Rebecca Paul MP: speeches

Speeches

• 19 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-seventh sitting) · Hansard source

  More

  I am absolutely reassured by the hon. Lady’s amendment, and I welcome it, but it is worth drawing attention to the fact that the sentence is important but identifying coercion and pressure can be difficult too. In written evidence, a social worker called Rose has cast doubt on the workability of the Bill. She was writing when the High Court safeguard was still part of the Bill, so we need to bear that in mind, but what she said applies to the panel too. She wrote that “based on lived experience…there is no authentic provision mechanism or route that cheaply and swiftly would allow an approved palliative care professional…or social worker to act to protect a vulnerable person under the grounds of coercion….Place yourself in a position of being sick or older, coerced by family for financial gain or by a practitioner wanting to save public costs to pursue assisted suicide, the social worker senses it by body language, a squeezing of their wrist, a sharp silencing look. Can you see a judge saying: ‘the social worker sensed a tension in the air and a look’. Do you think that would serve to reach the threshold to override a request for assisted suicide in a court of law? In practice, what would happen would be, the social worker will record her concerns on the system, share them with her manager who will go to her manager who will say we do not have funds to consult legal and your evidence provided does not reach threshold anyway.”

• 19 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-seventh sitting) · Hansard source

  More

  Thank you, Mr Dowd. In that case, I will stop there. I was just making the point that this is important. Amendment 509 states: “Proceedings for an offence under this section may be instituted only by or with the consent of the Director of Public Prosecutions.” I would find it useful to have more clarity around how the offence is used currently, why it is used and why it is appropriate to use it in this instance. Those are all genuine questions. I simply do not know, so I would be grateful for some input. I will leave it there.

• 19 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-seventh sitting) · Hansard source

  More

  I will be fairly brief. I welcome amendment 508, which would ensure that conviction for the offence leads to a necessarily serious result. However, it is not just the strength of the sentence that we need to think about; there is also a question about how difficult it can be to detect and demonstrate coercion in the first place. Domestic abuse prosecutions have followed an overall downward trend over the past decade, according to Women’s Aid. A report from the Domestic Abuse Commissioner in January found the criminal justice system unfit to hold abusers to account and safeguard domestic abuse victims. Domestic abuse victims are being failed by the criminal justice system at every stage, from police to probation. Victims seeking safety in justice routinely face a lack of specialist service referrals, poor enforcement of protective orders, court delays and early release of abusers. The commissioner also found that just 5% of police-recorded domestic abuse offences reached conviction and that less than a fifth of victims have the confidence to report to the police in the first place. Within the police workforce itself, only 4% of alleged domestic abuse perpetrators are dismissed. Women’s Aid says that trust in the criminal justice system is at an all-time low, with domestic abuse survivors not feeling that they will be believed and supported when reporting abuse. That is even more challenging for black and minoritised survivors, who face additional barriers and poor responses when they seek help.

• 19 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-seventh sitting) · Hansard source

  More

  I thank the Minister for those helpful clarifications. Was any consideration given to also exempting encouragement as an offence under the Suicide Act? I am interested in why it was not exempted in the same way as assistance, particularly given that if it did fall within coercion and pressure—based on what the Minister said—it would get picked up as a criminal offence anyway under the Bill. I appreciate that the Minister will write to me on some of this, but the issue comes back to what is encouragement. As the hon. Member for Spen Valley set out—

• 19 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-sixth sitting) · Hansard source

  More

  The conversation has moved on a little, but I was just going to make the point that the amendments that I tabled focus very much on the rights of the employer with respect to what they expect from their staff. I wonder whether it would be helpful to explore that a bit more.

• 19 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-sixth sitting) · Hansard source

  More

  The hon. Member is giving a powerful speech. My amendment is only to ensure that if the employee is working in an NHS clinic, they comply with the policy of that clinic. It would not restrict their doing other things in their own time. The wording of the amendment is clear, as I discussed with the hon. Member for Spen Valley yesterday, that it is just while the employee is performing services for the employer.

• 19 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-sixth sitting) · Hansard source

  More

  The amendment is simply to prevent a discrimination case. Let us take another example. A rape refuge may provide services to women who have suffered sexual abuse; it may be appropriate, in that instance, to hire only women to support those domestic abuse survivors. In order to prevent a discrimination claim when hiring, we have to rely on the Equality Act and the exemptions carved out. All my amendment says is that the same exemption would apply when a hospice or clinic is employing. It is just to avoid those issues down the road.

• 19 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-sixth sitting) · Hansard source

  More

  Does the hon. Lady have any concerns about what this position would mean for the end of life workforce? I know we are here to make law, but we cannot ignore the practical consequences for end of life care. If we do not have this carve-out, we could lose a lot of wonderful and great people who work in end of life care and who feel that they are not able to participate, if the hospice cannot specify.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  rose—

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  It is clear that the hon. Member for Harrogate and Knaresborough is trying to create equity, which we all understand. We need to think about the patient on the one hand, but also the doctors, nurses and medical practitioners involved. Does my hon. Friend agree that we need to think about the obligation and impact of such amendments on them?

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  I completely agree. We are giving the same courtesy and rights at organisation level as we do to individuals. I know that the Committee is very supportive of that position for individuals, so I question why it would not be the same for organisations.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  My hon. Friend the Member for East Wiltshire eloquently covered most of the things I would have said. We have probably not spoken enough to date about the impact on pharmacists, but we are getting to the point in the Bill where it is really important that we take on board the written evidence and feedback that we are hearing from them. The Royal Pharmaceutical Society said: “In dispensing a prescription, a pharmacist assumes a proportion of the responsibility for that prescription and therefore must be assured that all legal requirements are in place and that it is entirely appropriate for the patient. The link to the clinical assessment of eligibility criteria is essential and therefore the prescriber should always be one of the assessors. In addition to the usual practice of checking that the prescription fulfils the necessary legal requirement, pharmacists must have full access to the patient’s diagnosis and assisted dying care plan.” That raises a few valid and interesting points that we need to take on board to ensure that pharmacists can do their jobs in line with the regulations and laws they are subject to, which are ultimately there to maintain patient safety. I support amendment 466, tabled by my hon. Friend the Member for East Wiltshire, which would ensure that the Secretary of State must be of the opinion that there is scientific consensus that the drug is effective without causing pain. I am of the view that the Secretary of State is probably the right place for that responsibility to sit. One reason for that, which my hon. Friend spoke about, is that I am not sure that the MHRA is the right regulating body for that. I am no expert on this, and I am open to hearing the debate, but the MHRA’s remit covers medicines and healthcare products, so there is a question about whether legally the responsibility falls to it. If it does not, do we set up another body, or do we adjust its remit so that it is covered? I have reservations about doing anything that would merge assisted dying into normal healthcare, but I have laid that out many times over the weeks, so I will not go over that. My understanding is that, on top of all the things my hon. Friend set out, the MHRA’s role is to give marketing authorisation for the promotion and advertising of medicine. Once that has been given, reams of regulations and compliance must be done, including in respect of the labelling of medicine. I believe it would have to be put on packaging that a medicine could be used for assisted dying. We need to get clarity on that from experts in the field, so that we fully understand it. If that is the case, how do we feel about making it clear that said medicines, potentially out in the market, could be used for assisted dying? I suggest there could be some significant downsides to such clear labelling. That is something for us all to think about. I wanted to raise those important points.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  Before I get into my speech, I thank the hon. Lady for her useful questions, as it is important to explore these issues. I will talk in more detail about new clause 23, but I would happily expand its provision, if that would make her happy. I wish to speak to amendment 481 and new clause 23 in my name. I welcome clause 23, which makes it clear that no registered practitioner or other health professional is under any duty to participate in the provision of an assisted death. I believe, however, that it can be further bolstered by the amendments that my hon. Friend the Member for East Wiltshire has spoken to, including my amendment 481 and new clause 23. The amendments concern a practical issue that would face hospices and care homes from day one of the legislation coming into force—namely, how they can continue to operate effectively with a huge diversity of views among staff members. We will all remember Sarah Cox’s oral evidence to the Committee. She cited a 2023 Royal College of Physicians survey in which 43% of Association for Palliative Medicine members said that “if assisted dying were implemented within their organisation, they would have to leave.” Dr Cox said that if this Bill became law, it would have “a massive impact on palliative care, in terms of its potential to develop both our funding and our workforce, who are really concerned about this.” –– [ Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 70, Q83.] In written evidence, the Association for Palliative Medicine said: “The APM recognises the importance of organisations also being able to conscientiously object to involvement in assisted dying. This is essential for the organisation and also for healthcare professionals choosing where to work with their conscience. By not having robust conscientious objection at all levels, the Bill risks imposing harm on health or social care practitioners, violating their autonomy and risking an exodus of skilled and valuable health and social care practitioners.” There will be many people in the sector who support and want to participate in assisted dying, but it is likely that some institutions and organisations will want to have a clear policy of not providing assisted dying. Some nurses, doctors and other professionals will want to work only in that kind of organisation. Either we carve out a space for them, or we risk losing some very dedicated people from end-of-life care. I am trying, through amendment 481, to carve out that space. It allows an employer—a hospice, for instance—that has a blanket policy of not offering or supporting assisted dying to require their employees to adhere to their policy. My amendment clarifies that clause 23(2) does not make blanket policies impossible to enforce: a care home or hospice can prohibit its employees from participating in the provision of assisted dying. They can still believe whatever they want to believe, but it sets out clearly what is expected if they are employed in those premises.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  I thank my right hon. Friend and am sure I will come to his point. I echo what my hon. Friend the Member for East Wiltshire said about the definition of “assistance” in clause 23. If this legislation is to genuinely respect the preferences of doctors and other professionals, it is essential that “assistance” is read as including the matters in amendment 480 covering non-medical practitioners, too. I support that amendment, and what I am going to say is based on its definition of “assistance”. My amendment, it is important to say, works both ways. A care home or hospice can state that all employees must be willing to assist. We agreed to amendment 341, which allows individuals to opt out on conscience grounds. My amendment 481 gives institutions and organisations the same latitude. It opens the way to three kinds of institution: those that provide assisted dying as a matter of policy, those that will not provide it as a matter of policy, and those with no fixed policy, where some employees will assist and some will not. All those different approaches should be respected and supported. The legal basis for this is found in schedule 9 to the Equality Act 2010, which allows an employer to specify a “genuine occupational requirement”. A company can require a particular protected characteristic, as long as it is a work-related requirement and the requirement is a proportionate means of achieving a legitimate aim. The Equality and Human Rights Commission gives an example: a humanist organisation that promotes humanist philosophy and principles would probably be able to apply an occupational requirement for its chief executive to be a humanist. In this case, an organisation providing end-of-life care and with a blanket policy in either direction would not be found in breach of the Equality Act’s protection of beliefs. In healthcare, there is the obvious precedent of abortion. The British Pregnancy Advisory Service, as an abortion provider, is allowed to specify that employees must support its position. Without this amendment, we are looking at a legal and ethical minefield. If a hospice has a policy of helping with assisted dying requests and a staff member refuses to refer a patient to a doctor, can that staff member be sacked, or are they protected by clause 23? Surely we want to avoid the situation arising in the first place, by ensuring that employers can make clear their requirements on this front at the hiring stage. Conversely, what if a hospice has a policy of not participating in assisted dying? Many hospices may want to have such a policy, to reassure their patients on this front and provide a safe space for those who need it. In written evidence, Rowcroft hospice says: “Some patients may fear discussing pain and suffering in case assisted dying is suggested as an option.” According to an article in Annals of Palliative Medicine , this is a major concern in Oregon. One nurse is quoted as saying: “there’s all this advice about how to get information on Death with Dignity…already there is an attitude among many of our clients that ‘if I go into hospice, they’re going to kill me because that’s what a hospice does’”. Likewise, a healthcare professional in Australia is cited in one study as saying: “It’s affecting us in palliative medicine, more than we would like and more than it should because of the assumption that because we specialise in end-of-life care therefore, this is for us. And so, the general perception amongst medical practitioners, the health community and the general public is that this is our thing. And so, for a lot of us, we’re saying, no, this is not our thing.” Clearly, some hospices will want to have an explicit policy that assisted dying is not their thing, and they should have the right to do that. But what if an employee at that kind of hospice wants to help a patient with the assisted dying process? What if, for instance, a hospice doctor volunteers to do one of the assessments? That will obviously compromise the hospice’s policy, but are they in breach of the Equality Act 2010 if they only hire doctors who share that institution’s view of assisted dying? Again, without my amendment, it is not clear what the law allows. Amendment 441, in the name of the hon. Member for York Central, has a similar aim and would further clarify the legal position for institutions, so I am glad to support that, too. This kind of institutional opt-out is, I believe, standard practice in US states that have adopted assisted dying. California’s law includes the following provision: “a health care entity may prohibit its employees, independent contractors, or other persons or entities, including health care providers, from participating under” this legislation “while on premises owned or under the management or direct control of that health care entity or while acting within the course and scope of any employment by, or contract with, the entity.” There is also a good model in New Zealand, where the High Court has ruled that institutions can opt out. Hospice New Zealand, the organisation representing all hospice services in the country, sought a declaratory judgment because of exactly the kind of confusions that I have described. In its judgment, the High Court of New Zealand agreed that the ambiguity about institutional opt-outs was “causing confusion amongst those involved in palliative care and more generally.” The Court found that New Zealand’s assisted dying law “does not require hospices or other organisations to provide assisted dying services. They are entitled to choose not to provide these services. This does not depend on a hospice or other organisation having a conscientious objection, although that may often be the reason…Hospices or other organisations that choose not to offer assisted dying services may employ or engage health practitioners on the basis that these services are not provided by the hospices or organisations”. As a result, New Zealand hospices can set their own policy on whether to provide assisted dying. Sinéad Donnelly, professor of palliative care at the University of Otago, says that this judgment has proved very helpful to the hospice sector: “this has proven pivotal in retaining staff at hospices, many of whom would no longer be willing to work there if the assisted dying doctor or nurse practitioners were given access to the hospice to end a patient’s life.” Dr Siwan Seaman, a hospice doctor, says in written evidence: “I have liaised with a Medical Director of a hospice in New Zealand…The Medical Director in New Zealand believed that without the organisation-level conscientious objection that the hospice movement in New Zealand would have been under even more strain and look very different now.” Dr Seaman says that if we want the quality of palliative care provision across England and Wales to continue to improve, “the bill has to be amended to allow specialist palliative care services such as hospices to be separated from assisted dying processes.”

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  I apologise to my hon. Friend; I probably should not have used him as an example in that way—it is getting late. I actually think that this clause would benefit more those organisations that support assisted dying. It would ensure that they have the right people who support it working in there. We want patients to get the support and everything that they need.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  I will be very brief. I rise to ask a few questions about clause 21 as a whole. Following our debates on various amendments, I am aware that family and those close to the patient could not be involved in the process, although potentially for understandable reasons. I appreciate that we are not here to deal with the whole operational piece, but we should think about it. For example, what happens with notifying next of kin after death, bearing in mind that “next of kin” has a different meaning after death? That is when we start to get into legal considerations, such as who the executor is—and this could be the first time that they are hearing about it. What would be the process for that, given that the person has potentially died on their own at home with the doctor? What is the process for handling the next stage? Is there anything that we need to include in the Bill to make it a clearer, simpler and easier process? Who will the medical certificate of cause of death be given to for registration of the death? While all that is going on, what will happen to the body? At that point, we may not have family members to take care of that. Those are some questions arising from clause 21 that are worth reflecting on.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  Technically, our palliative care can be described as world leading, but we would all agree that much more is needed.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  I thank the Minister for that explanation. I suggest it would also be appropriate for him to set out the changes that could be put in place in order for the amendment to work in that way. To my mind, that would give the true neutrality that he is seeking to achieve. Rather than set out why something does not work, he could set out how it could work in order to deliver the spirit of the change.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  I do not think we should make the mistake of thinking belief is necessarily religious. I do not adhere to any faith, but I have beliefs about certain things that are protected—those beliefs are protected, and they do not necessarily have to relate to a religion. We are getting philosophical now!

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  I am going to read subsection (6)(c) again. It says: “assist that person to ingest or otherwise self-administer the substance.” I would interpret that slightly differently from the Minister. It talks about ingesting, which suggests the substance entering the body, so I would not suggest that sitting someone up would qualify. That in itself shows that perhaps there is some ambiguity here. The Minister has set out something that I had not read into the Bill. Will he comment further on that?

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  The Minister is being incredibly patient with our questions. The question from the hon. Member for Ashford raises exactly the point with which I am uncomfortable. To me, the phrase “assist that person to ingest” means something else. I am really concerned that it could be interpreted differently from how the Minister has laid it out. I want to place that on the record and raise that issue, which I believe the hon. Member was also raising.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  I am just making the point that palliative care has deteriorated in jurisdictions that have introduced assisted dying. Therefore, we need to bear that in mind for this country if assisted dying is introduced. This is also about competition for time and resources. One palliative care provider in Ontario has been cited as saying that “when a patient is requesting MAID [Medical Assistance in Dying], most of the resources have been sucked up by that one case and it’s all everyone’s talking about and they’re rushing to get stuff done…everyone from admin down to the bedside nurse is focusing on MAID…And all of the high-quality palliative care that we do falls by the wayside for the other patients.” One academic study found that “in Ontario, some palliative care nurses were tasked with administration and co-ordination of MAiD which has been taking up an increasing proportion of their roles—to the point that nurses have left their jobs because they were not able to provide palliative care.” In oral evidence, Dr Cox also said: “It is unclear how this is going to be funded. It looks as if it is going to be within healthcare, and if so, there will inevitably be competition with other aspects of healthcare, including palliative care, for those limited resources. There are finite numbers of doctors, nurses and side rooms in hospitals. If palliative care and assisted dying were funded from the same pot, I think there would be a massive detrimental effect on palliative care because we would be in competition for a limited resource.” –– [ Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 70, Q83.] I have outlined this at length—I thank Members for their patience—because how we vote on these amendments could have enormous consequences for the palliative care sector. At the moment, it is world-leading, but that does not mean there is not huge room for improvement or that it will not be affected by the same pressures as in other jurisdictions. Amendment 481 would institute a common-sense change that the British Medical Association has suggested. New clause 23 would protect the sector from unintended consequences and unfair funding cuts. I urge Members to support both. Ordered, That the debate be now adjourned.— (Bambos Charalambous.)

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  It is really helpful to have these questions. I would, of course, defer to the Ministers, as they will be best placed to answer that. However, I suspect the characteristic would be belief. We are trying to ensure that if a hospice has a policy of not providing assisted dying, it is not in a situation where it has employees who are not aware of that at the outset and then want to provide it—or conversely, the opposite situation. All we are trying to do is make sure we match the right employees with the right hospices, clinics and services provided, so that we avoid these issues as they come down. It is a well-intended amendment.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  It is in the top quartile. That does not mean it is good enough—not by any stretch—but I would prefer not to see it fall down.

• 18 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting) · Hansard source

  More

  I go back to my previous comment: I suggest that belief would be the protected characteristic.