Terminally Ill Adults (End of Life) Bill (Twenty-ninth sitting)

Debate between Stephen Kinnock and Lewis Atkinson

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[Lewis Atkinson]

That is exactly right. For those reasons, I think we need to retain the full five-year review period. As my hon. Friend the Member for Rother Valley outlined, the review of the Act by the Secretary of State will be in addition to the annual reporting from the commissioner and, if we accept new clause 35, in addition to annual reports from the disability advisory board. Clearly, over the course of multiple amendments, we will have strengthened the reporting requirements both in advance of and post implementation.

[Stephen Kinnock]

It is a pleasure to serve under your chairship, Sir Roger. Amendments 452 and 453 would amend the review provisions in clause 35. As the Bill stands, clause 35(1) provides that the Secretary of State must undertake a review of the operation of the Bill and lay a report before Parliament. This is a one-off obligation that must take place after a period of five years, beginning from the date the Bill is passed. Amendment 452 would amend that requirement, and instead require the Secretary of State to undertake a review, and prepare and publish a report every 12 months after the passing of the Bill. Amendment 453 would remove the definition of the initial five-year period and is consequential on amendment 452.

That increased frequency of reporting would naturally increase the administrative burden and cost of the Bill. It is also noted that there will be an implementation period following Royal Assent. It is unclear if the intention is to require the Secretary of State to undertake a review of the operation of the Bill and prepare a report during this implementation period.

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[Lewis Atkinson]

I rise to speak in support of new clause 40. Given the implementation period that we are talking about, the repeated and routine reporting to Parliament on progress is essential, especially for those who want to see this Bill implemented safely and properly. Nevertheless, there are people—some of whom have joined us in the Public Gallery in recent weeks—for whom that needs to be done with deliberate speed, but without any compromise on the safety and thoroughness of implementation. New clause 40 achieves that, and I commend it.

In a different world there would have been a way of us compositing new clause 28 with new clause 40, and I regret that the two are not compatible. My hon. Friend the Member for Bexleyheath and Crayford makes good points around the earlier assessment of palliative care; I do not think that is something that divides the Committee. There have been amendments tabled by many Members over the course of the Committee that have sought to improve and strengthen palliative care as part of a holistic package at the end of life. I wonder if that is something that I could work on with my hon. Friend on Report, even if it is not possible to agree to new clause 28 tonight.

[Stephen Kinnock]

The Government have worked with my hon. Friend the Member for Spen Valley on amendment 546 and new clause 40, which are consequential and linked to other amendments to clause 42, relating to the commencement of the legislation.

New clause 40 would require the Secretary of State to prepare, publish and lay before Parliament a report about progress made towards implementing the Bill, and the Secretary of State’s plans for implementation in subsequent reporting periods. The reporting periods are one year after Royal Assent, and every six months thereafter, until the sixth and final reporting period. Amendment 546 provides that new clause 40 will come into force on the day the Bill is passed.

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[Lewis Atkinson]

I understand somewhat where the hon. Member for East Wiltshire is coming from, but as a fundamental matter, people have to be paid for time worked. I feel that an interpretation of his amendment is that people would not be able to be paid for time worked. This is not about performance-related pay, as he suggests in that continuation of his—I suggest—scaremongering theme from before, but about remuneration for time worked. For example, if someone is referred for an additional capacity assessment, it is right that the person doing the assessment is paid for their time worked, not as an incentive, but as a normal payment for time worked. I think that the amendment is poorly drafted and not workable. I will therefore vote no.

[Stephen Kinnock]

The amendment is linked to clauses 5 and 8, which define who can and cannot be a co-ordinating or independent doctor. According to the clauses, a person who benefits financially from the death of the person cannot be a co-ordinating or independent doctor. As the Bill stands, clause 40(4) provides that a registered medical practitioner is not to be regarded as benefiting financially, or in any other material way, from the death of a person by reason only of the practitioner receiving reasonable remuneration for the provision of services in accordance with the Bill.

The amendment may broaden what is meant by “benefiting financially”, so that its effect may be to prohibit a person from being a co-ordinating or independent doctor if their remuneration is greater for applications that are accepted than for ones that are rejected. However, as drafted, it is not possible to determine the effect of the amendment with certainty, so further amending is likely to be required at a later stage should the Committee accept the amendment.

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[Lewis Atkinson]

I have great sympathy with the intent behind the amendment, and I would like us to get it into a workable form. The hon. Member for Reigate may wish to confirm this, but there is a similar offence in the Surrogacy Arrangements Act 1985—the advertising of surrogacy arrangements is an offence. The important difference in the Surrogacy Act is that there are some further caveats beyond those in the draft amendment— for example, to ensure that there is not inadvertent creation of offences of the type that the hon. Member for Solihull West and Shirley mentioned. The Surrogacy Act sets out that resulting prosecutions would be carried out only with the approval of the Director of Public Prosecutions, to ensure that such safeguards were in place. Although I await the Minister’s comments, I do not think it is possible to support new clause 9 in its current form, for the reasons that the hon. Gentleman lays out.

We have set out that there will potentially be a small number of doctors providing these services. A GP—not a member of the public—would need to know where to direct their patient. I cannot see how, other than by having some form of electronic directory or email correspondence, it would be possible for such people to become available.

I am not able to vote for the new clause at this stage, but I will put it on my notepad of things on which I am keen to work with colleagues on Report, perhaps by learning the lessons from the surrogacy advice and taking advice from Minister. I think we all agree that we should not be advertising to the general public and encouraging these services.

[Stephen Kinnock]

Thank you, Sir Roger, for giving me permission to remove my jacket. It is greatly appreciated. I assume that other hon. Gentlemen in the room are also able to do the same, should they wish to do so.

New clause 9 would make it a criminal offence for a person to advertise their services as a co-ordinating doctor or an independent doctor under the Bill. The offence would apply to a person who, in the course of a business, publishes or causes publication of an advertisement for the services of acting as a co-ordinating doctor or an independent doctor under the Bill, or who prints, devises or distributes an advertisement or causes that for the promotion of such services. The offence is wide-ranging and could include, for example, a person who unknowingly transmitted such advertising via electronic communications or social media.

Should the new clause be passed, further work may be needed to determine how the offence would be enforced. I also note that there is no provision for any defence in relation to the offences—for example, where a person responds to inquiries.

Restrictions on advertising always need careful consideration and drafting, given the potential unintended consequences and European convention on human rights impacts—particularly in relation to article 10, on freedom of speech. That is particularly so when breaches of the restrictions are made a criminal offence, as is the case here. However, article 10 is a qualified right, which means that interference can be justified provided that it is in accordance with the law, pursuant of a legitimate aim and necessary in a democratic society, so although the new clause could engage article 10, it may not violate it.

Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting)

Debate between Stephen Kinnock and Lewis Atkinson

Tuesday 18th March 2025 Public Bill Committees

[Lewis Atkinson]

The right hon. Gentleman is absolutely right. Another point we have not yet mentioned is that the Care Quality Commission regulates healthcare on the basis of location of delivery. Hospice services cannot just be provided from a random place: the place has to be registered with the CQC as suitable for the provision. I am sure that regime would continue in this instance.

[Stephen Kinnock]

Amendment 435 would require the co-ordinating doctor to escalate the care of an individual to the appropriate emergency medical services if the assisted dying procedure has failed. Requiring the co-ordinating doctor to make a referral may engage article 8 of the European convention on human rights—the right to family and private life—if the person has indicated that they do not wish to be referred to emergency services or do not wish to be resuscitated. In a situation where the procedure has failed, doctors would, as in their normal duties, support a person in line with their professional obligations and their understanding of the person’s wishes. This could include the involvement of the emergency services, but it would be unusual to specify a particular approach in legislation.

As currently drafted, clause 18(9) provides that:

“The coordinating doctor must remain with the person”

once the approved substance has been provided, until either

“the person has self-administered the approved substance and…the person has died, or…it is determined by the coordinating doctor that the procedure has failed”,

or, alternatively, until

“the person has decided not to self-administer the approved substance.”

Amendment 429 would remove the clarification currently provided for in clause 18(10) that the co-ordinating doctor does not have to be

“in the same room as the person”

once the approved substance has been provided. However, clause 18(9) requires the doctor only to

“remain with the person”.

It may still be possible that the co-ordinating doctor could remain with the person but in a different room if they decide that is more appropriate.

Amendment 436 would increase reporting obligations on the co-ordinating doctor in cases where complications have occurred. It is not clear in the amendment what would be considered a complication and therefore trigger the reporting requirement. It is also not clear what details should be set out in the person’s medical records or in the report to the chief medical officer and voluntary assisted dying commissioner.

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

Debate between Stephen Kinnock and Lewis Atkinson

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[Lewis Atkinson]

Yes, I do. I recognise the importance of independent assessment for prognosis and capacity. However, particularly with the issue of coercion, healthcare is a team sport, as anyone who has worked in healthcare knows. The more information and the more viewpoints we can get in those instances, the better. One of the strengths of the Bill is the team sense around it, which we will further in the amendments to clause 12 that we will come on to in due course.

I will finish briefly on amendment 460. I do not see the loophole that has been described. I think we would all want someone to be able to cancel their first declaration, and they are more likely to do so if they feel they have the option of going back and making a future first declaration. My worry with amendment 460 is that, by removing the word “particular”, it suggests that people are only able to make one first declaration in the course of their life. With the periods of reflection built into the Bill, which Members spoke about earlier, if someone changes their mind, they should cancel their first declaration. They are absolutely free to do so and the Bill, as currently drafted, makes good provision for that. To me, amendment 460 would remove the ability for that person to come back to that decision at a later point and go through the assessment process again. While I understand the motivations behind amendment 460, I am cautious about it for those reasons.

[Stephen Kinnock]

Amendment 348 seeks to add an additional requirement to clause 8(5). This would mean that, where the independent doctor is satisfied that the requirements under clause 8(2) have been met, they must

“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.”

Some elements of amendment 348 duplicate requirements that already appear in the Bill, such as the requirement in clause 8(5)(b) for the doctor to inform the co-ordinating doctor of the outcome, including providing a copy of the statement.

The amendment would also overlap with the requirements in clause 16 for the co-ordinating doctor to make entries in the person’s medical record that must include the original statement or declaration. Where the co-ordinating doctor is not with the person’s GP practice, they must also give notice to a registered medical practitioner with the person’s GP practice of the outcome of the assessments.

Amendment 303 seeks to prevent a person from seeking multiple second assessments from different independent doctors. It places a requirement on the independent doctor to confirm

“that no other practitioner has undertaken a second assessment for the same person.”

This amendment creates the risk of a medical practitioner inadvertently committing an offence if there is no centralised record-keeping. It may also have the impact of preventing the person seeking assistance from obtaining a second opinion, as provided for in clause 10. Under the amendment, as drafted, it is unclear how this is intended to interact with the possibility of an independent doctor’s becoming unable or unwilling to continue to act as the independent doctor following the second assessment, when an alternative independent doctor may therefore be required.

On amendment 458, as the Bill stands, clause 10 provides that if, following the second assessment, the independent doctor refuses to make the statement confirming that they are satisfied that matters in clause 8(2)(a) to (e) are met, the co-ordinating doctor may refer the person to a different registered medical practitioner who meets the requirements of clause 8(6), and is able and willing to carry out an assessment mentioning clause 8(2). The effect of the amendment is to restrict the circumstances in which the co-ordinating doctor can make a referral under clause 10(1) to a different registered medical practitioner to only when there has been a material change of circumstances. It is not clear from the amendment who is required to establish that there has been a material change in circumstances and/or how that will be proved. That may cause some uncertainty for the co-ordinating doctor.

I now turn to amendment 459. Clause 10 provides that if, following the second assessment, the independent doctor refuses to make the statement that they are satisfied that the person meets the criteria in clause 8(2)(a) to 8(2)(e) when conducting the second assessment, the co-ordinating doctor may, if requested to do so by the person who made the first declaration, refer that person to a different registered medical practitioner who meets the requirements of clause 8(6) and is able and willing to carry out an assessment of the kind mentioned in clause 8(2).

The effect of the amendment is that, where such a referral is made to the registered medical practitioner under clause 10(1), the co-ordinating doctor is required to provide them with the report by the independent doctor setting out their reasons for refusal. If the new registered medical practitioner reaches a different conclusion from the original independent doctor, they must produce a report setting out why they disagree. The two reports must be made available to any subsequent decision maker under the Bill, and to the commissioner. This additional requirement for reports on the reasons for refusal or differences in opinion may make the process of seeking assistance longer and add to capacity demands on co-ordinating and independent doctors.

Turning to amendment 460, clause 10(3) provides that if, following the second assessment, the independent doctor refuses to make the statement mentioned in clause 8(5), the co-ordinating doctor may make one referral for a second opinion. The effect of the amendment is to remove the word “particular” from clause 10(3), which says that only one second opinion may be sought

“In consequence of a particular first declaration made by a person.”

The amendment is unclear and could have several possible effects in practice. For example, it could have the effect of limiting the circumstances in which a referral can be made under clause 10(1) to the first time a person makes a first declaration.

I hope that these observations were helpful to the Committee.

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

Debate between Stephen Kinnock and Lewis Atkinson

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Stephen Kinnock]

rose—

[Lewis Atkinson (Sunderland Central) (Lab)]

rose—

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

Debate between Stephen Kinnock and Lewis Atkinson

Wednesday 5th March 2025 Public Bill Committees

[Stephen Kinnock]

rose—

[Lewis Atkinson (Sunderland Central) (Lab)]

rose—

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

Debate between Stephen Kinnock and Lewis Atkinson

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[Lewis Atkinson]

I accept that that is a risk factor, but it is by no means determinative. Therefore, that risk factor has to be considered in the round with other risk factors such as levels of family and social support. As set out, the amendment does not distinguish between someone receiving a terminal diagnosis by themselves without any support network, and someone who expects to receive a terminal diagnosis at the end of a very long illness. As a point of principle I do not accept that we should mandate psychosocial interventions or that people must receive a level of healthcare in order for them to access other options related to their care—let alone the practicalities, which I have laid out, about when the provision would apply in relation to diagnosis and the fact that it is an intervention, which is in no way an assessment or any such thing.

[Stephen Kinnock]

I have made it clear throughout the debate that I am not offering a Government view on the merits of amendments. My remarks are focused much more on the legal and practical impacts of amendments, to assist Members in undertaking line-by-line scrutiny.

The amendments were tabled by the right hon. Member for South West Wiltshire. They would create a further eligibility requirement of the person seeking assistance under the Bill. Amendment 271 and 272 would limit those eligible to seek assistance to end their own life, in circumstances where their terminal diagnosis was received less than six months prior to the date on which the person signs the first declaration, to those who have received a psychosocial intervention. This would be subject to any exceptions provided for by the Secretary of State in regulations. Amendment 271 does not define what is meant by “received a psychosocial intervention” in relation to their diagnosis.

The term “intervention” is usually employed in the health service to mean the provision of support or treatment. This is different from, for example, an assessment that a clinician might undertake to assess whether an intervention may be required. While there is not a standard definition of psychosocial intervention, we understand it to mean psychosocial interventions such as cognitive behavioural therapy. The amendment could create uncertainty as to what type of treatment a person will need to undergo to satisfy the requirement. If a person who would otherwise seek assistance to end their own life under the Bill is unable to, or does not wish to, receive a psychosocial intervention, unless an exemption applies, they may need to delay starting the assisted dying process until at least six months has elapsed from their terminal diagnosis. That could be challenging in circumstances where the terminal diagnosis has a prognosis of six months or less.

The amendment would also introduce a requirement for people in certain contexts to undergo an intervention that could undermine a person’s autonomy in making their own treatment decisions. Were the amendment made, it would confer a regulation-making power on the Secretary of State to create exceptions to the proposed provisions on psychosocial intervention. Regulations made using this power would be subject to the affirmative procedure. It would also give the Secretary of State the power to issue a code of practice in connection with the form of the psychosocial intervention required.

If the Committee decides to accept the amendment, further consideration would be needed on Report to ensure that it is operationally deliverable, and my earlier comments about the definition of psychosocial intervention and other comments would have to be clarified. The Government would, of course, stand ready to assist were the amendment to pass.

As I said earlier, the Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could be changed—as I have made clear, that is a matter for this Committee and for Parliament as a whole. However, I hope that these observations have been helpful, and thank the Committee for its attention.

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

Debate between Stephen Kinnock and Lewis Atkinson

Committee stage
Wednesday 26th February 2025 Public Bill Committees

[Lewis Atkinson]

The right hon. Gentleman makes a good point. For the reasons that I have outlined, I will not support amendment 50. However, I would hate for any of us who do so to be characterised as disagreeing with the provision of relevant and available information about care and treatment. I certainly believe, as do some colleagues, that that is best done through existing regulatory routes, and primarily through the GMC. That is why I am unable to support amendment 50.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mrs Harris. As usual, my remarks will focus on the legal and practical impact of amendments, to assist Members in their consideration.

This set of amendments seeks to change the way in which capacity is determined. As drafted, the Bill requires that a terminally ill person must have capacity to make a decision to end their own life before they meet the conditions for accessing assisted dying. Capacity in the Bill is determined in accordance with the Mental Capacity Act 2005, which presumes capacity unless it is established to the contrary. Amendment 322 would reverse the presumption of capacity and, in effect, establish a presumption of incapacity.

It may be helpful to the Committee if I set out the Government’s understanding of both the Mental Capacity Act and the implications for the Bill. Section 1 of the Act sets out several guiding principles, including that a person must be assumed to have capacity unless it is established that they lack capacity. Section 3 sets out a description of the factors that demonstrate that a person is unable to make a decision for themselves: that the person is unable to understand the information relevant to the decision; unable to retain that information; unable to use or weigh that information as part of the process of making the decision; or unable to communicate their decision. This inability must be because of an impairment or disturbance of the functioning of their mind or brain.

Turning to the Bill, at each stage of the process an assessment of capacity would be required. This assessment of capacity, in accordance with the Mental Capacity Act, is separate to the considerations of whether a person holds a clear, settled and informed wish to end their own life, which is also required by the Bill.

Amendment 322 would disapply section 1(3) of the Mental Capacity Act, which is the principle that a person would not be treated as lacking capacity unless all practicable steps had been taken to help them to make a decision. This could create challenges for practitioners who have experience using the Mental Capacity Act, as they would need to apply a new approach.

Amendment 49 seeks to apply a consistent approach to the burden of proof when assessing a terminally ill person’s capacity for assisted dying. The Mental Capacity Act has two evidential tests. In court proceedings to determine capacity, the balance of probabilities test applies. When care or treatment is given to someone on the basis that they lack capacity, there is protection from liability if there is a reasonable belief that the person lacks capacity and the intervention is in the person’s best interest. The amendment would diverge from this evidential approach. It would also have implications for the workforce. Requiring doctors who have experience in applying the reasonable belief test to instead apply a balance of probabilities test for assessing capacity would likely make the current established approach more complex and potentially less safe.

Amendment 50 seeks to specify certain matters that the person must be assessed as being able to understand in order for a determination to be made that they have capacity. Under the Mental Capacity Act, when a capacity assessment is carried out, the assessor must determine the salient information that the person needs to understand, retain and use or weigh based on the circumstances of the case. The amendment would diverge from this approach, both by specifying in statute the information to be understood and by including the requirement only to understand the information, not to retain, use or weigh it. The Committee may wish to consider whether that would in some respects weaken the test.

Amendment 50 might create two legally distinct frameworks for decision making that doctors would be expected to use. Again, this may introduce additional complexity for those undertaking these assessments.

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

Debate between Stephen Kinnock and Lewis Atkinson

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[Lewis Atkinson]

I do, and I thank my hon. Friend for bringing my attention to that; I was struggling to put my hands on it.

In my view, clause 2 does a difficult job very well in tightly drawing eligibility criteria so that the Bill does what it says on the face of it—that it allows access for terminally ill adults, at the end of their life. By having a six-month prognosis, rather than anything else, it allows individuals to put their lives in order and have the best last months of their lives possible. I therefore speak against the amendments and in favour of the clause as drafted.

[Stephen Kinnock]

As usual, I will make brief remarks on the legal and practical impact of amendments, while emphasising that the Government continue to remain neutral on the Bill and on assisted dying more broadly. This series of amendments, which I will take in turn, seeks to change the definition of “terminally ill”, either widening or narrowing the cohort of people able to access assisted dying services.

Amendment 123 would change what it is to be “terminally ill” for the purposes of the Bill from having an “inevitably” to a “typically” progressive illness, disease or medical condition that cannot be reversed by treatment. That would widen the pool of those able to access assisted dying services by reducing the level of certainty that a doctor must have that the illness, disease or medical condition in question is progressive—from one that is “inevitably” progressive to one that is “typically” progressive.

Amendment 9 seeks to amend the definition of “terminally ill” such that it would not include a person who has an inevitably progressive illness, disease or medical condition that can be reversed, controlled or substantially slowed by treatment. The effect of the amendment is that such a person would not be eligible for lawful assistance to voluntarily end their own life. Should the amendment be accepted, the effect would be to restrict the eligibility for assisted dying services to a narrower category of patients than is currently set out in the Bill. The amendment may make assessment of a person’s prognosis and eligibility under the Bill more extensive, as it would be likely to require an assessment of a broader range of treatment options.

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[Lewis Atkinson]

I rise to speak briefly in opposition to the amendments. When the chief medical officer gave oral evidence to the Committee, the hon. Member for Richmond Park asked him:

“Is it possible to come up with a list of illnesses that are terminal that would qualify under the legislation?”

The response was very clear:

“If I am honest, I think it would be extremely difficult.”

It is difficult in both directions, because some illnesses or diseases can be terminal, but are not necessarily terminal. People can live with prostate cancer for many years. Setting out in the Bill a list of specific diseases or illnesses that would be eligible risks achieving exactly the opposite of the amendment’s intention. To quote Professor Whitty again:

“Equally, there are people who may not have a single disease that is going to lead to the path to death, but they have multiple diseases interacting…I therefore think it is quite difficult to specify that certain diseases are going to cause death and others are not, because in both directions that could be misleading.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 32, Q5.]

Further to the point that the hon. Member for East Wiltshire made about on judicial oversight, my understanding is that giving power to the Secretary of State to make a list that includes only some diseases is absolutely inviting action through the courts on the reasonableness of why one disease is on the list while others are not. We would end up in much more of a legal quagmire than we otherwise would. The safeguards that we have talked about, as to eligibility criteria, terminality and capacity, are in the Bill as drafted. Those are the safeguards that we need. A list would further muddy the water and would create confusion.

[Stephen Kinnock]

I have some brief comments to make. Amendments 12 and 13 seek to further define a terminal illness for the purpose of the Bill; I will set out some details about their effect. The amendments would add a requirement that a list of a terminal illnesses for which people are eligible to seek assistance under the Bill be specified in regulations made by the Secretary of State. The effect would be that only a person who has an illness, disease or medical condition listed in regulations, and who meets the other eligibility criteria, would be eligible to be provided with lawful assistance to voluntarily end their own life.

I draw the Committee’s attention to the chief medical officer’s oral evidence given on 28 January, which was well articulated by my hon. Friend the Member for Sunderland Central. The CMO said that multiple diseases may interact, making it

“quite difficult to specify that certain diseases are going to cause death and others are not”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 32, Q5.]

It is also the case that many illnesses, diseases or conditions that may be terminal in one case may not be so in another. Committee members may therefore wish to consider where a focus on specific illnesses or diseases, rather than on the facts of an individual case, could aid clinicians in their decision making.

The amendments also include a discretionary power for the Secretary of State to make regulations that expire after 12 months in order to make temporary additions to the list of illnesses that meet the definition of terminal. It is not clear what types of illnesses, diseases or medical conditions are intended to be captured in such regulations. I hope that those observations on the purpose and effect of amendments 12 and 13 are helpful to the Committee in its considerations.