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

Jack Abbott Excerpts

Committee stage
Tuesday 18th March 2025 Public Bill Committees

[Sarah Olney]

The hon. Gentleman gives me an opportunity to conclude my remarks. I support amendment 429 because it is important to provide clarity that when we say “with the patient,” we mean in the room. However, I invite the Minister to expand further on the resource requirement of assisted dying. I want the doctor to remain with the patient, which I think is critical. That is why I support amendment 429, but the implication of the Bill is a considerable resource requirement, particularly for GPs, and I would like the Minister to respond to that.

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

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

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

“The coordinating doctor must remain with the person until”

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

Clause 9 states:

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

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

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

“the Bill would only permit”

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

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

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

“be too ill to make a second attempt”

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

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

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

[Danny Kruger]

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

[Jack Abbott]

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

[Danny Kruger]

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

[Jack Abbott]

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

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

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

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

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

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

[Kim Leadbeater]

My hon. Friend is referring to Oregon. Obviously every jurisdiction has its own methodology when it comes to assisted dying. Is he reassured somewhat by the evidence from Dignitas that for not one person did the procedure fail? A survey from Victoria in Australia showed that 1,076 deaths from the self-administration process took place, and 86% of patients died within one hour. There are different models, and it is important to look more broadly at this if we can.

[Jack Abbott]

I fully accept my hon. Friend’s points, and I agree. To reiterate, complications are not a regular occurrence by any means. They are relatively uncommon. In saying that, there are still 10% of people who did experience them. As she says, these complications are not huge, but there were issues with being able to ingest the substance or with regurgitating it. The figure of 86% that my hon. Friend refers to is absolutely correct, but that would suggest that for 14% of people it took longer than an hour. In my view, that is a relatively high percentage for what we are talking about here.

As I say, my amendment does not seek to stipulate in the Bill exactly what measures have to be taken in every single scenario. I am not suggesting for a moment that we have to legislate about what we must do in the event that, for instance, someone has difficulty ingesting the substance; I am sure that will come naturally with the GMC regulations. I fully appreciate the points made about how this will probably naturally occur, but it is important to provide a reassurance that we are looking at the long-term effects in such scenarios.

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[Jack Abbott]

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

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

[Danny Kruger]

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

[Jack Abbott]

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

[Danny Kruger]

I trust this Secretary of State.

[Jack Abbott]

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

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

“there is a greatly prolonged time to death”,

the person has been “rendered unconscious” or

“the person is otherwise undergoing complications.”

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

[Naz Shah]

My hon. Friend is making an important speech. He talked about percentages earlier. Is he aware of a study in the Netherlands that concluded that 21 people—18% of the cases in the study—were assisted with lethal injection? In five of those cases, that was because the person could not swallow, but in the rest, they were unable to complete.

[Jack Abbott]

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

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

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

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

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

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

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

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

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

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

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

[Danny Kruger]

Will the hon. Gentleman give way?

[Jack Abbott]

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

[Danny Kruger]

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

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[Jack Abbott]

I appreciate that point. Throughout this process we have spoken about the absolute need to ensure that very good palliative care options are being presented to everybody along this pathway. I do not think you can separate care homes and hospices from the Bill, but I fully appreciate and sympathise with what the hon. Gentleman is saying. As I have said, there may be some hospices that are simply not appropriate for this, so although amendment 533 does not seek to put that on the face of the Bill in terms of precluding any particular areas of our healthcare system, it would require the Secretary of State, through consultation, to make sure that the legislation is used properly, and make suitable recommendations.

[Naz Shah]

I rise to speak to amendment 436, tabled my hon. Friend the Member for York Central. The amendment concerns what would happen after a patient has suffered complications while going through the administration of lethal drugs. Let me stress that we know that people suffer complications when they are undergoing assisted deaths. Unfortunately, one thing we do not know is how common those complications are. Another thing we lack is data that would allow researchers to investigate whether certain drugs, perhaps in combination with certain medical conditions, were more likely to cause complications.

The reason that we do not know those things is because of the many gaps in the data collected in places that have assisted dying laws. It has been mentioned before, but very much bears mentioning again, that the Australian states’ reports on assisted dying do not publish data on complications suffered by patients who self-administer drugs, and that is the overwhelming majority of assisted deaths in Australia.

Western Australia’s most recent report does tell us how frequently there were complications in the cases that involved practitioner administration of lethal drugs—4.3% of those deaths were affected. I understand that the Bill does not allow practitioner administration, but that is not the relevant point. What is relevant is that first, the Australian data shows that some people given lethal drugs suffer complications, and secondly, those complications were ones that we would not wish on someone in their last minutes or hours of life. For example, five out of 198 practitioner administration deaths involved “other complications”, which included people coughing and/or reporting a burning throat after they were helped to swallow drugs,

“hiccups with gastric reflux, involuntary muscular contractions, and delayed loss of consciousness.”

Western Australia could be much better than other states on average in avoiding complications, or it could be worse. I am afraid that we really do not have the robust data that would allow us to make those comparisons. I repeat: the Australian state does not publish data on complications affecting the majority of assisted dying cases. They do not because they cannot, since no one is mandated to stay with the patient and observe their condition. We do not know, therefore, how common those complications are.

Record-keeping in other jurisdictions is also concerning. This House’s Health and Social Care Committee examined the records kept by the state health department in Oregon while inquiring into assisted dying. They found that Oregon authorities kept very poor records into how many patients suffered complications and what those were.

Amendment 436, tabled by my hon. Friend the Member for York Central, would take a very different approach. Under this amendment, the doctor attending the person having an assisted death would have to make “a detailed record” if the person suffered complications. They would then have to declare that the person had suffered complications, on the final statement concerning that case. Finally, they would have to make a report, to both the chief medical officer for either England or Wales and the voluntary assisted dying commissioner.

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[Jack Abbott]

I fully understand and am very sympathetic to my hon. Friend’s point about the family having privacy and space in the last moments. However—this is a genuine question—what happens if things start to go wrong? Although it is uncommon, we know it is possible. Do we expect the family members who are going through the last traumatic moments to have to go out of the room to find the doctor, albeit they might just be behind the door? I do not know that that would necessarily make it less traumatic, and for some people it could make it worse if the doctor is not there and present next to their bed.

[Dr Opher]

I think there is some truth in that, to be fair, but I believe we should leave it open to the family’s discretion, with the proviso that the doctor should be close at hand, whether that means outside the door or whatever. We need Government advice on whether amendment 429 is safe. I have nothing further to say.

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[Jack Abbott]

I appreciate what my hon. Friend is saying about the Secretary of State not stipulating every dot of every i and cross of every t in the regulations, but we are talking about something that has not been practised in this country, so we do not have existing guidance anywhere about what to do in this event. My hon. Friend may correct me, but I think it is really important that the Secretary of State has to give some direction through regulations on what a doctor is able or not able to do in these situations. I appreciate that there must remain room for a doctor’s best-case judgment in certain situations but, from a legal perspective and otherwise, the Secretary of State and the Department will have to give some thought to exactly how the regulations work.

[Lewis Atkinson]

To me, amendment 430, tabled by my hon. Friend the Member for Bexleyheath and Crayford, strikes the right balance. Under clause 30 the Secretary of State “may” make provision for codes of practice on these matters if that is required; I am uncomfortable with saying that the Secretary of State “must” do so, when it is likely that it will be more appropriate for the GMC or some other body to make those regulations. We get into a difficult precedent if the Secretary of State must specify the reaction in certain medical circumstances but we routinely leave that to medical regulation and practice more widely. I think a “may” power, as set out in amendment 430, would allow that backstop provision, but would not get into the issue of “must”. It is also likely to be more respectful of the conversations as outlined in clause 9.

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[Lewis Atkinson]

I am going to finish on this point.

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

[Jack Abbott]

No, is the short answer to that question. Because a doctor has to be present, are we saying that doctors have to go to someone’s home to administer this? Would the Secretary State say, for example—this is not my personal view; it is for discussion—that it would have to take place in a medical facility, or could people choose to have an assisted death at home? The amendment stipulates that the Secretary of State would have to give that guidance at the time. I do not see how we can have doctors going out to individuals’ homes to assist the process.

[Lewis Atkinson]

It is by no means clear that doctors would not go out to people’s homes, but my hon. Friend asks whether doctors would have to do that—there are no powers of compulsion anywhere in the Bill, because the entire model is an opt-in model at every stage, including the example he gave in respect of hospices. It is a matter between the resident of the home and the treating medical practitioner.

In reality, healthcare procedures do not happen ubiquitously: they happen in appropriate places with appropriate cultural sensitivity. We do not specify in primary legislation for that to happen. Health professionals, and those involved in the management and commissioning of health services, currently have ample opportunities to co-ordinate and consider such matters.

[Jack Abbott]

I appreciate my hon. Friend giving way again. For people in the Committee and our colleagues across the House, there has to be clarity. Perhaps it is a question for the Bill promoter’s and the Government. As I said, I have no personal problem with it, but is there an expectation that assisted dying will take place at home as well as in medical facilities?

[Lewis Atkinson]

I cannot speak for the Bill’s promoter or for others, but a significant number of people wish to die at home.

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[Kim Leadbeater]

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

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

[Jack Abbott]

I appreciate what my hon. Friend is getting at in terms of what might happen down the line, but the amendment would not restrict any doctor’s flexibility at all or bind them in any way. All it would do is ask the Secretary of State to form a set of regulations.

[Kim Leadbeater]

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

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

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

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