Category: euthanasia

  • 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.

  • 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.

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