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

Debate between Rebecca Paul and Lewis Atkinson

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[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.

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

Debate between Rebecca Paul and Lewis Atkinson

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[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.

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

Debate between Rebecca Paul and Lewis Atkinson

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.

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

Debate between Rebecca Paul and Lewis Atkinson

Committee stage
Wednesday 12th March 2025 Public Bill Committees

[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.

Terminally Ill Adults (End of Life) Bill (Twenty First sitting)

Debate between Rebecca Paul and Lewis Atkinson

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[Rebecca Paul]

I rise to speak against clause 10 as it allows doctor shopping in the event that someone does not qualify for assisted dying. “Not happy with the verdict? Just find another doctor!” How many times are we happy for a patient to try again with a different doctor? It is inevitable that at some point the patient will find someone willing to make the statement and put them on their way to an assisted death, even if their eligibility is in doubt.

When I put forward the amendments tabled by my hon. Friend the Member for West Worcestershire (Dame Harriett Baldwin), which requested residual discretion for doctors, they were challenged by Committee members on the basis that the whole point of having defined criteria was so that they determined whether a patient was eligible. I run the same argument now: if the process is followed to the hilt and the independent doctor refuses to issue the statement, why on earth would we allow another bite—or even multiple further bites—at the cherry? Surely that is to allow abusers a way to push their victims into an assisted death by re-running the process again and again until they find a less attuned doctor.

Imagine the case of an elderly woman who has spent a lifetime under the coercive control of her husband. She is completely done with it all, and sees death as a welcome way to escape this man, who has made her life a misery. The abuse has escalated since she has become ill: because of her ill health, she cannot cook or clean any more, and he hates that. But no one sees. She never wanted the kids to know; she is really good at hiding it. Now, he wants to seek an assisted death, because it is better for them all. She agrees. When asked by a doctor, she is unlikely to say, “My husband is pressuring me into this, and I’m afraid of not doing what he wants,” particularly if she has suffered abuse over many years.

Let us say that the first independent doctor does a really thorough job—the kind of job that we hope all doctors would do. Perhaps the doctor manages to discern that the patient is very much controlled and unduly influenced by her husband. The trouble is that it can be very difficult to find hard evidence of coercive control. According to recent figures, only 3.7% of recorded cases of controlling or coercive behaviour result in a charge, and more than half of cases are dropped because of evidential difficulties. The doctor therefore cannot get the police to intervene; his only lever is the power to reject the application. So that is what he does. But the patient does not give up; she is still absolutely sure that the best thing is an assisted death, and her abuser is still whispering in her ear, telling her she is right.

The second independent doctor does not have the same emotional intelligence as the first, and he does not see what the first doctor saw. He approves the application.

[Lewis Atkinson]

This is a similar point to the one I made before: amendment 459, which we have just passed, means that, in the scenario that the hon. Lady describes, the second independent doctor will have in their possession the first independent doctor’s concerns about coercion. Does she not agree?

[Rebecca Paul]

I will come to that exact point shortly.

Members of the Committee will recall that I previously tried to get “undue influence” and “encouragement” added to the Bill explicitly to deal with more subtle forms of influence and pressure, as opposed to those that are more obvious to third parties. When objecting to my amendments, the Minister said that they were unnecessary, because “coercion or pressure” already covered them. I hope that the Minister is proven to be correct.

The key point is that those forms of behaviour are not always easily discernible. Dr Mullock told us in oral evidence that

“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.]

These are the very real consequences of this clause, which undermines the independent doctor safeguard. In written evidence, Mr Michael Vidal hits the nail on the head:

“It seems to negate the purpose of having a second opinion if the second opinion can be ignored and a fresh second opinion obtained.”

I recognise and welcome the fact that amendment 459 has been accepted. It would mean that the second independent doctor would have the benefit of the report of the first independent doctor. However, this is not a failsafe protection and cannot be relied on entirely. First, the report of the first independent doctor is required to be made available to the patient. In a case such as this, would the first doctor want to spell out exactly what led to that conclusion, knowing that it could place the patient in harm’s way if her husband saw it? Also, he is not 100% sure; does he want to make such accusations in writing without hard evidence?

Secondly, even if the report was detailed and available to the second independent doctor, he would still need to make his own assessment, and he might not agree. Or it could be that although he recognises signs of coercion over a long period, he may truly believe that, to the best of his knowledge, the decision made by the patient has not been coerced in that moment.

I am afraid therefore that clause 10 is a loophole that will be exploited by domestic abusers, and it is largely women who will pay the price. For that reason, I cannot support it.

[Lewis Atkinson]

I was not going to speak to this clause, but I feel I must rebut some of the points made, which are clearly incorrect. The hon. Member for Reigate asks how many further opinions there will be; the answer is clearly one, because that is what is set out in the Bill. The safeguards in amendment 459 mean that it is not just the second doctor who will be aware of the first doctor’s concerns; any subsequent decision maker will be.

We are about to discuss significant amendments in clause 12. However, whether there is a panel or the decision remains with a High Court judge, it is inconceivable that, when presented with an initial assessment that the criteria are not met and a subsequent assessment that disagrees with it, that third-tier decision maker will not want to explore the issues in detail. I believe that all Committee members are trying to work together in a spirit of genuinely improving the legislation, but our arguments and discussions need to reflect the amendments that we have accepted. Clause 10, as amended, is significantly improved and strengthened. It continues to provide significant safeguards for the Bill, and I am happy to support it.

Amendment 205 agreed to.

Question put, That the clause, as amended, stand part of the Bill.

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

Debate between Rebecca Paul and Lewis Atkinson

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[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.

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

Debate between Rebecca Paul and Lewis Atkinson

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[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.

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

Debate between Rebecca Paul and Lewis Atkinson

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[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.

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

Debate between Rebecca Paul and Lewis Atkinson

Committee stage
Wednesday 29th January 2025 Public Bill Committees

[Rebecca Paul]

Don’t worry. Thank you very much.

[Lewis Atkinson (Sunderland Central) (Lab)]

Q Could I ask Dr Mullock another question? I was interested in what you said about your involvement with citizens’ juries, both here and elsewhere. As we as a Committee and Parliament are weighing up some of these issues, such as the points on autonomy and safeguards, where do you think the public settle on those when they investigate them in depth? In particular, can you say a bit about the eligibility criteria being six months with a terminal illness?

Dr Mullock: I am sorry; what do you mean by how the public settle on them?

--- Later in debate ---

[Lewis Atkinson]

No.

[Rebecca Paul]

Q My question is for Toby Porter, and it is probably quite timely. What are the risks and impact for the hospice sector if assisted dying becomes legal? Can you talk broadly about the implications, touching on the impact on the workforce and patients?

Toby Porter: In England and Wales, there are about 190 hospice charities and probably about 16,000 care staff, who will represent every different opinion on the spectrum. Hospice UK and most hospices have a position of no collective view on whether the law should change.

To summarise three impact areas, the first and most important one—this is why our written evidence stressed the need to sustain the public conversation about death and dying that this debate has started—is that, if people are made more comfortable, there is a real opportunity to talk about death and dying, as well as what services are available for everybody, including those who may want an assisted death. There is a real opportunity to improve palliative care, because most people in palliative and hospice care think that the golden thread is increasing people’s knowledge, ability and willingness to talk about what is happening to them and what services can help them.

Conversely, there is a risk. Modern palliative medicine and hospice care have for 30 or 40 years been working very hard to get people to access palliative care early—as soon as possible after diagnosis of a life-limiting condition. The language of, “I’m going to fight this”, “I’m going to defeat this cancer”, “I’m going to battle” or “I’m stronger than this” shows that we have a whole culture that works against that early access. Even today, people still sometimes associate accessing hospice care with admitting defeat and going too early. If hospices were involved in assisted dying, there is a theoretical risk that that would just reinforce an inaccurate perception about hospice and palliative care: the myth that you are helped along your way by doctors in hospices and hospitals. That is one risk.

More briefly, the second risk relates to the duty of care. What do you need for hospice and palliative care services? You need adequate resourcing, which means staff and finances. In terms of staff, the real fragility in the hospice and palliative care sector is a shortage of clinical staff—that is shared nationally with the NHS and other healthcare providers. You will know from Sarah Cox’s evidence that the majority of palliative care consultants hold views against assisted dying, many of them very strongly. If the consultants felt, for example, that they could not keep their distance from assisted dying in a 12-bed hospice unit in the way they could in an 800-bed hospital, you could very easily see that if this was not done properly and the consultants deserted the hospice sector, you could no longer offer the specialist care that is so important to the Minister, the NHS and every health and social care provider.

Thirdly, at the moment, every hospice operates with not just the consent, but the active financial support of its local community. This is, perfectly legitimately, a controversial issue, and there are very strong feelings on both sides. At the moment, we depend on charity to fund about 65% or 70%. There will be people who would stop funding hospices because they did not offer this service, if it became legal, and there will be people—this has already happened—who would stop funding hospices if they did. Those are the main strategic and operational challenges of the hospice sector. I hope you will think about how they might be mitigated in your deliberations.