Dr Neil Shastri-Hurst
MP for Solihull West and Shirley · Conservative · United Kingdom
“I am normally a temperate man, but this is a farcical situation. I have huge respect for the Leader of the House, but I suspect that he has come here with gritted teeth, because the reality is that our constituents want to hear from the new Prime Minister.”
“We have seen it in genomics and targeted therapies and we see it in the increasing recognition that treatment must be shaped by the biology of the disease and the needs of the patient. There is no reason that lobular breast cancer should be left behind in that progress. There has been movement—it is right to acknowledge that.”
“One duty of a good health system is to reduce the burden on the patient and prove that they are worth listening to. Susan Michaelis understood that deeply.”
“Compassion reminds us why we keep working. Responsibility requires us to bring those two factors together. The last Government invested in cancer research, including support for the Institute of Cancer Research and the Royal Marsden biomedical research centre, along with wider work relevant to lobular breast cancer.”
“We have heard about how she challenged assumptions, gathered evidence and pursued truth in an area where the consequences mattered for passengers, crews and the wider public. In 2013, she received her devastating diagnosis of invasive lobular breast cancer.”
“We cannot dispute that that is a significant sum, but we have to look at it in the context of national health spending and what cancer costs: the cost to families and patients and the cost to the NHS when it is detected late or treated inadequately. We have to bear those factors in mind.”
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“This gets to the root of how the law has operated in another jurisdiction, Switzerland, where Dignitas has managed this scenario over the past 40 years or so. The key—these are the words that its own guidance uses—is ensuring that the power of control remains with the person seeking the assisted death. That provides the individual who is making the choice with the ultimate autonomy at the end in controlling the circumstances and the manner in which they pass. I have set out why I feel that although amendment 463 arises from good intentions, it would not achieve what is intended. There is a real risk that the constraints that adopting the amendment would create would lead to the regrettable unintended consequence of individuals being forced to have an assisted death at an earlier stage than they would otherwise have wished.”
“Those sections specifically relate to an act “capable of encouraging or assisting the suicide or attempted suicide of another person”. Introducing the concept of additional assistance, as these amendments would, creates a legal uncertainty. The word “additional” creates a further concept that is beyond assistance but is, thus far, ill defined. Would it go as far as, for example, the clinician taking full control of administering the substance? It is entirely unclear. It would therefore place the clinician in an invidious position as to what it would mean for them to provide additional assistance in such circumstances. As I read the interplay between the Suicide Act and the proposed legislation, the clinician would not then be exempt by virtue of clause 24(3), leaving them open to prosecution under the Act.”
“In the case of the functional loss of limbs, as was discussed in the debate on the previous group, a range of assisted technologies are available that would remove the barriers that that would present. Beyond the necessity, or lack of necessity, of these amendments, I fear that they create legal uncertainty, which is clearly undesirable and, in this instance, could have a serious and significant unintended consequence through the amendments’ interaction with clause 24. Subsection (3) of that clause inserts proposed new section 2AA of the Suicide Act 1961, which is an exemption to that Act in respect of the assistance provided under this Bill. In effect, proposed new section 2AA disapplies sections 2(1) and 2A(1) of the Suicide Act where the provision of assistance is done in accordance with the Bill.”
“Although I have certain sympathies with these amendments, I do not feel that they are necessary or desirable. They are not necessary because of the provisions that are already stipulated in clause 18(6)(b), which provides the co-ordinating doctor with the ability to prepare “a medical device which will enable that person to self-administer the substance”. That subsection, in effect, negates the scenario that is put forward in amendment 350 around dysphagia or the loss of a limb. It would permit, for example, the use of a nasogastric tube or a percutaneous endoscopic gastrostomy feeding tube to be used for the administration of the substance in the case of dysphagia.”
“My hon. Friend hits the nail on the head, because it is the patient who is driving the decision. They are making that act by activating the electronic device—the computer or whatever it may be in terms of assistive technology—but they have the power and control over that decision-making process, which is completely distinct from a clinician doing that act. It is distinct because it is activated by the patient—by the person making that decision—and that is why I draw the distinction. My hon. Friend may not agree, but that is my rationale for drawing a distinction between the two.”
“I am grateful for that helpful and thoughtful intervention. For the reasons I have set out, I consider that the amendments create unnecessary and highly undesirable legal confusion, so I shall not support them.”
“Given that valid consent requires a voluntary and informed decision, can my hon. Friend set out why that would not involve being consulted on the matter in any event?”
“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.”
“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.”
“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.”
“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”.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“You will be delighted to learn that I have nothing further to add to this debate, Ms McVey. Amendment 93 agreed to. Amendment proposed : 305, in clause 9, page 6, line 3, after “about death” insert “and any other effects in addition to death.”— (Danny Kruger.) This amendment would require the assessing doctor to explain effects the provided substance would have in addition to death. Question put , That the amendment be made.”
“The hon. Gentleman makes a powerful argument about doctors being vilified in the press, but does he believe there is a risk that it may go further and present a genuine safety risk to those doctors?”
“The test would make the Bill less operable in reality, and it undermines everything that comes before it—there is no purpose to having criteria that we have to move through if we are then to say, “Actually, that is null and void, because I have a sense that I am just not comfortable with it.” If one is not comfortable with one stage of the criteria, that is enough for it to fall or to be referred to someone else—for example, to a capacity assessment, as has been suggested. The amendment is legal nonsense. I see where it is coming from, but it is legal nonsense in how it is drafted, and it does not assist in making a more meaningful or operable Bill. Therefore, I cannot support it.”
“It is a pleasure to serve under your leadership, Mrs Harris. I will speak to this octet of amendments and set out why I cannot support them. In my view, they are a classic example of legislative embroidery. If we wanted a better example, we could not find one. Sadly, they would achieve nothing but add a great deal of confusion to the situation. Throughout the Bill, a clear set of criteria must be fulfilled in order to move from one stage of the process to another. To lay on, additionally, a frankly woolly and ill-defined legal test that has not been set out in in this legislation and that overrides those criteria, without any reasoning to underpin it or any sense of purpose behind it, is simply confusing.”
“There is a concept of family, but the concept of family to me may be very different from that of my neighbour, or from that of someone who lives in another city. For example, for some people stepbrothers, stepsisters and step-parents are very much part of their family; for others, they are not. For some people, unmarried couples with children are a family; for others, they are not. For some people, unmarried couples without children are a family; for others, they are not.”
“I rise to set out why—reluctantly—I cannot support amendments 403 and 404, which have been tabled by my hon. Friend the Member for East Wiltshire. It is not because of the principle involved, because my hon. Friend was very clear in setting out the amendments. They would not provide for a prescriptive situation where an individual must tell their family. A range of options are set out, which I anticipate that any sensible and responsible doctor or clinician would take a patient through, encouraging them to involve their family in their decision making. The issue that I have is around the legal clarity of the wording of the amendments, because under the English and Welsh legal system there is no statutory definition of “family”.”
“That would satisfy me. The reason I say that is because at the moment the wording is too broad and ill-defined. The question is: is this about the closeness and proximity of a relationship? The suggested wording that my hon. Friend just put forward would be much closer to that and much clearer, and more akin with the language of medical registration. When someone turns up in A&E, they are asked to give the name of their next of kin. That defines the closeness, the proximity and the permanency of that relationship. If my hon. Friend was perhaps to consider withdrawing this amendment and tabling it again in an alternative form, or rewording it, that would certainly be something that I would be open to supporting. I have outlined why, as the amendments currently stand, I cannot support them.”
“May I join others in commending the Prime Minister for his diplomatic leadership over the last few days? Can he set out what steps he is taking to discourage third nations from providing hardware that the Russian military can use to prosecute its illegal war?”
“If we are to turn the tide on our recruitment policy and difficulties in this country, we need to tailor the medical requirements to the specific role. We must become more versatile and adaptive as a fighting force—like our friends in Ukraine. As a country, we are often guilty of preparing for the war that we have had, rather than the war that we will face in the future. As we reflect on the three years since Putin’s illegal invasion, I say to the Government that we should not waste any more time or waste what we have learned at the cost of so many thousand Ukrainian lives.”
“Rather than making a generic medical exemption list for the whole force, I invite the Minister at least to consider tailoring the medical requirements to the position being applied for. For example, what are the chances of a person’s glasses being blown off if they are operating from a chair in a drone centre hundreds of miles away? What is the reality of an intelligence officer in a remote location looking at satellite information losing the feeling in their fingers due to the cold because of Raynaud’s phenomenon? What are the chances of a Royal Navy dental officer not being able to complete a check-up because of pain in his knee? We need to be much more flexible. Although I accept that there is a certain degree of hyperbole in my argument, the point I am making is a serious one.”
“War is now in a much more hybrid state, fought not only in traditional land and maritime realms, but back in bases in remote locations, yet we still follow traditional medical guidelines setting out who can serve and who does not have the opportunity to do so. This where I feel we can learn from Ukraine, which, very early on in the conflict, amended and adjusted many of the medical requirements for its serving personnel. In our military, there is often a mindset of “soldier first”, which may well exempt someone who has suffered a knee injury while playing sport at school, anyone with Raynaud’s phenomenon, for example, or anyone wearing glasses over a certain prescription.”
“However, over the past eight months or so, we have entered a much more dangerous arena, and we need to be ready for any outcome. In the time available to me, I want to raise two further points. First, I reiterate the point made by my right hon. Friend the Member for Chingford and Woodford Green on the increasingly pressing need to release the $300 billion in frozen Russian assets to aid the Ukrainian Government in the rebuilding of their country. Secondly, I want to pick up on my right hon. Friend’s comments about what we can and must learn as an armed forces from this conflict and from the heroic efforts of the Ukrainian military, with many making the ultimate sacrifice in defence of the sovereignty of their country. The war has shown a clear shift in the nature of warfare and in the nature of each serving person’s working realities.”
“Many Members have spoken before me—not just in this debate, but through the course of the week—about the importance of the Government’s welcome announcement of increased defence spending and the need for our allies also to step up to the plate. While I do not intend to repeat those arguments today, I will add that we alone do not determine our defence spending: it is our enemies too, but it is also our allies. With the United States announcing a potential step back from their support for Ukraine, it is clear that we as a nation have an overriding obligation not only to Ukraine but to our citizens and the wider world to step up and keep Putin’s war machine at bay. If we fail to do so, we will be opening the gates to totalitarian regimes across the world. The reality is that the United Kingdom has armed forces that are fit for peace.”
“I start by congratulating my right hon. Friend the Member for Chingford and Woodford Green (Sir Iain Duncan Smith) on securing this important debate, and saluting him for the incredible work he has done in leading on this issue. As always, it is hugely heartening to see so many colleagues from across the House in the Chamber. It serves as a timely reminder of the united approach that we have taken on this issue and of our resolute and undiminished support for the Ukrainian people. In my constituency, we have welcomed many Ukrainian families, and I am always touched and moved by their stories of resilience in the face of the greatest hardship.”
“The mischief that I was seeking to address is that there are patients who, were this law to be enacted, would continue with their palliative care treatment right to the very end, before they chose to have an assisted death. Technically, there could be a scenario where that person, from the point at which they have gone through the two-stage assessment by a doctor and it is been approved by the panel—if that is approved in subsequent amendments—loses capacity after they have set out a desire to end their life through an assisted death, but there would be the option to remove the palliative treatment options at that point. There is a conflict in respect of an advanced directive that would enable the assisted death to take place, which would involve the removal of care.”
“It is a pleasure to serve under your chairmanship, Mrs Harris. I wish to concentrate my remarks on new clause 6, which I tabled, but also to speak to amendments 8 and 124. To be clear, new clause 6 is a probing amendment that was tabled to air the debate on the record. I tabled it because of the interplay between the Bill as currently drafted and section 26(1) of the Mental Capacity Act, which sets out that a “decision has effect as if” the individual “had made it, and had had capacity to make it, at the time when the question arises whether the treatment should be carried out or continued.” Of course, an advance directive relates to decisions around the removal of treatment.”
“There is interplay with the principles of Montgomery, which is clear that a doctor should discuss issues where a reasonable person in the patient’s position would attach significance to them or the doctor is, or should reasonably be aware, that that particular patient would attach significance to them. My hon. Friend the Member for East Wilshire asked for examples of that. There are scenarios where there are subtle hints from a patient who has been given a terminal diagnosis. They ask, “What is the implication of this terminal diagnosis? How am I going to die, doctor?” The doctor says, “There are variety of ways in which this may manifest itself” and goes through them. Some of them may be more tolerable to the patient than others.”
“My concern about the amendments is that while it is quite right that there should be no requirement to instigate those discussions, it would be equally wrong not to allow the flexibility to have that conversation in appropriate circumstances. The reality of clinical practice is that there are consultations within consultations. A patient who comes to a surgery to see their doctor may not feel able to articulate what they truly feel. They may give subtle hints, which doctors pick up during the course of a long career—to put it in lay terms, doctors read between the lines.”
“There has been much discussion and worthy debate on the position of Montgomery, which takes me back to my days as a pupil barrister grappling with issues of consent. I fear that we may be going down a rabbit hole in discussing Montgomery in this context. I agree with my hon. Friend the Member for East Wiltshire that an assisted death is not typical medical treatment in the normal sense of those words; it is a wider holistic medical intervention. Therefore, my understanding is that Montgomery would not apply in those circumstances. However, some of the principles around Montgomery way well have justification.”
“There is an element of mischief in my probing new clause, but it is to air the matter in debate. In truth, intervention there are a variety of options with any withdrawal of treatment or any treatment. I wanted that on the record. I have had assurances from the hon. Member for Spen Valley that that is clearly not the Bill’s intention—in many ways, I am arguing against my own new clause. Of course, this is a distinct scenario from an advance statement—the much more proactive step of, “These are the treatments or options that I would like if I lose capacity at a future date”—which has no legal footing. An advance directive, in comparison, is very much concentrated on the withdrawal of care. I do not propose to divide the Committee on the new clause; I merely tabled it so that this could be discussed. Let me turn to amendments 8 and 124.”
“The purpose of new clause 6 is to get clarity on that issue, because of the interplay with section 26 of the Mental Capacity Act, which states that if a patient “has made an advance decision which is...valid, and...applicable to a treatment...the decision has effect as if he had made it, and had had capacity to make it, at the time when the question arises whether the treatment should be carried out or continued.” I am not suggesting for a moment that seeking an assisted death is conventional treatment in the normal sense, but there will be patients who seek an assisted death and have palliative care treatment along the way, so there could be a technical scenario whereby the palliative care treatment is withdrawn for the assisted death to take place.”
“I understand where the amendment comes from, but without trusting in the judgment of clinicians, who know their patients well, we are setting them up to fail. We are setting the system up to be more clandestine. We are going to prevent what are very genuine and important conversations from taking place, because people are too scared of the operational framework that would be imposed on them. In those circumstances, we would put forward a Bill that does not function as intended. For those reasons, I will not support amendments 8 and 124.”
“In the scenario where that conversation arises, a patient has very clearly indicated that they want to know all the options available for how they would manage their death, and the doctor feels that is a cue, quite understandably and, in my view, rightly, to have a wider conversation that involves assisted death, along with other options, because he or she believes that the patient has indicated that that is what they wish. If we say that a doctor cannot have that conversation in any circumstances, we open up the clinician to the accusation, perhaps from a relative, who says, “Hang on a minute, doctor. My relative didn’t raise that with you. You raised it with them.” These are very subtle and carefully balanced conversations.”
“My hon. Friend summarises a much more complicated conversation; I think he distils it down to an over-simplistic representation of how the conversation would go. A patient says, “I hadn’t envisaged that I may die while vomiting up faeces. What could we do?” The clinician would go through a variety of options that would be available in that scenario, but that would include, potentially, having a discussion about assisted death, as that would be one way of avoiding that situation coming across the hills. This is the issue I have particular concern about.”
“It is a pleasure to serve under your chairmanship, Mr Efford. I start by gently pushing back on what my hon. Friend the Member for East Wiltshire said about this being a fork in the road. I do not see the Bill giving patients that ultimate option. They have the choice to opt for an assisted death while continuing with their palliative care all the way along; in fact, they could then decide that they did not wish to have an assisted death, although that opportunity would be open to them. I do not think that the choice is the binary one that has been presented; I am sure that was not the intention, but I just wanted to gently push back.”
“Member for Stroud will know particularly well given his former profession, there is another body of general practitioners, community nurses, district nurses, advanced nurse practitioners, pharmacists and social workers, who are all involved in this process. I think the amendment comes from a good place; at first blush, I can see absolutely where it is coming from. But despite that, it leads us down the bureaucratic thicket that Chris Whitty spoke about.”
“But are we saying that only a palliative care specialist is capable of having those discussions? Of course, those who work in the field are highly trained individuals, but we must not be unfair or do a huge disservice to other healthcare practitioners who provide excellent palliative care in this country. My father was a general practitioner for more than 40 years. He provided a huge amount of palliative care throughout his career, both in the community and in hospices. Look at Marie Curie’s own website, which talks about the provision of palliative care in this country and very much about primary care provision and secondary care provision. Within secondary care, of course, are the specialists—clinical nurse specialists, occupational therapists, physiotherapists; I could go on. But of course, as the hon.”
“I am grateful to you, Chair, and to my hon. Friend the Member for Reigate for her intervention. She is right: it is absolutely critical that patients are given the full information in order to make an informed choice. I do not think any of us would disagree with that. But actually that goes entirely with the wording of the Bill as it stands. The hon. Member for Stroud has already highlighted the relevant provision—clause (4)(4)(c), which states that the initial discussion must explain and discuss with the patient “any available palliative, hospice or other care, including symptom management and psychological support.” Therefore a requirement to have those discussions is already stipulated in the Bill. My hon. Friend the Member for Reigate makes an interesting point about who has that discussion.”
“That may not be applicable to each and every general practitioner, but those having those conversations should have that knowledge.”
“I am grateful for the hon. Member’s intervention, which leads on to the point I was going to make. We are getting bogged down in nomenclature about what speciality is involved when this is actually about training. It is about whether the individual having the conversation has the requisite skills to have a meaningful conversation. Clauses 5(3)(a) and 8(6)(a) stipulate that the co-ordinating doctor or independent doctor “has such training, qualifications and experience as the Secretary of State may specify by regulations”. That is the key part. This is about ensuring that people having incredibly sensitive, challenging and difficult conversations with patients about choices available to them at the end of life have the requisite skills and knowledge to do so.”
“I fear that my hon. Friend may be oversimplifying what I was saying. Perhaps I was not clear enough, so I will elucidate. I was certainly not suggesting that the required skills were merely those of being able to have a consultation and a conversation. I was talking about having the skills to have the information that needs to be imparted and the knowledge that underpins that and being able to articulate that within a consultation. It is a much wider picture than just having the communication skills—it is having the knowledge that underpins that. I am saying that that is not necessarily the domain only of someone who works in palliative care. There are a number of specialists who work within this field—it is a multidisciplinary field—and they all bring their expertise.”
“This comes back to the central point that Professor Whitty made in his evidence about overcomplicating Bills: we overcomplicate Bills out of good intentions, but rarely make the safeguards more robust—in truth, we make them less safe.”