The assisted suicide Bill Committee scrutinising Kim Leadbeater’s Terminally Ill Adults (End of Life) Bill met for its fourth week of sittings last week to continue its line-by-line scrutiny of the Bill.
On 4 and 5 March, MPs further considered the clauses of the Bill as well as a series of important amendments. By the end of the first day, MPs had rejected key amendments to the Bill that would have offered explicit protections to people with Down’s syndrome, autism and learning difficulties; Bill supporters rejected a proposal to prevent doctors from raising the option of assisted suicide with 16 and 17-year-olds; MPs voted for Clause 4 of the Bill, including its controversial provision that doctors can offer assisted suicide as an option to patients unprompted; Bill sponsor Kim Leadbeater had twice confirmed that her Bill would mean every doctor was required to mention assisted suicide to all terminally ill patients eligible under the Bill; the Committee voted against 28-day ‘cooling-off’ period safeguards, both before doctors can raise assisted suicide with patients after a terminal diagnosis and before a terminally ill patient can apply for assisted suicide; and Bill supporter Kit Malthouse MP repeatedly objected to critics voicing their concerns about the Bill and appeared to attempt to prevent outside groups from expressing legitimate concerns, including on social media.
By the end of the second day, an amendment to ensure doctors could not ‘tick off’ assisted suicide requests without a meaningful conversation with a patient was rejected; the Committee voted against a move that would have guaranteed approvals could not be signed off by a physician associate, doctor in training or locum doctor; the lack of clarity about who would implement assisted suicide and how was not resolved; one MP, himself a doctor, seemed to object to transparency concerning doctors who may make money out of assisted suicide services; Clause 5 of the Bill passed – the clause continues to allow assisted suicides to take place without the knowledge of next of kin; a requirement for photo ID before any assisted suicide sign-off was rejected; multiple attempts to protect people with mental disorders and eating disorders were rejected again; and a proposal to prevent approval for assisted suicide where there is any doubt about the eligibility criteria failed to pass.
Amendments rejected
A number of key amendments were rejected by MPs on the Committee that aimed to offer special safeguards for people who may be at particular risk if assisted suicide were made legal.
Down’s syndrome amendment rejected: Damien Hinds MP launched an amendment (368) to protect people with Down’s syndrome from assisted suicide, which MPs rejected 13 votes to 8. The amendment, if successful, would have required the publication of guidance consistent with the Down Syndrome Act 2022 to meet the needs of adults with Down’s syndrome.
Danny Kruger MP, who argued for the amendment on Hinds’ behalf, drew attention to the value of the lives of people with Down’s syndrome and pointed to the danger of how speaking about assisted suicide with someone with Down’s syndrome can be interpreted as a suggestion.
“The fact is that in our society we have persistent and entrenched discrimination against people with learning disabilities, particularly people with Down’s syndrome. There is a fundamental assumption that is too widely shared that the lives of people with Down’s are worth less than others’. One sees that, I am afraid to say, in the prevalence of prenatal screening and termination of Down’s babies. Yet we know from research that the lives of people with Down’s are as fulfilling, joyful, positive and constructive as everybody else’s”.
“A point that has been made, in particular by the Down’s Syndrome Research Foundation, is that a discussion with someone with Down’s can often feel to them as if a suggestion is being made. That is particularly relevant to the whole question of a doctor’s suggestion, which we will come on to—well, we are on it now. Certainly the whole matter of how a person with Down’s syndrome receives information needs to be taken into account in any work that is done” he said.
Kit Malthouse MP, a staunch supporter of the assisted suicide Bill, appeared to attempt to prevent Down’s syndrome campaigners and opponents of the Bill from publicising MPs’ rejection of explicit safeguards for people with Down’s syndrome. Danny Kruger agreed with the Chair that it’s not his job to police social media.
Discussion of assisted suicide only with over 18s amendment rejected: Under the terms of the Bill as written, anyone under the age of 18 would not be able to seek state assistance in suicide. However, the Bill does not prevent a doctor from discussing the possibility of assisted suicide with a child aged 16 or 17 in accordance with their professional judgment. Daniel Francis MP, therefore, launched an amendment (319) to ensure that doctors were unable to discuss the topic of assisted suicide with children under the age of 18. However, MPs voted this amendment down by 13 votes to 8.
Safeguards for people with autism amendment rejected: Daniel Francis also tabled an amendment (339) that would have required that “if the person is autistic or has a learning disability, they must be given accessible information and sufficient time to consider it. Additionally, there must be at least either a supporter or independent advocate”. However, MPs voted against this amendment 13 to 8.
Preventing doctors from proactively offering assisted suicide to patients amendment rejected: Under the Bill as written, a doctor is permitted to raise the possibility of assisted suicide with a patient unprompted by the patient. Chris Webb tabled an amendment (8) to prevent a medical practitioner from doing this. However, Bill sponsor Kim Leadbeater and her colleagues voted 13 to 8 against amending her Bill in this way.
After the amendment was rejected, Kruger said “I am afraid to say that, in rejecting the amendments, the Committee has endorsed the approach that people who are particularly marginalised and disadvantaged need to have this suggestion explicitly made to them. I am astonished that the Committee proposes to proceed on that basis, which completely misunderstands the dynamic of vulnerable people in the face of authority. I am very distressed to find that the Committee thinks that acceptable, and I am very sorry that apparently we are proceeding with the clause”.
On the wider point of conscientious objection, Rebecca Paul MP said the assisted suicide Bill “would place many doctors in an impossible position. Referral would mean writing a letter to, or putting the patient in touch with, another doctor. For many, doing so would be tantamount to involvement with assisted dying, and would not be something they are comfortable with. Dr David Randall, a consultant nephrologist at the Royal London Hospital and honorary senior lecturer at Queen Mary University of London, states in written evidence:
‘The Terminally Ill Adults (End of Life) Act will cause significant damage to the healthcare workforce by: imposing a duty of ‘effective referral’ on medical practitioners who object to direct involvement, an obligation which will drive some from the profession and impose moral injury on those who remain’.”
Danny Kruger also pointed out that “none of the legislation in Australia or New Zealand, or the legislation currently going through in the Isle of Man, puts an obligation to refer on to doctors. Victoria and South Australia’s legislation says that a doctor has the right to refuse to participate in the request for assistance process and to give information about voluntary assisted dying, so there is no duty to refer—not even a duty to provide information”.
28-day waiting period amendment rejected: Naz Shah MP tabled two amendments (276 and 277), which required that “a doctor could not conduct a preliminary assessment until 28 days
from the day the person received a diagnosis” that they had six months or less to live, and “a person could not make the first declaration until 28 days from the day they received a diagnosis” that they had six months or less to live.
Speaking for her amendment, Naz Shah said “To put the most important point first, the amendment aims to prevent people opting for assisted dying while they are suffering from the initial shock of having a serious illness diagnosed, by imposing a pause”.
“I ask hon. Members to support amendment 277. It will give patients time to think. It will give them that time near the beginning of the assisted dying process, whereas the Bill as currently drafted gives them time almost at the end of the process. Most importantly, it will give patients what senior psychiatrists have asked for: simply put, the chance for people who have received a shocking diagnosis and prognosis to work with their doctors and social carers to put new treatment plans in place”, she added.
Amendment 277 was defeated 12 to 7, and 276 was rejected by 14 to 7.
Ensure a doctor has a discussion with a patient before the first declaration for assisted suicide is signed: Danny Kruger launched an amendment (359) that would have required “that the coordinating doctor has conducted a preliminary discussion prior to witnessing the signing of the first declaration”.
Speaking in favour of his amendment, Kruger said “At the moment, the Bill allows someone to make the first declaration and state, ‘I wish to be provided with assistance to end my own life’, without any preparatory discussion about what that entails. It is significant that we heard evidence from Professor House—a professor of old-age psychiatry—that the preferences of the person doing the assessment can bias the capacity assessment. As he explains, we are much more likely to declare that somebody has capacity when they say they want to have the treatment we are offering them, but can we really be sure that the request is freely made and reflects the patient’s wishes?”.
“My amendment 359 would enhance the significance of the preliminary discussion. It would mean that the doctor who witnesses the declaration—who co-ordinates the process of the assisted death—has had the fullest possible discussion with the patient, and that they genuinely take responsibility for guaranteeing that the patient is fully informed and aware of all of their options”, he added.
A fully qualified doctor rather than a physician associate or doctor in training must sign off an assisted suicide amendment rejected: MPs on the assisted suicide Bill Committee rejected Rachael Maskell MP’s amendment (290) that would have explicitly required a fully qualified doctor rather than a physician associate or doctor in training to sign off an assisted suicide request.
Since the Bill requires sign-off for an assisted suicide from a “registered medical practitioner”, physician associates would not have been included. However, it remains significant that MPs chose not to make this explicit in the Bill.
The amendment was rejected 13 to 9.
Photographic ID requirement amendment rejected: MPs refused to back proposals (291, 292 and 293) to ensure photo ID would be required before an assisted suicide could be approved.
Inform family of decision to have assisted suicide amendment rejected: Danny Kruger MP tabled an amendment (418a) that would have required that the person seeking an assisted suicide sign a declaration saying they have or have not informed their family of their decision. It was not selected.
Speaking on this matter during the debate, Kruger said “That is the saddest thing, which was hinted at quite strongly—in fact, stated explicitly—in some of the evidence sessions. It has been suggested that wanting a loved one to live is seen by doctors as a form of coercion that should be resisted; that trying to argue a loved one out of an assisted death is the coercion that we need to guard against and, on that basis, we should not be making any expectation that families are informed. What a tragic thing for us to say. To enable doctors to issue lethal drugs that kill people without their family knowing is an absolutely tragic thing. I beg the Committee to consider what on earth we are doing allowing that”.
How thorough is the scrutiny of the assisted suicide Bill?
MPs have continued to raise grave concerns over the flaws in the assisted suicide Bill, warning that it is being rushed through Parliament without proper scrutiny. Elizabeth Gardiner, the drafter behind the Bill admitted that “we didn’t have time to go into all the detail” of the operation of assisted suicide regimes in other countries.
Kim Leadbeater MP confirmed that doctors would be expected to raise assisted suicide as an option for all terminally ill patients, fundamentally shifting the doctor-patient relationship.
Meanwhile, Kit Malthouse repeatedly attempted to police the debate by curtailing Danny Kruger or Naz Shah’s contributions, but was ultimately shut down by the Chair.
Danny Kruger MP exposed shocking loopholes, revealing that a proxy, who may have no medical training or personal knowledge of the patient, could sign an assisted suicide declaration on a patient’s behalf.
He also warned that, as seen in Oregon, the process can quickly become a “tick-box exercise” with just three people referred for psychiatric evaluation in 2023. Meanwhile, Naz Shah MP condemned the Bill for failing to protect the most vulnerable, warning that it overlooks systemic inequalities in end-of-life care. “If we want a Rolls-Royce service, and if this is to be the best Bill in the world, it cannot ignore the most vulnerable in society”, she stated. Despite attempts to brush off criticism, Shah reiterated that the Bill was not fit for purpose saying “I would slightly beg to differ with my hon. Friend in terms of making progress in the way that I would like to have seen”.
Assisted suicide is not healthcare
There has also been growing concern over the portrayal of assisted suicide as a form of healthcare. Rebecca Paul MP expressed reservations about framing assisted dying as another treatment option offered by medical practitioners, warning that it fundamentally contradicts the principles of medical care. “A medical treatment can be defined as something that combats disease or disorder. It is fundamentally about healing, relief of symptoms, recovery and cure. Straightaway, we have a conflict. Assisted dying ends the life of a person”. Naz Shah MP made a similar remark, reminding the Committee that the core principle of medical practice is to preserve life and avoid causing harm. This, she noted, is “why the vast majority of those who work in end-of-life care oppose this legislation”.
Danny Kruger MP pointed out the confusion surrounding whether assisted suicide would be viewed as a ‘treatment’, which could place an obligation on doctors to offer it, further complicating medical responsibilities. Paul echoed these concerns, asserting that assisted suicide must not be considered a ‘treatment’.
Remuneration and the role of the NHS vs private practice in assisted suicide
Danny Kruger MP raised serious concerns about the potential for assisted suicide to become a lucrative enterprise, highlighting that there is no provision preventing the advertising or profiting from assisted suicide. He questioned whether MPs understood the dangers of creating a profit motive for ending lives and whether remuneration for assisted suicide could influence a doctor’s decision-making. “Should we not have some unease at the idea that this could be a highly profitable specialism for private practice?” he asked.
Pro-assisted suicide MP Simon Opher appeared to object to too much transparency in assisted suicide, citing concerns about potential backlash over the amounts of money or the number of patients involved.
Depression, anorexia, and terminal illness
Sarah Olney MP highlighted the link between depression and terminal illness, pointing out that depression is common in such cases and often leads to a wish to hasten death. However, Olney stressed that this desire for death is significantly alleviated when depression is treated. She raised a critical question, asking, “If a person qualifies for assisted dying but is also experiencing impaired judgment due to a psychiatric condition, how can we be confident that their decision is truly autonomous?”
Despite these concerns, pro-Bill MP Lewis Atkinson argued that “We should not prevent anyone from accessing an option merely because of a mild element of, for example, depression”.
