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

Simon Opher Excerpts

Committee stage
Tuesday 11th March 2025 Public Bill Committees

Complications have been reported in other jurisdictions as well. In 2019, Washington state stopped reporting data relating to complications, despite multiple complications being reported in the years before then. None the less, complications including regurgitation, seizures and regaining consciousness have all been recorded since implementation in Washington. In 2018, there were eight recorded complications in Washington, all of which were regurgitation as a result of the ingestion of lethal drugs.

[Dr Simon Opher (Stroud) (Lab)]

I thank the hon. Gentleman for tabling amendment 362. Does he accept that Australia, for example, has a very different regime from America? In Australia, people are given pentobarbital, which has not failed on any occasion—in any of the 2,500 treatments since assisted dying was legalised. In America, people are not allowed to use that; instead, they use another cocktail of drugs, which is not as ideal and can have other side effects. May I also say that I am not sure whether it is totally relevant to discuss the problems of a drug given in America in this context? We are discussing just putting down in law what the doctor is obliged to say to the patient.

[Danny Kruger]

I am grateful to the hon. Gentleman for those points because he helps me to direct my argument. It is essential to discuss the evidence from abroad about the complications that arise from assisted suicide, but the evidence is very patchy: we know what we know, but we don’t know much. There is a complete dearth of evidence, including in Australia. When Australians gave evidence to the Committee, it was put to them, accurately, that there is a great lack of adequate data gathering in Australia, as in other countries too. So when he says there have been no complications in Australia, what he means is that there have been no reports of complications in Australia. As we always need to point out, absence of evidence is not evidence of absence.

[Danny Kruger]

Let us not rehash the conversations that we had in the evidence sessions, but I would advise Members to review those conversations. Indeed, there is further publicly available evidence, which I am happy to share, of the problems with data collection in Australia, as in other countries. To the point of the hon. Member for Stroud about the evidence of complications that arise in other jurisdictions being irrelevant to our discussions, because of the lack of clarity in the Bill about what drugs would be used to bring about the assisted suicides that we are proposing to legalise, all we can do is rely on evidence from abroad, and I will insist on doing so.

As well as questions about complications and side effects, there is also a crucial question about how long it takes to die. In Canada, a study demonstrated that in 5% of cases, patients experienced a prolonged time to death. Another study showed that 50% of cases in Canada with available data—again, there is a lack of data—were unsuccessful within 60 minutes. It is clearly common in other countries for death to take up to or more than an hour.

The Canadian Association of MAiD Assessors and Providers—the people who do it—acknowledged that patients who ingest assisted suicide drugs can experience burning, nausea, vomiting and regurgitation. I am not saying that that always happens, or that it happens in the majority of cases, but it clearly happens. It is therefore appropriate for patients to be properly informed of those risks, if they are associated with the drugs that will be used. We do not know what those are going to be at this stage.

In the Netherlands, where assisted dying or assisted suicide has been legal for 20 years, a third of people with assisted suicide deaths experience some adverse symptoms such as pain, restlessness, shortness of breath, secretions, nausea and vomiting—that is, a third of people experienced some of those distressing side effects as they died, so it is very far from a guarantee of a pain-free death. It is vital that people considering an assisted death are aware of those possible effects, in addition to the primary effect of the drugs which is, of course, to kill them.

There is also a question about the method of administration. People should know that where regimes use the intravenous route of a short-acting anaesthetic, that is also not without problems. People would understand, and potentially argue for, having an anaesthetic as the first part of the cocktail of drugs that will be administered, but evidence from abroad demonstrates that the anaesthetic induction agent, which is usually propofol, a drug that puts people to sleep before surgery, can wear off rapidly in some people, particularly in younger patients, those who are less ill and those who are larger in size.

In around two thirds of assisted deaths with administrations that use that technique, that anaesthetic is rapidly followed by a paralysing agent. The patient cannot then move a muscle and, unable to breathe at all, they die of asphyxia. Unfortunately, there has been no monitoring of patients while they are given those drugs to ascertain whether they regain consciousness as they die. They cannot move a muscle, so they cannot signal distress. We are unclear what the experience of the dying person is beneath the apparent calm that has been induced in them by the paralytic drug that they have been given.

We do know, however, that similar combinations have been used in judicial executions. Post mortems have shown, as reported in The Lancet in 2005, that the level of anaesthetic induction agent in the blood at the time of death was lower than that required for surgery in 88% of executed inmates. Shockingly, in 43%, the concentrations were consistent with awareness, meaning they may have suffered during the execution.

[Dr Opher]

The hon. Gentleman is bringing up lots of rather horrible stories about assisted death. That is why, in Australia, Switzerland and Holland, they have decided, instead of using the regime that he is talking about, to use pentobarbital. At 15 grams, that has not had any failures—no one has woken up. The only real side effect that people complain of before they go to sleep, which happens very quickly, is that it is very bitter. One of the reasons why Dignitas uses it is that it is so effective and it does not have those effects. I would push back on some of those scare stories.

[Danny Kruger]

I am afraid to say that the whole debate about assisted dying is replete with scare stories. The hon. Gentleman says that they are descriptions of horrible events, but that is the situation that we are dealing with. We are here to try to pass legislation that is designed to avert horrible deaths. I am absolutely committed to that as well, but the evidence from abroad shows that people can also have a horrible death with assisted dying.

The hon. Gentleman points to Australia, but the evidence from Western Australia in particular is that over 4% of assisted deaths reported complications. He might be right that it is a better regime than that used in the United States, but even there complications occur. We do not know yet what the regime will be here, but I am alerting the Committee to the genuine danger of an assisted dying regime that induces very unpleasant results for patients.

--- Later in debate ---

[Naz Shah]

I completely agree with the hon. Member. He said it much better than I did in response to my hon. Friend the Member for Ipswich, so I thank him for that.

[Dr Opher]

I will be brief, because I think we have discussed this enough. I totally agree with my hon. Friend the Member for Banbury. Patients need to be informed about the procedure—there is no argument about that—and I approve of the first three amendments in this group.

Let me say a bit about data. I met the pharmacist from Australia who is in charge of assisted dying and he had data on 2,500 assisted dying patients. The data is clear: all the patients died—no one survived. Almost everyone immediately goes to sleep, which can be a problem, because if they do not take all the medicine, it causes a slight difficulty that I will explain in a minute. Fifty per cent died within 30 minutes, 70% within an hour and 95% within two hours. One patient survived for 21 hours because she had not taken the full dose because she fell asleep; that is a potential problem. All these things should be described, and are routinely described to patients in Australia.

The first thing, then, is that we have plenty of data. The second thing I want to say is that we are dealing with the end of life. I have sat with patients as they have died; I have sometimes seen people being a little bit sick. We know how to cope with that. We do not need to specify how we cope with someone who is dying, because we have done it many, many times. I do not think amendment 306 will add anything to the Bill because it is part of what doctors do normally.

[Naz Shah]

I am genuinely trying to understand and would like my hon. Friend to clarify. He says that doctors generally do this anyway, but the difference is that, in this instance, somebody has chosen to die. Generally, when doctors do anything they are trying to save patients, are they not? The general rule of thumb is that a doctor saves lives. In this instance, they are not doing that because the patient wants death.

[Dr Opher]

We are not doing that in situations of terminal care—we are allowing someone to die. We are very experienced in allowing people to die. I have done it for 25 years. It is not a new skill just because we have the assisted dying element. We deal with the situation as it arises.

[Danny Kruger]

rose—

[Dr Opher]

I had virtually finished, but I give way.

[Danny Kruger]

The hon. Gentleman puts his finger on a key point. The hon. Member for Bradford West is absolutely right: surely the hon. Gentleman acknowledges that there is a difference between allowing somebody to die and giving them lethal drugs that make them die. I am sure he would acknowledge the practical, if not the moral, distinction between the two. He says he has lots of experience of helping people to die; has he ever had experience of watching somebody die after administering them lethal drugs? No.

[Dr Opher]

No, I have not, because that is currently illegal—this Committee is about changing that—but I have sat with patients who have slowly died. It is not about whether we get an ambulance; we know we do not do that. We are allowing the patient to die, and if something happens that involves having to help them, we just do it. We do not need to specify that in the Bill: it is part of normal medical practice.

[Jack Abbott]

I will be brief, as I have already alluded to my support. I put on the record my support for amendment 93. There has not been a lot of debate on it because it is a fairly straightforward proposal.

There has been a lot of discussion. Members on both sides of the Committee have spoken in defence of the medical profession in respect of huge parts of the Bill, although they should not have to. We have of course seen occasional bad practice, as we do in all professions, but we should take a moment to reflect on the dedication, diligence, hard work and expertise of medical professionals in everything they do. This debate has on occasion almost presented this as a 50:50 choice between good doctors and bad doctors. I think we would all agree that although we want to put in the right safeguards, that is not the case at all.

I have made this point a number of times, but I do not want to accept amendments that spell out all the rules and regulations so that every doctor has to go to the nth degree all the time. As my hon. Friend the Member for Stroud has said eloquently on a number of occasions, it is already in their codes of conduct, working practice, training and everything else. However, on occasion we cannot be satisfied that something is a given. For that reason, particularly in respect of amendments 142, 362 and perhaps 305, if we say that

“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)”

must be discussed, it is not a huge leap to say that we should also spell out how it may be administered and the possible risks and complications that come with that. As I have said, I do not think it will create any unintended consequences. I do not think it puts the full rulebook on the face of the Bill. If we are stipulating how it will bring about the death, it is not a huge leap to also talk about the other side effects.

Cutting through some of the stories, and everything else we have heard this afternoon, we should be considering what the amendments seek to do—what they say on the tin, as it were. We should be asking doctors to have the conversations, although I am absolutely sure that, as my hon. Friend the Member for Stroud said, those conversations will happen naturally anyway. I do not think there is anything harmful in the particular amendments, as we have discussed today.

Finally, on amendment 306, I understand the points that my hon. Friend the Member for Bradford West and the hon. Member for East Wiltshire made. To be totally honest, I fail to see how the amendment satisfies the arguments they were trying to make, as powerful as those arguments are. It does not solve the issue they are looking to solve; I do not think it answers any of those questions. For that reason, I will not support amendment 306, but I am minded to support the other amendments in the group.

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[Danny Kruger]

I am afraid there is a huge degree of subjectivity throughout the Bill, and we are putting an enormous obligation on doctors to use their best judgment. However, I think it is right to stipulate more clearly that it is appropriate, in general, to inform patients’ families. Leaving the vague term “appropriate” essentially implies that it is either/or—that it is a 50:50 choice whether they do so. So it is important to specify that the expectation is that they should do so. Of course, there will be circumstances in which that would not be the right thing to do, but as the amendments make clear, they should explain that clearly if they are not going to do so.

A doctor might hesitate to suggest a discussion with family if they suspect that there are strained relationships within it. My concern is that, without clear guidance, that judgment could be inconsistent or legally challenged. The doctor might know the next of kin and believe that they would try to stop the patient from ending their life. We have heard quite often the concern about the family being some sort of coercive force, trying to prevent people from fulfilling their autonomous choice to end their life, and that we should put in place barriers to stop families trying to dissuade their loved one from assisted suicide. We heard that repeatedly, particularly from the Australian witnesses.

My concern—this goes specifically to certain communities within our country—is that doctors from individualistic cultures, which we have in western Europe and North America, would prioritise personal autonomy. They would deem it inappropriate to suggest family involvement, viewing that as an intrusion on the patient’s rights. We need to state clearly that that is not the expectation and that the expectation is that they should consider involving the family in the discussion.

My concern is also about an exaggerated respect for medical confidentiality. As the Committee knows, my belief is that this is not a healthcare treatment at all, but if it is to be regarded as such, we should not assume that medical confidentiality applies in an absolute sense. There are specific differences between this so-called medical treatment and others, which do justify an override of the assumption of total medical confidentiality. It is therefore appropriate, as in certain other medical procedures, that family members should be involved.

I want to cite the written evidence from Dr Rosemarie Anthony-Pillai, who pointed out that clause 9

“lays bare the reality that in trying to, rightly, diminish any accusation of coercion or family disagreement, this Bill will lead many to a lonely death.”

She also said:

“Families/loved ones finding out only after the event how the person died will have its own bereavement issues that this Bill in no way seeks to consider.”

I also cite the written evidence we had from AtaLoss, which is a UK charity dedicated to ensuring that bereaved people can access support. It said that discovering the decision that somebody has had help to take their own life without prior warning

“can replicate the distress often associated with sudden or suicide-related deaths, thereby intensifying bereavement trauma and potential suicide contagion.”

That is a very significant threat. We will not rehash the argument about whether suicide increases in countries with assisted suicide, but my strong view, from the evidence, is that it does.

In terms of the patient’s safety, if the process is kept secret even from those who know the patient well, the assessing doctors and the panel will be asking very difficult questions about the patient’s feelings and circumstances partly blindfolded. If a patient is in a controlling relationship, they and the person abusing them are not going to volunteer to the doctor or the panel that there is any pressure going on—indeed, the patient may not even understand it to be pressure. It is very common for an abusive partner to try to isolate the victim from their close friends and family. The hon. Member for Ealing Central and Acton (Dr Huq) wrote recently about how this has come up in her constituency. The ex-husband of her constituent’s sister reappeared on the scene, charmed and isolated this woman, and got her to change her will in his favour. That is a technique of coercive control. Some level of required notification to the wider family would make it much harder for a controlling partner to push someone through this process without it being exposed.

It was made clear earlier today that the Bill’s supporters do not want any hard-edged reasons that count as bad reasons to die to be stated in the Bill—they do not want it asked at all why someone wants to have an assisted death. As it stands, the doctors and the panel would have to approve the death as long as it was the patient’s clear, settled and informed wish, but involvement of those who know the patient well might demonstrate that it was not clear, settled or informed. They may have regularly gone through patches of feeling unloved and unsupported all their life, and that could change. That is information that only the wider family would know.

To conclude, there is real suffering hereto—as I have said, nobody exists in a vacuum. I want to reference the opinion of Judge Elósegui in the European Court of Human Rights. Her opinion was a partial dissent in the Mortier case, which has been discussed before. She said:

“it should be underlined that it cannot be said in an exhaustive way that the principle of autonomy always and at all costs has primacy over the other three principles of bioethics. In particular, we must take into account the consequences of our actions on the rest of the family unit and on our circle of friends.”

That is highly relevant. If we see cases where somebody dies by assisted suicide, and the first thing their child or parent knows about it is they are told to come and collect the body, that will be a scandal. That has happened in other countries, and the Mortier case is a case in point.

I mentioned other cases in which it is obligatory to consult and inform family members. At the moment, that is what happens at the Court of Protection with much less serious applications. Practice directive 9B requires doctors to notify

“at least three persons who are likely to have an interest in being notified”.

That is in the case of organ donation and other procedures. Families are required to be notified, and an indicative list is given, which is supposed to be worked through in order—spouses, people who live with as a spouse, parents, children and so on. The authorities are to jump along through that list, again with some discretion given to them.

To end, on the standard guidance referred to in judgments on that procedure, the judgement of Senior Judge Lush in the Court of Human Rights included the observation that the decision not to notify someone who would otherwise be entitled to be notified is not something that just affects the applicant. It is not just about their interests; there is a wider concern for the whole of society and indeed the family. That is why I support the amendment.

[Dr Opher]

I thank my hon. Friend the Member for York Central for tabling the amendment. The crucial word that the hon. Member for East Wiltshire said in all that was “should”. It is really important that people are strongly encouraged to discuss this with their families. Clause 9(2)(f) states that

“in so far as the assessing doctor considers it appropriate, advise the person to consider discussing the request with their next of kin and other persons they are close to.”

I totally support all that the hon. Member said: the family should always be involved in every decision. However, in the way we practice medicine in this country, if a patient has capacity—if they are not under a section under the Mental Health Act, for example, and can show that they have capacity—they can make decisions about their own healthcare. That involves whether they tell their family.

I agree that not to tell the family is not the best thing and not something I would say that the patient should do, but that is in their remit. It is important because, if we change that, we get rid of all the basis and the foundation of medical care and consent in this country. I agree wholeheartedly with the hon. Member, and I am a strong supporter of the family—I also think that in almost every situation the family will be involved—but the patient does not have to tell the family. That must remain part of their decision.

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

I am torn by this amendment. I absolutely accept that it is the right, the autonomy, of an individual to make the decisions and to have confidentiality when making those decisions, but I will touch on a few things that I have said previously.

First, briefly, I hear what the hon. Member for East Wiltshire said about coercion. Secondly, however, there are two other aspects. Let me go back to something I have talked long and hard about, which is learning disability. One amendment has been accepted and I hope more are to come, but given what my hon. Friend the Member for Stroud said, in that scenario, someone might have to be helped by the doctor to make the decision, because of their level of capacity. When I have made the argument throughout our debates, that has never ever been doubted. The person who has been helped to make that decision may have decided, because they are a burden on their elderly parents, that they will not inform them. Again, that was the rationale of where I got to on Second Reading, frankly.

I see people with elderly parents, often now in their 70s or 80s, who have cared for that person throughout their life. As the Bill and the Mental Capacity Act are laid out, that person could go to the doctor to say, “I do not want my parents to know. I hear what you say, doctor, but under this provision of the Act”—clause 9 of the Bill—“I am not going to tell them.” Under the Mental Capacity Act, if the doctor had any queries about the capacity of that person to make those decisions, that doctor would have to assist them in making them. Let us be clear that that is what the Mental Capacity Act 2005 provides for, and that is what the code of practice says.

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

Simon Opher Excerpts

Wednesday 5th March 2025 Public Bill Committees

[Rebecca Paul]

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

[Dr Simon Opher (Stroud) (Lab)]

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

[Rebecca Paul]

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

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

In November, the hon. Member for Stroud said,

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

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

--- Later in debate ---

[Daniel Francis]

Absolutely. This amendment, of course, is widely supported by Committee members for that very reason. As I was saying, we already use that assessment for organ donation, and Members supporting this amendment believe that should be the case for those that are seeking an assisted death.

I now move on to amendment 284, in the name of my hon. Friend the Member for York Central. This amendment would change clause 9(3). Currently, that subsection lays out, and I will quote the language of the Bill, that the assessing doctor,

“(b) may, if they have doubt as to the capacity of the person being assessed, refer the person for assessment by a registered medical practitioner who is registered in the specialism of psychiatry in the Specialist Register kept by the General Medical Council or who otherwise holds qualifications in or has experience of the assessment of capability;”

This amendment would change the word “may” to “must”. In other words, the assessing doctor would have a duty to refer the person being assessed to a consultant psychiatrist if they had any doubt about that person’s capacity. I argue that this is a change that we both should make, and can easily make. If a doctor has doubts about the capacity of an applicant, it is good practice for them to refer that person to a doctor or a specialist in that field.

[Dr Opher]

Could I ask which amendment the hon. Member is talking about? Is it 284 or 6? Amendment 284 says that psychiatric assessment is mandatory in all cases, whereas amendment 6 says it is mandatory if capacity is in doubt. I just wondered which one he was talking about, because I support one and I do not support the other.

[The Chair]

Dr Opher, maybe you want to catch up on the papers and then intervene when you have a question to ask.

[Jake Richards]

I will be brief. I will talk about my amendment 280, which I will not press to a vote. There remains an area that needs more exploring in this legislation—it has come up in debates already, but needs to be looked at further—namely, that a person may have capacity but have other mental health conditions that may impair their judgment. In those circumstances, a more thorough assessment than the two-doctor stage there is at the moment would be right. In reality, that is very likely to happen under the current structure of the Bill. My amendment simply attempts to make sure that it is mandatory. Having had discussions with my hon. Friend the Member for Spen Valley, I know that she is sympathetic to that.

There are amendments in the next group that aim to do the same thing. They, along with my amendment, may not be quite right. I urge the Government to look at this issue and see how we can work together to come to a conclusion, because I think that all members of the Committee would want that. I also support amendment 6, as I think everyone does.

[Dr Opher]

I apologise, Mrs Harris—I have got slightly confused with all the amendments. I do not have a speech that has been prepared for me, or anything like that, but I would like to make some comments. I think this is about the role of psychiatry and capacity, and how we deal that in the Bill. All these amendments reflect that. I would like to concentrate on whether we should actually mandate referral for all patients to a consultant psychiatrist, or adopt amendment 6, which suggests that if one of the two assessing doctors has concerns about either capacity or mental health, they should refer the patient to a psychiatrist. Those are the two choices I think we have here.

--- Later in debate ---

[Danny Kruger]

I appreciate the hon. Member’s point, and it is very logical that it should only be in the case of doubt, but does he not recognise that in the case of organ donation, it is mandatory? If people have this proper assessment when they are giving an organ, why should they not be asked to have one if they propose to give their life?

[Dr Opher]

That is an interesting point, but we are not discussing organ donation, and we are dealing in a different environment here; the patients we are talking about are about to die, and all we are giving them is the right to control the moment and manner of that death. I acknowledge that using a psychiatrist in organ donation has its benefits, but in this service, getting every patient—who, for example, are frail and ill by definition, because they are about to die—to see a psychiatrist is frankly neither applicable nor appropriate.

[Kim Leadbeater]

My hon. Friend makes a powerful point. If we think about some of the people we have met—the families who have lost loved ones to terminal illness and the patients who are terminally ill—they are very clear in their decision. For me, it would be another barrier to those patients, who are dying people, to make them see a psychiatrist for every single case.

[Dr Opher]

I think it would create a barrier. We need to make sure that we deliver legislation that does what we are trying to do, which is to enable someone with a terminal illness, who has full capacity, to make a decision about the end of their life.

[Danny Kruger]

It is a very important point. Yes, we are talking about those people, but we are also talking about a different category of people who have a terminal diagnosis of six months or more, and may only be reasonably expected to die within six months. I am not just talking about people at the very end of their life, who are at death’s door; we are talking about people who qualify for the Bill, which is a much larger category of people, so it is appropriate to require them to do this.

[Dr Opher]

I agree with all of this. I think psychological assessment is incredibly important in all patients, and I personally specialise in it from a primary care basis. But we are suggesting here that the two other doctors have no ability to do any sort of psychological assessment, and that is simply not true.

[Naz Shah]

rose—

[Dr Opher]

I apologise to my hon. Friend; I will continue for a little bit. We use secondary care and psychiatrists when we have a doubt about our decisions. If we have a doubt, then it is entirely appropriate to use psychiatrists in that instance, and we must do so. That is why I approve of amendment 6.

[Kit Malthouse]

As I understand it, I do not think if someone is donating an organ that they do actually have to see a psychiatrist; they have to see somebody who is an appropriately trained assessor from the Human Tissue Authority. To me, that sounds equivalent to the second doctor in our process—someone who is appropriately trained to assess patients and what they need to do. This talk of it having to be a qualified registered psychiatrist, compared with an organ donation, is incorrect.

[Dr Opher]

I completely agree with the right hon. Gentleman. By amending clause 12 to include social workers, who specialise in spotting coercion, there would be a psychological component in that panel. I emphasise that the first two doctors are trained in psychological assessment—they have to be to become a doctor, and we must respect their knowledge and decision making. Psychiatrists will be incredibly useful in difficult cases of capacity, but using them in every case would not be using them in the best capacity.

[Naz Shah]

My hon. Friend is being generous with his time. I do not question the capability of those doctors, but how does that square with the concerns of the Royal College of Psychiatrists that if a doctor has never met the person before, they cannot make an assessment on coercion? That might impact on capacity.

[Dr Opher]

Sorry, could you make that point again? I did not quite understand it.

[The Chair]

No, I am afraid not.

[Dr Opher]

Fair enough. Thank you, Mrs Harris. I was warned yesterday not to take interventions and I should have followed that advice.

[The Chair]

Dr Opher, I remind you yet again that “you” is me, and I have not asked you any questions. It is “my hon. Friend”.

[Dr Opher]

I am grateful that you have not intervened as well, Mrs Harris. You did say that I am allowed to call you “you”.

I will finish on this serious point. Amendment 6 has much power, and we would all agree that if the first or second doctor has doubts, they must—not may—refer to a psychiatrist. Expecting every patient who requests assisted death to have a psychological or psychiatric assessment is simply not necessary, and it would not improve the safety of this Bill.

[Stephen Kinnock]

rose—

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

Simon Opher Excerpts

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Danny Kruger]

It certainly is. Okay, so it could be either. This will be an NHS service, with all the implications for general practice, doctor-patient relations and secondary care and social care, but there will also be an opportunity to deliver it privately, without any clarity or transparency on who is being paid and how.

In answer to my right hon. Friend the Member for North West Hampshire, this is different from cosmetic surgery, as even cosmetic surgery is regulated. In many ways, there is more regulation of the administering of Botox than there is in this Bill. The administering of assisted dying is of a significantly different category and gravity. It is appropriate and important that financial interests are clearly revealed and made public, particularly with the new intervention we are creating. If other hon. Members do not support the amendment, what provisions do they propose that would reveal where there may be potential conflicts of interest and how we may regulate this?

[Dr Simon Opher (Stroud) (Lab)]

I thank the hon. Member for East Wiltshire for the amendment. The set-up of this scheme is similar to other NHS services. Essentially, a medical professional will opt in to provide the service. That will involve extensive training followed by a short exam, as it does in Australia and California, after which they will be accredited under the scheme—that is how I understand it will happen in the UK. No one is forced to provide the service, but training is offered and many doctors take that up. Therefore, it is a medically based service.

The British Medical Association will then negotiate the fee for doing the assessment with the Department of Health and Social Care. That is not about agreeing to provide the service; it is about doing the assessment. That is mirrored in many aspects of general practice, which itself is a private service contracted to the NHS. It is very complicated. It would be inaccurate to portray this as a private service, where people may profiteer, as it is based on medical professionals performing a duty for which they are trained and for which the price is clear to the general public, because it is negotiated and published.

On publishing the number of patients seen by a single doctor and the fees that doctor has accrued from the scheme, that is not something that happens for things like minor operations, which we perform outside general medical services, although we are rewarded by the Government at a set fee. There are other such services—inserting a coil, for example—where we are given a certain amount of money.

How this is arranged is very complicated. Doing appraisals, being a trainer and all these things have a price attached, and we need training before we can perform the service. I see this scheme as no different. The problem with publishing how many patients have been seen by a single doctor regarding assisted dying is that it puts a target on that doctor. As we have seen with abortion clinics and even this Committee—certain Committee members have been targeted by the press for what they have said—this is a very sensitive issue, and it would not be fair to publish the figures so that doctors could be targeted in the press and made to feel unworthy in all those ways. It is extremely difficult.

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

The hon. Gentleman makes a powerful argument about doctors being vilified in the press, but does he believe there is a risk that it may go further and present a genuine safety risk to those doctors?

[Dr Opher]

Exactly. That is what worries me. I acknowledge what the hon. Member for East Wiltshire said about pharmaceutical sponsorship, but I do not think that has anything to do with what we are talking about here. What we are talking about is specifying what doctors are doing as part of their daily job, for which they are trained. It would not be fair to publish those figures and put those doctors at risk.

[Naz Shah]

I appreciate what my hon. Friend is saying, because I have mixed views on this. I would like to understand what would be appropriate. My concern is that there will be a difference, because doctors normally have these set-ups for treatment options but, in this instance, the service is not a treatment, so to speak. I genuinely want to understand: in his eyes, what would a good service that provided scrutiny and accountability look like?

[Dr Opher]

There are examples. Appraising other doctors, for instance, is specified as a job that doctors are trained for, and it is paid at a set rate agreed with the Department of Health and Social Care. There are many instances where this occurs. I totally agree that the fee a doctor attracts for the service should be clearly specified and in the public domain, but I do not agree that a single doctor should be identified as having seen, say, 10 patients who have requested assisted death. I think that is unnecessary, will not lead to increased patient safety and will make it less safe for the medical practitioners too.

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

Simon Opher Excerpts

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Rebecca Paul]

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

[Dr Simon Opher (Stroud) (Lab)]

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

[Rebecca Paul]

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

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

In November, the hon. Member for Stroud said,

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

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

--- Later in debate ---

[Daniel Francis]

Absolutely. This amendment, of course, is widely supported by Committee members for that very reason. As I was saying, we already use that assessment for organ donation, and Members supporting this amendment believe that should be the case for those that are seeking an assisted death.

I now move on to amendment 284, in the name of my hon. Friend the Member for York Central. This amendment would change clause 9(3). Currently, that subsection lays out, and I will quote the language of the Bill, that the assessing doctor,

“(b) may, if they have doubt as to the capacity of the person being assessed, refer the person for assessment by a registered medical practitioner who is registered in the specialism of psychiatry in the Specialist Register kept by the General Medical Council or who otherwise holds qualifications in or has experience of the assessment of capability;”

This amendment would change the word “may” to “must”. In other words, the assessing doctor would have a duty to refer the person being assessed to a consultant psychiatrist if they had any doubt about that person’s capacity. I argue that this is a change that we both should make, and can easily make. If a doctor has doubts about the capacity of an applicant, it is good practice for them to refer that person to a doctor or a specialist in that field.

[Dr Opher]

Could I ask which amendment the hon. Member is talking about? Is it 284 or 6? Amendment 284 says that psychiatric assessment is mandatory in all cases, whereas amendment 6 says it is mandatory if capacity is in doubt. I just wondered which one he was talking about, because I support one and I do not support the other.

[The Chair]

Dr Opher, maybe you want to catch up on the papers and then intervene when you have a question to ask.

[Jake Richards]

I will be brief. I will talk about my amendment 280, which I will not press to a vote. There remains an area that needs more exploring in this legislation—it has come up in debates already, but needs to be looked at further—namely, that a person may have capacity but have other mental health conditions that may impair their judgment. In those circumstances, a more thorough assessment than the two-doctor stage there is at the moment would be right. In reality, that is very likely to happen under the current structure of the Bill. My amendment simply attempts to make sure that it is mandatory. Having had discussions with my hon. Friend the Member for Spen Valley, I know that she is sympathetic to that.

There are amendments in the next group that aim to do the same thing. They, along with my amendment, may not be quite right. I urge the Government to look at this issue and see how we can work together to come to a conclusion, because I think that all members of the Committee would want that. I also support amendment 6, as I think everyone does.

[Dr Opher]

I apologise, Mrs Harris—I have got slightly confused with all the amendments. I do not have a speech that has been prepared for me, or anything like that, but I would like to make some comments. I think this is about the role of psychiatry and capacity, and how we deal that in the Bill. All these amendments reflect that. I would like to concentrate on whether we should actually mandate referral for all patients to a consultant psychiatrist, or adopt amendment 6, which suggests that if one of the two assessing doctors has concerns about either capacity or mental health, they should refer the patient to a psychiatrist. Those are the two choices I think we have here.

--- Later in debate ---

[Danny Kruger]

I appreciate the hon. Member’s point, and it is very logical that it should only be in the case of doubt, but does he not recognise that in the case of organ donation, it is mandatory? If people have this proper assessment when they are giving an organ, why should they not be asked to have one if they propose to give their life?

[Dr Opher]

That is an interesting point, but we are not discussing organ donation, and we are dealing in a different environment here; the patients we are talking about are about to die, and all we are giving them is the right to control the moment and manner of that death. I acknowledge that using a psychiatrist in organ donation has its benefits, but in this service, getting every patient—who, for example, are frail and ill by definition, because they are about to die—to see a psychiatrist is frankly neither applicable nor appropriate.

[Kim Leadbeater]

My hon. Friend makes a powerful point. If we think about some of the people we have met—the families who have lost loved ones to terminal illness and the patients who are terminally ill—they are very clear in their decision. For me, it would be another barrier to those patients, who are dying people, to make them see a psychiatrist for every single case.

[Dr Opher]

I think it would create a barrier. We need to make sure that we deliver legislation that does what we are trying to do, which is to enable someone with a terminal illness, who has full capacity, to make a decision about the end of their life.

[Danny Kruger]

It is a very important point. Yes, we are talking about those people, but we are also talking about a different category of people who have a terminal diagnosis of six months or more, and may only be reasonably expected to die within six months. I am not just talking about people at the very end of their life, who are at death’s door; we are talking about people who qualify for the Bill, which is a much larger category of people, so it is appropriate to require them to do this.

[Dr Opher]

I agree with all of this. I think psychological assessment is incredibly important in all patients, and I personally specialise in it from a primary care basis. But we are suggesting here that the two other doctors have no ability to do any sort of psychological assessment, and that is simply not true.

[Naz Shah]

rose—

[Dr Opher]

I apologise to my hon. Friend; I will continue for a little bit. We use secondary care and psychiatrists when we have a doubt about our decisions. If we have a doubt, then it is entirely appropriate to use psychiatrists in that instance, and we must do so. That is why I approve of amendment 6.

[Kit Malthouse]

As I understand it, I do not think if someone is donating an organ that they do actually have to see a psychiatrist; they have to see somebody who is an appropriately trained assessor from the Human Tissue Authority. To me, that sounds equivalent to the second doctor in our process—someone who is appropriately trained to assess patients and what they need to do. This talk of it having to be a qualified registered psychiatrist, compared with an organ donation, is incorrect.

[Dr Opher]

I completely agree with the right hon. Gentleman. By amending clause 12 to include social workers, who specialise in spotting coercion, there would be a psychological component in that panel. I emphasise that the first two doctors are trained in psychological assessment—they have to be to become a doctor, and we must respect their knowledge and decision making. Psychiatrists will be incredibly useful in difficult cases of capacity, but using them in every case would not be using them in the best capacity.

[Naz Shah]

My hon. Friend is being generous with his time. I do not question the capability of those doctors, but how does that square with the concerns of the Royal College of Psychiatrists that if a doctor has never met the person before, they cannot make an assessment on coercion? That might impact on capacity.

[Dr Opher]

Sorry, could you make that point again? I did not quite understand it.

[The Chair]

No, I am afraid not.

[Dr Opher]

Fair enough. Thank you, Mrs Harris. I was warned yesterday not to take interventions and I should have followed that advice.

[The Chair]

Dr Opher, I remind you yet again that “you” is me, and I have not asked you any questions. It is “my hon. Friend”.

[Dr Opher]

I am grateful that you have not intervened as well, Mrs Harris. You did say that I am allowed to call you “you”.

I will finish on this serious point. Amendment 6 has much power, and we would all agree that if the first or second doctor has doubts, they must—not may—refer to a psychiatrist. Expecting every patient who requests assisted death to have a psychological or psychiatric assessment is simply not necessary, and it would not improve the safety of this Bill.

[Stephen Kinnock]

rose—

--- Later in debate ---

[Rebecca Paul]

That is a “may” rather than a “must”. I hope that we would move to “must” in that event.

[Dr Opher]

This is just a point of accuracy: I think we are all going to support amendment 6, which would make it obligatory to refer to psychiatry if there were any doubts.

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

Simon Opher Excerpts

Committee stage
Tuesday 4th March 2025 Public Bill Committees

Patients who are considering assisted dying have had terrible news. They have been told that they may well die within six months. They will be grieving, uncertain and very scared. These people deserve to know the full picture when they have their initial discussions, and these intelligent and constructive amendments would help to ensure that they had the full picture. I ask all members of the Committee to support them.

[Dr Simon Opher (Stroud) (Lab)]

I will briefly go through my impressions of the amendments. A lot of amendments in this group call to mind one of the difficulties that we are having in Committee, which is about the role of professional integrity against what we should be putting down in law. One problem is that, if we state something in law and a professional does not do it, then they are acting in an illegal way—and that introduces a different concept into a medical consultation. We must be very careful about introducing to a medical consultation a load of requirements in law, therefore reducing the freedom of that consultation whereby the doctor and patient can decide on what is best for the patient.

Amendment 342 is in the name of my hon. Friend the Member for Shipley. I reiterate that all the amendments have been tabled in good faith, and I absolutely respect them. The amendment would mean that the initial doctor—who is likely to be a GP—to whom the person comes and wants to speak to about assisted dying “must” conduct a preliminary discussion, rather than

“may (but is not required to)”.

The problem there is that some doctors will be conscientious objectors to assisted dying and we have to protect their integrity. We must not force them to do something that is against their will.

I note that amendment 341, which we will come to later, is about the obligation to give information to the patient if they ask for assisted dying. That is an appropriate amendment, but forcing a doctor who does not agree with assisted dying to discuss it is not fair on the medical practitioner. That is not what the Bill is about. In many other places, there is freedom for the medical doctor to avoid getting involved in discussions if they do not wish to. That is an incredibly important part of, and concept in, this Bill. Without that, I think the medical profession would not accept the Bill. That is very important.

Amendment 285 is about needing to consult a specialist in the relevant illness. I think we need to understand the process of what will happen under the Bill. Let us take an example of a patient under an oncologist—a cancer specialist. The oncologist will almost certainly say at some point during the consultation with the patient, “I think that there is no further treatment that is going to prolong your life, and you are likely to have six months or less to live.” That will be done by a specialist. I do not know general practitioners who would confidently predict a prognosis of six months or less; it would come from a specialist. Indeed, cancer care in this country, until the palliative phase, is generally run by specialists and hospitals. GPs are not generally involved, apart from to support the patient. However, if the oncologist feels that the patient has less than six months to live, they would probably come to see the doctor under this legislation, and the initial discussion will then take place. They will already have a steer as to the likely prognosis.

[Naz Shah (Bradford West) (Lab)]

I am trying to understand. My hon. Friend is saying that the oncologist is a specialist, but that they might not be the first doctor to have the first discussion; he said that they might not want to be a part of this process. I would like to understand that a bit more.

[Dr Opher]

As far as I see, under the Bill there is an initial discussion when a patient who is requesting assisted dying goes to see a medical practitioner. It does not specify what type of practitioner, which is good because it means they can ask either the oncologist or the general practitioner. That initial discussion is with a doctor, and then the doctor will refer for the first declaration, or they may do the first declaration themselves. That is how the Bill is set out, but the general practitioner will have had specialist opinions on the patient. They would not just say, “Well, maybe you’ve got less than six months to live—I don’t really know, but let’s have a guess.” This will be based on informed information from a specialist.

[Danny Kruger]

I do not want to labour the point, but does the hon. Member not acknowledge the Bill does not require that at the moment? He is saying that it will happen. Why will it happen—just because the doctors do their job well? Does he recognise there is no obligation to have this wide consultation with other specialists under the Bill? The doctor could do just as he has described and take a decision on their own.

[Dr Opher]

Again, this is a really interesting part of the Bill. If a doctor is routinely giving prognoses of six months where that is not appropriate, they will come up against the General Medical Council for being poor doctors, and the regulation around poor doctors is within the medical profession. If it is proven that someone has given a diagnosis that they cannot back up in any way, they would then be subject to their own professional standards. That is one of the things here: we cannot go through this Bill and specify the medical requirements at every stage, because that comes under a different format, which is called the General Medical Council. If someone has given a prognosis of six months or less, and if that is clearly inaccurate and would be contested by other doctors, they would be brought before the General Medical Council.

[Lewis Atkinson]

Does my hon. Friend agree that the provision of a further independent doctor assessment—both one and two—in addition to the doctor conducting the initial discussion, would provide a further safeguard for a diagnosis, if terminality could not be supported by other professionals?

[Dr Opher]

I absolutely agree. We are imagining that the doctors will all be independent and will not know anything about what other doctors have said, but there will be communication and access to medical records, and they will also tell the original doctor what their opinion is, and so on.

If we accept these amendments, we risk over-embroidering the Bill, which will make it almost impossible for doctors to say anything in a consultation. We must leave that free, because that is a central tenet of medical care, and if we put laws around it, there will be legal process over the medical consultation, and doctors will be frozen with fear about breaking the law. They are regulated by the GMC, and we are all terrified of referrals to the General Medical Council for that very reason: because we are trying to operate at the best standard that we can. I truly understand the amendments, but I do not think they will make the Bill any safer, and that is what we are all here for.

[Jake Richards (Rother Valley) (Lab)]

I am very sympathetic to the amendment and have thought long and hard about it. Can my hon. Friend explain to me, from his experience, but also from looking at the Bill and speaking to others, the effect of clause 4(4)(b)? As a non-clinician layperson, it appears to me that if a medical practitioner is discussing the likely effect of any treatment, then by its very nature that would lead to a discussion about prognosis, and the uncertainty and certainty around that.

[Dr Opher]

What my hon. Friend points out is absolutely true. The Bill’s drafting is simple but very effective. For prognosis, for example, it says that it is

“reasonably…expected within 6 months.”

As we have discussed many times in this Committee, prognosis is not exact; it is an estimate. It suggests that the patient has a terminal illness—that is to say, the illness will lead to their death. All we are arguing about is exactly when that will happen. It is reasonable to say, as doctors already do, “It is likely that you have six months to live.” That is not exact—as doctors, we cannot predict the future, even if people think we can. I totally accept that. However, we can make estimates as to what is likely to happen.

As my hon. Friend just mentioned, there are lots of really good news stories of people living longer than their prognosis. However, for the Bill to be effective, and to give relief to people who genuinely need it, we have to have a prognosis, based on medical evidence, of six months.

--- Later in debate ---

[Naz Shah]

From what I hear, my hon. Friend is supportive of the amendment. Does he agree that it just sets out what he says is best practice? I am trying to understand the objection to setting out good practice on the face of the Bill.

[Dr Opher]

Again, I bring my hon. Friend back to the fact that this is a Bill in law, and what we have to guide us as doctors is the General Medical Council, which sets standards for doctors. That is how we do it. If we are hemmed in by legal matters, we can break the law without being aware of it, if we are not careful. If too many legal parameters are set around medical consultations, the patient will get less good care because the doctor will not be free to offer it. I can see that my hon. Friend does not agree with that, but it is the case.

[Danny Kruger]

The hon. Gentleman is praying in aid the General Medical Council as if it is some sort of effective backstop. He says that the guidance does not need to be in the Bill because it is there hovering over doctors anyway, but the Bill makes explicit reference to GMC guidance—some of it is in there. If he objects to our suggestion to include the full GMC guidance in the communication that should be had, why does he support the presence of some of the guidance that doctors should give? The Bill does not include what the GMC requires: uncertainties about diagnosis or prognosis. Why not include the full GMC guidance in the Bill, seeing as we are including some of it already?

[Dr Opher]

I just do not think it will strengthen the Bill. I thank you for your intervention. It is a moot point.

[The Chair]

Order. I did not intervene.

[Dr Opher]

Sorry, Mr Efford. I do not deny that the hon. Member makes a good point, but if we embroider this too much, the Bill will not be safe. That has been the case throughout. Any good medical care is based on giving treatment, availability and the likely effects of that, and on giving prognosis and the chance of the prognosis being longer or shorter. That is all based in good clinical care.

On amendment 343, the uncertainties of estimates of how long a person has to live are covered in clause 2(1)(b):

“the person’s death in consequence of that illness, disease or medical condition can reasonably be expected within 6 months.”

“Reasonably” is part of the Bill. It suggests that one cannot say that the estimate is exact. The Bill does not say that it is exact; it says that it is a reasonable estimate of that person’s life. I think that takes care of that amendment.

In amendment 344,

“the risks and benefits of such treatment, potential side effects, and the impact of the treatment”

are covered by

“any treatment available and the likely effect of it”

in clause 4(4)(b). My general point is that none of the amendments are actually wrong; they are just unnecessary. I would like to leave it at that.

[Lewis Atkinson]

I will be brief, as I am conscious that the Committee needs to make progress. I will speak briefly to amendment 275 in my name, which, as others have said, amends the current reference of “any available” to “all appropriate”. Listen—people at the end of their life deserve the best. They deserve to know about and have the option to access all appropriate care. In my experience of the NHS, that is exactly what clinical teams ensure patients get. But we need to guard against any suggestion that the information given should be somehow filtered around availability, which I know is not the intention of my hon. Friend the Member for Spen Valley.

In my experience, views on availability are often incorrect anyway, so ensuring that “all appropriate” options are offered in information is the best thing to do. If nothing else, it creates a level of societal pressure to ensure that all appropriate care is available, which I hope we can all support.

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

Simon Opher Excerpts

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Dr Simon Opher (Stroud) (Lab)]

Surely the hon. Member is describing exactly why we need the Bill. If they are given a diagnosis, at that point they can apply for assisted death. We know that there are statutory time limits built in, which I believe will take us to at least 21 days from the diagnosis. The danger is suicide in patients, which is what we are trying to avoid. Approximately 600 patients with terminal illness commit suicide in this country each year, and the Bill will prevent that by allowing them to apply for assisted death.

[Danny Kruger]

I hope that the hon. Member is not suggesting that all 600 would be averted by the Bill. He might be right that some would be, and I recognise that. However, the purpose of amendment 270 is to ensure that people who might be suicidal receive an assessment, whether they are inclined to apply for assisted death, if it is legal, or to take their own life in an unassisted way. If they expressed a wish under the clauses of the Bill to have an assisted death, they would have proper psychosocial assessment and proper steps would be taken to ask, if we are prepared to make this distinction, “Is it just that they are suicidal and not wanting an assisted death?” I find the distinction difficult to parse logically, but if that is the distinction that we are making, let us put it into the Bill and ensure that people are properly cared for in that very dangerous time after they get a terrible diagnosis.

I would like to quote from the written evidence that we received from a member of the Pathfinders Neuromuscular Alliance, which is a user-led charity for those with muscle-weakening conditions such as muscular dystrophy. This person said:

“I’ve been there, I’ve wanted to die, and I’ve been in the position where I would take that option if it was given to me”—

not if it was not. Interestingly, he would have taken that option if it was given to him, rather than suggesting that he was going to take his own life anyway. The quote continues,

“but looking back I can see I was depressed and now I’m so glad that I didn’t take that option.”

At the moment, the Bill does not require anyone to explore these psychosocial factors, and although the person can be referred to a psychiatrist—and, if we go on to accept the amendment, we would ensure that they must be if the doctor concludes that there is doubt—I do want to make a point about referrals. There is an assumption that the doctor will refer the person to a psychiatrist, but that will only happen if they have done their assessment well. We are assuming that they will do the assessment well, but we have heard repeatedly that such assessments are often not done well. I welcome the coming amendment—amendment 6—that says that if the doctor concludes that there is doubt about capacity, they “must” refer. That would be a step forward, but it is not sufficient. Even the psychiatrist will only answer the question, “Is this person able to make a decision?” That does not address any of these other factors.

In Oregon—we refer often to Oregon, and although this Bill is supposed to be the safest in the world, it is not as safe as Oregon in this respect—the doctors may refer the patient for counselling if the patient

“may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment”.

To conclude on this point, psychosocial care is fundamental to good end-of-life care. Members of the Committee have said that palliative care and assisted dying can complement each other; this assessment should be part of that picture, and it needs to come before the first declaration, because once somebody has signed that declaration they are already on the pathway—and there will not be an obligation on them to receive palliative care advice either, because we rejected that amendment. Amendment 270 provides for people’s needs to be met at the first opportunity.

Lastly, on the question of doctor-initiated conversations, I quote Professor Brassington, who submitted evidence to the Committee:

“In normal medical practice, the patient approaches the medic with a problem, and the medic suggests possible courses of action, not all of which would have been considered by the patient. The patient permits further action. But it is implicit that the practitioner who makes the suggestions thinks them good, and the patient is entitled to think that the practitioner endorses them all.”

In a normal scenario, the doctor would think about what is good for the patient. To raise an option is to endorse and encourage it, perhaps as one among a number of other options. It is to suggest that this is a good option—it might not be the one the doctor thinks is the best, but it is a good option for the patient; otherwise, they would not raise it. They can only make a recommendation for options that they consider would be appropriate to the situation.

--- Later in debate ---

[Danny Kruger]

I am absolutely sure that is right, and I am grateful to the hon. Lady for making that important point. For anybody, but particularly for the vulnerable and those in distress, as people are towards the end of their life, for those who have had a terrible diagnosis, and for those who feel a burden and recognise that the coming months might not be good for them or their family, of course the statement of this option has an implication—even if it is presented as neutrally as possible. It might well be received as a communication that the doctor is actually trying to say, “You are going to have a terrible death”, but does not want to say it out loud. It could be taken in all sorts of ways by patients.

[Dr Opher]

That is actually not right. In a medical consultation, a doctor gives a number of different options. A small example is that I might suggest to someone that there is an option of taking an antidepressant. Now, it is the patient’s choice as to whether they do that. My role is to give every option that is available, and to encourage and help the patient to make their own personal choice. That is a very basic tenet of clinical care.

[Danny Kruger]

I recognise that, but I repeat that by offering antidepressants, he is suggesting to his patients that it may well be the right thing for them to do. He puts in front of his patients a menu of options, with a degree of advice according to his expertise, but if assisted dying is on the menu, that is because assisted dying is regarded as something, as it were, that is healthy to eat. He would not put something on the menu that he did not think they should take. Everything on the menu is edible.

--- Later in debate ---

[Danny Kruger]

I recognise that. I should certainly address you, Mrs Harris.

[Dr Opher]

I would like to make a speech that answers some of these points, but I will intervene if that is more appropriate. What would the hon. Gentleman prefer?

--- Later in debate ---

[Dr Opher]

I will be really brief because many of my points have been made. Amendments 278, 8 and 124 are about doctor-initiated discussion. One of the really good things about the Bill, for medical practitioners and for patients, is that this law will clarify the situation. It is really important for doctors to know exactly where they stand. As mentioned by the hon. Member for Solihull West and Shirley, if we introduced the types of gagging order set out in these amendments, we would introduce a horrible blurring; doctors could be accused of bringing it up by relatives who do not want it to be done, and it creates a horrible morass in the law. I feel that it is not right to have a gag clause. The reason that it has been removed elsewhere is that it does not work; it does not protect patients and it does not protect doctors. We have to think of it in that way.

There are many ways in which patients can ask about all the options available, and we have to be able to say what they are. We cannot miss out one option because we are not allowed to say it. That is a very unhealthy doctor-patient relationship. If we want to foul up the doctor-patient relationship, this is a good way of doing it.

[Kit Malthouse]

What we have been talking about this afternoon does not necessarily affect the reality of what the vast majority of conversations are like. There are some people who show up, get a terminal diagnosis and are told they are going to die within a matter of weeks, and they need an approach. But the vast majority of people will have been having treatment over a series of weeks and months, and reached a point at which their death becomes inevitable. At that point, they often do—certainly in my family experience—express a desire to know how they can control their own death. Surely a doctor has to be allowed to evolve that conversation over the period of treatment.

[Dr Opher]

I completely agree. Interestingly, I am on a journey here. To begin with, I thought these were good amendments. I thought that we must not introduce certain things—the doctor being a powerful person and so on. I then asked a lot of my colleagues, and they said, “No, no—we’ve got to clarify the law. We do not want this blurring of the law.” I have actually moved in the other direction, and I think it is essential that we do not bring in these amendments. As my hon. Friends said, the BMA has support the subject being raised and there have been changes to the law in Victoria because the gag clause simply does not work. We need to protect patients and, in my opinion, these amendments are not a good way of doing that. The hon. Member for Solihull West and Shirley made such a compelling argument against those amendments, so I will not go on about them.

On Amendment 278, I actually agree with the Member for East Wiltshire, but probably for different reasons. Again, if we introduce the amendment, if the doctor does not see that a patient has said that they do not want assisted dying and they bring it up, the Bill will potentially criminalise their behaviour. I feel that would not work and it would complicate the law.

I agree with amendments 319 and 320, tabled by my hon. Friend the Member for Bexleyheath and Crayford, which concern age. They would be a good and—alongside his amendment 339—functional change to the Bill.

Amendment 270 is about psychological assessment. As far as I can read in the Bill, as part of the panel process, which we have not yet discussed, there will be a psychological and psychiatric assessment of the patient. Also, when assessing someone with a terminal illness, most doctors will assess their mental health.

[Danny Kruger]

It is very important that we do have psychiatrists involved. In that sense, the addition of the panel may be welcome, although I regret that it is replacing the judicial stage—but, crucially, it comes right at the end of the process, and as I understand it, there will be no obligation on the panel to meet the patient. That is in no way a psychiatric assessment, let alone one at the right moment.

--- Later in debate ---

[Dr Opher]

I would say that two doctors should be able to assess psychological health. That is their job; they would assess that at all times. I agree that it is a problem. The matter also relates to amendment 276. When someone is given a terminal diagnosis, that is shocking news—they will be depressed. However, the Bill is quite clear about the time intervals. With the panel also involved, there will be more than a month between the first time the patient sees a doctor and when they actually get a decision that they can end their life. I do think that that protects. I would support amendment 276, because it is important that people do not say, “Right—I would like my life to end now” and not to give due consideration, but due consideration is already written into the Bill.

Finally, I will address new clause 6, which is a probing amendment tabled by the hon. Member for Solihull West and Shirley. One danger in this Committee is that if we continuing to build and embroider the Bill, it will be very difficult to use. I do agree that someone has to have capacity at the time they take the medicine that will end their life, but I see where the probing amendment is coming from. We need to be careful that this remains a practical and workable Bill by the end of our deliberations.

Ordered, That the debate be now adjourned.—(Bambos Charalambous.)

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

Simon Opher Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

I have sympathy with amendments 399 and so on tabled by the hon. Member for East Wiltshire. On the understanding that I await Ministers’ input, a constellation of illnesses, diseases and so on can, combined, lead to an inevitable end of life, and it might be useful to have clarification on that. It is no one’s intention to widen the provisions, and if this is an example of where we, as a Committee, can work constructively together to ensure that clarification is given and the will of the House as expressed on Second Reading is followed, we can potentially do that.

[Dr Simon Opher (Stroud) (Lab)]

I would like to make a short comment. It is very important that the Committee does not get too hung up on anorexia, because the Bill is very clear about what is excluded. Deprivation of nutrition is always reversible. Someone who is anorexic and about to die would go into multi-organ failure and be unconscious and unable to give any sort of consent. Before that, the nutritional deprivation is reversible and therefore not covered under the Bill.

[Danny Kruger]

I just wanted the hon. Gentleman to comment on the reality in our NHS at the moment that people are described as terminally ill with anorexia. They are given the label of being terminally ill and put on palliative care pathways because it is assumed that their condition is not reversible. Doctors today, in this country, are concluding that people with eating disorders are going to die and are treating them accordingly. Is he aware of that, and how does it affect his comments?

[Dr Opher]

I am not aware of that. I believe that this is always reversible until a person goes into the absolute terminal stage of multi-organ failure. Before that, we can reverse nutritional deprivation. I do not accept that point, and I think it is important that we look at the Bill in all its detail. I think it has enough safeguards to exclude someone with anorexia.

[The Chair]

I have received a manuscript amendment from the hon. Member for East Wiltshire that he wishes to move. As the hon. Gentleman knows, a manuscript amendment requires a very high bar and exceptional circumstances. I do not believe that exceptional circumstances are present, and he will be aware that further amendments can be proposed to the clause for consideration on Report. That is my decision on the matter.

--- Later in debate ---

[Rebecca Paul]

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

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

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

[Dr Opher]

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

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

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

[Rebecca Paul]

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

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

--- Later in debate ---

[Naz Shah]

It is absolutely what is guiding me. I am sure we all know people who were told that they had six months to live and have lived a lot longer. We have heard stories of people who were told that they had six months to live and lived beyond 20 years more. We have heard lots of tragic cases, for example in the world of Dr Jamilla Hussain, that would really benefit from the Bill’s being available to them. But equally, there are other families whose loved ones have survived—and not just survived, but thrived for years and years. In fact, a close friend of mine, who happens to be a constituent of my hon. Friend the Member for Spen Valley, was diagnosed not to live very long. It was an emotional time for her daughters. Eighteen and a half years later, she is still alive, well and thriving.

[Dr Opher]

I must admit that I rejoice in these stories—it is fantastic that these things can happen—but shall we just outline exactly how the Bill will work? If you are given a prognosis of six months by a doctor and you decide that you want to—

[The Chair]

Order. Again, can we stop using the second person?

[Dr Opher]

Sorry—will my hon. Friend not accept that this Bill will work in such a way that people may register for assisted dying, but only actually do it when their death is close? Therefore, if they get better and unexpectedly live longer, they will not take their lives.

--- Later in debate ---

[Naz Shah]

I am happy to withdraw that comment, given the welcome intervention of my hon. Friend the Member for Spen Valley. When intervening on me in a previous sitting of the Committee, she stressed that most of the assisted deaths of people with eating disorders took place in the Netherlands and Belgium. The survey that Ms Roff and her colleagues carried out did find that the Netherlands and Belgium had more assisted deaths of people with eating disorders than Oregon, but it also found that Oregon itself had more than one such case. California and Colorado have also accepted people with eating disorders as subjects for assisted death. I remind hon. Members that, as I noted earlier, Oregon has a considerably smaller population than England and Wales. In 2023, the last year for which we have full data, Oregon had a population of just 4.25 million. By contrast, England and Wales had a population of 60.85 million—more than 14 times higher.

Perhaps it is the case that Oregon has had two assisted deaths for anorexia sufferers, as one witness told the Committee. In England and Wales, we have 14 times the population of Oregon. If it became legal for sufferers of advanced-stage anorexia to take their lives by assisted dying, we would almost certainly have more cases than Oregon.

[Dr Opher]

Does my hon. Friend not believe that an eating disorder is reversible? Under the Bill’s provisions, if someone has a condition that can be reversed by treatment, they would not be appropriate for assisted dying. Is she saying that eating disorders are not reversible?

[Naz Shah]

Absolutely not. That is not the point that I am making. Eating disorders are reversible, but it has been found that where this kind of legislation has been enacted, across the globe, somebody who has anorexia and decides not to eat then falls within the scope of assisted dying because it becomes a terminal illness.

[Naz Shah]

I concur with the hon. Member’s remarks.

[Dr Opher]

Actually, there is a lot of debate about whether terminal states of eating disorders actually exist or not, so they cannot be said to be a real thing in that way. Some people in the profession think they certainly do not exist, so I would contest the point made by the hon. Member for East Wiltshire.

[Naz Shah]

I thank my hon. Friend for his intervention, but the truth of the matter is we have 10 cases that have gone to the Court of Protection. In nine of those 10 cases, judges ruled that the young people—women and girls, one was only 19—did have the capacity not to take treatment.

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

Simon Opher Excerpts

Committee stage
Wednesday 29th January 2025 Public Bill Committees

[The Chair]

Colleagues, if we are to try to get everybody in, I will have to confine Members to one question each from now on. Panel, if you could, be kind and, without denying us the information we need, keep your answers as brief as possible.

[Dr Simon Opher (Stroud) (Lab)]

Q Could you briefly run through the patient pathway? Where does the patient first arrive in the healthcare setting? Who are the two doctors? Indeed, who provides assistance at the end of life?

Dr McLaren: Again, each of our states, as well as the Australian Capital Territory, has different legislation and therefore different processes. In broad speaking terms, say in Victoria, for example, a patient will express their wish to engage in voluntary assisted dying independently, and often they are connected to the state-wide patient navigator service, which will connect them with a doctor to receive that patient’s first request and become their co-ordinating medical practitioner. That doctor will then conduct the patient’s co-ordinating assessment and determine whether they believe the patient is eligible or ineligible. If the patient is eligible, the doctor will refer them on to a consulting doctor, or a doctor who acts as the consulting doctor, for a consulting assessment.

If that process is also approved and the patient is found eligible, they meet again with the co-ordinating medical practitioner to make a written application to engage in voluntary assisted dying. That process then goes to our review board, to ensure that it is compliant with the legislation, before we can apply for a permit to prescribe the medication. The permits are specific to our state; many other states, such as Dr Fellingham’s, do not require a specific permit for individual prescription. The permit will come back within three days, and then we write a prescription, which goes to our centralised pharmacy service. The pharmacy will wait for the patient or the contact person to contact the pharmacy and organise the delivery or dispensing of the medication.

In Victoria, self-administered oral medication will be dispensed to the patient, and that is then their property; they may use it immediately or never use it—that is completely up to them. They do not require medical attendance at that time, although I have provided that on many occasions, sitting with a patient and their family as the patient has taken their medication and died. If the medication is not used, the contact person nominated by the patient is legally required to return the medication to the pharmacy.

If the patient is unable to ingest or digest oral medication, we can apply for practitioner administration, which I believe your Bill does not currently provide for. This authorises a co-ordinating medical practitioner to administer the medication, either via a percutaneous endoscopic gastrostomy feeding tube or by other means, including intravenously, to the patient to bring about their death. I have certainly done that—I do not keep count, but I have engaged in that many a time.

[Dr Opher]

Can I just confirm—

[The Chair]

Order. I did say one question per person; we have to stick to the timings.

--- Later in debate ---

[The Chair]

I call Simon Opher.

[Dr Opher]

Actually, my question has already been asked.

Chelsea Roff: May I respond briefly? I want to address the question. I know it is not your intention for eating disorders to be included in this Bill, and I am grateful for that. When I started our research, I thought, “We just need stronger safeguards.” That was where I began, and after looking at 33 jurisdictions around the world, I have real doubt about whether safeguards are enough; I know how difficult it is to put it on the page, and I am seeing it expand and be applied through interpretation. I disagree with Professor Shakespeare, respectfully, that diabetes is a reversible condition. You cannot go back in time and reverse that condition.

I agree that you are doing this for a noble purpose, and there are members of my family that want this Bill to go through, and yet I emphasise to all of you on the Committee that the question before you is: could this Bill have knock-on effects for some of your most vulnerable constituents? How many deaths are you okay with? If the safeguards fail once, that is a human being who maybe, in a despairing moment, was handed a lethal medication instead of the care, the treatment and the help they needed. That is what we are talking about. You really have to get this right, because those people are depending on you.

[Lewis Atkinson]

Q Mr Amin, given your expertise in representing these cases in the court, can I ask you for your view around the Mental Capacity Act issue regarding eating disorders and other disorders? Obviously, we have heard one version of that. Given your experience of working with UK law to the highest level, what is your assessment of this?

Yogi Amin: I have worked in a range of medical treatment cases over many years, covering different illnesses and conditions, and clause 2 reads fine to me. It works. It is clear. I do not consider that it needs any additional words. I can understand, when we go to court, that cases will come through and they will fall within those definitions, and it will be clear. I do not consider anorexia to come under a terminal illness unless it is right at the end of life, and that does not really fit within the parameters of the Bill, because we are not talking about right at the end of life. We have section 63 of the Mental Health Act, which deals with anorexia, and there is force-feeding that clinicians consider. That is my view on the anorexia side of things.

Doctors will provide the evidence on terminal illness. You heard from the chief medical officer yesterday, and they will provide guidance around all of that. Subsequent to the Bill, there will be secondary legislation and then the guidance. They will provide clear guidance that will then feed into this and the evidence that will be before a judge that says, “Yes, it is a terminal illness, and this is the prognosis” and so on. It is nothing different from what we produce in medical treatment cases before the court at the moment, where the doctors produce expert reports and give evidence. They explain the condition, the prognosis and their decision on capacity, and they explain what is in the best interests of an individual if they lack capacity. As I understand it, the Bill is crafted to produce the evidence as you go along the path here, and then eventually to the judge.

Chelsea Roff: May I add one sentence, because it is related to eating disorders? I would refer to a 2012 Court of Protection case, where a 29-year-old with anorexia was described as being in the terminal stage of her illness and multiple physicians described her death as inevitable. I would also refer to a 2023 case seen at the Court of Protection, which said, “I recognise with deep regret that it will probably mean that she will die.” She was also described as being at the “pre-death stage”. Again, that young woman is still alive and still fighting for services. Although I respect what Mr Amin is saying, and I agree with his interpretation, we have case law in the UK where people with anorexia are being found to be terminal. We have to take that reality into account.

Yogi Amin: I do not think they were found to be terminal. They were described by a doctor in a case as being terminal, and that doctor may not have described it properly.

Chelsea Roff: Indeed, but a judge will be relying on doctors.

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

Simon Opher Excerpts

Wednesday 29th January 2025 Public Bill Committees

[The Chair]

Colleagues, if we are to try to get everybody in, I will have to confine Members to one question each from now on. Panel, if you could, be kind and, without denying us the information we need, keep your answers as brief as possible.

[Dr Simon Opher (Stroud) (Lab)]

Q Could you briefly run through the patient pathway? Where does the patient first arrive in the healthcare setting? Who are the two doctors? Indeed, who provides assistance at the end of life?

Dr McLaren: Again, each of our states, as well as the Australian Capital Territory, has different legislation and therefore different processes. In broad speaking terms, say in Victoria, for example, a patient will express their wish to engage in voluntary assisted dying independently, and often they are connected to the state-wide patient navigator service, which will connect them with a doctor to receive that patient’s first request and become their co-ordinating medical practitioner. That doctor will then conduct the patient’s co-ordinating assessment and determine whether they believe the patient is eligible or ineligible. If the patient is eligible, the doctor will refer them on to a consulting doctor, or a doctor who acts as the consulting doctor, for a consulting assessment.

If that process is also approved and the patient is found eligible, they meet again with the co-ordinating medical practitioner to make a written application to engage in voluntary assisted dying. That process then goes to our review board, to ensure that it is compliant with the legislation, before we can apply for a permit to prescribe the medication. The permits are specific to our state; many other states, such as Dr Fellingham’s, do not require a specific permit for individual prescription. The permit will come back within three days, and then we write a prescription, which goes to our centralised pharmacy service. The pharmacy will wait for the patient or the contact person to contact the pharmacy and organise the delivery or dispensing of the medication.

In Victoria, self-administered oral medication will be dispensed to the patient, and that is then their property; they may use it immediately or never use it—that is completely up to them. They do not require medical attendance at that time, although I have provided that on many occasions, sitting with a patient and their family as the patient has taken their medication and died. If the medication is not used, the contact person nominated by the patient is legally required to return the medication to the pharmacy.

If the patient is unable to ingest or digest oral medication, we can apply for practitioner administration, which I believe your Bill does not currently provide for. This authorises a co-ordinating medical practitioner to administer the medication, either via a percutaneous endoscopic gastrostomy feeding tube or by other means, including intravenously, to the patient to bring about their death. I have certainly done that—I do not keep count, but I have engaged in that many a time.

[Dr Opher]

Can I just confirm—

[The Chair]

Order. I did say one question per person; we have to stick to the timings.

--- Later in debate ---

[The Chair]

I call Simon Opher.

[Dr Opher]

Actually, my question has already been asked.

Chelsea Roff: May I respond briefly? I want to address the question. I know it is not your intention for eating disorders to be included in this Bill, and I am grateful for that. When I started our research, I thought, “We just need stronger safeguards.” That was where I began, and after looking at 33 jurisdictions around the world, I have real doubt about whether safeguards are enough; I know how difficult it is to put it on the page, and I am seeing it expand and be applied through interpretation. I disagree with Professor Shakespeare, respectfully, that diabetes is a reversible condition. You cannot go back in time and reverse that condition.

I agree that you are doing this for a noble purpose, and there are members of my family that want this Bill to go through, and yet I emphasise to all of you on the Committee that the question before you is: could this Bill have knock-on effects for some of your most vulnerable constituents? How many deaths are you okay with? If the safeguards fail once, that is a human being who maybe, in a despairing moment, was handed a lethal medication instead of the care, the treatment and the help they needed. That is what we are talking about. You really have to get this right, because those people are depending on you.

[Lewis Atkinson]

Q Mr Amin, given your expertise in representing these cases in the court, can I ask you for your view around the Mental Capacity Act issue regarding eating disorders and other disorders? Obviously, we have heard one version of that. Given your experience of working with UK law to the highest level, what is your assessment of this?

Yogi Amin: I have worked in a range of medical treatment cases over many years, covering different illnesses and conditions, and clause 2 reads fine to me. It works. It is clear. I do not consider that it needs any additional words. I can understand, when we go to court, that cases will come through and they will fall within those definitions, and it will be clear. I do not consider anorexia to come under a terminal illness unless it is right at the end of life, and that does not really fit within the parameters of the Bill, because we are not talking about right at the end of life. We have section 63 of the Mental Health Act, which deals with anorexia, and there is force-feeding that clinicians consider. That is my view on the anorexia side of things.

Doctors will provide the evidence on terminal illness. You heard from the chief medical officer yesterday, and they will provide guidance around all of that. Subsequent to the Bill, there will be secondary legislation and then the guidance. They will provide clear guidance that will then feed into this and the evidence that will be before a judge that says, “Yes, it is a terminal illness, and this is the prognosis” and so on. It is nothing different from what we produce in medical treatment cases before the court at the moment, where the doctors produce expert reports and give evidence. They explain the condition, the prognosis and their decision on capacity, and they explain what is in the best interests of an individual if they lack capacity. As I understand it, the Bill is crafted to produce the evidence as you go along the path here, and then eventually to the judge.

Chelsea Roff: May I add one sentence, because it is related to eating disorders? I would refer to a 2012 Court of Protection case, where a 29-year-old with anorexia was described as being in the terminal stage of her illness and multiple physicians described her death as inevitable. I would also refer to a 2023 case seen at the Court of Protection, which said, “I recognise with deep regret that it will probably mean that she will die.” She was also described as being at the “pre-death stage”. Again, that young woman is still alive and still fighting for services. Although I respect what Mr Amin is saying, and I agree with his interpretation, we have case law in the UK where people with anorexia are being found to be terminal. We have to take that reality into account.

Yogi Amin: I do not think they were found to be terminal. They were described by a doctor in a case as being terminal, and that doctor may not have described it properly.

Chelsea Roff: Indeed, but a judge will be relying on doctors.

Terminally Ill Adults (End of Life) Bill (Money)

Simon Opher Excerpts

Money resolution
Wednesday 22nd January 2025 Commons Chamber

[Sir John Hayes (South Holland and The Deepings) (Con)]

The hon. Member for Spen Valley (Kim Leadbeater) is right that this is not unprecedented; in fact, it is the normal procedure for a money resolution relating to a private Member’s Bill to be debated ahead of Report. That is not true of Government Bills, as you know, Madam Deputy Speaker. However, it is really important that we examine the detail of what we are presented with today, which is an open-ended commitment. The wording makes it absolutely clear that

“any expenditure incurred under or by virtue of the Act by the Secretary of State, and…any increase attributable to the Act in the sums payable under or by virtue of any other Act”,

money is so provided. The hon. Lady says that this is not a blank cheque, but it cannot get much more blank than that. Essentially, any moneys associated with the Bill—if it becomes an Act—will be provided.

Pertinent to this vote, we have to ask the question: where will that money come from? Presumably it can come only from existing resource, and one assumes palliative care; it will not come from A&E, surgical treatments or GPs, so it will presumably come from that source. One does not know, of course, but it is perfectly reasonable to ask that question.

[Dr Simon Opher (Stroud) (Lab)]

Will the right hon. Member give way?

[Sir John Hayes]

I will in a second.

On the judicial point, I simply say to the hon. Lady that the establishment of a judicial competence to deal with this system will be resource-hungry. To offer her a parallel example, when I took the Investigatory Powers Act 2016 through the House, we established what was then described as a double lock—it became a triple lock—which required a whole new judicial function to make it happen. It may well be that the same applies in this case, with immense cost and immense pressure on an already overstretched judiciary.

Therefore, in considering those precise matters—not the ethics of the Bill, which are an entirely different consideration, and highly questionable—it is absolutely right and pertinent to ask what this will cost, when, and how it will be delivered. Those questions have not been answered. I scanned the hon. Lady’s speech on Second Reading, and it contained no mention of scale or cost. That is why I am immensely sceptical about what we have before us. While I accept that the money resolution is not unprecedented, it is certainly not desirable.

--- Later in debate ---

[Dr Simon Opher (Stroud) (Lab)]

Will my hon. Friend give way?

[Maya Ellis]

I will not, if that is all right. Sorry.

At the other end of the spectrum, we need to be acutely aware that we are not today expanding overall budgets in the NHS, so what we agree to in this money resolution will put further strain on our already stretched NHS. That means that, for example, St Catherine’s hospice in my constituency, which already requires private fundraising for almost 80% of its income, will have further NHS funding pulled away to accommodate publicly funded assisted dying. It is prudent for us to make clear what we put at risk if we vote through the Bill, having agreed this money resolution. The resolution means that money for palliative care will likely be diminished. The House should consider that in the next stages of the Bill, given what it is supposedly designed to alleviate.

Finally, let us make it clear what we are agreeing to today. I have asked a few times, and never really got a clear answer, why making assisted dying legal has to go hand in hand with a commitment to funding assisted dying on the NHS. Most of us, including me, fiercely protect the idea of an NHS that is free at the point of use, but we risk maternity services encouraging women to pursue induced births rather than planned caesareans, partly because of resource limitations in the NHS. I caution against an agreement to spend money on guaranteeing dignity in dying when we lag so far behind on guaranteeing dignity in birth, and in many other areas.

--- Later in debate ---

[David Smith (North Northumberland) (Lab)]

I would like to raise a couple of practical and principled concerns about the finances around assisted dying. First, on the practical, I welcome the comment from my hon. Friend the Minister that there will be an impact assessment in due course. However, until we see it, we have no idea what the measure will cost. We are being asked to approve a blank cheque for assisted dying. We have heard that the NHS is a blank cheque, but the NHS has a clearly defined budget. At this point, we do not have any sense of what the Bill will cost. If that were the case for any other legislation, we would be shouting about it.

The Bill represents a profound change to the very nature of our healthcare system, and we are simply guessing at the cost. That is not good for the Bill Committee’s ability to scrutinise, and not good for this place, or for the democratic and legislative process. In order to legislate well, we need a firm commitment. I am glad to have heard that the impact assessment will be published before Report. We have heard from my hon. Friend the Member for Spen Valley (Kim Leadbeater) that the motion is routine, and I accept that. However, the consequences are extraordinary, and that is why this is an important moment.

On the principle, whatever the cost, once it is assessed, and despite the Government’s recent financial boost for the hospice sector, palliative care is massively underfunded. The postcode lottery in the provision of end of life care has led to some of the horror stories that we heard on Second Reading. The hospice sector has only 30% of its funding provided by central Government, so this technical stage represents a commitment to taking potentially scarce funding from end of life care and allocating it to ending lives.

[Dr Opher]

Will my hon. Friend give way?

[David Smith]

I do not have time. That opens up the dark possibility of a race to the bottom—to looking for savings in the health and social care budget. Any Government would be tempted, where cost saving is a possibility, to push assisted dying as a cost-saving measure; we have seen that in jurisdictions such as Canada.

Finally, let me say this with humility and respect to my hon. Friends on my left. I fear that the Bill will lead to the marketisation of death and dying. We have learned from other jurisdictions that many medical services and clinicians do not want to be part of the delivery of assisted dying, for reasons of principle or because they fear that they will be sued. Independent private health organisations will have to take over to fill the space. Those businesses will have shareholders and annual reports. They will be driven by the desire to maximise profit, with death for the bottom line. They will advertise and seek to expand their market share.

[Dr Opher]

Will my hon. Friend give way?

[David Smith]

I am sorry; I am almost finished. This could seem like a tangential point to make on a money resolution, but, to summarise this and my other points, I fear the consequences of the relationship between money—this resolution in particular—and assisted dying. Although I will not be voting against this resolution, because I believe in the democratic process, I think we seriously need to consider the relationship between money and this Bill.

--- Later in debate ---

[Antonia Bance (Tipton and Wednesbury) (Lab)]

Last summer’s Labour manifesto included the words

“Fully costed, fully funded—built on a rock of fiscal responsibility”,

and they were words on which I was proud to be elected. Money resolutions are normally a formality, but not this one—not today. This resolution asks us to give a blank cheque to this Bill, which makes me nervous, because that sounds like something that we in this changed Labour party just do not do. When we put forward a proposal for public spending, we know how we will fund it.

[Dr Opher]

Will my hon. Friend give way?

[Antonia Bance]

No, I will not.

In the case of this Bill, we not only do not know how much it will cost or how it will be paid for, but we do not even know what the money will be spent on. Let us think of the questions that we do not know the answers to. What will be the cost of NHS doctors attending the final appointment and waiting while their patient dies? What will be the cost of a second doctor to sign off? What drugs will be used, and how much will they cost? Will assisted dying happen in hospitals, in hospices or in new, purpose-built facilities? How many will there be, and where?