Kit Malthouse
MP for North West Hampshire · Conservative · United Kingdom
“We have heard time and time again that the situation that thousands of our constituents live with every single day is so horrific and appalling that even the best palliative care cannot alleviate their pain. I urge colleagues to consider what their vote may mean today.”
“I will not. Some of those Members had just a few months before been specifically rejected by the electorate and replaced in this House by others, and I am afraid that they cannot be trusted not to do the same thing again. I grant my right hon.”
“The Health and Social Care Committee of the House of Lords found that in territories that have assisted dying, palliative care generally improves, because people become less afraid of talking about death.”
“One of the most affecting people I have met over the last 11 years of campaigning on this issue is Warwick Jackson, who came to our party conference a couple of years ago. Warwick’s wife, Ann, was diagnosed with terminal peritoneal cancer. She basically knew that she was going to die a slow, suffocating death at the end.”
“I respect my right hon. and learned Friend’s expertise in this matter, but, as he has already heard on the Floor of the House, it is perfectly possible for this House to suggest amendments, negotiate them with the promoters of the Bill, place them against the legislation in the House of Lords and then have them come back to this House for…”
“As co-sponsor of the Bill once again, I am acutely conscious that there is more at stake today than merely the fate of those who are facing their end, because the conduct of the other place means that our democracy is also on trial today.”
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“Essentially, it provides that guidance should be issued by the Government to various institutions across the health service and civil society generally, that would be used to accommodate the needs of and be sensitive to dealing with people with Down’s syndrome, particularly as they reach adulthood. Although I am sympathetic to the amendment’s aims, there are a number of issues with it. I think its objectives could be, and frankly should be, addressed in other ways. Essentially, my reading of the Down Syndrome Act is that it is aimed at institutions such as health trusts and local authorities, not at individual practitioners. Unfortunately, under that Act, which asked the Government to issue guidance on Down’s syndrome, no guidance has been issued.”
“I rise to speak briefly to amendment 368, which stands in the name of my right hon. Friend and constituency neighbour the Member for East Hampshire (Damian Hinds). I thought it was an interesting amendment to table, not least because I witnessed the introduction of the Down Syndrome Act 2022 by our colleague—sadly, now former colleague—Dr Liam Fox. He was a casualty of the last general election and is a great loss to the Chamber. His successor should certainly feel guilty about what he achieved, in my view; I am not sure that everybody would share that view, but there we are. The Down Syndrome Act was an important private Member’s Bill that sought to recognise the status of people with Down’s syndrome in society and to sensitise institutions to their welfare and wellbeing.”
“I am very grateful to the hon. Lady. It would be fantastic if she did that. However, I think we could probably deal with the intent of the amendment if the Minister were willing to commit—it is not a big commitment to make—that in the making of regulations and in the instructions to the CMO to produce guidance, he will stress the importance of consulting those with Down’s syndrome and dealing with the issues that they face, notwithstanding the impact of new clause 8 and amendment 394, and recognising that there is no guidance yet under the Down Syndrome Act. That might be a more belt-and-braces approach to what the amendment is trying to achieve than hoping that that Act and this Bill will interact in a beneficial way.”
“I am not sure my hon. Friend is entirely right. My understanding is that under law and medical ethics, doctors have to discuss all courses of action with someone, even if they believe a course of treatment might have adverse consequences. It is not that they can restrict themselves; they have to give someone the full range. That sits behind informed consent, surely.”
“Maybe we have a different interpretation of the Montgomery case, but my interpretation is that it shifted the duty of doctors from being based on what a reasonable doctor should disclose to what a reasonable patient would want to know. In these circumstances, in which someone has a terminal diagnosis and only a few months to go, I guess we are saying in the Bill that a reasonable patient would want to know about this option.”
“What we have been talking about this afternoon does not necessarily affect the reality of what the vast majority of conversations are like. There are some people who show up, get a terminal diagnosis and are told they are going to die within a matter of weeks, and they need an approach. But the vast majority of people will have been having treatment over a series of weeks and months, and reached a point at which their death becomes inevitable. At that point, they often do—certainly in my family experience—express a desire to know how they can control their own death. Surely a doctor has to be allowed to evolve that conversation over the period of treatment.”
“I just want to quickly point out that we have a check on the conversations that happen in the first stages. In clause 8, which covers the second doctor’s assessment, that second doctor must be satisfied that the individual has a “clear, settled” and, critically, “informed” wish to end their own life. So, there will be a doctor who is verifying that the person is informed properly about their options. My concern about the amendments is that, as the hon. Lady says, we are inserting now a third doctor into a system which, with regard to the panel, will already have three, four or five specialists involved in the assessment of the care.”
“Let me give a quick example. Amyotrophic lateral sclerosis is described as a condition rather than a disease or an illness. ALS is not dissimilar to motor neurone disease, but nevertheless people regard themselves as having a condition rather than a disease.”
“If there has been a detection that they are trying to get themselves eligible by effectively causing organ failure by starvation, the system would have intervened well before then, effectively to force them to be treated.”
“I just want to illustrate to the Committee that people with eating disorders, certainly as they come towards the end of their life, are already subject to quite assertive action by the state. For example, over the past few years, generally, where hospitals have detected that an individual is effectively trying to starve themselves to death, they have applied to the Court of Protection and got orders for forcible treatment. In that application, it is determined that that person does not have the mental capacity to make decisions about their own medical care. I do not want the Committee to labour under the illusion that people with anorexia or other eating disorders are going to wander up and suddenly ask for an assisted death.”
“My understanding is that it is the other way around. In all but one case, force-feeding was decided by the courts. In the case the hon. Lady is referring to, L, the court did wrestle over that particular issue and realised that, such was the advanced stage of the patient’s condition and the complexities of force-feeding, it could not quite bring itself to authorise it. My understanding is that in all bar one case force-feeding has been authorised.”
“Just to clarify, what I said earlier was slightly incorrect—I misread my briefing. While the hon. Lady may be right that the court decided not to proceed with force-feeding, a number of those applications were by the individual to stop the force-feeding. While the court decided that, on balance, that was the right thing to do, in all those cases since 2012 the individual was not found to have capacity to make decisions about their own condition; the decision was made by the court for them. That means that, under the terms of the Bill, they would not qualify. Some of those cases were quite complicated. A number of them, as I read it—”
“I stand to be corrected, but my understanding is that in the seminal case that the hon. Lady is talking about, the case of The NHS Trust vs. L, the court decided not to force-feed L because the prognosis was that force-feeding would precipitate her death.”
“I think I’m going to have a horrible death, and I’m trying to decide.” We heard from families—and have done over the last 10 years—who, very often in anguish support their loved one, even to the extent that they are willing to break the law. As my hon. Friend the Member for Harrogate and Knaresborough said, the line between support and encouragement is quite fine. If somebody were to come forward and say, “Well, I’ve spoken to my family. They all think I am doing the right thing”, could that not be interpreted as encouragement? I am conscious that we should not try to police what should be open and natural discussions between families in a way that injects jeopardy for them and the person to the extent that they might start to modify what they say to the doctor to ensure that they get the outcome they want.”
“I understand that much of the difference between us on this may founder on our perception of what is actually happening. She speaks of suicide, and to some of us—certainly to me—suicide is a healthy person taking their life, but what we are talking about is somebody who is seeking to take control of their inevitable death in these circumstances. For me, those two are qualitatively different. I am concerned about my hon. Friend the Member for Reigate injecting an element of jeopardy into what should ordinarily be normal conversations with one’s family. For example, I could see a point at which, if I were in those circumstances and was thinking about seeking assistance to end my life, I would discuss that with my wife: “Darling, am I doing the right thing? Is it the best thing for the kids?”
“I think what the Minister was eloquently trying to establish was that we have to be careful about the clarity of the legal language, and not make it embroidered in a way that makes interpretation by laypeople as well as by lawyers more difficult and complicated. I will come on to this in the next grouping, but we must not use language in a way that skews behaviour, or that makes what should be healthy and fulsome discussions within families guarded and nervous.”
“But what about the majority of people in such circumstances, who might say, for example, “Darling, I am thinking about taking an assisted death because of my horrible disease. If you were me, what would you do?” If I then say, “Well, painful though it is for me, I would do exactly the same thing,” how would families interpret that? I also want to respond to the hon. Member for Bexleyheath and Crayford. He made a strong point, but I am not sure he is exactly right. I think that if at nine months I have a disease that is progressing, and somebody in my family says to me, “When it comes to it, Kit, you have absolutely got to take an assisted death. We really want you to,” and then when I get into the six-month period I do, and I tell the doctor, my interpretation is that would be covered under the Bill.”
“As the Minister pointed out, the concepts that the hon. Lady is trying to embed in the Bill are already covered by what is a settled legal interpretation and a framework that, over the last 10 years, has become used to dealing with those issues. Do not forget that families who are going through such situations will be advised and will examine the legislation quite carefully. I am nervous about injecting yet another level of consideration for them that might mean that conversations are interpreted—by them, but not necessarily in a legal sense—in a way that is not beneficial to the patient. I understand the group that the hon. Lady is seeking to protect—that is what we are all trying to do.”
“As I will refer to during our debate on the next grouping, they will also start to understand what they should not say, if we put into the Bill that there are things that will play negatively if they are revealed to the relevant authorities. My concern is that unless we keep the Bill simple and clear, and leave families and medics the space to have free, frank and open conversations that—from the medical point of view—cover the full range of options, we will start to restrict and police the conversation, and therefore make it that much more difficult.”
“My hon. Friend is asserting that those two things are different, but obviously, those assertions would be tested in court. If a person were to appear in front of the co-ordinating doctor and say, “Doctor, I want an assisted death and my husband thinks I should do it,” is that interpreted as encouragement? Is it support? Under the current legal framework, that would be interpretable and inquirable. However, as I said to my hon. Friend, I am not necessarily nervous that families would be dragged into some kind of legal conflict. I am concerned that they would seek to not get there at all, because the insertion of those words would make them so nervous about the conversation that they would become guarded. We know from other jurisdictions that over time, people will come to understand this process.”
“They might think, “I’ve got to be very careful not to do this or say that; because of the state of my body and the disease that is ravaging it, I am determined that I want an assisted death, and I am going to make sure that I do not say anything wrong in the discussion.” The more that we police it, the less likely people are to be open and free in their conversations, both within their families and with the professionals we want to assess them.”
“Forgive me, but I think my hon. Friend might have misunderstood me. My point was that the more we attempt to police discussions in families, the more guarded they will become; it was not necessarily that we should specifically authorise encouragement, or whatever he has suggested. He referred a moment ago to professionals being able to have conversations with individuals freely about their circumstances, their thinking, and how they had come to their decision. I am concerned—there are relevant amendments in the next grouping—that families will interpret these words in such a way that they start to talk about things they should not say.”
“To ensure that they are within the bounds of the law, a doctor may feel that they have specifically to say, “Have you been encouraged to do this?” That will then start to be interpreted by families in the way that they respond. What we really want is instead a general discussion, which is where, in my experience, professionals are expert at teasing out the understanding and motivation of individuals.”
“We need to think about this in practical terms. If the word “encouraged” is included in the Bill, a co-ordinating doctor may feel that it is their duty to say to somebody, “Has anybody encouraged you to take this decision?” They will use that specific word, rather than have a general conversation that is designed to detect coercion, which, as has been pointed out, covers the concept of encouragement or undue influence. My hon. Friend may think that that point is semantic, but we have to remember that the words will be interpreted relatively literally, certainly in the early stages after the passage of this legislation.”
“Member for Ipswich said, if it makes me happy—if part of my dying is me taking satisfaction in the fact that I am not burdening my children with the emotional trauma of watching me die in horrible circumstances—is that for my sake or for their benefit?”
“To me, they inject an element of complexity into what we hoped would be, as we discussed earlier, a settled and comprehensible legal framework, in which doctors have previously operated, and should operate into the future. As I say, my first objection is that the amendments inject novel concepts that are largely undefined and that may be actual or perceived, both by the person who is being assessed and by those who are presumably to be in receipt of the benefit. I am afraid there is also—I am not sure, particularly on the amendments tabled by my right hon. Friend the Member for Braintree—a question in my mind about where my “sake”, whatever that word means, collides with someone else’s “benefit”. As the hon.”
“I do not want to get to that stage, and I do not want to burden my child with that.” Do I have to say to the child, who is perhaps an adult child, “How do you feel about it? Are you going to benefit from this or not?” They will respond, “Absolutely not. I want my dad to live as long as possible,” or, “I want my dad to have what he wants to have.” It is very difficult in these circumstances—do not forget that this will be crawled over by lawyers and doctors—to understand what is actually meant by “benefit”. These are new words—novel concepts—that are being introduced into the law. I did look to see whether there were similar circumstances elsewhere in legislation, and I could not find any.”
“I find that the definition of “physical pain”, undefined as it is, and which may be a matter of degree, injects complexity for doctors and lawyers in their assessment of the motivation of a person seeking assisted dying. Similarly, I do not really know what “benefit” means in the amendments dealing with that. Does it mean financial benefit? Does it mean emotional benefit? Is it perceived or real benefit? Does the doctor have to assess whether a third party is actually getting benefit? Let us assume that it is emotional benefit and that I say—I think it is perfectly legitimate, as my hon. Friend said, for me to say this—“I do not wish my child to witness, know or even learn that the way I died was from the fungating tumours in my neck bursting and,” as we heard on Second Reading, “me drowning in my own bodily fluids.”
“In the closing stages of bowel cancer, for example, a number of things may happen and a number of things may cause somebody to die. They can have a perforated bowel caused largely by a blockage, as I am sure my hon. Friend the Member for Solihull West and Shirley would say. That would be incredibly painful and lead to peritonitis and organ failure, which eventually leads to death. However, there is a situation where a blockage in the bowel causes a person to vomit effectively semi-digested food and faeces. Is that painful? I do not know whether that is a classification of physical pain. It is certainly uncomfortable and unpleasant, but is it actually painful?”
“I should mention first, though, that she said that we are dealing with notions of autonomy and trying to achieve a position where people seeking an assisted death do so as a matter of free choice, and she is exactly right: that is what we are all about and trying to achieve. However, as I hope I can illustrate, the amendments may make that more difficult on three levels. We have talked a lot over the last few hours about precision and novel terms in legality. My first issue with the amendments is the lack of that precision. For example, what does “physical pain” mean? Is it all pain? Is it something as minor as a headache? Is it perceived or actual pain? Is it fear? Does fear become a physical pain, or is it a mental pain?”
“I have listened very carefully to the hon. Member, who represents the fine town of Bradford, and to her personal experiences, which have coloured her view. I understand that of which she speaks, and she might be interested to know that I was the author of the first ever violence against women and girls strategy in the country when I was at City Hall. I dealt closely with harmful cultural practices in that strategy, so I do understand the difficulties she elaborated with detecting and combating the influences to which she referred. However, I am going to disappoint her, because I am going to explain why I believe that the amendments make that more difficult and run the risk of making the Bill less safe.”
“I understand what the hon. Lady is saying, but I am afraid that the amendments do not say that. Even if they did, there would be some difficulty, because you are asking for a further level of complexity in what should be, we hope, a decision made between doctor and patient, in private and confidential circumstances where sensitivity is needed and where we are asking medics to tease out motivations from individuals. I hate to use a pejorative word like “woolly”, but I find the lack of precision in the language troubling. I think it will create yet more complexity and jeopardy for doctors and lawyers.”
“Palliative care is able to help with some of them, but not others. In my experience, the notion in people’s minds is that, as they approach that point, they just want the reassurance that they can control it and have the option, if they so wish. That is often their primary motivation. As the hon. Member for Bradford West said, there may be ancillary results and reasons why people want that control, but the primary purpose is control.”
“I am grateful to the hon. Gentleman because he brings me to my second point, which is exactly that—autonomy. We heard in oral evidence, and it comes through from some of the written evidence, that people’s motivations for seeking an assisted death are often a mixture—a cocktail—of different reasons. Some are about pain, and some are about trauma, for them and for others, but the overarching motivation is always this notion of control. What people seem to be most concerned about is, “If I contemplate my end, I want to have some kind of say, as I get to the end, about what it will be like. That end may be a variety of different outcomes.” As my hon. Friend the Member for Solihull West and Shirley, or any of the doctors in the room, will know, if someone is dying of bowel cancer, any number of things may kill them.”
“I may therefore wish to go a few weeks before that eventuality and say goodbye to them, gathering them around my deathbed—we heard very movingly about this from one of the witnesses—to say farewell while I still can, before my body is ravaged by the final stages of the disease that is destroying me. I do not think that relieving them from a traumatic burden is anything negative.”
“I will make two points in response to my hon. Friend. First, I am not sure that it is entirely accurate that burden is the primary purpose. It is certainly the case that when people going through this process in other jurisdictions are surveyed and rank their reasons, burden may be one. We heard that in some of the evidence that we had from overseas, but as I said at the start of my remarks, it depends what we mean by “burden”. Personally, I think it is perfectly legitimate for me to want to spare my children from witnessing, knowing or even learning that I may have died in a particularly unpleasant way.”
“The hon. Lady is quite right, and she makes my point very neatly for me: the language here is so wide-ranging that it could be anything. Other provisions in the Bill deal with exactly the concerns she expresses. A specific part of the Bill talks about people benefiting financially and how they may not participate. We had a long discussion about coercion and pressure.”
“My concern is that, as with a previous grouping, this attempt to micromanage and police the conversation, at the same time as attempting to police the way people should be thinking, threatens the whole concept of assessment and relationship, which we have heard about from many physicians—that is done on a daily basis in not dissimilar circumstances, where life and death is at stake. That complexity and those extra layers, in my view, start to make the Bill less safe.”
“For example, if the issue was physical pain, the conversation might go: “Why do you want an assisted death?” “Well, of course it is just the pain. It’s all the pain. That is all I want—I’m just frightened about the pain.” “Are you doing it for the benefit of others?” “No—absolutely not! I am doing it completely for myself.” We can see how people might start to modify their conversation, rather than having what should be a sympathetic, empathetic, conversation between doctor and patient about where they should go.”
“That determination comes through from those who go to Switzerland, often in the teeth of the wishes of their family. They will go in secrecy, not telling anyone, because they do not want to put anyone else under threat of criminal prosecution. We have heard lots of stories over the years—some were mentioned on Second Reading—of people who have killed themselves in terrible circumstances, again, secretly determined that they will not go through that end. My concern is that if we insert such amendments into the Bill, we start to police the conversation in a way that means that people determined to achieve an assisted death will do other than have a free and frank exchange in a sensitive way with their physician. Instead, they will try to tread the path to get what they want.”
“I am grateful to the hon. Lady, who has made the case much more eloquently than I could have done. She is quite right. We have heard endlessly from witnesses and others that simplicity is best, and that by inserting this kind of complexity, we create yet more difficulty. I have two other things to say. From the point of view of autonomy, the amendments are trying to police the thoughts of the individual who comes forward in a way that, as I said, may mean that they become guarded in conversations with their physicians. One of the things that I have learned over the past 10 years or so, and that we have heard from witnesses, is that many people who are in extremis at their end are very determined that they will achieve a death other than what nature has laid out before them.”
“The Bill makes it quite obvious that the doctor would not regard that as a legitimate reason to give people an assisted death, if that was their only purpose. As we said before, however, most people have a range of purposes for seeking an assisted death. In my view—certainly in my experience—the primary one is always having the option of control at the end.”
“As many of us know, because we have seen it, we live in an age of social media where it is perfectly possible to go on to the internet to get advice about how best to apply for certain benefits and welfare: how someone can best fill in a form, answer certain questions or go through a personal independence payment assessment to get what they want, even though that may not be appropriate for them. I have no doubt that if, as it develops, we delineate the issue in such a way that there are certain things one should say and certain things one should not, we will run the risk of limiting the conversation that the doctor can have, in a way that is not safe.”
“It would depend on the circumstances of whether the doctor perceived that the request was made under pressure or coercion. Pressure or coercion can be financial as well as emotional. I would expect and hope that a doctor would question a motivation on that basis. The point, however, is that we have to be very careful about making a law that attempts to police the thoughts of individuals. My concern is that if we start to delineate to an ever more exacting degree what is and is not acceptable as a motivation, we will start to steer people down a road on which they try—this phrase has been used—to game the system to get what they want.”
“I am not sure that that would be perfectly acceptable under the Bill; I would be interested to hear what clause my hon. Friend has in mind. As we have discussed, financial coercion is a well perceived concept. As we have heard from other Members, it can be subtle and implied. That will be for practice guidelines, but as far as I can see it is perfectly well covered in the legislation.”
“That is not my interpretation of the Bill, no. I would not be content for that to be somebody’s primary purpose—of course not. My point remains: we run into dangerous ground when we start, by legislation, to try to police the thoughts and motivation of an individual, other than in trying to detect external pressure from others. I am concerned that the amendments run us up that dead end.”
“For those reasons and because of the legal imprecision with which they are drafted, I am afraid I will be opposing the amendments, well motivated though they are.”
“That is exactly my point, and the point on which I was going to conclude. All of the Bill is designed to put control in the hands of dying people as they face what they regard as an undesirable ending to their life. We are trying to do so within the scope of safeguards that protect those who are vulnerable and not able to make a decision freely for themselves. If we continue down the line of inserting this kind of complexity into the system, I am afraid that we run the risk of creating a very narrow channel for people to navigate. That will mean either that they feel forced to navigate it in a particular way or that they cannot navigate it at all, which will serve to restrict the conversation between assessing medics and patients in an undesirable way.”
“For clarity, is my hon. Friend saying that he supports the amendments because he believes that the only reason that someone should have an assisted death is to avoid physical pain, not the circumstances that we have talked about—bursting arteries and fungating tumours—and therefore that if pain can be controlled, the notion of autonomy, control and choosing the time and place of my own death should all be dismissed?”
“Lady is trying to achieve, but I believe that we have achieved it by different means.”