• August 22, 2026

Old wine in old bottles: the resurrected Terminally Ill Adults Bill

The assisted suicide Bill introduced as a PMB by Lauren Edwards MP comes in exactly the same form as it had when it was Kim Leadbeater’s Bill and left the Commons to go to the Lords (the old wine). And it comes with exactly the same misleading marketing announcements (the old bottles).

Old wine…

The means of establishing eligibility are inadequately specified. Multimorbidity and frailty in the elderly, and physical-mental comorbidity, make assessment far from straightforward for the non-specialist. The Mental Capacity Act with its presumption of capacity is too blunt and non-specific for this purpose. There are numerous potentially remediable needs (social, psychological, functional, environmental) intervention for which might lead to a change of mind, but there is simply no need in the Bill to explore their presence.

Comprehensive and competent assessment is inadequately mandated. The qualification and expertise of the doctors involved is not specified. There is no account of the involvement of non-medics who are often in reality part of end-of-life care teams. The three-person panels described in the Bill are nothing like the multidisciplinary teams that are now routinely part of clinical practice.

Safeguards are inadequately integrated. The three-person panel is too hands off, only coming into play once the key decisions have been made. There is no requirement to talk to a family member. There is no clearly specified independent oversight of the practice of involved staff.

Oversight of the system is inadequately specified. There is little data collection of the sort that we have come to expect for example from the National Confidential Inquiry into suicide and (now returned) homicide. Such oversight as there is, is not independent. The coroner is now excluded from investigating the assisted suicide despite advice that medical examiners are not in a position to take on the work.

Inadequate attention is paid to how assisted suicide will work in the NHS if it is to be delivered (as apparently envisaged) as part of end-of-life care. The role of Hospice staff, palliative care teams more generally or nursing homes where many people spend the last months of their lives are not considered at all and the possibilities of individual or organisational opt out uh sidestepped.

In old bottles…

Not only are the problems with the Bill all the same as they were, its promotion comes with all the same misleading marketing claims. Here are some of the commonest:

The Bill only needs to come back like this because its progress in the Lords was blocked by a small number of ideologically opposed peers.

This line is repeatedly used, sometimes with the modification that the only objectors are religious zealots. It’s a ploy to sidestep a discussion of the objections raised by all the official bodies that were consulted. In truth it wouldn’t matter if every amendment had been proposed by just one peer, what matters is whether the proposed amendments helped overcome the objections raised. That after all was the promise. In fact no important amendment at all was accepted by Lord Falconer and his allies and of course there is none in the re-presented Bill.

The new law is designed to end suffering when somebody is dying

This claim has been a cornerstone of promoters of the Bill such as Dignity in Dying. They routinely exaggerate the horrors of natural death and are adept at using emotive case studies. But suffering does not feature at all in the Bill; amendments requiring for example assessment and treatment by a specialist palliative care service have been rejected.  It is telling that in Oregon requests include the rationale “inadequate pain control, or concern about it”.  Even so it does not feature in the top five reasons cited despite cancer being by a long way the commonest underlying illness.

It is the other 75-80% of recipients that worry experts in end-of-life care because they know people, not all of whom are facing imminent death, are asking to end their lives for reasons like a sense of being a burden, or loss of dignity or loss of independence and they know from clinical experience and research studies that these concerns are strongly associated with vulnerabilities other than simply approaching the end-of-life: poverty, loneliness, family tensions and lack of supportive relationships, mental health problems and especially a tendency to recurrent depression. Supporters of the Bill simply don’t engage with this evidence,

It’s the safest and most robust assisted dying law anywhere in the world (Lauren Edwards)

This claim raises two questions. The first is what measure of safety or robustness is being quoted and the second is whether assisted dying legislation elsewhere in the world is really the appropriate comparator.

In relation to the first question there are a number of metrics that might be used, such as error rates – for example the number of people who die under the legislation without meeting the relevant criteria – untoward incidents such as being given the wrong drugs or delayed or distressing death, unsafe practice, a non-trivial consideration given what we know about how few doctors participate and how idiosyncratic practise has emerged in other countries.  In relation to the second question we might ask whether a more appropriate comparator would be routine clinical practice given that the proposal is to embed assisted suicide in the NHS.

The truth of the matter is that supporters of the Bill don’t know how safe practice is in other countries because adequate data are not collected. It is for that reason that claims of safety are never accompanied by data.

The Bill is widely supported and has a democratic mandate

In fact support for assisted suicide or euthanasia comes from relatively superficial public polling seeking a yes/no answer to structured questions about the general principle. The more information people receive about the practicalities the less enthusiastic they are. Of course the truth is that the Bill itself is not widely supported because just about nobody has read it outside the small group with particular interests in the topic. Even in the debates in the House of Commons it was clear that some of the Bill’s supporters had not grasped the detail of the legislation or its consequences.

Who’s at risk, who might benefit?

All this puts people at risk in direct and indirect ways. Those vulnerable to the direct effects of the Bill are those who do not really have a free choice because they are pushed in a particular direction by external or internal influences or because there are no ready alternatives due to the lack of adequate service provision.

Those vulnerable to the indirect effects are those put at risk by changing attitudes to suicide. Promoters of the Bill are keen to avoid describing it as legitimising assisted suicide but that is what it is. They are likely to make the legally incorrect and logically indefensible claim that what is proposed is something other than assisted suicide and the ethically indefensible claim that it is offensive of opponents to suggest otherwise. Once we accept that assisting some suicide is acceptable- and supporters have made it clear that reasons such as poverty loneliness or a sense of burdensomeness can be acceptable reasons-then we have taken a large step in the direction of abandoning our responsibilities as a society.

Why is this happening? It is not about improving end-of-life care which major lobbying groups like Dignity in Dying have never shown the slightest interest. If improving end-of-life care were the aim there would be no logical reason to reject all amendments (despite claims that of course that wouldn’t happen in the Lords as it had in the Commons) coming as they do from entirely well-meaning and not ideologically opposed groups. But that is not the aim. If we get away from simpering about compassion what emerges clearly is that the Bill is designed to promote what its supporters call choice and autonomy. That is choice for those able to exercise it, presented as something like a consumer choice – hence the celebrity endorsement, merchandise and advertising slogans. Related is the idea of dignity, in one way something that should be attributed to all living things but in the real world a concept that is saturated with the idea of social status. Those endowed with dignity are able to choose how they live their lives and how they manage their deaths – ensuring what Philippe Ariès called the Tame or Beautiful Death.

The motivating ideology behind the Bill is a sort of libertarian individualism which either doesn’t recognize or doesn’t care about those in society for whom “choice and autonomy” is constrained by psychological and social factors beyond their control. Canada beckons – where nearly 5% of all deaths are now by lethal injection and the idea of terminal illness as the only criterion is a distant memory. That’s more than 30,000 people a year in the UK.

  • June 27, 2026

The draft Conversion Practices Bill: who is it for and how would it work?

When the debate about conversion practices (then more usually called conversion therapy) started a little while ago I was struck most obviously by the lack of clarity of definition of conversion therapy/practices and also by the poor evidence (reading as a researcher) about its effects. One interesting find was a study of same-sex attracted individuals affiliated with the Church of Jesus Christ of Latter-day Saints1, 720 of whom provided unstructured comments on their experiences of therapy, in addition to completing structured assessments. The authors note, of these comments “Many found therapy to be a helpful, even life-saving experience. To be able to talk to a knowledgeable professional about a very private concern was salutary. Others reported improved relationships with family or other close associates. Of particular interest was the large number of individuals who reported decreased levels of depression and anxiety and improved feelings of self-worth…For some participants, psychotherapy was clearly unrewarding. As a general rule, however, experiences of harm or iatrogenic distress were much less frequent than reports of benefit.”

Reading the Conversion Practices Draft Bill with that thought in mind is not a reassuring experience.

Conversion practice is defined in terms of the intention of the practitioner rather than of any inherent characteristics of the practice. The definition of abusive conversion practice on the other hand is said to be a matter of fact based upon the presence of certain defining characteristics; they include “words…of a sexual nature” and “use of psychological or emotional pressure” the latter apparently not the same as controlling or coercive words or behaviour and not further described. The offence of carrying out an abusive conversion practice is defined according to the effects of whatever practice is being considered. One of its features is causing serious alarm or distress which is apparently not the same as causing serious harm to somebody’s mental health. If the same “conversion practice” is found to help one person and distress another, is the practitioner guilty of two offences or one?

There is an offence of encouraging or assisting abusive conversion practice on a UK individual (to include anybody who is habitually resident in the UK and not necessarily a citizen). That offence consists in doing something that is capable of encouraging or assisting another person in an abusive conversion practice rather than in actually encouraging or assisting them, the abusiveness defined because the practice is likely to cause rather than has caused serious harm and there is in fact no need for a conversion practice to have taken place at all.

Nowhere in the bill is there mention of whether the practice has taken place with or without the consent of the individual involved. The bill gives the court powers to make an order- a so-called conversion practice protection order – for the purpose of protecting an individual against abusive conversion practices. The court must have regard to all the circumstances which include but are not apparently restricted to the need to secure the health safety and well-being of the individual to be protected. The aim is presumably to protect vulnerable individuals but there is no mention of what vulnerabilities might make the order necessary.

To somebody outside the law it is difficult to see where the new offences fit in. That is already legislation related to coercive and controlling behaviour, and sexual orientation and transgender identity are already protected characteristics. Without more precision I can’t see how we can have confidence that a new Bill will protect an otherwise unprotected and vulnerable group, without triggering a round of litigation that will itself be harmful to some of those involved.

  1. Kate Bradshaw, John P. Dehlin, Katherine A. Crowell, Renee V. Galliher & William S. Bradshaw (2015) Sexual Orientation Change Efforts Through Psychotherapy for LGBQ Individuals Affiliated With the Church of Jesus Christ of Latter-day Saints, Journal of Sex & Marital Therapy, 41:4, 391-412, DOI: 10.1080/0092623X.2014.915907

  • October 6, 2025

The ending of life unworthy of life: could we go there again?

Earlier this year I went to a presentation led by a team from the School of Health Care at my university entitled Finding Ivy: a life worthy of life. The topic was a project that identified and gave details of 13 victims of the Nazi Aktion T-4 programme who were unusual in having been born in the United Kingdom. It was named for a young woman Ivy Angerer who had a learning disability and who was murdered, during the initial formal stage of the programme,  along with an estimated 70-80,000 other people with learning disabilities, chronic mental illness or epilepsy as part of a mass killing campaign aimed at emptying the asylums of people with what was called life unworthy of life.

Aktion T-4, described in some detail in Michael Burleigh’s book Death and Deliverance, unfortunately out of print, is now little talked about. The Finding Ivy research project and presentation and the exhibition accompanying it brought the detail distressingly to life by putting real names and real people to the otherwise rather anonymous factual accounts of the matter. There is value in memorialising in the lives and deaths of people otherwise treated as worthless – both for their family’s sake and because it reminds us of an essential human value. At the same time the project raised some interesting and important questions.

What was the relation between the murderous Aktion T-4 campaign and the campaign that involved compulsory sterilisation of people with learning disabilities and mental illness?

What was the relation between the Aktion T-4 campaign and the much larger scale murder of Jews and other groups in the Holocaust? Does any of this have relevance to modern society, either now or for the direction in which society is travelling?

In the first part of the 20th century sterilisation campaigns were not uncommon in other countries besides Germany – the motivation coming apparently from eugenic theory. There were links also to ideas about degeneracy so that mental illness, epilepsy and intellectual disability could be seen as part of a cluster of genetically determined conditions. Sterilisation was therefore a way of improving the population gene pool.

But other sterilisation programmes did not go on to campaigns aimed at killing members of the same groups. Eugenics could not be evoked as a rationale for this development – the victims were already in institutional surroundings that made reproduction impossible so there was no genetic advantage to the killing. Instead, the argument was mainly economic; the occupants of the asylums were so-called ballast existence or useless eaters. They were drains on more worthwhile members of society – a line of thinking that was most infamously introduced in Binding and Hoche’s 1920 Allowing the Destruction of Life Unworthy of Life.  The callousness that made murder possible came perhaps from a certain indifference to violent death brought about by the experience of the Great War.

Although these two rationales feature strongly in arguments of the time and indeed since (see for example Dagmar Herzog’s recent The Question of Unworthy Life) there were other more emotional appeals at play. As well as looking on a group of people as unworthy of life for genetic or economic reasons, they could be presented as people who might themselves welcome release from an awful existence: expressions of revulsion or disgust were not uncommon.

What about the link of Aktion T-4 to the wider Holocaust? Was there an ideological connection or was it more accidental, simply that Aktion T-4 generated a technology that could be used for a completely different purpose? Insistence on the uniqueness of the Holocaust makes it difficult to see or explore links between mass murder (particularly of Jews) and other forms of institutionalised murder, but such links may be there nonetheless.

One pointer resides in the theoretical underpinnings of the national movement that placed those living lives unworthy of life as something more than simply an economic or social problem. They were now, like other enemies of the racial state, a profound existential threat to be answered by an increasing drift from consensus to coercion based upon a preoccupation with racial purity and the fulfilment of a quasi-religious destiny. The mobilising passions of Robert Paxton’s The Anatomy of Fascism.

So there is a common theme in the expansion of choice of victim – all were seen as enemies within: those who could poison the genetic pool; economic parasites; those were different and undermining beliefs and practices (Jews, Roma, homosexuals, communists…). A slightly different way of looking at it is to see the motivation as primarily racist. So-called race hatred (Rassenhaß) is directed at those outside the Volk (Jews, Roma, Blacks etc) while race anxiety (Rassenangst) is directed at those who belong to the Volk but who nonetheless threaten its existence by virtue of some unacceptable pathology (idiots, epileptics, homosexuals etc).

What about the present? Societal attitudes have changed in many ways since the 1940s, but some socially accepted practices may carry the same message today about lives not worth living. The discussion about Finding Ivy, and an associated journal article, have suggested a number of such practices: prenatal screening for Down syndrome with the expectation of termination of pregnancy if screening tests are positive; poor quality healthcare that is leading to people with learning disabilities dying up to 20 years earlier than the average; use of Do Not Attempt Resuscitation notices and delayed prioritisation of vaccination during the recent Covid pandemic all suggest a persistence of ideas about lives that are less valued than others.

A weakness of leaving it there is the non-specific nature of the attribution of “negative attitudes” to people with a learning disability. In aiming to being more specific, I think one clue lies in the rise in recent times of fraught debates about gender, neurodiversity and ethnicity. The vehement politics of identity nod at what has been called “..a sense of overwhelming crisis and victimhood, a fear of the decline of one’s group, a lust for purity and authority…”.

Another example. I went to the Finding Ivy presentation the day before parliament held the third reading and voted to approve Kim Leadbeater’s Terminally Ill Adults (End of Life) Bill. Its aim is to give some people with life limiting illnesses the option of a medically-assisted suicide. Those with learning disabilities are in the frame – with proxy signatories and advocates available to ensure they get full access, and no hint that the Bill’s sponsors understand the risks.  But there is a more fundamental point here. The lobby group Dignity in Dying says that these assisted suicides are not about shortening life but about shortening death. So the Bill does not require any exploration at all of why somebody might be asking for help in ending their life – it is simply taken as self-evident that they are leading (to put it bluntly) a sort of un-life, with no value lost from ending it.

This disdain for the un-life comes with an incongruous insistence on the central principle of the Bill being choice, autonomy and the importance of dignity. This is the dignity that is a characteristic of individuals – not innate but made by how they live and die, the latter by suicide, if desired. What PM Keir Starmer, a promoter of the Bill calls “Human dignity. The dignity of the individual. And the respect that goes with it.”  The link to the past is the idea of some sort of perfect individual – autonomous, dignified, the ideal citizen – but one who is likely to be undervalued, their wishes ignored, under threat from influences outside their control.

Even if we accept that there are similar psychological forces at play now as there were in inter-war Germany, there is clearly something radically different about where we are compared to the authoritarian or fascist regimes of that time. We lack the prevailing socio-political circumstances that might allow the emergence of a much more virulent form of discrimination. To get there we need two things. One is something equivalent to the extreme economic depressions of the interwar years. For this we can look to climate change and mass migration – even if they are to have their major effects in Western Europe.  The other is a genuinely charismatic and effective leader of the extreme right who can exploit the resulting unease. In her recent review of world politics and the threat they pose, Fascism a Warning, former US Secretary of State Madeleine Albright suggested that the rise of such a leader was facilitated by weak and unpopular social democratic alternatives and a degree of complicity with less extremist but nonetheless right wing political groups. Sounds familiar even if, again, we aren’t there yet in the UK .

So, I don’t want to pretend that we are anywhere near Aktion T-4, but neither do I want to pretend that such a thing is unimaginable. In his 1966 radio talk and essay Education After Auschwitz, Theodor Adorno asked how we could avoid a return to the barbarism of the holocaust. He concentrated on the psychological not because he thought social and political factors were unimportant but because he thought the former were more amenable to intervention. He argued for a sustained programme so that “education and enlightenment can still manage a little something”. Perhaps we could hope to see it start on the 60th anniversary of his talk.

  • September 9, 2025

Terminally Ill Adults (End of Life) Bill: how safe are the safeguards?

Leadbeater’s assisted suicide Bill is now with the House of Lords – 2nd reading due to take place on 12 September. On 2nd September I was with a number of experts present at a meeting organised by Baroness Finlay of Llandaff, one of a series aimed at informing peers about the detail of the Bill. Here is a summary of my own presentation, available as a handout on the day:

Safeguards in the proposed legislation

The Terminally Ill Adults (End of Life) Bill introduces a set of circumstances in which it becomes legal to assist the suicide of somebody with life-limiting disease.  One purpose of safeguards in the Bill is to ensure that assisted suicide is available only to those who meet the prescribed eligibility criteria. Safeguards are also required to ensure that the procedures outlined in the Bill are followed to a high standard and that the Bill is having the desired outcomes. Wider claims are made about the effect legislation will have on other risks faced by people with life-limiting illness.

The structures and processes defined in the Bill are located in healthcare services and involve medical practitioners, so the appropriate benchmark for safeguards is not existing international legislation on assisted suicide or euthanasia but safety standards that are equivalent to those found in current UK clinical practice. Safeguards should cover everybody to whom the Bill might apply. For example although the Bill refers to terminal illness, prognosis is notoriously difficult and a fifth or more of those given a 6-month life expectancy may in fact live for years1. Inadequate pain control or concern about it (itals added) is not in the top 5 reasons given for seeking assisted suicide in Oregon2 – which is often cited as a model for UK legislation. Safeguards therefore need to apply not just to those who are facing imminent death or who have uncontrolled pain, but also to those who might have years to live and have no major symptoms.

Safeguards in other areas of clinical practice

Ensuring safety in clinical practice involves: use of standardised (clearly defined) procedures for assessment and intervention that are widely supported by research, ethical guidelines (for example on informed consent) and clinical experience; practitioners who have the experience and expertise necessary for the procedures being undertaken; careful documentation of procedures followed and their effect including untoward events; oversight and regular appraisal of the practitioners involved; oversight and monitoring of the programme function and outcomes – sometimes called clinical governance.

How do safeguards in the two contexts match up?

Clinical assessment – there is no requirement in the Bill that the coordinating or independent doctors undertake any assessment at all of remediable psychological or social influences on the individual’s wish to end their own life, or that they consult family or health professionals who might be aware of such circumstances. This is at odds with standard approaches to assessing a person’s wish to take their own life and with NICE guidelines3 on assessment of similar presentations in other settings.

Clinical experience and expertise – no context-specific skill or experience (such as medicine of old age, end-of-life care or psychiatry) is specified in the Bill for either of the two involved medical practitioners. It is not entirely clear in the Bill if a physician assistant may take one of the “medical practitioner” roles. We know from other jurisdictions that in reality only 1-2% of clinicians are willing to undertake the practical roles specified in the Bill (the majority are GPs) so lack of specified expertise is an unsatisfactory necessity for supporters, to enable implementation of an assisted suicide programme.

Clinical intervention – internationally there is no standardised regime for assisted suicide and none of the drug regimes currently in use has regulatory approval. Side effects and complications are common4 but recording them is not mandated in the Bill. Setting up a medical device and assistance in its use are mentioned but without detail – in other countries this is the means by which euthanasia is effected, either initially or if oral medication fails to lead to death in a timely manner. The supervising medical practitioner does not have to remain in the room with the individual in the time between ingestion of drugs and death.

Clinical oversight and appraisal – The proposed three-person panel will not function like an independent multi-disciplinary team and again has no obligation to undertake its own detailed assessment as a way of corroborating the coordinating doctor’s decisions. There is no specified experience or expertise for the psychiatrist on the panel. An independent psychiatrist may have been consulted about the person’s mental capacity but there is no requirement to follow their advice. There is no mention of annual appraisal of the doctors involved, required in other areas of practice by the GMC.

Clinical governance – careful audit will, as in other jurisdictions, be all-but impossible because of the paucity of data being collected on the individual’s past physical and mental health, psychological state, social circumstances or recent experiences. Very limited data will be recorded on the clinical processes followed and none on complications or side effects. There is no mechanism by which family or others can raise concerns or complaints and no requirement that they are consulted at all; in Oregon 5% of assisted suicides occur without the family being informed2. The commissioner responsible for establishing the programme will monitor “the extent to which the Act has successfully met its aim” and for noting any concerns that have been raised, but there is no specified mechanism by which concerns can be raised.

At the level of investigation of the most serious concerns, automatic referral to the coroner is excluded by the Bill, and participant clinicians are exempted from criminal or civil liability – and presumably therefore professional responsibility.

Does the Bill offer indirect protections to others?

There is no evidence that assisted suicide legislation reduces unassisted suicide by offering a better alternative. To take one example suicides have increased by 20% in Oregon in the last decade. The proposed UK system will not replace travel to Switzerland for assisted suicide, since an estimated half of those who make the journey would not be eligible here5. In the UK,  in the 15 years to March 2025, there were 199 referrals to the Crown Prosecution Service following assisted suicide – 0.003% of all suicides. Five were successfully prosecuted (despite stringent public interest exclusions) and eight were referred onwards for prosecution for homicide or other serious crime6. The Bill does not propose decriminalisation of assisted suicide generally and will not (and should not) make police investigation unnecessary in all cases.

How safe are the safeguards? The professional perspective

Much of the public and parliamentary debate, and opinion polling, has been conducted as if the only issue is the acceptability in principle of physician-assisted suicide. It is not – the immediate question is whether the specific Bill before parliament is sufficiently robust to guarantee the safety of vulnerable people. Official medical opinion is clear on this point – the Royal College of Physicians, Royal College of Psychiatrists, Royal College of Pathologists (for medical examiners), Association for Palliative Medicine and British Geriatric Society have all said that it is not7. Their positions are not ideological ones but reflect concerns about a poorly drafted Bill that fails to provide adequate safeguards for the protection of vulnerable people.

  1. White N, Reid F, Harris A, Harries P, Stone P. A systematic review of predictions of survival in palliative care: how accurate are clinicians and who are the experts?. PloS One. 2016 Aug 25;11(8):e0161407;  Orlovic, M., Droney, J., Vickerstaff, V. et al. Accuracy of clinical predictions of prognosis at the end-of-life: evidence from routinely collected data in urgent care records. BMC Palliat Care 22, 51 (2023); Assisted dying row as patients given six months to live often survive for three years: One in five people given six months by NHS doctors is still alive three years later, figures show Janet Eastham Acting Religious and Social Affairs Editor Daily Telegraph 21 January 2025
  2. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year27.pdf
  3. National Institute for Health and Care Excellence (Great Britain). Depression in adults: treatment and management. National Institute for Health and Care Excellence (NICE); 2022. https://www.nice.org.uk/guidance/ng222;  Self-harm: assessment, management and preventing recurrence NICE guideline [NG225]Published: 07 September 2022 https://www.nice.org.uk/guidance/ng225
  4. Worthington A, Finlay I, Regnard C. Efficacy and safety of drugs used for ‘assisted dying’. British Medical Bulletin. 2022 Mar;142(1):15-22.
  5. Brewer C, Hopwood MC, Winyard G. Assisted deaths in Switzerland for UK residents: diagnoses and their implications for palliative medicine and assisted dying legislation. BMJ Supportive & Palliative Care. 2024 Feb 1;15(2):259-61.
  6. https://www.cps.gov.uk/publication/assisted-suicide
  7. https://www.rcp.ac.uk/media/rpcbqz4v/rcp-and-rcpsych-joint-statement-june-2025.pdf; https://www.rcpath.org/discover-pathology/public-affairs/royal-college-of-pathologists-statement-on-the-terminally-ill-adults-end-of-life-bill.html; https://www.bgs.org.uk/bgs-position-statement-on-assisted-dying; https://apmonline.org/wp-content/uploads/APM-Position-Statement-on-Assisted-Dying-October-2024-v2.pdf
  • April 21, 2025

The dark ideology behind the assisted suicide campaign

The Terminally Ill (Adults) Bill introduced to the Westminster Parliament at the end of last year seeks to make physician assisted suicide legal in the UK. From the start the legislation, introduced as a Private Members Bill by Kim Leadbeater MP, was recognized as problematic – with numerous ambiguities and gaps where important practical detail was missing. At the first debate in the House (the so-called second reading) MPs were encouraged to vote in favour even if they had misgivings: flaws in the bill as presented would be carefully considered and dealt with at committee stage. What followed instead was a pantomime of manipulation and incompetence.

Of the fifty experts called to give oral evidence to the public bill committee only six were opposed to assisted suicide. Many of the questions were soft-ball invitations to air unsubstantiated claims about the safety of what was proposed and the unalloyed success of implementation in other countries. Witnesses from Belgium, The Netherlands or Canada on mute of course. Proceedings were rushed so that committee members could not have had time to study carefully the more than 420 written evidence submissions.

I was invited to give oral evidence to the committee – initially one of only two psychiatrists, both giving evidence as individuals with relevant expertise. The committee had declined to invite the Royal College of Psychiatrists despite the legislation requiring a change to the Suicide Act (1961) and therefore to national suicide prevention strategy.  No need, said the bill’s co-sponsor Kit Malthouse MP, since we have already invited the General Medical Council – apparently unaware that the GMC is an overarching body regulating medical practice while the RCPsych is a membership body overseeing the training of and representing the interests of psychiatrists. A public outcry led to a U-turn and as a result I was one of three, all seen on different days.

My session was interrupted by Leadbeater who wanted to assure the committee that there is no association between what she is promoting and suicide. The people she is interested in, she says, are not suicidal, they don’t want to die but they are dying – they just want to choose how and when. But the legal definition of suicide makes no reference to the person’s circumstances, only to the act itself. The opening sentence of Leadbeater’s bill says that its purpose is to “Allow adults who are terminally ill…to request and be provided with assistance to end their own life…”.  And Clause 24 of the bill seeks to change the Suicide Act 1961 – which makes encouraging or assisting suicide an offence – to exclude the deaths she proposes in her bill. There can really be no doubt that what is proposed is assisted suicide, and since “suicidal” means “relating to or likely to lead to suicide”, then people requesting assisted suicide are by definition suicidal. What Leadbeater says is wrong legally and logically, so why does she keep saying it?

What is assisted dying? A 2021 Survation poll sheds light on what “overwhelming public support” means.

One possibility is that she is using a campaigning tactic. Assisted suicide and euthanasia have traditionally not been popular ideas with the public and the assisted dying euphemism avoids direct acknowledgement of what is being proposed while having the advantage that a lot of people are unclear what it means in practice. It is also possible that Leadbeater simply doesn’t know the facts about unassisted suicide. In other words she is doing more than deploying strategic vagueness, she is voicing a belief that people who die by suicide in other circumstances are fundamentally different from people who will die by assisted suicide if her bill passes into law. The facts suggest otherwise – for example data from the National Confidential Inquiry into Suicide show that people who have what it called major physical illness and who die by suicide may well have the same characteristics as those who die by suicide and do not have such a physical illness. And why not – there is nothing about having a life-limiting physical illness that protects you from other risk factors for suicide.  Exploring the presence of such risks isn’t intrusive, dangerous, excessively bureaucratic, offensive or unreasonably time consuming – so why will Leadbeater not include it in the bill’s safeguards?

Assessment in Leadbeater’s bill is limited to mental capacity and coercion. That is, whether the individual is able to make a request for assisted suicide, not why they might want to. This framing has been tested repeatedly in committee, for example in relation to undue influence short of coercion, financial worries, psychological problems such as depression or sense of burdensomeness, and severe anorexia. It has proved impossible to get the bill’s supporters to agree to any significant change that would require exploration of and a response to remediable psychological or social influences on the decision to ask for assisted suicide. Proposed amendments are routinely defeated by a block vote and dismissive pushback comes in the form of protests about bureaucratic barriers or deliberate attempts to derail the proceedings. In the end what has emerged, both from observation of committee proceedings and (eventually) from direct questioning of Leadbeater, is that psychological and social assessment isn’t included in the bill because it doesn’t matter what the answer is.

At the core of this position is a libertarian or hyper-individualistic privileging of personal choice to the exclusion of all other considerations: it doesn’t matter why the choice is being made, only that it is being made by an “autonomous” individual.

Leadbeater’s campaign is heavily supported and influenced by Dignity in Dying, an organisation that is estimated to have spent more than £25 million on this project since 2005, when it changed its name from the Voluntary Euthanasia Society. To some extent the nature of their ideology is obscured behind the name change and the marketing techniques they use – slogans, slick advertising campaigns, specious opinion polls and celebrity endorsements – and the ill-informed incompetence of much of the debate taking place at committee stage.

The same obfuscatory function is served by another striking feature of the public debate, which is the extraordinary prominence given to the views of media personalities such as Pru Leith and Esther Rantzen. Leith, Rantzen and others have no particular expertise in the management of life-limiting illness or in understanding what influences suicidal thoughts and feelings, so why are their opinions so routinely reported?  The answer is that their role isn’t simply to promote assisted suicide, the product they are promoting is the way the decision should be made. The celebrity endorsement message is twofold – personal opinion and anecdote is more important than careful appraisal of evidence, and meeting the personal preferences of some individuals is more important than concern about the personal vulnerability of others.

Sarcopod days

A few months ago there was a story circulating about a young woman whose “life began when she was allowed to die”. That is, she changed her mind after being offered euthanasia in the Netherlands. The language is worth noting. Was she really not living before the offer of euthanasia? Dignity in Dying would say not – assisted suicide and euthanasia is “not about shortening life it’s about shortening death”. Even allowing some rhetorical leeway, it is difficult to read this as other than a judgement about lives not worth living. There is a cruel twist in the tail of the assisted suicide campaign. Extreme individualism typically prioritises the wishes of privileged individuals over community or societal needs, and especially over protection of the most vulnerable. Here however we are invited to accept without explanation the request for assisted suicide not because the person making the request is of especially high social worth but because they are leading a sort of un-life, something so self-evidently valueless that there is no need to explore why they don’t want it.

2024 brought the world the Sarcopod – an individual gas chamber in which you can suffocate yourself by pressing a switch to replace the air supply with nitrogen. Initial concerns seem to have focused on the lack of regulatory approvals for the machine rather than the grotesqueness of the idea. Meanwhile Dying with Dignity Victoria has announced an exciting new scheme – The Young Ambassadors, “young people from across Australia who are passionate about improving access and quality of end-of-life choices, including VAD.” They will “Inform young people about end-of-life care choices available to them, including VAD.” And “Connect young people navigating end-of-life care, their carers and families to relevant support and services.” VAD (Voluntary Assisted Dying) means assisted suicide and euthanasia – both now legal in Australia.

Nobody who follows what is going on internationally can possibly imagine that Leadbeater’s bill represents the last we will hear from the assisted suicide and euthanasia lobby.  It is the first step onto a road down which we are being shepherded by radical libertarian ideologues with a chilling agenda for societal change that is far from the liberal reform claimed by their supporters.

  • April 5, 2025

Safeguards in the redrafted Terminally Ill (Adults) Bill: still woefully inadequate

Just before the second reading of the Kim Leadbeater’s Terminally Ill (Adults) Bill I made a note of the ten questions I would want answered before I could be convinced – at even a minimum threshold of certainty – that all safeguards had been carefully thought about and introduced.

Now the bill is back, to be presented at report stage and then voted on at 3rd reading within the next few weeks. My questions weren’t originally conceived to give a score, but to give an idea of how far off the bill is I have gone for a score out of 10, with half marks for a partial response and no marks if the response has been left to later regulations or a code of practice to be written by the Secretary of State – marks only for what’s on the face of the bill.

My conclusion = 2/10, straight fail – resit needed. Here’s why…

1. How is safe, competent medical practice ensured? Score 0

Experience elsewhere indicates a need for expertise in elderly care, palliative care or psychiatry. True independence is hard when only 1% of doctors are willing to participate.

…expertise of two main doctors left to SoS. The psychiatrist on the panel can come from any sub-specialty and needn’t be of consultant status. No requirement for expert assessment even if applicant identified as have a learning disability or as being liable to detention under the Mental Health Act.

2. How will safe “assistance” be ensured? Score 0

What drugs can a doctor administer for unpleasant side effects, delayed or unachieved death? What does use of a “medical device” and assistance in using it mean?

…Nine of this clarified at all in the bill

3. How will informed consent be ensured? Score 1/2

Consent in health care requires informed understanding of what is proposed, its potential complications and side effects, and alternative interventions.

…the bill indicates that the nature of the substances to be provided and their action must be explained but says nothing about side effects or complications. The doctor is required to discuss the person’s wishes in relation to complications without requiring that the nature of such complications has been previously explained in detail.

In relation to explaining the nature of the proposed procedures there are three under-specified areas:

  1. the nature of assistance in use of a medical device is not clear – for example in the case of somebody sufficiently disabled that they require a proxy signatory;
  2. what actions can or cannot legally be taken in the event of greatly prolonged time to death or even failure to die, especially if the person has been rendered unfit by initial actions;
  3. GMC guidance lists other examples of information that might be relevant as including “whether an option is an innovative treatment designed specifically for the person’s benefit.” Since there is no standardised medication regime with regulatory approval for use in physician assisted suicide and there is wide and changing variation in practice3 then any proposed prescription seems to fall within this remit.

4. Is there adequate ability for healthcare professionals and organisations (such as care homes) to opt out? Score 1/2

…The bill makes it clear that individuals need not participate beyond explaining to the applicant where they go if they want assisted suicide but does not allow for organisational opt out.

5. What aspects of assessment are mandated? Score 0

There is more to assessing somebody who wants to kill themselves than checking mental capacity and lack of coercion – a comprehensive personal and social history; interviewing a family member or close other; the GP and, as relevant, a key specialist.

…The bill sticks with the absurd and dangerous idea that all that’s needed is to check whether somebody is competent to make a decision, not why. No further information gathering is mandated.

6. What requirements are there for integrated medical record keeping and review? Score 1/2

What detailed recording of the assessment is mandated?

…The coordinating doctor is now required to ensure that their assessments and declarations are included in the medical record, but not that any more substantial assessment or further exploration has been undertaken.

7. How will clinical practice be supervised or monitored? Score 0

Adequate oversight can’t easily happen in a standalone service.

…Particularly important given that it has emerged that assisted suicide may be organised in the private sector. There is no mention at all of appraisal of medical practice. Oversight by the panels does not mandate an independent assessment of the applicant by each panel member (as happens eg in mental health review tribunals) and the commissioner’s review  will be bureaucratic, to ensure the letter of the bill is followed. No means of checking on concerning medical practice.

8. Requirements to monitor and report outcomes of the programme, for audit and quality control. Score 1/2

What wider psychological and social features will be recorded of those who die by assisted suicide? Is there a formal mechanism for responding promptly to adverse events?

…The bill requires that an annual report by the commissioner and that must include a note of persons who have died by assisted suicide and who had protected characteristics (an irony that escapes the drafters) but not how they will be identified. “Any other description of persons…” to be specified by the Secretary of State, a challenge since collection of the relevant information isn’t mandated.

9. Monitoring impacts on others. Score 0

Family outcomes and the impact on staff may be long-lasting.

…Doesn’t get a mention.

10. Is there a formal complaints and feedback process? Score 0

…Doesn’t get a mention. The medical examiner is required to interview a family member but the examiner isn’t mentioned in the bill, there is no requirement for the commissioner to share information with them and there is no mechanism for their findings to make their way into the process.

  • January 1, 2025

The reality of assisted dying – a sober, and sobering, account

A dispiriting feature of the current debate about assisted suicide legislation has been its low quality. Words like autonomy and dignity are used with no definition and the general style tends towards emotive case histories, marketing slogans and celebrity endorsement more reminiscent of the US presidential debates then a serious weighing of pros and cons. When the debate moved to parliament we weren’t served much better. Proposed legislation in the Commons and Lords has taken the form of skeleton bills with numerous so-called Henry VIII clauses that leave most of the detail to later executive decisions, while many of the key challenges are hardly touched upon, never mind carefully elucidated.

Into this space comes a new book – The Reality of Assisted Dying: Understanding the Issues Edited by Julian C Hughes and Ilora G Finlay (Open University Press. 2024) that offers a route to understanding the issues involved. Does it live up to that promise?

The book comprises 34 chapters written by 44 authors: clinicians from the main medical specialties you would hope to see; legal experts; ethicists and religious experts. A risk of multi-author books is wearisome repetition and difficulty in following themes. Helpfully and unusually an introductory section includes pointers to the location of discussion of key topics, and a lack of serious repetition suggests more careful attention to editing than is often the case.

I detect three super ordinate themes. First a careful elucidation of the meaning and relevance of terms such as autonomy, dignity, capacity, coercion and safeguards. These chapters are by no means abstract or over theoretical, instead they help to clarify the complicated issues at stake. In particular I liked the two chapters discussing autonomy, its features and the circumstances under which it should be constrained for the protection of others; they are models of clarity and concision.

A second theme covers the practical experiences in countries where assisted suicide or euthanasia legislation is already in place. Two main messages emerge. The first is a familiar one – there tends to be a move once initial legislation has been passed towards less restrictive criteria for participant eligibility and staff involvement and monitoring is limited, with no serious attempts to understand who is dying in such programmes. Second is a gradual change in culture as attitudes change towards end-of-life care and towards suicide.

A third theme covers the implications for staff and particularly doctors. In the doctor-patient relationship there can emerge a sort of expectation of involvement amounting at times to pressure. On the other hand apprehension from patients can make care more difficult to deliver; evidence suggests palliative care services decline rather than improve in countries where assisted suicide or euthanasia is legalised, while unassisted suicide rates either stay the same or increase.

There are inevitably some gaps in the coverage, reflecting mainly the limited existing evidence. For example there is little or nothing on the implications for staff other than doctors- nursing or care staff – or on the longer term impact on families and close others.

The overall tone of the book is negative towards the idea of legislating for assisted suicide or euthanasia and indeed both editors are well known campaigners in this country. It is difficult to see how it could be otherwise – the more one looks at the evidence from elsewhere the clearer it is that the bland reassurances of campaigners are not supported by evidence about how such legislation works in practice. Nonetheless the book should appeal to all readers. The presentations are well written, factually based and avoid a proselytising style. It is the best book I know about this individually and socially critical question and I recommend it highly.

A version of this review appeared in the December 2024 edition of the British Journal of Psychiatry

  • November 24, 2024

Marketing assisted suicide

A striking feature of the current UK debate about assisted suicide legislation is not the substance of what is being discussed but the way in which it is discussed. Here I outline some of my own observations.

First things first – what is assisted dying?

The Dignity in Dying campaign has argued for years that what it calls assisted dying is not the same as what is called physician assisted suicide in many other countries. The rationale is that assisted dying refers to people who take their own lives at a time when they can be considered to be dying, while assisted suicide refers to people who take their lives at a time when they are not believed to be dying. There is no justification in law for this distinction and indeed the campaign is aimed at changing the Suicide Act 1961 to decriminalise assisted suicide. It is as illogical an argument as the one that says people seeking assisted suicide are not suicidal – as if there is something called being suicidal that is different from wanting somebody to help you kill yourself.

Some of the slogans and jargon used by campaigners echo this fallacious argument. Even the acronym MAiD refers to medical assistance in dying rather than medical assistance to die. The slogan “It’s not about shortening life, it’s about shortening death” nods at the same logic, as if the last six months of one’s life are really the first six months of one’s death. Of course, this line is rather undermined by the Right to Die slogan – the claimed need for assistance to die (as if any of us had a choice) going against the suggestion that the only recipients will be those who are already dying.

What’s the argument?

Rather subtler is the appropriation of words like compassion and dignity. “Compassion” and “compassionate” are used freely as if all other deaths are a horror show and all opponents of assisted suicide are heartless in consigning people to what journalist Polly Toynbee has called a torture chamber. It has been a masterstroke to appropriate the word dignity to assisted suicide (Death with Dignity, Dignity in Dying, Dignitas) with its dual referents of avoiding demeaning experiences and maintaining personal standing. Its success depends of course on not mentioning the realities of the process of assisted suicide. So campaigners make no mention of complications associated with the assisted suicide process (distressing symptoms like retching, long delays in dying, recovering consciousness). In fact this is of a piece with a certain evasiveness about the nature of the assisted dying process more generally (see my notes on the Leadbeater bill)

Negative campaigning about palliative and end of life care form a part of the repertoire of assisted dying campaigners. It has elements of omission and commission.  It does not refer to research that shows a huge majority of people regard palliative care services as treating the dying with dignity and respect. Few go quite as far as journalist Polly Toynbee (again) who has claimed twice in the Guardian newspaper that a research report from the Office for Health Economics estimates that 17 people a day die in what she calls unrelieved agony or unimaginable pain when in fact the research did not quantify pain at all.

Another tack is simply not to mention palliative and end of life care at all. Baroness Meacher got the ball rolling with her remark that “Some people have to choose between suicide, suffering or Switzerland.” Less alliteratively and more inaccurately Kim Leadbeater announced the launch of her bill by saying” Today, somebody with a terminal condition and very little time left has only bad options. They can suffer in misery and often in great pain as their illness takes their life and dignity from them; travel to Switzerland- usually alone – if they are wealthy enough to pay for it; or take matters into their own hands…”

Marketing rather than critical appraisal of the case

Campaigners frequently site opinion polls suggesting the majority of the public is in favour of assisted suicide. It’s a claim that deserves some scrutiny. I have been impressed by how many people I discuss this with have a ready opinion and how few of them have reviewed any of the International evidence or reviewed the recent bills – McArthur in Scotland, Falconer in the Lords and now Leadbeater. So this idea is encouraged by polling – that you can have a view “in principle” without knowing what is being proposed in practice. It’s a bit like saying you approve Brexit or reform of the NHS “in theory” without knowing what they actually entail.

George Gallup sitting at his desk, working out how to get simple answers to complex questions.

There’s a reason such polls are popular with organisations like Dignity in Dying. It is not widely recognised that opinion polling has its origins in marketing. For that reason it was criticised early after its appearance for its tendency to reduce complicated matters to facile either/or stances: an early critic said:- ”Doctor Gallup does not make the public more articulate, he only estimates how in replying to certain questions it would say yes or no or don’t know. Instead of feeling the pulse of democracy Dr Gallup listens to its baby talk.” More recently it has been said that like advertising, “political polls are increasingly associated with attempts to manipulate public opinion, tailor messaging in superficial ways, and inform public relations strategies.”

Even more obviously out of the marketing playbook is the use of celebrity endorsement. It seems to go almost without questioning that actors, writers and TV presenters, and now even the daughter of a TV presenter, should have their views given prominence by the media. Why? The question is not why such public figures think what they do, but why their views are so widely broadcast. The answer resides in market research. Celebrities have an effect on the attractiveness of a proposition in a number ways. One way is by direct association with their own perceived attractiveness – what I call the “Why would I want to smell like Johnny Depp?” question. Another is that they give cultural meaning to the product they are endorsing. In the case of assisted suicide what they’re endorsing implicitly is not what they are endorsing explicitly – not the assisted dying process itself but the nature of the debate, one in which personal opinion is more important than careful critical appraisal of evidence and personal choice is privileged to the exclusion of other considerations.

Why it matters

The style of debate outlined above does not encourage critical appraisal of such evidence as there is, and its polarising influence means that important but nuanced arguments are not aired properly. For example, if there is a tension between allowing individual choice for some people while exposing other people to risk then how do we evaluate that trade-off? In other words, how much damage to one group of people is justifiable in the name of benefit for another group? There is another unresolved question that is reminiscent of the so-called ecological fallacy. Because a whole population is exposed to assisted suicide legislation we cannot assume that the proposed beneficiaries of the legislation (those who would otherwise have to face an unpalatable death) will actually be those who avail themselves of the opportunity of assisted suicide. We are pretty clear that unassisted suicide rates don’t go down; do we know about rates of undesirable deaths of other sorts?

My conclusion – marketing tactics have brought with them a superficial approach that has an undesirable influence on the form and content of debate in an important area of public health policy. It is much to be regretted that they have been embraced so whole-heartedly by proponents of assisted suicide.

  • November 21, 2024

Kim Leadbeater’s assisted suicide bill: who is vulnerable? where are the safeguards?

When MP Kim Leadbeater published her recent private members bill, which aims to decriminalise assisted suicide under certain criteria, she announced that it included: “the strictest safeguards anywhere in the world”. What she did not do (apart from not saying what a low bar that is) was explain specifically what those safeguards are or how they match the vulnerabilities of the people whose safety they are said to be protecting. It is these questions that I want to explore here, starting with the question of what vulnerability means in this context.

Assisted suicide legislation: who is vulnerable?

Taken on its own terms, the bill seeks to allow assisted suicide for anybody who meets certain illness criteria and who is making a personal choice to take their own lives, regardless of their reasons. So the main tests in the bill relate to the illness criteria (progressive, irreversible disease predicted to lead to death within six months) and personal choice (decision-making capacity and lack of coercion or undue pressure from another person).

It’s a narrow understanding of free choice, resting on a simplistic dichotomising of the population into a mentally competent, articulate, clear and uncoerced group and a muddled or coerced group without mental capacity. There is in truth a continuum, with a large ignored group occupying the ground between the two poles. Are there people in this grey area who can be seen as vulnerable in the context of a request for assisted suicide and if so, what is the nature of their vulnerability?

What all vulnerable groups caught up in the assisted suicide process will share is constrained decision-making. That is – the decisions available to them are limited as a result of external circumstances or as a result of their own inner state of mind.

Concern about some of the external constraints has already surfaced in discussions about Leadbeater’s bill. For example the limitation on possible decisions created by lack of comprehensive high quality palliative care including pain relief. Other external constraints include limited practical and financial freedom such as poor housing or an inability to live fully independently without practical and financial support from others.

Internal constraints are more difficult to recognise for the non-specialist. They include a sense of burdensomeness, aloneness and lack of confidence in the presence of mutually supportive relationships, hopelessness for the future and low mood. These features arise typically in response not just to an immediate physical illness but to the accumulation of life experiences. They feature strongly in thinking about suicide more generally, and therefore in exploring opportunities for suicide prevention.

When I talk with people who work in areas like mental health, disability services (including learning disability) or end of life care I find that they recognise these constraints and particularly the internal ones and can readily furnish their own examples. By contrast I find that these are vulnerabilities largely ignored by active campaigners for assisted suicide and in general not well recognised or understood by them. A result is that opponents of legislation are asked for illustrations and in response they often use broad descriptive categories of people likely to be vulnerable such as those living with disability or with significant mental illness. The riposte is – don’t worry they are excluded in the bill. This doesn’t address the more general problem about vulnerability nor in fact does it protect the disabled or those with severe mental illness because they are only excluded as long as they don’t have an eligible physical disorder. Once they do of course their vulnerabilities come fully into play.

With these ideas of vulnerability in mind we can ask questions about safeguards. They need to take into account that suicide will be assisted by medical professionals who undertake an initial assessment which involves clinical judgement and then are actively involved in a clinical intervention involving prescription and shared administration of potentially lethal drugs. So the benchmark is what one would expect to find in any setting where competent, conscientious doctors are working in a safe environment.

Oregon 2023 – world class safeguarding. 30/367 (8%) of deaths from prescriptions more than a year old. 141/560((25%) don’t know what happened next, even when 41/141 (29%) the person is dead.

The doctors and the intervention

The process requires two doctors who are expected to be independent.  It can however be hard to attract doctors to the work: in Oregon last year only 1.1% of all registered medical practitioners issued a lethal prescription. There are 571 registered GP’s in Leeds as I write so that would be 6 people. The coordinating medical practitioner is allowed to choose the second doctor and if they do not like the result they can approach a third doctor to obtain a second opinion. The expertise or experience required of either doctor is not specified.

There are two aspects of the act of assisting suicide itself that are hardly mentioned. One relates to the nature of assistance. An attending doctor can attach a “medical device” to deliver the fatal drugs and can assist the individual in using it. Given that an individual may be so disabled that they can use a proxy to sign the relevant documents it is difficult to know how this could work without it being a form of euthanasia. For example, can a proxy switch on the medical device?

A second question is this: the assessing doctor must discuss with the person their wishes in the event of complications arising in connection with the self-administration of an approved substance. There is however no indication of what the doctor is supposed to do with the resulting information. A doctor is required to stay with the person from the time of ingestion to the time of death – what are they supposed or allowed to do in the event of greatly delayed death or of the person waking up after being asleep or unconscious?

The assessment

Assessment of somebody expressing desire to take their own life usually involves careful review – of the reasons for the wishes, explored in more depth than simply check listing a number of ideas like lack of autonomy or lack of enjoyment in life; recent other life events or difficulties; household and financial circumstances; the situation of family and close others including their understanding of what is happening; and an account of past and current mental health problems including current mood. Of all these only an assessment of mental state is required and then only to exclude mental illness so severe that it is impairing decision-making capacity.

There is no requirement to talk to or even inform a member of the family or close other. Neither is there a requirement to seek the opinion of the GP or of a specialist such as a psychiatrist, except on occasion to confirm the presence of mental capacity.

Monitoring of the process

There is no requirement on the doctors involved to keep a full written record of whatever assessment is undertaken.

The person requesting help with their suicide does not have to sign a consent form of the sort used in other areas of the NHS – one that explains for example what the main complications might be.

It is suggested that a High Court judge will oversee the immediate process but as a number of expert commentators (see eg Munby and Chacko) have observed it is clear neither exactly what they will do apart from check paperwork nor whether it is feasible to expect the High Court to be able to undertake this work.

There is no requirement to keep a full record of or report side effects or complications associated with administration of the fatal substances, or of the time to death or of failure to die and in these circumstances of what the attending health professional did.

There is no indication of what would count as adverse events otherwise and no requirement to have an oversight system that allows for rapid response to severe adverse events.

All medical interventions (vaccination, general anaesthetic, antibiotics…) have complications and their safety is judged by balancing benefits against risks. If the risks are too great for any potential benefit then the intervention isn’t acceptable in medical practice. In this bill, as in all other assisted suicide bills, there is no mention of tracking untoward processes, no hint of what unacceptable rates of complications or protocol violations might be,  and there are no associated stopping rules to be applied either to individual doctors or to the assisted suicide programme as a whole.

There is no formal complaints or feedback procedure.

Can the detail be added later?

The answer to criticisms of the bill is always – don’t worry, it’ll be sorted out in committee.  Theoretically it could be but in reality it is a safe bet that it won’t be. There are two reasons why assisted suicide and euthanasia programmes internationally all have these problems. First, if all the amendments suggested by my commentary were included it would place participating doctors in an impossible position. They would be required to prescribe lethal medication and oversee death at the same time as exercising a duty of care and fulfilling their obligation to prevent suicide. Second, assisted suicide is not really about ensuring best care for everybody but about legislating so that one group of people can get what they want, in other words a libertarian privileging of individual choice. Sponsor of the bill Kim Leadbeater has made this clear on a number of occasions when she says personal choice is at the very centre of her bill.

A final note

There are of course other concerns raised by this bill that cannot be dealt with by any amount of re-drafting. There is the wider coarsening of societal attitudes to ageing, to end of life care, to the disabled. And there is the challenge to our approach to suicide prevention more generally when we stop saying all suicide is a tragedy we should work to prevent and start saying – not all lives are worth living and we will help you to end your own. There are other ways to express compassion besides helping people kill themselves.

  • October 28, 2024

Looking for safeguards in Assisted Suicide legislation – a 10 point checklist

Concerns about decriminalising assisted suicide, typically so that doctors can help people take their own lives, centre on one of four main themes:

  • Religious or moral objections.  They are important for those who hold religious beliefs but not for those who don’t – apart from the (often neglected) need to respect the expression of sincere views, as far as possible, of others. Their force is undercut somewhat by the observation that senior members of religious groups are found on both sides of the assisted suicide debate.
  • The likelihood of development from early restrictive use to wider application, the slackening of rules about who can assist or about cooling off periods – usually called the slippery slope argument. Campaigners for assisted suicide offer bland reassurance that no such thing is possible here – we are apparently unlike Canada, the Netherlands, Belgium, New Mexico, Vermont, or Washington State. Or like Oregon or Colorado, where slipperiness resides in re-interpreting the rules rather than rewriting them.
  • Worries that for many people choices are so restricted that real autonomy does not exist even in the absence of overt coercion. These worries are most evident in the reservations of those who point to the unavailability of comprehensive palliative care and end-of-life services, which depend heavily on charitable funding to deliver what they can.
  • A lack of immediate safeguards for the vulnerable. Supporters urge that proposed legislation is chock full of safeguards, while forwarding skeleton proposals that either have none of the relevant safeguards or defer their development to the executive, using so-called Henry VIII clauses. In Falconer’s House of Lords Bill many of the decisions were delegated to the Secretary of State, which creates an interesting dilemma if it is copied by Kim Leadbeater when she eventually lets us see her Bill: he has already said he will vote against it.

Here are my thoughts about what safeguards should look like, in a simple 10 point checklist – based upon the question – what would we expect in any other area of healthcare where we want to see competent and conscientios doctors working in a safe system? There’s a link at the bottom of the page.

What to recordRationale
How are the practicalities of assisting suicide specified?  
There is a lot of evasive vagueness in campaigns for assisted suicide, including avoidance of the term itself. People can’t give an informed opinion if they don’t know in detail what is proposed (think for example of consenting for surgery).		 
1. How is safe, competent medical practice ensured? 
For the doctors involved: what qualifications + experience are mandated how frequently can any one doctor prescribehow often should the same pair they work together, how the pairing is chosenTrue independence is hard when only 1% of doctors are willing to participate, as in Oregon. For example that’s 6 GPs where I live in LeedsIn Canada one doctor can choose the second opinion, and seek more than one.The case work indicates a need for experience in elderly care, palliative care or psychiatry Idiosyncratic or “overenthusiastic” practice is a risk.
If expectation of imminent death (say within 6 months) is a criterion, does it specify whether that is with or without treatment?There are medical conditions such as Type 1 diabetes or dialysis dependent renal failure where death will ensue if treatment stops. Diabetes is listed as the key underlying condition in cases in Oregon and Victoria.
2. How will safe, competent “assistance” be ensured? 
How will the decision be made about what drugs can be used with the aim of causing death in each case?There are no standardised regimes approved by regulatory authorities and it is acknowledged that none is perfect from experience in practice.   There is a need to monitor drugs used and compare to outcomes, otherwise there is no way to ensure acceptable practice.
What additional drugs can legally be used – after use of assisted suicide drugs and before death?Unpleasant side effects like retching are common (more than 10%), delayed death and not dying are well described (again 10%+).   If a health professional has to stay with the person until death, then they will be under pressure to ensure extra drugs are given in these circumstances. Death by assisted suicide isn’t always dignified!
What exact mode of administration and “assistance” is allowed?Most people imagine that assisted suicide involves swallowing an elixir or mixture of tablets. But use of a “medical device” and assistance to a very disabled person in using it (as for example in the Falconer Bill, and not excluded by the wording of the McArthur Bill) amounts to something much more like being given a lethal injection aka euthanasia. Will administration be allowed as in Victoria, Australia?   Public standing of the programme depends upon knowing the detail.
3. How will informed consent be ensured? 
What form of informed consent is required?Consent for any other procedure in health care requires informed understanding of exactly what is proposed, what its potential complications and side effects are, and what alternatives there are. The “declarations” in existing legislation do not cover all this ground.
4. Is there adequate ability for healthcare professionals to opt out? 
How far does conscientious objection and opting out go?   Can a whole organisation, such as a care home, nursing home or managed group of such, raise conscientious objections?“No duty to participate in anything authorised by the Act” does not seem to preclude eg requirement to inform patient it’s an option, or to refer if asked. Conscientious objection is not defined.   In Canada dissenting care or nursing homes risk losing their licence.  
5. What aspects of assessment are mandated?   
In competent clinical practice there is a great deal more to assessing somebody who is saying they want to kill themselves than simply checking mental capacity and lack of overt coercion. 
Is there a requirement to obtain: …    Mental health and alcohol use life history Family/household circumstancesRecent life events and difficulties &. financial circumstancesThese form an important part of assessing remediable factors in anybody at suicide risk, and certainly anybody who is saying they now actively want to kill themselves. Endorsed in suicide prevention strategies and in clinical guidelines and training.
Is there a requirement to interview a family member or close other?Part of assessment as above, and can provide important information not revealed by patient eg that points to undue external influence   Close others are interested parties because they are directly affected by the death
Is there a requirement to interview GP and, as relevant, key specialist?These people have a duty of care that the assisted suicide doctors don’t, and therefore have a right to be consulted.   They should be consulted because they are likely to have privileged information that may not be available otherwise, for example on prognosis or on external factors influencing the decision.
6. What requirements are there for integrated medical record keeping and review? 
Is there a requirement for medical records review and if so which, and for what part of the person’s life?Medical records may contain important information that is suppressed or forgotten by interviewees.
What detailed recording of the assessment is mandated?If assisted suicide is to be a part of end of life care in the health service, then records need to be kept and form part of the patient record, as for any other contact. “No notes, no defence” is a well known legal caveat. An important element of auditing practice.
7. How will clinical practice be supervised or monitored?   For early career staff, direct supervision is needed. For more experienced staff peer contact and informal observation may suffice – but can’t easily happen in a standalone service.   
What are the requirements for contemporaneous supervision or oversight of the clinical contacts? 
8. What are the requirements to monitor and report outcomes of the programme, for audit and quality control?  
Careful routine monitoring of performance against agreed outcomes (audit) is a standard part of good practice. Lack of it is a near uniform finding in investigations into healthcare failings.		 
 What characteristics will be recorded of those who die by assisted suicide?Reporting from other countries is often rudimentary – especially in relation to monitoring features of concern to those who worry about how the system protects vulnerable people. Will wider psychological and social features of individuals (as outlined in assessment) be included in monitoring reports?
Time to death/failure to dieAn important outcome to determine whether the process is working at an acceptable standard on its own terms   Information that needs to be provided to the patient to obtain informed consent 
Adverse eventsAn important outcome to determine whether the process is working at an acceptable standard on its own terms   Information that needs to be provided to the patient to obtain informed consent 
Is there a formal mechanism for monitoring untoward incidents and responding to them promptly? 
9. Monitoring impacts on others 
Family outcomes   Impact on staff, including emotional impact, staff departures and absenteeismAn important outcome to determine whether the process is working at an acceptable standard. Especially negative psychological outcomes may be long-lasting. There may also be practical implications for families such as disputes over bequests. It is too narrow to regard this process as affecting only one person.   Some of this is information that needs to be provided to the patient to obtain informed consent 
10. Is there a formal complaints and feedback process?Should be routinely sought and collated, as in any healthcare setting.

A list like this could serve two purposes.  It is a template for designing a programme – if these elements aren’t present then the programme cannot even a priori  claim to have sufficient safeguards. And it is a template for what should be collected in a monitoring and reporting a programme, without which claims for safety rest on no evidence base.

In fact no checklist like this has been applied to assisted dying legislation and there are two reasons for that; reasons that explain why such legislation is inherently unsafe. Assisted dying practice everywhere except Switzerland requires medical involvement – it requires doctors to prescribe and oversee death rather than to exercise the sort of duty of care or professional obligation to prevent suicide that is reflected in these safeguards. And legislation is not about (despite the rhetoric) ensuring best care for everybody but about allowing one group of people to have an unconstrained personal choice – framed as a human right. It is the libertarian privileging of individual choice over community responsibility.

For further reading I recommend the excellent The Reality of Assisted Dying: Understanding the Issues eds Julian C. Hughes, Ilora G Finlay Open University Press 2024

There’s a link to a Word version here:

safeguards checklistDownload