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

Debate between Danny Kruger and Sean Woodcock

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[Danny Kruger]

No, I fundamentally disagree: end-of-life care is healthcare. It is addresses symptoms and conditions, and it is designed in a way that is completely compatible with the founding principle of the NHS, whereas the Bill—I appreciate the honesty of the drafters in recognising this, even if they do not quite spell it out—and its proposal of an assisted suicide service is not compatible with the founding principle of the NHS. That is why adapting that founding subsection as in the original NHS Act is required. Of course I recognise that end-of-life care is healthcare and completely compatible with what the NHS does. I wish it were more part of the NHS—that is another debate. Palliative care should have been more closely integrated into NHS provision, and it still should be.

I want to tease out a tension among the drafters and advocates of the Bill about exactly how the assisted suicide service will be facilitated and provided. We have got a bit closer to it, but some questions remain, which is regrettable when here we are on the very last day of the Committee’s debate. Last month, the hon. Member for Spen Valley told the Committee:

“This is not assisted suicide by the state. The state is not involved.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 11 February 2025; c. 318.]

I am perplexed by that. I think many members of the public would not agree with that analysis of how the Bill has evolved in Committee. If involving the state in the provision of this service was not intended, then that is not the Bill we have.

In contradiction to that, and I think more accurately, the Minister for Care told us that the promoter’s intent—speaking for the hon. Member for Spen Valley—is

“to ensure that the assisted dying service is available as an integral part of the NHS. Officials are working on amendments to later clauses to establish the operating model for her consideration.” —[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 5 March 2025; c. 802.]

That is clearly what has happened, and it is where we are now. However, I am sorry to say that I do not feel that the operating model is now clear. We still do not have an impact assessment, we do not know how the Government envisage it working in practice, and important information is still lacking for the debate today. We do not know the possible impact on general practice or medical specialists, nor how it might impact money that is available for palliative care. I hope the Minister can tell us more today about how he envisages the service being implemented, especially in the light of the British Medical Association conference earlier this month, which supported the motion that

“Assisted dying is not a health activity and it must not take place in NHS or other health facilities”.

That is a principle I agree with.

On 5 March, the hon. Member for Spen Valley said:

“there is no expectation that assisted dying would be set up as a private enterprise or service. It would be delivered within the provision of the NHS.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 5 March 2025; c. 799.]

That now agrees with the Minister—fine, interesting; it is to be an NHS service not to be provided privately. But the new clauses do not rule out private provision, nor any profit making by providers or remuneration of people outside the NHS. Indeed, the new clauses refer to “voluntary assisted dying services”, which suggests the hon. Member for Spen Valley is supportive of services outside those that are NHS commissioned, which will be possible under subsections (1), (3) and (7)(a). That will be in line with comments made by my right hon. Friend the Member for North West Hampshire, who made a very coherent case for private provision of assisted suicide if that is what Parliament chooses to legalise; he said that nothing should prevent someone from opting for private provision. In response, the hon. Member for Spen Valley said:

“This service, like many others, will be delivered through a range of providers”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 5 March 2025; c. 800.]

I remain unclear about the extent to which this is an NHS monopoly, as it were, or whether there will be private provision that is privately paid for, or private provision that is publicly paid for. I would be grateful for the hon. Member’s clarification.

Lastly, on the question of profit, in an article in The Times that appeared to have some briefing behind it, there was a suggestion that there would be a cap on the profit of private companies providing the service, limiting them to “making a reasonable profit”. Again, there is nothing in the new clauses about limitations on providers’ profits. If the hon. Member could clarify how she envisages the private provision of the service, I would be grateful.

[Sean Woodcock (Banbury) (Lab)]

It is a pleasure to serve under your chairship, Ms McVey. I rise to speak to amendment (b) to new clause 36, which was tabled by my hon. Friend the Member for Shipley (Anna Dixon). The amendment states:

“Regulations under subsection (1) may not amend, modify or repeal section 1 of the National Health Service Act 2006.”

For clarity, I will read out the relevant part of section 1 of the 2006 Act:

“The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

(a)in the physical and mental health of the people of England, and

(b)in the prevention, diagnosis and treatment of physical and mental illness.”

Those core principles have remained the same since the National Health Service Act 1946. As the hon. Member for East Wiltshire stated, in a Britian that was devasted by war, Clement Attlee and Nye Bevan together promised a better future, one where healthcare should be available to all, regardless of wealth. It enshrined a principle that as a society we will care for the ill and we will do that together. No one’s health should be left behind, especially that of the vulnerable.

The NHS stands as the greatest legacy of a Labour Government—despite the input of Opposition parties referred to by the hon. Member for East Wiltshire—and perhaps of any Government since the second world war. The establishment of the NHS lives on in section 1 of the NHS Act. It is why at the height of the pandemic NHS staff courageously put themselves on the frontline to protect us. It is their mission to secure improvement in the physical and mental health of all, free at the point of service. As we consider assisted dying, we must not lose the values at the heart of the NHS.

Section 1 of the 2006 Act has changed little from the corresponding first section of the 1946 Act. It is not just a line in legislation; it has become part of our national story and our national identity, and amendment (b) to new clause 36 is about continuing that. It seeks to preserve the legacy of Attlee and Bevan, and that of Labour Governments committed to the betterment of the people.

Twenty-five senior doctors and pharmacists from Shetland and Orkney spoke of that legacy in their written evidence:

“We note with pride the founding principles of the NHS, with the 1946 National Health Service Act stating, ‘It shall be the duty of the Minister of Health…to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness.’ We believe that Parliament must reflect the lasting ethos of our founding document.”

There are very few lines in legislation that come to represent an institution in this way. It is a testament to the ideal of those founding principles in section 1 that they guide doctors to this very day. This is the thread that runs through the 1946 Act to the 2006 Act—two Labour Governments, 60 years apart, united by this mission to improve the physical and mental health of the people. This Committee should continue the thread of those principles.

Of course, I understand that previous legislation may need to be amended to provide assisted dying services, and that may include the 2006 Act. New clause 36(4) clarifies that specified references to commission voluntary dying services may be included in that Act. I note with regret that the new clause gives us so little information elsewhere about the use of these powers, which are commonly known as Henry VIII powers or clauses. This is not a term that I was familiar with until very recently. I am sure other Members are much more familiar with it than I am, but on the off-chance that there are one or two Members who need a reminder, I will read Parliament’s own official definition of the term:

“‘Henry VIII clauses’ are clauses in a bill that enable ministers to amend or repeal provisions in an Act of Parliament using secondary legislation, which is subject to varying degrees of parliamentary scrutiny.”

Helpfully, it adds:

“The expression is a reference to King Henry VIII’s supposed preference for legislating directly by proclamation rather than through Parliament.”

I accept that it might be rather odd to talk about Henry VIII in this debate, but we should not let that distract us from the serious question of this new clause, which could result in a significant transfer of power from Members of this House to the Secretary of State, and it is not clear what that power will be used for.

The Hansard Society has noted that there is little indication about what role or nature these powers will take, saying:

“A key principle that the House of Lords Constitution Committee has applied to delegated powers is that they ‘should not be framed in such a way that gives little indication of how they should be used.’ The Delegated Powers and Regulatory Reform Committee’s guidance to Departments states that the Delegated Powers Memorandum should set out how it is proposed that a power should be exercised.”

I would be grateful if my hon. Friend the Member for Spen Valley and Ministers could provide clarity on those questions. New clause 36(1) does not specify that voluntary assisted dying be provided on the NHS, but subsection (4) allows for the National Health Service Act 2006 to be amended. What is the intention of these powers? What will the structure of the voluntary assisted dying service be? How will it be funded and who will be responsible for the provision of the services? The answer to those questions will inform which legislation needs to be amended, and that information should be in the Bill.

To be clear, as I have said, I accept that changes to previous legislation may be required. However, the provision of assisted dying should not amend the foundational principles of the national health service. It should not break with the legacy of Attlee, of Bevan and of Labour. That is why I support amendment (b) to new clause 36.

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

Debate between Danny Kruger and Sean Woodcock

Tuesday 18th March 2025 Public Bill Committees

[Danny Kruger]

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

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

[Sean Woodcock]

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

[Danny Kruger]

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

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

Debate between Danny Kruger and Sean Woodcock

Committee stage
Tuesday 18th March 2025 Public Bill Committees

[Danny Kruger]

I am grateful to the hon. Lady. I hear what she has said; we have had this conversation before. I am afraid that I do insist on my right to use the English language accurately. What is proposed in the Bill is a carve-out of the Suicide Act, so I regret to say to the hon. Lady that I will continue to describe it in terms that are appropriate to it. I hope I do so with absolute sympathy and respect for the many families who have suffered from the trauma of seeing their loved ones die badly—loved ones who would have wished for an assisted death under the terms of the Bill. I am very glad to hear that the hon. Lady supports my amendment. I do not think it would be any sort of imposition on families for the doctors to let the patient know at the last moment that they have the opportunity to turn back.

[Sean Woodcock (Banbury) (Lab)]

The hon. Gentleman is making a really powerful speech, and I am minded to support the amendment on the basis that there will be a small but significant group of people who, having gone through the whole process, will feel they have been a burden on the people who have gone to all the effort, through every stage, to get to the end, so if they have doubts at the end, they may be reluctant to change their mind. It will be a very small group, but I do think it is significant. I see it as the re-establishment of autonomy for the patient, which we all believe in; does the hon. Gentleman agree?

[Danny Kruger]

That is absolutely right. We have to think about the no doubt quite turbulent emotions that people will have as they approach the end of their life, and to reiterate their genuine autonomy. They are not on a conveyor belt that they cannot get off until the very last moment—until they have passed through this gateway. The amendment seeks to remind them and, indeed, their families of that. I am afraid we do hear terrible stories of people who have arranged their assisted death: often family members have flown in from abroad, doctors have been summoned and so on, and then they feel they have to proceed because, as the hon. Gentleman says, they feel a burden as it is and do not want to be an annoyance at the end by making everybody wait. I am afraid that is indeed the reason for the amendment. I am pleased to hear that it sounds like it will be accepted, and I am grateful to Members who will support it.

Amendment 463 is the other, more substantial, amendment in my name in this group. It would leave out paragraph (c) of clause 18(6), which says that the doctor can assist the patient

“to ingest or otherwise self-administer the substance.”

Here we are in a lot of difficulty and a grey area. Let me try to unpack the reasons for objecting to paragraph (c). The hon. Member for Spen Valley argued in an interview that there is a “very clear line” between the Bill and euthanasia, which is someone else doing the deed. She said that the act

“has to be the decision of the individual, and it has to be the act of the individual”,

which

“creates that extra level of safeguards and protections”.

I agree with her—it is right that we introduce the additional safeguard of insisting that the patient performs the final act themselves.

I recognise that there is a distinction between euthanasia and assisted suicide, and I support the hon. Lady’s attempt to insist on that distinction in the law. It is another safeguard. But the fact is that there is a blurred line between the two, and I can also understand why many people object to the exclusion of euthanasia—of the fatal act being administered by other people. A doctor from Canada said it was inherently ableist to require the patient to self-administer, and I think that is unarguable. If that is the case, the logical provision would be to enable euthanasia, if one believes in the autonomy of the patient.

I am afraid my strong belief is that the reason why euthanasia has not been proposed in the Bill or by the campaign, which has been led by an organisation that used to call itself the Voluntary Euthanasia Society, is because the campaign has concluded that such a Bill would not pass Parliament and believes—I think correctly—that Members of Parliament and members of the public would object to euthanasia. But the logic of the Bill and of the campaign is actually for euthanasia, if one believes genuinely in autonomy, in equal rights and in not discriminating against people who are physically unable to perform the act themselves.

Despite my efforts, hon. Members have not been able to conceptualise the difference between withdrawing a medical treatment that affects a particular medical condition on the one hand, and administering drugs that annihilate the person on the other. There is a meaningful and important difference between those two things. One is a person declining to use a shield, and the other is the person using a sword against themselves. I think there is a difference there, and I regret that colleagues do not see it.

Where I do not see a difference, however, is between a person injecting themselves and asking someone else to inject them. There are two versions of the death of Saul in the Bible. I think this is the only reference to the Bible that I will make in this whole debate, and I make it partly to show that there is an inconsistency in the Bible—there is not a single Biblical view of these matters. In one account of the death of Saul, having been defeated by the Philistines, he asks his servant to run him through with his sword, but his servant refuses, so he falls on his own sword and kills himself. In the other version, he gets a passing soldier to run him through—to kill him.

To me it does not matter: the inconsistency in the story is interesting historically, but conceptually, logically and morally I do not see the difference. Whether you fall on your own sword or ask someone else to do it to you, it is still a sword, you are still actioning it and you are still responsible, if we recognise that the individual has autonomy. But there is a practical difference. We are talking about assistance to die and the role of another person who supports your decision and helps you to fulfil it, but that results in an obscuring of the practical difference. In practice, as we see in clause 18(6), the assistant comes very close to euthanasia. The role of the assistant, in my view, is closer to that of the soldier who kills Saul than of the servant who refused to do it.

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

Debate between Danny Kruger and Sean Woodcock

Committee stage
Wednesday 12th March 2025 Public Bill Committees

[Sean Woodcock]

That is my next point—and it is a good question. As I said, the panel is done with the right intention and would improve the process in many ways. My view is similar to that of the hon. Member for East Wiltshire—it is possibly one aspect on which we are in agreement—in that I think it comes at the wrong part of the process. If it was earlier in the process, it would improve things. Court capacity is an issue, but I take the point made by the right hon. Member for North West Hampshire that if we want the courts to do it, they need to get on and do it.

I keep coming back to the issue of what we are asking the state to do. Implementing the wishes and autonomy of the patient is important, but we also need to take very seriously what we are asking the state to allow to be done in its name. There is also the crucial matter of public trust, the condition of the national health service and the issue of capacity in the courts. As my hon. Friend the Member for Ipswich touched on, there is considerable disquiet and concern about how robust this process is going to be. Even though I think having the panel at the start of the process would improve what was put to the House on Second Reading, having judicial oversight at the very end would provide reassurance to the vast swathes of the public who are concerned about this, as well as to Members.

[Danny Kruger]

The hon. Gentleman is making an important point and I completely agree. Does he agree that the hon. Member for Spen Valley recognised the problems with the lack of a multidisciplinary team in the process and the problems of court capacity, and through her attempt to address both those problems we now have a multidisciplinary team instead of the judicial role? What we really need is both: we need a properly constituted multidisciplinary assessment at the beginning, and then we need the final process to be an approval by a judge. Does the hon. Gentleman agree that that would be a better process?

[Sean Woodcock]

Having thought about it, that would be my preference. I am in a difficult position in that there is a lot to be said for the panel, and it would improve the process in many ways, but I cannot get around the fact that the judicial aspect was put strongly before Parliament, and ensuring that we would have those safeguards provided reassurance to Members. When I have been out on the doorstep talking to people who are in favour of the Bill—people who wanted me to vote in favour of it—they have said to me that they think the proposal is safe because it includes two doctors and judicial oversight. That does come up, which is why I think we need to keep judicial oversight in the Bill. I do, though, I recognise the very genuine attempt by my hon. Friend the Member for Spen Valley to introduce the panel to improve on some aspects and address the concerns expressed in the witness testimony.

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

Debate between Danny Kruger and Sean Woodcock

Wednesday 12th March 2025 Public Bill Committees

[Sean Woodcock]

That is my next point—and it is a good question. As I said, the panel is done with the right intention and would improve the process in many ways. My view is similar to that of the hon. Member for East Wiltshire—it is possibly one aspect on which we are in agreement—in that I think it comes at the wrong part of the process. If it was earlier in the process, it would improve things. Court capacity is an issue, but I take the point made by the right hon. Member for North West Hampshire that if we want the courts to do it, they need to get on and do it.

I keep coming back to the issue of what we are asking the state to do. Implementing the wishes and autonomy of the patient is important, but we also need to take very seriously what we are asking the state to allow to be done in its name. There is also the crucial matter of public trust, the condition of the national health service and the issue of capacity in the courts. As my hon. Friend the Member for Ipswich touched on, there is considerable disquiet and concern about how robust this process is going to be. Even though I think having the panel at the start of the process would improve what was put to the House on Second Reading, having judicial oversight at the very end would provide reassurance to the vast swathes of the public who are concerned about this, as well as to Members.

[Danny Kruger]

The hon. Gentleman is making an important point and I completely agree. Does he agree that the hon. Member for Spen Valley recognised the problems with the lack of a multidisciplinary team in the process and the problems of court capacity, and through her attempt to address both those problems we now have a multidisciplinary team instead of the judicial role? What we really need is both: we need a properly constituted multidisciplinary assessment at the beginning, and then we need the final process to be an approval by a judge. Does the hon. Gentleman agree that that would be a better process?

[Sean Woodcock]

Having thought about it, that would be my preference. I am in a difficult position in that there is a lot to be said for the panel, and it would improve the process in many ways, but I cannot get around the fact that the judicial aspect was put strongly before Parliament, and ensuring that we would have those safeguards provided reassurance to Members. When I have been out on the doorstep talking to people who are in favour of the Bill—people who wanted me to vote in favour of it—they have said to me that they think the proposal is safe because it includes two doctors and judicial oversight. That does come up, which is why I think we need to keep judicial oversight in the Bill. I do, though, I recognise the very genuine attempt by my hon. Friend the Member for Spen Valley to introduce the panel to improve on some aspects and address the concerns expressed in the witness testimony.

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

Debate between Danny Kruger and Sean Woodcock

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Danny Kruger]

I am sorry for having begun speaking to the wrong amendments earlier. I was trying to speak to amendment 58—I could not read my own notes—not amendments 55 or 56.

I do not want to reheat the previous arguments about the imperative—as I believe it is—to refer to a psychiatrist. I support the suggestion of the hon. Member for Ashford and the hon. Member for Runnymede and Weybridge (Dr Spencer) that the independent doctor should have relevant qualifications in psychiatry and experience in assessing mental capacity through their professional qualifications. The importance of having a holistic multidisciplinary team has been well argued and subsequent amendments to the Bill have attempted to delivered that.

I want to emphasise that if we adopted the amendment tabled by the hon. Member for Ashford, we would be acknowledging the reality that assisted dying is not like other medical decisions. By explicitly including psychiatrically trained clinicians, we would be giving special regard to the mental state of patients making an existential decision, not just a treatment decision. That is particularly appropriate for patients who are not expecting to significantly suffer bodily due to their terminal illness.

We have heard many stories of people who have died in painful or undignified ways, but that does not reflect the experience of the majority of those with a terminal illness—90% of cases, according to some studies—who are able to receive adequate or complete pain relief. For people who do not have an obvious motivation to have an assisted death, such as avoiding extreme pain, an investigation by a psychiatrist of their mental state would surely help to safeguard against those with depression or other ameliorable mental conditions that impair capacity accessing an assisted death.

I want to emphasise the evidence that we received from Professor Gareth Owen, who in 2021 conducted a large-scale survey of medical professionals in England and Wales. That found that non-psychiatric doctors—general practitioners and other doctors not trained in psychiatry—were less confident than other professionals in assessing capacity. It also found that 6.9%—less than 7% —of non-psychiatric doctors rated themselves as assessing capacity very well, which I think is significant. To place all the responsibility for assessing capacity and coercion, which are difficult to assess and contain complexities that psychiatrists are best placed to appreciate, in the hands of doctors who do not have specialist expertise is to be content with coercion being missed and capacity being poorly assessed. If we want to ensure that these tests are done well, the only way to do that is to involve psychiatrists, as the hon. Member for Ashford said.

[Sean Woodcock]

I will speak briefly on amendment 21, although I will commend my hon. Friend the Member for Ashford for his contribution to the debate. He speaks with clear expertise and experience, and a real love for his profession, and we all benefit greatly from his insights.

Over the last few weeks, I have found myself voting the opposite way from the promoter of the Bill on a number of occasions, but I am not opposed to assisted dying in principle. My issue is more about whether we can ever make it safe enough; the difference between us is marginal. One thing that has been apparent throughout these debates is her passion for improving the training for those involved in palliative care, and in the wider NHS and social care generally.

That is why I want to speak to amendment 21. In the witness testimony, particularly from Rachel Clarke, there was a lot of concern about whether coercion and people being put under pressure to go for assisted dying would be picked up, and whether the NHS was geared up for that. I think that this amendment, tabled by my hon. Friend the Member for Lowestoft, goes some way to addressing that.

I do not think training is a silver bullet, hence my votes over previous weeks, but it would make a massive difference. That is true not only for the implementation of the Bill; it would have wider benefits for the NHS, social care and palliative care more generally. Even though those are not necessarily in scope of the Bill, I suggest that they are good things, which is why Committee members should get behind amendment 21.

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

Debate between Danny Kruger and Sean Woodcock

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[Danny Kruger]

The hon. Lady is absolutely right that that is what witnesses told us, but we need to ensure that it happens in all cases; the purpose of these amendments is to ensure that good practice is universal. In the case of assisted dying, bad practice would be terrible. Of course, good doctors seek the guidance of others and do not operate in isolation, but the Bill would allow them to do so. It is important to ensure that the system lives up to the good practice that she refers to.

Committee members will be glad to hear that I am not going to rehearse the arguments about capacity and coercion, but those concerns are why it is important to have a multidisciplinary team at an early stage. The Committee has rejected all attempts to strengthen the capacity test, but it could at least allow a psychiatrist to have an earlier role in the process of checking for capacity. We heard from multiple witnesses about the importance of doing that, and that is what National Institute for Health and Care Excellence guidance states. As the hon. Lady said, it is good practice, so as Professor House said in his evidence to us, it would not be “a terribly radical thing” to do it.

On coercion, as the social worker Jess Carrington wrote to us:

“The only people who are comprehensively trained to recognise signs of abuse, in particular, coercive control, are social workers.”

According to research by Dr David Ross, doctors suspect less than 5% of cases of elder abuse. I will not rehearse the arguments around coercion, but I hope that the Committee will note that the only way—or the best way; it will not be foolproof—to ensure that coercion is spotted is by having a social worker at the very beginning of the process.

I think that is enough from me, Mr Efford—I am sure you agree.

[Sean Woodcock (Banbury) (Lab)]

I rise to speak to amendments 108, 343 and 344. I am delighted that the promoter of the Bill, my hon. Friend the Member for Spen Valley, has said that she accepts amendment 108, which was tabled by my hon. Friend the Member for East Thanet. It would require a doctor who was having an initial conversation with a person about assisted dying to “offer” to refer them to a palliative medical specialist. That would give the patient a chance to discuss end of life matters in depth with somebody who has the necessary expertise.

We have spent much time in previous sittings on palliative care options, and there was some understandable concern about removing autonomy from those looking for assisted dying. I hope that amendment 108 strips away that concern, because it is about offering, not mandating, more information. When we are talking about autonomy, I think that all Committee members would agree that anybody making an autonomous choice could only benefit from more information, rather than suffer as a result of it.

The Bill says that when a doctor has an initial conversation with a person about assisted dying, they should explain and discuss

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

The amendment aims to ensure that the patient has access to the best available information to make a decision about what they do next. It would act as a safeguard to prevent people from choosing assisted dying because they did not have a chance to have a thorough and accurate discussion about the care options available to them.

As I said, several people were concerned about autonomy, and providing people with the opportunity to meet a specialist. The written evidence from Hospice UK explains that there are currently wide misunderstandings about hospice care at societal level. It says:

“Implementation of assisted dying without care given to public awareness about palliative care is likely to worsen individuals’ ability to make decisions regarding their end of life. People will need access to information about the services and support available to them.”

That reminds the Committee that terminally ill people at the end of their life often may not know the options available to them. I am sure that every Member in the room wants to avoid that situation, and the option of a discussion with a specialist aims to ease some of that fear and provide accurate information.

In order to make palliative and hospice care a genuine choice, it is important that patients with concerns are able to speak to someone who can answer all their questions and offer accurate information. Marie Curie’s written evidence says:

“There must be clear recognition within the Terminally Ill Adults (End of Life) Bill that genuine choice at the end of life cannot exist unless dying people are able to choose to receive high quality palliative and end of life care”.

Unfortunately, we know that the state of palliative care in this country is not yet of evenly accessible quality. The amendment would not solve that problem—there is quite a lot of work to do in that regard—but it would at least improve the Bill. It would give every patient the option of a discussion about palliative medicine and would make some ground on access. We all want to ensure that those with terminal illnesses are given good support and confidence in their decision at the end of their lives. Amendment 108 would do that, and would give people the opportunity of a real, informed choice, which is why I am delighted that the Bill’s promoter, my hon. Friend the Member for Spen Valley, has agreed to it.

My hon. Friend the Member for Shipley, who tabled amendments 343 and 344, has a distinguished record in policymaking in health and social care. She served as chief analyst and director of quality and strategy at the Department of Health. Both amendments are very thoughtful, and we would do well to adopt them. It would be helpful to explain what they would do before I set out why I think that hon. Members should vote for them. Amendment 343 would change clause 4(4), on page 2, which reads:

“If a registered medical practitioner conducts such a preliminary discussion with a person, the practitioner must explain to and discuss with that person—

(a) the person’s diagnosis and prognosis”.

If the amendment were made, subsection (4)(a), on line 28, would go on to read

“, including any relevant probabilities and uncertainties surrounding the person’s diagnosis and prognosis.”

Amendment 344 would change paragraph (b) on the next line, which says that the doctor must discuss with the patient

“any treatment available and the likely effect of it”.

If the amendment were made, paragraph (b) would go on to read

“, including the risks and benefits of such treatment, potential side effects, and the impact of the treatment on the person’s quality and length of life.”

Like amendment 108, amendments 343 and 344 are both intended to improve the quality of information that patients receive when they have their initial discussion about assisted dying. The first amendment addresses what many of the expert witnesses have identified as a key problem with the Bill. Clause 2 requires a doctor to have prognosed that

“the person’s death…can reasonably be expected within 6 months.”

I will not go over the various arguments that we have already had in Committee about that, but many of the very senior doctors who gave evidence to the Committee have said that it is extremely hard for medical professionals to give a prognosis with such assurance.

The Marie Curie palliative care research department at University College London also submitted written evidence, numbered TIAB 39. Those experts said:

“The Bill’s requirement for a prognosis of death within 6 months could lead to significant errors, where individuals either receive assisted dying prematurely or are denied it when desired. The variability in prognostic accuracy, especially for non-cancer illnesses, may exacerbate inequities in patient care.”

They went on to say:

“We also question how the term “reasonably” will be interpreted by doctors, and this is likely to vary between doctors, but also by the same doctor with different patients”.

The Marie Curie palliative care research department also said that predicting someone’s death “too soon” can result in early palliative care, and that such early care is

“not a harm in the same sense as might be implied in the context of assisted dying.”

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

Debate between Danny Kruger and Sean Woodcock

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Danny Kruger]

I am grateful to the hon. Lady and am sure that that will be welcomed. It does rather go back to the point that the organisations made at the outset, which is that they wish they had had more consultation earlier on, but I understand why that was not possible in all cases.

[Sean Woodcock (Banbury) (Lab)]

In oral evidence, Fazilet Hadi stated in answer to a direct question from me that she felt that disabled people had not been listened to properly. Will the hon. Member comment on that?

[Danny Kruger]

I am afraid that that seems to be the strong impression that many groups have.

I will quote quickly from a submission that we have received from someone at the National Down Syndrome Policy Group, Fionn Crombie Angus. I am not sure whether Fionn has Down’s syndrome, or is perhaps a parent, but the point is a striking one, which we have not heard enough:

“I do feel very sorry for the people who are suffering, but I think the people left behind, the relatives, will be scarred for life if they help people die. That is the main reason why I do not want the Assisted dying Bill to become law.”

That is not specifically relevant, because we are not discussing whether the whole thing should happen, but it strikes me that there, from a member of the Down’s community, we have a point that goes to the heart of our discussion on the Bill: it is not all about the individual who is seeking an assisted death. More people are involved in the decision.

I made a point in an earlier debate about relational autonomy, which is very significant. That particularly applies to this group of people, who will be making decisions in the context of their family and the people around them, including the doctor who is talking to them. That is why it is particularly important to have a wider set of expertise and advice around people with Down’s.

My concern is that Bill, as drafted, thanks to the inclusion of clause 3 and its reference to the Mental Capacity Act, will assume consent and support people with Down’s receiving this intervention. It would have been best if we had accepted the amendments tabled by my hon. Friend the Member for Reigate and the hon. Member for Bexleyheath and Crayford to reverse the burden of proof. Failing that, we need to ensure that the job is done properly. Amendment 368, tabled by my right hon. Friend the Member for East Hampshire, would address that point.

Given the real concern that we have all discussed about the application of the Mental Capacity Act, it is important to have real expertise, time and attention on behalf of Down’s people with the role of an independent advocate. In particular, that should be someone who has expertise in end-of-life decisions for people with Down’s syndrome, which will be a small group of experts, so we might have to end up widening that, I am sorry to say. We need people with proper expertise.

I think the point that my right hon. Friend the Member for North West Hampshire made about the interaction of the Bill with the Down Syndrome Act 2022 was absolutely right. My understanding is that he is right that it applies to authorities, but it strikes me that the purpose of the amendment 368 would be to insist that the provisions of the Act apply in the case of individuals as well.

My right hon. Friend may be right that there could be complications, so it would be good to hear whether the Minister agrees with him that we should take this topic away, with the hon. Member for Spen Valley, and see whether the provisions in the amendment can be introduced at a later stage of the Bill or in statutory guidance. However, I would want to hear explicitly from the Minister that he is confident that what my right hon. Friend the Member for East Hampshire was trying to do when he tabled the amendment will be reflected properly at a later stage of the Bill. On that basis, I am happy not to press the amendment to a vote unless others feel strongly that we should proceed.

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

Debate between Danny Kruger and Sean Woodcock

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[Danny Kruger]

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

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

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

[Sean Woodcock]

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

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

Debate between Danny Kruger and Sean Woodcock

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[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.

--- Later in debate ---

[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.

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

Debate between Danny Kruger and Sean Woodcock

Tuesday 11th February 2025 Public Bill Committees

[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.

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

Debate between Danny Kruger and Sean Woodcock

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[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.