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

Jake Richards Excerpts

Committee stage
Wednesday 19th March 2025 Public Bill Committees

[Danny Kruger]

I am conflating the two because they are conflated in reality. A care home where somebody lives is a residence, but it is also a community, a facility and a place where professionals work to support that individual. A clear demarcation between their living arrangements and the support they receive from the institution they live in does not exist in reality. That is why they are living there—because that distinction does not apply in their particular case. They require the support and help of the workers in the place where they live.

I am afraid it is not enough simply to say, “This is their home, and they should have exactly the same rights and freedoms as they would have if they were living alone in their own flat or house.” We have to recognise the reality of the situation, which is that they are living in a community, and what happens in the community affects them all. That is the nature of communal living. This is not individualised healthcare in the way that the hon. Gentleman imagines it is, and that is fundamentally our point of difference. This is separate or adjacent to healthcare, and it is delivered, by definition, by somebody else. By virtue of the Bill, it would have a separate regulatory environment to other healthcare treatments. Of necessity, it should have an appropriate legal framework to protect other people who are impacted by assisted death in a communal setting. That is my crucial point: if someone is living in a communal setting, what they do affects their neighbours.

[Jake Richards (Rother Valley) (Lab)]

Does the hon. Gentleman appreciate that, although this is different from the healthcare services we currently have, we have a legal framework that deals with many of these conflicting issues as and when they arise in lots of different circumstances that are not completely adjacent to these?

[Danny Kruger]

I do not know what those might be, but I would be interested to hear. That might well be the case. I am afraid that no hard-and-fast rules can be clearly applied here; or, rather, we have to apply hard-and-fast rules in the knowledge of the grey areas, the exceptions and the situations in which we might feel that the law is unjust in particular cases. We have heard examples of that, such as the evidence about the lady in Australia cited earlier by the hon. Member for Spen Valley. I can well imagine the distress involved if someone suddenly finds themselves in an institution that does not permit an assisted death, but they want one and are in their last days.

The alternative, however, is a different blanket rule. If we were to have a blanket rule that we can do an assisted death anywhere—that is one situation—there would be significant knock-on effects. Serious moral injury would be suffered by other professionals and residents. I recognise that my amendment could lead to someone having to relocate if they want to have an assisted death—I am sorry for that—but I think that we have to draw the line in a way that makes most sense.

--- Later in debate ---

I understand that Members might be concerned about vexatious litigation but, first, if such claims are meritless there is no need for this provision, as the courts already have the power to deal with vexatious litigation. Secondly, the clause, with or without the amendments, will not be enough to stop vexatious litigation if it occurs. The strongest protection would be to retain the role of the High Court judge. In that way, the fact that the criteria have been met has been established by a court, and that makes it very unlikely that another court would want to reopen the matter. We have not done that, and we are left with this civil liability exemption, which remains too wide. I welcome the amendments in the name of the hon. Member for Spen Valley, but they do not go far enough. I believe the whole clause is unnecessary and should be removed.

[Jake Richards]

I welcome the amendments tabled by my hon. Friend the Member for Spen Valley. As I think she accepts, given that she tabled the amendments, there is an oddity with the Bill as drafted that has to be fixed, and I think the amendments would do that.

I appreciate that there is some force to the argument of the hon. Member for East Wiltshire. I would be interested to hear what the Minister says, but it seems to me that there is a balancing act between ensuring that medical practitioners and clinicians are working in an environment in which they do not constantly feel the heat of a lawyer’s breath on their neck, and ensuring protections. There is some force to the argument for removing the clause altogether, but on balance I see more force in the argument that we should have more clarity.

I want to raise some more issues that need to be considered in the light of the provision for aspects of civil liability in this process. That is why last night I supported the amendment in the name of my hon. Friend the Member for Ipswich, which was not passed, relating to guidance for doctors in certain circumstances during this process. I raise those points about the standard of care and the duty that doctors and clinicians will be working to throughout the process for the record, and so that the Government and my hon. Friend the Member for Spen Valley can take them forward. I raise those questions not because they are unanswerable—I think they are answerable—but because we need to work out exactly what we are asking our doctors to work to, and what form that guidance comes in. Does it need to be legitimised by Parliament, or can it be undertaken by a Minister?

I do not think I need to expand greatly on the point, but we can all imagine circumstances in which clinicians are compromised in their view of the duty of care that they have to the patient. When this process begins in this jurisdiction, it needs to be clear what that is.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Dowd. Well done for arriving on time, by the way.

These amendments aim to ensure that, if passed, this legislation will be legally and operationally workable. I will offer a technical, factual explanation and rationale for them. Amendments 501, 502 and 503 replace clause 25(1) and instead provide that the provision of assistance in accordance with the Bill will, of itself, not give rise to civil liabilities in certain circumstances. Those circumstances are where an individual provides assistance in accordance with the Bill, where an individual performs any other function under the Bill in accordance with the Bill, and where an individual assists a person seeking to end their life under the Bill, in connection with the doing of anything under the Bill. Proposed new subsection (1A) would create an exception to the exclusion of civil liabilities, providing that civil liabilities can arise in cases when an act is performed dishonestly or otherwise than in good faith, as well as in cases of negligence. Without this amendment, there is the possibility that clause 25(1) could provide blanket immunity to a person from all civil liabilities, even when they may have been negligent in their actions in providing assistance in accordance with the provisions in the Bill.

--- Later in debate ---

[Kim Leadbeater]

That would be my understanding as well, but I am not a lawyer. Fortunately, a lawyer just tried to intervene on me, so he might want to step in.

[Jake Richards]

My intervention is on something completely different. I have been reminded that in Australia, there is a specific clause that relates to the provision in this amendment almost word for word, so I think the hon. Member for East Wiltshire may have been incorrect in his comments.

[Kim Leadbeater]

I thank my hon. Friend for that. Unless the Minister has anything to add on injunctions—

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

Jake Richards Excerpts

Committee stage
Wednesday 12th March 2025 Public Bill Committees

[Rebecca Paul]

My right hon. Friend makes an important point. I do not think family always know best. There are situations where someone rightly will want to exclude their family from the process, and I totally respect that choice. I am saying that there will be other situations in which family do have something valid to input that could impact the panel’s decision making. My right hon. Friend also mentioned injunctions; I am keen to understand more about how that process works as a protection, so perhaps the Minister could respond on that, because that may well give me some reassurance. I will come to judicial review in a moment.

My right hon. Friend is right that this is not easy. I am not saying that family should be involved in all situations. I am saying there is a balance to be struck, and I do not think we are getting it right, because at the moment it is all about full autonomy. The working assumption is that input from family must always be ignored if the patient wants that. There must be a balance, and it is difficult to say where that should sit, which is why we have such an incredibly difficult job with the Bill.

[Jake Richards (Rother Valley) (Lab)]

I have a genuine question: is the hon. Lady of the view that families’ views about whether the decision is right for the individual should be considered by the panel, tribunal or judge, or is it just their views about eligibility under clause 1?

[Rebecca Paul]

I thank the hon. Gentleman for that important point. My point is that the family should be listened to and should have a route to legally provide information to the panel. Right now, they have no right to do that. In reality, I think most panels would take that information. I would like to think that, 99 times out of 100, if a family member contacted the panel saying, “I have really important information,” it would listen to that. But I am legislating for the one case in 100 or 1,000 in which, for whatever reason, the panel refuses to engage with a family member who has a relevant bit of information, and not having the right information leads to someone’s death.

The amendment is about protecting panel members too. If I were a panel member, I would want this process in place, because it would protect me when I make a decision. I would take great comfort from knowing that a family member with relevant information has a legal right at least to communicate it to the panel.

--- Later in debate ---

[Rebecca Paul]

I thank my right hon. Friend for raising that point, because it gives me a wonderful opportunity to draw everyone’s attention to subsection (3) of my amendment, which states:

“The Commissioner may consider the application without a hearing if they consider it in the interests of justice to dispense with a hearing.”

My right hon. Friend is absolutely right that time is of the essence and that there will be situations in which it is right that things move as quickly as possible. I hope that that goes some way towards reassuring him that I am trying to come up with amendments that are balanced. I am aware that we have two different examples here; I am genuinely trying to make sure that I do not make it harder for those genuine cases, because I totally understand how important it is and I understand that there is a lot of pain and suffering, for all the reasons that have been set out. I hope that I am getting the balance right, but I am always happy to have further discussions.

Sir James Munby was one of the first to criticise the High Court safeguard; the hon. Member for Spen Valley says that she has taken those criticisms on board. His criticisms of the panel seem similarly acute. I hope that the Committee will agree that my amendment answers a real need and recognises the important role of family in the death of a loved one in most situations, although I accept not in all. It has a profound and long-lasting impact on them too, and their needs should not be entirely disregarded in the name of autonomy. The hon. Member for Rother Valley gave a very powerful speech yesterday on the subject, setting out that the amendment is not required because any decision could be judicially reviewed. I am not qualified to opine on whether judicial review would be relevant with this panel, but I look forward to the Minister covering the matter in her closing remarks. We need to be clear on that front.

Judicial reviews are a challenge to the way in which a decision has been made, rather than to the rights and the wrongs of the conclusion reached. It is important that this is understood. A judicial review just checks that the process was followed, not whether the right decision was made. That is why our role in setting the process is so important. If the new clause remains unchanged and there is no requirement for a panel to accept relevant evidence from a family member, there will be no avenue for appeal under judicial review if such information is not taken into consideration when making the decision, because the process will have been followed.

Our role on this Committee is a heavy one. It is about getting it right and setting the process for judicial review to work as it should. We have an appeal process in the new clause for when a panel wrongfully turns down an application, but not for when it wrongfully approves one. Why not, if judicial review is available and suitable? I suspect that it is because, as the hon. Member for Rother Valley is aware, the judicial review is not the best way to do it. It is a long, onerous process involving application for permission and, in some situations, the securing of legal aid, which is fraught with difficulty. I say gently to the hon. Member that if judicial review is not suitable when the panel has wrongfully turned down an application, then why is it suitable when they have wrongfully approved someone for an assisted death?

I think it is clear that my amendment is needed as a safeguard to prevent wrongful deaths under the Bill. It is a helpful safeguard. No panel will ever want to see someone assisted to die who should not have been, just because it did not have all the information. I suggest that the safeguard will help to secure panel members, because they will feel reassured that a process is in place to avoid mistakes. If my amendment is not agreed to, and if wrongful approvals have to rely on judicial review for a remedy, I suggest that the impact assessment will need to take into account the likely impact on socioeconomic groups that rely on legal aid for funding. I suspect that, owing to a lack of funds, they will find themselves with no avenue at all to appeal. I do not think that any of us wants a two-tier system in which rich families can intervene and poor families cannot.

[Jake Richards]

I have been rightly and fairly challenged in the hon. Member’s speech, but the difference is that if a family member has a right to appeal in the internal process, that family member would have to be a party in the original hearing. The whole point of the panel is that a person comes to it with their application. The family have the right to put information before the panel, but they do not have the right to make their case to the panel, because their views on the application are not relevant. Information that they might have is relevant, but their views are not. That is why there is a disparity between the person’s ability to appeal internally against a refusal of their application, and third parties having to take other routes. I hope that that offers some clarity as to why I am comfortable with the difference between the two. I reassure the hon. Member that I have thought about it long and hard as well.

[Rebecca Paul]

I thank the hon. Member. I would just clarify that currently there is no legal right for a family to provide information to the panel, which is part of the issue.

I turn to my amendment (c) to new clause 21. New clause 21 includes provision that, among other things, the panel’s function is to determine whether it is satisfied that the person has capacity, that they have a clear, settled and informed wish to end their life, and that they have not been coerced or pressured. However, it is not entirely clear what “satisfied” means in the new clause. My amendment assumes that, as in a civil court, it means “on the balance of probabilities”.

As I understand it, the leading case on the meaning of “satisfied” is a 1964 House of Lords case, in which the court held that “satisfied” meant “on the balance of probabilities”, rather than the tougher test of “beyond reasonable doubt”. In a later amendment, I will propose that we adopt that tougher standard, but this amendment assumes that the current wording will stand.

My view, as we have already established in lengthy debate, is that the capacity bar is low, because the doctor need only be 51% sure. On the clear, settled and informed wish and coercion test, the standard is only “to the best of the doctor’s knowledge”, which is not a particularly high bar to meet. We are therefore applying a low bar to a low bar. That certainly leaves us with a highly accessible process, but I suggest that that is not a positive or safe thing.

My amendment would bring in a further safeguard. As I have said several times, I would have preferred to see such safeguards in clauses 1 to 3, but as they were not accepted there, I am forced to propose them here, because it is better to have them than not. The amendment would give the panel the ability, if there is a “real risk” that the criteria have not been met, to pause and make further enquiries. They would not be obliged to give a decision that day, but would be obliged to look into the matter further, ask for more testimony, request more documents and consult experts.

The real risk test is taken from the jurisprudence of the European Court of Human Rights. Doctors will already be familiar with it, as they are already required under the Human Rights Act to assess when there is a real risk of suicide. It is not a strange novelty. The objection has been raised that introducing a real risk test to the doctors’ assessments would complicate matters, but the panel stage is a distinct stage with a distinct set of rules. I hope that the amendment will be seen not as introducing a complication but as filling a gap, particularly as this stage is meant to be more akin to a judicial stage.

Difficult situations will not necessarily be as rare as we hope. On coercive control, those with decades of experience of working with the most vulnerable have warned us time and again what the Bill could mean. Jane Monckton-Smith, one of the leading academics in the area, has said:

“Unless we do take this incredibly seriously, this Bill is going to be the worst thing, potentially, that we have ever done to domestic abuse victims.”

The consultant clinical psychologist Sue Smith, who specialises in cancer and palliative care, has submitted written evidence from which I will quote at length, because it vividly brings out the scale of the risk of coercive or controlling behaviour:

“In my clinical experience working with people who have cancer, a cancer diagnosis and treatment effects can amplify CCB…A woman asking for her needs to be seen and met alongside her increased physical and psychological vulnerability creates a change within the couple, which can lead to violent acts or CCB. The seriousness of the cancer diagnosis may be systematically and actively denied or minimised, claims can be made by the male partner that she is attention seeking, or she is accused of making up the effects of treatment, and can be left isolated and alone when in physical need, e.g. managing treatment effects like nausea or pain that restrict the ability to wash, dress and where she is reliant on others for help. At the same time a male partner may also state, ‘You are better off dead anyway,’ ‘Your children don’t care, and no one else in your life cares about whether you die.’ They may also threaten to leave. This pattern is extremely confusing, harmful and threatening. It continues over time, and a woman learns to doubt her reality and experience, and is extremely isolated. This can lead to heightened anxiety, hopelessness and helplessness, and abject despair, which can lead to a person wishing they were dead. The confidence and ability to know what one needs and wants is severely compromised when her reality is continually minimised or denied and will impact informed decision making.”

We can hope that the existing safeguards will catch some of those cases, but they will not catch all cases, so my amendment would go a little way towards improving the safeguards.

Amendment (a) to new clause 21 tries to pin down a missing detail, namely the standard by which the panel makes its decision. In a criminal trial, a jury is sent away to consider its verdict. The members of the jury know that they must be certain, beyond reasonable doubt, of the defendant’s guilt. It is not enough to think it likely on balance, nor is it enough that they have an opinion that they can justify with good reasons. It must meet a high threshold. Why is there such a high standard? Because we have to be sure about the decision, given the grave consequences. We are now considering a similar question: what is the right standard for a decision that will make the difference between life and death?

I turn to subsections (2) and (6) of new clause 21. We are told that the panel must be satisfied that the eligibility criteria have been met. The word “satisfied” is doing a lot of heavy lifting in the Bill. If a question subsequently comes to court, as has happened in Belgium where there was a wrongful assisted suicide, we will be asking the court to rule on whether the panel should have been satisfied. That raises an obvious question, which my amendment is designed to answer: what does “satisfied” mean?

I turn to a real-life example. In a famous case in Oregon, an elderly woman called Kate Cheney sought assisted suicide. She had a terminal cancer diagnosis; she also had dementia, so she was referred to a psychiatrist to establish whether she had capacity. She was accompanied to the appointment with the psychiatrist by her daughter Erika, who seemed extremely assertive about the assisted death. Kate Cheney denied that she was being pressured. However, the psychiatrist noticed that the daughter was coaching her mother. Referring to Kate, the psychiatrist wrote in his report:

“She does not seem to be explicitly pushing for this.”

He concluded that she did not have capacity to make the decision. The daughter was, in her own word, “incensed” that the psychiatrist was casting such a judgment on her mother. Kate applied for a second opinion and was assessed by a clinical psychologist. He found that Kate did have capacity, but he added that her

“choices may be influenced by her family’s wishes, and her daughter, Erika, may be somewhat coercive”.

Nevertheless, he gave the green light to the application and Kate received the go-ahead.

I ask members of the Committee whether they would be satisfied that Kate Cheney was eligible for an assisted death. Are they confident that colleagues would share the same judgment about being satisfied? Can they be sure that every social worker, legal figure and psychiatrist would be satisfied in the same direction? After all, the psychiatrists in Oregon were divided on it.

In written evidence, the most experienced clinicians have urged us to recognise that abuse is difficult to pick up. Sarah Grove, a consultant in palliative medicine, says:

“Over my years in practice, I have witnessed families acting for financial gain and not in their loved one’s best interests but in this kind of situation, this has always been impossible to prove.”

Dr Kathryn Myers, a retired palliative medicine consultant, says:

“I have seen coercion in the contexts of decision-making around the best place of care for patients and of money and property. Perpetrators are usually family members…Occasionally it has been overt and easy to detect, for example, threatening or manipulative words or actions. Most frequently it has been very subtle, one might even say, gentle. It can take skilled clinical nurse specialists highly trained in communication skills and in detecting coercion, who know the person well and who have a relationship of trust with them, several conversations over several days if not weeks to uncover that coercion has occurred.”

In such a case, with limited time, a panel may not be certain whether to give the green light to an application. That uncertainty will be even greater if it does not know what evidential standard to employ.

My amendment would clarify that grey area. It would bring in a standard that has been tried and tested and is well understood. To be clear, “beyond reasonable doubt” merely means that the panel is sure. The courts have said that the two phrases are equivalent, as has the Judicial College in its guide to judges, “The Crown Court Compendium”:

“What is required is a clear instruction to the jury that they have to be satisfied so that they are sure…if an advocate has referred to ‘beyond reasonable doubt’, the jury should be told that this means the same thing as being sure.”

The Crown Prosecution Service says:

“the magistrates or district judge in a magistrates’ court or the jury in a Crown Court must be sure that the defendant is guilty. Sometimes you’ll hear this described as ‘sure beyond a reasonable doubt’ or ‘satisfied so you are sure’.

Importantly, the word “satisfied” by itself is not enough. Juries must be not just “satisfied”, but

“satisfied so you are sure”.

The wording in the amendment would be equally strong. It opts for “beyond reasonable doubt” because it is a better known phrase and more widely understood than

“satisfied so you are sure”.

I do not want to get too hung up on which of those phrases to use. The point is to adopt the tried and tested standard that has worked in the courts. We want the Bill to have the highest standards and to protect people. Amendment (a) to new clause 21 would help to achieve that.

Members will all be delighted to know that I am moving on to the last amendment.

[Jake Richards]

I know that the hon. Lady has been on her feet for some time, but I just want to explore the difference between what a jury is doing and what this panel is doing. Let us, for example, consider the issue of coercion and a case where there is no evidence that the person is being coerced in any way, but of course the panel has not asked everyone in that person’s life. It has not heard evidence from everyone. There is no factual matrix determining what has happened or what has not happened. Can the panel sit there and say, “We are sure,” or do you think it would have to investigate all the circumstances of that person’s life and interview everyone that is in and around their social circle to be sure that they have not been coerced? Can you see why, as I set out in my speech, the “beyond reasonable doubt” burden is not appropriate for the task of this panel?

[The Chair]

Order. Can I gently again remind Members that “you” means me? Please refer to the hon. Lady.

[Jake Richards]

Forgive me, Chair.

[Rebecca Paul]

I thank the hon. Member for sharing that. It is useful to have these debates and conversations, but I would suggest that the panel needs to be sure off the back of the information that it has been given and the witness testimony, which goes back to why it is so important to ensure that we have that coverage and the right things feeding into the panel so it can get to that high threshold. I would expect the threshold to be at court level, given the huge, significant ramifications of this decision for that person.

Courts and Tribunals: Sitting Days

Jake Richards Excerpts

Wednesday 5th March 2025 Commons Chamber

[Shabana Mahmood]

My hon. Friend makes an important point. We are keeping the situation in relation to Nightingale courts under review. Where they are making a contribution that is assisting with caseflow through the system, there is a case for keeping them, but it is under review and the courts Minister, my hon. and learned Friend the Member for Finchley and Golders Green (Sarah Sackman), will be happy to write to her with further details.

[Jake Richards (Rother Valley) (Lab)]

I have been in this House for only a few months, but I must admit that I am absolutely staggered by the chutzpah of Conservative Members—most have left, but when they were here—in their attitude to this issue. In a competitive field, the state of our criminal courts and our criminal justice system perhaps wins the award for the most acute crisis as a result of the legacy of the previous Government. I really welcome today’s statement, in particular the emphasis not just on capacity but on productivity. May I just press the Government on whether that approach will also be taken in our family courts? I welcome the investment in infrastructure and capital spend in family courts, but we also need to look at how we can improve productivity.

[Shabana Mahmood]

My hon. Friend makes an incredibly important point on productivity. That is why the second phase of Sir Brian Leveson’s work is so crucial. He will know that we have expanded our pathfinder pilot, which is making a really important contribution to the flow of cases through the family court, and we are keeping it under review.

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

Jake Richards Excerpts

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Danny Kruger]

Exactly. A few more words of clarification should not be regarded as burdening the Bill or creating bureaucratic obstacles for doctors and patients; the amendment actually specifies more explicitly what is going on. It is almost akin to the debate we had on amendment 181 and those dangerous words “for the avoidance of doubt”; that is essentially what this amendment does, but it goes further, because it imposes clearer obligations on doctors to do their job properly.

[Jake Richards (Rother Valley) (Lab)]

Much has been covered today, and the issue of capacity was debated at length when the Committee considered clause 1, but I do have some observations.

I am sympathetic to the assertion that there should be changes to presumption and burden. Those are things that I have considered and spoken about with the promoter of the Bill and, outside the Committee, with experts who gave evidence to the Committee. I have spoken about them publicly as well; I am very sympathetic.

At the heart of this, we have two options. We could change the burden and presumption in the Mental Capacity Act 2005 for the purposes of assisted dying, rewriting 20 years of case law and medical practice. There is certainly some value to that, but that would be a radical departure from current medical practice, and there are other concerns. The alternative is to put in place rigorous processes and training around the Mental Capacity Act to ensure that it is implemented properly. After some reflection, I err on the side of the latter option, for a number of reasons.

First, I accept that there is debate among psychiatrists about this issue. We heard evidence from some who deem the Act not to be suitable for this new realm—I accept that we are entering new grounds, and I will come back to that point—but many psychiatrists and lawyers working in this area would deem it uncomfortable and unnecessary to depart from the Act.

Secondly, there is an oddity in changing presumption. There is an oddity in someone having to prove that they have capacity to fulfil their own desire. That oddity is one of the reasons that the Act is drafted as it is. It is partly—there are two sides to this coin—to ensure that there is no discrimination, partly to comply with the Human Rights Act 1998 and human rights more generally, and partly to ensure that we do not end up in a medical situation that is patrician, whereby medical doctors take an intrusive view of capacity rather than meeting the individual as they are.

Thirdly, the Bill, when amended—I will come on to the amendments that give me some comfort—will offer more safeguards than the Mental Capacity Act. Amendment 5 to clause 9(3) would ensure a further level of assessment. My hon. Friend the Member for Spen Valley has indicated that she will support that important amendment, as have all members of the Committee. If there is any doubt, there will be a further assessment by a psychiatrist. That goes some way to reassuring me that it is not necessary to rip up the burden or change the presumption in this area.

I want to make an observation about burden of proof, presumption and the nature of the assessment. Professor Whitty clarified his evidence. It is right that the burden and the presumption do not change, but of course the nature of the assessment rightly changes according to the circumstances. Every assessment of capacity is somewhat different, which is why amendment 50 is too prescriptive, in my view.

Of course, we can consider incredibly serious cases involving deprivation of liberty or the ability to conduct litigation. I have worked with parents whose children are being removed and looked at whether they have the capacity to make decisions about how they present their case. It is very dangerous to compare the severity and the profound nature of different circumstances, but let us not pretend that the Mental Capacity Act is not used to assess the most complex issues of capacity every day.

I am very sympathetic to amendment 50. I have met the hon. Member for Runnymede and Weybridge, who tabled it, and the hon. Member for Solihull West and Shirley to discuss it, but I stress that such a prescriptive provision is not appropriate for primary legislation when we are entering new ground. I accept, as hon. Members with different views have said, that we are entering new territory and that this is difficult. I accept that psychiatrists and medical practitioners will have to think long and hard about the nature of the capacity assessments, especially under clause 9(3), when that is activated. That work will have to be done. It has been set out in primary legislation through some of the training clauses, which have already been referred to.

There is no doubt that there will be a lot of work and consideration, but I do not deem it appropriate to have a clause drafted by one psychiatrist, albeit an undoubtedly esteemed and experienced one: the hon. Member for Runnymede and Weybridge, who tabled the amendment. Rather, the work needs to be done as the Bill is implemented over a two-year period. It needs to be done as part of a full consultation with psychiatrists, once the Bill has been passed, and that should be set out in guidance. That is what would usually happen with deprivation of liberty. I do not think it appropriate for primary legislation to set out the factors for a capacity assessment.

[Naz Shah]

My hon. Friend is saying that that will take two years. The MCA, which has been implemented over 20 years, is misunderstood. Does he not see the risk of two years? This is new territory, without change—

[Jake Richards]

We need to be careful when we say that the Mental Capacity Act is misunderstood, full stop. Let us be clear—

[Naz Shah]

Not full stop.

[Jake Richards]

Well, that was the sense—

[The Chair]

Order. Let the Member respond to the point made in the intervention.

[Jake Richards]

I am grateful, Mr Dowd.

The evidence that we have received is that this is a test. These are assessments that happen every day across the country. Now, there are more complex assessments, and there will without doubt be areas in which the assessment is not done as rigorously as it should be done, but that is why I am assured by the safeguards in the Bill that if there is any doubt—any doubt—as to capacity at first instance, there will be a full and thorough assessment by a psychiatrist.

Let us think that through for a minute. Any competent psychiatrist trained in this area will no doubt have a sense of what the Mental Capacity Act says and of the normal test for capacity. Someone who is seeking assistance to die from a doctor who has doubts as to their capacity will have been referred. To my mind, it is unfathomable that that assessment, at that stage, would not be rigorous and would not satisfy every Member that it had been done to the correct extent practicable.

[Naz Shah]

I absolutely agree with my hon. Friend about that in most cases, but in nine of the 10 cases that went to court, young girls were found to have capacity, but their treatment was stopped, leading to their inevitable death. That is not excluded here.

[Jake Richards]

We are debating lots of different things now, rather than just clause 3. There is an issue as to whether in those cases the individuals were found to have capacity, but we are talking about the process by which someone is found to have capacity, rather than what happens thereafter. We have had that debate, and I am happy to have it, but we are talking now about the process by which people are found to have capacity.

This is the problem with interventions: I have lost my train of thought. This is why people do not take them.

[Danny Kruger]

rose—

[Jake Richards]

But I am happy to take another, although I may come to regret it.

[Danny Kruger]

I have a simple point to make; the hon. Gentleman can work out what he is going to say next while I make my brief intervention.

The point is that the referral to a psychiatrist will happen if the doctor has doubts in their mind. There is not an obligation on the doctor to refer; there is only an opportunity for them to do so, if they conclude that there is a reason. May I put a scenario to the hon. Gentleman? It is not clear whether this could happen under the Bill; well, it could happen, because it is not prohibited. A private practice might establish itself to provide assisted death, with the medical assessments and the support right through to the end—to the final act.

In those circumstances, if a patient goes to one of those clinics, does the hon. Gentleman not see that there might be a risk that the whole incentive of the business, even if it is a charity, will be to expedite the process, tick the boxes and pass people through? Does he not consider it dangerous that there is not an absolute obligation to refer to a psychiatrist and in fact, an obligation to pass a higher capacity test than the one that is currently in the MCA?

--- Later in debate ---

[Jake Richards]

That was an intervention that I was grateful to take. I accept the point that there are dangers of a system that somehow incentivises this. That is why the Bill has to have such strict safeguards and such strict regulation of medical practitioners to comply with the law. The point about mandatory referral is key; I would have real concerns about this area of the Bill without that amendment, and unless the sponsor of the Bill had not made it very clear that she would be supporting it. But I take the point.

[Lewis Atkinson]

Does my hon. Friend agree that clause 8(6), which requires the second doctor to be independent of the first—they must not be

“a partner or colleague in the same practice or clinical team”—

would protect against the situation on which the hon. Member for East Wiltshire speculates?

[Jake Richards]

Yes, there are safeguards and mechanisms in the Bill to ensure that and to protect from a culture that would incentivise this practice.

[Naz Shah]

Will my hon. Friend give way?

[Jake Richards]

No, I am not going to, actually. I am taking my rights.

My final point concerns section 1(4) of the Mental Capacity Act and the discarding of the principle about whether a decision is deemed to be unwise. This is an issue we have already debated, but it is really important. Introducing a best interests test is, to my mind, impossible without ending up with a law that discriminates against certain groups. Essentially, it is impossible to do fairly.

I remain to be convinced. If there were an amendment that could do what I think the hon. Member for East Wiltshire wants, I would support it. If there were an amendment that could look into someone’s mind and make sure that they are doing this for reasons that society would deem fit, I would support it, but I think that that is impossible. What the Bill aims to do is assess a person’s capacity and ensure that they are making this decision voluntarily. It also aims to protect them from the influence of third parties and outside sources. That is the only way, if this principle is to be adhered to.

Finally, I will be voting against the amendments, but I will finish where I started. I have genuinely thought long and hard, in particular about the presumption. I have spoken to experts who disagree with me, but in my mind it comes down to whether we rip things up and start again or whether we add rigorous safeguards, practices and processes, which may be a bit more boring but will actually be more effective at protecting any patients who go down this road.

[Sojan Joseph (Ashford) (Lab)]

I rise to speak in support of the amendments. Having worked as a mental health nurse for 22 years, I completed mental capacity training many times in my career, and I carried out capacity assessments as part of my day-to-day job. I think that the capacity assessment proposed in the Bill is not safe enough. That was one of the main reasons I voted against the Bill on Second Reading. I have spoken to many people who oppose the Bill, and one of their concerns is about the capacity assessment.

We have talked about capacity assessments every day in this Committee. It is one of the key issues that we will need to resolve to strengthen the Bill if it goes through. One of the Royal College of Psychiatrists’ concerns is that capacity decisions are

“opinions with a margin of error and are time specific. A person’s capacity can change”.

I will talk about my experience with those margins of error.

A person’s capacity can be influenced by various factors, including their life circumstances, the medication they are taking or severe pain. Suicidal thoughts due to their mental state or depression can also influence their capacity. I have worked in acute mental health units. Every day, we carried out capacity assessments, including before we let someone out of the ward, whether they were admitted under the Mental Health Act or were receiving treatment as a voluntary patient. If somebody wanted to leave the ward, before the member of staff opened the door, they had to assess that person’s capacity. Sometimes a person might have said, “I am going to kill myself,” and the nurse would have had to decide whether or not they had capacity before opening the door.

My hon. Friend the Member for Bradford West has talked about unconscious bias. The initial capacity assessment when a person comes to a hospital is very important. If a doctor has assessed at the beginning that the person has capacity, the following assessment can be influenced by that initial assessment. I totally agree with my hon. Friend’s argument about unconscious bias in capacity assessments. As Members have mentioned, the Bill proposes many occasions in the process when capacity will be assessed, but I am still not confident that each capacity assessment will not be influenced by the initial assessment. The amendments would strengthen that area of concern.

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

Jake Richards Excerpts

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[Naz Shah]

I share my hon. Friend’s concerns about the Bill not being tightened and fit for purpose. We cannot afford for those people to slip through the net. One woman’s death is one too many. One older person’s death is one too many. That is the bar we have to set.

I come back to the words of Dr Jamilla: she said, “Yes, absolutely.” Every single Committee member, and anyone familiar with this debate, found it heartbreaking to listen to those who came in to give testimony about how members of their families died. Those stories will stay with us forever, and rightly so. That is why, in principle, I am supportive of where we need to get to with the Bill. However, as Dr Jamilla said, we cannot get there by ignoring this big lot of people with vulnerabilities and inequalities, who would absolutely need this legislation. We need to fix the inequalities first.

Let us be honest: as legislators, we know that we will not fix every ill in society, otherwise we would not need a police force. We would not need laws if everybody behaved as they should and supported each other. However, it is incumbent upon us, as legislators in this place, to try our best.

Nobody came to this Bill Committee thinking it was going to be a walk in the park. We certainly did not know that we were going to get evidence throughout it, and plenty of challenges are popping up. We came to this Committee—I came new to the subject—because it is of such importance. I sat in the Chamber for five hours on Second Reading, bobbing, but I did not get the chance to speak—and that happened to another 100 colleagues, who also did not get to speak. However, those who made contributions—whether they were for the Bill, concerned about the Bill or were clearly not going to support the Bill—did so because they feel very strongly about it. That is our responsibility.

I come back to amendment 23, which was tabled by the hon. Member for Reigate: we should really consider adding it to the Bill, because that would strengthen it. The amendment does not dilute the Bill, and it does not add another hurdle given that the Court of Appeal has already said that there is a responsibility to look for undue influence. I do not understand the resistance to the amendment, which I will support.

[Jake Richards (Rother Valley) (Lab)]

This debate has been very interesting and has reminded me of my life before being elected. When I was a barrister in court, I was often junior counsel and, by the time I stood up, all the best points had been taken. I feel a bit like that this morning.

I have some observations, the first of which is on what is in the Bill currently. My central submission is that the Bill does more than enough in this area, and that simplicity is what is required, especially when dealing with very complex and difficult subjects, which coercion is. There are two sides to the coin of coercion: one is about acts by third parties, such as family members or society at large, and the other is the individual making the decision.

Clause 1 is clear that, as part of the assessment made by the doctor, judge or panel, the person must have

“a clear, settled and informed wish to end their own life”

voluntarily. That precisely echoes words from the Crown Prosecution Service guidance on whether to prosecute that is currently in operation. That guidance has been in use for some time, and it seems perfectly rational and logical to continue that.

The focus of the assessment should be on the individual and whether they make the choice freely. Clause 1 makes that clear, and I presume purposefully echoes the language from the CPS guidance. It then says it must be established that the person has

“made the decision that they wish to end their own life voluntarily and has not been coerced or pressured by any other person into making it.”

That must of course be read with clause 26, which introduces a new offence:

“A person who, by dishonesty, coercion or pressure, induces another person to make a first or second declaration, or not to cancel such a declaration, commits an offence.”

That carries a sentence of up to 14 years in prison.

[Naz Shah]

I am trying to understand the expertise my hon. Friend is speaking from. Was he a criminal barrister?

[Jake Richards]

I am very happy to share my CV afterwards. I practised as a barrister mainly in family law and Court of Protection law, but back in the day I also practised criminal law as a very junior barrister in the magistrates courts up and down the land.

I do not want to delve into the criminal element too much, because we are on clause 1, but it appears to me that the criminal offence set out in clause 26 is far stronger than the Suicide Act 1961, which talks of an act of encouragement. That is not included in clause 26, which talks about inducement—a much more holistic and wider concept than that of an Act probably drafted back in the late 1950s. In my submission, that brings the law far more up to date with modern concepts of coercion and pressure.

[Rebecca Paul]

The hon. Gentleman is making interesting points. This is probably more a question for the Minister. I have been focused on clause 24, in terms of encouragement, but clause 26 obviously makes coercion and pressure a criminal offence. The hon. Gentleman says he thinks coercion includes undue influence; does it include encouragement?

I seek clarification of whether undue influence and encouragement are captured in clause 26. When I tabled the amendments, I assumed not. If it is the case, how does that interact with the Suicide Act, which already makes the encouragement of suicide a criminal offence, and is probably not—I have not checked, so I would have to look—consistent with this? That needs to be looked at. It is easy to say that undue influence is included in coercion, but it has a knock-on impact on a lot of other things. We need to be really clear on that point.

[Jake Richards]

My answer to the hon. Lady’s first question is yes. In my view, clause 26 covers undue influence and encouragement—I could go on to state why.

My reading of the Bill is that clause 24(3) essentially removes from the Suicide Act persons who are by all the other criteria eligible for assistance in death under the Bill. The Act that will be created is, in my view, stronger in any event. That is why—I genuinely mean this respectfully, because the hon. Lady made good points in an impassioned speech—this argument about encouragement in the Suicide Act does not follow through. What we have here is a much safer and more modern piece of legislation, which is reflective of what we all think of when we think of coercion and pressure.

[Rebecca Paul]

Forgive me—I hope the hon. Gentleman will bear with me as I seek to understand this; he is obviously very learned in these matters. My understanding is that clause 24 takes out only the assistance piece, not the encouragement piece. I think the hon. Gentleman just said, if I am right, that encouragement now falls under clause 26, but encouragement is also captured in the Suicide Act 1961. That is my non-lawyer interpretation of reading the Bill. I am not saying that is absolutely right, but I would appreciate it if he could clarify that.

[Jake Richards]

My reading of the Bill—we are dealing with clause 1, but we will get to clause 24—is that clause 24(3) says:

“In the Suicide Act 1961, after section 2A (acts capable of encouraging or assisting suicide) insert”,

followed by the provisions in new section 2AA.

[Juliet Campbell (Broxtowe) (Lab)]

I have a question for the promoter of the Bill, my hon. Friend the Member for Spen Valley. We are having a lengthy conversation about coercion and pressure, and whether those two words are a catch-all for things that can be much more subtle and nuanced. That is the point of the amendment, and it is the point that I will make when I speak to the amendment I have tabled. Clause 26 suddenly introduces new language, with the word “dishonesty”, which brings in another type of coercion and pressure. Could we rethink the wording of clause 1(2)(b), which refers to a person who

“has made the decision that they wish to end their own life voluntarily and has not been coerced or pressured”?

The words “coerced” and “pressured” are insufficient to cover the safeguards that we are asking for. They are not a catch-all. We are asking for something much more nuanced, and for other words to be added, just as the word “dishonesty” appears in clause 26.

[Jake Richards]

I did not draft the legislation, but my understanding is that the reason why the word “dishonesty” appears in clause 26—I do not know whether the Minister wants to comment on this—is that when there is a criminal offence, there needs to be a mens rea. The person who has committed the offence needs to have been intentional or reckless in doing so. As I say, I was a criminal barrister only very briefly; I am sure my law tutors are shaking their heads.

[Naz Shah]

The principle of statutory interpretation means that by mentioning one thing, we exclude others, so it is my understanding that having the terms coercion and pressure in the Bill excludes undue influence. Will my hon. Friend, who has clearly gone through this in detail, also comment on the fact that section 2A of the Suicide Act says that encouragement includes pressure?

[Jake Richards]

With respect, I think my hon. Friend is wrong: it is certainly not an exhaustive list of factors to be taken into account. The courts—this is why we have a common law system—interpret the language used in legislation.

[Naz Shah]

To build on that, I referred to the Court of the Appeal earlier, but when it comes to someone giving their organs, I think from the age of 12 or 13—I will try to find the reference—the words “undue influence” are used in the legislation. It comes back to the crux of my argument; I would like to understand why my hon. Friend is so concerned, from a legal perspective, about putting in the words “undue influence”, when they already appear in legislation.

[Jake Richards]

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

[Danny Kruger]

Will the hon. Gentleman give way?

[Jake Richards]

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

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

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

[Dr Tidball]

Does my hon. Friend agree, as Max Hill did in oral evidence, that it would be helpful to have definitions of the three concepts in clause 26? Although we are discussing an earlier clause, it is important to thread the needle with this statute and ensure that we are looking ahead, as the hon. Gentleman has rightly pointed out.

[Jake Richards]

That sounds very sensible—I think my hon. Friend is talking about her amendment.

[Rebecca Paul]

I am so glad that the hon. Member has spoken, because this is a really important conversation. I appreciate that we are getting a little ahead of ourselves, so I will be quick before the Chair tells me off. Section 2A of the Suicide Act includes pressure when it talks about encouragement. That is why it is so useful to have this conversation—because that could mean that encouragement is captured by clause 26. There is some work to be done. I stand by the amendments—it is really important that we have them on the face of the Bill—but, when we get to the relevant point in Committee, we need to think about the interactions of clauses 24 and 26 with the Suicide Act. I am sure that the Ministers will want to look at that, but we may need to be very clear what is included in what, which may require some things in the Bill so that there is no ambiguity. Does the hon. Gentleman agree?

[Jake Richards]

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

[Danny Kruger]

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

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

[Jake Richards]

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

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

[Juliet Campbell]

I rise to speak to amendments 113 to 115 and 118 to 121, which would require steps to be taken to establish that a person seeking assistance has not been manipulated by another person.

The amendments would require the co-ordinating doctor to ascertain whether, in their opinion, the person has been manipulated, and would account for additional ways that a person can be influenced by another person into choosing an assisted death. Pressure and coercion may leave an individual feeling that they have no choice but to take that path; however, manipulation can make the person think that they made the choice themselves. Coercion is an overt and clear means of controlling someone, whereas manipulation is a hidden, psychological and deceptive means of control.

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

Jake Richards Excerpts

Tuesday 11th February 2025 Public Bill Committees

[Jake Richards (Rother Valley) (Lab)]

I am trying to understand my hon. Friend’s argument. In terms of a person choosing to ask their doctor to turn off their life support machine, as opposed to someone offering a person drugs to self-administer, I understand that there are differences in terms of public policy and that, for some, there are differences morally. However, in terms of capacity—the decision as to whether that person can make that choice themselves—why is it different?

[Naz Shah]

The hon. Member for East Wiltshire answered that question eloquently earlier. Although the outcome is the same, we are asking two different questions. The question is not about turning off and unplugging a machine; it is about whether someone will take drugs to end their life.

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

Jake Richards Excerpts

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[Sarah Olney]

I look forward to the hon. Lady’s further comments, but as I said, the psychiatrists were very clear that they did not believe that this was a sufficient safeguard, and we should acknowledge that.

I was unable to put my question to Alex Ruck Keene KC during the oral evidence session, but he kindly agreed to give further evidence in writing in response to a letter I sent to him later that day. That exchange of letters has been published as written evidence. It was his position that, in actual fact, Professor Sir Chris Whitty misinterpreted the Mental Capacity Act when he gave evidence. There is no such requirement in the Mental Capacity Act that states that the more serious the decision, the greater the level of capacity that someone needs to have. Mr Ruck Keene’s view is that that was the common law prior to the Mental Capacity Act coming into force, whereas in actual fact the Mental Capacity Act does not require that the more serious the decision, the more capacity someone needs to be judged to have.

[Jake Richards (Rother Valley) (Lab)]

I am sympathetic to the problem the hon. Lady has identified of people who have a terminal illness as well as other mental health conditions. Instead of rewriting the Mental Capacity Act for this new context, would it not be better to secure safeguards through clause 9, through which further assessments are potentially going to be mandated, if the amendment from the hon. Member for St Albans (Daisy Cooper) is agreed to, for those cases where there is doubt as to capacity? That would add a further safeguard rather than rewriting the established Mental Capacity Act and case law.

[Sarah Olney]

I have no intention of rewriting the Mental Capacity Act. It should stand exactly as it is and be used for the purpose for which it is intended. That is not the intention behind my amendment, which merely proposes that we should assess people’s ability to make the decision and not just their capacity. Many of those who provided evidence demonstrated that merely testing somebody’s capacity to make a decision is insufficient in this case.

--- Later in debate ---

[Sarah Olney]

The hon. Member is absolutely right. That would be another weakness of the Mental Capacity Act being used in this context: if someone is judged to have capacity, they are free to make an unwise decision, yet there is nothing in the Bill to provide a safeguard against people who might have capacity and make an unwise decision because their thinking has been obscured by mental illness, depression or something else.

[Jake Richards]

I have a few questions for the hon. Member. Who does she propose will decide whether a decision by someone who has capacity is wise or unwise? Does she also propose changing the law around patients’ refusing life-saving treatment? Should that be handled under the Mental Capacity Act, as it is at the moment?

[Sarah Olney]

I am grateful to the hon. Member for his intervention, but I am not proposing to change any legislation other than the Bill before us. All the other legislation to which he refers should remain precisely as it is, and for the purpose for which it was intended. He asks who is to say whether someone is making a wise or unwise decision; that is the job of the people who are instructed to provide assessments under the Mental Capacity Act. As was clear from my response to the hon. Member for Reigate, if someone has been assessed as having capacity, there must not be any further interference in their decision-making process, even if there are distinct concerns that that person may be deciding to end their life not purely because of their terminal illness but because they are suffering from depression. There is no other mechanism in the Bill to enable that further safeguard.

--- Later in debate ---

[Dr Shastri-Hurst]

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

[Jake Richards]

I keep making the point that clause 9 adds a different element to this process. It says that, when undertaking the assessment, one of the two doctors

“may, if they have doubt as to…capacity…refer the person for assessment”

of their capacity by a psychiatrist. Does that reassure the hon. Member that there is a further layer of safeguards in this area?

[Dr Shastri-Hurst]

That is one of the additional safeguards in the Bill. This Bill has more in-built safeguards than any similar piece of legislation across the world. I think the hon. Gentleman makes a valid point: when a doctor has concerns about somebody’s mental state, they can escalate the case and seek further, specialist opinion.

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

Jake Richards Excerpts

Committee stage
Thursday 30th January 2025 Public Bill Committees

[Lewis Atkinson (Sunderland Central) (Lab)]

Q Mr Greenwich, we are minded that as well as passing really good legislation we want to get public confidence behind this. We have heard a level of concern from disabled people’s representative bodies about the inadvertent implications of this law for disabled people. Were those concerns shared when you took your legislation through, and how it has gone since the implementation of the legislation?

Alex Greenwich: In New South Wales, and across Australia, having a disability or complex mental health issue like anorexia does not make you eligible at all for voluntary assisted dying. The legislation we are dealing with and you are dealing with is not for people with a disability or anorexia nervosa, and not for people who feel they are a burden. It is for people with a terminal illness who may want the choice of a death that is better than what the illness would otherwise provide.

We worked closely with disability groups in New South Wales. Their main concern was that they would be treated equally in terms of access to the law if a person with a disability had a terminal illness. The key point is that this legislation is a safeguard to those concerns. To the point about people who are starving themselves, that is happening today in the UK because people do not have access to voluntary assisted dying. They are starving themselves to death rather than accessing a regulated scheme where they can discuss all their options and choices.

[Jake Richards (Rother Valley) (Lab)]

Q This question is probably best for Alex. Yesterday we heard evidence about the health inequalities in our society and fears that they would be exacerbated by the introduction of assisted dying. What was the experience in Australia?

Alex Greenwich: If I think of our health system and how we adopted voluntary assisted dying, like all health systems we were under pressure following the covid pandemic. By legislating in this space you give your health system the priority of dealing with this, making sure doctors are trained to be able to address it and that there is a good implementation period. I believe the Bill has two years, and I think that is completely appropriate to make sure your health system gets up to speed. When it comes to end-of-life choices and healthcare, voluntary assisted dying provides a great deal of honesty and safeguards.

[The Chair]

I think this will probably be the last question.

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

Jake Richards Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[Dr Tidball]

Q You have helpfully acknowledged the link that we need to make on coercion to strengthen this, but on the other two elements—dishonesty and pressure—is there anything else that we need to look to in order to make this more robust?

Sir Max Hill: “Dishonesty” is a term of art in common use, but it is also a term of statute. Anyone investigating or, still more, prosecuting would understand what dishonesty means. I accept that there is a wider point—not so much for interpretation but for understanding—that this Committee may want to consider, of how much of that existing definition needs to be imported into the Bill. As with mental capacity, I would suggest that, beyond perhaps the odd footnote, it is not necessary for you as a Committee to define again what dishonesty means, because we have it elsewhere.

Alex Ruck Keene: On pressure, I think the Committee would be really assisted by having a look at the learning of the High Court judges exercising their jurisdiction under the inherent jurisdiction in relation to people who are said to be vulnerable. They have developed an awful lot of tools, where they are trying to look at people in complicated situations—potentially, but not necessarily, with impairments—who are caught up in what one person brilliantly described as being caught in a spider’s web. Those are the sorts of sets of tools used when judges are trying to work out what is going on, and whether it is the side of the line we consider to be acceptable or the side of the line we consider unacceptable—because “pressure” is doing a lot of work there.

[Jake Richards (Rother Valley) (Lab)]

Q Thank you all for your written evidence. Sir Nicholas, in your helpful written evidence, you adopt Sir James Munby’s criticism of the current proposal for judicial oversight, and you instead recommend what you call a “Spanish-style specialist panel”. Could you set out for the Committee what you see as the benefit of that approach compared to what might be described as the stark judicial oversight of the High Court judge?

Sir Nicholas Mostyn: One per cent would be 6,000 deaths a year. If each took two hours to process in the High Court—you have to read it and hear the evidence; one of them has to be oral and you have to write a judgment—that is 12,000 hours. Each High Court judge does 1,000 hours in court—outside court, they do lots—so you are talking about nearly three quarters of the entire family division doing nothing but this. It is impossible, in my opinion, for this to be done by the High Court. It should be done in the Spanish way by a panel that is set up. In Spain, the chairperson of the regulator sets up a panel for each case—a doctor and a lawyer. They have to agree and they check that everything has been done lawfully. They do not make any value judgment about whether it is in the person’s best interest. They check that it has all been lawfully.

Interestingly, in 2023, 10% extra denials were done by the panel. I do not know whether that was because they were concerned about voluntariness or whether they were concerned about suffering—because the criterion is suffering there—but an extra 10% was done by the panel, so the panel was not just rubber-stamping. They denied an extra 10%. I believe that an ad hoc system like that, with a doctor and a lawyer doing a check, would be the best way of doing it. The High Court—trust me, I’ve just come from there—has not got the capacity to deal with 6,000 cases of this nature.

[Jake Richards]

Q Apart from capacity, which I appreciate, are there any other problems that you see with clause 12 on judicial oversight? Apart from capacity, is there any benefit that you see from the Spanish model? Alex, you similarly criticised the current judicial provision. You say in your very helpful written evidence at paragraph 10 that perhaps we need to consider a multidisciplinary approach.

Sir Nicholas Mostyn: Can I just answer before he does?

[Jake Richards]

Yes—it’s just that otherwise I will be cut off. I was trying to get two questions in.

[The Chair]

Order. I said earlier that this is not a dialogue. Address your comments to the Chair, and I will decide who speaks and when. I do not wish to be rude, but everybody’s got to have their fair share.

Sir Nicholas Mostyn: I do not know if you have seen Sir Stephen Sedley’s memo, which came today. He has suggested that the Official Solicitor should be the checker of these facts, which seems a sensible idea. The Official Solicitor would be able to recruit more staff to do this. It would not be nearly as expensive as High Court judges, and it would be an efficient way of dealing with the problem. The advantage of the Spanish system is that you have a qualified doctor as well as a lawyer doing the checking. Remember—a High Court judge is not going to be a qualified doctor. That is a significant advantage in my opinion.

--- Later in debate ---

[The Chair]

We have some Members who want to ask more questions; we have about six minutes or so. Jake Richards, you did have a possible question earlier on.

[Jake Richards]

Q Some of it has been answered, but on that point, I just wanted to explore the appeals point. If either side could appeal, as Alex suggested, who would be appealing against the decision to allow assisted dying?

Sir Nicholas Mostyn: Relations who say, for example, “My father has been pressured by his new wife to do this”. If a father has given permission and the child has asked to intervene, there would be some process where the child would be allowed to become a party to the proceedings, because that will have to be specified in rules, and that person would then be the appellant.

[Jake Richards]

Q The Bill at the moment—and for good reason, potentially—potentially does not provide for family members receiving notice of this.

Sir Nicholas Mostyn: Well, it does.

[Jake Richards]

It is an autonomous decision, so—

Sir Nicholas Mostyn: No, but it says, procedurally, they can determine their own procedure.

[Jake Richards]

Yes, sorry, I meant that, in terms of—

[The Chair]

Order. I am giving you an opportunity to ask a question, so ask the question, we will get the answer back and then we can move on. I do not want this dialogue, I am afraid.

[Jake Richards]

Forgive me, Mr Dowd. I meant that, in terms of the assisted dying process in the Bill, there is no automated mechanism for family members, or indeed any third parties, apart from the doctors, to have notice of this intention. Is there a concern, regarding this appeal point, that perhaps interested parties would not know?

Sir Max Hill: I would suggest that the key to this is in clause 12(5), and that is why I have recommended just striking out the words “High Court” and putting in the word “panel”, and then reading the whole of clause 12 as amended, with those situations in which there are steps that “must” be taken—and there are many—and those in which there are steps that “may” be taken.

In clause 12(5), following that logic, we would imagine that a panel, just as the High Court,

“may hear from and question, in person, the person who made the application”

but

“must hear from…the coordinating doctor”.

The appellate mechanism, which I agree there needs to be, will be looking sharply at the operation of that subsection. In other words, when the panel made its decision to refuse, on what basis did it make that decision and from whom had it heard? We can well imagine situations in which a co-ordinating doctor, having taken his or her own steps to ascertain the views of the nearest and dearest, would satisfy the panel as to what the views of the family are. The reverse of that is that there is no indication here that, having gone all the way through the panel, the family would have been made aware or considered at all. I think that that will be a rare scenario, but I am not a medical professional. I think you can cover that, perhaps with some changes here or there on what you impose on the panel as a mandatory duty and what you leave by way of discretion, subject to the rules of procedure that the panel would then adopt.

[Dr Tidball]

Q I have a question for Sir Max Hill and Alex Ruck Keene. Your insight on clause 12 has been helpful. What procedures would you recommend be adopted for testing and, if need be, challenging the evidence as part of an evidentiary process linked to the panel that you set out?

Alex Ruck Keene: This is, for the moment, predicated on the fact that we are still in the High Court, as opposed to slightly making up policy on the fly about a panel. Assuming it is the High Court, it seems to me the Court has to be discharging a properly inquisitorial jurisdiction, which means it has to be armed with the tools to do that, which includes arming it with the tools to call for its own evidence. It also seems to me that the High Court would have to be armed with its own ability to not just receive evidence from one side and have someone testing it. That then brings you to the only player in town who could possibly do that, which would be the Official Solicitor as advocate to the Court.

I do not want to emphasise too much the question of resources, because if Parliament thinks this is sufficiently important, the resources will be voted through. But it is vitally important to note that the Official Solicitor is completely overloaded, and we would be asking the Official Solicitor to act as advocate to the Court in every single one of these cases. You could not have it be optional; you cannot say that it is some and not others. If it is going to be inquisitorial, the High Court has to have the ability to say, “This is one-sided; someone needs to tease it out,” so the Official Solicitor would have to be funded to be advocate to the Court and, if necessary, instruct lawyers in every single case.

Sir Max Hill: The model that I was espousing would not necessarily involve the Official Solicitor at all. It would make no draw on the administration of the Court or any officer of the Court, still less full-time judges. It would allow the appointment of recently retired judges, as we have in a number of scenarios—surveillance commissioners, for example—and a fresh administration. With that, as with the High Court model at the moment, there is the primary set of provisions, which Parliament must impose, and it is important that that is sufficient for what Alex called an inquisitorial function. Those are in part mandatory—those things that the panel must be satisfied about, which are set out in clause 12(3). Then there are those that are discretionary, which are set out in clause 12(5).

What sits between the two is very important. That is currently expressed as “Rules of Court”, but it would be the rules of the panel, or the commission that appoints the panels. In a court scenario, we are all familiar with criminal procedure rules and civil procedure rules; that is the secondary stage that is reached once the primary legislation has been fixed. That, too, would apply to the commission or panel process, but I do not necessarily think that it would involve using existing, paid judicial resources at all.

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

Jake Richards Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[Sojan Joseph]

Q My next question is for Duncan. Nurses who work in stressful environments, such as people working in mental health wards, are expected to get clinical supervision. Do you think that the nurses who are going to work in these areas—if this Bill passes—would require that specialist clinical supervision? And do you think the NHS will have the capacity to provide clinical supervision for the nurses working in those areas?

Duncan Burton: I think you are absolutely right—anybody working in stressful environments. If the Bill is passed, we will need to make sure that we have sufficient psychological support for nurses and doctors working in these services, as we do now for many of our nurses and other professionals working in these kinds of situations. People working in end of life, or cancer nurses, for example, often have psychological support to help them deal with some very difficult conversations with patients.

We would need to look at that and make sure that sufficient support was in place for anybody working in these situations. We would also need to be mindful about the wider workforce, given the issues from such a debate as this and how the decisions to signpost people on to services might create—for some people—moral injury. We do need to think about the support in place for those people.

[Jake Richards (Rother Valley) (Lab)]

Q You have touched on this, but perhaps we could have some further clarity. Certain amendments have been suggested that are essentially more prescriptive about what factors need to be taken into account and what steps clinicians would have to take when considering capacity in this context, as well as to inform consent and inform about the options available. Of course this is a matter for Parliament, but would you err on the side of trusting clinicians’ professional judgment within the legal framework, as it is—in terms of the Mental Capacity Act and the guidance on informed consent—or would you deem it suitable for further prescriptive steps to be put into primary legislation in this context?

Professor Whitty: It is entirely a matter for Parliament, at one level, but I can give a view. It goes back to the point that Naz Shah and others made earlier: the situations that people find themselves in are extraordinarily different—culturally, where they are in their lives, where their families are and a whole variety of other issues. Only the clinicians dealing with that person will really know all the different factors at play. If there is a good therapeutic relationship, and you would certainly hope there was, they should understand a whole variety of things that are very difficult for people sitting around this table to predict, however wise you are—although I am sure you are extraordinarily wise, to be clear. That was not my point. My point is that this is very difficult and I could not, at this point, write down a law that would be helpful to someone dealing with a whole range of different scenarios in which they are going to have to have an end-of-life discussion.

My own view, for what it is worth, is that I would do fewer things rather than more. That is partly because simplicity is the key to really good safeguards, in my experience. If the safeguards are really clear and simple, everybody understands them—if you ask six people, “What does this mean?”, those six will give you the same answer. The more complicated you make things, the more room there is for ambiguity and uncertainty—because different things are playing in—and the more difficult it is for the patient, their family and the medical and nursing professionals assisting them, to navigate the system.

Without in any sense wishing to curtail what Parliament might wish to do, I would make a plea for simplicity wherever possible and for accepting the extraordinary variety of people’s lives, which may have unpredictable consequences in terms of the way the end of their lives plays out.

[Jake Richards]

Q In terms of setting standards and ensuring universality of understanding those safeguards, is that better done, in your view, by training and guidance rather than primary legislation setting up factors?

Professor Whitty: I would certainly recommend that this is done by guidance or in secondary legislation, which can be adjusted if it turns out that it is not having the desired effect. Two things can change: first, we can spot things we had not thought of in the first place, however far-sighted each of us is. The second is that medicine itself changes, the diseases people suffer from change and so on.

An Act has to be durable and that is why I have my view about secondary legislation and guidance, which have the ability to adapt in a way that primary legislation cannot. The fundamentals obviously need to be in primary legislation, but these kinds of issues are often done better in secondary legislation.

[The Chair]

I am very mindful of the time, as it is now three minutes past 10. This will be the last question of the session.

--- Later in debate ---

[Kim Leadbeater]

Q On the point about reporting, where patients take that right to refuse treatment, capacity must be assessed at that point if a patient has said, “Look, I don’t want any more treatment.” That is quite an important point to assess capacity. Are those cases logged and recorded?

Mark Swindells: Yes. It would be important for the patient’s records to cover the points of consent and that the doctor has recorded that they have interacted with the patient that way. I do not believe it is centrally held or collated in any sense like that, but I may be wrong.

[Jake Richards]

Q Dr Green, on subsections (4) and (5) of clause 4 and the information services, as opposed to the referral to a practitioner, I think your point has some weight. In terms of the rest of clause 4 as drafted, it has an opt-in, it gives wide discretion to practitioners and there is no obligation to raise it, so from my understanding of your written evidence, it ticks all the boxes. Is that fair?

Dr Green: Yes, with the exception of the referral.

[Jake Richards]

Thank you. I just wanted to clarify that.

Dr Green: Of course, we would regard much of clause 4(4) as normal care in any case.

[Jake Richards]

Q There are some amendments being tabled that would offer further clarification and include more things that have to be considered. I have a similar question to the one I asked the previous panel, when I think you were here in the Public Gallery. Would offering further guidance to your members be welcome, or would you again err on the side of trusting their professional discretion?

Dr Green: As Dr Whitty said, I think simplicity is the key here.

[Liz Saville Roberts]

Q Dr Green, you mentioned the different jurisdictions within the United Kingdom and the Crown dependencies. What issues have your members raised in relation to this legislation?

Dr Green: In terms of the cross-border issues?