Sarah Bool

I am grateful to speak in this debate, and I will focus on three amendments: new clause 9 and amendments 51 and 38. To save time, so that other Members can speak, I will not take interventions. New clause 9, which is in my name, would essentially establish the standard of proof—namely, the degree of certainty and the amount of evidence—required in decision making under this Bill. Let me put that into context. Various standards of proof are used in law. At the very lowest end of the scale is reasonable belief, which is a belief that would be held by an ordinary person in the same circumstances. There is then the civil standard of proof, known as the balance of probabilities, which is sometimes known as the 50% plus one rule, or “more likely than not”. Finally, we have the most serious standard: the “beyond reasonable doubt” test, which applies for criminal cases. That goes further than the balance of probabilities, and requires the person to be sure. Given the lack of clarity and confusion in Committee about whether the test for doctors should be reasonable belief or the balance of probabilities, I have proposed the new clause. As Members will see, it has three parts. Subsection (1) relates to the assessment by the co-ordinating and independent doctor. As Members will see, it has three parts. Subsection (1) relates to the assessment by the co-ordinating and independent doctor. Here I argue that the balance of probabilities test should be used, because it feels perhaps overly punitive to exclude someone from the process at the initial stage if it is more likely than not that they will meet the test, but there are some doubts. However, under subsection (2), when the assisted dying review panel is making its assessment, it must use the “beyond reasonable doubt” test. Given that, at this stage, it will have all the reports from the doctors and professionals, if it is not sure beyond a reasonable doubt, the application should not be approved. That is an essential safeguard. Subsection (3) relates to the moment of supplying the lethal drugs. The doctor is required to satisfy themselves that the person has capacity and a clear, settled and informed wish to end their life, and is not being coerced. At that point, the “balance of probabilities” test does not suffice; it must be “beyond reasonable doubt”—this is life and death. All hon. Members need to ask themselves whether, without this new clause, they are happy with someone being provided with lethal drugs to end their life by our NHS in circumstances where we are not absolutely certain of their intention. I acknowledge, for the record, that the hon. Member for Solihull West and Shirley (Dr Shastri-Hurst) has made an objection to the use of “beyond reasonable doubt”, asking whether it is right to apply a criminal standard of proof when a civil standard may be flexible enough. However, I note that in the House of Lords in re B case in 2008, Baroness Hale said, “There are some proceedings, though civil in form, whose nature is such that it is appropriate to apply the criminal standard of proof,” and a subsequent 2012 case affirmed that. If we stay silent and let the assisted dying review panel and the courts try to work out whether they should interpret “satisfied” as meaning satisfied to the civil or criminal standard, it would merely result in numerous litigation battles. On a matter as serious as death, Parliament must provide the clarity needed. Without it, the Bill is simply not safe. The second area I am focusing on is informed consent and complications, through amendment 51 to clause 11. The amendment would impose a duty on assessing doctors to inform individuals seeking an assisted death of any reasonable body of medical or scientific opinion indicating that the prescribed substance carries risks of complications, including pain. Clause 11 requires doctors to explain how the drug is expected to bring about death, and to discuss with the individual what ought to be done in the event of complications. However, it omits a critical element identified by the General Medical Council in its guidance on consent: the obligation to communicate known risks of harm and the uncertainty surrounding those risks. A patient cannot be said to give informed consent if they are not made aware of the full range of potential complications, including pain, distress and the possibility that the drug may not act as expected. The state of Oregon’s most recent data shows that complications were recorded in approximately 3% of cases in 2023, but historical data shows a complication rate of 11%. Since the introduction of the law there, there have been nine recorded incidents of patients regaining consciousness after ingesting the prescribed substances, and time to death has ranged from three minutes to 137 hours—that is, more than five and a half days. Canadian studies indicate that around 5% of oral assisted deaths result in a prolonged and often distressing process. In some instances, medical intervention is required. Evidence also suggests that younger adults, particularly those aged 18 to 24, are more likely to experience extended and unpredictable deaths. Furthermore, not all complications may be outwardly evident. High doses of barbiturates, combined with paralytic agents that suppress all voluntary muscle movement, may result in what outwardly appears to be a calm and peaceful death, but that may conceal considerable psychological suffering. The hon. Member for Spen Valley (Kim Leadbeater) talks about offering choice, but a choice made in the absence of information is not true autonomy; it is abdication. Making a meaningful decision requires the individual to be aware of not only what is intended to happen, but what may plausibly go wrong. In both Oregon and California, legislation explicitly requires that patients be informed of any known risks associated with the medication to be administered, so why would we adopt a lesser standard here? The amendment simply calls for honesty. Finally, but briefly, I also want to add my support for amendment 38, which clarifies that an individual who is not already terminally ill under the definition of clause 2(1) cannot qualify by refusing standard treatment or taking steps to induce a terminal condition. I live with type 1 diabetes, which, for the record, is a progressive illness that cannot be reversed by treatment. This condition is managed—or not, in cases of extreme stress—solely by the individual. I therefore recognise that the amendment is an incredibly important protection. Diabetics face multiple daily injections, and have to think about and monitor everything that they do, 24/7, and they can be at risk of diabetic distress, or even develop disordered eating. That could prove fatal if standard treatments are not accepted. They should never be offered assisted suicide; they could recover with the right support. I have spoken to the hon. Member for Spen Valley about my concern that conditions like diabetes may be caught unintentionally. The amendment would be a step to protect those who may be unable to protect themselves using standard means. Diabetes and anorexia have been a reason for assisted suicide in Oregon, so please be aware of what could happen.