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

Stephen Kinnock Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[Kim Leadbeater]

I am going to finish, if I may.

We need to be really careful that we take a person-centred approach, as happens now. Doctors, medical practitioners and healthcare professionals quite rightly take a holistic patient-centred approach. That approach will be further enhanced by the robust training the Bill incorporates, and by adding the extra layers of safeguards and protection. Really importantly, it would open up conversations about death and dying.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairmanship, Mr Efford.

As previously stated, my role, and that of the Minister of State, Ministry of Justice, my hon. and learned Friend the Member for Finchley and Golders Green, is not to give a Government view, given that the Government remain neutral on the Bill, but to outline the legal and practical impacts of amendments tabled.

The amendments are intended to add a new step in the process set out in the Bill, requiring consultation with a palliative care specialist. The purpose of amendment 281 is to require a person to have met a palliative care specialist before completing the required steps and assessments to end their life. The purpose of the amendment is to ensure that the person has understood the full range of end of life options available to them. Our assessment suggests that the present drafting, adding a subsection to clause 1(2), would not achieve that effect without further amendments to other clauses in the Bill. The amendment would increase demand on palliative care specialists and, should Members decide to amend the Bill in this way, we would need to work with the NHS and other provider organisations to assess how to operationalise it.

Amendments 298 and 299 would require the co-ordinating doctor to have received confirmation that the person seeking an assisted death has had a consultation with a specialist in palliative medicine about palliative care options before they are able to make a first statement under clause 7(3)(a). That would mean that a co-ordinating doctor would not be able to make a statement following a first assessment, and therefore refer a person to the independent doctor for a second assessment, unless the person had had a consultation about palliative care options with a palliative care specialist. As with previous amendments, the amendment would increase demand for palliative care specialists, and we would need to work with the NHS and other provider organisations to assess how to operationalise it, should hon. Members decide to pass amendments in that area.

--- Later in debate ---

[Naz Shah]

I just have some concluding remarks. None of the amendments was voted for. I feel that in the clause 1 stand part debate, huge opportunities have been missed. I have talked a lot, throughout the debates, about the issues of people from ethnic minority communities. Opportunities were missed to safeguard disabled people and people from ethnic minority backgrounds.

My hon. Friend the Member for Ipswich made a point about amendments being clear, and about ambiguity. The truth is that if the amendments were supported in principle, they could have been tidied up by Government. There are some good amendments that could have been clarified by the Government. In principle, they were good options. I struggle with the whole narrative throughout the debate on clause 1: “Yes, we accept the principle, but we are not going to do it because it is ambiguous or the wording is incorrect.” There is lots of wording that we will debate throughout the rest of the Bill that is not quite clear, and that is the whole point of going through this exercise. Going forward, I encourage us, as the hon. Member for Reigate did before me, to do as we have been doing, with sincerity, in trying to make this Bill the best in the world it can be, as my hon. Friend the Member for Spen Valley intends.

[Stephen Kinnock]

I will make some brief remarks on the legal and practical effect of clause 1, as amended, to assist hon. Members in making their own assessment. Clause 1 sets out the eligibility criteria that a person must meet in order to request to be provided with lawful assistance to end their own life under the provisions of this Bill. A person must be terminally ill; this term is defined in more detail in clause 2.

Clause 1(1) sets out a further four requirements, which require that a person must also have the necessary capacity to make the decision, which is to be read in accordance with the Mental Capacity Act 2005; be aged 18 or over; be ordinarily resident in England and Wales and have been resident for at least 12 months; and be registered as a patient with a GP practice in England or Wales. This clause provides that, in particular, clauses 5 to 22 of the Bill require steps to be taken to establish that the person has a clear, settled and informed wish to end their own life and has made the decision that they wish to end their own life voluntarily and has not been coerced or pressured by any other person in making that decision.

The clause, as amended by the insertion of new subsection (3), will ensure that the service can be accessed only by an individual ordinarily resident in England and Wales. That amendment, amendment 180, has been drafted to give effect to the policy intent of my hon. Friend the Member for Spen Valley for this legislation: that it is to apply only to those in England or Wales and is not to be accessed via medical tourism.

As I have said, the Government remain neutral on the substantive policy questions relevant to how the law in this area would be changed. The clause is a matter for the Committee and Parliament to consider, but the Government’s assessment is that the clause, as amended, is workable, effective and enforceable.

Question put and agreed to.

Clause 1, as amended, ordered to stand part of the Bill.

Clause 2

Terminal illness

[Danny Kruger]

I beg to move amendment 399, in clause 2, page 1, line 22, leave out “, disease or medical condition” and insert “or disease”.

This amendment ensures that a terminal illness under the Bill can only be an illness or a disease and not a medical condition.

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

Stephen Kinnock Excerpts

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[Naz Shah]

I thank my hon. Friend, but I feel that the point is being missed. It is true that there is no framework, but for somebody to get to this point in the first instance they need to have a terminal illness. There is a framework around domestic violence, and domestic violence laws exist for everybody. Frameworks already exist for women fleeing domestic violence, and there is no shortage of attempts to try to get those legal frameworks right across society. That is why we had the Domestic Abuse Act 2021, why we have committed to halving violence against women and girls, and why the Prime Minister made a personal commitment in that regard—and rightly so.

There has already been a test case in which a judge said that medics have an obligation in this context. An hon. Member referred yesterday to assisted dying being a treatment, although I disagree, and we had that conversation later.

[The Minister for Care (Stephen Kinnock)]

That was a misunderstanding; I was talking about “treatment” as a legal term.

[Naz Shah]

No, I was talking about another hon. Member, not the Minister. We already have laws to protect people from domestic violence, but that does not mean that they necessarily access them.

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

Stephen Kinnock Excerpts

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[Kim Leadbeater]

Absolutely, Ms McVey—thank you for allowing me to make some introductory comments.

Amendments 178 to 180, 182 and 193 simply clarify that only persons in England and Wales may be provided with assistance in accordance with the Act, and only medical practitioners in England and Wales can carry out the required roles at each stage of the process. Hopefully, this is a nice straightforward one to get us started.

[The Minister for Care (Stephen Kinnock)]

I thank my hon. Friend the Member for Spen Valley for her introductory comments. The Government will continue to remain neutral on the Bill and do not hold a position on assisted dying. I want to make it clear that I, along with the Minister of State, Ministry of Justice, my hon. and learned Friend the Member for Finchley and Golders Green, are speaking in Committee not as Members of Parliament, but as Government Ministers responsible for ensuring that the Bill, if passed, is effective, legally robust and workable.

To that end, we have been working closely with the hon. Member for Spen Valley and, where changes have been mutually agreed on by herself and the Government, we will offer a technical, factual explanation for the amendments. Therefore, I will not be offering up a Government view on the merits of any proposed changes put forward by other Members, but I will make brief remarks on an amendment’s legal and practical impact to assist Members in undertaking line-by-line scrutiny.

[Rebecca Paul (Reigate) (Con)]

May I ask how what the Minister has just said interacts with voting? He set out clearly his involvement in the Committee, so how does that impact any votes that he will take part in during it?

[Stephen Kinnock]

I am on the Committee as a Member of Parliament and I vote as such. When I speak on the Committee, I speak as a Government Minister in order to provide factual and technical explanations. As the Bill is a matter of conscience, I will be voting with my conscience on all the amendments as they come forward.

The amendments that we are now debating have been tabled by my hon. Friend the Member for Spen Valley in consultation with the Government. They relate to the location of the person seeking assistance under the Bill and are designed to ensure that the service can only be accessed by an individual present in England and Wales, with a view to preventing medical tourism.

I will take the amendments in turn. Amendments 178 and 193 would ensure that only a terminally ill person in England or Wales may be provided with assistance in accordance with the Bill. Further to that, a requirement is placed on the co-ordinating doctor to ascertain whether, in their opinion, the person who made the first declaration is in England and Wales as part of their first assessment. Amendment 179 would limit the assistance that may be provided in accordance with the Bill to assistance in England or Wales only. Amendment 180 would require the steps taken under clauses 5, 7, 8 and 13 that relate to both declarations and both doctors’ assessments to be taken by persons in England or Wales.

Amendment 182 would limit the provision of clause 4(3), where a person indicates to a registered medical practitioner their wish to seek assistance to end their own life, to cases where the person is physically present in England or Wales. It would prevent people who are outside of England or Wales from accessing assistance in accordance with the Act—for example, by online consultations from abroad.

As I said earlier, the Government will continue to remain neutral on the substantive policy questions relevant to how the law in this area could be changed. That is, as I have made clear, a matter for the Committee and for Parliament as a whole. However, I hope that these observations are helpful to Members in considering the Bill and the amendments tabled by my hon. Friend the Member for Spen Valley.

Amendment 178 agreed to.

[Sarah Olney (Richmond Park) (LD)]

I beg to move amendment 34, in clause 1, page 1, line 4, leave out “capacity” and insert “ability”.

This replaces the concept of capacity based on the Mental Capacity Act and replaces it with a new concept of ability which is defined in NC1.

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

Stephen Kinnock Excerpts

Tuesday 11th February 2025 Public Bill Committees

[Juliet Campbell]

I thank the Committee for allowing me to reiterate the importance of a stand-alone approach. The use of the Mental Capacity Act must be questioned, as the Act was never intended to legislate for assisted dying. Much of what has been said in favour of using the Mental Capacity Act has been about it being tried and tested, so people understand it and to use anything else would make life complicated for professionals who use it as part of their day-to-day activities in assessing capacity.

On the surface, those reasons do seem reasonable and make the Mental Capacity Act an easy option. If, however, the Act does not pass the threshold of meeting everyone’s needs, convenience should not be the deciding factor. Convenience cannot be considered a sufficient reason to use the Mental Capacity Act, as it is a fundamental element of the Bill. The Bill is in itself enough reason to have an alternative or stand-alone approach to determine an individual’s eligibility to be considered for an assisted death.

Capacity is a complicated issue and cannot be oversimplified for convenience. The MCA may be fit for its current purpose, but it is not fit for the purpose of the assisted dying Bill. I have spent more than 20 years working on the equalities agenda, and one of the things that I have learned—this has been a consistent shortfall—is that we try to address new challenges with old solutions, rather than trying to meet the needs of the people we intend to serve. That is the reason why I will be supporting the amendment.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Sir Roger. As was noted earlier, the Government remain neutral. My role here is not to offer a Government view on the merits of the amendments but to provide a factual explanation of their technical and practical effect, to assist the Committee in its scrutiny. This group of amendments focuses on the concept of mental capacity. As drafted, the Bill, in clause 3, states that

“references to a person having capacity are to be read in accordance with the Mental Capacity Act 2005”,

with sections 1 to 3 of that Act establishing the principles and criteria for assessing a person’s capacity to make decisions. New clause 1, which would replace clause 3, and amendments 34 to 47, would collectively introduce the concept of an individual having the ability to make the decision to request assistance to end their life. A person’s ability would be determined by whether they could

“fully understand, use and weigh the relevant information in accordance with regulations made by the Secretary of State”.

That is intended to replace the term “capacity”, used in the Mental Capacity Act 2005, which provides a very specific definition of what it means to lack capacity in relation to a particular decision. A lack of capacity under this framework means that a person must be unable to understand, use and weigh information relevant to the decision, and that that must be directly caused by

“an impairment of, or a disturbance in the functioning of, the mind or brain.”

The “ability” proposal, as drafted, deals only with the use and weight of information.

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

To go back to the point I made this morning—I am happy to stand corrected, but nobody has disputed it—two issues continue to concern me in relation to the Mental Capacity Act and the code of conduct. The first is that the doctor would have a choice, under chapter 5 of the guidance, as to whether it is practical and appropriate to consult other people—with regard to learning disability, for instance.

Also, we have not discussed principle 2 in chapter 2, which says that the doctor has to do everything practicable to try to help the person to make the decision for themselves, before concluding that they do not have the capacity to do so. The principal concern for some Members remains those issues in relation to the Mental Capacity Act, which have not been considered for this scenario. I would like the Minister to address them and the fact that that Act, which was written 20 years ago, was not written for this scenario.

[Stephen Kinnock]

The fundamental position of the Government is that the Mental Capacity Act as it stands is a known quantity. It provides the legal base for a whole range of measures and interventions, and the Government’s view is that it would be an adequate legal base to operationalise the Bill should it receive Royal Assent. Our position on it goes no further than that; it is simply a matter of fact that there is a piece of legislation that is a known quantity.

[Naz Shah]

The Minister makes an important point. I just want to understand something. He speaks on behalf of the Government and says that the Mental Capacity Act is an adequate legal base as it stands. Perhaps the issue is just that I am new to the process—I am happy to be guided, Sir Roger—but we have not had an impact assessment. Normally, Bills do have impact assessments beforehand and the Government go out to consult; they have a consultation process. None of that has happened because the Bill is a private Member’s Bill. I am just trying to understand: is what has been said still true? How do the Government come to that conclusion without all those robust mechanisms that would normally go before a Government Bill?

--- Later in debate ---

[Stephen Kinnock]

As I set out from the Dispatch Box when we had the money resolution, the Government will publish an impact assessment before Report. Given that this is a highly dynamic Bill, with a whole range of amendments having been tabled, and that it is not really possible to publish an impact assessment on the basis of a Bill that has not cleared a Bill Committee, there is a simple point of sequencing. That is why we are going to publish the impact assessment after the Bill Committee has completed.

[Liz Saville Roberts (Dwyfor Meirionnydd) (PC)]

I was glad to hear what the Minister said about the Government accepting the Mental Capacity Act as a basis. We should remember that in 2005, that Act widened the availability of autonomy for individuals. We are discussing that here: how to enable autonomy for individuals. I also really welcome what the hon. Member for Bradford West said about impact assessments. Can the Minister commit now to an impact assessment specifically for Wales? The context of health and social care there is very different from that in England.

[Stephen Kinnock]

I thank the right hon. Member for her intervention. We have had a conversation about the need to ensure that the impact assessment has a clear and specific focus on the impact in Wales. I can absolutely assure her that either there will be a separate impact assessment for Wales, or we will ensure that the impact assessment that we produce is absolutely clear in terms of the impact that it will have in Wales; it will be one of those two.

Personally, I am agnostic as to which of those it is. It is simply a question of what works best given the highly integrated nature of the conversation because the criminal justice aspects of it are a reserved competence, while health and care are a devolved competence. What is the best way to present that—having a single document or two separate documents? I am not entirely clear, but I have undertaken to check the matter with officials. I will get back to the right hon. Lady as soon as possible on that point.

[Danny Kruger]

I am very puzzled, on two grounds. The first is about the impact assessment. I simply do not understand the argument that the Government have to wait until the end of the Committee stage before they can have a view on the Bill and present it for Report. The fact is that the Bill could change again on Report, and the impact assessment would have to be updated further. Why on earth do we not have an impact assessment, which could advise the members of the Committee and the Government themselves on the appropriateness of the measures?

That brings me to my second point of confusion: I simply do not understand what on earth the Minister means when he says that he is neutral about the clauses. He has just given the view, from his position, that he objects to the amendment and that he supports the use of the Mental Capacity Act. He is basing his view— I had understood that, as a neutral member of the Committee, he was not going to express one—on something. What is he basing it on? Secondly, how can he express a view when he is supposed to be neutral?

--- Later in debate ---

[Stephen Kinnock]

The Government choose when to bring forward an impact assessment based on the passage of the Bill through the House. We have had reports today about a very substantial amendment to clause 12 that may well be brought forward by my hon. Friend the Member for Spen Valley, for example. It is not possible for the Government to conduct and publish an impact assessment when quite significant changes are being made.

I also gently point out to the hon. Member for East Wiltshire that this is not a Government Bill; it is a private Member’s Bill. It is also worth noting that it is unprecedented, as far as I know, to have oral evidence sessions for a private Member’s Bill, so we are already on relatively uncharted territory. It is also relatively uncharted territory to have, on a Bill Committee, Ministers who are neutral because the position of the Government is neutral. But that reflects the fact that this is indeed uncharted territory, so that is where we stand.

The hon. Gentleman made a point about our own positions on the subject; I speak also for the Minister of State, Ministry of Justice, my hon. and learned Friend the Member for Finchley and Golders Green. It is a matter of public record that I supported the Bill on Second Reading. It is also the case that we vote, as members of the Committee, on the basis of our conscience because this is a matter of conscience; that is why the Government are neutral on it. There is no whipping from the usual channels.

At the same time, we are articulating the position of the Government. The hon. Member for East Wiltshire asked how we come to that position. It is through the usual process of engaging with officials and experts in the field, and through taking into account all the considerations that the Government need to take into account for the operationalisation of the Bill. The Government then come to a view, and that is the view that I express when I am on the Committee.

[Sarah Olney (Richmond Park) (LD)]

The Minister says that the Government have made their own choice about when to do the impact assessment on the Bill. Does he not accept that it would have made sense to have done it before the Committee stage? Then, any evidence that the assessment threw up could have given rise to amendments tabled during the Committee stage—that would have made it an appropriate time to have done the impact assessment. The impact assessment could then always have been updated depending on how the Bill was then amended during Committee.

[Stephen Kinnock]

The hon. Member makes an interesting point. I simply reiterate that this is a very dynamic Bill Committee; I believe that 362 amendments have been tabled. Given the Government’s focus on establishing the Bill’s implementability, the coherence of the statute, the legal dimensions and the complexity of what we are dealing with, we took the position that it was better to wait for the Bill to clear Committee stage before producing an impact assessment. To do otherwise could have involved a large amount of second-guessing based on radical changes that might well have come out of the Bill Committee. I reiterate the logic of that sequencing.

On the point about the established legal framework, which clinicians have been applying since 2007, “capacity” would still be used for other decisions about care and treatment.

I turn to amendment 202, tabled by my hon. Friend the Member for Spen Valley on the advice of the Government. It ensures that the assessment of “capacity” is utilised by the assessing doctor, and corrects a typographical error in clause 9 to ensure that an assessment of capacity will apply consistently throughout the Bill. As I said earlier, how and whether the law on assisted dying should change is a matter for this Committee and for Parliament as a whole. However, I hope that these observations are helpful to the Committee when considering potential changes put forward.

[Kim Leadbeater]

I will try to keep my comments brief. It is excellent that we have had such a thorough debate on this particular issue, but I am also very conscious of time.

I will do the quick and easy bit first. As the Minister has just said, amendment 202 is to correct a typographical error in the initial drafting of the Bill—despite the high level of expertise involved in the initial drafting of the Bill, that one managed to sneak through. The amendment would simply change the word “capability” to “capacity”, to be consistent with the rest of the Bill.

I now come to amendments 34 to 47 and new clause 1. As we have discussed, those would replace the concept of “capacity”, which is based on the Mental Capacity Act, with a new concept of “ability”. I think that suggestion is coming from a good place and is made with good intention by the hon. Member for Richmond Park; I thank her for her positive engagement with the Bill. However, based on the oral evidence that we received, particularly from the chief medical officer and many other experts, the suggestion would seem unnecessary given that we already have—as has been discussed at length this afternoon—a very well established piece of legislation that is effective in this regard.

The primary purpose of the Mental Capacity Act is to promote and safeguard decision making within a legal framework. As the CMO and other colleagues have said, issues around mental capacity

“are dealt with every day, in every hospital up and down the country; every doctor and nurse above a certain level of seniority should be able to do that normally.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 31, Q3.]

That view was supported by Yogi Amin, an expert in Court of Protection work, human rights and civil liberties, who told us during the oral evidence sessions:

“It is well understood how capacity assessments are done, and it is ingrained”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 140, Q176.]

--- Later in debate ---

[The Chair]

Happily, that is not a matter for the Chair. However, let me make it clear that the two Ministers present are members of the Committee in their own right as Members of Parliament and are therefore permitted to speak and vote, as are all other Committee members. Were any Minister to feel that there was a conflict between their personal view and the view that the Government wish to express, my understanding is that that would be a matter for discussion between that Minister and the Government. More than that I am afraid I cannot offer.

[Stephen Kinnock]

Further to that point of order, Sir Roger. I thank the hon. Member for East Wiltshire for his question. Let us take this back to first principles.

This is a private Member’s Bill. A Bill Committee had to be formed. The Committee was formed in discussions between the Member sponsoring the Bill, the Whips and the House authorities. The principle of formulating the Committee was based in large part on the steer given by the debate and the vote on Second Reading, which delivered a majority of 55 in the House. The numerical composition of this Committee was therefore based on that majority of 55, broadly speaking. My hon. Friend the Member for Spen Valley needed to put together a Committee that reflected that.

The position was also taken that there should be Government Ministers on the Committee who had to speak for the Government with neutrality. It is with those two factors in mind that the Committee was put together. The two functions that my hon. and learned Friend the Member for Finchley and Golders Green and I have reflect the two purposes that were in mind when the Committee was put together.

[The Chair]

Again, that is not a matter for the Chair. Points of order are not matters for debate; they are points of order.

[Stephen Kinnock]

My apologies, Sir Roger. It was just a point of clarification.

[The Chair]

That is all right. Nevertheless, I am minded to refer the matter to the Clerk of the House for his consideration. This is no reflection on either of the hon. Gentlemen, or indeed on the Committee, but there are issues here that I think the Clerk of the House perhaps needs to consider in the broader context.

--- Later in debate ---

[Stephen Kinnock]

The amendments relate to the criteria that individuals would need to meet to request assistance to die under the Bill. All the amendments seek to amend the eligibility criteria in some manner. To reiterate, the Government have no view on the policy questions pertaining to the amendments, and my role here is to offer observations on the legal and practical impact of amendments tabled. The legal impact of these amendments will be the main focus of my remarks.

Amendment 353 seeks to make prisoners ineligible for assisted dying services even if they meet the definition of having a terminal illness. Amendments 354 and 355 are consequential amendments that would make it a requirement for the co-ordinating doctor in the first assessment and the court process to ascertain whether a person seeking assistance to end their own life is a prisoner.

Aside from the right to liberty, article 5 of the European convention on human rights requires that prisoners should have the same rights as those who are not prisoners. The rights engaged by the amendment are article 8 on the right to respect for private and family life and article 14 on the protection from discrimination. Making prisoners ineligible for assisted dying would, on the face of it, lead to a difference in treatment between prisoners and non-prisoners that would need to be objectively and reasonably justified. The justification test requires that the treatment in question is a proportionate means of achieving a legitimate aim.

[Naz Shah]

I note that the Minister used the word “treatment” twice, but we are not talking about a treatment; we are talking about assisted death. I think someone mentioned earlier that it is a treatment, but it is not a treatment, is it? I would welcome his clarification on that.

--- Later in debate ---

[Stephen Kinnock]

I thank my hon. Friend for that intervention. My understanding is that it is termed as a treatment under the law. The Government do not take a view on the semantics of the word; my understanding is that that is how it is classified under the law.

[Sarah Olney]

It is really important that we establish whether this will be defined as a treatment or indeed as something quite distinct in law. My understanding is that the word “treatment” should never apply to assisted dying. I would be grateful for the Minister’s clarification.

[Stephen Kinnock]

I apologise; I think I misunderstood the intervention of my hon. Friend the Member for Bradford West, so my comments were not clear. I meant the treatment of this matter under the law. As I said, the justification test requires that the treatment in question is a proportionate means of achieving a legitimate aim. That means the way in which the matter is treated under the law. That is what I meant; I think we got our wires crossed.

Finally, let me address amendments 356, 357 and 358, whose purpose is to exclude those who are homeless within the meaning of section 175 of the Housing Act 1996 from the definition of a “terminally ill person”. The effect of amendment 356 would be to amend the definition of a “terminally ill person”, as set out in clause 1 of the Bill, to expressly exclude a person who, notwithstanding that they met all the other requirements set out in paragraphs (a) to (d) of subsection (1), was homeless within the meaning of section 175 of the Housing Act 1996.

Amendments 357 and 358 seek to make consequential amendments to clause 7 on the first doctor’s assessment and clause 12 on court approval. These amendments would require the co-ordinating doctor and the court to be satisfied that, in their opinion, the person was not homeless within the meaning of section 175 of the Housing Act 1996 before making their statement or declaration to allow the person to proceed to the next stage of the assisted dying process.

Article 14 states that the rights set out in the ECHR should be secured for everyone without discrimination on any ground. This amendment engages article 8 on the right to respect for private and family life. Making those who are homeless ineligible for assisted dying would lead to a difference in treatment that will need to be objectively and reasonably justified. The justification test requires that the treatment in question is a proportionate means of achieving a legitimate aim.

I hope these observations may be helpful to Members in considering these amendments and making a determination about who should be eligible for accessing assisted dying services, should the Bill pass.

[Danny Kruger]

What an interesting debate—I am grateful to all hon. Members who participated.

I am interested in what the Minister was saying about the ECHR. Notwithstanding my general point about the sovereignty of Parliament, when Lord Sumption gave evidence to the Committee two weeks ago, he stressed the wide margin of appreciation given to member states on the ECHR. Does the Minister think that that will apply in this case to ensure that the British Parliament could vote to exclude these categories of people? If his view is that the Bill could be subject to challenges on discrimination grounds, however, particularly under article 14, I think we will have a lot of problems in applying the Bill. I wonder whether, in due course, we will be able to tease out how the ECHR will intersect with the Bill.

As the Minister says, the crucial point is that any discrimination must be justified on the basis of achieving a legitimate and proportionate aim. My suggestion is that there is an absolutely legitimate aim, and that this is a proportionate means of achieving it.

The debate got quite philosophical, which I found very interesting. I observe that my constituency neighbour, esteemed colleague and great Conservative, my right hon. Friend the Member for North West Hampshire, has a vision of our particular political creed that is entirely individualistic. He stresses the absolute importance of individual autonomy, treating everybody as an individual without reference to the context in which they live. I suggest to him, and to the Committee, that our freedom and autonomy depend on our relationships. Our autonomy proceeds from our socialisation. We do not emerge fully formed into the world with all our values and attributes; we acquire them by virtue of the people around us.

The crucial thing about the prison experience is that it disrupts the relationships that can make an individual genuinely free. Homelessness does likewise, and it sets up all sorts of new relationships and new socialisations that can often be very negative.

--- Later in debate ---

[Kit Malthouse]

I understand what the hon. Member for Broxtowe is trying to achieve, but I believe that her amendments are unnecessary. “Demonstrably” is a word that is commonly used in British law, effectively to emphasise that something is important, but also to ensure that something is proven. She will have seen that I have tabled amendments to the Bill to require two declarations to be produced: one by the patient, to say that they have had the conversation about all their options, understand their options and understand what their prognosis is likely to be; and one by the co-ordinating doctor, to say that they have had the conversation and that the patient is in full possession of all the facts they need and understands what has been communicated to them.

My view is that those declarations, as well as the assessment that the doctor has to go through to confirm that the person has a settled wish to do this, are enough to show that the person demonstrably wants to access the service for themselves. I am concerned that amendment 109, like other amendments that we will debate later, would insert into the Bill a series of individual words that will unnecessarily complicate its contemplation by doctors. We heard in evidence that for the Bill to work, it needs to be simple and understandable by everybody who is dealing with it. The more we can minimise the number of words that may be open to interpretation by lawyers —and we certainly have plenty of lawyers in the room— the better. From that point of view, I will oppose the amendment. I understand what the hon. Lady is trying to achieve, but I believe that we have achieved it by different means.

[Stephen Kinnock]

The amendments in the name of my hon. Friend the Member for Broxtowe relate to an individual who seeks to access assisted dying services demonstrating their wish to end their own life and demonstrating their understanding of the process by which that happens. To support the Committee’s deliberations, I will briefly summarise the Government’s analysis of the effect of the amendments.

Amendments 109, 110 and 111 would modify the requirement that the co-ordinating doctor and the independent doctor must undertake an assessment to ascertain whether, in their opinion, the person has a clear, settled and informed wish to end their own life. That would be amended to require the person to have a clear, settled and demonstrably informed wish. The term “demonstrably” would not provide further practical guidance beyond the words already in the Bill and could create uncertainty as to what constitutes being demonstrably informed.

I turn to amendment 112. Clause 9 currently provides that the co-ordinating and independent doctors must explain and discuss a number of matters with the person being assessed. These matters are set out in clause 9(2)(b), (c) and (d). In the interests of time, I will not go through each of those matters, but they include an explanation and discussion of the person’s diagnosis and prognosis, any treatment available and the likely effect of it, and the further steps that must be taken before assistance can lawfully be provided to the person under the Act.

The amendment would create an additional requirement for the co-ordinating and independent doctors. It would require them both to be satisfied that, in their opinion, the person seeking assistance has demonstrated their understanding of the matters that have been discussed under clause 9(2)(b), (c) and (d). The amendment does not specify in any further detail what the doctors would be required to look for to satisfy themselves that a person has demonstrated their understanding. That would be left to their professional judgment, with training, support and guidance, as with other concepts in the Bill. The amendment would leave it to the co-ordinating and independent doctor’s professional judgment to determine what “demonstrated their understanding” looked like in respect of each individual person.

I hope that those observations are helpful to the Committee.

[Danny Kruger]

I have just a few points to make. I very much applaud the hon. Member for Broxtowe for her amendment, which would genuinely—demonstrably, I might say—strengthen the Bill. It does not seem in any sense hostile to the principle or purpose of the Bill; it supports it.

To make a gentle criticism, I think that there is a concern about the lack, throughout the Bill, of a proper trail of documentary evidence following the applicant through the process. For example, the two conversations with the doctor would take place behind closed doors, and no record of their discussion would be made. I do not think that conducive to trust. There is no way to assess whether the safeguards are actually in operation.

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

Stephen Kinnock Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[Jack Abbott]

Q I will keep my question quite short. Is there anything about the law in either of your jurisdictions where you think there could be improvement, and that we can learn from in drafting our legislation here?

Dr Kaan: The thing I have been reading about that is concerning to me is the court approval that you seem to have written into your law. I heard your discussion this morning about how that might be done and whether it is a committee or the High Court and so on. I think that that is really going to limit access to this, and that makes the process a much lengthier one.

Again, these are people at the end of their life. People are not looking, by and large, to cut off a huge amount of their life; they are looking to shorten their death, not shorten their life. By making people go through a court appeal in addition to two qualified physicians, as well as the waiting period, I think that you are going to limit access for people who desperately want this option. It seems like that might be baked into your law, but I would say that that is a concerning feature to me. I think that you are going to limit access that way.

Dr Spielvogel: Something that it turned out was not in our law, but everyone thought that it was for a few years, and it really limited our practice, was that many people were under the impression that the physician could not bring up assisted dying with the patients, and that the patients had to bring it up themselves. That turned out not to be in our law, but that idea really hampered our ability to take care of patients, so I would strongly recommend that there not be anything like that in your Bill. People cannot make informed decisions for themselves if they do not know what their options are. While this is top of mind for all of you and for the doctors—we all know that this exists—even if this Bill becomes law, the general population is still not going to realise that it is an option.

I eat, sleep and breathe this. I am a primary care physician, and when I am going through the options with patients who are newly diagnosed with a serious life-threatening illness, I say, “Okay, here’s what disease-directed treatment would look like. We can continue with your chemo. Here are some side effects and complications that you might have, and here are the benefits of that. Here’s what palliative care or hospice care would look like.” Then I say, “I don’t know if you know this, but in our state we have this other option for people nearing the end of their lives when they have intolerable suffering. You can ask me to fill a lethal prescription for you to help end your suffering sooner.”

The number of times that people look at me and say, “You can do that? That’s an option here?” is astounding. I would say that nine out of 10 of patients I have conversations with have no idea that that is even legal. If they do not know it is an option, they are never going to ask for it. For physicians to do their jobs properly and deliver care to people, and for people to actually have a choice, physicians need to be able to discuss it with their patients.

Dr Kaan: I will just piggyback on that. I cannot count the number of times I have given a presentation or a talk to communities, and people—usually family members of someone who have died, not using this law—have come up to me afterwards and said, “Thank you for what you said. My loved one was interested in having this information, or wanted to talk to their doctor about it, but their doctor never brought it up, so we weren’t sure if we should be bringing it up.” It is a huge burden to put on patients and their loved ones if they have to bring it up themselves. I would highly caution against any sort of language that requires that, because it is just not fair to them. They are already going through so much and, as Dr Spielvogel said, you cannot have an informed decision-making discussion with a patient if they do not have all the options available for discussion.

[The Minister for Care (Stephen Kinnock)]

Q I want to drill down a bit more on the question of training. Could you say a bit more about how the training works? Is it mandatory for everyone who takes a medical qualification to a certain standard? How many class hours are required? Is there an in-practice shadowing process? Is there an assessment process to verify that the person is qualified as a result of the training? I am just trying to get a better sense of the detail of the training. I will perhaps start with Dr Kaan.

Dr Kaan: That is a really important question, because this is a really important topic in the United States. Our laws are very clear that participation is voluntary, so there is no such mandatory training across medical training in general. It is always voluntary. If a physician or provider wishes to have training, they can seek it out. What is available and the standard of care differ from state to state. Certainly, in the state of Washington, where I am the medical director of the organisation that is most largely involved with this, the bulk of my job is doing training, mentoring and shadowing. There is no exam at the end of that process, but there is certainly shadowing and a feedback process.

I am also heavily involved with the Academy of Aid-in-Dying Medicine, which has been very active in creating professional training. We have a Journal of Aid-in-Dying Medicine, which is a peer-reviewed journal that puts out articles that are relevant to the topic. The Academy of Aid-in-Dying Medicine is now undertaking certification pathways, so each level of provider—social workers, chaplains, physicians and anyone else who might be involved in the aid-in-dying process—will be able to take these certifications. A more uniform education system will be available. We are just at the beginning of creating those, but it is very exciting, and we are very happy to have those out. A lot of resources are out there in the world already, in general, to train providers in how to do this well, and it would be really smart to have something in your Bill that outlines what the training should be, whether you will make it mandatory or voluntary and perhaps some sort of certification pathway.

[Stephen Kinnock]

Dr Spielvogel, I do not know whether you have anything new to add to that. If not, that is fine.

Dr Spielvogel: Without repeating anything that Dr Kaan said, I was just going to say that in addition to my assisted dying hat, I am also the programme director for the family medicine residency programme, so my main job is actually training young physicians who are becoming what you would call GPs.

We have instituted curricula as part of our residency programme here to train interested physicians in learning how to do assisted dying. We go through a whole process for that, including lectures, them shadowing me and me shadowing them, listening in on their conversations, giving them pointers and walking them through the steps of the process. They then do this with multiple patients through the course of their residency, so when they graduate, they feel confident in being able to offer this care. As with most medical training, this should be included in that part of the training process. All the other things, such as pathways in continuing medical education, are very important for physicians out there in practice who want to start doing this, but really getting this into medical training at its roots is vital for normalising the practice.

Speaking of which, something else I have heard a lot is that this might be distressing to physicians, or that physicians would not want to offer this care. I would like to say that 80% of our residents on our programme opt to receive this training. When we did a study on this of graduates from our programme who were continuing to offer assisted dying, 70% of the surveyed residents said that their assisted dying work was more rewarding to them than the rest of their primary care work—70% said that it was more rewarding.

I want to come back to the notion that physicians would feel burdened or that this would be some sort of psychological negative to physicians practising it, because it is actually quite rewarding work. It has led me to be a better physician to all my patients because it has helped me with having these difficult end-of-life conversations with them. That was a bit of a twofer, sorry—I added that on there.

[Danny Kruger]

Q I have four very quick questions. I would be grateful if you could try to answer them quickly, because we have to let everybody else in before the end of the session. Dr Spielvogel, I was struck by you saying that nine out of 10 patients to whom you have suggested this option were not aware of it. How many people who did not know about it before and to whom you might have suggested assisted dying as an option do you think have taken it up? How many people do you think benefited from you telling them about the option?

Dr Spielvogel: A lot. I have actually been quite surprised. Everybody is different. This is the whole point: different people have different goals, objectives and values. I have mentioned it to people who say, “No, I would never do that,” and I never bring it up to them again.