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That is very much at the heart of why I lodged amendment 20. It is one thing to propose a notional opt-out, either for individuals or for organisations but, especially for hospices, it may be that the practice becomes such that opting out would not be a financial practicality, especially given the precarious financial circumstances in which hospices find themselves—they get only partial funding through the NHS. Again, we need to tread carefully. I recognise that it is a matter of balance but, given the very personal nature of the situation, it is important that we allow that flexibility, especially for hospices and care homes.

It is useful to follow Bob Doris. My amendments fall, like his, in multiple parts of the bill, so I ask for the committee’s forbearance.

This group of amendments is very important. It is entitled “Assessments of the terminally ill adult”, and those are at the heart of what the legislation is about. Indeed, they are critical to its operation. We have already heard that there will be a need for careful consideration by the co-ordinating medical practitioner, who will not always be able to deliver everything by themselves and will need to refer to other professionals or seek other information. It is important that we are clear about how that will work, and not just with regard to what is in the bill. Ultimately, we must recognise that it will need to be based on professional judgment, no matter how good the legislation, the guidance or the training might be. It will all boil down to medical practitioners and doctors making careful decisions in consultation with the person concerned and ensuring that that happens in a fully informed way.

The first set of amendments that I will speak to has been prepared in conjunction with CHAS. As we have already discussed with regard to previous sections, when it comes to situations involving young adults, there needs to be more careful consideration both of the nature of their illnesses, which can look very different, and of their vulnerability.

Amendment 50 provides for amendment 51, which sets out that, when someone is under the age of 25, there will be a referral to a registered social worker and a registered medical practitioner who is a specialist psychiatrist. That is to ensure not just that there is a vulnerability assessment, but that the young adult is making the decision in an informed way. It is important that, in such situations, there is referral to those specialists, because the decision involves a critical judgment, and such referrals will be critical in ensuring that the young person has capacity and understands fully what is inevitably going to be a very complex decision.

CHAS’s judgment is that the current assessment process does not make sufficient provision for assessing that capacity or providing the safeguards that it believes are needed for young people. I know that the numbers are likely to be very small, but it is important that we take the proposed approach, which I do not think would put undue pressure on social work or psychiatry systems.

Critically, the approach would not change the decision-making process, which will ultimately rest with the medical practitioner; there is simply a request that those referrals be made and those additional points of information be sought. As I set out at the beginning, these will be delicate judgments that are based on the relationship between the patient and the co-ordinating practitioner, but it is important that, in particular circumstances, additional points of information and professional judgments can be brought in.

Like some of the amendments that Bob Doris has lodged, amendment 93 has been prepared in conjunction with another organisation—in this case, Hospice UK. It is absolutely essential that anyone who requests an assisted death be fully informed of all the options, not just the one that they are requesting. In other words, when they make their request, they must be fully informed of the palliative options that are available to them. There can often be complex issues, and there might be other connotations that people might not have perceived in advance. In particular, not all doctors will have expertise in such care, which is why Hospice UK has asked that anyone who makes such a request be provided with that information and have the option of being referred to palliative care.

Amendment 75, which has been prepared in conjunction with the Royal College of Psychiatrists, is, in a sense, an extension of the amendments that were previously debated on the proposal for a register. In the royal college’s view, it is important that, where there are questions about capacity and in any borderline cases—especially complex cases such as those involving dementia or other complex mental health disorders—there is an avenue for further exploration of those issues and further consultation.

Finally, I turn to my own amendments, 5 and 6. We have heard a great deal from Bob Doris about the nature of the decision that is to be made by the co-ordinating practitioner and what that will look like. For me, that judgment is absolutely at the apex of the bill. As Bob Doris put it, we need to take great care that we do not turn this into simply a tick-box exercise.

My amendments are probing amendments. The fact is that we can put as much as we want in the bill, but we must ensure that the relationship in question is as effective as possible and that any judgment is made in as full a way as possible. To achieve that, I ask members to explore the nature of that relationship.

At the moment, co-ordinating practitioners are asked to sign the form in schedule 1, and they can literally just put their name and a date at the end of a block of text. The form does not ask any questions about the nature of the relationship or what has been explored, and it does not ask for an assessment. Bob Doris’s amendments are interesting, because they require a report, but I am simply asking the committee to think about whether we want to ask co-ordinating practitioners to declare any other information. The length of time for which a physician has known a patient is not a terribly good or accurate way of measuring the relationship, but—this is why amendments 5 and 6 are probing amendments—it is one way of getting a sense of how well the practitioner knows a patient.

Let me draw in some other examples from a health context. It is important that, although we are discussing a particular situation, the wider health system is not divorced from the discussion. I have been in a situation in which a physician whom I have known for only a very short time has provided me with an excellent level of in-depth information, which has allowed me to understand it. In particular, when my daughter was born, I was dealt a medical situation that I found quite overwhelming. However, I have also been in a situation in which I had surgery and, to this day, I am not clear about which physician performed the procedure on me.

I have also been in situations in which I have had to fight to get physicians to understand the full, broad range of circumstances, because they have been so busy. It might be that a physician ultimately signs off or authorises a procedure but, actually, a team of physicians is involved and the overstretched nature of the system means that no one person has a relationship with the individual.

We need to ensure that that is not the case under the bill—there must be a positive relationship that is well understood. The physician must not only take the time to understand the individual, their needs and why they are seeking to make this decision, but draw in other professional opinions and ensure that the person has the information that they need.

Amendments 5 and 6 do not ensure that. I am asking whether the declaration and the duties and obligations that we set out are sufficient. More needs to be done to ensure that they are, which cannot be a tick-box exercise, as we have seen happen time and time again. We can create a pro forma and a set of tick boxes, but that does not always mean that a relationship of the quality that we want, the information that we require people to have and the empowerment that we seek are provided. More needs to be done in the bill on that point.

Again, I would just say that the reverse could also be true. By not permitting that, you are, in effect, creating a mandate and therefore there is a concern that practice in palliative care will be inextricably altered by that practice. We need to listen to that concern.

The amendments that I will speak to in this grouping fall into three substantive sub-categories: the first is on individual opt-outs, the second is on organisations and particular views in relation to hospices and care homes, and the third is on a register for psychiatrists.

First, it is important that we ensure that individual opt-outs are as straightforward as possible. That speaks to amendments 11 and 16, in my name in particular. I will not reiterate the arguments that Miles Briggs set out very clearly.

Amendments 52 and 60, with regard to hospices, were also drafted in conjunction with CHAS. I listened carefully to what Liam McArthur said and I understand the broader point about an institutional and organisational opt-out. However, hospices require a particular degree of care and attention with regard to the bill. We are not talking about large, faceless institutions. Any of us who has visited a hospice will recognise that they are often small and very personal contexts, and they are not clinical environments. This is not necessarily about an ideological opt-out; it is about allowing hospices to look at the implications of the bill and get their care right for the people who are in their care, and I—

If I may, I will finish my sentence, at the very least.

The concern is that, because of the intimate nature of hospices, practice with regard to one person may well interact with practice for others in the same context. We are talking about small settings where the small numbers mean that there are not sufficient staff to undertake the proposed duties, particularly if there are staff who wish to opt out, which there may well be. There is a great deal of concern among those who work in hospices. I have spoken to such people—just outside my constituency, actually, rather than inside it—and there is concern that there may not be sufficient capacity or the necessary physical layout to provide what is proposed in the bill in a delicate and understanding way, because there will be implications for other people.

With that, I have finished my sentence, so I will first take Mr McArthur’s intervention and then listen to Mr Balfour.

I will be speaking to a number of Jackie Baillie’s amendments today, and I ask members to bear with me as they hear more than they might have expected to hear from me.

At last week’s meeting, we heard the concern that, although we can examine what is in the bill, what will be enacted and put into effect will be a matter of practice and of professional conduct. That is why training is so important both to how the bill operates at the start, should it be passed by Parliament, and to how it continues to operate as it evolves over time. It is important to ensure that the bill makes adequate provision both for the training that will be required by the professionals we will ask to make the most sensitive of judgments, and, critically, for the oversight of that training.

I am grateful for your reflections on those points. Do you acknowledge that the amendments that have come from the professional bodies themselves reflect a need or desire from the professions that we strike a slightly different balance as to where not just training but qualifications sit and how they are reviewed?

I understand Liam McArthur’s reluctance in relation to a full referral, but does he acknowledge that simply discussing options can sometimes be a little narrow? There needs to be the practical ability to act on those options. Does he agree that there is scope for looking at positively signposting options rather than simply discussing them or having a default referral? In a medical context, discussing options can sometimes be very narrow and about mere possibilities rather than actual things that a person can avail themselves of.

Yes. It is certainly not nonsense to raise concerns about patient pathways. In any clinical circumstances, a patient journey and the degree to which it is patient-centred is of critical salience. We live in a world in which healthcare settings are very complex, terminology is used that people do not necessarily understand or are not familiar with, and there are considerations and circumstances that people are not used to. Healthcare is often disempowering to the patient. Therefore, making sure that those settings are such that people are comfortable is important.

Another thing that very often happens in a healthcare setting is that people’s decisions are, naturally, influenced by the broader assumptions within such settings. I do not dismiss that for a moment. If the member is asking me whether there is speculation, my answer is, yes, there is. That is absolutely what stage 2 is about. It is about exploring such speculations.

I recognise the complexity of allowing opt-outs and that patients might need to move. I see that Sandesh Gulhane is forming words, but I would like to make a little progress. I did not intend to speak for so long on this group. I am just asking us to contemplate. It is not that I dismiss those things, but I ask those people who are asking about movement causing disruption or distress whether the reverse is also possibly true. Given the very intimate setting of a hospice, introducing someone into that environment with a set of assumptions in favour of assisted dying may well cause disruption or distress for the other cohort of people. I do not think that the issue is binary, but I ask the committee to consider that.

Amendments 74, 80, 81 and 82 were also drafted in conjunction with the Royal College of Psychiatrists. I promise that I will not speak to those at such great length as I have spoken to the previous amendments.

Amendment 80 would create a register of psychiatrists to undertake capacity assessments. The key point of amendment 74, if it is not pre-empted by amendment 159, is that such assessments should be drawn by practitioners from a central register. Amendment 81 would ensure that the register of psychiatrists was not just a list but would be used to improve learning and general clinical practice. It would enable data collection on assessments that were carried out under the bill to be used for oversight. Amendment 82 is a consequential amendment.

Throughout our deliberations, there has been a concern about making assessments of capacity. The psychiatric profession in particular is taking a keen interest in that. When it comes to people with associated mental health conditions—particularly. in later life, dementia—getting input and a detailed understanding from the psychiatric profession is very important.

Those points are well made, but we must be clear about what amendment 66 would do and, critically, where it comes from. Jackie Baillie’s amendments were drafted in conjunction with the British Medical Association and other professional bodies, so it is not MSPs who are asking for this but the profession itself, because doctors are concerned about the very points that I am setting out. Furthermore, amendment 71 states plainly that the regulations “must” be made in consultation

“with trade unions and professional bodies”.

Such matters are always about balance, but the medical profession and medical practice are highly regulated. It is not true that the law has nothing to say about medical practice or that it does not set out standards, review periods and expectations about training, because it does. Amendment 71 would require ministers to put in place regulations that set out training requirements and professional standards, which would be kept under review.

Amendments 66, 68, 70 and 72 are largely consequential. In addition to the medical and clinical considerations, amendment 71A sets out the need to consider domestic abuse. There has been a great deal of concern about the possibility of individuals facing undue pressure or coercion by third parties. Amendment 71A was drafted in consultation with Dr Anni Donaldson, an academic who is an expert on domestic abuse. It is important that any such training takes account of the dynamics of how domestic abuse can take place, how to respond effectively when that may be in play, and how treatment can be offered in such circumstances.

Amendment 49 was drafted in consultation with CHAS, which Liam McArthur referred to. Although CHAS operates in Jackie Baillie’s constituency, its office is in my constituency. I do not know whether that is a declaration of interest, but there is certainly an overlap.

It is true to say that the way in which terminal illnesses manifest in young people can be substantially different in how patients are treated and the nature of those illnesses. Understanding the prognoses requires a great deal of attention.

It is right that we think about how the provisions in the bill might extend to younger people—they will find themselves in a very different set of circumstances from the bulk of the people who we think of as being in this cohort, who will be substantially older. Amendment 49 therefore seeks to add specific training requirements for those who will consult young adults and younger people and assess the degree to which the illness is terminal, advanced and progressive. The amendment would require additional qualifications and understandings on that.