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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Wednesday 19th March 2025 Public Bill Committees

[Naz Shah]

My hon. Friend is absolutely right that we need to clarify this.

To sum up, this comes back to some of the questions I have for the Minister, and I wonder whether he can answer some of them. I say that especially because the Committee has had lots of debates on amendments tabled by the Government via my hon. Friend the Member for Spen Valley giving the Secretary of State statutory duties. Perhaps the Secretary of State will be able to clarify this issue and make it watertight using regulations.

Have we had an assessment of what the impact would be on the provision of healthcare if assisted death were permitted in either a hospice or care home, and is the Minister happy to share that assessment with the Committee? For example, if palliative care specialists are saying, “X amount of people would no longer want to be involved, so there is a real risk of an exodus of specialists from hospices,” we need to know whether there has been an assessment of that. Perhaps the Government can help us to understand that real concern from palliative care specialists.

Given that the Minister mentioned his visit to a hospice this week, has he had any discussions with Care England care homes about allowing this process to happen in care homes themselves? How have the concerns of clinical staff about allowing an assisted death in their healthcare facility been assessed, and have those concerns been put to him? How many staff have indicated that they would need to leave the NHS, care providers or hospices if an assisted death were mandated on their premises?

Coming back to beliefs, there is also the element of charitable bodies. Have we spoken to the Charity Commission about the impact on those bodies if they were pressured by the Bill into changing their charitable aims? Would they be protected from providing assisted death because of their charitable aims?

For me, this debate has raised more questions than answers, and there is much more discussion to be had. I am happy to listen to the hon. Member for East Wiltshire, as I can then intervene and probe further.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship this morning, Ms McVey, even though it is a little later than originally planned.

Amendment 480 is intended to extend the category of those protected from being obligated to participate in the provision of assisted dying under clause 23 from registered medical practitioners, registered nurses and registered pharmacists or pharmacy technicians to all individuals. The amendment also seeks to clarify what an individual can refuse to do under clause 23(1), by setting out a non-exhaustive list of activities under the Bill that an individual would not be obligated to participate in. The amendment also specifies that the ability not to participate in the provision of assisted dying does not override any duty to signpost someone to information about assisted dying; to perform clerical, secretarial or ancillary acts; or to perform life-saving acts or grave injury-saving acts.

The amendment would introduce significant legal uncertainty and may mean that a person who had opted in to providing services under the Bill could refuse to continue to do so or could use clause 23 as a justification not to perform their duties as described in the Bill. For example, they may use the amendment as justification for not checking eligibility criteria, discussing prognosis or palliative care options, or performing other requirements under the Bill.

Amendment 480 may also conflict with other provisions. It states:

“no individual is under any duty…to be involved, directly or indirectly, in the provision of assistance”,

in accordance with the Bill. That may, for example, mean that although doctors are required under the Bill to notify a cancellation, they would be allowed to refuse to do things under the Bill, even if they have opted in to providing assisted dying services. It is not clear which provision would take precedence, which could allow the doctor to decline to notify a cancellation, by arguing that they are relying on clause 23(1).

Amendment 483 is intended to extend

“the range of activities which medical practitioners and other healthcare providers are not under an obligation to provide to include activities closely related to the provision of assistance”

under clause 23(1).

Amendment 484 is intended to expand the protection from being subject to a detriment by an employer at clause 23(2), to include where a registered medical practitioner or health professional refuses to participate in activity closely related to the provision of assistance. The term,

“activity closely related to the provision of assistance”,

is not defined, and that could create uncertainty as to what types of activity it is intended to cover.

The Bill does not, as currently drafted, specify where the provision of assistance may or may not take place. Amendment 441 would prevent there being any obligation on a care home or hospice regulated by the Care Quality Commission or Care Inspectorate Wales to permit the provision of assistance to be carried out on their premises. The effect of the amendment may be to limit the places where assistance could be provided. It may thereby reduce access to an assisted death for those residing within a care home or hospice, if a care home or hospice did not wish to allow an assisted death to be provided on its premises. The amendment could preclude some people from accessing services under the Bill if they were near the end of life and leaving their usual place of residence was therefore impeded. It may result in inconsistent treatment for patients when seeking to access an assisted death. That could potentially engage a person’s rights under article 8 of the ECHR—the right to respect for private and family life.

Amendment 481 has two parts. The first aims to ensure that employees cannot participate in the assisted dying process in the course of their employment if their employer has chosen not to participate in assisted dying. The effect of the amendment could be to limit the places where assistance would be provided, and it may result in inconsistent treatment for patients when seeking to access an assisted death. That could engage a person’s rights under article 8 of the ECHR—the right to respect for private and family life.

The explanatory notes suggest that the second part of the amendment seeks to ensure that employers require employees to provide or not provide assisted dying under schedule 9 of the Equality Act 2010. That schedule enables an employer to specify that having a protected characteristic is a requirement of a job when having that characteristic is crucial to the post and a proportionate means of achieving a legitimate aim. The ability to specify occupational requirements is conferred by schedule 9 of the Equality Act, and reference to it in this amendment would not have any additional effect.

The purpose of new clause 22 is to provide that the owners or occupiers of a premises would not be obligated to permit the self-administration of an approved substance on their premises. This right to refuse would not extend to a person who has an interest in the land but who is not occupying or operating on those premises, such as a landlord. It is unclear if the term “premises” would apply to a residential property, care home or hospice. As a result, the amendment may mean that someone who is terminally ill and is residing in, for example, a care home or a hospice could be required to leave that care home or hospice in order to receive assistance under the Bill if the care home or hospice owner did not wish to allow assisted dying on their premises. That could engage a person’s rights under article 8 of the ECHR—the right to respect for private and family life.

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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Tuesday 18th March 2025 Public Bill Committees

[Stephen Kinnock]

Amendment 435 would require the co-ordinating doctor to escalate the care of an individual to the appropriate emergency medical services if the assisted dying procedure has failed. Requiring the co-ordinating doctor to make a referral may engage article 8 of the European convention on human rights—the right to family and private life—if the person has indicated that they do not wish to be referred to emergency services or do not wish to be resuscitated. In a situation where the procedure has failed, doctors would, as in their normal duties, support a person in line with their professional obligations and their understanding of the person’s wishes. This could include the involvement of the emergency services, but it would be unusual to specify a particular approach in legislation.

As currently drafted, clause 18(9) provides that:

“The coordinating doctor must remain with the person”

once the approved substance has been provided, until either

“the person has self-administered the approved substance and…the person has died, or…it is determined by the coordinating doctor that the procedure has failed”,

or, alternatively, until

“the person has decided not to self-administer the approved substance.”

Amendment 429 would remove the clarification currently provided for in clause 18(10) that the co-ordinating doctor does not have to be

“in the same room as the person”

once the approved substance has been provided. However, clause 18(9) requires the doctor only to

“remain with the person”.

It may still be possible that the co-ordinating doctor could remain with the person but in a different room if they decide that is more appropriate.

Amendment 436 would increase reporting obligations on the co-ordinating doctor in cases where complications have occurred. It is not clear in the amendment what would be considered a complication and therefore trigger the reporting requirement. It is also not clear what details should be set out in the person’s medical records or in the report to the chief medical officer and voluntary assisted dying commissioner.

[Naz Shah]

I am struggling with this. When amendments were tabled last week, there was a concise direction from the Minister that he understood the intention of the amendments. Could that approach not be applied to these amendments—that there is an understanding of the intention, and they can be tidied up in the wash-up process to make them tight? Could that not happen?

[Stephen Kinnock]

My job and that of my hon. and learned friend the Justice Minister is to defend the integrity and coherence of the statute. The concern that we have with the word “complication” is that it is a wide-ranging term and concept, and its inclusion could potentially undermine the integrity of the legal coherence of the Bill and how it could be interpreted in terms of its implementation. I am simply flagging the risk that if the Committee chooses to accept the amendment, there could be a muddying of the waters in terms of its meaning in law.

--- Later in debate ---

[Stephen Kinnock]

I think what I am saying is that the word “complication” contains a multitude of potential interpretations and meanings. The work that would need to be done by the Government to unpack it and understand what it means certainly could be done if the amendment passes, but the Government are saying that, as it stands, it is not clear. The drafting of the amendment is so ambiguous that it causes the Government concerns about its inclusion.

[Naz Shah]

This is a genuine question because I continue to struggle with this. What kinds of complications would we envisage if a lethal drug is being administered to a patient who has chosen assisted dying? What kinds of examples are there? Can the Minister help me understand?

[Stephen Kinnock]

With all due respect, I think it is more the responsibility of those who draft and table amendments to draft and table them in a way that leaves no room or as little room as possible for ambiguity. I think my hon. Friend would be better off addressing her question about the potential complications to somebody with clinical expertise, who could list off a series of potential physical manifestations. I am not qualified to do that. I do not have a clinical background so I am not able to answer her question.

Amendment 464 would impose a duty on the co-ordinating doctor not to do anything with the intention of causing the person’s death and to seek to revive the person if it appears to them that the procedure is failing. It is unclear what “appears to be failing” would mean, and what criteria would need to be met for the co-ordinating doctor to consider the procedure to be failing. It would be unusual for primary legislation to seek to mandate a clinical course of action in the way proposed by the amendment. In addition, the amendment could potentially create conflict for the co-ordinating doctor if the person has a “do not attempt cardiopulmonary resuscitation” order or a legally effective advance decision is in place, as the doctor would have to resuscitate them even if they had stated wishes to the contrary. That could give rise to engagement of article 8 of the European convention on human rights on respect for private and family life.

Amendment 532 would introduce a new duty on the Secretary of State to make regulations setting out what the co-ordinating doctor is legally permitted to do if they determine that the procedure under clause 18(2) has failed. Under the amendment, the regulations would also include specific actions that the co-ordinating doctor can legally take if there is a greatly prolonged death; if the person is unconscious and unable to make a second attempt at self-administration; or if the person has other complications. If specific actions that the co-ordinating doctor can legally take are set out, there is a risk that, when complications arise, they would be unable to take actions that are not listed. That may lead to uncertainty and restrict what the doctor can do, using their professional judgment, to respond to particular circumstances. It is unusual to set out a particular clinical approach in primary legislation.

Amendment 533 places a duty on the Secretary of State to make regulations specifying where the provision of assistance under the Bill may take place. It sets out a requirement on the Secretary of State to

“consult such persons as the Secretary of State considers appropriate”

prior to making such regulations, including certain specified groups.

I turn to amendment 430, which would broaden the Secretary of State’s power to issue codes of practice under clause 30 of the Bill. It would explicitly enable the Secretary of State to issue a code of practice in connection with

“responding to unexpected complications that arise in relation to the administration of the approved substance under section 18, including when the procedure fails”.

[Naz Shah]

I respectfully point out that the Minister says that it is not for him to make interpretations and that he has not got the clinical expertise. I genuinely appreciate that, but I am also trying to understand why he accepts provisions that are not clear in the Bill. Why is he okay with those but not with the amendments?

[Stephen Kinnock]

My hon. Friend will have noted that a number of amendments have been drafted in collaboration with the Bill’s promoter, my hon. Friend the Member for Spen Valley. I think that demonstrates that when the Government have seen a lacuna, a lack of clarity or ambiguities in the Bill, officials, along with the Justice Minister, my hon. and learned Friend the Member for Finchley and Golders Green, and I, have worked with my hon. Friend to table amendments to tighten up the Bill. We are doing that in areas where we feel that ambiguity exists. However, when we feel that the Bill, as drafted, does not give rise to such concerns, our position on the amendments is according to our position vis-à-vis the current wording of the Bill.

--- Later in debate ---

[Stephen Kinnock]

Of course, if we can find ways to improve the Bill, we should—that is what this Bill Committee is for. But the input from my officials and parliamentary counsel legal advice have raised red flags about the amendments because of how they are drafted and the ambiguity that they give rise to. Clearly, it is up to the Committee to decide whether it wants to include the amendments or whether those issues could be looked at later—either on Report or when the Bill is going through the other place.

[Naz Shah]

We cannot have things both ways. I have re-read amendment 436 and I am not convinced that the issue is the drafting. It is very clear:

“If complications occur as a result of the provision of assistance the coordinating doctor must…make a detailed record of the complications…make a declaration…and…make a report”.

I am struggling to differentiate between having a conversation about it and it actually happening—it is still a complication, so why the resistance? Can the Minister agree that the Government will look at this and, perhaps in the wash-up, tidy it up—if that is the issue, and they agree in that instance?

[Stephen Kinnock]

Fundamentally, the role of the promoter of the Bill is to decide whether the Bill, as passed through this Committee, meets the policy intent that she wishes to achieve. Our job as Ministers is to work with her to deliver that objective. If the promoter of the Bill comes to the view that any of the amendments should be considered and added to the Bill, we will of course work with her to enable them to be delivered. My job at the moment is simply to say that there are concerns about these amendments due to the issue of ambiguity.

--- Later in debate ---

[Naz Shah]

I am grateful for my hon. Friend’s intervention, which will make my speech much shorter—I have repeated it at least three times on all the other amendments. While I welcome the amendment, I hope we can work towards something that strengthens the Bill even further.

Under the amendment, regulations would be made governing the doctors who could fill the role in the clause. Those doctors would have to undergo mandatory training in respect of domestic abuse, including coercive control and financial abuse. Giving doctors that training would not remove the danger that they will overlook evidence of abuse and coercion, but it should decrease it. The doctors we are talking about will spend less time talking to the person seeking assisted death than either the co-ordinating or the independent doctors. None the less, they will spend some time with that person, so I thank my hon. Friend the Member for Batley and Spen—sorry, Spen Valley; I keep going back to Batley and Spen, but we campaigned hard to get her elected there.

[Stephen Kinnock]

There are some amendments in this grouping—namely, amendments 210 and 49—that we worked on with my hon. Friend the Member for Spen Valley, and I will come to them later in my remarks.

If amendment 408 is passed, the person to whom assistance is being provided would have to be consulted before they consent in writing to another medical practitioner being authorised to carry out the co-ordinating doctor’s functions. All registered medical practitioners must uphold the standards set out in the General Medical Council’s “Good medical practice”, which requires registered medical practitioners to support patients to make informed decisions prior to consenting. Therefore, the proposed amendment may have relatively minimal impact.

Turning to amendment 210, clause 19(2)(b) sets out that a registered medical practitioner may be authorised to carry out the co-ordinating doctor’s functions only where they have

“completed such training, and gained such qualifications and experience, as the Secretary of State may specify by regulations.”

The purpose of the amendment is to provide that the required training, qualifications or experience are to be determined by a person or organisation specified in the regulations. An example of such a specified organisation might be the General Medical Council. Allowing for that to be specified in regulations rather than on the face of the Bill ensures flexibility.

Amendment 499 provides that where a registered medical practitioner who is authorised to carry out the functions of the co-ordinating doctor is not satisfied that all matters have been met, they must notify the co-ordinating doctor immediately.

If amendment 22 is made, regulations made by the Secretary of State on the necessary training, qualifications and experience of the named registered medical practitioner who is authorised by the co-ordinating doctor to carry out the co-ordinating doctor’s functions under clause 18 would need to include mandatory training relating to domestic abuse, including coercive control and financial abuse. The Committee has already made equivalent changes to requirements on training for the co-ordinating and independent doctors, so this amendment would bring the clause into line, should the co-ordinating doctor change, for the purposes of clause 18. Should this amendment be accepted, it would require setting up training mechanisms to equip registered medical practitioners with the knowledge and skills needed to identify domestic abuse, including coercive control and financial abuse.

On clause 19—sorry, I was going to refer to clause 19 stand part. That is the end of my observations.

--- Later in debate ---

[Naz Shah]

I thank the hon. Member for his intervention.

We should be using the world-class pharmaceutical regulator we already have to oversee the drugs that will be used for assisted dying, and I urge all Committee members to support the amendment, which is a very important safeguard.

[Stephen Kinnock]

It is a pleasure to serve under your chairship, Mr Dowd.

The Government’s assessment of amendment 465 is that it would significantly impact the legal and operational delivery of the Bill. The Government anticipate that all substances used for assisted dying will have existing licences from the Medicines and Healthcare products Regulatory Agency for other indications, but the amendment would require the approved substances to be licensed by the MHRA specifically for the purpose of assisted dying. That would require additional powers or provisions to ensure consistency with the current legal framework. The Bill does not currently provide for that, so the amendment would create significant issues for the Bill’s operability.

Amendment 466 would require there to be scientific consensus regarding the efficacy of the substances to be used in assisted dying under the Bill. The availability of scientific evidence related to the substances used for assisted dying is limited and varied across international jurisdictions. Although expert advice from clinicians and scientists will be fundamental to agreeing a list of approved substances for this purpose, in any area of medicine it would be challenging to achieve consensus on the medicines or substances to be used. The amendment may therefore open up the regulation-making process to legal challenge on the basis that there is not unanimity, and that might extend the implementation process. In addition, there may be variations in product availability and in clinical practice among countries, and that may require different substances or combinations of substances to be used.

Secondly, the amendment would narrow the scope of the duty, focusing on the drug’s efficacy in eliminating pain as a priority impact over other factors that may be considered. Our assessment is that the experience of pain is subjective. The amendment may limit the ability of a doctor to make an appropriate clinical decision on which approved substances to prescribe for their patient. The decision on an appropriate approved substance would be a clinical decision between the doctor and the person seeking assisted dying, having regard to the needs of the relevant person, including that person’s experience of pain.

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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Tuesday 18th March 2025 Public Bill Committees

[Stephen Kinnock]

I am acutely conscious that every word we say in this Committee is on the record. My hon. Friend makes a valid point in that context.

The purpose of amendment 253 is to clarify that a person acting as a proxy can both sign and revoke a declaration on behalf of a person seeking assistance under the Bill. This amendment would extend the provisions under clause 15 to a person who is acting as proxy to the person seeking assistance under the Bill, enabling the proxy to act on behalf of the person to cancel their first or second declaration if they are unable to sign their own name by reason of physical impairment, being unable to read or for any other reason. I note that the cancellation of a declaration is governed by clause 14, and the cancellation may be given orally, via writing, or

“in a manner of communication known to be used by the person”.

It does not require the signature of the person seeking assistance under the Bill, so a proxy may not be required for some people in relation to revoking a declaration, even if they have been required under clause 15.

[Naz Shah]

On the point made by the Bill’s promoter, my hon. Friend the Member for Spen Valley, should the issue of proxy end up before a court, what will be relied on—the conversation that we are having here and the intentions stated in Committee, or a future statutory instrument and what the Secretary of State puts in the guidance?

[Stephen Kinnock]

The regulations will have primacy, and will be shaped by a range of inputs, including the conversation we have just had in Committee. The process is that the Bill gets Royal Assent, then the regulations are drawn up based on a range of consultations and inputs—including the Hansard. The regulations then become the basis on which this proxy process is managed, enforced and executed.

[Naz Shah]

I genuinely want to understand this issue. Even though we have had this conversation in Committee, what if the Secretary of State, following those consultations, decides otherwise? What recourse do we as a Committee have to challenge that?

[Stephen Kinnock]

The Bill, once it becomes an Act, places a legal duty on the Secretary of State to produce those regulations. The Secretary of State would be in breach of the law if he were not to enforce the conclusions of the Act.

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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[Naz Shah]

The hon. Member for East Wiltshire makes an important point. Where are the opportunities? When doctors are doing the assessment.

The other issue that speaks to me is the question of internalised bias. We will have professionals with subconscious bias or affirmed bias. They will be clinicians who have chosen or agreed to take part in the process; fundamentally, the majority of clinicians will not take part in this process because of their beliefs. It changes the relationship between doctor and patient from a societal perspective.

I know that a number of times I have been stopped during a process and asked a different question, and at times that opportunity for reflection—even without the pressure of knowing I have only six months to live—is of benefit to me. I am sure that others would benefit from it, too, particularly because the decision is so momentous. For that reason, I will certainly support amendment 468.

I thank my hon. Friend the Member for Spen Valley for tabling amendment 201. I have mixed views on it. I appreciate what my hon. Friend the Member for Luton South and South Bedfordshire said about medical records, especially when it comes to women and their past, but I also appreciated what my hon. Friend the Member for Ashford said about his experience from a mental health perspective.

I am still thinking about the amendment and I am not sure whether I will support it or not, but further thought needs to be given to the subject. There are the issues of mental health and women’s rights, but another issue applies, too. If someone has experienced trauma in childhood but that trauma has come out much more recently, even though it does not necessarily affect the decision at hand—whether to choose an assisted death—is there some kind of historical post-traumatic stress disorder that would then need to be explored? I do not have the answer, but I look forward to hearing the comments of my hon. Friend the Member for Spen Valley on that point. I would value hearing whether she has thought about that and what her understanding of it is.

[Stephen Kinnock]

As I have mentioned before, the Government have worked closely with my hon. Friend the Member for Spen Valley on some mutually agreed amendments, including amendments 201, 422 and 433. The amendments that the Government support aim to ensure the legal robustness and operability of the legislation, should it pass, and I will offer a technical explanation for them.

Amendment 201 will clarify the wording in clause 9 on the doctor’s assessment. It provides that the duty on an assessing doctor to examine a person’s medical records applies only to records that appear relevant to the doctor. The effect of the amendment is to make clear as part of the assessment process that the assessing doctor is required only to review medical records that are considered by the doctor to be relevant to the person’s request to seek an assisted death.

Amendment 422 would add an additional requirement on an assessing doctor to make inquiries of professionals who are providing or who have recently provided health or social care to the person and make such other inquiries as the assessing doctor considers appropriate. This applies to—

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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Naz Shah]

Thank you, Mr Dowd.

I come back to the issue of potential coercive control, which is what amendment 20 addresses. As I have outlined, there are patients who could be in that position. Given the examples that I have put before the Committee, I argue that the amendment, although it is brilliant in getting us to a better place than where we started out with the Bill—I am pleased that my hon. Friend the Member for Spen Valley has indicated that she is happy to discuss strengthening the safeguards—does not go far enough, for the very reasons that I have outlined, and no doubt will outline further when speaking to other amendments.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Dowd. As I have said, the Government remain neutral and my role is not to offer a Government view on the merits of the amendments, but to provide a factual explanation of their technical and practical effect to assist the Committee in its scrutiny.

The Government remain committed to ensuring the legal robustness and workability of all legislation, so I have worked closely with my hon. Friend the Member for Spen Valley on some amendments. Where changes have been mutually agreed by my hon. Friend and the Government, I will offer a technical, factual explanation and rationale for the amendments. Those include amendments 185 and 186 in this group. The Government remain neutral on the Bill and do not have a position on assisted dying.

This group relates to the necessary training, qualifications and experience of the co-ordinating doctor. As drafted, clause 5 gives the Secretary of State the power to specify the training, qualifications and experience required for a registered medical practitioner to act as a co-ordinating doctor, but there is no legal duty for the Secretary of State to do so. Amendments in this group either seek to change that power to a legal duty, or would introduce specific training, qualifications and experiential requirements for a registered medical practitioner to act as a co-ordinating doctor.

Amendments 185 and 186 tabled by my hon. Friend the Member for Spen Valley would introduce a duty on the Secretary of State to make regulations regarding the necessary training, qualifications and experience of the co-ordinating doctor. Giving the Secretary of State a duty rather than merely a power would ensure certainty as to the training, qualifications and experience that the registered medical practitioner must have in order to act as a co-ordinating doctor. The Secretary of State’s duty in this respect would include making provision in regulations about training for co-ordinating doctors relating to assessing capacity and assessing whether a person has been coerced or pressured by another person. Amendment 186 would also enable the Secretary of State, subject to the specific training requirements already mentioned, to delegate the determination of the training, qualifications and experience needed for a co-ordinating doctor to a person specified in the regulations. That would allow that determination to be delegated to a body or bodies with appropriate expertise, in line with other aspects of training for healthcare professionals.

--- Later in debate ---

[Stephen Kinnock]

The challenge in the hon. Gentleman’s amendment is the term “total turnover.” A GP would have to extrapolate from the service provided to a whole range of other costs that may apply—for example, the share of the overhead they pay into their primary care network, the share of admin costs or the rent on their building. The definition of total turnover is the entire cost and entire revenue from the tariffs. As officials have made clear, this additional level of complexity would be an onerous task, although not necessarily impossible.

Total turnover is one side of this issue; the other, much more salient point is the quantum leap between having transparency on a particular tariff and pointing at a specific doctor and saying, “You over there—you did this much work on that much tariff, and that’s how much money you made for it.” There is a big difference between the two.

[Naz Shah]

I also do not like the idea of doctors being identified in such a way, as they have with abortion clinics, but I am trying to understand how we will protect these services. If it is an NHS provision and specialty, with doctors in certain practices signing up to provide services for assisted dying and becoming either the primary or the secondary doctor, by definition those will be the practices to which people will refer. That will become common knowledge, just as it is for musculoskeletal or podiatry services, for example. In this instance, there would be an assisted death service, and there would clearly be practices that do not provide it. How would we then protect the doctors? How will the Government respond to all these concerns?

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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[Stephen Kinnock]

This series of amendments relates to the various discussions and assessments that registered medical practitioners, co-ordinating doctors and independent doctors will have with individuals seeking assistance to end their life in accordance with the Bill. In particular, they seek to amend the requirement for recording information about those discussions. As I have done throughout, I will limit my remarks to comments on legal and practical impacts of amendments. In executing our duty to ensure that the legislation, if passed, is legally robust and workable, the Government have worked with the hon. Member for Spen Valley on amendments to the Bill, including new clause 19 in this group.

Amendment 345 would require the registered medical practitioner, following a preliminary discussion with a person, to record and document in that patient’s medical records the discussion and any information provided to the patient, and it would require them to provide a copy to the patient.

Amendment 288 adds an additional requirement on the registered medical practitioner who conducts an initial discussion with the person on the subject of an assisted death to record all efforts to dissuade a person from ending their own life in the person’s medical records, and subsequently to make those records available to the medical examiner. As drafted, it is not clear whether the wording “all efforts” is intended to include efforts made by the registered medical practitioner alone, or to include efforts made by others that could be reported to the registered medical practitioner. Further clarity would be needed to establish the practical implications of the amendment. The amendment does not require this information to be recorded at a specific time. I would also note that, operationally, medical examiners are not involved in scrutinising all deaths. Some deaths are investigated by coroners. Clause 29 will consider inquests and death certifications in relation to assisted death.

Amendment 297 requires a full written transcript to be produced for any consultations that occur as part of the first assessment undertaken by the co-ordinating doctor. That would potentially add some operability challenges and, if passed, we would want to explore those further. For example, there could be situations in which the person seeking assistance does not want there to be a written transcript. Further clarity is also required on whether the amendment intends to capture only consultations between the co-ordinating doctor and the patient, or whether it also intends to capture conversations with relevant persons other than the person seeking an assisted death.

I turn now to amendment 295. As the Bill stands, if, having carried out the first assessment, the co-ordinating doctor is satisfied that the person being assessed has met all requirements in clause 7(2), the co-ordinating doctor must:

“(a)make a statement to that effect in the form set out in Schedule 2, and sign and date it,

(b) provide the person who was assessed with a copy of the statement, and

(c) refer that person, as soon as practicable, to another registered medical practitioner who…is able and willing to carry out the second assessment”.

Amendment 295 seeks to add an additional requirement for the co-ordinating doctor to

“collate all evidence provided regarding the condition of the patient in a document to be provided to the Medical Examiner and the…Chief Medical Officer after the person has received assistance to die”

in accordance with the Bill. The aim of the amendment is to ensure that the documentation will be available when required by the medical examiner.

[Naz Shah]

The Minister referred to a patient not wanting to keep a written record. How does that fare if there is a potential issue of negligence later on? Is that not a requirement of every NHS service that we provide? For example, in the case of a kidney donation where an independent assessor was needed, the details would have to be kept. I am just a bit confused. I wonder if the Minister might comment on that.

[Stephen Kinnock]

The challenge we found with amendment 297 is that it is not entirely clear what would happen if the person were to say expressly that they did not want a written record. That eventuality is not baked into the Bill as it is currently drafted, so I think it would require a lot of thinking through—again, we are back to the law of unintended consequences—about the impact the amendment would have in certain circumstances if, for example, someone were to say expressly that they did not want a written record. That is the question: the impact of the amendment is not clear.

[Naz Shah]

If that is an issue, then it is my understanding, being new to Bill Committees, that it is not because the provision is poorly drafted, but because the outcome is not clear. Can the Government not clarify that on Report or Third Reading? I have heard nothing from the Government, even where they are supportive of amendments, about going away and looking at them. There is none of that conversation coming from the Government. Perhaps the Minister will comment on that.

[Stephen Kinnock]

As my hon. Friend knows, there will be an impact assessment on the Bill once it has cleared Committee. The Government’s impact assessment would be based on the Bill as it cleared Committee, so it would include the amendment we are discussing, if it were to pass. As things stand, I cannot tell her what the impact of the amendment would be in the event that it passed, because that has not been thought through from all the different angles, including if someone were to expressly say that they did not want a written transcript.

I turn to amendment 300, which would require a full written transcript of the second assessment as a record of the conversation. This goes further than the requirement that the Bill currently places on the independent doctor, which is to make a statement in the form in schedule 3. As with amendment 297, further clarity is required on whether the amendment is intended only to cover consultations with the patient, or whether conversations with other individuals should also be transcribed.

Amendment 302 would require the independent doctor to provide details of the way in which the second assessment was conducted alongside a written transcript of any consultation to the relevant chief medical officer and the person’s GP.

--- Later in debate ---

[Naz Shah]

The Minister is being very generous with his time. I want to understand the idea that someone might say that they do not want a written transcript, when everybody in our country who uses the NHS has a written medical record. Why, in this instance, are the Government of the view that we should stray from normal practice?

[Stephen Kinnock]

I think it reflects the fact that, as the Committee has agreed, we are in uncharted territory on a whole range of issues here. I think it is best to think through the implications of every amendment. If it passes, every clause of the Bill will have to be assessed for its potential impact. I have other questions about amendment 297 in my notes. Does it intend to capture only the consultations between the co-ordinating doctor and the patient, or does it intend also to capture conversations with relevant persons other than the person seeking an assisted death? That is not clear from the amendment. What I am saying is that it poses more questions than it answers.

--- Later in debate ---

[Naz Shah]

The Minister is being generous with his time. I am even more confused now. Originally, the Minister suggested that a patient might not want a transcript, but in response to the question from my hon. Friend the Member for Spen Valley, he mentioned that under new clause 19 people will have access to their written records. That appears to be a contradiction. I just want to nail this down. What will it be? If a patient does not want a written record, we would not have a written record to access, so that contradicts the Minister’s response. I want to understand exactly what the Minister is suggesting.

[Stephen Kinnock]

The Government have worked with my hon. Friend the Member for Spen Valley on new clause 19. The Government’s view is that if the Committee accepts it, then that new clause will provide the level of robustness and resilience that the system requires. The Government are not convinced that, on its own, the amendment that my hon. Friend the Member for Bradford West is talking about would provide the level of robustness and resilience we would be looking for. As things stand, the choice has been made to work with my hon. Friend the Member for Spen Valley on new clause 19, and we are satisfied that that would provide us with the operational integrity we need.

Amendment 302 would require the independent doctor to provide details of the way in which the second assessment was conducted, alongside a written transcript of any consultation to the relevant chief medical officer and the person’s GP. The independent doctor would be required to maintain a copy of that record to provide to the relevant medical examiner.

As I have mentioned, in executing our duty to ensure that the Bill, if passed, is legally robust and workable, the Government have worked with my hon. Friend the Member for Spen Valley on new clause 19. The new clause would require a practitioner to include a record of a preliminary discussion having taken place under clause 4. The record of the preliminary discussion must be included in the person’s medical records. Where the medical practitioner is a member of the person’s GP practice, they must make such a record in the person’s medical records as soon as practicable. Where the medical practitioner is not a member of the person’s GP practice, they must, as soon as practicable, provide a written record of the preliminary discussion to a medical practitioner at the person’s GP practice, who will then be required by the new clause to include it in the person’s medical records as soon as practicable.

The Committee may wish to note that amendment 424 would add a definition of “preliminary discussion” to the Bill that would make it clear what discussion medical practitioners would be required by law to record.

That concludes my remarks on this group. I thank the Committee for its attention.

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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[Dr Tidball]

I will make progress.

In reply to a question from me about those who are seeking assistance, Dr Jane Neerkin, a consultant physician in palliative medicine, said:

“For them, it is about trying to regain some of that control and autonomy and being able to voice for themselves what they want. That is what I tend to see that people want back at the end of life.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 201, Q263.]

Importantly, amendments 183 and 275 would strengthen clause 4 to ensure that we avoid a situation that gives those with the most social capital more choice, while leaving those who might otherwise be unaware of all other options available to them without that choice. If the Bill is passed by Parliament without them, it will exacerbate health inequalities rather than abating them.

Together, the amendments expound and elaborate on the need for discussion of all appropriate palliative and other end-of-life options available to someone with a six-month terminal illness. I commend them to the Committee.

[Stephen Kinnock]

The amendments would make changes to the discussion between the medical practitioner and the patient. They are largely focused on clause 4, on the initial discussions, but several are thematically linked or related to later clauses.

Amendment 342 would impose a requirement on the registered medical practitioner to conduct a preliminary discussion with a person where that person has indicated that they wish to seek assistance to end their own life. As it stands, the Bill allows registered medical practitioners to opt out should they not wish to hold that conversation with someone, although they have an obligation under clause 4(5) to refer an individual to another medical practitioner for that discussion.

The amendment would remove that discretion and thus remove the opportunity for a medical professional to opt out of having the preliminary discussion. That may conflict with the principle set out in clause 23 that no registered medical practitioner or other healthcare professional is under any duty to participate in the provision of assistance. Our analysis suggests that in removing discretion as to participation, the amendment could interfere with an individual’s rights under article 9 of the European convention on human rights, on the freedom of thought, belief and religion, and article 14, on the prohibition of discrimination.

Amendment 285 would require the registered medical practitioner who conducts a preliminary discussion with a person on the subject of an assisted death to discuss with them, in consultation with a specialist, the person’s diagnosis and prognosis, any treatments available and their likely effects, and any available palliative, hospice or other care. The amendment would therefore require additional registered medical practitioners or other specialists to be consulted as part of the preliminary discussion under clause 4(4). The additional time required for consultation with specialists would be likely to lengthen the period over which a preliminary discussion can take place.

I also note that clause 9, “Doctors’ assessments: further provision”, will already require the assessing doctor to make such other inquiries as they consider appropriate in relation to the first and second assessments.

[Naz Shah]

The Minister’s point speaks to what my hon. Friend the Member for Stroud and I have spoken about in relation to the amendment, so I wonder which bit he supports. The Minister says that there will be extra time, but my hon. Friend pointed out that doctors do this routinely, so the objection is only that it will be on the face of the Bill. I just want to understand the Minister’s position on that.

[Stephen Kinnock]

If I understood the point that my hon. Friend the Member for Stroud was making, I think it was that the basic provisions in place enable doctors to carry out their work based on their experience and expertise, whereas the amendment would require additional registered medical practitioners or other specialists, so that would be in addition to what my hon. Friend was talking about.

I turn to amendment 343. As the Bill stands, a registered medical practitioner undertaking a preliminary discussion with a patient is required to discuss the person’s diagnosis and prognosis. The amendment would require a registered medical practitioner also to discuss any relevant probabilities and uncertainties of a person’s diagnosis and prognosis. It would put an additional legal requirement on what needs to be discussed during the preliminary discussion with the patient. In considering whether the amendment is required, the Committee may wish to note that all doctors acting in accordance with the General Medical Council’s “Good medical practice” are expected to discuss uncertainties about diagnosis and prognosis, and potential risks and uncertainties about treatment.

Under clause 4, the registered medical practitioner conducting the preliminary discussion must discuss any treatment available to the patient and the likely effect. Amendment 344 would require the registered medical practitioner conducting the initial discussion to discuss, as part of the conversation on the treatments available, the risks and benefits of such treatment, potential side effects and the impact of the treatment on the person’s quality and length of life. As with amendment 343, the Committee may wish to note, when considering whether the amendment is required, that all doctors acting in accordance with “Good medical practice” are expected to discuss the risks, benefits, uncertainties and the likelihood of success of treatment with a patient.

Amendment 275 would change the wording of clause 4(4)(c) to “all appropriate palliative hospice and other care”. That would require a registered medical practitioner who conducts a preliminary discussion with a person on the provision of an assisted death to explain and discuss palliative and hospice care on the basis of appropriateness for the individual, not on the basis of the care that is available. Clause 4(4) sets out that a registered medical practitioner who conducts the preliminary discussion on assisted dying must, as part of that discussion, explain and discuss the person’s diagnosis and prognosis, any treatment available and the likely effect—

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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[Naz Shah]

I apologise to my hon. Friend the Member for Sunderland Central; I was actually incorrect. The girls did not have capacity, so he was correct. However, in the cases that went before the court, those nine girls did not have capacity yet the judge made a decision that they should not be force-fed to keep them alive, and they should be allowed to die. Perhaps the Minister could comment on how the amendment would not meet that criteria. Would it fix that loophole?

[Stephen Kinnock]

I thank my hon. Friend for her intervention. I am just talking about the amendment to reduce the time from six months to one month. I will come on to the issue of eating and drinking in a second.

As amendment 282 would reduce the time within which the person is expected to die from six months to one month, it would also limit the number of people with a terminal illness who would be eligible for assisted dying under this legislation. Furthermore, there may be very challenging workability issues in delivering a service within one month, given the other time-dependent safeguards elsewhere in the Bill.

Amendment 51 would remove the requirement for the patient to have a six-month prognosis to be defined as “terminally ill”. If agreed to, it would expand the pool of people eligible for lawful assistance to voluntarily end their own life beyond those with a life expectancy of six months or less. In other words, it would remove the timeframe requirement of when death can be reasonably be expected.

Amendment 234 would widen eligibility to include cases of neurodegenerative diseases, illnesses or medical conditions where a person is reasonably expected to die within 12 months. Matters such as this are for the Committee, and ultimately for Parliament, to decide, but it is clear that the effect of the amendment would be to broaden the number of people eligible for lawful assistance to voluntarily end their own life under this legislation.

Amendment 10 would provide that, if treatment exists for a person’s progressive illness, disease or medical condition that alters the overall prognosis of that person’s condition, they are not terminally ill and would not be eligible for assisted dying services.

Amendment 402 would exclude a person who would not otherwise meet the definition of “terminally ill”—namely, being diagnosed with an inevitably progressive illness with six months or less to live—if that person meets that definition as a result of stopping eating or drinking. The effect of the amendment would be to prevent a person from being defined as “terminally ill” as a result of their own actions of stopping eating or drinking, or both. The Government’s analysis suggests that this may also exclude people who are terminally ill under the definitions of the Bill and who are, for various reasons, unwilling or unable to eat or drink. For example, it may include those with conditions such as oesophageal cancers, which could result in their being unable to eat or drink.

Furthermore, it is unclear whether someone who is on intravenous fluids or being fed through a feeding tube would be considered to have stopped eating or drinking under the amendment. I think that addresses the concern expressed by my hon. Friend the Member for Bradford West, but she is welcome to intervene again if she would like to. The amendment could therefore lead to uncertainty over the person’s eligibility for assistance under the Bill.

The Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could be changed. Questions around the definition of terminal illness and who should be eligible to access voluntary assisted dying under the legislation are matters for the Committee and for Parliament as a whole. However, I hope that these observations are helpful to the Committee in considering the Bill and the amendments tabled by various Members.

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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[Naz Shah]

I just have some concluding remarks. None of the amendments was voted for. I feel that in the clause 1 stand part debate, huge opportunities have been missed. I have talked a lot, throughout the debates, about the issues of people from ethnic minority communities. Opportunities were missed to safeguard disabled people and people from ethnic minority backgrounds.

My hon. Friend the Member for Ipswich made a point about amendments being clear, and about ambiguity. The truth is that if the amendments were supported in principle, they could have been tidied up by Government. There are some good amendments that could have been clarified by the Government. In principle, they were good options. I struggle with the whole narrative throughout the debate on clause 1: “Yes, we accept the principle, but we are not going to do it because it is ambiguous or the wording is incorrect.” There is lots of wording that we will debate throughout the rest of the Bill that is not quite clear, and that is the whole point of going through this exercise. Going forward, I encourage us, as the hon. Member for Reigate did before me, to do as we have been doing, with sincerity, in trying to make this Bill the best in the world it can be, as my hon. Friend the Member for Spen Valley intends.

[Stephen Kinnock]

I will make some brief remarks on the legal and practical effect of clause 1, as amended, to assist hon. Members in making their own assessment. Clause 1 sets out the eligibility criteria that a person must meet in order to request to be provided with lawful assistance to end their own life under the provisions of this Bill. A person must be terminally ill; this term is defined in more detail in clause 2.

Clause 1(1) sets out a further four requirements, which require that a person must also have the necessary capacity to make the decision, which is to be read in accordance with the Mental Capacity Act 2005; be aged 18 or over; be ordinarily resident in England and Wales and have been resident for at least 12 months; and be registered as a patient with a GP practice in England or Wales. This clause provides that, in particular, clauses 5 to 22 of the Bill require steps to be taken to establish that the person has a clear, settled and informed wish to end their own life and has made the decision that they wish to end their own life voluntarily and has not been coerced or pressured by any other person in making that decision.

The clause, as amended by the insertion of new subsection (3), will ensure that the service can be accessed only by an individual ordinarily resident in England and Wales. That amendment, amendment 180, has been drafted to give effect to the policy intent of my hon. Friend the Member for Spen Valley for this legislation: that it is to apply only to those in England or Wales and is not to be accessed via medical tourism.

As I have said, the Government remain neutral on the substantive policy questions relevant to how the law in this area would be changed. The clause is a matter for the Committee and Parliament to consider, but the Government’s assessment is that the clause, as amended, is workable, effective and enforceable.

Question put and agreed to.

Clause 1, as amended, ordered to stand part of the Bill.

Clause 2

Terminal illness

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

Debate between Naz Shah and Stephen Kinnock

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[Naz Shah]

I thank my hon. Friend, but I feel that the point is being missed. It is true that there is no framework, but for somebody to get to this point in the first instance they need to have a terminal illness. There is a framework around domestic violence, and domestic violence laws exist for everybody. Frameworks already exist for women fleeing domestic violence, and there is no shortage of attempts to try to get those legal frameworks right across society. That is why we had the Domestic Abuse Act 2021, why we have committed to halving violence against women and girls, and why the Prime Minister made a personal commitment in that regard—and rightly so.

There has already been a test case in which a judge said that medics have an obligation in this context. An hon. Member referred yesterday to assisted dying being a treatment, although I disagree, and we had that conversation later.

[The Minister for Care (Stephen Kinnock)]

That was a misunderstanding; I was talking about “treatment” as a legal term.

[Naz Shah]

No, I was talking about another hon. Member, not the Minister. We already have laws to protect people from domestic violence, but that does not mean that they necessarily access them.

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

Debate between Naz Shah and Stephen Kinnock

Tuesday 11th February 2025 Public Bill Committees

[Stephen Kinnock]

The fundamental position of the Government is that the Mental Capacity Act as it stands is a known quantity. It provides the legal base for a whole range of measures and interventions, and the Government’s view is that it would be an adequate legal base to operationalise the Bill should it receive Royal Assent. Our position on it goes no further than that; it is simply a matter of fact that there is a piece of legislation that is a known quantity.

[Naz Shah]

The Minister makes an important point. I just want to understand something. He speaks on behalf of the Government and says that the Mental Capacity Act is an adequate legal base as it stands. Perhaps the issue is just that I am new to the process—I am happy to be guided, Sir Roger—but we have not had an impact assessment. Normally, Bills do have impact assessments beforehand and the Government go out to consult; they have a consultation process. None of that has happened because the Bill is a private Member’s Bill. I am just trying to understand: is what has been said still true? How do the Government come to that conclusion without all those robust mechanisms that would normally go before a Government Bill?

--- Later in debate ---

[Stephen Kinnock]

The amendments relate to the criteria that individuals would need to meet to request assistance to die under the Bill. All the amendments seek to amend the eligibility criteria in some manner. To reiterate, the Government have no view on the policy questions pertaining to the amendments, and my role here is to offer observations on the legal and practical impact of amendments tabled. The legal impact of these amendments will be the main focus of my remarks.

Amendment 353 seeks to make prisoners ineligible for assisted dying services even if they meet the definition of having a terminal illness. Amendments 354 and 355 are consequential amendments that would make it a requirement for the co-ordinating doctor in the first assessment and the court process to ascertain whether a person seeking assistance to end their own life is a prisoner.

Aside from the right to liberty, article 5 of the European convention on human rights requires that prisoners should have the same rights as those who are not prisoners. The rights engaged by the amendment are article 8 on the right to respect for private and family life and article 14 on the protection from discrimination. Making prisoners ineligible for assisted dying would, on the face of it, lead to a difference in treatment between prisoners and non-prisoners that would need to be objectively and reasonably justified. The justification test requires that the treatment in question is a proportionate means of achieving a legitimate aim.

[Naz Shah]

I note that the Minister used the word “treatment” twice, but we are not talking about a treatment; we are talking about assisted death. I think someone mentioned earlier that it is a treatment, but it is not a treatment, is it? I would welcome his clarification on that.