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

Debate between Kim Leadbeater and Sojan Joseph

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Sojan Joseph]

I should like to speak to amendment 1 —I am pleased that I was able to table my amendment first. We have already discussed safeguarding many times and how capacity is central to these measures. As we know, clause 1 lists the qualifying criteria that a terminally ill person must meet, which includes having the capacity to make such a decision. Indeed, the qualifying criteria might not be written in any order of importance, but the fact that that appears first underlines its significance.

In many days of sittings the most spoken words have been mental health, capacity, coercion and suicidal thoughts, rather than pain, cancer and suffering. The importance of capacity as a safeguard is again demonstrated when we turn to clauses 7 and 8, which in turn set out what both the co-ordinating doctor and the independent doctor must assess in order for a terminally ill adult to be allowed to end their own life.

In clause 7, the first assessing doctor with responsibility is the co-ordinating doctor. In clause 8, the second doctor is the independent doctor. The doctors are expected to assess mostly the same things. For example, the first doctor will assess whether the person is terminally ill, has capacity to make the decision to end their own life, is aged 18 or over, is ordinarily resident in England, and is registered as a patient with a general medical practice in England. The second doctor does exactly the same and assesses whether the person is terminally ill, has capacity to make the decision to end their own life, is aged 18 years or over and so on.

Before coming to the first assessing doctor, the patient has already been treated by a consultant and been diagnosed as terminally ill, so the three doctors are basically doing the same job. That is important and relevant to my amendment 1, which asks that one of the two assessing doctors should be a qualified psychiatrist or a specialist in psychiatry. As I said earlier, the issues that have been most discussed by Committee members in the last few sittings were capacity, mental health and suicide. In my view, there is a gap that needs to be addressed.

We talked earlier about unconscious bias. There is already a provision in the Bill to refer a patient to a psychiatrist if one of the doctors thinks that there is an issue with their mental health or capacity. We discussed a similar concept when we debated the patient having access to a palliative care consultant. Some of the comments were that needing another person makes it complex, and it should be simplified. Do Members think that if any of the doctors thinks that there is an issue with the patient’s mental health or capacity assessment, making a referral creates that same kind of complexity? Getting access to a psychiatrist could be simplified by having that second doctor be a specialist in mental health. It is to be strongly welcomed that both co-ordinating doctors and independent doctors have to make an assessment that the person wanting to ending their life has the necessary capacity to make such an important decision.

The question came up during the debate about whether, if somebody has mild depression or another mental health disorder, but they still think that they have capacity, they should be allowed to choose this route. We have seen that, in some other countries where this route is already practised, mental health was originally excluded from the criteria but was later added. Are we saying that even if someone has mental ill health, mild depression or some sort of mental illness, if they have capacity, we can allow them to choose assisted dying? Who will make that decision?

In my experience of working in mental health for many years, I have seen many terminally ill people being admitted to mental health wards because of their increasing suicidal thoughts. Many people who have a mental illness for many years, especially chronically mentally ill people, lead a normal life with the support of medication, but when they are diagnosed with a terminal illness, such as cancer, and start chemotherapy or taking medication for that, it can interact with the medication that they were already taking. That can have an impact on their mental health or decision making, so it is important that those patients have access to a psychiatrist.

I am not asking to make the process more complex or for us to draw any more resources from the NHS by adding a psychiatrist into the assessment. All my amendment asks is for one of the two doctors to be a psychiatrist, which in fact makes the process safer and more secure—some of the concerns that we have talked about.

[Kim Leadbeater]

I congratulate my hon. Friend on tabling amendment 1 on the amendment paper—a lot has happened since he tabled that amendment, it is fair to say. I get the impression from the Committee that we will all be voting in favour of making it compulsory to refer to a psychiatrist when one of the doctors feels there is a need to. Is my hon. Friend somewhat reassured by that?

[Sojan Joseph]

I thank my hon. Friend for her timely intervention. I was going to say that having tabled amendment 1 asking for a psychiatrist to be involved, and having now been through many Committee sittings, I wonder whether I influenced an unconscious bias among Members to table more amendments relating to mental health, capacity and suicide. I say to my hon. Friend that although there can be a psychiatry referral, if we are talking about unconscious bias, as soon as the first and second doctor make the decision that the person has capacity, is terminally ill and is eligible for this process, the subsequent assessments can be influenced by the first assessment. That happens quite often in NHS healthcare, and especially mental health.

When the chief medical officer, Sir Chris Whitty, was before the Committee, I asked him about mental capacity assessments. He said:

“I would hope that most doctors are capable of identifying that someone has some degree…of mental health distress, or mental health illness”.

However, he went on to say:

“What not all doctors will feel comfortable doing is actually deciding whether that is sufficient to interfere with someone’s ability to make a decision with full capacity. That is where help from colleagues from psychiatry, and mental health more widely, is going to be useful.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 38, Q17.]

We have spoken about this many times, but in written evidence the Royal College of Psychiatrists said:

“A person’s capacity can change, and it is decision specific. While we are of the view that a person’s capacity to decide treatment can be reliably assessed, an assessment of a person’s mental capacity to decide to end their own life is an entirely different and more complex determination requiring a higher level of understanding.”

In a previous sitting, we discussed having a panel that is able to do a psychosocial assessment. I know that the new clauses are yet to be discussed, but the relevant new clause does not specify who the members of the panel will be and whether it should include a psychiatrist or a social worker. That is yet to be made clear, so I am not convinced about that.

[Kim Leadbeater]

To clarify, I think it is clear that the panel would include a psychiatrist and a social worker. I hope that reassures my hon. Friend.

[Sojan Joseph]

I thank my hon. Friend for confirming that. That is reassuring but, as I said earlier, I would like to know when the patient will have access to the panel. It is important that they access it early in the process, rather than later, because that is where unconscious bias comes in.

The purpose of my amendment is to save resources, because I know about the pressure on the NHS. Rather than having an additional psychiatrist on top of the two or three doctors, my amendment would simplify the process and save resources.

Although I acknowledge that the evidence I cited referred to the application of the Mental Capacity Act 2005 to the Bill—an issue on which the Committee has already decided—I would argue that it can equally be taken into consideration in this context. After all, in its written evidence, the Royal College of Psychiatrists said:

“Mental disorders, such as depression, are more common in people nearing the end of their life. Delirium is more common… Hopelessness is a common symptom of depression”,

and people’s capacity and consent can be affected when they are going through that condition. I can categorically confirm that I have seen that in my own practice. A person could be absolutely normal, but when they are diagnosed with a terminal illness, that can have an impact on their mental health. We have heard about post-traumatic stress disorder and many other events that can have an impact on people’s mental health and, in turn, on their decision making and capacity.

If the Bill enters the statute book, we should ensure that at least one of the doctors assessing a terminally ill adult who wants to use the legal mechanism to end their life is properly qualified to carry out mental capacity assessments. I know from my own experience that psychiatrists deal with complex mental capacity assessments and other cases every day. For example, psychiatrists who work in accident and emergency departments regularly see people who are intent on ending their life—that is the bread and butter of their work.

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

Debate between Kim Leadbeater and Sojan Joseph

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[Sojan Joseph (Ashford) (Lab)]

I rise in support of the amendments, especially amendments 342 and 425. We have discussed various aspects of the Bill, especially capacity, coercion and medical practices, under many previous amendments. As somebody who worked as a mental health nurse for many years, and who worked as part of a multidisciplinary team, I think that amendments 342 and 425 are some of the most important.

Amendment 342 talks about the preliminary conversation with the medical practitioner with whom the patient makes contact. Do we not think that the doctor who knows most about that patient is the best person to have that preliminary discussion? They will have the most information about them. When the patient, who has gone through so much difficulty, goes to their doctor or to a GP who knows them well and says, “I would like to choose the assisted dying pathway,” would that doctor then say, “I do not want to discuss this. Somebody else will.”?

[Kim Leadbeater]

Is my hon. Friend not concerned about the concept of conscientious objection? The BMA strongly opposes amendment 342, because it does not think doctors should be obligated to have that initial conversation if they do not want to.

[Sojan Joseph]

There are other people who support this concept, and they are the people who will be having the conversation—we have both sides of the argument. I believe that the best person to have that preliminary discussion would be the doctor who knows about that patient the most—about their circumstances, prognosis, family situation and pain. We talk about compassionate care, but where is the compassion in here? I am not saying that another doctor would deny that—but I am talking about compassion. Someone going through the most difficult time in their life would have the confidence to talk to the person who knows the most about them, which is why I fully support that the initial discussion should happen with them. I am not saying that they should say yes or no, but they should be talking about the care provisions and options available to the patient. Amendment 342 is one of the most important amendments we will debate.

I will move on to amendment 425. When I tabled amendment 1, my thinking was that a psychiatrist should be involved in these discussions, but I think amendment 425 will safeguard most of the concerns we have discussed in previous sittings. Amendment 425 talks about a “multidisciplinary team” and having a psychiatrist involved as well. Written evidence was sent to us on 29 January by the Royal College of General Practitioners, which recommended that a separate pathway that

“covered every stage of the process would ensure healthcare professionals of multiple disciplines…who wanted to do so could still opt in to provide assisted dying, but this would be arranged through a different pathway.”

The hon. Member for Sunderland Central spoke earlier about how patients may be going through many multidisciplinary teams already, but it could be that none of those multidisciplinary teams have talked with them about assisted dying. They could have been pharmacists or nurses talking about the patient’s care—not assisted dying. We are talking about setting up a multidisciplinary team with a mental health nurse, doctor and social worker who can look in detail at evidence of the patient’s capacity, whether they are choosing it because they feel they are a burden, and whether there is any coercion. I think that is a safeguard for most of the concerns we have discussed in previous sessions. I would love to see a psychiatrist involved, because psychiatrists deal with some of the most challenging patients, including those with suicidal thoughts, on a day-to-day basis. They are the most experienced people to carry out a capacity assessment and, if they are a part of the multidisciplinary team, it will safeguard the Bill.

I strongly support amendment 425 and I urge Members to consider it. It will reassure many people who are concerned about some of the discussions. I know it also talks about giving power to the Secretary of State to formalise who should be part of the multidisciplinary team, which would be a discussion for later. I thank the Committee for giving me the opportunity to speak in support of the amendment.

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

Debate between Kim Leadbeater and Sojan Joseph

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Sojan Joseph]

I agree that when an independent doctor comes to assess a patient’s capacity and sees them for the very first time, they are more likely to be influenced by the assessment made at the beginning by the doctor who has known them for many days, weeks or months. I agree with my hon. Friend’s argument.

[Kim Leadbeater]

To be clear, the word “independent” means independent of the other doctor, not independent of the patient. The independent doctor could well know the patient. I hope that that clarifies that point.

[Sojan Joseph]

But it could be the other way around. The Bill does not clarify that the second doctor would know the patient at all.

[Kim Leadbeater]

It is not guaranteed.

[Sojan Joseph]

It is not guaranteed. I am grateful for that intervention.

We have talked about training for all registered professionals who will be involved in the capacity assessments. As someone who has carried out that training many times, I draw the attention of the Committee to Dr Rachel—

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

Debate between Kim Leadbeater and Sojan Joseph

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Sojan Joseph]

I agree. As part of the code of practice, professionals are expected to complete the training that has been outlined already, but I am not confident that that is actually happening. Saying that there will be training does not reassure me that it will be robust enough.

[Kim Leadbeater (Spen Valley) (Lab)]

The hon. Member for East Wiltshire seemed reassured by the fact that there will be training in the Bill—it is on the face of the Bill and will therefore definitely take place—

[Kim Leadbeater]

I am pretty confident that an amendment is going to be tabled, if it has not been already, that would change that “may” to “must” in the clause on codes of practice.

[Sojan Joseph]

I would be happy to see the Bill make a strong case that the people who will take part in this process have training before they do so.

My larger issue is around the independent doctors. Again, I will use some examples of how the Mental Health Act 1983 has been carried out in its current format. Those cases always use a section 12-approved doctor, who is a second doctor and they may not have had any kind of contact with the patients. We may or may not end up in that sort of similar situation. That is the point I was making earlier.

As the Royal College of Psychiatrists mentioned, capacity can change and decisions are opinions with margins of error. I mentioned my experience working in mental health wards earlier, and the hon. Member for East Wiltshire talked about the capacity assessments carried out when patients are standing by or threatening to jump off a bridge. I am not comparing these situations or saying that they are similar, but we have to make decisions based on capacity. In my experience of discharging people from hospital in a mental health unit, when somebody is threatening, “I’m going to kill myself if you discharge me”, the multi-disciplinary team—the doctors and the nurses—have to make a decision on whether to discharge the patient based on their capacity at that time.

Capacity is assessed based on whether someone is able to understand information—can they retain, use and weigh information, and can they communicate their decision? We cannot compare that with the situation of somebody asking for assisted dying. I want to make it clear that the capacity assessment is the key. I would love to support this amendment. As I said earlier, this issue was one reason I voted against the Bill on Second Reading, but passing this amendment might change my position and I would love to support it.

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

It is a pleasure to serve under your chairship, Mrs Harris. I will speak specifically to amendment 50. I fully appreciate and accept the points made on a number of occasions during this debate by my hon. Friend the Member for Stroud—that many proposed changes either already feature in the Bill or are the current course of practice for doctors and other medical professionals. As I have said previously, I am not generally in the business of supporting amendments that, in my view, overcomplicate issues, are ambiguous and could lead to other consequences or are simply repetitious, but I do not think that amendment 50 would do those things.

Some proposed amendments are featured in the Bill, either directly or implicitly, but I do not see how amendment 50 would overcomplicate or lead to ambiguity. It is a quite direct and, dare I say, common-sense ask that we should all support. I take the point made by the right hon. Member for North West Hampshire on proposed new subsection (2)(f) of clause 3, as inserted by amendment 50, though I confess I did not read it in the same way that he did. I read it as saying that anyone looking to go down this route should be made aware of the legal consequences. That is a sensible suggestion.

I do not expect a doctor would be going into people’s bank accounts or deeply understanding their legal affairs, but due consideration, advice and information should be imparted to the person who is applying. That is how I read it; I did not think it would be a hugely intrusive, in-depth study into a person’s personal finances.

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

Debate between Kim Leadbeater and Sojan Joseph

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[Kim Leadbeater]

Yes. It sounds as though you are saying that your professionals are trained to have those conversations, which is very reassuring. Glyn, do you want to add anything?

Glyn Berry: Just to say that I absolutely agree with Professor Ranger. My experience of working with palliative nurses, and nurses in general, is long, and I have historically had exceptionally positive experiences and continue to do so. I think that we learn from each other, and it is really important that we can have those conversations with the person and ask questions that they might never have been asked before, such as, “What is it that you want?”

Professor Ranger is absolutely right in terms of autonomy and the person having control, because once that diagnosis is given, it can be a downward spiral for a person and they feel that they lose control. Patients and families talk about that—about having no control over what is happening. In effect, that is true in terms of what is happening in the disease or illness trajectory, but it is so important to remind a person that they are still the person that they were before that diagnosis, that they will continue to be that person, and that they still have a voice. In both our roles professionally, and alongside other clinicians, that is what we seek to do all the time. That is why a multidisciplinary team approach is so important.

Ultimately, we could find that, once you have asked all the appropriate questions and you have put potential safeguards in place following conversations, a person may not choose that particular point to end their life—as you mentioned, Kim—and may continue to live to the end of their natural life.

[Sojan Joseph]

Q When the RCN Scotland director gave evidence to the Scottish Parliament during the discussion of the Assisted Dying for Terminally Ill Adults (Scotland) Bill, he expressed the RCN’s concern that there were not sufficient safeguards in place to protect nurses and nursing practice around assisted dying in Scotland. Are you satisfied that the Bill we have before us in England and Wales addresses those concerns, or would you like to see amendments to ensure that the mental health and wellbeing of nurses involved in the process are protected, should the Bill become law?

Professor Ranger: Yes, we would want to see more support and protection for nurses. Of course, in the exploring of assisted dying legislation in Scotland, the second clinical decision maker is a nurse—so it a doctor and a nurse, whereas in England and Wales we are looking at two medically qualified practitioners. We absolutely want to make sure that the skills and support is there for nursing staff, and the ability—as I heard our medical colleagues saying—to not be involved in assisted dying absolutely has to be supported. It cannot be an expectation of the role; it has to be something you choose to proactively take part in as a conscious decision. It cannot ever be just an expectation of a nurse. We are absolutely adamant about that. The Bill cannot just support the needs of medical staff—nursing absolutely has to be included within that, both in skills and support.