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

Rebecca Paul Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[Kim Leadbeater]

Q To that point, in those conversations where patients are making very serious decisions, it is not uncommon that you would seek additional advice from other professions, such as a psychiatrist or possibly a social worker and other professionals, if you felt there was a need to do so.

Professor Whitty: The further you go up in the seriousness of the decision, the more you would do that. For example, if you were setting a finger that had been broken, you are not going to wait until a psychiatrist has said that you can do that. Within reason, provided that someone gives consent, you will do that. You will be much more cautious about moving forward with things like open heart surgery or deprivation of liberty if you think there is uncertainty. It should be clear. For the majority of people, it is very clear they have capacity or very clear they do not. There is a relatively small—but important—number in the middle where that is less clear and where additional views are relevant, particularly where there is a question of co-existing mental health issues. The fact of the mental health condition does not in itself mean that someone does not have capacity, but what has to be taken into account is, “Do they have the capacity for this decision at this point in time?” That is how the Mental Capacity Act works.

[Rebecca Paul (Reigate) (Con)]

Q The Bill sets out that it should be brought into force within two years. If the intention is to provide assisted dying through the NHS, can the NHS be ready in time to deliver the service equitably and safely? What needs to be deprioritised in order for it do to so?

Professor Whitty: As we have seen in covid, the NHS, like any service, can swing very fast if there is a need for speed. In this case, I think most people in society would say that the key thing is to get this right. Personally, I would rather it was not running against a timeline. You would not want it to drag on forever, because then you have uncertainty for everybody, but I think Duncan and I would both say that two years seems a reasonable starting point. With some things, it might take longer than that to work out how we are going to provide this in the most safe and equitable way—for example, in dealing with minority and other groups. We need to get all that right and, at least at first pass, get it as close to good as we possibly can.

Equally, we may find when we first start using the legislation that there are some things that we had not considered at the beginning, and therefore we need to go back and improve on them because we just had not thought about them in the first way through the gates; that is why I hope that some of the more operational issues are done through secondary legislation and regulation. Inevitably, that is true for many bits of legislation, but it is particularly important here.

I go back to my very first comment: the central person here is an average citizen in their last six months of life. What we do not want is a system very difficult for them to navigate so that they spend their entire last six months of life—if the Bill is passed and they choose to take account of it; they are going to be a minority—stuck in a bureaucratic thicket. We need to keep this simple. My view is that the best safeguards are simple safeguards. Overcomplicating usually makes the safeguard less certain.

[Rebecca Paul]

Q What is a reasonable timeframe, in your view? I appreciate that that is a bit like asking, “How long is a piece of string?” What would you ideally like to see?

Professor Whitty: I think that there is a big difference between the Act coming into initial force—that is, “This is now where the law is”—and the service being provided. On the second of those, I would argue against putting a firm deadline, with a reasonable expectation that the NHS and others should be involved in trying to make plans for this as fast as possible. But if the Bill is passed, we are going to have to sort out multiple different things to get this to work. If we were three months away from being able to get something sorted out, I would not want to have a situation where it all had to start the following day. I think that would make it much harder to provide a safe, fair and secure service.

Duncan Burton: In my understanding, the Bill does not call out the NHS specifically in terms of providing this service. A number of steps would have to be gone through to understand the implications—the operational and training implications, as we have already discussed—to understand the timeline required. For the reasons Chris has outlined and as mentioned earlier, when thinking about the wider implications for the workforce there would need to be sufficient time to be able to work through those.

[Rebecca Paul]

Q Would it be fair to say that you would need to know fairly quickly whether or not it would be provided through the NHS for planning purposes?

Professor Whitty: That is a key question, and to me that does seem something that Parliament may want to debate. That is not a question for us, but it is a point of principle one way or the other.

[Liz Saville Roberts (Dwyfor Meirionnydd) (PC)]

Q I have a question for Chris Whitty. You said you are here representing the chief medical officer for Wales as well. Health has been devolved for over 25 years, of course. What conversations have you had with the chief medical officer for Wales about the differences in how the NHS operates between Wales and England? What are the implications the Bill Committee should know about?

Professor Whitty: First, I have had quite a lot of conversations—not just with the chief medical officer for Wales, but all the other chief medical officers and indeed a much wider range of the medical profession; I wanted to feel that I was giving a central view of the medical profession in terms of the practicalities. My view is that, in a sense, the principles of the Bill are no different between England, Scotland, Wales and Northern Ireland, although the legislation would apply only to England and Wales were it to be passed.

The operational questions we have been talking about will be either subtly or importantly different between the different jurisdictions for a variety of different reasons. I do not think that is a problem, provided it is in secondary legislation and it allows the different jurisdictions to do things in the way that best suits their own set-up. Again, as we saw during covid, different nations will choose to reach the same end state using slightly different practical routes.

--- Later in debate ---

[The Chair]

We will now hear oral evidence from Glyn Berry, via Zoom—hello and welcome—and from Professor Nicola Ranger. We have until 11.25 am. Will the witnesses please introduce themselves?

Glyn Berry: Good morning. My name is Glyn Berry. I am a palliative care social worker and a lead allied health professional. I am co-chair of the Association of Palliative Care Social Workers.

Professor Ranger: I am Professor Nicola Ranger, chief exec and general secretary of the Royal College of Nursing. Previously, I was a chief nurse in acute hospitals for 10 years.

[Rebecca Paul]

Q This is a question for Glyn Berry. A statement that you published in November 2024 says:

“There is a risk that without a more sustainable model of funding for palliative care, many people will choose an assisted death, as the only way to escape from unbearable suffering.”

Can you elaborate on why you say that?

Glyn Berry: Yes. As experienced social workers, working within the realms of a society that is quite often split into “have” and “not have”, we already see the despair and the difficulties that people encounter with inequitable care in palliative care services. We know that a lot of services are delivered by charities as well as statutory agencies and the trusts, and we know that the funding for palliative and end-of-life care is a real issue and has been heading that way for some years.

We would hate to see what has been happening in other countries in which assisted dying is already in place, where people feel that they have no option other than to apply for assisted dying, because they do not know what else might be out there for them. That is the role of a social worker when we work with our patients: we look at the bigger picture, not just at what is happening clinically. Obviously we depend hugely on our clinical colleagues and expertise, but our specialism, if you like, is to look at what else is out there for a patient—and for their family and friends, because they are as much a part of the patient’s journey as the patient themselves.

We also know that palliative and end-of-life care is hit and miss in terms of what people can access. Marie Curie reporting in 2024 showed that there are massive disparities in terms of better care for people at end of life or with a palliative condition, and they have a significant effect. What we say to people is that we will help them to live as long as they can as well as they can in palliative and end-of-life care situations, but that is really difficult when the resources are not there and things become a huge priority.

[Rebecca Paul]

Q What would a more sustainable model of funding for palliative care look like?

[The Chair]

Order. We are going slightly off topic, so could we have a brief answer?

Glyn Berry: It would be something that is equitable for everybody. At this moment in time, it is not. As I say, some people get it and some people do not. A sustainable model would give fair access to everybody.

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

Rebecca Paul Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[Dr Tidball]

That is very helpful; thank you.

[Rebecca Paul (Reigate) (Con)]

Q My question is to Dr Sarah Cox. What do you think will be the impact on palliative care of introducing assisted dying?

Dr Cox: Professor Ahmedzai has talked about the evidence, which was written up to 10 years ago. There is actually more recent evidence, looking at the last 10 years, where European countries and American states have been assessed in terms of the development of palliative care services. That more recent evidence shows that although palliative care services have improved in those countries where assisted dying has been implemented, they have improved three times more in countries where assisted dying has not been implemented. The evidence from that study shows that the implementation of assisted dying is impeding the development of palliative care services.

The other thing we are really concerned about is the impact on funding. It is unclear how this is going to be funded. It looks as if it is going to be within healthcare, and if so, there will inevitably be competition with other aspects of healthcare, including palliative care, for those limited resources. There are finite numbers of doctors, nurses and side rooms in hospitals. If palliative care and assisted dying were funded from the same pot, I think there would be a massive detrimental effect on palliative care because we would be in competition for a limited resource.

I am also concerned about our palliative care workforce, which we know is already in crisis. Eighty-three per cent. of our members told the Royal College of Physicians in 2023 that they had staffing gaps, and more than 50% were unable to take leave because of those staffing gaps. Forty-three per cent. said that if assisted dying were implemented within their organisation, they would have to leave. This has a massive impact on palliative care, in terms of its potential to develop both our funding and our workforce, who are really concerned about this.

[Rebecca Paul]

Q In terms of the data showing that palliative care has not improved as quickly in locations that offer assisted dying, can you offer us any further insight into why that may be? What should the Committee be thinking about, in relation to the Bill, to safeguard against that happening? I think we all agree that we do not want to see palliative care decline.

Dr Cox: The first thing to say is that palliative care is currently inadequate. Not only do we need to ensure that it does not decline, but we need to massively improve it so that this Bill offers patients a real choice. We know that effective palliative care can change a terminally ill person’s point of view from wanting to die to wanting to live.

We also know that 25% of people who die in this country do not have the palliative care they need. That is more than 100,000 people a year. Providing palliative care, which might make their lives better, reduce their suffering and even change their perspective on whether they would want assisted dying, should be our priority in reducing suffering in this group.

I do not know how we prevent this from happening. Making sure that palliative care has separate funding is important, because assisted dying and palliative care need to be separate in how they are delivered and in how they are funded.

--- Later in debate ---

[Jack Abbott]

Q In your view, and that of the rest of the panel, is there a way to legislate to include them?

Sir Nicholas Mostyn: It has been suggested that I want to expand the definition of terminal illness. I do not want to expand it. I want to redefine it so that it is more appropriately focused, in my opinion, on what this Bill should be about, which is the relief of suffering. That is what I believe the Bill should be about. You should get the permission to have an assisted death if you are suffering intolerably within five months of death or seven months of death—there should not be this arbitrary line.

Moreover, it should not be open to people who are not suffering, but who happen to have a six-month life expectancy. There are probably quite a few of them, for one reason or another, whose life expectancy is short, but their pain is well-managed. I do not believe that assisted dying should necessarily be available for them. I do believe very strongly—this is not an expansion, but in my view, a more appropriate focused redefinition of terminal illness—that it should be, as in Spain and in Holland, focused on suffering.

[Rebecca Paul]

Q My questions are to Alex Ruck Keene. Thank you for your written evidence, which I read with great interest. I have two questions for you. This follows on nicely from the discussion we have just had. Is there any risk that if the terminal illness definition were to remain in the Bill, it could be challenged under the European convention on human rights?

My second question, which is completely different—just to mix it up—is on a really interesting point in your written statement about how we need to give consideration to the national suicide prevention strategy. I found that really interesting, because the Bill potentially turns on its head the way we view suicide, and obviously we have been sending a certain message out there, particularly to our young people. Could you elaborate on the point you were making in your written evidence to the Committee?

Alex Ruck Keene: Gosh—yes. There is absolutely no way that you can stop people trying to challenge whatever Act is passed; there is no way you can stop people seeking to challenge that under the ECHR. We then get into this enormous argument about whether it is inevitably discriminatory. Courts to date have been very clear: “We are not going to get into this; it is for Parliament to decide whether to make assisted dying legal.” Once it is made legal for some people, but not for others, there is a difference in treatment. Whether it is discriminatory, and therefore contrary to articles 8 and 14 of the EHCR, depends on whether that difference is justified.

I am trying to be very careful in my language, because I try to do that. The Bill Committee and Parliament need to be very clear how, if you are going to limit this to a cohort of people—I feel acutely conscious that I am sitting next to somebody who would be excluded—it could be explained to somebody that they are not eligible and that there is a difference in treatment but it is perfectly justified. If you cannot do that, it will be discrimination.

The courts have been very clear that you do not have to have a system, but if you are going to have one—for example for social security benefits—then you need to have one that is non-discriminatory. That is the answer I can give to that. The one thing I can say is that you cannot stop lawyers trying to challenge. That is what they will do.

Sir Nicholas Mostyn: All laws discriminate; 69 mph is not an offence but 71 mph is. All laws discriminate. The question is whether it is justifiable.

Sir Max Hill: It is also a question of providing legal certainty, which is why the definitions in the Bill are so important. Provided that it is articulated clearly and within what the European Court so often calls the margin of appreciation, which it gives to sovereign states, then although I agree with Alex that a challenge may be possible, I cannot see a successful challenge to the Bill if it is drawn with the sorts of provisions we have here. Indeed, we have not seen local nation state examples of this sort being struck down by the European Court elsewhere in Europe, so I think it is very unlikely that we would see such a strike-down here.

Alex Ruck Keene: I really hate to get into it with such eminent lawyers, but there has not been a case in Strasbourg seeking to say that a limited class of case is discriminatory, so we just do not know.

Sir Nicholas Mostyn: I agree with that. I have changed my mind twice about this subject.

Alex Ruck Keene: Do you mind if I quickly touch on something else?

[The Chair]

Not just at the moment. We will move to Daniel Francis.

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

Rebecca Paul Excerpts

Committee stage
Wednesday 29th January 2025 Public Bill Committees

[The Chair]

That was a specific question to Mr Amin, but it is an important issue. Does anyone else wish to come in, briefly please?

Chelsea Roff: One thing I would like to highlight in our study is that all 60 people who died—young women, mostly—were found to have mental capacity to make the decision to end their life, so I worry that mental capacity will not be an effective safeguard to prevent people with eating disorders from qualifying under the Bill.

I also note that Oregon and California, where I am from and where we have found cases, have an additional safeguard to mental capacity. That is, if there are any indications that the person might have a mental disorder, that person must be referred for a mental health assessment. It is important not to make a false equivalence between mental capacity and mental health.

We could, for instance, have a person who has a prognosis of six months or less, but their wish to die is emerging from severe depression, from suicidality. We saw very high rates of suicidality and depression: 89% were depressed and nearly half chronically suicidal when they died. Physicians emphasised, still, that the wish to die was not emerging from a mental illness, despite them having diagnosed mental illness.

[Rebecca Paul (Reigate) (Con)]

Q My question is to Chelsea Roff. First, thank you for your written evidence, which I found extremely helpful. It indicates that in Oregon, California and Colorado, patients with anorexia have qualified as having a terminal illness. There have been instances of patients suffering with anorexia being described as terminal, and of treatment being withdrawn, in the UK itself. Is it accurate to regard these young women as suffering with a terminal illness? What changes to the Bill would you suggest to protect them better?

Chelsea Roff: Thank you for that question. No, I do not think it is accurate, but I have to emphasise that laws in other countries have expanded through clinical interpretation, not just legislative amendment. There are clinicians—a very small minority—who disagree and who have characterised anorexia by name as a terminal illness, but they have also said that eating disorders qualify because of the physical manifestation of the disorder. You cannot disentangle a mental disorder from its physical effects. They cite terminal malnutrition; we have identified 25 cases between California and Colorado where malnutrition was listed as the terminal condition. I cannot rule out whether that was anorexia or something like voluntary stopping of eating and drinking, but I worry that it is the physical manifestations that will be cited and, without a mental health safeguard in the Bill, that puts a whole lot of people at risk.

[The Chair]

Dr Griffiths or Professor Shakespeare, do either of you wish to comment, because you have not spoken yet?

Professor Shakespeare: If you look at clause 2, the definition of terminal illness is very clear:

“a person is not to be considered to be terminally ill by reason…of…having one or both of…a mental disorder”

or “a disability”. I think that would cover that case.

Chelsea Roff: May I add one sentence? I think you have left out an operative word in that sentence, which is “only”. It reads,

“a person is not considered terminally ill by reason only of”—

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

Rebecca Paul Excerpts

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[The Minister for Care (Stephen Kinnock)]

I thank my hon. Friend the Member for Spen Valley for her introductory comments. The Government will continue to remain neutral on the Bill and do not hold a position on assisted dying. I want to make it clear that I, along with the Minister of State, Ministry of Justice, my hon. and learned Friend the Member for Finchley and Golders Green, are speaking in Committee not as Members of Parliament, but as Government Ministers responsible for ensuring that the Bill, if passed, is effective, legally robust and workable.

To that end, we have been working closely with the hon. Member for Spen Valley and, where changes have been mutually agreed on by herself and the Government, we will offer a technical, factual explanation for the amendments. Therefore, I will not be offering up a Government view on the merits of any proposed changes put forward by other Members, but I will make brief remarks on an amendment’s legal and practical impact to assist Members in undertaking line-by-line scrutiny.

[Rebecca Paul (Reigate) (Con)]

May I ask how what the Minister has just said interacts with voting? He set out clearly his involvement in the Committee, so how does that impact any votes that he will take part in during it?

[Stephen Kinnock]

I am on the Committee as a Member of Parliament and I vote as such. When I speak on the Committee, I speak as a Government Minister in order to provide factual and technical explanations. As the Bill is a matter of conscience, I will be voting with my conscience on all the amendments as they come forward.

The amendments that we are now debating have been tabled by my hon. Friend the Member for Spen Valley in consultation with the Government. They relate to the location of the person seeking assistance under the Bill and are designed to ensure that the service can only be accessed by an individual present in England and Wales, with a view to preventing medical tourism.

I will take the amendments in turn. Amendments 178 and 193 would ensure that only a terminally ill person in England or Wales may be provided with assistance in accordance with the Bill. Further to that, a requirement is placed on the co-ordinating doctor to ascertain whether, in their opinion, the person who made the first declaration is in England and Wales as part of their first assessment. Amendment 179 would limit the assistance that may be provided in accordance with the Bill to assistance in England or Wales only. Amendment 180 would require the steps taken under clauses 5, 7, 8 and 13 that relate to both declarations and both doctors’ assessments to be taken by persons in England or Wales.

Amendment 182 would limit the provision of clause 4(3), where a person indicates to a registered medical practitioner their wish to seek assistance to end their own life, to cases where the person is physically present in England or Wales. It would prevent people who are outside of England or Wales from accessing assistance in accordance with the Act—for example, by online consultations from abroad.

As I said earlier, the Government will continue to remain neutral on the substantive policy questions relevant to how the law in this area could be changed. That is, as I have made clear, a matter for the Committee and for Parliament as a whole. However, I hope that these observations are helpful to Members in considering the Bill and the amendments tabled by my hon. Friend the Member for Spen Valley.

Amendment 178 agreed to.

--- Later in debate ---

[Sarah Olney]

I agree exactly with the hon. Lady’s point. The Act was not designed for this purpose, and it is essential that we carefully scrutinise whether it should be used in this way.

[Rebecca Paul]

Will the hon. Lady give way?

[The Chair]

Order. I remind hon. Members that interventions are just interventions; there will also be speeches.

[Rebecca Paul]

I welcome the hon. Member’s attempt to improve safeguarding in the Bill, which I agree is currently not at the right level. Does she agree that the Mental Capacity Act assumes in the first instance that, if there is no evidence to the contrary, a person has capacity, and that whether a person lacks capacity must be decided on the balance of probabilities? Unwise decision making does not indicate a lack of capacity, and supported decision making is considered to be acceptable. We need all to be clear that that is what the Act says.

[Sarah Olney]

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

--- Later in debate ---

[Dr Shastri-Hurst]

With the greatest respect to the hon. Member, I think that she is conflating two issues. Someone can stop treatment under the MCA; over time, that will lead progressively to death, with some conditions—she gave the example of being a diabetic without insulin—but that would not be a terminal illness in reference to this Bill. The Bill is very clear that it is about an inevitable and progressive illness, disease, or medical condition that cannot be reversed by treatment. Diabetes, treated with insulin, is not a progressive condition that becomes a terminal diagnosis; it is terminal only by virtue of somebody refusing treatment, which therefore would not be captured within the Bill.

[Rebecca Paul]

I would like to understand why my hon. Friend thinks that diabetes could ever be considered reversible. It can be treated and managed, but surely we cannot turn back time.

[Dr Shastri-Hurst]

My hon. Friend makes a valid point—the Committee can see that I was an orthopaedic surgeon, not an endocrinologist. It is not necessarily a progressive condition; it is a condition that can be managed and maintained. It does not fall within the wording of the Bill. We are not talking about a condition that is inevitably progressive, and for which there is no treatment option available to pause, reverse or prevent its progression. We are talking about a relatively limited group of conditions that will inevitably lead to death when someone, for want of a less blunt phrase, has reached the end of the road in terms of their therapeutic treatment options.

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

Rebecca Paul Excerpts

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[The Chair]

Will everyone please ensure that all electronic devices are turned off or switched to silent? I like to maintain the flow of debate, so I remind everybody not to say “you” and “your”, as Members should speak through the Chair, and not to go out of scope. I will stop Members if that happens again today.

Clause 1

Assisted dying

[Rebecca Paul (Reigate) (Con)]

I beg to move amendment 23, in clause 1, page 1, line 19, after “coerced” insert “, unduly influenced”.

This amendment would include the absence of undue influence for the making of a person’s decision. This reflects the changes proposed in Amendments 24 to 33.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 82, in clause 1, page 1, line 19, after “coerced” insert “, encouraged”.

This would add a lack of encouragement to the list of requirements for a person to make a decision to request assistance. This reflects the changes proposed in Amendments 83 to 92.

Amendment 113, in clause 1, page 1, line 19, after “coerced” insert “, manipulated”.

This amendment reflects the changes in Amendments 114 to 115 which require steps to be taken to establish that the person seeking assistance has not been manipulated by any other person.

Amendment 24, in clause 7, page 4, line 14, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 83, in clause 7, page 4, line 14, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 114, in clause 7, page 4, line 14, after “coerced” insert “, manipulated”.

This amendment requires the coordinating doctor to ascertain whether, in their opinion, the person has manipulated.

Amendment 25, in clause 8, page 4, line 37, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 84, in clause 8, page 4, line 37, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 115, in clause 8, page 4, line 37, after “coerced” insert “, manipulated”.

This amendment requires the independent doctor to ascertain whether, in their opinion, the person has manipulated.

Amendment 26, in clause 12, page 8, line 13, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 85, in clause 12, page 8, line 13, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 27, in clause 13, page 9, line 33, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 86, in clause 13, page 9, line 33, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 28, in clause 18, page 12, line 26, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 87, in clause 18, page 12, line 26, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

New clause 5—Encouragement—

“(1) For the purposes of this Act, ‘encouraged’ means an act capable of encouraging suicide which would constitute an offence under section 2 (Criminal liability for complicity in another’s suicide) of the Suicide Act 1961.

(2) A person is not rendered ineligible to request assistance to end their own life on the basis of—

(a) an act of encouragement that they were unaware of when requesting and going through assisted dying, or

(b) an act of encouragement which was not specifically directed at that person.”

This amendment provides a definition of encouragement is consequential on Amendments 82 to 92.

Amendment 29, in schedule 1, page 25, line 22, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 88, in schedule 1, page 25, line 22, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 118, in schedule 1, page 25, line 22, after “coerced” insert “, manipulated”.

This amendment adds a requirement to the first declaration for the person to declare they have not been manipulated. It is linked to Amendment 113.

Amendment 30, in schedule 2, page 27, line 11, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 89, in schedule 2, page 27, line 11, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 119, in schedule 2, page 27, line 11, after “coerced” insert “, manipulated”.

This amendment requires the coordinating doctor to sign a declaration that to the best of their knowledge they believe that the person has not been manipulated. It is linked to Amendment 113.

Amendment 31, in schedule 3, page 28, line 9, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 90, in schedule 3, page 28, line 9, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 120, in schedule 3, page 28, line 9, after “coerced” insert “, manipulated”.

This amendment adds a requirement to the declaration that independent doctor has to sign, that they to the best of their knowledge they believe that the person not been manipulated. It is linked to Amendment 113.

Amendment 32, in schedule 4, page 29, line 5, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 91, in schedule 4, page 29, line 5, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 121, in schedule 4, page 29, line 5, after “coerced” insert “, manipulated”.

This amendment adds a requirement to the second declaration for the person to declare they have not been manipulated. It is linked to Amendment 113.

Amendment 33, in schedule 5, page 30, line 22, after “coerced” insert “, unduly influenced”.

This amendment is consequential on Amendment 23.

Amendment 92, in schedule 5, page 30, line 22, after “coerced” insert “, encouraged”.

This amendment is consequential on Amendment 82.

Amendment 122, in schedule 5, page 30, line 22, after “coerced” insert “manipulated”.

This amendment adds a requirement to the declaration that coordinating doctor has to sign, that they to the best of their knowledge they believe that the person not been manipulated. It is linked to Amendment 113.

[Rebecca Paul]

One of the major concerns that we have heard from members of the public and MPs relates to the importance of ensuring that appropriate safeguards are in place, so that people make genuine choices and do not request an assisted death because somebody else has pushed them towards it. For that reason, it is vital that subsection (2)(b) is as comprehensive as it can be. It currently refers specifically to a person having been “coerced” or “pressured”, which covers only the more direct kinds of influence, not more subtle ones. It seems clear to me that amendments are required to ensure that more subtle kinds of influence are covered adequately, and that clinicians do not just look for obvious signs of coercion or pressure when considering eligibility.

In her oral evidence on 29 January, Dr Mullock said:

“In terms of the Bill that we are discussing, one possible weakness here is that it identifies, only very obviously, problematic conduct in terms of coercion or pressure exerted by another person, and actually the kind of undue influence that might occur might be very subtle. More needs to be done to recognise that and the subtle encouragement that might take place, where a relative might frame their support for the person seeking to die in terms of, ‘This will be better for you,’ and, ‘Have you considered this?’ That is not necessarily an example of clear abuse, so when the person seeking to die then consults the doctor, they are not going to characterise what has happened to them as coercion or abuse. More needs to be done to discuss with the person whether or not they have been encouraged by the people around them.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 162, Q204.]

Amendment 23 would add the term “unduly influenced” to the clause. It is an important addition, as it is a recognised term in law. It is designed to ensure that relationships of dependence are considered. In some cases, there is no bad intent, but there is a power differential, subtle as it may be, and it is important that we recognise how strong it can be. A child not wanting to disappoint their parent; a wife not wanting to go against her husband’s wishes—there may well be no threats or explicit pressure, and there may be a lot of love shrouding it, but the influence is there and it is strong. That is why the concept is applied in probate cases to test whether someone has faced influence, domination or pressure that prevents them from exercising free and independent volition with regard to the act. It has also been applied in medical decisions, including over a refusal of treatment that can lead to death. For example, there was a case of a Jehovah’s Witness who refused a lifesaving blood transfusion under undue influence from her mother. It is therefore a natural addition to the Bill.

In important judgments, the courts have said that undue influence will have more impact on people who are very tired, in pain or depressed, and that

“a patient in a weakened condition may be unduly influenced in circumstances in which if he had been fit, he would have resisted the influence sought to be exercised over him.”

This legal concept could have been designed for the context of assisted dying. That is why it is important that the amendment is made. In her oral evidence on 28 January, Dr Cox said,

“I would say that you cannot always identify coercion. You can identify it when it is very obvious and extreme, but when it is very subtle, we cannot always identify it. After the event, there is nobody to tell us about coercion, so it is very difficult to monitor.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 73, Q90.]

I would also like to point out that California’s law prohibits coercion or undue influence, so there is established precedent in using this phrase in the safeguards of assisted dying law. If we have the ambition for our law—if it is to pass—to be the safest in the world, we need to add the term “undue influence” as a minimum.

Even with that additional safeguard, however, Dr Spielvogel rather worryingly said in his oral evidence,

“I have seen assisted dying laws go into practice across numerous states and have helped many, many people through this process, and I have never seen a case where I even suspected coercion.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 101, Q139.]

Richard Robinson of Hourglass, in his oral evidence, said,

“I think that coercion is underplayed significantly in cases of abuse of older people…One of the biggest issues we face is the fact that we have no idea of the levels of training that healthcare professionals and the judiciary receive to understand and recognise coercion. That leaves us in a situation where medical professionals say that coercion in these circumstances is minimal, but people need to understand what coercion is and how to recognise the signs of it in the first place, especially bearing in mind that the vast majority of cases that we see take place in the home and by family, rather than by professionals.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 158, Q196.]

Additionally, psychiatric and legal experts have said that undue influence is relevant in this context. In written evidence, Professor Allan House refers to undue influence as

“coercion in its less overt or threatening forms”.

He also draws attention to the great risk of undue influence in the case of couples seeking assisted suicide at the same time. The probate lawyer Tamasin Perkins, in an article on the Bill, says,

“Undue influence or coercion is depressingly common in the arena of contested wills and gifts.”

She suggests that the current law on undue influence could be usefully incorporated into the Bill. To those who worry that adding undue influence could make things more difficult for clinicians when assessing, I would say that it is absolutely right on something of this gravity that rigorous consideration is given to the possibility of undue influence.

I turn to amendment 82, which adds the term “encouraged” to coercion and pressure. This amendment is in line with Dr Mullock’s advice in both her written and oral evidence. It is important to note that encouraging suicide is currently a crime under section 2 of the Suicide Act 1961. It is also important to note that the Bill does not decriminalise encouragement, only assistance. Clause 24 decriminalises only the assistance component, not the encouragement component. Thus, if the Bill were to pass, encouragement of assisted dying would still be a crime. That is absolutely right and something that I fully support.

As encouragement of suicide is clearly recognised as a heinous crime, it surely must follow that when considering whether someone is eligible for such assistance to end their life, consideration is given to whether they have been a victim of such a crime. This feels like a rather basic safeguard that is missing from the Bill and must be rectified. As former Attorney General, Victoria Prentis, has written,

“maintaining the prohibition on encouraging suicide is key to protecting vulnerable people”.

She says it is a problem, though, that

“doctors and judges under the bill are not required to check whether the person’s decision is their own or whether they have been encouraged by others.”

She goes on to say that she hopes the Committee will support my amendment, and David Hughes—formerly of the Law Commission—says that keeping the offence of “encouragement” would help to prevent “insidious pressure”.

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

The hon. Lady uses the term “encouragement”. If I were in a situation where a loved one wanted to access assisted dying, and I said I supported their wishes, would that fall under the scope of encouragement? We do not want to end up in a situation where people who support their loved ones end up dragged through a legal process, when it is actually the case that they are there to enable their wishes, rather than pushing them to it. How would she differentiate between those?

[Rebecca Paul]

That is an important point. Obviously, case law becomes quite important in this. Supporting someone’s decision is very different from encouraging someone who was not in the place of wanting to go through with assisted dying. Again, these things do sometimes end up in the courts, because sometimes it can be a grey line. It is important that we have this protection. Right now, it is an offence to encourage someone to commit suicide, and we need to recognise that. That is the law right now.

[Kim Leadbeater (Spen Valley) (Lab)]

The hon. Lady makes an important point. The idea is that the Bill makes an exception to the Suicide Act. I fully support her point about the supportive nature of the conversations that would take place with families. If we use the word “encourage”, we are in danger of lacking clarity. Where is the line between encouragement and support? I would like her to expand on that, if she could.

--- Later in debate ---

[Rebecca Paul]

I do not think that we are trying to exempt something from the Suicide Act through the Bill; we are decriminalising something that is currently a criminal offence. Right now, it is a criminal offence to assist someone to commit suicide, and clause 24 decriminalises that. I totally support what you have done here, but your Bill does not decriminalise encouragement. I imagine that you have done that for very good reasons, which I support; we do not want people to be able to go round encouraging people to commit suicide. It is vital that there is protection for the vulnerable people we have talked about. You are absolutely right that what constitutes encouragement can be subjective and difficult to determine, but encouragement is already in the law, so we have to deal with it. It is already a criminal offence to encourage a suicide, so it does not make sense not to deal with it in this Bill.

[The Chair]

Order. I remind everybody that they should not be saying “you” and “yours”.

[Sean Woodcock (Banbury) (Lab)]

I will do my best to abide by that, Ms McVey. My recollection of the oral evidence is that the practitioners from California made it very clear that there was not a great deal of coercion, but they had seen families put undue pressure on people to prevent them from pursuing assisted dying. Given human nature, I find it incredible that the pressure would go only in that way and not in the other. I see the proposals as ensuring that and safeguarding people who are at a very vulnerable stage of their lives. Will the hon. Lady speak to that?

[Rebecca Paul]

I completely agree. It is important to recognise that different people will have different views on levels of coercion. I have already quoted some of the witnesses; I found it quite jarring that certain witnesses who had facilitated assisted dying for hundreds—perhaps thousands—of people said that there were no cases of coercion. I find that difficult to believe, although I do not doubt for a second that they believe it.

[Kim Leadbeater]

The witnesses gave evidence in good faith, and I would be uncomfortable if we started to question the validity or truth behind their testimony.

[Rebecca Paul]

Just to clarify, I am not questioning that they were not telling their truth. I completely believe that, from their perspective, they honestly believe they have never seen a case of coercion. Maybe I am more of a glass-half-empty kind of girl than some other people, but I question whether that is really the case. In my 45 years on this planet, I have learned enough about humankind to know that these things do happen, but different people will take different views when it comes to detecting them.

[Naz Shah (Bradford West) (Lab)]

The hon. Lady has made some important points. I repeat something I said yesterday in response to another Member: the word “coercion” and the idea of encouragement were not even in the vocabulary in this place until very recently—only 10 years ago. I do not want to dismiss people’s expertise, but for me it is quite a leap of faith—I wonder whether she shares that idea—to believe that in that jurisdiction, zero people were coerced, when every other jurisdiction records people being coerced and people saying they feel a burden.

--- Later in debate ---

[Rebecca Paul]

I completely agree. The hon. Member has made some powerful points over the course of this Committee. The reality of the matter is, like the hon. Lady said, this has not really been considered fully until recent times. I think we are now all much more aware of the coercion and pressure that goes on. It is only right, when we are making this decision now, to be fully aware of that and have our eyes wide open to the realities.

At the end of the day, we are not legislating for when it works perfectly for that ideal candidate who absolutely wants to do this for all the right reasons and they are in pain, which is exactly what the Bill is designed for. We are legislating for that big group of people who are vulnerable, and who it may not work for. That is a much bigger group. We heard compelling evidence from Dr Jamilla Hussain, which really impacted me, about this big group of vulnerable people who could be detrimentally impacted. We must make legislation for the group that could be negatively impacted. They should be our focus.

[Danny Kruger (East Wiltshire) (Con)]

I am very struck by that last point. Does my hon. Friend agree that the purposes of these amendments build on the principle of the Bill? The Bill recognises the existence of vulnerable groups and attempts to introduce safeguards. It is not a free-for-all. The absolute purpose of the Bill is to ensure that vulnerable groups are protected.

My hon. Friend’s amendments support the principle of the Bill, which says that encouraging suicide remains illegal. By implication of the Bill, to encourage people to take an assisted suicide should be illegal too. My hon. Friend is actually building on the principle of the hon. Member for Spen Valley’s Bill, and I hope the Committee will not regard these amendments as in any way harmful to its purpose or as an attempt to make it more impractical in operation. They would make the Bill clearer. To the point made by the hon. Member for Spen Valley about overcomplicating things—I think the complications exist in the current text of the Bill, whereas my hon. Friend the Member for Reigate would be clarifying its purpose.

[Rebecca Paul]

My hon. Friend makes the point powerfully. I say to everyone in this Committee—we had this discussion yesterday—that I am not opposed in principle to the concept of assisted dying, but I see my role here as to protect the vulnerable. That is what I am trying to do, and I know everyone here wants to do exactly that. I cannot really see any downside to these amendments. Why would the Committee not want them included, if we want to protect the most vulnerable? Yes, it may put a bit more onus on clinicians, because they would need to look for a lower level of coercion. But that is absolutely right—of course they should have to do that. We are talking about assisted death. It is really important that we have a higher level of consideration.

[Kit Malthouse (North West Hampshire) (Con)]

I understand that much of the difference between us on this may founder on our perception of what is actually happening. She speaks of suicide, and to some of us—certainly to me—suicide is a healthy person taking their life, but what we are talking about is somebody who is seeking to take control of their inevitable death in these circumstances. For me, those two are qualitatively different.

I am concerned about my hon. Friend the Member for Reigate injecting an element of jeopardy into what should ordinarily be normal conversations with one’s family. For example, I could see a point at which, if I were in those circumstances and was thinking about seeking assistance to end my life, I would discuss that with my wife: “Darling, am I doing the right thing? Is it the best thing for the kids? I think I’m going to have a horrible death, and I’m trying to decide.” We heard from families—and have done over the last 10 years—who, very often in anguish support their loved one, even to the extent that they are willing to break the law. As my hon. Friend the Member for Harrogate and Knaresborough said, the line between support and encouragement is quite fine. If somebody were to come forward and say, “Well, I’ve spoken to my family. They all think I am doing the right thing”, could that not be interpreted as encouragement? I am conscious that we should not try to police what should be open and natural discussions between families in a way that injects jeopardy for them and the person to the extent that they might start to modify what they say to the doctor to ensure that they get the outcome they want.

[Rebecca Paul]

I thank my right hon. Friend for that very useful contribution. First, I am saying “suicide” because we are talking about the Suicide Act, and I cannot perform this role without naming the actual bit of legislation that we are talking about. I know people here are a little bit squeamish about the word “suicide”, but it has a clear legal meaning.

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

Will the hon. Member give way?

[Rebecca Paul]

Not yet; I am finishing my point. It has a clear legal meaning, and we must not put the blinkers on. I would suggest to Members that if they have an issue with the word “suicide”, they remember that this will actually result in the end of someone’s life. We must not be squeamish about using correct and accurate terminology in what we describe.

The second point made by my right hon. Friend the Member for North West Hampshire is a really good point: it is a fine line and it is really difficult. I have proposed this amendment not because I want “encouragement” specifically to be in the Bill, but because the encouragement of suicide is already a crime. I am being logical and taking what is already a criminal offence under the Suicide Act. If we do not include it in the Bill, it means that someone can commit a criminal offence against a victim, and that does not preclude the victim from being eligible for assisted dying, so I am suggesting a very logical amendment. My right hon. Friend makes a great point, but if we have an issue with the word “encouragement”, we need to take that up with the drafters of the Suicide Act, which was long before my time in 1961.

[Sarah Olney (Richmond Park) (LD)]

Does the hon. Lady agree on the value of her amendment, and the value of introducing the word “encouraged” into the Bill? Reflecting on what has been said about the “fine line” argument by the right hon. Member for North West Hampshire and the hon. Member for Harrogate and Knaresborough, the value of inserting this amendment is that, where it can be proven beyond doubt that someone has encouraged or actively sought to influence someone else to choose assisted death, that is a crime encoded in the law.

To the point made by the right hon. Member for North West Hampshire, in discussions among families about this possibility, and where spouses are supporting each other in this decision, it will never be demonstrated beyond reasonable doubt that a crime of encouragement has taken place. By putting it in law, where encouragement can be proven—and it must be proven—it can be prosecuted as the criminal offence that it would be.

[Rebecca Paul]

As ever, the hon. Lady so eloquently makes her point and I completely agree. I am not a lawyer but, given that the Suicide Act made the encouragement of suicide a criminal offence back in 1961, I imagine there is quite a lot of case law that would help define where that line is drawn on encouragement, but I would refer to better qualified people than myself.

[Rachel Hopkins]

I reassure the hon. Lady that her sweeping statement about us all being squeamish when talking about suicide may not be accurate. I would put it back to her: how squeamish is she when talking about assisted death, because we are actually talking about two separate things here? I reiterate the point made by the right hon. Member for North West Hampshire: a healthy person taking their own life by suicide is different from a terminally ill person, who is facing their death, ending their life by shortening their death. Would she accept that point?

[Rebecca Paul]

I am talking in legal terms, because we must use the right language. Under the law, I think what the hon. Lady said is not correct. I stand to be corrected by someone who is a lawyer, but given that we are amending the Suicide Act, I think technically an assisted death is the assistance of a suicide. I understand that the hon. Lady would like to reframe that and use different words to describe it. Maybe that could be done, but right now, under the law, it would be suicide.

[Rachel Hopkins]

If the Bill becomes law it would be a different situation, which is exactly what we are scrutinising.

[Rebecca Paul]

My interpretation is that it would not.

[Danny Kruger]

What the hon. Member for Luton South and South Bedfordshire said is not the case at all. What the Bill would do is to exempt people who go under this new procedure from the operation of the Suicide Act. It would not create some new category of person; the law would just operate in a different way. I recognise that she is saying that, in her mind, there is a difference between somebody who is dying who has an assisted death and somebody who is healthy who commits suicide, but that is a completely arbitrary distinction in reality. Many people who have terrible diagnoses kill themselves, even though one might say that they are not actually dying and they could be treated. Should that person qualify?

Entering into the mind of someone who wants to take their own life is an absolute impossibility, and that is the whole problem with this Bill: we are trying to create distinctions that are impossible to police properly. It goes to the point of my right hon. Friend the Member for North West Hampshire about trying to police private conversations. That is what this Bill entails. We are inviting the state to intrude, in an absolutely impossible way, on what is going on in people’s minds. To go back to the point made by the hon. Member for Luton South and South Bedfordshire, there is no clear distinction between somebody who would choose assisted dying through a doctor’s prescription and one who would choose to take their own life without assistance. It is not possible to draw that distinction. In fact, we have seen so many times that people who might want to kill themselves one month change their mind a month later. I am afraid that this is the challenge with the whole Bill.

[Rebecca Paul]

I support my hon. Friend’s comments. Outside of this place, I speak about this topic in a manner that is as sensitive as possible. When we are talking about the legislative changes that are needed to this Bill and how it interacts with other legislation, I will use the correct legal terminology, because I think it is really important that we do that.

[Dr Marie Tidball (Penistone and Stocksbridge) (Lab)]

I appreciate the hon. Lady raising the need to use accurate legal language. Does she agree, therefore, that introducing “undue influence”, which is used regularly in the law of equity but not in the criminal law, would unhelpfully complicate matters, considering that coercive behaviour is defined in section 76 of the Serious Crime Act 2015 where it provides for an offence of controlling or coercive behaviour in that context? We have 10 years of case law. The hon. Lady rightly pointed to the importance of looking at case law and at how courts have dealt with this; the understanding of coercion in the criminal law offences is well known and well rehearsed, whereas the use of undue influence in the context of criminal law offences, which is what we are dealing with in clause 26, is not.

[Rebecca Paul]

I thank the hon. Lady for that point, but I do not think we are talking about criminal law here. This debate is not relevant to clause 24—it is relevant to eligibility. We are simply saying, through this amendment, that if a clinician thinks someone has been unduly influenced, they would not be eligible. I think the hon. Lady is crossing over to the encouragement point, but these are separate points.

[Dr Tidball]

Will the hon. Lady give way?

[Rebecca Paul]

I am sorry, but I am going to give way to the hon. Member for Bexleyheath and Crayford, if he still wishes to intervene, as I am aware that he has been waiting.

[Daniel Francis (Bexleyheath and Crayford) (Lab)]

I want to bring us back to the points raised by the right hon. Member for North West Hampshire. I may have misread this, but I understand that, under the current law and under the law as it would stand if this legislation were introduced, it would remain an offence to encourage somebody to commit suicide with a 12-month diagnosis—perhaps someone with motor neurone disease or Parkinson’s disease, who may still be a loved one. I do not understand the counter-argument about not using the word “encouraged”: it would remain a criminal offence, unless I am mistaken, to encourage someone to take that decision if they had a diagnosis of longer than six months left to live.

[Rebecca Paul]

That is exactly right. As I have mentioned, I am not bringing in the concept of encouragement; it is already in the law and currently an offence. I am putting forward this logical amendment in order for the Bill to deal with that. If we do not do that, we have not circled the wagons.

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

I have no doubt that my hon. Friend speaks to the amendment with very good intentions due to genuine concerns about the safeguards. We have talked a lot about coercion. Clause 1(2)(b) sets out a requirement that the person,

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

“Pressured” is an important word. If we look at the case law, there are the comments of Lord Nicholls in the case of Royal Bank of Scotland plc v. Etridge (No. 2) in 2002. He looked at two components of the concept of undue influence. There are acts of improper pressure or coercion, such as unlawful threats, which fit with the coercion element of the Bill as drafted. There are also relationships where one has acquired over another a measure of influence or ascendency, of which the ascendent person takes unfair advantage without any specific acts of coercion. Could my hon. Friend set out why she thinks “unduly influence” would add something beyond what “pressured” already does in the Bill?

[Rebecca Paul]

My hon. Friend is very knowledgeable about these things and is well qualified on the legal side. I value his contributions on this matter. The reason I want to include “unduly influence” is because it deals with those more subtle forms of coercion. Arguably, it could be included in “coerced or pressured”, but by including “unduly influence” in the Bill it becomes more explicit that a clinician has to be looking for it. In the absence of the language, clinicians will not be required to look for those more subtle forms of influence.

The provision is something that is included in the assisted dying laws of other jurisdictions. We have the opportunity here to learn and benefit from jurisdictions that have already implemented it. We heard various witnesses give us very useful evidence during the sessions. For example, California includes “undue influence” in the law. We should recognise that there is value in including it here. It is a well-established legal term that is used in myriad situations, so it is relevant that we include it.

[Naz Shah]

May I take the hon. Member back to the point of clause 24, and the issue of suicide and the terminology there? Perhaps the Minister could respond as well, although I am not sure how that would work in this Committee. What I think we are doing in clause 24 is to decriminalise encouraging suicide. That is my understanding. So can we have some clarity? Are we trying to decriminalise encouraging suicide? That is what clause 24 says, so in that case it would be absolutely right to talk about the word “encouragement”.

--- Later in debate ---

[Rebecca Paul]

Clause 24 decriminalises assistance to commit suicide, in order that assisted dying becomes lawful. It does not specifically decriminalise encouragement, which means that the Suicide Act 1961 still applies if someone were to encourage someone to commit suicide. It would therefore be a crime and have a sentence associated with it. However, the hon. Lady makes a really good point: it would be of great value at the relevant time to hear from the Minister on the legal point I am making. I hope everything I am saying is coherent and sound, but it would be useful to hear from the Minister.

[Kim Leadbeater]

The hon. Lady is doing an amazing job—and taking lots of interventions. As I have always said, I am very open-minded to whatever we need to do to make the Bill more robust. I am not a lawyer, like the hon. Lady—we have lawyers in the room, fortunately, who can provide guidance and assistance in that regard—but what has been made clear to me is that the law needs clarity.

The hon. Lady has already mentioned a couple of times that this change could be described as a lower level of coercion, or it could be argued that there is a lack of clarity there. I think the sentiment is absolutely right, and I really support that, but we need the law to be clear. And if legal colleagues are assuring us that the concept of undue influence would be covered under “coercion”—and I am kind of hearing that—then I think it would be covered. I think that point about the law being clear is really important. Does the hon. Lady agree with that?

[Rebecca Paul]

I thank the hon. Lady for that intervention. I know that she is wholeheartedly seeking to make sure that the safeguards in the Bill are as good as they can be, so I very much appreciate her recognising the positive intent behind my amendments.

It would be useful to understand whether those who are legally qualified believe that undue influence is already covered by “coercion”. I am not qualified to give a view on that, but if that were the case, that would provide some reassurance, and that could then maybe be included in guidance. However, I would want to see a legal opinion on that.

In the absence of such a legal opinion, putting that on the face of the Bill is the safest—and the right—thing to do at this point in time. I suspect that we will be voting on this shortly, before we can get a legal opinion, and given that we are talking about safety here, I would rather go for belt and braces and include “undue influence” on the face of the Bill.

[Lewis Atkinson (Sunderland Central) (Lab)]

Can I just clarify something? As my hon. Friend the Member for Penistone and Stocksbridge said, I understand that “undue influence” has an existing meaning, but only in equity law. The hon. Lady herself mentioned wills, for example, being challenged in probate. There, as I understand it, the burden of proof rests fully on the person challenging the will; there is not an active test that someone has not been unduly influenced. If the hon. Lady is to use undue influence as an existing legal concept, would she favour reversing the presumption on the burden of evidence? In addition, I think there is a distinction between actual undue influence and presumed undue influence in the case law. I wonder which of those she thinks we should be using when considering this amendment.

[Rebecca Paul]

I thank the hon. Member for that intervention. I think the point on probate is right; it is commonly used there, but it is not just used in that situation. My understanding is that, when it comes to decisions by clinicians with regard to withdrawing life-sustaining treatment, undue influence is one of the considerations.

[Danny Kruger]

Just to amplify that point, my hon. Friend is absolutely right. In the “Re T” case, the Court of Appeal judged that undue influence should be taken into account in medical decisions, so that is an existing principle in law. It feels totally appropriate to bring that in here, seeing as, as we have discussed, the principle already exists that it is wrong to encourage suicide, and that it is possible to have undue influence without coercion or pressure being present. To address the point made by the hon. Member for Spen Valley, I do not think those terms are adequate to include undue influence; undue influence can exist even when there is no evidence of coercion.

[Rebecca Paul]

I thank my hon. Friend for that intervention. The point that I would make is about an example that we talked about a lot yesterday, so I know that it resonates for many on the Committee. If someone is making a decision and a treatment is being withdrawn, or life support is being turned off, undue influence is already one of the things they consider, so when we are considering assisted death, surely, in order to be consistent, we would apply undue influence to that as well, rather than having a lower level. Why would we have a lower threshold for assisted dying compared with withdrawal of treatment?

[Sarah Olney]

The hon. Members for Sunderland Central and for Penistone and Stocksbridge said of existing concepts in law, “This is how they have always been used.” It was reminiscent of the conversation we had yesterday about the Mental Capacity Act 2005, and mental capacity being an established concept in law, and “This is the way that it is always applied.” Does the hon. Lady agree that although precedent and established usage are extremely important, the Bill is quite a novel piece of legislation, and it is really incumbent on us as a Committee to ask ourselves whether we need to approach this piece of legislation in a different way, compared with other pieces of legislation that have gone before; and whether, just because something has always been used in a particular way, it is still appropriate for it to be used in that way for this legislation, as a general principle?

[Rebecca Paul]

I completely agree. If we do not incorporate undue influence, we are at a lower threshold compared with withdrawal of life-sustaining treatment. That does not feel to me like the right position, but equally, this is a novel bit of legislation and we need to increase the safeguards further. Obviously, we shall be debating numerous amendments whose purpose is to raise that threshold. It is always very hard—how long is a piece of string?—to know exactly where to set a threshold. Different people have different views. My personal view is that in this Bill the threshold is too low, so we need to raise it by agreeing some of these amendments. So far, none of the amendments that have been suggested has been accepted. I really hope that during this Committee stage we will increase the safeguards.

[Kim Leadbeater]

Hopefully this will be my final point on this subject. I believe there is consensus in the room; no one is saying that undue influence is acceptable. The question is, where does it sit within the Bill in terms of definitions? That is where I would appreciate, along with the hon. Lady, advice from legal experts—and indeed the Minister—around whether we are confident that with the concept of coercion we are including undue influence. Does she agree that that clarity would be helpful?

[Rebecca Paul]

I absolutely agree that such clarity would be very useful. The hon. Member and I both want to ensure that undue influence is captured somewhere; I am less picky about where. As long as it gets covered somewhere in the Bill, that would be an improvement to the Bill, and I hope that everyone would really welcome that. I think everyone recognises the issue. I am not hearing that people are opposed to this; they recognise that there can be more subtle forms of coercion. If we can work together to find the best place for that to go in the Bill, I am very open to that.

[The Minister of State, Ministry of Justice (Sarah Sackman)]

It might help if I offer—with the usual caveat that of course the Government are neutral—the Government’s position with respect to what the hon. Lady has been discussing. It is important to point out that the terms “coercion” and “coercive behaviour” and “pressure” that are used on the face of the Bill appear in existing legislation without statutory definition. In other words, they are given their ordinary meaning and they operate effectively in that manner in the criminal law. The hon. Lady is absolutely right that clause 26, which we shall come to in due course, is a separate matter, but of course it will be important to review the Bill as a whole and to understand the interaction between the different provisions in clause 1, as we trace it through to the criminal offences.

It is the Government’s view that manipulative behaviour or undue influence—the terms that the hon. Lady is using—would come within the normal meaning as understood in case law by the judiciary of the terms “pressure” and “coercion”. In terms of the integrity of the statute book, there is a concern that by adding additional terms, we run the risk of creating confusion, because when it comes to the interpretation of those provisions, judges will be looking to understand and ascertain what Parliament meant by “undue influence” that was not currently covered by coercion. Given that those terms are commonly broadly interpreted, it is the Government’s view that the sorts of behaviours that the hon. Lady is describing—“undue influence”—would be covered by the terms used on the face of the Bill. For simplicity, given that our existing body of law interprets those provisions widely, and to ensure consistent application of the law in this context and other contexts where coercion arises, it is important from the Government’s point of view to retain the Bill’s current wording.

--- Later in debate ---

[Rebecca Paul]

It is helpful to understand the Government’s position. If the amendment is not made, I hope that the Minister is right, but one thing that I have learned in my time is that different judges will have different views on these things. Personally, I would prefer to see this provision in the Bill, as it would absolutely ensure that the protection is in place. We all know that decisions in the courts can sometimes go a different way from what we expect.

[Naz Shah]

I have a concern about what the Minister says. As one psychiatrist put it, the Bill is very novel and untested. The MCA has not been tested. Now the Government say that this will work, without consultation or any impact assessment. I struggle to understand that. Does the hon. Lady share my concern that this does not feel right?

[Rebecca Paul]

It is reassuring to hear that I am not the only one worried about this, so I thank the hon. Lady for that.

[Danny Kruger]

I understood the Minister to say that the judge needs clarity when they come to adjudicate on a case. We have heard through the media, although an amendment has not yet been tabled, that a judge will not oversee the process. Does my hon. Friend share my concern that we are setting up a legal system that will not provide proper legal oversight of the proposed measures?

[Rebecca Paul]

My hon. Friend’s point goes to the heart of the case, and to the point that I made earlier: it is extremely difficult when the Bill is a moving feast. We are tabling amendments to the Bill as drafted, but if substantial changes are made, that will impact some of what we did earlier.

[Kim Leadbeater]

We are looking at different amendments as the Bill progresses, but a judge would always be involved in criminal offences, which is what we are talking about now.

[Rebecca Paul]

I thank the hon. Member for sharing her view on that.

[Danny Kruger]

This is a very helpful conversation, and I am grateful to my hon. Friend for allowing all these interventions. It is right that there would be a judge in the event of a criminal offence. We are trying to ensure that we do not get to that point by insisting that in the early stages of the process, when a doctor makes their assessment—indeed, when a judge makes their assessment, if there is still that judicial stage, as we hope there will be—they are required to ensure that there has not been undue influence. It is important that, at that early stage, they are asked to check not just whether there has been coercion. I hear what the Minister says about the concept of undue influence hopefully somehow being incorporated in the definition of coercion or pressure, but we need to ensure that that test is applied at a very early stage. The first people who discuss the matter with the patient should ensure that there has been no undue influence, which by the way is about much more than outright coercion; it is about an imbalance of power in the relational dynamics within families, which as we all know can be very complicated. That is what necessitates the amendment.

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[Rebecca Paul]

I completely agree with my hon. Friend. As always, he makes the point powerfully.

[Naz Shah]

Does the hon. Lady share my concern? My understanding is that, in normal parliamentary business, if the Government announce any changes to the law in the press first, they are usually rebuked by Mr Speaker in the Chamber. I appreciate that this is a private Member’s Bill, but a Guardian piece yesterday outlined how we will now scrap the involvement of a High Court judge and have a panel instead, with an amendment to be tabled to that effect. I am happy for my hon. Friend the Member for Spen Valley to clarify how the system is going to change.

Once we have debated the amendments on undue influence and coercion, we have debated them. We cannot then come back to them, because of the nature of private Members’ Bills. Does the hon. Lady share my concern that, as we said yesterday, the horse has bolted? We are having to go over things and we might not be able to revisit this issue, which is why it is even more important to have probing conversations on the record so that, if nothing else, we can refer to them on Third Reading, for which we have only five hours.

[Rebecca Paul]

I completely agree with the hon. Lady. We should not make the mistake of assuming that certain amendments will be accepted. Until there is a Division, we do not know what the Bill is going to look like. It is incredibly difficult to table amendments early on when we do not know whether other fundamental things are going to change. That is why it is important that we are really thorough and improve the safeguards as much as we can, clause by clause. I do not want to get to the end of this process without our having accepted any of the improved safeguards, only for the Bill to be turned on its head at the end when there is a Division on something fundamental. As the hon. Lady rightly says, we do not get the opportunity to come back and review the decisions we have made on the back of that.

[Sarah Olney]

Further to the point made by the hon. Member for Bradford West, is it not a further complication that if a question is put in Committee and considered settled, it cannot be revisited on Report by any other Member outside the Committee? It may well be the case that amendments that are accepted further down the line fundamentally change the nature of the Bill, and Members who are not on this Committee will be prevented from revisiting questions in respect of the early clauses because the matter has been discussed in Committee, is considered settled and cannot be revisited on Report.

[Rebecca Paul]

As a new MP—there are many in the room today—I am still very much learning the process; we have to contend with not quite understanding how the full process works. In two years’ time, I think that I and many other new colleagues would be in a different position and would fully understand all the interactions and the subtleties of the legislative process. But it is a challenge I have, which is why, right now, I will always table the most robust amendments that I think will safeguard the most vulnerable in our society.

[Dr Simon Opher (Stroud) (Lab)]

I would like to bring the Committee back to a certain amount of reality. What we are talking about is how we can assist clinicians to assess coercion and pressure. I like the way we have discussed this in a very good way, trying to make the Bill safe, but would the hon. Lady’s amendment make that any easier for the clinician? I do not think it would. The Bill is very clear as it is. I do not think there will be any implications if there are further amendments, because the Bill provides a statement of what we do; as a clinician, I would understand and be able to apply that.

[Rebecca Paul]

The hon. Member is absolutely right that the amendment would not make it easier for the clinician. My job is not to make it easier for the clinician to determine that someone is eligible for assisted death. It should be a robust, rigorous and well-considered process.

[Liz Saville Roberts (Dwyfor Meirionnydd) (PC)]

I find the hon. Lady’s point about the mechanism by which we are making this legislation to be very pertinent. I have been here for almost 10 years. As somebody from a small party, I suspect we are all experiencing how Bill Committees work from the outside, if you like. We need a note of humility. On the one hand, we are all here trying to make this Bill a piece of legislation that is as watertight as possible. That very much then comes over to the Government; I know we are here on a private Member’s Bill because of the nature of the ethical question with this Bill, and I am very comfortable with that, but none the less there is an immense responsibility in the next stages with the questions we raise. Perhaps it might be an idea not to push this question to a vote—although I leave that entirely to the hon. Lady—because that keeps the matter alive. There is an immense responsibility on the Government to listen to the issues that we can only touch upon here and to ensure they are all sewn together.

[Rebecca Paul]

I thank the right hon. Lady for that really helpful intervention. That is exactly the kind of advice that is extremely useful to us new MPs undertaking this process. I will have to make the decision on that question in a matter of minutes, and it is very difficult, but I will do my best to make the right decision.

New clause 5 seeks to define encouragement for the purposes of the Bill and includes some exclusions. We have already talked about some of the challenges with exactly what encouragement means, and clearly there are certain acts that we do not want to be captured by it. The aim of the clause is just to ensure that it is only intentional, targeted and effective encouragement that is covered. I am very open to working with the Government to ensure that the drafting reflects the intent; it may well be that some other things go in there to address some of the concerns raised by my right hon. Friend the Member for North West Hampshire around support being given by families. No one wants to see that included in this definition—I think we all agree on that.

In summary, I hope hon. Members will view these amendments, incorporating undue influence and encouragement into clause 1, favourably, in order to bolster the safeguards in this Bill. It is vital that subtler forms of influence are addressed, to protect patients and to ensure that it is not just the obvious signs of coercion that are looked for. I also welcome amendment 113, tabled by the hon. Member for Broxtowe, which is very much in the same spirit as amendments 23 and 82 and would insert the word “manipulated”. I hope we will debate it because, if accepted, it would certainly improve the safeguards in the Bill.

[Naz Shah]

It is a pleasure to follow the hon. Lady. Just to put it out there, to begin with on amendment 23, the Court of Appeal, in the case of “Re T (Adult: Refusal of Medical Treatment)”, held that undue influence was relevant to medical decisions and said that doctors must check for it. Undue influence is about power imbalance, rather than outright coercion.

That brings me nicely on to the points we discussed in some detail yesterday. The right hon. Member for North West Hampshire talked about having a conversation with his family, with his wife and children and so on. I will give another example. Say there is a woman who has been the victim of domestic violence—we know this happens; we know two women a week are killed in this country, to this day—and she is subtly encouraged: “Sweetheart, you’ve got a diagnosis and the option is to have this.” There is a fine line, and the fine line conversation has been mentioned quite often as well, but I would rather stay on the side of caution with that fine line conversation when it comes to domestic abuse, coercion and the power imbalance in a relationship.

Let me come back to that woman or elderly person whose loved ones have the conversation—and they indeed have the conversation; it happens every day. Ask any victim of domestic violence. On average, it takes a woman 40 attempts to leave an abusive partner—that is the fact—because we do not even recognise it.

I know somebody who recently left an abusive partner—that took three years of encouragement because she did not recognise that what was happening to her was about power and control. It is when power is juxtaposed with vulnerability that there is the potential for abuse. That happens—it happens every single day. Victims of domestic abuse are not just younger people; according to Age Concern, over 375,000 older people are at risk of domestic abuse.

The abuse of people is a cancer in our society, and that very subtle power imbalance is where the fine line is crossed. Given that the Court of Appeal has ruled and is already saying that medics have to look out for undue influence, I would argue that amendment 23 actually strengthens the Bill. My hon. Friend the Member for Spen Valley has repeatedly insisted that this Bill needs to be the tightest in the world. How does the amendment not complement her view? How does it not strengthen the Bill, to protect victims?

--- Later in debate ---

[Jake Richards]

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

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

[Rebecca Paul]

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

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

[Jake Richards]

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

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

[Rebecca Paul]

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

[Jake Richards]

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

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

followed by the provisions in new section 2AA.

--- Later in debate ---

[Jake Richards]

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

[Rebecca Paul]

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

[Jake Richards]

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

--- Later in debate ---

[Rebecca Paul]

In the light of my hon. Friend’s points, I have an interesting fact that he might enjoy: “encourage” was added to the Suicide Act by the last Labour Government in 2009, and replaced “aids” and “abets”, so it is not that archaic.

[Danny Kruger]

My goodness, 2009 might be in the mists of history for the hon. Member for Rother Valley, but it was the last Labour Government. That is very good to know, and I am grateful to my hon. Friend.

The hon. Member for Spen Valley made the point, which is quite often made in defence of the Bill, that there is currently no framework to spot coercion, therefore the Bill creates greater protections for people. The fact is that, as the hon. Member for Bradford West said, there is no law that currently allows assisted dying, so no framework is necessary to prohibit encouragement or inducement to an assisted death—the opportunity does not exist. I think everyone must acknowledge that, if we pass the Bill, we may open up a new avenue for abuse, and it is necessary that the Bill close it off. That is right and appropriate.

Coercion and abuse no doubt go on and are tragically common, but the answer to that problem is not to legalise assisted suicide and put a regulatory framework around it with limited protections against coercion and influence. We have to deal with the terrible cancer of abuse and coercion that exists in our society, as the hon. Member for Bradford West said. If we are concerned about undue pressure in families, that should be our social mission. If we are to have an assisted dying law, let us make it as strong as possible. As I say, we are potentially opening up a new avenue for abuse within families.

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

Rebecca Paul Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[Rebecca Paul (Reigate) (Con)]

I appreciate your giving way. The point that we are trying to make is that it is important to provide the information about palliative care. I understand the reservations of the hon. Member for Stroud about forcing someone to see a palliative specialist, but wording can be tweaked or changed to allow that choice. The key thing is that the opportunity to meet a palliative care specialist is provided so that the patient has the option, if they so wish, to seek that information.

At the end of the day, I think we can all agree that information allows people to make the right decision for themselves. Rather than getting too hung up on the exact wording of the amendment, I suggest that—this applies to quite a lot of the amendments—we think about the spirit of what we are trying to do.

[The Chair]

Before the hon. Member for Solihull West and Shirley continues, I should point out that when Members say “you” or “your” they are referring to me in the Chair. It has happened a couple of times. We all do it—we all make mistakes—but please make the effort not to use “you”.

--- Later in debate ---

[Rebecca Paul]

Will my hon. Friend give way?

[Dr Shastri-Hurst]

I am feeling generous—it is a Tuesday.

[Rebecca Paul]

A thought has suddenly been triggered: we are talking as if the provision of this service is undertaken by the NHS, but what are my hon. Friend’s thoughts if the service were being delivered privately? How does that interact with his automatic assumption that there would be a referral to a palliative care specialist?

[Dr Shastri-Hurst]

I do not think that offends the principle at all. Whether I was working within the NHS or the private sector, if a patient requested an onward referral to a different specialist, I would action that. If I did not have the requisite skills or knowledge, or felt that they would be better served by a different speciality, I would refer on to another clinician. I do not see how it would be treated any differently in the NHS than it would be privately. I am afraid that I do not follow that argument.

--- Later in debate ---

[Kim Leadbeater]

The right hon. Gentleman is absolutely right. It feeds into comments that have already been made about how difficult we are making the process. I agree that this should be a difficult process—it should be a robust process, with thorough checks, safeguards and balances throughout—but we are in danger of forgetting the dying person at the heart of the process.

[Rebecca Paul]

Will the hon. Lady give way?

[Kim Leadbeater]

I am going to finish, if I may.

We need to be really careful that we take a person-centred approach, as happens now. Doctors, medical practitioners and healthcare professionals quite rightly take a holistic patient-centred approach. That approach will be further enhanced by the robust training the Bill incorporates, and by adding the extra layers of safeguards and protection. Really importantly, it would open up conversations about death and dying.

--- Later in debate ---

[Danny Kruger]

We have debated that issue; I apologise.

My concern is that the Bill, which is masquerading as a safeguarding Bill but is actually an autonomy Bill, will end in less autonomy for the most vulnerable patients, who will find themselves on this conveyor belt, internally pressured and encouraged to seek an assisted death when it is not in their interests. I invite the Committee to reflect on what we have done, but as I have said, I do not propose to divide the Committee on clause 1 stand part.

[Rebecca Paul]

Under our current law, assisting someone to commit suicide is a criminal act. Clause 1 of this Bill is where we cross the Rubicon, moving away from well-established principles into a new era in which the state is empowered to help individuals to die.

This monumental decision is one for Parliament in the coming months. However, what we must do on this Committee is bolster the safeguards so that the Bill is truly as safe as it can be. Our priority must always be the vulnerable: those who could be coerced into something that is not in their best interests, and those with no one to advocate for them or protect them, who could end upbeing pushed into a process because that is the easiest and cheapest option for everyone. This law must work for everyone, not just the privileged few.

That is why I am so disappointed that at the end of nearly three days of debate, there has been not one improvement to the safeguards—not one. We asked for amendments to exclude people with impaired judgment and the depressed and suicidal; this Committee said no. We asked to protect those who are unduly influenced or encouraged by others to seek assisted dying—

[The Chair]

Order. We are not discussing the amendments again now. This debate is about clause 1 standing part of the Bill.

[Rebecca Paul]

Thank you, Mr Efford. I am perplexed as to why some of the straightforward improvements to the safeguards have not been accepted. That should give us all pause for thought. If everyone here wants this to be the safest assisted dying service in the world, we must learn from other territories and improve the safeguards. Our priority should not be to make the service as accessible as possible, with as few barriers as possible, or to make it as easy as possible for medical practitioners to sign off. Time and again, throughout our proceedings, the importance of autonomy has been given as the reason why amendments cannot be accepted, but surely that must be balanced against what is in someone’s best interests.

It is clear that in other areas of medicine a best interests approach is taken, for example under section 63 of the Mental Health Act 1983, which states:

“The consent of a patient shall not be required for any medical treatment given to him for the mental disorder from which he is suffering”.

A patient can thus be deemed to have capacity, and yet still receive treatment that they have refused, for example in the force-feeding of a young girl with anorexia. Those who argue for full autonomy would no doubt rail against this best interests approach. However, I suggest that it is always worth considering what we would want to happen if it were our daughter.

This is not an easy balance to get right—I completely concede that—but right now the Bill has no best interests component. That means that if anyone inadvertently qualifies for assisted dying but should not, for example an anorexic girl who has refused treatment, there is no safety mechanism to take her out of scope. The amendment tabled by my right hon. Friend the Member for Braintree (Mr Cleverly) would have gone some way to addressing that.

Clause 1 will profoundly change how society views suicide. Data from overseas territories indicates that introducing assisted dying can actually increase the number of unassisted suicides. In Oregon, whose system this Bill is specifically based on, non-assisted suicide has increased by a statistically significant amount. That demonstrates the seismic shift in attitudes that accompanies this, so when we tell our young people that suicide is not the answer and to seek help, we must do so knowing full well that the key message will be undermined by the availability of an assisted dying service, which may be plastered across billboards and advertised on daytime TV.

[Dr Opher]

May I say that this is skewed statistics? There is no statistical evidence that suicide increases in jurisdictions that have assisted dying.

--- Later in debate ---

[Rebecca Paul]

I thank the hon. Member for his intervention, but I respectfully suggest that that is not the case and there is data. Professor David Paton found a 6% increase overall, and interestingly it was 13% for women.

[Kim Leadbeater]

I would be interested to know whether that data shows a link or a direct causation effect.

[Rebecca Paul]

I thank the hon. Lady for raising that point. I think that what has been looked at is the number of unassisted suicides. The hon. Lady makes the good point that obviously we need to look at all the different factors that could be part of that, but I am just making the point that when we look at territories that have introduced assisted dying, we find that at the point at which it is introduced, we generally see, in most territories, an increase in unassisted suicide. I do not think that we should rush to disregard that. We need to recognise that in helping a small group of people at the end of their life, which undoubtedly this Bill will do, there will be a price to be paid. That price will be paid by our young people and other vulnerable groups.

I will not vote in favour of clause 1—I do not think that there will be a Division on it anyway—but I will not oppose it either, for the reasons that my hon. Friend the Member for East Wiltshire set out. I understand that it is the key clause in order for us to progress and continue the debate, which is what Parliament wishes us to do, but I hope that the Committee will be more receptive to improving the safeguards as we progress through the Bill. The amendments really were tabled in good faith. We did our best to write them in a clear way, but obviously the private Member’s Bill process makes that more difficult. This is not a Government Bill, but we are all doing the best we can to table amendments that would improve the safety of the Bill.

[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.

--- Later in debate ---

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

I have great sympathy with amendment 11 in particular, which is clearly motivated by a desire to ensure that having a mental illness or disability alone does not qualify someone for an assisted death under the Bill. It is worth saying that clause 2(3) already does that and, therefore, the amendment is not necessary. However, the hon. Member for Spen Valley has tabled amendment 181, which further tightens that language. In my view, amendment 181 strengthens the Bill by simplifying the language to make it absolutely clear that a person is not considered to be terminally ill if they have a mental disorder or a disability alone. The chief medical officer, Professor Whitty, encouraged us to keep this simple, and that is precisely what amendment 181 does. Therefore, I support the amendment.

[Rebecca Paul]

I rise to speak to amendment 11, which stands in the name of my hon. Friend the Member for South Northamptonshire. This is one of the areas of the Bill where we all agree on what we are trying to achieve, so it comes down to making sure that the drafting does exactly what we all intend in order to protect people.

The definition of “terminal illness” in the Bill has two components. The first is that the person has an inevitably progressive and irreversible condition; the second is that their prognosis is less than six months. An issue raised in our evidence sessions is that there is a risk that a person with a mental disorder or disability will meet that definition if they are suffering physical symptoms that mean that they satisfy both parts of the test; a possible example could be a young woman suffering with severe malnutrition as a consequence of anorexia. With respect to the point that the hon. Member for Stroud made, I agree that anorexia on its own would not qualify, but the issue arises when there is a physical manifestation from that disorder such as severe malnutrition or even diabetes, which can co-occur, as we heard in the evidence sessions.

It is clear that that is not the intention of the hon. Member for Spen Valley or anyone on the Committee, as evidenced by the inclusion of subsection (3). I thank the hon. Member for making that point; it is much welcomed. However, in oral evidence, Chelsea Roff said that

“we have case law in the UK where people with anorexia are being found to be terminal. We have to take that reality into account.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 153, Q194.]

Before I get into amendment 11, which aims to address the issue, it is important to understand what clause 2(3) is trying to do. It reads as follows:

“For the avoidance of doubt, a person is not to be considered to be terminally ill by reason only of the person having one or both”

of a mental disorder or a disability; it refers to the relevant bits of law. As my hon. Friend the Member for East Wiltshire has set out, the words “for the avoidance of doubt” make it clear that this is a clarifying subsection that does not make any change to the rest of clause 2. It appears to be clarifying that mental disorders and disabilities alone will never qualify someone for assisted dying—I think we all concur with that—unless they also have a physical condition that meets the terminal illness test, namely that it is inevitably progressive and irreversible and that the person has a prognosis of less than six months.

This is where the problem lies. If someone has a physical condition arising from their mental illness, such as severe malnutrition resulting from anorexia, and if the physical condition meets the definition of a terminal illness, they will qualify. As the Royal College of Psychiatrists said in its position statement:

“The wording of the Bill could also be interpreted to include those whose sole underlying medical condition is a mental disorder. While anorexia nervosa, for example, does not itself meet the criteria for terminal illness as it is not an ‘inevitably progressive illness, disease or medical condition which cannot be reversed by treatment,’ its physical effects (for example, malnutrition) in severe cases could be deemed by some as a terminal physical illness, even though eating disorders are treatable conditions and recovery is possible even after decades of illness.”

To remedy the issue, amendment 11 would remove the words “For the avoidance of doubt”, to make this a legally effective clause, rather than just a clarifying one. That means that it is providing an additional safeguard to those with mental disorders and/or disabilities. It would also remove the word “only”, to ensure that a physical condition resulting from a mental disorder or a disability will not make a person eligible for assisted dying. The amendment is further bolstered by amendment 283, tabled by the hon. Member for York Central, which would make it clear that comorbidities arising from a mental disorder do not qualify a patient for an assisted death.

I thank the hon. Member for Spen Valley for tabling amendment 181 to try to address the issue, but I do not believe that would quite solve the problem, which is quite a tricky one. “For the avoidance of doubt” would still be there, as would “only”. The sentence beginning with “Nothing in this subsection” makes it crystal clear that if a condition meets the six-month condition and the rest of the definition, it will be considered a terminal illness. There is therefore no exclusion for physical symptoms manifesting from mental illness or disability, which I think is what we are all trying to get to.

In my view, the only amendment that would address the issue is amendment 11, tabled by my hon. Friend the Member for South Northamptonshire. It would remove both “For the avoidance of doubt” and “only”, and would therefore better ensure that a physical condition resulting from mental illness or a disability does not make a person eligible for assisted dying.

[Naz Shah]

I rise to speak to amendments 10, 181 and 283. I will start with amendment 10, which is very significant: it would make a small but crucial change to clause 2.

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

Rebecca Paul Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

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

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

I rise in support of amendment 234. I acknowledge the point made by the hon. Member for Harrogate and Knaresborough about not pushing it to a Division, but it is important to hear why it would benefit the Bill if it was agreed to. It would allow a terminally ill person with a neurodegenerative illness, disease or condition who has fewer than 12 months left to live—rather than six—the right to choose an assisted death. I speak as a humanist, because I am very alive to many members of the public, and some MPs, wanting a wider scope of eligibility to cover intolerable suffering. In fact, some want no timescales, and an amendment has been tabled for that. I believe that my hon. Friend the Member for Spen Valley, who introduced the Bill, has had people speak to her and say the Bill needs to go further.

Like all of us, I want to make this a good Act that will have strong safeguards while allowing people choice at the end of life, and I want it to command the support of the House. I reflected on whether we need to have such a wide definition to cover intolerable suffering, and I thought that a change to 12 months for those with neurodegenerative diseases would be a good way to reflect the breadth of voices we have heard in debates on the Bill. It is an appropriate compromise. One of the things we have seen over the course of our Committee debates is the real pulling apart and consideration of what this legislation will mean in practice.

As the hon. Member for Harrogate and Knaresborough set out so well, a 12-month timescale for those with neurodegenerative diseases would mean that people could make decisions while they still have mental capacity. As he rightly said, their condition would so often see a cognitive decline before six months. The Motor Neurone Disease Association—another organisation that supports people living with terminal neurodegenerative diseases—highlighted problems with the six-month criteria and the inequity that arises.

Again, I reference the testimony of medical practitioners from Australia, where some states have eligibility criteria for assisted dying that includes an illness, disease or condition that is expected to cause death within 12 months. It is out there in practice, so it is not a new concept. Professor Meredith Blake said in oral evidence:

“Queensland legislation is different: it sets a 12-month period of expected death, and the reason for that approach was in response to feedback from people living with neurodegenerative disease that they felt that they were being put in a different position to people suffering from, or experiencing, other terminal illnesses.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 211, Q270.]

I will draw my remarks to a close, but there is a personal reason why it is important to me that we reflect on 12-month eligibility: the case of Diane Pretty. Diane Pretty was from Luton, albeit she lived in the neighbouring constituency, and some 25 years ago she was diagnosed with motor neurone disease. She tried to change the law then so that she could access assisted dying, such was the pain and suffering that she endured because of her terminal illness. What she said is fundamental and at the heart of what we are trying to do here, 25 years later:

“I want to have a quick death, without suffering, at home and surrounded by my family.”

In the end, Diane Pretty was not successful, and she died aged 43 on 11 May 2002. She did not have a choice. She could not choose the death she wanted. Much has been said about rushing the Bill, but that was over 20 years ago, so the debate has been going on for many years. That is why I speak in support of amendment 234, so that those with neurodegenerative terminal illnesses, whose death is reasonably expected within 12 months, can access assisted death.

[Rebecca Paul (Reigate) (Con)]

I will speak to amendments 9 and 10, which were tabled by my hon. Friend the Member for South Northamptonshire (Sarah Bool). Members will spot the trend: I have been speaking in favour of a lot of her amendments.

Amendments 9 and 10 would make sure the Bill does what it aims to do: ensure that assisted death is available only to those who are genuinely at the end of life. Under clause 2, a person is terminally ill if they have a prognosis of less than six months and if they have

“an inevitably progressive illness, disease or medical condition which cannot be reversed by treatment”.

That wording gives rise to a risk of unintended cases meeting eligibility criteria.

In Oregon, conditions such as anorexia, diabetes, arthritis, HIV/AIDS and hernias have all qualified for assisted death. That is partly because the Oregon law uses the language of “irreversible”, just as the Bill says

“cannot be reversed by treatment”.

Conditions like diabetes arguably cannot ever be “reversed”, which suggests something more akin to “cured”; they can only be managed. The definition of terminal illness is now broader than it was ever intended to be.

[Tom Gordon]

Prior to being elected to Parliament, I worked for a type 1 diabetes charity—I feel like I have been saying that a lot recently. When we talk about diabetes, we often do not consider the fact that there are different types, including type 1, type 2 and gestational. They are not all akin, or the same. Furthermore, the NHS in its own language has referred to it as “a lifelong condition”, rather than a disease or anything that is terminal. How would the hon. Lady reflect on that?

[Rebecca Paul]

I thank the hon. Member for that thoughtful intervention, and I completely concede that it is not entirely clear, and there are different sources that describe it differently, which, for a non-medical person like myself, makes it difficult. There are certain websites, including NHS England, that may reference it as “progressive”, but equally I am sure that there are other sources that do not describe it in the same way. The hon. Member for Harrogate and Knaresborough makes a really good point, and he will see that I quite often talk about things arguably being the case; I am not saying that it definitely is—I am just highlighting that there is a risk, because if people disagree on whether it is progressive, that is when we have an issue. I see this as an opportunity to tighten up any of that potential risk.

I would say the ordinary person on the street would not expect diabetes to ever fall within the definition of a terminal illness, yet there is a risk that it could do, for the reasons I have explained. That means that the drafting of clause 2 is not quite tight enough in my view.

[Kim Leadbeater]

Just before the hon. Lady moves on, we may actually have come to a very sensible position based on the other amendments we have been discussing—amendments 399 to 401. I have done a little bit of googling, and diabetes generally is referred to as a “condition”. It might be referred to in other ways as well, but maybe that would be another reason for us all to support amendments 399 to 401.

[Rebecca Paul]

I thank the hon. Lady for that extremely good news. That would definitely be helpful and provide some reassurance.

Amendments 9 and 10 are essential to ensure that those people who are never intended to eligible for assisted dying under this Bill are kept outside of it. Amendment 9 seeks to ensure that it is not just illnesses that can be reversed by treatment, but illnesses where the progress can be controlled or substantially slowed by treatment, that are ineligible—diabetes being the classic case, which can be slowed and controlled by treatment. Amendment 10 further bolsters that by ensuring that treatments that improve prognosis are not disregarded under clause 2(1)(a).

The problem that we have with clause 2 in its current form is that it fails to distinguish between those who are truly at the end of their life and those who only become terminal if they do not access treatment. There is no requirement for a person to be receiving medical care when their prognosis is assessed, which means that many manageable but irreversible conditions—like diabetes, potentially, and chronic kidney disease—could qualify as terminal if treatment is stopped. Let us take the example of someone with type 1 diabetes, like my hon. Friend the Member for South Northamptonshire (Sarah Bool), who tabled these amendments. If she were to stop taking her insulin, she might meet the criteria for terminal illness under the Bill and qualify for an assisted death—I mean, I certainly hope she would not. Without treatment, type 1 diabetes could arguably be an inevitably progressive and irreversible condition that would result in death within weeks or months.

[Dr Opher]

There is nothing inevitable about a diabetic getting worse; they just need to take the right treatment, so I would say that “inevitable” is a key word. I respect what the hon. Lady is saying about the amendments, and they do have some value, but I do think it is covered by the current language—

“inevitably progressive…disease…which cannot be reversed.”

I think “inevitable” and “cannot be reversed” are enough of a safeguard to make this a good clause.

[Rebecca Paul]

I know the hon. Member has a huge amount of experience on this matter given his career, so I thank him for that contribution.

It must not be forgotten that it is the nature of such illnesses for there to be periods of unwellness, when people are at their lowest ebb, and it is our job to protect them from something that could sound appealing at that moment in time. The crux of this issue is that—subject to the point that the hon. Member for Spen Valley made about the improvements that we may now see following the amendments that we have just discussed—the Bill makes no distinction between a condition that is inevitably fatal and one that could be substantially slowed with treatment.

[Dr Shastri-Hurst]

My hon. Friend is making a valid argument, but I want to pick up the point made by the hon. Member for Stroud. He talked about illnesses that are inevitably progressive and cannot be reversed by treatment. For type 1 diabetes—I think that is what my hon. Friend the Member for South Northamptonshire (Sarah Bool) is addressing, as opposed to other forms of diabetes—a person either has insulin or does not.

[Dr Shastri-Hurst]

Forgive me, Chair. I will come to the point. If the person does not have insulin, the diabetes could be treated by administering it. Does my hon. Friend accept that, in those circumstances, it would fall within this clause?

[Rebecca Paul]

I thank my hon. Friend—another doctor. I would suggest that diabetes cannot be reversed, but can be managed with treatment. All I am trying to do is make sure that that piece is picked up. I think we all agree that we would not expect diabetes to fall within the terminal illness diagnosis.

No fewer than 15 clinicians and medical researchers mentioned diabetes in written evidence. Other conditions are mentioned too. Two consultant physicians—Rosemarie Anthony-Pillai and DP Whitehouse—say that those on medication for heart failure could qualify if they stopped taking their medication. Dr David Randall, a consultant nephrologist at the Royal London Hospital, sets out in written evidence the example of a young man who has benefited from a kidney transplant but stopped his immunosuppression medication. That would lead to transplant rejection and, likely, death within a few months. Would he qualify as terminally ill if we were not to agree to these amendments?

[Lewis Atkinson]

The examples that the hon. Lady gives of the refusal of life-preserving treatment—for example, stopping insulin—would inevitably lead to death, so why does she believe that anyone in such a situation would need to seek voluntary assisted dying?

[Rebecca Paul]

I am sharing the content of written evidence. People working in this arena—medical professionals and clinicians—have taken the time to submit written evidence, which suggests that they see a risk, so this is something that we need to think about. The hon. Gentleman could be right when he asks why someone would seek assisted death in that situation, but it is more about if someone technically qualifies. Obviously, we are still yet to get through the Bill, and there is lots for us to debate, but we want to ensure that people are not put on that pathway if they are not actually terminally ill and their condition can be managed. People could be in a low place, and we need to provide support. This comes back to my point about the balance of best interests. It is really difficult to set the right level, but we need to think about best interests and protect people at their lowest point.

In Oregon, conditions such as anorexia, diabetes, arthritis and hernias have qualified for assisted death, not because they are inherently fatal but because treatment was refused or was unaffordable. We also need to think about situations such as supply chain issues with certain treatments. Situations that we do not want to happen could arise, and we need to think about what that means for this Bill.

Some lawyers and doctors in the US have advised patients on how to bypass the terminal illness criteria by refusing food and water until they become terminal—we have talked about that quite a lot today. There is some evidence of that happening. Cody Sontag, an Oregon woman with early-stage dementia, had few symptoms and was not eligible for assisted death, but after she refused food and water for a few days, her doctor ruled that she met the six-month prognosis requirement.

It is important that we carefully consider young women suffering with eating disorders, but I appreciate we have spoken about that group a lot today, so I will be brief. In Chelsea Roff’s evidence, she set out that at least 60 people around the world have been euthanised or assisted in suicide where anorexia nervosa has been listed by name as a terminal condition. In 100% of the cases, the people were women, a third were between the ages of 18 and 30, and two thirds were under the age of 40. Roff said,

“I have to emphasise that these were young women who did not have failing organs and did not have comorbid terminal conditions…they had decades of life ahead of them.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 139, Q175.]

UK courts have already ruled that treatment can be withdrawn from young women with anorexia, acknowledging that the likely result will be their death, after doctors framed their condition as terminal or untreatable. These examples powerfully demonstrate why it is vital these amendments are accepted, so that these conditions do not lead to a person qualifying for assisted death, if they can be managed sufficiently with treatment. In oral evidence, Dr Miro Griffiths asked us,

“What constitutes six months left to live, particularly if you are engaging with technological devices, medical assistance and so on? For example, I have a progressive condition that continuously makes me weaker and has respiratory complications and so on. If I remove the ventilator that I use at night, if I remove my other medical devices and if I stop my engagement with therapeutic services, does that constitute me having a terminal illness, because my rapid acceleration towards death becomes more evident?”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 142-143, Q179.]

In written evidence, Pathfinders Neuromuscular Alliance warned that for those with conditions like muscular dystrophy, access to treatment is essential. It said,

“It would not be unreasonable therefore to suggest an individual with neuromuscular respiratory failure could die within six months—and yet they might also live 20 to 30 additional years in this state.”

In written evidence, a group of leading physicians and researchers, including experts from John Hopkins University and the Royal College of Psychiatrists said,

“The Bill’s definition of terminal may not adequately distinguish between a condition that is inevitably fatal and one that only becomes terminal without adequate care.”

They added,

“Under this Bill, patients with incurable but treatable conditions could become terminal if they are unable to access timely treatment or choose to forego life-sustaining care.”

It is therefore vital that the definition of terminal illness is tightened to avoid unintended consequences. These amendments would ensure that the Bill applies only to those who are generally at the end of life, without prospect of recovery. I urge the Committee to give consideration to accepting them.

[Naz Shah]

First, I will speak to amendments 9 and 10, then to amendment 234, and then to my own amendments 48 and 402. I hope it is in order to note that the hon. Member for South Northamptonshire (Sarah Bool), as the hon. Member for Reigate already mentioned, is a type 1 diabetes sufferer. Amendments 9 and 10 both concern matters of which she has a personal understanding.

Amendment 9 would mean that an illness, disease or medical condition, the progress of which can be managed or controlled by treatment, would not be characterised as a terminal illness. The amendment provides that instead of saying that the illness cannot be “reversed” by treatment, the Bill should say that its progress cannot be “controlled or substantially slowed”. The amendment is clearly a most important one. It seeks to prevent illnesses that can, in fact, be treated effectively from being classified as terminal illnesses.

The amendment would work to mitigate two very serious risks posed by the Bill. First, it would make it more difficult for someone who, for whatever reason, wished for an assisted death to qualify for that process by failing to follow a reasonable course of treatment. I do not say that the amendment would make it impossible for anyone not to do so, but it is an important safeguard. It would also provide a safeguard against the expansion of those conditions that would qualify people for assisted death.

My hon. Friend the Member for Spen Valley and members of the Committee have repeatedly praised the Oregon law, but we surely do not want to follow that example in every way, since we know that in Oregon, sufferers of anorexia have been able to access assisted dying. Again, I do not say that the amendment would make it impossible to expand the list of conditions, but it would make it harder. My hon. Friend has said repeatedly that she wants the Bill to have the strongest safeguards of any assisted dying law in the world, so I hope that she will join me in voting for amendment 9.

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

Rebecca Paul Excerpts

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Rebecca Paul (Reigate) (Con)]

I rise to speak to my amendment 398. I recognise that much debate about capacity has already taken place, so I will do my best not to be too repetitive, but it is an important topic and I want to cover a few things.

Fundamentally, I consider the bar for the capacity to make a decision to seek an assisted death to be far too low if, as we have already discussed, the approach currently proposed in the Bill is adopted. The Committee has received powerful written evidence that the Mental Capacity Act, as it stands, is not suitable for assisted dying. The Royal College of Psychiatrists says in its written evidence:

“It is the RCPsych’s view that the MCA is not sufficient for the purposes of this Bill.”

The former president of the Royal College of Psychiatrists, Baroness Hollins, says:

“The Mental Capacity Act has proved very difficult to implement and doctors have not been found to be good judges of capacity.”

The eating disorders expert Chelsea Roff says:

“The MCA is not fit for purpose for determinations of capacity in life-ending decisions.”

I do not think it is contentious to say that there should be a higher standard for ending one’s own life than for other courses of action. Baroness Hale has called the Mental Capacity Act threshold “not a demanding one.” The Royal College of Psychiatrists says in its written evidence:

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

Even if the Mental Capacity Act is working well in some other contexts, it does not necessarily translate well to assisted dying. Professor Gareth Owen told the Committee in oral evidence that although the Mental Capacity Act is quite reliable in current practice,

“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.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 239, Q303.]

The Mental Capacity Act definition of capacity was not created with such a monumental decision with respect to assisted dying in mind. Although I note Chris Whitty’s recommendation that it is the starting point, I do not think it can be the end point. Further provisions are needed to ensure that it is fit for purpose, given the significance of the decision being made. Professor Owen said:

“I have looked at mental capacity a lot in research, and there is no experience of the decision to end one’s own life. It is outside the experience of the Mental Capacity Act, the Court of Protection, the associated research and practitioners on the ground. The reference to the Mental Capacity Act in clause 3 puts you into an area where there is no experience of the central capacity question under consideration. It is very important that Parliament be clear-eyed about that.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 226, Q287.]

Dr Sarah Hooper, a retired oncologist, says that

“the patient in question may undoubtedly have ‘capacity’ for most important decisions. However, in the early days after a cancer diagnosis their ability to make clear judgements is nevertheless likely to be impacted. This kind of decision (for assisted suicide), once acted upon, is plainly irreversible. It is a very bad time to make that kind of decision.”

It is true that the Mental Capacity Act is used for decisions to stop life-sustaining treatment, but, as Professor Owen said, we should not simply equate that with assisted dying. As he pointed out:

“One is a refusal; one is a request. One is traditionally considered to be about bodily integrity—it is the so-called shield of the person, or the patient, against the intervention on the body that is being made by the medical profession. You are giving the patient an important right, which is a shield-like right. That contrasts with a request for assisted dying, which is a request. You are involving other people in an act that is an act of ending one’s life. That is not something that the medical profession has been comfortable with, going back thousands of years.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 236, Q288.]

I also draw attention to a great deal of written evidence making the point that the current Mental Capacity Act is not as well understood by medical practitioners as we hope or expect. Alexander Elphinston, a retired solicitor, says,

“from my experience doctors and other medical practitioners often applied the test of mental (in)capacity incorrectly.”

Victoria Wheatley, a palliative medicine consultant, says,

“I have observed a tendency to overestimate a person’s mental capacity in the absence of obvious features to the contrary.”

Alan Thomas, a professor of old age psychiatry at Newcastle University, says:

“The preferences of the assessor bias the capacity decision towards the assessor’s preference.”

I will move on to the specific issues with the current definition of people who lack capacity under the Mental Capacity Act when applied to assisted dying, all of which my amendment 398 attempts to address. Part of my amendment does exactly the same as amendment 322, tabled and already eloquently spoken to by the hon. Member for Bexleyheath and Crayford, so I will be brief on those overlapping bits.

Under the Mental Capacity Act, there is a starting presumption of capacity. That is too lax a standard, as the Royal College of Psychiatrists says in written evidence. I quote:

“The presumption of capacity may be problematic in the context”

of assisted dying, given that the consequence would be the person’s death. This is literally a matter of life and death, and the presumption of capacity must not apply; the work must be done to assess capacity properly and thoroughly. Professor Preston said during the evidence session:

“I think the aim is to have that bit of extra concern, so that we do not presume capacity, but instead almost presume that there is not capacity.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 241, Q307.]

I think those are wise words, and my amendment and amendment 322 seek to give that protection.

Both amendments also disapply section 1(3) of the Mental Capacity Act on helping a person to make a decision. The hon. Member for Bexleyheath and Crayford has already made his point powerfully about that, so I will not add anything further.

There are some differences where my amendment 398 goes further than amendment 322. First, given the uniqueness and irreversibility of the decision, there should also be a higher threshold of probability. As it stands, a person should be treated as having capacity if that is more likely than not, which is sometimes referred to as the “51% sure” approach. It would be much safer if doctors and judges had to establish beyond reasonable doubt that an applicant has capacity, given the significance of the decision. In my view, 51% sure is just not good enough for such a monumental decision, and amending this part of the Bill would ensure a more rigorous and comprehensive assessment.

Secondly—for me, this is one of the biggest issues with the current approach—the Mental Capacity Act requires an impairment of, or a disturbance to, the mind or brain for someone to be considered not to have capacity, irrespective of whether they can make a decision. Under the Bill currently, even if someone cannot understand, retain or use the information to make a decision—they cannot communicate that decision—they will still be deemed capacitous in the absence of an impairment, or a disturbance, of the mind or brain. In the real world, a doctor could assess a patient who gives the impression of being confused, illogical, erratic or inconsistent—everything about them could scream that they are not in a good place to make the decision—but they will still be considered to have capacity if there is no identifiable impairment of, or disturbance in, the function of the mind or brain at that point in time. That potentially puts those with depression, anxiety, learning disabilities or eating disorders, or even those in physical pain, in danger of being considered capacitous.

In oral evidence, Professor Alex Ruck Keene said,

“If I doubt that you have capacity to make the decision to take your own life, or end your life, but I cannot prove it, is it logical or are we required to proceed on the basis that you do?...In other words, I think you cannot understand the information, but I cannot prove the reason that you cannot understand it is that you have an impairment or disturbance.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 90, Q120.]

According to his written evidence to the Committee, this means that someone could be approved for assisted dying even if they did not understand the relevant information, as long as they do not have an identifiable impairment of, or disturbance in, the mind or brain. He wrote,

“the Committee may well feel that it would be problematic that such a person should be considered to be eligible for the receipt of assistance in dying.”

In a letter to the hon. Member for Richmond Park, Professor Alex Ruck Keene KC said,

“no matter how intensive the scrutiny of the person’s capacity, this would not address the issue of the situation where the person appears not to be able to understand, retain, use and weigh the relevant information but that is not caused by an impairment of, or disturbance in, the functioning of their mind or brain.”

That is why my amendment seeks to remove this diagnostic element, so that section 2(1) of the Mental Capacity Act for the purposes of this Bill only would read as,

“a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter.”

That would provide better protections for this life and death decision, and I hope it addresses the issue raised so powerfully by Professor Alex Ruck Keene KC.

As I close, I would like to make reference to amendment 49, tabled by my hon. Friend the Member for Runnymede and Weybridge, which sets out starkly the deficiencies of the current capacity test if it remains unamended for the purposes of this Bill. If autonomy is what counts, and we are using the Mental Capacity Act as gatekeeper for assisted death, then the Bill in its current form means that: a person is assumed to have a capacity as a starting point; a clinician only needs to be just over 50% sure that a person has capacity; unwise decision making is not taken into account in determining capacity; and supported decision making is acceptable—for example, for those with learning disabilities.

I ask the Committee members whether they are comfortable with that. If not, then as a minimum, amendment 322 should be accepted, but ideally my amendment 398 should also be, as it goes even further to increase the threshold for capacity and it addresses the significant issue with the diagnostic leg of the test. I am pleased to say that Baroness Finlay, who established and chaired the National Mental Capacity Forum, supports my amendment. Unlike the current drafting of the Bill, my amendment requires that a person is not assumed to have capacity in the first instance. It requires capacity to be proven beyond reasonable doubt, that unwise decision making is considered in assessing, and that a person is not helped to make a decision. I hope the Committee will support it.

[Danny Kruger]

I am pleased to follow my hon. Friend the Member for Reigate, who set out with incredible clarity the challenges here and the opportunity we have to build on the Mental Capacity Act, and to fulfil its purposes and the purposes of the Bill to ensure that capacity is properly assessed. I will speak to all the amendments in the group very briefly; I certainly will not repeat material points that have been made already. To clarify, I do not propose to push amendment 49 in the name of my hon. Friend the Member for Runnymede and Weybridge to a vote, although I will speak to it briefly. I hope we will vote on the other amendments.

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

Rebecca Paul Excerpts

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[Stephen Kinnock]

It is absolutely the hon. Member’s prerogative to press the amendment to a vote if he so wishes. As things stand, because of the baseline, which is the GMC guidance that I have just read out, we constantly go back to the Government’s position that the current corpus of guidance, regulations, advice, training, expertise and professional judgment is, in essence, satisfactory to the Department. We believe in and rely on the professional judgment of the experts in the field. That remains our fundamental position.

The effect of amendment 320 would be that the safeguards in clause 4(4) in respect of the preliminary discussion apply only where the person seeking assistance is aged 18 or over. The amendment would not prevent a discussion with a person under 18. As the Committee will be aware, there is already a requirement that, to be eligible for the provision of assistance under the Bill, a person must be 18 or over when they make their first declaration under clause 1(1)(b).

Amendment 270 would make it a requirement for a registered medical practitioner to ensure that there are no remediable suicide risk factors before proceeding to the initial discussion about assisted dying. The amendment does not state what is to happen if the practitioner considers that there are remediable suicide risk factors. As the Committee will be aware, we rely on medical practitioners to make judgments in relation to their patients that draw on their training, experience and expertise. We would expect the judgment and skill of a medical professional to be brought to bear where there are remediable suicide risk factors.

Amendment 276 would mean that a person is unable to have a preliminary discussion or make a first declaration to be provided with assistance to end their own life until 28 days after receiving a terminal diagnosis. The amendment would add an additional pause into the process for a person who has received a terminal diagnosis in the preceding 28 days. The 28-day pause would apply regardless of the patient’s prognosis, even if they had only one month left to live, for example.

New clause 6 would ensure that an advance decision to refuse treatment under the Mental Capacity Act 2005 cannot be used to seek assisted dying. Our analysis suggests that the new clause is not necessary, because an assisted death is available only to those with capacity, whereas advance decisions provide for a person to be able to refuse treatment at a future time when they have lost capacity. If a person still has capacity, they may be eligible for an assisted death. If they do not have capacity, they will not be eligible, irrespective of whether they have made an advance decision.

That concludes my remarks on this group of amendments. As I say, the Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could change. However, I hope my comments and observations are helpful to Committee members in considering the Bill.

[Rebecca Paul (Reigate) (Con)]

I appreciate the opportunity to speak briefly, Mr Efford. Many other speakers have already made excellent points in support of the amendments, so I will not repeat them, but I would like to put on record one pertinent point.

During these proceedings, there has been a tendency by some to speak as though assisted dying were another type of treatment or healthcare option being offered by medical practitioners, rather than a completely different and separate offering. I have grave concerns about that. The legal norm, and GMC guidance, is that patients should be offered all reasonable medical treatments. A medical treatment can be defined as something that combats disease or disorder. It is fundamentally about healing, relief of symptoms, recovery and cure. Straightaway, we have a conflict. Assisted dying ends the life of a person. It is not a treatment in the normal sense—

[The Chair]

Order. You need to speak to the amendments in this group.

[Rebecca Paul]

I am. It is relevant, because we are talking—

[The Chair]

You will need to explain to me how you are speaking to the amendments.

--- Later in debate ---

[Rebecca Paul]

We are talking about what a medical practitioner can and cannot say. During the debate, there was a lot of talk about whether it was a medical treatment or not. If so, guidance indicates how it should be treated, so whether it is a medical treatment or not is relevant and pertinent to the clause. I have an important point that I would like to put on the record; I am happy to raise it at a different point, but I honestly believe that clause 4 is the right place.

[The Chair]

The problem is that this is not a general debate on clause 4; it is a debate about a specific group of amendments. We may come later to a general debate on clause 4.

[Rebecca Paul]

I can wait until the stand part debate.

[The Chair]

If there is a stand part debate, that will be the right time to make a contribution about the general principles of clause 4.

[Rebecca Paul]

Okay. I will just put it on the record that whether or not something is a medical treatment is vital. It is possible to give medical treatments without consent, so we need to have that debate.

[The Chair]

That is for the wider debate. I call Kim Leadbeater.

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

Rebecca Paul Excerpts

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[Liz Saville Roberts]

That is exactly what I am seeking to do, and I am seeking to do it as co-operatively and collegiately as possible. But we need to have clarity on this, and our discussions need to be thorough and exact in order to be accurate.

When it comes to the individual’s right to use Welsh in their daily lives, two pieces of legislation are relevant to the Bill: the Welsh Language Act 1993, which predates devolution, and the Senedd’s Welsh Language (Wales) Measure 2011. The Welsh Language Act remains applicable for reserved matters, such as justice, and the Ministry of Justice operates a Welsh language scheme that enables people to use Welsh in courts, tribunals and other areas of justice. The Welsh Language Measure established the office of the Welsh Language Commissioner, who has the power to investigate complaints from Welsh speakers who assert that their freedom to use Welsh has been interfered with; created a Welsh language tribunal to hear appeals against the commissioner’s decisions; and enabled the development standards, which are particularly significant here.

The Welsh Language Measure states that individuals in Wales should be able to conduct their lives through the medium of Welsh if that is what they choose to do. Under the Measure, the NHS in Wales has a statutory duty to deliver services to the public in both Welsh and English. The Welsh language standards are a set of statutory requirements that set out responsibilities to provide services, and they apply to health boards in Wales, as well as to NHS primary care services that are contracted by the health boards. The standards do not apply to independent providers, which since 2019 must follow six Welsh language duties, one of which is to establish and record the language preference of patients. That is where I have got the terminology used in amendment 413.

That is a summary of the relevant considerations but, before I close, it is important to say why this matters to Welsh speakers. I spoke recently to medical practitioners in Wales who wanted me to emphasise their concerns at the lack of specific mention of language rights. I also spoke to the Welsh Language Commissioner’s officers, who advised me on the necessity of the amendments. There is a critique against providing Welsh language services that shrugs its shoulders and says, “Why bother? They all speak English anyway.” That is to ignore how integral language use is to the individual.

We are drafting a Bill to do two things in a very delicate balance: to respect the autonomy of the individual and to safeguard people against abuse in any form. For many Welsh speakers, Welsh is the language of their emotions. It is the language in which they express themselves most fluently, and the first language of their feelings. It matters to this Bill. English is the language of authority, and many Welsh speakers are anxious not to challenge the authority of high-status people such as doctors. They do that out of ingrained politeness, and out of fear of not being able to access services if they put any barriers in the way. That is the way that language gets used. Welsh speakers do not use Welsh in the way that monolingual English speakers use English; monolingual English speakers use English because it is the only language they have. For anyone who is bilingual or multilingual, the use of language is very complicated and sophisticated, and we need to be alert to it in all its respects.

I return to the nature of the relationship between doctors and their patients. Doctors have high status, and a patient approaches a doctor seeking services, advice and context. That is not a power dynamic that we should allow to go unchecked, so I urge the Committee to consider the amendment. I do not intend to press it to a vote, but I want a response from the Ministers. Before Report, I want absolute clarity on its legal necessity or otherwise. I feel instinctively—especially because the Welsh Language Commissioner’s office has told me this—that it should be in the Bill. I would also like a response from Ministers on amendment 414, tabled by the hon. Member for Ipswich.

[Rebecca Paul (Reigate) (Con)]

I rise to speak briefly to amendments 413 and 414, which are very thoughtful and well-considered amendments. I thank the right hon. Member for Dwyfor Meirionnydd for setting out powerfully and persuasively the importance of the subject. I support the amendments, but in reality we probably need to go further by specifying exactly who would be interpreting and making sure that it is regulated reliably. We do not want just anyone coming in off the street and doing that. That would not be appropriate, so we need to think about whether we need to go further. However, the amendments are a great starting point and would move us closer to where we need to be.

There is much subtlety in this debate. We talked a little in the first week of this Committee about the importance of language and the words that are used. We always need to be cognisant that when we are imparting information to people, particularly in a healthcare context, it is vital that we use language that people understand so that the ramifications of what is being discussed are clear. That is where these amendments become really important, because for those for whom English is not their first language, some of the subtlety and nuance around what a term means could be lost. Interpreters could be an important part of adding the clarity required to ensure that everyone going through the process understands exactly what it involves.

A 2024 Nuffield Council on Bioethics survey found that 39% of people think that assisted dying means withdrawing life support, 19% think that it means providing people who are dying with drugs that relieve symptoms of pain or suffering, and 13% think that it means providing hospice care. That echoes our debate a couple of weeks ago about how assisted dying can be interpreted in quite a few different ways. It is really important that we are clear in the language we use and what we mean by it.

We also find that among ethnic minorities there is sometimes a greater misunderstanding about palliative care. A 2024 King’s College London survey found that 6% of people believe that it is accurate that palliative care involves giving people medicines in order to shorten their life, but 18% of ethnic minority groups think that. We need to be cognisant of that. While 18% of people trust healthcare providers “not very much” or “not at all” to provide high-quality care towards the end of life, that figure increases to 30% for ethnic minority groups. While 6% of people say they have not heard of palliative care, that increases to 22% of people in ethnic minority groups.

It is important to recognise that the text of the amendment is much less stringent than that of section 7 of South Australia’s Voluntary Assisted Dying Act 2021, which strictly regulates interpreters. That goes back to my initial point. Under the South Australian law, they must be

“accredited by a prescribed body”.

They cannot be a family member, cannot stand to benefit from the will and cannot be involved in the patient’s healthcare. It is really important to ensure that a recognised professional is involved in this most important of processes and information sharing.

I support the amendments, although I think they need to go a little further. I look forward to hearing what other hon. Members have to say.

[Daniel Francis (Bexleyheath and Crayford) (Lab)]

I echo the points that have been made about the importance of the initial conversations, particularly for those who do not have English as their first language. I made a commitment to my hon. Friend the Member for Ipswich that in his absence I would press amendments 414 and 415 to a Division, as he requested.

I support the general principles of the amendments relating to those who are seeking or who need interpretation to explain aspects of assisted dying to them. I support the merit of that principle and the intention behind amendments 414 and 415.

--- Later in debate ---

[Danny Kruger]

I rise to speak to this important group of amendments, which are all relevant to the duty to refer, whereby a doctor who does not want to advise a patient on assisted dying is obliged to send them to somebody who does. In different ways, we each seek to provide more protections for those medical professionals.

There are two main reasons why doctors may not want the obligation to refer that is in the Bill. The first is the central point that this is not a healthcare treatment, as is traditionally understood. Assisted dying does not address the condition or treat the illness; it treats only the symptoms, in the sense that it obliterates the existence of the patient. Like the advert for bleach says, it “kills all known germs”—it kills every experience that the patient has or could have. It is not part of the range of treatments that a doctor should have to offer, as clause 4(1) makes clear.

That point similarly relates to the question of referring to somebody who can offer that discussion. I suggest that the act of referring is an act of endorsement, just as offering the intervention itself is an act of endorsement. Dr Green from the BMA made it clear during oral evidence that the BMA does not like the word “refer”, as it implies assent to the option that is being offered. Indeed, the hon. Member for Spen Valley, in conversation with Dr Green during evidence, accepted that the word “refer” was “not…quite right”, as she put it, because it has the particular implication and expectation of a form of endorsement.

We have heard the same opinion from multiple witnesses in written and oral evidence to the Committee, particularly from Muslim medical professionals and their trade body. Those representing pharmacists also expressed significant concern that they might find themselves included in the definition of medical practitioner. The Association of Anaesthetists and the Royal College of Nursing were worried as well. A range of professional bodies and representative organisations share my concern that imposing a duty to refer—an obligation to assist somebody to have an assisted death by finding them a doctor who will conduct the preliminary discussion—is itself a breach of their rights of conscience.

The second reason follows from the first. Doctors may reasonably conclude that being in a position to help with assisted dying puts them in a totally different relationship with their patients. That is why the BMA is so unhappy and has asked for the requirement to be removed. It has an alternative, which some of these amendments also propose. It said:

“We urge the committee to remove the referral requirement and, instead, make it clear that the doctor’s duty is to direct patients to where they can obtain information”.

That is what amendment 341, in the name of my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson), would do. The BMA suggests that

“this should be an official body set up to provide individual information and advice to patients, to which patients could be referred or directed to, or could self-refer.”

My preference would be not to have any obligation on doctors to make any kind of referral, but I respect the aspiration of the amendment, which is to ensure that there is an independent body to give advice that patients can seek out themselves or that they can be advised of, so there is no expectation of a referral to a doctor who can facilitate the assisted death.

The Royal College of General Practitioners is also unhappy about the provision. It suggests that instead of expecting doctors

“to refer directly to a medical practitioner who is ‘willing and able to conduct that discussion’”—

as per the Bill—

“the doctor’s duty would be to direct patients to an official service where they can obtain objective and accurate information”.

I think we should pay heed to the advice of the professionals.

As ever, I would like to refer to the experience of foreign jurisdictions, because we are constantly told that this Bill is the safest in the world. None of the legislation in Australia or New Zealand, or the legislation currently going through in the Isle of Man, puts an obligation to refer on to doctors. Victoria and South Australia’s legislation says that a doctor has the right to refuse to participate in the request for assistance process and to give information about voluntary assisted dying, so there is no duty to refer—not even a duty to provide information.

I conclude with an observation that was submitted to us by Dr David Randall, a consultant nephrologist. It was very telling that he said in written evidence:

“I would not be willing to act in accordance with Section 4(5) of the Bill. I am a doctor in good standing with the GMC, and who has always striven to provide the highest standards of care to patients. Passage of this Bill would place my practice in direct opposition to the criminal law.”

He talks about “moral injury”, which is a very important principle. We have an obligation to protect the conscience and human rights of medical professionals.

We are still unclear whether this process will take place within the NHS or outside it. Nevertheless, the obligation to refer in the Bill would be a direct breach of doctors’ rights and would impose a moral injury on them. My preference is to remove clause 4(5) altogether, as that would be consistent with the Abortion Act 1967 and similar legislation on assisted dying in other countries. If we are not prepared to do that, we should at least restrict the obligation and provide more protections, as per the amendments in the names of other hon. Members.

[Rebecca Paul]

I rise to speak in support of amendment 341 in the name of my hon. Friend the Member for Sleaford and North Hykeham. It would provide that a registered medical practitioner who is unable or unwilling to have the preliminary discussion must provide information to the patient about where they can have that discussion, but that need not take the form of a referral.

One of the messages that we heard loud and clear in the evidence sessions was that medical practitioners do not wish to be put under an obligation to refer a patient to another registered medical practitioner by the Bill. “Referral” has a very specific meaning in medicine, and it is that word and the corresponding action required of it that many doctors have an issue with. A referral puts a patient on a pathway, whereas the provision of information merely indicates where such a pathway can be found. During oral evidence, Dr Green said:

“The word ‘referral’, to a doctor, means writing a letter or communicating with another doctor to see, but some doctors would find themselves not able to do that. For that reason, we believe that there should be an information service for the doctor to direct to.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 48, Q41.]

We are well aware that assisted dying is a complex issue and a matter of conscience for many. It is therefore important that we respect the personal views of medical practitioners. One of the points that I have made several times in these proceedings is that assisted dying affects not just the patient but other people participating and supporting. Some medical practitioners will be comfortable with it, but many others will not. It is therefore vital that we recognise their rights and needs, not just the patients’, when formulating this law. If for whatever reason a doctor does not want to refer a patient, they should not have to. Their legal responsibility should be limited to directing the patient to where they can find the relevant information that they need. Doctors should have no further obligation.

--- Later in debate ---

[Rebecca Paul]

I thank the hon. Lady for that intervention, which I welcome.

[Lewis Atkinson (Sunderland Central) (Lab)]

I will be brief. I am pleased to hear my hon. Friend the Member for Spen Valley confirm that she is minded to support amendment 341. It is incumbent on all of us, but perhaps particularly those in favour of the Bill, to place on record our appreciation and recognition of the fact that many people who work in our health services have strongly held religious beliefs, or beliefs of conscience—however they are motivated. As is the case for a range of other procedures and medical interventions, the law has to allow them scope to continue to practise. They make a valuable contribution to our health service and national life, and we should not do anything to impinge on that.

There is already strong guidance from the General Medical Council about personal belief, and that applies, as the hon. Member for Reigate mentioned, to the Abortion Act, as well as to the Human Fertilisation and Embryology Act 1990, the Female Genital Mutilation Act 2003 and other procedures. It is not for any of us to second-guess someone’s conscience.

--- Later in debate ---

[The Chair]

I understand that the hon. Member for Reigate wishes to make a point on clause 4 stand part. I am minded to allow a debate on clause 4 stand part, but I remind hon. Members that I do not expect relitigating or rehashing. The debate will have a very narrow scope; it will not be an opportunity to rehash. The Question is simply whether the clause, as amended, should stand part of the Bill. With that caveat, I call Rebecca Paul.

[Rebecca Paul]

I very much appreciate the opportunity, Mr Dowd. I will attempt to be brief.

First, I welcome the acceptance of amendment 414, in the name of the hon. Member for Ipswich; of amendment 108, in the name of the hon. Member for East Thanet; of amendment 275, in the name of the hon. Member for Sunderland Central; and of amendment 341, in the name of my hon. Friend the Member for Sleaford and North Hykeham. The amendments strengthen the clause, so I thank Committee members for accepting them.

I have one pertinent point to put on the record about clause 4. The clause deals with what is and is not included in the initial discussion with registered medical practitioners, so the definition of assisted dying, as well as what it actually is, becomes relevant to understanding what guidance does and does not come into play. During these proceedings, there has been a tendency to speak as if assisted dying were another type of treatment or healthcare option being offered by medical practitioners, rather than a completely different and separate offering. It has been said many times that assisted dying should be treated in the same way as any other treatment and that the existing guidance from the GMC sets out appropriate best practice and should applicable and relied on. I have some concerns about that, which I wish to put on the record.

The legal norm, and GMC guidance, is that patients should be offered all reasonable medical treatments. A medical treatment can be defined as something that combats disease or disorder. It is fundamentally about healing, relief of symptoms, recovery and cure, so straightaway we have a conflict. Assisted dying ends the life of a person; it is not a treatment in the normal sense of the word. It is important that it is not a treatment, so that doctors are not obliged to offer it in the same way that they would offer another, more normal, medical treatment.

The Association for Palliative Medicine’s written evidence covers the point:

“A crucial question is whether or not assisted death by lethal medication is considered to be a medical treatment. Given that doctors are required to assess eligibility for, prescribe, and be present at the administration of the medication, AD might be considered to be a ‘medical treatment’. If this is the case then either assisted dying should be offered to all people meeting the eligibility criteria, or doctors need to behave differently towards this medical treatment than to all other treatments. Both of these approaches are contrary to all prior medical practice and public expectation, and laden with risks of unintended consequences.

The APM recommends that if AD is implemented in England & Wales it is done outside of ‘usual medical practice’ and is not regarded as medical treatment.”

This is because there are detrimental consequences from classifying assisted dying as treatment and relying on guidance. First, it could undermine the doctor-patient relationship by confusing the distinction between healing and ending life. Patients who are used to looking to their caregivers for help may worry that they will instead be put on a pathway to an assisted death. That could deter them from seeking medical help when they need it. Dr Jamilla Hussain spoke powerfully on that point, so I will not repeat it.

Secondly, the word “treatment” currently has largely positive connotations. If the word starts to be used for assisted dying, its meaning will change entirely. I wonder about the intersection with other pieces of guidance and law that refer to treatment, for example where treatment can legally be given without the consent of the patient. We all agree that assisted dying should never be administered without consent, but that is why we must be careful with our language and definitions. In certain situations, treatment can lawfully be given without consent, so it must follow that, to protect against the risk of unintended consequences, assisted dying is not deemed to be a treatment.

I ask the Minister’s view on that risk—I note that there is no reference in the Bill to assisted dying being a treatment, which is really good news—and his advice on how best to ensure that assisted dying is not and will never be considered a treatment as a consequence of the Bill or of any other statute or guidance. I also ask his view on the appropriateness of relying so heavily on GMC guidance for best practice, as I imagine that that guidance could change at any point without the consent of Parliament.

[The Chair]

At this point, I will not necessarily call Members, including the Minister, unless they particularly want to speak. If Members do wish to speak, will they please bob?

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

Rebecca Paul Excerpts

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Stephen Kinnock]

Amendments 360 and 361 introduce requirements on the co-ordinating doctor. Amendment 360 would insert an additional condition into the definition of a co-ordinating doctor and would require a co-ordinating doctor who receives financial payment for providing assisted dying to make an annual statement declaring publicly their total turnover from providing the service, the number of people they have assisted and any other information specified in regulations.

The related amendment 361 would require that any regulations specifying the information to be made available must be subject to the affirmative procedure. It is not clear whether the amendments are intended to apply to both private and NHS providers. It could create difficulty if the requirement were to apply to NHS providers, as a doctor is unlikely to know the total turnover from providing an assisted dying service.

As the Bill’s promoter, my hon. Friend the Member for Spen Valley has said that her intent is to ensure that the assisted dying service is available as an integral part of the NHS. Officials are working on amendments to later clauses to establish the operating model for her consideration.

[Rebecca Paul (Reigate) (Con)]

Does the Minister not think the word “remuneration” refers to the amount of income received specifically by the doctor, rather than by any organisation or company?

[Stephen Kinnock]

As my hon. Friend the Member for Stroud has just said, the picture is very complex because there are tariffs for services. Doctors receive a tariff for each service across the entire panoply of everything they do, particularly general practitioners who provide a very wide range of services. They are remunerated on the basis of a tariff that is negotiated in the GP contract between the Department of Health and Social Care and, primarily, the BMA. When a doctor operates in that environment, it is difficult to pick out their turnover from a particular service.

As my hon. Friend the Member for Stroud said, picking out an individual doctor and saying how much money they have made from a particular service, whether assisted dying or any other service, would put a particular focus on that doctor. We are drawing a distinction here with what the tariff could and should be, which we will need to discuss alongside the operating model in later clauses. Moving from being transparent on the tariff to saying, “That doctor over there made this much money from providing this service,” is a whole new ball game.

--- Later in debate ---

[Stephen Kinnock]

If we are specifically talking about the amendments tabled by the hon. Member for East Wiltshire, he is saying that the total turnover from providing this service should be publicly available—it should be published—so I assume he thinks it should be on a website that everybody can see.

My hon. Friend the Member for Bradford West is asking about the knowledge that, if someone wishes to seek an assisted death, they can go to a particular practitioner or service. That is baked into the Bill, and clearly those doctors who wish to opt into the service will be doing so with their eyes open—they will know that they are providing that service. We must ensure that doctors feel protected if there is a sense of risk.

It would of course be deeply regrettable if there were to be threats or risks to doctors, but the evidence from other countries suggests this has not led to some of the deeply unfortunate things we have seen around abortion clinics, for example. It does not seem to have led to that, but of course we as a Government always need to be vigilant in monitoring all our services to ensure that our excellent medical professionals are getting the support they need.

[Rebecca Paul]

I thank the Minister for that useful explanation. Does he agree that the setting of the tariff will be key, because it could either incentivise or disincentivise the provision of the service?

[Stephen Kinnock]

I agree. Like any other aspect of what doctors and general practitioners do, this service is based on remuneration. They are professionals and should be remunerated as such, so the tariff will be important. It is also important that we do not jump ahead into defining the operating model. As I said, officials are working on this with the Bill’s promoter, and it will be made clear when we get to the relevant clauses.

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

Rebecca Paul Excerpts

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Stephen Kinnock]

This group of amendments refines the requirements related to the first declaration, clarifying the witnessing process, identity verification and regulatory obligations. I will take the amendments in turn.

In executing our duties to ensure that the legislation, if passed, is legally robust and workable, in this group the Government have worked with my hon. Friend the Member for Spen Valley on amendments 189 to 191 and 419. Amendment 189 would clarify the requirement for proof of identity when making a first declaration. It would adjust the wording to make it clear that proof of identity must be provided before a person signs a declaration, ensuring no ambiguity about when the requirement applies.

As with amendment 189, amendment 190 clarifies the requirement for proof of identity when making a first declaration. This amendment would make it clear that a person must provide two forms of proof of identity before signing the declaration, rather than simply at the same time. That ensures that both the co-ordinating doctor and the witness have received the necessary proof before the declaration is signed.

Amendment 191 ensures that the co-ordinating doctor can witness the first declaration only if they are satisfied that the person has provided two forms of proof of identity. The doctor must therefore first be satisfied that the required proof has been given to them and to the witness before proceeding with witnessing the signing of the declaration.

Amendment 419 requires that, before witnessing the first declaration, the co-ordinating doctor must be satisfied that a preliminary discussion has taken place, whether that was conducted by the co-ordinating doctor or another registered medical practitioner. The co-ordinating doctor must also have made or seen a written record of the preliminary discussion.

Amendment 291 adds to the requirement around proof of identity when making a first declaration. It requires that one of the forms of ID provided to the co-ordinating doctor and witness be photographic. The person must also provide proof of residence at this stage of the process. I note we would expect this type of issue to be considered by the Secretary of State when making regulations about forms of proof of identity that are acceptable, as already provided for in clause 6(3). Requiring a person to provide proof that they have been resident in the UK for at least 12 months appears to impose a different residency requirement to other parts of the Bill. Specifically, “being resident” is a looser test than being “ordinarily resident”, in clause 1, and “in the UK” is broader than “in England and Wales”, also in clause 1. In consequence, our assessment is that this amendment may make the Bill less legally coherent.

[Rebecca Paul (Reigate) (Con)]

I want to raise a question on photo ID. My apologies, I probably should have spoken sooner. Thinking this through as we have debated, I think photographic ID is important to avoid mistaken identity and fraud, and to make sure everything works as it should. With respect to this process, would the Minister normally expect photographic ID to be an acceptable or appropriate form of identification?

[Stephen Kinnock]

Yes, I believe so. Photographic ID would be the standard to which we would aspire. I do not know whether there was anything else under her question? I think the answer is yes.

--- Later in debate ---

[Juliet Campbell (Broxtowe) (Lab)]

I will speak to amendment 127, which is a probing amendment. I will not press it to a vote, but the reason I tabled it is that I felt that the phrase “as soon as reasonably practicable” was a little vague. I was taking into consideration the fact that we often talk about people who have six months to live, who are eligible for the assisted death, but sometimes people learn later on and do not have six months. If people are thinking about having an assisted death, there might be some pace at which the doctors need to work together—the co-ordinating doctor and whoever else they speak to.

I put 10 days, because I needed to put something down, and that is why I am saying amendment 127 is probing, but I do think that we need to be a little tighter with the timeframe in which we enable doctors to speak to each other, so that the patient is aware of what is happening. Also, if the patient wants to change their mind and is speaking to another doctor, they would know what timeframe they have got. The amendment is probing, and I will not press it to a vote.

[Rebecca Paul]

I think most points have been covered, so I will be brief. The point of the amendment 296 is to recognise the challenges faced by medical practitioners in the NHS. It is really well intended. I suspect that there are different ways to do this, which we could discuss, but the amendment would recognise that medical practitioners will come under a lot of pressure.

The very nature of the assisted dying process means there is pressure to move quickly—for obvious reasons. If someone is in pain and an assisted death is what they have chosen to do, they are going to want to move forward at pace. It cannot be as usual, with however long it can take in the NHS—often for a normal procedure. The point of the amendment is simply to be cognisant of the fact that other patients, too, require healthcare. This comes back to the debate we have had many times about what is healthcare and what is not. It is one of the issues that comes up when we have assisted dying amalgamated with general healthcare in the NHS.

We are hearing concerns from doctors on the frontline. In written evidence, eight doctors, six of them GPs, say that the NHS lacks both the time and the capacity to create the new role of co-ordinating doctor with its grave responsibilities. The statistics bear out their concerns. In a 2024 survey by the Royal College of General Practitioners, over 40% of UK GPs who responded said that they were “unlikely” to be practising still in five years’ time; 40% feel stressed to the point of “not coping” at least once a week; and 79% are concerned about having fewer GPs at their practice and its impact on the quality of care that their practice can deliver. The reality of the matter is that we have to recognise that the introduction of assisted dying places another pressure on our health system, and to try to address that head on.

[Kim Leadbeater]

The hon. Lady is making some interesting points, but would she agree that we are talking about not new patients, but existing patients who are already in their last few months of life? It will not create a whole new pressure on the health service, because they are already receiving treatment.

[Rebecca Paul]

I thank the hon. Member for that point. There will absolutely be some occasions where that is the case, but assisted dying is a different pathway—and we have a whole Bill on it, so there will be other formalities and safeguards. We are all here to make sure that rigour is applied to that pathway. With the best will in the world, there will always be more work and pressure, especially time pressure, on doctors. That time pressure will be critical.

[Danny Kruger]

I completely agree. The hon. Member for Spen Valley makes the important point that these patients are, indeed, being treated already; one would hope that the palliative care process would continue alongside their application. It is absolutely right that they are being treated, but as my hon. Friend the Member for Reigate says, there would be additional work being done for them. Does she agree that there is also an opposite threat—that the resource being expended on the patient might be less as a result of the assisted death that they get? I am afraid to say that that would introduce a terrible new incentive into the system, as happens elsewhere.

[Rebecca Paul]

This is a complex issue, and that is why I welcome the debate on this group. There are lots of things that need to be thought through to make sure that, if assisted dying is legalised, we manage it in the most effective way for patients.

[Dr Simon Opher (Stroud) (Lab)]

I thank the hon. Lady for making this point, which is important, although probably not specifically relevant to what we are talking about in general with regard to making the Bill safe. Has the hon. Member for East Wiltshire not just completely contradicted the whole point of the amendment, however, by saying that we really do not know whether this process will cost more or less time for the NHS?

[Rebecca Paul]

Different situations will give a different result. It is a complex situation. We could have a patient who, if they did not have an assisted death, would be on a palliative care pathway, which might not involve as much time from their GP—the assessing doctor, in that instance. If they moved on to the assisted dying pathway, however, the assessment process would need to start, and it has to happen quickly for all the reasons that I have set out.

The Bill relies on doctors being highly conscientious and hard-working, but it also risks taking them for granted if it makes no allowance for the present realities that they face in our healthcare system. This amendment tries to reflect and recognise that.

In November, the hon. Member for Stroud said,

“I have watched with horror as our NHS has gone from being the best health service in the world…to being a service on its knees.”—[Official Report, 6 November 2024; Vol. 756, c. 358.]

If the NHS is to get off its knees, surely we cannot afford for assisted suicide to jeopardise the care of patients who already struggle to get an appointment. We must recognise that there are people out there who cannot get an appointment to see their GP, and reflect that in the Bill.

[Sojan Joseph]

I rise to speak briefly to amendment 296. We all know how the NHS operates, how the appointment system works in the NHS and how long people have to wait to see a doctor. I do not think that my hon. Friend the Member for York Central tabled the amendment with any ill thought, but just to highlight the issue. I do not think that the amendment will make the Bill any safer or stronger, or safeguard anything, but the Committee needs to acknowledge it.

I will quote the Royal College of Physicians, which represents 40,000 doctors who primarily work in hospitals, including on palliative care. The Royal College of Physicians took a neutral position on the Bill. In its written evidence, it highlighted,

“We recognise that the ultimate decision on assisted dying rests with society through Parliament, however any changes to the law will significantly affect clinical practice beyond palliative care…Should the law change, the RCP strongly argues that assisted dying must not divert resources from end of life and palliative care provision, which are not currently adequate.”

With amendment 296, my hon. Friend the Member for York Central is trying to get the Committee to acknowledge that some NHS departments work with vacancies of 50 medical professionals. A patient who has been waiting for six months should not have their appointment cancelled because the provision here is prioritised. I think that is what my hon. Friend meant with her amendment, and I commend her thought about wider NHS provision.

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

Rebecca Paul Excerpts

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[Dr Simon Opher (Stroud) (Lab)]

I thank the hon. Member for Richmond Park for her considered amendments. I would like to go through all the amendments in the group.

Amendment 348 is about the doctor communicating the outcome of the assessment, but I understand that that is already covered in clause 8(5)(b), which states that, having carried out the second assessment, the independent doctor will

“provide each of the coordinating doctor and the person who was assessed with a copy of the statement.”

I therefore do not think the amendment is necessary—it would be doubling up.

[Rebecca Paul (Reigate) (Con)]

I just point out that the amendment states that the independent doctor would

“inform the person’s usual or treating doctor”,

and that is not covered by the paragraph the hon. Gentleman just mentioned. I hope that is helpful.

[Dr Opher]

I do not see what that would add to the Bill. The co-ordinating doctor would have a result and the patient would have had the report back. I do not feel the amendment is necessary—it would over-complicate the Bill—but we can see what the Government’s legal position is on that.

Amendment 303, tabled by my hon. Friend the Member for York Central, suggests that the independent doctor should have to check that there has not already been a second opinion. We need to step back a bit and remember how the Bill will work. Basically, a doctor will refer to a co-ordinating doctor, who will make a full assessment of the patient. If, having carried out the first assessment, the co-ordinating doctor is satisfied that the requirements in the Bill are met, they will refer the person for the independent assessment. That doctor will therefore need to see a report, because he is the co-ordinating doctor. He cannot then get a second opinion from a different doctor; that would not be part of the process under the Bill. I do not feel the amendment would make the Bill any safer.

--- Later in debate ---

[The Chair]

Order. Rebecca Paul has an amendment tabled in this group, so I shall call her next. I have had indications from Rachel Hopkins and Dr Opher that they wish to speak, and I see two others, of whom I shall make a note.

[Rebecca Paul]

It is a pleasure to serve under your chairmanship, Sir Roger. I rise to speak to my amendment 468 to clause 9, which would ensure that the assessing doctor must

“ask the person why they are seeking an assisted death.”

We have heard a lot in this Committee about the importance of the patient-doctor relationship. My hon. Friend the Member for Solihull West and Shirley said that we should be

“trusting in the judgment of clinicians, who know their patients well”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 26 February 2025; c. 634.]

He also said that patients

“may want to speak to their GP because they have had a relationship with them over 30 or 40 years”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 25 February 2025; c. 481.]

It is therefore worth asking how the Bill shapes the patient-doctor relationship.

The Bill asks doctors to do many things to and for patients. It asks doctors to consider whether to raise the subject of assisted suicide; personally, I wish we had agreed to the amendment that would have ensured that it was the patient who brought the subject up first, but we are where we are. The Bill asks doctors to explain the patient’s diagnosis and prognosis and to lay out options for treatment and palliative care, if there is any available; if there is not, the doctor can only state that point and move on. Nevertheless, we are asking the doctor to look into the matter and lay out possibilities.

The Bill asks doctors to check for capacity and for coercion, to ascertain whether the patient has a clear, settled and informed wish to end their own life, to witness declarations and, eventually, to give the patient a substance and oversee the patient taking it. In other words, it makes doctors absolutely central to the process, as the facilitators of the process, as the people who accompany the patient and as the professionals with the biggest responsibility for ensuring that the safeguards are followed, yet it never asks doctors to make a simple but vital inquiry: why?

That is all that my amendment would add. It would simply require the assessing doctors to ask the person why they are seeking an assisted death. I hope that the Committee will agree that that would be a reasonable and not overly burdensome change. Some hon. Members have suggested that certain amendments embroider the Bill too much, but in this case, the patient-doctor conversation is already embroidered. The Bill makes some very specific demands of the doctor as to what the conversation should cover. Surely it is only natural, amid all the conversations, for the doctor to take a moment—perhaps more than a moment, but a moment at the very least—to help the patient to talk through their reasons. This is a very vulnerable moment in somebody’s life.

The simplest of questions can often unlock the most information. In some cases, for the small number who would benefit from the Bill, the answer would probably reassure the doctor, but for those others we worry about, the question would provide another important safeguard. It would be another opportunity to check that this really is in the best interests of the patient.

How would the conversation go? I do not think that we can generalise. It might be the briefest exchange or it might lead to a really searching discussion. Doctors know how to take their cue from the patients in these things. Crucially, the doctor’s role is not just to offer advice or information. Even if the doctor says nothing, it may make all the difference for the patient to be able to speak aloud their concerns, their confusion and their hopes and fears. I absolutely accept that many doctors, if not most doctors, would ask the question why anyway, but given its importance, I still urge the Committee to set that out in the Bill. In doing so, we would be affirming that this is more than a bureaucratic exercise; it is about a person and about getting to the truth of what they want and need.

I do not think we should not make the mistake of assuming that every doctor has the time, or will take the time, to have the in-depth conversations needed to really understand what is driving a patient’s request. It is up to us to make legislation that keeps standards high at all times. There is currently nothing in the Bill that will guarantee an in-depth conversation. I am afraid that not all doctors believe that that is even a likely outcome. In written evidence, the GP Edward Tulloch states:

“To conduct the required assessments outlined in 7.2 and 8.2 of the Bill within a standard GP appointment (lasting 10-15 minutes) is completely unrealistic. It will require multiple appointments to properly carry out such detailed discussions and complete the associated legal paperwork.”

We all know what pressure the NHS is currently under. Many of us cannot get a GP appointment. So, how certain are we that adequate time can be allocated to the assisted dying process to ensure the criteria are truly met?

By putting the “why” question on the face of the Bill, my amendment would bring us closer to the possibility of real, serious and honest conversations about a patient’s reason for seeking an assisted death. That would be especially helpful for those who have just received a terminal diagnosis. We have received some important written evidence from six palliative care doctors, who state that

“our experience is that many patients experience a period of adjustment to ‘bad news’ and may say that they cannot live under these conditions. However, after a period of reflection and adjustment, the majority come to find peace and value in their altered life circumstance, in a way they would not have believed possible.”

The consultant psychiatrist Jennifer Bryden provides an especially interesting perspective, as someone who has seen this from both sides:

“Having gone through several long episodes of illness, I now know that feeling entirely useless and a burden to everyone is a phase that will pass. For many people a terminal diagnosis will be their first time through the cycle and they will believe those thoughts represent reality. In coming to terms with a severe illness, depression is an expected phase and learning to accept all humans need each other takes time”.

Dr Bryden goes on to say that the current cooling-off period is not enough time for people to come to terms with such a diagnosis. Clearly, people may need all the help they can get to understand their new situation. Asking the patient for their reasons is only the beginning of that process, but one that may help them come to terms with their situation and validate, or not, their initial inclination.

Finally, asking why can identify those patients who are being coerced or pressured. Nobody should think that that is easy to spot. According to the charity SafeLives, which counters domestic abuse, it takes the average person who experiences violent abuse 2.3 years to access effective help. In the year before they finally get help, 85% of victims will have sought help of some kind from an average of five professionals. Often, sad to say, those who missed the signs will have been healthcare professionals. That is for physical abuse; psychological abuse will be far harder to spot. We cannot put in enough safeguards to ensure that doctors have all the tools they need and all the opportunities they can, to spot those signs.

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

For clarity, at what point in the conversation does the hon. Member expect the question to be raised? In reference to an assessing doctor, do I take it that the question must be asked twice, at different times, by both the co-ordinating and the independent doctor?

[Rebecca Paul]

I thank the hon. Member for his very good questions. I suggest that it be asked twice, because it makes a lot of sense to ensure that the patient is given the chance to really explain what is driving their decision. It is the simplest of questions, but it is amazing what can sometimes come out of the simplest question.

I return to the safeguard against coercion. In a sense, this is not a new safeguard; rather, it confirms and bolsters the other safeguards in the Bill, which are there to explore the reasons for assisted dying. Asking why will help doctors to better understand what is driving a patient’s decision and to give that patient an opportunity to validate that they are truly eligible. It is the simplest of questions, driving the most significant conversation that a doctor and patient can have. I hope that hon. Members will support my amendment.

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

It is a pleasure to serve under your chairship, Sir Roger. I rise to speak in support of amendments 201, 422 and 423, which stand in the name of my hon. Friend the Member for Spen Valley, and against amendment 468.

On amendment 201, a point was made earlier about the relevance of records. It was mentioned that it might well not be relevant to look at a childhood tonsillectomy. However, I wish to speak in slightly more specific terms, in support of women and their reproductive rights, and to highlight the risk of unconscious bias if all records are to be looked at.

If a woman had a termination in her teenage years, that will be highly irrelevant to her decision, many decades later, whether to choose an assisted death. Relevance is very important, because there will be a high level of record keeping in the process. It is not only the doctors working with the patient on the assessment who will read the records and reports; ultimately, it will also be the panel. I make the point again that so many parts of a patient’s medical records are highly irrelevant to the diagnosis and prognosis of a terminal illness, and to the six months under the eligibility criteria. Indeed, there is a risk of unconscious bias in the judgment. It is about the professionalism of the doctor in respect of understanding the records that are relevant for the process.

--- Later in debate ---

[Naz Shah]

I absolutely accept that it is the patient’s right to say, “It’s none of your business”, with the really clear caveat that they could well be a vulnerable patient. They might say that it was none of the doctor’s business, and that doctor might then not be able to explore the other things going on with that patient. That is why, for me, this does not wash.

The point that I am trying to make is that, in the course of a normal consultation, it is presumed that every doctor will know their patient and be able to have these conversations. In most cases, they probably will because we have amazing doctors; I have amazing relationships with my doctors. But does that mean that the doctors will ask that one question: “Why?” That is the crux of the whole Bill.

[Rebecca Paul]

The right to say, “It’s none of your business” might be fine when no one else is involved, but if someone seeks an assisted death, that involves multiple members of NHS staff. There is an impact on all those people, who need to be comfortable with what they are doing. Maybe the person needs to accept that they do need to provide some information so that the medical staff feel comfortable about the question of eligibility.

[Naz Shah]

That opens up a whole different debate for me. Some clinicians will not sign up to this process and some will. That is a whole different debate, but I take the point that there has to be a reason.

We talk about the option for referral to palliative care. I have previously moved amendments that would have meant a referral, without the option; however, when considering that option, a doctor needs to understand that if a patient says, “I do not have to explain myself—full stop”, or, “I do not want to talk about palliative care”, that should raise alarm bells. If a doctor says, “You’ve got this terminal illness. These are the options—let me spell them out for you. You have the option of referral to palliative care and the option of these drugs, so why do you want to kill yourself?”, and the patient turns around and says, “It’s none of your business”—

--- Later in debate ---

[Naz Shah]

I respectfully disagree. I am making the case that there is a conversation to be had. Yes, there is informed choice but is my hon. Friend suggesting that the question should not be asked at all? I take the point that with an informed choice there would have been an exploratory conversation, but sometimes just calling something out, or stating the obvious, makes a huge difference.

[Rebecca Paul]

I wish to clarify that the amendment is about not an additional assessment but merely a simple question. Like many who have spoken, I hope that most good doctors would ask the question anyway and take the answer. It may inform them or it may not but sometimes, as the hon. Member for Bradford West has just discussed so powerfully, it is helpful to remind medical staff, who are under lots of time pressure, that sometimes it is worth stepping back and asking why.

[Naz Shah]

I agree. Sometimes it will be the simple thing of asking the question as a human being—among all the conversations that are happening, just stopping and asking why.

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

Rebecca Paul Excerpts

Committee stage
Wednesday 12th March 2025 Public Bill Committees

[The Chair]

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

Amendment 371, in clause 13, page 9, line 5, leave out paragraph (a) and insert—

“(a) a certificate of eligibility has been granted in respect of a person, and”.

This amendment is consequential on NC21.

Amendment 61, in clause 13, page 9, line 5, leave out from “the” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 372, in clause 13, page 9, line 12, leave out from third “the” to end of line 13 and insert

“certificate of eligibility was granted,”.

This amendment is consequential on NC21.

Amendment 62, in clause 13, page 9, line 13, leave out from “the” to “or” in line 14 and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 373, in clause 13, page 9, line 17, leave out “declaration was made” and insert “certificate was granted”.

This amendment is consequential on NC21.

Amendment 377, in clause 16, page 11, line 12, leave out paragraph (d) and insert—

“(d) a certificate of eligibility has been granted in respect of a person;

(da) a panel has refused to grant such a certificate;”.

This amendment is consequential on NC21.

Amendment 63, in clause 16, page 11, line 12, leave out “the” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 378, in clause 18, page 12, line 9, leave out paragraph (a) and insert—

“(a) a certificate of eligibility has been granted in respect of a person,”.

This amendment is consequential on NC21.

Amendment 64, in clause 18, page 12, line 9, leave out from “the” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 381, in clause 27, page 16, line 16, leave out sub-paragraph (iii) and insert—

“(iii) a certificate of eligibility,”.

This amendment is consequential on NC21.

Amendment 65, in clause 27, page 16, line 16, leave out from “the” to “under” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 388, in clause 34, page 20, line 40, leave out paragraph (c) and insert—

“(c) a panel has refused to grant a certificate of eligibility;”.

This amendment is consequential on NC21.

Amendment 66, in clause 34, page 20, line 40, leave out from “the” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 390, in clause 40, page 23, line 24, at end insert—

“‘certificate of eligibility’ has the same meaning as in section (Determination by panel of eligibility for assistance);”.

This amendment is consequential on NC21.

Amendment 391, in clause 40, page 23, line 24, at end insert—

“‘the Commissioner’ has the meaning given by section (Voluntary Assisted Dying Commissioner);”.

This amendment is consequential on NC14.

New clause 14—Voluntary Assisted Dying Commissioner—

“(1) There is to be a Voluntary Assisted Dying Commissioner.

(2) The Commissioner is to be appointed by the Prime Minister.

(3) The person appointed must hold or have held office as a judge of—

(a) the Supreme Court,

(b) the Court of Appeal, or

(c) the High Court.

(4) The Commissioner’s principal functions are—

(a) receiving documents made under this Act;

(b) making appointments to a list of persons eligible to sit on Assisted Dying Review Panels (see Schedule (Assisted Dying Review Panels));

(c) making arrangements in relation to such panels and referring cases to them (see section (Referral by Commissioner of case to multidisciplinary panel));

(d) determining applications for reconsideration of panel decisions under section (Reconsideration of panel decisions refusing certificate of eligibility);

(e) monitoring the operation of this Act and reporting annually on it (see section 34).

(5) In this Act “the Commissioner” means the Voluntary Assisted Dying Commissioner.

(6) Schedule (The Voluntary Assisted Dying Commissioner) makes provision about the Commissioner.”.

This new clause provides for there to be a Voluntary Assisted Dying Commissioner.

New clause 15—Referral by Commissioner of case to multidisciplinary panel—

“(1) This section applies where the Commissioner receives—

(a) a first declaration made by a person,

(b) a report about the first assessment of the person which contains a statement indicating that the coordinating doctor is satisfied as to all of the matters mentioned in section 7(2)(a) to (g), and

(c) a report about the second assessment of the person which contains a statement indicating that the independent doctor is satisfied as to all of the matters mentioned in section 8(2)(a) to (e).

(2) The Commissioner must, as soon as reasonably practicable, refer the person’s case to an Assisted Dying Review Panel for determination of the person’s eligibility to be provided with assistance under section 18.

(3) But where the Commissioner receives a notification that the first declaration has been cancelled—

(a) the Commissioner must not refer the person’s case to such a panel, and

(b) if the person’s case has already been so referred, the Commissioner must notify the panel of the cancellation.

(4) Schedule (Assisted Dying Review Panels) makes provision about Assisted Dying Review Panels.”

This new clause provides for the Voluntary Assisted Dying Commissioner to refer a person’s case to a multidisciplinary panel, to be called an Assisted Dying Review Panel.

New clause 17—Reconsideration of panel decisions refusing certificate of eligibility—

“(1) This section applies where—

(a) a person’s case is referred under section (Referral by Commissioner of case to multidisciplinary panel) to an Assisted Dying Review Panel (“the first panel”), and

(b) the first panel refuses to grant a certificate of eligibility in respect of the person.

(2) The person may apply to the Commissioner for their case to be reconsidered on the ground that the first panel’s decision—

(a) contains an error of law,

(b) is irrational, or

(c) is procedurally unfair.

(3) The Commissioner must consider an application without a hearing.

(4) On the application—

(a) if the Commissioner is satisfied that any of the grounds mentioned in subsection (2) applies, they must as soon as reasonably practicable refer the person’s case to a different Assisted Dying Review Panel for a fresh determination under section (Determination by panel of eligibility for assistance);

(b) in any other case, the Commissioner must dismiss the application.

(5) The Commissioner must give reasons, in writing, for their decision.

(6) The Commissioner must notify the following of the outcome of the application, and give them a document containing their reasons for their decision—

(a) the person who made the application;

(b) the coordinating doctor;

(c) any other person specified in regulations made by the Secretary of State.”

This new clause provides for certain decisions of Assisted Dying Review Panels to be referred to a different panel for reconsideration.

Amendment (a) to new clause 17, leave out subsections (1) to (3) and insert—

“(1) The person applying for assisted dying, their next of kin, any of their relatives (within the meaning of the Family Law Act 1996), the registered medical practitioners who are treating them and anyone who took part in proceedings before the panel or gave evidence to the panel may apply to the Commissioner for the Panel’s decision to be reconsidered.

(2) The Commissioner will allow the application for reconsideration if the Panel’s decision was—

(a) wrong, or

(b) unjust because of a serious procedural or other irregularity in the proceedings.

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

New clause 21—Determination by panel of eligibility for assistance—

“(1) This section applies where a person’s case is referred under section (Referral by Commissioner of case to multidisciplinary panel) or (Reconsideration of panel decisions refusing certificate of eligibility) to an Assisted Dying Review Panel (“the panel”).

(2) The panel’s function is to determine whether it is satisfied of all of the following matters—

(a) that the requirements of sections 5 to 9 have been met in relation to—

(i) the first declaration,

(ii) the first assessment and the report under section 7 on that assessment, and

(iii) the second assessment and the report under section 8 on that assessment;

(b) that the person is terminally ill;

(c) that the person has capacity to make the decision to end their own life;

(d) that the person was aged 18 or over at the time the first declaration was made;

(e) that before making the first declaration, but when the person was aged 18 or over, a registered medical practitioner conducted a preliminary discussion with the person;

(f) that the person is ordinarily resident in England and Wales and has been so resident for at least 12 months ending with the date of the first declaration;

(g) that the person is registered as a patient with a general medical practice in England or Wales;

(h) that the person has a clear, settled and informed wish to end their own life;

(i) that the person made the first declaration voluntarily and was not coerced or pressured by any other person into making that declaration.

(3) Subject to the following and to Schedule (Assisted Dying Review Panels), the panel may adopt such procedure as it considers appropriate for the case.

(4) The panel—

(a) must hear from, and may question, the coordinating doctor or the independent doctor (and may hear from and question both);

(b) must (subject to subsection (5)) hear from, and may question, the person to whom the referral relates;

(c) in a case to which section 15 applies, may hear from and may question the person’s proxy;

(d) may hear from and may question any other person;

(e) may ask any person appearing to it to have relevant knowledge or experience to report to it on such matters relating to the person to whom the referral relates as it considers appropriate.

In paragraphs (a) to (c) the reference to hearing from or questioning a person is to hearing from them, or questioning them, in person or by live video or audio link.

(5) The duty under subsection (4)(b) to hear from the person to whom the referral relates does not apply if the panel is of the opinion that there are exceptional circumstances which justify not hearing from that person.

(6) The panel—

(a) must, if it is satisfied of all of the matters mentioned in subsection (2), grant a certificate to that effect (a “certificate of eligibility”);

(b) must refuse to do so in any other case.

(7) The panel must notify the following of its decision—

(a) the person to whom the referral relates;

(b) the coordinating doctor;

(c) the Commissioner;

(d) any other person specified in regulations made by the Secretary of State.

Where it grants a certificate of eligibility, it must give a copy of the certificate to each of these persons.

(8) If the panel is notified that the first declaration has been cancelled, it must cease to act in relation to the referral (and, in particular, it may not grant a certificate of eligibility).”

This new clause provides for a person’s eligibility to be provided with assistance under clause 18 to be determined by a multidisciplinary panel (instead of the High Court).

Amendment (d) to new clause 21, in subsection (4), leave out paragraphs (a) to (e) and insert—

“(a) must hear from, and must question, the coordinating doctor and the independent doctor;

(b) must (subject to subsection (5)) hear from, and must question, the person to whom the referral relates;

(c) in a case to which section 15 applies, must hear from and must question the person’s proxy;

(d) must consider hearing from and questioning—

(i) persons properly interested in the welfare of the person who made the application for the declaration and other persons they are close to; and

(ii) any other person who has provided treatment or care for the person being assessed in relation to that person’s terminal illness; and

(e) may hear from and may question any other person, including any person appearing to it to have relevant knowledge or experience to report to it on such matters relating to the person to whom the referral relates as it considers appropriate.”

Amendment (c) to new clause 21, in subsection (4), after paragraph (e) insert—

“(aa) if it considers that the matters mentioned in subsection 2(c), (h) or (i) are established on a balance of probabilities but still considers that there is a real risk that they are not satisfied, then the panel must stay its proceedings until such further inquiries it orders are made,”.

Amendment (e) to new clause 21, after subsection (4) insert—

“(4A) Where the panel considers it appropriate for medical reasons, it may make provision for the use of pre-recorded audio or video material for the purposes of subsection (4).”

Amendment (a) to new clause 21, in subsection (6)(a), after “satisfied” insert “beyond reasonable doubt”.

Amendment (b) to new clause 21, in subsection (6)(a), after “subsection (2)” insert

“unless it believes that there are particular circumstances which make it inappropriate for the person to be assisted to end their own life,”.

New clause 2—Tribunal authorisation—

“(1) Where—

(a) a person has made a first declaration under section 5 which has not been cancelled,

(b) the coordinating doctor has made the statement mentioned in section 7(3), and

(c) the independent doctor has made the statement mentioned in section 8(5), that person may apply to the First-tier Tribunal (“the Tribunal”) for a declaration that the requirements of this Act have been met in relation to the first declaration.

(2) On an application under this section, the Tribunal—

(a) must make the declaration if it is satisfied of all the matters listed in subsection (3), and

(b) in any other case, must refuse to make the declaration.

(3) The matters referred to in subsection (2)(a) are that—

(a) the requirements of sections 5 to 9 of this Act have been met in relation to the person who made the application,

(b) the person is terminally ill,

(c) the person has capacity to make the decision to end their own life,

(d) the person has relevant and available palliative care options available to them,

(e) the person is not liable to be detained under the Mental Health Act 1983,

(f) the person was aged 18 or over at the time the first declaration was made,

(g) the person is ordinarily resident in England and Wales and has been so resident for at least 12 months ending with the date of the first declaration,

(h) the person is registered as a patient with a general medical practice in England or Wales,

(i) the person has a clear, settled and informed wish to end their own life, and

(j) the person made the first declaration and the application under this section voluntarily and has not been coerced or pressured by any other person into making that declaration or application.

(4) The Tribunal—

(a) may hear from and question, in person, the person who made the application for the declaration;

(b) must hear from and may question, in person, the coordinating doctor or the independent doctor (or both);

(c) for the purposes of paragraph (b), may require the coordinating doctor or the independent doctor (or both) to appear before the tribunal.

(5) For the purposes of determining whether it is satisfied of the matters mentioned in subsection (3)(g) and (h), the Tribunal may also—

(a) hear from and question any other person;

(b) ask a person to report to the Tribunal on such matters relating to the person who has applied for the declaration as it considers appropriate.

(6) In considering an application under this section, the panel must consist of—

(a) a sitting judge,

(b) a medical practitioner, and

(c) a lay person.

(7) In subsection (4)—

(a) in paragraph (a), the reference to the person who made the application includes, in a case where the person’s first declaration was signed by a proxy under section 15, that proxy, and

(b) “in person” includes by means of a live video link or a live audio link.”

This new clause would replace the role of the High Court with the tribunal system.

New clause 3—Tribunals in Wales—

“(1) For the purposes of this Act, the First-tier Tribunal and the Upper Tribunal, in exercising functions under or arising from this Act in relation to Wales, are to be treated as devolved tribunals within the meaning of paragraph 9 of Schedule 7A to the Government of Wales Act 2006.

(2) The Welsh Ministers may by regulations make provision relating to the procedure to be followed by the First-tier Tribunal and the Upper Tribunal in exercising functions under this Act in relation to Wales.

(3) Statutory instruments containing regulations made under this section may not be made unless a draft of the instrument has been laid before and approved by resolution of Senedd Cymru.”

Amendment 67, in schedule 4, page 28, line 32, leave out from “The” to “has” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 68, in schedule 5, page 30, line 6, leave out from “the” to “made” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 69, in schedule 5, page 30, line 10, leave out from “the” to end of line and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

Amendment 70, in schedule 6, page 32, line 3, leave out from “of” to “declaration” and insert “First-tier Tribunal”.

This amendment is consequential on NC2 and NC3.

New schedule 1—The Voluntary Assisted Dying Commissioner—

“Status

1 (1) The Commissioner is to be a corporation sole.

(2) The Commissioner is not to be regarded as—

(a) the servant or agent of the Crown, or

(b) as enjoying any status, immunity or privilege of the Crown.

(3) The Commissioner’s property is not to be regarded as property of, or property held on behalf of, the Crown.

General powers

2 The Commissioner may do anything the Commissioner considers appropriate for the purposes of, or in connection with, the Commissioner’s functions.

Deputy Commissioner

3 (1) The Prime Minister must appoint a person to be the Deputy Voluntary Assisted Dying Commissioner (the “Deputy Commissioner”).

(2) The person appointed must hold or have held office as a judge of—

(a) the Supreme Court,

(b) the Court of Appeal, or

(c) the High Court.

(3) The Commissioner may delegate any of the Commissioner’s functions to the Deputy Commissioner, to the extent and on the terms that the Commissioner determines.

(4) The delegation of a function under sub-paragraph (3) does not prevent the Commissioner from exercising that function.

(5) The functions of the Commissioner are to be carried out by the Deputy Commissioner if—

(a) there is a vacancy in the office of the Commissioner, or

(b) the Commissioner is for any reason unable or unwilling to act.

Appointment and tenure of office

4 (1) A person holds and vacates office as the Commissioner or Deputy Commissioner in accordance with the terms and conditions of their appointment as determined by the Secretary of State, subject to the provisions of this paragraph.

(2) An appointment as the Commissioner or Deputy Commissioner is to be for a term not exceeding five years.

(3) A person may not be appointed as the Commissioner or Deputy Commissioner if a relevant appointment of them has been made on two occasions. “Relevant appointment” here means appointment as the Commissioner or Deputy Commissioner.

(4) The Commissioner or Deputy Commissioner may resign by giving written notice to the Secretary of State.

(5) The Secretary of State may by notice in writing remove a person from the office of Commissioner or Deputy Commissioner if satisfied that the person—

(a) has behaved in a way that is not compatible with their continuing in office, or

(b) is unfit, unable or unwilling to properly discharge their functions.

Remuneration

5 The Secretary of State may pay to, or in respect of, the person holding office as the Commissioner or Deputy Commissioner—

(a) remuneration;

(b) allowances;

(c) sums by way of or in respect of pensions.

Staff: appointed by Commissioner

6 (1) The Commissioner may appoint staff.

(2) Staff are to be appointed on terms and conditions determined by the Commissioner.

(3) The terms and conditions on which a member of staff is appointed may provide for the Commissioner to pay to or in respect of the member of staff—

(a) remuneration;

(b) allowances;

(c) sums by way of or in respect of pensions.

(4) In making appointments under this paragraph, the Commissioner must have regard to the principle of selection on merit on the basis of fair and open competition.

(5) The Employers’ Liability (Compulsory Insurance) Act 1969 does not require insurance to be effected by the Commissioner.

Staff: secondment to Commissioner

7 (1) The Commissioner may make arrangements for persons to be seconded to the Commissioner to serve as members of the Commissioner's staff.

(2) The arrangements may include provision for payments by the Commissioner to the person with whom the arrangements are made or directly to seconded staff (or both).

(3) A period of secondment to the Commissioner does not affect the continuity of a person's employment with the employer from whose service he or she is seconded.

Staff: general

8 (1) Before appointing staff under paragraph 6 or making arrangements under paragraph 7(1), the Commissioner must obtain the approval of the Secretary of State as to the Commissioner's policies on—

(a) the number of staff to be appointed or seconded;

(b) payments to be made to or in respect of staff;

(c) the terms and conditions on which staff are to be appointed or seconded.

(2) A function of the Commissioner may be carried out by any of the Commissioner's staff to the extent authorised by the Commissioner (but this is subject to sub-paragraph (3)).

(3) Sub-paragraph (2) does not apply in respect of—

(a) the Commissioner’s function under paragraph 2(1) of Schedule (Assisted Dying Review Panels) of making appointments to the list of persons eligible to be panel members;

(b) the Commissioner’s function of determining applications for reconsideration under section (Reconsideration of panel decisions refusing certificate of eligibility).

Financial and other assistance from the Secretary of State

9 (1) The Secretary of State may—

(a) make payments to the Commissioner of such amounts as the Secretary of State considers appropriate;

(b) give such financial assistance to the Commissioner as the Secretary of State considers appropriate.

(2) The Secretary of State may—

(a) provide staff in accordance with arrangements made by the Secretary of State and the Commissioner under paragraph 7;

(b) provide premises, facilities or other assistance to the Commissioner.

Accounts

10 (1) The Commissioner must—

(a) keep proper accounts and proper records in relation to them, and

(b) prepare a statement of accounts in respect of each financial year in the form specified by the Secretary of State.

(2) The Commissioner must send a copy of each statement of accounts to the Secretary of State and the Comptroller and Auditor General—

(a) before the end of August next following the end of the financial year to which the statement relates, or

(b) on or before such earlier date after the end of that year as the Treasury may direct.

(3) The Comptroller and Auditor General must—

(a) examine, certify and report on the statement of accounts, and

(b) send a copy of the certified statement and the report to the Secretary of State.

(4) The Secretary of State must lay before Parliament each document received under sub-paragraph (3)(b).

(5) In this paragraph, “financial year” means—

(a) the period beginning with the date on which the Commissioner is established and ending with the second 31 March following that date, and

(b) each successive period of 12 months.

Application of seal and proof of documents

11 (1) The application of the Commissioner's seal is to be authenticated by the signature of—

(a) the Commissioner, or

(b) a person who has been authorised by the Commissioner for that purpose (whether generally or specially).

(2) A document purporting to be duly executed under the Commissioner’s seal or signed on the Commissioner’s behalf —

(a) is to be received in evidence, and

(b) is to be treated as duly executed or signed in that way, unless the contrary is shown.

Public Records Act 1958

12 In Part 2 of the Table in paragraph 3 of the First Schedule to the Public Records Act 1958 (bodies whose records are public records), at the appropriate place insert “The Voluntary Assisted Dying Commissioner”.

House of Commons Disqualification Act 1975

13 In Part 3 of Schedule 1 to the House of Commons Disqualification Act 1975 (offices disqualifying person from membership of House of Commons), at the appropriate place insert—

“The Voluntary Assisted Dying Commissioner or the Deputy Voluntary Assisted Dying Commissioner.”

Freedom of Information Act 2000

14 In Part 6 of Schedule 1 to the Freedom of Information Act 2000 (public authorities for the purposes of the Act), at the appropriate place insert—

“The Voluntary Assisted Dying Commissioner.”

Equality Act 2010

15 In Part 1 of Schedule 19 to the Equality Act 2010 (public authorities subject to public sector equality duty), at the end of the group of entries for bodies whose functions relate to health, social care and social security insert—

“The Voluntary Assisted Dying Commissioner.””

This new Schedule contains provision about the Voluntary Assisted Dying Commissioner and the Deputy Commissioner.

New schedule 2—Assisted Dying Review Panels—

“Introduction

1 In this Schedule—

(a) “referral” means a referral under section (Referral by Commissioner of case to multidisciplinary panel) or (Reconsideration of panel decisions refusing certificate of eligibility) (and similar references are to be construed accordingly);

(b) “panel” means an Assisted Dying Review Panel.

List of persons eligible to be panel members

2 (1) The Commissioner must make appointments to a list of persons eligible to sit as members of panels.

(2) A person may be appointed to the list only if—

(a) the person (a “legal member”)—

(i) holds or has held high judicial office,

(ii) is one of His Majesty’s Counsel, or

(iii) has (at any time) been requested to act as a judge of the Court of Appeal or the High Court by virtue of section 9(1) of the Senior Courts Act 1981,

(b) the person (a “psychiatrist member”) is—

(i) a registered medical practitioner,

(ii) a practising psychiatrist, and

(iii) registered in one of the psychiatry specialisms in the Specialist Register kept by the General Medical Council, or

(c) the person is registered as a social worker in a register maintained by Social Work England or Social Work Wales (a “social worker member”).

(3) In this paragraph “high judicial office” means office as—

(a) a judge of the Supreme Court,

(b) a judge of the Court of Appeal, or

(c) a judge or deputy judge of the High Court.

Tenure of persons appointed to list

3 (1) Subject to the provisions of this paragraph, persons on the list hold and vacate their appointments in accordance with the terms on which they are appointed.

(2) An appointment to the list is to be for a period not exceeding five years.

(3) A person who has held appointment to the list is eligible for re-appointment for one further period not exceeding five years.

Membership of panels

4 (1) The Commissioner must make arrangements for determining the membership of a panel.

(2) The arrangements must ensure that a panel consists of—

(a) a legal member,

(b) a psychiatrist member, and

(c) a social worker member.

Decisions of panels

5 (1) The legal member of a panel is to act as its chair.

(2) Decisions of a panel may be taken by a majority vote; but this is subject to sub-paragraph (3).

(3) The panel is to be treated as having decided to refuse to grant a certificate of eligibility if any member votes against a decision to grant such a certificate.

Panel sittings

6 (1) Panels are to determine referrals in public (but this is subject to sub-paragraph (2)).

(2) The chair of a panel may, at the request of the person to whom a referral relates, decide that the panel is to sit in private.

Staff and facilities

7 The Commissioner may make staff and other facilities available to panels.

Practice and procedure

8 (1) The Commissioner may give guidance about the practice and procedure of panels.

(2) Panels must have regard to any such guidance in the exercise of their functions.

Reasons

9 Panels must give reasons, in writing, for their decisions.

Money

10 The Commissioner may pay to or in respect of members of panels—

(a) remuneration;

(b) allowances;

(c) sums by way of or in respect of pensions.

House of Commons Disqualification Act 1975

11 In Part 3 of Schedule 1 to the House of Commons Disqualification Act 1975 (offices disqualifying persons from membership of House of Commons), at the appropriate place insert—

“Person on the list of those eligible for membership of an Assisted Dying Review Panel.””

This new Schedule contains provision about Assisted Dying Review Panels.

Amendment (c) to new schedule 2, in paragraph 4, after

“(c) a social worker member.”

insert—

“(3) The Commissioner must ensure that each member of a panel has had training in respect of domestic abuse, including coercive control and financial abuse.”

Amendment (a) to new schedule 2, in paragraph 4, after

“(c) a social worker member.”

insert—

“(3) Each member of a panel must have fluent proficiency in the Welsh language if services or functions in the Act are to be provided to an individual in Welsh.”

Amendment (b) to new schedule 2, in paragraph 8, leave out sub-paragraphs (1) and (2) and insert—

“(1) The Commissioner must give guidance about the practice and procedure of panels.

(2) Such guidance must prescribe a procedure which in relation to each application appoints a person nominated by the Official Solicitor to act as advocate to the panel.

(3) Panels must have regard to such guidance in the exercise of their functions.”

This amendment would require Assisted Dying Panels to follow an adversarial process to test the evidence by appointing an advocate to the panel.

I trust that that is absolutely clear to everybody. I understand that at the end of the last sitting Ms Paul graciously and courteously sat down in order to enable the Adjournment to be moved—as all Members will have worked out by now, the Adjournment cannot be moved while somebody is speaking—but that she had not finished what she had to say. On that basis, Rebecca Paul has the floor.

[Rebecca Paul (Reigate) (Con)]

I rise to speak to new clauses 17 and 21 and to the four associated amendments. There is a lot to say, so please bear with me, but I will do my best not to repeat myself.

How exactly will the panel operate and function? I appreciate some of the explanations provided by the hon. Member for Spen Valley, and I look forward to hearing from the Minister on the point, but I have concerns about exactly what the panel will do and how it will do it. I will do my best not to repeat what others have said, but I reiterate the concerns as to whether it is indeed a better safeguard than the High Court one that was originally envisaged, given that it will have no full judicial role.

On a practical level, I question whether it is even feasible to find sufficient numbers of psychiatrists and social workers who are able and willing to perform this very burdensome role. As we all know, social workers do an incredibly important job, but people with their skillset are in extremely high demand. The hon. Member has made it clear that she is removing the High Court safeguards not because of the capacity concerns raised in oral evidence in January, but because she believes that this is truly a better and safer model.

I am also concerned that something that was originally meant to bring judicial oversight into the process has been replaced with something that is not judicial. I welcome more involvement from psychiatrists and social workers, who have a key role to play in the process, but I have concerns about whether the panel is the right place for it. Its expertise would be more valuable earlier in the process, when the co-ordinating doctor and the independent doctor are performing their assessments, rather than at the stage with the legal oversight component. A panel’s involvement in a truly multidisciplinary approach during the clinical stage of the assessment process would have been a gold-standard safeguard, but unfortunately that approach was not put on the face of the Bill.

How the panel will operate is an issue of great significance. If we do not flesh out the detail now, when will we? We must have this conversation. I have looked for this information in the new provisions. According to new schedule 2,

“The Commissioner may give guidance about the practice and procedure of panels.”

That is all there is. I cannot see any further information. Disappointingly, it is not even that the commissioner “must” give guidance—it “may”—so the operation of panels may change depending on who is in the role of commissioner. Given that this is a new approach and process, I urge the promoter and the Government to ensure that it is adequately fleshed out to avoid ambiguity.

When I imagine the panel, I am not sure what I am supposed to be imagining. Is it an administrative process—three people checking the papers—or is it more like a court, calling in evidence? Yesterday, the hon. Member for Banbury eloquently set out the practical realities of the new provisions with regard to witnesses. According to new clause 21, the panel “must hear from” at least one of the doctors, but it does not need to question him or her, so what is it exactly that the panel is required to hear? What does “hear” mean, and does it cover anything specific? Does it cover all the items in new clause 21(2), or just some? The new clause does not specify.

It is the same for the patient. The panel just needs to “hear” from him or her; it does not need to question them. As I will come to shortly, in exceptional cases, even the patient will not need to be heard from. Again, I would be grateful to the Justice Minister for clarity on what “hear” means and what she would expect would be covered.

We do know that the panel must be “satisfied” of the relevant matters, yet how it is to be satisfied, and even what that means, is not clear. The only person who must be heard from is either the co-ordinating doctor or the independent doctor—just one person. That may be fine, or it may not, but I put it on the record here, because it is important that we are clear-eyed about it.

Compare the process with an employment tribunal. Someone litigating an employment claim would know well in advance the rules that the tribunal would apply, what test the tribunal would apply to the facts, the legal representation they can have, and how and on what basis they can appeal. That kind of clarity is essential, but I cannot find it in the new clause. I also do not know whether the panel is inquisitorial or adversarial.

[Kim Leadbeater (Spen Valley) (Lab)]

I am very happy to clarify that the panel is not adversarial, but inquisitorial and investigative.

[Rebecca Paul]

I thank the hon. Member for that confirmation. Now that I have that clarity, I will skip on.

One aspect of the panel that gives me cause for concern is that the panel would not hear from the patient themselves where there are “exceptional circumstances”. What are exceptional circumstances? The Bill does not say or provide any guidance. Many people with a terminal diagnosis who are seeking assisted dying could consider their circumstances exceptional; many undoubtedly will be too unwell to attend. That means that such panels could be making these decisions based on testimony from only one doctor. I am not for one second suggesting that people on their deathbeds should have to attend a panel—that is the point of exceptional circumstances—but I urge the promoter and Ministers to ensure that the much-need clarity around the meaning of the term is set out in order to reduce ambiguity in this area.

[Danny Kruger (East Wiltshire) (Con)]

It was helpful to hear the Bill’s promoter suggest that the system will be inquisitorial—that is not sufficiently apparent in the new clause, as my hon. Friend the Member for Reigate says. Does she agree that the panel must therefore have proper inquisitorial powers and authority? At the moment, there is a lack of genuine power to investigate the circumstances. If it not going to be adversarial but inquisitorial, it should have proper powers to make an investigation.

[Rebecca Paul]

My hon. Friend makes a good point; I completely agree with him on that front. This goes back to being clear on the face of the Bill about what the panel does and the powers it has in order to avoid ambiguity. It is important that we set that out now, during this process, rather than finding ourselves in a position in two years where it is all starting to happen, if the Bill is approved, and the questions starting at that point. Let us try to answer them now and be really clear about it.

Where a panel does not hear directly from a patient, it may be forced to rely on second-hand accounts. In law, second-hand evidence is known as hearsay and is always handled with a lot of provisions and warnings across our criminal and civil legal systems, because it can be inaccurate or of lower quality than evidence directly from a source. However, the panel is open to depending on such evidence. We must be clear-eyed about the risks that come with that.

In summary, I do not believe that new clause 21 gives sufficient clarity on how the panel will perform its role and what evidential standard it would apply. We do not know if it is an administrative task or a judicial one. We do now know that the panel is inquisitorial—I thank the Bill’s promoter for that—but we do not know how much it will rely on hearsay evidence in practice. I will say this again, because it is really important: the panel is required to hear from only one doctor and does not need to question them. Under the Bill, would it be legally acceptable for the doctor to turn up, say, “No concerns”—and that’s the end of that? I am here to tell Committee members who think that that will not happen if the Bill allows it: somewhere, with some panel, it absolutely will—particularly as our society gets desensitised and more comfortable with the concept of assisted dying.

I urge the Committee to be precise with the legislation it is passing for the sake of the statute book and, more importantly, for the sake of all the people who may find themselves being assessed by such a panel.

[Lewis Atkinson (Sunderland Central) (Lab)]

The hon. Lady sketches out a very short exchange. Does she think that we should specify in primary legislation the exact nature of interactions in these sorts of matters elsewhere—in the High Court, employment tribunals and so on? In my understanding, we do not: we trust regulated professionals to have appropriate interactions. It is not for Parliament to say that a lawyer or doctor should ask x or y question. Does she agree?

[Rebecca Paul]

I am afraid I do not agree. I do not think that we should not put in place precise legislation because we trust that everyone will do the right thing. Our job as lawmakers is to always think about the worst possible situation that could arise and legislate accordingly to protect against that as best as possible. In 99 cases out of 100, it will work perfectly fine and people will do their job as they are meant to. The point I am trying to draw out is about exactly what the Bill says, and what it says is required is actually very little. The panel is required to “hear” from only one of the doctors. I still do not know what “hear” means. Exactly what content are they meant to provide? That is the point I am making. It is important that we make legislation for the worst-case scenario. That is our job.

[Lewis Atkinson]

I am not going to pursue that exact line of argument. The point of discussion, and the point of the vote, is whether we think this proposal, which, to me, is robust—the panel “must hear” from doctors and “must…hear” from the patient unless there are exceptional circumstances, and three professionals are involved—is stronger than the previous draft that involved the High Court and had no such requirements. Even if the hon. Lady does not think the new clause is perfect, does she think it is a stronger set of safeguards—surely it is—and will she support it?

[Rebecca Paul]

Again, I am not sure I agree that that is what I am here to do today. I think my job is to set out the strengths and weaknesses of the proposed amendment, and I do think that the High Court judge safeguard, on the face of it, was probably safer. I appreciate, value and truly welcome what the new clause attempts to do by bringing in psychiatrists and social workers, but it has come in at the wrong phase of the process. I am not sure we are really getting the value of that expertise at the judicial point; we would have got that value at the clinical stage.

I ask Members to take what I am saying in the good faith that it is meant. My intention is to make sure that the Bill is as safe as possible. I do not profess to have all the answers, but I do have questions, and sometimes it is useful to ask questions, because there are others here who can answer them. I hope that, by asking questions when we are uncertain whether something is the right way forward, we will get a stronger piece of legislation.

[Kim Leadbeater]

The hon. Member is absolutely right that we are here to ask questions, and I appreciate those questions being asked. On what happens earlier in the process, I hope she is reassured by the fact that we will now have compulsory referral to a psychiatrist if there is a doubt about capacity, and we have specified in the Bill doctors consulting other health and social care professionals, to provide for a holistic approach earlier in the process.

[Rebecca Paul]

I absolutely welcome those amendments. I do think they improve the safety of the Bill. As I have mentioned, I would have liked to see a truly multidisciplinary approach. At the moment, we have just included something in the Bill, as the hon. Lady says, stating that a doctor can refer to another specialist if they so wish. I would have liked to see that team pulled together, and that recognised in the Bill—we heard strong oral evidence about that.

[Kim Leadbeater]

The other point I would reiterate is that none of that stops happening. We have heard from professionals and experts that that happens. Someone who has cancer will have a multidisciplinary team around them as part of their natural treatment process. Nothing in the Bill stops that happening.

[Rebecca Paul]

I take that point. In an ideal world where our public services were not under pressure, I might be more reassured, but I am a local councillor, and I am well aware how difficult it is to get social workers involved in all the things that they need to be involved in, because they are spread so thin. The hon. Lady lays out very well how things should work, but when I take off my rose-tinted glasses, I am concerned that they will not work like that in the real world. That is why I always go back to putting things in the Bill, because that forces them to happen—doing so here would force that treatment to happen.

The Committee will be pleased to hear that I now turn to my amendments—but I am afraid there are four of them, so bear with me. Amendment (a) to new clause 17 may be one of the most important amendments that I will speak about. This is something that I feel very passionately about. One of the most important questions we should ask is how the panel might deal with a family member with concerns, for example, that a relative was being coerced. Would the family member be afforded the status of a party to proceedings? Would they have a right to see the relevant documents before the panel? Would they have a right to be informed that a panel was taking place? If they are not a party to proceedings, is their status that of a witness? If they are a witness, do they have the right to observe proceedings when a panel sits in private? Do they have a right to be heard by the panel? Again, I am asking questions. I am not necessarily saying one way or the other what the answer should be, but those are questions I have.

None of this is laid out in the new clauses that we are considering. In fact, I suggest that in the struggle to balance autonomy with the rights of impacted others in the Bill, autonomy is very much winning the fight. I was struck yesterday by various Members setting out their fears that the first a family could know about an assisted death is when they are called upon to make arrangements for the burial. That would be an awful situation, and I strongly believe that families and loved ones should not be cut out of the process without good reason, especially when, no doubt, they will be required to bury the person and pay for it, as I assume the state will not take on that responsibility. I suggest that this point on funeral arrangements and expenses needs further thought as the Bill progresses.

From reading the Bill, all we know is that the panel may

“hear from and question any other person”.

There is no mechanism for family members to have a right to be heard or even to submit information. That needs to be rectified. The panel could reach its conclusions without hearing at all from the family. That is unacceptable. If someone’s mother, father, son or daughter were going in front of an assisted dying panel, that person would at least want to know and be clear about their rights and available options to feed into the process.

We then come to the big issue. What if a mistake is made and a relevant piece of information is not provided to the panel by the people it hears from? My amendment (a) to new clause 17 seeks to help the panel to avoid making the wrong decision, and give time for it to be remedied before the patient is dead.

--- Later in debate ---

[Kim Leadbeater]

Is the hon. Lady reassured by the fact that, under the Bill, coercion becomes a criminal offence with a serious prison sentence? If any family members are in any doubt as to whether coercion is taking place, it is straightforward: they go to the police.

[Rebecca Paul]

I welcome the hon. Lady’s intervention, but the point I am making is not about coercion; it is about the subtleties in families’ relationships. I was trying to bring to life a situation—sometimes it is families who understand the relationships, the dynamics and the pressure points. It is very hard for professionals to get underneath that.

In a sense, families are the greatest experts, but the process as drafted excludes that expertise. Under my amendment, if a family member had knowledge that could make the difference between life and death, they would be able to apply to the panel. If there had been a clear error in applying the eligibility criteria, the application would be reconsidered. It is true that the panel will be informed by at least one of the doctors and that it has the option of hearing from others. Perhaps the panel will always be incredibly thorough and explore every avenue, but we have to legislate for every situation, including situations that are not ideal.

We can learn a lot from other jurisdictions. In written evidence, the academic Christopher Lyon from the University of York describes his experience in Canada. Dr Lyon writes that his father, who was “openly suicidal” and had a “history of mental illness”, qualified for medical assistance in dying in 2021. In Dr Lyon’s words:

“He was classed as having a ‘foreseeable natural death’ (i.e., terminal illness), my family was told, because he had momentarily skipped some meals at his residence and had an elevated but unremarkable white blood cell (WBC) count that the AD doctor suggested might be an infection that, if untreated, might become lethal, despite being a common side effect of his arthritis medication.”

Dr Lyon says that when he was informed two days before the event, he pushed for an urgent psychiatric assessment to be carried out. Dr Lyon has obtained a copy and says that it is

“full of errors. It claims he wasn’t suicidal, when he had a whole history of suicidality. It states he didn’t think he was depressed, and yet on the list of medications there was listed antidepressants.”

Dr Lyon’s concerns about his father’s prognosis, the assessment and other aspects of the events were widely shared, he says:

“After he died, the provincial regulatory college, police, and even other AD clinicians suggested his death was questionable or even wholly unlawful. However, privacy law and the continuing resistance from the local health authority have so far succeeded in blocking access to his medical records necessary for a full investigation”.

In Ontario, meanwhile, the chief coroner has published a report detailing the assisted death of an anonymous patient, Mr A, who had inflammatory bowel disease. He was unemployed, dependent on his family for housing and financial support, and struggled with alcohol and opioid misuse. He received an assisted death on the basis that his illness was advanced, irreversible and causing intolerable suffering. According to the coroner, the family were not consulted by those involved with processing the application, even though it was recorded that the family expressed concerns. Most members of the death review committee thought that shutting the family out was a mistake. The committee concluded:

“Engagement with family and/or close relations in the MAiD process should aim to be a key component of MAiD practice.”

We can hope that these were exceptional events, but they are the kinds of situation in which a panel might have benefited from a family perspective, which is the reason why I cite them.

[Kit Malthouse (North West Hampshire) (Con)]

As my hon. Friend heard yesterday from the hon. Member for Rother Valley, there are multiple points in the new system at which family could make their views known. Indeed, they could apply very quickly for an injunction if they thought something was untoward.

My hon. Friend has talked a lot about families knowing best. Surely it should be the dying person who chooses how best to handle their family. The evidence overseas is that giving dying people choice about the manner and time of their death also gives them the choice about how to handle their family, and particularly their children. My hon. Friend might have a particular approach, and mine might be completely different, but I should have that choice. She seems to think the family know best for the dying person—how come she does not think the dying person knows best for their family?

[Rebecca Paul]

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

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

[Jake Richards (Rother Valley) (Lab)]

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

[Rebecca Paul]

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

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

[Danny Kruger]

This is a very helpful exchange, for which I am grateful to my hon. Friend. In response to the hon. Member for Rother Valley, does my hon. Friend agree that although there should be an obligation to help the decision maker to conclude as to whether the eligibility criteria have been properly met, there is no best-interest consideration, as there might be if some of us were designing the Bill? Nevertheless, the role of the family is to enable the decision maker to conclude as to whether there have been issues of coercion or lack of capacity, to ensure the decision is properly informed. We are concerned that the Bill as drafted does not do that.

--- Later in debate ---

[Rebecca Paul]

I completely agree. Some of the amendments were tabled because there is not a best-interest component in the Bill. In an ideal world, I would have liked it to have included a best-interest component; that would have given me some reassurance. Some of the amendments that I will discuss today were tabled because other amendments were voted down. I would not have tabled them had we taken different decisions earlier. I am trying to put the safeguards in somewhere, although we can have an argument about whether they are in the right place. They were ruled out when we debated earlier clauses, so I have been left in this situation.

We can hope that the events I have described were exceptional, but they are the kinds of situation in which a panel may have benefited from a family perspective or, as my amendment (a) would allow, for second thoughts from one of the assessing doctors or any of the other people whose expertise the panel calls on. The amendment would protect not just the family but the doctors. If a family member suddenly became aware of something, there would be another avenue by which they could appeal the decision, so the amendment would be positive for the co-ordinating doctor, the independent doctor, social workers, psychiatrists and anyone else who had been involved throughout the process.

I would like briefly to outline two additional practical benefits to my amendment. First, it would resolve issues before legal disputes arise. In Belgium, the long-running case of Tine Nys has been pursued in both criminal and civil courts after her family argued that she did not meet the eligibility criteria for euthanasia. In Canada, a man’s family launched a legal challenge after he received medical assistance in dying while on a day pass from a psychiatric ward. They claim that he lacked mental capacity. It is all too easy to imagine similar cases coming to court here, but if there were a chance to challenge the decision earlier, that might allow families to come to terms with the decision before having to launch legal action.

Secondly, my amendment could help families to come to terms with grief. There are several stories from other jurisdictions about the grief felt by relatives at being cut out of the assisted dying process. In written evidence, the National Bereavement Alliance said:

“We believe that as currently drafted, the Bill overlooks the needs of families and friends…While it rightly includes safeguards to protect people against coercion, it does not include reciprocal clauses to address the health, welfare and wellbeing of the family and friends who will be bereaved…As drafted, the Bill prioritises the autonomy of the person who is choosing to access an assisted death. This is appropriate: however, it does not mean that the Bill should not also address the needs of family members and friends in relation to the decision.”

--- Later in debate ---

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

The hon. Lady has highlighted a few different legal cases from around the world; is she aware of the case currently going on in Spain, where a family member is challenging his daughter’s wish to have an assisted death? That challenge has been funded by religious groups—Christian groups—and is not actually going through the parent. He had the option and ability to raise the case, and it has then been funded and hijacked by outside groups. How would the hon. Lady see her amendment as helping to protect against that sort of thing?

[Rebecca Paul]

This is a really important opportunity to share all these examples. I have to be honest that I am not sure I see the relevance of how a case is funded, and I cannot speak on that person’s behalf. I am going to talk about some of the inequalities that come from this, because there will be people—we will come to this when we discuss judicial review—who will rely on legal aid to challenge a decision. If we do not get this right, we are in danger of creating a situation in which poor families cannot appeal and rich families can. That could give rise to the less than ideal situation the hon. Gentleman has raised. If we get this right and make sure that an appeals process is available on an equal basis to everyone in the country, that will prevent the kind of situation the hon. Gentleman has raised. I thank him for that, because he has helped to support the case for my amendment.

[Kit Malthouse]

I have to say that my concern about the hon. Lady’s amendment is growing. We have talked in the past about policing the conversation and the process to the point that it becomes guarded. Say I had a strong, long-standing conviction that I wanted assisted dying if I was in extremis, but I had a child who I knew was violently against assisted dying; if the hon. Lady’s amendment were in place, and there was the possibility of appeal, surely my tendency would be to keep my disease and diagnosis, and my approach to the system, secret from that person. By opening this formal door, I would effectively be encouraged to conceal the process from a family member who I know may object.

I say that particularly in the light of the fact that, as we heard from overseas experience, coercion more often than not comes the other way. That is certainly what they see in Australia, where families try to persuade somebody not to do it. I think the hon. Lady has good motivations, but I am concerned that she might actually produce the opposite effect and drive people into secrecy.

[Rebecca Paul]

I thank my right hon. Friend for that alternative perspective. The appeal process is valid only if there is new and relevant information that the panel did not have. For someone who is absolutely eligible, nothing has been excluded from the process that would change their eligibility. There is nothing to worry about here, so I am not sure that I concur that my amendment would prevent sharing information. However, it would provide important protection when a bit of relevant information has not been shared with the panel, which I think is the greater harm. We are trying to weigh up the harms to make sure that they do not outweigh the benefits; I honestly believe that the amendment would help to balance the scales a little better.

[Danny Kruger]

The scenario that my right hon. Friend the Member for North West Hampshire suggests implies that the patient has no faith in the panel. The patient would be concluding that they did not want to go through the formal process for an assisted death and explain it to their relatives, because they fear that the panel’s decision might be overturned on application by their relative. That objection is predicated on a lack of faith in the process that is being decided. If we are to have confidence in the process, we should trust that people will expect it to work properly. There is nothing wrong with giving a family member the right to make an application to the panel or the commissioner, because they would have every right to reject that family member’s application if they concluded that the original decision was valid.

[Rebecca Paul]

I completely agree. While I was preparing my speech, as is often the way, I found myself wishing that I had tabled an amendment to add a legal requirement that the family be able to feed into the panel and share information. Perhaps that is something that can be picked up at a later stage. The nature of the process is that as we debate these things and think about them in detail, other ideas come through.

[Kim Leadbeater]

The hon. Lady mentioned a few moments ago that the family would make such an appeal only if there was new information, but her amendment does not say that, and it has no explanatory statement. Could she clarify what she meant?

[Rebecca Paul]

That comes under subsection (2) of my amendment:

“The Commissioner will allow the application for reconsideration if the Panel’s decision was—

(a) wrong, or

(b) unjust”.

It is implied that the decision is wrong because there is missing information. Missing information is one example; other things would enable an appeal, but the obvious and most likely reason in this instance would be that a certain bit of information had not been shared.

I am not saying that the amendment is perfect in any way. It is set out clearly in guidance on the private Member’s Bill process that amendments will not necessarily be drafted perfectly and that it is incumbent on the Government to take the spirit of what is intended and get the clause to an appropriate place to deliver that. I am happy to work with the Government to ensure that the wording works and is clear. I think the hon. Lady’s point may be that it is unclear; I am happy to work in any way to improve that clarity.

[Kit Malthouse]

Through my hon. Friend, may I respond to the point made by my hon. Friend the Member for East Wiltshire? It is not necessarily about not having faith in the panel. Somebody may, for example, have a relative driven by a strong religious faith who wants to create some form of delay in the system, just to put off the awful day. Even if a commissioner were to take that relative’s application and decide that it was not valid, that would inject delay into what is naturally a time-limited process.

A person may want to retain the right to handle their family themselves, and have the choice about how to do that. If the state, rather than the dying person, is effectively deciding how the family should be handled, we are naturally giving that person an incentive to keep this thing quiet until they are ready to tell their family, which may be well towards the end of the process. As the hon. Member for Rother Valley said, there are multiple points at which the family can intervene if they know. My concern is that this kind of—what is the word we have been using?—embroidery actually drives people in the opposite direction to the one my hon. Friend the Member for Reigate wants to achieve.

[Rebecca Paul]

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

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

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

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

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

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

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

[Jake Richards]

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

[Rebecca Paul]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Crown Prosecution Service says:

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

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

“satisfied so you are sure”.

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

“satisfied so you are sure”.

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

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

[Jake Richards]

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

[Jake Richards]

Forgive me, Chair.

[Rebecca Paul]

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

[Naz Shah (Bradford West) (Lab)]

The hon. Lady is making a powerful point. I refer back to the point on jury trials. When we have criminal trials and jury trials, they go through not every single thing in somebody’s life, but the actual act of criminality itself and what is relative to that criminal act. That does not mean to say they trudge through a person’s whole life.

[Rebecca Paul]

I thank the hon. Member for that intervention. She eloquently explains exactly the point I was trying to make. That is absolutely right. Clearly, we do not expect the panel to pore over everything. It can only be sure based on the evidence put before it, so I reiterate: that is why it is really important that all the right and relevant information can be fed into the panel in order to get a good, robust, solid decision.

Members will all be relieved to know that I am now coming to the last amendment, amendment (b) to new clause 21. It puts in an additional mechanism for the panel not to grant an application when particular circumstances make it inappropriate. I do not think many in the Committee are going to like the amendment. I make the point again that, in an ideal world, there would have been a best interest clause or something similar in the Bill to protect patients from opting for assisted dying due to some other perfectly solvable challenge in their life, such as being homeless, but, given our amendments were not accepted, I am putting this amendment forward again as a responsibility of the panel, given its oversight role. This is likely to be where the social worker on the panel can play an important part.

In Ontario, assisted dying is monitored by a team of nurse and coroner investigators who review every reported death. The state has also established a death review committee. A recent report shows some of the difficulties for a panel in making its decision. A patient referred to as Ms B successfully applied for an assisted death. She suffered from multiple chemical sensitivity syndrome, which made it difficult for her to find appropriate accommodation. The report found that

“As a result of her housing situation and conditions, necessary to address her MCSS, Ms. B experienced social isolation, which greatly contributed to her suffering and request for MAiD.”

--- Later in debate ---

[Kim Leadbeater]

I might have misheard, but I believe the hon. Member asked what happens when a patient asks for assisted death not as a result of illness. If that was the case, then they would not fall under the criteria of the Bill.

[Rebecca Paul]

I am making a point regarding if a person fitted the diagnosis in that they are terminally unwell, but it is actually the fact that they have got nowhere to live that is really driving the decision rather than the terminal illness. My apologies if that was not clear.

In Oregon there was the case of Barbara Wagner, who had recurring lung cancer. She had been prescribed a drug, Tarceva, which had an excellent record. It increased patients’ one-year survival rate by 45%. Oregon’s state Medicaid provider sent Wagner a letter saying that her insurance plan would not cover the drug, but would cover other options, including assisted dying. Wagner said:

“I got a letter in the mail that basically said if you want to take the pills, we will help you get that from the doctor and we will stand there and watch you die. But we won’t give you the medication to live.”

Those are her own words, not my words. Recently in Australia, similar cases have been reported of people choosing assisted dying because they were put on too long a waiting list for a home care package. One man said of his mother:

“Her pride wouldn’t allow any of her boys to take care of her or to bathe her so she got approved for the assisted dying”,

and a few months ago proceeded with it.

There are many other situations where everyone would benefit from the panel having broader discretion. Think of one of the cases I talked about earlier—and have done throughout the various Committee sessions—where somebody appears to be a possible victim of coercion, or a case where someone with diabetes, for instance, wishes to bring themselves within the six-month definition by stopping treatment, or someone with anorexia brings themselves within the definition by stopping eating and drinking. The capacity safeguard would not defend them. The courts have found that people have capacity to refuse lifesaving treatment, even if their decision is strongly influenced by other factors.

Hon. Members may worry that giving the panel discretion is too open-ended. The truth is that, in our legal system, discretion is the norm. Whether in sentencing guidelines or in custody cases, the law nearly always recognises that sometimes a general rule has to be departed from. If the panel is compelled to make its decisions only by a checklist with no other option, the Bill is saying that the panel is less trustworthy than the courts. If this panel is to be a safeguard, we should be clear about how it functions. It needs to be open to correcting mistakes. It needs to have a clear standard of proof, which will protect people and not just hastily steer them towards assisted death, and it needs a wide degree of discretion if it is truly to be more than a tick-box exercise. I hope the Committee will agree and support these amendments.

[The Chair]

It is open to any Member to speak more than once in a debate, as the Committee knows. Naz Shah has indicated to me that, because of the size and complexity of the groupings of amendments, she wishes to speak not once but three times to break her comments into bite-sized chunks. I draw that to the Committee’s attention to put down a marker in case anyone else feels the same way.

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

Rebecca Paul Excerpts

Committee stage
Wednesday 12th March 2025 Public Bill Committees

[Danny Kruger]

The hon. Lady does always come back to that point, and I respect it. She imagines that the good practice that is prevalent in the system will obtain automatically, in all cases, under the assisted dying regime, even though that regime is completely new. She says that she cannot envisage a scenario in which the doctors would not hear from all the professionals we all think should be consulted at this stage of the process. I have two points to make on that. First, why not make it explicit that that is required? Secondly, I am afraid that I can envisage scenarios in which for doctors—perhaps some years down the line, once this model of death has become normalised, as it has in Canada and elsewhere, with up to 10% of deaths coming through assisted dying—it just becomes a procedure.

Again, we have not ruled out the possibility—the likelihood, in fact—of independent clinics establishing themselves with a business that is about providing the support for people who want to end their life. There will be doctors who are happy to conduct the assessments; to take at face value what they hear from the patient; not to involve a wider multidisciplinary team in their consultations; and to expedite the process as the Bill, as drafted and amended, allows. I am afraid I do foresee a scenario in which the good practice in which all believe does not happen. My concern, and I expect the hon. Lady’s is the same, is to prevent that.

[Rebecca Paul (Reigate) (Con)]

My hon. Friend is making a powerful point. One of my concerns is about what happens if someone seeks assisted dying privately through a clinic. I see risks with multidisciplinary teams involving social workers continuing in that instance. Does my hon. Friend share my concern?

[Danny Kruger]

I certainly do. That is exactly the scenario that I fear, and I fear it within the NHS too. Let us not imagine that every NHS doctor has all the time and the access to the wider specialisms that they would wish. Under the Bill in its current form, there will be a very strong incentive and a very strong personal instinct for compassionate doctors, who believe in the autonomy of patients and in respecting the patient’s wishes, to take at face value what they are told and not to seek the expertise that would happen automatically if there were a proper multidisciplinary team at that stage of the process.

My point is that we do need a multidisciplinary team, but what is in the Bill is not it. At best, it is half a multidisciplinary team. There is no doctor on it. There is a lawyer, pointlessly. There is a sort of quasi-MDT—a duo-disciplinary team—but it is in the wrong place, and it will not assess, which is the job it should do, but judge. It will not diagnose or advise in the way that a clinician should; it will simply decide whether the criteria have been met for an assisted death. That job was rightly given to judges in the Bill that the House of Commons voted for, but this Bill does not have the powers, the safeguards, the accountability or the independence of a tribunal, let alone that of a court.

As the hon. Member for Spen Valley candidly says, the panel is not a judicial entity in any sense. It is a weird creature, neither one thing nor the other: a quasi-multidisciplinary team, at the wrong stage in the process, for the wrong purpose. I have said that it is not a multidisciplinary team, but it is not really a judicial entity either, as the hon. Lady has mentioned. It is certainly not “judge-plus”, as was originally suggested. There is no judge, just a legal member—not a judicial member but a legal member, who might be a lawyer.

--- Later in debate ---

[Sarah Sackman]

I thank hon. Members for their interventions.

In respect of the standard that would be applied in order for the panel to be satisfied, in practice, as I was saying, the panel would establish a case on the balance of probability in those circumstances only on the basis of strong evidence. In other words, the more serious the issue to be determined, the closer the scrutiny and the stronger the evidence required.

Introducing a requirement for the panel to be satisfied beyond all reasonable doubt at this stage would create a difference to, or a divergence from, the standard applied by professionals earlier in the process, such as by the doctors in the first and second assessments, and—I think the hon. Member for Reigate acknowledged this in her speech—to ascertain whether, among other things, the person has capacity to make the decision to end their own life, whether they have a clear, settled and informed wish to do so, and that they have not been pressured or coerced. Such a requirement would create the problem of making the application of the Bill incoherent because, of course, if a civil standard has been applied earlier in the process, the higher, criminal bar could never be satisfied at the panel stage. The principal decision is what standard should be applied and, as I have said, the civil standard is used in other end-of-life decisions, but there is also a question of the internal coherence of the Bill.

[Rebecca Paul]

I thank the Minister for the very clear way in which she is explaining everything. I completely acknowledge what she has just said. As she rightly said, I alluded to the fact that I tried to make the change at an earlier stage, but was unsuccessful, and I am now trying to put it through here. Can the Minister comment on the meaning of “satisfied”? If we are not going to have “beyond reasonable doubt”, can she expand a little on the meaning of “satisfied” and whether she is comfortable that that is clear enough for these purposes?

[Sarah Sackman]

The answer is yes. I, on behalf of the Government, am satisfied that that would be commonly and well understood by those applying it, and any court construing it, that the standard to be applied is the civil standard. That would be understood by not just the commissioner in terms of laying down the rules for the panels, but the panels themselves. It is important to recall that as Lord Bingham, one of the most distinguished judges that this country has ever produced, once said,

“The civil standard is a flexible standard to be applied with greater or lesser strictness according to the seriousness of what has to be proved”,

and there is no doubt, based on what Parliament has debated, about the utmost seriousness of these issues. To answer the hon. Member’s question, the answer is yes, I think it is clear. That is the Government’s position.

Amendment (b) to new clause 21 would give the panel discretion to refuse to grant a certificate of eligibility where the requirements stated in the Bill are met if it believes there are

“particular circumstances which make it inappropriate for the person”

to be provided with assistance. The Government’s view is that this could risk unpredictability and inconsistency in the panel’s decision making and reduce legal certainty for the person seeking assistance, as well as for the panel.

Amendment (c) to new clause 21 concerns three specific requirements under subsection (2):

“(c) that the person has capacity…(h) that the person has a clear, settled and informed wish to end their own life”

and

“(i) that the person made the first declaration voluntarily and was not coerced or pressured by any other person”.

The amendment would mean that despite finding that those criteria had been met on the balance of probabilities, the panel could stay proceedings when it believed there was a real risk that they have not been satisfied. As with amendment (b) to new clause 21, this could result in uncertainty for the applicant and in terms of what is required of the panel in its decision making.

As I referred to earlier, in a lot of these decisions, the question of whether somebody has capacity or is being coerced is ultimately a binary decision for each panel member. The person has capacity or they do not. In applying the civil standard with the rigour that Lord Bingham spoke about in the most serious cases in circumstances when the panel or its members identify that there is a real risk, one would expect them to exercise their discretionary powers to seek more evidence to remove that risk and doubt, and if that persists, to refuse and make the binary choice that the person does not have capacity or is being coerced, or vice versa.

Amendment (d) to new clause 21 would require the panel to hear from and question both assessing doctors, as opposed to the requirement that the person must hear from, and may question, one of the doctors, and may hear from and question both. The amendment would also require the panel to hear from and question the person seeking assistance and the person’s proxy when clause 15 applies. Under new clause 21, the panel must hear from and may question the person seeking assistance and would have the ability to hear from and question their proxy.

The amendment would also make it explicit that the panel must consider hearing from and questioning parties interested in the welfare of the person and those involved in the person’s care. Under new clause 21, the panel would have the ability to hear from any other person, which could include family members, caregivers and whomever else it deems appropriate.

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

Rebecca Paul Excerpts

Committee stage
Tuesday 18th March 2025 Public Bill Committees

[Stephen Kinnock]

One of the fundamental principles of the Bill, which my hon. Friend the Member for Spen Valley has prioritised, is self-administration. It is not for me as a Minister to opine on that; it is simply there in the Bill. Once that fundamental principle is established, it is about defining what “assistance” means, compared with what “self-administration” means. As I was setting out, I think “assistance” can mean things like helping the patient to sit up; it does not mean actually administering the substance to the patient. It is about the dividing line between assistance and self-administration—hence the term “assisted dying”, I suppose, which is very different from the doctor actually administering the substance.

[Rebecca Paul (Reigate) (Con)]

I am going to read subsection (6)(c) again. It says:

“assist that person to ingest or otherwise self-administer the substance.”

I would interpret that slightly differently from the Minister. It talks about ingesting, which suggests the substance entering the body, so I would not suggest that sitting someone up would qualify. That in itself shows that perhaps there is some ambiguity here. The Minister has set out something that I had not read into the Bill. Will he comment further on that?

[Stephen Kinnock]

I will pretty much repeat what I have just said to my hon. Friend the Member for Ashford. There is a dividing line, as the Government see it, between assistance and administration. There is a dividing line between making the patient comfortable, enabling the procedure to take place, and the doctor actually putting the substance into the body of the patient. From the Government’s point of view, simply from the position of having a picture of the process in our mind, that dividing line is clear enough in the drafting of the clause.

--- Later in debate ---

[Stephen Kinnock]

In order to ingest, there has to be self-administration. The self-administration is the precondition for ingesting the substance. That is my reading. I hope that that satisfies my hon. Friend.

[Rebecca Paul]

The Minister is being incredibly patient with our questions. The question from the hon. Member for Ashford raises exactly the point with which I am uncomfortable. To me, the phrase

“assist that person to ingest”

means something else. I am really concerned that it could be interpreted differently from how the Minister has laid it out. I want to place that on the record and raise that issue, which I believe the hon. Member was also raising.

[Stephen Kinnock]

The hon. Member’s concerns are absolutely noted. I completely understand that hon. Members are not comfortable with this, but what I am trying to do is set out the Government’s view on the workability of what my hon. Friend the Member for Spen Valley is seeking to achieve and the basic principles on which that is built.

Amendment 497, on which the Government have worked jointly with my hon. Friend, would amend clause 18(11), which states:

“Where the person decides not to self-administer the approved substance, or there is any other reason that the substance is not used, the coordinating doctor must remove it immediately from that person.”

Under the clause as it is currently drafted, there could be difficulties in relation to the duties of the co-ordinating doctor where the co-ordinating doctor does not know what the person has decided. Amendment 497 seeks to resolve that ambiguity by clarifying that the duty on the co-ordinating doctor to remove the approved substance applies where the person

“informs the coordinating doctor that they have decided”

not to self-administer the approved substance.

I turn to amendment 498. At present, clause 18(11) provides that the co-ordinating doctor has the duty to immediately remove the approved substance where the person decides not to self-administer the approved substance, or there is any other reason that the substance is not used. The amendment clarifies that the duty to remove the substance arises when the co-ordinating doctor believes that the substance will not be used. I hope that those observations have been helpful to the Committee.

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[Danny Kruger]

I hope the hon. Gentleman is right. Nevertheless, one of my concerns about the Bill is that we are leaving enormous areas of clinical practice, and regulated conduct for the professionals involved in assisted suicide, to be performed under guidance that is still to be set out and that it is the job of future Ministers to determine.

I pay tribute to the hon. Gentleman, because he has correctly identified a group of patients for whom the drafted Bill may present obstacles to the fulfilment of their wish for an assisted death. My belief is that the ability to assist will probably cover almost anybody who wants it and has found a doctor who wants to help them, but the hon. Gentleman is right that there are some groups for whom that might be more of a challenge than others. I think the answer we are going to get—it is one made by hon. Members in the debate already—is that technology will fix it, and I fear it will, because I think we are going to find ourselves in a world in which it is perfectly possible for the administration of death to be enabled through some kind of technological device, which somebody with the most limited physical mobility will nevertheless be able to activate.

I fear the insistence that we have on self-administration. Although we can all acknowledge, as referenced in the previous debate, the conceptual difference between administration and self-administration, we do have this idea that we are individuals cut off from each other and that there is an essential gap between us and other people. At the very end of life, though—in the moments that we are considering and legislating for—that distinction is void, because we are intimately connected with other people, as per the clauses that we are debating. I fear that we are going to find ourselves in a world in which a laptop will be set up and even a movement as small as the blink of an eyelid by the patient will be enough to trigger what will be called “self-administration” of the fatal dose.

I oppose this group of amendments, moved by the hon. Member for Harrogate and Knaresborough, because I do not believe in assisted suicide. I do not understand why other supporters of the Bill are not following the hon. Gentleman’s lead, and acknowledging that if we believe in autonomy and assisted suicide, of course we should enable patients to have the final act performed upon them, rather than insisting on this arbitrary distinction that it is possible to insist on self-administration in all cases.

[Rebecca Paul]

It is clear that the hon. Member for Harrogate and Knaresborough is trying to create equity, which we all understand. We need to think about the patient on the one hand, but also the doctors, nurses and medical practitioners involved. Does my hon. Friend agree that we need to think about the obligation and impact of such amendments on them?

[Danny Kruger]

Yes. We discussed this briefly this morning. There is an important consideration about the effect on medical staff involved in the administration of assisted suicide, and we have to make sure that those who do not want to participate are properly insulated from any sort of obligation, which I know is the intention of the Bill’s promoter, the hon. Member for Spen Valley. Nevertheless, I am concerned about the knock-on effect of participation in assisted suicide spreading across a practice. I agree with my hon. Friend that we have to be mindful of the impact on doctors. The more we widen the scope—as logic compels us to do, as the hon. Member for Harrogate and Knaresborough suggests—the more it is about not just discretion, but an obligation on doctors to approve.

We need to think about the conversation that doctors will be required to have with patients who are expressing that wish. If the Bill is widely drawn, as it would be if we were to accept these amendments, there is more opportunity for a doctor to feel compelled to assent to a request.

--- Later in debate ---

[Dr Opher]

I thank my hon. Friend for his experience in a clinical setting. I would remind everybody that in the Bill we are trying to help people die in a comfortable way, and I do not feel it is the Bill’s job to define exactly how we treat nausea or abdominal obstruction and so on. What we would like to do here is ensure that a patient has a pain-free death, and a death that they are in control of.

[Rebecca Paul]

rose—

[Dr Opher]

I will make a little progress and will then take my hon. Friend’s intervention.

On amendment 436, all medical practitioners are required under their code of practice to record any event they come across. I feel there should be better data and I agree with the hon. Member for East Wiltshire that we need to collect data. We are actually very good at doing that in the NHS. Under clauses 21 and 22 there are provisions for the Secretary of State to collect data on complications. I am therefore not sure that particular amendment tabled by my hon. Friend the Member for York Central is necessary. I think I have covered amendment 464, from the hon. Member for East Wiltshire.

On amendment 429, about the doctor being in the same room, I totally understand the anxieties presented by my hon. Friend the Member for Bexleyheath and Crayford, but I feel that whether the doctor is there should be the choice of the family and the patient. There may be some confusion about this, but to me, what the Bill implies—I am interested to hear the Government’s opinion—is that the doctor should deliver the medicine to the patient, check that the patient is willing to take the medicine as per amendment 462 from the hon. Member for East Wiltshire, give the medicine to the patient, and then ask the family whether they want them to be there or in the next room. They need to be available, but do they need to be in the same room? I think that should be the choice of the family.

--- Later in debate ---

[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.

[Rebecca Paul]

Following on from the point made by the hon. Member for Bradford West, has the Minister taken into account the guidance on private Members’ Bills? It says exactly what the hon. Member has just set out: the spirit of amendments should be taken, and it is for the Government to ensure that the integrity of the statute is respected with the final version. That is to allow a free-flowing discussion and to ensure that we capture everything we need to in the Bill, in the light of the fact that many of us are not lawyers or experts.

[Stephen Kinnock]

Absolutely, if the Committee chooses to accept the amendment, it goes into the Bill. If the Bill gets Royal Assent, it becomes the responsibility of the Government to ensure that the Bill, as passed by Parliament, is implemented in the best possible way.

The hon. Lady is right that the Government’s responsibility is to take on whatever passes through Parliament and implement it to the best of our ability. My job in this Committee is to raise concerns about risks of amendments that could potentially muddy the waters more than other amendments, or more than the Bill as it currently stands. It is a balanced judgment about whether we are better off with the Bill as it currently stands, whether the amendment would improve the Bill, or whether it could lead to concerns about the integrity of the statute if it were included.

[Rebecca Paul]

I thank the Minister for that explanation. I suggest it would also be appropriate for him to set out the changes that could be put in place in order for the amendment to work in that way. To my mind, that would give the true neutrality that he is seeking to achieve. Rather than set out why something does not work, he could set out how it could work in order to deliver the spirit of the change.

[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.

--- Later in debate ---

[Naz Shah]

I rise to speak to amendment 499, tabled by my hon. Friend the Member for Spen Valley. Let me outline what the amendment does and why I believe that it provides an inadequate safeguard. Under clause 19, the co-ordinating doctor may authorise another doctor to provide assistance—meaning that they will help the patient to take the lethal drugs. For clarity, I will refer throughout my speech to this other doctor who may step in to provide lethal drugs as the second doctor.

Under clause 18(4), the co-ordinating doctor must be satisfied of three conditions before they proceed to assist the person to take lethal drugs. Those three conditions are that the person has a clear, settled and informed desire to end their life, has capacity under the Mental Capacity Act 2005, and is not subject to coercion. Implicitly, the co-ordinating doctor can therefore end the procedure if they are not satisfied that those conditions apply. Under clause 19(3), the second doctor has the same duty as the co-ordinating doctor to be satisfied of those conditions before the assisted dying procedure can go ahead.

Amendment 499 would impose a new duty on the second doctor: if they suspected coercion, lack of capacity or lack of clear, settled and informed desire, they would have to inform the co-ordinating doctor. I suggest that the amendment does not take things far enough. It is a very serious matter if any doctor, be it the co-ordinating doctor or the second doctor, suspects coercion, lack of capacity or lack of desire. That means that a very serious mistake may well have been made, and that mistake could lead to someone having an assisted death who should not have qualified for it.

There should be several more safeguards in this part of the Bill. First, let us consider a situation where there was no previous suspicion that a patient had been coerced but where the doctor now suspects that they may have been. There should be a proper system of notification for such cases. It is true that doctors have a duty of care for patients, but it is also true that, given our overstressed, underfunded social care, health and policing systems, difficult cases sometimes fall through the cracks. The Bill should have a clear system for an authority to check back with the social care authorities and a person’s GP to make sure that steps are being taken to protect them from potential coercion. Secondly, the report that the second doctor makes in those circumstances should go to not only the co-ordinating doctor, but the voluntary assisted dying commissioner. Thirdly, when that happens, the commissioner should investigate the incident.

To repeat: if a doctor originally assessed a patient as qualifying for an assisted death, but a second doctor could not support that assessment, that is a serious incident that could lead to the assisted death of someone who should not have qualified for it. That does not mean that the co-ordinating doctor was necessarily at fault—not at all. The co-ordinating doctor will have been taking very difficult decisions under considerable stress. However, it does mean that the proper authorities should investigate the initial assessment, whether it was wrong and, if so, why it was wrong.

We see something similar with the Air Accidents Investigation Branch, which investigates not only accidents, but near misses that could have caused serious accidents. It does not assume fault when it investigates near misses. Often, it finds that there has been no human error. However, it has a statutory duty to investigate serious near misses. That is because the law passed by this House recognises that we need to understand why they happened in order to prevent fatal accidents from ever happening in the future.

For that reason, I do not think that my hon. Friend’s amendment is sufficient to fix the problems with this part of the Bill. I hope we can think about how better to address those problems, but I cannot support the amendment.

[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?

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[Rebecca Paul]

I would like to think that that would naturally happen, and we have had lots of conversations where we have said, “In reality, of course this conversation would happen.” But I always like to be belt and braces, and I would like to have these things covered in the Bill. If Committee members are confident that these things would happen anyway, I am not sure there would be any detriment to accepting this amendment.

I want to finish with a question for the Ministers. I have been worried—perhaps unnecessarily—about the lack of photographic identification in this process, and I can see a situation where allowing another doctor to provide assistance could create a risk. Although it might be less of a risk in someone’s home, because it would probably be clear who the person is, I am worried about a doctor in a hospital or clinic being substituted in at the final hour with no photographic verification of the person. At the point where they assist the patient to take the approved substance, how can the doctor be sure that it is the appropriate person if they have not had any involvement with the patient before? I accept, given some of the deep sighs I can hear, that that may be a rare occurrence, but it is worth thinking about. The simple inclusion of a photographic ID check would address some of that risk. I will not go over old ground, but I have been worrying about that.

[Naz Shah]

I rise to support amendment 22, in the name of my hon. Friend the Member for Lowestoft. Before I carry on, I am happy to give my hon. Friend the Member for Spen Valley the opportunity to say whether she will accept the amendment, because my hon. Friend the Member for Lowestoft has had a hat-trick of amendments being accepted around training on coercion.

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[Danny Kruger]

I entirely agree. The regulations need to specify not only what drugs may be approved, but, as the hon. Gentleman suggests, how they should be stored and transported. I would expect that to be part of the package of regulations under the Bill.

As I have stated, I do not accept that we are talking about healthcare here; nevertheless, we are using products that are comparable to health products. The MHRA would need to significantly adapt its work in order to identify the most effective drug to cause what we currently perceive as harm—namely, the death of a patient. I recognise that that would be a significant change of remit and work for the MHRA, but we need to do it. One of the reasons that we need regulation of approved substances is to help ensure that falsified versions of the drug—drugs that do not have a licence for use in assisted dying—cannot enter the market. Such drugs may not be effective and could cause distress to those ending their lives and their families. I would be grateful if the Minister could clarify whether, in his view, clause 20 is sufficient to establish the necessary regulatory regime, or whether further legislation will be needed.

We had evidence from Greg Lawton, and other pharmacists, who wrote to the Committee to suggest that the approved substances would not legally come within the definition of a “medicinal product”, so medicines law, the protections associated with medicines and the MHRA licensing process might not apply. If that is the case, what do we do about it? We need a new licensing regime to ensure that the MHRA is able to properly regulate the substances, or, potentially, another regulatory agency would need to be established to do the job.

The Committee needs to make sure that there is a process that applies to approved substances used for assisted dying. It is not necessarily the case that a product licensed for treating a medical condition could not be used to bring about death—it is not the case that we cannot use any drug that is currently used for genuine health treatment—but it would not be being used as a medicine, so medicines law may not apply to its use for that purpose. There is an ambiguity, and I would be grateful for clarity on it.

The amendments that I am supporting would ensure that the MHRA had approved the drug for the specific purpose of ending someone’s life, and that there was scientific consensus that the drug would be effective for that purpose. The MHRA, in the marketing authorisation for the approved substance, would define the dosage of the drug required to bring about death. It would also ensure that specific considerations and warnings were placed in the product licence.

For example, some patients have allergies to certain drugs. If they decide to end their own life, that should be brought about as a result of the effect of the drug, not an unintended allergic reaction to it. Some patients would not be able to take drugs orally and might need to have the drug administered through a tube into the stomach, so different formulations would need to be available. Some drugs may need to be administered by injection. Patients may be unable to do the injection themselves, as we have discussed. Even if the patient is physically capable, injection techniques require proper training, and that needs to be considered when licensing drugs for assisted dying if the patient is responsible for self-administration.

There will be further considerations when deciding what drugs can be used. Patients will have a right to know what to expect. If they take the drug orally, how long will they have to wait before they die? Will they lose consciousness first? If so, how long will that take? Could there be some side effects or reactions after taking the drug, such as seizures or choking, that the family or carers will have to deal with? Can the drug be taken at home—that relates to the point that the hon. Member for Ashford made—or must it be used in a clinical setting? We have suggested that it could be used at home, so questions about transportation arise. Is a combination of drugs required? If so, in what order should they be taken? What happens if the patient passes out before taking the entire concoction of drugs? Has the drug formulation been optimised for the purpose of assisted dying, so that it reaches maximum blood levels as quickly as possible?

All these sorts of questions are appropriate for medical regulators. The MHRA could ensure that the patient information leaflet, and the warnings associated with it, given with the drug when it is prescribed prompt doctors to think about what drugs are most suitable for the patient and to provide information to the patient about what to expect.

Parliament must have oversight. It must bear responsibility for the kinds of deaths that it approves. Both Houses of Parliament should approve the statutory instrument. To inform that decision, the Secretary of State should provide all relevant information on the likely time to death, and on complications and side effects. When the state is creating a regime that will end lives, there must be maximum transparency and accountability, yet the Bill provides that this will be done by a negative statutory instrument. In other words, Parliament will get a say on the regulations only if the Leader of the Opposition prays against them—that is the process for a negative SI. That is the only circumstance under which the Government would make time for a debate and a vote on a negative SI. Given that this is an issue of conscience, I find it inconceivable that the Leader of the Opposition would want to take a position on it and so pray against it to trigger a proper debate. I think it is highly likely that Parliament would never get a say on this crucial issue because of the use of the negative procedure.

That situation has been recognised repeatedly as being unacceptable. When Lord Falconer introduced his Assisted Dying Bill to the House of Lords in 2014, it too provided for a negative SI power on this matter. The highly respected House of Lords Delegated Powers and Regulatory Reform Committee—we do not have an equivalent Committee in the Commons, but it sits over Parliament—said that it did not consider either the power or the procedure in the Falconer Bill to be appropriate, yet that is the procedure that we are being presented with here.

In 2021, when Baroness Meacher introduced her Assisted Dying Bill to the House of Lords, the Delegated Powers and Regulatory Reform Committee again issued a report, in which it said:

“In the interests of clarity and transparency on such important issues of public policy, the matters that are in due course to be dealt with under clause 4(7) by negative regulations should in our view be spelled out in detail on the face of the Bill from the outset. Accordingly, the Bill should contain a definitive list of medicines, and details of the manner and conditions under which such medicines are to be dispensed, stored, transported, used and destroyed. The power to amend such matters should be a matter for regulations subject to the affirmative procedure.”

We then come to Lord Falconer’s 2024 Assisted Dying for Terminally Ill Adults Bill, which he withdrew following the introduction of this Bill by the hon. Member for Spen Valley. That Bill in part took on that feedback from the Lords Committee. Although it did not provide a list of medicines, it did at least provide that the power to specify the drugs would be through the affirmative procedure.

The Hansard Society, which is non-partisan and neutral on assisted dying, has issued a critical report on this power. It says:

“MPs may wish to enquire why Kim Leadbeater has chosen not to adopt the scrutiny procedure set out in the 2024 bill, but has preferred that proposed in the 2014 and 2021 incarnations of the bill, despite the advice to the contrary of the Delegated Powers Committee.”

I would be grateful to learn from the hon. Lady why she has chosen this procedure.

It might be objected that the list that I am requesting might need to be modified quickly and that the affirmative procedure—having a parliamentary vote—would be an obstacle to doing that. The Hansard Society anticipated that objection. It said that

“this could be addressed by making provision for the use of the ‘made affirmative’ procedure in urgent cases where the Secretary of State wishes to remove a substance from the approved list and is of the opinion that it is necessary to do so immediately in order to prevent adverse medical events or failed assisted deaths. This would mean Ministers could act expeditiously but Parliament would have to debate and approve – albeit retrospectively – the change in the list. Whilst not perfect it would provide more opportunity for oversight than that offered by the negative scrutiny procedure.”

It seems to me that there is no justification for this vital matter to be regulated under the negative procedure. Too much power and responsibility is being given to Ministers subsequent to the passage of the Bill— if that is what happens. My amendment 467 would ensure that Parliament has a meaningful say, through the affirmative procedure, and that a report is published as part of that process setting out the expected efficacy of the drugs that will be used. I hope that the Committee will support it.

[Rebecca Paul]

My hon. Friend the Member for East Wiltshire eloquently covered most of the things I would have said.

We have probably not spoken enough to date about the impact on pharmacists, but we are getting to the point in the Bill where it is really important that we take on board the written evidence and feedback that we are hearing from them. The Royal Pharmaceutical Society said:

“In dispensing a prescription, a pharmacist assumes a proportion of the responsibility for that prescription and therefore must be assured that all legal requirements are in place and that it is entirely appropriate for the patient. The link to the clinical assessment of eligibility criteria is essential and therefore the prescriber should always be one of the assessors. In addition to the usual practice of checking that the prescription fulfils the necessary legal requirement, pharmacists must have full access to the patient’s diagnosis and assisted dying care plan.”

That raises a few valid and interesting points that we need to take on board to ensure that pharmacists can do their jobs in line with the regulations and laws they are subject to, which are ultimately there to maintain patient safety.

I support amendment 466, tabled by my hon. Friend the Member for East Wiltshire, which would ensure that the Secretary of State must be of the opinion that there is scientific consensus that the drug is effective without causing pain. I am of the view that the Secretary of State is probably the right place for that responsibility to sit. One reason for that, which my hon. Friend spoke about, is that I am not sure that the MHRA is the right regulating body for that. I am no expert on this, and I am open to hearing the debate, but the MHRA’s remit covers medicines and healthcare products, so there is a question about whether legally the responsibility falls to it. If it does not, do we set up another body, or do we adjust its remit so that it is covered? I have reservations about doing anything that would merge assisted dying into normal healthcare, but I have laid that out many times over the weeks, so I will not go over that.

My understanding is that, on top of all the things my hon. Friend set out, the MHRA’s role is to give marketing authorisation for the promotion and advertising of medicine. Once that has been given, reams of regulations and compliance must be done, including in respect of the labelling of medicine. I believe it would have to be put on packaging that a medicine could be used for assisted dying. We need to get clarity on that from experts in the field, so that we fully understand it. If that is the case, how do we feel about making it clear that said medicines, potentially out in the market, could be used for assisted dying? I suggest there could be some significant downsides to such clear labelling. That is something for us all to think about. I wanted to raise those important points.

[Naz Shah]

I rise to speak in support of amendment 465, tabled by the hon. Member for East Wiltshire. It is a pleasure to follow the hon. Member for Reigate, who has made some powerful contributions. As we have heard, the amendment states that a drug may be approved under the Bill only if it has been approved by the Medicines and Healthcare products Regulatory Agency for that purpose.

--- Later in debate ---

[Naz Shah]

I rise to speak to amendment 439, tabled by my hon. Friend the Member for York Central, which would amend clause 21 such that the relevant body would provide the chief medical officer and the commissioner with the full set of documents relating to a person who had undergone assisted dying. The relevant body would be the co-ordinating doctor if that person were a practitioner with the person’s GP practice. If the co-ordinating doctor did not meet that condition, the person’s GP practice would have the responsibility of sending those documents.

Those documents would be the person’s full medical records, court records and all documentation relating to assessments and procedures relating to the person’s assisted death. I note that “court record” refers to the Bill before we agreed to the amendments and new clauses that replace the High Court procedure with a panel system. We should be able to slightly tweak the wording to reflect that when we tidy up the Bill. That is what the amendment does. Let me say a little about why it does so and how it would make the Bill stronger.

The key aim is to ensure proper public oversight of any assisted dying scheme. The Bill creates the role of the voluntary assisted dying commissioner, who will look at and report on the workings of the system, appoint panel members and be the final court of appeal, so to speak. Those are far too many powers to give to one person, but if we are giving the commissioner a duty to report on how the system works, they should have the best possible information. It is only right that the information also be sent to the chief medical officer for England or for Wales, as appropriate; they are both very senior public officials and experienced doctors.

My hon. Friend the Member for Spen Valley has tabled amendment 382, which, to quote the explanatory statement,

“provides for monitoring, investigation and reporting functions under Clause 34 to be carried out by the Voluntary Assisted Dying Commissioner (instead of the Chief Medical Officers for England and for Wales).”

I will have more to say on that amendment when we come to it, but removing the chief medical officer from the monitoring, investigation and reporting functions is not a good idea.

What use could the commissioner and the chief medical officers make of the data provided under amendment 439? Let me give some practical examples. If there were reported instances of a person experiencing discomfort or pain as a result of taking the medication, that would be of interest to the CMO and the assisted dying commissioner. It could trigger a further exploration of the titration of medication used in the procedure. As another example, let us think about what could happen if a family raised concerns about a person receiving assisted dying despite lacking capacity or being coerced. The CMO and assisted dying commissioner could use the information provided to investigate those allegations.

The amendment will ensure that the assisted dying commissioner and the chief medical officer receive detailed qualitative as well as quantitative data on people who have received assisted deaths. It is an important step towards making sure that the assisted dying scheme receives proper, well-informed scrutiny. In turn, that scrutiny will make it less likely that the scheme will allow abuses or ignore serious problems. I urge hon. Members to support the amendment.

[Rebecca Paul]

I will be very brief. I rise to ask a few questions about clause 21 as a whole. Following our debates on various amendments, I am aware that family and those close to the patient could not be involved in the process, although potentially for understandable reasons. I appreciate that we are not here to deal with the whole operational piece, but we should think about it. For example, what happens with notifying next of kin after death, bearing in mind that “next of kin” has a different meaning after death? That is when we start to get into legal considerations, such as who the executor is—and this could be the first time that they are hearing about it. What would be the process for that, given that the person has potentially died on their own at home with the doctor?

What is the process for handling the next stage? Is there anything that we need to include in the Bill to make it a clearer, simpler and easier process? Who will the medical certificate of cause of death be given to for registration of the death? While all that is going on, what will happen to the body? At that point, we may not have family members to take care of that. Those are some questions arising from clause 21 that are worth reflecting on.

[Stephen Kinnock]

The amendments relate to clause 21, which applies where the person has been provided with assistance to end their own life in accordance with the Bill and has died as a result. Throughout this process, we have worked with my hon. Friend the Member for Spen Valley. Amendments 379 and 500 have been mutually agreed on by her and the Government, so I will offer a few technical and factual comments.

Amendment 379 would require that, where a person has been provided with assistance to end their life and has died as a result, the co-ordinating doctor must provide the voluntary assisted dying commissioner with a copy of the final statement under clause 21 as soon as practicable. That links to the commissioner’s role in monitoring the operation of the Bill, as set out in new clause 14. Amendment 500 sets out the information that must be included in the form of a final statement, which is to be set out in regulations in accordance with amendment 214.

The effect of amendment 439 would be to introduce a new requirement for the relevant body, defined as either the co-ordinating doctor or the person’s GP practice, to provide full medical records, court records and all documentation related to assessments and procedures relating to bringing about the death of the person in accordance with the Bill to the chief medical officer and the voluntary assisted dying commissioner. The amendment is broad, and it is not clear whether doctors would be able to comply with the duties fully.

For example, GPs do not normally have access to court records, and would need to request them to provide them to the chief medical officer and the commissioner. Currently, a decision to share court records is made at the discretion of the judiciary in most cases. As such, any statutory burden to disclose court records agreed by both Houses would require consultation with the independent judiciary. Depending on the type of record, there could also be data protection considerations.

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

Rebecca Paul Excerpts

Committee stage
Wednesday 19th March 2025 Public Bill Committees

[Lewis Atkinson (Sunderland Central) (Lab)]

It is a pleasure to serve under your chairmanship, Ms McVey, fortified as I am now with a touch of breakfast.

I wish to open my comments on this set of amendments by reiterating the importance of respecting people’s beliefs in healthcare and the contribution that people of different faiths, beliefs and positions make, no matter where they come from, in the context of the activities under the Bill.

I accept and recognise that amendment 480, in the name of the hon. Member for East Wiltshire, would do an important job in strengthening the Bill’s provisions. I obviously want to hear what the Minister says, and I note the comments from my hon. Friend the Member for Spen Valley, but I would want to see this sort of expansion in the final Bill when it goes back to the House. If they may not be the exact right words today, I repeat the offer that my hon. Friend has made to work across the divide, as it were, to ensure that such provisions are included in the Bill.

With the benefit of an overnight reflection, I feel that last night we got somewhat muddled around some of the objections on conscience, particularly when we go beyond the individual. Amendment 480 and equivalent amendments deal very clearly with individuals not having an obligation to carry out acts that would offend their conscience in the provision of these services. I think we can broadly agree on that. The remainder of the debate got rather muddled between organisations providing assistance under the Bill and the locations at which the final act of an assisted death may take place. I think those are importantly different.

On organisations providing assistance, I want to reset things with a common-sense approach to how it will work in practice. The hon. Member for Reigate made the point that hospices should be under no obligation as organisations to provide specific services. I agree. The powers set out under clause 32 for the Secretary of State to make arrangements for the provision of these services, which we will come on to debate at some point, will operate as they do elsewhere across the health service. An NHS organisation or another organisation will say, “This is the set of services that we provide as an organisation.” I see nothing in this Bill that will compel them to do anything other than that. Healthcare organisations up and down the land now make decisions about what is appropriate for them to deliver, based on skills, expertise and demand and whether they think they are well placed to provide care.

I agree with the hon. Member for Reigate, but it does not follow that the amendments are required to enforce that principle. As I understand it, because it is permissible, every organisation and every individual practising healthcare professional will be able to say, “On my own bat, I’m not going to participate in this, regardless of what my employer believes,” not least because of clinical governance and regulation. There is already a strong body of healthcare regulation around the acts and services that are provided. It is currently overseen by the Care Quality Commission. We do not need to reinvent that regime.

I reassure Members that I think it entirely appropriate for hospices or other providers of palliative care to consider whether they want to participate, should the Bill become law. I imagine we will get to a situation in which some will and some will not, which is absolutely appropriate. Particularly in end-of-life cases, a patient will make a choice on the back of that. I am aware that some end-of-life care providers in my area are actively considering whether this is something that they will do; I am equally aware that there are others that think it is not for them. We heard in evidence that in Australia some providers of palliative care provide integrated, holistic care in which it is one of a number of options, whereas other providers do not.

Amendment 481 would insert a new subsection (3)(a) into clause 23, which suggests that an employer has the power to veto an employee doing an act on their time. That is moot: it is not necessary. In the healthcare environments in which I have worked, a doctor may practise elsewhere, doing their own thing, but while they are employed in a certain NHS trust to do an NHS service, they cannot suddenly decide to do something else.

[Rebecca Paul (Reigate) (Con)]

The hon. Member is giving a powerful speech. My amendment is only to ensure that if the employee is working in an NHS clinic, they comply with the policy of that clinic. It would not restrict their doing other things in their own time. The wording of the amendment is clear, as I discussed with the hon. Member for Spen Valley yesterday, that it is just while the employee is performing services for the employer.

[Lewis Atkinson]

I agree that that is what the wording says, but my point is that it is moot. The hon. Lady herself states that the amendment is to prevent an employee from going against the policies of the employer. That power already exists. No healthcare professional says, “Even though I’m employed as a doctor today by such and such a trust, I’m going to do a set of procedures or practices that I want to do.” It is moot.

I have no issue with subsection (3)(a) in amendment 481, although I think it is unnecessary. However, I think subsection (3)(b) is deeply problematic. It cuts across employment law protections by referring to selection when hiring employees. There is a reference to the Equality Act, but as others have noted, it is not clear what protected characteristics we are talking about. At a deeper level, if we accept that there is going to be mixed provision, I would argue—and I think this Committee, in a small way, has shown this—that there is some benefit to that. We should not get to a position where every medic of a certain viewpoint on assisted dying works for one organisation and every healthcare professional of a different viewpoint works for another.

That is not to say, by any stretch, that organisations would be forced to offer assisted dying. Clearly they would not. If the Bill becomes law, however, I want a society that is relatively at peace with it in healthcare, recognising people’s ability to conscientiously object as individuals. Setting up a dichotomy from the start, in which where a medic decides to work is determined by their views on such and such a procedure, is not a road that we should go down. I also have serious concerns, in terms of employment law, about subsection (3)(b).

[Rebecca Paul]

The amendment is simply to prevent a discrimination case. Let us take another example. A rape refuge may provide services to women who have suffered sexual abuse; it may be appropriate, in that instance, to hire only women to support those domestic abuse survivors. In order to prevent a discrimination claim when hiring, we have to rely on the Equality Act and the exemptions carved out. All my amendment says is that the same exemption would apply when a hospice or clinic is employing. It is just to avoid those issues down the road.

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[Naz Shah]

I thank my hon. Friend for her intervention, which gives me a lot to think about. That is why I said that I genuinely do not have the answers. I want to have this discussion so that I can make the choice whether to support the amendments. I want to explore this issue further, because it is really important.

[Rebecca Paul]

The conversation has moved on a little, but I was just going to make the point that the amendments that I tabled focus very much on the rights of the employer with respect to what they expect from their staff. I wonder whether it would be helpful to explore that a bit more.

[Naz Shah]

If we are talking about employers and employees, not people who are accessing the service as service users, I hope the scenario to which my hon. Friend the Member for Penistone and Stocksbridge referred would not happen.

--- Later in debate ---

[Kim Leadbeater]

The right hon. Gentleman makes an important point. The word that we have used a lot—maybe not enough in some respects—is choice. That is important for individuals, but it is important for institutions as well. Putting an institutional opt-out in the Bill would risk creating confusion and distress for patients and their loved ones, and indeed for staff and volunteers.

[Rebecca Paul]

Does the hon. Lady have any concerns about what this position would mean for the end of life workforce? I know we are here to make law, but we cannot ignore the practical consequences for end of life care. If we do not have this carve-out, we could lose a lot of wonderful and great people who work in end of life care and who feel that they are not able to participate, if the hospice cannot specify.

[Kim Leadbeater]

The hon. Lady is absolutely right to acknowledge the wonderful workforce working in end of life care, but there is a range of views within that workforce and there is the individual opt-out. No one has to be involved in this process if they do not want to be. That is clear in the Bill as it stands. I hope that, working together, we can make that even clearer if needed.

Under the Bill, doctors and health professionals already have the ability to opt out for any reason, wherever they work.

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

Rebecca Paul Excerpts

Committee stage
Wednesday 19th March 2025 Public Bill Committees

[Kim Leadbeater]

These amendments relate to criminal liability under the Bill. They get to the heart of why the legislation is needed. Amendment 504 seeks to clarify the language of clause 24 and provide reassurance that it will not be considered an offence to perform a function under the provisions of the Bill or to assist a person seeking to end their own life in connection with anything done under the Bill. It will ensure that those acting within the law, and with compassion, to assist terminally ill individuals who wish to end their suffering and take control at the end of their life are protected under the law.

Amendment 505 ensures that the provisions of the Terminally Ill Adults (End of Life) Act 2025 will supersede the Suicide Act 1961, providing clarity that actions taken under the new Act will not be subject to the outdated legal framework established under the 1961 Act. That is a crucial step in modernising our laws to reflect the values of compassion, dignity and personal autonomy. These amendments bring us closer to a legal framework that is clear and safe.

Our Prime Minister, my right hon. and learned Friend the Member for Holborn and St Pancras (Keir Starmer), the former Director of Public Prosecutions, stated in relation to assisted dying, “The law must reflect the changing moral landscape of society, and in cases such as this, where the individual’s autonomy and suffering are at stake, our legal framework must offer clarity and compassion.” During his tenure as DPP, Sir Keir also emphasised the importance of not criminalising individuals who act out of compassion, particularly in difficult and morally complex situations. He said, “The law must be clear, and it must ensure that those who act with the intention to relieve suffering are not penalised, as long as their actions are in accordance with the law.” That sentiment is echoed in the amendments before us today, which ensure that those who assist individuals under the Bill are protected by law, offering clarity and reassurance to both the public and professionals who may be involved in such decisions.

Sir Max Hill, another former Director of Public Prosecutions, remarked in 2019, “The law around assisted dying is often unclear and creates a great deal of uncertainty for both individuals and healthcare professionals. What we need is a system that balances compassion with protection, ensuring that people who are at their most vulnerable are supported in a way that is both legal and ethical.” Sir Max Hill’s words emphasise the need for clear, compassionate guidance, which these amendments will provide. They will help to eliminate the legal uncertainty that can cause fear and hesitation in those who act in the best interests of individuals facing terminal illness.

The 2010 DPP policy clarified that assisting someone to end their life was not automatically criminal and that each case would be assessed on its individual facts. However, that has not changed the law and many people are still being failed by the law as it stands. These amendments create clarity and prevent ambiguity around what constitutes a criminal act versus an action legally protected by the new law.

I will finish with a very powerful testimony from Louise Shackleton from Scarborough. Louise accompanied her husband to Dignitas last December. I believe she was the first person to make that trip since Second Reading. Louise talks about the trip she made to Switzerland with her husband. She says:

“This is not an easy process as some against Assisted Dying might have you believe, might try and convince you. It is a robust and thorough almost an ordeal in itself. Then there is the cost, not just financially but mentally and physically as he had to be able to get to Zurich and someone had to assist him to do this…My husband did not deserve this to be his end nor did I deserve this to be his end, my last memory of him…I accompanied my husband to Switzerland, where we had 4 wonderful days together, my husband’s mood had lifted, he was at peace, it was as if the weight of the world had been lifted from his shoulders. He was not scared, no anxiety, his emotional suffering had ceased. You cannot imagine unless you see and feel this he was looking forward to his peaceful death, looking forward to leaving his pain, suffering…At the end, my husband was able to die on his own terms, pain-free and peaceful, held in my arms as his heart gently slowed and finally stopped, granting him the dignified and serene farewell that he had wished for. But where was I? alone in a strange country alone, scared, bereft, organising an Uber to take me away from the…Dignitas House, I was vulnerable and in utter shock, now having to leave my dead husband alone, leave his body to be cared for by people I had never met…Due to our draconian laws my husband had to be in a foreign country, had to be cremated to be brought back home. No funeral that he would have chosen, no mourners, no ceremony, cremated with no Reverend to pray for him, returned to me in a cardboard box. The pain is excruciating beyond any other loss I have experienced”.

She then says:

“I have been arrested and spent just under three hours being interviewed by two CID officers. Four days after my husband left my world there I was stuck in a Police station being cautioned, questioned, having to relive my trauma, for my crime, a crime made by love, a crime made by adoration, a crime of compassion and respect of my husband’s last wish.”

She now faces a prolonged police investigation. She tells us,

“My husband was the first British person to go to Dignitas after parliament debated on Friday 29^th Of November 2024. You have the power, the power is yours to be human, to follow Gods wish, to ‘suffer’ choices that other people may make even if its uncomfortable for you. Palliative care I hear you say, My Husband did not want palliative care…Please give others the gift of dignity and a good death in their homes…You have the power to do something amazing, give people the choice.”

I commend these amendments, which will help many people. Sadly, it is too late for Louise, but they will help many other families who will potentially go through what she has been through.

[Rebecca Paul (Reigate) (Con)]

I rise to speak briefly on clause stand part. As I noted a few weeks back—it feels a long time ago—when we debated amendment 82, the clause leaves the law in a strange position. I hope that we will now have the opportunity to explore that and make sure that we are comfortable with the position and have identified whether any changes are needed.

Section 2(1) of the Suicide Act 1961 criminalises both assisting and encouraging suicide:

“A person (‘D’) commits an offence if—

(a) D does an act capable of encouraging or assisting the suicide or attempted suicide of another person, and

(b) D’s act was intended to encourage or assist suicide or an attempt at suicide.”

It is a single offence, but can be committed in two ways: either through assistance or through encouragement.

Clause 24(3), both as drafted and as amended by amendment 505, would make an exception from criminal liability under the Suicide Act, but in respect only of assistance, not of encouragement. It would cover:

“(a) providing assistance to a person to end their own life in accordance with the Terminally Ill Adults (End of Life) Act 2025, or performing any other function under that Act in accordance with that Act, or

(b) assisting a person seeking to end their own life in accordance with that Act, in connection with the doing of anything under that Act.”

In other words, it is strictly limited to assisting suicide. It only covers the actions in the Bill around conducting the preliminary discussion, assessing the applicant, giving the applicant the approved substance and so on. What happens to the other half of section 2 of the Suicide Act: the offence of encouraging suicide? I will not rehash the debates that we had over amendment 82, but I must point out that as that amendment was rejected, the law does not dovetail. Encouragement would still be very much an offence under the Suicide Act, as it has not been excepted under the Bill.

Because my amendment was not agreed to, we will have the absurd situation in which somebody can commit the crime of actively encouraging someone to take their own life, yet that will not be looked for or taken into account when assessing someone’s eligibility for an assisted death. On the flipside, there is a very real risk for families and friends of loved ones who could inadvertently overstep the mark and move from support of a loved one to encouragement. It does not take much imagination to realise that that could lead to accusations and potentially even to prosecution if the law is not sorted and clarified at this stage.

We already know how difficult it has been for family members who want to accompany loved ones to Dignitas but fear that they could face prosecution; the hon. Member for Spen Valley has made that point so eloquently. No one wants that, so it is important that we ensure that the Bill does not create a similar situation in which someone could be unfairly prosecuted for encouragement, which is still very much a crime under the Suicide Act.

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[Sarah Sackman]

Again, it would depend on the actual facts. However, if they were attempting to perform duties under the Bill, it is highly unlikely that, in circumstances where the facts establish and meet the threshold of gross negligence manslaughter, they could be said to have carried out those duties in accordance with the Bill. They might have been carrying out duties that they thought were what the Bill prescribed, but if they have done that in such a way that it amounts to gross negligence manslaughter, then clause 24(1) would not apply.

The hon. Gentleman makes the point about what the pharmacist in that scenario believes they are doing; that belief has to be reasonable, and that is a test that our courts are well used to applying. That is why the amendments introduce the belief that someone is acting in accordance with the Bill. It is not enough that they think they are doing it; it has to be a reasonable belief. That is an objective standard.

[Rebecca Paul]

I thank the Minister for those helpful clarifications. Was any consideration given to also exempting encouragement as an offence under the Suicide Act? I am interested in why it was not exempted in the same way as assistance, particularly given that if it did fall within coercion and pressure—based on what the Minister said—it would get picked up as a criminal offence anyway under the Bill. I appreciate that the Minister will write to me on some of this, but the issue comes back to what is encouragement. As the hon. Member for Spen Valley set out—

[The Chair]

Order. As I have said time after time, if it is a question of receiving clarification, Members should keep their comments short, rather than expanding on them.

[Rebecca Paul]

My apologies, Mr Dowd, but it is a technical point. I think the Minister understands what I am asking.

[Sarah Sackman]

Helpfully, the hon. Member has also set out her questions fully and precisely in a letter to me, so I think I know what she is asking and I will try and answer it as best I can. I reiterate, as I and the Minister for Care have said throughout, that the policy choices have been for the promoter—the Government remain neutral. The offence of encouraging or assisting suicide or attempted suicide in section 2 of the Suicide Act is well established. Encouraging someone to go through the assisted dying process under the Bill with the intention of encouraging suicide or an attempt at suicide would therefore remain a criminal offence under section 2 of the Suicide Act. That is what I made clear earlier.

What we are talking about will always depend on the particular circumstances of the case. It is the Government’s view that in a scenario—I think this is what the hon. Member for Reigate is getting at—where a family member or friend simply suggests to a person with a terminal condition that the option of assisted death under the Bill is something they may wish to consider, and nothing more, it is unlikely—dare I say, inconceivable—that that would amount to an offence under the 1961 Act.

However, if someone encourages a person in a more tangible way, such as encouraging or pressuring them to make the first declaration, that could well amount to an offence under the 1961 Act. Where that encouragement crosses the threshold into what, interpreted in line with their natural meaning, the courts would understand as pressure or coercion, that could amount to an offence under clause 26 of the Bill, which we will come to in due course. I hope that that addresses the hon. Lady’s question. I will set that out to her in writing, and she is welcome to write back if there is any ambiguity.

I hope that that assists the Committee. I am going to sit down before anybody else intervenes.

[The Chair]

May I make an observation? I understand where the hon. Member for Reigate is coming from, but if letters have gone back and forth to the Department and other Committee members are not privy to what they say, the debate gets a little abstract. That is all I am trying to get to—we should not get too abstract, so that everybody knows what is being said.

[Rebecca Paul]

I appreciate that, Mr Dowd, which is why I was elaborating—I wanted to make sure that everyone understood the nature of the question without having seen the letter. In order to summarise, following your instruction, I refer to the letter.

[Kim Leadbeater]

I have nothing further to add.

Amendment 504 agreed to.

Amendment made: 505, in clause 24, page 15, leave out lines 22 and 23 and insert

“—

(a) providing assistance to a person to end their own life in accordance with the Terminally Ill Adults (End of Life) Act 2025, or performing any other function under that Act in accordance with that Act, or

(b) assisting a person seeking to end their own life in accordance with that Act, in connection with the doing of anything under that Act.”.—(Kim Leadbeater.)

This amendment ensures that it is not an offence under the Suicide Act 1961 to perform a function under the Bill, or to assist a person seeking to end their own life, in connection with the doing of anything under the Bill.

Clause 24, as amended, ordered to stand part of the Bill.

Clause 25

Civil liability for providing assistance

--- Later in debate ---

Amendment 509 ensures that prosecution for any offence under this clause can only be initiated by, or with the consent of, the Director of Public Prosecutions. This is an important safeguard, ensuring that prosecutions are handled with the utmost care and consideration. By involving the Director of Public Prosecutions, we make sure that decisions to prosecute are made fairly, consistently and with proper oversight. This also aligns the approach to assisted dying with the principles of prosecutorial discretion seen in the Suicide Act. This will ensure that cases are reviewed for their individual circumstances before a decision to prosecute is made, ensuring that the individual circumstances of the case are assessed based on the case’s merits. The amendments refine and clarify the Bill’s provisions by ensuring that legal terminology is more precise, penalties are more aligned with the seriousness of offences, and stronger oversight mechanisms such as the DPP’s consent for prosecutions are in place. They aim to protect the integrity of the assisted dying system while offering greater accountability, punishment and deterrence against fraudulent or coercive practices.

[Rebecca Paul]

I will be fairly brief. I welcome amendment 508, which would ensure that conviction for the offence leads to a necessarily serious result. However, it is not just the strength of the sentence that we need to think about; there is also a question about how difficult it can be to detect and demonstrate coercion in the first place.

Domestic abuse prosecutions have followed an overall downward trend over the past decade, according to Women’s Aid. A report from the Domestic Abuse Commissioner in January found the criminal justice system unfit to hold abusers to account and safeguard domestic abuse victims. Domestic abuse victims are being failed by the criminal justice system at every stage, from police to probation. Victims seeking safety in justice routinely face a lack of specialist service referrals, poor enforcement of protective orders, court delays and early release of abusers. The commissioner also found that just 5% of police-recorded domestic abuse offences reached conviction and that less than a fifth of victims have the confidence to report to the police in the first place. Within the police workforce itself, only 4% of alleged domestic abuse perpetrators are dismissed.

Women’s Aid says that trust in the criminal justice system is at an all-time low, with domestic abuse survivors not feeling that they will be believed and supported when reporting abuse. That is even more challenging for black and minoritised survivors, who face additional barriers and poor responses when they seek help.

[Kim Leadbeater]

The hon. Lady is making a point that we have already covered several times in the debate. It is an important point, but I hope that she is reassured by the offences to be included in the Bill, which create sentences that do not currently exist.

[Rebecca Paul]

I am absolutely reassured by the hon. Lady’s amendment, and I welcome it, but it is worth drawing attention to the fact that the sentence is important but identifying coercion and pressure can be difficult too.

In written evidence, a social worker called Rose has cast doubt on the workability of the Bill. She was writing when the High Court safeguard was still part of the Bill, so we need to bear that in mind, but what she said applies to the panel too. She wrote that

“based on lived experience…there is no authentic provision mechanism or route that cheaply and swiftly would allow an approved palliative care professional…or social worker to act to protect a vulnerable person under the grounds of coercion….Place yourself in a position of being sick or older, coerced by family for financial gain or by a practitioner wanting to save public costs to pursue assisted suicide, the social worker senses it by body language, a squeezing of their wrist, a sharp silencing look. Can you see a judge saying: ‘the social worker sensed a tension in the air and a look’.

Do you think that would serve to reach the threshold to override a request for assisted suicide in a court of law?

In practice, what would happen would be, the social worker will record her concerns on the system, share them with her manager who will go to her manager who will say we do not have funds to consult legal and your evidence provided does not reach threshold anyway.”

[The Chair]

Order. I am genuinely trying to give as much latitude as possible, but the issue of coercion has come up before. In the context of the offence, I am not sure that this is necessarily pertinent or relevant. Will the hon. Lady bear that in mind during her speech, please?

[Rebecca Paul]

Thank you, Mr Dowd. In that case, I will stop there. I was just making the point that this is important.

Amendment 509 states:

“Proceedings for an offence under this section may be instituted only by or with the consent of the Director of Public Prosecutions.”

I would find it useful to have more clarity around how the offence is used currently, why it is used and why it is appropriate to use it in this instance. Those are all genuine questions. I simply do not know, so I would be grateful for some input. I will leave it there.

[Danny Kruger]

I will be grateful if the Minister or the hon. Member for Spen Valley can explain the situations in which behaviour criminalised by clause 26(2) would not also amount to an offence under section 2 of the Suicide Act, as amended, or indeed to murder. What behaviour would be criminalised here that is not already criminal? Can the hon. Lady think of any instance in which there would be no crime under section 2 of the Suicide Act, but there would be an offence under clause 26(2)? If there is no such instance—I cannot think of one—it strikes me that, at least in respect of coercion and pressure, the offence being created here is redundant and duplicative.

Ministers have rightly stressed the importance of their duty to the statute book. My understanding is that having redundant or duplicative legislation, or indeed duplicative offences, would be inconsistent with our duty to the statute book. One might ask, “What does it matter? Wouldn’t it be helpful to have additional belt-and-braces safeguards in the Bill?” I agree in principle, but I note that when other Members have deployed that argument in relation to adding terms such as “undue influence”, the neutral Ministers have rebuked them by appealing to the duty that we are supposed to have to the statute book. I think the point cuts both ways. Why are we embroidering the statute book with duplicative offences?

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

Rebecca Paul Excerpts

Committee stage
Tuesday 25th March 2025 Public Bill Committees

Hon. Members could argue that, if the assisted dying service was turned over to the charitable sector, it would become underfunded in comparison with other NHS services. However, that argument does not wash because, if the Bill passes, I hope it goes without saying that it would be a state-funded service, fully funded through the taxpayer. I look forward to hearing what the Minister has to say on that because, in the absence of an impact assessment and clarity on what model is being proposed, I have not been able to unpick this in its entirety as I would have liked. We should therefore support amendment 537, tabled by my hon. Friend the Member for Shipley.

[Rebecca Paul (Reigate) (Con)]

It is a pleasure to serve under your chairmanship, Ms McVey. I rise to speak on clause stand part and new clause 36, and in support of amendment 525 and amendment (a) to new clause 36, tabled by my hon. Friend the Member for East Wiltshire. This is a really important debate. The NHS is the greatest achievement of any Labour Government, and maybe even of any Government.

[Danny Kruger]

Steady on!

[Rebecca Paul]

It transformed the quality of life of British citizens at a time of mass unemployment and widespread slums, ensuring free healthcare, in the words of Beveridge, from cradle to grave. The provision of healthcare free at the point of delivery was life-changing and life-prolonging. Although it is far from perfect, we have seen time and time again that as a country we can be very proud of the NHS.

The National Health Service Act 1946 came into effect on 5 July 1948, as a direct consequence of the Beveridge report. Section 1 of the Act states:

“It shall be the duty of the Minister of Health…to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness”.

It was set up to help people to get better and live healthy lives, and to give hope in situations where otherwise there would be despair. It was lifesaving and life-changing. New clause 36 turns all that on its head. Subsection (4) states that:

“Regulations under this section may for example provide that specified references in the National Health Service Act 2006 to the health service continued under section 1(1) of that Act include references to commissioned VAD services.”

If this new clause passes, the founding principles of the NHS will be monumentally changed to include helping eligible people to commit suicide. That is what it does.

I want to be really clear that it is entirely possible to support assisted dying—to want to ensure that a small group of people, whom palliative care cannot help, have that assisted dying option—but not to support this new clause, which forces provision of the service through the same channels as normal healthcare. Assisted dying is not a medical treatment or a healthcare service and accordingly there should be a degree of separation.

We should be incredibly cautious about incorporating the service into the NHS. It will forever change the relationship between doctor and patient, breed mistrust and fear, discourage vulnerable groups from seeking the healthcare they need and fundamentally violate the Hippocratic oath. Dr Catherine Day, a senior partner of a large GP practice in Coventry, states:

“Trust lies at the heart of the doctor patient relationship. I believe this trust will be shattered if patients consider that their GP…may think that they should end their life and stop being a drain on our NHS.”

Siwan Seaman, a palliative care consultant said:

“How could a terminally ill patient trust a doctor if they know that the doctor was prescribing medication to the patient in the next bed in a bay or cubicle with the intention of ending their life. Letting these assessments take place alongside other NHS services will irreversibly impact on patients’ trust in healthcare professionals and negatively impact our therapeutic relationship with patients as doctors.”

[Kim Leadbeater]

If the hon. Lady is saying that she would not want to see assisted dying services within the NHS, then where does she think they would sit? Would she support my hon. Friend the Member for Shipley’s suggestion that this should be done by the voluntary sector and charities, or would she suggest the private sector?

[Rebecca Paul]

It is important that there is a degree of separation, but I would say to the hon. Lady that it would have made more sense for her to put forward a proposal that we could evaluate, assess, and identify the upsides and downsides of. It would be much easier for me to then come up with suggestions. It does not make sense to ask me, “What is the solution and how would you do this?”, and for me to lay out the many different ways that this could be done, without having first laid a proposal in front of me.

[Kim Leadbeater]

There is a clause that I have laid before the hon. Lady—that is what we are discussing. I will come on to that in my comments. Since she is clear that she does not think this sits within the NHS, she must have given consideration to where she thinks it should sit, if it were to come into effect.

[Rebecca Paul]

I will come on to some of that, and it goes back to my belief that there should be a degree of separation. I think it should be separate from normal healthcare services and there are multiple ways that we could do that. I regret that we are not specifically debating the various different options, with a proposal in front of us detailing exactly how it would work. I am assuming, from the new clause put forward, that the proposal is for this to go through the NHS as healthcare; that is the only assumption I can make based on what is in front of me in this Bill, because there is no other detail to give me any other impression.

Sarah Davies, a consultant respiratory physician in north Wales, argues for a separate service so that ordinary NHS care is not associated with assisted dying. She said:

“It is already my experience that patients and their families are anxious about limiting treatment when they are dying. Many people believe that symptom control medication, such as those delivered in a syringe-driver to aid symptom control amount to hastening or bringing on death. This perception can hinder the patient’s acceptance of medications which can afford significant alleviation of distressing symptoms.”

I have raised my concerns about providing an assisted dying service alongside and in conjunction with day-to-day healthcare many times over the last few weeks. I think it is a massive mistake both for patients and healthcare staff. It blurs the lines of what a treatment is, increases the risk of bad decisions and, as we heard so powerfully from Dr Jamilla Hussain, it will discourage some of the most vulnerable groups from seeking essential healthcare. We have received so much evidence and it is really important that we take it on board, so I will be quoting some in my speech.

Dr Green of the BMA said:

“It should be set up through a separate service with a degree of separation. We believe that is important for patients, because it would reassure patients who may be anxious about the service that it would not just be part of their normal care… It would reassure doctors, because doctors who did not want to have any part would not feel that it was part of their normal job, whereas the doctors who wanted to go ahead would be assured of having support, emotional support and proper training.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 45, Q32.]

In oral evidence, Professor Preston argued for a separate system and pointed to the Swiss example. She said:

“In covid, we did research in care homes, and there was real concern about ‘do not resuscitate’ orders and emergency care plans that were blanketed across the care homes. Care home staff were traumatised by that, so there are real issues. We know that there are real issues day to day in how people are treated within the NHS. I think it is unconscious—I do not think people are intending it—but we know that people are treated differently and that different things are done. That is partly why we think a system outside that would protect them, because then you are not within the healthcare team that is treating you and giving you advice about such things”.

She went on to talk about the Swiss system, also being adopted in Germany and Austria, which seeks to

“protect these people by keeping it one step removed”

from normal healthcare. She said:

“Most hospitals in Switzerland will not allow assisted dying to occur, because they do not want a lack of trust in their patient group.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 246, Q317.]

I therefore support amendment 525, tabled by my hon. Friend the Member for East Wiltshire, which would amend clause 32 in order not to allow the provision of the assisted dying service to be done through the health service. That would ensure that much-needed degree of separation. In light of what the Bill’s promoter has said, I recognise that there are different ways to do that; I am very open to those different ways, but I need to see that degree of separation from normal healthcare. I also support new amendment (a) to new clause 36, also tabled by my hon. Friend, which does the same thing.

Let me come to the other amendments in this group. Amendments 537 and 528, tabled by the hon. Members for Shipley and for Richmond Park respectively, are important to debate—we have had some good debate on them this morning—as they raise the different ways of delivering an assisted dying service. I have been listening closely to the points made. Amendment 537 would limit the provision of an assisted death to charities rather than to the NHS, and conversely, amendment 528 would limit provision to public authorities only.

I do not have the answer on the best way to do this, and that is why I regret that a royal commission has not been set up to properly investigate and evaluate all the options and recommend the best way forward. Instead, we are here without all the relevant information and expertise available to us, trying to land on the best way to do it. That is not the way to make such an important decision. I can tell the Committee, however, that—like many others, including my hon. Friend the Member for East Wiltshire—I have huge reservations about delivering such a service through the NHS alongside normal healthcare.

I agree with much of the evidence that has already been cited: there should be a degree of separation. The BMA said that assisted dying could be part of the NHS, but should be outside existing care pathways and separate in some way:

“Our view is that assisted dying should not be part of the standard role of doctors or integrated into existing care pathways—it is not something that a doctor can just add to their usual role… The separate service could take the form of a professional network of specially trained doctors from across the country who have chosen to participate, who come together to receive specialised training, guidance, and both practical and emotional support. They would then provide the service within their own locality—for example, in the patient’s usual hospital, or their home. Or it could be a combination of some specialist centres and an outreach facility.”

In its written evidence, the Royal College of General Practitioners also proposed a separate service:

“The establishment of a separate service which covered every stage of the process would ensure healthcare professionals of multiple disciplines (including GPs) who wanted to do so could still opt in to provide assisted dying, but this would be arranged through a different pathway.”

I agree with both bodies that the service should be separated out in some way. It is now apparent that my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer), whose amendments would have created an assisted dying agency, was on the right track. I regret that the Committee did not explore his ideas in any real detail during our proceedings.

We received important written evidence from Robert Twycross, a pioneer of palliative care who sadly died in October, but had given his friend Ariel Dempsey permission to submit it. Dr Dempsey writes:

“Twycross recommends a de-medicalized model in which AD is a separate service, delivered outside of healthcare practice. He argues for a standalone Department for Assisted Dying, separate from the NHS. He writes, ‘Data indicate that the primary reason for a persistent desire for AD is to relieve distress over a perceived loss of autonomy and to experience a sense of personal control over the circumstances of their dying. These are not medical reasons. Thus, for patients fulfilling the legal criteria, a separate AD service should be established. Indeed, this would be the best way to prevent a corrosive effect on medical practice generally.’ ‘Given the widespread disquiet felt by doctors, a law with minimal medical involvement would be the most equitable.’ He suggests, ‘One way to achieve this would be for [AD] to be delegated to a stand-alone Department for Assisted Dying, completely separate from the NHS and with its own budget. Victoria almost achieves this with its combination of Care Navigators, mandatory training for participating doctors, and a separate Voluntary Assisted Dying Statewide Pharmacy Service.’

Twycross emphasizes that hospice and palliative care must be a ‘sanctuary’ for patients – ‘an assisted dying free zone. Even in the absence of AD, some people decline referral to palliative care despite unrelieved pain and/or other distressing symptoms because they fear they will be “drugged to death”…This unfounded fear will most likely be enhanced if AD is legalized, particularly if palliative care is involved’ and result in an overall increase in suffering.”

--- Later in debate ---

[Dr Opher]

Briefly, the hon. Lady says that only 30% of palliative care is funded by the NHS, but that is quite spurious, because everyone who gives palliative care—all doctor time, palliative care consultants, palliative care departments, all GP services, all district nurses—gives it under the NHS. What she must be talking about is social care, which is obviously very different from medical NHS care.

[Rebecca Paul]

I thank the hon. Member for his intervention. I was quoting written evidence, so I just quoted it, of course, as written.

We should be ashamed if what I have set out is where we end up as a result of this Bill. How would it in any way recognise patient autonomy and give them a real choice? Clearly, it would not. We will end up with patients taking an assisted death because there is no alternative to dying well. If as much effort was put into improving palliative care as has been put into legalising assisted dying, a much greater number of people would be given the dignified, comfortable deaths they rightly deserve. It is a travesty that we find ourselves considering the introduction of assisted dying while hospices are on their knees and patients face a postcode lottery when it comes to receiving adequate end-of-life care. Accordingly, I will vote against new clause 36.

[Lewis Atkinson (Sunderland Central) (Lab)]

It is a pleasure to serve under you this this morning, Ms McVey.

I rise in support of new clause 36, which sets out an entirely workable, appropriate and safe set of provisions for the Secretary of State to ensure that these services are provided across England, as well as appropriate powers for Wales, although I am far from being an expert on those matters.

The new clause would convey powers to the Secretary of State to commission services free at the point of use, in a way that is entirely analogous to the commissioning of other health services that are provided, as we know, by a range of providers.

I came to this place having been an NHS manager for nearly 20 years, and I feel that the debate has sometimes slightly confused elements of commissioning, provision and the way in which the NHS commissions and manages services. My hon. Friend the Member for Banbury said that the state must oversee and regulate the service, and I entirely agree. Commissioning powers sitting with the Secretary of State will ensure that that is the case. The hon. Member for Richmond Park said that the issue is who is commissioning. Again, we are clear that the only person doing any commissioning will be the Secretary of State, potentially delegating this to NHS structures at the time.

The NHS and the Secretary of State are not unused to commissioning highly specialised, sensitive services in this way. Indeed, I would be amazed if the Minister and my hon. Friend the Member for Spen Valley do not confirm that the Government were involved in the drafting of this new clause to ensure that it is equivalent to the other powers that the Secretary of State has.

This will clearly be a specialist service. It is a new service. At high levels of NHS England and equivalent bodies, there is significant expertise and practice in commissioning specialised services. The importance of the commencement period, which I hope we will discuss later today, is that engagement around the exact service specification will be drawn up in just the same way that it would be for a new cancer treatment or a treatment for a rare disease. It is right that the time will be taken to engage on that.

Fundamentally, services have to be commissioned. Some suggest that this will be a free-for-all, that anyone can provide this service and that anyone can be paid for it, but that idea is nonsense. There is no obligation for the Secretary of State to reimburse anyone who decides they want to provide this service. The service must be explicitly commissioned.