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

Neil Shastri-Hurst Excerpts

Committee stage
Tuesday 18th March 2025 Public Bill Committees

[The Chair]

I remind the Committee that with this we are discussing the following:

Amendment 463, in clause 18, page 12, line 34, leave out paragraph (c).

Amendment 497, in clause 18, page 13, line 9, leave out “decides” and insert

“informs the coordinating doctor that they have decided”.

This amendment provides that the duty to remove the approved substance arises on the coordinating doctor being informed that the person has decided not to self-administer the substance.

Amendment 498, in clause 18, page 13, line 10, leave out

“that the substance is not”

and insert

“to believe that the substance will not be”.

This amendment clarifies the circumstances in which the coordinating doctor is under a duty to remove the approved substance from the person.

[Dr Neil Shastri-Hurst (Solihull West and Shirley) (Con)]

It is a pleasure to serve under your chairmanship, Sir Roger. My hon. Friend the Member for East Wiltshire was mid-intervention when the Committee adjourned this morning, and I would not want to pull the rug from underneath him. Does he wish to intervene again?

[Danny Kruger (East Wiltshire) (Con)]

I am grateful to my hon. Friend. I was simply asking what causes him to object to physician-administered assistance to die. If he supports the principle of assisted suicide and believes in doctor autonomy, why does he not think that doctors should be able to administer the fatal dose?

[Dr Shastri-Hurst]

This gets to the root of how the law has operated in another jurisdiction, Switzerland, where Dignitas has managed this scenario over the past 40 years or so. The key—these are the words that its own guidance uses—is ensuring that the power of control remains with the person seeking the assisted death. That provides the individual who is making the choice with the ultimate autonomy at the end in controlling the circumstances and the manner in which they pass.

I have set out why I feel that although amendment 463 arises from good intentions, it would not achieve what is intended. There is a real risk that the constraints that adopting the amendment would create would lead to the regrettable unintended consequence of individuals being forced to have an assisted death at an earlier stage than they would otherwise have wished.

I can deal with amendments 497 and 498 in short order. They would tighten up the Bill by providing greater clarity around the circumstances in which the substance would be removed from the presence of the individual who had previously indicated a wish to have an assisted death. Amendment 497 specifies that the individual would need to set out to the co-ordinating doctor that they no longer desired to go through with the process. In my view, that is eminently sensible. Amendment 498 elaborates on the Bill to provide greater clarity to those who will be operating it. It will make it a much more workable piece of legislation. I support both amendments.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Sir Roger. Before I speak to amendments 497 and 498, on which the Government have worked with my hon. Friend the Member for Spen Valley, let me address amendments 462 and 463.

Amendment 462 would amend clause 18 to require the co-ordinating doctor to explain to the person that they do not have to proceed and self-administer the approved substance, and that they may still cancel their declaration. Although it is not specified, it is presumed that the amendment refers to the second declaration that the person will have made. The Committee may wish to note that there is already a requirement in clause 18(4)(b) that,

“at the time the approved substance is provided”,

the co-ordinating doctor must be satisfied that the person

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

The purpose of amendment 463 is to limit what the co-ordinating doctor is permitted to do in relation to providing the person with an approved substance under clause 18. As the clause stands, subsection (6) sets out the activities that the co-ordinating doctor is permitted to carry out in respect of an approved substance provided to the person under subsection (2). It states that the co-ordinating doctor may

“(a) prepare that substance for self-administration by that person,

(b) prepare a medical device which will enable that person to self-administer the substance, and

(c) assist that person to ingest or otherwise self-administer the substance.”

Additionally, subsection (7) provides that

“the decision to self-administer the approved substance and the final act of doing so must be taken by the person to whom the substance has been provided.”

Amendment 463 would remove subsection (6)(c), which would result in the co-ordinating doctor being unable to assist the person

“to ingest or otherwise self-administer”

the approved substance. The co-ordinating doctor would still be permitted to prepare that substance for self-administration and to prepare a medical device to enable the person to self-administer the substance. This could mean that a co-ordinating doctor may not be able to provide assistance such as helping the person to sit up to help with swallowing, or explaining how the medical device for self-administering the substance works. This could result in practical difficulties in self-administration of the substance and/or place the co-ordinating doctor in a difficult position.

--- Later in debate ---

[Danny Kruger]

I am absolutely certain that if the amendment had been in the original Bill, the Bill would not have passed Second Reading, because it would have validated the argument that many of us made that the implication of assisted suicide is euthanasia. The distinction between them, while valid in the abstract, does not apply in practice, and that distinction will be quickly overridden in time. I agree with the hon. Gentleman.

[Dr Shastri-Hurst]

Although I have certain sympathies with these amendments, I do not feel that they are necessary or desirable. They are not necessary because of the provisions that are already stipulated in clause 18(6)(b), which provides the co-ordinating doctor with the ability to prepare

“a medical device which will enable that person to self-administer the substance”.

That subsection, in effect, negates the scenario that is put forward in amendment 350 around dysphagia or the loss of a limb. It would permit, for example, the use of a nasogastric tube or a percutaneous endoscopic gastrostomy feeding tube to be used for the administration of the substance in the case of dysphagia. In the case of the functional loss of limbs, as was discussed in the debate on the previous group, a range of assisted technologies are available that would remove the barriers that that would present.

Beyond the necessity, or lack of necessity, of these amendments, I fear that they create legal uncertainty, which is clearly undesirable and, in this instance, could have a serious and significant unintended consequence through the amendments’ interaction with clause 24. Subsection (3) of that clause inserts proposed new section 2AA of the Suicide Act 1961, which is an exemption to that Act in respect of the assistance provided under this Bill. In effect, proposed new section 2AA disapplies sections 2(1) and 2A(1) of the Suicide Act where the provision of assistance is done in accordance with the Bill. Those sections specifically relate to an act

“capable of encouraging or assisting the suicide or attempted suicide of another person”.

Introducing the concept of additional assistance, as these amendments would, creates a legal uncertainty. The word “additional” creates a further concept that is beyond assistance but is, thus far, ill defined. Would it go as far as, for example, the clinician taking full control of administering the substance? It is entirely unclear. It would therefore place the clinician in an invidious position as to what it would mean for them to provide additional assistance in such circumstances. As I read the interplay between the Suicide Act and the proposed legislation, the clinician would not then be exempt by virtue of clause 24(3), leaving them open to prosecution under the Act.

[Danny Kruger]

I am grateful for that; I particularly respect my hon. Friend’s concern to protect the doctors from any confusion in the law they might be operating under. Just to take him back to the question of technology resolving what I regard as an insuperable problem—the difference between assistance and administration—is it my understanding that my hon. Friend would oppose a patient’s being able to ask a doctor to administer a lethal drug to him or her, but that he would support a patient’s being able to ask a computer to administer a lethal drug to him or her? Would he accept the computer performing the act at the patient’s request?

[Dr Shastri-Hurst]

My hon. Friend hits the nail on the head, because it is the patient who is driving the decision. They are making that act by activating the electronic device—the computer or whatever it may be in terms of assistive technology—but they have the power and control over that decision-making process, which is completely distinct from a clinician doing that act. It is distinct because it is activated by the patient—by the person making that decision—and that is why I draw the distinction. My hon. Friend may not agree, but that is my rationale for drawing a distinction between the two.

[Dr Opher]

rose—

[Dr Shastri-Hurst]

I am being ambushed by the left.

[Dr Opher]

I agree with all the hon. Gentleman’s points. In terms of assistance, what we are talking about, potentially, if the technology arrives at that, is that the doctor may be able to put a Venflon into the patient’s vein, but they would not put the drug through the Venflon into the vein. That would enable the patient to have control. That is the type of assistance that could be quite useful in this scenario, but it would not involve the doctor actually delivering the drug.

[Dr Shastri-Hurst]

I am grateful for that helpful and thoughtful intervention.

For the reasons I have set out, I consider that the amendments create unnecessary and highly undesirable legal confusion, so I shall not support them.

[Stephen Kinnock]

Currently, clause 18(6) permits the co-ordinating doctor, in respect of an approved substance provided to the person under subsection (2), to undertake the following activities: prepare the approved substance for self-administration; prepare a medical device to enable self-administration of the approved substance; and assist the person to ingest or otherwise self-administer the substance. Furthermore, subsection (8) expressly provides that subsection (6)

“does not authorise the coordinating doctor to administer an approved substance to another person with the intention of causing that person’s death.”

Amendment 350 seeks to enable the co-ordinating doctor, in the presence of an independent witness, to provide “additional assistance” to the person to administer the approved substance. Such assistance can be provided only where the person has authorised it, and where the person is

“permanently and irreversibly unable to self-administer the substance”

due to a significant risk of choking due to difficulty swallowing—dysphagia—or loss of the use of their limbs. The term “additional assistance” is not defined in these amendments.

Amendment 351 is consequential to amendment 350 and would require any decision to authorise additional assistance for the self-administration of the substance to be made by the person to whom the substance has been provided. Amendment 352 would create an exception to the condition in clause 18(8), and would have the effect of permitting the co-ordinating doctor to administer an approved substance to another person with the intention of causing that person’s death where the criteria introduced in amendment 350 are met—that is, where the co-ordinating doctor is satisfied that the person is permanently and irreversibly unable to self-administer the substance, and that the person has authorised that the additional assistance be provided.

Our assessment is that the amendments would enable the co-ordinating doctor to administer the approved substance to the person, rather than merely assisting the person, in the limited circumstances provided for in clause 18(6), to self-administer. That would be a significant change to one of the fundamental principles of the promoter’s Bill—that the final act of administering the approved substance must be taken by the person themselves, and not by a co-ordinating doctor. That is a policy matter and a decision for the Committee.

However, should the amendments be accepted, further amendments may be needed to ensure that this provision is fully legally coherent and workable in several areas. First, amendment 350 does not define who qualifies as an independent witness—for example, whether this would have to be a health professional or whether it could be a family member. Secondly, it does not address whether anyone would be disqualified from being an independent witness, as provided for through clause 36, which is entitled “Disqualification from being witness or proxy”.

Finally, as drafted, amendment 350 does not detail how authorisation of the additional assistance must be obtained and/or recorded in order to be valid. It also does not require that any details about the independent witness be recorded. This could lead to difficulties in complying with and/or evidencing that the requirements to provide the additional assistance have been met. By extension, there will be a lack of clarity over when and how the criminal provisions are to apply. I hope that those observations were helpful.

--- Later in debate ---

[Rebecca Paul]

I rise to speak in support of amendment 408, in the name of the hon. Member for Broxtowe. I also support amendments 499 and 210, in the name of the hon. Member for Spen Valley, and amendment 22, in the name of the hon. Member for Lowestoft (Jess Asato).

Clause 19 states that

“the coordinating doctor may authorise, in writing, a named registered medical practitioner to carry out the coordinating doctor’s functions under section 18…A registered medical practitioner may be authorised under subsection (1) only if…the person to whom the assistance is being provided has consented, in writing, to the authorisation of that practitioner”.

I support amendment 408, which adds that the person must also have been consulted.

I am sure the Committee recognises that, even where someone has basic training and the experience specified, delegating care at the end of life is something that must be done with great care, given the vulnerability of patients. If a co-ordinating doctor has guided someone through this profound and significant process, there are some intrinsic risks that come with delegating the administration of the final approved substance to someone else. I concede that there will be situations where a substitute may be required, but it will not be the doctor that the patient has trusted, confided in and relied on.

A new doctor will of course do the final checks for capacity and consent, but they do not necessarily have any specific detailed knowledge of the patient and may be unable to pick up less obvious cues that someone who knows the patient may be better able to. That gap matters, and history shows that it can lead to problems. The risks of delegation are well documented. If we take the Mid Staffordshire NHS foundation trust scandal in 2005 to 2009, detailed in the Francis report, consultants often delegated tasks to junior staff or nurses without adequate supervision, which contributed to poor care and an estimated 400 to 1,200 excess deaths. Patients suffered from neglect, untreated infections, dehydration and medication errors. That was partly because delegated staff lacked the training or authority to act decisively, and consultants failed to monitor effectively.

In surgical contexts, delegation can also falter. A 2006 Daily Mail report highlighted NHS payouts exceeding £1 million for wrong-site surgeries, where consultants delegated preparatory or operative tasks to trainees or assistants, who then misidentified sites—for example, operating on the wrong leg or tooth. Those errors often stemmed from inadequate briefing or supervision, pointing to a systemic delegation risk. We have to be really aware of this.

Those examples suggest that when consultants delegate, whether to junior doctors or other practitioners, including their peers, things can go wrong if communication breaks down, or if the replacement lacks equivalent expertise or is simply not aware of some of the detailed information. In order to manage some of the risks better, patients must be consulted about who takes over their care, and not just asked to consent after the co-ordinating doctor has decided what will happen.

[Dr Shastri-Hurst]

Given that valid consent requires a voluntary and informed decision, can my hon. Friend set out why that would not involve being consulted on the matter in any event?