear in front of the co-ordinating doctor and say, “Doctor, I want an assisted death and my husband thinks I should do it,” is that interpreted as encouragement? Is it support? Under the current legal framework, that would be interpretable and inquirable. However, as I said to my hon. Friend, I am not necessarily nervous that families would be dragged into some kind of legal conflict. I am concerned that they would seek to not get there at all, because the insertion of those words would make them so nervous about the conversation that they would become guarded.

We know from other jurisdictions that over time, people will come to understand this process. As I will refer to during our debate on the next grouping, they will also start to understand what they should not say, if we put into the Bill that there are things that will play negatively if they are revealed to the relevant authorities. My concern is that unless we keep the Bill simple and clear, and leave families and medics the space to have free, frank and open conversations that—from the medical point of view—cover the full range of options, we will start to restrict and police the conversation, and therefore make it that much more difficult.

[Danny Kruger]

The risk of gaming—of patients playing the game, and doctors seeking out words to say or not say—is an issue throughout the Bill. That is a general problem with the Bill; thankfully, it is not just a free-for-all. However, in the scenario that my right hon. Friend suggests, that is exactly my concern: if the patient says that their spouse agrees with them or encourages them, that should be a red flag. Under the current Bill, it is not clear that it would be. There is no obligation on the doctor to record that there has been undue influence or to push back, because at the moment, the doctor is looking only for evidence of coercion. As I will come to later, that bar is too low to use, so if the doctor hears those words, I would like him or her to start asking questions, to push back, and to satisfy himself or herself that there has been no overt encouragement or undue influence. That is the point of what we are trying to do.

[Naz Shah]

To come back to an earlier point—I want to make these points, simply because it is really important that we get them on the record—my hon. Friend the Member for Rother Valley talked about undue influence and encouragement perhaps being archaic terminology. However, just last year, the Digital Markets, Competition and Consumers Act 2024 cited undue influence, as did the Anatomy Act 1984. Acts passed by Parliament in the last few years have used that terminology, so does the hon. Member for East Wiltshire share my concern about the resistance to having those words added to this Bill?

[Danny Kruger]

The hon. Member is absolutely right—undue influence does exist in law, including in laws that have been passed very recently. I recognise that the hon. Member for Rother Valley is not impressed by laws that are more than 10 years old, but I hope he might be satisfied that a law passed last year is sufficiently up to date and modern for him to regard as morally valid. Undue influence is an existing term, and we should apply it in this case.

[Kim Leadbeater]

On that point, and in response to the comment made by my hon. Friend the Member for Bradford West, although I stand to be corrected by my hon. Friend the Member for Rother Valley, I do not think that he said that undue influence was an archaic term. I think it was the word “encouraged”.

--- Later in debate ---

[Danny Kruger]

If we are going to rule out the word “encouraged” on the basis of archaism, I do not know what we are going to do with the language. It is a perfectly acceptable term. We are still governed by the Suicide Act, to which the Bill refers and in which context it is framed, so it is appropriate to remember that the Act specifically prohibits encouragement and includes pressure within that concept. The two terms co-exist in the same section of the Suicide Act, so the idea that we cannot have more than one word, and that that is somehow confusing, is wrong.

[Rebecca Paul]

In the light of my hon. Friend’s points, I have an interesting fact that he might enjoy: “encourage” was added to the Suicide Act by the last Labour Government in 2009, and replaced “aids” and “abets”, so it is not that archaic.

[Danny Kruger]

My goodness, 2009 might be in the mists of history for the hon. Member for Rother Valley, but it was the last Labour Government. That is very good to know, and I am grateful to my hon. Friend.

The hon. Member for Spen Valley made the point, which is quite often made in defence of the Bill, that there is currently no framework to spot coercion, therefore the Bill creates greater protections for people. The fact is that, as the hon. Member for Bradford West said, there is no law that currently allows assisted dying, so no framework is necessary to prohibit encouragement or inducement to an assisted death—the opportunity does not exist. I think everyone must acknowledge that, if we pass the Bill, we may open up a new avenue for abuse, and it is necessary that the Bill close it off. That is right and appropriate.

Coercion and abuse no doubt go on and are tragically common, but the answer to that problem is not to legalise assisted suicide and put a regulatory framework around it with limited protections against coercion and influence. We have to deal with the terrible cancer of abuse and coercion that exists in our society, as the hon. Member for Bradford West said. If we are concerned about undue pressure in families, that should be our social mission. If we are to have an assisted dying law, let us make it as strong as possible. As I say, we are potentially opening up a new avenue for abuse within families.

[Kim Leadbeater]

For me, the law needs to change for a number of reasons, and we will talk about some of them as Committee proceedings continue: autonomy, dignity, personal choice and bodily autonomy. In terms of this issue, we heard from families who faced police investigations as a result of a loved one taking their own life. Not only were they dealing with the trauma, grief and loss of their bereavement, but they faced often months and months of police investigation. In the oral evidence sessions, we heard from Pat Malone, who was in that situation after his brother took his own life. Surely the hon. Member has to acknowledge that that is a problem. It is not the only problem, and it is not the only reason for the Bill, but he has to acknowledge that we as legislators have a duty to correct it.

[Danny Kruger]

I am sure that the hon. Lady will acknowledge that those investigations will still happen, because not everybody who commits suicide will be subject to the Bill; not everybody who is terminally ill and wants to take their life with the assistance of their loved ones will be caught under it. I am sure she acknowledges that it is therefore still appropriate to have safeguards against assisted suicide outside the law—in fact, the Bill strengthens those safeguards. Those will still continue. I also regard it as appropriate and necessary to have a law against assisted suicide, for all the reasons that we have been discussing.

The hon. Lady is right that it is appropriate for Parliament or the authorities in general to ensure that cases such as those we have discussed, and that have been powerfully testified to us, are handled sensitively. In an overwhelming number of cases, the police do handle them well and sensitively. It might be that we need to improve the guidance around prosecution, and that is an important question. I certainly do not want the families of people who have taken their own lives to be harassed and chased through the courts, and I think we would all agree on that. In that respect, the guidance for the CPS and the police will always evolve.

[Naz Shah]

The hon. Member may recall that we heard from the former head of the CPS in the oral evidence sessions, and I asked him whether the Bill would address concerns about such prosecutions. I absolutely agree with my hon. Friend the Member for Spen Valley that we want to address that. However, this Bill is not the route to address those issues unless they fall into that six-month bracket.

[Danny Kruger]

I think that is right. I do not accept the claim that this Bill is somehow a response to the problem of abuse, coercion or the pressure to end life in families. Tragically, in jurisdictions that have an assisted dying law, the number of unassisted suicides—suicides that happen outside of the law—go up, because no law can catch all the people who might want to take their own lives. Thankfully, there is no blanket support for any assisted suicide; all the jurisdictions have some restrictions.

More significantly, if the state said that some people’s lives are not worth living and that it is an acceptable choice for them to end their own life—which is not what the current law says; we have legalised suicide, not actually endorsed it—by passing a law that endorsed the choice of some people to take their own life, we would be sending a signal that we agree that some people’s lives are not worth living. The social consequence of that is clear in the evidence from other jurisdictions: suicide in the general population goes up as a result of an assisted dying law.

[Kim Leadbeater]

On that point, the evidence does not clearly show that there is a direct relationship between those two things; there are other factors and no way of knowing that. On the concept of ending one’s own life and giving people the choice under the provisions of the Bill, what would the hon. Gentleman say to people who frame that concept very differently—as a way to shorten their death? Those terminally ill people, in my experience—I have met many of them now—do not view this as a way of ending their life, because they want to live, but the reality is that they are dying and want to take control of what their death looks like. How would he respond to that?

--- Later in debate ---

[Danny Kruger]

First, there might not be a causal link between assisted suicide laws and the increase in unassisted suicides in those places, but there is such a clear correlation that it is difficult to understand what else might be going on—unless there is something in the water in Canada, Australia, New Zealand and the Netherlands that is not there in other countries. It might be that those countries have such a disrespect for the frail, elderly and ill that they are taking their lives. However, I think there would be a direct social impact from the signal that this law would send into our culture, which is very concerning.

I hear the hon. Lady use that phrase quite often about people wanting to shorten their death rather than their life, but I am afraid to say that it is absolutely meaningless. We are here to make law. Death happens: you are either alive or you are dead. People might want to shorten their death, and might use that phrase, but what they are doing is shortening their life. There is no conceptual difference and certainly no legal difference between those two things. Trying to say that some people’s motivation for suicide is legitimate and some people’s is not makes no sense. This law will allow them to shorten their life and have assistance in committing suicide, and there is no other way to describe it in any terms that make sense. I do not regard the distinction that the hon. Lady makes as valid.

Our obligation to ensure that the Bill sets out what it is claimed that we all want it to do, which is to ensure that people are not pressured unduly into taking an assisted death, means that we should put that in black and white. The hon. Member for Rother Valley said that the current term is more than enough, and we had a bit of an exchange about that. I emphasise that it is a clear principle of the statutory interpretation of law that courts will look at not just the words that are in the Bill, but the words that are not. The decision to include some words and not others is regarded as significant by courts. If the term coercion is there but not influence, it is appropriate for the courts to conclude that influence was not intended by Parliament. It might be the case that the term coercion is interpreted to include influence, but if so, let us make that clear.

[Sean Woodcock]

I am grateful to the hon. Gentleman for giving way while he is in full flow. One of the areas that I have been confused about in this debate is that the Minister said—I have no reason to dispute it—that coercion is a clear term, so the courts know where they are with it, because they are already dealing with it. However, we have also heard from proponents of the Bill that it is about making life easier for the professionals who are involved. I mention that because, overhanging all of this is the fact that the Bill as it stands—as it passed Second Reading—has a High Court judge intervention. We are told that an amendment is coming that will remove that for a potential panel of professionals—

Terminally Ill Adults (End of Life) Bill (Eleventh sitting)

Danny Kruger Excerpts

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[The Chair]

I remind the Committee that with this we are discussing the

following:

Amendment 82, in clause 1, page 1, line 19, after “coerced” insert “, encouraged”.

This would add a lack of encouragement to the list of requirements for a person to make a decision to request assistance. This reflects the changes proposed in Amendments 83 to 92.

Amendment 113, in clause 1, page 1, line 19, after “coerced” insert “, manipulated”.

This amendment reflects the changes in Amendments 114 to 115 which require steps to be taken to establish that the person seeking assistance has not been manipulated by any other person.

Amendment 24, in clause 7, page 4, line 14, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 83, in clause 7, page 4, line 14, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 114, in clause 7, page 4, line 14, after “coerced” insert “, manipulated”.

This amendment requires the coordinating doctor to ascertain whether, in their opinion, the person has manipulated.

Amendment 25, in clause 8, page 4, line 37, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 84, in clause 8, page 4, line 37, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 115, in clause 8, page 4, line 37, after “coerced” insert “, manipulated”.

This amendment requires the independent doctor to ascertain whether, in their opinion, the person has manipulated.

Amendment 26, in clause 12, page 8, line 13, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 85, in clause 12, page 8, line 13, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 27, in clause 13, page 9, line 33, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 86, in clause 13, page 9, line 33, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 28, in clause 18, page 12, line 26, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 87, in clause 18, page 12, line 26, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

New clause 5—Encouragement—

“(1) For the purposes of this Act, ‘encouraged’ means an act capable of encouraging suicide which would constitute an offence under section 2 (Criminal liability for complicity in another’s suicide) of the Suicide Act 1961.

(2) A person is not rendered ineligible to request assistance to end their own life on the basis of—

(a) an act of encouragement that they were unaware of when requesting and going through assisted dying, or

(b) an act of encouragement which was not specifically directed at that person.”

This amendment provides a definition of encouragement is consequential on Amendments 82 to 92.

Amendment 29, in schedule 1, page 25, line 22, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 88, in schedule 1, page 25, line 22, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 118, in schedule 1, page 25, line 22, after “coerced” insert “, manipulated”.

This amendment adds a requirement to the first declaration for the person to declare they have not been manipulated. It is linked to Amendment 113.

Amendment 30, in schedule 2, page 27, line 11, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 89, in schedule 2, page 27, line 11, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 119, in schedule 2, page 27, line 11, after “coerced” insert “, manipulated”.

This amendment requires the coordinating doctor to sign a declaration that to the best of their knowledge they believe that the person has not been manipulated. It is linked to Amendment 113.

Amendment 31, in schedule 3, page 28, line 9, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 90, in schedule 3, page 28, line 9, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 120, in schedule 3, page 28, line 9, after “coerced” insert “, manipulated”.

This amendment adds a requirement to the declaration that independent doctor has to sign, that they to the best of their knowledge they believe that the person not been manipulated. It is linked to Amendment 113.

Amendment 32, in schedule 4, page 29, line 5, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 91, in schedule 4, page 29, line 5, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 121, in schedule 4, page 29, line 5, after “coerced” insert “, manipulated”.

This amendment adds a requirement to the second declaration for the person to declare they have not been manipulated. It is linked to Amendment 113.

Amendment 33, in schedule 5, page 30, line 22, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 92, in schedule 5, page 30, line 22, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 122, in schedule 5, page 30, line 22, after “coerced” insert “manipulated”.

This amendment adds a requirement to the declaration that coordinating doctor has to sign, that they to the best of their knowledge they believe that the person not been manipulated. It is linked to Amendment 113.

[Danny Kruger (East Wiltshire) (Con)]

This morning, we adjourned in the middle of an intervention. I do not know whether the hon. Member for Banbury wants to resume it.

[Sean Woodcock (Banbury) (Lab)]

I think I had got to the end of it. I will let you carry on, sir.

[Danny Kruger]

Okay. I am grateful to the hon. Gentleman for his intervention.

We have received significant written and oral evidence on how common it is, sadly, that vulnerable people experience this sort of subtle coercion—the undue influence from which we all want to ensure that people are protected. The lawyer Tamasin Perkins was referenced earlier, but not fully quoted. She is a private wealth disputes partner, so deals with a lot of complexities around people’s deaths. She has said:

“Coercion can be very difficult to spot as a legal professional (and for medical professionals too)…the real influence occurs behind closed doors.”

She went on to talk about

“frailty and vulnerability…a too close involvement in the decision-making process, or a sudden and inexplicable change of heart.”

All that is often teased out only through the course of the quite in-depth relationship that a lawyer can form in the course of supporting somebody to settle their financial affairs. That is not what is proposed in the Bill. The law firm Scott Bailey has made the point that

“sadly, we all too often speak to individuals who do not realise they are victims until they talk to us about their relationship”.

While the Bill correctly seeks to protect people from direct coercion, indirect coercion is much harder to spot, as is the coercion that people apply to themselves, which we will come to in the next group of amendments. I recognise that the Committee and the promoter of the Bill, the hon. Member for Spen Valley, have taken pains to ensure that we prevent coercion. I put on the record my support for the amendments in the name of the hon. Member for Lowestoft (Jess Asato) about the importance of providing training to all the professionals involved with coercive control, but I am not sure that training will be sufficient. It is important to insist that doctors who assess such applications are required to look directly for these particular forms of influence.

Let me explain our concerns as crisply as I can. At the moment, encouraging suicide will remain illegal under the Bill. That is an important principle. Clause 24 specifies that to assist someone to die according to the processes of the scheme set out in the Bill will not be treated as assisting suicide. The implication is that encouraging assisted suicide remains illegal. To the point made earlier by my right hon. Friend the Member for North West Hampshire, if we are worried that there might be a chilling effect due to the concept of encouragement still being illegal, logically the Committee should amend clause 24 to explicitly allow encouragement in order to prevent such a chilling effect. Either encouragement is okay, and we allow it as a concept, or we do not.

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

Forgive me, but I think my hon. Friend might have misunderstood me. My point was that the more we attempt to police discussions in families, the more guarded they will become; it was not necessarily that we should specifically authorise encouragement, or whatever he has suggested. He referred a moment ago to professionals being able to have conversations with individuals freely about their circumstances, their thinking, and how they had come to their decision. I am concerned—there are relevant amendments in the next grouping—that families will interpret these words in such a way that they start to talk about things they should not say. They might think, “I’ve got to be very careful not to do this or say that; because of the state of my body and the disease that is ravaging it, I am determined that I want an assisted death, and I am going to make sure that I do not say anything wrong in the discussion.” The more that we police it, the less likely people are to be open and free in their conversations, both within their families and with the professionals we want to assess them.

[Danny Kruger]

I recognise my right hon. Friend’s argument. The fact is that encouraging assisted suicide is theoretically illegal—in fact, it will be illegal under the Bill—so there is already that potential for the policing of conversations. If it is concluded that a family member has encouraged somebody to an assisted suicide, that would be illegal, because that has not been specifically allowed. The law already specifies that it is illegal; we are concerned about ensuring that that is fully checked for in the early conversations that people have with their doctors—that the applicant does not simply have to get over the coercion bar, but that they have to get over this lower but just as important bar around the potential for encouragement and undue influence. If my right hon. Friend is concerned that the concept of encouragement will have a chilling effect on family conversations, he should legislate accordingly, so as to prevent it from being used at the later, criminal stage.

[Kit Malthouse]

We need to think about this in practical terms. If the word “encouraged” is included in the Bill, a co-ordinating doctor may feel that it is their duty to say to somebody, “Has anybody encouraged you to take this decision?” They will use that specific word, rather than have a general conversation that is designed to detect coercion, which, as has been pointed out, covers the concept of encouragement or undue influence.

My hon. Friend may think that that point is semantic, but we have to remember that the words will be interpreted relatively literally, certainly in the early stages after the passage of this legislation. To ensure that they are within the bounds of the law, a doctor may feel that they have specifically to say, “Have you been encouraged to do this?” That will then start to be interpreted by families in the way that they respond. What we really want is instead a general discussion, which is where, in my experience, professionals are expert at teasing out the understanding and motivation of individuals.

[Danny Kruger]

If my right hon. Friend just wants a free and easy, free-flowing discussion that has no specific questions that need to be asked or answered, there should not be any requirement for them to be testing for coercion. There is already a requirement to ensure that there has been no coercion and that the person is making the decision voluntarily. That imposes an expectation that they would be asking a specific question to the applicant. Personally, I think it is appropriate to ask the applicant, “Have you been encouraged? Has influence been put upon you?” If the answer is, “No, it’s all fine; my wife agrees with me, but I have not been encouraged to it,” then the test is passed.

[Rebecca Paul (Reigate) (Con)]

rose—

[Jake Richards (Rother Valley) (Lab)]

rose—

[Danny Kruger]

I will give way first to my hon. Friend and then to the hon. Gentleman.

[Rebecca Paul]

I completely recognise what my hon. Friend says, but there is another way to deal with the issue. Encouragement is already illegal. The other option is that we decriminalise it through in clause 24, but right now the Bill does not do that. That is why we are saying that we need to have the word “encouraged” in clause 1. There are other ways to do it, but until someone tables an amendment to clause 24 to decriminalise encouragement —I do not think that anyone has—then amendment 82 is very logical, and brings together all the legislation in a coherent way.

[Danny Kruger]

I am very grateful to my hon. Friend.

[Jake Richards]

The issue in this interesting debate between the hon. Member and the right hon. Member for North West Hampshire is whether the assessment is of the person making that decision—have they been coerced?—or of actions of a third party. Someone cannot themselves be encouraged; someone else encourages them. It may very well be the case that an individual making a decision has been encouraged to do so, but the issue for an assessing doctor, panel or judge is surely whether that person’s ability to make the decision has been affected. That is not about their being encouraged; it is about whether they have been coerced. That is the differentiation between the two concepts. The concept of coercion is a much better way of ensuring the assessment is about the person’s ability to make the decision, not about third-party factors.

[Danny Kruger]

The hon. Gentleman makes an important point. However, as we discussed earlier, the terms of the Suicide Act 1961—which explicitly include the term “encouragement”—include pressure. The understanding and interpretation of “encouragement” include the effect of the encouragement, which is that someone has been persuaded by a third party to take this step, whereas the principle of the Bill is that people are acting entirely autonomously.

[Dr Simon Opher (Stroud) (Lab)]

This is a really interesting discussion, but it misses the point of how clinical people assess coercion. What we really do not want is a tick-list saying, “Confirm that you have not been encouraged” and so on, on a piece of paper. It is a much more open discussion. To get to real coercion, we have to leave it completely open. We follow the flow of the patient’s conversation. I do not think that any particular words will help in that context.

[Danny Kruger]

I am grateful to the hon. Gentleman for stating so clearly the ultra-libertarian position: “Leave it all open; trust the doctors—allow them to conclude if there has been any problem.” The implication of the Bill is that some questions will be asked, appropriately, but I do not think the questions are quite tight enough. I am afraid to say that I disagree with the hon. Gentleman’s suggestion that leaving it “completely open”, as he puts it, to doctors would be safe.

[Daniel Francis (Bexleyheath and Crayford) (Lab)]

To pick up the points made by the right hon. Member for North West Hampshire and the hon. Member for Reigate, my understanding of the discussion we had this morning and where we now are is that it would be an offence under the Suicide Act to encourage a loved one to commit suicide when they have nine months left to live but that it would not be an offence under the Bill to encourage a loved one to take assisted death when they have six months left to live. My understanding is that the hon. Member for Reigate is saying that, whether we do it now or in later clauses, we should try to bring the two pieces of legislation in line with each other on the term “encouragement”.

[Danny Kruger]

There is a certain confusion about the extent to which encouragement of assisted suicide—assisted dying, under the terms of the Bill—would be legal or not. The Bill does not decriminalise encouragement either to an assisted suicide, which is an assisted death within the scope of the Bill, or to an unassisted suicide—suicide outside the scope of the Bill, as it were. What we have heard, and certainly the implication of the Bill, is that encouraging either would be illegal in principle. The purpose behind the amendments would be to ensure that the doctors doing the initial assessment are obliged to check and satisfy themselves that there has not been encouragement.

[Kim Leadbeater (Spen Valley) (Lab)]

I might have missed it this morning, but what definition of “encouragement” are the hon. Gentleman and the hon. Member for Reigate proposing to use? Having looked at various definitions myself, I do not think that there is a definitive legal definition, but please correct me if I am wrong. Some definitions that I have seen include: to encourage somebody, to give someone confidence or to support someone to do something. Are we saying that it would be wrong to give someone the confidence or support someone to do something? That would feel very wrong and very different from coercing someone to do something.

[Danny Kruger]

On the point about encouragement, I am grateful to my hon. Friend the Member for Reigate for reminding me that her new clause 5 specifies a definition of encouragement:

“an act capable of encouraging suicide which would constitute an offence under section 2”

of the Suicide Act. Encouragement is encouragement—the term exists in the Suicide Act already. It exists in case law and in statute, so the term is what it is.

[Kim Leadbeater]

I am very open minded on these issues, but are the amendments trying to stop someone giving someone else confidence or supporting them to do something? That would feel wrong.

[Danny Kruger]

We are suggesting that an application in which the applicant has been encouraged—or coerced, unduly influenced or manipulated—would not be acceptable. The assessing doctor must confirm that there has been no encouragement. That is the purpose of the amendment. I hope that satisfies.

[Dr Neil Shastri-Hurst (Solihull West and Shirley) (Con)]

I just want to understand this, so that I can appreciate the amendment in full. I believe that my hon. Friend—he will correct me if I misheard—spoke of encouragement effectively being pressure: that there is the act of encouragement and then an individual being pressured into making a decision that is not in their best interests. We have talked much about coercion but if that is my hon. Friend’s position, can he elucidate why the words “or pressured” are not sufficient to deal with the issue that concerns him?

[Danny Kruger]

The value of the word “encouragement” is that it is broader than simply “pressure” or “coercion”. In response to the points made by the hon. Members for Spen Valley and for Rother Valley, the purpose of these amendments is not to criminalise the pressure—there are other clauses that address that question—but to ensure that somebody cannot proceed with an assisted death if the doctor concludes that that person has been subject to encouragement, manipulation or undue influence. The word “encouragement” entails that they have made their decision on the basis of that encouragement—that is the clear implication. I hope that is helpful.

[Dr Shastri-Hurst]

It may be that I am a dense former surgeon, so please help me, but could my hon. Friend the Member for East Wiltshire give an example of what, in the definition of “encouragement”, would be broader than “pressure”? If we are not saying that supporting somebody through this process is acceptable, what would be a specific example where “encouragement” comes into this that would fall outside the scope of “pressure”?

[Danny Kruger]

I am trying to ensure that there will be a sufficiently broad scope that doctors must be obliged to check that there has been no undue influence, pressure or encouragement. An example would be an elderly person who has been actively encouraged: it has been suggested in all love, and possibly with perfectly decent motives in the mind of the person applying the encouragement, that it would be best for them, their family and society as a whole if they would expedite their death—earlier than would otherwise happen in the natural course of things. “Encouragement” is a more comprehensive term and concept than “pressure” or “coercion”.

Our concern is that a doctor applying the current test in the Bill will simply look for evidence of direct, fairly forceful pressure or coercion, as it is understood in the more heinous cases, with which we are all familiar, of partners applying coercive control or direct abuse. We obviously all want to exclude that, and it is already excluded. What we are concerned about here is the more insidious, subtle and—I am afraid to say—widespread pressure that the evidence from our witnesses told us about. We are concerned that it is not possible to ensure that people will be protected if the terms currently in the Bill stand.

[Kim Leadbeater]

I am concerned that the hon. Member did exactly what we are in danger of doing by saying, “Whether it’s under influence, whether it’s pressure, whether it’s coercion, whether it’s other things.” We are in danger of using these words interchangeably, as he just did. That is not what the law needs. The law needs certainty, with clear expressions. I think that the hon. Member also said that encouragement is a broader form of pressure, but who is saying that? Is he saying that? Is the hon. Member for Reigate saying that? Is that a legal summation? I am not entirely sure where encouragement fits in with these other points.

[Danny Kruger]

I am not sure that we are going to satisfy each other on this point. A lot of the evidence that we have heard conclusively asserts that there is a widespread problem of families applying—and I do use these terms fairly interchangeably—undue influence, encouragement and manipulation. Pressure and coercion form a subset of those terms. They are at the sharp end—the more obvious forms of encouragement and manipulation. Those terms exist in law, and this certainly exists in society, as we have heard from Members and witnesses. It feels to me entirely appropriate and consistent with the principles of the Bill that we are trying to ensure that the new law will only be available to people who are acting entirely autonomously, without having been in any way—however subtly—the victims of any sort of undue influence. That is the purpose of these amendments.

[Naz Shah (Bradford West) (Lab)]

Earlier, the hon. Member gave some examples of subtle encouragement or undue influence. If an elderly person has only one living relative, and they could benefit from their will, the encouragement could be so subtle. They could say to their dad or mum, “This an option available for you,” and not necessarily encourage or talk about palliative care. I know that is a conversation we will come to when we discuss later amendments, but this particular point is about people being driven in a certain direction, and that is so subtle.

As a mother to my children, I encourage them to do certain things, because I want to have that control over their behaviour because they are children. It is a normal thing to do. But when it comes to life or death, as a responsible parent it is my job to get them to think like I do or how I want to shape them. I think it is that subtle. Does the hon. Member agree that it is so subtle that sometimes we have to put it into the letter of the law to make sure it is there consciously, as opposed to expecting people subconsciously to understand the words “under coercion”?

[Danny Kruger]

I emphasise that the basis of the Bill, despite what many campaigners might want, is not one of total autonomy. The Bill requires us to have some responsibility towards the applicant, and not simply to say “Do you want it? You can have it.” There are already provisions in the Bill that put an obligation on the assessing doctors and then the judge not so much to conclude that it is in the person’s best interests—I am afraid it does not have that stipulation—but it does seek to insist that they make their own decision.

As the hon. Lady said, many people make a decision and might not even be fully aware themselves that they are the subject of undue influence. They may be being deceived by their loved ones. Their loved ones might be deceiving themselves about the pressure they are putting on them, but let us just talk about a genuine intent to persuade, which does happen. In answer to the question, “Have you been coerced or pressured?”, the patient may say, “No, of course not.” But if they are asked, “Have you been encouraged?”, they might say, “Actually, yes, I have.” That should raise a very significant red flag, and it is absolutely appropriate and sufficient at that point to say, “I’m sorry, but I don’t conclude that this is an autonomous decision.”

To conclude, I refer back to the debate we have been having since the news broke two days ago that there will be an amendment to scrap the judicial stage that is currently in the Bill. If there were a High Court judge sitting at the end of this process, as we were promised and as was understood by the House when it voted on Second Reading—if there were a judge sitting over each individual case, rather than sitting at the head of a national assisted dying commission, and if there were a judge sitting in court reviewing the case properly—there might arguably be no need for the amendment on undue influence.

It is possible, as the Minister explained, that coercion would sufficiently capture the more insidious undue influence and encouragement we are concerned about. It is possible that we could strengthen the definition of coercion through guidance, or through further definition in the Bill. But if we are going to have a panel, and not a court or a judicial process at all, it is even more necessary that we insist on added protection.

[Kim Leadbeater]

Surely, as I thought I heard the hon. Gentleman say on the radio yesterday morning, it is better to have expertise of this nature involved in the process. On the issue of coercion and the evidence that we received from psychiatrists—which was more in terms of capacity, but on coercion as well—and certainly from social workers, the Association of Palliative Care Social Workers was very clear that this is what they do. Surely the hon. Gentleman has to agree that by involving those people in the process, we are strengthening the issues he is concerned about.

[Danny Kruger]

At the risk of debating an amendment that has not even been tabled yet and that will come later in the Bill—I wish we were able to see it—the hon. Lady is absolutely right: I do indeed believe it would be very helpful to have as many professional eyes on each case as possible, so I welcome the suggestion of more experts. I am not clear what they will be yet, and in fact I support amendments that will insist on psychiatric assessments, but those need to come earlier.

It is appropriate and absolutely right—not necessarily for this clause, but for the one we will come to shortly on assessment—that there should be as many professional eyes on the case as possible, but there does need to be a judge at the end of the process. That is certainly what the House of Commons voted for, and I think it is what the public would require. In the absence of that—if there is not going to be a judge applying this somewhat legalistic definition of coercion that apparently should include all the more insidious forms of influence that we are concerned about—in my view it is even more imperative that we specify very early that the first doctor who sees the patient must ensure that there has been no undue influence, manipulation or encouragement.

[The Chair]

Before I call Minister Sackman, I remind Members that “you” refers to me, not the person they are speaking to. Can we be very careful with the use of “you”?

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[Sarah Sackman]

To bring it back to the specific debate about the amendments, the terms “coercive” or “coerce” and “pressure” appear in the criminal law and have broad definitions. That is how they have been interpreted by the courts. Others have referred to section 76 of the Serious Crime Act 2015, which created an offence of controlling or coercive behaviour. In that context and the relevant Bill, Parliament chose not to make a specific legislative definition, but the way in which it has been interpreted, in accordance with its natural meaning, has vindicated the proposition that a broad meaning is given to those terms. For example, that offence could include coercive behaviour such as repeatedly putting somebody down, telling them they are worthless, seeking to control their daily routines or isolating them from friends and family to put pressure on them. As my hon. Friend says, we understand those sorts of behaviours in a much broader way in a changing society.

[Danny Kruger]

Will the Minister give way?

[Sarah Sackman]

I am going to make a little more progress; we will come back to that in a moment. It is really important that we have these concepts in other parts of criminal law and other parts of our legislation. I come back to the point that we run a risk, which runs counter to the intent that lies behind the amendments, if we add additional language into the Bill. I will develop that point and then take further interventions.

As we have seen, clause 1 includes the terms “pressured” and “coerced”. The ordinary meaning of the word “pressure” is the use of persuasion or intimidation to make someone do something. There are broad types of behaviour, many of which have been eloquently brought into this debate, that would come within that. The ordinary meaning of the word “coerce” is to persuade someone to do something against their best interests by using force or threats. That could be subtle or it could be very blatant, but the word “coerce” is understood in that way by our courts and in other areas of our legislation. One can readily see how an act of manipulation such as in the examples used earlier, or the exertion of undue influence—I think the term “unduly pressured” was used—would all fall within the terms “coerced” and “pressured”. That is the settled view of the Government.

There is a consensus that none of these things, including applying undue pressure, are desirable or acceptable in this or any other context, but there is a risk that adding terminology does not do what hon. Members intend, which is to create more safeguards. The risk is that by adding new words, those tasked with applying and interpreting legislation, if it comes to court, will assume there must be some specific reason for their inclusion. They will assume that the words must have some meaning distinct from the other words in the list—coercion and pressure—notwithstanding the fact that, on their natural meaning, the terms overlap and, in the Government’s view, are inclusive of those sorts of behaviours. That risks the effect of narrowing the interpretation of the words used rather than inviting our courts to give them their usual expansive meaning.

In turn, that risks casting doubt on the current interpretation of those words in existing statutes such as the Serious Crime Act, which created an offence for coercive and controlling behaviour, and limits any read-across on interpretations from previous decisions into the application that we are debating. In short, it may actually serve to limit, not to add, to the safeguards in the process. It may risk adding confusion and uncertainty where what is already provided for in clause 1, with the words “coercion” and “pressure”, are simple, readily understood, expansive definitions that would cover precisely the behaviours that I think the hon. Members who tabled the amendments are concerned about.

[Danny Kruger]

I think the Minister just suggested that if we were to amend the Bill, there would be some kind of unfortunate knock-on effect with other legislation, which would thereby be weakened. I hope the argument being made is not that we should leave this Bill weaker in order to protect other legislation. We need to get this right.

I have another suggestion, which I would be grateful if the Minister could elucidate a little more. The fact is that no official definitions of coercion or pressure that exist in statute either. The definition of coercion that she used—what case law has taught us coercion means—and the examples she gave of people essentially exerting coercive pressure on partners would, of course, be captured by the Bill currently but, as we have heard, there are circumstances that would not meet that threshold but that we all agree would be unacceptable. The only way to capture properly those examples of people being encouraged and unduly influenced into an assisted death is by making it clear that that is what doctors are required to look for.

I revert to the point I have made a number of times; I would be grateful for the Minister’s response to it. The Suicide Act, which the Bill amends, explicitly uses the term “encouragement” for what people should not be subject to, and pressure is a subset of encouragement. It is not the other way around. Encouragement is not captured in pressure; pressure is captured in encouragement. Why do we not acknowledge that encouragement is the correct catch-all term for all the sorts of undue influence we are trying to protect against?

[Sarah Sackman]

On the hon. Gentleman’s first point, there is no suggestion that we should somehow accept any weaker form of provision in this Bill to protect other parts of the law. Having said that, he would well expect me, as a Government Minister, to be concerned with the integrity of our statute book as a whole.

It is because the Government take a holistic view of how the criminal law and other areas of our law operate and define these concepts, and how they are read across the piece, that we make our contention in respect of these particular provisions, because the terms “coercion” and “pressure” are given their natural meaning and are expansive. In the Government’s settled view, they would be inclusive of the types of behaviour that are described in the amendments before us—namely manipulation, undue pressure and the sort of encouragement that I think, when he keeps coming back to it, the hon. Gentleman is referring to, which is not encouragement in a benign way as might exist between two perfectly supportive family members in a normal conversation, but the sort of encouragement that is intended to lead to coercive ends.

The hon. Gentleman says that pressure is a subset of encouragement; the Government’s view is that coercion and pressure would cover off the other behaviours that are described in the amendments. It is not necessary to include those additional concepts, because it risks sowing confusion that somehow they are not included in the concepts of coercion and pressure.

--- Later in debate ---

With those considerations in mind, it is the Government’s view that with the Bill as drafted, the courts will, in all likelihood, give the terms “coerced” or “pressured” their natural meaning and that this will ordinarily cover the additional terminology that is being proposed. It is, of course, for the Committee to decide whether these amendments should form part of the Bill, but I hope that my remarks will have provided some assistance to the Committee.

[Danny Kruger]

On a point of order, Mrs Harris. The Minister gave a brilliant speech in support of the Bill as it stands, so I simply do not understand how, having explained so clearly why she believes that the amendment is inappropriate, she can claim to have a neutral position on it. This is not in any way personal; she made a very good speech and she ended it with—

[The Chair]

Order. That is not a matter for the Chair.

--- Later in debate ---

[Danny Kruger]

Okay. I am sorry to hear that.

[Kim Leadbeater]

I will speak briefly because we have had a thorough discussion about these issues. I completely understand the sincere intention behind these amendments. It is clear from the fulsome discussion we have had that colleagues across the Committee agree that undue influence and manipulation should be covered by the Bill—as should all types of coercive behaviour. The question is, “How?” I feel reassured by comments from legal colleagues and the Minister that the language currently used in the Bill—“coercion” and “pressure”—covers these additional concepts, as those terms appear in existing criminal offences, and the statutory guidance from the Home Office in 2023 along with the Crown Prosecution Service legal guidance cover the broad range of coercive behaviours. It is up to hon. Members to decide whether to push these amendments to a vote. I am understanding of the intention and appreciative of the comprehensive debate that we have had.

[Rebecca Paul]

I thank all Members for their contributions. I echo the hon. Member for Spen Valley when I say that this is one particular case where we all agree on what should be happening functionally and practically. We have had some quite technical arguments today about the meanings and definitions of certain words and how they would apply. It has been a constructive and interesting debate. As a first-timer to a Bill Committee, it has been a great experience.

It is clear from the evidence received and the contributions from Members that subtle coercion is something we are all concerned about and recognise needs to be dealt with. We have heard powerful stories today and from witnesses in recent weeks, so it is incumbent on us to listen and take action. One of the points that resonated with me yesterday was that made by the hon. Member for Bradford West. I am now paraphrasing a little bit: essentially, she said that we are not legislating for a perfect world where everyone is treated equally; that our society is filled with inequality, and we must legislate for the reality, not for the rose-tinted version that we would all prefer. Coercion and undue influence does happen more commonly than we might think, and it is hard to detect. It is therefore vital that when we go through this Bill, we always have the most vulnerable at front of mind. It is not about when everything works perfectly, as intended, for the very small group of people who would benefit from the Bill, but what happens when it does not work, and the impact on a potentially bigger, more vulnerable group. That is the crux of our roles here today.

I thank the Minister for her very informative and helpful speech setting out the Government’s position on legalities of the various definitions. There will, however, be different legal opinions on this. I sought advice from former Attorney General Victoria Prentis KC, who takes a different view. I am very aware that when it comes to going through the courts, there will be different interpretations and views. I am not a lawyer, so I do not know which is right, but I do know that if I put this amendment on the face of the Bill, it is there and it is safer. That is where I am coming from on this. I reiterate that we do see these terms “coerced”, “pressured” and “unduly influenced” in various bits of legislation. Those words are chosen for specific reasons. It is important to note that.

On encouragement, I am going to talk again about the purpose of the amendment. Right now, under the Suicide Act, assisting someone to commit suicide is a crime, but encouraging someone to commit suicide is also a crime. Clause 24 of the Bill decriminalises the assistance piece to allow legalisation of assisted dying, but it does not decriminalise the encouragement piece. I have tabled amendment 82, because we need to address that. The clause is limited to the provision of assistance and does not include the encouragement of a person to end their own life.

I understand the concerns of my right hon. Friend the Member for North West Hampshire about how “encouragement” could be interpreted, which is a really good point. I also take the point that although it is referred to in the Suicide Act, there is no clear definition, so we are relying on case law. If we all came to this with a blank bit of paper, we might come up with different laws. However, we have laws that are already in place, and that is why I have tabled this amendment. The reality is that encouragement of suicide is a criminal activity right now, which is why we need to address it here.

On undue influence, the Minister set out that the amendment is not legally necessary. The hon. Members for Rother Valley and for Penistone and Stocksbridge gave interpretations of this point, but I gently point out that they contradicted each other, which shows how complicated the situation is. Different people will have different views. The hon. Member for Penistone and Stockbridge said that “undue influence” is a term in equity, and that it is not proper to have it as part of the criminal offence of coercion in clause 26, but the hon. Member for Rother Valley said that coercion in that provision does not include undue influence. Does that not show that the legal meaning of the Bill is unclear and would benefit from some clarification?



Amendment 23 on undue influence first appeared on the amendment paper on 21 January, almost three weeks ago. My understanding from those who were previously in government, including at the Ministry of Justice, is that when an MP tables an amendment that is legally unnecessary, the Government would seek to meet them, together with Government lawyers, to explain why the Government believe the amendment is legally unnecessary and to give them time to reflect. It is my understanding that, with respect to the amendment in the name of my hon. Friend the Member for South Northamptonshire (Sarah Bool), that was not done. She met the Bill’s promoter, the hon. Member for Spen Valley, on Monday, but they did not discuss the amendment on undue influence.

Similarly, my amendment 82 on encouragement appeared on the amendment paper on 4 February, over a week ago, and I have had no communication from either the Government or the Bill’s promoter about it. The first time I or my hon. Friend the Member for South Northamptonshire have heard that our amendments might be legally unnecessary or problematic is today. When formulating my amendment, I had the benefit of advice from former Attorney General Victoria Prentis KC, who has written a letter to The Times endorsing it; the Minister will appreciate that I would not want to withdraw my amendment without the benefit of further advice from her, so I will press it to a vote.

However, if there are any points of technical drafting relating to the amendment that the Government would like to deal with through tidying-up amendments, I would very much welcome that. What has come out of this conversation is that it is not straightforward or clear; there are some things that need to be thought through, including the interactions between clause 24 and clause 26 and the various definitions, so that we are being really clear. I am open to doing that in the most suitable and appropriate way.

[Danny Kruger]

I am interested in what my hon. Friend said about not having had conversations with the Government or the promoter about the details of these amendments. I could understand that if this was purely a private Member’s Bill, but the fact is that the Government clearly are involved; we have heard it said today very clearly that the Minister supports the text of the Bill as it stands. Is my hon. Friend aware whether the Government have directly fed into the drafting of the Bill or discussed with the Bill’s promoter the appropriate response to these amendments? Does she agree that, if so, it would have been appropriate, as she suggests, to have had conversations with her or the other hon. Members who are moving these amendments, in order to do what normally happens in the course of a Bill’s process and convey the Government’s position ahead of the debate so that, if it is appropriate for amendments to be withdrawn or for concessions to be made by the Government or the promoter to amend the Bill in due course, that could have happened—rather than hearing today for the first time that the Government object to these amendments? Does she agree that that would have been an appropriate process?

[Rebecca Paul]

I agree that that would have been helpful. We have spent many, many hours today debating these amendments, and having had advance notice would have allowed some reflection and appropriate advice to be taken. If, indeed, the Minister’s position is right, I could have looked at withdrawing the amendment or tabling a new one. However, I have not had time to do that, so I am in a situation where I have to follow the advice that I have had. I think, if the Minister is right, having this on the face of the Bill is potentially a little messy because we would be duplicating, but that is not a massive downside from my perspective, whereas the upside is that, if she is wrong and I and the advice that I have had are right, we would be ensuring a higher level of safeguarding in this Bill.

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[Kit Malthouse]

I am grateful to the hon. Gentleman because he brings me to my second point, which is exactly that—autonomy. We heard in oral evidence, and it comes through from some of the written evidence, that people’s motivations for seeking an assisted death are often a mixture—a cocktail—of different reasons. Some are about pain, and some are about trauma, for them and for others, but the overarching motivation is always this notion of control. What people seem to be most concerned about is, “If I contemplate my end, I want to have some kind of say, as I get to the end, about what it will be like. That end may be a variety of different outcomes.”

As my hon. Friend the Member for Solihull West and Shirley, or any of the doctors in the room, will know, if someone is dying of bowel cancer, any number of things may kill them. Palliative care is able to help with some of them, but not others. In my experience, the notion in people’s minds is that, as they approach that point, they just want the reassurance that they can control it and have the option, if they so wish. That is often their primary motivation. As the hon. Member for Bradford West said, there may be ancillary results and reasons why people want that control, but the primary purpose is control.

[Danny Kruger]

My right hon. Friend says that the primary purpose is control, and that is certainly the argument made by some of the most passionate advocates of this sort of legislation. However, does he recognise that, in the majority of cases, in jurisdictions where this is legal, being a burden is a primary cause for people to seek an assisted death? People request an assisted death explicitly for the purpose of not being a burden on others. If my right hon. Friend is content with that because he respects their autonomy, and he thinks that that is an acceptable reason for people to want to die, that is fine, and let us say so. However, I do not think it is acceptable to hide behind the idea that we are talking about people who simply want to control their own passing. In fact, many want to do this because they are concerned about being a burden on others.

[Kit Malthouse]

I will make two points in response to my hon. Friend. First, I am not sure that it is entirely accurate that burden is the primary purpose. It is certainly the case that when people going through this process in other jurisdictions are surveyed and rank their reasons, burden may be one. We heard that in some of the evidence that we had from overseas, but as I said at the start of my remarks, it depends what we mean by “burden”. Personally, I think it is perfectly legitimate for me to want to spare my children from witnessing, knowing or even learning that I may have died in a particularly unpleasant way. I may therefore wish to go a few weeks before that eventuality and say goodbye to them, gathering them around my deathbed—we heard very movingly about this from one of the witnesses—to say farewell while I still can, before my body is ravaged by the final stages of the disease that is destroying me. I do not think that relieving them from a traumatic burden is anything negative.

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[Kit Malthouse]

The Bill makes it quite obvious that the doctor would not regard that as a legitimate reason to give people an assisted death, if that was their only purpose. As we said before, however, most people have a range of purposes for seeking an assisted death. In my view—certainly in my experience—the primary one is always having the option of control at the end.

[Danny Kruger]

Will my right hon. Friend explain what the doctor would do if he or she did not think that there was an appropriate reason to approve the death? The Bill simply requires there to be a settled and informed view. As the hon. Member for Richmond Park says, the motivation might be that the person wanted to save their children the care costs—at which point the doctor, if they could not find evidence of coercion, would say, “Go for it. That is a perfectly good reason.” Is that not the case?

[Kit Malthouse]

It would depend on the circumstances of whether the doctor perceived that the request was made under pressure or coercion. Pressure or coercion can be financial as well as emotional. I would expect and hope that a doctor would question a motivation on that basis. The point, however, is that we have to be very careful about making a law that attempts to police the thoughts of individuals. My concern is that if we start to delineate to an ever more exacting degree what is and is not acceptable as a motivation, we will start to steer people down a road on which they try—this phrase has been used—to game the system to get what they want.

As many of us know, because we have seen it, we live in an age of social media where it is perfectly possible to go on to the internet to get advice about how best to apply for certain benefits and welfare: how someone can best fill in a form, answer certain questions or go through a personal independence payment assessment to get what they want, even though that may not be appropriate for them.

I have no doubt that if, as it develops, we delineate the issue in such a way that there are certain things one should say and certain things one should not, we will run the risk of limiting the conversation that the doctor can have, in a way that is not safe.

[Danny Kruger]

Obviously, we do not want people gaming the system, but I would rather that there were a system, even if it were gamed, than to have no safeguards whatever—which, I am afraid to say, is the case with this Bill. The only coercion that the doctor is looking for is coercion from other people; we do not think that that barrier is strong enough, but it is about coercion from outside. But internal coercion—people saying, “I want to do this to save my family care costs, and not just the sight of me in agony”—would be perfectly acceptable under the Bill. Is my right hon. Friend content with that?

[Kit Malthouse]

I am not sure that that would be perfectly acceptable under the Bill; I would be interested to hear what clause my hon. Friend has in mind. As we have discussed, financial coercion is a well perceived concept. As we have heard from other Members, it can be subtle and implied. That will be for practice guidelines, but as far as I can see it is perfectly well covered in the legislation.

--- Later in debate ---

[Danny Kruger]

I am sorry to push my right hon. Friend further but to reiterate my point, we are not talking about external coercion. We are talking about the explicit motivation of somebody with a settled and informed wish that they want to die to save their family the cost of their care. My understanding is that the Bill would allow that. Does he agree and is he content with that?

[Kit Malthouse]

That is not my interpretation of the Bill, no. I would not be content for that to be somebody’s primary purpose—of course not. My point remains: we run into dangerous ground when we start, by legislation, to try to police the thoughts and motivation of an individual, other than in trying to detect external pressure from others. I am concerned that the amendments run us up that dead end.

[Kit Malthouse]

That is exactly my point, and the point on which I was going to conclude. All of the Bill is designed to put control in the hands of dying people as they face what they regard as an undesirable ending to their life. We are trying to do so within the scope of safeguards that protect those who are vulnerable and not able to make a decision freely for themselves.

If we continue down the line of inserting this kind of complexity into the system, I am afraid that we run the risk of creating a very narrow channel for people to navigate. That will mean either that they feel forced to navigate it in a particular way or that they cannot navigate it at all, which will serve to restrict the conversation between assessing medics and patients in an undesirable way. For those reasons and because of the legal imprecision with which they are drafted, I am afraid I will be opposing the amendments, well motivated though they are.

[Danny Kruger]

The purpose of the amendments, and the reason why I am supporting them, is that they make the Bill honest. They will make the Bill do what the public think it does and is the reason why so many people around the country and in Parliament have supported it: because they understand it to be for exactly the purpose specified in the amendments. In fact, the amendments add safeguards that at least two strong supporters of the Bill in the House of Commons—I will not mention them—thought were already there. Those people have gone on the record stating that these safeguards exist in the Bill, but they do not.

We need to acknowledge motivation. As I said in my exchange with my right hon. Friend the Member for North West Hampshire, my concern is that the absence of recognition of motivation is a significant lacuna in the Bill. Earlier—or perhaps it was yesterday—my hon. Friend the Member for Solihull West and Shirley sought to draw a distinction between a depressed person who wants to die because of their terminal illness and someone who wants to die because of their depression. But in the Bill as it is written, there is no requirement for any causal link between the terminal illness and the desire to die. Under the Bill, someone’s reason for wanting to die does not need to be linked to the terminal illness; in fact, no reason is required. The Bill is totally neutral—in fact, it is silent—on the whole question of motivation. My hon. Friend also talked in an intervention about people who want to end their lives because of suffering and pain—again, that is not mentioned in the Bill. I will come to that shortly when I discuss amendment 235.

There is no reason required to see a clear, settled and informed wish. As discussed earlier, I recognise that there are safeguards intended to detect coercion or pressure, but that does not include people putting pressure on themselves. It is important to consider people’s motivation in situations such as the example given of somebody who wants to spare their family the ordeal—the trauma—of witnessing a bad death. Those sorts of people do not write in to us, by the way. Evidence has been submitted by many people who have experienced the trauma of having watched their relative die badly, but there is also the experience of people whose relatives have been through an assisted death.

I was talking earlier to the noble Baroness Finlay, the former chair of the National Council for Palliative Care, who cited evidence heard by the Commission on Palliative and End-of-Life Care. A man requested and received an assisted death in the Netherlands for the explicit purpose of sparing his son from seeing him degenerate and die badly. The son was desperate for his father to stay alive—he wanted to go with him through the ordeal—but the father refused. The impact on that young man has been significant, traumatic and destructive.

Even if the patient wishes to do something for the sake of their children, it is not necessarily the case that that will happen or that it will be a good thing. Children can be traumatised by such decisions. Crucially, we should insist that the Bill does what it aspires to do and what many of its advocates have set out clearly over many months. Its purpose is to help people to die, specifically to avoid terrible pain and suffering—but crucially, for themselves and not because they fear that they will be a burden. The fact is that many people do feel that they would be a burden.

I pay tribute to the hon. Member for Harrogate and Knaresborough, who has intervened a couple of times this afternoon and made a very coherent argument about the importance of autonomy. I think he was suggesting—my right hon. Friend the Member for North West Hampshire hinted at this, too—that it is an appropriate decision if a person seeks an assisted death because they do not want to be a burden on others.

In fact, that point was made by people giving evidence to us from abroad. Some of the Australian witnesses—and, I think, the American witnesses—openly said, “Why not? This is consistent with people’s autonomous choice, and if they want to die to save their children’s inheritance or to prevent them from seeing them suffer, that is legitimate.” I would like more people to say openly, as a reason to legalise assisted death, that that is appropriate and that nobody should object—that the judges, doctors and everyone else should nod that through. I do not think that was the sense of the House on Second Reading and I do not personally think it is the view of the public, but if people think that is an acceptable reason to legislate for assisted dying, let us hear it.

I want to emphasise the point about the number of people who genuinely seek an assisted death because they feel that they are a burden on others—not for their own sake, but to save their loved ones money or to avert their distress. A very large number of people—I said most, but I correct myself; I think it is getting on for half of the relevant people in Oregon, Canada and elsewhere—cite burden as the reason for seeking an assisted death.

I note in passing—I hope the Committee will pay attention to this point—that I am concerned that we often feel we are legislating into a vacuum: we pass a law, it will apply, and that is that. As I said yesterday, the law is a teacher and has a direct cultural effect on society. It is very noteworthy that in countries where there is data on motivation, the number of people seeking an assisted death because they feel that they are a burden has risen significantly. It all started, naturally enough, with just the very desperate cases that we are all familiar with and we all understand the rationale for, but the number rose sharply. In the early years, between 12% and 34% across those four jurisdictions cited being a burden as a reason for seeking an assisted death. That has gone up to between 35% and 59% in the four jurisdictions—from around a quarter to around a half in terms of people who seek it. We could pass this law for the small number of people we think we want to help, but in due course many more people will avail themselves of an assisted death because they feel they are a burden.

[Kim Leadbeater]

I welcome the broader debate, but I am very conscious that the amendment does not actually use the word “burden”. It talks about someone

“acting for their own sake rather than for the benefit of others.”

Although the broader debate is welcome, it is important to look at the detail of the amendment.

[Danny Kruger]

That is fair enough. The amendment seeks to insist that people will have an assisted death for their own sake. What we are trying to exclude is the opposite of that—that they are doing it for others. The principal reason why people want an assisted death, if they are not being coerced—which we have already sought to exclude—is that their own internalised view that it would be better for other people for them to do so.

[Jake Richards]

Will the hon. Gentleman give way?

[Danny Kruger]

We want to ensure that people decide for their own sake—I will give way in a moment; this is a good opportunity to make this point. The hon. Member for Ashford referred to the Mental Capacity Act, which we have retained as the basis of the capacity test. The Bill would introduce a version of the best interests consideration, which, as we discussed yesterday, will not be triggered in the Bill because that consideration is not triggered if there is capacity—and if there is not capacity, things do not proceed.

I think it is appropriate that the people making the decision have some consideration of their best interests. I understand that we want to make this all about autonomy, so perhaps a better description is a self-interest consideration. That is what the amendment requires doctors and, later, the judges to conclude: is the person making the decision in their own interests, for their own sake? Are they doing it for themselves? If they are doing it for other people, that is problematic.

[Tom Gordon]

I want to make two points that reflect on the oral evidence that we heard. I cannot remember exactly which witness it was, but someone said something along the lines of there being something quite British about feeling a bit like a burden. That point really stuck with me, because we say it all the time and that was the point made by the person giving evidence. When we talk about the amendment in the context of someone acting for their own sake or for the benefit of others and whether that means that they feel like a burden or otherwise, I think that is something to bear in mind. Might the hon. Member reflect on the fact that people who die natural deaths also feel like a burden at the end of their life? So when we talk about stats pertaining to that, how do we decipher between the two?

[Danny Kruger]

I am very conscious that people feel like a burden at the end of their life. It is quite right that at the moment the system says, “No, you are not. You have value. You might feel a burden, but we want to sustain your life until its natural end. If you want to withdraw or decline treatment, that is your autonomous choice, but we do not recognise you as a burden.” It is very important that the British state does not tell people or confirm to people that they are a burden, which is what we would do in the Bill.

To the point that the British people are very self-effacing, I should say that I suspect we would be at extreme risk from this law. I think many people would indeed feel like a burden. If we pass this law, we are explicitly saying, “Yes, you may well be a burden and it might well be right for you to seek an assisted death.” My right hon. Friend the Member for Braintree, who tabled the amendment, makes the powerful point that a right to die should not become a duty to die. Nobody wants that. Nevertheless, the implication of a law that confirms that people may seek to get the state’s help to kill themselves—not for their own sake but because they feel a burden to others—is incredibly dangerous for our society and for our culture. I would be very concerned if we proceeded with it.

I will now conclude on the amendment before quickly talking about pain. It addresses the motivation of doing things for one’s own sake. I do not underestimate the difficulties. My right hon. Friend the Member for North West Hampshire has stated a number of them at least, as have other Members.

Implementing this safeguard will be difficult, but the fact is that the Bill’s sponsors have already put enormous faith in doctors and judges, or other experts, to detect external coercion and make all sorts of judgments—to ferret around in people’s minds and in their lives to understand what they are doing. We have to consider how best to implement this safeguard, but at the moment the Bill does not even say that asking for an assisted death for other people is something that should be protected against. That is wrong, and it is right that we make the amendment.

I will proceed quickly to a few points about the amendments in the name of my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson), which specify that the purpose of seeking an assisted death must be the avoidance of pain. They would make the Bill honest. The point has been made repeatedly by advocates in the media and in Parliament, including in our evidence sessions, that the reason why we need an assisted dying law is that so many people die terribly. My right hon. Friend the Member for North West Hampshire has referred to some of that today, and he did so very powerfully on Second Reading too.

Sir Nicholas Mostyn made a fairly unarguable case that if we are honest about what we are trying to do here, it is unclear why we have a period of prognosis as a qualifying factor: why should people have to be within six months of their death in order to qualify if we are concerned about the avoidance of suffering? If the logic of the Bill’s proponents and the argument for it is followed through, of course it should be only about the avoidance of pain. I recognise that “suffering” is a more complicated word, but I do not agree with my right hon. Friend that pain is too difficult to determine. The motivation of avoiding pain is straightforward. It should be simply about pain, and unless someone is a full-blown ethical egoist who believes there should be no restrictions on someone seeking the assistance of others to take their life—

[Dr Tidball]

The hon. Gentleman may remember the speech that I made in the Chamber about my own experience of extreme physical pain, and indeed extreme physical suffering, as a child. The level of morphine that I needed was so high that my skin began to itch. I would not have voted for the Bill to proceed to Committee if it had been based on suffering. I voted for it because it was defined very tightly around the language of terminal illness. With the greatest respect to the hon. Gentleman, I think he undermines that case by arguing that we should move to the extremis and focus on pain. We all want to ensure that the Bill gives people the choice to seek assistance with six months’ terminality, set among other choices, including the ability to palliate and achieve other support at the end of life. I am afraid that the amendments would undermine that and, for the reasons that I set out on Second Reading and have just highlighted, I do not support them.

[Danny Kruger]

I remember the hon. Lady’s very powerful speech on Second Reading and I fully recognise that, which is why I said that I recognise that including suffering would be problematic. I understand her point about pain as well. I think we need belt and braces. If we are going to do this, we should have strict restrictions on prognosis, because I want to restrict the time limit. I could go further than six months; we keep hearing about people in the very last stages of their life, and I think it should be restricted to them, but I also think the purpose of seeking an assisted death should be consistent with all the arguments that we keep hearing about people suffering terribly at the end from an agonising death, and we need to restrict it to those cases as well. It should be for people at the very end of their life, for the avoidance of suffering terrible pain. Those are the reasons that the public, in so far as they do support the Bill, support it—they support it for those reasons only.

[Dr Opher]

In my experience, often the reason people talk to me about assisted death—obviously, it is not legal at the moment—is fear of uncertainty at the end of life. That is one of the major things. For example, if someone has a bronchial tumour, it might suddenly haemorrhage, causing them to die by drowning in their own blood. That is something that people will do a lot to avoid. That is not pain; it is something else. As the right hon. Member for North West Hampshire mentioned, a tumour on the carotid artery can suddenly bleed catastrophically. That is not pain, but it is another reason for doing it. I believe it is that fear of what might happen at the end of life that drives most of this. Sometimes it cannot, but usually pain can be palliated —there are many ways to do that—but that fear of what will happen cannot be. We must not do this just for pain.

[Danny Kruger]

The amendment would require people to request an assisted death for the purpose of avoiding pain. If the purpose is to avoid the pain of the death that the hon. Gentleman described, they would qualify under the amendment. I want to push back slightly. I recognise that he is a doctor and I am not, but the case that was cited on Second Reading has been refenced a number of times. I want to look more closely at it, because I have heard from a number of professionals that the account given was not reflective of the usual course of events for that illness. I am sure that, as a doctor, when people say that they fear that sort of death, he does not confirm that it is likely to happen to them.

I want to come to the reality, as I understand it from the evidence, of the genuine opportunities that medicine gives to afford people a good death, which is what medicine should be about.

[Dr Opher]

In carcinoma of the bronchus, it is a real risk—and it is a risk that oncologists will tell me and tell the patient. That is the sort of thing that people adopt assisted dying to avoid.

[Danny Kruger]

I am grateful to the hon. Gentleman.

[Kit Malthouse]

For clarity, is my hon. Friend saying that he supports the amendments because he believes that the only reason that someone should have an assisted death is to avoid physical pain, not the circumstances that we have talked about—bursting arteries and fungating tumours—and therefore that if pain can be controlled, the notion of autonomy, control and choosing the time and place of my own death should all be dismissed?

[Danny Kruger]

The amendment is clear that the primary purpose should be to avoid physical pain. That needs no further clarification.

Let me turn to the discussion of pain. As I have said, the amendment would make the Bill honest and make it do what most people out there want it do. It would also have the great benefit, in my view at least, of reducing those who would be eligible for an assisted death to very a small number. I have heard the Bill’s advocates make the point repeatedly that we are talking about only a very small number of people.

The fact is that the most common reason for assisted suicide in other countries is not pain. Usually, in those countries, the law was passed on a wave of sympathy for people in agony at the end of their life, but most people do not seek an assisted death for the purpose of avoiding pain. The most common reason in Oregon, according to research there, is existential angst—emotional distress—not physical suffering. The Committee heard evidence from Western Australia that the most common reasons are loss of dignity, autonomy and the ability to enjoy life. In Tasmania, another place where there has been research, only 16% of people cite avoidance of pain as the reason for seeking an assisted death.

In my view, if we focused the Bill on pain, we could do even more to reduce the number of people who die in pain, because it should be even smaller than it is. Let me say a word or two about the palliation of pain. We have no doctors in the Committee who are on my side of the argument to make this point, so I refer to experts outside the room. Quite a lot of weight has been put on research published last year by the Office of Health Economics that said that 20 people would die every day in pain, even with access to palliative care. The point is often made that palliative care is wonderful—we all agree that it needs more resourcing and it should be more widely available—but even if it were provided brilliantly for everyone, a large number of people would still die in pain.

Without digging into the problems with the research, I simply point out that the methodology was very suspect. It assumed that people who receive hospice care are the same with respect to pain as people who do not. It just looked at the hospice population and extrapolated more broadly. That is, of course, ridiculous, because people in a hospice are much more likely to be suffering and to be experiencing bad pain; often, that is the reason that they are admitted to the hospice. That extrapolation was inappropriate.

--- Later in debate ---

[The Chair]

The Clerks are quite happy with it, but thank you for your assistance.

[Danny Kruger]

I always worry when the doctor is providing assistance. [Laughter.] No, I am grateful to the hon. Gentleman for trying to get me back on track.

We hear about morphine allergy, and I recognise that apparently it does exist, albeit very rarely. Patients with a morphine allergy can still receive opioid analgesics—there are different sorts of opioids—and there are case studies in the literature that show they can achieve good palliation.

[Kim Leadbeater]

As someone who lives with someone who has a very severe morphine allergy, I can assure the hon. Gentleman that those things do exist and are very real, and they create a huge sense of fear in people. Having met a terminally ill woman who is also allergic to opioids, I think it is really important to acknowledge that these are very real problems for people.

[Danny Kruger]

I totally acknowledge that. I fully recognise that, as I said, morphine allergy does indeed exist, but I am told that it is very rare. I hope that the hon. Lady’s relative will confirm that there are other things that can be done for people who suffer from pain if morphine is not appropriate.

I suppose that is the point that I want to make: no palliative care professional would ever say that they cannot help somebody in terrible pain. There is always something that they would like to do and always more that they can do to assist. The simple reality is that palliative care is improving so much that there is only an infinitesimally small number of people whom palliative care professionals would confirm they cannot help. I recognise that those people exist. I am not being naive or Panglossian and suggesting that palliative care can be perfect in all cases, but if we are serious about the purpose of the Bill, which is to help those whom palliative care cannot help, I suggest that that number will be very small.

I pay tribute to the hon. Member for York Central (Rachael Maskell) and to the noble Baroness Finlay, whom I mentioned. They are leading a commission on palliative care at the moment, which is a helpful corollary to the debate we are having here. They will make a series of recommendations, which I will not go into.

I want to conclude with this obvious point. I am repeating myself, in a sense, so I will be quick. If we are going to do this, let us be honest and straightforward about what we want to achieve. We want people who are dying in extreme agony at the very end of their life to avoid the pain of death and be able to avail themselves of this service. It is either that or we say, “No, we have no interest in people’s motivation for wanting it. We simply respect their autonomy. Unless we can detect external coercion,” which is the only thing that the Bill currently seeks to exclude, “and as long as a doctor can give confirmation that they have six months to live,” which is not difficult to get, “we don’t care why they’re doing it. We respect their wish, and whoever they are and whatever is going on behind the scenes, they can go for it.” We either have a Bill based on full autonomy—I think that is what some hon. Members genuinely believe we should do—or we try to restrict it to just those people who face an agonising death at the very end.

[Dr Shastri-Hurst]

My hon. Friend makes a powerful argument, but if that is his intention, the amendment does not achieve it. It does not refer to agonising pain; it just refers to “physical pain”. On a scale of nought to 10, it could be one or two—it does not necessarily mean that it is nine or 10. While his intention is clear, can he explain how the amendment achieves that wish?

[Danny Kruger]

Well, perhaps my hon. Friend wants to come up with a further amendment, to strengthen it even more and say that we should restrict it only to agony or extreme pain. No, I am trying to be reasonable and say that the case made for the Bill, in public and I think in the public mind, is that its beneficiaries will be those who face terrible pain at the very end of their life, and if that is our intention, let us specify that. That is what the Bill does.

[Dr Opher]

I do not believe that the intention of the Bill is simply about being able to have an assisted death because of pain. Nothing in the Bill says that. We heard evidence from Dr Hussain, who was against assisted dying, but she admitted that there are people for whom we cannot control the pain, so that is another point. The whole interpretation of the Bill is incorrect. It is not about pain at the end of life; it is about controlling one’s own death.

[Danny Kruger]

That is exactly my point. There are those who think that it should be just for people facing terrible pain at the end of life, but that is not what the Bill does, and it is not what the hon. Gentleman says it should do. He would like there to be a Bill that says simply, “If you want to take your own life with the help of the state, you should be allowed to do so.” That is the logic of his position. I do not see why there are any other safeguards—if we believe in absolute autonomy, that is where we are. It is either/or. Either this is a Bill for full autonomy, or there are safeguards to restrict it to the people whom the public are rightly concerned about: those who suffer terribly at the end of life.

[Jake Richards]

The hon. Member is making a powerful argument, but there is a difference between trying to control external factors that may affect an individual making a decision and primary legislation that tries to regulate a person with capacity making an assessment of what is in their best interest. Can he think of any other circumstances in our society or our law where someone with capacity is restrained from making a best-interest decision in primary legislation?

[Danny Kruger]

I am grateful to the hon. Gentleman because he highlights the absolute novelty of this law. We are proposing to do something completely unprecedented. As hon. Members have tried to argue over the last two days, it takes us into extremely dangerous waters with respect to the most vulnerable, so what we are trying to do, through what I concede are some fairly blunt instruments, is to write into the Bill some very strong and clear protections for the most vulnerable people. We have tried to do that in various different ways.

This would be novel. Of course, it is true that the criminal law currently recognises motivation—there are all sorts of aggravating factors that look into the motivation of an individual, so the law is not incapable of making that sort of judgment—but the hon. Gentleman is right to say that this would be a novelty. I am afraid the whole Bill is a novelty.

[Sean Woodcock]

While the oral evidence was divided on many things, I think there was unanimity that palliative care is in need of serious improvement across the board. I do not think a single witness said that palliative care was good across the country and could not be improved significantly. I mention that, linking back to the comment from the hon. Member for Richmond Park, because we are looking to create this law in a situation where a serious risk has been identified of people choosing to opt for assisted dying because of a fear of care costs and so on. That is my concern, and I see this as a safeguard to prevent that. Is that the hon. Member’s view?

[Danny Kruger]

That is absolutely right. It is a very depressing fact that it seems to be the sentiment of the Committee that we should allow people to request and receive an assisted death for the purpose of saving their relatives money. That does seem to be what people are saying.

[Dr Opher]

There is something called continuing healthcare, which would fund end-of-life care, if someone has a terminal prognosis of six months or less, so care costs would be covered by the state.

[Danny Kruger]

That is a fair point. I do not propose to push the amendment to a vote, but I hope that the point has landed sufficiently. There is a genuine concern that people will, as they do in other countries, with increasing regularity and in concerning numbers, seek to have an assisted death not with their own personal interests in mind but for the sake of others. That may be generous-spirited of them, but it is not the purpose of this Bill as far as I understand it.

--- Later in debate ---

[Kim Leadbeater]

This point is about training, and so about hearing from the right people when it comes to the training of professionals. It is important that we ensure that the Secretary of State must consult such people, and I anticipate that organisations such as the Association of Palliative Care Social Workers would be consulted. The statement continues:

“as well as protecting people from abuse, neglect and coercion at a time…when they are most vulnerable…Our expertise includes building trusting relationships, comprehensive knowledge of safeguarding”.

By looking at the training process, people’s motivations for seeking an assisted death would hopefully be considered.

[Danny Kruger]

Would the hon. Lady be content if somebody who had capacity chose an assisted death for the purpose of saving their family money?

[Kim Leadbeater]

Very few cases are as straightforward as that, and that is where conversations with doctors and professionals are really important. I think it was the doctor from California who said that if someone said to him, “I am doing this because I am a burden,” that would be a red flag. There would have to be a much more detailed, complex conversation with patients about what their motivations were, and it is important that we acknowledge, as medical colleagues have, what those conversations might look like.

[Danny Kruger]

But if the doctor concluded that they were doing it because they felt they were a burden, they would still be able to get the assisted death under the hon. Lady’s Bill. The only question is whether they have capacity. If they have been judged to have capacity, choosing to have the assisted death in order to save their family money would be acceptable under her Bill, would it not?

[Kim Leadbeater]

We are oversimplifying a complex situation and a difficult conversation. We have talked about coercion and pressure a lot. If someone says, “I just want it all to be over, because I feel like a burden”, that is the sort of conversation that doctors acknowledge would be a red flag. Those are complex, difficult conversations; we need the expertise that we would get by providing serious amounts of training around this issue so that those conversations can take place in a sensitive way.

[Danny Kruger]

This is my last intervention, I promise. I want to hear the hon. Lady confirm that under the Bill as currently drafted, after all these conversations have taken place, as long as the doctor cannot find evidence of coercion, they would be obliged to approve the assisted death, as would the judge and the judicial panel. If that is the case, and they conclude that a person has capacity and there is no evidence of coercion, no matter what conversations go on—if the person wants to do it in order to save their family money—the doctors and the judges would have to say yes.

[Kim Leadbeater]

I, again, refer the hon. Gentleman to my previous points; we are oversimplifying a really complex conversation, which would take into account lots of different factors for each individual. That is all I will say on that point.

Terminally Ill Adults (End of Life) Bill (Twelfth sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[Naz Shah]

Amendment 281 would ensure that the patient receives advice on palliative care options from a specialist in the field. Medicine is fast-paced, with innovative and new medicines becoming available in quick succession. Although those in the profession try to keep abreast of developments, it is hard to maintain the depth of knowledge necessary in all specialties. A co-ordinating doctor may or may not have specialist knowledge in palliative medicine. Some courses may provide the opportunity to learn more, but others only touch on palliative medicine—covering it in less than a day of a five-year medical degree. Specialists who are leading in this field of medicine, innovating advances and working to palliate a patient’s symptoms at the end of life will have far greater knowledge of the specialism. Even in this wider debate, many who work in a different field of medicine or in general practice have simply got their facts wrong when speaking about palliative medicine—not through intent but because they have drawn on their own, perhaps out-of-date, experience or simply do not have the competencies to understand all that palliative care can provide.

Pain and symptom control techniques are advancing; in our debates on this Bill, people have articulated instances of poor care rather than what clinical experts are able to achieve. It is therefore essential that a patient has a consultation with an expert in the field of palliative medicine, who can alleviate a patient’s fear, support them with a plan for the end of their life, and discuss how pain and symptoms can be managed. Hearing an alternative approach to the end of life can be life-affirming, help people discuss their fears and concerns about dying, and provide a patient with what they are seeking physically, psychologically, emotionally, socially and perhaps spiritually. Specialists in palliative medicine are trained to home in on the challenges that people naturally have on receiving a diagnosis of terminal illness and are skilled at supporting a patient to explore what end of life could look like for them.

If the Committee does not pass this amendment, it would be placing itself above palliative care specialists when talking about such matters. It would undermine the need for such a specialty in medicine, like a GP who may not know the breadth of palliative medicine options for their patients. The Committee must not assume that it knows those options. Rather, it should enable those with a specialist understanding of palliative medicine to deploy their skills in this process by working through palliative care options with patients before the consideration of a path that will end with an assisted suicide.

Amendment 299 is consequential on amendment 298, which would ensure that a person has a consultation or consultations with a palliative care specialist. Amendment 298 would further embed this into the practice of managing the end-of-life process to provide the patient real choice over their options at the end of life, as what can be achieved through the practice of high-quality palliative care is often significantly different from people’s perceptions—even those of clinicians. Palliative care, like so many fields of medicine, continues to advance in its application and in the steps that can be made available to palliate a person’s pain and symptoms. When pain is difficult to control using oral or intravenous pharmacology, other interventions, such as a nerve block, can result in the absence of pain. A specialist is required to provide such a procedure, but for most people who are in receipt of palliative care, this option is rarely made available. Palliative care is about not just pain and symptom control, but the holistic journey of a patient at the end of life.

[Danny Kruger (East Wiltshire) (Con)]

The hon. Member mentions the principle that palliative care is a holistic service. Does she agree that, given that the Bill’s advocates—including the promoter, the hon. Lady for Spen Valley—emphasise the need for a holistic range of opportunities for end-of-life care, palliative care needs to be central to that? Rather than suggesting that there is an either/or between palliative care and assisted dying, the advocates of the Bill have often stressed the importance of having both options. Does the hon. Member for Bradford West agree that it is strange that the Bill does not require palliative care consultation as part of the range of services that are offered to patients when they are having their consultation?

[Naz Shah]

I completely agree, which is why the amendment tabled by my hon. Friend the Member for York Central (Rachael Maskell) is very important. I urge the Committee to accept it, as it would ensure the provision of a palliative care consultation. As my hon. Friend the Member for Spen Valley has always said, it is about having a holistic approach—we need to get back to that.

In the evidence sessions, we heard that palliative care social workers can play a pivotal role in supporting patients. Those from other professions—psychological services, chaplaincy services, physiotherapists, occupational therapists and speech therapists—along with specialist nurses and medics can all contribute to the care of a patient at the end of life. In discussions with palliative care specialists who listened to the debate on 29 November, they were perplexed by the symptoms that were graphically described in the case studies, and cited poor care as the reason for them. Many such symptoms can be controlled, and they were shocked that such examples of poor care were presented as a reason for assisted death, rather than for making good quality palliative care available to all patients.

We further heard evidence, especially from Dr Jamilla Hussain, that access to palliative care is inequitable. We know that those from minoritised communities and from low socioeconomic backgrounds have poorer access to good palliative care, and that people can have poor access depending on where they live, and on the day of the week or the hour of the day. Through this amendment, we want to ensure that everyone who is seeking an assisted death, or who has it suggested to them, as this Bill allows, is able to access a consultation or consultations with a palliative care specialist, who can dispel the myths while supporting them with their end-of-life plan.

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[Naz Shah]

I completely agree. It is imperative that those options—pain options and care options, including with the family—are explored in detail. The last time that I spent time in a hospice was when my brother-in-law was dying of cancer, and I remember that, as a family, we were very much involved in those conversations. Having such expertise empowers not just the patient but the family. Losing somebody who has a life-threatening condition is a difficult time for families and loved ones. When the wraparound model of palliative care, with specialist nurses and doctors, is good, it can be amazing. I have heard plenty of stories about when it is good. Last week, I mentioned a friend of mine who lost her husband last year, and she said that the palliative care nurses and doctors could not do enough. That gives the family confidence to explore the options. In that instance, that person would have benefited from this Bill—she encouraged me to support it.

As Dr Jamilla said, some people would absolutely benefit from the Bill, and they cannot be dismissed, but how do we legislate to cover people who do not have equal access to palliative care or to healthcare? There is discrimination. The covid experience that we went through recently showed the impact of inequalities. Disabled people, people with mental health conditions, elderly people, and people from black and minority ethnic communities, say that they were DNR-ed—subject to “do not resuscitate” orders. There is already a lack of trust in services, so we need to strengthen palliative care.

There is a fear among these communities that they will be pushed towards assisted dying. A consultation with participants from Pakistani, Roma, Nigerian, black Caribbean and Indian backgrounds revealed overwhelming mistrust, which is deeply rooted in the experience of discrimination and the disproportionate impact of covid-19. As one participant put it,

“They are doing this to save money…to kill us off.”

To get confidence among communities back, we need specialists people can rely on. That is what the amendment speaks to, and I hope that the Committee will support it.

[Danny Kruger]

I rise to briefly speak in support of amendment 281, moved by the hon. Lady and tabled by the hon. Member for York Central (Rachael Maskell).

At the moment that somebody seeks assisted death through a consultation with a doctor, they stand at a fork in the road: they can either proceed towards the assisted death about which they are inquiring, or turn towards other treatment options. On Second Reading, almost every Member on both sides of this debate stated that we need more palliative care, and everybody emphasised the value of providing good palliative care to all who need it. The amendments in this group would simply give force and power to the clear call of the House of Commons for a strong, realistic palliative care option as an alternative to assisted death, and I would be astonished if members of this Committee chose to vote them down. They give clear expression to the will of the House: that palliative care should be offered, and that it should be apparent that a patient has clearly understood their palliative care options.

I implore members of the Committee to consider what they would be communicating if they rejected the amendments. They would be saying that this is not a fork in the road, but a one-way street: there is only one way that someone is likely to go, and that is onwards to an assisted death. If that is the will of the Committee, it should vote the amendment down. If it thinks, as so many people said on Second Reading, that there should be real choice, and that palliative care should be explained and properly available, then I implore the Committee to support the amendment.

[Dr Simon Opher (Stroud) (Lab)]

I thank my hon. Friend the Member for Bradford West and the hon. Member for East Wiltshire for their speeches. I also thank my hon. Friend the Member for York Central (Rachael Maskell), who is a fantastic campaigner for excellent palliative care, for tabling the amendment.

I cannot disagree with almost everything that has been said: people need to be given real choice, and they certainly need to be given the choice of palliative care. As the hon. Member for East Wiltshire said, people need to be offered palliative care. That is absolutely crucial to the Bill. However, the amendment would make it a requirement that a patient has met someone in palliative care. What would happen to a patient’s autonomy if they did not wish to see a palliative care doctor? Would they be excluded from the process? It is incredibly important that people have real choices with respect to palliative care in this process.

I note to the Committee the fact that clause 4(4) states:

“If a registered medical practitioner conducts…a preliminary discussion”

with a person, they have to also discuss with that person

“any available palliative, hospice or other care, including symptom management and psychological support.”

That is in the Bill. It needs to be offered.

I have had patients who have not wished to see a palliative care consultant. It is their autonomy to make that choice. I do not think that it is a wise choice—I think almost every doctor would try to push them towards palliative care—but we must not exclude those patients from accessing an assisted death if that is what they want. That does not mean that people should face a fork in the road, as the hon. Member for East Wiltshire just mentioned. This is not an either/or: sometimes people can receive excellent palliative care and still request an assisted death, as my hon. Friend the Member for Spen Valley said.

I absolutely agree with many of the things you have been saying. I totally agree that we need better palliative care—although, actually, we have pretty good palliative care. In 2017, palliative care in this country was the best in the world, and we need to rebuild back to that again. But having a requirement that someone has to have seen a palliative care consultant will weaken the Bill. I urge the Committee to reject the amendment.

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[Dr Shastri-Hurst]

I am grateful for the hon. Member’s intervention, which leads on to the point I was going to make. We are getting bogged down in nomenclature about what speciality is involved when this is actually about training. It is about whether the individual having the conversation has the requisite skills to have a meaningful conversation. Clauses 5(3)(a) and 8(6)(a) stipulate that the co-ordinating doctor or independent doctor

“has such training, qualifications and experience as the Secretary of State may specify by regulations”.

That is the key part. This is about ensuring that people having incredibly sensitive, challenging and difficult conversations with patients about choices available to them at the end of life have the requisite skills and knowledge to do so. That may not be applicable to each and every general practitioner, but those having those conversations should have that knowledge.

[Danny Kruger]

My hon. Friend is making a thoughtful speech, but I am concerned that he suggests that the skills required are simply the skills of conversation. The skills required are the skills to understand the patient’s condition and lay out very clearly to them their prognosis and the treatment options available to them.

With all respect to my hon. Friend’s father and other GPs, I cannot accept that every GP is fully qualified to understand the dying trajectory of the patient before them—perhaps my hon. Friend will confirm his belief that that is so. If that is true, what is the point of the palliative care profession? We have GPs already and are now introducing psychiatrists and social workers into the mix; I do not understand why on earth it should be regarded as unnecessary to include professionals in palliative care—the key skill that we all recognise as so important in this space. Why not?

[Dr Shastri-Hurst]

I fear that my hon. Friend may be oversimplifying what I was saying. Perhaps I was not clear enough, so I will elucidate. I was certainly not suggesting that the required skills were merely those of being able to have a consultation and a conversation. I was talking about having the skills to have the information that needs to be imparted and the knowledge that underpins that and being able to articulate that within a consultation. It is a much wider picture than just having the communication skills—it is having the knowledge that underpins that. I am saying that that is not necessarily the domain only of someone who works in palliative care. There are a number of specialists who work within this field—it is a multidisciplinary field—and they all bring their expertise. The issue is about ensuring that anybody having these conversations has the knowledge base to conduct them properly.

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[Kim Leadbeater]

It is a pleasure to serve under your chairship, Mr Efford. I will address the amendments in two different ways. I will start by looking at the technical issues around amendment 281, and then I will look at why I believe, as other colleagues have said, that the amendments are not necessary given what already exists both in the Bill and in terms of good practice in our health service.

First, I worry that amendment 281 will not have the effect that my hon. Friend the Member for York Central (Rachael Maskell) intends. Clause 1(2), to which the amendment relates, provides an overview of the other clauses in the Bill, and therefore cross-refers to sections 5 to 22. Clause 1(2) does not impose duties on persons in and of itself. The duties are set out in the later clauses to which it refers. Adding an additional subsection to clause 1, as proposed by the amendment, would not result in a requirement that the person must meet a palliative care specialist. That is a technical detail to reflect on.

In addition, the term “palliative care specialist” is not a defined term. Palliative medicine is a designated speciality of the General Medical Council, and a doctor can apply to be entered on to the GMC specialist register for the speciality provided that they have the specialist medical qualification, training or experience. However, the current wording of the amendment means that it is not clear whether it is seeking to require the person concerned to meet with one of those specialist doctors, or whether a meeting with another medical professional specialising in palliative care—for example, a specialist palliative care nurse—would suffice. There is no equivalent specialist register for specialist palliative care nurses. It is a technical issue, but an important one.

I also point out that my hon. Friend the Member for York Central has put an incorrect explanatory note with the amendment, which refers to terminal illness. That might just be an error, but I wanted to point that out.

Coming on to the broader grouping of the provisions: as has been said by colleagues, the amendments are tabled with really good intentions by someone who cares passionately about the palliative care sector. But they are not necessary given the process that is already set out by the Bill. Both doctors already have to discuss all treatment options, and must make a referral if they have any doubt about the diagnosis. It is very clear from clauses 4 and 9 that both the co-ordinating doctor and the independent doctor must discuss all treatment options with the patient, so they will have all the options laid out before them. That is really important because we have to think about what happens in reality. This initial discussion, in many cases, may actually take place with a palliative care doctor, and in many cases it will be highly likely, given the nature of the conditions we are talking about, that the patient may already be receiving treatment or advice from a palliative care team.

We seem to have created a narrative where this conversation is happening in isolation. Actually, as other colleagues have alluded to, we have a patient-centred approach in our healthcare. This person does not just suddenly arrive and have this one random conversation. I am sure medical colleagues will correct me if I am wrong, but if a doctor is dealing with a condition of which they have very limited knowledge, one of the first things they would do would be to refer to a specialist.

As is covered in clause 9(3)(a), if the doctor has any

“doubt as to whether the person being assessed is terminally ill,”

they must

“refer the person for assessment by a registered medical practitioner who holds qualifications in or has experience of the diagnosis and management of the illness, disease or condition in question;”

Clause 9(2)(a) also states that both doctors must assess the patient’s

“medical records and make such other enquiries as the assessing doctor considers appropriate;”

They can speak to anyone they want to, and they would in reality—of course that is what they would do. They would not sit there and think, “Oh, I don’t know enough about this condition so I will just keep going.” They would refer to specialists.

It is also really important to acknowledge what goes on at the moment. I was looking at some research last night: NHS England also has comprehensive guidance on personalised palliative and end-of-life care through a comprehensive personalised care model. None of this stops with the introduction of assisted dying as a choice for people. It would continue to happen. Patients are already getting that really good level of care.

[Danny Kruger]

The hon. Lady is making a very good speech about how things should work and how things do work, in many cases, when the NHS does its job brilliantly. First, I want to correct the hon. Lady: subsequent amendments do impose the duty that is consequent to these amendments to clause 1, so it would be an obligation. Surely that is the point to make: what if the doctors are not as brilliant as she suggests? What if there is not an expectation that they should definitely seek expertise that they do not have themselves? To the point made by my hon. Friend the Member for Reigate, what if this service is provided outside the NHS by an independent charity or private provider set up explicitly to facilitate people’s assisted death requests, and has no intention of referring people to palliative care if they do not ask for it themselves? Would she be content for a private provider to refer somebody for an assisted death without a palliative care referral?

[Kim Leadbeater]

I do worry about the lack of faith in our professionals. We have medical practitioners on the Committee and we have heard stories of the very good practice that happens, so it concerns me that we are so cynical about our system. Ultimately, we have to put faith in our professionals to do their job and to take that patient-centred approach, as I firmly believe they do. Dr Sarah Cox from the Association for Palliative Medicine said in her evidence to the Committee:

“In clinical practice, we make all these decisions in multi-professional teams…shared decisions are much better quality, much more robust and much safer.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 74, Q90.]

I absolutely agree with her, and that would continue to be the case.

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[Naz Shah]

I have a few concerns about what we have just heard in relation to the amendment. One of them is in relation to Dr Cox’s evidence. What Dr Cox actually said was:

“The second difference, I would say, is that you are absolutely right that we do make those decisions with patients—with their families, if they wish—but in a multi-professional team. I would almost never make those decisions as an individual doctor without the support of my colleagues, for several reasons. First, as I have said already, that makes for much better decisions”. ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 74, Q91.]

[Danny Kruger]

To pick up on that point about Dr Cox, I think it is critical that the hon. Member for Spen Valley cited Dr Cox in support of the hon. Lady’s contention that the Bill is adequate. Dr Cox, in her evidence, was saying that there is a problem with the Bill because it does not require the multidisciplinary consultation that we all think needs to happen. Dr Cox was suggesting that the Bill should be amended in order to ensure that the NHS does its job properly, and that multidisciplinary consultations are held. Her evidence was not in support of the Bill as it stands.

[Naz Shah]

I thank the hon. Gentleman for his intervention.

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[The Chair]

I point out that this is an opportunity to discuss clause stand part, not to cover the ground of amendments that have already been debated.

[Danny Kruger]

I will be quick, Mr Efford. I appreciate that we have been exhaustively over the detail of the amendments. I deeply regret that none of the amendments that were tabled to introduce stronger safeguards has been accepted. I want to take this opportunity to explain briefly what the Committee has done by rejecting those amendments and what we will be doing by agreeing to the clause without the amendments. I will not seek to divide the Committee on the clause, because I recognise that it enables the whole Bill to proceed, as the House wished on Second Reading, so I recognise that the principle of the Bill is represented in the clause. We wanted to tighten it, but have failed to do so.

[Jack Abbott (Ipswich) (Lab/Co-op)]

I say gently to the hon. Member that—particularly on the previous clause—I have been very sympathetic to several of the amendments. Candidly, however, with due respect to all the hon. Members across the House who submitted this, I do not think that they have been particularly well written. I think that they leave quite a lot of ambiguity in a lot of areas. We had a discussion in the week before the recess, on a number of areas, about the word “only”. I heard it suggested earlier that the principle is about the spirit in which things are taken.

The reality is that I am very sympathetic to a lot of what is proposed, but a number of the amendments leave quite a lot of open ends. That has been a particular issue. I have been very open and have said that in principle I am supportive of assisted dying, but that I could not support it because the Bill was not strong enough in its current state. I do not think that the amendments tabled so far will strengthen the Bill; in fact, they might leave a lot of open ends, despite the very good intentions behind a lot of them.

[Danny Kruger]

I am grateful to the hon. Gentleman for explaining why, having opposed the Bill on Second Reading, he now seems to be supporting it. I wish I had heard, during our debates in the past two weeks, his specific objections to the amendments. If he felt, as he says, that the Bill is not strong enough, we would have welcomed his own amendments to strengthen the Bill in a form of words that he would find adequate. Perhaps that is what we will hear from him.

[Jack Abbott]

I did articulate a number of times where I felt that some of the amendments were not tight enough in those areas.

[Danny Kruger]

The hon. Gentleman has been on his feet; I appreciate that and am very grateful for his contribution to the debates that we have had.

I simply want to make the point that what the House voted for on Second Reading was the principle of assisted dying. What many members of the public who support the Bill think they are getting is a Bill that is safe—a Bill that is restricted explicitly to people at the very end of their life, who face extreme pain and suffering as they die; who are fully informed of what they are doing; who face no questions of external or indeed internal coercion; who have the absolute ability to understand what they are doing. Those are the things that people want to see in the Bill; those are the things that we have sought to effect through the amendments that we have tabled, and which the Committee has rejected.

Very explicitly, as a result of the rejection of these, I believe, very plainly written amendments, the fact is that under this Bill you can be depressed and suicidal and still regarded as having capacity to have an assisted death. You can be very marginalised—you can be a prisoner, you can be homeless—and still be regarded as eligible. You can have been influenced or encouraged by others and still be eligible. You can do it because you feel a burden. You do not need to be in any kind of pain. You do not need to be in the tiny proportion of cases that palliative care cannot help. As the hon. Member for Spen Valley accepted in the previous sitting, you can seek an assisted death for the sole reason of saving your family money, and you would be granted an assisted death on those grounds. The fact is that in rejecting these amendments, the Committee has decided and has demonstrated that the Bill is much wider than the campaigners portray.

I want to end with this point. I think there are two ways of approaching assisted dying—two essential framings of a Bill to legalise it. One is an autonomy Bill, which simply says that if people seek help to commit suicide, within certain broad parameters they should be able to do so, and there is no question of other people interfering with that choice; if they sign the requisite paperwork, they should be able to have an assisted death. The alternative is what we might call a safeguarding Bill—one where eligibility for the procedure is strictly limited and there are very strong, robust safeguards in place to protect the most vulnerable people.

The hon. Lady, and Members speaking in support of the Bill, have repeatedly emphasised that this is a safeguarding Bill. They want this Bill to be built around safeguards for the vulnerable. They respect the arguments that we make about the dangers that an open-ended assisted dying Bill would create. But the fact is that, as we have seen in the course of the debates on this clause, this is not a safeguarding Bill; it is an autonomy Bill. It is one that allows people to proceed to an assisted death because they want one, if they meet certain very loosely drawn criteria.

[Kim Leadbeater]

The reality is that this Bill is both. Of course it is about personal autonomy, choice and dignity for people who are coming towards the end of their life, but it has to be safeguarded as well. It is both. If I may say so, I think that the hon. Member makes quite an unfair characterisation of the robust, powerful debate that has taken place in Committee during the time that we have spent together. I think it has been extremely well informed. People have listened intently to other points of view and opinions, and it does the Committee a disservice to suggest otherwise.

[Danny Kruger]

We are all being very courteous, and it is absolutely right that we should be. I have absolute respect for the good faith of every Member here, but let us not use cotton wool in these debates. I am sorry to say that I do not accept that the Committee has listened—well, it might have listened closely, but it has not accepted a single amendment, including amendment 281, which would have put into law the principle in which the hon. Member for Bradford West believes, which is that palliative care should be an option. Why was that not accepted? The Committee has decided that it will proceed with the Bill as it is.

The fact is that the Bill will give maximum autotomy, within very broad parameters, to patients, many of whom will be very vulnerable. It is an autonomy Bill masquerading as a safeguarding Bill. When we attempt to strengthen the safeguards, they are described as bureaucratic hurdles. If the Bill becomes law, I worry about what will happen to the very limited safeguards that do exist. What we see elsewhere will happen, which is that the safeguards that do exist are treated as bureaucratic hurdles. They are in fact treated, and explicitly described, as we heard from the Australian witnesses, as barriers to a human right. What were safeguards become discrimination. I am afraid that that is the road we are going down.

The point about autonomy is often made. As I say, I think that this Bill actually has autonomy at its heart. The hon. Member for Spen Valley is right to make that point. That is really what is going on here. She wants people to be able to request help to commit suicide—to end their lives. The fact is that for the most vulnerable people, creating this option, especially when we have now switched off the obligation to seek a palliative care pathway and directed people straight down the road towards an assisted death—

[Kit Malthouse]

That is a misrepresentation.

[Danny Kruger]

I am sorry if it offends Members, but the fact is that the Bill in its present form, with the amendments rejected, will place no obligation on doctors to refer people to palliative care or to seek a palliative care consultation. Many will do so, of course—many good doctors will do exactly that—but they will not be obliged to. If we are imagining that every doctor will be as brilliant as the best doctors, I am afraid that I will have to talk about the Liverpool care pathway and the many tragic scandals that we are constantly dealing with. It is simply not the case that the option of a palliative care consultation equates to the absolute expectation that it will happen.

[The Chair]

Order. We have debated that issue.

[Danny Kruger]

We have debated that issue; I apologise.

My concern is that the Bill, which is masquerading as a safeguarding Bill but is actually an autonomy Bill, will end in less autonomy for the most vulnerable patients, who will find themselves on this conveyor belt, internally pressured and encouraged to seek an assisted death when it is not in their interests. I invite the Committee to reflect on what we have done, but as I have said, I do not propose to divide the Committee on clause 1 stand part.

[Rebecca Paul]

Under our current law, assisting someone to commit suicide is a criminal act. Clause 1 of this Bill is where we cross the Rubicon, moving away from well-established principles into a new era in which the state is empowered to help individuals to die.

This monumental decision is one for Parliament in the coming months. However, what we must do on this Committee is bolster the safeguards so that the Bill is truly as safe as it can be. Our priority must always be the vulnerable: those who could be coerced into something that is not in their best interests, and those with no one to advocate for them or protect them, who could end upbeing pushed into a process because that is the easiest and cheapest option for everyone. This law must work for everyone, not just the privileged few.

That is why I am so disappointed that at the end of nearly three days of debate, there has been not one improvement to the safeguards—not one. We asked for amendments to exclude people with impaired judgment and the depressed and suicidal; this Committee said no. We asked to protect those who are unduly influenced or encouraged by others to seek assisted dying—

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[Stephen Kinnock]

I will make some brief remarks on the legal and practical effect of clause 1, as amended, to assist hon. Members in making their own assessment. Clause 1 sets out the eligibility criteria that a person must meet in order to request to be provided with lawful assistance to end their own life under the provisions of this Bill. A person must be terminally ill; this term is defined in more detail in clause 2.

Clause 1(1) sets out a further four requirements, which require that a person must also have the necessary capacity to make the decision, which is to be read in accordance with the Mental Capacity Act 2005; be aged 18 or over; be ordinarily resident in England and Wales and have been resident for at least 12 months; and be registered as a patient with a GP practice in England or Wales. This clause provides that, in particular, clauses 5 to 22 of the Bill require steps to be taken to establish that the person has a clear, settled and informed wish to end their own life and has made the decision that they wish to end their own life voluntarily and has not been coerced or pressured by any other person in making that decision.

The clause, as amended by the insertion of new subsection (3), will ensure that the service can be accessed only by an individual ordinarily resident in England and Wales. That amendment, amendment 180, has been drafted to give effect to the policy intent of my hon. Friend the Member for Spen Valley for this legislation: that it is to apply only to those in England or Wales and is not to be accessed via medical tourism.

As I have said, the Government remain neutral on the substantive policy questions relevant to how the law in this area would be changed. The clause is a matter for the Committee and Parliament to consider, but the Government’s assessment is that the clause, as amended, is workable, effective and enforceable.

Question put and agreed to.

Clause 1, as amended, ordered to stand part of the Bill.

Clause 2

Terminal illness

[Danny Kruger]

I beg to move amendment 399, in clause 2, page 1, line 22, leave out “, disease or medical condition” and insert “or disease”.

This amendment ensures that a terminal illness under the Bill can only be an illness or a disease and not a medical condition.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 400, in clause 2, page 2, line 1, leave out “, disease or medical condition” and insert “or disease”.

This amendment is consequential on Amendment 399.

Amendment 401, in clause 2, page 2, line 5, leave out “, disease or medical condition” and insert “or disease”.

This amendment is consequential on Amendment 399.

Amendment 11, in clause 2, page 2, line 7, leave out from beginning to first “of” in line 8 and insert—

“(3) A person is not to be considered to be terminally ill by reason”.

This amendment amends clause 2 to say that a person cannot be considered terminally ill by reason of having mental illness or a disability.

Amendment 181, in clause 2, page 2, line 8, leave out from “ill” to end of line 10 and insert—

“only because they are a person with a disability or mental disorder (or both).

Nothing in this subsection results in a person not being regarded as terminally ill for the purposes of this Act if (disregarding this subsection) the person meets the conditions in paragraphs (a) and (b) of subsection (1).”

This amendment clarifies that the purpose of subsection (3) is to emphasise that only having a disability or mental order does not make a person “terminally ill” and therefore eligible for assistance.

Amendment 283, in clause 2, page 2, line 10, at end insert—

“or one or more comorbidities alongside a mental disorder within the meaning of the Mental Health Act 1983”.

This amendment would set out that a person who has a co-morbidity with one or both of a mental disorder or a disability is not considered terminally ill by virtue of those comorbidities alone.

[Danny Kruger]

I said in the last debate that this is either a safeguarding Bill or an autonomy Bill. [Interruption.] Or that it is both, but the claim has been that it is a safeguarding Bill and that there are very strong safeguards. If so, and if we are going to stress the safeguards, as I think we should, that means being very clear about who is eligible. It means having proper, meaningful guardrails showing who is inside and who is outside the scope of the Bill. I suggest that the Bill’s guardrails are not strong, safe or impermeable; they are broken fences. We need to mend those fences in this Committee in order to make the Bill safe.

This group of amendments includes a set in my name that would restrict eligibility to people with terminal diseases or illnesses, and another set that would build stronger safeguards explicitly for disabled people and people with mental disorders. The purpose of the two sets of amendments is the same, but they approach the challenge from opposite ends. I will speak first to the amendments in my name.

Quite simply, I want to remove the words “medical condition” from the definition of terminal illness. The reason for that is straightforward: some medical conditions are likely to also amount to a disability. As Fazilet Hadi, the head of policy at Disability Rights UK, told the Committee in evidence, there is a “huge overlap” between disability and terminal illness. The distinction between the two is notoriously blurred, and there is a reason why no disability rights organisation backs this Bill: it is here in this innocuous phrase “medical condition”. Removing that phrase will provide an additional degree of protection for some disabled people, which I think is a good enough reason to do it.

There is another group of people whom we do not hear from much in these discussions, but about whom we should perhaps be most concerned, because there are so many of them—they are almost all of us. I am talking about the frail. Frailty is an important word in this debate. I refer hon. Members to the briefing submitted in recent days by the British Geriatrics Society; it is a powerful document that highlights an essential challenge for this Bill. What is frailty? Is it a disability? Is it a terminal illness? Is it both? Is it neither? It can be noted on a death certificate as a cause of death and, even if it is not listed as a cause of death—this is a crucial point—it is the most common dying trajectory for people in the UK. More people are frail as they approach the end of life than are not.

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[Kim Leadbeater]

I am interested to know where the hon. Member has got the idea that someone is going to scrap the six-month prognosis from.

[Danny Kruger]

Well, if the hon. Lady will say that she will never, at any stage, support a proposal to extend it beyond six months, I will be very glad to hear it. My concern is that we already have amendments tabled to do exactly that, which we will be debating shortly. I hope they will be rejected, but my confident expectation, on the basis of other countries, including the Australians who gave evidence to this Committee, is that the six-month safeguard will soon be seen as a barrier to a human right, because there is indeed no logical basis for such an arbitrary date.

The people who currently deal with the six-month prognosis, in the context of benefits and pensions, campaign that it is arbitrary and unworkable—rightly, I think—so I am afraid that I confidently expect the six-month barrier to be challenged in due course. If the hon. Lady is prepared to say that she would never do that, however, I would be very reassured.

[Kim Leadbeater]

Would the hon. Member agree that the purpose of the Committee is to look at the Bill before us? That is why we are here. I understand his concerns, his reservations and his nervousness about what might happen in future, and that is an important conversation to have, but the purpose of the Committee is to look at the Bill as it stands today; that should be the focus of our deliberations.

[Danny Kruger]

Yes, but I simply state on the record that I believe that this is not the end, but the beginning of a wider Bill that would follow if we passed this one. I am encouraged by what the hon. Lady says, or implies: that she does not want to go further than this Bill.

My plea to the Committee is straightforward. Let us confine eligibility to the people who the campaigners talk about: those with diseases or illnesses that are genuinely terminal. We can do more to strengthen that definition with later amendments, but, first, we have to remove the gaping hole in the fence that is this term “medical condition”. Let us remove that term.

[Tom Gordon (Harrogate and Knaresborough) (LD)]

Marie Curie’s definition of a terminal illness is

“an illness or condition which cannot be cured and is likely to lead to someone’s death”.

It is obviously one of the best-known end of life charities, so how does the hon. Member reconcile the differences he has with its professional expertise?

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[Danny Kruger]

I am very happy to use the word “condition”—we all use it quite casually, including me—but we are concerned about legislation here. As I explained, if we include the term “medical condition”, courts could interpret that as a development—an addition—to the existing law on terminal illness, which refers only to illness and disease. The courts would be right to conclude that Parliament meant more than illness or disease, which is why it is important to be explicit about what we are talking about: illness or disease.

I think we should remove that term, but if other Members do not, I would like to understand why. The hon. Members for Harrogate and Knaresborough or for Spen Valley might have some suggestions, but I would be grateful if somebody could clarify, explicitly, what is meant by “medical condition” that is not caught by the terms “illness” or “disease”. What are the meanings of the three terms, and why do we have to have “medical condition”? It might well be that there are conditions that would not be captured by “illness” or “disease” that would be appropriate.

[Lewis Atkinson (Sunderland Central) (Lab)]

On that point, I will quote directly from Chris Whitty’s evidence to the Committee:

“there are people who may not have a single disease that is going to lead to the path to death, but they have multiple diseases interacting, so they are highly frail; it is therefore not the one disease that is the cause, but the constellation that is clearly leading them on a path inexorably to…death”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 32, Q5.]

From my perspective, it is about that “constellation” where death is clearly going to happen as a result of a combination of different conditions, illnesses or diseases. That it is where that is very clear, and, because of the six-month eligibility in the Bill, we have that nailed down. That is the importance of including the term, because it is not one disease that leads to death; it is the constellation of diseases and illnesses that will inexorably lead to death.

[Danny Kruger]

I am grateful to the hon. Gentleman. I thought that might be the case too, and I was wondering about that, but I am very concerned about some of the evidence that Professor Whitty gave. I regret that the hon. Member for Spen Valley has removed the role of the chief medical officer from the process that she is designing by introducing the new commissioner, but I will not be sorry to see that particular chief medical officer excluded from the process. He has made significant mistakes; he had to write to the Committee to explain that he had misrepresented the Mental Capacity Act, and, on his evidence, the Committee voted to reject certain amendments.

I am concerned about what Professor Whitty said, but if the reason for including “medical condition” is to reflect the fact that there might be multiple diseases or illnesses that, together, mean that somebody is terminally ill, that is what should be stated in the Bill. It could very well include “a combination of illnesses or diseases that amount to terminal illness”. My concern is about this new concept of a medical condition, which, as I have said, implies something different from a disease or illness.

The Bill would say “the person’s death in consequence of illness or disease”—if we remove “medical condition” —so that would be the qualification or eligibility. If there is a number of illnesses or diseases that amount to a fatal prognosis, that would be captured in the clause, even once we have excluded medical condition, because the singular “illness” or “disease” would, as I understand it from our guidance on statutory interpretation, include the plural. If it is about there being a number of illnesses or diseases that add up to a fatality, the Bill as I propose to amend it would be adequate to the scenario that the hon. Member for Sunderland Central described and that Professor Whitty accounted for. The question is, what is additional illness or disease, or illnesses or diseases, that are captured by the term “medical condition”?

[Kit Malthouse]

Let me give a quick example. Amyotrophic lateral sclerosis is described as a condition rather than a disease or an illness. ALS is not dissimilar to motor neurone disease, but nevertheless people regard themselves as having a condition rather than a disease.

[Danny Kruger]

Again, I am interested in that, because I would be surprised if that condition were not adequately captured by the term “illness” or “disease”. If not, we should seek further clarification, because we need to be very specific. Illness or disease has been adequate; it is adequate in the current law on terminal illness for eligibility for benefits and pensions. I await clarification on what is added by the term “medical condition”, because my concern is that it opens the door to frailty. Going back to Chris Whitty’s evidence, I am concerned at his suggestion that frailty should be an eligible condition for an assisted death.

I will wrap up shortly so that hon. Members have time to speak to other amendments, but I will quickly refer to amendment 181 tabled by the hon. Member for Spen Valley and amendment 11 tabled by my hon. Friend the Member for South Northamptonshire (Sarah Bool), which attempt to do the same thing as my amendments. They seek to protect disabled or mentally ill people, but they do so explicitly by disapplying the provisions of the Bill for those groups, or they attempt to do so. Only amendment 11 actually does, while amendment 181 fails to do so, in my view.

Let us look at subsection (3), which attempts to protect disabled people and those with mental disorders, but which, on closer inspection, is ineffective or even meaningless. In statutory interpretation, the first phrase,

“For the avoidance of doubt.”

indicates that the subsection does not add anything to the Bill except clarity. It is intended not to change the law that is being enacted by the Bill, but to clarify the meaning of the Bill. My point is that it does not add anything—in fact, it signals that the clause can be disregarded. It is like an explanatory note and not actually relevant to the Bill. Its effect therefore negates the point that it tries to make. In including it, the hon. Lady protests too much and exposes the weakness that the clause fails to overcome. It invites a court to disregard the protection it pretends to offer by stating that that protection has no force except what is elsewhere in the Bill.

[Kim Leadbeater]

I agree with the hon. Member to some degree in terms of the legal drafting. I have been advised that the expression “for the avoidance of doubt” is not generally used in a Bill if the Bill is already clear, which this is—I have been reassured by parliamentary counsel about that—but I was keen, having met disabled people and disability rights activists, to have it very clearly in the Bill that by virtue of having a disability, a mental health condition or a mental disorder, someone would not be in scope of the Bill. It was a very clear drafting decision and I stand by that decision; I think it is the right thing to do so that we are clear who is not covered by the Bill.

[Danny Kruger]

I am grateful to the hon. Lady; it is helpful to understand her thinking. Her amendment is an attempt to further clarify her purpose, which is to communicate that we cannot have an assisted death only because of a mental disorder or a disability. I know that other colleagues will speak to that point more explicitly.

My point is that

“For the avoidance of doubt”

is a massive signal to the courts that the subsection is meaningless. The advice was right that it is not usual to include that phrase, as it signals that nothing is being added. My concern is that it does not add anything, and the inclusion of the word “only” further demonstrates the hollowness of the protection that it purports to offer. The fact is that someone will still be able to get an assisted death because of a physical illness that derives from a mental disorder or disability. That is my concern with the later parts of the clause, but I will leave other Members to make that point.

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[Naz Shah]

I appreciate that cancer does come under disability, and that people with cancer can identify as a disabled person, but my initial thought is that that weakens the Bill.

[Danny Kruger]

The fact that cancer is included in the Equality Act definition does expose a concern about the Bill. It suggests that there is a real connection there, which is of concern. I think the solution is to accept the amendment 11 and ensure that disabled people and those with mental health conditions would not be eligible for assisted dying, and then to introduce a further amendment—either now, as a manuscript amendment, or later—to exclude cancer from the definition. That is a tidying-up exercise that could be done in light of the point that the hon. Member for Spen Valley made about the reference in the Equality Act. The most important thing is that we tighten the clause to protect disabled people.

[Naz Shah]

I wonder whether my hon. Friend the Member for Spen Valley has considered whether she would tighten the clause. Have any options been explored, and what have the Government said about her removal of the Equality Act—

Terminally Ill Adults (End of Life) Bill (Thirteenth sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[Danny Kruger (East Wiltshire) (Con)]

The hon. Gentleman is making a very important point, and he picks up the observation by the hon. Member for Bradford West that there is a link, through the Equality Act, with disability. It is absolutely right that we address that. Does he agree that the way to do so is not to accept amendment 181 tabled by the hon. Member for Spen Valley, which would retain the dangerous words “only” and “for the avoidance of doubt”, but to accept amendment 11, which would exclude those words and ensure that someone could not get an assisted death by reason of disability or mental illness? Because of that concern, perhaps we need to table a further amendment to exclude the Equality Act from the operation of this clause, and I await the Chair’s ruling on whether that is possible at this stage. Amendment 181 does not refer to the Equality Act, although the Bill does, so we should follow that point. Rather than accepting that amendment, which would not move us forward, we should accept amendment 11. I hope that that is clear and that it might satisfy the hon. Gentleman’s concern.

[Daniel Francis]

I will return to that. I understand what amendment 11 seeks to do, but I think we should have a hybrid, because I do not think either amendment would completely achieve what we want. I will seek the Minister’s advice in due course. I understand the legal advice to my hon. Friend the Member for Spen Valley on this matter, and I understand that all the amendments have been tabled in good faith, but I am concerned about the loopholes that could remain.

We heard on Second Reading that assisted dying will not be available to disabled people, but let us imagine an individual who does not consider themselves to be disabled. If they were diagnosed with cancer tomorrow, our current legislation states that they would be disabled from the point of diagnosis. They could live with that cancer and receive treatment for a considerable time, while continuing to have no other disability. When they receive a six-month prognosis, they would be eligible for assisted dying due to the same disability they have had for a very considerable time, and it would remain the only disability they have had in their entire life. I remain concerned that my hon. Friend’s amendment still talks about disability, potentially leaving that loophole.

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[Dr Simon Opher (Stroud) (Lab)]

I would like to make a short comment. It is very important that the Committee does not get too hung up on anorexia, because the Bill is very clear about what is excluded. Deprivation of nutrition is always reversible. Someone who is anorexic and about to die would go into multi-organ failure and be unconscious and unable to give any sort of consent. Before that, the nutritional deprivation is reversible and therefore not covered under the Bill.

[Danny Kruger]

I just wanted the hon. Gentleman to comment on the reality in our NHS at the moment that people are described as terminally ill with anorexia. They are given the label of being terminally ill and put on palliative care pathways because it is assumed that their condition is not reversible. Doctors today, in this country, are concluding that people with eating disorders are going to die and are treating them accordingly. Is he aware of that, and how does it affect his comments?

[Dr Opher]

I am not aware of that. I believe that this is always reversible until a person goes into the absolute terminal stage of multi-organ failure. Before that, we can reverse nutritional deprivation. I do not accept that point, and I think it is important that we look at the Bill in all its detail. I think it has enough safeguards to exclude someone with anorexia.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Dowd. Although it is for Parliament to progress any Bill, the Government have a responsibility to make sure that legislation on the statute book is effective and enforceable. For that reason, the Government have worked with my hon. Friend the Member for Spen Valley; where changes have been agreed mutually between her and the Government, I will offer a technical, factual explanation of the rationale for those amendments. That applies to amendment 181 in this group.

This group of amendments is linked to how the Bill’s definition of a terminal illness applies to those with a mental disorder or disability. Amendments 399 to 401 would remove the term “medical condition” from the Bill’s definition of a terminal illness, so that only those with an inevitably progressive illness or disease would be able to request to end their life, rather than, as under the current drafting, those with a “disease or medical condition”.

The amendments could narrow the scope of those who may access assisted dying services. However, clinical advice suggests that the use of the terms has changed over time, may not be used consistently and remains debated in both medical and lay circumstances. Removing the term “medical condition” may lead to disputes or protracted debates about whether a particular condition is or is not a defined disease or illness, despite there being medical consensus around whether it will lead to death within six months.

[Danny Kruger]

I am grateful for that clarification, but it rather concerns me. Can the Minister elucidate exactly which conditions might fall into the category of medical condition that would not be captured by “illness” or “disease”? Does he accept the point that I made in my speech—that the interpretation of the law by the court will be that the phrase expands the definition of a terminal illness beyond illness or disease, as it is in the current law? What are the new conditions that will be captured by the term?

[Stephen Kinnock]

What the hon. Member will have picked up throughout this debate, on every day that we have met, is that the Government are concerned about adding or taking away terminology that delivers clarity, stability and familiarity.

I have to say that I am quite torn on the hon. Member’s amendment 399, because I absolutely see where he is coming from. It is one of those situations in which my position as a Government Minister is made somewhat more complex by my personal view that his amendment is perfectly reasonable. My instinct—speaking personally as a Member of Parliament, rather than as a Government Minister—is that the remaining terms in the Bill, if we removed “medical condition”, would continue to cover the waterfront or spectrum of conditions. It is possible that this is a case in which there has been an overabundance of caution on the part of the Government. I am delivering the Government’s position, but I want the hon. Member to know that that will not necessarily determine how I vote if this amendment does go to a vote.

[Danny Kruger]

I was going to remind the Minister that he is, in his strange Jekyll and Hyde personality, speaking as a Minister but voting as a Member of Parliament, so if he has given the Government’s view that my amendment is not acceptable, but he personally thinks that it is, I hope that he will vote for it.

[Stephen Kinnock]

It is a well-made case; I am still reflecting on it, because of the somewhat complex nature of my role on this Committee, but I am inclined to support the hon. Member’s amendment.

Amendment 11 also seeks to amend clause 2(3). Our assessment of the effect of this amendment is that a person who has a mental disorder and/or a disability may not qualify under the Bill as terminally ill, even if they have an inevitably progressive illness and can be reasonably expected to die within six months. There might be concerns from the point of view of the European convention on human rights and the Equality Act if the amendment were passed as currently drafted, because its effect would be to exclude people from the provisions of the Bill if they had a disability or a mental disorder. That may not be the intention of the hon. Members who tabled the amendment.

I turn to amendment 181. In executing our duty to ensure that the legislation, if passed, is legally robust and workable, the Government have advised my hon. Friend the Member for Spen Valley in relation to the amendment. It clarifies that a person who seeks assistance to end their own life based only on a mental disorder or a disability, or both, would not be considered terminally ill for the purposes of the Bill. Such a person would therefore not be eligible to be provided with assistance to end their own life under the Bill. Someone who has a disability or a mental disorder, or both, and who also already meets all the criteria for terminal illness set out in the Bill would not be excluded by the amendment, as drafted. The amendment therefore brings important legal clarity to the Bill.

Amendment 283 sets out that a person who has one or more comorbidities, alongside a mental disorder within the meaning of the Mental Health Act 1983, would not be considered terminally ill by virtue of those comorbidities alone. The reality of modern healthcare is that many patients, not least those towards the end of life, will be dealing with several conditions or comorbidities. The term “comorbidity” in a clinical context can sometimes be used to distinguish the main problem that someone has experienced experiencing from additional but less serious problems, but it can also be used by those specialising in one or more other aspects of a patient’s care to distinguish their area of focus from other issues.

In the context of the Bill, the essential test is whether any morbidity, comorbidity or otherwise, meets the requirements in the Bill. Although it is unlikely that a terminal morbidity would be thought of as a comorbidity, it is not inconceivable that it might be, for the reasons that I have set out. The phrasing of the amendment, notably the term “alongside”, potentially increases that possibility. The effect might be that a condition that would otherwise be considered terminal would instead be considered a comorbidity alongside a mental disorder. The amendment would prevent a person with a mental disorder who would, but for the amendment, have been considered terminally ill from accessing assisted dying services under the Bill.

As I have said, the Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could be changed. However, to ensure that the legislation works as intended, we have advised the sponsor in relation to amendment 181, to further clarify the Bill such that only having a disability and/or mental disorder does not make a person terminally ill and eligible for assistance in accordance with the Bill.

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[Kim Leadbeater]

My apologies; I am speaking to amendments 399, 400 and 401. I will be happy to come back to that point at the appropriate time, but I first want to finish my comments on those amendments.

As I have said, the hon. Member for East Wiltshire has done a good job this morning of improving the clarity of the issue. That shows that the Committee is doing its job and working effectively. I am therefore open to supporting those amendments.

[Danny Kruger]

I am delighted to hear it. I am grateful to the hon. Lady and to other hon. Members who have indicated their sympathy for the amendment. I look forward to the Division and to the Minister’s decision.

May I follow up on a point made by the hon. Member for Bradford West? I do not know whether the hon. Member for Spen Valley would like to intervene to help me understand the point. Amendment 181 would redraft clause 3(2) to make it clear that a person does not qualify as terminally ill

“only because they are a person with a disability or mental disorder”.

It would add to clause 3(2) the following additional sentence:

“Nothing in this subsection results in a person not being regarded as terminally ill for the purposes of this Act if…the person meets the conditions in paragraphs (a) and (b)”.

Does the hon. Member for Spen Valley agree that that will essentially mean that the clause does nothing? It confirms the terms of eligibility set out earlier in the Bill, and confirms that a person would still be eligible to receive an assisted death if they had conditions that were a consequence of a mental disorder or a disability. If she feels like intervening on me, I would like her to help me understand what that additional sentence adds. To my mind, it negates the purpose of the clause.

[Dr Tidball]

I stand here as a disabled woman. Under the Bill, as a disabled woman, I would not —by reason only of being a disabled woman—be eligible to have access to assisted dying. The amendment clarifies that I would not be eligible only through being a woman who has a disability. However, if I develop a condition that means that I have a terminal illness, leaving me with only six months left to live, I would be permitted to have that choice. It is right, I think, that I should have that choice. As I said in my Second Reading speech, this is about giving people access to a good death and living a good death. This is about giving that choice, where they choose to make it, to disabled people, while building in sufficient safeguards so that this is not something pressed upon them—

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[Danny Kruger]

I am grateful, Mr Dowd. I recognise the force of what the hon. Member for Penistone and Stocksbridge is saying. To be clear, the amendments that I am supporting would not deny disabled people any of the other rights that are being awarded in the Bill. She is absolutely right that a disabled person with a terminal illness would qualify just as much as someone who was not disabled. That is absolutely right.

The purpose of the amendment is to ensure that people whose illness is a direct consequence of a mental disorder in particular would not be eligible. The reference to disability is because of the confusion, which I expect the hon. Member for Spen Valley recognises in current law and guidance, about where the distinction between disability and terminal illness lies. That is our concern. The purpose of the amendment is to ensure that people would not be deemed as eligible for an assisted death in consequence of disability or mental illness. I know that is what the hon. Lady is trying to do with the amendment, and with the clause that it amends, so we are on the same page. Our concern is that, by including the words “For the avoidance of doubt” and the word “only”, we will be leaving quite a large loophole, through which, I am afraid to say, some vulnerable people might fall.

I look forward to the Division on the amendments. We have not been able to discuss them all in close detail, but I am grateful to Members for the debate that we have had.

Amendment 399 agreed to.

[Juliet Campbell (Broxtowe) (Lab)]

I beg to move amendment 123, in clause 2, page 1, line 23, leave out “an inevitably” and insert “a typically”.

This amendment changes the definition of what it is to be terminally ill from having an “inevitably” to a “typically” progressive illness, disease or medical condition that cannot be reversed by treatment.

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[Naz Shah]

Absolutely not. That is not the point that I am making. Eating disorders are reversible, but it has been found that where this kind of legislation has been enacted, across the globe, somebody who has anorexia and decides not to eat then falls within the scope of assisted dying because it becomes a terminal illness.

[Danny Kruger]

I do not want to cut off the hon. Lady in full flow, but I want to echo her points. The hon. Member for Stroud has made his point before and we have had an exchange on it. There is quite a lot of research, to which I refer him, that shows how people in the UK, being treated by the NHS, are having diagnoses of terminal anorexia. It is happening. I refer him to Professor Agnes Ayton, the campaigner Hope Virgo and the eating disorders all-party parliamentary group in this place, which is looking at that. It seems bizarre to us, because of course someone can resume eating, but the fact is that anorexia is treated as a terminal illness in parts of the NHS today.

[Naz Shah]

I concur with the hon. Member’s remarks.

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[Danny Kruger]

I will be as quick as I can be. I recognise the powerful contributions that have been made on a number of the amendments. I pay tribute to the hon. Member for Broxtowe, who made a very interesting speech in support of her amendment 123. I was struck by her point that we should do what we can to reflect the reality of clinical situations in people’s lives. I very much respect the power of the arguments she made. My concern is that by changing “inevitably” to “typically”, her amendment, although it might reflect reality more closely, would widen the scope of eligibility. I am afraid I will not support her amendment, but she made an important speech about how things actually work.

I will speak briefly in support of amendment 282 in the name of the hon. Member for York Central (Rachael Maskell), and of amendments 48 and 402 in the name of the hon. Member for Bradford West. At the end, I will refer quickly to the amendments in the names of the hon. Member for Harrogate and Knaresborough and of my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer). All those amendments, with exception of the last ones, fit the Bill to the campaign—they make the Bill more accurately applicable to the people whom the campaigners have been campaigning for and whom everyone has the most sympathy with.

Amendment 282 in the name of the hon. Member for York Central would restrict eligibility to people with a one-month diagnosis only. I stress that the amendment is probing and I do not propose to press it to a vote on her behalf. She tabled it and I am speaking to it to make the point that, if we are serious about the Bill being for people who are dying and not for people who are not—for people at the very end of their life, as we hear so often—we need to be much stricter about the period of prognosis. I will not repeat points that have been made by other hon. Members, but the fact is that the six-month test is literally as good as tossing a coin. It has a less than 50% accuracy. In particular for advanced cancers and neurological conditions, accuracy is very low.

[Jack Abbott]

A line has to be drawn in the sand somewhere. Will the hon. Member define what an adequate timeline would look like for him to be satisfied?

[Danny Kruger]

The hon. Member invites me to suggest that I think it would be possible to draw a safe safeguard. I do not. I think that one month is better than six months, because with one month we can have more accuracy and doctors are more genuinely right when they say that someone is close to death at that point, while six months is much more inaccurate and 12 months is notoriously inaccurate. If we restrict the Bill by using a time limit, that limit should be as close to death as possible in my view.

[Kim Leadbeater]

Does the hon. Member agree that if we were to reduce it to one month, there would be absolutely no way to have the robust process set out in the Bill—or, indeed, I would argue, to have any sort of robust process?

[Danny Kruger]

I accept that, which is why amendment 282 is probing only. It is trying to demonstrate the point. I recognise that even the expedited process is likely to take up to a month to get through, so that would be difficult. Nevertheless, if our intention is to restrict this to people who are literally in their last days, which is frequently what we hear, I think it would be appropriate to restrict the time.

[Naz Shah]

The hon. Member talks about the amendment being probing. Does he know why we went for six months? Was it was based on research? I am not sure whether he is aware or can help me understand that.

[Danny Kruger]

I am not. I think we have allowed six months to creep into common legal parlance because of the Social Security Contributions and Benefits Act 1992; we now recognise in law that it is possible to have certain rights and entitlements on the basis of a six-month prognosis. I presume that is the basis of it. It does feel like a reasonable period, and I understand the rationale for it, but given the difficulty of prognosis and the intense seriousness of what we are doing, I think it is inappropriate and dangerous.

Another way of achieving greater safety—less precise but perhaps more generous to people who want an assisted death—is to tighten the definition of terminal illness to mean those whom doctors think it is reasonably certain, rather than reasonably expected, will die within six months. That is the intent of amendment 48 tabled the hon. Member for Bradford West. The amendment also insists that the condition is terminal even with “all recommended treatment”, so that somebody could not make themselves eligible by refusing treatment. That is a very important point that the hon. Lady is trying to insist on.

By the way, that does not mean—and I hope people will not conclude that it does—that someone is required to have every treatment that might be possible, including invasive and unpleasant chemotherapy. The point is that it would have to be treatment recommended by the doctor: if the doctor recommends it, then it is appropriate. A doctor might be offering chemotherapy, but they would not be recommending it in all circumstances.

For the avoidance of doubt—an important phrase— I think that the hon. Lady’s amendment 402 is very important too. Just in case nutrition is not seen as treatment—perhaps it is arguable that it may not be—it is very important that we specify explicitly that declining food or drink does not qualify someone for an assisted death.

[Naz Shah]

Does the hon. Member agree that one point that is really important in this afternoon’s debate is that a person has a right to refuse treatment, and indeed food and water, if they have capacity, but that malnutrition is practically reversible? The argument has been made by doctors in Oregon around the voluntary stopping of eating and drinking that doctors cannot legally force a person with capacity to eat, and if they refuse food, their condition can be considered irreversible and terminal. That is the crux of the point. Does he agree with me?

[Danny Kruger]

I think so. The hon. Lady is absolutely right that there is this difficult loophole that somebody may have capacity and be refusing food and drink and would therefore potentially be eligible. In the Bill as it stands, we have an expedited process for people whose prognosis is only a month. There, the 14-day waiting period could be reduced to just 48 hours. If a person stopped eating and drinking, their death would almost certainly happen within a month. In other words, a person who is not terminally ill could make themselves eligible for an assisted death within 48 hours simply by refusing sustenance. It is very important that we recognise that and explicitly exclude it.

I will refer quickly to other jurisdictions where this specific situation occurs and the voluntary stopping of eating and drinking is used to qualify for legal drugs. A peer-reviewed article in the Journal of the American Geriatrics Society discusses this case—it may be the one referred to earlier. The authors noted that if anyone can access VSED—voluntary stopping of eating and drinking—then anyone can qualify for medical assistance in dying. In Colorado, 12 people qualified for assisted suicide based on a diagnosis of severe malnutrition.

The American Clinicians Academy on Medical Aid in Dying, an organisation of doctors who provide assisted suicide, acknowledges this loophole. Its guidance states that

“there is nothing in the letter of the law”

to prevent voluntary stopping of eating and drinking from being used in this way. It adds that that would

“essentially eliminate the criteria of terminal illness,”

because a person could always qualify as having terminal illness if they stopped eating and drinking. That is obviously not what the Bill’s sponsor and drafters wish. I hope they will consider accepting the amendment to close that loophole.

I will not repeat points made very eloquently by my hon. Friend the Member for Reigate, but I echo the need to ensure that the Bill is not for conditions that, although they cannot be reversed by treatment, can nevertheless be controlled or substantially slowed. I will therefore support the amendments in the name of my hon. Friend the Member for South Northamptonshire.

I pay tribute to the hon. Member for Harrogate and Knaresborough and to the people he speaks for in tabling amendment 234. I recognise absolutely that the MND Association has pointed out that the six-month rule would not work for all MND sufferers. It successfully persuaded the last Government to change the rules on benefits in recognition of that point, and its evidence to us, it has requested a clear and workable definition for assisted suicide. It was not very clear on what that would be, and there are practical problems with extending to 12 months, specifically the one we have with six months—the difficulty of prognosis, which would be twice as bad. I also refer to the evidence from Professor Sleeman, who made the point that a non-neurologist would find it particularly difficult to make an accurate 12-month prognosis for MND.

The main reason to object to the principle of the amendment—I appreciate that the hon. Gentleman is not moving it, but it is an important principle to discuss—is that it makes no sense at all to have two different prognosis periods. Of course, we can see where it will go. The fact that the amendment has been tabled and selected, that it is in scope, and that people will support it in this Committee or beyond, or outside Parliament, is evidence of where things go. We saw it very clearly in the evidence we heard from witnesses from Australia, who pointed out that there is no logical reason to have two prognoses—one for cancer and one for neuro-degenerative disorders. Their response was, “Well, let’s make it 12 months for everyone,” and of course that is the way things would go.

I finish with a tribute to the great quixotic effort of my hon. Friend the Member for Runnymede and Weybridge, who is not on the Committee. Runnymede is the home of Magna Carta; the spirit of liberalism lives on in my hon. Friend, a genuine liberal who wants to scrap the period of prognosis altogether, because he genuinely believes in absolute autonomy. I have been trying to make the Bill live up to its claim to be a Bill for safeguarding; he wants it to live up to its claim to be a Bill for autonomy. In principle—in logic—he is absolutely right. If we think that some people should have access to suicide assisted by the state, then why should person A get it and not person B? Needless to say, I disagree with him.

[Lewis Atkinson]

I rise to speak in favour of the current, tightly drawn eligibility criterion of a six-month terminal diagnosis. I agree with my hon. Friend the Member for Bradford West that that was a central plank of the Bill as introduced and as debated across the House on Second Reading. I therefore rise to speak against all the amendments tabled to the clause.

Dying people want to put their affairs in order. That includes thinking about the death that they want and how they want to spend their time with their family. Dying people do not want to die, but they do not have an option to live. I feel that the way we talk about death perhaps has not been fully reflected in the debate we have had on the amendments.

In my mind, the evidence from elsewhere is very clear that those who seek assisted dying seek approval for it, going through the safeguards—significant safeguards, as set out in the Bill—so that they can spend the remaining time with their family, with enhanced feelings of control and autonomy, removing some of the fear that causes them to ask, “What if I will have no way out of inevitable pain?” That does not mean, of course, that people wish to die more quickly. The fact that the Bill sets out a six-month eligibility criterion does not mean that people will rush to end their own lives as soon as it is possible to do so. It means that six months is the threshold at which they can start potentially exploring the options and getting through the onerous—rightly onerous—process of eight different stages of capacity checks, three different stages of approval, multiple doctors and so on, so that they have the option. Indeed, as my hon. Friend the Member for Spen Valley set out earlier, a significant proportion of people who have been approved for assisted dying elsewhere do not take up that option, because their end of life is not painful—and that is fantastic—or can be managed through palliative care. That is something that we would all want. However, knowing that they have the option significantly increases their quality of life, their ability to relax with their families and their ability to spend time with their loved ones.

--- Later in debate ---

Division 9

Question accordingly negatived.

Ayes: 8

Noes: 15

[Danny Kruger]

I beg to move amendment 12, in clause 2, page 2, line 2, at end insert—

“(c) their illness, disease or medical condition is found on a list that the Secretary of State may by regulations specify.”

This amendment would require an illness, disease or medical condition to be specified in regulations that may be made by the Secretary of State to be considered a terminal illness under the Act.

[The Chair]

With this it will be convenient to discuss amendment 13, in clause 2, page 2, line 10, at end insert—

“(4) Regulations under subsection (1)(c) are subject to the affirmative procedure.

(5) The Secretary of State may, where they consider it appropriate, make regulations that expire after twelve months from their being made to include temporary additions to the list under subsection (1)(c).

(6) Regulations under subsection (5) are subject to the negative procedure.”

This amendment is consequential on Amendment 12 and specifies regulations under that amendment must be made by the affirmative procedure. Temporary additions could be made by regulations subject to the negative procedure.

[Danny Kruger]

I will be fairly brief in speaking to the amendments, but they go to the heart of things. We have tried to tighten the Bill by excluding medical conditions from the definition of a terminal illness; I am very pleased that the Committee has accepted that tightening. We have also sought to exclude illnesses that are consequent on mental disorders and disabilities; we have not succeeded with that tightening. We have further sought to tighten the Bill by circumscribing the prognosis period more precisely.

The amendments would tighten the Bill further by explicitly listing the illnesses that qualify. The argument is quite straightforward. The problem that we are trying to address is that, under the Bill, it will be up to doctors and potentially to the court—or a panel, if that is where we go—to decide whether a particular condition is terminal. It would be set by case law and by medical doctors deciding what conditions qualify.

--- Later in debate ---

[Stephen Kinnock]

I have some brief comments to make. Amendments 12 and 13 seek to further define a terminal illness for the purpose of the Bill; I will set out some details about their effect. The amendments would add a requirement that a list of a terminal illnesses for which people are eligible to seek assistance under the Bill be specified in regulations made by the Secretary of State. The effect would be that only a person who has an illness, disease or medical condition listed in regulations, and who meets the other eligibility criteria, would be eligible to be provided with lawful assistance to voluntarily end their own life.

I draw the Committee’s attention to the chief medical officer’s oral evidence given on 28 January, which was well articulated by my hon. Friend the Member for Sunderland Central. The CMO said that multiple diseases may interact, making it

“quite difficult to specify that certain diseases are going to cause death and others are not”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 32, Q5.]

It is also the case that many illnesses, diseases or conditions that may be terminal in one case may not be so in another. Committee members may therefore wish to consider where a focus on specific illnesses or diseases, rather than on the facts of an individual case, could aid clinicians in their decision making.

The amendments also include a discretionary power for the Secretary of State to make regulations that expire after 12 months in order to make temporary additions to the list of illnesses that meet the definition of terminal. It is not clear what types of illnesses, diseases or medical conditions are intended to be captured in such regulations. I hope that those observations on the purpose and effect of amendments 12 and 13 are helpful to the Committee in its considerations.

[Danny Kruger]

I sense that the wish of the Committee is probably not to accept the amendment, so I do not propose to press it to a Division, but we have just heard quite clearly, in response to the amendment, that the Bill is essentially permissive. Once again, we have declined to put clear parameters around the eligibility for this new law. We have heard specific conditions mentioned so many times in the course of the debates over the preceding months. It is a shame that we are not prepared to state those conditions clearly in the Bill, with the opportunity for Parliament to amend them over time.

I end by echoing a point that the hon. Member for Spen Valley made about the importance of good data. I hope that if the Bill passes, we will have the best data collection in the world. I am afraid to say that data collection is not good in other jurisdictions. Nevertheless, it is possible to see how often in Oregon, Australia, Canada, and Europe, albeit in a minority of cases, conditions that most people would not recognise as deserving of assisted dying, including anorexia, arthritis, hernias and diabetes, are listed as causes of death. Indeed, so is frailty, as I discussed earlier.

My fear is that if we pass the Bill, we too—if we do data collection properly—will have a shameful appendix to the annual report showing that people have had an assisted death for reasons that most people would regard as inappropriate. I will leave it there. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment made: 401, in clause 2, page 2, line 5, leave out “, disease or medical condition” and insert “or disease”.—(Danny Kruger.)

This amendment is consequential on Amendment 399.

Amendment proposed: 402, in clause 2, page 2, line 6, at end insert—

“(2) A person who would not otherwise meet the requirements of subsection (1), shall not be considered to meet those requirements as a result of stopping eating or drinking.”—(Naz Shah.)

This amendment means that someone who is not terminally ill within the meaning of subsection (1) cannot bring themselves within that definition by stopping eating or drinking or both.

Question put, That the amendment be made.

Terminally Ill Adults (End of Life) Bill (Fourteenth sitting)

Danny Kruger Excerpts

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Dr Opher]

Well, that was disputed by other psychiatrists. We are asking questions about whether the Mental Capacity Act is safe and correct for the Bill. This whole Committee is about making the Bill safe. None of us would dispute that. However, I think that if we accept the amendment, the Bill will become less safe because the amendment would change a massive piece of legislation and therefore have a number of repercussions that we do not understand.

[Danny Kruger (East Wiltshire) (Con)]

Chris Whitty made the same point that the hon. Gentleman has just made: that there would be knock-on effects and that the Mental Capacity Act works very well currently. Does the hon. Gentleman acknowledge that Chris Whitty himself misrepresented the Mental Capacity Act in the evidence he gave to the Committee? He had to write to us subsequently to clarify his comment, and his clarification contradicted the hon. Gentleman’s implication that the Mental Capacity Act has different thresholds for different levels of decision. Does the hon. Gentleman acknowledge that it does not? The Act has one threshold: capacity as it defines it. Some doctors may have longer conversations than others depending on the severity of the case, but the threshold is the same—Chris Whitty misrepresented it.

[Dr Opher]

I agree that the threshold is the same: does the patient have capacity or not? That is the single threshold. We often do mental capacity assessments for inheritance, control of bank accounts and that sort of thing; sometimes we do a very quick mental capacity assessment about the refusal of treatment. How long we take depends on how important the decision is. I suggest that a doctor assessing someone’s capacity to make a decision to end their life would have a serious, long discussion—up to 90 minutes, or possibly even two hours—to make sure that the doctor is convinced that the patient has capacity. The threshold is the same—it is about whether they have capacity—but that does not mean that the conversation is the same. In clinical terms, it is very clear that a conversation on those grounds would be much more involved than, for example, whether a person sees a dentist or not, or other conversations like that.

I totally understand the concerns that the amendment has been tabled to cover; however, my main point is that if we accept the amendment, it will make the Bill less safe. The reason for that is that, as I have said before, if we change something that is well used, and repeatedly used, it will make the interpretation much more complicated. We will have to re-train all the doctors and, I think, it will not protect patients.

--- Later in debate ---

[Rebecca Paul (Reigate) (Con)]

I rise to speak to my amendment 398. I recognise that much debate about capacity has already taken place, so I will do my best not to be too repetitive, but it is an important topic and I want to cover a few things.

Fundamentally, I consider the bar for the capacity to make a decision to seek an assisted death to be far too low if, as we have already discussed, the approach currently proposed in the Bill is adopted. The Committee has received powerful written evidence that the Mental Capacity Act, as it stands, is not suitable for assisted dying. The Royal College of Psychiatrists says in its written evidence:

“It is the RCPsych’s view that the MCA is not sufficient for the purposes of this Bill.”

The former president of the Royal College of Psychiatrists, Baroness Hollins, says:

“The Mental Capacity Act has proved very difficult to implement and doctors have not been found to be good judges of capacity.”

The eating disorders expert Chelsea Roff says:

“The MCA is not fit for purpose for determinations of capacity in life-ending decisions.”

I do not think it is contentious to say that there should be a higher standard for ending one’s own life than for other courses of action. Baroness Hale has called the Mental Capacity Act threshold “not a demanding one.” The Royal College of Psychiatrists says in its written evidence:

“While we are of the view that a person’s capacity to decide treatment can be reliably assessed, an assessment of a person’s mental capacity to decide to end their own life is an entirely different and more complex determination requiring a higher level of understanding.”

Even if the Mental Capacity Act is working well in some other contexts, it does not necessarily translate well to assisted dying. Professor Gareth Owen told the Committee in oral evidence that although the Mental Capacity Act is quite reliable in current practice,

“in areas of decision making where the decision itself is unsettled or conceptually much more profound or novel—I would suggest that the decision to end one’s own life has those characteristics—you cannot expect there to be such levels of reliability.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 239, Q303.]

The Mental Capacity Act definition of capacity was not created with such a monumental decision with respect to assisted dying in mind. Although I note Chris Whitty’s recommendation that it is the starting point, I do not think it can be the end point. Further provisions are needed to ensure that it is fit for purpose, given the significance of the decision being made. Professor Owen said:

“I have looked at mental capacity a lot in research, and there is no experience of the decision to end one’s own life. It is outside the experience of the Mental Capacity Act, the Court of Protection, the associated research and practitioners on the ground. The reference to the Mental Capacity Act in clause 3 puts you into an area where there is no experience of the central capacity question under consideration. It is very important that Parliament be clear-eyed about that.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 226, Q287.]

Dr Sarah Hooper, a retired oncologist, says that

“the patient in question may undoubtedly have ‘capacity’ for most important decisions. However, in the early days after a cancer diagnosis their ability to make clear judgements is nevertheless likely to be impacted. This kind of decision (for assisted suicide), once acted upon, is plainly irreversible. It is a very bad time to make that kind of decision.”

It is true that the Mental Capacity Act is used for decisions to stop life-sustaining treatment, but, as Professor Owen said, we should not simply equate that with assisted dying. As he pointed out:

“One is a refusal; one is a request. One is traditionally considered to be about bodily integrity—it is the so-called shield of the person, or the patient, against the intervention on the body that is being made by the medical profession. You are giving the patient an important right, which is a shield-like right. That contrasts with a request for assisted dying, which is a request. You are involving other people in an act that is an act of ending one’s life. That is not something that the medical profession has been comfortable with, going back thousands of years.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 236, Q288.]

I also draw attention to a great deal of written evidence making the point that the current Mental Capacity Act is not as well understood by medical practitioners as we hope or expect. Alexander Elphinston, a retired solicitor, says,

“from my experience doctors and other medical practitioners often applied the test of mental (in)capacity incorrectly.”

Victoria Wheatley, a palliative medicine consultant, says,

“I have observed a tendency to overestimate a person’s mental capacity in the absence of obvious features to the contrary.”

Alan Thomas, a professor of old age psychiatry at Newcastle University, says:

“The preferences of the assessor bias the capacity decision towards the assessor’s preference.”

I will move on to the specific issues with the current definition of people who lack capacity under the Mental Capacity Act when applied to assisted dying, all of which my amendment 398 attempts to address. Part of my amendment does exactly the same as amendment 322, tabled and already eloquently spoken to by the hon. Member for Bexleyheath and Crayford, so I will be brief on those overlapping bits.

Under the Mental Capacity Act, there is a starting presumption of capacity. That is too lax a standard, as the Royal College of Psychiatrists says in written evidence. I quote:

“The presumption of capacity may be problematic in the context”

of assisted dying, given that the consequence would be the person’s death. This is literally a matter of life and death, and the presumption of capacity must not apply; the work must be done to assess capacity properly and thoroughly. Professor Preston said during the evidence session:

“I think the aim is to have that bit of extra concern, so that we do not presume capacity, but instead almost presume that there is not capacity.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 241, Q307.]

I think those are wise words, and my amendment and amendment 322 seek to give that protection.

Both amendments also disapply section 1(3) of the Mental Capacity Act on helping a person to make a decision. The hon. Member for Bexleyheath and Crayford has already made his point powerfully about that, so I will not add anything further.

There are some differences where my amendment 398 goes further than amendment 322. First, given the uniqueness and irreversibility of the decision, there should also be a higher threshold of probability. As it stands, a person should be treated as having capacity if that is more likely than not, which is sometimes referred to as the “51% sure” approach. It would be much safer if doctors and judges had to establish beyond reasonable doubt that an applicant has capacity, given the significance of the decision. In my view, 51% sure is just not good enough for such a monumental decision, and amending this part of the Bill would ensure a more rigorous and comprehensive assessment.

Secondly—for me, this is one of the biggest issues with the current approach—the Mental Capacity Act requires an impairment of, or a disturbance to, the mind or brain for someone to be considered not to have capacity, irrespective of whether they can make a decision. Under the Bill currently, even if someone cannot understand, retain or use the information to make a decision—they cannot communicate that decision—they will still be deemed capacitous in the absence of an impairment, or a disturbance, of the mind or brain. In the real world, a doctor could assess a patient who gives the impression of being confused, illogical, erratic or inconsistent—everything about them could scream that they are not in a good place to make the decision—but they will still be considered to have capacity if there is no identifiable impairment of, or disturbance in, the function of the mind or brain at that point in time. That potentially puts those with depression, anxiety, learning disabilities or eating disorders, or even those in physical pain, in danger of being considered capacitous.

In oral evidence, Professor Alex Ruck Keene said,

“If I doubt that you have capacity to make the decision to take your own life, or end your life, but I cannot prove it, is it logical or are we required to proceed on the basis that you do?...In other words, I think you cannot understand the information, but I cannot prove the reason that you cannot understand it is that you have an impairment or disturbance.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 90, Q120.]

According to his written evidence to the Committee, this means that someone could be approved for assisted dying even if they did not understand the relevant information, as long as they do not have an identifiable impairment of, or disturbance in, the mind or brain. He wrote,

“the Committee may well feel that it would be problematic that such a person should be considered to be eligible for the receipt of assistance in dying.”

In a letter to the hon. Member for Richmond Park, Professor Alex Ruck Keene KC said,

“no matter how intensive the scrutiny of the person’s capacity, this would not address the issue of the situation where the person appears not to be able to understand, retain, use and weigh the relevant information but that is not caused by an impairment of, or disturbance in, the functioning of their mind or brain.”

That is why my amendment seeks to remove this diagnostic element, so that section 2(1) of the Mental Capacity Act for the purposes of this Bill only would read as,

“a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter.”

That would provide better protections for this life and death decision, and I hope it addresses the issue raised so powerfully by Professor Alex Ruck Keene KC.

As I close, I would like to make reference to amendment 49, tabled by my hon. Friend the Member for Runnymede and Weybridge, which sets out starkly the deficiencies of the current capacity test if it remains unamended for the purposes of this Bill. If autonomy is what counts, and we are using the Mental Capacity Act as gatekeeper for assisted death, then the Bill in its current form means that: a person is assumed to have a capacity as a starting point; a clinician only needs to be just over 50% sure that a person has capacity; unwise decision making is not taken into account in determining capacity; and supported decision making is acceptable—for example, for those with learning disabilities.

I ask the Committee members whether they are comfortable with that. If not, then as a minimum, amendment 322 should be accepted, but ideally my amendment 398 should also be, as it goes even further to increase the threshold for capacity and it addresses the significant issue with the diagnostic leg of the test. I am pleased to say that Baroness Finlay, who established and chaired the National Mental Capacity Forum, supports my amendment. Unlike the current drafting of the Bill, my amendment requires that a person is not assumed to have capacity in the first instance. It requires capacity to be proven beyond reasonable doubt, that unwise decision making is considered in assessing, and that a person is not helped to make a decision. I hope the Committee will support it.

[Danny Kruger]

I am pleased to follow my hon. Friend the Member for Reigate, who set out with incredible clarity the challenges here and the opportunity we have to build on the Mental Capacity Act, and to fulfil its purposes and the purposes of the Bill to ensure that capacity is properly assessed. I will speak to all the amendments in the group very briefly; I certainly will not repeat material points that have been made already. To clarify, I do not propose to push amendment 49 in the name of my hon. Friend the Member for Runnymede and Weybridge to a vote, although I will speak to it briefly. I hope we will vote on the other amendments.

--- Later in debate ---

[Dr Opher]

On tightening capacity assessments, which is what the amendment is trying to do, I would point out that there are a number of amendments coming up that would mandate training for doctors who are registered to assess capacity—for example, amendment 186. In addition, amendment 6 would mandate psychiatric referral if there was any doubt of capacity. Does that not satisfy the hon. Member?

[Danny Kruger]

It pleases me but it does not satisfy me. I am encouraged by it, but I am not fully satisfied. Obviously, it is insufficient. The hon. Gentleman and the hon. Member for Spen Valley put great faith in the training that we are going to introduce. Well, I hope they are right. Let us certainly do as much training as we can— likewise, let us get as much data as we can—but the provision set out is not sufficient, not least because the training will be in the application of the Mental Capacity Act, which we are saying, even if properly applied, has all sorts of problems with it, as my hon. Friend the Member for Reigate explained.

Yes to training and yes to the option of the referral—that should be mandatory, and I think there is a proposal to effect that. Every additional safeguard is welcome. It goes back to my point about whether we are being thorough or simplistic. I am not sure. If I think there are four assessments, but the hon. Member for Stroud thinks there are eight, does that not fail Chris Whitty’s test of being simple? If eight is in fact thorough, would nine not be even more thorough? The suggestion that we have hit it at the perfect sweet spot and that to veer one side is to introduce all sorts of bureaucratic hurdles seems unrealistic. Surely we can apply a little more rigour to this exercise.

[Lewis Atkinson]

I know that we have interacted before about our fundamental difference on the ventilator test: someone saying, “I want to die, please turn off my ventilator” as opposed to, “I want to die, please let me take this substance.” Although we may have a fundamental disagreement on whether those things are the same or different, if he still thinks it is appropriate for the Mental Capacity Act to be used as a one-off test, with no other safeguards, for turning off a ventilator, then why is it appropriate in that situation but not when tested multiple times in this instance?

[Danny Kruger]

I recognise that this is a vital point; I am not surprised that we keep returning to this important distinction. I do think that there is a vital distinction between accepting treatment and declining a treatment. In fact, the treatment proposed here is not a treatment at all—the British Medical Association specifies that it is not a medical treatment. The termination of life deliberately does not apply to a particular condition, whereas a ventilator, or any treatment that one might decline or withdraw, is specific to a particular condition or illness. There is a difference in purpose, even if the effect—which is death—is the same.

To the hon. Member’s point on whether the MCA is appropriate in cases of withdrawal of treatment; well, there we do seem to have a substantial body of clinical practice over many years, to which I am not aware of many objections. My non-expert view is that it is probably appropriate to continue with the MCA in those cases. I do not have an objection there and I am certainly not making that argument. It may well be that it is appropriate, and I am sure we will constantly review the applicability of that particular test in those circumstances. It might well be that some of the problems that I am identifying with the proposed law may also apply in cases of withdrawal of treatment—but I am not aware of that, because I do think they are substantially different. Even if it were perfectly acceptable to apply the MCA in cases of withdrawal of treatment, that does not mean it is appropriate in this case, because they are fundamentally different scenarios. I do not detect that I have satisfied the hon. Member, but it is always good to have the exchange.

I will conclude my challenge to the suggestion that the MCA is universally understood and properly applied. The Court of Protection case of Patricia, a patient with anorexia nervosa, has been referred to a number of times in the course of our debate. We heard evidence from a group of anorexia sufferers who wrote to the Committee to say:

“The judge in the Court of Protection case of Patricia…stated that he had changed his mind several times while considering the evidence. He then came to a different view on capacity from the treatment team. This single case exemplifies how complex the processes described under Clauses 7, 8 and 12 of the Bill in relation to assessment of capacity are likely to be”.

We are not talking about a straightforward process. It is clear from all the evidence we have had that there is a real problem with the way that the MCA would apply.

I want to make a rather obvious point, which is that when the MCA was debated and passed 20 years ago, assisted dying, or assisted suicide, was not on the table; it was not part of those considerations, as far as I am aware. It turns out that Dignity in Dying was on the case back in those days, although I think it was still called the Voluntary Euthanasia Society then. That group was conscious of what would come—I do not think that others were—and I detect that it is quite pleased now with the influence applied then to ensure that the presumption of capacity would be very useful one day when it came to passing an assisted dying law. It was not the intention of the House of Commons or of the Committee that considered that Bill that in fact they were establishing a test that would be applied in the case of assisting suicide and changing the terms of the Suicide Act. I am sure that if that had been the case, it would have been commented on, and I daresay the Mental Capacity Act would not be in its current form, or there would have been some addendum to that effect.

My hon. Friend the Member for Reigate referred to the very powerful evidence from lawyers, Baroness Hale and the Royal College of Psychiatrists about the challenge here. I want to quickly say, in support of amendment 322 in the name of the hon. Member for Bexleyheath and Crayford, that my hon. Friend the Member for Reigate made a powerful argument about impairment; it is striking that the MCA only applies when there are cases of impairment of, or disturbance in, the functioning of the mind or brain—I will not repeat the point she made, but I urge Members to reflect on it.

I will quote Ruth Hughes, a barrister specialising in mental capacity law and inheritance. This refers back to the point that my hon. Friend the Member for Reigate and I discussed in an earlier sitting about the clear opportunity that the Bill affords people to seek an assisted death for the sole purpose of saving their family money. Ruth Hughes says:

“If the…Bill is passed, then this will lead to some of the most vulnerable people dying for others’ financial gain. That is certain…Although in general I would, of course, accept the importance of the presumption of capacity, in relation to assisted dying, I consider that, the burden of proof for capacity should be reversed so that it is necessary to establish capacity to decide to die positively.”

Amendment 322 is tabled for that very obvious reason: there is a clear financial advantage for family members, and, I am afraid to say, there are many other distressing motivations that people might have that are not intended by the Bill’s promoter, the hon. Member for Spen Valley. It feels absolutely appropriate that we reverse the burden and have a much higher test of eligibility than that afforded by the Mental Capacity Act.

I want to make another point, although I do not know how hon. Members will feel about it because a lot of people do not accept that we are talking about suicide, even though it is in the terms in the Bill that we are amending the Suicide Act. The assumption of capacity in somebody taking their own life is what is proposed if we adopt clause 3: we are proposing that somebody has capacity if they end their own life. That implies directly that somebody who is standing on a window ledge or a bridge, about to commit suicide, is assumed to have capacity and to be making a rational decision, which other people should support. I say that directly, because there is a direct read-across with the whole topic of suicide prevention, which obviously we all strongly believe in. How can we say that somebody who is about to take their own life, unassisted, does not have capacity and is not making a settled and informed wish? In which case, why should we stop them or try to wrestle them back from the edge?

[Tom Gordon (Harrogate and Knaresborough) (LD)]

When people are in what is often termed a “crisis”, that would indicate that they are not in a situation where they have capacity. I do not see how the hon. Gentleman can think that it is reasonable to make a comparison between these two things; they are entirely different, and I am sure everyone here would broadly agree with that—I think, on this one, he is sort of on his own. Would the hon. Gentleman be able to offer any further insight into why he thinks that two wildly different situations are analogous—one is in a medical context where people have all the safeguards, and that layer of security and checking, and the other is someone who might be doing something in a moment of desperation?

[Danny Kruger]

The connection is explicitly in terms of the Bill. The Bill disapplies section 2 of the Suicide Act, which makes it illegal to assist somebody to commit suicide. It says that that section no longer applies. This Bill assists people to take their own life—I will not use the word “suicide” if people do not like it. There are other eligibility criteria: I totally acknowledge the hon. Member for Harrogate and Knaresborough pointing out that someone has to have a diagnosis of terminal illness, but that is not the point I am making. I am making the point that, under clause 3, we are saying that somebody who wants to take their own life has capacity, according to the very low bar of having a settled and informed wish. We are assuming capacity in the person who wants to end their own life. I suggest that that presents a real challenge to our national suicide prevention strategy—I will leave that point there, but I welcome any challenges to it.

[Liz Saville Roberts (Dwyfor Meirionnydd) (PC)]

I question whether the hon. Gentleman is making a false equivalence here in the very title of this Bill relating to terminally ill adults.

[Danny Kruger]

There are huge challenges around the definition of terminal illness, as we have already acknowledged—but if the right hon. Lady thinks that somebody who is terminally ill should be allowed to jump off a bridge or out of a window without anybody saying, “Wrestle them back,” she should say so. We think that, whether someone has capacity or is in their right mind or not, they should not end their own life. That is the settled view of this country. That is what the law determines. Currently, it is illegal to help someone to do that. We are proposing to change that, to enable people to help somebody to do that in a medical setting.

The implication of clause 3 is very clear: if one has a settled wish, ending one’s own life is something that we regard as acceptable. It will be very difficult to apply the principles of national suicide prevention when we have acknowledged that suicidal people have capacity. I will leave that point—it is not receiving a great echo of affirmation—but I have not heard any objection to it, other than a lot of head shaking.

--- Later in debate ---

[Jack Abbott (Ipswich) (Lab/Co-op)]

Upcoming amendment 339 to clause 4 addresses that specific point. The hon. Gentleman has been asked this a number of times today, but would he be satisfied if that amendment was passed?

[Danny Kruger]

Sorry—remind me of the detail of the amendment.

[Jack Abbott]

Essentially, the amendment would require that if a person is autistic or has a learning disability, they must be given accessible information and sufficient time to consider it. Additionally, there must be at least either a supporter or an independent advocate there. That amendment was tabled by my hon. Friend the Member for Bexleyheath and Crayford and will be discussed later.

[Danny Kruger]

I would indeed support that amendment; it would go a long way to addressing the concerns that we have here. When we discuss clause 4, I will come on to some suggestions for how we can make sure that people with learning disabilities are properly supported, particularly people with Down’s syndrome.

To finish, I will speak to amendment 50, also tabled by my hon. Friend the Member for Runnymede and Weybridge. If we are going to proceed with the MCA, we need to have it on the face of the Bill, to ensure standardisation —hon. Members have confidently asserted that it happens anyway, although the evidence we have been presented with demonstrates that it does not in all cases. Let us be much more explicit about the requirements that are needed. We should specify the minimum of what needs to be understood for capacity, including understanding the likely process of all treatment options, including non-treatment, and prognostic uncertainty. It is not acceptable, in my view, to have all of that worked out later by clinicians. Parliament must clearly say at this stage what is important.

While Members are looking at the quite extensive terms of amendment 50, it would be good to know what in that list they would object to and why any of it should not be included. It does not change the Mental Capacity Act; it preserves the integrity of the Act. It simply specifies more precisely and gives clear guidance to doctors to ensure that they do the best job they can. Lastly, it states that the patient must have full understanding of the consequences of

“requesting assistance in ending their own life”.

That includes the potential for medical complications at the end. That is a point that has been touched on a little in debate, but I will quickly say a word on that.

It is very important, in my view, that we are clear about what the patient should do, what the doctor should do, what the patient is entitled to do and what the doctor will do, in the event of complications at the end. This is not an abstract question. The Association for Palliative Medicine of Great Britain and Ireland gave evidence to us, stating:

“It is important to highlight the lack of scientific evidence for the effectiveness, failure rates or complications of any ‘approved substance’”,

and pointing out that the proposals in the Bill fall quite short of

“the usual practice of approving treatments in the UK, which mandates careful assessment of drugs and their combinations.”

We do not know how that will be applied in this case. It is a point for later in the Bill how we consider which drugs should be used, but it is relevant at this stage to insist that patients are made fully aware of the drugs that will be used and their potential complications. We often refer to Oregon as an inspiration for the Bill, and the law in Oregon requires the applicant to be fully informed by the attending physician of the

“potential risks associated with taking the medication to be prescribed”.

It might be worth considering that.

Professor House, in evidence to us, pointed out that informed consent—which is obviously a principle of the Bill—

“is not really specified properly. The doctor is required to ask the person what they want to happen in the event of complications without having previously explained to them what all the complications might be.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 169, Q216.]

So I think it is important that we specify that those complications are explained to them clearly at the outset.

This is not an abstract point. Sarah Wootton, chief executive of Dignity in Dying—my least favourite organisation—wrote in her book “Last Rights”:

“We have to move away from idealised, sanitised, nursery-rhyme accounts of what death can be…towards truthful, no bullshit, plain-spoken explanations of what could happen.”

I do not think Dignity in Dying applied that test when putting those disgraceful adverts in the tube, showing people dancing round their kitchens anticipating their lovely death, but she is right that we need to be very clear about what actual death can be like with these drugs.

I want to end with a reference to the work of Dr Joel Zivot, an American academic. The only proper study that can be done into people who have been given lethal drugs to die, using any of the drugs that will be used in this case, is of people who have been executed in the United States. Of course it is not possible to do many studies into the after-effects on people who have had an assisted death, but there have been some studies of people on death row. Dr Zivot’s point is that there is real evidence of what looked like trauma, distress and pain suffered by people as they died. Even if they themselves look peaceful—because often the first drug that is administered is a paralytic, so they are rendered immobile, and they may look very peaceful—it is evident that in some cases there is real distress going on beneath that peaceful exterior. We need to do a lot more work on understanding which drugs would be used and what their effects would be, and that needs to be properly explained to patients. All of that would be captured in amendment 50.

[Dr Opher]

We are talking about a whole different area now, but I would say that, as a medical professional, if someone is gaining consent to a treatment it is in their code of practice under the General Medical Council that they explain all these things. We do not need to write it into the Act; that is already in existence. A more general point is that there is a lot of stuff already in the public domain on doctors’ behaviour that does not need to be restated in the Bill. The more we write, the more likely it is that it will be less safe for patients. I would keep it very simple.

[Danny Kruger]

I really want someone to explain this point to me: how can it make it more unsafe for patients to state the safeguards explicitly? How can it possibly make it harder, or more dangerous, if we specify what—as the hon. Gentleman said—is good practice currently, which the best doctors already do? I greatly respect him and his medical practice, but is he really saying that every doctor conforms perfectly to the GMC guidance? There are obviously clear problems with the way in which some doctors operate, and this is uncharted territory. Surely for the sake of doctors, as well as patients, it would be appropriate to specify explicitly how they should conduct these assessments, what communications they should make and what patients should be properly informed of. I cannot see how that makes it more dangerous.

[Kim Leadbeater]

I want to concur briefly with my hon. Friend the Member for Stroud; I have done a lot of research into this, believe me. We have the GMC, the British Medical Association and organisations that represent medical practitioners. They have very lengthy codes of conduct and behaviour codes. What we cannot do—and I have tried—is to include all that in the Bill, and we have to be cognisant of that in some of the amendments that we make.

[Danny Kruger]

I challenge the hon. Lady, and I would welcome her response to this: we clearly can specify some things that can be done, which is what my hon. Friend the Member for Runnymede and Weybridge has done in half a page with amendment 50, which clarifies explicitly what information the patient should receive and what they should properly understand. How does including this list of pieces of information make the Bill more dangerous for patients?

[Kim Leadbeater]

I am not saying that this amendment would make it more dangerous, but it would overcomplicate things. That is the point that my hon. Friend the Member for Stroud was making. We need to have a very clear piece of good law, and I think the Bill already covers the points in amendment 50 and others, which I fully appreciate have been put forward in good faith. It is the clarity of the law that sometimes has to be the focus. I absolutely concur with the hon. Member for East Wiltshire on safeguards, but unfortunately I feel that we will probably never get to a point with the Bill where he is happy with the level of safeguards, and maybe he is prepared to acknowledge that.

[Danny Kruger]

It is unlikely that I would ever vote for an assisted dying law but, if we are going to have one, I want to make it as safe as possible, which we all want. On those terms, in the spirit of a Bill that is going to pass, why not include these specific pieces of information? The hon. Lady says that, while it would not make the Bill more dangerous, it would overcomplicate it. Again, how does it overcomplicate it to add a few clauses specifying information that must be clearly communicated?

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

Amendment 50 requires that whoever is medically assessing capacity is also able to understand the legal implications. The final point of the amendment says that they have to understand what the insurance implications are likely to be, which would mean that they would have to inquire into the individual’s financial circumstances. They possibly might need to understand what provision they have made for their family.

It also references what the designation of death is likely to be, which again requires them to decide there and then what they will write on the death certificate, when it happens. As the hon. Member for Stroud said, much of what is in amendment 50 is already either in the Bill or implied by it. As Ministers have said before, we have a duty to the statute book not to embroider it to the extent that it becomes overcomplicated and unworkable. I do not think that any of us would necessarily argue with the points in amendment 50, other than perhaps the last one about legal expertise, but clarity leads to certainty, which leads to safety.

[Danny Kruger]

By that logic, the safest, clearest Bill would be one that simply authorised an assisted death without any of these checks whatsoever. My right hon. Friend made the point that this amendment requires the doctor to discuss with a patient all the implications of their death. That is perfectly appropriate—in fact, if that is not being done at some stage in the process, and if that is not clear in the Bill, it absolutely should be. Otherwise, how can we be sure that the person is making a settled, informed decision, with all considerations taken on board?

I am sorry if that imposes a little extra burden on the doctor. One of the great challenges of the Bill is that, if we are to do it properly and genuinely make it a Bill that is strong in its safeguards, a whole lot of people will have to do a whole lot of work. There will be a huge demand on all parts of the public sector. This is required, I am afraid. I do not accept that the content of the amendment is either already in the Bill or implied in it. There might be some remote piece of GMC guidance that touches on this, which we would hope is properly applied, and I appreciate the point about embroidery. Nevertheless, this is not embroidery; this is upholstery—it is necessary for the Bill to be strong.

[Sarah Olney]

I want to pick up on a point that the hon. Member made before the previous intervention about the rights of the doctors themselves. This is an important point that we do not consider enough. We talk a lot about the rights of the patient, quite rightly, but this Bill will provide the means by which another person can get involved in someone’s death. It is really important that the legislation protects the rights of that person—the doctor involved—as well. Does he agree that providing greater clarity about the standard required to assess capacity will help the doctor to protect their own rights, perhaps in response to legal challenge from families, and that it is important that we consider the rights of the doctor as well as the patient?

[Danny Kruger]

The hon. Lady is absolutely right. It is an interesting irony of the Bill that it is presented as the free choice of individuals, but actually it imposes all sorts of obligations and repercussions on other people—the very term “assisted” conveys that. Many other people will be affected by the decision to take an assisted death. She is right that it would be very helpful for the doctors to be confident that they have done their job properly because they have a clear list of communications they are expected to make.

My understanding is that doctors are indemnified against legal challenge in consequence of decisions they make around this; that is an interesting point and one that I am uncomfortable with, but we will come to that later in the Bill. Leaving lawsuits out of it, from the point of view of the doctor’s professional conduct and their peace of mind, it would be very helpful for them to have it clearly specified what information they are required to convey.

I am grateful for Members’ interventions, and I appreciate the good faith and good sense that has been spoken, but I have not yet heard any reason for objecting to this amendment, other than the possible question of its being otiose and not necessary. That is not a sufficient reason to object to an amendment. We should not be objecting simply on drafting grounds. There can be tidying-up exercises later if there is repetition. I have not heard objections to the content of the amendment, and I would very much welcome Members’ support.

[Naz Shah]

Does the hon. Member agree that the amendment ultimately aims to provide clarity, and that clarity ultimately leads to safety?

[Danny Kruger]

Exactly. A few more words of clarification should not be regarded as burdening the Bill or creating bureaucratic obstacles for doctors and patients; the amendment actually specifies more explicitly what is going on. It is almost akin to the debate we had on amendment 181 and those dangerous words “for the avoidance of doubt”; that is essentially what this amendment does, but it goes further, because it imposes clearer obligations on doctors to do their job properly.

[Jake Richards (Rother Valley) (Lab)]

Much has been covered today, and the issue of capacity was debated at length when the Committee considered clause 1, but I do have some observations.

I am sympathetic to the assertion that there should be changes to presumption and burden. Those are things that I have considered and spoken about with the promoter of the Bill and, outside the Committee, with experts who gave evidence to the Committee. I have spoken about them publicly as well; I am very sympathetic.

At the heart of this, we have two options. We could change the burden and presumption in the Mental Capacity Act 2005 for the purposes of assisted dying, rewriting 20 years of case law and medical practice. There is certainly some value to that, but that would be a radical departure from current medical practice, and there are other concerns. The alternative is to put in place rigorous processes and training around the Mental Capacity Act to ensure that it is implemented properly. After some reflection, I err on the side of the latter option, for a number of reasons.

First, I accept that there is debate among psychiatrists about this issue. We heard evidence from some who deem the Act not to be suitable for this new realm—I accept that we are entering new grounds, and I will come back to that point—but many psychiatrists and lawyers working in this area would deem it uncomfortable and unnecessary to depart from the Act.

Secondly, there is an oddity in changing presumption. There is an oddity in someone having to prove that they have capacity to fulfil their own desire. That oddity is one of the reasons that the Act is drafted as it is. It is partly—there are two sides to this coin—to ensure that there is no discrimination, partly to comply with the Human Rights Act 1998 and human rights more generally, and partly to ensure that we do not end up in a medical situation that is patrician, whereby medical doctors take an intrusive view of capacity rather than meeting the individual as they are.

Thirdly, the Bill, when amended—I will come on to the amendments that give me some comfort—will offer more safeguards than the Mental Capacity Act. Amendment 5 to clause 9(3) would ensure a further level of assessment. My hon. Friend the Member for Spen Valley has indicated that she will support that important amendment, as have all members of the Committee. If there is any doubt, there will be a further assessment by a psychiatrist. That goes some way to reassuring me that it is not necessary to rip up the burden or change the presumption in this area.

I want to make an observation about burden of proof, presumption and the nature of the assessment. Professor Whitty clarified his evidence. It is right that the burden and the presumption do not change, but of course the nature of the assessment rightly changes according to the circumstances. Every assessment of capacity is somewhat different, which is why amendment 50 is too prescriptive, in my view.

Of course, we can consider incredibly serious cases involving deprivation of liberty or the ability to conduct litigation. I have worked with parents whose children are being removed and looked at whether they have the capacity to make decisions about how they present their case. It is very dangerous to compare the severity and the profound nature of different circumstances, but let us not pretend that the Mental Capacity Act is not used to assess the most complex issues of capacity every day.

I am very sympathetic to amendment 50. I have met the hon. Member for Runnymede and Weybridge, who tabled it, and the hon. Member for Solihull West and Shirley to discuss it, but I stress that such a prescriptive provision is not appropriate for primary legislation when we are entering new ground. I accept, as hon. Members with different views have said, that we are entering new territory and that this is difficult. I accept that psychiatrists and medical practitioners will have to think long and hard about the nature of the capacity assessments, especially under clause 9(3), when that is activated. That work will have to be done. It has been set out in primary legislation through some of the training clauses, which have already been referred to.

There is no doubt that there will be a lot of work and consideration, but I do not deem it appropriate to have a clause drafted by one psychiatrist, albeit an undoubtedly esteemed and experienced one: the hon. Member for Runnymede and Weybridge, who tabled the amendment. Rather, the work needs to be done as the Bill is implemented over a two-year period. It needs to be done as part of a full consultation with psychiatrists, once the Bill has been passed, and that should be set out in guidance. That is what would usually happen with deprivation of liberty. I do not think it appropriate for primary legislation to set out the factors for a capacity assessment.

--- Later in debate ---

[Jake Richards]

We are debating lots of different things now, rather than just clause 3. There is an issue as to whether in those cases the individuals were found to have capacity, but we are talking about the process by which someone is found to have capacity, rather than what happens thereafter. We have had that debate, and I am happy to have it, but we are talking now about the process by which people are found to have capacity.

This is the problem with interventions: I have lost my train of thought. This is why people do not take them.

[Danny Kruger]

rose—

[Jake Richards]

But I am happy to take another, although I may come to regret it.

[Danny Kruger]

I have a simple point to make; the hon. Gentleman can work out what he is going to say next while I make my brief intervention.

The point is that the referral to a psychiatrist will happen if the doctor has doubts in their mind. There is not an obligation on the doctor to refer; there is only an opportunity for them to do so, if they conclude that there is a reason. May I put a scenario to the hon. Gentleman? It is not clear whether this could happen under the Bill; well, it could happen, because it is not prohibited. A private practice might establish itself to provide assisted death, with the medical assessments and the support right through to the end—to the final act.

In those circumstances, if a patient goes to one of those clinics, does the hon. Gentleman not see that there might be a risk that the whole incentive of the business, even if it is a charity, will be to expedite the process, tick the boxes and pass people through? Does he not consider it dangerous that there is not an absolute obligation to refer to a psychiatrist and in fact, an obligation to pass a higher capacity test than the one that is currently in the MCA?

[The Chair]

A handy household hint: Members do not have to take interventions if they do not wish to do so. If a Member wants to keep their train of thought, they should feel free not to take an intervention.

Terminally Ill Adults (End of Life) Bill (Fifteenth sitting)

Danny Kruger Excerpts

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Danny Kruger (East Wiltshire) (Con)]

I completely agree with what the hon. Gentleman is saying about the importance of getting the training right, but even if the training were right it might not be robust enough. The point was made earlier in the debate that there is a clause towards the end of the Bill about codes of practice that specifies that medical professionals must have regard for a code of practice that “may” be set out by the Secretary of State. Does he agree that that is a very thin defence to rely on? We are not talking about anything in primary or secondary legislation; it will be in a code of practice that may be laid down by the Secretary of State with no obligation or legal liability for a doctor to follow it. We are talking about some layers down from what needs to be in the Bill in terms of the assessments that should be conducted.

[Sojan Joseph]

I agree. As part of the code of practice, professionals are expected to complete the training that has been outlined already, but I am not confident that that is actually happening. Saying that there will be training does not reassure me that it will be robust enough.

--- Later in debate ---

[Lewis Atkinson (Sunderland Central) (Lab)]

I was not intending to, but I will speak very briefly to follow my hon. Friend the Member for Ipswich. I agree that what is set out in amendment 50 is entirely sensible and I support such provisions. However, I will not vote for it, and I want to explain why.

We will go down a very difficult route if we set out the regulation in primary legislation for every individual area of medical practice in this country. We do not have an equivalent version for how doctors should talk to their cancer patient and what information they should provide. We do not have the equivalent in various other sensitive acts, such as the Abortion Act 1967, the Human Fertilisation and Embryology Act 2008 and so on. The reason is that we rely, as set out in statute, on regulation through the General Medical Council.

I want to read into the record some of the existing General Medical Council guidance for doctors on giving information to patients. Of course, this covers any doctor-patient interaction, and it would apply in this case as well:

“The information you give patients

10. You must give patients the information they want or need to make a decision.

This will usually include:

a. diagnosis and prognosis

b. uncertainties about the diagnosis or prognosis, including options for further investigation…

c. options for treating or managing the condition, including the option to take no action

d. the nature of each option, what would be involved, and the desired outcome

e. the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action.”

That is already set out by the General Medical Council.

[Danny Kruger]

The hon. Gentleman is making an important point about the obligations on doctors to communicate the range of options that patients have, and we are going to discuss that more precisely when we consider the next clause, but his suggestion that this should be treated just like any other medical treatment is surely contradicted by clause 4(1), which specifically disapplies the Montgomery ruling, which I think he is relying on there. That ruling specifies that doctors must communicate all available options to patients. In clause 4(1), the doctor is not obliged to communicate this particular option. Does the hon. Gentleman accept that it is already acknowledged in the Bill that assisted dying is not the same as all other medical treatments and it does not have to be communicated in the same way?

[The Chair]

Order. Can we please keep interventions as short as possible?

--- Later in debate ---

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mrs Harris. As usual, my remarks will focus on the legal and practical impact of amendments, to assist Members in their consideration.

This set of amendments seeks to change the way in which capacity is determined. As drafted, the Bill requires that a terminally ill person must have capacity to make a decision to end their own life before they meet the conditions for accessing assisted dying. Capacity in the Bill is determined in accordance with the Mental Capacity Act 2005, which presumes capacity unless it is established to the contrary. Amendment 322 would reverse the presumption of capacity and, in effect, establish a presumption of incapacity.

It may be helpful to the Committee if I set out the Government’s understanding of both the Mental Capacity Act and the implications for the Bill. Section 1 of the Act sets out several guiding principles, including that a person must be assumed to have capacity unless it is established that they lack capacity. Section 3 sets out a description of the factors that demonstrate that a person is unable to make a decision for themselves: that the person is unable to understand the information relevant to the decision; unable to retain that information; unable to use or weigh that information as part of the process of making the decision; or unable to communicate their decision. This inability must be because of an impairment or disturbance of the functioning of their mind or brain.

Turning to the Bill, at each stage of the process an assessment of capacity would be required. This assessment of capacity, in accordance with the Mental Capacity Act, is separate to the considerations of whether a person holds a clear, settled and informed wish to end their own life, which is also required by the Bill.

Amendment 322 would disapply section 1(3) of the Mental Capacity Act, which is the principle that a person would not be treated as lacking capacity unless all practicable steps had been taken to help them to make a decision. This could create challenges for practitioners who have experience using the Mental Capacity Act, as they would need to apply a new approach.

Amendment 49 seeks to apply a consistent approach to the burden of proof when assessing a terminally ill person’s capacity for assisted dying. The Mental Capacity Act has two evidential tests. In court proceedings to determine capacity, the balance of probabilities test applies. When care or treatment is given to someone on the basis that they lack capacity, there is protection from liability if there is a reasonable belief that the person lacks capacity and the intervention is in the person’s best interest. The amendment would diverge from this evidential approach. It would also have implications for the workforce. Requiring doctors who have experience in applying the reasonable belief test to instead apply a balance of probabilities test for assessing capacity would likely make the current established approach more complex and potentially less safe.

Amendment 50 seeks to specify certain matters that the person must be assessed as being able to understand in order for a determination to be made that they have capacity. Under the Mental Capacity Act, when a capacity assessment is carried out, the assessor must determine the salient information that the person needs to understand, retain and use or weigh based on the circumstances of the case. The amendment would diverge from this approach, both by specifying in statute the information to be understood and by including the requirement only to understand the information, not to retain, use or weigh it. The Committee may wish to consider whether that would in some respects weaken the test.

Amendment 50 might create two legally distinct frameworks for decision making that doctors would be expected to use. Again, this may introduce additional complexity for those undertaking these assessments.

[Danny Kruger]

As I understand it, the objection to the amendment is on the basis that it sets up an alternative framework for other healthcare decisions. Is it the Minister’s view that assisted dying is a healthcare treatment?

[Stephen Kinnock]

We are talking about the holistic nature of the engagement between patients and medical specialists. In some cases that is for treatment, and in others it is for the withdrawal of treatment. The answer to the hon. Gentleman’s question is that what we are talking about here—the two distinct legal frameworks— relates both to treatment and the withdrawal of treatment. This Bill fits into that category, in the sense that it is part of the engagement and conversation between a patient and a medical practitioner.

[Danny Kruger]

I am not talking about the withdrawal of treatment, which I recognise is covered by the same legal framework—particularly the Mental Capacity Act—as other healthcare interventions, because that concerns the withdrawal of a healthcare intervention. Is it the Government’s view that the administration of assisted dying under this Bill would be a healthcare treatment?

[Stephen Kinnock]

It is the view of the Government that this is a new piece of legislation that introduces a new type of engagement between somebody who meets the conditions and criteria set out in clause 1, and medical practitioners and other experts, as set out in the Bill. I am not quite sure what the hon. Gentleman is driving at. I do not know whether he wants to get into a discussion about the definition of the word “treatment”. It is absolutely clear that this Bill introduces changes into the system, including a new part of the conversation that would take place between medical practitioners and patients who have less than six months to live.

--- Later in debate ---

[Stephen Kinnock]

That goes back to what I was saying earlier, which is that this is fundamentally a judgment call: do we make the system more robust, resilient and effective by adding more complexity and bringing in a new and parallel legislative framework, or is it best to work with a legislative framework that is well established and well understood by practitioners, and then to enhance that through regulations and training? It is the Government’s view that the latter is a more effective way of doing this legislation, but I accept that the hon. Members who have tabled this group of amendments clearly would not agree with that analysis.

[Danny Kruger]

Last intervention, I promise—maybe. I do not mean it is my last intervention ever, just in this speech—no, in this minute!

An amendment was tabled by the hon. Member for Richmond Park that would have replaced clause 3 altogether, and that would have been understood as a parallel system—which would be appropriate because we are discussing a new order of intervention, which I will not call a medical treatment—but we are not doing that. We are accepting the Mental Capacity Act. It is not a parallel process: it is one that builds on the foundation of the Mental Capacity Act in a way that already happens in other respects, as the Minister has described. It is a question of putting it in legislation or into a code of practice. I recognise his arguments, but will he please acknowledge that we are proposing to build on the Mental Capacity Act and enhance it in legislation to make it safer?

[Stephen Kinnock]

I thank the hon. Member for the last intervention that he will ever make on me.

The Government’s analysis of this group of amendments is that, to varying degrees, they would not add clarity; they would add more complexity, partly because they would either create a parallel legal framework or put new elements into the mix that would create operational challenges for practitioners. That is the Government’s fundamental analysis, but it is a finely balanced judgment and I absolutely accept the hon. Member’s argument.

--- Later in debate ---

[Dr Tidball]

I am sorry, Mrs Harris, but I may have risen too soon. I want to speak to amendment 339, but I would first like to hear from my hon. Friend the Member for Bexleyheath and Crayford, who tabled it.

[Danny Kruger]

I rise to speak to new clause 6, in the name of my hon. Friend the Member for Solihull West and Shirley; to amendment 368, in the name of my right hon. Friend the Member for East Hampshire; to amendment 270, in the name of my right hon. Friend the Member for South West Wiltshire (Dr Murrison); and to amendment 278, in the name of the hon. Member for Wells and Mendip Hills. I will canter through them as quickly as I can.

My concern about new clause 6, which specifies that an advance directive would be inapplicable in the case of assisted dying, is that, as we discussed briefly at a previous sitting, advance directives are currently about the refusal of treatment. That is what they exist to do. Under the new clause, as in the Mental Capacity Act 2005, the effect of an advance decision would be that

“the specified treatment is not to be carried out or continued”.

However, under clause 18, the doctor must be satisfied at the time that the lethal substance is provided that the patient has capacity. I do not think that the new clause is necessary; it is otiose or even nonsensical, because the Bill already assumes that the patient has capacity at the very end. [Interruption.] The hon. Member for Spen Valley agrees with that point. I invite my hon. Friend the Member for Solihull West and Shirley to consider whether he wants to press new clause 6 at all.

On amendment 368, which relates to people with Down’s syndrome, I hear what my right hon. Friend the Member for North West Hampshire says. I strongly agree with him; I will make a couple of points and then respond to his suggestion.

I look forward to the points from the hon. Member for Spen Valley. I do not say this in a carping spirit, but it is relevant that the National Down Syndrome Policy Group opened its submission with a series of complaints about the process. The group feels that the consultation process has been rushed: we have not had the usual 12 to 16-week public consultation. It talks about limited professional and affected population engagement in the course of the drafting of the Bill, and a lack of accessible consultation materials; I mention that not to revisit the debate that we had about the process, but because it is a bad start. In the group’s mind, it is a harbinger of how the Bill might operate, and I understand why it thinks that.

The fact is that in our society we have persistent and entrenched discrimination against people with learning disabilities, particularly people with Down’s syndrome. There is a fundamental assumption that is too widely shared that the lives of people with Down’s are worth less than others’. One sees that, I am afraid to say, in the prevalence of prenatal screening and termination of Down’s babies. Yet we know from research that the lives of people with Down’s are as fulfilling, joyful, positive and constructive as everybody else’s. The most marvellous fact is that 99% of people with Down’s syndrome say that they are happy with their life, which I am sure is more than on this Committee and probably more than in the general population.

As a society, we serially misunderstand and degrade the value of people with Down’s syndrome. They are victims of the system, particularly in healthcare. People with intellectual disabilities died at rates three to four times higher than the general population during the covid crisis, often with inappropriately applied “do not resuscitate” orders put on them. The representation from the National Down Syndrome Policy Group was signed by 50 organisations, all representing people with Down’s syndrome, so it is pretty widespread.

Expert advice is that it is very difficult to spot coercion when dealing with people with Down’s syndrome. It is very difficult to ensure that one is getting informed consent. A point that has been made, in particular by the Down’s Syndrome Research Foundation, is that a discussion with someone with Down’s can often feel to them as if a suggestion is being made. That is particularly relevant to the whole question of a doctor’s suggestion, which we will come on to—well, we are on it now. Certainly the whole matter of how a person with Down’s syndrome receives information needs to be taken into account in any work that is done.

[Kim Leadbeater]

The hon. Member is making an important point. As someone with friends who have children with Down’s who, as he says, absolutely have very fulfilling lives, I hear every word that he is saying. Will he take a commitment from me back to those organisations? I commit personally to meeting them, perhaps alongside the right hon. Members for East Hampshire and for North West Hampshire, at a time convenient to them.

[Danny Kruger]

I am grateful to the hon. Lady and am sure that that will be welcomed. It does rather go back to the point that the organisations made at the outset, which is that they wish they had had more consultation earlier on, but I understand why that was not possible in all cases.

[Sean Woodcock (Banbury) (Lab)]

In oral evidence, Fazilet Hadi stated in answer to a direct question from me that she felt that disabled people had not been listened to properly. Will the hon. Member comment on that?

[Danny Kruger]

I am afraid that that seems to be the strong impression that many groups have.

I will quote quickly from a submission that we have received from someone at the National Down Syndrome Policy Group, Fionn Crombie Angus. I am not sure whether Fionn has Down’s syndrome, or is perhaps a parent, but the point is a striking one, which we have not heard enough:

“I do feel very sorry for the people who are suffering, but I think the people left behind, the relatives, will be scarred for life if they help people die. That is the main reason why I do not want the Assisted dying Bill to become law.”

That is not specifically relevant, because we are not discussing whether the whole thing should happen, but it strikes me that there, from a member of the Down’s community, we have a point that goes to the heart of our discussion on the Bill: it is not all about the individual who is seeking an assisted death. More people are involved in the decision.

I made a point in an earlier debate about relational autonomy, which is very significant. That particularly applies to this group of people, who will be making decisions in the context of their family and the people around them, including the doctor who is talking to them. That is why it is particularly important to have a wider set of expertise and advice around people with Down’s.

My concern is that Bill, as drafted, thanks to the inclusion of clause 3 and its reference to the Mental Capacity Act, will assume consent and support people with Down’s receiving this intervention. It would have been best if we had accepted the amendments tabled by my hon. Friend the Member for Reigate and the hon. Member for Bexleyheath and Crayford to reverse the burden of proof. Failing that, we need to ensure that the job is done properly. Amendment 368, tabled by my right hon. Friend the Member for East Hampshire, would address that point.

Given the real concern that we have all discussed about the application of the Mental Capacity Act, it is important to have real expertise, time and attention on behalf of Down’s people with the role of an independent advocate. In particular, that should be someone who has expertise in end-of-life decisions for people with Down’s syndrome, which will be a small group of experts, so we might have to end up widening that, I am sorry to say. We need people with proper expertise.

I think the point that my right hon. Friend the Member for North West Hampshire made about the interaction of the Bill with the Down Syndrome Act 2022 was absolutely right. My understanding is that he is right that it applies to authorities, but it strikes me that the purpose of the amendment 368 would be to insist that the provisions of the Act apply in the case of individuals as well.

My right hon. Friend may be right that there could be complications, so it would be good to hear whether the Minister agrees with him that we should take this topic away, with the hon. Member for Spen Valley, and see whether the provisions in the amendment can be introduced at a later stage of the Bill or in statutory guidance. However, I would want to hear explicitly from the Minister that he is confident that what my right hon. Friend the Member for East Hampshire was trying to do when he tabled the amendment will be reflected properly at a later stage of the Bill. On that basis, I am happy not to press the amendment to a vote unless others feel strongly that we should proceed.

--- Later in debate ---

[Dr Simon Opher (Stroud) (Lab)]

Surely the hon. Member is describing exactly why we need the Bill. If they are given a diagnosis, at that point they can apply for assisted death. We know that there are statutory time limits built in, which I believe will take us to at least 21 days from the diagnosis. The danger is suicide in patients, which is what we are trying to avoid. Approximately 600 patients with terminal illness commit suicide in this country each year, and the Bill will prevent that by allowing them to apply for assisted death.

[Danny Kruger]

I hope that the hon. Member is not suggesting that all 600 would be averted by the Bill. He might be right that some would be, and I recognise that. However, the purpose of amendment 270 is to ensure that people who might be suicidal receive an assessment, whether they are inclined to apply for assisted death, if it is legal, or to take their own life in an unassisted way. If they expressed a wish under the clauses of the Bill to have an assisted death, they would have proper psychosocial assessment and proper steps would be taken to ask, if we are prepared to make this distinction, “Is it just that they are suicidal and not wanting an assisted death?” I find the distinction difficult to parse logically, but if that is the distinction that we are making, let us put it into the Bill and ensure that people are properly cared for in that very dangerous time after they get a terrible diagnosis.

I would like to quote from the written evidence that we received from a member of the Pathfinders Neuromuscular Alliance, which is a user-led charity for those with muscle-weakening conditions such as muscular dystrophy. This person said:

“I’ve been there, I’ve wanted to die, and I’ve been in the position where I would take that option if it was given to me”—

not if it was not. Interestingly, he would have taken that option if it was given to him, rather than suggesting that he was going to take his own life anyway. The quote continues,

“but looking back I can see I was depressed and now I’m so glad that I didn’t take that option.”

At the moment, the Bill does not require anyone to explore these psychosocial factors, and although the person can be referred to a psychiatrist—and, if we go on to accept the amendment, we would ensure that they must be if the doctor concludes that there is doubt—I do want to make a point about referrals. There is an assumption that the doctor will refer the person to a psychiatrist, but that will only happen if they have done their assessment well. We are assuming that they will do the assessment well, but we have heard repeatedly that such assessments are often not done well. I welcome the coming amendment—amendment 6—that says that if the doctor concludes that there is doubt about capacity, they “must” refer. That would be a step forward, but it is not sufficient. Even the psychiatrist will only answer the question, “Is this person able to make a decision?” That does not address any of these other factors.

In Oregon—we refer often to Oregon, and although this Bill is supposed to be the safest in the world, it is not as safe as Oregon in this respect—the doctors may refer the patient for counselling if the patient

“may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment”.

To conclude on this point, psychosocial care is fundamental to good end-of-life care. Members of the Committee have said that palliative care and assisted dying can complement each other; this assessment should be part of that picture, and it needs to come before the first declaration, because once somebody has signed that declaration they are already on the pathway—and there will not be an obligation on them to receive palliative care advice either, because we rejected that amendment. Amendment 270 provides for people’s needs to be met at the first opportunity.

Lastly, on the question of doctor-initiated conversations, I quote Professor Brassington, who submitted evidence to the Committee:

“In normal medical practice, the patient approaches the medic with a problem, and the medic suggests possible courses of action, not all of which would have been considered by the patient. The patient permits further action. But it is implicit that the practitioner who makes the suggestions thinks them good, and the patient is entitled to think that the practitioner endorses them all.”

In a normal scenario, the doctor would think about what is good for the patient. To raise an option is to endorse and encourage it, perhaps as one among a number of other options. It is to suggest that this is a good option—it might not be the one the doctor thinks is the best, but it is a good option for the patient; otherwise, they would not raise it. They can only make a recommendation for options that they consider would be appropriate to the situation.

[Kim Leadbeater]

On that point, I fundamentally disagree, although I will stand corrected by medical colleagues. I do not think that the doctor in this instance is making any suggestion; what they have the responsibility to do is to lay out the options, but it is up to the patient to choose. I would imagine—again, I will stand corrected by medical colleagues—that that is standard practice.

[Danny Kruger]

This is an important debate to have, because the clear implication of a doctor making a recommendation is that this option would be good for the patient. It is one of many—

[Kim Leadbeater]

It is not a recommendation.

[Danny Kruger]

Indeed, it is not a recommendation; but in laying out this option for the patient, the doctor is clearly communicating that it might be the right thing for the patient to do and that it might address their needs. If the suggestion is that they are making a suggestion that might not be good for the patient, then that is of serious concern to us, is it not? The clear implication of current law—with reference specifically to Montgomery v. Lanarkshire Health Board, which determines that we have patient-led medicine in this country now—is that a doctor is obliged to set out all the options that he or she thinks might be appropriate to the case. That goes back to the question about whether we regard assisted dying as a healthcare intervention, but if we do regard it as one, then if it is suggested, it is because it might be the right thing for the patient to do. Implicitly, there is a suggestion that it could be the right option for the patient.

It is interesting that clause 4(1) disapplies Montgomery and says that a doctor is not obliged to make this suggestion. That poses the question: is it therefore a treatment at all?

[Kit Malthouse]

I am not sure my hon. Friend is entirely right. My understanding is that under law and medical ethics, doctors have to discuss all courses of action with someone, even if they believe a course of treatment might have adverse consequences. It is not that they can restrict themselves; they have to give someone the full range. That sits behind informed consent, surely.

[Danny Kruger]

Certainly, there are adverse consequences for all sorts of treatments, but putting assisted dying on the table and making it clear that this is an option for the patient can only be done, morally and legally, if the doctor thinks that it may be an appropriate treatment or intervention for the patient. Otherwise, if we are suggesting that the doctor might not think that this is a good thing for the patient to be doing, it is a serious breach of medical ethics for them to suggest it. It is one or the other. Either this a good thing for a doctor to suggest, or it is not.

[Juliet Campbell (Broxtowe) (Lab)]

A very quick question: does the hon. Member agree that the weight of a doctor’s words weighs heavily on patients?

[Danny Kruger]

I am absolutely sure that is right, and I am grateful to the hon. Lady for making that important point. For anybody, but particularly for the vulnerable and those in distress, as people are towards the end of their life, for those who have had a terrible diagnosis, and for those who feel a burden and recognise that the coming months might not be good for them or their family, of course the statement of this option has an implication—even if it is presented as neutrally as possible. It might well be received as a communication that the doctor is actually trying to say, “You are going to have a terrible death”, but does not want to say it out loud. It could be taken in all sorts of ways by patients.

[Dr Opher]

That is actually not right. In a medical consultation, a doctor gives a number of different options. A small example is that I might suggest to someone that there is an option of taking an antidepressant. Now, it is the patient’s choice as to whether they do that. My role is to give every option that is available, and to encourage and help the patient to make their own personal choice. That is a very basic tenet of clinical care.

[Danny Kruger]

I recognise that, but I repeat that by offering antidepressants, he is suggesting to his patients that it may well be the right thing for them to do. He puts in front of his patients a menu of options, with a degree of advice according to his expertise, but if assisted dying is on the menu, that is because assisted dying is regarded as something, as it were, that is healthy to eat. He would not put something on the menu that he did not think they should take. Everything on the menu is edible.

[Kit Malthouse]

Maybe we have a different interpretation of the Montgomery case, but my interpretation is that it shifted the duty of doctors from being based on what a reasonable doctor should disclose to what a reasonable patient would want to know. In these circumstances, in which someone has a terminal diagnosis and only a few months to go, I guess we are saying in the Bill that a reasonable patient would want to know about this option.

--- Later in debate ---

[Danny Kruger]

I think my hon. Friend is suggesting that a doctor should suggest assisted dying as an option in every case, because if he is suggesting that a reasonable patient would want to know this towards the end of their life, he is saying that every dying patient should be told, “What about assisted dying?” That is a very concerning suggestion. The question is: how would a doctor decide when or when not to make this suggestion?

I will go back to Montgomery and make this point as clearly as I can. The Bill accepts that assisted dying is not an ordinary medical treatment, which is why I pressed the Minister on this question. Clause 4(1) disapplies the Montgomery case law, which requires, as part of informed consent, that the patient be informed of all appropriate options. Having conceded that assisted dying is not an ordinary medical treatment, the objection to a prohibition on doctors raising it makes little sense.

It is true that having such a prohibition would be unlike any other medical treatment, but the Bill has already crossed the Rubicon of saying that assisted dying is different from all other medical treatments, because in clause 4(1) it says that doctors are not obliged to offer it. It is either the case that they must offer it or they must not. There is no grey area. If they do not have to suggest it in any case, that implies that assisted dying is unnecessary in all cases and there no cases where it should be used. I would like to hear from any Member who has an answer to this: in what circumstances might it be appropriate for a doctor to suggest assisted dying?

[Dr Tidball]

Does the hon. Member therefore disagree with the British Medical Association, whose evidence to the Committee has said specifically:

“We support the Bill’s balanced position such that there is no prohibition on raising assisted dying with eligible patients where, in their professional judgement, the doctor considers this to be appropriate—but there is also no duty to raise it”.

The implication is that the Bill gets that balance correct.

[Danny Kruger]

I am grateful to the hon. Member for highlighting that. I disagree with the BMA—I think that its idea of balance is actually an incoherence in the Bill. I note that the BMA elsewhere has suggested that assisted dying should not be regarded as a normal healthcare option or treatment. It is itself a victim of the confusion that is reflected in the Bill about whether or not this is healthcare. As I said, the disapplication of Montgomery in clause 4(1) suggests that it is not actually healthcare treatment and should not be managed in the same way as everything else.

[Jake Richards (Rother Valley) (Lab)]

I have been listening to the argument in some detail. Is there not a danger here of trying to translate the dry words of clause 4 to the conversations that naturally happen between clinicians and patients? Subsection (3) attempts to give some discretion as to when, how and whether to raise this prospect, instead of making it mandatory on any prognosis of terminality.

[Danny Kruger]

I recognise that it is an attempt to give maximum leeway to doctors. I think that is dangerous and puts doctors in a very difficult position. The BMA made the point that it is appropriate to enable doctors to raise this option as if it were just another treatment, even though it has also said it is not just another treatment.

I would challenge the BMA with the Medical Defence Union, which is the union that supports doctors in litigation. It points out, more correctly, that this is the worst of all worlds for doctors because they would be liable to complaints in either situation: if they do not raise it, a complaint can be made against them for not having done so; and if they do raise it, a complaint can be made against them on those grounds. We are being extremely unclear by leaving it entirely up to doctors. As I have said, it is not clear to me the circumstances in which it would be appropriate for a doctor to suggest an assisted death to somebody who has not raised it themselves. I would very much like to hear somebody tell me what those circumstances might be and to paint a scenario for us in which it is appropriate.

[Naz Shah]

Surely all medical codes of practice explicitly or implicitly bar doctors from raising courses of action that they believe could unquestionably harm a patient. Does it therefore not follow that doctors only raise courses of action for patients that they believe will not unquestionably harm them, even if they believe some courses of action are more likely to be in the patient’s best interests?

[Danny Kruger]

That is absolutely right. Either this is a medical treatment—in which it should be obligatory for a doctor presented with a patient who qualifies under the Bill and has the symptoms that we are talking about to say, “By the way, there is also this option”, which is what I think my right hon. Friend the Member for North West Hampshire is suggesting—or it is not a healthcare treatment at all. Clause 4(1) states that they do not have to raise the subject, in which case they should not raise it, because to raise it is to put it on a par with other healthcare options and therefore implicitly, or indeed pretty explicitly, to say, “This is an option that might be good for you”, which is an enormous communication to make.

I go back once again to the difference between this and withdrawing treatment. I have to say this so many times because it is so important: this is not equivalent to withdrawing treatment because this is not specific to the illness being treated. A person can have a treatment or not, and that will address the condition that they are suffering from. The termination of life does not address someone’s symptoms, treatment, condition or illness; it kills them. It is a different order of intervention. I do not think it is a healthcare treatment at all, and it should not be treated as such.

[Kim Leadbeater]

The hon. Member makes a valid point about the circumstances in which this option would be considered a valid choice for a patient. That brings us back to the fact that we are talking about someone who is going to die; the question is how they are going to die. It is not someone who is going to get better—they are not going to wake up and find that everything is going to be fine. This is about what that death looks like.

Pat Malone—one of our witnesses in oral evidence—had a brother who had seen his father die under circumstances so horrible that he had begged his children to help him die. Then the brother got the same condition and could see what his death could look like. Does the hon. Member not value the choice that assisted dying would give that patient to take back control of what their death could look like, with their loved ones around them? This is a very real situation for, sadly, lots of people, and could be where that choice could be valid.

[Danny Kruger]

I was not asking for cases in which it might be the right choice for somebody—I recognise the argument there. I am asking when it might be appropriate for a doctor to suggest it. In the case of the Malone family, if this law had been enforced, they would have requested it themselves. Again, I want to know under what circumstances it would be best for the patient—in their interests—for an assisted death to be suggested to them by a doctor, when they had not raised it themselves. Under what circumstances might that happen?

[Kim Leadbeater]

The concept of a suggestion is also not particularly accurate—it is a choice, in the same way that the other options are a choice. Families could only ask for this conversation if they knew about it, and while we are all living and breathing this Bill at the moment, even if it does come to fruition and the law is changed, there will be people who do not know about this option. Surely, it would not be informed consent for a person to suffer a horrible death if they were not told about this option.

[Danny Kruger]

On the suggestion that people will not know that this option is on the table, who are we talking about in those circumstances? I suggest we would be talking about people who are extremely marginalised, and I would be very concerned about a doctor suggesting an option to them. There may be a tiny number of people who would not know that this option is legal, but I am afraid it would be very widely known the minute that it is law.

[Kim Leadbeater]

rose—

[Danny Kruger]

I will certainly give way in a moment. An enormous number of people will be dragged into the scope of the Bill by suggestions being made to the vulnerable people that we are concerned about. I really do invite her to answer this as honestly as she can; does she not accept that being given this option by a doctor—given the doctor’s position of power and the vulnerable position that the patient is in—could well be interpreted as a suggestion that this might be a good thing for them to do? Does she does not recognise that?

[The Chair]

Order. We should not be addressing Members in that way.

[Danny Kruger]

You are absolutely right, Mrs Harris; I am inviting her hon. Lady to intervene as she wishes to, but I recognise she does not have to do that at all.

[The Chair]

You should be addressing the Chair.

[Danny Kruger]

I recognise that. I should certainly address you, Mrs Harris.

[Dr Opher]

I would like to make a speech that answers some of these points, but I will intervene if that is more appropriate. What would the hon. Gentleman prefer?

--- Later in debate ---

[The Chair]

Order. That is not a decision for Mr Kruger. If you wish to make a speech, if you indicate to me as the Chair, I will call you at an appropriate time. If you wish to make interventions, please do so, but could you keep them short? Have you decided which option you prefer—at your convenience?

[Danny Kruger]

I will decline the hon. Gentleman’s intervention—how about that? I will make his decision for him. Would that be acceptable? I look forward to his speech.

Let me wind up to the general satisfaction of the Committee with a couple of points about some other amendments. On amendment 278, which was moved by the hon. Member for Chesham and Amersham and tabled by the hon. Member for Wells and Mendip Hills—it is a very south and south-west debate—the suggestion is that if somebody has indicated in advance that they do not wish to have a conversation about assisted dying, the doctor will not raise it. That sounds welcome, but I am in fact afraid in practice that I think that this is quite simply an invitation to raise the idea if a declaration has not been made.

The absence of a declaration could well be interpreted as a willingness to have that conversation. Practically, how would it work? Would patients be informed of the need to make a declaration in advance of a doctor’s appointment? Would we all have to think, “Goodness, if I don’t make this declaration, the doctor might be suggesting an assisted death to me”? Should we all do that? Suddenly, we are having discussions about assisted death even before we see a doctor. All over the Mendip hills, people will be worrying that before they see a doctor, they had better sign a declaration.

To make a serious point, although the Bill is frequently framed as a choice only for the people who might take it, with no impact on the rest of society, my great concern is that it will actually impose an obligation on every family with a frail, elderly person in it. It will impose an obligation on all of us as we approach our end to consider whether we should take this option or not. It is not neutral in its effect on everybody. My concern is that amendment 278 will bring that home and make it even more explicitly required that we all consider whether we want to have an assisted death well before the time comes.

[Tom Gordon (Harrogate and Knaresborough) (LD)]

I think there is already broad consensus in this country: people would like the option of assisted dying. Polling shows overwhelming support for it. I accept that there are disagreements about what the option looks like, but this is not something that people have never thought about before and would suddenly pop into their minds; they have been talking about it for decades and decades. What would the hon. Gentleman say to that?

[Danny Kruger]

The hon. Gentleman is right that people are well aware of this topic, and they would be quickly aware of the option if the Bill became law. Without getting into the question of the bogus polling that claims to demonstrate public support, I would simply observe—[Interruption.] Well, it demonstrates support for something called “assisted dying”, but if we drill into the data and ask people explicitly what they mean, we find that they often mean palliative care. The more that people understand what is proposed in this Bill, the less they like it. Actually, other polling shows that there is a majority against the provisions of this Bill, but let us not banter polling around here. We make the law, and we are not responsive to polls, are we?

There is a challenge about making advance notices, and my strong suggestion is that we do not support amendment 278. I had better leave it there; I think we have all had enough of me—me included.

[Juliet Campbell]

Amendment 124 would prevent a registered medical practitioner from discussing the provision of assistance under the Bill unless it is first raised by the person themselves. This is very similar to another discussion we have had. The reason for my amendment is that the doctor will be suggesting, offering or endorsing assisted dying as a treatment pathway—and that would be new—and the patient may take that as a recommendation or endorsement, which could impede their freedom to autonomously choose assisted death.

Another reason I tabled the amendment is that the Bill risks exacerbating the existing pervasive health inequalities. I am very concerned that biases, both conscious and unconscious, have the potential to significantly impact the treatment pathways offered to people, particularly those who fall under the nine protected characteristics of the Equality Act 2010. Medical practitioners have the potential to influence the treatment pathways offered to people, particularly those from those backgrounds, and I therefore see no reason why assisted dying would be offered as a treatment pathway.

I was thinking of the following example. Under maternity services, we also have abortion services. If someone presented themselves to a doctor and said that they were in the early stages of pregnancy, they would not be offered abortion as an option; they would be asked, “Do you want to have your baby at home or at a hospital? Would you like shared care between your GP and the hospital?” They would not be asked, “Would you like an abortion?” because that is not part of the pathway. For that to happen, the person would go to the doctor and say, “I am pregnant and I would not like to have this baby.” It is therefore important that the individual first approaches the doctor or clinician and says, “I am interested in an assisted death” or “I would like an assisted death.” Assisted dying should not be a treatment option, even if it is part of end-of-life care.

The doctor’s position is one of knowledge and expertise that far exceeds that of their patient, and that places them in a position of power and influence over their patient. Given that power imbalance, the doctor’s suggestion seems like a recommendation. If an individual chooses assisted death because it feels like a recommendation, that decision is no longer autonomous.

I will quote a GP, Dr Hannah Denno, who put in some written evidence. She cited her role as a GP as being one that needs her patients to take her words as guidance:

“I believe that in my role as a GP, to make such a suggestion”—

choosing assisted death, for example—

“would put pressure on some patients to accept it. At a time of vulnerability many patients are very sensitive to any suggestions raised by a health care professional.”

--- Later in debate ---

[Danny Kruger]

I am grateful to my hon. Friend for setting it out so clearly, but I would like a little more clarity because I do not fully understand. My understanding from the Bill is that at the moment of the administration of the fatal drugs—the final act, as it is called—the administering doctor has to be confident of capacity. Were a person no longer conscious at that point, the doctor would not be able to proceed.

[Dr Shastri-Hurst]

The purpose of new clause 6 is to get clarity on that issue, because of the interplay with section 26 of the Mental Capacity Act, which states that if a patient

“has made an advance decision which is...valid, and...applicable to a treatment...the decision has effect as if he had made it, and had had capacity to make it, at the time when the question arises whether the treatment should be carried out or continued.”

I am not suggesting for a moment that seeking an assisted death is conventional treatment in the normal sense, but there will be patients who seek an assisted death and have palliative care treatment along the way, so there could be a technical scenario whereby the palliative care treatment is withdrawn for the assisted death to take place.

There is an element of mischief in my probing new clause, but it is to air the matter in debate. In truth, intervention there are a variety of options with any withdrawal of treatment or any treatment. I wanted that on the record. I have had assurances from the hon. Member for Spen Valley that that is clearly not the Bill’s intention—in many ways, I am arguing against my own new clause. Of course, this is a distinct scenario from an advance statement—the much more proactive step of, “These are the treatments or options that I would like if I lose capacity at a future date”—which has no legal footing. An advance directive, in comparison, is very much concentrated on the withdrawal of care. I do not propose to divide the Committee on the new clause; I merely tabled it so that this could be discussed.

Let me turn to amendments 8 and 124. There has been much discussion and worthy debate on the position of Montgomery, which takes me back to my days as a pupil barrister grappling with issues of consent. I fear that we may be going down a rabbit hole in discussing Montgomery in this context. I agree with my hon. Friend the Member for East Wiltshire that an assisted death is not typical medical treatment in the normal sense of those words; it is a wider holistic medical intervention. Therefore, my understanding is that Montgomery would not apply in those circumstances.

However, some of the principles around Montgomery way well have justification. My concern about the amendments is that while it is quite right that there should be no requirement to instigate those discussions, it would be equally wrong not to allow the flexibility to have that conversation in appropriate circumstances. The reality of clinical practice is that there are consultations within consultations. A patient who comes to a surgery to see their doctor may not feel able to articulate what they truly feel. They may give subtle hints, which doctors pick up during the course of a long career—to put it in lay terms, doctors read between the lines.

There is interplay with the principles of Montgomery, which is clear that a doctor should discuss issues where a reasonable person in the patient’s position would attach significance to them or the doctor is, or should reasonably be aware, that that particular patient would attach significance to them. My hon. Friend the Member for East Wilshire asked for examples of that. There are scenarios where there are subtle hints from a patient who has been given a terminal diagnosis. They ask, “What is the implication of this terminal diagnosis? How am I going to die, doctor?” The doctor says, “There are variety of ways in which this may manifest itself” and goes through them. Some of them may be more tolerable to the patient than others.

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Under the proposed amendment, the doctor would not be able to raise assisted death at that point, which is an option that is available if the law passes. It may not be an option that is palatable to some people, even after the debate—people may have, for very valid reasons, a moral objection or a principled objection to anybody undergoing an assisted death—but once it is on the statute book, it is an option for individuals. The danger is that we place our clinicians in an unenviable position. We cannot force them to have that conversation, but if the patient clearly indicates that they want it—they have indicated that they want to know the options available to them—where does that leave the clinician?

[Danny Kruger]

I am grateful to my hon. Friend for setting out the scenario so clearly. To summarise, he is suggesting that if a patient with bowel cancer says to their doctor, “How am I going to die?”, the doctor would say, “Well, one possibility is that you will die very badly, vomiting faeces,” to which the patient says, “My goodness, I’d never thought of that. What can we do about it?”, to which the doctor should say, “Well, there’s always assisted dying.” I summarise and condense the conversation, but that is the conversation that my hon. Friend is envisaging, is it not?

[Dr Shastri-Hurst]

My hon. Friend summarises a much more complicated conversation; I think he distils it down to an over-simplistic representation of how the conversation would go. A patient says, “I hadn’t envisaged that I may die while vomiting up faeces. What could we do?” The clinician would go through a variety of options that would be available in that scenario, but that would include, potentially, having a discussion about assisted death, as that would be one way of avoiding that situation coming across the hills.

This is the issue I have particular concern about. In the scenario where that conversation arises, a patient has very clearly indicated that they want to know all the options available for how they would manage their death, and the doctor feels that is a cue, quite understandably and, in my view, rightly, to have a wider conversation that involves assisted death, along with other options, because he or she believes that the patient has indicated that that is what they wish. If we say that a doctor cannot have that conversation in any circumstances, we open up the clinician to the accusation, perhaps from a relative, who says, “Hang on a minute, doctor. My relative didn’t raise that with you. You raised it with them.”

These are very subtle and carefully balanced conversations. I understand where the amendment comes from, but without trusting in the judgment of clinicians, who know their patients well, we are setting them up to fail. We are setting the system up to be more clandestine. We are going to prevent what are very genuine and important conversations from taking place, because people are too scared of the operational framework that would be imposed on them. In those circumstances, we would put forward a Bill that does not function as intended. For those reasons, I will not support amendments 8 and 124.

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[Naz Shah]

I am not sure that the amendment would be that kind of gag clause, so I disagree. If a patient says, “Give me all the options to bring an end to this,” the judgment of the doctor could be that assisted dying is an option. If that is the case, perhaps we need to look to the Government’s and Ministers’ wash-up process. When we are tidying up this Bill, I am sure that there will be plenty of opportunities for the Government to put in the significant words that safeguard patients. That is my feeling, but I thank my hon. Friend for his intervention.

[Danny Kruger]

The clear implication of the amendment is that if the patient requests to know what can be done to end their life, that is an invitation to raise the option of assisted dying; if they ask the doctor about what can be done to deal with the pain, symptoms and illness, they should be offered information on that. I am afraid that it comes back to the distinction between its being a healthcare option and not being a healthcare option. Does the hon. Lady agree that the evidence from Australia is clear that the minute there is a law like this, there will be challenges to the safeguards? Each safeguard will be seen as a barrier to a human right and a barrier to access. That is what the Australians told us.

[Naz Shah]

I agree that that is what the evidence shows us, and there are many concerns in other jurisdictions as well. I will come back to that distinction.

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[Sarah Olney (Richmond Park) (LD)]

I wish to speak briefly to amendment 270, in the name of the right hon. Member for South West Wiltshire, to which I have put my name. It is about the really important issue of assessing suicidal intent as part of the assessment as to whether somebody has capacity to seek an assisted death. It is a really important point. The Bill expressly sets out that the person seeking an assisted death should have

“a clear, settled and informed wish to end their own life,”.

Amendment 270 seeks to establish that the wish cannot be clear or settled if there is any doubt about whether the person has a suicidal intention instead of seeking an assisted death on the basis that they have a terminal illness. In its current form, the Bill does not require a structured assessment of whether a patient is experiencing remediable suicidal risk factors, such as treatable depression, external pressures or suicidal ideation, before assisted dying is discussed.

In the oral evidence, Dr Mulholland said that most people with depression, anxiety and other mental health problems “would have capacity” under the Mental Capacity Act because it would be presumed. It is not necessarily an obstruction to people being referred for anything. It is an important point that someone can have depression and that it can lead them to have suicidal thoughts, but under the Mental Capacity Act they would still be assessed as having capacity to decide that they wanted an assisted death.

What is really important is that we have, over some years in this country, developed a suicide prevention strategy. I am sure that every Member in this room has had constituents approach them, as I certainly have, about family members who have committed suicide, where they were able to identify factors that made that suicide preventable. That is why it is so important that the suicide prevention strategy has been developed and continues to be developed, and why leading figures associated with that strategy—and with suicide prevention more widely—are concerned that a Bill for assisted dying may undermine suicide prevention strategies. We should take every care to prevent that in this Bill.

The current UK suicide prevention strategy cites early intervention as a priority to implement tangible actions aiming to reduce the risk factors of suicide. In line with that strategy, amendment 270 provides early intervention that aims to identify the symptoms of suicidality in a patient before the initial discussion about assisted dying can take place. At the bare minimum, someone who is severely suicidal will not be allowed to enter into conversations about receiving an assisted death.

It is important to reflect that suicidal ideation is not the same as a settled wish to die. Evidence shows that when mental health issues are treated, many patients no longer seek to end their life by suicide. Dr Price, in the oral evidence, said that 20% of terminally ill patients experienced depression, which is strongly associated with the wish to hasten death. When depression is identified and treated, the wish to die often diminishes. It is so important to distinguish and make provision for those people who are experiencing a wish to die as suicidal ideation, as opposed to the

“clear, settled and informed wish”

specified in the Bill.

Research from the Office for National Statistics, King’s College London and the University of Manchester suggests that people diagnosed with a physical terminal illness are at an elevated risk of death by suicide, because of an increase in the psychological distress that can lead to severe depression in many patients, but data from the study shows that it is a more pronounced risk of suicide in the first six months after diagnosis or first treatment and, on average, suicide rates in the first year after a terminal diagnosis were 21.6%. Of course, it is important to reflect on the fact that a diagnosis of a terminal illness can take place some years in advance of the actual prognosis that the person’s death may occur. We are looking at a group of people who are within six months of their death as far as can be established by what is, as we know, uncertain prognosis—yet the incidence of suicide among those with a terminal illness is much more weighted towards those who have just received a diagnosis. These, of course, are not the same group of people; there may well be overlap, but they are definitively not the same.

Evidence on the gov.uk website suggests that

“over half of men aged 40 to 54 who died by suicide had a physical health condition.”

We know that having a physical health condition or any kind of terminal illness has an impact, and that evidence demonstrates the impact that poor physical health has on mental wellbeing. We know that thereDr Louis Appleby, a psychiatrist who leads the national suicide prevention strategy for England and directs the national confidential inquiry into suicide, has expressed concerns that the Bill fundamentally undermines the basis of the suicide prevention strategy. Identifying and diagnosing capacity and mental disorders are easy to put down in writing, but in practice it is much harder for professionals to make a correct judgment straightaway. Where we do not want someone to die, we intervene by offering mental health support, crisis services and what we hope is a comprehensive suicide prevention strategy, but for those who qualify under this Bill, instead of that suite of support, we allow them to progress straight into discussion to end their life.

It is really important that we have had a debate today about how the discussion should be initiated and the appropriate way to do that, but what is important about amendment 270 is that it takes into account the specific factor of suicidal ideation. It would mean that whatever the outcome of the decision about how the conversation should be initiated, the possibility that the person wishes to commit suicide is nevertheless taken into account.

[Danny Kruger]

The hon. Lady has just made a very important point. Does she agree that there will be profound awkwardness for a medic? In a hospital, when somebody says they want to die, they are at the moment referred to the mental health team—basically to be put on suicide watch—but under the Bill, without this provision, the obligation would be to say, “Well, maybe that’s the right thing to do,” and refer them to the assisted suicide team. What is being proposed through this amendment, as I understand it, is more or less to do both.

[Sarah Olney]

That is absolutely right. I think it becomes quite challenging for medical professionals when they are presented with a patient who expresses a wish to die: is this a suicidal intent or is it a clear, settled and informed wish to end their life under the provisions of the Bill? That is why it is really, really important that the possibility of suicidal intent is ruled out, as set out in amendment 270, which I support.

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[Dr Opher]

I completely agree. Interestingly, I am on a journey here. To begin with, I thought these were good amendments. I thought that we must not introduce certain things—the doctor being a powerful person and so on. I then asked a lot of my colleagues, and they said, “No, no—we’ve got to clarify the law. We do not want this blurring of the law.” I have actually moved in the other direction, and I think it is essential that we do not bring in these amendments. As my hon. Friends said, the BMA has support the subject being raised and there have been changes to the law in Victoria because the gag clause simply does not work. We need to protect patients and, in my opinion, these amendments are not a good way of doing that. The hon. Member for Solihull West and Shirley made such a compelling argument against those amendments, so I will not go on about them.

On Amendment 278, I actually agree with the Member for East Wiltshire, but probably for different reasons. Again, if we introduce the amendment, if the doctor does not see that a patient has said that they do not want assisted dying and they bring it up, the Bill will potentially criminalise their behaviour. I feel that would not work and it would complicate the law.

I agree with amendments 319 and 320, tabled by my hon. Friend the Member for Bexleyheath and Crayford, which concern age. They would be a good and—alongside his amendment 339—functional change to the Bill.

Amendment 270 is about psychological assessment. As far as I can read in the Bill, as part of the panel process, which we have not yet discussed, there will be a psychological and psychiatric assessment of the patient. Also, when assessing someone with a terminal illness, most doctors will assess their mental health.

[Danny Kruger]

It is very important that we do have psychiatrists involved. In that sense, the addition of the panel may be welcome, although I regret that it is replacing the judicial stage—but, crucially, it comes right at the end of the process, and as I understand it, there will be no obligation on the panel to meet the patient. That is in no way a psychiatric assessment, let alone one at the right moment.

Terminally Ill Adults (End of Life) Bill (Sixteenth sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Efford.

As I have stated previously, my remarks on behalf of the Government on these amendments will provide a factual explanation. I shall not offer a position on how the Committee should vote, as that remains a matter of conscience. The overarching theme of the amendments relates to the requirement on how and when a medical practitioner may raise the matter of assisted dying.

Clause 4(2), as drafted, provides that nothing prevents a medical practitioner from using their professional judgment to decide when to raise the subject of assisted dying. Amendment 278 seeks to prevent a doctor from raising the subject of assisted dying if the person has a recorded advance decision in their medical records that states that in future they will not want assisted dying.

The Mental Capacity Act 2005 enables a person with capacity to make an advance decision to refuse a specified form of treatment in future, should they lack capacity. A person who has lost capacity under the Mental Capacity Act would not be eligible for assisted dying under the Bill. Where such an advance decision is in place, the effect of the amendment would be to prevent the doctor from raising the subject of assisted dying, unless the person indicates to the doctor that they wish to change their previous decision, that they wish to seek assistance under the legislation and that they have the capacity to do so.

Technically, amendment 278 appears unnecessary, because advance decisions under the Mental Capacity Act are not relevant to assisted dying. That is because advance decisions are about refusing treatment at a time when a person no longer has capacity, and assisted death would be available only to those who have capacity.

As drafted, clause 4(1) states:

“No registered medical practitioner is under any duty to raise the subject of the provision of assistance in accordance with this Act with a person”.

but clause 4(2) specifies that they may do so if, in exercising their professional judgment, they consider it appropriate. Amendment 8 would prevent a registered medical practitioner from raising with a person the subject of provision of assistance under the Bill, unless the person has indicated to that practitioner or to another registered medical practitioner that they wish to seek assistance to end their own life. The effect would be that any conversation on assisted dying will need to be patient-initiated, and not at the discretion of the medical professional within a wider conversation about end-of-life care.

The effect of amendment 124, as with amendment 8, would be to prevent a registered medical practitioner from raising with a person the subject of provision of assistance under the Bill. That would mean that the person will need to indicate to a registered medical practitioner that they wish to seek assistance to end their own life before an initial discussion can take place. The effect would be that assisted dying can be discussed only if the patient has initiated the conversation.

The Government’s assessment of amendment 319 is that, as drafted, it would not prevent the subject of an assisted death from being discussed with a person who is under 18. There is already a requirement that, to be eligible for the provision of assistance under the Bill, a person must be aged 18 or over at the time that they make their first declaration under clause 1(1)(b).

Amendment 319 would impose additional requirements on the approach that a medical practitioner must make if raising the subject of assisted dying with a person who has a learning disability or is autistic. It would require the person to be provided with accessible information and given sufficient time to consider it. It would further require that they must have a supporter and/or independent advocate present for the initial discussion. The amendment would require that a person with autism or a learning disability must have a supporter or independent advocate present for the discussion, even when they have capacity or are high-functioning. Autism is a spectrum disorder, meaning that autistic people have diverse and varying needs, so the effect of the amendment would vary among individuals.

It is already the case that all registered medical practitioners, in meeting their professional standards, are expected to communicate information clearly and effectively. That includes allowing sufficient time for the individual to consider and process the information provided. For example, the General Medical Council’s “Good medical practice” states that all GMC-registered clinicians

“must take steps to meet patients’ language and communication needs”

to support them to

“engage in meaningful dialogue and make informed decisions about their care.”

Amendment 368 would require registered medical practitioners, when deciding if and when it is appropriate to discuss assisted dying with a person with Down’s syndrome, to act in accordance with the Down Syndrome Act 2022. The Act requires the Secretary of State to issue guidance to relevant authorities on what they should be doing to meet the needs of people with Down’s syndrome. Although this work is being taken forward as a priority by the Department, no statutory guidance has yet been published under the Act.

The relevant authorities in scope of the Act are institutions such as NHS trusts. The Act does not provide for guidance to be prepared for individual doctors. The relevant authorities must have due regard to the statutory guidance, which enables them a degree of discretion in following it, but the amendment would require medical practitioners to act in accordance with the guidance. It might therefore create uncertainty as to how a doctor can comply with their obligations under the Bill.

[Danny Kruger (East Wiltshire) (Con)]

I hear what the Minister says—the guidance does not exist and there is concern that the amendment may therefore induce some confusion—but would the answer not be to put a commitment into the Bill that the Secretary of State will issue guidance on how the 2022 Act could be applied in the context of the Bill?

In the light of our conversation at the Committee’s last sitting, I put on the record my intention to press the amendment if the Minister cannot give a commitment now to introduce an amendment later that the Secretary of State will introduce statutory guidance to ensure that proper care is taken of people with Down’s syndrome in accordance with amendment 368.

[Stephen Kinnock]

The challenge is the dissonance in how the guidance under the Down Syndrome Act, which is currently very close to publication, is directed towards authorities such as trusts, but there is no coverage around individual doctors. At this stage, without seeing a clear distinction between the two or how it would work for individual doctors, the Department’s concern is that it could create confusion as to the obligations on individual medical practitioners under the 2022 Act. I am obviously open to conversations about how to clear that up, but the lacuna between the authorities and the individual doctors is the problem being flagged by the Department.

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[Stephen Kinnock]

I thank the right hon. Gentleman for that clarification and apologise for my misunderstanding; I thought he was referring to the guidance that we are currently working on under the terms of the 2022 Act. Yes, absolutely: the Bill currently specifies a two-year commencement period, within which a whole range of operationalisation work will need to be done. All of that will need to be consulted on; we will not do it all in an ivory tower from Whitehall or Westminster.

[Danny Kruger]

It is welcome that a commitment has been made to meet my right hon. Friend the Member for East Hampshire, who tabled the amendment, but a commitment to consult is not the same thing as specific protections in the Bill for people with Down’s syndrome. What we really need is a commitment in the Bill that there will be statutory guidance. There will be opportunities for that later, so we may not need to press the amendment to a vote, but if we cannot have a commitment, we must press it.

[Stephen Kinnock]

It is absolutely the hon. Member’s prerogative to press the amendment to a vote if he so wishes. As things stand, because of the baseline, which is the GMC guidance that I have just read out, we constantly go back to the Government’s position that the current corpus of guidance, regulations, advice, training, expertise and professional judgment is, in essence, satisfactory to the Department. We believe in and rely on the professional judgment of the experts in the field. That remains our fundamental position.

The effect of amendment 320 would be that the safeguards in clause 4(4) in respect of the preliminary discussion apply only where the person seeking assistance is aged 18 or over. The amendment would not prevent a discussion with a person under 18. As the Committee will be aware, there is already a requirement that, to be eligible for the provision of assistance under the Bill, a person must be 18 or over when they make their first declaration under clause 1(1)(b).

Amendment 270 would make it a requirement for a registered medical practitioner to ensure that there are no remediable suicide risk factors before proceeding to the initial discussion about assisted dying. The amendment does not state what is to happen if the practitioner considers that there are remediable suicide risk factors. As the Committee will be aware, we rely on medical practitioners to make judgments in relation to their patients that draw on their training, experience and expertise. We would expect the judgment and skill of a medical professional to be brought to bear where there are remediable suicide risk factors.

Amendment 276 would mean that a person is unable to have a preliminary discussion or make a first declaration to be provided with assistance to end their own life until 28 days after receiving a terminal diagnosis. The amendment would add an additional pause into the process for a person who has received a terminal diagnosis in the preceding 28 days. The 28-day pause would apply regardless of the patient’s prognosis, even if they had only one month left to live, for example.

New clause 6 would ensure that an advance decision to refuse treatment under the Mental Capacity Act 2005 cannot be used to seek assisted dying. Our analysis suggests that the new clause is not necessary, because an assisted death is available only to those with capacity, whereas advance decisions provide for a person to be able to refuse treatment at a future time when they have lost capacity. If a person still has capacity, they may be eligible for an assisted death. If they do not have capacity, they will not be eligible, irrespective of whether they have made an advance decision.

That concludes my remarks on this group of amendments. As I say, the Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could change. However, I hope my comments and observations are helpful to Committee members in considering the Bill.

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“create opportunities for patients to raise concerns and fears about the progression of their disease and about their death and to express their wishes…listening to patients, providing them with information, and respecting their decisions and choices, are integral parts of good practice.”

[Danny Kruger]

The hon. Lady says that the GMC states that doctors have an obligation to raise the treatment options before them, and I think that she thinks that this is a treatment option. Surely the obligation is on doctors to raise assisted dying in all cases where it may be an option for the patient. Does the hon. Lady agree that doctors should offer assisted dying when that treatment may be appropriate for the patient?

[Kim Leadbeater]

I agree that, under the provisions of the Bill, the doctor will have a duty to lay out options available to the patient, if they meet the eligibility criteria—absolutely. That is the whole purpose of the Bill.

[Danny Kruger]

I am grateful to the hon. Lady for giving me a very clear answer. I just want to be totally clear that we understand each other. Is she saying that every doctor facing a terminally ill patient—someone who is eligible under the Bill—should make clear to them that they have the option of an assisted death?

[Kim Leadbeater]

Well, that is the purpose of clause 4: the doctor has to lay out the options available to the patient as long as all the criteria are met.

We can see from the guidance that currently exists that doctors take a very sensitive and patient-centred approach to end-of-life conversations. If the law were to change, that approach would continue with additional training specifically related to assisted dying, as has been discussed. It would also mean that the issues that doctors currently face around discussing assisted dying would be addressed.

As the BMA says, at the moment

“The law does not provide a clear definition of which actions might constitute assisting or encouraging suicide…What if a patient wishes to travel abroad for assisted dying? While the act of travelling abroad for assisted dying is not illegal, assisting, facilitating, or encouraging someone to do so is a criminal offence…doctors need to be aware of the possibility of legal and professional sanctions if they were to do so.”

I imagine that that must create a real sense of jeopardy for doctors. Similarly, the GMC recognises that doctors will face challenges in

“ensuring that patients do not feel abandoned”,

while ensuring that the advice or information that they provide does not encourage or assist a person to end their own life.

These are very difficult conversations for patients and doctors, but by legalising assisted dying in this country we can give clear guidance through a robust legal framework, and create the thorough, transparent process that is currently lacking. These conversations provide a safeguard while the person is still alive. As the former director of public prosecutions, Sir Max Hill, told the Committee,

“In each of the 27 cases I considered, the deceased individual was already dead, and that is when the scrutiny started. The major advantage of the Bill, if I can put it that way, is that that will be reversed, and scrutiny will be before death.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 86, Q111.]

Mark Swindells from the General Medical Council told us:

“We do get inquiries from doctors who are concerned that they are doing the right thing when it might become apparent to them that a patient wants to travel overseas to access assisted dying.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 46, Q36.]

Bringing those conversations out into the open has to be better for the patient and the practitioner.

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[Kim Leadbeater]

The right hon. Gentleman is absolutely right. As I have said, the BMA has been very clear that doctors should use their professional judgment. For example, if they had a patient whom they knew to be deeply religious and who had no interest whatsoever in an assisted death, it is highly unlikely that they would raise the possibility. It is up to them to use their professional judgment to accommodate the wishes of the patient. It has to be a patient-centred approach.

[Danny Kruger]

Will the hon. Lady give way?

[Kim Leadbeater]

I am done.

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Division 22

Question accordingly negatived.

Ayes: 8

Noes: 13

[Danny Kruger]

I beg to move amendment 342, in clause 4, page 2, line 23, leave out

“may (but is not required to)”

and insert “must”.

This amendment would strengthen the requirement for a registered medical practitioner to conduct a preliminary discussion.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 285, in clause 4, page 2, line 28, leave out paragraphs (a) to (c) and insert—

“(a) the person’s diagnosis and prognosis, in consultation with a specialist in the relevant illness, disease or medical condition,

(b) any treatment available and the likely effect of it, in consultation with a specialist in the provision of such treatment,

(c) any palliative, hospice or other care, including symptom management and psychological support, in consultation with a specialist in palliative care.”

This amendment ensures that a specialist carries out the assessment of the patient, the treatment options available and the palliative care options available, since these may not be known to a doctor coordinating an assisted death.

Amendment 343, in clause 4, page 2, line 28, at end insert

“, including any relevant probabilities and uncertainties surrounding the person’s diagnosis and prognosis.”

This amendment would make clear that the doctor conducting an initial discussion is required to discuss the probabilities and uncertainties of any estimates of how long a person may have to live.

Amendment 344, in clause 4, page 2, line 29, at end insert

“, including the risks and benefits of such treatment, potential side effects, and the impact of the treatment on the person’s quality and length of life.”

This amendment would make clear that the doctor conducting an initial discussion is required to discuss the impact of any treatment available.

Amendment 275, in clause 4, page 2, line 30, leave out “any available” and insert “all appropriate”.

Amendment 108, in clause 4, page 2, line 31, at end insert

“and offer to refer them to a registered medical practitioner who specialises in such care for the purpose of further discussion.”

This amendment would require the doctor who has an initial discussion with a person about assisted dying to offer to refer them to a specialist in palliative, hospice or other care.

Amendment 183, in clause 4, page 2, line 31, at end insert—

“(and, accordingly, such a preliminary discussion may not be conducted in isolation from an explanation of, and discussion about, the matters mentioned in paragraphs (a) to (c)).”

This amendment emphasises that the initial discussion mentioned in subsection (3) may not be conducted without also explaining and discussing the matters mentioned in subsection (4).

Amendment 425, in clause 4, page 2, line 31, at end insert—

“(4A) Where a person indicates to a registered medical practitioner their wish to seek assistance to end their own life in accordance with this Act, they must be referred to a multidisciplinary team to explore options for relevant care and support.

(4B) The Secretary of State may by regulations specify the requirements for the multidisciplinary team under subsection (4A).

(4C) The regulations must include a requirement for the multidisciplinary team to include all of—

(a) a registered medical practitioner or registered nurse,

(b) a person registered as a social worker in a register maintained by Social Work England or Social Work Wales, and

(c) a practising psychiatrist registered in one of the psychiatry specialisms.”

Amendment 53, in clause 7, page 4, line 8, at end insert—

“(ca) has relevant and available palliative care options.”

This amendment would mean that someone is only eligible for assistance in ending their own life under this Act if they have relevant and available palliative care options.

Amendment 54, in clause 7, page 4, line 17, leave out “(g)” and insert “(h)”.

This amendment is consequential on Amendment 53.

Amendment 426, in clause 7, page 4, line 26, at end insert—

“(4) The coordinating doctor may not take the steps set out in subsection (3) unless they receive confirmation from a multidisciplinary team that the person has had a meeting with that multidisciplinary team as specified in section 4.”

Amendment 286, in clause 9, page 5, line 36, leave out paragraphs (a) to (c) and insert—

“(a) the person’s diagnosis and prognosis, in consultation with a specialist in the relevant illness, disease or medical condition,

(b) any treatment available and the likely effect of it, in consultation with a specialist in the provision of such treatment,

(c) any palliative, hospice or other care, including symptom management and psychological support, in consultation with a specialist in palliative care.”

This amendment ensures that a specialist carries out the assessment of the patient, the treatment options available and the palliative care options available, since these may not be known to a doctor coordinating an assisted death.

Amendment 424, in clause 40, page 23, line 37, at end insert—

“‘preliminary discussion’ means a discussion of a kind mentioned in section 4(3);”.

This is a drafting change.

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[The Chair]

I suggest that you take the advice of the House on that, because what people say outside of the Committee is beyond my jurisdiction. The House has rules, and if those rules are breached, it is up to any hon. Member, including the Member himself, to raise that with the appropriate authorities.

[Danny Kruger]

On that ruling, Mr Efford, I concur that it is not your job to police social media but I respect the point made by my right hon. Friend the Member for North West Hampshire: it is important that we accurately reflect the debates held in this place. For my part, I will not be commenting externally that the House has disregarded people with Down’s syndrome. I respect and appreciate the point made by the Minister and the hon. Member for Spen Valley that there will be an effort to engage with the Down’s syndrome community in the drafting of further consultation and guidance. Nevertheless, the Committee did just choose to reject an amendment that would have required the Government to put into the Bill the protections specified by the Down’s syndrome community and my right hon. Friend the Member for East Hampshire. I will be making that point, but I undertake to do so accurately and fairly.

I turn to amendment 342 and the other amendments in this group. There is a lot to discuss, and I will get through it as fast as I can. We are talking about the “initial discussion” and the “preliminary discussion”. It might be helpful to clarify those terms, because clause 4 is confusing. The clause refers to an “initial discussion”, which is when the doctor, or maybe the patient, raises the idea—it is unclear who will do that and how. The initial discussion does not actually need to take place at all, but if it does, then, according to the Bill, a preliminary discussion “may” be held, at which the topic is discussed in more detail and there is discussion of the requirements that need to be met, and so on.

I welcome amendment 342, which was tabled some time ago by the hon. Member for Shipley (Anna Dixon). It provides that if an initial discussion is held—that is to say, if the topic is raised as an option and the patient indicates their wish for an assisted death—then a preliminary discussion must also be held. Over the weekend the hon. Member for Spen Valley tabled amendment 419. That would amend clause 6, but I mention it here because it reaches back to clause 4 by stating that the co-ordinating doctor must either hold a preliminary discussion or see evidence that one has been held at an earlier stage.

I was alarmed that the Bill initially envisaged a situation in which someone could turn up to an assisted dying provider and pay their registration and administration fees, and the only thing the co-ordinating doctor would be required to do is check their photo ID. It is extraordinary that that was viewed as acceptable in the first place, so I welcome the tabling of amendment 419. My difficulty is that it leaves clause 4 quite vague and optional about whether a preliminary discussion would take place, and then it applies a retrospective compulsion at a later stage. It allows the preliminary discussion to be not very preliminary at all, because it might take place quite some time later, at the point the co-ordinating doctor is witnessing the first declaration. It could be weeks or months after the process has started, once the patient has found a doctor willing to do the assessment and the paperwork for assisted dying. Rather than tacking the provision on to clause 6, which deals with proof of identity for the witnessing of the declaration later on, let us have it where it is needed—let us insist on it here at the outset of the process.

What should the preliminary discussion consist of? I will speak now to amendment 183 in the name of the hon. Member for Spen Valley, and amendments 343 and 344 in the name of the hon. Member for Shipley. In her explanatory statement to amendment 183, the hon. Member for Spen Valley suggests that it “emphasises” that the preliminary discussion must include a discussion of palliative care options. That is, I am afraid to say, repetitive of the sentence at the start of clause 4(4), which says that the practitioner conducting a preliminary discussion must discuss all the options listed. In the words of my right hon. Friend the Member for North West Hampshire, this is embroidery of the Bill—it is fine lacework, unrelated to the job of the clause itself. The statement in the clause that the doctor must discuss palliative care is, of course, already the law under the Montgomery judgment. There is a genuine obligation on the doctor to discuss all the options that the patient has, which will obviously include palliative care.

I welcome the amendments tabled by the hon. Member for Shipley, which would require the doctor to be clear about the uncertainties of the prognosis and the risks and benefits of the various treatment options. That is absolutely right. That is not embroidery. As a result, patients will make better-informed decisions with full awareness of what is known and, crucially, what is unknown about their prognosis. A requirement in the Bill leaves no room for doubt.

I am concerned by the suggestion that has been repeatedly made that adding obligations for doctors to do their job as guidance currently states is somehow unnecessary or harmful. Indeed, the selective approach of referencing only some elements of GMC guidance in the Bill increases legal uncertainty. Clauses 7 and 9 include only some elements of GMC guidance on the information that doctors must give to patients. There are five areas that the GMC says information should usually include, but the Bill omits

“uncertainties about the diagnosis or prognosis, including options for further investigation”

and

“the potential benefits, risks of harm, uncertainties”

and so on. The guidance explains:

“By ‘harm’ we mean any potential negative outcome, including a side effect”.

Those are quotes from the GMC guidance that are not reflected in the Bill at the moment. Some parts are, but some are not. I think the fact that some guidance has been excluded would be treated as legally significant by the courts. I would be interested to know why the hon. Member for Spen Valley takes the position that those aspects of the guidance should be excluded, and whether she feels that uncertainties and risks of harm are not relevant to the discussion that doctors should have.

We are often told that this Bill is the safest in the world. Other jurisdictions that have inspired the Bill specify in more detail what informed consent should consist of. In Oregon, the doctor must cover the potential risks, the probable result of taking the medication and the feasible alternatives. In Victoria, the doctor is required to discuss the potential risks—in fact there is a whole series of obligations on them. Interestingly, they are encouraged to inform the registered medical practitioner, so to tell the patient’s doctor what is happening, if they do not know already. South Australia specifies all the same things. In his amendment 50, my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer) is trying to mirror precisely that. That is exactly what should be in the Bill, and yet we are told that it is the safest legislation in the world.

Other amendments in this group address who should do the preliminary discussion or referral, and who else should be involved. Amendment 108 in the name of the hon. Member for East Thanet (Ms Billington), which would require the doctor to offer a referral to a palliative care specialist, is very helpful. It is significant that the Committee has already voted not to mandate referral to a palliative care practitioner at the early stage—that fork in the road that we debated earlier—so people will be facilitated down one fork in the road only. This is an opportunity to ensure that there is in fact a referral to a palliative care specialist.

[Kim Leadbeater]

I just want to let the hon. Gentleman and the Committee know that I met my hon. Friend the Member for East Thanet last night, and I am delighted to support her amendment 108.

[Danny Kruger]

I am very pleased to hear that. That is very encouraging news, because I have been concerned that the hon. Lady was resting her case on amendments to clause 12, which would not require a palliative care specialist. I am grateful to her for intervening to inform us of that.

Nevertheless, we need to go further. The amendments in the name of the hon. Member for York Central (Rachael Maskell) would require that a specialist, rather than just a GP, leads the initial assessment. The fact is that despite their enormous range of expertise, general practitioners are not qualified or confident in making prognoses of terminal illness. The written evidence from the Association for Palliative Medicine of Great Britain and Ireland cited a 2021 paper showing that over half of GPs were not consistent in how they applied their predictions to different patients. It is important that specialists in the relevant conditions should be involved in these assessments so that patients receive expert input with a lower risk of error.

It is significant that, during the Second Reading debate on 29 November, the House was unanimous in its appreciation of, and praise for, palliative care specialists. It seems strange that their expertise should not be considered essential to a terminally ill person’s consideration for an assisted death. When we look at other countries, we see that it is not an exceptional safeguard. South Australia’s Voluntary Assisted Dying Act 2021 specifies:

“Either the coordinating medical practitioner or each consulting medical practitioner must have relevant expertise and experience in the disease, illness or medical condition”—

we are not using that any more—

“expected to cause the death of the person being assessed.”

I urge the Committee to reflect on the South Australia model, which is good in this regard.

I turn to amendment 53, in the name of my hon. Friend the Member for Runnymede and Weybridge, and amendment 275, in the name of the hon. Member for Sunderland Central. The Bill currently requires doctors to discuss “available” palliative care options, but that may limit what patients are told. Amendment 275 would provide that patients should be informed of “all appropriate” palliative care alternatives, even if they are not readily available in their local area. We do not want patients choosing assisted dying simply because of unequal geographic provision of palliative care making them unaware of alternatives that could improve their quality of life.

I would go even further in support of amendment 53, which hits the nail on the head. Fundamentally, we have always said that assisted dying should be available only to people who palliative care cannot help. That is what amendment 53 entails: it states that assisted dying should be available only for people for whom the relevant palliative care is actually an option and, if they decline it, that would be their choice.

Finally, I will speak to amendments 425 and 426 in my name, which express the need for a proper multidisciplinary team at the right stage of the assisted dying process. The hon. Member for Spen Valley has emphasised the importance of multidisciplinary teams, and I welcome everything she said. It is very good to get her agreement, through the amendments that she has tabled, that two doctors working alone are not enough to protect and support every patient. I welcome that recognition.

Amendments to clause 12 attempt to fill this gap by introducing the expertise of a psychiatrist and a social worker, but they do not fulfil the role of a multidisciplinary panel. Rachel Clarke, one of the witnesses who told us to consider multidisciplinary assessments, has written subsequent to the amendments being tabled: “A ‘judge plus’ panel”—there will not actually be a judge, so perhaps we should call it a “lawyer plus” panel—

“is not an MDT…the panel’s scrutiny comes only at the end of the process, not at the beginning, when a patient first asks for the intervention of assisted dying. Yet this is a moment of peak vulnerability.”

We will get on to the question of whether a judicial panel should replace a High Court judge, but I emphasise very strongly that the introduction of this process is not the equivalent of having a proper multidisciplinary team considering the application for an assisted death at the appropriate moment.

As the Association for Palliative Medicine said last week, the Bill

“does not align with the standard multi-professional team…decision-making process used across the health service.”

It said that the panel is too distant from the patient and comes too late in the process. It said that the Bill would be stronger if the initial assessments were

“carried within a multi-professional team model”.

It is at the stage we are debating here—in the initial assessments—that the MDT needs to apply. For the record, if it has not been properly noted before, I also state that when the hon. Member for Spen Valley quoted Dr Sarah Cox on the importance of multidisciplinary teams, Dr Cox was not endorsing clause 12, but explicitly arguing for earlier introduction of the multidisciplinary process.

[Kim Leadbeater]

To be clear on the multidisciplinary approach, the point that I was making in that contribution was that that happens already. We are misrepresenting what goes on in current practice with terminally ill patients if we say that there is not a multidisciplinary approach, as indeed various witnesses told us. It is important to acknowledge that.

[Danny Kruger]

The hon. Lady is absolutely right that that is what witnesses told us, but we need to ensure that it happens in all cases; the purpose of these amendments is to ensure that good practice is universal. In the case of assisted dying, bad practice would be terrible. Of course, good doctors seek the guidance of others and do not operate in isolation, but the Bill would allow them to do so. It is important to ensure that the system lives up to the good practice that she refers to.

Committee members will be glad to hear that I am not going to rehearse the arguments about capacity and coercion, but those concerns are why it is important to have a multidisciplinary team at an early stage. The Committee has rejected all attempts to strengthen the capacity test, but it could at least allow a psychiatrist to have an earlier role in the process of checking for capacity. We heard from multiple witnesses about the importance of doing that, and that is what National Institute for Health and Care Excellence guidance states. As the hon. Lady said, it is good practice, so as Professor House said in his evidence to us, it would not be “a terribly radical thing” to do it.

On coercion, as the social worker Jess Carrington wrote to us:

“The only people who are comprehensively trained to recognise signs of abuse, in particular, coercive control, are social workers.”

According to research by Dr David Ross, doctors suspect less than 5% of cases of elder abuse. I will not rehearse the arguments around coercion, but I hope that the Committee will note that the only way—or the best way; it will not be foolproof—to ensure that coercion is spotted is by having a social worker at the very beginning of the process.

I think that is enough from me, Mr Efford—I am sure you agree.

[Sean Woodcock (Banbury) (Lab)]

I rise to speak to amendments 108, 343 and 344. I am delighted that the promoter of the Bill, my hon. Friend the Member for Spen Valley, has said that she accepts amendment 108, which was tabled by my hon. Friend the Member for East Thanet. It would require a doctor who was having an initial conversation with a person about assisted dying to “offer” to refer them to a palliative medical specialist. That would give the patient a chance to discuss end of life matters in depth with somebody who has the necessary expertise.

We have spent much time in previous sittings on palliative care options, and there was some understandable concern about removing autonomy from those looking for assisted dying. I hope that amendment 108 strips away that concern, because it is about offering, not mandating, more information. When we are talking about autonomy, I think that all Committee members would agree that anybody making an autonomous choice could only benefit from more information, rather than suffer as a result of it.

The Bill says that when a doctor has an initial conversation with a person about assisted dying, they should explain and discuss

“any available palliative, hospice or other care, including symptom management and psychological support.”

The amendment aims to ensure that the patient has access to the best available information to make a decision about what they do next. It would act as a safeguard to prevent people from choosing assisted dying because they did not have a chance to have a thorough and accurate discussion about the care options available to them.

As I said, several people were concerned about autonomy, and providing people with the opportunity to meet a specialist. The written evidence from Hospice UK explains that there are currently wide misunderstandings about hospice care at societal level. It says:

“Implementation of assisted dying without care given to public awareness about palliative care is likely to worsen individuals’ ability to make decisions regarding their end of life. People will need access to information about the services and support available to them.”

That reminds the Committee that terminally ill people at the end of their life often may not know the options available to them. I am sure that every Member in the room wants to avoid that situation, and the option of a discussion with a specialist aims to ease some of that fear and provide accurate information.

In order to make palliative and hospice care a genuine choice, it is important that patients with concerns are able to speak to someone who can answer all their questions and offer accurate information. Marie Curie’s written evidence says:

“There must be clear recognition within the Terminally Ill Adults (End of Life) Bill that genuine choice at the end of life cannot exist unless dying people are able to choose to receive high quality palliative and end of life care”.

Unfortunately, we know that the state of palliative care in this country is not yet of evenly accessible quality. The amendment would not solve that problem—there is quite a lot of work to do in that regard—but it would at least improve the Bill. It would give every patient the option of a discussion about palliative medicine and would make some ground on access. We all want to ensure that those with terminal illnesses are given good support and confidence in their decision at the end of their lives. Amendment 108 would do that, and would give people the opportunity of a real, informed choice, which is why I am delighted that the Bill’s promoter, my hon. Friend the Member for Spen Valley, has agreed to it.

My hon. Friend the Member for Shipley, who tabled amendments 343 and 344, has a distinguished record in policymaking in health and social care. She served as chief analyst and director of quality and strategy at the Department of Health. Both amendments are very thoughtful, and we would do well to adopt them. It would be helpful to explain what they would do before I set out why I think that hon. Members should vote for them. Amendment 343 would change clause 4(4), on page 2, which reads:

“If a registered medical practitioner conducts such a preliminary discussion with a person, the practitioner must explain to and discuss with that person—

(a) the person’s diagnosis and prognosis”.

If the amendment were made, subsection (4)(a), on line 28, would go on to read

“, including any relevant probabilities and uncertainties surrounding the person’s diagnosis and prognosis.”

Amendment 344 would change paragraph (b) on the next line, which says that the doctor must discuss with the patient

“any treatment available and the likely effect of it”.

If the amendment were made, paragraph (b) would go on to read

“, including the risks and benefits of such treatment, potential side effects, and the impact of the treatment on the person’s quality and length of life.”

Like amendment 108, amendments 343 and 344 are both intended to improve the quality of information that patients receive when they have their initial discussion about assisted dying. The first amendment addresses what many of the expert witnesses have identified as a key problem with the Bill. Clause 2 requires a doctor to have prognosed that

“the person’s death…can reasonably be expected within 6 months.”

I will not go over the various arguments that we have already had in Committee about that, but many of the very senior doctors who gave evidence to the Committee have said that it is extremely hard for medical professionals to give a prognosis with such assurance.

The Marie Curie palliative care research department at University College London also submitted written evidence, numbered TIAB 39. Those experts said:

“The Bill’s requirement for a prognosis of death within 6 months could lead to significant errors, where individuals either receive assisted dying prematurely or are denied it when desired. The variability in prognostic accuracy, especially for non-cancer illnesses, may exacerbate inequities in patient care.”

They went on to say:

“We also question how the term “reasonably” will be interpreted by doctors, and this is likely to vary between doctors, but also by the same doctor with different patients”.

The Marie Curie palliative care research department also said that predicting someone’s death “too soon” can result in early palliative care, and that such early care is

“not a harm in the same sense as might be implied in the context of assisted dying.”

--- Later in debate ---

[Dr Opher]

As far as I see, under the Bill there is an initial discussion when a patient who is requesting assisted dying goes to see a medical practitioner. It does not specify what type of practitioner, which is good because it means they can ask either the oncologist or the general practitioner. That initial discussion is with a doctor, and then the doctor will refer for the first declaration, or they may do the first declaration themselves. That is how the Bill is set out, but the general practitioner will have had specialist opinions on the patient. They would not just say, “Well, maybe you’ve got less than six months to live—I don’t really know, but let’s have a guess.” This will be based on informed information from a specialist.

[Danny Kruger]

I do not want to labour the point, but does the hon. Member not acknowledge the Bill does not require that at the moment? He is saying that it will happen. Why will it happen—just because the doctors do their job well? Does he recognise there is no obligation to have this wide consultation with other specialists under the Bill? The doctor could do just as he has described and take a decision on their own.

[Dr Opher]

Again, this is a really interesting part of the Bill. If a doctor is routinely giving prognoses of six months where that is not appropriate, they will come up against the General Medical Council for being poor doctors, and the regulation around poor doctors is within the medical profession. If it is proven that someone has given a diagnosis that they cannot back up in any way, they would then be subject to their own professional standards. That is one of the things here: we cannot go through this Bill and specify the medical requirements at every stage, because that comes under a different format, which is called the General Medical Council. If someone has given a prognosis of six months or less, and if that is clearly inaccurate and would be contested by other doctors, they would be brought before the General Medical Council.

--- Later in debate ---

[Dr Opher]

Again, I bring my hon. Friend back to the fact that this is a Bill in law, and what we have to guide us as doctors is the General Medical Council, which sets standards for doctors. That is how we do it. If we are hemmed in by legal matters, we can break the law without being aware of it, if we are not careful. If too many legal parameters are set around medical consultations, the patient will get less good care because the doctor will not be free to offer it. I can see that my hon. Friend does not agree with that, but it is the case.

[Danny Kruger]

The hon. Gentleman is praying in aid the General Medical Council as if it is some sort of effective backstop. He says that the guidance does not need to be in the Bill because it is there hovering over doctors anyway, but the Bill makes explicit reference to GMC guidance—some of it is in there. If he objects to our suggestion to include the full GMC guidance in the communication that should be had, why does he support the presence of some of the guidance that doctors should give? The Bill does not include what the GMC requires: uncertainties about diagnosis or prognosis. Why not include the full GMC guidance in the Bill, seeing as we are including some of it already?

[Dr Opher]

I just do not think it will strengthen the Bill. I thank you for your intervention. It is a moot point.

--- Later in debate ---

My hon. Friend the Member for Stroud made some valid points. I do not feel that amendment 285 undermines what he said; I think his points actually strengthen the argument for the amendment, which would put the detail on the face of the Bill and would clarify a great deal. I do not expect it to tie us up in legal proceedings or to bring the fear of legal proceedings to doctors. As he said, the fear of being pulled up by the General Medical Council if they do something wrong already exists for doctors every day.

[Danny Kruger]

I am afraid the situation is even worse, because the fact is that under the Bill they will not be liable for mistakes made in pursuit of the scheme set out in the Bill. They will be exempt. They are indemnified against civil liabilities for malpractice in the course of their job. It is only guidance, and GMC guidance specifies that breaking the guidance is not itself necessarily considered a serious matter. The provisions are not strong enough at all.

[Naz Shah]

The hon. Member makes a valid point. That brings us to a very important question: do we wait for something to have happened? In this instance, people will have died.

If we were considering kidneys, for example, and the issue of consent, it would require somebody independent. It needs a specialist. We come back to the point about specialisms: whether they relate to diagnosis, coercion, the care pathway, palliative care or the drugs that bring a person’s life to an end, which we will discuss later, these are specialisms. I know that later my hon. Friend the Member for Spen Valley will speak to her amendment about the panel, which is intended to require expertise. That is what amendment 285 speaks to, and I hope hon. Members will support it.

Amendment 286 would set out the requirements for the co-ordinating doctor and ensure that the standards are upheld throughout the process of assessment, so that the patient and clinician have the highest levels of advice available. Even though the co-ordinating doctor might already have sought the advice of specialists as part of their assessment, the purpose of having an independent doctor is to assess the patient without preconceptions influenced by the co-ordinating doctor’s decision-making process. It is therefore important for the clinician to have access to the same level of advice to inform their clinical decision making.

In medical practice, should a second opinion be sought, the person providing that second opinion might consult a range of sources to establish an opinion. This measure would therefore be in line with normal medical practice. I hope that hon. Members will support the amendments.

--- Later in debate ---

Amendment 183 would enable us to mirror that provision in the Bill. It would achieve the strengthening that I sought on Second Reading, by ensuring that a preliminary discussion must include explanation and discussion of the person’s diagnosis, prognosis, any treatment available and its likely effect, as well as all appropriate palliative, hospice or other care, including symptom management and psychological support.

[Danny Kruger]

Will the hon. Lady give way?

Terminally Ill Adults (End of Life) Bill (Seventeenth sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[Danny Kruger (East Wiltshire) (Con)]

On a point of order, Mr Dowd. My understanding is that we are planning to sit a bit later today, which is fine by me. I wanted clarity from you that the Committee has no hard deadline—that although the intention is that Report stage will take place on 25 April, if the Committee wished to go further, it could. I was a little concerned by some of the remarks made in this morning’s sitting about people being conscious of time; there is a sense of being asked to speed up as we go. Am I right in saying that the Committee can take as long as it needs to, and that in fact it should, to debate this very important matter?

[The Chair]

The short answer is yes. I think Members will inevitably deal with this in as sensitive and conciliatory fashion as possible, notwithstanding that point.

Clause 4

Initial discussions with registered medical practitioners

Amendment proposed (this day): 342, in clause 4, page 2, line 23, leave out

“may (but is not required to)”

and insert “must”.—(Danny Kruger.)

This amendment would strengthen the requirement for a registered medical practitioner to conduct a preliminary discussion.

Question again proposed, That the amendment be made.

--- Later in debate ---

[Kim Leadbeater (Spen Valley) (Lab)]

I will try to keep my comments as brief as possible because we have had another very thorough discussion. First, my amendment 424 is, as the Minister said, a simple drafting change in clause 40 that confirms that “preliminary discussion” means a discussion as per clause 4(3).

Amendment 275 from my hon. Friend the Member for Sunderland Central would, in many circumstances, broaden the scope of the conversation that the doctor would have with the patient, and I am happy to support it.

I am also happy to support the very sensible amendment 108 from my hon. Friend the Member for East Thanet (Ms Billington). It is perfectly acceptable to ask the doctor to offer to refer the patient to a specialist, as they would probably do in most cases anyway, but the amendment is for clarity.

I refer colleagues to the comprehensive comments on my amendment 183 earlier in proceedings, and also to the support of the British Medical Association. Following Second Reading, I listened carefully to Members’ concerns about the possibility of doctors only discussing assisted dying with patients. Even though the Bill states that that cannot be the case, for the avoidance of any doubt the amendment emphasises that the initial discussion mentioned in clause 4(3) may not be conducted without also explaining and discussing the matters mentioned in subsection (4). Accordingly, such a preliminary discussion may not be conducted in isolation from an explanation of and discussion about the matters mentioned in paragraphs (a) to (c) of that subsection—that is, doctors cannot discuss the option of assisted dying in isolation but only in conjunction with discussion about all other available and appropriate treatment.

Indeed, Andrew Green of the BMA told us that

“some patients find it very difficult to bring up sensitive subjects with their doctors, even when those are the most important thing on their mind.”

He asked us to

“please do not pass legislation that makes it harder for doctors to understand their patients.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 42, Q24.]

That concludes my remarks.

[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment proposed: 270, in clause 4, page 2, line 25, at end insert—

“(3A) Before conducting a preliminary discussion under subsection (2) the registered medical practitioner must ensure that the person has no remediable suicide risk factors which pose a significant risk to their life.”—(Danny Kruger.)

This amendment requires that the doctor ensures that there are no remediable suicide risk factors before proceeding to the initial discussion about assisted dying.

Question put, That the amendment be made.

--- Later in debate ---

This amendment emphasises that the initial discussion mentioned in subsection (3) may not be conducted without also explaining and discussing the matters mentioned in subsection (4).

[Danny Kruger]

I beg to move amendment 71, in clause 4, page 2, line 31, at end insert—

“(4A) The practitioner must, following the preliminary discussion under subsection (3), refer that person to the Assisted Dying Agency if the person asks them to do so.”

This amendment is consequential on NC4 and would establish a pathway by which a person is referred to the Assisted Dying Agency.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 72, in clause 5, page 3, line 16, leave out paragraph (b) and insert—

“(b) has been assigned to the person by the Assisted Dying Agency,”

This amendment is consequential on NC4 and provides that the coordinating doctor must have been assigned to the person by the Assisted Dying Agency.

Amendment 73, in clause 7, page 4, line 21, leave out paragraphs (b) and (c) and insert—

“(b) provide the person who was assessed and the Assisted Dying Agency with a copy of the statement.

(3A) Upon receipt of the statement specified in subsection (3)(a), the Assisted Dying Agency must assign to the person, as soon as practicable, another registered medical practitioner who meets the requirements of section 8(6) for the second assessment (‘the independent doctor’).”

This amendment is consequential on NC4 and would require the coordinating doctor to send a copy of their statement to the Assisted Dying Agency. That Agency must then to assign an “independent doctor” to the person.

Amendment 75, in clause 8, page 5, line 9, leave out “coordinating doctor” and insert “Assisted Dying Agency”.

This amendment is consequential on NC4.

Amendment 74, in clause 8, page 5, line 16, at end insert—

“(ba) has been assigned to the person by the Assisted Dying Agency,”.

This amendment is consequential on NC4 and provides that the independent doctor must have been assigned to the person by the Assisted Dying Agency.

Amendment 76, in clause 9, page 6, line 14, leave out paragraph (e).

This amendment is consequential on NC4.

Amendment 77, in clause 11, page 7, line 18, after “appointment,” insert

“by the Assisted Dying Agency”.

This amendment is consequential on NC4.

Amendment 78, in clause 14, page 10, line 7, leave out from “person)” to end of line 12 and insert “the Assisted Dying Agency”.

This amendment is consequential on NC4.

Amendment 79, in clause 16, page 11, line 18, leave out subsections (2) and (3) and insert—

“(1A) The Assisted Dying Agency must, as soon as practicably possible, record the making of the statement or declaration.”

This amendment is consequential on NC4.

Amendment 80, in clause 17, page 11, line 36, leave out subsections (2) and (3) and insert—

“(1A) The Assisted Dying Agency must record the cancellation.”

This amendment is consequential on NC4.

New clause 4—Assisted Dying Agency—

“(1) There shall be a body known as the Assisted Dying Agency (‘The Agency’).

(2) The purpose of the body is to coordinate requests from people to be considered for assisted dying, including assigning, at the appropriate junctures, a coordinating doctor and independent doctor for a person seeking assistance to end their own life.

(3) Where a person has previously been referred to the Agency, no future referral relating to that person can be proceeded with by the Agency unless it considers there has been a material change in the person’s circumstances.

(4) The Secretary of State must make regulations setting out—

(a) the staffing and remuneration of such staff,

(b) the procedures of the Agency, and

(c) the means by which the Agency can pay coordinating doctors and independent doctors for services rendered under this Act.

(5) The Agency’s expenditure is to be paid out of money provided for by Parliament.

(6) The Agency must, for each financial year, prepare accounts in accordance with directions given to it by the Treasury.

(7) The Agency’s chief executive is its accounting officer.

(8) As soon as reasonably practicable after the end of each financial year, the Agency must prepare a report about the performance of its functions during that year and lay that report before both Houses of Parliament.

(9) Regulations under subsection (4) are subject to the affirmative procedure.”

This new clause would create a new body that was principally responsible for coordinating and recording statements and declarations in relation to a person’s request for assistance to end their own life.

--- Later in debate ---

[Danny Kruger]

Although these provisions may seem irrelevant to the Bill—I do not think any of us wishes to see the creation of an assisted dying agency—I am nevertheless grateful to my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer) for tabling them. He is playing his usual role of keeping us honest.

It is extraordinary that nowhere does the Bill lay out exactly how the assisted dying service would be delivered—whether it would be an NHS service, a private service or some mix of the two. I am therefore grateful to my hon. Friend for being clear in his suggestion that it should be a non-NHS service and that, if we are to pass this law, we should establish a bespoke agency for the explicit purpose of delivering that service. It is a rather macabre but logical way of delivering on the proposal in the Bill.

The fact is that many doctors, faced with the prospect of being asked to participate in assisted dying, have expressed their preference for it to be delivered outside the NHS. In its written evidence, the British Medical Association, which has been cited a number of times today, says:

“There is nothing in the Bill about how an assisted dying service might be delivered, although the possibility of a separate service is mentioned in the explanatory notes.”

The BMA’s view is that assisted dying

“should not be part of the standard role of doctors or integrated into existing care pathways”.

I stress that point, because it has often been suggested in the course of debate that the way assisted dying will work will be as part of a holistic range of options—pretty indistinguishable from palliative care or other treatment options put before patients. The BMA is clear that assisted dying

“is not something that a doctor can just add to their usual role.”

The Royal College of General Practitioners has also pointed out in evidence that the shape of the service is not set out in the Bill.

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

On a point of order, Mr Dowd. In his opening sentence, my hon. Friend said that none of us wanted to see the creation of an assisted dying agency. My interpretation of our speaking to a particular amendment is that we have to address what it intends to do in the Bill. My hon. Friend said that he does not want what the amendment intends and that he is speaking more generally about the delivery of the service. Could we have your guidance as to whether that is in order? One of our problems is that we are having very expansive debates, and previous Chairs have sought to keep everyone in order. I am anxious that my hon. Friend does not exhaust himself by straying from the central point in the amendment.

[The Chair]

The fact of the matter is that the hon. Member does not have to agree with the amendment, so he is perfectly entitled to speak in that regard.

[Danny Kruger]

I am grateful to you, Mr Dowd, and to my right hon. Friend for his concern for my welfare, which is much appreciated. However, he will be relieved to know that I have plenty of energy and can keep going.

To speak seriously, it is very germane to the Bill that the amendments are considered. As I was explaining, GPs and other medical practitioners have been concerned about the absence from the Bill of clauses to specify the delivery of the service, so I am grateful that we have this opportunity to discuss that and to hear from the Minister and the sponsor how they imagine the Bill would operate and whether it would, indeed, be appropriate to establish some kind of agency along the lines proposed. The reason I object to an assisted dying agency is that I object to assisted dying, but I see the logic of the proposal if we are to proceed with the principle of the Bill.

It is extraordinary that this crucial question is not set out. In his evidence to us, Chris Whitty said rather airily that it was for Parliament to decide how the service should be delivered. I would stress that most medics involved, particularly in palliative care and care for people at the end of life, are very hostile personally to the suggestion that they should participate in assisted dying. The BMA’s 2020 survey of its members found that 76% of palliative medicine doctors would be unwilling to participate if assisted dying were legalised. The Royal College of Physicians 2019 members’ poll found that 84% were opposed.

[Kit Malthouse]

This is not in order; it has nothing to do with the amendment.

--- Later in debate ---

[Kit Malthouse]

I am grateful, Mr Dowd.

[Danny Kruger]

I, too, am grateful, Mr Dowd. I stress that I am discussing the suggestion in the amendment that assisted dying be taken out of the NHS and not be part of the normal pathways doctors are invited to participate in. It strikes me as relevant that most doctors, were the law to be passed, would wish for something along the lines of the amendment to be included.

We do not know exactly how that would work. We know that it could potentially be private, according to the scheme set out in the amendment, or it could be within the NHS. We know from the references in clause 40 that private provision is envisaged, because of the talk of reasonable remuneration for the provision of services. So it would be outside the normal service expectation of medical professionals employed by the NHS; indeed, we know that it could be a lucrative market.

[Sojan Joseph]

Does the hon. Member think that, if we bring in an agency from outside the NHS—from the private sector—this will become like a business?

[Danny Kruger]

The hon. Gentleman is absolutely right. The opportunity is there in the Bill for private businesses to be established to deliver assisted dying services. Indeed, it would be quite a lucrative money-making enterprise. Estimates have been given of between 5,000 and 17,000 assisted deaths per year, depending on how they are arrived at. If the charges employed by Dignitas—which is in a sense the model being proposed here—are anything to go by, it could be in the region of £5,000 to £10,000 per patient. Even a small proportion of that would be significant—a multimillion-pound business would be possible under the Bill. Advertising would also probably be possible; we saw TfL suggest that the Dignity in Dying adverts in the tube before Second Reading were compliant. There is no prohibition in the Bill on advertising or on people making money from it.

However, the Bill also specifies that this would be a state-protected service, so if it were to be a private enterprise, it would have all sorts of state protections that would not normally apply to private providers of anything. Under clause 25, the providers would be exempt from any civil liability for providing assistance under the Bill. Under clause 29, a death would be exempt from investigation under the Coroners and Justice Act 2009. Clause 30 says that a failure to comply with any code of practice

“does not of itself render a person liable to…criminal or civil proceedings”.

The only monitoring that would be done would be undertaken by the voluntary assisted dying commissioner, who is not an independent figure, but the person responsible for setting up the panels that approve the deaths.

[The Chair]

Order. We need to get back to the assisted dying agency. Can the hon. Member keep to that, please?

[Danny Kruger]

I shall—I am winding up now, Mr Dowd. These amendments go to the heart of this great absence—this blank space—in the middle of the Bill, which is how on earth it will be delivered. Who would deliver it, and under what regulation? What would be their terms of engagement? All of that represents quite a scandalous gap in the Bill, and my concern is with that enormous gap.

I want to conclude with a reflection on that lack of clarity. Elizabeth Gardiner, who I understand was the very experienced parliamentary drafter who contributed her time to draft the Bill, talked on the Hansard Society podcast of the opportunity that drafting has to change the law. She noted that if the law

“is a restriction that would curtail the ability of this to be delivered through the National Health Service, the Bill could change that.”

So it has been suggested that the Bill would require changes to the National Health Service Act 1946 to remove what the Hansard Society calls the “duty to protect”.

[The Chair]

Order. The hon. Gentleman heard what I said earlier, and I do not want to reaffirm it, but can we get back to the substance of the assisted dying agency provision, please?

[Danny Kruger]

I have one last point to make, Mr Dowd, which I hope you will regard as in order because, as I said, it goes to the heart of things. At the moment, the Bill does not specify how these things should be done, and Elizabeth Gardiner, the drafter behind it, said on the radio:

“we didn’t have time to go into all the detail of how those regimes work and to make the provision on the face of the Bill. And so there are regulation making powers there, which enable that provision to be set out”—

I believe that that is in clause 32. Enormous Henry VIII powers are being established. I deeply regret the gap in the Bill, and I am grateful to my hon. Friend the Member for Runnymede and Weybridge, who tabled these proposals, for enabling us to have this debate.

[The Chair]

Order. I remind the hon. Member to keep to the issue that we are discussing, because if he or any other Member does not, and goes beyond the scope of what they really should be sticking to, I will take a much less lateral approach in future. I say that gently and with the best intention.

[Kim Leadbeater]

I have nothing to add, other than to agree with the hon. Member for East Wiltshire; I do not think any of us on the Committee are keen on the implementation of the assisted dying agency.

[Danny Kruger]

Will the hon. Member give way?

[The Chair]

Too late.

[Danny Kruger]

I really regret that we have had such a small debate on the enormous question of how on earth assisted dying would actually be delivered. We are leaving it to Ministers, subsequent to the passage of the Bill, to design this service. The clear possibility is that a private enterprise could run the service. It might be an NHS service. The fact that that is unclear in the Bill is shameful, but I am grateful we have had the opportunity to debate the matter, sort of, and I am not going to press the amendment to a vote. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn. 

Amendment proposed: 276, in clause 4, page 2, line 31, at end insert—

“(4A) A medical practitioner must not conduct a preliminary discussion with a person under subsection (3) until a period of 28 days has elapsed, beginning with the day the person had received a diagnosis of the terminal illness.” —(Naz Shah.)

This amendment would mean a doctor could not conduct a preliminary assessment until 28 days from the day the person received a diagnosis of the terminal illness.

--- Later in debate ---

[The Chair]

Before I call Danny Kruger to move amendment 412, I remind Members to keep within scope and to ensure that any points raised are relevant and not repetitive, or I will intervene.

[Danny Kruger]

I beg to move amendment 412, in clause 4, page 2, line 32, leave out subsection (5).

[The Chair]

With this it will be convenient to discuss the following:

Amendment 341, in clause 4, page 2, line 33, leave out from “subsection (3)” to the end of line 36 and insert

“is not required to refer the person to another medical practitioner but must ensure that the person is directed to where they can obtain information and have the preliminary discussion.”

This amendment would provide that a registered medical practitioner who is unable or unwilling to have the preliminary discussion with a person must provide information to the person about where they can have that discussion, but that this need not take the form of a referral.

Amendment 338, in clause 4, page 2, line 34, leave out from “so” to end of line 36 and insert

“direct them to another registered medical practitioner or the independent information and referral service established under section [Independent information and referral service]”.

This amendment, which is linked to NC13, would mean that a registered medical practitioner who was unwilling to have preliminary discussions would direct the person to another registered medical practitioner or an independent information and referral service.

Amendment 287, in clause 4, page 2, line 34, leave out from “practitioner” to end of line 36, and insert

“who is qualified to undertake such a preliminary discussion, and set out palliative medicine options to provide the patient with appropriate end of life care, including referring them to a palliative medicine expert.”

This amendment means that the medical practitioner who is unwilling to have an initial discussion with a person must, both refer them to another registered medical practitioner and set out the palliative care options including referring them to a specialist.

New clause 13—Independent information and referral service—

“(1) The Secretary of State must, by regulations, make provision to establish an independent information and referral service to—

(a) provide information to persons who are, or may be, eligible for assisted dying in accordance with this Act, and

(b) where requested, facilitate the person’s access to assisted dying in accordance with this Act.

(2) Regulations under subsection (1) are subject to the affirmative procedure.”

This new clause would require the Secretary of State to make provision for an independent information and referral service.

[Danny Kruger]

I rise to speak to this important group of amendments, which are all relevant to the duty to refer, whereby a doctor who does not want to advise a patient on assisted dying is obliged to send them to somebody who does. In different ways, we each seek to provide more protections for those medical professionals.

There are two main reasons why doctors may not want the obligation to refer that is in the Bill. The first is the central point that this is not a healthcare treatment, as is traditionally understood. Assisted dying does not address the condition or treat the illness; it treats only the symptoms, in the sense that it obliterates the existence of the patient. Like the advert for bleach says, it “kills all known germs”—it kills every experience that the patient has or could have. It is not part of the range of treatments that a doctor should have to offer, as clause 4(1) makes clear.

That point similarly relates to the question of referring to somebody who can offer that discussion. I suggest that the act of referring is an act of endorsement, just as offering the intervention itself is an act of endorsement. Dr Green from the BMA made it clear during oral evidence that the BMA does not like the word “refer”, as it implies assent to the option that is being offered. Indeed, the hon. Member for Spen Valley, in conversation with Dr Green during evidence, accepted that the word “refer” was “not…quite right”, as she put it, because it has the particular implication and expectation of a form of endorsement.

We have heard the same opinion from multiple witnesses in written and oral evidence to the Committee, particularly from Muslim medical professionals and their trade body. Those representing pharmacists also expressed significant concern that they might find themselves included in the definition of medical practitioner. The Association of Anaesthetists and the Royal College of Nursing were worried as well. A range of professional bodies and representative organisations share my concern that imposing a duty to refer—an obligation to assist somebody to have an assisted death by finding them a doctor who will conduct the preliminary discussion—is itself a breach of their rights of conscience.

The second reason follows from the first. Doctors may reasonably conclude that being in a position to help with assisted dying puts them in a totally different relationship with their patients. That is why the BMA is so unhappy and has asked for the requirement to be removed. It has an alternative, which some of these amendments also propose. It said:

“We urge the committee to remove the referral requirement and, instead, make it clear that the doctor’s duty is to direct patients to where they can obtain information”.

That is what amendment 341, in the name of my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson), would do. The BMA suggests that

“this should be an official body set up to provide individual information and advice to patients, to which patients could be referred or directed to, or could self-refer.”

My preference would be not to have any obligation on doctors to make any kind of referral, but I respect the aspiration of the amendment, which is to ensure that there is an independent body to give advice that patients can seek out themselves or that they can be advised of, so there is no expectation of a referral to a doctor who can facilitate the assisted death.

The Royal College of General Practitioners is also unhappy about the provision. It suggests that instead of expecting doctors

“to refer directly to a medical practitioner who is ‘willing and able to conduct that discussion’”—

as per the Bill—

“the doctor’s duty would be to direct patients to an official service where they can obtain objective and accurate information”.

I think we should pay heed to the advice of the professionals.

As ever, I would like to refer to the experience of foreign jurisdictions, because we are constantly told that this Bill is the safest in the world. None of the legislation in Australia or New Zealand, or the legislation currently going through in the Isle of Man, puts an obligation to refer on to doctors. Victoria and South Australia’s legislation says that a doctor has the right to refuse to participate in the request for assistance process and to give information about voluntary assisted dying, so there is no duty to refer—not even a duty to provide information.

I conclude with an observation that was submitted to us by Dr David Randall, a consultant nephrologist. It was very telling that he said in written evidence:

“I would not be willing to act in accordance with Section 4(5) of the Bill. I am a doctor in good standing with the GMC, and who has always striven to provide the highest standards of care to patients. Passage of this Bill would place my practice in direct opposition to the criminal law.”

He talks about “moral injury”, which is a very important principle. We have an obligation to protect the conscience and human rights of medical professionals.

We are still unclear whether this process will take place within the NHS or outside it. Nevertheless, the obligation to refer in the Bill would be a direct breach of doctors’ rights and would impose a moral injury on them. My preference is to remove clause 4(5) altogether, as that would be consistent with the Abortion Act 1967 and similar legislation on assisted dying in other countries. If we are not prepared to do that, we should at least restrict the obligation and provide more protections, as per the amendments in the names of other hon. Members.

[Rebecca Paul]

I rise to speak in support of amendment 341 in the name of my hon. Friend the Member for Sleaford and North Hykeham. It would provide that a registered medical practitioner who is unable or unwilling to have the preliminary discussion must provide information to the patient about where they can have that discussion, but that need not take the form of a referral.

One of the messages that we heard loud and clear in the evidence sessions was that medical practitioners do not wish to be put under an obligation to refer a patient to another registered medical practitioner by the Bill. “Referral” has a very specific meaning in medicine, and it is that word and the corresponding action required of it that many doctors have an issue with. A referral puts a patient on a pathway, whereas the provision of information merely indicates where such a pathway can be found. During oral evidence, Dr Green said:

“The word ‘referral’, to a doctor, means writing a letter or communicating with another doctor to see, but some doctors would find themselves not able to do that. For that reason, we believe that there should be an information service for the doctor to direct to.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 48, Q41.]

We are well aware that assisted dying is a complex issue and a matter of conscience for many. It is therefore important that we respect the personal views of medical practitioners. One of the points that I have made several times in these proceedings is that assisted dying affects not just the patient but other people participating and supporting. Some medical practitioners will be comfortable with it, but many others will not. It is therefore vital that we recognise their rights and needs, not just the patients’, when formulating this law. If for whatever reason a doctor does not want to refer a patient, they should not have to. Their legal responsibility should be limited to directing the patient to where they can find the relevant information that they need. Doctors should have no further obligation.

--- Later in debate ---

[Kim Leadbeater]

I rise to speak to amendments 341, 338 and 412 together, and I welcome the debate on these important amendments. Choice is one of the key tenets of the Bill, primarily—but not exclusively—for terminally ill adults with a limited time to live. Choice is also very important for medical practitioners, and I am very respectful of, and acknowledge the importance of, conscientious objection for doctors. When it comes to assisted dying, I believe that they should also have choice. Indeed, the Bill is written so that they can choose not to participate in the process for any reason. That is the BMA’s view, and I agree with it.

The BMA has a position of neutrality on assisted dying, and there are a range of views within medical professions, as there are within all groups of people. That is why I have adopted its position of an opt-in model for the purposes of the Bill. Nevertheless, the process must remain patient focused at all times, and that means enabling them to have a discussion on such an important matter. It would not be right to rely on online advice or even the best-designed written materials. As we have already established, doctors are used to having sensitive and compassionate discussions with people who are terminally ill, and there can be no substitute for that. While a doctor may not wish to participate themselves, and I fully respect that, they still have a responsibility towards their patients, and that should include ensuring that they can speak to a properly qualified medical practitioner at such a difficult time.

I understand that the BMA and others would not be comfortable with the word “refer”, which I understand to have a special meaning within medical practice. The GMC guidelines use different language. They talk about where a doctor has a conscientious objection, in which case they are advised that they must make sure that arrangements are made for another suitably qualified colleague to take over their role. The BMA’s guidance says that patients must be able to see another doctor, as appropriate, and that it need not always be a formal procedure. It is not, however, sufficient to simply tell the patient to seek a view elsewhere—I agree completely.

The BMA supports amendment 341, which says that a doctor

“must ensure that the person is directed to where they can obtain information and have the preliminary discussion.”

I am therefore happy to support the amendment today and, if it were to need further adjustment, I am very happy to consider alternatives based on existing best practice. I would be very happy to meet with the hon. Member for Sleaford and North Hykeham, who is herself a doctor, to discuss her thoughts and draw on her considerable medical experience.

[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment made: 341, in clause 4, page 2, line 33, leave out from “subsection (3)” to the end of line 36 and insert

“is not required to refer the person to another medical practitioner but must ensure that the person is directed to where they can obtain information and have the preliminary discussion.”—(Rebecca Paul.)

This amendment would provide that a registered medical practitioner who is unable or unwilling to have the preliminary discussion with a person must provide information to the person about where they can have that discussion, but that this need not take the form of a referral.

[Juliet Campbell]

I beg to move amendment 125, in clause 4, page 2, line 35, leave out from start of line to end of line 36 and insert

“who is on the Register of Assisted Dying Medical Practitioners.”

This amendment provides that only a medical practitioner who is on the Register of Assisted Dying Medical Practitioners as provided for in NC7 would have a person referred to them.

--- Later in debate ---

[The Chair]

At this point, I will not necessarily call Members, including the Minister, unless they particularly want to speak. If Members do wish to speak, will they please bob?

[Danny Kruger]

I think that we are just concluding one of the most important debates that the Committee will have: the debate on clause 4. I welcome the concession from the hon. Member for Spen Valley, particularly her commitment to modify the obligation to refer. That is welcome and will make the Bill a little safer.

In our debates on the clause, there has been clear confusion, as my hon. Friend the Member for Reigate has just mentioned, about the extent to which assisted dying is a healthcare treatment. That speaks to the question of whether there is an obligation on doctors to offer this treatment—as there should be, if it is a treatment that is one of a range of options for which the patient is eligible—or whether it is something that they are not obliged to offer. That confusion, which was present in the Committee’s exchanges, remains. I want to record in hon. Members’ memory the fact that that question was unresolved. In my view, that is extremely unsatisfactory.

Despite some welcome concessions, the Committee has just decided to reject a series of amendments that would have protected both doctors and patients. Most concerningly, we rejected an amendment to give children the right to be protected from the suggestion of an assisted death before they are even eligible for it.

I will conclude by referring to evidence, which I do not believe has been referred to so far in the debate, on the question of how assisted dying is received as a suggestion or offer, particularly by marginalised groups. I was very concerned by the oral evidence that we took from Professor Ahmedzai, who supports assisted dying. In written evidence, he has said explicitly that he especially wants the option to raise assisted dying with

“patients who are poorly educated, ill-informed or seem to be unaware of the option”.

He has explicitly required and requested the opportunity to put it to these disadvantaged, marginalised patients: “poorly-educated, ill-informed” people. Compassion in Dying, the sister organisation to Dignity in Dying, which supports the Bill, makes the same point: that marginalised people will need to be “directly prompted” with the offer.

I am afraid to say that, in rejecting the amendments, the Committee has endorsed the approach that people who are particularly marginalised and disadvantaged need to have this suggestion explicitly made to them. I am astonished that the Committee proposes to proceed on that basis, which completely misunderstands the dynamic of vulnerable people in the face of authority. I am very distressed to find that the Committee thinks that acceptable, and I am very sorry that apparently we are proceeding with the clause. I do not propose to put it to the vote, because the Committee’s will to proceed is fairly clear, but I hope that everybody is fully aware of what they are doing.

--- Later in debate ---

[Danny Kruger]

I am grateful for the points made by my right hon. Friend the Member for North West Hampshire. I will speak briefly to amendments 403 and 404, which would create an expectation that a patient at least addresses the question of whether their family is aware of the decision they are making. In an amendment that has not been selected for debate today, I proposed simply to make that expectation clear.

My personal view is that I do not accept that this is healthcare, and therefore that a doctor would have an obligation to ensure that the next of kin of somebody to whom they are proposing to give lethal drugs is informed. However, in the spirit of the Bill, which is all about autonomy, and in an attempt to be constructive and put forward amendments that might be accepted, I accept that this is a decision for the individual in the same way as a healthcare decision, and that there is therefore no obligation under rules of patient confidentiality and the expectations around healthcare that the family should be informed.

Nevertheless, creating a moment at which the first doctor the patient speaks to gently encourages them to consider telling their family before taking the enormous step of signing the first declaration is appropriate. The amendment would give the patient three options: first, to confirm that they have informed their family of their wish to be provided with assistance to end their life.

[The Chair]

Order. I understand that the hon. Gentleman wants to touch on that amendment, but it has not been chosen today. He is talking about the declaration that the person has informed their family of their decision and taken their opinions into consideration. We are not dealing with that today.

[Danny Kruger]

Nevertheless, amendments 403 and 404 have been selected for debate, and it is those amendments that would effect that declaration in the Bill.

[The Chair]

I ask the hon. Gentleman to take the spirit of what I am saying into account.

[Danny Kruger]

I am grateful to you, Mr Dowd, but I want to explain why these amendments are appropriate to the Bill.

The patient would have the opportunity to declare clearly that they do not have a family. I take the point made by my right hon. Friend the Member for North West Hampshire; it is not always clear what a family is. Nevertheless, if the patient wants to specify that they have no family or do not want to inform their family, the amendments would give them that right. I want to emphasise the importance of this consideration. I recognise that clause 9, which will come later in the process, includes consideration of the family. It states that, in so far as the assessing doctor considers it appropriate, they may advise the patient to inform their family, so there is recognition of that question a little later. My suggestion is that it should come earlier because it needs to take place before the first declaration is signed.

Crucially, we need to consider the wider impact of not considering or involving the family, particularly when children or dependants are involved. The Bill accepts the scenario where a family can find out after the fact—not through any formal notification, they just discover—that their loved one has ended their life with the help of doctors and the state. Families can be badly impacted by an assisted suicide: clinical grief disorders, depression and post-traumatic stress disorder are all harms that can follow from a family member taking an assisted death. It is unethical and irresponsible not to factor that in as we discuss and design the new law.

A parent may choose to end their life under the Bill, but is not required in any way to consider notifying their family. I wonder if the sponsor could clarify what would happen if they were the sole carer of a minor—would there be an obligation for anyone to inform the child that this was happening? One hopes that that would be an extremely rare scenario; nevertheless, it is possible under the Bill.

I want to mention two more groups quickly. In written evidence, a group of anorexia nervosa sufferers and carers said:

“The Bill does not anticipate situations where someone seeks to end their life as a result of cognitive symptoms inherent to the illness, as is the case with AN. For these patients, families would often be needed to advocate for their loved ones and their potential to recover…Without family involvement, patients may make decisions in isolation, potentially influenced by cognitive distortions or feelings of hopelessness inherent to the illness.”

I hope that we do not want to allow that scenario.

Finally, Dr Jamilla Hussain, who we have heard from a few times, said in written evidence that in her

“consultation with structurally disadvantaged ethnic minority groups”—

which include Pakistani, Roma and Black Caribbean community groups, they showed much concern about the exclusion of families. She said:

“it was emphasised that, traditionally, family and community members provide hope and strength when someone feels like life is too much. There is apprehension that such expressions of care and support could be reframed through a medical or legal lens as coercion.”

That is the saddest thing, which was hinted at quite strongly—in fact, stated explicitly—in some of the evidence sessions. It has been suggested that wanting a loved one to live is seen by doctors as a form of coercion that should be resisted; that trying to argue a loved one out of an assisted death is the coercion that we need to guard against and, on that basis, we should not be making any expectation that families are informed. What a tragic thing for us to say. To enable doctors to issue lethal drugs that kill people without their family knowing is an absolutely tragic thing. I beg the Committee to consider what on earth we are doing allowing that.

[The Chair]

I apologise to the Member, who was within his rights to speak to amendments 403 and 404.

--- Later in debate ---

[Dr Neil Shastri-Hurst (Solihull West and Shirley) (Con)]

I rise to set out why—reluctantly—I cannot support amendments 403 and 404, which have been tabled by my hon. Friend the Member for East Wiltshire. It is not because of the principle involved, because my hon. Friend was very clear in setting out the amendments. They would not provide for a prescriptive situation where an individual must tell their family. A range of options are set out, which I anticipate that any sensible and responsible doctor or clinician would take a patient through, encouraging them to involve their family in their decision making.

The issue that I have is around the legal clarity of the wording of the amendments, because under the English and Welsh legal system there is no statutory definition of “family”. There is a concept of family, but the concept of family to me may be very different from that of my neighbour, or from that of someone who lives in another city. For example, for some people stepbrothers, stepsisters and step-parents are very much part of their family; for others, they are not. For some people, unmarried couples with children are a family; for others, they are not. For some people, unmarried couples without children are a family; for others, they are not.

[Danny Kruger]

I take that point; families are difficult to define. Nevertheless, the Bill currently refers to the opportunity for a doctor, or the suggestion that a doctor,

“in so far as the assessing doctor considers it appropriate, advise the person to consider discussing the request with their next of kin and other persons they are close to.”

That is more precise. Would my hon. Friend accept an amendment along the lines that I have proposed, prior to the first declaration, but using the language that is currently in the Bill about

“their next of kin and other persons they are close to”?

[Dr Shastri-Hurst]

That would satisfy me. The reason I say that is because at the moment the wording is too broad and ill-defined. The question is: is this about the closeness and proximity of a relationship? The suggested wording that my hon. Friend just put forward would be much closer to that and much clearer, and more akin with the language of medical registration. When someone turns up in A&E, they are asked to give the name of their next of kin. That defines the closeness, the proximity and the permanency of that relationship.

If my hon. Friend was perhaps to consider withdrawing this amendment and tabling it again in an alternative form, or rewording it, that would certainly be something that I would be open to supporting. I have outlined why, as the amendments currently stand, I cannot support them.

Terminally Ill Adults (End of Life) Bill (Eighteenth sitting)

Danny Kruger Excerpts

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Daniel Francis]

I hear that, and I think my hon. Friend and I are on the same page on many of these matters. I think there were some drafting issues when I discussed amendments with Mencap at an earlier stage.

I commend to the Committee the six amendments in my name in this group: new clause 12 and amendments 336, 337, 335, 340 and amendment (a) to amendment 186.

[Danny Kruger (East Wiltshire) (Con)]

I want to quickly indicate my support for the amendments tabled by the hon. Member for Bexleyheath and Crayford, amendment 290 in the name of the hon. Member for York Central and amendment 20 in the name of the hon. Member for Lowestoft about specific training on domestic abuse and coercive control.

I will now speak to my own amendments, which would require there to be a preliminary discussion before the signing of the first form. At the moment, the Bill allows someone to make the first declaration and state, “I wish to be provided with assistance to end my own life”, without any preparatory discussion about what that entails. It is significant that we heard evidence from Professor House—a professor of old-age psychiatry—that the preferences of the person doing the assessment can bias the capacity assessment. As he explains, we are much more likely to declare that somebody has capacity when they say they want to have the treatment we are offering them, but can we really be sure that the request is freely made and reflects the patient’s wishes?

The fact is, we still do not know from the framework of the Bill how the process would be implemented, but the assessor is likely to be one of a small number of doctors who are willing to do this work on the NHS or somebody who is working for a private provider. Research suggests that the assessing physician’s own personal values and opinions may bias their judgment of a person’s mental capacity. Effectively, research says that the doctor will say that a person has capacity for treatment when he or she wants them to have it or believes that they should. That is significant.

We see from other jurisdictions that the assessment process can quickly become a tick-box exercise in which proper consideration is not given to what might be going on behind the declared wish. In Oregon in 2023, only three people were referred for a psychiatric evaluation by the assessing doctor—down from 33% of people in the early years. It is clear that evaluators have become less cautious when they come to sign the initial paperwork. In California, less than 1% of patients requesting an assisted death are referred for a mental health assessment. These are significant warning signs for us.

I am aware that the hon. Member for Spen Valley has tabled a helpful amendment—amendment 419—to clause 6, which is the clause dealing with the requirement for proof of identity. As I said yesterday, this retrofits a requirement for a preliminary discussion before the process can proceed. It is good that the hon. Member recognises the point that a proper preliminary assessment must be done before the declaration is signed, but I simply do not understand why that should be in clause 6; surely it should be in one single, consistent place, here in clause 5, relating to when the co-ordinating doctor first meets the patient to witness their form. I hope we might recognise that if the principle is being conceded by the amendment tabled by the hon. Member for Spen Valley, we should put that change into its rightful place.

It is worth nothing that at the moment someone could get a proxy to sign for them. The proxy does not need to know the patient or be known to them; they just need to be a person of good standing in the community. They need to undertake no training at all. We have been talking during in this debate about the importance of training, but the proxy who signs on the patient’s behalf does not need to have any training to inform the judgment that they are

“satisfied that the person understands the nature and effect of the making of the declaration”.

Frankly, a stranger to the person, who is not a medic, can sign that declaration on their behalf. At the moment, they can do so without a preliminary discussion taking place. It is only after making that crucial declaratory statement that the co-ordinating doctor discusses the person’s diagnosis. I welcome the tabling of amendment 419, but I think it is in the wrong place. If we do not ensure that that preliminary discussion takes place when we are debating this group of amendments, it might be too late if amendment 419 does not pass, or if it is unsatisfactory, as I think it is.

There is another related problem. Amendment 419 would allow the co-ordinating doctor to confirm that a preliminary discussion has taken place. That means that the discussion could have taken place before the first declaration—in a sense, that is welcome, because that discussion should be taking place—but it does not have to take place with the co-ordinating doctor. The co-ordinating doctor, who is taking responsibility for the whole process of the assisted death for this patient, is not required to have this preliminary discussion themselves. They are not required to go through the very important process of properly discussing the assisted death and informing the patient of what it entails and what the other options are.

My amendment 359 would enhance the significance of the preliminary discussion. It would mean that the doctor who witnesses the declaration—who co-ordinates the process of the assisted death—has had the fullest possible discussion with the patient, and that they genuinely take responsibility for guaranteeing that the patient is fully informed and aware of all of their options. I urge the Committee to support these amendments as well.

[Liz Saville Roberts (Dwyfor Meirionnydd) (PC)]

I am very glad that amendment 427 has now been unstarred for today, because it develops on what I initiated yesterday with amendment 413, when we were discussing identifying the preferred language of the individual and whether that is Welsh or English.

Of course, if we have identified the preferred language of an individual, we would then take every step to make sure that we satisfy them and that we provide services in their preferred language. The amendment also recognises, when we are talking about specific individuals, possibly in a specific location, whether providing that is possible or not. I have tried to reflect that in using the terminology “all reasonable steps” to ensure that the practitioner has “fluent proficiency” in Welsh if that is the preferred language of the individual with whom they are conducting the initial conversation. Bear in mind, of course, that practitioners who can hold a conversation with fluent proficiency in Welsh will also be able to hold a conversation with fluent proficiency in English.

The “all reasonable steps” phraseology comes from legislation already extant in Wales in relation to educational tribunals, which again recognise that it may not be possible to find an individual with sufficient proficiency. We are trying to find a balance here between the pressure of time and being able to move ahead without having a bureaucratic thicket while also acknowledging that if we do recognise an individual’s preferred language, that we do take “all reasonable steps”.

As with amendment 413, amendment 427 is an amendment that I tabled having met an officer from the Welsh Language Commissioner’s office last week. It would establish a pathway for people for whom Welsh is their preferred language. Reflecting the comments from the Minister and the Bill’s promoter, the hon. Member for Spen Valley yesterday, I need to know—as do the Committee and the Senedd—whether this needs to be on the face of the Bill or whether it could be elsewhere.

I do not intend to push amendment 427 to a vote today, but we very much need clarity on this issue. I suspect that this may not be so easy to clarify as yesterday’s point. We are talking about the rights of individuals in one of the most difficult, emotional, intimate discussions of their lives. We need to reflect that those individuals have a clear right to use the language which they have a choice in law to use. We must make sure that we get everything correct in this Bill. Diolch yn fawr iawn.

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[Naz Shah]

I thank you, Mr Dowd. My apologies. I have made a mistake, but I was referencing the comments of the right hon. Member for Dwyfor Meirionnydd about the use of languages, which is the subject of one of the amendments; that is my understanding. But again, I am happy to be guided by you, Mr Dowd.

To come back to the issue of training and domestic violence, in Committee, we heard evidence from Dr Jamilla Hussain about minoritised women. Again, from the data collection of ethnic minority groups, training is right at the top of the agenda, whether it be training of doctors or specialists.

Language is important when it comes to training as well. When people are training or trained to look at coercive control and to spot that coercive control, there is often an interpreter between them and the victim who is being assessed. They may be an ethnic minority woman or a man from an ethnic minority background whose first language is not English, so that training would need to include cultural sensitivities in relation to spotting coercion and control, and to repeated coercion in particular.

These are subjects that are already taboo for people to discuss. We know the issue of domestic violence is hard to spot. We have repeated that time and again, as have others. We talk about training, but that has to go further when it comes to victims or people seeking assisted dying who are from ethnic minority backgrounds and who have different cultural understandings. I talked about yesterday that. The hon. Member for Reigate also talked about the issue: the understanding of assisted dying among ethnic minority communities is very different if there is a language barrier.

I would like to ask the promoter of the Bill, my hon. Friend the Member for Spen Valley, whether her amendment will go further in addressing some of the inequalities and intricacies that are presented when we are dealing with women from ethnic minority communities or elderly people from ethnic minority communities. I would be happy to sit down and talk her through those issues, so that I can support the development of her amendment to address the concerns I have raised today.

[Danny Kruger]

The hon. Lady talked earlier about the tragedy of victims of coercive control who commit suicide. Does she consider that the amendments we are looking at will help to address that challenge? What specific support does she think victims of coercive control would need to prevent them from taking that terrible step?

[Naz Shah]

The hon. Member asks a very important question. When I am talking about reflective services for black and minority ethnic communities, which is something I have delivered training on and worked on in a previous role, I often use the example of my mother, who was a victim of domestic violence. Had she been arrested by a woman instead of a man, her experience might have been different. Had she had a solicitor who was a woman, not a man, her experience might have been different. Had she had judges who were women, not men, her experience might have been different. Let us now add another layer to that. Had the police officer been a woman from the background she was from, they might have understood it.

The same analogy potentially applies to patients who are asking about going down the route of assisted dying, because it is helpful if somebody comes from the same cultural background. If a female victim of domestic violence or coercive control meets a specialist doctor who looks very similar to the hon. Member for East Wiltshire—a white, middle-class male—and he does not have that cultural understanding, he will then rely upon training, and he will no doubt rely upon an interpreter to translate.

That is the kind of thing I am trying to tease out, and these are the kinds of protections I want to see in the Bill. If we want a Rolls-Royce service, and if this is to be the best Bill in the world, it cannot ignore the most vulnerable in society. If the patient is a disabled woman, it is whammy upon whammy and layers upon layers of intersectionality that the Bill does not address. That is why I want to see the Bill strengthened.

I want to talk about the training that doctors get and the training in palliative care. We heard from Dr Jamilla Hussain, who was very clear about the fear among minoritised communities because of what happened during the covid pandemic, with “do not resuscitate” orders and their whole experience. Some people potentially died who could have been saved because they did not have the trust in NHS services to access them.

In this instance, it is important that we have a first doctor. That first doctor might have no relationship with the patient because their regular doctor does not want to engage in the process. Let us take the example of a patient in Bradford West who has had a diagnosis of terminal illness. They might well have a doctor or consultant who has been dealing with them for six months or even a year, to the point where they have reached the terminal stage. They might have a relationship with that doctor, who might have spoken their language and might be from a particular faith background but who does not want to engage in the assisted dying process. According to the Bill, that doctor would then have to refer that patient on to somebody who is prepared to have that conversation, but that person might not have that training or those language skills, and they might not—

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Amendment 359 would require the co-ordinating doctor to be the same person as the registered medical practitioner conducting a preliminary discussion under clause 4. The amendment would have the additional effect of requiring the registered medical practitioner who undertook the initial discussion to have met the specific training requirements and qualifications that the co-ordinating doctor will need to have met. That could have the effect of limiting the numbers of registered medical practitioners that can undertake the preliminary discussions.

[Danny Kruger]

Will the Minister clarify that point? Is he suggesting that because fewer doctors might be eligible or willing to conduct the preliminary assessment, we should not require it at that early stage?

[Stephen Kinnock]

What we are trying to say is that the important thing here is to ensure that, when the Secretary of State brings the regulations forward, the hands of the Secretary of State are not tied too tightly, so that the Secretary of State is able to bring together the right people, to deliver the right training, to achieve the outcomes that are required through the regulations. Our assessment is that this amendment would, in essence, narrow the pool of people available to do the training. That would seem to pre-empt the idea behind doing this through regulations, which is to ensure that there is up-to-date training that is responsive to where we may or may not be two years down the line from the Bill having its commencement. It is about having that flexibility and that ability to build capacity.

Amendment 340 would place the Secretary of State under a duty to make regulations requiring a co-ordinating doctor to have specific and up-to-date training relating to reasonable adjustments and safeguards for autistic people and people with a learning disability. I note that amendments 185 and 186, if passed, would impose a duty on the Secretary of State to specify the training, qualifications and experience that the co-ordinating doctor will need.

The consequence of this amendment would be to require the Secretary of State to introduce a further requirement on the co-ordinating doctor—to have undergone training relating to reasonable adjustments and safeguards for autistic people and people with a learning disability. In considering whether the amendment is required, I note that the Health and Social Care Act 2008 requires that all CQC-registered health and adult social care providers ensure that their staff receive specific training on learning disability and autism.

Amendment 427 would impose an obligation to take all reasonable steps to ensure that the co-ordinating doctor is proficient in the Welsh language if services or functions under this legislation are to be provided to an individual in Welsh in Wales. The amendment does not make it clear who would be obliged to ensure that those steps were taken, or who would assess and enforce whether the “fluent proficiency” standard was met.

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Amending clause 40 through amendments 170 and 171 would give the Senedd and the Welsh Government the rightful authority to ensure that provisions are ready, adequate and enforceable in the Welsh context before their commencement in Wales—in other words, before the end of the two-year period. I tabled the amendments in an attempt to provide Senedd Cymru—the Welsh Parliament—and Welsh Ministers with their correct and rightful powers in areas that are devolved to Wales. We must be clear on that. That is what I have set out to do: that has always been my stated aim as a member of this Committee. I hope that Committee members will consider these practical amendments and support their inclusion in the Bill.

[Danny Kruger]

I will speak briefly in support of the amendments. The right hon. Member for Dwyfor Meirionnydd may want to intervene to request that the Minister respond to a couple of additional points.

It is very uncomfortable that the Bill ignores the devolution settlement in this way. It is regrettable that it was introduced in its current form in the knowledge that the Senedd in Wales rejected assisted dying a month earlier. That suggests either that originally little thought was given to including Wales in the Bill or that, subsequent to the vote in the Senedd, it was decided that the Bill would be imposed on Wales. It would be helpful to have clarification about the original intent.

I very much echo the points that the right hon. Lady made. She is absolutely right about the appropriateness of giving the Welsh Government powers to manage the Bill’s operation and implementation if it passes. I would suggest a stronger process of implementation, reflecting the advice given by Professor Lewis, who gave evidence to us on Welsh law. In the light of the vote in the Senedd to reject assisted dying, he pointed out:

“The vote was against ‘the principles of assisted dying’, not only about how the NHS in Wales might be affected. It was a decision which the majority of the Senedd made about those principles, having reflected on the…issues raised.”

Professor Lewis proposed a straightforward way of respecting that vote while recognising that, if this Bill passes, it will apply to Wales. He suggests that we should

“provide for different commencement provisions in the Bill. As things stand, under clause 42 of the Bill, most of the Bill will not come into force until the Secretary of State has brought it into force, with the approval of the UK Parliament. Why not provide that the Bill will only come into force in Wales when and if the Welsh Ministers bring it into force with the approval of the Senedd?”

The objection might be made that cross-border issues would be created if Wales does not proceed but England does. Nevertheless, that is a matter that devolution can cope with. It will have to cope with the cross-border issues that will arise if the Scottish Bill does not proceed, and of course we have cross-border issues between Wales and England with respect to organ donation, so I do not accept that the two countries need a uniform policy. I do not know whether the right hon. Lady or the Minister wish to comment on the suggestion that the Bill should commence in Wales only if Ministers bring it forward with the approval of the Senedd.

[Liz Saville Roberts]

The evidence for a commencement date would be associated with an impact assessment in Wales. That is why it is so important that Welsh Ministers have the power to get the information they need and to implement any changes that come forward.

[Danny Kruger]

I absolutely agree with the right hon. Lady. There is a whole set of challenges, including in England, in respect of the impact assessment and the Bill’s commencement. Nevertheless, my suggestion is that we strengthen her proposal to empower Welsh Ministers to proceed. We should respect the devolution settlement and reflect what she describes as the “correct and rightful powers” of the Welsh Parliament to ultimately decide whether this law were to come into effect in Wales.

[Stephen Kinnock]

Amendments 144 to 171, tabled by the right hon. Member for Dwyfor Meirionnydd, relate to the powers and duties vested in the Secretary of State under the Bill. The purpose of the amendments is to change all references throughout the Bill from “Secretary of State” to “appropriate authority”. Amendment 169 defines “appropriate authority” as the Secretary of State in relation to England and as Welsh Ministers in relation to Wales. I note the intent of the promoter of the Bill, my hon. Friend the Member for Spen Valley, that the Bill’s provisions extend and apply to both England and Wales.

The amendments would mean that all the powers and duties vested in the Secretary of State are instead shared between the Secretary of State where they relate to England and Welsh Ministers where they relate to Wales. I would like to put on the record the Government’s continued commitment to devolution and to working with the devolved Governments. Having taken a neutral position on the Bill and the matter of assisted dying, the Government are still committed to working with the Welsh Government to resolve legal and technical issues and discuss constitutional matters that might arise thoughtfully and amicably.

With regard to the phrase “appropriate authority”, the challenge is that in each case throughout the Bill the appropriate authority would be determined by the devolution position of the clause in question—what is the underlying question that the clause seeks to address, and is that a reserved or devolved matter? I have discussed this with parliamentary counsel and others, and the concern is that a blanket provision of this nature may well be premature at this stage. Until we have finalised and determined the constitutional nature and impact of each clause, putting a blanket provision in place may run counter to that process.

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[Danny Kruger]

I beg to move amendment 360, in clause 5, page 3, line 23, at end insert—

“(e) who, If receiving remuneration for the provision of services in connection with the provision of assistance to that person in accordance with this Act, makes publicly available an annual statement setting out total turnover from the provision of services under this Act and the number of patients assisted, and such other information as the Secretary of State may specify by regulations.”

This provides that if the coordinating doctor receives remuneration for providing assisted dying, they must then make a public annual statement about their operation.

[The Chair]

With this it will be convenient to discuss amendment 361, in clause 5, page 3, line 28, at end insert—

“(7) Regulations under subsection (3)(e) are subject to the affirmative procedure.”

This is linked to Amendment 360.

[Danny Kruger]

The amendment speaks to the general confusion we remain in about how the assisted dying law would be implemented and who would operate it. We are in a great cloud of unknowing about whether we are talking about an NHS service or a private service. If there were to be a private service and people were to be paid to deliver it outside the NHS, the amendment would clarify obligations regarding how their remuneration would be recorded.

There is an established precedent for publishing financial interests where there is a potential for a conflict of interest. Senior officials in NHS England, NHS trusts and the Medicines and Healthcare products Regulatory Agency must declare financial interests—including relationships with pharmaceutical companies—in public registers. Those interests include consultancy fees, gifts, hospitality, shareholdings in pharmaceutical companies or research funding, because there is a concern that those influence drug approvals, procurement and healthcare policy and that there is a risk of bias.

NHS England guidance on managing conflicts of interest encourages the detailed disclosure of significant payments from pharmaceutical companies, often with exact figures or ranges for payments above a £500 threshold. The Association of the British Pharmaceutical Industry runs Disclosure UK, which requires pharmaceutical companies to publicly report payments to healthcare professionals and organisations. It would be appropriate to follow this well-established precedent and ensure that people involved in the administration of assisted dying are accountable for the transparency for their remuneration.

Clause 5(3) recognises that there could be a conflict of interest and that there is a risk that someone who is related or might benefit financially may not be a neutral assessor of someone who wishes to die, but clause 40(4), which comes rather late in the Bill—it should be up front—specifies that

“a registered medical practitioner is not to be regarded as benefiting financially or in any other material way from the death of a person by reason only of the practitioner receiving reasonable remuneration for the provision of services”.

Here is where we discover that the Bill does envisage remuneration, but people being remunerated are excluded from the definition of people who financially benefit from the service. To me, that feels dangerous.

Although it has not resolved the question of whether assisted dying is to be an NHS service, the Bill clearly envisages the establishment of a private market for these services, perhaps with a specialist service like Dignitas. Are we content with the Bill’s assertion that remuneration is not a matter for scrutiny? What level of remuneration would we consider reasonable? What level would we consider excessive—remuneration that is capable of influencing a doctor’s thinking? Would they be paid for administering assisted death on a per patient basis, or as a cumulative practice?

As MPs, should we not have some unease at the idea that this could be a highly profitable specialism for private practice? Transparency on what is being charged and who is profiting from the service would help us to understand what is happening in the system that is being established. I suggest that we bring more sunlight into the system, as we do in many other areas.

It is notable that there is little public data on what is charged, or how much revenue assisted dying generates for medical practices, in other countries where assisted dying is a private service. That is regrettable, and I hope we will not replicate that here. We do know that at Dignitas, which is a not-for-profit, the cost for a single patient is between £5,000 and £8,500 in fees alone. What is reasonable remuneration for a practice that provides assisted dying here in the UK? The term is entirely undefined, and I would be grateful for any clarity.

[Kim Leadbeater]

I understand the hon. Gentleman’s keenness to get to the debate on clause 32, on the provision of the service—we will come to that in due course—but this conversation is about the amendment. To be clear, there is no expectation that assisted dying would be set up as a private enterprise or service. It would be delivered within the provision of the NHS.

[Danny Kruger]

I am glad to have that suggestion. Clause 32 is extremely broad. It basically empowers the Secretary of State to set up a service in any way they choose, potentially including in the private sector. The hon. Lady says it is not envisaged that would happen, as she is suggesting this should be an NHS service. I am grateful for the clarity, but I wish it were clearer in the Bill.

[Kim Leadbeater]

It will be.

[Danny Kruger]

I am glad to hear we will have more clarity. Having assisted suicide as an NHS service is fraught with enormous risks, along the lines we have discussed and will no doubt continue to discuss. At least we have that clarity. If the hon. Lady is going to rule out private provision and profit making or remuneration of people outside the NHS, I would be grateful for amendments specifying that. That would help to address this question.

My amendments would mean that if there is private provision of assisted suicide, as the Bill currently allows, the public and Parliament could understand who is being paid what, which I think is very appropriate.

[Jack Abbott]

To give the Committee a sense of clarity, is the hon. Gentleman saying he wants the finances to be in the public domain, so that if provision were to go down a private route, everyone would know what an individual is charging for these services? Or is he suggesting a cap on services? What is the intention of his amendments?

[Danny Kruger]

My amendments state that if a medical professional is paid for delivering assisted suicide, the money they receive should be transparent. The answer is therefore the former.

I do not propose any cap. If we end up with a private service, although the hon. Member for Spen Valley has just told us that we will not, it might be appropriate to create a scale of charges. My suggestion is that we need absolute clarity. I also think we should use the affirmative procedure to approve the regulations on the transparency of finances. This should be something that Parliament expressly approves.

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

My interpretation of what the hon. Member for Spen Valley said is that, as long as the service is available on the NHS, it is up to me whether I go private. In such circumstances, I could have it on the NHS if I really wanted. If I chose to go private, as I might if I were having a baby at the Portland hospital or cosmetic surgery at King Edward VII’s hospital in Marylebone, why would my hon. Friend the Member for East Wiltshire want to know the private arrangement between me and my physician?

[Danny Kruger]

I am grateful for that clarity, although we now seem to be less clear than we were. I understood the hon. Member for Spen Valley to be saying that there will not be private provision, but my right hon. Friend is saying that there may be.

[Kim Leadbeater]

Will the hon. Gentleman give way?

[Danny Kruger]

It would be helpful if the hon. Lady clarified whether private provision will be allowed under the Bill, because I think we have a party split. My right hon. Friend the Member for North West Hampshire supports private provision, but the hon. Lady suggests this should be done only on the NHS.

[Kim Leadbeater]

This service, like many others, will be delivered through a range of providers, as alluded to by the right hon. Member for North West Hampshire. I understand the keenness to have this debate now, but we will come on to it further down the line. The hon. Member for East Wiltshire is right that this is really important.

[Danny Kruger]

It certainly is. Okay, so it could be either. This will be an NHS service, with all the implications for general practice, doctor-patient relations and secondary care and social care, but there will also be an opportunity to deliver it privately, without any clarity or transparency on who is being paid and how.

In answer to my right hon. Friend the Member for North West Hampshire, this is different from cosmetic surgery, as even cosmetic surgery is regulated. In many ways, there is more regulation of the administering of Botox than there is in this Bill. The administering of assisted dying is of a significantly different category and gravity. It is appropriate and important that financial interests are clearly revealed and made public, particularly with the new intervention we are creating. If other hon. Members do not support the amendment, what provisions do they propose that would reveal where there may be potential conflicts of interest and how we may regulate this?

[Dr Simon Opher (Stroud) (Lab)]

I thank the hon. Member for East Wiltshire for the amendment. The set-up of this scheme is similar to other NHS services. Essentially, a medical professional will opt in to provide the service. That will involve extensive training followed by a short exam, as it does in Australia and California, after which they will be accredited under the scheme—that is how I understand it will happen in the UK. No one is forced to provide the service, but training is offered and many doctors take that up. Therefore, it is a medically based service.

The British Medical Association will then negotiate the fee for doing the assessment with the Department of Health and Social Care. That is not about agreeing to provide the service; it is about doing the assessment. That is mirrored in many aspects of general practice, which itself is a private service contracted to the NHS. It is very complicated. It would be inaccurate to portray this as a private service, where people may profiteer, as it is based on medical professionals performing a duty for which they are trained and for which the price is clear to the general public, because it is negotiated and published.

On publishing the number of patients seen by a single doctor and the fees that doctor has accrued from the scheme, that is not something that happens for things like minor operations, which we perform outside general medical services, although we are rewarded by the Government at a set fee. There are other such services—inserting a coil, for example—where we are given a certain amount of money.

How this is arranged is very complicated. Doing appraisals, being a trainer and all these things have a price attached, and we need training before we can perform the service. I see this scheme as no different. The problem with publishing how many patients have been seen by a single doctor regarding assisted dying is that it puts a target on that doctor. As we have seen with abortion clinics and even this Committee—certain Committee members have been targeted by the press for what they have said—this is a very sensitive issue, and it would not be fair to publish the figures so that doctors could be targeted in the press and made to feel unworthy in all those ways. It is extremely difficult.

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[Stephen Kinnock]

As my hon. Friend the Member for Stroud has just said, the picture is very complex because there are tariffs for services. Doctors receive a tariff for each service across the entire panoply of everything they do, particularly general practitioners who provide a very wide range of services. They are remunerated on the basis of a tariff that is negotiated in the GP contract between the Department of Health and Social Care and, primarily, the BMA. When a doctor operates in that environment, it is difficult to pick out their turnover from a particular service.

As my hon. Friend the Member for Stroud said, picking out an individual doctor and saying how much money they have made from a particular service, whether assisted dying or any other service, would put a particular focus on that doctor. We are drawing a distinction here with what the tariff could and should be, which we will need to discuss alongside the operating model in later clauses. Moving from being transparent on the tariff to saying, “That doctor over there made this much money from providing this service,” is a whole new ball game.

[Danny Kruger]

I am grateful to the Minister for raising a number of points, including the extraordinary revelation that we are about to find out how the Bill will operate in practice, with amendments yet to be developed even though we have been debating the Bill for a couple of weeks.

The difference between the tariff and a doctor’s income is fine, but if the tariff is to be clearly specified—no doubt it will be—how could it be complicated to determine how many tariffs a particular practice has received? I recognise that there is a separate question about whether it is appropriate to reveal that, but why is it difficult to identify how many individual tariffs a particular practice has received?

The Minister has described the tariff income, but my other concern is about the sponsorship, gifts, hospitality and fees of all sorts that the pharmaceutical companies are always trying to administer. Will he address the question of whether that should be transparent as well?

[Stephen Kinnock]

The challenge in the hon. Gentleman’s amendment is the term “total turnover.” A GP would have to extrapolate from the service provided to a whole range of other costs that may apply—for example, the share of the overhead they pay into their primary care network, the share of admin costs or the rent on their building. The definition of total turnover is the entire cost and entire revenue from the tariffs. As officials have made clear, this additional level of complexity would be an onerous task, although not necessarily impossible.

Total turnover is one side of this issue; the other, much more salient point is the quantum leap between having transparency on a particular tariff and pointing at a specific doctor and saying, “You over there—you did this much work on that much tariff, and that’s how much money you made for it.” There is a big difference between the two.

Terminally Ill Adults (End of Life) Bill (Nineteeth sitting)

Danny Kruger Excerpts

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Kim Leadbeater (Spen Valley) (Lab)]

I have nothing further to add in this debate.

[Danny Kruger (East Wiltshire) (Con)]

In the light of the suggestion from the hon. Member for Spen Valley that there will be further amendments later, when we can discuss the shape of the provision and presumably any remuneration, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment proposed: 186, in clause 5, page 3, line 23, at end insert—

“(3A) The Secretary of State must by regulations make provision about the training, qualifications and experience that a registered medical practitioner must have in order to act as the coordinating doctor.

(3B) The regulations must include training about—

(a) assessing capacity;

(b) assessing whether a person has been coerced or pressured by any other person.

(3C) Subject to that, the regulations may in particular provide that the required training, qualifications or experience is to be determined by a person specified in the regulations.”—(Kim Leadbeater.)

See the statement for Amendment 185.

Amendment made to amendment 186: (a), after

“(b) assessing whether a person has been coerced or pressured by any other person.”

insert

“(c) specific and up-to-date training on reasonable adjustments and safeguards for autistic people and people with a learning disability.”—(Daniel Francis.)

Amendment 186, as amended, agreed to.

[Kim Leadbeater]

I beg to move amendment 187, in clause 5, page 3, line 24, leave out subsection (4).

This amendment is consequential on NC8, which contains a single duty to consult before making regulations under various provisions of the Bill.

[Kim Leadbeater]

This group of amendments is consequential on new clause 8, which would create a single duty for the Secretary of State to consult before making regulations under various provisions of the Bill. It would consolidate the previous requirements to consult in relation to clauses 5, 8 and 19 and expand the duty to cover additional clauses. It would require the Secretary of State to consult the Equality and Human Rights Commission and such other persons as the Secretary of State considers appropriate. The persons to be consulted under subsection (1)(b) must include persons appearing to the Secretary of State to have expertise in matters relating to whether persons have capacity, and persons appearing to the Secretary of State to have expertise in matters relating to whether persons have been coerced.

This is an important strengthening of the Bill. It applies to multiple clauses: clauses 5, 7, 8, 13, 19 and 21. The duty to consult experts, particularly on issues around capacity and assessing for coercion, is an important change that reflects the detailed debate that the Committee has undertaken on those two important issues.

Amendment 233 brings together the various provisions about the procedure for regulations. It would make the regulations to be made under clauses 5 and 8, on training, qualifications and experience, subject to the draft affirmative procedure, so that Parliament has to debate and approve them first. Again, that would strengthen the Bill.

[Danny Kruger]

In a sense, this is a technical set of amendments that consolidate the provisions for secondary legislation. However, it reflects the seriousness of a concern that I and others have raised, which is that so much in this Bill will be left to the discretion of Ministers, often through the negative procedure.

It is important to reflect briefly on the questions that we are considering. The hon. Lady has mentioned quite a few of them, but we are talking about the training of doctors; the High Court procedure, if there is one; the substances that may be used in the administration of assisted death; the prescribing of those substances; the registration of deaths; the codes of practice to be introduced; provision through the NHS; notification to the chief medical officers; changing the schedules in the Bill, and so on.

Those are important matters. I recognise that many of them are complicated and technical, and that it is appropriate to leave them to a degree of professional and ministerial discretion. Nevertheless, my great concern, which relates to the parliamentary procedure—you may have a view on this, Mrs Harris—is that we are having this debate without the benefit of a delegated powers memorandum to explain why each power has been taken, the nature of it, the reason for taking the power and the procedure to be selected.

In a recent report on the Bill, the Hansard Society notes that under the Government’s “Guide To Making Legislation”, a delegated powers memorandum would normally be published prior to Second Reading for a private Member’s Bill on issues of conscience on which the Government are neutral. The report explains that a delegated powers memorandum gives

“details of each power in the bill, including its context, its scope, to whom the power is delegated, and the parliamentary scrutiny procedure…the reasons for taking the power; and…why.”

It points out that

“where the responsible department recommends that the Government should support the Private Member’s Bill or remain neutral then a DPM should be produced for consideration by the relevant Cabinet Committee—the Parliamentary Business and Legislation (PBL) Committee—alongside other key documents such as the explanatory notes, a legal issues memorandum, and an impact assessment”.

We have not yet had an impact assessment either.

[The Chair]

Order. I ask the hon. Member to speak to the amendments. You have gone out of scope.

[Danny Kruger]

I am sorry about that. I am trying to make the point that the amendments would all grant a large number of powers to Ministers through the statutory instrument procedure. That is why I am referring to the Hansard Society report.

[The Chair]

Please stick to the amendments.

[Danny Kruger]

I understand, but it would be interesting to know whether the Government have produced a delegated powers memorandum, and when it will be published.

I have four quick points to make about my concerns about the amendments and new clause 8. First, new clause 8 provides that when making the SIs, the Secretary of State must consult the Equality and Human Rights Commission. That is a very positive step, but the other provisions on who should be consulted are, on closer inspection, illusory. The Secretary of State must consult those with expertise on capacity and coercion—that is all great—unless he or she considers that

“it would not be appropriate”.

What the new clause gives with one hand, it takes with the other. It would be good to identify in the Bill who the groups are that the Secretary of State must consult for each power.

Secondly, the vast majority of the SIs made under the Bill, as amended by the amendments, are to be made by the negative procedure. The last time that an SI subject to the negative procedure was annulled by the House of Commons was 1979. The procedure gives only the outward appearance of involving Parliament again. The SIs take effect when signed by the Minister, subject only to a motion of either House to annul them. However, by strong convention the Lords will do no such thing, and the convention in the Commons is that the Government will make time to debate such a motion only if it is put forward by the Opposition Front Bench, and it is at the Government’s discretion.

This being a matter of conscience, it is unlikely that any Opposition Front Bench would be in a position to table such a motion, and no one else has any standing. In practice, that means that there will be no opportunity for parliamentary scrutiny on, which lethal substances may be approved, for example, or on what events should be notified to the chief medical officer. These are not mere details.

Thirdly, on some of the matters addressed in the amendments it is doubtful whether the use of delegated powers is even appropriate, because even if there is a debate and a vote in Parliament, debate on an SI is limited to 90 minutes only and an SI is not amendable. In fact, the House of Lords Delegated Powers and Regulatory Reform Committee considered it improper that the Assisted Dying Bill introduced by Baroness Meacher gave the power to the Secretary of State to decide which substances should be allowed to cause death, because it was an inappropriate question for an SI.

Finally, and perhaps most substantially, clause 32 will establish a vast Henry VIII power. It allows Ministers even to amend primary legislation, and those changes would be subject to a simple yes or no vote in the Commons, without the possibility of amendment. It has been suggested in the Hansard Society podcast with the drafter of the Bill that the power is there because provision on the NHS could be made only if section 1 of the National Health Service Act were modified, removing the duty of the Secretary of State to improve the “physical and mental health” of the public. I look forward to seeing whether the amendments that have been promised include that. However, they will not necessarily amend the National Health Service Act, because that could be done under the statutory instruments created in these amendments.

If such a foundational piece of legislation as the National Health Service Act needs to be modified to allow this law to pass, surely it would be better to do it on the face of the Bill. I want to know why a Henry VIII power is needed. I hope that the Government might bring forward the relevant amendments to the Bill so that a Henry VIII power is not needed. I see that the hon. Member for Spen Valley is nodding, which is encouraging.

I stress that the Committee must bear it in mind that this power would exist on the statute book forever, unless the statute is repealed, so any Government could use this power. The last time that a Parliament found its voice to reject an SI by the negative procedure was back in the 1970s. When we come to a decision on amendment 233 and new clause 8, I will seek to make further amendments.

[Daniel Francis (Bexleyheath and Crayford) (Lab)]

It is a pleasure to serve under your chairship, Mrs Harris. It would be remiss of me not to comment briefly on new clause 8, given that throughout this process I have consistently raised issues around evidence given by the Equality and Human Rights Commission, and given that new clause 8 states that before making a recommendation the Secretary of State must consult the commission.

I remind hon. Members that the commission has told us that it strongly recommends that

“at the earliest opportunity, Parliament is provided with further information and assurance about the bill’s compatibility with equality and human rights.”

It went on to say that its concerns were that the Bill

“may also particularly impact disabled people. We recognise that this bill is focused on assisted dying for adults who are terminally ill, and does not propose access to assisted dying on the basis of disability or chronic conditions. However, there is not always a clear line between terminal illness and disability. Disabled people can also suffer from terminal illness, and illness may itself amount to a disability.”

It has also stated:

“A vital factor in determining how to manage access to assisted dying will be the concept of mental capacity…It will be important to ensure that all decision-makers involved in the process have a full and clear understanding of the law around mental capacity under the Mental Capacity Act 2005.”

I welcome new clause 8, which is in the name of my hon. Friend the Member for Spen Valley, as it would ensure that the Equality and Human Rights Commission is consulted. We await its comments, which hopefully we will have before Report, on whether the concerns that it raised, both in writing before Second Reading and in their oral evidence, have been allayed. However, I welcome this initial commitment, and we will see where that brings us on Report.

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[Naz Shah (Bradford West) (Lab)]

I rise to speak to amendments 291, 292 and 293, which were tabled by my hon. Friend the Member for York Central (Rachael Maskell). I do not intend to press them to a vote; they are probing amendments. They all relate to the amendments tabled by my hon. Friend the Member for Spen Valley about the identification required of applicants for assisted dying. They do not change those requirements; they take a more logical and businesslike approach to proving that those requirements are met.

Amendment 291 would change the current requirements on identification and require applicants for assisted dying to produce a piece of photo ID and proof of residence in the UK for the previous year. As currently written, clause 6(2) states:

“The person must, at the same time as that declaration is made, provide two forms of proof of identity to the coordinating doctor and the witness mentioned in section 5(2)(c)(ii).”

Subsection (3) states:

“The Secretary of State may, by regulations, make provision about the forms of proof of identity that are acceptable for the purposes of subsection (2).”

Surely that is not tight enough.

In particular, the Bill as written does not specify that either form of proof of identity should be photo ID. That may be a major omission. For much less significant decisions, the law of England and Wales requires at least one form of photographic ID. For example, there is currently a requirement to have photo identity to work on the parliamentary estate, vote, or have a bus pass or railcard. None of those is as important as applying for an assisted death.

I remind hon. Members that assisted death is a process that would end in a person being issued with and then taking a mixture of lethal drugs. In a hospital setting where drugs are dispensed, rigorous processes are undertaken to verify the patient. Drug errors are not uncommon. The previous Health and Social Care Committee’s report into pharmacy witnessed how clinical practice was being improved to reduce drug errors. Given that a lethal dose is dispensed as part of this process, the identification mechanisms are weak and should be addressed in this preliminary stage through the provisions set out in this amendment. It is possible that the wrong person could be prescribed the medication. That would be an extreme case, but we are talking about creating a wholly new power that would relate to life and death. We are talking about making assisted dying available to people who are, in many cases, extremely distressed. People in extreme circumstances will sometimes do extreme things. We should expect some extreme cases and seek to guard against them.

Amendment 291 would provide such a safeguard. The Bill says that to qualify for assisted dying, applicants must have been resident in the UK for at least a year, but it does not ask them to provide any proof of that residence. In such a serious matter, we surely cannot simply accept someone’s word that they live in the UK. Making that a requirement without a test to establish it de-values the importance of the criteria for qualifying.

Amendment 292 would change clause 6(3), which currently reads,

“The Secretary of State may, by regulations, make provision about the forms of proof of identity that are acceptable for the purposes of subsection (2).”

The amendment would change that “may” to a “must”, as the former treats the identification process with reduced seriousness. If the word “may” stays in legislation, there is no obligation to have rigour in the identification process. As drafted, the Bill is more open for abuse.

Amendment 293 seeks to place the regulations concerning identification under the affirmative procedure, which the hon. Member for East Wiltshire mentioned earlier. Assisted dying is so important that no regulations made under it should be drawn using the negative procedure. As Members will know, if a statutory instrument is made under the affirmative procedure, it must be approved by Parliament within a certain timeframe, which is usually 28 or 40 days. If that does not happen, the change to the law made by the statutory instrument will not take place. In the Bill as drafted, these regulations are covered by the negative procedure, which means that if and when the Secretary of State decides to change them, they could go through on the nod unless Members raised an objection. A statutory instrument laid through the negative procedure becomes law on the day the Minister signs it and automatically remains law unless a motion rejecting it is passed by either House within 40 sitting days.

Placing all changes to regulations under the affirmative procedure would ensure that we have scrutiny by Parliament. We should all approve this. Our responsibility for this legislation will not end when and if it becomes an Act of Parliament. These amendments speak to tighter safeguards and parliamentary scrutiny for all new regulations made by the Secretary of State in relation to identity and residence. All hon. Members should support them.

[Danny Kruger]

I will quickly echo the points well made by the hon. Member for Bradford West in support of the amendments in the name of the hon. Member for York Central. It is important to specify the form of identity that will be presented. The person presenting themselves for an assisted death needs to be who they say they are. At the moment, the power to specify the forms of proof of identity has no minimum requirements. As written, it does not require the Secretary of State to specify what is acceptable.

Two specific aspects we have to pay particular care to are age and residency. The process must be accessible only to over-18s. I am concerned that we rejected amendments yesterday that would have prevented people under 18 having the conversation. In light of that, it is even more important that we make it clear that people who access assisted death must be adults. We need to ensure that the forms of identity are specified and that Parliament can satisfy itself that they are robust.

[Kim Leadbeater]

We did not reject proposals for the preliminary discussion not to be taken by people under 18. We actually put a clause into the Bill that would ensure that the preliminary discussion was not taken with someone under 18.

[Danny Kruger]

That is right. The preliminary discussion will not, but there is nothing to stop the conversation beginning before the person is 18. I know they cannot formally begin the process of an assisted death, but the concern—although I will not revisit the debate—was that the topic should not be raised or discussed with children, and we did not succeed in that.

The proposal is to ensure that we have proper ID—a passport, driving licence or other combined photo ID and proof of age, so a birth certificate must be paired with something if it is to be robust. We think such questions should be reflected more clearly in the Bill. All sorts of ID would not be appropriate, such as student ID, a sworn statement with no underpinning official record and other such things, which we want to avoid.

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[Jake Richards (Rother Valley) (Lab)]

I was expecting someone else to have spoken in support of amendment 296, but I will be very brief. The tone of the debate so far has been respectful, and it should continue to be so. I hope that this will not be characterised as a personal attack on my hon. Friend the Member for York Central, who tabled the amendment, or anyone else who supports it, but this is a shocking amendment. It is shocking because I doubt that the motives behind it are to improve the Bill or make it safer. In fact, I fear that the motives are to build a political attack to support opposition to the Bill, rather than to be constructive in improving it.

I have come to that conclusion because there is no concept in any other piece of legislation, or in any healthcare guidance in operation, that would ever presuppose that a clinician would undertake a consultation, assessment or meeting that would ever put other patients in danger. I fear that this amendment has been tabled because some people are attempting to assert, perhaps not purposefully or wilfully, that the introduction of an assisted dying system would somehow force clinicians to put other patients at risk. If that is the assertion, that is wrong and—in my view—shocking. It is a shocking indictment on their view of our medical practitioners in the NHS.

[Danny Kruger]

The hon. Gentleman is impugning the motivation of his colleague, the hon. Member for York Central, who is herself an experienced practitioner in the NHS. To suggest that she has tabled this amendment improperly is a serious accusation, which I cannot believe that he really wants to make against his colleague. He said that the amendment’s intention is to suggest that assisted dying would cause problems in the NHS, but the explicit terms of the amendment are to ensure that that does not happen. Of course, no practitioner would want to take choices that would prejudice other patients’ care.

[The Chair]

Order. Mr Kruger, you are down to speak and you can make your point then. I want interventions to be short.

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[The Chair]

I call Danny Kruger.

[Danny Kruger]

I was not intending to speak on this amendment, but since you have called me, Mrs Harris, I will quickly respond to the comments of the hon. Member for Rother Valley. I sincerely think that he should withdraw the suggestion that the amendment was made in bad faith and his remarks about the motivation of the hon. Member for York Central. She clearly tabled it only to make the Bill safer, which is the purpose of all the amendments, even if there might be very good reasons to disagree with them, so I regret that attack on her integrity.

On the point that we should simply rely on the integrity of clinicians—although the hon. Member for Rother Valley has not done so in respect of the hon. Member for York Central, who is herself a clinician—of course we do that. Nevertheless, the laws we make and the guidance we introduce send strong signals about priorities. The purpose of the amendment is to ensure that doctors do not feel that the obligations created by the Bill impose a duty on them to prioritise the assisted death procedure over other priorities. In fact, it would give clinicians genuine autonomy and freedom to make their own decisions—obviously, in consultation with colleagues and patients—about the appropriate prioritisation of the treatments and services they are offering.

The hon. Member for Rother Valley made the point that there is, in a sense, an attempt to suggest that the Bill should not become law because of the pressures it could impose on the NHS. I think that such pressures are a valid concern. When we create new laws, we should consider what new burdens they will place on existing services. We should consider whether the new service will be introduced and implemented safely, and its knock-on implications for the wider system.

[Jake Richards]

The point is that the amendment is not about the wider system; it is about a clinician’s individual decision making. Does the hon. Gentleman agree that that is a very different prospect?

[Danny Kruger]

Well, that concern for the individual clinician is in the context of their wider obligation to treat their patients well and to manage a resource—their own time—in a way that is equitable to all the patients they have to see. As often in these debates, we are really considering the extent to which we should be putting into the Bill an obligation on doctors to do the job that we hope that they are doing anyway. We do have such rules in the system to clarify what we expect of clinicians, however, and I think they would be appropriate in this case, given the resource requirements—which are unknowable, but with common sense one can see that they will be quite significant—that this new service would entail for many clinicians in the NHS.

[Jake Richards]

If the Government were to introduce legislation to expand the NHS’s role in how it undertakes operations in a certain area, would the hon. Member suggest that similar amendments should be added to that legislation, or it is just about this issue?

[Danny Kruger]

There is no rule that can be applied universally in the abstract. All rules take their value from how they are introduced. On the hon. Gentleman’s hypothesis, I do not in principle suggest that every new treatment and every new obligation that is created in the NHS should require laws determining how clinicians prioritise them. In the case of a new service—I am trying not to use the word “treatment”, because I do not accept it as such, but it sounds like it will be treated as an NHS treatment—that is very significant and whose resource implications are unknown, it strikes me as appropriate that, as far as possible, we should be clear that doctors should manage the resource demands placed on them by the Bill in the context of their other obligations to patients.

[Kit Malthouse]

Can my hon. Friend not see that, as the hon. Member for Rother Valley said, the amendment is based on what could be construed as an offensive assumption: that doctors otherwise might or would? Effectively, it is the legislative equivalent of the “When did you stop beating your wife?” question.

--- Later in debate ---

[Danny Kruger]

I am afraid to say that we do impose obligations on doctors to do the things that we expect them to do. If that is offensive to doctors, so is all the guidance from the General Medical Council. It might well be argued that the amendment is otiose, because of course we would expect doctors to manage their resource requirements appropriately and to consider other patients. Nevertheless, the point that is being made in defence of the amendment, about which I feel strongly, is that we are creating a new service with unknowable resource implications, with strong parliamentary backing behind it, and with a whole set of guidance that will be created ex nihilo by the Secretary of State and that Parliament will have little control over.

Because we have not seen the amendments on the design of the service, we do not even know what the service will involve and how much work it will take. It is therefore appropriate to specify explicitly that doctors have an obligation to consider the potential impact on other patients.

[Kit Malthouse]

I understand where my hon. Friend is coming from. To give us fair warning, if the Committee votes the amendment down, how will he portray that publicly? Will he say to the public that the Committee has voted for doctors to harm other patients?

[The Chair]

Order. That is not a relevant question, Mr Malthouse.

[Danny Kruger]

I am grateful for your ruling, Mrs Harris, but I hope you will not mind if I do respond to the question.

[The Chair]

Order. I do mind.

[Danny Kruger]

Okay. I might address the question at a future point, because the issue of how we reflect on these proceedings outside this place has come up privately.

[Kim Leadbeater]

I do not consider for one second that there is any ill intent behind the amendment, but I am slightly concerned about the language, which is what I think my hon. Friend the Member for Rother Valley meant. The issue is the suggestion that a doctor would, in any circumstances, jeopardise the care of other patients. We are talking about doctors a lot, and we have the utmost respect for medical practitioners, but I imagine that that would be a worrying concept to have in writing from their perspective.

[Danny Kruger]

I respect that point, and it is a fair charge: that doctors would not do this. Nevertheless, as I have been stressing, we are in uncharted territory, and there is a genuine concern about the resource implications of the Bill.

The Bill clarifies and emphasises things in lots of other places—“for the avoidance of doubt” and so on—and the amendment would clarify that the procedure under the Bill would not take precedence in a clinician’s time over other matters that they also consider to be pressing and urgent. That is an appropriate safeguard for doctors.

[Jack Abbott (Ipswich) (Lab/Co-op)]

The problem with the amendment, which has been mentioned before—I will not go as far as my hon. Friend the Member for Rother Valley and say that it would essentially nullify the Bill—is that it is entirely subjective. It is not guidance or a clear point of reference; it is entirely subjective to each individual doctor.

[Danny Kruger]

I am afraid that the English language is rather subjective. The service would rely on guidance or case law that had been built up, although one hopes that there would not have to be court cases in respect of it. The interpretation of the language of the Bill would be the duty of clinicians and, ultimately, NHS trusts and their lawyers.

[Jack Abbott]

A lot of the conversations we have had in Committee have been about eliminating the lottery that exists in our healthcare system. What the hon. Gentleman is suggesting will be exactly that: a lottery according to each individual clinician and doctor.

[Danny Kruger]

We cannot have it both ways. We cannot give doctors and clinicians autonomy, which the Committee has repeatedly seen as a ground to reject all sorts of obligations that I and others have proposed to ensure that doctors do the job in a specific way, and then suggest the opposite in this instance. I recognise what the hon. Gentleman says, and he may be right that that is inappropriate.

[Naz Shah]

Does the hon. Member agree that perhaps the amendment is not just about the context in which it has been referred to so far, but about protecting doctors in future? When mistakes happen, people would have a means to protect themselves.

[Danny Kruger]

The hon. Lady is absolutely right. We should not forget that doctors are indemnified against any civil claims under the Bill. Nevertheless, they will want to protect themselves against the accusation that they inappropriately prioritised one case over another. That is the purpose of the amendment, and I urge the Committee to support it.

I will finish with this point. I am ashamed to say it, because my party was responsible for the NHS for the 14 years until last year, but the fact is, as Labour Members said frequently when they were in opposition, that there are enormous resource constraints on the frontline in the NHS. I do not think that is inappropriate to consider, when we create a new service, how it might have an impact on existing treatments in the NHS. Leaving aside all the ethical questions, including on coercion and capacity and our concerns in that respect, what will this mean for hard-pressed GPs and clinicians of all sorts on the frontline? What protections can we offer them when they make difficult decisions about whether to support an assisted death application?

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[Rebecca Paul]

I thank the hon. Member for that point. There will absolutely be some occasions where that is the case, but assisted dying is a different pathway—and we have a whole Bill on it, so there will be other formalities and safeguards. We are all here to make sure that rigour is applied to that pathway. With the best will in the world, there will always be more work and pressure, especially time pressure, on doctors. That time pressure will be critical.

[Danny Kruger]

I completely agree. The hon. Member for Spen Valley makes the important point that these patients are, indeed, being treated already; one would hope that the palliative care process would continue alongside their application. It is absolutely right that they are being treated, but as my hon. Friend the Member for Reigate says, there would be additional work being done for them. Does she agree that there is also an opposite threat—that the resource being expended on the patient might be less as a result of the assisted death that they get? I am afraid to say that that would introduce a terrible new incentive into the system, as happens elsewhere.

[Rebecca Paul]

This is a complex issue, and that is why I welcome the debate on this group. There are lots of things that need to be thought through to make sure that, if assisted dying is legalised, we manage it in the most effective way for patients.

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[Sojan Joseph]

I rise to speak briefly to amendment 296. We all know how the NHS operates, how the appointment system works in the NHS and how long people have to wait to see a doctor. I do not think that my hon. Friend the Member for York Central tabled the amendment with any ill thought, but just to highlight the issue. I do not think that the amendment will make the Bill any safer or stronger, or safeguard anything, but the Committee needs to acknowledge it.

I will quote the Royal College of Physicians, which represents 40,000 doctors who primarily work in hospitals, including on palliative care. The Royal College of Physicians took a neutral position on the Bill. In its written evidence, it highlighted,

“We recognise that the ultimate decision on assisted dying rests with society through Parliament, however any changes to the law will significantly affect clinical practice beyond palliative care…Should the law change, the RCP strongly argues that assisted dying must not divert resources from end of life and palliative care provision, which are not currently adequate.”

With amendment 296, my hon. Friend the Member for York Central is trying to get the Committee to acknowledge that some NHS departments work with vacancies of 50 medical professionals. A patient who has been waiting for six months should not have their appointment cancelled because the provision here is prioritised. I think that is what my hon. Friend meant with her amendment, and I commend her thought about wider NHS provision.

[Danny Kruger]

I appreciate the point that the hon. Gentleman is making, and that he will not be able to support the amendment, but does he acknowledge that its purpose is to clarify the triage process that needs to be done by doctors? It is a perfectly appropriate request to make of doctors.

[Sojan Joseph]

I agree. It highlights the point that the impact assessment will be very important here, to see from where the resources are being pulled to provide this. The Committee should acknowledge amendment 296.

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I have been a doctor for 37 years, and have never known a psychiatrist involved in palliative or terminal care. I have never come across that as a concept. I am not saying that that is not a good idea, but it is not common that psychiatrists get involved, because the primary doctors often treat the mental health issues. For example, I have treated depression many times in people with a palliative or terminal diagnosis, because I recognised that they were depressed on top of that diagnosis. It is only in areas where we have doubt that we should be using a specialist service such as psychiatry to give us a reasonable opinion of that.

[Danny Kruger]

I appreciate the hon. Member’s point, and it is very logical that it should only be in the case of doubt, but does he not recognise that in the case of organ donation, it is mandatory? If people have this proper assessment when they are giving an organ, why should they not be asked to have one if they propose to give their life?

[Dr Opher]

That is an interesting point, but we are not discussing organ donation, and we are dealing in a different environment here; the patients we are talking about are about to die, and all we are giving them is the right to control the moment and manner of that death. I acknowledge that using a psychiatrist in organ donation has its benefits, but in this service, getting every patient—who, for example, are frail and ill by definition, because they are about to die—to see a psychiatrist is frankly neither applicable nor appropriate.

[Dr Opher]

I think it would create a barrier. We need to make sure that we deliver legislation that does what we are trying to do, which is to enable someone with a terminal illness, who has full capacity, to make a decision about the end of their life.

[Danny Kruger]

It is a very important point. Yes, we are talking about those people, but we are also talking about a different category of people who have a terminal diagnosis of six months or more, and may only be reasonably expected to die within six months. I am not just talking about people at the very end of their life, who are at death’s door; we are talking about people who qualify for the Bill, which is a much larger category of people, so it is appropriate to require them to do this.

[Dr Opher]

I agree with all of this. I think psychological assessment is incredibly important in all patients, and I personally specialise in it from a primary care basis. But we are suggesting here that the two other doctors have no ability to do any sort of psychological assessment, and that is simply not true.

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[Lewis Atkinson]

Thank you, Mrs Harris—you really are giving the Minister some exercise during these long sittings.

Amendment 14 likens assisted dying to organ donation. I understand that an organ donor, before the point of independent assessment, has had no other independent assessment, which is in stark contrast to this Bill. The idea that, by failing to support this amendment, we are somehow adopting a weaker framework than for organ donation is patently false.

As the Bill sets out, there are already at least two assessments by independent doctors. As per the amendments we have already agreed, those doctors must have training, as specified by the Secretary of State, on the assessment of capacity and coercion. The rationale behind this amendment is already met, and it is significantly more strenuous than the framework for independent assessment in the event of organ donation.

[Danny Kruger]

I am not sure that is right. The amendment insists that this referral and assessment should happen at the earliest stage possible, in the same way as for organ donation. One of the confusions of the Bill is that multiple different conversations could happen. The purpose is to ensure that this conversation with a psychologist or social worker, as per organ donation, happens at the very earliest opportunity.

[Lewis Atkinson]

I disagree with the hon. Gentleman’s reading. The amendment talks about the co-ordinating doctor, as in the first independent assessor, and that is the case in the provisions we have already adopted. Clearly, the co-ordinating doctor may consult—and must consult, as per the amendment we are about to get to—psychiatric or other expertise, if there is any doubt in their mind. Amendment 14 would not bring forward that assessment earlier than elsewhere. I urge hon. Members to bear in mind that the idea that this proposal is somehow weaker than the current human tissue regulations is absolutely false.

On the point made by my hon. Friend the Member for Bradford West, the amendment does nothing to address coercion by a medical professional who knew the person beforehand. Under the amendment, it is by definition an independent person who has no prior relationship with the person.

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[Danny Kruger]

I am afraid that that is a risk in our own country too. Does the hon. Lady acknowledge that some young women have been put on palliative care pathways in the NHS? They have been diagnosed as having terminal anorexia.

[Sarah Olney]

The hon. Member is absolutely right. The Court of Protection has described eating disorders using language typically reserved for terminal illnesses. It has described an eating disorder as being in “the terminal stage”, talked of “all treatment options” having “been exhausted” and used words such as “incurable”. It is immensely regrettable, but nevertheless the case—even though eating disorders are always treatable—that if a person suffering from an eating disorder is deemed to have capacity and is refusing treatment, there may well be nothing that can be done to stop them choosing that path, which may ultimately lead to their death.

--- Later in debate ---

Division 36

Question accordingly negatived.

Ayes: 3

---

Conservative: 2
Liberal Democrat: 1

Noes: 18

---

Labour: 14
Conservative: 2
Liberal Democrat: 1
Plaid Cymru: 1

[Danny Kruger]

I beg to move amendment 257, in clause 7, page 4, line 15, at end insert—

“and that there is no real risk that the criteria in paragraphs (a) to (g) have not been met.”

This amendment provides that the request for assisted dying will not go ahead if there is a real risk that the eligibility criteria are not met.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 258, in clause 8, page 4, line 38, at end insert—

“and that there is no real risk that the criteria in paragraphs (a) to (e) have not been met.”

This amendment provides that the request for assisted dying will not go ahead if there is a real risk that the eligibility criteria are not met.

Amendment 259, in clause 12, page 8, line 14, at end insert—

“and that there is no real risk that the criteria in paragraphs (b) to (h) have not been met.”

This amendment provides that the request for assisted dying will not go ahead if there is a real risk that the eligibility criteria are not met.

Amendment 260, in clause 13, page 9, line 34, at end insert—

“and that there is no real risk that the criteria in paragraphs (a) to (d) have not been met.”

This amendment provides that the request for assisted dying will not go ahead if there is a real risk that the eligibility criteria are not met.

Amendment 261, in clause 18, page 12, line 26, at end insert—

“and that there is no real risk that the criteria in paragraphs (a) to (c) have not been met.”

This amendment provides that the request for assisted dying will not go ahead if there is a real risk that the eligibility criteria are not met.

Amendment 262, in schedule 2, page 27, line 12, at end insert—

“and that there is no real risk that the criteria in paragraphs (a) and (b) have not been met.”

This amendment provides that the request for assisted dying will not go ahead if there is a real risk that the eligibility criteria are not met.

Amendment 263, in schedule 3, page 28, line 10, at end insert—

“and that there is no real risk that the criteria in paragraphs (a) and (b) have not been met.”

This amendment provides that the request for assisted dying will not go ahead if there is a real risk that the eligibility criteria are not met.

Amendment 264, in schedule 5, page 30, line 22, at end insert—

“and that there is no real risk that the criteria in paragraphs (a) to (c) have not been met.”

This amendment provides that the request for assisted dying will not go ahead if there is a real risk that the eligibility criteria are not met.

[Danny Kruger]

I was going to speak briefly to amendment 420(a), as per your ruling earlier, Mrs Harris.

[The Chair]

You can move it, but it cannot be debated.

[Danny Kruger]

I had misunderstood you; that is a shame. I have moved the amendment in the name of my hon. Friend the Member for West Worcestershire (Dame Harriett Baldwin), but I will not speak to it.

[The Chair]

Do you wish to speak to the amendment?

[Danny Kruger]

I do not, but other colleagues will, I am sure.

[Rebecca Paul]

rose—

--- Later in debate ---

[Kim Leadbeater]

I have nothing to add, Mrs Harris.

[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment proposed: 14, in clause 7, page 4, line 15, at end insert—

“(2A) The coordinating doctor must take the report required under subsection (2B) into account in making an assessment under paragraph (2)(b), (f) and (g).

(2B) One or more qualified persons must have conducted a separate interview with the person and made a report to the coordinating doctor on the matters specified in subsection (2C).

(2C) The matters that must be covered in the report required under subsection (2B) are—

(a) any evidence of duress or coercion affecting the person’s decision to end their life,

(b) any difficulties of communication with the person interviewed and an explanation of how those difficulties were overcome, and

(c) the capacity of the person interviewed to understand the information given to them under paragraph (9)(2), (b), (c) and (d).

(2D) A person shall be taken to be qualified to conduct an interview under subsection (2B) if that person—

(a) is a registered medical practitioner who—

(i) is registered in the specialism of psychiatry in the Specialist Register kept by the General Medical Council, or

(ii) has such training, qualifications and experience as the Secretary of State may by regulations specify,

(b) has not provided treatment or care for the person being assessed in relation to that person’s terminal illness,

(c) is not a relative of the person being assessed,

(d) is not a partner or colleague in the same practice or clinical team as the coordinating doctor,

(e) did not witness the first declaration made by the person being assessed, and

(f) does not know or believe that they—

(i) are a beneficiary under a will of the person, or

(ii) may otherwise benefit financially or in any other material way from the death of the person.

(2E) Before making regulations under subsection (2D)(a), the Secretary of State must consult such persons as they consider appropriate.

(2F) Regulations under subsection (2D)(a) are subject to the negative procedure.”—(Daniel Francis.)

This amendment, and its consequential and linked amendments (15, 16, 17, 18 and 19), would provide for an independent assessment, via an interview conducted by a specialist, of a person’s capacity to make the decision to end their own life, their clear, settled and informed wish to do so, and that they have made the first declaration voluntarily and without coercion.

Question put, That the amendment be made.

--- Later in debate ---

[Danny Kruger]

On a point of order, Mrs Harris. I defer to you, but my understanding is that amendments 346 and 348 and new clause 11, which are in group 6, have not fallen yet.

[The Chair]

They have fallen. If we are all satisfied, can we make progress?

[Danny Kruger]

You’re the boss.

[The Chair]

I was beginning to wonder, Mr Kruger.

Clause 7, as amended, ordered to stand part of the Bill.

Clause 8

Second doctor’s assessment (independent doctor)

[Danny Kruger]

I rise to speak to amendment 55, in clause 71, page 4, line 33, leave out paragraph (a).

The amendment would ensure that the independent doctor has qualifications and experience in psychiatry or in assessing mental capacity. We have heard a lot in the debate about the importance of a holistic, multi-disciplinary approach to patient care at the end of life. We have also discussed the need for that to happen throughout the process and, in particular, during the crucial stages of the patient’s assessment. In the oral evidence sessions, we heard from Dr Rachel Clarke about the need for teams to be involved with patients throughout the process. By requiring the input of a psychiatrically trained clinician in the assessment by the doctors, we would be making explicit the expectation that assisted dying should adhere to the best practice, which we already see in end of life care in our country. We would also be bringing our practice into line with jurisdictions such as Oregon, which require referral to a psychiatrist, as has been discussed.

[Kit Malthouse]

On a point of order, Mrs Harris. I do not think that the amendment is actually about qualifications or training. It is about the removal of certain assessments.

[Danny Kruger]

My right hon. Friend is absolutely right, I apologise. I am speaking to later amendments, so I apologise to the Chair and to the Committee.

[The Chair]

Do you actually want to move the amendment?

[Danny Kruger]

No. I am so sorry. The confusion of the last group has thrown me. I am very grateful to my right hon. Friend.

--- Later in debate ---

[Danny Kruger]

I am sorry for having begun speaking to the wrong amendments earlier. I was trying to speak to amendment 58—I could not read my own notes—not amendments 55 or 56.

I do not want to reheat the previous arguments about the imperative—as I believe it is—to refer to a psychiatrist. I support the suggestion of the hon. Member for Ashford and the hon. Member for Runnymede and Weybridge (Dr Spencer) that the independent doctor should have relevant qualifications in psychiatry and experience in assessing mental capacity through their professional qualifications. The importance of having a holistic multidisciplinary team has been well argued and subsequent amendments to the Bill have attempted to delivered that.

I want to emphasise that if we adopted the amendment tabled by the hon. Member for Ashford, we would be acknowledging the reality that assisted dying is not like other medical decisions. By explicitly including psychiatrically trained clinicians, we would be giving special regard to the mental state of patients making an existential decision, not just a treatment decision. That is particularly appropriate for patients who are not expecting to significantly suffer bodily due to their terminal illness.

We have heard many stories of people who have died in painful or undignified ways, but that does not reflect the experience of the majority of those with a terminal illness—90% of cases, according to some studies—who are able to receive adequate or complete pain relief. For people who do not have an obvious motivation to have an assisted death, such as avoiding extreme pain, an investigation by a psychiatrist of their mental state would surely help to safeguard against those with depression or other ameliorable mental conditions that impair capacity accessing an assisted death.

I want to emphasise the evidence that we received from Professor Gareth Owen, who in 2021 conducted a large-scale survey of medical professionals in England and Wales. That found that non-psychiatric doctors—general practitioners and other doctors not trained in psychiatry—were less confident than other professionals in assessing capacity. It also found that 6.9%—less than 7% —of non-psychiatric doctors rated themselves as assessing capacity very well, which I think is significant. To place all the responsibility for assessing capacity and coercion, which are difficult to assess and contain complexities that psychiatrists are best placed to appreciate, in the hands of doctors who do not have specialist expertise is to be content with coercion being missed and capacity being poorly assessed. If we want to ensure that these tests are done well, the only way to do that is to involve psychiatrists, as the hon. Member for Ashford said.

[Sean Woodcock]

I will speak briefly on amendment 21, although I will commend my hon. Friend the Member for Ashford for his contribution to the debate. He speaks with clear expertise and experience, and a real love for his profession, and we all benefit greatly from his insights.

Over the last few weeks, I have found myself voting the opposite way from the promoter of the Bill on a number of occasions, but I am not opposed to assisted dying in principle. My issue is more about whether we can ever make it safe enough; the difference between us is marginal. One thing that has been apparent throughout these debates is her passion for improving the training for those involved in palliative care, and in the wider NHS and social care generally.

That is why I want to speak to amendment 21. In the witness testimony, particularly from Rachel Clarke, there was a lot of concern about whether coercion and people being put under pressure to go for assisted dying would be picked up, and whether the NHS was geared up for that. I think that this amendment, tabled by my hon. Friend the Member for Lowestoft, goes some way to addressing that.

I do not think training is a silver bullet, hence my votes over previous weeks, but it would make a massive difference. That is true not only for the implementation of the Bill; it would have wider benefits for the NHS, social care and palliative care more generally. Even though those are not necessarily in scope of the Bill, I suggest that they are good things, which is why Committee members should get behind amendment 21.

Terminally Ill Adults (End of Life) Bill (Twentieth sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[The Chair]

I remind the Committee that with this we are discussing the following:

Amendment 317, in clause 13, page 9, line 12, leave out “14” and insert “28”.

This amendment would provide 28 days for the second period of reflection instead of 14.

Amendment 314, in clause 13, page 9, line 17, leave out

“48 hours beginning with that day”

and insert

“7 days beginning with that day and the person must be referred immediately for urgent specialist palliative care.”

This amendment would increase the second period of reflection in cases where the coordinating doctor reasonably believes the person will die within a month from 48 hours to seven days.

Amendment 315, in clause 13, page 9, line 17, leave out “48 hours” and insert “7 days”.

This amendment would increase the second period of reflection in cases where the coordinating doctor reasonably believes the person will die within a month from 48 hours to seven days.

[Danny Kruger (East Wiltshire) (Con)]

It is a pleasure to serve under your chairmanship once again, Sir Roger. I am looking forward to this week’s debating.

I want to draw the Committee’s attention to further evidence that has come in since the debate got under way. Since we started the Committee, we have had more than 400 pieces of evidence, so I apologise for not having got to this earlier, but it is relevant. I do not want people who have submitted evidence to us to feel that their submissions have fallen into a black hole and are not being considered, and I think this is significant evidence. We are talking about the necessity of a proper period of reflection, which is acknowledged in the Bill—it is understood that it is inappropriate for people to be able to request and receive an assisted death in very short order. The debate is about the extent of that reflection period. I am supporting amendments that suggest that we need slightly longer in some cases.

I want to refer to two pieces of the evidence that has come in. One is from six palliative care doctors who wrote that

“our experience is that many patients experience a period of adjustment to ‘bad news’ and may say that they cannot live under these conditions. However, after a period of reflection and adjustment, the majority come to find peace and value in their altered life circumstance, in a way they would not have believed possible. This may often take many weeks and sometimes short months. It is our profound concern that the two ‘periods of reflection’…would not allow time for this adjustment. This is even more so the case where these periods of reflection are reduced for patients predicted to have an even shorter prognosis. It is thus a reality that patients and their families may miss out on a period of life they would have valued by seeking to end their lives prematurely, and these days, weeks and perhaps even months will never be regained.”

The other piece of evidence is from Tom Pembroke and Clea Atkinson, who are experts in hepatology and palliative care in Cardiff. They raised the problems of the seven-day reflection period where there is alcohol misuse. I do not think this topic came up in last week’s debate, but it is worth acknowledging because liver disease is the most common cause of death for people in middle age. It is also worth noting that liver disease disproportionately affects the people who are most disadvantaged in our society. These experts say:

“Prognostication in advanced liver disease is challenging as management of the underlying causes, including abstinence from alcohol, potentially reverses advanced liver failure…The neurocognitive and depressive effects of alcohol misuse disorder frequently requires more than seven days to resolve following abstinence. Advanced liver disease frequently manifests with hepatic encephalopathy which can affect the ability to make informed decisions.”

Their concern is that

“A seven-day review period is not sufficient to ensure that there is an enduring wish to die which is not influenced by alcohol misuse.”

Considering the prevalence of alcohol misuse in our society, the extent to which so many people tragically die of it and the difficulties in prognostication, I suggest to the Committee that there is a particular argument to be made for extending that short period at the end for the expedited process that is being considered. I beg the Committee to consider accepting the amendment.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship again, Sir Roger.

Amendment 301 would prolong the first period of reflection, after which point the independent doctor can conduct the second assessment. In the original draft of the Bill, the first period of reflection is seven days, but the amendment would extend that period to 14 days. That means 14 days would have to pass between the time that the co-ordinating doctor has made their statement following the first assessment, and the independent doctor carrying out the second assessment.

Amendment 317 would increase the duration of the period of reflection before a person may make a second declaration from 14 days to 28 days. It relates to cases where a person’s death is not reasonably expected within one month of the date of the court’s declaration.

Amendments 314 and 315 would increase the duration of the second period of reflection before a person may make a second declaration, in cases where a person’s death is reasonably expected within one month of the date of the court’s declaration, from 48 hours to seven days. They would also introduce a requirement for a mandatory immediate referral for urgent specialist palliative care. The requirement would be introduced into the definition of the second period of reflection. It is unclear what impact it would have on the duration of the period of reflection. The amendments do not say who should be responsible for making the referral or where it should be recorded. The drafting is also ambiguous as to what happens if a person does not consent to such a referral or care.

I hope these observations are helpful to the Committee in considering the Bill and the amendments put forward by various Members. Whether these amendments should form part of the Bill is a matter for the Committee to decide.

[Naz Shah (Bradford West) (Lab)]

I have a couple of additional comments. We talked last week about the reflection periods. I referred to the fact that when even someone buys something from a shop, they have 28 days to return it; when they are deciding on whether to have an assisted death, there is a great deal more at stake. During that debate, someone asked, “What if someone had a prognosis of just one month?”, but clause 13 has an option for a fast-track process in that situation—the person would be able to access the service in 48 hours.

I beg to differ with my hon. Friend the Member for Spen Valley, the Bill’s promoter, who said that we have enough reflection periods in the Bill. Yes, there are reflection periods, but they come after the panel’s decision. The reality is that the NHS is under so much duress, with patients waiting weeks to see their GP for anything other than urgent treatment, that getting an appointment with another GP in seven days is unlikely; it is unlikely to happen given how uncommon that is at the moment. It is right that doctors are able to triage their patients to prioritise those who require medical intervention to keep them well, to prevent hospital admission, or to stop them deteriorating or even dying.

The Government are trying to protect the NHS, and the best way of achieving that is to ensure that medical interventions are provided at the earliest opportunity before a patient deteriorates. In some cases, a medical appointment may need to take priority over an appointment for an assisted death. If someone who is dying has longer—even just a further week—in which to reflect, it removes the pressure from GPs and consultants, and enables them to prioritise properly their patients. It does not build up false expectation in patients that they have a right to a rapid consultation process. Likewise, we know that it can currently take a few weeks for patients to see another consultant, if not months or even over a year. It is therefore more helpful for the patient to have a more realistic period of reflection before moving to the next stage of their assessment.

Issues of such intensity as someone planning to take their own life should not be rushed. We know from all the work that has been undertaken on suicide that other interventions and conversations can help with reflection and reconsideration. It is important that people are given this opportunity. In their first raising the matter with a doctor, the doctor would have provided a lot of information about alternatives to the patient, such as what treatment options would be available. Perhaps they would have had a discussion with a palliative medicine consultant to review their options. There needs to be time for a patient to really reflect on all this new information. If the patient does want to explore assisted dying, there will also be all the conversations about drugs and their impact, which we will come to when we discuss later clauses.

Amendment 317 to clause 13 seeks to increase the reflection period from 14 days to 28 days. I gently suggest that we should have the reflection period before the decision, whether it be by the judge or a panel, to give people the right amount of time to consider; currently, the reflection period is afterwards. This is such a monumental decision that people should be able to contemplate all other options available. As it is, the process is rushed, and a patient could be caught up in the moment of concentrating on getting through the stages. I appreciate that others have suggested that once we have got past that stage, with the paperwork and all those things out of the way, then there is time to reflect. During the process, however, the patient has not had time to consider the options in making their decision. I am not convinced that there is enough reflection during, as opposed to after, the process.

Amendment 314 seeks to increase the reflection period from 48 hours to seven days for patients who have been given a month to live. In that case, seven days is quite adequate time to reflect on the information they have received to make informed choices. If this is about autonomy, which my hon. Friend the Member for Spen Valley has talked about many a time, it is important for people to have choices. To have that autonomy is surely to have the options in front of us and be able to consider them in detail.

In considering whether to sit on this Bill Committee, I slept on the decision. I can usually make instantaneous decisions, but knowing the amount of work, knowing that I was new to the subject, and knowing the things that I knew then—not the things that I know now—it was a big decision for me. I was even thinking about how I would manage the workload. We are talking about something that is not at all comparable. We are talking about somebody who will be taking a decision to potentially exercise the right—if the Bill becomes law—to an assisted death. That is really important for me.

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendments made: 195, in clause 8, page 4, line 40, leave out “statement” and insert “report”.

This amendment is consequential on Amendment 420.

Amendment 421, in clause 8, page 5, line 4, leave out subsection (5) and insert—

“(5) After carrying out the second assessment, the independent doctor must—

(a) make a report about the assessment (which must meet the requirements of regulations under subsection (5A)), and

(b) give a copy of the report to—

(i) the person who was assessed,

(ii) the coordinating doctor,

(iii) if neither the independent doctor nor the coordinating doctor is a practitioner with the person’s GP practice, a registered medical practitioner with that practice, and

(iv) any other person specified in regulations made by the Secretary of State.

(5A) The Secretary of State must by regulations make provision about the content and form of the report.

(5B) The regulations must provide that the report must—

(a) contain a statement indicating whether the independent doctor is satisfied as to all of the matters mentioned in subsection (2)(a) to (e);

subsection (2)(a)

(b) contain an explanation of why the independent doctor is, or (as the case may be) is not, so satisfied;

(c) contain a statement indicating whether the independent doctor is satisfied as to the following—

(i) that a record of the preliminary discussion has been included in the person’s medical records;

(ii) that the person signed the first declaration;

(iii) that the making of the first declaration has been recorded in the person’s medical records;

(iv) that the first declaration has not been cancelled;

(d) be signed and dated by the independent doctor.”—(Kim Leadbeater.)

This amendment provides that the independent doctor must make a report about the second assessment, and makes provision about the report.

[Danny Kruger]

I beg to move amendment 348, in clause 8, page 5, line 10, at end insert—

“(c) inform the person’s usual or treating doctor and, where relevant, the doctor who referred the person to the independent doctor, of the outcome of the assessment.”

This amendment would ensure that the independent doctor communicates the outcome of their assessment to the referring doctor as well as the usual or treating doctor.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 303, in clause 8, page 5, line 12, at end insert—

“(aa) has confirmed that no other practitioner has undertaken a second assessment for the same person.”

This amendment would prevent a patient from seeking multiple assessments from different doctors.

Amendment 458, in clause 10, page 6, line 45, after “declaration” insert “and if there has been a material change of circumstances,”

Amendment 459, in clause 10, page 7, line 3, at end insert—

“(2A) (a) Where a referral is made to a registered medical practitioner under subsection (1), the coordinating doctor must provide that new registered medical practitioner with the report by the independent doctor setting out their reasons for refusal.

(b) If the new registered medical practitioner reaches a different conclusion from the original independent doctor, they must produce a report setting out why they disagree.

(c) Those two reports must be made available to any subsequent decision maker under this Act and to the Commissioner.”

Amendment 460, in clause 10, page 7, line 9, leave out “particular”.

[Danny Kruger]

This is a key group of amendments. I shall specifically speak to amendment 303, which would prevent a person from seeking multiple assessments from alternative doctors if a second assessment had already been undertaken. I am not sure that I will press that amendment to a vote, but it is important to explore this issue. I will take the view of the Committee on it.

Last week, my right hon. Friend the Member for North West Hampshire said that it was important to avoid doctor-shopping. He made that point in reference to the suggestion that there would be a list of professionals that would administer the procedure. I respect that view; I think it is absolutely right. It needs to be clear in law that we avoid doctor-shopping. For that reason, it is important that the independent doctor should seek to establish whether the patient has previously had a second assessment. That could be very material.

Clause 10 states:

“In consequence of a particular first declaration made by a person, the coordinating doctor may make only one referral for a second opinion under subsection (1).”

This only limits the number of times that a person can seek another medical assessment. Amendment 303 to clause 8, in the name of the hon. Member for York Central (Rachael Maskell) , would further strengthen the current safeguards against doctor-shopping, by placing a duty on the doctor to confirm that there had not been previous assessments.

Doctor shopping is not a hypothetical concern. We have seen it take place in other jurisdictions. An understanding develops that some doctors are more likely to grant an application for an assisted death. That is totally natural. Professor Preston said in oral evidence to us:

“People go doctor shopping—they are going to multiple doctors until they get the right answer.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 245, Q315.]

According to an official report in 2021, one Oregon doctor wrote one eighth of all the prescriptions for assisted death. I met a doctor in Canada who had performed hundreds of assisted suicides. It was her whole practice; that was what she did, and people knew to go to her.

Doctors who are reluctant to grant an application may instead refer a person to doctors they know are more likely to grant the person’s application for an assisted death, so those practitioners become the go-to when other doctors deny applications. Over time, the safeguards can become weakened and circumvented by a system of doctors who apply the criteria quite loosely, as was found in Ontario. The Ontario review committee found evidence of patients doctor shopping for approval. Some 8% of non-terminally ill people who died by assisted dying had made previous requests. People do try again, naturally enough, if they do not get the answer they wanted.

--- Later in debate ---

[Naz Shah]

Does the hon. Member share my concern that if a doctor refused somebody an assisted death because they thought there was some form of coercion, the door could be open for people to keep going back through this route?

[Danny Kruger]

The hon. Lady is absolutely right. We will address in later debates the point that insufficient attention will be given to the reasons why an application has been refused. If an application has been refused on the grounds of coercion, a future doctor will not necessarily know that that was the reason. As the hon. Lady says, in cases of coercive control there is a very real danger that if a person has been unduly influenced to seek an assisted death and the doctor declines their application, possibly because they detected coercive control, the patient can then be coerced, or influenced, into starting again with a new doctor. There is nothing to stop that in the Bill. We have a real problem, and I hope the Committee will consider the amendments.

[Sarah Olney (Richmond Park) (LD)]

It is a pleasure to serve under your chairmanship, Sir Roger. I will speak to my amendments 458 to 460, which would tighten the process around seeking a determination from a second independent doctor if the first has refused to say that the criteria are met. The amendments relate to clause 10, which I will say more about when we come to it, but they have been selected for debate in this group.

The risks of abuse in seeking a second independent doctor’s opinion are well illustrated by the evidence we have received from Dr Sharon Quick, the president of the Physicians for Compassionate Care Education Foundation, who tells us about the experience of Dr Charles Bentz, who refused to provide a second opinion for a physician-assisted suicide for a patient he had referred to an oncologist for cancer treatment. The co-ordinating doctor persisted and clearly found a compliant second opinion, as two weeks later his patient was dead.

Dr Charles Bentz said in his testimony:

“I was caring for a 76 year-old man who came in with a sore on his arm. The sore was ultimately diagnosed as a malignant melanoma, and I referred him to two cancer specialists for evaluation and therapy. I had known this patient and his wife for over a decade. He was an avid hiker, a popular hobby here in Oregon. As he went through his therapy, he became less able to do this activity, becoming depressed, which was documented in his chart.

During this time, my patient expressed a wish for doctor-assisted suicide to one of the cancer specialists. Rather than taking the time and effort to address the question of depression, or ask me to talk with him as his primary care physician and as someone who knew him, the medical oncologist called me and asked me to be the ‘second opinion’ for his suicide. She told me that barbiturate overdoses ‘work very well’ for patients like this, and that she had done this many times before.

I told her that assisted-suicide was not appropriate for this patient and that I did not concur. I was very concerned about my patient’s mental state, and I told her that addressing his underlying issues would be better than simply giving him a lethal prescription. Unfortunately, my concerns were ignored, and approximately two weeks later my patient was dead from an overdose prescribed by this doctor. His death certificate, filled out by this doctor, listed the cause of death as melanoma. When I reviewed his chart, the radiation oncologist documented a clear diagnosis of depression.

My patient did not die from his cancer, but at the hands of a once-trusted colleague who failed to recognize and treat his depression. This experience has affected me, my practice, and my understanding of what it means to be a physician. What happened to this patient, who was weak and vulnerable, raises several questions that I have had to answer.”

I appreciate that, under the Bill, Dr Bentz could not have been the independent doctor as he already knew the patient and was treating him, but in that case that contributed to enhanced safety. Dr Bentz’s example illustrates the real risks of abuse in a person being able to seek the opinion of a second independent doctor. The starting point is that the task of the independent doctor is not that of a normal doctor. It is not to cure the patient or to provide advice about medical treatments: it is to check whether the eligibility requirements are met. It is a decision-making function, not a medical one—albeit, of course, a decision-making function that is informed by medical expertise.

In the light of that function, it is not appropriate for someone to seek another decision simply because they do not like the answer that has been given. The independent doctor is asked to apply an objective set of criteria against the evidence in front of them in order to make an assessment. It is not the case—or it should not be—that a different doctor would come to a different assessment based on the same criteria and the same evidence. If we are doing our job properly in the Committee, we should not expect that a second opinion could be arrived at.

I have no objection to provision being made for a person to see a second independent doctor if the first did not manage to finish the task. Nor do I object in respect of cases in which there is a change of circumstances—for example, if the patient’s condition deteriorates to such a degree that although the first independent doctor thought the six-month prognosis test was not met, it becomes clear that it is met—which is the point of my amendment 458. In such circumstances, it would make sense to allow the patient to go to a second independent doctor. Although my preference in such a situation would be to go back to the original independent doctor and ask them to reconsider in the light of the change of circumstances, that may not always be possible. Amendment 458 is an attempt to find a middle ground.

Amendment 459 seeks to reduce the possibility of abuse by ensuring that the second independent doctor has available the reasons why the first independent doctor concluded that the person was not eligible. That would allow the second independent doctor to approach the assessment with open eyes. Such a report would be particularly useful when it comes to the detection of coercion or pressure, as the first independent doctor might have spotted something that the second independent doctor might not easily see.

Let us consider the evidence of Dr Tim Howard, who has been deeply involved in end-of-life palliative care and assisted dying for many years. He has been a non-exec director of a health authority, a member of an ethics committee, a postgraduate teacher and, finally, chair of the General Medical Council fitness to practise tribunals, dealing with complex medico-legal principles and decisions in public. He also helped to set up the Medical Practitioners Tribunal Service, which separated medical standard setting and investigation from adjudication.

Dr Howard says:

“I remain uncomfortable that when either doctor, the assessing doctor or the independent doctor, declines to agree with a request for”

assisted dying,

“they take no further action. I feel that the reasons for their refusal should, as well as being given to the patient, be recorded in the patient’s notes, and given to any ‘second opinion’ independent doctor. This is not an attempt to bias; it is a value judgement that criteria are not being met, and as such, is sharing an early warning to be extra careful.”

The Committee should note that he has, in his own words,

“been a strong proponent of medical assistance in dying…and a member of Dignity in Dying for many years.”

[Danny Kruger]

It does seem an extraordinary gap in the Bill, but I am afraid it is not unique to this Bill. In countries where assisted dying in some form is legal, there are remarkable failures to insist on the proper recording of applications that are declined or about which there are concerns. This speaks to the general cloud of unknowing that we are operating in. Does the hon. Lady agree that were we to pass the Bill, it would be great if, at least in this country, we kept proper records?

[Sarah Olney]

The hon. Member is exactly right. An assessment of whether somebody should qualify for assisted dying needs to be based on objective criteria. If those are not met, the only way that a second independent doctor should have a role is if either the circumstances have changed or, for whatever reason, the first doctor is unable to reach a conclusion. There must not be a situation in which the first doctor has made one decision and a second doctor arrives at a different decision, because that would imply a variability in the way the objective assessments are made. Not tightening this loophole would imply that we are prepared to allow such a variability across the medical profession, and I do not think we should allow that.

My final amendment in this group is amendment 460. I am concerned that the word “particular” in clause 10(3) negates the subsection’s purpose of ensuring that only one second opinion from the co-ordinating doctor can be sought, because a person could withdraw their first declaration, make a new one and start the process afresh; that declaration would then not be the “particular” first declaration. By removing “particular”, the loophole would be closed, and the safeguard would be made more effective. This concern was brought out well in Disability Labour’s written evidence:

“We are concerned that whilst 10(3) only allows for one second opinion to be sought, there appears to be nothing in the bill that stipulates a waiting period before a new application can be made. This risks applications being repeated until a supporting opinion can be obtained, thus negating the purpose of 10(3).”

I hope the Committee will accept my amendments.

--- Later in debate ---

[Sarah Olney]

Will the hon. Gentleman give way?

[Danny Kruger]

Will the hon. Gentleman give way?

[Dr Opher]

Actually no, I will not. I will go on, if that is okay.

Amendment 459 states that the second-opinion doctor “must produce a report” outlining their reasons for reaching a different opinion, but the whole nature of this is that the doctor is independent. As we have heard, if it is suggested that someone either is or is not allowed to get an assisted death, that might affect the assessment of the independent doctor. It would not be good medical practice to have that assessment in front of the independent doctor—that would lead to poor assessments. We need a right to a second opinion and we should have a truly independent doctor.

Amendment 460, which is the last in the group, would allow a patient only one declaration in any part of their lives, even if circumstances change. Although there will be vanishingly few instances where that would be relevant, I do not feel that such a provision would make the Bill any fairer or safer.

Amendment 143, tabled by my hon. Friend the Member for Broxtowe, would allow a second and a third opinion. It is my opinion, and the opinion of many of us, that we do not want doctor shopping. We want to allow one second opinion from an independent doctor, but not more than that.

--- Later in debate ---

[Kim Leadbeater]

I associate myself with the Minister’s comments regarding the other amendments in the group; however, I listened carefully to the debate on amendment 459 and the points made by the hon. Member for Richmond Park, my hon. Friend the Member for Stroud and the Minister. My view on that amendment has changed: I do think independence is really important in the doctor’s opinions during the normal process that the Bill sets out. However, it is a really fair point to make that if the independent doctor refuses the patient, there needs to be transparency about that, and it is important that everybody involved in the process can see how that decision has been made. That is a really valid point. It is a good example of how this Bill Committee is operating, and should be operating, in that we have been listening to different views and opinions.

I take on board the Minister’s point on capacity. We need to be aware of that. We will hopefully debate the third layer later today. That layer may be a panel of experts who are there to oversee the full picture of the patient journey. For them to see what has happened with the doctors that they have interacted with is very important. Therefore, I am minded to support amendment 459.

[Danny Kruger]

I want to respond to a point made by the hon. Member for Stroud. It is relevant to the whole debate about whether we are talking about a medical treatment at all. He made the point, in respect of the question of a second or subsequent referral to an independent doctor, that it is appropriate in medicine to have second opinions; he said that that is normal in medicine, and he is absolutely right. Indeed, there is nothing to stop a patient seeking a third, fourth or any number of opinions if they want to do that and can get a doctor to consider them. The fact is that what we are discussing here is not a medical diagnosis—that is not what is being asked for when someone goes to see the second doctor, or indeed the first. What they are asking for is permission to proceed with the process.

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[Kim Leadbeater]

Amendment 201 provides that the duty on an assessing doctor to examine a person’s medical records is limited to records appearing to the doctor to be relevant, which makes sense. Amendment 422 requires an assessing doctor to make such inquiries of professionals who are providing, or have recently provided, health or social care to the person as the assessing doctor considers appropriate. Amendment 423 requires the assessing doctor to consider whether they should consult health or social care professionals, and to consult them if they consider there is a need to do so. A record of any consultation must be shared with the other assessing doctor.

The amendments seek to emphasise the importance of taking a holistic and multidisciplinary approach to the assessments by both doctors. The Bill as drafted provides that the assessing doctor must

“make such other enquiries as the assessing doctor considers appropriate”

when making the first and second assessments. With the amendments, I have sought to strengthen that language, by being much more explicit and making specific reference to consulting health and social care professionals. I have done so in response to the evidence we have received from professionals such as nurses and social workers, who often spend a significant amount of time with terminally ill adults.

It is clearly right that the assessing doctors should have access to all relevant details of a person’s medical records. If the records show that the person has recently been receiving health or social care, that may impact their application, so the doctors have to consult the providers of that care. As is the case at all stages in the process, records should be kept of any and all such discussions, and reports should be shared where appropriate.

Taken together, the amendments would ensure that the doctors’ assessments are thorough and comprehensive, and have taken into consideration the views and opinions of any wider health and social care team that may be working with a patient.

[Danny Kruger]

I will speak briefly to each of the amendments in this group. I will allow my hon. Friend the Member for Reigate to speak to the amendment in her name, but I state clearly that I very much support it. In my view, it is very important that the doctor asks the simple question of the patient, “Why do you want an assisted death?” The question is not being asked at the moment.

I respect the points that the hon. Member for Spen Valley has just made about amendment 201, and that the amendment may be intended to focus assessments on the information that is relevant. Nevertheless, it would introduce subjectivity into what is deemed relevant, and by narrowing the scope of the review of patient records, it could unintentionally allow for incomplete assessments, thereby undermining the safeguards that we all want to see. The risk is that potentially crucial medical history, including past mental health concerns, poor coercion indicators or undisclosed diagnoses, might be overlooked.

I call the Committee’s attention to the evidence from the British Geriatrics Society, which raised concerns that the definition of terminal illness in the Bill is often vague and risks misclassification, especially for older patients. Limiting the review of medical records could exacerbate that issue, as doctors may not have a full picture of the patient’s long-term prognosis and their mental health history. The General Medical Council has called for strong regulatory oversight to ensure that eligibility assessments are thorough.

Allowing doctors to determine which records are relevant, without standardised criteria for that judgment in the Bill, risks inconsistency and potential misdiagnosis. The criteria should include diagnosis and prognosis, treatment history, consultation, second opinions and mental health history. Consideration should also be given to disclosures of domestic violence and abuse, or patterns in medical records that might indicate domestic abuse without explicit disclosure, such as frequent visits for unexplained pain, chronic pain complaints, mental health concerns such as anxiety and depression, inconsistent explanations for injuries, and multiple visits to different healthcare providers. All of that should be properly considered by the assessing doctor.

I draw the Committee’s attention to the fact that in the Netherlands, 1% to 2% of assessments annually—a significant number when we consider the volumes we are talking about—are deemed “not careful” under the law. Other countries do not have adequate ability to look into the data, but that is significant, and it is often due to inadequate consultation or documentation. I also draw attention to the fact that in our country, I am afraid to say, the cause of death listed by doctors is too frequently inaccurate. Analysis of postmortems suggests that one in 20 deaths have been wrongly recorded. Clearly, mistakes are made in medical records, and therefore it is particularly appropriate to require doctors to give complete consideration to the full medical history of the patient.

I recognise very much that we are trying to create a Bill that works in practice; nevertheless, I think we can emphasise streamlining and efficiency at the expense of patient safety, and we are doing that here. If we tell doctors that they are only required to sift through records that appear relevant to them—a quick skim of recent notes, a glance at the obvious items in a medical history—that may sound efficient, streamlined and practical, but it is likely to leave the vulnerable exposed, in particular when social workers and psychiatrists are not involved at this early stage, as they plainly should be. No multidisciplinary team is looking at the patient at this stage.

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[Lewis Atkinson]

Does the hon. Member share my concern that the wording in medical records has no duration over a person’s lifetime? For example, consulting all the medical records of someone in their 70s or 80s at the end of their life would surely include the records from when they were a child—childhood vaccinations, the removal of tonsils and so on—and that would clearly be impractical. Does he not agree that amendment 201 would clarify that element?

[Danny Kruger]

What the amendment clarifies is that the doctor does not have to look at any records at all unless he or she considers them relevant. It gives total discretion to the doctor to disregard huge swathes of the patient’s history. Yes, I do expect the doctor to review the entirety of a patient’s record—obviously, the record of a childhood broken leg can be skipped over quickly. What I do not want to do, as the Bill currently does, is allow the doctor to say, “Oh, I missed this evidence of a mental health condition” or “this indication of coercion from five or 10 years ago, because I didn’t consider that aspect of their records to be relevant.” It places a significant obligation on the doctor, but that is, I am afraid, what we are doing in the Bill. We are placing huge obligations on doctors and we should do it properly.

[Dr Opher]

As the amendment states, it is about examining medical records for things that are relevant. If we are talking about coercion or capacity, these sorts of items will be relevant. I do not know if Members have ever seen medical records. Some people have extremely large medical records, and we have summaries for that, but if a part of that summary indicated something that we were suspicious of, we would look into it. As my hon. Friend the Member for Sunderland Central has just said, the complexities of childhood tonsillitis do not really need to be examined in this case. We have to, and we always do, specify what we look into doctors.

[Danny Kruger]

As I have said in my many exchanges with the hon. Gentleman, I want to see the good practice that he claims—absolutely accurately, I am sure—to perform is applied across the system. He says that if doctors see in the summary some indication of concerns, they will look more closely into it. Well, I jolly well hope they would. The problem is that the summary might not be complete. I suppose the distillation of my point is that we should say, “Don’t rely on the summary. Proceed with a proper analysis. Take responsibility for making sure that you have reviewed the entirety of the patient’s record.”

We have to address throughout our consideration of the Bill the workload that we are placing on busy professionals. Nevertheless, if we consider that this matters—and it is a question about knock-on effects on the NHS, which we could discuss in due course—it is appropriate to expect proper time to be taken. A specialist with two hours and a full record in front of them might spot the misdiagnoses, question the prognosis, flag the depression and catch the abuse. If given half the time and a licence to skim the record, as the amendment would give them, they could very easily miss something, so I think the word “relevant” is a great gamble.

[Lewis Atkinson]

The hon. Member is discussing amendment 201, but there is also amendment 422, which indicates that the professional should make inquiries of other healthcare professionals who have been involved in treatment recently. Does he not agree that that would mitigate against the sort of scenario he describes?

[Danny Kruger]

I will come on to that. I agree with him: amendment 422 is a very helpful amendment, and I support that. It is a very good suggestion that wider consultation should be made, and it is a point that we have been trying to make with amendments throughout. I recognise that that would enhance the safeguards in the Bill—I am grateful to the hon. Gentleman.

Amendment 422 seeks to introduce an additional requirement that the assessing doctor must consider whether to consult health or social care practitioners who are providing, or have recently provided, care to the patient. The amendment is presented as addressing previously expressed concerns, but I regret to say that I feel it is excessively weak. It is a positive step in recognising the issue, but it does not ensure a broader and more informed assessment of a patient’s condition and external influences.

Patients with terminal illnesses often receive care from palliative care teams, social workers or community nurses who might have crucial insights into their wellbeing and the potential external pressures on them. The British Psychological Society has highlighted that mental health and social pressures are often overlooked in assisted dying requests in other countries. Social workers and allied health professionals play a key role in assessing whether a patient feels pressurised due to financial, social or familial burdens. As I have repeatedly said and we will debate further in due course, in my view it is very important that that assessment comes earlier in the process.

We have evidence from doctors—I will not cite it at length—pointing out that independent doctors who refuse assisted dying requests are often ignored, and patients are simply referred to another doctor willing to approve the request, as we have discussed. Consultation with health and social care professionals could act as an additional safeguard against that practice. Although the amendment introduces an obligation to consult other professionals, it leaves it to the discretion of the assessing doctor. It relies on the doctor’s subjective judgment

“if they consider that there is a need”.

I think that is too weak for assisted dying, where consistency is so critical. One doctor might consult a palliative care specialist to explore pain relief options, while another might not, assuming that they understand the patient’s suffering sufficiently. The variability in the Bill—this discretion—undermines fairness and safeguarding.

There is also a lack of accountability in what is a very sensitive process. There is no requirement to document the consideration process, which weakens oversight in a context where errors could be fatal. I respect the point made by my right hon. Friend the Member for North West Hampshire that we must not police conversations and that being prescriptive may encourage a tick-box approach. I am afraid that we risk that tick-box approach if this amendment is all that we do on this subject. We can imagine a scenario in which a doctor simply makes a note in the record with little underpinning substance.

There is also no obligation to act on the specialist input, so the duty ends at the consultation. There is no requirement to integrate the findings of the additional input that the doctor has received, which is a glaring flaw in what is an irreversible procedure that is being authorised. Finally, there is insufficient rigour for the ethical stakes. This discretionary duty is too weak to catch the difficult cases.

[Kim Leadbeater]

On the hon. Member’s point about recording those consultations, amendment 423 states in its proposed new subsection (2B):

“Where an assessing doctor consults a professional…the assessing doctor must give a written record of the consultation to the other assessing doctor.”So the consultation is recorded.

[Danny Kruger]

The hon. Lady is absolutely right, and that is very welcome. My concern is that there is no obligation to do anything about it. There is no obligation for the doctor to integrate the conclusions of the additional professionals that they have consulted into their treatment. I recognise that that provision is valuable and I welcome the amendments, but I suggest that they do not go far enough.

Let me use a hypothetical example to bring my point home to the Committee. Imagine a woman with terminal lung cancer asking to end her life. Her assessing doctor considers consulting a palliative care specialist for symptom control or a social worker to check on her home life, but decides, “My notes are enough. There’s no need for that.” What if the patient’s pain could be eased with a new approach that the doctor does not know about? What if her family’s pushing her to spare them the burden of her care goes unnoticed without a social worker’s input? The lady might die needlessly or be denied treatment unfairly.

The discretionary duty that the amendment would introduce essentially collapses because it does not force the broader scrutiny that patients deserve. The amendment sees the problem, but it is too feeble: it is too discretionary, too vague and too unenforceable for a choice as profound as assisted dying. While I will support it, I do not think it goes far enough.

Amendment 423 builds on amendment 422 by requiring that if the assessing doctor consults a specialist, a written record of that consultation must be shared, as the hon. Member for Spen Valley just mentioned. It is critical for transparency, consistency and accountability in decision making. In high-stakes cases, such as assisted dying requests, paper trails matter. Without a formal record, one assessing doctor might dismiss concerns raised by another professional without accountability—a point made by the hon. Member for Richmond Park.

As I pointed out in an intervention on the hon. Member for Richmond Park, it is remarkable how few jurisdictions around the world have such safeguards. The American model in Oregon, Washington and California does not track how many doctors a patient consults before finding one willing to approve an assisted dying request, so we do not know the extent of doctor shopping abroad. Canada’s system does not require refusals to be formally documented, making it difficult to assess the patterns of approval. Ensuring that records are available to both assessing doctors would add an extra layer of scrutiny and help to prevent doctor shopping.

However, while the amendment is a step in the right direction, it does not require an independent review of the records. Sir James Munby, the former president of the family division of the High Court, has criticised the lack of procedural rigour in oversight mechanisms, warning that assisted dying laws risk becoming a rubber-stamp exercise if refusals and approvals are not documented with transparency. The Royal College of General Practitioners has called for independent oversight of the entire process, not just a reliance on individual doctors. These amendments would partially address that, but would not fully resolve it.

Amendments 422 and 423 are welcome but otiose: they would simply give doctors permission to do what they should be doing anyway. If they are conscientious, they will do it anyway, and if not, they will not. It is slightly like an illegal gun amnesty: the good guys will not have illegal firearms in the first place, and the bad guys with guns are not going to hand them in voluntarily. I fear that we are requiring good behaviour of good people, and not requiring it of doctors who are not doing their job properly.

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[Rachel Hopkins (Luton South and South Bedfordshire) (Lab)]

It is a pleasure to serve under your chairship, Sir Roger. I rise to speak in support of amendments 201, 422 and 423, which stand in the name of my hon. Friend the Member for Spen Valley, and against amendment 468.

On amendment 201, a point was made earlier about the relevance of records. It was mentioned that it might well not be relevant to look at a childhood tonsillectomy. However, I wish to speak in slightly more specific terms, in support of women and their reproductive rights, and to highlight the risk of unconscious bias if all records are to be looked at.

If a woman had a termination in her teenage years, that will be highly irrelevant to her decision, many decades later, whether to choose an assisted death. Relevance is very important, because there will be a high level of record keeping in the process. It is not only the doctors working with the patient on the assessment who will read the records and reports; ultimately, it will also be the panel. I make the point again that so many parts of a patient’s medical records are highly irrelevant to the diagnosis and prognosis of a terminal illness, and to the six months under the eligibility criteria. Indeed, there is a risk of unconscious bias in the judgment. It is about the professionalism of the doctor in respect of understanding the records that are relevant for the process.

[Danny Kruger]

Will the hon. Lady give way?

[Rachel Hopkins]

I will continue, if I may.

I turn to amendments 422 and 423. The importance of a rounded, holistic assessment and discussion with the patient has been pointed out in many of our discussions, as has the importance of the multidisciplinary team and the other health and care professionals who support the patient with health and social care. That would all have to be recorded—the conversations that have been had, and why the assessing doctors and other health and social care professionals were involved. In oral evidence, many doctors in other jurisdictions said that they worked in multidisciplinary teams. The amendment would firm that up. It is about being clearer, because the clarity that the amendments provide would make for a stronger process.

On amendment 468, the hon. Member for Reigate pointed out that it asks a very simple question. However, I return to the point about the professionalism of the doctors involved in the process, who will be working within the legal requirement under the Bill that the individual have a clear, settled and informed wish. The doctors will have to check individuals’ eligibility under the requirements, for example that they are over 18 and have a terminal illness with a six-month prognosis. The doctors will use their expertise and professionalism, and that of the multidisciplinary team, to make assessments about coercion. They have strong rules about assessing for capacity.

The requirement to ask why someone wants an assisted death is a requirement to police the conversation that the doctor has with their patient. Setting it out in primary legislation would lead to a tick-box exercise, with doctors saying, “You’ve told me a number of times already in our conversation that I’ve been having with you, but I’m sorry: I have to officially ask this question and tick the box.” That could lead to an insensitive conversation and relationship between the relevant people in the process.

To a certain degree, the patient may think, “So what? Do I have to tell you why? It is none of your business why I want to pursue this legal course of action down the line.” I appreciate where the hon. Member for Reigate is coming from, but with the best of intentions, her amendment would actually lessen the individual’s autonomy and their right to choose what if the Bill passes will be a legal course of action. I am content that the stringent training that will be required for any of the assessing healthcare professionals will enable a good holistic conversation so that good judgments can be made. Adding this extra sentence would detract from that, so I cannot support the amendment.

--- Later in debate ---

[Naz Shah]

That example is a good example that strengthens my position.

[Danny Kruger]

I completely agree with the hon. Lady’s point. The conversation goes on in the way the doctor would want it to, but they have at least asked the question. Is it not very simple? The Bill already requires doctors to look for signs of external coercion. As we have acknowledged, there is no way to determine internal coercion—the influence people have on themselves. There is no way in the Bill at the moment to identify whether somebody feels that they want an assisted death because they fear that they are a burden to others. This question is the only opportunity we have to tease out that answer: does she agree?

[Naz Shah]

I thank the hon. Member for that intervention and he makes an important point.

Terminally Ill Adults (End of Life) Bill (Twenty First sitting)

Danny Kruger Excerpts

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[Dr Shastri-Hurst]

It is a pleasure to serve under your chairmanship, Ms McVey, and to speak to this group of amendments. Amendments 93, 305, 142 and 362 relate to clause 9(2)(b)(iv); amendment 306, tabled by the hon. Member for York Central (Rachael Maskell), relates to clause 9(2)(c).

Clause 9(2)(b)(iv) stipulates:

“The assessing doctor must…explain to and discuss with the person being assessed…the nature of the substance that might be provided to assist the person to end their own life (including how it will bring about death)”.

My amendment 93 would replace “might” with “is to”. In my view, the word “might” creates an air of possibility. The Oxford English Dictionary gives the following definition:

“A possibility as distinct from a certainty”.

The Cambridge Dictionary goes somewhat further, defining “might” as the expression of a

“possibility that something will happen or be done, or that something is true although not very likely”.

In the context of the Bill, I consider that the use of “might” would create too ill-defined a concept.

For a patient to provide informed consent, it is necessary that the healthcare professional set out the relevant information in sufficient detail to enable that person to make an educated decision. In the circumstances of providing a substance, it follows that that information must include what that substance is. In my submission, it is insufficient simply to inform a patient that they might be provided with a substance, although they are just as likely, if not more likely, to receive another substance. Changing “might” to “is to” would provide greater certainty and precision in the wording of the Bill.

I recognise the concerns that have been raised that adopting amendment 93 would overly restrict which substance can be used, which may create an issue if the substance needs to be changed, for example if it was to be taken orally but has to be administered via a different route because the individual is no longer able to ingest orally. To my mind, however, the amendment would not prohibit a clinician from setting out to the individual a range of substances that could be used to provide them with the ability to end their own life, as long as the clinician includes the substance that is used and, crucially, the person seeking an assisted death indicates that in those circumstances they are content for that particular substance to be used. For example, it would be entirely open to an individual to inform a clinician that they are happy with regimes A, B and C, but not D.

[Danny Kruger (East Wiltshire) (Con)]

I absolutely agree with what my hon. Friend is trying to do. This is a genuine question: does he think that it is possible at this stage for the Government, the Medicines and Healthcare products Regulatory Agency, the NHS or whoever to provide the information that would be required? What is needed to enable the Bill to come into effect with the amendment that he proposes, so doctors are able to say exactly what drugs will be used?

[Dr Shastri-Hurst]

In the scenario that I envisage, as we have seen in other jurisdictions, there are a variety of regimes that could be used in the given circumstances. It would be appropriate for an approved list of medications and substances to be a delegated matter for the Secretary of State. As medical and pharmacological studies progress, there may be changes to those regimes, so I do not propose putting a list on the face of the Bill. The way I envisage it operating, if the Bill comes into law, is that there would be an approved list of substances that would be open to use. There would have to be a range; we are acutely aware that there are supply chain issues at times, so limiting it to just one regime would be impracticable. I believe that amendment 93 would strengthen the wording of the Bill to provide greater certainty that the nature of the substance to be provided will be explained to and discussed with the person who is seeking an assisted death. I am grateful to my hon. Friend for indicating his broad support for the amendment.

I turn to amendment 305, tabled by the hon. Member for York Central. I appreciate the premise of the amendment, but I have some concerns about the precision of the drafting. It would require the assessing doctor to explain the effects of the provided substance, in addition to how it would bring about death. In its current form, the Bill requires the discussion with the assessing doctor to set out how the provided substance will result in death. My understanding is that the intent of amendment 305 is that they set out the side effects beyond those directly related to the mechanics of bringing about death; this would include any wider discussion around side effects.

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[Juliet Campbell (Broxtowe) (Lab)]

I will speak to amendment 142, which would insert

“and how it will be administered”

into the Bill. It would require the assessing doctor to explain and discuss with the person how the substance that might be provided to assist them to end their life will be administered.

The amendment would be a key step towards giving peace of mind to a terminally ill individual who is seeking an assisted death. It would also preserve their autonomy right up to the final stage. Ensuring that the method of administration is thoroughly explained would provide the doctors and the individual seeking an assisted death with the opportunity to consider the options—if there are options available to them—and decide which method would best preserve the autonomy of that individual.

Assisted dying presents many opportunities for individuals to be coerced, especially at the final stage—death itself. Therefore, the method of administration is key information for the individual to know, and it is not sufficient for it to be withheld from them. We must make it a prerequisite of the Bill that it is supplied. Making an informed choice about the assisted death pathway involves careful consideration, and knowing and understanding every step of the process. It is appropriate for the person to maintain their agency. Minimising the role played by the doctor at the administration stage is also key to ensure that the final act belongs to that individual.

We must acknowledge that many individuals seeking assisted death may experience significant mobility and physical limitations, particularly because of their terminal illness. Those limitations can affect their ability to engage with the process in ways other people may take for granted. For example, a patient suffering from severe weakness, paralysis or chronic pain might have difficulty physically positioning themselves or administering some types of substance, depending on the options available. A person may have difficulty swallowing and would not be able to ingest a substance in the form of a pill, but they may be able to autonomously operate a system that would allow them intravenous administration.

In these cases, the method of administration must be carefully considered and explained in a way that accommodates the patient’s unique physical needs. By discussing the challenges openly at this stage, doctors can help to ensure that the patient understands the options open to them, while making the process as comfortable and accessible as possible. Addressing their mobility and physical limitations in this context is not only a matter of practicality, but a reflection of our compassion and respect for that individual’s circumstances.

By limiting the doctor’s physical role, we also ensure that the patient retains control over the process. Making the act of self-administration as independent as possible ensures that the final part of the process gives the patient agency in choosing how and when to end their life. The individual must maintain a primary role in their death, but the actual administration is the final assurance and assertion of the individual’s choice to end their life. The amendment emphasises the importance of ensuring that, within the Bill, the doctor’s involvement is limited to preparation and support. That is key to making sure that the patient’s final moments are self-directed and as free from any unnecessary external interventions as possible.

Subsection 6 of clause 18, on the provision of assistance, discusses the role of the doctor in administration. It says that a doctor might

“assist that person to ingest or otherwise self-administer the substance.”

By ensuring that the method of administration of the substance aligns with the physical capabilities that a person has to self-ingest, which may be limited, we limit the role played by the doctor at this crucial stage, and limit the chance of the coercion of the individual or of the individual having a death that lacks real autonomy.

In conclusion, amendment 142 plays a crucial role in safeguarding the rights and autonomy of a terminally ill individual seeking an assisted death. By ensuring that the method of administration is clearly explained, we empower patients to make an informed, autonomous decision about the way in which they wish to end their life.

[Danny Kruger]

It is a pleasure to serve under your chairmanship, Dame Esther. [Interruption.] You are Dame Esther, aren’t you?

[The Chair]

I am not.

[Danny Kruger]

Are you not? That is an extraordinary oversight. That must be rectified as soon as possible— I am sure it will be. I will speak in support of the amendment in my name and those in the names of the hon. Member for York Central and my hon. Friend the Member for Solihull West and Shirley. As he has explained, amendment 93 requires doctors to specify what drug “is to” be used, not just “might be” used. My amendment 362 states that there must be clarity on the complications and risks involved in the procedure. Amendment 305 states that we must be clear about

“other effects in addition to death.”

Amendment 306 discusses escalation in the event of complications.

We have discussed informed consent previously. We have identified that the General Medical Council’s guidance on critical information that patients must receive has been selectively placed in clause 7. Of the five areas that the GMC says should usually be conveyed to patients, two were omitted: first,

“uncertainties about the diagnosis or prognosis, including options for further investigation”,

and secondly,

“the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action. By ‘harm’ we mean any potential negative outcome, including a side effect or complication.”

It is not being explicitly stated that doctors should communicate that to patients.

Telling a patient exactly which drug or substance will be used to end their life, and its likely side effects, is critical if they are to have informed consent. Full understanding requires the patient to know the specific drug that will be used. It lets the patient grasp the method, its effects and its finality. Patients deserve to know how the drug will work; what its administration will be, whether oral or intravenous; the time it will take to have an effect, whether that is minutes or hours; and the other sensations that will be felt. It is difficult to say that we can convey that information without being specific about which drug will be used.

In other countries, for instance in the Netherlands, the criteria require that patients are fully informed, including about the drug that will be used and the method. In Oregon, the Death with Dignity Act similarly requires discussing the prescription of the specific drugs. That equips the patient to find out more, should they wish to do so, and to ask questions. A patient with a terminal disease needs to know the drug to confirm if it aligns with his or her wish for a peaceful death—it is not just an abstract agreement to die, trusting that medicine will do the trick.

An important consideration to note is age. Dr Jessica Kaan, writing in the Journal of Aid-in-Dying Medicine, found

“a clear and linear correlation between younger patient age and longer times to death. Older-age patients have, on average, shorter deaths.”

It is important for clinicians to be aware of that research. She continued:

“Clinicians should consider and discuss this information as part of informed decision-making…with patients.”

They can do that only if they are aware of what the drugs will be.

--- Later in debate ---

[Dr Simon Opher (Stroud) (Lab)]

I thank the hon. Gentleman for tabling amendment 362. Does he accept that Australia, for example, has a very different regime from America? In Australia, people are given pentobarbital, which has not failed on any occasion—in any of the 2,500 treatments since assisted dying was legalised. In America, people are not allowed to use that; instead, they use another cocktail of drugs, which is not as ideal and can have other side effects. May I also say that I am not sure whether it is totally relevant to discuss the problems of a drug given in America in this context? We are discussing just putting down in law what the doctor is obliged to say to the patient.

[Danny Kruger]

I am grateful to the hon. Gentleman for those points because he helps me to direct my argument. It is essential to discuss the evidence from abroad about the complications that arise from assisted suicide, but the evidence is very patchy: we know what we know, but we don’t know much. There is a complete dearth of evidence, including in Australia. When Australians gave evidence to the Committee, it was put to them, accurately, that there is a great lack of adequate data gathering in Australia, as in other countries too. So when he says there have been no complications in Australia, what he means is that there have been no reports of complications in Australia. As we always need to point out, absence of evidence is not evidence of absence.

[Kim Leadbeater]

That question was indeed put to the experts from Australia, but actually they were quite clear that there is a huge amount of evidence. Indeed, there is a very robust reporting mechanism in Australia—the best in the world, I suggest—so there is a huge amount of evidence from that jurisdiction.

[Danny Kruger]

Let us not rehash the conversations that we had in the evidence sessions, but I would advise Members to review those conversations. Indeed, there is further publicly available evidence, which I am happy to share, of the problems with data collection in Australia, as in other countries. To the point of the hon. Member for Stroud about the evidence of complications that arise in other jurisdictions being irrelevant to our discussions, because of the lack of clarity in the Bill about what drugs would be used to bring about the assisted suicides that we are proposing to legalise, all we can do is rely on evidence from abroad, and I will insist on doing so.

As well as questions about complications and side effects, there is also a crucial question about how long it takes to die. In Canada, a study demonstrated that in 5% of cases, patients experienced a prolonged time to death. Another study showed that 50% of cases in Canada with available data—again, there is a lack of data—were unsuccessful within 60 minutes. It is clearly common in other countries for death to take up to or more than an hour.

The Canadian Association of MAiD Assessors and Providers—the people who do it—acknowledged that patients who ingest assisted suicide drugs can experience burning, nausea, vomiting and regurgitation. I am not saying that that always happens, or that it happens in the majority of cases, but it clearly happens. It is therefore appropriate for patients to be properly informed of those risks, if they are associated with the drugs that will be used. We do not know what those are going to be at this stage.

In the Netherlands, where assisted dying or assisted suicide has been legal for 20 years, a third of people with assisted suicide deaths experience some adverse symptoms such as pain, restlessness, shortness of breath, secretions, nausea and vomiting—that is, a third of people experienced some of those distressing side effects as they died, so it is very far from a guarantee of a pain-free death. It is vital that people considering an assisted death are aware of those possible effects, in addition to the primary effect of the drugs which is, of course, to kill them.

There is also a question about the method of administration. People should know that where regimes use the intravenous route of a short-acting anaesthetic, that is also not without problems. People would understand, and potentially argue for, having an anaesthetic as the first part of the cocktail of drugs that will be administered, but evidence from abroad demonstrates that the anaesthetic induction agent, which is usually propofol, a drug that puts people to sleep before surgery, can wear off rapidly in some people, particularly in younger patients, those who are less ill and those who are larger in size.

In around two thirds of assisted deaths with administrations that use that technique, that anaesthetic is rapidly followed by a paralysing agent. The patient cannot then move a muscle and, unable to breathe at all, they die of asphyxia. Unfortunately, there has been no monitoring of patients while they are given those drugs to ascertain whether they regain consciousness as they die. They cannot move a muscle, so they cannot signal distress. We are unclear what the experience of the dying person is beneath the apparent calm that has been induced in them by the paralytic drug that they have been given.

We do know, however, that similar combinations have been used in judicial executions. Post mortems have shown, as reported in The Lancet in 2005, that the level of anaesthetic induction agent in the blood at the time of death was lower than that required for surgery in 88% of executed inmates. Shockingly, in 43%, the concentrations were consistent with awareness, meaning they may have suffered during the execution.

[Dr Opher]

The hon. Gentleman is bringing up lots of rather horrible stories about assisted death. That is why, in Australia, Switzerland and Holland, they have decided, instead of using the regime that he is talking about, to use pentobarbital. At 15 grams, that has not had any failures—no one has woken up. The only real side effect that people complain of before they go to sleep, which happens very quickly, is that it is very bitter. One of the reasons why Dignitas uses it is that it is so effective and it does not have those effects. I would push back on some of those scare stories.

[Danny Kruger]

I am afraid to say that the whole debate about assisted dying is replete with scare stories. The hon. Gentleman says that they are descriptions of horrible events, but that is the situation that we are dealing with. We are here to try to pass legislation that is designed to avert horrible deaths. I am absolutely committed to that as well, but the evidence from abroad shows that people can also have a horrible death with assisted dying.

The hon. Gentleman points to Australia, but the evidence from Western Australia in particular is that over 4% of assisted deaths reported complications. He might be right that it is a better regime than that used in the United States, but even there complications occur. We do not know yet what the regime will be here, but I am alerting the Committee to the genuine danger of an assisted dying regime that induces very unpleasant results for patients.

[Jack Abbott (Ipswich) (Lab/Co-op)]

The hon. Member may be surprised to hear that I am inclined to support his amendment 362 and amendment 142 tabled by my hon. Friend the Member for Broxtowe, not because of, in the words of my hon. Friend the Member for Stroud, the scare stories or the examples that the hon. Member has been giving, but predominantly because of what the amendment says on the tin: that a person must be given a full explanation of the risks of complications and how a substance should be administered. As I have said a number of times in Committee—

[Jack Abbott]

It is an intervention, Ms McVey. My plea to the hon. Member is to focus on exactly what the amendment states. I appreciate all the stories and examples that he wishes to make, but it is important to reflect on the words of the amendment. As I said, I am minded to support it.

[Danny Kruger]

I am grateful to the hon. Member for his intervention.

Amendment 306, tabled by the hon. Member for York Central, addresses the question of what to do in the event of complications. I recognise that clause 9 states that that must be discussed, which I welcome. I think, though, that there is a significant absence that this amendment would address, which is what to do in the event of complications—specifically, which intervention would be appropriate.

Here we get into a very difficult area. I personally find it difficult to understand a way out of it, because it is a consequence of the sort of legislation that we are considering: what do we do when complications arise? Specifically, what do we do when the patient does not die and is still alive some hours later, possibly in distress? I have cited evidence about some of the complications that occur and the prevalence—for example, that 10% of such people in Oregon experience complications, including some who simply wake up again. We need to resolve this. On explaining possible side effects and complications, under the Bill as it stands none of the declarations that are signed by the doctors or the person requesting assistance confirm in writing that the criterion has been met for proper communication, so that is one concern.

My more substantial concern—I will finish with this—is that at the moment the doctors have to explain the complications, even though we do not know what the drugs are going to be yet, but they cannot discuss or decide with the patient what they would do in the event of complications. We know that the doctor must be present at the end or in the next room, but can they halt the process if complications arise—if the patient wakes up or is exhibiting signs of distress? That would be against the last known wishes of the patient who had said that they wanted to go ahead with the death. Should the doctor expedite the death knowing that that is what the patient theoretically wanted? Of course not, because that would be euthanasia; it would be the doctor actually killing the patient, which is illegal under the Bill. Do they stand by and do nothing at all, which goes against the doctor’s obligations to address symptoms and illness in a patient? If the patient is fitting or vomiting, the doctor would normally clear their airways. Should they do that, knowing that that might bring the patient back to life—that it might resuscitate them and stop the assisted death?

When we debate clause 18, we will discuss the process of the assistance that the doctor gives, but we are obliged, when we come to debate the Bill fully, to choose between three options. We could allow complications without any guidance, which is what the Bill does; that raises all sorts of challenges, and practical and ethical concerns, for doctors. We could stipulate that the patient should be revived, perhaps if a certain degree of distress is witnessed or if the patient is still alive after a certain period of time. Finally, we could allow euthanasia and say that, in that event, the doctor should be authorised to expedite the death. I do not know what the option should be. That is a question that a doctor would have to face in reality, in the bedroom of a patient who is exhibiting complications. I do not know what to do, but I do not think we should be proceeding with this Bill. Those who do believe in it have to answer this question: what does a doctor do if a patient is exhibiting distress and not dying—do they bring them back to life, expedite their death or do nothing?

--- Later in debate ---

[Naz Shah]

I thank my hon. Friend for his intervention. As drafted, the Bill does not include effects. All it says is “complications”. It does not include the potential effects of the drugs that will be used. That is how the amendment would strengthen the Bill.

[Danny Kruger]

We might appear to be dancing on a pinhead, but this goes to the heart of the question about what on earth we do in the event of complications. As the hon. Member for Spen Valley says, the Bill as drafted says that discussions should be had about wishes in the event of complications. That might simply be, “Do you want us to call somebody? Do you want us to try to make you more comfortable?” The amendment would require a discussion of escalation—what further medical interventions might be appropriate in the event of complications arising. There is a huge question for us, which we have not yet had answered, about what on earth should be the range of options for a doctor. The importance of the amendment is to specify that there may be further medical interventions in the event of complications. Does the hon. Lady agree that that is the value of it?

[Naz Shah]

I completely agree with the hon. Member. He said it much better than I did in response to my hon. Friend the Member for Ipswich, so I thank him for that.

--- Later in debate ---

[Dr Opher]

We are not doing that in situations of terminal care—we are allowing someone to die. We are very experienced in allowing people to die. I have done it for 25 years. It is not a new skill just because we have the assisted dying element. We deal with the situation as it arises.

[Danny Kruger]

rose—

[Dr Opher]

I had virtually finished, but I give way.

[Danny Kruger]

The hon. Gentleman puts his finger on a key point. The hon. Member for Bradford West is absolutely right: surely the hon. Gentleman acknowledges that there is a difference between allowing somebody to die and giving them lethal drugs that make them die. I am sure he would acknowledge the practical, if not the moral, distinction between the two. He says he has lots of experience of helping people to die; has he ever had experience of watching somebody die after administering them lethal drugs? No.

[Dr Opher]

No, I have not, because that is currently illegal—this Committee is about changing that—but I have sat with patients who have slowly died. It is not about whether we get an ambulance; we know we do not do that. We are allowing the patient to die, and if something happens that involves having to help them, we just do it. We do not need to specify that in the Bill: it is part of normal medical practice.

--- Later in debate ---

[Stephen Kinnock]

The basic position of the Department of Health and Social Care and, by extension, the Government is that we rely on and trust our medical professionals to make judgments and do the right thing. They take the Hippocratic oath, so they are going to do what is right for the patient in the circumstances of their interaction with that patient. That is set out in guidance and in the corpus of law that we already have. There is a risk of destabilising the system by introducing measures that may well cause confusion and muddy the waters when the waters do not need to be muddied.

[Danny Kruger]

I am afraid that the waters are pretty muddied by the Bill. It states a direct contradiction of the Hippocratic oath, which requires doctors to save people’s lives and do nothing to bring about their death—including giving them lethal drugs. It is right there in the Hippocratic oath. There is obviously a real challenge if somebody has had assisted death drugs and then exhibits complications—if they are not dying quickly, for example, or are showing distress. Normally, the obligation on a doctor would be to relieve their symptoms and try to bring them back to life. Is the Minister saying that is what they should do—and if not, what should they do?

[Stephen Kinnock]

There is a debate to be had about the Bill’s effect on support for a patient. I am not here as a member of the Government to comment on the rights and wrongs of that, but those who support the Bill would argue that a doctor participating in and facilitating assisted dying is actually helping the patient and is, therefore, absolutely aligned with the Hippocratic oath, which is to do no harm. That is in the eye of the beholder, as I am sure the hon. Member would agree, and it is not my job to get into the whys and wherefores of the philosophy that underpins the Bill.

--- Later in debate ---

Division 45

Question accordingly negatived.

Ayes: 9

---

Labour: 6
Conservative: 2
Liberal Democrat: 1

Noes: 13

---

Labour: 8
Liberal Democrat: 2
Conservative: 2
Plaid Cymru: 1

[Danny Kruger]

I beg to move amendment 307, in clause 9, page 6, line 18, leave out from beginning to “advise” and insert

“unless the assessing doctor has concluded in good faith, that this would not be in the person’s best interests.”

This amendment would require the assessing doctor to inform the person’s next of kin that the person wishes to seek assistance to end their own life unless it is not in the person’s best interests.

[The Chair]

With this it will be convenient to discuss amendment 308, in clause 9, page 6, line 20, at end insert—

“(g) If that doctor considers that it is not in the person’s best interests under paragraph (f), this decision and the doctor’s reasoning must be documented.”

This amendment is consequential to Amendment 307 and would require a decision that it is not in the person’s best interests to inform their next of kin to be documented with its reasoning.

[Danny Kruger]

Amendments 307 and 308 concern the question of who should be informed when an application has been made or when an assisted death has been approved, and at what stage it is appropriate for family members or next of kin to be informed. During the debate on clause 8, we discussed whether a patient should be asked to state whether they have informed their family.

I think it is appropriate to have a stronger requirement for doctors to notify a patient’s next of kin. Amendment 307 would remove the phrase

“in so far as the assessing doctor considers it appropriate,”

leaving that they should

“advise the person to consider discussing the request with their next of kin”.

Amendment 308 is either supplementary to amendment 307 or could work in isolation, because it states:

“If that doctor considers that it is not in the person’s best interests under paragraph (f), this decision and the doctor’s reasoning must be documented.”

These are important amendments because they communicate the truth that it is not just the patient who is affected by an assisted death; I suggest that others are affected. Conversely, behind that apparently autonomous individual patient, who might think they are acting with absolute autonomy and without reference to others, there may somebody who is exercising undue influence on them.

To me, these amendments speak to the essential tension at the heart of the Bill: whether we are talking about isolated individuals or recognising the reality that no man or woman is an island. We are all connected and we all have obligations, whether as a society to the people who will be involved in the administration of the procedure or, more directly and obviously, to family members or to the patient themselves, to be sure they are not subject to undue influence. There are many ways to try to identify undue influence, but one important one that would be addressed by this amendment is the opportunity to involve a person’s wider family in the discussions leading up to their assisted death.

--- Later in debate ---

[Jake Richards (Rother Valley) (Lab)]

The amendment that the hon. Member is supporting speaks of a doctor having to consider what is

“in the person’s best interests”,

which is wholly subjective. Does he not agree that the same difficulties he identifies with the current drafting are extrapolated greatly by the amendment?

[Danny Kruger]

I am afraid there is a huge degree of subjectivity throughout the Bill, and we are putting an enormous obligation on doctors to use their best judgment. However, I think it is right to stipulate more clearly that it is appropriate, in general, to inform patients’ families. Leaving the vague term “appropriate” essentially implies that it is either/or—that it is a 50:50 choice whether they do so. So it is important to specify that the expectation is that they should do so. Of course, there will be circumstances in which that would not be the right thing to do, but as the amendments make clear, they should explain that clearly if they are not going to do so.

A doctor might hesitate to suggest a discussion with family if they suspect that there are strained relationships within it. My concern is that, without clear guidance, that judgment could be inconsistent or legally challenged. The doctor might know the next of kin and believe that they would try to stop the patient from ending their life. We have heard quite often the concern about the family being some sort of coercive force, trying to prevent people from fulfilling their autonomous choice to end their life, and that we should put in place barriers to stop families trying to dissuade their loved one from assisted suicide. We heard that repeatedly, particularly from the Australian witnesses.

My concern—this goes specifically to certain communities within our country—is that doctors from individualistic cultures, which we have in western Europe and North America, would prioritise personal autonomy. They would deem it inappropriate to suggest family involvement, viewing that as an intrusion on the patient’s rights. We need to state clearly that that is not the expectation and that the expectation is that they should consider involving the family in the discussion.

My concern is also about an exaggerated respect for medical confidentiality. As the Committee knows, my belief is that this is not a healthcare treatment at all, but if it is to be regarded as such, we should not assume that medical confidentiality applies in an absolute sense. There are specific differences between this so-called medical treatment and others, which do justify an override of the assumption of total medical confidentiality. It is therefore appropriate, as in certain other medical procedures, that family members should be involved.

I want to cite the written evidence from Dr Rosemarie Anthony-Pillai, who pointed out that clause 9

“lays bare the reality that in trying to, rightly, diminish any accusation of coercion or family disagreement, this Bill will lead many to a lonely death.”

She also said:

“Families/loved ones finding out only after the event how the person died will have its own bereavement issues that this Bill in no way seeks to consider.”

I also cite the written evidence we had from AtaLoss, which is a UK charity dedicated to ensuring that bereaved people can access support. It said that discovering the decision that somebody has had help to take their own life without prior warning

“can replicate the distress often associated with sudden or suicide-related deaths, thereby intensifying bereavement trauma and potential suicide contagion.”

That is a very significant threat. We will not rehash the argument about whether suicide increases in countries with assisted suicide, but my strong view, from the evidence, is that it does.

In terms of the patient’s safety, if the process is kept secret even from those who know the patient well, the assessing doctors and the panel will be asking very difficult questions about the patient’s feelings and circumstances partly blindfolded. If a patient is in a controlling relationship, they and the person abusing them are not going to volunteer to the doctor or the panel that there is any pressure going on—indeed, the patient may not even understand it to be pressure. It is very common for an abusive partner to try to isolate the victim from their close friends and family. The hon. Member for Ealing Central and Acton (Dr Huq) wrote recently about how this has come up in her constituency. The ex-husband of her constituent’s sister reappeared on the scene, charmed and isolated this woman, and got her to change her will in his favour. That is a technique of coercive control. Some level of required notification to the wider family would make it much harder for a controlling partner to push someone through this process without it being exposed.

It was made clear earlier today that the Bill’s supporters do not want any hard-edged reasons that count as bad reasons to die to be stated in the Bill—they do not want it asked at all why someone wants to have an assisted death. As it stands, the doctors and the panel would have to approve the death as long as it was the patient’s clear, settled and informed wish, but involvement of those who know the patient well might demonstrate that it was not clear, settled or informed. They may have regularly gone through patches of feeling unloved and unsupported all their life, and that could change. That is information that only the wider family would know.

To conclude, there is real suffering hereto—as I have said, nobody exists in a vacuum. I want to reference the opinion of Judge Elósegui in the European Court of Human Rights. Her opinion was a partial dissent in the Mortier case, which has been discussed before. She said:

“it should be underlined that it cannot be said in an exhaustive way that the principle of autonomy always and at all costs has primacy over the other three principles of bioethics. In particular, we must take into account the consequences of our actions on the rest of the family unit and on our circle of friends.”

That is highly relevant. If we see cases where somebody dies by assisted suicide, and the first thing their child or parent knows about it is they are told to come and collect the body, that will be a scandal. That has happened in other countries, and the Mortier case is a case in point.

I mentioned other cases in which it is obligatory to consult and inform family members. At the moment, that is what happens at the Court of Protection with much less serious applications. Practice directive 9B requires doctors to notify

“at least three persons who are likely to have an interest in being notified”.

That is in the case of organ donation and other procedures. Families are required to be notified, and an indicative list is given, which is supposed to be worked through in order—spouses, people who live with as a spouse, parents, children and so on. The authorities are to jump along through that list, again with some discretion given to them.

To end, on the standard guidance referred to in judgments on that procedure, the judgement of Senior Judge Lush in the Court of Human Rights included the observation that the decision not to notify someone who would otherwise be entitled to be notified is not something that just affects the applicant. It is not just about their interests; there is a wider concern for the whole of society and indeed the family. That is why I support the amendment.

[Dr Opher]

I thank my hon. Friend the Member for York Central for tabling the amendment. The crucial word that the hon. Member for East Wiltshire said in all that was “should”. It is really important that people are strongly encouraged to discuss this with their families. Clause 9(2)(f) states that

“in so far as the assessing doctor considers it appropriate, advise the person to consider discussing the request with their next of kin and other persons they are close to.”

I totally support all that the hon. Member said: the family should always be involved in every decision. However, in the way we practice medicine in this country, if a patient has capacity—if they are not under a section under the Mental Health Act, for example, and can show that they have capacity—they can make decisions about their own healthcare. That involves whether they tell their family.

I agree that not to tell the family is not the best thing and not something I would say that the patient should do, but that is in their remit. It is important because, if we change that, we get rid of all the basis and the foundation of medical care and consent in this country. I agree wholeheartedly with the hon. Member, and I am a strong supporter of the family—I also think that in almost every situation the family will be involved—but the patient does not have to tell the family. That must remain part of their decision.

--- Later in debate ---

On balance, because I believe in autonomy, I may well not support the amendments, but these are the issues that I have wrestled with, because as the Bill stands, someone could simply go to a doctor, the doctor could say, “Have you told your loved one—your partner, your husband, your wife?” and they could say, “No, I’m not going to, because I do not want them to suffer anymore, caring for me in these circumstances.”

[Danny Kruger]

As ever, the hon. Gentleman speaks very powerfully. Does he acknowledge that under the amendments, and under the Bill, it would be possible for a patient to proceed without informing their wider family, if they and the doctor conclude that it is not appropriate or necessary? The value of the amendments is that they would require a conversation to be had about why that is not happening. Does the hon. Gentleman not recognise that such a conversation would be appropriate?

--- Later in debate ---

[Jake Richards]

I agree. I think in some of these debates—I am probably guilty of this as well—we forget the context in which we are operating: someone is dying, imminently. Therefore, how we approach these conversations, these assessments and this process must take that into account.

[Danny Kruger]

The hon. Gentleman accurately points out that doctors are not social workers or psychiatrists, and we are asking them to make a difficult judgment, in consultation with the patient, about whether they should engage wider family in the discussion. That goes to the broader point: we are imposing a huge obligation on doctors to make very complicated decisions about capacity, coercion and the psychosocial circumstances of the patient. The value of this amendment’s saying, “I think we should involve the family if it is safe to do so”—it might very well not be in certain circumstances—is surely to assist them in having the wider conversation that is necessary.

--- Later in debate ---

[Kim Leadbeater]

I have nothing to add, other than that I will not be supporting amendments 307 and 308. I associate myself with the comments made by my hon. Friends the Members for Rother Valley, for Stroud and for Sunderland Central.

[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendments made: 423, in clause 9, page 6, line 20, at end insert—

“(2A) To inform their assessment, the assessing doctor must—

(a) consider whether they should consult a health professional or social care professional with qualifications in, or experience of, a matter relevant to the person being assessed;

(b) consult such a professional if they consider that there is a need to do so.

(2B) Where an assessing doctor consults a professional under subsection (2A)(b), the assessing doctor must give a written record of the consultation to the other assessing doctor.”—(Kim Leadbeater.)

This amendment requires the assessing doctor to consider whether they should consult specialist health or social care professionals, and to consult them if they consider there is a need to do so. A record of any consultation must be shared with the other assessing doctor.

Amendment 415, in clause 9, page 6, line 20, at end insert—

“(2A) When making an assessment under subsection (2), the assessing doctor must first ensure the provision of adjustments for language and literacy barriers, including the use of interpreters.”—(Jack Abbott.)

Amendment 6, in clause 9, page 6, line 27, leave out “may” and insert “must”.—(Sarah Olney.)

This amendment would require the assessing doctor to refer the person being assessed for a mental capacity assessment if the assessing doctor had doubt as to the person’s capacity.

Amendment 370, in clause 9, page 6, line 29, leave out

“registered in the specialism of psychiatry”

and insert

“a practising psychiatrist registered in one of the psychiatry specialisms”.

This is a drafting change.

Amendment 202, in clause 9, page 6, line 31, leave out “capability” and insert “capacity”.—(Kim Leadbeater.)

This amendment corrects a typographical error.

Clause 9, as amended, ordered to stand part of the Bill.

Clause 10

Another independent doctor: second opinion

Amendments made: 203, in clause 10, page 6, line 42, at end insert—

“(A1) This section applies where the independent doctor has—

(a) carried out the second assessment, and

(b) made a report stating that they are not satisfied as to all of the matters mentioned in section 8(2)(a) to (e).”

This amendment is consequential on Amendment 421.

Amendment 204, in clause 10, page 6, line 43, leave out from beginning to second “the” in line 44.—(Kim Leadbeater.)

This amendment is consequential on Amendment 203.

Amendment proposed: 458, in clause 10, page 6, line 45, after “declaration” insert “and if there has been a material change of circumstances,”.—(Sarah Olney.)

Question put, That the amendment be made.

--- Later in debate ---

[Danny Kruger]

I want to speak briefly in support of the hon. Lady’s amendment and also in support of amendment 310, tabled by the hon. Member for York Central. The hon. Member for Richmond Park is absolutely right. I will not rehearse her argument, which is very straightforward. The question is: what other reason could there be to justify a co-ordinating doctor transferring the case? The Committee might reject that amendment, in which case I hope they will accept the amendment tabled by the hon. Member for York Central, which specifies that whatever the reason, particularly if it is other than death or illness, it is important for the High Court or the panel to be notified of the substitution and the reason why.

[Sarah Green (Chesham and Amersham) (LD)]

Maternity leave is one reason and retirement might be another.

[Danny Kruger]

Those might be appropriate reasons; I hope that can be specified. The crucial thing is that if there is an unwillingness—not an incapacity but an unwillingness—to proceed, that is of some concern. It is not that they are no longer able to do it—possibly for the reasons that the hon. Lady suggested—but if there is an actual unwillingness to proceed, what is the reason?

On amendment 309, if the first doctor is replaced for whatever reason, surely it is imperative that the new doctor conduct their own assessment, rather than taking the previous doctor’s word for it. A doctor is legally responsible, obliged under all medical regulation and law for their actions, and they cannot rely on a previous assessment. If the first doctor gave up the case because of some kind of incapacity—an illness, or, indeed, their demise—it might be that their own judgment was impaired at the time. I would have thought it was obvious that the new doctor should take responsibility for conducting an assessment and proceeding with full responsibility for the case.

[Naz Shah]

I rise to speak to amendment 309 tabled by my hon. Friend the Member for York Central. The amendment proposes that if a doctor changes, there should be a reassessment of the patient. My understanding is that that is in line with current practice: if a doctor is changed, the new doctor has to assess a patient to their own satisfaction because they cannot rely on just looking at notes. It is a sensitive issue where a doctor is required to make objective and subjective assessments, as has been agreed by the Committee to date, in clinical decision making. A clinician does not inherit the risk of another clinician without being satisfied themselves that the conclusion of another clinician aligns with their own.

For instance, the clinician has a responsibility to fulfil their own professional standards and their own duty of care. In the light of the significant impact of the decision, it is important that the doctor can be satisfied as they will need to consent to a patient having capacity and not being coerced. They cannot just take the word of another clinician who has managed the case before them. They themselves need to be satisfied. If a doctor does not do that and something goes wrong, and it comes to light that the patient did not have capacity, the clinician who is the new co-ordinating doctor would carry liability. It does not stand up if they say, “But someone else assessed that the patient had capacity” or, “Someone else said that the patient had not been coerced” if it comes to light later that they have.

This measure would therefore protect the clinician and ensure that the patient understood that a further assessment would need to take place. Having this measure in law would hopefully dissuade doctors from transferring their patients unless absolutely necessary for the continuity of care. It would also dissuade the clinician from taking on a new case if they were aware that continuity of care would be disrupted, due to, for example, a move.

--- Later in debate ---

[Danny Kruger]

I beg to move amendment 432, in clause 12, page 8, line 31, leave out paragraph (a).

This amendment is linked to amendments which remove proxies from the Bill.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 433, in clause 19, page 13, line 26, leave out subsection (4).

This amendment is linked to amendments which remove proxies from the Bill.

Amendment 434, in clause 36, page 22, line 16, leave out paragraph (c).

This amendment is linked to amendments which remove proxies from the Bill.

[Danny Kruger]

I recognise that we are moving on and that we want to get on to the substantive clauses, and I certainly will not press these amendments to a vote. However, I want to put on record that I have extreme concerns about the role of the proxy in clause 15. It is unclear to me why a proxy is needed. I regret that we are not sticking with the High Court process, which would have enabled us to debate these amendments at this stage, but I will let it pass.

[Sarah Sackman]

Amendments 432 to 434 would remove provisions regarding proxies from the Bill. They deal with proxies in the context of the High Court process. As a consequence, the High Court would be unable to hear from the person’s proxy where the proxy has signed the first declaration, and the person would be unable to use a proxy to authorise a medical practitioner to provide assistance to end their own life. Removing the ability for persons seeking assistance to use a proxy would limit access to the assisted dying process for people who, for example, have a physical impairment, are unable to read or are for some other reason unable to sign the declaration. As I said earlier, the Government remain neutral, but I hope that provides some context and an explanation of how the amendments would operate.

[Kim Leadbeater]

I will be brief, because we will come on to this debate when we get to clause 15. To be clear, the circumstances where a proxy would be involved in this process are literally when somebody is so ill that they are unable to sign their own name, so it is a very limited set of circumstances.

[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Danny Kruger]

I beg to move amendment 312, in clause 12, page 8, line 34, at end insert—

“(7A) Any person who wishes to challenge an application for a declaration under subsection (1) must enter a caveat in any district registry of the High Court within 14 days of the application being lodged or received, stating their belief that the requirements of this Act have not been met in relation to the first declaration, with specific reference to the matters listed in subsection (3).

(7B) Where a caveat is entered under subsection (7A), the High Court must hear from the person who has entered the caveat in addition to those persons listed in subsections (5) and (6).”.

This amendment would allow a person who believes that the requirements of the Act have not been met to make this known to the High Court and be heard before a declaration is made.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 269, in clause 12, page 8, line 35, leave out subsections (8) to (11) and insert—

“(8) Any party to the proceedings may apply for permission to appeal to the Court of Appeal in accordance with the applicable Rules of Court.”.

This amendment would allow any party to apply for permission to appeal a decision and remove the requirement for the Court of Appeal to conduct a re-hearing.

Amendment 313, in clause 12, page 9, line 1, leave out subsection (11).

This amendment would enable appeals to be heard against a decision by the High Court to make a declaration.

[Danny Kruger]

Again, I will not press this amendment; I just want to put on record my support for the principle. This amendment, tabled by the hon. Member for York Central, is quite a clever device: if we were sticking with the High Court, it would have meant that someone with genuine concerns, for example a family member or acquaintance of a patient, could flag them without needing to be informed that the application was going ahead.

As we have discussed, there is a concern about these proceedings happening in the dark, as it were, without wider family being informed. If a family member suspected that there might be an assisted dying application in the works and that they were being excluded from consideration or discussion of that, there would have been the opportunity to put on record their concern, which would have required the judge to take a wider consideration than would be enabled without this amendment. I regret that that is not happening, but it may be possible through the course of the Bill to ensure that there will be further opportunities to introduce such measures. I welcome that new clause 21 would impose a requirement on the panel to consider family members, so there is an element of the right system there.

[Sarah Sackman]

Amendments 312 and 313 would make several changes to the process for High Court approval of applications under the Bill as drafted. Amendment 312 would allow a person who believes that the requirements of the Act have not been met to make that known to the High Court and to be heard before a declaration is made. The proposed mechanism is that the person would enter a caveat in any district registry of the High Court within 14 days of the application being lodged or received.

Of course we will come to later amendments, but under the Bill as drafted, the High Court has the power to hear from and question any person to determine whether the applicant has a clear, settled and informed wish to end their own life, and that they have not been pressured or coerced, so there is that mechanism to hear from others through that channel.

Amendment 313 would enable appeals to be made against a decision by the High Court to make a declaration, as opposed to only where a declaration is not granted. As drafted, the Bill provides that any person may seek a judicial review of any decision of the High Court, including the decision to make a declaration, if they are adjudged to have standing.

Amendment 269 would enable any person, other than the person seeking assistance, to apply for permission to appeal to the Court of Appeal against a decision of the High Court. The amendment would also enable appeals to be made against a decision by the High Court to grant a declaration, as opposed to only where a declaration is not granted. The Court of Appeal would not be obliged to consider the matters set out in the Bill when forming its decision. It is important to say that whether with or without the amendment, any person may still seek a judicial review of any decision of the High Court, if they are adjudged to have standing.

[Kim Leadbeater]

I have nothing to add.

[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 371, in clause 13, page 9, line 5, leave out paragraph (a) and insert—

“(a) a certificate of eligibility has been granted in respect of a person, and”.

This amendment is consequential on NC21.

Amendment 61, in clause 13, page 9, line 5, leave out from “the” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 372, in clause 13, page 9, line 12, leave out from third “the” to end of line 13 and insert

“certificate of eligibility was granted,”.

This amendment is consequential on NC21.

Amendment 62, in clause 13, page 9, line 13, leave out from “the” to “or” in line 14 and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 373, in clause 13, page 9, line 17, leave out “declaration was made” and insert “certificate was granted”.

This amendment is consequential on NC21.

Amendment 377, in clause 16, page 11, line 12, leave out paragraph (d) and insert—

“(d) a certificate of eligibility has been granted in respect of a person;

(da) a panel has refused to grant such a certificate;”.

This amendment is consequential on NC21.

Amendment 63, in clause 16, page 11, line 12, leave out “the” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 378, in clause 18, page 12, line 9, leave out paragraph (a) and insert—

“(a) a certificate of eligibility has been granted in respect of a person,”.

This amendment is consequential on NC21.

Amendment 64, in clause 18, page 12, line 9, leave out from “the” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 381, in clause 27, page 16, line 16, leave out sub-paragraph (iii) and insert—

“(iii) a certificate of eligibility,”.

This amendment is consequential on NC21.

Amendment 65, in clause 27, page 16, line 16, leave out from “the” to “under” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 388, in clause 34, page 20, line 40, leave out paragraph (c) and insert—

“(c) a panel has refused to grant a certificate of eligibility;”.

This amendment is consequential on NC21.

Amendment 66, in clause 34, page 20, line 40, leave out from “the” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 390, in clause 40, page 23, line 24, at end insert—

“‘certificate of eligibility’ has the same meaning as in section (Determination by panel of eligibility for assistance);”.

This amendment is consequential on NC21.

Amendment 391, in clause 40, page 23, line 24, at end insert—

“‘the Commissioner’ has the meaning given by section (Voluntary Assisted Dying Commissioner);”.

This amendment is consequential on NC14.

New clause 14—Voluntary Assisted Dying Commissioner—

“(1) There is to be a Voluntary Assisted Dying Commissioner.

(2) The Commissioner is to be appointed by the Prime Minister.

(3) The person appointed must hold or have held office as a judge of—

(a) the Supreme Court,

(b) the Court of Appeal, or

(c) the High Court.

(4) The Commissioner’s principal functions are—

(a) receiving documents made under this Act;

(b) making appointments to a list of persons eligible to sit on Assisted Dying Review Panels (see Schedule (Assisted Dying Review Panels));

(c) making arrangements in relation to such panels and referring cases to them (see section (Referral by Commissioner of case to multidisciplinary panel));

(d) determining applications for reconsideration of panel decisions under section (Reconsideration of panel decisions refusing certificate of eligibility);

(e) monitoring the operation of this Act and reporting annually on it (see section 34).

(5) In this Act “the Commissioner” means the Voluntary Assisted Dying Commissioner.

(6) Schedule (The Voluntary Assisted Dying Commissioner) makes provision about the Commissioner.”.

This new clause provides for there to be a Voluntary Assisted Dying Commissioner.

New clause 15—Referral by Commissioner of case to multidisciplinary panel—

“(1) This section applies where the Commissioner receives—

(a) a first declaration made by a person,

(b) a report about the first assessment of the person which contains a statement indicating that the coordinating doctor is satisfied as to all of the matters mentioned in section 7(2)(a) to (g), and

(c) a report about the second assessment of the person which contains a statement indicating that the independent doctor is satisfied as to all of the matters mentioned in section 8(2)(a) to (e).

(2) The Commissioner must, as soon as reasonably practicable, refer the person’s case to an Assisted Dying Review Panel for determination of the person’s eligibility to be provided with assistance under section 18.

(3) But where the Commissioner receives a notification that the first declaration has been cancelled—

(a) the Commissioner must not refer the person’s case to such a panel, and

(b) if the person’s case has already been so referred, the Commissioner must notify the panel of the cancellation.

(4) Schedule (Assisted Dying Review Panels) makes provision about Assisted Dying Review Panels.”

This new clause provides for the Voluntary Assisted Dying Commissioner to refer a person’s case to a multidisciplinary panel, to be called an Assisted Dying Review Panel.

New clause 17—Reconsideration of panel decisions refusing certificate of eligibility—

“(1) This section applies where—

(a) a person’s case is referred under section (Referral by Commissioner of case to multidisciplinary panel) to an Assisted Dying Review Panel (“the first panel”), and

(b) the first panel refuses to grant a certificate of eligibility in respect of the person.

(2) The person may apply to the Commissioner for their case to be reconsidered on the ground that the first panel’s decision—

(a) contains an error of law,

(b) is irrational, or

(c) is procedurally unfair.

(3) The Commissioner must consider an application without a hearing.

(4) On the application—

(a) if the Commissioner is satisfied that any of the grounds mentioned in subsection (2) applies, they must as soon as reasonably practicable refer the person’s case to a different Assisted Dying Review Panel for a fresh determination under section (Determination by panel of eligibility for assistance);

(b) in any other case, the Commissioner must dismiss the application.

(5) The Commissioner must give reasons, in writing, for their decision.

(6) The Commissioner must notify the following of the outcome of the application, and give them a document containing their reasons for their decision—

(a) the person who made the application;

(b) the coordinating doctor;

(c) any other person specified in regulations made by the Secretary of State.”

This new clause provides for certain decisions of Assisted Dying Review Panels to be referred to a different panel for reconsideration.

Amendment (a) to new clause 17, leave out subsections (1) to (3) and insert—

“(1) The person applying for assisted dying, their next of kin, any of their relatives (within the meaning of the Family Law Act 1996), the registered medical practitioners who are treating them and anyone who took part in proceedings before the panel or gave evidence to the panel may apply to the Commissioner for the Panel’s decision to be reconsidered.

(2) The Commissioner will allow the application for reconsideration if the Panel’s decision was—

(a) wrong, or

(b) unjust because of a serious procedural or other irregularity in the proceedings.

(3) The Commissioner may consider the application without a hearing if they consider it in the interests of justice to dispense with a hearing.”

New clause 21—Determination by panel of eligibility for assistance—

“(1) This section applies where a person’s case is referred under section (Referral by Commissioner of case to multidisciplinary panel) or (Reconsideration of panel decisions refusing certificate of eligibility) to an Assisted Dying Review Panel (“the panel”).

(2) The panel’s function is to determine whether it is satisfied of all of the following matters—

(a) that the requirements of sections 5 to 9 have been met in relation to—

(i) the first declaration,

(ii) the first assessment and the report under section 7 on that assessment, and

(iii) the second assessment and the report under section 8 on that assessment;

(b) that the person is terminally ill;

(c) that the person has capacity to make the decision to end their own life;

(d) that the person was aged 18 or over at the time the first declaration was made;

(e) that before making the first declaration, but when the person was aged 18 or over, a registered medical practitioner conducted a preliminary discussion with the person;

(f) that the person is ordinarily resident in England and Wales and has been so resident for at least 12 months ending with the date of the first declaration;

(g) that the person is registered as a patient with a general medical practice in England or Wales;

(h) that the person has a clear, settled and informed wish to end their own life;

(i) that the person made the first declaration voluntarily and was not coerced or pressured by any other person into making that declaration.

(3) Subject to the following and to Schedule (Assisted Dying Review Panels), the panel may adopt such procedure as it considers appropriate for the case.

(4) The panel—

(a) must hear from, and may question, the coordinating doctor or the independent doctor (and may hear from and question both);

(b) must (subject to subsection (5)) hear from, and may question, the person to whom the referral relates;

(c) in a case to which section 15 applies, may hear from and may question the person’s proxy;

(d) may hear from and may question any other person;

(e) may ask any person appearing to it to have relevant knowledge or experience to report to it on such matters relating to the person to whom the referral relates as it considers appropriate.

In paragraphs (a) to (c) the reference to hearing from or questioning a person is to hearing from them, or questioning them, in person or by live video or audio link.

(5) The duty under subsection (4)(b) to hear from the person to whom the referral relates does not apply if the panel is of the opinion that there are exceptional circumstances which justify not hearing from that person.

(6) The panel—

(a) must, if it is satisfied of all of the matters mentioned in subsection (2), grant a certificate to that effect (a “certificate of eligibility”);

(b) must refuse to do so in any other case.

(7) The panel must notify the following of its decision—

(a) the person to whom the referral relates;

(b) the coordinating doctor;

(c) the Commissioner;

(d) any other person specified in regulations made by the Secretary of State.

Where it grants a certificate of eligibility, it must give a copy of the certificate to each of these persons.

(8) If the panel is notified that the first declaration has been cancelled, it must cease to act in relation to the referral (and, in particular, it may not grant a certificate of eligibility).”

This new clause provides for a person’s eligibility to be provided with assistance under clause 18 to be determined by a multidisciplinary panel (instead of the High Court).

Amendment (d) to new clause 21, in subsection (4), leave out paragraphs (a) to (e) and insert—

“(a) must hear from, and must question, the coordinating doctor and the independent doctor;

(b) must (subject to subsection (5)) hear from, and must question, the person to whom the referral relates;

(c) in a case to which section 15 applies, must hear from and must question the person’s proxy;

(d) must consider hearing from and questioning—

(i) persons properly interested in the welfare of the person who made the application for the declaration and other persons they are close to; and

(ii) any other person who has provided treatment or care for the person being assessed in relation to that person’s terminal illness; and

(e) may hear from and may question any other person, including any person appearing to it to have relevant knowledge or experience to report to it on such matters relating to the person to whom the referral relates as it considers appropriate.”

Amendment (c) to new clause 21, in subsection (4), after paragraph (e) insert—

“(aa) if it considers that the matters mentioned in subsection 2(c), (h) or (i) are established on a balance of probabilities but still considers that there is a real risk that they are not satisfied, then the panel must stay its proceedings until such further inquiries it orders are made,”.

Amendment (e) to new clause 21, after subsection (4) insert—

“(4A) Where the panel considers it appropriate for medical reasons, it may make provision for the use of pre-recorded audio or video material for the purposes of subsection (4).”

Amendment (a) to new clause 21, in subsection (6)(a), after “satisfied” insert “beyond reasonable doubt”.

Amendment (b) to new clause 21, in subsection (6)(a), after “subsection (2)” insert

“unless it believes that there are particular circumstances which make it inappropriate for the person to be assisted to end their own life,”.

New clause 2—Tribunal authorisation—

“(1) Where—

(a) a person has made a first declaration under section 5 which has not been cancelled,

(b) the coordinating doctor has made the statement mentioned in section 7(3), and

(c) the independent doctor has made the statement mentioned in section 8(5), that person may apply to the First-tier Tribunal (“the Tribunal”) for a declaration that the requirements of this Act have been met in relation to the first declaration.

(2) On an application under this section, the Tribunal—

(a) must make the declaration if it is satisfied of all the matters listed in subsection (3), and

(b) in any other case, must refuse to make the declaration.

(3) The matters referred to in subsection (2)(a) are that—

(a) the requirements of sections 5 to 9 of this Act have been met in relation to the person who made the application,

(b) the person is terminally ill,

(c) the person has capacity to make the decision to end their own life,

(d) the person has relevant and available palliative care options available to them,

(e) the person is not liable to be detained under the Mental Health Act 1983,

(f) the person was aged 18 or over at the time the first declaration was made,

(g) the person is ordinarily resident in England and Wales and has been so resident for at least 12 months ending with the date of the first declaration,

(h) the person is registered as a patient with a general medical practice in England or Wales,

(i) the person has a clear, settled and informed wish to end their own life, and

(j) the person made the first declaration and the application under this section voluntarily and has not been coerced or pressured by any other person into making that declaration or application.

(4) The Tribunal—

(a) may hear from and question, in person, the person who made the application for the declaration;

(b) must hear from and may question, in person, the coordinating doctor or the independent doctor (or both);

(c) for the purposes of paragraph (b), may require the coordinating doctor or the independent doctor (or both) to appear before the tribunal.

(5) For the purposes of determining whether it is satisfied of the matters mentioned in subsection (3)(g) and (h), the Tribunal may also—

(a) hear from and question any other person;

(b) ask a person to report to the Tribunal on such matters relating to the person who has applied for the declaration as it considers appropriate.

(6) In considering an application under this section, the panel must consist of—

(a) a sitting judge,

(b) a medical practitioner, and

(c) a lay person.

(7) In subsection (4)—

(a) in paragraph (a), the reference to the person who made the application includes, in a case where the person’s first declaration was signed by a proxy under section 15, that proxy, and

(b) “in person” includes by means of a live video link or a live audio link.”

This new clause would replace the role of the High Court with the tribunal system.

New clause 3—Tribunals in Wales—

“(1) For the purposes of this Act, the First-tier Tribunal and the Upper Tribunal, in exercising functions under or arising from this Act in relation to Wales, are to be treated as devolved tribunals within the meaning of paragraph 9 of Schedule 7A to the Government of Wales Act 2006.

(2) The Welsh Ministers may by regulations make provision relating to the procedure to be followed by the First-tier Tribunal and the Upper Tribunal in exercising functions under this Act in relation to Wales.

(3) Statutory instruments containing regulations made under this section may not be made unless a draft of the instrument has been laid before and approved by resolution of Senedd Cymru.”

Amendment 67, in schedule 4, page 28, line 32, leave out from “The” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 68, in schedule 5, page 30, line 6, leave out from “the” to “made” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 69, in schedule 5, page 30, line 10, leave out from “the” to end of line and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 70, in schedule 6, page 32, line 3, leave out from “of” to “declaration” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

New schedule 1—The Voluntary Assisted Dying Commissioner—

“Status

1 (1) The Commissioner is to be a corporation sole.

(2) The Commissioner is not to be regarded as—

(a) the servant or agent of the Crown, or

(b) as enjoying any status, immunity or privilege of the Crown.

(3) The Commissioner’s property is not to be regarded as property of, or property held on behalf of, the Crown.

General powers

2 The Commissioner may do anything the Commissioner considers appropriate for the purposes of, or in connection with, the Commissioner’s functions.

Deputy Commissioner

3 (1) The Prime Minister must appoint a person to be the Deputy Voluntary Assisted Dying Commissioner (the “Deputy Commissioner”).

(2) The person appointed must hold or have held office as a judge of—

(a) the Supreme Court,

(b) the Court of Appeal, or

(c) the High Court.

(3) The Commissioner may delegate any of the Commissioner’s functions to the Deputy Commissioner, to the extent and on the terms that the Commissioner determines.

(4) The delegation of a function under sub-paragraph (3) does not prevent the Commissioner from exercising that function.

(5) The functions of the Commissioner are to be carried out by the Deputy Commissioner if—

(a) there is a vacancy in the office of the Commissioner, or

(b) the Commissioner is for any reason unable or unwilling to act.

Appointment and tenure of office

4 (1) A person holds and vacates office as the Commissioner or Deputy Commissioner in accordance with the terms and conditions of their appointment as determined by the Secretary of State, subject to the provisions of this paragraph.

(2) An appointment as the Commissioner or Deputy Commissioner is to be for a term not exceeding five years.

(3) A person may not be appointed as the Commissioner or Deputy Commissioner if a relevant appointment of them has been made on two occasions. “Relevant appointment” here means appointment as the Commissioner or Deputy Commissioner.

(4) The Commissioner or Deputy Commissioner may resign by giving written notice to the Secretary of State.

(5) The Secretary of State may by notice in writing remove a person from the office of Commissioner or Deputy Commissioner if satisfied that the person—

(a) has behaved in a way that is not compatible with their continuing in office, or

(b) is unfit, unable or unwilling to properly discharge their functions.

Remuneration

5 The Secretary of State may pay to, or in respect of, the person holding office as the Commissioner or Deputy Commissioner—

(a) remuneration;

(b) allowances;

(c) sums by way of or in respect of pensions.

Staff: appointed by Commissioner

6 (1) The Commissioner may appoint staff.

(2) Staff are to be appointed on terms and conditions determined by the Commissioner.

(3) The terms and conditions on which a member of staff is appointed may provide for the Commissioner to pay to or in respect of the member of staff—

(a) remuneration;

(b) allowances;

(c) sums by way of or in respect of pensions.

(4) In making appointments under this paragraph, the Commissioner must have regard to the principle of selection on merit on the basis of fair and open competition.

(5) The Employers’ Liability (Compulsory Insurance) Act 1969 does not require insurance to be effected by the Commissioner.

Staff: secondment to Commissioner

7 (1) The Commissioner may make arrangements for persons to be seconded to the Commissioner to serve as members of the Commissioner's staff.

(2) The arrangements may include provision for payments by the Commissioner to the person with whom the arrangements are made or directly to seconded staff (or both).

(3) A period of secondment to the Commissioner does not affect the continuity of a person's employment with the employer from whose service he or she is seconded.

Staff: general

8 (1) Before appointing staff under paragraph 6 or making arrangements under paragraph 7(1), the Commissioner must obtain the approval of the Secretary of State as to the Commissioner's policies on—

(a) the number of staff to be appointed or seconded;

(b) payments to be made to or in respect of staff;

(c) the terms and conditions on which staff are to be appointed or seconded.

(2) A function of the Commissioner may be carried out by any of the Commissioner's staff to the extent authorised by the Commissioner (but this is subject to sub-paragraph (3)).

(3) Sub-paragraph (2) does not apply in respect of—

(a) the Commissioner’s function under paragraph 2(1) of Schedule (Assisted Dying Review Panels) of making appointments to the list of persons eligible to be panel members;

(b) the Commissioner’s function of determining applications for reconsideration under section (Reconsideration of panel decisions refusing certificate of eligibility).

Financial and other assistance from the Secretary of State

9 (1) The Secretary of State may—

(a) make payments to the Commissioner of such amounts as the Secretary of State considers appropriate;

(b) give such financial assistance to the Commissioner as the Secretary of State considers appropriate.

(2) The Secretary of State may—

(a) provide staff in accordance with arrangements made by the Secretary of State and the Commissioner under paragraph 7;

(b) provide premises, facilities or other assistance to the Commissioner.

Accounts

10 (1) The Commissioner must—

(a) keep proper accounts and proper records in relation to them, and

(b) prepare a statement of accounts in respect of each financial year in the form specified by the Secretary of State.

(2) The Commissioner must send a copy of each statement of accounts to the Secretary of State and the Comptroller and Auditor General—

(a) before the end of August next following the end of the financial year to which the statement relates, or

(b) on or before such earlier date after the end of that year as the Treasury may direct.

(3) The Comptroller and Auditor General must—

(a) examine, certify and report on the statement of accounts, and

(b) send a copy of the certified statement and the report to the Secretary of State.

(4) The Secretary of State must lay before Parliament each document received under sub-paragraph (3)(b).

(5) In this paragraph, “financial year” means—

(a) the period beginning with the date on which the Commissioner is established and ending with the second 31 March following that date, and

(b) each successive period of 12 months.

Application of seal and proof of documents

11 (1) The application of the Commissioner's seal is to be authenticated by the signature of—

(a) the Commissioner, or

(b) a person who has been authorised by the Commissioner for that purpose (whether generally or specially).

(2) A document purporting to be duly executed under the Commissioner’s seal or signed on the Commissioner’s behalf —

(a) is to be received in evidence, and

(b) is to be treated as duly executed or signed in that way, unless the contrary is shown.

Public Records Act 1958

12 In Part 2 of the Table in paragraph 3 of the First Schedule to the Public Records Act 1958 (bodies whose records are public records), at the appropriate place insert “The Voluntary Assisted Dying Commissioner”.

House of Commons Disqualification Act 1975

13 In Part 3 of Schedule 1 to the House of Commons Disqualification Act 1975 (offices disqualifying person from membership of House of Commons), at the appropriate place insert—

“The Voluntary Assisted Dying Commissioner or the Deputy Voluntary Assisted Dying Commissioner.”

Freedom of Information Act 2000

14 In Part 6 of Schedule 1 to the Freedom of Information Act 2000 (public authorities for the purposes of the Act) , at the appropriate place insert—

“The Voluntary Assisted Dying Commissioner.”

Equality Act 2010

15 In Part 1 of Schedule 19 to the Equality Act 2010 (public authorities subject to public sector equality duty), at the end of the group of entries for bodies whose functions relate to health, social care and social security insert—

“The Voluntary Assisted Dying Commissioner.””

This new Schedule contains provision about the Voluntary Assisted Dying Commissioner and the Deputy Commissioner.

New schedule 2—Assisted Dying Review Panels—

“Introduction

1 In this Schedule—

(a) “referral” means a referral under section (Referral by Commissioner of case to multidisciplinary panel) or (Reconsideration of panel decisions refusing certificate of eligibility) (and similar references are to be construed accordingly);

(b) “panel” means an Assisted Dying Review Panel.

List of persons eligible to be panel members

2 (1) The Commissioner must make appointments to a list of persons eligible to sit as members of panels.

(2) A person may be appointed to the list only if—

(a) the person (a “legal member”)—

(i) holds or has held high judicial office,

(ii) is one of His Majesty’s Counsel, or

(iii) has (at any time) been requested to act as a judge of the Court of Appeal or the High Court by virtue of section 9(1) of the Senior Courts Act 1981,

(b) the person (a “psychiatrist member”) is—

(i) a registered medical practitioner,

(ii) a practising psychiatrist, and

(iii) registered in one of the psychiatry specialisms in the Specialist Register kept by the General Medical Council, or

(c) the person is registered as a social worker in a register maintained by Social Work England or Social Work Wales (a “social worker member”).

(3) In this paragraph “high judicial office” means office as—

(a) a judge of the Supreme Court,

(b) a judge of the Court of Appeal, or

(c) a judge or deputy judge of the High Court.

Tenure of persons appointed to list

3 (1) Subject to the provisions of this paragraph, persons on the list hold and vacate their appointments in accordance with the terms on which they are appointed.

(2) An appointment to the list is to be for a period not exceeding five years.

(3) A person who has held appointment to the list is eligible for re-appointment for one further period not exceeding five years.

Membership of panels

4 (1) The Commissioner must make arrangements for determining the membership of a panel.

(2) The arrangements must ensure that a panel consists of—

(a) a legal member,

(b) a psychiatrist member, and

(c) a social worker member.

Decisions of panels

5 (1) The legal member of a panel is to act as its chair.

(2) Decisions of a panel may be taken by a majority vote; but this is subject to sub-paragraph (3).

(3) The panel is to be treated as having decided to refuse to grant a certificate of eligibility if any member votes against a decision to grant such a certificate.

Panel sittings

6 (1) Panels are to determine referrals in public (but this is subject to sub-paragraph (2)).

(2) The chair of a panel may, at the request of the person to whom a referral relates, decide that the panel is to sit in private.

Staff and facilities

7 The Commissioner may make staff and other facilities available to panels.

Practice and procedure

8 (1) The Commissioner may give guidance about the practice and procedure of panels.

(2) Panels must have regard to any such guidance in the exercise of their functions.

Reasons

9 Panels must give reasons, in writing, for their decisions.

Money

10 The Commissioner may pay to or in respect of members of panels—

(a) remuneration;

(b) allowances;

(c) sums by way of or in respect of pensions.

House of Commons Disqualification Act 1975

11 In Part 3 of Schedule 1 to the House of Commons Disqualification Act 1975 (offices disqualifying persons from membership of House of Commons), at the appropriate place insert—

“Person on the list of those eligible for membership of an Assisted Dying Review Panel.””

This new Schedule contains provision about Assisted Dying Review Panels.

Amendment (c) to new schedule 2, in paragraph 4, after

“(c) a social worker member.”

insert—

“(3) The Commissioner must ensure that each member of a panel has had training in respect of domestic abuse, including coercive control and financial abuse.”

Amendment (a) to new schedule 2, in paragraph 4, after

“(c) a social worker member.”

insert—

“(3) Each member of a panel must have fluent proficiency in the Welsh language if services or functions in the Act are to be provided to an individual in Welsh.”

Amendment (b) to new schedule 2, in paragraph 8, leave out sub-paragraphs (1) and (2) and insert—

“(1) The Commissioner must give guidance about the practice and procedure of panels.

(2) Such guidance must prescribe a procedure which in relation to each application appoints a person nominated by the Official Solicitor to act as advocate to the panel.

(3) Panels must have regard to such guidance in the exercise of their functions.”

This amendment would require Assisted Dying Panels to follow an adversarial process to test the evidence by appointing an advocate to the panel.

[Danny Kruger]

Could you just repeat that? [Laughter.]

[Kim Leadbeater]

I hope you are sitting comfortably, Mrs Harris; it is a pleasure to see you this evening. I rise to speak to new schedules 1 and 2, new clauses 14, 15, 17 and 21, and their consequential amendments. These provisions relate to the introduction of the assisted dying commission, which would oversee the assisted dying process in England and Wales, and the multi-disciplinary panels of experts, which will operate as part of the commission, should the Bill be passed.

It has always been my view, and I have always been clear, that there should be a third layer of scrutiny and safeguarding in the assisted dying process, particularly given the significance of the change in the law. However, I appreciate that, if we compare the Bill with the many other models of assisted dying around the world, this is very unusual. Most jurisdictions have a process that involves two doctors, as the Bill does, but there is no additional stage.

There are different views as to whether a third layer is necessary; many other jurisdictions have processes that provide a very compassionate, patient-centred and well-safeguarded approach to assisted dying without it. Indeed, some of the most difficult emails I receive are from terminally ill people who are very concerned about the complexity of the process laid out in the Bill. They feel that it is overcomplicated and too bureaucratic to navigate for people who are in their dying days and weeks. I am very sensitive to that. I am also aware that the thorough process set out in the Bill will take time, and there will be people who embark upon it who will die before they can complete it, as happens in other jurisdictions. That is, of course, extremely sad.

I also know that, certainly in this country, people feel strongly that oversight and scrutiny of what we might call the initial medical stages of the assisted dying process are important. The challenge is achieving an appropriate balance between compassion and patient autonomy, and robust safeguarding—plus, of course, medical autonomy.

If there is to be a third layer, what should it look like? As the Bill stands, the third layer of scrutiny is a High Court judge, who would make the final decision regarding a patient’s choice to have an assisted death. I was, and remain, very confident in the ability of High Court judges to have that role, but it is fair to say that there is a range of views on the suitability of the judiciary to fulfil this function—not least from ex-judges themselves. It is important that we as a Committee acknowledge that.

Barrister and former Supreme Court judge Lord Sumption said that

“clause 12 is unnecessary and in some respects undesirable.”

He went on:

“The concern that I have about clause 12 in its current form is that it is not entirely clear what the judge is supposed to do…is he there in order to ensure that the two doctors have done their job and that the ducks are all in a row, or is he there to form his own view on all of those matters, completely independently of those who have already given their certificates?...It seems to me that this is a protection that no other country, so far as I am aware, among those that have authorised one or other form of assisted dying has included.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 172-173, Q222.]

Lord Sumption has been critical of the complexity of the process set out in the Bill as drafted, describing it as

“over-engineered, bureaucratic, and coldly inhumane”.

He told us in evidence that he disagreed with the inclusion of the need for High Court approval of a person’s application for an assisted death.

Former High Court judge Sir James Munby has written various articles in this regard. In his piece “Assisted dying: what role for the judge?” he asks:

“Should the judges be involved at all in this process? Is what is proposed a proper judicial function?”

He continues:

“Is this, indeed, truly a judicial function at all? Many would say that it is not. Where else in our judicial system does one find a judge, sitting judicially as a judge, whose function is not to decide some disputed issue or…to resolve some controversy but only to certify, as it were, that some decision taken by a private individual complies with the law? That, it might be said, is not what judges do and not what judges are for.”

He also expresses his concerns around conscientious objection and the challenges of ensuring

“an open and transparent process that may deter those for whom the scheme is designed, and a secret process destructive of the integrity of the scheme and corrosive of the judicial function.”

I absolutely agree that this is a very tricky balance.

[Danny Kruger]

The hon. Lady cites James Munby, who correctly identified the problems with the High Court process as it was designed and exists in the Bill. Is she aware that he also strongly objects to the amendments? He thinks that the newly proposed scheme fails on all the same tests, and he regards it as just as unsafe as the previous one.

[Kim Leadbeater]

The hon. Gentleman makes a good point. It is fair to say that there is a range of views on this subject from the judiciary. Ex-judges have commented, and I will come to those comments shortly.

In his evidence, the chief medical officer, Professor Sir Chris Whitty, said that the best safeguards were the simple ones and warned that patients could find themselves in “a bureaucratic thicket” at the end of life if there is too much to navigate. I am very sensitive to that. Responding to his comments, Lord Sumption said:

“I do agree with that…one suggestion that I think would make a significant difference…is the removal of the clause 12 stage.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 182, Q236.]

That shows the difference of opinion among former judges.

--- Later in debate ---

I think that is really important, and I know colleagues will be reassured by it.

[Danny Kruger]

I have made this point before, but I will do so again: it is very welcome to have these extra professionals involved in the process. Does the hon. Lady not recognise that it would be so much more appropriate to have them involved early on, at the assessment stage? We all want it not to be just a rubber stamp, but they are currently to be involved at the approval stage, at the end of the process, essentially fulfilling a judicial function of deciding yes or no. Why are these professionals not involved earlier?

[Kim Leadbeater]

I disagree: they are involved earlier. I have talked about the amendments we have already made around health and social care professionals. We have tabled those amendments, changed the Bill and added that provision on the basis of the evidence we heard. Remember that either doctor can speak to any other health or social care professional they wish. I would say that, actually, a multidisciplinary approach is taken throughout the Bill and, by ending the process with the panel, that is reinforced.

The hon. Member for East Wiltshire said in his radio interview on 12 February, “I do welcome”—as he has confirmed today—“the additional role of more experts in the process”. Hopefully, irrespective of our different views, that is something that the idea of the panel can coalesce around. Despite the hon. Gentleman’s opposition to assisted dying, I hope that, in the interests of strengthening the Bill, he will be able to support the amendments today, because that is the job of this Committee—to strengthen the Bill, not to try to stop it, however strongly people may feel about the issue.

A significant part of the strengthening is through additional patient-centred safeguards. I firmly believe that the introduction of the assisted dying commission and the addition of the multidisciplinary expertise and oversight provided by the panels are a crucial part of that. The panel will look at the detail of every individual case and scrutinise the doctors’ reports. It must hear from and may question the co-ordinating doctor or the independent doctor; it may hear from and question both; and it must hear from and may question the patient themselves. I mentioned that in relation to the amendment from my hon. Friend the Member for Broxtowe earlier. It is the default.

This was a difficult decision. I appreciate that to make the patient undergo another level of personal scrutiny could be viewed as cruel. Indeed, a number of people have said to me that they feel it will be too burdensome on the patient during what is already a deeply emotional, highly personal and stressful time, when they are likely to be in pain and having treatment. I acknowledge that. Again, this is about finding the very difficult balance between avoiding an unduly stressful bureaucratic process and ensuring that the patient is making, as the Bill says, a “clear, settled and informed” decision. There is a very strong argument that in order to do so, the panel should hear from the person themselves. That is the decision I have taken, addressing the concerns of colleagues who have tabled amendments to the same effect. Indeed, Lord Munby said of the Bill as it stands that

“the absence of any requirement that the judge ‘must’ hear from and question the patient is a quite extraordinary lacuna.”

I appreciate, though, that there will be exceptional circumstances, which we know may be the case if the patient is very ill and in their last few weeks of life.

The panel may also ask any person who appears to have relevant knowledge or experience to report to it on such matters relating to the person as it considers appropriate. It can basically ask to hear from anybody it wishes. That would obviously vary from case to case. Every case will be different, as we have discussed, and flexibility is really important. Only if all three members of the panel are satisfied that all the criteria have been met will it issue a certificate of eligibility. It must refuse to do so if it is not satisfied. The decision of the panel has to be unanimous. If there is any doubt from any of the panel members that the criteria have been met, the patient cannot proceed.

The patient then enters a 14-day period of reflection, before making their second declaration. It is worth reiterating that, as has been said previously, a significant number of patients get to that stage and never actually continue with an assisted death, but the comfort it provides enables them to live out their final weeks and days with a sense of reassurance. As families have described, a weight is lifted. Indeed, Professor Michael Dooley, who is the director of pharmacy at Alfred Health and the head of Victorian voluntary assisted dying pharmacy services, and who some of us met yesterday, told us that in that state in Australia some 90% of assisted dying patients also still access palliative care. That shows the holistic approach that can be taken.

There is of course another very important role for the commission, which is in relation to the monitoring and reporting of cases—something I feel very strongly about. The details are set out in my amendment 455 to clause 34. The commission must produce an annual report, which must include details about the application of the Act. That report must include details in relation to persons who have protected characteristics, and details of any other description of people specified. That would include data on demographics; statistics on the populations and characteristics of the patients who have chosen an assisted death; their age and gender; geographical analysis; data regarding the illnesses and diseases; how many cases were rejected; and how many patients did not complete the process and so on. When completing the annual report, the commissioner must consult the chief medical officers for England and for Wales, and anyone who represents the interests of people with protected characteristics.

The Law Society, which is neutral on assisted dying, says that if the law were to change, the system must have

“robust, accessible and independent safeguards”

as well as

“strong independent monitoring and review mechanisms”.

I agree. The introduction of a multidisciplinary panel of experts to consider all applications for an assisted death, overseen by a commissioner in the form of a High Court judge, sitting or retired, really does achieve that, and embeds a truly robust, multidisciplinary approach, which I am confident will put patients at the centre of the assisted dying process and provide additional scrutiny, safeguards and protections.

[Naz Shah]

I rise to speak to new clause 21, new clause 14, new clause 16, new schedule 2 and amendment (b) to new schedule 2. I will start with new clause 21—and have a break in between.

I oppose new clause 21, tabled by my hon. Friend the Member for Spen Valley. I also wish to oppose new clauses 14, 15, 16 and 17, which between them set out the panel procedure to replace the use of a High Court judge, but I will focus my remarks on new clause 21. That is because, first, it is the most recently tabled of my hon. Friend’s new clauses on the panel. Secondly, and perhaps more importantly, it seems to be an attempt to solve some of the problems of the earlier new clauses.

I welcome what I think my hon. Friend’s intentions are with the new clauses. The Bill as drafted did not provide anything like adequate safeguards. The new clause states that the panel must hear from, and may then question, the doctors who made the certification, the applicant for assisted death, and any other person who may have relevant information. These moves are very welcome steps towards a tighter set of safeguards, but they are inadequate because of what they leave out.

Sir James Munby, the former president of the family division of the High Court of England and Wales, has written several times about the problems with the Bill. It is a matter of great regret to me that we did not hear from Sir James; I appreciate that my hon. Friend the Member for Spen Valley set out that he was invited to give evidence to the Committee. Sir James has expressed profound concern about the series of new clauses— new clauses 14, 15, 16 and 17—that my hon. Friend has tabled. He wrote that the new clauses did address some of the problems of the original Bill, but he went on:

“These changes are to be welcomed, so far as they go. It is important to recognise, however, that they do not, in my opinion, go anything like far enough.”

As I have said, some elements of new clause 21 do indeed address some of the problems that Sir James identified but, again, the new clause unfortunately still leaves many of the biggest problems untouched.

The Bill does not set out that evidence must be heard under oath. That is an extraordinary omission. Sir James Munby asks, in his most recent essay:

“is the panel to hear evidence on oath? Indeed, will the panel have power to administer an oath?”

We rightly expect our courts to hear evidence under oath if they deal with cases concerning property or contract. The matters the panels will be dealing with are far more important than that. It is baffling to me why we should hear evidence on these matters without making witnesses swear oaths to tell the whole truth and nothing but the truth. Anyone speaking to one of these panels should do so with the same commitment to telling the truth as they would in a court of law.

[Danny Kruger]

rose—

[The Chair]

I call Kit Malthouse.

[Danny Kruger]

Danny Kruger; we are easily confused. [Laughter.]

The hon. Lady talks about the question of oaths, and it is extraordinary. Does she agree that it speaks to the confusion about whether the panels are a judicial construct at all? They have a judicial function—they exercise a judicial responsibility—but they are composed of non-lawyers. Maybe that explains why there is no oath, but I agree with the hon. Lady that there should be one. Does it not speak to the confusion in the new clause?

[Naz Shah]

As I make progress, I will speak to that point, but I share the hon. Gentleman’s concern. I will return to my speech and expand on the point when I arrive at that juncture.

Sir James goes on to say that there are even graver problems with the panel procedure. I appreciate that his paper was published before new clause 21 was tabled, but it does not address all the concerns he raised. He referred particularly to new clause 16, but it is relevant to note that the problem he identified is left untouched by new clause 21. Sir James says of new clause 16:

“It says very little about the procedures to be adopted for testing and, if need be, challenging the evidence”.

He goes on to say that

“it says nothing about who should exercise that function; nor about the nature of any independent evidential investigation and nothing about who is to undertake this and who is to pay for it.”

Finally on this point, he says that new clause 16

“says nothing about what, if any, public funding arrangements there will be for the applicant, the two doctors, and any other parties or expert or lay witnesses.”

The first point raised by Sir James is an extraordinary one. The panels will bring together three people: a lawyer, a consultant psychiatrist and a social worker. They will sit on what is a quasi-judicial body. The latter two will not necessarily have any experience of questioning witnesses and assessing evidence as part of a quasi-judicial process. The first person—the lawyer—will have such experience. What is going to happen? Are we just hoping that they will successfully make it up as they go along? Is there not a danger that in some cases the non-legal members of the panel end up deferring to the wishes of the lawyer, who has more experience in these matters?

--- Later in debate ---

[Naz Shah]

As I make progress I will address some my hon. Friend’s points—I have a fairly long speech—but I will say now that when the Bill passed on Second Reading, one of the safeguards was that it included judicial oversight. That is very different to what we are talking about now.

[Danny Kruger]

This is a very important point, and I am grateful for the hon. Member for Spen Valley’s admission that this is not a judicial process. We have constantly been told that the Bill has been gold-plated with the judicial stage of the application process, but we have now heard that there is not a judicial stage. We have also heard that this is “judge-plus” and somehow an improvement—it is a judge and others—but we should be clear that there is not necessarily a judge in the process, and it is very unlikely that there would be. We have just heard conclusively that the judicial stage of the process in the Bill has been dropped.

[Naz Shah]

I agree: there is not a judicial process, so to speak. There most definitely is not. As I make progress, I will outline my concerns about that very clearly.

Let us take the second point raised by Sir James. He asked who will go about

“testing and, if need be, challenging the evidence”?

New clause 21 finally gives the panel the power to call people to give evidence who are neither the applicant nor the doctor. New clause 21(4) says that the panel

“may hear from and may question any other person”

and

“may ask any person appearing to it to have relevant knowledge or experience to report to it on such matters relating to the person to whom the referral relates as it considers appropriate.”

I welcome that as a start, because it acknowledges that there will be cases in which people other than the applicant and the doctors have vital information. But that really should not be where we finish—not if we want a genuinely robust assisted dying Bill with strong safeguards for vulnerable people.

The ability of the panel to hear evidence from other parties would indeed be one step towards detecting whether people are, for example, being coerced towards an assisted death. That would be one step towards being able to detect whether people were choosing assisted death because of a lack of palliative care or social care. But how will the panels know which witnesses are most likely to have or be aware of the significant evidence they seek?

The panel members will have the statements by the applicant and the doctors, and they will have the answers to any questions they have of the applicant and the doctors. I ask Members to think through how certain it is that those sources alone will be enough to find all the people who might have significant knowledge of a person’s circumstances. I would argue that it will not be certain. Yes, in some cases there will be no hidden circumstances that a panel would hear of from a witness only if they were called, but in other cases there will be, and those circumstances are much more likely to occur in the cases of people who are coerced or who feel like a burden to their families. They will be more likely to occur for those who have poor mental health, who are isolated, or who lack the social care they need. The panels are not likely to find witnesses with relevant information if what they have to go on is the statement of witness evidence of a person who has, for example, been successfully and skilfully coerced.

--- Later in debate ---

[Naz Shah]

I either misheard my hon. Friend or did not understand his earlier point, so let me speak to the point he makes now. My understanding is that sectioning someone under the Mental Health Act is a very extreme measure. Someone is sectioned in circumstances in which lots and lots of evidence has been taken from people who know the person, and there is a history. That was certainly the case when I chaired a mental health charity. Whether it is carers or other people who contribute to that, there is a long-standing relationship; from my understanding, it is very rare for something to happen otherwise. That is my understanding and experience of it, but I am happy to have a chat with my hon. Friend to talk more about it and understand it more.

[Danny Kruger]

Does the hon. Lady agree that the intervention of the hon. Member for Sunderland Central is very helpful because it highlights the difference between a genuine judicial tribunal, as he suggests, and what is being proposed here? This is not a tribunal. It would not sit in a judicial capacity. Its members would not take oaths in the way that members of a tribunal do. They are not appointed through the independent appointments process that tribunals have. This is a multidisciplinary team masquerading as some sort of final judicial stage, without the proper accountability of a judicial stage. On that basis, we cannot regard it as any sort of improvement to the Bill.

[Naz Shah]

I thank the hon. Member for reminding me of that; I talked about that earlier. I agree with him that this is about the legalities. Ultimately, it comes back to judicial oversight, which is what was promised originally. That is why judges were part of the original proposals for the Bill. The words we must listen to are Sir James Munby’s. If we want an assisted dying Bill with real safeguards for the vulnerable, then we should reject new clauses 14 to 17 and new clause 21. They are not thorough enough to do the job.

--- Later in debate ---

[Danny Kruger]

The hon. Gentleman is making a very good speech in defence of the change, but could he help me understand something? He said that he supported the previous proposal, involving a High Court judge; he is now suggesting that it would be completely inappropriate to have any sort of judicial oversight of the process. How could it have worked better?

The hon. Gentleman talks about there being no need for any sort of adversarial system, but does he not recognise that there might be another side to the story, and that it would be appropriate for somebody, whether that is a judge or someone else, to hear arguments against the application?

[Jake Richards]

Let me deal with the first point first. A High Court judge could have exercised this function themselves. As I set out in public very soon after Second Reading, I was struck by the fact that we were asking a High Court judge to do this, even though they have no particular expertise in the issues that so concerned hon. Members on Second Reading, whether they voted in favour of the Bill or against it. I thought about the process more, as we are all doing, to try to understand what it would look like in practice. What questions might be asked? Where does a panel or judge need to go? To my mind, psychiatrists and social workers are much better placed than High Court judges to know what avenues to further explore.

I have forgotten the hon. Gentleman’s second question.

[Danny Kruger]

I was making the point that there is surely some value in what the hon. Gentleman describes as an adversarial process, in which the decision maker is required to consider whether there are circumstances that the applicant is not presenting.

[Jake Richards]

I will come on to that issue. First, there are avenues for the panel to have information put before it that will be pertinent to the decision at hand and that may be pivotal to that process. That is not quite adversarial. Secondly, there is always a route for an adversarial contest in this matter through judicial review. I hope that that will be very rare, but it is certainly possible, and that has to be maintained. I think my hon. Friend the Member for Spen Valley and the Minister would accept that that would be an avenue.

The panel will have an array of information to consider. It will have two reports: one from the co-ordinating doctor and one from the independent doctor. In any event, it is often likely to seek medical records. It will speak to the co-ordinating doctor or independent doctor about capacity and any issues of coercion. Crucially, it will speak to the person themselves unless there are extraordinary circumstances that oblige it not to. One can imagine the vast array of circumstances that will come before the panel, but it will have the discretion and freedom to explore as appropriate. That will be a process that is appreciative of the specific facts before the panel.

I made this point earlier, but it is important to remember that this is a very human moment. A person is dying; they come to the panel seeking help. It is right to ensure that there are hurdles to consideration for eligibility, but the idea that a person should be forced to win a trial or a case, or see through complex litigation, is surely not right.

--- Later in debate ---

That is not a remote possibility; indeed, it seems very likely to happen at some point, given that we have had similar cases in all the jurisdictions where assisted dying has been going on for some time. That is why I intervened on my hon. Friend the Member for Rother Valley to ask whether there would be a JR process. If we are talking about a judicial review of any of the decisions by the panel in a case where somebody has less than six months to live, raising the funds and finding somebody to take that to court would potentially take time. Would that time elapse after the person’s death or before? I would really value understanding from the Minister or the Bill’s sponsor what safeguards there are for a potential JR. Have those been built in or not?

[Danny Kruger]

This conversation is very helpful, and the point the hon. Lady makes is absolutely right. If we are going to rely on JR as a sort of appeal process, we need to make it clear how that would work. Would there be legal aid? How quickly could these things be done? I think that that needs to be built in. Does she agree?

[Naz Shah]

I absolutely agree that we have not thought this through enough, because that process has not been laid out. We really need to think about these potential eventualities.

When such cases happen, the public, including family members of the person who has died, will rightly demand answers, and so will the media. They will want to know who the panel members were and why they made the judgment they did. In such cases, who would investigate whether panel members had got it wrong? The commissioner who had appointed them? The commissioner, or any person, no matter how honest and how learned, would come back to that question with a very strong bias. The commissioner will mark their own homework. That is not a system that anyone can argue will provide proper safeguards.

Hon. Members might object that the voluntary assisted dying commissioner will be a very senior judge. According to the new clause, the commissioner

“must hold or have held office as a judge of—

the Supreme Court

the Court of Appeal, or

the High Court.”

I agree that only people of high intelligence and good standing become judges in those courts, but that does not mean that the very highest judges in the land do not sometimes make mistakes—sometimes very bad ones.

--- Later in debate ---

[Naz Shah]

I am grateful for my hon. Friend’s intervention, but I reject the facetiousness of his point.

Let me speak to the issue of unconscious bias in relation to the proposal before us. In 1992, there was a jury trial, which found my mother guilty of murdering an abusive partner. In 1998, I went to the High Court and put it to three white middle-class judges that my mother could not tell the truth because of the abuse, the dishonour and the concept of izzat, which defined her existence as a woman. They were not capable of believing that, because they did not have that cultural understanding —so, yes, unconscious bias does exist, even in criminal cases in courts of law.

Returning to my argument, I remind hon. Members of the testimony of Dr Ryan Spielvogel from California, who said:

“when I am going through the options with patients who are newly diagnosed with a serious life-threatening illness, I say, ‘Okay, here’s what disease-directed treatment would look like. We can continue with your chemo. Here are some side effects and complications that you might have, and here are the benefits of that. Here’s what palliative care or hospice care would look like.’ Then I say, ‘I don’t know if you know this, but in our state we have this other option for people nearing the end of their lives when they have intolerable suffering. You can ask me to fill a lethal prescription for you to help end your suffering sooner.’…The number of times that people look at me and say, ‘You can do that? That’s an option here?’ is astounding. I would say that nine out of 10 of patients I have conversations with have no idea that that is even legal. If they do not know it is an option, they are never going to ask for it.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 105, Q143.]

I wonder whether I would be comfortable—this is just a personal thing, but I want to put it out there for people to think about—about a doctor such as that, who really supports assisted dying, being on the panel. I am not casting aspersions on him, but I genuinely am unsure.

Of course, the panel will be chaired by lawyers. I would like to remind hon. Members of the evidence of Professor Meredith Blake, who is a senior legal adviser to the Western Australian government on their assisted dying law. Professor Blake’s evidence was quite extraordinary. My hon. Friend the Member for Banbury asked her:

“Does it concern you that a large proportion of people who opted for assisted dying cited being a burden as their reason?”

She replied:

“That is not the evidence that we have got.”

My hon. Friend responded:

“Let me just clarify. The state’s own report in 2023-24 had 35%.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 220, Q284.]

I do not recall having a satisfactory answer from Professor Blake to that question, but please feel free to check Hansard.

If we see a series of questionable decisions by one or more panel member, the only official scrutiny will come from the person who appointed them to do their jobs, and that is not a robust safeguard. Furthermore, my hon. Friend the Member for Spen Valley said earlier that decisions would be unanimous, but that is not entirely correct, and I am happy to point to the relevant bit in the Bill. If two people decide they agree, and the other decides to stay quiet, that would be seen as a unanimous decision, and the panel would proceed. I am happy to point that bit of the Bill out to my hon. Friend, as I would love to see an amendment if one were needed.

[Danny Kruger]

I think the point the hon. Lady is making is that each member of the panel has a veto over the decision so, in a sense, there has to be unanimity about the approval. However, she is absolutely right that if two members disagree with one another about any other aspect of their proceedings, including who to invite to give evidence, they could be overruled, so there is not unanimity there.

[Naz Shah]

I completely agree. That is the case in the Bill, which raises concerns.

Finally, Parliament needs to get back into the habit of holding powerful commissioners accountable. There is no mechanism in the Bill for removing a commissioner even if they somehow failed significantly in their duties. We might say to ourselves, “If that happened, they would do the right thing and resign,” or, “They would resign if the Prime Minister said something in public.” I am sorry, but we cannot leave that to chance.

There has been a very telling example recently of just how badly quasi-judicial institutions can fail, and just how hard it is to get their senior leadership to accept responsibility. The Criminal Cases Review Commission mishandled the Andrew Malkinson case. Mr Malkinson was falsely convicted of raping a woman in 2003. She had been raped by another man.

--- Later in debate ---

[Rebecca Paul]

First, I apologise: I have quite a lot to talk about.

[Danny Kruger]

On a point of order, Mrs Harris. I do not know whether this is appropriate, but was there a proposal to adjourn? I am conscious that my hon. Friend is about to make a very long speech.

[The Chair]

Yes, there was, but you cannot move the Adjournment while the hon. Lady is still speaking.

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

Danny Kruger Excerpts

Committee stage
Wednesday 12th March 2025 Public Bill Committees

[Rebecca Paul]

I thank the hon. Member for that confirmation. Now that I have that clarity, I will skip on.

One aspect of the panel that gives me cause for concern is that the panel would not hear from the patient themselves where there are “exceptional circumstances”. What are exceptional circumstances? The Bill does not say or provide any guidance. Many people with a terminal diagnosis who are seeking assisted dying could consider their circumstances exceptional; many undoubtedly will be too unwell to attend. That means that such panels could be making these decisions based on testimony from only one doctor. I am not for one second suggesting that people on their deathbeds should have to attend a panel—that is the point of exceptional circumstances—but I urge the promoter and Ministers to ensure that the much-need clarity around the meaning of the term is set out in order to reduce ambiguity in this area.

[Danny Kruger (East Wiltshire) (Con)]

It was helpful to hear the Bill’s promoter suggest that the system will be inquisitorial—that is not sufficiently apparent in the new clause, as my hon. Friend the Member for Reigate says. Does she agree that the panel must therefore have proper inquisitorial powers and authority? At the moment, there is a lack of genuine power to investigate the circumstances. If it not going to be adversarial but inquisitorial, it should have proper powers to make an investigation.

[Rebecca Paul]

My hon. Friend makes a good point; I completely agree with him on that front. This goes back to being clear on the face of the Bill about what the panel does and the powers it has in order to avoid ambiguity. It is important that we set that out now, during this process, rather than finding ourselves in a position in two years where it is all starting to happen, if the Bill is approved, and the questions starting at that point. Let us try to answer them now and be really clear about it.

Where a panel does not hear directly from a patient, it may be forced to rely on second-hand accounts. In law, second-hand evidence is known as hearsay and is always handled with a lot of provisions and warnings across our criminal and civil legal systems, because it can be inaccurate or of lower quality than evidence directly from a source. However, the panel is open to depending on such evidence. We must be clear-eyed about the risks that come with that.

In summary, I do not believe that new clause 21 gives sufficient clarity on how the panel will perform its role and what evidential standard it would apply. We do not know if it is an administrative task or a judicial one. We do now know that the panel is inquisitorial—I thank the Bill’s promoter for that—but we do not know how much it will rely on hearsay evidence in practice. I will say this again, because it is really important: the panel is required to hear from only one doctor and does not need to question them. Under the Bill, would it be legally acceptable for the doctor to turn up, say, “No concerns”—and that’s the end of that? I am here to tell Committee members who think that that will not happen if the Bill allows it: somewhere, with some panel, it absolutely will—particularly as our society gets desensitised and more comfortable with the concept of assisted dying.

I urge the Committee to be precise with the legislation it is passing for the sake of the statute book and, more importantly, for the sake of all the people who may find themselves being assessed by such a panel.

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[Rebecca Paul]

I thank the hon. Gentleman for that important point. My point is that the family should be listened to and should have a route to legally provide information to the panel. Right now, they have no right to do that. In reality, I think most panels would take that information. I would like to think that, 99 times out of 100, if a family member contacted the panel saying, “I have really important information,” it would listen to that. But I am legislating for the one case in 100 or 1,000 in which, for whatever reason, the panel refuses to engage with a family member who has a relevant bit of information, and not having the right information leads to someone’s death.

The amendment is about protecting panel members too. If I were a panel member, I would want this process in place, because it would protect me when I make a decision. I would take great comfort from knowing that a family member with relevant information has a legal right at least to communicate it to the panel.

[Danny Kruger]

This is a very helpful exchange, for which I am grateful to my hon. Friend. In response to the hon. Member for Rother Valley, does my hon. Friend agree that although there should be an obligation to help the decision maker to conclude as to whether the eligibility criteria have been properly met, there is no best-interest consideration, as there might be if some of us were designing the Bill? Nevertheless, the role of the family is to enable the decision maker to conclude as to whether there have been issues of coercion or lack of capacity, to ensure the decision is properly informed. We are concerned that the Bill as drafted does not do that.

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[Rebecca Paul]

I thank my right hon. Friend for that alternative perspective. The appeal process is valid only if there is new and relevant information that the panel did not have. For someone who is absolutely eligible, nothing has been excluded from the process that would change their eligibility. There is nothing to worry about here, so I am not sure that I concur that my amendment would prevent sharing information. However, it would provide important protection when a bit of relevant information has not been shared with the panel, which I think is the greater harm. We are trying to weigh up the harms to make sure that they do not outweigh the benefits; I honestly believe that the amendment would help to balance the scales a little better.

[Danny Kruger]

The scenario that my right hon. Friend the Member for North West Hampshire suggests implies that the patient has no faith in the panel. The patient would be concluding that they did not want to go through the formal process for an assisted death and explain it to their relatives, because they fear that the panel’s decision might be overturned on application by their relative. That objection is predicated on a lack of faith in the process that is being decided. If we are to have confidence in the process, we should trust that people will expect it to work properly. There is nothing wrong with giving a family member the right to make an application to the panel or the commissioner, because they would have every right to reject that family member’s application if they concluded that the original decision was valid.

[Rebecca Paul]

I completely agree. While I was preparing my speech, as is often the way, I found myself wishing that I had tabled an amendment to add a legal requirement that the family be able to feed into the panel and share information. Perhaps that is something that can be picked up at a later stage. The nature of the process is that as we debate these things and think about them in detail, other ideas come through.

--- Later in debate ---

I now turn to some queries and concerns about what is before us.

[Danny Kruger]

Before the hon. Gentleman moves on, I want to reiterate the value of his point. This is an enormous change to the Bill and totally transforms it, but we did not have the opportunity to hear evidence on it. Is he also aware that many of the distinguished people who gave evidence against the traditional stage, which has now been scrapped, have not endorsed the proposal to change it? In fact, some of them are equally opposed to the new proposal. We have not had confirmation that this is the right system, and we did not get the opportunity to hear proper evidence on it.

[Daniel Francis]

Yes, I am aware of some of those submissions from those individuals. I will come to this, but clearly even some people who were in support of making changes did not recommend the ones that we have now incorporated.

First, I would argue that people giving evidence to the panels should be doing so under oath. In my 20 long years as a local councillor, I gave evidence under oath to an investigation by a health and safety executive into the demolition of a building. I would say that the demolition of a building and this matter are very different, and therefore I query why this evidence is not being given under oath.

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[Daniel Francis]

I think that is the case. As the hon. Member said yesterday, people from those professional fields—in their written evidence, particularly—asked to be included in the process, but I do not think they were asking to be included at the end of the process; I think they were asking to be included earlier.

[Danny Kruger]

The hon. Gentleman has explained clearly in personal terms why it is important to involve the family, and I concur with the hon. Member for Richmond Park. I want to take the hon. Gentleman back to the rather abstract question of whether there are two sides to these cases. In contradiction to the hon. Member for Spen Valley, I think there are two sides to these cases, as she herself recognises whenever she says that this is a finely balanced judgment. The fact is that a decision can go either way, and it is very important that the decision makers are considering two sides. It is not just the immediate stated wish of the applicant that is the only consideration, as the Bill acknowledges. Does the hon. Gentleman agree that it is important to have the widest possible input into the decision, so that both options—to proceed or not—can be properly considered?

[Daniel Francis]

I hear what the hon. Member says. My concern has always been the scenario that I described. If this legislation is passed and we push it forward, one death that occurs where somebody has concerns about the process would be one too many. I said that clearly when we debated clause 3, and that remains my principal concern. It is not necessarily about two sides, but in cases where there are concerns, we need to do everything we can to ensure that that does not happen.

I have a query about the resourcing of the panel. Part of the reason why we ended up here was the queries about the resourcing of the judicial role in the process. We would need to find skilled professionals, especially consultant psychiatrists and social workers, to sit on the panel. If we look at the per capita rates in the Australian and American states that have assisted dying, we can estimate that the number of cases of assisted dying each year in England and Wales would be in the low thousands. Any consultant psychiatrist or senior social worker who sits on these panels will have to spend hours on each case. We do not yet know how many hours it would be on average, but for complicated cases, it could be many hours. What analysis has been undertaken of the capacity of consultant psychiatrists and senior social workers? Their professional bodies are beginning to look at that, but again, we were not able to ask them that during oral evidence, and because the written evidence was submitted so heavily in advance of these amendments and new clauses being tabled, we do not have that information in front of us.

We hear about the resourcing of our NHS mental health services and the fact that we do not have enough psychiatrists, so I query whether we have enough senior social workers. A senior social worker visits my house every year, but I have never seen the same social worker twice, because of the turnover issues, capacity issues and the lack of staff.

What will the Government do to ensure that the panels fulfil their responsibilities? We would be dealing with applicants who have very little time left, and being able to properly staff the panels must be a priority. We must not take psychiatrists and social workers away from their other work, while ensuring that people seeking an assisted death do not wait a long time. That is another matter on which we would have benefited from oral evidence from expert witnesses. We would also have benefited from the normal consultation that there would have been on a Government Bill, because we would have been looking at that matter for several months.

In summary, I accept that this set of new clauses and amendments is an effort to fix problems with the Bill, but problems remain, and there are probably some new ones as well. I will therefore not support a number of the provisions.

[Jack Abbott (Ipswich) (Lab/Co-op)]

It is a pleasure to serve under your chairship, Sir Roger. I rise to speak to several new clauses and to amendment (e) to new clause 21.

There were many comments yesterday about the fact that a number of Members across the House had cited the judicial stage as an important reason why they supported the Bill. I challenge the notion that they voted for it exclusively for that reason, but I recognise the strength of feeling. To be frank, I was not one of them. I was not persuaded, not least because of a number of points made yesterday by my hon. Friend the Member for Rother Valley, that the judicial stage would be anything other than a rubber-stamping exercise. I am certainly not going to go into “good judge, bad judge”. I hugely respect the legal profession, of which there are many representatives present.

The legal profession has a huge range of expertise and experience, but it could not be expected to cover in depth the psychiatric and social care aspects of the process, about which we have being raising concerns for weeks. For that reason, and especially given that we are retaining legal experience on the panel alongside social workers and psychiatrists—a triple-threat approach, as it were—I fail to see how anyone could reasonably argue that this approach is weaker. In my eyes, it is much stronger.

Of course, some people will always say that it does not go far enough; we have heard that several times. As has been acknowledged, we will never convince everybody that an amendment is safe or good enough. An uncomfortable truth that is rarely recognised but is worth mentioning—I am sure that I will shortly be misrepresented on social media for saying it—is that no safeguard that we could put in any Bill, on any subject, will 100% ensure that there will never be any mistakes.

We have to do our level best to ensure that the probability is reduced to an absolute minimum. However, when someone goes into surgery, there may always be complications that cannot be foreseen, and we know that there have been awful miscarriages of justice; as a new Government, we have spoken about them, from the Post Office scandal to infected blood. We also have to rely on the fact that we are entrusting experienced, trained professionals with carrying out this work. Not only more often than not, but in nearly every situation, bar the awful cases of which we are all aware, they do their work to the best of their ability, and we have to be absolutely honest about that.

We should not look at the new clauses in isolation. They are part of a package. A number of amendments have been agreed to, about coercion and about ensuring that medical professionals are trained to the right standard. Like my hon. Friend, I hope we will see further amendments on special educational needs and learning disabilities. Those things are really important, so it is worth recognising that in addition to the new clauses, which in my view ensure a much stronger approach to the final judgment, we have agreed to a number of other amendments.

I want to pick up the issue of whether the process should be adversarial or inquisitive. I am sure that hon. Friends who have served at the Bar will tell me if I am wrong, but in my view an adversarial process is one of competition: it pits someone trying to prosecute an argument against someone trying to defend it. In contrast, an inquisitive approach is about asserting the truth. In my view, people who are not only going through agonising pain but making agonising decisions about what to do with the remaining days of their life should not be on trial. We should approach them from a position not of suspicion, but of support. Of course, that is caveated by all the things we have talked about, particularly on things like coercion. If there is any idea that a person has been coerced into the decision, of course we should investigate that, but the process should not be adversarial.

The connecting element is that we should ensure that we get the balance right between safeguards and safety. We should not add so many barriers and layers that a person can never access the process because it is too cumbersome. I do not want people to spend the remaining days of their life sitting in endless meetings, consultations and an adversarial court process, or whatever it might be. But we absolutely have to have all the right safeguards: as we have said, if there is any suspicion that someone may have been coerced or does not have mental capacity, of course we should go down the relevant routes to ensure that that is not the case.

Part of the reason why people will make the decision is that they want the autonomy to go out on their own terms, plan their remaining months and enjoy experiences with their family. We must ensure that those precious days are spent with their family, not in endless meeting rooms, so we absolutely have to get the balance right. As has been acknowledged, the diagnosis is a really important part of it. We regularly talk about the six-month point in the diagnosis, but we know when many people receive their diagnosis, their final days will be much shorter, so in the main people do not have time to go through a lengthy, difficult process.

[Danny Kruger]

Is the hon. Gentleman not making a case against a third stage altogether?

[Jack Abbott]

No.

[Danny Kruger]

I would be grateful if the hon. Gentleman could explain that. If his concern is about asking patients to go through a third stage, after the doctor’s assessment—

[Jack Abbott]

indicated dissent.

--- Later in debate ---

[Danny Kruger]

In that case, what is the difference? It is not necessarily the case that the judicial stage has to be incredibly time-consuming, onerous or distressing for the patient. It is about the legitimacy of the process and the rigour that is applied to it. If the hon. Gentleman wants people to be sped through the process without going through the distress of further explanations, surely he should be objecting to the panel too.

[Jack Abbott]

I thank the hon. Gentleman for that question, but he is entirely misrepresenting my position. I have said that there should be a balance between safeguarding and ensuring that the process works for people. I have just spoken in support of the panel stage, and I think it is important that it is robust. We are including social care workers and psychiatrists alongside legal professionals. I have not for a moment used any language that suggests that I am not in favour of that. I am talking about the idea that it does not go far enough. We have spoken a number of times about adding additional layers beyond the processes that are already in the Bill, which we are debating today.

[Danny Kruger]

I was not suggesting that the hon. Gentleman opposed the panel. I recognise that he is speaking in support of it. My concern was that he was suggesting that there was a problem with the High Court stage. I now appreciate that he is objecting to some sort of fourth stage that some people might be suggesting on top of the panel. I personally am not proposing that; I think that there should be a multidisciplinary team as part of the assessment process and then a judicial stage, as originally planned.

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

Danny Kruger Excerpts

Committee stage
Wednesday 12th March 2025 Public Bill Committees

[Jack Abbott (Ipswich) (Lab/Co-op)]

I feel huge responsibility for my “EastEnders”-style ending, Ms McVey. Unfortunately, my speech is not going to be as radical as some may have hoped.

I was discussing the bandwidth or capacity of the professionals involved in the process. We have been very good at leaving party politics at the door, but Opposition Members have mentioned the state of the NHS and the wider healthcare system on a couple of occasions. I could probably go further and mention the huge backlogs in the courts and wider criminal justice system. It is fair enough to consider the Bill in that wider context; I have considered that point deeply, as I know Members from across the Committee have.

We asked earlier whether there is capacity in the system to support the panels—that is, are there enough psychiatrists and social workers? However, it is inconsistent to then also say that we need more psychiatrists and social workers in other areas of the process. I am not sure that we can have it both ways. This is something to consider—the Committee has discussed it—but ultimately it is a matter for Members of the House.

The Committee is not here to debate whether the systems in place can deal with an assisted dying Bill. Whether or not assisted dying is introduced into our healthcare and judicial systems, it will not fundamentally change the challenges that the country faces in these areas. We are here to ensure that we present back to the House a Bill that has the safeguards and balances that I mentioned this morning, so that it can progress. I certainly would not want to produce anything that paralyses the system, but new clause 21 would not do so. In fact, in the long run, the panel approach would help the process along. For that reason, I am not sure that the capacity of professionals provides a valid argument against the panel—if anything, quite the reverse. As I said, that point really was not worthy of an “EastEnders” cliffhanger.

We have had positive murmurings and acknowledgments about amendment (e) to new clause 21. The panel approach represents a huge leap forward. I appreciate that Members in the room and across the House may say that the approach does not go far enough. I go back to my earlier point: for some Members, no amendment, change or safeguard will ever be enough for them to support the Bill. As a Committee, we have to come out with a strong, robust process that puts the patient first, and ensure that we are acting in their interests. We must make sure patients are safe and have the capacity to make these decisions, but I do not want any individual looking to go down this route to be stuck in endless meetings or courtrooms, when they should be spending time with their loved ones. I think this strikes the right balance between safeguarding—bringing in all of the professional expertise that we have been looking to do as a Committee—and making sure this process is fair and equitable. I urge Members to support amendment (e) to new clause 21, but I will also be supporting the new clauses today.

[Danny Kruger (East Wiltshire) (Con)]

On Second Reading on 29 November, the hon. Member for Spen Valley said:

“Under the Bill, any terminally ill person who wants to be considered for an assisted death would have to undertake a thorough and robust process involving two doctors and a High Court judge. No other jurisdiction in the world has those layers of safeguarding.”—[Official Report, 29 November 2024; Vol. 757, c. 1019.]

There can be no doubt that the High Court judge safeguard was presented to the House as globally exceptional, unusually thorough and robust, as compared to other jurisdictions. It was also a prominent feature of the public campaign around the Bill. We were told it was a Bill designed for exceptional circumstances, with robust safeguards—the High Court judge being the pre-eminent one. It was not a trivial detail; it was the centrepiece of a safeguarding regime arranged around a small number of vulnerable people. Over 60 Members of Parliament are on the record as saying that it was this safeguard that helped persuade them to vote in favour on Second Reading.

[Kim Leadbeater (Spen Valley) (Lab)]

I will stand corrected if this is not true, but my understanding is that Hansard will show a very different story. I do not think that 60 people got up and said on record that this element was why they were voting for the Bill.

[Danny Kruger]

To be clear, I was not suggesting that they all said so on Second Reading, because not everybody spoke in that debate—nor am I saying that it is only because of this safeguard that MPs voted for the Bill, but there are 60 colleagues of ours who have cited the judicial safeguard as a reason for supporting the Bill. Indeed, I hope the Committee will agree that this was always presented as a very significant aspect of the safeguarding regime, if not the most significant aspect. I suggest it was the most significant, because it enabled people to argue that this was the strongest Bill in the world, given that other regimes do not have a judicial element.

I opposed the Bill on Second Reading and I expect that I will oppose it on Third Reading, but I respect the Committee process enough to accept that the House wanted the Bill debated. Because I respect the process, I have not opposed clauses that concern the heart of the Bill, but we are now going to see the hon. Member for Spen Valley, Government Ministers and their supporters vote against this clause—the essential safeguard in the Bill, and the principal element used to persuade the House that the Bill was safe—standing part of the Bill. It is an extraordinary thing that we are going to see the Bill’s promoter and the Government oppose the centrepiece of this Bill.

[Kim Leadbeater]

I understand the hon. Member’s framing of this and it might very well be his perspective, but there were 650 MPs who voted on Second Reading that day, so I think it is unfair to represent colleagues who did not have the view that this is the central component of the Bill. There are lots of other components to the Bill that colleagues have certainly spoken to me about, and it is important to acknowledge that.

[Danny Kruger]

I am happy to acknowledge that there are many other components of the Bill, but many Members, including the hon. Lady, cited this safeguard as an essential element of the safeguarding regime—if not the most essential. Crucially, it was presented to the House of Commons as such, and it is a central clause of the Bill, and the hon. Lady is now proposing to vote against that element. My view is that a change this substantial—a fundamental and radical change to the structure of the process that is being designed—should be presented on Report. The whole House should have the opportunity to discuss and debate properly whether that element should be changed. Every Member should have the opportunity to have a say on this central point.

[Tom Gordon (Harrogate and Knaresborough) (LD)]

The hon. Gentleman will have to forgive me, because I am a relatively new MP and there are still bits of parliamentary procedure that I have not yet got my head round, but is it not the case that MPs will have a say on Report, when they can table amendments to take the Bill back to how it was? That point could therefore be debated on Report.

[Danny Kruger]

Of course that is correct: a small number of amendments will be selected for debate and vote on Report, and if somebody wants to table an amendment on this issue it might indeed make it through Mr Speaker’s selection, but the point of the Committee process is to consider the Bill that was passed on Second Reading and come back to the House with the Bill either unamended or amended. This is a very substantial change to the Bill that was presented and voted for on Second Reading. As I say, many Members supported this clause, no doubt including the hon. Gentleman.

[Kim Leadbeater]

The hon. Gentleman is making a point that we hopefully all agree with. The job of the Committee is to take evidence and look at ways of improving the Bill on that basis. This is a really good example of where we have actually done our job and done it very, very well.

[Danny Kruger]

I do not think the hon. Lady can say she has done her job very, very well if, after presenting a Bill, and after months and months of work and debate, including many hours’ debate on Second Reading, she suddenly decides that its central part is deficient. She talks about the opportunity for the Committee to take and debate evidence, but we have not had evidence on this new element—these new clauses and the panel process. There were vague suggestions from some of the people we heard evidence from that it might be appropriate, but although we heard evidence on the High Court stage and the deficiencies therein, we have not had the opportunity to properly examine the panel element that is now being introduced.

[Kim Leadbeater]

Will the hon. Gentleman give way one more time?

[Danny Kruger]

With great pleasure.

[Kim Leadbeater]

I thank the hon. Gentleman for giving way again; I will sit down after this. I will not take it too personally that he thinks I have done a very poor job, but the point is that we heard a broad range of evidence from professionals including legal experts, medical experts, psychiatrists and social workers—lots of different people. We have also had evidence come in over recent weeks and months that has added to that and has talked about these changes. It is important to acknowledge that.

[Danny Kruger]

The hon. Lady must not apologise for intervening on me. I can hardly be one to object to people intervening. This is a very good forum for the kind of exchanges we are having, so I am very happy to take interventions. She is absolutely right that lots of evidence has been presented. I cite it myself all the time. Further evidence is coming in, and much of it is very critical of the new proposals. That is an absolutely fair point, but my point remains that we invited witnesses and had three days of evidence on a Bill whose core safeguard has now fundamentally changed—well, it has not changed yet, but I suspect it is about to.

[Dr Marie Tidball (Penistone and Stocksbridge) (Lab)]

I supported the Bill on Second Reading on the basis of the High Court proposal, but then read very closely the evidence from Justice Munby on the need for a strengthened evidentiary process so that this is not just a rubber-stamping exercise. He said, secondly, that it would be better to replace the High Court with another system because of the position that it would place judges in. Having listened to 50 witnesses, I am satisfied with this proposal; I was persuaded through this cross-party process, which is an incredible example of deliberative decision making. Does the hon. Gentleman agree that our ability to amend the Bill where the evidence shows that we must do so demonstrates the strength of this process, and has enabled us to produce something much better and more in alignment with public opinion?

[Danny Kruger]

I greatly respect the position that the hon. Lady has come to. She has been persuaded that this is an improvement on the Bill, and I respect that. I recognise that that is what the hon. Member for Spen Valley and others think, but I am afraid I do not accept that the process has been adequate. The hon. Member for Penistone and Stocksbridge cites Justice Munby and others who criticised the High Court proposals. I also have my criticisms of them—I think they were inadequate—but the response to that is not to scrap them all together, but to strengthen them, as Justice Munby suggested. The hon. Lady will know that Justice Munby is not supportive of the new proposals either; he thinks they also fail the essential test of being an effective safeguard. Nor does the new proposal—the panel—provide the opportunity for evidentiary investigation, which would indeed be appropriate if we were to have a proper safeguard at this stage. I respect the hon. Lady’s position, but I am not persuaded.

[Lewis Atkinson (Sunderland Central) (Lab)]

rose—

--- Later in debate ---

[Danny Kruger]

I am about to come to that. I am going to suggest how we could have done it better. I take the hon. Member’s point. I do need to answer that question.

[Kit Malthouse]

I am just intrigued. My hon. Friend is talking a lot about the evidence. Did any evidence on anything in the Bill change his mind on any aspect of it?

[Danny Kruger]

Was there any evidence that changed my mind?

[The Chair]

That is out of scope of the group, but you carry on and think, Mr Kruger.

[Danny Kruger]

Thank you, Ms McVey. I do not want to be facetious because it is a serious point, but lots of new points were made in evidence to the Committee, including some in favour of the Bill as it is and some of the amendments that I have opposed. We have had some helpful evidence that has helped to shore up the case made by the Bill’s promoter, as well as evidence that suggested otherwise, and some points in debate have been very well made. I was nearly floored by an intervention by the hon. Member for Chesham and Amersham yesterday, for instance. I do respect the points that have been made in Committee, including at the evidence stage.

My suggestion is that we should be doing this on Report, if we do it at all, because that would reflect the seriousness of the proposal and the fact that the House voted for the clause on Second Reading. There were problems with the High Court stage, as has been acknowledged, and others have referred to it in support of the change. I want to quickly acknowledge, perhaps in response to my right hon. Friend the Member for North West Hampshire, the points made by Lord Sumption, Max Hill, Alex Ruck Keene and Nicholas Mostyn—all senior barristers and judges. It became obvious that there were significant issues, particularly around the power of the court to investigate applications or to hear evidence on them, and about the capacity of the judicial system to cope with the demand.

It was clear that further thought was needed on the High Court stage. Indeed it was apparent that further thought was already under way. There is an interesting exchange in the record of the evidence sessions between the Justice Minister, the hon. Member for Finchley and Golders Green, and those witnesses, particularly Max Hill, who said that he was quite close to the construction of the Bill. That clearly shows, in my view, that there already was thinking under way behind the scenes that have led to these changes.

My view is that, rather than ditching clause 12, we should be seeking to make it work in ways that many hon. Members have proposed. I am afraid we just skipped over those proposals in earlier groupings on the clause because there was no point—we were obviously proceeding to the stand part debate and to eliminate the involvement of the court all together.

There were things the Committee could have set itself to address, but we have not done that. I hope you will excuse me, Ms McVey, for making what might be a cynical observation: I think the High Court stage was recognised as popular and as useful to the campaign to get the Bill through the House of Commons. It was predicated specifically on the point, which was clearly communicated and understood by the public, that this measure of assisted dying is intended for very few people. It is for the most exceptional cases: people at the very end of their life, in desperate circumstances, in desperate pain and suffering. Very few people need it. However, I believe this change is predicated on the real intent of the Bill: far wider eligibility than just that tiny group.

We have seen that through the rejection of a series of amendments that would have restricted eligibility specifically to that group—a group for whom we all understand the case for an assisted death; again, the public support it in those specific cases of people at the very end of their life, who are suffering intolerably. The Bill is not restricted to that group only, and that is why we need to redesign the system to enable this larger group to make use of it.

[Kim Leadbeater]

The hon. Gentleman is been very generous with his time. I am interested in how he can conclude that the eligibility criteria have somehow been expanded by adding an expert panel with a psychiatrist and a social worker.

[Danny Kruger]

I am sorry; I did not intend to give that impression. That is not what I am suggesting. What I am saying is that we have seen the rejection of a series of amendments that would have restricted eligibility, or ensured that only certain people would be eligible: those for whom we all understand the reason for the case for assisted death. Whether our amendments related to the burden, the pain, or questions around capacity and coercion, our amendments would have restricted access to only the most desperate people.

On that basis, it would have been appropriate to have a High Court stage, because the High Court could have accommodated that lower demand. Given the opportunity that the Bill affords to a larger group of people to gain access to assisted death, it has become obvious—I presume, in the mind of Government and others—that there is insufficient capacity in the court system to accommodate the regime being instituted here.

I think the question of High Court capacity has been driven by the desire for a system that can cope with many thousands of deaths per year. I have seen ranges suggesting between 6,000 and 17,000 deaths per year. If Members have other calculations or estimates, I would be grateful to hear them. In fact, it would be good to know whether the Government have done any estimation of the numbers we are looking at.

It is not simply a case of averting those desperate cases of people who help their relatives to die by going to Switzerland or who assist them in committing suicide in other ways—we heard from Max Hill that only a handful of cases cross his desk every year. It is clearly the intention to greatly widen the scope beyond that desperate group. It is unclear what the overall number is, but my strong sense is that we are looking at many thousands, and for that reason, it has been decided that the High Court would not have the capacity to cope with this.

[Jack Abbott]

We go back to the inconsistency argument. On the one hand, we are saying that we must have more psychiatrists, social workers and palliative care experts in the process. This change is now being proposed, and the hon. Gentleman is using that as a reason to say that there is bad faith here and the sponsors of the Bill just want to widen the scope. I do not think he can have it both ways.

[Danny Kruger]

I am not suggesting bad faith here. I think there is a genuine view, and it might well come from the Government’s official advice, that the Bill, as drafted and as amended, will allow many thousands of people to gain access to assisted death every year. On that basis, we will need a system that can cope with them. The judiciary clearly communicated that it could not cope, and I understand why it would do so.

[Jack Abbott]

I appreciate that, but just this morning we heard from the hon. Member for Reigate that, because there are not enough psychiatrists and social workers, this panel is not workable either. Again, there is an inconsistency here. There is either enough capacity in the system or there is not—which is it?

[Danny Kruger]

I am sorry to disappoint the hon. Member, but I am afraid I am going to have it both ways. I think the Bill is profoundly flawed, particularly if large numbers of people will be going through this system. Whether they are going through a judicial system or a panel system, there will be huge capacity constraints on the professionals involved, and we have transferred that responsibility and that problem from the judiciary to psychiatry and social work—unless, of course, it is a rubber-stamp exercise, which I fear it might be, but even then, we are still involving psychiatrists and social workers in a rubber-stamp exercise.

[Jack Abbott]

But that demolishes the central argument that the hon. Gentleman is making. On the one hand, he says that we are expanding access, but on the other, he says that the panel system will not be able to expand it. If the motive of the promoter of the Bill was to expand the system to make more people eligible, the hon. Gentleman has just said that the constraints of the panel will mean that that does not happen anyway. He is conflating different things and being totally inconsistent.

[Danny Kruger]

All right. I regret my failure to assuage the anxieties of the hon. Member.

Let me explain why it was so important that we had a judicial stage. My complaints were never against the principle, but always against the practicalities, for the reasons I have just given and will go on to say more about. The value of a judicial stage is that it gave the doctors certainty and, indeed, protection for the process they were responsible for.

I want to cite the evidence from the Medical Defence Union, which provides doctors with insurance against claims of medical negligence. Responding to the suggestion that judicial involvement could be replaced by some other decision-making body, it stated:

“The MDU strongly rejects this assertion. The involvement of the judiciary is essential. Its absence leaves doctors unduly exposed. Media reports suggest that an alternative safeguard is being mooted. No ‘independent panel’, however so constituted, can replace the legal authority of a course of action sealed and ratified by a judge. Doctors deserve that certainty when relying upon this Bill to provide the very best for their patients at the most delicate moment of their duty of care.”

I will also cite the evidence that we received from Ruth Hughes, a senior barrister with 17 years of experience in mental capacity law. I cannot say that she is a King’s counsel because she does not become one until later this month—congratulations to her. She stated in her written evidence that

“if there is no judicial declaration because the judicial safeguard is not enacted, then there is a risk that the estates of persons who have been assisted to die will be sent into turmoil. This is due to the possibility of arguments being made that beneficiaries of the estate have ‘influenced’ the person into obtaining the assisted death.”

She said that

“even if there is no conviction but another person asserts there was ‘influence’…not undue influence”—

and certainly not coercion, which is banned by the Bill—

“but a lower standard of ‘influence’ by a beneficiary of the estate…then the personal representatives will be advised to obtain directions from the Court as to how to administer the estate.”

Her point is that, even if the bar for the assisted death is met, in terms of influence, coercion and so on, the testamentary or probate challenges that the estates will then go into are considerable.

The fact is that somebody has to be the judge—somebody has to take legal responsibility for the decision that is made. In the common law system, we do not give powers of life and death to panels; we give them to legally constituted bodies with judicial authority. To cite the MDU again:

“To put it plainly, without judicial involvement someone will have to take responsibility for the legality of the action.”

[Dr Simon Opher (Stroud) (Lab)]

Again, I thank the hon. Member for quoting all this, but does it mean that he supports the original clause 12?

[Danny Kruger]

I will be voting for clause 12 to stand part, because I think it is an essential safeguard, but it is not strong enough. There are all sorts of problems with it around capacity and the way it is constituted, and I will come on now to how I think it can be improved.

[Dr Opher]

indicated dissent.

[Danny Kruger]

The hon. Gentleman does not seem impressed by my straight answer to his straight question. Yes, I do support clause 12. I think we should strengthen it, in the ways that I will now explain. We do need a court, and I think Parliament was right to demand this, or to support it. We have a comparable model in the Court of Protection, which applies when there are disputed decisions about whether to withdraw life support. By the way, I mention to hon. Members who have referred to this—just to go back to an earlier debate—that, with the Court of Protection, one is obliged to notify the family. So even there, when there is a decision to withdraw life support, the family is notified, but we have decided not to notify the family under this Bill. But anyway, the Court of Protection does provide an appropriate comparison.

Whether we are talking about the Court of Protection or the High Court, either would work if the system was set up right. The crucial thing, in my view, is that it needs a proper adversarial arrangement so that the judge can actually judge. The way that judges work in this country, under the common law system, is that they hear arguments and then make decisions. It has been suggested that there could be a role for the official solicitor in acting “for the state”, as it were—or indeed “for society”, perhaps, or however we would want to put it—to perform the role of challenging the application and taking responsibility for presenting any alternative pieces of information that the judge should consider.

[Jack Abbott]

I do not want to make implications about what the hon. Gentleman might be saying, but am I correct that, with the adversarial position that he is supporting, a person coming to the end of their life, who had gone through this process, would essentially have to argue their case in front of a judge?

[Danny Kruger]

No, I do not think it is necessary for the applicant to come to court and present their case—that might be completely impossible or inappropriate—but a case does need to be made to the judge about why it should proceed, which is part of the original proposal. Indeed, that is what is proposed under the panel system as well: the case is made for whether it should go ahead.

My suggestion is that there needs to be representatives of the applicant—who may want to appear themselves—but there also needs to be somebody who is putting the other side of the story: “Maybe this isn’t the right thing to do. Has the judge considered these parts of the evidence, or this aspect of the report from the assessing doctors?” That would be an appropriate procedure, which is completely consistent with how these important decisions are taken in other aspects of our system.

[Jack Abbott]

There is a difference between an adversarial system and an inquisitorial system, which is what I believe is proposed for this panel. The panel would take not an adversarial but an inquisitive position. I do not think that is a million miles away from what the hon. Gentleman is saying, but there is a distinct difference. If he is arguing for the panel to take an adversarial position, that is very different from where the panel currently is.

[Danny Kruger]

Yes; it would be inappropriate to ask a panel to operate in an adversarial system. It would be inappropriate to ask a psychiatrist and a social worker to act as a judge. We need a proper court system, as we always do with other important decisions in which two sides make arguments. Let me try to explain. I agree that what is being proposed is an inquisitorial system through a panel, which is completely alien to the British common law model of making important decisions. That is what is being suggested, but I do not think it is appropriate.

I do not believe in assisted dying; I think it is the wrong thing to do. But if we were to do it, we should have a proper multidisciplinary team at the outset—I sort of feel that that is where we have got to through these debates, and if the debates had happened properly and prior to the Bill being drafted, something more like this system might have been proposed. Perhaps a doctor does the first declaration as proposed, but we then go into a proper multidisciplinary team, rather than just having the options to refer to psychiatrists if appropriate or to maybe consult palliative care specialists.

The involvement of all the appropriate specialists in assessing capacity and coercion, making clear the alternatives that the patient has, making a proper diagnosis, and hearing from family members—all the appropriate processes that should be followed in a case like this—should happen at the very beginning of the process. There is no need for a lawyer at that stage on the multidisciplinary team that we have created; it will be a proper combination of clinical and social work professionals. Their reports would then feed into the judicial process, which would be the second or third stage, if we have a doctor at the beginning. The judge would then hear arguments from, as it were, both sides. That need not be a distressing or time-consuming process, but it would be an appropriate one under British law to make decisions of life and death. That court would clearly hear arguments made by both sides.

[Kit Malthouse]

To be clear, does my hon. Friend envisage that I would either be in the hearing, or lying in my bed listening to the hearing—the fungating tumours in my neck restricting my ability to breathe—having gone through all the eligibility criteria, but having to listen to someone argue that I should go through a death that I am trying to avoid, by arguing that I do not have capacity? Does he not see that that could be profoundly distressing to someone who is in the closing moments of their life? In many ways, it might actually be cruel and traumatic for me to hear somebody arguing, frankly, that I should endure the pain, in their opinion.

[Danny Kruger]

I regret that my right hon. Friend is making that argument. The fact is that the panel is already going to consider whether it is appropriate. There might not be some professional who is there with the purpose of suggesting that there are other things that the panel should consider, but the patient is already lying there waiting for powerful people in another room to make a decision about whether they are going to get an assisted suicide or not. That process is already going on.

On my right hon. Friend’s point that it is intolerable for somebody to hear the case made against their assisted death, let me put to him an alternative hypothesis. Rather than somebody in the situation that he describes, let us imagine somebody who is the victim of years of coercive control, who has undiagnosed mental health conditions, who is feeling a burden on their family and whose relatives want their money. None of that has yet been fully identified through the initial doctor’s stage of the process, but it has been commented on in some of the evidence that the multidisciplinary team heard. That person might hope that somebody is there making the case for them, as might their family.

It is totally appropriate for a court to hear that this procedure should not go ahead because of those other factors, which are only now being properly understood by the decision maker. That decision maker is doing so openly, not in a private session. The decision is being made not by people who are committed to the procedure and process of assisted suicide, but by an independent judge, sitting in their judicial capacity in open court, with all the safeguards and accountability that the judicial system has. That feels to me like a perfectly appropriate safeguard, and I suggest that it is, in principle, what the House of Commons thought they were getting when they supported this.

[Sarah Olney (Richmond Park) (LD)]

I am just reflecting on the right hon. Member for North West Hampshire’s intervention. Does the hon. Gentleman not agree that the purpose either of the panel or the High Court judge is to establish beyond all doubt that if a person is assisted in their death, no crime is being committed, and that in order to establish that, we need to apply the highest standards of evidence? Whether an adversarial or an inquisitorial process is used to collect that evidence, there must be some sort of process. That may be uncomfortable for the patient but it is necessary for their friends, relatives and the doctors being asked to assist. That is really what we are trying to achieve.

[Danny Kruger]

I am grateful to the hon. Lady for making that absolutely central point. This is a judicial process, and a decision is being made. I recognise that the hon. Member for Spen Valley has correctly abandoned the claim that this is a judge-led process—because it is not—but the function of this panel will be essentially judicial, not least because the decision to proceed with an assisted death entails the people involved in administering it being exempt from criminal law and not being liable to prosecution under the Suicide Act 1961. We have made an exemption for what is otherwise a crime, and if they do not get the go-ahead from this panel, they will be committing a crime if they proceed. So in all essence, a judicial decision is being made, and it is right that we have the protections of a court.

Let me make a couple of brief points about the practicalities, and they have partly been made by others. The central point is that we do not know whether the professionals who will be required to take part in this panel have the capacity to do so. We know that the judges do not have the capacity under the current design of the law, which is an essential flaw—or we think they do not, because that point has been comprehensively argued by the judiciary and I suspect by officials at the Ministry of Justice. What we do not know is whether the psychiatry and social work professions have adequate capacity. There has been no impact assessment, and we have had a lot of comments from representative bodies expressing anxiety about the capacity of these professions to supply the panels.

The point I am trying to make is that we cannot, and should not, legislate in the dark. We should not draft laws in ignorance of these basic facts. We need to know whether the law before us is workable in the real world, and I would be grateful for clarification on that from Ministers when they speak to this clause. In my view, we need robust and clear data on how many professionals might take up the posts, and more importantly, we need the clearest and earliest warning of where there might be deficits that would compromise the entire system, particularly around the capacity of psychiatrists. We have a central problem with ignorance around capacity, but my strong view is that we do have a problem with capacity.

An important point was made by Alex Ruck Keene in evidence around the judge-led process, which we discussed earlier. His point was that it would not be possible for the judge to decline an assisted death on the basis of what he calls service denial—that is, there is not enough social care treatment or medical treatment available for the patient. If the reason why the patient were to receive an assisted death was that the local authority would not provide them with improvements to their home or funding, or that they could not get the medical treatment they wanted early enough, that would be a legitimate reason, or would not be a reason not to proceed with an assisted death. That is a very grave concern to us, and it is what happens in other countries. We heard this morning about evidence that when a patient is denied the medical or social care that they need to carry on living and living well, they are offered an assisted death. In those circumstances, I would really hope that the decision maker would conclude that it is wrong that we offer an assisted death, and that we in fact need to insist that they get the support they need to live well. I reference that because, as I understand it, there is no opportunity in the new clauses for the panel to decline an assisted death on grounds that it is being sought only because of the inadequacy of the wider care system.

It has been suggested that the judicial option remains, through the judicial review system. Other hon. Members have responded to that point, so I will not labour it. However, I want to make the point that new clause 17 makes judicial review less likely because it offers the opportunity for a sort of appeal. It is an appeal only in one direction—against a refusal—but there is a sort of appeal process in the system. As my hon. Friend the Member for Reigate said, if there is a JR, it is likely to take a long time. There is nothing about whether legal aid will be arranged. The state has proposed to pay for people to go through the assisted dying process, but is not prepared to pay anybody to challenge it, so they would have to raise their own money. It would also take a long time. It would be much simpler and better, whether it is a panel or a judge, to set up the system in a way that allows both sides to be told and that does not rely on a cumbersome judicial review system.

I reiterate that I support the multidisciplinary team. It is a very good thing that the hon. Member for Spen Valley has decided to introduce a proper stage at which a psychiatrist and a social worker will have to consider the application properly. I have concerns about how it would actually work, which I will come on to, but having a multidisciplinary team is in principle the right system. I stress that the professionals who made the case for multidisciplinary teams as part of the assessment process have not endorsed the new clauses. They are not saying that we have adequately met their concerns about the process.

[Kim Leadbeater]

I am not entirely sure who the hon. Gentleman is referring to, but it is fair to say that there is a range of views across a range of professions. It is important to acknowledge that.

[Danny Kruger]

I apologise; the hon. Lady is absolutely right. No doubt there are representative bodies, whether it is patients’ groups or bodies representing professionals, that are satisfied with the new proposal. I do not know which—genuinely, I just have not come across them—but I have no doubt that there are some.

[Kim Leadbeater]

To clarify, the point that I am making is that there is a range of views across a range of organisations—many of which are neutral on the issue of assisted dying, full stop—and a range of views within each profession. We heard evidence from people working in palliative care with different views, and from medical people with different views. It is important to acknowledge that.

[Danny Kruger]

Yes, a number are neutral. I will be grateful if the hon. Lady can tell the Committee if there are any representative bodies working with the professionals who administer end-of-life care that have endorsed either the Bill as it was or the Bill as it is. I do not believe there are.

[Kim Leadbeater]

I will check.

[Danny Kruger]

The hon. Lady is going to check. My understanding is that all the bodies that represent palliative care professionals and end-of-life specialists are opposed to the Bill as it was and as it is. I think there are straightforward reasons for that.

Everybody agrees that there is value in the multidisciplinary team approach. The British Association of Social Workers provided evidence setting out what it thought was needed, namely an MDT working at the assessment stage. This is not that. It is very important that we do not confuse the provisions made under the new clauses with a multidisciplinary team operating at the appropriate moment in the process. We have to have public confidence in the process. It is very important that the composition of the new proposed panels is not conflated with the separate matter of a multidisciplinary team model. It would be very unfortunate if that confusion obtained.

The Bill, as drafted, rejects the involvement of a multi-professional team model for the conduct of the assessments, preferring two doctors working alone without input from a multidisciplinary team. I recognise that there are opportunities for them to hear from other professionals, but it is not a multidisciplinary team in any recognisable sense of the term.

[Kim Leadbeater]

Will the hon. Gentleman give way on that point?

[Danny Kruger]

I will in a moment. I was going to finish by saying that it is not correct or accurate to give the impression that Dr Cox or the Association for Palliative Medicine supports the proposed approach.

[Kim Leadbeater]

It is really important to be clear about this. I do not think anyone is suggesting that what is in the Bill will replace existing good practice. That is really important. We probably all have family and friends who are being treated for cancer now, and they are looked after and cared for by a multidisciplinary team. That team does not suddenly disappear, to be replaced by what is in the Bill; it can continue. The assisted dying option involves the two doctors, and I struggle to envisage any situation in which they would not work with the multidisciplinary team and add on, where appropriate and necessary, psychiatric intervention, social care and healthcare professionals. I always come back to the point that I do not think the two things will operate independently.

[Danny Kruger]

The hon. Lady does always come back to that point, and I respect it. She imagines that the good practice that is prevalent in the system will obtain automatically, in all cases, under the assisted dying regime, even though that regime is completely new. She says that she cannot envisage a scenario in which the doctors would not hear from all the professionals we all think should be consulted at this stage of the process. I have two points to make on that. First, why not make it explicit that that is required? Secondly, I am afraid that I can envisage scenarios in which for doctors—perhaps some years down the line, once this model of death has become normalised, as it has in Canada and elsewhere, with up to 10% of deaths coming through assisted dying—it just becomes a procedure.

Again, we have not ruled out the possibility—the likelihood, in fact—of independent clinics establishing themselves with a business that is about providing the support for people who want to end their life. There will be doctors who are happy to conduct the assessments; to take at face value what they hear from the patient; not to involve a wider multidisciplinary team in their consultations; and to expedite the process as the Bill, as drafted and amended, allows. I am afraid I do foresee a scenario in which the good practice in which all believe does not happen. My concern, and I expect the hon. Lady’s is the same, is to prevent that.

[Rebecca Paul (Reigate) (Con)]

My hon. Friend is making a powerful point. One of my concerns is about what happens if someone seeks assisted dying privately through a clinic. I see risks with multidisciplinary teams involving social workers continuing in that instance. Does my hon. Friend share my concern?

[Danny Kruger]

I certainly do. That is exactly the scenario that I fear, and I fear it within the NHS too. Let us not imagine that every NHS doctor has all the time and the access to the wider specialisms that they would wish. Under the Bill in its current form, there will be a very strong incentive and a very strong personal instinct for compassionate doctors, who believe in the autonomy of patients and in respecting the patient’s wishes, to take at face value what they are told and not to seek the expertise that would happen automatically if there were a proper multidisciplinary team at that stage of the process.

My point is that we do need a multidisciplinary team, but what is in the Bill is not it. At best, it is half a multidisciplinary team. There is no doctor on it. There is a lawyer, pointlessly. There is a sort of quasi-MDT—a duo-disciplinary team—but it is in the wrong place, and it will not assess, which is the job it should do, but judge. It will not diagnose or advise in the way that a clinician should; it will simply decide whether the criteria have been met for an assisted death. That job was rightly given to judges in the Bill that the House of Commons voted for, but this Bill does not have the powers, the safeguards, the accountability or the independence of a tribunal, let alone that of a court.

As the hon. Member for Spen Valley candidly says, the panel is not a judicial entity in any sense. It is a weird creature, neither one thing nor the other: a quasi-multidisciplinary team, at the wrong stage in the process, for the wrong purpose. I have said that it is not a multidisciplinary team, but it is not really a judicial entity either, as the hon. Lady has mentioned. It is certainly not “judge-plus”, as was originally suggested. There is no judge, just a legal member—not a judicial member but a legal member, who might be a lawyer.

[Kim Leadbeater]

There is a judge—it may be a retired judge—who is the commissioner, who heads up the entire assisted dying commission, and there is a legal expert on the panel as well, as the hon. Gentleman said. That could be a retired judge, so there is legal expertise there. I think the hon. Gentleman also made the point that there is not a doctor on the panel. My understanding is that psychiatrists are doctors, but I will stand corrected if that is not true.

[Danny Kruger]

The hon. Lady is absolutely right; I do apologise. There is indeed a doctor—a psychiatrist—but not a doctor specialising in their condition.

[Kim Leadbeater]

We have had two of them already.

[Danny Kruger]

No, we have had a couple of GPs. We have not had a doctor who is a specialist in their condition.

[Kim Leadbeater]

If needed.

[Danny Kruger]

If needed, there is the opportunity to refer to one. It is perfectly possible that the whole process of an assisted death could be done very well under the Bill—that is good news—but there is a very great risk that the process will not be done well, because there are huge gaps through which bad practice can creep. My specific concern about this stage is that we do not have the appropriate expertise on the panel.

On the hon. Lady’s point about there being a judge in the process, there is a distant judge who sits above a quango that appoints the panels. They take a view on a specific case only if there is an appeal against a refusal. They are not directly judging on the case, as the House of Commons was told would happen.

[Kim Leadbeater]

The reports for the case would go to the commissioner, so he or she would see the reports.

[Danny Kruger]

Yes, but he or she will consider a reconsideration only on the basis of an application to reconsider made by the applicant. There is only one opportunity for an appeal and it can happen in only one direction: against a refusal. I will come on to the role of the commissioner in a moment, but in the great majority of cases there will not be a judge involved in the decision. There might be a retired judge on the panel, but that is extremely unlikely; it is more likely to be a lawyer. It is a judicial exercise that is being conducted, so it would be appropriate for it to be a judge sitting properly in a court.

[Naz Shah (Bradford West) (Lab)]

Does the hon. Member share my concern that the Bill does not say that the panel can call people and ask them to swear under oath, unlike a mental health tribunal?

[Danny Kruger]

The hon. Lady is absolutely right. Having said that the panel is not a proper multidisciplinary team, I agree that it is not a proper judicial entity either. It is a panel with judicial power to approve life-or-death decisions, but it is without a judge or the normal judicial processes that would happen in a tribunal or court. There is no oath being taken by members of the panel or by witnesses; there is no independent appointment process, so the members of the panel will be appointed by the commissioner; there is no power to order the disclosure of information to the panel; there is no power to investigate wills, financial records or anything like that; and there is no requirement to meet the doctors or even to discuss the case with the patient themselves, if the panel considers that appropriate.

There is also no appeal against an approval, just a one-way appeal against a refusal. That appeal goes not to an independent judge sitting in a court, but to a commissioner—an appointee of the Government, who has been set up to facilitate the whole system.

Let me turn to the role of the VAD commissioner, or the Vader as I think of it; I will not labour the point. They can be a sitting judge, which is good, but I suggest to the Committee that it is highly unusual for sitting judges to be appointed to other public functions that are unrelated to a judicial role. I would be interested in the Minister’s view on that. Judges can be appointed to a second judicial job, such as chairing the Sentencing Council, but I am not aware of many examples in which a sitting judge sits in a non-judicial function.

Having looked into it, I discovered that there are three exceptions to the rule. First, the Master of the Rolls holds a number of sinecures in relation to the keeping of the public archives and the payment of the national debt, so that is a non-judicial function that a judge carries. Secondly, the chair of the Law Commission is a sitting High Court or Court of Appeal judge. Thirdly, and exceptionally, with permission of the senior judiciary, sitting judges can be asked to conduct public inquiries. A singular public inquiry, which is time-limited and essentially judicial in its purpose of determining what happened, and which will of course operate in an adversarial way, hearing proper evidence from counsel, is the only exception. However, that is not comparable to the model being set out here, in which a sitting judge is being asked to chair a permanent quango—a Government body.

[Kim Leadbeater]

Does the hon. Gentleman agree that that is exactly the point? This is a unique situation, and therefore we need a unique system. That is the perfect opportunity to use the skills that a judge or retired judge has.

[Danny Kruger]

Throughout this debate, the hon. Lady and others have frequently made the case that we should stick with the existing systems, such as the Mental Capacity Act 2005 and the use of doctors to make decisions about healthcare. Now the opposite point is being made: that we have a unique system and we therefore need to tear up the current way of working. In this one case, I think we need to stick with the current way of working: in the British judiciary, the High Court of England is the appropriate body to make decisions about life and death. That is how it works in other major decisions of life and death. These are questions that go to court.

On the point about the VAD commissioner being a sitting judge, even when it comes to inquiries that judges conduct outside their role as sitting judges in court, my understanding is that the Executive do not pick whichever sitting judge they want for the role. Instead, they request that the Lady Chief Justice make a judge available, and the Lady Chief Justice will select the appointee. What is proposed here is that the Prime Minister should pick from the bench of judges his or her preferred candidate. That feels like the use of a judge simply to fulfil a role that, frankly, does not need to be carried out by a judge.

For clarity, I emphasise that I am very much in favour of judges deciding on cases, but I do not see why a judge should fulfil the role of chief quangocrat for the administration of the regime. When we look at the functions the commissioner will have, it is quite right that, under the previous version of the Bill, most of those functions were given to the chief medical officer, because most of the required functions have to do with the administration of the medical aspects of the Bill. The collection of data and the monitoring of the operation of the Act are best left to a medic with experience of our healthcare system, rather than to a judge. These are not judicial functions.

The only function carried out by the commissioner that would require one to be a judge, or that is in a sense judicial, is the review of panel decisions, because a judicial decision is being made. Under new clause 17(2), the test is limited to an error of law, irrationality or procedural unfairness; those are the grounds for judicial review. If we did not have new clause 17, the ability for judicial review of panel decisions would remain. It could be argued that the new clause would actually limit judicial review by only allowing the person concerned to apply for reconsideration.

I understand that some courts in Canada, which has a comparable judicial and common law system to ours, have held that family members do not have standing to judicially review decisions to authorise medical assistance in dying. The suggestion has been made that families who are concerned that an error has been made in a decision to approve a death should be able to quickly get an injunction through a JR. I hope that that will be the case, if this law passes as proposed, but it certainly is not the experience elsewhere and I fear it might not be the experience here.

I am afraid that we have a dog’s breakfast of a system: all the problems of the High Court system that have been aired, but without any of the benefits. I will finish by quoting Sir James Munby. I know he has been cited regularly, but the hon. Member for Spen Valley said yesterday that, having listened to Sir James, she set herself the task of designing a system that would satisfy a former president of the family division. I am afraid to say that she has not succeeded in her task. I will quote a few points that Sir James made in response to the proposals in these new clauses. He stated:

“The process…is simply not apt to enable the panel to perform its function…The panel is given an extraordinary degree of discretion in relation to the process it is to adopt”.

He suggested that the panel is

“little more than a rubber stamp providing a veneer of judicial approbation”—

I do not think that rubber stamps provide veneers, but his point is well made and I respect it—

“and that is fundamentally unacceptable”.

Finally, he said:

“If the panel is to perform its function effectively and do more than just ‘check the paperwork’—if it is to be the real safeguard intended by its proponents—then its processes must be much more thorough than is currently proposed…All in all, in relation to the involvement of the panel in the process, the Bill still falls lamentably short of providing adequate safeguards.”

[Kim Leadbeater]

Many of us have quoted Sir James Munby, for whom I have a huge amount of respect, but there are a number of other views from ex-judges and very highly-regarded legal professionals that conflict with what Sir James says.

[Danny Kruger]

It would be very helpful if the hon. Lady could—not now; it need not be in the course of these deliberations—publish the evidence of that assertion. Which senior judicial figures have endorsed the new plan? It would be very helpful to hear from them.

We heard many criticisms of the previous regime. In my view, those objections prompted the change of heart that the new clauses derive from. From what I have seen, the weight of evidence indicates that we still have many of the problems that the High Court system had: a lack of effective powers and questions around capacity. We also have a whole new load of problems to do with the essential illegitimacy of a quasi-medical panel of people making an essentially judicial decision without the opportunity to hear in a meaningful way from all the different stakeholders who should be consulted.

[Naz Shah]

I want to understand and clarify something. The hon. Gentleman said earlier that the commissioner is sitting as a judge, but my understanding is that the commissioner is not sitting as a judge. What did he mean?

[Danny Kruger]

I think the hon. Member for Spen Valley said yesterday that we had to grapple with this confusion, which is that there is a judge not sitting as a judge. It is slightly like a Minister not sitting as a Minister; the Bill has provided all sorts of interesting hybrid creations of people who inhabit split personalities and dual roles.

The hon. Member for Bradford West is, I think, right. From the evidence we have heard from the hon. Member for Spen Valley, although there will be a judge, which satisfies the cosmetic need to present this as some sort of continuation of the High Court stage that the House of Commons voted for, they will not sit as a judge. It is rather like having a hobby or a second job. I am not sure judges do that, but it is like chairing a football club on the side. Their status derives from their judicial role, but they are sitting as the commissioner in a lay capacity—I think I have that right.

[Kim Leadbeater]

We have already talked about this, and I think the hon. Gentleman mentioned it himself: there is a similar situation with public inquiries, on which a judge sits because of their skillset and who they are, but not necessarily in a traditional judicial capacity.

[Danny Kruger]

It will be interesting to hear from the Minister, who is more equipped than the rest of us to opine on this. My understanding is that a judge sitting as chair of a judicial inquiry might not be sitting in court, but they are there because they are a judge; their function, as the chair of the inquiry, is essentially judicial. That is the only comparison and it is essentially different, because the exercise of a public inquiry is time-limited and specific to a particular case, which is to determine the truth or otherwise of what happened in whatever situation it is being asked to inquire into.

Here, we are setting up a quango—an arm’s length body of Government—that will sit in perpetuity and oversee a bureaucracy of state. That is something that no judge does in our system and, in my view, would be completely inappropriate for a sitting judge to do, even if we could find a sitting judge prepared to fulfil that function, which I think might be challenging.

The other key difference is that a judge chairing a public inquiry is appointed by the Lady Chief Justice; they are essentially judicial in their appointment and work. The judiciary appoints one of its own to fulfil a judicial function as the chair of an inquiry. It is being proposed here that the Government—the Executive, not the judiciary—appoint the chair of the commission from the Bench of judges.

[Naz Shah]

What the hon. Gentleman has said creates another concern for me. If we do have a judge, and if the expectation is that they sit in a judicial capacity, does that not raise concerns that an appeal is allowed one way—if an assisted death is refused—but not the other way, if someone wants to appeal against an assisted death? By definition, does that position not become compromised?

[Danny Kruger]

I am afraid that that is absolutely right. There is an essential problem with the role of the commissioner as the backstop—the Court of Appeal, as it were—for what are effectively judicial decisions made by the non-judicial panel. The fact that appeals can be heard only against a refusal and not an approval confuses the whole question of appeal and judicial review. It is plainly unjust, and does indeed compromise the idea that the judicial figure has the independence that a judge should properly have. I agree with the hon. Member for Bradford West.

[Naz Shah]

I want to speak to amendment (c) to new schedule 2, tabled by my hon. Friend the Member for Lowestoft. The amendment requires members of the panel to have undertaken training in respect of domestic abuse, including coercive control, and financial abuse. It extends the principle of amendments 20, 21, and 22, also tabled in the name of my hon. Friend, which require the medical practitioners involved in the assisted dying process to have undertaken similar training.

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[Kit Malthouse]

I rise briefly to amplify a couple of points from the excellent speeches by the hon. Members for Rother Valley and for Ipswich. First, in clarification, I understand that there are situations where judges can sit in essentially supervisory positions—not least, for example, on the BBC board—and they can of course be Cross Benchers in the House of Lords. They are allowed to undertake other charitable trustee roles, although they are restricted in their activities.

[Danny Kruger]

I think this is important. Those roles are what those judges do in their spare time—they could also chair a football club or something as well. The point is that they are being asked here to fulfil a function on behalf of the Government in their working hours, explicitly because they are a judge—yet they are not sitting as one. Surely my right hon. Friend acknowledges that that is essentially unprecedented.

[Kit Malthouse]

No, I do not acknowledge that at all. Over the years we have started to use judges relatively flexibly—even, for example, for non-statutory inquiries; my hon. Friend has referred only to statutory inquiries—and that is so much the better. I am not a lawyer myself but I believe in the rule of law, so I think that having judges opining on our freedoms or otherwise is generally good for the country.

I want to amplify a couple of points. On Second Reading, I made the case for the High Court to be involved. I agree with my hon. Friend the Member for East Wiltshire: at that stage, I was very happy for there to be effectively a scrutiny and authorisation third layer to the Bill. My understanding of judicial opinion was that, certainly in Lord Sumption’s view, that level was unnecessary; I think he referred to it being a profoundly intimate conversation that really should just be between the patient and the doctor. However, I think my hon. Friend the Member for East Wiltshire is right that the weight of the moment and opinion in the House then was that there should be that third layer of scrutiny and opinion.

I also dismiss the argument about the capacity of the judiciary to absorb this. I fear that if we start to accept that argument, we go down a very difficult road for Parliament—not least, for example, because we should then have opposed the Bill that went through the House on Monday night, because of its greater impositions. As many will know, the Crime and Policing Bill went through without a vote. It will impose new burdens on the judiciary and the police, as will the new offence of spiking. No doubt the immigration Bill coming through will also put significant extra burdens on the police and the courts.

There are two separate questions here: one is what Parliament does, and the other is the capacity of the public sector to absorb that. The answer is not to say, “Well, I am afraid all you people have to go through a death you do not want to go through”; it is to say that we do not have enough judges and to recruit more judges, if that is required. In my personal view it is not, but at the time my view was that if as a footballer I could show up in the middle of the night and get an injunction to stop The Daily Mirror from publishing unpleasant stories about me, then the judges should be able to find time in their schedule to accommodate the requirements of my death.

[Danny Kruger]

My right hon. Friend is absolutely right. If Parliament decides that we should proceed, then we should, and the public sector will be obliged to make accommodation and provide the necessary resources. Does he agree that, on that basis, it would be appropriate for the Government to have clarified by this stage what the resource requirements of the new system would be, to make clear that there is the capacity in the system to do it? Does he share my regret that that has not been done?

[Kit Malthouse]

No, I do not share that regret, because until today, and until we all vote on it, the Government do not actually know what they are facing. They have undertaken that they will produce exactly the assessment that my hon. Friend is talking about between the end of this process and Report, so we can all have a look at what it will be.

At that point, Members can put a price on other people’s death and other people’s pain if they want to, but there are lots of situations where the House of Commons decides about things on the basis of moral principle and public interest, and then we ask the public sector to absorb it. If that causes operational problems, then we solve those separately. In my 10 years in the House, I cannot remember anybody ever standing up and saying, “We shouldn’t do this because the public sector can’t cope.”

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[Lewis Atkinson]

I rise to respond to some of the points made by the hon. Member for East Wiltshire. I looked back on the Hansard report of the Second Reading debate and his position there, and I am somewhat confused. In his speech in that debate, he was entirely dismissive of the judge as a safeguard, but now, in Committee, he seems to have had a Damascene conversion in favour. That gets to the question of whether, as others have asked, there are any safeguards that would satisfy opponents of the Bill in principle.

I entirely respect the position of principled opponents to the Bill.

[Danny Kruger]

I look forward to hearing the hon. Member’s substantive remarks, but in explanation I should say that there are no safeguards that I think will make an assisted dying Bill adequate. I will oppose the Bill whatever happens because I think it would be dangerous for people however we do it. But if we are going to do it, let us do it as safely as we can. There are definitely ways in which we could improve the safety of the Bill, which have been suggested in the many amendments I have supported.

On the point about the judicial stage, I am very critical of clause 12 as it stands because it does not provide sufficient rigour and there are major questions about the capacity of the judiciary, as has been discussed. But the principle is absolutely right. It is important that, if we are going to do this, we have a judge to make the final decision. I was not satisfied with the Bill as presented, but I think we should be building on it, rather than reducing the judicial safeguard.

[Lewis Atkinson]

I thank the hon. Member for that point, but when someone cannot describe any version of safeguards that would be possible, and in the light of some of the other conversations we have had, one is led to believe, entirely respectfully, that some people are opposed to the Bill in principle in any instance.

The point that my hon. Friend the Member for Spen Valley made on Second Reading that this was the safest model in the world was not just about the fact that there was a judge, but about the fact that there was a third tier. That is not something that is in place in Oregon, or even in Australia, as we heard in evidence. Now, not only are we going to have a third tier of scrutiny, but we are going to have three professionals who must unanimously accept that the strict conditions for eligibility have been reached. I absolutely refute the suggestion that amending away from a High Court model and towards a panel model means that we have to recant any suggestion that this is the strongest model in the world.

--- Later in debate ---

[Lewis Atkinson]

No, I am in a flow, so I am just going to keep going. I am mainly rebutting at this point, and I do not want to open the debate that much wider.

Invariably, we already have individuals at the end of their lives with multidisciplinary input that is appropriate to them, and we have heard already how the independent doctors and the panels will rightly seek input from all those involved in care.

It has been some time since the hon. Member for East Wiltshire and I had an exchange on our difference on the ventilator test, but I know that we have a fundamental, philosophical difference on that. I believe that a dying person saying, “Please, doctor, turn off my ventilator; I want to die,” is not fundamentally different from that person saying, “Please, doctor, let me take that medicine; I want to die.” I assert that the person in the street is closer to my view of that situation than to his, although I respect that people have different philosophical opinions about it. However, let us not forget that we sometimes conduct this debate about the correct oversight of the third tier in a theoretical manner, as if these people were not dying anyway, and as if deaths relating to refusal of treatment, and suicide, were not happening anyway.

[Danny Kruger]

Let us not rehash the argument about whether there is a difference between withdrawing treatment and actively killing somebody or giving them the opportunity to kill themselves. On the point about withdrawal of treatment, does the hon. Member acknowledge that when there is dispute over whether somebody should have their treatment withdrawn, it goes to a court and there is representation from both sides of that argument about whether the treatment should be withdrawn? If he is saying that these measures are essentially identical in principle, surely we should have the same mechanism to resolve disputes.

[Lewis Atkinson]

I thank the hon. Member for his intervention, but I am afraid he is confused. It goes to the Court of Protection when the individual is not capable of making that decision and there is a dispute about what the best-interests decision may be for that individual. That is entirely different from the dying person saying, “Please turn off my ventilator.” In that case, the Mental Capacity Act 2005 applies, as we have discussed at length in the Committee, but there are no further checks for coercion, capacity or motivation in the way that has been described. With the three panel members, we will now have at least five professionals, who must all be satisfied that there is no coercion. How many individuals should there be?

I see speculation, including on social media, about the number of people who might seek an assisted death and who may be subject to coercion. How many people who refuse treatment at the moment, without any of those checks, are subject to coercion? How many people who go to Switzerland, or who end their own lives, are subject to those checks? We do not know because we have no robust oversight of those instances. While I have absolute sympathy with the points raised by my hon. Friend the Member for Bexleyheath and Crayford, who made a very thoughtful and personal speech, as he always does, the exact same instances that he described would be permissible right here and now.

The hon. Member for Reigate shared some upsetting stories, I think from Canada, about the impact on family in speaking to the amendments on that subject. First, I point out that Canada’s system is nothing akin to the one that we are proposing, because it does not have the third-tier protections that my hon. Friend the Member for Spen Valley proposes in the Bill.

However, it is also important that we bring the debate back to talking about dying people here in the UK, and that we have some of their voices and experiences, and their families, in the room. We know that already, 650 terminally ill people end their own lives each year in the UK. Anil Douglas’s dad, Ian, took his life the day before his 60th birthday. He was in the terminal stages of multiple sclerosis, and he ended his own life without notifying his family, because he felt he had to protect them, due to the state of the current law. He managed to obtain opioids from the dark web and subsequently overdosed. In his final note, he wrote:

“I would like to have to put on record that had we had more sympathetic assisted-dying laws in this country, in all probability I would still be alive today.”

I will give one more example. On returning home from a trip to London, Peter Wilson discovered his wife, Beverly, dead in their home. She had terminal oesophageal cancer and had taken her own life, alone at their home in Nottinghamshire, when she knew that Peter would be 120 miles away. Even though Peter could prove that he was not present at the time of death, he was questioned by police for seven hours, and he was fingerprinted and photographed within hours of her death. That is the current situation that families—those we have discussed maximising care for—are facing in the UK. That is why we need a change in the law that includes robust, third-tier oversight.

--- Later in debate ---

[Sean Woodcock]

That is my next point—and it is a good question. As I said, the panel is done with the right intention and would improve the process in many ways. My view is similar to that of the hon. Member for East Wiltshire—it is possibly one aspect on which we are in agreement—in that I think it comes at the wrong part of the process. If it was earlier in the process, it would improve things. Court capacity is an issue, but I take the point made by the right hon. Member for North West Hampshire that if we want the courts to do it, they need to get on and do it.

I keep coming back to the issue of what we are asking the state to do. Implementing the wishes and autonomy of the patient is important, but we also need to take very seriously what we are asking the state to allow to be done in its name. There is also the crucial matter of public trust, the condition of the national health service and the issue of capacity in the courts. As my hon. Friend the Member for Ipswich touched on, there is considerable disquiet and concern about how robust this process is going to be. Even though I think having the panel at the start of the process would improve what was put to the House on Second Reading, having judicial oversight at the very end would provide reassurance to the vast swathes of the public who are concerned about this, as well as to Members.

[Danny Kruger]

The hon. Gentleman is making an important point and I completely agree. Does he agree that the hon. Member for Spen Valley recognised the problems with the lack of a multidisciplinary team in the process and the problems of court capacity, and through her attempt to address both those problems we now have a multidisciplinary team instead of the judicial role? What we really need is both: we need a properly constituted multidisciplinary assessment at the beginning, and then we need the final process to be an approval by a judge. Does the hon. Gentleman agree that that would be a better process?

[Sean Woodcock]

Having thought about it, that would be my preference. I am in a difficult position in that there is a lot to be said for the panel, and it would improve the process in many ways, but I cannot get around the fact that the judicial aspect was put strongly before Parliament, and ensuring that we would have those safeguards provided reassurance to Members. When I have been out on the doorstep talking to people who are in favour of the Bill—people who wanted me to vote in favour of it—they have said to me that they think the proposal is safe because it includes two doctors and judicial oversight. That does come up, which is why I think we need to keep judicial oversight in the Bill. I do, though, I recognise the very genuine attempt by my hon. Friend the Member for Spen Valley to introduce the panel to improve on some aspects and address the concerns expressed in the witness testimony.

--- Later in debate ---

[Sarah Sackman]

It is a majority vote for the other decisions that a panel may make, but in respect of certification, the decision is unanimous. Paragraph 5(2) of new schedule 2 states:

“Decisions of a panel may be taken by a majority vote”.

Such decisions include whether to hear from an additional expert, or whether further investigation is required in respect of an aspect that the panel may be concerned about, such as coercion or capacity. While those decisions can be taken by a majority vote, in respect of certification and granting a certificate of eligibility, I refer my hon. Friend to paragraph 5(3), which states:

“The panel is to be treated as having decided to refuse to grant a certificate of eligibility if any member votes against a decision to grant such a certificate.”

That is a slightly mealy-mouthed way of saying that if any member of the panel resists the grant of the certificate, no certificate can be issued.

[Danny Kruger]

I just want to support the hon. Member for Bradford West. She is absolutely right. It is clearly intended that there should be a unanimous decision but, in fact, as the hon. Lady pointed out, if one of the members decides effectively to abstain, the procedure does go ahead. It is not that they all have to actively support the decision; only two of them have to do that. One of them could have their doubts and sit on their hands, and it would still go ahead.

[Sarah Sackman]

That might be something that other hon. Members wish to take away with them, whatever the policy intent may have been. In fairness, I do not think that the question of whether there is a requirement to give a positive indication of a decision either way is on the face of the Bill. However, I think that clearly the intention behind paragraph 5(3) of new schedule 2 is that there is unanimity in relation to the grant of an eligibility certificate.

--- Later in debate ---

[Sarah Sackman]

There is no doubt that, as we will see later, the panel would be subject in all its decisions to public law principles, including procedural propriety. The absence of any suggestion of bias—even of the appearance of bias—is an important public law principle. In any event, given the recruitment process, the interviews that would be undertaken and the professional standards to which all these people would be held, I think that they would apply their independent and impartial skills and judgment to the decision making and the assessment of eligibility in a manner appropriate to the task set out in the Bill.

One would expect professionals on the panel to adhere to their professional standards and act with impartiality in ascertaining whether the eligibility criteria have been met. Speaking as the Minister—indeed, even speaking for myself—I have no reason to doubt the independence, impartiality and professionalism of the panel or see any suggestion of bias.

[Danny Kruger]

I appreciate that an impact assessment is due to come later, after we have debated whether we should have this system or not. Nevertheless, will the Minister tell the Committee whether officials in her Department or in the Department of Health and Social Care have informed the hon. Member for Spen Valley whether the workforce will have sufficient capacity to provide the professionals required? Has any estimate been made of the number of people who will be required to step forward to take part in these panels?

I note the point that the reason why the proposed High Court stage was dropped was not that Ministry of Justice officials had informed the hon. Member for Spen Valley that the family court system would be overwhelmed. Can the Minister confirm that there was no communication to the hon. Member that the courts would not be able to cope with the demand? That was clearly reported in the media at the time, but can she confirm that it was not the case?

[Sarah Sackman]

The hon. Gentleman’s first point is a matter for the impact assessment itself. Clearly both Departments have data on the state of the professions, on how many KCs there are in the country and on how many people will be needed to provide the service. As I say, if Parliament wishes it and legislates for it, the state will work to deliver it, but the detail will come in the impact assessment.

On the hon. Gentleman’s second question, as I made clear earlier, the effective shift away from the High Court model in clause 12 to the model in the new clauses has been driven by the policy intent of my hon. Friend the Member for Spen Valley. I will not get into the precise chronology of when the matter was raised, but it came from my hon. Friend.

Yesterday, I hotfooted it from the Committee to Justice questions, where I was delighted to see the hon. Member for Reigate. We discussed capacity issues in our Crown courts and civil courts. Those issues are well reported in the media, but there is no connection between them and the policy shift here. If this is what Parliament chooses to legislate, the state will work to deliver it.

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[Danny Kruger]

I appreciate the Minister’s point about the Parole Board. Does she acknowledge that in the Parole Board example there is the essence of an adversarial system, because the victim is invited to give a statement? The board therefore hears opinions from, as it were, both sides of the case. Who will fulfil that second role in the proposals before the Committee?

[Sarah Sackman]

I drew the comparison for the purpose of showing where judges and legal experts are deployed in a multidisciplinary forum that is not a court or tribunal. I was not suggesting that there is a straight-line analogy. After all, a Parole Board panel is performing a different function to make a global assessment of risk. That is what it is ultimately doing; it is not strictly speaking an adversarial process in that sense.

The situation that the Bill addresses is that of an individual seeking to establish their eligibility for a right that—if the Act is passed—Parliament will have conferred on those who meet the criteria. It is not an adjudication. It is the panel’s function to assess, through the various conversations and provisions and by interrogating the information that has been provided, whether it is properly satisfied that the eligibility of the person’s election to avail themselves of that right is sound.

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[Sarah Sackman]

It is a pleasure to serve under your chairship, Sir Roger.

New clause 17, tabled by my hon. Friend the Member for Spen Valley, will establish an internal review process. Where a panel refuses to grant a certificate of eligibility, the person seeking assistance would have the option to apply to the commissioner for their case to be reconsidered on the grounds that the first panel’s decision contains an error of law, is irrational or is procedurally unfair—essentially public law grounds. If the commissioner is satisfied that any of those grounds apply, having considered the case without a hearing, they must refer the case to the second panel for a fresh determination. The commissioner will be required to give reasons for their decision in writing. The decision should be shared with the person seeking assistance, the co-ordinating doctor and any other person specified in regulations.

In addition to this internal review process, decisions made by the commissioner or a panel will be amenable to judicial review. It will be for the court to decide whether an individual or group is sufficiently impacted to have standing.

Amendment (a) to new clause 17 proposes a change to who can apply for reconsideration of the initial panel’s decision. This amendment, tabled by the hon. Member for Reigate, seeks to make changes to the process of applying to the commissioner for reconsideration of a panel’s decision, as set out in new clause 17. It would widen the range of persons eligible to apply for a reconsideration, to include not just the person seeking assistance but their next of kin and other relatives, the medical practitioners treating them, and any other person who engaged in the first panel’s proceedings.

Secondly, the commissioner would be able to allow the application for reconsideration on the basis that the first panel’s decision was wrong or unjust because of a procedural or other irregularity in the proceedings. This could include scenarios where a person wishes to challenge the panel’s decision to grant a certificate of eligibility. “Wrong” is an unspecific, subjective and uncertain term that is not typically used in legislation for these reasons: it is a far broader criterion than that set out in new clause 17 and would give the commissioner a significant degree of discretion on whether to exercise the power to have the matter reconsidered.

Lastly, amendment (a) to new clause 17 would make it mandatory for the commissioner to consider each reconsideration with a hearing, unless they consider it to be in the interests of justice to proceed without a hearing. This could increase the time it takes to complete the process, as well as the complexity of the process.

In addition to the internal review process under new clause 17, any decision made by the commissioner or any individual panel would be amenable to judicial review. It would be for the court to decide in each and every case whether an individual or group challenging any such decisions is sufficiently impacted to have standing for the purposes of judicial review.

[Danny Kruger]

I would be grateful for the Minister’s advice on whether she thinks a family member will always have standing. I appreciate her point that it will be for the panel to consider, but is it her view that in law, as in our experience, family members, in the normal understanding of the term—again, we are conscious of the definition of “family members”—will have sufficient standing? Or can she foresee circumstances in which it might be concluded that family members do not have sufficient standing to make a representation?

[Sarah Sackman]

The hon. Gentleman asks about standing and the process of judicial review. It is fair to say that, in our corpus of administrative law, the rules of standing are fairly liberal. On having a sufficient interest to bring a case, the case needs to be meritorious and would need to meet the permission threshold, which again is a relatively low standard: does one have an arguable case? A family member who has identified a procedural irregularity or a public law error that is arguable will have standing, I would have thought, to bring a judicial review.

The hon. Gentleman also asks about the potential for judicial review of individual decisions to issue a certificate of eligibility, but of course any decision by the commission, the commissioner or any of the subordinate panels will be amenable to judicial review. For example, the decision to issue guidance or policy documents relating to the commission’s operations will be amenable to judicial review. One can imagine that, under our broadly liberal rules of standing within the administrative court, a range of bodies not pertaining to the case of an individual and their family, but having an interest in those rules, might be eligible. Ultimately—as the Minister for courts, I would say this—that will be a matter for the independent judiciary, but it is right that, within our public law system, the rules of standing are fairly broad.

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[Kim Leadbeater]

It is a pleasure to serve under your chairmanship, Sir Roger. It was a delight to see the mum of the hon. Member for East Wiltshire. Sadly, I think she is no longer in the Public Gallery, but I hope they had a really good chat.

[Danny Kruger]

I am sorry to report that my mother could not hear a word of the proceedings. I am exaggerating, but she grumbled about the mumbling, which is a lesson for us all.

[Kim Leadbeater]

We have all been told off, and quite rightly.

I thank colleagues for another powerful, robust and thorough debate on this important subject. I thank the Minister for providing such an excellent and clear description of the changes to clause 12 that I have proposed this afternoon—I will not repeat that description. The Bill is already the strongest of its kind anywhere in the world. My amendments will make it even more robust. As we have heard, the Bill is much safer than the existing ban on assisted dying, which leaves terminally ill people and their families without any such protections at all.

The proposal to have a multidisciplinary panel, appointed by a judge, to examine each request, following earlier assessments by two independent doctors and, where necessary, a psychiatrist, reflects the expert testimony we have heard during our proceedings. It strengthens the Bill by adding more varied expertise to the decision-making process, with judicial oversight, and it includes an important monitoring and reporting function in the commissioner.

My amendments show the Committee process working exactly as it should, reflecting on evidence from the UK and around the world, and making a strong Bill even stronger. I appreciate that, for procedural reasons, we will not vote on the replacement of clause 12 until the new clauses are put, but I am encouraged that colleagues have offered positive responses and comments to the proposal for a commissioner and a multidisciplinary panel, regardless of how they voted on Second Reading. That tells me that, whatever our views on the Bill, there is a shared commitment to getting protections for terminally ill adults right, which means that we are doing our job.

Amendment (c) to new schedule 2 was tabled by my hon. Friend the Member for Lowestoft (Jess Asato). I was pleased to support my hon. Friend’s amendment on additional training on domestic abuse, coercive control and financial abuse for doctors who take part in the assisted dying process. As members appointed to the panel will already be very well qualified in the fields of law, psychiatry and social work, I am confident that they will have the necessary expertise to determine referrals, but I appreciate the challenges in detecting the subtleties of coercion, as the Committee has discussed at length. As such, I support amendment (c).

Amendment (a) to new schedule 2 was tabled by the right hon. Member for Dwyfor Meirionnydd. I am fully supportive of her position on ensuring accessibility and equality for Welsh speakers, but in this instance I have some concerns about the barrier her amendment may create for patients in accessing the assisted dying process in a timely manner, and therefore about the workability of the amendment.

Under the Welsh Language Act 1993, as the Minister said, all public bodies operating in Wales must create a Welsh language scheme with the aim of ensuring that Welsh and English are treated equally in all aspects of public service delivery. The Ministry of Justice’s Welsh language scheme, for example, sets out where services can be provided in Welsh, typically through translation services.

I take on board the right hon. Lady’s comments about the limitations of using translators. Given the sensitivity of the conversations and deliberations we are discussing, we need to be sensitive to that. It is, of course, the patient’s prerogative to request a fully Welsh-speaking panel, if that is what they want at such a difficult time—as long as they are made aware of the potential delays this may or may not create. That is my concern.

My reading of amendment (a) is that it is not the right hon. Lady’s intention that this will be required in every case. However, it will ensure a very patient-centred approach, in which I believe passionately. I take on board the Minister’s concerns, which I appreciate may need to be considered further down the line, but I am minded to support amendment (a) to new schedule 2.

Finally, amendment (e) to new clause 21, tabled by my hon. Friend the Member for Filton and Bradley Stoke (Claire Hazelgrove), in on audio and video material. I think this comes from a really personal, sensitive and important place, and demonstrates a very patient-centred approach, so I am also minded to support it this afternoon.

I would welcome the clarity from the Minister regarding some of the legal language and terminology around other amendments, and as such, I will not be supporting them this afternoon. We have had another thorough debate, and I welcome the contributions from colleagues across the Committee.

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

Danny Kruger Excerpts

Committee stage
Tuesday 18th March 2025 Public Bill Committees

[Danny Kruger (East Wiltshire) (Con)]

I will speak briefly to amendment 316 in the name of the hon. Member for York Central (Rachael Maskell). She has tabled a sensible suggestion that if a patient makes a statement after the second period of reflection, there should be an automatic referral to palliative care. We have heard how expected and usual that is anyway, and the hon. Member for Spen Valley has frequently made the point that people who are having an assisted death, or going through the process, are likely to be in palliative care anyway—it is not an either/or. It is important that we clarify that expectation.

It will obviously be the case that the patient is not required to take up the referral, and if the referral already exists, that case is dealt with, but let us be absolutely clear that the decision to take an assisted death is not a fork in the road, as would be my concern. If that is not the case and that, in fact, palliative care and the assisted death process go hand in hand and will be seen as part of an integrated package of support for patients, my view is that we should specify clearly that in the event of a decision to proceed down the road to an assisted death, a palliative care referral should be made.

Bluntly, I want to make this as clear as we can, although I am not sure that we will ever be able to do that fully. It really has to be very plain to healthcare commissioners and managers that there is to be no cost saving as a result of an assisted death referral. I very much doubt that a single commissioner or manager would have that at the forefront of their mind; nevertheless, incentives apply in healthcare decisions. Ultimately, we have a ration system, and resource allocation necessarily is the job of commissioners.

If, as we are saying, a decision to proceed with an assisted death will be in parallel with palliative care, let us make that plain, so that if indeed it is the case that the patient requires the investment of palliative care services—hospice treatment or otherwise, even though, as we know, hospice care is inadequately funded through public money—nevertheless, there is a resource requirement. It is important that we specify to everybody in the system that an assisted death is not a way of avoiding the expense of proper end-of-life care.

I hope that Members will recognise that amendment 316 is consistent with the arguments that have been made consistently by advocates of the Bill, which is that there is not an either/or between palliative care and assisted death, and that, in fact, it is appropriate for patients to be on both tracks simultaneously.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Ms McVey.

The purpose of amendment 457 is to exclude a person who has less than one month to live from being eligible for the shorter second period of reflection of 48 hours if that person has voluntarily stopped eating and drinking. That person would instead be required to comply with a second period of reflection of 14 days under clause 13(2)(a). The amendment could create uncertainty as to the required length of the period of reflection. It is unclear, for example, if “voluntarily” would include where someone’s appetite has naturally declined as they approach the end of life, and therefore whose decision to stop eating or drinking may not be deliberate.

As I have said previously, the Government have worked with my hon. Friend the Member for Spen Valley on certain amendments to bolster the legal and workability sides of the Bill, and the purpose of amendment 471 is to clarify that the co-ordinating doctor needs to be satisfied that, immediately before witnessing the second declaration, the criteria set out at subsection (4) are met, and not at any time before. That also ensures consistency with the duty on the co-ordinating doctor in respect of the first declaration.

Amendment 316 would require that where the co-ordinating doctor reasonably believes that the person seeking assistance has less than one month to live from the court declaration, they must refer that person for urgent specialist palliative care. As the referral must be made whether the patient wants that referral or not, this may result in unwanted referrals. The effect of this amendment is unclear.

As drafted, clause 13(2)(b) sets out that where the person’s death is likely to occur within one month, the period of reflection is then 48 hours. Amendment 316 sets out that the referral to urgent palliative care must be made alongside the co-ordinating doctor making the statement, which is the last step to be completed before the provision of assistance under clause 18. That would mean that in some circumstances, there may be insufficient time to make a referral before the person is provided with assistance to end their life.

--- Later in debate ---

[Kim Leadbeater]

I hope that these are a couple of nice, simple amendments. The right of the patient to cancel at any time is obviously really important. It is also important that, for the purpose of monitoring and reporting the process, the commissioner, as proposed, is kept informed at every stage. I hope that the whole Committee can see the necessity of these amendments.

[Danny Kruger]

The hon. Lady is quite right that there is nothing to object to in these amendments or the clause. It is worth stating at this point, though, that in the context of the debate we are having in this Committee, we are moving at some pace. The likelihood is that there will be opportunity for only a five-hour debate on Report—maybe more, but possibly not. This Committee is the time we have to consider in detail the content of the Bill. My concern is that moving too quickly and trying to do too much too soon means that we will miss the opportunity to debate very important aspects of the Bill.

The hon. Lady says that these are “nice, simple” amendments, as if the only thing being discussed here is the paperwork around the declaration. What should we say to patients who decide to cancel their declaration? My concern—I am unaware of any other point when we could appropriately discuss this question—is what happens in the event of a cancellation. What duty of care do doctors have to patients who have decided not to proceed with an assisted death? The Bill does not currently address that question: it imposes no obligation on doctors to follow up in any way after a declaration has been cancelled.

--- Later in debate ---

[Kit Malthouse]

rose—

[Danny Kruger]

Before I give way to my right hon. Friend, I want to posit the hypothesis of a private provider that has been established explicitly for the purpose of facilitating the assisted death procedure for patients. If that provider steps back when the patient decides to cancel their declaration, the provider is required to notify the GP as soon as practicable, whatever that means—the timeframe there is clearly at the convenience of the provider, not the patient. My concern is what happens when the patient’s GP is not quickly informed that they have decided not to proceed with the assisted death and they are sitting in limbo. Obviously, there are significant concerns about their wellbeing, given their decision and the state they are in. It is not yet fully clear to me what the obligations on the doctors would be at that stage.

[Kit Malthouse]

I am not entirely certain that my hon. Friend’s remarks are germane to the amendments, but nevertheless. As we discussed when debating clause 13, at the stage he is talking about, the patient will have had all their options—“all appropriate”, as I think we have amended the Bill to say, services that will be available to them—explained to them. If they are cancelling, the presumption has to be, in respecting their autonomy, that they are choosing one of the alternative paths that has been laid out to them. It is quite hard to legislate for a negative.

[Danny Kruger]

I am speaking to the group as a whole, which includes clause stand part. I have no objection to the amendments. My right hon. Friend is absolutely right. As I said, the expectation is that the medical professionals involved in the person’s care will have laid out their options clearly. We are to a certain degree trusting in that because amendments to insist on it have been rejected, although I recognise that it will be the clear expectation. He is right that it is hard, as it were, to prove a negative.

Nevertheless, the purpose of my speech at this point is to tease out from the advocates of the Bill what their expectation is. My right hon. Friend has clearly explained his expectation, which is that we are dealing with somebody whose mind is clear, rational, uncluttered by other concerns and entirely free of any undue influences or anxieties about the different choices they might make. Having previously decided in the fullness of their autonomy that they wanted to go through the procedure, they have now decided in the fullness of their autonomy that they want to do the opposite, and we should say, “Fine. We have no further interest in your decision making. It is your choice—you’re on your own.” I am very concerned about the implication of my right hon. Friend’s comments about the sorts of patients who might be involved in the process of assisted dying.

[Kim Leadbeater]

To allay those fears, perhaps the fundamental answer to the question is that those people do not stop being patients—sadly, they do not stop being terminally ill patients. They have just chosen to cancel the declaration, and they will already have wraparound care. To some degree, the hon. Gentleman answered his own question when he said that doctors have a duty of care. That duty of care does not stop because the person has chosen to take this course of action. They will still be cared for by the professionals looking after them.

[Danny Kruger]

Well, we certainly hope so. Nevertheless, that is inconsistent with the doctrine of absolute patient autonomy, which in this circumstance allows a patient to withdraw from the medical treatment, or at least from the support of the medics who had been facilitating their assisted death. They are rightly under no obligation to receive any other sort of care.

Of course, one would assume that in most cases medics will be closely involved in looking after these patients, because they are likely to be very ill. Nevertheless, the Bill has nothing more to say about patients who have just stepped back from the brink of suicide; the medics will have no further obligation to ensure that they will be looked after—except by the GP, as soon as it is practicable for the provider who has just been denied the business of looking after the assisted death to get round to emailing them. If that is seen as sufficient to ensure that those patients will be properly looked after, I beg to differ.

[Kit Malthouse]

I am not sure what compulsion there is in wider legislation for there to be a duty of care to patients who do not choose assisted dying in the first place. For thousands and thousands of patients who die, there is no legislation that imposes certain duties on medics or others to look after them; we rely on the professional standards and overall atmosphere of the healthcare system, as we would in the case of these patients.

As my hon. Friend knows, overseas experience shows that a large proportion of the people who obtain the right to an assisted death—up to a third—do not cancel but do not exercise it. As we have said before, for many people assisted dying is an insurance card that they may choose to use if and when they think their life becomes intolerable.

[Danny Kruger]

I recognise that, but that is not germane to the debate that we are having, which is about the actual cancellation. There is a question about why there would have been a cancellation. My right hon. Friend is right that there is no obligation to proceed once a patient passes a particular hurdle. Many will not, but when someone decides actively to renounce their decision, a big question should be asked: what is going on, and what further help is needed?

My right hon. Friend suggests that we do not step in and ensure that care is provided—that, in other circumstances, there is no additional obligation in relation to patients. I am afraid to say that he has, as ever, a coldly rationalistic vision of healthcare and of the sorts of patients we are dealing with. As I have said to him, these patients will be acting much as I imagine he would imagine—I think from a position of health and self-confidence—himself acting in that circumstance. In fact, we are dealing with people who have decided to renounce their decision to proceed, and so are by definition in some turmoil.

I crave the indulgence of the Committee, because I am talking at length about a set of amendments that I do not intend to oppose, and I recognise the value and necessity of the clause. However, I draw to the Committee’s attention that we are dealing not simply with a bit of paperwork, but with a human being who, having made one enormous decision—to die—is now making an enormous decision to live, and we are treating it as if it is only a bureaucratic question.

I finish with a question to the hon. Member for Spen Valley or to the Minister, to help me understand something that confuses me in the clause.

[Naz Shah]

I have not given this matter as much thought as the hon. Member has. My interest is very much in the issue of domestic violence. Does he agree that this could be somebody who has experienced domestic violence? Or children could be at risk. This person may then decide not to take the option, even though they wanted to, because of obligations elsewhere.

[Danny Kruger]

The hon. Lady is right, and her point goes to the question that runs through all of these clauses: why? As a Committee, we rejected the obligation on the doctors to ask, “Why are you doing this?” It was suggested by one hon. Member that it was nobody’s business why somebody was trying to take their own life and that if that person qualified, they should be able to summon the agents of the state to provide them with lethal drugs without any question about their motivation.

I agree with the hon. Lady. There is an equal expectation in my mind that doctors should ask the question, “Why are you changing your mind?” I would expect that. The clause could clarify what further referrals would need to be made, if they had not already been; as we have acknowledged, we would expect appropriate care to be provided by doctors anyway.

I conclude with a factual question. Clause 14(1) lets a patient cancel a first or second declaration, but subsection (4) says only that the duties of the doctor stop when a first declaration is cancelled. I would be grateful if the hon. Member for Spen Valley would explain what happens if the patient cancels a second declaration. It strikes me that there would be a need for urgency because if a patient decides to change their mind at that point, that is arguably a more dangerous situation. What would be the obligations on the doctor at that point? Should we read across from subsection (4) that their duties stop in the same way? Perhaps that could be clarified in later drafting, if necessary.

To conclude, my general point is that the issue of a cancelled declaration is about more than the paperwork. Although, of course, we respect the autonomy of a patient to make their own decision to cancel a declaration—obviously, I would insist that that right should be in the Bill—it nevertheless raises a question in my mind: why is that happening, and what should we expect the patient’s medical team, or others, to do in that circumstance?

[Stephen Kinnock]

The Government have worked with my hon. Friend the Member for Spen Valley on amendments 375 and 376. The amendments require that where the co-ordinating doctor, or any registered practitioner from the person’s GP practice, receives a notification or indication from the person seeking assistance under the Bill that the person wishes to cancel their first or second declaration, the doctor or practitioner must inform the voluntary assisted dying commissioner as soon as practicable. Where a registered practitioner from the person’s GP practice has received a notification or indication from the person to cancel their first or second declaration, they must also inform the co-ordinating doctor. I hope those observations are helpful to the Committee.

--- Later in debate ---

[Daniel Francis]

I welcome my hon. Friend’s acceptance of the amendment, and I think she sees the point behind it. It was meant not to be awkward—I do not think I have been at all awkward during this process—but simply to state that, if there were concerns later, the reason why the proxy was required should be there in a transparent way. I commend amendment 321 to the Committee.

[Danny Kruger]

I am grateful to the hon. Gentleman and I very much support his amendment; it is good to hear that the Bill’s promoter, the hon. Member for Spen Valley, will as well. The hon. Member for Bexleyheath and Crayford has made his points very powerfully, and it is good that we are in agreement.

I also support amendment 431, tabled by the hon. Member for York Central, which would restrict proxies to donees of lasting power of attorney. The point is that somebody who has been through the process of taking on power of attorney has been properly vetted and approved; they are required to demonstrate their fitness for the role and undertake a meaningful duty of care to the person for whom they are a proxy. That strikes me as an appropriate suggestion from the hon. Lady.

Amendment 411, tabled by the hon. Member for Broxtowe, suggests that the phrase

“a person who is of good standing in the community”

should be deleted. I think she is absolutely right to suggest that. I made the point on Second Reading that—

[Kim Leadbeater]

Will the hon. Member give way?

[Danny Kruger]

I think the hon. Lady is about to say that her own amendment addresses that point.

[Kim Leadbeater]

My point was that I think amendment 411 has been withdrawn.

[Danny Kruger]

Is that the case? I apologise.

[The Chair]

I will double check.

[Danny Kruger]

Okay. I am grateful to the hon. Member for Spen Valley, if so. I regret it, because I think amendment 411 had a good suggestion. It would have been my preference if we were just amending the provision, although removing the whole question of a proxy might be the safest thing. Nevertheless, if we are proceeding with the proxy arrangement, it strikes me as dangerous to include a person of good standing in the community. While it sounds like an old-fashioned and sonorous expression, as if it has genuine meaning and recognition, I do not think it is an acknowledged concept and does not appear in English law much, if at all. It obviously begs the question of what on earth it means, and who is to determine who is of good standing.

I labour the point even though the amendment might have been withdrawn, because amendment 473 in the name of the hon. Member for Spen Valley proposes to delete that phrase and give the responsibility for who the proxies could be to the Secretary of State. That is another important instance of a running flaw in the Bill, and particularly the amendments tabled in Committee, which is the transferring of important decisions beyond the Committee and Parliament to the Government and the Minister of the day.

That matters, because we are trying to ensure that when the Bill passes—if it passes—it is safe, but a blank space is being left on the important question of who can determine who the proxies are. The proxies have enormous power to do the paperwork and to answer the questions—to essentially act on behalf of the patient who, in the scenario envisaged, would be silent. It matters who the proxy is.

The decision of the hon. Member for Spen Valley is not to resolve that question here in Committee but to pass it on to a future Minister. My concern is that the same ambiguity or openness that is currently in the Bill about this person of good standing—a serious-sounding but actually vacuous concept—could be replicated in the regulations specified by the Secretary of State.

I am worried about where we are going here. Instead, I wish that we could restrict the proxy to somebody known to the patient, without the inclusion of the person of good standing or, if we are to do without that phrase and imagine that there will be other criteria and other individuals judged appropriate to be the proxy, that we had the will to determine that now. The hon. Member for Spen Valley, working with the Government, may well have concluded that they did not have enough time to come up with such a list or to think through the various complications involved in deciding who the proxy should be. Again, if that was the case, I regret the pace at which we are moving. I do not see why the decision has to be delayed until the Secretary of State comes up with a plan in a couple of years’ time and why it is not being resolved in the Bill now.

[The Chair]

I confirm that amendment 411 has been withdrawn. I see no other Members bobbing; I call the Minister.

--- Later in debate ---

[Stephen Kinnock]

I am not a lawyer, but thankfully I am sitting next to a very eminent and distinguished one—my hon. and learned Friend the Member for Finchley and Golders Green—who has confirmed that everything the hon. Member for East Wiltshire said was correct from a legal standpoint, so I shall leave it at that.

Clause 15(5) of the Bill defines a proxy as

“(a) a person who has known the person making the declaration personally for at least 2 years, or

(b) a person who is of good standing in the community.”

Amendment 473 would remove subsection (b) from the definition of proxy, instead introducing a regulation-making power to specify the persons who may act as proxy. That would avoid any ambiguity around the meaning of a person who is of good standing in the community and retain flexibility to amend the specified list in regulations.

[Danny Kruger]

Will the Minister confirm that the Secretary of State could simply reintroduce that ambiguous term at their own discretion? If they are being given the freedom to decide who can be a proxy, they might decide that it should be a term of equal ambiguity. My right hon. Friend the Member for North West Hampshire is absolutely right that I have great respect for the concept of “standing”; nevertheless, I do not believe that the Government have yet been able to define exactly what that means. Does the Minister agree that there is still the opportunity for ambiguity? We are just leaving it completely blank at this stage and hoping that some future Secretary of State will have more clarity than we do.

[Stephen Kinnock]

I would not want to pre-empt the regulations, because clearly that is the point of the process. If this Bill gets Royal Assent, we then move on to making regulations, and I have confidence in the good offices of parliamentary counsel, legal advice and the drafting process. I absolutely agree with the hon. Gentleman, however, that the purpose of those regulations must be to remove ambiguity, not to increase it. I am confident that the system will produce regulations that address his concern.

--- Later in debate ---

[Kim Leadbeater]

I will speak first to my amendment 473. It is important to be clear that the role of the proxy is very specific and would be used only in a very limited number of cases, where the patient is not able to sign their own name. That is, however, important when we are talking about terminally ill people who may be physically impaired, as my hon. Friend the Member for Bexleyheath and Crayford alluded to.

[Danny Kruger]

I am sorry to interrupt the hon. Lady so soon into her speech. Nevertheless, the clause says that someone can use a proxy when they are unable to sign their name

“by reason of physical impairment, being unable to read or for any other reason”.

Does the hon. Lady acknowledge that that is tantamount to saying that somebody can have a proxy for any reason at all? There is literally no restriction in the clause on the reason for why somebody could have a proxy—anybody could have one.

[Kim Leadbeater]

That is why amendment 321 in the name of my hon. Friend the Member for Bexleyheath and Crayford is really important. We have to put the reason down for why there is a proxy. It depends on personal circumstances and what that patient is going through, so we have to have a bit of flexibility, but they have to be unable to sign their name and they have to explain why they are unable to sign their name.

[Danny Kruger]

I hope that this does not appear pedantic, but we are talking about life and death after all. The patient’s inability to sign their name could be psychological; it is not as if they will have to do a writing test. They simply have to say that they are unable to sign their name, unless the hon. Lady is proposing that there could be some sort of test for that.

I entirely support amendment 321 in the name of the hon. Member for Bexleyheath and Crayford about the proxy being obliged to state the reason why—it is good to finally have the question “Why?” being asked in the Bill. Nevertheless, there is no obligation for anything to be done about that reason; someone could give a reason that would be regarded as irrelevant. I respect the intention behind the amendment, but it does not clarify the point that literally anybody could effectively get a proxy to sign their name, having said to the assessing doctor, “I want my friend to sign for me.”

[Kim Leadbeater]

That is the sort of thing that the doctor would explore with the patient. It would happen in a very limited set of circumstances. We have to accommodate people who are physically impaired as a result of their terminal illness, and we have to include that there are a range of circumstances where this might apply. The proxy is being asked not to make any kind of judgment or assessment, but merely to act as an intermediary for the patient if they are unable to sign for themselves. They would have to explain why they are unable to sign for themselves, and the proxy has to be satisfied that the person understands the nature and effect of the making of the declaration.

I thought long and hard about who should and should not be accepted as a proxy. As always, I try to imagine how it would be seen by someone with a terminal illness. As we know, no two people are the same, nor are their circumstances. The hon. Member for East Wiltshire said that surely it should be done by someone the patient knows. The clause defines a proxy as someone the patient has known for two years, which is an important inclusion, but not everyone might have known for two years a person who they are comfortable asking to undertake that role.

I also appreciate the challenges with the wording

“of good standing in the community”.

I will let the hon. Member for East Wiltshire and the right hon. Member for North West Hampshire fight that out among themselves. I am sure we all have our own version of what that means.

I have explored various options and, contrary to the suggestion of the hon. Member for East Wiltshire, I have spent a huge amount of time on this question, because it is very important. Looking at different lists, there is the list of people who can sign the back of someone’s passport. I do not think that would be appropriate, so I moved away from that. I have also looked at much shorter lists. I do think that this question would be part of a consultation; it is really important to get it right, which is why we must have it as part of a consultation. I am content that having the Secretary of State put it in regulations is the right thing to do.

As I said, I am happy to support amendment 321 in the name of my hon. Friend the Member for Bexleyheath and Crayford. It is a sensible amendment that makes the reasons for the use of the proxy more transparent. If amendment 253 in the name of my hon. Friend the Member for Filton and Bradley Stoke (Claire Hazelgrove) is moved, I am happy to support that too. As the Minister said, a cancellation need not be in writing; it can be made orally or through any other form of communication.

Amendment 321 agreed to.

Amendment made: 473, in clause 15, page 11, line 3, leave out from “person” to end of line and insert

“of a description specified in regulations made by the Secretary of State.”—(Kim Leadbeater.)

This amendment provides that persons of a description specified in regulations (rather than persons “of good standing in the community”) may be proxies.

Amendment made: 253, in clause 15, page 11, line 3, at end insert—

“(6) For the purposes of this section “declaration” includes the cancellation of a declaration.”—(Sean Woodcock.)

This would allow a cancellation of the first or second declaration to be signed by a proxy.

Clause 15, as amended, ordered to stand part of the Bill.

Clause 16

Recording of declarations and statements etc

Amendments made: 209, in clause 16, page 11, line 8, leave out paragraphs (b) and (c) and insert—

“(b) a report about the first assessment of a person is made under section 7;

(c) a report about the second assessment of a person is made under section 8;”.

This amendment is consequential on Amendments 420 and 421.

Amendment 377, in clause 16, page 11, line 12, leave out paragraph (d) and insert—

“(d) a certificate of eligibility has been granted in respect of a person;

(da) a panel has refused to grant such a certificate;”.—(Kim Leadbeater.)

This amendment is consequential on NC21.

--- Later in debate ---

[Kim Leadbeater]

The amendments are designed to streamline the drafting of the Bill. Taken together, they create a new definition of a recordable event, namely those events set out in clause 16(1), where declarations and statements are required at any stage of the process. We can all agree that record keeping is essential, so it is necessary to define the events that should be recorded. I commend the amendments to the Committee.

[Danny Kruger]

I very much respect the hon. Lady’s intention, and I support the amendments. On clause 16, however, I must take the opportunity to express a certain concern. The clause applies if, under subsection (1)(b), the co-ordinating doctor

“refuses to make…a statement”

to be entered into the person’s medical records. That is good but, as I understand it, a statement could be made that complies with the Bill but does not put on record, in relation to subsection (2), which requirements the co-ordinating doctor did not believe were satisfied. We have missed an opportunity to have more clarity about which exact requirements have not been met. There is also the eternal question about the co-ordinating doctor’s reasons for reaching that conclusion. I just note the missed opportunity to be a little safer with the drafting.

My more general point is about the importance of effective record keeping and declaration. I thank the hon. Member for Spen Valley, who throughout the whole Bill process has stressed the importance of good data collection and record keeping, which will be vital so that in later years, if the Bill passes, we can judge whether it is working as intended.

I am concerned about going on the evidence of other countries, which is frequently adduced in support of the Bill, particularly in respect of the absence of evidence of coercion, questions around capacity, proper administration of drugs or the support that patients receive. It is often said that concerns are exaggerated or inappropriate, “because look at what happens in other countries”, but let me briefly run through some evidence from abroad.

The fact is that no other country does adequate record keeping. One ambition of the hon. Member for Spen Valley that I really do share is to have a better system of keeping data than in other countries. In Oregon, the most recent annual report demonstrates a whole series of failures in record keeping. Ingestion status was unknown for 25% of the patients prescribed the drugs, so we do not know whether they took the drugs or what the process was. In 72% of cases, it was unknown whether there were complications; we have been talking about how exaggerated my concerns and those of other Members are about complications, but in 72% of cases in Oregon we do not know. In 30% of cases, it was unknown whether a healthcare provider was present. In 44% of cases, the duration between ingestion and death was unknown.

I very much recognise that the intention of the Bill is not to have those sorts of mistake. Indeed, the intention is to ensure that some of them should be impossible, because a doctor should be present and so on. Nevertheless, there is evidence that in other countries that have inspired the Bill, the data is inadequate. I will give a few more examples.

British Columbia has poor documentation, incomplete assessments, recurrent and excessive delays in reporting. In the debate on the last group of amendments, we spoke about the necessity that a doctor be informed if a declaration is cancelled; I am very concerned that that will not happen quickly and that people could fall through the gaps. That is what happens abroad. We have seen evidence from the former Attorney-General of Victoria, Australia, of all sorts of irregularities, with doctors falsely certifying that patients had signed statements and so on.

[Kim Leadbeater]

I do not know the details of the individual cases that the hon. Member speaks about, but he makes a powerful point and we absolutely agree on the importance of recording and monitoring. I know that he voted against the changes at clause 12, but I hope he gets some reassurance from the changes that the commission would bring in. Having the commission and the panels would ensure robust monitoring and reporting. I hope he agrees that that is a positive step.

[Danny Kruger]

I absolutely recognise that the hon. Lady has every intention of insisting that the system works well, that doctors do their job and that good record keeping happens. My concern throughout has been that we have not been robust enough in ensuring that all of that happens.

A huge amount of faith is being placed in the good professional conduct of doctors. Patient autonomy has been stressed, but it often translates into doctor autonomy. We are relying enormously on doctors doing their job well, and we are giving them significant latitude to do their job properly. As we see in other jurisdictions, particularly when assisted suicide becomes normalised and services are established explicitly to provide assisted suicide, we get into a dangerous area in which adequate documentation and reporting might not happen.

I will conclude with evidence from Canada, which is a very comparable country; it has a slightly different mechanism for delivering assisted suicide, but its legal framework is very similar to ours. The Health and Social Care Committee in our last Parliament received evidence from an academic in Canada, Dr Kotalik, who stated that federal regulations had been

“mandating a collection of data from MAID providers”,

just as the Bill will do. However, he noted that

“those legal and regulatory efforts have yet to produce evidence that the program operates as intended. We have no publicly accessible evidence that the eligibility criteria and safeguards prescribed by law were respected and that the Criminal Code has not been transgressed.”

It is fine for us, in this Committee and in Parliament, to specify that all doctors should do their job properly and that all data should be appropriately collected, transmitted and recorded. Nevertheless, as we all know from our casework, the reality is often one of bureaucratic mistakes being made, albeit not with any ill will. Given the volumes that we may well be dealing with, I think it is appropriate to raise significant concerns about the operation of the Bill and the data collection that we seek.

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[Kim Leadbeater]

I commend the amendment to the Committee.

Amendment 479 agreed to.

Clause 17, as amended, ordered to stand part of the Bill.

Clause 18

Provision of assistance

Amendment made: 378, in clause 18, page 12, line 9, leave out paragraph (a) and insert—

“(a) a certificate of eligibility has been granted in respect of a person,”.—(Kim Leadbeater.)

This amendment is consequential on NC21.

[Danny Kruger]

I beg to move amendment 462, in clause 18, page 12, line 20, at end insert—

“(3A) When providing a substance under subsection (3) the coordinating doctor must explain to the person that they do not have to go ahead and self administer the substance and they may still cancel their declaration.”

[The Chair]

With this it will be convenient to discuss the following:

Amendment 463, in clause 18, page 12, line 34, leave out paragraph (c).

Amendment 497, in clause 18, page 13, line 9, leave out “decides” and insert

“informs the coordinating doctor that they have decided”.

This amendment provides that the duty to remove the approved substance arises on the coordinating doctor being informed that the person has decided not to self-administer the substance.

Amendment 498, in clause 18, page 13, line 10, leave out

“that the substance is not”

and insert

“to believe that the substance will not be”.

This amendment clarifies the circumstances in which the coordinating doctor is under a duty to remove the approved substance from the person.

[Danny Kruger]

This group of amendments contains two sub-groups that I shall deal with separately. Amendment 462, in my name, and amendments 497 and 498, in the name of the hon. Member for Spen Valley, concern the information given at the provision of assistance and decisions around that. My amendment 463 concerns the question of assistance in the final act.

This is a rather sombre moment in the Bill, because it is somewhere in clause 18, between subsection (9)(a) and subsection (9)(a)(i)—between the self-administration and “the person has died”—that the death happens. The amendments are about making sure that we understand what is happening here and whether it is safe.

Amendment 462 would require the doctor to make it clear to the patient at the final moment that they do not have to proceed. Of course, this is clearly the implication of the Bill. We have stressed autonomy all along. Everybody who is helping us to draft the Bill, all colleagues in the House and all doctors understand that of course the patient is not obliged to proceed at this point. The reason for the amendment is to think about the patient: to put ourselves in the mind of the person who has gone a long way down the road, who has summoned multiple professionals to endorse a decision that they have made and who has, we hope, involved their family and other people in their life, all of whom will be aware of what is about to happen and will, we also hope, be supportive of that decision or at least neutral about it.

That person finds themselves suddenly at the moment when the drugs are due to be set up for self-administration, a point that we will come on to. That is the final opportunity that they have to decline to proceed. Throughout the Bill, hurdles and gateways have been introduced through which a patient must proceed. In many respects I do not think them adequate, but it is acknowledged by the framers of the Bill that it is necessary to pass through certain hurdles and, in what might appear to be quite a formulaic way, require the patient to confirm and reconfirm that they have a clear, settled and informed wish.

What we do not have at this vital moment—in a sense, the only moment that matters, because everything up to this point has been preliminary; it is at this point that they step through the final gateway—is an obligation, expectation or requirement for any conversation to take place. The doctor is expected to satisfy himself or herself that the patient

“has a clear, settled and informed wish to end their own life”

and must be prepared to swear to that. Nevertheless, there is no expectation that they will have a conversation. We can pretend, imagine, hope or surmise that some kind of conversation would happen at that point—“Do you want to proceed?” “Yes, I do”—but we are not requiring it.

I raise this point in the clear and certain knowledge that many people do, at that moment, have second thoughts. We know that from the number of people who contemplate and get very close to the act of unassisted suicide and step back, literally, from the brink. I want to insist that there is an opportunity here to step back from the brink, just as our suicide prevention strategy seeks to ensure that at the moment when and in the places where many people tragically do take their own life, on bridges or on Beachy Head, there are signs saying, “Call the Samaritans” or “You are not alone”. I want to specify clearly that this is that moment, rather than it being assumed that the train has left the station and the person is just on it now. I think it would be a helpful amendment.

I cite written evidence from Dr Philippa Youd, writing in a personal capacity:

“I have witnessed ‘post-euthanasia regret’. I was 18 when my mother took her own life due to ‘interminable suffering’. She knew what she was doing—she had tried before. Just before she slipped into a coma, she told me she was sorry and that she regretted it. The inquest therefore deemed her death an ‘open verdict’. It was suicide, but it was suicide that was regretted, despite true intent and interminable suffering”—

and no doubt capacity and a lack of coercion. Dr Youd continues:

“No one can EVER be sure they want to die until the moment of death. They may still change their mind and then it is too late. No one can know what patients will truly face, emotionally and cognitively, at the point of death. I have witnessed firsthand the tragic circumstance of someone changing their mind after choosing to die. There is no peace in that.”

I hope that hon. Members will not consider that this amendment is unnecessary embroidery or that requiring a simple statement to be made is some kind of imposition on the autonomy of doctors or patients. Someone should still be able to turn back and change their mind at this point.

[Kim Leadbeater]

The hon. Gentleman is making a powerful speech, and I thank him for the respectful way in which he is doing so. He has given an example of a very personal story; it is also important to remember the other personal stories we have all heard. We have with us today in the Public Gallery family members who have lost loved ones. Catie’s mum went to Dignitas in Switzerland for an assisted death, and her daughter could not go with her. As a family they have suffered to this day as a result of that experience.

We need to be really careful about the language we use around suicide. We have spoken about this before. The cases we have heard of are not people who want to die. They are people who want to live, but they are terminally ill. We need to be really sensitive to that, having heard so many examples of families who have been through these really difficult situations. But the hon. Gentleman makes a very good point, and I am minded to support his amendment because I think it comes from a good place.

[Danny Kruger]

I am grateful to the hon. Lady. I hear what she has said; we have had this conversation before. I am afraid that I do insist on my right to use the English language accurately. What is proposed in the Bill is a carve-out of the Suicide Act, so I regret to say to the hon. Lady that I will continue to describe it in terms that are appropriate to it. I hope I do so with absolute sympathy and respect for the many families who have suffered from the trauma of seeing their loved ones die badly—loved ones who would have wished for an assisted death under the terms of the Bill. I am very glad to hear that the hon. Lady supports my amendment. I do not think it would be any sort of imposition on families for the doctors to let the patient know at the last moment that they have the opportunity to turn back.

[Sean Woodcock (Banbury) (Lab)]

The hon. Gentleman is making a really powerful speech, and I am minded to support the amendment on the basis that there will be a small but significant group of people who, having gone through the whole process, will feel they have been a burden on the people who have gone to all the effort, through every stage, to get to the end, so if they have doubts at the end, they may be reluctant to change their mind. It will be a very small group, but I do think it is significant. I see it as the re-establishment of autonomy for the patient, which we all believe in; does the hon. Gentleman agree?

[Danny Kruger]

That is absolutely right. We have to think about the no doubt quite turbulent emotions that people will have as they approach the end of their life, and to reiterate their genuine autonomy. They are not on a conveyor belt that they cannot get off until the very last moment—until they have passed through this gateway. The amendment seeks to remind them and, indeed, their families of that. I am afraid we do hear terrible stories of people who have arranged their assisted death: often family members have flown in from abroad, doctors have been summoned and so on, and then they feel they have to proceed because, as the hon. Gentleman says, they feel a burden as it is and do not want to be an annoyance at the end by making everybody wait. I am afraid that is indeed the reason for the amendment. I am pleased to hear that it sounds like it will be accepted, and I am grateful to Members who will support it.

Amendment 463 is the other, more substantial, amendment in my name in this group. It would leave out paragraph (c) of clause 18(6), which says that the doctor can assist the patient

“to ingest or otherwise self-administer the substance.”

Here we are in a lot of difficulty and a grey area. Let me try to unpack the reasons for objecting to paragraph (c). The hon. Member for Spen Valley argued in an interview that there is a “very clear line” between the Bill and euthanasia, which is someone else doing the deed. She said that the act

“has to be the decision of the individual, and it has to be the act of the individual”,

which

“creates that extra level of safeguards and protections”.

I agree with her—it is right that we introduce the additional safeguard of insisting that the patient performs the final act themselves.

I recognise that there is a distinction between euthanasia and assisted suicide, and I support the hon. Lady’s attempt to insist on that distinction in the law. It is another safeguard. But the fact is that there is a blurred line between the two, and I can also understand why many people object to the exclusion of euthanasia—of the fatal act being administered by other people. A doctor from Canada said it was inherently ableist to require the patient to self-administer, and I think that is unarguable. If that is the case, the logical provision would be to enable euthanasia, if one believes in the autonomy of the patient.

I am afraid my strong belief is that the reason why euthanasia has not been proposed in the Bill or by the campaign, which has been led by an organisation that used to call itself the Voluntary Euthanasia Society, is because the campaign has concluded that such a Bill would not pass Parliament and believes—I think correctly—that Members of Parliament and members of the public would object to euthanasia. But the logic of the Bill and of the campaign is actually for euthanasia, if one believes genuinely in autonomy, in equal rights and in not discriminating against people who are physically unable to perform the act themselves.

Despite my efforts, hon. Members have not been able to conceptualise the difference between withdrawing a medical treatment that affects a particular medical condition on the one hand, and administering drugs that annihilate the person on the other. There is a meaningful and important difference between those two things. One is a person declining to use a shield, and the other is the person using a sword against themselves. I think there is a difference there, and I regret that colleagues do not see it.

Where I do not see a difference, however, is between a person injecting themselves and asking someone else to inject them. There are two versions of the death of Saul in the Bible. I think this is the only reference to the Bible that I will make in this whole debate, and I make it partly to show that there is an inconsistency in the Bible—there is not a single Biblical view of these matters. In one account of the death of Saul, having been defeated by the Philistines, he asks his servant to run him through with his sword, but his servant refuses, so he falls on his own sword and kills himself. In the other version, he gets a passing soldier to run him through—to kill him.

To me it does not matter: the inconsistency in the story is interesting historically, but conceptually, logically and morally I do not see the difference. Whether you fall on your own sword or ask someone else to do it to you, it is still a sword, you are still actioning it and you are still responsible, if we recognise that the individual has autonomy. But there is a practical difference. We are talking about assistance to die and the role of another person who supports your decision and helps you to fulfil it, but that results in an obscuring of the practical difference. In practice, as we see in clause 18(6), the assistant comes very close to euthanasia. The role of the assistant, in my view, is closer to that of the soldier who kills Saul than of the servant who refused to do it.

[Kim Leadbeater]

The hon. Member is making an interesting philosophical point with his biblical references. I think the point he may be making is that there might not be any difference for the individual, as the result is sadly the same, but I put it to him that there is quite a significant difference for the other person. If we think about the autonomy of the medical professionals we ask to be involved in the process, there is a strong argument that it would be very different for them to be more involved in the process. Does that makes sense?

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[Danny Kruger]

I am grateful—I really do thank the hon. Lady, because the effect of this process on the medical professionals who will be involved is a very important consideration, and one that we have perhaps not given enough attention to. That is why we will come to the conscience clause in due course, although we have discussed it a little already. The hon. Lady is absolutely right that there is a difference for the medics in the extent to which they are involved in the administration of the death. I am afraid I do not see a major moral difference between providing the wherewithal—setting things up for, or indeed helping, the patients to ingest or otherwise self-administer the fatal drug—and people performing the act themselves. The distinction is very obscure; there is a significant grey area there.

On the hon. Lady’s point about appropriate consideration of the feelings of the medical profession, if she believes in doctor autonomy, she should believe that doctors ought to have the autonomy to decide for themselves whether to perform euthanasia, if euthanasia were legal. That is what happens in other countries. In Canada, doctors can decline to take part, or they can participate.

Given the question of autonomy, it is worth noting that in countries where euthanasia is legal, it is the overwhelming choice of the patients, as I think it would be for me. If I were facing that terrible moment and choice—we will come in due course to the question of the drugs involved and the process of taking them, but swallowing all these pills is not a pleasant process—it would be far easier, more humane and less painful for a doctor to administer the drugs intravenously. I visited Canada and met a doctor who had been responsible for over 300 deaths, which she herself has performed, because that is the overwhelming choice of the patients. As I am sure the hon. Lady would agree, that doctor is acting with full professional discretion and autonomy.

To go back to my point, I am afraid this is one of the impossible dilemmas that the Bill and the whole concept of assisted dying set up: whether we allow the doctor to do it to us. My concern is that if the stress on self-administration is genuinely felt—not, as I cynically believe, because this is the only way to get assisted dying through the House of Commons—because the Bill’s authors recognise the need to be absolutely sure that the act is voluntary, and if the reason why we insist on self-administration is because we want to be sure that the act is voluntary, what does that say about all the so-called safeguards that exist up to this point? We have been told that those safeguards are sufficient to ensure that we have absolute confidence about the person’s clear and settled wish.

If we are sure that people at this stage in the process have a settled, informed and free wish to end their lives, why should they not be able to ask a doctor to do it to them? The only answer to that question can be that we do not genuinely believe that we are completely sure. We want, subsequent to death, to be sure—in terms of our own moral propriety and sense of amour-propre—that those people did it themselves. It was not our choice; it was not us doing it to them—they did it.

[Kit Malthouse]

I am a little confused by my hon. Friend’s logic. He has literally just proposed an amendment for the doctor to ask, at the last, whether the person still wants to proceed. Surely self-administration is the ultimate act of consent, which his own amendment requires a doctor to establish right at the last moment.

--- Later in debate ---

[Danny Kruger]

My right hon. Friend is absolutely right. I support the distinction between self-administration and euthanasia. I am in favour of all possible safeguards and every possible opportunity to give the patient the chance to step back from the brink. The point I am making is that I do not recognise the logic of the distinction that the Bill insists on. Indeed, in the provision that I am concerned about, subsection (6), the distinction in fact does not apply.

If we believe in autonomy and in giving people the opportunity for assisted suicide, we are, naturally enough, concerned that that should be available to people who cannot physically perform the act themselves. I am not trying to argue in favour of euthanasia; I am saying that we will get to euthanasia if we let the Bill through. Even in the Bill as it stands, we are halfway to euthanasia with subsection (6). I am confident that, in due course, the campaign for it will grow. In fact, it already exists: people already object to the restrictions implied in the Bill. The campaign will grow to widen the opportunity for assistance to ensure that we can have physician-administered suicide, as happens in Canada and elsewhere, very logically. Once we have crossed the Rubicon of assisted death, it is a straight road to euthanasia. [Interruption.] I am sorry that the hon. Member for Stroud is amused.

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[Danny Kruger]

Once again, we are in an extraordinary no man’s land between medical treatment and something else that we cannot find a word for. The hon. Gentleman is absolutely right. Of course, it is appropriate in medical treatment for a nurse or doctor to assist in the administration of a treatment. As he suggests, if the person found it difficult to raise a cup to their lips, the nurse would help them. Indeed, if they found it difficult to perform an injection, it would be expected that that would be done by the nurse or doctor anyway. But here we are setting up a strange new method of administering a so-called treatment in which the patient has to perform the physical act themselves.

It is apparent from the clause that it is very unclear what assistance actually looks like, so yes, I absolutely imagine that if the patient were struggling to raise the cup to their lips, a nurse or doctor who was present at the final act in an assisted suicide would help them to do so. Similarly, if the patient were finding it difficult to put their finger on the syringe, it would be appropriate—normally, one would expect—for the medical professional to lift the patient’s finger and put it in the right place. What happens next? Do they then apply a little pressure if the patient is finding it difficult to depress the plunger on the syringe? If the cup is at the lips, do they tip it up and let gravity take its course? These very complicated questions about where assistance ends and autonomy begins are, I am afraid to say, impossible to specify in the Act; therefore, it is apparent that we have a grey area.

I conclude with some evidence that we received from Iain Brassington, professor of applied and legal philosophy at Manchester University. He says:

“how are we to determine how the ‘final act’ of self-administration is to be differentiated from the penultimate act, in which the doctor may assist? How would helping a patient lift the cup to her lips be distinguished from helping her ingest its contents?”—

the hon. Member for Ashford referred to that. He goes on to say that

“the definition of the ‘final act’ is unclear, especially granted the wording of”

subsection (6)(c), and:

“The proposed law says that a doctor may not administer a substance with the intention of causing death, but also that a doctor may help a person self-administer. But how should we draw the boundary between helping a person self-administer, and playing a role in administration?”

I come to the penultimate point—not the final act—of my speech. There is some odd phrasing in subsection (7), and I wonder whether the hon. Member for Spen Valley or the Minister can help to parse the English. It says that

“the decision to self-administer the approved substance and the final act of doing so must be taken by the person”.

We understand about the decision being taken by the person, but the phrasing is that the final act “must be taken” by the person. I am not familiar with that construction. Does one take an act? Is that English? You perform an act—an act is not taken, it is done, by a person acting autonomously. The question of whether this is an active or a passive concept runs to the heart of my concern about the clause, and we need to think about redrafting, at least in deference to the English language.

Somewhere in this clause there is a magic moment when assistance gives way to autonomy, and the penultimate act by the doctor yields to the final act, which is supposed to be by the patient. We cannot tell when the responsibility for the action passes from one to the other. In proper medicine it does not matter because the medic works with the patient, but here it does matter. We are insisting that there is a difference between a doctor setting up a death, and the patient performing the action of suicide.

I will end by referencing the case of R v. Kennedy in 2007, a case on which Lord Bingham opined, about the culpability of someone who died from a heroin overdose. Was the person who gave him the drugs and tied the tourniquet around his arm responsible? Was it murder, or indeed assisted suicide? The judge decided that it was not, but made this point:

“It is possible to imagine factual scenarios in which two people could properly be regarded as acting together to administer an injection.”

Given that ruling, we are in a world of difficulty with the suggestion that it is legally possible for a doctor to assist a patient to ingest or otherwise self-administer. To assist someone to self-administer is tantamount to administering. I welcome suggestions from other Members, the Minister, or the hon. Member for Spen Valley about whether it is possible to provide guidance that gives greater clarity on what the clause means, or whether subsequent amendments will help to resolve the problems that I have, but I am afraid I do not think it will be possible to make an adequate distinction between assisted suicide on the one hand—in which full responsibility, not just for the decision but for the performance, rests with the patient—and euthanasia on the other. I do not think there is an adequate logical difference, and the practical difference we are attempting to enshrine here will be very quickly obscured.

[Naz Shah]

I thank the hon. Member for East Wiltshire for his amendment, and for speaking in the powerful, sensitive way that he did. I also thank my hon. Friends the Members for Spen Valley and for Banbury, who made interventions.

I did not intend to speak to this amendment, but having heard the hon. Member for East Wiltshire speak so powerfully and sensitively, it is important for me to share a few things. My hon. Friend the Member for Spen Valley has said a couple of times that the difference between people who commit suicide and those who will take this route is that the patients have been given less than six months to live, and that was not a choice. I was a Samaritan for years, because I had two failed suicide attempts in my early years, and since then I have battled with mental health demons all my life because of my experiences. To suggest that there is a difference between someone who gets a terminal illness and wants to take this act and people who want to commit suicide, and to suggest that they are doing it out of choice, is wrong. I felt really emotional when that exchange was happening. The reason why I think it is wrong is that, at the time that I wanted to commit suicide, I did not feel that I had a choice. I could not see a way out.

When I was on those Samaritans phonelines, speaking to people who rang in to unpick their feelings about what was driving them to feel suicidal in that moment, it was not because they want to die, but because they were in circumstances that drove them to feel that they had no option but to commit suicide. In some instances, it takes an amount of courage and bravery to even contemplate that option. To diminish that, which I feel is what has, intentionally or unintentionally, happened on occasion, is really wrong, because I have been there, and it was not easy and it was not because I wanted to die.

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[Danny Kruger]

My point is that it is very difficult to draw a line here. I recognise the scenario that my hon. Friend raises: why should a nurse not be able to hold a straw for a person to drink from? I might say that should be acceptable; however, I do not think it should be acceptable for the nurse to tip the pills into the patient’s mouth. Does he think that scenario would be acceptable? Or to give another one, would it be acceptable to actively provide force on top of a patient’s finger to press a syringe? Would he regard that as acceptable assistance?

[Dr Shastri-Hurst]

That is why clause 18(7) is so important: the final act must be undertaken by the person seeking an assisted death. The example my hon. Friend gives of tipping tablets into a mouth is a final act. Pushing a syringe is a final act. There is a significant distinction between an individual or practitioner holding a cup with a straw and the person seeking an assisted death moving their mouth towards the straw, sucking from it and imbibing the substance and the passive act of a substance being raised to that individual’s lips and poured in without any movement by the individual seeking an assisted death themselves.

[Danny Kruger]

When we talk about this in future debates, it might be appropriate for this conversation to be referenced. I think my hon. Friend is suggesting that it should be acceptable, and that assisted death would be legal, as long as the patient moved their head towards the straw and cup, and that it would be illegal, according to my hon. Friend’s definition, were a doctor applying a cup to a patient’s lips and the drugs fell in by gravity. Is that right? Is that how judges in future should determine whether assistance has crossed the line?

[Dr Shastri-Hurst]

It is very clear from subsection (7) that this must be an active step taken by the individual. There is a risk that we go down a rabbit hole in terms of—[Interruption.] I am sure my hon. Friend would like me to finish my point. We risk going down a rabbit hole in drawing examples. I raised the example of a cup, but of course there are much wider assistive technologies that can be used and are used in different jurisdictions. I gave the example to illustrate the point that this is an active act, not a passive act.

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[Dr Shastri-Hurst]

My right hon. Friend makes an important and powerful point. I think there is a consensus among the Committee that there is no desire for people to take this ultimate step at an earlier stage than is absolutely necessary for them. My very real fear is that, were we to adopt this amendment, we would bring forward that point of decision.

[Danny Kruger]

The logic of that argument is to allow physician-administered suicide, because there will be a point at which people are physically unable to perform the act but have capacity, and their autonomy should be respected—

[The Chair]

Order.

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

Danny Kruger Excerpts

Committee stage
Wednesday 19th March 2025 Public Bill Committees

[Lewis Atkinson]

I am afraid I cannot agree. The situation that I set out, in which a hospice makes an organisational decision that it does not wish to provide assisted dying services, is entirely legitimate under the Bill, as drafted. I do not, however, think it should screen which applicants have a certain view, which would be legal under the amendment. The example that the hon. Lady gives is rather different, because it relates to a particular protected characteristic. I am not an expert in the area, so maybe colleagues can help me, but this relates to specific services.

[Danny Kruger (East Wiltshire) (Con)]

Will the hon. Gentleman give way?

[Lewis Atkinson]

I will move on, because we have started slightly late and I am not sure that we are going to add anything on this point.

There is a fundamental distinction between providing assistance and being the location in which people may self-administer an assisted death. In his speech on new clause 22, the hon. Member for East Wiltshire somewhat overlapped those two things, if I may say so. Having established that a hospice would be under no obligation to provide, an individual would clearly not be able to turn up and say, “Your staff must help me to do this.” However, that is different from a situation in which someone living in their own private home— that might include a room in a care home or sheltered accommodation—decides that they want their healthcare team to carry out entirely lawful and appropriate activities under the Bill.

I therefore cannot agree with new clause 22. People are legally resident in these premises. They are registered to vote. In some cases, such as in warden-provided accommodation, they have a lease. It is not a landlord in absentia. I know that the hon. Gentleman has provided an opt-out for some situations, but what about warden and supported housing situations? We would not accept operators or owners policing what lawful activities should happen in someone’s own home within that environment. That is entirely different from the situation that the hon. Gentleman sketched out, in which everyone has to be involved. There would be no obligation whatever on any staff of that establishment to participate in an ancillary manner or otherwise, but in a private residence, such as someone’s room in a care home, we cannot allow that to be prohibited.

[Danny Kruger]

As always, the hon. Gentleman is making a helpful and intelligent speech, and I appreciate the distinction that he is trying to draw. There is a lot to say, and I will respond more when I wind up, but does he think that it would be an acceptable condition of a lease—or whatever the living arrangement is for residents of sheltered accommodation or shared places—for the operator to specify that no assisted dying shall be performed in those premises, and for that to be a condition of coming to live there?

--- Later in debate ---

[Naz Shah]

If we are talking about employers and employees, not people who are accessing the service as service users, I hope the scenario to which my hon. Friend the Member for Penistone and Stocksbridge referred would not happen.

[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.

[Naz Shah]

I thank the hon. Member. What he said is really helpful.

I want to come back to the issue of opioids. As someone who suffers from chronic pain, my understanding is that I have a choice over whether I take opioids or other medication. So when people are allergic to opioids, they can potentially access other medication for pain relief.

--- Later in debate ---

[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.

--- Later in debate ---

These are sensitive issues, and there is a range of views across the various professions involved in end of life care. Hospice UK recognises that, which is why, representing its members’ different views, its formal position is that it has no collective view. It recognises that staff, volunteers and hospice trustees will look at the Bill’s implications in a variety of ways, and we should give them the time and space to do so, rather than the Bill’s dictating what they should or should not do. We probably all have hospices in our constituencies and local areas, which we visit and have good relationships with, and we probably all have family and friends who have benefited from the care of those amazing places—I know I have. That local dialogue is important—almost as important as what goes into this legislation.

[Danny Kruger]

Obviously, the sentiment that we should work with hospices and let them set their own policy is absolutely right—that is the purpose of the amendment—but does the hon. Lady acknowledge that the Minister just said that if any hospice attempts to prevent assisted dying from taking place on their premises, there will be human rights claims? They can have all the consultations and conversations they want, but unless the Bill specifies that they are allowed to opt out, they will be forced to do it.

[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.

--- Later in debate ---

[Kim Leadbeater]

It is a good point. My understanding—the Minister might correct me—is that pharmacists currently are within the definition of health professionals, but if they are not, that is an important point, which would be covered by making the change to ensure that no one is under any duty. However, I will definitely check that.

Mr Porter also said:

“hospices evolved out of the community. They exist because communities wanted better deaths. In the end, it is the job of institutions to evolve to fit the values and laws of society as they evolve, rather than vice versa.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 202, Q264.]

The polling on assisted dying shows significant public support for a change in the law, which is one of the main reasons we are here discussing the issue today. The latest figures from the British social attitudes survey, published just this week by the National Centre for Social Research, show that support at 79%, which is unchanged or slightly up on a decade ago. Although I cannot support these amendments, this is an important debate. I think we have conducted ourselves extremely well over the past 24 hours. I think it is important that we continue the debate respectfully and sensitively.

[Danny Kruger]

I, too, am very grateful to you for rescuing us, Ms McVey; thank you. I also thank the hon. Member for Spen Valley: it is nice to be commended for our good conduct, so I am grateful for that. This has been a very interesting debate, and I thank all hon. Members for participating. I appreciate the fact that we have made some progress in understanding each other and potentially improving the Bill, although I regret the lack of support from the Government Front Bench for the amendments that I have tabled.

Let me just refresh memories on the purpose of my amendments. The Bill promoter has tabled amendments to clauses 24 and 25, which we will come to and which keep the phrase

“providing assistance to a person in accordance with this Act”,

but add to it these two other phrases:

“performing any other function under that Act”

and

“assisting a person seeking to end their own life in accordance with that Act”.

Those amendments expand the protection from criminal and civil liability. They mean that performing any other function under the Act and assisting a person seeking to end their own life, in connection with the doing of anything under the Act, are both protected from criminal and civil liability. But the hon. Lady has not tabled a similar amendment to clause 23, and there is a real risk. The British Medical Association, the Royal Pharmaceutical Society and the Royal College of Nursing, as I mentioned yesterday, have all warned that the protection of conscience clause is limited solely to the final act, rather than applying to all functions under the Act. I appreciate that the hon. Lady expresses a commitment to trying to ensure that we do cover everybody and all appropriate actions and activities that take place, but I suggest that that is what my amendment would do.

In response to the objections to the amendment, I appreciate the sudden interest in precision in drafting.

[Kim Leadbeater]

It is not sudden!

[Danny Kruger]

Well, every time that those on my side of the debate raise detailed, particular points we are told, “Oh, the spirit of the text is clear. We’ll sort that out later. It’ll come in guidance.” We are told that we should not be nitpicking, embroidering and so on. Anyway, I appreciate the attention to detail, and I want to respond to some of the points.

With respect, the Minister made a pretty tendentious suggestion that a doctor could opt in to assisted dying and take part in some of the procedures but then suddenly decide to neglect performing others, and that that would not be negligent. I cannot conceive of any court or tribunal conceding that it would not be negligent not to fulfil the obligations under the Act once the procedure has begun—once the doctor has made commitments and already undertaken activities to progress an assisted dying case.

The hon. Member for Luton South and South Bedfordshire objected on the grounds that the amendment might give a gardener or cleaner the right to opt out. Proposed new subsection (1B)(b) of clause 23 actually makes it clear that “ancillary” activities are not protected by the conscience clause, so the gardener would not be off the hook—under the amendment, the gardener would still have to mow the lawn.

I recognise that the drafting might not be perfect, but I emphasise that the PBL “Guide to Making Legislation”—by the secretariat to the Parliamentary Business and Legislation Cabinet Committee—makes it clear that Government should not object to Back-Bench amendments on drafting grounds. If there are issues with particular phrasing that cause the Government or the promoter concern, that can be addressed subsequently, so I regret it if the Minister is using drafting issues to justify a refusal to support these amendments.

On new clause 22 and the issue of premises, which we have discussed very interestingly, a couple of objections have been raised. The first relates to shared ownership schemes, which we are all familiar with, particularly for elderly people. The answer is simple. The corporate owner under a shared ownership scheme is not in occupation. Being in occupation has a particular meaning in land law, and it is not the case here that a tenant genuinely in occupation of their own premises could somehow be denied their right to have an assisted death in their own home because of the freehold arrangement of the premises they occupy.

I am grateful for the indication given by Members, particularly my right hon. Friend the Member for North West Hampshire, that there may well be circumstances in which it is appropriate for particular premises to opt out of the obligation to facilitate assisted dying, so that a particular institution would have the right to deny permission for assisted death.

[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.

[Liz Saville Roberts (Dwyfor Meirionnydd) (PC)]

We should acknowledge the reasons that people go into residential and nursing care homes. They go into them because they need day-to-day help to live. Would the hon. Gentleman reconsider what he has just said? It seems to fundamentally discriminate between people who are able to live at home, have families or carers around them and can operate in that way and people who need to go into residential, and particularly nursing, homes.

[Danny Kruger]

The right hon. Lady clarifies the point very well. I concede—that is right. When someone goes to live in a care home, they yield, by necessity, a whole set of freedoms that one has in one’s own home. That is the consequence of the stage of life they are at, the conditions they have, and indeed their own choice to live in that particular care home.

[Liz Saville Roberts]

They might not have one.

[Danny Kruger]

I appreciate that—there might be very little choice or no alternative. I am speaking in terms of the reality of life. We can do everything we can through the law to obviate reality—to give people as much autonomy as possible, even though they are very dependent on other people. That is why it is so important to consider the autonomy of the elderly, the frail and people with disabilities or who are ill. They require other people to give them what fully healthy and able-bodied people are able to do for themselves. I recognise that I am suggesting that somebody who lives in a care home would not have the same freedom of action as somebody living in their own home.

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

Danny Kruger Excerpts

Committee stage
Wednesday 19th March 2025 Public Bill Committees

[The Chair]

I remind the Committee that with this we are discussing the following:

Amendment 483, in clause 23, page 15, line 5, after “assistance” insert

“, or in any activity closely related to the provision of assistance,”.

This amendment would widen 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 the Act.

Amendment 484, in clause 23, page 15, line 8, after “Act” insert

“, or in any activity closely related to the provision of assistance under this Act,”.

Amendment 441, in clause 23, page 15, line 9, at end insert—

“(3) There is no obligation on any care home or hospice regulated by the Care Quality Commission or the Care Inspectorate Wales to permit the provision of assistance under this Act on their premises.”

This amendment prevents there being any obligation on a care home or hospice which is regulated in England or Wales to permit the provision of assistance under the Act on their premises.

Amendment 481, in clause 23, page 15, line 9, at end insert—

“(3) Nothing in subsection (2)—

(a) prevents an employer who has chosen not to participate in the provision of assistance in accordance with this Act from prohibiting their employees from providing such assistance in the course of their employment with that employer, or

(b) prevents an employer from specifying occupational requirements in relation to the provision of assistance in accordance with this Act in accordance with Schedule 9 of the Equality Act when hiring employees.”

This amendment ensures that employees cannot provide assisted dying against the wishes of their employers and that employers can still rely, in appropriate cases, on the occupational requirements of the Equality Act to either require employees to provide or not to provide assisted dying.

New clause 22—No obligation for occupiers and operators of premises—

“(1) Any individual, business, organisation, or association who occupies or operates premises has the right to refuse to permit the self-administration of an approved substance on their premises.

(2) Nothing in subsection (1) confers any right on anyone with an interest in the land but who is not occupying or operating those premises.”

This new clause would mean that the owners or occupiers of premises — but not landlords not currently in occupation — are not obliged to permit the self-administration of approved substances on their premises.

New clause 23—No detriment for care home or hospice not providing assistance—

“(1) No regulated care home or hospice shall be subject to any detriment by a public authority as a result of not—

(a) providing assistance in accordance with this Act, or

(b) permitting such assistance to take place on their premises.

(2) No funding given by a public authority to a regulated care home or hospice can be conditional on that care home or hospice—

(a) providing assistance in accordance with this Act, or

(b) permitting such assistance to take place on their premises.”

This new clause would mean that regulated care homes and hospices cannot be subject to any detriment for not providing or permitting assistance in accordance with this Act, and that their funding cannot be conditional on them providing or permitting such assistance.

Clause stand part.

[Danny Kruger (East Wiltshire) (Con)]

I was just concluding my remarks on the amendment. I will quickly finish responding to the hon. Member for Spen Valley and others, who suggested that it would be improper to deny people living in a care home, hospice setting or other communal environment the right and opportunity to request assisted dying. I was suggesting that that right needs to be tempered by an acknowledgment that they do not live there alone, and that there are also rights, properly held, by the occupier of the premises, the individual’s neighbours and others.

My concern is that, just as suicide itself is contagious, so the practice of assisted suicide will have social ramifications. We fully recognise that, if the Bill is passed, people will have the absolute right to request the service in their own home, but when someone is living among others, that right needs to be tempered by the consideration that the occupier should ultimately decide whether he or she is prepared to allow the practice to take place on his or her premises.

Some hon. Members suggested that, if an institution receives public funding, it would be appropriate for it to be obligated to deliver the service. I am concerned about the implication of that, which might be that institutions that did not wish to provide or facilitate assisted suicide but did receive public money, for instance care homes or hospices, would be at risk of losing that money—essentially being defunded—on the grounds of their conscientious objection to participating in assisted dying. I would be grateful if the hon. Member for Spen Valley or Ministers would confirm that it is not their intention to penalise bodies that do not deliver assisted dying by withdrawing public money.

On the impact on staff, I am grateful to the hon. Lady for acknowledging that we might need to tighten the Bill to ensure that it is clear that people will not be required to participate in any stage of the process of assisted dying, and not just in the actual provision of assistance towards the final act. Nevertheless, my concern is that if we do not give institutions the right to opt out of provision, there will be an exodus of staff who object to being involved in any way with, or working for an institution that facilitates, assisted dying, as has happened in other jurisdictions where assisted suicide is legal.

I point particularly to evidence we heard from Australia. We were told that, in consequence of assisted dying being legalised in Australian states, there was an exodus of workers from the healthcare system—nurses and others—and the social care system. It was therefore no coincidence when one of the Australian witnesses who supports assisted suicide declared breezily that, although there were significant objections among the care workforce to the introduction of assisted dying when the law was first debated, five years later there was overwhelming support for assisted dying among them. Well, that is no surprise, because all the objectors had left, and I am afraid that is what we will see here.

A comparison would be the exodus of care workers that we saw after the last Government mandated covid vaccination. Some 40,000 care workers left their jobs rather than accept compulsory vaccination. If they were prepared to do that on those grounds, I fear we might see a similar phenomenon if we mandate that institutions facilitate assisted dying.

[Lewis Atkinson (Sunderland Central) (Lab)]

May I check that the hon. Member’s understanding is the same as mine—that nothing in the Bill compels an organisation to participate in the way that he describes?

[Danny Kruger]

No, I am afraid I do not concede that. At the moment, it is not apparent from the Bill or the amendments that have been accepted that an organisation would be enabled to decline to facilitate the provision of assisted dying. No organisation will be compelled to do so, but if a resident were to request assisted dying in their care home, my understanding is that the care home would be obliged to facilitate it.

It might well not be the intention behind the Bill, because I know that the hon. Member for Spen Valley and Members who agree with her recognise the importance of a conscience exception; they have been very clear on that, and I am grateful to them. Nevertheless, my concern is that on human rights grounds, as we have heard from the Minister, the likelihood is that there would be a claim on behalf of an applicant against the institution they reside in that assisted suicide must be provided to them in that place. I am afraid the Bill at the moment does not give an adequate exemption to institutions.

[Lewis Atkinson]

Does the hon. Member accept the distinction that I made between an organisation choosing to provide assisted dying services and the instance he outlined of this being done in someone’s home that happens to be a care home? They are entirely different points, and I fear that, particularly with regard to hospices, he is conflating the two.

[Danny Kruger]

I am conflating the two because they are conflated in reality. A care home where somebody lives is a residence, but it is also a community, a facility and a place where professionals work to support that individual. A clear demarcation between their living arrangements and the support they receive from the institution they live in does not exist in reality. That is why they are living there—because that distinction does not apply in their particular case. They require the support and help of the workers in the place where they live.

I am afraid it is not enough simply to say, “This is their home, and they should have exactly the same rights and freedoms as they would have if they were living alone in their own flat or house.” We have to recognise the reality of the situation, which is that they are living in a community, and what happens in the community affects them all. That is the nature of communal living. This is not individualised healthcare in the way that the hon. Gentleman imagines it is, and that is fundamentally our point of difference. This is separate or adjacent to healthcare, and it is delivered, by definition, by somebody else. By virtue of the Bill, it would have a separate regulatory environment to other healthcare treatments. Of necessity, it should have an appropriate legal framework to protect other people who are impacted by assisted death in a communal setting. That is my crucial point: if someone is living in a communal setting, what they do affects their neighbours.

[Jake Richards (Rother Valley) (Lab)]

Does the hon. Gentleman appreciate that, although this is different from the healthcare services we currently have, we have a legal framework that deals with many of these conflicting issues as and when they arise in lots of different circumstances that are not completely adjacent to these?

[Danny Kruger]

I do not know what those might be, but I would be interested to hear. That might well be the case. I am afraid that no hard-and-fast rules can be clearly applied here; or, rather, we have to apply hard-and-fast rules in the knowledge of the grey areas, the exceptions and the situations in which we might feel that the law is unjust in particular cases. We have heard examples of that, such as the evidence about the lady in Australia cited earlier by the hon. Member for Spen Valley. I can well imagine the distress involved if someone suddenly finds themselves in an institution that does not permit an assisted death, but they want one and are in their last days.

The alternative, however, is a different blanket rule. If we were to have a blanket rule that we can do an assisted death anywhere—that is one situation—there would be significant knock-on effects. Serious moral injury would be suffered by other professionals and residents. I recognise that my amendment could lead to someone having to relocate if they want to have an assisted death—I am sorry for that—but I think that we have to draw the line in a way that makes most sense.

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

It would be interesting, if my hon. Friend’s amendments go through, to see the series of plebiscites taking place in care homes and communal situations across the country as to what the residents do and do not want, presumably by a majority. He asserted that there had been a mass exodus of healthcare workers when VAD came in, but I am struggling to find any evidence to support that claim. In fact, the evidence seems to say that that is not the case. Although there have been some resignations, that has largely been because of pay and conditions, as one might expect.

[Danny Kruger]

My right hon. Friend seems hung up on this suggestion that there needs to be a plebiscite or communal decision making—some kind of citizens’ jury. I am not suggesting that for one moment. In fact, I am sure that I have said explicitly that what I want, and what the amendment would enable, is that the owner or occupier, who would probably be an individual or a board of directors, would decide what happens. If they are a decent, compassionate organisation, they might well consult residents—in fact, I would very much expect that to happen if they are doing their job properly—but I am talking about the importance of communal living; and the fact is that a communal living arrangement has leadership. The residents have signed terms and conditions, in a contract, under which they have agreed to abide by certain rules of the house. My suggestion is that if the charity, company or organisation that is managing a care home wants to stipulate that there shall be no provision of assisted dying in that care home, they should have the right to do so. I hope my right hon. Friend would acknowledge that that is consistent with English property rights.

On my right hon. Friend’s second point, I am grateful to him and he might well be right. I am happy to consult my evidence pack, which I do not have at my fingertips, about the effect on the Australian workforce in consequence of the introduction of assisted dying. My memory is that we heard such evidence, or had it submitted to us in written form—his knowledge of the 500 submissions might be better than mine. Let us check and we will have it out, perhaps on social media; I know how much he enjoys those forums.

Question put, That the amendment be made.

--- Later in debate ---

Under clause 26, coercing or pressuring a person into an assisted death is a criminal offence, and rightly so. There has, however, been much debate on whether undue influence and encouragement are also covered. The Minister advised previously that undue influence is covered, and I seem to recall that encouragement could be covered as well. If that is correct, we would have the sloppy situation in which encouragement could be a criminal offence both under the Bill and under the Suicide Act. It would be really helpful if the Minister set out the position clearly on the point, to make sure that we do not inadvertently end up in that situation. I imagine that best practice is to have only one criminal liability in one Act or the other, if it is appropriate at all.

[Danny Kruger]

It is an honour to follow my hon. Friend the Member for Reigate; I very much agree with the points that she made, and I hope that Ministers will respond. I will try not to repeat her arguments.

The hon. Member for Spen Valley says that clause 24 is, in a sense, the heart of the Bill. I agree. Without the clause the Bill would be ineffective, because the service that we are proposing to legalise would be illegal. We have heard many objections to the term “assisted suicide”, but the necessity of the clause exposes the fact that what is being legalised, at least in part, is assisted suicide. Calling it assisted suicide is therefore not improper; it is simply using the correct terminology, as I believe we should in this place. That is particularly important because the use of the euphemism “assisted dying” masks what this is really about and what the Bill would actually legalise: that somebody could help somebody else to commit suicide.

It is no surprise that the euphemism is deployed, because support for what is called assisted dying is driven in part by a failure to realise what it actually is and what the words mean. I cite a 2024 Nuffield Council on Bioethics survey of the public, which found that 39% of people think that assisted dying means withdrawing life support, 19% think that it means providing people who are dying with drugs that relieve symptoms of pain or suffering, and 13% think that it means providing hospice care, all of which is legal currently and is good medical practice.

[Lewis Atkinson]

The hon. Gentleman says that he is clear that those actions are assisting suicide and that he thinks that they are illegal. Is it right that members of the public, in the instance to which my hon. Friend the Member for Spen Valley referred, be investigated by the police on their return from trips to Switzerland?

[Danny Kruger]

Let me come to the question of investigation by the police in due course, but I am not sure that the hon. Gentleman heard me clearly. I was not talking about offences that I think are rightly criminal; I was talking about offences that are not offences at all. Providing hospice care, helping people to relieve symptoms of pain or suffering and withdrawing life support are all perfectly permitted and legal in our system. The issue is that a significant proportion of the public think that those activities are what assisted dying entails. I do, however, recognise the point and the power of the testimony recited by the hon. Member for Spen Valley, to which I will come on in due course.

I understand that in order to make the Bill effective, an exception must be made to section 2 of the Suicide Act. Section 1 says that someone is allowed to commit suicide; section 2 says that one cannot help somebody else to do so. I agree that such an exception is necessary if we are to pass the Bill, but I cannot follow why clause 24(1) is needed. I will be grateful if the hon. Member for Spen Valley or the Minister can explain which other offences would necessarily be committed by a doctor properly carrying out his or her functions under the Bill. What other offences might be caught that require clause 24(1)?

Clause 18 will forbid a doctor from engaging in euthanasia. One criminal law from which an exemption is not necessary is the law on murder, yet ostensibly subsection (1) has no such limitation. I would be grateful for the Minister’s confirmation that subsection (1) will not afford a defence when the charge is murder. I presume that that is not the intention.

What about manslaughter, and particularly gross negligence manslaughter? Under the Bill, a pharmacist performing the function of prescribing or dispensing the legal drugs would be, to use the wording of amendment 504, “performing” a “function under this Act”. If a pharmacist makes a grossly negligent mistake and mislabels a drug, which is then sent to another patient who takes it and dies, that would quite clearly be gross negligence manslaughter. Can the Minister explain why clause 24(1), as amended by amendment 504, would not allow someone to benefit from an immunity in respect of gross negligence manslaughter? To be clear, I agree that if the pharmacist intentionally mislabelled the drug, he could not be described as

“performing any other function under this Act”,

so he would not have that defence. However, in a case where, in good faith, he had made a fatal and grossly negligent mistake, surely he would have been performing such a function, albeit performing it very badly.

Can the Minister clearly set out the reasoning to explain why there is no chance of such a defence under the clause? Of course the hon. Member for Spen Valley does not intend to exempt from criminal liability a pharmacist acting in that grossly negligent way, but I am trying to make sense of the drafting of the amendment. If there is any criminal offence, other than in the Suicide Act, that requires an exemption, it would be best to say so clearly in the Bill rather than relying on a catch-all term, as subsection (1) does.

I concur with the points made by my hon. Friend the Member for Reigate and will not repeat them, but I do find it interesting that the hon. Member for Spen Valley has chosen to retain the offence of assisting and encouraging suicide. This is because two arguments made by proponents of the Bill lead to the logical conclusion that the offence should either be repealed entirely or limited to self-conduct, as is the case in Switzerland. Let us look at the two arguments in turn.

The first argument relates to autonomy. If an autonomous individual with capacity decides to end their own life and requests the assistance of another person, why should that other person be criminalised? After all, that person is simply helping another person to do something to their own body that the law has not prohibited since 1961, so surely it is a violation of autonomy to criminalise such conduct of assisting in suicide.

Lord Mance, a former justice of the Supreme Court, put the matter as follows on Second Reading of the Meacher Bill in the other place:

“Suicide is decriminalised, yet assisting suicide remains criminal—probably a unique exception to the principle that you can only be an accomplice to an act that is itself criminal.”

It is bizarre that the act is not itself criminal but being an accomplice to it is. Lord Mance went on to say:

“If a person may choose freely to commit suicide, what justifies a refusal to allow them to obtain willing assistance?”—[Official Report, House of Lords, 22 October 2021; Vol. 815, c. 408.]

I believe in the value of a prohibition on assistance, but the logic of the argument from autonomy—that someone should be allowed to request assistance to help them to die—surely obviates the distinction. I do not see why we have kept section 2 at all, and I would be interested in hearing from the supporters of the Bill what the limiting principle is. Why do they think assisted suicide should remain a crime, despite its being a limitation on autonomy, outside the scheme created by the Bill? Why are we simply creating a scheme within the Bill?

The second argument given, which I think relates to the intervention from the hon. Member for Sunderland Central and to the point made by the hon. Member for Spen Valley, is based on the fact that the current law requires people to travel to Switzerland. The argument against the current system comes in three forms. One stresses the toll that it places on families to know that the people who assist have committed a criminal offence and could be investigated by the police, even though the chances of prosecution are remote. I fully recognise and share all the concerns among Members about the terrible distress faced by people who may in any way have assisted their loved one to take their own life.

The second objection to the status quo makes the point about the unfairness that the situation creates. The hon. Member for Liverpool Wavertree (Paula Barker) said on Second Reading:

“I do not want choice to be available only to those who can afford to pay. That is not just or equitable.”—[Official Report, 29 November 2024; Vol. 797, c. 1073.]

The suggestion is that to have to pay to go to Switzerland is a violation of equality.

The third is a constitutional argument. It is said that it is constitutionally improper for the Director of Public Prosecutions to have effectively decriminalised assisted suicide for people who travel to Switzerland. But the point I am trying to make is that under the Bill, anyone helping their relative to travel to Switzerland, or any other country, would still be committing an offence under section 2 of the Suicide Act.

Research from My Death, My Decision, a campaign group pushing for a wider Bill than the current one—it supports the Bill but clearly wants it to go further—has found that 50% of cases going to Dignitas would not be eligible under the Bill. It helps to make my point, which is that I am afraid that if the Bill were passed we would still have stories like the very moving testimony read out by the hon. Member for Spen Valley. In fact, as my hon. Friend the Member for Reigate said, there is a significant likelihood that there would be more prosecutions. If the Bill were enacted, the conclusion of the Crown Prosecution Service and the police might well be that, given the existence of an assisted dying regime within the UK, assisting one’s relative to go to Switzerland should be subject to a greater likelihood of prosecution. That is a legitimate concern.

[Tom Gordon (Harrogate and Knaresborough) (LD)]

The point that the hon. Gentleman is making is actually one that I made yesterday. I appreciate that we are on entirely different sides of the debate, but that is exactly why I was talking about ensuring wider eligibility—the point he makes in relation to My Death, My Decision—and ensuring the provision of assistance for people who might have illnesses such as motor neurone disease. We have had to put a cut-off somewhere, and some people fall outside it, but does he accept that fundamentally this is about making sure that there are safeguards? That is the key point: that we should ensure safeguards. What the hon. Gentleman is talking about is exactly that.

[Danny Kruger]

I am grateful. With great respect to other members of the Committee, I think the hon. Gentleman is the most honest advocate of assisted dying among us, because he genuinely recognises that autonomy demands the widest possible range of eligibility. It might be that other Members feel that we have the balance exactly right. I recognise the force of his argument that if we are going to introduce a new human right, it is very difficult to circumscribe its boundaries. He himself thinks that there should be some boundaries: he proposed an amendment that specified 12 months, and he thinks that only certain people should be able to ask someone else to perform assisted death to them. Nevertheless, he is acknowledging that if we believe in autonomy, the Bill would not satisfy some people.

I think it would be intellectually coherent and more logical for proponents of the Bill to want to repeal section 2 of the Suicide Act, and I do not understand why they are not doing so. We could certainly continue to insist on prohibitions against any form of coercion, persuasion or inducement to take one’s own life, but if somebody is clearly in their right mind and wants to receive assistance to kill themselves, that is the principle of the Bill. It would be neater if we amended the Suicide Act accordingly.

The fact that proponents do not want to do so suggests that they see some value in the law and that they consider that that value trumps concerns about autonomy and the impact of the law on family members of someone who wishes to travel to Switzerland to end their life. I agree that there are such principles—namely, the intrinsic value of life and the protection of the vulnerable—but I do not see why proponents of the Bill consider that such principles trump autonomy when it comes to terminally ill adults in England.

[The Minister of State, Ministry of Justice (Sarah Sackman)]

It is a pleasure to serve under your chairship, Mr Dowd. My remarks, as ever, will focus on the legal and practical impact of the amendments to assist Members in undertaking line-by-line scrutiny. In exercising our duties to ensure that legislation that is passed is legally robust and workable, the Government have worked closely with my hon. Friend the Member for Spen Valley to reflect her intent.

Clause 24, as amended by amendments 504 and 505, will mean that individuals who assist a person to end their life in accordance with the terms of the Bill are not subject to criminal prosecution. Currently, it is a criminal offence under section 2 of the Suicide Act 1961 for a person to do an act that is

“capable of encouraging or assisting the suicide or attempted suicide of another person”

and intended

“to encourage or assist suicide or an attempt at suicide.”

That offence attracts a maximum penalty of 14 years’ imprisonment. Amendment 504 would amend clause 24(1) to ensure that a person is not guilty of an offence—[Interruption.]

--- Later in debate ---

[Sarah Sackman]

I was introducing amendment 504, which amends clause 24(1) to ensure that a person is not guilty of an offence by virtue of providing assistance in accordance with, or performing a function under, the Bill—for example, by undertaking the first or second assessment or providing the approved substance. The effect of the amendment is to ensure that a person is not guilty of an offence by virtue of assisting a person seeking to end their own life in accordance with the Bill. The phrase “in accordance with” the Bill is key. For example, where someone accompanies a person to the appointment at which they will self-administer the substance, the amendment would carve out any criminal liability for the accompanying person.

As originally drafted, the wording would have limited the protection offered by subsection (1) to the far narrower situation of the medical professionals providing assistance under clause 18. The amendment will give effect to the policy intent of the hon. Member for Spen Valley of applying that protection to all those who provide assistance in accordance with, or by performing a function under, the Bill. Subsection (2) clarifies that the clause does not override other ways in which a court may find that a person is not guilty of an offence.

Clause 24(3) inserts proposed new section 2AA into the Suicide Act 1961. As amended by amendment 505, that new section ensures that it is not an offence under the Suicide Act to perform a function under the Bill, or to assist a person seeking to end their own life by doing anything under the Bill. That is for the same reasons that I set out in relation to subsection (1). The new section also provides a defence to the offence of encouraging or assisting suicide, where a person reasonably believes that they were acting in accordance with the Bill, and that they took all reasonable precautions and exercised all due diligence to avoid committing the offence.

Taken as a package, the effect of these amendments is to make the Bill legally workable. To do that, it is necessary to ensure that those who assist a person to use the lawful route are not then subject to criminal liability for doing so. Clause 24 clause, taken together with amendments 504 and 505, gives effect to that.

Let me address some of the issues raised by Opposition Members. There was a question as to whether there is any overlap between offences under the Bill—we will come to some of those offences in due course with clauses 26 and 27—and offences that remain on the statute book under the Suicide Act. The short answer to the question from the hon. Member for Reigate, although I know she has written to my Department, and I will ensure that she receives a full written answer, is that it would remain an offence under the Suicide Act 1961 to encourage suicide, including an assisted death under this Bill.

To the extent that any overlapping offences remain, that is not an unusual approach to drafting in the criminal law. However, the effect of the clause is that it would remain an offence under the 1961 Act to encourage someone to commit suicide. Where a person’s “encouragement”—the hon. Member focused on that term—is such that it amounts to what the courts would understand to be pressure or coercion, that could be an offence under clause 26, which we will come to. As I said, it is not unusual to have a degree of overlap in criminal offences. Again, what someone is charged and prosecuted with falls to the prosecutor, depending on the specific circumstances of the case and what would be most appropriate in that scenario.

I also want to address the scenario that the hon. Member for East Wiltshire posited, about whether a pharmacist who acted in a way that amounted to gross negligence manslaughter would benefit from immunity under clause 24(1) as amended. Again, with the important caveat that it will depend on the particular facts of the case, the offence of gross negligence manslaughter is committed where a death is the result of gross negligence in what would otherwise be a lawful act or omission on the part of the defendant, and where the defendant owes a duty of care to the victim—there are a number of actors within the Bill’s process who owe a duty of care to the person applying for assisted dying.

Let us assume for a moment that, in the hon. Member’s scenario, we do have gross negligence manslaughter on the particular facts; in those circumstances, the Government are content that the pharmacist could not be properly said to be performing a function under the Bill, or in accordance with the Bill, so clause 24(1)—the carve-out from criminal liability—would not apply. I think that that covers most of the questions that were posited earlier.

[Danny Kruger]

It may well be that the Minister has clarified the case sufficiently, but will she explain something for my sake? She is suggesting that the pharmacist inadvertently but negligently caused the death of a patient, having performed the duties under the Bill and believing that they were doing so. Surely, they were performing duties under the Bill, so they would potentially be captured by the carve-out.

[Sarah Sackman]

Again, it would depend on the actual facts. However, if they were attempting to perform duties under the Bill, it is highly unlikely that, in circumstances where the facts establish and meet the threshold of gross negligence manslaughter, they could be said to have carried out those duties in accordance with the Bill. They might have been carrying out duties that they thought were what the Bill prescribed, but if they have done that in such a way that it amounts to gross negligence manslaughter, then clause 24(1) would not apply.

The hon. Gentleman makes the point about what the pharmacist in that scenario believes they are doing; that belief has to be reasonable, and that is a test that our courts are well used to applying. That is why the amendments introduce the belief that someone is acting in accordance with the Bill. It is not enough that they think they are doing it; it has to be a reasonable belief. That is an objective standard.

--- Later in debate ---

[Kim Leadbeater]

The amendments ensure that the exclusion from civil liability applies in relation to persons performing functions under the Bill and persons assisting a person seeking to end their own life in connection with the doing of things under the Bill. Importantly, they also rightly exempt from the exclusion from civil liability things done dishonestly or not in good faith, and any liability arising from negligence.

Proposed new subsection (1) in amendment 501 makes it clear that anyone providing assistance to a person to end their own life in accordance with the Bill will not face civil liability simply for doing so. That is crucial in offering clarity and confidence for healthcare professionals, family members or others who might otherwise hesitate due to fear of being sued for assisting a loved one or patient who wishes to end their life as a result of their terminal illness.

However, although we are providing protection, amendment 501 does not allow for unfettered actions without any accountability. Proposed new subsection (1A) ensures that any actions that are dishonest or done in bad faith are not protected from civil liability. Additionally, it states that breaches of a duty of care, such as negligence, are also not exempt from liability. This provision is a critical safeguard. It ensures that, although we provide legal protection for those acting with compassion and integrity, we also prevent exploitation or irresponsible actions, by making it clear that there is no immunity for actions that are dishonest or negligent. That strikes the right balance between compassionate assistance and legal accountability.

The amendment particularly reassures doctors, nurses, and healthcare workers—those who are most likely to be involved in the process. Often, they are deeply committed to palliative care and to supporting patients through their end of life journey, and the amendment ensures that they will not face legal risk if they provide assistance to eligible individuals under the Bill.

[Danny Kruger]

I rise to speak to clause 25 as a whole. First, though, I welcome the amendments tabled by the hon. Member for Spen Valley, because I recognise that she is attempting to fix a problem with the Bill.

However, I am afraid that my objection remains: the fact is that no other assisted suicide law in the world—including in common law jurisdictions similar to our own, such as Australia or New Zealand—has such a clause. There can be no justification for it. If, in the course of providing assistance under this Bill, a doctor commits a civil wrong, they ought to be liable for it in the usual way.

I am glad the hon. Lady has realised that a total exclusion of civil liability is not justifiable, but her change does not go far enough. Her amendments would preserve civil liability where an act was done dishonestly—not in good faith—or for liability in tort, based on the breach of a duty of care, or in other words the tort of negligence. However, it is worth noting that that still excludes civil liability in other respects, and we should ask whether that is justifiable.

First, the clause would still exclude civil liability under a contract, so a patient who has received improper care in breach of contract would not fall within either of the exceptions of proposed new subsection (1A). I take the point that, in the case of negligent care, there would often be a concurrent liability under the tort of negligence, and that that is preserved by new subsection (1A)(b), but that is not the case for other forms of contractual arrangements.

That might be particularly relevant in the situation of subcontracting. An example would be where an outsourcing company is tasked with transporting the lethal substance. Given the risks involved, the contract specifies strict rules that must be complied with, but the company does not comply with those rules. Under clause 25, even as amended, my concern is that they could not be sued for that breach of contract. What is the justification for excluding civil liability in contracts?

Secondly, there is the tort of trespass to the person, which is commonly relevant to medical practice, as it is under such torts that cases where there was no consent or capacity are handled. Those torts can be committed recklessly, but recklessness is not the same as bad faith or dishonesty, so liability could not be established under new subsection (1A)(a). Such torts are also different from negligence—they do not involve a duty of care—so they would not be covered by new subsection (1A)(b). I appreciate that, in many cases, liability could also be established under the tort of negligence, but that would not be the case in all cases. So I ask again: what is the justification for this exclusion?

Finally, and most concerning, we were told in previous debates that if it turned out that the criteria for an assisted death were not met, one could always apply for an injunction. Leaving aside the practical and financial obstacles involved in seeking an injunction at the last minute, which we have discussed before, my concern is that a private law injunction requires that a civil wrong either has been committed or is about to be committed. However, in a case where the doctors consider, in good faith and without negligence, that the criteria have been met, but the family has new evidence to show that that is not the case, the effect of clause 25, even as amended, would be that no civil wrong has been, or would be, committed in that instance, so the test for a private law injunction would not be met.

I might be wrong, so I would be interested to hear whether the Minister or the hon. Member for Spen Valley disagree with that analysis. I would be grateful if they could point out how the private law test for an interim injunction is met in such an instance.

All this could be much simpler if clause 25 were left out of the Bill entirely. Australia and New Zealand do not have such a clause or a civil liability exemption for practitioners of assisted suicide, and I am not aware of that having caused problems for practitioners, so I would be interested to understand why we need such a measure here.

--- Later in debate ---

[Rebecca Paul]

Thank you, Mr Dowd. In that case, I will stop there. I was just making the point that this is important.

Amendment 509 states:

“Proceedings for an offence under this section may be instituted only by or with the consent of the Director of Public Prosecutions.”

I would find it useful to have more clarity around how the offence is used currently, why it is used and why it is appropriate to use it in this instance. Those are all genuine questions. I simply do not know, so I would be grateful for some input. I will leave it there.

[Danny Kruger]

I will be grateful if the Minister or the hon. Member for Spen Valley can explain the situations in which behaviour criminalised by clause 26(2) would not also amount to an offence under section 2 of the Suicide Act, as amended, or indeed to murder. What behaviour would be criminalised here that is not already criminal? Can the hon. Lady think of any instance in which there would be no crime under section 2 of the Suicide Act, but there would be an offence under clause 26(2)? If there is no such instance—I cannot think of one—it strikes me that, at least in respect of coercion and pressure, the offence being created here is redundant and duplicative.

Ministers have rightly stressed the importance of their duty to the statute book. My understanding is that having redundant or duplicative legislation, or indeed duplicative offences, would be inconsistent with our duty to the statute book. One might ask, “What does it matter? Wouldn’t it be helpful to have additional belt-and-braces safeguards in the Bill?” I agree in principle, but I note that when other Members have deployed that argument in relation to adding terms such as “undue influence”, the neutral Ministers have rebuked them by appealing to the duty that we are supposed to have to the statute book. I think the point cuts both ways. Why are we embroidering the statute book with duplicative offences?

[Kim Leadbeater]

I would have thought, given the hon. Gentleman’s views on the Bill, that he would welcome having an actual offence for the purposes of the Bill. Surely that is something that we should all support.

[Danny Kruger]

I support the principle of insisting that inducing people by dishonesty, coercion or pressure to kill themselves should be illegal, but my understanding is that it already is. If it is not illegal, or if there are circumstances in which we need this additional offence that are not already captured by the Suicide Act or the law on murder, I would like to understand what they are. As I say, while it might be helpful to duplicate the offence, I understand that the very sensible convention in our law is that it is not helpful to have two offences relating to the same act because of the opportunity for offenders to play off one offence against the other.

Having duplicative criminal offences can make prosecuting cases harder because the defendant can raise abuse-of-process arguments about whether they have been charged with the most appropriate offence. I understand that the Attorney General’s Office and the Ministry of Justice are therefore usually very keen to avoid duplicative offences.

Let me give an example of the difference in the treatment of the offence. It is proposed that this offence would be subject to a life sentence, which requires the consent of the DPP. But at least in the one case where it overlaps with murder, this would provide a more favourable treatment for the accused than the other obvious charge. Can that be justified?

Duplicating criminal liability by introducing new offences has far-reaching implications that can disturb the coherence and certainty of criminal law. If one introduces a law that gives prosecutors two criminal offences to choose from to cover one act, some prosecutors will choose one and some will choose the other. This is generally undesirable; indeed, it is unprecedented in the case of homicide, where there is every reason to suspect that it could cause chaos for grieving families in search of justice. Such chaos is all too predictable, for a number of reasons.

Let me give an example. A defendant proven to have procured a suicide by deception will be well advised to plead guilty to the offence contrary to section 26(2) and then contest any attempt to introduce murder proceedings. This matters profoundly. A decision to prosecute is an administrative decision and is subject to judicial review. This is not an academic point; it could cause real distress for bereaved families in deep turmoil seeking justice.

Let us imagine that a person, A, is a new coercive and controlling partner of person B and procures by deception their suicide in order to profit from a will. The family of person B grow suspicious and provide the police with a convincing case for a murder prosecution. The CPS agrees and charges A with murder. A accepts that he procured the suicide by deception. On that basis, he appeals, seeking a remedy in judicial review, saying that the CPS should have charged him with a clause 26(2) offence, not murder. The JR is backed by wealthy pressure groups and is beset with administrative adjournments and so on. From the filing of the claim form to the final judgment of the administrative court within the High Court, the case takes 24 gruelling, painful, awful months for the bereaved family.

Throughout this time, the lawyers for A, the defendant, tell him to stay the course and continue to offer the plea to section 26(2), because the family will be exhausted by the reality of litigation. The family have no legal aid, no support, no charity backing and no one interested in their case. The war of attrition in litigation finally defeats them. They advise the CPS that they will accept a plea under the section 26(2) offence, and not the murder that actually occurred. That is the reality of duplicating criminal liability. In that example, A has got away with murder by judicial review.

We must be clear about what we are being asked to do. It is not simple. We are being asked to innovate in the law of murder. We are being asked to do so without the assistance of the Law Commission, without the careful eye of legal or judicial bodies alive to the difficulties of duplicating liability and without the input of any bodies that represent the victims of crime on how this might affect them. There are no Government consultations with such bodies before us. There is no expert assistance from judicial or legal figures on how the good intentions around clause 26(2) might unintentionally lead to serious and undesirable consequences such as those that I have described.

--- Later in debate ---

[Sarah Sackman]

The clause, as amended by amendments 506 to 509, creates two stand-alone criminal offences that apply when a person uses dishonesty, coercion or pressure to induce a person to do a particular act. Subsection (1) creates an offence of inducing another person to make a first or second declaration, or not to cancel such a declaration, by dishonesty, coercion or pressure. That offence, as we heard, will carry a maximum penalty of 14 years’ imprisonment, ensuring consistency with the maximum penalty under the Suicide Act.

Subsection (2), as amended by amendment 506, creates an offence of inducing another person to self-administer and approve substances provided under the Bill, by dishonesty, coercion or pressure. Amendment 506 replaces “in accordance with” with “under” for this offence. That gives effect to the policy intent of my hon. Friend the Member for Spen Valley that the offence should capture those who induce a person to self-administer a substance that, due to some error in the process, has not been provided strictly in accordance with the processes in the Bill. The amendment therefore ensures that the offence in subsection (2) will operate effectively.

Amendment 508 inserts proposed new subsection (4) to establish life imprisonment as the maximum penalty for the offence in subsection (2). That amendment gives effect to the policy intent of my hon. Friend by emphasising that inducing someone to undergo an unwanted assisted death through a legal system established by Parliament is a grave offence warranting the most severe penalty of life imprisonment. Amendment 507 is consequential on amendment 508 and amends subsection (3) to reflect the policy intent of my hon. Friend that the offence in subsection (2) should carry a maximum penalty of life imprisonment, rather than 14 years’ imprisonment.

Amendment 509, which a number of Members mentioned, amends the clause to provide that neither of the offences could be prosecuted without the consent of the Director of Public Prosecutions. That amendment achieves the policy intent of my hon. Friend that the legislation, first, be consistent with the Suicide Act 1961, which makes the same provision for the DPP’s involvement and where such consent is required; and, secondly, to ensure that spurious prosecutions are not brought, for example, by those who may oppose the process that the applicant for assisted dying is undergoing simply because they oppose it, rather than because of any illegality or criminality. That is the function of having the DPP consent baked into the legislation.

To be clear, the terms “coercion”, “dishonesty” and “pressure” remain undefined in the clause. That was an issue that we touched on right back in the early days of clause 1. Without a statutory definition, the terms will carry their natural, ordinary meaning, well understood by the public and the courts alike.

I want to pick up on two other points touched on in various speeches. The first has to do with the issue of coercion, coercive control and its subtleties, the way in which that is dealt with and, indeed, the painfully low conviction rates for domestic abuse and coercion. I am not seeking to make a wider political point beyond the amendments that we are discussing, but the hon. Member for Reigate and my hon. Friend the Member for Bradford West know that the Government have a mission to halve violence against women and girls. I assure the Committee that, in my capacity as Minister of State in the Ministry of Justice, we are intently focused on addressing that, and ensuring that the criminal justice system plays its part more widely. The offences sit in that context.

The other point that I want to address, and touched on earlier, was the one made by the hon. Member for East Wiltshire about our duties to the statute book. It is right that there is a degree of duplication and to acknowledge that, as the Government do in working with the promoter of the Bill to reflect her policy intent. That is not unusual. It is something those in law enforcement, in particular in the CPS, are well versed in. It will be for them to make the appropriate charging decisions, depending on the facts in the particular case.

The function of the offence created under subsection (2) and the penalty attached to it affect the gravity that the promoter of the Bill sought to indicate for the offence of inducing someone to undergo something through dishonesty, coercion or pressure, in the context of what we all acknowledge is a new process. If the Bill is passed, there will be a new legal regime for assisted dying. The manipulation of such a new regime to ends that are criminalised under the provision is reflected in that specific offence. To be clear, the degree of duplication is acknowledged, but the Government’s view is that that is neither unusual nor poses a problem for the CPS.

[Danny Kruger]

That is helpful and makes sense. The only justification for duplication must be that the duplication is only partial, which the Minister has just suggested it is. Not a complete overlap—some cases will fall into one category, but not into the other. I wonder if she could help us to understand with an example that would help the CPS when it makes its decisions about which offence to charge someone under—an example of an offence that would be illegal under this clause and not already illegal under the Suicide Act or the laws of homicide.

[Sarah Sackman]

I am not going to answer that question directly, because I will not get into hypotheticals, which would be a test. I understand the question the hon. Gentleman is asking. As I said, the policy intent here—the policy of including the specific offence within the context of this new legal regime and the signal that doing so would send to all those participating in this regime by attaching the severest penalty of life imprisonment to the offence created under subsection (2)—has been a matter for the Bill’s promoter. The Government have worked with her to create a workable regime.

I will not proffer on my feet a hypothetical factual scenario that would be caught by this offence, but would not be caught under other offences that exist in our criminal law. The point is that overlapping criminal offences exist in our criminal law. That is not unusual. The CPS is well versed in dealing with that. The charging decisions will be for the CPS, with the consent of the DPP. Satisfying the purpose of having criminal liability—to catch those who perpetrate what would be, in any view, a heinous crime, and to deter such crime—would be discharged by the drafting that we have here.

[Danny Kruger]

I respect the difficulty of the position that the Minister is in, but I am afraid that we have to consider hypothetical scenarios, because we are creating law. Does she acknowledge that, even if she cannot imagine, or cannot suggest to us, a case that falls under the provisions of this clause, but is not caught by the Suicide Act or law of murder, someone who is charged with murder could plausibly claim that, in fact, they should have been charged with the offence under clause 26(2) of the Bill? Plausibly, they could make a case, perhaps through judicial review, that the charging decision was wrong, and we would have months of litigation before we even got to the prosecution beginning. Can she envisage such a scenario happening?

[Sarah Sackman]

I find that highly implausible; the likelihood is that the CPS will apply the appropriate charging decision to fit the facts as they have arisen. If they have arisen within the context of this legal regime, for someone acting nefariously, dishonestly or coercively about assisted dying, the charge under this clause would be the appropriate one. I find it implausible that the other scenario would arise. As I said, the CPS is well versed in applying the appropriate charging decision to the appropriate crime on the facts of the crime. I will not speculate or hypothesise on what that might be.

[Sarah Sackman]

That is a good example. One knows from charging decisions that often, on indictment, one might have multiple offences to capture the totality of the criminal behaviour. Some of those may be made out, some of them may not. What the Government have sought to do here, working with the Bill’s promoter, is to reflect her policy intent: to convey the gravity of the offence in this wholly new legal regime. As the right hon. Gentleman pointed out earlier, we are sanctioning and decriminalising conduct that has previously been criminal, while ensuring that this offence captures what would be criminal under the new legal regime. From the promoter’s point of view, it is important to signal that the Government have worked with her on this, and the Government’s position is that the result, in this amended form of the Bill, gives both some satisfaction to her policy intent and is compatible with how our criminal law routinely works, so it is workable from the point of view of the CPS.

[Danny Kruger]

I acknowledge the point that the Minister is making. To the point made by my right hon. Friend the Member for North West Hampshire, we are talking not about two categories of offence within the same legal framework, namely GBH, but about two different legal frameworks altogether, the law of homicide and the law on assisted dying. Does the Minister agree that the clause as it is to be amended will create the opportunity for a murderer who would otherwise be convicted of or charged with murder to claim that, in fact, he was committing an offence under the assisted suicide law? We are creating a new opportunity for someone who would otherwise, were it not for this law, be legitimately charged with murder to claim that they are committing this offence instead.

[Sarah Sackman]

I do not consider that through this amended form of the Bill—if the Committee chooses to vote that way—we will have created an opportunity that could be exploited in that way. The hon. Gentleman said earlier that there has not been consultation on that point, but there has been close working of highly experienced Government lawyers with the promoter to reflect her policy intent.

What the clause interlocking—and indeed overlapping, as I have acknowledged—with the Suicide Act does is prescribe new forms of criminal offence and liability that will capture criminal behaviour, which is ultimately what the measure is about. Tellingly, the punishment attached to the clause 26 offence is the same as the maximum punishment for murder, that of life imprisonment, which is indicative of the gravity of the offence that would be caught.

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[Kim Leadbeater]

These amendments relate to the falsification or destruction of documentation and are very straightforward. Amendment 510 makes a drafting change to align the wording of subsection (1)(b) with wording used elsewhere in the clause. Amendments 511 and 512 clarify that the offence under subsection (2) relates only to an opinion about a matter relating to a function under the Bill rather than to the person. Amendment 513 clarifies the scope of the offence under subsection (3) by providing that the offence occurs where a doctor fails to comply with a notification or recording obligation in relation to the cancelling of a first or second declaration.

The amendments significantly improve the clarity, scope and precision of the offences in clause 27, align it with the language used in the rest of the Bill and ensure that it is more consistent. They refine the original provisions, focusing on serious misconduct and offences covered by the clause.

[Danny Kruger]

It is good to see you this evening, Mrs Harris.

I have no objection to the hon. Lady’s amendments. I think there is value in broadening the offence to include actions performed intentionally or recklessly, as that is critical for patient safety. Given the finality of the result of assisted death, there should not be any room for carelessness, and liability must ensure that not only deliberate misconduct but negligent record keeping is subject to legal scrutiny. I want to put on the record the evidence we had from the British Journal of Nursing, which has documented the serious risks of poor record keeping in medical practice. That demonstrates how inadequate documentation contributes to clinical errors.

I think the hon. Lady recognises that this is not just a matter of bureaucratic tidying-up. The principle is straightforward: if the decision to assist in ending a life is to be lawful, the documentation supporting it must be unimpeachable. Expanding liability to cover reckless documentation is entirely consistent with existing legal and professional standards in the UK medical profession.

[Sarah Sackman]

It is a pleasure to serve under your chairmanship, Mrs Harris. I will be brief. As we have heard, clause 27 creates various stand-alone criminal offences regarding the falsification or destruction of documentation related to assisted dying. Amendment 510 replaces “wilfully” with “intentionally or recklessly” in subsection (1)(b), to align the wording with that used elsewhere in the clause. The Government have worked with my hon. Friend the Member for Spen Valley on the other amendments, to tighten up and improve the workability and operability of the Bill.

Amendment 510 agreed to.

Amendments made: 511, in clause 27, page 16, line 22, leave out “that person” and insert “a relevant matter”.

This amendment and amendment 512 clarify that the offence under subsection (2) relates only to an opinion about a matter relating to a function under the Bill.

Amendment 512, in clause 27, page 16, line 23, at end insert—

“(2A) In subsection (2) “relevant matter” means a matter relating to any function under this Act.”

See the statement for amendment 511.

Amendment 513, in clause 27, page 16, line 24, leave out subsection (3) and insert—

“(3) A person commits an offence if they intentionally or recklessly fail to comply with an obligation under—

(a) section 14(1A) or (2) (notification of cancellation of declaration), or

(b) section 17 (recording of cancellations).”—(Kim Leadbeater.)

This amendment clarifies the scope of the offence under subsection (3), by providing that the offence occurs where a doctor fails to comply with a notification or recording obligation in relation to the cancelling of a first or second declaration.

--- Later in debate ---

[Sojan Joseph (Ashford) (Lab)]

I rise to speak in support of these important amendments. The prescribing, dispensing and transporting of these medications is very important. In my experience, and as the Care Quality Commission reports, many healthcare settings have issues with the storage and disposal of medications. Amendment 442 is a straightforward one that would change “may” to “must”. I think it is right that the Secretary of State “must” by regulations make the provisions listed.

In oral evidence, we heard of one incident in Australia where the patient was given medication and did not take it but passed away, and then her partner took it and died. Amendment 444, which would provide that the substances must not be left unsupervised by a medical practitioner at any time, is very important. I urge the Committee to accept it, and amendment 445, which would also change a “may” to a “must”. These are straightforward but important amendments that seek to safeguard relatives, staff and the public. We must not leave these medications unattended at any time.

[Danny Kruger]

It is a pleasure to follow the hon. Members for Ashford and for Banbury. I entirely concur with their points, particularly those that derive from the expertise of the hon. Member for Ashford.

This is a very important group of amendments, which concern what is in a sense the heart of the Bill—the management of the lethal drugs. The question of what drugs we are talking about remains open, which is a cause of deep concern to me, but whatever they happen to be, we need to make sure that the management— the regime of dispensing, transporting and prescribing —is safe.

I will not reprise the details of all the amendments. Their purpose is to ensure a stricter, more transparent and safer regime for the management of the drugs. Amendment 521, which is in my name, would ensure that the regulations that we arrive at are laid before Parliament, and debated and approved by both Houses of Parliament. Amendment 485 in the name of the hon. Member for York Central would address the same issue.

The amendments seek to address the dangerous absence of an adequate regulatory regime in the Bill for the lethal drugs and approved substances. Once again, significant questions are ignored in clause 28. Ministers will be given the power to make regulations for the prescription, dispensing, transportation, storage, handling and disposal of approved substances. The clause is envisaged as sufficient for an entire regulatory regime for approved substances. It is just 87 words. It is as if it is an afterthought—as, it seems, is the role of pharmacists, by the way.

The regulations are subject to the negative procedure, which means they are highly unlikely to be debated at all or voted upon, for reasons given in my earlier complaints about the use of the negative procedure. Indeed, it is discretionary whether the regulations will be made at all.

Last night, the Minister told us that the Government objected to the Medicines and Healthcare products Regulatory Agency approving the drugs or substances in amendment 465, which I had tabled. He said:

“The Government’s assessment of amendment 465 is that it would significantly impact the legal and operational delivery of the Bill. The Government anticipate that all substances used for assisted dying will have existing licences from the Medicines and Healthcare products Regulatory Agency for other indications, but the amendment would require the approved substances to be licensed by the MHRA specifically for the purpose of assisted dying.”––[Official Report, Terminally Ill Adults (End of Life) Bill Public Bill Committee, 18 March 2025; c. 1224.]

That was indeed the purpose of that amendment.

If there is anxiety that I am somehow straying from the relevant clause and amendments, which I detect from Members who are clearly looking forward to their dinner, I do insist—[Interruption.]

[The Chair]

Order. Mr Kruger, can we please stick to the point?

[Danny Kruger]

Sorry, Mrs Harris. I do not appreciate the sense of impatience in the Committee; these are very important matters.

[The Chair]

Can we just stick to the point, please?

[Danny Kruger]

Absolutely; that is what I am doing.

I referenced the debate we had last night, which I hope is within scope, because the suggestion has been either that the Bill insufficiently addresses the need for a regulatory regime for the approval of drugs specifically for the purpose of assisted dying or, as the Government are saying, that the drugs’ existing licences are sufficient for these purposes. Is the Government’s position that there will be no regulator involved and that this will sit entirely with the Minister, as in this clause? If regulators are to be involved, will further legislation be needed?

I will not repeat evidence from the Royal Pharmaceutical Society concerning the legal arrangement, but I will refer to evidence submitted by Máire Stapleton, a pharmacist with more than 30 years’ experience in clinical governance, who made this point:

“Based upon a preliminary review of current published data, it is difficult to see how the regulatory and professional standards for prescribing and dispensing unlicensed drugs can be met.”

There is further evidence to that effect from the Royal Pharmaceutical Society, pharmacists and barristers.

Given that there is so little on the face of the Bill and no guardrails for the use of the power that will be given to the Secretary of State, why is the negative procedure judged appropriate for something of this significance? It cannot be argued that the negative procedure is needed because the amendments might need to be made quickly and frequently—that cannot be the case, because we have not yet authorised the regime. The negative procedure would allow the Secretary of State quite unjustified ability to change these processes without any requirement for a parliamentary debate or vote.

Lord Hermer, the Attorney General, has said that this new Government will take a new approach, considering the

“real need to consider the balance between primary and secondary legislation, which in recent years has weighed too heavily in favour of delegated powers.”

He criticised the previous Government’s

“excessive reliance on delegated powers, Henry VIII clauses, or skeleton legislation,”

which

“upsets the proper balance between Parliament and the executive. This not only strikes at the rule of law values I have already outlined, but also at the cardinal principles of accessibility and legal certainty.

In my view, the new Government offers an opportunity for a reset in the way that Government thinks about these issues. This means, in particular, a much sharper focus on whether taking delegated powers is justified in a given case, and more careful consideration of appropriate safeguards.”

I conclude with this question to the Minister: has she considered the advice of Lord Hermer in coming to a view on the appropriateness of this clause and the way that these powers have been taken? As the Hansard Society notes,

“the Government has an overriding duty of care to the statute book. As such, any powers that may accrue to Ministers because of a Private Member’s Bill must be acceptable to the Government. It must therefore take a view on the powers and their scrutiny”.

Has the sponsor or the Minister consulted with the Royal Pharmaceutical Society on the sufficiency of this power? Has sufficient work been done to look at the workability and operationalisation of this clause? I hope the Committee will join me in supporting these amendments.

[Stephen Kinnock]

It is a great pleasure to serve under your chairship today, Mrs Harris. Amendment 442 would require the Secretary of State to make regulations for the prescribing, dispensing, transporting, storage, handling and disposal of approved substances, including the keeping of records relating to those activities. That differs from the Bill’s current approach, which enables the exercise of a power by the Secretary of State to make such regulations.

In practice, where the Secretary of State makes regulations specifying substances for the purpose of the Bill under clause 20, they will necessarily also make regulations for the prescribing, dispensing and transporting of said substances under clause 28. However, requiring, rather than enabling, the regulations under clause 28 to be made may reduce flexibility in terms of their timing as there is a range of technical issues that may need to be resolved—for example, clinical questions on how an approved substance should be prescribed or dispensed.

Amendment 443 would mean that regulations for the prescribing and dispensing of approved substances could be made only in relation to substances that have already been approved by

“the Medicines and Healthcare products Regulatory Agency and either the National Institute for Clinical Excellence or the All Wales Medicines Strategy Group”.

That may impact the operational delivery of the Bill as the drafting is ambiguous. One possible interpretation is that the amendment may require the approved substances to be licensed by the MHRA specifically for the purpose of assisted dying. That would require additional powers to amend medicines regulations, which are not currently provided for in the Bill. NICE and the All Wales Medicines Strategy Group typically make recommendations only on medicines that have already been proven to be safe and efficacious. They do not approve medicines in the way the amendment implies, and this could infringe upon the role of the MHRA.

--- Later in debate ---

[Stephen Kinnock]

Amendment 445 would require that the Secretary of State make regulations about enforcement, including provision of imposing civil penalties, when making regulations for prescribing, dispensing, transporting, storage, handling and disposal of approved substances, including the keeping of records relating to those activities. That would be a change from the current approach in the Bill, which gives a power to the Secretary of State to make such provisions. In practice, where the Secretary of State makes regulations specifying substances under clause 20, they will necessarily make regulations under clause 28 for the prescribing, dispensing and transporting of said substances, and on enforcement, which would include imposing civil penalties.

[Danny Kruger]

Further to the intervention from the hon. Member for Bradford West, I would like to understand whether the Minister envisages an independent regulator of any sort being responsible for overseeing the regime? We currently do not know what that will be—a future Secretary of State will design it—but does he envisage that there will be some sort of regulatory body with that job, and if not the MHRA, who?

[Stephen Kinnock]

We will at some point get to clause 32, which is about the way in which the system will work, specifically with the NHS, and the role of regulation will absolutely be debated in that context. My sense is that it would be best to confront that issue when we debate clauses 32 and 39. Officials are currently working with the promoter of the Bill, my hon. Friend the Member for Spen Valley. We know that her policy intent is for the service to be an integral part of the NHS, but with some flexibility in the way it is delivered; we have briefly touched on that in previous debates. As an integral part of the NHS, it will have to be a regulated service, based on the foundations of the way in which the NHS is regulated more broadly. I think the answer to the hon. Gentleman’s question is basically yes, but the right place to debate it and potentially amend the Bill would be in clauses 32 to 39.

[Danny Kruger]

We look forward to the amendments that the Government are working on, but, as part of that process, does the Minister envisage that there will be amendments to NHS legislation itself?

[The Chair]

Order. We need to discuss the amendment, not speculate about the future.

[Kim Leadbeater]

I will speak briefly about amendments 485 and 521, on which I will respectfully disagree—not for the first time—with the hon. Member for East Wiltshire. I believe the negative procedure is perfectly adequate in matters of this kind. We had a similar debate the other day.

I will also speak to amendments 442 and 445 in the name of my hon. Friend the Member for York Central. Although I take on board the comments of the Minister about time pressures, I am minded to support both these amendments. Regulations are important and I have no problem with placing the duty on the Secretary of State in those two instances.

[Danny Kruger]

It might appear a procedural issue, but does the hon. Lady acknowledge that there is a profound difference between the negative and affirmative procedure? Why is she content that the regime for the regulation of these lethal drugs, which are at the absolute core of her Bill, be subject to the discretion of the Secretary of State, without any likelihood or any real possibility of any sort of debate in Parliament? Why should this not be through the affirmative procedure?

[Kim Leadbeater]

I am not aware of any situation in which we debate the drugs for any other type of medical provision or healthcare. I appreciate the gravity of the situation but, with all due respect to colleagues, we are not best placed to make those kinds of decisions and it is unnecessary for us to have that debate. Clinicians and experts in pharmacology and medicines are best placed to do that, under the guidance of the Secretary of State.

[Danny Kruger]

Nevertheless, the hon. Lady is proposing that this passes through Parliament, just through the negative procedure. If she thinks there is an appropriate rubberstamp by Parliament—that Parliament needs to approve this regime—why should it not have the opportunity to debate it?

[Kim Leadbeater]

As I have said, I think the negative procedure is the correct level of parliamentary involvement in that process.

Amendment 442 agreed to.

Amendment proposed: 443, in clause 28, page 17, line 4, after “substances” insert

“as approved through the Medicines and Healthcare products Regulatory Agency and either the National Institute for Clinical Excellence or the All Wales Medicines Strategy Group processes”.—(Sean Woodcock.)

This amendment requires any regulations made about the prescribing and dispensing of approved substances to be on substances approved through the Medicines and Healthcare products Regulatory Agency and either the National Institute for Clinical Excellence or the All Wales Medicines Strategy Group processes.

Question put, That the amendment be made.

--- Later in debate ---

Inquests, death certification etc

[Danny Kruger]

I beg to move amendment 522, in clause 29, page 17, line 14, leave out subsection (1).

In a letter to the editor of The Telegraph, the former chief coroner of England and Wales, Thomas Teague KC, wrote that clause 29

“would prohibit a coroner from investigating any death where the duty to do so arises only because the deceased died as a consequence of the provision of assistance in accordance with the Bill. But for that clause, the coroner would be under a statutory duty to investigate such a death and, if satisfied at inquest that the deceased had used an approved lethal substance to end his or her life with the intention of doing so, would be obliged to record a conclusion of suicide.

Since the coroner’s jurisdiction affords a powerful deterrent against misfeasance, the public may wonder why the Bill proposes to abandon such a robust safeguard. The approval of the High Court is no substitute as it would be given in advance of death and could offer no assurance”

—we have scrapped the approval of the High Court, but it would have been no substitute, and it will be the same for the panel system—

“that the assistance had been provided in strict compliance with the law or that the circumstances of the case had not changed following the court’s declaration.

If the Bill becomes law, who will provide the necessary posthumous judicial scrutiny of these unnatural deaths?”

That is a powerful suggestion from the former chief coroner.

--- Later in debate ---

[Kim Leadbeater]

That is indeed what would happen under the Bill as it stands.

[Danny Kruger]

The concern is that it should be automatic. I just cite Professor Ahmedzai’s recognition of the frequent necessity, or the distinct possibility, of a referral to the coroner being appropriate. I suggest that it should happen as a matter of course. I would be grateful to understand from the hon. Lady or the Minister under what circumstances they feel it would be appropriate for a coroner to be involved. The difficulty is that we are putting a lot of emphasis on the role of the local medical examiner to decide whether it should be appropriate for the coroner to consider a case; I suggest that they should consider all cases.

The obligation on coroners need not be over-burdensome. Some coroner’s inquests can be dealt with in as little as 20 minutes if matters are simple and not in dispute, which they would be in the great majority of the cases we are talking about. The presence of this jurisdiction—the ability of the coroner to investigate—would be a most valuable safeguard. It would help to identify whether matters have gone wrong in the act of self-administration and the process of dying, which could significantly assist whatever regulatory regime—we are yet to discover that—oversees the process. It could assist the continuous improvement of the regime.

It would also help to identify issues relating to misdiagnosis, which we know happens often. It is remarkable—and worth pointing out in response to the suggestion that terminal diagnoses are always accurate—that one study found, after autopsy, that one in four cases had been misdiagnosed. Doctors might say somebody is dying of a certain condition, but it turns out they were not.

I take the point that a coroner would not be prohibited by clause 29(1) from launching an investigation in appropriate cases, but given that we do not know what we do not know, it might be hard to decide when that is required. With a new scheme like this, it would be best to start with an investigation in every case. If, in a few years’ time, it appears that the safeguard is not needed, a future Parliament could change the law to reduce it, but I implore the Committee to consider the idea that we should start with the safest Bill we can.

[Sarah Sackman]

Under the Coroners and Justice Act 2009, coroners have a duty to investigate and certify deaths that are reported to them. That duty is triggered when they have a reason to suspect that the deceased died a violent or unnatural death, the cause of death is unknown, or the deceased died while in custody or otherwise in state detention. There are also regulations made under the powers of the 2009 Act that require medical practitioners to notify such deaths to the coroner.

Clause 29(1) disapplies the coroner’s duty to investigate in the case of an assisted death that has been carried out in accordance with the Bill’s provisions. In practice, that would mean the assisted death would instead be certified by an attending practitioner—the doctor who has attended the patient—and scrutinised by an independent medical examiner working in the NHS. Therefore, the attending practitioner and medical examiner, rather than the coroner, would certify the cause of death. It would remain open to anyone—such as a family member or a medical practitioner who has interacted with the deceased and has concerns—to report a death to the coroner if they had concerns that it had not occurred in line with the provisions of the Bill.

Amendment 522 would remove the disapplication of the coroner’s duty to investigate in relation to assisted deaths, essentially reversing the Bill’s current provisions. Consequently, given that assisted deaths are inherently unnatural, the amendment would require that the coroner has a duty to investigate each and every assisted death and then certify the cause of death. To answer the hon. Member for East Wiltshire’s point, the bereaved family would, as I have said, be able to raise any concerns with the medical examiner, and the coroner’s duty to investigate would be triggered if they suspected that death had not occurred in line with the process prescribed.

It is important to note that medical examiners follow their own structured process of investigation. They review medical records, consult practitioners involved in the case and then apply the criteria set out from the Notification of Deaths Regulations 2019 to determine whether the death meets the threshold for a coroner referral. In doing so, they would proactively speak to family members, thereby providing the opportunity for any concerns to be raised; if there are any, they would make the referral to the coroner. I hope that assists the Committee.

[Kim Leadbeater]

I will be very brief. My understanding is—I think the Minister said this—that the attending practitioner, the medical examiner or anybody else, including family members, could refer to the coroner if they felt it was necessary or suspected anything untoward. If that is the case, I am content that the Bill is fit for purpose as it stands.

[Danny Kruger]

I will respond quickly. My concern is that, as Thomas Teague said, without clause 29 the coroner would be under a statutory duty to investigate. I recognise that there is an opportunity for an investigation if a family member or the medical practitioner decides to refer it to the coroner. It is unlikely—although they might—that the medical practitioner who has overseen the death would suggest that they themselves had somehow failed in their duty or that there had been a complication they could not have dealt with.

The fact is that the only way a coroner would get involved under the Bill as it stands is if they conclude that there is something wrong on the basis of not knowing what has happened, because they have not performed any investigation. The purpose behind the amendment is to ensure that there is a statutory duty for the coroner to review the death. It is also a point of principle that it is appropriate to record the death as suicide, because that is what has happened—assisted suicide. Nevertheless, given the state of the debate, and that I suspect I am not in the majority in supporting the amendment, I will not press it to a vote. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

--- Later in debate ---

[Danny Kruger]

I think the hon. Member for Penistone and Stocksbridge meant the previous Conservative and Liberal Democrat Government—just to be strictly accurate.

[Sarah Olney]

I expect the hon. Lady did, but since none of us in the room was a member of that Government—I think—or indeed Members of Parliament at the time, I do not know how hon. Members want me to respond to that. It remains the case, I believe, that socioeconomic status is not currently a protected characteristic under the Equality Act. If anyone wants to reopen that debate, I am sure there would be an appetite for it.

--- Later in debate ---

[Sarah Olney]

I know: the Barnes ward in my constituency is one of the most unequal wards in the country, so I fully appreciate the right hon. Gentleman’s point. As I say, that is the socioeconomic indicator that I have for now, thanks to the failings of our predecessors to include it in the Equality Act, but I am open to amendments on Report if anybody has something more compelling. I do think that it really matters that we look at the socioeconomic status of people who are seeking an assisted death, and I welcome feedback—and, as I say, further amendments—on how that particular part of clause 29 could be improved.

Lastly, I included whether someone has a disability, which obviously has come up many times in the written and oral evidence. That is why I specified those characteristics in response to the evidence that we received, and why I am keen to press amendment 273 to a vote.

Amendment 273 agreed to.

[Danny Kruger]

I beg to move amendment 446, in clause 29, page 18, line 9, at end insert—

“(4) The Secretary of State must, by regulation, specify the data sets which must be made available by the Registrar General for England and Wales.

(5) Any regulations made under subsection (4) are subject to the affirmative procedure.”

This amendment requires the Secretary of State to specify in regulations the data sets which are to be made available by the Registrar General for England and Wales.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 486, in clause 29, page 18, line 9, at end insert—

“(4) A report provided under subsection (3) must include statistical analysis of—

(a) demographic information relating to those who have received assistance under the Act, including breakdowns by the protected characteristics defined under section 4 of the Equality Act 2010;

(b) the length of time between the taking of approved substances and the time of death; and

(c) any complications that occurred as a result of the administration of a substance under the provisions of this Act.”

This amendment determines the data to be collated in the reports of the Registrar General.

Clause stand part.

[Danny Kruger]

These amendments were tabled by the hon. Member for York Central. As discussed, clause 29 requires the Registrar General to

“prepare and lay before Parliament a report providing a statistical analysis of deaths”

arising. We have spoken before about the paucity of data from other jurisdictions and the problems arising when data is not collected from the start; when data is collected only in relation to one thing, such as disability in Canada; when data collection is suddenly discontinued, as in Washington state as I understand it; or when data is insufficiently granular, so that we get only the headlines. I therefore think that this approach is valuable, and I welcome the Committee’s decision to support amendment 273 tabled by the hon. Member for Richmond Park. Amendments 446 and 486 would ensure that we fix those problems from the start.

Amendment 446 would give the Secretary of State the power to specify the datasets that must be made available, and those must be approved by Parliament. MPs would then be able to interrogate what data we are collecting and what questions that enables us to answer. Ensuring that that is determined by regulation places it in law, and ensures ministerial responsibility and parliamentary oversight.

Amendment 486 sets out the data that must be included. That includes demographic information, including breakdowns by protected characteristics—and I acknowledge the conversation that has just been had on that topic—and the length of time between the taking of the approved substances and the time of death. It strikes me that that is a very important consideration. I hope that that would be specified in the data that the Registrar General will provide, but that is not clear at the moment. It is also vital that any complications are properly reported—not just recorded, but reported.

I do not propose to push these amendments to a vote; I think that the argument has been sufficiently made. I am grateful to the Committee for supporting the previous amendment. However, I wish that things were otherwise and that we were specifying more clearly what data will be collected. I hope that perhaps this debate will encourage the Registrar General to ensure that the most comprehensive data is presented to Parliament.

[Sarah Sackman]

In light of the hon. Gentleman’s remarks, I do not have anything further to add, other than to note what he has said.

[Kim Leadbeater]

I have nothing to add.

[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 29, as amended, ordered to stand part of the Bill.

Clause 30

Codes of practice

[Naz Shah]

I beg to move amendment 447, in clause 30, page 18, line 12, leave out “may” and insert “must”.

This amendment requires the Secretary of State to issue Codes of Conduct.

--- Later in debate ---

[Jack Abbott]

We all know that inequitable access to good quality health and palliative care is a massive issue across the country. People in certain communities—for example, those living in areas of high deprivation, those from black, Asian and minority ethnic communities and those from inclusion health groups, such as the homeless—already experience significant challenges in accessing quality care.

We have a duty to ensure that anyone meeting the eligibility criteria who wishes to seek an assisted death under the Bill can do so. We must therefore ensure that the requirements for which forms of proof of identity are acceptable do not exacerbate existing inequalities of access and prevent those who would otherwise meet the eligibility criteria from seeking an assisted death should they choose to.

The question of which forms of proof of identity are acceptable is therefore essential, as we know that photo ID requirements can present additional barriers to certain demographics and communities. Data from the Electoral Commission following the 2023 local elections found that while only 3% of all non-voters said that they did not vote because they did not have the required ID, that figure was 8% for unemployed non-voters and 9% for disabled non-voters who reported being “limited a lot” by their disability or health condition.

The data also found that awareness of ID requirements was lower among those without an accepted form of ID—only 74%, in contrast with 92% of the population overall. Awareness of the requirement was also lower among young people and those from black and ethnic minority communities. Clearly, a photo ID requirement could present barriers to equitable access to assisted dying. We must ensure that requirements about which forms of proof of identity are acceptable do not create new inequalities of access.

The requirement for proof of identity has been included in the Bill for a good reason, because it is a necessity and a critical safeguard. Ensuring that the Bill has the requisite safeguards for assisted dying to be safely implemented is essential to what the Committee is doing. It is therefore important to get right the question of what forms of proof of identity are acceptable for someone to access assisted dying under the Bill. We must also ensure equity of access to the service without diluting critical safeguards.

Clause 6 says that the regulations regarding the forms of proof of identity that are acceptable are subject to the negative procedure, but the issue is too important to be left to that negative procedure without sufficient parliamentary scrutiny. By including the requirements for which forms of proof of identity are acceptable in clause 30, the amendment would rectify that. It would entail that the regulations pertaining to which forms of proof of identity are acceptable under clause 6 are subject to the affirmative procedure and that, prior to the Secretary of State issuing a code of practice in relation to the question, they would have to consult such persons as they considered appropriate.

By agreeing the amendment, we would guarantee that the question of which forms of proof of identity are acceptable is given the requisite consideration. That would ensure that the requirements do not act as a barrier to equitable access to assisted dying, without diluting the safeguards that the requirement inserts into the Bill.

[Danny Kruger]

I want to quickly explain that my amendment 523 is consequential on amendment 447, but there is drafting issue. I will not go into the details but, if amendment 447 is made, as I understand it will be, my amendment 523 is not necessary. I would be grateful for the Minister’s guidance: if he has been advised by parliamentary counsel that the clause as amended by amendment 447 is okay and there is no need for amendment 523, I do not propose to press it to a vote.

[Stephen Kinnock]

This group of amendments relates to clause 30 of the Bill and the codes of practice that may be issued by the Secretary of State.

As the Bill is drafted, the Secretary of State may issue one or more codes of practice in connection with arrangements pertinent to the assisted dying process. Amendment 447 requires the Secretary of State to issue such codes, substituting “must” for “may”. As such, codes of practice would need to be issued for all matters listed in clause 30(1).

Amendment 394 has the effect of broadening to Secretary of State’s power to issue codes of practice, explicitly enabling the Secretary of State to issue guidance in connection with

“information and support to persons with learning disabilities who are eligible to request assistance”

under the Bill, including information and support about the role of advocates. I note that under the Equality Act 2010, health providers are already under a duty to make reasonable adjustments in the provision of services, including for persons with a learning disability. That duty includes taking steps to provide information, including on what support services are available.

As drafted, clause 30(1)(c) provides that the Secretary of State may issue codes of practice on

“the arrangements for ensuring effective communication in connection with the provision of assistance…including the use of interpreters”.

Amendment 448 provides that, if the Secretary of State issues codes of practice that include the use of interpreters, those interpreters should be “registered and qualified”. The amendment would limit those who are able to translate to only those who are registered and have a recognised qualification. However, the amendment does not state who or what such a registration would be with, or what would constitute a recognised and appropriate level of qualification.

Amendment 534 adds to the list of codes of practice that the Secretary of State may issue. The addition is a code of practice on the acceptable forms of proof of identity when a person makes a first declaration. Clause 6(3) of the Bill already provides a regulation-making power that sets out the acceptable forms of proof of identity. Amendment 534 would give the Secretary of State a power to make codes of practice about how someone can ensure they are compliant with the requirements set out under clause 6(3). The amendment has little practical effect, because clause 30(1)(e) already provides a wide power for issuing codes of practice, providing that the Secretary of State may issue codes of practice on

“such other matters relating to the operation of this Act as the Secretary of State considers appropriate.”

Amendment 523 allows the Secretary of State to issue further codes of practice at his discretion, should they not be covered by the preceding subsection (1) of this clause. The Bill’s promoter has said she is minded to support amendment 447, and the hon. Member for East Wiltshire asks whether, if amendment 447 is incorporated into the Bill, that renders amendment 523 unnecessary or surplus to requirements. I am not entirely sure, so I will quickly check while the Bill’s promoter is making her remarks and come back to him immediately.

--- Later in debate ---

[Daniel Francis]

My hon. Friend knows my concerns but she knows that I will be supporting the amendment this evening.

Advocates must have an understanding of the available end-of-life options and be able to communicate clearly and explain to patients the medical treatments available: palliative care, social care and assisted death. That is quite complex. As I have said previously, my own experience of mental capacity relates to my daughter: she would never have the capacity to be able to make such a decision. But on a daily basis, including this morning, I have to explain a two or three-point decision-making process. It is vital that advocates are there and that they have the training.

For many people such as my daughter, who is almost blind as well as being learning disabled, there are additional communication skills given that they have those extra sensory difficulties. It is vital for people such as Mrs Cook’s daughter, who might be vulnerable to influence, that the advocate must be able to explain all the options clearly without pressurising the person down one route. I believe the amendment will provide important support to those with less capacity or difficulty in understanding all the options in front of them.

As I have said, the two things that I have banged on about consistently in this process have been about learning disability and mental capacity. There has been a conflict for me, even with this amendment, but I am confident that the amendment tabled by my hon. Friend the Member for Penistone and Stocksbridge comes from a very good place. We will come to this next week but, like my hon. Friend, I have consistently listened to Mencap’s evidence, which also talked about reviewing the Bill at an earlier stage than is currently envisaged. That is why I have tabled amendments 493, 494 and 495 for next week.

My view is that if the Bill becomes law, the system will work well if the regulations are implemented correctly. I will support the amendment tabled by my hon. Friend the Member for Penistone and Stocksbridge; I thank her for bringing it forward. I know that my hon. Friend the Member for Spen Valley has listened hard, and I am grateful. I think there will be a degree of unanimity this evening.

[Danny Kruger]

I pay tribute to the hon. Member for Penistone and Stocksbridge for the amendments that she tabled and to the work that she has been doing on our Committee. I regret her victory over my friend, the former MP for Penistone and Stocksbridge, but the hon. Lady is bringing a lot to Parliament and to this Committee.

I am happy to follow the hon. Member for Bexleyheath and Crayford in supporting the amendments. I do not know whether the hon. Lady is in a position to respond with a further speech or by intervening, but I have some concerns about their operation. I recognise that the role of the independent advocate exists in our system already, very usefully and importantly: I see its value and appropriateness for an assisted dying regime. But if the amendments are accepted, we will be introducing the role of the independent advocate with the sombre recognition that it is necessary, in consequence of a Bill that will allow doctors to discuss ending the patient’s life as an option with anybody, no matter how well-equipped or ill-equipped that person may be to handle such a conversation on their own, and no matter how old they are—they could even be 18 years old. I support the amendments, but I do so in recognition of the very significant dangers that I think the Bill represents to all potential applicants.

I want to ask the hon. Member for Penistone and Stocksbridge, or perhaps the Minister or the Bill’s promoter, whether they feel that the amendments go to the heart of the concerns raised by the hon. Member for Bexleyheath and Crayford. I am pleased to hear that he is satisfied and will support the amendments, although I echo some of the suggestions of concern that he just made.

New clause 25 makes it clear that the advocate is there to provide support if the person

“is seeking to understand options around end of life care, including the possibility of requesting assistance to end their own life”.

Amendment 517 addresses the need for a code of practice when a qualifying person is requesting assistance to end their own life.

My question is whether the new clause and the amendment fully cater for a situation in which that individual is not requesting assistance to end their own life—when they are not seeking to explore that particular option. Given that we have retained the right of medical professionals to raise the possibility of assisted dying unprompted with patients, I am concerned about whether, as I think the hon. Member for Bexleyheath and Crayford implied, the medical professional initiates the conversation, or the advocate themselves is supportive of assisted dying and they deliberately or inadvertently have the effect of encouraging the patient to consider that option.

As I think the hon. Member for Penistone and Stocksbridge said in her intervention on the hon. Member for Bexleyheath and Crayford, new clause 25 creates the role of independent advocate to provide support to a patient, to help them to effectively understand and engage with all the provisions in the Bill. It does not specify that the advocate should be obliged, equipped or experienced in supporting the patient to engage with other options.

[Dr Tidball]

First, it is necessary that a patient should be able to engage with all the provisions in the Bill. The reason I did not support the previous amendments from my hon. Friend the Member for Bexleyheath and Crayford was that they would only have provided advocacy at too late a stage and would not effectively support a patient at that point we talked about in clause 4, which is around the moment of seeking assistance. I hope that answers the question.

[Danny Kruger]

I am grateful to the hon. Lady. That is very helpful. That is my concern: we need to ensure all necessary support for the patient at the earliest stage possible.

--- Later in debate ---

[The Chair]

Order. The Member will have an opportunity to speak at the end of the debate. I call Danny Kruger.

[Danny Kruger]

I thank the hon. Lady. I worry a little about the magic powers of the training fairy, whom we frequently invoke to resolve all the anxieties. We are putting the resolution of difficult tensions on to future professionals and imagining that through training we can resolve all the difficult challenges. However, given the absolute and obvious value of an independent advocate for the people who need that role in the process and given that the hon. Member for Penistone and Stocksbridge has asserted that it is important for the role to be fulfilled at the earliest stage possible, which I entirely agree with, I am happy to support the amendments.

--- Later in debate ---

[Dr Tidball]

I am grateful for the support of my hon. Friends the Members for Spen Valley and for Bexleyheath and Crayford. It sounds that I may also have the support of the hon. Member for East Wiltshire, which also makes me very happy at this stage of the evening!

I tabled these amendments because I passionately believe in inclusive healthcare for disabled people, removing barriers to such healthcare where possible, and ensuring that disabled people have a strong voice in advocating for themselves and the healthcare they need or desire. I have tried to write the amendment and the new clause to ensure that access to an independent advocate operates across the functions of the Bill. I have been keen to ensure that this provision acts in conjunction with new clause 27, which I will speak about at a later stage. I hope, as I said in an earlier response to the hon. Member for East Wiltshire, that that will provide a solid and robust opportunity to monitor the impact on disabled people of the Bill, if it does pass through Parliament, through its implementation and in practice. Taken together, the measures will create a solid foundation to enable disabled people to have a voice and will provide a strong structure for accountability in the Bill.

I acknowledge the Minister’s comments, and will work with him and my hon. Friend the Member for Spen Valley to ensure that it is watertight.

Amendment 517 agreed to.

Amendment made: 534, in clause 30, page 18, line 30, at end insert—

“(da) the forms of proof of identity that are acceptable for the purposes of section 6.”—(Jack Abbott.)

Amendment made: 523, in clause 30, page 18, line 31, leave out paragraph (e) and insert—

“(1A) The Secretary of State may issue one or more codes of codes of practice in connection with any matters relating to the operation of this Act not required under subsection (1) as the Secretary of State considers appropriate.”—(Danny Kruger.)

This amendment, which works together with Amendment 447, would clarify that the Secretary of State is not required to issue a code of practice under subsection (1)(e) but instead has the discretionary power to issue further codes of practice as the Secretary of State considers appropriate.

Amendment made: 417, in clause 30, page 18, line 32, at end insert—

“(1A) The Secretary of State must, within six months of the passing of this Act, issue one or more codes of practice in connection with the arrangements for ensuring effective communication in connection with the provision of assistance to persons in accordance with this Act, including the use of interpreters.”—(Jack Abbott.)

This amendment is linked to Amendment 416.

Amendments made: 216, in clause 30, page 18, line 37, leave out subsection (4).

See the statement for Amendment 188.

Amendment 217, in clause 30, page 18, line 38, leave out “that procedure” and insert “section 39”.—(Kim Leadbeater.)

See the statement for Amendment 188.

[Danny Kruger]

On a point of order, Mrs Harris. Before I move the next amendment, I wish to correct the record. I do not know if this is the moment to do so, but I wish to correct a mistake I made earlier today.

[The Chair]

Yes, go on then.

[Danny Kruger]

I am grateful, Mrs Harris. Earlier, I cited evidence about an exodus of care workers from the Australian care system. Members challenged me on that—fairly. I have been looking since, and I could not find the evidence that was in my mind. I think I was confusing it with evidence about the number of palliative care professionals who said that they would not want to work in the sector if assisted dying were performed by their organisations. The only evidence I have got on Australia was from Robert Clark, the Attorney General, who, rather than referring to statistics, gave his own evidence on how many professionals are leaving the Victorian hospital system in consequence of the introduction of voluntary assisted dying. I thought I had statistical evidence to show an exodus, but I did not. I am correcting the record and I apologise to the Committee.

[The Chair]

I thank the hon. Member.

[Danny Kruger]

I beg to move amendment 524, in clause 30, page 18, line 40, leave out from “have regard to” and insert “comply with”.

This amendment would require individuals to comply with the Codes of Practice issued by the Secretary of State.

[The Chair]

With this it will be convenient to discuss clause stand part.

[Danny Kruger]

The amendment would specify that individuals should comply with the codes of practice issued by the Secretary of State. I am glad that the hon. Member for Spen Valley agreed to accept an earlier amendment requiring the Secretary of State to issue codes of practice. That was a helpful step, but it is not quite sufficient, because it does not address the critical weakness in the Bill. Time and again, we have been told that amendments tabled are not suitable for the face of the Bill and that we should rely on codes of practice and guidance that will be issued subsequently. Now we are at this point, though, and it is clear that under clause 30(6) the code of practice is something that those

“performing any function under this Act must”,

simply, “have regard to”.

We have been told repeatedly by the Minister that the Government’s preference is to leave things until later and not to address issues on the face of the Bill, because additional words, phrases and amendments would increase risk and be counterproductive. That is an argument that we have heard from the Government Front Bench repeatedly. Other Members have dismissed as embroidery suggested amendments to strengthen safeguards; it has been suggested that the more we write, the less safe the Bill will be. I do not think those arguments will survive the other place, if the Bill arrives there. There is a vast difference between something in the Bill that must be “complied with” because it is in legislation, and something that those providing assistance under the Bill must only “have regard to”. It is perplexing that the Bill does not clearly specify that practitioners should “follow” or “act in accordance with” the guidance. These words matter.

The Office of the Parliamentary Counsel explores the choice of these different phrases in its guidance on common legislative problems. That guidance was produced by the drafter of this Bill, the former First Parliamentary Counsel, Elizabeth Gardiner. It is quite a deliberate policy choice to leave compliance with these codes of practice to the discretion of the individuals rather than to require it. The guide to making the legislation—the Cabinet Office manual, which the drafter would have been very familiar with—states:

“A ‘code of practice’ is an authoritative statement of practice to be followed in some field. It typically differs from legislation in that it offers guidance rather than imposing requirements: its prescriptions are not hard and fast rules but guidelines which may allow considerable latitude in their practical application and may be departed from in appropriate circumstances. The provisions of a code are not directly enforceable by legal proceedings…

Codes of practice are not to be used to define specific legal obligations. Where specific legal obligations are to be imposed, breach of which leads directly to civil or criminal liability, their content should be spelled out in primary or secondary legislation. A code of practice is not appropriate for this purpose, either to delineate the main obligation or to provide for exceptions or defences.”

I do not think it appropriate that so much is being left to ministerial discretion. I find this perplexing. Not to make a party-political point, but we know how much Labour MPs distrust Conservatives, and yet they are seemingly willing—as indeed, Conservative colleagues in support of this are—

[The Chair]

Order. Can we keep to the point?

[Danny Kruger]

The point I am making is that we are suggesting that some future Secretary of State, in a different Government of which we know nothing, might decide to issue codes of practice that will determine how this process is delivered, but I will leave that point.

We must address the weak status of these codes of practice. I regret that they are being left in this weak form. At a minimum level, we should require that they are properly complied with. This cannot be remedied after the Bill has passed. No matter how strong the language in the codes of practice, that language cannot override or change the nature of a statutory duty. Any enhanced duty has to come from a source external to the document being considered itself—namely, the statute. I ask the hon. Member for Spen Valley, why not insist that practitioners comply with the relevant provisions of the code?

[Stephen Kinnock]

I will speak on amendment 524, in the name of the hon. Member for East Wiltshire. As the Bill stands, a person is required to “have regard to” any codes of practice issued by the Secretary of State when performing a function under the Bill. Amendment 524 would mean that individuals are instead required to “comply with” the codes of practice issued. That could limit someone to doing only what is specified in the code, rather than allowing them to exercise their professional discretion to perform the function in the most appropriate way, having given regard to the code. It is also unclear from the amendment who would monitor or enforce compliance with the codes. Codes of practice are normally detailed practical guidance on how to comply with legal obligations, and are generally not legally binding.

I hope those observations are helpful to the Committee.

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

Danny Kruger Excerpts

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[The Chair]

Would everyone ensure that all electronic devices are turned off or switched to silent mode? Tea and coffee are not allowed in the Committee Room. I remind Members that interventions should be short, and raise points of clarification or questions; they should not be speeches in and of themselves. Members who do wish to give a speech should bob and continue to do so throughout the debate that they wish to speak in, until they are called. When Members say “you”, they are referring to the Chair. “You” should not be used to refer to each other. Debate should come through the Chair.

Clause 32

Secretary of State’s powers to ensure assistance is available

[Danny Kruger (East Wiltshire) (Con)]

I beg to move amendment 525, in clause 32, page 19, line 26, leave out subsection (2).

[The Chair]

With this it will be convenient to discuss the following:

Amendment 537, in clause 32, page 19, line 27, after “assistance” insert

“by a registered charity but not”.

This amendment would limit the provision of an assisted death to charitable providers and not permit provision as part of the National Health Service.

Amendment 528, in clause 32, page 19, line 27, at end insert—

“(2A) Regulations under subsection (1) cannot authorise a body other than a public authority from providing such assistance even if that body is to be contracted by a public authority to do so.”

Amendment 529, in clause 32, page 19, line 28, leave out subsection (3).

Amendment 530, in clause 32, page 19, line 31, at end insert—

“(5) The Secretary of State may not lay a draft statutory instrument before either House of Parliament that makes provision containing (whether alone or with other provision) regulations under subsection (1) unless they also lay before both Houses an impact assessment on such regulations.

(6) The impact assessment under subsection (5) must include an assessment of the impact of such regulations on the workforce of health professionals and on the National Health Service.”

Clause stand part.

Amendment 545, in clause 39, page 23, line 6, leave out subsections (3) to (5) and insert—

“(3) The Secretary of State may not make a statutory instrument containing (whether alone or with other provision) regulations under section 5(3A), 8(6A),30(3), (Voluntary assisted dying services: England) or (Voluntary assisted dying services: Wales) unless a draft of the instrument has been laid before, and approved by a resolution of, each House of Parliament.

(4) Any other statutory instrument made by the Secretary of State containing regulations under this Act is subject to annulment in pursuance of a resolution of either House of Parliament.

(5) The Welsh Ministers may not make a statutory instrument containing regulations under section (Voluntary assisted dying services: Wales) unless a draft of the instrument has been laid before, and approved by a resolution of, Senedd Cymru.”

This amendment brings together the various provisions about the procedure for regulations. It also makes regulations under clauses 5 and 8 about training, qualifications and experience, and regulations under NC36 and NC37, subject to the draft affirmative procedure.

New clause 36—Voluntary assisted dying services: England—

“(1) The Secretary of State must by regulations make provision securing that arrangements are made for the provision of voluntary assisted dying services in England.

(2) In this section ‘commissioned VAD services’ means services provided by virtue of regulations under subsection (1).

(3) The Secretary of State may by regulations make other provision about voluntary assisted dying services in England (whether or not the services are commissioned VAD services).

(4) Regulations under this section may for example provide that specified references in the National Health Service Act 2006 to the health service continued under section 1(1) of that Act include references to commissioned VAD services.

(5) Regulations under this section must provide that section 1(4) of that Act (services to be provided free of charge except where charging expressly provided for) applies in relation to commissioned VAD services.

(6) Regulations under this section may make any provision that could be made by an Act of Parliament; but they may not amend this Act.

(7) In this section ‘voluntary assisted dying services’ means—

(a) services for or in connection with the provision of assistance to a person to end their own life in accordance with this Act, and

(b) any other services provided by health professionals for the purposes of any of sections 4 to 22 except section (Determination by panel of eligibility for assistance).”

This new clause imposes a duty on the Secretary of State to make regulations securing that arrangements are made for the provision of voluntary assisted dying services in England. It also confers a power to make other provision about voluntary assisted dying services in England.

Amendment (a) to new clause 36, after subsection (1) insert—

“(1A) Regulations under subsection (1) cannot authorise the National Health Service in England to provide voluntary assisted dying services.”

Amendment (c) to new clause 36, after subsection (1) insert—

“(1A) Regulations under subsection (1) cannot authorise a body other than a public authority to provide voluntary assisted dying services if that body is to be contracted by a public authority to do so.”

Amendment (b) to new clause 36, leave out subsections (4) and (5) and insert—

“(4) Regulations under subsection (1) may not amend, modify or repeal section 1 of the National Health Service Act 2006.”

Amendment (d) to new clause 36, leave out subsection (6).

Amendment (e) to new clause 36, after subsection (6) insert—

“(6A) The Secretary of State may not lay a draft statutory instrument before either House of Parliament that makes provision containing (whether alone or with other provision) regulations under subsection (1) unless they also lay before both Houses an impact assessment on such regulations.

(6B) The impact assessment under subsection (6A) must include an assessment of the impact of such regulations on the workforce of health professionals and on the National Health Service.”

New clause 37—Voluntary assisted dying services: Wales—

“(1) The Welsh Ministers may by regulations make provision about voluntary assisted dying services in Wales, including provision securing that arrangements are made for the provision of such services.

(2) Regulations under subsection (1) may make any provision that—

(a) could be made by an Act of Senedd Cymru, and

(b) would be within the legislative competence of the Senedd if it were contained in such an Act.

(3) The Secretary of State may by regulations make provision about voluntary assisted dying services in Wales.

(4) Regulations under subsection (3) may make any provision that—

(a) could be made by an Act of Parliament, and

(b) would not be within the legislative competence of the Senedd if it were contained in an Act of the Senedd.

(5) Regulations under this section may not amend this Act.

(6) In this section ‘voluntary assisted dying services’ has the meaning given by section (Voluntary assisted dying services: England).”

This new clause confers a power on the Welsh Ministers to make provision about voluntary assisted dying services in Wales, including provision securing that arrangements are made for the provision of such services. It also confers a power on the Secretary of State to make provision about such services, where the provision would be outside the legislative competence of Senedd Cymru.

[Danny Kruger]

It is very good to serve under your chairmanship, Ms McVey, on what is probably our last day in Committee. I fully expect that we will reject clause 32 in due course, so although I want to move my amendment, I have no intention of pushing it or any of the other amendments in this group to a vote, but I do want to take the opportunity to address the clause and to speak to the amendment in my name.

Clause 32 was always going to be an important one, because it would have allowed the Government to provide money to fund the assistance to die; it would have allowed the Secretary of State to make financial arrangements to secure the provision of assistance under the Bill. What we might have been debating if we were sticking with this clause—I think it is still worth inviting the hon. Member for Spen Valley and people who support the Bill to speak to this point—is that the Bill will require the Government to fund the provision of assisted suicide services, but it makes no provision to fund the supply of palliative care. I think everyone in this Committee recognises the absolute imperative of a properly supported palliative care sector, and I deeply regret that although the Government are supporting a resourcing of this new service, there is no balancing commitment to provide what we have all acknowledged is the essential corollary of any assisted dying service. What is worse, in clause 32 and in new clause 36, which will replace it, we have something different.

Last Wednesday night, just as the Committee rose, the hon. Member for Spen Valley tabled amendment 538, which would remove clause 32 from the Bill. This is the clause that committed the Secretary of State to make the financial commitments—commitments that were debated in principle when the House debated the money resolution on 22 January. Once again, I regret that important undertakings that were made by the Government and by the hon. Lady have, in the course of the debate subsequent to Second Reading and now subsequent to the money resolution, been superseded by further provisions.

Amendment 538 is consequential on two new clauses, one of which is new clause 37, which will allow Welsh Ministers to set up a system to implement the Bill in Wales. This will give very wide powers to Welsh Ministers, including the powers to make provision about the service that would be outside the legislative competence of Welsh Ministers. That is significant. Unlike clause 32 and new clause 36, which will replace it, new clause 37 does not make any reference to the health service in Wales. I think it is worth us teasing out the challenge to the devolution settlement that these new clauses represent; I am sure the right hon. Member for Dwyfor Meirionnydd will speak to that.

I want to speak briefly, but I hope clearly and powerfully, to the essential challenge. Without getting too involved in the party politics, we all talk about “our NHS”, and in a sense it is our NHS: this nation’s great domestic institution, created in the 20th century in response to the shamefully inequitable provision of healthcare that preceded 1946. Labour rightly claims the credit for having introduced the NHS under the Attlee Government and in fact the Liberals also have a good claim to it—it was a Liberal, Beveridge, who first advocated the provision of a national health service—but what is not enough recognised is that, as I am sure my hon. Friends are proud to say, it was a Conservative Health Secretary who first put before the House of Commons a plan for a national health service: Henry Willink, Health Secretary in the wartime coalition Government. Unfortunately, the public voted us out of power in 1945 and it fell to Labour to implement a slightly different plan. Nevertheless, we can all claim some parentage of this great institution, the NHS. That is why it is so significant that in the new clauses we are debating, a fundamental change to the NHS in England is proposed.

The duty on the Secretary of State under the National Health Service Act 1946, as updated in 2006, is to promote

“a comprehensive health service designed to secure improvement in the physical and mental health of the people of England…and the prevention, diagnosis and treatment of illness”—

that is, physical and mental illness. That has been the purpose of the NHS since 1946.

I find it curious that a linguistic sleight of hand is being practised in new clause 36. The new phrase, “voluntary assisted dying services” or “VAD services”, is introduced, and it is used to avoid having to spell out that section 1(1) of the NHS Act 2006 will now include references to “assistance to end” the lives of people in England and Wales—that is the language of the Bill as introduced, in the long title and in nearly every clause up to this point. The explicit language that this is about ending people’s lives is avoided in the new clause. Why? I put it to the Committee that it is a hard thing to do: to take a red pen to Bevan’s legacy, to fundamentally change the NHS from one that is

“designed to secure improvement…in the physical and mental health”

of the people of England and Wales, and dedicated to

“the prevention, diagnosis and treatment of…illness”,

and to add to that founding clause “to end” the lives of terminally ill people.

I will be blunter than the drafters have been. New clause 36 changes the NHS from being the national health service to the national health and assisted suicide service. That is its direct implication. Furthermore, the new clause is also designed not only to alter fundamentally the national health service, but to enable the private sector to be paid from NHS funds to end the lives of terminally ill people—and not only that, but to do so with a Henry VIII power so broad as to enable any changes in the NHS or any law to facilitate that goal.

[Dr Simon Opher (Stroud) (Lab)]

Does the hon. Gentleman accept that end-of-life care is also part of the NHS? That has always been part of the NHS, and it is not promoting health but enabling a good death.

[Danny Kruger]

No, I fundamentally disagree: end-of-life care is healthcare. It is addresses symptoms and conditions, and it is designed in a way that is completely compatible with the founding principle of the NHS, whereas the Bill—I appreciate the honesty of the drafters in recognising this, even if they do not quite spell it out—and its proposal of an assisted suicide service is not compatible with the founding principle of the NHS. That is why adapting that founding subsection as in the original NHS Act is required. Of course I recognise that end-of-life care is healthcare and completely compatible with what the NHS does. I wish it were more part of the NHS—that is another debate. Palliative care should have been more closely integrated into NHS provision, and it still should be.

I want to tease out a tension among the drafters and advocates of the Bill about exactly how the assisted suicide service will be facilitated and provided. We have got a bit closer to it, but some questions remain, which is regrettable when here we are on the very last day of the Committee’s debate. Last month, the hon. Member for Spen Valley told the Committee:

“This is not assisted suicide by the state. The state is not involved.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 11 February 2025; c. 318.]

I am perplexed by that. I think many members of the public would not agree with that analysis of how the Bill has evolved in Committee. If involving the state in the provision of this service was not intended, then that is not the Bill we have.

In contradiction to that, and I think more accurately, the Minister for Care told us that the promoter’s intent—speaking for the hon. Member for Spen Valley—is

“to ensure that the assisted dying service is available as an integral part of the NHS. Officials are working on amendments to later clauses to establish the operating model for her consideration.” —[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 5 March 2025; c. 802.]

That is clearly what has happened, and it is where we are now. However, I am sorry to say that I do not feel that the operating model is now clear. We still do not have an impact assessment, we do not know how the Government envisage it working in practice, and important information is still lacking for the debate today. We do not know the possible impact on general practice or medical specialists, nor how it might impact money that is available for palliative care. I hope the Minister can tell us more today about how he envisages the service being implemented, especially in the light of the British Medical Association conference earlier this month, which supported the motion that

“Assisted dying is not a health activity and it must not take place in NHS or other health facilities”.

That is a principle I agree with.

On 5 March, the hon. Member for Spen Valley said:

“there is no expectation that assisted dying would be set up as a private enterprise or service. It would be delivered within the provision of the NHS.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 5 March 2025; c. 799.]

That now agrees with the Minister—fine, interesting; it is to be an NHS service not to be provided privately. But the new clauses do not rule out private provision, nor any profit making by providers or remuneration of people outside the NHS. Indeed, the new clauses refer to “voluntary assisted dying services”, which suggests the hon. Member for Spen Valley is supportive of services outside those that are NHS commissioned, which will be possible under subsections (1), (3) and (7)(a). That will be in line with comments made by my right hon. Friend the Member for North West Hampshire, who made a very coherent case for private provision of assisted suicide if that is what Parliament chooses to legalise; he said that nothing should prevent someone from opting for private provision. In response, the hon. Member for Spen Valley said:

“This service, like many others, will be delivered through a range of providers”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 5 March 2025; c. 800.]

I remain unclear about the extent to which this is an NHS monopoly, as it were, or whether there will be private provision that is privately paid for, or private provision that is publicly paid for. I would be grateful for the hon. Member’s clarification.

Lastly, on the question of profit, in an article in The Times that appeared to have some briefing behind it, there was a suggestion that there would be a cap on the profit of private companies providing the service, limiting them to “making a reasonable profit”. Again, there is nothing in the new clauses about limitations on providers’ profits. If the hon. Member could clarify how she envisages the private provision of the service, I would be grateful.

[Sean Woodcock (Banbury) (Lab)]

It is a pleasure to serve under your chairship, Ms McVey. I rise to speak to amendment (b) to new clause 36, which was tabled by my hon. Friend the Member for Shipley (Anna Dixon). The amendment states:

“Regulations under subsection (1) may not amend, modify or repeal section 1 of the National Health Service Act 2006.”

For clarity, I will read out the relevant part of section 1 of the 2006 Act:

“The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

(a)in the physical and mental health of the people of England, and

(b)in the prevention, diagnosis and treatment of physical and mental illness.”

Those core principles have remained the same since the National Health Service Act 1946. As the hon. Member for East Wiltshire stated, in a Britian that was devasted by war, Clement Attlee and Nye Bevan together promised a better future, one where healthcare should be available to all, regardless of wealth. It enshrined a principle that as a society we will care for the ill and we will do that together. No one’s health should be left behind, especially that of the vulnerable.

The NHS stands as the greatest legacy of a Labour Government—despite the input of Opposition parties referred to by the hon. Member for East Wiltshire—and perhaps of any Government since the second world war. The establishment of the NHS lives on in section 1 of the NHS Act. It is why at the height of the pandemic NHS staff courageously put themselves on the frontline to protect us. It is their mission to secure improvement in the physical and mental health of all, free at the point of service. As we consider assisted dying, we must not lose the values at the heart of the NHS.

Section 1 of the 2006 Act has changed little from the corresponding first section of the 1946 Act. It is not just a line in legislation; it has become part of our national story and our national identity, and amendment (b) to new clause 36 is about continuing that. It seeks to preserve the legacy of Attlee and Bevan, and that of Labour Governments committed to the betterment of the people.

Twenty-five senior doctors and pharmacists from Shetland and Orkney spoke of that legacy in their written evidence:

“We note with pride the founding principles of the NHS, with the 1946 National Health Service Act stating, ‘It shall be the duty of the Minister of Health…to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness.’ We believe that Parliament must reflect the lasting ethos of our founding document.”

There are very few lines in legislation that come to represent an institution in this way. It is a testament to the ideal of those founding principles in section 1 that they guide doctors to this very day. This is the thread that runs through the 1946 Act to the 2006 Act—two Labour Governments, 60 years apart, united by this mission to improve the physical and mental health of the people. This Committee should continue the thread of those principles.

Of course, I understand that previous legislation may need to be amended to provide assisted dying services, and that may include the 2006 Act. New clause 36(4) clarifies that specified references to commission voluntary dying services may be included in that Act. I note with regret that the new clause gives us so little information elsewhere about the use of these powers, which are commonly known as Henry VIII powers or clauses. This is not a term that I was familiar with until very recently. I am sure other Members are much more familiar with it than I am, but on the off-chance that there are one or two Members who need a reminder, I will read Parliament’s own official definition of the term:

“‘Henry VIII clauses’ are clauses in a bill that enable ministers to amend or repeal provisions in an Act of Parliament using secondary legislation, which is subject to varying degrees of parliamentary scrutiny.”

Helpfully, it adds:

“The expression is a reference to King Henry VIII’s supposed preference for legislating directly by proclamation rather than through Parliament.”

I accept that it might be rather odd to talk about Henry VIII in this debate, but we should not let that distract us from the serious question of this new clause, which could result in a significant transfer of power from Members of this House to the Secretary of State, and it is not clear what that power will be used for.

The Hansard Society has noted that there is little indication about what role or nature these powers will take, saying:

“A key principle that the House of Lords Constitution Committee has applied to delegated powers is that they ‘should not be framed in such a way that gives little indication of how they should be used.’ The Delegated Powers and Regulatory Reform Committee’s guidance to Departments states that the Delegated Powers Memorandum should set out how it is proposed that a power should be exercised.”

I would be grateful if my hon. Friend the Member for Spen Valley and Ministers could provide clarity on those questions. New clause 36(1) does not specify that voluntary assisted dying be provided on the NHS, but subsection (4) allows for the National Health Service Act 2006 to be amended. What is the intention of these powers? What will the structure of the voluntary assisted dying service be? How will it be funded and who will be responsible for the provision of the services? The answer to those questions will inform which legislation needs to be amended, and that information should be in the Bill.

To be clear, as I have said, I accept that changes to previous legislation may be required. However, the provision of assisted dying should not amend the foundational principles of the national health service. It should not break with the legacy of Attlee, of Bevan and of Labour. That is why I support amendment (b) to new clause 36.

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[Sarah Olney (Richmond Park) (LD)]

It is a pleasure to serve under your chairmanship, Ms McVey.

In Richmond Park, a Henry VIII power has traditionally meant the right of the monarch to hunt the deer in the large open space that gives my constituency its name—something that I am sorry to say he has in common with the dog of the hon. Member for East Wiltshire—

[Danny Kruger]

I didn’t know it was illegal. [Laughter.]

[Sarah Olney]

He paid a hefty fine, I think.

The efforts of Henry VIII’s descendants to try to enclose the park and maintain the powers for the exclusive benefit of the royal family were defeated by a popular and somewhat genteel uprising of the residents of Richmond. I stand here today as the Member for Richmond Park to do a similar job: to assert the rights of the House of Commons and the Houses of Parliament to determine what legislation is, and not to allow it to be delegated under Henry VIII powers.

The normal approach is that legislation made by Ministers is delegated legislation, and such legislation is therefore of subsidiary character to primary legislation. However, there is a type of power, known as a Henry VIII power, that gives Ministers the power to amend even primary legislation. The glossary on Parliament’s website says:

“The expression is a reference to King Henry VIII’s supposed preference for legislating directly by proclamation rather than through Parliament.”

We may in the course of time start to refer to them as President Trump powers—who knows?—but that is the precedent we act on.

The Hansard Society, a non-partisan organisation that is neutral on assisted dying, issued a report that was critical of the power in the Bill. It said this:

“little can be deduced about how it is thought this power will be used in practice, beyond the fact that it may, in particular, be used to enable the provision of assisted deaths through the National Health Service.

But as the DPRRC”—

the Delegated Powers and Regulatory Reform Committee—

“has previously stated, where a power provides that delegated legislation may ‘in particular’ include a specified matter, it implies the legislation may deal with matters beyond that specified matter. The explanatory notes shed little more light, except to clarify that the power could be used to make arrangements for the funding of any provision made by the regulations. Could the regulations thus be used to enable the provision of assistance through the private sector on behalf of the health service in England and in Wales? If the intention is that the regulations will be used only to establish an assisted dying service, either within or separately to the NHS, would they require that the service be free at the point of access to the person requesting assistance?

A key principle that the House of Lords Constitution Committee has applied to delegated powers is that they ‘should not be framed in such a way that gives little indication of how they should be used.’ The DPRRC’s Guidance to Departments states that the Delegated Powers Memorandum should set out how it is proposed that a power should be exercised.

In the current absence of the DPM, MPs may therefore wish to seek clarification from the sponsor of the Bill, Kim Leadbeater, about how she envisages the power being used, and similarly from Ministers how they expect to use this power if it were granted to them.”

The drafter of the Bill, Dame Elizabeth Gardiner, appeared on the Hansard Society podcast and gave some further detail on this power and how it arose:

“In other areas, like, is it going to be delivered through the National Health Service or in some other way, indeed the regulation of any substances that might be involved, in the time available, we didn’t have time to go into all the detail of how those regimes work and to make the provision on the face of the Bill, and so there are regulation making powers there, which enable that provision to be set out in detail, as you say, when the Government has looked at it and decided how it would implement it.”

Given the time available and the constraints of the private Member’s Bill process, the hon. Member for Spen Valley can be forgiven for not including the detail of how assisted dying will be provided on the NHS in the Bill on its introduction, but she and the Government have now had months to think about it. Many people had hoped that clause 32 would be replaced with detailed arrangements for the delivery of the service, to be put on the face of the Bill by way of an amendment, which the Committee could properly scrutinise.

On 5 March, the hon. Member for Spen Valley repeatedly said that it would be made clear by clause 32. When the hon. Member for East Wiltshire called for clarity in the Bill as to how the service would be delivered, the hon. Member for Spen Valley said: “It will be.” The Minister said:

“Officials are working on amendments to later clauses to establish the operating model for her consideration.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 5 March 2025; c. 802.]

This does not appear to have happened, which means Parliament will be limited to a 90-minute debate on this issue when the regulations are eventually made, and such a motion will be unamendable. Surely the issue of how the service is to be delivered is much more important than that and deserves greater scrutiny.

It is disappointing to see new clauses 36 and 37 as the replacement clauses. Ideally, instead of the new clauses we would have had a detailed set of amendments to specify exactly how assisted dying is to be delivered. We do not have that; instead, we have a Henry VIII power that provides even more power than the one in clause 32, because the new one includes a power to modify Acts of Parliament passed subsequent to this legislation.

New clause 36 provides very little guidance on how the Henry VIII power would be exercised. Will assisted dying be provided by the state? If so, would that be on the NHS or through another body? Subsection (1) one does not specify that it must be on the NHS. Subsection (4) gives the power, but not the duty, to change section 1 of the National Health Service Act 2006—a foundational piece of Labour legislation if there ever was one, as the hon. Member for Banbury said—but subsection (5) requires it to be free at the point of use.

The question of whether assisted dying should be provided as part of normal NHS services, or in a parallel service, as requested by both the BMA and the Royal College of General Practitioners, is not answered by new clause 36, although hopefully it can be fleshed out in the debate on the amendments in the name of the hon. Member for East Wiltshire. Alternatively, it would seem that the power can be used to commission private providers to deliver the service on behalf of the state. Instead of deciding between the various models, new clause 36 simply leaves it open. It therefore gives very little indication about how it should be used.

When giving the Gray’s Inn reading at Gresham College last year, Lord Falconer said:

“The wider the power—because there is less material in primary legislation to define how it should be exercised—the greater the reduction in parliamentary scrutiny, but also the harder”—

it would be—

“to identify any legal basis of challenge.”

He went as far as to suggest that such wide Henry VIII powers were “unconstitutional”. Given his great support for the Bill, it would be interesting to hear the response of the hon. Member for Spen Valley and the Minister to Lord Falconer’s remarks.

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[Sarah Olney]

I think I said very clearly to the hon. Member for Stroud that it is not about the doctors. It is about the people who are commissioning them. I absolutely do not believe that about doctors operating in the private sector, who in my experience are often the same doctors as the ones in the NHS. It is about who is commissioning them and who is asking them to carry out this work, and whether those commissioners are motivated by a profit incentive as opposed to the incentive in the NHS to provide the best possible care.

[Danny Kruger]

I entirely agree with the hon. Lady. We are all equally ethical and unethical—the point is that we respond to incentives, and incentives have their effect. Does she agree that there is a further concern? If we had a tariff system, which we probably would, that would by definition create a market, if there was the opportunity for private provision, to earn tariffs—to make more money the more assisted deaths one provides. Furthermore, to the point made by the hon. Member for Stroud that this is all perfectly fine and normal, what about the opportunity to top up the public provision—the tariff one gets from the NHS—with one’s own money, therefore definitely creating the opportunity for some sort of upmarket arrangement through the additional fees and services that might be provided? As the hon. Member for Bexleyheath and Crayford said, we could see expos dedicated to providing the most luxury or glamorous forms of assisted death through private providers with NHS funding.

[Sarah Olney]

That is not a prospect I particularly want to reflect on, but it is worth noting that the particular risk in assisted dying services is that, as we heard in oral evidence from the chief medical officer, it is really hard to define, first, whether an illness is going to be terminal and, secondly, that somebody has only six months to live. There is an element of subjective judgment in assessing who is going to be eligible for assisted dying. Aligning subjective judgment to a profit incentive could create a serious ethical minefield.

I want to state absolutely clearly for the record that I am not questioning the ethics of doctors or the ethical standards of doctors or of any of the bodies that represent them in any way at all. My question is merely about introducing a profit incentive to this issue. As I said, this process could be contrasted with something like the provision of abortion services. Abortion services are clearly available only to pregnant women. The fact that the qualification, as it were, for this service is on a rather more subjective basis creates a risk.

Without this amendment, I am concerned that the Bill commodifies the end-of-life process and pushes what should be a sensitive, careful process towards being a transactional one. It also increases the risk that everything becomes focused on facilitating ending the patient’s life rather than supporting the holistic ethos of the NHS in addressing all the patient’s needs. Without the amendment, I worry that the Bill opens a door to the commodification of death, as the hon. Member for East Wiltshire has so graphically anticipated. What should be a careful, compassionate process could slide into something more transactional: a service that is marketed, packaged and sold.

We need look only to the parallel of care homes to see that danger writ large. In England, social care has been quietly overtaken by for-profit providers. Today, 75% of adult care homes, and over 80% of children’s homes, are run for profit—not by design or explicit policy, but by the slow creep of market forces. The Economics Observatory, drawing on studies such as Patwardhan et al. 2022, Barron and West 2017 and Bach-Mortensen et al. 2022, reveals a stark truth: for-profit care, particularly where private equity is involved, consistently delivers worse outcomes.

Similarly, a 2019 BMJ study found that private providers running NHS-funded services had higher rates of complications in procedures such as hip replacements compared with NHS trusts. The focus on cost efficiency can lead to skimping on follow-up care or using less experienced staff. Why does that happen? Profit-seeking behaviour drives cuts to staff, to resources and to time. Now, if we transpose that to assisted dying, let us imagine the pressures on a private provider to trim costs and the pressures on the quality of assessments. How thoroughly are mental health conditions, or the risk that something else might be going on, explored? How great is the depth of attention to medical records? Is what is relevant to the doctor influenced by the ticking clock? Will they tick a box rather than a safeguard?

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[Sarah Olney]

I thank my hon. Friend for his intervention, but those incentives are not about creating profits that make money for individuals. They are about directing the way that resources are allocated to ensure that a broader range of health outcomes are achieved. When I talk about a profit incentive, it is an entirely different kind of incentive from the one he has just raised.

[Danny Kruger]

This is a very important debate, and my concern is that there is a naive assumption that the innate goodness of doctors will render them impervious to all the incentives in the system. As the hon. Lady suggests, if it were possible, as I think it is under the Bill, for a profit-making organisation—a company—to set itself up to provide an assisted suicide conveyer belt as a pathway through this process, and to earn money publicly or privately according to the volume of the provision it enables, we are setting up incentives that would corrupt the doctors who would be required to sign it off.

I regret that my right hon. Friend the Member for North West Hampshire has such an optimistic view of human nature that he thinks that no doctor would respond to the incentives in the way that is clearly enabled through the Bill. There are other medical professionals—ethical doctors—who do respond to incentives, such as those in the cosmetic surgery industry.

[Dr Opher]

Will the hon. Member give way?

[Danny Kruger]

I would, but actually I am making an intervention. It may appear that I am making a speech, so I will soon sit down, but I would be interested in the hon. Gentleman’s response to the suggestion that even he —the paragon of virtue that he is—might not be entirely resistant to the economic incentives in the system. That is why we have an NHS that explicitly tries to exclude profit making from the provision of healthcare.

[Sarah Olney]

I thank the hon. Member for his intervention, but I do not associate myself with his use of the word “corrupt”; I am absolutely not implying that in any way, and I want to be very clear about that. However, there is a grave risk—even for the most ethical person, if they are offered money to carry out an action that they are inclined to carry out anyway as part of their professional practice—that those incentives drive behaviour that leads to worse outcomes for patients, specifically in relation to assisted dying.

--- Later in debate ---

[Sarah Olney]

But the Bill does not say that. It does not say that the payment to the doctor should not include any consideration of profit. Regarding hip operations, someone would have one only if they needed it. My point is that assisted dying is one of a range of options at the end of life being presented here. The concern is that people motivated by profit would be incentivised to push for assisted dying at the expense of other options for the patient that do not attract the same level of reward. That is the issue. It is not a binary decision in the way that most treatments are.

[Danny Kruger]

In response to the hon. Member for Spen Valley, the scenario that she mentions is exactly the problem in many healthcare systems around the world, particularly in America, where doctors are incentivised to deliver volumes of treatments and procedures that are often not strictly necessary. We do have a problem even in our own system with the over-prescription of certain medical treatments, particularly pharmaceuticals, so incentives do apply. Doctors are subject to them, and we do our best to regulate them out of the system. One of the great advantages of the NHS compared with other healthcare systems is that we manage to prevent the over-provision of services in response to economic incentives. That is a founding principle of the NHS that we are overriding with this process.

[Sarah Olney]

I will conclude my remarks by observing that the only reason that we are looking at contracting out assisted dying services to a private provider is that the country is simply not ready for assisted dying. We know how overstretched and under-resourced our NHS is, and we are looking at cutting corners in the Bill, in our policymaking, in our scrutiny of this legislation, and in how this legislation and the service is delivered.

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[Rebecca Paul (Reigate) (Con)]

It is a pleasure to serve under your chairmanship, Ms McVey. I rise to speak on clause stand part and new clause 36, and in support of amendment 525 and amendment (a) to new clause 36, tabled by my hon. Friend the Member for East Wiltshire. This is a really important debate. The NHS is the greatest achievement of any Labour Government, and maybe even of any Government.

[Danny Kruger]

Steady on!

[Rebecca Paul]

It transformed the quality of life of British citizens at a time of mass unemployment and widespread slums, ensuring free healthcare, in the words of Beveridge, from cradle to grave. The provision of healthcare free at the point of delivery was life-changing and life-prolonging. Although it is far from perfect, we have seen time and time again that as a country we can be very proud of the NHS.

The National Health Service Act 1946 came into effect on 5 July 1948, as a direct consequence of the Beveridge report. Section 1 of the Act states:

“It shall be the duty of the Minister of Health…to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness”.

It was set up to help people to get better and live healthy lives, and to give hope in situations where otherwise there would be despair. It was lifesaving and life-changing. New clause 36 turns all that on its head. Subsection (4) states that:

“Regulations under this section may for example provide that specified references in the National Health Service Act 2006 to the health service continued under section 1(1) of that Act include references to commissioned VAD services.”

If this new clause passes, the founding principles of the NHS will be monumentally changed to include helping eligible people to commit suicide. That is what it does.

I want to be really clear that it is entirely possible to support assisted dying—to want to ensure that a small group of people, whom palliative care cannot help, have that assisted dying option—but not to support this new clause, which forces provision of the service through the same channels as normal healthcare. Assisted dying is not a medical treatment or a healthcare service and accordingly there should be a degree of separation.

We should be incredibly cautious about incorporating the service into the NHS. It will forever change the relationship between doctor and patient, breed mistrust and fear, discourage vulnerable groups from seeking the healthcare they need and fundamentally violate the Hippocratic oath. Dr Catherine Day, a senior partner of a large GP practice in Coventry, states:

“Trust lies at the heart of the doctor patient relationship. I believe this trust will be shattered if patients consider that their GP…may think that they should end their life and stop being a drain on our NHS.”

Siwan Seaman, a palliative care consultant said:

“How could a terminally ill patient trust a doctor if they know that the doctor was prescribing medication to the patient in the next bed in a bay or cubicle with the intention of ending their life. Letting these assessments take place alongside other NHS services will irreversibly impact on patients’ trust in healthcare professionals and negatively impact our therapeutic relationship with patients as doctors.”

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[Lewis Atkinson]

No, it will not, in the same way that G4S does not suddenly appear and provide treatment through a new cancer service that the Secretary of State decides to commission under specialist powers.

I am afraid that some opponents of the Bill are trying to scaremonger about potential provision as a way of altering the way people voted on Second Reading. A number of amendments clearly deal with whether potential providers should be public sector, voluntary or, indeed, private organisations. I emphasise that the overwhelming majority of GP services in this country are private contractors. It is inconsistent for Members to argue that we should maximise continuity of care and have the best safeguards around coercion and capacity by having someone who has known the individual for a long time, while also arguing that the Secretary of State should not be permitted to commission that individual’s GP to play any role. I challenge opponents on that matter.

[Danny Kruger]

As ever, the hon. Gentleman is speaking very coherently in support of the Bill and the principles behind it. I think he does regard assisted suicide as another form of healthcare that, as he says, should therefore be completely consistent with the normal duties of every medical professional. I would genuinely like him to help me to understand this. Does he envisage the service being provided by bespoke clinics in the NHS? Would established professionals set themselves up with the purpose of delivering it, or would it genuinely just be something that any general practitioner would provide as part of their services? Does he imagine that there will be specialists in the NHS whose sole job, or most of whose job, would be to provide this service?

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[Lewis Atkinson]

The right hon. Gentleman is entirely right. These powers need to provide for that patient-centric nature, in a service that is explicitly commissioned by the Secretary of State, which will vary in different parts of the country, and not just in the provision landscape. The services provided in rural North Northumberland will, by their nature, probably be different from those provided in London, and that is entirely appropriate.

[Danny Kruger]

And yet the irony of this measure is that it is not specific to the patient. Genuine healthcare treats the symptoms and condition of the individual patient. This proposed treatment has nothing to do with the individual symptoms or the condition of the patient; it just kills them. It is totally unrelated to the condition, which is why it is not healthcare.

The hon. Gentleman suggested earlier that the Bill somehow ensures that the provision and the pathway are deliberately fragmented because the second doctor needs to be independent of the first. Does he agree that, with that single exception, it would be perfectly possible for an independent provider to set up to provide for the whole pathway of assisted death, with the single requirement that the co-ordinating doctor, who would manage the whole process from beginning to end, must get a second opinion from outside their organisation to sign the paperwork for the second assessment? With that single exception, the whole process could be managed by an independent, profit-making provider—commissioned by the NHS or otherwise—entirely on its own.

[Lewis Atkinson]

The hon. Gentleman is providing a masterclass in scaremongering. I know he needs Labour votes to switch before Third Reading, but this service must be explicitly commissioned by the Secretary of State, and it is inconceivable that they would commission that in the way that the hon. Gentleman describes. The co-ordinating doctor is of course one person, and they would be involved in the first assessment and the provision of assistance. Whether that is a doctor employed by the NHS or somebody else, it can only be one individual, but there are the other safeguards we have talked about, such as the panel, which the hon. Gentleman has spoken against. It is absolutely appropriate that the Secretary of State has the powers and the duty to commission the service, and that they will do so from range of providers, reflecting the differences.

On the other point that some hon. Members have made about regulation, I remind the Committee that any provider will be regulated not only under this Act, but by the Care Quality Commission, in entirely uniform manner. I am therefore confused by the points made by opponents of the Bill. Some have said there should be no provision of this by the NHS or any public body, some say there should be no provision by charities—including, presumably, local hospices, should they make that decision—while others say there should be no provision by local GP practices to provide continuity of care.

Perhaps those different points reflect different ideologies within the Committee that are deeper than this issue, but they perhaps also reflect the fact that opponents of the Bill simply do not want this service to be provided at all.

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[Danny Kruger]

The hon. Lady is absolutely right. I am not sure that anything in the Bill would preclude a private provider—“Virgin Health” or some such organisation—from providing the whole pathway of the assisted death, including employing, albeit in separate clinics or separate practices, the two doctors who would provide the two assessments. The provider would comply with the Bill, but the doctors might be part of the same organisation even if they work in different practices.

[Naz Shah]

I thank the hon. Member for his intervention. I have observed two things this morning. First, the reality has really hit home. Are we going to look at the amendment regarding local authorities providing the service? Are we excluding private providers? Are we excluding big firms? A new service has to be designed. Will it be two organisations or one? How will the Bill be delivered? We do not even have that before us, and that concerns me deeply.

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

Danny Kruger Excerpts

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[Naz Shah]

I am happy to, Mrs Harris.

We should be determined not to see big outsourcing companies bidding for assisted dying contracts and then potentially misusing them the way in which they have misused other public services. That is not because I am opposed to firms operating in a free market or making money when they do their job well; it is because the way we run outsourced Government contracts in this country often has nothing to do with the free market and nothing to do with companies working well.

Finally, we need to ask hard questions about how the contracts for assisted dying would be structured. Would companies be paid a fee for each stage of the assisted dying process that they have provided: one fee for providing the first assessment by a doctor, another for a second assessment and so on, up until the final fee for helping the patient take the lethal drugs? As I said this morning, we do not know what the proposal for the structure is. That is why it is important that we explore and understand the risks of every structure.

There are Government services that we can safely outsource. Assessing whether people are fit to end their life is not one of them, and neither is helping people to take lethal drugs. These clauses will enable future Governments to open up lucrative contracts for assisted dying that will almost certainly be won by companies that have often been incompetent and have potentially been dishonest. I strongly oppose the new clauses.

[Danny Kruger (East Wiltshire) (Con)]

I share all the hon. Lady’s concerns. In relation to the intervention made by the hon. Member for Spen Valley, is she aware that G4S has a health services division in the UK that directly employs doctors and other healthcare professionals?

[The Chair]

Order. Mr Kruger, we have already had that issue. We need to stick to the amendments.

[Danny Kruger]

I take your ruling, Mrs Harris, but the amendment is explicitly about this.

[Naz Shah]

When it comes to NHS providers, or any service providers, and contracting or outsourcing, we have legislation in this place for whistleblowing. I raised the subject with the Health Secretary in relation to my local trust only today. With the best will in the world, mistakes happen. We legislated to protect whistleblowers, and that ties in directly to these risks. We must do everything we can to mitigate such risks in the Bill.

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New clause 36 imposes a duty on the Secretary of State to make regulations to ensure that arrangements are made for voluntary assisted dying services to be provided in England. It also imposes a power on the Secretary of State to make other provision about matters related to voluntary assisted dying services in England. The regulations made by the Secretary of State can provide that references to the health service in the National Health Service Act 2006 include references to a voluntary assisted dying service in England. That ensures that voluntary assisted dying services can be provided via the NHS. The new clause further ensures that voluntary assisted dying services provided as part of the health service must be free of charge unless charging is expressly provided for.

[Danny Kruger]

First, on the proposed amendment to the NHS Act, will the Minister confirm that the implication is that it is not currently possible to deliver assisted dying services under the Act? Secondly, to help me understand new clause 36, is it proposed that the Government will amend the NHS Act through regulations, a statutory instrument, or will the courts read the new clause as inferring that assisted dying is compatible with the NHS Act? Is there an intention to change the wording of the NHS Act, or is it just that we should now read “healthcare” as including assisted dying? I would be very grateful if the Minister could explain, because it is not clear to me from the phrasing.

[Stephen Kinnock]

New clause 36 creates the basis for the provision of assisted dying services, in compliance with all the legislation that defines how the national health service works. If the new clause is agreed by the Committee, and ultimately by Parliament, further amendments and changes will not be required. It will be the basis for the provision of the assisted dying service, within the framework of all the legislation that defines how the NHS works.

[Danny Kruger]

New clause 36 specifies that the NHS Act will require amendment. Is the Minister saying that that is not in fact the case?

[Stephen Kinnock]

New clause 36 specifies that the Secretary of State will, by regulation, set out the operating framework for the delivery of the assisted dying service. That will be the change to the legislation that is required. I apologise to the hon. Gentleman if I am missing something. I do not know whether we are talking at cross purposes here. What I am saying is that new clause 36 provides the basis for the delivery of the service. I am sorry if I am missing his point, but that is my understanding.

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[Kim Leadbeater]

We have had some excellent and extremely thorough debates covering all aspects of the Bill since the Committee first met. There has been an unprecedented level of scrutiny, and rightly so, given the gravity of the issue. The clause before us is one of the most important that we will consider. Without it, the Bill’s objective of offering a compassionate and dignified choice to terminally ill adults could not be met. The injustices of the status quo would remain, with too many people travelling abroad to seek an assisted death or taking matters into their own hands here at home, alone and often before they need to, in order to protect their loved ones from the threat of prosecution. Those people would be left, as they are now, with no protections against coercion or pressure to end their life and, crucially, with no ability to choose the manner and timing of their death so that they can say goodbye and be remembered by their loved ones as they would wish.

Clearly, some hon. Members do not want those people to have that choice. They are fully entitled to that view. However, if Parliament decides otherwise and gives that choice, it is our responsibility to ensure that it can be exercised without adding constraints and impediments that would serve only to make people’s last days and weeks more traumatic, not less. That is one reason, although not the only reason, why I am clear that the process must be available as part of the range of services available to patients under the NHS and free at the point of need. It must be for the Secretary of State to make provision for the service in England, and for Ministers in Wales to do the same in Wales if the Senedd agrees. The House of Commons must have the opportunity to scrutinise the regulations under the affirmative procedure.

Despite the challenges that it faces, the NHS is a trusted institution staffed by some of the best qualified and skilled health professionals anywhere in the world. Not all of them will want to participate, and it is their absolute right not to, but patients and the wider public should be reassured that assisted dying services would be commissioned and regulated in the same way as other services through the NHS, a system with which they are familiar.

There is another very important reason why I do not believe that voluntary assisted dying should be a service that is separate from the core responsibilities of the NHS. The hon. Member for East Wiltshire and others have described the decision to request an assisted death as a fork in the road. I fundamentally disagree. “Fork in the road” implies that once someone decides which route they will take, that is it: they have chosen their direction of travel. That goes completely against the principles behind the Bill.

The option of an assisted death is just that: it is an option throughout. Right up until the final moment, the person can decide not to exercise that choice. Experience from around the world suggests that consistently 30% to 40% of people do not, but knowing that they have the option has given them the comfort and reassurance that they need to make their final days less stressful and less fearful. It is crucial that the option of a voluntary assisted death remain part of an holistic approach to end-of-life care. If other options—including palliative care or the comfort provided by a hospice or other institution—are working for the individual, they have no need to take it up, but if it remains their clear, settled and informed wish to do so, that is their decision.

My belief that a person requesting an assisted death should be guided through the process, in a health and care environment that they trust and are familiar with, extends to private provision. Other commissioned and regulated services are supplied by a range of providers; the same should apply in this context, as my hon. Friend the Member for Sunderland Central said.

NHS trusts and ICBs may use private providers in some circumstances, as they already do. This provides flexibility, which is important, but what matters is that the safeguards and protections in this Bill will apply no matter where the service is supplied. The same requirements on doctors will apply, including the need to prepare reports and send them to the commissioner, and the stipulation that a medical practitioner cannot benefit financially or in any material way from the death of a person and can only receive reasonable remuneration for providing the service. My new clauses 36 and 37 make provision for this. The amendments to the new clauses seek to frustrate or delay that intention, and I cannot support them.

Perhaps it is the Committee that is at a fork in the road. One route leads towards the correction of an injustice that has already lasted too long, and it offers a safe and compassionate choice at the end of life. The other route is to say that we are okay leaving things as they are, that the status quo is defensible and that people do not deserve to be given that choice.

[Danny Kruger]

I hope the hon. Lady does not really think that I or others think the status quo defensible. There are clearly major problems with our palliative care system that we all recognise and want to improve. I would be grateful if she acknowledged that we need to improve palliative care.

On the hon. Lady’s point about remuneration, the Bill specifies that it would not be regarded as illegitimate for doctors to earn reasonable remuneration. What does she think “reasonable” is? How would we designate the appropriate remuneration for doctors? Does she agree that there is nothing in the Bill to stop private providers supplying the service and making money from it?

[Kim Leadbeater]

The approach to reasonable remuneration would be the same as in any other service commissioned by the NHS. There are tariffs for services that doctors provide. That is not for us in Parliament to decide; it would be up to the NHS and the commissioning bodies.

I understand that some people might be uncomfortable with private providers. If so, I suggest that they are probably uncomfortable—which might be surprising, given their politics—with the concept of private healthcare provision per se. Whatever our moral view on that is, we cannot take assisted dying out of the system that we currently have. I think it is really important that the choice is given to terminally ill patients within the framework that we have.

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[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 32 disagreed to.

Clause 33

Notifications to Chief Medical Officers

[Kim Leadbeater]

I beg to move amendment 539, in clause 33, page 19, line 34, leave out subsections (1) and (2) and insert—

“(1) The Secretary of State may by regulations make provision requiring a registered medical practitioner to notify the Commissioner of the occurrence of an event of a specified description.”

This amendment replaces a power to make regulations requiring practitioners to notify the relevant Chief Medical Officer of certain events, including any events specified in regulations, with a power to make regulations requiring practitioners to notify the Commissioner of any event specified in the regulations.

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[Kim Leadbeater]

Amendment 382 and the consequential amendments provide for monitoring, investigation and reporting functions under clause 34 to be carried out by the voluntary assisted dying commissioner. The commissioner will submit an annual report to the appropriate national authority—Parliament or the Senedd—on the operation of the Act, as set out in amendment 389. The appropriate national authority must publish any report received under this section, prepare and publish a response to any such report, and lay before Parliament or Senedd Cymru a copy of the report and the response. I think the Committee is in agreement about the importance of reporting and monitoring under the Act, and I hope it can support these amendments.

[Danny Kruger]

I appreciate that the amendments are necessary for the new design of the Bill, but I want to express my concern that they establish an assisted dying regime that is left to monitor itself. When the person who facilitates these profound decisions is also the one who reviews them, it threatens not just the integrity of the system but the safety and trust of those it serves. Without labouring the point, other jurisdictions have significant problems with reporting and the information being the responsibility of those delivering the service. In Oregon, where assisted dying has been legal since 1997, the state relies on doctors to self-report compliance. We are left trusting that every form filled in will tell the whole story.

Robert Clark, the former Attorney-General of Victoria, is very concerned about the operation of the legislation in Australia. He has highlighted how the voluntary assisted dying review board, which is a similar arrangement to the commission proposed here, relies on paperwork from the doctors themselves, with no routine audits or real-time checks. He pointed out that a tiny group of doctors—in fact, only 10—handled 55% of all cases in 2023-24, according to the review board’s data. Many of those doctors were advocates for the legalisation of the programme. I am concerned about the implications of a system that effectively trusts doctors to provide information without any proper review.

Lastly, with all due respect to whoever comes in as commissioner, the replacement of the chief medical officer with the commissioner represents a downgrading of the scrutiny the Bill offers. We know that the commissioner is likely to be a retired judge, which is a very distinguished position, but they will not be somebody with the serious political status of the chief medical officer. The CMO role is equivalent to a permanent secretary. I am sure the hon. Member for Spen Valley acknowledges that our current CMO is probably the best-known public servant in the country. It is very significant that we are proposing to downgrade the role fulfilled by the CMO. I do not think a retired High Court judge will have the same status.

[Kim Leadbeater]

I thought the hon. Gentleman was quite keen on a judge, but now maybe less so. I hope he is reassured by amendment 455, which requires the commissioner to consult the chief medical officer. That shows really clear intent for the post to have judicial and medical expertise and oversight.

[Danny Kruger]

I am keen on actual judges who sit in court with the full authority of a judge, not a retired judge sitting at the head of a quango very far away from the decisions made about assisted dying. Nevertheless, I am grateful to the hon. Lady, and I appreciate the fact that there will be a duty to consult. We want to have as much input from the CMO as possible in the administration of the service.

[Naz Shah]

I rise to speak to amendment 382. My hon. Friend the Member for Spen Valley may argue that some of my criticisms of the amendment relate in particular to two other amendments she has tabled: amendments 455 and 456. Indeed, I took an intervention on the matter earlier. I have read those amendments and they do not answer my concerns about amendment 382. They were grouped with amendment 382 until this morning, when the grouping was changed, so I will address them in my next speech.

This is a good moment to pay tribute to the Committee Clerks for their extremely hard work. I thank them for the way they have coped with the complex groupings and huge numbers of amendments that are unprecedented for a private Member’s Bill in this century.

My hon. Friend’s explanatory statement gives a clear explanation about what amendment 382 does. It provides for the monitoring, investigation and reporting functions under clause 34 to be carried out by the voluntary assisted dying commissioner instead of the chief medical officers for England and Wales. I can think of two possible arguments in support of it. I do not know whether either was behind my hon. Friend’s decision to table the amendment, but they are certainly the best to my mind.

The first argument in favour is that the chief medical officers for England and Wales already have a great many demands on their time. Members might say that we should not risk overloading them and should instead give another official the responsibility of looking at how assisted dying systems work. The second argument in favour is that the amendments to the Bill create a voluntary assisted dying commissioner, and that person and their officials will build up expertise in that field, so it could be argued that the commissioner would be the best person to lead monitoring, investigation and reporting.

Unfortunately I do not think those arguments hold water. On the first, it is true that CMOs have a great deal to do, but if we pass the Bill, it will be one of the biggest changes made to the duties of doctors in this country. For the first time, they will be able to help patients to take lethal drugs solely in order to bring about their death. The chief medical officers for England and Wales are senior doctors who advice Governments on all medical matters; of course they should be centrally involved in seeing whether the system works and whether there are any problems.

The second argument—that the commissioner’s office will become assisted dying subject matter experts—does not stand up either. It is true that the commissioner and the officials they recruit will come to know a great deal about the system they set up, but the very fact that they will set up and run the system means they should not take the lead on monitoring, investigating and reporting. That would mean that the commissioner and their staff would be the first people who decide whether they are doing a good job. Asking people to mark their own homework is a really bad way to check that any system is working properly. It is not how we inspect and report on schools; Ofsted has that job, not headteachers or local councils. It is not how we regulate banks, which are overseen by independent authorities.

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[Naz Shah]

Under the Bill as presented on Second Reading, the Secretary of State would have to report to Parliament on how the assisted dying system was functioning, but they would do so only after the system had been in operation for five years. Under amendment 452, tabled by my hon. Friend the Member for York Central, the Secretary of State would be required to report annually on how the system was working.

The Bill’s original provision for a five-yearly report was extremely surprising. The requirement on the Secretary of State to report to Parliament is a major safeguard that will prompt them and their officials to probe all the available data on the system. It will also allow Members of this House and the other place to go over that information and look for problems, should they arise, and ways to resolve them. It could be one way to identify failings in the system early. Given that we are discussing a system to allow people to take lethal drugs, that is surely what we should aim for. We cannot afford to wait through years of media reports and complaints before then having to investigate alleged problems.

If the amendment is accepted, it will not be certain that the Secretary of State’s report and the scrutiny of Parliament will identify problems in a timely way, but that possibility will be increased. If we have to wait five years for a report, it is much less likely that we will spot any problems before they have had terrible consequences. I urge Members to vote for the amendment to replace the five-yearly report.

[Danny Kruger]

I concur with the points made by the hon. Member for Bradford West. I very much appreciate the presence of clause 35 in the Bill—it is helpful that we ensure a proper review—but, as the hon. Lady said, five years feels too long to wait, so I support the amendment in the name of the hon. Member for York Central, as well as amendments 493 to 495, tabled by the hon. Member for Bexleyheath and Crayford, who has suggested a three-year review period.

My simple further point is that we are potentially creating threshold legislation: once we take the step down this road, there is no going back. The Bill leaves so much open for further expansion, I suggest, but certainly for the modification and clarification of the operation of the legislation. There is a lot left for ministerial discretion, guidance and codes of practice, as we have debated, and indeed new powers have been added, including a widening of the Henry VIII power. I think, then, that it is important to bring forward the review period.

As my amendment 526 suggests, I also think it is not sufficient simply to undertake a review, even one that is annual or every three years. There must be a guaranteed right to a debate and to hold Ministers to account at the Dispatch Box, which my amendment would insist on.

Lastly, on the inherent potential for expansion due to the wide discretion that the Bill still gives future Ministers, my concern is that the review itself might become a Trojan horse for further expansion, because that is what we see in other countries. It is held out as a safeguard, and that is exactly how we should regard it—I hope it will be that. Having a proper debate and proper ministerial accountability will allow us to check the operation of the Bill thoroughly and enable Parliament to keep it under very close scrutiny.

--- Later in debate ---

Question proposed, That the clause stand part of the Bill.

[Danny Kruger]

I do not want to take the Committee’s time, but I invite the Bill’s promoter or the Minister to make an observation about the implications of clause 38, because the power to make

“such supplementary, incidental or consequential provision…as the Secretary of State considers appropriate for the purposes or in consequence of any provision made by this Act.”

reads to me as extremely broad. Not to repeat the point ad nauseam, but I am concerned, as ever, about the degree of discretion given to Ministers—most of it under the negative procedure. I invite the promoter or the Minister to lay out, in as much detail as they are able, the purpose of this clause and what sorts of provisions it might enable.

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[Naz Shah]

I thank my hon. Friend for her explanation, which was very good. I do not have time to go away and think more about it from a legal perspective, because I have only just heard her arguments, but at the moment I absolutely agree.

As for my hon. Friend the Member for Lowestoft, I thank her for her attempt to explain. She has years of experience of working in the field. She tabled that amendment in response to the amendment from my hon. Friend the Member for Penistone and Stocksbridge, with the best of intentions and to strengthen the legislation. I will look at it, and I may even return to it during the debate.

[Danny Kruger]

That was an interesting exchange. I think I agree with the hon. Member for Penistone and Stocksbridge more than I do with the hon. Member for Bradford West, which is an uncomfortable situation for me, but I want to show that I am actually listening. I also agree with the Minister of State, Ministry of Justice, the hon. and learned Member for Finchley and Golders Green, who said last week that, without a statutory meaning, the terms “coercion” and “pressure” have their natural, ordinary meaning, which is well understood by the public and the courts alike.

I have encouraged more clarification and clarity throughout the Committee’s deliberations, and I accept the point made by the hon. Member for Penistone and Stocksbridge and the Minister that we are in a good place in outline in terms of understanding these concepts. However, I agree with the hon. Members for Penistone and Stocksbridge and for Bradford West that it would be helpful to have further clarity from the Ministers. If there is guidance to come, it is important that we proceed with due respect to the points that have been made, including the proposals from the hon. Member for Lowestoft, which I agree with in principle.

However, I want to make the point behind my amendment (a) to amendment 518, tabled by the hon. Member for Penistone and Stocksbridge, even though I understand she will not push it to a vote, so I cannot push mine. She challenged me about the purpose of my amendment, so I want to explain it. There are two places in the Bill where the concepts of coercion and pressure occur: one is in the context of the assessment process for eligibility for assisted death, and the other is in terms of the criminal offence of coercion into an assisted death. Those are two separate areas of the Bill, but they use the same terminology, and the same principle of coercion is behind them both.

The point of my amendment is to make clear the distinction between eligibility and the criminality involved in coercion. Although I entirely agree with the hon. Member for Penistone and Stocksbridge that it is appropriate to retain the principle of intention—to be clear, my amendment would remove the requirement for evidence of intention to coerce, leaving just the fact of coercion in the definition—her point was that it is important to retain evidence of intention in order for the criminal offence to be meaningful. I accept that that is a point in criminal law.

However, it is important that we do not include intention in the context of the assessment of eligibility criteria, for the simple reason that somebody may well be coerced into an assisted death in a way that we would all understand, but the perpetrator may not have had the explicit intention of that outcome. An example would be where an abusive husband, through abuse, victimisation, relentless unkindness and perhaps the direct communication of, “You’d be better off dead,” has the effect of coercing his victim—his wife—into seeking an assisted death, which might well be subject to criminal prosecution on these terms. He would nevertheless be able potentially to claim that that was not his intention, and, indeed, perhaps it was not. He might not have had the explicit thought in his head, “I want to make her apply for an assisted death.” Nevertheless, that is the consequence of his coercive behaviour.

I would hope that when the doctors assessed that particular case and came across evidence of that pattern of abuse, they would conclude that this person was being coerced, and would therefore not award the applicant the green light to proceed. That is an example of where it is important to remove the intention of coercion from the definition. I entirely agree with the hon. Member for Penistone and Stocksbridge about the value and necessity of including intention where we are talking about the criminal offence of inducing somebody to have an assisted death.

Lastly, let us think about this from the point of view of the doctor or panel who are being asked to approve the application. If the definition of coercion includes the intention to coerce, we are inviting—in fact, requiring— the doctor or panel to seek evidence of the intention of the person doing the coercion, rather than just the fact of the patient having been coerced. We would require them somehow to interview the abuser, so I think we would get into difficult territory if we insisted on evidence of coercion in order to deny the application on that basis.

I hope that that helps to explain the purpose behind my amendment. I know it is slightly academic, because we are not proceeding with amendment 518, but I hope the Minister and the hon. Member for Spen Valley reflect on the points made by the hon. Member for Penistone and Stocksbridge and take them on board in subsequent amendments or guidance.

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[Stephen Kinnock]

The Government have been working with my hon. Friend the Member for Spen Valley, and some amendments—including all three in this group—have been mutually agreed by her and the Government with the aim of ensuring the workability of the Bill. I shall provide a brief technical, factual explanation and rationale for the amendments.

Amendment 392 would add the meaning of “first assessment” and “first declaration” to the list of definitions in the interpretation provision in clause 40. The effect of the amendment is to ensure that all references to “first assessment” and “first declaration” throughout the Bill are interpreted consistently.

Amendment 393 would insert the meaning of “second assessment” and “second declaration” to the list of definitions in the interpretation provision in clause 40. The effect of the amendment is to ensure that all references to “second assessment” and “second declaration” throughout the Bill are interpreted consistently.

I turn to amendment 424. Clause 4(3) states:

“Where a person indicates to a registered medical practitioner their wish to seek assistance to end their own life in accordance with this Act, the registered medical practitioner may…conduct a preliminary discussion about the requirements that need to be met for such assistance to be provided.”

Clause 4(4), as amended, sets out that where a practitioner conducts a preliminary discussion, they must explain and discuss certain matters with the person concerned. These are:

“(a) the person’s diagnosis and prognosis;

(b) any treatment available and the likely effect of it;

(c) all appropriate palliative, hospice or other care, including symptom management and psychological support”.

The preliminary discussion may not be conducted in isolation from an explanation of and discussion about these matters. Amendment 424 would add a definition of “preliminary discussion” to the list of definitions in clause 40 to ensure that all references to a “preliminary discussion” in the Bill are interpreted in line with the description of the discussion in clause 4(3).

Amendment 392 agreed to.

Amendments made: 226, in clause 40, page 23, leave out line 37.

The amendment is consequential on Amendment 545.

Amendment 424, in clause 40, page 23, line 37, at end insert—

“‘preliminary discussion’ means a discussion of a kind mentioned in section 4(3);”

This is a drafting change.

Amendment 393, in clause 40, page 24, line 5, at end insert—

“‘second assessment’ has the same meaning as in section 8;

“‘second declaration’ has the same meaning as in section 13;”.—(Kim Leadbeater.)

This is a drafting change.

[Danny Kruger]

I beg to move amendment 527, in clause 40, page 24, line 14, at end insert

“provided that such remuneration is not structured in a manner where it would be greater as a result of the registered medical practitioner approving the request.”

This is the point at which the season of consensus is over; I am back to opposing. Amendment 527 would insist that any remuneration for taking part in assisted dying on behalf of the medical profession would not enable a system whereby a medic, practice or private provider would be remunerated according to approving the different stages of the process. I am trying to prevent the provision of any incentive in the system for moving people through it.

We know that there can be a paid private service delivered under the Bill. The concern is that we will create perverse incentives in the system that will prejudice objective decision making. I take the points about the disinterested good faith of all medics; nevertheless, I do not want to put them in danger of feeling the pressure of perverse incentives. We must recognise the importance of keeping absolute financial neutrality in the operation of the Bill. There would be significant ethical red flags about a system that essentially enabled performance-related pay tied to approving requests for assisted dying, let alone paying doctors to provide referrals to a co-ordinating doctor. At the moment, I do not see that the Bill prevents that.

Even if there were no such danger, I am not sure that patients would buy it. From the point of view of trust in the medical profession, we must bear in mind that any doctor could be involved. Any doctor could either raise the suggestion or be required to signpost a patient who raised it themselves—the whole of the NHS is essentially implicated in the proposed system. As the hon. Member for Spen Valley has reiterated today, she wants assisted dying to be an integral part of the NHS. Let us protect the NHS from the distrust of patients by ensuring that financial incentives are not in the mix for these life and death decisions.

[Dr Opher]

Although I see the hon. Gentleman’s ideas and points, what will be paid for here is the assessment. I know no medical process where the outcome is paid for, rather than the assessment. Although I can see that his concerns are real, I do not believe—

[Danny Kruger]

I am sorry to cut off the hon. Gentleman mid-flow, but he says he cannot think of an instance when the outcome will be paid for. It would perhaps not be about paying for the outcome—paying for death; for a dead body—but there could well be payments for the process leading up to that. That is the way medical payments work at the moment. Someone might get paid for the assessment, the second assessment, or the administration of the drugs. People do get paid in the NHS for delivering a treatment. Why would that not be the case here?

[Dr Opher]

I understand the hon. Gentleman’s concern, but that is just not the way that medicine works. The doctor is under a code of practice, so if he is seen to lie about assessment of capacity or coercion, for example, to enable him to approve the decision and then go on to assist the dying, he would be well outside that code. He would be referred to the General Medical Council and, in such a case, struck off the medical register. I understand the reason for the amendment moved by the hon. Gentleman, but I do not feel that it is necessary in this part of the primary legislation.

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[Kim Leadbeater]

I will not test the patience of the Committee by repeating the comments of my hon. Friends the Members for Sunderland Central and for Stroud and, indeed, of the Minister. I am comfortable that subsection (4) as it stands is perfectly acceptable on the remuneration that a doctor can receive. I will not support the amendment.

[Danny Kruger]

I must conclude from that that the promoter of the Bill, the hon. Member for Spen Valley, and the Minister would be content with an arrangement whereby a doctor was paid more for accepting an application and processing it, and for referring a patient—

[Kim Leadbeater]

Will the hon. Member give way?

[Danny Kruger]

Suddenly the debate is occurring. I am happy to give way.

[Kim Leadbeater]

That absolutely is not what we have said.

[Danny Kruger]

In opposing my amendment, the hon. Member is declaring herself content with the text of the clause as it is. The text as drafted would allow a doctor to be paid more, the more applications that they receive, process and refer on. That might not be, in her mind, how the system should work—I would be grateful to know how the system should work, because it is not in the Bill or in the amendments. We have a very vague arrangement here, whereby a private provider would be enabled to deliver assisted dying—indeed, a profit-making organisation would be able to manage the entire process from beginning to end, even referring a second assessment to another part of their own company.

[Kim Leadbeater]

Will the hon. Member give way?

[Danny Kruger]

In a moment. The potential—as would happen in other parts of genuine healthcare—is that the more work people do, the more money they get. My concern is that that induces a dangerous incentive into the system. Having a global fee paid to a provider who managed the service would be much safer. The crucial point is that we prevent people being paid for approving and enabling assisted deaths, and that is what my amendment would do.

[Jake Richards]

I appreciate the point that the hon. Member is trying to make and I think it is a fair one, but how does he think this could work? As he said in his own intervention, people might have to be paid for one part of the process, and then for the next. If we appreciate the principle that people get paid for time, there is inevitably more money involved as the process goes on, so can he explain how his amendment would work?

[Danny Kruger]

I intend, in a later debate when we come to the new clause, to try to explain how I think we should have done this. The answer to the hon. Gentleman’s question is that an organisation should be resourced—I think through philanthropy, rather than taxpayers’ money or people paying out of their own pocket, but the point stands however we do it—to deliver the assisted dying service, but crucially it should not be paid more per service, treatment or customer. We should not have the concept of customers in this arrangement; there should be a provider who is resourced to deliver this service. The crucial point is that they should not be paid more per client or for progressing people through the system.

[Naz Shah]

That is the exact point I was about to raise. Is another amendment needed to ensure that providers of this service are not given more money if a patient goes through the process than if the process is stopped?

[Danny Kruger]

That is the purpose of my amendment.

[Kim Leadbeater]

The hon. Member is making some interesting points, but they are not related to the point of this amendment, which talks about the doctor being given more money for approving the request. That is not quite the same point that he is making.

[Danny Kruger]

I imagine that a doctor who works for the non-profit service I am envisioning would be paid a salary and do their work, but would not be paid on a per-client basis—they would not be paid a tariff for the number of people they passed through the system, let alone for the different chunks of the process. People need to be paid, but they should not be paid on a per-client basis, because that would introduce dangerous incentives into the system.

[Lewis Atkinson]

The hon. Member is making an interesting point, particularly in relation to the commissioning of the service. In the NHS, we generally commission on a block basis and a fee-per-activity basis. I can entirely see that that block basis would be appropriate for this commission, and I am happy to work with him on Report to make that the case. That is not what this amendment says, though. It talks about payment for individual doctors, which gets into the issue of people being fairly paid for their time, which he referenced. I invite him to collaborate on the commissioning arrangements on Report, rather than pressing this amendment.

[Danny Kruger]

We can distinguish between the organisational income and the specific doctor’s income, but the same applies in both cases. Explicitly, the doctor who is making the decisions should not feel the pressure or the temptation of financial reward to expedite or approve applications for assisted dying. I am grateful for the hon. Gentleman’s invitation. By all means, let us try to make sure that, should the Bill reach Report stage, we remove the danger of perverse incentives in the way that the service is commissioned.

Question put, That the amendment be made.

--- Later in debate ---

Brought up, and read the First time.

[Danny Kruger]

I beg to move, That the clause be read a Second time.

This will be my last speech in this Committee, so before I speak to the important principle expressed in new clause 34, may I thank you, Sir Roger, and all your colleagues who have chaired the Committee? I also thank the Clerks, who have done a huge amount of amazing work behind the scenes, and all members of the Committee; I particularly thank the hon. Member for Spen Valley for her good faith and good nature throughout the process. I have great respect for all Committee members. A particular hero was the hon. Member for Southgate and Wood Green, who was the most popular speaker every day. [Laughter.] I am looking forward to his final speech.

I pay tribute to all those hon. Members who did not serve on the Committee but contributed to our debates by tabling amendments; I really am encouraged by many of them. I pay particular tribute to the hon. Member for York Central, who has been a very powerful influence on me and has attempted to do very good work with the Committee. I also wish to mention my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer). Perhaps in sympathy with the hon. Member for Harrogate and Knaresborough, the most liberal member of the Committee, he has attempted to create an assisted dying Bill that does justice to the principles of autonomy behind it.

My new clause reflects my hon. Friend’s conception of the Bill. His amendments would have taken assisted dying out of the NHS, and indeed out of healthcare altogether. He was right to try to do that. If we are to do this thing, we should recognise that what we are proposing to legalise is not healthcare. Indeed, new clause 36 recognises the essential incompatibility between the service proposed here and healthcare as it is traditionally understood in our country and enshrined in the NHS Act.

More than that, the foundations of healthcare in the west are contravened by the Bill. The Hippocratic oath contains the promise:

“Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.”

That is the oath that doctors take, and it has been the ethical basis of medical practice in the west for millennia. The Bill would be the final, official abandonment of that ethical tradition.

I implore the Committee to reflect on the essential principle that healthcare is the antidote to sickness, whereas this proposal for assisted suicide is the antidote to life. That is the treatment that the Bill proposes to legalise. It is entirely different from healthcare, in principle and in practice. It is therefore no surprise that so many of the professional bodies involved in healthcare regard this proposed treatment as incompatible with their professions. The BMA agrees that this should be a separate service.

I was struck by a BMJ article that appeared last November, “Reframing assisted dying through the civil law: possibilities and challenges for the UK”, which was written by a group of palliative care professionals. It sets out how, if assisted dying is to be legalised in this country, it might best be organised and delivered. New clause 34 and all that flows from it would enable us to design a better assisted suicide service than the one that the Bill would give us.

The hon. Member for Spen Valley this morning and the hon. Member for Sunderland Central this afternoon asked how it should be done, if we are to do it. My hon. Friend the Member for Reigate offered some suggestions. I will build on what she said by saying how I think the Bill should have been framed—indeed, how I and others, through the amendments we have tabled, have tried to ensure it is framed.

We have tried to match the Bill to the campaign for assisted suicide. Understandably, there is considerable public support for people at the end of their life, who are at risk of suffering a terrible, agonising death and whom palliative care cannot help, to have the right to end their life a few days or weeks early. We can argue about how many people that is. I think the number of people whom palliative care could not help if we organised our palliative care system properly is infinitesimally small—almost non-existent. However, we disagree on that, so let us assume that there are some people who will fall into that category. The campaign for this Bill is the campaign for those people to have the right to an assisted death, but that is not what we have in the Bill. What we have is a right for anybody who in the opinion of two doctors might reasonably be expected to die within six months to request and receive lethal drugs, all paid for and assisted by the NHS. That is not what the campaign has been for.

Let me suggest how, if we are to be honest to the campaign, we should design this thing: not as healthcare, but as a compassionate suicide service for people facing physical agony at the very end of their life. As we tried to ensure at the beginning of our deliberations, eligibility would be for people fearing pain, not for those feeling a burden. There would be a proper capacity test, not the Mental Capacity Act 2005 test. There would be proper, meaningful safeguards against coercion. We would have doctors and a multidisciplinary team at the right stage of the process: right at the beginning, at the first assessment. We would have all the appropriate signposting and palliative care provision as an alternative to assisted suicide. We would then have a proper judicial process to decide whether to approve the application.

As for provision, from assessment through to the final act it should not be in the NHS. It should not be provided by any profit-making providers advertising their services and receiving money for every death that they assist, which is what we have probably got with the Bill. It should be provided by non-profit organisations, should be tightly regulated and should be funded not through NHS commissioning or by the patients, but by philanthropy.

The scale of all this is to be discovered, I guess, if we pursue the Bill. It has been suggested that the lower end of the expectation is about 6,000 deaths per year. On the calculations made by the experts in the paper I cited, it would need a budget of about £10 million a year to manage a 6,000-person caseload. That is in the ballpark of what the campaign groups promoting the Bill have been spending, so I do not think that there would be any difficulty in raising that sort of money if it is what people want. After all, hospices have to raise millions of pounds every year to fund their work. I do not see why assisted dying services should not be able, and required, to do the same thing.

There was a way to do this more consistently with the campaign for assisted suicide. For the avoidance of doubt, I would have opposed that too, because even that much more honest and tightly circumscribed service would profoundly alter our society—it would send the signal that some people are better off dead, and I think it would be wrong for our country—but at least it would be honest. It would be consistent with the campaign.

I will end with the observation that what I have just described is what I think the public think the Committee is doing: designing a service like that for the small number of people at the very end of their life who are facing a terrible physical death. That is not what we have done, it is not what the Committee has approved, it is not what the original Bill said and it is not what the Bill now says as we send it back to the House. I hope that the public and our colleagues in Parliament will recognise that this Bill is not the one that they thought they were getting.

[Rebecca Paul]

I rise to support new clause 34, which clarifies that assisted dying is not a medical treatment—not only because of the principle behind it, which I have talked a lot about already, but because of the unintended results. We need to recognise that many laws, rules and regulations have been written using the word “treatment” that never envisaged assisted dying being included. Every bit of law that refers to when treatment can be given, with or even without consent, such as section 63 of the Mental Health Act 1983, will become a potential problem if assisted dying is technically viewed as a medical treatment. New clause 34 is therefore essential to protect the meaning and integrity of the current law and to protect patients in future.

In written evidence, Professor David Jones points out that there are dangerous consequences to classifying death as a medical treatment. As a general principle, he observes:

“If an effective medical treatment cannot be self-administered orally then other routes should be considered, including those administered by a healthcare professional.”

We can immediately see the problem that will arise if assisted dying is a treatment. The view that such a treatment can be administered by a healthcare professional suddenly moves us into euthanasia territory, which is clearly not the intention of the Bill. Professor Jones goes on to say:

“If a treatment effectively reduces distressing symptoms in one category of patient (adults at the end of life), then it should be considered for treating other categories of patient”.

If we substitute the word “treatment” with “assisted dying”, we get a wholly unacceptable approach that could open the way to offering assisted dying to under-18s, as in Belgium, or to people whose psychological suffering is unbearable, as we have seen in Belgium and the Netherlands with the euthanasia of people with mental health conditions. Finally, Professor Jones says:

“Where a patient does not have capacity to consent to medical treatment then doctors should provide whatever treatment is ‘of overall benefit’ to the patient.”

If we substitute the same words, we can see that once again it leaves us with a big issue.

The Bill already has requirements relating to capacity, age and physical illness, and a requirement for self-administration, but the point is that by classifying assisted dying as a medical treatment we are making those requirements less stable and introducing the potential for conflict within the existing law. We are inviting future Parliaments to question why they are there in the first place. Why arbitrarily restrict this medical treatment when we do not restrict other treatments in the same way?

If we do not rule out assisted dying as a medical treatment, we are potentially opening the Bill up for challenge by the courts when assisted dying treatment is limited to certain groups. That is one reason why the Association for Palliative Medicine has explicitly backed the principle represented in the new clause. It has said in written evidence that defining death as treatment would be

“contrary to all prior medical practice and public expectation, and laden with risks of unintended consequences.”

The Bill may look set in stone, but the law can easily be amended in future, for instance by amending a major health Bill. What we decide in this Committee could have major consequences in a few years’ time. I urge that we future-proof the Bill now by explicitly declaring in it that assisted dying is not a medical treatment, so that the issues I have set out will not arise at any point.

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[The Chair]

The hon. Member for Spen Valley is entitled to respond if she so chooses, but I think she has sat down.

[Danny Kruger]

I will press new clause 34 to a vote.

Question put, That the clause be read a Second time.

Terminally Ill Adults (End of Life) Bill

Danny Kruger Excerpts

Report stage
Friday 13th June 2025 Commons Chamber

[Kim Leadbeater]

I am going to make some progress, I am afraid.

The Secretary of State must also consult providers of health and care services, including palliative and end-of-life care. I am really pleased that Hospice UK is supporting this amendment—it is very important that those voices are heard. The Secretary of State can also consult anyone else they feel to be appropriate, creating a flexible and holistic approach.

Turning to devolution, this long-overdue reform would apply to England and Wales, which share a criminal justice system. Health is a devolved matter, of course, and I have recognised from the outset that the legislation must respect devolution. I am fully committed to observing the same conventions that the Government would if this were a Government Bill. I have worked with UK Government officials to ensure that the right steps are taken at the right time by the right people. I have engaged with colleagues in the Welsh Government—I met the Welsh Health Minister in Cardiff, and there have been ongoing detailed discussions between the two teams of Government officials to ensure the workability of the legislation in both jurisdictions, in line with the devolution settlement.

Amendments 92 to 95 also ensure that the devolution settlement is respected and adhered to. I thank the right hon. Member for Dwyfor Meirionnydd (Liz Saville Roberts) and the hon. Member for Chesham and Amersham (Sarah Green), not only for their diligent work on the Bill Committee but for working with me on the amendments in relation to Wales, and I thank the Welsh Government for their guidance and support. I hope that colleagues across the House can support these new clauses and amendments.

I now turn to new clause 21, which makes specific provision about the use of the Welsh language. The conversations that happen at the end of a person’s life are extremely personal and should be handled with the utmost sensitivity. It is very important that they are conducted in the best interests of the patient, and a big part of that is using clear communication. In this respect, language matters, so if a patient in Wales has Welsh as their first or preferred language, all efforts should be made to ensure they can communicate with voluntary assisted dying services in Welsh. I committed to this in Committee, and have made good on that commitment.

Turning to amendments 76 and 77, as with any Bill, it is important that the amending legislation secures overall coherence with the statute book. As such, the clauses relating to medicines, advertising and employment protections amend, or confer power to amend, other legislation that currently extends to parts of the UK. Of course, this does not mean the provision of assisted dying, but, for example, they extend the prohibition on advertising to the whole of the UK and apply the employment protections in the Bill to Scotland. That is in line with the guidance I have received from legal experts, and as such I hope all colleagues can support these amendments. If the Bill passes, I will, if necessary, work with other devolved Administrations in the same way as I have worked with the Welsh Government to ensure that devolution is respected.

That concludes the explanations of the amendments tabled in my name. Many colleagues are keen to speak, so I am not going to comment on all the amendments in the group; I will just make two comments about amendments that are not in my name, and allow other people plenty of time to speak.

Amendment 42, tabled by my hon. Friend the Member for Newcastle-under-Lyme (Adam Jogee), would not only try to remove the backstop for the provision of assisted dying in England, but create a number of other issues in relation to commencement. If Parliament chooses to give this choice to terminally ill people, there cannot be a clause in the Bill that would prevent that from being available as soon as it was safe and practicable. But the amendment would remove the four-year backstop. It would also prevent the appointment of the voluntary assisted dying commissioner and create a potential commencement gap between England and Wales. Given that, I have been strongly advised that the amendment would create serious workability issues. I urge colleagues who want an operable Bill to join me in rejecting the amendment.

To finish, I am pleased to support amendment 21, tabled by the hon. Member for Twickenham (Munira Wilson). I thank her for her engagement with the Bill and the amendment, which would require the Secretary of State to prepare and publish an assessment of the availability, quality and distribution of palliative and end-of-life care, as part of the first report on the implementation of the Act, mirroring the assessment already required as part of the five-year review.

Although the Bill seeks to address what in some respects is a very specific issue in terms of the failings of the current law, it has become part of a much-needed broader conversation about death, dying and end-of-life care. We all have our own experiences of death, loss and grief, and we do not talk about them enough. I am really pleased that the Bill has led to many conversations up and down the country; whatever our views, that has to be a positive thing.

[Danny Kruger (East Wiltshire) (Con)]

Will the hon. Lady give way?

[Kim Leadbeater]

I have nearly finished.

I have had many such conversations over recent months with those who support the amendment, including with palliative care doctors, nurses, hospice staff, GPs, Hospice UK and Marie Curie. I thank them all for their constructive engagement with the Bill. I cannot imagine that anyone in this place is not truly grateful for the outstanding work done every day by the wonderful people working in palliative and end-of-life care in every one of our constituencies. Many of us, if not most of us, will have personal experience of the kindness and compassion that those people have shown to our own families and friends.

But this is not an either/or conversation. Palliative and end-of-life care and assisted dying can and do work side by side to give terminally ill patients the care and choice that they deserve in their final days. Just as there should not be an either/or for dying people, there should also not be an either/or for us as legislators in having to choose between supporting assisted dying or other end-of-life choices. That is why I am supporting amendment 21: to ensure that in this place we channel our energies into supporting all options available to terminally ill people—something that I have always committed to do.

--- Later in debate ---

[Paul Waugh]

The point of my amendment is to make sure that a future Secretary of State would have to come before the House with primary legislation.

Report stage is not about the principles of the Bill. It is not about whether a Member may, in principle, support the idea of assisted dying, as Mr Speaker will point out to everybody who strays from the amendments. It is about the individual Bill before us today. We have to ask: what will it mean in the real world for our very real constituents?

[Danny Kruger]

Will the hon. Gentleman give way?

[Paul Waugh]

I will not; I am short of time.

Just how strong are the Bill’s safeguards? We are not commentators; we are legislators. Our job is to scrutinise, to test and to test again the Bills that come to this place. I spent 26 years up there in the Press Gallery writing about politics, but the big difference between them and us is that we have a vote in this place. With that vote, particularly a free vote, comes responsibility, and there is no greater responsibility than protecting the vulnerable from feeling they have to end their life. That is why I tabled the amendment.

I am not driven by religion, though I do not believe that those with religious faiths should be denigrated or patronised, as they have been during the passage of the Bill. It is worth saying that some of those who passionately support assisted dying have a faith—a devout faith—that their world view is the right one. I am driven instead by my duty as a legislator to get this Bill right, and by what I see as my moral duty to protect the most vulnerable in society.

I believe that my duty is to protect those who do not have celebrity names or campaign groups behind them—the people who do not get heard, who do not want to be a bother, who do not want to make a fuss, and who feel at the end of their lives that they are a burden on their family but may never say so. I worry about the unheard, the unseen, the ignored and the marginalised. Most of all, I worry about the heartbreaking modesty of that phrase we often hear from older people: “I don’t want to be any trouble, love.” We need, for their sakes, to make sure that the safeguards in the Bill are the strongest they can possibly be.

--- Later in debate ---

[John Glen (Salisbury) (Con)]

I am grateful to have my first opportunity to contribute on this Bill. It would not be appropriate to dilate on my profound anxieties about it, but I approach these amendments in the spirit of constructive engagement. I rise to speak to linked amendments 82 to 86, which would strengthen the panel by giving it some of the features of the High Court safeguard that was, regrettably, removed.

We heard from the hon. Member for Spen Valley (Kim Leadbeater) that the panel will now be stronger because it includes a broader range of expertise. The argument against that, of course, is that the High Court was a stronger safeguard because it has the powers of a court and the independence of the judiciary. My amendments would mean that we do not have to choose between the two: the panel is part of the Bill, but we can have a better panel if we give it some of the features of the High Court, namely its independence, the calibre of its judges, and its powers as a court.

Amendment 82 would require all panel members to be appointed by the Judicial Appointments Commission, which nominates judges in England and Wales. Currently, the selection of panel members is wholly down to the voluntary assisted dying commissioner. Schedule 2 says:

“The Commissioner must make appointments to a list of persons eligible to sit as members of panels.”

I have absolutely no doubt that the commissioner will be someone of great integrity and experience, but he or she will certainly be a strong advocate of assisted dying, as will those who put themselves forward for the panels. That may create an impression that the VAD commission is a self-selecting group with a particular set of institutional views.

If the system is to command public confidence, I believe that appointments would be best administered by an external body, and the Judicial Appointments Commission is the obvious choice. We in this country trust the judiciary, partly because we know that they represent no set of opinions.

[Danny Kruger]

I am grateful to my right hon. Friend for his amendments. He is absolutely right to say that this country trusts the judges, which is why this House was so enthusiastic about the inclusion of the High Court in the original Bill. Does he agree that by reintroducing proper judicial scrutiny at this stage we would be reverting to the Bill that the House voted for on Second Reading?

[John Glen]

It will not surprise my hon. Friend to hear that I agree wholeheartedly. I recognise that that was a major reason that many colleagues gave at earlier points in our discussions and deliberations.

--- Later in debate ---

[Mr Alex Barros-Curtis (Cardiff West) (Lab)]

I stand in support of new clauses 20 and 21, along with amendments 89 and 90 and 92 to 95, all of which are in the name of my hon. Friend the Member for Spen Valley (Kim Leadbeater). Colleagues need not fear—I will not speak to all of them.

I am a proud Welsh MP, and a lot of the debate today has centred on differences or confusion about the distinction on devolution on aspects of the Bill. Focusing on new clause 21 and consequential amendment 90, I pay tribute to my hon. Friend the Member for Spen Valley and to the right hon. Member for Dwyfor Meirionnydd (Liz Saville Roberts) for their work together on this issue to ensure that people in Wales can access the assisted dying process in the Welsh language, if that is their preference.

In the last few months, I have met with many constituents about this Bill, including medical professionals and palliative care consultants. One of their overarching concerns is a fear that the language barrier may inadvertently impact on the ability of a relevant person in Wales properly to access and understand the assisted dying process. I am grateful to those constituents, including Dr Siwan Seaman and Professor Mark Taubert.

Accordingly, new clause 21 and amendment 90 are important. They seek to replace clause 47 and provide Welsh versions of the forms for the first or second declaration, the report about the first or second assessment of a person, and the final statement. Further, they stipulate that where a relevant person informs the voluntary assisted dying commissioner that they wish to communicate in Welsh, the commissioner must take all reasonable steps to ensure that that wish is respected and that communications by the relevant assisted dying review panel are in Welsh. These are important amendments, as they are about accessibility and respect, ensuring that language is never a barrier to compassionate end-of-life care. They uphold the principle of linguistic equality, which is well-established in public services in Wales, and I trust that that should not be controversial to colleagues when they come to vote later on.

As a Welsh MP, I am pleased to see the inclusion of amendments 92, 93, 94 and 95. While they may appear to be small amendments, they are important. As my hon. Friend the Member for Spen Valley said, they fully respect the devolution settlement by ensuring that Welsh Ministers have all necessary powers on devolved aspects of the Bill—health—while retaining the powers of UK Ministers over aspects that are not devolved. I think that was slightly misunderstood earlier by some in this debate.

Taken together, the amendments provide clarity and legal certainty and offer reassurance to patients, clinicians and Government agencies in Wales. That principle should be uncontroversial. I know from my own discussions with the Welsh Government and the Welsh Health Minister that he is extremely grateful for the interactions he has had with my hon. Friend the Member for Spen Valley, and he is confident this measure is workable from the Welsh perspective.

New clause 5 seeks to mandate that the Secretary of State must, within six months, publish a report setting out the impact of this legislation on the civil procedure rules and probate proceedings. During the debate and the streams of evidence we have heard, I do not recall a suggestion that this Bill is likely to result in any serious changes to those specifically referenced matters. On the contrary, England’s CMO, Professor Sir Chris Whitty, warned against creating a “bureaucratic thicket”, saying that the best safeguards are the simplest ones. Let us keep that at the centre of our minds when we consider this legislation and avoid inserting amendments that are no doubt well-intentioned but would create such a thicket.

I conclude by sharing one story from a constituent of mine who was focused very much on safeguards, which has been the debate on all these amendments and new clauses.

[Danny Kruger]

Will the hon. Gentleman give way?

[Mr Barros-Curtis]

I will not, because I want to finish up; I appreciate the hon. Member’s forbearance.

That constituent was Claire O’Shea. Claire was originally diagnosed with irritable bowel syndrome; it was only much later that it was realised she had stage 4 cancer. Within an hour of this House voting to pass this Bill on Second Reading, Claire messaged me to say:

“What a powerful debate today. It’s hard to say I’m ‘pleased’ as it’s a terrible issue to have to contemplate. But it’s such a relief to know the next stage is open and hopefully allays the fears of those talking about safeguards.”

Claire lost her battle with cancer last month, so I am pleased that we are here again, discussing the specifics of this Bill and talking about amendments in good faith that either side thinks will enhance its safeguards. In honour of Claire and for all those like her, I urge colleagues to support the amendments and new clauses I have outlined and to support the Bill itself.

--- Later in debate ---

[Richard Tice (Boston and Skegness) (Reform)]

I rise to support new clauses 13 to 15, and to oppose amendment 42. I commend the hon. Member for Spen Valley (Kim Leadbeater) on the way that she has navigated this incredibly difficult and sensitive process.

In considering these clauses and the passage of the Bill, I have kept in mind the simple but difficult word “pain”, because the legislation is about those who face a certain death in unimaginable pain, and its relationship with palliative care and the word “choice”.

[Danny Kruger]

On that point, will the hon. Member give way?

[Richard Tice]

I will not, because so many hon. Members wish to speak.

In this country we are lucky enough to have some of the finest palliative care in the world, and it is a noble aspiration to want to improve that—to be the best in the world. Nevertheless, many of us will have seen loved ones, family members and friends, suffer huge pain even given the finest palliative care. The trauma that that leaves for those left behind can be painful and enduring, which is why we are where we are.