Eating Disorders: Prevention of Deaths

Danny Kruger Excerpts

Tuesday 2nd September 2025 Westminster Hall

[Danny Kruger (East Wiltshire) (Con)]

I will be quick, in that case. I express my appreciation to the hon. Member for Isle of Wight West (Mr Quigley) for a very important speech; I am grateful to him. I particularly welcome the points made by him and the hon. Member for Carlisle (Ms Minns) about the need for better understanding and collaboration in the system, and I echo his call for the national register of deaths to reflect deaths from eating disorders.

I pay tribute to the Cotswold House unit, run by the Oxford Health NHS Foundation Trust in Marlborough in my constituency, which is a really important in-patient and out-patient unit working with adults. I echo the points, which I think are shared across the Chamber, about the value of NHS units as opposed to operations run by private equity companies, whose work I have real concerns about.

I want to add a couple of points to those made by hon. Members about the very legitimate campaigns of the organisations to which we are all indebted for their work. First, the point about early intervention has been made and I will not repeat it, but we clearly need to invest in more understanding both at GP level and among communities and families, and support people while they are still at home. Secondly, we must ensure we have a better and more adequate transition from children’s to adult services, which is a real issue I have come across in casework.

My final point is about the importance of step-down provision. It is not enough just to get people back to a healthy weight and then leave them to themselves; they need proper support for many months—

[Sir Desmond Swayne (in the Chair)]

Order.

Oral Answers to Questions

Danny Kruger Excerpts

Tuesday 17th June 2025 Commons Chamber

[Wes Streeting]

Given the state of the NHS in Scotland, I suspect my counterpart needed to go and drown his sorrows. The truth is that the longer the SNP is in government, the longer the NHS in Scotland is on the road to nowhere. The SNP is now on its fifth health plan in four years. Thanks to the decisions taken by the Chancellor, it is not just the NHS in England that is receiving record investment, but the Scottish Government. I have used that investment to cut waiting lists by almost a quarter of a million people; the same could be true in Scotland, if the Scottish people boot out the SNP and elect Anas Sarwar and Jackie Baillie to deliver the change that Scotland’s NHS needs.

[Danny Kruger (East Wiltshire) (Con)]

A good way to save money in the NHS is to invest in palliative and end-of-life care, because it averts costs that would otherwise go into the acute sector, including into ambulances. However, this Government are taking money from that sector through their national insurance rises. Given that integrated care boards are supposed to commission palliative care, will the Secretary of State commit in the 10-year health plan to a proper revenue funding model for hospices, and for a minimum service specification for palliative care?

[Wes Streeting]

I can reassure the hon. Member that end-of-life care is featured in the 10-year plan for health. I also recognise the pressure on our hospice sector, which is why this Government, as well as delivering £26 million through the children’s hospice grant, committed £100 million of capital investment— the biggest in a generation for our hospices. None the less, hospices do rely on the generosity of donors and I am keen to work in partnership with the sector to look at what more we can do to encourage investment. The final thing I would say is that the Opposition parties welcomed the investment in the national health service while opposing the means of raising it. They cannot have it both ways; either they support the investment and the revenue raisers or they have to be honest with the public that they would be cutting the NHS.

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.

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[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.

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[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.

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[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.

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[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.

Eating Disorder Awareness

Danny Kruger Excerpts

Tuesday 1st April 2025 Westminster Hall

[Danny Kruger (East Wiltshire) (Con)]

I acknowledge and thank the hon. Member for Bath (Wera Hobhouse) for her long campaign on this topic, for securing this debate and for all that she has done and will probably have to continue to do on this agenda for a while. I entirely endorse the campaign and the things that need to happen that she and the hon. Member for Salford (Rebecca Long Bailey) have outlined.

Eating disorders present an utter tragedy to families and to young people. Last week I met a family in my constituency whose daughter is in the grip of anorexia. We had a long conversation about both the services available and the nature of the illness itself. I asked the simple question, “What is anorexia and where does it come from?” Despite the extent of their experience and all the reading they have done, it was a very difficult question to answer. The answer included that it is like an addiction, or has the qualities of an addiction. There is apparently a genetic component, and a link with autism. As the hon. Member for Bath suggested, there is a clear element of social contagion—her points about social media are extremely important. It strikes me that in many ways anorexia is an illness of modernity. It is a consequence of the pressures that young people and, indeed, older people can face in this very difficult world we live in. That suggests that a multiplicity of responses are appropriate.

I pay tribute not just to colleagues here, on the APPG and across the House who campaign on this issue, but to campaigners from outside Parliament, including Chelsea Roff, Hope Virgo, Agnes Ayton and others, whom I have got to know in the last couple of years. I honour their expertise and commitment.

As the hon. Member for Bath said, and as cannot be pointed out too often, eating disorders, and anorexia in particular, are treatable illnesses. The services are in absolute crisis, as we have heard, but we should never lose sight of the fact that the illnesses are treatable. There is clearly desperate confusion in the NHS between the physical and mental dimensions, particularly when it comes to the extreme acute phase of anorexia. We know it is the most dangerous mental illness in terms of the tragedy of death. There is clearly a lot to do in reconciling the mental and physical sides of our health service.

The hon. Member for Bath and I are on different sides on this, and the Minister and I have been debating it over the last month or so, but I have to acknowledge my concern about the Terminally Ill Adults (End of Life) Bill. Currently, there are patients in our NHS who are diagnosed with eating disorders—anorexia in particular—who are categorised as terminally ill by the system and put on a palliative care pathway, because the system decides that their condition is not in fact treatable. It is scandalous and tragic that people who have a condition that is eminently treatable are categorised as terminally ill.

My great concern is that if we were to pass that Bill, we would end up with people being diagnosed as eligible for an assisted death. It is important to acknowledge that in other countries that have assisted dying laws, our understanding is that, in all those jurisdictions, people with anorexia have qualified for and been given an assisted death. In 100% of the cases that we know about, they passed the capacity test that we would apply here in our country. That is my great concern.

[Wera Hobhouse]

It is important that we stress that an eating disorder is not a terminal illness and therefore should not fall under that legislation. I know that the hon. Gentleman and I agree on that; I think we disagree on his worries about how it would be treated, practically, in the future. An eating disorder is not a terminal illness.

[Danny Kruger]

I am grateful to the hon. Lady, and I entirely agree. It is vital to stress that point, and I am sure the Minister agrees.

I agree with the hon. Lady and the hon. Member for Salford that we need a complete reformation of the system—I will not repeat the points of the campaign, which I endorse. I am deeply concerned about the prospect of cuts to eating disorder services. It is a great shame that the proportion of NHS spending on mental health is declining. That is very significant.

I pay tribute to the sufferers—these amazing people who battle through this awful illness. They are mostly girls but also young men—I know a young man who is still in the grip of the condition. And I pay tribute to their families. I emphasise, as I am sure the hon. Member for Bath would, given her experience, that there is hope. We must not give up on these young people. We must absolutely provide the services that are needed. We need to get our systems and our society right.

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.

--- Later in debate ---

[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 (Twenty-fifth sitting)

Danny Kruger Excerpts

Tuesday 18th March 2025 Public Bill Committees

[Danny Kruger (East Wiltshire) (Con)]

I am grateful to my hon. Friend. I was simply asking what causes him to object to physician-administered assistance to die. If he supports the principle of assisted suicide and believes in doctor autonomy, why does he not think that doctors should be able to administer the fatal dose?

[Dr Shastri-Hurst]

This gets to the root of how the law has operated in another jurisdiction, Switzerland, where Dignitas has managed this scenario over the past 40 years or so. The key—these are the words that its own guidance uses—is ensuring that the power of control remains with the person seeking the assisted death. That provides the individual who is making the choice with the ultimate autonomy at the end in controlling the circumstances and the manner in which they pass.

I have set out why I feel that although amendment 463 arises from good intentions, it would not achieve what is intended. There is a real risk that the constraints that adopting the amendment would create would lead to the regrettable unintended consequence of individuals being forced to have an assisted death at an earlier stage than they would otherwise have wished.

I can deal with amendments 497 and 498 in short order. They would tighten up the Bill by providing greater clarity around the circumstances in which the substance would be removed from the presence of the individual who had previously indicated a wish to have an assisted death. Amendment 497 specifies that the individual would need to set out to the co-ordinating doctor that they no longer desired to go through with the process. In my view, that is eminently sensible. Amendment 498 elaborates on the Bill to provide greater clarity to those who will be operating it. It will make it a much more workable piece of legislation. I support both amendments.

--- Later in debate ---

[Stephen Kinnock]

I will pretty much repeat what I have just said to my hon. Friend the Member for Ashford. There is a dividing line, as the Government see it, between assistance and administration. There is a dividing line between making the patient comfortable, enabling the procedure to take place, and the doctor actually putting the substance into the body of the patient. From the Government’s point of view, simply from the position of having a picture of the process in our mind, that dividing line is clear enough in the drafting of the clause.

[Danny Kruger]

I am grateful that the Minister is allowing us to push him on this, because it is crucial. This is the moment beyond which there is no return. He thinks that helping a patient to sit up would be within the scope of the clause. Does he think that holding the patient’s hand and tipping a cup of pills into their mouth would be consistent with the clause?

[Stephen Kinnock]

My interpretation is that it would not be, because if someone were actually tipping the pills into the mouth of the patient, they would be going through the act of putting the substance into the patient. This Bill is founded on the principle of self-administration. However, there are acts such as helping the patient to sit up that are not direct administration but assistance enabling it to take place. That is where the distinction lies.

[Danny Kruger]

That is helpful, but if the patient were holding the cup and the doctor held their hand to help them tip it into their mouth, it is not clear to me at what point assistance would end and self-administration would begin. I would be grateful if the Minister could explain that. What about the scenario in which the patient’s finger is on the plunger of a syringe and the doctor assists by putting their finger on top of the patient’s and assists them to press the button, adding a little force to that being given by the patient? Does he regard that as within the scope of self-administration, or does that cross the line into directly administering the procedure?

[Stephen Kinnock]

I thank the hon. Member for that intervention. The hon. Member for Solihull West and Shirley pointed out earlier that the scenario that he has just described would constitute more than assistance; it would be moving into administration by the doctor, rather than self-administration. I think that that aligns with the Government’s view, so I refer the hon. Member for East Wiltshire to those comments from the hon. Member for Solihull West and Shirley, who has far more clinical experience than I do.

[Danny Kruger]

I am grateful for that, and I will leave it there, but does the Minister agree that it is incredibly difficult to distinguish who is administering the treatment in that scenario? If both their hands are on the instrument, whatever it is—a cup, a syringe or a button on a computer screen—it is very hard to know who has actually delivered the final act.

[Stephen Kinnock]

What is hard to do in this Committee is imagine and agree on how many different scenarios there can be. Every circumstance and every individual experience will be different, so it is difficult for us to envision all the different scenarios. Nothing about this is easy, of course. We would not have been sitting in this Bill Committee for hours on end if it were all easy, but from the Government’s point of view there is a clear enough distinction between assistance and self-administration. As long as we are clear on those basic principles, we feel that that gives enough safety to the Bill and enough clarity around the process.

--- Later in debate ---

[Danny Kruger]

I propose to press both my amendments to a vote if necessary.

Amendment 462 agreed to.

Amendment made: 496, in clause 18, page 12, line 28, after “professionals” insert “, and such other persons,”.—(Kim Leadbeater.)

This amendment provides that the coordinating doctor may be accompanied by such persons (other than health professionals) as the doctor considers necessary.

[Danny Kruger]

On a point of order, Sir Roger. I am sorry if I missed it, but are we not going to debate amendment 496?

[The Chair]

I put the Question and nobody spoke. I am afraid the moment has passed. Under this Chairman, you have to be fleet of foot.

[Danny Kruger]

Clearly! Fair enough.

Amendment proposed: 463, in clause 18, page 12, line 34, leave out paragraph (c)—(Danny Kruger.)

Question put, That the amendment be made.

--- Later in debate ---

[Naz Shah (Bradford West) (Lab)]

I rise to oppose amendments 350 to 352, tabled by my hon. Friend the Member for Gedling (Michael Payne). They would allow the co-ordinating doctor to provide additional assistance to administer the substance in the presence of an independent witness, in some circumstances. Those circumstances would be when, as amendment 350 says, the doctor determines that the person is

“permanently and irreversibly unable to self-administer”

the lethal substance because of an inability to swallow or the loss of use of the limbs. The amendments do not spell out what the additional assistance would be, but I think it is reasonable to believe that it refers to the doctor injecting the lethal substance into a person’s circulatory system.

My hon. Friend’s amendments comes from genuine concern about the situation that some people may well find themselves in. Some people who might otherwise qualify for assisted dying under the Bill might be unable to swallow or inject the lethal drugs. We should all respect the feeling that lies behind the amendments, but we should reject them. If we pass them, we will have accepted that doctors can help people who have qualified for assisted dying to prepare to inject themselves with lethal drugs or swallow them. The Bill does not say that doctors can do that. I do not know whether the House would have voted for the Bill on Second Reading if it had, but that is beside the point—it was not part of the Bill. If we were ever to consider taking such a radical step, we should only do so after hearing as much evidence as possible on why and how this might be necessary. I urge the Committee to oppose the amendment.

[Danny Kruger]

It is a pleasure to follow the hon. Lady; I very much agree with her points. I also pay tribute to the hon. Member for Harrogate and Knaresborough, who spoke with his now customary intellectual clarity and moral constituency. He believes in autonomy, and he is doing what he can to resolve the essential contradiction in the Bill, which is designed to enable people to end their lives at their own discretion. He recognises that some of the safeguards in the Bill, which of course I do support, nevertheless represent barriers to what we are now suggesting is a human right, and that that human right will be restricted to a limited number of people, according to the Bill.

It is my view that the pressure, momentum or inherent direction of travel that the Bill sets us on will necessarily result in these sorts of amendments to the legislation in due course, whether in the form of subsequent amendments passed through legislation, the guidance that is issued, or indeed the practice of doctors. As I tried to explain in my comments on the previous group, my concern is that the Bill allows for quite a wide degree of discretion, naturally and necessarily enough, in the form of doctors interpreting their ability to assist in ways that respect the autonomy of patients, but are, in fact, a step beyond what the Bill—quite rightly, in my view—seeks to allow.

[Tom Gordon]

The hon. Member mentioned that down the line the Bill could be changed through guidance. I do not think there would be any scope or ability to do that. Does he agree that that point might be a little bit beyond what we all think might be possible under the terms of guidance?

[Danny Kruger]

I hope the hon. Gentleman is right. Nevertheless, one of my concerns about the Bill is that we are leaving enormous areas of clinical practice, and regulated conduct for the professionals involved in assisted suicide, to be performed under guidance that is still to be set out and that it is the job of future Ministers to determine.

I pay tribute to the hon. Gentleman, because he has correctly identified a group of patients for whom the drafted Bill may present obstacles to the fulfilment of their wish for an assisted death. My belief is that the ability to assist will probably cover almost anybody who wants it and has found a doctor who wants to help them, but the hon. Gentleman is right that there are some groups for whom that might be more of a challenge than others. I think the answer we are going to get—it is one made by hon. Members in the debate already—is that technology will fix it, and I fear it will, because I think we are going to find ourselves in a world in which it is perfectly possible for the administration of death to be enabled through some kind of technological device, which somebody with the most limited physical mobility will nevertheless be able to activate.

I fear the insistence that we have on self-administration. Although we can all acknowledge, as referenced in the previous debate, the conceptual difference between administration and self-administration, we do have this idea that we are individuals cut off from each other and that there is an essential gap between us and other people. At the very end of life, though—in the moments that we are considering and legislating for—that distinction is void, because we are intimately connected with other people, as per the clauses that we are debating. I fear that we are going to find ourselves in a world in which a laptop will be set up and even a movement as small as the blink of an eyelid by the patient will be enough to trigger what will be called “self-administration” of the fatal dose.

I oppose this group of amendments, moved by the hon. Member for Harrogate and Knaresborough, because I do not believe in assisted suicide. I do not understand why other supporters of the Bill are not following the hon. Gentleman’s lead, and acknowledging that if we believe in autonomy and assisted suicide, of course we should enable patients to have the final act performed upon them, rather than insisting on this arbitrary distinction that it is possible to insist on self-administration in all cases.

[Rebecca Paul]

It is clear that the hon. Member for Harrogate and Knaresborough is trying to create equity, which we all understand. We need to think about the patient on the one hand, but also the doctors, nurses and medical practitioners involved. Does my hon. Friend agree that we need to think about the obligation and impact of such amendments on them?

[Danny Kruger]

Yes. We discussed this briefly this morning. There is an important consideration about the effect on medical staff involved in the administration of assisted suicide, and we have to make sure that those who do not want to participate are properly insulated from any sort of obligation, which I know is the intention of the Bill’s promoter, the hon. Member for Spen Valley. Nevertheless, I am concerned about the knock-on effect of participation in assisted suicide spreading across a practice. I agree with my hon. Friend that we have to be mindful of the impact on doctors. The more we widen the scope—as logic compels us to do, as the hon. Member for Harrogate and Knaresborough suggests—the more it is about not just discretion, but an obligation on doctors to approve.

We need to think about the conversation that doctors will be required to have with patients who are expressing that wish. If the Bill is widely drawn, as it would be if we were to accept these amendments, there is more opportunity for a doctor to feel compelled to assent to a request.

[Sean Woodcock]

The hon. Member for Harrogate and Knaresborough is clearly trying to right what he believes to be an inherent injustice in the Bill, but is the hon. Member for East Wiltshire concerned, as I am, that if the amendment were to pass, it would take the debate from a place of being about assisted dying towards what many people would term euthanasia? That is not something that the House in any way endorsed by voting for the Bill on Second Reading.

[Danny Kruger]

I am absolutely certain that if the amendment had been in the original Bill, the Bill would not have passed Second Reading, because it would have validated the argument that many of us made that the implication of assisted suicide is euthanasia. The distinction between them, while valid in the abstract, does not apply in practice, and that distinction will be quickly overridden in time. I agree with the hon. Gentleman.

[Dr Shastri-Hurst]

Although I have certain sympathies with these amendments, I do not feel that they are necessary or desirable. They are not necessary because of the provisions that are already stipulated in clause 18(6)(b), which provides the co-ordinating doctor with the ability to prepare

“a medical device which will enable that person to self-administer the substance”.

That subsection, in effect, negates the scenario that is put forward in amendment 350 around dysphagia or the loss of a limb. It would permit, for example, the use of a nasogastric tube or a percutaneous endoscopic gastrostomy feeding tube to be used for the administration of the substance in the case of dysphagia. In the case of the functional loss of limbs, as was discussed in the debate on the previous group, a range of assisted technologies are available that would remove the barriers that that would present.

Beyond the necessity, or lack of necessity, of these amendments, I fear that they create legal uncertainty, which is clearly undesirable and, in this instance, could have a serious and significant unintended consequence through the amendments’ interaction with clause 24. Subsection (3) of that clause inserts proposed new section 2AA of the Suicide Act 1961, which is an exemption to that Act in respect of the assistance provided under this Bill. In effect, proposed new section 2AA disapplies sections 2(1) and 2A(1) of the Suicide Act where the provision of assistance is done in accordance with the Bill. Those sections specifically relate to an act

“capable of encouraging or assisting the suicide or attempted suicide of another person”.

Introducing the concept of additional assistance, as these amendments would, creates a legal uncertainty. The word “additional” creates a further concept that is beyond assistance but is, thus far, ill defined. Would it go as far as, for example, the clinician taking full control of administering the substance? It is entirely unclear. It would therefore place the clinician in an invidious position as to what it would mean for them to provide additional assistance in such circumstances. As I read the interplay between the Suicide Act and the proposed legislation, the clinician would not then be exempt by virtue of clause 24(3), leaving them open to prosecution under the Act.

[Danny Kruger]

I am grateful for that; I particularly respect my hon. Friend’s concern to protect the doctors from any confusion in the law they might be operating under. Just to take him back to the question of technology resolving what I regard as an insuperable problem—the difference between assistance and administration—is it my understanding that my hon. Friend would oppose a patient’s being able to ask a doctor to administer a lethal drug to him or her, but that he would support a patient’s being able to ask a computer to administer a lethal drug to him or her? Would he accept the computer performing the act at the patient’s request?

[Dr Shastri-Hurst]

My hon. Friend hits the nail on the head, because it is the patient who is driving the decision. They are making that act by activating the electronic device—the computer or whatever it may be in terms of assistive technology—but they have the power and control over that decision-making process, which is completely distinct from a clinician doing that act. It is distinct because it is activated by the patient—by the person making that decision—and that is why I draw the distinction. My hon. Friend may not agree, but that is my rationale for drawing a distinction between the two.

--- Later in debate ---

[Tom Gordon]

I will keep it short and sweet. I had not intended to push the amendments to a vote and will not be doing so. A lot of important points have been raised. Irrespective of whether the amendments were going to be pushed to a vote or would have been successful, it is important that we listen to and take into account the voices of people with different diseases who might wish to access an assisted death. We must also take into account the evidence that organisations have submitted, because it is important that those voices are heard too. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Danny Kruger]

I beg to move amendment 435, in clause 18, page 13, line 6, at end insert—

“(9A) Where the procedure has failed, the coordinating doctor must escalate the care of the person by making the appropriate referral to emergency medical services.”

This amendment would require the doctor to escalate the care of the person in cases in which the procedure fails.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 429, in clause 18, page 13, line 7, leave out subsection (10).

Amendment 436, in clause 18, page 13, line 8, after “provided” insert—

“(10A) If complications occur as a result of the provision of assistance the coordinating doctor must—

(a) make a detailed record of the complications in the patient’s medical records,

(b) make a declaration on the final statement issued under section 21, and

(c) make a report to the relevant Chief Medical Officer and the Voluntary Assisted Dying Commissioner.”

This amendment would require the coordinating doctor to record any complications in the patient’s medical records, to make a declaration on the final statement issued under section 21, and make a report to the relevant Chief Medical Officer and the Voluntary Assisted Dying Commissioner.

Amendment 464, in clause 18, page 13, line 8, at end insert—

“(10A) If the person loses consciousness and it appears to the coordinating doctor that the procedure is failing, the coordinating doctor—

(a) must not do anything with the intention of causing the person’s death, and

(b) must seek to revive the person.”

Amendment 532, in clause 18, page 13, line 12, at end insert—

“(12) The Secretary of State must by regulations make provision about what the coordinating doctor is legally permitted to do if it is determined by the coordinating doctor that the procedure has failed.

(13) The regulations under subsection (12) must include what specific actions can legally be taken by the coordinating doctor if—

(a) there is a greatly prolonged time to death,

(b) the person has been rendered unconscious, or rendered unfit to make a second attempt at self-administration, but has not died, or

(c) the person is otherwise undergoing complications.”

Amendment 533, in clause 18, page 13, line 12, at end insert—

“(12) For the purposes of subsections (2) to (11), the Secretary of State must, by regulations, specify where the provision of assistance under this Act may take place.

(13) Before making regulations under subsection (12), the Secretary of State must consult such persons as the Secretary of State considers appropriate.

(14) The persons to be consulted under subsection (12A) may include—

(a) persons requesting or considering requesting assistance to end their own lives, and

(b) professionals working in palliative and end-of-life care, including hospice staff, and

(c) persons from disadvantaged and marginalised communities, and

(d) registered medical professionals and other healthcare professionals.”

Amendment 430, in clause 30, page 18, line 30, at end insert—

“(da) responding to unexpected complications that arise in relation to the administration of the approved substance under section 18, including when the procedure fails;”

Amendment 255, in schedule 6, page 32, line 13, at end insert—

[Danny Kruger]

I am supportive of all the amendments in this grouping, including amendment 255 in the name of the hon. Member for Filton and Bradley Stoke (Claire Hazelgrove) about the importance of recording the means of administration of the substance. We have discussed that a bit, and I think it is important to include it. The amendments tabled by the hon. Member for Bexleyheath and Crayford are also important, as they insist on the actual physical presence of a doctor while the treatment is being carried out. His amendments also suggest that there should be a code of practice about what should happen when things go wrong; I want to go further than that, but I do approve of that measure.

On amendments 532 and 533, tabled by the hon. Member for Ipswich, I again support in principle the requirement—although there is a little too much regulation by the Secretary of State, in my view—that we be clear about where the act should take place and make provision about what the co-ordinating doctor is legally permitted to do if they determine that the procedure has failed. That is the point I really want to discuss; the amendments tabled by the hon. Member for York Central (Rachael Maskell), and the amendment that I tabled, would impose an obligation on the co-ordinating doctor to provide assistance if the procedure fails.

Let me take a moment to explain to the Committee how important it is that we recognise the genuine risk of that eventuality in the case of assisted suicide being performed. There is significant evidence—even given the lack of adequate data collection and the paucity of record keeping, with over half of assisted deaths not properly recorded at all in many places—that in places such as Oregon, which is one of the worst offenders when it comes to data collection, there are significant rates of complication. These can be difficulty with ingesting the drugs, regurgitation and seizures. As I said, 72% of deaths do not record whether complications have occurred, but among the quarter that do, there are significant rates of complication.

Sometimes death can take days, and there can be a long time of unconsciousness. The Committee has heard from me and others in previous debates about the extent to which there is real concern about the actual experience of the administration of assisted death. But it is striking how ill-defined the current Bill is on the point about complications, compared to jurisdictions where such laws are in operation. In other countries, there is clear guidance in law for what should be done. In the Netherlands, euthanasia is recommended when assisted suicide seems to be failing; in Canada, doctors are likewise given licence to administer the death themselves if it fails. The Committee has decided not to proceed down that road. Nevertheless, the question arises as to what on earth patients should do.

To the point that we are talking about a small or non-existent population group—those we might have to worry will experience complications after the administration of fatal drugs—I refer back to a previous debate, when the hon. Member for Stroud, referring to me, said:

“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…One of the reasons why Dignitas uses it is that it is so effective and it does not have those effects.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 11 March 2025; c. 925.]

Having looked into the issue and consulted other medics, I am afraid that the fact is that the safety of pentobarbital is highly contested. It has been debated in litigation in the United States because of its use as a death penalty drug. The executioners who used it said that the deaths were peaceful and akin to falling asleep, but lawyers for inmates on death row have said that

“pentobarbital caused flash pulmonary edema, in which fluid rushes through quickly disintegrating membranes into lungs and airways, causing pain akin to being suffocated or drowned.”

That is evidence from professionals who have examined the effect of pentobarbital on deceased people.

The anesthesiologist Joel Zivot of Emory University hospital in the United States testified to the Canadian Senate on the subject of assisted suicide drugs. He said that when he researched the autopsies of those executed by lethal injection, he stumbled on an alarming discovery:

“When I looked at the autopsies, to my surprise, I found that, in most of the cases, the individuals who had been executed by pentobarbital had fluid congested in their lungs. The lungs of these individuals were twice the normal weight, full of water. Now, the only way that this could have happened would have been as a direct consequence of the pentobarbital that was injected into these individuals.”

What is the relevance of that for assisted dying?

[Kim Leadbeater]

I am not aware of the situation in America, but is the hon. Gentleman not reassured that the evidence from Dignitas, which we all now have access to, says that there have been

“no cases of failure at Dignitas using this medication”?

[Danny Kruger]

Let me come on to that, because I am not aware of any evidence from Dignitas that disputes the assertion that is being made—certainly none that would meet the concerns raised by the genuine evidence of the effect of pentobarbital on death row patients. Again, the absence of evidence is not evidence of absence. I do not think that Dignitas has supplied evidence to contradict the point that I am making.

[Kim Leadbeater]

For the hon. Gentleman’s reference, I believe that the evidence is TIAB 425.

[Danny Kruger]

I am grateful to the hon. Lady. Let me let me look that up later. I am happy to exchange data, because this is clearly something we should be trying to get right.

Nevertheless, I want to try to explain why I am suggesting that we have a problem with the drugs that are used in assisted dying and that it has been suggested we use here. Let me continue the quote from Dr Zivot:

“When one watches an execution, it’s not clear that this is happening”—

meaning that it looks like a peaceful, painless death. He continues:

“There is not much to see. Executions, like, I imagine, medical assistance in dying, are a rather bloodless event; not much can be seen outwardly. But the autopsies revealed a very disturbing and surprising finding.”

He makes the point that that is particularly disturbing, given that assisted dying often uses a paralysing drug, which induces the impression of peace and calm in the patient, when in fact something else might be going on below the surface.

To conclude my quote from Dr Zivot, he says:

“To claim that this is a death that is peaceful, well, it can be nothing else because now a person is unable to move in any way, but whether or not they have any conscious experience of what is happening is unknown…it should be clear to the Canadian public that the kind of death that they will experience…will be something other than the way it is represented. It could be exceedingly painful and more akin to drowning.”

I cannot judge whether Dr Zivot is right, but we should be very wary of any claims that there is a simple answer to the question surrounding lethal drugs. To the point made by the hon. Lady, and I think by the hon. Member for Stroud, there is no evidence in the many reports from Dignitas, which has a regime very similar to the one we are imagining here—I will certainly look at the evidence mentioned made by the hon. Lady—that contradicts the concerns raised by Dr Zivot.

[Sojan Joseph]

Does this not show that clinical documentation is very important? We debated the issue in Committee earlier, when we talked about professionals being required to complete all relevant documentation. Maybe we are missing certain data because these things are not clearly documented in other places. Should we not take from that the learning that if we go ahead with this proposal, we should have proper documentation and make it clear to the clinician what they should and should not document?

[Danny Kruger]

I entirely agree that there is great concern about the lack of evidence in countries on which we are constantly relying for evidence of why this proposal is safe. I have suggested that, from the quite limited evidence we have, that it may not be safe. The hon. Gentleman is absolutely right that if we are to proceed, we need to be extremely strict about data collection.

To the hon. Gentleman’s point about making it clear to clinicians what drugs they are permitted to use, we also need to have a proper regime of clearing and approving those drugs. In earlier clauses, we debated the imperative on the NHS, the Medicines and Healthcare products Regulatory Agency and the Department of Health to properly authorise the specifics of what drugs will be used. It is not clear at the moment what those would be, and I very much agree that we need to be clearer on that.

I finish with a reference to an earlier debate, in which it was suggested, on the basis of the Australian example, that there is no evidence of complications. The hon. Member for Stroud talked about horrible stories from the United States and Canada. He also referred to Australia, where there is apparently no evidence of problems. In fact, I understand that of the six states, only Western Australia records complications, and it does so in relation only to practitioner administration—when the doctor administers the drug—which we do not propose to do here. It does not record complications in relation to self-administration, which is what the Bill proposes. In Western Australia, complications have been reported in 4.3% of cases involving practitioner administration. Again, we are dealing with the great mystery and enigma of how death happens with assisted suicide, and it is certainly unclear what we should do about it.

--- Later in debate ---

[Naz Shah]

Following the intervention of my hon. Friend the Member for Spen Valley, I have just looked at some of the evidence, and it does not cite any papers. In effect, the evidence says the effect can be seen in three documentaries. Nor does it explain why Dr Zivot’s concerns are scientifically accurate. Does the hon. Gentleman want to speak to that?

[Danny Kruger]

There is great anxiety about the validity of much of the evidence in this space. I have great respect for the work of Dr Zivot, because nothing else gets us close to understanding the actual effect of these drugs, once somebody has died.

[Kim Leadbeater]

In response to the intervention of my hon. Friend the Member for Bradford West, the evidence from Dignitas is really clear: there have been no cases of failure when using this medication.

[Danny Kruger]

My strong suspicion is that this is because the evidence is not being accurately collected or reported. With Dignitas and in all these jurisdictions, as the hon. Lady has acknowledged, there are significant failures of data and record keeping. Obviously, it is very much in Dignitas’s interest not to collect and certainly not to publicise evidence of things going wrong. However, that clearly happens in jurisdictions where data is properly collected.

[Naz Shah]

I recognise that the written evidence, particularly TIAB 425, says there have not been any failures at Dignitas, but it does not cite any published, let alone peer-reviewed, research, nor does it challenge the analysis of scientists such as Dr Zivot. That remains a grey area.

[Danny Kruger]

I agree.

[Dr Opher]

Actually, if we did an autopsy on any person who has died, pulmonary oedema would almost certainly be found because that is what happens in death—the heart stops and the lungs fill with fluid. I would also like to correct the idea that there is neuromuscular paralysis with pentobarbital. There is no way that barbiturates act in that way. All they do is sedate and put the person to sleep, and death comes afterwards.

[Danny Kruger]

I was not suggesting that pentobarbital has a paralytic effect. Often in assisted dying, a paralytic is administered first as part of the cocktail of drugs. Subsequently, we discover that while the patient may have appeared entirely calm, sleeping peacefully, significant trauma may have been occurring beneath the surface.

I defer to the hon. Member’s knowledge, but my understanding from the scientific evidence I have read, and that medics have given to me, is that the extent to which people executed by lethal injection, by pentobarbital, have their lungs fill with fluid is peculiar—it is remarkable. They effectively drown beneath their peaceful exterior.

I intend to press amendment 464 to a vote, and I intend to support other amendments in this group. Although I support the aspiration of amendment 532 to make provision for what to do in the event of a procedure’s failure, I think it gives too much leeway to the Secretary of State, so I will oppose that amendment. I think the amendments that the hon. Member for York Central and I have tabled are preferable.

To make the obvious case for those amendments, and as I said in a previous debate, there are three choices in the event of failure. The first is to ignore the plain signs of distress, of things going wrong and of the patient suffering, which is clearly a failure of the doctor’s duty of care. The second is to expedite the death, which we have decided would be illegal under the Bill. Therefore, the only option is to revive the patient and escalate treatment, rather than actively or passively facilitate their death.

I hope Members will agree that, on the rare occasions when assisted suicide goes wrong, it is right that the patient is immediately revived and taken to hospital, or for the doctor to take whatever action is necessary. I am interested to understand why those amendments should not be supported.

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

It is a pleasure to serve under your chairship, Sir Roger. I will speak to amendments 429 and 430 in my name. During oral evidence, we discussed the issues in subsections (9) and (10) of clause 18 and whether there is a contradiction. Subsection (9) states that the co-ordinating doctor

“must remain with the person”

and subsection (10) says:

“For the purposes of subsection (9), the coordinating doctor need not be in the same room as the person”.

We also discussed how that works in other jurisdictions. My amendment 429 would deal with that conflict. If the Bill were to become law, that conflict could be queried.

We also need to consider the possibility of complications. Clearly, if there are complications and the doctor is not in the same room, they would not necessarily be aware of those complications. I accept that, in some normal circumstances, doctors and medical professionals are not present in the room at the time of death; at other times, they are present. The amendment would mean that if something were to go wrong and someone was having a painful reaction to the drugs, the doctor would be there to see and help.

I do not understand what the Bill means when it says the doctor does not have to be in the same room. How far away would the doctor have to be? One subsection says the doctor has to remain with the person, and the following subsection says they do not have to be in the same room. If the Bill were to pass, we would be asking doctors to do something that is unprecedented. If the person were to suffer complications such as seizures or vomiting, or if they were exhibiting signs of distress, it appears that the doctor should be present. Members may think this could encroach on a patient’s privacy, but I think there is a discrepancy between the two subsections.

On amendment 430, I am conscious that my hon. Friend the Member for Ipswich has tabled a similar amendment. The intention of my amendment is to ensure there are regulations in responding to any unexpected complications that arise in relation to the administration of the approved substance, including when the procedure fails. I am conscious that if a doctor intervenes, they could end up in breach of the Suicide Act 1961. I therefore left the wording in that vein, as I understand that we will receive more information in due course.

Again, we received oral evidence from a number of people that what a doctor is meant to do in the event of unexpected complications is a matter of concern from both a legal and a medical perspective. We know from the evidence received from other jurisdictions that—I accept in a small minority of cases—there can be complications or the death can take much longer than expected. We also received evidence that, on rare occasions, death can take days.

Amendment 430 would show we have thought about those circumstances and provided for them by giving doctors a code of practice to refer to, rather than being left in the dark if a difficult situation arises at the time of death. We must not find ourselves in a circumstance in which doctors and patients are unprepared. It is important for us to think through, provide for and safeguard against all possible scenarios, however rare they might be. Of course, we would not want them to happen, but in some circumstances they might, and we would not want there to be a legal hole. Accepting the amendment would mean the Secretary of State has the opportunity to provide a code of practice for such circumstances. I hope hon. Members will be able to support the amendments in my name.

--- Later in debate ---

[Jack Abbott (Ipswich) (Lab/Co-op)]

I rise to speak to amendments 532 and 533, standing in my name, and in support of amendments 429 and 430, tabled by my hon. Friend the Member for Bexleyheath and Crayford. I appreciate that my amendments are similar to amendment 430. They go a little bit further, but probably not as far as we have previously discussed in the Committee.

I totally understand the concerns about the Bill being overly prescriptive about the regulations that could be passed down to the doctors making such decisions. However, it is important that we enable the Secretary of State to provide guidance, in addition to GMC regulations, on what the co-ordinating doctor must do if the procedure has failed. At the moment, the Bill simply states:

“The coordinating doctor must remain with the person until”

that time. However, I appreciate that amendment 429, if passed, would cover that issue.

Clause 9 states:

“The assessing doctor must…discuss with the person their wishes in the event of complications arising in connection with the self-administration of an approved substance under section 18”.

However, the Bill as drafted is not clear about what a doctor is legally permitted to do in the event of such complications. That is particularly important, as the Bill expressly states that the final act of administration must be taken by the person themselves. Therefore, the Bill as it stands stipulates that the doctor must discuss the patient’s wishes in the event of complications without stipulating what actions the doctor can take in such an event and thus what the patient’s options actually are.

There is a gap in the Bill and a lack of clarity on that critical issue, which has been raised frequently in both written and, to an extent, oral evidence. Dr Alexandra Mullock argued that, as

“the Bill would only permit”

a doctor only to assist in the patient’s self-administering a substance,

“administering drugs to end the life of a patient who might be unconscious (but not dying) is not permitted.”

She also raised the possibility that a patient might regain consciousness, but

“be too ill to make a second attempt”

at self-administration. What should a doctor do if that occurs? Unless the Secretary of State clarifies what a doctor can do in that situation—my amendment would not do that; it would merely give the Secretary of State direction to do so—the co-ordinating director could be placed in a difficult position.

Professor Alex Ruck Keene argued that the Bill as it stands could lead to the potential for medical professionals to be “required to stand by”, yet without being able to take steps to respond to complications so as to ensure that the process is completed. I fully appreciate that all doctors would use their good training, common sense and years of extensive practice to make a best-case judgment, and we would always support them in that, but the Bill has the unintended consequence of not giving doctors true cover in that area.

Dr Mullock also asked what should occur if the patient survives a procedure, “but is badly affected”. What treatment should be provided? Should the patient be moved to hospital? Should the patient be sedated or made comfortable until a natural death occurs, or should the doctor be able to take steps for the patient to die following the initial failed attempt? We need answers to those questions. Amendment 532 does not seek to answer them, but it would stipulate that the Secretary of State must do so at a certain point.

[Danny Kruger]

The hon. Gentleman is making an excellent speech, setting out the gap at the heart of the Bill. Does he agree—I think that he does, as he has just explained it—that there are quite straightforward choices: to expedite a death, which is illegal; to do nothing, which is inhumane; or to treat, revive or resuscitate? Why does he think that should not be clearer in the Bill? Why does he want to leave it for the Secretary of State to determine that in the future? Why do we as Parliament not get to decide what the right options should be?

[Jack Abbott]

I appreciate the hon. Gentleman’s question. In short, the answer is because we are not medical professionals. [Interruption.] Well, some members of the Committee are medical professionals, but not all of us are. I do not think that it is for the Committee to make a judgment on whether to put that in the Bill. I am happy and comfortable to leave such a directive and further recommendations, in addition to the GMC guidance, as further work to do in the coming months and years ahead of the Bill’s implementation. I think that is a healthy and strong thing to do. This is an important compromise to some of the conversations we have had in this Committee over the weeks. The amendment seeks to give a clear direction that these sorts of regulations and procedures should be stipulated at some point down the line.

[Danny Kruger]

The hon. Gentleman suggests that this is something that should be left to the medics. Nevertheless, here we are legislating for medics to be able to administer lethal drugs to people; we are responsible for what happens subsequent to the administration. Let me put this another way: does the hon. Gentleman foresee any scenario in which the guidance from the Secretary of State could be anything other than that the patient should be revived and helped to live in the circumstances where there are clearly complications under way? What else could be the appropriate direction given by the Secretary of State?

[Jack Abbott]

I appreciate the point that the hon. Gentleman is trying to make. We have discussed this point at length, across a range of subject areas, but we cannot legislate for every single permutation that could possibly happen. That could be about the initial conversations, when the patient is given a terminal diagnosis. Where do those conversations leave us? Clearly there will be a number of different scenarios, which could occur to various degrees.

I do not think it is possible to legislate for every single eventuality. I do not believe that whether to revive or not revive will be so black and white; it will completely depend on the scenario at that particular moment in time. Therefore, further work would need to be done over the coming months and years before the final introduction of the Bill. I believe that it is important to allow the time for that work to happen alongside the existing guidance as it stands.

I do not seek in my amendment to stipulate exactly what every single permutation might be—indeed, that could run to many pages and beyond. The amendment seeks to empower the Secretary of State and the Department to make sure that those eventualities, and the concerns that the hon. Member for East Wiltshire has raised, are covered by regulations over time.

In my view, the failure to provide a clear answer to these questions is an oversight. Data from Oregon shows that it is unfortunately not totally uncommon for patients to suffer complications following the administration of a lethal substance. In 2023, of the 102 patients for whom we have data on whether they suffered complications—out of a total of 367 patients who died by assisted death in Oregon in that year—10 suffered complications. That is just under 10% of the patients we have data for.

Of those 10, eight had difficulty ingesting the substance or regurgitated it. One suffered a seizure, and for one we have no data of what complications occurred. If I may say so to the hon. Member for East Wiltshire, that goes back to the variances that I referred to. It is not as simple as whether to resuscitate or otherwise. There are a number of different factors. Although that is a relatively small sample size, it shows the diversity of the challenges ahead.

In Oregon, information about complications is reported only when a physician or another healthcare provider is present at the time of death, which means that we evidently have less data on this issue than is desirable. However, despite the small sample size, that data would put the complication rate at one in 10. It would not be a completely uncommon occurrence for patients to experience complications following the administration of a lethal substance, although it would be rare.

--- Later in debate ---

[Jack Abbott]

I thank my hon. Friend for the question; I agree that 10% is a statistically reasonable figure and should be noted, which is part of the reason for my amendment. However, this is still relatively uncommon from the small sample sizes we have. For example, while it is important to refer to the Oregon example, the sample size is only 100 people, so we should always keep that in context. Will fewer people choose to go down that path because they feel, for example, there is potentially a small chance they might struggle to ingest the substance? To be perfectly honest with my hon. Friend, that will completely be their personal choice, and it is really important that, in every stage of the process, we are very clear with those looking to go down this path about what those eventualities might be.

Everyone will take their own personal opinion about that, but we want to be very clear about any risks that might come about, and we have already stipulated that this will be part of the process. Everyone should be very clear about the process—what it will look like and the associated risks. Many people will look at this and still say, “This is the path for me”, but that of course will be their own judgment.

[Danny Kruger]

I wonder whether, in the hon. Gentleman’s view, it might be appropriate for the Secretary of State, when framing the guidance he requests, to leave it to a doctor’s discretion. Would that be an appropriate outcome that he would be happy with? My concern is that we will end up with a Bill that has a blank space when it comes to what should be done in the event of complications, as it does currently, and that the Secretary of State might find it equally confusing and unclear and might be reluctant to specify too precisely what should be done in the range of different circumstances that the hon. Gentleman has mentioned. Will we not end up with a further passing of the buck to clinicians to make that decision? Given that, is it not even more appropriate at this stage for us to give a direction to the Secretary of State stipulating that, whatever the guidance will be, it is entirely inappropriate for a doctor to expedite the death of the patient in any way?

[Jack Abbott]

In the case of this Secretary of State, he is more than happy, as we have seen in the last week or so, to take decision making back in-house and make them himself as well, although that is perhaps a separate political point.

[Danny Kruger]

I trust this Secretary of State.

[Jack Abbott]

Absolutely, I know. I am sure the Committee supports him as well.

I would also point the hon. Gentleman to proposed new subsection (13), which my amendment 532 would introduce, saying what “specific actions” can legally be taken, for example, if

“there is a greatly prolonged time to death”,

the person has been “rendered unconscious” or

“the person is otherwise undergoing complications.”

That quite clearly states that we expect the Secretary of State, through this amendment, to take specific co-ordination actions on that. Under proposed new subsection (12) alone, the Secretary of State would have to make provision on that, which could lead to what the hon. Gentleman is alluding to. However, what I propose in proposed new subsection is very clear: that we would expect specific actions from the Secretary of State in that area.

[Jack Abbott]

I have used the statistic of 10%; we might find additional statistics from different jurisdictions that put that figure slightly higher or slightly lower. The point I am trying to make is that this is a relatively uncommon occurrence; none the less, this is an area of the Bill that we can make stronger with additional provisions.

I will make some progress on amendment 532. I have made the basis of my point and want to get on to amendment 533. As I have said, amendment 532 seeks to provide clarity on what doctors can do if the procedure fails or is failing by stipulating that the Secretary of State must specify in regulations what actions the co-ordinating doctor can legally take if there is a prolonged time to death; if the person has been rendered unconscious or unfit to make a second attempt at self-administration, but has not died; or if the person is undergoing complications following the initial attempt.

While there is existing GMC guidance, if no further guidance comes forward in the coming years, we risk placing some doctors in an incredibly difficult position. We always say that we should abide by good practice and the experience of many doctors, but additional cover is no bad thing. We need to say what doctors are legally permitted to do in the event of a patient undergoing severe complications. Leaving aside the doctors, that presents a risk to the patient, who may suffer needlessly and intolerably because the co-ordinating doctor does not know what they are legally allowed to do and is thus seeking to avoid legal ramifications of actions. We do not want them to take steps to respond to those complications or support the patient to die in a painful manner.

I will speak briefly to my amendment 533, which is about where assisted dying can take place. The Committee has already touched on that, and I do not want the Bill to be too prescriptive, which is why I have not stipulated exactly where the locations should be. However, this question was raised a number of times in the submitted written evidence. It is incredibly important that we address this question to ensure that assisted dying takes place at a certain location and does not have a detrimental effect on that location or community, and that the implementation of assisted dying does not exacerbate existing healthcare inequalities or deepen the mistrust of the healthcare system that exists among some ethnic minority communities in particular.

We have a duty to ensure that anyone seeking an assisted death under the Bill feels that it is safe to do so, is able to experience the positives of assisted dying and is not traumatised or retraumatised by the process. That is not possible if assisted dying takes place in settings in which people feel unsafe, which they feel unable to control or in which they have no agency. The amendment seeks to ensure that the question of where assisted dying can take place is properly addressed and that the possible impacts of assisted dying taking place at any particular location are fully considered. Only then can we address and mitigate its possible detrimental impacts.

That is a particularly important point because the criterion in the Bill that the doctor must remain with the patient until they have died realistically precludes assisted dying taking place at home, as there may be a prolonged time to death. As my hon. Friend the Member for Spen Valley said, 86% of patients in Western Australia died within the hour, but 14% took longer than that. To use another comparison, in Oregon, 87.7% of those who died via an assisted death in 2023 did so at home. If we are essentially precluding assisted dying from taking place at home because of the stipulation that a doctor has to be in attendance, we must answer the question of where it can take place.

In written evidence, Sue Ryder and the National Care Forum cited concerns about the impact on the wellbeing of staff and the other residents of hospices and accommodation-based services, should assisted dying take place within those communities. Dr Jamilla Hussain, in arguing that the question of where assisted dying could take place needed to be addressed, stated that her consultations with

“ethnic minority groups across Bradford highlighted the risk that AD could significantly deepen mistrust in healthcare services, including but not limited to palliative care.”

She argued that that needed to be considered when determining where assisted dying would take place, and because of that it would be preferable to avoid

“healthcare settings that these communities rely on, such as hospitals and hospices.”

Again, amendment 533 does not seek to specify where assisted dying should take place—I think further work is possibly needed over the coming months and years before this policy is potentially implemented—or to prohibit any particular location, I must add. The rationale behind the amendment is to ensure that through extensive consultation with relevant parties, the possible impacts of assisted dying taking place at any particular location are fully and comprehensively considered, and thereby any potential harm is addressed and mitigated against.

[Danny Kruger]

Will the hon. Gentleman give way?

[Jack Abbott]

I was just finishing, but the hon. Gentleman has timed it perfectly, so I will.

[Danny Kruger]

I think the hon. Gentleman is right about this one. Does he agree that the hospices that have written to us have a very valid point of concern that they might be required to facilitate assisted dying on their premises, even if many members of staff or other residents do not wish that to happen? Does he agree that it is important that we protect hospices from having to have anything to do with assisted dying?

--- Later in debate ---

[Dr Opher]

I thank my hon. Friend for his sensitive and clear worry. But it is important to note that we would not in any circumstances try to do something that would finish someone’s life after they had been given their self-take medicine, because that is against the law. In the Bill we have made a clear distinction between the doctor—a euthanasian, if you like—taking the life, and the patient taking medicine that finishes life. What we need to do is simply support the patient. If, as my hon. Friend suggests, they are in pain we would give them a morphine drip, which is in common use in terminal care. I absolutely respect what he says, but the same treatment principles would be in place as in terminal care.

[Danny Kruger]

Even in terminal care, when it is understood that a patient is close to death, doctors would surely not overlook a patient for whom an assisted death is clearly failing. The hon. Gentleman suggests that it would be inappropriate to—and that he would never—call an ambulance, or send a patient to A&E; I wonder whether he also means that he would never seek to revive a patient or bring them back to life, as it were, if they were experiencing complications. To his often-repeated suggestion that there is no difference between this and normal medical treatment, there is an enormous difference. Doctors administer lethal drugs to a patient, and are then also supposed to be somehow caring for the patient in the traditional way that doctors should. These things are inherently incompatible, and there is a choice between the two : is the doctor helping the patient to die, or is he helping them to live? That questions remains, and does he not acknowledge that there will be circumstances where it would be appropriate to revive the patient, and seek to support them as if they were living?

[Dr Opher]

I almost agreed with the hon. Gentleman earlier, when he asked at one point, should we not just leave this to doctors?

One of the key things the hon. Gentleman said is that the doctor administers the drug. This is self-administered, first of all, so that is a very clear line. However, also, in a case of terminal care—this is what I am trying to get across to the Committee—we know the patient is dying, and therefore if they are becoming worse we simply do things to make them comfortable, and we do not try to revive them, because they are dying. It is important that we realise that this is a very different medical situation from normal care, and that it actually needs very different skills as a doctor. Here, a doctor is not trying to prolong life, but trying to make a death as comfortable as possible.

That is why I support the Bill—because I think it will enhance a comfortable death. I wanted to make it clear that that is normal practice now in terminal care: we do not revive a patient with a terminal diagnosis who is in terminal care, but we make them comfortable.

--- Later in debate ---

[Lewis Atkinson]

My hon. Friend is absolutely right and articulated that better than I was managing to.

[Danny Kruger]

We are not necessarily talking about someone who is dying right here and now in consequence of the drugs they have taken—we could be talking about someone who is many months away from their death. The scenario we are envisaging is that fatal drugs —poisonous drugs—have been administered to the patient’s body and we are asking doctors to be normal doctors in that scenario. In a genuinely normal scenario of doctors being doctors, they would attempt to revive the patient and to save their life in that circumstance. If the parallel is with the last moments of someone’s natural death, the doctor’s job is simply to make them comfortable, but that it is not the scenario. The scenario is some months away from their natural death, when they have months to live. They may not even be exhibiting extreme illness—they may just have a terminal disease. If they have been given fatal drugs, what on earth is the doctor to do in the scenario where the drugs are not working? Surely that is a question for all of us, rather than just leaving it up to the doctors.

[Lewis Atkinson]

I disagree. As clause 9 makes clear, the doctor will have had a conversation with the patient about their wishes in advance, in exactly the same way as a surgeon would have a conversation with a patient in advance of high-risk surgery—

[Lewis Atkinson]

I am not going to take any further interventions; I am going to answer this point and make some progress.

The surgeon would say, “If this procedure fails, would you wish me to attempt resuscitation? Would you wish to be put on a support system?” The hon. Gentleman misunderstands current practice on consultation with patients, in advance of procedures, about their wishes, which is where there is significant established evidence.

[Danny Kruger]

rose—

[Lewis Atkinson]

I am going to finish on this point.

On amendment 533, tabled by my hon. Friend the Member for Ipswich, I suspect that, in dealing with a later clause, we will have a conversation about issues around hospices and care homes, but again I find the requirements under the amendment unduly onerous. As my hon. Friend the Member for Stroud and others have said, often people’s preferred place of death is at home. Are we really saying that the Secretary of State would specify addresses or the nature of places where these procedures should take place?

--- Later in debate ---

[Stephen Kinnock]

My hon. Friend will have noted that a number of amendments have been drafted in collaboration with the Bill’s promoter, my hon. Friend the Member for Spen Valley. I think that demonstrates that when the Government have seen a lacuna, a lack of clarity or ambiguities in the Bill, officials, along with the Justice Minister, my hon. and learned Friend the Member for Finchley and Golders Green, and I, have worked with my hon. Friend to table amendments to tighten up the Bill. We are doing that in areas where we feel that ambiguity exists. However, when we feel that the Bill, as drafted, does not give rise to such concerns, our position on the amendments is according to our position vis-à-vis the current wording of the Bill.

[Danny Kruger]

The Minister said that the Government find it impossible to understand the word “complications” —that it is too complex and full of ambiguity. Yet in clause 9 of the Bill, we have that very word. The suggestion is that the doctor should

“discuss with the person their wishes in the event of complications”.

Is that unclear? If not, what is the difficulty with specifying “complications” in clause 30?

[Stephen Kinnock]

The challenge with amendment 436 is that the policy intent is not as clear as it is in clause 9. That clause is about conversations in advance of decisions about committing to the procedure, whereas when it comes to complications that have arisen in a rapid and fast-moving situation, the view of the Government is that it is adequate to rely on the professional judgment of the medical practitioner to take the decision that best suits that situation.

One is a conversation that can be explored between the clinician and the patient in advance, in a managed environment; the dialogue can take place in a considered manner. The second situation is one in which there is a particular physical manifestation and it is up to the clinician to take a rapid position and to decide, according to all the elements that they usually use, such as the GMC’s “Good medical practice”, other codes of practice and their own professional judgment.

[Danny Kruger]

The Minister suggests that it is appropriate for the patient to give some advance indication of what should be done in the event of complications, but that it would not be right for Parliament, too, to give advance direction of the sorts of responses that would be appropriate in the circumstances.

I am afraid that I do not understand the Minister’s distinction. Either it is possible to set in advance the sorts of responses that would be appropriate in the event of complications—the word “complications” is already in the Bill, so is clearly acceptable—or it is not. In the event of complications arising when the patient has not given clear instructions in advance, surely it is appropriate for the doctor to be able to rely on guidance, whether that is in the Bill or set out by the Secretary of State subsequently.

There needs to be clarity about what to do because, to repeat the point, this is not normal medicine—a fatal drug has been introduced into the body. That is not a normal medical situation in which a doctor just uses their clinical judgment; the only appropriate clinical judgment in such circumstances is to attempt to save the patient’s life, because that is what doctors are supposed to do. But we are telling them that they have been allowed to help a patient to die artificially. In that circumstance, what are they supposed to do when that is clearly not working?

--- Later in debate ---

[Kim Leadbeater]

I thank colleagues for a thorough discussion of a group of interesting and important amendments. Amendment 429, tabled by my hon. Friend the Member for Bexleyheath and Crayford, would require the doctor to remain in the same room as the person. I respectfully disagree with my hon. Friend on that point. If a person is literally in the last few minutes and moments of their life, it should be up to them to decide who is in the room with them. In some cases, that might be the doctor, but I suspect that in many cases it would be loved ones and close family members.

We have had a thorough discussion of the range of amendments that look at how we deal with complications. My view is that amendment 430 would do what needs to be done. We need the Bill to show that this has been considered, and the logical place for that would be clause 30, on codes of practice. I am happy to support that amendment when the time comes to vote on it.

[Danny Kruger]

The Minister suggested that there will be a code of practice, but clause 30 says that there “may” be a code of practice. Does the hon. Member accept that there might not be one and that, even if there were, the only obligation on professionals would be to have regard to such a code? There is a big difference between that and a stipulation in the Bill.

[Kim Leadbeater]

I believe that amendment 447, tabled by my hon. Friend the Member for York Central, would change the “may” to a “must”. I am minded to support it for that very reason.

Amendment 532, tabled by my hon. Friend the Member for Ipswich, comes from a good place as is meant to be a way of trying to help the doctor, but I worry, as medical colleagues have commented during our deliberations, that it could create more of a problem for the doctor in that it would remove flexibility and the use of their clinical judgment and expertise. It always worries me when we are considering putting that level of detail in the Bill.

[Kim Leadbeater]

The challenge would be in whether the co-ordinating doctor would be able to take actions that were not listed. I worry that a list would be quite restrictive. Amendment 430, which would look at the code of practice, would achieve something in a less restrictive way, which is why I am minded to support it.

We have had a really interesting discussion about amendment 533, and we will probably come further down the line to discuss where patients should have the choice to have an assisted death. I am not entirely sure how the amendment would work, which is why I am not minded to support it.

I am slightly concerned about the terminology and am not sure what the definition of “disadvantaged and marginalised communities” would be for the purposes of the amendment. I refer my hon. Friend the Member for Ipswich to new clause 8—the duty to consult—bearing in mind that there will be a long period of consultation before the Bill, if it passes, is enacted.

The Minister referred to amendment 255, which I think will fall as it refers to a schedule that has been removed from the Bill.

[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

--- Later in debate ---

[Sarah Olney]

I have nothing to add.

Amendment 408 agreed to.

Amendments made: 210, in clause 19, page 13, line 22, at end insert—

“(2A) Regulations under subsection (2)(b) may in particular provide that the required training, qualifications or experience is to be determined by a person specified in the regulations.”

This amendment enables regulations under subsection (2)(b) to provide that the required training, qualifications or experience is to be determined by a person specified in the regulations.

Amendment 499, in clause 19, page 13, line 25, at end insert—

“(3A) Where a registered medical practitioner who is authorised under subsection (1) is not satisfied of all of the matters mentioned in section 18(4), they must notify the coordinating doctor immediately.”

This amendment provides that where a practitioner authorised under clause 19(1) is not satisfied of all of the matters mentioned in clause 18(4), they must immediately notify the coordinating doctor.

Amendment 211, in clause 19, page 13, line 31, leave out subsection (5).—(Kim Leadbeater.)

See the statement for Amendment 187.

Amendment made: 22, in clause 19, page 13, line 32, at end insert—

“(5A) Regulations under subsection (2)(b) must specify that training in respect of domestic abuse, including coercive control and financial abuse is mandatory.”—(Naz Shah.)

This amendment would require that, in the event of the coordinating doctor authorising another registered medical practitioner to provide assistance under the Act, that other registered medical practitioner must also have undertaken training on domestic abuse, including coercive control and financial abuse.

Amendment made: 212, in clause 19, page 13, line 33, leave out subsection (6).—(Kim Leadbeater.)

See the statement for Amendment 188.

Clause 19, as amended, ordered to stand part of the Bill.

Clause 20

Meaning of “approved substance”

[Danny Kruger]

I beg to move amendment 409, in clause 20, page 13, line 35, leave out from “specify” to “for” and insert—

“two or more drugs or other substances with different techniques of administration”.

The amendment requires that the Secretary of State specifies two or more drugs or other substances, which have different techniques of administration.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 465, in clause 20, page 13, line 36, at end insert—

“(1A) A drug may only be approved under this Act if it has been approved by the Medicines and Healthcare products Regulatory Agency for that purpose.”

Amendment 466, in clause 20, page 13, line 36, at end insert—

“(1A) A drug may only be approved under this Act if the Secretary of State is reasonably of the opinion that there is a scientific consensus that this drug or combination of drugs, is effective at ending someone’s life without causing pain.”

Amendment 437, in clause 20, page 13, line 38, at end insert—

“(2A) The doses and types of lethal drugs specified in any regulations made under subsection (1) must be licensed by the Medicines and Healthcare products Regulatory Agency.”

This amendment would require that any drugs and doses to bring an end to someone’s life under the Act be licensed by the Medicines and Healthcare Products Regulatory Agency.

Amendment 438, in clause 20, page 13, line 38, at end insert—

“(2A) The doses and types of lethal drugs to bring about the person’s death must be recommended by either the National Institute of Clinical Excellence or the All Wales Medicines Strategy Group in Wales’ guidelines as appropriate prior to licensing.”

This amendment will require the doses and types of lethal drugs must be recommended by either the National Institute of Clinical Excellence or the All Wales Medicines Strategy Group in Wales as appropriate.

Amendment 467, in clause 20, page 13, line 38, at end insert—

“(2A) Regulations under subsection (1) are subject to the affirmative procedure and when tabling the draft of the statutory instrument the Secretary of State must at the same time lay before both Houses of Parliament a report setting out all relevant information on the likely time to death, complications and likely side effect.”

Amendment 482, in clause 20, page 13, line 39, leave out “negative” and insert “affirmative”.

Clause stand part.

[Danny Kruger]

I rise to speak primarily to the amendments in my name and those in the name of the hon. Member for York Central with respect to the regulations for the approval of the approved substances—the drugs that will be used in the procedure of assisted death.

My amendment 465 states:

“A drug may only be approved under this Act if it has been approved by the Medicines and Healthcare products Regulatory Agency”.

Amendment 437 in the name of the hon. Member for York Central would achieve a similar objective. My amendment 466 would require that the drugs

“may only be approved under this Act if the Secretary of State is reasonably of the opinion that there is a scientific consensus that this drug or combination of drugs, is effective at ending someone’s life without causing pain.”

I also support amendment 482 in the name of the hon. Member for York Central, which would move the approval of the regulations to the affirmative procedure.

Those who support this Bill argue that death through the administration of lethal drugs offers dignity and the avoidance of suffering. If that is to be the case, the drugs used must be effectively regulated and life must be ended effectively and without pain. The amendments I have mentioned specify the role of the Medicines and Healthcare products Regulatory Agency; in my view, to leave this entirely in the hands of the Secretary of State, as clause 20 does, is quite an extraordinary step. It feels remarkable that the Bill as drafted leaves this enormous question to the Secretary of State.

[Peter Dowd in the Chair]

Good afternoon, Mr Dowd; it is a pleasure to serve under your chairmanship.

Throughout the Bill, important questions are left to regulations made subsequently by the Secretary of State. I think that is inappropriate here. When patients are prescribed medicines, in most cases the medicine will be licensed by the MHRA for use for the treatment of the particular condition. Patients can be assured that the medicine has been evaluated by the MHRA to ensure that it meets safety and efficacy standards. The MHRA reviews clinical trial data, inspects manufacturing facilities, monitors post-market safety and conducts independent quality testing so that there is regulation of medicine.

I have two concerns with my own amendments here; they might have occurred to other hon. Members, too, if they are paying attention. First, I do not accept that the procedure we are debating here is in fact healthcare. The question then arises, “Why are you proposing that the healthcare regulator would oversee the administration of the drugs?” My response to that is, “Well, somebody’s got to do it.” In fact, we are talking about substances that might be used in a medical setting, that would be appropriate in other medical settings, and that will have an effect on the body comparable to that for which they are licensed for medicine. Obviously, the intention is the direct opposite: they are licensed for genuine medicine and healthcare in order to preserve life and treat symptoms, but the intention here is to eliminate life without reference to symptoms.

Nevertheless, the only appropriate authority in our country is the MHRA—unless we were to conceive of another new body that would have that specific responsibility. However, that body would have the same obligations that the MHRA does to ensure that the substance is safe, paradoxically, in the sense of not causing unwanted side effects or distress to the patient.

The second objection—there is no reason why hon. Members present would know about it, but I have spoken in the main Chamber before about my concerns about the MHRA—is that, while I have just cited all the work that the MHRA is supposed to do in the regulation of medicines and healthcare products, I am afraid it does not do that job well. I do not want to give the Committee the impression that I think we have a perfect regulator; I think we have a very imperfect regulator in all sorts of ways.

In fact, the hon. Member for Stroud and I have participated in debates on the regulation of antidepressants and addiction-forming prescribed drugs, an important debate in which he and I are on the same side. There is genuine concern about the way the health regulator operates—we will not get into covid vaccines and other things at this moment; we have enough on our plate.

Nevertheless, despite the problems with the MHRA and the fact that I do not want to give the impression that I am concluding that assisted suicide is in fact healthcare, somebody has to do this. We cannot allow a situation in which the patient takes an overdose of a drug with no controls to ensure that the drug meets quality standards and does the job that it is meant to do. A tablet that is licensed for prescription or sale would need to have a minimum level of purity of the active substance, and to be free from other substances and contaminants that might cause unpleasant side effects or reactions. Without regulation, there is a risk that the drug may fail to work as intended or may induce unwanted side effects, such as those that we are all concerned about.

The question is: what safety standards should apply to an approved substance used for the purpose of assisted dying? A drug used to bring about death is not curing or preventing disease, or alleviating symptoms to improve death.

[Sojan Joseph]

We had some discussion earlier about how we will potentially be assisting dying in people’s own homes—that was not previously known to us; we thought it would be always in clinical settings—so medication will be transported from where it is stored as a controlled drug, in a hospital setting, to the patient’s home. Does the hon. Gentleman think that it is important that we have clear guidance as to how we store this medication?

[Danny Kruger]

I entirely agree. The regulations need to specify not only what drugs may be approved, but, as the hon. Gentleman suggests, how they should be stored and transported. I would expect that to be part of the package of regulations under the Bill.

As I have stated, I do not accept that we are talking about healthcare here; nevertheless, we are using products that are comparable to health products. The MHRA would need to significantly adapt its work in order to identify the most effective drug to cause what we currently perceive as harm—namely, the death of a patient. I recognise that that would be a significant change of remit and work for the MHRA, but we need to do it. One of the reasons that we need regulation of approved substances is to help ensure that falsified versions of the drug—drugs that do not have a licence for use in assisted dying—cannot enter the market. Such drugs may not be effective and could cause distress to those ending their lives and their families. I would be grateful if the Minister could clarify whether, in his view, clause 20 is sufficient to establish the necessary regulatory regime, or whether further legislation will be needed.

We had evidence from Greg Lawton, and other pharmacists, who wrote to the Committee to suggest that the approved substances would not legally come within the definition of a “medicinal product”, so medicines law, the protections associated with medicines and the MHRA licensing process might not apply. If that is the case, what do we do about it? We need a new licensing regime to ensure that the MHRA is able to properly regulate the substances, or, potentially, another regulatory agency would need to be established to do the job.

The Committee needs to make sure that there is a process that applies to approved substances used for assisted dying. It is not necessarily the case that a product licensed for treating a medical condition could not be used to bring about death—it is not the case that we cannot use any drug that is currently used for genuine health treatment—but it would not be being used as a medicine, so medicines law may not apply to its use for that purpose. There is an ambiguity, and I would be grateful for clarity on it.

The amendments that I am supporting would ensure that the MHRA had approved the drug for the specific purpose of ending someone’s life, and that there was scientific consensus that the drug would be effective for that purpose. The MHRA, in the marketing authorisation for the approved substance, would define the dosage of the drug required to bring about death. It would also ensure that specific considerations and warnings were placed in the product licence.

For example, some patients have allergies to certain drugs. If they decide to end their own life, that should be brought about as a result of the effect of the drug, not an unintended allergic reaction to it. Some patients would not be able to take drugs orally and might need to have the drug administered through a tube into the stomach, so different formulations would need to be available. Some drugs may need to be administered by injection. Patients may be unable to do the injection themselves, as we have discussed. Even if the patient is physically capable, injection techniques require proper training, and that needs to be considered when licensing drugs for assisted dying if the patient is responsible for self-administration.

There will be further considerations when deciding what drugs can be used. Patients will have a right to know what to expect. If they take the drug orally, how long will they have to wait before they die? Will they lose consciousness first? If so, how long will that take? Could there be some side effects or reactions after taking the drug, such as seizures or choking, that the family or carers will have to deal with? Can the drug be taken at home—that relates to the point that the hon. Member for Ashford made—or must it be used in a clinical setting? We have suggested that it could be used at home, so questions about transportation arise. Is a combination of drugs required? If so, in what order should they be taken? What happens if the patient passes out before taking the entire concoction of drugs? Has the drug formulation been optimised for the purpose of assisted dying, so that it reaches maximum blood levels as quickly as possible?

All these sorts of questions are appropriate for medical regulators. The MHRA could ensure that the patient information leaflet, and the warnings associated with it, given with the drug when it is prescribed prompt doctors to think about what drugs are most suitable for the patient and to provide information to the patient about what to expect.

Parliament must have oversight. It must bear responsibility for the kinds of deaths that it approves. Both Houses of Parliament should approve the statutory instrument. To inform that decision, the Secretary of State should provide all relevant information on the likely time to death, and on complications and side effects. When the state is creating a regime that will end lives, there must be maximum transparency and accountability, yet the Bill provides that this will be done by a negative statutory instrument. In other words, Parliament will get a say on the regulations only if the Leader of the Opposition prays against them—that is the process for a negative SI. That is the only circumstance under which the Government would make time for a debate and a vote on a negative SI. Given that this is an issue of conscience, I find it inconceivable that the Leader of the Opposition would want to take a position on it and so pray against it to trigger a proper debate. I think it is highly likely that Parliament would never get a say on this crucial issue because of the use of the negative procedure.

That situation has been recognised repeatedly as being unacceptable. When Lord Falconer introduced his Assisted Dying Bill to the House of Lords in 2014, it too provided for a negative SI power on this matter. The highly respected House of Lords Delegated Powers and Regulatory Reform Committee—we do not have an equivalent Committee in the Commons, but it sits over Parliament—said that it did not consider either the power or the procedure in the Falconer Bill to be appropriate, yet that is the procedure that we are being presented with here.

In 2021, when Baroness Meacher introduced her Assisted Dying Bill to the House of Lords, the Delegated Powers and Regulatory Reform Committee again issued a report, in which it said:

“In the interests of clarity and transparency on such important issues of public policy, the matters that are in due course to be dealt with under clause 4(7) by negative regulations should in our view be spelled out in detail on the face of the Bill from the outset. Accordingly, the Bill should contain a definitive list of medicines, and details of the manner and conditions under which such medicines are to be dispensed, stored, transported, used and destroyed. The power to amend such matters should be a matter for regulations subject to the affirmative procedure.”

We then come to Lord Falconer’s 2024 Assisted Dying for Terminally Ill Adults Bill, which he withdrew following the introduction of this Bill by the hon. Member for Spen Valley. That Bill in part took on that feedback from the Lords Committee. Although it did not provide a list of medicines, it did at least provide that the power to specify the drugs would be through the affirmative procedure.

The Hansard Society, which is non-partisan and neutral on assisted dying, has issued a critical report on this power. It says:

“MPs may wish to enquire why Kim Leadbeater has chosen not to adopt the scrutiny procedure set out in the 2024 bill, but has preferred that proposed in the 2014 and 2021 incarnations of the bill, despite the advice to the contrary of the Delegated Powers Committee.”

I would be grateful to learn from the hon. Lady why she has chosen this procedure.

It might be objected that the list that I am requesting might need to be modified quickly and that the affirmative procedure—having a parliamentary vote—would be an obstacle to doing that. The Hansard Society anticipated that objection. It said that

“this could be addressed by making provision for the use of the ‘made affirmative’ procedure in urgent cases where the Secretary of State wishes to remove a substance from the approved list and is of the opinion that it is necessary to do so immediately in order to prevent adverse medical events or failed assisted deaths. This would mean Ministers could act expeditiously but Parliament would have to debate and approve – albeit retrospectively – the change in the list. Whilst not perfect it would provide more opportunity for oversight than that offered by the negative scrutiny procedure.”

It seems to me that there is no justification for this vital matter to be regulated under the negative procedure. Too much power and responsibility is being given to Ministers subsequent to the passage of the Bill— if that is what happens. My amendment 467 would ensure that Parliament has a meaningful say, through the affirmative procedure, and that a report is published as part of that process setting out the expected efficacy of the drugs that will be used. I hope that the Committee will support it.

[Rebecca Paul]

My hon. Friend the Member for East Wiltshire eloquently covered most of the things I would have said.

We have probably not spoken enough to date about the impact on pharmacists, but we are getting to the point in the Bill where it is really important that we take on board the written evidence and feedback that we are hearing from them. The Royal Pharmaceutical Society said:

“In dispensing a prescription, a pharmacist assumes a proportion of the responsibility for that prescription and therefore must be assured that all legal requirements are in place and that it is entirely appropriate for the patient. The link to the clinical assessment of eligibility criteria is essential and therefore the prescriber should always be one of the assessors. In addition to the usual practice of checking that the prescription fulfils the necessary legal requirement, pharmacists must have full access to the patient’s diagnosis and assisted dying care plan.”

That raises a few valid and interesting points that we need to take on board to ensure that pharmacists can do their jobs in line with the regulations and laws they are subject to, which are ultimately there to maintain patient safety.

I support amendment 466, tabled by my hon. Friend the Member for East Wiltshire, which would ensure that the Secretary of State must be of the opinion that there is scientific consensus that the drug is effective without causing pain. I am of the view that the Secretary of State is probably the right place for that responsibility to sit. One reason for that, which my hon. Friend spoke about, is that I am not sure that the MHRA is the right regulating body for that. I am no expert on this, and I am open to hearing the debate, but the MHRA’s remit covers medicines and healthcare products, so there is a question about whether legally the responsibility falls to it. If it does not, do we set up another body, or do we adjust its remit so that it is covered? I have reservations about doing anything that would merge assisted dying into normal healthcare, but I have laid that out many times over the weeks, so I will not go over that.

My understanding is that, on top of all the things my hon. Friend set out, the MHRA’s role is to give marketing authorisation for the promotion and advertising of medicine. Once that has been given, reams of regulations and compliance must be done, including in respect of the labelling of medicine. I believe it would have to be put on packaging that a medicine could be used for assisted dying. We need to get clarity on that from experts in the field, so that we fully understand it. If that is the case, how do we feel about making it clear that said medicines, potentially out in the market, could be used for assisted dying? I suggest there could be some significant downsides to such clear labelling. That is something for us all to think about. I wanted to raise those important points.

--- Later in debate ---

The MHRA is undoubtedly the best qualified agency in this country to undertake such a task. We could create another quango to specifically monitor the efficacy of and complications around lethal drugs, but that organisation would be starting from scratch, and it would almost certainly have to recruit its staff from the MHRA. We could give the task of monitoring drug efficacy and complications to the newly created commissioner, but I have warned before that we are giving the commissioner—one person—too much power to mark their own homework and, again, the commissioner would have to recruit experts in pharmacology, whereas the MHRA already has some of the best in the world.

[Danny Kruger]

The hon. Lady puts her finger on the tension—my hon. Friend the Member for Reigate and I expressed it as well—about whether it is appropriate to give the health regulator responsibility for regulating a product that is about not health, but death. Does the hon. Lady agree that no other agency would be appropriate, given the skills she has set out? The purpose of these lethal drugs is to kill the patient; nevertheless, it is appropriate that we consider them in terms of not only that objective but their potential side effects. The purpose is not one of healthcare, but the product is very close to a healthcare intervention. Therefore, despite all our anxieties, it feels appropriate for the healthcare regulator to oversee this.

[Naz Shah]

I absolutely agree and share those concerns. This is important. I appreciate that we have had this debate for many days now. Is this a healthcare intervention? Is it a treatment? What words should we apply? In this instance, when it comes to drugs, there are potential side effects. We have seen that they do not work everywhere and that they create complications. We have just debated whether a doctor should be in the room, outside the room or round the corner, as well as whether they should be visible or able to see what is going on. Ultimately, this is about the drugs. Having looked at the issue, I genuinely cannot imagine anything but the MHRA in this role. Are we really going to set up something completely new, outside our health service, that regulates drugs, their side effects and the potential implications?

--- Later in debate ---

[Naz Shah]

My hon. Friend clearly speaks with expertise. There are other regulators, but the reason why I support amendment 465 is that the MHRA is an institution that we trust and that has the expertise. My understanding—my hon. Friend might be able to tell me differently—is that, of the regulators, the MHRA is the body that does the ultimate rubber-stamping and gives our country confidence in the national health service.

[Danny Kruger]

The hon. Lady is right that there is no other agency that is appropriate. The difficulty is that the MHRA is itself highly conflicted—we will come in due course to discuss the role of the profit motive in this mooted procedure—and the big problem is that it is overwhelmingly funded by the pharmaceutical companies. We have to ensure that there is no hint of corruption in the system, but I agree with the hon. Lady that the only way to do this is through that agency, but perhaps after reform.

[Naz Shah]

I thank the hon. Member for his intervention.

We should be using the world-class pharmaceutical regulator we already have to oversee the drugs that will be used for assisted dying, and I urge all Committee members to support the amendment, which is a very important safeguard.

--- Later in debate ---

[Kim Leadbeater]

My view is that this is very clearly a matter for the Secretary of State, but with expert clinical and medical guidance. These are the people who should be making the decisions about such drugs. The evidence about this type of medication exists. As part of the commencement period and the consultation period, I anticipate there will be wide consultation about the drugs that are available. I think it is best left with the Secretary of State, so I would leave the clause unamended.

[Danny Kruger]

I will press amendments 465 to 467, but not amendment 409. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[The Chair]

Before we continue, let me make a point about the process for tonight. We are not far off a vote in the main Chamber: it may happen in the next half-hour. There may be four or five votes, including a potential Division on Third Reading of the Children’s Wellbeing and Schools Bill. No doubt people will need a comfort break, so my intention is that when the Division bell rings, we will suspend for an hour and 15 minutes. I am not saying that that will absolutely the right period, but it is as good as we can judge at this stage.

Amendment proposed: 465, in clause 20, page 13, line 36, at end insert—

“(1A) A drug may only be approved under this Act if it has been approved by the Medicines and Healthcare products Regulatory Agency for that purpose.”—(Danny Kruger.)

Question put, That the amendment be made.

--- Later in debate ---

[Kim Leadbeater]

Amendment 379 would ensure that the co-ordinating doctor provides the commissioner with a copy of their final statement in cases in which the person has successfully been provided with assistance to end their life in accordance with the Bill. That is an important part of the reporting procedures and of the role of the commissioner. If agreed to, the amendment will ensure a robust recording and monitoring process for assisted dying.

Amendment 500 provides that regulations about the form of the final statement must make the provision mentioned in paragraphs (a) to (i) of proposed new subsection (3A). It builds on my amendment 214, which would amend subsection (3)(a) to require that the form of the final statement must be set out in

“regulations made by the Secretary of State”.

This is another way of ensuring robust and thorough reporting.

[Danny Kruger]

I thank the hon. Lady for explaining the purpose of the amendments. Amendment 500 specifies the information that a final statement must contain. Will she clarify why there is no requirement to record any details of what happened once the drugs were administered, other than the time between the use of the approved substance and death?

In this debate, we have acknowledged the importance of record keeping. If the intention is to maintain public confidence in the system, should there not be some provision to record whether complications happen and what complications there were? This skirting of the issue of complications is concerning. We have ruled out explicitly informing patients of the risk of complications.

[Kim Leadbeater]

I do not think that anyone has ruled out discussing complications. Clause 9 makes it clear that the doctor has a very clear discussion with the patient about what will happen if they proceed with an assisted death.

[Danny Kruger]

I am sorry; I mis-spoke. I should have said that we have ruled out clarifying the expectations of what doctors should do in the event of an assisted death, and whether or not that is specified by the patient.

Earlier today, the Committee again ruled out specifying what the obligations on doctors are if complications arise, whatever the patient has discussed earlier. With this amendment, we now seem to be ruling out gathering any information about what happened, which is surely vital not just for safeguarding but to develop good practice in the operation of the Bill, a point that the hon. Member for Ashford made earlier. There is too much silence in the Bill, between the taking of the substance and death, on what happens if there are complications, what is permitted and, now, what is recorded. Amendment 439, in the name of the hon. Member for York Central, attempts to address that point. I hope that the Committee will accept it.

[Naz Shah]

I rise to speak to amendment 439, tabled by my hon. Friend the Member for York Central, which would amend clause 21 such that the relevant body would provide the chief medical officer and the commissioner with the full set of documents relating to a person who had undergone assisted dying. The relevant body would be the co-ordinating doctor if that person were a practitioner with the person’s GP practice. If the co-ordinating doctor did not meet that condition, the person’s GP practice would have the responsibility of sending those documents.

Those documents would be the person’s full medical records, court records and all documentation relating to assessments and procedures relating to the person’s assisted death. I note that “court record” refers to the Bill before we agreed to the amendments and new clauses that replace the High Court procedure with a panel system. We should be able to slightly tweak the wording to reflect that when we tidy up the Bill. That is what the amendment does. Let me say a little about why it does so and how it would make the Bill stronger.

The key aim is to ensure proper public oversight of any assisted dying scheme. The Bill creates the role of the voluntary assisted dying commissioner, who will look at and report on the workings of the system, appoint panel members and be the final court of appeal, so to speak. Those are far too many powers to give to one person, but if we are giving the commissioner a duty to report on how the system works, they should have the best possible information. It is only right that the information also be sent to the chief medical officer for England or for Wales, as appropriate; they are both very senior public officials and experienced doctors.

My hon. Friend the Member for Spen Valley has tabled amendment 382, which, to quote the explanatory statement,

“provides for 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 for Wales).”

I will have more to say on that amendment when we come to it, but removing the chief medical officer from the monitoring, investigation and reporting functions is not a good idea.

What use could the commissioner and the chief medical officers make of the data provided under amendment 439? Let me give some practical examples. If there were reported instances of a person experiencing discomfort or pain as a result of taking the medication, that would be of interest to the CMO and the assisted dying commissioner. It could trigger a further exploration of the titration of medication used in the procedure. As another example, let us think about what could happen if a family raised concerns about a person receiving assisted dying despite lacking capacity or being coerced. The CMO and assisted dying commissioner could use the information provided to investigate those allegations.

The amendment will ensure that the assisted dying commissioner and the chief medical officer receive detailed qualitative as well as quantitative data on people who have received assisted deaths. It is an important step towards making sure that the assisted dying scheme receives proper, well-informed scrutiny. In turn, that scrutiny will make it less likely that the scheme will allow abuses or ignore serious problems. I urge hon. Members to support the amendment.

--- Later in debate ---

[Danny Kruger]

I rise to speak to amendment 440, which stands in the name of the hon. Member for York Central. I echo the points made by the hon. Member for Banbury. Surely it is the case that the interventions made by a medical practitioner in response to the procedure failing, and the timing of those interventions, must be properly recorded. Should the procedure fail, the need for record keeping is of significant importance, as with all medical record keeping.

The doctor with the patient should write up the notes, including the times at which they reacted negatively to the procedure, the amount of medication that they consumed, any side effects and any action taken. That is good practice. In other jurisdictions there has been poor record keeping, as I mentioned, when things have not gone according to plan. We do not fully understand what happened in those instances or, more generally, the prevalence of complications in those jurisdictions. That information will be vital if further interventions are required, including emergency care.

Clause 22 deals with two situations: if the person decides not to take the substance or if the procedure fails—the phrase “Other matters to be recorded in medical records” seems a rather innocuous title for a clause that deals with such situations. In fact, I think that is the only mention of the procedure failing in the whole Bill. However, the clause, and amendment 380, simply require the co-ordinating doctor to notify the commissioner that it has happened as soon as practicable. Do we have any sense of when the doctor should judge the procedure to have failed? I would be grateful if the Minister or the promoter could offer a definition of procedural failure. What does that actually mean?

That question arises in other jurisdictions that have assisted dying laws. A 2019 paper by the Canadian Association of MAiD Assessors and Providers said:

“There is no clear cut-off for what constitutes ‘delayed time to death’ or ‘failed oral MAID’.”

At what point does a delayed time to death yield to failure? That question is not just abstract for us; it is a philosophical question in other contexts, but we are required to answer it. That paper goes on to suggest that

“clinicians should decide with patients in advance at what point they will consider inserting an IV and completing the provision”,

which is a rather euphemistic term but we know what it means. That is legal in Canada, but it would not be here, so what happens?

In written evidence, Dr Alexandra Mullock, who is a senior lecturer in medical law and co-director of the Centre for Social Ethics and Policy at the University of Manchester, pointed out:

“The Bill is silent on the precise obligations of the doctor if the procedure fails.”

Clause 18(9)(a)(ii) states that the doctor must remain with the person, but what the doctor should be permitted to do, either in relation to aiding recovery or supporting the person to die after the initial attempt has failed, is unclear. She said:

“During my work with the Nuffield Citizen’s Jury, the issue of what happens if the drugs do not end the person’s life was raised within the evidence presented to the jury, and this became a point of concern for several jurors.”

She also said:

“By not addressing this question within the Bill, it allows doctors to exercise clinical discretion, however, it is arguably legally and ethically preferable to clarify the position and address public concern by including a clause that covers this problem.”

I hope that is helpful.

I will end by referencing the hon. Member for York Central, who tabled amendment 440 and made the case very powerfully. She said that should the procedure fail, the need for record keeping is of significant importance, as with all medical record keeping. I have already said that, but we cannot have too much of the hon. Member for York Central.

[Stephen Kinnock]

Amendment 380 is one that the Government have worked on with my hon. Friend the Member for Spen Valley. As the Bill currently stands, clause 22 sets out that where a person decides not to take an approved substance provided under clause 18 or where the procedure fails, the co-ordinating doctor must record that that has happened in the person’s medical record or inform a registered medical practitioner with the person’s GP practice. The amendment would require that in those circumstances, the voluntary assisted dying commissioner must also be notified.

I turn to amendment 440. As I have just mentioned, clause 22 provides that the co-ordinating doctor is required either to record in the person’s medical records or inform a medical practitioner registered at that person’s GP practice if the person has decided not to take the substance or the procedure has failed.

The amendment increases the requirements on the co-ordinating doctor to document in such cases any interventions made by a medical practitioner and the timing of those interventions. The requirement on the co-ordinating doctor to record interventions following a failed procedure is open-ended in time, which could lead to operational challenges. For example, the co-ordinating doctor would remain obliged to record the medical interventions made by others in response to the procedure failing, even if those interventions took place weeks or months after the event itself. I hope that those observations have been helpful to 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.

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[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.

--- Later in debate ---

[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.

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[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 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 (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.

--- Later in debate ---

[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.

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[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 (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.