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

Stephen Kinnock Excerpts

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[The Chair]

I remind the Committee that with this we are discussing the following:

Amendment 422, in clause 9, page 5, line 36, after “records” insert

“make such enquiries of professionals who are providing or have recently provided health or social care to the person as the assessing doctor considers appropriate,”.

This amendment requires an assessing doctor to make such enquiries of professionals who are providing, or have recently provided, health or social care to the person as the assessing doctor considers appropriate.

Amendment 468, in clause 9, page 5, line 37, at end insert—

“(aa) ask the person why they are seeking an assisted death.”.

Amendment 423, in clause 9, page 6, line 20, at end insert—

“(2A) To inform their assessment, the assessing doctor must—

(a) consider whether they should consult a health professional or social care professional with qualifications in, or experience of, a matter relevant to the person being assessed;

(b) consult such a professional if they consider that there is a need to do so.

(2B) Where an assessing doctor consults a professional under subsection (2A)(b), the assessing doctor must give a written record of the consultation to the other assessing doctor.”.

This amendment requires the assessing doctor to consider whether they should consult specialist health or social care professionals, and to consult them if they consider there is a need to do so. A record of any consultation must be shared with the other assessing doctor.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship this afternoon, Ms McVey. When we adjourned at 11.25 this morning, I had just been discussing amendment 201, but I will start again.

Amendment 201 seeks to clarify the wording in clause 9 relating to doctors’ assessments. It provides that the duty on an assessing doctor to examine a person’s medical records applies only to records that appear relevant to the doctor. The effect of the amendment is to make it clear as part of the assessment process that the assessing doctor is required only to review medical records that are considered by the doctor to be relevant to the person’s request to seek an assisted death.

Amendment 422 would add an additional requirement on an assessing doctor to make inquiries of professionals who are providing or have recently provided health or social care to the person and make such other inquiries as the assessing doctor considers appropriate. This applies to the co-ordinating doctor carrying out the first assessment and the independent doctor carrying out the second assessment.

Amendment 423 would require the assessing doctor to consider whether they should consult specialist health or social care professionals. These professionals should have qualifications in or experience of a matter relevant to the person being assessed, and they must be consulted if the assessing doctor considers that there is a need. This applies to the co-ordinating doctor carrying out the first assessment and to the independent doctor carrying out the second assessment. The amendment also provides that a record of any consultation with the specialist health or social care professionals must be shared with the other assessing doctor.

As the Bill is currently drafted, the co-ordinating doctor and the independent doctor are required to ascertain that the person has

“a clear, settled and informed wish to end their own life”.

That is set out in clauses 7 and 8. There is also a power in clause 30(1)(a) for the Secretary of State to issue codes of practice in connection with

“the assessment of whether a person has a clear and settled intention to end their own life”.

There are requirements for the assessing doctors to ascertain that a person is making the declaration

“voluntarily and has not been coerced or pressured by any other person”.

That is set out in clauses 7(2)(g) and 8(2)(e). Amendment 468 would supplement those requirements with a requirement for the assessing doctor to ask a person why they are seeking an assisted death. I hope that those observations have been helpful to the Committee.

[Kim Leadbeater (Spen Valley) (Lab)]

I have nothing further to add.

Question put, That the amendment be made.

--- Later in debate ---

[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.

[Stephen Kinnock]

Amendment 93 relates to the discussion during the assessment that the co-ordinating doctor and the independent doctor are required to have with the person. The amendment would require that each of those doctors, during their assessment, must discuss the nature of the substance that “is to be provided” to the patient to end their life, rather than the substance that “might be provided”.

On amendment 305, clinicians in all areas are expected to work with patients to make decisions about their care and treatment as part of a shared decision-making process, including by discussing the risks, benefits and possible consequences of different options. The Committee may wish to note that the GMC’s “Good medical practice” states that when discussing a patient’s condition doctors must discuss with patients

“the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option.”

[Naz Shah]

That is the very point I am struggling with. Generally speaking, the GMC guidelines are absolutely right, and doctors are saving lives and making the person better. In this instance, somebody might have complications and they might vomit, for example—that happens a lot because people are unconscious. What does the clinician then do? Do they proceed with an assisted death, or do they get the person into A&E? I am trying to understand the answer to that question, and I hope the Minister can respond.

[Stephen Kinnock]

My hon. Friend will know that the Bill states that the assessing doctor must discuss with the individual

“their wishes in the event of complications”,

which could include medical interventions. What is also absolutely clear is that the Bill precludes the doctor from making any intervention, vis-à-vis the patient, that may lead to the patient’s death. The Bill is based on self-administration, not on administration by the doctor. By definition, the actions that can be taken by the doctor are things like calling an ambulance; they would not be things like escalating the substance that has been used in order to bring about the death of the patient. I hope that is clear to my hon. Friend.

[Rebecca Paul (Reigate) (Con)]

I thank the Minister for that explanation. What happens if the patient sets out in advance that they want no interventions? What if they have said, under the clause as the Minister laid out, “In the event of complications, if I am vomiting and in distress, I want no interventions”, but when that happens the pain and distress are at a different level and they are begging the doctor to help them? What does the doctor do in that instance?

[Stephen Kinnock]

The key point, and what takes primacy above all else, is the professional judgment of the doctor. I commend the words of my hon. Friend the Member for Ipswich about every doctor in the profession; he reinforced the point about the immense skill, professionalism and judgment of clinicians and medical professionals across the length and breadth of our country. Clearly, in a crisis situation such as the one the hon. Lady described, the professional judgment of the doctor would kick in and they would take whatever action is necessary. If a patient stipulated what they wanted to happen in the event of complications and something like the hon. Lady just described were to happen, I do not think the doctor would accept those conditions.

[Rebecca Paul]

I thank the Minister for that clarity. Does he think it would be worth while setting that out in more detail, in order to protect doctors and make it really clear what would happen in such a situation? This would be an unprecedented, unique and very new process, and I can imagine substantial moral injury to doctors from being put in that predicament if we are not very clear about what they are required to do and what they are required not to do.

[Stephen Kinnock]

The basic position of the Department of Health and Social Care and, by extension, the Government is that we rely on and trust our medical professionals to make judgments and do the right thing. They take the Hippocratic oath, so they are going to do what is right for the patient in the circumstances of their interaction with that patient. That is set out in guidance and in the corpus of law that we already have. There is a risk of destabilising the system by introducing measures that may well cause confusion and muddy the waters when the waters do not need to be muddied.

[Danny Kruger]

I am afraid that the waters are pretty muddied by the Bill. It states a direct contradiction of the Hippocratic oath, which requires doctors to save people’s lives and do nothing to bring about their death—including giving them lethal drugs. It is right there in the Hippocratic oath. There is obviously a real challenge if somebody has had assisted death drugs and then exhibits complications—if they are not dying quickly, for example, or are showing distress. Normally, the obligation on a doctor would be to relieve their symptoms and try to bring them back to life. Is the Minister saying that is what they should do—and if not, what should they do?

[Stephen Kinnock]

There is a debate to be had about the Bill’s effect on support for a patient. I am not here as a member of the Government to comment on the rights and wrongs of that, but those who support the Bill would argue that a doctor participating in and facilitating assisted dying is actually helping the patient and is, therefore, absolutely aligned with the Hippocratic oath, which is to do no harm. That is in the eye of the beholder, as I am sure the hon. Member would agree, and it is not my job to get into the whys and wherefores of the philosophy that underpins the Bill.

[The Chair]

Order. If we could come back to the amendments, that would be helpful.

[Stephen Kinnock]

I will do so with huge pleasure—thank you, Ms McVey—but I would be more than happy to take up that discussion with the hon. Member for East Wiltshire at another time.

On amendment 142, it is worth noting that options for the method of administration of the substance may change if a patient’s condition alters as they progress through the process set out in the Bill.

Amendment 362 would add to the list of matters that must be discussed at the first and second assessments by the co-ordinating and independent doctors. It would require the assessing doctor to include an explanation and discussion of not only how the approved substance will bring about death, as set out in the Bill as drafted, but the risk and nature of any possible complications, including pain. The Committee may wish to note that the GMC’s “Good medical practice” already states that doctors must discuss with a patient

“the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option”

when discussing their condition.

As it stands, the Bill specifies that the assessing doctor must discuss the individual’s

“wishes in the event of complications”,

which could include medical interventions. However, amendment 306 would go further and specify that medical intervention must be discussed.

I hope those observations were helpful to the Committee.

[Kim Leadbeater]

I will start with amendment 93 tabled by the hon. Member for Solihull West and Shirley. He made a really important point about the language in the clause, and I am very happy to support the amendment.

It is quite clear that, across the Committee, there is no disagreement that a terminally ill person requesting assistance to shorten their death should be given all the information necessary to help them make the clear, informed and settled decision the Bill requires. That should include an explanation of the drugs that are likely to be used—bearing in mind that there may be more than one option available to the person when the time comes, depending on their medical circumstances—and how they would be administered. As such, I am minded to support amendment 142, tabled by my hon. Friend the Member for Broxtowe. Amendments 142 and 93 both provide helpful clarity for the Bill.

There are good intentions behind amendments 305, 306 and 362, but I am confident that they are already covered by clause 9(2)(b)(iv) and clause 9(2)(c). I do, however, take on board the point made by the hon. Member for Solihull West and Shirley about the concept of side effects. Going forward, it might be helpful to look at that use of language. To conclude, I am minded to support amendments 93 and 142.

--- Later in debate ---

[Stephen Kinnock]

The amendments relate to whether the assessing doctor advises the person seeking assistance to end their own life to discuss that with their next of kin and other persons they are close to. Amendment 307 would change the test that the assessing doctor must apply before advising a person to consider doing so. The current test, as set out in clause 9(2)(f), is that

“in so far as the assessing doctor considers it appropriate,”

they must

“advise the person to consider discussing the request with their next of kin and other persons they are close to.”

The effect of amendment 307 is that the assessing doctor must advise the person to consider discussing their request with their next of kin and other persons they are close to, unless the assessing doctor has concluded in good faith that it would not be in the person’s best interests to do so. It should be noted that the amendment as drafted would not require the assessing doctor to inform the person’s next of kin, although there is some confusion, as that appears to be what is suggested by the explanatory statement.

Amendment 308 is consequential to amendment 307 and requires that

“If that doctor considers that it is not in the person’s best interests under paragraph (f), this decision and the doctor’s reasoning must be documented.”

I hope those observations were helpful.

--- Later in debate ---

[Kim Leadbeater]

I will speak briefly to this small amendment, which provides that a further referral be made under clause 10 when a practitioner dies or is unable or unwilling to act as the independent doctor due to illness. In the very unlikely circumstances that the doctor who has agreed to give a second opinion dies or—because of illness or whatever reason—is unable to continue before making a report into the case, it would be right to seek a second opinion elsewhere. I hope the Committee will support my amendment 205.

[Stephen Kinnock]

This is one of the amendments on which the Government have worked with my hon. Friend the Member for Spen Valley to ensure that the Bill is legally robust and workable. As the Bill is currently drafted, in clause 11 there is provision to replace a registered medical practitioner acting as the co-ordinating doctor if they become ill or die. However, there is no similar provision to replace a registered medical practitioner acting as the independent doctor should they be unable to complete their role.

Amendment 205 makes provision under clause 10 that a further referral may be made by the co-ordinating doctor to another independent doctor if the second independent doctor becomes unable or unwilling to continue to make a report of their assessment due to their death or illness, provided that the second independent doctor has not prepared a report. It would thereby ensure internal consistency in the Bill in relation to this matter.

[Sarah Olney (Richmond Park) (LD)]

I reiterate the concern I raised when speaking to my amendments this morning: as far as I can see, seeking the second opinion of a second independent doctor allows the person seeking assisted suicide to have a second bite at the cherry if their first independent doctor has not granted permission. I do not think anyone has an objection to going to a second independent doctor if the first independent doctor has been unable, through either death or illness, to complete the task; nor is there any objection if there has been a material change of circumstances, which my amendment 458 sought to add.

However, the possibility of seeking the view of another doctor simply because the first one did not give the desired answer is a troubling one. There is no objection to patients seeking a second, third or even fourth opinion in medicine when it is about what different treatment pathways might be available, but there is a crucial difference between seeking different appropriate treatment options and what is being proposed in the Bill. In the Bill, the function of the two doctors is not primarily diagnostic or advisory; it is a safeguarding role.

The doctors will have been entrusted by Parliament to make sure that the criteria for assisted dying are met. Their determination makes the difference between a lawful act and the commission of an act that, as per clause 24, Parliament would still regard as sufficiently serious to be a crime. Their role is therefore that of a decision maker, and in no other setting can someone go to a different decision maker if they do not like the answer given by the first. Even in appeals before our courts, an appellate judge would not interfere with a decision simply because they would have reached a different conclusion; the appellate judge must consider that the decision was in some way incorrectly reached.

It is also true that in some settings one can ask a decision maker to reconsider a matter, but that is not what is being proposed in clause 10 either. Instead, the clause allows the person to try again with a different referee if the first one did not give the desired answer. It is true that there is an added layer of protection from the High Court or the possibility of a panel, but under the Bill as it currently is there is no procedure whereby the High Court or the panel will hear from the first independent doctor. That is concerning. They would have to go simply on the basis of the second independent doctor, without any awareness of why the two disagreed.

--- Later in debate ---

[Naz Shah]

I rise to speak to amendment 309 tabled by my hon. Friend the Member for York Central. The amendment proposes that if a doctor changes, there should be a reassessment of the patient. My understanding is that that is in line with current practice: if a doctor is changed, the new doctor has to assess a patient to their own satisfaction because they cannot rely on just looking at notes. It is a sensitive issue where a doctor is required to make objective and subjective assessments, as has been agreed by the Committee to date, in clinical decision making. A clinician does not inherit the risk of another clinician without being satisfied themselves that the conclusion of another clinician aligns with their own.

For instance, the clinician has a responsibility to fulfil their own professional standards and their own duty of care. In the light of the significant impact of the decision, it is important that the doctor can be satisfied as they will need to consent to a patient having capacity and not being coerced. They cannot just take the word of another clinician who has managed the case before them. They themselves need to be satisfied. If a doctor does not do that and something goes wrong, and it comes to light that the patient did not have capacity, the clinician who is the new co-ordinating doctor would carry liability. It does not stand up if they say, “But someone else assessed that the patient had capacity” or, “Someone else said that the patient had not been coerced” if it comes to light later that they have.

This measure would therefore protect the clinician and ensure that the patient understood that a further assessment would need to take place. Having this measure in law would hopefully dissuade doctors from transferring their patients unless absolutely necessary for the continuity of care. It would also dissuade the clinician from taking on a new case if they were aware that continuity of care would be disrupted, due to, for example, a move.

[Stephen Kinnock]

This set of amendments relates to the Secretary of State’s ability to make provision, by regulations, for the replacement of the co-ordinating doctor if they are unable to continue to carry out the functions of the co-ordinating doctor.

I will turn first to amendment 461. Clause 11, as currently drafted, provides the Secretary of State with a discretionary power to make regulations that provide for cases

“where, after a first declaration has been witnessed by the coordinating doctor, that doctor dies or through illness or otherwise is unable or unwilling to continue”.

Amendment 461 removes the “or otherwise”. The effect could be to limit scenarios in which the Secretary of State could make provision via regulations for the replacement of the co-ordinating doctor. The Secretary of State could not provide for replacing the co-ordinating doctor in circumstances other than a doctor’s death or illness, which could include family issues or retirement. That would mean that the person seeking an assisted death may need to begin the process again.

Amendment 310 expands the list of matters that regulations made under subsection (1) may cover. That includes notifying the High Court of substitutions of the co-ordinating doctor, where the co-ordinating doctor is unable to continue to carry out their functions. It should be noted that clause 11 confers only a power, not a duty, on the Secretary of State to make regulations about replacing the co-ordinating doctor. It is not certain that the matter of a substitution of the doctor would be covered in those regulations.

The explanatory statement for amendment 309 suggests that the amendment aims to ensure that a replacement co-ordinating doctor is required to carry out a new assessment of the patient—in other words, to repeat the first assessment made under clause 7. The amendment requires that the regulations that may be made by the Secretary of State under subsection (1) make provision for such cases. Although the Secretary of State has a power to make regulations to provide that the co-ordinating doctor be replaced by another doctor, that is not a requirement. The amendment assumes that there will be a replacement co-ordinating doctor, which is not a specific requirement of the legislation.

[Kim Leadbeater]

I will speak briefly about amendment 461. A co-ordinating doctor is central to the whole process set out in the Bill, from start to finish. If a co-ordinating doctor becomes unavailable, a replacement would need to be found. There may be a number of reasons, not restricted to the doctor’s own death or illness, why that could happen. We have already heard a few examples—it could be retirement, maternity leave or anything going on in that doctor’s personal life. A close family member might fall ill or die, or something else might happen in the doctor’s life that forces them to withdraw. We have talked a lot about patient autonomy, quite rightly, but we need to think about the autonomy of the doctors involved in the process as well. It is therefore important that they have the ability to step away, as set out in clause 11. Additionally, I associate myself with the Minister’s comments about amendments 309 and 310. It feels as though those amendments do not necessarily do what was intended.