Terminally Ill Adults (End of Life) Bill

Public Bill Committee, 28 January 2025.

Examination of Witnesses

Esther McVey (Conservative, Tatton)

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.

Naseem Shah (Labour, Bradford West)

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

“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?

Naseem Shah (Labour, Bradford West)

So would it be safe?

Naseem Shah (Labour, Bradford West)

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?

Lewis Atkinson (Labour, Sunderland Central)

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 coercionQ ?

Lewis Atkinson (Labour, Sunderland Central)

Q I have one follow-up on that. At the moment, we are aware that there are instances across the NHS every day where people make decisions around refusing the treatment that would be required to prolong their life. Doctors, nurses and the healthcare team would be involved in assessing capacity and coercion around those cases. Can you tell me a bit about any learnings from that, about the levels of skill required in the current practice around refusing lifesaving treatment, and about how that might be taken into account in the Bill?

Sarah Olney (Liberal Democrat, Richmond Park)

Professor Whitty, the definition of “terminal illness” is attracting some attention. Some people say it is difficult to define a terminal illness. Would it improve the Bill if we had a specified list of illnesses that would apply? Is it possible to come up with a list of illnesses that are terminal that would qualify under the legislation?Q

Sarah Olney (Liberal Democrat, Richmond Park)

Q Can you talk a little bit more about whether you perceive any difficulties in having a definition of terminal illness in the Act? How do you think the medical profession will interpret that?

Kim Leadbeater (Labour, Spen Valley)

Thank you for coming to give evidence this morning, gentlemen. I would like to pick up on coercion and capacity, because they are two really important points in the Bill. I would like to know a little more about the work that doctors and nurses do to check for coercion and assess capacity when patients are making really important decisions and choices at the end of life, but maybe in other contexts as well. The Bill refers to the Mental Capacity Act. That Act is a big piece of legislation, but I am conscious that there is only a short reference to it in the Bill. Is there anything we could add to the Bill that would improve the robustness of the reference to mental capacity? What does it look like now, and is there anything we could add?Q

Kim Leadbeater (Labour, Spen Valley)

Q To that point, in those conversations where patients are making very serious decisions, it is not uncommon that you would seek additional advice from other professions, such as a psychiatrist or possibly a social worker and other professionals, if you felt there was a need to do so.

Rebecca Paul (Conservative, Reigate)

The Bill sets out that it should be brought into force within two years. If the intention is to provide assisted dying through the NHS, can the NHS be ready in time to deliver the service equitably and safely? What needs to be deprioritised in order for it do to so?Q

Rebecca Paul (Conservative, Reigate)

Q What is a reasonable timeframe, in your view? I appreciate that that is a bit like asking, “How long is a piece of string?” What would you ideally like to see?

Rebecca Paul (Conservative, Reigate)

Q Would it be fair to say that you would need to know fairly quickly whether or not it would be provided through the NHS for planning purposes?

Liz Saville-Roberts (Plaid Cymru, Dwyfor Meirionnydd)

I have a question for Chris Whitty. You said you are here representing the chief medical officer for Wales as well. Health has been devolved for over 25 years, of course. What conversations have you had with the chief medical officer for Wales about the differences in how the NHS operates between Wales and England? What are the implications the Bill Committee should know about?Q

Liz Saville-Roberts (Plaid Cymru, Dwyfor Meirionnydd)

Q May I develop that a tiny bit? In that case, you would see the timeline possibly being different for England or Wales in order to respect and take account of those operational differences?

Daniel Francis (Labour, Bexleyheath and Crayford)

I hear what you have said already regarding capacity. Of course, the Mental Capacity Act relies on the capacity principles. They include the presumption of capacity, the principle that a person cannot be seen as lacking capacity unless all practicable steps have been taken to support them to make a decision, and the principle that a person cannot be seen as lacking capacity merely because the decision is unwise.Q

I also heard what you said about the scaling of decision making, but within the Bill, in some of those scenarios there is no mandating; the word “may” is used rather than “must”. I want to understand your viewpoint on whether it would provide stronger safeguards if those parts of the Bill were tightened to include “must” rather than “may”, and if the reference to capacity were replaced with a separate definition of “ability”, as proposed in our amendments.

Simon Opher (Labour, Stroud)

You have already said some words about prognosis, which is causing some anxiety. First, are you happy with a six-month prognostic period? Secondly, the Bill says that death shouldQ

“reasonably be expected within 6 months.”

Is that in line with your thoughts on the matter?

Simon Opher (Labour, Stroud)

Q I am interested in the opt-out whereby ethically, doctors can opt out of taking the decision for patients. Would they then need to steer someone towards another doctor, or can they just simply refuse to do it?

Sojan Joseph (Labour, Ashford)

SirQ Chris Whitty, you said that not all mental capacity assessments are safe. Do you think that hopelessness and low mood can affect someone’s capacity and that a sudden diagnosis of terminal illness can lead to some of those states—depression, low mood and hopelessness? Do you think that all doctors are capable of identifying those states?

Sojan Joseph (Labour, Ashford)

Q My next question is for Duncan. Nurses who work in stressful environments, such as people working in mental health wards, are expected to get clinical supervision. Do you think that the nurses who are going to work in these areas—if this Bill passes—would require that specialist clinical supervision? And do you think the NHS will have the capacity to provide clinical supervision for the nurses working in those areas?

Jake Richards (Labour, Rother Valley)

You have touched on this, but perhaps we could have some further clarity. Certain amendments have been suggested that are essentially more prescriptive about what factors need to be taken into account and what steps clinicians would have to take when considering capacity in this context, as well as to inform consent and inform about the options available. Of course this is a matter for Parliament, but would you err on the side of trusting clinicians’ professional judgment within the legal framework, as it is—in terms of the Mental Capacity Act and the guidance on informed consent—or would you deem it suitable for further prescriptive steps to be put into primary legislation in this contextQ ?

Jake Richards (Labour, Rother Valley)

Q In terms of setting standards and ensuring universality of understanding those safeguards, is that better done, in your view, by training and guidance rather than primary legislation setting up factors?

Esther McVey (Conservative, Tatton)

I am very mindful of the time, as it is now three minutes past 10. This will be the last question of the session.

Jack Abbott (Labour/Co-operative, Ipswich)

Thank you, Professor WhittyQ and Duncan, for being with us this morning. Professor Whitty, in October you and a number of chief medical officers published an advice note to doctors about a range of guidance on this issue. In it, you said that a couple of things are “unanimous” for medical professionals. I am focusing on the line where it says that

“we must not undermine the provision of good end-of-life care for all including the outstanding work done by palliative care clinicians”.

Do we take it, by implication, that you are fearful that this Bill could undermine good end-of-life care? In your view, how might we mitigate some of those risks in the Bill?

Esther McVey (Conservative, Tatton)

Order. That brings us to the end of our allocated time with these witnesses.

Esther McVey (Conservative, Tatton)

Q I will let you say a few words if you wish to, Duncan, but that was the end of this panel.

Esther McVey (Conservative, Tatton)

I thank our witnesses, Professor Chris Whitty and Duncan Burton, on behalf the Committee. I also thank Committee members for their short questions.

Esther McVey (Conservative, Tatton)

Q We will now hear oral evidence from Mark Swindells, who is assistant director for standards and guidance at the General Medical Council, and Dr Andrew Green, who is chair of the medical ethics committee at the British Medical Association. We have until 10.45 am for this session. Could witnesses please introduce themselves and give a brief statement?

Esther McVey (Conservative, Tatton)

Thank you very much. For broadcast purposes, can everyone make sure that they are as loud and clear as possible?

Neil Shastri-Hurst (Conservative, Solihull West and Shirley)

Good morning, gentlemen. The initial discussion is dealt with in clause 4 of the Bill. There has been some significant concern about whether doctors should be initiating that conversation with patients who are terminally ill. The Bill states, in subsection (1):Q

“No registered medical practitioner is under any duty to raise the subject of provision”.

What are your views on the compatibility of that element of the Bill with the principles under Montgomery consent?

Neil Shastri-Hurst (Conservative, Solihull West and Shirley)

Q Has the GMC undertaken a legal assessment of the openness to legal challenge around that Montgomery point—if those conversations were not initiated and patients say that they were not given all the options available to them?

Jack Abbott (Labour/Co-operative, Ipswich)

Q This might sound like playing devil’s advocate, and I fully appreciate that you do not want to reduce this to a tick-box exercise, as you described it. Some might argue that the risk of what you describe is that it creates a lottery, because you would be relying on doctors to use their personal judgment as to when to have that conversation. For example, if a patient and doctor do not have a particularly close or long-standing relationship, the doctor may not know what the signs are, so the patient, who may need to have that conversation, may never have it. The risk is that you would be reliant on good relationships forming over time and doctors using their intuition, so that some patients will have the conversations they need but others will not.

Sean Woodcock (Labour, Banbury)

The issue of coercion came up with our previous witnesses, and they were talking about GPs, doctors and nurses being able to spot it because of their level of training, experience and so on. How frequently does coercion, or lesser versions of it, such as familial pressure and societal pressure, come up in the day-to-day life of a medical practitioner? Is it like the asbestos awareness training that I had in a previous job—something I had to have because I might very rarely bump into asbestos—or is it a tick-box exercise?Q

Kit Malthouse (Conservative, North West Hampshire)

I have been searching for parallels in current practice, and one that seemed close to me was if I wanted to donate an organ—say, a kidney—to a relative. As I understand it, a doctor can raise that possibility, even if I have not thought of it at the front end of that family decision, and coercion and capacity are then assessed later via a trained individual. Do you think it would be possible to translate both of those into this situation?Q

As I understand it, the General Medical Council already has guidance on dealing with assisted dying if it is raised by a patient, and how doctors should handle that. How easy would it be to translate that guidance—the process struck me as something that does not hinder but also does not enable—into something more informative?

Kit Malthouse (Conservative, North West Hampshire)

Q You are clear, though, that doctors should be free to have an open discussion with their patients about the whole variety of possibilities or paths that may be available to them as they face a terminal disease?

Kit Malthouse (Conservative, North West Hampshire)

Q In the run-up to Second Reading, we heard from some of the overseas experience that where there was effectively a gag clause on doctors, it was proving to be extremely difficult, and the medical profession felt that that was a big barrier to discharging its duties. Would you recognise that?

Danny Kruger (Conservative, East Wiltshire)

It is noteworthy that in Australia and New Zealand, palliative care professionals are very keen on retaining that safeguard, to ensure that it is not suggested to patients that they might have an assisted death unless they have brought it up themselves.Q

I would like a quick clarification from Dr Green. In terms of the survey, my understanding is that the British Medical Association’s official position is to be neutral. The majority in favour of neutrality—moving away from an opposed position—were junior doctors and those not working with the elderly and the dying, whereas the great majority of doctors who work in palliative care and work with dying people remain firmly opposed to a change in the law. Is that your understanding?

Danny Kruger (Conservative, East Wiltshire)

Q I understand—thank you.

I have a question for you, Dr Green, on the delivery of the service if it is brought into law. Is it your understanding that the Bill mandates the NHS to provide an assisted dying service? I appreciate that it is not clear in the Bill. Nevertheless, it does authorise the Government to pay for it and it establishes this right. My question to you is this: is this a medical procedure that we are proposing to legalise, and should the NHS provide it? If the answer is yes, should that be a separate service within the NHS or should it just be part of general practice?

Danny Kruger (Conservative, East Wiltshire)

Q What are the implications for resources? I appreciate that that is your view, and I recognise that it makes very good sense. Are you concerned about the resourcing of that service, in terms of whether there might be implications for other parts of the NHS if it was to be a separate service?

Danny Kruger (Conservative, East Wiltshire)

Mark, I have a question about the end, or “the final act” as I think it is called in the Bill. Do you think there needs to be more specific guidance in the Bill about what should happen in the case of complications—if the death is taking a long time? It can take up to an hour quite commonly in other countries. There may be complications. Again, that happens. What would happen if a doctor were to intervene to genuinely assist the patient to die, if something was going wrong? Are you worried about the legal implications for doctors in those circumstances?Q

Danny Kruger (Conservative, East Wiltshire)

Very quickly on that last point, it is not totally clear what kind of medical professional would be in attendance at the end. Do you think it Q should be a fully trained doctor? Should there be some separate professional in that role? How should that work?

Lewis Atkinson (Labour, Sunderland Central)

Q I want to cover two areas. I will start with the current law. I am interested in the position that doctors are currently in, both regulatorily and around the current law. The Suicide Act 1961 and so on clearly prohibit this. A number of us have heard from families who have gone to Switzerland, and so on, and who have returned and had a conversation with their family doctor around the death of a loved one. There have been incidents in which people have attempted to take their own lives, given that there is no current assisted dying provision. Could you say a little about the dilemmas facing doctors on the current law as it stands?

Lewis Atkinson (Labour, Sunderland Central)

Q Moving on to the next issue, you have both spoken fairly clearly about—or advocated against—having an absolute ban on doctors discussing or raising the issue. I want to tease out whether there is a difference between raising it and recommending it. Dr Green, you suggested that it might be appropriate for a doctor to recommend that someone seeks further information from an independent source, for example. If Parliament so wished, would it be appropriate for Parliament to be clear that no doctor should recommend assisted dying as a course of action?

Lewis Atkinson (Labour, Sunderland Central)

Sorry—I meant the provision of information for someone.

Lewis Atkinson (Labour, Sunderland Central)

Q I am going to try again. Some people advocate for a ban on this issue being discussed at all, which we have heard your answers on. A different version of that is a ban on any sense that doctors would recommend it as a course of action, in the way that an oncologist, say, might recommend a course of chemotherapy. Could you comment on that as a potential approach to assuage some questions or concerns among the public, and how that would sit in terms of regulation?

Lewis Atkinson (Labour, Sunderland Central)

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

Naseem Shah (Labour, Bradford West)

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?

Lewis Atkinson (Labour, Sunderland Central)

indicated assent.

Simon Opher (Labour, Stroud)

Q I have a couple of points to make. First, clause 4(5) states that a

“registered medical practitioner who is unwilling”

to go forward with the assisted dying request

“must, if requested…refer…to another registered medical practitioner”.

Are you happy with that clause?

Simon Opher (Labour, Stroud)

Q My other point follows on from the previous question and is about status. The GMC and the BMA have all specialties of doctors beneath them. Would it be appropriate to have, for example, both doctors as general practitioners, or should there be provision for different doctors as the second doctor?

Simon Opher (Labour, Stroud)

Q In some legal medical situations, you need to be five years post training before you can have a view. Is that something you would have in both of these practitioners, or is that not necessary?

Sarah Olney (Liberal Democrat, Richmond Park)

Q Leading on from Dr Opher’s question about the “must refer” clause, you and Professor Whitty both stress the importance of the relationship between the doctor and the patient, yet there may be doctors who feel very strongly against mentioning assisted dying. Given the existence of clause 4(5) and the “must refer”, do you think there is a danger that there might be doctors who would be reluctant to provide a prognosis of six months or less if they thought that that would make the patient eligible for assisted dying, and that simply was not something they could support?

Kim Leadbeater (Labour, Spen Valley)

Q On the point about referral, what happens in the case of abortion? That is one of the closest parallels we can get. If we have a doctor who is not comfortable having that conversation, presumably they cannot just leave that person with nowhere to go.

Kim Leadbeater (Labour, Spen Valley)

Q Exactly, so although the terminology of “refer” might not be quite right, are we saying that we have got to provide that patient with a course of action?

Kim Leadbeater (Labour, Spen Valley)

Q That is very helpful. Let me turn to when the GMC guidance on arrangements about assistance to die is raised with practitioners. Part of the guidance is that practitioners have to

“respect competent patients’ right to make decisions about their care, including their right to refuse treatment, even if this will lead to their death”.

I am interested in how that fits in with those very difficult conversations. When a patient executes that right to refuse treatment, are those cases logged? Are they monitored or reported on?

Kim Leadbeater (Labour, Spen Valley)

Q On the point about reporting, where patients take that right to refuse treatment, capacity must be assessed at that point if a patient has said, “Look, I don’t want any more treatment.” That is quite an important point to assess capacity. Are those cases logged and recorded?

Jake Richards (Labour, Rother Valley)

Q Dr Green, on subsections (4) and (5) of clause 4 and the information services, as opposed to the referral to a practitioner, I think your point has some weight. In terms of the rest of clause 4 as drafted, it has an opt-in, it gives wide discretion to practitioners and there is no obligation to raise it, so from my understanding of your written evidence, it ticks all the boxes. Is that fair?

Jake Richards (Labour, Rother Valley)

Thank you. I just wanted to clarify that.

Jake Richards (Labour, Rother Valley)

Q There are some amendments being tabled that would offer further clarification and include more things that have to be considered. I have a similar question to the one I asked the previous panel, when I think you were here in the Public Gallery. Would offering further guidance to your members be welcome, or would you again err on the side of trusting their professional discretion?

Liz Saville-Roberts (Plaid Cymru, Dwyfor Meirionnydd)

Q Dr Green, you mentioned the different jurisdictions within the United Kingdom and the Crown dependencies. What issues have your members raised in relation to this legislation?

Liz Saville-Roberts (Plaid Cymru, Dwyfor Meirionnydd)

Yes.

Liz Saville-Roberts (Plaid Cymru, Dwyfor Meirionnydd)

And of course legislation is progressing in Scotland, which has different definitions from the legislation that we are discussing here.

Liz Saville-Roberts (Plaid Cymru, Dwyfor Meirionnydd)

Q With the GMC, do you have any commentary on the fact that health is devolved in Scotland, Wales and Northern Ireland, and that we have a different set of jurisdictions in some instances?

Esther McVey (Conservative, Tatton)

I am mindful of time, so this will probably be the last question.

Sojan Joseph (Labour, Ashford)

Q What is your view on the accuracy of the prognoses that we make in this country? If somebody is told that they may live for three years instead of six months, it will make a difference to their decision making. Does the GMC or the BMA have any data or studies on the accuracy of prognosis?

Esther McVey (Conservative, Tatton)

As we still have a little time, I will call Kit Malthouse.

Kit Malthouse (Conservative, North West Hampshire)

Q I just want to clarify the referral issue. As I understand it—I may have it wrong—your 2013 guidance on medical practice and personal beliefs says that doctors should refer, in cases such as those of abortion, to a colleague or service provider rather than a general information source.

Kit Malthouse (Conservative, North West Hampshire)

Q I understand the BMA’s concern, but my concern is about saying, “Here’s a leaflet—you’re on your own,” or “You can get information from this place.” For somebody who is in extremis at that point in their life, that might prove a significant barrier. Would doctors reflect that in their sense of responsibility towards the patient? Should we leave that open rather than having what is currently in the Bill?

Kit Malthouse (Conservative, North West Hampshire)

Right, so professional judgment again—

Esther McVey (Conservative, Tatton)

Order. We have come to an end, but you may complete your sentence, Dr Green.

Esther McVey (Conservative, Tatton)

Excellent. That was perfectly timed.

That brings this session to a close. On behalf of the Committee, I thank the witnesses: Mark Swindells, assistant director of standards and guidance at the General Medical Council, and Dr Andrew Green, chair of the medical ethics committee at the British Medical Association.

Esther McVey (Conservative, Tatton)

We will now hear oral evidence from Glyn Berry, via Zoom—hello and welcome—and from Professor Nicola Ranger. We have until 11.25 am. Will the witnesses please introduce themselves?

Rebecca Paul (Conservative, Reigate)

Q This is a question for Glyn Berry. A statement that you published in November 2024 says:

“There is a risk that without a more sustainable model of funding for palliative care, many people will choose an assisted death, as the only way to escape from unbearable suffering.”

Can you elaborate on why you say that?

Rebecca Paul (Conservative, Reigate)

Q What would a more sustainable model of funding for palliative care look like?

Esther McVey (Conservative, Tatton)

Order. We are going slightly off topic, so could we have a brief answer?

Tom Gordon (Liberal Democrat, Harrogate and Knaresborough)

In its current form, the Bill looks quite heavily at medical professionals; we have already heard from lots of experts in that area. In social care and palliative care, you often deal with those difficult conversations. What lessons and advice might you be able to give? How might you feed into the process?Q

Tom Gordon (Liberal Democrat, Harrogate and Knaresborough)

Q That is really helpful. I wonder how people like you and organisations like yours see your role in the assisted dying process. Do you think it might be better if you were further involved?

Tom Gordon (Liberal Democrat, Harrogate and Knaresborough)

That was a really comprehensive answer. I think the key point that you touched on is the multidisciplinary approach.

Juliet Campbell (Labour, Broxtowe)

Thank you both very much for being here today. Throughout this whole discussion, for many months, there has been a lot of talk about palliative care and pain management, which can lead patients to come to a decision or to consider assisted dying as an option. If a doctor has suggested to a patient that assisted dying is an option, or a patient has said that they are considering assisted dying, do you think that they should be referred to another clinician? Or do you think that there should be an independent organisation—a non-clinical setting—where a patient can go to have further discussions before taking the assisted dying route?Q

Juliet Campbell (Labour, Broxtowe)

Q So rather than going straight to “I have made this request, or this has been suggested to me, and this is the path we are going down,” there is something that should happen in between.

Marie Tidball (Labour, Penistone and Stocksbridge)

Professor Ranger, may I pick up on the points that Glyn Berry made about the different circumstances in which patients find themselves? The barriers to healthcare as a result of health inequalities, access to education and disability are well documented. How could your members help to remove the barriers for such groups in access to the provision of assisted dying?Q

Marie Tidball (Labour, Penistone and Stocksbridge)

Q To pick up on your important point about advocacy, how would your members detect coercion, undue pressure or dishonesty by family members or other supporting parties on which the patient was relying in relation to seeking assisted dying? At what point would there be a report to the police by your members?

Marie Tidball (Labour, Penistone and Stocksbridge)

Q Just to follow up on that, because it is really important: do you think your members would have the ability to pick up on such coercion, dishonesty and pressure from other parties potentially being placed on a patient who is seeking assisted dying? What other training or support would be needed for your members?

Marie Tidball (Labour, Penistone and Stocksbridge)

Q But you believe that your members would be able to pick up on and identify issues such as coercion?

Jack Abbott (Labour/Co-operative, Ipswich)

Q My question, which relates to some of the points made earlier, is for Glyn Berry. Your organisation has recommended a new role: the approved palliative care professional. To go into the detail a bit more, you make a number of recommendations on what that role would include, such as ensuring that the person has the mental capacity to make the decision. First, are you therefore saying that this new role should sit alongside the two-doctor process, which has already been outlined in terms of final decision making? If the approved palliative care professional felt, for example, that this person did not have mental capacity, should they be able to, as it were, stop the process?

Secondly, what level of training would that person need in terms of time? We have, for example, been talking about a two-year process. If this new role came into effect, how long would that person need to be trained for to fulfil it adequately? Thirdly, do you have a sense of how many of these professionals we would need to make this a functioning system? Those are three separate questions.

Kim Leadbeater (Labour, Spen Valley)

Q Thank you for coming and giving evidence today, and for meeting with me recently. You both represent organisations that have neutral positions on assisted dying. I am really interested in this multidisciplinary approach that you are talking about, and I think it is a really valuable conversation, so thank you for raising those points.

I want to ask a bit more about what this end-of-life conversation looks like in your experience, because you are absolutely right; of all the people who are spending time with patients in their last few months of life, it is often nurses and palliative care social workers. You have a really important role to play.

I am also interested in what this would look like in reality. There has been talk of a kind of separation of palliative care and assisted dying, but, actually, I think we should be looking to embrace a holistic approach to end-of-life conversations and end-of-life care, which is what has happened in other jurisdictions. You might have a patient who has signed up for assisted dying but never does it because they have good palliative care and they work with their palliative care experts and specialists. Therefore, I think it is important that we do not try to separate these things.

I would like your views on that, but I think that one of the strengths is that having these conversations about death, about dying and about end of life is a really positive thing. Your members have an important role to play in that, so could you talk a little bit about the holistic approach that your members take?

Kim Leadbeater (Labour, Spen Valley)

Q That is incredibly helpful, thank you. You are absolutely right to bring it back to patient autonomy—patient choice—so that, while putting all the safeguards in place, we are very clear that it is their genuine choice based on what they really want to do. It sounds as though you are saying—

Esther McVey (Conservative, Tatton)

Order. Is there a question there?

Kim Leadbeater (Labour, Spen Valley)

Yes. It sounds as though you are saying that your professionals are trained to have those conversations, which is very reassuring. Glyn, do you want to add anything?

Sojan Joseph (Labour, Ashford)

Q When the RCN Scotland director gave evidence to the Scottish Parliament during the discussion of the Assisted Dying for Terminally Ill Adults (Scotland) Bill, he expressed the RCN’s concern that there were not sufficient safeguards in place to protect nurses and nursing practice around assisted dying in Scotland. Are you satisfied that the Bill we have before us in England and Wales addresses those concerns, or would you like to see amendments to ensure that the mental health and wellbeing of nurses involved in the process are protected, should the Bill become law?

Kit Malthouse (Conservative, North West Hampshire)

Q Professor, I want to test a little further the notion of a separate organisation that you mentioned. I can understand a separate discipline emerging, acquired by training, which is what happens in palliative care at the moment. We heard from previous witnesses that simplicity in safeguards is key, and in particular from the CMO that we have to avoid the last 6 months of someone’s life being a bureaucratic nightmare. 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. If you are supporting people in those circumstances as they move towards their death, do you think that it could be absorbed within the current functions, rather than having a separate organisation?

Danny Kruger (Conservative, East Wiltshire)

Q You have done this very powerful report, the “Last Shift”, and talked about the moral injuries—a very powerful phrase—felt by nurses in the light of shortages in care in the NHS and social care. What should a nurse, or indeed any health professional, do in circumstances where a patient is requesting assisted dying and qualifies for it, when that professional thinks that what they really need is palliative care, but that is not available because of the shortages in the palliative care system?

Danny Kruger (Conservative, East Wiltshire)

Q Just to be clear, do you think it is possible for every patient who needs it to get the palliative care that they should have?

Danny Kruger (Conservative, East Wiltshire)

Q So somebody could request assisted dying because of the absence of adequate palliative care.

Danny Kruger (Conservative, East Wiltshire)

Q Indeed. Lastly, I am very interested in your suggestions about a separate service and about the importance of protecting the rights of professionals who do not want to be involved. I was very conscious of the plight of care home workers in the pandemic, and I regretted my vote to mandate the vaccine to them.

Do you think—I cannot decide for myself what the answer is—it should be possible for a care home director to exempt their whole service, that care home and the people who work in that care home, from being involved in assisted dying? That is where people live, after all. If somebody is having it there, it could affect the entire atmosphere of the place, and the work that all of the people there have to do. Do you think they should be protected as an organisation?

Esther McVey (Conservative, Tatton)

Q We have about 40 seconds left, so I do not think we will get in another question. Glyn, do you want to add anything to any of the points?

Esther McVey (Conservative, Tatton)

That brings us to the end of the time allocated for the Committee to ask any questions. I thank our witnesses on behalf of the Committee, Glyn Berry, co-chair of the Association of Palliative Care Social Workers, who appeared via Zoom, and Professor Nicola Ranger, chief executive and general secretary of the Royal College of Nursing. Thank you all very much indeed.

(Afternoon)

Examination of Witnesses

Peter Dowd (Labour, Bootle)

Q76 We are now sitting in public and the proceedings are being broadcast. Before we begin, I remind Members to please switch electronic devices to silent. We will now hear oral evidence from Dr Rachel Clarke, who is a palliative care doctor; Dr Sam Ahmedzai, who is an emeritus professor in the medical school at the University of Sheffield; James Sanderson, who is chief executive at Sue Ryder; and Dr Sarah Cox, who is the president of the Association for Palliative Medicine. We have until 3.15 pm for this session. Could the witnesses please introduce themselves for the record?

Peter Dowd (Labour, Bootle)

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

Naseem Shah (Labour, Bradford West)

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?Q

Naseem Shah (Labour, Bradford West)

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?

Sean Woodcock (Labour, Banbury)

CoercionQ 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?

Marie Tidball (Labour, Penistone and Stocksbridge)

My question is for Dr Ahmedzai. The Select Committee inquiry into assisted dying received evidence that there were not any indications of palliative or end-of-life care deteriorating in quality or provision following the introduction of assisted dying. Indeed, the introduction of it has been linked with an improvement in palliative care in several jurisdictions. I have two questions, if I may. What more could the Bill do to strengthen the available choice at the end of life and the regulation of these choices as set out in the codes of practiceQ ? If you could answer that one first, I will come back to my second question.

Marie Tidball (Labour, Penistone and Stocksbridge)

I have two follow-up questions on that basis.

Peter Dowd (Labour, Bootle)

Order. I do not want to squash any discussion, but I ask Members and the panel to bear in mind that we have until 3.15 pm for this session. I will be as lenient as I can with questions.

Marie Tidball (Labour, Penistone and Stocksbridge)

Q On the basis of your 39 years of experience and the Select Committee evidence that I mentioned earlier, do you acknowledge that improvements on both assisted dying and palliative care can run in parallel and do not need to be mutually exclusive?

Marie Tidball (Labour, Penistone and Stocksbridge)

Q You talked about the role of medical practitioners discussing this issue, which is of course in clause 4(2) of the Bill. Paragraph 4.2 in your own evidence was very helpful in discussing that, as it makes it clear that it is

“entirely consistent with current medical practice and with compassionate care”

to raise assisted dying. You also said that raising the topic did not have adverse effects. How could clause 4 be strengthened to ensure that patients are presented with a range of treatment options at the end of life and relay any concerns that others have raised about suggestibility where this is mentioned in isolation?

Marie Tidball (Labour, Penistone and Stocksbridge)

That is very helpful; thank you.

Rebecca Paul (Conservative, Reigate)

MyQ question is to Dr Sarah Cox. What do you think will be the impact on palliative care of introducing assisted dying?

Rebecca Paul (Conservative, Reigate)

Q In terms of the data showing that palliative care has not improved as quickly in locations that offer assisted dying, can you offer us any further insight into why that may be? What should the Committee be thinking about, in relation to the Bill, to safeguard against that happening? I think we all agree that we do not want to see palliative care decline.

Sarah Green (Liberal Democrat, Chesham and Amersham)

Dr Clarke, what are the existing statutory guidelines on end-of-life practice? How are those decisions logged, recorded and monitoredQ ?

Sarah Green (Liberal Democrat, Chesham and Amersham)

Q I have a follow-up question. The Bill introduces a monitoring and review process, including an annual report by the chief medical officer. Do you have any reflections on whether that needs strengthening?

Daniel Francis (Labour, Bexleyheath and Crayford)

My question is to Dr Ahmedzai. In the paper you produced you talked about specific recommendations regarding the training and experience of the doctors involved in the process. You suggested five years, for instance, and some other experience. Have you got examples elsewhere in the world where such a scheme has been implemented? Do you believe that we have enough trained doctors in the United Kingdom who have that level of experience and would therefore be taking part in this part of the processQ ?

Daniel Francis (Labour, Bexleyheath and Crayford)

Q Just to clarify, is there nowhere else in the UK where we have that? I am just trying to understand, because we would need to go away and do a piece of work on whether there are enough doctors with that level of experience if we were to take on that kind of recommendation. Is there nowhere else in the medical profession in the UK where we insist on that level of experience?

Simon Opher (Labour, Stroud)

Thank you for all giving up your time, with your very high level of palliative care expertise and experience. I am a practising GP, and GPs and district nurses do a lot of palliative care with a lot of advice from you people. I have also noticed that, even with the absolute best quality palliative care, some people have still talked to me about an assisted death, or shortening their death. I would like to hear your comments. Is this more about autonomy than symptom control?Q

Danny Kruger (Conservative, East Wiltshire)

I will ask you one quick question, Dr Cox. Dr Clarke said that the capacity assessment was poorly conducted. Do you think that the threshold is appropriate, using the Mental Capacity Act 2005? Assuming that we could conduct these assessments adequately, do you think that the threshold is safeQ ?

Kit Malthouse (Conservative, North West Hampshire)

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. Presumably, you already have guidelines or training about assessing coercion and capacity in those circumstances. I think in some—for example, advance directives—you are legally obliged to comply with a patient’s wishes. Are those guidelines and safeguards broadly translatable across into what, from my point of view, is another choice that a patient may make to end their lifeQ ?

Kit Malthouse (Conservative, North West Hampshire)

Q Understood. My other question is for all of you, but particularly Dr Clarke. You have mentioned autonomy a number of times. The Bill is trying to pass autonomy to the individual at a particular moment at the end of their life. It feels to me that the picture painted currently is a largely unregulated one. Dr Clarke, I think you said that there are no regulations or guidelines about what is going on. As my colleague Sarah Green said, there is no monitoring or measuring of what is going on. In general terms, given that patient autonomy is at the centre of this, would you welcome a set of rules that is understandable by patients and doctors, rather than what we have at the moment, which is—casual is not the right word—an ad-hoc negotiation at the time, depending on what the patient wants to do?

Kit Malthouse (Conservative, North West Hampshire)

Q Sorry to interrupt you, but I am conscious of the time. We heard this morning how vital training is; I think that is broadly accepted from a number of voices. I want to question you about the issue of the choice people face. I understand the point you are making about the variable state of palliative care versus the choices people face, but that is quite macro. Day by day, patients are facing a choice about what is ahead of them in the next few months. I would not want to put words in your mouth, but I presume you are not saying that, for the good of the whole, they should go through an awful death that they do not want to go through while we wait for palliative care to catch up.

Peter Dowd (Labour, Bootle)

Order. We have half an hour left. Nine people have asked questions and there are eight people left who want to. If we want to get through the questions by 3.15 pm, people will have to be self-disciplined when they ask their questions.

To the panel, forgive me, but we need answers in as reasonable a time as possible given the circumstances. Dr Clarke, if you wish to answer the last point, feel free.

Juliet Campbell (Labour, Broxtowe)

I have a question for James Sanderson and one for Dr Clarke. They are quite similar, but I will refer to things you have said. James, you said:Q

“Sadly, only half the people who need palliative care receive it.”

In your opinion, who are the people who receive palliative, and who does do not?

My question to Dr Clarke is similar. You have talked about the population being

“carved up into two groups…those who deserve to live and those are expendable”.

Could you expand on that quote and the two groups you referred to, as well as the impact that has on their treatment and care?

Neil Shastri-Hurst (Conservative, Solihull West and Shirley)

I have a question for Dr Clarke and Dr Cox about the registration of deaths, which is dealt with in clause 29. Do you feel that the provisions set out in the clause are sufficient? If not, what further bolstering would provide the oversight needed to ensure that the processes and procedures are followed correctly?Q

Jack Abbott (Labour/Co-operative, Ipswich)

Dr Cox, may I follow up on one of the things you said earlier? Forgive me if I have misunderstood; I want to be clear. Earlier, I think you said that in the countries that do not have assisted dying, the state of palliative care has improved more quickly than in countries that do. Is that a fair representation of what you saidQ ?

Jack Abbott (Labour/Co-operative, Ipswich)

Q The whole panel has painted—and we have heard this previously—a pretty bleak picture of the state of palliative care in the UK. Would you say that it was better or worse than it was, say, 10 years ago?

Jack Abbott (Labour/Co-operative, Ipswich)

Q I guess what I am driving towards is that simply not having assisted dying is not necessarily causation for improvement in palliative care. In this country, for example, we have not seen palliative care improve from where it was 10 years ago, the last time this debate came to Parliament.

Jack Abbott (Labour/Co-operative, Ipswich)

Q Sure. That is a really fair argument. Again, what I am driving towards is the point you were trying to make earlier, which is—I think this is fair to say—that countries that do not implement assisted dying improve their palliative care system. Clearly, that did not happen in the UK, so my guess is that that is not direct causation, is it? There are a number of other factors, although I agree that—

Jack Abbott (Labour/Co-operative, Ipswich)

Yes, so the direct comparison is not necessarily relevant. Is that correct?

Peter Dowd (Labour, Bootle)

Order. Can you address the Chair? This is not a dialogue.

Jack Abbott (Labour/Co-operative, Ipswich)

Sorry. I was trying to make a point—

Peter Dowd (Labour, Bootle)

I understand that, but address it through the Chair.

Tom Gordon (Liberal Democrat, Harrogate and Knaresborough)

To build on that point—which is pretty much what I was going to ask and what I am trying to get to—Sue Ryder’s evidence to the Health and Social Care Committee inquiry into assisted dying gave examples of exactly that: cases where increases in the funding of palliative care came alongside the introduction of assisted dying. You talk about people not being able to have an informed choice unless palliative care is fixed, but do you accept that improvements can run in parallel for both assisted dying and palliative care, and that the small number of people for whom palliative care cannot help and cannot reduce their suffering are currently left without a choice?Q

Tom Gordon (Liberal Democrat, Harrogate and Knaresborough)

Q What further steps do we need to take to improve palliative care? How do you define when palliative care is sufficient to allow assisted dying? I am struggling with how we say we have reached that threshold. Is there ever going to be a point where we can say we have got the best palliative care?

Tom Gordon (Liberal Democrat, Harrogate and Knaresborough)

Q Since the assisted dying Bill had its Second Reading, we have seen announcements from the Government about investment into palliative care. Obviously that is mostly capital and we need to see more long-term funding. Do you feel we are already seeing increases as a result of this conversation? Is there any reason why that should not continue?

Kim Leadbeater (Labour, Spen Valley)

Goodness me, there is a lot to cover.Q

To go back to your point, Mr Sanderson, it is important to acknowledge the fantastic work that palliative care professionals do. Indeed, it is extremely important that we are having these conversations, which is why we gave extra time to this panel of witnesses.

Dr Cox, on your point about the pressure on the individual doctors involved in the process, the Bill is very clear that if they do not have the relevant specialism, they must refer to a specialist in that condition, and they “can” refer to a psychiatrist. There is probably consensus that we maybe need to strengthen the Bill in that regard. When there are doubts around capacity, doctors probably “must” refer to a psychiatrist. That is something I am taking away from these sessions.

I was interested in the comments about the multidisciplinary approach. We heard about that this morning from colleagues in social work and in nursing. I would love to know your thoughts, Dr Ahmedzai, about the idea of a multidisciplinary approach. I think there is a lot of value in that.

Dr Clarke, on this concept around training, it worries me that we have seen this afternoon a very different picture painted by you and others compared with what we heard this morning, when we had doctors and nurses telling us that they regularly assess for capacity and coercion. They said it is part of their day-to-day work and they were very confident in their ability to do that. Training is fundamental, and this is an opportunity to look at gold-standard training. I would be interested to know your thoughts on that.

Kim Leadbeater (Labour, Spen Valley)

Can I ask a quick follow-up, Chair?

Peter Dowd (Labour, Bootle)

We will come back to that once I get other Members in.

Lewis Atkinson (Labour, Sunderland Central)

Clause 35 introduces a duty on the Secretary of State to report on a periodic basis to Parliament on the accessibility and quality of palliative care. As I understand it, that would be a new duty that we are pioneering. What is your reaction to that? Will it be helpful in continuing the momentum to make improvements to palliative care? Are there any further reporting requirements as part of that assessment—for example, around equity of access, which some have mentioned—that we could think about when considering amendmentsQ ?

Lewis Atkinson (Labour, Sunderland Central)

Q I think around 650 people with a terminal illness currently take their own lives a year. If we see a success with the Bill, I wonder whether there would be a reduction of that number going forward. Do you think that could be incorporated in monitoring going forward? Do you think there are opportunities to avoid that suffering? People are clearly experiencing traumatic deaths at the moment.

Rachel Hopkins (Labour, Luton South and South Bedfordshire)

I want to build on the comments about the multidisciplinary teams that you all work with. The chief medical officer said, in one of the sessions earlier, that discussions about death, dying and end of life are increasing. They are getting better. However, importantly, when we heard from Professor Ranger of the RCN and from the Association of Palliative Care Social Workers, they also talked about the conversations that they have, as part of the wider team. Quite often, it is nurses having those conversations.Q

I was struck by the way the RCN talked—and you, Dr Clarke, used the word as well—about not being paternalistic, about having the patient at the centre of that conversation, and about ensuring that we listen to the patient and ask them, “What is it that you want?” That, for me, is all about autonomy. Do you agree? The emphasis must be on patient autonomy and their choice at the end of life.

Rachel Hopkins (Labour, Luton South and South Bedfordshire)

Can I ask Mr Sanderson to reflect on that, for the different context, Mr Dowd?

Peter Dowd (Labour, Bootle)

No. Order. We have two and a half minutes to go. One other hon. Member wants to ask a question. I want them to come in.

Sarah Olney (Liberal Democrat, Richmond Park)

Thank you, Mr Dowd. I have a quick question for Dr Cox. Earlier on, in the context of multidisciplinary teams, you mentioned how important the family of the patient is. There is currently no role in the Bill, as it is currently drafted, for the next of kin or for any family member. Do you think that is a mistake? Is that something we should look to amendQ ?

Peter Dowd (Labour, Bootle)

One last question, very quickly.

Kim Leadbeater (Labour, Spen Valley)

Q I have a very quick one. You talked about inequality in healthcare and in systems. What I would like to come back to is the status quo. What are your comments on the inequality that exists currently, where assisted dying is available to people who have got the money to go to Switzerland, or another jurisdiction, and have an assisted death? I ask Dr Ahmedzai, first of all.

Kim Leadbeater (Labour, Spen Valley)

Does anybody else want to comment? Dr Cox?

Kim Leadbeater (Labour, Spen Valley)

But those deaths do exist.

Peter Dowd (Labour, Bootle)

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

Peter Dowd (Labour, Bootle)

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?

Naseem Shah (Labour, Bradford West)

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?

Naseem Shah (Labour, Bradford West)

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?

Marie Tidball (Labour, Penistone and Stocksbridge)

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.

Marie Tidball (Labour, Penistone and Stocksbridge)

Q I want to follow up, because this is really important in strengthening the Bill. Based on your prosecutorial experience, what key elements should be present in the definitions of coercion, pressure and dishonesty? I also have a bit of a technical question, if I may. Do you think they would be better placed in clause 26 or in clause 40, under interpretation? I am asking what more you can say on the key elements of coercion, pressure and dishonesty, and I am asking about their placement in the Bill to make them as accessible as possible to medical practitioners and patients who will want to rely on it.

Marie Tidball (Labour, Penistone and Stocksbridge)

Q You have helpfully acknowledged the link that we need to make on coercion to strengthen this, but on the other two elements—dishonesty and pressure—is there anything else that we need to look to in order to make this more robust?

Jake Richards (Labour, Rother Valley)

Thank you all for your written evidence. Sir Nicholas, in your helpful written evidence, you adopt Sir James Munby’s criticism of the current proposal for judicial oversight, and you instead recommend what you call a “Spanish-style specialist panel”. Could you set out for the Committee what you see as the benefit of that approach compared to what might be described as the stark judicial oversight of the High Court judge?Q

Jake Richards (Labour, Rother Valley)

Q Apart from capacity, which I appreciate, are there any other problems that you see with clause 12 on judicial oversight? Apart from capacity, is there any benefit that you see from the Spanish model? Alex, you similarly criticised the current judicial provision. You say in your very helpful written evidence at paragraph 10 that perhaps we need to consider a multidisciplinary approach.

Jake Richards (Labour, Rother Valley)

Yes—it’s just that otherwise I will be cut off. I was trying to get two questions in.

Peter Dowd (Labour, Bootle)

Order. I said earlier that this is not a dialogue. Address your comments to the Chair, and I will decide who speaks and when. I do not wish to be rude, but everybody’s got to have their fair share.

Danny Kruger (Conservative, East Wiltshire)

Q I have a quick question for each of you. Sir Max, as you point out, the Bill does not repeal the ban on assisted suicide. It would still be illegal to assist someone to go to Switzerland. Alex Goodman KC, giving an opinion on behalf of Dignity in Dying, the campaign group that champions the Bill, thinks it is more likely that there would be prosecutions for people who assist their relatives to go to Switzerland once this Bill is passed. Do you share that view?

Danny Kruger (Conservative, East Wiltshire)

Q Sir Nicholas, do you want to comment? I have another question for you as well, but is it the case that prosecutions will be more likely? Maybe you disagree.

Danny Kruger (Conservative, East Wiltshire)

Q You do not agree. In that case, this Bill would be worse for somebody with your condition because it does not address your condition and it would put your relatives at greater risk if they did assist you—but you do not think there is a danger of prosecution.

Danny Kruger (Conservative, East Wiltshire)

Q I wanted to follow up further, but because time is tight I will jump to Mr Ruck Keene. Can you explain a little bit about your concerns about the Mental Capacity Act and its interaction with the Bill? Do you think the threshold of capacity, as set out, is adequate?

Peter Dowd (Labour, Bootle)

I will move on to Sojan Joseph, but perhaps you can pick this up. We have eight people wanting to ask questions and half an hour, tops.

Sojan Joseph (Labour, Ashford)

Alex, thanks for the written evidence and your experience in capacity assessment. We heard from the previous panel, especially from the practising Dr Clarke, how complex it is. She was explaining how she does not think everyone has enough training in capacity assessment, and it is so complex in NHS healthcare areas. You made an observation about multidisciplinary involvement, rather than just two doctors. Do you think having more than two people involved in the decision making can strengthen the Bill?Q

Jack Abbott (Labour/Co-operative, Ipswich)

Q Sir Nicholas, I am going to paraphrase a little bit, but you said people with Parkinson’s will never get a terminal diagnosis, so this Bill is no use to you at all—I think you used stronger language than that when you made your original statement.

Jack Abbott (Labour/Co-operative, Ipswich)

Q Sure. Let us phrase it in a different way today. Would you be able to expand on your thinking there?

Jack Abbott (Labour/Co-operative, Ipswich)

Q In your view—I think you kind of said it before, and I would hate to put words in your mouth—are you saying that Parkinson’s sufferers and other similar—

Jack Abbott (Labour/Co-operative, Ipswich)

Yes, those with such conditions. Are they left out of this debate?

Jack Abbott (Labour/Co-operative, Ipswich)

Q In your view, and that of the rest of the panel, is there a way to legislate to include them?

Rebecca Paul (Conservative, Reigate)

Q My questions are to Alex Ruck Keene. Thank you for your written evidence, which I read with great interest. I have two questions for you. This follows on nicely from the discussion we have just had. Is there any risk that if the terminal illness definition were to remain in the Bill, it could be challenged under the European convention on human rights?

My second question, which is completely different—just to mix it up—is on a really interesting point in your written statement about how we need to give consideration to the national suicide prevention strategy. I found that really interesting, because the Bill potentially turns on its head the way we view suicide, and obviously we have been sending a certain message out there, particularly to our young people. Could you elaborate on the point you were making in your written evidence to the Committee?

Peter Dowd (Labour, Bootle)

Not just at the moment. We will move to Daniel Francis.

Daniel Francis (Labour, Bexleyheath and Crayford)

Q Alex, in paragraph 8 of your written evidence you touch on clauses 9, 15 and 18 of the Bill and the potential complications that could arise when the substance is taken. Could you expand on the concerns you have about that?

Neil Shastri-Hurst (Conservative, Solihull West and Shirley)

Q I want to stick with clause 18, because as it stands there can be some assistance by the clinician but there cannot be total delivery or administration by the clinician. You could end up with a scenario where, for instance, you have somebody who is tetraplegic and then gets a terminal diagnosis, has capacity to make the decision and wants to end their life, but they do not have the physical means of doing so. Do you think that is open for challenge on grounds of discrimination?

Neil Shastri-Hurst (Conservative, Solihull West and Shirley)

Q Sir Nicholas, can I bring you in on that? You referred to it directly in your proposed amendment.

Lewis Atkinson (Labour, Sunderland Central)

Q We have heard from two witnesses—you, Sir Nicholas, and Dr Ahmedzai from the earlier panel—on the question of judicial oversight. While we have you here, Sir Max and Mr Ruck Keene, what are your observations on the proposals from those two witnesses that an alternative to a High Court judge overseeing the process would be some form of panel or tribunal, potentially multidisciplinary? What is your view on that and the legal implications for that?

Liz Saville-Roberts (Plaid Cymru, Dwyfor Meirionnydd)

I have a question for Alex Ruck Keene. I noticed the concerns in your evidence about presumption of capacity, and I know that you have written in the past about concerns over different disciplines having different definitions of capacity. Later on in your evidence, you also mention multidisciplinary consideration of circumstances in assessing eligibility. How might that multidisciplinary eligibility assessment alleviate some of your concerns in relation to capacity decisionsQ ?

Sarah Sackman (Labour, Finchley and Golders Green)

I want to pick up on your evidence, Sir Nicholas, in relation to the panel that we have just been discussing with Sir Max. I have three questions. First, what do you envisage the panel doing under your model? Will it be ensuring that a lawful process has been followed or doing something more than thatQ ?

Sarah Sackman (Labour, Finchley and Golders Green)

Q That is helpful. Secondly, what information do you think the panel will need in order to reach a determination on that question?

Sarah Sackman (Labour, Finchley and Golders Green)

Q I suppose my third question, then, is how do you envisage such a panel, if at all, interacting with the High Court—with, say, a final right of appeal to the High Court, similar to what is in the Bill?

Sarah Sackman (Labour, Finchley and Golders Green)

Thank you.

Peter Dowd (Labour, Bootle)

We have some Members who want to ask more questions; we have about six minutes or so. Jake Richards, you did have a possible question earlier on.

Jake Richards (Labour, Rother Valley)

Q Some of it has been answered, but on that point, I just wanted to explore the appeals point. If either side could appeal, as Alex suggested, who would be appealing against the decision to allow assisted dying?

Jake Richards (Labour, Rother Valley)

Q The Bill at the moment—and for good reason, potentially—potentially does not provide for family members receiving notice of this.

Jake Richards (Labour, Rother Valley)

It is an autonomous decision, so—

Jake Richards (Labour, Rother Valley)

Yes, sorry, I meant that, in terms of—

Peter Dowd (Labour, Bootle)

Order. I am giving you an opportunity to ask a question, so ask the question, we will get the answer back and then we can move on. I do not want this dialogue, I am afraid.

Jake Richards (Labour, Rother Valley)

Forgive me, Mr Dowd. I meant that, in terms of the assisted dying process in the Bill, there is no automated mechanism for family members, or indeed any third parties, apart from the doctors, to have notice of this intention. Is there a concern, regarding this appeal point, that perhaps interested parties would not know?

Marie Tidball (Labour, Penistone and Stocksbridge)

Q I have a question for Sir Max Hill and Alex Ruck Keene. Your insight on clause 12 has been helpful. What procedures would you recommend be adopted for testing and, if need be, challenging the evidence as part of an evidentiary process linked to the panel that you set out?

Peter Dowd (Labour, Bootle)

Unless there are any more pressing questions—

Sarah Olney (Liberal Democrat, Richmond Park)

indicated assent.

Peter Dowd (Labour, Bootle)

We have one and a half minutes, so it will be a 10-second question and a 20-second answer; unless you can do that, I am going to call it to a close.

Sarah Olney (Liberal Democrat, Richmond Park)

indicated dissent.

Simon Opher (Labour, Stroud)

Q Sir Nicholas, I have great sympathy with your position, but how would you frame this law so that it would cover yourself?

Peter Dowd (Labour, Bootle)

Thank you. That brings us to the end of the time allotted for the Committee to ask questions. I thank our witnesses on behalf of the Committee; thank you for your forbearance.

Sarah Olney (Liberal Democrat, Richmond Park)

On a point of order, Mr Dowd. I had my hand up at the beginning. I was really keen to ask a question in this session because it is pertinent to an amendment that I have tabled. Could you advise how best I can have the opportunity to ask my question?

Peter Dowd (Labour, Bootle)

I am more than happy to speak to you afterwards. We have had lots of questions today and I tried to get people in as much as possible, but there has to be an element of self-discipline from the people asking the questions and interrupting. I am happy to facilitate if I possibly can, but I am afraid that there is also a responsibility on Members to look to other Members’ needs.

Peter Dowd (Labour, Bootle)

We will now hear oral evidence from Dr Ryan Spielvogel, who is senior medical director for aid in dying services at Sutter Health, California, and Dr Jessica Kaan, who is medical director for End of Life Washington. Both witnesses will appear via Zoom. I call on Members to ask questions, but in view of the last point of order, I must be absolutely clear that I will interrupt if questions to the witnesses are too long. We do not have much time and people want to get their questions in—there has to be an element of self-discipline in that regard.

Kim Leadbeater (Labour, Spen Valley)

Q I will try to be brief. I thank the witnesses for joining us from wherever they are in the world—it is great to have you with us today. I will get straight to the point. There is understandably a significant amount of nervousness about the potential change that the Bill would create within England and Wales. Could you talk to us a little bit about what the process has been like in your jurisdictions and what it looks like now? What are your experiences, particularly focusing on questions around mental capacity and coercion? Dr Spielvogel can go first.

Kim Leadbeater (Labour, Spen Valley)

Q That is incredibly helpful—thank you. Dr Kaan, do you want to add anything to that, and maybe touch on the training that takes place around identifying these things and the conversations that take place?

Bambos Charalambous (Labour, Southgate and Wood Green)

My question is about how the legislation is going and how you have implemented it. What changes have you made since it began? What teething problems did you find as you were going along? What adjustments have you made to your process?Q

Peter Dowd (Labour, Bootle)

We were in the middle of your reply, Dr Spielvogel. Could you pick up where you left off?

The rest of the debate is in Hansard.