Terminally Ill Adults (End of Life) Bill

Rebecca Paul Excerpts

Friday 16th May 2025 Commons Chamber

[Kim Leadbeater]

I am going to leave it there for now, if I may.

I am conscious that many colleagues wish to speak in this important debate, and I am keen to hear their contributions, so I will conclude my remarks there. I thank colleagues for listening, and I hope they are able to support the amendments in my name today in the interests of strengthening the workability of the Bill and providing greater flexibility and safeguards for patients and professionals.

[Rebecca Paul (Reigate) (Con)]

It is a privilege to speak in this place on such an important Bill. Having been part of the Committee that scrutinised it line by line, and, on some occasions, word by word, for several months earlier this year, it is a pleasure to see so many of my colleagues from Committee Room 10 present today—a reunion of sorts. I am here, as always, with the intention of improving the Bill, so that if it does indeed pass, vulnerable people are as protected as they can possibly be from unintended consequences.

It is important to remember that on Report and Third Reading we are not voting on whether we agree with the principle of assisting someone to end their own life. Our role is to vote on the law in front of us—on whether the words on the page are clear and do what is intended, on whether the statutory process is safe, and ultimately on whether the provision of assisted dying benefits our community.

I am not against assisted dying in principle, but I am against this Bill. I am happy to put it on the record now that I have no personal religious beliefs; I am against the Bill for the simple reason that it will harm far more people than it will help. The people who will be harmed are the most vulnerable in our communities, and I am not willing to accept that collateral damage.

Today is important, because we have the opportunity to improve the safeguards in the Bill so that some of those groups are better protected. I urge Members to take that opportunity to the full. It requires very little skill to draft law that works for 90% of cases, but there is much skill in ensuring that the other 10% is catered for as well. I urge everyone to set the highest standards today and think about how we can ensure that those unordinary and unexpected cases are adequately protected, too. It really is life and death, so please do not accept anything that is not good enough.

[Iqbal Mohamed (Dewsbury and Batley) (Ind)]

Does the hon. Member agree that one of the greatest risks in this Bill is around coercion? It is not just about coercion from family members or friends, but about societal coercion and circumstances. The current state of palliative care in our country is among the worst in the developed world. Without adequate palliative care, patients might feel pressure to go down the assisted dying route instead.

[Rebecca Paul]

I wholeheartedly agree.

There is much to discuss today and there is little time, so I will start at the beginning of the Bill, at the point at which the criteria for eligibility for an assisted death are set. It is there that important safeguards are needed to ensure that those who should never be eligible are excluded. We should not make the mistake of assuming that a doctor will always make the right decision or that they are infallible. It is incumbent on us to put in place law that makes it harder for them to get it wrong—that makes it harder for someone vulnerable to fall between the cracks.

[Mr Perkins]

The hon. Lady has just agreed with a point made by the hon. Member for Dewsbury and Batley (Iqbal Mohamed). Exactly the same point was made when this House voted against the Assisted Dying (No. 2) Bill back in 2015. Would she say that in the nine years after the House voted against the Bill, we saw a golden age in palliative care as a result, or does she think that if we wait for palliative care to be perfect we might never vote in favour of assisted dying?

[Rebecca Paul]

The evidence is clear that palliative care does not get better when assisted dying is introduced; we heard that in the Bill Committee. We should absolutely look to address palliative care, because that will benefit more people. I will come to that point later in my speech, so I will not discuss it any further now. I do not want to get ahead of myself.

There are many helpful amendments in this vein—namely, new clause 16, new clause 9 and amendments 80, 14, 38, 81, 24, 30 and 31. In simple terms, they seek to tighten and refine the eligibility criteria for an assisted death by setting out when and for what reasons an assisted death should be allowed, and by ensuring that those who are vulnerable are protected from something that may not be in their best interests.

Interestingly, on Second Reading the argument put forward for assisted death was that those who are dying should be spared unbearable pain. This is an argument that everyone understands and has full sympathy with. No one in this place wants people to endure pain as they come to the end of their life; I certainly would not want that for my loved ones or indeed for myself when my time comes.

But then the arguments being put forward changed. There was less emphasis on pain, and more on choice and autonomy. The word “autonomy” came up again and again in Committee—and autonomy is important, of course, but up to a point. From a proposal to provide a humane end to someone’s pain when it cannot be relieved in the last months of their life, we have moved to a proposal to provide an assisted death service to those who choose it for any reason, even if the pain can be alleviated by palliative care. This approach, however, comes with a cost to others: family, clinicians and broader society. This really is momentous. There is no going back from such a massive shift. A move to autonomy trumping everything else changes everything.

--- Later in debate ---

[Rebecca Paul]

I thank my right hon. Friend for making that point; he is absolutely right.

I have tabled amendment 80, which would bring the Bill back to its original intentions. It would require that in order to be eligible for an assisted death, the pain and discomfort experienced or expected from a person’s terminal illness could not be reasonably relieved to their satisfaction through palliative care. It seeks to limit assisted death to the very small group of people who may benefit from it, not the larger group who just need adequate palliative care to give them the comfortable, dignified death they deserve.

[Dr Jeevun Sandher (Loughborough) (Lab)]

The hon. Member’s amendment speaks of “severe pain and discomfort”, but there is a reason why the medical profession has not gone for that. How does she propose we assess severe pain and discomfort as opposed to medium pain? Is a fungating wound part of severe pain and discomfort?

[Rebecca Paul]

The key point is that we need to improve palliative care. We are spending so much time and effort focusing on this Bill rather than doing the thing that would actually help more people. My amendment 80, in combination with amendments 30 and 31 tabled by my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer), would drive significant improvements to palliative and end-of-life care, getting us closer to consistent and universally available care for all.

[Anna Dixon (Shipley) (Lab)]

I support the hon. Lady’s amendment. As the Royal College of Psychiatrists pointed out, pain from unresolved physical symptoms and the fear of physical pain or death can make a person want to die, and depression, which is also associated with a wish to die, is often missed. Does she agree that it is vital that people are supported to be free from pain by having access to good palliative and end-of-life care, and that the Bill’s provisions should be available only to those whom that cannot help?

[Rebecca Paul]

I completely concur.

[Jim Shannon]

I commend the hon. Lady for tabling her amendments. Amendments that would have protected palliative care and hospices from facilitating assisted suicide services on their premises for ethical or practical reasons have been rejected, so the Bill leaves hospices with little choice but to comply. It also puts them in a difficult position when it comes to funding. Hospices will also have to provide a staff member to do this work. The problems that will create for palliative care and hospices cannot be ignored. The Bill goes against that right in its totality.

--- Later in debate ---

[Rebecca Paul]

I agree, and I will come to that point in more detail in the second half of my speech.

[Dr Neil Hudson (Epping Forest) (Con)]

With regard to these amendments, we are so blessed to have our precious NHS. At vital stages, the NHS quite rightly delivers care in obstetrics, gynaecology, neonatology and paediatrics, but at the end of life about 70% of care is delivered outside the NHS, largely by charities, and that figure is even higher for children’s palliative and hospice care—so the state pays for how we enter this life, but not for how we depart it. There is something deeply wrong about that for our society. Does my hon. Friend agree that surely we must address that, and the delivery of universal palliative and hospice care, before we go anywhere near the measures in this assisted dying Bill?

[Rebecca Paul]

My hon. Friend makes a good point, and I agree. In the interests of time, I will make some progress.

The current situation, whereby fully funded palliative and end-of-life care is not available in certain postcodes, means that those unfortunate patients do not have a real choice. We know that 25% of people who die in this country do not get the palliative care they need—that is more than 100,000 people a year—and if the Bill goes through, they will be offered a fully funded assisted death as the only reliable way to end their pain. That is no choice. I urge Members who want to see improvements in palliative and end-of-life care to vote for my amendment 80, and for amendments 30 and 31, tabled by my hon. Friend the Member for Runnymede and Weybridge, if they are pushed to a vote.

[Dr Johnson]

Will my hon. Friend give way?

[Rebecca Paul]

I will not because I do not have much time.

I will move on to the lack of a best interests test in the Bill, which my new clause 16 seeks to remedy. Patient autonomy is of course important, but it must be balanced against what is in someone’s best interests. In certain situations, when it is in their best interests, treatment can be given against a patient’s will—for example, force-feeding a young girl with anorexia. It is not an easy balance to get right, but in the absence of any best interests test in the Bill, following the process rigidly would lead to devastating results in some cases.

The Bill currently prioritises autonomy of the patient in a specific moment of time, rather than what might be in their best interests in the long run. It makes no allowance for the fact that someone may feel a certain way temporarily due to other considerations. For example, when someone has just received a terminal diagnosis, it can understandably cause a depressive state and suicidal feelings, but those feelings do not necessarily last, so it may be in the best interests of the patient to allow a little time to pass, to give them a little breathing space before considering the assisted death route.

New clause 16 essentially tries to provide a best interests test by excluding certain reasons, other than the alleviation of pain, that might be driving a patient’s decision. For example, we have heard a great deal about the internal pressure from patients themselves that is driven by their concern not to be a burden, and we heard clearly in Committee that a patient could tell a doctor that they are want an assisted death only for financial reasons, and that would still be approved. We know from the experience of overseas territories that patients will often opt for an assisted death because of social and welfare issues, such as being homeless.

[Paula Barker (Liverpool Wavertree) (Lab)]

Will the hon. Lady give way?

[Rebecca Paul]

I am sorry, but I do not have much time and I wish to get through my points.

How can we be happy with a process that does not exclude such reasons? Instead of providing the support that is actually needed, the state is content to put them on a pathway that leads to their death. I hope that the House will recognise that, whether one supports assisted dying in principle or not, it is morally bankrupt not to have some kind of best interests test to protect those who are not seeking death to alleviate pain from a terminal illness.

Another group that is particularly vulnerable is those with eating disorders. In Chelsea Roff’s oral evidence, she set out that

“at least 60 people around the world have been euthanised or assisted in suicide”

with

“anorexia nervosa listed by name as a terminal condition.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 139, Q175.]

To paraphrase her, these were young women who were not terminally ill and had decades of life ahead of them. It is important to make the point that someone suffering—

[Christine Jardine (Edinburgh West) (LD)]

rose—

[Ellie Chowns (North Herefordshire) (Green)]

rose—

[Rebecca Paul]

I would love to give way, but—

[Mr Speaker]

Order. The hon. Lady has said that she is not going to give way. We are aiming for 15 minutes for each speech, but it is going to be 20 minutes if we do not pick up the pace.

[Rebecca Paul]

I apologise, but I do want to get through my speech.

It is important to make the point that someone suffering with anorexia, or indeed any mental condition, is not intended to be eligible for an assisted death. However, in the case of anorexia there are physical manifestations of the illness, such as malnutrition and diabetes, that might mean the patient meets the definition of being terminally ill, and that is the nub of the problem: the Bill does not adequately rule out physical manifestations caused by mental illness. That is why amendment 14, tabled by the hon. Member for Bradford West (Naz Shah), is so important, because it would ensure that anyone who voluntarily stops eating or drinking is ineligible for assisted dying. I support the amendment strongly as it addresses a big risk.

Lastly, on eligibility specifically, I want to talk about capacity. There are such problems with the current approach to determining capacity that I barely know where to start. When it comes to ending one’s own life, a higher standard should be applied. The current definition of capacity was not created with such a monumental decision in mind, and if it were being drafted from scratch today, it would look very different. That is one of the reasons why the Royal College of Psychiatrists does not support the Bill.

Under the Bill, a person is assumed to have capacity in the first instance. A clinician only needs to be over 50% sure that a person has capacity. If the person is making unwise decisions, that is not taken into account, and a person can be “helped” to make a decision—for example, when a patient has learning disabilities. I ask all Members today whether they are happy with that. Does that sound like a robust approach to assessing whether someone has capacity to make the decision to end their own life?

Let us begin with the starting presumption of capacity. That, too, lacks the standard for assisted death decisions. I therefore support amendment 24, tabled by the hon. Member for Bexleyheath and Crayford (Daniel Francis), which would disapply section 1(2) of the Mental Capacity Act 2005 for the purposes of assisted dying. One of the biggest issues for me is the fact that the current approach requires an impairment or disturbance of the brain in order for someone to be considered not to have capacity, irrespective of whether they can make a decision. In the real world, that would mean a doctor could assess a patient who gives the impression of being confused, illogical, erratic, inconsistent—everything about them could scream that they are not in a good place to make this decision at that point in time—but they would still be considered to have capacity if there is no identifiable impairment or disturbance of their mind or brain. That could potentially put those with depression, anxiety, learning disabilities or eating disorders, or even those just experiencing physical pain that is driving them to distraction, in danger of being considered to have capacity when they do not.

So far I have focused on eligibility. I will now talk about hospices.

[Mr Speaker]

Order. Please, I really want to get as many people in as possible. If you can come to a conclusion, that would be helpful.

[Rebecca Paul]

I will therefore speak to my new clauses 17 and 18, which would provide important protections for hospices, which are currently lacking in the Bill. New clause 18 makes it crystal clear that any regulated care home or hospice can decide whether to provide assisted dying on its premises, and new clause 17 makes it clear that they cannot be subject to any detriment for not providing or permitting assisted deaths, and that their public funding cannot be conditional on their providing this service. Whether one is in favour of assisted dying or not, we must preserve the rights of organisations, companies and charities to choose whether to offer it. They must never be forced into it by public funding being conditional on the provision of assisted dying.

I note that new clause 10, tabled by the hon. Member for Spen Valley (Kim Leadbeater), would expand the protection for individuals not to participate in the assisted dying process if they so wish. It seeks to protect employees from being subjected to any detriment for participating or not participating in the provision of assisted dying. This sensible protection would ensure that if an NHS hospital provides an assisted death service, any member of staff who does not want to participate would not have to do so and would suffer no detriment as a result. However, there needs to be a sensible mechanism balancing that against the employer’s right to set their own policy on assisted dying, and that is what my amendment (a) to new clause 10 seeks to do—we have already talked about that, so I will not go over it again.

I did want to talk about process and family, but it looks like I will not have time to do that. I will end there. I thank you for your patience and generosity, Mr Speaker. I am grateful that I have had the chance to speak in support of the amendments, and I look forward to hearing from other Members.

[Dame Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op)]

I rise to speak to new clauses 1 and 2, which stand in my name, and consequential amendment 2, and I will touch on others at the end. These amendments—without being dismissive of those who helped me draft them—are imperfect. Those of us who are not the promoter of the Bill have not had the support of Government drafters in tidying up the Bill. We need to acknowledge that the Bill in front of us today is the Bill—more or less—that will or will not be passed by this House. For any amendments made, by the point of Third Reading, that is it—there will be no further opportunity to redraft them.

Sadly, one of these amendments was rejected in Committee. If those changes had been discussed before the original Bill was published, or even in evidence before Committee, we would have been in a better place to get that tighter drafting that is needed in making good legislation. We are not a debating society; we are now legislating for a law that would enable the state to assist in people taking their lives. I am sad that we are able to discuss these amendments only now. I did not get the opportunity to be on the Bill Committee, but I commend all Members who spend so many hours discussing and debating those issues.

The ramifications of the clauses I want to talk about are important for potential users of a service, for medical professionals, for families and for other health professionals. The Bill currently allows doctors to suggest assisted dying to a patient who has not raised it themselves. This, I believe—as I know many others do—presents a serious risk that terminally ill patients, already highly vulnerable, will feel pressured to end their lives.