Terminally Ill Adults (End of Life) Bill

Naz Shah Excerpts

2nd reading
Friday 29th November 2024 Commons Chamber

[Tim Farron (Westmorland and Lonsdale) (LD)]

The motives of those proposing the Bill are grounded in compassion—in the heat of this debate, I want to seriously acknowledge that—particularly the hon. Member for Spen Valley (Kim Leadbeater), who has conducted herself with great dignity throughout. Neither side has a monopoly on compassion—I will always be affected by watching my mum suffer at her death at the age I am now—so let us not think badly of one another’s motives; let us instead be courteous and let us be curious.

My opposition to the Bill is grounded in compassion. To legalise assisted dying would be to create the space for coercion that would undoubtedly see people die who would not otherwise have chosen to do so. There are no safeguards in the Bill that would prevent that.

[Naz Shah (Bradford West) (Lab)]

Will the hon. Member give way?

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

Naz Shah Excerpts

Committee stage
Tuesday 21st January 2025 Public Bill Committees

[Kit Malthouse]

I was going to make exactly the same point. I think my hon. Friend the Member for East Wiltshire has fundamentally misunderstood what is happening. He referred to there being a discussion through the usual channels. What the hon. Member for Spen Valley has proposed is that we have that discussion now—she said informally—because we have not had the chance to do so before, and that we then return. Then my hon. Friend is free to say whatever he likes about whatever witnesses and table his own amendments as he wishes. There is no intention to conceal anything. If I might be so bold, I think he has misunderstood the process.

[Naz Shah (Bradford West) (Lab)]

Just following on from the speech of the right hon. Member for North West Hampshire, I would not read the situation as a misunderstanding by the hon. Member for East Wiltshire. I read the motion to sit in private not as an informal discussion, but as a very formal discussion. I am grateful to the lead Member for the Bill, my hon. Friend the Member for Spen Valley, who before this meeting explained to me what has now been explained here—about the issue of people’s availability, privacy and so on. But I do not suspect that we will be going into those details. If people are not available, we do not have to discuss why they are not. We do not have to discuss their personal lives. I am not sure that that is a good enough reason not to have a discussion in public. I trust colleagues across the Committee to be collegiate enough and big enough to refer to witnesses with respect. I think that is a given, considering the way in which we have conducted the Bill so far. I therefore do not support the motion to sit private.

[Sean Woodcock (Banbury) (Lab)]

rose—

--- Later in debate ---

[Kim Leadbeater]

I beg to move,

That—

(1) the Committee shall (in addition to its first meeting at 2.00 pm on Tuesday 21 January) meet—

(a) at 9.25 am and 2.00 pm on Tuesday 28 January;

(b) at 9.25 am and 2.00 pm on Wednesday 29 January;

(c) at 11.30 am and 1.00 pm on Thursday 30 January.

(2) during further proceedings on the Terminally Ill Adults (End of Life) Bill, the Committee do meet on Tuesdays and Wednesdays while the House is sitting at 9.25 am and 2.00 pm.

(3) the Committee shall hear oral evidence in accordance with the following Table:

[Naz Shah]

I beg to move manuscript amendment (b), after “General Medical Council”, insert “, Royal College of Psychiatrists”.

[The Chair]

With this it will be convenient to discuss the following:

Manuscript amendment (c), after

“Dr Ryan Spielvogel (Senior Medical Director for Aid in Dying Services, Sutter Health, USA)”,

leave out

“Dr Jessica Kaan (Medical Director, End of Life Washington)”

and insert—

“Dr Ramona Coelho (Family Physician in Ontario Canada, founding member of Physicians Together with vulnerable Canadians)”.

Manuscript amendment (d), after

“Dr Miro Griffiths (University of Leeds)”,

leave out

“Yogi Amin (Partner, Irwin Mitchell)”

and insert—

“Ellen Clifford (Co-ordinator, UK Deaf and Disabled People’s Monitoring Coalition. Author and Visiting Research Fellow within the Centre for Applied Philosophy, Politics and Ethics at Brighton)”.

Manuscript amendment (e), after “Lord Sumption” insert “Karon Monaghan KC”.

Manuscript amendment (f), leave out

“Dr Chloe Furst (Geriatrician and Palliative Care Physician, Adelaide), Alex Greenwich MP (MP for Sydney, Parliament of New South Wales), Professor Meredith Blake (University of Western Australia)”

and insert—

“Dr John Daffy, previously head of infectious diseases at St Vincent’s Hospital in Melbourne, Dr Stephen Parnis, previous Vice-President of the Australian Medical Association, Professor Sinead Donnelly, a Consultant Palliative Medicine Professor in New Zealand”.

Manuscript amendment (g), leave out “Dr Amanda Ward” and insert

“Barbara Rich (Barrister) and Dr Philip Murray (University of Cambridge)”.

Manuscript amendment (i), at end of table, insert—

[Naz Shah]

On amendment (b), given the issue we are considering, I think it is important that the Royal College of Psychiatrists is involved. One thing that is very important to me is the issue of coercion, and the royal college would be able to shed light on that. One of the many reasons advanced for giving the Bill its Second Reading was that we would have further debate, and the royal college would add value to that.

On amendment (c), Dr Ramona Coelho is a physician with well-founded concerns about the operation of the law in Canada. She is a member of the Ontario Medical Assistance in Dying Death Review Committee, and she gave evidence to the Scottish Parliament Committee that considered the Assisted Dying for Terminally Ill Adults (Scotland) Bill.

On amendment (d), Ellen Clifford is co-ordinator of the UK Deaf and Disabled People’s Monitoring Coalition, and she has a key role in advocating for people with disabilities.

[Danny Kruger]

I want to speak in support of the proposed addition of Ellen Clifford. Last week, she won a High Court case against the previous Government for their consultation on benefits reform, so she is no friend of my party, but she is a powerful advocate on behalf of disabled people, and she represents the deaf and disabled people’s organisations that are so important in informing the Government on the implementation of policy that affects disabled people. I recognise that the hon. Lady has included some representatives of the disabled community, but I suggest that there would be particular value in hearing from Ms Clifford because of her role as the co-ordinator of the monitoring coalition of all these deaf and disabled people’s organisations across the country. She is the best person to advise the Committee on the operation of the Bill.

--- Later in debate ---

[Naz Shah]

Given what you have just said, Sir Roger, I would be happy not to go through the individual amendments unless anybody wants to comment or wants me to add anything.

[The Chair]

I do not wish to prevent the hon. Lady from speaking to any of the other amendments, because we have grouped them all. She was doing very well. If she works through them, that will tell other Members where she is coming from.

[Naz Shah]

Thank you, Sir Roger.

By adding Karon Monaghan KC, an eminent equality and human rights law barrister, amendment (e) would add balance among the lawyers in the Committee. I would also like to add James Munby, or someone from His Majesty’s Courts and Tribunals Service, because we need someone who can speak to court capacity issues in relation to the Bill. Professor Katherine Sleeman is a great expert on all these matters.

I am going through the list, and I am unclear what the Australian MP would add. If we remove the other two, there are other pro-AD Australian experts who will speak instead. If we replace those three, who are experts from—

[Kim Leadbeater]

On a point of order, Sir Roger. My hon. Friend has just mentioned two names that are not in her amendment, and I find that slightly confusing.

[Naz Shah]

These are replacements of the words in your paper.

[The Chair]

Order. First, they are not mine. Please remember that you are addressing the Chair.

Secondly, the hon. Member for Bradford West has a list of amendments that she has tabled, to add some people and remove others. Patently, she cannot refer to people who are not on that list. If she works through it name by name, I think we will get to where we need to be.

[Naz Shah]

I appreciate that, Sir Roger. Adding Richard Robinson—

[Hon. Members]

Not on the list.

[The Chair]

Are we working from the same list? [Interruption.] Order. Continue to work through the list and you will get to where you need to be.

[Naz Shah]

Thank you, Sir Roger.

[Danny Kruger]

I want to make a general point in support of the hon. Lady’s suggestions.

[The Chair]

No, I am sorry. Please let the hon. Lady finish her speech.

[Naz Shah]

I apologise. I thank everybody for bearing with me on this one.

Amendment (e) would insert Karon Monaghan KC after Lord Sumption. I have said that I would like her added because of her expertise.

Amendment (f) would insert Dr John Daffy, previously head of infectious disease at St Vincent’s hospital in Melbourne, Dr Stephen Parnis, previous vice-president of the Australian Medical Association, and Professor Sinéad Donnelly, a consultant palliative medical professor in New York. That is what I was speaking to when I was talking about having three people from one country and not having an alternative voice. I think it is really important to have an alternative voice, and I am not sure what added value the MP for Sydney would bring to the debate when we have so many people contributing from countries that are pro and delivering, rather than from those that have concerns.

Amendment (g) would remove Dr Amanda Ward and insert Barbara Rich, barrister, and Dr Philip Murray from the University of Cambridge.

[The Chair]

I think you have one more. Would you also like to speak to amendment (i)? It is on the other side of the amendment paper, which we nearly all missed.

Let me assist the hon. Lady: she wishes us to insert, at the end of the table in the sittings motion, a new set of witnesses on Thursday 30 January, to give evidence until no later than 5 pm.

--- Later in debate ---

[Kit Malthouse]

I rise to speak to amendment (b) and to the other amendments tabled by the hon. Member for Bradford West. As we discussed in private, I am concerned that the promoter of the Bill, the hon. Member for Spen Valley, has been through an extensive period of trying to collate everybody’s recommendations for the Bill and reach a list that is both manageable within the timeframe and a compromise for all of us on what we would like to see.

The odd adjustment here and there is fine, but we ought to bear in mind that in any one session we need to have sufficient time for people to speak. We have to be careful not to double up because we may or may not think that a particular witness might propose a view with which we are sympathetic, when we already have people who are covering the same subject. On amendment (b), for example, all psychiatrists are regulated by the General Medical Council, as I am sure the hon. Member for Bradford West knows, so effectively the royal college is a doubling up of expertise, which is not necessarily in the interests of time. Similarly, in amendment (c), the hon. Lady is proposing a physician from Canada—

[Naz Shah]

rose—

[Kit Malthouse]

I will just finish, if I may. Our Bill is built on a very different legal framework from Canada’s. Drawing legislative parallels between the two seems like a cul-de-sac, not least because, as the hon. Lady will know, the legal framework in Canada is dictated by the charter of rights and freedoms, effectively a constitution, which has been used there to widen the scope of the law. Canada started from a very different place as well, so I am not totally convinced.

What the hon. Member for Spen Valley has tried to do with the list is to find overseas territories that are analogous to our own and have adopted a model similar to ours. We are therefore trying to learn lessons from the process of debate and legislative procedure that they went through—either to learn from them or to learn from their mistakes. For example, knocking out the Member of Parliament from Australia would be a mistake, not least because Australia has been through a number of iterations with its law. Most of Australia has a bar on doctor initiation of the conversation. The medical profession think that that is a big negative in Australia, as I understand it, so I would like to understand why, politically and in legislation, it was felt that that was needed or helpful, and why it was imposed.

On the other amendments, the hon. Member for Bradford West is making a value judgment about comparative expertise between Amanda Ward and whoever she wants to propose instead—Philip Murray. I do not know why she is making that value judgment, but as far as I can see, the names were properly submitted in the process. The hon. Lady obviously had the chance to submit names during the process. For better or worse, as she may see fit, the hon. Member for Spen Valley has come up with a list that is a compromise. That is not to say that the hon. Member for Bradford West cannot arrange briefings with any of these experts outside the formal process, for Members to attend should they so wish, or that she cannot seek advice from them during the process of the Bill.

My primary concern about the amendments is that we are opening up a whole area of debate where we could all have gone with our suggestions. I would rather stick with the list that we have, because I fear that the hon. Member for Bradford West is doubling up and making value judgments about expertise that are not necessarily warranted.

--- Later in debate ---

[Kim Leadbeater]

I thank colleagues for their time this afternoon. It has been an extremely productive session. I am very proud of the tone of the debate: I think we have done a very good job, as we did on Second Reading, of showing this place in a good light.

I reiterate that there are a range of views in this Bill Committee, in the same way that there are a range of views across the House on this significant and deeply emotive issue. There are a range of views among the witnesses we will hear from, and I spent a huge amount of time ensuring that. Colleagues have given me more than 100 names of people they might like to hear from. I had my own list of people I would like to hear from, and many of them are not on the list of those who will give oral evidence.

I have tried to be extremely balanced, so we will hear from people with a range of views and opinions, but most importantly we will hear from people with expertise. That is the purpose of the Committee: to hear from people who can advise us on the detail of the Bill. We will go through this Bill line by line, and we need to hear from people who can help us to do that. We have some fantastic expertise on the Committee, but for many of us there are areas that we need to learn more about. It is important that the witnesses give us the information to enable us to do that, rather than—as numerous colleagues have said—once again going over the fundamental principles around assisted dying, because we did an excellent job of that on Second Reading.

At the end of our endeavours, we will produce a piece of legislation that will be re-presented to the House, and colleagues will again have the opportunity to vote on it however they see fit. There may be people in this room who vote differently from how they voted on Second Reading; there may be colleagues out there who do likewise, one way or the other.

I am very clear about this Committee’s role, which is to work on the Bill together, collegiately and collaboratively, irrespective of our different views, and re-present it to the House so that the House can continue to do its job. It is not just the Commons; the Lords will also have the opportunity to scrutinise the Bill and table amendments. I have always been open about the fact that this is about us working together. Where the Bill needs to be amended to make it more robust and alleviate people’s concerns, whether that is around coercion or capacity, that is now the Committee’s job. I stand ready to serve and to do that.

We have spent a lot of time this afternoon on this, and quite rightly so. As far as I am concerned, we are now in a position to move forward. I am very happy that we will hear from so many witnesses over several days, and I am happy that I have added more time to that so that we can hear from more witnesses, which I think is important. As colleagues have said, our job now is to get on with this really important piece of work.

[Naz Shah]

I thank my hon. Friend the Member for Spen Valley, the promoter of this Bill, because she has been very helpful. She has certainly added one of my key witnesses to her list, and I am grateful for that.

I want to respond to some of the points that have been made. One of the biggest issues for me is amendment (b), which would insert “Royal College of Psychiatrists”. My hon. Friend the Member for Ashford made the point that all psychiatrists come under the GMC, but not every member of the GMC is a psychiatrist. That speaks to the issue of coercion, mental health and capacity. That is the expertise that I am looking for in the line-by-line scrutiny of the Bill, and I would really like to hear from the Royal College of Psychiatrists.

I am happy to be guided by you, Sir Roger, because I am new to this process and I have not done a Bill of this nature before, but my only worry with the outside evidence and briefings is that they will not be on the record when we are looking at Hansard and seeing whether they have been taken into account. I would be happy to receive some assurance about that. Yes, we can organise lots of briefings and lots of experts, but does that not defeat the object of having this debate so robustly in the first instance?

The hon. Member for Harrogate and Knaresborough raised the issue of language, and the point about added value. I think that language is correct, because I do want to add value to this debate. I want value added, because it is important for my constituents that when I vote on the Bill on Report, I do so knowing that I have listened to all sides of the debate.

My hon. Friend the Member for Stroud asked whether this is a for-and-against argument. In particular, he said that we do not need to hear from those who are opposed, because we want to strengthen the Bill so that it can go through the House. Although I appreciate the sentiment, I put it to everyone that it is not about getting the Bill through; it is about getting the right information so we can scrutinise whether it is fit to go through the House. For that reason, it is important to hear from those who are opposed. It is naive to think that we only need to hear from people who are in support.

[Tom Gordon]

Will the hon. Member give way?

[Naz Shah]

Sorry—may I just make my point?

I need to know the other side of the argument in order to make a balanced decision. Those who are opposed to the Bill might have very valid concerns, while those who have expertise in support of the Bill might not give me the same arguments. I want to hear a balance. At the moment, I think there is a real discrepancy between the number of people who are for and against the Bill; it is not very close.

I appreciate that my hon. Friend the Member for Spen Valley, the Bill’s promoter, really wants to get this legislation through Parliament. I also value how she has taken part in the debate and been amenable to having discussions both in Committee and in our offices. I have given my reasons for tabling the amendment, and I particularly want the Committee to accept amendment (b), on the Royal College of Psychiatrists; that is my top amendment.

Question put, That the amendment be made.

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

Naz Shah Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[The Chair]

We are now sitting in public and the proceedings are being broadcast. Before we begin, I remind Members to switch electronic devices off or to silent. Tea and coffee are not allowed during sittings. Before we start hearing from the witnesses, do any Members wish to make declarations of interest in connection with the Bill? No.

We will now hear oral evidence from Professor Sir Chris Whitty, chief medical officer for England, and Duncan Barton, chief nursing officer for England, NHS England. Before calling the first Member to ask a question, I remind Members that questions should be limited to matters within the scope of the Bill. I also remind Members that time is tight, so please keep your questions to the point. We must stick to the timings in the sittings resolution that the Committee has already agreed. For this session, we have until 10.05 am. Will the witnesses please briefly introduce themselves for the record? If you are to give an opening statement, please keep it short.

Professor Whitty: I am Chris Whitty, the chief medical officer for England, and I am also representing the chief medical officer for Wales. One statement, which is on behalf of Duncan and myself, and all the CMOs, is that we are completely neutral on the principles of the Bill, which we consider are entirely for society and therefore for Parliament. Although we are answering technical questions, we will not be answering questions of principle, because we feel that is a societal question. We have made it clear to the medical profession, however, that individual doctors should be able to make whatever statements they wish. Obviously, doctors have strong views on all sides of this argument, as members of society do.

Duncan Burton: Good morning. I am Duncan Burton, the chief nursing officer for England. For transparency, I will say that I am also a volunteer trustee of a hospice.

[Naz Shah (Bradford West) (Lab)]

Q Sir Chris, I draw your attention to clause 42(3):

“But if any provision of this Act has not been fully brought into force before the end of the period of 2 years beginning with the day on which this Act is passed, that provision (so far as not already in force) comes into force at the end of that period.”

My question is: do you believe that it would be safe to implement this legislation if those provisions had not been fully put in place?

Professor Whitty: If this Bill is passed—I want to stress that; I will say it once, but assume it applies for all the answers I subsequently give—we will clearly need both: a period to make sure that there is technical guidance and legislation, via secondary legislation, because obviously the primary legislation is the Bill; and necessary training for people to be able to do this in an appropriate and dignified way, if that is what Parliament chooses.

[Naz Shah]

So would it be safe?

Professor Whitty: We would want to have the time to do that, but you can do things at speed if you need to. My view is that this is something that is best not done at speed if we can avoid it.

[Naz Shah]

Q I am a former NHS commissioner, Sir Chris. In Bradford West, we have stark health inequalities. Dr Jamilla Hussain, as part of John Wright’s team, will be providing evidence this week. She has found huge mistrust among marginalised ethnic groups—even more so since covid. We know that covid brought to light the inequalities in healthcare access that already existed, especially for economically disadvantaged communities. What lessons do we need to learn from covid and its disproportionate impact on ethnic minority communities when it comes to this Bill in particular and its implementation?

Professor Whitty: That is an absolutely critical question, because it is very important that if the Bill is passed, all parts of society, of whatever ethnicity and of whatever background, have equal access to the Bill—or not, as Parliament determines. That will require adjustment in a variety of ways. Some can be done at a macro level—for example, making sure that everything is translated into the major languages spoken in the United Kingdom—but a lot of it will be to do with the individual interactions that doctors, nurses and other healthcare providers have with individual patients, which must take into account their own starting point, their own knowledge and, most importantly, their own beliefs.

[Lewis Atkinson (Sunderland Central) (Lab)]

Q Sir Chris, you mentioned having time to ensure that people are appropriately trained, and the Bill includes provisions for the Secretary of State to make orders around required training. Could you say a little bit more about that? If Parliament decide to pass an Act of this nature, what training would be helpful and required—in particular around skills, and the assessment of capacity and coercion?

Professor Whitty: I will give my view, and it might be useful to get Duncan’s view on the nursing side, because nurses will often be heavily involved in these discussions.

I would divide the kind of training that is needed into two broad groups: training that is essentially normal medical practice but may need some variation, and things that are clearly specific to this Bill. Issues, for example, around mental capacity—as determined by the Mental Capacity Act 2005—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. It may require some slight adjustment. There is an absolute expectation within the Act, for example, that the more serious the decision, the greater the level of capacity that someone needs to have. That is already built into the principles of the Act and the way that things are done. I would extend that to the management of end of life, which should be a normal part of medical and nursing practice—we will all die eventually, and that has always been part of medicine, and always should be. That training should be generic, but may need some adaption.

There will then be some specific things that will be necessary for people to understand the legislation, including, in some cases—if this Bill is passed—if they are to take part in the final part of prescribing drugs to patients. It is much more likely that a very large number of doctors and nurses may get involved in the very earliest stages, because someone may raise an issue with their GP, nurse or consultant, who will need to have the basic understanding for that. In my view, the more detailed later stages will require some specific training. I think there will be a gradation of doctors: those who are happy to have the general, initial conversation; those who are happy to have the structured conversation that follows; and a minority who will be happy to go on to take part in the final stages.

It is very important that the wishes of the patient are respected. That is the central point of this. We must start with what is good for someone in their last six months of life, and for their immediate family, but we must also make sure that the wishes of healthcare professionals around this area are absolutely protected, when it comes to conscience and to choice.

Duncan Burton: I am mindful that there are two groups of staff who would potentially be working in this service, if the Bill is passed, but also of the wider workforce. At 2 o’clock in the morning, when a patient wants to have a conversation with somebody about end of life, it is going to be a nurse with them, or a nurse in a care home, or a specialist nurse providing cancer care, so we have to think about the training and support that is required for them, be that around signposting or explaining where they can go to access more information. There is an important part about the entire wider workforce that we need to think about.

Clearly, for those people who are working in such a service, we need to think about the safeguarding elements, and how we make sure there is support through safeguarding training and confidentiality—particularly mindful that some patients may choose not to tell their families about this. We need to think about how we enable and support staff in managing those kinds of circumstances and navigating the legal requirements through the Bill. We need to think ahead about what we need to do in undergraduate training for doctors and nurses, and in the curriculum.

--- Later in debate ---

[Lewis Atkinson]

Q So you would be happy if there was an explicit prohibition on recommendation.

Dr Green: I am reluctant to make a statement on that in this forum. We will go away and discuss it, and come back to you.

[Naz Shah]

Q This question applies to both of you. On there being a first doctor and a second doctor, the first doctor is required to determine that the patient has a terminal illness, that they have capacity, and that they are not being coerced or pressured. Again, it is for the second doctor to make sure that the patient has a terminal illness, that they have capacity and, again, that they are not being coerced or pressured. I appreciate that Sir Chris Whitty talked about doctors, and you talked about everybody, being trained in capacity and coercion issues, but those doctors may never have met in the first instance the person who is seeking assisted dying.

The question that worries me is, to be able to fulfil all those actions in all cases, without fear of mis-determining, the two doctors would have to be specialists in all the relevant diseases. For example, if somebody has a brain tumour, lung cancer, or a different type of cancer, would the doctor have to be an expert in that to determine that the person is terminally ill?

From the GMC’s point of view, would we find ourselves in a situation where doctors are working outside their professional competencies and expertise? From the BMA’s point of view, how do we protect doctors from finding themselves having to diagnose life expectancy for a disease they are not a specialist in, or to determine capacity when they are not a specialist in that, or to determine a lack of coercion when they potentially do not know the patient and do not have experience of that? Finally, when the next step is taken and the court has to rely on the testimony of these doctors to protect the patient, can those testimonies safely be relied on by a court and by a judge, given all those concerns?

Mark Swindells: There are quite a few points there—let me work through them backwards. We have some existing guidance for doctors when they act as a witness—for example, in a court setting or a medical legal situation—that talks in general terms about the importance of being an appropriate witness. Inherent to that is some expertise and understanding of the topic they are assisting the court on. I suppose that those sorts of principles would be ones that, if the Bill is passed in this form—I say again, the GMC does not have a view on what the delivery mechanism or the Bill should look like—are applicable points from the guidance, which would read across.

You heard from the chief medical officer his caution with regards to going with a condition-based assessment for this sort of thing. We would not have a particular view on that, but there is one thing that I want to highlight. The Bill talks about specialism in the context and seeking advice from a psychiatrist. On the specialist register held by the GMC, there are five specialisms connected with psychiatry, so some clarity—whether the Bill is intended to cover any, or a particular one, of those—would be good.

I know that it is not restricted in the “independent doctor” and “coordinating doctor” roles in the Bill either, but we are aware that when doctors pursue a specialty, in the sense that they become accredited and go on to our specialist register, that does not fix in time their individual scope of practice or expertise. Many doctors will go into slightly different fields, or focus on one particular area, so one cannot necessarily rely on the specialist register as a current indication of a doctor’s area of competence in that way. On what the precise delivery mechanism is and the point you make about whether either of those two roles of doctor have seen the person, because we have not taken a view on what the law should be, we have not taken a firm view of any process or eligibility, but I note the point.

Dr Green: If I may, I will clarify my previous answer, having had a little more thought. I do not believe that it is ever appropriate for a doctor to recommend that a patient goes through an assisted dying process. My internal thoughts on whether it should be on the face of the Bill, contained in guidance or contained in good medical practice was the point that I was unsure about.

[Lewis Atkinson]

indicated assent.

Dr Green: With regard to the specific questions, no, I do not believe that a doctor has to be a specialist in the individual disease at stake to advise a patient about prognosis. I can only refer you back to what Dr Whitty said: that in the majority of cases, it is fairly clear—this applies to capacity, too—but in some cases, it is not so clear. What is important is that the doctor has the ability to seek further advice if they need it; it is not always required.

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

Naz Shah Excerpts

Committee stage
Tuesday 28th January 2025 Public Bill Committees

[The Chair]

Members should indicate if they wish to ask a question and who they wish to ask.

[Naz Shah (Bradford West) (Lab)]

Q Thank you very much for those introductions. I have a few questions for each person on the panel. Mr Sanderson, do you think palliative care in this country is fit for purpose?

James Sanderson: There are clearly gaps in the provision of palliative care. However, to start with a positive, I think that the provision of palliative care in this country is exceptional. We are leaders in many ways across the world in the way in which we support people who are facing those challenges in their lives. However, our findings in relation to palliative care show that, although about 90% of the population could benefit from palliative care, only 50% of people are currently able to access it.

One of our concerns is that the provision of palliative care across the country is quite patchy at the moment. I do not think there has been a thorough assessment of the level of palliative care in place—not just the provision of palliative care specifically, but how other services, such as district nursing services, interact with palliative care. In some areas, the provision of district nursing services for general care and support for people who may be at the end of their life is very strong and in other areas it is not so strong.

At Sue Ryder, there is one thing that we are really concerned about. In our survey, 77% of respondents said that they were concerned that the lack of availability of palliative care might enable more people to consider an assisted death than otherwise would. That concern went up to 84% for those who were in favour of assisted dying. We really need to look at the provision of palliative care and the specifics in the Bill that make reference to the fact that people should be offered what is available to them. We need to have a much clearer definition of what “available” means.

[Naz Shah]

Q Dr Ahmedzai, in the evidence you submitted, you said:

“I have studied the reports from, and spoken with medical and nursing clinicians from US and Australian jurisdictions and am satisfied that external coercion has never been reported or led to a prosecution.”

The state of Oregon carried out a survey of people who died under its assisted dying scheme in 2023. Its report stated that 43% of those who chose to die said they did so because they felt they were, and I quote directly from the term used in the survey, a

“Burden on family, friends/caregivers”.

Is that something you are prepared to see happen in the UK?

Dr Ahmedzai: It goes absolutely to the core of being British—we are always saying sorry, aren’t we? We apologise for everything. In everything we do, or everything we might do, we think we might be treading on toes and are always worried about being an imposition. All my professional life, I have come across patients and families in which there clearly is that feeling going on, usually with an older person or even a younger person who is drawing a lot on the emotional and physical resources of the family. It is natural that we feel a burden; it is impossible to take that out of human nature.

The issue is, does feeling that one is, or might become, a burden something that could influence a decision as major as looking for assisted dying? In that respect, I look to all those jurisdictions that have been offering assisted dying in different ways, and I have never seen a single case ever taken to the police or prosecuted. Evidence I have heard from other jurisdictions shows that, yes, it is possible—we all go through life feeling that we are a burden on someone—but it does not influence people in this particular decision. If anything, I am told that, in other jurisdictions, families are saying, “No, don’t do it.” They are exerting negative coercion—“don’t do it” coercion—but people are saying, “No. It’s my life. I’ve made my mind up.” They have mental capacity, and we respect that.

[Sean Woodcock (Banbury) (Lab)]

Q Coercion is one of the main issues that people who are concerned about the Bill raise in opposition to it. That would include myself. We had many distinguished witnesses this morning, and the view was that coercion is “rare” in healthcare generally. It was almost given across that we did not need to worry about it, because staff are so well trained in safeguarding and so on, and they have such a level of experience. What are the views of the panel on that? Is coercion something that we should really not be so concerned about?

Dr Clarke: Based on my clinical experience, I would push back on that in the strongest terms. I am the kind of doctor who believes there is nothing to be gained from sugar coating reality. We have to be absolutely honest with patients and the public about shortcomings, failings and areas where my profession and the rest of the NHS are getting things wrong.

It is my clinical experience that not only are the majority of doctors not necessarily trained in spotting coercion explicitly, but they are often not trained explicitly in having so-called advance care planning conversations with patients around the topic of death and dying, and how a patient would like the end of their life to proceed. It is almost impossible for me to overstate how much avoidable suffering occurs right now in the NHS not because of a lack of resources for palliative care—although that is an enormous problem—but because of a lack of confidence, skill and expertise among the medical profession writ large with these very difficult conversations.

We are all familiar with the idea of death and dying being a taboo in society. People are scared of it, and they hesitate to bring it up with their friends and family. In my experience, many medical students and doctors also suffer from that anxiety. They are scared, and they find it a taboo subject. What that means is that sometimes coercion occurs because the doctor—the consultant responsible for this person’s care—will not even bring up the fact that they think the patient is dying, because it is an uncomfortable conversation. Conversely, I have worked with senior hospital consultants in the NHS who have deliberately prevented our team from accessing their patients, because they believe that the hospital palliative care team wants to kill the patients, and that if I go and see the patient, I will give them a lethal dose of drugs.

These are the kinds of extraordinary misunderstandings and failures to prioritise patient autonomy that are happening now. That is even before we get started on conversations around whether someone would like to consider assisted dying, so it is a huge problem.

--- Later in debate ---

[The Chair]

Q We will now hear oral evidence from Sir Max Hill, former director of public prosecutions, Alex Ruck Keene, a barrister specialising in mental capacity, and Sir Nicholas Mostyn, who is a former High Court and Court of Protection judge. For this session we have until 4.15 pm. We may be interrupted by a Division. Could the witnesses please introduce themselves for the record?

Sir Max Hill: Good afternoon. I am not sure how much by way of introduction you want, so please stop me. I was the UK independent reviewer of terrorism legislation 2017-18, and the director of public prosecutions 2018 to 2023—so I stopped 15 months ago. I am not a campaigner; I am here to bring any experience of criminal casework that I may have picked up along the way, as that was part of my diet as DPP. I have been quite close to the construction of the Bill, and I am happy to deal with any questions that I can.

Sir Nicholas Mostyn: I am Nicholas Mostyn, and I was a judge of the High Court family division, of the Court of Protection and of the administrative court until 2023, when I retired with the onset of Parkinson’s disease—which is a genuine slippery slope, unfortunately. I am now a podcaster and devoting myself to alleviating the hardships of people living with Parkinson’s.

Alex Ruck Keene: I am Alex Ruck Keene. I am a barrister in independent practice, and I need to emphasise that I am giving my evidence as a self-employed barrister, not on behalf of any organisation I am associated with. You will have seen from my written evidence that I am associated with quite a few different organisations, because my practice and career straddles both advising and appearing in court cases involving mental capacity. I teach law on the end of life as a professor of practice at King’s College London. I am also heavily involved in law reform in different ways; for instance, I was the legal adviser to the Independent Review of the Mental Health Act 1983. I also do an awful lot of training in the context of mental capacity of both healthcare and social care professionals.

[Naz Shah]

Q I have just one question, and it is for Sir Max. You have said that you were very concerned about the CPS, during your time at DPP, having to investigate people who accompanied their loved ones to Switzerland to end their lives. I share that concern. However, my understanding is that around half of those who currently visit Dignitas would not qualify for assisted dying under the Bill, because they do not have a diagnosis of six months to live. Is the Bill the right measure to solve the problem that you are actually worried about?

Sir Max Hill: If the problem is anybody in future going on their own or accompanied by their loved ones to Dignitas, the answer is no—this Bill does not satisfy that. What we have learned from other jurisdictions around the world, where we see broader or multiple groups beyond the terminally ill who are entitled to use new legislation, has not been the model for this legislation, unless you and Parliament were to dramatically change it. The nuanced answer to your question is that this Bill does provide an opportunity for those in the category of being terminally ill, as defined in the Bill, to no longer have to resort, on their own or supported by loved ones, to going to Dignitas. So, yes, it can and will make a positive difference.

I should add, in answering this question, that my often-quoted personal experience is that 27 cases investigated as assisted suicide came across my own desk as the DPP —five to six cases a year. A substantial proportion of those cases did involve Dignitas, because an accompanying relative who had returned alone was then investigated, but a proportion did not involve Dignitas at all, because there had been deaths at home. Of all those 27 cases, I made the decision to prosecute in only one, which was the case of an individual who was 19 years of age encouraging another teenager to end their life. That was a correct and successful prosecution.

I will also add—because until 15 months ago I was a prosecutor, and prosecutors look to bring criminal cases whenever the law is broken—that there was an additional handful of cases in which, although I was not making the personal decision, I supported authorisation of charges for murder or manslaughter where it was clear that an individual’s life had been brought to an end not at the time of their choosing. It is perhaps important to remember that this Bill, as and when passed—that is a matter for Parliament—would not truncate the homicide jurisdiction in this country. It will still be possible to prosecute for murder in those cases when one would expect to be prosecuted for murder. I think it is important to say that, as a very recent former prosecutor.

[Naz Shah]

Q Following up on that, in the cases in which you authorised prosecution for murder or manslaughter, were issues of coercion ever involved? What were the bold points—the top lines—of those prosecutions?

Sir Max Hill: That small handful of cases involved an elderly couple where either he—it was usually a he—or she had chosen to bring to an end the life of their lifelong partner and, once that act had been carried out, claimed that it was an assisted suicide in circumstances where the surviving partner was merely carrying out the wish of the person now dead. There are a handful of cases in which that is clearly wrong and should not be accepted and where murder should be the offence brought before the court.

The point, though, is that throughout the time that I served as DPP—and, indeed, the time served by all my predecessors—we did not have the coercion offences created by the Bill, which I suggest would be a significant advance, and nor did we have a legal system in which the investigation was taking place before the death. It was the other way around. In each of the 27 cases I considered, the deceased individual was already dead, and that is when the scrutiny started. The major advantage of the Bill, if I can put it that way, is that that will be reversed, and scrutiny will be before death. In the case of coercion, where it fits the new potential clauses, prosecutions can—and, I am sure, will—be brought.

[Dr Tidball]

Q It is extremely helpful to understand the opportunity for scrutiny before death. Building on that point, are there any safeguards around those practices that are not currently included in the Bill but should be, particularly around detecting coercion and exploring alternative care options? I also have one follow-up question, if I may.

Sir Max Hill: I think that coercion and the coercion clauses in the Bill should be read alongside the capacity clauses. What we are looking for, as required by clause 1(1) and clause 1(2), is a clear, settled and informed wish, voluntarily made without coercion or pressure. Those aspects were taken, at least in part, from the Crown Prosecution Service guidance on 1961 Act cases. Capacity involves understanding information, retaining it, using it and communicating it. If those hallmarks are not there, you may be in a situation where you should be considering coercion. I think you read the two together.

To answer your question directly, the criminal liability clauses—clause 24, and the new offences in clauses 26 and 27—are robust. As a matter for your scrutiny, they are aspects that we do not have in the law at present. There is, of course, the addition of clause 36, under which you cannot be a witness or a proxy to the procedure that is enshrined in the Bill if you are too close to the terminally ill person. That is another hallmark of the Bill that will hedge against coercion.

--- Later in debate ---

[Danny Kruger]

Q I will just jump straight to my final question. Dr Kaan, you said that you felt that people who felt they might be a burden were exercising their autonomy, and it was a perfectly appropriate reason to seek an assisted death. Is that right, and do you think there is anything more we should do to make it easier for people to access this right? Do you think they should be asserting anything other than their wish to do so?

Dr Kaan: You characterised it correctly in that I think that for people who have capacity, and who are making the decision to have this as an option, a part of their reasoning is that they want to save their family from an onerous caregiving experience. I think that is their right and it is part of their value system.

Of course, if that is the only reason, we are going to be exploring that. As Dr Spielvogel has said, that is a red flag. We are going to be exploring that, and exploring whether acceptable alternatives exist and what are the resources that the person may not be aware of. That is always part of the discussion. These discussions are always broad and multifactorial. But I think it is appropriate and okay for somebody to say, “I do not want my family to experience what I myself had to experience when I was caregiving for my elderly parents with dementia.” I have heard that many, many times. I do think people who have capacity should have their autonomy respected, in terms of the values that are driving them to make this decision.

We always want to work towards improving the social support for caregiving that exists in our society. There is certainly a lack of it here in the US, and probably there in the UK as well. Hand in hand with allowing people to make an informed decision about the option of having an assisted death, you should also be a strong advocate for social support and caregiving services at the end of life, because those really are important and needed.

[Naz Shah]

Q Dr Spielvogel, there is a Bill in California, SB 1196, which was introduced on 24 February 2024. It proposes, first, to remove the six-month terminal illness prognosis and allow requests from those with a “grievous and irremediable” disease causing unbearable suffering; secondly, to allow dementia patients to request assisted suicide if two doctors deem them to have capacity; thirdly, to allow self-administration of lethal drugs via intravenous injection; and, fourthly, to eliminate the sunset clause in the current law. Do you know what the status of that Bill is? Is it still live? It suggests a significant broadening of the law, which would have similarities to that in Canada, and it would seem to reinforce the slippery slope argument.

Dr Spielvogel: That is a good question. I do not know the specific status of the Bill, but I would assume that it has itself undergone an assisted death at this point. That Bill is not really being supported by any of our advocacy groups or, by and large, the physicians who perform assisted dying, because it is, as you mentioned, very broad and not aligned with how we feel standard practice is going and where we would want it to go. That Bill did not receive support from many of us.

[Naz Shah]

Q In California—we are talking specifically about renal failure—they have got a six-month limit, in some cases, because of insurance policies. Is that being broadened out? I understand there is a huge difference in American politics in the laws regarding lobby groups, and so on, and the influence of those insurance companies. We have an NHS to which those restrictions do not apply. Have you done any analysis on that? How would you respond to that?

Dr Spielvogel: Can you clarify what you mean about kidney disease and the six-month prognosis, and the interplay with insurance there?

[Naz Shah]

Q When it comes to renal failure, in particular, there are people who can request assisted dying because their insurance company will not pay for more than six months. Here we have an NHS, in which there is no limit on the kind of interventions you would have to live a longer life.

Dr Spielvogel: That is not factually accurate. When people go on dialysis, they automatically get Medicare, which is our version of the NHS, more or less. That is a national health insurance for people who are 65 and older or who have certain kinds of diseases. When you have end-stage kidney disease and you need dialysis, you automatically get Medicare and you get dialysis for the rest of your life, however long that is. People are often on dialysis for years. It is not that you are on it for six months and then you are off.

[Naz Shah]

Q Does that cover all conditions?

Dr Spielvogel: We were just talking about kidney disease.

[Naz Shah]

Q Yes, but does it cover any conditions that would fall under the scope of a six-month bill?

Dr Spielvogel: If you have a six-month prognosis to live, regardless of the condition, that would fall under this. That would make you eligible. That has nothing to do with insurance coverage for your condition. Insurance coverage is completely separate. It is not tied to this. All that prognosis does is to allow the individual to seek this care.

[Naz Shah]

Q Sorry, but just to clarify, the question was: would the availability of Medicare apply to all those conditions that come under the six-month prognosis? As for kidney failure, would they be entitled to Medicare? Would all the other conditions included also be entitled to Medicare once the insurance ran out?

Dr Spielvogel: No. Insurance does not run out. There is maybe a misunderstanding of how medical insurance works in the US. Medical insurance does not run out. I think we are talking about two different things.

[Naz Shah]

Q But there are cases where insurance companies would stop paying for the treatment of the individual. Am I right?

Dr Spielvogel: No, I actually do not think that you are right. When we are talking about lifesaving interventions such as chemotherapy or dialysis, that is not correct. They are bound by law to cover all things that are medically necessary. They do not say, “You have gotten six months of chemo. We are not paying for any more.” That is not how it works.

[Sean Woodcock]

Q It seems clear from what you are saying that in your view, coercion is rare, or at least it is rare in comparison to familial pressure not to go ahead with assisted dying. It does sound, though, like you are saying that it is more common for people to say that they feel as though they are a burden towards the end. I think Dr Kaan said it was common, or certainly less rare than coercion to go ahead with assisted dying.

We heard from experts earlier about the paucity and lack of provision of care across the country. Certain people can get access to very good care, but too many people struggle to, particularly people of certain ethnic backgrounds, people on low income, and so on. Please correct me if I have misinterpreted your views, but from what you have said so far, it sounds as if you think that exercising the right to assisted dying because there is a paucity of appropriate care in your locality, or because you cannot afford it, is a perfectly legitimate exercise of autonomy, based on the society around you. Would that be a fair assumption of your views?

Dr Kaan: I think that is not an entirely fair representation of what I am saying. Yes, we do need respect for people’s autonomy and the reasons they may come to this choice, but I also think that from what I have heard this morning, it sounds like there is a conception that people choose assisted dying and then they do it. What I see, by and large, is that people want to have this as an option. It is an option among the other options of hospice palliative care or palliative treatments. The availability of this as an option often brings people tremendous relief from their suffering—just from the anxiety over how they might die, or what suffering might be in store.

I had a case of a woman with ALS, or amyotrophic lateral sclerosis. She was very afraid of how she might die with that condition, and she felt like she might suffocate to death. She was so focused on having the option of aid in dying because she was terrified of what might be in store for her. We were able to incorporate her into a hospice that offered comprehensive end-of-life care, including the option of aid in dying. We got her through the process, we had the medications available and she told me how much relief she felt from having it as an option, but ultimately she decided not to use it. She decided that she was getting really good care from her palliative care and hospice teams, and that her symptoms were well controlled. Although she was extremely grateful that she knew the medications were available should she decide to use them, she did not end up needing to use them or wanting to use them.

That is the reality of what is happening in a lot of cases where this is an option among other options. The availability of this option is, in and of itself, a palliative care treatment for many people. On whether or not wanting to avoid being “a burden” to a family member or to a caregiving team is a valid reason to pursue this, yes, I think that is a valid reason among many for people who have a value system that highly orders that.

Dr Spielvogel: I just wanted to add something, if I may. I have heard this argument—or rather, this concern—a few different times, and it strikes me as what is called a false dilemma logical fallacy: that there is either/or, when in reality there are many alternatives that people can choose from. Saying “If we don’t have all of these types of care, we shouldn’t offer this option” is like a hospital that does not have sufficient amounts of IV pain medications saying to a labouring woman, “Well, we don’t have enough IV pain medications, so we are not going to offer you a labour epidural, because that is a false choice.” That does not actually make sense.

Look at it from a patient’s perspective. Think about a patient who is dying from terminal cancer, is in lots and lots of pain and does not have any good options for their pain control. Imagine saying to that person, “We don’t have all of this care or this option over here available to you, so we are not going to allow you to have an assisted death”, even if they are telling you, “This is what I want. Why won’t you give this to me?”. It does not make sense to remove this as an option just because all of the options might not be available to everyone all of the time. It is a bit cruel when you think about it from a patient’s perspective.

--- Later in debate ---

[Kim Leadbeater]

These amendments allow additional witnesses to be called to give oral evidence, including representatives from Disability Rights UK, the Royal College of General Practitioners, the Royal College of Psychiatrists, and an expert in Welsh devolution and constitutional matters.

As the sessions today have shown, hearing from expert witnesses is an extremely important part of this process, so I hope I have the support of the Committee in making these additions. On the motion to call additional witnesses tabled by my hon. Friend the Member for Bradford West, I respect the suggestion but I am confident that we have an eminently qualified witness to cover issues of coercion and domestic abuse in Professor Jane Monckton-Smith, who was suggested by my hon. Friend.

We have also heard today—and will hear from many witnesses over the next few days—from medical doctors, social workers, nurses, palliative care experts and geriatricians. That is around 50 witnesses in total. While I fully appreciate that a wide range of additional charities and organisations has valuable contributions to make, I would encourage them to submit written evidence so that the Committee has the benefit of their thoughts.

Regarding the start of the line-by-line scrutiny of the Bill, given the huge volume of evidence—both oral and written—that we have received and are still receiving, I have consulted with colleagues across the Committee and there is a consensus that having next week to absorb and evaluate the evidence, and to prepare any amendments in light of it, is extremely important. Consequently, we would begin line-by-line scrutiny on Tuesday 11 February, as per the amendment.

I hope that these amendments demonstrate the robust approach that the Committee and I are taking to our work, and I encourage colleagues to support them.

[Naz Shah]

I beg to move an amendment to motion (a), at end insert—

“Richard Robinson, CEO of Hourglass, Cherry Henry-Leach of STADA, Standing Together Against Domestic Abuse ”.

I completely agree with my hon. Friend the Member for Spen Valley and I am grateful to her for adding Professor Jane Monckton-Smith to the witness list. I also absolutely agree that the evidence we receive is really valuable.

This is an amendment tabled yesterday by the Mother of the House, my right hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott) yesterday, to which I have added my name.

The reason for the amendment is that Hourglass focuses on domestic abuse of older people and it has particularly noted that the majority of such victims are female. Hourglass estimates that one in six elderly people are victims of coercion in the UK. This raises serious concerns that such people could be pushed into ending their lives if the Bill is enacted. Hourglass has not published a public opinion on the Bill.

Standing Together Against Domestic Abuse has said that

“We must echo concerns raised by the VAWG sector”—

the violence against women and girls sector—

“and disability activists about the bill’s current safeguards. There is insufficient clarity on what constitutes coercion and limited reflection on carer capacity to support someone terminally ill. Without robust measures, there is a real risk that assisted dying could be exploited as a tool for coercion or even femicide.

Statistics show that over 88% of unlawful ‘mercy killings’ are perpetrated by men towards women, often involving violent means. These troubling realities demand urgent consideration in shaping this legislation.

We also highlight the health sector’s role in identifying domestic abuse. With 80% of victim-survivors having their first or only point of contact in healthcare, it is critical that health professionals are equipped to identify and respond to abuse.

We call on the Government to ensure the proposed bill includes stringent safeguards and that healthcare systems are equipped to recognise and prevent the potential misuse of assisted dying. Femicide is already a crisis in the UK, and no law should inadvertently contribute to its escalation.”

All my adult life, I have had experience of dealing with domestic abuse and coercion, and I draw on that experience to speak to these amendments. Although Professor Jane Monckton-Smith is an expert, she is an academic. These two organisations work with people who have been victims of abuse.

In addition, we had an official meeting with the Clerk to discuss the proposals for Committee sittings. It was said at that meeting that we would only have witnesses who would give evidence, particularly in person, that would contribute to the deliverability and the workability of the Bill. Since then, we have had families added to the list of witnesses. That adds weight to the argument that we should have witnesses who are providing a service to victims directly.

[Dr Tidball]

I, too, support my hon. Friend the Member for Spen Valley and in particular I want to highlight the helpful addition of Kamran Mallick of Disability Rights UK. That augments an already comprehensive list of expert disabled people, which includes: Professor Tom Shakespeare, an internationally renowned disability rights academic; Dr Miro Griffiths, a Disability Studies scholar at the University of Leeds; and Chelsea Roff, the founder of Eat Breathe Thrive. On the panel, we will also have a representative of the Equality and Human Rights Commission, who will be able to give a good overview on the intersection between protected characteristics. Finally, there will be Jon Sparkes, the representative of Mencap.

I am really pleased that my hon. Friend has worked so hard to ensure that the voices of disabled people are integrated across a number of the panels that we will see over the next two days, and the addition in her amendment is really helpful. I commend her for it.

[Lewis Atkinson]

I agree with my hon. Friend the Member for Spen Valley. Having agreed to extend the time on Thursday to hear devolution issues and from the Royal College of General Practitioners and the Royal College of Psychiatrists, by adding two further witnesses, the amendment to the amendment would reduce the time available on those options. In an ideal world we would like to hear from all sorts of people. The option of written evidence is available. We have got other evidence, and I want to ensure that Thursday’s session is focused on the proposals that my hon. Friend has made.

[Naz Shah]

There is nothing in my amendment that suggests Professor Monckton-Smith is not capable in her expertise. I am asking for other expertise to be brought to the table. Yes, there is the argument that people can submit written evidence—but so could every witness we have heard from today, and that we will hear from tomorrow and the day after. If that is the yardstick, is this just a tokenistic exercise? I would argue that for women in particular, who are the victims of domestic abuse—

[Dr Tidball]

I note that Laura Hoyano, who is giving evidence on Thursday, is a domestic abuse barrister. She has also been involved in inquiries on child sexual abuse, and has a great range of experience in that area. She will bring that to the table as a practising barrister working closely on such cases.

--- Later in debate ---

[Naz Shah]

I welcome my hon. Friend’s intervention and I recognise Laura Hoyano’s expertise. I would respectfully push back that, as a victim of domestic violence—as a person who has experienced it and campaigned on it for all my adult life—there is a difference between an academic who has studied it and people who have worked with victims, in particular elderly women. The expert is a barrister with experience of young people and children and domestic abuse, and Professor Monckton-Smith is also an academic—yes, she has been a police officer—but I would value a witness who has worked with victims of domestic abuse. That is all I have to say on it.

Question put, That the amendment be made.

Question negatived.

Main Question put and agreed to.

Resolved,

That in the list of witnesses set out in the table in the sittings resolution agreed by the Committee on 21 January 2025, after “Professor Aneez Esmail (University of Manchester)” insert “Disability Rights UK”.—(Kim Leadbeater.)

Resolved,

That in the list of witnesses set out in the table in the sittings resolution agreed by the Committee on 21 January 2025, after “Dr Lewis Graham (University of Cambridge),” leave out “John Kirkpatrick” and insert “Baroness Falkner”.—(Kim Leadbeater.)

Resolved,

That in paragraph (2) of the sittings resolution agreed by the Committee on 21 January 2025, after “Wednesdays” insert “starting on 11 February 2025”.—(Kim Leadbeater.)

Ordered, That further consideration be now adjourned. —(Kit Malthouse.)

5.30 pm

Adjourned till Wednesday 29 January at twenty-five minutes past Nine o’clock.

Written evidence reported to the House

TIAB 01 Ben Scott

TIAB 02 Michael Vidal

TIAB 03 Compassion in Care

TIAB 03(a) Compassion in Care (further evidence)

TIAB 04 Dr George Gillett, an NHS doctor and psychiatrist

TIAB 05 Dr Stephen Hutchison MD

TIAB 06 Dr Andrew Boorne

TIAB 07 Jess Carrington, Registered Social Worker and Best Interests Assessor

TIAB 08 Greg Lawton MPharm MRPharmS FFRPS MBCS LLM, Barrister and Pharmacist

TIAB 09 Australian Care Alliance

TIAB 10 Dr Peter Knight

TIAB 11 Dr Isky Gordon FRCR, FRCP, Emeritus Professor Paediatric Imaging, UCL, London

TIAB 12 Dr Peter O’Halloran, RN, PhD, Registered Nurse, Senior Lecturer, Queen’s University Belfast, Researcher in chronic illness, palliative and end-of-life care

TIAB 13 Rose

TIAB 14 Dr Rachel Fisher

TIAB 15 Nigel Andrew Gordon Jones, a retired Consultant General Surgeon

TIAB 16 St Gemma’s Hospice

TIAB 17 Sir Nicholas Mostyn

TIAB 18 Leah Locke

TIAB 19 Alison Taylor

TIAB 20 Dr Katharine Crossland

TIAB 21 John Forrester

TIAB 22 Don Stickland

TIAB 23 Christina Blandford-Beards

TIAB 24 Society for the Protection of Unborn Children (SPUC)

TIAB 25 Catholic Bishops’ Conference of England and Wales

TIAB 26 British Association of Social Workers

TIAB 27 Plunkett Centre for Ethics: A centre of Australian Catholic University located at St Vincent’s Hospital Sydney

TIAB 28 Dame Sarah Mullally, Bishop of London, Lead Bishop on Health and Social Care for the Church of England and former Chief Nursing Officer for England on behalf of the Bishops of the Church of England and the Archbishops’ Council

TIAB 29 Cicely Saunders International

TIAB 30 Lejeune Clinic for Children with Down Syndrome

TIAB 31 Voice for Justice UK

TIAB 32 Get on Downs - a Down Syndrome Support Group

TIAB 33 British Medical Association (BMA)

TIAB 34 Portsmouth Down Syndrome Association

TIAB 35 Better Way campaign

TIAB 36 Hospice UK

TIAB 37 Association of Catholic Nurses for England and Wales

TIAB 38 East Midlands Palliative Medicine Consultants and Specialty Doctors

TIAB 39 Marie Curie Palliative Care Research Department, University College London (UCL)

TIAB 40 Humanists UK

TIAB 41 Nuffield Council on Bioethics’ (NCOB)

TIAB 42 Marie Curie

TIAB 43 LOROS, the Leicestershire and Rutland Hospice

TIAB 44 Professor Emeritus Sam H Ahmedzai

TIAB 45 Professor Nancy Preston, Professor of the International Observatory on End of Life Care, Lancaster University; and Professor Suzanne Ost, Law School, Lancaster University

TIAB 46 Professor Alex Ruck Keene KC (Hon)

TIAB 47 Anureg Deb and Dr Lewis Graham

TIAB 48 Australian Centre for Health Law Research, Queensland University of Technology, Australia

TIAB 49 The Bios Centre

TIAB 50 The Orders of St John Care Trust

TIAB 51 Living and Dying Well

TIAB 52 Professor Katherine Sleeman, King’s College London

TIAB 53 British Islamic Medical Association (BIMA)

TIAB 54 Joint written evidence submitted by Chelsea Roff (Eat Breathe Thrive, UK), Dr Angela Guarda (Johns Hopkins University School of Medicine, US), Dr Philip Mehler (University of Colorado School of Medicine, US), Dr Patricia Westmoreland (University of Colorado, US), Dr Scott Crow (University of Minnesota, US), Dr Catherine Cook-Cottone (University at Buffalo, SUNY, US), Dr Anita Federici (York University, Canada), and Dr Agnes Ayton (Oxford Health NHS Foundation Trust, UK)

TIAB 55 Professor Allan House

TIAB 56 National Care Forum (NCF)

TIAB 57 AtaLoss

TIAB 58 Compton Care

TIAB 59 Dr Odette Spruijt, Medical Director, Launceston Specialist Palliative Care Service

TIAB 60 Rachel Pegrum, Independent Social Worker

TIAB 61 Abdul Rahman Badran

TIAB 62 Alan Thomas, Professor of Old Age Psychiatry, Director of Brains for Dementia Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University

TIAB 63 Dr Julian Neal

TIAB 64 Dr Raymond Towey

TIAB 65 Multiple System Atrophy Trust

TIAB 66 Dr Adrian Tookman

TIAB 67 Royal College of Psychiatrists

TIAB 68 UK Medical Freedom Alliance

TIAB 69 Association of Anaesthetists

TIAB 70 Catholic Union of Great Britain

TIAB 71 My Death, My Decision

TIAB 72 Health Advisory and Recovery Team (HART)

TIAB 73 Kyam Maher MLC, the Attorney-General of South Australia, in his capacity as a member of the Legislative Council of South Australia

TIAB 74 Dr Calum MacKellar, Director of Research, Scottish Council on Human Bioethics

TIAB 75 Christian Medical Fellowship

TIAB 76 Christian Medical and Dental Association of Canada

TIAB 77 Christian Legal Centre

TIAB 78 Written evidence submitted on behalf of a group of anorexia nervosa sufferers and carers

TIAB 79 Dr Angelika Reichstein, Associate Professor in Law, University of East Anglia

TIAB 80 Dr David Randall

TIAB 81 Cruse Bereavement Support

TIAB 82 Compassion in Dying

TIAB 83 General Medical Council (GMC)

TIAB 84 Pathfinders Neuromuscular Alliance

TIAB 85 Royal Pharmaceutical Society

TIAB 86 Motor Neurone Disease Association

TIAB 87 Dr Simon Eyre

TIAB 88 Macdonald Amaran

TIAB 89 Patrick Pullicino

TIAB 90 Luis Espericueta, Researcher and lecturer in bioethics at the University of Granada, Spain

TIAB 91 Healthcare Professionals for Assisted Dying

TIAB 92 PSP Association (PSPA)

TIAB 93 Association for Palliative Medicine of Great Britain and Ireland (APM)

TIAB 94 Academy of Medical Royal College's

TIAB 95 Care Not Killing

TIAB 96 Dr Alexandra Mullock, Senior Lecturer in Law

TIAB 97 Rt Hon. Sir Stephen Sedley

TIAB 98 Carole O’Reilly

TIAB 99 Dr Hannah Denno

TIAB 100 Prof B Anthony Bell MD, Neurosurgeon, University of London

TIAB 101 Matthew Hoyle, Barrister

TIAB 102 Royal College of Nursing

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

Naz Shah Excerpts

Committee stage
Wednesday 29th January 2025 Public Bill Committees

[Sarah Olney]

Q There is no evidence that it reduces it, so it continues at the same rate: it does not increase, and it does not reduce. Is that what you are saying?

Professor House: Well, it increases, but there are so many factors. I will give you one example. Oregon has been widely cited as a model for this sort of thing, although people have been a bit more uncertain in recent times. At the time that Lord Falconer introduced his Bill in the Lords in 2014, Oregon was cited as a place where levels had stayed much the same—not of suicide, but of people receiving assisted dying. In the decade since then, the number of people going through the assisted dying programme has gone up 500%, and the number of suicides has gone up 20%.

[Naz Shah (Bradford West) (Lab)]

Q Professor House, you have said that people applying for assisted dying may be in a state of vulnerability. What is vulnerability and how can the Bill be amended to make sure that vulnerable people do not inappropriately choose assisted dying?

Professor House: Vulnerability is not just an inherent characteristic of individuals. It is the presence of these external factors, circumstances, and internal factors, state of mind, that influence and bias somebody’s thinking about whether their life is worth continuing with and whether they want to end their life. Its importance is that exploring those factors and considering what can be done to ameliorate them can lead to a change of mind. If we do not explore those factors and we do not attempt to ameliorate them, we are losing an opportunity to change the mind of people who may rethink their desire to end their life.

Why I think of it as a vulnerability, rather than just as factors that influence a rational decision, which feels rather like how it is considered in the Bill, is that the emotional tone of the discussion that you have with people about all those factors is negative. They are not people asserting autonomy and pleasure in their ability to make a choice; they are people describing to you things that are negative influences on their life. The worry is that because there is nothing in the current medical assessment that requires a careful exploration of these factors, there is really no opportunity to change them.

[Naz Shah]

Q Richard, thank you for coming in at such short notice. It is very much appreciated. Do you have concerns about whether the safeguards in the Bill adequately protect against coercion and vulnerability as Professor House has just described?

Richard Robinson: Yes, we have concerns. I understand there is a potential amendment around ensuring that training and extra safeguarding elements are added to the Bill. We would be very supportive of that. As I have already said, while we have concerns, we also need to weigh that up around the notion that older people deserve the same kind of independence and autonomy as any other demographic. Therefore, the notion of vulnerability only extends to a proportion of those people who are older. Not all older people are vulnerable; it is important to say that.

I have already said in an answer to another question that we are very concerned that the knowledge of even the notion of the abuse or coercion of older people is not widespread across the UK. If anything, that is getting worse rather than better, so this Bill really shines a light on a microcosm of society. We could be working together more adequately to ensure that older people are better represented, from an abuse and a coercion perspective, to ensure that any decision making is done within a safeguarding context. We are some way away from that at the moment.

[Naz Shah]

Q Finally, to Dr Mullock, you have said that in all jurisdictions that have legalised assisted dying, the only meaningful gatekeeping is done by medical professionals. We only have retrospective monitoring that is primarily reliant on honest reporting, particularly discovering whether, or how frequently, coercion or flawed assessment has led to inappropriate assisted dying, and therefore challenging it, so it is impossible to know how many people have been sacrificed with lawful AD regimes. We have witnesses who have said there is no evidence of coercion, especially in examples in Australia and some US states where some assisted dying schemes have been implemented. When they say that, do you think they are being accurate?

Dr Mullock: I am sure they are being accurate in terms of the data before them. The problem is that it is difficult to know and, as Richard Robinson has pointed out, this is a hidden problem. In terms of the Bill that we are discussing, one possible weakness here is that it identifies, only very obviously, problematic conduct in terms of coercion or pressure exerted by another person, and actually the kind of undue influence that might occur might be very subtle. More needs to be done to recognise that and the subtle encouragement that might take place, where a relative might frame their support for the person seeking to die in terms of, “This will be better for you,” and, “Have you considered this?” That is not necessarily an example of clear abuse, so when the person seeking to die then consults the doctor, they are not going to characterise what has happened to them as coercion or abuse. More needs to be done to discuss with the person whether or not they have been encouraged by the people around them.

[Bambos Charalambous (Southgate and Wood Green) (Lab)]

Q This is a question to Professor House. I know you are opposed to the Bill, but if it were to pass, what role do you see for psychiatrists in a multidisciplinary approach?

Professor House: It is a difficult question, isn’t it? I have already said that there is an element of assessment that is needed here—that is not currently acknowledged very much in the Bill—of somebody’s psychological state. I say “psychological state”, which has these elements to it, one of which is the presence of diagnosable mental disorder—the top of the list of importance is depression, which is well known, particularly in the elderly, not to be that easy. Older people do not express distress necessarily as openly and obviously as younger people do. There is an element of the psychological bit of assessment, which you could call psychiatric assessment, that attempts to identify and diagnose mental disorders, particularly depressive disorders. That is particularly difficult in the elderly because they are sometimes what is called “masked”. There is then the element, which is mentioned in the Bill, of the difficulty at times of judging somebody’s mental capacity. The trouble with the ideas of incapacity and coercion, both of which float around a lot, is that they suggest a very high threshold. There is this middle ground, which we have just been hearing about, with a degree of impairment of judgment, or bias in judgment because of what is going on. Those are the sorts of areas where you would want a mental health professional and probably a psychiatrist, but a psychiatrist with a particular interest in this sort of area.

--- Later in debate ---

[The Chair]

I am sorry—just bear with me. Seven people wish to ask questions, and we have just half an hour. If you do answer, can it be very succinct if possible?

Fazilet Hadi: Thank you. I just wanted to support the Baroness, and also say that we believe the Bill will pose a challenge to protected characteristics, particularly of disabled people—and indeed other groups, because disabled people are LGBTQ+ and are black and minority ethnic. The equality journey for disabled people is relatively recent in this country. The Disability Discrimination Act was only passed in 1995, and the Equality Act was only 15 years ago. We are a country that is unequal—that has internalised ableism against disabled people—so I do think the Bill will have a serious and profound negative impact against the valuing of disabled people’s lives.

[Naz Shah]

Q I have one question following up with Baroness Falkner; then I will come to you, Fazilet, if I may. The Equality and Human Rights Commission’s briefing says that

“to ensure that assisted dying is compatible with Article 2 and Article 3 rights…high-quality palliative care should be available to all who need it.”

Given that there is no requirement of an assessment of the availability of palliative care before the Bill is passed, how certain are you, Baroness—and how certain do you think we can be—that in passing this Bill, article 2 and 3 rights are not being breached?

Baroness Falkner: Forgive me; I should have been clearer about that. That was what I was referring to earlier. We have quite a lot of evidence. Marie Curie published a “Better End of Life” report in 2024 that talked of

“patchy and inconsistent provision of care”.

There is regional variability. The Care Quality Commission and Hospice UK have raised the issue of poorer access to palliative care for people with learning disabilities. In 2022, Marie Curie also highlighted the issue of cultural and ethnic inequalities. That is why an assessment at this point in time, before MPs have a definitive vote on the proposals, would be the right thing to do. It would also increase public confidence in the Bill. We think that public confidence in the measures being proposed would be profoundly important to people’s trusting that doctors and judges will also be mindful of their responsibilities in an adequate manner where terms are not clearly defined.

[Naz Shah]

Q Fazilet, doctors are members of a caring profession, but there are ways in which—wittingly or unwittingly—they can end up coercing disabled people; there are reports of that. Would I be right in saying that? If so, how does this happen and how common is this experience for disabled people?

Fazilet Hadi: Disabled people share their stories with us and other organisations. I am sure that doctors are a mixed bag, like all of us, but our experience of the NHS and of the medical profession is not wholly positive. We often find that doctors, because they cannot treat or cure us, do devalue our lives. We have had disabled people who have actually had it suggested to them or their families that their lives are expendable, when actually those people have got a lot of years to give.

We also know that when you acquire disability, which most people do—most people are not born with one—it is absolutely frightening. I am sure that most of you would be absolutely frightened to be blind; it is not something you are going to die of, but you will have that fear, because you are not used to it. Whenever you acquire a disability or that disability gets worse, you will have fears, and I suppose that makes what doctors say even more important.

If doctors are not on our side because they are thinking, “Should we mention the fact that they could have an assisted death?”, that poses a big cultural issue for the NHS, but also for us having confidence in the NHS. I actually find the NHS to be one of the organisations and institutions in this country that is least comfortable with disability; honestly, I could probably get better equality at my railway station. I say that because I think doctors have a very medical model—of course, we welcome that: they want to cure, they want to treat. But they do not always have the empathy to understand that some of us lead really good, fulfilled lives with the most complicated health conditions or impairments.

Treating doctors as absolutely scientific and the fount of all knowledge: I think those days are gone. On giving them the powers to steer us towards assisted dying, I should say that they are not a group always on the side of people with disabilities. I am not really picking on doctors. To be honest, society has a lot of internalised ableism, and doctors are just part of that wider society.

[Lewis Atkinson]

Q I have a question for Baroness Falkner. I want particularly to probe the socioeconomic duty. What is your assessment of that as it relates to agency and control at the end of life? My constituents in Sunderland, unfortunately, are on average notably less well off than the rest of the UK. Is it not the case that at the moment there is choice at the end of life for people who are well off and able to travel to Switzerland, but poorer people do not have that choice? What is the EHRC’s view from a socioeconomic point of view?

Baroness Falkner: For clarity, a socioeconomic duty has not been incorporated. It is the current Government’s intention to incorporate that part of the Equality Act, but it has not been incorporated so we are not looking at it through that specific prism. But you make a very valid point because inequalities in healthcare, housing and all the associated factors that play into good health and wellbeing are there, and they exist palpably—even across geographical parts, from one bit of an area to another. They play actively into it.

Ms Hadi will be able to give better testimony than I could on this but, from what one understands, GP provision and general access to healthcare are poorer where demographics are poorer than it is in the better performing parts of the country. One other factor to consider in terms of a postcode lottery is that people in wealthier parts of the country tend to be more highly represented in private healthcare than in public healthcare and use of the NHS. That also impacts their choices and the care they get.

Fazilet Hadi: On health inequality, I take your point about how some of us can afford to fly off to Switzerland and some cannot, but some of us live in boroughs where we will die 10 years earlier and some of us have learning disabilities and might die 27 years earlier. I know you are looking at clauses, but this Bill will go into the real world, and that is what is happening in the real world—people are not getting social care and not getting palliative care. They are dying earlier. More poor people will die earlier and more poor people will have fewer options, fewer choices, less nice homes and fewer facilities to support them. As Baroness Falkner said earlier, they will unfortunately have insufficient social care and palliative care. When we are looking at inequalities, we need to note that this Bill is going to be plunged into a society that has deep, entrenched health inequalities that do not play out well for people who are poorer.

--- Later in debate ---

[The Chair]

Order. I repeat that we have about 15 minutes left and four people left to ask questions, plus the previous question. Could hon. Members appoint who might answer the question? I do not want to cut off witnesses right at the end; it would be rude to do so. Who wants to take that question?

Dr Hussain: I will take that one. As I have said, in Bradford I have been going into the communities and meeting them in community groups where they already meet—it is their safe space. Over the last three to four years, we have done a series of workshops just opening it up: “What is death and dying like for you?” We have done that with the Pakistani women’s group in particular. We have recently moved on to go, “What stuff do you want to know about?” We had a series of four workshops where they could choose anything, so they talked about stuff such as religion and what services are available—none of them knew what services we had, which is shocking. But the workshop that they all voted for the most—and it was packed—was on benefits. These women are structurally so disadvantaged; they were asking about pensions and so we had benefits advisers come in. The women asked, “Please could we set this up monthly, for you to come speak to us and inform us?”, but it was a “No, we don’t have capacity.”

I have been asking for these workshops to be scaled up across Bradford. What do I get told? That it is not the hospices’ role, not the hospital’s, not the integrated care board’s. I have gone and presented my data and the feasibility with “This is how we can do it, this works really well”, but everyone says it is not their job. That is why I think the public health approach going into communities requires a completely different approach—it needs people who are seen as trustworthy and it requires us to be trustworthy, that is, we go in there, genuinely listen, and do stuff about the stuff talked about. I have done it and that is where the trust comes from.

It requires core funding, and the hospices cannot stretch to that—that is a huge issue. I have done it with a few groups, and to do that at scale in a place like Bradford—it absolutely has all the assets to do this—the funding has to happen. That is absolutely needed. We need to have that reciprocity, genuinely going in there and saying, “We’re here to hear, and we will act on that.”

Sam Royston: I agree with everything Jamilla says, as always. There are two connected issues here. One is about better whole-community conversations about death and dying, and death cafés are a fantastic example of that. I also think, incidentally, we need much better conversations about death, dying and bereavement in schools. We have worked recently with a number of other charities on getting bereavement education on the national curriculum, which I think would be a fantastic step forward. We need better whole-society conversations about death, dying and bereavement.

However, there is another conversation, which is about practical discussions about people’s preferences at the end of life—advance care planning conversations. We need to get much better at them—better at them happening and particularly better at them being acted on. We did a survey recently on why people do not have those conversations about their cares and wishes for their end-of-life preferences, and the key reason people said they did not have them was because they felt they would not be acted on. So we need to make sure that we are thinking about—and this includes ensuring access to palliative care support—how to enable those conversations, when they happen, to be acted on.

We also, incidentally—this is a bit of a technical point—need to make sure that those preferences are shared across services. There is very poor data sharing at the moment; ambulance services and the hospice needs to have that, and the GP and hospital need to know what people’s preferences are. We need to make sure that everyone involved in the care of that person is able to respond to those preferences.

[Naz Shah]

Q Thank you to all of you and for what you do. I will direct my question to Dr Jamilla—it is so lovely to hear so much about Bradford. I want to talk about what Dr Rachel Clarke said yesterday. She said that when patients had begged her to end their life, it was not because of the cancer but because they had not received proper palliative care. From your research and experience, would you say that ethnic minorities or those from socioeconomically deprived backgrounds do not always receive good palliative care? What are the dangers in this Bill for you?

Dr Hussain: The data is quite clear: ethnic minority groups do not have good access to palliative care services. We have been talking today about increasing the access to palliative care, but we need culturally competent and safe palliative care to meet the needs of those people, particularly those who are most disadvantaged. We do not just need to increase the offer; it also has to meet the needs of those who are most structurally disadvantaged. In Bradford, I have spent three years trying to collect all the data so that I can understand the inequalities. But in our specialist palliative care team we reduce the inequalities for ethnic minorities, because we see them in A&E and the hospital, and we go to where they are at. The risk for somewhere like Bradford, where we are doing okay—we have a long way to go—is that the Bill creates a fear in those communities. I have been going out and trying to build trust—being trustworthy—and they made it really clear to me by saying, “We trust you; we don’t trust the system. So if I came into hospital, even if your team was there, I would be really scared to access palliative care.” In a system that is doing okay, we are now adding this new risk. We need to mitigate against that.

The public health approach is really important, as is going into those communities. But we got a lot wrong for those communities post-covid, and the reason we got a lot wrong was that we did not have representation from those groups at the decision-making table at the most senior level. The people who were represented were consulted. We need that representation. I think we can do this, but the change we need is that at the most senior level we need representation from those communities. They need to have the power to make decisions. It is those people, who are going to be most harmed by this, who should be deciding what “safe” is. They should be the ones who decide if we have reached that safety level, otherwise we are going to see the same things that we saw in covid.

[Naz Shah]

Q Building on that, Chris Whitty and the British Medical Association said, from an ethnic minorities and reflection point of view, that the Mental Capacity Act 2005 and safeguarding training are fit for purpose. We know that we do not have a workforce that is reflective of the communities it serves and that we do not have representation at high levels, so in your clinical experience, for disadvantaged groups, do you think the training on capacity and coercion is fit for purpose?

[The Chair]

Order. I am sorry to do this but we have eight minutes left, and Members have three questions. This is the fourth question, so I ask those who answer to be as concise as they can, otherwise we will not get through the questions.

Dr Hussain: I think I have touched on that before. From my experience, there are discrepancies—it is not like six doctors always come out with the same answer. I have the utmost respect for Professor Chris Whitty; I know that we was not saying that this is the case across the board. We see those discrepancies, and with those vulnerable groups—ethnic minorities and those from poor or disadvantaged backgrounds—we have to spend even more time to get to understand it. So there are even more discrepancies for those groups. Ultimately, I do not think the Mental Capacity Act and safeguarding training are fit for purpose. For something like assisted dying, we need a higher bar—we need to reduce the variability in practice. I think that is a real challenge, but it is doable if we can get everyone on the same page.

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

Naz Shah Excerpts

Committee stage
Wednesday 29th January 2025 Public Bill Committees

[The Chair]

Do either of the other witnesses want to come in on that?

Dr McLaren: When we started this in Victoria, we saw a bit of a gap with the implementation. A lot of the education was surrounding the legalities of providing an assessment service in a way that conformed with the legislation, rather than that focused on the clinical skills and applications. I am quite proud of the role that we have had in rolling that out, in providing that peer experience, and in focusing more on some of the clinical skills that apply within a VAD context.

[Naz Shah (Bradford West) (Lab)]

Q I have a couple of questions. Dr Fellingham, Victoria is quite a rural state and I imagine there are difficulties reaching all parts of it. Am I right that a state-wide pharmacy service that delivers assisted dying drugs across the whole state has been set up, but there is no comparable service for the delivery of pain reduction?

Dr Fellingham: A point of clarification: I work in Western Australia, rather than Victoria, but I can give you a view for Western Australia, which is significantly larger, so the problem you have alluded to is much more complicated. Would you like me to speak about the Western Australian context?

[Naz Shah]

I was talking about southern Australia, in particular. That is fine; we can move on. Thank you.

Dr McLaren: I can speak to the Victoria question, if you prefer. To answer your question, we have a state-wide service that supplies the medication across the state. Medication for pain relief is available through standard pharmacy access, so there are no barriers to accessing medication for palliative purposes in rural Australia. It is quite hard to get voluntary assisted dying medication dispensed to Mildura, which is many hours away from the single-state pharmacy, so access is more difficult for voluntary assisted dying than for palliative medication.

[Naz Shah]

Q Thank you. The Australian and British media reported the tragic story of Cyril Tooze, an elderly and terminally ill 84-year-old man in southern Australia, who requested voluntary assisted dying. Mr Tooze stated that he was applying for voluntary assisted dying after waiting nearly a year for the state government to implement a care and housing package for him. He died while waiting for the application process to end. How much does social detriment influence requests for voluntary assisted dying? Please speak from your own experience and about published data.

Dr Mewett: From a palliative care perspective, like Cam and Clare, I have been involved in assessing and having discussions with many, many patients who have requested assisted dying. These patients come from a whole range of socioeconomic backgrounds. In fact, if anything, they tend to come from a perhaps slightly higher, more well-educated background. There is no evidence in our jurisdiction of Victoria, where we have had five and a half years’ experience, that people who are underprivileged, less educated or vulnerable in some other way have readier access to or apply more for VAD.

The case you alluded to, like many cases that are reported from Canada, is certainly tragic in its own way, but such cases are an absolute minority compared with patients who are genuinely determined to have a choice about the way they die and when. Those are separate issues: one is a social welfare issue, and the other is a VAD issue. A patient such as that would not be found eligible, unless he was eligible under the strict criteria that apply in the state in which he lived.

Dr McLaren: As Greg touched on there, when that gentleman applied for voluntary assisted dying, that may have been one of his drivers, but it certainly would not have made him eligible. He did not access voluntary assisted dying, so the system worked. We do see higher socioeconomic status patients applying for voluntary assisted dying. That is evidenced in our Voluntary Assisted Dying Review Board reports, which show a greater proportion of people with higher levels of education. That data is freely available through the Victoria Government website.

[The Chair]

Dr Fellingham, you had your hand up.

Dr Fellingham: Ms Shah asked for some evidence, and I have just looked this up. Our Voluntary Assisted Dying Board reports from Western Australia are also freely available, publicly searchable documents. Each year, the board asks the patients’ reasons for accessing voluntary assisted dying. In order of commonality, the only ones over 50% are

“Loss of dignity, or concern about it…Loss of autonomy, or concern about it”,

and

“Less able to engage in activities making life enjoyable, or concern about it”.

What that reflects to me is that the type of people who seek access to assisted dying are those who tend to be, as my colleagues said, more health literate and more socioeconomically advantaged than your average healthcare consumer, and people for whom the existential reasons that upset them about their disease process are the primary drivers for seeking access to voluntary assisted dying. It is very rarely the absence of service provision or because they feel that they do not have any other choice.

--- Later in debate ---

[The Chair]

I think that is a matter that we may have to pursue elsewhere.

[Naz Shah]

Q I have a quick question for Dr Griffiths and then Chelsea. Dr Griffiths, how does the Bill exacerbate issues for disabled women in particular who might be experiencing abuse or other vulnerabilities?

Dr Griffiths: There is no indication of how you would place the infrastructure for support for people whose discrimination or injustice is exacerbated through an intersectional lens—for example, the cross-cutting of different experiences—and how that can be attested for within the Bill. For example, if an individual comes forward to discuss with their doctor their concerns, there is no infrastructure for how that would be acknowledged with an intersectional critique.

There is also a concern that many within disabled people’s communities from particular backgrounds, such as women, are pre-exposed to further levels of injustice that are not accounted for, and their experiences of trying to access support for certain aspects of their life are compounded by inequalities. These issues are not addressed by the Bill. In my view, if this mechanism becomes available, the issues that some individuals face in terms of injustice will play into the consciousness of their decision to go forward with this. I cannot think of any clause or amendment that would address that issue in its totality.

[Naz Shah]

Q Before I move on to Chelsea, I want to point out that Professor Shakespeare said that most disabled people support the Bill. But, actually, only one deaf and disabled people’s organisation that opposes it is giving evidence. I just wanted that point noted for the Committee.

Chelsea, thank you for your evidence. Eating disorders are classified as mental disorders under the Mental Health Act. The Bill explicitly states that a person cannot be considered terminally ill only because of a mental disorder. You have also talked about the withdrawal of insulin. Could you respond to both of these? Why do you believe that eating disorders would still meet the criteria under the Bill, and likewise for the issue of stopping insulin?

Chelsea Roff: There is a false distinction being made in the Bill between a mental disorder and its somatic or physical manifestations. Mental disorders, especially eating disorders—not just anorexia—impact the body, and have life-threatening consequences. We had 20,000 acute hospitalisations for eating disorders in this country last year, and we have massive gaps in care. Those are individuals who, if they were to choose to forgo treatment or could not access treatment because they were on a wait list for a long period of time, would qualify under this Bill.

I draw your attention to the evidence I submitted with Dr Agnes Ayton from the Royal College of Psychiatrists, and Dr Angela Guarda, a leading physician from John Hopkins University. I also draw you to our own case law in the Court of Protection where we have had physicians represent eating disorders as terminal conditions, as in the end stage of their illness.

I am grateful that you have drawn the connection to diabetes, because it is not just about eating disorders. Substance use disorders would have the same effect. Outside of mental disorders, HIV/AIDS is a progressive condition that cannot be reversed by treatment. Are you okay with a 19-year-old young man who decides to discontinue treatment qualifying under this Bill? Those are the questions you have to ask. I am not, in principle, against the Bill, but you have to look at the letters on the page, because they will be interpreted after the Bill is passed. Your constituents are depending on you.

[The Chair]

I am sorry, but we still have more Members and questions than we have time, so I am going to come down to one question per Member.

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

Naz Shah Excerpts

Committee stage
Thursday 30th January 2025 Public Bill Committees

[Dr Opher]

Q Just to confirm—you have not had any failures of treatment, as far as you are aware?

Dr Furst: There have been no failures of treatment in South Australia, as far as I am aware. I am not aware of any other particular ones around the country that have been heavily broadcast to us.

[Naz Shah (Bradford West) (Lab)]

Q To follow up on that, there is no requirement that the doctor is present when the person self-administers the substance that leads to assisted dying. Am I correct? If that is the case, why does the law not make it necessary for the doctor to remain present until death, because at that point, the doctor would pick up any complications, would they not?

Dr Furst: Every legislation within Australia is slightly different. For South Australia and Victoria, you are correct—well, there is pretty much no obligation all around Australia for a doctor to be present for self-administration. The reason for that is to give individuals autonomy over their death, and over the time and place of their choosing. We in South Australia do touch base with what we call the individual’s contact person to understand if there have been any complications and to check in after the death. A large number of our patients, though, will seek out support from a voluntary assisted dying nurse navigator, who is often present in the house just as a support person. We do also have a lot of feedback from them as to any complications, but the doctor often, or a nurse, will come at a later time to declare life extinct.

The reasoning was that we did not think that there would be complications and we wanted to give people autonomy. We work on a permit system in a lot of jurisdictions in Australia, so people have a permit; they get given their substance and they can take their substance at a time of their choosing. They might have the substance in their house for weeks or months, potentially. Again, there is no obligation to follow through with taking that substance, which we also think is quite important. We know that in Australia, about 30% of patients who have a permit or who are approved for voluntary assisted dying actually decide that they do not want to consume the substance, but it is about giving them that choice and autonomy, and the strength to maybe pursue other lines of therapy.

[Naz Shah]

Q We have had lots of witnesses testifying about gaps in palliative care and end-of-life care provision here in the UK. What is the current state of palliative care and end-of-life care provision in Western Australia, please?

Dr Furst: I am in South Australia, but a recent survey by Palliative Care Australia surveyed over 900 palliative care specialists, and more than 80% of patients receiving voluntary assisted dying are actually getting combined palliative care and voluntary assisted dying. In our legislation in South Australia, there are key provisions for the monitoring of the funding to palliative care to ensure that no palliative care funding is diverted to voluntary assisted dying, but we feel very strongly that palliative care and voluntary assisted dying should go hand in hand. That is a feeling that is being seen around the country now. Palliative care physicians who are finishing off training now see voluntary assisted dying as part of their core business. It is no longer seen as something that should be provided by separate practitioners. It is really becoming quite integrated.

Professor Blake: I am coming in from Western Australia. We were the second jurisdiction in Australia to introduce voluntary assisted dying laws. Ours have been operative since July 2021, so we have had the opportunity to collect quite a lot of data. Year on year, the number of people utilising voluntary assisted dying in Western Australia is increasing. In the year 2023-24, there were 292 deaths by voluntary assisted dying, which represented 1.6% of WA deaths. I agree with Chloe and confirm her view around the palliative care side of things: 83.8% of those persons who accessed voluntary assisted dying were also accessing palliative care.

[Sarah Green (Chesham and Amersham) (LD)]

Q On that point about palliative care, I will direct my question to Dr Furst. What has been the response from palliative care professionals to the introduction of assisted dying in Australia? We have heard evidence from people working in the sector in the UK, but I am keen to hear about your experience in Australia. I understand that Palliative Care Australia’s national workforce survey explicitly looked at this, so I am keen to hear what its findings were.

Dr Furst: It has been a journey, certainly. Victoria started their voluntary assisted dying in 2019. I would be lying if I said that the palliative care community were completely on board with it at that point, but over the last five to six years there has been a real shift in mentality. We have seen that they can go hand in hand. Palliative care is about end-of-life choices. Voluntary assisted dying is about end-of-life choices. It is about putting the patient and the individual front and centre, and working with them. That is fundamental to palliative care. We have realised that voluntary assisted dying is a promotion of palliative care and it gives back choices.

Probably some of the older palliative care clinicians have not embraced voluntary assisted dying quite as much. That is probably very generalised, but certainly new consultants and new doctors that are coming through really see this as something that they want to do. I do not think that there is any animosity any more between the practitioners that choose to work in this space and those that do not. I get huge amounts of support from other palliative care physicians that do not necessarily act as practitioners. There is no real divide. It has been embraced, to be honest. In another five years, I think there will probably be very few palliative care practitioners who do not support this, unless they are true conscientious objectors for their own reasons—I guess, probably religious reasons. Palliative Care Australia and the peak medical bodies in Australia have generally shifted to see this as part of patient choice.

Alex Greenwich: The journey to voluntary assisted dying in New South Wales, and indeed across every Australian state, has benefited palliative care access and funding. In New South Wales, 85% of people who have accessed voluntary assisted dying are receiving palliative care. As part of the process, the co-ordinating and consulting practitioners also advise them on palliative care. The doctors are trained on the latest advances in palliative care. Baked into the principles of our legislation is access to palliative care for all citizens of New South Wales. Importantly, throughout our debate, whether Members supported or opposed the reform, our entire Parliament came together to ensure palliative care received an increase in funding and any access issues were addressed. The Australian experience with voluntary assisted dying is that it benefits and strengthens the palliative care system.

Professor Blake: Can I can I add to that? The Voluntary Assisted Dying Board in WA, as in all the other jurisdictions, produces a report. The very strong sentiment of the Voluntary Assisted Dying Board, and indeed within the Western Australia community, is that voluntary assisted dying is seen as part of the end-of-life journey. The board’s report states that the statistics and experience of Western Australians

“confirms…that voluntary assisted dying is an established and enduring end of life choice”.

For that reason, there has been quite a significant awareness that practitioners should be able to bring up voluntary assisted dying with the patient as part of that suite of end-of-life choices. That has been something that the evidence has suggested is very important, because if the practitioners are feeling that they cannot raise it in that context, that is having a detrimental effect on the patients who would like information on it. That has been our experience in Western Australia.

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

Naz Shah Excerpts

Committee stage
Thursday 30th January 2025 Public Bill Committees

[Tom Gordon (Harrogate and Knaresborough) (LD)]

Q Dr Ward, I think the point about a holistic and evidence-based approach is critical. In the work that you did in the Scottish example you gave, how was the terminal illness definition arrived at? How are you capturing those people who are vulnerable and want to have an assisted death, but might end up limited in their scope and ability to access it?

Dr Ward: Look: assisted dying is the same as any other healthcare choice. It is always going to be limited. We are not going to reach everyone that we absolutely would want to. There are people who want to have this option and this choice who will not qualify under a terminal illness definition, but we have to draw the line somewhere. We looked at international evidence from Commonwealth countries that are very closely linked to Scotland and the UK. We drew the line with the definition that the person has an advanced progressive illness from which they are unable to recover and that will cause their premature death. For us, that demands the support of Members of Parliament in Scotland and the support of the public.

I really stress the fact that each jurisdiction has to legislate according to its own constitutional, societal, legal and cultural considerations, which is what we have done in Scotland. That is the definition that is working for us now. Previously, there were more liberal attempts that did not gain the support of the House. We believe that we have arrived at a situation that is very similar to the definition of terminal illness here in Westminster, and that is both safe and compassionate but also draws the line so that people who should not be able to access this do not.

[Naz Shah (Bradford West) (Lab)]

Q Professor Owen, yesterday Professor Allan House gave evidence and talked about capacity and coercion, and I want to pick up on some of the concerns. In all four of the jurisdictions that collect data on the issue—Oregon, Canada, Western Australia and Washington—between 35% and 59% of people cite being a burden as a reason for assisted dying. What do you think is the level of confidence of psychiatrists to assess capacity and consent reliably? What would your concerns be, if any?

Professor Owen: This is an essential question. I work clinically in the over-65 age group, where there is a lot of terminal illness, some of it in the last six months. You have to understand the population. The population is typically over 65 and frail. There can be a terminal illness, very typically with comorbidity. That comorbidity is often mental health comorbidity. Depression is at rates of 20% or thereabouts. Delirium and cognitive impairment is very common and often not picked up. There is patchy safeguarding, patchy access to social care and, as I know you have been hearing, patchy access to palliative care.

That is the ordinary person in the NHS. I know people who select into assisted dying are not necessarily that mean person, so to speak, but that is just a picture of what it looks like for me when I go to work. That is where one starts. Now think about burden. Well, this is a group that do feel very burdened. You might think some of that is excessive; some of it maybe is natural, given the life stage. So it is a mixed picture.

When it comes to pressure and coercion, I know you have been grappling with this a lot as a Committee, and I know there have been some amendments that address this. We have talked about clause 26 particularly in relation to this. Of course, when it comes back to the training question, you can take evidence on the state of safeguarding and how people are really able to assess coercive control, domestic violence and so on.

I would like to draw attention to something else that I am not sure has come so much to the attention of the Committee, which is not the offences or the criminal side of this; it is the common or garden capacity assessment side of it. This relates really to clause 1. It is the issue of how you deal with interpersonal pressures on somebody in a situation where there may be a mental health problem and there may not even be a diagnosis. You might be talking about a kind of cognitive impairment that has not reached the threshold for a diagnosis of dementia; you might be talking about a kind of mood problem or an anxiety problem that is sub-clinical; or you might be talking about a level of intelligence that is not clinically a learning disability. But it is there and it is interacting with a form of pressure within a family, let us say, which is often not malign in its intentions, but it exists. It is a very overvalued relationship, for example, with a strong sense of loyalty to somebody, or an enmeshment, for example.

What you have are situations where there is an impairment and also an interpersonal pressure. They interact and they amplify each other. That can have an important consequence in terms of the functional ability of mental capacity. Outside of the assisted dying context, when you look at that in the Court of Protection, which has been struggling with quite a lot of cases like this, that phenomenon of interaction that I am talking about between interpersonal pressure and impairment is recognised. It struggles with it. I have been involved in some research to try to structure the understanding of it, but it is not at the point where it is a kind of training manual that you can lift down from the shelf and roll out across the workforce. It is much more in a kind of research and development phase.

So it is important to draw attention to pressure not necessarily as malign in its intention, but which nevertheless operates in these situations and can have a subtle impact on the functional test of decision-making capacity. To bring us back to what the decision-making capacity is that we are talking about, it is the decision to end one’s own life.

[Bambos Charalambous (Southgate and Wood Green) (Lab)]

Q Dr Ward and Professor Hoyano, we heard yesterday evidence about the interplay between assisted dying, the Equality Act 2010 and the European convention on human rights. Should amendments be made to the Bill to deal with those issues? What are your thoughts about the interaction between those pieces of legislation and the Bill?

Dr Ward: I heard the session yesterday and would agree with the comments that were made there, particularly around proportionality. Article 2 is an absolute right —the right to life—whereas article 8 is a qualified right. Again, it is about that balancing act. The courts have been very clear that we need to protect vulnerable people, and I feel strongly that the Bill straddles that very well by giving choice but in a very limited set of circumstances.

On the Equality Act, there have been some claims made—this happened in Scotland—that the definition of disability in the Equality Act would cover people who are terminally ill. That that is not my reading of it, and that position is widely shared by the people advising us in Scotland on the legal capacity. That is all I have to say.

Professor Hoyano: I would only point out to the Committee that the common law entrenched the human rights of the patient a long time before the Human Rights Act 1998. We must remember that we do not just have to look at the European convention and Strasbourg. The common law has been very active in entrenching fundamental principles of the rights of the patient, particularly their autonomy in decision making regarding their own body, since long before the HRA.

--- Later in debate ---

[The Chair]

I call Naz Shah to ask the final question.

[Naz Shah]

Q Professor Owen, to follow up on the interaction that Mr Atkinson talked about, where are the gaps in research right now?

Professor Owen: There are a lot of gaps. Take that point as I intend it—I do not say it as a downer on this project; I say it because it is true. There are just a lot of gaps. We are going into uncharted territory, so you might think it would be good to have more of a map before we start. This is one area where there are evidentiary gaps. It is not clear how those sorts of interactions should be assessed, what sorts of threshold should be set or what kind of training should be available. There has been a lot of talk about training; training is all very well and good, but you need to know what the point and purpose of the training is. The training has to be valid before you can roll it out. There are lots of gaps here.

That relates to the question of mental capacity assessment. It is often said, “Why are we worried about mental capacity? We have so much experience of doing it in health and social care contexts; we have the Mental Capacity Act, the Court of Protection and all this experience.” We do, and that extremely important work has been done since the parliamentary discussions you had about the Mental Capacity Act all those years ago. In some areas, it is being done reasonably well: in relation to treatment and care residents’ decisions, one can talk about a body of professionals who understand the concepts, can do the assessments and can achieve, at least when trained, good levels of agreement, so you can get the system to work.

But in areas of decision making where the decision itself is unsettled or conceptually much more profound or novel—I would suggest that the decision to end one’s own life has those characteristics—you cannot expect there to be such levels of reliability. That can be shown empirically in other areas where the decision making is unsettled. The question of how well capacity assessment works is actually matter-specific. That should not surprise us, because the whole concept of mental capacity is that it is matter-specific. That is the whole functional idea of mental capacity. The matter here is of the decision making to end one’s own life.

[The Chair]

That brings us to the end of the allocated time for the Committee to ask questions. I thank the witnesses on behalf of the Committee for their evidence.

Examination of Witnesses

Professor Preston, Dr Richards and Claire Williams gave evidence.

--- Later in debate ---

[Dr Tidball]

Yes.

Dr Richards: Maybe Nancy knows the evidence on that. Talking about gaps in research, I am an anthropologist, so I am interested in the discourse and the conversations that are happening, and I think there is a lack of evidence about that. We have a lot of evidence where it is tick boxes, for example, about motivations and procedure being following. We have less qualitative, in-depth, interactional evidence about that kind of holistic decision making.

Professor Preston: We have done some research where we interviewed doctors and healthcare workers who have had those conversations. The majority decide against it, but they are still having those conversations. We also heard the experience of the bereaved family, and what it was like to have those conversations. On the whole, the conversation is predominantly about palliative care—“Can we do something different? How can we meet and assess your needs?”

In some cases, the doctors in palliative care, particularly in Switzerland, certainly would never suggest assisted dying, but if the patient asks for it, they equally do not advise them how to get an assisted death. In some cases they said they sort of consciously blocked the conversation, so that the person timed out and could not have it. The emphasis is perhaps the other way in places like the Netherlands and Belgium, where it has been around longer and is much more integrated into other services, such as care homes and palliative care, as part of a holistic assessment.

I remember visiting a team in the Netherlands, and when they got a new patient they said, “We assess them for their preferences about whether they want to die, about resuscitation, about advance care planning and about euthanasia.” My jaw dropped; I was British—this was illegal. They do it in such a natural way. They said, “We need to plan that for them, because we need to understand what is right for them.” They are not suggesting it—they are just trying to take it on board. I would say that the predominance of the conversation is about palliative care, but if the patient wants the assisted death, they either might assist—which is rare—or suggest how they go to a right-to-die association. But more likely they will still tell them how palliative care can help.

[Naz Shah]

Q Professor Preston, in your written evidence to the Committee, you said that Parliament should:

“Consider whether there should be a stated exception to the usual presumption of capacity under the Mental Capacity Act 2005 in the Bill.”

What kind of standard do you think Parliament should consider adopting instead of the use of the Mental Capacity Act, and why do you think that?

Professor Preston: Again, this came from my colleague Suzanne Ost, who is a professor of law. As Naomi said, this is something very different from choosing to consent to an operation or even a research study. This is finite—it is a finite decision, so therefore the assessment should be a bit more. What I will say about mental capacity is that we had a PhD student who assessed mental capacity decisions by hospice care staff—particularly doctors, but also a lot of the nursing team who were making the decisions. She was a lawyer, and her conclusion was that it was incredibly well assessed. That was in terms of safeguarding—so, when people were going back to what we might consider unsafe homes—but that is what the person wanted, because their life was that unsafe home. I am talking about social deprivation and things like that. The people in this particular team were very good at assessing that and applying the Mental Capacity Act, according to her research.

[Rachel Hopkins (Luton South and South Bedfordshire) (Lab)]

Q Claire, you mentioned multidisciplinary teams and decision making. We have heard in a couple of other evidence sessions from palliative care social workers, nurse practitioners and the Royal College of Nursing about the multidisciplinary approach in care. What are your thoughts on the ultimate approval as set out in the Bill being a doctor, another doctor and then a legal okay at the end? Would a more multidisciplinary approach to approval have stronger outcomes or better safeguards?

Claire Williams: I absolutely agree that a panel/committee approach would have better safeguarding for patients, because the decision is being made collectively with legal expertise and with other healthcare professionals—that might be palliative—or ethicists like myself. It is having that collective view, ensuring that everybody is happy and that that is exactly what the patient wants. I believe it should be a committee/panel-based approach for the final decision. As I said before, expecting a High Court judge—just one individual—to make that decision alone is hugely burdensome and not an approach that we should be taking.

--- Later in debate ---

[Dr Opher]

I think that my question has been covered by my hon. Friend the Member for Bexleyheath and Crayford. I just wanted to be sure that we were secure if the doctor was not in the room, but that has been answered.

[Naz Shah]

Q My question is to Dr Richards. I will get to where I need to get to, so bear with me. You talk about this being a very explicit conversation, but I would argue that that is not entirely true. We are talking about a set of doctors who will have opted in to have that conversation; not all doctors will do that. We have also had evidence from people suggesting that doctors and lots of other people would leave hospice care if assisted death was provided on the NHS. Yesterday, we had care providers telling us that if people engaged in providing voluntary assisted death, they would leave those hospices. So it is not quite as explicit as what you are suggesting, is it?

Dr Richards: It would have to be. Those examples that you have just given would not mean that it was not an explicit conversation.

[Naz Shah]

But it is not, because—

[The Chair]

Order. One question, one answer. I call Danny Kruger.

--- Later in debate ---

[The Chair]

Before we move to the next panel, is there anyone else who has pressing questions, or would you prefer to have a five-minute comfort break?

[Naz Shah]

Q Dr Richards, you were talking about elderly people in particular. We have heard evidence, particularly yesterday, about young women under 40 where terminal illness was deemed legislatively applicable to anorexia. It appears that that is quite a phenomenon. When we talk about the explicit conversation that you are suggesting, I would argue that it is not necessarily clear cut. Do you agree that there would be a risk there when it comes to people with anorexia?

Dr Richards: I do not really understand why the case of terminal anorexia would be different to any other case in terms of the conversation. It would be necessary to have a very explicit conversation with somebody requesting assisted death; it does not matter what their illness is.

On the issue of anorexia, the numbers are really tiny. In the Oregon model, which is what is in the Bill, you are talking about one or two people in the history of assisted dying. It is a very minor issue to get focused on. I have seen so much about this in the press and being discussed here. If you are very concerned about terminal anorexia, I am sure you could do some tinkering with the Bill so that people would not be eligible for assisted dying, but in terms of the empirical data in jurisdictions that have legalised the Oregon model, which is what this is, there are one or two cases.

This should not be given a huge amount of time, because it is a distraction from the fact that really we are talking about a new mode of dying, which is a cultural response. Just as palliative care is a cultural response to suffering at the end of life, so is assisted dying. It is a different track; it is offering something different. Different types of people will want to go for that. It is a response to the protracted dying trajectory that we see now, which is new. In the history of human dying, we have never taken so long to die before. There has never been so much medical intervention at the end of life, and assisted dying is a cultural response to that. To get fixated on the two people with terminal anorexia who have accessed assisted dying in the States is a bit of a red herring.

[The Chair]

Thank you.

--- Later in debate ---

[Danny Kruger]

Q This is a question for Mr Malone. May I say how greatly I sympathise with what you have been through? I am very sorry to be fighting against you in this matter. I really can imagine how that feels. Thank you for what you said. I just want to ask about your sister’s experience. On the eligibility question, is it your belief that she would have qualified for an assisted death under the Bill, with the six-month terminal illness criterion? To follow up on that, do you think we should expand the scope to include people with motor neurone disease who might not fall within the six months?

Pat Malone: She would not qualify, because there was no telling how long she would live as a live brain in a dead body, as she said. It could have been months or even years, so she would not qualify in any case under this Bill. However, you have moved mountains to get to this point, so the last thing in the world I want to do is pile more requirements on the Bill. I would like to see some stuff stripped out of it, actually, to make it easier, but I am not going to ask for that because we desperately need to get away from the status quo. This Bill gets us away from the status quo.

[Naz Shah]

Q Thank you very much for coming today and sharing your stories. I have two questions. Julie, you said that you had family liaison and counselling. How long did that go on for? This Bill does not have that requirement, so do you think it is something that we should put in it?

Julie Thienpont: Maybe I said “counselling”, but it was not a session of counselling. It was somebody asking my opinion to check that I was 100% behind Guy. His son also did that by proxy—via us—because he was in a different part of Spain. They wanted to ensure that he had talked it over with family members. It was not hastened along, because he had been given a short life span, so it did not take terribly long. He had to wait about three weeks before the initial ball started rolling, and then two weeks later a family doctor and nurses from the hospital came round for form filling, reading through, translating and signatures, and again another two weeks after that. Each time, I believe it went before a panel. We did not, but the paperwork had to go before a panel. They were left in no uncertain terms that that was the way he wanted to end his life.

It was a very peaceful, serene and beautiful death, as opposed to what it would have been like. He was able to speak to his relatives in Australia, his brothers in Belgium and other family members, and I was able to hold his hand. Guy had always been a bit of an old cowboy, and he always said that he wanted to die with his boots on. I am proud to say that that is what he did. At the end, we were holding hands, and I said to him, “Don’t be afraid.” He said, “I’m not afraid,” and he winked at me just before he closed his eyes.

On the process, perhaps I should have said that it was intravenous, so he had a drip in each arm. It was quite a quick process—maybe 10 to 15 minutes, which I thought was quite quick—but we had had lots of time that morning, you know. It was a beautiful end—the wink especially. I am left with very good memories of such a peaceful death, which was going to happen regardless. He was at peace with it, so that helped me.

[Naz Shah]

Q Thank you very much for sharing such personal experiences. Liz, you talked about your brother, and going over, and how peaceful it was for you. We have heard lots of witnesses talking about people who have felt like a burden. I am glad that was not the case with your brother’s death. Would you support adding more safeguards to the Bill to make sure that we protect those who are at risk from coercion and who might not have capacity?

Liz Reed: I understand the big focus on coercion. It is very similar in Australia. The difference between the Queensland Bill, specifically, and the Bill proposed here is that, in the Queensland Bill, coercion is punishable both ways: you can be punished for trying to coerce someone into an assisted death but also for trying to change their mind the other way. Those safeguards are in place because you hear anecdotally from practitioners that, broadly, people are being coerced out of this.

In our experience, the day before my brother died our mum said to him, “Are you sure?” She was not trying to coerce him, but was she trying to make him go on longer? Absolutely. That is her son, and that is completely natural and normal. She did not want to see him die. His response was, “This isn’t living.”

[Naz Shah]

Thank you very much.

Pat Malone: As far as my brother and sister were concerned, there was no check for coercion. There needs to be, as in the Bill, but there are many more safeguards in the Bill than there are now. The people who are contemplating suicide now have no safeguards at all.

--- Later in debate ---

[Dr Shastri-Hurst]

Q My question is directed to Dr Mulholland. Thank you to the Royal College of General Practitioners for the helpful written evidence. I want to pick up on something in it, which is summarised in paragraph 6 but gone into in more detail in paragraph 7, and that is around the refusal of practitioners to engage in the assisted dying process. I note the wording that has been used by the Royal College, which is that GPs and any other healthcare professionals can refuse “on any ground”. That is distinct from the Abortion Act 1967, which in section 4(1) sets out that it can be a conscientious objection. Can you explain why you have decided to take what appears to be a broader expansion of that definition, and why you have chosen that particular wording?

Dr Mulholland: We are aware that we have a range of views in RCGP across general practitioners. Some of them have very strong views for or against based on moral grounds, and some of those are based on religious grounds—traditional conscientious objection grounds. But others do not want to take part in assisted dying just because they do not want to; they do not feel it is part of what being a GP is, or part of what they trained for.

In discussion with colleagues today, someone shared with me that for 35 years they have spent their time trying to extend the life of patients—that has been our role—and to help them towards the end of life. It is a philosophical change if they start to think about whether the patient’s life should end earlier. There are some colleagues who may decide that for those reasons, they do not want to take part in this. There will be others who very definitely do. We have that range, so we feel that a doctor or a health professional should have the right not to take part on any ground, and that should be protected—they should not feel the obligation to do something that they do not feel is within their wishes.

[Naz Shah]

Q My question is to Dr Price. We heard yesterday from Professor House and this afternoon from Professor Owen, who were talking about capacity and coercion. They also talked about how different people’s life experiences impact their ability and their state of mind, and the lack of research or evidence in that area—the courts are grappling with those issues at the moment. Is there any evidence about the effect on patients’ mental health when they have a diagnosis of a terminal or serious physical illness?

Dr Price: There is a lot of research evidence around depression in people with palliative care needs and people nearing the end of life. We know that depression is common, and across a number of studies it is at around 20%—much more common than in the general population. We know that depression is strongly associated with a wish to hasten death, and that if depression is found and treated in that group of patients, there will be significant change in the wish to hasten death.

There are a number of associations other than depression with a wish to hasten death, and they include difficult symptom experience, poor functional status—needing a lot of help with things—and being socially isolated. Those are really key ones. They also include a sense of loss of dignity and feeling like a burden on others. These things can all come together to make life feel very unbearable. We know that there is also an overlap between a wish to hasten death, which is a response to suffering, and feeling that one is better off dead, ending one’s own life or harming oneself. I was involved in a study where we asked people both the wording of “a wish to hasten death” and the suicide question from the PHQ9, which is a depression screening tool. Those who had a wish to hasten death were 18 times more likely to also feel suicidal, according to the psychiatric definition, than people who did not have a wish to hasten death. There is a strong association.

[Lewis Atkinson]

Q My question is for Dr Price as well, please. We heard in the week from the chief medical officer earlier, who said that he was “relieved” that this Act based capacity on the Mental Capacity Act, noting that it already provides that

“the more serious the decision, the greater the level of capacity”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 30, Q3.]

and that it is used in tens, if not hundreds, of life and death cases in the NHS every week. The example he gave was someone refusing blood products that they would need to continue their life. In the light of that, I suppose I am a bit confused about your evidence saying that the MCA is not suitable for life or death decisions of this type. Do you think the MCA is not fit for purpose for those current life or death decisions that are being made, or is there something about the life or death decisions that would be made in an assisted dying context that makes that different?

Dr Price: The assumption that the Mental Capacity Act can translate neatly into this specific decision without a really clear sense of what that would look like in clinical practice is something that needs more careful thought.

I was involved in research in this area, and one of the things that I did was to scrutinise the concept of capacity as discussed in a number of forums—for example, the Commission on Assisted Dying, discussions in the House of Lords, and also interviews with doctors in England and Wales and in Oregon. There is a broad sense of what capacity is. For some, it is a very tight, cognitive definition that would mean that in practice, in assisted dying, most people would be found to be capacitous. Those who advocate a much broader sense of what capacity is—these can be contained within the framework of the Mental Capacity Act—would advocate a much broader sense of what that is, thinking about values and the person’s life experience and making more judgments, really, about that person’s life in a general sense.

What I do not think we have really pinned down is what concept of capacity is operating in the thoughts behind this Bill. Is it enough to say that we will essentially refer to the Mental Capacity Act, or do we need to be more specific about what is capacity for this decision? Is it sufficient to say, “We will refer out”, or do we need it on the face of the Bill so that anybody assessing capacity for this decision knows exactly what they should be doing and exactly how they should be having that conversation? Even though you may be operating within a legal framework, I think that the actual conversation —the actual content—will vary across practitioners. Is that good enough? Is that sufficient? Is that a good enough standard? When I do a capacity assessment, I have in mind that it may be appealed against—that is somebody’s right—and it should be available for scrutiny by a court. Essentially, that is the standard we are looking for, so it needs to be clear where the standard lies.

--- Later in debate ---

[The Chair]

There are three people left who want to ask questions, so can I beg for brevity?

[Naz Shah]

Q Under clause 4(2), doctors would be allowed to raise the issue of assisted dying with a patient, unprompted. Dr Rachel Clarke gave evidence to this Committee that, in some circumstances,

“The very act of raising assisted dying in that way will make that vulnerable patient think, ‘God, is this doctor telling me that my life is not worth living any more?’”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 75, Q93.]

We heard from Dr Jamilla Hussain yesterday. She talked about mistrust of the NHS, particularly post-covid, where people had DNRs attached to them—disabled people and people of ethnic minority backgrounds in particular. Dan, are you concerned about the potential impact on people with learning disabilities?

Dan Scorer: Yes. One of the first things that I said earlier was about how the initiation of that first conversation is potentially an extremely risky and dangerous moment for people with a learning disability who are terminally ill. Your question is absolutely spot on, from the point of view that it could be highly suggestive and push people on a course that they may not want to go down. That is why I am suggesting that that initial conversation has to be incredibly well supported and structured.

There should, in our view, be an advocate who is supporting the person and preparing them for that discussion. Under the principles of the Mental Capacity Act 2005, the person should have accessible information in advance of that discussion so that they are fully informed about all their rights in terms of treatment options at end of life. That discussion with a clinician should not be taking place until the person has been able to consider that information and have support from an advocate, so when the conversation does happen the person is fully informed and has had time to think about what their wishes might be. That would reduce the risk, which is absolutely there, that people could take the initiation of that discussion as a statement, “This is what you should do.” We absolutely do not want people to be in that position. We want strong safeguards and support in place if the Bill becomes law.

[Dr Tidball]

Q Dan, I am really keen that we ensure that if the Bill passes, the voices of disabled people are continually involved in understanding its impact, particularly on the issue that you have just raised. Earlier, we heard evidence about implementation taskforces that are used in other jurisdictions. I am considering tabling an amendment on an advisory council. How might we ensure that the voices of people with learning disabilities can be included in such a body?

Dan Scorer: There are a couple of things that I would like to say in response. One is about clause 31, on guidance from chief medical officers. Immediately, I would say that people with a learning disability should be involved in the development of that guidance from chief medical officers. That guidance will be key to many of the issues that we have discussed.

Clause 35 is about the review of the Act. The lived experience of people is absolutely vital to that. The Bill says that it will be five years until we have that review. Our view is that that is far too long. If the Bill becomes law and if there are really serious issues and discrimination taking place against people, we will want to know that a lot earlier than in five years’ time, and we will want action to be taken. Our suggestion is that review should be earlier. We would want to see strong representation from patient groups across that, as well as from people who have been involved in the process, such as family members, advocates and clinicians, to make sure that if serious issues are being raised, they can be picked up early and addressed.

[Lewis Atkinson]

Q It is late, and I am far from being an expert on Welsh devolution, but I want to ask Professor Lewis a question, not least because we have not come to him for a little while.

Although it is not my area, I absolutely note the concerns and the discussion about respecting the democratic will of the Senedd in these matters. Would you suggest any potential avenues in the Bill to incorporate an element of positive affirmation by the Senedd, or its consent? What do you suggest we look at?

Professor Lewis: Formally, there is a need in any event for a legislative consent motion in relation to the specific bits I mentioned earlier, I have suggested one potential avenue, which is that the Senedd and Welsh Government take on responsibility for whether and when the Act commences in Wales. Another option might be to do a thorough “think once, think twice, think Wales” review to see to what extent other functions of the Secretary of State might be better exercised in Wales by the Welsh Ministers. That is a non-exhaustive list, but I hope it helps.

[Naz Shah]

Q Dr Price, you talked in your earlier evidence about depression. One Committee member suggested that 20% of people were on antidepressants; actually, the factual position is that 10% to 11% of the adults in this country are on antidepressant medication, according to the latest statistics. To be clear, are you saying that people who are depressed are more likely to ask for or go down the road of assisted dying?

Dr Price: The evidence that we have from research—this is in populations who would fulfil the criteria in terms of terminal illness—is that the prevalence of depression is around 20%. That is across a number of populations. It is associated with a wish to hasten death. Depression might impact upon that person’s decision making; I am not saying that it absolutely would, but it might. Also, treatment might change their view. We know that there is a strong association, for example, between pain and a wish to hasten death. Unresolved physical symptoms make people want to die, and when that pain is better, people no longer feel that way.

That is borne out in my clinical practice. We will get urgent referrals to see somebody who wants to die and who they are very concerned about. Then the pain is under control: we see them that day or the next day and they say, “Do you know what? The pain’s better. I don’t feel like that any more.” When we think about symptoms, we need to think carefully about what is treatable and what is remediable. That may be about psychiatric interventions, but it is often about a biological, psychological and social approach.

[The Chair]

May I thank the panel for giving evidence today? We really appreciate your attendance.

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

Naz Shah Excerpts

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[The Chair]

I thank the Member for making that point of order. It is normal practice for evidence to come in, and for it to be submitted as it comes in. However, due to the large amount of evidence and its substance, and to the importance of the Bill and this line-by-line scrutiny, I will seek the advice of the Clerk and will come back to him.

[Naz Shah (Bradford West) (Lab)]

Further to that point of order, Ms McVey. My concern is about written evidence that has been submitted but not yet read—I have certainly not been through the last batch of evidence that we have had. How do we proceed when, for example, we might have gone through clauses 1 and 2, or even up to clause 4 or 5, and we receive evidence related to those clauses? We will have already discussed them in Committee. We have been told we will only get five hours on Report, while on Second Reading more than 100 MPs, including me, were unable to speak. The evidence could inform amendments. I am struggling to understand how this will be workable. I would value your advice.

[The Chair]

I am pleased that people feel they are free to make those points. It is for the Committee to decide how fast to move through the Bill.

--- Later in debate ---

[Sarah Olney]

I heard Sir Chris Whitty in particular say that it would be preferable to have a more straightforward Bill that did not have too many bureaucratic hurdles for people to overcome. That was why he was keen for the Mental Capacity Act to be retained. However, I tabled the amendment precisely because, when people are thinking about whether assisted dying is an appropriate decision for them, I do not think that it is safe for them to be judged merely on the basis of their capacity. It is by no means my intention to increase bureaucracy; I am merely proposing that the Act is not sufficient in this case.

[Naz Shah]

Three psychiatrists gave evidence to the Committee in person: Professor Allan House, Dr Annabel Price, of the Royal College of Psychiatrists, and Professor Gareth Owen. All expressed doubts about the use of the Mental Capacity Act to assess whether a person was in a fit state of mind to undertake assisted dying. Does the hon. Lady agree that we should place great weight on the opinion of psychiatrists when assessing whether the Act should be used to assess applicants for assisted dying? It is a horse before the cart scenario, because the Act was not made for this context; when it was passed, we were not talking about the ability to choose to die.

[Sarah Olney]

I agree exactly with the hon. Lady’s point. The Act was not designed for this purpose, and it is essential that we carefully scrutinise whether it should be used in this way.

--- Later in debate ---

[Dr Tidball]

I appreciate the hon. Member’s intervention, but I do not agree. Taken together, the parameters around the six-month limit, clause 2(3) and the requirement for a mental capacity test cumulatively create a safeguard in the Bill.

Importantly, the MCA’s two-stage capacity test is already underpinned by robust safeguards, which address exactly the issue the hon. Gentleman raised. Stage one asks whether there is a disturbance or impairment in the person’s brain or mind, and stage two asks whether the disturbance or impairment is severe enough that the person cannot make a specific decision. That two-stage test already deals with the issue he raised. The references to the Mental Capacity Act in the relevant clauses of the Bill ensure, crucially, that we import that test too.

Elements of the language in the new concept of ability proposed by the hon. Member for Richmond Park appear to attempt to echo the second stage of the Mental Capacity Act test, as just described. That has four elements: understanding information about the decision to be made, retaining that information in the mind, using or weighing that information as part of the decision-making process, and communicating the decision by talking, using sign language or any other means. It is important to say that those core elements are built on the scaffolding of the five principles of the MCA, working in a progressive way.

Opposition Members talked about the unwise decision, but the principles in the Mental Capacity Act work collectively and cumulatively together. That is only one step, then, which is followed by the fact that decisions must be taken in the person’s best interest, and there is well-worn and well-trodden understanding of how we ascertain that. It is important that those things all work together. The issue is already addressed under the MCA; if we do away with the MCA, we lose not only the scaffolding of the five principles, but the important safeguards of the two-stage test.

[Naz Shah]

My hon. Friend made reference to that already being done, but where is the evidence that the capacity stage she talked about is actually happening? We had evidence from the Royal College of Psychiatrists and, as she said, Professor Chris Whitty. Where is the evidence that it is being done well, as things stand?

[Dr Tidball]

I do not have a list of the case law in front of me—I am sure it will be possible for that to be found for my hon. Friend—but it is done regularly. The Mental Capacity Act is used regularly in decisions about the withdrawal of life-support treatment. That is the case, and she is welcome to search for the case law.

--- Later in debate ---

[Dr Shastri-Hurst]

The hon. Member makes a reasonable point. I agree with her on many issues, but on this issue I have some reservations. Clause 18(4) says:

“The coordinating doctor must be satisfied, at the time the approved substance is provided, that the person to whom it is provided…has capacity…has a clear, settled and informed wish to end their own life”.

Of course, under the wording of section 26(1) of the Mental Capacity Act, that decision can be made at an earlier time and deemed to have currency, once capacity has been lost, for its enactment at a later date. I think that there could be a minor tightening of the wording or reassurances from Government to address that, but it is an important point to raise and air.

[Naz Shah]

rose—

[The Chair]

Order. Before we proceed any further, I remind hon. Members that we are discussing capacity and ability.

[Naz Shah]

I am just trying to understand what the hon. Member is communicating. Under the Bill, if somebody has anorexia, diabetes or kidney failure and has the capacity to make that decision because they meet the criteria for the capacity to refuse treatment, will that mean that they can decide to sign up to this option?

[Dr Shastri-Hurst]

The Bill is very clear in determining that it is for those who have a progressive illness, disease or medical condition that cannot be reversed by treatment. On my reading of the Bill, it excludes that category of individuals who choose not to engage with treatment that in ordinary circumstances would prevent the progression or deterioration of their condition. I therefore do not see it as analogous with the hon. Member’s scenario of someone who could have a long life expectancy if they had taken their treatment, but who chooses not to. That is not captured within the Bill, in my interpretation.

[Naz Shah]

I am struggling with this, because it is clear from the evidence from our witnesses that that is the case where somebody has anorexia, for example, and they make that choice. As has been referred to plenty of times in the context of the Bill, the Mental Capacity Act has been used, and is sufficiently used, for people to withdraw treatment. Personally, I think that that is a pretty false equivalence, because when a person’s life support machine is turned off, the decision is made not by the person receiving lifesaving treatment, but by their loved ones.

According to what we have heard this morning, if someone has the mental capacity to use the MCA to withdraw treatment for a condition, that will lead to a diagnosis of terminal illness. It could kill someone. If I refused to take insulin, and I was diabetic, I would have the mental capacity to say, “Actually, I’m not going to take this treatment, so can I make a decision?” I am just trying to check the hon. Gentleman’s understanding.

[Dr Shastri-Hurst]

With the greatest respect to the hon. Member, I think that she is conflating two issues. Someone can stop treatment under the MCA; over time, that will lead progressively to death, with some conditions—she gave the example of being a diabetic without insulin—but that would not be a terminal illness in reference to this Bill. The Bill is very clear that it is about an inevitable and progressive illness, disease, or medical condition that cannot be reversed by treatment. Diabetes, treated with insulin, is not a progressive condition that becomes a terminal diagnosis; it is terminal only by virtue of somebody refusing treatment, which therefore would not be captured within the Bill.

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

Naz Shah Excerpts

Committee stage
Tuesday 11th February 2025 Public Bill Committees

[The Chair]

It might be helpful for the Committee to know that I was bequeathed a list by Ms McVey. I understand that those wishing to speak are the hon. Member for Bradford West, the Minister, and the promoter of the Bill, the hon. Member for Spen Valley. I shall then call the hon. Member for Richmond Park, who tabled the amendment, to wind up the debate.

If anybody else wishes to speak, please indicate in the normal fashion by rising. I will call the hon. Member for Broxtowe if she wishes to speak, but I need to know whether she wants to. If she stands up at the right time, that will be fine. Please be aware that once I have called the mover of the amendment to wind up, there will be no further debate on the subject. That really will be the end of the debate.

[Naz Shah (Bradford West) (Lab)]

I rise to speak in support of the amendment tabled by the hon. Member for Richmond Park.

The key word here is “capacity”. There has been much debate around the Mental Capacity Act. I will go back to the oral evidence we heard, as well as the written evidence and submissions in relation to the amendments and the clause. The psychiatrists who have advised are against it. I appreciate and recognise the contributions from my hon. Friends the Members for Penistone and Stocksbridge and for Bexleyheath and Crayford, who spoke eloquently about the word “ability” from his experience. I recognise that we have not had the opportunity to test the concept of ability.

[Dr Marie Tidball (Penistone and Stocksbridge) (Lab)]

I appreciate my hon. Friend bringing up that point. It is important to note that all Commonwealth jurisdictions that have assisted dying use the concept of mental capacity. We are basing the utility of the Mental Capacity Act not only on 20 years of the courts and medics dealing with it, but on the learning of other jurisdictions that have put assisted dying in place. The concept of ability, however, has no basis in law.

[Naz Shah]

I absolutely concur that we are testing in regard to other jurisdictions. In Oregon, there is not just the assessment of capacity but a referral to a counsellor.

We have had lots of evidence when it comes to capacity, and I will go back to some of the key points. The Royal College of Psychiatrists stated explicitly that the Mental Capacity Act is

“not sufficient for the purposes of this Bill.”

Explaining why, the Royal College of Psychiatrists said that assessing the capacity to end one’s life is “entirely different” from assessing for the capacity to decide treatment.

Three psychiatrists who gave evidence to the Committee —Professor Allan House, Dr Annabel Price and Professor Gareth Owen—all expressed doubts about the use of the Mental Capacity Act to assess whether a person was in a fit state of mind to undertake assisted dying. When Professor Allan House was asked why some people might choose assisted dying, he said they are vulnerable. When asked what he meant by that, he said:

“They are not people asserting autonomy and pleasure in their ability to make a choice; they are people describing to you things that are negative influences on their life.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 161, Q202.]

Professor Gareth Owen said:

“I have looked at mental capacity a lot in research, and there is no experience of the decision to end one’s own life. It is outside the experience of the Mental Capacity Act, the Court of Protection, the associated research and practitioners on the ground. The reference to the Mental Capacity Act in clause 3 puts you into an area where there is no experience of the central capacity question under consideration. It is very important that Parliament be clear-eyed about that.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 226, Q287.]

[Dr Tidball]

On the hon. Lady’s point about being clear-eyed, it is important that we look closely at the drafting of the Bill and the utility of the Mental Capacity Act. There are eight occasions on which a person who might seek assistance can formally consider their decision making, and the Mental Capacity Act would come into play at each of those stages. A person with a terminal illness who wishes to seek assistance does not make a one-off decision; they make the decision eight times during the process, so we have a wide variety of opportunities to ensure that their consent is ongoing.

[Naz Shah]

I recognise that there are eight occasions, but when we debate later clauses I will talk about coercion and manipulation. Those also apply to the issue of capacity, and the Bill refers to them on numerous occasions.

[Rebecca Paul (Reigate) (Con)]

A very good point has been made about looking at the Mental Capacity Act at different times during the process. However, it does not matter how many times a bad process is applied; if the process is insufficient and does not have a high enough safeguard, it will never give the right answer. We need to ensure that we have the right test. It is absolutely right that we apply it multiple times, but does the hon. Lady agree that we need to consider the quality of what we are applying in the first place?

[Naz Shah]

I completely agree.

Professor Owen also said:

“I have had over 20 years of research interest in mental capacity. When I look at the issues relating to mental capacity with the Bill…the other important point to understand is that they are very novel. We are in uncharted territory with respect to mental capacity, which is very much at the hub of the Bill.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 226, Q286.]

Like my hon. Friend the Member for Bexleyheath and Crayford, I am certainly not a doctor, although I have experience in the NHS, but I do know that we do not have psychiatric experts or experts on capacity in this Committee.

[Sean Woodcock (Banbury) (Lab)]

Earlier, the hon. Member for Solihull West and Shirley made a point about public confidence in the Bill. In oral evidence, the representatives from the Royal College of Psychiatrists—we nearly did not hear from them; we had a vote about whether we would, and they were added later—made it clear that they have severe doubts about applying the Mental Capacity Act to the Bill. Does my hon. Friend share those concerns?

[Naz Shah]

I absolutely share those concerns, which is why I pressed the issue to a vote. As I have explained to my hon. Friend the Member for Spen Valley, I am grateful that the Royal College of Psychiatrists gave evidence. It said that the Mental Capacity Act

“is not sufficient for the purposes of this Bill”.

In oral evidence, Professor Jamilla Hussain, an expert in palliative care and health inequalities, highlighted an inequity in assessment using the Mental Capacity Act. She said that she does not think that

“the Mental Capacity Act and safeguarding training are fit for purpose. For something like assisted dying, we need a higher bar—we need to reduce the variability in practice.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 199, Q260.]

My hon. Friend the Member for Penistone and Stocksbridge mentioned the process in the Bill being repeated eight times, but I want to bring us back to the issue of capacity in relation to coercion. The Royal College of Psychiatrists said:

“In any assessment of capacity, we must also consider whether a person is making the request because they consider that they are a burden or because they do not consider that they have access to effective treatments or good-quality palliative care. At a population level, palliative care, social care and mental health service provision may impact the demand”

for an assisted dying service. Although I appreciate that we will debate this in greater detail later, on clauses relating to coercion, it relates to the issue of capacity. In her evidence to the Committee, Chelsea Roff, a specialist in eating disorders, said:

“One thing I would like to highlight in our study is that all 60 people who died”

by assisted dying after suffering from anorexia, who were mostly young women,

“were found to have mental capacity to make the decision to end their life, so I worry that mental capacity will not be an effective safeguard to prevent people with eating disorders from qualifying under the Bill.

I also note that Oregon and California, where I am from and where we have found cases, have an additional safeguard to mental capacity. That is, if there are any indications that the person might have a mental disorder, that person must be referred for a mental health assessment.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 141, Q177.]

[Tom Gordon (Harrogate and Knaresborough) (LD)]

I completely agree with the point the hon. Lady is making about mental capacity applying to eating disorders, but would that not be better debated in relation to defining an eating disorder as a terminal illness, rather than in regard to mental capacity?

[Naz Shah]

I will be speaking to the issue in relation to terminal illness, because it relates to my amendment in another grouping. The reason I am making this point now is that it also impacts on capacity. When we are assessing capacity—again, this talks to the point—the truth is that nobody in this Bill Committee or otherwise can tell me that the Mental Capacity Act has been applied to the question, “Would you like assisted dying?”

[Dr Simon Opher (Stroud) (Lab)]

First, it is impossible to argue that, because we have never been able to have assisted dying in this country, so it is a spurious argument. However, I do not quite understand the argument here. You are suggesting—

[Dr Opher]

I am sorry. My hon. Friend is suggesting that a system that has been tried and tested in court and by clinicians throughout the country over the last 20 years is not preferrable to a new system that is completely untried. I thought this Committee was about making these things safe for patients, and I cannot see how the amendment makes them more safe.

[Naz Shah]

My hon. Friend speaks to my point and the idea that the Act has been tried and tested. When we are talking about coercion, and capacity in relation to coercion, I come back to the point that we in this House have only just, in 2015 and 2021, made legislation using the word “coercion”. It was not recognised before. On the idea that this has been tried and tested for the last 20 years, I simply beg to differ.

Coercion does come into the issue of capacity. We are looking at the Mental Capacity Act, which was introduced in 2005 and is 20 years old. These conversations were not being had in Parliament at that time; the vocabulary did not include “coercion” or “undue influence”, even at the time the Mental Capacity Act was passed by this House. Again, that speaks to my point: are we really saying that we want to test the Mental Capacity Act on something that has never been done before?

[Jake Richards (Rother Valley) (Lab)]

I am trying to understand my hon. Friend’s argument. In terms of a person choosing to ask their doctor to turn off their life support machine, as opposed to someone offering a person drugs to self-administer, I understand that there are differences in terms of public policy and that, for some, there are differences morally. However, in terms of capacity—the decision as to whether that person can make that choice themselves—why is it different?

[Naz Shah]

The hon. Member for East Wiltshire answered that question eloquently earlier. Although the outcome is the same, we are asking two different questions. The question is not about turning off and unplugging a machine; it is about whether someone will take drugs to end their life.

[Jack Abbott (Ipswich) (Lab/Co-op)]

To follow the basic premise of your argument—

[Jack Abbott]

It is not your argument, Sir Roger; it is my hon. Friend’s argument. I apologise.

To follow the basic premise of my hon. Friend’s argument, she is saying that the Mental Capacity Act is not tried and tested for what we are discussing. However, by definition, neither is this amendment; if anything, it is even worse, because words such as “ability”, which we are discussing here, have absolutely no basis, as was admitted by the hon. Member for East Wiltshire. On that basic premise, my hon. Friend will not agree with any amendment that is tabled today, because none of them is tried and tested. Is that correct?

[Naz Shah]

My hon. Friend is not wrong, in so far as there can be two truths. There is a truth, for me, that the Mental Capacity Act does not deliver what we need it to deliver, and that is the concern we have heard from people who have given us evidence. We have not talked about the word “ability”—as hon. Members have pointed out, it is not set out in law—so there is a conversation to be had.

As my hon. Friend the Member for Spen Valley, the promoter of the Bill, clearly stated, this is about strengthening the Bill and bringing the best Bill to Parliament to give people a choice. That is what this is about.

[Danny Kruger]

The hon. Member is making such an important speech, and I am very grateful to her. This is a crucial discussion. The hon. Member for Ipswich suggested that the amendment would make things worse because it would apply a new test.

--- Later in debate ---

[Danny Kruger]

I will conclude my intervention very quickly. I fear that I may have mischaracterised the hon. Member for Bradford West when I said that she is opposed to the Bill in principle; in fact, I do not think that is the case. I am not sure what the difference is between opposition in principle and opposition to the detail, but I recognise that she is certainly not opposed to the Bill in principle, so I apologise to her.

Does the hon. Lady agree that the Bill would take a great leap in the dark by legalising assisted dying? At the moment, that leap lands on the uneven ground of the Mental Capacity Act. Does she agree that, if we want to do this properly, we should prepare a solid, cushioned, safe landing space that is appropriate for the Bill, rather than the inappropriate mess that the Mental Capacity Act would induce?

[Naz Shah]

I am grateful to the hon. Gentleman for his correction. To clarify, I do not think anybody in this House disagrees in principle with the idea of not letting people suffer. I am very much about principle, and I came to this Committee very much in that spirit. When I was asked to join this Committee, I had to sleep on it, and I now realise why.

I am grateful for the interventions from my hon. Friends the Members for Rother Valley and for Ipswich. There are a couple of things that are important for us to understand. The Mental Capacity Act has not been tried in any of the other jurisdictions across the world on which we are basing this law, so we cannot make a comparison.

On the issue of whether it is either/or—whether it is the Mental Capacity Act or the word “ability”—the Secretary of State has the power to change that. If we are to be true to the spirit in which we have come to this debate to make the Bill as safe as possible, given that so many psychiatrists and experts have said that they are not convinced that the Mental Capacity Act is fit for purpose in this regard, surely it is incumbent on us to make that case.

[Jack Abbott]

My hon. Friend said that the Mental Capacity Act is not tried and tested, and I was challenging the premise that we should apply a concept that is not tried and tested in this or any other country. She is saying, “I can’t support the Mental Capacity Act in its current form because it is not tried and tested,” but, following that argument, she would presumably not support this amendment or any others because what they propose is also not tried and tested.

[Naz Shah]

This amendment is an attempt to have that conversation and to strengthen the concepts that we are debating. That is the whole point of the Committee. As my hon. Friend the Member for Spen Valley said, there is no point in having witnesses if we do not listen to what they say. This is what the witnesses said.

My hon. Friend the Member for Ipswich makes a valid point. He asks whether I would, by that definition, support this amendment. I support it because it has led to a debate that we have had all morning, and that we are carrying on into the afternoon. As it is, the Bill does not give me confidence, whether it is due to the use of the Mental Capacity Act or the definition of “ability”. I feel that it needs to go much further, perhaps through the Secretary of State tabling another amendment at a later point.

[Sojan Joseph (Ashford) (Lab)]

We heard many pieces of oral evidence from expert psychiatrists, including from the Royal College of Psychiatrists, saying that the Mental Capacity Act is not fit for the Bill. Even if we use the Act, many conditions such as depression or delirium —or the effects of some medication—can impact on people’s decision making. It is worrying when someone like Dr Rachel Clarke, who has extensive experience in the Mental Capacity Act and has been training medical students and nurses, says of those mental capacity assessments that

“it is often the case that they are…poorly conducted.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 71, Q85.]

Would my hon. Friend agree that rather than use the Mental Capacity Act, the “ability” amendment tabled by the hon. Member for Richmond Park would be more suitable and make the Bill safer?

[Naz Shah]

I know that my hon. Friend comes from a mental health background and has worked as a professional in this area. I absolutely agree that we need to strengthen the Bill, which is why I will support the amendment. I feel that we must strengthen it because the Secretary of State can make some interventions.

[Kit Malthouse]

I want to clarify what the Royal College of Psychiatrists actually said, because I realise that the hon. Member is relying a lot on that evidence. In an exchange with me in their oral evidence, the doctor from the royal college said that if I were to equate the decision to refuse treatment with the decision to request a hastening of my death in extremis as qualitatively the same, and of the same seriousness and outcome, then the Mental Capacity Act may well be appropriate for the decision. The difference was information. We would be relying on the notion of informed consent, and therefore on the information that the person was being given about the consequences of that decision.

We will be debating later in Committee the information that is given to a person to form that decision, but I do not think it is quite the case that the psychiatrist said that it could not be or was not fit for purpose. Actually, they said that it may well be sufficient if we equate those two decisions—and many of us do.

[Naz Shah]

I know the right hon. Member speaks with a huge amount of experience. I am very new to the subject, but I know that the evidence from the psychiatrist was very certain—not “may well be”. The language that they used, which I referred to earlier, was very clear that it is not a good standard. They said:

“We are in uncharted territory with respect to mental capacity, which is very much at the hub of the Bill”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 226, Q286.]

and there is an inequity in assessment using the Mental Capacity Act. There were other categorical statements made—there was no “maybe” in there. For me, a “maybe” does not cut it at this level; the test should be much higher in order to take the option of assisted death.

[Kit Malthouse]

If the hon. Lady goes to column 277 of Hansard from that oral evidence session, Dr Price said:

“You are equating a refusal of treatment, in capacity terms, to hastening death by assisted dying. If those two things are equated, in terms of the gravity and the quality of the decision, the Mental Capacity Act may well be sufficient, but there are differences. There are differences in the information that the person would need and what they would need to understand.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 277, Q361.]

It is clear what Dr Price said. To be honest, the question was partly prompted as we had become a little confused, because the whole practice of psychiatry in the UK is founded on the Act at the moment. She seemed to be implying that somehow the entire practice of psychiatry in the UK was on unstable ground—and I do not think anybody is claiming that.

[Danny Kruger]

rose—

[Naz Shah]

I will take this intervention and then address both points.

--- Later in debate ---

[Naz Shah]

I think that the hon. Member’s intervention responds to some of the points of the right hon. Member for North West Hampshire.

We have heard a lot about the equivalence of endings versus decisions. The example given earlier, of somebody pulling the plug because they did not want treatment any more, happens in very few cases. From my experience of working in the NHS and with disabled people, when people are at the end of life, their cases sometimes do end up in court in front of a judge. That may be because there is a difference of opinion—be it medical, between the family, to do with capacity, or whatever the issue is. We are removing that. My understanding is that the promoter of the Bill is removing the need for the judge and is proposing a panel, which is what I read in The Guardian earlier.

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

I wonder whether the hon. Lady can help me with an area of her argument that I am conflicted by. I have heard the points made by my hon. Friend the Member for East Wiltshire, drawing the distinction between those who refuse treatment for a condition that is then terminal and those actively seeking assistance in ending their life. There is a third group who choose to refuse food and nutrition. That is not a treatment in the conventional sense, to combat a disease process, that is normal sustenance that would keep someone alive. Given that the MCA applies to that decision and someone’s ability to refuse on that basis, how does that interplay with the amendment as proposed?

[Naz Shah]

I have tabled an amendment to a later clause that talks specifically to that. The word “only” needs to be removed. We have seen this in Oregon, which I will come to later. We heard in the oral evidence that 60 women assessed to have capacity died because they had anorexia.

[Kim Leadbeater]

In respect of those numbers, it is important to be really clear that the vast majority of those circumstances were in the Netherlands and in other jurisdictions that have a much broader set of eligibility criteria than the Bill. We are talking about a very small number of cases in jurisdictions with a similar set of criteria to ours. It is important to make that point.

--- Later in debate ---

[Naz Shah]

My understanding, which comes from Chelsea Roff, was that that happened specifically in places such as Oregon and California, but I am happy to revisit that. Coming back to the point, we must ensure that people with an eating disorder such as anorexia or a mental health condition will be excluded from the Bill. That will be my second amendment. I do not know if that answers the question.

[Dr Shastri-Hurst]

It may well have been the way that I phrased it, but the point I was seeking to make was that the Mental Capacity Act, as it currently operates, can be used for those patients who choose to refuse food and water. My view would be that that is a distinct group of people who are refusing active treatment. Given the hon. Lady’s distinction between those who refuse treatment in the conventional sense and those who are seeking assisted dying and her view that for the latter group the MCA is not the appropriate mechanism, is she saying that for that group of individuals who refuse food and water—effectively choosing to end their life through starvation—the MCA is not an appropriate mechanism to assess their capacity?

[Naz Shah]

I thank the hon. Member for his intervention, but we are not here legislating on anorexia; we are here legislating on the option of assisted death. I am trying to understand where he is going with that argument. It genuinely does not make sense to me.

[Kim Leadbeater]

I do not think that the hon. Member for Solihull West and Shirley is saying that this is about people with eating disorders or anorexia; he is asking about people who are terminally ill who stop eating and drinking. They do that as a course of action to essentially end their own lives. It does happen on a fairly regular basis. We have had testimonies from families who have watched loved ones essentially starve themselves to death. It is different from having an eating disorder or being anorexic.

[Naz Shah]

My understanding, when it concerns eating disorders and anorexia—let me get this right: are hon. Members trying to equate new clause 1 with that condition?

[Rebecca Paul]

I think that one of the points being made is the difference between something that is active and something that is passive—for example, someone who chooses not to take that next level of chemotherapy because they have had enough, they have gone through a lot of it or it was painful, and chooses, in the example the hon. Member for Spen Valley just gave, not to eat and drink. That is one case, but it is very different from someone choosing to end their own life, which requires active participation and involves other people too. That would be the key difference, which I wonder if the Member for Bradford West agrees with.

[Naz Shah]

I do agree. I also want to push back on the idea that it happens fairly regularly. I would welcome my hon. Friend the Member for Spen Valley giving us the evidence of where it says that, because that is not my recollection of the evidence we have gone through so far. I appreciate that we have not gone through all of it; there might be more that we have not seen.

[Sojan Joseph]

On a point of clarification, under the Mental Capacity Act, if somebody decided to stop eating and drinking, we would let them do it until they became unconscious, and then their best interests would come into effect. We would take them into treatment if there were a risk to their life. Would my hon. Friend agree that that needs to be clarified?

[Naz Shah]

This whole conversation has taught me that we are not on top of the Mental Capacity Act or the conversation about ability, which is why it is so important to have these conversations, even if it is just to try to get to the nub of the issue. Amendments that I will speak to later will clarify my position, but from the evidence I have heard, I will be supporting the amendment tabled by the hon. Member for Richmond Park. That is because the test needs to be much higher than the Mental Capacity Act on its own when it concerns the issue of choosing assisted dying. For that reason, I will support the amendment.

[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.

--- Later in debate ---

[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 ---

[Kim Leadbeater]

That is a point worth making, and something we will look at through the amendments that my hon. Friend has proposed. I am very happy to look at those, as I have already said, but the idea of creating a whole new concept of ability seems wholly unnecessary in the context of a piece of legislation that has stood the test of time for over 20 years.

I come back to training. Although the full details of the training programme that would accompany the Bill cannot be put on the face of the Bill, I have discussed the issue at length with officials in the Department of Health and I have included amendments to that effect. Amendments 186 and 198 specifically state that training must include assessing capacity and assessing whether a person has been coerced or pressured by any other person. Further comprehensive training will be included in regulations set out by the Secretary of State, and the chief medical officer is confident that that is the correct way to proceed.

Furthermore, as has been referred to, there are multiple opportunities within the process to assess capacity by a range of professionals. I have also tabled new clause 8, which would create a duty for the Secretary of State to consult before making regulations relating to training. Within that, there would be a duty to consult not only the Equality and Human Rights Commission, which is important, but persons with expertise in matters relating to whether persons have capacity and whether persons have been coerced.

[Naz Shah]

To go back to the point about multiple opportunities and capacity, my understanding from this morning’s Guardian is that an amendment has been tabled—it was mentioned earlier; I do not know whether others have had sight of it, but I certainly have not—on potentially having a panel instead of a judge. My hon. Friend the Member for Bexleyheath and Crayford has just asked a question, and my hon. Friend the Member for Spen Valley responded by saying that she would come back to it, but my concern is that we are looking at the clause now, and once we have discussed it there will be no going back to it. I am trying to understand at what stage in the process she will come back and fix it. If we are going to address it under clause 9, clause 8 or wherever, how will that impact on clause 1? How will it address the issues that we are debating right now?

[Kim Leadbeater]

At the moment, we are addressing the fitness for purpose of the Mental Capacity Act, but there are other amendments that will take on board some of my hon. Friend’s points, particularly about people with learning disabilities. I am very happy to look at that. I am working to table an amendment before the recess, to give the Committee an opportunity to look at it in great detail. My hon. Friend the Member for Bradford West is right that that would provide another opportunity for assessment of capacity with the involvement of psychiatrists and social workers, who have said that that is their expertise and what they excel in, and who feel that they have a valuable role to play in the process.

[Naz Shah]

At what stage will we know how the amendments that my hon. Friend proposes have an impact on clause 1? If we make amendments later in the Bill, how will that have an impact on the amendments that we have discussed this morning, in particular in relation to capacity?

[Kim Leadbeater]

Clause 1 is very specifically about the Mental Capacity Act, on which we should get a chance to vote this afternoon. Other amendments can be tabled ahead of Report, but the fitness for purpose of the Mental Capacity Act is a concept on which we will get a chance to vote this afternoon. Other things can be added to the Bill that would enhance other aspects, but the point that we have discussed this afternoon is about the fitness for purpose of the Act. There are different views on the Committee, which is understandable. I believe that using the well-established legal framework of the Mental Capacity Act, introducing gold-standard training and consulting experts in assessing capacity will mean that there is no need to develop a whole new framework around the concept of ability, particularly on the points made by my hon. Friend the Member for Penistone and Stocksbridge. I therefore do not support the amendments.

--- Later in debate ---

There may be people out there who think that prisoners do not deserve it. That would be the flipside of the argument. I understand my hon. Friend is not making it; he wants to protect them because they are vulnerable. To me, however, that seems like a cruel and unusual punishment for people who are already serving time in prison, to whom we should not deny the same health-related services that everybody else receives. I will therefore oppose the amendments.

[Naz Shah]

I support the amendment for a number of reasons. I have a huge amount of experience of dealing with women, domestic violence and prisons. The first time I came to this House was to lobby the then Labour Home Secretary to reduce my mother’s tariff, because she served 14 years in prison. When my mother was in prison, I was left homeless, so I have experience of that as well. I have experience of, while I was homeless, attempting suicide on two occasions, and I ended up having my stomach pumped. I therefore speak with a reasonable amount of experience in dealing with this.

From a domestic violence point of view, which is why my mother killed an abusive partner, and having been a victim of domestic abuse, I also understand the vulnerabilities concerning women in particular—less so men, although I know the hon. Member for East Wiltshire has done a lot of work on that in his adult life. The majority of women who end up in prison—we have seen this from review of the courts, time and again—are victims of abuse, whether sexual, domestic or another kind. The majority of our women prisoners are in that position.

The suicide rate among the population in England and Wales is 11.4 per 100,000, but for prisoners, that goes up to 108 per 100,000, which is nearly 10 times as high. We also know from research that one third of female prisoners in England and Wales self-harm. We know from the Home Affairs Committee report in the last Parliament on health in the English prison system that standards of health deteriorated in recent years due to budget reduction, loss of prison officers, staff shortages and overcrowding. We know that the Government have had to bring forward early releases, because the prison system is not fit for purpose after the cutbacks of the last 14 years.

All this speaks to me of vulnerability. I hear the points that both the right hon. Member for North West Hampshire and the hon. Member for East Wiltshire have made that, in an ideal world, people should absolutely have equal access to healthcare, but the problem is that we are not in an ideal world. From my perspective, we have a prison system that has had to have emergency interventions since the Labour party came into government, because it is not fit for purpose.

From a healthcare perspective, going back to what Dr Jamilla said and the numerous bits of evidence we heard about health inequalities, I know from a place such as Bradford West that people from ethnic minority backgrounds have less trust in healthcare services. I know that we do not have equity in healthcare services. As a former NHS commissioner, I know that those health inequalities impact on quality of life and that it is a postcode lottery. I am thinking about New Hall women’s prison in Wakefield and Armley prison, which is near Bradford. I am not familiar with London prisons, but I imagine the vulnerability of the women at New Hall. This comes back to the conversation about capacity: by some definition, they might have capacity.

However, we also heard from eminent psychiatrists that when someone has a diagnosis, it impacts on their mental health. In this instance, we are talking about six months, which the right hon. Member for North West Hampshire referred to a number of times. In that six months, access to visitors might not come for another few weeks. A person might not even have a member of their family next to them when they get that diagnosis. They could well be innocent; they could well have been a victim of domestic violence and ended up in prison because they killed an abusive partner after years of abuse.

They could be in a number of situations, but the one thing I concur with is the amount of vulnerability here, in particular for women, which speaks to the issues of capacity and coercion. It speaks to all the things that we are debating here, which is why I support this amendment: it would protect those who are vulnerable. If there was a diagnosis, prison systems would kick in. If someone was given less than six months to live, they would invoke compassionate grounds to leave the prison system, but I would be really uncomfortable seeing anybody in prison being given the option without that comfort.

I cannot imagine being in the position of, say, my mum. I cannot imagine—I would not dare imagine; I do not think I could handle it—the idea of being taken away from my family and being incarcerated, rightfully or wrongfully, guilty or not guilty. I would be in a place, a system and an institution where, depending on which category of prison I was in, the institutional wraparound and the interventions are very different. It depends on the stage of the sentence that somebody is in. If they are in at stage 1 at a category A prison, there are much stricter rules and regulations. Imagine a person being faced with all that and finding out that they have six months to live. As the right hon. Member for North West Hampshire said, there is no guarantee that it is six months—more than 40% of those diagnoses do not turn out to be correct, and they could live longer. What would the impact be on that person? Could they make that decision? From a capacity point of view, I am not sure that that would exist.

[Kit Malthouse]

The hon. Lady is feeling towards the point I was trying to make, perhaps slightly incoherently. The point is that in my view, whether or not those people have access to this service, it should be based on an assessment of them as themselves, including their mental capacity, particular characteristics and their settled will, just as it would be for everyone else under the Bill. The fact that they are, at that point, a prisoner impacts on the context in which their capacity is assessed, which must be the critical factor. Having a blanket ban on all prisoners, capable or otherwise, seems cruel, if I am honest.

We know that prisons have to assess capacity in difficult circumstances. There are prisoners who decide to decline food and water and starve themselves to death. They are assessed as having capacity, if that is not the case, and in certain circumstances they are force fed, if it is seen that they do not have the capacity to take that decision themselves. In fact, the reason why prisons have created hospices within prisons is to deal with exactly such end of life decisions.

If we are doing it for non-assisted dying, why would we deny people the choice and autonomy, having been assessed as capable of making the decision, to do it in prison? Worse than that, if we are going to release them on compassionate grounds, why would we give them a shorter period to access the service than anybody else?

[Naz Shah]

I appreciate where the right hon. Member is coming from—I sincerely do. It comes back to the heart of the issue around capacity. We heard from the psychiatrist—her name escapes me, but she was on the right-hand side—that, where there is an increase of vulnerability, if somebody is told they would get pain relief, they would choose an alternative path. Those were similar words, and I will find the reference.

My point is that we do not have equal healthcare access in prison. We provide prisoners with healthcare, but it is in no way equitable. The health inequalities that exist outside prison are bad enough. Palliative care is not fit for purpose in our country—it is a postcode lottery. Depending on which prison someone goes to, that will determine what kind of access they have to palliative care. It is not a level playing field.

[Dr Opher]

I have a simple question: is it not illegal to deprive people in prison and homeless people of the same care that the rest of the population receives?

[Naz Shah]

It would be if we were making treatment equitable, but if we apply the test of legality, and this is about pain—we have already seen the amendments tabled by the hon. Member for Harrogate and Knaresborough, which would widen the scope from six months to 12 months—where do we draw the line in terms of equity and legality? The Bill is open to a lot of legal challenges, and if we want to go down that route, there would be plenty of them.

[Tom Gordon]

There is a fundamental difference between trying to ensure that people have equal access to assisted dying and prohibiting a specific group or category. Does the hon. Member understand that?

[Naz Shah]

I understand that perfectly well. On the idea of not giving people assisted dying, as the Bill stands, the category also includes people who decide to stop eating or taking insulin and people who decide not to go on dialysis. It includes a whole host of illnesses. If we are talking about the legal challenges, which my hon. Friend the Member for Stroud started with, the legal challenges for the Bill are vast as it stands.

--- Later in debate ---

[Kim Leadbeater]

rose—

[Naz Shah]

I give way to the hon. Gentleman first.

[Danny Kruger]

On the point of legality, of course a law could be challenged under the European convention on human rights, but Parliament is sovereign. If Parliament decides to exclude a particular category, we in this place have to take this enormous responsibility—we make the law in this country.

[Naz Shah]

I give way to my hon. Friend.

[Kim Leadbeater]

My hon. Friend has listed certain categories of people, and we will come on to the definition of terminal illness. I am confident that, given the definition of terminal illness in the Bill, some of the groups of people she has talked about will not be included in its scope.

[Naz Shah]

Where does it specify that? I know we are going to debate that subject later, but right now there is nothing that gives me assurance that those people will be excluded. Unless there is an amendment that my hon. Friend the Member for Spen Valley will support, the Bill, as drafted, would still apply to somebody if they decided not to carry on with treatment, or if they decided they did not want to take their insulin or other medication and that would lead to their death. I am happy to give way to my hon. Friend so that she can explain how she is going to deal with that.

[Kim Leadbeater]

I will. Let me read from the Bill. The definition of “terminal illness” under the Bill is that

“the person has an inevitably progressive illness, disease or medical condition which cannot be reversed by treatment”.

The conditions that my hon. Friend is describing can be reversed by treatment and are not inevitably progressive. We will come to that debate in due course, but that definition is crucial.

[Naz Shah]

I beg to differ on the wording that my hon. Friend just used. It actually makes my point. As it stands, if I were an insulin-dependent diabetic—and I have been so on three occasions, with my children— I could say that if I stopped taking that insulin, I would become terminally ill. In the Bill as it stands, and as it is drafted, I would meet the criteria.

[Kim Leadbeater]

My hon. Friend would not meet the criteria. She might be describing a condition that cannot be reversed, but it is the “inevitably progressive” part that we are talking about. Because it can be treated, it is not an

“inevitably progressive illness, disease or medical condition”.

[The Chair]

Order. A debate about the definition of “terminal illness” will come later in the Bill, and it might help us all if we were to swiftly move forward to that point.

[Naz Shah]

Absolutely—we will come back to that conversation.

[Sean Woodcock]

My hon. Friend the Member for Stroud, in his rebuttal to my hon. Friend the Member for Bradford West, described assisted dying as “medical care”. Personally, I do not regard assisted dying as medical care. Does my hon. Friend agree?

[Naz Shah]

I am still having that debate in my head, and I am not convinced. I will not digress—I will come to the point—but there is a conversation about whether it is “treatment”, “assisted suicide” or “assisted death”. Those terms have been bandied about. I genuinely think that, ultimately, we have to use the word “suicide” because we are amending the Suicide Act 1961. I appreciate the context in which the promoter of the Bill puts it forward, but the truth is that it is about taking one’s life, so that is how I respond to that question.

To come back to the amendments tabled by the hon. Member for East Wiltshire, the reason why I will support them is that I have way too much experience of people in vulnerable positions, and I have a lifetime of experience of seeing what happens. I do think there are options when somebody has a diagnosis of terminal illness. The prison systems are set up to be able to give them compassionate leave and to explore other avenues. Once they are outside that system, they can access support and have their vulnerability reduced.

[Dr Shastri-Hurst]

Will the hon. Lady help me to understand her position? Is it a fundamental disagreement with any prisoner having access to assisted dying, or is it a fundamental issue with completing the final act, as set out in clause 18, while being a prisoner? For example, the hon. Lady touched on early release on compassionate grounds. Under those circumstances, there may be a prisoner who has been given a six-month diagnosis, and their early release may not be until the last couple of weeks of their life. Should they be deprived of going through the process and the assessment, albeit not enacting the final act until they have been released?

[Naz Shah]

Yes, I think there should be a deprivation of that final act, because there are vulnerabilities with that prisoner while they are inside a prison. What they need is not an option of assisted death at that point. That speaks to the amendment that I tabled, which is about making sure that we do not have the conversation in the first four weeks in any case, because a diagnosis of terminal illness affects people’s mental capacity and mental health. We know that: we have heard it from the psychiatrists. It is common sense; it does not take a genius to work it out.

We know that people in prison have additional vulnerabilities. We are having a debate about the issue of capacity, which we have clearly not agreed on. A person-centred care package needs to be about supporting the person, removing vulnerabilities, giving autonomy, and offering choices around accessing palliative care and medication, so that they are in a much stronger position to make an informed choice.

[Kit Malthouse]

I am grateful to the hon. Lady for allowing me to intervene again. Can she not see that by supporting the hon. Gentleman’s amendment she is basically defining all prisoners as de facto vulnerable? It is not the case. Although many are vulnerable, both my hon. Friend the Member for East Wiltshire and I have met a lot of criminals and prisoners in our time, and quite a lot of them are smart, capable people who made a stupid decision. They are not vulnerable; they deeply regret what they did and go on to live perfectly functional lives.

We should be applying to prisoners exactly the same criteria of assessment—around capacity, vulnerability and settled will—at the time they are diagnosed with a terminal disease as we do to everybody else, because if we are not going to differentiate among prisoners, in many ways we are dehumanising the entire population. We are saying, “You are all vulnerable—no question—and we are excluding you completely on that basis.” As the hon. Member for Harrogate and Knaresborough said, that is in many ways a fundamental denial of a basic human right.

[Naz Shah]

The idea that it is the fundamental denial of a human right is not quite correct. We are talking about the denial of a provision in a Bill that has not come into law. It is a potential legal position; it is not necessarily a human right yet. If the Bill comes into force, at that point it becomes an option that could be denied. There are many prisoners. Prison serves many purposes, one of which is to reform. There will be many prisoners who go in there and get a degree in criminality because they are surrounded by other prisoners. There are people who make choices.

In the first four weeks we should not have the conversation around assisted death in any case. I have tabled an amendment to that effect and will speak to it when we come to it. In the meantime, a person has an added layer of pressure if they are in prison. It does not mean that everybody is necessarily vulnerable from a starting position. I agree that there may be prisoners who are not vulnerable, but there is an added pressure if somebody is homeless or in prison, not having family or security, that would no doubt compound their mental health. Whether that is a slight or a large impact is for somebody else to assess, but as it is I support the amendment.

[Tom Gordon]

I can understand where the hon. Lady is coming from, but I wonder whether she has any specific examples of groups such as people who are homeless or prisoners having other rights denied to them. That is what I am struggling with, although I can understand her point about people being vulnerable. The only other example that strikes me is that people who are incarcerated are unable to vote. I cannot think of any other instance where people would have any particular right removed from them. Does the hon. Lady have any other examples or comparable situations she can share to help us?

[Naz Shah]

I do not have any comparable situations; this is uncharted territory.

[Danny Kruger]

Prisoners are denied their liberty, not just their vote. They are treated as a single class of people who the state has specific responsibilities for, because it essentially owns them for the time that they are incarcerated. Prisoners have particular protections, but they are also denied a whole range of human rights and opportunities that the rest of society can have. It is not inappropriate to treat prisoners as a distinct class of people to whom the state has a specific responsibility.

[Naz Shah]

The hon. Gentleman clearly has more recent experience of prisons than I have—thankfully. In closing, I will be supporting his amendments to protect people who are vulnerable in prison and people who are homeless.

[Sojan Joseph]

I want to contribute to this discussion based on my experience as a mental health nurse. I worked in mental health services for 22 years, including managing a medium secure forensic unit. I have worked with many homeless people and people who were detained under the Mental Health Act by the criminal justice system in those medium secure units and who had been involved in criminal activities.

With my experience, I can categorically say that that group of people is very vulnerable. As the hon. Member for East Wiltshire said, self-harming and suicidal tendencies are very high among that group. As part of the risk assessments that we carry out in the mental health system, one of the questions is whether they are homeless. That question is asked to identify that vulnerability.

These amendments bring up the importance of a psychosocial assessment, which was highlighted in many pieces of our oral evidence. If we are looking to bring more safeguards into this Bill, that is something we should consider to safeguard this group of people.

I want to make one more point about what the right hon. Member for North West Hampshire said: not all homeless people are homeless in the same way; some people choose to sleep rough. I am not clear whether, if somebody is sleeping rough and is diagnosed with a terminal illness, we are looking to bring them back into an NHS bed to assist them to die. I do not know whether there is a provision to identify how we would manage those sorts of situations.

--- 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 ---

[Juliet Campbell]

I still think that it is important to add “demonstrably”. The word should be included; I do not see that it would create any additional confusion. The right hon. Member for North West Hampshire said that he had tabled some amendments later on in the Bill. However, that is later on. Putting in “demonstrably” here would strengthen his proposal.

[Naz Shah]

Does my hon. Friend share my frustration that when the Minister says, “This is the Government’s position,” he says so in the absence of an equality assessment or impact assessment? I appreciate that the Government have outlined that the process is different, but in the absence of those assessments, where do we find the weight to support those positions?

[Juliet Campbell]

I absolutely agree. The word “demonstrably” could produce that weight. It could add to every other part of the Bill that a person must be able to demonstrate to health and social care professionals that they understand what assisted dying is and understand the process that will be gone through. The person needs to be able to demonstrate to other professionals that they understand. A written report by a health or social care professional is not enough; the person themselves will have to demonstrate that they have a full and clear understanding.

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

Naz Shah Excerpts

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[Rebecca Paul]

Just to clarify, I am not questioning that they were not telling their truth. I completely believe that, from their perspective, they honestly believe they have never seen a case of coercion. Maybe I am more of a glass-half-empty kind of girl than some other people, but I question whether that is really the case. In my 45 years on this planet, I have learned enough about humankind to know that these things do happen, but different people will take different views when it comes to detecting them.

[Naz Shah (Bradford West) (Lab)]

The hon. Lady has made some important points. I repeat something I said yesterday in response to another Member: the word “coercion” and the idea of encouragement were not even in the vocabulary in this place until very recently—only 10 years ago. I do not want to dismiss people’s expertise, but for me it is quite a leap of faith—I wonder whether she shares that idea—to believe that in that jurisdiction, zero people were coerced, when every other jurisdiction records people being coerced and people saying they feel a burden.

--- Later in debate ---

[Rebecca Paul]

My hon. Friend is very knowledgeable about these things and is well qualified on the legal side. I value his contributions on this matter. The reason I want to include “unduly influence” is because it deals with those more subtle forms of coercion. Arguably, it could be included in “coerced or pressured”, but by including “unduly influence” in the Bill it becomes more explicit that a clinician has to be looking for it. In the absence of the language, clinicians will not be required to look for those more subtle forms of influence.

The provision is something that is included in the assisted dying laws of other jurisdictions. We have the opportunity here to learn and benefit from jurisdictions that have already implemented it. We heard various witnesses give us very useful evidence during the sessions. For example, California includes “undue influence” in the law. We should recognise that there is value in including it here. It is a well-established legal term that is used in myriad situations, so it is relevant that we include it.

[Naz Shah]

May I take the hon. Member back to the point of clause 24, and the issue of suicide and the terminology there? Perhaps the Minister could respond as well, although I am not sure how that would work in this Committee. What I think we are doing in clause 24 is to decriminalise encouraging suicide. That is my understanding. So can we have some clarity? Are we trying to decriminalise encouraging suicide? That is what clause 24 says, so in that case it would be absolutely right to talk about the word “encouragement”.

--- Later in debate ---

[Rebecca Paul]

It is helpful to understand the Government’s position. If the amendment is not made, I hope that the Minister is right, but one thing that I have learned in my time is that different judges will have different views on these things. Personally, I would prefer to see this provision in the Bill, as it would absolutely ensure that the protection is in place. We all know that decisions in the courts can sometimes go a different way from what we expect.

[Naz Shah]

I have a concern about what the Minister says. As one psychiatrist put it, the Bill is very novel and untested. The MCA has not been tested. Now the Government say that this will work, without consultation or any impact assessment. I struggle to understand that. Does the hon. Lady share my concern that this does not feel right?

[Rebecca Paul]

It is reassuring to hear that I am not the only one worried about this, so I thank the hon. Lady for that.

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[Naz Shah]

Does the hon. Lady share my concern? My understanding is that, in normal parliamentary business, if the Government announce any changes to the law in the press first, they are usually rebuked by Mr Speaker in the Chamber. I appreciate that this is a private Member’s Bill, but a Guardian piece yesterday outlined how we will now scrap the involvement of a High Court judge and have a panel instead, with an amendment to be tabled to that effect. I am happy for my hon. Friend the Member for Spen Valley to clarify how the system is going to change.

Once we have debated the amendments on undue influence and coercion, we have debated them. We cannot then come back to them, because of the nature of private Members’ Bills. Does the hon. Lady share my concern that, as we said yesterday, the horse has bolted? We are having to go over things and we might not be able to revisit this issue, which is why it is even more important to have probing conversations on the record so that, if nothing else, we can refer to them on Third Reading, for which we have only five hours.

[Rebecca Paul]

I completely agree with the hon. Lady. We should not make the mistake of assuming that certain amendments will be accepted. Until there is a Division, we do not know what the Bill is going to look like. It is incredibly difficult to table amendments early on when we do not know whether other fundamental things are going to change. That is why it is important that we are really thorough and improve the safeguards as much as we can, clause by clause. I do not want to get to the end of this process without our having accepted any of the improved safeguards, only for the Bill to be turned on its head at the end when there is a Division on something fundamental. As the hon. Lady rightly says, we do not get the opportunity to come back and review the decisions we have made on the back of that.

--- Later in debate ---

[Rebecca Paul]

I thank the right hon. Lady for that really helpful intervention. That is exactly the kind of advice that is extremely useful to us new MPs undertaking this process. I will have to make the decision on that question in a matter of minutes, and it is very difficult, but I will do my best to make the right decision.

New clause 5 seeks to define encouragement for the purposes of the Bill and includes some exclusions. We have already talked about some of the challenges with exactly what encouragement means, and clearly there are certain acts that we do not want to be captured by it. The aim of the clause is just to ensure that it is only intentional, targeted and effective encouragement that is covered. I am very open to working with the Government to ensure that the drafting reflects the intent; it may well be that some other things go in there to address some of the concerns raised by my right hon. Friend the Member for North West Hampshire around support being given by families. No one wants to see that included in this definition—I think we all agree on that.

In summary, I hope hon. Members will view these amendments, incorporating undue influence and encouragement into clause 1, favourably, in order to bolster the safeguards in this Bill. It is vital that subtler forms of influence are addressed, to protect patients and to ensure that it is not just the obvious signs of coercion that are looked for. I also welcome amendment 113, tabled by the hon. Member for Broxtowe, which is very much in the same spirit as amendments 23 and 82 and would insert the word “manipulated”. I hope we will debate it because, if accepted, it would certainly improve the safeguards in the Bill.

[Naz Shah]

It is a pleasure to follow the hon. Lady. Just to put it out there, to begin with on amendment 23, the Court of Appeal, in the case of “Re T (Adult: Refusal of Medical Treatment)”, held that undue influence was relevant to medical decisions and said that doctors must check for it. Undue influence is about power imbalance, rather than outright coercion.

That brings me nicely on to the points we discussed in some detail yesterday. The right hon. Member for North West Hampshire talked about having a conversation with his family, with his wife and children and so on. I will give another example. Say there is a woman who has been the victim of domestic violence—we know this happens; we know two women a week are killed in this country, to this day—and she is subtly encouraged: “Sweetheart, you’ve got a diagnosis and the option is to have this.” There is a fine line, and the fine line conversation has been mentioned quite often as well, but I would rather stay on the side of caution with that fine line conversation when it comes to domestic abuse, coercion and the power imbalance in a relationship.

Let me come back to that woman or elderly person whose loved ones have the conversation—and they indeed have the conversation; it happens every day. Ask any victim of domestic violence. On average, it takes a woman 40 attempts to leave an abusive partner—that is the fact—because we do not even recognise it.

I know somebody who recently left an abusive partner—that took three years of encouragement because she did not recognise that what was happening to her was about power and control. It is when power is juxtaposed with vulnerability that there is the potential for abuse. That happens—it happens every single day. Victims of domestic abuse are not just younger people; according to Age Concern, over 375,000 older people are at risk of domestic abuse.

The abuse of people is a cancer in our society, and that very subtle power imbalance is where the fine line is crossed. Given that the Court of Appeal has ruled and is already saying that medics have to look out for undue influence, I would argue that amendment 23 actually strengthens the Bill. My hon. Friend the Member for Spen Valley has repeatedly insisted that this Bill needs to be the tightest in the world. How does the amendment not complement her view? How does it not strengthen the Bill, to protect victims?

[Sojan Joseph (Ashford) (Lab)]

My hon. Friend mentioned domestic violence and vulnerable people. Do we not also need to think about the many people in hospital beds and nursing homes who may not have any relatives? They might get influenced or encouraged to choose this route by professionals because of the pressure on the NHS and hospices. Amendment 23 would strengthen the Bill in that respect as well.

[Naz Shah]

I would like to hope that that would never happen; I have a huge love of the NHS and of the people I know in it who make decisions every day, particularly given all the cuts—even more so, post covid. But there is that risk; I would like to hope that it is very small.

When it comes to mental health, the debate is similar to the one about capacity: it is the same conversation about whether something is fit for purpose. Just because something already exists does not mean that it will necessarily suit what we are doing here.

On International Women’s Day, the Minister for Safeguarding and Violence against Women and Girls, my hon. Friend the Member for Birmingham Yardley (Jess Phillips), eloquently reads out a list of victims of domestic violence who have been murdered. There are two a week—I make no apologies for keeping coming back to this. Only yesterday, there was an article about women’s charities that support victims of domestic abuse citing their concerns. The amendment speaks to those concerns. How could it not be supportive?

I am not convinced by the idea that the amendment would introduce an element of jeopardy. People make decisions with their families every day. We sit and have conversations. I speak from a position of privilege—as we all do in this place, frankly. We speak from positions of privilege about how we could have these conversations with our families. But we know that inequalities exist and that some people do not have those privileges. We know that society is unequal. We know that domestic abuse, elder abuse and mental health issues exist.

In my constituency, it takes 14 months just to get a child and adolescent mental health services referral for a young person; I appreciate that we are not talking about young people. My point is that there is a real backlog in the NHS—in terms of waiting times and pain medication, for example. Palliative care is not equal, as I said yesterday. I am genuinely asking Committee members: which bit of the amendment can we not support?

[Sarah Olney]

The hon. Lady is making a powerful speech. She referred to an article she read yesterday about domestic violence in relation to the Bill; it may have been the article by Sarah Ditum in the New Statesman, which I also read yesterday. It cited two cases in which people had been on trial for murder and had pleaded mercy killing, or said that they had carried out the killing of their spouse or partner on the basis that that person was suffering greatly at the end of their life. In both cases, when the evidence was examined, the men were found guilty of murder, because it was very clear that that was what had actually happened.

The article had a profound impact on me, because it demonstrated the risk that we are running: that people will be able to use the Bill in instances of domestic violence. We have to take that very seriously and consider the implications.

[Naz Shah]

I thank the hon. Member for her powerful intervention. She is right: that was the article I mentioned. Reading about such stories does have a profound impact.

[Kim Leadbeater]

My hon. Friend is making some powerful and important points about, sadly, a lot of the ills in society, which we all deal with.

Let us take the example of a woman who has a terminal illness and is coerced and pressured by a loved one to end her own life. At the moment, we have no idea whether that has happened, because there is no legal framework around that dreadful situation. The Bill would create a legal framework, so that conversations would be had with that woman prior to that point and, hopefully, that point would never come. She would speak to two doctors, potentially a psychiatrist, and other experts to ensure that that did not happen. At the moment, there is no legal framework around that. The Bill also includes a criminal offence of coercion, for which someone could go to prison for 14 years. At the moment, that just is not there.

[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.

[Daniel Francis]

From what I understand from the promoter of the Bill, the argument is that we should put these measures in place to protect from coercion people who have less than six months to live, but we would not put those protections in place for people who have nine or 12 months to live. If we are putting the measures in place for someone with six months to live, why are we not doing so for someone with nine or 12 months to live?

[Naz Shah]

My hon. Friend makes a valid point. There has already been a test case, and the Court of Appeal has ruled that undue influence is relevant to medical decisions and that doctors must look at it. If that is already a ruling, I struggle to understand the resistance to adding the words “undue influence” to a Bill that, in the promoter’s own words, should be the safest in the world. A judge has already ruled on it. We already know that we are not going to get to a judge. I struggle to understand this.

[Kit Malthouse]

As the Minister pointed out, the concepts that the hon. Lady is trying to embed in the Bill are already covered by what is a settled legal interpretation and a framework that, over the last 10 years, has become used to dealing with those issues. Do not forget that families who are going through such situations will be advised and will examine the legislation quite carefully. I am nervous about injecting yet another level of consideration for them that might mean that conversations are interpreted—by them, but not necessarily in a legal sense—in a way that is not beneficial to the patient.

I understand the group that the hon. Lady is seeking to protect—that is what we are all trying to do. But what about the majority of people in such circumstances, who might say, for example, “Darling, I am thinking about taking an assisted death because of my horrible disease. If you were me, what would you do?” If I then say, “Well, painful though it is for me, I would do exactly the same thing,” how would families interpret that?

I also want to respond to the hon. Member for Bexleyheath and Crayford. He made a strong point, but I am not sure he is exactly right. I think that if at nine months I have a disease that is progressing, and somebody in my family says to me, “When it comes to it, Kit, you have absolutely got to take an assisted death. We really want you to,” and then when I get into the six-month period I do, and I tell the doctor, my interpretation is that would be covered under the Bill.

I think what the Minister was eloquently trying to establish was that we have to be careful about the clarity of the legal language, and not make it embroidered in a way that makes interpretation by laypeople as well as by lawyers more difficult and complicated. I will come on to this in the next grouping, but we must not use language in a way that skews behaviour, or that makes what should be healthy and fulsome discussions within families guarded and nervous.

[Naz Shah]

I have to respectfully disagree with the right hon. Member that this is a settled position. I also challenge, on the record, what the Minister said. I struggle to understand how the Minister and the Government can say that this is a settled position without having gone to consultation on the Bill and without having an impact assessment. That does not satisfy me. My role when I agreed to be on the Committee was to come in to scrutinise and help strengthen the legislation. In doing so, these are the things that I am pointing out, because the safeguards are not strong enough for me.

I come back to the Court of Appeal. This would be a medical intervention, albeit to end somebody’s life. It would be administering a lethal drug to end somebody’s life, and it would be done by medics. Medics are involved in every stage. If there is case law that has already established that doctors have to look at undue influence in medical decisions, then I say to every single person on the Committee: what are we resisting? When the Court of Appeal has already said so, why is the Committee debating keeping this language out because it makes things complicated?

Let us go back to the words of Dr Jamilla Hussain, who gave evidence to the Committee. She is a clinician, and she absolutely accepts that there are some people who would really benefit from this law. As a clinician, she wants to get there. Indeed, I spoke to Professor John Wright, and he said, “Naz, absolutely—this is where we need to be.”

[Sean Woodcock]

My hon. Friend is making a very powerful argument. She is absolutely right to focus on protecting the vulnerable people who this law might apply to. She has touched on medics. I also want to mention the state and its role in what we are talking about. For example, I am opposed to capital punishment, and I link this discussion to that because we are talking about the state providing an individual with a method by which they can end their own life, such as by handing them a pill. I am concerned that, if we are not taking these safeguards seriously, we are abandoning vulnerable people by allowing the state to aid and abet the misuse of the Bill against them. Does my hon. Friend share my concerns?

[Naz Shah]

I share my hon. Friend’s concerns about the Bill not being tightened and fit for purpose. We cannot afford for those people to slip through the net. One woman’s death is one too many. One older person’s death is one too many. That is the bar we have to set.

I come back to the words of Dr Jamilla: she said, “Yes, absolutely.” Every single Committee member, and anyone familiar with this debate, found it heartbreaking to listen to those who came in to give testimony about how members of their families died. Those stories will stay with us forever, and rightly so. That is why, in principle, I am supportive of where we need to get to with the Bill. However, as Dr Jamilla said, we cannot get there by ignoring this big lot of people with vulnerabilities and inequalities, who would absolutely need this legislation. We need to fix the inequalities first.

Let us be honest: as legislators, we know that we will not fix every ill in society, otherwise we would not need a police force. We would not need laws if everybody behaved as they should and supported each other. However, it is incumbent upon us, as legislators in this place, to try our best.

Nobody came to this Bill Committee thinking it was going to be a walk in the park. We certainly did not know that we were going to get evidence throughout it, and plenty of challenges are popping up. We came to this Committee—I came new to the subject—because it is of such importance. I sat in the Chamber for five hours on Second Reading, bobbing, but I did not get the chance to speak—and that happened to another 100 colleagues, who also did not get to speak. However, those who made contributions—whether they were for the Bill, concerned about the Bill or were clearly not going to support the Bill—did so because they feel very strongly about it. That is our responsibility.

I come back to amendment 23, which was tabled by the hon. Member for Reigate: we should really consider adding it to the Bill, because that would strengthen it. The amendment does not dilute the Bill, and it does not add another hurdle given that the Court of Appeal has already said that there is a responsibility to look for undue influence. I do not understand the resistance to the amendment, which I will support.

[Jake Richards (Rother Valley) (Lab)]

This debate has been very interesting and has reminded me of my life before being elected. When I was a barrister in court, I was often junior counsel and, by the time I stood up, all the best points had been taken. I feel a bit like that this morning.

I have some observations, the first of which is on what is in the Bill currently. My central submission is that the Bill does more than enough in this area, and that simplicity is what is required, especially when dealing with very complex and difficult subjects, which coercion is. There are two sides to the coin of coercion: one is about acts by third parties, such as family members or society at large, and the other is the individual making the decision.

Clause 1 is clear that, as part of the assessment made by the doctor, judge or panel, the person must have

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

voluntarily. That precisely echoes words from the Crown Prosecution Service guidance on whether to prosecute that is currently in operation. That guidance has been in use for some time, and it seems perfectly rational and logical to continue that.

The focus of the assessment should be on the individual and whether they make the choice freely. Clause 1 makes that clear, and I presume purposefully echoes the language from the CPS guidance. It then says it must be established that the person has

“made the decision that they wish to end their own life voluntarily and has not been coerced or pressured by any other person into making it.”

That must of course be read with clause 26, which introduces a new offence:

“A person who, by dishonesty, coercion or pressure, induces another person to make a first or second declaration, or not to cancel such a declaration, commits an offence.”

That carries a sentence of up to 14 years in prison.

[Naz Shah]

I am trying to understand the expertise my hon. Friend is speaking from. Was he a criminal barrister?

[Jake Richards]

I am very happy to share my CV afterwards. I practised as a barrister mainly in family law and Court of Protection law, but back in the day I also practised criminal law as a very junior barrister in the magistrates courts up and down the land.

I do not want to delve into the criminal element too much, because we are on clause 1, but it appears to me that the criminal offence set out in clause 26 is far stronger than the Suicide Act 1961, which talks of an act of encouragement. That is not included in clause 26, which talks about inducement—a much more holistic and wider concept than that of an Act probably drafted back in the late 1950s. In my submission, that brings the law far more up to date with modern concepts of coercion and pressure.

--- Later in debate ---

[Jake Richards]

I did not draft the legislation, but my understanding is that the reason why the word “dishonesty” appears in clause 26—I do not know whether the Minister wants to comment on this—is that when there is a criminal offence, there needs to be a mens rea. The person who has committed the offence needs to have been intentional or reckless in doing so. As I say, I was a criminal barrister only very briefly; I am sure my law tutors are shaking their heads.

[Naz Shah]

The principle of statutory interpretation means that by mentioning one thing, we exclude others, so it is my understanding that having the terms coercion and pressure in the Bill excludes undue influence. Will my hon. Friend, who has clearly gone through this in detail, also comment on the fact that section 2A of the Suicide Act says that encouragement includes pressure?

[Jake Richards]

With respect, I think my hon. Friend is wrong: it is certainly not an exhaustive list of factors to be taken into account. The courts—this is why we have a common law system—interpret the language used in legislation.

[Naz Shah]

To build on that, I referred to the Court of the Appeal earlier, but when it comes to someone giving their organs, I think from the age of 12 or 13—I will try to find the reference—the words “undue influence” are used in the legislation. It comes back to the crux of my argument; I would like to understand why my hon. Friend is so concerned, from a legal perspective, about putting in the words “undue influence”, when they already appear in legislation.

[Jake Richards]

The issue I have is that if we open the door to all different types of terminology, it will never end. The law is best served when it is clear, simple and straightforward.

--- Later in debate ---

[Juliet Campbell]

rose—

[Naz Shah]

In response to the intervention of my hon. Friend, we are here to make the Bill as safe as possible, but this is a new thing. When the Bill returns to the House, I have to make a decision on whether to support a new Bill that is of such huge magnitude to our communities and the whole country. This Committee is the only process available to us, and words matter.

I support the amendment tabled by my hon. Friend the Member for Broxtowe. The concept of manipulation, as she set out, is very important. I come back to the issue of abuse, particularly in respect of women. I have never heard the phrase “Fifty Shades of Manipulation”—that is an interesting one—but this happens every day, across society. I encourage people to talk about these words. We, as parliamentarians, benefit from that: we are better people for understanding other experiences, because different people bring different experiences to this conversation. I have certainly learned a lot, and it strengthens the House itself when we speak from positions that we have debated. That is the whole purpose of us being here. I am not concerned by talking about adding language—I hope my hon. Friend the Member for Broxtowe shares my view—because that is point of us being here in the first place.

[Juliet Campbell]

To reply to my hon. Friend the Member for Stroud, I understand that the writers, promoter and sponsors of the Bill want it to be as simple as possible. The thought is that if we make it as simple as possible, there is less room for confusion and misinterpretation, but there are times when we can make things so simple that we allow far too much interpretation. Words such as those that the hon. Member for Reigate wants to be put into the Bill are really important. Manipulation is really important. Coercion and pressure are not measures of every type of controlling behaviour that happens to individuals.

[Juliet Campbell]

I thank my hon. Friend for looking that up so swiftly. I still think that those additional words need to be included in the Bill. “Coercion” and “pressure” are used as a catch-all for manipulation, but the Bill does not allow people who are using it in their everyday life—doctors, clinicians, nurses and social workers—to understand that.

[Naz Shah]

I thank my hon. Friend for being so generous with her time. To come back to the CPS’s terminology, does she agree that, in an ideal situation, the Bill would be so safe that we would not need to look at that CPS definition? The Bill would be so tightly defined that nobody could be prosecuted for coercing somebody into taking the option of assisted death.

[Juliet Campbell]

I absolutely agree that we do not want people not to understand what the Bill allows them to do or not do. We spoke earlier about making the Bill simple enough for professionals to understand so that they know how to deal with particular instances, but it is not here to make life easy for professionals; it is here to ensure that anyone who is vulnerable—anyone who has six months to live, or for whatever other reason—is protected.

A continuous theme of our debates and all our conversations is that we must make safeguarding as tight as possible so that people are protected. I believe it is not too much to ask to include those additional words to ensure that the wording is as tight as possible and protects the people who need our protection every single day.

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[Danny Kruger]

The risk of gaming—of patients playing the game, and doctors seeking out words to say or not say—is an issue throughout the Bill. That is a general problem with the Bill; thankfully, it is not just a free-for-all. However, in the scenario that my right hon. Friend suggests, that is exactly my concern: if the patient says that their spouse agrees with them or encourages them, that should be a red flag. Under the current Bill, it is not clear that it would be. There is no obligation on the doctor to record that there has been undue influence or to push back, because at the moment, the doctor is looking only for evidence of coercion. As I will come to later, that bar is too low to use, so if the doctor hears those words, I would like him or her to start asking questions, to push back, and to satisfy himself or herself that there has been no overt encouragement or undue influence. That is the point of what we are trying to do.

[Naz Shah]

To come back to an earlier point—I want to make these points, simply because it is really important that we get them on the record—my hon. Friend the Member for Rother Valley talked about undue influence and encouragement perhaps being archaic terminology. However, just last year, the Digital Markets, Competition and Consumers Act 2024 cited undue influence, as did the Anatomy Act 1984. Acts passed by Parliament in the last few years have used that terminology, so does the hon. Member for East Wiltshire share my concern about the resistance to having those words added to this Bill?

[Danny Kruger]

The hon. Member is absolutely right—undue influence does exist in law, including in laws that have been passed very recently. I recognise that the hon. Member for Rother Valley is not impressed by laws that are more than 10 years old, but I hope he might be satisfied that a law passed last year is sufficiently up to date and modern for him to regard as morally valid. Undue influence is an existing term, and we should apply it in this case.

--- Later in debate ---

[Danny Kruger]

I am sure that the hon. Lady will acknowledge that those investigations will still happen, because not everybody who commits suicide will be subject to the Bill; not everybody who is terminally ill and wants to take their life with the assistance of their loved ones will be caught under it. I am sure she acknowledges that it is therefore still appropriate to have safeguards against assisted suicide outside the law—in fact, the Bill strengthens those safeguards. Those will still continue. I also regard it as appropriate and necessary to have a law against assisted suicide, for all the reasons that we have been discussing.

The hon. Lady is right that it is appropriate for Parliament or the authorities in general to ensure that cases such as those we have discussed, and that have been powerfully testified to us, are handled sensitively. In an overwhelming number of cases, the police do handle them well and sensitively. It might be that we need to improve the guidance around prosecution, and that is an important question. I certainly do not want the families of people who have taken their own lives to be harassed and chased through the courts, and I think we would all agree on that. In that respect, the guidance for the CPS and the police will always evolve.

[Naz Shah]

The hon. Member may recall that we heard from the former head of the CPS in the oral evidence sessions, and I asked him whether the Bill would address concerns about such prosecutions. I absolutely agree with my hon. Friend the Member for Spen Valley that we want to address that. However, this Bill is not the route to address those issues unless they fall into that six-month bracket.

[Danny Kruger]

I think that is right. I do not accept the claim that this Bill is somehow a response to the problem of abuse, coercion or the pressure to end life in families. Tragically, in jurisdictions that have an assisted dying law, the number of unassisted suicides—suicides that happen outside of the law—go up, because no law can catch all the people who might want to take their own lives. Thankfully, there is no blanket support for any assisted suicide; all the jurisdictions have some restrictions.

More significantly, if the state said that some people’s lives are not worth living and that it is an acceptable choice for them to end their own life—which is not what the current law says; we have legalised suicide, not actually endorsed it—by passing a law that endorsed the choice of some people to take their own life, we would be sending a signal that we agree that some people’s lives are not worth living. The social consequence of that is clear in the evidence from other jurisdictions: suicide in the general population goes up as a result of an assisted dying law.

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

Naz Shah Excerpts

Committee stage
Wednesday 12th February 2025 Public Bill Committees

[Danny Kruger]

I am not sure that we are going to satisfy each other on this point. A lot of the evidence that we have heard conclusively asserts that there is a widespread problem of families applying—and I do use these terms fairly interchangeably—undue influence, encouragement and manipulation. Pressure and coercion form a subset of those terms. They are at the sharp end—the more obvious forms of encouragement and manipulation. Those terms exist in law, and this certainly exists in society, as we have heard from Members and witnesses. It feels to me entirely appropriate and consistent with the principles of the Bill that we are trying to ensure that the new law will only be available to people who are acting entirely autonomously, without having been in any way—however subtly—the victims of any sort of undue influence. That is the purpose of these amendments.

[Naz Shah (Bradford West) (Lab)]

Earlier, the hon. Member gave some examples of subtle encouragement or undue influence. If an elderly person has only one living relative, and they could benefit from their will, the encouragement could be so subtle. They could say to their dad or mum, “This an option available for you,” and not necessarily encourage or talk about palliative care. I know that is a conversation we will come to when we discuss later amendments, but this particular point is about people being driven in a certain direction, and that is so subtle.

As a mother to my children, I encourage them to do certain things, because I want to have that control over their behaviour because they are children. It is a normal thing to do. But when it comes to life or death, as a responsible parent it is my job to get them to think like I do or how I want to shape them. I think it is that subtle. Does the hon. Member agree that it is so subtle that sometimes we have to put it into the letter of the law to make sure it is there consciously, as opposed to expecting people subconsciously to understand the words “under coercion”?

[Danny Kruger]

I emphasise that the basis of the Bill, despite what many campaigners might want, is not one of total autonomy. The Bill requires us to have some responsibility towards the applicant, and not simply to say “Do you want it? You can have it.” There are already provisions in the Bill that put an obligation on the assessing doctors and then the judge not so much to conclude that it is in the person’s best interests—I am afraid it does not have that stipulation—but it does seek to insist that they make their own decision.

As the hon. Lady said, many people make a decision and might not even be fully aware themselves that they are the subject of undue influence. They may be being deceived by their loved ones. Their loved ones might be deceiving themselves about the pressure they are putting on them, but let us just talk about a genuine intent to persuade, which does happen. In answer to the question, “Have you been coerced or pressured?”, the patient may say, “No, of course not.” But if they are asked, “Have you been encouraged?”, they might say, “Actually, yes, I have.” That should raise a very significant red flag, and it is absolutely appropriate and sufficient at that point to say, “I’m sorry, but I don’t conclude that this is an autonomous decision.”

To conclude, I refer back to the debate we have been having since the news broke two days ago that there will be an amendment to scrap the judicial stage that is currently in the Bill. If there were a High Court judge sitting at the end of this process, as we were promised and as was understood by the House when it voted on Second Reading—if there were a judge sitting over each individual case, rather than sitting at the head of a national assisted dying commission, and if there were a judge sitting in court reviewing the case properly—there might arguably be no need for the amendment on undue influence.

It is possible, as the Minister explained, that coercion would sufficiently capture the more insidious undue influence and encouragement we are concerned about. It is possible that we could strengthen the definition of coercion through guidance, or through further definition in the Bill. But if we are going to have a panel, and not a court or a judicial process at all, it is even more necessary that we insist on added protection.

--- Later in debate ---

As with the other amendments in the group, there is a risk in introducing additional or overlapping terminology —the right hon. Member for North West Hampshire referred to “embroidering” the legislation with terms such as “unduly influenced” or “manipulated”. As a general principle, and in order to preserve the integrity of the statute book, where a term is not given a statutory definition, it will be understood that Parliament intended the term to have its ordinary meaning. Indeed, that is how the courts will interpret it.

[Naz Shah]

Many of us on the Committee are first-timers. My understanding is that in a normal Government process we would have gone out to consultation. We are talking about coercion and undue influence, and undue influence in particular is not something that does not appear on the statute books in other legislation, as the Minister may recall I said earlier. We would normally go out and consult and speak to charities, particularly domestic violence charities.

As many Members have said throughout the last few days and this morning, we know that terminology changes. We did not previously have the vocabulary of coercion and the words that we have today. When was the last time, for any Bill—apart from in respect of Domestic Violence Act 2021 under the previous Government—that we actually went out to consult people? Given that there is no impact assessment, which we are so desperately missing and which is a huge chunk of this issue, I want to understand how we can be sure, and how the Government can come here and be absolutely sure, that this will work, given that this is a whole new concept.

This is not domestic violence, with which we have some familiarity. We had one Select Committee inquiry in 2015, and my understanding is that it did not produce anything conclusive either to support or not to support the concept of assisted dying. We have not had the debates to tease this out. Other Members may be much more familiar with these concepts, but will the Minister comment on that?

[Sarah Sackman]

To bring it back to the specific debate about the amendments, the terms “coercive” or “coerce” and “pressure” appear in the criminal law and have broad definitions. That is how they have been interpreted by the courts. Others have referred to section 76 of the Serious Crime Act 2015, which created an offence of controlling or coercive behaviour. In that context and the relevant Bill, Parliament chose not to make a specific legislative definition, but the way in which it has been interpreted, in accordance with its natural meaning, has vindicated the proposition that a broad meaning is given to those terms. For example, that offence could include coercive behaviour such as repeatedly putting somebody down, telling them they are worthless, seeking to control their daily routines or isolating them from friends and family to put pressure on them. As my hon. Friend says, we understand those sorts of behaviours in a much broader way in a changing society.

--- Later in debate ---

[Sarah Sackman]

On the hon. Gentleman’s first point, there is no suggestion that we should somehow accept any weaker form of provision in this Bill to protect other parts of the law. Having said that, he would well expect me, as a Government Minister, to be concerned with the integrity of our statute book as a whole.

It is because the Government take a holistic view of how the criminal law and other areas of our law operate and define these concepts, and how they are read across the piece, that we make our contention in respect of these particular provisions, because the terms “coercion” and “pressure” are given their natural meaning and are expansive. In the Government’s settled view, they would be inclusive of the types of behaviour that are described in the amendments before us—namely manipulation, undue pressure and the sort of encouragement that I think, when he keeps coming back to it, the hon. Gentleman is referring to, which is not encouragement in a benign way as might exist between two perfectly supportive family members in a normal conversation, but the sort of encouragement that is intended to lead to coercive ends.

The hon. Gentleman says that pressure is a subset of encouragement; the Government’s view is that coercion and pressure would cover off the other behaviours that are described in the amendments. It is not necessary to include those additional concepts, because it risks sowing confusion that somehow they are not included in the concepts of coercion and pressure.

[Naz Shah]

I want to understand the Minister’s point about multiple words. We have the Digital Markets, Competition and Consumers Act 2024, referring to both coercion and pressure, and undue influence is also included. Those three terms are used in the same Act. Undue influence is also included in multiple additional statutes—over 10, including the Anatomy Act 1984, which is about people leaving their body to medicine for the purposes of tests and so on. Is the Minister saying that those are bad Acts, because they could confuse people? That is the test we are applying.

[Sarah Sackman]

I am certainly not saying that those are bad Acts, and I do not want anyone to quote me as saying that. We could in theory sit here and come up with a whole set of terms that would be descriptive of types of pressure and coercion. We have come up with a number of those, including “undue influence”, “manipulation” and “unduly pressured”. There are other types of behaviour that we might seek to describe. Indeed, if one refers to the Crown Prosecution Service’s guidance in respect of the offence in section 76 of the Serious Crime Act 2015, there are a whole load of descriptors of different types of behaviour. We could name and enumerate all those different types of behaviours, but, in the Government’s view, that is not the best way to create legislation that is workable.

It is the Government’s settled view that the words “coercion” and “pressure” cover off the types of behaviour that Members suggesting these amendments would wish to include. The risk is that such amendments create more confusion and shed more heat than light, if you like. Indeed, there is then the risk that the definition of coercion is narrower than it in fact is under our law as it is understood in our courts and in the body of common law and case law, which has been developed in construing those sorts of terms.

We are still on clause 1, and we have spoken a little about the interplay between clause 1 and later clauses, particularly clause 26, which engages the criminal offence as drafted in the Bill. I want to stress that while the procedural clauses 1, 7, 8 and 12 may use the same language as the criminal offences in clause 26, they are conceptually distinct, as others have noted. Although it is right that a court could be expected to construe legislation as a whole, case law in relation to one provision will not necessarily flow through directly to a later provision.

It may be helpful to illustrate that with the word “encouragement”, which has been raised. As we know, it is an offence to encourage or assist a person to commit suicide. As the hon. Member for Reigate pointed out earlier, it will continue to be so if the Bill is passed, outside of the specific exemption in the Bill. It is generally also an offence to encourage or assist a person to commit any other offence under the Serious Crime Act 2007. Specifically, it is an offence to do an act capable of encouraging or assisting suicide or another offence. The term “encouraged” is not defined in either statute. While it is true to say that section 2A(3) of the Suicide Act—which was added in 2009—clarified that doing an act that is capable of encouraging suicide includes a reference to a person doing so

“by threatening another person or otherwise putting pressure on another person”,

that was intended to be illustrative of the meaning of “encouraged” in that context; it does not serve as a general definition.

Within the Bill, it is important to keep in mind the difference between the procedural requirements—which is what we are discussing in this group—and the criminal offence requirements. Adding words to one provision because they are found in a criminal offence elsewhere risks, in the Government’s view, unintended consequences. Adding “encouragement” to the procedural clauses is perhaps an example of this.

--- Later in debate ---

Division 5

Question accordingly negatived.

Ayes: 8

---

Labour: 5
Conservative: 2
Liberal Democrat: 1

Noes: 15

---

Labour: 10
Liberal Democrat: 2
Conservative: 2
Plaid Cymru: 1

[Naz Shah]

I beg to move amendment 94, in clause 1, page 1, line 20, at end insert

“, and

(c) is acting for their own sake rather than for the benefit of others.”

This amendment requires that a person requesting assistance must be acting for their own sake, not the benefit of others. This amendment reflects the proposed changes in Amendments 95 to 104.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 235, in clause 1, page 1, line 20, at end insert

“, and

(c) is acting for the primary purpose of avoiding physical pain.”

This amendment, along with Amendments 236 to 245, seeks to ensure that the primary motivation of the patient is to avoid physical pain.

Amendment 95, in clause 7, page 4, line 15, at end insert

“, and

(h) is acting for their own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 236, in clause 7, page 4, line 15, at end insert

“, and

(h) is acting for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

Amendment 96, in clause 8, page 4, line 38, at end insert

“, and

(f) is acting for their own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 237, in clause 8, page 4, line 38, at end insert

“, and

(f) is acting for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

Amendment 97, in clause 12, page 8, line 14, at end insert

“, and

(i) is acting for their own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 238, in clause 12, page 8, line 14, at end insert

“, and

(i) is acting for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

Amendment 98, in clause 13, page 9, line 34, at end insert

“, and

(e) is acting for their own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 239, in clause 13, page 9, line 34, at end insert

“, and

(e) is acting for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

Amendment 99, in clause 18, page 12, line 26, at end insert

“, and

(d) is acting for their own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 240, in clause 18, page 12, line 26, at end insert

“, and

(d) is acting for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

Amendment 100, in schedule 1, page 25, line 22, at end insert—

“3A I am doing so for my own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 241, in schedule 1, page 25, line 22, at end insert—

“3A I wish to be provided with assistance to end my own life for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

Amendment 101, in schedule 2, page 27, line 12, at end insert

“, and

(c) the patient is acting for their own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 242, in schedule 2, page 27, line 12, at end insert

“, and

(c) is acting for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

Amendment 102, in schedule 3, page 28, line 10, at end insert

“, and

(c) the patient is acting for their own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 243, in schedule 3, page 28, line 10, at end insert

“, and

(c) is acting for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

Amendment 103, in schedule 4, page 29, line 5, at end insert—

“7A I am doing so for my own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 244, in schedule 4, page 29, line 5, at end insert—

“7A I make this second declaration for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

Amendment 104, in schedule 5, page 30, line 22, at end insert

“, and

(d) the patient is acting for their own sake rather than for the benefit of others.”

This amendment is consequential on Amendment 94.

Amendment 245, in schedule 5, page 30, line 22, at end insert

“, and

(d) the patient is acting for the primary purpose of avoiding physical pain.”

This amendment is consequential on Amendment 235.

[Naz Shah]

I rise to speak to support the amendment in the name of the right hon. Member for Braintree (Mr Cleverly), because I believe there is a need to include it in the Bill to ensure real protections against coercion.

Before I get to the substantive nub of the conversation, I want to understand something that I have just experienced. Again, the Chair might want to guide me and I am happy to take guidance. I am trying to understand this because we are all relatively new to the process, as is the Minister who responded earlier, the hon. and learned Member for Finchley and Golders Green. It appeared to me that the Government had a position on the amendments that were tabled. I recognise that my hon. Friend the Member for Rother Valley has set out that that is how debates happen, but actually, that is not my experience of how amendments are tabled in this House. We have notice of amendments. They are not tabled on the day, apart from manuscript amendments. They are tabled before the House rises, which gives us enough time to respond to those amendments, take advice on them and so on.

[The Chair]

Order. That is not in scope of the Bill. Please stick to the amendment.

[Naz Shah]

But in sticking to the amendment—

[The Chair]

Order. I am not having a conversation. Stick to the amendment. It is out of scope; I have been informed by the Clerk.

[Naz Shah]

Thank you, Mrs Harris. Sticking to the amendment, can I ask whether the Government will have already taken a position on it before I get to the end of my speech? Can they not share that before I make my speech? Is that within the scope of the conversation?

[The Chair]

I would suggest that you contact the Minister directly and ask the question, and perhaps she can give you a written response.

[Naz Shah]

Can I not ask for it now while we are in the debate?

[The Chair]

We are debating this amendment, and we are sticking to this amendment. You moved an amendment —can you please continue to speak to that amendment?

[Naz Shah]

I am happy to debate, Mrs Harris, but I am trying to understand because this is new to me. If I speak to the amendment and the Minister already has a position, I would value knowing that position, because otherwise it feels pointless for me to debate it.

[The Chair]

I have already said that you can talk about the amendment and not anything else. Could you speak to the amendment, or we will move on to the next speaker?

[Naz Shah]

Okay, I am happy to turn back to the amendment.

This issue is far too serious for us to overlook. I do not believe that many people, including medical professionals, are properly trained to recognise coercion or undue influence. To illustrate, I will refer back to my own experiences, like I did yesterday. I have had many unfortunate experiences in my life, but they have certainly prepared me for this space. I was forced into a marriage at the age of 15. I was 12 when I went to Pakistan, and although I was not physically bound or coerced in an overtly aggressive way, I was coerced none the less. I made the decision not for my own sake but for the benefit of others. At the time, I did not think for myself but for the benefit of my extended family members. It was clearly not my choice, and I understand that now. The power of influence from people we often trust and rely on in our everyday lives, especially when seeking their advice, can often lead to life-changing consequences. In the case of the Bill, it would be life-ending consequences.

In my forced marriage, and in those of others, because they do happen up and down the country, we can look back and realise what led us to make decisions that were neither in our best interests nor of our own choosing. Although my marriage occurred when I was under age, many people are coerced into forced marriages even in their late 20s and 30s for the benefit of others. The burden of holding family relations together, making other people happy and seeking approval can push a person into a forced marriage—something they never wanted. In my case, it was about keeping relationships between siblings and extended family intact, and the pressure fell on me, as a 15-year-old child. But me being 15 then is beside the point; the fact is that this happens today.

--- Later in debate ---

[Sean Woodcock]

On the point of people feeling that they are a burden, one moment that stood out in the oral evidence was that, although the Western Australian Government’s own statistics show that 35% of people opting for assisted dying cited being a burden as their reason for doing so, the practitioners who offer assisted dying to people were not aware of this fact. I had to clarify it for them. Is that part of my hon. Friend’s motivation for supporting the amendment?

[Naz Shah]

It is very much in support of that, and I want to tease out what my hon. Friend just said, which is important. One conversation we are having is about being a burden—my hon. Friend referred to the evidence that we heard—but another side to that is that when people feel like a burden, somebody benefits from that. That benefit is what the amendment teases out. That is what I want to understand.

[Tom Gordon (Harrogate and Knaresborough) (LD)]

I completely understand where the hon. Lady is coming from, but this is the conflict between someone feeling like a burden because of their own personal choice and autonomy, and how those might impact other people in their surroundings. Does she accept that among the reasons that many people might want to access an assisted death is that they do not want to lose that autonomy? That is not necessarily anything to do with feeling like a burden on other people; it is about their own choice.

--- Later in debate ---

[Naz Shah]

The hon. Member makes a valid point: it could be an absolutely autonomous decision. In an ideal world, that is what we would like to get to, but we are not in an ideal world.

[Sean Woodcock]

I am grateful to my hon. Friend for giving way again, and I am sorry to interrupt her when her speech is in full flow. My response to the hon. Member for Harrogate and Knaresborough, which links to my previous point about Western Australia, is that we have been told throughout this process that clinicians can spot the signs of coercion and whether people feel that they are being manipulated. However, in Western Australia, the people administering assisted dying—who we are trusting, in this Bill, to be able to spot those things—were not aware that 35% of people in the state cited “being a burden” as their reason for going for assisted dying. That is my concern. Does my hon. Friend have a response to that?

[Naz Shah]

My hon. Friend makes a very important point—because if we visit this issue afterwards, that person is dead.

[Dr Opher]

I do believe that what was actually said in evidence was that one of the reasons was that the person felt a burden, but there were other reasons. From the Californian doctors, we heard that feeling a burden is not in itself a reason to approve an assisted dying request.

[Naz Shah]

My hon. Friend is right, but the point I am trying to come back to is to do with those people who feel a burden; wherever they feel a burden, somebody is benefiting from that, because we are taking the burden away—there is ultimately a benefit to somebody.

We have talked a lot about people feeling a burden in terms of potential coercion, potential financial issues and all those things, but we have not discussed this in detail. It is important that we do so if we are to make this Bill, as my hon. Friend the Member for Spen Valley intends, the safest Bill in the world. It is incumbent on us to look at both sides. Just like in the earlier debate about whether we choose assisted dying or choose to take out the plug, ultimately the end is the same—it is death—but they are two different things. The amendment tabled by the right hon. Member for Braintree is very much about the question of who is benefiting from the person taking that decision.

[Dr Shastri-Hurst]

The hon. Lady spoke movingly about her own experiences, which clearly fell into the category of benefiting others, with no benefit for herself. Can she elucidate how she envisages this amendment working in the following scenario? Let us say that in some years to come, this law is enacted and I have a terminal illness—I have six months or less to live—and I do not want to face intolerable pain and suffering in those last moments of life, but I also do not want my son or my wife to watch me suffer. They benefit from that decision, because they do not see me suffering, but I am also doing it for my own sake. How does the amendment fit into that scenario?

[Naz Shah]

The hon. Member makes an important point. That is precisely why we need to have a conversation to ascertain that autonomy, which is what this comes back to—the whole purpose of this Bill is to give people autonomy. It is important that when benefit is being derived, it is not because they are a burden. We need to ascertain that that has been explored and was not about that, but that it is an informed choice and an autonomous decision. That comes back to the conversation around coercion, manipulation or whatever word we want to use; we voted down provisions on the term “undue influence”, but those are the words that apply.

In my understanding, this amendment is about having a conversation to probe what measures will be in place to ascertain what that person is actually saying. I would not wish that experience on the hon. Member, but he could be in that situation, and make that informed choice and be able to demonstrate that—again, we discussed the amendment from my hon. Friend the Member for Broxtowe on the word “demonstrably”. I am very keen to have those conversations, and that is the purpose of this amendment.

[Rachel Hopkins (Luton South and South Bedfordshire) (Lab)]

The point about conversations is really important. I wonder how many conversations my hon. Friend has had with terminally ill people, their family members and children, because I have had quite a few, like the example given by the hon. Member for Solihull West and Shirley, over a number of years now. It is so important to recognise that it is about the individual’s autonomy, but we cannot take away the fact that their loved ones may also derive a benefit in a way that the hon. Gentleman elucidated. Can my hon. Friend see how so many of us here want clarity, but do not want to put at risk an individual’s autonomy with a very subjective decision?

[Naz Shah]

I am sure my hon. Friend did not mean to suggest it in that way, but I feel slightly taken aback by the questioning of whether I understand the importance of this. I remind hon. Members that nobody in this room has had a forced marriage apart from me. That does not mean to say that they do not have empathy when I share my experience. To suggest—

[Rachel Hopkins]

Will my hon. Friend give way?

[Naz Shah]

Let me finish. Perhaps my hon. Friend did not mean to question whether I understand and appreciate it, but it suggests to me, does anybody? Yes, we heard witnesses. We heard evidence. I have heard about it in my own friendship circles. I had a young intern with me not so long ago who had cancer. We talked about this, when I decided to come on to this Bill Committee. A dear friend of mine lost her husband and asked me to support this Bill because of his experiences. I speak to doctors regularly. I have had one parent who died of cancer; the other survived cancer. I have had recent deaths; my own father was in a hospice, and others were in a hospice. To be really clear, I do not think the importance of autonomy is lost on any Member on this Committee or in the House. It is because of that importance that I agreed to take part in this Committee.

[Rachel Hopkins]

I hope that my hon. Friend will accept that I was not questioning her ability to understand the importance of the matter. I wanted only to place on record the importance of having those conversations and to ask whether she recognised that. I am really pleased that she has had so many conversations. That is why so many of us are here and want to see the change in the law, but we do not want to tie it so tightly that it would reduce the autonomy of an individual.

[Naz Shah]

I am grateful that we have been able to have this conversation as we have done. I share my hon. Friend’s concern. Equally, I am also concerned that we may now not have a judge’s oversight on this. There is potentially an amendment seeking to replace that with a panel of experts, which we will not get to debate until we have seen it.

Returning to amendment 94, tabled by the right hon. Member for Braintree, I have already talked about Professor Allan House’s contribution. The importance of the issue is not lost on the House. This includes people who do not want to take up their children’s time. As the hon. Member for Solihull West and Shirley suggested, there is that conversation to be had with families, no doubt. We speak from the privileged position of being able to have those conversations. In an ideal world, we would all be equal, but we are not.

[Daniel Francis]

The one thing that covid taught me was what my hon. Friend is alluding to. Hon. Members heard yesterday a bit about my family situation. I have a child who will never walk, will always be in nappies, will always need to be fed, and will always need to be dressed. During that period, no carer was allowed in the house, and as people know, my wife was also having chemotherapy —thankfully, she successfully recovered. As the carer, who everyone is reliant on, I saw that power imbalance. Everybody in my house was reliant on me during those three months—no one was allowed in the house, my wife was having chemo and my daughter needed round-the-clock care, so to speak. That is the position, which is why I understand this wording. That is the imbalance, whereby somebody could realise that this change in the law now gives them the power to release the burden of their loved one, not for any other reason—that they want their suffering to end—but because they want their loved one to have their life back. I do not know whether my hon. Friend has any comments on that.

[Naz Shah]

I thank my hon. Friend for his valuable intervention. He speaks from his personal experience, and this place and this debate are richer for having those experiences shared. It comes back to the comment made by the hon. Member for Solihull West and Shirley; this is about where there is autonomy. This is about people who make that informed choice without coercion, loss of autonomy, undue influence or encouragement. We are talking about those people; we are not talking about those who do not fall into that category.

Those of us in this House know of inequalities that exist in our communities for disabled people, women, or people with mental health illnesses. We already know that; this is about safeguarding and making sure that we are exploring the reasons why, to safeguard those who do arrive at those conclusions—at that decision of autonomy—so that, should this Bill be passed and become law in two years, we as a Committee will know that we have tried our hardest and our best to support my hon. Friend the Member for Spen Valley to make it the safest Bill in the world.

[Jake Richards]

I am very sympathetic to the amendment, which aims to tackle a mischief that we are all worried about, but there are two fundamental problems. The first, which builds on the intervention from the hon. Member for Solihull West and Shirley, is this issue of deciphering if an action is for your own sake or the sake of others. It is a philosophical question: is there ever really a selfless act? Even if we take an act that may be deemed to be for someone else, it may be because we want that person to receive some pleasure, joy or relief, so in my mind there is a danger that this could become a tautology.

Secondly—I hope that you might be able to comment on this—is there not a danger that we are then putting it on doctors and others in this process to undertake an assessment of welfare? When you are deciding whether something is for an individual’s sake, you are making some determination, are you not, as to what is in their best interests? That directly conflicts with the principles of the Bill, which is all about autonomy and an individual’s choice, rather than others saying what you should and should not do.

[Jake Richards]

Forgive me, Mrs Harris. I apologise profusely.

[Naz Shah]

If we are talking about welfare, I would have thought that this Bill would have included welfare checks, which are absolutely crucial. My definition of welfare encompasses the whole being, with the person at the centre. In this case, welfare would mean putting somebody with a terminal diagnosis at the centre of what service provision looks like, be it for assisted dying or a care pathway through palliative care.

[Jake Richards]

rose—

[Naz Shah]

I am happy to give way if my hon. Friend wants to elaborate.

[The Chair]

Order. Before the hon. Gentleman starts, can I ask for short interventions, please, not speeches?

[Jake Richards]

What I meant by a welfare decision is a paternalistic view, whereby medical practitioners and others say what is in the best interests of an individual, rather than the individual themselves.

[Naz Shah]

I appreciate the clarification and the explanation. I do not feel that having doctors doing this is a contradiction of this Bill at all, because if we go by the letter of the Bill and how it is set out, when a doctor offers those choices, whether it is assisted dying or palliative care, they are giving a choice of welfare options to their patients. That is my understanding, and I am not sure that this is contradicts with the Bill in any way, shape or form.

I have answered my hon. Friend’s first question; can he remind me of his second?

[Jake Richards]

My question was building on the intervention made by the hon. Member for Solihull West and Shirley. It was about whether there can ever be a selfless act.

[Naz Shah]

If we make philosophical and idealistic arguments, we will not be able to legislate on anything. Philosophically, there are people in this House who wear red, blue, green or the colours of smaller parties. We are all different in our positions philosophically. For me, this process is about legislating as well as we can to put safeguards in place that are as strong as possible. I cannot get into that debate because it would not apply to the legal aspect.

[Jack Abbott (Ipswich) (Lab/Co-op)]

To move away from the theoretical, like my hon. Friend the Member for Rother Valley I am sympathetic to what this amendment is trying to do. To give a practical example, let us say that I have been given a terminal diagnosis and say to the doctor, “I personally do not want to go through pain and agony over the next few months, but I am also thinking about my family—I do not want them to suffer alongside me.” I would therefore fall under the definition in this amendment—the hon. Member for Bradford West is shaking her head, but the reality is that I would—because I would also be acting for the benefit of others; I have cited that alongside my own physical pain as a potential reason that I want to do this. As I say, I am sympathetic to what the amendment is trying to do, but I feel that the way it is written would inadvertently include a huge amount of people who are doing it for their own motivations, but clearly the reality of life is that we consider other people as well.

[Naz Shah]

The hon. Member makes a valid point that it would ultimately benefit others. It would—that is a given—but that was not my reading of the way the amendment is drafted. My reading was that “only for your own benefit” means that someone is not being driven by the benefit of others, financial or otherwise. From the point of view of autonomy, if someone chooses to make that decision, of course others will benefit. I take the point that there appears to be a contradiction, but that is not my understanding of how the amendment is written and it is not what I am talking about.

[Jack Abbott]

My hon. Friend mentions the word “only”, but that word does not appear in this amendment. That is the issue: we are opening this up. The amendment says:

“acting for their own sake rather than for the benefit of others.”

In my example, I cited the benefit of others as potential reason that I might seek this.

[Naz Shah]

The hon. Member makes valid point. Maybe the Government would be able to mop this up if this amendment was accepted. That can happen—it is not beyond the scope of Government or the Ministers present.

[Sean Woodcock]

I am grateful for this debate, particularly as lots of people who, on Second Reading, were happy to pass the Bill through to Committee wanted the debate to happen. We should all welcome that, as I know the promoter of the Bill, the hon. Member for Spen Valley, does. I am grateful that we are here.

I will move away from the philosophical debate and return to what I said before lunch: this is about not just the role of the individual—though that is clearly important—but what we see as the role of the state and what we are comfortable with the state allowing. I see this amendment as very much linked to that. Does my hon. Friend the Member for Bradford West think there is something in that—about whether the state is happy for people to cite the benefit of others as a reason for opting for assisted dying?

[Naz Shah]

I thank my hon. Friend for his intervention. That is not something I had spoken to the right hon. Member for Braintree about. Thinking about it, his point is valid: there is always an overlap in terms of whether this is the state interfering or not interfering. In this instance, it is about the state and legislation protecting the individual and ensuring that an autonomous decision, which is what we are trying to get to, was reached, without any coercion, undue influence or subtle manipulation—whatever word we choose to use in these proceedings—and not for the benefit of others.

Too many arguments that I hear in support of the Bill seem to assume that all those who seek assisted dying will do so as a matter of autonomy—as a free choice. Honestly, it would be much easier to support the Bill if that were true, and I sincerely wish it were, because we would not have the issues we have been talking about all today and yesterday. However, we must pay heed to those who do not live their lives in that way. We in this House have a duty to protect those who feel like a burden to those close to them—or who are made to feel like a burden, whichever route that may take, and we have had plenty of conversations about that.

The amendment tabled by the right hon. Member for Braintree would permit doctors to halt an application for assisted dying if they had good reason to believe that an applicant was not acting for their own benefit.

[Sojan Joseph (Ashford) (Lab)]

Would inserting the line in the amendment not also give us another opportunity to assess the patient’s capacity? Under the Mental Capacity Act 2005, a person should be able to “understand” and “weigh” the information, so does having this line not also help us to assess a person’s capacity?

[Naz Shah]

I agree with my hon. Friend’s point. We are not dealing with capacity in this amendment, but I agree that every one of these extra checks and balances would also support the exploration of capacity and would definitely strengthen those conversations with any patient.

The amendment tabled by the right hon. Member for Braintree would not be a perfect safeguard. As we know in this House and across society, nothing, including legislation, is absolutely foolproof. There will be people where, despite the best efforts of the NHS, despite having palliative care and despite having people in these positions, things will be missed. Unfortunately, that happens.

Before I make my closing remarks, I want to come back to where I started—forced marriage. We heard from Dr Jamilla about inequalities and how to spot coercion. There is an added layer to all of this when it comes to women, and also when it comes to people from ethnic minority backgrounds, who already have an inherent distrust, which was magnified during covid.

When it comes to domestic violence, we also know it is harder to spot the coercion, because of the conditioning and the cultural conditioning. My personal conditioning was very different, and it took me until my 30s—years into my adulthood—to recognise it and call it out, despite being an active campaigner against domestic abuse and having access to amazing campaigners in the UK. Going back to Dr Jamilla, some of the conversation she has been having around this issue is about people having that distrust. Coming back to the amendment, we must be able to point out—to draw out—that “benefit of others”. It is harder to spot, so there have to be safeguards.

This amendment, and all the amendments we have talked about today, would benefit the Bill; they would strengthen it. They would in no way, as the Government have suggested, weaken or confuse it or the people applying it.

[Tom Gordon]

Can the hon. Member elaborate on what the amendment would add that previous amendments we have debated would not?

[Naz Shah]

The issue for us in the conversation on this amendment is that we have talked about coercion, undue pressure, undue influence, encouragement and all that, but we have not talked about the benefit to others. It is simply a different conversation; it is about understanding that a person has been coerced and so on, but also for what reason. What is the benefit to others? That is my understanding of the amendment, and that is why I am speaking to and supporting it.

Unfortunately, the Bill as it stands does not have all the necessary safeguards for all those who see themselves as burdens to others, and that is why I support the amendment.

[Kit Malthouse]

I have listened very carefully to the hon. Member, who represents the fine town of Bradford, and to her personal experiences, which have coloured her view. I understand that of which she speaks, and she might be interested to know that I was the author of the first ever violence against women and girls strategy in the country when I was at City Hall. I dealt closely with harmful cultural practices in that strategy, so I do understand the difficulties she elaborated with detecting and combating the influences to which she referred. However, I am going to disappoint her, because I am going to explain why I believe that the amendments make that more difficult and run the risk of making the Bill less safe.

I should mention first, though, that she said that we are dealing with notions of autonomy and trying to achieve a position where people seeking an assisted death do so as a matter of free choice, and she is exactly right: that is what we are all about and trying to achieve. However, as I hope I can illustrate, the amendments may make that more difficult on three levels.

We have talked a lot over the last few hours about precision and novel terms in legality. My first issue with the amendments is the lack of that precision. For example, what does “physical pain” mean? Is it all pain? Is it something as minor as a headache? Is it perceived or actual pain? Is it fear? Does fear become a physical pain, or is it a mental pain?

In the closing stages of bowel cancer, for example, a number of things may happen and a number of things may cause somebody to die. They can have a perforated bowel caused largely by a blockage, as I am sure my hon. Friend the Member for Solihull West and Shirley would say. That would be incredibly painful and lead to peritonitis and organ failure, which eventually leads to death. However, there is a situation where a blockage in the bowel causes a person to vomit effectively semi-digested food and faeces. Is that painful? I do not know whether that is a classification of physical pain. It is certainly uncomfortable and unpleasant, but is it actually painful? I find that the definition of “physical pain”, undefined as it is, and which may be a matter of degree, injects complexity for doctors and lawyers in their assessment of the motivation of a person seeking assisted dying.

Similarly, I do not really know what “benefit” means in the amendments dealing with that. Does it mean financial benefit? Does it mean emotional benefit? Is it perceived or real benefit? Does the doctor have to assess whether a third party is actually getting benefit? Let us assume that it is emotional benefit and that I say—I think it is perfectly legitimate, as my hon. Friend said, for me to say this—“I do not wish my child to witness, know or even learn that the way I died was from the fungating tumours in my neck bursting and,” as we heard on Second Reading, “me drowning in my own bodily fluids. I do not want to get to that stage, and I do not want to burden my child with that.” Do I have to say to the child, who is perhaps an adult child, “How do you feel about it? Are you going to benefit from this or not?” They will respond, “Absolutely not. I want my dad to live as long as possible,” or, “I want my dad to have what he wants to have.”

It is very difficult in these circumstances—do not forget that this will be crawled over by lawyers and doctors—to understand what is actually meant by “benefit”. These are new words—novel concepts—that are being introduced into the law. I did look to see whether there were similar circumstances elsewhere in legislation, and I could not find any. To me, they inject an element of complexity into what we hoped would be, as we discussed earlier, a settled and comprehensible legal framework, in which doctors have previously operated, and should operate into the future. As I say, my first objection is that the amendments inject novel concepts that are largely undefined and that may be actual or perceived, both by the person who is being assessed and by those who are presumably to be in receipt of the benefit.

I am afraid there is also—I am not sure, particularly on the amendments tabled by my right hon. Friend the Member for Braintree—a question in my mind about where my “sake”, whatever that word means, collides with someone else’s “benefit”. As the hon. Member for Ipswich said, if it makes me happy—if part of my dying is me taking satisfaction in the fact that I am not burdening my children with the emotional trauma of watching me die in horrible circumstances—is that for my sake or for their benefit?

[Naz Shah]

The right hon. Gentleman is making a powerful speech. In response to the comment by my hon. Friend the Member for Ipswich, people can have, and will have, an incidental benefit when somebody with autonomy makes a decision. The Government could table tidying-up amendments to clarify that and make this amendment stronger, if it gives an extra safeguard for those who are seeking assisted dying, should the Bill become law.

[Kit Malthouse]

I understand what the hon. Lady is saying, but I am afraid that the amendments do not say that. Even if they did, there would be some difficulty, because you are asking for a further level of complexity in what should be, we hope, a decision made between doctor and patient, in private and confidential circumstances where sensitivity is needed and where we are asking medics to tease out motivations from individuals. I hate to use a pejorative word like “woolly”, but I find the lack of precision in the language troubling. I think it will create yet more complexity and jeopardy for doctors and lawyers.

--- Later in debate ---

[Naz Shah]

That speaks to my earlier point, where I was seeking clarification. I find that I feel very uncomfortable with this process, where the Government are very clearly taking a position, without having an impact assessment in place, on whether the previous amendments and the ones I am talking about would confuse the courts or create uncertainty. Perhaps the Minister can provide clarification, but my interpretation is that the Government are taking a view, not just sharing the position of the Government.

[Stephen Kinnock]

I thank my hon. Friend for that intervention. I will just take us back to the first principles. This is not a Government Bill; it is the Bill of my hon. Friend the Member for Spen Valley, who came top of the ballot for private Members’ Bills. She chose to bring forward this piece of legislation. The Government had absolutely no role whatsoever in drafting the legislation. The Prime Minister then made it clear that the Government will remain neutral in their position on the Bill. However, it is the constitutional duty of the Government to ensure that every Bill that passes through Parliament and secures Royal Assent is workable, deliverable, viable and coherent in terms of the statute.

How does that play into this Bill Committee? Members of the Committee who are not Ministers are here to debate the philosophical, moral, ethical and, in some cases, legal and perhaps clinical aspects of the Bill. Members of the Committee who are Ministers—namely myself and the Justice Minister, my hon. and learned Friend the Member for Finchley and Golders Green—are here to provide observations on the Bill with regard to its legal, practical, technical and operational impact, to ensure that we are doing our constitutional duty to deliver the objectives I just outlined to my hon. Friend the Member for Bradford West.

The answer to the question from my hon. Friend is that when my hon. and learned Friend the Justice Minister and I speak, we focus our remarks exclusively on the legal, practical, technical and operational considerations of the Bill. I assume that the Committee finds it useful to know what the Government’s position is on those matters. We do not opine on the philosophical, ethical or moral considerations that are at the heart of the Bill.

[Naz Shah]

I thank the Minister greatly for his explanation. I am trying to separate the two points. I appreciate the role of both Ministers in providing the Committee with that guidance, as many of us are new to the process. What I am trying to understand, with respect to the amendment from the right hon. Member for Braintree, which I just talked about, is that the Government have asserted a view that the language included would create uncertainty.

[The Chair]

Order. The hon. Member has asked a question and had a response. This Committee is not debating the Government’s stance. It is debating the Bill.

[Naz Shah]

Can I come back to the amendment?

[The Chair]

I am not going to take any more interventions. I will move on to Kim Leadbeater unless the Minister has not finished.

[Kim Leadbeater]

Returning to the amendments before us, I will try to keep my comments brief, as we have had a thorough debate this afternoon. On amendments 95 to 104, I have spoken to the right hon. Member for Braintree and I know that these amendments seek to stimulate discussion, and I am very pleased that they have done that this afternoon. I also know that they come from a good place.

I have already discussed the additional safeguards around training that would be added to the Bill through new clause 8, which states that the Secretary of State must consult

“persons appearing to…have expertise in matters relating to whether persons have been coerced”.

That would consolidate the existing measures in the Bill and, I hope, relate to the concerns expressed in the amendment to some degree.

More broadly, the reasons that someone might choose an assisted death may well include sparing those they love the pain of seeing them suffer, as we have heard this afternoon. That is certainly something that members of my family and people I have spoken to say would matter to them. That should not prevent the provision of assistance. It is surely for that person to decide.

During oral evidence, we heard powerful testimony from Liz Reed about her brother Rob, who had an assisted death in Queensland, Australia. Rob was 39 years old and had a young family when he was diagnosed with stage 4 terminal lung cancer. He was fit, young and healthy, and did not smoke. As well as taking back control at the end of his life, one of his main reasons for choosing an assisted death was so that his young family could remember him as the man and the dad he was. He was not afraid of death, but he was afraid of dying in an undignified and painful way; he was afraid of not getting to say goodbye to his wife and children, or them having to find him after his having had a massive heart attack. Surely we should not decide that that is not acceptable and understandable. It is a perfectly understandable reason for choosing an assisted death.

Liz told us that Rob

“was able to change his mind, which he did, in terms of dates and when it would happen. His views and the views of his family were also taken into account and, through the process, he was treated like a person with autonomy whose choices were being respected.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 254, Q328.]

If relatives were implicitly or explicitly coercing or pressuring someone, that would of course be very different—and that is covered by the Bill—but to prevent someone from wanting to consider their loved ones in their final weeks and months of life does not seem at all reasonable to me.

I have talked about training, which is important and feeds into the debate about the assessment of coercion and pressure—here, I refer again to my new clause 8. As we heard during the oral evidence, who is involved in that training is important. We heard from the Association of Palliative Care Social Workers. Its position statement on assisted dying states:

“As social workers we bring a distinctive perspective and skill set. Our focus is on helping people to get practical needs met; to enable them and their families cope with the impact of serious illness and dying and to plan ahead”.

[Naz Shah]

My understanding is that the judges’ views on capacity relate to the fact that there are only 200 qualified palliative care social workers in the country.

[Kim Leadbeater]

This point is about training, and so about hearing from the right people when it comes to the training of professionals. It is important that we ensure that the Secretary of State must consult such people, and I anticipate that organisations such as the Association of Palliative Care Social Workers would be consulted. The statement continues:

“as well as protecting people from abuse, neglect and coercion at a time…when they are most vulnerable…Our expertise includes building trusting relationships, comprehensive knowledge of safeguarding”.

By looking at the training process, people’s motivations for seeking an assisted death would hopefully be considered.

--- Later in debate ---

[Naz Shah]

My hon. Friend has referred a few times now to us not having this framework. We do not have this framework because we do not have this law. Maybe she can help me to understand or correct me if I am wrong, but this framework does not exist because we do not have this law. For this law to exist, we have to have the framework. I am inferring from her a suggestion that she is somehow intervening for people who might be being coerced in a hospital setting or at the end of life in any case, but that is not the case.

[Kim Leadbeater]

I am not quite sure I understand the point. My point is that there is no law that is checking people’s motivations for ending their lives when they are terminally ill, and that is what this law would do.

I will make some progress, and come to amendments 235 to 245. As we have heard from witnesses, choice at the end of life is not just about physical pain, be it current or potential. It can also be about psychological suffering and mental torment as a result of being terminally ill —and it is of course about taking back control, bodily autonomy, dignity and choice. What about patients who are in severe mental torment and fear as a result of their condition, and terminally ill people who want the autonomy and dignity of taking back control at the end of their lives? Who are we to ask them to prove their level of physical pain or desire to avoid physical pain, and to deny them the choice in their final few weeks or months?

--- Later in debate ---

[The Chair]

I call Naz Shah to wind up. It would be helpful if the hon. Member would indicate whether she wishes to push amendment 94 to a vote.

[Naz Shah]

Yes, Mrs Harris, I do want to push the amendment to a vote.

In summary, the reference to “coerced or pressured” in clause 1 relates only to coercion or pressure by another person and does not cover internalised pressure. In written evidence, the Royal College of Psychiatrists said:

“The Bill focuses on external coercion. That is, for example, coercion from family members with personal or financial motivations to hasten death. While this type of coercion may not always be clear, internal and societal pressures that may reach the threshold of coercion can be even more difficult to detect.”

I am not going to rehash that. I appreciate where we are at with this conversation. The royal college says that the Bill does not address

“more subtle forms of coercion, such as where a person may internalise a feeling of being a burden to others. How might such internalised pressure be identified or responded to in this context?”

It is that important question that we are left with. It continues:

“At what level would implicit or internal pressures amount to coercion? At what point would supporting a person to have capacity to make a decision to request assistance to die constitute coercion?”

That coercion may be used for the benefit of others.

That brings me back to the crux of this amendment: it is about the benefit of others. There is nothing to suggest that there would not be an incidental benefit for people; there can absolutely be an incidental benefit. For the avoidance of doubt, this amendment is not about that. We have had votes on adding language to the Bill, which I voted for. We have heard the Government responses, which I struggle with. Ultimately, I want to push this amendment to a vote because I feel that we need to strengthen the Bill. As it is, there are loopholes, and one loophole is one loophole too many.

Question put, That the amendment be made.

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

Naz Shah Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[The Chair]

Electronic devices should be turned off or switched to silent. The only cups that I should see are those filled with the water provided in the room—no tea or coffee. Let us continue our line-by-line consideration of the Bill.

Clause 1

Assisted dying

[Naz Shah (Bradford West) (Lab)]

I beg to move amendment 281, in clause 1, page 1, line 20, at end insert—

“(c) has met with a palliative care specialist for the purposes of being informed about the medical and care support options.”

This amendment would mean that illness, disease or medical condition etc, the progress of which can be managed or controlled by treatment are not characterised as terminal illness.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 299, in clause 7, page 4, line 17, after “(g)” insert

“and the condition in subsection (4) has been met”.

This amendment is consequential on Amendment 298.

Amendment 298, in clause 7, page 4, line 26, at end insert—

“(4) The coordinating doctor may not take the steps set out in subsection (3) unless they receive confirmation from a palliative care specialist that the person has had a consultation with that specialist about the palliative care options available to them.”

This will require the coordinating doctor to be of the opinion that the person has had a consultation with a specialist in palliative medicine.

Amendment 304, in clause 9, page 5, line 41, leave out “any available” and insert

“the person’s experience of specialist”.

This amendment would require the assessing doctor to discuss the person’s experience of specialist palliative, hospice or other care.

Amendment 311, in clause 12, page 8, line 14, at end insert

“and

(i) the person has had a consultation with a consultant who is a specialist in palliative medicine.”

This amendment would require that a person has had a consultation with a specialist in palliative medicine before the High Court could issue a declaration.

[Naz Shah]

Amendment 281 would ensure that the patient receives advice on palliative care options from a specialist in the field. Medicine is fast-paced, with innovative and new medicines becoming available in quick succession. Although those in the profession try to keep abreast of developments, it is hard to maintain the depth of knowledge necessary in all specialties. A co-ordinating doctor may or may not have specialist knowledge in palliative medicine. Some courses may provide the opportunity to learn more, but others only touch on palliative medicine—covering it in less than a day of a five-year medical degree. Specialists who are leading in this field of medicine, innovating advances and working to palliate a patient’s symptoms at the end of life will have far greater knowledge of the specialism. Even in this wider debate, many who work in a different field of medicine or in general practice have simply got their facts wrong when speaking about palliative medicine—not through intent but because they have drawn on their own, perhaps out-of-date, experience or simply do not have the competencies to understand all that palliative care can provide.

Pain and symptom control techniques are advancing; in our debates on this Bill, people have articulated instances of poor care rather than what clinical experts are able to achieve. It is therefore essential that a patient has a consultation with an expert in the field of palliative medicine, who can alleviate a patient’s fear, support them with a plan for the end of their life, and discuss how pain and symptoms can be managed. Hearing an alternative approach to the end of life can be life-affirming, help people discuss their fears and concerns about dying, and provide a patient with what they are seeking physically, psychologically, emotionally, socially and perhaps spiritually. Specialists in palliative medicine are trained to home in on the challenges that people naturally have on receiving a diagnosis of terminal illness and are skilled at supporting a patient to explore what end of life could look like for them.

If the Committee does not pass this amendment, it would be placing itself above palliative care specialists when talking about such matters. It would undermine the need for such a specialty in medicine, like a GP who may not know the breadth of palliative medicine options for their patients. The Committee must not assume that it knows those options. Rather, it should enable those with a specialist understanding of palliative medicine to deploy their skills in this process by working through palliative care options with patients before the consideration of a path that will end with an assisted suicide.

Amendment 299 is consequential on amendment 298, which would ensure that a person has a consultation or consultations with a palliative care specialist. Amendment 298 would further embed this into the practice of managing the end-of-life process to provide the patient real choice over their options at the end of life, as what can be achieved through the practice of high-quality palliative care is often significantly different from people’s perceptions—even those of clinicians. Palliative care, like so many fields of medicine, continues to advance in its application and in the steps that can be made available to palliate a person’s pain and symptoms. When pain is difficult to control using oral or intravenous pharmacology, other interventions, such as a nerve block, can result in the absence of pain. A specialist is required to provide such a procedure, but for most people who are in receipt of palliative care, this option is rarely made available. Palliative care is about not just pain and symptom control, but the holistic journey of a patient at the end of life.

[Danny Kruger (East Wiltshire) (Con)]

The hon. Member mentions the principle that palliative care is a holistic service. Does she agree that, given that the Bill’s advocates—including the promoter, the hon. Lady for Spen Valley—emphasise the need for a holistic range of opportunities for end-of-life care, palliative care needs to be central to that? Rather than suggesting that there is an either/or between palliative care and assisted dying, the advocates of the Bill have often stressed the importance of having both options. Does the hon. Member for Bradford West agree that it is strange that the Bill does not require palliative care consultation as part of the range of services that are offered to patients when they are having their consultation?

[Naz Shah]

I completely agree, which is why the amendment tabled by my hon. Friend the Member for York Central (Rachael Maskell) is very important. I urge the Committee to accept it, as it would ensure the provision of a palliative care consultation. As my hon. Friend the Member for Spen Valley has always said, it is about having a holistic approach—we need to get back to that.

In the evidence sessions, we heard that palliative care social workers can play a pivotal role in supporting patients. Those from other professions—psychological services, chaplaincy services, physiotherapists, occupational therapists and speech therapists—along with specialist nurses and medics can all contribute to the care of a patient at the end of life. In discussions with palliative care specialists who listened to the debate on 29 November, they were perplexed by the symptoms that were graphically described in the case studies, and cited poor care as the reason for them. Many such symptoms can be controlled, and they were shocked that such examples of poor care were presented as a reason for assisted death, rather than for making good quality palliative care available to all patients.

We further heard evidence, especially from Dr Jamilla Hussain, that access to palliative care is inequitable. We know that those from minoritised communities and from low socioeconomic backgrounds have poorer access to good palliative care, and that people can have poor access depending on where they live, and on the day of the week or the hour of the day. Through this amendment, we want to ensure that everyone who is seeking an assisted death, or who has it suggested to them, as this Bill allows, is able to access a consultation or consultations with a palliative care specialist, who can dispel the myths while supporting them with their end-of-life plan.

[Kim Leadbeater (Spen Valley) (Lab)]

My hon. Friend talked about the stories that we heard on Second Reading. Does she acknowledge, as Dr Sarah Cox from the Association for Palliative Medicine said, that there are cases where palliative care cannot meet a patient’s needs? We have a lady in the Public Gallery this morning whose mother had a horrible death, having had ovarian cancer and mouth cancer; she had to have her tongue removed, so she could not eat and drink, and she essentially starved to death. We have to be careful not to dismiss those cases, because they are real stories of real human beings, and we have to acknowledge the limitations of palliative care.

[Naz Shah]

I absolutely agree. Nobody in this Committee, from what I have heard over the weeks of evidence that we have taken, is suggesting in any way that we are dismissive of people who actually need an assisted death and would benefit from the Bill. As I have said previously, and as Dr Jamilla said very clearly, there are some patients who clinically would benefit from an intervention such as an assisted death. I came on to this Bill Committee to ensure we have the best legislation and safeguards in place. The Bill currently does not ensure that people are aware of the options. This amendment would ensure that people have considered all options and can make an informed choice. If there is no requirement to speak to a specialist, I am afraid the Bill would do a disservice to those who might want to use it to seek an assisted death by not presenting them with those options.

In evidence from the representative of the Royal College of Psychiatrists, we heard an example of somebody who was in lots of pain and decided to seek an assisted death, but changed their mind once they understood that their pain could be alleviated. That is what this amendment is about. I urge the Committee to vote for it, because it is fundamental that we enable people to make an informed choice and to understand the services and options available to them.

[Sojan Joseph (Ashford) (Lab)]

Does my hon. Friend think that giving everyone access to palliative care would resolve some of the concerns about coercion and consent?

[Naz Shah]

My hon. Friend comes from a mental health background, and I appreciate his expertise. We have talked a great deal about coercion—we have debated it for hours and hours—and I agree palliative care specialists, who deal with such issues as their day job, can provide that intervention and support the patient by establishing a much stronger relationship with them. I added my name to this amendment because I feel very strongly that palliative care must be a central part of the Bill if it is to provide patients a real choice at end of life. There should not be an assumption, as there is in the Bill as drafted, that assisted death is the predominant option once a person embarks on this pathway.

Let me return to the matter of minoritised voices. Dr Jamilla submitted written evidence, and spoke passionately, about the options available to people from black and minority ethnic communities. She said that they feel very much ignored. As I have said previously, palliative care is not fit for purpose because there is postcode lottery: provision depends on where a person lives, whether they have a hospice nearby, what the hospital options are and so on. There is a fear among ethnic minority communities of being pushed towards assisted death.

[Sarah Olney (Richmond Park) (LD)]

Does the hon. Lady agree that the purpose of this amendment is to ensure the Bill delivers for the people for whom it is intended, such as the person the hon. Member for Spen Valley spoke about? It would put in place protections for the people for whom there is a choice, and that where those choices exits, they are laid out in full and properly examined before a final decision is made.

[Naz Shah]

I completely agree. It is imperative that those options—pain options and care options, including with the family—are explored in detail. The last time that I spent time in a hospice was when my brother-in-law was dying of cancer, and I remember that, as a family, we were very much involved in those conversations. Having such expertise empowers not just the patient but the family. Losing somebody who has a life-threatening condition is a difficult time for families and loved ones. When the wraparound model of palliative care, with specialist nurses and doctors, is good, it can be amazing. I have heard plenty of stories about when it is good. Last week, I mentioned a friend of mine who lost her husband last year, and she said that the palliative care nurses and doctors could not do enough. That gives the family confidence to explore the options. In that instance, that person would have benefited from this Bill—she encouraged me to support it.

As Dr Jamilla said, some people would absolutely benefit from the Bill, and they cannot be dismissed, but how do we legislate to cover people who do not have equal access to palliative care or to healthcare? There is discrimination. The covid experience that we went through recently showed the impact of inequalities. Disabled people, people with mental health conditions, elderly people, and people from black and minority ethnic communities, say that they were DNR-ed—subject to “do not resuscitate” orders. There is already a lack of trust in services, so we need to strengthen palliative care.

There is a fear among these communities that they will be pushed towards assisted dying. A consultation with participants from Pakistani, Roma, Nigerian, black Caribbean and Indian backgrounds revealed overwhelming mistrust, which is deeply rooted in the experience of discrimination and the disproportionate impact of covid-19. As one participant put it,

“They are doing this to save money…to kill us off.”

To get confidence among communities back, we need specialists people can rely on. That is what the amendment speaks to, and I hope that the Committee will support it.

[Danny Kruger]

I rise to briefly speak in support of amendment 281, moved by the hon. Lady and tabled by the hon. Member for York Central (Rachael Maskell).

At the moment that somebody seeks assisted death through a consultation with a doctor, they stand at a fork in the road: they can either proceed towards the assisted death about which they are inquiring, or turn towards other treatment options. On Second Reading, almost every Member on both sides of this debate stated that we need more palliative care, and everybody emphasised the value of providing good palliative care to all who need it. The amendments in this group would simply give force and power to the clear call of the House of Commons for a strong, realistic palliative care option as an alternative to assisted death, and I would be astonished if members of this Committee chose to vote them down. They give clear expression to the will of the House: that palliative care should be offered, and that it should be apparent that a patient has clearly understood their palliative care options.

I implore members of the Committee to consider what they would be communicating if they rejected the amendments. They would be saying that this is not a fork in the road, but a one-way street: there is only one way that someone is likely to go, and that is onwards to an assisted death. If that is the will of the Committee, it should vote the amendment down. If it thinks, as so many people said on Second Reading, that there should be real choice, and that palliative care should be explained and properly available, then I implore the Committee to support the amendment.

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[Naz Shah]

Professor Sleeman’s evidence to me around palliative care says:

“‘Essential’ services are not provided: A good example is that our study of community services that are provided to people with advanced illness found that just 1 in 3 areas consistently provides a 24/7 palliative care telephone advice line—even though this has been a NICE recommendation since 2011…Another example is that the most recent NACEL audit (National audit) found just 60% of hospitals provide a 7 day face to face palliative care service— even though this is also a NICE recommendation, and was a recommendation in the One Chance to Get it Right report (that came out of the Neuberger review—around 2015.)”

I appreciate the hon. Gentleman’s important point, but does he agree that not every GP is able to keep abreast of all the palliative care advances being made, which palliative care consultants would know about?

[Dr Shastri-Hurst]

I am grateful for the hon. Member’s intervention, which leads on to the point I was going to make. We are getting bogged down in nomenclature about what speciality is involved when this is actually about training. It is about whether the individual having the conversation has the requisite skills to have a meaningful conversation. Clauses 5(3)(a) and 8(6)(a) stipulate that the co-ordinating doctor or independent doctor

“has such training, qualifications and experience as the Secretary of State may specify by regulations”.

That is the key part. This is about ensuring that people having incredibly sensitive, challenging and difficult conversations with patients about choices available to them at the end of life have the requisite skills and knowledge to do so. That may not be applicable to each and every general practitioner, but those having those conversations should have that knowledge.

[Dr Shastri-Hurst]

I fear that my hon. Friend may be oversimplifying what I was saying. Perhaps I was not clear enough, so I will elucidate. I was certainly not suggesting that the required skills were merely those of being able to have a consultation and a conversation. I was talking about having the skills to have the information that needs to be imparted and the knowledge that underpins that and being able to articulate that within a consultation. It is a much wider picture than just having the communication skills—it is having the knowledge that underpins that. I am saying that that is not necessarily the domain only of someone who works in palliative care. There are a number of specialists who work within this field—it is a multidisciplinary field—and they all bring their expertise. The issue is about ensuring that anybody having these conversations has the knowledge base to conduct them properly.

[Naz Shah]

Will the hon. Member give way?

[Dr Shastri-Hurst]

I will try to make some progress. I want to move on to the other point I want to address, which is around bogging down the whole process with layer upon layer of bureaucracy. We are talking about a relatively small group of patients who are in the last six months of life and are then battling against the system that is meant to be helping them. If we put in layer upon layer and hurdle upon hurdle, it will become a much more difficult system for people to navigate. That does not mean that it would be a less robust system, but it would be a more difficult system. We are trying to make life easier, not harder, for those patients. This comes back to the central point that Professor Whitty made in his evidence about overcomplicating Bills: we overcomplicate Bills out of good intentions, but rarely make the safeguards more robust—in truth, we make them less safe.

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[Naz Shah]

rose—

[Dr Shastri-Hurst]

I will give way because the hon. Lady has been very patient.

[Naz Shah]

I am grateful to the hon. Gentleman, who is being generous with his time. I want to bring in something that is very real for me at the moment. As a result of a hit and run, I have nerve pain for which I receive steroid treatment. I had treatment a couple of weeks ago and suffer from pain at the moment. My doctor is not a specialist in nerve pain; he has to refer me to a musculoskeletal service and I have been waiting for over a year for surgery.

I mention that because we already have care pathways for specialisms such as nerve pain. My hon. Friend the Member for Spen Valley referred earlier to somebody who had cancer and it was a horrible experience. I would like to have thought that in that instance they would have been offered tube feeding. However, to go back to the point, the GP does not necessarily have the skillset. My GP, and there are lots of them in that practice—it is a brilliant practice at Kensington Street—has to refer me on. That is the point of the Bill. The amendment speaks to developing an established care pathway. If we are to pass this legislation into law, we must ensure that there is a care pathway to explore palliative care.

At the moment clause 4(4), which my hon. Friend the Member for Stroud referred to earlier, says this has to be explored in the wider term. However, what that looks like is not a specialty. For some people with cancer and palliative care needs and six months to live, their trajectories could be—

[The Chair]

Order. This is supposed to be a short intervention.

[Naz Shah]

Sorry, Mr Efford. How can a GP guarantee that all those options have been covered, even in that initial discussion?

[Dr Shastri-Hurst]

I am grateful to the hon. Lady for her intervention. She makes a number of points. First, may I say that I am sorry about her own health issues? I think she hit the nail on the head when she said that the GP may not be able to offer that service. For instance, take shoulder injections. Some GPs can do a shoulder injection with steroids; some will refer to the hospital for it. My father was a GP who could do them, but others would have referred to me when I was an orthopaedic surgeon and I would have done them in clinic.

This will not be right for every single general practitioner; the issue is about having a cohort of general practitioners who have the skill and ability, and about having a flexible system that works for patients. It all circles back to the training point. The individuals who do this have to have the requisite skills. That, of course, will be set down in regulation.

The other point that the hon. Member for Bradford West made is that clause 4(4)(c) says that any clinician having that discussion must be able to explain

“any available palliative, hospice or other care.”

It therefore follows that if the clinician is unable to do that because of a lack of skill or knowledge, they should refer on to somebody who can do it. That is the fundamental principle of having informed consent and discussion with patients. If a clinician cannot provide that information, they ask for somebody who can. That was not uncommon in my practice: if I had something that was outside of my area of knowledge or specialist interest, I would refer it to a colleague. That is how those conversations take place.

The Bill as it stands allows that flexibility for patients without confining them. But it gives them the very welcome option of a palliative care referral; that is entirely open to them—it is not closed off from them. Of course, they will be fed into the palliative care route anyway, following the trigger of their terminal diagnosis. They will be going on the journey, and having further conversations around their end of life care. Those are the points that I wish to make.

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[Kim Leadbeater]

I do worry about the lack of faith in our professionals. We have medical practitioners on the Committee and we have heard stories of the very good practice that happens, so it concerns me that we are so cynical about our system. Ultimately, we have to put faith in our professionals to do their job and to take that patient-centred approach, as I firmly believe they do. Dr Sarah Cox from the Association for Palliative Medicine said in her evidence to the Committee:

“In clinical practice, we make all these decisions in multi-professional teams…shared decisions are much better quality, much more robust and much safer.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 74, Q90.]

I absolutely agree with her, and that would continue to be the case.

[Naz Shah]

The hon. Member mentioned earlier the idea that this is happening in isolation, but it is her Bill that is saying that it will just be two doctors, not a team of medical professionals.

[Kim Leadbeater]

But it does not say that at all. It actually says that they have to refer, and that they have to consult with other people. That is part of the process. That is exactly what happens now. Professor Aneez Esmail, who is the emeritus professor of general practice at the University of Manchester and who has been a practising GP for over 30 years, told us in his evidence to the Committee:

“In terms of holistic care, currently when I look after dying people I never do it on my own; I am with district nurses, Macmillan nurses, or on call to a palliative care consultant. There is already a team of people looking after dying people…palliative care…works very well and it works in a multidisciplinary way. I think that this legislation will allow a much more open discussion and proper monitoring. It will improve training, guidance and everything else. People say that it will enhance palliative care, and that is what I think will happen.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 171, Q219.]

Indeed, as was referred to by the hon. Member for Solihull West and Shirley, if we consider the training included in the Bill, which doctors will undergo as part of the introduction of assisted dying, evidence from other jurisdictions shows that these are very detailed conversations where health professionals work together in the same way as they do at the moment in end of life care and decision making. As I have said repeatedly, the training is fundamental. I agree absolutely with Dr Rachel Clarke, who told us:

“If there is one thing that I would say to the Committee regarding making the Bill as robust, strong and safe as possible, it is: please consider seriously the matter of education and training”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 71, Q85.]

I agree 100% and I have embedded that in the Bill.

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The Government remain neutral on the substantive policy questions related to how the law in this area could change. However, I hope those observations on the purpose and effect of the amendments are helpful to Members of the Committee in their consideration.

[Naz Shah]

I have a few concerns about what we have just heard in relation to the amendment. One of them is in relation to Dr Cox’s evidence. What Dr Cox actually said was:

“The second difference, I would say, is that you are absolutely right that we do make those decisions with patients—with their families, if they wish—but in a multi-professional team. I would almost never make those decisions as an individual doctor without the support of my colleagues, for several reasons. First, as I have said already, that makes for much better decisions”. ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 74, Q91.]

[Danny Kruger]

To pick up on that point about Dr Cox, I think it is critical that the hon. Member for Spen Valley cited Dr Cox in support of the hon. Lady’s contention that the Bill is adequate. Dr Cox, in her evidence, was saying that there is a problem with the Bill because it does not require the multidisciplinary consultation that we all think needs to happen. Dr Cox was suggesting that the Bill should be amended in order to ensure that the NHS does its job properly, and that multidisciplinary consultations are held. Her evidence was not in support of the Bill as it stands.

[Naz Shah]

I thank the hon. Gentleman for his intervention.

[Kim Leadbeater]

On the point made by the hon. Member for East Wiltshire, the Bill does not replace what already happens, and what Dr Cox was saying was that those conversations are already happening in a multidisciplinary way. We do not take that away.

[Naz Shah]

One of my concerns is that although the Government position in relation to the Bill, as they have said, is neutrality, the Government, in my opinion, have taken a position without an impact assessment, which might suggest that there is some ambiguity. Would the Minister therefore support redrafting potential amendments to include that? If it did specify a doctor or nurse, would the Government then, in their tidying-up, be prepared to accept that amendment?

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

Referring back to Dr Cox, she said:

“We need to make sure that the 75% to 90% of people who are dying and need palliative care are getting it. We need to make sure that there is not inequity in palliative care, so that you do not have to be white and rich and have cancer to get good palliative care. We need to make sure that hospitals have seven-day services. Seven-day-a-week cover is unavailable at 40% of hospitals.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 78, Q101.]

Does my hon. Friend agree that we need an inequality impact assessment to understand the current position and to get that right, in line with the Bill?

[Naz Shah]

My hon. Friend is absolutely right. Without the impact assessment, how do we know what we are dealing with? That would be a normal way of progressing a Bill and dealing with amendments such as these. It feels as though we have just talked about something when the Government have already had a position on it, or have supported a particular position on an amendment.

To conclude, I will press the amendment to a vote, simply because it is important that we explore every option. We are already specifying what doctors have to do. I maintain again that there are 100,000 people in this country who do not access palliative care as it is. Palliative care is crucial when we are talking about end of life and people who have had a diagnosis of less than six months to live.

We will talk about illness and diagnosis in the next round of amendments, but on this amendment, I do not think that ensuring that somebody has at least explored that option is, as the hon. Member for Solihull West and Shirley repeated at least three or four times, “bogged down”. For me, it is not bogging down when we are talking about providing assisted death. The Bill is the biggest legislation on a conscience vote since 1967 in this House, and I do not care how long it takes. I feel very strongly that if we are to deliver a Bill that my hon. Friend the Member for Spen Valley said has the tightest safeguards in the world, then this debate has to happen. These conversations must happen and be explored not just for us here as parliamentarians, but in order for us to go away and say that we have done the best we can.

Question put, That the amendment be made.

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[Rebecca Paul]

I thank the hon. Lady for raising that point. I think that what has been looked at is the number of unassisted suicides. The hon. Lady makes the good point that obviously we need to look at all the different factors that could be part of that, but I am just making the point that when we look at territories that have introduced assisted dying, we find that at the point at which it is introduced, we generally see, in most territories, an increase in unassisted suicide. I do not think that we should rush to disregard that. We need to recognise that in helping a small group of people at the end of their life, which undoubtedly this Bill will do, there will be a price to be paid. That price will be paid by our young people and other vulnerable groups.

I will not vote in favour of clause 1—I do not think that there will be a Division on it anyway—but I will not oppose it either, for the reasons that my hon. Friend the Member for East Wiltshire set out. I understand that it is the key clause in order for us to progress and continue the debate, which is what Parliament wishes us to do, but I hope that the Committee will be more receptive to improving the safeguards as we progress through the Bill. The amendments really were tabled in good faith. We did our best to write them in a clear way, but obviously the private Member’s Bill process makes that more difficult. This is not a Government Bill, but we are all doing the best we can to table amendments that would improve the safety of the Bill.

[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

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[Rebecca Paul]

I rise to speak to amendment 11, which stands in the name of my hon. Friend the Member for South Northamptonshire. This is one of the areas of the Bill where we all agree on what we are trying to achieve, so it comes down to making sure that the drafting does exactly what we all intend in order to protect people.

The definition of “terminal illness” in the Bill has two components. The first is that the person has an inevitably progressive and irreversible condition; the second is that their prognosis is less than six months. An issue raised in our evidence sessions is that there is a risk that a person with a mental disorder or disability will meet that definition if they are suffering physical symptoms that mean that they satisfy both parts of the test; a possible example could be a young woman suffering with severe malnutrition as a consequence of anorexia. With respect to the point that the hon. Member for Stroud made, I agree that anorexia on its own would not qualify, but the issue arises when there is a physical manifestation from that disorder such as severe malnutrition or even diabetes, which can co-occur, as we heard in the evidence sessions.

It is clear that that is not the intention of the hon. Member for Spen Valley or anyone on the Committee, as evidenced by the inclusion of subsection (3). I thank the hon. Member for making that point; it is much welcomed. However, in oral evidence, Chelsea Roff said that

“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.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 153, Q194.]

Before I get into amendment 11, which aims to address the issue, it is important to understand what clause 2(3) is trying to do. It reads as follows:

“For the avoidance of doubt, a person is not to be considered to be terminally ill by reason only of the person having one or both”

of a mental disorder or a disability; it refers to the relevant bits of law. As my hon. Friend the Member for East Wiltshire has set out, the words “for the avoidance of doubt” make it clear that this is a clarifying subsection that does not make any change to the rest of clause 2. It appears to be clarifying that mental disorders and disabilities alone will never qualify someone for assisted dying—I think we all concur with that—unless they also have a physical condition that meets the terminal illness test, namely that it is inevitably progressive and irreversible and that the person has a prognosis of less than six months.

This is where the problem lies. If someone has a physical condition arising from their mental illness, such as severe malnutrition resulting from anorexia, and if the physical condition meets the definition of a terminal illness, they will qualify. As the Royal College of Psychiatrists said in its position statement:

“The wording of the Bill could also be interpreted to include those whose sole underlying medical condition is a mental disorder. While anorexia nervosa, for example, does not itself meet the criteria for terminal illness as it is not an ‘inevitably progressive illness, disease or medical condition which cannot be reversed by treatment,’ its physical effects (for example, malnutrition) in severe cases could be deemed by some as a terminal physical illness, even though eating disorders are treatable conditions and recovery is possible even after decades of illness.”

To remedy the issue, amendment 11 would remove the words “For the avoidance of doubt”, to make this a legally effective clause, rather than just a clarifying one. That means that it is providing an additional safeguard to those with mental disorders and/or disabilities. It would also remove the word “only”, to ensure that a physical condition resulting from a mental disorder or a disability will not make a person eligible for assisted dying. The amendment is further bolstered by amendment 283, tabled by the hon. Member for York Central, which would make it clear that comorbidities arising from a mental disorder do not qualify a patient for an assisted death.

I thank the hon. Member for Spen Valley for tabling amendment 181 to try to address the issue, but I do not believe that would quite solve the problem, which is quite a tricky one. “For the avoidance of doubt” would still be there, as would “only”. The sentence beginning with “Nothing in this subsection” makes it crystal clear that if a condition meets the six-month condition and the rest of the definition, it will be considered a terminal illness. There is therefore no exclusion for physical symptoms manifesting from mental illness or disability, which I think is what we are all trying to get to.

In my view, the only amendment that would address the issue is amendment 11, tabled by my hon. Friend the Member for South Northamptonshire. It would remove both “For the avoidance of doubt” and “only”, and would therefore better ensure that a physical condition resulting from mental illness or a disability does not make a person eligible for assisted dying.

[Naz Shah]

I rise to speak to amendments 10, 181 and 283. I will start with amendment 10, which is very significant: it would make a small but crucial change to clause 2.

[The Chair]

Order. I think you are speaking to the wrong amendment.

[Naz Shah]

Sorry, I mean amendment 11. Thank you, Mr Efford.

I think it will be helpful to spell out what the Bill currently says, and what it would say if amendment 11 were adopted. I will also set why the amendment would provide a much stronger safeguard than amendment 181, which was tabled by my hon. Friend the Member for Spen Valley.

Clause 2(3) states:

“For the avoidance of doubt, a person is not to be considered to be terminally ill by reason only”

—I stress the word “only”—

“of the person having one or both of—

(a) a mental disorder, within the meaning of the Mental Health 1983;

(b) a disability, within the meaning of section 6 of the Equality Act 2010.”

If amendment 11 is agreed to, clause 2(3) will read:

“A person is not to be considered to be terminally ill by reason of the person having one or both of—

(a) a mental disorder, within the meaning of the Mental Health 1983;

(b) a disability, within the meaning of section 6 of the Equality Act 2010.”

That may seem a very small change, but it is an extremely important one.

The Bill, as presented to Parliament on Second Reading, would allow someone to qualify for assisted dying if they had a mental health condition such as anorexia nervosa and a physical condition such as malnutrition. To put it with absolute bluntness, that means that somebody with anorexia nervosa could stop eating until they suffered so badly from malnutrition that two doctors prognose that the patient is likely to die within six months. That person, under the Bill, would then qualify for assisted dying.

[Kim Leadbeater]

This is a really important discussion and I am so glad that we are having it—some brilliant points have been made. As someone who has worked with people with anorexia, I am very aware of the sensitivities of the condition and the issues around it. Would my hon. Friend agree that, as part of this discussion, we have to consider the capacity assessment of people with eating disorders? It is a very serious mental health condition; it would require a lot for somebody with anorexia to pass the capacity threshold for making a decision of this magnitude. It is certainly the sort of instance where I would be very surprised if a doctor did not refer to an eating disorder specialist. Does my hon. Friend agree that we have to look at the condition and how the patient should be cared for holistically?

[The Chair]

Order. I remind hon. Members that there are a set of amendments in the next group about anorexia. Let us not go too far down this road.

[Naz Shah]

I absolutely agree with my hon. Friend that there need to be specialists—we will come to that debate later. Let me bring our debate back to the amendment we are discussing. I understand that the Bill is drafted so that people who suffer mental disorders, such as anorexia nervosa, cannot qualify for assisted death—when my hon. Friend the Member for Spen Valley sets that out, I have absolutely no reason to doubt it—but that is not enough to safeguard people with such disorders. As we know, people with anorexia can and have stopped eating until they suffer advanced malnutrition, which is a physical disorder. In some cases, that malnutrition becomes so advanced that doctors will prognose death within six months.

If we wish to protect people with anorexia and other eating disorders, we must rewrite the Bill. We must ensure that people who have those disorders, and who also have a physical disorder, cannot qualify for assisted dying. I must underline that this is not a hypothetical point or some clever objection that has been dreamed up without reference to the real world. It has actually happened—not once, but dozens of times in countries that have assisted dying.

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[Kim Leadbeater]

My hon. Friend is making a powerful point. Does she agree that the reporting and data around assisted dying are fundamental? That is why it is important that, if the law is to change in this country, we get that absolutely right. What we propose in the Bill is closest to the laws in Australia, and in my understanding there have been no assisted deaths of people with anorexia in Australia. However, my hon. Friend makes a valid point about the accuracy of reporting; we do not know whether those examples were people with anorexia who happened to have cancer as well. We just do not know, and that is not good enough.

[Naz Shah]

I absolutely agree that if the Bill is to get through Parliament, it has to have those mechanisms and safeguards in place, but I am sure we will come to those later. If we do not know with any reasonable degree of accuracy how many cases there have been worldwide, we cannot say where the majority of such cases have occurred. When we are told that there have been zero assisted deaths of people with anorexia in Australia, I would err on the side of caution—another witness said that there were zero deaths involving coercion.

I understand that my hon. Friend’s amendment 181 also attempts to change clause 2, but the change would still allow people to qualify for an assisted death if they had a mental disorder alongside a physical disorder. I have no doubt that this stems from a compassionate desire not to exclude—for example, someone who has mild depression and a major physical illness—but its effect is to create a major risk for people suffering from both a mental health disorder that affects their eating and a physical disorder caused by not eating. To avoid that risk, the Bill must be much more tightly worded than it was when presented to the House on Second Reading, and it must be much more tightly worded than amendment 181 would make it.

We must make it much harder in the Bill for people to qualify for assisted death by way of having malnutrition caused by an eating disorder. It is a complex problem, and I believe no one amendment will solve it completely. I have submitted two amendments with the aim of making a contribution. Amendment 11 would also make a significant contribution to solving the problem, and I urge all Members to support it.

I turn to amendment 181, tabled by my hon. Friend the Member for Spen Valley. Although the Acts mentioned in clause 2 define mental illness and disability as being taken from the clear medical model, it is not clear if she is further suggesting that a new definition should be used—for instance, the social model. Someone could have a significant impairment under a social model of disability, and for the purposes of the Bill, not consider themselves to be a disabled person. Therefore, they could qualify for an assisted death, thus rendering the provision of no worth.

It is therefore unclear what my hon. Friend is similarly proposing with regard to mental illness. Amendment 11 is needed to provide assurance that if someone does have a mental illness, then it is tightly defined and would preclude them from being able to access an assisted suicide, in case the reason they are seeking it is the mental illness and not the terminal diagnosis. I will speak further on that later.

If amendment 181 was agreed to, the clause would read that a person is not to be considered terminally ill

“only because they are a person with a disability”.

There are two obvious problems with the amendment. First, the amendment removes references to the Equality Act 2010 and the Mental Health Act, which previously defined who did and did not have a disability or a mental health disorder, but having removed those definitions, it does not then define disability or mental disorder in the Bill. What definition will medical practitioners, and indeed applicants, use to determine who does or does not have a disability or mental disorder?

[Kim Leadbeater]

In terms of the removal of references to the Equality Act, I was not aware when the Bill was initially drafted that cancer is actually classed as a disability. Given the fact that in some countries 70% of assisted deaths are for cancer patients, it would seem ridiculous to exclude cancer patients from having the option of assisted death. I hope that goes some way towards explaining that point.

[Naz Shah]

I thank my hon. Friend for clarifying that—that is really helpful. But where does the amendment leave us in terms of disabled people? I am just trying to understand.

[Kim Leadbeater]

The concepts of a mental disorder and a disability are well understood, and those terms are well used. In the eyes of the law, we would not need to provide a definition of those in the Bill, but the removal of the reference that would include people with cancer is an important thing to do.

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[Naz Shah]

I appreciate that cancer does come under disability, and that people with cancer can identify as a disabled person, but my initial thought is that that weakens the Bill.

[Danny Kruger]

The fact that cancer is included in the Equality Act definition does expose a concern about the Bill. It suggests that there is a real connection there, which is of concern. I think the solution is to accept the amendment 11 and ensure that disabled people and those with mental health conditions would not be eligible for assisted dying, and then to introduce a further amendment—either now, as a manuscript amendment, or later—to exclude cancer from the definition. That is a tidying-up exercise that could be done in light of the point that the hon. Member for Spen Valley made about the reference in the Equality Act. The most important thing is that we tighten the clause to protect disabled people.

[Naz Shah]

I wonder whether my hon. Friend the Member for Spen Valley has considered whether she would tighten the clause. Have any options been explored, and what have the Government said about her removal of the Equality Act—

[The Chair]

Order.

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

Naz Shah Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[Naz Shah (Bradford West) (Lab)]

Before we adjourned, I was talking about the two obvious problems with amendment 181. The first is that it would remove references to the Equality Act 2010 and the Mental Health Act 1983, which previously defined who did or did not have a disability or mental disorder. The amendment would remove those definitions, and the Bill would not define disability or mental disorder. What definition would medical practitioners, and indeed applicants, use to determine who does and does not have a disability or mental health disorder?

I appreciate that, as my hon. Friend the Member for Spen Valley explained, that was done on the basis of advice she took to remove the references to the Equality Act because people with cancer could also declare themselves to be disabled people. However, that leaves a real opening, which weakens the clause even further. I cannot understand why we would remove one clear definition but not provide a replacement. That is a serious concern.

However, there is a bigger problem with the clause as it would be changed by my hon. Friend’s amendment. In referring to someone who could not be disqualified from assisted dying, the clause would still use the word “only”—again, I emphasise the word “only”. That leaves the door open for individuals with mental health disorders or disabled people to qualify for an assisted death based on the physical consequences of their condition. If the goal is to prevent people with mental illness or disabled people from qualifying, this amendment fails to do that. It weakens, rather than strengthens, the Bill’s safeguards.

As we heard in oral evidence, there are now 60 documented cases of individuals with eating disorders who have died by assisted death internationally.

[Lewis Atkinson (Sunderland Central) (Lab)]

Does my hon. Friend accept that nearly all those cases were in jurisdictions whose schemes bear no resemblance to the one proposed in the Bill?

[Naz Shah]

I accept that the majority of those 60 cases are in such jurisdictions, but to me it does not matter whether it is the majority or one—one death is too many, as I am sure my hon. Friend will agree. In Oregon, the evidence was that it was two, but it is also important to reflect on the fact that Oregon does not record these things. There is no record of the people who had anorexia—by and large, it is women—and who felt that they fit the criteria for assisted death, or that they were on a trajectory to fit it, because they had decided not to eat. So we cannot exactly rely on the two cases that have been found—and those were found only because of the research that was carried out. That does not quite satisfy the question.

[Sarah Olney (Richmond Park) (LD)]

Does the hon. Lady agree that it really does not matter what happens in other jurisdictions? The question is, does this legislation prevent people who are currently suffering from anorexia from seeking an assisted death or not?

[Naz Shah]

I completely agree with the hon. Member.

Coming back to the physicians who justified eligibility by citing the physical complications of anorexia, not just the mental disorder itself, we know that in all 60 of the cases that have been cited, the person did not have a terminal illness other than the one that was caused by anorexia, because that then fit the definition. Under the Bill, the same could happen here. I say in response to the hon. Member for Richmond Park that eating disorders or substance use disorders could still qualify if a doctor determines that the resulting physical deterioration meets the criteria for terminal illness. I will speak to anorexia in much more detail when we debate a further amendment that I have tabled.

Amendment 181 would also remove references to the Equality Act and the Mental Health Act, and the Bill would not define disability or mental disorder. That raises serious concerns, so I will not support the amendment. I encourage Committee members to strengthen the Bill in this regard and not weaken it. The Acts define mental illness and disability as taking a clear medical model, and again it is not clear whether my hon. Friend the Member for Spen Valley is further suggesting that a new definition should be used—but I am going over ground that I have already been over.

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

The amendments before us have left me in a significant quandary, as some Members are aware. I am concerned that while their proposers are genuinely seeking to improve the Bill, legal loopholes may remain.

Prior to Second Reading, the Equality and Human Rights Commission produced a briefing note on the Bill. It included a section relating specifically to discrimination and equality considerations, which stated:

“It may also particularly impact disabled people. We recognise that this bill is focused on assisted dying for adults who are terminally ill, and does not propose access to assisted dying on the basis of disability or chronic conditions. However, there is not always a clear line between terminal illness and disability. Disabled people can also suffer from terminal illness, and illness may itself amount to a disability. Parliament should note that the exclusion of disability as a standalone criterion for accessing assisted dying does not mean that the rights of, and protections for, disabled people do not need to be considered in relation to this bill.”

I note that amendment 181, tabled by my hon. Friend the Member for Spen Valley, seeks to clarify these matters, but I remain concerned that, with its reference to

“only because they are a person with a disability”,

it would retain the ambiguity that she is seeking to remove. I understand the legal advice that she has received on this matter. My view is that although the amendment would remove the reference to the Equality Act, that Act still sets out that disability is one of the specified protected characteristics. Paragraph A9 of the Government’s guidance on the Equality Act reads:

“The Act states that a person who has cancer, HIV infection or multiple sclerosis (MS) is a disabled person. This means that the person is protected by the Act effectively from the point of diagnosis.”

I remain concerned about this point. I have previously raised my concerns about the language used on Second Reading and, if I had spoken then, I would have raised this point. We have heard throughout the Bill’s passage that being a disabled person does not make someone eligible for assisted dying, but I have just diagnosed three disabilities in the Equality Act that may or may not be eligible under this Bill.

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[Naz Shah]

My hon. Friend is making her points very clearly. The last words of amendment 181 are:

“Nothing in this subsection results in a person not being regarded as terminally ill for the purposes of this Act if (disregarding this subsection) the person meets the conditions in paragraphs (a) and (b) of subsection (1).”

Does that not demonstrate that the amendment does not change the test for terminal illness?

[Kim Leadbeater]

My apologies; I am speaking to amendments 399, 400 and 401. I will be happy to come back to that point at the appropriate time, but I first want to finish my comments on those amendments.

As I have said, the hon. Member for East Wiltshire has done a good job this morning of improving the clarity of the issue. That shows that the Committee is doing its job and working effectively. I am therefore open to supporting those amendments.

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[Rebecca Paul]

I am sharing the content of written evidence. People working in this arena—medical professionals and clinicians—have taken the time to submit written evidence, which suggests that they see a risk, so this is something that we need to think about. The hon. Gentleman could be right when he asks why someone would seek assisted death in that situation, but it is more about if someone technically qualifies. Obviously, we are still yet to get through the Bill, and there is lots for us to debate, but we want to ensure that people are not put on that pathway if they are not actually terminally ill and their condition can be managed. People could be in a low place, and we need to provide support. This comes back to my point about the balance of best interests. It is really difficult to set the right level, but we need to think about best interests and protect people at their lowest point.

In Oregon, conditions such as anorexia, diabetes, arthritis and hernias have qualified for assisted death, not because they are inherently fatal but because treatment was refused or was unaffordable. We also need to think about situations such as supply chain issues with certain treatments. Situations that we do not want to happen could arise, and we need to think about what that means for this Bill.

Some lawyers and doctors in the US have advised patients on how to bypass the terminal illness criteria by refusing food and water until they become terminal—we have talked about that quite a lot today. There is some evidence of that happening. Cody Sontag, an Oregon woman with early-stage dementia, had few symptoms and was not eligible for assisted death, but after she refused food and water for a few days, her doctor ruled that she met the six-month prognosis requirement.

It is important that we carefully consider young women suffering with eating disorders, but I appreciate we have spoken about that group a lot today, so I will be brief. In Chelsea Roff’s evidence, she set out that at least 60 people around the world have been euthanised or assisted in suicide where anorexia nervosa has been listed by name as a terminal condition. In 100% of the cases, the people were women, a third were between the ages of 18 and 30, and two thirds were under the age of 40. Roff said,

“I have to emphasise that these were young women who did not have failing organs and did not have comorbid terminal conditions…they had decades of life ahead of them.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 139, Q175.]

UK courts have already ruled that treatment can be withdrawn from young women with anorexia, acknowledging that the likely result will be their death, after doctors framed their condition as terminal or untreatable. These examples powerfully demonstrate why it is vital these amendments are accepted, so that these conditions do not lead to a person qualifying for assisted death, if they can be managed sufficiently with treatment. In oral evidence, Dr Miro Griffiths asked us,

“What constitutes six months left to live, particularly if you are engaging with technological devices, medical assistance and so on? For example, I have a progressive condition that continuously makes me weaker and has respiratory complications and so on. If I remove the ventilator that I use at night, if I remove my other medical devices and if I stop my engagement with therapeutic services, does that constitute me having a terminal illness, because my rapid acceleration towards death becomes more evident?”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 142-143, Q179.]

In written evidence, Pathfinders Neuromuscular Alliance warned that for those with conditions like muscular dystrophy, access to treatment is essential. It said,

“It would not be unreasonable therefore to suggest an individual with neuromuscular respiratory failure could die within six months—and yet they might also live 20 to 30 additional years in this state.”

In written evidence, a group of leading physicians and researchers, including experts from John Hopkins University and the Royal College of Psychiatrists said,

“The Bill’s definition of terminal may not adequately distinguish between a condition that is inevitably fatal and one that only becomes terminal without adequate care.”

They added,

“Under this Bill, patients with incurable but treatable conditions could become terminal if they are unable to access timely treatment or choose to forego life-sustaining care.”

It is therefore vital that the definition of terminal illness is tightened to avoid unintended consequences. These amendments would ensure that the Bill applies only to those who are generally at the end of life, without prospect of recovery. I urge the Committee to give consideration to accepting them.

[Naz Shah]

First, I will speak to amendments 9 and 10, then to amendment 234, and then to my own amendments 48 and 402. I hope it is in order to note that the hon. Member for South Northamptonshire (Sarah Bool), as the hon. Member for Reigate already mentioned, is a type 1 diabetes sufferer. Amendments 9 and 10 both concern matters of which she has a personal understanding.

Amendment 9 would mean that an illness, disease or medical condition, the progress of which can be managed or controlled by treatment, would not be characterised as a terminal illness. The amendment provides that instead of saying that the illness cannot be “reversed” by treatment, the Bill should say that its progress cannot be “controlled or substantially slowed”. The amendment is clearly a most important one. It seeks to prevent illnesses that can, in fact, be treated effectively from being classified as terminal illnesses.

The amendment would work to mitigate two very serious risks posed by the Bill. First, it would make it more difficult for someone who, for whatever reason, wished for an assisted death to qualify for that process by failing to follow a reasonable course of treatment. I do not say that the amendment would make it impossible for anyone not to do so, but it is an important safeguard. It would also provide a safeguard against the expansion of those conditions that would qualify people for assisted death.

My hon. Friend the Member for Spen Valley and members of the Committee have repeatedly praised the Oregon law, but we surely do not want to follow that example in every way, since we know that in Oregon, sufferers of anorexia have been able to access assisted dying. Again, I do not say that the amendment would make it impossible to expand the list of conditions, but it would make it harder. My hon. Friend has said repeatedly that she wants the Bill to have the strongest safeguards of any assisted dying law in the world, so I hope that she will join me in voting for amendment 9.

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[Dr Tidball]

Just to clarify, I will not be supporting that amendment.

[Naz Shah]

I agree very strongly with the sentiments expressed by my hon. Friends the Members for Spen Valley and for Penistone and Stocksbridge, and I hope that the Committee can later return to the state of palliative care in this country.

I underline that the matter of the six-month prognosis was not some minor detail on Second Reading; rather, it was a central plank of the arguments made by those who said that we should pass the Bill because its safeguards were the toughest of any assisted dying law in the world. It is less than three months since my hon. Friends spoke those words, and yet we are already discussing an amendment that would remove the six-month prognosis.

[Kim Leadbeater]

We need to be fair to the hon. Member for Harrogate and Knaresborough, who has said that he will not press the amendment to a Division. Indeed, it would not be something that I would support if he did do so, for the reasons that my hon. Friend has stated. I also think that we need to give him credit for ensuring that the voices of people with neurodegenerative conditions, such as MND, Parkinson’s and Huntingdon’s, are heard. They are an important part of this debate, whatever our views might be on the tightness that is needed in the Bill.

[Naz Shah]

I thank my hon. Friend, and my hon. Friend the Member for Penistone and Stocksbridge, for making it clear that they would not vote for the amendment. I also thank the hon. Member for Harrogate and Knaresborough for bringing forward an amendment that discusses those issues. However, whether it is withdrawn or not, it is an amendment that we are debating and talking to.

The hon. Member for Harrogate and Knaresborough, who tabled the amendment, no doubt feels very strongly that the conditions of patients with neurodegenerative diseases make a case for relaxing the six-month prognosis to 12. There may well be a good case for doing so, but we can only consider the case for extending the prognosis to 12 months because of the challenges created by neurodegenerative diseases if we have first considered that extremely complex subject.

We cannot say that the Committee has studied the difficult subject of neurodegenerative diseases and how they would affect the administration of the Bill. We have not heard from witnesses on the subject, and we have not been able to ask them questions. We did solicit evidence on whether neurodegenerative diseases would affect the ability to self-administer lethal drugs, but we have not had time to study the written evidence.

I appreciate that the hon. Member for Harrogate and Knaresborough is not going to press the amendment to a Division, which leaves some of what I wrote earlier obsolete. I appreciate the hon. Member’s efforts. We are sent here by our constituents to represent them to the best of our ability. I certainly try to do that, and I know my hon. Friend the Member for Spen Valley always tries to do that—I have no doubt that the hon. Member for Harrogate and Knaresborough and all others are trying to do that. We vow to represent our constituents, and had the amendment gone to a Division I would not have been able to support it, simply because we cannot make those difficult decisions without being properly informed. We cannot make up our minds to change the Bill because of a complex set of diseases.

[Jack Abbott]

Just as a point of clarification, I remember asking one of the witnesses at our oral evidence sessions about this very issue—Sir Nicholas Mostyn, an esteemed judge who has written and spoken about the issue extensively. We asked his views about neurodegenerative diseases and extending the time to 12 months, so it was something that we were aware of and discussed as a Committee. In fairness to the hon. Member for Harrogate and Knaresborough, it has not come completely out of the blue.

[Naz Shah]

I agree that we did hear that, but we did not hear from experts in the Bill, and at that point it was not discussed. While I acknowledge my hon. Friend’s point that we did speak to Sir Nicholas Mostyn, we did not have further evidence, and this measure was not in the Bill when we took evidence from those witnesses.

[Tom Gordon]

I find this a little bit baffling, because we had a comprehensive list of witnesses that we were able to circulate in advance. The format in which those oral evidence sessions were held was really helpful and informative. We were able to ask questions, and as the hon. Member for Ipswich mentioned, we were interacting with people and families. We heard from Pat, who gave oral evidence about his sister who had to go to Dignitas. Again, it was not just a small figure; a number of people brought this issue up. Could the hon. Member reflect on that?

[Naz Shah]

The crux for me is that at Second Reading, when the Bill was voted on, many Members cited that one of the central planks to that debate at the time was the six-month prognosis. The amendment would increase that to 12 months. As I have said, my concerns are that we are only three months on from that conversation and we are already trying to expand the Bill, which is why I would not support the amendment. I have said quite a bit on amendment 234, so I will leave it.

I will now speak to amendment 48, which I tabled. Under the current wording of the Bill, a person is terminally ill if their death

“can reasonably be expected within 6 months.”

My amendment would change that so that for a person to be considered terminally ill their death would have to be

“expected with reasonable certainty within 6 months, even if the person were to undergo all recommended treatment”.

One of the risks that confronts the Bill is that of misdiagnosis. That is not some remote possibility. Let me go into detail. As hon. Members know from the evidence brought before the Committee, prognosis is not a precise science. Even with physical illnesses, determining life expectancy is highly unreliable. Government data from the Department for Work and Pensions reveals that one in five people given six months to live are still alive after three years. A study spanning 16 years found that doctors wrongly predict how long terminally ill patients will survive in half of cases. Out of 6,495 patients who were predicted to die within six to 12 months, more than half—3,516, to be precise—lived longer than expected. If the Government themselves cannot accurately determine terminal illness for benefits, how can we rely on such predictions to justify ending lives?

Studies cited in written evidence submitted to the Committee have found that clinicians are routinely inconsistent and inaccurate in their prognostic assessments, often underestimating survival. Professor Katherine Sleeman, a palliative care specialist, underlined that point in her evidence to the Committee. Doctors face considerable difficulty in prognosing whether somebody is in the last six months of their life. Professor Sleeman cites studies based on large samples of patients for whom doctors prognosed life expectancy. The studies found that 47% of the patients whom they predicted to have six months to live in fact lived for longer than that—in some cases considerably longer.

I would argue that there is a danger in using the standard of prognosis currently in the Bill. The current research into doctors’ prognoses indicates that almost half of their estimates that a patient has six months to live are incorrect. We do not want people to choose assisted dying on the basis that they have only six months to live when a very high proportion of them will in fact live longer if they are not given assistance to die by taking a lethal drug or drugs.

My amendment would hold doctors to a higher standard of certainty. Under that measure, they would be explicitly held to prognosing that death would occur with “reasonable certainty” within six months, and that that would be true even if the patient underwent all recommended treatment.

[Sean Woodcock (Banbury) (Lab)]

I think we all accept that prognosis is quite difficult, but one reason why I think this is fundamentally important is that a member of my constituency Labour party was given a prognosis of 12 months in 2012. Last year, they were out delivering leaflets for me in the general election. That is why it is so important that we make sure we get this right. I am sure that my hon. Friend has examples of her own. Is that what is guiding her to press this amendment?

[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—

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[Naz Shah]

I thank my hon. Friend for his intervention. Actually, there is nothing in the Bill that suggests that. We can only imagine and try to empathise as much as we possibly can with any person who has been given a diagnosis of six months to live. In that six-month process, they might not wait; as my hon. Friend, who is a doctor himself, has said, this is about autonomy. They might not wait until they get to a position where there is a lot of suffering; they might not wait to see those six months out. They might decide they do not want to take that risk, when actually they might have lived another 15 years, another year or another two years. That is the point of this amendment.

[Kim Leadbeater]

My hon. Friend is making a powerful speech and it is good to have this debate. May I ask her opinion on two things? One is that, as my hon. Friend the Member for Stroud has alluded to, the research around the world shows that between 30% and 40% of people who sign up for assisted death never actually do it, because they do get better or because the treatment makes their condition manageable—or because they have a death in a different way. What are her thoughts on that? The other thing to point out is the number of people who we know, sadly, are taking their own lives because they are terminally ill at the moment. I go back to the point that I make quite regularly: no one is monitoring that—

[The Chair]

Order. As I said before, these are interventions seeking clarification. They are not mini-speeches.

[Naz Shah]

I thank my hon. Friend for her intervention. If we take that 30% to 40% figure, and the figure—she might correct me if I am wrong here, and I am happy to be corrected—that there are about 600 people on average going to Dignitas, for example—

[Kim Leadbeater]

It is people taking their own lives.

[Naz Shah]

Sorry—would my hon. Friend like to intervene?

[Kim Leadbeater]

Just to clarify, my understanding is that it is between 600 and 700 people who take their own lives; it is suicide.

[Naz Shah]

If we take that number, then that 30% or 40% who do not take that decision is maybe a few hundred people. However, the truth from Professor Sleeman’s evidence is that we are talking about thousands of people who are misdiagnosed every single year. She was talking about 3,516 who lived longer than expected. Yes, I recognise and value my hon. Friend’s comment that 30% or 40% of people do not take up assisted dying, but—perhaps I will talk about this when I move on to the next amendment—there is also a risk. If we go back to the Bill promoter’s intention to make the wording tighter, then surely this is a safeguard that she would support, just to ensure that we are making it as tight as we possibly can.

[Jake Richards (Rother Valley) (Lab)]

Can my hon. Friend clarify for me what she means by “reasonable certainty”, and how that differs from the clause as drafted? Can she also explain why, in her amendments, normal language around the burden of proof, such as “on the balance of probabilities” or “beyond reasonable doubt” is not used?

[Naz Shah]

First, this is not an issue for a tribunal, where it would be on the balance of probabilities; it is not an issue for a court of law or a criminal court, where we would be using proof beyond reasonable doubt. What I am trying to demonstrate is that doctors, in those diagnoses where they do get it right, have much more certainty. It might be that people have six months to live because they have different types of cancer. I am certainly not a clinician or an oncologist, but I know from the evidence we have had and from speaking to people that some people’s diseases—the specialists know better—have a trajectory of plateauing out and then dropping right at the end and some have a jagged kind of decline. Some of those diseases can be predicted with much more clarity than others. On the surface of it, in September, it might be the case for somebody that that is within the time—as for one lady who was told that she would not have more than six months to live. She is the founder of the Music of Black Origin awards and I was with her last week. She was absolutely fighting; she was not supposed to make it to that day. It is for the medics to decide—it is not for me to decide—but I would like medics to have much more certainty than they currently do, so that we would not have 47% of cases being misdiagnosed. That is what I am trying to get to, but I thank my hon. Friend for his intervention.

I argue that there is still a danger of using the standard prognosis that is currently in the Bill. The current research into doctors’ prognoses indicates that about half of their estimates are incorrect. My amendment would hold doctors to a higher standard of certainty. Under the measure, they would be explicitly held to a prognosis that death would occur with reasonable certainty within six months, and that that would have to be true even if the patient underwent all recommended treatment.

To go back to my hon. Friend’s intervention, this amendment is about raising the bar for how our medics make decisions. I submit that it would be a stronger test than the one currently included in the Bill. My hon. Friend the Member for Spen Valley has frequently stated that she wishes to create a Bill with the toughest safeguards in the world. I keep coming back to that, because the whole purpose of speaking to all these amendments is to put in opportunities to try to strengthen the Bill. By their nature, all these amendments reflect hon. Members’ concerns. This amendment would tighten the prognostic standard required of doctors and would therefore contribute towards tightening the Bill’s safeguards. I hope that hon. Members support it.

Finally, I turn to amendment 402. I will repeat a lot about anorexia, but it is an important amendment. I have tabled it for a simple but extremely important purpose: to prevent people from qualifying for assisted dying by stopping eating and drinking to the degree that they develop severe malnutrition, such that a doctor would give them a prognosis of six months to live. It specifically aims to protect people with severe eating disorders, including anorexia nervosa, and would also protect people with a severe wish, as one of the psychiatrists who testified before the Committee put it, to “hasten death”. I hope that my hon. Friend the Member for Spen Valley, and all other Committee members, will support this amendment.

Let us make no mistake: the Bill, as currently drafted, has a horrible loophole that all of us should seek to close. We know that anorexia sufferers and other people with eating disorders can and do stop eating to the point where they are dying of malnutrition. We should not allow such people to qualify for assisted death. Unfortunately, that is not a hypothetical danger; it is happening.

We know from the evidence that the Committee has received that that has happened in other countries. A group of eight experts on eating disorders submitted written evidence TIAB54 to the Committee some weeks ago. The experts included Chelsea Roff, who has been referred to many times in this Committee, and who gave clear testimony before the Committee, as well as seven medical doctors from hospitals in the UK, the US and Canada.

I hope that all Committee members have read the evidence, but I would understand if they had not, because we have had nearly 400 pieces of evidence to go through and very little time to read it. It seems to me, however, that if we are trying to write the best possible Bill, with the strongest possible safeguards, we have to pay the written evidence of experts the attention that it deserves. In their written evidence, that group of experts said:

“Patients with severe eating disorders frequently experience profound psychological distress and may express a desire to die. While this may appear to reflect a clear and informed wish, it is often a symptom of their psychiatric condition, which is remediable with appropriate treatment.”

The experts found that at least 60 patients with eating disorders received assisted death in several jurisdictions worldwide, including the US, Canada, the Netherlands and Belgium. I stress the phrase “at least 60” because we cannot be entirely sure that that is the full total. It is sadly the case that some jurisdictions are much more painstaking and transparent in the data they publish on assisted death than others.

In itself, it is tragic that people died in that way, but two things surely make the fact even worse. There are certainly men with eating disorders, but this is a problem that disproportionately affects women and girls. We know that the incidence of anorexia nervosa is much higher among women than among men in every age group. That is tragic. In every case we know of where a person with an eating disorder received an assisted death, that person has been a woman. I say it again: we cannot allow the Bill, as currently written, to stand. The Labour Government was elected with a mandate to reduce violence against women and girls. We surely cannot pursue that goal while at the same time increasing the vulnerability of women and girls who have eating disorders. There is nothing in the Bill as it currently stands that would stop doctors signing off on assisted death for someone who had starved themselves into malnutrition.

The courts in England and Wales have already begun accepting that some people with anorexia have reached a terminal stage. In the Court of Protection case, The NHS Trust v. L & Others, which took place in 2012, a 29-year-old with severe anorexia was described in the ruling as follows:

“The prospects of her recovery overall approach zero…given that it is extremely unlikely that Ms L will recover from her anorexia…in best interests to move to palliative care if L…in terminal stage of her illness.”

The right hon. Member for North West Hampshire raised the Court of Protection. There are 10 cases where the Court of Protection has made rulings. Of them, only one case, in 2012, ruled that the young lady could be force-fed.

[Kit Malthouse]

It is the other way around.

[The Chair]

Order.

[Naz Shah]

Thank you, Mr Dowd. I have it in evidence and I am happy to provide the reference.

[Kit Malthouse]

My understanding is that it is the other way around. In all but one case, force-feeding was decided by the courts. In the case the hon. Lady is referring to, L, the court did wrestle over that particular issue and realised that, such was the advanced stage of the patient’s condition and the complexities of force-feeding, it could not quite bring itself to authorise it. My understanding is that in all bar one case force-feeding has been authorised.

[Naz Shah]

Actually, it was the other way around and I am happy to provide a reference to the right hon. Gentleman. Nine cases found lack of capacity, but still not in the best interest. One of the girls was 19 years old. The judge found that they lacked capacity to make decisions about their treatment. The question of whether they had the capacity to decide to end their life is completely different and not something we have asked judges to rule on before. The judge’s ruling clearly implied the capacity to refuse force-feeding even if it resulted in their death. I am happy to provide the references for that. It was against their best interest to force-feed them. Tragically, in nine of the 10 cases the judges accepted that that would inevitably lead to the deaths of those young girls.

My hon. Friend the Member for Spen Valley has repeatedly stressed that her Bill is modelled on the Death with Dignity law in Oregon.

[Kim Leadbeater]

Actually, I have not said that.

[The Chair]

Order. With the greatest respect to Members, this is not a dialogue; this is a debate. This is not chit-chat. It is a very serious issue and interventions of that nature are not helpful.

[Naz Shah]

I am happy to correct the record.

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[The Chair]

That is ultimately a matter of opinion. If the hon. Lady wishes to ask the hon. Member for Bradford West a question and get clarity from her, that is fine, but this is becoming a dialogue. People cannot hear what is being said. I want the Committee to be run in an appropriate fashion. We have rules of debate in the House and I am trying to apply them. Otherwise, there lies perdition and chaos.

[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.

[Danny Kruger]

I do not want to cut off the hon. Lady in full flow, but I want to echo her points. The hon. Member for Stroud has made his point before and we have had an exchange on it. There is quite a lot of research, to which I refer him, that shows how people in the UK, being treated by the NHS, are having diagnoses of terminal anorexia. It is happening. I refer him to Professor Agnes Ayton, the campaigner Hope Virgo and the eating disorders all-party parliamentary group in this place, which is looking at that. It seems bizarre to us, because of course someone can resume eating, but the fact is that anorexia is treated as a terminal illness in parts of the NHS today.

[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.

[Kit Malthouse]

Just to clarify, what I said earlier was slightly incorrect—I misread my briefing. While the hon. Lady may be right that the court decided not to proceed with force-feeding, a number of those applications were by the individual to stop the force-feeding. While the court decided that, on balance, that was the right thing to do, in all those cases since 2012 the individual was not found to have capacity to make decisions about their own condition; the decision was made by the court for them. That means that, under the terms of the Bill, they would not qualify. Some of those cases were quite complicated. A number of them, as I read it—

--- Later in debate ---

[The Chair]

To some extent, there is an issue here of repetition. Standing Order No. 42 gives me the power to stop potential repetition. I do not want to use it—I do not want to interfere with the debate—but I am afraid we are getting to the point of repetition. If I need to invoke Standing Order No. 42, I will.

[Naz Shah]

I thank the right hon. Member for his intervention, but my understanding is that the judge found that those individuals lacked capacity to make decisions about their treatment; whether they had the capacity to decide to end their life is a completely different test. I apologise in advance for repeating this, but it is not something that we have tested. They had the capacity to refuse. The judge ruled that they could not be force-fed. Tragically, in nine cases, while not force-feeding those young women would lead to their death, the judge insisted that force-feeding would not be in their best interests. That is what happened in those cases.

[Kit Malthouse]

I stand to be corrected, but my understanding is that in the seminal case that the hon. Lady is talking about, the case of The NHS Trust vs. L, the court decided not to force-feed L because the prognosis was that force-feeding would precipitate her death.

[Naz Shah]

I thank the right hon. Member for his intervention. I have talked about that case, and the court concluded:

“The prospects of her recovery overall approach zero… Given that it is extremely unlikely that Ms L will recover from her anorexia it is…in her best interests to”

move to palliative care, as it was considered a terminal illness. In some ways, that makes my point for me: she was diagnosed as terminally ill. The purpose of the amendment is to close that loophole. The majority of these cases are young girls and young women. I do not want them to get to a stage where they qualify under the Bill because they have a terminal illness due to refusing food, because that can be treated. That is the point that I am trying to make.

Let us say that only one or two people with anorexia have an assisted death if the Bill becomes law without my amendment. I hope that every member of the Committee would agree that even one such death would be unacceptable. Some might say, “Oh, but we must not make the perfect the enemy of the good.” That has been said in the debate, or sentiments have been expressed that reflect that sentence.

That is a good argument to make when we are trying to persuade our teenagers to finish their homework for school and so on. It does not wash for me when we are trying to create a Bill with the strongest possible safeguards for vulnerable adults, and it is too close to the arguments made in favour of brutal actions across the globe. We say things like, “To make an omelette, you’ve got to crack a few eggs.” If we want to make the Bill the best it can be, we cannot use such arguments. Perfection is not the enemy of the good—perfection is absolutely what we should be pursuing in this Committee.

Reference was made to one of the witnesses who gave oral evidence. I remember being aghast at the idea that these two people who died in Oregon were somehow a red herring and that there had been only two. It was really disappointing, and I was extremely angry at that comment. That is not something we should be doing or the standard we should be setting. We cannot be saying that.

There is nothing good about letting people who have sadly reached an advanced state of malnutrition be given assisted dying. Surely we can agree on that. If this Bill does not include my safeguard, it will do two things. First, it will increase the dangers of anorexia. People already develop anorexia to such a degree that they perish of malnutrition. Allowing such people to apply for assisted dying will mean that more severe anorexics die. If we do not adopt my safeguard, we run the further risk that those who are not anorexic, but wish to hasten death, stop eating in order to qualify for an assisted death. Both of those would be truly malign. I would hope all Members of the Committee will accept my amendment to protect those who would otherwise be at risk of starving themselves to an assisted death.

I also want to bring to the Committee’s attention a public letter that has been released this afternoon by nearly 40 individuals who work in the field of eating disorders. They have said, on the amendment to which I am speaking:

“This amendment states that mental illness alone does not qualify as a terminal illness, but as the legal text (“Nothing in this subsection…”) makes clear it has no effect beyond restating that the condition must meet the requirements of clause 2(1). If a doctor holds that a mental illness meets the test in clause 2(1) for terminal illness, this amendment will do nothing to prevent that.”

They further say:

“Eating disorders are treatable. They are life-threatening when left untreated or poorly treated, but this risk is preventable, and deaths from eating disorders are not inevitable. As campaigners, clinicians, charities, and organisations working with those affected, we urge the committee to take these concerns seriously and ensure this bill does not put people with eating disorders at risk of premature death under the guise of assisted dying.”

On my amendment 402, they say:

“Amendment 402: Explicitly states that a person cannot be deemed terminally ill because they have stopped eating or drinking.”

On amendment 48, they say:

“Amendment 48: Clarifies that a person is only considered terminally ill if their death is reasonably certain within six months, even with all recommended treatment.”

They are supporting those amendments, 9, 10, 48, 402 and 11. On that note, I will finish.

[Sarah Olney]

I rise briefly to speak against amendment 234 in the name of my good and hon. Friend the Member for Harrogate and Knaresborough. I will keep it brief as I know he is not going to press to a vote.

First, the Bill that was voted on on Second Reading was a Bill for terminally ill adults in the last six months of their lives. I do not believe attempting to amend the scope of the Bill in Committee is what the House has asked us to do. I think the House voted for a Bill that was specifically for people within the last six months of their lives and that to be amending it—although I accept he is not putting it to a vote—is not in order.

Secondly, I want to reflect on Professor Sir Chris Whitty’s oral evidence to the Committee about how difficult it is to determine when somebody is within six months of the end of their life and how much more difficult it would be to determine whether someone is within the last 12 months of their life, notwithstanding that we are talking about a very specific category of people. For me, that really does give rise to the fear that we would not be able to make a specific determination on whether somebody was in the last 12 months of their life. There would be a risk that people actually have many years left to live. In the case of motor neurone disease, for example, we have seen prognoses of between two and five years, so we risk shortening people’s lives unduly. Furthermore, people might not want to make the prognosis, and therefore people who would like to have the right to end their life in their final 12 months because they have a neurodegenerative disorder might be denied that right, because it is impossible to come to such a determination.

--- Later in debate ---

[Danny Kruger]

I accept that, which is why amendment 282 is probing only. It is trying to demonstrate the point. I recognise that even the expedited process is likely to take up to a month to get through, so that would be difficult. Nevertheless, if our intention is to restrict this to people who are literally in their last days, which is frequently what we hear, I think it would be appropriate to restrict the time.

[Naz Shah]

The hon. Member talks about the amendment being probing. Does he know why we went for six months? Was it was based on research? I am not sure whether he is aware or can help me understand that.

[Danny Kruger]

I am not. I think we have allowed six months to creep into common legal parlance because of the Social Security Contributions and Benefits Act 1992; we now recognise in law that it is possible to have certain rights and entitlements on the basis of a six-month prognosis. I presume that is the basis of it. It does feel like a reasonable period, and I understand the rationale for it, but given the difficulty of prognosis and the intense seriousness of what we are doing, I think it is inappropriate and dangerous.

Another way of achieving greater safety—less precise but perhaps more generous to people who want an assisted death—is to tighten the definition of terminal illness to mean those whom doctors think it is reasonably certain, rather than reasonably expected, will die within six months. That is the intent of amendment 48 tabled the hon. Member for Bradford West. The amendment also insists that the condition is terminal even with “all recommended treatment”, so that somebody could not make themselves eligible by refusing treatment. That is a very important point that the hon. Lady is trying to insist on.

By the way, that does not mean—and I hope people will not conclude that it does—that someone is required to have every treatment that might be possible, including invasive and unpleasant chemotherapy. The point is that it would have to be treatment recommended by the doctor: if the doctor recommends it, then it is appropriate. A doctor might be offering chemotherapy, but they would not be recommending it in all circumstances.

For the avoidance of doubt—an important phrase— I think that the hon. Lady’s amendment 402 is very important too. Just in case nutrition is not seen as treatment—perhaps it is arguable that it may not be—it is very important that we specify explicitly that declining food or drink does not qualify someone for an assisted death.

[Naz Shah]

Does the hon. Member agree that one point that is really important in this afternoon’s debate is that a person has a right to refuse treatment, and indeed food and water, if they have capacity, but that malnutrition is practically reversible? The argument has been made by doctors in Oregon around the voluntary stopping of eating and drinking that doctors cannot legally force a person with capacity to eat, and if they refuse food, their condition can be considered irreversible and terminal. That is the crux of the point. Does he agree with me?

[Danny Kruger]

I think so. The hon. Lady is absolutely right that there is this difficult loophole that somebody may have capacity and be refusing food and drink and would therefore potentially be eligible. In the Bill as it stands, we have an expedited process for people whose prognosis is only a month. There, the 14-day waiting period could be reduced to just 48 hours. If a person stopped eating and drinking, their death would almost certainly happen within a month. In other words, a person who is not terminally ill could make themselves eligible for an assisted death within 48 hours simply by refusing sustenance. It is very important that we recognise that and explicitly exclude it.

I will refer quickly to other jurisdictions where this specific situation occurs and the voluntary stopping of eating and drinking is used to qualify for legal drugs. A peer-reviewed article in the Journal of the American Geriatrics Society discusses this case—it may be the one referred to earlier. The authors noted that if anyone can access VSED—voluntary stopping of eating and drinking—then anyone can qualify for medical assistance in dying. In Colorado, 12 people qualified for assisted suicide based on a diagnosis of severe malnutrition.

The American Clinicians Academy on Medical Aid in Dying, an organisation of doctors who provide assisted suicide, acknowledges this loophole. Its guidance states that

“there is nothing in the letter of the law”

to prevent voluntary stopping of eating and drinking from being used in this way. It adds that that would

“essentially eliminate the criteria of terminal illness,”

because a person could always qualify as having terminal illness if they stopped eating and drinking. That is obviously not what the Bill’s sponsor and drafters wish. I hope they will consider accepting the amendment to close that loophole.

I will not repeat points made very eloquently by my hon. Friend the Member for Reigate, but I echo the need to ensure that the Bill is not for conditions that, although they cannot be reversed by treatment, can nevertheless be controlled or substantially slowed. I will therefore support the amendments in the name of my hon. Friend the Member for South Northamptonshire.

I pay tribute to the hon. Member for Harrogate and Knaresborough and to the people he speaks for in tabling amendment 234. I recognise absolutely that the MND Association has pointed out that the six-month rule would not work for all MND sufferers. It successfully persuaded the last Government to change the rules on benefits in recognition of that point, and its evidence to us, it has requested a clear and workable definition for assisted suicide. It was not very clear on what that would be, and there are practical problems with extending to 12 months, specifically the one we have with six months—the difficulty of prognosis, which would be twice as bad. I also refer to the evidence from Professor Sleeman, who made the point that a non-neurologist would find it particularly difficult to make an accurate 12-month prognosis for MND.

The main reason to object to the principle of the amendment—I appreciate that the hon. Gentleman is not moving it, but it is an important principle to discuss—is that it makes no sense at all to have two different prognosis periods. Of course, we can see where it will go. The fact that the amendment has been tabled and selected, that it is in scope, and that people will support it in this Committee or beyond, or outside Parliament, is evidence of where things go. We saw it very clearly in the evidence we heard from witnesses from Australia, who pointed out that there is no logical reason to have two prognoses—one for cancer and one for neuro-degenerative disorders. Their response was, “Well, let’s make it 12 months for everyone,” and of course that is the way things would go.

I finish with a tribute to the great quixotic effort of my hon. Friend the Member for Runnymede and Weybridge, who is not on the Committee. Runnymede is the home of Magna Carta; the spirit of liberalism lives on in my hon. Friend, a genuine liberal who wants to scrap the period of prognosis altogether, because he genuinely believes in absolute autonomy. I have been trying to make the Bill live up to its claim to be a Bill for safeguarding; he wants it to live up to its claim to be a Bill for autonomy. In principle—in logic—he is absolutely right. If we think that some people should have access to suicide assisted by the state, then why should person A get it and not person B? Needless to say, I disagree with him.

--- Later in debate ---

In some cases, a terminal illness progresses more slowly, and as we heard in evidence, prognosis is not an exact thing. If a dying person’s terminal illness progresses more slowly than might have been expected, they are delighted. They do not think, “Well, I have this approval, so I am going to access assisted dying anyway.” I feel like some of our debate has missed the essential humanity of people at the end of their lives, as though, just because people are able to do something, they will. That is as much about autonomy, dignity and respect as anything else we are talking about in this debate.

[Naz Shah]

My hon. Friend is making a powerful speech, and I agree with what he says about autonomy. As I said earlier, autonomy does not necessarily have to lead to pain, and it could be that I do not want to get to that stage. People will never know whether they could have lived longer. Does he not agree?

[Lewis Atkinson]

Sensible amendments have been tabled elsewhere in the Bill—not to the clause that we are debating—that would strengthen the initial conversations and ensure that people make informed decisions and have access to, and conversations about, all the forms of support, psychological or otherwise. I think that those will address my hon. Friend’s point.

In terms of the eligibility criteria, Chris Whitty was clear that there is diagnostic uncertainty in both directions. He said that

“a significant minority of people die before they actually get to the point”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 37, Q15.]

of the six-month prognosis. Because of that uncertainty, if we attempted to make the criterion much less than six months, we would end up excluding people. From all the conversations I have had, it is clear that once people have a terminal diagnosis, they want to put their affairs in order; doing so means that they can enjoy their final months with their families. We must not reduce eligibility and limit access to those whose disease unfortunately progresses more quickly than they would like and the prognosis suggests. I therefore oppose amendment 48, in the name of my hon. Friend the Member for Bradford West.

The amendment talks about “recommended treatment”. In all my years in the NHS, shared decision making has been a key principle. No one other than the person in question can make the decision about what trade-off they are willing to accept. Invasive chemotherapy may have a 20% chance of elongating my life. Am I willing to accept a 20% chance? Am I willing to accept a 30% chance? What I decide is right for me may be different from what other individuals decide, so a doctor is not in a position to say, “You should accept this because it will give you a 10% chance,” or, “It will give you a certain level of pain that I’m willing to accept.” We each have to make those decisions ourselves.

[Naz Shah]

Will my hon. Friend give way?

[Lewis Atkinson]

No, I will make some progress.

I feel that the amendment risks pressuring people to accept courses of intervention against their will, and I do not think it is consistent with the important principles of autonomy and consent. Because of the safeguards, approvals and reflection periods built into the Bill, going through the process of approval will clearly take in excess of a month. That is why amendment 282, in the name of my hon. Friend the Member for York Central, which would limit the eligibility to one month, is fundamentally not compatible with the safeguards in the Bill, as my hon. Friend the Member for Spen Valley made clear. To me, six months is absolutely the right balance. It reflects people’s wish to put their affairs in order and allows for prognostic uncertainty on the downside—someone given six months may actually only have two or three months to live—but it still allows the operation of robust safeguards and reflection periods.

I turn briefly to the other amendments. I commend my hon. Friend the Member for Broxtowe for the points she made. I share the concern that replacing “inevitably” with “typically” would risk weakening the definition of “terminal illness” and expanding access to other conditions. I fear that “typically progressive” is a weaker interpretation, so I cannot support the change, because I support a tightly drawn Bill with tightly drawn eligibility criteria. For the same reason, although I have sympathy for the amendment tabled by the hon. Member for Harrogate and Knaresborough, I think it goes beyond the scope of what the House discussed in November and the contours of the current debate.

Amendments 9 and 10 refer to disease being controlled or substantially slowed. Those are not recognised medico-legal terms. What is the definition of “substantially slowed”? Who would define it? Is it something that takes 20%, 50% or 100% longer? We talk about the risk of inserting undefined terms and of court interpretation, and I fear that introducing such an amendment would give rise to that.

The people best placed to make decisions about whether the treatment will suitably slow the progression of the disease are the dying people themselves. They are the only people who should do that—fully informed, of course, by their medical and clinical teams. Each of us, when the end is nigh—it will come to me, as it will to us all—has to make that decision ourselves, not on the basis of a recommendation mandated in law or some definition of “controlled” or “substantially slowed”. It feels that the legislature would be putting in primary legislation decisions that I should make about the treatment that I should accept, so I am not in favour of those amendments.

I finish with reference to amendment 402. Although earlier I wanted to make progress, I do not want to rule out any further interventions, if my hon. Friend the Member for Bradford West or others would like to come in. I recognise the concern, and we need to talk about people with anorexia with the respect, dignity and seriousness they deserve. I have heard it said—I think my hon. Friend said it—that there is nothing in the Bill to stop that being the case, and I fundamentally disagree for many reasons. First, as the Bill sets out, capacity is checked eight times. The Court of Protection has repeatedly found that people with anorexia do not have the capacity to make decisions about stopping eating. Although a best interest test may have been made, that is not relevant, as set out in the Bill. People have to have the capacity to request an assisted death, checked eight times. My hon. Friend the Member for Spen Valley has already set out that she is minded to accept—or will accept—amendment 6 to clause 9(3)(b), so that, if there is any doubt about capacity, a psychiatric opinion “must” be sought.

Like my hon. Friend the Member for Bradford West, I considered the written evidence saying that, in instances of a patient with anorexia, psychiatric input is absolutely necessary. Absolutely—in every case where someone has anorexia, under an amended clause 9, psychiatric opinion must be sought as to capacity. That is before we get to the further set of amendments to clause 12.

[Naz Shah]

In the cases that went before the court, the judges, in nine out of 10 cases, found that all those young ladies did indeed have capacity to refuse their food, and it was as a result of that that their deaths became inevitable. Will my hon. Friend comment on that?

[Lewis Atkinson]

That is not my understanding, and I have sought some clarification, including from Professor Hoyano, who provided oral evidence to us, and I believe that that was not her understanding either.

Given the “must” in clause 9 regarding psychiatric referral to a third tier panel—which, let us remind ourselves, is not in place in any of these jurisdictions from which figures are cited around potential deaths of people with anorexia—I feel there are significant safeguards. Furthermore, we have just agreed to amendment 399 tabled by the hon. Member for East Wiltshire, clarifying the “medical condition” piece, which provides a further safeguard.

I respect the need for us to consider these matters carefully, but I urge a degree of holistic thinking when we talk about individual clauses. Some of the statements being made—that there are no protections in place—just do not fly, to me, given the Bill as a whole.

--- Later in debate ---

Amendment 282 is similar to amendment 48 but would require the co-ordinating doctor and the independent doctor to have “reasonable certainty” that a person can be expected to die in consequence of their inevitably progressive illness or disease within one month, instead of six months, even if that person were to undergo all recommended treatment. As with amendment 48, this carries risks of making the assessment of a person’s prognosis more complicated from the point of view of the assessing doctors. I have already set out why that can be challenging. It is an established principle that a patient with capacity must always retain the right to refuse treatment, if that is their wish.

[Naz Shah]

I apologise to my hon. Friend the Member for Sunderland Central; I was actually incorrect. The girls did not have capacity, so he was correct. However, in the cases that went before the court, those nine girls did not have capacity yet the judge made a decision that they should not be force-fed to keep them alive, and they should be allowed to die. Perhaps the Minister could comment on how the amendment would not meet that criteria. Would it fix that loophole?

[Stephen Kinnock]

I thank my hon. Friend for her intervention. I am just talking about the amendment to reduce the time from six months to one month. I will come on to the issue of eating and drinking in a second.

As amendment 282 would reduce the time within which the person is expected to die from six months to one month, it would also limit the number of people with a terminal illness who would be eligible for assisted dying under this legislation. Furthermore, there may be very challenging workability issues in delivering a service within one month, given the other time-dependent safeguards elsewhere in the Bill.

Amendment 51 would remove the requirement for the patient to have a six-month prognosis to be defined as “terminally ill”. If agreed to, it would expand the pool of people eligible for lawful assistance to voluntarily end their own life beyond those with a life expectancy of six months or less. In other words, it would remove the timeframe requirement of when death can be reasonably be expected.

Amendment 234 would widen eligibility to include cases of neurodegenerative diseases, illnesses or medical conditions where a person is reasonably expected to die within 12 months. Matters such as this are for the Committee, and ultimately for Parliament, to decide, but it is clear that the effect of the amendment would be to broaden the number of people eligible for lawful assistance to voluntarily end their own life under this legislation.

Amendment 10 would provide that, if treatment exists for a person’s progressive illness, disease or medical condition that alters the overall prognosis of that person’s condition, they are not terminally ill and would not be eligible for assisted dying services.

Amendment 402 would exclude a person who would not otherwise meet the definition of “terminally ill”—namely, being diagnosed with an inevitably progressive illness with six months or less to live—if that person meets that definition as a result of stopping eating or drinking. The effect of the amendment would be to prevent a person from being defined as “terminally ill” as a result of their own actions of stopping eating or drinking, or both. The Government’s analysis suggests that this may also exclude people who are terminally ill under the definitions of the Bill and who are, for various reasons, unwilling or unable to eat or drink. For example, it may include those with conditions such as oesophageal cancers, which could result in their being unable to eat or drink.

Furthermore, it is unclear whether someone who is on intravenous fluids or being fed through a feeding tube would be considered to have stopped eating or drinking under the amendment. I think that addresses the concern expressed by my hon. Friend the Member for Bradford West, but she is welcome to intervene again if she would like to. The amendment could therefore lead to uncertainty over the person’s eligibility for assistance under the Bill.

The Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could be changed. Questions around the definition of terminal illness and who should be eligible to access voluntary assisted dying under the legislation are matters for the Committee and for Parliament as a whole. However, I hope that these observations are helpful to the Committee in considering the Bill and the amendments tabled by various Members.

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

Naz Shah Excerpts

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Dr Opher]

Yes, I totally accept that. The Mental Capacity Act is set so that we assume capacity and look for evidence of lack of capacity. The great danger with the amendment is that it would change a whole raft of very well used provisions. As Professor Whitty said, the Act is used up and down the country every day; I have used it myself many times, and taught it as well. If we change the emphasis from the presumption of capacity to the presumption of incapacity, which is what my hon. Friend is suggesting, that is a major change in the Act.

[Naz Shah (Bradford West) (Lab)]

Given what my hon. Friend has just said—that he accepts the premise of my hon. Friend the Member for Bexleyheath and Crayford that the doctor would have to assist—can he help me to understand where that leaves the issue of autonomy if a doctor is, as he has agreed, allowed to assist in the decision?

[Dr Opher]

The way the doctor assists, if making a mental capacity assessment, is to try to tease out the four concepts. Does the patient understand what they are being asked to agree to? Sometimes mental capacity assessments are very straightforward and last five minutes; sometimes they last an hour. I have done one that lasted about 90 minutes because it was really important to tease out whether the patient genuinely understood what they were doing. That is the sort of assistance I am talking about. It is not about trying to persuade them to make a decision that I think is the right decision; it is just making sure that they understand it, can remember it and so on.

[Naz Shah]

How does my hon. Friend respond to not one, not two, but multiple witnesses, including the Royal College of Psychiatrists, saying, absolutely contrary to what he is saying, that the Mental Capacity Act is not the right bar and that the bar is too low?

[Dr Opher]

Well, that was disputed by other psychiatrists. We are asking questions about whether the Mental Capacity Act is safe and correct for the Bill. This whole Committee is about making the Bill safe. None of us would dispute that. However, I think that if we accept the amendment, the Bill will become less safe because the amendment would change a massive piece of legislation and therefore have a number of repercussions that we do not understand.

--- Later in debate ---

[Dr Opher]

I understand what the amendment is trying to do; my argument is that it will not achieve that because it will muddy the waters of a mental capacity assessment, which will make how we do it less safe. I would also like to return to Professor Whitty’s comments and to say that in the majority of cases mental capacity is very clear. It does not actually take very long to assess whether someone has mental capacity.

[Naz Shah]

Will the hon. Gentleman give way?

[The Chair]

Can the hon. Gentleman be allowed to fully answer the questions that the hon. Member for East Wiltshire and the hon. Member for Richmond Park asked, before we have an intervention on another point?

--- Later in debate ---

[Dr Opher]

It is really important to understand that for the majority of people mental capacity can be assessed reasonably quickly because it is very clear whether they have it or do not have it. What we are talking about, I think, is a small proportion of patients in which it is unclear whether they have mental capacity. There is scope in the Bill for those circumstances, when the patient should be referred to an enhanced level of mental capacity assessment by a psychiatrist or a psychological nurse. In that way, it makes it much safer. We do not need to redesign the Act for that small number of patients because we already have a very safe route to assess capacity.

[Naz Shah]

I thank the hon. Gentleman for giving way; he has been generous with his time. I do not know whether the hon. Gentleman has seen the evidence from Alex Ruck Keene KC on mental capacity. He sets out very clearly the myths around mental capacity, one of which is that mental capacity is well understood. He argues that it is not. How would the hon. Gentleman respond to that?

[Dr Opher]

I think that in most cases mental capacity is very well understood, and it is very clear, as I have said. I would say that, as practising clinicians, almost every GP has to do it. I would not sign up a doctor in training if they could not do it. I think it is a little bit rich to suggest that we cannot assess capacity. I agree with many of the comments that have been made about assessing capacity in more difficult cases for most doctors, and I think we do need an avenue, in those situations, to get further opinions.

[Naz Shah]

The hon. Gentleman said it would be rich for people to say that capacity cannot be assessed. That is not the case. I am not convinced about that, and I am not sure, from the evidence I have seen, that anybody is saying that anybody is not capable of assessing capacity per se. Would the hon. Gentleman agree that the argument is about assessing capacity for this Bill in particular? That has not been tested. The Royal College of Psychiatrists is very clear, as are many other experts, including legal experts, that the Bill has not been tested for that purpose. Therefore, the Mental Capacity Act does not meet the purpose for the Bill.

[The Chair]

Order. I will give people the opportunity to explore this issue but, as I have said, interventions are not mini speeches.

--- Later in debate ---

[Naz Shah]

I will pick up on some of the points to which my hon. Friend the Member for Stroud referred, given his expertise. We heard from three senior psychiatrists during the evidence sessions, who were very clear; I have already mentioned much of their evidence. The Royal College of Psychiatrists’ written evidence states:

“It is the RCPsych’s view that the MCA is not sufficient for the purposes of this Bill. Extensive consideration needs to be given to what an assessment of mental capacity should consist of for AD/AS prior to the passing of legislation and, indeed, whether a determination through such an assessment can be reliably arrived at in this novel context.”

It goes on to say that the capacity to end one’s life is “entirely different” from assessing for the capacity of deciding treatment.

The Bill moves us into new territory. We need a definition that meets the criteria of what we are assessing, which is to end one’s life. That has never been applied in this country. The Mental Capacity Act, as it stands, requires assessors to presume that someone has capacity until incapacity can be proven, as my hon. Friend the Member for Bexleyheath and Crayford referred to in moving amendment 322.

Dr Annabel Price, Professor Allan House and Professor Gareth Owen all expressed doubts about the use of the Mental Capacity Act to assess whether a person is in a fit state of mind to undertake assisted dying. Because there is nothing in the current medical assessment that requires careful explanation of these factors, there is a real worry that there will be no opportunity to change them. It is outside the experience of the Mental Capacity Act, the Court of Protection, the associated research and practitioners on the ground.

Professor Owen said:

“I have looked at mental capacity a lot in research, and there is no experience”.

The reference to the Mental Capacity Act in clause 3 puts us into an area where there is no experience of the central capacity issue under consideration. He said:

“It is very important that Parliament be clear-eyed about that.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 226, Q287.]

He further said that we are in “uncharted territory”, because the ideas in the Bill are very novel. That is the hub of the Bill: it requires assessors to assume capacity as a starting point. To make the Bill the safest in the world, that is not the yardstick that we should be applying, according to very senior psychiatrists across the country.

Alex Ruck Keene KC also provided evidence to the Committee. He set out some of the myths in a video. There are a few things in this for me. One is the article in The Telegraph, which senior psychiatrists alluded to, that suggested there was a shortage of specialist psychiatrists. We have already had a conversation about the shortage of judges, but we are now having a conversation about the shortage of psychiatrists. Should the measure remain in the Bill as it stands? I would like to understand from the Minister whether that is something that has been assessed, given that we do not have an impact assessment.

Alex Ruck Keene referred to the National Institute for Health and Care Research, which funded a number of research projects in 2022 under the umbrella topic of implementing the Mental Capacity Act in practice—the rationale being that

“The Mental Capacity Act…is designed to empower and protect people who may lack the mental capacity to make their own decisions about their support and treatment, ranging from everyday issues to more serious, life-changing decisions.”

Evidence has highlighted several aspects of the way that the assessments are being carried out that are not compliant with the Mental Capacity Act. If we already have issues with how the Act is being implemented in the everyday work of the NHS and psychiatrists, how many mistakes will be made if the Bill goes through as it is? How much potential is there for mistakes to be made when assessing the capacity of those who are most vulnerable?

The Care Quality Commission in its most recent “State of Care” report in October last year said:

“The Mental Capacity Act 2005 (MCA) directly affects the lives of millions of people. Everyone providing care to people over the age of 16 must be familiar with this vital piece of legislation, which introduced rights and protections for people who may lack mental capacity. A decade after the House of Lords report, we continue to find a lack of understanding of the MCA among providers.”

That is the most recent research, and it is telling us that we have not got this right.

The Mental Capacity Act was passed over 20 years ago in 2005, but is still not understood properly or being applied for the reasons it was supposed to be. If we have not got that right in 20 years, how can we as a Committee be assured that the legislation will be applied properly when it is applied to something that it has never been applied to before and that has not been tested? How can we say that we should be rejecting an amendment that would change that and raise the bar for people? Ultimately, this affects people who are vulnerable; I will come on to that in more detail in the next group of amendments.

That is a real concern, which is why I urge Committee members to support amendment 322 to get the safeguards right. We spent hours talking about capacity, but the amendments to clause 1 were not accepted. This amendment comes from experience, and I really appreciate the personal experience of my hon. Friend the Member for Bexleyheath and Crayford on this issue, because he speaks about the reality. We are not the experts, and we should be relying on the experts who give us their witness testimony.

[Daniel Francis]

In the evidence from Mencap and in large swathes of the written evidence, we have heard grave concerns from communities representing people with learning disabilities about how this legislation was enacted during covid, particularly with “do not resuscitate” notices. Evidence shows that people with learning disabilities were far more likely to have those placed on them. The written evidence we have suggests that that is due to a misinterpretation of the Mental Capacity Act or bias within the medical community. Can my hon. Friend comment on that?

[Naz Shah]

My hon. Friend makes a very valid point. Another issue that we have not got to yet, but that we will be looking at, is the doctors who do not want to take part in this process. We must consider whether there will be a bias; he is right to point that out. Will there be a subconscious bias towards helping people? My hon. Friend the Member for Stroud suggested earlier that doctors assist a person to reach a decision, according to the Mental Capacity Act. This is the crux of it for me: when a doctor is assisting a person in their best interests to come to a decision about treatment, for example, that is a different test from what we are testing here.

[Lewis Atkinson (Sunderland Central) (Lab)]

I share the concerns of my hon. Friend the Member for Bexleyheath and Crayford about the use of DNRs—what happened during covid to people, particularly those with disabilities, was a disgrace. Does my hon. Friend the Member for Bradford West accept that this is an entirely different situation, however, in that people must actively seek it, be tested multiple times, and express a wish for it? The situation with DNRs involved medical professionals making decisions on behalf of a patient without their input.

[Naz Shah]

I thank my hon. Friend for his intervention. I will be speaking to that in the next group of amendments, so I do not want to go through it in detail now, but I absolutely accept that that was a disgraceful situation—

[The Chair]

Order. Can Members please address the Chair?

[Naz Shah]

Apologies. My hon. Friend is right that those were different situations, but I remind him of the evidence that we heard from Dr Jamilla, for example. I am glad that he reminded me of this point, because although what happened in covid was done under different circumstances—I agree that what happened with DNRs was a “disgrace”, in his words—that is where the trust in NHS providers was lost. That leads me on to my next point: where there is no trust, there is vulnerability, and that vulnerability, in turn, affects capacity.

That brings me to what Alex Ruck Keene said about vulnerability. If people feel—as they did during covid-19—that they have been DNR-ed and that, as some have said, “They’re going to kill us off!”, then the vulnerability directly impacts on their capacity. I accept that, as my hon. Friend says, these are different situations, but the argument is strong and speaks to supporting this amendment.

There is a myth that mental capacity is well understood, but we have gone through that—there are a lot of myths about mental capacity. The reason that mental capacity is always difficult to assess, according to Alex Ruck Keene, is because 85% of capacity determinations by those who actually understand the law are relatively straightforward—that concurs with the point of my hon. Friend the Member for Stroud—with difficulty arising usually because of not having enough time or not listening to the person. Some research was conducted into the experience of liaison psychiatrists through an interview study across three jurisdictions, which concluded that there are four key sources of difficulty in capacity assessment, spanning both clinical and ethical domains.

Those four sources included, first, a difficulty determining whether the decision is the patient’s own or driven by illness. That is important because we are talking about people who are terminally ill, so their decision-making processes may be impacted because of that, or because there is a vulnerability—either could be possible. The 15% of mental capacity determinations that are difficult include for such people. There may also be, secondly, a difficulty in applying ethical principles or, thirdly, a difficulty in avoiding personal bias. Again, that speaks to the point of my hon. Friend the Member for Bexleyheath and Crayford—if doctors are already signed up to this Bill and believe in it, will they have a personal bias? A lot of doctors and psychiatrists—according to the last article I read—are saying that they do not agree with it.

--- Later in debate ---

[Danny Kruger]

The hon. Lady is absolutely right. It is an interesting irony of the Bill that it is presented as the free choice of individuals, but actually it imposes all sorts of obligations and repercussions on other people—the very term “assisted” conveys that. Many other people will be affected by the decision to take an assisted death. She is right that it would be very helpful for the doctors to be confident that they have done their job properly because they have a clear list of communications they are expected to make.

My understanding is that doctors are indemnified against legal challenge in consequence of decisions they make around this; that is an interesting point and one that I am uncomfortable with, but we will come to that later in the Bill. Leaving lawsuits out of it, from the point of view of the doctor’s professional conduct and their peace of mind, it would be very helpful for them to have it clearly specified what information they are required to convey.

I am grateful for Members’ interventions, and I appreciate the good faith and good sense that has been spoken, but I have not yet heard any reason for objecting to this amendment, other than the possible question of its being otiose and not necessary. That is not a sufficient reason to object to an amendment. We should not be objecting simply on drafting grounds. There can be tidying-up exercises later if there is repetition. I have not heard objections to the content of the amendment, and I would very much welcome Members’ support.

[Naz Shah]

Does the hon. Member agree that the amendment ultimately aims to provide clarity, and that clarity ultimately leads to safety?

[Danny Kruger]

Exactly. A few more words of clarification should not be regarded as burdening the Bill or creating bureaucratic obstacles for doctors and patients; the amendment actually specifies more explicitly what is going on. It is almost akin to the debate we had on amendment 181 and those dangerous words “for the avoidance of doubt”; that is essentially what this amendment does, but it goes further, because it imposes clearer obligations on doctors to do their job properly.

[Jake Richards (Rother Valley) (Lab)]

Much has been covered today, and the issue of capacity was debated at length when the Committee considered clause 1, but I do have some observations.

I am sympathetic to the assertion that there should be changes to presumption and burden. Those are things that I have considered and spoken about with the promoter of the Bill and, outside the Committee, with experts who gave evidence to the Committee. I have spoken about them publicly as well; I am very sympathetic.

At the heart of this, we have two options. We could change the burden and presumption in the Mental Capacity Act 2005 for the purposes of assisted dying, rewriting 20 years of case law and medical practice. There is certainly some value to that, but that would be a radical departure from current medical practice, and there are other concerns. The alternative is to put in place rigorous processes and training around the Mental Capacity Act to ensure that it is implemented properly. After some reflection, I err on the side of the latter option, for a number of reasons.

First, I accept that there is debate among psychiatrists about this issue. We heard evidence from some who deem the Act not to be suitable for this new realm—I accept that we are entering new grounds, and I will come back to that point—but many psychiatrists and lawyers working in this area would deem it uncomfortable and unnecessary to depart from the Act.

Secondly, there is an oddity in changing presumption. There is an oddity in someone having to prove that they have capacity to fulfil their own desire. That oddity is one of the reasons that the Act is drafted as it is. It is partly—there are two sides to this coin—to ensure that there is no discrimination, partly to comply with the Human Rights Act 1998 and human rights more generally, and partly to ensure that we do not end up in a medical situation that is patrician, whereby medical doctors take an intrusive view of capacity rather than meeting the individual as they are.

Thirdly, the Bill, when amended—I will come on to the amendments that give me some comfort—will offer more safeguards than the Mental Capacity Act. Amendment 5 to clause 9(3) would ensure a further level of assessment. My hon. Friend the Member for Spen Valley has indicated that she will support that important amendment, as have all members of the Committee. If there is any doubt, there will be a further assessment by a psychiatrist. That goes some way to reassuring me that it is not necessary to rip up the burden or change the presumption in this area.

I want to make an observation about burden of proof, presumption and the nature of the assessment. Professor Whitty clarified his evidence. It is right that the burden and the presumption do not change, but of course the nature of the assessment rightly changes according to the circumstances. Every assessment of capacity is somewhat different, which is why amendment 50 is too prescriptive, in my view.

Of course, we can consider incredibly serious cases involving deprivation of liberty or the ability to conduct litigation. I have worked with parents whose children are being removed and looked at whether they have the capacity to make decisions about how they present their case. It is very dangerous to compare the severity and the profound nature of different circumstances, but let us not pretend that the Mental Capacity Act is not used to assess the most complex issues of capacity every day.

I am very sympathetic to amendment 50. I have met the hon. Member for Runnymede and Weybridge, who tabled it, and the hon. Member for Solihull West and Shirley to discuss it, but I stress that such a prescriptive provision is not appropriate for primary legislation when we are entering new ground. I accept, as hon. Members with different views have said, that we are entering new territory and that this is difficult. I accept that psychiatrists and medical practitioners will have to think long and hard about the nature of the capacity assessments, especially under clause 9(3), when that is activated. That work will have to be done. It has been set out in primary legislation through some of the training clauses, which have already been referred to.

There is no doubt that there will be a lot of work and consideration, but I do not deem it appropriate to have a clause drafted by one psychiatrist, albeit an undoubtedly esteemed and experienced one: the hon. Member for Runnymede and Weybridge, who tabled the amendment. Rather, the work needs to be done as the Bill is implemented over a two-year period. It needs to be done as part of a full consultation with psychiatrists, once the Bill has been passed, and that should be set out in guidance. That is what would usually happen with deprivation of liberty. I do not think it appropriate for primary legislation to set out the factors for a capacity assessment.

[Naz Shah]

My hon. Friend is saying that that will take two years. The MCA, which has been implemented over 20 years, is misunderstood. Does he not see the risk of two years? This is new territory, without change—

[Jake Richards]

We need to be careful when we say that the Mental Capacity Act is misunderstood, full stop. Let us be clear—

[Naz Shah]

Not full stop.

[Jake Richards]

Well, that was the sense—

[Jake Richards]

I am grateful, Mr Dowd.

The evidence that we have received is that this is a test. These are assessments that happen every day across the country. Now, there are more complex assessments, and there will without doubt be areas in which the assessment is not done as rigorously as it should be done, but that is why I am assured by the safeguards in the Bill that if there is any doubt—any doubt—as to capacity at first instance, there will be a full and thorough assessment by a psychiatrist.

Let us think that through for a minute. Any competent psychiatrist trained in this area will no doubt have a sense of what the Mental Capacity Act says and of the normal test for capacity. Someone who is seeking assistance to die from a doctor who has doubts as to their capacity will have been referred. To my mind, it is unfathomable that that assessment, at that stage, would not be rigorous and would not satisfy every Member that it had been done to the correct extent practicable.

[Naz Shah]

I absolutely agree with my hon. Friend about that in most cases, but in nine of the 10 cases that went to court, young girls were found to have capacity, but their treatment was stopped, leading to their inevitable death. That is not excluded here.

[Jake Richards]

We are debating lots of different things now, rather than just clause 3. There is an issue as to whether in those cases the individuals were found to have capacity, but we are talking about the process by which someone is found to have capacity, rather than what happens thereafter. We have had that debate, and I am happy to have it, but we are talking now about the process by which people are found to have capacity.

This is the problem with interventions: I have lost my train of thought. This is why people do not take them.

--- Later in debate ---

[Jake Richards]

Yes, there are safeguards and mechanisms in the Bill to ensure that and to protect from a culture that would incentivise this practice.

[Naz Shah]

Will my hon. Friend give way?

[Jake Richards]

No, I am not going to, actually. I am taking my rights.

My final point concerns section 1(4) of the Mental Capacity Act and the discarding of the principle about whether a decision is deemed to be unwise. This is an issue we have already debated, but it is really important. Introducing a best interests test is, to my mind, impossible without ending up with a law that discriminates against certain groups. Essentially, it is impossible to do fairly.

I remain to be convinced. If there were an amendment that could do what I think the hon. Member for East Wiltshire wants, I would support it. If there were an amendment that could look into someone’s mind and make sure that they are doing this for reasons that society would deem fit, I would support it, but I think that that is impossible. What the Bill aims to do is assess a person’s capacity and ensure that they are making this decision voluntarily. It also aims to protect them from the influence of third parties and outside sources. That is the only way, if this principle is to be adhered to.

Finally, I will be voting against the amendments, but I will finish where I started. I have genuinely thought long and hard, in particular about the presumption. I have spoken to experts who disagree with me, but in my mind it comes down to whether we rip things up and start again or whether we add rigorous safeguards, practices and processes, which may be a bit more boring but will actually be more effective at protecting any patients who go down this road.

[Sojan Joseph (Ashford) (Lab)]

I rise to speak in support of the amendments. Having worked as a mental health nurse for 22 years, I completed mental capacity training many times in my career, and I carried out capacity assessments as part of my day-to-day job. I think that the capacity assessment proposed in the Bill is not safe enough. That was one of the main reasons I voted against the Bill on Second Reading. I have spoken to many people who oppose the Bill, and one of their concerns is about the capacity assessment.

We have talked about capacity assessments every day in this Committee. It is one of the key issues that we will need to resolve to strengthen the Bill if it goes through. One of the Royal College of Psychiatrists’ concerns is that capacity decisions are

“opinions with a margin of error and are time specific. A person’s capacity can change”.

I will talk about my experience with those margins of error.

A person’s capacity can be influenced by various factors, including their life circumstances, the medication they are taking or severe pain. Suicidal thoughts due to their mental state or depression can also influence their capacity. I have worked in acute mental health units. Every day, we carried out capacity assessments, including before we let someone out of the ward, whether they were admitted under the Mental Health Act or were receiving treatment as a voluntary patient. If somebody wanted to leave the ward, before the member of staff opened the door, they had to assess that person’s capacity. Sometimes a person might have said, “I am going to kill myself,” and the nurse would have had to decide whether or not they had capacity before opening the door.

My hon. Friend the Member for Bradford West has talked about unconscious bias. The initial capacity assessment when a person comes to a hospital is very important. If a doctor has assessed at the beginning that the person has capacity, the following assessment can be influenced by that initial assessment. I totally agree with my hon. Friend’s argument about unconscious bias in capacity assessments. As Members have mentioned, the Bill proposes many occasions in the process when capacity will be assessed, but I am still not confident that each capacity assessment will not be influenced by the initial assessment. The amendments would strengthen that area of concern.

[Naz Shah]

My hon. Friend is making a very important speech. Members have alluded to the provision in the Bill that the patient would be present and would potentially have an option to be reassessed. We have heard evidence from various experts on capacity, particularly on the issues of coercion and vulnerability, and doctors have told us that it takes years to build rapport with people. At the second stage, the doctor has to be somebody independent who nobody has met, so how would they be able to tease out whether that person has capacity and whether those other influences are affecting them? Does my hon. Friend share that concern?

[Sojan Joseph]

I agree that when an independent doctor comes to assess a patient’s capacity and sees them for the very first time, they are more likely to be influenced by the assessment made at the beginning by the doctor who has known them for many days, weeks or months. I agree with my hon. Friend’s argument.

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

Naz Shah Excerpts

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Naz Shah (Bradford West) (Lab)]

Does my hon. Friend agree that the GMC writes this in detail for the purposes of treatment? The Bill is not about treatment, so therefore there is a difference in its very nature.

[Lewis Atkinson]

No, I do not agree. The GMC guidance in many ways talks about not accepting treatment. It is equally as useful in situations involving the withdrawal of treatments and the end of life. Fundamentally, it goes back to the point that I made in my speech yesterday on informed decision making and the autonomy of the patient. They have to be informed, whether they are seeking treatment, the withdrawal of treatment or no treatment at all.

--- Later in debate ---

[Stephen Kinnock]

What we are talking about today with this Bill—and the job of this Bill Committee is to improve the Bill—is a number of safeguards that ensure that the patient is absolutely consulted and positively and constructively engaged every step of the way. In that sense this is different from the situation my hon. Friend describes. I bow to his expertise as a medical practitioner in this field, and it sounds as though what he has described is not an ideal situation, but certainly this Bill, it would appear, has safeguards that ensure that the situation he describes should never arise.

[Naz Shah]

Building on the intervention by my hon. Friend the Member for Ashford, in most cases where life-support machines are switched off, by definition people are being supported to stay alive. In most cases, I would argue, they do not have the capacity—their capacity is not tested. The Minister appears very certain that the amendment would not be workable, but how can the Government be so certain of that, in the absence of any impact assessments on the workability of the Bill in the first instance?

[Stephen Kinnock]

I thank my hon. Friend for that intervention. Fundamentally, the balance of judgment of risk is based on whether, if we add additional words, phrases and amendments to a piece of legislation, it would have the result of decreasing the risk we are trying to address, or of increasing that risk. The Government’s view is that the Mental Capacity Act is a robust foundation for the decisions and processes set out in the Bill. Hon. Members are, of course, absolutely welcome to say that they do not believe that the Mental Capacity Act does what it should be doing and that that is why they have tabled amendments. However, the Government’s view is that the proposed changes would increase the risk of somehow creating a parallel framework to the Mental Capacity Act, rather than keeping it as the foundation. The system is very familiar with it and knows how it works, and that is the best way to minimise the risks that I think all hon. Members are keen to minimise to the greatest extent possible.

--- Later in debate ---

[Stephen Kinnock]

Without knowing the exact implications for the number of people who the hon. Member mentioned, it is difficult to answer her question, but fundamentally the Government’s position on every aspect of the Bill is to be clear that we want the Bill Committee to make informed decisions. Those informed decisions should be based on whether the Government think that amendments to the Bill would have a positive or negative impact on its workability and the legal framework. We also have to ensure that we protect the integrity of the statute book.

[Naz Shah]

I thank the Minister for giving way for what might not be my last intervention. Everybody agrees that the legislation is new—it is not something that we have done before—so have the Government made any assessment of the training that would be required for people who deliver assisted dying? Who would set that training?

--- Later in debate ---

[Danny Kruger]

I recognise that it is an attempt to give maximum leeway to doctors. I think that is dangerous and puts doctors in a very difficult position. The BMA made the point that it is appropriate to enable doctors to raise this option as if it were just another treatment, even though it has also said it is not just another treatment.

I would challenge the BMA with the Medical Defence Union, which is the union that supports doctors in litigation. It points out, more correctly, that this is the worst of all worlds for doctors because they would be liable to complaints in either situation: if they do not raise it, a complaint can be made against them for not having done so; and if they do raise it, a complaint can be made against them on those grounds. We are being extremely unclear by leaving it entirely up to doctors. As I have said, it is not clear to me the circumstances in which it would be appropriate for a doctor to suggest an assisted death to somebody who has not raised it themselves. I would very much like to hear somebody tell me what those circumstances might be and to paint a scenario for us in which it is appropriate.

[Naz Shah]

Surely all medical codes of practice explicitly or implicitly bar doctors from raising courses of action that they believe could unquestionably harm a patient. Does it therefore not follow that doctors only raise courses of action for patients that they believe will not unquestionably harm them, even if they believe some courses of action are more likely to be in the patient’s best interests?

[Danny Kruger]

That is absolutely right. Either this is a medical treatment—in which it should be obligatory for a doctor presented with a patient who qualifies under the Bill and has the symptoms that we are talking about to say, “By the way, there is also this option”, which is what I think my right hon. Friend the Member for North West Hampshire is suggesting—or it is not a healthcare treatment at all. Clause 4(1) states that they do not have to raise the subject, in which case they should not raise it, because to raise it is to put it on a par with other healthcare options and therefore implicitly, or indeed pretty explicitly, to say, “This is an option that might be good for you”, which is an enormous communication to make.

I go back once again to the difference between this and withdrawing treatment. I have to say this so many times because it is so important: this is not equivalent to withdrawing treatment because this is not specific to the illness being treated. A person can have a treatment or not, and that will address the condition that they are suffering from. The termination of life does not address someone’s symptoms, treatment, condition or illness; it kills them. It is a different order of intervention. I do not think it is a healthcare treatment at all, and it should not be treated as such.

--- Later in debate ---

[Daniel Francis]

It is a pleasure to serve under your chairship, Mrs Harris.

Of the three amendments in my name, I come first to amendments 319 and 320. Clause 1 outlines that the legislation relates to a terminally ill person who

“is aged 18 or over at the time the person makes a first declaration”.

It does not, however, refer to the age that an individual needs to be at the time of an initial discussion in line with clause 4. The definitions in the Mental Capacity Act, which have now been agreed as part of the Bill, relate to those aged 16 and over. Given that we have now accepted that, I presume that the discussions referred to in clause 4 could be held with 16 and 17-year-olds.

I appreciate that there will be different views on the matter, in relation to autonomy, but I think that even some of the strongest supporters of the Bill will be uncomfortable with those conversations being undertaken with someone as soon as that person turns 16. My amendments seek to make sure that the Bill includes the strongest possible safeguards, by ensuring that the relevant aspects of the Bill relate to those who have attained the age of 18. Surely it would make sense that if a person has to be 18 to agree to the first declaration, they also have to be 18 to have the initial discussion.

I now turn to amendment 339, which stands in my name. As hon. Members know, this issue has been a great preoccupation of mine on the Committee. I know that my hon. Friend the Member for Penistone and Stocksbridge wishes to comment on the matter, and I am aware that there may be concerns about some of the wording in the amendment, but it was tabled following the oral evidence we received from Mencap and was, in the initial instance, in the wording that Mencap requested.

I remind hon. Members of the evidence from Mencap. Dan Scorer talked to us about two principal concerns, initially. One was about preliminary discussions, and how the initial conversation is initiated and structured is a key area that Mencap has concerns about. He said that for Mencap

“that really leads into a conversation around rights to advocacy. It would be extremely concerning if people with a learning disability who were terminally ill were not fully prepared and supported for that discussion…For us, this links into the experiences that we had during the pandemic, which were touched on in yesterday’s evidence session by Dr Griffiths and others. We had people with a learning disability who were being consulted by medical professionals about ‘do not resuscitate’ or ‘do not treat’ decisions, and they were not being properly prepared for or supported in those discussions.”

He went on to say that Mencap wants to see

“a right to advocacy included within the Bill to support people considering their end of life options.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 269, Q350.]

We then move into the domain of amendment 8—tabled by my hon. Friend the Member for Blackpool South (Chris Web)—on initial discussions. As Dan Scorer told us, Mencap’s concern is about how discussions around assisted dying are initiated:

“For many people with a learning disability who are terminally ill and in an incredibly vulnerable position, doctors are very important and influential figures. Having a doctor come to you and say, ‘What do you think about assisted dying—is that something you might want to consider?’ could move them towards or into potentially accepting a course of action that they had never considered before.”

That is why he then went on to talk about advocacy supporting that discussion, saying:

“Individuals should be able to choose who supports them with those discussions, whether it is friends or family members or an independent advocate”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 273, Q355.]

In concluding, he said he felt that some of that

“would reduce the risk, which is absolutely there, that people could take the initiation of that discussion as a statement, ‘This is what you should do.’”.

He said Mencap’s position was:

“We absolutely do not want people to be in that position. We want strong safeguards and support in place if the Bill becomes law.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 280, Q366.]

It is no secret that my greatest concerns relate to capacity and supporting those with learning disabilities. As well as my earlier two amendments, I will press my amendment 339; I hear that there may not be a vote on it. I also want to touch on amendment 368, in the name of the right hon. Member for East Hampshire (Damian Hinds), as it also feeds into the conversation about the initial discussions.

There are swathes of written evidence from the Down’s syndrome community. The written evidence supplied by Lucienne Davies from Get On Down’s states:

“There is an obvious worry about informed consent for people with learning disabilities. As a group we are fully aware that people with Down syndrome are extremely vulnerable to the intentions and suggestions of caregivers, health professionals and authority figures, informed consent is therefore a major concern in end-of-life decisions.”

The Down’s Syndrome Research Foundation UK also emphasised the issues that arose during the covid-19 pandemic, when

“we saw a deluge of temporary changes sweep away many safeguards and rights. During the pandemic, individuals with learning disabilities, including those with Down syndrome, had a death rate of six times higher than average. It is not known how much the actions of health professionals played into this, but there are some disturbing concerns.”

The Portsmouth Down Syndrome Association has listed a whole range of concerns. It says that standard practice has not been followed with this Bill. I know that the hon. Member for East Wiltshire has mentioned some of this, but the association’s evidence says:

“Typically, the government recommends a 12–16-week period for public consultations to ensure comprehensive input and discussion. This Bill has not adhered to this standard, compromising the depth and quality of the consultation process. Rushing the legislative process has led to insufficient public engagement, overlooking diverse societal values and ethical viewpoints.”

The evidence goes on to lay out concerns about vulnerability to coercion, challenges in assessing capacity, ethical implications, misinterpretation of wishes and an over-emphasis on disability.

The all-party parliamentary group on Down syndrome has provided us with a lengthy submission. Again, I will not go into great detail on it, but it mentions expert consultation, the legal requirements and the challenges in front of us, those medical capacity considerations, the vulnerability of individuals with learning disabilities, additional complicating factors and ethical challenges, and, again, the learning disability mortality rate.

My intention is to press the three amendments in my name, amendments 319, 320 and 339. I have concerns, as many people do, about the discrepancy between the wording in clause 4 and in later clauses, in relation to the age requirement of 18. I look forward to the debate on amendment 339, which relates to learning disabilities; other amendments on the topic may well come forward in due course.

We have heard very clearly the concerns from the Down’s syndrome community and from Mencap about learning disability and the role of advocates, family members and carers. It is incumbent on us to listen to that advice and ensure the strongest possible safeguards for the people who are most vulnerable in this conversation. We must ensure that those safeguards are in the Bill.

[Naz Shah]

It is an honour to follow my hon. Friend the Member for Bexleyheath and Crayford. I rise to speak to amendment 8, which stands in the name of my hon. Friend the Member for Blackpool South (Chris Webb), and amendment 276, in my own name. I note that the hon. Member for Solihull West and Shirley spoke to amendments 8 and 124, which overlap and complement each other, although they are slightly different.

Before I get to the crux of why the Committee should support amendment 8, it may be helpful to spell out what it would do. Currently, clause 4(1) reads:

“No registered medical practitioner is under any duty to raise the subject of the provision of assistance in accordance with this Act with a person.”

The amendment would change that to:

“No registered medical practitioner shall raise the subject of the provision of assistance in accordance with this Act with a person who has not indicated to that or another registered medical practitioner that they wish to seek assistance to end their own life.”

In a nutshell, that would mean that a doctor could not be the first person to raise assisted dying with a patient. The patient would have to raise it first, either with the doctor who had the initial discussion or with another doctor who referred the patient onward.

I urge Members to support the amendment, because it would provide another safeguard for vulnerable people. Many people affected by the Bill will be isolated; many will be poorly informed on medical matters and reluctant to ask questions of doctors.

[Jack Abbott]

My hon. Friend makes the case that some people will not be given the full range of medical options available to them. Presumably, though, the amendment would limit that even further, because they will not be able to understand assisted dying fully unless they have raised it themselves. We are actually restricting the full range of medical options for those people.

[Naz Shah]

That is not what I am trying to get to here. Maybe there is some confusion on my part; I will make it clear as I carry on. The issue is that people already know that assisted death is an option in the wider context, just like when we talk about abortion, as my hon. Friend the Member for Broxtowe pointed out earlier. I am supporting amendment 8 because it further safeguards people, as the practitioner cannot be the one to raise it. Perhaps if I continue with my speech, my hon. Friend the Member for Ipswich may find his answer. We can come back to it if necessary.

As I was saying, many people will be poorly informed on medical matters and reluctant to ask questions of doctors. Many will have capacity under the Mental Capacity Act but, as we have heard from my hon. Friend the Member for Bexleyheath and Crayford, they will have greater capacity to take some decisions than others. For all those people, there is a danger that if a doctor raises this subject first, they will hear it not as a neutral comment, but as a suggestion. Not all of them will hear it as such, but some will.

Although not all expert witnesses who appeared before us endorsed that view, it is a concern that some raised. Others took a different view, such as the British Medical Association, which wants doctors to be able to raise assisted dying. It gave several reasons in its written evidence:

“Doctors should be able to talk to patients about all reasonable and legally available options…Doctors should be trusted to use their professional judgement to decide when and if a discussion about assisted dying would be appropriate, taking their cue from the patient as they do on all other issues…A prohibition would also create uncertainty and legal risks for doctors, which may inhibit effective doctor/patient communication and understanding.”

We cannot simply adopt or reject the amendment because of what the experts say. Instead, we must go through the arguments that the different experts made and consider which we find most convincing. It is our responsibility as legislators to make this decision. Personally, I found the voices raising concerns to be deeply convincing.

As with all this Committee’s inquiries, we must look at everything from the angle of safeguarding those who are vulnerable across society. For example, if someone is isolated, with very few close relatives or friends, and if they feel that they cannot challenge what the doctors say to them, they will be deeply trusting of or even dependent on their own doctor. That is not to say that we should be cynical about doctors, who are giving vital support to our most vulnerable citizens; it is to say that we have to look at the reality.

There is one kind of relationship between a confident and socially well-supported person and their doctor. For some who may lack confidence and have little or no social support, that relationship may well be very different. That point was repeatedly stressed by senior doctors who gave evidence to the Committee. We heard from witnesses that they do not think that this is a hypothetical danger.

Let me remind hon. Members of some of the expert witnesses who told us about the real risks posed. Dr Rachel Clarke, a palliative medicine doctor at Oxford, said:

“If, for instance, you say to a vulnerable patient who has just been told they have a diagnosis of terminal cancer, ‘Have you thought about assisted dying?’, I would suggest that stating it broadly like that is a form of pressure and that you are potentially unintentionally coercing that patient. The very act of raising assisted dying in that way will make that vulnerable patient think, ‘God, is this doctor telling me that my life is not worth living any more?’ Autonomy is much more subtle and complicated than we assume from outside.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 75, Q93.]

[Jack Abbott]

My hon. Friend makes a powerful point, but I would gently point out, as has been said already this afternoon, that the conversations between doctor and patient will not be that straightforward. A range of options will be presented to the patients. I do not think it would be a case of “Here is the option of assisted dying. This is your only option.” There will be a huge range of options on the table, as is right and proper.

[Naz Shah]

It is the right and proper thing to do to give options, but we are talking about vulnerability. We have had the debate a few times now about people with vulnerability, and we heard during evidence sessions about coercion, capacity and all the issues relating to amendment 8 in respect of those with vulnerabilities being presented the option of assisted death. When I speak to my next amendment, I will cover some of this, because the Bill does not necessarily leave us with confidence that vulnerable people will be safeguarded. That is what amendment 8 also seeks to address.

Dr Rachel Clarke is a doctor who spends every working day with people who need palliative care. Her evidence cannot be laid aside. Dr Jamilla Hussain, who also gave evidence, is in favour of assisted dying in principle, but she raised significant concerns about the Bill as drafted, including on this issue. Dr Hussain said that her patients in Bradford have reduced access to palliative care, partly because they fear that doctors might try to end their life. She talked about how she worked with

“not only ethnically diverse communities, but those who are socially disadvantaged…I have taken this Bill to them and they have made it really clear—this is not just one community, but several, and I am not speaking on my behalf, but on theirs—that they are really fearful because this is what happened to them in covid. It affected everyone, but it affected some communities disproportionately because our services are not equitable. That could profoundly affect their healthcare, and not only in terms of end-of-life care. They are saying, ‘We will not even come to hospital ourselves, because we are worried that this would happen.’ This is not an academic or theoretical risk. We saw it happen in covid in Bradford. There were communities so worried that their loved ones were dying in hospital that they stayed at home and died earlier.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 190, Q247.]

Perhaps in some cases they died a death that could have been preventable. Dr Hussain said that it is “not a theoretical risk.”

Dr Hussain also said:

“The risk for somewhere like Bradford, where we are doing okay—we have a long way to go—is that the Bill creates a fear in those communities. I have been going out and trying to build trust—being trustworthy—and they made it really clear to me by saying, ‘We trust you; we don’t trust the system. So if I came into hospital, even if your team was there, I would be really scared to access palliative care.’ In a system that is doing okay, we are now adding this new risk. We need to mitigate against that.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 199, Q259.]

That is what we need to do. We need to listen to what the doctors who are treating vulnerable patients say about the risks to those people.

[Lewis Atkinson]

My hon. Friend will recall that we heard evidence from doctors from Victoria, which has a so-called gag clause; I think it was Dr Furst who said that that was “really problematic”. What does my hon. Friend make of the guidance from the Victoria Government? It states that under that clause a patient who asks a doctor, “Can you give me all the options?” is not allowed to discuss assisted dying; indeed, if a patient says, “Isn’t there something you can do to help me put an end to this?” the doctor cannot discuss assisted dying either. Does my hon. Friend agree that that is an example of a gag clause being deeply unhelpful to doctor-patient discussions?

[Naz Shah]

I am not sure that the amendment would be that kind of gag clause, so I disagree. If a patient says, “Give me all the options to bring an end to this,” the judgment of the doctor could be that assisted dying is an option. If that is the case, perhaps we need to look to the Government’s and Ministers’ wash-up process. When we are tidying up this Bill, I am sure that there will be plenty of opportunities for the Government to put in the significant words that safeguard patients. That is my feeling, but I thank my hon. Friend for his intervention.

[Danny Kruger]

The clear implication of the amendment is that if the patient requests to know what can be done to end their life, that is an invitation to raise the option of assisted dying; if they ask the doctor about what can be done to deal with the pain, symptoms and illness, they should be offered information on that. I am afraid that it comes back to the distinction between its being a healthcare option and not being a healthcare option. Does the hon. Lady agree that the evidence from Australia is clear that the minute there is a law like this, there will be challenges to the safeguards? Each safeguard will be seen as a barrier to a human right and a barrier to access. That is what the Australians told us.

[Naz Shah]

I agree that that is what the evidence shows us, and there are many concerns in other jurisdictions as well. I will come back to that distinction.

[Jake Richards]

The evidence that I have heard, both in Committee and from other sources, shows that the gagging clause leads to complete absurdities. Doctors feel completely unable to look after their patients and inform them of their options, and this leads to conversations that involve winks and nods. That is exactly what the Bill is trying to stop. Does my hon. Friend agree? I sense not.

[Naz Shah]

Unfortunately, I do not agree. I do not even agree with the term “gag clause”, which has been used a few times now. From where I stand, this is not a gag clause; it is an amendment that protects those who are most vulnerable. In Committee I have referred continuously to the most vulnerable, as have other hon. Members, and I will return to the evidence from Dr Jamilla Hussain. I do not agree with my hon. Friend’s position.

We need to listen to what doctors who are treating vulnerable patients say about the risks to those people, and then we need to amend the Bill to reduce those risks. Bluntly, there is a choice here. The British Medical Association says that if the Bill becomes law, doctors should be able to raise the subject of assisted dying with patients. Palliative medicine doctors such as Rachel Clarke and Jamilla Hussain, who deal with this every day, are deeply concerned by that prospect, and they want us to avoid it. There is no papering over this: the doctors disagree and it is up to us—the Committee— as lawmakers, and this House, to decide which of them makes the stronger case.

I genuinely think that the BMA makes a strong case. There is no doubt in my mind that it is motivated by empowering doctors to give the best possible care to their patients. It is natural that the BMA looks at existing practice among doctors. Currently, doctors can discuss all possible treatments and pathways with patients—the key words being “possible treatments and pathways”—so the BMA makes the case that that should also be true for assisted death.

In the end, however, I cannot agree with the BMA for one reason: assisted dying will be qualitatively different from every previous kind of medical intervention that has been legally permitted in this country. We have never permitted doctors to legally assist patients to take lethal drug combinations with the sole purpose of ending their lives. Some things really are different from what has come before; if the Bill becomes law, assisted dying will be one of those things.

--- Later in debate ---

[Kim Leadbeater]

In the interests of balance, would my hon. Friend also acknowledge the testimonies we heard from Dr Jane Neerkin, Dr Sam Ahmedzai and other palliative care specialists who had a very different view?

[Naz Shah]

I do acknowledge that, but ultimately I am a Member of Parliament for my constituency of Bradford West, and we have a doctor who has been doing research with its communities. I come from a community where there is huge deprivation: Bradford West has two of the most deprived wards, and one of the youngest populations. During covid, people there were DNR-ed—so they do not have that confidence.

I accept that others may have different opinions, but I come back to the point that I made earlier: which case is more convincing? Do we raise the safeguards? Dr Jamilla supports assisted dying but she made it clear that, although she supports it for some people, who may well benefit from assisted death, the truth is that there are people who the Bill fails to protect. That is what I am speaking to, and that is what amendment 8, tabled by my hon. Friend the Member for Blackpool South, speaks to.

The Committee is talking about people who are facing the ends of their lives. On every day of their working lives, doctors who have spoken to this Committee talk to those people. They are treating exactly the kind of patients who may seek assisted dying if the Bill becomes law. They are deeply concerned that if doctors raise the subject of assisted dying with their patients it will, in too many cases, seem like a suggestion.

I appreciate that this is a private Member’s Bill and not a Government Bill, but that places an even heavier burden on us to get things right. We cannot ignore the testimony of those who have the most relevant experience. Too many Government Ministers, MPs and local councils from all parties, including mine, have done that in recent decades.

For example, the sub-postmasters and sub-postmistresses said for years that the Horizon system was not working, but Ministers from my party, and from the Conservatives and the Liberal Democrats, said that they were wrong. Time and again, they were dismissed. Ministers thought that they knew more than the people who were using Horizon on a daily basis. Now we know exactly who was right.

Similarly, for three decades, several thousand NHS patients, mainly haemophiliacs, claimed that they had been negligently given transfusions of blood infected with hepatitis and HIV. Minister after Minister, first from the Labour Government of the ’70s, then from the Conservatives, then Labour and then the Conservatives again, insisted that no such thing had happened. Some conceded that perhaps it had happened—but on a small scale. In 2017, to her credit, the then Prime Minister Theresa May announced a public inquiry into those claims. It turned out that the patients were right and the Ministers had been wrong.

That is what I am talking about. Several highly experienced palliative medicine doctors warned us—

[The Chair]

Order. I remind the hon. Member that while her arguments are valid, she needs to come to the end of her examples.

[Naz Shah]

I have just finished that example, Mrs Harris.

Several highly experienced palliative medicine doctors have warned us that doctors raising assisted dying with patients would have two very harmful effects. The doctors said that it would scare patients away from palliative care, especially those from minority communities or disadvantaged backgrounds. They also warned that in some cases, if a doctor raised the subject of assisted dying with a vulnerable patient, that person would not hear it as a possibility being discussed; instead, they would hear it as a suggestion from a powerful person who, in some instances, they might be scared to challenge.

The question we have to ask ourselves is: are we going to be that Committee that ignored the evidence of the experts who deal with this issue on a daily basis on the frontline with those very people at the end of life who the Bill is actually aimed at? Or are we going to risk being part of a future assisted dying Bill scandal because we placed ourselves above those experts by supporting a view of a wider body? That body has very valid reasons—no doubt—from its own position but is not, in its entirety, a frontline delivery expert, as palliative care doctors are.

Those warnings are too stark for me—for any of us, I submit—to ignore. We cannot ignore the concerns that those doctors have raised. If any Committee member accepts the concerns of the experts, that a vulnerable person would not hear assisted dying as a possibility being discussed but instead as a suggestion from a powerful person, I sincerely hope that they will vote in favour of this amendment.

I turn to amendment 276, which I tabled. It would add a subsection to clause 4, which concerns the initial discussion between a person with a severe illness and a medical practitioner. This new subsection would impose a pause or an interval of 28 days between a person receiving a diagnosis and prognosis of the illness that might end their life within six months, and when they could speak to a doctor about assisted death. Currently, there is no such interval. I tabled this amendment in response to the concerns raised by several senior and experienced doctors in evidence to this Committee.

Several doctors who gave evidence—especially the psychiatrists—noted that a diagnosis of serious illness often leads to a major increase in depression and a desire to hasten death. However, on depression and the desire for death, the psychiatrists also said that when a patient gets treatment for their physical symptoms alongside social care and sometimes psychological treatment, that person may well change their mind. This amendment aims to prevent people from opting for assisted dying while they are suffering from the initial shock of having a serious illness diagnosed.

Let me talk in more detail about some of that evidence. In particular, I will bring the Committee’s attention back to Dr Annabel Price, vice chair of the liaison faculty at the Royal College of Psychiatrists, who has great expertise in this field. I will quote from her evidence at some length, because she talks very clearly about the evidence that we have about the effect of a diagnosis of serious illness on somebody’s mental health. Her evidence raises very important concerns about how the Bill, as it is written, would affect patients who have just received a diagnosis of serious illness. She said that

“if we think about people with palliative care needs towards the end of life—so the people who would qualify under this Bill—around 20% will have diagnosable depression, around 10% will have a wish to hasten death, and around 4% will have a more persistent wish to hasten death. Those wishes may not be expressed unless they are assessed for. One of the things that I would do in my clinical practice would be to look for treatable mental disorder in people who express a wish to hasten death.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 270, Q351.]

Dr Price went on to say:

“There is a lot of research evidence around depression in people with palliative care needs and people nearing the end of life. We know that depression is common, and across a number of studies it is at around 20%—much more common than in the general population. We know that depression is strongly associated with a wish to hasten death, and that if depression is found and treated in that group of patients, there will be significant change in the wish to hasten death.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 275, Q359.]

Dr Price also went further and said:

“There are a number of associations other than depression with a wish to hasten death, and they include difficult symptom experience, poor functional status—needing a lot of help with things—and being socially isolated. Those are really key ones. They also include a sense of loss of dignity and feeling like a burden on others. These things can all come together to make life feel very unbearable. We know that there is also an overlap between a wish to hasten death, which is a response to suffering, and feeling that one is better off dead, ending one’s own life or harming oneself. I was involved in a study where we asked people both the wording of “a wish to hasten death” and the suicide question from the PHQ9, which is a depression screening tool. Those who had a wish to hasten death were 18 times more likely to also feel suicidal, according to the psychiatric definition, than people who did not have a wish to hasten death. There is a strong association.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 275-276, Q359.]

I have quoted Dr Price at length because she sets out clearly some of the problems we need to address before the Bill will be fit for purpose. From her evidence, we know that when people receive a diagnosis of a serious illness with a prognosis that they may have around six months to live, that has serious psychological effects. We also know from her evidence that one of those psychological effects is what she called an increased desire to “hasten death”. She said that, in some cases, this means that the patient becomes “suicidal”, while in others it may not mean that the patient is suicidal, because they do not want to positively do something such as killing themselves, but they do wish that death would come to them sooner. It should be clear to us that a desire to hasten death will certainly be relevant to the decisions of any patient who wants a discussion on assisted dying.

Finally, and perhaps most importantly, Dr Price provided evidence that if a patient’s desire to hasten death increases immediately after the diagnosis of a serious illness, it is likely to decrease once several things have happened. In a psychiatrists’ survey of patients, they found that the desire to hasten death often decreased once the patient had time to reflect on their diagnosis and prognosis; once they had received adequate medical care; once they had social care to allow them to live their day-to-day lives and, in some cases, to relieve their isolation; or in some cases, once they had psychiatric support and adequate pain relief or intervention to relieve them of their pain. In practical terms, we have evidence that a patient who has just had a diagnosis of serious illness with a prognosis of possible or likely death within six months would be more likely to want to die.

[Sojan Joseph]

The amendment would add a 28-day period between the diagnosis and the start of the conversation about assisted dying. Having listened to hon. Members speak and given the evidence that we have heard, does my hon. Friend think that patients should have not only a 28-day gap, but access to a psychiatrist before the discussion of assisted suicide should start?

[Naz Shah]

My hon. Friend no doubt speaks from his experience of being a mental health nurse. I think there is space for that, and there are amendments that we will come on to when we talk about later parts of the Bill that deal with those initial conversations. I will be happy to address that issue then. I also welcome any more support that he can offer on those conversations based on his expertise.

As I was saying, in practical terms, we have evidence that in many cases, although not all, that desire will fall once a patient has had time to think through their diagnosis and once they have had good medical care for their illness or condition, and, in some cases, psychiatric support—a holistic package, perhaps even with social work intervention. Surely all Members would agree that we should give seriously ill people, who have just had such a shocking diagnosis and prognosis, time to think and to receive good medical care before they start the process of applying for assisted death. That surely applies to those of us who voted for the Bill on Second Reading every bit as much as those of us who voted against.

I will put it as plainly as I can: there is a significant risk from the Bill that people will be shocked by their initial diagnosis and prognosis, and, in that shocked state, will be more likely to apply for assisted dying. There is also evidence, however, that if they were to pause between the diagnosis and applying for assisted dying, they would be much less likely to have an increased desire to hasten death. This amendment would not be a perfect protection for people suffering from the shock of their initial diagnosis and prognosis, but it would be a clear safeguard that would protect many of them.

I want to make it clear that I was probably 60% against and 40% in favour of the Bill on Second Reading; I want to see a stronger Bill, with protections for the vulnerable. There is a significant group of vulnerable people who this Bill would put at increased risk—those who might take a decision to apply for assisted dying that, if they had had time to consider it and to receive medical and social care, many would not have taken. I ask hon. Members to support my amendment.

[Dr Tidball]

It is a pleasure to serve under your chairship, Mrs Harris. I will be supporting amendments 319 and 320 tabled by my hon. Friend the Member for Bexleyheath and Crayford. I am a great admirer of my hon. Friend’s work in championing people with learning disabilities, and his mission to give them a strong voice in this Bill. It is an area very close to my heart, having spent over a decade and a half working with people with learning disabilities and the advocacy organisations that support them.

I will, however, not be supporting my hon. Friend’s amendment 339, merely because I am drafting something to strengthen those measures even further. My amendments will go beyond amendment 339 and amend the code of practice so that seeking advocacy and access to an appropriate adult applies across the pathway to those seeking assistance, not merely in relation to the content of clause 4, as in that amendment.

I want to ensure that access to an independent advocate or appropriate adult is expanded to cover those with autism, a learning disability or a mental disorder, which is not currently covered by amendment 339. That will enable those people to engage with any of the provisions under this Bill through the support that they would receive from an independent advocate or appropriate adult.

As I say, I am also seeking to strengthen access to such advocacy across the pathway, through seeking assistance at each stage. I have huge respect for my hon. Friend, but I want to make sure that we specifically include the language of “mental disorder”, to make sure that that particular group of people with mental health problems is able to access independent advocates, as well as those with learning disabilities and autism.

I am also looking at whether we need a consequential amendment or new clause that would make the Secretary of State put in place provisions for regulations as to the appointment of persons as independent advocates in order to ensure that those seeking assistance under the legislation who have a learning disability, autism or a mental disorder can have proper access to such advocates. That would strengthen the resource provision and access for that group.

I have worked closely with Mencap on the amendments that I am drawing up and will continue to do so, and I would welcome input from my hon. Friend the Member for Bexleyheath and Crayford. Although I support his intent in principle, I will be tabling amendments to cover a broader group of individuals to access such appropriate adults and independent advocates, so that they can seek and access advocacy across the pathway and period of seeking assistance. My amendments would put access to appropriate adults and independent mental health advocates on a much firmer footing in the Bill.

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

Naz Shah Excerpts

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[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.

--- Later in debate ---

On the part of the amendment about the treatment available and the likely effect of it, those are the discussions we have. We sometimes say to people, “Well, you can go for further chemotherapy. It will often make you sick and you might lose your hair”—we give all the disadvantages—“but it might give you another couple of months of life.” Those are the general discussions we have as medical practitioners.

[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.

--- Later in debate ---

[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.

[Naz Shah]

Will my hon. Friend give way?

[Lewis Atkinson]

No, I am going to make some progress because I am conscious of the time, and we want to get through these provisions.

I want to speak in favour of amendments 108 and 183. Those two amendments, taken together with amendment 275, create additional safeguards and assurances on the points made by colleagues on Second Reading that this is not cannot be raised in isolation—as my hon. Friend the Member for Spen Valley has made clear should not be the case—and that referral should always be offered to specialists in palliative and wider care.

As others have said, those patients will almost undoubtedly be in touch with a variety of different multidisciplinary healthcare teams. The suggestion that there must be a further referral to another multidisciplinary team under the Bill, regardless of which teams an individual is seeing, is therefore not appropriate. I also refer Members to amendment 6 to clause 9, which states that a referral to a psychiatrist “must” be made. My hon. Friend the Member for Spen Valley has indicated that she is in favour of that amendment. That reinforces the fact that there will be a multidisciplinary approach, including psychiatric input, where there is any doubt before the third-tier stage of the panel.

For those reasons, I do not feel the other amendments—285, 343 and so on—are necessary. By accepting amendments 275, 108 and 183, we will be able to strengthen the Bill in the way that was set out to the House, and as we heard in oral and written evidence.

--- Later in debate ---

[Sojan Joseph]

There are other people who support this concept, and they are the people who will be having the conversation—we have both sides of the argument. I believe that the best person to have that preliminary discussion would be the doctor who knows about that patient the most—about their circumstances, prognosis, family situation and pain. We talk about compassionate care, but where is the compassion in here? I am not saying that another doctor would deny that—but I am talking about compassion. Someone going through the most difficult time in their life would have the confidence to talk to the person who knows the most about them, which is why I fully support that the initial discussion should happen with them. I am not saying that they should say yes or no, but they should be talking about the care provisions and options available to the patient. Amendment 342 is one of the most important amendments we will debate.

I will move on to amendment 425. When I tabled amendment 1, my thinking was that a psychiatrist should be involved in these discussions, but I think amendment 425 will safeguard most of the concerns we have discussed in previous sittings. Amendment 425 talks about a “multidisciplinary team” and having a psychiatrist involved as well. Written evidence was sent to us on 29 January by the Royal College of General Practitioners, which recommended that a separate pathway that

“covered every stage of the process would ensure healthcare professionals of multiple disciplines…who wanted to do so could still opt in to provide assisted dying, but this would be arranged through a different pathway.”

The hon. Member for Sunderland Central spoke earlier about how patients may be going through many multidisciplinary teams already, but it could be that none of those multidisciplinary teams have talked with them about assisted dying. They could have been pharmacists or nurses talking about the patient’s care—not assisted dying. We are talking about setting up a multidisciplinary team with a mental health nurse, doctor and social worker who can look in detail at evidence of the patient’s capacity, whether they are choosing it because they feel they are a burden, and whether there is any coercion. I think that is a safeguard for most of the concerns we have discussed in previous sessions. I would love to see a psychiatrist involved, because psychiatrists deal with some of the most challenging patients, including those with suicidal thoughts, on a day-to-day basis. They are the most experienced people to carry out a capacity assessment and, if they are a part of the multidisciplinary team, it will safeguard the Bill.

I strongly support amendment 425 and I urge Members to consider it. It will reassure many people who are concerned about some of the discussions. I know it also talks about giving power to the Secretary of State to formalise who should be part of the multidisciplinary team, which would be a discussion for later. I thank the Committee for giving me the opportunity to speak in support of the amendment.

[Naz Shah]

I rise to speak to amendments 285 and 286, tabled by my hon. Friend the Member for York Central. On amendment 285, we have to understand that, in medicine, clinicians only retain the areas of expertise in which they have clear confidence. I am grateful to my hon. Friend the Member for Stroud, who made very powerful points that, if anything, actually support this amendment. This is why we have developed a health system with so many specialities. Although generalists have incredible knowledge, they cannot confess to the depth of understanding that someone who dedicates their career to a speciality has. Therefore, the amendment seeks to draw on such knowledge rather than assume that a GP, for example, specialises in all fields of medicine.

Clause 4(4) would require a generalist to work alongside a specialist to secure the understanding of a patient’s diagnosis and prognosis. Once again, I recognise that my hon. Friend the Member for Stroud suggested that that already happens and does not need to be tied up in law. However, I feel the amendment gives us more protections if we are to make the Bill safe. It would then enable specialist clinical advice to be provided in the conversation about treatment options.

--- Later in debate ---

[Danny Kruger]

I am afraid the situation is even worse, because the fact is that under the Bill they will not be liable for mistakes made in pursuit of the scheme set out in the Bill. They will be exempt. They are indemnified against civil liabilities for malpractice in the course of their job. It is only guidance, and GMC guidance specifies that breaking the guidance is not itself necessarily considered a serious matter. The provisions are not strong enough at all.

[Naz Shah]

The hon. Member makes a valid point. That brings us to a very important question: do we wait for something to have happened? In this instance, people will have died.

If we were considering kidneys, for example, and the issue of consent, it would require somebody independent. It needs a specialist. We come back to the point about specialisms: whether they relate to diagnosis, coercion, the care pathway, palliative care or the drugs that bring a person’s life to an end, which we will discuss later, these are specialisms. I know that later my hon. Friend the Member for Spen Valley will speak to her amendment about the panel, which is intended to require expertise. That is what amendment 285 speaks to, and I hope hon. Members will support it.

Amendment 286 would set out the requirements for the co-ordinating doctor and ensure that the standards are upheld throughout the process of assessment, so that the patient and clinician have the highest levels of advice available. Even though the co-ordinating doctor might already have sought the advice of specialists as part of their assessment, the purpose of having an independent doctor is to assess the patient without preconceptions influenced by the co-ordinating doctor’s decision-making process. It is therefore important for the clinician to have access to the same level of advice to inform their clinical decision making.

In medical practice, should a second opinion be sought, the person providing that second opinion might consult a range of sources to establish an opinion. This measure would therefore be in line with normal medical practice. I hope that hon. Members will support the amendments.

[Dr Marie Tidball (Penistone and Stocksbridge) (Lab)]

rose—

--- Later in debate ---

[Dr Tidball]

I will make progress.

Clause 4 creates no duty to raise assisted dying, a point supported by the BMA. Keeping things secret is not helpful for the patient making such difficult decisions about how best to live their death with dignity and respect.

[Naz Shah]

Will my hon. Friend give way?

[Dr Tidball]

I will make progress.

In reply to a question from me about those who are seeking assistance, Dr Jane Neerkin, a consultant physician in palliative medicine, said:

“For them, it is about trying to regain some of that control and autonomy and being able to voice for themselves what they want. That is what I tend to see that people want back at the end of life.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 201, Q263.]

Importantly, amendments 183 and 275 would strengthen clause 4 to ensure that we avoid a situation that gives those with the most social capital more choice, while leaving those who might otherwise be unaware of all other options available to them without that choice. If the Bill is passed by Parliament without them, it will exacerbate health inequalities rather than abating them.

Together, the amendments expound and elaborate on the need for discussion of all appropriate palliative and other end-of-life options available to someone with a six-month terminal illness. I commend them to the Committee.

[Stephen Kinnock]

The amendments would make changes to the discussion between the medical practitioner and the patient. They are largely focused on clause 4, on the initial discussions, but several are thematically linked or related to later clauses.

Amendment 342 would impose a requirement on the registered medical practitioner to conduct a preliminary discussion with a person where that person has indicated that they wish to seek assistance to end their own life. As it stands, the Bill allows registered medical practitioners to opt out should they not wish to hold that conversation with someone, although they have an obligation under clause 4(5) to refer an individual to another medical practitioner for that discussion.

The amendment would remove that discretion and thus remove the opportunity for a medical professional to opt out of having the preliminary discussion. That may conflict with the principle set out in clause 23 that no registered medical practitioner or other healthcare professional is under any duty to participate in the provision of assistance. Our analysis suggests that in removing discretion as to participation, the amendment could interfere with an individual’s rights under article 9 of the European convention on human rights, on the freedom of thought, belief and religion, and article 14, on the prohibition of discrimination.

Amendment 285 would require the registered medical practitioner who conducts a preliminary discussion with a person on the subject of an assisted death to discuss with them, in consultation with a specialist, the person’s diagnosis and prognosis, any treatments available and their likely effects, and any available palliative, hospice or other care. The amendment would therefore require additional registered medical practitioners or other specialists to be consulted as part of the preliminary discussion under clause 4(4). The additional time required for consultation with specialists would be likely to lengthen the period over which a preliminary discussion can take place.

I also note that clause 9, “Doctors’ assessments: further provision”, will already require the assessing doctor to make such other inquiries as they consider appropriate in relation to the first and second assessments.

[Naz Shah]

The Minister’s point speaks to what my hon. Friend the Member for Stroud and I have spoken about in relation to the amendment, so I wonder which bit he supports. The Minister says that there will be extra time, but my hon. Friend pointed out that doctors do this routinely, so the objection is only that it will be on the face of the Bill. I just want to understand the Minister’s position on that.

[Stephen Kinnock]

If I understood the point that my hon. Friend the Member for Stroud was making, I think it was that the basic provisions in place enable doctors to carry out their work based on their experience and expertise, whereas the amendment would require additional registered medical practitioners or other specialists, so that would be in addition to what my hon. Friend was talking about.

I turn to amendment 343. As the Bill stands, a registered medical practitioner undertaking a preliminary discussion with a patient is required to discuss the person’s diagnosis and prognosis. The amendment would require a registered medical practitioner also to discuss any relevant probabilities and uncertainties of a person’s diagnosis and prognosis. It would put an additional legal requirement on what needs to be discussed during the preliminary discussion with the patient. In considering whether the amendment is required, the Committee may wish to note that all doctors acting in accordance with the General Medical Council’s “Good medical practice” are expected to discuss uncertainties about diagnosis and prognosis, and potential risks and uncertainties about treatment.

Under clause 4, the registered medical practitioner conducting the preliminary discussion must discuss any treatment available to the patient and the likely effect. Amendment 344 would require the registered medical practitioner conducting the initial discussion to discuss, as part of the conversation on the treatments available, the risks and benefits of such treatment, potential side effects and the impact of the treatment on the person’s quality and length of life. As with amendment 343, the Committee may wish to note, when considering whether the amendment is required, that all doctors acting in accordance with “Good medical practice” are expected to discuss the risks, benefits, uncertainties and the likelihood of success of treatment with a patient.

Amendment 275 would change the wording of clause 4(4)(c) to “all appropriate palliative hospice and other care”. That would require a registered medical practitioner who conducts a preliminary discussion with a person on the provision of an assisted death to explain and discuss palliative and hospice care on the basis of appropriateness for the individual, not on the basis of the care that is available. Clause 4(4) sets out that a registered medical practitioner who conducts the preliminary discussion on assisted dying must, as part of that discussion, explain and discuss the person’s diagnosis and prognosis, any treatment available and the likely effect—

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

Naz Shah Excerpts

Committee stage
Tuesday 4th March 2025 Public Bill Committees

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

I echo the points that have been made about the importance of the initial conversations, particularly for those who do not have English as their first language. I made a commitment to my hon. Friend the Member for Ipswich that in his absence I would press amendments 414 and 415 to a Division, as he requested.

I support the general principles of the amendments relating to those who are seeking or who need interpretation to explain aspects of assisted dying to them. I support the merit of that principle and the intention behind amendments 414 and 415.

[Naz Shah (Bradford West) (Lab)]

Like the right hon. Member for Dwyfor Meirionnydd and the hon. Member for Reigate, I will not press the amendments to a vote, but I certainly want to speak to them. I do not think that they go far enough. Let us put ourselves in the position of people of colour: if the English language is seen as superior to or more powerful than Welsh, that means an extra layer of intervention that I do not think the amendments quite capture. We have not even talked about British Sign Language in our discussion of languages, but it is also really important.

I am a qualified interpreter from Urdu to English—in health, funnily enough—and I can tell the Committee that in Urdu there is not even a word for depression. The word for depression does not exist. In a previous life I chaired the largest mental health charity outside London for ethnic minority communities, and I am a former NHS commissioner, so when we talk about health inequalities and patient intervention, I understand acutely the nuances involved in translating from one language to another.

In the first instance, there is a language that someone does not understand. In the second instance, particularly for minority communities who speak languages from the south Asian subcontinent such as Punjabi, Urdu or Hindi, the words do not exist to translate the Bill literally or to talk about assisted death. That speaks to the point that the hon. Member for Reigate made about understanding what it means. I have the same stats that she cited, which show that people do not understand what assisted death is.

I would really value a response from the Minister and from my hon. Friend the Member for Spen Valley to these questions about the nuances of having such a difficult conversation. These are really brave conversations, both on the doctor’s side and on the patient’s. Take a woman from an ethnic minority background whose first language is not English and whose doctor is unable to translate their conversation with her. Would that conversation be disempowering? Would it be empowering? Would we be doing a disservice to that person, with the best will in the world from the doctor? I really would like to understand what consideration is being given to making this accessible, if it is to be a service and a piece of legislation that is open equally to all.

I have mentioned this point a few times and have raised it with the Minister, and I appreciate that the Minister has responded, but this is where my frustration—for want of a better word—comes from about not having an impact assessment in the first place. If we had had an impact assessment, the Government would have looked at these things. Even with small Bills, we go out to consultation for weeks and weeks. With this Bill, we have not spoken to anybody during Committee stage about the nuances of the provisions on languages and what they will mean for patients. Although I support the essence of what the amendments are attempting to achieve, they fall short of providing the necessary protections. I do not know how the Government will address that.

--- Later in debate ---

[Sean Woodcock]

I am grateful for that intervention, which goes to the heart of my next question: why would we record and document later conversations, but not the initial one? That conversation could be one in which coercion takes place and without a record of it happening, patients and doctors are at risk. We have acknowledged that patients can be influenced by their doctors, whether consciously or unconsciously. We also noted how certain groups lack trust in the healthcare system. Dr Jamilla Hussain, in her written evidence, TIAB252, explained that the various inequalities faced by certain communities

“contribute to mistrust in health and social care services”

and that

“minority patients frequently express fear of having their lives shortened by healthcare providers, especially at the end-of-life with medication such as morphine and midazolam.”

In situations where patients are uncertain or lack trust in medical professionals, a record of the initial conversation is important to protect everyone involved. As Professor House stated, documenting the process and making records is common medical practice, so why would we differ here? We must protect patients and doctors, and making clear records at every stage of the process contributes to that.

[Naz Shah]

I rise to speak to amendments 288 and 295 tabled by my hon. Friend the Member for York Central (Rachael Maskell), both of which would improve the quality of records kept about people applying for assisted dying. Their aim is to make parliamentary and public scrutiny of the system easier and better. Amendment 288 would insert a new subsection at the end of clause 4, on page 2, line 36, reading:

“All efforts to dissuade the person from ending their own life must be recorded in the clinical records and subsequently made available to the medical examiner.”

That recognises that a doctor may follow existing guidelines and seek to dissuade the person from ending their life. It would ensure that such efforts are recorded to improve understanding of the Bill and its interaction with suicide prevention. As Professor Allan House noted in his written evidence, the National Institute for Health and Care Excellence guidelines apply

“in other areas where it is important to explore thoughts about life not being worth living”.

After an episode of self-harm or instances of suicidal thoughts, the medical professionals will explore

“current and recent personal and social circumstances, recent adversities, psychological state beyond merely assessing mental capacity and the presence of severe mental illness.”

In line with this suicide prevention strategy, a doctor may feel the need to explore those psychosocial factors and seek to dissuade the person from ending their life. We know that suicidal thoughts and depression are particularly common among terminally ill people. Dr Annabel Price, a member of the faculty of liaison psychiatry at the Royal College of Psychiatrists, gave oral evidence that among people who need palliative care at the end of their life,

“20% will have diagnosable depression, around 10% will have a wish to hasten death, and around 4% will have a more persistent wish to hasten death.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 270, Q351.]

She went on to say:

“Those who had a wish to hasten death were 18 times more likely to also feel suicidal”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 275-276, Q359.]

Terminally ill people are therefore at particular risk, and it is vital that the Bill does not diminish wider suicide prevention strategies. The amendment would record instances where the medical practitioner may try to dissuade the person from ending their life. Some doctors may take the view of Professor Allan House, who said in his written evidence,

“a statement about wanting to end one's life cannot be simply taken as the result of a straightforward rational decision to choose one type of end of life care over others.”

Furthermore, this amendment would also address some of the concerns about unconscious bias. Recording efforts to dissuade the person from ending their life would show when doctors assume a person should have an assisted death where others should not. Fazilet Hadi of Disability Rights UK spoke about this in her oral evidence:

“We often find that doctors, because they cannot treat or cure us, do devalue our lives. We have had disabled people who have actually had it suggested to them or their families that their lives are expendable, when actually those people have got a lot of years to give.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 180, Q234.]

Providing records of a doctor’s efforts to dissuade the person from ending their life will address some of these concerns. It will ensure that there can be a more meaningful review of the impact of the Bill on different groups, so that the right to die does not become a duty to die.

In conclusion, amendment 288 would strengthen the safeguards in the Bill by ensuring transparency and accountability in doctor-patient discussions by requiring the documentation of efforts to dissuade individuals from ending their lives. We would lessen the impact of the Bill on wider suicide prevention strategies and provide evidence for meaningful review at a later date.

Amendment 295, also tabled by my hon. Friend the Member for York Central, is about enabling public and parliamentary scrutiny of the assisted dying system. It will ensure that, if the Bill passes, there are good records of all applications for assisted dying and that they are readily available to the medical examiner. Some Members will know exactly what the medical examiner does, but I note for the record that it is a newly created public office, in operation since 2024. The task of the medical examiner is to examine any deaths within the context of healthcare, whether NHS or private, that are not being examined by a coroner.

In light of the magnitude of the decision being made, it is important for records to reflect that. It is equally important that those who will depend on the evidence can access the same evidence on which the co-ordinating doctor made their determinations. Therefore, it is essential that the basis of the decision making is accurately recorded, along with the evidence from other practitioners. For instance, if a palliative care specialist, a clinical consultant and a psychiatrist or psychologist have been consulted, evidence of what they did and said must be readily available, and it is essential that that sits with the record of the co-ordinating doctor. The information must be gathered for the medical examiner to be able to come to their determination with all the evidence before them. It is also vital for the reporting mechanisms to be deployed for the process by which the chief medical officer compiles their report. That is ultimately what Parliament will be able to scrutinise.

Both these amendments would greatly improve the quality of records kept on assisted dying. If I recall correctly, the role of the medical examiner was brought into legislation following Shipman, to tidy up and tighten the records we keep—because clearly we had lessons to learn from them. Also, we have heard in evidence that some other jurisdictions keep good medical records, especially when that speaks to people who are potentially coerced. In one jurisdiction, we had somebody who said that they had never felt a burden, but there were many more who said that they had felt a burden.

There is no doubt that these services will continuously need improving. If we keep these records and understand that these conversations have been had then, ultimately, should this Bill become law, these records would form part of the data collection that we could rely on as parliamentarians and for those service improvements. The amendment speaks not just to the Bill itself, but to ensuring that it continues to do what it is intended to do going forward.

These amendments improve equality in assisted dying. That, in turn, will make it far easier for us in Parliament, for our constituents and for the media to find out what is happening with any assisted dying system. In this country, we believe in open justice and open Government. Assisted dying is much too important to be allowed to operate without strong scrutiny by the press, the public and ourselves in Parliament. I therefore urge hon. Members to vote for both these amendments.

--- Later in debate ---

[Stephen Kinnock]

This series of amendments relates to the various discussions and assessments that registered medical practitioners, co-ordinating doctors and independent doctors will have with individuals seeking assistance to end their life in accordance with the Bill. In particular, they seek to amend the requirement for recording information about those discussions. As I have done throughout, I will limit my remarks to comments on legal and practical impacts of amendments. In executing our duty to ensure that the legislation, if passed, is legally robust and workable, the Government have worked with the hon. Member for Spen Valley on amendments to the Bill, including new clause 19 in this group.

Amendment 345 would require the registered medical practitioner, following a preliminary discussion with a person, to record and document in that patient’s medical records the discussion and any information provided to the patient, and it would require them to provide a copy to the patient.

Amendment 288 adds an additional requirement on the registered medical practitioner who conducts an initial discussion with the person on the subject of an assisted death to record all efforts to dissuade a person from ending their own life in the person’s medical records, and subsequently to make those records available to the medical examiner. As drafted, it is not clear whether the wording “all efforts” is intended to include efforts made by the registered medical practitioner alone, or to include efforts made by others that could be reported to the registered medical practitioner. Further clarity would be needed to establish the practical implications of the amendment. The amendment does not require this information to be recorded at a specific time. I would also note that, operationally, medical examiners are not involved in scrutinising all deaths. Some deaths are investigated by coroners. Clause 29 will consider inquests and death certifications in relation to assisted death.

Amendment 297 requires a full written transcript to be produced for any consultations that occur as part of the first assessment undertaken by the co-ordinating doctor. That would potentially add some operability challenges and, if passed, we would want to explore those further. For example, there could be situations in which the person seeking assistance does not want there to be a written transcript. Further clarity is also required on whether the amendment intends to capture only consultations between the co-ordinating doctor and the patient, or whether it also intends to capture conversations with relevant persons other than the person seeking an assisted death.

I turn now to amendment 295. As the Bill stands, if, having carried out the first assessment, the co-ordinating doctor is satisfied that the person being assessed has met all requirements in clause 7(2), the co-ordinating doctor must:

“(a)make a statement to that effect in the form set out in Schedule 2, and sign and date it,

(b) provide the person who was assessed with a copy of the statement, and

(c) refer that person, as soon as practicable, to another registered medical practitioner who…is able and willing to carry out the second assessment”.

Amendment 295 seeks to add an additional requirement for the co-ordinating doctor to

“collate all evidence provided regarding the condition of the patient in a document to be provided to the Medical Examiner and the…Chief Medical Officer after the person has received assistance to die”

in accordance with the Bill. The aim of the amendment is to ensure that the documentation will be available when required by the medical examiner.

[Naz Shah]

The Minister referred to a patient not wanting to keep a written record. How does that fare if there is a potential issue of negligence later on? Is that not a requirement of every NHS service that we provide? For example, in the case of a kidney donation where an independent assessor was needed, the details would have to be kept. I am just a bit confused. I wonder if the Minister might comment on that.

[Stephen Kinnock]

The challenge we found with amendment 297 is that it is not entirely clear what would happen if the person were to say expressly that they did not want a written record. That eventuality is not baked into the Bill as it is currently drafted, so I think it would require a lot of thinking through—again, we are back to the law of unintended consequences—about the impact the amendment would have in certain circumstances if, for example, someone were to say expressly that they did not want a written record. That is the question: the impact of the amendment is not clear.

[Naz Shah]

If that is an issue, then it is my understanding, being new to Bill Committees, that it is not because the provision is poorly drafted, but because the outcome is not clear. Can the Government not clarify that on Report or Third Reading? I have heard nothing from the Government, even where they are supportive of amendments, about going away and looking at them. There is none of that conversation coming from the Government. Perhaps the Minister will comment on that.

[Stephen Kinnock]

As my hon. Friend knows, there will be an impact assessment on the Bill once it has cleared Committee. The Government’s impact assessment would be based on the Bill as it cleared Committee, so it would include the amendment we are discussing, if it were to pass. As things stand, I cannot tell her what the impact of the amendment would be in the event that it passed, because that has not been thought through from all the different angles, including if someone were to expressly say that they did not want a written transcript.

I turn to amendment 300, which would require a full written transcript of the second assessment as a record of the conversation. This goes further than the requirement that the Bill currently places on the independent doctor, which is to make a statement in the form in schedule 3. As with amendment 297, further clarity is required on whether the amendment is intended only to cover consultations with the patient, or whether conversations with other individuals should also be transcribed.

Amendment 302 would require the independent doctor to provide details of the way in which the second assessment was conducted alongside a written transcript of any consultation to the relevant chief medical officer and the person’s GP.

--- Later in debate ---

[Naz Shah]

The Minister is being very generous with his time. I want to understand the idea that someone might say that they do not want a written transcript, when everybody in our country who uses the NHS has a written medical record. Why, in this instance, are the Government of the view that we should stray from normal practice?

[Stephen Kinnock]

I think it reflects the fact that, as the Committee has agreed, we are in uncharted territory on a whole range of issues here. I think it is best to think through the implications of every amendment. If it passes, every clause of the Bill will have to be assessed for its potential impact. I have other questions about amendment 297 in my notes. Does it intend to capture only the consultations between the co-ordinating doctor and the patient, or does it intend also to capture conversations with relevant persons other than the person seeking an assisted death? That is not clear from the amendment. What I am saying is that it poses more questions than it answers.

--- Later in debate ---

[Naz Shah]

The Minister is being generous with his time. I am even more confused now. Originally, the Minister suggested that a patient might not want a transcript, but in response to the question from my hon. Friend the Member for Spen Valley, he mentioned that under new clause 19 people will have access to their written records. That appears to be a contradiction. I just want to nail this down. What will it be? If a patient does not want a written record, we would not have a written record to access, so that contradicts the Minister’s response. I want to understand exactly what the Minister is suggesting.

[Stephen Kinnock]

The Government have worked with my hon. Friend the Member for Spen Valley on new clause 19. The Government’s view is that if the Committee accepts it, then that new clause will provide the level of robustness and resilience that the system requires. The Government are not convinced that, on its own, the amendment that my hon. Friend the Member for Bradford West is talking about would provide the level of robustness and resilience we would be looking for. As things stand, the choice has been made to work with my hon. Friend the Member for Spen Valley on new clause 19, and we are satisfied that that would provide us with the operational integrity we need.

Amendment 302 would require the independent doctor to provide details of the way in which the second assessment was conducted, alongside a written transcript of any consultation to the relevant chief medical officer and the person’s GP. The independent doctor would be required to maintain a copy of that record to provide to the relevant medical examiner.

As I have mentioned, in executing our duty to ensure that the Bill, if passed, is legally robust and workable, the Government have worked with my hon. Friend the Member for Spen Valley on new clause 19. The new clause would require a practitioner to include a record of a preliminary discussion having taken place under clause 4. The record of the preliminary discussion must be included in the person’s medical records. Where the medical practitioner is a member of the person’s GP practice, they must make such a record in the person’s medical records as soon as practicable. Where the medical practitioner is not a member of the person’s GP practice, they must, as soon as practicable, provide a written record of the preliminary discussion to a medical practitioner at the person’s GP practice, who will then be required by the new clause to include it in the person’s medical records as soon as practicable.

The Committee may wish to note that amendment 424 would add a definition of “preliminary discussion” to the Bill that would make it clear what discussion medical practitioners would be required by law to record.

That concludes my remarks on this group. I thank the Committee for its attention.

--- Later in debate ---

[Lewis Atkinson (Sunderland Central) (Lab)]

I will be brief. I am pleased to hear my hon. Friend the Member for Spen Valley confirm that she is minded to support amendment 341. It is incumbent on all of us, but perhaps particularly those in favour of the Bill, to place on record our appreciation and recognition of the fact that many people who work in our health services have strongly held religious beliefs, or beliefs of conscience—however they are motivated. As is the case for a range of other procedures and medical interventions, the law has to allow them scope to continue to practise. They make a valuable contribution to our health service and national life, and we should not do anything to impinge on that.

There is already strong guidance from the General Medical Council about personal belief, and that applies, as the hon. Member for Reigate mentioned, to the Abortion Act, as well as to the Human Fertilisation and Embryology Act 1990, the Female Genital Mutilation Act 2003 and other procedures. It is not for any of us to second-guess someone’s conscience.

[Naz Shah]

I would like to add that there is nothing about female genital mutilation in anybody’s religion. It is not a religious belief; it is cultural, and it is actually child abuse. That is what it is—there are no ifs or buts about it.

[Lewis Atkinson]

I do not disagree with my hon. Friend. I gently say that the GMC guidance specifically references that Act, so that is what I was referring to.

I am pleased to see amendment 341, which I believe would bring the legislation into line with that GMC guidance, ensuring that removing the duty to refer would absolutely not be a licence for people to be left without access to care. The GMC is very clear, as the hon. Member for Reigate said, that people must be given sufficient information and be empowered to seek the options and information that they need. Therefore, I am pleased to support the amendment.

[Daniel Francis]

It is a pleasure to serve under your chairmanship, Mr Dowd. I note that my hon. Friend the Member for Spen Valley has said that she is minded to accept amendment 341. I will, however, still briefly speak to amendment 338 and new clause 13, which stand in my name.

The British Medical Association has said that it strongly urges MPs to support the amendments, which would remove the referral requirement in relation to preliminary discussions and establish an official body to provide factual information to patients about the range of options available to them. As the hon. Member for East Wiltshire mentioned, Dr Green, in his oral evidence, said:

“The provision of information would be very useful, because in a situation where a doctor was unwilling to have an initial discussion with the patient, it would provide a way for the patient to get that information that was in no way obstructive.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 46, Q37.]

He went on to say:

“I do not believe that it is ever appropriate for a doctor to recommend that a patient goes through an assisted dying process.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 48, Q40.]

He also said:

“The word “referral”, to a doctor, means writing a letter or communicating with another doctor to see, but some doctors would find themselves not able to do that. For that reason, we believe that there should be an information service for the doctor to direct to.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 48, Q41.]

The BMA’s position is that the proposal is analogous to doctors’ professional legal obligations regarding abortion, and consistent with the Bill’s inclusion in clause 23 of a right to refuse, for any reason, to carry out activities directly related to assisted dying. It has said:

“In tandem, we believe creating an official body to provide individual information and advice to patients, to which doctors could direct (rather than refer) patients, would ensure that the doctor’s views are respected, whilst also—crucially—ensuring that patients can easily access the information and support they need. Currently, whilst the Bill acknowledges the need for accurate, impartial information and advice for patients, it gives no indication of how this might be delivered—generic published information would not be sufficient. Patients would need individual advice, guidance, and support so that they can make informed decisions, and an independent information service could meet this need.”

As the hon. Member for Reigate mentioned, a member of the Royal College of General Practitioners also said:

“The BMA referred to the word “refer”—referring to a colleague, for those who did not want to do it. We agree that signposting is a better process.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 279, Q365.]

He went on to say:

“Similar to other services, such as termination of pregnancy, we think that the best option would probably be that the GP could signpost to an information service, such as something like what the BMA suggested the other day. They would not have to do anything more than that, and they would not withhold any option from the patient.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 273, Q354.]

Therefore, I commend amendment 338 and new clause 13 to the Committee.

[Naz Shah]

It is a pleasure to follow my hon. Friend the Member for Bexleyheath and Crayford. I rise to speak to amendment 287, tabled by my hon. Friend the Member for York Central. Clause 4(5) currently says:

“A registered medical practitioner who is unwilling or unable to conduct the preliminary discussion mentioned under subsection (3) must, if requested by the person to do so, refer them to another registered medical practitioner whom the first practitioner believes is willing and able to conduct that discussion.”

If this amendment was to be adopted, it would read:

“A registered medical practitioner who is unwilling or unable to conduct the preliminary discussion mentioned under subsection (3) must, if requested by the person to do so, refer them to another registered medical practitioner who is qualified to undertake such a preliminary discussion, and set out palliative medicine options to provide the patient with appropriate end of life care, including referring them to a palliative medicine expert.”

Put simply, the amendment would mean that if a doctor met with a patient with a severe illness who might die within six months, but the doctor was themselves unwilling to have an initial discussion on assisted dying, they would still have to refer the patient on to a doctor who was willing to have that discussion. The patient’s decision to explore assisted dying would not be obstructed; the main change would be that that doctor would now have to discuss palliative care options with the patient. That is surely a measure that would increase the patient’s welfare.

Let us think about the kind of patient who can apply for assisted dying. They must have a diagnosis of a serious illness and a prognosis that they are likely to die within six months. The Bill’s supporters have said many times that they are worried about any changes that will reduce the autonomy of people seeking assisted death. This amendment quite obviously does not in any way reduce people’s autonomy, nor does it in any way place an unreasonable burden upon doctors. If a patient has a diagnosis of a serious illness, and if they have themselves asked for a conversation on assisted dying, then it surely must be good practice for that doctor to discuss palliative care options.

It is also only good practice that one of those options would be for the doctor, if the patient wishes, to refer the patient to a palliative medicine specialist who is more able to talk about such options. That means that the amendment would not place any undue burden on either the doctor or the patient. The doctor ought to be offering such advice on palliative care. The patient may or may not decide to take the doctor’s advice on palliative care, but they have had it, and the patient may well benefit from having had advice on palliative care.

Given the conversations we had this morning, I can foretell one objection to this amendment: that since good doctors will do this anyway, it is unnecessary to have a provision on the face of the Bill to ensure it. This seems to me a very weak objection. Let us be honest, the doctors that we have in this country are of extremely high quality. They are dedicated, skilled and compassionate men and women. We are lucky to have them, but we cannot say that every doctor participating in all the processes that they currently undertake always follow best practice.

Similarly, we simply cannot say that in any assisted dying process doctors will always automatically follow best practice. People make mistakes. That includes people who are highly trained and extremely compassionate. I would be astonished if we could find a doctor who said they had always got everything right. As lawmakers, we have to guard against the fact that even some of our most admired professionals can and sometimes will make mistakes. One way that we will guard against that is to set out duties that they have to follow. This amendment does just that.

I hope that we will not hear the objection that we have heard to a great many good amendments: that it will somehow make the Bill more dangerous by adding complications. The amendment simply adds a small step, by placing a duty on a doctor to give palliative care advice to a patient with a diagnosis of serious illness. Surely the Bill cannot be so lacking in robustness that such a small change would make it dangerous.

In summary, the amendment is a sensible change. It would in no way block the ability of adults who meet the conditions set out by this Bill to explore assisted dying, nor would it place any burden at all upon doctors. It would simply place upon them a duty to follow what we can all surely agree is best practice, and it would greatly improve the early access to palliative care advice for patients with a diagnosis of serious illness. That would improve those patients’ chances of receiving good palliative care. I therefore urge hon. Members to support the amendment.

--- Later in debate ---

[Kit Malthouse]

I understand that, but amendment 126 also refers to a register of appropriate medical practitioners being maintained. Of course, new clause 7 would similarly create such a list. We are debating all three proposals, so I wanted to explain why I oppose them, as indeed the BMA does.

As has been outlined in previous speeches, the Bill creates an opt-in model effectively, whereby people who want to be the co-ordinating doctor or indeed the second doctor have to opt in and be trained, and therefore become accredited, so by definition they would be approved for that service.

However, the Bill does not envisage that the initial conversation is necessarily with the co-ordinating doctor. There might well be other medical personnel or practitioners—we have talked a lot about semantics in this debate—who are presented with the situation where a desperate person, somebody who has been given some extremely bad news, wants to talk about their situation and what their options might be. We hope and believe that training will spread throughout the NHS to those who want it. Nevertheless, we have to leave open the option that someone may not be accredited and that they may need to pass on someone, by whatever means the Bill determines, to a doctor who is accredited, who can act as the co-ordinating doctor, who has had the appropriate training and opted in, and I am afraid the register would not allow for that.

The second thing that concerns me slightly, and which we need to avoid for the benefit of both the patient and the system, is any kind of “doctor shopping”—the notion that there is a list of doctors that I can shop around and choose from. I worry slightly about that.

My hope is that these types of conversations, which are necessarily private and sensitive, will take place in an environment of embrace and familiarity between doctor and patient. We have talked a bit about whether doctors have to refer or provide information—obviously, we have just accepted an amendment that seeks to set out how that will work. What I would oppose, for two reasons, is the creation of a list that people can move up and down on, and pick somebody they like the look of, or who they think might be handy for them. First, I am not sure that it would be entirely reputable; secondly, we have to remember who we are dealing with here. These are dying people who may not have long left to live—we are talking about six months as a minimum, but actually they might have only two or three months to go. We need to create a sense that this is something that will be provided to them in an environment that is familiar. They will not have to spend their time finding a doctor on a list, and their phone number, then ringing up their office and saying, “This is what I want to do. Can I make an appointment?” There is a privacy aspect to it.

My third objection is, to be honest, about privacy—not just that of the patient, but that of the doctor. The hon. Lady will know that unfortunately—I do not know whether she thinks it is unfortunate, but I do—there are some people who object so strongly, for example, to abortion that they are willing to go and protest outside clinics that provide that service. This House has legislated to balance the rights of those who want to avail themselves of that service and those who want to protest. That has been a source of conflict.

I am afraid that a public list of doctors who provide this service would raise questions about the privacy of doctors, about patient privacy and about access to that service. I am concerned about it from that point of view.

[Naz Shah]

I hear what the right hon. Member says, and I get his point, but we already have lists of specialists. With Choose and Book, for example, although it is for treatments, the NHS provides a list of doctors, so why would this be any different?

[Kit Malthouse]

We do not necessarily have specific registers. People are members of professional bodies, and within those professional bodies, people become accredited because of their training. As the Minister referred to earlier, there is no such thing as a list of palliative care specialists; it is not defined in that way. Creating a list in this way would present problems for the privacy of doctor and patient as they go about what I hope we all acknowledge is a very sensitive and private process at the very end of someone’s life. I will conclude at that point and say that, unfortunately, with great respect to the hon. Member for Broxtowe, I oppose these amendments.

--- Later in debate ---

[Naz Shah]

I rise briefly to put on the record my disappointment. In our debates today on various amendments, we have discussed how some patients could see doctors’ language as a suggestion rather than an option. I make no apologies for the fact that I said that this could be the next Horizon scandal or the next infected blood scandal. I struggle with that.

A chap called Nick Wallis, who exposed the Horizon scandal, said something pertinent that I want to put on the record. He said that the difference is that there will not be anybody else left to campaign—

[The Chair]

Order. I am genuinely trying to provide as much latitude as possible, but the Question before the Committee is whether the clause stands part of the Bill.

[Naz Shah]

Thank you, Mr Dowd. I will not oppose clause 4 stand part, but I put on the record my disappointment that we did not go further by putting in the safeguards that we had the option to add.

--- Later in debate ---

[The Chair]

I apologise to the Member, who was within his rights to speak to amendments 403 and 404.

[Naz Shah]

I rise to speak to my amendment 277, which would add a new subsection to clause 5. Like my amendment 276, it would alter the time that must elapse between a person receiving a diagnosis of severe illness and their discussion of assisted dying with a medical practitioner. To put the most important point first, the amendment aims to prevent people opting for assisted dying while they are suffering from the initial shock of having a serious illness diagnosed, by imposing a pause. There would have to be 28 days between when a person receives a diagnosis and prognosis of the illness that might end their life within six months, and when they could have their second consultation with a doctor about assisted dying.

The right hon. Member for North West Hampshire asked me whether I was aware of pancreatic cancer. A dear friend of mine, who was known as the “king of curry” in Bradford, told me only in June—the day I launched my election campaign, funnily enough—that he had been diagnosed with terminal cancer. In October, he was gone. I am overly familiar with pancreatic cancer and how fast he went down from being a healthy individual. He is greatly missed in Bradford.

The Committee has already rejected amendment 276. I ask all Members to think again and in particular to consider the evidence given to us by several distinguished doctors, including senior psychiatrists. What those doctors said to us, in both written and spoken evidence, was that immediately after someone receives a diagnosis of serious illness they often experience a major increase in depression and a desire to hasten death. For some patients, that desire to hasten death is what psychiatrists call an increase in suicidality; that is, the patient wants to actively do something to end their own life. For other patients, they do not have an active desire to carry out a physical act to end their life, but they do wish that their life would end sooner.

We can all empathise with people who have just received such a shocking diagnosis and prognosis. They have been told that they are likely to die soon. They may also either have been given information that makes them think their remaining months of life will be degrading and painful, or they may assume that they will be. That might well be how many of us would think if we had such devastating news. But the psychiatrists who gave evidence also said that depression and a desire for death are often not permanent conditions for people who have received such a diagnosis. When a patient gets treatment for their physical symptoms plus social care, and if necessary psychological treatment, the desire to hasten death will often fall.

Let me refer to the evidence of Dr Annabel Price, vice chair of the Royal College of Psychiatrists Liaison Faculty. I appreciate, Mr Dowd, that I am repeating some things I have mentioned previously, but when I spoke previously with reference to this evidence it was to other amendments. Hence, I am having to repeat it for the purpose of this amendment in particular. She said:

“There is a lot of research evidence around depression in people with palliative care needs and people nearing the end of life. We know that depression is common, and across a number of studies it is at around 20%—much more common than in the general population. We know that depression is strongly associated with a wish to hasten death, and that if depression is found and treated in that group of patients, there will be significant change in the wish to hasten death.”

She said that there were a number of factors besides depression that were associated with the wish to hasten death. In those who had received a diagnosis of serious illness, she told us:

“they include difficult symptom experience, poor functional status—needing a lot of help with things—and being socially isolated. Those are really key ones. They also include a sense of loss of dignity and feeling like a burden on others.”

For patients who have all those factors, she said:

“These things can all come together to make life feel very unbearable.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 275, Q359.]

Perhaps the most important part of Dr Price’s evidence was when she said what good medical and social care could do for people who felt their lives were unbearable. She said:

“The evidence that we have from research—this is in populations who would fulfil the criteria in terms of terminal illness—is that the prevalence of depression is around 20%. That is across a number of populations. It is associated with a wish to hasten death. Depression might impact upon that person’s decision making; I am not saying that it absolutely would, but it might. Also, treatment might change their view. We know that there is a strong association, for example, between pain and a wish to hasten death.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 281, Q369.]

[Kit Malthouse]

On a point of order, Mr Dowd. I am very sorry, but I just want your guidance. The hon. Lady is giving a speech which I am afraid we have covered before. We have had extensive debates on the impact of terminal diagnosis on people’s mental health and depression. I just want your guidance on what the Committee should do to resist the temptation to repeat debates that we have already had extensively, while we are considering these amendments.

[The Chair]

I thank the right hon. Gentleman for that point of order. I reiterate the point I have made on a number of occasions. I do not want to interrupt Members when they are making a point, because we are in a very sensitive situation—of that there is no doubt. I exhort Members, when they are discussing these things, to bear in mind those factors and those issues.

[Naz Shah]

Thank you, Mr Dowd. Before I carry on, may I just add to that? I did refer to that and I appreciate the right hon. Gentleman’s point of order, but these things speak to this particular amendment on 28 days. While they speak to many other debates, the Committee will have no doubt that there are many issues in which one piece of evidence crosses over many amendments. I assure the Committee that my intention is just to draw attention to the evidence that is related to the particular amendment that I am speaking to. I appreciate there that there is huge repetition—for want of a better word—but I feel that it is necessary, unless advised otherwise. I would be happy to take your guidance, Mr Dowd.

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

Naz Shah Excerpts

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[The Chair]

Will hon. Members please ensure that all electronic devices are turned off or switched to silent mode? Tea and coffee are not allowed in the Committee Room. We are continuing line-by-line consideration of the Terminally Ill Adults (End of Life) Bill. I remind Members that the most valuable of all talents is never using two words when one will do. I take that from Thomas Jefferson.

Clause 5

Initial request for assistance: first declaration

[Naz Shah (Bradford West) (Lab)]

I beg to move amendment 290, in clause 5, page 3, line 13, at end insert

“who is not a physician associate or doctor in any training grade or in postgraduate training or a locum tenens post and—”.

This amendment would exclude physician associates and doctors in training from acting as a coordinating doctor.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 185, in clause 5, page 3, line 14, leave out from “who” to end of line 15 and insert

“meets the requirements specified in regulations under subsection (3A)”.

This amendment and Amendment 186 impose a duty on the Secretary of State to make regulations about the training, qualifications and experience required in order to act as the coordinating doctor.

Amendment 335, in clause 5, page 3, line 14, after “such” insert “specialised”.

This amendment is linked with NC12.

Amendment 52, in clause 5, page 3, line 15, leave out from “State” to end and insert

“must specify by regulations, including experience of managing terminal illnesses,”.

This amendment would require the coordinating doctor to have experience of managing terminal illness.

Amendment 359, in clause 5, page 3, line 18, at end insert—

“(ba) who has conducted the preliminary discussion in accordance with section 4,”.

This amendment requires that the coordinating doctor has conducted a preliminary discussion prior to witnessing the signing of the first declaration.

Amendment 186, in clause 5, page 3, line 23, at end insert—

“(3A) The Secretary of State must by regulations make provision about the training, qualifications and experience that a registered medical practitioner must have in order to act as the coordinating doctor.

(3B) The regulations must include training about—

(a) assessing capacity;

(b) assessing whether a person has been coerced or pressured by any other person.

(3C) Subject to that, the regulations may in particular provide that the required training, qualifications or experience is to be determined by a person specified in the regulations.”

See the statement for Amendment 185.

Amendment (a) to amendment 186, after

“(b) assessing whether a person has been coerced or pressured by any other person.”

insert

“(c) specific and up-to-date training on reasonable adjustments and safeguards for autistic people and people with a learning disability.”

Amendment 340, in clause 5, page 3, line 23, at end insert—

“(3A) The Secretary of State must make regulations under subsection 3(a) specifying specific and up to date training on reasonable adjustments and safeguards for autistic people and people with a learning disability.”

Amendment 427, in clause 5, page 3, line 23, at end insert—

“(3A) In Wales, all reasonable steps must be taken to ensure the practitioner under subsection (3) has fluent proficiency in the Welsh language if services or functions in the Act are to be provided to an individual in Welsh.”

Amendment 20, in clause 5, page 3, line 25, at end insert—

“(4A) Regulations under subsection (3)(a) must specify that training in respect of domestic abuse, including coercive control and financial abuse is mandatory.”

This amendment would require the registered medical practitioner acting as the coordinating doctor to have undertaken training on domestic abuse, including coercive control and financial abuse.

Amendment 336, in clause 8, page 5, line 13, after “such” insert “specialised”.

This amendment is linked with NC12.

Amendment 337, in clause 19, page 13, line 20, after “such” insert “specialised”.

This amendment is linked with NC12.

New clause 12—Obligations related to training—

“(1) No registered medical practitioner or other health professional is under any duty to opt in to undertake specialised training wholly or largely relating to the provision of assisted dying in accordance with this Act.

(2) No medical practitioner or other health professional who has carried out training as may be specified by the Secretary of State under—

(a) section 5(3)(a),

(b) section 8(6)(a), or

(c) section 19(2)(b),

is under any duty to participate in the provision of assisted dying under the terms of this Act.”

This new clause would set out that a registered medical practitioner or other health professional is not under any duty to undertake training in relation to the provision of assisted dying. And anyone who undertakes such training is not under a duty to provide assisted dying under the Act.

[Naz Shah]

Amendment 290 was tabled by my hon. Friend the Member for York Central (Rachael Maskell). Clarity is needed on who a medical practitioner is. With the regulation of physician associates, there was much unease from the British Medical Association and others on the role and function of the new profession. Although I do not want to debate the merit of this today, it is clear that involvement in the assisted dying process requires someone of significant experience to support a patient while undertaking complex assessments and co-ordinating their care between specialists and others.

In some jurisdictions, we have heard that clinicians have extensive clinical experience, whereas they do not in others. Therefore, being able to determine the level of experience and competencies of the medical practitioner is important to ensure that the patient is receiving care from someone who has significant practice expertise. A doctor in training, whether as a specialist or general practitioner, although making very specific clinical decisions, should not be deemed as having the experience, competencies or breath of experience for the purposes of this process. An associate practitioner should also not be deemed to reach these thresholds. Amendment 290 would therefore show the public that the person who would act as the co-ordinating doctor held such experience, and that there was no doubt in their standing to register for such a role. The public can already be confused on the exact status of the clinician they are under or indeed the profession itself. Including this safeguard would ensure that the patient’s interests are upheld.

[Rachel Hopkins (Luton South and South Bedfordshire) (Lab)]

It is a pleasure to serve under your chairship, Mr Dowd.

I rise to speak in support of amendment 185, in the name of the hon. Member for Spen Valley, the Bill’s promoter, regarding training requirements that need to be made by regulation. It would place a duty on the Secretary of State to make regulations about training qualifications and experience required in order to act as a co-ordinating doctor. Similarly, amendment 186 says that the regulations should specifically include training relating to the assessment of capacity and assessing whether a person is being coerced or pressured by any other person. Proposed new subsection (3C), introduced by amendment 186, would make provision that

“the required training, qualifications or experience is to be determined by a person specified in the regulations.”

In making those regulations, reflection of expertise is vital. We heard from many experts who gave us evidence about the importance of training, development and mentorship, which we would expect to see covered in the regulations. Placing those requirements in regulations would mean that they could be developed through consultation with experts and stakeholders, after gaining a wide range of feedback. It would also future-proof the requirement of any training to be developed and strengthened through future experience.

As part of the safeguards in the Bill, the key principles around assessing capacity and potential coercion are really important. I am therefore minded to press the hon. Member for Spen Valley also to support amendment 20, in the name of my hon. Friend the Member for Lowestoft (Jess Asato), which states:

“Regulations under subsection (3)(a) must specify that training in respect of domestic abuse, including coercive control and financial abuse is mandatory.”

That would provide further clarity, and would further strengthen training on assessing coercion in all senses of the word as part of the safeguards, which many Members, even in the earlier debates, have said that it is so important that they see. I agree, and I hope that the promoter of the Bill will support amendment 20.

--- Later in debate ---

[Naz Shah]

I rise to speak to amendment 20, which was tabled by my hon. Friend the Member for Lowestoft (Jess Asato).

The key point for me is that doctors are not specialists in coercive control, but this amendment would give them training to spot abusive and coercive relationships, which are difficult to detect. Domestic abuse and coercive control have a disproportionate effect on women and disabled people, and if doctors just rely on their experience to detect coercive control and abuse, they are more likely to miss cases. Some doctors will be more experienced or more perceptive than others. This amendment is not a perfect safeguard, but it will improve the chances of doctors stopping people being coerced.

The amendment would ensure that co-ordinating doctors must have undertaken training on domestic abuse, including coercive control and financial abuse. It is a significant and distinct amendment. In particular, it addresses the issue of repeated coercive control, which so far has been overlooked in the Bill. I believe that amendments seeking to improve safeguards against coercion that do not address the issue of repeated coercive behaviour are inadequate in protecting vulnerable people, particularly women.

It is regrettable that in our witness sessions we did not hear from any experts on repeat coercive control. Such testimony would have been valuable, helping the Committee to understand why this specific environment puts people at risk with regard to the Bill.

We have already spoken a great deal about coercion in this Committee and other Members have referred to that. We have raised concerns about someone coercing another person into the process of assisted dying in a one-off incident. However, we have not yet discussed the very real issue of repeated coercive control and what it means to live in that environment, nor the implications that the Bill may have for people in those situations.

Dr Hannah Denno submitted written evidence to this Committee. She wrote:

“As a doctor I am not trained to detect coercion, and I do not believe that the Bill pays sufficient attention to the detection of those who are under pressure from themselves or others to end their lives. The Bill describes two independent medical assessments, both can be carried out by doctors who have never previously met or cared for the patient.”

[Kim Leadbeater (Spen Valley) (Lab)]

I just want to provide some reassurance to my hon. Friend the Member for Bradford West. I have met my hon. Friend the Member for Lowestoft and today I will support amendment 20, which she has tabled. I hope that provides some reassurance to my hon. Friend the Member for Bradford West.

[Naz Shah]

I am grateful to my hon. Friend for that intervention and I am really grateful that she is supporting the amendment. However, the reason I am making this speech is that I do not think the amendment goes far enough in terms of providing safeguards within the Bill. So, I will make some progress with my speech and then I will address some of the issues that are not addressed in this particular amendment, and set out how we can go further, as well as highlighting some of my concerns.

I return to what Dr Denno wrote in the evidence that she submitted. She wrote that she was:

“not trained to detect coercion”.

And she also wrote that

“Social workers are better placed to screen for coercion but are not mentioned in the Bill.”

Since that submission, my hon. Friend the Member for Spen Valley has tabled an amendment that would mandate a social worker to sit on a panel to consider each application for assisted death. However, I am afraid that I must repeat several points about these panels, points that have already been made frequently. These panels are under no obligation to interview the applicant for assisted death in person. Panel members may do so if they have any concerns, but they may not. That makes it harder for panel members to detect possible coercion.

There is also an absence of any mechanism for people who know assisted dying applicants to report any concerns they have that that person is being coerced into this form of action. The panels are not used in that way, which is the way that multidisciplinary panels are used in the NHS to decide on the pathway for a patient. Instead, the panels introduced by my hon. Friend’s amendment would wait until the two doctors have submitted their statements on the applicant and then the panel members would scrutinise those statements. If they spot problems with the way that the doctors have determined that the patient is not being coerced, then, yes, they would call the patient in for more scrutiny. However, they will first have to come to that conclusion without seeing the patient. That is not a very robust safeguard.

[Kim Leadbeater]

I am in the process of tabling an amendment that would change the panel to that effect, so that it would speak to the patient. Hopefully, that provides some more reassurance for my hon. Friend. I am sure that we are working very effectively through the Committee process to achieve what we all want to see.

[Naz Shah]

I am pleased to hear that my hon. Friend will table further amendments, but I have not seen that amendment, so I cannot speak to it.

I would slightly beg to differ with my hon. Friend in terms of making progress in the way that I would like to have seen. I would just gently remind her that I am not convinced that we are. I think we are making good progress, but I also voted against one clause stand part and had lots of concerns about another one, so we will agree to disagree on that one.

The non-governmental organisation The Other Half observes in its written evidence to this Committee—TIAB 104—that the Bill makes no provision to identify family members who may benefit financially from the death of a patient, and, therefore, the Bill is unable to protect the vulnerable. That is something that I have said before in this Committee.

This amendment makes training in respect of financial abuse mandatory. It is vital that a medical practitioner is trained on how to identify coercion—we can all agree on that—but coercion is different from domestic abuse. Coercion may be relatively obvious to spot, but, in contrast, coercive and controlling behaviour is much less obvious. It can be subtle. It can be hidden, and unexpected to an outsider. It requires much more sensitive questioning and a degree of a doctor-patient relationship to identify. Multiple people have raised that a patient-doctor relationship is important for spotting that, and, currently, there is nothing in the Bill to say that the two independent doctors have to have met the patient before.

That subtle coercion could have happened over years. We have repeatedly heard from people giving evidence that it is really hard to spot, and the reason it is hard to spot is because it is a matter of trust for a patient to be able to tell somebody—for a victim of coercive control to be able to express that. Even recognising that there is subtle coercion going on is hard for victims of that coercion to understand.

If there is domestic violence—again, I say in this Committee that I first campaigned on domestic abuse in the mid-1990s, and I am not convinced that the stats have changed much. I will refer to some more later on, as I make progress, but it takes women, on average, 40 times to leave an abusive partner—40 times—and it took me a long time to leave my abusive forced marriage when I was very young. The coercion that happens is so subtle and, again, when it is repeated coercion, it is hard to even recognise it as a victim, let alone for a professional to be able to see it. Even when a professional may pick up on it, it is acknowledgment from the victim—that they recognise what is happening—that is important, and that often is not the case.

Again, multiple people have raised that the doctor-patient relationship is important, and there is nothing currently in the Bill to ensure that there is a long-standing relationship between the doctor and the patient. Therefore, it is unreasonable to assume that someone in an abusive relationship, or who experiences coercive and controlling behaviour on top of their terminal illness, would be willing and able to disclose that to a stranger, even if that stranger is a doctor.

On top of that, research suggests that a significant proportion of medical staff in the UK do not feel that they have had adequate training to spot domestic abuse. Research by YouGov and the charity SafeLives in 2018-19 found that half of UK healthcare professionals are untrained to spot domestic abuse.

I understand the current difficulty in ensuring that doctors have a prior relationship with patients; it may not be practically possible. In many cases, where patients will know their doctors, or even know them well, it is even more vital that both doctors have been thoroughly trained in spotting coercive-control behaviour.

Like the other Labour MPs on the Committee, I was elected on a manifesto pledge to halve violence against women and girls within the next 10 years. We must not forget that as we scrutinise this legislation; I want my colleagues and I to remain committed to that in this Bill.

This Bill will have particularly grave consequences for women, since we know that domestic abuse disproportionately affects them. The crime survey for England and Wales estimated that 2.3 million people aged 16 years and over experienced domestic abuse in the year ending March 2024. Of those, 1.6 million were women and 712,000 were men. In the same year, there were only 51,183 domestic abuse-related prosecutions—a very small number compared with the number of people who experienced domestic abuse. That is in addition to the abuse of our elderly, on which Age Concern submitted evidence. Those figures demonstrate that we already frequently struggle with bringing domestic abuse cases to prosecution stage. They show that even the dedicated members of our caring professions have trouble detecting domestic abuse. If something is hard, we need to train our doctors to do it.

Our society already diminishes the status of elderly, infirm women and I have concerns that the Bill will further entrench that. We need to be aware of and ensure that we address the problem of mercy killings in the Bill. That issue is distinctly gendered and the Bill as currently worded will have a distinctly gendered impact if we do not address it. In 2024, The Other Half carried out a review of more than 100 UK cases of so-called mercy killings. It found that

“‘mercy killings’ are not the wanted, ‘hastened’ deaths that need assisted dying.”

Instead, the review found that:

“They are overwhelmingly violent domestic homicides of women, by men: and show that our society is still poor at detecting and responding to domestic abuse.”

Some groups are more vulnerable to domestic abuse than others. A higher proportion of people aged 16 and over with a disability—a group that we know is vulnerable in relation to the Bill—experienced domestic abuse in the last year than those without a disability.

The law and Parliament have, unfortunately, taken a very long time to even start adequately responding to these problems. Coercive control was first recognised as a distinct offence in English law only in the Serious Crime Act 2015. As written, the Bill would not mandate training to the doctors whose role it would be to consider assisted dying cases. Of course, no training can be perfect, but to allow the Bill to go forward without ensuring that doctors have training in this complex matter would be negligent. It would mean that we were failing to even try to carry out our responsibilities to protect people, especially women, in abusive and coercive relationships.

I appreciate that my hon. Friend the Member for Spen Valley has said that she will accept the amendment, but it does not go far enough. The question is: how do we prevent abusers making use of the Bill if it becomes law? The amendment gives us one way of mitigating that risk to a degree. We already have issues recognising domestic abuse. The amendment cannot perfectly solve that problem, but it would take steps to do so.

We must safeguard vulnerable people who live subject to coercive and controlling behaviour on a daily basis from opting for assisted dying as a result of that environment. Thorough and specific training on spotting that is vital for doctors. I am grateful that my hon. Friend, in accepting the amendment, will ensure that some of that training will be forthcoming. Even one abused person being driven by their abuser to use assisted dying is one too many. I am confident that all hon. Members would agree with me on that deeply important point.

In the last few days, I have been looking at suicide, and one of the issues that has come up is that last year, for the first time in our history, suicide by victims of domestic violence overtook deaths from what we would term intimate partner homicide. In the last two weeks, there have been further reports highlighting that the number of women driven to suicide because of the experience of domestic violence has risen. Tomorrow, my hon. Friend the Member for Birmingham Yardley (Jess Phillips) will read the name of every woman who has been killed in the last year, as she does every year. Two of those women were my constituents, and many more kill themselves to get away from their abusers.

[The Chair]

Order. I understand where the hon. Member is coming from, but I think she is very close to moving outside the scope of the amendment, so can I ask her to bear that in mind? As I have said, this is a very sensitive issue and I am giving people latitude, but that cannot go too far. I do not want to interrupt Members, but I will if they do not stick to the confines of the amendment.

[Naz Shah]

I am grateful, Mr Dowd. I will bring my remarks back to the issue in the amendment, which is related to training. I will also bring them back to the issue of interpreters.

In November 2023, the Imkaan group issued a report, “Life or Death?” It literally is a matter of life and death. The report talked about the use of interpreters, training and minoritised women. Imkaan said that

“The availability and use of quality interpreting services can be critical to women’s access to safety and protection”

and that the current position on police use of interpreters breaches the Equality Act and amounts to indirect discrimination. It also breaches the commitments under the Istanbul convention. I appreciate that that issue is about police training, but surely the principles are exactly the same. We have a service—the police and domestic violence services—which supports victims of coercive control and of domestic violence. Unfortunately they come into contact with it, as our NHS and our medics do, way too often for my liking.

[The Chair]

Order. The issue of interpreters is not within this group. I am just trying to look for that and it is not in this group, so I am afraid the hon. Lady is out of scope of the clause. It is in a later group, so perhaps she could pick it up then.

[Naz Shah]

I thank you, Mr Dowd. My apologies. I have made a mistake, but I was referencing the comments of the right hon. Member for Dwyfor Meirionnydd about the use of languages, which is the subject of one of the amendments; that is my understanding. But again, I am happy to be guided by you, Mr Dowd.

To come back to the issue of training and domestic violence, in Committee, we heard evidence from Dr Jamilla Hussain about minoritised women. Again, from the data collection of ethnic minority groups, training is right at the top of the agenda, whether it be training of doctors or specialists.

Language is important when it comes to training as well. When people are training or trained to look at coercive control and to spot that coercive control, there is often an interpreter between them and the victim who is being assessed. They may be an ethnic minority woman or a man from an ethnic minority background whose first language is not English, so that training would need to include cultural sensitivities in relation to spotting coercion and control, and to repeated coercion in particular.

These are subjects that are already taboo for people to discuss. We know the issue of domestic violence is hard to spot. We have repeated that time and again, as have others. We talk about training, but that has to go further when it comes to victims or people seeking assisted dying who are from ethnic minority backgrounds and who have different cultural understandings. I talked about yesterday that. The hon. Member for Reigate also talked about the issue: the understanding of assisted dying among ethnic minority communities is very different if there is a language barrier.

I would like to ask the promoter of the Bill, my hon. Friend the Member for Spen Valley, whether her amendment will go further in addressing some of the inequalities and intricacies that are presented when we are dealing with women from ethnic minority communities or elderly people from ethnic minority communities. I would be happy to sit down and talk her through those issues, so that I can support the development of her amendment to address the concerns I have raised today.

[Danny Kruger]

The hon. Lady talked earlier about the tragedy of victims of coercive control who commit suicide. Does she consider that the amendments we are looking at will help to address that challenge? What specific support does she think victims of coercive control would need to prevent them from taking that terrible step?

[Naz Shah]

The hon. Member asks a very important question. When I am talking about reflective services for black and minority ethnic communities, which is something I have delivered training on and worked on in a previous role, I often use the example of my mother, who was a victim of domestic violence. Had she been arrested by a woman instead of a man, her experience might have been different. Had she had a solicitor who was a woman, not a man, her experience might have been different. Had she had judges who were women, not men, her experience might have been different. Let us now add another layer to that. Had the police officer been a woman from the background she was from, they might have understood it.

The same analogy potentially applies to patients who are asking about going down the route of assisted dying, because it is helpful if somebody comes from the same cultural background. If a female victim of domestic violence or coercive control meets a specialist doctor who looks very similar to the hon. Member for East Wiltshire—a white, middle-class male—and he does not have that cultural understanding, he will then rely upon training, and he will no doubt rely upon an interpreter to translate.

That is the kind of thing I am trying to tease out, and these are the kinds of protections I want to see in the Bill. If we want a Rolls-Royce service, and if this is to be the best Bill in the world, it cannot ignore the most vulnerable in society. If the patient is a disabled woman, it is whammy upon whammy and layers upon layers of intersectionality that the Bill does not address. That is why I want to see the Bill strengthened.

I want to talk about the training that doctors get and the training in palliative care. We heard from Dr Jamilla Hussain, who was very clear about the fear among minoritised communities because of what happened during the covid pandemic, with “do not resuscitate” orders and their whole experience. Some people potentially died who could have been saved because they did not have the trust in NHS services to access them.

In this instance, it is important that we have a first doctor. That first doctor might have no relationship with the patient because their regular doctor does not want to engage in the process. Let us take the example of a patient in Bradford West who has had a diagnosis of terminal illness. They might well have a doctor or consultant who has been dealing with them for six months or even a year, to the point where they have reached the terminal stage. They might have a relationship with that doctor, who might have spoken their language and might be from a particular faith background but who does not want to engage in the assisted dying process. According to the Bill, that doctor would then have to refer that patient on to somebody who is prepared to have that conversation, but that person might not have that training or those language skills, and they might not—

[The Chair]

Order. The hon. Lady needs to keep her remarks to amendment 20. I have looked at other amendments to which this is relevant, including amendment 186, but that has been starred. I exhort the hon. Lady to focus on the particular issues covered by amendment 20.

[Naz Shah]

Thank you, Mr Dowd. My understanding is that this all relates to amendment 20, and I am happy to clarify why. Ultimately, this is about the professional’s intervention with a patient, and the amendment is about training people adequately to assess coercive control and domestic violence. I am trying to demonstrate—I accept that I might not be doing it well enough—that there is a pathway and a catalogue of things that relate back to the person who is being assessed. I am trying to explain to the Committee in detail, because I feel very strongly about it, what that care pathway might look like for somebody, and why the amendment, although I welcome it, does not safeguard the most vulnerable in society. I am happy to be guided if that is not what I am doing, but that is certainly what I am attempting to do. May I carry on, Mr Dowd?

[The Chair]

The hon. Lady should take this in the spirit in which it is intended. Dipping in and out of issues throughout the course of a speech is okay, but I am afraid that dipping in and out of issues that are not relevant is not, and we are getting to the stage where the information she is imparting is not necessarily relevant, in significant elements, to the amendments that we are dealing with.

[Naz Shah]

Thank you, Mr Dowd. I would argue otherwise. I would say that actually, every single—

[The Chair]

Order. My ruling from the Chair cannot be challenged. I exhort the hon. Lady to stick to the amendments before us. If she does not, I will have no other option but to intervene and move the debate on.

[Naz Shah]

Thank you, Mr Dowd.

I come back to the issue of potential coercive control, which is what amendment 20 addresses. As I have outlined, there are patients who could be in that position. Given the examples that I have put before the Committee, I argue that the amendment, although it is brilliant in getting us to a better place than where we started out with the Bill—I am pleased that my hon. Friend the Member for Spen Valley has indicated that she is happy to discuss strengthening the safeguards—does not go far enough, for the very reasons that I have outlined, and no doubt will outline further when speaking to other amendments.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Dowd. As I have said, the Government remain neutral and my role 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.

The Government remain committed to ensuring the legal robustness and workability of all legislation, so I have worked closely with my hon. Friend the Member for Spen Valley on some amendments. Where changes have been mutually agreed by my hon. Friend and the Government, I will offer a technical, factual explanation and rationale for the amendments. Those include amendments 185 and 186 in this group. The Government remain neutral on the Bill and do not have a position on assisted dying.

This group relates to the necessary training, qualifications and experience of the co-ordinating doctor. As drafted, clause 5 gives the Secretary of State the power to specify the training, qualifications and experience required for a registered medical practitioner to act as a co-ordinating doctor, but there is no legal duty for the Secretary of State to do so. Amendments in this group either seek to change that power to a legal duty, or would introduce specific training, qualifications and experiential requirements for a registered medical practitioner to act as a co-ordinating doctor.

Amendments 185 and 186 tabled by my hon. Friend the Member for Spen Valley would introduce a duty on the Secretary of State to make regulations regarding the necessary training, qualifications and experience of the co-ordinating doctor. Giving the Secretary of State a duty rather than merely a power would ensure certainty as to the training, qualifications and experience that the registered medical practitioner must have in order to act as a co-ordinating doctor. The Secretary of State’s duty in this respect would include making provision in regulations about training for co-ordinating doctors relating to assessing capacity and assessing whether a person has been coerced or pressured by another person. Amendment 186 would also enable the Secretary of State, subject to the specific training requirements already mentioned, to delegate the determination of the training, qualifications and experience needed for a co-ordinating doctor to a person specified in the regulations. That would allow that determination to be delegated to a body or bodies with appropriate expertise, in line with other aspects of training for healthcare professionals.

--- Later in debate ---

[The Chair]

It is not for me to make that decision.

[Naz Shah]

I wish to divide the Committee on amendment 290.

Question put, That the amendment be made.

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[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.

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[Stephen Kinnock]

The challenge in the hon. Gentleman’s amendment is the term “total turnover.” A GP would have to extrapolate from the service provided to a whole range of other costs that may apply—for example, the share of the overhead they pay into their primary care network, the share of admin costs or the rent on their building. The definition of total turnover is the entire cost and entire revenue from the tariffs. As officials have made clear, this additional level of complexity would be an onerous task, although not necessarily impossible.

Total turnover is one side of this issue; the other, much more salient point is the quantum leap between having transparency on a particular tariff and pointing at a specific doctor and saying, “You over there—you did this much work on that much tariff, and that’s how much money you made for it.” There is a big difference between the two.

[Naz Shah]

I also do not like the idea of doctors being identified in such a way, as they have with abortion clinics, but I am trying to understand how we will protect these services. If it is an NHS provision and specialty, with doctors in certain practices signing up to provide services for assisted dying and becoming either the primary or the secondary doctor, by definition those will be the practices to which people will refer. That will become common knowledge, just as it is for musculoskeletal or podiatry services, for example. In this instance, there would be an assisted death service, and there would clearly be practices that do not provide it. How would we then protect the doctors? How will the Government respond to all these concerns?

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

Naz Shah Excerpts

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Kim Leadbeater]

Amendment 419 provides that the co-ordinating doctor may witness the first declaration only if satisfied that a preliminary discussion of the kind mentioned in clause 4 has taken place and that a written record of it has been made. The co-ordinating doctor must have made or seen a written record of the preliminary discussion. Amendment 189 adjusts the wording so as not to suggest that a first declaration has been made before it is witnessed to clarify that proof of identity must be provided before the declaration is signed and witnessed.

Amendment 190 provides that the required two forms of proof of identity must be provided before the person signs the first declaration. Amendment 191 provides that the co-ordinating doctor may witness the first declaration only if satisfied that the requirements of clause 6(2) are met; that is to say, that the patient has provided two forms of identity to the co-ordinating doctor. This is a relatively straightforward set of amendments to tidy up the requirements around proof of identity.

[Naz Shah (Bradford West) (Lab)]

I rise to speak to amendments 291, 292 and 293, which were tabled by my hon. Friend the Member for York Central (Rachael Maskell). I do not intend to press them to a vote; they are probing amendments. They all relate to the amendments tabled by my hon. Friend the Member for Spen Valley about the identification required of applicants for assisted dying. They do not change those requirements; they take a more logical and businesslike approach to proving that those requirements are met.

Amendment 291 would change the current requirements on identification and require applicants for assisted dying to produce a piece of photo ID and proof of residence in the UK for the previous year. As currently written, clause 6(2) states:

“The person must, at the same time as that declaration is made, provide two forms of proof of identity to the coordinating doctor and the witness mentioned in section 5(2)(c)(ii).”

Subsection (3) states:

“The Secretary of State may, by regulations, make provision about the forms of proof of identity that are acceptable for the purposes of subsection (2).”

Surely that is not tight enough.

In particular, the Bill as written does not specify that either form of proof of identity should be photo ID. That may be a major omission. For much less significant decisions, the law of England and Wales requires at least one form of photographic ID. For example, there is currently a requirement to have photo identity to work on the parliamentary estate, vote, or have a bus pass or railcard. None of those is as important as applying for an assisted death.

I remind hon. Members that assisted death is a process that would end in a person being issued with and then taking a mixture of lethal drugs. In a hospital setting where drugs are dispensed, rigorous processes are undertaken to verify the patient. Drug errors are not uncommon. The previous Health and Social Care Committee’s report into pharmacy witnessed how clinical practice was being improved to reduce drug errors. Given that a lethal dose is dispensed as part of this process, the identification mechanisms are weak and should be addressed in this preliminary stage through the provisions set out in this amendment. It is possible that the wrong person could be prescribed the medication. That would be an extreme case, but we are talking about creating a wholly new power that would relate to life and death. We are talking about making assisted dying available to people who are, in many cases, extremely distressed. People in extreme circumstances will sometimes do extreme things. We should expect some extreme cases and seek to guard against them.

Amendment 291 would provide such a safeguard. The Bill says that to qualify for assisted dying, applicants must have been resident in the UK for at least a year, but it does not ask them to provide any proof of that residence. In such a serious matter, we surely cannot simply accept someone’s word that they live in the UK. Making that a requirement without a test to establish it de-values the importance of the criteria for qualifying.

Amendment 292 would change clause 6(3), which currently reads,

“The Secretary of State may, by regulations, make provision about the forms of proof of identity that are acceptable for the purposes of subsection (2).”

The amendment would change that “may” to a “must”, as the former treats the identification process with reduced seriousness. If the word “may” stays in legislation, there is no obligation to have rigour in the identification process. As drafted, the Bill is more open for abuse.

Amendment 293 seeks to place the regulations concerning identification under the affirmative procedure, which the hon. Member for East Wiltshire mentioned earlier. Assisted dying is so important that no regulations made under it should be drawn using the negative procedure. As Members will know, if a statutory instrument is made under the affirmative procedure, it must be approved by Parliament within a certain timeframe, which is usually 28 or 40 days. If that does not happen, the change to the law made by the statutory instrument will not take place. In the Bill as drafted, these regulations are covered by the negative procedure, which means that if and when the Secretary of State decides to change them, they could go through on the nod unless Members raised an objection. A statutory instrument laid through the negative procedure becomes law on the day the Minister signs it and automatically remains law unless a motion rejecting it is passed by either House within 40 sitting days.

Placing all changes to regulations under the affirmative procedure would ensure that we have scrutiny by Parliament. We should all approve this. Our responsibility for this legislation will not end when and if it becomes an Act of Parliament. These amendments speak to tighter safeguards and parliamentary scrutiny for all new regulations made by the Secretary of State in relation to identity and residence. All hon. Members should support them.

[Danny Kruger]

I will quickly echo the points well made by the hon. Member for Bradford West in support of the amendments in the name of the hon. Member for York Central. It is important to specify the form of identity that will be presented. The person presenting themselves for an assisted death needs to be who they say they are. At the moment, the power to specify the forms of proof of identity has no minimum requirements. As written, it does not require the Secretary of State to specify what is acceptable.

Two specific aspects we have to pay particular care to are age and residency. The process must be accessible only to over-18s. I am concerned that we rejected amendments yesterday that would have prevented people under 18 having the conversation. In light of that, it is even more important that we make it clear that people who access assisted death must be adults. We need to ensure that the forms of identity are specified and that Parliament can satisfy itself that they are robust.

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[Danny Kruger]

We cannot have it both ways. We cannot give doctors and clinicians autonomy, which the Committee has repeatedly seen as a ground to reject all sorts of obligations that I and others have proposed to ensure that doctors do the job in a specific way, and then suggest the opposite in this instance. I recognise what the hon. Gentleman says, and he may be right that that is inappropriate.

[Naz Shah]

Does the hon. Member agree that perhaps the amendment is not just about the context in which it has been referred to so far, but about protecting doctors in future? When mistakes happen, people would have a means to protect themselves.

[Danny Kruger]

The hon. Lady is absolutely right. We should not forget that doctors are indemnified against any civil claims under the Bill. Nevertheless, they will want to protect themselves against the accusation that they inappropriately prioritised one case over another. That is the purpose of the amendment, and I urge the Committee to support it.

I will finish with this point. I am ashamed to say it, because my party was responsible for the NHS for the 14 years until last year, but the fact is, as Labour Members said frequently when they were in opposition, that there are enormous resource constraints on the frontline in the NHS. I do not think that is inappropriate to consider, when we create a new service, how it might have an impact on existing treatments in the NHS. Leaving aside all the ethical questions, including on coercion and capacity and our concerns in that respect, what will this mean for hard-pressed GPs and clinicians of all sorts on the frontline? What protections can we offer them when they make difficult decisions about whether to support an assisted death application?

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[Kim Leadbeater]

That has been a very useful discussion. I have nothing to add.

[Naz Shah]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Daniel Francis]

I beg to move amendment 347, in clause 7, page 4, line 4, leave out from “to” to the second “the” in line 5 and insert—

“ensure that steps have been taken to confirm that”.

This amendment would remove the emphasis on the role of the coordinating doctor in making these assessments.

--- Later in debate ---

[Daniel Francis]

I agree with my hon. Friend about the number of amendments in this vein, but clearly the amendments suggested by my hon. Friend the Member for Hackney South and Shoreditch bring us into line with existing regulations. In her evidence, Dr Cox said:

“If we look at the evidence of suicide, we know that it is increased in people with serious illnesses, but it is actually increased in the first six months after diagnosis, not in the last six months of their lives, so it is about the trauma of the diagnosis.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 82, Q105.]

It is likely, therefore, that those diagnosed with a terminal illness will experience mental distress that could affect their capacity to make a decision about an assisted death. In her written evidence, Dr Virginia Goncalves, a retired clinical psychiatrist with over 30 years of experience in the NHS, writes:

“In my consultant psychiatrist role, I have encountered many desperate and suicidal patients wanting to end their lives after struggling with longstanding mental distress, who could have easily sought the option of assisted suicide if it had been available to them! But however depressed and hopeless they felt, with a compassionate and hope filled approach from their care givers and the correct medical and psychological treatment, the vast majority recovered enough to be able to have a ‘life worth living’. In so many cases, these patients have thanked me later for not giving up on them! Not once have I heard anyone say ‘you should have let me die when I wanted to do it’.”

A meeting with a psychiatrist or other psychological specialist will protect people who may otherwise not have chosen assisted dying. I emphasise again that we already ensure that patients who will donate an organ have this assessment, so why not those seeking an assisted death? We must protect vulnerable terminally ill people from being coerced into assisted death, and psychiatrists and other specialists are best placed to spot that. That is why the assessment is included for living organ donation.

[Naz Shah]

Does my hon. Friend agree that this is a safeguard that would actually strengthen this Bill, especially given the conversations we have had around repeated coercion?

[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.

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[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.

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[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.

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[Sarah Olney]

The hon. Member is absolutely right. The Court of Protection has described eating disorders using language typically reserved for terminal illnesses. It has described an eating disorder as being in “the terminal stage”, talked of “all treatment options” having “been exhausted” and used words such as “incurable”. It is immensely regrettable, but nevertheless the case—even though eating disorders are always treatable—that if a person suffering from an eating disorder is deemed to have capacity and is refusing treatment, there may well be nothing that can be done to stop them choosing that path, which may ultimately lead to their death.

[Naz Shah]

Is the hon. Member aware that in nine of the 10 cases that went before the Court of Protection, the young ladies were deemed not to have capacity, but the judge still decided that it would not be in their best interests to feed them, and they were put on palliative care pathways?

[Kit Malthouse]

They did not have capacity.

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[Lewis Atkinson]

Indeed, and that is why I support amendment 6, which we have just debated, to mandate referral for psychiatric assessment in cases where there is any doubt whatever. I think we have incorporated those safeguards and more but, fundamentally, as Chris Whitty said in evidence, for this legislation to be as secure as possible, we have to base it on the Mental Capacity Act, which has been tried and tested through the courts for more than 20 years.

The insertion of language talking about impairments of judgment clearly deviates from that Act, where an impairment test is already set out. I do not feel that is appropriate. I absolutely applaud the sentiments behind the amendment, but I feel we have sufficiently strengthened the Bill elsewhere and that the MCA and other provisions give the safeguards and the reassurance that we need on these issues.

[Naz Shah]

Apologies, Mrs Harris: I was late returning to my seat earlier and missed the opening remarks from the hon. Member for Richmond Park on this amendment. I am happy to be corrected, but my understanding is that, as it is, if somebody has anorexia—we are not talking about capacity, which I referred to in the cases of the nine girls I spoke about—that is an accepted mental health condition and the amendment is trying to exclude those people from having an assisted death. In the nine cases I spoke of, the court found that those girls with anorexia had capacity and ruled that they had a terminal illness.

[Kim Leadbeater]

I apologise, but I thought my hon. Friend said that they did not have capacity.

[Naz Shah]

Sorry—they did not have capacity, but the Court of Protection still ruled that they would be taken down the route of palliative care. This is not just a matter of capacity; in this instance, when we talk about mental health—before we even get to the capacity question—the issue is that anorexia is a recognised mental health condition. I beg to differ from my hon. Friend the Member for Sunderland Central on whether we have enough provision. We keep coming back to this issue time and again.

[Kit Malthouse]

I want to be clear, because the hon. Lady and I have exchanged views on this issue: my recollection from reading the briefing—I am happy to go back to it—is that, in those nine cases, the girls were found not to have capacity, but the judge then took the decision not to force-feed them because force-feeding them was likely to be threatening to their health and might precipitate their deaths. I do not think it is quite right to say that the judges put them on a palliative pathway. They declined to force-feed them on the basis that they thought it was in their best interests and that force-feeding them might actually precipitate their deaths.

[Naz Shah]

I thank the right hon. Gentleman for his intervention. When I came to this place, somebody said to me, “There’s the letter of the law and there’s the essence of the law.” As lawmakers, we make indications, and so do judges. By not opposing something, does that mean that by default we are supporting it? That is the question here for me. In those cases, those judges accepted—as he says—that those girls would inevitably die. Although the judges did not state that they put the girls on a palliative care pathway, by default, in my understanding, that was a palliative care pathway because it was accepted that those young girls were going to die by not being fed. It is just a matter of semantics for me.

I come back to the debate that we have just had. For me, the crux of the issue is that if someone has a mental health condition that then, by definition, becomes a terminal illness—regardless of the capacity conversation—this amendment surely strengthens the safeguard for them. By and large, this involves women who experience anorexia so this conversation is very gendered. I am happy to be corrected. That is all I have to say on the matter.

--- Later in debate ---

[Jake Richards]

I want to speak to amendment 57. I do not intend to press it to a vote, but I will explore whether and how the Bill could be improved in terms of the relationship between the two doctors. There is a tension here. On one hand, we want to keep the two doctors separate, because the second one can then assess the person with a fresh perspective. We have had a debate about where there is a relationship between the doctors, which could cause problems as well. On the other hand, the evidence that we heard from some witnesses who gave evidence to the Committee was that decisions or assessments taken together can be more efficient and safer.

We may come back to this issue when we consider clause 9—next week, I presume, looking at the clock—but I wanted to raise it now. I have had conversations with the promoter of the Bill about it, but we also need to have conversations with Ministers about the best way to regulate the relationship between the two doctors to ensure that it is safe in the way that it keeps them separate but allows them to confer.

[Naz Shah]

I rise to speak to amendment 21, tabled by my hon. Friend the Member for Lowestoft, which is about the second, independent doctor. We debated amendment 20 earlier, and I am genuinely very pleased that the promoter of the Bill accepted that amendment. Some of what I would like to say now will be repetition, because it is a similar amendment, but I will try to keep my remarks contained and shorter.

I am not sure whether the promoter of the Bill is planning to accept amendment 21 as well as amendment 20 —for both doctors. I will be happy to give way if she wants to clarify that now.

[Kim Leadbeater]

I am indeed happy to accept amendment 21 as well.

[Naz Shah]

Oh, perfect. I am really pleased that my hon. Friend will accept both amendments 20 and 21, tabled by my hon. Friend the Member for Lowestoft. Amendment 21 is about training. Although I welcome the amendments being accepted, my concern is that the amendment for training does not go far enough. We are talking about repeated coercion here, and my hon. Friend’s intention with the amendment was for people to be trained in picking up repeated coercive control. That is very different from domestic abuse, in terms of its manifestation and how it is picked up. From lots of evidence we have received, both written and oral, we know that coercive control is hard to detect. When it is repeated coercive control, it is even harder.

I want the Bill to be strengthened, especially when it comes to minoritised communities and older people. From a safeguarding perspective, the Bill’s impact is very gendered. It is International Women’s Day this week, and this is a very heightened issue. We celebrate women in this place because we do not have equality for women in our systems, across the globe and in this country. From the research and evidence we have had, we know that this Bill would impact more upon women, so it is important that we extend the training. As I suggested earlier, I would be happy to work with my hon. Friend the Member for Spen Valley to look at tabling another amendment and strengthening this safeguard, because I really want to get this one right.

Although I talked about this earlier, there are some statistics on suicide that I did not mention, which is why I want this training. Only this afternoon, I came across some research from the Kent and Medway NHS trust. In addition to research from last year, it has been found that women will kill themselves when they experience domestic abuse. For the first time, the number of women killing themselves as a result of domestic abuse has overtaken the number of women who are killed from domestic violence in intimate partner relationships. Bear with me—I will return to the research from the Kent and Medway trust in a moment, because I cannot seem to locate the statistics I wanted to point out. Either way, I want to support my hon. Friend the Member for Spen Valley to get this Bill right.

[Sojan Joseph]

We are talking about a very important issue in relation to training. Most training provided in the NHS, whether on the capacity assessment or domestic violence, is mandatory training that people are expected to retake yearly. Unfortunately, reports—especially the CQC reports—show that NHS trusts across the country are not fully compliant with this training, especially doctors, who are conducting this kind of training very poorly. Does my hon. Friend agree that just introducing training is not enough, and that we have to monitor compliance as well?

[Naz Shah]

I thank my hon. Friend. I agree with his previous point, as well as the point made by the promoter of the Bill that the training that will be provided under this Bill should welcome that conversation with women, especially those who are victims of domestic abuse.

I have now found the research I wanted to share. Tim Woodhouse is a suicide prevention expert from Kent and Medway council, and he carried out research over five years until 2024. He estimated that about 30% of all suicides in that sample of people, largely women, experienced domestic abuse. Woodhouse estimates, in the UK as a whole, that

“over 1,800 lives are being lost in domestic abuse related suicides every year.”

He described that as

“a scandal, and national tragedy,”

and I completely agree with Tim’s assertion. When it comes to women from ethnic minorities who have cultural differences, potentially including language barriers and different understandings of coercion, it is even harder to tease out their experience in any assessment from the first doctor or second doctor. I would therefore welcome any strengthening of the amendments.

[The Chair]

I call Steve Kinnock—sorry, I meant Minister Kinnock; he is Steve to his friends.

--- Later in debate ---

[Kim Leadbeater]

I will not test the patience of the Committee by repeating the Minister’s comments on amendments 197 and 198, but he is absolutely right that they relate to the duty imposed on the Secretary of State to make regulations about the training, qualifications and experience required to act as the independent doctor. I hope that Committee members can support them.

Amendment 21 was tabled by my hon. Friend the Member for Lowestoft, and further to my comments this morning on the very similar amendment 20, I am very pleased to support amendment 21. We have spoken a lot about the training requirements for the provisions of the Bill, and I firmly believe that we have to set ourselves the very high standard of having the best training that we possibly can for medical practitioners involved in the processes set out in the legislation. It is vital because only those medical practitioners who have chosen to undergo such training would be allowed to play the role of assessing doctors.

We have already discussed many of the components that will be required in that training, but it must include assessing capacity and detecting coercion or pressure, which is in line with this amendment, so I am very pleased to support it in that regard. Doctors must have appropriate qualifications and experience to ensure that those seeking assistance under the legislation are in the best possible hands throughout.

I also welcome the comments made by my hon. Friend the Member for Banbury about the wider benefits of such training, which is a really important point to make. It feeds into the wider benefits that there would be for not just the health service but society as a whole. It also feeds into the work that is being done by the Home Office and my hon. Friend the Member for Birmingham Yardley (Jess Phillips), who is the Minister for Safeguarding and Violence Against Women and Girls—I just had to google the fancy title that she goes by nowadays. There is a broader conversation to be had about society and the role of training for coercive control, financial abuse and domestic abuse. I support amendment 21, along with my amendments 197 and 198.

Amendment 56 negatived.

[Naz Shah]

I beg to move amendment 301, in clause 8, page 4, line 39, leave out “7” and insert “14”.

This amendment would increase the period of reflection to 14 days.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 317, in clause 13, page 9, line 12, leave out “14” and insert “28”.

This amendment would provide 28 days for the second period of reflection instead of 14.

Amendment 314, in clause 13, page 9, line 17, leave out

“48 hours beginning with that day”

and insert

“7 days beginning with that day and the person must be referred immediately for urgent specialist palliative care.”.

This amendment would increase the second period of reflection in cases where the coordinating doctor reasonably believes the person will die within a month from 48 hours to seven days.

Amendment 315, in clause 13, page 9, line 17, leave out “48 hours” and insert “7 days”.

This amendment would increase the second period of reflection in cases where the coordinating doctor reasonably believes the person will die within a month from 48 hours to seven days.

[Naz Shah]

These amendments were tabled by my hon. Friend the Member for York Central. Amendment 301 seeks to provide a time of reflection of 14 days, not seven. As somebody pointed out, the industry standard for returning something bought in a shop far exceeds the cool-off period set out in the Bill. The reality is that the NHS is under such duress, with patients waiting weeks to see their GP for anything other than urgent treatment, that being able to get an appointment with a GP in seven days is something that we are unlikely to see.

It is right that doctors are able to triage their patients to ensure that those who require medical interventions to keep them well, prevent hospital admissions, or stop them deteriorating or even dying, are seen as a priority. This Government are trying to protect the NHS, and the best way of achieving that is to ensure that medical interventions are sought and provided at the earliest opportunity before a patient deteriorates. Giving someone who is dying within the terms of this legislation longer to reflect—just a further week—removes such pressure from GPs or consultants and enables them to properly prioritise their patients. It does not build a false expectation in patients that they have a right to rapidly have a consultation. Likewise, we know that it can currently take weeks, if not months or over a year, for patients to see another consultant, but the clause does not suggest that. It would therefore be helpful and better for the patient to have a more realistic period before moving to the next stage of their assessment.

Issues of intensity, such as someone planning to take their own life, should not be rushed. We know from all the work that has been undertaken on suicide that other interventions, conversations and reflections can help with reflection and reconsideration. It is important that people are given that opportunity. The first time a patient raises the matter with their doctor, the doctor would have provided them with lot of alternative information—for instance, on what treatment options are available. They might also have had a palliative medicine consultation to review their options. There needs to be time for the patient to really reflect on all that new information.

We know that when people are presented with information, it takes time for them to absorb and analyse it. Therefore, extending the period to two weeks—although that is arguably still too short a timescale—would be good practice. It would be in the interest of the person and of the carers, as we know from other jurisdictions that family often say that the process was too quick for them to be able to absorb. It could also enable a patient to make alternative choices. In medicine, practitioners want patients to make informed decisions and to have time to assure themselves of the choices they make. In the light of the Committee’s vote to block the amendment that would have ensured that a palliative care specialist was involved in the counsel to support someone with decision making as they are dying, it is right that more time is given for patients’ considerations.

Amendment 317 would provide 28 days, not 14, for second period of reflection. In line with good practice, extending the reflection period is important. I spoke about that at length when we debated my amendment 277. It is important for the patient to be able to fully explore their options and seek wider counsel before determining to take the route of assisted death. This part of the process is perhaps the most important. The period after a patient has completed their assessment and received court approval or that of the commission and panel—should the Committee choose to change this—will be the main period where they determine whether they want to go through with ending their life. It is right to ensure that the legislation provides time. This is such a monumental decision, so that a patient has to be assured that they are making the right decision and have had time to really reflect on it and contemplate all other options available to them.

The process appears to be very rushed, and a patient could be caught up in the moment of getting through the stages. It will be intense. There will be lots of information. There may be new things for the patient to consider. Having a proper break clause would enable a patient proper time to reflect and consider in detail everything that has happened in the process to date, and then to contemplate their further options. We know that patients often need to hear information several times before they fully absorb what is being said and what is happening.

--- Later in debate ---

[Kit Malthouse]

I completely agree. We have to strike a balance here. The point I am making is that, within an envelope of six months, 42 days is far too long, so I am afraid that I flatly oppose the amendments. They are based on a fundamental misunderstanding: the idea that people will just show up at six months, that their disease progression will be linear, and that they will then take the decision immediately, the moment they finish the reflection period. I can tell hon. Members that the entire six months, from the moment someone gets a six-month diagnosis, will be a reflection period.

[Naz Shah]

I appreciate the right hon. Gentleman’s comments. He referred to the same thing twice, yesterday and today, and I just want to clarify it. He said that most people are ill for a while. I have a genuine question. I do not have the research, but my understanding, as a member of the public and a Member of Parliament, is that for many people who get a terminal diagnosis of six months, it will have been very sudden. Does he have any research to suggest that most of these patients will have been on the kind of trajectory he describes?

[Kit Malthouse]

I depends on the disease, but many people will struggle with, for example, breast cancer for five years, go through repeated rounds of chemotherapy and undergo terrible operations to try to survive; then, there will come a point when the clinicians and oncologists say, “There isn’t much more we can do for you; we think you have a few months left to live, because there is no further treatment we can offer, so aggressive is your cancer.” Other people have cancer and are free of it within two or three months, because of the nature of the cancer. Some people will reach a six-month point suddenly—it will not be dead-on six months; it might be either side—and some people will be diagnosed with pancreatic cancer with two weeks to go. We have to strike a balance and be humane in what we impose on these people, who will have a lot more to think about than the regulations.

[Naz Shah]

I want to explore that point a bit further. When I talk about a period of reflection, I am referring to the evidence that we have had from psychiatrists, who said that people’s abilities would be impacted in this situation. That is where the amendments are coming from. To come back to the previous point, is there any research or evidence that would back up the claim that many cases are longer-term illnesses, rather than people who have just got the diagnosis?

[Kit Malthouse]

Maybe I was not clear: it depends on the disease. For example, the median survival range for pancreatic cancer is six to 12 months, because it does not exhibit symptoms; people only learn very late that they have it, and that is why the normal survival curve is quite a short one. We need to bear that in mind.

We also need to remember that the more we extend the periods of reflection, the longer people will have to live with the fear of what their death will be like, and with the nervousness about whether they will be allowed to control their own death—we are granting permission here. If I have to wait 42 days, that is 42 days out of whatever I might have left—perhaps 120 days, if I am lucky—that I am spending concerned about whether I am going to die in a particular way. To me, that seems crazy.

Two of the amendments propose extending the 48-hour period to seven days. These are people who have been told they are going to die within a month. They have less than 30 days to deal with their affairs, deal with their children, talk to their family and decide what they are going to do, and the amendments propose that for seven days of that, they will have to contemplate their fear of death, rather than rush it through. It is rushing it through in 48 hours—reflecting the fact that they are going to die.

The misunderstanding is most illustrated by the fact that amendment 314 proposes that, with the extension to seven days, there should be a mandatory referral to palliative care. With a month to go, these people are by definition already being palliated. The idea that somehow they are just waltzing up, unattended to, with a month to go, and that the NHS is going to say, “Actually, we’re not going to do anything to help you” fundamentally misunderstands what disease is like at the end of life. I am afraid that I vehemently oppose these amendments. The balance in the Bill is exactly right, and I hope that the Committee will agree.

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

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

Naz Shah Excerpts

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[Kim Leadbeater (Spen Valley) (Lab)]

I have nothing to add on this group of amendments. I am confident that the Bill as drafted already includes significant periods of reflection. Bearing in mind that we are putting dying people through a very lengthy process already, I remain confident that the periods of reflection are adequate as set out in the Bill.

[Naz Shah (Bradford West) (Lab)]

I have a couple of additional comments. We talked last week about the reflection periods. I referred to the fact that when even someone buys something from a shop, they have 28 days to return it; when they are deciding on whether to have an assisted death, there is a great deal more at stake. During that debate, someone asked, “What if someone had a prognosis of just one month?”, but clause 13 has an option for a fast-track process in that situation—the person would be able to access the service in 48 hours.

I beg to differ with my hon. Friend the Member for Spen Valley, the Bill’s promoter, who said that we have enough reflection periods in the Bill. Yes, there are reflection periods, but they come after the panel’s decision. The reality is that the NHS is under so much duress, with patients waiting weeks to see their GP for anything other than urgent treatment, that getting an appointment with another GP in seven days is unlikely; it is unlikely to happen given how uncommon that is at the moment. It is right that doctors are able to triage their patients to prioritise those who require medical intervention to keep them well, to prevent hospital admission, or to stop them deteriorating or even dying.

The Government are trying to protect the NHS, and the best way of achieving that is to ensure that medical interventions are provided at the earliest opportunity before a patient deteriorates. In some cases, a medical appointment may need to take priority over an appointment for an assisted death. If someone who is dying has longer—even just a further week—in which to reflect, it removes the pressure from GPs and consultants, and enables them to prioritise properly their patients. It does not build up false expectation in patients that they have a right to a rapid consultation process. Likewise, we know that it can currently take a few weeks for patients to see another consultant, if not months or even over a year. It is therefore more helpful for the patient to have a more realistic period of reflection before moving to the next stage of their assessment.

Issues of such intensity as someone planning to take their own life should not be rushed. We know from all the work that has been undertaken on suicide that other interventions and conversations can help with reflection and reconsideration. It is important that people are given this opportunity. In their first raising the matter with a doctor, the doctor would have provided a lot of information about alternatives to the patient, such as what treatment options would be available. Perhaps they would have had a discussion with a palliative medicine consultant to review their options. There needs to be time for a patient to really reflect on all this new information. If the patient does want to explore assisted dying, there will also be all the conversations about drugs and their impact, which we will come to when we discuss later clauses.

Amendment 317 to clause 13 seeks to increase the reflection period from 14 days to 28 days. I gently suggest that we should have the reflection period before the decision, whether it be by the judge or a panel, to give people the right amount of time to consider; currently, the reflection period is afterwards. This is such a monumental decision that people should be able to contemplate all other options available. As it is, the process is rushed, and a patient could be caught up in the moment of concentrating on getting through the stages. I appreciate that others have suggested that once we have got past that stage, with the paperwork and all those things out of the way, then there is time to reflect. During the process, however, the patient has not had time to consider the options in making their decision. I am not convinced that there is enough reflection during, as opposed to after, the process.

Amendment 314 seeks to increase the reflection period from 48 hours to seven days for patients who have been given a month to live. In that case, seven days is quite adequate time to reflect on the information they have received to make informed choices. If this is about autonomy, which my hon. Friend the Member for Spen Valley has talked about many a time, it is important for people to have choices. To have that autonomy is surely to have the options in front of us and be able to consider them in detail.

In considering whether to sit on this Bill Committee, I slept on the decision. I can usually make instantaneous decisions, but knowing the amount of work, knowing that I was new to the subject, and knowing the things that I knew then—not the things that I know now—it was a big decision for me. I was even thinking about how I would manage the workload. We are talking about something that is not at all comparable. We are talking about somebody who will be taking a decision to potentially exercise the right—if the Bill becomes law—to an assisted death. That is really important for me.

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendments made: 195, in clause 8, page 4, line 40, leave out “statement” and insert “report”.

This amendment is consequential on Amendment 420.

Amendment 421, in clause 8, page 5, line 4, leave out subsection (5) and insert—

“(5) After carrying out the second assessment, the independent doctor must—

(a) make a report about the assessment (which must meet the requirements of regulations under subsection (5A)), and

(b) give a copy of the report to—

(i) the person who was assessed,

(ii) the coordinating doctor,

(iii) if neither the independent doctor nor the coordinating doctor is a practitioner with the person’s GP practice, a registered medical practitioner with that practice, and

(iv) any other person specified in regulations made by the Secretary of State.

(5A) The Secretary of State must by regulations make provision about the content and form of the report.

(5B) The regulations must provide that the report must—

(a) contain a statement indicating whether the independent doctor is satisfied as to all of the matters mentioned in subsection (2)(a) to (e);

subsection (2)(a)

(b) contain an explanation of why the independent doctor is, or (as the case may be) is not, so satisfied;

(c) contain a statement indicating whether the independent doctor is satisfied as to the following—

(i) that a record of the preliminary discussion has been included in the person’s medical records;

(ii) that the person signed the first declaration;

(iii) that the making of the first declaration has been recorded in the person’s medical records;

(iv) that the first declaration has not been cancelled;

(d) be signed and dated by the independent doctor.”—(Kim Leadbeater.)

This amendment provides that the independent doctor must make a report about the second assessment, and makes provision about the report.

[Danny Kruger]

I beg to move amendment 348, in clause 8, page 5, line 10, at end insert—

“(c) inform the person’s usual or treating doctor and, where relevant, the doctor who referred the person to the independent doctor, of the outcome of the assessment.”

This amendment would ensure that the independent doctor communicates the outcome of their assessment to the referring doctor as well as the usual or treating doctor.

--- Later in debate ---

Let us be clear what we are doing: if the first doctor declines an application, a person can shop around until they find a doctor who will approve it, and there is nothing to stop private practices springing up that would be happy to accommodate that request. If the second independent doctor declines, the person can also shop around, although that is limited to a single second attempt, but in that case the person could just go back to the beginning and start again. If we want simply to allow anyone with a terminal diagnosis to have an assisted death, the Bill will do that. Let us not pretend that we have safeguards to stop people shopping around until they find a doctor willing to help them.

[Naz Shah]

Does the hon. Member share my concern that if a doctor refused somebody an assisted death because they thought there was some form of coercion, the door could be open for people to keep going back through this route?

[Danny Kruger]

The hon. Lady is absolutely right. We will address in later debates the point that insufficient attention will be given to the reasons why an application has been refused. If an application has been refused on the grounds of coercion, a future doctor will not necessarily know that that was the reason. As the hon. Lady says, in cases of coercive control there is a very real danger that if a person has been unduly influenced to seek an assisted death and the doctor declines their application, possibly because they detected coercive control, the patient can then be coerced, or influenced, into starting again with a new doctor. There is nothing to stop that in the Bill. We have a real problem, and I hope the Committee will consider the amendments.

--- Later in debate ---

[Sojan Joseph (Ashford) (Lab)]

I support amendments 422, 468 and 423, which I think would strengthen and safeguard the Bill. However, as someone who worked in mental health for many years, I have grave concerns about amendment 201, which would restrict access to medical records. Health professionals work in environments with great confidentiality of records; I have no concern about health professionals or doctors having access to health records. Some Committee members have talked about doctors not needing to know whether a person had tonsillitis, but most medical records or GP summaries will note whether someone has had tonsillitis, along with details about vaccinations and infections. I do not think that those records will necessarily be relevant or that a doctor would look in detail at what medication they have had in that respect.

What is relevant, however, are records for people who have a mental health disorder or are vulnerable. For example, people with serious mental illnesses such as chronic treatment-resistant schizophrenia may be on treatments such as clozapine that, if stopped, will have an impact on their mental health. The treatment that they may undergo during terminal illness may have an interaction, and medication that they have been using for many years to treat their mental health condition may have to be stopped. Doctors need to know why the person wanted to choose that route, and whether it will have an impact on their mental health.

Restricting access to important medical records by the doctor who makes the decision will have an impact on very vulnerable people. As we have discussed before, people may be homeless or may not have any family members, and it will all have an impact on why they decide to seek the assisted dying route. People may feel that they are a burden to society and the system. If there is any documentation from six months or a year ago, it will be relevant for the doctor. Removing access to medical records for doctors will have an impact on people with mental disorders, intellectual disabilities and neurodevelopmental conditions, so I oppose amendment 201, although I support the other amendments.

[Naz Shah]

I will try to keep my remarks brief. I first speak to amendment 468, tabled by the hon. Member for Reigate, on the asking of the question why someone wants to have an assisted death. When I originally came to this debate, Dermot, a humanist who was also my election agent—a lovely guy—came to me and said, “Now that this Bill is going through Parliament, will you support it”? I said, “Explain it to me.” He never once mentioned the word “autonomy”. If I remember correctly, what he talked about was suffering, pain and horrible deaths, which many hon. Members have referred to. We have heard lots of examples during this Bill Committee.

My hon. Friend the Member for Luton South and South Bedfordshire said that the decision was none of a doctor’s business and that the issue was about autonomy. However, if a woman was being coerced into an assisted death, the idea that it was none of the doctor’s business would not quite wash with me. We talk about autonomy, but if someone does not have autonomy in their lives—if they are in an abusive relationship, are a victim of coercion or have a vulnerability—they might not have the choice.

When we ask a question, it is often about something else. I have experienced this myself. I am very passionate; when I am talking about things, somebody might just stop me and say, “Naz—what’s this actually about?” That is all it takes to make me stop, take a step back and a breather, and think for a deeper minute about whether the issue could actually be about something else. We do not always stop to think.

[Dr Opher]

The amendment is good practice; I do not in any way deny that. The hon. Member for Reigate is obviously coming from a really good place. However, the amendment is almost like specifying that when someone goes to see a doctor, the doctor has to say, “How can I help? What is wrong?” It is just unnecessary; that is my only feeling about it. If someone came in and said, “I would like to request an assisted death”, the doctor would not just say, “Okay”—they would ask how the patient was feeling. It is normal medical practice to ask what is going on in someone’s mind, so that does not need to be specified in the Bill.

[Naz Shah]

I thank my hon. Friend for his intervention. There is a medical model and a social model of intervention. If I walk into a GP surgery with a really bad headache, I am prescribed paracetamol. If the headache gets worse, I am prescribed something stronger—maybe co-codamol or codeine. Doctors are really busy. We have had to add another 40,000 appointments just for people to get through systems, so we know how hard it is to get a GP appointment.

If the person who turns up at the GP’s with a headache is usually quite healthy, the doctor might not take a minute to ask about what has actually happened. If I say, “I have a headache because I am banging my head against the wall—I have that much stress”, that is a whole different conversation. Having that conversation with the patient—probing a little more—is, for me, very important from a holistic point of view.

[Rachel Hopkins]

I want to check that my hon. Friend was not implying that I had not thought deeply—for more than a minute–in the course of making my comments earlier.

[Naz Shah]

No, that was not my implication. When referring to my hon. Friend’s remarks, I was speaking about a patient perhaps saying “It is none of your business” or that my hon. Friend was talking just about autonomy.

[Rachel Hopkins]

I am grateful to my hon. Friend for reiterating those points. Does she accept that it is a patient’s right to say, “It’s none of your business” in the course of the conversation?

[Naz Shah]

I absolutely accept that it is the patient’s right to say, “It’s none of your business”, with the really clear caveat that they could well be a vulnerable patient. They might say that it was none of the doctor’s business, and that doctor might then not be able to explore the other things going on with that patient. That is why, for me, this does not wash.

The point that I am trying to make is that, in the course of a normal consultation, it is presumed that every doctor will know their patient and be able to have these conversations. In most cases, they probably will because we have amazing doctors; I have amazing relationships with my doctors. But does that mean that the doctors will ask that one question: “Why?” That is the crux of the whole Bill.

[Rebecca Paul]

The right to say, “It’s none of your business” might be fine when no one else is involved, but if someone seeks an assisted death, that involves multiple members of NHS staff. There is an impact on all those people, who need to be comfortable with what they are doing. Maybe the person needs to accept that they do need to provide some information so that the medical staff feel comfortable about the question of eligibility.

[Naz Shah]

That opens up a whole different debate for me. Some clinicians will not sign up to this process and some will. That is a whole different debate, but I take the point that there has to be a reason.

We talk about the option for referral to palliative care. I have previously moved amendments that would have meant a referral, without the option; however, when considering that option, a doctor needs to understand that if a patient says, “I do not have to explain myself—full stop”, or, “I do not want to talk about palliative care”, that should raise alarm bells. If a doctor says, “You’ve got this terminal illness. These are the options—let me spell them out for you. You have the option of referral to palliative care and the option of these drugs, so why do you want to kill yourself?”, and the patient turns around and says, “It’s none of your business”—

[Rachel Hopkins]

Will my hon. Friend give way?

[Naz Shah]

Sorry, I will just finish my point.

From a common sense perspective—I am not medically qualified—that situation should make me, as a human being, want to understand more. As a human being, I would like to understand whether something else was going on, such as anger towards—

[Jake Richards]

Will my hon. Friend give way?

[Naz Shah]

Sorry, I will not give way until I have finished my point.

I would like those conversations to be at least explored, which is why I support the amendment.

[Rachel Hopkins]

The Bill already sets out a number of things that a doctor has to assure themselves of, with regard to coercion and capacity. They would do that having had a significant amount of training to establish, in the round, after consulting others, that one way or another the legal requirements have been met. The “Why?” question appears to me to bring in a judgmental element—

[Rachel Hopkins]

Indeed: subjective, as the right hon. Gentleman said. That is the point that I am trying to get at. There is an objective assessment, which is wholly appropriate, but a subjective assessment would lead down a different route and muddy the objective assessment.

[Naz Shah]

I absolutely see where my hon. Friend is coming from and appreciate her concern, but we will have to agree to disagree as we have a difference of opinion. A subjective assessment might reveal that something else is going on for that patient.

I hate to put myself in this position, but imagine I have just received a diagnosis and I am going to die within six months. I could have a whole load of anger about that happening to me and I could say, “I don’t want this. I don’t want to talk about it. It’s none of your business. I’m angry—this is what I want.” At that point, does the doctor stop? In most cases, my hon. Friend the Member for Luton South and South Bedfordshire is absolutely right, but in some cases she might not be. I might want to shut the conversation down because I am angry or because other things are going on in my head and I do not want to explain. Amendment 468 would allow the doctor, from a compassionate point of view, to have another conversation with the patient.

[Jake Richards]

Does my hon. Friend agree that she is making a powerful case against amendment 468? A multitude of conversations and different circumstances will need to be taken into account; it is wholly inappropriate to have a mandated question in primary legislation. We should go back to clause 1, which I think the Bill is actually about. It states that the person must have

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

Does my hon. Friend agree that that is what is at the heart of the Bill, rather than decisions about what is in the person’s best interests?

[Naz Shah]

I respectfully disagree. I am making the case that there is a conversation to be had. Yes, there is informed choice but is my hon. Friend suggesting that the question should not be asked at all? I take the point that with an informed choice there would have been an exploratory conversation, but sometimes just calling something out, or stating the obvious, makes a huge difference.

[Rebecca Paul]

I wish to clarify that the amendment is about not an additional assessment but merely a simple question. Like many who have spoken, I hope that most good doctors would ask the question anyway and take the answer. It may inform them or it may not but sometimes, as the hon. Member for Bradford West has just discussed so powerfully, it is helpful to remind medical staff, who are under lots of time pressure, that sometimes it is worth stepping back and asking why.

[Naz Shah]

I agree. Sometimes it will be the simple thing of asking the question as a human being—among all the conversations that are happening, just stopping and asking why.

[Jack Abbott]

I appreciate that my hon. Friend has given way a number of times, but I gently suggest that we already know the crux of the Bill and what we are debating. The “why” is that people with a terminal diagnosis, with six months to live, would like a course of action to end their lives in a pain-free way and to have the autonomy to do so.

We are in danger of over-legislating for a range of different permutations that could potentially happen in conversations. I agree that these kinds of questions are absolutely crucial, but it may satisfy my hon. Friend that amendment 21, to which we agreed a few moments ago, requires medical practitioners to take training on

“domestic abuse, including coercive control and financial abuse”.

That sort of protection and safeguard has already been agreed to.

We will rely on highly specialised individuals to pick up on these issues. They may want to explore, through further questioning, why people are making these decisions but we cannot legislate for all the different sorts of conversations, and all the emotions that may be going through people’s minds. If someone comes back and says, as my hon. Friend put it, “Well, it’s none of your business,” or whatever the answer may be, we will rely on the specialised professionals to pick up on danger signs. However, that would not necessarily lead them in every single conversation to have a suspicion of the patient’s motives. Life and conversation do not work like that and we cannot legislate in that way.

[Naz Shah]

I absolutely agree that life does not work like that. Life is very complicated and that is why I want the conversation to happen. My hon. Friend referred to amendment 21, which we have just agreed to. I spoke extensively about why that is a brilliant amendment that moves us towards much more safeguarding, but I also think that it does not go far enough for women, marginalised communities and people from ethnic minority backgrounds. I genuinely do not feel that amendment 468 is about over-legislating. It is just stating an obvious fact: sometimes, even in normal life, we go around the houses to get to a conversation and get to the right point. That is what I want to get to.

[Jack Abbott]

To follow up on the example my hon. Friend gave earlier, if—to be glib—someone said, “None of your business”, she would want the doctor to keep probing. At what point does that end? If someone genuinely does not want to have that conversation and says, “I want to end my life because I have a terminal diagnosis. I live in fear of the pain that could await me and I don’t really want to go into much detail,” where does that end? Where does that conversation continue to?

[Naz Shah]

My hon. Friend makes my case for me. If that person says, “It’s none of your business, but I have so much pain,” at that point, automatically, as we naturally do as human beings—

[Jack Abbott]

But this is a pure example.

[Naz Shah]

That example is a good example that strengthens my position.

[Danny Kruger]

I completely agree with the hon. Lady’s point. The conversation goes on in the way the doctor would want it to, but they have at least asked the question. Is it not very simple? The Bill already requires doctors to look for signs of external coercion. As we have acknowledged, there is no way to determine internal coercion—the influence people have on themselves. There is no way in the Bill at the moment to identify whether somebody feels that they want an assisted death because they fear that they are a burden to others. This question is the only opportunity we have to tease out that answer: does she agree?

[Naz Shah]

I thank the hon. Member for that intervention and he makes an important point.

[Kit Malthouse]

What is an acceptable answer? Can we have a list?

[Naz Shah]

Does the right hon. Gentleman want to intervene?

[Kit Malthouse]

indicated dissent.

[Naz Shah]

The hon. Member for East Wiltshire makes an important point. Where are the opportunities? When doctors are doing the assessment.

The other issue that speaks to me is the question of internalised bias. We will have professionals with subconscious bias or affirmed bias. They will be clinicians who have chosen or agreed to take part in the process; fundamentally, the majority of clinicians will not take part in this process because of their beliefs. It changes the relationship between doctor and patient from a societal perspective.

I know that a number of times I have been stopped during a process and asked a different question, and at times that opportunity for reflection—even without the pressure of knowing I have only six months to live—is of benefit to me. I am sure that others would benefit from it, too, particularly because the decision is so momentous. For that reason, I will certainly support amendment 468.

I thank my hon. Friend the Member for Spen Valley for tabling amendment 201. I have mixed views on it. I appreciate what my hon. Friend the Member for Luton South and South Bedfordshire said about medical records, especially when it comes to women and their past, but I also appreciated what my hon. Friend the Member for Ashford said about his experience from a mental health perspective.

I am still thinking about the amendment and I am not sure whether I will support it or not, but further thought needs to be given to the subject. There are the issues of mental health and women’s rights, but another issue applies, too. If someone has experienced trauma in childhood but that trauma has come out much more recently, even though it does not necessarily affect the decision at hand—whether to choose an assisted death—is there some kind of historical post-traumatic stress disorder that would then need to be explored? I do not have the answer, but I look forward to hearing the comments of my hon. Friend the Member for Spen Valley on that point. I would value hearing whether she has thought about that and what her understanding of it is.

[Stephen Kinnock]

As I have mentioned before, the Government have worked closely with my hon. Friend the Member for Spen Valley on some mutually agreed amendments, including amendments 201, 422 and 433. The amendments that the Government support aim to ensure the legal robustness and operability of the legislation, should it pass, and I will offer a technical explanation for them.

Amendment 201 will clarify the wording in clause 9 on the doctor’s assessment. 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 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 who have recently provided health or social care to the person and make such other inquiries as the assessing doctor considers appropriate. This applies to—

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

Naz Shah Excerpts

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[Sean Woodcock (Banbury) (Lab)]

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

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

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

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

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

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

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

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

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

[Naz Shah (Bradford West) (Lab)]

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

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

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

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

Clause 9(2)(b) states:

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

among other things,

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

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

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

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

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

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

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

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

“including the escalation of medication intervention”.

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

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

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

[Kim Leadbeater]

My hon. Friend raises a really important point. As clause 9 says, the doctor has an obligation to discuss with the person their wishes in the event of complications, so that conversation would have happened with the patient. To be clear, the doctor cannot intervene to expediate the patient’s death. That is very clear in the Bill.

[Naz Shah]

I thank my hon. Friend for her intervention. Actually, clause 9(2)(c) covers the complications but does not state clearly what would happen in the event of those complications. Would the patient still want to carry on down that path?

[Kim Leadbeater]

To be clear, it does say

“discuss with the person their wishes”.

That includes whether they would want the doctor to call an ambulance if things got complicated, or whether they would want to be left—so the doctor would discuss with the patient their wishes in that situation. Fortunately, it does not happen very often.

[Naz Shah]

Yes, fortunately not. I am not convinced that the clause covers it. I will go back to that, but I have just read it because the hon. Member for Solihull West and Shirley raised it and I support his amendment, and somebody else raised it earlier.

I am not convinced that the complications are covered, because the clause does not set it out. In the usual sense, complications are side effects from medications. We have research and literature given to us and we understand the potential side effects. In this instance, we do not have a yardstick. I do not know whether the Minister can speak about the Government’s intentions—it would be helpful to have an impact assessment—and whether any research has been done in this area.

I am not convinced that clause 9(2)(c) actually covers this point, and I think the amendment would make the Bill much stronger. Ultimately, these drugs have not been tested—and for a very good reason, because they lead to death. We are in unchartered territory. When we are doing things that we have not done before, we cannot just pick and choose what we apply an analogy to. We need to be careful. We really need to consider the options to make this clause in particular much stronger.

[Jack Abbott]

I completely understand what my hon. Friend is saying about what may need to happen in respect of medical intervention, but I gently point out that the amendment would not cover that. It does not spell out in any way, shape or form what a medical intervention would look like. It says that there needs to be a random discussion, but it does not lay out any sense of the medical intervention. I do not see how the amendment will do what my hon. Friend is looking for.

[Naz Shah]

I thank my hon. Friend for his intervention. As drafted, the Bill does not include effects. All it says is “complications”. It does not include the potential effects of the drugs that will be used. That is how the amendment would strengthen the Bill.

[Danny Kruger]

We might appear to be dancing on a pinhead, but this goes to the heart of the question about what on earth we do in the event of complications. As the hon. Member for Spen Valley says, the Bill as drafted says that discussions should be had about wishes in the event of complications. That might simply be, “Do you want us to call somebody? Do you want us to try to make you more comfortable?” The amendment would require a discussion of escalation—what further medical interventions might be appropriate in the event of complications arising. There is a huge question for us, which we have not yet had answered, about what on earth should be the range of options for a doctor. The importance of the amendment is to specify that there may be further medical interventions in the event of complications. Does the hon. Lady agree that that is the value of it?

[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.

--- Later in debate ---

[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.

--- Later in debate ---

[Danny Kruger]

Those might be appropriate reasons; I hope that can be specified. The crucial thing is that if there is an unwillingness—not an incapacity but an unwillingness—to proceed, that is of some concern. It is not that they are no longer able to do it—possibly for the reasons that the hon. Lady suggested—but if there is an actual unwillingness to proceed, what is the reason?

On amendment 309, if the first doctor is replaced for whatever reason, surely it is imperative that the new doctor conduct their own assessment, rather than taking the previous doctor’s word for it. A doctor is legally responsible, obliged under all medical regulation and law for their actions, and they cannot rely on a previous assessment. If the first doctor gave up the case because of some kind of incapacity—an illness, or, indeed, their demise—it might be that their own judgment was impaired at the time. I would have thought it was obvious that the new doctor should take responsibility for conducting an assessment and proceeding with full responsibility for the case.

[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.

--- Later in debate ---

[Naz Shah]

I rise to speak to new clause 21, new clause 14, new clause 16, new schedule 2 and amendment (b) to new schedule 2. I will start with new clause 21—and have a break in between.

I oppose new clause 21, tabled by my hon. Friend the Member for Spen Valley. I also wish to oppose new clauses 14, 15, 16 and 17, which between them set out the panel procedure to replace the use of a High Court judge, but I will focus my remarks on new clause 21. That is because, first, it is the most recently tabled of my hon. Friend’s new clauses on the panel. Secondly, and perhaps more importantly, it seems to be an attempt to solve some of the problems of the earlier new clauses.

I welcome what I think my hon. Friend’s intentions are with the new clauses. The Bill as drafted did not provide anything like adequate safeguards. The new clause states that the panel must hear from, and may then question, the doctors who made the certification, the applicant for assisted death, and any other person who may have relevant information. These moves are very welcome steps towards a tighter set of safeguards, but they are inadequate because of what they leave out.

Sir James Munby, the former president of the family division of the High Court of England and Wales, has written several times about the problems with the Bill. It is a matter of great regret to me that we did not hear from Sir James; I appreciate that my hon. Friend the Member for Spen Valley set out that he was invited to give evidence to the Committee. Sir James has expressed profound concern about the series of new clauses— new clauses 14, 15, 16 and 17—that my hon. Friend has tabled. He wrote that the new clauses did address some of the problems of the original Bill, but he went on:

“These changes are to be welcomed, so far as they go. It is important to recognise, however, that they do not, in my opinion, go anything like far enough.”

As I have said, some elements of new clause 21 do indeed address some of the problems that Sir James identified but, again, the new clause unfortunately still leaves many of the biggest problems untouched.

The Bill does not set out that evidence must be heard under oath. That is an extraordinary omission. Sir James Munby asks, in his most recent essay:

“is the panel to hear evidence on oath? Indeed, will the panel have power to administer an oath?”

We rightly expect our courts to hear evidence under oath if they deal with cases concerning property or contract. The matters the panels will be dealing with are far more important than that. It is baffling to me why we should hear evidence on these matters without making witnesses swear oaths to tell the whole truth and nothing but the truth. Anyone speaking to one of these panels should do so with the same commitment to telling the truth as they would in a court of law.

[Danny Kruger]

rose—

[Danny Kruger]

Danny Kruger; we are easily confused. [Laughter.]

The hon. Lady talks about the question of oaths, and it is extraordinary. Does she agree that it speaks to the confusion about whether the panels are a judicial construct at all? They have a judicial function—they exercise a judicial responsibility—but they are composed of non-lawyers. Maybe that explains why there is no oath, but I agree with the hon. Lady that there should be one. Does it not speak to the confusion in the new clause?

[Naz Shah]

As I make progress, I will speak to that point, but I share the hon. Gentleman’s concern. I will return to my speech and expand on the point when I arrive at that juncture.

Sir James goes on to say that there are even graver problems with the panel procedure. I appreciate that his paper was published before new clause 21 was tabled, but it does not address all the concerns he raised. He referred particularly to new clause 16, but it is relevant to note that the problem he identified is left untouched by new clause 21. Sir James says of new clause 16:

“It says very little about the procedures to be adopted for testing and, if need be, challenging the evidence”.

He goes on to say that

“it says nothing about who should exercise that function; nor about the nature of any independent evidential investigation and nothing about who is to undertake this and who is to pay for it.”

Finally on this point, he says that new clause 16

“says nothing about what, if any, public funding arrangements there will be for the applicant, the two doctors, and any other parties or expert or lay witnesses.”

The first point raised by Sir James is an extraordinary one. The panels will bring together three people: a lawyer, a consultant psychiatrist and a social worker. They will sit on what is a quasi-judicial body. The latter two will not necessarily have any experience of questioning witnesses and assessing evidence as part of a quasi-judicial process. The first person—the lawyer—will have such experience. What is going to happen? Are we just hoping that they will successfully make it up as they go along? Is there not a danger that in some cases the non-legal members of the panel end up deferring to the wishes of the lawyer, who has more experience in these matters?

[Kim Leadbeater]

I appreciate the point my hon. Friend is making, and it is a shame that we did not hear from James Munby in evidence. I understand why he says that: he is looking at it through a judicial lens, because he is a judge. But this is not a judicial entity. It is a panel—it is not a court—and the range of expertise on it is actually a strength, not a weakness.

--- Later in debate ---

[Naz Shah]

As I make progress I will address some my hon. Friend’s points—I have a fairly long speech—but I will say now that when the Bill passed on Second Reading, one of the safeguards was that it included judicial oversight. That is very different to what we are talking about now.

[Danny Kruger]

This is a very important point, and I am grateful for the hon. Member for Spen Valley’s admission that this is not a judicial process. We have constantly been told that the Bill has been gold-plated with the judicial stage of the application process, but we have now heard that there is not a judicial stage. We have also heard that this is “judge-plus” and somehow an improvement—it is a judge and others—but we should be clear that there is not necessarily a judge in the process, and it is very unlikely that there would be. We have just heard conclusively that the judicial stage of the process in the Bill has been dropped.

[Naz Shah]

I agree: there is not a judicial process, so to speak. There most definitely is not. As I make progress, I will outline my concerns about that very clearly.

Let us take the second point raised by Sir James. He asked who will go about

“testing and, if need be, challenging the evidence”?

New clause 21 finally gives the panel the power to call people to give evidence who are neither the applicant nor the doctor. New clause 21(4) says that the panel

“may hear from and may question any other person”

and

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

I welcome that as a start, because it acknowledges that there will be cases in which people other than the applicant and the doctors have vital information. But that really should not be where we finish—not if we want a genuinely robust assisted dying Bill with strong safeguards for vulnerable people.

The ability of the panel to hear evidence from other parties would indeed be one step towards detecting whether people are, for example, being coerced towards an assisted death. That would be one step towards being able to detect whether people were choosing assisted death because of a lack of palliative care or social care. But how will the panels know which witnesses are most likely to have or be aware of the significant evidence they seek?

The panel members will have the statements by the applicant and the doctors, and they will have the answers to any questions they have of the applicant and the doctors. I ask Members to think through how certain it is that those sources alone will be enough to find all the people who might have significant knowledge of a person’s circumstances. I would argue that it will not be certain. Yes, in some cases there will be no hidden circumstances that a panel would hear of from a witness only if they were called, but in other cases there will be, and those circumstances are much more likely to occur in the cases of people who are coerced or who feel like a burden to their families. They will be more likely to occur for those who have poor mental health, who are isolated, or who lack the social care they need. The panels are not likely to find witnesses with relevant information if what they have to go on is the statement of witness evidence of a person who has, for example, been successfully and skilfully coerced.

[Dr Marie Tidball (Penistone and Stocksbridge) (Lab)]

New clause 21(4)(e) says that the panel

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

Does my hon. Friend not agree that the expertise of the three panel members, as set out in the new clause, will mean they will very much have the ability to identify, on the basis of that subsection, the kind of individuals and the knowledge required?

[Naz Shah]

As I have stated before—I will make reference to that very point later—I would argue the safeguards are just not robust enough.

There should be a mechanism for trained and experienced people to find witnesses who might have relevant information. This could relate to another criticism that Members have made of the panel system: there is no provision for the Official Solicitor to act on behalf of the applicant. Sir James Munby argues that we should strongly consider this, saying that

“there must be a rigorous procedure in every case for testing and if need be challenging the evidence, including an independent evidential investigation, perhaps by the Official Solicitor, of the kind discussed in Conway. There are two reasons why this is essential in every case…Without this, it will not be proper for a judge to be involved in the process as a member of the panel.”

He goes on to make it plain that by “judge” he means the legal member of the panel.

[Kim Leadbeater]

I appreciate that this is slightly difficult to get our heads around, but we have legal expertise—we potentially have a judge, a sitting judge, a retired judge or an eminent KC—but they are not there in their capacity as a judge. I understand that that is tricky for people to understand, but they are there because of their skillset. That is the important distinction.

[Naz Shah]

That is the very distinction I am trying to highlight further, because the panel takes away the judicial oversight. Yes, they have expertise—there is no question about people’s expertise—but Sir James Munby says clearly that these people will not be sitting in their capacity as judges, as my hon. Friend just outlined, but just as experts. That does not provide judicial oversight. That is not what the panel does.

[Kim Leadbeater]

My hon. Friend is absolutely right, and that is the whole point: Sir James Munby said he did not think that was the job for the judge.

[Naz Shah]

I will go into this in even greater detail in later speeches, but I will say now that although the process was not fit for purpose, Sir James Munby also says that this one is not fit for purpose. Neither process gives us the legal aspect—if anything, the Bill has been watered down. As I make progress, I will outline how I think Sir James Munby’s evidence is clear that the safeguard has been watered down. I appreciate the mood in the room while I insist on talking about this, but it is very, very important, because when we voted in the House to send the Bill to Committee, one of the biggest reasons why we did so was judicial oversight. Many Members have said that they let the Bill get to this stage because of that.

[Kim Leadbeater]

Will my hon. Friend give way on that point?

[Naz Shah]

I will make some progress. As it is, we have removed the judicial oversight. I appreciate what my hon. Friend says about the panels having expertise, but that is not judicial oversight.

--- Later in debate ---

[Lewis Atkinson]

I think my hon. Friend just said that the amendments would allow the Official Solicitor to act on behalf of the applicant. Why would that strengthen the process?

[Naz Shah]

I think that by making some progress I will answer that question.

Turning to Sir James Munby’s question about what, if any, public funding arrangements there will be for the applicant, the two doctors and any other parties, experts or lay witnesses, each time a panel meets we will be asking three senior professionals to give up many hours of their time to scrutinise applications, listen to and perhaps question witnesses, and then decide whether to call further witnesses. I could ask many questions about funding, but I will ask just one at the moment. Both Ministers will be well aware that courts and tribunals in England and Wales face lengthy delays—in some cases, delays of years. Will the Government commit to adequately funding the panel so that applicants do not face lengthy delays?

Another question about the resourcing of the panels is just as important: can we make good on the commitment in the Bill to provide a consultant psychiatrist for every panel? I think the answer may well be no. We spoke to the Royal College of Psychiatrists during our evidence sessions, but at that stage my hon. Friend the Member for Spen Valley had not tabled the amendments that would create a panel including a consultant psychiatrist, so we did not ask the professional body whether it would be able to do so.

I have had private conversations with my team of senior psychiatrists. We asked whether England and Wales had enough consultant psychiatrists to serve on each panel. They said it was extremely unlikely. I would like to understand whether my hon. Friend consulted the Royal College of Psychiatrists before she tabled those amendments. If she did not, that seems an extraordinary omission.

Ministers keep saying that the Government will release an impact assessment only when the Committee has finished amending the Bill. I say again: that seems to me a most unsatisfactory approach to a Bill that would lead to such a huge change. Surely the Minister could ask civil servants to prepare a preliminary estimate of how many applicants there might be in England and Wales. It should probably be phrased as a likely minimum and likely maximum number. That would be extremely helpful. Surely the Government could do the preliminary work on whether the psychiatric profession in England and Wales is capable of meeting that demand. I say this in the light of my understanding that the present state of the country’s judiciary contributed to the removal of the judge in the first instance.

[Kim Leadbeater]

Just to be clear, that was not the reason for the change. We need to be very clear about that. The reason for the change was that it strengthens the Bill.

[Naz Shah]

That was not my understanding; I will come back to that point, because I am sure I have references to where that has been talked about. There is also the question of whether panels should be heard in public. Under new clause 16, the legal member of a panel would decide whether it should sit in public.

Finally, I return to Sir James Munby’s paper on this question. As I have gone through in some detail, he raised significant concerns about panel procedures set out in new clauses 14 to 17. Unfortunately, it seems to me that most of those concerns have not been addressed by new clause 21. Sir James was a very senior judge, who headed the family division of the High Court, and is someone we should listen to with the utmost attention on these matters. He said:

“I appreciate that some may point to the multidisciplinary membership of the panel and to an assumption that the function and process of the panel may (it is said) be inquisitorial rather than adversarial. Plainly, it might be thought, it is an advantage that the panel has a multidisciplinary membership, and it is often said that three heads are better than one. Yet it would be a mistake to think that either of these features of what is now proposed are sufficient to overcome the very real problems I have identified. They are not. What remains crucial is the substance, not mere appearances. If the panel is to perform its function effectively and do more than just ‘check the paperwork’—if it is to be the real safeguard intended by its proponents—then its processes must be much more thorough than is currently proposed.”

[Lewis Atkinson]

Has my hon. Friend had the opportunity to consider the functioning of mental health tribunals, which operate as panels in a very similar way to this proposal: chaired by a legal member with a specialist member and a medical member? They perform a similar quasi-judicial function, receive evidence and make important decisions on people’s healthcare choices. Does she not agree that that model provides a good example of how this system could work?

[Naz Shah]

My hon. Friend’s intervention takes us back to the concerns I already have. I understand that mental health tribunals relate to the Mental Capacity Act 2005, which would inform people on that panel in making their judgments. I have spoken extensively against the use of the Mental Capacity Act in this particular field.

[Lewis Atkinson]

I thank my hon. Friend for engaging on this issue, but this is not about the Mental Capacity Act; it is about the Mental Health Act 1983 and whether someone would be sectioned and denied liberty—a significant decision against the person’s own wishes. That determination is made by mental health tribunals sitting in that judicial function, day in, day out, with exactly the sort of panel membership outlined here.

[Naz Shah]

I either misheard my hon. Friend or did not understand his earlier point, so let me speak to the point he makes now. My understanding is that sectioning someone under the Mental Health Act is a very extreme measure. Someone is sectioned in circumstances in which lots and lots of evidence has been taken from people who know the person, and there is a history. That was certainly the case when I chaired a mental health charity. Whether it is carers or other people who contribute to that, there is a long-standing relationship; from my understanding, it is very rare for something to happen otherwise. That is my understanding and experience of it, but I am happy to have a chat with my hon. Friend to talk more about it and understand it more.

[Danny Kruger]

Does the hon. Lady agree that the intervention of the hon. Member for Sunderland Central is very helpful because it highlights the difference between a genuine judicial tribunal, as he suggests, and what is being proposed here? This is not a tribunal. It would not sit in a judicial capacity. Its members would not take oaths in the way that members of a tribunal do. They are not appointed through the independent appointments process that tribunals have. This is a multidisciplinary team masquerading as some sort of final judicial stage, without the proper accountability of a judicial stage. On that basis, we cannot regard it as any sort of improvement to the Bill.

[Naz Shah]

I thank the hon. Member for reminding me of that; I talked about that earlier. I agree with him that this is about the legalities. Ultimately, it comes back to judicial oversight, which is what was promised originally. That is why judges were part of the original proposals for the Bill. The words we must listen to are Sir James Munby’s. If we want an assisted dying Bill with real safeguards for the vulnerable, then we should reject new clauses 14 to 17 and new clause 21. They are not thorough enough to do the job.

[The Chair]

I should let the hon. Member know that I am happy for her to make five speeches, as she has indicated, but each one needs to be specific to the clause and not replicating the previous speech.

--- Later in debate ---

[Naz Shah]

Given my hon. Friend’s expertise, does he anticipate JR being allowed in the panel setting? If so, would it be before the death or after? Can the decision by the panel be judicially reviewed?

[Jake Richards]

In my mind, any decision to give a certificate of eligibility could be subject to judicial review.

Third parties can put evidence before the panel to be considered, but it is not right that third parties might challenge the application. As I have set out before, this is not a dispute but a rigorous safeguarding process. If they have information about the person’s capacity, their diagnosis or any other relevant factors, they can and must ensure that the panel—if not the doctors or indeed the police—be seized of the information. Third parties can appeal the decision by way of judicial review. That would provide for a decision that was

“wrong, or…unjust because of a serious procedural or other irregularity in the proceedings”,

per amendment (a) to new clause 17. An injunction would be applied and the matter would have to be dealt with expeditiously. It is worth saying that all the evidence suggests that that would happen incredibly rarely. In Spain—

--- Later in debate ---

[The Chair]

I call Naz Shah for part 2.

[Naz Shah]

Part 2 of five, I might add, Mrs Harris.

I rise to oppose new clause 14 from my hon. Friend the Member for Spen Valley. The clause would create the post of a voluntary assisted dying commissioner. It is quite an extraordinary clause, and I am not sure we have seen anything like it in recent legislation. What I am sure of is that we have not seen a law as far-reaching as this introduced without any of the detailed work that should have been done on it by the civil service.

The voluntary assisted dying commissioner—I will call them the VAD commissioner—created by the new clause would have unusual powers. The commissioner would select the members of the panel, who would in turn decide on people’s assisted dying applications. The commissioner would be the authority to whom people could appeal if their application was refused. The commissioner would also decide if particular panel members had made any mistakes or shown any misconduct in their work.

In this country, we do not give one person the job of selecting judges, overseeing their work and then functioning as a court of appeal, even if that one person is extremely well qualified. That is for good reason. But the new clause suggests giving all those powers to one person. Hon. Members might object and say that the comparison is not exact, and that there will be fewer assisted dying cases heard by the proposed new panels than there are cases heard before the courts, but that misses the point. We do not put all the powers over the judiciary into the hands of one man or woman because it would be a lot of work for them. No, we do not do that, because we do not wish to put too much power into the hands of any one person. However, under the new clause, we would do exactly that.

--- Later in debate ---

[Danny Kruger]

This conversation is very helpful, and the point the hon. Lady makes is absolutely right. If we are going to rely on JR as a sort of appeal process, we need to make it clear how that would work. Would there be legal aid? How quickly could these things be done? I think that that needs to be built in. Does she agree?

[Naz Shah]

I absolutely agree that we have not thought this through enough, because that process has not been laid out. We really need to think about these potential eventualities.

When such cases happen, the public, including family members of the person who has died, will rightly demand answers, and so will the media. They will want to know who the panel members were and why they made the judgment they did. In such cases, who would investigate whether panel members had got it wrong? The commissioner who had appointed them? The commissioner, or any person, no matter how honest and how learned, would come back to that question with a very strong bias. The commissioner will mark their own homework. That is not a system that anyone can argue will provide proper safeguards.

Hon. Members might object that the voluntary assisted dying commissioner will be a very senior judge. According to the new clause, the commissioner

“must hold or have held office as a judge of—

the Supreme Court

the Court of Appeal, or

the High Court.”

I agree that only people of high intelligence and good standing become judges in those courts, but that does not mean that the very highest judges in the land do not sometimes make mistakes—sometimes very bad ones.

[Jack Abbott]

If we follow that argument, does that mean that we would support the new clauses? If we are moving from that single point of reference—a High Court judge and judicial review—it is surely much safer to move to what is proposed.

[Naz Shah]

The truth is—I said this in my previous speech, which I will not repeat, as instructed by you, Mrs Harris—that neither of the safeguards is strong enough. As it was, the Bill was not strong enough—that has been recognised and changes have been proposed—but neither is the idea of a commissioner.

There is another great problem raised by this set of changes to the Bill: they seem likely to increase the prospect of group-think when it comes to members of the panel. I would argue that that danger has been greatly increased by the move away from the High Court judge model that was originally in the Bill.

When my hon. Friend the Member for Spen Valley introduced the Bill on Second Reading, she reassured the House that all assisted dying applications would have to be examined by a High Court judge. There were problems with that proposal, which is why she abandoned it. But there was one strength in making a High Court judge the arbiter: the Crown does not appoint High Court judges on the basis of whether they agree with assisted dying. We could all reasonably expect High Court judges to have a range of views on assisted dying; there is no reason I can think of that would mean that High Court judges, as a body, were biased in favour of assisted dying.

Something different will happen if a commissioner selects people to serve on these panels. Anyone serving on a panel will know that they will have to approve some applications for assisted death. We do not know how many applications for assisted death the Government expect to have. We also do not know how many social workers, psychiatrists and lawyers would be unwilling to approve any assisted death applications at all—I do not want to repeat myself, but I will be referring back to psychiatrists in another amendment. However, the number of psychiatrists who are strongly opposed to assisted death is very high, according the Royal College of Psychiatrists. We have also heard strong reservations expressed by the Association of Palliative Care Social Workers. Therefore, many professionals will choose not to sit on these panels, because they will not want to approve any cases. That means that some panel members are likely to end up dealing with dozens of cases per year. That poses the danger that some of the people who sit most on these panels will be advocates of assisted dying and will approve applications that other members may not have.

[Rachel Hopkins (Luton South and South Bedfordshire) (Lab)]

I thank my hon. Friend for discussing her view of the approach of the proposed panel members. Does she recognise that all three of those professions have professional requirements to act with integrity and in accordance with the law? It is highly unlikely that they will push forward, as she seems to suggest, and risk their professional accreditation.

[Naz Shah]

I am not questioning people’s integrity; I am putting it to the Committee that people have biases. We all have subconscious biases. We have things that we like; we know that that exists, whether it is a subconscious bias or a conscious bias. As human beings, we all have that. In this instance, I am suggesting that if we have members of a panel who choose to be there because they have a fundamental belief, which is different from that of those who oppose assisted dying, there is a risk of subconscious bias and group-think.

[Rachel Hopkins]

rose—

[Jake Richards]

rose—

[Naz Shah]

I am happy to take an intervention from my hon. Friend the Member for Luton South and South Bedfordshire, and then I will come to my hon. Friend the Member for Rother Valley.

[The Chair]

Order. I call Rachel Hopkins for an intervention, but we need to keep to the point and not labour one particular thing.

[Rachel Hopkins]

The point I was making was that no professional would want to risk their professional accreditation and career by allowing a complete bias to take over any decision making. In fact, I would suggest that some may want to prove their integrity by being involved in these decisions and making them in line with their professional practice.

[Naz Shah]

I disagree with my hon. Friend. Subconscious bias operates in society; this is not about being held to account. People are not doing these things deliberately, but because they have a subconscious bias.

[Jake Richards]

My hon. Friend is making a fine speech. She said that High Court judges make mistakes, which is undoubtedly true. She also said that the panel may be guilty of unconscious bias. Is there any layer of scrutiny that would satisfy her? What does she think about jury trials?

[The Chair]

Could the hon. Lady make progress now, please?

[Naz Shah]

I am grateful for my hon. Friend’s intervention, but I reject the facetiousness of his point.

Let me speak to the issue of unconscious bias in relation to the proposal before us. In 1992, there was a jury trial, which found my mother guilty of murdering an abusive partner. In 1998, I went to the High Court and put it to three white middle-class judges that my mother could not tell the truth because of the abuse, the dishonour and the concept of izzat, which defined her existence as a woman. They were not capable of believing that, because they did not have that cultural understanding —so, yes, unconscious bias does exist, even in criminal cases in courts of law.

Returning to my argument, I remind hon. Members of the testimony of Dr Ryan Spielvogel from California, who said:

“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.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 105, Q143.]

I wonder whether I would be comfortable—this is just a personal thing, but I want to put it out there for people to think about—about a doctor such as that, who really supports assisted dying, being on the panel. I am not casting aspersions on him, but I genuinely am unsure.

Of course, the panel will be chaired by lawyers. I would like to remind hon. Members of the evidence of Professor Meredith Blake, who is a senior legal adviser to the Western Australian government on their assisted dying law. Professor Blake’s evidence was quite extraordinary. My hon. Friend the Member for Banbury asked her:

“Does it concern you that a large proportion of people who opted for assisted dying cited being a burden as their reason?”

She replied:

“That is not the evidence that we have got.”

My hon. Friend responded:

“Let me just clarify. The state’s own report in 2023-24 had 35%.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 220, Q284.]

I do not recall having a satisfactory answer from Professor Blake to that question, but please feel free to check Hansard.

If we see a series of questionable decisions by one or more panel member, the only official scrutiny will come from the person who appointed them to do their jobs, and that is not a robust safeguard. Furthermore, my hon. Friend the Member for Spen Valley said earlier that decisions would be unanimous, but that is not entirely correct, and I am happy to point to the relevant bit in the Bill. If two people decide they agree, and the other decides to stay quiet, that would be seen as a unanimous decision, and the panel would proceed. I am happy to point that bit of the Bill out to my hon. Friend, as I would love to see an amendment if one were needed.

[Danny Kruger]

I think the point the hon. Lady is making is that each member of the panel has a veto over the decision so, in a sense, there has to be unanimity about the approval. However, she is absolutely right that if two members disagree with one another about any other aspect of their proceedings, including who to invite to give evidence, they could be overruled, so there is not unanimity there.

[Naz Shah]

I completely agree. That is the case in the Bill, which raises concerns.

Finally, Parliament needs to get back into the habit of holding powerful commissioners accountable. There is no mechanism in the Bill for removing a commissioner even if they somehow failed significantly in their duties. We might say to ourselves, “If that happened, they would do the right thing and resign,” or, “They would resign if the Prime Minister said something in public.” I am sorry, but we cannot leave that to chance.

There has been a very telling example recently of just how badly quasi-judicial institutions can fail, and just how hard it is to get their senior leadership to accept responsibility. The Criminal Cases Review Commission mishandled the Andrew Malkinson case. Mr Malkinson was falsely convicted of raping a woman in 2003. She had been raped by another man.

[The Chair]

Order. Can the hon. Lady keep to the issue?

[Naz Shah]

This relates to my point, Mrs Harris, I promise you. DNA evidence subsequently proved that Andrew Malkinson was indeed innocent, yet he was allowed to remain in jail.

Members of this House expressed serious disquiet about the conduct of the chairwoman of the CCRC, Helen Pitcher, over the Malkinson case. In July last year, my right hon. Friend the Justice Secretary called for Ms Pitcher to step down, but she refused to do so and remained in office until January. I note that Ms Pitcher remains chairman of the Judicial Appointments Commission—and that is where the link is.

[Jack Abbott]

My hon. Friend is saying that there is no mechanism to remove the voluntary assisted dying commissioner. Actually, paragraph 4(5) of new schedule 1 says:

“The Secretary of State may by notice in writing remove a person from the office of Commissioner or Deputy Commissioner if satisfied that the person—

(a) has behaved in a way that is not compatible with their continuing in office”—

I think that addresses a lot of the concerns that she has been expressing—

“or

(b) is unfit, unable or unwilling to properly discharge their functions.”

There is a mechanism in the new schedule that would give the Secretary of State the power to remove the commissioner.

[Naz Shah]

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

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

[Sean Woodcock]

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

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

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

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

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

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

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

New clause 21 states only that the panel

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

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

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

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

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

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

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

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

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

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

Naz Shah Excerpts

Committee stage
Wednesday 12th March 2025 Public Bill Committees

[Rebecca Paul]

I thank the hon. Member for sharing that. It is useful to have these debates and conversations, but I would suggest that the panel needs to be sure off the back of the information that it has been given and the witness testimony, which goes back to why it is so important to ensure that we have that coverage and the right things feeding into the panel so it can get to that high threshold. I would expect the threshold to be at court level, given the huge, significant ramifications of this decision for that person.

[Naz Shah (Bradford West) (Lab)]

The hon. Lady is making a powerful point. I refer back to the point on jury trials. When we have criminal trials and jury trials, they go through not every single thing in somebody’s life, but the actual act of criminality itself and what is relative to that criminal act. That does not mean to say they trudge through a person’s whole life.

[Rebecca Paul]

I thank the hon. Member for that intervention. She eloquently explains exactly the point I was trying to make. That is absolutely right. Clearly, we do not expect the panel to pore over everything. It can only be sure based on the evidence put before it, so I reiterate: that is why it is really important that all the right and relevant information can be fed into the panel in order to get a good, robust, solid decision.

Members will all be relieved to know that I am now coming to the last amendment, amendment (b) to new clause 21. It puts in an additional mechanism for the panel not to grant an application when particular circumstances make it inappropriate. I do not think many in the Committee are going to like the amendment. I make the point again that, in an ideal world, there would have been a best interest clause or something similar in the Bill to protect patients from opting for assisted dying due to some other perfectly solvable challenge in their life, such as being homeless, but, given our amendments were not accepted, I am putting this amendment forward again as a responsibility of the panel, given its oversight role. This is likely to be where the social worker on the panel can play an important part.

In Ontario, assisted dying is monitored by a team of nurse and coroner investigators who review every reported death. The state has also established a death review committee. A recent report shows some of the difficulties for a panel in making its decision. A patient referred to as Ms B successfully applied for an assisted death. She suffered from multiple chemical sensitivity syndrome, which made it difficult for her to find appropriate accommodation. The report found that

“As a result of her housing situation and conditions, necessary to address her MCSS, Ms. B experienced social isolation, which greatly contributed to her suffering and request for MAiD.”

--- Later in debate ---

[The Chair]

It is open to any Member to speak more than once in a debate, as the Committee knows. Naz Shah has indicated to me that, because of the size and complexity of the groupings of amendments, she wishes to speak not once but three times to break her comments into bite-sized chunks. I draw that to the Committee’s attention to put down a marker in case anyone else feels the same way.

[Naz Shah]

It is an honour to follow the hon. Member for Reigate, who takes the record for being on her feet the longest in this Committee.

[Rachel Hopkins (Luton South and South Bedfordshire) (Lab)]

Oh no—that’s yours!

[Naz Shah]

She beats my record for sure. I assure the Committee that my comments on new clause 17(a) will be brief in comparison with my previous speech.

Yesterday, my hon. Friend the Member for Ipswich and I disagreed on a point of detail. In fact, he was right and I was wrong. As he said, a provision in paragraph 4 of new schedule 1 allows the Secretary of State to dismiss a bad commissioner if the circumstances merit it. Although I still maintain my position that too much power is being given to a single person, I thank my hon. Friend both for pointing that out and for the courteous way in which he did so.

The hon. Member for Reigate has spoken very eloquently in defence of her amendment. Just to recap, new clause 17, tabled by my hon. Friend the Member for Spen Valley, would allow a person seeking an assisted death to appeal to the commissioner if a panel refuses their request. However, it would not allow any other person to lodge such an appeal.

By contrast, new clause 17(a) would allow several other parties to lodge such an appeal, including the two doctors who took part in the process, the applicant’s next of kin or relatives, or anyone who took part in the proceedings before the panel or who gave evidence to the panel. I acknowledge that there are genuine arguments against accepting new clause 17(a), and I have listened to them in detail and given them sincere thought. The family members who might appeal against a decision could perhaps have little or no contact with the person on whose behalf they say they are appealing; I note that the hon. Member for Harrogate and Knaresborough made a very honest and personal intervention on that subject yesterday, and I accept that that is a real possibility. As we all know, families are complicated.

There is also a likelihood that allowing more people to appeal against a panel’s decision, both for and against an assisted death, could mean that the commissioner will need considerably more resources. Otherwise. it is very likely that appeals will not be heard within a reasonable period.

Those are genuine arguments, but there are equally strong counterarguments. If the Bill passes, we simply do not know how many coercive or abusive people will seek to drive others towards assisted death. My hon. Friend the Member for Spen Valley spoke about coercion being a criminal offence, but the last figures I have seen show that only 4% of cases result in a conviction. However, it is worth noting that many people with experience in this area are very concerned about the possibility.

We also do not know how many people will opt for an assisted death because their palliative or social care needs are not being met. Again, as I referred to extensively in previous speeches, many people with first-hand experience of this field are extremely concerned about that.

We also do not know how many people will opt for an assisted death partly because they do not want to be a burden on their loved ones. We do not know how many of those loved ones would, in fact, be ready to care for the person who feels like a burden, nor do we know what safeguards, if any, will prove effective against any of those dangers.

One thing we do know is that relatives or carers of someone seeking an assisted death may be able to bring those dangers to light. A family member, a GP or even a paid carer may have seen someone come under coercive control. As new clause 17 stands, they might feel that the panel had made a terrible mistake in ignoring the evidence of that. The hon. Member for Reigate’s amendment (a) to the new clause would give those people the chance to bring their evidence before the commissioner.

I have to say that, as it stands, new clause 17 seems to make some fairly odd assumptions. It would allow an appeal if the applicant’s request for an assisted death were turned down, which means that my hon. Friend the Member for Spen Valley acknowledges that the panels may on occasion get things wrong. But the right of appeal is only one way, which seems extremely odd. It surely cannot be the case that the panels might get things wrong when they turn down a request for assisted dying, but are always right when they accept them.

There surely needs to be an amendment that allows people with knowledge of the situation to appeal if they think the panel has made a mistake in allowing an assisted death. Amendment (a) to new clause 17 would also reduce some of the dangers that we first faced. On that basis, I urge the Committee to support the amendment.

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

It is a pleasure to serve under your chairship, Sir Roger. I will be speaking to new clauses 14 to 17 and 21, new schedules 1 and 2, and amendments 371 to 373, 377, 378, 381, 388, 390 and 391—although I assure you I will not speak for as long as the hon. Member for Reigate did.

Yesterday, my hon. Friend the Member for Spen Valley referred to the Law Society’s neutral position on the new clauses and new schedules. I will not read out all four pages of its most recent submission on the matter, but, although it is neutral, it does continue to have concerns and queries about the new provisions. I will just read out the headlines.

The Law Society remains concerned about the role of the review, whether it would be accessible and workable for people seeking assistance, and the resourcing required. It seeks clarification on the nature of the functions to be exercised by the commissioner and by panels. It still seeks clarity on how panels will deal with cases and asks us to consider where lawyers may need to play a role and the availability of legal aid. We touched on that matter this morning. I accept that the Law Society’s position was used in evidence on the other side of the argument yesterday and that it is neutral, but I could have read all four pages of its response if I had really wanted. That is its position.

I will oppose some of the new clauses and raise concerns about others, including some of the amendments to new clauses tabled by my hon. Friend the Member for Spen Valley. As we have heard, the new clauses and amendments would replace the High Court judge mechanism in the original draft of the Bill with a three-person panel. As we said yesterday, that fundamentally changes the Bill from what the House voted for on Second Reading last November.

The panel will consist of a consultant psychiatrist, social worker and legal member who would chair it. I concur with those who have said that it would help if those individuals were involved earlier in the process. Several concerns have been raised about the High Court judge mechanism in the evidence that we have received. Although I accept that the new panel mechanism would address some of those, it would also leave some untouched and in some cases it could make the position worse.

During oral evidence, we asked witnesses whether and how the High Court judge system would work. Some said that they did not believe that it would. I credit my hon. Friend the Member for Spen Valley for listening to those points, but our problem and predicament now is that we were not able to seek oral evidence on the panel arrangement now before us, and that a large amount of the written evidence had already been submitted beforehand. I will come to this again later, but if we had gone through the normal process of a Government Bill—I accept that this is not a Government Bill—we would not be in this position now.

As a group, the 23 of us are now debating these schedules and clauses before Report, but we have not had any oral evidence on what is before us, and I would argue that we have also had a lack of written evidence. The panel system has complications, and it will be of life-and-death importance. We should have been able to ask witnesses whether a system would work, and how, but we have not been able to do that.

--- Later in debate ---

[Daniel Francis]

I accept what my hon. Friend says, but there are differences of opinion. I accept that that is a very serious matter, but I would argue that a matter of life and death is more serious, and there are processes that we know. As I said, I gave evidence under oath about the demolition of a building and whether someone had followed the correct health and safety regulations, yet we would not be doing so in this case.

[Naz Shah]

My understanding is that, at the mental health tribunal, a person would be entitled to legal representation, which would be an officer of the court or a lawyer, so the bar is very different. Does my hon. Friend agree that actually this is like comparing an apple to a pear?

[Daniel Francis]

Indeed, these are complex matters and these comparisons are made. We have heard a lot about Spain, which I will briefly refer to later, but Spain has a very different legal process from us.

Returning to my comments, currently an individual would not have to give evidence under oath. As I said, the matters discussed by a panel are as important as they can be. In my opinion, people should be giving evidence to the same standards that they do so in a civil or criminal court.

My second concern relates to the procedures for investigating any doubts that the panels may have, and we have heard about that. The panel must hear from at least one doctor and from the applicant under this new set of proposals. They must read the two doctors’ statements and the applicant’s declaration, and then they can decide to ask questions of the applicant and/or one or both of the doctors. The panel can also hear from and ask questions of any other person. How is the panel going to know which people to talk to? Will the panel be asking the right questions of applicants? Applicants will have different circumstances in different cases. Will those professionals also be skilled investigators? I accept the evidence we had on the skills those people have and bring, but it is not clear to me whether they will be acting in a quasi-judicial way. We have heard that it will not be an adversarial system. Although I can see the problems with creating an adversarial system for the panel, there are systems in other countries where that is allowed, and a different appeal system also exists elsewhere.

On the third point, which is about the standard of proof, if the panel finds matters that worries it, but does not find actual evidence of coercion, then it is not clear to me what it does. The panel could find that a patient qualifies for assisted dying on the balance of probabilities, and then approve that request. Three members of the panel could decide that a patient is, on the balance of probabilities, free to make the decision. People have heard my concerns about capacity, and whether the process for determining that is correct. We talked yesterday about how decisions are made in new schedule 2, and particularly subsection 5. There are differing views on the Committee about subsection 5(2), which talks about a “majority vote”, and how that may align with subsection 5(3).

My fourth concern is that there is no provision made in the new schedule or amendments for how the panels will deal with people with learning disabilities. There may be a further amendment to come on that matter. I accept that we agreed to an amendment regarding training for individuals, but I have concerns about how learning disabilities could be judged by the panel. I referred yesterday to how people with learning disabilities could go through this process with no support from friends and family, and then be presented before a panel. Under the Mental Capacity Act 2005 and its code of practice, would the panel have to assist the person in making a decision? That is what, in my mind, the Mental Capacity Act states: that if someone requires help to make that decision, individuals with the power should help them to do so.

There are wide differences in how professionals talk to, listen to and interpret people with learning disabilities. I know that first hand, on a day-to-day basis. The Bill should set out best practice in this field from the start, so that we do not see discrepancies between how panels undertake their work with learning disabilities. I do not think I need to spell out how a bad decision in this field could lead someone choosing assisted death to a place where others may not want to take them.

The fifth area relates to appeals, and that they can only go one way. A person whose application for assisted death is rejected can appeal to the voluntary assisted dying commissioner. The commissioner can then either uphold the decision or allow the person to have an assisted death. We have discussed what happens if a person who knows that that person applying for assisted death has grounds for concern about the case. We have discussed the legal means of people wishing to seek a judicial review, which causes me grave concern. Under the Bill as written, the person known to the person seeking assisted death cannot appeal against a decision. I heard the debate this morning on the amendments tabled by the hon. Member for Reigate. The Bill says that the panel can choose to hear from any person who has a relevant connection, but there appears to be no mechanism for someone to apply to register any concerns with the panel.

In the oral evidence we received we heard concerns from Sir Nicholas Mostyn and Alex Ruck Keene that both sides should have the right of appeal. We heard that from a legal background, from supporters—I hear that Alex Ruck Keene was referred to as an objector, but I think he would say he is neutral in the process. People who have differing views about the process said to us in their oral evidence that both sides should have the right to appeal.

[Naz Shah]

My hon. Friend is making very important points. Is he aware that Professor Mark Elliott, one of the UK’s leading professors of public law and a former chair of the Cambridge law faculty, has spoken about the

“asymmetrical nature of appeals under the Bill,”

and said:

“At best, suggestions that judicial review is an adequate substitute for families who wish to challenge decisions indicate a fundamental misapprehension about the nature of JR.”

On the suggestion that injunctions might work, is my hon. Friend aware that between January 2017 and 2021, the administrative court has issued only one injunction?

[Daniel Francis]

I thank my hon. Friend for that statistic, which I was not aware of. It relates back to concerns that I have had through the process, particularly on learning disabilities and how a family member finds out during the process what processes would be open to them. In my opinion, it is unclear how the proposed panel fits into our legal system. Again, there are all kinds of quasi-judicial panels that do fit into our legal system, and they have an appeal process, of course. They would normally see two parties in a case. I hear what has been said this morning about Spain. It was put to us in oral evidence from a supporter of the Bill that we should look at that part of the Spanish model about having both sides of the process, although I accept that Spain has a very different legal system from the United Kingdom.

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

Naz Shah Excerpts

Committee stage
Wednesday 12th March 2025 Public Bill Committees

[Danny Kruger]

Yes, but he or she will consider a reconsideration only on the basis of an application to reconsider made by the applicant. There is only one opportunity for an appeal and it can happen in only one direction: against a refusal. I will come on to the role of the commissioner in a moment, but in the great majority of cases there will not be a judge involved in the decision. There might be a retired judge on the panel, but that is extremely unlikely; it is more likely to be a lawyer. It is a judicial exercise that is being conducted, so it would be appropriate for it to be a judge sitting properly in a court.

[Naz Shah (Bradford West) (Lab)]

Does the hon. Member share my concern that the Bill does not say that the panel can call people and ask them to swear under oath, unlike a mental health tribunal?

[Danny Kruger]

The hon. Lady is absolutely right. Having said that the panel is not a proper multidisciplinary team, I agree that it is not a proper judicial entity either. It is a panel with judicial power to approve life-or-death decisions, but it is without a judge or the normal judicial processes that would happen in a tribunal or court. There is no oath being taken by members of the panel or by witnesses; there is no independent appointment process, so the members of the panel will be appointed by the commissioner; there is no power to order the disclosure of information to the panel; there is no power to investigate wills, financial records or anything like that; and there is no requirement to meet the doctors or even to discuss the case with the patient themselves, if the panel considers that appropriate.

There is also no appeal against an approval, just a one-way appeal against a refusal. That appeal goes not to an independent judge sitting in a court, but to a commissioner—an appointee of the Government, who has been set up to facilitate the whole system.

Let me turn to the role of the VAD commissioner, or the Vader as I think of it; I will not labour the point. They can be a sitting judge, which is good, but I suggest to the Committee that it is highly unusual for sitting judges to be appointed to other public functions that are unrelated to a judicial role. I would be interested in the Minister’s view on that. Judges can be appointed to a second judicial job, such as chairing the Sentencing Council, but I am not aware of many examples in which a sitting judge sits in a non-judicial function.

Having looked into it, I discovered that there are three exceptions to the rule. First, the Master of the Rolls holds a number of sinecures in relation to the keeping of the public archives and the payment of the national debt, so that is a non-judicial function that a judge carries. Secondly, the chair of the Law Commission is a sitting High Court or Court of Appeal judge. Thirdly, and exceptionally, with permission of the senior judiciary, sitting judges can be asked to conduct public inquiries. A singular public inquiry, which is time-limited and essentially judicial in its purpose of determining what happened, and which will of course operate in an adversarial way, hearing proper evidence from counsel, is the only exception. However, that is not comparable to the model being set out here, in which a sitting judge is being asked to chair a permanent quango—a Government body.

--- Later in debate ---

[Danny Kruger]

It would be very helpful if the hon. Lady could—not now; it need not be in the course of these deliberations—publish the evidence of that assertion. Which senior judicial figures have endorsed the new plan? It would be very helpful to hear from them.

We heard many criticisms of the previous regime. In my view, those objections prompted the change of heart that the new clauses derive from. From what I have seen, the weight of evidence indicates that we still have many of the problems that the High Court system had: a lack of effective powers and questions around capacity. We also have a whole new load of problems to do with the essential illegitimacy of a quasi-medical panel of people making an essentially judicial decision without the opportunity to hear in a meaningful way from all the different stakeholders who should be consulted.

[Naz Shah]

I want to understand and clarify something. The hon. Gentleman said earlier that the commissioner is sitting as a judge, but my understanding is that the commissioner is not sitting as a judge. What did he mean?

[Danny Kruger]

I think the hon. Member for Spen Valley said yesterday that we had to grapple with this confusion, which is that there is a judge not sitting as a judge. It is slightly like a Minister not sitting as a Minister; the Bill has provided all sorts of interesting hybrid creations of people who inhabit split personalities and dual roles.

The hon. Member for Bradford West is, I think, right. From the evidence we have heard from the hon. Member for Spen Valley, although there will be a judge, which satisfies the cosmetic need to present this as some sort of continuation of the High Court stage that the House of Commons voted for, they will not sit as a judge. It is rather like having a hobby or a second job. I am not sure judges do that, but it is like chairing a football club on the side. Their status derives from their judicial role, but they are sitting as the commissioner in a lay capacity—I think I have that right.

[Danny Kruger]

It will be interesting to hear from the Minister, who is more equipped than the rest of us to opine on this. My understanding is that a judge sitting as chair of a judicial inquiry might not be sitting in court, but they are there because they are a judge; their function, as the chair of the inquiry, is essentially judicial. That is the only comparison and it is essentially different, because the exercise of a public inquiry is time-limited and specific to a particular case, which is to determine the truth or otherwise of what happened in whatever situation it is being asked to inquire into.

Here, we are setting up a quango—an arm’s length body of Government—that will sit in perpetuity and oversee a bureaucracy of state. That is something that no judge does in our system and, in my view, would be completely inappropriate for a sitting judge to do, even if we could find a sitting judge prepared to fulfil that function, which I think might be challenging.

The other key difference is that a judge chairing a public inquiry is appointed by the Lady Chief Justice; they are essentially judicial in their appointment and work. The judiciary appoints one of its own to fulfil a judicial function as the chair of an inquiry. It is being proposed here that the Government—the Executive, not the judiciary—appoint the chair of the commission from the Bench of judges.

[Naz Shah]

What the hon. Gentleman has said creates another concern for me. If we do have a judge, and if the expectation is that they sit in a judicial capacity, does that not raise concerns that an appeal is allowed one way—if an assisted death is refused—but not the other way, if someone wants to appeal against an assisted death? By definition, does that position not become compromised?

[Danny Kruger]

I am afraid that that is absolutely right. There is an essential problem with the role of the commissioner as the backstop—the Court of Appeal, as it were—for what are effectively judicial decisions made by the non-judicial panel. The fact that appeals can be heard only against a refusal and not an approval confuses the whole question of appeal and judicial review. It is plainly unjust, and does indeed compromise the idea that the judicial figure has the independence that a judge should properly have. I agree with the hon. Member for Bradford West.

[Naz Shah]

I want to speak to amendment (c) to new schedule 2, tabled by my hon. Friend the Member for Lowestoft. The amendment requires members of the panel to have undertaken training in respect of domestic abuse, including coercive control, and financial abuse. It extends the principle of amendments 20, 21, and 22, also tabled in the name of my hon. Friend, which require the medical practitioners involved in the assisted dying process to have undertaken similar training.

[Kim Leadbeater]

rose—

[Naz Shah]

I am happy to give way to my hon. Friend, the sponsor of the Bill. I am really pleased that she accepted the previous amendments. I do not know whether she will accept this one.

[Kim Leadbeater]

A strong argument has been made to me that the professionals on the panel would have the skills and training to fulfil their role, but it is important, particularly given the time we have spent discussing this issue, that they do have it, so I am happy to support that amendment.

[Naz Shah]

I appreciate that. None the less, I will speak briefly to the amendment as I still have concerns. The amendment provides an absolutely necessary safeguard and I welcome the fact that my hon. Friend has accepted it. I am pleased that it extends to panel members, but it does not meet the safeguarding needs when it comes to people of ethnic minority backgrounds, coercion, cultural competence and so on. People and organisations have raised concerns about that.

The truth is that the Bill is very gendered: the analysis by women’s organisation The Other Half has found that if the Bill passes, and trends follow those of Australia, 1.65% of all deaths in this country could take place via assisted dying. If so, as many as 1,400 domestic abuse victims could die each year through that process. It is vital that Members on both sides of the debate are conscious that we are opening up a new avenue for domestic abuse through the Bill. That is what the amendment speaks to. To save the Committee time, I will not go over the detail because it was covered during our discussions of the previous three amendments.

[Kit Malthouse]

I rise briefly to amplify a couple of points from the excellent speeches by the hon. Members for Rother Valley and for Ipswich. First, in clarification, I understand that there are situations where judges can sit in essentially supervisory positions—not least, for example, on the BBC board—and they can of course be Cross Benchers in the House of Lords. They are allowed to undertake other charitable trustee roles, although they are restricted in their activities.

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[Lewis Atkinson]

I thank the hon. Member for that point, but when someone cannot describe any version of safeguards that would be possible, and in the light of some of the other conversations we have had, one is led to believe, entirely respectfully, that some people are opposed to the Bill in principle in any instance.

The point that my hon. Friend the Member for Spen Valley made on Second Reading that this was the safest model in the world was not just about the fact that there was a judge, but about the fact that there was a third tier. That is not something that is in place in Oregon, or even in Australia, as we heard in evidence. Now, not only are we going to have a third tier of scrutiny, but we are going to have three professionals who must unanimously accept that the strict conditions for eligibility have been reached. I absolutely refute the suggestion that amending away from a High Court model and towards a panel model means that we have to recant any suggestion that this is the strongest model in the world.

[Naz Shah]

Will my hon. Friend give way?

[Lewis Atkinson]

I am going to continue this point, if I may.

The hon. Member for East Wiltshire asked what the purpose of the panel is. As is set out very clearly in new clause 21, it is about determining eligibility for assistance, with reference to the stringent rules and conditions that we will lay out in the Bill. The hon. Gentleman went on to ask about the purpose of the judge and suggested that it is a bureaucratic role. As new clause 14(4)(c) makes clear, the commissioner’s role is making arrangements for panels, and new schedule 2 is clear that the commissioner has powers to give guidance about the “practice and procedure” of those panels. Clearly, the commissioner will be a judicial figure with experience of proper process and procedure, and it is absolutely right that that person, who will set out the procedure for each of the panels, is a judge.

The hon. Gentleman made a point about MDTs. I am not sure whether he has worked in or around healthcare, as I and other members of the Committee have, but I say gently that the suggestion that individuals at the end of their lives are not in contact with multiple professionals is highly implausible. We are blessed in this country that we have some of the best cancer nursing in the world, and that we have palliative care social work. He previously asked which bodies had come out in support of this change. Well, the Association of Palliative Care Social Workers says:

“The inclusion of social workers as core members of these panels shows that Kim Leadbeater and her colleagues have taken on board our arguments that social workers are uniquely qualified and equipped to undertake the complex and sensitive tasks of assessing mental capacity and safeguarding individuals who may be subject to any form of undue influence or coercion.”

[Naz Shah]

Will my hon. Friend give way on that point?

[Lewis Atkinson]

No, I am in a flow, so I am just going to keep going. I am mainly rebutting at this point, and I do not want to open the debate that much wider.

Invariably, we already have individuals at the end of their lives with multidisciplinary input that is appropriate to them, and we have heard already how the independent doctors and the panels will rightly seek input from all those involved in care.

It has been some time since the hon. Member for East Wiltshire and I had an exchange on our difference on the ventilator test, but I know that we have a fundamental, philosophical difference on that. I believe that a dying person saying, “Please, doctor, turn off my ventilator; I want to die,” is not fundamentally different from that person saying, “Please, doctor, let me take that medicine; I want to die.” I assert that the person in the street is closer to my view of that situation than to his, although I respect that people have different philosophical opinions about it. However, let us not forget that we sometimes conduct this debate about the correct oversight of the third tier in a theoretical manner, as if these people were not dying anyway, and as if deaths relating to refusal of treatment, and suicide, were not happening anyway.

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I again gently say that I understand there are in-principle opponents of the Bill, but we are working in good faith through these amendments to respond to the evidence that we have heard and to improve the lives of families and dying people in this country. That is why I am proud to be supporting the amendments in the promoter’s name.

[Naz Shah]

I will speak to amendment (b) to new schedule 2, but before I do, I will address some of what my hon. Friend the Member for Sunderland Central just talked about. To clarify something for the record, Glyn Berry, co-chair of the Association of Palliative Care Social Workers, of which there are 200 members—there are 200 social workers for palliative care in the country as it stands—has not given an endorsement, and has categorically said that the association does not support the panel structure, as it fails to support what the Bill is intended to do on assisted dying. I am happy to send my hon. Friend the reference for that.

The right hon. Member for North West Hampshire referred to panels in particular. I tried to intervene and ask him about this directly, but I will mention it now and I will be happy to give way should he wish me to. He told the Hansard Society that he was not supporting palliative care specialists at an earlier stage, simply because the issue of palliative care would be addressed in the structure of the panels, but that has not happened. I just wanted to put those concerns on the record before I moved on to my substantive speech.

Amendment (b) to new schedule 2, tabled by my hon. Friend the Member for Derby North (Catherine Atkinson), would amend the new schedule, tabled by my hon. Friend the Member for Spen Valley, to ensure that the Official Solicitor will nominate a person to represent the applicant before the panel. As it stands, the new schedule does not require the commissioner to give guidance about the practice and procedure of panels. However, if guidance is given, the panels, under paragraph 8(2),

“must have regard to any such guidance in the exercise of their functions.”

Amendment (b) would remove the relevant sub-paragraphs and replace them with the following:

“(1) The Commissioner must give guidance about the practice and procedure of panels.

(2) Such guidance must prescribe a procedure which in relation to each application appoints a person nominated by the Official Solicitor to act as advocate to the panel.

(3) Panels must have regard to such guidance in the exercise of their functions.”

What effect would this have?

I refer hon. Members to the written evidence submitted by Ruth Hughes, a senior barrister due to be appointed King’s counsel on 24 March. The written evidence number is 161. Ms Hughes notes that she has

“17 years’ experience of specialising in mental incapacity and the law in relation to vulnerable adults”

and that she has

“advised the Ministry of Justice on capacity related issues.”

She describes herself as

“one of the most experienced barristers specialising in the property and affairs of persons who lack mental capacity in the country.”

In this context, it is particularly noteworthy that Ms Hughes has frequently appeared in court instructed by the Office of the Official Solicitor and the Office of the Public Guardian. She says:

“In my professional experience, financial abuse of the vulnerable and those who lack mental capacity, or are approaching the borderline, is depressingly common.”

Ms Hughes is not someone who opposes the Bill at all costs; she seeks to strengthen its safeguards for those at risk of coercion. She states in her evidence that

“whilst I do not oppose the Bill, I am highly concerned that the safeguards proposed are insufficient to protect vulnerable people from exploitation for financial gain. I suggest it would be profoundly disturbing and wrong for Parliament to enact legislation which put vulnerable people at risk of being killed for financial gain without creating adequate safeguards to protect them.”

Those are very strong words from someone who I suspect is not in the habit of crying wolf. If we hear that kind of warning from a senior lawyer with Ms Hughes’s specialised knowledge of protecting at-risk adults, we should certainly listen.

Ms Hughes was a strong supporter of the use in the Bill as drafted of a High Court judge as the authority who would decide on assisted dying applications. She wrote:

“I suggest that the judicial safeguard is fundamentally important.”

She recommended, however, that the Bill should be amended to include five additional safeguards. I am pleased to say that my hon. Friend the Member for Spen Valley has accepted one of the five proposed protections: the requirement to hear from the person who wishes to die. Ms Hughes’s fifth recommendation bears directly on the amendment we are discussing. She says that the Bill should be amended to include an advocate who would

“ensure that the evidence in support of a claim is appropriately tested.”

Ms Hughes made that recommendation when my hon. Friend was still advocating for a High Court judge, rather than a panel, as the arbiter, but I do not see that the change from court to panel has in any way weakened the argument she made for an independent advocate. Explaining why she wants to increase safeguards, she says that in the Bill as drafted

“there is likely to be significantly less scrutiny of a decision by the Court in relation to assisted dying than there is for example currently in relation to a decision of the Court of Protection to withdraw life-sustaining treatment from a person, or even a decision as to where a person lacking capacity should live or with whom they should have contact.”

Ms Hughes said that one problem was that

“importantly, there is no person appointed to assist the Court to consider and test the evidence before it. Our Court system is inherently adversarial. Generally, two or more parties to a dispute will present evidence and argument to the Court and the Court will make findings of fact on the evidence and come to decisions on the law in accordance with those arguments. The Court is not hidebound, but equally it is not set up to obtain evidence itself. A scheme which does not provide for an independent party to consider the evidence and present arguments against an application will be unlikely to be robust and will not be well designed to identify, for example, a lack of capacity or the existence of coercion or pressure.”

This part of Ms Hughes’s evidence seems to be particularly important:

“Doctors, for example, may not be well placed to identify coercion, pressure or control. In my experience they are often missed by solicitors taking instructions for the making of gifts or wills. The best solution, perhaps the only good solution, to this problem would be to require the Official Solicitor to act as advocate to the Court in cases brought under the proposed legislation.”

It would be helpful if we explained the term “advocate to the court.” The Ministry of Justice published the following explanation of what an advocate to the court is and what they do, based on a 2001 memorandum agreement between the Attorney General and the Lord Chief Justice. The Ministry said:

“A court may properly seek the assistance of an Advocate to the Court when there is a danger of an important and difficult point of law being decided without the court hearing relevant argument. In those circumstances the Attorney General may decide to appoint an Advocate to the Court…It is important to bear in mind that an Advocate to the Court represents no one. Their function is to give to the court such assistance as they are able on the relevant law and its application to the facts of the case.”

We should all see the advantage of being able, through the Official Solicitor, to give the panel the assistance of specialist lawyers. We should particularly see the advantage of the Official Solicitor being able to appoint barristers who are experienced in cases where capacity was in doubt or where people were possibly being coerced.

The Ministry of Justice explanation goes on to say:

“An Advocate to the Court will not normally be instructed to lead evidence, cross-examine witnesses, or investigate the facts.”

The word “normally” is important in this context. The advocate will perhaps not carry out these functions when acting to advise assisted dying panels, but we should note that the Ministry’s guidance does not state that they will never carry out such functions. As we have remarked more than once, we are in unmarked territory here.

I will end by quoting some more of Ms Hughes’s evidence, because it is clearly written by an expert in their field. She says:

“In my experience it is not uncommon where a vulnerable person is controlled or is lacking capacity for the person to be apparently expressing wishes in a clear and forceful manner. This can easily be mistaken for a person acting freely and with capacity.”

That statement is a powerful counterpoint to some of the confident claims we heard from witnesses about it being relatively easy for doctors to detect coercion. Some of the witnesses from Australia and California were particularly noteworthy in that regard.

Ms Hughes goes on:

“In short, the risks of the Bill are real and substantial. The challenge for Parliament is how to mitigate them. The current drafting is inadequate.”

That is evidence we should not ignore. It comes from a distinguished lawyer who is not an opponent of the Bill but who fears that, as drafted, it will not protect the vulnerable. She has offered us what seems to be a workable solution to the problem that concerns her: create a mechanism to involve the Official Solicitor. Amendment (b) to new schedule 2, tabled by my hon. Friend the Member for Derby North, would allow us to put that into practice. I hope that all Committee members can support the amendment and increase the protection that the Bill offers to vulnerable people at risk of coercion.

[Sean Woodcock (Banbury) (Lab)]

It is a pleasure to have you here this afternoon, Ms McVey. I did not intend to make a contribution, but given the number of contributions that have been made, I wanted to respond to them. It has been a really interesting and important sitting.

My hon. Friend the Member for Ipswich is right. I see the panel as a genuine attempt to respond to the evidence we heard in the witness sessions and improve the process. I take that absolutely as read, particularly in respect of the evidence from Rachel Clarke, whose view was that coercion is happening and that we should take the NHS as it is, not as we would like it to be. I see the attempt at introducing a panel as a response to that.

The right hon. Member for North West Hampshire is absolutely right to state that if there is a moral imperative to do something, Parliament should look at passing it and then the public services should figure out how they implement it afterwards. He is right in that. There is obviously a question about whether there is that moral imperative, but he is right to point that out.

Although I take the panel as a sincere attempt to strengthen the Bill, I feel that, as put before us, it is not strong enough. That is why I spoke yesterday to amendment (d) to new clause 21, tabled by my hon. Friend the Member for Derby North, which would ensure that the process was done properly and robustly. Nobody wants to see people dragged in front of a court when they are unwell, but there is the matter of safeguarding, and we do have a concern over coercion. It is integral to ensure we have public trust, so I urge the Bill’s proponents to consider those concerns again.

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[Sean Woodcock]

Having thought about it, that would be my preference. I am in a difficult position in that there is a lot to be said for the panel, and it would improve the process in many ways, but I cannot get around the fact that the judicial aspect was put strongly before Parliament, and ensuring that we would have those safeguards provided reassurance to Members. When I have been out on the doorstep talking to people who are in favour of the Bill—people who wanted me to vote in favour of it—they have said to me that they think the proposal is safe because it includes two doctors and judicial oversight. That does come up, which is why I think we need to keep judicial oversight in the Bill. I do, though, I recognise the very genuine attempt by my hon. Friend the Member for Spen Valley to introduce the panel to improve on some aspects and address the concerns expressed in the witness testimony.

[Naz Shah]

If I may, Ms McVey, I will speak to the issue of the judicial oversight of the panel and the whole of new clause 21. I would like to understand something, and perhaps the Minister or my hon. Friend the Member for Spen Valley could help me. We have been talking a lot about judicial oversight. My concern is that even if we had judicial oversight, there is no liability if something goes wrong. We would have had judicial oversight, but now we have panel oversight—non-judicial oversight—of the decision. Even then, what if somebody went down the assisted dying route and an issue was raised afterwards? What recourse would anybody—family members and so on—have to hold anybody liable if they did something wrong, including, potentially, the commissioner?

[The Minister of State, Ministry of Justice (Sarah Sackman)]

It is a pleasure to serve under your chairship, Ms McVey.

As my hon. Friend the Minister for Care and I have made clear throughout debate, the Government continue to remain neutral on the Bill and do not have a position on assisted dying. Once again, my remarks will focus on the legal and practical impacts of the amendments, with a view to assisting Committee members. I will first speak to amendments 371 to 373, 377, 378, 381, 388, 390 and 391, new clauses 14, 15, 17 and 21, and new schedules 1 and 2, all tabled by my hon. Friend the Member for Spen Valley.

In executing our duties to ensure that the legislation, if passed, is legally robust and workable, the Government have worked with my hon. Friend the Member for Spen Valley in relation to the amendments, which propose the voluntary assisted dying commission and the panels. They reflect my hon. Friend’s intent to replace the court approval process that is currently set out in the Bill. I confirm that this change was driven not by capacity concerns from within Government, but by the Bill promoter’s policy intent. Let me be clear: the High Court stage could be made to work, but if the Committee and Parliament elect for the commissioner and panel model, the state will work to deliver that.

New clause 14 and consequential amendment 391 would provide for the establishment of a voluntary assisted dying commissioner. In keeping with other appointments of this significance, the commissioner would be appointed by the Prime Minister, and the individual in post must hold or have held office—so it is not sitting judges, but could be a retired judge—as a judge of the Supreme Court, the Court of Appeal or the High Court.

New clause 14 sets out the central functions of the commissioner, which will be detailed further in new clauses 15 and 17 and new schedule 1. The commissioner would receive documents, including the reports from the co-ordinating doctor and declarations under the legislation, make appointments to the list of persons eligible to sit on assisted dying review panels, and refer cases to those panels, which would replace the role of the High Court in the original draft of the Bill. In addition, the commissioner would have the responsibility for monitoring the Bill’s operation and reporting annually to Parliament, which we will no doubt come to in clause 34. It is important to pause there, because that is one aspect in which the commissioner model is distinct from that of a court or tribunal. It will serve multiple functions, not least the monitoring of the Bill’s operation and reporting on that annually to Parliament.

New schedule 1 contains practical arrangements for the office of the voluntary assisted dying commissioner, as established in new clause 14. In practice, we anticipate that the commissioner’s office will be a non-departmental public body. The establishment of such an office to support the Government-appointed chair or commissioner is common practice for roles of this nature. One such model is the Investigatory Powers Commissioner, which is chaired by a person who is holding or who has held high judicial office. The schedule also introduces the role of a deputy commissioner, who, like the commissioner, must have been appointed by the Prime Minister and hold or have held office as a judge of the Supreme Court, the Court of Appeal or the High Court.

Both the commissioner and deputy commissioner would be appointed for terms of five years, with their remuneration set by the Secretary of State. The commissioner would have the ability to appoint their own staff, having obtained approval from the Secretary of State in regard to the number of staff, the remuneration and the terms, as well as providing an annual statement of accounts. In the ordinary way, such a public body would be subject to other statutory provisions, not least the Equality Act 2010.

New clause 15 would establish the mechanism for the referral by the voluntary assisted dying commissioner to an assisted dying review panel. When the commissioner receives a first declaration from the person seeking assistance, and reports from the co-ordinating and independent doctors as to their assessments of the person—including a statement by those doctors as to the person’s eligibility for assistance—they would be required to refer the case to a panel as soon as reasonably practical. In practice, the task of organising the work of each panel would fall to the commissioner’s office. The co-ordinating doctor would be required to inform the commissioner where a first or second declaration is cancelled. Where the commissioner is informed of the cancellation of the first declaration, they must not refer the case to a panel, or must inform the panel to disregard the application if already referred.

Amendments 371, 372, 373, 377, 378, 381, 388 and 390 are all consequential amendments on new clause 21, and together establish the mechanism for the consideration of cases by the assisted dying review panels in place of the High Court. Panels would be required to review each case and issue a certificate of eligibility where they are satisfied that all requirements set out in the Bill have been met.

--- Later in debate ---

Amendment (a) would require the panel to be satisfied “beyond reasonable doubt”—the criminal standard of proof—that the Bill’s criteria have been met. In law, the balance of probability standard means that a court is satisfied that an event occurred if it considers that, based on the evidence, the occurrence of the event was more likely than not. The civil standard is currently used for end-of-life decisions and in other similar contexts. In addition to being the relevant standard of proof when deciding whether a person has capacity under the Mental Capacity Act 2005, including for serious medical treatment, the civil standard, which would be applied under new clause 21, is also applied in serious cases such as suicide inquests, withdrawal of life support and childcare proceedings. In practice, the panel would establish a case on the balance of probabilities only on the basis of strong evidence, including contemporaneous documentation, records, or hearing from the relevant persons whom they are required to hear from. The panel’s decision must be unanimous.

[Naz Shah]

We have heard before that the panel’s decision must be unanimous. However, I have tried looking in the Bill and it does not state that specifically. My understanding is that two people could nod their head, the other one would not have to, and it would still pass.

[Sarah Sackman]

I believe it is in there. Let me find the relevant provision so that I can refer my hon. Friend to it.

[Naz Shah]

It is a majority vote, not unanimous.

[Sarah Sackman]

It is a majority vote for the other decisions that a panel may make, but in respect of certification, the decision is unanimous. Paragraph 5(2) of new schedule 2 states:

“Decisions of a panel may be taken by a majority vote”.

Such decisions include whether to hear from an additional expert, or whether further investigation is required in respect of an aspect that the panel may be concerned about, such as coercion or capacity. While those decisions can be taken by a majority vote, in respect of certification and granting a certificate of eligibility, I refer my hon. Friend to paragraph 5(3), which states:

“The panel is to be treated as having decided to refuse to grant a certificate of eligibility if any member votes against a decision to grant such a certificate.”

That is a slightly mealy-mouthed way of saying that if any member of the panel resists the grant of the certificate, no certificate can be issued.

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[Naz Shah]

I appreciate that, under the new clause, the panel can hear from anybody. Can the Minister confirm that the panel is unable, unlike a mental health tribunal, to summon people to appear before them or insist that witnesses appear, and to make them swear under oath when presenting their evidence?

[Sarah Sackman]

My hon. Friend is absolutely right. Under the Bill as drafted, a panel and the commission are not invested with powers of summons, and the evidence that is heard and requested is not conveyed under oath. It is not a court or a tribunal. Those provisions do not apply, so she is absolutely right. They can make the request, but they cannot compel someone to attend.

Amendment (e) to new clause 21 would make it explicit that, when considered appropriate for medical reasons, the panel would be able to use pre-recorded audio or video material when considering evidence for the purposes of determining a person’s eligibility for assistance. Panel procedure would be set out in guidance issued by the commissioner, which would detail the processes governing the panel process in general, but also for the use of that form of evidence.

New schedule 2, which was tabled by my hon. Friend the. Member for Spen Valley, builds on the new clause 21. The new schedule further details the composition and the intended proceedings of the assisted dying review panels. As we have heard, panels would be formed of three members, including a legal member sitting as chair, a psychiatrist and a social worker.

Thanks to the hon. Member for Richmond Park, we have dealt with the provision on decisions to grant the certificate of eligibility and how they will be determined by members of the panel. We heard from the promoter herself, my hon. Friend the Member for Spen Valley, that the intention is that such decisions are unanimous.

The commissioner would be responsible for making appointments to a list of persons eligible to sit as members of the multidisciplinary panels, and for establishing those panels. Under the schedule, the legal member as chair of the panel must hold or have held high judicial office, be one of His Majesty’s counsel—that is a KC—or have been authorised as a temporary judge in the High Court. The psychiatrist member must be a registered medical practitioner and a practising registered psychiatrist, and the social worker member must appear on the register maintained by Social Work England or Social Work Wales.

[Naz Shah]

The Minister is being generous with her time. I just want to confirm that the Bill does not require the social worker to be a palliative care specialist. Am I right in thinking that?

[Sarah Sackman]

I think the hon. Lady is right that that is not specified as a requirement. All three panel members would be drawn from the relevant professions and would therefore be subject to the standards pertaining to those professions. In the legal profession, they will be practitioners who are experienced in analysis and reaching decisions based on facts and law. The professional standards for all three regulated professions place a high value not just on integrity, but on impartiality. For the commissioner and for any judges on the panel, the “Guide to Judicial Conduct” makes the principles explicit.

[Naz Shah]

The Minister mentions impartiality. As things stand, the doctors who take part in the process will have made the choice to do so. Would the same yardstick be applied to the panel, or would its members just be appointed? Could they choose not to participate in the process?

[Sarah Sackman]

I anticipate that members of the professions will apply to be members of the panel. There will have to be a recruitment process, which is something that the commissioner, who is appointed by the Prime Minister, will undertake. I emphasise the point that all the professions, in their different ways—I am obviously most familiar with the legal profession, particularly the Bar—are governed by professional standards that specify the need for and place a high value on not just integrity, but impartiality.

[Naz Shah]

I struggle to agree that there would be impartiality, because there are people who are committed, believe in, agree with or are advocates for assisted dying. Does that not raise a concern about potential bias—subconscious bias, even?

[Sarah Sackman]

There is no doubt that, as we will see later, the panel would be subject in all its decisions to public law principles, including procedural propriety. The absence of any suggestion of bias—even of the appearance of bias—is an important public law principle. In any event, given the recruitment process, the interviews that would be undertaken and the professional standards to which all these people would be held, I think that they would apply their independent and impartial skills and judgment to the decision making and the assessment of eligibility in a manner appropriate to the task set out in the Bill.

One would expect professionals on the panel to adhere to their professional standards and act with impartiality in ascertaining whether the eligibility criteria have been met. Speaking as the Minister—indeed, even speaking for myself—I have no reason to doubt the independence, impartiality and professionalism of the panel or see any suggestion of bias.

--- Later in debate ---

[Naz Shah]

The Minister is being very generous in giving way. I want to understand something. She says that the Official Solicitor is there to help with adults who lack capacity, but in the cases before the Court of Protection of the girls who had anorexia, the judges took a decision that they should not continue to be force-fed. The judges concluded in nine of 10 cases that they lacked capacity, and yet accepted that these girls were inevitably going to die. In that case, would the role of the Official Solicitor not be helpful as a further safeguard?

[Sarah Sackman]

It is important to look at this issue in the context of what my hon. Friend the Member for Spen Valley is setting out to do through the legislation, and what the panel’s function is, which is the function that was discussed in the debate. This is not a trial or an inquiry. That is not what is being undertaken by the panel. The panel’s purpose is to ensure that the eligibility criteria process has been followed in a correct, lawful and safe way. As others have pointed out, it is not adversarial, and will not be described as such in the Bill.

All that I am saying on behalf of the Government is that the Official Solicitor’s role is most frequently to assist in court with a difficult or novel point of law when the person cannot do it themselves. Well, we do not have that here. We are not determining points of law; we are determining whether this person has met the eligibility criteria. Secondly, the Official Solicitor’s role is for when individuals lack capacity. In the Bill, by definition, the person who is applying has already satisfied two doctors that they have capacity. Of course, the question of capacity may be something that the panel wishes to explore further—it has the three panel members and the ability to draw on its powers to seek further information to test that—but it is not clear, without altering the current role that the Official Solicitor plays within our legal system, what role they would be serving.

[Naz Shah]

I appreciate the Minister’s position and am grateful for her explanation, but it does not address the central point, which is that nine girls were deemed not to have capacity. Despite all the amendments that have been tabled and the letter from all the charities about anorexia, that has not been addressed. In absence of any impact assessment on one of the issues that most frustrates me, how do the Government conclude that the workability of the Bill is sufficient? Will it work, given that we do not have the protection for those girls who may have anorexia? There is precedent for such girls who did not have capacity. How will the Government safeguard those girls in particular?

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

Naz Shah Excerpts

Committee stage
Tuesday 18th March 2025 Public Bill Committees

[Naz Shah (Bradford West) (Lab)]

As we heard from the hon. Member for Richmond Park, her amendment concerns the second period for reflection under the Bill as drafted. The second period of reflection would take place after the panel had approved a person’s application for assisted death. The Bill states that that period would be 14 days, unless

“the coordinating doctor reasonably believes that the person’s death is likely to occur before the end of the period of one month beginning with the day that declaration was made”;

in that case, the second period is shortened to 48 hours.

Some people who have a strong desire to hasten death might wish to avoid the second period for reflection. If they refused food, there would be a strong possibility that their physical condition would deteriorate, so that a doctor would indeed believe that they were likely to die within one month. That is not a hypothetical possibility. We know that there are people who do refuse food to the point where they become gravely ill with malnutrition.

The right hon. Member for North West Hampshire said something that I think is relevant here. He was asking questions of a witness before this Committee, Professor Nicola Ranger of the Royal College of Nursing, on 28 January. To quote Hansard, the right hon. Gentleman said:

“At the moment, within palliative care and palliative nursing generally, you are already dealing with patients who are electing to refuse treatment, food and water, or are supporting patients following an advance directive.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 59, Q70.]

On the same day, the right hon. Gentleman said something similar to another witness, Dr Sarah Cox:

“I want to pursue that point a little with you, Dr Cox. My understanding is that your profession is already taking these decisions, or supporting patients to take these decisions—for example, the withdrawal of ventilation for an MND patient towards the end, or if I decide to decline treatment or food and water to end my life as quickly as I can.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 74, Q91.]

In other words, it is not some remote possibility that patients who are already ill may decide to refuse food. That is one thing I hope that the right hon. Gentleman and I can agree on. We also know from the survey undertaken by a group of specialists in eating disorders that, in countries that have assisted dying laws, at least 60 people have qualified for assisted death because they suffered advanced malnutrition.

Some people who are seriously ill and who wish, in the words of a psychiatric witness, to “hasten death”, may see the 14-day period as intolerable. An alarming possibility is that they might stop eating in order to worsen their physical condition and qualify for the 48-hour period. Amendment 457 would remove that possibility. I strongly recommend that hon. Members support it.

People would qualify for a shortened period for reflection only if they

“have not voluntarily stopped eating and drinking”.

That word “voluntarily” is important. I understand the reason that the Bill’s drafters included a provision for a shorter, second period of reflection, but as with much of the rest of the Bill, I am sorry to say that I do not think that they have provided strong enough safeguards. This is a well drafted amendment that would tighten those safeguards. I urge Members to support it.

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[Danny Kruger]

I recognise that, but that is not germane to the debate that we are having, which is about the actual cancellation. There is a question about why there would have been a cancellation. My right hon. Friend is right that there is no obligation to proceed once a patient passes a particular hurdle. Many will not, but when someone decides actively to renounce their decision, a big question should be asked: what is going on, and what further help is needed?

My right hon. Friend suggests that we do not step in and ensure that care is provided—that, in other circumstances, there is no additional obligation in relation to patients. I am afraid to say that he has, as ever, a coldly rationalistic vision of healthcare and of the sorts of patients we are dealing with. As I have said to him, these patients will be acting much as I imagine he would imagine—I think from a position of health and self-confidence—himself acting in that circumstance. In fact, we are dealing with people who have decided to renounce their decision to proceed, and so are by definition in some turmoil.

I crave the indulgence of the Committee, because I am talking at length about a set of amendments that I do not intend to oppose, and I recognise the value and necessity of the clause. However, I draw to the Committee’s attention that we are dealing not simply with a bit of paperwork, but with a human being who, having made one enormous decision—to die—is now making an enormous decision to live, and we are treating it as if it is only a bureaucratic question.

I finish with a question to the hon. Member for Spen Valley or to the Minister, to help me understand something that confuses me in the clause.

[Naz Shah]

I have not given this matter as much thought as the hon. Member has. My interest is very much in the issue of domestic violence. Does he agree that this could be somebody who has experienced domestic violence? Or children could be at risk. This person may then decide not to take the option, even though they wanted to, because of obligations elsewhere.

[Danny Kruger]

The hon. Lady is right, and her point goes to the question that runs through all of these clauses: why? As a Committee, we rejected the obligation on the doctors to ask, “Why are you doing this?” It was suggested by one hon. Member that it was nobody’s business why somebody was trying to take their own life and that if that person qualified, they should be able to summon the agents of the state to provide them with lethal drugs without any question about their motivation.

I agree with the hon. Lady. There is an equal expectation in my mind that doctors should ask the question, “Why are you changing your mind?” I would expect that. The clause could clarify what further referrals would need to be made, if they had not already been; as we have acknowledged, we would expect appropriate care to be provided by doctors anyway.

I conclude with a factual question. Clause 14(1) lets a patient cancel a first or second declaration, but subsection (4) says only that the duties of the doctor stop when a first declaration is cancelled. I would be grateful if the hon. Member for Spen Valley would explain what happens if the patient cancels a second declaration. It strikes me that there would be a need for urgency because if a patient decides to change their mind at that point, that is arguably a more dangerous situation. What would be the obligations on the doctor at that point? Should we read across from subsection (4) that their duties stop in the same way? Perhaps that could be clarified in later drafting, if necessary.

To conclude, my general point is that the issue of a cancelled declaration is about more than the paperwork. Although, of course, we respect the autonomy of a patient to make their own decision to cancel a declaration—obviously, I would insist that that right should be in the Bill—it nevertheless raises a question in my mind: why is that happening, and what should we expect the patient’s medical team, or others, to do in that circumstance?

--- Later in debate ---

[Stephen Kinnock]

I am acutely conscious that every word we say in this Committee is on the record. My hon. Friend makes a valid point in that context.

The purpose of amendment 253 is to clarify that a person acting as a proxy can both sign and revoke a declaration on behalf of a person seeking assistance under the Bill. This amendment would extend the provisions under clause 15 to a person who is acting as proxy to the person seeking assistance under the Bill, enabling the proxy to act on behalf of the person to cancel their first or second declaration if they are unable to sign their own name by reason of physical impairment, being unable to read or for any other reason. I note that the cancellation of a declaration is governed by clause 14, and the cancellation may be given orally, via writing, or

“in a manner of communication known to be used by the person”.

It does not require the signature of the person seeking assistance under the Bill, so a proxy may not be required for some people in relation to revoking a declaration, even if they have been required under clause 15.

[Naz Shah]

On the point made by the Bill’s promoter, my hon. Friend the Member for Spen Valley, should the issue of proxy end up before a court, what will be relied on—the conversation that we are having here and the intentions stated in Committee, or a future statutory instrument and what the Secretary of State puts in the guidance?

[Stephen Kinnock]

The regulations will have primacy, and will be shaped by a range of inputs, including the conversation we have just had in Committee. The process is that the Bill gets Royal Assent, then the regulations are drawn up based on a range of consultations and inputs—including the Hansard. The regulations then become the basis on which this proxy process is managed, enforced and executed.

[Naz Shah]

I genuinely want to understand this issue. Even though we have had this conversation in Committee, what if the Secretary of State, following those consultations, decides otherwise? What recourse do we as a Committee have to challenge that?

[Stephen Kinnock]

The Bill, once it becomes an Act, places a legal duty on the Secretary of State to produce those regulations. The Secretary of State would be in breach of the law if he were not to enforce the conclusions of the Act.

--- Later in debate ---

[Danny Kruger]

Once again, we are in an extraordinary no man’s land between medical treatment and something else that we cannot find a word for. The hon. Gentleman is absolutely right. Of course, it is appropriate in medical treatment for a nurse or doctor to assist in the administration of a treatment. As he suggests, if the person found it difficult to raise a cup to their lips, the nurse would help them. Indeed, if they found it difficult to perform an injection, it would be expected that that would be done by the nurse or doctor anyway. But here we are setting up a strange new method of administering a so-called treatment in which the patient has to perform the physical act themselves.

It is apparent from the clause that it is very unclear what assistance actually looks like, so yes, I absolutely imagine that if the patient were struggling to raise the cup to their lips, a nurse or doctor who was present at the final act in an assisted suicide would help them to do so. Similarly, if the patient were finding it difficult to put their finger on the syringe, it would be appropriate—normally, one would expect—for the medical professional to lift the patient’s finger and put it in the right place. What happens next? Do they then apply a little pressure if the patient is finding it difficult to depress the plunger on the syringe? If the cup is at the lips, do they tip it up and let gravity take its course? These very complicated questions about where assistance ends and autonomy begins are, I am afraid to say, impossible to specify in the Act; therefore, it is apparent that we have a grey area.

I conclude with some evidence that we received from Iain Brassington, professor of applied and legal philosophy at Manchester University. He says:

“how are we to determine how the ‘final act’ of self-administration is to be differentiated from the penultimate act, in which the doctor may assist? How would helping a patient lift the cup to her lips be distinguished from helping her ingest its contents?”—

the hon. Member for Ashford referred to that. He goes on to say that

“the definition of the ‘final act’ is unclear, especially granted the wording of”

subsection (6)(c), and:

“The proposed law says that a doctor may not administer a substance with the intention of causing death, but also that a doctor may help a person self-administer. But how should we draw the boundary between helping a person self-administer, and playing a role in administration?”

I come to the penultimate point—not the final act—of my speech. There is some odd phrasing in subsection (7), and I wonder whether the hon. Member for Spen Valley or the Minister can help to parse the English. It says that

“the decision to self-administer the approved substance and the final act of doing so must be taken by the person”.

We understand about the decision being taken by the person, but the phrasing is that the final act “must be taken” by the person. I am not familiar with that construction. Does one take an act? Is that English? You perform an act—an act is not taken, it is done, by a person acting autonomously. The question of whether this is an active or a passive concept runs to the heart of my concern about the clause, and we need to think about redrafting, at least in deference to the English language.

Somewhere in this clause there is a magic moment when assistance gives way to autonomy, and the penultimate act by the doctor yields to the final act, which is supposed to be by the patient. We cannot tell when the responsibility for the action passes from one to the other. In proper medicine it does not matter because the medic works with the patient, but here it does matter. We are insisting that there is a difference between a doctor setting up a death, and the patient performing the action of suicide.

I will end by referencing the case of R v. Kennedy in 2007, a case on which Lord Bingham opined, about the culpability of someone who died from a heroin overdose. Was the person who gave him the drugs and tied the tourniquet around his arm responsible? Was it murder, or indeed assisted suicide? The judge decided that it was not, but made this point:

“It is possible to imagine factual scenarios in which two people could properly be regarded as acting together to administer an injection.”

Given that ruling, we are in a world of difficulty with the suggestion that it is legally possible for a doctor to assist a patient to ingest or otherwise self-administer. To assist someone to self-administer is tantamount to administering. I welcome suggestions from other Members, the Minister, or the hon. Member for Spen Valley about whether it is possible to provide guidance that gives greater clarity on what the clause means, or whether subsequent amendments will help to resolve the problems that I have, but I am afraid I do not think it will be possible to make an adequate distinction between assisted suicide on the one hand—in which full responsibility, not just for the decision but for the performance, rests with the patient—and euthanasia on the other. I do not think there is an adequate logical difference, and the practical difference we are attempting to enshrine here will be very quickly obscured.

[Naz Shah]

I thank the hon. Member for East Wiltshire for his amendment, and for speaking in the powerful, sensitive way that he did. I also thank my hon. Friends the Members for Spen Valley and for Banbury, who made interventions.

I did not intend to speak to this amendment, but having heard the hon. Member for East Wiltshire speak so powerfully and sensitively, it is important for me to share a few things. My hon. Friend the Member for Spen Valley has said a couple of times that the difference between people who commit suicide and those who will take this route is that the patients have been given less than six months to live, and that was not a choice. I was a Samaritan for years, because I had two failed suicide attempts in my early years, and since then I have battled with mental health demons all my life because of my experiences. To suggest that there is a difference between someone who gets a terminal illness and wants to take this act and people who want to commit suicide, and to suggest that they are doing it out of choice, is wrong. I felt really emotional when that exchange was happening. The reason why I think it is wrong is that, at the time that I wanted to commit suicide, I did not feel that I had a choice. I could not see a way out.

When I was on those Samaritans phonelines, speaking to people who rang in to unpick their feelings about what was driving them to feel suicidal in that moment, it was not because they want to die, but because they were in circumstances that drove them to feel that they had no option but to commit suicide. In some instances, it takes an amount of courage and bravery to even contemplate that option. To diminish that, which I feel is what has, intentionally or unintentionally, happened on occasion, is really wrong, because I have been there, and it was not easy and it was not because I wanted to die.

[Kim Leadbeater]

My hon. Friend makes a powerful point. I certainly have not heard anyone try to diminish the experience of suicidal people. We probably all have our own stories of loved ones who we have either lost to suicide—I know that I do—or who had very severe mental health issues. The point I would make is that the families I have met who have lost loved ones through assisted dying or a harrowing terminal-illness death have said that they desperately wanted to live. That is the distinction I would make, but I appreciate that my hon. Friend is absolutely right that people with suicidal tendencies and ideation also want to live—they just do not feel they have a choice. It is a very delicate debate to have, but please be assured of my sensitivities to it.

[Naz Shah]

I am genuinely grateful for my hon. Friend’s intervention, because I do not want the Committee—or our constituents—to feel that there is an equivalence. There is not. People who are in that space, who ring the Samaritans helpline to speak to them, all desperately want to live a brilliant life. That is what brings us here: each and every one of us wants to make this place the best it can be, so that our country is the best it can be and all our communities, people and constituents—all members of society—thrive. It is a sensitive debate, but let us be careful not to draw a parallel where there is not one. It was important for me to put that on the record.

I will support the amendment tabled by the hon. Member for East Wiltshire because we have already voted down an amendment requiring doctors to simply ask the question why. This speaks to the point that my hon. Friend the Member for Banbury raised: I know, through my experience at the Samaritans, as somebody who has attempted suicide and as somebody who has gone on to chair a charity that leads mental health interventions, how difficult it is for a patient has gone through the process of having had that conversation with their family, who might not necessarily agree, and having convinced them that they are going to take this option because they want autonomy, and fear losing it.

I cannot imagine what it must be like for those people, at that moment, saying their final goodbyes, and the level of potential pressure they face right at the last minute, having spoken to everybody and put their family members, and indeed themselves, through the process. Would they not feel internal pressure on themselves to go through with it? Would they really have the option, and not feel, in a sense, obliged to say, “Yes”? Do we really not want to ask that question?

When we debated the amendment requiring doctors to ask the question why, my hon. Friend the Member for Stroud said that doctors would ask it anyway, but that argument would not work in this instance because doctors would not do this anyway. They would not say, “I am about to give you something—have you changed your mind?”, because by that point they are in a process. The drug, in whatever form it takes, is in the process of being, or will have been, handed over to the person who wants to take that option, so it is not the same. I genuinely hope that the Committee will support the amendment, because it is our last option to make this intervention.

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

Naz Shah Excerpts

Committee stage
Wednesday 19th March 2025 Public Bill Committees

[Lewis Atkinson]

In considering the offer of any health or care-related activity, the appropriateness and suitability of the place is always in people’s mind, and clearly that varies. As I mentioned yesterday, we already have a licensing regime under which the CQC specifically licenses places for particular activity. I think my hon. Friend is right, but this is a normal part of decision making in the provision of health services and I do not think we should try to constrain it in primary legislation. However, as I started by saying, I recognise that we must enshrine the rights of individual conscientious objectors, which I think the hon. Member for East Wiltshire is trying to do with amendment 480, and I hope that we can do that, through some route, with the Bill.

[Naz Shah (Bradford West) (Lab)]

I rise to speak to amendments 441 and 484, tabled by my hon. Friend the Member for York Central (Rachael Maskell), and in support of new clause 23, tabled by the hon. Member for Reigate.

Amendment 441 would amend clause 23 so that there would be

“no obligation on any care home or hospice regulated by the Care Quality Commission or the Care Inspectorate Wales to permit the provision of assistance under this Act on their premises.”

I think it is clear that “assistance” in this context means the act of administering lethal drugs. That is the sense in which the word is used in clause 18, for example.

Amendment 484 would tighten that restriction somewhat by providing that there is no obligation on any hospice to permit

“any activity closely related to the provision of assistance under this Act”.

New clause 23 would also apply to all regulated care homes and hospices in England and Wales. It would provide that none of those organisations can

“be subject to any detriment by a public authority as a result of not—

(a) providing assistance in accordance with this Act, or

(b) permitting such assistance to take place on their premises.”

The new clause would also provide that no public authority can make its funding for a regulated care home or hospice dependent on the care home or hospice agreeing to provide assisted dying or to allow assisted dying to take place on its premises.

All the amendments have the same goal: to ensure that the Bill does not harm this country’s hospices. We have heard from many witnesses how much hospices do in providing palliative and end-of-life care. Caring for people who are close to the end of life is difficult and vital work. The people who do that on our behalf include some of the very best in our society. We should all hold ourselves responsible for not making the task of hospices more difficult. The idea that the Bill might do that has been raised with us by people working in this country’s hospices.

Hospice UK takes a neutral position on whether assisted dying should be legal in England and Wales, but it has set out clear positions on how the Bill should and should not affect hospices. On funding, its written evidence TIAB 36 states:

“If assisted dying is legalised and becomes part of the health service, steps should also be taken to ensure there is no financial detriment to any hospice, whatever their positioning on the practice.”

I agree strongly with that argument, for several reasons. The hospice sector in this country receives a mixture of public funds and private or charitable money, including donations and the proceeds of charity shops and fundraising events. Like the rest of the population, the people who work in and run hospices have a mixture of views on assisted dying. Many have strong objections on various grounds. If public funds were made dependent on hospices agreeing to assisted dying taking place, we would see several things happen, all of them bad.

In evidence to the Committee on 28 January, Dr Sarah Cox, a consultant in palliative care and president of the Association for Palliative Medicine, said:

“I am also concerned about our palliative care workforce, which we know is already in crisis. Eighty-three per cent. of our members told the Royal College of Physicians in 2023 that they had staffing gaps, and more than 50% were unable to take leave because of those staffing gaps. Forty-three per cent. said that if assisted dying were implemented within their organisation, they would have to leave. This has a massive impact on palliative care, in terms of its potential to develop both our funding and our workforce, who are really concerned about this.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 70, Q83.]

In evidence to the Committee on 29 January, Toby Porter, chief executive officer of Hospice UK, said:

“If hospices were involved in assisted dying, there is a theoretical risk that that would just reinforce an inaccurate perception about hospice and palliative care: the myth that you are helped along your way by doctors in hospices and hospitals. That is one risk.

More briefly, the second risk relates to the duty of care. What do you need for hospice and palliative care services? You need adequate resourcing, which means staff and finances. In terms of staff, the real fragility in the hospice and palliative care sector is a shortage of clinical staff—that is shared nationally with the NHS and other healthcare providers.”

Mr Porter also mentioned the evidence of Dr Cox. He told us:

“You will know from Sarah Cox’s evidence that the majority of palliative care consultants hold views against assisted dying, many of them very strongly. If the consultants felt, for example, that they could not keep their distance from assisted dying in a 12-bed hospice unit in the way they could in an 800-bed hospital, you could very easily see that if this was not done properly and the consultants deserted the hospice sector, you could no longer offer the specialist care that is so important to the Minister, the NHS and every health and social care provider.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 196, Q256.]

Many people would be entirely willing to enter a care home or hospice if they thought they might receive assisted dying there, but others already fear that they might be pressured into taking assisted dying if they enter palliative care. They may be wrong to fear that, but they do. We heard evidence on that point from Dr Jamilla Hussain, who gave evidence to the Committee on 29 January:

“I work predominantly with an ethnically diverse population. I have gone into those communities and I have spoken to them about this Bill. What they say overwhelmingly to me is, ‘We’re scared. We’re really fearful that this is going to result in a disproportionate impact on our community. We have seen that through covid and we’re so scared. We already don’t access your services. We’re really worried that we won’t want to access them any more, and we won’t want to access the hospitals.’”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 187, Q245.]

That fear will only grow if we use public funds to oblige hospices to permit assisted dying on their premises. Hospices should be able to say clearly to their patients that they do not allow assisted dying to take place on their premises. The dedicated professionals who work in hospices and who deeply object to people being helped to die with lethal drugs must also be protected. They should be free from having to work on premises where something they might disagree with happens.

I anticipate that some hon. Members may argue that amendment 484 draws its restrictions too tightly. They might argue that it would mean that a doctor working on a hospice’s premises or making a visit to a patient in a hospice could not have the preliminary discussion about assisted death with that person. However, I want to be clear that these measures relate to the provision of assistance under this Bill. “Provision of assistance” is the phrase used throughout the Bill to refer not to the preliminary discussion, nor to the interviews with doctors, nor to the panel process, but to that part of the process at which the person takes lethal drugs with a doctor present.

--- Later in debate ---

[Kit Malthouse]

This is obviously a difficult and sensitive area, but does the hon. Lady think, for example, that a women’s refuge run by a Catholic foundation should be allowed to evict a woman who wants or has an abortion?

[Naz Shah]

I absolutely do not think that, because her abortion rights are set out in law. However, I also think that when that woman is going into a refuge, that refuge will make it clear that she may choose not to. It is about empowering both sides.

I am grateful for the right hon. Member’s intervention, but let us follow that argument. Let us say that somebody wants to pursue assisted death, and they want to go into a place, but they are informed that that organisation does not want to provide or has not signed up to providing an assisted death. It comes back to the issue that my hon. Friend the Member for Sunderland Central rightly raised, which is that people do not deliberately go out looking to offend people. If we were in that space—I cannot imagine being there, but I am trying to understand it—would we want to access that service, because its religious belief differs from assisted dying as a principle?

[Dr Marie Tidball (Penistone and Stocksbridge) (Lab)]

Just so I am clear, if a young woman is escaping domestic abuse and goes to a domestic violence space close to her home so that her children can carry on going to school, but finds out once she is there that she is pregnant by the abuser, does my hon. Friend think that that is acceptable?

[Naz Shah]

Sorry, do I think which bit is acceptable?

[Dr Tidball]

That the domestic violence protection centre or home can refuse to let that lady stay there because she has latterly discovered that she is pregnant as a result of the abuse and wants to seek an abortion.

[Naz Shah]

Absolutely not. I would be horrified if that were the case. I know we have had cutbacks and we do not have the access, but I cannot imagine any refuge of any religious belief in this country turning away a woman in the situation that my hon. Friend describes.

[Dr Tidball]

I am glad to hear my hon. Friend’s answer. I ask that question because I can imagine an analogous situation of a woman suffering from breast cancer who is allergic to opioids but does not know that when she enters the care home. If her cancer reaches a stage of terminality but she cannot pursue palliative options because of her allergy to opioids, assisted dying would be the only option for her to die with dignity and not in great discomfort. Under my hon. Friend’s scenario, that woman would not be able to pursue an assisted death in that care home.

--- Later in debate ---

[Naz Shah]

My hon. Friend makes a really important point, and I absolutely hear what she is saying. If the woman were going into that hospice or care home when she was pursuing an assisted death, I am not sure how that would work.

[Dr Tidball]

To clarify, in my very clear example—it is a real-life example that reflects the experiences of someone who attended this Committee yesterday—the person has a terminal condition and enters a care home that makes her comfortable and is near her family, but discovers while the hospice or care home is trying to find methods to palliate that she is allergic to opioids and therefore her condition cannot be palliated. In the hon. Lady’s scenario, she would not be able to choose assisted death because that care home has a blanket policy against it. That would discriminate against that young woman, who has an allergy to opioids that means that she cannot be palliated.

[Naz Shah]

I thank my hon. Friend for her intervention, which gives me a lot to think about. That is why I said that I genuinely do not have the answers. I want to have this discussion so that I can make the choice whether to support the amendments. I want to explore this issue further, because it is really important.

[Rebecca Paul]

The conversation has moved on a little, but I was just going to make the point that the amendments that I tabled focus very much on the rights of the employer with respect to what they expect from their staff. I wonder whether it would be helpful to explore that a bit more.

[Naz Shah]

If we are talking about employers and employees, not people who are accessing the service as service users, I hope the scenario to which my hon. Friend the Member for Penistone and Stocksbridge referred would not happen.

[Danny Kruger]

There is much to get into, and I will try to respond a bit more when I speak again. I do not want to revisit the whole question of palliative care but, on the scenario set out by the hon. Member for Penistone and Stocksbridge, the strong advice that I have received from palliative care professionals is that it is not accurate to say that somebody’s pain cannot be palliated. It might well be that there is a difficulty with particular opioids, but there are other palliative care options available to everybody. No palliative care doctor ever says that there is nothing they can do.

[Danny Kruger]

Well, we have been over the whole question of palliative care and alternatives to assisted suicide; nevertheless, I wanted to challenge that scenario.

On the suggestion that there is a comparison with an abortion service no one is suggesting that a woman who goes into a refuge, discovers she is pregnant and wants to have a termination is somehow obliged to have it on the premises of the refuge, which does not believe in abortion. That is not a scenario that could happen, because that is not how abortion operates. What we are suggesting is that somebody who arrives in a care home or hospice that does not want to facilitate assisted suicide would not be able to receive such assistance there. There is no objection to their believing in or desiring an assisted suicide; the point is to protect the institution.

I recognise the difficulty with the specific case the hon. Member for Penistone and Stocksbridge raised. Nevertheless, the alternative is to have blanket permission for any resident of any care home or hospice to insist that they can receive an assisted death in that home or hospice, despite what the rest of that community and the management might want. Indeed, the patient might have signed a contract specifying that they will not seek an assisted death in that home or hospice. There is much more to discuss, but I hope that that is helpful for the hon. Lady.

[Naz Shah]

I thank the hon. Member. What he said is really helpful.

I want to come back to the issue of opioids. As someone who suffers from chronic pain, my understanding is that I have a choice over whether I take opioids or other medication. So when people are allergic to opioids, they can potentially access other medication for pain relief.

[Jack Abbott]

A lot of the focus in the last few minutes has been about a care home having already made it clear that it does not support the process of assisted dying and the fact that anyone entering it would therefore know that. However, there is a clear scenario where some care homes might change their position over time. Someone may be in a care home for many years, but then the care home might change its position and say, “Actually, now we do not support assisted dying.” In that scenario, people would actually have gone into that setting thinking that it supported assisted dying.

Although I am sympathetic to the issue of place being made clear, it has real ramifications. Again, I do not think it is as black and white as saying, “This care home already had a set position.” Some care homes or other settings might change their position over time, even when residents are in situ for a long time. That is the big problem with this particular clause: the situation is not as straightforward as some Members have perhaps suggested today.

[Naz Shah]

My hon. Friend makes a very valid point: it is not straightforward. That is why people are tabling amendments and having this discussion—to iron this issue out and make sure we nail it, to make the process as safe as possible.

There are laws in our country that protect people’s religious views—for example, we have the Equality Act 2010—and those laws are there for a reason. Speaking to all the amendments, I would not want to see hospices not being funded because they take a certain position. Also, from an employer’s perspective—I appreciate the scenario that has been mentioned, and I will come back to it—they may be recruiting in accordance with their values. We are all in politics, and we all sign up to a particular view of politics. When we recruit our staff, we put on the application form, or other information, that we would like applicants to believe in our value system. That is not discriminating against somebody who has a different value system. That would be my response.

[Lewis Atkinson]

I just want to nail this point about employers and recruitment. We have said that no organisation will be obliged to provide these services, in exactly the same way as with abortion. The example I would give is this: a provider of women’s services says, “We are not providing abortion. But, in addition, we are going to ask staff members we are recruiting if they believe it is ever legal for abortion to take place.” That is exactly the same test of belief, although on a different medical procedure, that my hon. Friend is proposing in this instance.

[Naz Shah]

That is not what I am saying. I am saying very clearly that when we recruit people to any job, we ask them to have the values that we have as an organisation. I appreciate my hon. Friend’s intervention, but what he says is certainly not the point I am trying to make, and I cannot imagine anybody—even for religious reasons, and even if they have changed their position—genuinely treating somebody in that way. We just do not do that.

[Jack Abbott]

I appreciate that, but as my hon. Friend has said a number of times over the last few weeks, some of these things unfortunately do happen. As I am sure we all do, I have had casework involving people with guide dogs saying that they have been refused certain services, including taxis, even though that is a civil offence because they have a guide dog with them. We have said a number of times that there are flaws in every single system. I appreciate that we want to adopt a good-will attitude, and I am sure the vast majority of settings across the country will operate on that basis, but we know that, in certain circumstances, that is not always the case. That is why, if we put anything in the Bill, it needs to have real clarity and not unintended consequences.

[Naz Shah]

My hon. Friend is absolutely right that we need to clarify this.

To sum up, this comes back to some of the questions I have for the Minister, and I wonder whether he can answer some of them. I say that especially because the Committee has had lots of debates on amendments tabled by the Government via my hon. Friend the Member for Spen Valley giving the Secretary of State statutory duties. Perhaps the Secretary of State will be able to clarify this issue and make it watertight using regulations.

Have we had an assessment of what the impact would be on the provision of healthcare if assisted death were permitted in either a hospice or care home, and is the Minister happy to share that assessment with the Committee? For example, if palliative care specialists are saying, “X amount of people would no longer want to be involved, so there is a real risk of an exodus of specialists from hospices,” we need to know whether there has been an assessment of that. Perhaps the Government can help us to understand that real concern from palliative care specialists.

Given that the Minister mentioned his visit to a hospice this week, has he had any discussions with Care England care homes about allowing this process to happen in care homes themselves? How have the concerns of clinical staff about allowing an assisted death in their healthcare facility been assessed, and have those concerns been put to him? How many staff have indicated that they would need to leave the NHS, care providers or hospices if an assisted death were mandated on their premises?

Coming back to beliefs, there is also the element of charitable bodies. Have we spoken to the Charity Commission about the impact on those bodies if they were pressured by the Bill into changing their charitable aims? Would they be protected from providing assisted death because of their charitable aims?

For me, this debate has raised more questions than answers, and there is much more discussion to be had. I am happy to listen to the hon. Member for East Wiltshire, as I can then intervene and probe further.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship this morning, Ms McVey, even though it is a little later than originally planned.

Amendment 480 is intended to extend the category of those protected from being obligated to participate in the provision of assisted dying under clause 23 from registered medical practitioners, registered nurses and registered pharmacists or pharmacy technicians to all individuals. The amendment also seeks to clarify what an individual can refuse to do under clause 23(1), by setting out a non-exhaustive list of activities under the Bill that an individual would not be obligated to participate in. The amendment also specifies that the ability not to participate in the provision of assisted dying does not override any duty to signpost someone to information about assisted dying; to perform clerical, secretarial or ancillary acts; or to perform life-saving acts or grave injury-saving acts.

The amendment would introduce significant legal uncertainty and may mean that a person who had opted in to providing services under the Bill could refuse to continue to do so or could use clause 23 as a justification not to perform their duties as described in the Bill. For example, they may use the amendment as justification for not checking eligibility criteria, discussing prognosis or palliative care options, or performing other requirements under the Bill.

Amendment 480 may also conflict with other provisions. It states:

“no individual is under any duty…to be involved, directly or indirectly, in the provision of assistance”,

in accordance with the Bill. That may, for example, mean that although doctors are required under the Bill to notify a cancellation, they would be allowed to refuse to do things under the Bill, even if they have opted in to providing assisted dying services. It is not clear which provision would take precedence, which could allow the doctor to decline to notify a cancellation, by arguing that they are relying on clause 23(1).

Amendment 483 is intended to extend

“the range of activities which medical practitioners and other healthcare providers are not under an obligation to provide to include activities closely related to the provision of assistance”

under clause 23(1).

Amendment 484 is intended to expand the protection from being subject to a detriment by an employer at clause 23(2), to include where a registered medical practitioner or health professional refuses to participate in activity closely related to the provision of assistance. The term,

“activity closely related to the provision of assistance”,

is not defined, and that could create uncertainty as to what types of activity it is intended to cover.

The Bill does not, as currently drafted, specify where the provision of assistance may or may not take place. Amendment 441 would prevent there being any obligation on a care home or hospice regulated by the Care Quality Commission or Care Inspectorate Wales to permit the provision of assistance to be carried out on their premises. The effect of the amendment may be to limit the places where assistance could be provided. It may thereby reduce access to an assisted death for those residing within a care home or hospice, if a care home or hospice did not wish to allow an assisted death to be provided on its premises. The amendment could preclude some people from accessing services under the Bill if they were near the end of life and leaving their usual place of residence was therefore impeded. It may result in inconsistent treatment for patients when seeking to access an assisted death. That could potentially engage a person’s rights under article 8 of the ECHR—the right to respect for private and family life.

Amendment 481 has two parts. The first aims to ensure that employees cannot participate in the assisted dying process in the course of their employment if their employer has chosen not to participate in assisted dying. The effect of the amendment could be to limit the places where assistance would be provided, and it may result in inconsistent treatment for patients when seeking to access an assisted death. That could engage a person’s rights under article 8 of the ECHR—the right to respect for private and family life.

The explanatory notes suggest that the second part of the amendment seeks to ensure that employers require employees to provide or not provide assisted dying under schedule 9 of the Equality Act 2010. That schedule enables an employer to specify that having a protected characteristic is a requirement of a job when having that characteristic is crucial to the post and a proportionate means of achieving a legitimate aim. The ability to specify occupational requirements is conferred by schedule 9 of the Equality Act, and reference to it in this amendment would not have any additional effect.

The purpose of new clause 22 is to provide that the owners or occupiers of a premises would not be obligated to permit the self-administration of an approved substance on their premises. This right to refuse would not extend to a person who has an interest in the land but who is not occupying or operating on those premises, such as a landlord. It is unclear if the term “premises” would apply to a residential property, care home or hospice. As a result, the amendment may mean that someone who is terminally ill and is residing in, for example, a care home or a hospice could be required to leave that care home or hospice in order to receive assistance under the Bill if the care home or hospice owner did not wish to allow assisted dying on their premises. That could engage a person’s rights under article 8 of the ECHR—the right to respect for private and family life.

--- Later in debate ---

[Kim Leadbeater]

The hon. Lady is absolutely right to acknowledge the wonderful workforce working in end of life care, but there is a range of views within that workforce and there is the individual opt-out. No one has to be involved in this process if they do not want to be. That is clear in the Bill as it stands. I hope that, working together, we can make that even clearer if needed.

Under the Bill, doctors and health professionals already have the ability to opt out for any reason, wherever they work.

[Naz Shah]

Pharmacies have not been mentioned. Would they have the ability to opt out?

[Kim Leadbeater]

It is a good point. My understanding—the Minister might correct me—is that pharmacists currently are within the definition of health professionals, but if they are not, that is an important point, which would be covered by making the change to ensure that no one is under any duty. However, I will definitely check that.

Mr Porter also said:

“hospices evolved out of the community. They exist because communities wanted better deaths. In the end, it is the job of institutions to evolve to fit the values and laws of society as they evolve, rather than vice versa.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 202, Q264.]

The polling on assisted dying shows significant public support for a change in the law, which is one of the main reasons we are here discussing the issue today. The latest figures from the British social attitudes survey, published just this week by the National Centre for Social Research, show that support at 79%, which is unchanged or slightly up on a decade ago. Although I cannot support these amendments, this is an important debate. I think we have conducted ourselves extremely well over the past 24 hours. I think it is important that we continue the debate respectfully and sensitively.

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

Naz Shah Excerpts

Committee stage
Wednesday 19th March 2025 Public Bill Committees

We cannot risk an innovation in the law of murder with the unintended consequence that some murders go unprosecuted and unpunished. We must pass quality law that solves rather than creates problems. I do not intend to oppose the amendments, except amendment 509, as I do not see why the consent of the DPP should be required in the case of dishonesty, coercion or pressure. It is good that there is clarity on what people are prohibited from doing, but I am anxious that the Government discharge their duty to the statute book and that they do so in an even-handed manner.

[Naz Shah (Bradford West) (Lab)]

I thank the hon. Member for East Wiltshire, who has raised some concerns for me. I rise to speak in support of the amendments, but also to raise some points. I share the hon. Gentleman’s concerns, but let me begin by speaking about the bits that I feel pleased with and able to support.

My hon. Friend the Member for Spen Valley has already explained the amendments and may explain them more later. I am pleased that they tidy up errors in the original construction of the Bill. In its original form, subsection (2) rightly states:

“A person who, by dishonesty, coercion or pressure, induces another person to self-administer an approved substance provided in accordance with this Act commits an offence.”

Unfortunately, in the Bill as drafted, the penalty for such an act is only a prison sentence of 14 years. It is quite right for that to be the penalty for the offence detailed in subsection (1), namely when someone,

“by dishonesty, coercion or pressure, induces another person to make a first or second declaration”,

but does not actually succeed in getting them to the end of the assisted dying process. However, it is easy to agree that 14 years is an inadequate penalty for successfully coercing or pressurising somebody into an assisted death. I am glad that my hon. Friend the Member for Spen Valley has recognised that problem and has tabled an amendment that would impose a maximum penalty of life imprisonment for such an offence.

My hon. Friend the Member for Sunderland Central made a powerful speech in this Committee the other day, in which he said that abusive or coercive people are already likely to be forcing their victims to starve themselves or refuse treatment. That is true, and I thank him for raising that important point. I will welcome all measures to make it harder for abusers to do so and will gladly work with hon. Members to do so. However, I want to sound a strong note of caution.

Creating an offence and giving it a strong maximum penalty is only one of the ways to deter abuse and coercion, and perhaps the easiest. As I have mentioned before, the conviction rate for coercion is only about 4%. There are other things that we need to do to deter and prevent abuse. We need the people who may come into contact with it to be aware of what could happen; we need them to be able to spot the signs that it may be happening; we need ways to investigate those signs carefully. Only when we have done those things can we move on to the CPS potentially prosecuting somebody for an offence and, if they are found guilty by the court, to sentencing that person. Those are matters that this clause deals with, and they come at the end of a process.

I welcome the amendment tabled by my hon. Friend the Member for Lowestoft (Jess Asato), which makes training in domestic abuse and coercion mandatory for professionals working on assisted dying cases, and which my hon. Friend the Member for Spen Valley has accepted. However, new training on its own will not be enough to make it near-impossible for abusers to succeed. Having unfortunately had lots of experience in the area—having seen it in my own life, the lives of people close to me and the lives of constituents—I know that sometimes abusers are not subtle. Even so, they can be hard to catch, because their victims cannot recognise that they are being abused. The classic—I wish I had a pound for every time I heard it—is “He’s changed.” There are hundreds of justifications and some are very subtle indeed. These people can be very hard to catch, or they may never be caught at all.

I have heard hon. Members say—I think my hon. Friend the Member for Spen Valley said it earlier—that the Bill strengthens the safeguards around people who are terminally ill, because those are not there in the first place. I appreciate that idea, but that is just for those people who are terminally ill. I want to strengthen safeguards more generally. In some ways, the Bill offers people a new opportunity to be coercive, controlling and dishonest. That is why I have been banging on about safeguards so much in this Committee; perhaps people find it a bit much, but I do it because abusers are very persistent and clever people and we have to be clever and persistent in how we devise our safeguards against them.

Although I welcome the clause and the amendments tabled by my hon. Friend the Member for Spen Valley, I am disappointed that other safeguards have been rejected. I still say that the panel procedure could and should be much tougher. That would not guarantee that abusers would be caught, but it would make it more likely.

[The Chair]

Order. Members cannot continue to talk about the substance of amendments that have already been rejected, and we are now going into that territory. I am not going to stop the hon. Lady talking, but rehashing debates about amendments that we have already had is not in order.

[Naz Shah]

I apologise, Mr Dowd. I will not refer to them.

I come back to the point made by the hon. Member for East Wiltshire about DPP consent. I will be grateful if the Minister picks up some of these queries. In this place, we make laws. My experience of the law on forced marriage—I was a victim of forced marriage—was that we made a law but never got any convictions. Very little moved on it, because we already had laws in place to prosecute that offence. I am not saying that the same is happening here, but I draw the Committee’s attention to the fact that we may be making a law that already exists. If it already exists in the Suicide Act, are we just making a law for the sake of putting something on the statute book or on the face of the Bill?

We have talked a lot about how we should not complicate things. The word “complication” has been used quite a lot in this Committee. Are we adding another layer of complication by putting this measure in the Bill, when we are not prepared to do so for other things that people feel strongly about? This is also something that already exists.

My understanding is that if we were prosecuting coercion, for which unfortunately the prosecution rate is only 4%, that would not need DPP consent. It would be needed, potentially, for assisting suicide, but not for coercion. Do we need some clarity about the application of the law in this regard? Suppose we had a scenario in which somebody was murdered: it was premeditated, and somebody had thought through how to use this process as an avenue to kill that person. I do not want us to make a law that would allow somebody to literally get away with murder. More thought needs to be given to that. I am not an expert or an eminent lawyer like the Minister, but I am concerned by the comments of the hon. Member for East Wiltshire, having looked more closely at the issue. I would welcome the Minister’s comments.

[Jake Richards]

You intimated, Mr Dowd, that we can speak for as long as we want, but I will not speak for long on this clause, partly because I fear that we are making a mountain out of a molehill. The clause creates new criminal offences; I am not a criminal lawyer, but that is my reading of the clause and the amendments tabled to it by my hon. Friend the Member for Spen Valley. There are an array of reasons why criminal offences are legislated for. One good reason is to provide deterrence against committing such an offence. If the Bill receives Royal Assent, we are entering new ground. We are developing a new process in our healthcare system that will affect how our society and culture works, and creating a new legal process, which we had lengthy discussions about when discussing the provisions that will replace clause 12, in the debate over the panel.

In my mind, it is wholly appropriate to have an offence specifically in this very new area. I cannot see any weight to the argument that it undermines the law of homicide in our country and jurisdiction. Respectfully, I cannot see how Members who have been, understandably, worried about the Bill cannot see that this only strengthens it. I would gently say that the arguments that this somehow undermines the law of murder or homicide are slightly disingenuous. I had hoped that debate on this clause would be straightforward, with the Committee seeing that it clearly strengthens the safeguards around assisted dying.

[Naz Shah]

I have taken your advice, Mr Dowd, because my points would have made for a long intervention. First, I gently remind my hon. Friend the Member for Rother Valley that we have not used the word “disingenuous” in this Committee, so I sincerely wish that he reflects on that. Regardless of the debate we are having, everyone on the Committee is very committed to what we are doing here.

Secondly, my hon. Friend said that we were making a mountain out of a molehill. I refer again to the issue of forced marriage, legislation on which went through the House when police forces already had legislation to prosecute for it. As legislators, we should have ensured that we raised awareness and trained our police officers and communities to apply that—

[The Chair]

Order. We are dealing with clause 26 and the amendments to it, specifically in relation to these offences. Can the hon. Lady please speak to the clause and the amendments?

[Naz Shah]

I am speaking to the clause, Mr Dowd. I apologise—I will try to be clearer. Clause 25 creates a new offence, and I am trying to give an example of past legislation that speaks to the same principle. If we are creating a new offence that the DPP needs to consent to, and we already have an offence, then are we complicating it for the CPS or our police forces?

Take the issue of coercion, because that is what the clause refers to. We only have a 4% conviction rate for coercion. My hon. Friend the Member for Spen Valley referred to a horrific case of a lady who was investigated, and talked about her husband’s death. We need to be clearer about what the new offence would lead to. What would it actually protect? Are we protecting cases such as that referred to by my hon. Friend, or we making it more complicated for our law enforcement to police this? Ultimately, if passed, that is what the amendments and the legislation will mean—real-time legislative changes and potential cases to prosecute. That is my point.

--- Later in debate ---

I turn to amendment 444. As the Bill currently stands, the Secretary of State may by regulations make provisions relating to the prescribing, dispensing, disposal and transporting of approved substances. If the amendment were accepted, regulations made by the Secretary of State relating to the transportation, storage, handling and disposal of approved substances would need to specify that those substances must at no time be left unsupervised by a medical practitioner. The operational impact of the amendment would be to place a duty on a medical practitioner to ensure that approved substances must at no time be left unsupervised. That would increase the obligations on the co-ordinating doctor, and potentially any medical practitioners with access to approved substances. It is unclear when the duty on the medical practitioner would apply. For example, would it apply when the approved substance is in transit, or only once it has been provided to the person?

[Naz Shah]

Would the Government’s intention not be to sign this duty over to a regulator?

[Stephen Kinnock]

My understanding is that the amendment would place the duty on a medical practitioner. I am speaking to the purpose and effect of the amendment, which is not about a regulator; it is about a medical practitioner. Does that answer my hon. Friend’s question?

[Naz Shah]

I am not sure, but I will give it more thought.

--- Later in debate ---

[Naz Shah]

I was not intending to speak to this group, but I am now trying to find amendment 500.

[Kit Malthouse]

Amendment 500 was to clause 21 and we have agreed it already.

[Naz Shah]

In responding to my hon. Friend the Member for Sunderland Central, I appreciate that we do not want to put too much detail in the Bill, but with some of the commitments that we have made as a Government on collecting data we need to go further. That is for the simple reason that our equality laws are not right when we look at other issues, such as the gender pay gap.

[The Chair]

Order. Can we stick to the amendment that we are debating?

[Naz Shah]

Amendment 273 would strengthen our position to collect that data, which is really important if we are serious about potentially reviewing the legislation by looking at the loopholes and at which communities are taking up assisted dying. The data in other jurisdictions says that it would be people from affluent backgrounds, but the hon. Member for Richmond Park powerfully raised concerns about the risks, as we heard in evidence from people such as Dr Jamilla and others. I strongly support the amendment, but I will also look at the Equality and Human Rights Commission issues that my hon. Friend the Member for Sunderland Central raised; I thank him for raising them.

[Lewis Atkinson]

Does my hon. Friend agree that to keep the list of characteristics on which we have to collect information up to date, we need a level of flexibility—not in primary legislation? Would she comment on the fact that no information regarding sexuality or other protected characteristics is included in the Bill?

[Naz Shah]

My hon. Friend makes a valid point; that is an issue. If we are going to do this right, are we going to be looking at all six characteristics? That is important, so I agree with him.

--- Later in debate ---

[Danny Kruger]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 29, as amended, ordered to stand part of the Bill.

Clause 30

Codes of practice

[Naz Shah]

I beg to move amendment 447, in clause 30, page 18, line 12, leave out “may” and insert “must”.

This amendment requires the Secretary of State to issue Codes of Conduct.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 394, in clause 30, page 18, line 24, at end insert—

“(ba) the provision of information and support to persons with learning disabilities who are eligible to request assistance to end their own life under this Act, including the role of advocates for such persons;”

Amendment 448, in clause 30, page 18, line 27, after “of” insert “registered and qualified”.

This amendment requires a code of practice on the use of interpreters to be, instead, on the use of “registered and qualified” interpreters.

Amendment 534, in clause 30, page 18, line 30, at end insert—

“(da) the forms of proof of identity that are acceptable for the purposes of section 6.”

Amendment 523, in clause 30, page 18, line 31, leave out paragraph (e) and insert—

“(1A) The Secretary of State may issue one or more codes of codes of practice in connection with any matters relating to the operation of this Act not required under subsection (1) as the Secretary of State considers appropriate.”

This amendment, which works together with Amendment 447, would clarify that the Secretary of State is not required to issue a code of practice under subsection (1)(e) but instead has the discretionary power to issue further codes of practice as the Secretary of State considers appropriate.

[Naz Shah]

Amendment 447 was tabled by my hon. Friend the Member for York Central; I also speak in support of amendment 523, which was tabled by the hon. Member for East Wiltshire and helpfully clarifies amendment 447. My understanding was that the Bill’s promoter indicated that this was something she would support; I am happy to give way so she can clarify.

[Kim Leadbeater]

I confirm that I am happy to support amendment 447.

[Naz Shah]

Perfect. I thank my hon. Friend—I like it when we get to amendments that are supported.

Amendment 447 would literally change the word “may” to “must” in clause 30. The first four matters that the clause lists are so important that issuing codes of practice cannot be left just as a choice for the Secretary of State; it must be something that the Secretary of State has to do. It is worth pointing out, as I am learning about this new process, that when we leave it to the Secretary of State, that means a Secretary of State under any Government, depending on how long it takes. It is not necessarily just our Government; it could be another Government. I am just pointing that out, because somebody pointed it out very clearly to me, and I was shocked by that detail.

The Bill sets out five areas of responsibility that the codes could cover. They include some of the most consequential matters that this Committee is considering, as set out in clause 30. The first four are doctor’s assessments of

“whether a person has a clear and settled intention to end their own life,”

and whether that person has capacity to do so, accounting for the effect of depression and other mental disorders on decision making; the

“treatment or palliative, hospice or other care available to the person”;

the provisions for effectively communicating with them; and

“the arrangements for providing approved substances to the person… and the assistance which such a person may be given”.

They are all vital and I am pleased that this amendment would ensure that the Secretary of State has to issue codes of conduct, rather than being able to decide that they may not do so.

If these matters were not covered by codes of practice, they could be left to individual doctors to interpret, which would mean that doctors would face having to make unfamiliar and complex decisions without the clear guidance that a code of practice would give. That could have created—indeed, it would have created—dangers for both doctors and for people seeking assisted dying.

The fifth area of responsibility for the Secretary of State, as set out in clause 30, is codes of practice on:

“such other matters relating to the operation of this Act as the Secretary of State considers appropriate.”

It seems clear to me that, because the Secretary of State will issue codes of practice for the first four areas of responsibility, they must also issue codes for other matters if they see a need for them. I am confident that we all agree on that.

Amendment 523 would make it clear that the Secretary of State can issue codes of practice on any other matters as they see appropriate, but they would not have to do so if they thought there were no other matters that needed such codes. That is a sensible clarification that preserves what the Bill drafters were doing when they wrote the clause. If the Bill passes, we will be authorising doctors to depart from centuries of previous practice. They will face decisions that they have not previously had to take. I am pleased that, if the Bill passes, the Government will be able to set out the clearest possible guidelines for medical professionals in accordance with the many provisions in this clause.

Doctors in England and Wales have never previously had to assess whether someone has a clear and settled intention, and it is surely unfair to ask them to work out how to make that judgment without clear guidance from a code of practice. A code of practice also mitigates the risk that different doctors will approach this task in widely differing ways. The truth is that the use of the Mental Capacity Act 2005 is untested in relation to assisted death, where a person will take lethal drugs to end their life.

Codes of practice will address important and difficult questions of interpretation. Again, that will give us much-needed clarity, including in the area of the provision of palliative care to people considering assisted dying and how doctors advise them. The independent commission on palliative and end of life care found that knowledge of palliative care among doctors is often limited, so the Secretary of State’s intervention will be much appreciated, and the codes will give a settled direction.

I am grateful that my hon. Friend the Member for Spen Valley has accepted amendment 447. I look forward to working through the rest of the Bill and getting some more amendments passed.

[Daniel Francis]

I will speak to amendment 394 in my name, which provides that codes of practice may be issued on

“the provision of information and support to persons with learning disabilities who are eligible to request assistance to end their own life under this Act, including the role of advocates for such persons”.

I am aware that my hon. Friend the Member for Spen Valley may speak to amendment 517 and new clause 25, which we will discuss shortly.

I tabled a number of amendments, one of which was accepted, following conversations with Mencap. Dan Scorer from Mencap gave us oral evidence on advocacy support, the discussions and the role of families and said:

“Individuals should be able to choose who supports them with those discussions, whether it is friends or family members or an independent advocate—that would probably be our preference—who is specifically trained to support people with a learning disability who are considering their end-of-life options.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 273, Q355.]

I will not go on at great length—hon. Members have heard my views on support for people with learning disabilities, and I am conscious that we will come to other amendments on this issue—but I will move my amendment when we get to the relevant stage, in a manner consistent with the approach that I have taken in Committee so far.

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

Naz Shah Excerpts

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[Sarah Olney]

I will conclude my remarks by observing that the only reason that we are looking at contracting out assisted dying services to a private provider is that the country is simply not ready for assisted dying. We know how overstretched and under-resourced our NHS is, and we are looking at cutting corners in the Bill, in our policymaking, in our scrutiny of this legislation, and in how this legislation and the service is delivered.

[Naz Shah (Bradford West) (Lab)]

It is interesting to follow the hon. Member for Richmond Park, because I rise to speak to amendment 537, tabled by my hon. Friend the Member for Shipley. The amendment goes further than the hon. Member for Richmond Park would as far as local authorities are concerned.

The amendment also concerns both the national health service and the provision of healthcare by charities. My hon. Friend the Member for Shipley knows both fields extremely well. She was the director of quality and strategy and chief analyst at the Department of Health, and then had a senior role at the Centre for Ageing Better. Her amendment would mean that assisted dying services could be provided only by charitable organisations and not by the national health service.

I strongly support the general principle that if we do have assisted dying, it should be free at the point of use. If this House decides that people do indeed have the right to an assisted death under the conditions that this Bill sets out, then it should not be something limited to those who can afford private healthcare. There are, however, strong objections among general practitioners to providing assisted dying as part of their services, and I do not think we should plan to have private firms work under contract from the NHS to provide assisted dying either.

The Royal College of General Practitioners said in its written evidence that

“any assisted dying service should be seen as a standalone specialised service that healthcare professionals may opt to provide with additional training and should not be deemed core GP work.”

The royal college’s advice, which is founded on the views of its members, means that we should give very strong consideration to putting assisted dying outside the normal workings of the NHS. If we do that, it seems that there are a few options. One is for the Secretary of State to invite private firms to tender for contracts and administer assisted dying services. As I have said, there are very strong reasons why we should not plan to have private firms work under contract to the NHS to provide assisted dying; for me, that it is one of the worst possible options.

Another option is for the NHS to fund a specialised assisted dying service that would be separate from its other functions. That could potentially be feasible, but it could also represent a significant cost for the NHS, because we still have not had the impact assessment from the Government and we have no idea how significant that cost may be.

There is also the worry that if assisted dying becomes available on the NHS, some people will become too frightened to access palliative care, as was outlined to the Committee by Dr Jamilla Hussain. I will read a brief part of her written evidence to the Committee. After talking to the patients in ethnic minority and other disadvantaged groups, she said:

“Overwhelmingly, racialised communities expressed deep concerns that they would be more likely to be pushed towards AD through systemic biases and societal attitudes about whose lives are valued… While safeguards were acknowledged, many remained sceptical that they would be applied fairly and equitably, fearing that vulnerable individuals, particularly those who lack strong advocates or English proficiency, might be at greater risk of being guided towards AD rather than offered appropriate care options.”

I want to share something with the Committee. We often get taxis to and from work and home; I got into a cab yesterday, and the chap who was driving was called Dave. His 84-year-old aunt died on Friday. When we were discussing this option, he told me really clearly that she has opted for a cremation, which would cost less money, just because she internalised that idea of burden and she did not want a cost for those that she left behind. She had not seen a doctor for 40 years. That brought home the idea of internalised coercion, internalised pressure and mistrust, because he also talked about what happened during covid. We had an interesting conversation. I told him that it was interesting that he had said that, and today I am talking about it. That is the reality: it is about how people perceive healthcare provision, the potential inequalities, and what the barriers are to access—all the preconceived ideas that we have about the provision of healthcare.

That brings me to a potential third way, which is what amendment 537 is about: charities. Charities are one way of addressing the concerns I and the hon. Member for Richmond Park have outlined about the risk with private companies and the risk of loss of confidence and access to the NHS, as well as the concerns outlined by the Royal College of General Practitioners. They could well be mitigated by ensuring that the lead responsibility for administering assisted dying is given to charities rather than the NHS.

--- Later in debate ---

[Lewis Atkinson (Sunderland Central) (Lab)]

It is a pleasure to serve under you this this morning, Ms McVey.

I rise in support of new clause 36, which sets out an entirely workable, appropriate and safe set of provisions for the Secretary of State to ensure that these services are provided across England, as well as appropriate powers for Wales, although I am far from being an expert on those matters.

The new clause would convey powers to the Secretary of State to commission services free at the point of use, in a way that is entirely analogous to the commissioning of other health services that are provided, as we know, by a range of providers.

I came to this place having been an NHS manager for nearly 20 years, and I feel that the debate has sometimes slightly confused elements of commissioning, provision and the way in which the NHS commissions and manages services. My hon. Friend the Member for Banbury said that the state must oversee and regulate the service, and I entirely agree. Commissioning powers sitting with the Secretary of State will ensure that that is the case. The hon. Member for Richmond Park said that the issue is who is commissioning. Again, we are clear that the only person doing any commissioning will be the Secretary of State, potentially delegating this to NHS structures at the time.

The NHS and the Secretary of State are not unused to commissioning highly specialised, sensitive services in this way. Indeed, I would be amazed if the Minister and my hon. Friend the Member for Spen Valley do not confirm that the Government were involved in the drafting of this new clause to ensure that it is equivalent to the other powers that the Secretary of State has.

This will clearly be a specialist service. It is a new service. At high levels of NHS England and equivalent bodies, there is significant expertise and practice in commissioning specialised services. The importance of the commencement period, which I hope we will discuss later today, is that engagement around the exact service specification will be drawn up in just the same way that it would be for a new cancer treatment or a treatment for a rare disease. It is right that the time will be taken to engage on that.

Fundamentally, services have to be commissioned. Some suggest that this will be a free-for-all, that anyone can provide this service and that anyone can be paid for it, but that idea is nonsense. There is no obligation for the Secretary of State to reimburse anyone who decides they want to provide this service. The service must be explicitly commissioned.

[Naz Shah]

My hon. Friend says that this will be explicitly commissioned. I completely agree with everything he has said, but this will be a newly designed service by definition, so will that not leave the door open for new providers, such as Serco or G4S, to come in, design a new service and bring in the expertise to deliver it?

[Lewis Atkinson]

No, it will not, in the same way that G4S does not suddenly appear and provide treatment through a new cancer service that the Secretary of State decides to commission under specialist powers.

I am afraid that some opponents of the Bill are trying to scaremonger about potential provision as a way of altering the way people voted on Second Reading. A number of amendments clearly deal with whether potential providers should be public sector, voluntary or, indeed, private organisations. I emphasise that the overwhelming majority of GP services in this country are private contractors. It is inconsistent for Members to argue that we should maximise continuity of care and have the best safeguards around coercion and capacity by having someone who has known the individual for a long time, while also arguing that the Secretary of State should not be permitted to commission that individual’s GP to play any role. I challenge opponents on that matter.

--- Later in debate ---

[Daniel Francis]

It is a pleasure to serve under your chairship, Ms McVey. I genuinely did not intend to speak today, but the debate, particularly the speech by the hon. Member for Richmond Park and the intervention from my hon. Friend the Member for Luton South and South Bedfordshire, has brought me to my feet.

It was 13 or 14 years ago that my wife and I embarked on the IVF road. It never worked—our children came naturally in the end—but I know the pain and despair of that process. Although I do not call into question the efficacy of any doctor, some companies, looking to their profit margins, will always prey on people.

We have had discussions today about the regulations to be made under new clause 36, but we need some clarity on Report. I referred to the annual fertility show at the Kensington Olympia; I have checked, and it is still held. I visited it about 13 years ago. Frankly, it is complete marketisation. People who are already on their knees and really depressed are left feeling that companies are simply trying to make a profit out of them. People can already book their tickets for the event in May and navigate a path through it: there are expert-led seminars, real stories, whereby people connect with others who have been through the process, wellbeing workshops and more than 70 exhibitors. Of course, they are all paying a fee to be there, and they all aim to have made a profit by the end.

Our first set of IVF treatment was free on the NHS. We paid £7,000 for our second, which was again through the NHS. We went through several visits to NHS and private providers to assess whether we were willing to pay a top-up for a slightly better service. I really did not intend to speak this morning, but I wonder whether, in the final part of the process that we are considering, there would be the sort of upsetting process that has taken root in the fertility industry in this country. We need more clarity on that by Report.

[Naz Shah]

I stopped myself intervening on my hon. Friend the Member for Sunderland Central; I had lots of questions, and he has confused me even more. He referred to the provision in clause 8(6)(d) about the doctors being different. If I am right, healthcare providers such as Aspire or Ramsay Health Care could be commissioned to deliver the services. If so, does that mean, as the hon. Member for East Wiltshire suggested, that we will need two separate doctors or providers because the co-ordinating doctor and the second doctor cannot be linked? That confuses me even further. After what we have heard this morning, it strikes me that we do not have any proposed model and the measure has not been thought through. It speaks to the idea that this is not right. We are spending hours and hours going through hypotheticals and possibilities—this could happen, that could happen—but there is nothing actually before us.

[Danny Kruger]

The hon. Lady is absolutely right. I am not sure that anything in the Bill would preclude a private provider—“Virgin Health” or some such organisation—from providing the whole pathway of the assisted death, including employing, albeit in separate clinics or separate practices, the two doctors who would provide the two assessments. The provider would comply with the Bill, but the doctors might be part of the same organisation even if they work in different practices.

[Naz Shah]

I thank the hon. Member for his intervention. I have observed two things this morning. First, the reality has really hit home. Are we going to look at the amendment regarding local authorities providing the service? Are we excluding private providers? Are we excluding big firms? A new service has to be designed. Will it be two organisations or one? How will the Bill be delivered? We do not even have that before us, and that concerns me deeply.

[Kim Leadbeater]

As my hon. Friend the Member for Sunderland Central said, it is common practice in healthcare and in the NHS for services to be commissioned in a range of ways. We would not put such a level of detail in the Bill, but it would be normal practice for the Secretary of State to do that commissioning work. My hon. Friend the Member for Bradford West has her own experience of that, I imagine.

[Naz Shah]

Absolutely. As a former commissioner, I am very familiar with commissioning; I commissioned millions of pounds’ worth of services across Bradford when I was in the NHS. The difference is that that was under Government Bills that had pre-consultation, impact assessments and a model that was debated. None of that has happened with this Bill. I agree that in an ideal world the process set out in new clauses 36 and 37 would be the right one, but without an impact assessment and a consultation, I am afraid that I have been left really disheartened.

I am disheartened about something else, too. I thank all Committee members, regardless of the points that they have or have not made, for the way in which the debate has been conducted, both before and during our sittings. On a few occasions, hon. Members have questioned other Members’ reasons for tabling amendments—but to suggest, as has been suggested today, that we are scaremongering, when we are actually going through the detail, is something else.

I am afraid. This is not me scaremongering; this is me being afraid for women who are anorexic. This is a gendered Bill. There are amendments that I support because I want to strengthen the Bill. I genuinely do not think that the Bill, as it stands, has that strength. I feel disheartened that we are talking about what is going to happen on Third Reading and potential votes, when we should be concentrating on the amendments on the selection list.

I oppose the new clauses tabled by my hon. Friend the Member for Spen Valley, which would replace clause 32. As my hon. Friend explained, new clause 36 outlines the powers that the Secretary of State for Health would have over voluntary assisted dying services in England. New clause 37 does the same for Wales, but makes changes that are necessary because health is a devolved power. I will concentrate on new clause 36, as I represent a constituency in England.

Put very simply, if new clause 36 is agreed to, it will give the Secretary of State three sorts of power. First, it will give the Health Secretary powers under subsection (4) to, effectively, change the National Health Service Act 2006. Secondly, it will give the Health Secretary powers to set out regulations about how any service, whether public or private, carries out assisted dying services. Thirdly, the Health Secretary will have powers under subsection (1) to commission assisted dying services. As I understand it, the wording means that assisted dying services could be provided directly by the NHS or by private firms working on contract for the NHS. I will discuss those powers in the order in which I mentioned them.

Subsection (4) of new clause 36 says that the Health Secretary may pass regulations that

“may for example provide that specified references in the National Health Service Act 2006 to the health service continued under section 1(1) of that Act include references to commissioned VAD services.”

To make it clear how the new clause works, I will quote from the subsection of the National Health Service Act 2006 that it would affect. It states:

“The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

(a) in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of physical and mental illness.”

That Act is an adaptation of the original National Health Service Act 1946, section 1(1) of which states:

“It shall be the duty of the Minister of Health…to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness”.

The 1946 and 2006 Acts both give the Health Secretary a very clear set of duties that I think we can all support. Those duties have been the basis of how the NHS has been run for the nearly eight decades for which it has existed.

My hon. Friend’s Bill would give the Secretary of State powers to change the duties set out in section 1(1) of the 2006 Act. I ask my hon. Friend and both Ministers why the Bill needs to give the Secretary of State those powers. The only reason I can think of is that someone who was part of the drafting process has pointed out that the Health Secretary’s current duties might be incompatible with assisted dying.

The Health Secretary has duties to secure improvement in the people’s physical and mental health and in the prevention, diagnosis and treatment of physical and mental illness. Someone could bring a legal challenge on the basis that assisted dying does not fit with that duty, and that challenge might well succeed. I think that, to prevent that happening, my hon. Friend has proposed subsection (1) of new clause 36. If there is any other reason why she has suggested that we should give those powers to the Secretary of State, it is important that the Committee understands and hears it.

What is proposed underlines just how major a change the Bill would make. Since the NHS started operations in 1948, we have had a clear understanding of what it is there for. The 2006 Act is little different from the 1946 Act in that respect. For nearly 80 years, we have had an NHS that is there to improve health and to improve the prevention, diagnosis and treatment of illnesses. The fact that we may have to change that shows us that we are taking a very big step indeed. To make such a fundamental change to the NHS, we should have had the best possible evidence and proper consultation, not three days of witness hearings and then hundreds of pieces of written evidence, often published after we had finished discussing the topics to which they relate. That is nowhere near good enough.

The next set of powers that I want to talk about is mentioned in subsection (3) of new clause 36, which says that the Health Secretary

“may by regulations make other provision about voluntary assisted dying services in England (whether or not the services are commissioned VAD services).”

I absolutely accept that if we have assisted dying services in England, the Health Secretary should ensure that they are properly regulated. That will have to include privately provided services as well as those offered on the NHS. However, I must ask: why does the Bill say that the Secretary of State “may” pass such regulations? The best interpretation I can think of is that a future Health Secretary might decide that private firms should provide assisted dying services directly to paying customers rather than via outsourced NHS contracts. In that case, the Health Secretary would need to provide regulations for those private sector services.

If that interpretation is correct, surely we could have tighter wording. For example, the new clause could say that if the Secretary of State decides to allow private firms to provide assisted dying to paying customers, the Secretary of State must make regulations to govern that. I would welcome clarification on the point, because I know that my hon. Friend the Member for Spen Valley previously accepted an amendment—I think it was amendment 477—

[The Chair]

Order.

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

Naz Shah Excerpts

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[The Chair]

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

Amendment 537, in clause 32, page 19, line 27, after “assistance” insert

“by a registered charity but not”.

This amendment would limit the provision of an assisted death to charitable providers and not permit provision as part of the National Health Service.

Amendment 528, in clause 32, page 19, line 27, at end insert—

“(2A) Regulations under subsection (1) cannot authorise a body other than a public authority from providing such assistance even if that body is to be contracted by a public authority to do so.”

Amendment 529, in clause 32, page 19, line 28, leave out subsection (3).

Amendment 530, in clause 32, page 19, line 31, at end insert—

“(5) The Secretary of State may not lay a draft statutory instrument before either House of Parliament that makes provision containing (whether alone or with other provision) regulations under subsection (1) unless they also lay before both Houses an impact assessment on such regulations.

(6) The impact assessment under subsection (5) must include an assessment of the impact of such regulations on the workforce of health professionals and on the National Health Service.”

Clause stand part.

Amendment 545, in clause 39, page 23, line 6, leave out subsections (3) to (5) and insert—

“(3) The Secretary of State may not make a statutory instrument containing (whether alone or with other provision) regulations under section 5(3A), 8(6A),30(3), (Voluntary assisted dying services: England) or (Voluntary assisted dying services: Wales) unless a draft of the instrument has been laid before, and approved by a resolution of, each House of Parliament.

(4) Any other statutory instrument made by the Secretary of State containing regulations under this Act is subject to annulment in pursuance of a resolution of either House of Parliament.

(5) The Welsh Ministers may not make a statutory instrument containing regulations under section (Voluntary assisted dying services: Wales) unless a draft of the instrument has been laid before, and approved by a resolution of, Senedd Cymru.”

This amendment brings together the various provisions about the procedure for regulations. It also makes regulations under clauses 5 and 8 about training, qualifications and experience, and regulations under NC36 and NC37, subject to the draft affirmative procedure.

New clause 36—Voluntary assisted dying services: England—

“(1) The Secretary of State must by regulations make provision securing that arrangements are made for the provision of voluntary assisted dying services in England.

(2) In this section “commissioned VAD services” means services provided by virtue of regulations under subsection (1).

(3) The Secretary of State may by regulations make other provision about voluntary assisted dying services in England (whether or not the services are commissioned VAD services).

(4) Regulations under this section may for example provide that specified references in the National Health Service Act 2006 to the health service continued under section 1(1) of that Act include references to commissioned VAD services.

(5) Regulations under this section must provide that section 1(4) of that Act (services to be provided free of charge except where charging expressly provided for) applies in relation to commissioned VAD services.

(6) Regulations under this section may make any provision that could be made by an Act of Parliament; but they may not amend this Act.

(7) In this section “voluntary assisted dying services” means—

(a) services for or in connection with the provision of assistance to a person to end their own life in accordance with this Act, and

(b) any other services provided by health professionals for the purposes of any of sections 4 to 22 except section (Determination by panel of eligibility for assistance).”

This new clause imposes a duty on the Secretary of State to make regulations securing that arrangements are made for the provision of voluntary assisted dying services in England. It also confers a power to make other provision about voluntary assisted dying services in England.

Amendment (a) to new clause 36, after subsection (1) insert—

“(1A) Regulations under subsection (1) cannot authorise the National Health Service in England to provide voluntary assisted dying services.”

Amendment (c) to new clause 36, after subsection (1) insert—

“(1A) Regulations under subsection (1) cannot authorise a body other than a public authority to provide voluntary assisted dying services if that body is to be contracted by a public authority to do so.”

Amendment (b) to new clause 36, leave out subsections (4) and (5) and insert—

“(4) Regulations under subsection (1) may not amend, modify or repeal section 1 of the National Health Service Act 2006.”

Amendment (d) to new clause 36, leave out subsection (6).

Amendment (e) to new clause 36, after subsection (6) insert—

“(6A) The Secretary of State may not lay a draft statutory instrument before either House of Parliament that makes provision containing (whether alone or with other provision) regulations under subsection (1) unless they also lay before both Houses an impact assessment on such regulations.

(6B) The impact assessment under subsection (6A) must include an assessment of the impact of such regulations on the workforce of health professionals and on the National Health Service.”

New clause 37—Voluntary assisted dying services: Wales—

“(1) The Welsh Ministers may by regulations make provision about voluntary assisted dying services in Wales, including provision securing that arrangements are made for the provision of such services.

(2) Regulations under subsection (1) may make any provision that—

(a) could be made by an Act of Senedd Cymru, and

(b) would be within the legislative competence of the Senedd if it were contained in such an Act.

(3) The Secretary of State may by regulations make provision about voluntary assisted dying services in Wales.

(4) Regulations under subsection (3) may make any provision that—

(a) could be made by an Act of Parliament, and

(b) would not be within the legislative competence of the Senedd if it were contained in an Act of the Senedd.

(5) Regulations under this section may not amend this Act.

(6) In this section “voluntary assisted dying services” has the meaning given by section (Voluntary assisted dying services: England).”

This new clause confers a power on the Welsh Ministers to make provision about voluntary assisted dying services in Wales, including provision securing that arrangements are made for the provision of such services. It also confers a power on the Secretary of State to make provision about such services, where the provision would be outside the legislative competence of Senedd Cymru.

[Naz Shah (Bradford West) (Lab)]

It is a pleasure to serve under your chairmanship, Mrs Harris, for what might be the last time on this Bill Committee. When we adjourned this morning, I was speaking to new clauses 36 and 37. To bring us up to speed, I will repeat my last paragraph.

If the interpretation that I suggested this morning is correct, surely we could have tighter wording. For example, the new clause could say that if the Secretary of State decides to allow private firms to provide assisted dying to paying customers, the Secretary of State must make regulations to govern that. I would welcome clarification from my hon. Friend the Member for Spen Valley on whether she would be minded to accept such an amendment, given that she accepted a change from “may” to “must” in previous amendments.

Finally, we come to what I think is the most important part of new clause 36: the powers in subsection (1) to commission assisted dying services. How the Secretary of State uses those powers will be crucial to the transparency of the system and to the impact of assisted dying on the NHS.

We do not know whether the Health Secretary will contract private firms to provide services to the NHS or whether all assisted dying will be provided under the NHS. We do know, however, that many parts of the medical profession are strongly alarmed by the idea that the NHS would provide assisted dying. For example, the Royal College of General Practitioners said in its written evidence TIAB 108 that it

“does not believe that, if assisted dying is legalised, the process should be integrated into existing care pathways as part of the standard care and treatment they provide i.e. assisted dying should not be deemed core GP work…As such, we consider that if assisted dying is legalised the Bill should make provision to establish a separate Assisted Dying service. This may help to ensure that assisted dying was not a core part of GP work and that any doctor who did not want to be involved would not be forced to do so.”

There is a problem here. Giving the Health Secretary the power to commission private firms to work as contractors to provide assisted dying would perhaps solve that problem, with skilled healthcare professionals working in the private sector. In an interview with The Guardian on 10 January, the Health Secretary said:

“Where there is spare capacity in the independent sector we will use it. We have agreed that we will work with them, and they will work with us to cut NHS waiting times…At the same time the independent sector has to pull its weight. It’s got to be genuinely additional capacity. I’m entirely pragmatic about this”.

I agree entirely with my right hon. Friend that where there is genuine capacity in the private sector to help the NHS to complete its tasks, we should of course use that capacity. However, it is not only private sector healthcare firms that are likely to bid for any future assisted dying contract. There are other firms with a good chance of winning those contracts that we should be very concerned about.

The Minister for Care has made it clear that the Government are considering using private firms for assisted dying. He gave an important interview on assisted dying to PoliticsHome, which was published on 11 March. He said that my hon. Friend the Member for Spen Valley

“has said that she wants this service to be an integral part of the NHS, meaning free at the point of use. Certainly the advice that we as ministers have given her is we’ve clearly understood that that is her wish, and that is a wish that can be delivered and carried out. Now, free at point of use doesn’t preclude the use of independent contractors to deliver the service. So, yeah, we’re comfortable with that.”

Unfortunately, we have seen major failings in the way private firms handle important contracts given to them by the Government. Those failings have happened under all three major parties in England and Wales. I want to quote from an excellent book by Sam Freedman, “Failed State”, which is not about some foreign country but about our own. I should say that Sam Freedman was a special adviser to Michael Gove under the Conservative Government, so he is not someone on the far left.

Chapter 3 of the book, which concerns outsourcing, is entitled “Contract Killing”. It says that outsourcing contracts can work well if three conditions are met. First, there need to be many firms or public organisations competing to offer a service. Secondly, the regulator needs to be able to measure clearly whether the firms have delivered the service to a good standard. Finally,

“government needs to be able to hand over most of the risk of failure—if the taxpayer is still on the hook for picking the costs if things go wrong then the premium paid to private firms is not justified.”

There are fields in which Government contracts do meet those criteria and outsourcing works very well—cleaning services, for example. There are some diagnostic or therapeutic services in the NHS for which private firms can make a genuinely competitive offer. A lot of the time, however, that does not happen:

“For more complex services, though, often none of these criteria apply. Take a specialist activity like running immigration processing. There is no existing market. That means there are few plausible bidders outside of a handful of huge multinational outsourcing firms.”

It means, as Freedman notes, that the UK’s outsourcing market is dominated by the big four: Serco, Capita, Atos and G4S. There must be a very good chance that these companies will end up bidding for assisted dying services. Freedman gives immigration processing as an example of a complex service in which there are not going to be a lot of companies making good, competitive bids. Assisted dying is even more complex than immigration processing, and it is even more important to get it right.

To bid for assisted dying services, companies will need experience in securing complex Government contracts. They will need very good legal advice. They will need to hire doctors and other specialist staff. They will need the facilities to transport and store lethal drugs. We are almost certainly going to see the same old big four outsourcing companies bidding for these contracts. That would be a major problem, because the big four have a terrible record. I apologise for not being able to give a complete list of the scandals in which these four firms have been involved while running Government contracts—after all, time is limited—but it is worth mentioning a few.

In 2013, both Serco and G4S were found to have spent years keeping inaccurate records on how they tagged and monitored dangerous criminals. As a result, they had overcharged the Government by tens of millions of pounds. Serco was eventually fined £23 million for fraud and false accounting; G4S was fined £44 million for the same scandal, but that only happened in 2020, seven years after its fraud was first revealed. These two companies committed fraud against the taxpayer worth tens of millions of pounds.

[The Chair]

Order. Please could I ask the hon. Member to stick to the point?

[Naz Shah]

I will get back to the point, Mrs Harris.

Serco and G4S carried on getting huge public contracts because the Government found it too hard to replace them. Assisted dying would also be a specialised service.

[Kim Leadbeater (Spen Valley) (Lab)]

My hon. Friend has mentioned a couple of companies. I have to say that I do not know very much about those companies. Are they healthcare providers? Do they deliver healthcare?

[Naz Shah]

Some of them do, or they deliver parts of healthcare. Any company can bid or design a service to recruit doctors, as I said earlier. That is the reason I mention these companies. Big companies already do provide some services to our NHS, albeit that they may be in different areas at the moment.

[The Chair]

Order. Can we stick to the point, please?

[Naz Shah]

I am happy to, Mrs Harris.

We should be determined not to see big outsourcing companies bidding for assisted dying contracts and then potentially misusing them the way in which they have misused other public services. That is not because I am opposed to firms operating in a free market or making money when they do their job well; it is because the way we run outsourced Government contracts in this country often has nothing to do with the free market and nothing to do with companies working well.

Finally, we need to ask hard questions about how the contracts for assisted dying would be structured. Would companies be paid a fee for each stage of the assisted dying process that they have provided: one fee for providing the first assessment by a doctor, another for a second assessment and so on, up until the final fee for helping the patient take the lethal drugs? As I said this morning, we do not know what the proposal for the structure is. That is why it is important that we explore and understand the risks of every structure.

There are Government services that we can safely outsource. Assessing whether people are fit to end their life is not one of them, and neither is helping people to take lethal drugs. These clauses will enable future Governments to open up lucrative contracts for assisted dying that will almost certainly be won by companies that have often been incompetent and have potentially been dishonest. I strongly oppose the new clauses.

[Danny Kruger (East Wiltshire) (Con)]

I share all the hon. Lady’s concerns. In relation to the intervention made by the hon. Member for Spen Valley, is she aware that G4S has a health services division in the UK that directly employs doctors and other healthcare professionals?

[Danny Kruger]

I take your ruling, Mrs Harris, but the amendment is explicitly about this.

[Naz Shah]

When it comes to NHS providers, or any service providers, and contracting or outsourcing, we have legislation in this place for whistleblowing. I raised the subject with the Health Secretary in relation to my local trust only today. With the best will in the world, mistakes happen. We legislated to protect whistleblowers, and that ties in directly to these risks. We must do everything we can to mitigate such risks in the Bill.

[The Minister for Care (Stephen Kinnock)]

It is a great pleasure to serve under your chairship this afternoon, Mrs Harris. The Government remain committed to ensuring the legal robustness and workability of all legislation. For that reason, we have worked with my hon. Friend the Member for Spen Valley on some amendments to the Bill. Where changes have been mutually agreed by my hon. Friend and the Government, I will offer a technical, factual explanation and a rationale for the amendments.

Amendment 525 would remove the Secretary of State’s explicit power to make regulations enabling the provision of assistance as part of the health service in England and Wales. It might therefore prevent such assistance from being provided by the NHS. The Secretary of State would still have the power to make arrangements for the provision of assistance or to delegate the making of arrangements. However, it is doubtful that those arrangements could be made through the NHS; rather, the Secretary of State could, for example, make arrangements for another body to provide assistance.

The effect of amendment 537, as drafted, is potentially ambiguous. However, the Government’s assessment is that it could be interpreted as allowing regulations to enable the provision of assisted dying by a registered charity, while not allowing provision as part of the health service. That could put into doubt whether assisted dying could be provided as part of the NHS in England and Wales.

Amendment 528 would prevent any body other than a public authority from being authorised by regulations to provide assistance as set out in the Bill, regardless of whether that body is contracted to do so by a public authority. That would limit the scope of the Secretary of State’s powers to ensure that assistance is available in the absence of a definition. The meaning of “public authority” might be unclear.

Amendment 529 would remove the power to amend, revoke or repeal legislation via regulations made under clause 32(1) concerning arrangements for assistance, where passed or made before the end of the Session in which the Bill is passed. That could lead to gaps in the Secretary of State’s regulation-making powers and in other legislation. It could also have an impact on the workability of arrangements for assistance and, ultimately, the Bill.

Amendment 530 would add two requirements when making regulations under clause 32, which sets out the Secretary of State’s powers to ensure that assistance is available. The first is that the Secretary of State may not lay regulations before either House under subsection (1) unless an impact assessment of those regulations is also laid before both Houses. The second is that the impact assessment must include an assessment of the impact of the regulations both on the health professional workforce and on the NHS itself. Impact assessments are routinely prepared to accompany secondary legislation. However, the amendment would impose a statutory requirement on the Secretary of State to prepare an impact assessment, which would need to be laid before both Houses. It would therefore create a legal requirement that is not the standard for secondary legislation.

--- Later in debate ---

[Naz Shah]

I rise to speak in support of amendments 172 and 173, tabled by the hon. Member for Reigate, and against amendment 539, moved by my hon. Friend the Member for Spen Valley.

Clause 33 currently provides that the Health Secretary “may” bring forward regulations to require a doctor to report any notifiable event to the chief medical officer. That would be either the CMO for England or the CMO for Wales, according to where the assisted death takes place. The clause lists those notifiable events, such as the first declaration, the two statements by the doctors, including when they refuse to make such a statement, and the final statement that follows the person’s death. The weakness in the clause as originally written is its use of the word “may”. It should not be optional for the Secretary of State to make such regulations. Amendment 539 retains that weakness, while adding what I view as a new problem. The new weakness is that the amendment removes the requirement for doctors to notify the CMO of the events. Instead, it specifies that they should notify the voluntary assisted dying commissioner.

By all means let us have doctors reporting these events to the commissioner, but they should still be required to report the events to the chief medical officers too. There are at least two good reasons for that. First, the chief medical officers are extremely experienced, senior doctors. They and their staff have the ability to look at this kind of data from a medical and especially a public health perspective. The VAD commissioner will come from a legal, not medical background. They will have other abilities but they will not look at this through the lens that a senior doctor would. Secondly, it cannot be good governance that the only person who must see the data is the commissioner—the official who runs the assisted dying system and who appoints all the panel members.

[Kim Leadbeater]

I hope that my hon. Friend can take some reassurance from amendment 455, which says that

“the Commissioner must consult… the Chief Medical Officer for England”

and

“the Chief Medical Officer for Wales”

when making a report.

[Naz Shah]

I will come on to that point.

As I have said previously, this Bill will not just create a VAD commissioner, but give them the power to assess their own work. That means it is much less likely they will critically assess the data for any signs of a major problem. We all suffer from unconscious bias, even the very senior legal officials who will be eligible to become VAD commissioners. If the data were sent to the chief medical officers as well as the commissioner, that would mean two sets of officials with different perspectives and fields of expertise looking for problems. We would have a much better chance of locating problems earlier that way.

Amendment 172 would change the clause so that the Health Secretary must bring forward such regulations. As things stand, regulations brought forward under the clause would be subject to the negative procedure, which, as all hon. Members know, considerably reduces the amount of parliamentary scrutiny they receive.

Amendment 173 would make regulations under the clause subject to the affirmative procedure. I honestly try to see the arguments for and against each amendment, but I have real difficulty in seeing what the arguments against these two might be. Clearly, notifiable events are important information that must be collected nationally for a transparent assisted dying system. Equally, they need to be governed by regulations so that all doctors participating in the scheme have a clear picture of their responsibilities.

Finally, on such an important matter, Parliament should be required to vote to accept such regulations, as that will increase the scrutiny from both this House and the other place. I appreciate that my hon. Friend the Member for Spen Valley drew my attention to her amendment, which says the commissioner must consult the chief medical officer. However, it does not specify whether the consultation should include data or if it is the beginning of the process; those things are not stated on the face of the Bill. That leaves it open to interpretation, which is why I support the amendments tabled by the hon. Member for Reigate. I thank her for tabling those two very sensible amendments and I urge hon. Members to vote for them. From my perspective, amendment 539 weakens the Bill and we should vote against it.

[Stephen Kinnock]

These amendments seek to ensure that the voluntary assisted dying commissioner receives the necessary information to fulfil their functions in monitoring the operation of the Bill. Amendment 539 empowers the Secretary of State to make regulations requiring registered medical practitioners to notify the commissioner, instead of the relevant chief medical officer, of any event specified in such regulations. That could include the events currently listed under clause 33(2), such as where a practitioner carries out a first or second assessment and provides or refuses to provide a supporting statement. Setting out these events in regulations would allow for greater flexibility.

Amendment 540 empowers the Secretary of State to make regulations enabling the commissioner to require persons or specified descriptions of persons to provide information. For example, this could be access to medical records to inform panel deliberation. The regulations made by the Secretary of State under amendments 539 and 540 may also provide for how such regulations are to be enforced. The enforcement mechanism would help ensure compliance regarding the notification of provision of information to the commissioner under the regulations. Amendments 541 to 544 are consequential amendments.

I turn to amendment 172. As introduced, clause 33(1) provides that

“The Secretary of State may, by regulations, require any registered medical practitioner to notify the relevant Chief Medical Officer of any notifiable event.”

A list of such events is provided in clause 33(2). The effect of amendment 172 would be that the Secretary of State would instead be required to make regulations under clause 33(1), requiring any registered medical practitioner to notify the CMO of any notifiable event. Amendment 173 would require any regulations under clause 33 to be made under the affirmative procedure, rather than the negative procedure, meaning that they would be laid before and approved by both Houses of Parliament.

The purpose of new clause 38 is to allow the sharing of information between the voluntary assisted dying commissioner and certain persons. It would create an information-sharing gateway between the voluntary assisted dying commissioner and the Care Quality Commission, the General Medical Council, the General Pharmaceutical Council and the Nursing and Midwifery Council. The new clause includes a regulation-making power for the Secretary of State to specify any other person that the commissioner may share information with and vice versa. It also creates an information-sharing gateway between the commissioner and the Secretary of State, to enable the sharing of information for the purpose of any function of the commissioner, or any function of the Secretary of State, relating to the operation of the Bill.

New clause 39 provides that where there is a disclosure of information that is required or authorised under the Bill, it will not amount to a breach of confidence or any other restrictions placed on the disclosure of information. The new clause makes clear that data protection legislation still applies and will need to be complied with. It is essential that any provisions under the Bill that require data to be shared do not undermine the public’s trust, security and privacy in terms of their personal data. I hope that those observations will be helpful to the Committee.

Question put, That the amendment be made.

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[Danny Kruger]

I am keen on actual judges who sit in court with the full authority of a judge, not a retired judge sitting at the head of a quango very far away from the decisions made about assisted dying. Nevertheless, I am grateful to the hon. Lady, and I appreciate the fact that there will be a duty to consult. We want to have as much input from the CMO as possible in the administration of the service.

[Naz Shah]

I rise to speak to amendment 382. My hon. Friend the Member for Spen Valley may argue that some of my criticisms of the amendment relate in particular to two other amendments she has tabled: amendments 455 and 456. Indeed, I took an intervention on the matter earlier. I have read those amendments and they do not answer my concerns about amendment 382. They were grouped with amendment 382 until this morning, when the grouping was changed, so I will address them in my next speech.

This is a good moment to pay tribute to the Committee Clerks for their extremely hard work. I thank them for the way they have coped with the complex groupings and huge numbers of amendments that are unprecedented for a private Member’s Bill in this century.

My hon. Friend’s explanatory statement gives a clear explanation about what amendment 382 does. It provides for the monitoring, investigation and reporting functions under clause 34 to be carried out by the voluntary assisted dying commissioner instead of the chief medical officers for England and Wales. I can think of two possible arguments in support of it. I do not know whether either was behind my hon. Friend’s decision to table the amendment, but they are certainly the best to my mind.

The first argument in favour is that the chief medical officers for England and Wales already have a great many demands on their time. Members might say that we should not risk overloading them and should instead give another official the responsibility of looking at how assisted dying systems work. The second argument in favour is that the amendments to the Bill create a voluntary assisted dying commissioner, and that person and their officials will build up expertise in that field, so it could be argued that the commissioner would be the best person to lead monitoring, investigation and reporting.

Unfortunately I do not think those arguments hold water. On the first, it is true that CMOs have a great deal to do, but if we pass the Bill, it will be one of the biggest changes made to the duties of doctors in this country. For the first time, they will be able to help patients to take lethal drugs solely in order to bring about their death. The chief medical officers for England and Wales are senior doctors who advice Governments on all medical matters; of course they should be centrally involved in seeing whether the system works and whether there are any problems.

The second argument—that the commissioner’s office will become assisted dying subject matter experts—does not stand up either. It is true that the commissioner and the officials they recruit will come to know a great deal about the system they set up, but the very fact that they will set up and run the system means they should not take the lead on monitoring, investigating and reporting. That would mean that the commissioner and their staff would be the first people who decide whether they are doing a good job. Asking people to mark their own homework is a really bad way to check that any system is working properly. It is not how we inspect and report on schools; Ofsted has that job, not headteachers or local councils. It is not how we regulate banks, which are overseen by independent authorities.

[Rachel Hopkins (Luton South and South Bedfordshire) (Lab)]

On my hon. Friend’s point about marking one’s own homework, does she agree that many public bodies do a self-assessment that is then looked at by the regulator? It is as important a part of the process of self-regulations as external inspection.

[Naz Shah]

As far as I have seen, no regulatory system has been proposed in regard to the Bill. I am happy to be corrected. Yes, in other instances we have regulators, but in this instance no regulator is specified. That is why I will come back to my argument about the amendment, but I value my hon. Friend’s intervention.

This is not how we regulate banks, which are overseen by independent authorities. We have seen what happens when there is light-touch regulation. Banks told us all that they were doing a great job until it turned out that they were not. There is an Independent Police Complaints Commission—I could go on, as the list is very long, but I hope we can all agree on the principle. When we regulate an important system in this country, we should not allow the people who run it to be the only people to tell us whether it is working as it should. Although we respect the highly skilled people who run our schools and police our streets, we have independent people whose job it is to check whether there are any major issues.

The assisted dying system created by the Bill is both complicated and, potentially, very dangerous. If the system gets things wrong, it will mean that people will be given lethal drugs who should not have had them. That is why I would strongly support keeping the chief medical officers as the people who run monitoring, investigating and reporting. Perhaps there could be a dual system in which both the CMOs and the VAD commissioner have some kind of role. That would at least be an improvement on allowing the assisted dying commissioner to say, “There’s nothing to see here.” In my view, the best choice would be to retain the system that the Bill started out with and keep the chief medical officers as the people with the main responsibility for oversight.

Members disagreed with my comparison of assisted dying with the scandal of what happened to the sub-postmasters and mistresses, but we have to think about what we have learned about the causes of that scandal. Under the law, Ministers had responsibility for the Post Office. Even though it was an arm’s length responsibility, they still had it. When complaints about the Horizon IT system, and then complaints about miscarriages of justice, started to come through to MPs, Ministers asked the experts in the field. Who were those experts? The executives who ran the Post Office and the engineers at Fujitsu who had set up and then run the Horizon system. What did those experts say for about 15 years? That there were no serious problems with Horizon, that the sub-postmasters and mistresses who said otherwise were lying and that all their convictions were safe. We know how that turned out.

That surely leads us to a clear lesson: we cannot ask powerful people who have created and are in charge of a system—in this case, the assisted dying system—to be the ones who report on it. I am not saying that we would see a deliberate cover-up, as there seems to have been in the Post Office scandal. What I am saying is that we all have unconscious biases and all of us are biased to think that the work we do is good and that there are no serious problems with it.

Amendment 382 significantly weakens the version of the Bill that was presented to the House on Second Reading. We are being asked to let the commissioner report on their own work. That makes it much less likely that we would be able to spot any problems with the assisted dying system at an early stage. I therefore urge Members to vote against the amendment.

[The Minister of State, Ministry of Justice (Sarah Sackman)]

It is a pleasure to serve under your chairship, Mrs Harris. I will speak first to lead amendment 382 in the name of my hon. Friend the Member for Spen Valley, and then to consequential amendments 383 to 387 and 389, on which the Government have worked with the Bill’s promoter.

As the Committee will know, the Bill currently requires the relevant chief medical officers to submit an annual report to the relevant national authority. The amendments would require that the monitoring, investigation and reporting functions under clause 34 are carried out by the voluntary assisted dying commissioner, as opposed to the chief medical officers for England and for Wales, as currently drafted. The functions are to

“monitor the operation of the Act, including compliance with its provisions and any regulations or codes of practice”

that are developed; to investigate and report on

“any matter connected with the operation of the Act”,

including those that have been referred to the Secretary of State or Welsh Ministers; and to “submit an annual report”. The Secretary of State or Welsh Ministers would be required to lay the commissioner’s annual report before, respectively, Parliament or the Senedd, and issue a formal response.

--- Later in debate ---

This amendment is consequential on Amendment 382.

[Naz Shah]

I beg to move amendment 450, in clause 34, page 20, line 33, at end insert—

“(1A) The relevant Chief Medical Officer must produce an annual equality impact assessment of access to both palliative care and assisted dying on the basis of—

(a) protected characteristics as set out in the section 4 of the Equality Act 2010,

(b) socioeconomic status,

(c) geographical location.”

This amendment will ensure that a full impact assessment is carried out on the access to both palliative care services and assisted dying services.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 451, in clause 34, page 20, line 43, at end insert—

“(e) there were complications in the procedure.

(2A) The Commissioner’s report must include analysis of the following—

(a) information about the patients’ diagnosis/es;

(b) information about the patients’ prognosis;

(c) any instances where concerns were raised about the patients’ capacity;

(d) any instances where concerns raised about the patient being coerced;

(e) any concerns raised by the multi-disciplinary panel;

(f) any concerns raised by family members;

(g) and demographic data on the patients, including socioeconomic data, information on protected characteristics; and

(h) data obtained from the recording of the consultation.”

This amendment would require reporting under section 34 to include various information on diagnoses, complications, concerns about capacity and other matters.

Amendment 455, in clause 34, page 20, line 43, at end insert—

“(2A) An annual report must include information about the application of the Act in relation to—

(a) persons who have protected characteristics, and

(b) any other description of persons specified in regulations made by the Secretary of State.

(2B) When preparing an annual report, the Commissioner must consult—

(a) the Chief Medical Officer for England,

(b) the Chief Medical Officer for Wales, and

(c) such persons appearing to the Commissioner to represent the interests of persons who have protected characteristics as the Commissioner considers appropriate.”

This amendment requires an annual report to include information about the application of the Bill to persons with protected characteristics and other descriptions of persons specified in regulations. It also requires the Commissioner to consult the chief medical officers and persons representing the interests of those with protected characteristics, when preparing an annual report.

Amendment 456, in clause 34, page 21, line 28, at end insert—

“(8) In this section ‘protected characteristics’ has the same meaning as in Part 2 of the Equality Act 2010 (see section 4).”

This is consequential to Amendment 455.

New clause 33—Collection of Statistics (No. 2)—

“(1) The Voluntary Assisted Dying Commissioner must ensure that the statistics specified in Schedule [Statistics to be collected] are collected.

(2) The Commissioner must publish a yearly report setting out those statistics.

(3) The Secretary of State may by regulation vary the contents of Schedule [Statistics to be collected].”

New schedule 3—Statistics to be Collected—

“Characteristics

1 The Voluntary Assisted Dying Commissioner must collect the following information about persons requesting assisted dying—

(a) sex,

(b) age,

(c) self-reported ethnicity,

(d) level of education,

(e) Index of Multiple Deprivation based on postcode,

(f) region of residence,

(g) marital status,

(h) living status (alone, with others, in a care home etc),

(i) main condition leading to ‘terminal illness’ fulfilment,

(j) other medical conditions,

(k) other psychiatric/mental health conditions,

(l) presence of physical disability, and

(m) presence of intellectual disability.

Health and Care Support

2 The Commissioner must collect statistics on the following information about health and care support—

(a) whether the person was, before the request—

(i) under a specialist palliative care team, and

(ii) under a psychiatry team;

(b) whether following the request there has been—

(i) referral to specialist palliative care team, and

(ii) referral to psychiatry team following request.

Information about requests

3 The Commissioner must collect statistics on the following information about the requests for assistance—

(a) main reason for requesting assisted dying,

(b) any other subsidiary reason for requesting assisted dying,

(c) any previous requests for assisted dying from that patient,

(d) time between first request and subsequent request(s),

(e) number of times a second opinion was requested under section 10, and

(f) number of times the second opinion disagreed with the first.

Information about refused requests

4 The Commissioner must collect statistics following information about requests that are refused—

(a) at what stage of the process was the request refused, and

(b) reasons for refusal.

Information about the process

5 The Commissioner must collect statistics on the following information about the process—

(a) time from initial discussion to first declaration,

(b) time from first declaration to first doctor’s assessment,

(c) time from first doctor’s assessment to second doctor’s assessment,

(d) time from second doctor’s assessment to panel approval,

(e) time from panel approval to second declaration,

(f) time from second declaration to provision of assistance to self-administer lethal drugs,

(g) time from panel approval to death (whether by lethal drug or natural causes),

(h) duration of relationship between patient and coordinating doctor at first request, and

(i) use of a proxy and reason for using proxy.

Information about clinicians and pharmacies

6 The Commissioner must collect statistics on the following information about clinicians and pharmacies—

(a) number of clinicians participating, their speciality, and number of assisted deaths each carries out per year, and

(b) number of participating pharmacies; number of times AD drugs are dispensed.

Information about Assisted Dying Panel processes

7 The Commissioner must collect statistics on the following information about Assisted Dying Panel process—

(a) number of applications made,

(b) number of applications granted and rejected,

(c) reasons for rejection,

(d) whether family members informed of proceedings,

(e) whether family members took part in proceedings,

(f) number of requests for reconsideration made,

(g) number of reconsideration requests granted and rejected, and

(h) reasons for granting requests.

Information on approved substances

8 The Commissioner must collect statistics on the following information about the approved substances—

(a) name of drug(s) used for the assisted death,

(b) whether IV or oral self-administration is used,

(c) presence and nature of complications following self-administration of drugs (vomiting, regurgitation, seizures, regained consciousness, other),

(d) time from self-administration to loss of consciousness,

(e) time from self-administration to death,

(f) were emergency services called at any time following self-administration of drugs,

(g) location of death,

(h) health care professionals present at self-administration,

(i) non-professionals present at self-administration,

(j) health care professionals present at death,

(k) non-professionals present at death.”

[Naz Shah]

Amendments 450 and 451 were tabled by my hon. Friend the Member for York Central. Let me first set out broadly what the amendments would do. They would mean that the reports of the chief medical officers for England and Wales had to include qualitative as well as quantitative data on assisted deaths.

Subsection (2) of clause 34 says that the chief medical officer’s report “must include information about” when four different events happen: if either of the examining doctors refuses to make a statement saying that the person is qualified for assisted dying, meaning they do not pass the tests set by the Bill; if the panel decides that the person does not pass those tests; or if the co-ordinating doctor decides that the person’s final statement does not pass the tests.

Amendment 451 would add a requirement that the chief medical officers for England or for Wales would have to report on patients’ diagnosis and prognosis, any concerns expressed about capacity or the patient being coerced, and any concerns expressed by the panel or family members. The CMO’s report would also have to include data on the patients, including socioeconomic information and their protected characteristics under the Equality Act 2010. It would also have to include information that the doctors had gathered during their consultations with people seeking an assisted death.

I anticipate Members objecting to “socioeconomic data” as the term is vague. It is important to note that the chief medical officers’ reports on other matters already make considerable use of socioeconomic data. For example, the CMO for England’s 2024 report on health in cities gave detailed information on urban populations’ socioeconomic categories. The report looked at urban populations by indices of multiple deprivation and ethnicity, and how those factors interacted with their health. The CMOs for England and for Wales are used to working with such data. Indeed, they state in reports that using that type of information is vital to understanding the health needs of different parts of the population.

We should take this approach to understanding the people who access assisted dying—who they are, where they live and which groups they belong to. [Interruption.]

[The Chair]

Order. We think there will be six votes in the House, so we will aim to reconvene at 17.15.

--- Later in debate ---

On resuming—

[Naz Shah]

I was talking about amendments 450 and 451 and explaining why we should take an approach that involves understanding who the people who access assisted dying are, where they live and to which groups they belong.

We have heard frequently from some hon. Members that assisted dying in other countries is disproportionately accessed by people with above-average incomes. They have cited data from those countries as a reason why we should be reassured that the Bill will not have harmful effects on people from ethnic minorities, say, or from economically disadvantaged backgrounds. I am sure that hon. Members would want us to gather the same information in England and Wales to ensure that people with protected characteristics or from disadvantaged communities are not harmed or discriminated against.

[Sir Roger Gale in the Chair]

Having covered what the amendments would do, I want to explain why they would improve the Bill. They would increase the qualitative and quantitative data in the CMO’s reports. Such data has all kinds of benefits. It can improve the training for healthcare professionals; it can also make it easier for researchers to dig into trends in the data. We can all agree that if we are to have assisted dying in this country, it must be a much more transparent process than the one that we see in Australia, for example.

Amendment 455, tabled by my hon. Friend the Member for Spen Valley, would require the reports to include some of the information that amendments 450 and 451 would add. I will speak to amendment 455 in more detail later, but let me say that I am glad that my hon. Friend recognises the importance of reporting on protected characteristics.

Amendment 451 would oblige the chief medical officers to report on complications that people may suffer during their assisted death. I am sure all colleagues will agree that that is a vital topic for CMOs to gather data on. If we are to have assisted dying, we need to understand how often complications occur and what factors they are associated with. That information can be used to inform the decision whether to choose an assisted death. Perhaps most importantly, it can be used to reduce the number of assisted deaths in which people suffer painful complications. It will also inform our decisions in this House if we have to amend legislation or vote on regulations.

The amendment would require the commissioner to report on the diagnoses of people who apply for assisted death, which is an extremely important provision. The duty will mean that they look for patterns of diagnoses, making it very likely that the CMOs or other researchers using the same data could spot any particular conditions presented or special problems for palliative care. Identifying such problems will give us the impetus needed to look at how the NHS can improve palliative care for those conditions.

Similarly, it is important that the CMOs look at cases in which people have raised concerns about a person’s capacity or about coercion. I understand that the voluntary assisted dying commissioner has a duty to report on those and other matters, but surely hon. Members agree that this issue is so serious that we cannot allow just one official to report on possible concerns. That is particularly true because the commissioner is the person who appoints panel members and rules on appeals against decisions.

I have said it before and I say it again: it is never a good idea to allow anyone powerful to mark their own homework. This is a clear case in which we need other senior officials looking at the data for signs of things going wrong. I anticipate that the Minister is very likely to say that the Government can see problems with that part of the amendment, because he has given the same response to other amendments that include the word “complications”. He has said that the Government’s view is that it is not clear what the word means, so we cannot use it to impose duties on doctors or others. That troubles me, and I would like to explore it in depth with him.

Actually, the Bill uses the word “complications” in the same sense as the amendment. I refer the Minister to clause 9(2)(c), which states that the assessing doctor must

“discuss with the person their wishes in the event of complications arising in connection with the self-administration of an approved substance under section 18”.

I am sure the Minister will agree that if we can accept the word “complications” in clause 9 to describe unwanted or unpleasant circumstances during and after the self-administration of lethal drugs, we can accept its use in the same sense in amendment 451. If he objects to the word outside clause 9, I would be happy to hear a detailed explanation, because it is important that we understand why.

Amendment 450, the other amendment tabled by my hon. Friend the Member for York Central, reads:

“The relevant Chief Medical Officer must produce an annual equality impact assessment of access to both palliative care and assisted dying on the basis of—

(a) protected characteristics as set out in the section 4 of the Equality Act 2010,

(b) socioeconomic status,

(c) geographical location.”

I understand that my hon. Friend the Member for Spen Valley has tabled an amendment that would require the commissioner to report on people with protected characteristics, but it would only look at how those people were affected by assisted dying. That does not go far enough.

Several doctors and experts who gave evidence to this Committee feared that people might be more likely to choose assisted dying if they had no access to good palliative care. Several experts told us that access to good palliative care varies according to where someone lives. We should not just shrug our shoulders and say that it is a terrible shame that palliative care is in bad shape in some parts of the country while it is good in others.

Amendment 451 would mean that the chief medical officers and their teams use their ability and knowledge to scrutinise the assisted dying system. Their reports would help us to identify serious problems early and then deal with them. Amendment 450 would give Parliament the regular information that it needs about whether people in this country can access palliative care. If we are serious about improving people’s opportunity to have good-quality care at the end of their life, we should support it. I urge hon. Members to support both amendments.

[The Chair]

I will now suspend the sitting for about three minutes.

--- Later in debate ---

[Sarah Olney (Richmond Park) (LD)]

It is a pleasure to serve under your chairmanship, Sir Roger. I rise to speak in support of new clause 33 and new schedule 3.

I am concerned that amendment 455 will be inadequate to maintain trust in the system. Collecting comprehensive data, such as the detailed statistics outlined, in an assisted dying regime serves several critical purposes that revolve around ensuring transparency, accountability, safety, equity and continuous improvement of the system. It is about ensuring from the very start that there is good data and learning from the paucity or the blanks in other regimes and from where they have been criticised.

The Secretary of State would have the power to amend the new schedule, but Parliament’s intent and our expectation that the system will be scrutinised would be crystal clear. We need to collect data for monitoring and oversight and gather detailed information about individuals who request assisted dying, and about the process itself. That would allow regulators to monitor how the system is functioning, which would help to ensure that the law is being applied consistently and fairly, preventing misuse or abuse.

We need to safeguard our vulnerable population. Data on characteristics such as age, ethnicity, disability and mental health conditions and on deprivation indices can reveal whether certain groups are disproportionately seeking or being denied assisted dying. That helps to identify potential coercion, discrimination or gaps in care that might drive requests, ensuring that the system protects vulnerable individuals.

For the purpose of improving healthcare and support services, information about the prior involvement of palliative care or psychiatry teams, and about referrals made after requests, highlights whether patients are receiving adequate support before opting for assisted dying. If data shows low referral rates or unmet needs, it could prompt improvements in healthcare, access or quality, potentially reducing the number of requests driven by untreated suffering.

For the purpose of evaluating the process, tracking timelines—that is to say, from initial discussion to death—and procedural steps such as second opinions and panel decisions ensures that the process is efficient yet thorough. It can reveal bottlenecks, delays or inconsistencies, allowing policymakers to refine the system for both patients and clinicians.

For the purpose of understanding motivations and outcomes, collecting the reasons for requests, refusals and complications such as drug efficacy or adverse reactions provides insight into why people seek assisted dying and how the process unfolds. That can inform public policy, clinician training and patient counselling, ensuring that decisions are well informed and voluntary.

For the purpose of ensuring accountability, data on clinicians, pharmacies and panel decisions creates a transparent record of who is involved and how often. That helps to prevent overreliance on a small group of professionals, ensures that ethical standards are upheld and allows for audits if concerns arise.

For the purpose of public trust and ethical debate, detailed statistics foster transparency, which is essential for maintaining public confidence in a sensitive and controversial practice. They also provide evidence for ongoing ethical and legal debates, enabling society to assess whether assisted dying aligns with its values and goals, and for the purpose of learning and adaptation. By analysing complications, drug effectiveness and reconsideration requests, authorities can refine protocols, such as by adjusting approved substances or dosages, to make the process safer and more humane. Long-term data collection supports evidence-based adjustments to the regime.

Almost all jurisdictions around the world have systems for reporting on people requesting and having assisted deaths. However, there is a high degree of variability in the data reported around the world; very few data items are published consistently in all jurisdictions. We have an opportunity to learn from monitoring and reporting systems elsewhere, and to put the most robust possible system in place.

Research published in BMJ Supportive & Palliative Care in 2022 examined in depth the data reported in jurisdictions around the world. It identified official data reports from 16 jurisdictions in which assisted suicide or euthanasia is legal. It found that although most jurisdictions report the number of patients who die by assisted dying, only three—New Zealand, Canada and the state of Victoria in Australia—document the number of patients who make a request to die by assisted dying. The research is from 2022, so it is possible that there are now a few more jurisdictions.

Unless we know about the applications that are assessed as ineligible, we will not have adequate insight into the functioning of patient safeguards and eligibility criteria. That is a point that Dr Annabel Price made in oral evidence and in an editorial in The BMJ in 2015. We need to understand not just who has an assisted death, but who is ineligible and why, to understand how the safeguards are functioning.

The 2022 paper identified Colorado, Hawaii and Maine as reporting the number of patients who received assisted suicide prescriptions, but not the number of persons who actually die by their ingestion. In these jurisdictions, there is no record of how many of the patients ingested the prescribed drugs. This is stipulated in the 2021 data summary for the Colorado End-of-life Options Act, which states that the Act

“does not authorize or require the Colorado Department of Public Health and Environment to follow up with physicians who prescribe aid-in-dying medication, patients, or their families to obtain information about the use of aid-in-dying medication.”

The official statistics reported therefore

“reflect all deaths identified among individuals by prescribed aid-in-dying medication…irrespective of whether their death was caused by ingestion of medication, the underlying terminal illness or condition, or some other cause.”

These states do not appear to have a mechanism to ascertain the amount of unused assisted suicide drugs circulating within the community. The fate of many therapeutic drugs with the potential for abuse or use for fatal overdose, such as diazepam or morphine, is not monitored, but the doses and combinations of lethal drugs used in assisted suicide and euthanasia may present a heightened risk, so monitoring the fate of those drugs should be considered.

Concern about pressure on vulnerable groups warrants the detailed reporting of patient demographics. It is needed to ensure patient safety because it allows researchers and monitoring organisations to monitor trends to determine whether there is disproportionate participation among vulnerable or minority groups and, if so, why.

Even basic patient characteristics, including gender, age and ethnicity, are not universally reported in other jurisdictions. Although marital status could be an indicator of at-home support, fewer than half of reports include it. The level of education can be an indicator of socioeconomic position, but is not routinely reported by many jurisdictions.

Although we have been told that studies that have analysed routine statistics did not indicate a disproportionate use by lower socioeconomic groups, socioeconomic trends have changed over time and new evidence has emerged. For example, in Oregon, the proportion of assisted dying patients on state health aid has doubled in the past decade; it reached 79% in 2021. That indicates an increase in use over time by those in a lower socioeconomic position.

Similarly, an in-depth review by Ontario’s coroner last year showed that those dying by their assisted death legislation, both track 1 and track 2, were more likely to be those with longer prognoses. Given the impossibility of prognostication and the pressure being brought to bear by some campaign groups for the Bill to be wider, socioeconomic data will be very important to ascertain whether there is equity of access to assisted dying and whether financial pressures, including access to benefits, are involved in areas of higher or lower uptake.

Knowing whether patients have received care from hospice or palliative care services provides an understanding of whether patients have been provided with alternative end of life care options. That information is included in fewer than one half of the reports from jurisdictions around the world, with none providing information on the duration or scope of hospice or palliative care involvement. For example, while official reports indicate that 80% to 90% of Canadian patients who have assisted deaths receive palliative care, other studies have shown that fewer than half of such patients had seen a specialist palliative care team.

It is also essential to have information about the clinicians who participate in assisted dying, because the clinical demand of assisted suicide and euthanasia is highly time-consuming, with evidence from other jurisdictions, such as an Australian study of those participating clinicians, showing that it takes 60-plus hours of work per assisted death. Understanding the number of clinicians participating in assisted dying and their speciality is important in understanding the willingness of clinicians to participate, and how the clinical demand for assisted dying is distributed across specialities and practitioners.

Information on the drugs used in assisted deaths is critical to understanding the safety and efficacy of different drugs and drug combinations. The 2022 paper found that just six jurisdictions report the drugs used to bring about patient death. There is no one drug or drug combination that has been shown to be most effective and safe for ending patients’ lives. If that research existed, we would not see such variation in the drugs used. Data on complications following drug ingestion or administration is needed to understand the safety of different drug combinations, but it is rarely reported.

Even in jurisdictions where information on safety is included, missing data can be high. For example, in Oregon, data on complications is unknown in up to 70% of cases annually. Reporting the drugs used to bring about patient death, as well as information about the assisted dying process, including the time from drug ingestion or administration to patient unconsciousness and death, and the presence of complications, would enable the safety and efficacy of these drugs to be assessed.

As in many jurisdictions around the world, what I am proposing relies on retrospective reporting of data, after the patient has died. I suggest that this is the minimum standard that must be achieved. Ideally, we would also build in processes for prospective scrutiny, before the person has died, as well as formal review processes that scrutinise individual cases in more detail. Analyses from Belgium and the Netherlands, where review processes are established, have shown that 48% of assisted deaths in Belgium, and one in five of such deaths in the Netherlands, are not reported via the official reporting system. In some cases, legal requirements are not followed.

Setting up a post-event review panel, such as happens in the Netherlands and Ontario, would improve understanding and safety. In the Netherlands, every case is reviewed by a panel, and many cases, especially the controversial ones, are published to promote education and debate. Controversial or worrying cases will occur in England and Wales if this Bill passes, and it is essential for ongoing patient safety that these are not swept under the carpet, but that there are transparent processes to understand and learn from them.

We have heard frequently in Committee that there is no evidence of harm from other jurisdictions, but we have also heard it powerfully argued that other jurisdictions do not collect the data we would need to determine that. In Oregon, information on complications following ingestion of lethal substances is missing in around 70% of cases. Robert Clark, the former Attorney-General for Victoria, has written:

“The Victorian oversight and accountability structure can best be described as one of ‘hear no evil, see no evil, speak no evil’. In other words, it appears designed for the regulator to find out nothing, investigate nothing and report nothing that could suggest that assisted dying has been anything other than an unblemished success.”

Let us not repeat those mistakes. We can lead the way in rigorous, comprehensive data collection and transparent monitoring.

Amendments tabled by the hon. Member for Spen Valley change responsibility for oversight from the Secretary of State and chief medical officers to the commissioner. This brings a danger of bias in reporting, as there could be an element of marking one’s own homework. This means that there is even more reason for complete data reporting and transparency. Ensuring that data collected is comprehensive and reporting is transparent may go some way to assuage that concern. Importantly, strengthening data collection reporting and monitoring will not make the process harder or more lengthy for the person requesting an assisted death. It just makes the system safer and stronger.

In this amendment, I am not proposing doing anything new or radical. We are simply taking the strongest aspects of what is done in other jurisdictions and bringing them together to enable the best and most comprehensive reporting in the world. All new laws have risks as well as benefit. We must identify and be open about those risks in order to learn from harms and improve onward safety. New schedule 3 will help us to achieve that.

[Naz Shah]

I rise to speak to amendments 455 and 456, tabled by my hon. Friend the Member for Spen Valley. Under the Bill as drafted, an annual report would be issued by the chief medical officers for England and Wales. If the other amendments pass, that report will be issued by the voluntary assisted dying commissioner.

Amendment 455 will do two things, broadly speaking. Proposed new subsection (2A) states that the commissioner’s report

“must include information about the application of the Act in relation to…persons who have protected characteristics”.

Amendment 456 clarifies that the definition of “protected characteristics” is the same as that used in the Equality Act 2010. Proposed new subsection (2A) also provides that the commissioner must report on any other description of persons specified in regulations made by the Secretary of State.

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[Sarah Sackman]

It is a pleasure to serve under your chairship, Sir Roger. I will turn first to the lead amendment, amendment 450, in the name of my hon. Friend the Member for York Central.

As clause 34 stands, the chief medical officer must submit an annual report on the operation of the Bill. Under amendments tabled by the promoter, my hon. Friend the Member for Spen Valley, that would be the responsibility of the commissioner. Amendment 450 would require the chief medical officer to produce an annual equality impact assessment that assesses access to both assisted dying and palliative care for those with protected characteristics, and by socioeconomic status and geographical location.

The amendment seems intended to ensure that monitoring and reporting considers the impact of the Bill on vulnerable groups. Protected characteristics are defined by reference to section 4 of the Equality Act 2010, which means that the report would need to consider the characteristics of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.

The term “equality impact assessment” is not defined in the amendment or elsewhere in the Bill. While equality impact assessments are produced routinely by Government and other public bodies in order to discharge the public sector equality duty, it is not clear what type of assessment amendment 450 would require, so, in practice, there may be difficulties for the chief medical officer in understanding whether the duty has been discharged. Impact assessments are not within the purview of a chief medical officer and should be undertaken by those who are appropriately qualified to carry them out.

In addition, “socioeconomic status” and “geographical location” are also undefined in the amendment and are not defined elsewhere in the Bill. Socioeconomic status and geographical location are not of themselves protected characteristics under the Equality Act, so are not required to be considered as part of the public sector equality duty. It is not clear, therefore, what the assessment of those factors is intended to involve.

[Naz Shah]

While I appreciate that it is not necessarily a duty as defined in law, does the Minister not agree that, given the way our Government operates, we need that data to inform us, in order to improve services elsewhere? We could apply that to this Bill as well.

[Sarah Sackman]

It is right that the commissioner, in their role of scrutinising the operation and workability of the assisted dying regime, could, under the powers conferred by the Bill, look at a range of factors, and indeed at whatever they deemed relevant to discharging that exercise. The question is: what is appropriate to be defined within primary legislation? The Government’s position is that, given that all public bodies are governed by the Equality Act, due regard to all those protected characteristics would be included. However, what is not defined within amendment 450 is socioeconomic status or geographic location. If, down the line, the commissioner wanted to look at those things, they could look at them.

[Naz Shah]

From a public health perspective, we have been having a huge debate for weeks and weeks about whether or not this is a health intervention and whether it should be provided in the NHS or elsewhere. When I was a public health commissioner, we collected socioeconomic data to learn about not just protected characteristics but socioeconomic background. There are concerns that disadvantaged groups are more vulnerable. Would it not be appropriate for the Bill to address those safeguarding issues?

[Sarah Sackman]

I suggest that those are ultimately policy choices, first for the promoter, my hon. Friend the Member for Spen Valley, and then—if the regime is voted on and passed—for the commissioner. In reality, a lot of the data that one will collect when one has due regard to the differential impact on these protected groups will in practice have a large degree of overlap with other aspects of socioeconomic disadvantage, as is so often the case in equality impact assessments.

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Review of this Act

[Naz Shah]

I beg to move amendment 452, in clause 35, page 21, line 30, leave out from “must” to end of line 31 and insert

“every 12 months after the passing of this Act—”

This amendment will replace the review conducting after five years of the passing of the Act with an annual review starting 12 months after the passing of the Act.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 493, in clause 35, page 21, line 31, leave out “5-year” and insert “3-year”.

Amendment 453, in clause 35, page 21, line 36, leave out subsection (2).

This amendment is consequential on Amendment 452.

Amendment 494, in clause 35, page 21, line 36, leave out “5-year” and insert “3-year”.

Amendment 495, in clause 35, page 21, line 36, leave out “5 years” and insert “3 years”.

Amendment 526, in clause 35, page 22, line 10, at end insert—

“(4) A Minister of the Crown must make arrangements for—

(a) a motion in neutral terms, to the effect that the House of Commons has considered the report, to be moved in that House by a Minister of the Crown within the period of 14 Commons sitting days beginning with the day after the report is laid before Parliament, and

(b) a motion for the House of Lords to take note of the report to be moved in that House by a Minister of the Crown within the period of 14 Lords sitting days beginning with the day after the review is laid before Parliament.”

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[Naz Shah]

Under the Bill as presented on Second Reading, the Secretary of State would have to report to Parliament on how the assisted dying system was functioning, but they would do so only after the system had been in operation for five years. Under amendment 452, tabled by my hon. Friend the Member for York Central, the Secretary of State would be required to report annually on how the system was working.

The Bill’s original provision for a five-yearly report was extremely surprising. The requirement on the Secretary of State to report to Parliament is a major safeguard that will prompt them and their officials to probe all the available data on the system. It will also allow Members of this House and the other place to go over that information and look for problems, should they arise, and ways to resolve them. It could be one way to identify failings in the system early. Given that we are discussing a system to allow people to take lethal drugs, that is surely what we should aim for. We cannot afford to wait through years of media reports and complaints before then having to investigate alleged problems.

If the amendment is accepted, it will not be certain that the Secretary of State’s report and the scrutiny of Parliament will identify problems in a timely way, but that possibility will be increased. If we have to wait five years for a report, it is much less likely that we will spot any problems before they have had terrible consequences. I urge Members to vote for the amendment to replace the five-yearly report.

[Danny Kruger]

I concur with the points made by the hon. Member for Bradford West. I very much appreciate the presence of clause 35 in the Bill—it is helpful that we ensure a proper review—but, as the hon. Lady said, five years feels too long to wait, so I support the amendment in the name of the hon. Member for York Central, as well as amendments 493 to 495, tabled by the hon. Member for Bexleyheath and Crayford, who has suggested a three-year review period.

My simple further point is that we are potentially creating threshold legislation: once we take the step down this road, there is no going back. The Bill leaves so much open for further expansion, I suggest, but certainly for the modification and clarification of the operation of the legislation. There is a lot left for ministerial discretion, guidance and codes of practice, as we have debated, and indeed new powers have been added, including a widening of the Henry VIII power. I think, then, that it is important to bring forward the review period.

As my amendment 526 suggests, I also think it is not sufficient simply to undertake a review, even one that is annual or every three years. There must be a guaranteed right to a debate and to hold Ministers to account at the Dispatch Box, which my amendment would insist on.

Lastly, on the inherent potential for expansion due to the wide discretion that the Bill still gives future Ministers, my concern is that the review itself might become a Trojan horse for further expansion, because that is what we see in other countries. It is held out as a safeguard, and that is exactly how we should regard it—I hope it will be that. Having a proper debate and proper ministerial accountability will allow us to check the operation of the Bill thoroughly and enable Parliament to keep it under very close scrutiny.

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[Naz Shah]

I am surprised by what the Minister says on the cost of the Bill. My understanding from our debates on cost is that, if the Bill is passed, its cost will be footed. Why is there a cost implication to this amendment and not to other provisions?

[Stephen Kinnock]

I make these comments without a value judgment; it is simply a statement of fact that an increase in the amount of reporting, and the time and resource that that would take, would inevitably lead to a cost. I make no value judgment on that; I am merely here to point out to the Committee the Government’s view on all aspects of the Bill’s technical implementation, and the consequences of any changes that the Committee may wish to make to it.

Amendments 493 to 495 would change the period after which a review of the Bill is required from five years to three years. As I mentioned, clause 35 provides that the Secretary of State must undertake a review of the operation of the Act and lay a report before Parliament within 12 months of the end of the five-year period after the Bill is passed. The amendments would instead require the review of the operation of the Act and the preparation and laying of the report to take place within 12 months of the end of the three-year period that immediately follows the day on which the Bill is passed. [Interruption.]

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I urge the Secretary of State and the chief medical officers, along with the Ministers and policymakers implementing the Bill, to perceive a very clear intent when producing the codes of practice and guidance by the chief medical officer to spell out in more detail the application of the concepts of dishonesty, coercion and pressure in the specific context of the Bill.

[Naz Shah]

I rise to speak to amendment (b) to amendment 518, and amendment (b) to amendment 520. Although I appreciate that my hon. Friend the Member for Penistone and Stocksbridge is not pressing her amendments to a vote, it is important to get a few things on the record. I am speaking to these amendments to her amendments because they were tabled by my hon. Friend the Member for Lowestoft.

Before I speak further, my hon. Friend the Member for Spen Valley, the Bill’s promoter, has accepted several amendments tabled by my hon. Friend the Member for Lowestoft before—I do not know what her response is, given that my hon. Friend the Member for Penistone and Stocksbridge is not pressing her amendments to a vote. That has thrown me off track, to be fair, because I was not expecting that. Either way, let us move on.

I thank my hon. Friend the Member for Penistone and Stocksbridge for her detailed, interesting presentation to the Committee, though I am not sure I entirely agree with it. Although there might a point, from a legal perspective, where these offences actually do exist in the law, the truth remains, and the facts remain, that when it comes to domestic violence—coercion and so on, which we have debated extensively—we have put the training in, but not putting the offences on the face of the Bill slightly contradicts the conversation we had last week, when my hon. Friend the Member for Spen Valley, the promoter, specified that the sentence for somebody who is found guilty of coercion would be put on the face of the Bill; for example, if a person were found to be guilty of coercing somebody who then died, that would carry a life sentence. My understanding is that there would have been no need for the amendments on that, because we already have those laws in existence for murder, and that would be murder.

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[Naz Shah]

I thank my hon. Friend for her detailed explanation. She makes sense—I would not want to restrict that either. Perhaps she is entirely correct—no doubt she has researched it well—but clause 26 mentions coercion and pressure. It says all of that on the face of the Bill. My hon. Friend wants to leave it in that context—

“by dishonesty, coercion and pressure, induces another person to self-administer an approved substance”,

which is repeated in clause 26(1) and (2). I would still be minded to put at least something further in the Bill. I am not sure that it would restrict us; it would just be helpful. If my hon. Friend does not press the amendment to a vote, would the Ministers accept that there will be statutory guidance on that? I do not know whether the Ministers can respond now or want to wait until they sum up. I am happy to give way. They are not going to bite; that is fine.

Just for the record, I want to talk through the amendments tabled by my hon. Friend the Member for Lowestoft and why she and I feel that they are important. Amendment 518 would put in the Bill a definition of “coercion”. Amendment 520 would do the same for “pressure”. Those amendments give welcome clarity to the Bill on two important issues. Where they talk about a “person or organisation” engaging in coercion or pressure, respectively, my hon. Friend’s amendments would have added,

“including where the person is in an intimate or family relationship with that other person”.

That would make sure that we covered that.

[Dr Tidball]

I thank my hon. Friend for her speech. I think we are united in principle, but perhaps take different views on the best way to ensure that this happens in practice. To give an example, if the word “intimate” is used in those circumstances, were a court to interpret it, it might include a husband, wife or partner, but not a brother, sister or parent. So already, in using that one word, we have potentially created further risks. By defining it, in the circumstances set out by my hon. Friend the Member for Lowestoft, we are excluding a relationship that we would want the court to look at, to weigh and judge whether there was potential dishonesty, coercion or pressure by that person, in that relationship with the person seeking assistance. I give that as just one example of the risk created by adding language, rather than leaving it more broadly for a court to interpret on the basis of the facts of the case.

[Naz Shah]

I will re-read it. It is,

“including where the person is in an intimate or family relationship with that other person”.

The “family relationship”, I think, means that it is extended to siblings. That was my interpretation. Last week, or the week before, we spoke extensively about suicide, and women in particular. The number of women who have committed suicide, particularly following domestic violence, has increased. Indeed, it was on the front page of The Guardian today. It is defined by our lawmakers as intimate partner violence, but it could be other violence. In those cases, as a Government and as lawmakers, we do define those women who are killed by members of their family or intimate partners. Our Minister for Safeguarding and Violence Against Women and Girls reads out that list.

[Dr Tidball]

Alex Ruck Keene’s sage words to me were that the problem with putting in more words is that it creates an opportunity for lawyers to find loopholes. In the example that the hon. Lady has just given, when we are talking about family relationships, I think we would all agree that, having thoroughly considered the evidence in this Committee, we do not want any interpretation of the offences set out in section 26 to exclude, for example, carer relationships. That is not a family member, but a carer might give close personal care to someone with a terminal illness. We do not want the courts to think that it was the parliamentary intention of the Committee to delimit it to only intimate or family relationships. There is a risk that the more we narrow it by example, rather than leaving the term broad, as it is currently—“person”—we risk delimiting it too far. We do not want to exclude a situation involving an offence that we hope would be brought before the courts for prosecution.

[Naz Shah]

I thank my hon. Friend for her explanation, which was very good. I do not have time to go away and think more about it from a legal perspective, because I have only just heard her arguments, but at the moment I absolutely agree.

As for my hon. Friend the Member for Lowestoft, I thank her for her attempt to explain. She has years of experience of working in the field. She tabled that amendment in response to the amendment from my hon. Friend the Member for Penistone and Stocksbridge, with the best of intentions and to strengthen the legislation. I will look at it, and I may even return to it during the debate.

[Danny Kruger]

That was an interesting exchange. I think I agree with the hon. Member for Penistone and Stocksbridge more than I do with the hon. Member for Bradford West, which is an uncomfortable situation for me, but I want to show that I am actually listening. I also agree with the Minister of State, Ministry of Justice, the hon. and learned Member for Finchley and Golders Green, who said last week that, without a statutory meaning, the terms “coercion” and “pressure” have their natural, ordinary meaning, which is well understood by the public and the courts alike.

I have encouraged more clarification and clarity throughout the Committee’s deliberations, and I accept the point made by the hon. Member for Penistone and Stocksbridge and the Minister that we are in a good place in outline in terms of understanding these concepts. However, I agree with the hon. Members for Penistone and Stocksbridge and for Bradford West that it would be helpful to have further clarity from the Ministers. If there is guidance to come, it is important that we proceed with due respect to the points that have been made, including the proposals from the hon. Member for Lowestoft, which I agree with in principle.

However, I want to make the point behind my amendment (a) to amendment 518, tabled by the hon. Member for Penistone and Stocksbridge, even though I understand she will not push it to a vote, so I cannot push mine. She challenged me about the purpose of my amendment, so I want to explain it. There are two places in the Bill where the concepts of coercion and pressure occur: one is in the context of the assessment process for eligibility for assisted death, and the other is in terms of the criminal offence of coercion into an assisted death. Those are two separate areas of the Bill, but they use the same terminology, and the same principle of coercion is behind them both.

The point of my amendment is to make clear the distinction between eligibility and the criminality involved in coercion. Although I entirely agree with the hon. Member for Penistone and Stocksbridge that it is appropriate to retain the principle of intention—to be clear, my amendment would remove the requirement for evidence of intention to coerce, leaving just the fact of coercion in the definition—her point was that it is important to retain evidence of intention in order for the criminal offence to be meaningful. I accept that that is a point in criminal law.

However, it is important that we do not include intention in the context of the assessment of eligibility criteria, for the simple reason that somebody may well be coerced into an assisted death in a way that we would all understand, but the perpetrator may not have had the explicit intention of that outcome. An example would be where an abusive husband, through abuse, victimisation, relentless unkindness and perhaps the direct communication of, “You’d be better off dead,” has the effect of coercing his victim—his wife—into seeking an assisted death, which might well be subject to criminal prosecution on these terms. He would nevertheless be able potentially to claim that that was not his intention, and, indeed, perhaps it was not. He might not have had the explicit thought in his head, “I want to make her apply for an assisted death.” Nevertheless, that is the consequence of his coercive behaviour.

I would hope that when the doctors assessed that particular case and came across evidence of that pattern of abuse, they would conclude that this person was being coerced, and would therefore not award the applicant the green light to proceed. That is an example of where it is important to remove the intention of coercion from the definition. I entirely agree with the hon. Member for Penistone and Stocksbridge about the value and necessity of including intention where we are talking about the criminal offence of inducing somebody to have an assisted death.

Lastly, let us think about this from the point of view of the doctor or panel who are being asked to approve the application. If the definition of coercion includes the intention to coerce, we are inviting—in fact, requiring— the doctor or panel to seek evidence of the intention of the person doing the coercion, rather than just the fact of the patient having been coerced. We would require them somehow to interview the abuser, so I think we would get into difficult territory if we insisted on evidence of coercion in order to deny the application on that basis.

I hope that that helps to explain the purpose behind my amendment. I know it is slightly academic, because we are not proceeding with amendment 518, but I hope the Minister and the hon. Member for Spen Valley reflect on the points made by the hon. Member for Penistone and Stocksbridge and take them on board in subsequent amendments or guidance.

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[Danny Kruger]

I intend, in a later debate when we come to the new clause, to try to explain how I think we should have done this. The answer to the hon. Gentleman’s question is that an organisation should be resourced—I think through philanthropy, rather than taxpayers’ money or people paying out of their own pocket, but the point stands however we do it—to deliver the assisted dying service, but crucially it should not be paid more per service, treatment or customer. We should not have the concept of customers in this arrangement; there should be a provider who is resourced to deliver this service. The crucial point is that they should not be paid more per client or for progressing people through the system.

[Naz Shah]

That is the exact point I was about to raise. Is another amendment needed to ensure that providers of this service are not given more money if a patient goes through the process than if the process is stopped?

[Danny Kruger]

That is the purpose of my amendment.

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[Dr Opher]

I will be very brief. This is the most difficult speech I have had to make in the Committee. I think all of us who support the Bill are disappointed; I am sure that my hon. Friend the Member for Spen Valley is incredibly disappointed. I believe that the Bill is deliverable within two years, but I have wanted this legislation for about 25 years, and my main aim is that the Bill passes. I understand, from certain dialogues I have had, that that is more likely if we accept amendment 548. In short, therefore, I will support the amendment. I will do so reluctantly, but it has my full support and I will vote for it.

[Naz Shah]

May I thank the hon. Member for Harrogate and Knaresborough for sharing something so deeply personal? I am sure I speak on behalf of the whole Committee in wishing his mum well and hoping that she never has that diagnosis.

I rise to speak to amendments 489 and 488. Amendment 489, tabled by my hon. Friend the Member for York Central, would prevent the Bill’s provisions from coming into effect automatically after a certain period had elapsed. The Bill in its original form includes a measure to that effect, in clause 42(3):

“But if any provision of this Act has not been fully brought into force before the end of the period of 2 years beginning with the day on which this Act is passed, that provision (so far as not already in force) comes into force at the end of that period.”

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[Rebecca Paul]

I think we would be talking about an advert via electronic form, marketing a particular service. We would have to go back to the meaning of “advert” to answer that. Obviously, there are broader ways of advertising on social media and so on, which I also seek to prevent with the amendment.

That is why banning the advertising of such services is so important, so that a pro-suicide message is not inadvertently delivered to millions of people who assisted dying is not appropriate for. We have to recognise that there are vulnerable people out there who could be influenced by it. It is my view that conversations about assisted dying should happen in person, between the relevant doctor and the patient; they should not be prompted by a TV ad or something seen on a bus. Ads should not be coming up on someone’s Facebook feed every time they log on.

I hope Committee members will support this common-sense amendment. I think that for it to be properly effective, it needs to be expanded to also cover clinics or other organisations advertising assisted dying services more broadly. I very much welcome the opportunity to work with Ministers and the Bill’s sponsor to get this right, if the Committee is disposed to supporting such an amendment.

[Naz Shah]

Does the hon. Lady agree that banning advertising also mitigates the issue of advertising to young people? She mentioned young people and suicide from a social media perspective. Young people, or anybody else who has an eating disorder, may see that as an option to enable them to qualify for assisted dying. That is because, under the Bill as it stands, they would qualify for it if they were termed terminally ill due to their eating disorder.

[Rebecca Paul]

I completely agree. That is exactly what the amendment is intended to do. We are trying to prevent advertising of an inappropriate service to inappropriate groups. It makes sense, therefore, to effectively ban advertising. I think most people would agree that it would be distasteful and inappropriate to have adverts for assisted dying everywhere people look. I hope that hon. Members will consider supporting the amendment, even if that is in an amended form.

Terminally Ill Adults (End of Life) Bill

Naz Shah Excerpts

Report stage & 3rd reading
Friday 20th June 2025 Commons Chamber

[Naz Shah (Bradford West) (Lab)]

I start by thanking my hon. Friend the Member for Spen Valley (Kim Leadbeater), all the Members who served on the Committee and, indeed, the whole House for the approach that everyone has taken to this Bill.

I want to make it clear that I came to this Bill with an open mind. Like many, I supported it in principle at first glance, but this debate is no longer about the principle of assisted death—that is not the decision before us today; it is not the issue on which we will walk through the Lobby when we decide to vote for or against this Bill. Our responsibility in this place is to make sure that the Bill is safe, workable and effective. That is the test that will lead us to vote for or against the Bill today. As the Bill stands, it presents a public safety issue.

[Jim Shannon]

I spoke to the hon. Lady beforehand, and I understand her concerns. They are the same concerns I have, on behalf of those who have anorexia, those with mental health conditions, troubled people—those who would be vulnerable when this idea was presented to them. Does she think, like I do, that this Bill does not in any way address the issue of those who are vulnerable, when it comes to assisted dying?

[Naz Shah]

I thank the hon. Member for his intervention. I think he might have read some of my speech, which I will carry on with.

I will set out why the Bill is not safe, and speak about the two amendments that I tabled: amendment 14, which we have nodded through today, and amendment 38, which we will not get the chance to vote on. Amendment 14 dealt with the issue of voluntarily stopping eating and drinking, or VSED, which has been used as a “bridge” to assisted death in other jurisdictions. I am pleased that my hon. Friend the Member for Spen Valley accepted that amendment, but let me be very clear: this does not close the anorexia loophole—that was the subject of another amendment. Voluntarily stopping eating and drinking is not what happens to people with anorexia. People with anorexia stop eating and drinking because they have a psychiatric illness. Those are two categorically different issues. I must make it absolutely clear that even though amendment 14 has passed today, it does not address concerns about anorexia or close that loophole.

Members in the other place are already raising the concern that, because this is a private Member’s Bill, they do not believe that they can provide all the necessary safeguards if we give a Third Reading today to a Bill that is not safe to be delivered to the public. At least 60 women with anorexia in multiple countries have died by assisted death when they needed treatment, not help to die. Every one of them was assessed to have capacity by two doctors.

[Kim Leadbeater]

Will my hon. Friend give way?

[Naz Shah]

I will make some progress.

Hundreds of eating disorder experts, doctors, lawyers, charities, family members and people with lived experience urged Parliament to close this loophole and support amendment 38. As a Committee, we failed to heed their warning. We have now learned that the one remaining amendment that could protect people with eating disorders will not even be voted on.

Our responsibility is to make the Bill safe. We know what happens when politicians think they know better than the experts. Let us make it clear: the Royal College of Psychiatrists, the Royal College of Physicians, the Royal College of Pathologists, palliative care doctors, the British Geriatrics Society, almost every eating disorder charity and almost every disabled people’s group do not support this Bill. That is not because they do not believe in the principle; they are warning us about the dangers of this Bill, and of getting this wrong.

Our job is not to be activists—to fight until our last breath for the principle, whatever shape or form it is delivered in. Of course we believe in causes—that is why each and every one of us is in Parliament—but we legislators must listen to the experts, heed the evidence, scrutinise and debate the ideas that are before us, and deliver for our constituents laws that are safe, workable and effective. We have a proud history; the likes of Florence Nightingale—the lady with the lamp—broke every barrier possible to heal the wounded, provide care for the vulnerable and reduce the chance of death. Those are the principles that our great NHS was founded on. We must ask ourselves whether those fundamental principles will still be intact if the Bill passes. Will they be there to protect those who face a postcode lottery in healthcare and palliative care, the most vulnerable, and those who have faced the greatest hardships in life and feel like a burden? Will those principles be there to protect those who feel like giving up, but whom we could help back up and push towards a better life? Instead, we will be giving them a way to give up, even if they could have survived.

This is the question for all Members: what is the margin of error that we are willing to risk today when it comes to something as serious as death? I urge Members to vote against this Bill.

Terminally Ill Adults (End of Life) Bill

Naz Shah Excerpts

Report stage
Friday 13th June 2025 Commons Chamber

[Dr Sandher]

We do know. Ethnic minorities are less likely to access assisted dying in jurisdictions where it is in place. In Oregon, 10% of those accessing assisted dying are ethnic minorities, but they make up 40% of the population. In California, ethnic minorities make up 15% of people accessing the option, but 30% of the population. However, that is not the point. The point of the Bill is to give people the choice to end their life regardless of the colour of their skin. There is no special quality about the colour of my skin that affects my access or the need for a special representative in this case, which is covered by the ECHR and by the Secretary of State.

[Naz Shah (Bradford West) (Lab)]

I am quite perplexed by my hon. Friend’s speech, but I would like to understand whether he has data related to the demographics of those jurisdictions compared with the UK. If he does, could he present it to the House to support his argument?

[Dr Sandher]

I have spent a lot of time around data, but I am not sure that I understand the question.

--- Later in debate ---

[Rebecca Smith]

I thank my hon. Friend. The statistics I quoted earlier are pretty clear on the point he makes. Let me make some progress.

The work undertaken by the coroner is not a box-ticking exercise or a bureaucratic hurdle. In the context of assisted dying, it is an extremely powerful deterrent against abuse and malpractice. Again, to quote Judge Thomas Teague KC, in a letter to The Times on 7 May this year, he said that the removal of

“any realistic prospect of an effective inquest...would magnify, rather than diminish, the obvious risks of deception and undue influence”.

[Naz Shah]

I thank the hon. Member; she is making a very powerful speech. Does she share my concern about the removal of the coroner, as stated clearly by the Royal College of Pathologists, which speaks to her amendment?

[Rebecca Smith]

I thank the hon. Member and I will come to that point very soon. I will now make some progress; I will not take any further interventions.

I struggle to see how removing automatic oversight of assisted deaths squares with a commitment to enact legislation with the “strongest safeguards in the world”. By doing so, the Bill sets a lower bar for scrutiny and review, and creates an information deficit. Put another way, we simply do not know what we do not know. Implementing a novel piece of legislation such as this without ensuring the most robust possible scrutiny of deaths taking place under the Act is astonishing. Under the Bill, assisted deaths would be the outlier, as any other intentionally procured death would automatically be reviewed by a coroner. Why should deaths under this legislation be any different?

Requiring automatic scrutiny from a coroner for assisted deaths should not be viewed as an add-on at the end of the process or perhaps just a safety net, although it is that.

--- Later in debate ---

[Dr Allison Gardner (Stoke-on-Trent South) (Lab)]

I rise to support a number of new clauses and amendments to the Bill. The common thread running through all of them is a need to address some of the gaps in the safeguards and oversight. Should the Bill pass, I at least want to ensure that we improve its protections and remove some of the risks that it contains.

New clause 4 requires the chief medical officer to monitor the operation of the legislation, rather than depending solely on the assisted dying commissioner. Alongside the requirement for a High Court judge, oversight by the CMO was removed during the Committee stage. This means that, essentially, the assisted dying commissioner would mark their own homework. New clause 4 returns the safeguard of independent oversight, which is sensible given the significant concerns expressed by many experts and organisations, which were often neutral on the principle, but concerned about the Bill. They include the Royal College of Psychiatrists, the Association for Palliative Medicine, the British Geriatrics Society, the Royal College of Physicians and many experts such as Professor James Monckton Smith, a leading criminologist, Baroness Finlay, Parliament’s leading expert on palliative care, Sir David Haslam, former head of the British Medical Association and of the National Institute for Health and Care Excellence—my previous employer—and many more. All have expressed concerns, even when neutral on the principle of the adequacy of the Bill.

Hence new clause 4 requires an annual report to include

“information about the application of the Act in relation to—

persons who have protected characteristics, and

any other description of persons specified in regulations made by the Secretary of State.”

I fervently hope that that includes domestic violence victims.

Amendment 13 very sensibly adds the requirement that the commissioner appointment is not the sole remit of the Prime Minister at the time, by requiring the consent of the Health and Social Care Committee. This provides a safeguard against ideological and politically motivated appointments, and I would be very critical of anyone who would want to prevent that.

Amendment 15 addresses the significant concerns about the involvement of private—for profit—providers of assisted dying. There are concerns that, when there is a commercial relationship between providers, there will be a gaming of the system. That risks compromising the relationship between the co-ordinating doctor and the independent doctor. Likewise, the existence of such providers does not allay concerns about doctor shopping, as was raised in the previous debate. Hence amendment 15 will require private providers to be transparent and provide reports on service members, service numbers, costs and revenue.

In previous debates and in the public discourse I have found it very disconcerting that, in response to legitimate concerns, all that we have been offered—as we have seen today—are some promised, unspecified future regulations that will fix the gap—[Hon. Members: “Hear, hear!”]

[Naz Shah]

My hon. Friend is making a powerful point. Does she share my concern that most of our discussions today were thrashed out in Committee, and now we are being told that we have to leave them to the Lords, because we cannot fix the issues here? That is a really flawed process.

[Dr Gardner]

I entirely agree with my hon. Friend.

To expect MPs to improve the Bill without clarity as to what the regulations are or what they will be, and how the service will be delivered without rigorous regulatory oversight is fundamentally wrong.

Furthermore, the fact that the implementation of the Bill will be automatic in 2029—a general election year, incidentally—is not realistic when reflecting on the many areas that still lack detail. Hence I support amendment 42, proposed by my hon. Friend the Member for Newcastle-under-Lyme (Adam Jogee), which allows the Secretary of State to determine the appropriate date for the Bill to be implemented. This would allow time to make the NHS fit for purpose, to strengthen palliative care, and for Parliament to draft and scrutinise adequate regulations without being rushed.

Similarly, but fundamental to the society in which we live, amendment 12 protects the status of our most dear institution, the NHS. The Bill before us provides Henry VIII powers to amend the National Health Service Act 2006 without limit, which could include a specification of charges. If, as Labour MPs, we are committed to the NHS remaining free at the point of use, then amendment 12 is vital, as it will require any changes to the 2006 Act to be made by an Act of Parliament. The future is uncertain. We must build safeguards in the Bill to protect us from measures that fundamentally alter the fabric of our society.

Briefly, amendment 27 requires the MHRA to license the drugs used for assisted dying. Research has shown that painful and protracted deaths via assisted dying drugs are not uncommon, with deaths ranging from three minutes to 137 hours—nearly a week— with up to eight hours to lose consciousness. Furthermore, serious side effects disproportionately affect younger people. Amendment 27 will help to ensure the safety and efficacy of these substances.

I will close by quoting Sir David Haslam on how we balance some of the individual stories used on both sides of the debate with the good of society. As we know, NICE has to make the difficult decision to approve or not approve medications and treatments based on a cost and clinical effectiveness model. It is experienced in weighing up societal good—[Interruption.] I will be quick, Madam Deputy Speaker—versus the needs and wishes of individuals.

--- Later in debate ---

[Dr Huq]

No, because I will not get any more time.

Given the cost of care, people could convince themselves that elderly relatives would be better off out of the way, in order to get the younger generation on the ladder.

We know from the experience of other places that once assisted dying is allowed, the scope broadens—depressed 12-year-olds in Holland can get it—and the incentive to fix palliative care will lessen. Why now, with the state of the NHS? What of Suicide Prevention Week? Yes, we know that public opinion is in favour of assisted dying, but public opinion also supports bringing back hanging.

[Naz Shah]

On that point, will my hon. Friend give way?

[Dr Huq]

No, I am not giving way.

At my advice surgery, people have pointed out the unfairness of the £10,000 cost of Dignitas. We know that the status quo is imperfect, but let us not remedy it with something that will make things worse. We need to get this 100% right if we are going to do it all.

Although well intentioned, the Bill has too much room for error, manipulation, misapplication and unintended consequences. Six months to live is impossible to predict and, with life and death, it is too late to change your mind after the latter has happened, is it not? This week, 1,000 doctors have argued that it will widen inequalities and it is simply not safe. These amendments strengthen the Bill by taking ethnic minorities into account, when hitherto they have been completely unacknowledged by it. They must be incorporated into any assisted dying legislation, but the best thing of all would be not to rush down this road with indecent haste in the first place, because it is so littered with obstacles.