Terminally Ill Adults (End of Life) Bill

Public Bill Committee, 11 March 2025.

Roger Gale (Conservative, Herne Bay and Sandwich)

I have a few housekeeping announcements. Will everybody ensure that electronic devices are turned off or switched to silent. I remind hon. Members that tea and coffee are not allowed in the Committee Room.

We are due to continue line-by-line consideration. I am asked to remind Members that interventions should be short, and should raise points of clarification or ask questions; they should not be speeches in and of themselves. Members who do wish to give a speech should bob, please—we are not mind readers—and continue to do so throughout the debate in which they take part unless and until they are called.

When Members say “you”, they are referring to the Chair. “You” should not be used to refer to each other in any circumstances. Debate should be through the Chair.

Members may find it convenient to know that the Committee will be sit this afternoon and until 8 o’clock this evening. Please bear in mind that if there are Divisions on the Floor of the House and the sitting is not adjourned, then it will be suspended for the Division, which means that Members will have to come back even if the witching hour of 8 o’clock has passed. At that point, Members will sit again until the adjournment is moved formally. That can be done only when the floor is vacated, not in the middle of a speech.

Clause 8 - Second doctor’s assessment (independent doctor)

Roger Gale (Conservative, Herne Bay and Sandwich)

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

Amendment 317, in clause 13, page 9, line 12, leave out “14” and insert “28”.

This amendment would provide 28 days for the second period of reflection instead of 14.

Amendment 314, in clause 13, page 9, line 17, leave out

“48 hours beginning with that day”

and insert

“7 days beginning with that day and the person must be referred immediately for urgent specialist palliative care.”

This amendment would increase the second period of reflection in cases where the coordinating doctor reasonably believes the person will die within a month from 48 hours to seven days.

Amendment 315, in clause 13, page 9, line 17, leave out “48 hours” and insert “7 days”.

This amendment would increase the second period of reflection in cases where the coordinating doctor reasonably believes the person will die within a month from 48 hours to seven days.

Danny Kruger (Conservative, East Wiltshire)

It is a pleasure to serve under your chairmanship once again, Sir Roger. I am looking forward to this week’s debating.

I want to draw the Committee’s attention to further evidence that has come in since the debate got under way. Since we started the Committee, we have had more than 400 pieces of evidence, so I apologise for not having got to this earlier, but it is relevant. I do not want people who have submitted evidence to us to feel that their submissions have fallen into a black hole and are not being considered, and I think this is significant evidence. We are talking about the necessity of a proper period of reflection, which is acknowledged in the Bill—it is understood that it is inappropriate for people to be able to request and receive an assisted death in very short order. The debate is about the extent of that reflection period. I am supporting amendments that suggest that we need slightly longer in some cases.

I want to refer to two pieces of the evidence that has come in. One is from six palliative care doctors who wrote that

“our experience is that many patients experience a period of adjustment to ‘bad news’ and may say that they cannot live under these conditions. However, after a period of reflection and adjustment, the majority come to find peace and value in their altered life circumstance, in a way they would not have believed possible. This may often take many weeks and sometimes short months. It is our profound concern that the two ‘periods of reflection’…would not allow time for this adjustment. This is even more so the case where these periods of reflection are reduced for patients predicted to have an even shorter prognosis. It is thus a reality that patients and their families may miss out on a period of life they would have valued by seeking to end their lives prematurely, and these days, weeks and perhaps even months will never be regained.”

The other piece of evidence is from Tom Pembroke and Clea Atkinson, who are experts in hepatology and palliative care in Cardiff. They raised the problems of the seven-day reflection period where there is alcohol misuse. I do not think this topic came up in last week’s debate, but it is worth acknowledging because liver disease is the most common cause of death for people in middle age. It is also worth noting that liver disease disproportionately affects the people who are most disadvantaged in our society. These experts say:

“Prognostication in advanced liver disease is challenging as management of the underlying causes, including abstinence from alcohol, potentially reverses advanced liver failure…The neurocognitive and depressive effects of alcohol misuse disorder frequently requires more than seven days to resolve following abstinence. Advanced liver disease frequently manifests with hepatic encephalopathy which can affect the ability to make informed decisions.”

Their concern is that

“A seven-day review period is not sufficient to ensure that there is an enduring wish to die which is not influenced by alcohol misuse.”

Considering the prevalence of alcohol misuse in our society, the extent to which so many people tragically die of it and the difficulties in prognostication, I suggest to the Committee that there is a particular argument to be made for extending that short period at the end for the expedited process that is being considered. I beg the Committee to consider accepting the amendment.

Stephen Kinnock (Labour, Aberafan Maesteg)

It is a pleasure to serve under your chairship again, Sir Roger.

Amendment 301 would prolong the first period of reflection, after which point the independent doctor can conduct the second assessment. In the original draft of the Bill, the first period of reflection is seven days, but the amendment would extend that period to 14 days. That means 14 days would have to pass between the time that the co-ordinating doctor has made their statement following the first assessment, and the independent doctor carrying out the second assessment.

Amendment 317 would increase the duration of the period of reflection before a person may make a second declaration from 14 days to 28 days. It relates to cases where a person’s death is not reasonably expected within one month of the date of the court’s declaration.

Amendments 314 and 315 would increase the duration of the second period of reflection before a person may make a second declaration, in cases where a person’s death is reasonably expected within one month of the date of the court’s declaration, from 48 hours to seven days. They would also introduce a requirement for a mandatory immediate referral for urgent specialist palliative care. The requirement would be introduced into the definition of the second period of reflection. It is unclear what impact it would have on the duration of the period of reflection. The amendments do not say who should be responsible for making the referral or where it should be recorded. The drafting is also ambiguous as to what happens if a person does not consent to such a referral or care.

I hope these observations are helpful to the Committee in considering the Bill and the amendments put forward by various Members. Whether these amendments should form part of the Bill is a matter for the Committee to decide.

Kim Leadbeater (Labour, Spen Valley)

I have nothing to add on this group of amendments. I am confident that the Bill as drafted already includes significant periods of reflection. Bearing in mind that we are putting dying people through a very lengthy process already, I remain confident that the periods of reflection are adequate as set out in the Bill.

Naseem Shah (Labour, Bradford West)

I have a couple of additional comments. We talked last week about the reflection periods. I referred to the fact that when even someone buys something from a shop, they have 28 days to return it; when they are deciding on whether to have an assisted death, there is a great deal more at stake. During that debate, someone asked, “What if someone had a prognosis of just one month?”, but clause 13 has an option for a fast-track process in that situation—the person would be able to access the service in 48 hours.

I beg to differ with my hon. Friend the Member for Spen Valley, the Bill’s promoter, who said that we have enough reflection periods in the Bill. Yes, there are reflection periods, but they come after the panel’s decision. The reality is that the NHS is under so much duress, with patients waiting weeks to see their GP for anything other than urgent treatment, that getting an appointment with another GP in seven days is unlikely; it is unlikely to happen given how uncommon that is at the moment. It is right that doctors are able to triage their patients to prioritise those who require medical intervention to keep them well, to prevent hospital admission, or to stop them deteriorating or even dying.

The Government are trying to protect the NHS, and the best way of achieving that is to ensure that medical interventions are provided at the earliest opportunity before a patient deteriorates. In some cases, a medical appointment may need to take priority over an appointment for an assisted death. If someone who is dying has longer—even just a further week—in which to reflect, it removes the pressure from GPs and consultants, and enables them to prioritise properly their patients. It does not build up false expectation in patients that they have a right to a rapid consultation process. Likewise, we know that it can currently take a few weeks for patients to see another consultant, if not months or even over a year. It is therefore more helpful for the patient to have a more realistic period of reflection before moving to the next stage of their assessment.

Issues of such intensity as someone planning to take their own life should not be rushed. We know from all the work that has been undertaken on suicide that other interventions and conversations can help with reflection and reconsideration. It is important that people are given this opportunity. In their first raising the matter with a doctor, the doctor would have provided a lot of information about alternatives to the patient, such as what treatment options would be available. Perhaps they would have had a discussion with a palliative medicine consultant to review their options. There needs to be time for a patient to really reflect on all this new information. If the patient does want to explore assisted dying, there will also be all the conversations about drugs and their impact, which we will come to when we discuss later clauses.

Amendment 317 to clause 13 seeks to increase the reflection period from 14 days to 28 days. I gently suggest that we should have the reflection period before the decision, whether it be by the judge or a panel, to give people the right amount of time to consider; currently, the reflection period is afterwards. This is such a monumental decision that people should be able to contemplate all other options available. As it is, the process is rushed, and a patient could be caught up in the moment of concentrating on getting through the stages. I appreciate that others have suggested that once we have got past that stage, with the paperwork and all those things out of the way, then there is time to reflect. During the process, however, the patient has not had time to consider the options in making their decision. I am not convinced that there is enough reflection during, as opposed to after, the process.

Amendment 314 seeks to increase the reflection period from 48 hours to seven days for patients who have been given a month to live. In that case, seven days is quite adequate time to reflect on the information they have received to make informed choices. If this is about autonomy, which my hon. Friend the Member for Spen Valley has talked about many a time, it is important for people to have choices. To have that autonomy is surely to have the options in front of us and be able to consider them in detail.

In considering whether to sit on this Bill Committee, I slept on the decision. I can usually make instantaneous decisions, but knowing the amount of work, knowing that I was new to the subject, and knowing the things that I knew then—not the things that I know now—it was a big decision for me. I was even thinking about how I would manage the workload. We are talking about something that is not at all comparable. We are talking about somebody who will be taking a decision to potentially exercise the right—if the Bill becomes law—to an assisted death. That is really important for me.

I beg to ask leave to withdraw the amendment.

Danny Kruger (Conservative, East Wiltshire)

I beg to move amendment 348, in clause 8, page 5, line 10, at end insert—

“(c) inform the person’s usual or treating doctor and, where relevant, the doctor who referred the person to the independent doctor, of the outcome of the assessment.”

This amendment would ensure that the independent doctor communicates the outcome of their assessment to the referring doctor as well as the usual or treating doctor.

Roger Gale (Conservative, Herne Bay and Sandwich)

With this it will be convenient to discuss the following:

Amendment 303, in clause 8, page 5, line 12, at end insert—

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

This amendment would prevent a patient from seeking multiple assessments from different doctors.

Amendment 458, in clause 10, page 6, line 45, after “declaration” insert “and if there has been a material change of circumstances,”

Amendment 459, in clause 10, page 7, line 3, at end insert—

“(2A) (a) Where a referral is made to a registered medical practitioner under subsection (1), the coordinating doctor must provide that new registered medical practitioner with the report by the independent doctor setting out their reasons for refusal.

(b) 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.

(c) Those two reports must be made available to any subsequent decision maker under this Act and to the Commissioner.”

Amendment 460, in clause 10, page 7, line 9, leave out “particular”.

Danny Kruger (Conservative, East Wiltshire)

This is a key group of amendments. I shall specifically speak to amendment 303, which would prevent a person from seeking multiple assessments from alternative doctors if a second assessment had already been undertaken. I am not sure that I will press that amendment to a vote, but it is important to explore this issue. I will take the view of the Committee on it.

Last week, my right hon. Friend the Member for North West Hampshire said that it was important to avoid doctor-shopping. He made that point in reference to the suggestion that there would be a list of professionals that would administer the procedure. I respect that view; I think it is absolutely right. It needs to be clear in law that we avoid doctor-shopping. For that reason, it is important that the independent doctor should seek to establish whether the patient has previously had a second assessment. That could be very material.

Clause 10 states:

“In consequence of a particular first declaration made by a person, the coordinating doctor may make only one referral for a second opinion under subsection (1).”

This only limits the number of times that a person can seek another medical assessment. Amendment 303 to clause 8, in the name of the hon. Member for York Central (Rachael Maskell) , would further strengthen the current safeguards against doctor-shopping, by placing a duty on the doctor to confirm that there had not been previous assessments.

Doctor shopping is not a hypothetical concern. We have seen it take place in other jurisdictions. An understanding develops that some doctors are more likely to grant an application for an assisted death. That is totally natural. Professor Preston said in oral evidence to us:

“People go doctor shopping—they are going to multiple doctors until they get the right answer.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 245, Q315.]

According to an official report in 2021, one Oregon doctor wrote one eighth of all the prescriptions for assisted death. I met a doctor in Canada who had performed hundreds of assisted suicides. It was her whole practice; that was what she did, and people knew to go to her.

Doctors who are reluctant to grant an application may instead refer a person to doctors they know are more likely to grant the person’s application for an assisted death, so those practitioners become the go-to when other doctors deny applications. Over time, the safeguards can become weakened and circumvented by a system of doctors who apply the criteria quite loosely, as was found in Ontario. The Ontario review committee found evidence of patients doctor shopping for approval. Some 8% of non-terminally ill people who died by assisted dying had made previous requests. People do try again, naturally enough, if they do not get the answer they wanted.

In 2023, a memo was sent out to practitioners in Quebec affirming that administrators needed to be careful to respect the criterion concerning the diagnosis of serious illness and incurable disease as agreed in Quebec, and that shopping for a favourable second opinion was not an acceptable practice. Clearly, there had been a problem there with non-compliant administration of the efforts to prevent that. As I say, we found such evidence in Oregon too.

The fact is that there is nothing in the Bill to prevent a person who has failed in their attempt with one co-ordinating doctor to receive approval to die from continuing to search for different co-ordinating doctors to receive a different answer, and thereby start the whole process again. I recognise that if someone was judged ineligible but their circumstances have changed, they understandably might want to try again, and it may be appropriate for them to do so; however, there is no requirement in the Bill for a new application to be made on the basis of new circumstances regarding a person’s condition or capacity. Amendment 458, tabled by the hon. Member for Richmond Park, would address that by requiring that new applications be made, appropriately, on the basis of a change in circumstances, but even were that amendment accepted, as I hope it will be, it would simply mean that the applicant would have to cite some potentially quite minor change in their circumstances or symptoms to justify a new application.

Let us be clear what we are doing: if the first doctor declines an application, a person can shop around until they find a doctor who will approve it, and there is nothing to stop private practices springing up that would be happy to accommodate that request. If the second independent doctor declines, the person can also shop around, although that is limited to a single second attempt, but in that case the person could just go back to the beginning and start again. If we want simply to allow anyone with a terminal diagnosis to have an assisted death, the Bill will do that. Let us not pretend that we have safeguards to stop people shopping around until they find a doctor willing to help them.

Naseem Shah (Labour, Bradford West)

Does the hon. Member share my concern that if a doctor refused somebody an assisted death because they thought there was some form of coercion, the door could be open for people to keep going back through this route?

Danny Kruger (Conservative, East Wiltshire)

The hon. Lady is absolutely right. We will address in later debates the point that insufficient attention will be given to the reasons why an application has been refused. If an application has been refused on the grounds of coercion, a future doctor will not necessarily know that that was the reason. As the hon. Lady says, in cases of coercive control there is a very real danger that if a person has been unduly influenced to seek an assisted death and the doctor declines their application, possibly because they detected coercive control, the patient can then be coerced, or influenced, into starting again with a new doctor. There is nothing to stop that in the Bill. We have a real problem, and I hope the Committee will consider the amendments.

Sarah Olney (Liberal Democrat, Richmond Park)

It is a pleasure to serve under your chairmanship, Sir Roger. I will speak to my amendments 458 to 460, which would tighten the process around seeking a determination from a second independent doctor if the first has refused to say that the criteria are met. The amendments relate to clause 10, which I will say more about when we come to it, but they have been selected for debate in this group.

The risks of abuse in seeking a second independent doctor’s opinion are well illustrated by the evidence we have received from Dr Sharon Quick, the president of the Physicians for Compassionate Care Education Foundation, who tells us about the experience of Dr Charles Bentz, who refused to provide a second opinion for a physician-assisted suicide for a patient he had referred to an oncologist for cancer treatment. The co-ordinating doctor persisted and clearly found a compliant second opinion, as two weeks later his patient was dead.

Dr Charles Bentz said in his testimony:

“I was caring for a 76 year-old man who came in with a sore on his arm. The sore was ultimately diagnosed as a malignant melanoma, and I referred him to two cancer specialists for evaluation and therapy. I had known this patient and his wife for over a decade. He was an avid hiker, a popular hobby here in Oregon. As he went through his therapy, he became less able to do this activity, becoming depressed, which was documented in his chart.

During this time, my patient expressed a wish for doctor-assisted suicide to one of the cancer specialists. Rather than taking the time and effort to address the question of depression, or ask me to talk with him as his primary care physician and as someone who knew him, the medical oncologist called me and asked me to be the ‘second opinion’ for his suicide. She told me that barbiturate overdoses ‘work very well’ for patients like this, and that she had done this many times before.

I told her that assisted-suicide was not appropriate for this patient and that I did not concur. I was very concerned about my patient’s mental state, and I told her that addressing his underlying issues would be better than simply giving him a lethal prescription. Unfortunately, my concerns were ignored, and approximately two weeks later my patient was dead from an overdose prescribed by this doctor. His death certificate, filled out by this doctor, listed the cause of death as melanoma. When I reviewed his chart, the radiation oncologist documented a clear diagnosis of depression.

My patient did not die from his cancer, but at the hands of a once-trusted colleague who failed to recognize and treat his depression. This experience has affected me, my practice, and my understanding of what it means to be a physician. What happened to this patient, who was weak and vulnerable, raises several questions that I have had to answer.”

I appreciate that, under the Bill, Dr Bentz could not have been the independent doctor as he already knew the patient and was treating him, but in that case that contributed to enhanced safety. Dr Bentz’s example illustrates the real risks of abuse in a person being able to seek the opinion of a second independent doctor. The starting point is that the task of the independent doctor is not that of a normal doctor. It is not to cure the patient or to provide advice about medical treatments: it is to check whether the eligibility requirements are met. It is a decision-making function, not a medical one—albeit, of course, a decision-making function that is informed by medical expertise.

In the light of that function, it is not appropriate for someone to seek another decision simply because they do not like the answer that has been given. The independent doctor is asked to apply an objective set of criteria against the evidence in front of them in order to make an assessment. It is not the case—or it should not be—that a different doctor would come to a different assessment based on the same criteria and the same evidence. If we are doing our job properly in the Committee, we should not expect that a second opinion could be arrived at.

I have no objection to provision being made for a person to see a second independent doctor if the first did not manage to finish the task. Nor do I object in respect of cases in which there is a change of circumstances—for example, if the patient’s condition deteriorates to such a degree that although the first independent doctor thought the six-month prognosis test was not met, it becomes clear that it is met—which is the point of my amendment 458. In such circumstances, it would make sense to allow the patient to go to a second independent doctor. Although my preference in such a situation would be to go back to the original independent doctor and ask them to reconsider in the light of the change of circumstances, that may not always be possible. Amendment 458 is an attempt to find a middle ground.

Amendment 459 seeks to reduce the possibility of abuse by ensuring that the second independent doctor has available the reasons why the first independent doctor concluded that the person was not eligible. That would allow the second independent doctor to approach the assessment with open eyes. Such a report would be particularly useful when it comes to the detection of coercion or pressure, as the first independent doctor might have spotted something that the second independent doctor might not easily see.

Let us consider the evidence of Dr Tim Howard, who has been deeply involved in end-of-life palliative care and assisted dying for many years. He has been a non-exec director of a health authority, a member of an ethics committee, a postgraduate teacher and, finally, chair of the General Medical Council fitness to practise tribunals, dealing with complex medico-legal principles and decisions in public. He also helped to set up the Medical Practitioners Tribunal Service, which separated medical standard setting and investigation from adjudication.

Dr Howard says:

“I remain uncomfortable that when either doctor, the assessing doctor or the independent doctor, declines to agree with a request for”

assisted dying,

“they take no further action. I feel that the reasons for their refusal should, as well as being given to the patient, be recorded in the patient’s notes, and given to any ‘second opinion’ independent doctor. This is not an attempt to bias; it is a value judgement that criteria are not being met, and as such, is sharing an early warning to be extra careful.”

The Committee should note that he has, in his own words,

“been a strong proponent of medical assistance in dying…and a member of Dignity in Dying for many years.”

Danny Kruger (Conservative, East Wiltshire)

It does seem an extraordinary gap in the Bill, but I am afraid it is not unique to this Bill. In countries where assisted dying in some form is legal, there are remarkable failures to insist on the proper recording of applications that are declined or about which there are concerns. This speaks to the general cloud of unknowing that we are operating in. Does the hon. Lady agree that were we to pass the Bill, it would be great if, at least in this country, we kept proper records?

Sarah Olney (Liberal Democrat, Richmond Park)

The hon. Member is exactly right. An assessment of whether somebody should qualify for assisted dying needs to be based on objective criteria. If those are not met, the only way that a second independent doctor should have a role is if either the circumstances have changed or, for whatever reason, the first doctor is unable to reach a conclusion. There must not be a situation in which the first doctor has made one decision and a second doctor arrives at a different decision, because that would imply a variability in the way the objective assessments are made. Not tightening this loophole would imply that we are prepared to allow such a variability across the medical profession, and I do not think we should allow that.

My final amendment in this group is amendment 460. I am concerned that the word “particular” in clause 10(3) negates the subsection’s purpose of ensuring that only one second opinion from the co-ordinating doctor can be sought, because a person could withdraw their first declaration, make a new one and start the process afresh; that declaration would then not be the “particular” first declaration. By removing “particular”, the loophole would be closed, and the safeguard would be made more effective. This concern was brought out well in Disability Labour’s written evidence:

“We are concerned that whilst 10(3) only allows for one second opinion to be sought, there appears to be nothing in the bill that stipulates a waiting period before a new application can be made. This risks applications being repeated until a supporting opinion can be obtained, thus negating the purpose of 10(3).”

I hope the Committee will accept my amendments.

Simon Opher (Labour, Stroud)

I thank the hon. Member for Richmond Park for her considered amendments. I would like to go through all the amendments in the group.

Amendment 348 is about the doctor communicating the outcome of the assessment, but I understand that that is already covered in clause 8(5)(b), which states that, having carried out the second assessment, the independent doctor will

“provide each of the coordinating doctor and the person who was assessed with a copy of the statement.”

I therefore do not think the amendment is necessary—it would be doubling up.

Rebecca Paul (Conservative, Reigate)

I just point out that the amendment states that the independent doctor would

“inform the person’s usual or treating doctor”,

and that is not covered by the paragraph the hon. Gentleman just mentioned. I hope that is helpful.

Simon Opher (Labour, Stroud)

I do not see what that would add to the Bill. The co-ordinating doctor would have a result and the patient would have had the report back. I do not feel the amendment is necessary—it would over-complicate the Bill—but we can see what the Government’s legal position is on that.

Amendment 303, tabled by my hon. Friend the Member for York Central, suggests that the independent doctor should have to check that there has not already been a second opinion. We need to step back a bit and remember how the Bill will work. Basically, a doctor will refer to a co-ordinating doctor, who will make a full assessment of the patient. If, having carried out the first assessment, the co-ordinating doctor is satisfied that the requirements in the Bill are met, they will refer the person for the independent assessment. That doctor will therefore need to see a report, because he is the co-ordinating doctor. He cannot then get a second opinion from a different doctor; that would not be part of the process under the Bill. I do not feel the amendment would make the Bill any safer.

On the idea of doctor shopping, one of the provisions in the Bill is specifically concerned with that: it allows one, and only one, second opinion to the independent doctor. In medical practice, it is normal and fair that a patient has one second opinion on any assessment, so it is fair to the patient that they can go back to the co-ordinating doctor and get referred for a second opinion from another person.

Sarah Olney (Liberal Democrat, Richmond Park)

Will the hon. Gentleman give way?

Danny Kruger (Conservative, East Wiltshire)

Will the hon. Gentleman give way?

Simon Opher (Labour, Stroud)

Actually no, I will not. I will go on, if that is okay.

Amendment 459 states that the second-opinion doctor “must produce a report” outlining their reasons for reaching a different opinion, but the whole nature of this is that the doctor is independent. As we have heard, if it is suggested that someone either is or is not allowed to get an assisted death, that might affect the assessment of the independent doctor. It would not be good medical practice to have that assessment in front of the independent doctor—that would lead to poor assessments. We need a right to a second opinion and we should have a truly independent doctor.

Amendment 460, which is the last in the group, would allow a patient only one declaration in any part of their lives, even if circumstances change. Although there will be vanishingly few instances where that would be relevant, I do not feel that such a provision would make the Bill any fairer or safer.

Amendment 143, tabled by my hon. Friend the Member for Broxtowe, would allow a second and a third opinion. It is my opinion, and the opinion of many of us, that we do not want doctor shopping. We want to allow one second opinion from an independent doctor, but not more than that.

Juliet Campbell (Labour, Broxtowe)

Amendment 143 has been withdrawn.

Simon Opher (Labour, Stroud)

Has it? Okay. I thank my hon. Friend.

The amendments in this group all come from a good place, and I understand where hon. Members are coming from, but I do not feel that anything in them would make the Bill any safer or fairer for patients.

Lewis Atkinson (Labour, Sunderland Central)

It is a pleasure to serve under your chairship, Sir Roger.

I rise to speak to a couple of the amendments. Amendment 348 is likely unnecessary. I would have been minded to support it had it referred to a registered GP, but the language of “usual or treating doctor” is unconvincing. I am not sure what those terms refer to. The registered GP absolutely should be informed, and both normal practice and the provisions in the Bill about entering information into medical records would mean that that is the case. For me, “usual doctor” is not the right terminology; it does not achieve what I think some of its proponents want. With reluctance, I will vote against that amendment because it does not refer to a registered general practitioner.

On amendments 303 and 458, I believe there must be provision for a second opinion. However, I am persuaded by the points made by the hon. Member for Richmond Park about amendment 459. I slightly disagree with my hon. Friend the Member for Stroud: although the independence of the second opinion is important on matters such as the terminal prognosis, when it comes to the detection of coercion, the more information, the better. It is one thing to be independent in a medical assessment, but the amendment speaks to a psychosocial assessment. We are trying to detect coercion, so it is important that every decision maker gets further information as the process progresses.

The provision for five different touchpoints of assessment is one of the strengths of the Bill. Each assessment should be done in a way that can be progressed with more information. It is not just five different independent points of information; because of the Bill’s record-keeping provisions, the assessment should become increasingly informed throughout the process. I certainly think that the panel, or whatever we get to, should have sight of any negative assessment from an independent doctor, as well as any positive one. The panel will then be able to do its job of scrutinising the two decisions, potentially weighing them up, and calling the different doctors who have given different decisions. I am, then, persuaded by amendment 459.

Jake Richards (Labour, Rother Valley)

It came up in the debates last week that we heard some evidence from medical practitioners on how decisions and assessments were better made when done collaboratively. That means that we need to keep them independent but that, where possible, doctors should be working together in this process. Does my hon. Friend agree that amendment 459, tabled by the hon. Member for Richmond Park, may assist in that?

Lewis Atkinson (Labour, Sunderland Central)

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 (Labour, Aberafan Maesteg)

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.

Kim Leadbeater (Labour, Spen Valley)

I associate myself with the Minister’s comments regarding the other amendments in the group; however, I listened carefully to the debate on amendment 459 and the points made by the hon. Member for Richmond Park, my hon. Friend the Member for Stroud and the Minister. My view on that amendment has changed: I do think independence is really important in the doctor’s opinions during the normal process that the Bill sets out. However, it is a really fair point to make that if the independent doctor refuses the patient, there needs to be transparency about that, and it is important that everybody involved in the process can see how that decision has been made. That is a really valid point. It is a good example of how this Bill Committee is operating, and should be operating, in that we have been listening to different views and opinions.

I take on board the Minister’s point on capacity. We need to be aware of that. We will hopefully debate the third layer later today. That layer may be a panel of experts who are there to oversee the full picture of the patient journey. For them to see what has happened with the doctors that they have interacted with is very important. Therefore, I am minded to support amendment 459.

Danny Kruger (Conservative, East Wiltshire)

I want to respond to a point made by the hon. Member for Stroud. It is relevant to the whole debate about whether we are talking about a medical treatment at all. He made the point, in respect of the question of a second or subsequent referral to an independent doctor, that it is appropriate in medicine to have second opinions; he said that that is normal in medicine, and he is absolutely right. Indeed, there is nothing to stop a patient seeking a third, fourth or any number of opinions if they want to do that and can get a doctor to consider them. The fact is that what we are discussing here is not a medical diagnosis—that is not what is being asked for when someone goes to see the second doctor, or indeed the first. What they are asking for is permission to proceed with the process.

The job of the doctor is not primarily one of diagnosis or advice to a patient, as is appropriate in medicine and is exactly what a second, third or fourth opinion is for. The doctors are giving permission, or otherwise, to proceed. It is a decision that is being made, not a diagnosis. That is very important, because in no other area of law or civil life is the decision by an authority able to be second-guessed with another opinion. People cannot just say, “I don’t agree with this decision; I am going to go and get another one,” unless circumstances change, which is why the amendment 458, tabled by the hon. Member for Richmond Park, is so important.

What is being asked for in these situations is not a second opinion in the medical sense, but a decision. On that basis, it is important that we recognise that the decision has to be final. If the decision is made not to proceed, people cannot shop around until they find someone who will disagree with that first doctor.

Roger Gale (Conservative, Herne Bay and Sandwich)

I am satisfied that the items contained within the clause have been adequately debate. I do not therefore propose to permit a clause stand part debate.

Clause 9 - Doctors’ assessments: further provision

Kim Leadbeater (Labour, Spen Valley)

I beg to move amendment 201, in clause 9, page 5, line 36, leave out “and their medical records” and insert

“, examine such of their medical records as appear to the assessing doctor to be relevant,”.

This amendment provides that the duty on an assessing doctor to examine a person’s medical records is limited to records appearing to the doctor to be relevant.

Roger Gale (Conservative, Herne Bay and Sandwich)

With this it will be convenient to discuss the following:

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

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

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

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

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

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

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

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

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

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

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

Kim Leadbeater (Labour, Spen Valley)

Amendment 201 provides that the duty on an assessing doctor to examine a person’s medical records is limited to records appearing to the doctor to be relevant, which makes sense. Amendment 422 requires an assessing doctor to make such inquiries of professionals who are providing, or have recently provided, health or social care to the person as the assessing doctor considers appropriate. Amendment 423 requires the assessing doctor to consider whether they should consult health or social care professionals, and to consult them if they consider there is a need to do so. A record of any consultation must be shared with the other assessing doctor.

The amendments seek to emphasise the importance of taking a holistic and multidisciplinary approach to the assessments by both doctors. The Bill as drafted provides that the assessing doctor must

“make such other enquiries as the assessing doctor considers appropriate”

when making the first and second assessments. With the amendments, I have sought to strengthen that language, by being much more explicit and making specific reference to consulting health and social care professionals. I have done so in response to the evidence we have received from professionals such as nurses and social workers, who often spend a significant amount of time with terminally ill adults.

It is clearly right that the assessing doctors should have access to all relevant details of a person’s medical records. If the records show that the person has recently been receiving health or social care, that may impact their application, so the doctors have to consult the providers of that care. As is the case at all stages in the process, records should be kept of any and all such discussions, and reports should be shared where appropriate.

Taken together, the amendments would ensure that the doctors’ assessments are thorough and comprehensive, and have taken into consideration the views and opinions of any wider health and social care team that may be working with a patient.

Danny Kruger (Conservative, East Wiltshire)

I will speak briefly to each of the amendments in this group. I will allow my hon. Friend the Member for Reigate to speak to the amendment in her name, but I state clearly that I very much support it. In my view, it is very important that the doctor asks the simple question of the patient, “Why do you want an assisted death?” The question is not being asked at the moment.

I respect the points that the hon. Member for Spen Valley has just made about amendment 201, and that the amendment may be intended to focus assessments on the information that is relevant. Nevertheless, it would introduce subjectivity into what is deemed relevant, and by narrowing the scope of the review of patient records, it could unintentionally allow for incomplete assessments, thereby undermining the safeguards that we all want to see. The risk is that potentially crucial medical history, including past mental health concerns, poor coercion indicators or undisclosed diagnoses, might be overlooked.

I call the Committee’s attention to the evidence from the British Geriatrics Society, which raised concerns that the definition of terminal illness in the Bill is often vague and risks misclassification, especially for older patients. Limiting the review of medical records could exacerbate that issue, as doctors may not have a full picture of the patient’s long-term prognosis and their mental health history. The General Medical Council has called for strong regulatory oversight to ensure that eligibility assessments are thorough.

Allowing doctors to determine which records are relevant, without standardised criteria for that judgment in the Bill, risks inconsistency and potential misdiagnosis. The criteria should include diagnosis and prognosis, treatment history, consultation, second opinions and mental health history. Consideration should also be given to disclosures of domestic violence and abuse, or patterns in medical records that might indicate domestic abuse without explicit disclosure, such as frequent visits for unexplained pain, chronic pain complaints, mental health concerns such as anxiety and depression, inconsistent explanations for injuries, and multiple visits to different healthcare providers. All of that should be properly considered by the assessing doctor.

I draw the Committee’s attention to the fact that in the Netherlands, 1% to 2% of assessments annually—a significant number when we consider the volumes we are talking about—are deemed “not careful” under the law. Other countries do not have adequate ability to look into the data, but that is significant, and it is often due to inadequate consultation or documentation. I also draw attention to the fact that in our country, I am afraid to say, the cause of death listed by doctors is too frequently inaccurate. Analysis of postmortems suggests that one in 20 deaths have been wrongly recorded. Clearly, mistakes are made in medical records, and therefore it is particularly appropriate to require doctors to give complete consideration to the full medical history of the patient.

I recognise very much that we are trying to create a Bill that works in practice; nevertheless, I think we can emphasise streamlining and efficiency at the expense of patient safety, and we are doing that here. If we tell doctors that they are only required to sift through records that appear relevant to them—a quick skim of recent notes, a glance at the obvious items in a medical history—that may sound efficient, streamlined and practical, but it is likely to leave the vulnerable exposed, in particular when social workers and psychiatrists are not involved at this early stage, as they plainly should be. No multidisciplinary team is looking at the patient at this stage.

Medical records in England and Wales are not an easy read, which is perhaps why concerns have been expressed about the requirement that doctors address the entirety of a patient’s medical history. That is a problem. There is a sprawling and fragmented archive of information. I have been discussing that with doctors to try to understand what they have to do. A patient’s story spills across GP files on EMIS or TPP, hospital notes from separate NHS trusts and scraps of paper from decades past. The NHS app gives a snapshot, but not the full picture.

Great care is needed from a doctor reviewing an assisted dying request, not only when it comes to diagnosis and prognosis—as we have discussed at length—but to gain a complete picture of the patient. Mental health history is where vulnerability screams the loudest. I have discussed this with doctors who have raised their concerns with me. A recent record might say, “Anxiety: sertraline prescribed”, which would appear relevant, but what if a psychiatry file siloed in another trust states: “Severe depression, 2023: suicidal ideation”? What if a GP note from five years back states: “Patient tearful, family pressure”? Those are not flashing neon signs, but they are there. The complex and difficult cases that we have spoken about again and again are the ones that are missed when a doctor skips the deep dive—when they look just for what they regard as relevant information, providing the necessary legal cover for any criticism after the event.

Let us think about abuse. Coercion does not advertise itself. A patient’s “yes” to assisted dying in last month’s consultation might look voluntary, leading us to close the case, but a safeguarding log saying, “Concerns raised about son’s influence, 2022” or “A&E visit: bruising unexplained” might sit untouched in files that might be dismissed as irrelevant. We know that these things are already missed too often.

This is not hypothetical. Buckinghamshire Disability Service informed me that disabled people are so used to finding that their NHS records are incomplete or inaccurate that Citizens Advice and other advice agencies recommend to them that they get their local record—their summary health record—personal independence payment-ready before they apply for disability benefits. People extremely commonly find diagnoses and treatments missing, wrong dates and inaccurate statements—the wrong leg listed as amputated; allergies or medication intolerance wrongly cited; major health incidents, including heart attacks, not listed; long-term conditions such as diabetes wrongly listed or not included. Mental health conditions are particularly likely to be missed off health summaries. This is not about bureaucracy or drowning doctors in paperwork.

Lewis Atkinson (Labour, Sunderland Central)

Does the hon. Member share my concern that the wording in medical records has no duration over a person’s lifetime? For example, consulting all the medical records of someone in their 70s or 80s at the end of their life would surely include the records from when they were a child—childhood vaccinations, the removal of tonsils and so on—and that would clearly be impractical. Does he not agree that amendment 201 would clarify that element?

Danny Kruger (Conservative, East Wiltshire)

What the amendment clarifies is that the doctor does not have to look at any records at all unless he or she considers them relevant. It gives total discretion to the doctor to disregard huge swathes of the patient’s history. Yes, I do expect the doctor to review the entirety of a patient’s record—obviously, the record of a childhood broken leg can be skipped over quickly. What I do not want to do, as the Bill currently does, is allow the doctor to say, “Oh, I missed this evidence of a mental health condition” or “this indication of coercion from five or 10 years ago, because I didn’t consider that aspect of their records to be relevant.” It places a significant obligation on the doctor, but that is, I am afraid, what we are doing in the Bill. We are placing huge obligations on doctors and we should do it properly.

Simon Opher (Labour, Stroud)

As the amendment states, it is about examining medical records for things that are relevant. If we are talking about coercion or capacity, these sorts of items will be relevant. I do not know if Members have ever seen medical records. Some people have extremely large medical records, and we have summaries for that, but if a part of that summary indicated something that we were suspicious of, we would look into it. As my hon. Friend the Member for Sunderland Central has just said, the complexities of childhood tonsillitis do not really need to be examined in this case. We have to, and we always do, specify what we look into doctors.

Danny Kruger (Conservative, East Wiltshire)

As I have said in my many exchanges with the hon. Gentleman, I want to see the good practice that he claims—absolutely accurately, I am sure—to perform is applied across the system. He says that if doctors see in the summary some indication of concerns, they will look more closely into it. Well, I jolly well hope they would. The problem is that the summary might not be complete. I suppose the distillation of my point is that we should say, “Don’t rely on the summary. Proceed with a proper analysis. Take responsibility for making sure that you have reviewed the entirety of the patient’s record.”

We have to address throughout our consideration of the Bill the workload that we are placing on busy professionals. Nevertheless, if we consider that this matters—and it is a question about knock-on effects on the NHS, which we could discuss in due course—it is appropriate to expect proper time to be taken. A specialist with two hours and a full record in front of them might spot the misdiagnoses, question the prognosis, flag the depression and catch the abuse. If given half the time and a licence to skim the record, as the amendment would give them, they could very easily miss something, so I think the word “relevant” is a great gamble.

Lewis Atkinson (Labour, Sunderland Central)

The hon. Member is discussing amendment 201, but there is also amendment 422, which indicates that the professional should make inquiries of other healthcare professionals who have been involved in treatment recently. Does he not agree that that would mitigate against the sort of scenario he describes?

Danny Kruger (Conservative, East Wiltshire)

I will come on to that. I agree with him: amendment 422 is a very helpful amendment, and I support that. It is a very good suggestion that wider consultation should be made, and it is a point that we have been trying to make with amendments throughout. I recognise that that would enhance the safeguards in the Bill—I am grateful to the hon. Gentleman.

Amendment 422 seeks to introduce an additional requirement that the assessing doctor must consider whether to consult health or social care practitioners who are providing, or have recently provided, care to the patient. The amendment is presented as addressing previously expressed concerns, but I regret to say that I feel it is excessively weak. It is a positive step in recognising the issue, but it does not ensure a broader and more informed assessment of a patient’s condition and external influences.

Patients with terminal illnesses often receive care from palliative care teams, social workers or community nurses who might have crucial insights into their wellbeing and the potential external pressures on them. The British Psychological Society has highlighted that mental health and social pressures are often overlooked in assisted dying requests in other countries. Social workers and allied health professionals play a key role in assessing whether a patient feels pressurised due to financial, social or familial burdens. As I have repeatedly said and we will debate further in due course, in my view it is very important that that assessment comes earlier in the process.

We have evidence from doctors—I will not cite it at length—pointing out that independent doctors who refuse assisted dying requests are often ignored, and patients are simply referred to another doctor willing to approve the request, as we have discussed. Consultation with health and social care professionals could act as an additional safeguard against that practice. Although the amendment introduces an obligation to consult other professionals, it leaves it to the discretion of the assessing doctor. It relies on the doctor’s subjective judgment

“if they consider that there is a need”.

I think that is too weak for assisted dying, where consistency is so critical. One doctor might consult a palliative care specialist to explore pain relief options, while another might not, assuming that they understand the patient’s suffering sufficiently. The variability in the Bill—this discretion—undermines fairness and safeguarding.

There is also a lack of accountability in what is a very sensitive process. There is no requirement to document the consideration process, which weakens oversight in a context where errors could be fatal. I respect the point made by my right hon. Friend the Member for North West Hampshire that we must not police conversations and that being prescriptive may encourage a tick-box approach. I am afraid that we risk that tick-box approach if this amendment is all that we do on this subject. We can imagine a scenario in which a doctor simply makes a note in the record with little underpinning substance.

There is also no obligation to act on the specialist input, so the duty ends at the consultation. There is no requirement to integrate the findings of the additional input that the doctor has received, which is a glaring flaw in what is an irreversible procedure that is being authorised. Finally, there is insufficient rigour for the ethical stakes. This discretionary duty is too weak to catch the difficult cases.

Kim Leadbeater (Labour, Spen Valley)

On the hon. Member’s point about recording those consultations, amendment 423 states in its proposed new subsection (2B):

“Where an assessing doctor consults a professional…the assessing doctor must give a written record of the consultation to the other assessing doctor.”So the consultation is recorded.

Danny Kruger (Conservative, East Wiltshire)

The hon. Lady is absolutely right, and that is very welcome. My concern is that there is no obligation to do anything about it. There is no obligation for the doctor to integrate the conclusions of the additional professionals that they have consulted into their treatment. I recognise that that provision is valuable and I welcome the amendments, but I suggest that they do not go far enough.

Let me use a hypothetical example to bring my point home to the Committee. Imagine a woman with terminal lung cancer asking to end her life. Her assessing doctor considers consulting a palliative care specialist for symptom control or a social worker to check on her home life, but decides, “My notes are enough. There’s no need for that.” What if the patient’s pain could be eased with a new approach that the doctor does not know about? What if her family’s pushing her to spare them the burden of her care goes unnoticed without a social worker’s input? The lady might die needlessly or be denied treatment unfairly.

The discretionary duty that the amendment would introduce essentially collapses because it does not force the broader scrutiny that patients deserve. The amendment sees the problem, but it is too feeble: it is too discretionary, too vague and too unenforceable for a choice as profound as assisted dying. While I will support it, I do not think it goes far enough.

Amendment 423 builds on amendment 422 by requiring that if the assessing doctor consults a specialist, a written record of that consultation must be shared, as the hon. Member for Spen Valley just mentioned. It is critical for transparency, consistency and accountability in decision making. In high-stakes cases, such as assisted dying requests, paper trails matter. Without a formal record, one assessing doctor might dismiss concerns raised by another professional without accountability—a point made by the hon. Member for Richmond Park.

As I pointed out in an intervention on the hon. Member for Richmond Park, it is remarkable how few jurisdictions around the world have such safeguards. The American model in Oregon, Washington and California does not track how many doctors a patient consults before finding one willing to approve an assisted dying request, so we do not know the extent of doctor shopping abroad. Canada’s system does not require refusals to be formally documented, making it difficult to assess the patterns of approval. Ensuring that records are available to both assessing doctors would add an extra layer of scrutiny and help to prevent doctor shopping.

However, while the amendment is a step in the right direction, it does not require an independent review of the records. Sir James Munby, the former president of the family division of the High Court, has criticised the lack of procedural rigour in oversight mechanisms, warning that assisted dying laws risk becoming a rubber-stamp exercise if refusals and approvals are not documented with transparency. The Royal College of General Practitioners has called for independent oversight of the entire process, not just a reliance on individual doctors. These amendments would partially address that, but would not fully resolve it.

Amendments 422 and 423 are welcome but otiose: they would simply give doctors permission to do what they should be doing anyway. If they are conscientious, they will do it anyway, and if not, they will not. It is slightly like an illegal gun amnesty: the good guys will not have illegal firearms in the first place, and the bad guys with guns are not going to hand them in voluntarily. I fear that we are requiring good behaviour of good people, and not requiring it of doctors who are not doing their job properly.

We are constantly told that the Bill is about patient autonomy, but in fact we are creating huge doctor autonomy, and in one direction only. Amendment 201 refers to

“appearing to the assessing doctor to be relevant”,

amendment 422 to

“as the assessing doctor considers appropriate”,

and amendment 423 to

“if they consider that there is a need to do so.”

That is helpful in so far as it makes it clear they should pursue good practice, but there is a real concern that it will be seen as unnecessary to query the patient’s wish, examine their records or consult previous medics or other specialists, because it will be regarded as bureaucracy.

It has been suggested in this Committee that we are creating unnecessary hoops for doctors and patients to jump through. I am afraid that leaving it to the doctor’s discretion will compound the problem. Any discretionary inquiry to other doctors will be seen by the patient as unnecessary delay and will be potentially very stressful to them. My view is that inquiries should be routine and mandatory, but meaningful. They should be done properly. The only way to ensure that is by strengthening the Bill in the way we have suggested.

Roger Gale (Conservative, Herne Bay and Sandwich)

Order. Rebecca Paul has an amendment tabled in this group, so I shall call her next. I have had indications from Rachel Hopkins and Dr Opher that they wish to speak, and I see two others, of whom I shall make a note.

Rebecca Paul (Conservative, Reigate)

It is a pleasure to serve under your chairmanship, Sir Roger. I rise to speak to my amendment 468 to clause 9, which would ensure that the assessing doctor must

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

We have heard a lot in this Committee about the importance of the patient-doctor relationship. My hon. Friend the Member for Solihull West and Shirley said that we should be

“trusting in the judgment of clinicians, who know their patients well”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 26 February 2025; c. 634.]

He also said that patients

“may want to speak to their GP because they have had a relationship with them over 30 or 40 years”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 25 February 2025; c. 481.]

It is therefore worth asking how the Bill shapes the patient-doctor relationship.

The Bill asks doctors to do many things to and for patients. It asks doctors to consider whether to raise the subject of assisted suicide; personally, I wish we had agreed to the amendment that would have ensured that it was the patient who brought the subject up first, but we are where we are. The Bill asks doctors to explain the patient’s diagnosis and prognosis and to lay out options for treatment and palliative care, if there is any available; if there is not, the doctor can only state that point and move on. Nevertheless, we are asking the doctor to look into the matter and lay out possibilities.

The Bill asks doctors to check for capacity and for coercion, to ascertain whether the patient has a clear, settled and informed wish to end their own life, to witness declarations and, eventually, to give the patient a substance and oversee the patient taking it. In other words, it makes doctors absolutely central to the process, as the facilitators of the process, as the people who accompany the patient and as the professionals with the biggest responsibility for ensuring that the safeguards are followed, yet it never asks doctors to make a simple but vital inquiry: why?

That is all that my amendment would add. It would simply require the assessing doctors to ask the person why they are seeking an assisted death. I hope that the Committee will agree that that would be a reasonable and not overly burdensome change. Some hon. Members have suggested that certain amendments embroider the Bill too much, but in this case, the patient-doctor conversation is already embroidered. The Bill makes some very specific demands of the doctor as to what the conversation should cover. Surely it is only natural, amid all the conversations, for the doctor to take a moment—perhaps more than a moment, but a moment at the very least—to help the patient to talk through their reasons. This is a very vulnerable moment in somebody’s life.

The simplest of questions can often unlock the most information. In some cases, for the small number who would benefit from the Bill, the answer would probably reassure the doctor, but for those others we worry about, the question would provide another important safeguard. It would be another opportunity to check that this really is in the best interests of the patient.

How would the conversation go? I do not think that we can generalise. It might be the briefest exchange or it might lead to a really searching discussion. Doctors know how to take their cue from the patients in these things. Crucially, the doctor’s role is not just to offer advice or information. Even if the doctor says nothing, it may make all the difference for the patient to be able to speak aloud their concerns, their confusion and their hopes and fears. I absolutely accept that many doctors, if not most doctors, would ask the question why anyway, but given its importance, I still urge the Committee to set that out in the Bill. In doing so, we would be affirming that this is more than a bureaucratic exercise; it is about a person and about getting to the truth of what they want and need.

I do not think we should not make the mistake of assuming that every doctor has the time, or will take the time, to have the in-depth conversations needed to really understand what is driving a patient’s request. It is up to us to make legislation that keeps standards high at all times. There is currently nothing in the Bill that will guarantee an in-depth conversation. I am afraid that not all doctors believe that that is even a likely outcome. In written evidence, the GP Edward Tulloch states:

“To conduct the required assessments outlined in 7.2 and 8.2 of the Bill within a standard GP appointment (lasting 10-15 minutes) is completely unrealistic. It will require multiple appointments to properly carry out such detailed discussions and complete the associated legal paperwork.”

We all know what pressure the NHS is currently under. Many of us cannot get a GP appointment. So, how certain are we that adequate time can be allocated to the assisted dying process to ensure the criteria are truly met?

By putting the “why” question on the face of the Bill, my amendment would bring us closer to the possibility of real, serious and honest conversations about a patient’s reason for seeking an assisted death. That would be especially helpful for those who have just received a terminal diagnosis. We have received some important written evidence from six palliative care doctors, who state that

“our experience is that many patients experience a period of adjustment to ‘bad news’ and may say that they cannot live under these conditions. However, after a period of reflection and adjustment, the majority come to find peace and value in their altered life circumstance, in a way they would not have believed possible.”

The consultant psychiatrist Jennifer Bryden provides an especially interesting perspective, as someone who has seen this from both sides:

“Having gone through several long episodes of illness, I now know that feeling entirely useless and a burden to everyone is a phase that will pass. For many people a terminal diagnosis will be their first time through the cycle and they will believe those thoughts represent reality. In coming to terms with a severe illness, depression is an expected phase and learning to accept all humans need each other takes time”.

Dr Bryden goes on to say that the current cooling-off period is not enough time for people to come to terms with such a diagnosis. Clearly, people may need all the help they can get to understand their new situation. Asking the patient for their reasons is only the beginning of that process, but one that may help them come to terms with their situation and validate, or not, their initial inclination.

Finally, asking why can identify those patients who are being coerced or pressured. Nobody should think that that is easy to spot. According to the charity SafeLives, which counters domestic abuse, it takes the average person who experiences violent abuse 2.3 years to access effective help. In the year before they finally get help, 85% of victims will have sought help of some kind from an average of five professionals. Often, sad to say, those who missed the signs will have been healthcare professionals. That is for physical abuse; psychological abuse will be far harder to spot. We cannot put in enough safeguards to ensure that doctors have all the tools they need and all the opportunities they can, to spot those signs.

Jack Abbott (Labour/Co-operative, Ipswich)

For clarity, at what point in the conversation does the hon. Member expect the question to be raised? In reference to an assessing doctor, do I take it that the question must be asked twice, at different times, by both the co-ordinating and the independent doctor?

Rebecca Paul (Conservative, Reigate)

I thank the hon. Member for his very good questions. I suggest that it be asked twice, because it makes a lot of sense to ensure that the patient is given the chance to really explain what is driving their decision. It is the simplest of questions, but it is amazing what can sometimes come out of the simplest question.

I return to the safeguard against coercion. In a sense, this is not a new safeguard; rather, it confirms and bolsters the other safeguards in the Bill, which are there to explore the reasons for assisted dying. Asking why will help doctors to better understand what is driving a patient’s decision and to give that patient an opportunity to validate that they are truly eligible. It is the simplest of questions, driving the most significant conversation that a doctor and patient can have. I hope that hon. Members will support my amendment.

Rachel Hopkins (Labour, Luton South and South Bedfordshire)

It is a pleasure to serve under your chairship, Sir Roger. I rise to speak in support of amendments 201, 422 and 423, which stand in the name of my hon. Friend the Member for Spen Valley, and against amendment 468.

On amendment 201, a point was made earlier about the relevance of records. It was mentioned that it might well not be relevant to look at a childhood tonsillectomy. However, I wish to speak in slightly more specific terms, in support of women and their reproductive rights, and to highlight the risk of unconscious bias if all records are to be looked at.

If a woman had a termination in her teenage years, that will be highly irrelevant to her decision, many decades later, whether to choose an assisted death. Relevance is very important, because there will be a high level of record keeping in the process. It is not only the doctors working with the patient on the assessment who will read the records and reports; ultimately, it will also be the panel. I make the point again that so many parts of a patient’s medical records are highly irrelevant to the diagnosis and prognosis of a terminal illness, and to the six months under the eligibility criteria. Indeed, there is a risk of unconscious bias in the judgment. It is about the professionalism of the doctor in respect of understanding the records that are relevant for the process.

Danny Kruger (Conservative, East Wiltshire)

Will the hon. Lady give way?

Rachel Hopkins (Labour, Luton South and South Bedfordshire)

I will continue, if I may.

I turn to amendments 422 and 423. The importance of a rounded, holistic assessment and discussion with the patient has been pointed out in many of our discussions, as has the importance of the multidisciplinary team and the other health and care professionals who support the patient with health and social care. That would all have to be recorded—the conversations that have been had, and why the assessing doctors and other health and social care professionals were involved. In oral evidence, many doctors in other jurisdictions said that they worked in multidisciplinary teams. The amendment would firm that up. It is about being clearer, because the clarity that the amendments provide would make for a stronger process.

On amendment 468, the hon. Member for Reigate pointed out that it asks a very simple question. However, I return to the point about the professionalism of the doctors involved in the process, who will be working within the legal requirement under the Bill that the individual have a clear, settled and informed wish. The doctors will have to check individuals’ eligibility under the requirements, for example that they are over 18 and have a terminal illness with a six-month prognosis. The doctors will use their expertise and professionalism, and that of the multidisciplinary team, to make assessments about coercion. They have strong rules about assessing for capacity.

The requirement to ask why someone wants an assisted death is a requirement to police the conversation that the doctor has with their patient. Setting it out in primary legislation would lead to a tick-box exercise, with doctors saying, “You’ve told me a number of times already in our conversation that I’ve been having with you, but I’m sorry: I have to officially ask this question and tick the box.” That could lead to an insensitive conversation and relationship between the relevant people in the process.

To a certain degree, the patient may think, “So what? Do I have to tell you why? It is none of your business why I want to pursue this legal course of action down the line.” I appreciate where the hon. Member for Reigate is coming from, but with the best of intentions, her amendment would actually lessen the individual’s autonomy and their right to choose what if the Bill passes will be a legal course of action. I am content that the stringent training that will be required for any of the assessing healthcare professionals will enable a good holistic conversation so that good judgments can be made. Adding this extra sentence would detract from that, so I cannot support the amendment.

Sojan Joseph (Labour, Ashford)

I support amendments 422, 468 and 423, which I think would strengthen and safeguard the Bill. However, as someone who worked in mental health for many years, I have grave concerns about amendment 201, which would restrict access to medical records. Health professionals work in environments with great confidentiality of records; I have no concern about health professionals or doctors having access to health records. Some Committee members have talked about doctors not needing to know whether a person had tonsillitis, but most medical records or GP summaries will note whether someone has had tonsillitis, along with details about vaccinations and infections. I do not think that those records will necessarily be relevant or that a doctor would look in detail at what medication they have had in that respect.

What is relevant, however, are records for people who have a mental health disorder or are vulnerable. For example, people with serious mental illnesses such as chronic treatment-resistant schizophrenia may be on treatments such as clozapine that, if stopped, will have an impact on their mental health. The treatment that they may undergo during terminal illness may have an interaction, and medication that they have been using for many years to treat their mental health condition may have to be stopped. Doctors need to know why the person wanted to choose that route, and whether it will have an impact on their mental health.

Restricting access to important medical records by the doctor who makes the decision will have an impact on very vulnerable people. As we have discussed before, people may be homeless or may not have any family members, and it will all have an impact on why they decide to seek the assisted dying route. People may feel that they are a burden to society and the system. If there is any documentation from six months or a year ago, it will be relevant for the doctor. Removing access to medical records for doctors will have an impact on people with mental disorders, intellectual disabilities and neurodevelopmental conditions, so I oppose amendment 201, although I support the other amendments.

Naseem Shah (Labour, Bradford West)

I will try to keep my remarks brief. I first speak to amendment 468, tabled by the hon. Member for Reigate, on the asking of the question why someone wants to have an assisted death. When I originally came to this debate, Dermot, a humanist who was also my election agent—a lovely guy—came to me and said, “Now that this Bill is going through Parliament, will you support it”? I said, “Explain it to me.” He never once mentioned the word “autonomy”. If I remember correctly, what he talked about was suffering, pain and horrible deaths, which many hon. Members have referred to. We have heard lots of examples during this Bill Committee.

My hon. Friend the Member for Luton South and South Bedfordshire said that the decision was none of a doctor’s business and that the issue was about autonomy. However, if a woman was being coerced into an assisted death, the idea that it was none of the doctor’s business would not quite wash with me. We talk about autonomy, but if someone does not have autonomy in their lives—if they are in an abusive relationship, are a victim of coercion or have a vulnerability—they might not have the choice.

When we ask a question, it is often about something else. I have experienced this myself. I am very passionate; when I am talking about things, somebody might just stop me and say, “Naz—what’s this actually about?” That is all it takes to make me stop, take a step back and a breather, and think for a deeper minute about whether the issue could actually be about something else. We do not always stop to think.

Simon Opher (Labour, Stroud)

The amendment is good practice; I do not in any way deny that. The hon. Member for Reigate is obviously coming from a really good place. However, the amendment is almost like specifying that when someone goes to see a doctor, the doctor has to say, “How can I help? What is wrong?” It is just unnecessary; that is my only feeling about it. If someone came in and said, “I would like to request an assisted death”, the doctor would not just say, “Okay”—they would ask how the patient was feeling. It is normal medical practice to ask what is going on in someone’s mind, so that does not need to be specified in the Bill.

Naseem Shah (Labour, Bradford West)

I thank my hon. Friend for his intervention. There is a medical model and a social model of intervention. If I walk into a GP surgery with a really bad headache, I am prescribed paracetamol. If the headache gets worse, I am prescribed something stronger—maybe co-codamol or codeine. Doctors are really busy. We have had to add another 40,000 appointments just for people to get through systems, so we know how hard it is to get a GP appointment.

If the person who turns up at the GP’s with a headache is usually quite healthy, the doctor might not take a minute to ask about what has actually happened. If I say, “I have a headache because I am banging my head against the wall—I have that much stress”, that is a whole different conversation. Having that conversation with the patient—probing a little more—is, for me, very important from a holistic point of view.

Rachel Hopkins (Labour, Luton South and South Bedfordshire)

I want to check that my hon. Friend was not implying that I had not thought deeply—for more than a minute–in the course of making my comments earlier.

Naseem Shah (Labour, Bradford West)

No, that was not my implication. When referring to my hon. Friend’s remarks, I was speaking about a patient perhaps saying “It is none of your business” or that my hon. Friend was talking just about autonomy.

Rachel Hopkins (Labour, Luton South and South Bedfordshire)

I am grateful to my hon. Friend for reiterating those points. Does she accept that it is a patient’s right to say, “It’s none of your business” in the course of the conversation?

Naseem Shah (Labour, Bradford West)

I absolutely accept that it is the patient’s right to say, “It’s none of your business”, with the really clear caveat that they could well be a vulnerable patient. They might say that it was none of the doctor’s business, and that doctor might then not be able to explore the other things going on with that patient. That is why, for me, this does not wash.

The point that I am trying to make is that, in the course of a normal consultation, it is presumed that every doctor will know their patient and be able to have these conversations. In most cases, they probably will because we have amazing doctors; I have amazing relationships with my doctors. But does that mean that the doctors will ask that one question: “Why?” That is the crux of the whole Bill.

Rebecca Paul (Conservative, Reigate)

The right to say, “It’s none of your business” might be fine when no one else is involved, but if someone seeks an assisted death, that involves multiple members of NHS staff. There is an impact on all those people, who need to be comfortable with what they are doing. Maybe the person needs to accept that they do need to provide some information so that the medical staff feel comfortable about the question of eligibility.

Naseem Shah (Labour, Bradford West)

That opens up a whole different debate for me. Some clinicians will not sign up to this process and some will. That is a whole different debate, but I take the point that there has to be a reason.

We talk about the option for referral to palliative care. I have previously moved amendments that would have meant a referral, without the option; however, when considering that option, a doctor needs to understand that if a patient says, “I do not have to explain myself—full stop”, or, “I do not want to talk about palliative care”, that should raise alarm bells. If a doctor says, “You’ve got this terminal illness. These are the options—let me spell them out for you. You have the option of referral to palliative care and the option of these drugs, so why do you want to kill yourself?”, and the patient turns around and says, “It’s none of your business”—

Rachel Hopkins (Labour, Luton South and South Bedfordshire)

Will my hon. Friend give way?

Naseem Shah (Labour, Bradford West)

Sorry, I will just finish my point.

From a common sense perspective—I am not medically qualified—that situation should make me, as a human being, want to understand more. As a human being, I would like to understand whether something else was going on, such as anger towards—

Jake Richards (Labour, Rother Valley)

Will my hon. Friend give way?

Naseem Shah (Labour, Bradford West)

Sorry, I will not give way until I have finished my point.

I would like those conversations to be at least explored, which is why I support the amendment.

Rachel Hopkins (Labour, Luton South and South Bedfordshire)

The Bill already sets out a number of things that a doctor has to assure themselves of, with regard to coercion and capacity. They would do that having had a significant amount of training to establish, in the round, after consulting others, that one way or another the legal requirements have been met. The “Why?” question appears to me to bring in a judgmental element—

Kit Malthouse (Conservative, North West Hampshire)

Subjective.

Rachel Hopkins (Labour, Luton South and South Bedfordshire)

Indeed: subjective, as the right hon. Gentleman said. That is the point that I am trying to get at. There is an objective assessment, which is wholly appropriate, but a subjective assessment would lead down a different route and muddy the objective assessment.

Naseem Shah (Labour, Bradford West)

I absolutely see where my hon. Friend is coming from and appreciate her concern, but we will have to agree to disagree as we have a difference of opinion. A subjective assessment might reveal that something else is going on for that patient.

I hate to put myself in this position, but imagine I have just received a diagnosis and I am going to die within six months. I could have a whole load of anger about that happening to me and I could say, “I don’t want this. I don’t want to talk about it. It’s none of your business. I’m angry—this is what I want.” At that point, does the doctor stop? In most cases, my hon. Friend the Member for Luton South and South Bedfordshire is absolutely right, but in some cases she might not be. I might want to shut the conversation down because I am angry or because other things are going on in my head and I do not want to explain. Amendment 468 would allow the doctor, from a compassionate point of view, to have another conversation with the patient.

Jake Richards (Labour, Rother Valley)

Does my hon. Friend agree that she is making a powerful case against amendment 468? A multitude of conversations and different circumstances will need to be taken into account; it is wholly inappropriate to have a mandated question in primary legislation. We should go back to clause 1, which I think the Bill is actually about. It states that the person must have

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

Does my hon. Friend agree that that is what is at the heart of the Bill, rather than decisions about what is in the person’s best interests?

Naseem Shah (Labour, Bradford West)

I respectfully disagree. I am making the case that there is a conversation to be had. Yes, there is informed choice but is my hon. Friend suggesting that the question should not be asked at all? I take the point that with an informed choice there would have been an exploratory conversation, but sometimes just calling something out, or stating the obvious, makes a huge difference.

Rebecca Paul (Conservative, Reigate)

I wish to clarify that the amendment is about not an additional assessment but merely a simple question. Like many who have spoken, I hope that most good doctors would ask the question anyway and take the answer. It may inform them or it may not but sometimes, as the hon. Member for Bradford West has just discussed so powerfully, it is helpful to remind medical staff, who are under lots of time pressure, that sometimes it is worth stepping back and asking why.

Naseem Shah (Labour, Bradford West)

I agree. Sometimes it will be the simple thing of asking the question as a human being—among all the conversations that are happening, just stopping and asking why.

Jack Abbott (Labour/Co-operative, Ipswich)

I appreciate that my hon. Friend has given way a number of times, but I gently suggest that we already know the crux of the Bill and what we are debating. The “why” is that people with a terminal diagnosis, with six months to live, would like a course of action to end their lives in a pain-free way and to have the autonomy to do so.

We are in danger of over-legislating for a range of different permutations that could potentially happen in conversations. I agree that these kinds of questions are absolutely crucial, but it may satisfy my hon. Friend that amendment 21, to which we agreed a few moments ago, requires medical practitioners to take training on

“domestic abuse, including coercive control and financial abuse”.

That sort of protection and safeguard has already been agreed to.

We will rely on highly specialised individuals to pick up on these issues. They may want to explore, through further questioning, why people are making these decisions but we cannot legislate for all the different sorts of conversations, and all the emotions that may be going through people’s minds. If someone comes back and says, as my hon. Friend put it, “Well, it’s none of your business,” or whatever the answer may be, we will rely on the specialised professionals to pick up on danger signs. However, that would not necessarily lead them in every single conversation to have a suspicion of the patient’s motives. Life and conversation do not work like that and we cannot legislate in that way.

Naseem Shah (Labour, Bradford West)

I absolutely agree that life does not work like that. Life is very complicated and that is why I want the conversation to happen. My hon. Friend referred to amendment 21, which we have just agreed to. I spoke extensively about why that is a brilliant amendment that moves us towards much more safeguarding, but I also think that it does not go far enough for women, marginalised communities and people from ethnic minority backgrounds. I genuinely do not feel that amendment 468 is about over-legislating. It is just stating an obvious fact: sometimes, even in normal life, we go around the houses to get to a conversation and get to the right point. That is what I want to get to.

Jack Abbott (Labour/Co-operative, Ipswich)

To follow up on the example my hon. Friend gave earlier, if—to be glib—someone said, “None of your business”, she would want the doctor to keep probing. At what point does that end? If someone genuinely does not want to have that conversation and says, “I want to end my life because I have a terminal diagnosis. I live in fear of the pain that could await me and I don’t really want to go into much detail,” where does that end? Where does that conversation continue to?

Naseem Shah (Labour, Bradford West)

My hon. Friend makes my case for me. If that person says, “It’s none of your business, but I have so much pain,” at that point, automatically, as we naturally do as human beings—

Jack Abbott (Labour/Co-operative, Ipswich)

But this is a pure example.

Naseem Shah (Labour, Bradford West)

That example is a good example that strengthens my position.

Danny Kruger (Conservative, East Wiltshire)

I completely agree with the hon. Lady’s point. The conversation goes on in the way the doctor would want it to, but they have at least asked the question. Is it not very simple? The Bill already requires doctors to look for signs of external coercion. As we have acknowledged, there is no way to determine internal coercion—the influence people have on themselves. There is no way in the Bill at the moment to identify whether somebody feels that they want an assisted death because they fear that they are a burden to others. This question is the only opportunity we have to tease out that answer: does she agree?

Naseem Shah (Labour, Bradford West)

I thank the hon. Member for that intervention and he makes an important point.

Kit Malthouse (Conservative, North West Hampshire)

What is an acceptable answer? Can we have a list?

Naseem Shah (Labour, Bradford West)

Does the right hon. Gentleman want to intervene?

Kit Malthouse (Conservative, North West Hampshire)

indicated dissent.

Naseem Shah (Labour, Bradford West)

The hon. Member for East Wiltshire makes an important point. Where are the opportunities? When doctors are doing the assessment.

The other issue that speaks to me is the question of internalised bias. We will have professionals with subconscious bias or affirmed bias. They will be clinicians who have chosen or agreed to take part in the process; fundamentally, the majority of clinicians will not take part in this process because of their beliefs. It changes the relationship between doctor and patient from a societal perspective.

I know that a number of times I have been stopped during a process and asked a different question, and at times that opportunity for reflection—even without the pressure of knowing I have only six months to live—is of benefit to me. I am sure that others would benefit from it, too, particularly because the decision is so momentous. For that reason, I will certainly support amendment 468.

I thank my hon. Friend the Member for Spen Valley for tabling amendment 201. I have mixed views on it. I appreciate what my hon. Friend the Member for Luton South and South Bedfordshire said about medical records, especially when it comes to women and their past, but I also appreciated what my hon. Friend the Member for Ashford said about his experience from a mental health perspective.

I am still thinking about the amendment and I am not sure whether I will support it or not, but further thought needs to be given to the subject. There are the issues of mental health and women’s rights, but another issue applies, too. If someone has experienced trauma in childhood but that trauma has come out much more recently, even though it does not necessarily affect the decision at hand—whether to choose an assisted death—is there some kind of historical post-traumatic stress disorder that would then need to be explored? I do not have the answer, but I look forward to hearing the comments of my hon. Friend the Member for Spen Valley on that point. I would value hearing whether she has thought about that and what her understanding of it is.

Stephen Kinnock (Labour, Aberafan Maesteg)

As I have mentioned before, the Government have worked closely with my hon. Friend the Member for Spen Valley on some mutually agreed amendments, including amendments 201, 422 and 433. The amendments that the Government support aim to ensure the legal robustness and operability of the legislation, should it pass, and I will offer a technical explanation for them.

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

Amendment 422 would add an additional requirement on an assessing doctor to make inquiries of professionals who are providing or who have recently provided health or social care to the person and make such other inquiries as the assessing doctor considers appropriate. This applies to—

Roger Gale (Conservative, Herne Bay and Sandwich)

Order.

Esther McVey (Conservative, Tatton)

I remind the Committee that electronic devices should be turned off or switched to silent mode and that tea and coffee are not allowed in the Committee Room.

We will now continue line-by-line consideration of the Bill. I remind Members that interventions should be interventions, by which I mean that they should be short and should raise a point of clarification or ask a question; they are not speeches. Members who wish to give a speech should bob, and should continue to do so at the appropriate points in the debate in which they wish to take part. When Members say “you”, they are referring to the Chair, which is me. If they do not mean me, they might find it easier to look at me and direct their speeches to me, so that they address the Committee correctly.

Esther McVey (Conservative, Tatton)

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

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

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

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

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

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

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

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

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

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

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

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

Stephen Kinnock (Labour, Aberafan Maesteg)

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

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

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

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

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

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

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

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

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

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

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

Kim Leadbeater (Labour, Spen Valley)

I have nothing further to add.

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

I beg to move amendment 93, in clause 9, page 6, line 1, leave out “might” and insert “is to”.

Esther McVey (Conservative, Tatton)

With this it will be convenient to discuss the following:

Amendment 305, in clause 9, page 6, line 3, after “about death” insert

“and any other effects in addition to death.”

This amendment would require the assessing doctor to explain effects the provided substance would have in addition to death.

Amendment 142, in clause 9, page 6, line 3, after “death” insert

“and how it will be administered”.

This amendment requires the assessing doctor to explain and discuss with the person how the substance that might be provided to assist the person to end their own life will be administered.

Amendment 362, in clause 9, page 6, line 3, after “death” insert

“and the risk and nature of possible complications including pain”.

This requires the doctor to explain the risk of possible complications to the person.

Amendment 306, in clause 9, page 6, line 6, after “section 18” insert

“including the escalation of medical intervention”.

This would require the assessing doctor to include the escalation of medical intervention in their discussion of the person’s wishing in the event of complications arising in the administration of the substance under section 18.

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

It is a pleasure to serve under your chairmanship, Ms McVey, and to speak to this group of amendments. Amendments 93, 305, 142 and 362 relate to clause 9(2)(b)(iv); amendment 306, tabled by the hon. Member for York Central (Rachael Maskell), relates to clause 9(2)(c).

Clause 9(2)(b)(iv) stipulates:

“The assessing doctor must…explain to and discuss with the person being assessed…the nature of the substance that might be provided to assist the person to end their own life (including how it will bring about death)”.

My amendment 93 would replace “might” with “is to”. In my view, the word “might” creates an air of possibility. The Oxford English Dictionary gives the following definition:

“A possibility as distinct from a certainty”.

The Cambridge Dictionary goes somewhat further, defining “might” as the expression of a

“possibility that something will happen or be done, or that something is true although not very likely”.

In the context of the Bill, I consider that the use of “might” would create too ill-defined a concept.

For a patient to provide informed consent, it is necessary that the healthcare professional set out the relevant information in sufficient detail to enable that person to make an educated decision. In the circumstances of providing a substance, it follows that that information must include what that substance is. In my submission, it is insufficient simply to inform a patient that they might be provided with a substance, although they are just as likely, if not more likely, to receive another substance. Changing “might” to “is to” would provide greater certainty and precision in the wording of the Bill.

I recognise the concerns that have been raised that adopting amendment 93 would overly restrict which substance can be used, which may create an issue if the substance needs to be changed, for example if it was to be taken orally but has to be administered via a different route because the individual is no longer able to ingest orally. To my mind, however, the amendment would not prohibit a clinician from setting out to the individual a range of substances that could be used to provide them with the ability to end their own life, as long as the clinician includes the substance that is used and, crucially, the person seeking an assisted death indicates that in those circumstances they are content for that particular substance to be used. For example, it would be entirely open to an individual to inform a clinician that they are happy with regimes A, B and C, but not D.

Danny Kruger (Conservative, East Wiltshire)

I absolutely agree with what my hon. Friend is trying to do. This is a genuine question: does he think that it is possible at this stage for the Government, the Medicines and Healthcare products Regulatory Agency, the NHS or whoever to provide the information that would be required? What is needed to enable the Bill to come into effect with the amendment that he proposes, so doctors are able to say exactly what drugs will be used?

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

In the scenario that I envisage, as we have seen in other jurisdictions, there are a variety of regimes that could be used in the given circumstances. It would be appropriate for an approved list of medications and substances to be a delegated matter for the Secretary of State. As medical and pharmacological studies progress, there may be changes to those regimes, so I do not propose putting a list on the face of the Bill. The way I envisage it operating, if the Bill comes into law, is that there would be an approved list of substances that would be open to use. There would have to be a range; we are acutely aware that there are supply chain issues at times, so limiting it to just one regime would be impracticable. I believe that amendment 93 would strengthen the wording of the Bill to provide greater certainty that the nature of the substance to be provided will be explained to and discussed with the person who is seeking an assisted death. I am grateful to my hon. Friend for indicating his broad support for the amendment.

I turn to amendment 305, tabled by the hon. Member for York Central. I appreciate the premise of the amendment, but I have some concerns about the precision of the drafting. It would require the assessing doctor to explain the effects of the provided substance, in addition to how it would bring about death. In its current form, the Bill requires the discussion with the assessing doctor to set out how the provided substance will result in death. My understanding is that the intent of amendment 305 is that they set out the side effects beyond those directly related to the mechanics of bringing about death; this would include any wider discussion around side effects.

It is important to consider the specific meaning of “side effect”: an effect of a drug, chemical or other medicine that is in addition to its intended consequences. My understanding is that specifically using the term “side effect” in amendment 305 would make the drafting more precise and would achieve the effect that the hon. Member for York Central intends.

In many ways, however, I feel that the amendment is unnecessary, because a discussion of side effects should be incorporated into any informed consent discussion. Additionally, subsections (2)(b)(iv) and (2)(c) of clause 9 indicate, in conjunction, that there will be a discussion of any complications that may arise as a result of substances given. It flows from that, I submit, that there must be a conversation about side effects.

Sojan Joseph (Labour, Ashford)

Currently, when we start a patient on any medication, we usually give out information on indications and contraindications. If patients ask for one, we will give them a leaflet with information about the medication. Can the hon. Member clarify whether the amendment would help in that situation? Does he agree that a leaflet should be given to the patient?

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

The hon. Member makes an important point. In practice, one would of course discuss the side-effect profile of any medication or substance to be administered. I do not feel that specifying that in the Bill, as amendment 305 is drafted, would achieve its purpose. The amendment refers to “any other effects”, but it does not specifically mention side effects. In any event, it must flow from the interaction between clause 9(2)(b)(iv) and clause 9(2)(c) that the conversation about complications as a result of the administration of a substance will encompass a conversation about side effects.

It is worth noting that all substances have a side-effect profile; what the side effects are will be specific to the substance in question. I do not think it a helpful improvement to the Bill to presuppose what the side effects may be. Amendment 305, although imperfect, is therefore preferable in my view to amendment 362, which would require that specific side effects be set out and which presupposes a scenario involving a particular set of medication.

Nevertheless, I remain concerned about the wording of amendment 305. I would be grateful if the hon. Member for Spen Valley provided some reassurances as to the steps she has taken to honour the intention of the amendment tabled by the hon. Member for York Central and achieve a tighter piece of legislative drafting.

I turn to amendment 142, tabled by the hon. Member for Broxtowe. It seeks to ensure that the discussion with the assessing doctor includes a discussion of how the substance will be administered. Although it may not be strictly necessary, because that should be a conversation that takes place when someone is going through an informed consent process, I do not consider that its inclusion would undermine the operability of the Bill. I am therefore minded to support the amendment. I do not consider that it will be restrictive should the circumstances change, because there may be a broad conversation about the variety of substances that can be administered, depending on the circumstances. As the drafting of the Bill does not preclude or prohibit such a wider discussion, it would be eminently sensible to include the route of administration.

Amendment 306, in the name of the hon. Member for York Central, would require the assessing doctor to include the escalation of medical intervention in their discussion should complications arise. In many ways, that issue is covered by clause 9(2)(c), so the amendment would not aid the operability or interpretation of the Bill. It would be much better dealt with under the code of conduct, to avoid the Bill becoming overly prescriptive and to allow flexibility as scientific and medical knowledge adjusts and adapts over time.

Juliet Campbell (Labour, Broxtowe)

I will speak to amendment 142, which would insert

“and how it will be administered”

into the Bill. It would require the assessing doctor to explain and discuss with the person how the substance that might be provided to assist them to end their life will be administered.

The amendment would be a key step towards giving peace of mind to a terminally ill individual who is seeking an assisted death. It would also preserve their autonomy right up to the final stage. Ensuring that the method of administration is thoroughly explained would provide the doctors and the individual seeking an assisted death with the opportunity to consider the options—if there are options available to them—and decide which method would best preserve the autonomy of that individual.

Assisted dying presents many opportunities for individuals to be coerced, especially at the final stage—death itself. Therefore, the method of administration is key information for the individual to know, and it is not sufficient for it to be withheld from them. We must make it a prerequisite of the Bill that it is supplied. Making an informed choice about the assisted death pathway involves careful consideration, and knowing and understanding every step of the process. It is appropriate for the person to maintain their agency. Minimising the role played by the doctor at the administration stage is also key to ensure that the final act belongs to that individual.

We must acknowledge that many individuals seeking assisted death may experience significant mobility and physical limitations, particularly because of their terminal illness. Those limitations can affect their ability to engage with the process in ways other people may take for granted. For example, a patient suffering from severe weakness, paralysis or chronic pain might have difficulty physically positioning themselves or administering some types of substance, depending on the options available. A person may have difficulty swallowing and would not be able to ingest a substance in the form of a pill, but they may be able to autonomously operate a system that would allow them intravenous administration.

In these cases, the method of administration must be carefully considered and explained in a way that accommodates the patient’s unique physical needs. By discussing the challenges openly at this stage, doctors can help to ensure that the patient understands the options open to them, while making the process as comfortable and accessible as possible. Addressing their mobility and physical limitations in this context is not only a matter of practicality, but a reflection of our compassion and respect for that individual’s circumstances.

By limiting the doctor’s physical role, we also ensure that the patient retains control over the process. Making the act of self-administration as independent as possible ensures that the final part of the process gives the patient agency in choosing how and when to end their life. The individual must maintain a primary role in their death, but the actual administration is the final assurance and assertion of the individual’s choice to end their life. The amendment emphasises the importance of ensuring that, within the Bill, the doctor’s involvement is limited to preparation and support. That is key to making sure that the patient’s final moments are self-directed and as free from any unnecessary external interventions as possible.

Subsection 6 of clause 18, on the provision of assistance, discusses the role of the doctor in administration. It says that a doctor might

“assist that person to ingest or otherwise self-administer the substance.”

By ensuring that the method of administration of the substance aligns with the physical capabilities that a person has to self-ingest, which may be limited, we limit the role played by the doctor at this crucial stage, and limit the chance of the coercion of the individual or of the individual having a death that lacks real autonomy.

In conclusion, amendment 142 plays a crucial role in safeguarding the rights and autonomy of a terminally ill individual seeking an assisted death. By ensuring that the method of administration is clearly explained, we empower patients to make an informed, autonomous decision about the way in which they wish to end their life.

Danny Kruger (Conservative, East Wiltshire)

It is a pleasure to serve under your chairmanship, Dame Esther. [Interruption.] You are Dame Esther, aren’t you?

Esther McVey (Conservative, Tatton)

I am not.

Danny Kruger (Conservative, East Wiltshire)

Are you not? That is an extraordinary oversight. That must be rectified as soon as possible— I am sure it will be. I will speak in support of the amendment in my name and those in the names of the hon. Member for York Central and my hon. Friend the Member for Solihull West and Shirley. As he has explained, amendment 93 requires doctors to specify what drug “is to” be used, not just “might be” used. My amendment 362 states that there must be clarity on the complications and risks involved in the procedure. Amendment 305 states that we must be clear about

“other effects in addition to death.”

Amendment 306 discusses escalation in the event of complications.

We have discussed informed consent previously. We have identified that the General Medical Council’s guidance on critical information that patients must receive has been selectively placed in clause 7. Of the five areas that the GMC says should usually be conveyed to patients, two were omitted: first,

“uncertainties about the diagnosis or prognosis, including options for further investigation”,

and secondly,

“the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action. By ‘harm’ we mean any potential negative outcome, including a side effect or complication.”

It is not being explicitly stated that doctors should communicate that to patients.

Telling a patient exactly which drug or substance will be used to end their life, and its likely side effects, is critical if they are to have informed consent. Full understanding requires the patient to know the specific drug that will be used. It lets the patient grasp the method, its effects and its finality. Patients deserve to know how the drug will work; what its administration will be, whether oral or intravenous; the time it will take to have an effect, whether that is minutes or hours; and the other sensations that will be felt. It is difficult to say that we can convey that information without being specific about which drug will be used.

In other countries, for instance in the Netherlands, the criteria require that patients are fully informed, including about the drug that will be used and the method. In Oregon, the Death with Dignity Act similarly requires discussing the prescription of the specific drugs. That equips the patient to find out more, should they wish to do so, and to ask questions. A patient with a terminal disease needs to know the drug to confirm if it aligns with his or her wish for a peaceful death—it is not just an abstract agreement to die, trusting that medicine will do the trick.

Simon Opher (Labour, Stroud)

I thank the hon. Gentleman for tabling amendment 362. Does he accept that Australia, for example, has a very different regime from America? In Australia, people are given pentobarbital, which has not failed on any occasion—in any of the 2,500 treatments since assisted dying was legalised. In America, people are not allowed to use that; instead, they use another cocktail of drugs, which is not as ideal and can have other side effects. May I also say that I am not sure whether it is totally relevant to discuss the problems of a drug given in America in this context? We are discussing just putting down in law what the doctor is obliged to say to the patient.

Danny Kruger (Conservative, East Wiltshire)

I am grateful to the hon. Gentleman for those points because he helps me to direct my argument. It is essential to discuss the evidence from abroad about the complications that arise from assisted suicide, but the evidence is very patchy: we know what we know, but we don’t know much. There is a complete dearth of evidence, including in Australia. When Australians gave evidence to the Committee, it was put to them, accurately, that there is a great lack of adequate data gathering in Australia, as in other countries too. So when he says there have been no complications in Australia, what he means is that there have been no reports of complications in Australia. As we always need to point out, absence of evidence is not evidence of absence.

Kim Leadbeater (Labour, Spen Valley)

That question was indeed put to the experts from Australia, but actually they were quite clear that there is a huge amount of evidence. Indeed, there is a very robust reporting mechanism in Australia—the best in the world, I suggest—so there is a huge amount of evidence from that jurisdiction.

Danny Kruger (Conservative, East Wiltshire)

Let us not rehash the conversations that we had in the evidence sessions, but I would advise Members to review those conversations. Indeed, there is further publicly available evidence, which I am happy to share, of the problems with data collection in Australia, as in other countries. To the point of the hon. Member for Stroud about the evidence of complications that arise in other jurisdictions being irrelevant to our discussions, because of the lack of clarity in the Bill about what drugs would be used to bring about the assisted suicides that we are proposing to legalise, all we can do is rely on evidence from abroad, and I will insist on doing so.

As well as questions about complications and side effects, there is also a crucial question about how long it takes to die. In Canada, a study demonstrated that in 5% of cases, patients experienced a prolonged time to death. Another study showed that 50% of cases in Canada with available data—again, there is a lack of data—were unsuccessful within 60 minutes. It is clearly common in other countries for death to take up to or more than an hour.

The Canadian Association of MAiD Assessors and Providers—the people who do it—acknowledged that patients who ingest assisted suicide drugs can experience burning, nausea, vomiting and regurgitation. I am not saying that that always happens, or that it happens in the majority of cases, but it clearly happens. It is therefore appropriate for patients to be properly informed of those risks, if they are associated with the drugs that will be used. We do not know what those are going to be at this stage.

In the Netherlands, where assisted dying or assisted suicide has been legal for 20 years, a third of people with assisted suicide deaths experience some adverse symptoms such as pain, restlessness, shortness of breath, secretions, nausea and vomiting—that is, a third of people experienced some of those distressing side effects as they died, so it is very far from a guarantee of a pain-free death. It is vital that people considering an assisted death are aware of those possible effects, in addition to the primary effect of the drugs which is, of course, to kill them.

There is also a question about the method of administration. People should know that where regimes use the intravenous route of a short-acting anaesthetic, that is also not without problems. People would understand, and potentially argue for, having an anaesthetic as the first part of the cocktail of drugs that will be administered, but evidence from abroad demonstrates that the anaesthetic induction agent, which is usually propofol, a drug that puts people to sleep before surgery, can wear off rapidly in some people, particularly in younger patients, those who are less ill and those who are larger in size.

In around two thirds of assisted deaths with administrations that use that technique, that anaesthetic is rapidly followed by a paralysing agent. The patient cannot then move a muscle and, unable to breathe at all, they die of asphyxia. Unfortunately, there has been no monitoring of patients while they are given those drugs to ascertain whether they regain consciousness as they die. They cannot move a muscle, so they cannot signal distress. We are unclear what the experience of the dying person is beneath the apparent calm that has been induced in them by the paralytic drug that they have been given.

Simon Opher (Labour, Stroud)

The hon. Gentleman is bringing up lots of rather horrible stories about assisted death. That is why, in Australia, Switzerland and Holland, they have decided, instead of using the regime that he is talking about, to use pentobarbital. At 15 grams, that has not had any failures—no one has woken up. The only real side effect that people complain of before they go to sleep, which happens very quickly, is that it is very bitter. One of the reasons why Dignitas uses it is that it is so effective and it does not have those effects. I would push back on some of those scare stories.

Danny Kruger (Conservative, East Wiltshire)

I am afraid to say that the whole debate about assisted dying is replete with scare stories. The hon. Gentleman says that they are descriptions of horrible events, but that is the situation that we are dealing with. We are here to try to pass legislation that is designed to avert horrible deaths. I am absolutely committed to that as well, but the evidence from abroad shows that people can also have a horrible death with assisted dying.

The hon. Gentleman points to Australia, but the evidence from Western Australia in particular is that over 4% of assisted deaths reported complications. He might be right that it is a better regime than that used in the United States, but even there complications occur. We do not know yet what the regime will be here, but I am alerting the Committee to the genuine danger of an assisted dying regime that induces very unpleasant results for patients.

Jack Abbott (Labour/Co-operative, Ipswich)

The hon. Member may be surprised to hear that I am inclined to support his amendment 362 and amendment 142 tabled by my hon. Friend the Member for Broxtowe, not because of, in the words of my hon. Friend the Member for Stroud, the scare stories or the examples that the hon. Member has been giving, but predominantly because of what the amendment says on the tin: that a person must be given a full explanation of the risks of complications and how a substance should be administered. As I have said a number of times in Committee—

Esther McVey (Conservative, Tatton)

Order. Can I just check that this is an intervention?

Jack Abbott (Labour/Co-operative, Ipswich)

It is an intervention, Ms McVey. My plea to the hon. Member is to focus on exactly what the amendment states. I appreciate all the stories and examples that he wishes to make, but it is important to reflect on the words of the amendment. As I said, I am minded to support it.

Danny Kruger (Conservative, East Wiltshire)

I am grateful to the hon. Member for his intervention.

Amendment 306, tabled by the hon. Member for York Central, addresses the question of what to do in the event of complications. I recognise that clause 9 states that that must be discussed, which I welcome. I think, though, that there is a significant absence that this amendment would address, which is what to do in the event of complications—specifically, which intervention would be appropriate.

Here we get into a very difficult area. I personally find it difficult to understand a way out of it, because it is a consequence of the sort of legislation that we are considering: what do we do when complications arise? Specifically, what do we do when the patient does not die and is still alive some hours later, possibly in distress? I have cited evidence about some of the complications that occur and the prevalence—for example, that 10% of such people in Oregon experience complications, including some who simply wake up again. We need to resolve this. On explaining possible side effects and complications, under the Bill as it stands none of the declarations that are signed by the doctors or the person requesting assistance confirm in writing that the criterion has been met for proper communication, so that is one concern.

My more substantial concern—I will finish with this—is that at the moment the doctors have to explain the complications, even though we do not know what the drugs are going to be yet, but they cannot discuss or decide with the patient what they would do in the event of complications. We know that the doctor must be present at the end or in the next room, but can they halt the process if complications arise—if the patient wakes up or is exhibiting signs of distress? That would be against the last known wishes of the patient who had said that they wanted to go ahead with the death. Should the doctor expedite the death knowing that that is what the patient theoretically wanted? Of course not, because that would be euthanasia; it would be the doctor actually killing the patient, which is illegal under the Bill. Do they stand by and do nothing at all, which goes against the doctor’s obligations to address symptoms and illness in a patient? If the patient is fitting or vomiting, the doctor would normally clear their airways. Should they do that, knowing that that might bring the patient back to life—that it might resuscitate them and stop the assisted death?

When we debate clause 18, we will discuss the process of the assistance that the doctor gives, but we are obliged, when we come to debate the Bill fully, to choose between three options. We could allow complications without any guidance, which is what the Bill does; that raises all sorts of challenges, and practical and ethical concerns, for doctors. We could stipulate that the patient should be revived, perhaps if a certain degree of distress is witnessed or if the patient is still alive after a certain period of time. Finally, we could allow euthanasia and say that, in that event, the doctor should be authorised to expedite the death. I do not know what the option should be. That is a question that a doctor would have to face in reality, in the bedroom of a patient who is exhibiting complications. I do not know what to do, but I do not think we should be proceeding with this Bill. Those who do believe in it have to answer this question: what does a doctor do if a patient is exhibiting distress and not dying—do they bring them back to life, expedite their death or do nothing?

Sean Woodcock (Labour, Banbury)

I rise to speak in support of amendment 362, tabled by the hon. Member for East Wiltshire, which requires the registered medical practitioner to explain and discuss the nature and the risk of the lethal drugs. There is a bit of a theme to the amendments I have tabled so far: they have almost all been about giving the patient more information. The promoter of the Bill, my hon. Friend the Member for Spen Valley, is quite right in focusing on the importance of the patient’s autonomy. I absolutely believe in and value that autonomy—I am sure everybody across the Committee does so too—but true autonomy is linked to having access to good quality and accurate information. It can severely impact someone’s autonomy if they do not. This Bill states that the person must have an informed wish to end their own life. I believe that this must explicitly include an understanding of the nature of, and the risks of, the lethal drugs involved in assisted dying.

This Bill’s passage through this place has led to lots of conversations and a greater awareness of the issue of death across the country. Morbid as that is, it is a really good, healthy thing that people are talking about end of life—something which we will all encounter—and that is welcome. The debate on assisted dying has made many people concerned about the nature of death and the choice that they might face at the end of their life. Inevitably, for some, the impression has been given that an assisted death uniformly provides a pain-free alternative. I accept that that is absolutely what the promoter of the Bill, and those in support of it, are aiming for—that is not in question—but we have heard from the hon. Member for East Wiltshire about issues with that, and that there have been exceptions in places where such laws have been put in place. I also point to the evidence of James Haslam, a consultant in anaesthesia and intensive care medicine, who put in his written evidence to the Committee that assisted dying

“does not guarantee a painless, peaceful and dignified death.”

The key word there is “guarantee” because, unfortunately, some people who ingest the prescribed lethal drugs do experience distress and complications. In the Netherlands, a high dose of barbiturates is used for all administrations of lethal drugs, and in two thirds of cases—the majority—the person dies within 90 minutes, but a third of cases do take longer and can take up to 30 hours. Complications include difficulty swallowing the whole prescribed dose, vomiting, and in some cases re-emergence from coma. I do not accept that this is an incidental concern. Vomiting affects up to 10% of assisted deaths by oral administration in the Netherlands. There is no easy way to research the efficacy of these drugs on humans given their lethal effects, and as a result there is no regulatory authority in the world that has approved these drugs to be used for this purpose. The data that we have shows that these complications take place in all jurisdictions that have assisted dying. As the hon. Member for East Wiltshire has already mentioned with respect to Oregon, between 2012 and 2022, 11% of the time there were complications.

These complications raise important ethical and medical questions for the doctor and for the terminally ill person. Of course, by the time complications occur, it is too late to discuss or reconsider the person’s options. That is why it is essential that the registered medical practitioner has already explained and discussed with the person the risk and nature of the lethal drugs. Choice is about not simply having options available, but understanding them. That goes to the point I made at the beginning: autonomy is absolutely linked to the quality of the information that someone has been given in order to make that autonomous choice. That requires the registered medical practitioner to explain the full risk and the nature of the possible complications from the lethal drugs.

The General Medical Council sets out five points of guidance for doctors on how they should hold a dialogue with their patients about reaching a decision. Three of the five GMC points are already covered by the Bill, but two are excluded: uncertainties about the diagnosis or prognosis, including options for further investigation; and the potential benefits, risks of harm, uncertainties about and likelihood of success of each option, including the option to take no action.

I can see no good reason why we would not want doctors to be entirely honest with patients who are considering assisted dying, even to the point of saying that the vast majority of people will not have any complications, but there is a chance. Personally, I see no issue with that, or why there should be. Doctors should give their patients that information; not only is that good practice—as we heard from my hon. Friend the Member for Stroud and the hon. Member for Solihull West and Shirley—but, as the GMC guidance makes it clear, they should do so because we should not give people with serious illnesses a false picture of what assisted death means. I link back to the emphasis on the word “guarantee”, as per the written evidence I quoted.

Amendment 362 would affirm the commitment of the Bill’s promoter, my hon. Friend the Member for Spen Valley, to upholding medical standards. It would clarify the full responsibilities of the registered medical practitioner under the General Medical Council guidelines. Perhaps more importantly, it would put the terminally ill person in a better position to understand fully the options available and the associated risks.

In Committee, we have heard frequently that the Bill is about expanding choice and autonomy at the end of life. To act autonomously, terminally ill people need— I emphasise this again—to understand what they are facing as best they can, with the best and most accurate information available to them as early as possible. That is why I support amendment 362, and I urge the Committee to do so, too.

Naseem Shah (Labour, Bradford West)

I rise to speak in support of amendments 305 and 306, in the name of my hon. Friend the Member for York Central.

Under amendment 305, a doctor would have to explain what effects the medicines would have as well as death. I appreciate the points made by the hon. Member for Solihull West and Shirley, and what other Members have said about effects and side effects. I would first say: we do not know the side effects. There is no research into any of the drugs being used for the purpose that we are looking at—for assisted suicide, euthanasia or whatever whichever jurisdiction calls it. We therefore cannot give a clear view of what the side effects are; they are largely unknown, as I understand it.

In addition, there are different drugs. My hon. Friend the Member for Stroud mentioned one drug, pentobarbital, which has caused huge concern. I did not know about the issue in Australia, but I know the evidence from death row in America, after Texas started using pento-barbital; there have been huge concerns and lawsuits there. I am happy to be referred to other evidence. In some cases, the effect of the drug has been described as akin to suffocating or even as being waterboarded or drowning.

Concerns have been expressed about the use of such drugs in other jurisdictions. I agree with the hon. Member for East Wiltshire that we should be looking at all such jurisdictions, because this is something new for us. If we are to learn from other jurisdictions where assisted dying has happened and it has been okay for people, whether that is Australia or others, it is equally right that we hear from those jurisdictions where things have not gone right or to plan. That is important.

Clause 9(2)(b) states:

“The assessing doctor must…explain to and discuss with the person being assessed”,

among other things,

“the nature of the substance that might be provided to assist the person to end their own life (including how it will bring about death)”.

Amendment 305 would instead require that the assessing doctor explain to and discuss with the person being assessed the nature of the substance that might be provided to assist the person to end their life, including how it will bring about death and any other effects it would have in addition to death. That is really important.

There are several relevant things that patients should know if they are to be able to make an informed choice. First, they should have as clear an idea as possible what the experience of taking the lethal drug is like. In some countries where people undergo assisted dying, they swallow a cocktail of drugs. Patients whose assisted dying process did not succeed have said that the drugs are bitter tasting. If this is to be the method used in assisted death in this country, applicants should be aware of that, because some people do not take tablets—they just will not do it. If other methods are to be used, doctors should inform patients of what the experience will be like to the best of their knowledge.

The second thing assisted death applicants should know is that they may suffer complications. We know from countries and states that have assisted dying that some patients undergo complications during the process. It has been said before, but I will repeat the point, because it is really important: there can be complications. People may vomit or undergo seizures. One assisted dying recipient took 137 hours to die. That is five days and 17 hours.

We do not know the full number of patients who have died very lengthy deaths in Oregon, because the lethal drugs are self-administered, usually with no doctor present, but just because there is no report saying that things have gone wrong, it does not mean that everything has gone right. Oregon also found that at least nine patients failed to die from lethal drugs. We do not know whether that is the total number—again, because the assisted dying applicants in Oregon self-administer drugs. We can say with certainty that complications exist, although, unfortunately, gaps in the data mean that we do not know how common they are.

Amendment 306 would change the duties of a doctor present during the assisted dying process. Currently, clause 9(2)(c) states that the co-ordinating doctor must discuss with the person

“their wishes in the event of complications arising in connection with the self-administration of an approved substance”.

If the amendment were accepted, the clause would state that the co-ordinating doctor must discuss with the person their wishes in the event of complications arising in connection with the self-administration of an approved substance

“including the escalation of medication intervention”.

This is a point of great importance, both for the person seeking assisted dying and the doctor, who would have to be present for the process. It would mean that the applicant and the doctor would have to think through what they wanted to happen if the applicant did develop complications. Should the doctor at a certain point act to revive an applicant—for example, if the person seemed to be suffering extreme pain as a result of a lethal drug? Alternatively, should the doctor remain as an observer and, if it were clinically possible, someone to administer further pain-relieving drugs? Not doing anything is clearly not an option. Both courses of action might seem harrowing to the person seeking assisted dying, but it is something that they should clearly discuss with the doctor, because these situations could really happen.

There are clearly no easy answers to these questions, but if applicants are to take an informed choice over assisted dying and if we want to provide autonomy, they must know that these questions exist and they must discuss them with their doctors. We have talked a lot about autonomy for people with serious illness. Those people will not have autonomy unless they are informed in accurate detail about the possible outcomes of assisted dying, and these amendments would ensure that.

Ultimately, if someone takes a drug to end their life, they will either die or not die and be left in a compromised state. Are they then escalated to A&E, because leaving them in that state is not an option for any doctor—or does the doctor proceed to administer more drugs? What does the doctor do?

Kim Leadbeater (Labour, Spen Valley)

My hon. Friend raises a really important point. As clause 9 says, the doctor has an obligation to discuss with the person their wishes in the event of complications, so that conversation would have happened with the patient. To be clear, the doctor cannot intervene to expediate the patient’s death. That is very clear in the Bill.

Naseem Shah (Labour, Bradford West)

I thank my hon. Friend for her intervention. Actually, clause 9(2)(c) covers the complications but does not state clearly what would happen in the event of those complications. Would the patient still want to carry on down that path?

Kim Leadbeater (Labour, Spen Valley)

To be clear, it does say

“discuss with the person their wishes”.

That includes whether they would want the doctor to call an ambulance if things got complicated, or whether they would want to be left—so the doctor would discuss with the patient their wishes in that situation. Fortunately, it does not happen very often.

Naseem Shah (Labour, Bradford West)

Yes, fortunately not. I am not convinced that the clause covers it. I will go back to that, but I have just read it because the hon. Member for Solihull West and Shirley raised it and I support his amendment, and somebody else raised it earlier.

I am not convinced that the complications are covered, because the clause does not set it out. In the usual sense, complications are side effects from medications. We have research and literature given to us and we understand the potential side effects. In this instance, we do not have a yardstick. I do not know whether the Minister can speak about the Government’s intentions—it would be helpful to have an impact assessment—and whether any research has been done in this area.

I am not convinced that clause 9(2)(c) actually covers this point, and I think the amendment would make the Bill much stronger. Ultimately, these drugs have not been tested—and for a very good reason, because they lead to death. We are in unchartered territory. When we are doing things that we have not done before, we cannot just pick and choose what we apply an analogy to. We need to be careful. We really need to consider the options to make this clause in particular much stronger.

Jack Abbott (Labour/Co-operative, Ipswich)

I completely understand what my hon. Friend is saying about what may need to happen in respect of medical intervention, but I gently point out that the amendment would not cover that. It does not spell out in any way, shape or form what a medical intervention would look like. It says that there needs to be a random discussion, but it does not lay out any sense of the medical intervention. I do not see how the amendment will do what my hon. Friend is looking for.

Naseem Shah (Labour, Bradford West)

I thank my hon. Friend for his intervention. As drafted, the Bill does not include effects. All it says is “complications”. It does not include the potential effects of the drugs that will be used. That is how the amendment would strengthen the Bill.

Danny Kruger (Conservative, East Wiltshire)

We might appear to be dancing on a pinhead, but this goes to the heart of the question about what on earth we do in the event of complications. As the hon. Member for Spen Valley says, the Bill as drafted says that discussions should be had about wishes in the event of complications. That might simply be, “Do you want us to call somebody? Do you want us to try to make you more comfortable?” The amendment would require a discussion of escalation—what further medical interventions might be appropriate in the event of complications arising. There is a huge question for us, which we have not yet had answered, about what on earth should be the range of options for a doctor. The importance of the amendment is to specify that there may be further medical interventions in the event of complications. Does the hon. Lady agree that that is the value of it?

Naseem Shah (Labour, Bradford West)

I completely agree with the hon. Member. He said it much better than I did in response to my hon. Friend the Member for Ipswich, so I thank him for that.

Simon Opher (Labour, Stroud)

I will be brief, because I think we have discussed this enough. I totally agree with my hon. Friend the Member for Banbury. Patients need to be informed about the procedure—there is no argument about that—and I approve of the first three amendments in this group.

Let me say a bit about data. I met the pharmacist from Australia who is in charge of assisted dying and he had data on 2,500 assisted dying patients. The data is clear: all the patients died—no one survived. Almost everyone immediately goes to sleep, which can be a problem, because if they do not take all the medicine, it causes a slight difficulty that I will explain in a minute. Fifty per cent died within 30 minutes, 70% within an hour and 95% within two hours. One patient survived for 21 hours because she had not taken the full dose because she fell asleep; that is a potential problem. All these things should be described, and are routinely described to patients in Australia.

The first thing, then, is that we have plenty of data. The second thing I want to say is that we are dealing with the end of life. I have sat with patients as they have died; I have sometimes seen people being a little bit sick. We know how to cope with that. We do not need to specify how we cope with someone who is dying, because we have done it many, many times. I do not think amendment 306 will add anything to the Bill because it is part of what doctors do normally.

Naseem Shah (Labour, Bradford West)

I am genuinely trying to understand and would like my hon. Friend to clarify. He says that doctors generally do this anyway, but the difference is that, in this instance, somebody has chosen to die. Generally, when doctors do anything they are trying to save patients, are they not? The general rule of thumb is that a doctor saves lives. In this instance, they are not doing that because the patient wants death.

Simon Opher (Labour, Stroud)

We are not doing that in situations of terminal care—we are allowing someone to die. We are very experienced in allowing people to die. I have done it for 25 years. It is not a new skill just because we have the assisted dying element. We deal with the situation as it arises.

Danny Kruger (Conservative, East Wiltshire)

rose—

Simon Opher (Labour, Stroud)

I had virtually finished, but I give way.

Danny Kruger (Conservative, East Wiltshire)

The hon. Gentleman puts his finger on a key point. The hon. Member for Bradford West is absolutely right: surely the hon. Gentleman acknowledges that there is a difference between allowing somebody to die and giving them lethal drugs that make them die. I am sure he would acknowledge the practical, if not the moral, distinction between the two. He says he has lots of experience of helping people to die; has he ever had experience of watching somebody die after administering them lethal drugs? No.

Simon Opher (Labour, Stroud)

No, I have not, because that is currently illegal—this Committee is about changing that—but I have sat with patients who have slowly died. It is not about whether we get an ambulance; we know we do not do that. We are allowing the patient to die, and if something happens that involves having to help them, we just do it. We do not need to specify that in the Bill: it is part of normal medical practice.

Jack Abbott (Labour/Co-operative, Ipswich)

I will be brief, as I have already alluded to my support. I put on the record my support for amendment 93. There has not been a lot of debate on it because it is a fairly straightforward proposal.

There has been a lot of discussion. Members on both sides of the Committee have spoken in defence of the medical profession in respect of huge parts of the Bill, although they should not have to. We have of course seen occasional bad practice, as we do in all professions, but we should take a moment to reflect on the dedication, diligence, hard work and expertise of medical professionals in everything they do. This debate has on occasion almost presented this as a 50:50 choice between good doctors and bad doctors. I think we would all agree that although we want to put in the right safeguards, that is not the case at all.

I have made this point a number of times, but I do not want to accept amendments that spell out all the rules and regulations so that every doctor has to go to the nth degree all the time. As my hon. Friend the Member for Stroud has said eloquently on a number of occasions, it is already in their codes of conduct, working practice, training and everything else. However, on occasion we cannot be satisfied that something is a given. For that reason, particularly in respect of amendments 142, 362 and perhaps 305, if we say that

“the nature of the substance that might be provided to assist the person to end their own life (including how it will bring about death)”

must be discussed, it is not a huge leap to say that we should also spell out how it may be administered and the possible risks and complications that come with that. As I have said, I do not think it will create any unintended consequences. I do not think it puts the full rulebook on the face of the Bill. If we are stipulating how it will bring about the death, it is not a huge leap to also talk about the other side effects.

Cutting through some of the stories, and everything else we have heard this afternoon, we should be considering what the amendments seek to do—what they say on the tin, as it were. We should be asking doctors to have the conversations, although I am absolutely sure that, as my hon. Friend the Member for Stroud said, those conversations will happen naturally anyway. I do not think there is anything harmful in the particular amendments, as we have discussed today.

Finally, on amendment 306, I understand the points that my hon. Friend the Member for Bradford West and the hon. Member for East Wiltshire made. To be totally honest, I fail to see how the amendment satisfies the arguments they were trying to make, as powerful as those arguments are. It does not solve the issue they are looking to solve; I do not think it answers any of those questions. For that reason, I will not support amendment 306, but I am minded to support the other amendments in the group.

Stephen Kinnock (Labour, Aberafan Maesteg)

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

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

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

Naseem Shah (Labour, Bradford West)

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

Stephen Kinnock (Labour, Aberafan Maesteg)

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

“their wishes in the event of complications”,

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

Rebecca Paul (Conservative, Reigate)

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

Stephen Kinnock (Labour, Aberafan Maesteg)

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

Rebecca Paul (Conservative, Reigate)

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

Stephen Kinnock (Labour, Aberafan Maesteg)

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

Danny Kruger (Conservative, East Wiltshire)

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

Stephen Kinnock (Labour, Aberafan Maesteg)

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

Esther McVey (Conservative, Tatton)

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

Stephen Kinnock (Labour, Aberafan Maesteg)

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

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

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

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

when discussing their condition.

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

“wishes in the event of complications”,

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

I hope those observations were helpful to the Committee.

Kim Leadbeater (Labour, Spen Valley)

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

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

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

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

You will be delighted to learn that I have nothing further to add to this debate, Ms McVey.

Danny Kruger (Conservative, East Wiltshire)

I beg to move amendment 307, in clause 9, page 6, line 18, leave out from beginning to “advise” and insert

“unless the assessing doctor has concluded in good faith, that this would not be in the person’s best interests.”

This amendment would require the assessing doctor to inform the person’s next of kin that the person wishes to seek assistance to end their own life unless it is not in the person’s best interests.

Esther McVey (Conservative, Tatton)

With this it will be convenient to discuss amendment 308, in clause 9, page 6, line 20, at end insert—

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

This amendment is consequential to Amendment 307 and would require a decision that it is not in the person’s best interests to inform their next of kin to be documented with its reasoning.

Danny Kruger (Conservative, East Wiltshire)

Amendments 307 and 308 concern the question of who should be informed when an application has been made or when an assisted death has been approved, and at what stage it is appropriate for family members or next of kin to be informed. During the debate on clause 8, we discussed whether a patient should be asked to state whether they have informed their family.

I think it is appropriate to have a stronger requirement for doctors to notify a patient’s next of kin. Amendment 307 would remove the phrase

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

leaving that they should

“advise the person to consider discussing the request with their next of kin”.

Amendment 308 is either supplementary to amendment 307 or could work in isolation, because it states:

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

These are important amendments because they communicate the truth that it is not just the patient who is affected by an assisted death; I suggest that others are affected. Conversely, behind that apparently autonomous individual patient, who might think they are acting with absolute autonomy and without reference to others, there may somebody who is exercising undue influence on them.

To me, these amendments speak to the essential tension at the heart of the Bill: whether we are talking about isolated individuals or recognising the reality that no man or woman is an island. We are all connected and we all have obligations, whether as a society to the people who will be involved in the administration of the procedure or, more directly and obviously, to family members or to the patient themselves, to be sure they are not subject to undue influence. There are many ways to try to identify undue influence, but one important one that would be addressed by this amendment is the opportunity to involve a person’s wider family in the discussions leading up to their assisted death.

I want to read out some of the short testimonies we have received—again, I do not want people who have submitted evidence to feel that their efforts have been in vain and that it has gone into a black hole. Some of us, at least, have digested it, and I want to repeat some of it for the benefit of the Committee. Let me quote Anna Bossong:

“I was at home late one evening in London when I received an unexpected call from a nurse at my mother’s nursing home in Australia. She said to me “I am calling from your mother’s room. All her friends are around her bed and are singing as they see her off. She has a morphine pump in her hand and I am helping her to pump it.

It is an understatement to say that I was shocked as this had come totally out of the blue.”

She goes on to explain the efforts she made, and the enormous trauma she suffered, as a consequence of this event happening without her prior knowledge.

Alicia Duncan also gave evidence to us:

“My mother informed us of her scheduled MAiD”—

that is a reference to the Canadian medical assistance in dying system—

“less than 48 hours before her initial appointment, leaving my sister and me scrambling to respond. Over the next five days, we used every legal tool available, including obtaining a warrant under the Mental Health Act, to try to keep her alive through all legal means. She was admitted to a psychiatric unit but released after 48 hours and died without our knowledge just four hours later. Both of us have been diagnosed with Post-Traumatic Stress Disorder (PTSD) as a result of these events.”

I am afraid to say that there are a number of terrible examples of this happening in jurisdictions where assisted dying is legal, and such things would be possible in our country too. I draw the Committee’s attention to the points made by the hon. Member for York Central, who tabled this amendment, about a constituent whose parent had an assisted death without her knowledge and about the trauma she suffered because she felt that it was the wrong thing to do and that the medical team should have had more knowledge of the circumstances surrounding her parent’s life.

We had evidence from the British Association of Social Workers, who wrote in after the oral sessions, conveying significant concerns about the Bill and stressing the absolute imperative of having proper family input at the right stage of the process. Indeed, the point seems to be half-recognised in the Bill, because clause 9 uses the phrase:

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

Again, doctors are being given that discretion not to proceed and to make sure that families are informed.

Requiring the doctor, when considering a patient’s request for assistance to end their life, to decide whether it is appropriate to advise them to discuss it with their next of kin introduces several problems. It places a subjective burden on the doctor. The term “appropriate” is very vague. Does it hinge on the patient’s family dynamics, their emotional state or indeed the doctor’s own biases?

Jake Richards (Labour, Rother Valley)

The amendment that the hon. Member is supporting speaks of a doctor having to consider what is

“in the person’s best interests”,

which is wholly subjective. Does he not agree that the same difficulties he identifies with the current drafting are extrapolated greatly by the amendment?

Danny Kruger (Conservative, East Wiltshire)

I am afraid there is a huge degree of subjectivity throughout the Bill, and we are putting an enormous obligation on doctors to use their best judgment. However, I think it is right to stipulate more clearly that it is appropriate, in general, to inform patients’ families. Leaving the vague term “appropriate” essentially implies that it is either/or—that it is a 50:50 choice whether they do so. So it is important to specify that the expectation is that they should do so. Of course, there will be circumstances in which that would not be the right thing to do, but as the amendments make clear, they should explain that clearly if they are not going to do so.

A doctor might hesitate to suggest a discussion with family if they suspect that there are strained relationships within it. My concern is that, without clear guidance, that judgment could be inconsistent or legally challenged. The doctor might know the next of kin and believe that they would try to stop the patient from ending their life. We have heard quite often the concern about the family being some sort of coercive force, trying to prevent people from fulfilling their autonomous choice to end their life, and that we should put in place barriers to stop families trying to dissuade their loved one from assisted suicide. We heard that repeatedly, particularly from the Australian witnesses.

My concern—this goes specifically to certain communities within our country—is that doctors from individualistic cultures, which we have in western Europe and North America, would prioritise personal autonomy. They would deem it inappropriate to suggest family involvement, viewing that as an intrusion on the patient’s rights. We need to state clearly that that is not the expectation and that the expectation is that they should consider involving the family in the discussion.

My concern is also about an exaggerated respect for medical confidentiality. As the Committee knows, my belief is that this is not a healthcare treatment at all, but if it is to be regarded as such, we should not assume that medical confidentiality applies in an absolute sense. There are specific differences between this so-called medical treatment and others, which do justify an override of the assumption of total medical confidentiality. It is therefore appropriate, as in certain other medical procedures, that family members should be involved.

I want to cite the written evidence from Dr Rosemarie Anthony-Pillai, who pointed out that clause 9

“lays bare the reality that in trying to, rightly, diminish any accusation of coercion or family disagreement, this Bill will lead many to a lonely death.”

She also said:

“Families/loved ones finding out only after the event how the person died will have its own bereavement issues that this Bill in no way seeks to consider.”

I also cite the written evidence we had from AtaLoss, which is a UK charity dedicated to ensuring that bereaved people can access support. It said that discovering the decision that somebody has had help to take their own life without prior warning

“can replicate the distress often associated with sudden or suicide-related deaths, thereby intensifying bereavement trauma and potential suicide contagion.”

That is a very significant threat. We will not rehash the argument about whether suicide increases in countries with assisted suicide, but my strong view, from the evidence, is that it does.

In terms of the patient’s safety, if the process is kept secret even from those who know the patient well, the assessing doctors and the panel will be asking very difficult questions about the patient’s feelings and circumstances partly blindfolded. If a patient is in a controlling relationship, they and the person abusing them are not going to volunteer to the doctor or the panel that there is any pressure going on—indeed, the patient may not even understand it to be pressure. It is very common for an abusive partner to try to isolate the victim from their close friends and family. The hon. Member for Ealing Central and Acton (Dr Huq) wrote recently about how this has come up in her constituency. The ex-husband of her constituent’s sister reappeared on the scene, charmed and isolated this woman, and got her to change her will in his favour. That is a technique of coercive control. Some level of required notification to the wider family would make it much harder for a controlling partner to push someone through this process without it being exposed.

It was made clear earlier today that the Bill’s supporters do not want any hard-edged reasons that count as bad reasons to die to be stated in the Bill—they do not want it asked at all why someone wants to have an assisted death. As it stands, the doctors and the panel would have to approve the death as long as it was the patient’s clear, settled and informed wish, but involvement of those who know the patient well might demonstrate that it was not clear, settled or informed. They may have regularly gone through patches of feeling unloved and unsupported all their life, and that could change. That is information that only the wider family would know.

To conclude, there is real suffering hereto—as I have said, nobody exists in a vacuum. I want to reference the opinion of Judge Elósegui in the European Court of Human Rights. Her opinion was a partial dissent in the Mortier case, which has been discussed before. She said:

“it should be underlined that it cannot be said in an exhaustive way that the principle of autonomy always and at all costs has primacy over the other three principles of bioethics. In particular, we must take into account the consequences of our actions on the rest of the family unit and on our circle of friends.”

That is highly relevant. If we see cases where somebody dies by assisted suicide, and the first thing their child or parent knows about it is they are told to come and collect the body, that will be a scandal. That has happened in other countries, and the Mortier case is a case in point.

I mentioned other cases in which it is obligatory to consult and inform family members. At the moment, that is what happens at the Court of Protection with much less serious applications. Practice directive 9B requires doctors to notify

“at least three persons who are likely to have an interest in being notified”.

That is in the case of organ donation and other procedures. Families are required to be notified, and an indicative list is given, which is supposed to be worked through in order—spouses, people who live with as a spouse, parents, children and so on. The authorities are to jump along through that list, again with some discretion given to them.

To end, on the standard guidance referred to in judgments on that procedure, the judgement of Senior Judge Lush in the Court of Human Rights included the observation that the decision not to notify someone who would otherwise be entitled to be notified is not something that just affects the applicant. It is not just about their interests; there is a wider concern for the whole of society and indeed the family. That is why I support the amendment.

Simon Opher (Labour, Stroud)

I thank my hon. Friend the Member for York Central for tabling the amendment. The crucial word that the hon. Member for East Wiltshire said in all that was “should”. It is really important that people are strongly encouraged to discuss this with their families. Clause 9(2)(f) states that

“in so far as the assessing doctor considers it appropriate, advise the person to consider discussing the request with their next of kin and other persons they are close to.”

I totally support all that the hon. Member said: the family should always be involved in every decision. However, in the way we practice medicine in this country, if a patient has capacity—if they are not under a section under the Mental Health Act, for example, and can show that they have capacity—they can make decisions about their own healthcare. That involves whether they tell their family.

I agree that not to tell the family is not the best thing and not something I would say that the patient should do, but that is in their remit. It is important because, if we change that, we get rid of all the basis and the foundation of medical care and consent in this country. I agree wholeheartedly with the hon. Member, and I am a strong supporter of the family—I also think that in almost every situation the family will be involved—but the patient does not have to tell the family. That must remain part of their decision.

Daniel Francis (Labour, Bexleyheath and Crayford)

I am torn by this amendment. I absolutely accept that it is the right, the autonomy, of an individual to make the decisions and to have confidentiality when making those decisions, but I will touch on a few things that I have said previously.

First, briefly, I hear what the hon. Member for East Wiltshire said about coercion. Secondly, however, there are two other aspects. Let me go back to something I have talked long and hard about, which is learning disability. One amendment has been accepted and I hope more are to come, but given what my hon. Friend the Member for Stroud said, in that scenario, someone might have to be helped by the doctor to make the decision, because of their level of capacity. When I have made the argument throughout our debates, that has never ever been doubted. The person who has been helped to make that decision may have decided, because they are a burden on their elderly parents, that they will not inform them. Again, that was the rationale of where I got to on Second Reading, frankly.

I see people with elderly parents, often now in their 70s or 80s, who have cared for that person throughout their life. As the Bill and the Mental Capacity Act are laid out, that person could go to the doctor to say, “I do not want my parents to know. I hear what you say, doctor, but under this provision of the Act”—clause 9 of the Bill—“I am not going to tell them.” Under the Mental Capacity Act, if the doctor had any queries about the capacity of that person to make those decisions, that doctor would have to assist them in making them. Let us be clear that that is what the Mental Capacity Act 2005 provides for, and that is what the code of practice says.

I am sorry to keep talking about myself, but as I have said previously in these debates, during covid I was the carer for my whole household. My wife was having chemo and both my children were off school. One of my children needed full-time care, and no carers were allowed in the house. In that period, I really saw the power dynamic. I know exactly when it was: on the evening of Maundy Thursday, my wife had an enormous epileptic seizure during her chemotherapy treatment. I remember being on the phone to the cancer nurse who was saying, “Put her in an ambulance.” I said, “I’m not putting her in an ambulance because of covid.” I am sorry to be so graphic, folks, but that evening I had my wife in one bed covered in vomit and my daughter in one bed lying in her own faeces. The next morning, my wife would have done anything to remove me from that situation, quite frankly.

We were so lucky: a few months later, my wife’s chemo was finished and she was cancer free. We are out of that pandemic, thank goodness, but there are people out there who have had a loved one by their side for 30, 40, 50 or 60 years and do not want to see them go through that pain anymore. They will not take the decision out of fear; those who have six months left do not know what their end will be, and whether it will be painful or not. They just do not want the person who has stood by them all those years to have to be their carer. That is the power dynamic.

On balance, because I believe in autonomy, I may well not support the amendments, but these are the issues that I have wrestled with, because as the Bill stands, someone could simply go to a doctor, the doctor could say, “Have you told your loved one—your partner, your husband, your wife?” and they could say, “No, I’m not going to, because I do not want them to suffer anymore, caring for me in these circumstances.”

Danny Kruger (Conservative, East Wiltshire)

As ever, the hon. Gentleman speaks very powerfully. Does he acknowledge that under the amendments, and under the Bill, it would be possible for a patient to proceed without informing their wider family, if they and the doctor conclude that it is not appropriate or necessary? The value of the amendments is that they would require a conversation to be had about why that is not happening. Does the hon. Gentleman not recognise that such a conversation would be appropriate?

Daniel Francis (Labour, Bexleyheath and Crayford)

That is what I have wrestled with. That conversation will happen, and at the end of it, I accept that the autonomy is with the individual, who may well make a decision that they believe is for the best but with which their loved one does not necessarily agree. I think there are examples from overseas of that having happened.

Kit Malthouse (Conservative, North West Hampshire)

I agree about the primacy of autonomy, but does the hon. Gentleman agree that, given the status quo and the many stories that we have heard about individuals who took their lives but kept it secret from their families, whether by going to Switzerland or by doing it in a horrible way in lonely circumstances, a regulated atmosphere would makes it more likely that people will talk to their family about what their death will be like and, as we have learned from overseas, make arrangements for their family to be around them, or at least to say goodbye, as they move into that process? At the moment, because this area is unregulated, way more people do it in secret than need to.

Daniel Francis (Labour, Bexleyheath and Crayford)

I am not entirely persuaded. I think there is currently a mixture of cases, and there will potentially be a mixture of cases in future. I hear what the right hon. Member says, but my primary concern is about the way things are. As I say, I am minded not to support the amendments on balance, but I am concerned that we could end up hearing stories about someone’s loved one of 50 years, or their child with a learning disability, having had an assisted death—and the first they knew about it was when it was too late.

Lewis Atkinson (Labour, Sunderland Central)

It is a pleasure to serve under your chairship this afternoon, Ms McVey.

I feel that we are dancing on the head of a pin, but I oppose the amendment. Members across the debate have recognised that, as Dr Sarah Cox from the Association for Palliative Medicine said, it is always for the patient to decide. As my hon. Friend the Member for Rother Valley pointed out, both the original clause and the amendment rightly retain that decision with the patient. They also retain the discretion of the doctor, whether that is on an appropriate test or a best interests test.

I note that in its submission the Royal College of Physicians advocated the removal of the clause, saying that it goes beyond current practice. I support the clause on balance, because of the importance of these conversations and so on, but the physicians who are likely to carry out the conversations think that it is inappropriate to specify these conversations in primary legislation.

There are two phrases in the amendment that I think are entirely inappropriate. First, there is “concluded in good faith”. I am sure it is not the intent of the author and mover of the amendment, but it suggests that in other instances people might be acting other than in good faith. I commend the words from my hon. Friend the Member for Ipswich. We have to start from the point that doctors are operating in good faith. It is dangerous to set up a good faith test, as opposed to an “other faith” test, in primary legislation.

Secondly, I am certainly not trying to reopen the long debates we had about the Mental Capacity Act, but Members will recall that in those debates we were very clear that the “best interests” test should not and does not apply. Introducing language about best interests the first time in the Bill is very dangerous, and totally against the spirit and principle of what we have debated so far. For those reasons, I am against both amendments.

Jake Richards (Labour, Rother Valley)

My hon. Friend the Member for Sunderland Central has made many of the points that I planned to, so I will be brief. The primacy of patient autonomy when it comes to familial relationships is a principle that should not be interfered with in the medical sphere, which this is—we can call it treatment or something else, but it is undoubtedly a relationship between a doctor and a person.

I agree with my hon. Friend on the term “good faith”. I do not doubt the motives, but it put forwards the proposition that a doctor would act in bad faith and not tell a family member. It is a rather bizarre drafting, and wholly unhelpful for the intent for which it was put forward.

The most alarming is the second part and the issue of “best interests”. I will not labour the point that my hon. Friend has made, but what is a doctor to do? A doctor is not a social worker. A doctor is not a family support worker. What questions are they to ask? If someone says, “Oh, I don’t really want to tell my next of kin, who is my sister. We fell out last year because of tit for tat,” is the doctor going to make a value judgment as to whether that argument is profound enough to stop the notification?

Tom Gordon (Liberal Democrat, Harrogate and Knaresborough)

The point that the hon. Member makes is, I think, exactly the case—raising this conversation and talking about it is probably not in anyone’s best interests in the first instance. I think about my own situation. If I were to find myself terminally ill and falling within the scope of this law, and my mum had passed away, then my dad, who I have not spoken to in over a decade, with whom I have a very difficult and estranged relationship, would have to be notified and we would have to have a conversation about it. On my deathbed, the last thing I want to be thinking about is some childhood trauma being brought back before me in the confines of that terminal illness. Does the hon. Member agree that, while the intention might be good, the consequences could be damaging to the patient and their best interests?

Jake Richards (Labour, Rother Valley)

I agree. I think in some of these debates—I am probably guilty of this as well—we forget the context in which we are operating: someone is dying, imminently. Therefore, how we approach these conversations, these assessments and this process must take that into account.

Danny Kruger (Conservative, East Wiltshire)

The hon. Gentleman accurately points out that doctors are not social workers or psychiatrists, and we are asking them to make a difficult judgment, in consultation with the patient, about whether they should engage wider family in the discussion. That goes to the broader point: we are imposing a huge obligation on doctors to make very complicated decisions about capacity, coercion and the psychosocial circumstances of the patient. The value of this amendment’s saying, “I think we should involve the family if it is safe to do so”—it might very well not be in certain circumstances—is surely to assist them in having the wider conversation that is necessary.

Jake Richards (Labour, Rother Valley)

As we heard in evidence from the chief medical officer, doctors deal with capacity issues on a day-to-day basis; I am not sure they necessarily need assistance from family members in that regard. However, I appreciate the point—I was going to come to that—

Daniel Francis (Labour, Bexleyheath and Crayford)

Will my hon. Friend give way on that point?

Jake Richards (Labour, Rother Valley)

I am going to make some progress, because I am not sure that point is crucial to the debate about this amendment; I am sure my hon. Friend will grab me afterwards. I did not mean to mischaracterise the evidence on that point.

I accept that there is a tension here. No man is an island, as the hon. Member for East Wiltshire notes, and of course this process may cause upset to others. Equally, the input of third parties to the assessment of all the issues of eligibility is worth while, but it has to be dealt with in a proportionate way. When we debate clause 12—hopefully shortly—perhaps we can discuss that, and I hope to speak to that point.

However, this amendment is trying to crack that delicate nut with a huge hammer. It fundamentally changes the relationship between doctor and patient, and puts the doctor in a position where they do not have the skills or expertise to make that best interest decision. The amendment therefore fails, and that is why I will vote against it.

Rebecca Paul (Conservative, Reigate)

I am concerned that maybe I am misunderstanding the debate. For clarity, right now clause 9 says that

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

they should

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

It will read very similarly if the amendment is agreed to. Instead, it will say,

“unless the assessing doctor has concluded in good faith, that this would not be in the person’s best interests, advise the person to consider discussing the request with their next of kin and other persons they are close to”.

That is a very subtle change—it is just a little more encouragement to consider contacting the family. No one here is telling the doctor that they must tell the patient to contact the family; it is just a little bit of strengthening to encourage that. I invite the hon. Gentleman to confirm if I have misinterpreted, but that is my understanding of the clause.

Jake Richards (Labour, Rother Valley)

I will double check whether this is right, but the explanatory statement suggests that that is not the case. It says:

“This amendment would require the assessing doctor to inform the person’s next of kin that the person wishes to seek assistance to end their own life unless it is not in the person’s best interests.”

Rebecca Paul (Conservative, Reigate)

That is not what it says.

Jake Richards (Labour, Rother Valley)

Even if that is not what it says, and even if the explanatory statement is wrong, it is not appropriate for doctors to advise patients what they should do with their family. Yes, they should consider it, but that is what this clause does. I will be voting against this amendment.

Stephen Kinnock (Labour, Aberafan Maesteg)

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

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

they must

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

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

Amendment 308 is consequential to amendment 307 and requires that

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

I hope those observations were helpful.

Kim Leadbeater (Labour, Spen Valley)

I have nothing to add, other than that I will not be supporting amendments 307 and 308. I associate myself with the comments made by my hon. Friends the Members for Rother Valley, for Stroud and for Sunderland Central.

Danny Kruger (Conservative, East Wiltshire)

I beg to ask leave to withdraw the amendment.

Clause 10 - Another independent doctor: second opinion

Kim Leadbeater (Labour, Spen Valley)

I beg to move amendment 205, in clause 10, page 7, line 11, at end insert

“; but this is subject to subsection (4).

(4) Where—

(a) a referral is made under subsection (1) to a practitioner,

(b) the practitioner dies or through illness is unable or unwilling to act as the independent doctor, and

(c) no report under section 8 has been made by virtue of the referral,

a further referral may be made under subsection (1).”.

This amendment provides that a further referral may be made under this clause where a practitioner dies or is unable or unwilling to act as the independent doctor due to illness.

Esther McVey (Conservative, Tatton)

With this it will be convenient to discuss clause stand part.

Kim Leadbeater (Labour, Spen Valley)

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

Stephen Kinnock (Labour, Aberafan Maesteg)

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

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

Sarah Olney (Liberal Democrat, Richmond Park)

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

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

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

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

Lewis Atkinson (Labour, Sunderland Central)

I fear that the point the hon. Lady is making relates to before her amendment 459 was accepted. Does she not agree that by accepting amendment 459, we have guarded against the first independent assessment not being available for subsequent decision makers?

Sarah Olney (Liberal Democrat, Richmond Park)

I am not used to my amendments being accepted. The hon. Gentleman is, of course, absolutely right.

Dr Matthew Doré, the palliative medicine consultant and honorary secretary of the Association for Palliative Medicine, said in written evidence:

“Allowing patients to seek multiple opinions undermines procedural integrity. Furthermore, allowing the coordinating doctor to seek multiple opinions even further undermines the selection of doctors willing to provide AD”—

that is, assisted dying. He goes on:

“The lack of a centralised tracking system facilitates ‘doctor shopping’.”

Notwithstanding the fact that amendment 459 has now been accepted, there is still grave concern about the possibility of doctor shopping. We should take steps to avoid it. That is why I am speaking against clause 10 in its entirety.

Under clause 8, the independent doctor has five matters to verify: that the person is terminally ill; that they have capacity; that they have a clear, settled and informed wish to end their own life; that they are acting voluntarily and without coercion or pressure; and they are over 18. The last requirement is unlikely ever to be in any form of doubt, so I will focus on the other four. The effect of clause 10 is to allow someone to be assisted to die when one out of three doctors who examined them had concluded that they were not terminally ill, that they lacked capacity, that they did not have a settled wish to die or they were coerced. It therefore raises a real risk that someone not actually eligible for assisted dying would none the less be so assisted. In such matters of life and death, we ought to proceed with great caution.

Doctors can get things wrong, of course. If the first independent doctor did get it completely wrong, I would have no objection to the second independent doctor effectively acting as a form of appeal—or, to borrow the test from the law of medical negligence, if the first independent doctor reached a conclusion not supported by a reasonable body of medical opinion, of course it would be right for that opinion to be disregarded. But that is not what the Bill provides for, which is not an appeal or reconsideration but picking a new referee simply because the first answer was not desired.

I still have misgivings about clause 10 notwithstanding the fact that it has been amended. I urge other Committee members to vote against it. I appreciate your indulgence, Ms McVey.

Rebecca Paul (Conservative, Reigate)

I rise to speak against clause 10 as it allows doctor shopping in the event that someone does not qualify for assisted dying. “Not happy with the verdict? Just find another doctor!” How many times are we happy for a patient to try again with a different doctor? It is inevitable that at some point the patient will find someone willing to make the statement and put them on their way to an assisted death, even if their eligibility is in doubt.

When I put forward the amendments tabled by my hon. Friend the Member for West Worcestershire (Dame Harriett Baldwin), which requested residual discretion for doctors, they were challenged by Committee members on the basis that the whole point of having defined criteria was so that they determined whether a patient was eligible. I run the same argument now: if the process is followed to the hilt and the independent doctor refuses to issue the statement, why on earth would we allow another bite—or even multiple further bites—at the cherry? Surely that is to allow abusers a way to push their victims into an assisted death by re-running the process again and again until they find a less attuned doctor.

Imagine the case of an elderly woman who has spent a lifetime under the coercive control of her husband. She is completely done with it all, and sees death as a welcome way to escape this man, who has made her life a misery. The abuse has escalated since she has become ill: because of her ill health, she cannot cook or clean any more, and he hates that. But no one sees. She never wanted the kids to know; she is really good at hiding it. Now, he wants to seek an assisted death, because it is better for them all. She agrees. When asked by a doctor, she is unlikely to say, “My husband is pressuring me into this, and I’m afraid of not doing what he wants,” particularly if she has suffered abuse over many years.

Let us say that the first independent doctor does a really thorough job—the kind of job that we hope all doctors would do. Perhaps the doctor manages to discern that the patient is very much controlled and unduly influenced by her husband. The trouble is that it can be very difficult to find hard evidence of coercive control. According to recent figures, only 3.7% of recorded cases of controlling or coercive behaviour result in a charge, and more than half of cases are dropped because of evidential difficulties. The doctor therefore cannot get the police to intervene; his only lever is the power to reject the application. So that is what he does. But the patient does not give up; she is still absolutely sure that the best thing is an assisted death, and her abuser is still whispering in her ear, telling her she is right.

The second independent doctor does not have the same emotional intelligence as the first, and he does not see what the first doctor saw. He approves the application.

Lewis Atkinson (Labour, Sunderland Central)

This is a similar point to the one I made before: amendment 459, which we have just passed, means that, in the scenario that the hon. Lady describes, the second independent doctor will have in their possession the first independent doctor’s concerns about coercion. Does she not agree?

Rebecca Paul (Conservative, Reigate)

I will come to that exact point shortly.

Members of the Committee will recall that I previously tried to get “undue influence” and “encouragement” added to the Bill explicitly to deal with more subtle forms of influence and pressure, as opposed to those that are more obvious to third parties. When objecting to my amendments, the Minister said that they were unnecessary, because “coercion or pressure” already covered them. I hope that the Minister is proven to be correct.

The key point is that those forms of behaviour are not always easily discernible. Dr Mullock told us in oral evidence that

“the kind of undue influence that might occur might be very subtle. More needs to be done to recognise that and the subtle encouragement that might take place, where a relative might frame their support for the person seeking to die in terms of, ‘This will be better for you,’ and, ‘Have you considered this?’ That is not necessarily an example of clear abuse, so when the person seeking to die then consults the doctor, they are not going to characterise what has happened to them as coercion or abuse. More needs to be done to discuss with the person whether or not they have been encouraged by the people around them.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 162, Q204.]

These are the very real consequences of this clause, which undermines the independent doctor safeguard. In written evidence, Mr Michael Vidal hits the nail on the head:

“It seems to negate the purpose of having a second opinion if the second opinion can be ignored and a fresh second opinion obtained.”

I recognise and welcome the fact that amendment 459 has been accepted. It would mean that the second independent doctor would have the benefit of the report of the first independent doctor. However, this is not a failsafe protection and cannot be relied on entirely. First, the report of the first independent doctor is required to be made available to the patient. In a case such as this, would the first doctor want to spell out exactly what led to that conclusion, knowing that it could place the patient in harm’s way if her husband saw it? Also, he is not 100% sure; does he want to make such accusations in writing without hard evidence?

Secondly, even if the report was detailed and available to the second independent doctor, he would still need to make his own assessment, and he might not agree. Or it could be that although he recognises signs of coercion over a long period, he may truly believe that, to the best of his knowledge, the decision made by the patient has not been coerced in that moment.

I am afraid therefore that clause 10 is a loophole that will be exploited by domestic abusers, and it is largely women who will pay the price. For that reason, I cannot support it.

Lewis Atkinson (Labour, Sunderland Central)

I was not going to speak to this clause, but I feel I must rebut some of the points made, which are clearly incorrect. The hon. Member for Reigate asks how many further opinions there will be; the answer is clearly one, because that is what is set out in the Bill. The safeguards in amendment 459 mean that it is not just the second doctor who will be aware of the first doctor’s concerns; any subsequent decision maker will be.

We are about to discuss significant amendments in clause 12. However, whether there is a panel or the decision remains with a High Court judge, it is inconceivable that, when presented with an initial assessment that the criteria are not met and a subsequent assessment that disagrees with it, that third-tier decision maker will not want to explore the issues in detail. I believe that all Committee members are trying to work together in a spirit of genuinely improving the legislation, but our arguments and discussions need to reflect the amendments that we have accepted. Clause 10, as amended, is significantly improved and strengthened. It continues to provide significant safeguards for the Bill, and I am happy to support it.

Clause 11 - Replacing the coordinating doctor on death etc

Sarah Olney (Liberal Democrat, Richmond Park)

I beg to move amendment 461, in clause 11, page 7, line 15, leave out “or otherwise”.

Esther McVey (Conservative, Tatton)

With this it will be convenient to discuss the following:

Amendment 310, in clause 11, page 7, line 23, at end insert

“and

(c) to ensure the High Court is notified of the substitution of the coordinating doctor and the reason for the substitution.”

This amendment would include ensuring the High Court is notified of substitutions of the coordinating doctor in the list of matters the Secretary of State may by regulations make provision for.

Amendment 309, in clause 11, page 7, line 23, at end insert—

“(3) Regulations under subsection (1) must include provision to require the reassessment of the patient under section 7.”

This amendment would require a regulations covering the replacement of the coordinating doctor to include a reassessment of the person by the new coordinating doctor.

Clause stand part.

Sarah Olney (Liberal Democrat, Richmond Park)

The amendment would remove the phrase “or otherwise” in the clause. All I am proposing is for the wording to be consistent with amendment 205 to clause 10, which has just been agreed. It does not specify “or otherwise”, but simply uses the words,

“the practitioner dies or through illness is unable or unwilling”.

What might “otherwise” incorporate? It indicates that there might be a range of reasons beyond death or illness why the co-ordinating doctor would drop out. In many ways, I am trying to probe what the other reasons might be. If there are no other reasons, and consistent with amendment 205 that we have just agreed, we should drop the phrase “or otherwise”.

Danny Kruger (Conservative, East Wiltshire)

I want to speak briefly in support of the hon. Lady’s amendment and also in support of amendment 310, tabled by the hon. Member for York Central. The hon. Member for Richmond Park is absolutely right. I will not rehearse her argument, which is very straightforward. The question is: what other reason could there be to justify a co-ordinating doctor transferring the case? The Committee might reject that amendment, in which case I hope they will accept the amendment tabled by the hon. Member for York Central, which specifies that whatever the reason, particularly if it is other than death or illness, it is important for the High Court or the panel to be notified of the substitution and the reason why.

Sarah Green (Liberal Democrat, Chesham and Amersham)

Maternity leave is one reason and retirement might be another.

Danny Kruger (Conservative, East Wiltshire)

Those might be appropriate reasons; I hope that can be specified. The crucial thing is that if there is an unwillingness—not an incapacity but an unwillingness—to proceed, that is of some concern. It is not that they are no longer able to do it—possibly for the reasons that the hon. Lady suggested—but if there is an actual unwillingness to proceed, what is the reason?

On amendment 309, if the first doctor is replaced for whatever reason, surely it is imperative that the new doctor conduct their own assessment, rather than taking the previous doctor’s word for it. A doctor is legally responsible, obliged under all medical regulation and law for their actions, and they cannot rely on a previous assessment. If the first doctor gave up the case because of some kind of incapacity—an illness, or, indeed, their demise—it might be that their own judgment was impaired at the time. I would have thought it was obvious that the new doctor should take responsibility for conducting an assessment and proceeding with full responsibility for the case.

Naseem Shah (Labour, Bradford West)

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

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

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

Stephen Kinnock (Labour, Aberafan Maesteg)

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

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

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

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

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

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

Kim Leadbeater (Labour, Spen Valley)

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

Sarah Olney (Liberal Democrat, Richmond Park)

I beg to ask leave to withdraw the amendment.

Clause 12 - Court approval

Daniel Francis (Labour, Bexleyheath and Crayford)

I beg to move amendment 105, in clause 12, page 8, line 15, leave out subsections (4) and (5) and insert—

“(4A) Rules of Court must secure that in relation to an application under subsection (1), the High Court must—

(a) prescribe a procedure which in relation to each application appoints a person (the Official Solicitor in cases in brought in England and Wales) to act as advocate to the Court,

(b) hear from and question, in person—

(i) the person who made the application for the declaration,

(ii) the coordinating doctor,

(iii) the independent doctor, and

(c) consider hearing from and questioning, in person—

(i) persons properly interested in the welfare of the person who made the application for the declaration and other persons they are close to, and

(ii) any other person who has provided treatment or care for the person being assessed in relation to that person’s terminal illness.”

This amendment would require court rules to be made that would ensure an adversarial court process, by appointing an advocate to the court. It would also require them to hear from the person seeking assistance to end their life and both assessing doctors, and to consider also hearing from family members and others involved in the person’s care.

Carolyn Harris (Labour, Neath and Swansea East)

With this it will be convenient to discuss the following:

Amendment 407, in clause 12, page 8, line 19, leave out “may” and insert “must”.

This amendment would require the High Court to hear from and question the person who made the application for the declaration.

Amendment 410, in clause 12, page 8, line 27, leave out subsection (6).

The amendment would remove the ability of the court to hear from and question any person other than the person who made the application for the declaration and the assessing doctors.

Amendment 106, in clause 12, page 8, line 30, leave out “(5)” and insert “(4A)”.

This amendment is consequential on Amendment 105.

Amendment 107, in clause 12, page 8, line 44, leave out “(4)” and insert “(4A)”.

This amendment is consequential on Amendment 105.

Daniel Francis (Labour, Bexleyheath and Crayford)

I will withdraw amendment 105 later, but will speak to it briefly, as my name is on it. The amendment aims to require court rules to be made that would ensure an adversarial court process, by appointing an advocate to the court. It would also require them to hear from the person seeking assistance to end their life and both assessing doctors, and to consider also hearing from family members and others involved in the person’s care.

In our oral evidence sessions, we heard from Nicholas Mostyn and Alex Ruck Keene about some of the merits of doing so, with reference to the Bill that was before us at that stage. Since then, a significant number of amendments and new clauses have been tabled, so I will not press this amendment to a vote, given the other amendments now before the Committee.

Juliet Campbell (Labour, Broxtowe)

I rise to speak to amendments 407 and 410. Amendment 407 would leave out the word “may” and insert the word “must”, and would require the High Court to hear from and question all persons who made the application for a declaration. It is a probing amendment, which aims to question the guidelines for the judge to question and hear from some people and not all people. I will not press the amendment to a vote, but I seek clarity on what the criteria would be for the judge to question some people and not others.

Kim Leadbeater (Labour, Spen Valley)

I hope I can provide some reassurance. This issue is covered by my new clause 21. The amendment, I think, asks why the High Court would not have heard from the patient. My new clause would ensure that the panel—as it potentially would be—will hear from the patient.

Juliet Campbell (Labour, Broxtowe)

I thank my hon. Friend for that explanation.

I move on to amendment 410, which would remove the ability of the court to hear from and question any person other than the person who made the application or the declaration for an assisted death and the assessing doctors. I have strong reservations about using a proxy or giving another person the right to speak on behalf of an individual who wishes to have an assisted death, and I question the scope of those people who could be the proxy to speak on behalf of a person requesting an assisted death. Who exactly would those people be?

One of the arguments we have consistently debated in this Committee is around coercion and patient autonomy. When multiple third parties such as family members or caregivers are allowed to testify, there is an increased risk that an individual might influence the court’s decision in a way that is not aligned to the true wishes of the applicant. In some cases we have talked about pressure from family members or loved ones, for whatever reason—whether their vested interest is financial or something else—to have the applicant hasten their death or have an assisted death. I would not want that kind of pressure to be put on the person and I do not believe any third party should be allowed to speak on their behalf or to be a proxy.

By limiting the scope of the testimony to the applicant and assessing doctors only, the amendment helps to safeguard against such manipulative tactics and ensures that the court focuses solely on the applicant’s own will and the medical assessment of their eligibility, removing the potential for family dynamics or any other outside influence to interfere with the judicial review. It offers a necessary refinement to the Bill for assisted deaths, a request that is both efficient and respectful of the autonomy of all people involved. By limiting the court testimony to the applicant and assessing doctor, the amendment addresses several of the concerns I have spoken about.

Jake Richards (Labour, Rother Valley)

I will speak briefly, because many of these issues and themes will be debated in clause stand part and amendments 371 and the others from my hon. Friend the Member for Spen Valley. Amendment 267 was not moved, but I would have opposed it in any event, on the basis that the discretion given there was way too wide and I did not understand the basis of the amendment in any way. Amendments 105 to 107, tabled my hon. Friend the Member for Derby North (Catherine Atkinson), attempt to add an adversarial element to proceedings. Again, I will not comment too much because that issue comes back in the fourth grouping under this clause.

I turn briefly to amendment 410, to which my hon. Friend the Member for Broxtowe just spoke. My understanding is that, although this relates to the High Court—which may be deemed redundant as we move on through this clause—the amendment aims to limit the people that the judge or panel can hear from. In my view that would be wrong and dangerous. The purpose of a judge or a panel is to explore the circumstances in this matter. That must mean that they have discretion to hear from others as well. In my view, this amendment, if passed, would significantly limit the safeguards and be quite dangerous.

As my hon. Friend has already said, amendment 407 has been superseded, and I think we all agree on that.

Sarah Sackman (Labour, Finchley and Golders Green)

It is a pleasure to serve under your chairship, Mrs Harris. As I and my colleague and hon. Friend the Member for Aberafan Maesteg have made clear throughout the debate, the Government continue to remain neutral on this Bill and do not take a position on assisted dying. My remarks will therefore focus on the legal and practical impact of the amendments, to assist the members of this Committee in undertaking line-by-line scrutiny.

Amendments 267 and 105 to107, which have now been withdrawn, deal with the Bill as currently drafted in relation to the High Court. Clause 12 as currently drafted would require the High Court to make a declaration that the requirements of the Bill have been met, following a person’s first declaration to receive assistance to end their own life, with statements from a co-ordinating doctor and an independent doctor. The amendments relate to how the High Court will declare itself satisfied that a person has a clear, settled and informed wish to end their own life and that they have not been coerced or pressured.

Briefly, amendments 407 and 410 seek to change who the High Court—as others have said, we might come on to debate some of these themes relation to the panel—would engage with when considering applications for assistance under the Bill. In determining whether the person has a clear, settled, and informed wish to end their life and that they have not been coerced or pressured, the High Court would be required to hear from and question the person seeking assistance, as opposed to having the option to do so. As my hon. Friend the Member for Spen Valley pointed out, in the later provision in relation to the panel, that has now become a requirement.

As my hon. Friend the Member for Broxtowe made clear, under her amendment 410 the High Court would lose the ability to hear from or indeed question any other party other than the person seeking assistance and the assessing doctors. Removing the ability—whether of the High Court or, as we may come on to debate, of the panel—to hear from and question any other party may limit that body or court’s ability to interrogate wider evidence or points of view.

Juliet Campbell (Labour, Broxtowe)

The probe that I have on that point is that the individual who is seeking the assisted death, and the doctors who have been working with that person, really have all the information. I am trying to ascertain, if we are not going to agree on this amendment, who else they would be seeking information from. Is there a risk if they are getting evidence from family members or other people, or having them give evidence or speak on behalf of that declaration?

Sarah Sackman (Labour, Finchley and Golders Green)

As I understand it, both in the context of the High Court—which has the ability to speak to whomever it likes—and of the panel, when we come to debate its role, that is a discretion. It is a requirement to hear from the person seeking an assisted death; it is a requirement to hear from the co-ordinating doctor. However, hearing from others is discretionary, which means that, if it is necessary in order to be satisfied that the eligibility criteria are met—which is what the scheme requires—in that context, under the panel’s or the High Court’s discretion, it may seek evidence from elsewhere. That is what the provision, as the Government reads it, is designed to do.

The amendment that my hon. Friend the Member for Broxtowe puts forward clearly limits that discretion; whether that is desirable is a policy choice, but that is how it is intended to function. As I have said, the Government will continue to remain neutral on these substantive policy questions, but I hope that is useful to members of the Committee.

Kim Leadbeater (Labour, Spen Valley)

I think I have responded to the hon. Member for Broxtowe on amendment 407 by saying that the concern will potentially be covered by my new clause 21. On amendment 410, it is also my view that, whether it is the High Court or the panel or whoever we end up having over the course of this Committee, that third layer of scrutiny and safeguarding should be able to hear from other people, not just the patient and the doctor, so I would not support that amendment.

Daniel Francis (Labour, Bexleyheath and Crayford)

I beg to ask leave to withdraw the amendment.

Danny Kruger (Conservative, East Wiltshire)

I beg to move amendment 432, in clause 12, page 8, line 31, leave out paragraph (a).

This amendment is linked to amendments which remove proxies from the Bill.

The rest of the debate is in Hansard.