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”?

--- Later in debate ---

[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.

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[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.

--- Later in debate ---

[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.

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[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.