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

Sean Woodcock Excerpts

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[Sean Woodcock (Banbury) (Lab)]

I rise to speak in support of amendment 362, tabled by the hon. Member for East Wiltshire, which requires the registered medical practitioner to explain and discuss the nature and the risk of the lethal drugs. There is a bit of a theme to the amendments I have tabled so far: they have almost all been about giving the patient more information. The promoter of the Bill, my hon. Friend the Member for Spen Valley, is quite right in focusing on the importance of the patient’s autonomy. I absolutely believe in and value that autonomy—I am sure everybody across the Committee does so too—but true autonomy is linked to having access to good quality and accurate information. It can severely impact someone’s autonomy if they do not. This Bill states that the person must have an informed wish to end their own life. I believe that this must explicitly include an understanding of the nature of, and the risks of, the lethal drugs involved in assisted dying.

This Bill’s passage through this place has led to lots of conversations and a greater awareness of the issue of death across the country. Morbid as that is, it is a really good, healthy thing that people are talking about end of life—something which we will all encounter—and that is welcome. The debate on assisted dying has made many people concerned about the nature of death and the choice that they might face at the end of their life. Inevitably, for some, the impression has been given that an assisted death uniformly provides a pain-free alternative. I accept that that is absolutely what the promoter of the Bill, and those in support of it, are aiming for—that is not in question—but we have heard from the hon. Member for East Wiltshire about issues with that, and that there have been exceptions in places where such laws have been put in place. I also point to the evidence of James Haslam, a consultant in anaesthesia and intensive care medicine, who put in his written evidence to the Committee that assisted dying

“does not guarantee a painless, peaceful and dignified death.”

The key word there is “guarantee” because, unfortunately, some people who ingest the prescribed lethal drugs do experience distress and complications. In the Netherlands, a high dose of barbiturates is used for all administrations of lethal drugs, and in two thirds of cases—the majority—the person dies within 90 minutes, but a third of cases do take longer and can take up to 30 hours. Complications include difficulty swallowing the whole prescribed dose, vomiting, and in some cases re-emergence from coma. I do not accept that this is an incidental concern. Vomiting affects up to 10% of assisted deaths by oral administration in the Netherlands. There is no easy way to research the efficacy of these drugs on humans given their lethal effects, and as a result there is no regulatory authority in the world that has approved these drugs to be used for this purpose. The data that we have shows that these complications take place in all jurisdictions that have assisted dying. As the hon. Member for East Wiltshire has already mentioned with respect to Oregon, between 2012 and 2022, 11% of the time there were complications.

These complications raise important ethical and medical questions for the doctor and for the terminally ill person. Of course, by the time complications occur, it is too late to discuss or reconsider the person’s options. That is why it is essential that the registered medical practitioner has already explained and discussed with the person the risk and nature of the lethal drugs. Choice is about not simply having options available, but understanding them. That goes to the point I made at the beginning: autonomy is absolutely linked to the quality of the information that someone has been given in order to make that autonomous choice. That requires the registered medical practitioner to explain the full risk and the nature of the possible complications from the lethal drugs.

The General Medical Council sets out five points of guidance for doctors on how they should hold a dialogue with their patients about reaching a decision. Three of the five GMC points are already covered by the Bill, but two are excluded: uncertainties about the diagnosis or prognosis, including options for further investigation; and the potential benefits, risks of harm, uncertainties about and likelihood of success of each option, including the option to take no action.

I can see no good reason why we would not want doctors to be entirely honest with patients who are considering assisted dying, even to the point of saying that the vast majority of people will not have any complications, but there is a chance. Personally, I see no issue with that, or why there should be. Doctors should give their patients that information; not only is that good practice—as we heard from my hon. Friend the Member for Stroud and the hon. Member for Solihull West and Shirley—but, as the GMC guidance makes it clear, they should do so because we should not give people with serious illnesses a false picture of what assisted death means. I link back to the emphasis on the word “guarantee”, as per the written evidence I quoted.

Amendment 362 would affirm the commitment of the Bill’s promoter, my hon. Friend the Member for Spen Valley, to upholding medical standards. It would clarify the full responsibilities of the registered medical practitioner under the General Medical Council guidelines. Perhaps more importantly, it would put the terminally ill person in a better position to understand fully the options available and the associated risks.

In Committee, we have heard frequently that the Bill is about expanding choice and autonomy at the end of life. To act autonomously, terminally ill people need— I emphasise this again—to understand what they are facing as best they can, with the best and most accurate information available to them as early as possible. That is why I support amendment 362, and I urge the Committee to do so, too.

[Naz Shah (Bradford West) (Lab)]

I rise to speak in support of amendments 305 and 306, in the name of my hon. Friend the Member for York Central.

Under amendment 305, a doctor would have to explain what effects the medicines would have as well as death. I appreciate the points made by the hon. Member for Solihull West and Shirley, and what other Members have said about effects and side effects. I would first say: we do not know the side effects. There is no research into any of the drugs being used for the purpose that we are looking at—for assisted suicide, euthanasia or whatever whichever jurisdiction calls it. We therefore cannot give a clear view of what the side effects are; they are largely unknown, as I understand it.

In addition, there are different drugs. My hon. Friend the Member for Stroud mentioned one drug, pentobarbital, which has caused huge concern. I did not know about the issue in Australia, but I know the evidence from death row in America, after Texas started using pento-barbital; there have been huge concerns and lawsuits there. I am happy to be referred to other evidence. In some cases, the effect of the drug has been described as akin to suffocating or even as being waterboarded or drowning.

Concerns have been expressed about the use of such drugs in other jurisdictions. I agree with the hon. Member for East Wiltshire that we should be looking at all such jurisdictions, because this is something new for us. If we are to learn from other jurisdictions where assisted dying has happened and it has been okay for people, whether that is Australia or others, it is equally right that we hear from those jurisdictions where things have not gone right or to plan. That is important.

Clause 9(2)(b) states:

“The assessing doctor must…explain to and discuss with the person being assessed”,

among other things,

“the nature of the substance that might be provided to assist the person to end their own life (including how it will bring about death)”.

Amendment 305 would instead require that the assessing doctor explain to and discuss with the person being assessed the nature of the substance that might be provided to assist the person to end their life, including how it will bring about death and any other effects it would have in addition to death. That is really important.

There are several relevant things that patients should know if they are to be able to make an informed choice. First, they should have as clear an idea as possible what the experience of taking the lethal drug is like. In some countries where people undergo assisted dying, they swallow a cocktail of drugs. Patients whose assisted dying process did not succeed have said that the drugs are bitter tasting. If this is to be the method used in assisted death in this country, applicants should be aware of that, because some people do not take tablets—they just will not do it. If other methods are to be used, doctors should inform patients of what the experience will be like to the best of their knowledge.

The second thing assisted death applicants should know is that they may suffer complications. We know from countries and states that have assisted dying that some patients undergo complications during the process. It has been said before, but I will repeat the point, because it is really important: there can be complications. People may vomit or undergo seizures. One assisted dying recipient took 137 hours to die. That is five days and 17 hours.

We do not know the full number of patients who have died very lengthy deaths in Oregon, because the lethal drugs are self-administered, usually with no doctor present, but just because there is no report saying that things have gone wrong, it does not mean that everything has gone right. Oregon also found that at least nine patients failed to die from lethal drugs. We do not know whether that is the total number—again, because the assisted dying applicants in Oregon self-administer drugs. We can say with certainty that complications exist, although, unfortunately, gaps in the data mean that we do not know how common they are.

Amendment 306 would change the duties of a doctor present during the assisted dying process. Currently, clause 9(2)(c) states that the co-ordinating doctor must discuss with the person

“their wishes in the event of complications arising in connection with the self-administration of an approved substance”.

If the amendment were accepted, the clause would state that the co-ordinating doctor must discuss with the person their wishes in the event of complications arising in connection with the self-administration of an approved substance

“including the escalation of medication intervention”.

This is a point of great importance, both for the person seeking assisted dying and the doctor, who would have to be present for the process. It would mean that the applicant and the doctor would have to think through what they wanted to happen if the applicant did develop complications. Should the doctor at a certain point act to revive an applicant—for example, if the person seemed to be suffering extreme pain as a result of a lethal drug? Alternatively, should the doctor remain as an observer and, if it were clinically possible, someone to administer further pain-relieving drugs? Not doing anything is clearly not an option. Both courses of action might seem harrowing to the person seeking assisted dying, but it is something that they should clearly discuss with the doctor, because these situations could really happen.

There are clearly no easy answers to these questions, but if applicants are to take an informed choice over assisted dying and if we want to provide autonomy, they must know that these questions exist and they must discuss them with their doctors. We have talked a lot about autonomy for people with serious illness. Those people will not have autonomy unless they are informed in accurate detail about the possible outcomes of assisted dying, and these amendments would ensure that.

Ultimately, if someone takes a drug to end their life, they will either die or not die and be left in a compromised state. Are they then escalated to A&E, because leaving them in that state is not an option for any doctor—or does the doctor proceed to administer more drugs? What does the doctor do?

--- Later in debate ---

[Naz Shah]

I thank my hon. Friend for pointing that out, and I will look at it, but that was not my understanding.

There are multiple reasons to oppose new clause 21. With it, the Bill will reduce the impartiality that would have been provided by having a High Court judge rule on applications. It will increase the risk that a large number of decisions are taken by people who are enthusiastic proponents of assisted dying, which will reduce patient safety. It will also create a powerful new commissioner, who will appoint panel members and will then rule on whether they have made the right decision. That same commissioner will also be able to decide whether to overturn a panel’s decision to reject an assisted death application. That is a huge amount of power to put in one person’s hands and we should not do so. I urge hon. Members to reject the new clause.

[Sean Woodcock]

May I say what a privilege it is to have you in the Chair, Mrs Harris? [Laughter.] Clearly, I know how to win and lose an audience.

I rise to speak to amendment (d) to new clause 21, which has been tabled by my hon. Friend the Member for Derby North. I will start by saying how glad I am that the promoter of the Bill, my hon. Friend the Member for Spen Valley, has recognised some of the concerns regarding the multidisciplinary panel, and I welcome the improvements that she has made in the new clause.

I am pleased that the panel “must” now hear from the person to whom the referral relates, whereas previously it was the case that the panel “may” hear from them. That is a partial concession, but an important one. It will allow the commissioner to have greater scrutiny over the application and better assess the person’s eligibility for assisted dying.

Amendment (d) is a technical amendment. We have discussed a number of such amendments before in this Committee, many of which have fallen for reasons that I understand, even if I do not agree with them, including on the basis that doctors are already having these conversations and we do not want to police them. The panel stage is brand new; given that and given the level of public scrutiny of the Bill, I make no apology for supporting putting something into primary legislation to say what is expected of this process. It is very important that we make sure from the off that we get things right.

I am deeply concerned about some of the potential oversights in the panel model. The purpose of the panel is to provide meaningful scrutiny of a person’s application. The panel draws on a wider range of experts to assess the complex aspects of the application, such as assessing for coercion and capacity. However, the panel’s ability to fulfil this scrutinising role is in many ways quite limited.

Amendment (d), which was tabled by my hon. Friend the Member for Derby North, would address the significant oversights in new clause 21. It would introduce a far more comprehensive set of requirements for the panel in its review. Those changes are not barriers to access; rather, the amendment would ensure that the panel has a far wider range of information—a theme to which I referred earlier—on which to review the application for an assisted death. Fundamentally, the amendment would give the panel more tools to conduct meaningful scrutiny.

However, let me list what the panel is not required to do under new clause 21. It does not have to hear from one of the two registered medical practitioners. It will hear from the other registered medical practitioner, perhaps via audio link, but it does not have to question them. Likewise, it will hear from the person, perhaps via audio link, but it does not have to question them. The person may have a proxy to sign their declarations, but the panel does not have to hear from or question the proxy. The panel does not have to hear from or question any other person. Let us be clear who that includes: the panel could assess the person’s application without any information from the person’s relatives, family members, friends, social workers or care workers.

New clause 21 states only that the panel

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

Subsection (4) makes it clear that, whereas paragraphs (a) to (c) require the panel to hear by live audio from the person seeking assisted dying, the evidence that the panel chooses to take from anybody else could be in written form.

Let me draw out with an example what that might mean in practice. A person is diagnosed with a terminal illness—in this case, heart failure arising from coronary heart disease. Both doctors approve the person’s application for assisted dying, on the balance of probability. The person has a physical disability and asks a proxy—a neighbour, say—to sign off the application. The first doctor speaks to the panel via video link restating the schedule forms and providing no new information. The panel then hears from the person, also via video link. It cannot see the person, but after hearing their statement it decides that it is satisfied that the conditions are met and approves the person’s assisted death.

The panel has not spoken to the second doctor and has not put any questions to the second doctor or to the person applying for an assisted death. Incredibly, the panel has not spoken to the proxy, who may just be someone of good standing in the community. Nor has it spoken to the person’s relatives, to anyone standing to benefit from the person’s death or to anyone in the person’s care. Any one of those people could have concerns that the person is being coerced into an assisted death. They may even have evidence of coercive behaviour. However, at no point is the panel required to consider speaking to any of those people.

Time and again, the Committee has heard from experts that coercion and controlling behaviour can be extremely difficult to detect. Often, the person will not reveal that they are suffering from that form of coercion, yet it is often those who are closest to the sufferer—a close relative, a member of the family or a social worker—who pick up the signals. Any of them could be looking out for the person’s welfare and noticing them becoming more isolated and emotionally manipulated by another. At no point, however, does the panel have to consider hearing from that person. If this Bill is going to do everything to safeguard against the risk of coercion, as everybody on this Committee believes it should, that should change.

The panel must consider listening to the people closest to the person. Amendment (d) to new clause 21, in the name of my hon. Friend the Member for Derby North, would address those flaws by giving the panel a higher standard of scrutiny. The panel would have to hear from and question both doctors. It would have to question the person, not simply hear from them. If the person has a proxy, as under clause 15, the panel would have to hear from and question that proxy. Crucially, the panel would have to consider hearing from and questioning persons properly interested, and any other person who has provided treatment or care for the person being assessed in relation to that person’s terminal illness. It would also be able to hear from and question any other person whom new clause 21 states can be asked to report to the panel.

The changes in the amendment would significantly improve the scrutiny provided by the multidisciplinary panel. It would provider a broader range and greater detail of evidence for the panel to base its review on. Ultimately, it would make the multidisciplinary review far more meaningful. Why is this greater scrutiny necessary? This is about protecting the vulnerable people who are easily forgotten. The amendment seeks to provide the strongest possible protection for them. This robust and comprehensive scrutiny is necessary to have a better chance of preventing the worst abuses.

I foresee one possible criticism from some hon. Members, which is that the amendment would slow down the decision-making process for people who are at no risk of coercion. That may well be true, but if the amendment is accepted, the panel would have to question both doctors, not just hear from one, and it would have to determine whether to hear from and question other people. In straightforward cases, in which the panel discovers no initial evidence that disquiets it, a small amount of time might be added to the hearing; in cases in which the panel finds evidence that means it may need to dig deeper, there could be a greater delay to the decision.

Personally, I do not see how we can avoid that. If we are serious about having safeguards to protect the most vulnerable, we should and must accept it. The process of vetting applications will take more time on average, and a lot more time in some cases, but the alternative is a simpler and faster system in which it will be much harder for the panel to detect coercion and other disqualifying factors. In that case, the chances will be higher that some coercive or abusive people will find it possible to push people towards an assisted death. Such a system is what we see in new clause 21, as drafted. We face an inescapable trade-off. We cannot lift protection for those who are most vulnerable to coercion because it would make the process easier for people who do not face that risk. I urge hon. Members seriously to consider supporting the amendment.

[Sarah Green]

I rise to speak to two aspects of this group of amendments. The first is the inclusion of social workers. When we first started receiving written evidence, I found the submissions from social workers the most compelling. I agreed with them that their profession has a key role to play in the process. I am pleased that they will feature on the panel: I believe that that will strengthen the safeguards in the Bill.

My second point relates to amendment (a) to new schedule 2, in the name of the right hon. Member for Dwyfor Meirionnydd. I was fortunate to grow up in a Welsh-speaking part of rural north Wales. I am a Welsh speaker, and Welsh is the first language of some of my friends, my neighbours and my family members. It is the language that they dream in, the language they count in and the language that they are most comfortable using, so when it comes to end-of-life conversations it is important that they can use the language in which they are most proficient and fluent.

Should an individual choose to access an assisted death through the medium of Welsh, they should be able to do so without the use of an interpreter. Crucially for the panel, that means that where an individual has chosen that route, the panel will need Welsh proficiency. Welsh speakers have had the right to ask for services in Welsh for years now, so assisted dying should be no different. That is why services in Welsh need to be on the face of the Bill. I wholeheartedly support the amendment and will vote for it if the right hon. Member chooses to press it.