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

Naz Shah Excerpts

Committee stage
Thursday 30th January 2025 Public Bill Committees

[Dr Opher]

Q Just to confirm—you have not had any failures of treatment, as far as you are aware?

Dr Furst: There have been no failures of treatment in South Australia, as far as I am aware. I am not aware of any other particular ones around the country that have been heavily broadcast to us.

[Naz Shah (Bradford West) (Lab)]

Q To follow up on that, there is no requirement that the doctor is present when the person self-administers the substance that leads to assisted dying. Am I correct? If that is the case, why does the law not make it necessary for the doctor to remain present until death, because at that point, the doctor would pick up any complications, would they not?

Dr Furst: Every legislation within Australia is slightly different. For South Australia and Victoria, you are correct—well, there is pretty much no obligation all around Australia for a doctor to be present for self-administration. The reason for that is to give individuals autonomy over their death, and over the time and place of their choosing. We in South Australia do touch base with what we call the individual’s contact person to understand if there have been any complications and to check in after the death. A large number of our patients, though, will seek out support from a voluntary assisted dying nurse navigator, who is often present in the house just as a support person. We do also have a lot of feedback from them as to any complications, but the doctor often, or a nurse, will come at a later time to declare life extinct.

The reasoning was that we did not think that there would be complications and we wanted to give people autonomy. We work on a permit system in a lot of jurisdictions in Australia, so people have a permit; they get given their substance and they can take their substance at a time of their choosing. They might have the substance in their house for weeks or months, potentially. Again, there is no obligation to follow through with taking that substance, which we also think is quite important. We know that in Australia, about 30% of patients who have a permit or who are approved for voluntary assisted dying actually decide that they do not want to consume the substance, but it is about giving them that choice and autonomy, and the strength to maybe pursue other lines of therapy.

[Naz Shah]

Q We have had lots of witnesses testifying about gaps in palliative care and end-of-life care provision here in the UK. What is the current state of palliative care and end-of-life care provision in Western Australia, please?

Dr Furst: I am in South Australia, but a recent survey by Palliative Care Australia surveyed over 900 palliative care specialists, and more than 80% of patients receiving voluntary assisted dying are actually getting combined palliative care and voluntary assisted dying. In our legislation in South Australia, there are key provisions for the monitoring of the funding to palliative care to ensure that no palliative care funding is diverted to voluntary assisted dying, but we feel very strongly that palliative care and voluntary assisted dying should go hand in hand. That is a feeling that is being seen around the country now. Palliative care physicians who are finishing off training now see voluntary assisted dying as part of their core business. It is no longer seen as something that should be provided by separate practitioners. It is really becoming quite integrated.

Professor Blake: I am coming in from Western Australia. We were the second jurisdiction in Australia to introduce voluntary assisted dying laws. Ours have been operative since July 2021, so we have had the opportunity to collect quite a lot of data. Year on year, the number of people utilising voluntary assisted dying in Western Australia is increasing. In the year 2023-24, there were 292 deaths by voluntary assisted dying, which represented 1.6% of WA deaths. I agree with Chloe and confirm her view around the palliative care side of things: 83.8% of those persons who accessed voluntary assisted dying were also accessing palliative care.

[Sarah Green (Chesham and Amersham) (LD)]

Q On that point about palliative care, I will direct my question to Dr Furst. What has been the response from palliative care professionals to the introduction of assisted dying in Australia? We have heard evidence from people working in the sector in the UK, but I am keen to hear about your experience in Australia. I understand that Palliative Care Australia’s national workforce survey explicitly looked at this, so I am keen to hear what its findings were.

Dr Furst: It has been a journey, certainly. Victoria started their voluntary assisted dying in 2019. I would be lying if I said that the palliative care community were completely on board with it at that point, but over the last five to six years there has been a real shift in mentality. We have seen that they can go hand in hand. Palliative care is about end-of-life choices. Voluntary assisted dying is about end-of-life choices. It is about putting the patient and the individual front and centre, and working with them. That is fundamental to palliative care. We have realised that voluntary assisted dying is a promotion of palliative care and it gives back choices.

Probably some of the older palliative care clinicians have not embraced voluntary assisted dying quite as much. That is probably very generalised, but certainly new consultants and new doctors that are coming through really see this as something that they want to do. I do not think that there is any animosity any more between the practitioners that choose to work in this space and those that do not. I get huge amounts of support from other palliative care physicians that do not necessarily act as practitioners. There is no real divide. It has been embraced, to be honest. In another five years, I think there will probably be very few palliative care practitioners who do not support this, unless they are true conscientious objectors for their own reasons—I guess, probably religious reasons. Palliative Care Australia and the peak medical bodies in Australia have generally shifted to see this as part of patient choice.

Alex Greenwich: The journey to voluntary assisted dying in New South Wales, and indeed across every Australian state, has benefited palliative care access and funding. In New South Wales, 85% of people who have accessed voluntary assisted dying are receiving palliative care. As part of the process, the co-ordinating and consulting practitioners also advise them on palliative care. The doctors are trained on the latest advances in palliative care. Baked into the principles of our legislation is access to palliative care for all citizens of New South Wales. Importantly, throughout our debate, whether Members supported or opposed the reform, our entire Parliament came together to ensure palliative care received an increase in funding and any access issues were addressed. The Australian experience with voluntary assisted dying is that it benefits and strengthens the palliative care system.

Professor Blake: Can I can I add to that? The Voluntary Assisted Dying Board in WA, as in all the other jurisdictions, produces a report. The very strong sentiment of the Voluntary Assisted Dying Board, and indeed within the Western Australia community, is that voluntary assisted dying is seen as part of the end-of-life journey. The board’s report states that the statistics and experience of Western Australians

“confirms…that voluntary assisted dying is an established and enduring end of life choice”.

For that reason, there has been quite a significant awareness that practitioners should be able to bring up voluntary assisted dying with the patient as part of that suite of end-of-life choices. That has been something that the evidence has suggested is very important, because if the practitioners are feeling that they cannot raise it in that context, that is having a detrimental effect on the patients who would like information on it. That has been our experience in Western Australia.

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

Naz Shah Excerpts

Committee stage
Thursday 30th January 2025 Public Bill Committees

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

Q Dr Ward, I think the point about a holistic and evidence-based approach is critical. In the work that you did in the Scottish example you gave, how was the terminal illness definition arrived at? How are you capturing those people who are vulnerable and want to have an assisted death, but might end up limited in their scope and ability to access it?

Dr Ward: Look: assisted dying is the same as any other healthcare choice. It is always going to be limited. We are not going to reach everyone that we absolutely would want to. There are people who want to have this option and this choice who will not qualify under a terminal illness definition, but we have to draw the line somewhere. We looked at international evidence from Commonwealth countries that are very closely linked to Scotland and the UK. We drew the line with the definition that the person has an advanced progressive illness from which they are unable to recover and that will cause their premature death. For us, that demands the support of Members of Parliament in Scotland and the support of the public.

I really stress the fact that each jurisdiction has to legislate according to its own constitutional, societal, legal and cultural considerations, which is what we have done in Scotland. That is the definition that is working for us now. Previously, there were more liberal attempts that did not gain the support of the House. We believe that we have arrived at a situation that is very similar to the definition of terminal illness here in Westminster, and that is both safe and compassionate but also draws the line so that people who should not be able to access this do not.

[Naz Shah (Bradford West) (Lab)]

Q Professor Owen, yesterday Professor Allan House gave evidence and talked about capacity and coercion, and I want to pick up on some of the concerns. In all four of the jurisdictions that collect data on the issue—Oregon, Canada, Western Australia and Washington—between 35% and 59% of people cite being a burden as a reason for assisted dying. What do you think is the level of confidence of psychiatrists to assess capacity and consent reliably? What would your concerns be, if any?

Professor Owen: This is an essential question. I work clinically in the over-65 age group, where there is a lot of terminal illness, some of it in the last six months. You have to understand the population. The population is typically over 65 and frail. There can be a terminal illness, very typically with comorbidity. That comorbidity is often mental health comorbidity. Depression is at rates of 20% or thereabouts. Delirium and cognitive impairment is very common and often not picked up. There is patchy safeguarding, patchy access to social care and, as I know you have been hearing, patchy access to palliative care.

That is the ordinary person in the NHS. I know people who select into assisted dying are not necessarily that mean person, so to speak, but that is just a picture of what it looks like for me when I go to work. That is where one starts. Now think about burden. Well, this is a group that do feel very burdened. You might think some of that is excessive; some of it maybe is natural, given the life stage. So it is a mixed picture.

When it comes to pressure and coercion, I know you have been grappling with this a lot as a Committee, and I know there have been some amendments that address this. We have talked about clause 26 particularly in relation to this. Of course, when it comes back to the training question, you can take evidence on the state of safeguarding and how people are really able to assess coercive control, domestic violence and so on.

I would like to draw attention to something else that I am not sure has come so much to the attention of the Committee, which is not the offences or the criminal side of this; it is the common or garden capacity assessment side of it. This relates really to clause 1. It is the issue of how you deal with interpersonal pressures on somebody in a situation where there may be a mental health problem and there may not even be a diagnosis. You might be talking about a kind of cognitive impairment that has not reached the threshold for a diagnosis of dementia; you might be talking about a kind of mood problem or an anxiety problem that is sub-clinical; or you might be talking about a level of intelligence that is not clinically a learning disability. But it is there and it is interacting with a form of pressure within a family, let us say, which is often not malign in its intentions, but it exists. It is a very overvalued relationship, for example, with a strong sense of loyalty to somebody, or an enmeshment, for example.

What you have are situations where there is an impairment and also an interpersonal pressure. They interact and they amplify each other. That can have an important consequence in terms of the functional ability of mental capacity. Outside of the assisted dying context, when you look at that in the Court of Protection, which has been struggling with quite a lot of cases like this, that phenomenon of interaction that I am talking about between interpersonal pressure and impairment is recognised. It struggles with it. I have been involved in some research to try to structure the understanding of it, but it is not at the point where it is a kind of training manual that you can lift down from the shelf and roll out across the workforce. It is much more in a kind of research and development phase.

So it is important to draw attention to pressure not necessarily as malign in its intention, but which nevertheless operates in these situations and can have a subtle impact on the functional test of decision-making capacity. To bring us back to what the decision-making capacity is that we are talking about, it is the decision to end one’s own life.

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

Q Dr Ward and Professor Hoyano, we heard yesterday evidence about the interplay between assisted dying, the Equality Act 2010 and the European convention on human rights. Should amendments be made to the Bill to deal with those issues? What are your thoughts about the interaction between those pieces of legislation and the Bill?

Dr Ward: I heard the session yesterday and would agree with the comments that were made there, particularly around proportionality. Article 2 is an absolute right —the right to life—whereas article 8 is a qualified right. Again, it is about that balancing act. The courts have been very clear that we need to protect vulnerable people, and I feel strongly that the Bill straddles that very well by giving choice but in a very limited set of circumstances.

On the Equality Act, there have been some claims made—this happened in Scotland—that the definition of disability in the Equality Act would cover people who are terminally ill. That that is not my reading of it, and that position is widely shared by the people advising us in Scotland on the legal capacity. That is all I have to say.

Professor Hoyano: I would only point out to the Committee that the common law entrenched the human rights of the patient a long time before the Human Rights Act 1998. We must remember that we do not just have to look at the European convention and Strasbourg. The common law has been very active in entrenching fundamental principles of the rights of the patient, particularly their autonomy in decision making regarding their own body, since long before the HRA.

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[The Chair]

I call Naz Shah to ask the final question.

[Naz Shah]

Q Professor Owen, to follow up on the interaction that Mr Atkinson talked about, where are the gaps in research right now?

Professor Owen: There are a lot of gaps. Take that point as I intend it—I do not say it as a downer on this project; I say it because it is true. There are just a lot of gaps. We are going into uncharted territory, so you might think it would be good to have more of a map before we start. This is one area where there are evidentiary gaps. It is not clear how those sorts of interactions should be assessed, what sorts of threshold should be set or what kind of training should be available. There has been a lot of talk about training; training is all very well and good, but you need to know what the point and purpose of the training is. The training has to be valid before you can roll it out. There are lots of gaps here.

That relates to the question of mental capacity assessment. It is often said, “Why are we worried about mental capacity? We have so much experience of doing it in health and social care contexts; we have the Mental Capacity Act, the Court of Protection and all this experience.” We do, and that extremely important work has been done since the parliamentary discussions you had about the Mental Capacity Act all those years ago. In some areas, it is being done reasonably well: in relation to treatment and care residents’ decisions, one can talk about a body of professionals who understand the concepts, can do the assessments and can achieve, at least when trained, good levels of agreement, so you can get the system to work.

But in areas of decision making where the decision itself is unsettled or conceptually much more profound or novel—I would suggest that the decision to end one’s own life has those characteristics—you cannot expect there to be such levels of reliability. That can be shown empirically in other areas where the decision making is unsettled. The question of how well capacity assessment works is actually matter-specific. That should not surprise us, because the whole concept of mental capacity is that it is matter-specific. That is the whole functional idea of mental capacity. The matter here is of the decision making to end one’s own life.

[The Chair]

That brings us to the end of the allocated time for the Committee to ask questions. I thank the witnesses on behalf of the Committee for their evidence.

Examination of Witnesses

Professor Preston, Dr Richards and Claire Williams gave evidence.

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[Dr Tidball]

Yes.

Dr Richards: Maybe Nancy knows the evidence on that. Talking about gaps in research, I am an anthropologist, so I am interested in the discourse and the conversations that are happening, and I think there is a lack of evidence about that. We have a lot of evidence where it is tick boxes, for example, about motivations and procedure being following. We have less qualitative, in-depth, interactional evidence about that kind of holistic decision making.

Professor Preston: We have done some research where we interviewed doctors and healthcare workers who have had those conversations. The majority decide against it, but they are still having those conversations. We also heard the experience of the bereaved family, and what it was like to have those conversations. On the whole, the conversation is predominantly about palliative care—“Can we do something different? How can we meet and assess your needs?”

In some cases, the doctors in palliative care, particularly in Switzerland, certainly would never suggest assisted dying, but if the patient asks for it, they equally do not advise them how to get an assisted death. In some cases they said they sort of consciously blocked the conversation, so that the person timed out and could not have it. The emphasis is perhaps the other way in places like the Netherlands and Belgium, where it has been around longer and is much more integrated into other services, such as care homes and palliative care, as part of a holistic assessment.

I remember visiting a team in the Netherlands, and when they got a new patient they said, “We assess them for their preferences about whether they want to die, about resuscitation, about advance care planning and about euthanasia.” My jaw dropped; I was British—this was illegal. They do it in such a natural way. They said, “We need to plan that for them, because we need to understand what is right for them.” They are not suggesting it—they are just trying to take it on board. I would say that the predominance of the conversation is about palliative care, but if the patient wants the assisted death, they either might assist—which is rare—or suggest how they go to a right-to-die association. But more likely they will still tell them how palliative care can help.

[Naz Shah]

Q Professor Preston, in your written evidence to the Committee, you said that Parliament should:

“Consider whether there should be a stated exception to the usual presumption of capacity under the Mental Capacity Act 2005 in the Bill.”

What kind of standard do you think Parliament should consider adopting instead of the use of the Mental Capacity Act, and why do you think that?

Professor Preston: Again, this came from my colleague Suzanne Ost, who is a professor of law. As Naomi said, this is something very different from choosing to consent to an operation or even a research study. This is finite—it is a finite decision, so therefore the assessment should be a bit more. What I will say about mental capacity is that we had a PhD student who assessed mental capacity decisions by hospice care staff—particularly doctors, but also a lot of the nursing team who were making the decisions. She was a lawyer, and her conclusion was that it was incredibly well assessed. That was in terms of safeguarding—so, when people were going back to what we might consider unsafe homes—but that is what the person wanted, because their life was that unsafe home. I am talking about social deprivation and things like that. The people in this particular team were very good at assessing that and applying the Mental Capacity Act, according to her research.

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

Q Claire, you mentioned multidisciplinary teams and decision making. We have heard in a couple of other evidence sessions from palliative care social workers, nurse practitioners and the Royal College of Nursing about the multidisciplinary approach in care. What are your thoughts on the ultimate approval as set out in the Bill being a doctor, another doctor and then a legal okay at the end? Would a more multidisciplinary approach to approval have stronger outcomes or better safeguards?

Claire Williams: I absolutely agree that a panel/committee approach would have better safeguarding for patients, because the decision is being made collectively with legal expertise and with other healthcare professionals—that might be palliative—or ethicists like myself. It is having that collective view, ensuring that everybody is happy and that that is exactly what the patient wants. I believe it should be a committee/panel-based approach for the final decision. As I said before, expecting a High Court judge—just one individual—to make that decision alone is hugely burdensome and not an approach that we should be taking.

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[Dr Opher]

I think that my question has been covered by my hon. Friend the Member for Bexleyheath and Crayford. I just wanted to be sure that we were secure if the doctor was not in the room, but that has been answered.

[Naz Shah]

Q My question is to Dr Richards. I will get to where I need to get to, so bear with me. You talk about this being a very explicit conversation, but I would argue that that is not entirely true. We are talking about a set of doctors who will have opted in to have that conversation; not all doctors will do that. We have also had evidence from people suggesting that doctors and lots of other people would leave hospice care if assisted death was provided on the NHS. Yesterday, we had care providers telling us that if people engaged in providing voluntary assisted death, they would leave those hospices. So it is not quite as explicit as what you are suggesting, is it?

Dr Richards: It would have to be. Those examples that you have just given would not mean that it was not an explicit conversation.

[Naz Shah]

But it is not, because—

[The Chair]

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

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[The Chair]

Before we move to the next panel, is there anyone else who has pressing questions, or would you prefer to have a five-minute comfort break?

[Naz Shah]

Q Dr Richards, you were talking about elderly people in particular. We have heard evidence, particularly yesterday, about young women under 40 where terminal illness was deemed legislatively applicable to anorexia. It appears that that is quite a phenomenon. When we talk about the explicit conversation that you are suggesting, I would argue that it is not necessarily clear cut. Do you agree that there would be a risk there when it comes to people with anorexia?

Dr Richards: I do not really understand why the case of terminal anorexia would be different to any other case in terms of the conversation. It would be necessary to have a very explicit conversation with somebody requesting assisted death; it does not matter what their illness is.

On the issue of anorexia, the numbers are really tiny. In the Oregon model, which is what is in the Bill, you are talking about one or two people in the history of assisted dying. It is a very minor issue to get focused on. I have seen so much about this in the press and being discussed here. If you are very concerned about terminal anorexia, I am sure you could do some tinkering with the Bill so that people would not be eligible for assisted dying, but in terms of the empirical data in jurisdictions that have legalised the Oregon model, which is what this is, there are one or two cases.

This should not be given a huge amount of time, because it is a distraction from the fact that really we are talking about a new mode of dying, which is a cultural response. Just as palliative care is a cultural response to suffering at the end of life, so is assisted dying. It is a different track; it is offering something different. Different types of people will want to go for that. It is a response to the protracted dying trajectory that we see now, which is new. In the history of human dying, we have never taken so long to die before. There has never been so much medical intervention at the end of life, and assisted dying is a cultural response to that. To get fixated on the two people with terminal anorexia who have accessed assisted dying in the States is a bit of a red herring.

[The Chair]

Thank you.

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[Danny Kruger]

Q This is a question for Mr Malone. May I say how greatly I sympathise with what you have been through? I am very sorry to be fighting against you in this matter. I really can imagine how that feels. Thank you for what you said. I just want to ask about your sister’s experience. On the eligibility question, is it your belief that she would have qualified for an assisted death under the Bill, with the six-month terminal illness criterion? To follow up on that, do you think we should expand the scope to include people with motor neurone disease who might not fall within the six months?

Pat Malone: She would not qualify, because there was no telling how long she would live as a live brain in a dead body, as she said. It could have been months or even years, so she would not qualify in any case under this Bill. However, you have moved mountains to get to this point, so the last thing in the world I want to do is pile more requirements on the Bill. I would like to see some stuff stripped out of it, actually, to make it easier, but I am not going to ask for that because we desperately need to get away from the status quo. This Bill gets us away from the status quo.

[Naz Shah]

Q Thank you very much for coming today and sharing your stories. I have two questions. Julie, you said that you had family liaison and counselling. How long did that go on for? This Bill does not have that requirement, so do you think it is something that we should put in it?

Julie Thienpont: Maybe I said “counselling”, but it was not a session of counselling. It was somebody asking my opinion to check that I was 100% behind Guy. His son also did that by proxy—via us—because he was in a different part of Spain. They wanted to ensure that he had talked it over with family members. It was not hastened along, because he had been given a short life span, so it did not take terribly long. He had to wait about three weeks before the initial ball started rolling, and then two weeks later a family doctor and nurses from the hospital came round for form filling, reading through, translating and signatures, and again another two weeks after that. Each time, I believe it went before a panel. We did not, but the paperwork had to go before a panel. They were left in no uncertain terms that that was the way he wanted to end his life.

It was a very peaceful, serene and beautiful death, as opposed to what it would have been like. He was able to speak to his relatives in Australia, his brothers in Belgium and other family members, and I was able to hold his hand. Guy had always been a bit of an old cowboy, and he always said that he wanted to die with his boots on. I am proud to say that that is what he did. At the end, we were holding hands, and I said to him, “Don’t be afraid.” He said, “I’m not afraid,” and he winked at me just before he closed his eyes.

On the process, perhaps I should have said that it was intravenous, so he had a drip in each arm. It was quite a quick process—maybe 10 to 15 minutes, which I thought was quite quick—but we had had lots of time that morning, you know. It was a beautiful end—the wink especially. I am left with very good memories of such a peaceful death, which was going to happen regardless. He was at peace with it, so that helped me.

[Naz Shah]

Q Thank you very much for sharing such personal experiences. Liz, you talked about your brother, and going over, and how peaceful it was for you. We have heard lots of witnesses talking about people who have felt like a burden. I am glad that was not the case with your brother’s death. Would you support adding more safeguards to the Bill to make sure that we protect those who are at risk from coercion and who might not have capacity?

Liz Reed: I understand the big focus on coercion. It is very similar in Australia. The difference between the Queensland Bill, specifically, and the Bill proposed here is that, in the Queensland Bill, coercion is punishable both ways: you can be punished for trying to coerce someone into an assisted death but also for trying to change their mind the other way. Those safeguards are in place because you hear anecdotally from practitioners that, broadly, people are being coerced out of this.

In our experience, the day before my brother died our mum said to him, “Are you sure?” She was not trying to coerce him, but was she trying to make him go on longer? Absolutely. That is her son, and that is completely natural and normal. She did not want to see him die. His response was, “This isn’t living.”

[Naz Shah]

Thank you very much.

Pat Malone: As far as my brother and sister were concerned, there was no check for coercion. There needs to be, as in the Bill, but there are many more safeguards in the Bill than there are now. The people who are contemplating suicide now have no safeguards at all.

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[Dr Shastri-Hurst]

Q My question is directed to Dr Mulholland. Thank you to the Royal College of General Practitioners for the helpful written evidence. I want to pick up on something in it, which is summarised in paragraph 6 but gone into in more detail in paragraph 7, and that is around the refusal of practitioners to engage in the assisted dying process. I note the wording that has been used by the Royal College, which is that GPs and any other healthcare professionals can refuse “on any ground”. That is distinct from the Abortion Act 1967, which in section 4(1) sets out that it can be a conscientious objection. Can you explain why you have decided to take what appears to be a broader expansion of that definition, and why you have chosen that particular wording?

Dr Mulholland: We are aware that we have a range of views in RCGP across general practitioners. Some of them have very strong views for or against based on moral grounds, and some of those are based on religious grounds—traditional conscientious objection grounds. But others do not want to take part in assisted dying just because they do not want to; they do not feel it is part of what being a GP is, or part of what they trained for.

In discussion with colleagues today, someone shared with me that for 35 years they have spent their time trying to extend the life of patients—that has been our role—and to help them towards the end of life. It is a philosophical change if they start to think about whether the patient’s life should end earlier. There are some colleagues who may decide that for those reasons, they do not want to take part in this. There will be others who very definitely do. We have that range, so we feel that a doctor or a health professional should have the right not to take part on any ground, and that should be protected—they should not feel the obligation to do something that they do not feel is within their wishes.

[Naz Shah]

Q My question is to Dr Price. We heard yesterday from Professor House and this afternoon from Professor Owen, who were talking about capacity and coercion. They also talked about how different people’s life experiences impact their ability and their state of mind, and the lack of research or evidence in that area—the courts are grappling with those issues at the moment. Is there any evidence about the effect on patients’ mental health when they have a diagnosis of a terminal or serious physical illness?

Dr Price: There is a lot of research evidence around depression in people with palliative care needs and people nearing the end of life. We know that depression is common, and across a number of studies it is at around 20%—much more common than in the general population. We know that depression is strongly associated with a wish to hasten death, and that if depression is found and treated in that group of patients, there will be significant change in the wish to hasten death.

There are a number of associations other than depression with a wish to hasten death, and they include difficult symptom experience, poor functional status—needing a lot of help with things—and being socially isolated. Those are really key ones. They also include a sense of loss of dignity and feeling like a burden on others. These things can all come together to make life feel very unbearable. We know that there is also an overlap between a wish to hasten death, which is a response to suffering, and feeling that one is better off dead, ending one’s own life or harming oneself. I was involved in a study where we asked people both the wording of “a wish to hasten death” and the suicide question from the PHQ9, which is a depression screening tool. Those who had a wish to hasten death were 18 times more likely to also feel suicidal, according to the psychiatric definition, than people who did not have a wish to hasten death. There is a strong association.

[Lewis Atkinson]

Q My question is for Dr Price as well, please. We heard in the week from the chief medical officer earlier, who said that he was “relieved” that this Act based capacity on the Mental Capacity Act, noting that it already provides that

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

and that it is used in tens, if not hundreds, of life and death cases in the NHS every week. The example he gave was someone refusing blood products that they would need to continue their life. In the light of that, I suppose I am a bit confused about your evidence saying that the MCA is not suitable for life or death decisions of this type. Do you think the MCA is not fit for purpose for those current life or death decisions that are being made, or is there something about the life or death decisions that would be made in an assisted dying context that makes that different?

Dr Price: The assumption that the Mental Capacity Act can translate neatly into this specific decision without a really clear sense of what that would look like in clinical practice is something that needs more careful thought.

I was involved in research in this area, and one of the things that I did was to scrutinise the concept of capacity as discussed in a number of forums—for example, the Commission on Assisted Dying, discussions in the House of Lords, and also interviews with doctors in England and Wales and in Oregon. There is a broad sense of what capacity is. For some, it is a very tight, cognitive definition that would mean that in practice, in assisted dying, most people would be found to be capacitous. Those who advocate a much broader sense of what capacity is—these can be contained within the framework of the Mental Capacity Act—would advocate a much broader sense of what that is, thinking about values and the person’s life experience and making more judgments, really, about that person’s life in a general sense.

What I do not think we have really pinned down is what concept of capacity is operating in the thoughts behind this Bill. Is it enough to say that we will essentially refer to the Mental Capacity Act, or do we need to be more specific about what is capacity for this decision? Is it sufficient to say, “We will refer out”, or do we need it on the face of the Bill so that anybody assessing capacity for this decision knows exactly what they should be doing and exactly how they should be having that conversation? Even though you may be operating within a legal framework, I think that the actual conversation —the actual content—will vary across practitioners. Is that good enough? Is that sufficient? Is that a good enough standard? When I do a capacity assessment, I have in mind that it may be appealed against—that is somebody’s right—and it should be available for scrutiny by a court. Essentially, that is the standard we are looking for, so it needs to be clear where the standard lies.

--- Later in debate ---

[The Chair]

There are three people left who want to ask questions, so can I beg for brevity?

[Naz Shah]

Q Under clause 4(2), doctors would be allowed to raise the issue of assisted dying with a patient, unprompted. Dr Rachel Clarke gave evidence to this Committee that, in some circumstances,

“The very act of raising assisted dying in that way will make that vulnerable patient think, ‘God, is this doctor telling me that my life is not worth living any more?’”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 75, Q93.]

We heard from Dr Jamilla Hussain yesterday. She talked about mistrust of the NHS, particularly post-covid, where people had DNRs attached to them—disabled people and people of ethnic minority backgrounds in particular. Dan, are you concerned about the potential impact on people with learning disabilities?

Dan Scorer: Yes. One of the first things that I said earlier was about how the initiation of that first conversation is potentially an extremely risky and dangerous moment for people with a learning disability who are terminally ill. Your question is absolutely spot on, from the point of view that it could be highly suggestive and push people on a course that they may not want to go down. That is why I am suggesting that that initial conversation has to be incredibly well supported and structured.

There should, in our view, be an advocate who is supporting the person and preparing them for that discussion. Under the principles of the Mental Capacity Act 2005, the person should have accessible information in advance of that discussion so that they are fully informed about all their rights in terms of treatment options at end of life. That discussion with a clinician should not be taking place until the person has been able to consider that information and have support from an advocate, so when the conversation does happen the person is fully informed and has had time to think about what their wishes might be. That would reduce the risk, which is absolutely there, that people could take the initiation of that discussion as a statement, “This is what you should do.” We absolutely do not want people to be in that position. We want strong safeguards and support in place if the Bill becomes law.

[Dr Tidball]

Q Dan, I am really keen that we ensure that if the Bill passes, the voices of disabled people are continually involved in understanding its impact, particularly on the issue that you have just raised. Earlier, we heard evidence about implementation taskforces that are used in other jurisdictions. I am considering tabling an amendment on an advisory council. How might we ensure that the voices of people with learning disabilities can be included in such a body?

Dan Scorer: There are a couple of things that I would like to say in response. One is about clause 31, on guidance from chief medical officers. Immediately, I would say that people with a learning disability should be involved in the development of that guidance from chief medical officers. That guidance will be key to many of the issues that we have discussed.

Clause 35 is about the review of the Act. The lived experience of people is absolutely vital to that. The Bill says that it will be five years until we have that review. Our view is that that is far too long. If the Bill becomes law and if there are really serious issues and discrimination taking place against people, we will want to know that a lot earlier than in five years’ time, and we will want action to be taken. Our suggestion is that review should be earlier. We would want to see strong representation from patient groups across that, as well as from people who have been involved in the process, such as family members, advocates and clinicians, to make sure that if serious issues are being raised, they can be picked up early and addressed.

[Lewis Atkinson]

Q It is late, and I am far from being an expert on Welsh devolution, but I want to ask Professor Lewis a question, not least because we have not come to him for a little while.

Although it is not my area, I absolutely note the concerns and the discussion about respecting the democratic will of the Senedd in these matters. Would you suggest any potential avenues in the Bill to incorporate an element of positive affirmation by the Senedd, or its consent? What do you suggest we look at?

Professor Lewis: Formally, there is a need in any event for a legislative consent motion in relation to the specific bits I mentioned earlier, I have suggested one potential avenue, which is that the Senedd and Welsh Government take on responsibility for whether and when the Act commences in Wales. Another option might be to do a thorough “think once, think twice, think Wales” review to see to what extent other functions of the Secretary of State might be better exercised in Wales by the Welsh Ministers. That is a non-exhaustive list, but I hope it helps.

[Naz Shah]

Q Dr Price, you talked in your earlier evidence about depression. One Committee member suggested that 20% of people were on antidepressants; actually, the factual position is that 10% to 11% of the adults in this country are on antidepressant medication, according to the latest statistics. To be clear, are you saying that people who are depressed are more likely to ask for or go down the road of assisted dying?

Dr Price: The evidence that we have from research—this is in populations who would fulfil the criteria in terms of terminal illness—is that the prevalence of depression is around 20%. That is across a number of populations. It is associated with a wish to hasten death. Depression might impact upon that person’s decision making; I am not saying that it absolutely would, but it might. Also, treatment might change their view. We know that there is a strong association, for example, between pain and a wish to hasten death. Unresolved physical symptoms make people want to die, and when that pain is better, people no longer feel that way.

That is borne out in my clinical practice. We will get urgent referrals to see somebody who wants to die and who they are very concerned about. Then the pain is under control: we see them that day or the next day and they say, “Do you know what? The pain’s better. I don’t feel like that any more.” When we think about symptoms, we need to think carefully about what is treatable and what is remediable. That may be about psychiatric interventions, but it is often about a biological, psychological and social approach.

[The Chair]

May I thank the panel for giving evidence today? We really appreciate your attendance.

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

Naz Shah Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[The Chair]

We are now sitting in public and the proceedings are being broadcast. Before we begin, I remind Members to switch electronic devices off or to silent. Tea and coffee are not allowed during sittings. Before we start hearing from the witnesses, do any Members wish to make declarations of interest in connection with the Bill? No.

We will now hear oral evidence from Professor Sir Chris Whitty, chief medical officer for England, and Duncan Barton, chief nursing officer for England, NHS England. Before calling the first Member to ask a question, I remind Members that questions should be limited to matters within the scope of the Bill. I also remind Members that time is tight, so please keep your questions to the point. We must stick to the timings in the sittings resolution that the Committee has already agreed. For this session, we have until 10.05 am. Will the witnesses please briefly introduce themselves for the record? If you are to give an opening statement, please keep it short.

Professor Whitty: I am Chris Whitty, the chief medical officer for England, and I am also representing the chief medical officer for Wales. One statement, which is on behalf of Duncan and myself, and all the CMOs, is that we are completely neutral on the principles of the Bill, which we consider are entirely for society and therefore for Parliament. Although we are answering technical questions, we will not be answering questions of principle, because we feel that is a societal question. We have made it clear to the medical profession, however, that individual doctors should be able to make whatever statements they wish. Obviously, doctors have strong views on all sides of this argument, as members of society do.

Duncan Burton: Good morning. I am Duncan Burton, the chief nursing officer for England. For transparency, I will say that I am also a volunteer trustee of a hospice.

[Naz Shah (Bradford West) (Lab)]

Q Sir Chris, I draw your attention to clause 42(3):

“But if any provision of this Act has not been fully brought into force before the end of the period of 2 years beginning with the day on which this Act is passed, that provision (so far as not already in force) comes into force at the end of that period.”

My question is: do you believe that it would be safe to implement this legislation if those provisions had not been fully put in place?

Professor Whitty: If this Bill is passed—I want to stress that; I will say it once, but assume it applies for all the answers I subsequently give—we will clearly need both: a period to make sure that there is technical guidance and legislation, via secondary legislation, because obviously the primary legislation is the Bill; and necessary training for people to be able to do this in an appropriate and dignified way, if that is what Parliament chooses.

[Naz Shah]

So would it be safe?

Professor Whitty: We would want to have the time to do that, but you can do things at speed if you need to. My view is that this is something that is best not done at speed if we can avoid it.

[Naz Shah]

Q I am a former NHS commissioner, Sir Chris. In Bradford West, we have stark health inequalities. Dr Jamilla Hussain, as part of John Wright’s team, will be providing evidence this week. She has found huge mistrust among marginalised ethnic groups—even more so since covid. We know that covid brought to light the inequalities in healthcare access that already existed, especially for economically disadvantaged communities. What lessons do we need to learn from covid and its disproportionate impact on ethnic minority communities when it comes to this Bill in particular and its implementation?

Professor Whitty: That is an absolutely critical question, because it is very important that if the Bill is passed, all parts of society, of whatever ethnicity and of whatever background, have equal access to the Bill—or not, as Parliament determines. That will require adjustment in a variety of ways. Some can be done at a macro level—for example, making sure that everything is translated into the major languages spoken in the United Kingdom—but a lot of it will be to do with the individual interactions that doctors, nurses and other healthcare providers have with individual patients, which must take into account their own starting point, their own knowledge and, most importantly, their own beliefs.

[Lewis Atkinson (Sunderland Central) (Lab)]

Q Sir Chris, you mentioned having time to ensure that people are appropriately trained, and the Bill includes provisions for the Secretary of State to make orders around required training. Could you say a little bit more about that? If Parliament decide to pass an Act of this nature, what training would be helpful and required—in particular around skills, and the assessment of capacity and coercion?

Professor Whitty: I will give my view, and it might be useful to get Duncan’s view on the nursing side, because nurses will often be heavily involved in these discussions.

I would divide the kind of training that is needed into two broad groups: training that is essentially normal medical practice but may need some variation, and things that are clearly specific to this Bill. Issues, for example, around mental capacity—as determined by the Mental Capacity Act 2005—are dealt with every day, in every hospital up and down the country; every doctor and nurse above a certain level of seniority should be able to do that normally. It may require some slight adjustment. There is an absolute expectation within the Act, for example, that the more serious the decision, the greater the level of capacity that someone needs to have. That is already built into the principles of the Act and the way that things are done. I would extend that to the management of end of life, which should be a normal part of medical and nursing practice—we will all die eventually, and that has always been part of medicine, and always should be. That training should be generic, but may need some adaption.

There will then be some specific things that will be necessary for people to understand the legislation, including, in some cases—if this Bill is passed—if they are to take part in the final part of prescribing drugs to patients. It is much more likely that a very large number of doctors and nurses may get involved in the very earliest stages, because someone may raise an issue with their GP, nurse or consultant, who will need to have the basic understanding for that. In my view, the more detailed later stages will require some specific training. I think there will be a gradation of doctors: those who are happy to have the general, initial conversation; those who are happy to have the structured conversation that follows; and a minority who will be happy to go on to take part in the final stages.

It is very important that the wishes of the patient are respected. That is the central point of this. We must start with what is good for someone in their last six months of life, and for their immediate family, but we must also make sure that the wishes of healthcare professionals around this area are absolutely protected, when it comes to conscience and to choice.

Duncan Burton: I am mindful that there are two groups of staff who would potentially be working in this service, if the Bill is passed, but also of the wider workforce. At 2 o’clock in the morning, when a patient wants to have a conversation with somebody about end of life, it is going to be a nurse with them, or a nurse in a care home, or a specialist nurse providing cancer care, so we have to think about the training and support that is required for them, be that around signposting or explaining where they can go to access more information. There is an important part about the entire wider workforce that we need to think about.

Clearly, for those people who are working in such a service, we need to think about the safeguarding elements, and how we make sure there is support through safeguarding training and confidentiality—particularly mindful that some patients may choose not to tell their families about this. We need to think about how we enable and support staff in managing those kinds of circumstances and navigating the legal requirements through the Bill. We need to think ahead about what we need to do in undergraduate training for doctors and nurses, and in the curriculum.

--- Later in debate ---

[Lewis Atkinson]

Q So you would be happy if there was an explicit prohibition on recommendation.

Dr Green: I am reluctant to make a statement on that in this forum. We will go away and discuss it, and come back to you.

[Naz Shah]

Q This question applies to both of you. On there being a first doctor and a second doctor, the first doctor is required to determine that the patient has a terminal illness, that they have capacity, and that they are not being coerced or pressured. Again, it is for the second doctor to make sure that the patient has a terminal illness, that they have capacity and, again, that they are not being coerced or pressured. I appreciate that Sir Chris Whitty talked about doctors, and you talked about everybody, being trained in capacity and coercion issues, but those doctors may never have met in the first instance the person who is seeking assisted dying.

The question that worries me is, to be able to fulfil all those actions in all cases, without fear of mis-determining, the two doctors would have to be specialists in all the relevant diseases. For example, if somebody has a brain tumour, lung cancer, or a different type of cancer, would the doctor have to be an expert in that to determine that the person is terminally ill?

From the GMC’s point of view, would we find ourselves in a situation where doctors are working outside their professional competencies and expertise? From the BMA’s point of view, how do we protect doctors from finding themselves having to diagnose life expectancy for a disease they are not a specialist in, or to determine capacity when they are not a specialist in that, or to determine a lack of coercion when they potentially do not know the patient and do not have experience of that? Finally, when the next step is taken and the court has to rely on the testimony of these doctors to protect the patient, can those testimonies safely be relied on by a court and by a judge, given all those concerns?

Mark Swindells: There are quite a few points there—let me work through them backwards. We have some existing guidance for doctors when they act as a witness—for example, in a court setting or a medical legal situation—that talks in general terms about the importance of being an appropriate witness. Inherent to that is some expertise and understanding of the topic they are assisting the court on. I suppose that those sorts of principles would be ones that, if the Bill is passed in this form—I say again, the GMC does not have a view on what the delivery mechanism or the Bill should look like—are applicable points from the guidance, which would read across.

You heard from the chief medical officer his caution with regards to going with a condition-based assessment for this sort of thing. We would not have a particular view on that, but there is one thing that I want to highlight. The Bill talks about specialism in the context and seeking advice from a psychiatrist. On the specialist register held by the GMC, there are five specialisms connected with psychiatry, so some clarity—whether the Bill is intended to cover any, or a particular one, of those—would be good.

I know that it is not restricted in the “independent doctor” and “coordinating doctor” roles in the Bill either, but we are aware that when doctors pursue a specialty, in the sense that they become accredited and go on to our specialist register, that does not fix in time their individual scope of practice or expertise. Many doctors will go into slightly different fields, or focus on one particular area, so one cannot necessarily rely on the specialist register as a current indication of a doctor’s area of competence in that way. On what the precise delivery mechanism is and the point you make about whether either of those two roles of doctor have seen the person, because we have not taken a view on what the law should be, we have not taken a firm view of any process or eligibility, but I note the point.

Dr Green: If I may, I will clarify my previous answer, having had a little more thought. I do not believe that it is ever appropriate for a doctor to recommend that a patient goes through an assisted dying process. My internal thoughts on whether it should be on the face of the Bill, contained in guidance or contained in good medical practice was the point that I was unsure about.

[Lewis Atkinson]

indicated assent.

Dr Green: With regard to the specific questions, no, I do not believe that a doctor has to be a specialist in the individual disease at stake to advise a patient about prognosis. I can only refer you back to what Dr Whitty said: that in the majority of cases, it is fairly clear—this applies to capacity, too—but in some cases, it is not so clear. What is important is that the doctor has the ability to seek further advice if they need it; it is not always required.

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

Naz Shah Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[The Chair]

Members should indicate if they wish to ask a question and who they wish to ask.

[Naz Shah (Bradford West) (Lab)]

Q Thank you very much for those introductions. I have a few questions for each person on the panel. Mr Sanderson, do you think palliative care in this country is fit for purpose?

James Sanderson: There are clearly gaps in the provision of palliative care. However, to start with a positive, I think that the provision of palliative care in this country is exceptional. We are leaders in many ways across the world in the way in which we support people who are facing those challenges in their lives. However, our findings in relation to palliative care show that, although about 90% of the population could benefit from palliative care, only 50% of people are currently able to access it.

One of our concerns is that the provision of palliative care across the country is quite patchy at the moment. I do not think there has been a thorough assessment of the level of palliative care in place—not just the provision of palliative care specifically, but how other services, such as district nursing services, interact with palliative care. In some areas, the provision of district nursing services for general care and support for people who may be at the end of their life is very strong and in other areas it is not so strong.

At Sue Ryder, there is one thing that we are really concerned about. In our survey, 77% of respondents said that they were concerned that the lack of availability of palliative care might enable more people to consider an assisted death than otherwise would. That concern went up to 84% for those who were in favour of assisted dying. We really need to look at the provision of palliative care and the specifics in the Bill that make reference to the fact that people should be offered what is available to them. We need to have a much clearer definition of what “available” means.

[Naz Shah]

Q Dr Ahmedzai, in the evidence you submitted, you said:

“I have studied the reports from, and spoken with medical and nursing clinicians from US and Australian jurisdictions and am satisfied that external coercion has never been reported or led to a prosecution.”

The state of Oregon carried out a survey of people who died under its assisted dying scheme in 2023. Its report stated that 43% of those who chose to die said they did so because they felt they were, and I quote directly from the term used in the survey, a

“Burden on family, friends/caregivers”.

Is that something you are prepared to see happen in the UK?

Dr Ahmedzai: It goes absolutely to the core of being British—we are always saying sorry, aren’t we? We apologise for everything. In everything we do, or everything we might do, we think we might be treading on toes and are always worried about being an imposition. All my professional life, I have come across patients and families in which there clearly is that feeling going on, usually with an older person or even a younger person who is drawing a lot on the emotional and physical resources of the family. It is natural that we feel a burden; it is impossible to take that out of human nature.

The issue is, does feeling that one is, or might become, a burden something that could influence a decision as major as looking for assisted dying? In that respect, I look to all those jurisdictions that have been offering assisted dying in different ways, and I have never seen a single case ever taken to the police or prosecuted. Evidence I have heard from other jurisdictions shows that, yes, it is possible—we all go through life feeling that we are a burden on someone—but it does not influence people in this particular decision. If anything, I am told that, in other jurisdictions, families are saying, “No, don’t do it.” They are exerting negative coercion—“don’t do it” coercion—but people are saying, “No. It’s my life. I’ve made my mind up.” They have mental capacity, and we respect that.

[Sean Woodcock (Banbury) (Lab)]

Q Coercion is one of the main issues that people who are concerned about the Bill raise in opposition to it. That would include myself. We had many distinguished witnesses this morning, and the view was that coercion is “rare” in healthcare generally. It was almost given across that we did not need to worry about it, because staff are so well trained in safeguarding and so on, and they have such a level of experience. What are the views of the panel on that? Is coercion something that we should really not be so concerned about?

Dr Clarke: Based on my clinical experience, I would push back on that in the strongest terms. I am the kind of doctor who believes there is nothing to be gained from sugar coating reality. We have to be absolutely honest with patients and the public about shortcomings, failings and areas where my profession and the rest of the NHS are getting things wrong.

It is my clinical experience that not only are the majority of doctors not necessarily trained in spotting coercion explicitly, but they are often not trained explicitly in having so-called advance care planning conversations with patients around the topic of death and dying, and how a patient would like the end of their life to proceed. It is almost impossible for me to overstate how much avoidable suffering occurs right now in the NHS not because of a lack of resources for palliative care—although that is an enormous problem—but because of a lack of confidence, skill and expertise among the medical profession writ large with these very difficult conversations.

We are all familiar with the idea of death and dying being a taboo in society. People are scared of it, and they hesitate to bring it up with their friends and family. In my experience, many medical students and doctors also suffer from that anxiety. They are scared, and they find it a taboo subject. What that means is that sometimes coercion occurs because the doctor—the consultant responsible for this person’s care—will not even bring up the fact that they think the patient is dying, because it is an uncomfortable conversation. Conversely, I have worked with senior hospital consultants in the NHS who have deliberately prevented our team from accessing their patients, because they believe that the hospital palliative care team wants to kill the patients, and that if I go and see the patient, I will give them a lethal dose of drugs.

These are the kinds of extraordinary misunderstandings and failures to prioritise patient autonomy that are happening now. That is even before we get started on conversations around whether someone would like to consider assisted dying, so it is a huge problem.

--- Later in debate ---

[The Chair]

Q We will now hear oral evidence from Sir Max Hill, former director of public prosecutions, Alex Ruck Keene, a barrister specialising in mental capacity, and Sir Nicholas Mostyn, who is a former High Court and Court of Protection judge. For this session we have until 4.15 pm. We may be interrupted by a Division. Could the witnesses please introduce themselves for the record?

Sir Max Hill: Good afternoon. I am not sure how much by way of introduction you want, so please stop me. I was the UK independent reviewer of terrorism legislation 2017-18, and the director of public prosecutions 2018 to 2023—so I stopped 15 months ago. I am not a campaigner; I am here to bring any experience of criminal casework that I may have picked up along the way, as that was part of my diet as DPP. I have been quite close to the construction of the Bill, and I am happy to deal with any questions that I can.

Sir Nicholas Mostyn: I am Nicholas Mostyn, and I was a judge of the High Court family division, of the Court of Protection and of the administrative court until 2023, when I retired with the onset of Parkinson’s disease—which is a genuine slippery slope, unfortunately. I am now a podcaster and devoting myself to alleviating the hardships of people living with Parkinson’s.

Alex Ruck Keene: I am Alex Ruck Keene. I am a barrister in independent practice, and I need to emphasise that I am giving my evidence as a self-employed barrister, not on behalf of any organisation I am associated with. You will have seen from my written evidence that I am associated with quite a few different organisations, because my practice and career straddles both advising and appearing in court cases involving mental capacity. I teach law on the end of life as a professor of practice at King’s College London. I am also heavily involved in law reform in different ways; for instance, I was the legal adviser to the Independent Review of the Mental Health Act 1983. I also do an awful lot of training in the context of mental capacity of both healthcare and social care professionals.

[Naz Shah]

Q I have just one question, and it is for Sir Max. You have said that you were very concerned about the CPS, during your time at DPP, having to investigate people who accompanied their loved ones to Switzerland to end their lives. I share that concern. However, my understanding is that around half of those who currently visit Dignitas would not qualify for assisted dying under the Bill, because they do not have a diagnosis of six months to live. Is the Bill the right measure to solve the problem that you are actually worried about?

Sir Max Hill: If the problem is anybody in future going on their own or accompanied by their loved ones to Dignitas, the answer is no—this Bill does not satisfy that. What we have learned from other jurisdictions around the world, where we see broader or multiple groups beyond the terminally ill who are entitled to use new legislation, has not been the model for this legislation, unless you and Parliament were to dramatically change it. The nuanced answer to your question is that this Bill does provide an opportunity for those in the category of being terminally ill, as defined in the Bill, to no longer have to resort, on their own or supported by loved ones, to going to Dignitas. So, yes, it can and will make a positive difference.

I should add, in answering this question, that my often-quoted personal experience is that 27 cases investigated as assisted suicide came across my own desk as the DPP —five to six cases a year. A substantial proportion of those cases did involve Dignitas, because an accompanying relative who had returned alone was then investigated, but a proportion did not involve Dignitas at all, because there had been deaths at home. Of all those 27 cases, I made the decision to prosecute in only one, which was the case of an individual who was 19 years of age encouraging another teenager to end their life. That was a correct and successful prosecution.

I will also add—because until 15 months ago I was a prosecutor, and prosecutors look to bring criminal cases whenever the law is broken—that there was an additional handful of cases in which, although I was not making the personal decision, I supported authorisation of charges for murder or manslaughter where it was clear that an individual’s life had been brought to an end not at the time of their choosing. It is perhaps important to remember that this Bill, as and when passed—that is a matter for Parliament—would not truncate the homicide jurisdiction in this country. It will still be possible to prosecute for murder in those cases when one would expect to be prosecuted for murder. I think it is important to say that, as a very recent former prosecutor.

[Naz Shah]

Q Following up on that, in the cases in which you authorised prosecution for murder or manslaughter, were issues of coercion ever involved? What were the bold points—the top lines—of those prosecutions?

Sir Max Hill: That small handful of cases involved an elderly couple where either he—it was usually a he—or she had chosen to bring to an end the life of their lifelong partner and, once that act had been carried out, claimed that it was an assisted suicide in circumstances where the surviving partner was merely carrying out the wish of the person now dead. There are a handful of cases in which that is clearly wrong and should not be accepted and where murder should be the offence brought before the court.

The point, though, is that throughout the time that I served as DPP—and, indeed, the time served by all my predecessors—we did not have the coercion offences created by the Bill, which I suggest would be a significant advance, and nor did we have a legal system in which the investigation was taking place before the death. It was the other way around. In each of the 27 cases I considered, the deceased individual was already dead, and that is when the scrutiny started. The major advantage of the Bill, if I can put it that way, is that that will be reversed, and scrutiny will be before death. In the case of coercion, where it fits the new potential clauses, prosecutions can—and, I am sure, will—be brought.

[Dr Tidball]

Q It is extremely helpful to understand the opportunity for scrutiny before death. Building on that point, are there any safeguards around those practices that are not currently included in the Bill but should be, particularly around detecting coercion and exploring alternative care options? I also have one follow-up question, if I may.

Sir Max Hill: I think that coercion and the coercion clauses in the Bill should be read alongside the capacity clauses. What we are looking for, as required by clause 1(1) and clause 1(2), is a clear, settled and informed wish, voluntarily made without coercion or pressure. Those aspects were taken, at least in part, from the Crown Prosecution Service guidance on 1961 Act cases. Capacity involves understanding information, retaining it, using it and communicating it. If those hallmarks are not there, you may be in a situation where you should be considering coercion. I think you read the two together.

To answer your question directly, the criminal liability clauses—clause 24, and the new offences in clauses 26 and 27—are robust. As a matter for your scrutiny, they are aspects that we do not have in the law at present. There is, of course, the addition of clause 36, under which you cannot be a witness or a proxy to the procedure that is enshrined in the Bill if you are too close to the terminally ill person. That is another hallmark of the Bill that will hedge against coercion.

--- Later in debate ---

[Danny Kruger]

Q I will just jump straight to my final question. Dr Kaan, you said that you felt that people who felt they might be a burden were exercising their autonomy, and it was a perfectly appropriate reason to seek an assisted death. Is that right, and do you think there is anything more we should do to make it easier for people to access this right? Do you think they should be asserting anything other than their wish to do so?

Dr Kaan: You characterised it correctly in that I think that for people who have capacity, and who are making the decision to have this as an option, a part of their reasoning is that they want to save their family from an onerous caregiving experience. I think that is their right and it is part of their value system.

Of course, if that is the only reason, we are going to be exploring that. As Dr Spielvogel has said, that is a red flag. We are going to be exploring that, and exploring whether acceptable alternatives exist and what are the resources that the person may not be aware of. That is always part of the discussion. These discussions are always broad and multifactorial. But I think it is appropriate and okay for somebody to say, “I do not want my family to experience what I myself had to experience when I was caregiving for my elderly parents with dementia.” I have heard that many, many times. I do think people who have capacity should have their autonomy respected, in terms of the values that are driving them to make this decision.

We always want to work towards improving the social support for caregiving that exists in our society. There is certainly a lack of it here in the US, and probably there in the UK as well. Hand in hand with allowing people to make an informed decision about the option of having an assisted death, you should also be a strong advocate for social support and caregiving services at the end of life, because those really are important and needed.

[Naz Shah]

Q Dr Spielvogel, there is a Bill in California, SB 1196, which was introduced on 24 February 2024. It proposes, first, to remove the six-month terminal illness prognosis and allow requests from those with a “grievous and irremediable” disease causing unbearable suffering; secondly, to allow dementia patients to request assisted suicide if two doctors deem them to have capacity; thirdly, to allow self-administration of lethal drugs via intravenous injection; and, fourthly, to eliminate the sunset clause in the current law. Do you know what the status of that Bill is? Is it still live? It suggests a significant broadening of the law, which would have similarities to that in Canada, and it would seem to reinforce the slippery slope argument.

Dr Spielvogel: That is a good question. I do not know the specific status of the Bill, but I would assume that it has itself undergone an assisted death at this point. That Bill is not really being supported by any of our advocacy groups or, by and large, the physicians who perform assisted dying, because it is, as you mentioned, very broad and not aligned with how we feel standard practice is going and where we would want it to go. That Bill did not receive support from many of us.

[Naz Shah]

Q In California—we are talking specifically about renal failure—they have got a six-month limit, in some cases, because of insurance policies. Is that being broadened out? I understand there is a huge difference in American politics in the laws regarding lobby groups, and so on, and the influence of those insurance companies. We have an NHS to which those restrictions do not apply. Have you done any analysis on that? How would you respond to that?

Dr Spielvogel: Can you clarify what you mean about kidney disease and the six-month prognosis, and the interplay with insurance there?

[Naz Shah]

Q When it comes to renal failure, in particular, there are people who can request assisted dying because their insurance company will not pay for more than six months. Here we have an NHS, in which there is no limit on the kind of interventions you would have to live a longer life.

Dr Spielvogel: That is not factually accurate. When people go on dialysis, they automatically get Medicare, which is our version of the NHS, more or less. That is a national health insurance for people who are 65 and older or who have certain kinds of diseases. When you have end-stage kidney disease and you need dialysis, you automatically get Medicare and you get dialysis for the rest of your life, however long that is. People are often on dialysis for years. It is not that you are on it for six months and then you are off.

[Naz Shah]

Q Does that cover all conditions?

Dr Spielvogel: We were just talking about kidney disease.

[Naz Shah]

Q Yes, but does it cover any conditions that would fall under the scope of a six-month bill?

Dr Spielvogel: If you have a six-month prognosis to live, regardless of the condition, that would fall under this. That would make you eligible. That has nothing to do with insurance coverage for your condition. Insurance coverage is completely separate. It is not tied to this. All that prognosis does is to allow the individual to seek this care.

[Naz Shah]

Q Sorry, but just to clarify, the question was: would the availability of Medicare apply to all those conditions that come under the six-month prognosis? As for kidney failure, would they be entitled to Medicare? Would all the other conditions included also be entitled to Medicare once the insurance ran out?

Dr Spielvogel: No. Insurance does not run out. There is maybe a misunderstanding of how medical insurance works in the US. Medical insurance does not run out. I think we are talking about two different things.

[Naz Shah]

Q But there are cases where insurance companies would stop paying for the treatment of the individual. Am I right?

Dr Spielvogel: No, I actually do not think that you are right. When we are talking about lifesaving interventions such as chemotherapy or dialysis, that is not correct. They are bound by law to cover all things that are medically necessary. They do not say, “You have gotten six months of chemo. We are not paying for any more.” That is not how it works.

[Sean Woodcock]

Q It seems clear from what you are saying that in your view, coercion is rare, or at least it is rare in comparison to familial pressure not to go ahead with assisted dying. It does sound, though, like you are saying that it is more common for people to say that they feel as though they are a burden towards the end. I think Dr Kaan said it was common, or certainly less rare than coercion to go ahead with assisted dying.

We heard from experts earlier about the paucity and lack of provision of care across the country. Certain people can get access to very good care, but too many people struggle to, particularly people of certain ethnic backgrounds, people on low income, and so on. Please correct me if I have misinterpreted your views, but from what you have said so far, it sounds as if you think that exercising the right to assisted dying because there is a paucity of appropriate care in your locality, or because you cannot afford it, is a perfectly legitimate exercise of autonomy, based on the society around you. Would that be a fair assumption of your views?

Dr Kaan: I think that is not an entirely fair representation of what I am saying. Yes, we do need respect for people’s autonomy and the reasons they may come to this choice, but I also think that from what I have heard this morning, it sounds like there is a conception that people choose assisted dying and then they do it. What I see, by and large, is that people want to have this as an option. It is an option among the other options of hospice palliative care or palliative treatments. The availability of this as an option often brings people tremendous relief from their suffering—just from the anxiety over how they might die, or what suffering might be in store.

I had a case of a woman with ALS, or amyotrophic lateral sclerosis. She was very afraid of how she might die with that condition, and she felt like she might suffocate to death. She was so focused on having the option of aid in dying because she was terrified of what might be in store for her. We were able to incorporate her into a hospice that offered comprehensive end-of-life care, including the option of aid in dying. We got her through the process, we had the medications available and she told me how much relief she felt from having it as an option, but ultimately she decided not to use it. She decided that she was getting really good care from her palliative care and hospice teams, and that her symptoms were well controlled. Although she was extremely grateful that she knew the medications were available should she decide to use them, she did not end up needing to use them or wanting to use them.

That is the reality of what is happening in a lot of cases where this is an option among other options. The availability of this option is, in and of itself, a palliative care treatment for many people. On whether or not wanting to avoid being “a burden” to a family member or to a caregiving team is a valid reason to pursue this, yes, I think that is a valid reason among many for people who have a value system that highly orders that.

Dr Spielvogel: I just wanted to add something, if I may. I have heard this argument—or rather, this concern—a few different times, and it strikes me as what is called a false dilemma logical fallacy: that there is either/or, when in reality there are many alternatives that people can choose from. Saying “If we don’t have all of these types of care, we shouldn’t offer this option” is like a hospital that does not have sufficient amounts of IV pain medications saying to a labouring woman, “Well, we don’t have enough IV pain medications, so we are not going to offer you a labour epidural, because that is a false choice.” That does not actually make sense.

Look at it from a patient’s perspective. Think about a patient who is dying from terminal cancer, is in lots and lots of pain and does not have any good options for their pain control. Imagine saying to that person, “We don’t have all of this care or this option over here available to you, so we are not going to allow you to have an assisted death”, even if they are telling you, “This is what I want. Why won’t you give this to me?”. It does not make sense to remove this as an option just because all of the options might not be available to everyone all of the time. It is a bit cruel when you think about it from a patient’s perspective.

--- Later in debate ---

[Kim Leadbeater]

I beg to move amendment (a), in the list of witnesses set out in the table in the Sittings Motion agreed by the Committee on 21 January 2025, after Mencap (Thursday 30 January, until no later than 5.00 pm), leave out “Representative of Senedd Cymru” and insert—

“Professor Emyr Lewis (Emeritus Professor, Department of Law and Criminology, University of Aberystwyth), Royal College of General Practitioners, Royal College of Psychiatrists.”

These amendments allow additional witnesses to be called to give oral evidence, including representatives from Disability Rights UK, the Royal College of General Practitioners, the Royal College of Psychiatrists, and an expert in Welsh devolution and constitutional matters.

As the sessions today have shown, hearing from expert witnesses is an extremely important part of this process, so I hope I have the support of the Committee in making these additions. On the motion to call additional witnesses tabled by my hon. Friend the Member for Bradford West, I respect the suggestion but I am confident that we have an eminently qualified witness to cover issues of coercion and domestic abuse in Professor Jane Monckton-Smith, who was suggested by my hon. Friend.

We have also heard today—and will hear from many witnesses over the next few days—from medical doctors, social workers, nurses, palliative care experts and geriatricians. That is around 50 witnesses in total. While I fully appreciate that a wide range of additional charities and organisations has valuable contributions to make, I would encourage them to submit written evidence so that the Committee has the benefit of their thoughts.

Regarding the start of the line-by-line scrutiny of the Bill, given the huge volume of evidence—both oral and written—that we have received and are still receiving, I have consulted with colleagues across the Committee and there is a consensus that having next week to absorb and evaluate the evidence, and to prepare any amendments in light of it, is extremely important. Consequently, we would begin line-by-line scrutiny on Tuesday 11 February, as per the amendment.

I hope that these amendments demonstrate the robust approach that the Committee and I are taking to our work, and I encourage colleagues to support them.

[Naz Shah]

I beg to move an amendment to amendment (a), at end insert—

“Richard Robinson, CEO of Hourglass, Cherry Henry-Leach of STADA, Standing Together Against Domestic Abuse ”.

I completely agree with my hon. Friend the Member for Spen Valley and I am grateful to her for adding Professor Jane Monckton-Smith to the witness list. I also absolutely agree that the evidence we receive is really valuable.

This is an amendment tabled yesterday by the Mother of the House, my right hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott) yesterday, to which I have added my name.

The reason for the amendment is that Hourglass focuses on domestic abuse of older people and it has particularly noted that the majority of such victims are female. Hourglass estimates that one in six elderly people are victims of coercion in the UK. This raises serious concerns that such people could be pushed into ending their lives if the Bill is enacted. Hourglass has not published a public opinion on the Bill.

Standing Together Against Domestic Abuse has said that

“We must echo concerns raised by the VAWG sector”—

the violence against women and girls sector—

“and disability activists about the bill’s current safeguards. There is insufficient clarity on what constitutes coercion and limited reflection on carer capacity to support someone terminally ill. Without robust measures, there is a real risk that assisted dying could be exploited as a tool for coercion or even femicide.

Statistics show that over 88% of unlawful ‘mercy killings’ are perpetrated by men towards women, often involving violent means. These troubling realities demand urgent consideration in shaping this legislation.

We also highlight the health sector’s role in identifying domestic abuse. With 80% of victim-survivors having their first or only point of contact in healthcare, it is critical that health professionals are equipped to identify and respond to abuse.

We call on the Government to ensure the proposed bill includes stringent safeguards and that healthcare systems are equipped to recognise and prevent the potential misuse of assisted dying. Femicide is already a crisis in the UK, and no law should inadvertently contribute to its escalation.”

All my adult life, I have had experience of dealing with domestic abuse and coercion, and I draw on that experience to speak to these amendments. Although Professor Jane Monckton-Smith is an expert, she is an academic. These two organisations work with people who have been victims of abuse.

In addition, we had an official meeting with the Clerk to discuss the proposals for Committee sittings. It was said at that meeting that we would only have witnesses who would give evidence, particularly in person, that would contribute to the deliverability and the workability of the Bill. Since then, we have had families added to the list of witnesses. That adds weight to the argument that we should have witnesses who are providing a service to victims directly.

[Dr Tidball]

I, too, support my hon. Friend the Member for Spen Valley and in particular I want to highlight the helpful addition of Kamran Mallick of Disability Rights UK. That augments an already comprehensive list of expert disabled people, which includes: Professor Tom Shakespeare, an internationally renowned disability rights academic; Dr Miro Griffiths, a Disability Studies scholar at the University of Leeds; and Chelsea Roff, the founder of Eat Breathe Thrive. On the panel, we will also have a representative of the Equality and Human Rights Commission, who will be able to give a good overview on the intersection between protected characteristics. Finally, there will be Jon Sparkes, the representative of Mencap.

I am really pleased that my hon. Friend has worked so hard to ensure that the voices of disabled people are integrated across a number of the panels that we will see over the next two days, and the addition in her amendment is really helpful. I commend her for it.

[Lewis Atkinson]

I agree with my hon. Friend the Member for Spen Valley. Having agreed to extend the time on Thursday to hear devolution issues and from the Royal College of General Practitioners and the Royal College of Psychiatrists, by adding two further witnesses, the amendment to the amendment would reduce the time available on those options. In an ideal world we would like to hear from all sorts of people. The option of written evidence is available. We have got other evidence, and I want to ensure that Thursday’s session is focused on the proposals that my hon. Friend has made.

[Naz Shah]

There is nothing in my amendment that suggests Professor Monckton-Smith is not capable in her expertise. I am asking for other expertise to be brought to the table. Yes, there is the argument that people can submit written evidence—but so could every witness we have heard from today, and that we will hear from tomorrow and the day after. If that is the yardstick, is this just a tokenistic exercise? I would argue that for women in particular, who are the victims of domestic abuse—

[Dr Tidball]

I note that Laura Hoyano, who is giving evidence on Thursday, is a domestic abuse barrister. She has also been involved in inquiries on child sexual abuse, and has a great range of experience in that area. She will bring that to the table as a practising barrister working closely on such cases.

--- Later in debate ---

[Naz Shah]

I welcome my hon. Friend’s intervention and I recognise Laura Hoyano’s expertise. I would respectfully push back that, as a victim of domestic violence—as a person who has experienced it and campaigned on it for all my adult life—there is a difference between an academic who has studied it and people who have worked with victims, in particular elderly women. The expert is a barrister with experience of young people and children and domestic abuse, and Professor Monckton-Smith is also an academic—yes, she has been a police officer—but I would value a witness who has worked with victims of domestic abuse. That is all I have to say on it.

Question put, That the amendment be made.

Question negatived.

Main Question put and agreed to.

Amendments made: (b), in the list of witnesses set out in the table in the Sittings Motion agreed by the Committee on 21 January 2025, after

“Professor Aneez Esmail (University of Manchester)”

insert “Disability Rights UK”.

Amendment (c), in the list of witnesses set out in the table in the Sittings Motion agreed by the Committee on 21 January 2025, after

“Dr Lewis Graham (University of Cambridge),”

leave out “John Kirkpatrick” and insert “Baroness Falkner”.

Amendment (d), in paragraph (2) of the sittings motion agreed by the Committee on 21 January 2025, after “Wednesdays” insert

“starting on 11 February 2025”.—(Kim Leadbeater.)

Ordered, That further consideration be now adjourned. —(Kit Malthouse.)

5.30 pm

Adjourned till Wednesday 29 January at twenty-five minutes past Nine o’clock.

Written evidence reported to the House

TIAB 01 Ben Scott

TIAB 02 Michael Vidal

TIAB 03 Compassion in Care

TIAB 03(a) Compassion in Care (further evidence)

TIAB 04 Dr George Gillett, an NHS doctor and psychiatrist

TIAB 05 Dr Stephen Hutchison MD

TIAB 06 Dr Andrew Boorne

TIAB 07 Jess Carrington, Registered Social Worker and Best Interests Assessor

TIAB 08 Greg Lawton MPharm MRPharmS FFRPS MBCS LLM, Barrister and Pharmacist

TIAB 09 Australian Care Alliance

TIAB 10 Dr Peter Knight

TIAB 11 Dr Isky Gordon FRCR, FRCP, Emeritus Professor Paediatric Imaging, UCL, London

TIAB 12 Dr Peter O’Halloran, RN, PhD, Registered Nurse, Senior Lecturer, Queen’s University Belfast, Researcher in chronic illness, palliative and end-of-life care

TIAB 13 Rose

TIAB 14 Dr Rachel Fisher

TIAB 15 Nigel Andrew Gordon Jones, a retired Consultant General Surgeon

TIAB 16 St Gemma’s Hospice

TIAB 17 Sir Nicholas Mostyn

TIAB 18 Leah Locke

TIAB 19 Alison Taylor

TIAB 20 Dr Katharine Crossland

TIAB 21 John Forrester

TIAB 22 Don Stickland

TIAB 23 Christina Blandford-Beards

TIAB 24 Society for the Protection of Unborn Children (SPUC)

TIAB 25 Catholic Bishops’ Conference of England and Wales

TIAB 26 British Association of Social Workers

TIAB 27 Plunkett Centre for Ethics: A centre of Australian Catholic University located at St Vincent’s Hospital Sydney

TIAB 28 Dame Sarah Mullally, Bishop of London, Lead Bishop on Health and Social Care for the Church of England and former Chief Nursing Officer for England on behalf of the Bishops of the Church of England and the Archbishops’ Council

TIAB 29 Cicely Saunders International

TIAB 30 Lejeune Clinic for Children with Down Syndrome

TIAB 31 Voice for Justice UK

TIAB 32 Get on Downs - a Down Syndrome Support Group

TIAB 33 British Medical Association (BMA)

TIAB 34 Portsmouth Down Syndrome Association

TIAB 35 Better Way campaign

TIAB 36 Hospice UK

TIAB 37 Association of Catholic Nurses for England and Wales

TIAB 38 East Midlands Palliative Medicine Consultants and Specialty Doctors

TIAB 39 Marie Curie Palliative Care Research Department, University College London (UCL)

TIAB 40 Humanists UK

TIAB 41 Nuffield Council on Bioethics’ (NCOB)

TIAB 42 Marie Curie

TIAB 43 LOROS, the Leicestershire and Rutland Hospice

TIAB 44 Professor Emeritus Sam H Ahmedzai

TIAB 45 Professor Nancy Preston, Professor of the International Observatory on End of Life Care, Lancaster University; and Professor Suzanne Ost, Law School, Lancaster University

TIAB 46 Professor Alex Ruck Keene KC (Hon)

TIAB 47 Anureg Deb and Dr Lewis Graham

TIAB 48 Australian Centre for Health Law Research, Queensland University of Technology, Australia

TIAB 49 The Bios Centre

TIAB 50 The Orders of St John Care Trust

TIAB 51 Living and Dying Well

TIAB 52 Professor Katherine Sleeman, King’s College London

TIAB 53 British Islamic Medical Association (BIMA)

TIAB 54 Joint written evidence submitted by Chelsea Roff (Eat Breathe Thrive, UK), Dr Angela Guarda (Johns Hopkins University School of Medicine, US), Dr Philip Mehler (University of Colorado School of Medicine, US), Dr Patricia Westmoreland (University of Colorado, US), Dr Scott Crow (University of Minnesota, US), Dr Catherine Cook-Cottone (University at Buffalo, SUNY, US), Dr Anita Federici (York University, Canada), and Dr Agnes Ayton (Oxford Health NHS Foundation Trust, UK)

TIAB 55 Professor Allan House

TIAB 56 National Care Forum (NCF)

TIAB 57 AtaLoss

TIAB 58 Compton Care

TIAB 59 Dr Odette Spruijt, Medical Director, Launceston Specialist Palliative Care Service

TIAB 60 Rachel Pegrum, Independent Social Worker

TIAB 61 Abdul Rahman Badran

TIAB 62 Alan Thomas, Professor of Old Age Psychiatry, Director of Brains for Dementia Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University

TIAB 63 Dr Julian Neal

TIAB 64 Dr Raymond Towey

TIAB 65 Multiple System Atrophy Trust

TIAB 66 Dr Adrian Tookman

TIAB 67 Royal College of Psychiatrists

TIAB 68 UK Medical Freedom Alliance

TIAB 69 Association of Anaesthetists

TIAB 70 Catholic Union of Great Britain

TIAB 71 My Death, My Decision

TIAB 72 Health Advisory and Recovery Team (HART)

TIAB 73 Kyam Maher MLC, the Attorney-General of South Australia, in his capacity as a member of the Legislative Council of South Australia

TIAB 74 Dr Calum MacKellar, Director of Research, Scottish Council on Human Bioethics

TIAB 75 Christian Medical Fellowship

TIAB 76 Christian Medical and Dental Association of Canada

TIAB 77 Christian Legal Centre

TIAB 78 Written evidence submitted on behalf of a group of anorexia nervosa sufferers and carers

TIAB 79 Dr Angelika Reichstein, Associate Professor in Law, University of East Anglia

TIAB 80 Dr David Randall

TIAB 81 Cruse Bereavement Support

TIAB 82 Compassion in Dying

TIAB 83 General Medical Council (GMC)

TIAB 84 Pathfinders Neuromuscular Alliance

TIAB 85 Royal Pharmaceutical Society

TIAB 86 Motor Neurone Disease Association

TIAB 87 Dr Simon Eyre

TIAB 88 Macdonald Amaran

TIAB 89 Patrick Pullicino

TIAB 90 Luis Espericueta, Researcher and lecturer in bioethics at the University of Granada, Spain

TIAB 91 Healthcare Professionals for Assisted Dying

TIAB 92 PSP Association (PSPA)

TIAB 93 Association for Palliative Medicine of Great Britain and Ireland (APM)

TIAB 94 Academy of Medical Royal College's

TIAB 95 Care Not Killing

TIAB 96 Dr Alexandra Mullock, Senior Lecturer in Law

TIAB 97 Rt Hon. Sir Stephen Sedley

TIAB 98 Carole O’Reilly

TIAB 99 Dr Hannah Denno

TIAB 100 Prof B Anthony Bell MD, Neurosurgeon, University of London

TIAB 101 Matthew Hoyle, Barrister

TIAB 102 Royal College of Nursing

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

Naz Shah Excerpts

Committee stage
Tuesday 21st January 2025 Public Bill Committees

[Kit Malthouse]

I was going to make exactly the same point. I think my hon. Friend the Member for East Wiltshire has fundamentally misunderstood what is happening. He referred to there being a discussion through the usual channels. What the hon. Member for Spen Valley has proposed is that we have that discussion now—she said informally—because we have not had the chance to do so before, and that we then return. Then my hon. Friend is free to say whatever he likes about whatever witnesses and table his own amendments as he wishes. There is no intention to conceal anything. If I might be so bold, I think he has misunderstood the process.

[Naz Shah (Bradford West) (Lab)]

Just following on from the speech of the right hon. Member for North West Hampshire, I would not read the situation as a misunderstanding by the hon. Member for East Wiltshire. I read the motion to sit in private not as an informal discussion, but as a very formal discussion. I am grateful to the lead Member for the Bill, my hon. Friend the Member for Spen Valley, who before this meeting explained to me what has now been explained here—about the issue of people’s availability, privacy and so on. But I do not suspect that we will be going into those details. If people are not available, we do not have to discuss why they are not. We do not have to discuss their personal lives. I am not sure that that is a good enough reason not to have a discussion in public. I trust colleagues across the Committee to be collegiate enough and big enough to refer to witnesses with respect. I think that is a given, considering the way in which we have conducted the Bill so far. I therefore do not support the motion to sit private.

[Sean Woodcock (Banbury) (Lab)]

rose—

--- Later in debate ---

[Kim Leadbeater]

I beg to move,

That—

(1) the Committee shall (in addition to its first meeting at 2.00 pm on Tuesday 21 January) meet—

(a) at 9.25 am and 2.00 pm on Tuesday 28 January;

(b) at 9.25 am and 2.00 pm on Wednesday 29 January;

(c) at 11.30 am and 1.00 pm on Thursday 30 January.

(2) during further proceedings on the Terminally Ill Adults (End of Life) Bill, the Committee do meet on Tuesdays and Wednesdays while the House is sitting at 9.25 am and 2.00 pm.

(3) the Committee shall hear oral evidence in accordance with the following Table:

[Naz Shah]

I beg to move manuscript amendment (b), after “General Medical Council”, insert “, Royal College of Psychiatrists”.

[The Chair]

With this it will be convenient to discuss the following:

Manuscript amendment (c), after

“Dr Ryan Spielvogel (Senior Medical Director for Aid in Dying Services, Sutter Health, USA)”,

leave out

“Dr Jessica Kaan (Medical Director, End of Life Washington)”

and insert—

“Dr Ramona Coelho (Family Physician in Ontario Canada, founding member of Physicians Together with vulnerable Canadians)”.

Manuscript amendment (d), after

“Dr Miro Griffiths (University of Leeds)”,

leave out

“Yogi Amin (Partner, Irwin Mitchell)”

and insert—

“Ellen Clifford (Co-ordinator, UK Deaf and Disabled People’s Monitoring Coalition. Author and Visiting Research Fellow within the Centre for Applied Philosophy, Politics and Ethics at Brighton)”.

Manuscript amendment (e), after “Lord Sumption” insert “Karon Monaghan KC”.

Manuscript amendment (f), leave out

“Dr Chloe Furst (Geriatrician and Palliative Care Physician, Adelaide), Alex Greenwich MP (MP for Sydney, Parliament of New South Wales), Professor Meredith Blake (University of Western Australia)”

and insert—

“Dr John Daffy, previously head of infectious diseases at St Vincent’s Hospital in Melbourne, Dr Stephen Parnis, previous Vice-President of the Australian Medical Association, Professor Sinead Donnelly, a Consultant Palliative Medicine Professor in New Zealand”.

Manuscript amendment (g), leave out “Dr Amanda Ward” and insert

“Barbara Rich (Barrister) and Dr Philip Murray (University of Cambridge)”.

Manuscript amendment (i), at end of table, insert—

[Naz Shah]

On amendment (b), given the issue we are considering, I think it is important that the Royal College of Psychiatrists is involved. One thing that is very important to me is the issue of coercion, and the royal college would be able to shed light on that. One of the many reasons advanced for giving the Bill its Second Reading was that we would have further debate, and the royal college would add value to that.

On amendment (c), Dr Ramona Coelho is a physician with well-founded concerns about the operation of the law in Canada. She is a member of the Ontario Medical Assistance in Dying Death Review Committee, and she gave evidence to the Scottish Parliament Committee that considered the Assisted Dying for Terminally Ill Adults (Scotland) Bill.

On amendment (d), Ellen Clifford is co-ordinator of the UK Deaf and Disabled People’s Monitoring Coalition, and she has a key role in advocating for people with disabilities.

[Danny Kruger]

I want to speak in support of the proposed addition of Ellen Clifford. Last week, she won a High Court case against the previous Government for their consultation on benefits reform, so she is no friend of my party, but she is a powerful advocate on behalf of disabled people, and she represents the deaf and disabled people’s organisations that are so important in informing the Government on the implementation of policy that affects disabled people. I recognise that the hon. Lady has included some representatives of the disabled community, but I suggest that there would be particular value in hearing from Ms Clifford because of her role as the co-ordinator of the monitoring coalition of all these deaf and disabled people’s organisations across the country. She is the best person to advise the Committee on the operation of the Bill.

--- Later in debate ---

[Naz Shah]

Given what you have just said, Sir Roger, I would be happy not to go through the individual amendments unless anybody wants to comment or wants me to add anything.

[The Chair]

I do not wish to prevent the hon. Lady from speaking to any of the other amendments, because we have grouped them all. She was doing very well. If she works through them, that will tell other Members where she is coming from.

[Naz Shah]

Thank you, Sir Roger.

By adding Karon Monaghan KC, an eminent equality and human rights law barrister, amendment (e) would add balance among the lawyers in the Committee. I would also like to add James Munby, or someone from His Majesty’s Courts and Tribunals Service, because we need someone who can speak to court capacity issues in relation to the Bill. Professor Katherine Sleeman is a great expert on all these matters.

I am going through the list, and I am unclear what the Australian MP would add. If we remove the other two, there are other pro-AD Australian experts who will speak instead. If we replace those three, who are experts from—

[Kim Leadbeater]

On a point of order, Sir Roger. My hon. Friend has just mentioned two names that are not in her amendment, and I find that slightly confusing.

[Naz Shah]

These are replacements of the words in your paper.

[The Chair]

Order. First, they are not mine. Please remember that you are addressing the Chair.

Secondly, the hon. Member for Bradford West has a list of amendments that she has tabled, to add some people and remove others. Patently, she cannot refer to people who are not on that list. If she works through it name by name, I think we will get to where we need to be.

[Naz Shah]

I appreciate that, Sir Roger. Adding Richard Robinson—

[Hon. Members]

Not on the list.

[The Chair]

Are we working from the same list? [Interruption.] Order. Continue to work through the list and you will get to where you need to be.

[Naz Shah]

Thank you, Sir Roger.

[Danny Kruger]

I want to make a general point in support of the hon. Lady’s suggestions.

[The Chair]

No, I am sorry. Please let the hon. Lady finish her speech.

[Naz Shah]

I apologise. I thank everybody for bearing with me on this one.

Amendment (e) would insert Karon Monaghan KC after Lord Sumption. I have said that I would like her added because of her expertise.

Amendment (f) would insert Dr John Daffy, previously head of infectious disease at St Vincent’s hospital in Melbourne, Dr Stephen Parnis, previous vice-president of the Australian Medical Association, and Professor Sinéad Donnelly, a consultant palliative medical professor in New York. That is what I was speaking to when I was talking about having three people from one country and not having an alternative voice. I think it is really important to have an alternative voice, and I am not sure what added value the MP for Sydney would bring to the debate when we have so many people contributing from countries that are pro and delivering, rather than from those that have concerns.

Amendment (g) would remove Dr Amanda Ward and insert Barbara Rich, barrister, and Dr Philip Murray from the University of Cambridge.

[The Chair]

I think you have one more. Would you also like to speak to amendment (i)? It is on the other side of the amendment paper, which we nearly all missed.

Let me assist the hon. Lady: she wishes us to insert, at the end of the table in the sittings motion, a new set of witnesses on Thursday 30 January, to give evidence until no later than 5 pm.

--- Later in debate ---

[Kit Malthouse]

I rise to speak to amendment (b) and to the other amendments tabled by the hon. Member for Bradford West. As we discussed in private, I am concerned that the promoter of the Bill, the hon. Member for Spen Valley, has been through an extensive period of trying to collate everybody’s recommendations for the Bill and reach a list that is both manageable within the timeframe and a compromise for all of us on what we would like to see.

The odd adjustment here and there is fine, but we ought to bear in mind that in any one session we need to have sufficient time for people to speak. We have to be careful not to double up because we may or may not think that a particular witness might propose a view with which we are sympathetic, when we already have people who are covering the same subject. On amendment (b), for example, all psychiatrists are regulated by the General Medical Council, as I am sure the hon. Member for Bradford West knows, so effectively the royal college is a doubling up of expertise, which is not necessarily in the interests of time. Similarly, in amendment (c), the hon. Lady is proposing a physician from Canada—

[Naz Shah]

rose—

[Kit Malthouse]

I will just finish, if I may. Our Bill is built on a very different legal framework from Canada’s. Drawing legislative parallels between the two seems like a cul-de-sac, not least because, as the hon. Lady will know, the legal framework in Canada is dictated by the charter of rights and freedoms, effectively a constitution, which has been used there to widen the scope of the law. Canada started from a very different place as well, so I am not totally convinced.

What the hon. Member for Spen Valley has tried to do with the list is to find overseas territories that are analogous to our own and have adopted a model similar to ours. We are therefore trying to learn lessons from the process of debate and legislative procedure that they went through—either to learn from them or to learn from their mistakes. For example, knocking out the Member of Parliament from Australia would be a mistake, not least because Australia has been through a number of iterations with its law. Most of Australia has a bar on doctor initiation of the conversation. The medical profession think that that is a big negative in Australia, as I understand it, so I would like to understand why, politically and in legislation, it was felt that that was needed or helpful, and why it was imposed.

On the other amendments, the hon. Member for Bradford West is making a value judgment about comparative expertise between Amanda Ward and whoever she wants to propose instead—Philip Murray. I do not know why she is making that value judgment, but as far as I can see, the names were properly submitted in the process. The hon. Lady obviously had the chance to submit names during the process. For better or worse, as she may see fit, the hon. Member for Spen Valley has come up with a list that is a compromise. That is not to say that the hon. Member for Bradford West cannot arrange briefings with any of these experts outside the formal process, for Members to attend should they so wish, or that she cannot seek advice from them during the process of the Bill.

My primary concern about the amendments is that we are opening up a whole area of debate where we could all have gone with our suggestions. I would rather stick with the list that we have, because I fear that the hon. Member for Bradford West is doubling up and making value judgments about expertise that are not necessarily warranted.

--- Later in debate ---

[Kim Leadbeater]

I thank colleagues for their time this afternoon. It has been an extremely productive session. I am very proud of the tone of the debate: I think we have done a very good job, as we did on Second Reading, of showing this place in a good light.

I reiterate that there are a range of views in this Bill Committee, in the same way that there are a range of views across the House on this significant and deeply emotive issue. There are a range of views among the witnesses we will hear from, and I spent a huge amount of time ensuring that. Colleagues have given me more than 100 names of people they might like to hear from. I had my own list of people I would like to hear from, and many of them are not on the list of those who will give oral evidence.

I have tried to be extremely balanced, so we will hear from people with a range of views and opinions, but most importantly we will hear from people with expertise. That is the purpose of the Committee: to hear from people who can advise us on the detail of the Bill. We will go through this Bill line by line, and we need to hear from people who can help us to do that. We have some fantastic expertise on the Committee, but for many of us there are areas that we need to learn more about. It is important that the witnesses give us the information to enable us to do that, rather than—as numerous colleagues have said—once again going over the fundamental principles around assisted dying, because we did an excellent job of that on Second Reading.

At the end of our endeavours, we will produce a piece of legislation that will be re-presented to the House, and colleagues will again have the opportunity to vote on it however they see fit. There may be people in this room who vote differently from how they voted on Second Reading; there may be colleagues out there who do likewise, one way or the other.

I am very clear about this Committee’s role, which is to work on the Bill together, collegiately and collaboratively, irrespective of our different views, and re-present it to the House so that the House can continue to do its job. It is not just the Commons; the Lords will also have the opportunity to scrutinise the Bill and table amendments. I have always been open about the fact that this is about us working together. Where the Bill needs to be amended to make it more robust and alleviate people’s concerns, whether that is around coercion or capacity, that is now the Committee’s job. I stand ready to serve and to do that.

We have spent a lot of time this afternoon on this, and quite rightly so. As far as I am concerned, we are now in a position to move forward. I am very happy that we will hear from so many witnesses over several days, and I am happy that I have added more time to that so that we can hear from more witnesses, which I think is important. As colleagues have said, our job now is to get on with this really important piece of work.

[Naz Shah]

I thank my hon. Friend the Member for Spen Valley, the promoter of this Bill, because she has been very helpful. She has certainly added one of my key witnesses to her list, and I am grateful for that.

I want to respond to some of the points that have been made. One of the biggest issues for me is amendment (b), which would insert “Royal College of Psychiatrists”. My hon. Friend the Member for Ashford made the point that all psychiatrists come under the GMC, but not every member of the GMC is a psychiatrist. That speaks to the issue of coercion, mental health and capacity. That is the expertise that I am looking for in the line-by-line scrutiny of the Bill, and I would really like to hear from the Royal College of Psychiatrists.

I am happy to be guided by you, Sir Roger, because I am new to this process and I have not done a Bill of this nature before, but my only worry with the outside evidence and briefings is that they will not be on the record when we are looking at Hansard and seeing whether they have been taken into account. I would be happy to receive some assurance about that. Yes, we can organise lots of briefings and lots of experts, but does that not defeat the object of having this debate so robustly in the first instance?

The hon. Member for Harrogate and Knaresborough raised the issue of language, and the point about added value. I think that language is correct, because I do want to add value to this debate. I want value added, because it is important for my constituents that when I vote on the Bill on Report, I do so knowing that I have listened to all sides of the debate.

My hon. Friend the Member for Stroud asked whether this is a for-and-against argument. In particular, he said that we do not need to hear from those who are opposed, because we want to strengthen the Bill so that it can go through the House. Although I appreciate the sentiment, I put it to everyone that it is not about getting the Bill through; it is about getting the right information so we can scrutinise whether it is fit to go through the House. For that reason, it is important to hear from those who are opposed. It is naive to think that we only need to hear from people who are in support.

[Tom Gordon]

Will the hon. Member give way?

[Naz Shah]

Sorry—may I just make my point?

I need to know the other side of the argument in order to make a balanced decision. Those who are opposed to the Bill might have very valid concerns, while those who have expertise in support of the Bill might not give me the same arguments. I want to hear a balance. At the moment, I think there is a real discrepancy between the number of people who are for and against the Bill; it is not very close.

I appreciate that my hon. Friend the Member for Spen Valley, the Bill’s promoter, really wants to get this legislation through Parliament. I also value how she has taken part in the debate and been amenable to having discussions both in Committee and in our offices. I have given my reasons for tabling the amendment, and I particularly want the Committee to accept amendment (b), on the Royal College of Psychiatrists; that is my top amendment.

Question put, That the amendment be made.

Terminally Ill Adults (End of Life) Bill

Naz Shah Excerpts

2nd reading
Friday 29th November 2024 Commons Chamber

[Tim Farron (Westmorland and Lonsdale) (LD)]

The motives of those proposing the Bill are grounded in compassion—in the heat of this debate, I want to seriously acknowledge that—particularly the hon. Member for Spen Valley (Kim Leadbeater), who has conducted herself with great dignity throughout. Neither side has a monopoly on compassion—I will always be affected by watching my mum suffer at her death at the age I am now—so let us not think badly of one another’s motives; let us instead be courteous and let us be curious.

My opposition to the Bill is grounded in compassion. To legalise assisted dying would be to create the space for coercion that would undoubtedly see people die who would not otherwise have chosen to do so. There are no safeguards in the Bill that would prevent that.

[Naz Shah (Bradford West) (Lab)]

Will the hon. Member give way?

Criminal Law

Naz Shah Excerpts

Thursday 25th July 2024 Commons Chamber

[Naz Shah (Bradford West) (Lab)]

May I congratulate you, Madam Deputy Speaker, on taking your space, even more so as a female Muslim in this House of Kashmiri heritage? It gives me great pleasure and pride to see not only a female Muslim Deputy Speaker of Kashmiri heritage, but also a Lord Chancellor who is the first female Muslim of Kashmiri heritage in that role. I am sure the whole House and the whole country shares our pride in celebrating Britain, the House and democracy at their best.

I am grateful to the Lord Chancellor for all her work to address this issue, picking up the mess left by the previous Government. I would welcome a bit of humility from the shadow Minister. The reason we did not vote with his Government’s policies was precisely because they did not have a plan and they did not know what they were doing—otherwise, we would not have to clear this mess up on their behalf. The people recognised that, and that is why we are having to deal with it.

I make a request to the Lord Chancellor that, during her review, she accepts an invitation to visit Bradford West, and the Muslim women in prison project, which supports Muslim women in prison and their return out into the community. We all recognise the disparity of services and rehabilitation when it comes to people of ethnic minority heritage. That is an open invitation.

Once again, I thank the Lord Chancellor for giving huge consideration to the sentences she is proposing to reduce and making sure that we are still protecting the public, which the previous Government failed to do, by ensuring that we keep serious offenders out of that category and are doing the best we can do for our country.

Violence Reduction, Policing and Criminal Justice

Naz Shah Excerpts

Wednesday 15th November 2023 Commons Chamber

[Naz Shah (Bradford West) (Lab)]

I rise to speak to amendments (h) and (r). As I have stated publicly, the attack against innocent Israelis on 7 October was an egregious crime against humanity. The families of those killed continue to mourn the loss of their loved ones, and the families of those taken hostage pray for their safe return. It would be a grave injustice not to recognise the acts of terror committed by Hamas for what they are. In the same way, it would be a grave injustice if the world turned a blind eye while innocent Palestinians are being murdered by the hour.

More civilians have been killed in six weeks in Gaza than were killed in 20 months in the Russia-Ukraine war. More children have been killed in Gaza than the annual number of children killed across all conflict zones since 2019. More United Nations workers have been killed in Gaza than in any comparable period in the UN’s history, and more journalists have been killed in Gaza than in any conflict period since 1992. Hospitals have been bombed, refugee camps have been bombed and United Nations schools have been bombed. Ambulances, bombed; bakeries, bombed; mosques and churches, bombed; northern Gaza, bombed; Gaza City, bombed; Khan Yunis, bombed; the Rafah border, bombed. Almost every inch of the Gaza strip has been bombed.

More than 11,000 innocent civilians have been killed, and the hopes, dreams, and futures of nearly 5,000 Palestinian children have ended in mass graves. Some 2.3 million people are fleeing death and destruction, with babies dying in incubators, and pregnant women having caesareans without anaesthetic. There is no fuel to power hospitals, no food to feed the living, and when searching for clean water, it is as rare as when searching for gold. Make no mistake, this is a humanitarian catastrophe. That is why I urge Members to back an immediate ceasefire on all sides, and push for the release of hostages.

That call is backed by 120 members of the UN Security Council, 17 UN agencies, the UN Secretary-General, the World Health Organisation, the World Food Programme, Amnesty International, and more than 600 leading international non-governmental organisations, including Oxfam, Save the Children, Christian Aid, Medical Aid for Palestinians, the UN Refugee Agency, the Pope and the Archbishop of Canterbury. It is backed overwhelmingly by the British public, and now it is backed by President Macron of France. Almost every international aid agency in the world is saying that vital humanitarian aid cannot be delivered to people without a ceasefire. Those are the very agencies whose expertise we rely on in other conflicts and take their lead, so why not this time?

We need a political solution to an issue that leads to peace, not one that ends in a way so horrific that it emboldens more terror in the region. Injustice is the greatest barrier to peace, and we cannot expect peace unless we enable justice to be delivered. Nothing symbolises our British values better than the statue of Lady Justice towering over the Old Bailey. She is figuratively blinded because justice is unbiased, with the scales representing the impartiality of decisions, and the sword a symbol of power and justice. When Israel acts with impunity and attacks hospitals, UN schools and refugee camps, and the case for the Palestinians is vetoed by the US and UK at the International Criminal Court, the world asks whether our justice is really unbiased.

When we rightfully condemn extremist and genocidal statements by Hamas, but fail to utter a single word about the genocidal rhetoric being spouted by Netanyahu and his right-wing Government, the world asks whether our scales of justice are truly impartial. When we follow the path of justice and the rule of law in the face of Putin’s aggression, yet Israel continues to defy UN resolutions with empty words and no action, the world wonders where is the sword of justice. When we fail to provide equal application of justice, in the eyes of the world, it is

“one rule for the allies of the US and another rule for the rest.”—[Official Report, 17 March 2003; Vol. 401, c. 728.]

Those are not my words, but those uttered by the former Labour Foreign Secretary, the late Robin Cook, in this very Chamber—words that sadly ring true 20 years on.

Our values push us to do better, which is why, despite all the risks to our personal positions, we must do what is right. While it may be a matter of convention to follow our

closest ally, the US, in the interest of foreign policy, it is a matter of conscience to step away from our closest ally in the interest of peace.

We know that eventually there will be a ceasefire in this current crisis—every war ends with a cessation of hostilities. The question is not if there will be a ceasefire, but when. For the people of Palestine, every minute, every hour and every day that we wait is another orphan, another grieving mother and another family wiped out. That is why, in standing to save the innocent lives of Palestinians and Israelis and in representing the people of Bradford West, I will be supporting the amendment that seeks an immediate ceasefire.

[Several hon. Members rose—]

Draft Misuse of Drugs Act 1971 (Amendment) Order 2022

Naz Shah Excerpts

Thursday 27th January 2022 General Committees

[Naz Shah (Bradford West) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Hollobone. I thank the Minister for his remarks. The Opposition supports the proposals in this statutory instrument, which will introduce restrictions around the drug GHB and related substances by moving them from class C to class B, following recommendations by the independent Advisory Council on the Misuse of Drugs. The instrument will also bring forward measures on two substances—GBL and 1,4-butanediol—that can be converted to GHB on ingestion, as the Minister suggested, so that those wishing to possess them for legitimate industrial purposes will require a licence. GHB causes profound unconsciousness and has been used to facilitate some appalling crimes, such as those committed by Stephen Port, who used GHB to incapacitate his victims, and Reynhard Sinaga, who was found guilty of 136 counts of rape.

We are committed to working with the Government, the police and other public bodies to tackle drug misuse, strengthen controls on dangerous substances and widen the availability of treatments to prevent overdose deaths and get drug users clean. Clearly, where drugs cause harm, they must be classified and enforcement action must be taken to better protect victims from criminal abuse. In recent years, GHBRS have been used by prolific serial rapists, but rapists are more likely to get away with their crimes than to be prosecuted. The Government should be working much harder to reduce the prevalence of sexual violence and improve the shockingly low charge rate for rape. I have to remind the Minister of the context of the statutory instrument—that rapists are getting away with it—to show that this welcome change is just one part of the solution.

The impact assessment for the statutory instrument states that

“statistical experiments cannot conclusively state whether reclassification causes an increase or decrease in consumption/prevalence of a drug. The evidence base for the effects of reclassification is mixed.”

Can the Minister set out how he expects the reclassification to decrease the prevalence of GHB? We absolutely support the change to reschedule GBL and 1,4-BD from a bespoke status to schedule 1. The impact assessment tells us that the change

“will correspond to a reduction in the supply of these drugs because, in practice, the current legislation allows for unimpeded access to these drugs via the clear web.”

Does the Minister have any plans to tackle the sale of GHBRS on the dark web?

According to the Office for National Statistics, between 2008 and 2017 there were, on average, 19 deaths related to GHB per year. The ACMD tells us:

“There is evidence of increasing mortality associated with GHBRS use”,

and:

“Although the overall number of deaths is relatively low there was a steep rise in deaths between 2008 and 2015…However, mortality figures are likely to be an underestimate due to the challenges in testing for and identifying GHBRS in post-mortem samples”.

That makes it hard to make pronouncements in criminal cases, as does the fact that victims sometimes do not remember that they have been the victim of a crime, or they remember very little about it.

The withdrawal symptoms of GHBRS are severe and can be life-threatening, with high relapse rates. The ACMD says that

“more research is needed to investigate effective clinical management of withdrawal, and effective relapse prevention.”

Survivors of a drug-facilitated sexual assault will experience a complex combination of harms and require support from various different services. There are concerns that the reclassification may make people less likely to ask for help or for an ambulance. I ask the Minister for some assurances about those who purchase GHB to use consensually, many of whom are LGBTQ+. How will their safety be ensured? The ACMD report states that

“there is significant evidence of stigma experienced by LGBT GHBRS users, which is a barrier to service access. The complex harms—both physical, mental and social—experienced by MSM require specialist sexual assault support, and it is reported that users believe that current services do not meet these needs.”

Will the Government introduce any increased harm reduction services or victim support alongside the measures in the statutory instrument?

As the Minister will know, the ACMD made eight recommendations in its report. Some are reflected in the SI, but some really important recommendations are not reflected. Clearly, the control of substances and drugs is extremely important, but people’s safety and the reduction of harm will not be addressed by tighter controls alone. As the report’s recommendations suggest, better data collection and reporting of GHBRS use is vital. We need more routine testing for it in cases of unexplained sudden death, better integration of drug treatment and sexual health services, and better education for frontline staff in the health and social care system who come into contact with GHBRS users, as well as improved treatment interventions and more information and support for those at the highest risk of harms associated with GHBRS. Will the Minister set out the Government’s response to the other recommendations in the ACMD report?

We welcome the statutory instrument. It is absolutely right to update the controls and classification of drugs that are dangerous and that are sometimes used for sickening sexual crimes, but we must also acknowledge that this is a small part of what is needed. So much more needs to be done to reduce the prevalence of these crimes, to increase prosecutions for rape and to tackle the perpetrators of sexual violence. We all know the terrible impact that drugs can have on individuals, families and communities. Increasing enforcement of drug misuse, and stamping out the organised criminals and drug gangs that profit from it, is incredibly important, but it is one part of the solution. The other part must be drug treatment and preventive services, in order to properly break the cycle of drug misuse.

Divorce, Dissolution and Separation Bill [Lords]

Naz Shah Excerpts

Committee stage & 3rd reading & 3rd reading: House of Commons & Committee: 1st sitting & Committee: 1st sitting: House of Commons
Wednesday 17th June 2020 Commons Chamber

[Alex Cunningham]

We do take the facts on board. People may feel that they have got it wrong, and we have all seen examples of people who get married, get divorced and get remarried. We have seen examples where people have done that more than once, which is remarkable. People have the choice, but that does not mean we should lengthen the period that people have to wait before they can divorce. It will be particularly interesting to see how many couples opt for no-fault divorces as an alternative to laying the blame at the feet of one person in the relationship.

Some of the impact of this Bill may be unmeasurable, but it does not make that impact less important. For example, we might not know the true impact of quicker and more amicable divorces on children and how that affects their wellbeing and future lives, but I am confident in saying that having two parents apart but happy is infinitely better for a child than having parents stuck in an unhappy marriage for years on end. I hope the Minister will comment on that.

That leads me to new clause 3, which would reduce the time period to allow a divorce with consent from two years to one. I do not believe the new clause is needed, as the provisions within the Bill are better than what the new clause would achieve. It would still require couples to stay married for a year before they can petition for divorce, and it completely ignores the reality in which people live their lives. To be separated, people have to live apart and at least sleep apart, which simply is not possible for many people. Many homes do not have the luxury of extra bedrooms, and I doubt that 12 months on a sofa is very acceptable. Many couples do not have the disposable income for them to live separately and they have nowhere else to go, so I am not sure what benefit the new clause is supposed to have. Allowing a no-fault divorce is infinitely preferable to forcing an unhappy couple to stay married for a year before they can divorce.

New clause 4, which stands in the name of the Leader of the Opposition, me and other hon. and right hon. Members, relates to funds and income. It is undeniable that there is a problem with access to legal aid, not just in divorce, but across a wide spectrum of areas. The huge cuts made to funding over the past 10 years have led to unfairness and a lack of justice across our nation. Without adequate legal aid for divorce proceedings, we have a situation where some people cannot afford to petition for divorce. We are essentially forcing people to stay married to someone they do not want to be married to simply because they do not have enough money to take legal action.

If the Minister agreed to act, he would have the support of the Law Society. In a briefing, it told me that respondents should have sufficient time to respond to a petition and seek advice. It also stated:

“In our evidence to the Joint Committee on Human Rights in regard to the human rights implications of the Bill, we highlighted that there is the potential for issues under article 14 of the Human Rights Act 1998 due to its potential to have a particularly detrimental impact on women, who due to a range of societal issues are more likely to be less resilient to financial risks…While divorce affords some protections to women at the end of a marriage, they can only make best use of these legal safeguards if they can participate in the proceedings fully.”

It is right and just that we extend legal aid to divorce, dissolution and separation proceedings to allow people to escape unhappy marriages and civil partnerships. While we welcome the provisions in the Bill to make divorce easier, will the Government acknowledge that without legal aid, we are simply making divorce easier for those who have the funds to petition, while little change will be made for those who do not have such funds? I hope the Minister will go away and consider that, as we must do better for those who do not have the resources to use the legal system.

New clause 5 would require the Secretary of State to carry out a review within six months on the impact of extending legal aid for divorce proceedings. We on this side of the House are particularly interested in the disproportionate impact that an absence of legal aid has on women and how Government can help put a stop to that. Does the Minister agree that we should be conducting research to collect facts about the impacts of decisions made by this House and the potential impacts that decisions made by this House could have? With this in mind, I hope the Minister will accept that we must actively seek out areas where a group of people are being disproportionately negatively impacted, and make the necessary changes to fix that.

We know that legal aid is available in some circumstances, but, as we say in new clause 6, we would like to see financial abuse listed as a specific condition under which civil legal aid may be provided in matters arising out of family relationship. If a person is being financially abused, they simply do not have the funds to petition for a divorce. Does the Minister accept and acknowledge this fact? If he does, perhaps we can make some progress. This could be transformational change for those who have been essentially kept from having their freedom by their partners because they do not have the resources to pursue a divorce. Can the Minister tell me now whether he will seek to introduce financial abuse as a part of the domestic abuse conditions that allow access to legal aid? If not, is it the case that the Government do not wish to provide real and tangible assistance to those who are being financially abused and cannot escape an abusive relationship without that assistance?

There are other areas of family law that I would like to be addressed in the Bill, such as the out-of-date, archaic approach which means that families are entitled to bereavement support only if the parents are married. Not only does this fail to recognise that many families have happy and secure lives without the need for marriage, but it means unhappy couples may be discouraged from petitioning for a divorce because of the potential financial consequences. However, it goes much wider than that.

I have a constituent who when living with her partner had a child with him. Sadly, the relationship was not sustained but her partner, who left, kept up regular maintenance payments for his child until his death. Despite having those regular payments, my constituent is denied bereavement support. When I wrote to the Government seeking clarity on this, the Under-Secretary of State for Work and Pensions, Baroness Stedman-Scott, responded by simply saying that marriage was a key part of benefit entitlement. This is an outdated approach, and we must reframe our public policy on it. We live in a society where families come in all shapes and sizes, and we should not be deeming one shape or size as preferable to another.

The chief executive of Child Bereavement UK said:

“The inequality that unmarried parents face in the bereavement system denies them access to this financial support at a time of great distress and anxiety on many levels following the death of a partner…It is a gross injustice that the current system ultimately disadvantages bereaved children, who have no influence over their parents’ marital status.”

For bereavement support when one parent dies to be permitted only if the parents were married is backwards, and I hope the Government recognise that and will take action to right this wrong.

New clause 9, which is in the name of my hon. Friend the Member for Walthamstow (Stella Creasy) and in mine, is an important one. I will not steal my hon. Friend’s thunder, but it is absolutely right that the Secretary of State publish by the end of this year a report on how this legislation will affect the financial status of children and families where benefit entitlement is linked to the civil partnership or marriage status of one or both parents. As I have said, basing benefit entitlement on marital status is outdated and not representative of the modern society in which we live.

[Naz Shah (Bradford West) (Lab)]

Is my hon. Friend aware of the YouGov poll commissioned by Resolution, which represents more than 6,000 family lawyers and family law professionals? It shows that 71% of the population agrees that no-fault divorce is urgently needed to protect the long-term interests of children.

[Alex Cunningham]

I have seen that particular information. It cuts to the very core of what this is about. It is not just about the two partners in a relationship; it is about the children. The hon. Member for Congleton (Fiona Bruce) spoke about the extended family and the need for grandparents to be involved with their grandchildren. It would absolutely break my heart if I were to lose contact with my grandson. It is very important that we recognise that this will actually make life easier for children, which is why we support it.

As I was saying, basing benefit entitlement on marital status is outdated, so I hope the Minister will go away and collect the information to share with the House. The Government have acknowledged that we need to make divorce easier and more straightforward, which this Bill does, but the Government cannot and should not ignore the negative repercussions of the positive changes being brought in with this Bill.

In conclusion, this is a good Bill that will change people’s lives for the better. But there is always room for improvement, especially changes in the spirit of this Bill recognising modern relationships and families as well as legal aid. I hope the Minister will agree that there is much more change needed in this area of family law, but this is a good first step.

--- Later in debate ---

[Sir Robert Neill]

I think it rather depends on the grounds on which the petition is abandoned. If someone was coerced into abandoning a petition, I would not regard it as something to celebrate, to be perfectly frank, as that would be allowing a coercive party to win. That may not be the case in most instances, but that is a reality as well. The evidence also shows that about 10% of petitions do not proceed to their final conclusion, but that is very often because of procedural reasons, and sometimes because of no co-operation on the part of the respondent. With respect, I am not sure that that is the best argument.

Unfortunately, and as has been pointed out, amendment 1 appears simply to delay dealing with an issue that needs to be resolved. It is merely reinserting and increasing the time period. The longer the period goes on, the greater is the likelihood of conflict and hardship, and the greater is the risk that the stronger partner—whether financially or emotionally—in a relationship that has not always been happy and who may have verged on being coercive or been outright coercive, will have all the cards in their hands. The longer it goes on, the more they can push back against the person who is seeking to leave an unhappy relationship and genuinely move their life on. I do not believe the amendment would have the effect my hon. Friend seeks of making the divorce process easier or better.

[Naz Shah]

The hon. Gentleman is making very valid points, which I agree with. Does he agree with me that, especially where domestic violence is involved, that partner has the power to prolong cases for up to two years —in some cases, five years—which has a negative impact on both the abused partner and on the children?

[Sir Robert Neill]

Unfortunately, that is also true. I think most of us will have seen that in our surgeries.

It is also worth saying that the pilot information meetings held under the Family Law Act 1996, which was passed but never brought into force, indicated very strongly that, by this stage, very often people have made a decision and want to move on. In reality, there may be another family, or a new relationship has started. People should not be forced to point a finger of blame. A law that requires that is doing no social or ethical good.

Amendment 3, in effect, restates and retains the fault- based approach. That is opposed by Resolution—an admirable body—and not supported by the Marriage Foundation either. I simply do not think that professionals believe that anything is gained by this approach.