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

Danny Kruger Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[Naz Shah]

Amendment 281 would ensure that the patient receives advice on palliative care options from a specialist in the field. Medicine is fast-paced, with innovative and new medicines becoming available in quick succession. Although those in the profession try to keep abreast of developments, it is hard to maintain the depth of knowledge necessary in all specialties. A co-ordinating doctor may or may not have specialist knowledge in palliative medicine. Some courses may provide the opportunity to learn more, but others only touch on palliative medicine—covering it in less than a day of a five-year medical degree. Specialists who are leading in this field of medicine, innovating advances and working to palliate a patient’s symptoms at the end of life will have far greater knowledge of the specialism. Even in this wider debate, many who work in a different field of medicine or in general practice have simply got their facts wrong when speaking about palliative medicine—not through intent but because they have drawn on their own, perhaps out-of-date, experience or simply do not have the competencies to understand all that palliative care can provide.

Pain and symptom control techniques are advancing; in our debates on this Bill, people have articulated instances of poor care rather than what clinical experts are able to achieve. It is therefore essential that a patient has a consultation with an expert in the field of palliative medicine, who can alleviate a patient’s fear, support them with a plan for the end of their life, and discuss how pain and symptoms can be managed. Hearing an alternative approach to the end of life can be life-affirming, help people discuss their fears and concerns about dying, and provide a patient with what they are seeking physically, psychologically, emotionally, socially and perhaps spiritually. Specialists in palliative medicine are trained to home in on the challenges that people naturally have on receiving a diagnosis of terminal illness and are skilled at supporting a patient to explore what end of life could look like for them.

If the Committee does not pass this amendment, it would be placing itself above palliative care specialists when talking about such matters. It would undermine the need for such a specialty in medicine, like a GP who may not know the breadth of palliative medicine options for their patients. The Committee must not assume that it knows those options. Rather, it should enable those with a specialist understanding of palliative medicine to deploy their skills in this process by working through palliative care options with patients before the consideration of a path that will end with an assisted suicide.

Amendment 299 is consequential on amendment 298, which would ensure that a person has a consultation or consultations with a palliative care specialist. Amendment 298 would further embed this into the practice of managing the end-of-life process to provide the patient real choice over their options at the end of life, as what can be achieved through the practice of high-quality palliative care is often significantly different from people’s perceptions—even those of clinicians. Palliative care, like so many fields of medicine, continues to advance in its application and in the steps that can be made available to palliate a person’s pain and symptoms. When pain is difficult to control using oral or intravenous pharmacology, other interventions, such as a nerve block, can result in the absence of pain. A specialist is required to provide such a procedure, but for most people who are in receipt of palliative care, this option is rarely made available. Palliative care is about not just pain and symptom control, but the holistic journey of a patient at the end of life.

[Danny Kruger (East Wiltshire) (Con)]

The hon. Member mentions the principle that palliative care is a holistic service. Does she agree that, given that the Bill’s advocates—including the promoter, the hon. Lady for Spen Valley—emphasise the need for a holistic range of opportunities for end-of-life care, palliative care needs to be central to that? Rather than suggesting that there is an either/or between palliative care and assisted dying, the advocates of the Bill have often stressed the importance of having both options. Does the hon. Member for Bradford West agree that it is strange that the Bill does not require palliative care consultation as part of the range of services that are offered to patients when they are having their consultation?

[Naz Shah]

I completely agree, which is why the amendment tabled by my hon. Friend the Member for York Central (Rachael Maskell) is very important. I urge the Committee to accept it, as it would ensure the provision of a palliative care consultation. As my hon. Friend the Member for Spen Valley has always said, it is about having a holistic approach—we need to get back to that.

In the evidence sessions, we heard that palliative care social workers can play a pivotal role in supporting patients. Those from other professions—psychological services, chaplaincy services, physiotherapists, occupational therapists and speech therapists—along with specialist nurses and medics can all contribute to the care of a patient at the end of life. In discussions with palliative care specialists who listened to the debate on 29 November, they were perplexed by the symptoms that were graphically described in the case studies, and cited poor care as the reason for them. Many such symptoms can be controlled, and they were shocked that such examples of poor care were presented as a reason for assisted death, rather than for making good quality palliative care available to all patients.

We further heard evidence, especially from Dr Jamilla Hussain, that access to palliative care is inequitable. We know that those from minoritised communities and from low socioeconomic backgrounds have poorer access to good palliative care, and that people can have poor access depending on where they live, and on the day of the week or the hour of the day. Through this amendment, we want to ensure that everyone who is seeking an assisted death, or who has it suggested to them, as this Bill allows, is able to access a consultation or consultations with a palliative care specialist, who can dispel the myths while supporting them with their end-of-life plan.

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[Naz Shah]

I completely agree. It is imperative that those options—pain options and care options, including with the family—are explored in detail. The last time that I spent time in a hospice was when my brother-in-law was dying of cancer, and I remember that, as a family, we were very much involved in those conversations. Having such expertise empowers not just the patient but the family. Losing somebody who has a life-threatening condition is a difficult time for families and loved ones. When the wraparound model of palliative care, with specialist nurses and doctors, is good, it can be amazing. I have heard plenty of stories about when it is good. Last week, I mentioned a friend of mine who lost her husband last year, and she said that the palliative care nurses and doctors could not do enough. That gives the family confidence to explore the options. In that instance, that person would have benefited from this Bill—she encouraged me to support it.

As Dr Jamilla said, some people would absolutely benefit from the Bill, and they cannot be dismissed, but how do we legislate to cover people who do not have equal access to palliative care or to healthcare? There is discrimination. The covid experience that we went through recently showed the impact of inequalities. Disabled people, people with mental health conditions, elderly people, and people from black and minority ethnic communities, say that they were DNR-ed—subject to “do not resuscitate” orders. There is already a lack of trust in services, so we need to strengthen palliative care.

There is a fear among these communities that they will be pushed towards assisted dying. A consultation with participants from Pakistani, Roma, Nigerian, black Caribbean and Indian backgrounds revealed overwhelming mistrust, which is deeply rooted in the experience of discrimination and the disproportionate impact of covid-19. As one participant put it,

“They are doing this to save money…to kill us off.”

To get confidence among communities back, we need specialists people can rely on. That is what the amendment speaks to, and I hope that the Committee will support it.

[Danny Kruger]

I rise to briefly speak in support of amendment 281, moved by the hon. Lady and tabled by the hon. Member for York Central (Rachael Maskell).

At the moment that somebody seeks assisted death through a consultation with a doctor, they stand at a fork in the road: they can either proceed towards the assisted death about which they are inquiring, or turn towards other treatment options. On Second Reading, almost every Member on both sides of this debate stated that we need more palliative care, and everybody emphasised the value of providing good palliative care to all who need it. The amendments in this group would simply give force and power to the clear call of the House of Commons for a strong, realistic palliative care option as an alternative to assisted death, and I would be astonished if members of this Committee chose to vote them down. They give clear expression to the will of the House: that palliative care should be offered, and that it should be apparent that a patient has clearly understood their palliative care options.

I implore members of the Committee to consider what they would be communicating if they rejected the amendments. They would be saying that this is not a fork in the road, but a one-way street: there is only one way that someone is likely to go, and that is onwards to an assisted death. If that is the will of the Committee, it should vote the amendment down. If it thinks, as so many people said on Second Reading, that there should be real choice, and that palliative care should be explained and properly available, then I implore the Committee to support the amendment.

[Dr Simon Opher (Stroud) (Lab)]

I thank my hon. Friend the Member for Bradford West and the hon. Member for East Wiltshire for their speeches. I also thank my hon. Friend the Member for York Central (Rachael Maskell), who is a fantastic campaigner for excellent palliative care, for tabling the amendment.

I cannot disagree with almost everything that has been said: people need to be given real choice, and they certainly need to be given the choice of palliative care. As the hon. Member for East Wiltshire said, people need to be offered palliative care. That is absolutely crucial to the Bill. However, the amendment would make it a requirement that a patient has met someone in palliative care. What would happen to a patient’s autonomy if they did not wish to see a palliative care doctor? Would they be excluded from the process? It is incredibly important that people have real choices with respect to palliative care in this process.

I note to the Committee the fact that clause 4(4) states:

“If a registered medical practitioner conducts…a preliminary discussion”

with a person, they have to also discuss with that person

“any available palliative, hospice or other care, including symptom management and psychological support.”

That is in the Bill. It needs to be offered.

I have had patients who have not wished to see a palliative care consultant. It is their autonomy to make that choice. I do not think that it is a wise choice—I think almost every doctor would try to push them towards palliative care—but we must not exclude those patients from accessing an assisted death if that is what they want. That does not mean that people should face a fork in the road, as the hon. Member for East Wiltshire just mentioned. This is not an either/or: sometimes people can receive excellent palliative care and still request an assisted death, as my hon. Friend the Member for Spen Valley said.

I absolutely agree with many of the things you have been saying. I totally agree that we need better palliative care—although, actually, we have pretty good palliative care. In 2017, palliative care in this country was the best in the world, and we need to rebuild back to that again. But having a requirement that someone has to have seen a palliative care consultant will weaken the Bill. I urge the Committee to reject the amendment.

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[Dr Shastri-Hurst]

I am grateful for the hon. Member’s intervention, which leads on to the point I was going to make. We are getting bogged down in nomenclature about what speciality is involved when this is actually about training. It is about whether the individual having the conversation has the requisite skills to have a meaningful conversation. Clauses 5(3)(a) and 8(6)(a) stipulate that the co-ordinating doctor or independent doctor

“has such training, qualifications and experience as the Secretary of State may specify by regulations”.

That is the key part. This is about ensuring that people having incredibly sensitive, challenging and difficult conversations with patients about choices available to them at the end of life have the requisite skills and knowledge to do so. That may not be applicable to each and every general practitioner, but those having those conversations should have that knowledge.

[Danny Kruger]

My hon. Friend is making a thoughtful speech, but I am concerned that he suggests that the skills required are simply the skills of conversation. The skills required are the skills to understand the patient’s condition and lay out very clearly to them their prognosis and the treatment options available to them.

With all respect to my hon. Friend’s father and other GPs, I cannot accept that every GP is fully qualified to understand the dying trajectory of the patient before them—perhaps my hon. Friend will confirm his belief that that is so. If that is true, what is the point of the palliative care profession? We have GPs already and are now introducing psychiatrists and social workers into the mix; I do not understand why on earth it should be regarded as unnecessary to include professionals in palliative care—the key skill that we all recognise as so important in this space. Why not?

[Dr Shastri-Hurst]

I fear that my hon. Friend may be oversimplifying what I was saying. Perhaps I was not clear enough, so I will elucidate. I was certainly not suggesting that the required skills were merely those of being able to have a consultation and a conversation. I was talking about having the skills to have the information that needs to be imparted and the knowledge that underpins that and being able to articulate that within a consultation. It is a much wider picture than just having the communication skills—it is having the knowledge that underpins that. I am saying that that is not necessarily the domain only of someone who works in palliative care. There are a number of specialists who work within this field—it is a multidisciplinary field—and they all bring their expertise. The issue is about ensuring that anybody having these conversations has the knowledge base to conduct them properly.

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[Kim Leadbeater]

It is a pleasure to serve under your chairship, Mr Efford. I will address the amendments in two different ways. I will start by looking at the technical issues around amendment 281, and then I will look at why I believe, as other colleagues have said, that the amendments are not necessary given what already exists both in the Bill and in terms of good practice in our health service.

First, I worry that amendment 281 will not have the effect that my hon. Friend the Member for York Central (Rachael Maskell) intends. Clause 1(2), to which the amendment relates, provides an overview of the other clauses in the Bill, and therefore cross-refers to sections 5 to 22. Clause 1(2) does not impose duties on persons in and of itself. The duties are set out in the later clauses to which it refers. Adding an additional subsection to clause 1, as proposed by the amendment, would not result in a requirement that the person must meet a palliative care specialist. That is a technical detail to reflect on.

In addition, the term “palliative care specialist” is not a defined term. Palliative medicine is a designated speciality of the General Medical Council, and a doctor can apply to be entered on to the GMC specialist register for the speciality provided that they have the specialist medical qualification, training or experience. However, the current wording of the amendment means that it is not clear whether it is seeking to require the person concerned to meet with one of those specialist doctors, or whether a meeting with another medical professional specialising in palliative care—for example, a specialist palliative care nurse—would suffice. There is no equivalent specialist register for specialist palliative care nurses. It is a technical issue, but an important one.

I also point out that my hon. Friend the Member for York Central has put an incorrect explanatory note with the amendment, which refers to terminal illness. That might just be an error, but I wanted to point that out.

Coming on to the broader grouping of the provisions: as has been said by colleagues, the amendments are tabled with really good intentions by someone who cares passionately about the palliative care sector. But they are not necessary given the process that is already set out by the Bill. Both doctors already have to discuss all treatment options, and must make a referral if they have any doubt about the diagnosis. It is very clear from clauses 4 and 9 that both the co-ordinating doctor and the independent doctor must discuss all treatment options with the patient, so they will have all the options laid out before them. That is really important because we have to think about what happens in reality. This initial discussion, in many cases, may actually take place with a palliative care doctor, and in many cases it will be highly likely, given the nature of the conditions we are talking about, that the patient may already be receiving treatment or advice from a palliative care team.

We seem to have created a narrative where this conversation is happening in isolation. Actually, as other colleagues have alluded to, we have a patient-centred approach in our healthcare. This person does not just suddenly arrive and have this one random conversation. I am sure medical colleagues will correct me if I am wrong, but if a doctor is dealing with a condition of which they have very limited knowledge, one of the first things they would do would be to refer to a specialist.

As is covered in clause 9(3)(a), if the doctor has any

“doubt as to whether the person being assessed is terminally ill,”

they must

“refer the person for assessment by a registered medical practitioner who holds qualifications in or has experience of the diagnosis and management of the illness, disease or condition in question;”

Clause 9(2)(a) also states that both doctors must assess the patient’s

“medical records and make such other enquiries as the assessing doctor considers appropriate;”

They can speak to anyone they want to, and they would in reality—of course that is what they would do. They would not sit there and think, “Oh, I don’t know enough about this condition so I will just keep going.” They would refer to specialists.

It is also really important to acknowledge what goes on at the moment. I was looking at some research last night: NHS England also has comprehensive guidance on personalised palliative and end-of-life care through a comprehensive personalised care model. None of this stops with the introduction of assisted dying as a choice for people. It would continue to happen. Patients are already getting that really good level of care.

[Danny Kruger]

The hon. Lady is making a very good speech about how things should work and how things do work, in many cases, when the NHS does its job brilliantly. First, I want to correct the hon. Lady: subsequent amendments do impose the duty that is consequent to these amendments to clause 1, so it would be an obligation. Surely that is the point to make: what if the doctors are not as brilliant as she suggests? What if there is not an expectation that they should definitely seek expertise that they do not have themselves? To the point made by my hon. Friend the Member for Reigate, what if this service is provided outside the NHS by an independent charity or private provider set up explicitly to facilitate people’s assisted death requests, and has no intention of referring people to palliative care if they do not ask for it themselves? Would she be content for a private provider to refer somebody for an assisted death without a palliative care referral?

[Kim Leadbeater]

I do worry about the lack of faith in our professionals. We have medical practitioners on the Committee and we have heard stories of the very good practice that happens, so it concerns me that we are so cynical about our system. Ultimately, we have to put faith in our professionals to do their job and to take that patient-centred approach, as I firmly believe they do. Dr Sarah Cox from the Association for Palliative Medicine said in her evidence to the Committee:

“In clinical practice, we make all these decisions in multi-professional teams…shared decisions are much better quality, much more robust and much safer.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 74, Q90.]

I absolutely agree with her, and that would continue to be the case.

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[Naz Shah]

I have a few concerns about what we have just heard in relation to the amendment. One of them is in relation to Dr Cox’s evidence. What Dr Cox actually said was:

“The second difference, I would say, is that you are absolutely right that we do make those decisions with patients—with their families, if they wish—but in a multi-professional team. I would almost never make those decisions as an individual doctor without the support of my colleagues, for several reasons. First, as I have said already, that makes for much better decisions”. ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 74, Q91.]

[Danny Kruger]

To pick up on that point about Dr Cox, I think it is critical that the hon. Member for Spen Valley cited Dr Cox in support of the hon. Lady’s contention that the Bill is adequate. Dr Cox, in her evidence, was saying that there is a problem with the Bill because it does not require the multidisciplinary consultation that we all think needs to happen. Dr Cox was suggesting that the Bill should be amended in order to ensure that the NHS does its job properly, and that multidisciplinary consultations are held. Her evidence was not in support of the Bill as it stands.

[Naz Shah]

I thank the hon. Gentleman for his intervention.

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[The Chair]

I point out that this is an opportunity to discuss clause stand part, not to cover the ground of amendments that have already been debated.

[Danny Kruger]

I will be quick, Mr Efford. I appreciate that we have been exhaustively over the detail of the amendments. I deeply regret that none of the amendments that were tabled to introduce stronger safeguards has been accepted. I want to take this opportunity to explain briefly what the Committee has done by rejecting those amendments and what we will be doing by agreeing to the clause without the amendments. I will not seek to divide the Committee on the clause, because I recognise that it enables the whole Bill to proceed, as the House wished on Second Reading, so I recognise that the principle of the Bill is represented in the clause. We wanted to tighten it, but have failed to do so.

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

I say gently to the hon. Member that—particularly on the previous clause—I have been very sympathetic to several of the amendments. Candidly, however, with due respect to all the hon. Members across the House who submitted this, I do not think that they have been particularly well written. I think that they leave quite a lot of ambiguity in a lot of areas. We had a discussion in the week before the recess, on a number of areas, about the word “only”. I heard it suggested earlier that the principle is about the spirit in which things are taken.

The reality is that I am very sympathetic to a lot of what is proposed, but a number of the amendments leave quite a lot of open ends. That has been a particular issue. I have been very open and have said that in principle I am supportive of assisted dying, but that I could not support it because the Bill was not strong enough in its current state. I do not think that the amendments tabled so far will strengthen the Bill; in fact, they might leave a lot of open ends, despite the very good intentions behind a lot of them.

[Danny Kruger]

I am grateful to the hon. Gentleman for explaining why, having opposed the Bill on Second Reading, he now seems to be supporting it. I wish I had heard, during our debates in the past two weeks, his specific objections to the amendments. If he felt, as he says, that the Bill is not strong enough, we would have welcomed his own amendments to strengthen the Bill in a form of words that he would find adequate. Perhaps that is what we will hear from him.

[Jack Abbott]

I did articulate a number of times where I felt that some of the amendments were not tight enough in those areas.

[Danny Kruger]

The hon. Gentleman has been on his feet; I appreciate that and am very grateful for his contribution to the debates that we have had.

I simply want to make the point that what the House voted for on Second Reading was the principle of assisted dying. What many members of the public who support the Bill think they are getting is a Bill that is safe—a Bill that is restricted explicitly to people at the very end of their life, who face extreme pain and suffering as they die; who are fully informed of what they are doing; who face no questions of external or indeed internal coercion; who have the absolute ability to understand what they are doing. Those are the things that people want to see in the Bill; those are the things that we have sought to effect through the amendments that we have tabled, and which the Committee has rejected.

Very explicitly, as a result of the rejection of these, I believe, very plainly written amendments, the fact is that under this Bill you can be depressed and suicidal and still regarded as having capacity to have an assisted death. You can be very marginalised—you can be a prisoner, you can be homeless—and still be regarded as eligible. You can have been influenced or encouraged by others and still be eligible. You can do it because you feel a burden. You do not need to be in any kind of pain. You do not need to be in the tiny proportion of cases that palliative care cannot help. As the hon. Member for Spen Valley accepted in the previous sitting, you can seek an assisted death for the sole reason of saving your family money, and you would be granted an assisted death on those grounds. The fact is that in rejecting these amendments, the Committee has decided and has demonstrated that the Bill is much wider than the campaigners portray.

I want to end with this point. I think there are two ways of approaching assisted dying—two essential framings of a Bill to legalise it. One is an autonomy Bill, which simply says that if people seek help to commit suicide, within certain broad parameters they should be able to do so, and there is no question of other people interfering with that choice; if they sign the requisite paperwork, they should be able to have an assisted death. The alternative is what we might call a safeguarding Bill—one where eligibility for the procedure is strictly limited and there are very strong, robust safeguards in place to protect the most vulnerable people.

The hon. Lady, and Members speaking in support of the Bill, have repeatedly emphasised that this is a safeguarding Bill. They want this Bill to be built around safeguards for the vulnerable. They respect the arguments that we make about the dangers that an open-ended assisted dying Bill would create. But the fact is that, as we have seen in the course of the debates on this clause, this is not a safeguarding Bill; it is an autonomy Bill. It is one that allows people to proceed to an assisted death because they want one, if they meet certain very loosely drawn criteria.

[Kim Leadbeater]

The reality is that this Bill is both. Of course it is about personal autonomy, choice and dignity for people who are coming towards the end of their life, but it has to be safeguarded as well. It is both. If I may say so, I think that the hon. Member makes quite an unfair characterisation of the robust, powerful debate that has taken place in Committee during the time that we have spent together. I think it has been extremely well informed. People have listened intently to other points of view and opinions, and it does the Committee a disservice to suggest otherwise.

[Danny Kruger]

We are all being very courteous, and it is absolutely right that we should be. I have absolute respect for the good faith of every Member here, but let us not use cotton wool in these debates. I am sorry to say that I do not accept that the Committee has listened—well, it might have listened closely, but it has not accepted a single amendment, including amendment 281, which would have put into law the principle in which the hon. Member for Bradford West believes, which is that palliative care should be an option. Why was that not accepted? The Committee has decided that it will proceed with the Bill as it is.

The fact is that the Bill will give maximum autotomy, within very broad parameters, to patients, many of whom will be very vulnerable. It is an autonomy Bill masquerading as a safeguarding Bill. When we attempt to strengthen the safeguards, they are described as bureaucratic hurdles. If the Bill becomes law, I worry about what will happen to the very limited safeguards that do exist. What we see elsewhere will happen, which is that the safeguards that do exist are treated as bureaucratic hurdles. They are in fact treated, and explicitly described, as we heard from the Australian witnesses, as barriers to a human right. What were safeguards become discrimination. I am afraid that that is the road we are going down.

The point about autonomy is often made. As I say, I think that this Bill actually has autonomy at its heart. The hon. Member for Spen Valley is right to make that point. That is really what is going on here. She wants people to be able to request help to commit suicide—to end their lives. The fact is that for the most vulnerable people, creating this option, especially when we have now switched off the obligation to seek a palliative care pathway and directed people straight down the road towards an assisted death—

[Kit Malthouse]

That is a misrepresentation.

[Danny Kruger]

I am sorry if it offends Members, but the fact is that the Bill in its present form, with the amendments rejected, will place no obligation on doctors to refer people to palliative care or to seek a palliative care consultation. Many will do so, of course—many good doctors will do exactly that—but they will not be obliged to. If we are imagining that every doctor will be as brilliant as the best doctors, I am afraid that I will have to talk about the Liverpool care pathway and the many tragic scandals that we are constantly dealing with. It is simply not the case that the option of a palliative care consultation equates to the absolute expectation that it will happen.

[The Chair]

Order. We have debated that issue.

[Danny Kruger]

We have debated that issue; I apologise.

My concern is that the Bill, which is masquerading as a safeguarding Bill but is actually an autonomy Bill, will end in less autonomy for the most vulnerable patients, who will find themselves on this conveyor belt, internally pressured and encouraged to seek an assisted death when it is not in their interests. I invite the Committee to reflect on what we have done, but as I have said, I do not propose to divide the Committee on clause 1 stand part.

[Rebecca Paul]

Under our current law, assisting someone to commit suicide is a criminal act. Clause 1 of this Bill is where we cross the Rubicon, moving away from well-established principles into a new era in which the state is empowered to help individuals to die.

This monumental decision is one for Parliament in the coming months. However, what we must do on this Committee is bolster the safeguards so that the Bill is truly as safe as it can be. Our priority must always be the vulnerable: those who could be coerced into something that is not in their best interests, and those with no one to advocate for them or protect them, who could end upbeing pushed into a process because that is the easiest and cheapest option for everyone. This law must work for everyone, not just the privileged few.

That is why I am so disappointed that at the end of nearly three days of debate, there has been not one improvement to the safeguards—not one. We asked for amendments to exclude people with impaired judgment and the depressed and suicidal; this Committee said no. We asked to protect those who are unduly influenced or encouraged by others to seek assisted dying—

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[Stephen Kinnock]

I will make some brief remarks on the legal and practical effect of clause 1, as amended, to assist hon. Members in making their own assessment. Clause 1 sets out the eligibility criteria that a person must meet in order to request to be provided with lawful assistance to end their own life under the provisions of this Bill. A person must be terminally ill; this term is defined in more detail in clause 2.

Clause 1(1) sets out a further four requirements, which require that a person must also have the necessary capacity to make the decision, which is to be read in accordance with the Mental Capacity Act 2005; be aged 18 or over; be ordinarily resident in England and Wales and have been resident for at least 12 months; and be registered as a patient with a GP practice in England or Wales. This clause provides that, in particular, clauses 5 to 22 of the Bill require steps to be taken to establish that the person has a clear, settled and informed wish to end their own life and has made the decision that they wish to end their own life voluntarily and has not been coerced or pressured by any other person in making that decision.

The clause, as amended by the insertion of new subsection (3), will ensure that the service can be accessed only by an individual ordinarily resident in England and Wales. That amendment, amendment 180, has been drafted to give effect to the policy intent of my hon. Friend the Member for Spen Valley for this legislation: that it is to apply only to those in England or Wales and is not to be accessed via medical tourism.

As I have said, the Government remain neutral on the substantive policy questions relevant to how the law in this area would be changed. The clause is a matter for the Committee and Parliament to consider, but the Government’s assessment is that the clause, as amended, is workable, effective and enforceable.

Question put and agreed to.

Clause 1, as amended, ordered to stand part of the Bill.

Clause 2

Terminal illness

[Danny Kruger]

I beg to move amendment 399, in clause 2, page 1, line 22, leave out “, disease or medical condition” and insert “or disease”.

This amendment ensures that a terminal illness under the Bill can only be an illness or a disease and not a medical condition.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 400, in clause 2, page 2, line 1, leave out “, disease or medical condition” and insert “or disease”.

This amendment is consequential on Amendment 399.

Amendment 401, in clause 2, page 2, line 5, leave out “, disease or medical condition” and insert “or disease”.

This amendment is consequential on Amendment 399.

Amendment 11, in clause 2, page 2, line 7, leave out from beginning to first “of” in line 8 and insert—

“(3) A person is not to be considered to be terminally ill by reason”.

This amendment amends clause 2 to say that a person cannot be considered terminally ill by reason of having mental illness or a disability.

Amendment 181, in clause 2, page 2, line 8, leave out from “ill” to end of line 10 and insert—

“only because they are a person with a disability or mental disorder (or both).

Nothing in this subsection results in a person not being regarded as terminally ill for the purposes of this Act if (disregarding this subsection) the person meets the conditions in paragraphs (a) and (b) of subsection (1).”

This amendment clarifies that the purpose of subsection (3) is to emphasise that only having a disability or mental order does not make a person “terminally ill” and therefore eligible for assistance.

Amendment 283, in clause 2, page 2, line 10, at end insert—

“or one or more comorbidities alongside a mental disorder within the meaning of the Mental Health Act 1983”.

This amendment would set out that a person who has a co-morbidity with one or both of a mental disorder or a disability is not considered terminally ill by virtue of those comorbidities alone.

[Danny Kruger]

I said in the last debate that this is either a safeguarding Bill or an autonomy Bill. [Interruption.] Or that it is both, but the claim has been that it is a safeguarding Bill and that there are very strong safeguards. If so, and if we are going to stress the safeguards, as I think we should, that means being very clear about who is eligible. It means having proper, meaningful guardrails showing who is inside and who is outside the scope of the Bill. I suggest that the Bill’s guardrails are not strong, safe or impermeable; they are broken fences. We need to mend those fences in this Committee in order to make the Bill safe.

This group of amendments includes a set in my name that would restrict eligibility to people with terminal diseases or illnesses, and another set that would build stronger safeguards explicitly for disabled people and people with mental disorders. The purpose of the two sets of amendments is the same, but they approach the challenge from opposite ends. I will speak first to the amendments in my name.

Quite simply, I want to remove the words “medical condition” from the definition of terminal illness. The reason for that is straightforward: some medical conditions are likely to also amount to a disability. As Fazilet Hadi, the head of policy at Disability Rights UK, told the Committee in evidence, there is a “huge overlap” between disability and terminal illness. The distinction between the two is notoriously blurred, and there is a reason why no disability rights organisation backs this Bill: it is here in this innocuous phrase “medical condition”. Removing that phrase will provide an additional degree of protection for some disabled people, which I think is a good enough reason to do it.

There is another group of people whom we do not hear from much in these discussions, but about whom we should perhaps be most concerned, because there are so many of them—they are almost all of us. I am talking about the frail. Frailty is an important word in this debate. I refer hon. Members to the briefing submitted in recent days by the British Geriatrics Society; it is a powerful document that highlights an essential challenge for this Bill. What is frailty? Is it a disability? Is it a terminal illness? Is it both? Is it neither? It can be noted on a death certificate as a cause of death and, even if it is not listed as a cause of death—this is a crucial point—it is the most common dying trajectory for people in the UK. More people are frail as they approach the end of life than are not.

--- Later in debate ---

[Kim Leadbeater]

I am interested to know where the hon. Member has got the idea that someone is going to scrap the six-month prognosis from.

[Danny Kruger]

Well, if the hon. Lady will say that she will never, at any stage, support a proposal to extend it beyond six months, I will be very glad to hear it. My concern is that we already have amendments tabled to do exactly that, which we will be debating shortly. I hope they will be rejected, but my confident expectation, on the basis of other countries, including the Australians who gave evidence to this Committee, is that the six-month safeguard will soon be seen as a barrier to a human right, because there is indeed no logical basis for such an arbitrary date.

The people who currently deal with the six-month prognosis, in the context of benefits and pensions, campaign that it is arbitrary and unworkable—rightly, I think—so I am afraid that I confidently expect the six-month barrier to be challenged in due course. If the hon. Lady is prepared to say that she would never do that, however, I would be very reassured.

[Kim Leadbeater]

Would the hon. Member agree that the purpose of the Committee is to look at the Bill before us? That is why we are here. I understand his concerns, his reservations and his nervousness about what might happen in future, and that is an important conversation to have, but the purpose of the Committee is to look at the Bill as it stands today; that should be the focus of our deliberations.

[Danny Kruger]

Yes, but I simply state on the record that I believe that this is not the end, but the beginning of a wider Bill that would follow if we passed this one. I am encouraged by what the hon. Lady says, or implies: that she does not want to go further than this Bill.

My plea to the Committee is straightforward. Let us confine eligibility to the people who the campaigners talk about: those with diseases or illnesses that are genuinely terminal. We can do more to strengthen that definition with later amendments, but, first, we have to remove the gaping hole in the fence that is this term “medical condition”. Let us remove that term.

[Tom Gordon (Harrogate and Knaresborough) (LD)]

Marie Curie’s definition of a terminal illness is

“an illness or condition which cannot be cured and is likely to lead to someone’s death”.

It is obviously one of the best-known end of life charities, so how does the hon. Member reconcile the differences he has with its professional expertise?

--- Later in debate ---

[Danny Kruger]

I am very happy to use the word “condition”—we all use it quite casually, including me—but we are concerned about legislation here. As I explained, if we include the term “medical condition”, courts could interpret that as a development—an addition—to the existing law on terminal illness, which refers only to illness and disease. The courts would be right to conclude that Parliament meant more than illness or disease, which is why it is important to be explicit about what we are talking about: illness or disease.

I think we should remove that term, but if other Members do not, I would like to understand why. The hon. Members for Harrogate and Knaresborough or for Spen Valley might have some suggestions, but I would be grateful if somebody could clarify, explicitly, what is meant by “medical condition” that is not caught by the terms “illness” or “disease”. What are the meanings of the three terms, and why do we have to have “medical condition”? It might well be that there are conditions that would not be captured by “illness” or “disease” that would be appropriate.

[Lewis Atkinson (Sunderland Central) (Lab)]

On that point, I will quote directly from Chris Whitty’s evidence to the Committee:

“there are people who may not have a single disease that is going to lead to the path to death, but they have multiple diseases interacting, so they are highly frail; it is therefore not the one disease that is the cause, but the constellation that is clearly leading them on a path inexorably to…death”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 32, Q5.]

From my perspective, it is about that “constellation” where death is clearly going to happen as a result of a combination of different conditions, illnesses or diseases. That it is where that is very clear, and, because of the six-month eligibility in the Bill, we have that nailed down. That is the importance of including the term, because it is not one disease that leads to death; it is the constellation of diseases and illnesses that will inexorably lead to death.

[Danny Kruger]

I am grateful to the hon. Gentleman. I thought that might be the case too, and I was wondering about that, but I am very concerned about some of the evidence that Professor Whitty gave. I regret that the hon. Member for Spen Valley has removed the role of the chief medical officer from the process that she is designing by introducing the new commissioner, but I will not be sorry to see that particular chief medical officer excluded from the process. He has made significant mistakes; he had to write to the Committee to explain that he had misrepresented the Mental Capacity Act, and, on his evidence, the Committee voted to reject certain amendments.

I am concerned about what Professor Whitty said, but if the reason for including “medical condition” is to reflect the fact that there might be multiple diseases or illnesses that, together, mean that somebody is terminally ill, that is what should be stated in the Bill. It could very well include “a combination of illnesses or diseases that amount to terminal illness”. My concern is about this new concept of a medical condition, which, as I have said, implies something different from a disease or illness.

The Bill would say “the person’s death in consequence of illness or disease”—if we remove “medical condition” —so that would be the qualification or eligibility. If there is a number of illnesses or diseases that amount to a fatal prognosis, that would be captured in the clause, even once we have excluded medical condition, because the singular “illness” or “disease” would, as I understand it from our guidance on statutory interpretation, include the plural. If it is about there being a number of illnesses or diseases that add up to a fatality, the Bill as I propose to amend it would be adequate to the scenario that the hon. Member for Sunderland Central described and that Professor Whitty accounted for. The question is, what is additional illness or disease, or illnesses or diseases, that are captured by the term “medical condition”?

[Kit Malthouse]

Let me give a quick example. Amyotrophic lateral sclerosis is described as a condition rather than a disease or an illness. ALS is not dissimilar to motor neurone disease, but nevertheless people regard themselves as having a condition rather than a disease.

[Danny Kruger]

Again, I am interested in that, because I would be surprised if that condition were not adequately captured by the term “illness” or “disease”. If not, we should seek further clarification, because we need to be very specific. Illness or disease has been adequate; it is adequate in the current law on terminal illness for eligibility for benefits and pensions. I await clarification on what is added by the term “medical condition”, because my concern is that it opens the door to frailty. Going back to Chris Whitty’s evidence, I am concerned at his suggestion that frailty should be an eligible condition for an assisted death.

I will wrap up shortly so that hon. Members have time to speak to other amendments, but I will quickly refer to amendment 181 tabled by the hon. Member for Spen Valley and amendment 11 tabled by my hon. Friend the Member for South Northamptonshire (Sarah Bool), which attempt to do the same thing as my amendments. They seek to protect disabled or mentally ill people, but they do so explicitly by disapplying the provisions of the Bill for those groups, or they attempt to do so. Only amendment 11 actually does, while amendment 181 fails to do so, in my view.

Let us look at subsection (3), which attempts to protect disabled people and those with mental disorders, but which, on closer inspection, is ineffective or even meaningless. In statutory interpretation, the first phrase,

“For the avoidance of doubt.”

indicates that the subsection does not add anything to the Bill except clarity. It is intended not to change the law that is being enacted by the Bill, but to clarify the meaning of the Bill. My point is that it does not add anything—in fact, it signals that the clause can be disregarded. It is like an explanatory note and not actually relevant to the Bill. Its effect therefore negates the point that it tries to make. In including it, the hon. Lady protests too much and exposes the weakness that the clause fails to overcome. It invites a court to disregard the protection it pretends to offer by stating that that protection has no force except what is elsewhere in the Bill.

[Kim Leadbeater]

I agree with the hon. Member to some degree in terms of the legal drafting. I have been advised that the expression “for the avoidance of doubt” is not generally used in a Bill if the Bill is already clear, which this is—I have been reassured by parliamentary counsel about that—but I was keen, having met disabled people and disability rights activists, to have it very clearly in the Bill that by virtue of having a disability, a mental health condition or a mental disorder, someone would not be in scope of the Bill. It was a very clear drafting decision and I stand by that decision; I think it is the right thing to do so that we are clear who is not covered by the Bill.

[Danny Kruger]

I am grateful to the hon. Lady; it is helpful to understand her thinking. Her amendment is an attempt to further clarify her purpose, which is to communicate that we cannot have an assisted death only because of a mental disorder or a disability. I know that other colleagues will speak to that point more explicitly.

My point is that

“For the avoidance of doubt”

is a massive signal to the courts that the subsection is meaningless. The advice was right that it is not usual to include that phrase, as it signals that nothing is being added. My concern is that it does not add anything, and the inclusion of the word “only” further demonstrates the hollowness of the protection that it purports to offer. The fact is that someone will still be able to get an assisted death because of a physical illness that derives from a mental disorder or disability. That is my concern with the later parts of the clause, but I will leave other Members to make that point.

--- Later in debate ---

[Naz Shah]

I appreciate that cancer does come under disability, and that people with cancer can identify as a disabled person, but my initial thought is that that weakens the Bill.

[Danny Kruger]

The fact that cancer is included in the Equality Act definition does expose a concern about the Bill. It suggests that there is a real connection there, which is of concern. I think the solution is to accept the amendment 11 and ensure that disabled people and those with mental health conditions would not be eligible for assisted dying, and then to introduce a further amendment—either now, as a manuscript amendment, or later—to exclude cancer from the definition. That is a tidying-up exercise that could be done in light of the point that the hon. Member for Spen Valley made about the reference in the Equality Act. The most important thing is that we tighten the clause to protect disabled people.

[Naz Shah]

I wonder whether my hon. Friend the Member for Spen Valley has considered whether she would tighten the clause. Have any options been explored, and what have the Government said about her removal of the Equality Act—

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

Danny Kruger Excerpts

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[The Chair]

I remind the Committee that with this we are discussing the

following:

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

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

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

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

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

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

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

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

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

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

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

New clause 5—Encouragement—

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

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

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

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

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

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

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

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

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

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

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

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

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

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

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

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

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

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

This amendment is consequential on Amendment 23.

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

This amendment is consequential on Amendment 82.

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

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

[Danny Kruger (East Wiltshire) (Con)]

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

[Sean Woodcock (Banbury) (Lab)]

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

[Danny Kruger]

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

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

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

She went on to talk about

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

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

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

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

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

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

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

[Danny Kruger]

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

[Kit Malthouse]

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

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

[Danny Kruger]

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

[Rebecca Paul (Reigate) (Con)]

rose—

[Jake Richards (Rother Valley) (Lab)]

rose—

[Danny Kruger]

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

[Rebecca Paul]

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

[Danny Kruger]

I am very grateful to my hon. Friend.

[Jake Richards]

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

[Danny Kruger]

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

[Dr Simon Opher (Stroud) (Lab)]

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

[Danny Kruger]

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

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

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

[Danny Kruger]

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

[Kim Leadbeater (Spen Valley) (Lab)]

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

[Danny Kruger]

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

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

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

[Kim Leadbeater]

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

[Danny Kruger]

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

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

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

[Danny Kruger]

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

[Dr Shastri-Hurst]

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

[Danny Kruger]

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

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

[Kim Leadbeater]

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

[Danny Kruger]

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

[Naz Shah (Bradford West) (Lab)]

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

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

[Danny Kruger]

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

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

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

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

[Kim Leadbeater]

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

[Danny Kruger]

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

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

[The Chair]

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

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[Sarah Sackman]

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

[Danny Kruger]

Will the Minister give way?

[Sarah Sackman]

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

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

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

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

[Danny Kruger]

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

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

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

[Sarah Sackman]

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

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

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

--- Later in debate ---

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

[Danny Kruger]

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

[The Chair]

Order. That is not a matter for the Chair.

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[Danny Kruger]

Okay. I am sorry to hear that.

[Kim Leadbeater]

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

[Rebecca Paul]

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

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

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

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

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

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



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

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

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

[Danny Kruger]

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

[Rebecca Paul]

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

--- Later in debate ---

[Kit Malthouse]

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

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

[Danny Kruger]

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

[Kit Malthouse]

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

--- Later in debate ---

[Kit Malthouse]

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

[Danny Kruger]

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

[Kit Malthouse]

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

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

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

[Danny Kruger]

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

[Kit Malthouse]

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

--- Later in debate ---

[Danny Kruger]

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

[Kit Malthouse]

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

[Kit Malthouse]

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

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

[Danny Kruger]

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

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

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

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

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

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

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

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

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

[Kim Leadbeater]

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

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

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

[Danny Kruger]

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

[Jake Richards]

Will the hon. Gentleman give way?

[Danny Kruger]

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

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

[Tom Gordon]

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

[Danny Kruger]

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

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

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

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

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

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

[Dr Tidball]

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

[Danny Kruger]

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

[Dr Opher]

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

[Danny Kruger]

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

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

[Dr Opher]

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

[Danny Kruger]

I am grateful to the hon. Gentleman.

[Kit Malthouse]

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

[Danny Kruger]

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

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

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

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

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

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[The Chair]

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

[Danny Kruger]

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

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

[Kim Leadbeater]

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

[Danny Kruger]

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

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

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

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

[Dr Shastri-Hurst]

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

[Danny Kruger]

Well, perhaps my hon. Friend wants to come up with a further amendment, to strengthen it even more and say that we should restrict it only to agony or extreme pain. No, I am trying to be reasonable and say that the case made for the Bill, in public and I think in the public mind, is that its beneficiaries will be those who face terrible pain at the very end of their life, and if that is our intention, let us specify that. That is what the Bill does.

[Dr Opher]

I do not believe that the intention of the Bill is simply about being able to have an assisted death because of pain. Nothing in the Bill says that. We heard evidence from Dr Hussain, who was against assisted dying, but she admitted that there are people for whom we cannot control the pain, so that is another point. The whole interpretation of the Bill is incorrect. It is not about pain at the end of life; it is about controlling one’s own death.

[Danny Kruger]

That is exactly my point. There are those who think that it should be just for people facing terrible pain at the end of life, but that is not what the Bill does, and it is not what the hon. Gentleman says it should do. He would like there to be a Bill that says simply, “If you want to take your own life with the help of the state, you should be allowed to do so.” That is the logic of his position. I do not see why there are any other safeguards—if we believe in absolute autonomy, that is where we are. It is either/or. Either this is a Bill for full autonomy, or there are safeguards to restrict it to the people whom the public are rightly concerned about: those who suffer terribly at the end of life.

[Jake Richards]

The hon. Member is making a powerful argument, but there is a difference between trying to control external factors that may affect an individual making a decision and primary legislation that tries to regulate a person with capacity making an assessment of what is in their best interest. Can he think of any other circumstances in our society or our law where someone with capacity is restrained from making a best-interest decision in primary legislation?

[Danny Kruger]

I am grateful to the hon. Gentleman because he highlights the absolute novelty of this law. We are proposing to do something completely unprecedented. As hon. Members have tried to argue over the last two days, it takes us into extremely dangerous waters with respect to the most vulnerable, so what we are trying to do, through what I concede are some fairly blunt instruments, is to write into the Bill some very strong and clear protections for the most vulnerable people. We have tried to do that in various different ways.

This would be novel. Of course, it is true that the criminal law currently recognises motivation—there are all sorts of aggravating factors that look into the motivation of an individual, so the law is not incapable of making that sort of judgment—but the hon. Gentleman is right to say that this would be a novelty. I am afraid the whole Bill is a novelty.

[Sean Woodcock]

While the oral evidence was divided on many things, I think there was unanimity that palliative care is in need of serious improvement across the board. I do not think a single witness said that palliative care was good across the country and could not be improved significantly. I mention that, linking back to the comment from the hon. Member for Richmond Park, because we are looking to create this law in a situation where a serious risk has been identified of people choosing to opt for assisted dying because of a fear of care costs and so on. That is my concern, and I see this as a safeguard to prevent that. Is that the hon. Member’s view?

[Danny Kruger]

That is absolutely right. It is a very depressing fact that it seems to be the sentiment of the Committee that we should allow people to request and receive an assisted death for the purpose of saving their relatives money. That does seem to be what people are saying.

[Dr Opher]

There is something called continuing healthcare, which would fund end-of-life care, if someone has a terminal prognosis of six months or less, so care costs would be covered by the state.

[Danny Kruger]

That is a fair point. I do not propose to push the amendment to a vote, but I hope that the point has landed sufficiently. There is a genuine concern that people will, as they do in other countries, with increasing regularity and in concerning numbers, seek to have an assisted death not with their own personal interests in mind but for the sake of others. That may be generous-spirited of them, but it is not the purpose of this Bill as far as I understand it.

--- Later in debate ---

[Kim Leadbeater]

This point is about training, and so about hearing from the right people when it comes to the training of professionals. It is important that we ensure that the Secretary of State must consult such people, and I anticipate that organisations such as the Association of Palliative Care Social Workers would be consulted. The statement continues:

“as well as protecting people from abuse, neglect and coercion at a time…when they are most vulnerable…Our expertise includes building trusting relationships, comprehensive knowledge of safeguarding”.

By looking at the training process, people’s motivations for seeking an assisted death would hopefully be considered.

[Danny Kruger]

Would the hon. Lady be content if somebody who had capacity chose an assisted death for the purpose of saving their family money?

[Kim Leadbeater]

Very few cases are as straightforward as that, and that is where conversations with doctors and professionals are really important. I think it was the doctor from California who said that if someone said to him, “I am doing this because I am a burden,” that would be a red flag. There would have to be a much more detailed, complex conversation with patients about what their motivations were, and it is important that we acknowledge, as medical colleagues have, what those conversations might look like.

[Danny Kruger]

But if the doctor concluded that they were doing it because they felt they were a burden, they would still be able to get the assisted death under the hon. Lady’s Bill. The only question is whether they have capacity. If they have been judged to have capacity, choosing to have the assisted death in order to save their family money would be acceptable under her Bill, would it not?

[Kim Leadbeater]

We are oversimplifying a complex situation and a difficult conversation. We have talked about coercion and pressure a lot. If someone says, “I just want it all to be over, because I feel like a burden”, that is the sort of conversation that doctors acknowledge would be a red flag. Those are complex, difficult conversations; we need the expertise that we would get by providing serious amounts of training around this issue so that those conversations can take place in a sensitive way.

[Danny Kruger]

This is my last intervention, I promise. I want to hear the hon. Lady confirm that under the Bill as currently drafted, after all these conversations have taken place, as long as the doctor cannot find evidence of coercion, they would be obliged to approve the assisted death, as would the judge and the judicial panel. If that is the case, and they conclude that a person has capacity and there is no evidence of coercion, no matter what conversations go on—if the person wants to do it in order to save their family money—the doctors and the judges would have to say yes.

[Kim Leadbeater]

I, again, refer the hon. Gentleman to my previous points; we are oversimplifying a really complex conversation, which would take into account lots of different factors for each individual. That is all I will say on that point.

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

Danny Kruger Excerpts

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[Rebecca Paul]

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

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

[Danny Kruger (East Wiltshire) (Con)]

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

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

[Rebecca Paul]

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

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[Rebecca Paul]

My interpretation is that it would not.

[Danny Kruger]

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

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

[Rebecca Paul]

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

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[Rebecca Paul]

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

[Danny Kruger]

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

[Rebecca Paul]

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

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[Rebecca Paul]

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

[Danny Kruger]

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

[Rebecca Paul]

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

[Rebecca Paul]

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

[Danny Kruger]

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

--- Later in debate ---

[Jake Richards]

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

[Danny Kruger]

Will the hon. Gentleman give way?

[Jake Richards]

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

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

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

--- Later in debate ---

[Jake Richards]

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

[Danny Kruger]

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

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

[Jake Richards]

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

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

--- Later in debate ---

[Juliet Campbell]

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

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

[Danny Kruger]

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

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

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

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

[Kit Malthouse]

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

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

[Danny Kruger]

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

[Naz Shah]

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

[Danny Kruger]

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

[Kim Leadbeater]

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

--- Later in debate ---

[Danny Kruger]

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

[Rebecca Paul]

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

[Danny Kruger]

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

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

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

[Kim Leadbeater]

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

[Danny Kruger]

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

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

[Naz Shah]

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

[Danny Kruger]

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

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

[Kim Leadbeater]

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

--- Later in debate ---

[Danny Kruger]

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

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

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

[Sean Woodcock]

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

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

Danny Kruger Excerpts

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[The Chair]

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

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

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment corrects a typographical error.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

New clause 1—Ability to make decision—

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

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

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

“the ability to make a decision”.

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

“the ability to make a decision”.

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

“the ability to make a decision”.

[Danny Kruger (East Wiltshire) (Con)]

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

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

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

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

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

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

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

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

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

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

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

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

[Danny Kruger]

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

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

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

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

[Danny Kruger]

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

[Kit Malthouse]

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

[Danny Kruger]

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

[Kim Leadbeater (Spen Valley) (Lab)]

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

[Kim Leadbeater]

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

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

[Danny Kruger]

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

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

[Kim Leadbeater]

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

[Juliet Campbell (Broxtowe) (Lab)]

rose—

[Danny Kruger]

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

[The Chair]

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

[Danny Kruger]

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

[Juliet Campbell]

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

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

[The Chair]

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

[Danny Kruger]

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

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

--- Later in debate ---

[Naz Shah]

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

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

[Danny Kruger]

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

[Jack Abbott]

I was just following the argument.

[Danny Kruger]

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

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On resuming—

[Danny Kruger]

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

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

[Naz Shah]

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

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

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

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[Kit Malthouse]

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

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

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

[Danny Kruger]

rose—

[Naz Shah]

I will take this intervention and then address both points.

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[Danny Kruger]

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

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

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

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

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[Stephen Kinnock]

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

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

[Danny Kruger]

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

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

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Division 2

Question accordingly negatived.

Ayes: 8

---

Labour: 5
Conservative: 2
Liberal Democrat: 1

Noes: 15

---

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

[Danny Kruger]

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

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

[The Chair]

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

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[The Chair]

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

[Danny Kruger]

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

“, and

(e) is not a prisoner”.

This amendment makes prisoners ineligible for assisted dying.

[The Chair]

With this it will be convenient to discuss the following:

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

“, and

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

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

“(ea) is not a prisoner,”.

This amendment is consequential on Amendment 353.

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

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

This amendment is consequential on Amendment 356.

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

“(fa) the person is not a prisoner”.

This amendment is consequential on Amendment 353.

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

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

This amendment is consequential on Amendment 356.

[Danny Kruger]

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

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

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[Kim Leadbeater]

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

[Danny Kruger]

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

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

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

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

[Kit Malthouse]

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

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

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

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

[Danny Kruger]

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

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

[Kit Malthouse]

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

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

[Danny Kruger]

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

[Kit Malthouse]

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

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

--- Later in debate ---

[Kit Malthouse]

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

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

[Danny Kruger]

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

[Kit Malthouse]

They would, yes.

[Danny Kruger]

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

[Kit Malthouse]

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

--- Later in debate ---

[Danny Kruger]

rose—

[Kim Leadbeater]

rose—

[Naz Shah]

I give way to the hon. Gentleman first.

[Danny Kruger]

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

[Naz Shah]

I give way to my hon. Friend.

--- Later in debate ---

[Naz Shah]

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

[Danny Kruger]

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

[Naz Shah]

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

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[Stephen Kinnock]

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

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

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

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

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

[Danny Kruger]

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

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

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

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

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

[Kit Malthouse]

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

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

[Danny Kruger]

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

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

[Sean Woodcock]

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

[Danny Kruger]

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

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

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

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

Amendment, by leave, withdrawn.

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

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

[Juliet Campbell]

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

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

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[Stephen Kinnock]

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

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

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

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

I hope that those observations are helpful to the Committee.

[Danny Kruger]

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

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

[Kit Malthouse]

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

[Danny Kruger]

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

[Kim Leadbeater]

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

[Danny Kruger]

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

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

[Tom Gordon]

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

[Danny Kruger]

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

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

[Juliet Campbell]

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

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

Danny Kruger Excerpts

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[The Chair]

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

[Danny Kruger (East Wiltshire) (Con)]

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

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

[The Chair]

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

--- Later in debate ---

[Kim Leadbeater]

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

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

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

[Danny Kruger]

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

[Kim Leadbeater]

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

--- Later in debate ---

[Sarah Olney]

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

[Danny Kruger]

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

[Sarah Olney]

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

--- Later in debate ---

[Sarah Olney]

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

[Danny Kruger]

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

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

[The Chair]

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

--- Later in debate ---

[Danny Kruger]

Will the hon. Lady give way?

[Dr Tidball]

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

[Dr Tidball]

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

[Danny Kruger]

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

--- Later in debate ---

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

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

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

[Danny Kruger]

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

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

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

[Dr Shastri-Hurst]

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

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

--- Later in debate ---

[Dr Shastri-Hurst]

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

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

[Danny Kruger]

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

[Dr Shastri-Hurst]

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

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

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

--- Later in debate ---

[Dr Shastri-Hurst]

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

[Danny Kruger]

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

[Dr Shastri-Hurst]

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

--- Later in debate ---

[Daniel Francis]

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

Dr Hussain went on to say:

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

Professor Owen said:

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

Dr Price said:

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

[Danny Kruger]

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

[Daniel Francis]

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

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

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

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

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

[Danny Kruger]

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

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

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

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

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

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

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

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

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

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

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

to understand the information relevant to the decision,

to retain that information,

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

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

[Danny Kruger]

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

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

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

[Kim Leadbeater]

Will the hon. Gentleman give way?

[Danny Kruger]

The hon. Lady does not like my terminology.

[Kim Leadbeater]

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

[Danny Kruger]

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

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

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

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

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

--- Later in debate ---

[Lewis Atkinson (Sunderland Central) (Lab)]

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

[Danny Kruger]

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

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

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

He talked about

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

and about situations

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

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

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

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

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

[Kim Leadbeater]

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

[Danny Kruger]

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

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

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

[Lewis Atkinson]

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

[Danny Kruger]

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

[Dr Tidball]

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

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

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

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

Danny Kruger Excerpts

Tuesday 11th February 2025 Public Bill Committees

[The Chair]

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

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

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment corrects a typographical error.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

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

This amendment is consequential on Amendment 34 and NC1.

New clause 1—Ability to make decision—

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

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

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

“the ability to make a decision”.

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

“the ability to make a decision”.

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

“the ability to make a decision”.

[Danny Kruger (East Wiltshire) (Con)]

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

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

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

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

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

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

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

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

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

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

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

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

[Danny Kruger]

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

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

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

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

[Danny Kruger]

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

[Kit Malthouse]

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

[Danny Kruger]

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

[Kim Leadbeater (Spen Valley) (Lab)]

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

[Kim Leadbeater]

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

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

[Danny Kruger]

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

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

[Kim Leadbeater]

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

[Juliet Campbell (Broxtowe) (Lab)]

rose—

[Danny Kruger]

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

[The Chair]

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

[Danny Kruger]

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

[Juliet Campbell]

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

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

[The Chair]

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

[Danny Kruger]

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

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

--- Later in debate ---

[Naz Shah]

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

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

[Danny Kruger]

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

[Jack Abbott]

I was just following the argument.

[Danny Kruger]

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

--- Later in debate ---

On resuming—

[Danny Kruger]

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

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

[Naz Shah]

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

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

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

--- Later in debate ---

[Kit Malthouse]

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

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

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

[Danny Kruger]

rose—

[Naz Shah]

I will take this intervention and then address both points.

--- Later in debate ---

[Danny Kruger]

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

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

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

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

--- Later in debate ---

[Stephen Kinnock]

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

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

[Danny Kruger]

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

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

--- Later in debate ---

Division 2

Question accordingly negatived.

Ayes: 8

Noes: 15

[Danny Kruger]

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

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

[The Chair]

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

--- Later in debate ---

[The Chair]

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

[Danny Kruger]

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

“, and

(e) is not a prisoner”.

This amendment makes prisoners ineligible for assisted dying.

[The Chair]

With this it will be convenient to discuss the following:

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

“, and

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

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

“(ea) is not a prisoner,”.

This amendment is consequential on Amendment 353.

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

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

This amendment is consequential on Amendment 356.

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

“(fa) the person is not a prisoner”.

This amendment is consequential on Amendment 353.

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

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

This amendment is consequential on Amendment 356.

[Danny Kruger]

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

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

--- Later in debate ---

[Kim Leadbeater]

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

[Danny Kruger]

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

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

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

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

[Kit Malthouse]

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

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

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

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

[Danny Kruger]

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

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

[Kit Malthouse]

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

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

[Danny Kruger]

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

[Kit Malthouse]

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

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

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[Kit Malthouse]

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

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

[Danny Kruger]

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

[Kit Malthouse]

They would, yes.

[Danny Kruger]

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

[Kit Malthouse]

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

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[Danny Kruger]

rose—

[Kim Leadbeater]

rose—

[Naz Shah]

I give way to the hon. Gentleman first.

[Danny Kruger]

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

[Naz Shah]

I give way to my hon. Friend.

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[Naz Shah]

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

[Danny Kruger]

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

[Naz Shah]

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

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[Stephen Kinnock]

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

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

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

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

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

[Danny Kruger]

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

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

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

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

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

[Kit Malthouse]

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

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

[Danny Kruger]

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

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

[Sean Woodcock]

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

[Danny Kruger]

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

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

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

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

Amendment, by leave, withdrawn.

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

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

[Juliet Campbell]

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

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

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[Stephen Kinnock]

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

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

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

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

I hope that those observations are helpful to the Committee.

[Danny Kruger]

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

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

[Kit Malthouse]

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

[Danny Kruger]

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

[Kim Leadbeater]

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

[Danny Kruger]

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

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

[Tom Gordon]

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

[Danny Kruger]

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

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

[Juliet Campbell]

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

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

Danny Kruger Excerpts

Committee stage
Thursday 30th January 2025 Public Bill Committees

[The Chair]

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

[Danny Kruger (East Wiltshire) (Con)]

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

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

[Lewis Atkinson (Sunderland Central) (Lab)]

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

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

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

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

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

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[The Chair]

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

[Danny Kruger]

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

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

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

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

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

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

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

[Kim Leadbeater]

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

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

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

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

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

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

--- Later in debate ---

[Lewis Atkinson]

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

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

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

[Danny Kruger]

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

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

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

[Kit Malthouse]

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

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

--- Later in debate ---

[The Chair]

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

[Danny Kruger]

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

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

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

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

[Lewis Atkinson]

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

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

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

--- Later in debate ---

[Rachel Hopkins]

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

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

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

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

[Danny Kruger]

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

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

[Naz Shah]

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

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

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

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

--- Later in debate ---

[The Chair]

As we have time, I call Danny Kruger.

[Danny Kruger]

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

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

[Dr Opher]

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

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

--- Later in debate ---

[Sarah Sackman]

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

[Danny Kruger]

On a point of order, Mrs Harris.

[The Chair]

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

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

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

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

Danny Kruger Excerpts

Committee stage
Thursday 30th January 2025 Public Bill Committees

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

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

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

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

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

[Danny Kruger (East Wiltshire) (Con)]

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

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

[Danny Kruger]

Q Okay. Thank you very much for that.

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

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

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

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

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

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

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

[The Chair]

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

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

Danny Kruger Excerpts

Thursday 30th January 2025 Public Bill Committees

[The Chair]

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

[Danny Kruger (East Wiltshire) (Con)]

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

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

[Lewis Atkinson (Sunderland Central) (Lab)]

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

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

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

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

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

--- Later in debate ---

[The Chair]

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

[Danny Kruger]

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

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

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

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

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

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

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

[Kim Leadbeater]

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

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

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

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

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

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

--- Later in debate ---

[Lewis Atkinson]

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

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

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

[Danny Kruger]

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

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

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

[Kit Malthouse]

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

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

--- Later in debate ---

[The Chair]

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

[Danny Kruger]

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

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

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

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

[Lewis Atkinson]

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

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

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

--- Later in debate ---

[Rachel Hopkins]

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

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

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

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

[Danny Kruger]

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

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

[Naz Shah]

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

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

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

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

--- Later in debate ---

[The Chair]

As we have time, I call Danny Kruger.

[Danny Kruger]

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

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

[Dr Opher]

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

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

--- Later in debate ---

[Sarah Sackman]

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

[Danny Kruger]

On a point of order, Mrs Harris.

[The Chair]

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

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

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

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

Danny Kruger Excerpts

Committee stage
Wednesday 29th January 2025 Public Bill Committees

[Kit Malthouse]

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

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

[Danny Kruger (East Wiltshire) (Con)]

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

[The Chair]

If you are quick.

[Danny Kruger]

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

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

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

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

[Danny Kruger]

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

Professor House: As part of the assessment, yes.

[Danny Kruger]

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

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

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

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

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

[Sarah Olney (Richmond Park) (LD)]

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

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

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

--- Later in debate ---

[Dr Tidball]

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

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

[Danny Kruger]

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

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

“significantly more justification in assisting people to die”

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

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

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

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

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

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

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

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

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

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

[Tom Gordon]

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

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

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

--- Later in debate ---

[The Chair]

This will be the last question for today.

[Danny Kruger]

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

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

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

[The Chair]

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

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