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

Rebecca Paul Excerpts

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[Stephen Kinnock]

I think we are all moving in a direction where, if this Bill passes, we would like its delivery in England and Wales to be compatible, based on full respect for the devolution settlement and for the legislative consent motions. Divergence in the context of the devolution settlement is what the right hon. Lady is keen to achieve, and I think she is working with my hon. Friend the Member for Spen Valley to achieve that aim.

Amendment (b) to new clause 36 would provide that the Secretary of State must, by regulations, make arrangements for the provision of assisted dying services in England. The amendment would remove the provision that regulations under new clause 36 may provide that specified references to the health service in the NHS Act include reference to commissioned assisted dying services. Secondly, it removes subsection (5), which states that regulations under new clause 36

“must provide that section 1(4) of”

the NHS Act

“applies in relation to commissioned VAD services”,

which provides that health services must be free of charge unless exceptions apply. Finally, amendment (b) to new clause 36 explicitly provides that regulations made under subsection (1)

“may not amend, modify or repeal section 1 of the National Health Service Act 2006.”

If accepted, the proposed amendment may impact the provision of assisted dying services through the health service in England. The effect would be that section 1 of the NHS Act could not be amended, modified or repealed via regulations under new clause 36(1). The proposed amendment applies only to England, and the restriction does not apply to Welsh Ministers. This could result in a divergence between England and Wales in the provision of assisted dying services, as Welsh Ministers could amend section 1 of the National Health Service (Wales) Act 2006.

Amendment (c) to new clause 36 would limit the scope of the Secretary of State’s power in subsection (1) of new clause 36 to make regulations that secure arrangements for the provision of voluntary assisted dying services in England. Under this amendment, such regulations cannot authorise the provision of assistance by a body other than a public authority, even if that body is contracted by a public authority to do so. That would effectively prevent the NHS from contracting with private providers to provide assistance. The NHS regularly contracts private providers to provide NHS services. It is possible that being unable to do so here may present operational challenges. The amendment applies only to England, and the restriction does not apply to Welsh Ministers. That could result in a divergence between England and Wales in the provision of voluntary assisted dying services.

Amendment (d) to new clause 36 seeks to limit the Secretary of State’s power to amend, revoke or repeal other legislation for the purpose of making provision for assisted dying services.

[Rebecca Paul (Reigate) (Con)]

I am sorry to backtrack slightly, but I want to clarify that the Isle of Man is a Crown dependency and not part of the UK.

[Stephen Kinnock]

The hon. Member is absolutely right that it is a different situation from the point of view of devolution. Perhaps my answer was conditioned by the intervention of the right hon. Member for Dwyfor Meirionnydd, so I perhaps jumped to a conclusion.

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[Kim Leadbeater]

The purpose of these amendments is to enhance the effectiveness and efficiency of the notification process within the context of the Bill and to ensure that the commissioner, who plays a key role in monitoring and reporting, receives the necessary information to fulfil their duties effectively. The amendments will empower the Secretary of State to make regulations that require registered medical practitioners to notify the commissioner of any events specified. This change is a critical step towards centralising the notification process and will ensure that the commissioner is directly involved in overseeing these events in a manner that supports the broader goals of the Bill.

Under the amendments, the Secretary of State will have the authority to make regulations that require medical practitioners to notify the commissioner and that grant the commissioner the power to request information. They are designed to enhance the commissioner’s ability to effectively monitor the operations of the Bill.

New clauses 38 and 39 are designed to facilitate the proper and secure exchange of information between the commissioner, various regulatory bodies and the Secretary of State in relation to the voluntary assisted dying framework. These provisions are critical to ensuring that the operation of the Bill is transparent, effective and within a secure, legally compliant framework.

New clause 38 seeks to create a structured system for the exchange of information between the commissioner and key bodies involved in healthcare regulation and oversight. This is an essential provision to ensure that all relevant parties can co-operate in the administration of the Bill and that the commissioner has access to the necessary data to fulfil their duties effectively.

New clause 39 addresses a critical issue regarding the disclosure of information under the Bill. It will ensure that information can be shared as required without compromising data protection laws or breaching confidentiality obligations; it seeks to ensure that while the Bill facilitates necessary data sharing, it will not override the existing protections for privacy and confidentiality. That is crucial both for the professionals and for the individuals involved in the processes established by the Bill.

New clauses 38 and 39 will ensure that the voluntary assisted dying commissioner can effectively share information with key bodies while maintaining strict adherence to confidentiality and data protection laws.

[Rebecca Paul]

I rise to speak briefly to amendments 172 and 173, in my name, but amendment 172 will fall if amendment 539 is voted through. The point of amendment 172 is to ensure that the commissioner has adequate data about important events. It turns a “may” into a “must”. It means that the Secretary of State must issue regulations requiring a doctor to notify the chief medical officer, or the commissioner as in all likelihood it will be, of any notifiable event.

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[Kim Leadbeater]

I will double-check, but I am pretty confident that those reporting mechanisms are covered elsewhere in the Bill. I am very happy to confirm, but I think they are covered in clauses 7 and 8.

[Rebecca Paul]

It would be reassuring if that were the case because such data can be very useful. By making sure we get into the routine of providing it, it is there if we ever need it.

Amendment 173 provides that any regulations under the clause must be made under the affirmative rather than the negative statutory instrument procedure. In the interests of using our time well, I will not repeat the arguments that were made last week on this. However, if amendment 539 is accepted, the Bill will again defer a lot to ministerial powers and non-binding guidance and codes of practice. Under the negative procedure, Parliament is reduced to watching rather than properly participating in the decision-making process.

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[Rebecca Paul]

It is a pleasure to serve under your chairmanship, Sir Roger. I rise to speak about amendments 518 and 520. As we have said, it is important that we understand what coercion means in a legal sense, and I am really grateful to the hon. Member for Penistone and Stocksbridge for trying to set that out, because it is not an easy task. Like her, I am concerned that defining it in this way may make it harder to prove coercion and may undermine the safeguards in the Bill.

Under the amendments, the assessing doctors and the panel are meant to look not just for evidence of coercion but for evidence of intent to induce assisted suicide, and they will have to show that the applicant is requesting assisted suicide against their will. That could make the law powerless against many kinds of behaviour that we want to prohibit.

To start with the point about intent, coercion and pressure take many forms, and they do not always involve a clear intent. Amendment (b) to amendment 518 and amendment (b) to amendment 520, in the name of the hon. Member for Lowestoft, very reasonably draw attention to family relationships. On Second Reading, the right hon. Member for Hackney North and Stoke Newington (Ms Abbott) said:

“people do not generally write letters to sick relatives urging them to consider assisted suicide and then put those letters on file. Coercion in the family context can be about not what you say but what you do not say—the long, meaningful pause.”—[Official Report, 29 November 2024; Vol. 757, c. 1030.]

But even in more blatant cases, we cannot necessarily prove intent directed towards assisted suicide. Sue Smith, a clinical psychologist, said in written evidence that coercive control often ramps up when the abused partner receives a cancer diagnosis:

“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…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.”

That could be seen as coercion towards assisted suicide, but in that scenario does the abusive partner demonstrate clear intent? I am not sure the doctor or panel could demonstrate that in that instance, especially as they need to be satisfied only on the balance of probabilities that there is no coercion. If the panel think that there is a 45% chance that there is intent, but no more than that, they have to grant the application.

The harrowing story of Ryan Wellings and Kiena Dawes shows that even when coercion can be proved, proving that an abuser intends someone else’s suicide is a completely different matter. After Kiena Dawes took her own life, Wellings was convicted of coercive control and assault. The judge told him:

“from May 2020 until her death you abused, assaulted, exploited, controlled and demeaned her. When she died it is clear that she had begun to believe your lies to the effect that she was deranged, physically disgusting, friendless, worthless and an unfit mother. You had persuaded her that she had no one to turn to.”

Before her death, Dawes wrote a note saying, “Ryan Wellings killed me.” Although he was convicted on other counts, Wellings was acquitted of manslaughter. That demonstrates that coercive control, even if it is followed by suicide, does not always mean that intent can be demonstrated. It is really tricky.

Similarly, people may pressurise a relative without intending to override their will. The barrister Ruth Hughes KC, who has been quoted before, said:

“It is surprisingly easy for a relative, whilst completing a variation on ‘the classic asset strip’, to persuade themselves that they are actually acting in their aunt Dorothy’s best interests or in accordance with her wishes”.

In other words, someone can pressurise a relative into assisted suicide without intending to. Again, including intent here could actually muddy the waters.

I have a similar concern about the phrase

“against that other person’s will”.

That sounds very straightforward, but in practice it can be much less clear. Part of the effect of coercion is that people lose confidence in their own will and adopt that of others. In written evidence, many frontline workers pointed out that coercion does not always clearly appear as someone acting against their will. Janet Reiss, a specialist doctor in palliative care in Wolverhampton, says patients will not

“even necessarily be aware of being coerced”.

Dr Jennifer Hardes Dvorak, a senior lecturer at Canterbury Christ Church University specialising in medical law, states that the Bill

“does not consider how people internalise feelings of coercion and…act on this.”

If someone has internalised a feeling that they would be better off dead, that may be their will, even if we hope we could change it.

Anni Donaldson, a domestic abuse expert at the University of Strathclyde, said:

“Decades of work examining the impact of coercive and controlling behaviour has shown that ‘coercive control’ is not merely persuasion, but a complete change in the perspective of the victim so that she truly believes that she is worthless, a burden to her partner or wider family, and would not be missed should she die…Women are regularly humiliated, demeaned, and told they would be ‘better off dead’, or, that they are a ‘useless mother’, or that the children would be better off without them. This abuse erodes women’s confidence, autonomy, and self-esteem. Cut off from support, women often come to believe these lies, fearing reprisals from their partner if they report the abuse, many choose to tell no one. This long term, relentless, dehumanising process can result in a woman believing that she is ‘disposable’.”

Similarly, the writer and campaigner Sarah Ditum warns that the Bill may not protect

“the patient who, through lengthy cruelty and coercion from a partner or carer, becomes genuinely convinced that she (or sometimes he) is a burden who would be better off dead. Such a person may even refuse treatment, causing a curable disease to become terminal and placing them within the purview of the bill.”

So we might not believe that assisted suicide is in someone’s best interests, but there is no best interest test in the Bill or the amendments—just a reference to the person’s will. If a victim of coercive control truly believes they ought to die, it is not clear how the doctor or the panel can refuse their application, unless coercion can actually be proved, and proving it is not always easy, as we have just discussed.

My hon. Friend the Member for East Wiltshire has tabled amendments to remove the phrase

“against that other person’s will”.

Obviously, that is all academic now, as we are not pressing the amendment to a vote, but I would support doing that, because that phrase does more to narrow the definition than anything else.

On another point, amendments 518 and 520 refer to pressure and coercion from organisations. I do not know exactly what the hon. Member for Penistone and Stocksbridge has in mind with that. I guess an example might be the cases we have heard about in other jurisdictions where a health insurer or provider tells someone that they cannot fund a treatment but can fund assisted dying options. It could be that the hon. Lady had other things in mind there. That would possibly count as pressure under some circumstances, but it would be very hard to show that there was intent on the part of the organisation. It is not clear that the amendments help us to identify and avoid coercion and pressure in that sense.

Before I finish, I would like to point out something else that might be missing from the amendments: it is my favourite topic, the question of undue influence—my apologies to the Justice Minister, because I know we have gone over it a few times.

[Dr Tidball]

Just to put this one to bed, which is where we all need to go at this stage, I did seek advice from those that have worked in this field, and it is not a concept used commonly in the criminal law. It is instead used in the law of equity and would not be as relevant in this context. There were other, sharper elements that could make up this concept of coercion that were better and more well understood in the context of the criminal law.

[Rebecca Paul]

I thank the hon. Lady for that clarification of the information she has been given.

We have gone over the question of undue influence a few times. I promise I will not talk about it for much longer, but it is relevant, which is why I keep raising it. In a judgment that my hon. Friend the Member for Solihull West and Shirley has previously mentioned, Lord Nicholls said that undue influence includes two things. The first is

“overt acts of improper pressure or coercion”.

The second is a kind of influence that

“arises out of a relationship between two persons where one has acquired over another a measure of influence, or ascendancy, of which the ascendant person then takes unfair advantage...The influence one person has over another provides scope for misuse without any specific overt acts of persuasion. The relationship between two individuals may be such that, without more, one of them is disposed to agree a course of action proposed by the other.”

That definition suggests something broader than what is described in amendments 518 and 520, but I take the point that the hon. Member for Penistone and Stocksbridge has just clarified. The amendments suggest that somebody will actively interfere with someone else’s “decision-making autonomy” and have an intention to induce them to do something. But Lord Nicolls’s definition of undue influence is much less dramatic; it just identifies a relationship where one person’s view holds a lot of sway. For the last time—I promise—I would be grateful for the Minister’s view on that. I am sure she will talk through that point and advise on the clarification the hon. Lady has just given.

In conclusion, the amendments are completely well intended. It is helpful that the hon. Lady tabled them and that we have had this debate, and I am grateful to her for that. However, I am inclined to think that they would narrow the definition too much. My preference would be to remain with what we have, subject to the points I have raised many times on undue influence.

[Dr Tidball]

Does the hon. Member agree that it is helpful to have it on record that we have evaluated these concepts from all sides, but determined that putting them in the Bill is not the right thing to do and would be too restrictive at this point?

[Rebecca Paul]

I would not choose to have this specific definition in the Bill. There may well be another definition that I would be more comfortable with, so I cannot rule that out. However, I completely agree with the hon. Lady that this has been a helpful debate, and I really appreciate her tabling the amendments so that we could have it.

[Sarah Sackman]

Bear with me one moment, Sir Roger. I have just had a message, and I want to see whether it is relevant to what I want to say. Forgive me.

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Brought up, and read the First time.

[Rebecca Paul]

I beg to move, That the clause be read a Second time.

The new clause would make the advertising of services by a co-ordinating and/or independent doctor by a person in the course of a business an offence with a sentence of up to two years in prison or a fine or both. As we have discussed previously, we will likely see private provision of assisted dying services, if the Bill is approved. That will create a potentially lucrative opportunity for private businesses, particularly if provision on the NHS is not consistent across the country or is overwhelmed.

“Advertising” means the techniques used to bring attention to a product or service with the aim of presenting it as something a potential customer might need or want. The overarching aim of advertising by a business is to ultimately sell more of a product or service. We must keep that overarching reason in mind when considering the amendment. It would be incredibly inappropriate for such services to be advertised on billboards, public transport or daytime telly, targeting those who may be approaching the end of their life, with ads run repeatedly along with those for stairlifts and life insurance. Such advertising could also undermine our national suicide prevention strategy by normalising suicide in certain situations. It becomes much harder to say to people that suicide is not the answer if we are content to say that it is in certain situations.

I can only imagine some of the difficult conversations that could be generated from an advert seen by a young girl or boy already battling with suicidal thoughts. How does a parent or guardian explain why suicide is not right for them? Imagine the potential impact on men, too. As we all know, suicide is a leading cause of death in men in this country. In 2022, for males between the ages of 20 and 34, one in four deaths was categorised as “intentional self-harm” or “event of undetermined intent”. That is a shocking statistic. That is why banning the advertising of such services is so important.

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

My hon. Friend is making an passionate argument. I think most of us would agree that billboards and television adverts would be egregious. I note that subsection (3) talks about “electronic form”. That could involve email correspondence between parties. How would that not be an advertisement under the amendment?

[Rebecca Paul]

I think we would be talking about an advert via electronic form, marketing a particular service. We would have to go back to the meaning of “advert” to answer that. Obviously, there are broader ways of advertising on social media and so on, which I also seek to prevent with the amendment.

That is why banning the advertising of such services is so important, so that a pro-suicide message is not inadvertently delivered to millions of people who assisted dying is not appropriate for. We have to recognise that there are vulnerable people out there who could be influenced by it. It is my view that conversations about assisted dying should happen in person, between the relevant doctor and the patient; they should not be prompted by a TV ad or something seen on a bus. Ads should not be coming up on someone’s Facebook feed every time they log on.

I hope Committee members will support this common-sense amendment. I think that for it to be properly effective, it needs to be expanded to also cover clinics or other organisations advertising assisted dying services more broadly. I very much welcome the opportunity to work with Ministers and the Bill’s sponsor to get this right, if the Committee is disposed to supporting such an amendment.

[Naz Shah]

Does the hon. Lady agree that banning advertising also mitigates the issue of advertising to young people? She mentioned young people and suicide from a social media perspective. Young people, or anybody else who has an eating disorder, may see that as an option to enable them to qualify for assisted dying. That is because, under the Bill as it stands, they would qualify for it if they were termed terminally ill due to their eating disorder.

[Rebecca Paul]

I completely agree. That is exactly what the amendment is intended to do. We are trying to prevent advertising of an inappropriate service to inappropriate groups. It makes sense, therefore, to effectively ban advertising. I think most people would agree that it would be distasteful and inappropriate to have adverts for assisted dying everywhere people look. I hope that hon. Members will consider supporting the amendment, even if that is in an amended form.

[Lewis Atkinson]

I have great sympathy with the intent behind the amendment, and I would like us to get it into a workable form. The hon. Member for Reigate may wish to confirm this, but there is a similar offence in the Surrogacy Arrangements Act 1985—the advertising of surrogacy arrangements is an offence. The important difference in the Surrogacy Act is that there are some further caveats beyond those in the draft amendment— for example, to ensure that there is not inadvertent creation of offences of the type that the hon. Member for Solihull West and Shirley mentioned. The Surrogacy Act sets out that resulting prosecutions would be carried out only with the approval of the Director of Public Prosecutions, to ensure that such safeguards were in place. Although I await the Minister’s comments, I do not think it is possible to support new clause 9 in its current form, for the reasons that the hon. Gentleman lays out.

We have set out that there will potentially be a small number of doctors providing these services. A GP—not a member of the public—would need to know where to direct their patient. I cannot see how, other than by having some form of electronic directory or email correspondence, it would be possible for such people to become available.

I am not able to vote for the new clause at this stage, but I will put it on my notepad of things on which I am keen to work with colleagues on Report, perhaps by learning the lessons from the surrogacy advice and taking advice from Minister. I think we all agree that we should not be advertising to the general public and encouraging these services.

[Kim Leadbeater]

New clause 9 specifically relates to the advertising of assisted dying services. I fully understand the intent behind it—to prevent the unethical advertising of assisted dying services. I thank the hon. Member for West Worcestershire (Dame Harriett Baldwin) for bringing the issue to the Committee’s attention. However, there are important nuances with the new clause as drafted that need to be addressed, to avoid criminalising individuals or organisations simply for providing information that is essential for those seeking access to those services. I have looked into this issue because it is an important point for the Committee to consider.

Section 4 of the Cancer Act 1939, a useful reference point, bans advertising for cancer treatment. It prevents the advertising of any treatments, regardless of whether they are evidence-based. Similarly, as my hon. Friend the Member for Sunderland Central mentioned, the Surrogacy Arrangements Act 1985 prohibits the advertising of surrogacy services. Both Acts are aimed at protecting individuals from misleading or unethical commercial activity.

The situation with assisted dying is more complex. The new clause is not about advertising unregulated or unproven services; it is actually about doctors who are offering a legal, regulated service to those who meet the criteria. I therefore have the same concerns as the hon. Member for Solihull West and Shirley.

Subsection (3) states:

“Distributing an advertisement includes transmitting it in electronic form, participating in doing so, and providing the means of transmission.”

That is particularly concerning because it could criminalise doctors involved in the process of simply communicating with their patients, such as by sending an email, if they were seen as participating in the distribution of an advert.

The intent is clear: we must prevent the unethical advertising of assisted dying services. However, we must ensure that the new clause does not inadvertently hinder access to legal services by criminalising the actions of doctors who are simply making themselves available in accordance with the law. We must not create barriers for those who need the service, nor should we penalise doctors for providing legitimate, legal services. I recognise the need to prevent the unethical advertising of assisted dying services, especially to avoid commercial exploitation or coercion, but it is essential that we carefully calibrate the clause to ensure that it targets unethical advertising practices without sweeping in legitimate and necessary actions that help people find the care they need in a manner that is lawful and respectful of their autonomy. As such, I am very happy to work with colleagues, including the hon. Member for Reigate, to look at how we can produce something to that effect ahead of Report.

[Rebecca Paul]

I thank everyone for all the very constructive points they made. I completely agree with the points raised; I think some work is needed, but I am pleased that the hon. Member for Spen Valley and other Committee members are willing to work with me and the tabling Member—my hon. Friend the Member for West Worcestershire—to get this measure into a place where it does what we want it to do, without capturing things that we do not want it to capture. I completely take the point on the concern about emails; that is not what we want to capture.

[Kit Malthouse]

My hon. Friend is making a good point, but I want to make a constructive suggestion. It might be worth our having a look at Switzerland, where advertising is actually banned but the provision of information is not. It is a fine line, but the Swiss seem to get the balance right.

[Rebecca Paul]

I thank my right hon. Friend for that point. He is absolutely right that we can learn from what other jurisdictions have done, leverage that and create an amendment or new clause that works for what we are trying to achieve, and know that it will target the advertising that we seek to target.

[The Chair]

Does the hon. Lady wish to press new clause 9 to a division?

[Rebecca Paul]

Given the spirit of it, I feel like we should. That does not prevent me from tabling it on Report—so yes, I will press it to a vote.

Question put, That the clause be read a Second time.

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[Danny Kruger]

I beg to move, That the clause be read a Second time.

This will be my last speech in this Committee, so before I speak to the important principle expressed in new clause 34, may I thank you, Sir Roger, and all your colleagues who have chaired the Committee? I also thank the Clerks, who have done a huge amount of amazing work behind the scenes, and all members of the Committee; I particularly thank the hon. Member for Spen Valley for her good faith and good nature throughout the process. I have great respect for all Committee members. A particular hero was the hon. Member for Southgate and Wood Green, who was the most popular speaker every day. [Laughter.] I am looking forward to his final speech.

I pay tribute to all those hon. Members who did not serve on the Committee but contributed to our debates by tabling amendments; I really am encouraged by many of them. I pay particular tribute to the hon. Member for York Central, who has been a very powerful influence on me and has attempted to do very good work with the Committee. I also wish to mention my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer). Perhaps in sympathy with the hon. Member for Harrogate and Knaresborough, the most liberal member of the Committee, he has attempted to create an assisted dying Bill that does justice to the principles of autonomy behind it.

My new clause reflects my hon. Friend’s conception of the Bill. His amendments would have taken assisted dying out of the NHS, and indeed out of healthcare altogether. He was right to try to do that. If we are to do this thing, we should recognise that what we are proposing to legalise is not healthcare. Indeed, new clause 36 recognises the essential incompatibility between the service proposed here and healthcare as it is traditionally understood in our country and enshrined in the NHS Act.

More than that, the foundations of healthcare in the west are contravened by the Bill. The Hippocratic oath contains the promise:

“Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.”

That is the oath that doctors take, and it has been the ethical basis of medical practice in the west for millennia. The Bill would be the final, official abandonment of that ethical tradition.

I implore the Committee to reflect on the essential principle that healthcare is the antidote to sickness, whereas this proposal for assisted suicide is the antidote to life. That is the treatment that the Bill proposes to legalise. It is entirely different from healthcare, in principle and in practice. It is therefore no surprise that so many of the professional bodies involved in healthcare regard this proposed treatment as incompatible with their professions. The BMA agrees that this should be a separate service.

I was struck by a BMJ article that appeared last November, “Reframing assisted dying through the civil law: possibilities and challenges for the UK”, which was written by a group of palliative care professionals. It sets out how, if assisted dying is to be legalised in this country, it might best be organised and delivered. New clause 34 and all that flows from it would enable us to design a better assisted suicide service than the one that the Bill would give us.

The hon. Member for Spen Valley this morning and the hon. Member for Sunderland Central this afternoon asked how it should be done, if we are to do it. My hon. Friend the Member for Reigate offered some suggestions. I will build on what she said by saying how I think the Bill should have been framed—indeed, how I and others, through the amendments we have tabled, have tried to ensure it is framed.

We have tried to match the Bill to the campaign for assisted suicide. Understandably, there is considerable public support for people at the end of their life, who are at risk of suffering a terrible, agonising death and whom palliative care cannot help, to have the right to end their life a few days or weeks early. We can argue about how many people that is. I think the number of people whom palliative care could not help if we organised our palliative care system properly is infinitesimally small—almost non-existent. However, we disagree on that, so let us assume that there are some people who will fall into that category. The campaign for this Bill is the campaign for those people to have the right to an assisted death, but that is not what we have in the Bill. What we have is a right for anybody who in the opinion of two doctors might reasonably be expected to die within six months to request and receive lethal drugs, all paid for and assisted by the NHS. That is not what the campaign has been for.

Let me suggest how, if we are to be honest to the campaign, we should design this thing: not as healthcare, but as a compassionate suicide service for people facing physical agony at the very end of their life. As we tried to ensure at the beginning of our deliberations, eligibility would be for people fearing pain, not for those feeling a burden. There would be a proper capacity test, not the Mental Capacity Act 2005 test. There would be proper, meaningful safeguards against coercion. We would have doctors and a multidisciplinary team at the right stage of the process: right at the beginning, at the first assessment. We would have all the appropriate signposting and palliative care provision as an alternative to assisted suicide. We would then have a proper judicial process to decide whether to approve the application.

As for provision, from assessment through to the final act it should not be in the NHS. It should not be provided by any profit-making providers advertising their services and receiving money for every death that they assist, which is what we have probably got with the Bill. It should be provided by non-profit organisations, should be tightly regulated and should be funded not through NHS commissioning or by the patients, but by philanthropy.

The scale of all this is to be discovered, I guess, if we pursue the Bill. It has been suggested that the lower end of the expectation is about 6,000 deaths per year. On the calculations made by the experts in the paper I cited, it would need a budget of about £10 million a year to manage a 6,000-person caseload. That is in the ballpark of what the campaign groups promoting the Bill have been spending, so I do not think that there would be any difficulty in raising that sort of money if it is what people want. After all, hospices have to raise millions of pounds every year to fund their work. I do not see why assisted dying services should not be able, and required, to do the same thing.

There was a way to do this more consistently with the campaign for assisted suicide. For the avoidance of doubt, I would have opposed that too, because even that much more honest and tightly circumscribed service would profoundly alter our society—it would send the signal that some people are better off dead, and I think it would be wrong for our country—but at least it would be honest. It would be consistent with the campaign.

I will end with the observation that what I have just described is what I think the public think the Committee is doing: designing a service like that for the small number of people at the very end of their life who are facing a terrible physical death. That is not what we have done, it is not what the Committee has approved, it is not what the original Bill said and it is not what the Bill now says as we send it back to the House. I hope that the public and our colleagues in Parliament will recognise that this Bill is not the one that they thought they were getting.

[Rebecca Paul]

I rise to support new clause 34, which clarifies that assisted dying is not a medical treatment—not only because of the principle behind it, which I have talked a lot about already, but because of the unintended results. We need to recognise that many laws, rules and regulations have been written using the word “treatment” that never envisaged assisted dying being included. Every bit of law that refers to when treatment can be given, with or even without consent, such as section 63 of the Mental Health Act 1983, will become a potential problem if assisted dying is technically viewed as a medical treatment. New clause 34 is therefore essential to protect the meaning and integrity of the current law and to protect patients in future.

In written evidence, Professor David Jones points out that there are dangerous consequences to classifying death as a medical treatment. As a general principle, he observes:

“If an effective medical treatment cannot be self-administered orally then other routes should be considered, including those administered by a healthcare professional.”

We can immediately see the problem that will arise if assisted dying is a treatment. The view that such a treatment can be administered by a healthcare professional suddenly moves us into euthanasia territory, which is clearly not the intention of the Bill. Professor Jones goes on to say:

“If a treatment effectively reduces distressing symptoms in one category of patient (adults at the end of life), then it should be considered for treating other categories of patient”.

If we substitute the word “treatment” with “assisted dying”, we get a wholly unacceptable approach that could open the way to offering assisted dying to under-18s, as in Belgium, or to people whose psychological suffering is unbearable, as we have seen in Belgium and the Netherlands with the euthanasia of people with mental health conditions. Finally, Professor Jones says:

“Where a patient does not have capacity to consent to medical treatment then doctors should provide whatever treatment is ‘of overall benefit’ to the patient.”

If we substitute the same words, we can see that once again it leaves us with a big issue.

The Bill already has requirements relating to capacity, age and physical illness, and a requirement for self-administration, but the point is that by classifying assisted dying as a medical treatment we are making those requirements less stable and introducing the potential for conflict within the existing law. We are inviting future Parliaments to question why they are there in the first place. Why arbitrarily restrict this medical treatment when we do not restrict other treatments in the same way?

If we do not rule out assisted dying as a medical treatment, we are potentially opening the Bill up for challenge by the courts when assisted dying treatment is limited to certain groups. That is one reason why the Association for Palliative Medicine has explicitly backed the principle represented in the new clause. It has said in written evidence that defining death as treatment would be

“contrary to all prior medical practice and public expectation, and laden with risks of unintended consequences.”

The Bill may look set in stone, but the law can easily be amended in future, for instance by amending a major health Bill. What we decide in this Committee could have major consequences in a few years’ time. I urge that we future-proof the Bill now by explicitly declaring in it that assisted dying is not a medical treatment, so that the issues I have set out will not arise at any point.

--- Later in debate ---

[Kim Leadbeater]

We are entering deeply philosophical territory, which is welcome and has happened several times before during the Committee’s proceedings. As ever, the hon. Member for East Wiltshire has raised some interesting points, but my view is that his new clause should not be in the Bill. We all have our views on how we frame assisted dying and choice at the end of life, but I do not think that assisted dying should be defined—or rather not defined—in this way in the Bill.

[Rebecca Paul]

Will the hon. Lady give way?

[The Chair]

The hon. Member for Spen Valley is entitled to respond if she so chooses, but I think she has sat down.