euthanasia Archives - Allan House

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 20^th 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 60^th 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.

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
https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year27.pdf
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
Worthington A, Finlay I, Regnard C. Efficacy and safety of drugs used for ‘assisted dying’. British Medical Bulletin. 2022 Mar;142(1):15-22.
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.
https://www.cps.gov.uk/publication/assisted-suicide
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.

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 record	Rationale
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 chosen	True 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 circumstances	These 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 die	An 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 events	An 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 absenteeism	An 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 checklist Download

November 29, 2023

Marketing medical assistance in dying and the privileging of personal choice

One of the defining features of a functioning state is usually taken to be that the state holds a monopoly of violence – especially violence towards its own citizens. There are however a number of situations in which the state sanctions killing, or at least does not punish it. Putting aside the activities of the armed forces and police, the other common situations fall under the umbrella of what might (surprisingly) be thought of as the public health. They include, in jurisdictions where they are allowed (not criminalised): termination of pregnancy, suicide and euthanasia.

I discern a number of influences at play when decisions are being made about the exact circumstances under which the state will allow ending of life. There may be others, but as a starter my list is:

The degree to which the life under consideration is regarded, by the person living it, as so burdensome as to no longer be worth living;
The social value of the life under consideration – that is, how others view the individual per se or as a result of any condition from which they suffer;
The practical, technical or emotional difficulties inherent in the process of ending the life – what we might call barriers to implementation;
The degree to which differences of opinion have to be taken into consideration in arriving at a final decision.

These sorts of ideas are encapsulated in enabling legislation, of course each being given different weight according to the exact circumstances.

I was recently listening to a talk about medical assistance in dying (MAID) given by the historian Kevin Yuill during a meeting in Jersey. Yuill introduced me to another angle on this, which is thinking about the motivational influences: not how the decision is made but something like why it is being made at all. Yuill suggests that in the history of euthanasia and assisted suicide, the main motivating factors have been ideas about utility and compassion. Utility has featured most brutally in pro-euthanasia and eugenicist ideas about ballast existence and while compassion could be instrumentalised in support of these endeavours, it also has a more altruistic side. More recently however, an appeal to autonomy has come to dominate: euthanasia and suicide (assisted or not) are argued to be, in the right circumstances, individual choices which should not be blocked by authoritarian government actions.

This proposition struck a chord – when I speak with friends and colleagues about MAID, the response of those who support it is that it is a personal choice that they would like to be able to make for themselves if they were in a position where it was relevant. If they have thought further, it is only to consider briefly (and dismiss as avoidable) the slippery slope argument.

And the appeal to autonomy describes neatly how the campaign for medical assistance in dying (which in the UK means physician-assisted suicide) is being framed. What is going on in the public debate about MAID legislation is not that supporters are contributing to a dispassionate assessment of the pros and cons of a momentous change in the law – with potential direct and indirect harms being considered as well as potential individual benefits. Instead the idea is promoted (marketed) that MAID is evidently something people will want to choose and that preventing that choice is wrong. The emotive case histories/horror stories, celebrity endorsement and misrepresentation of the alternatives as the quiet dignity of assisted suicide versus giving oneself up to the horrors of end-of-life or palliative care, are all designed to arouse anger about a right denied.

When the exercise of personal choice becomes the paramount consideration we are in a society where the individual’s wishes overshadow questions of the public good. Now how could that not strike a chord…

February 8, 2023

Medical assistance in dying is another name for physician assisted suicide

The rebranding should not blind us to the risks involved.

The argument for what is now called ‘assisted dying’ is often framed in terms of personal autonomy – the right to choose the time and mode of one’s death.

Individuals included in media reports as pressing for that right are typically mentally competent, educated, and supported by a partner or family member who affirms their desire to die. Campaigners pressing for change suggest (at times in strikingly gothic terms) that if their wishes are denied, the likely alternative is a difficult death during which pain is inadequately treated and distressing symptoms are mismanaged. ‘Assisted dying’ is thereby positioned as a form of patient-centred care – a death with ‘dignity’.

Put like this, the case can seem incontrovertible. Who wouldn’t want a ‘dignified death’ in which their own wishes were central to any decisions about their treatment? But this is a narrow and unbalanced way of framing the discussion; it fails to communicate the full range of questions that arise when thinking about serious illness. “Assisted dying’ is a euphemism for physician assisted suicide; it involves prescribing lethal drugs to somebody who will then self-administer them to end their life. Framing the practice like this gives a different perspective that is masked by the rebadging as assisted dying. What we know about suicide more widely becomes relevant in informing what we think about doctor-assisted suicide.

People living with severe, persistent physical illness can of course feel that their condition is intolerable. Indeed, research shows that about one in ten describe having thoughts that their life is not worth living, or that they might be better off dead. And suicide rates in people with a severe health condition are double those of the general population. Even so, recent data from the Office for National Statistics suggest that in absolute terms fewer than 10% of suicides are in people with a severe health condition. Some of the study findings come as a surprise; for example of 17,195 suicides identified from 2014-2017, only 58 (0.3%) were in people with what the study called low survival cancer. This is about three times the general population suicide rate but accounts for only 3 in every 10,000 of those recorded as having low survival cancer in the study period. In other words the great majority of people (more than 99%) with negative thoughts about their circumstances do not take their own lives.

What does research into suicide in the wider population suggest might make suicide more likely? Many of the leading risks are social – loneliness, living alone, low income and lack of employment, and a lack of social support. A history of problems with alcohol or drugs is also common, especially in men. So is a history of mental health problems – typically not psychotic illness but recurrent episodes of depression. More than half of those who take their own lives have a history of previous self-harm. These risks are also prominent when suicide occurs in the setting of severe physical illness, even among those who are simultaneously in contact with mental health services.

Suicide associated with severe physical illness occurs most commonly in the first year after diagnosis, especially in the first six months. This observation is in line with research showing that rather than intolerable and untreatable symptoms it is concerns about the future and loss of independence that motivate many requests for physician-assisted suicide.

US psychologist Thomas Joiner has outlined an influential interpersonal theory of suicide that makes much sense of these findings. He outlines three risks for suicide – thwarted belongingness (closely-related to the idea of lack of social connectedness), perceived burdensomeness, and acquired capability (overcoming the fear of death). Thinking about suicide in this way helps us to be clearer about the nature of suicide in the physically ill and therefore ‘assisted dying’, which is a risk for exactly those people whose suicide we are used to working to prevent, by actively helping people to “acquire capability”.

The response to these concerns rests upon assurances that only carefully selected cases will be accepted into a programme of assisted suicide. We can have no confidence that such “safeguards” will be adhered to. For example in one study from the Netherlands, 12% of those accepted failed to meet the criterion of there being no alternatives for palliative treatment and 7% were not reported has experiencing unbearable suffering. I have yet to see a statement from supporters of medical assistance in dying about their opinion on what is an acceptable error rate in the system.

There is another reason for concern about doctor-assisted suicide – less tangible perhaps but with far-reaching consequences. It fundamentally changes our approach to suicide, Under the Suicide Act 1961 an act “intended to encourage or assist suicide” is a criminal offence. There are no exclusions – it is an all-encompassing approach that is reflected in our National Suicide Prevention Strategy. What is proposed is a radical overhaul of the way we approach suicide – a move away from trying to prevent all instances to a world in which we attempt to prevent suicide except when we decide to make it easier.

We are facing in medical assistance in dying a privileging of personal preference over social concern. It represents not just a modification of individual clinical practice but a societal intervention designed to change how we think about and respond to suicidal wishes. I find it hard to believe that the longer-term consequences, intended or otherwise, will be of universal benefit to those most in need of our care.

January 17, 2022

Culture wars, economic hardship and disdain for mental illness and learning disability – a dangerous mix.

Germany’s asylums between the world wars housed a mixed population – mainly of people with a learning disability or a severe and persistent mental illness. These people became the focus of Nazi interest for two reasons.

First – and this isn’t as widely known as it should be – residents of the asylums were the first large scale victims of the Nazi’s mass murder programmes. The technologies used later, on Jews, Roma, homosexuals, communists and others, were first developed in what is usually known as Aktion T4 (named prosaically enough for the original HQ address Tiergarten 4). That is, T4 developed gas chambers as an efficient method of killing, purpose-built crematoria for disposal of the bodies, and an associated propaganda programme that is hard not to see as enabling a sort of collusion with the general public. An estimated 200,000 people from the asylums were eventually killed in T4 and its sequelae. This history is covered in some detail in Michael Burleigh’s extraordinary 1994 book Death and Deliverance: “euthanasia” in Germany 1900-1945 (Cambridge UP, listed unbelievably as out of print now).

An apparently separate campaign waged by the Nazis took the form of what we would now call culture wars, with modern art as a particular target. The infamous Entartete Kunst (Degenerate Art) exhibitions curated by party members and promoted by Goebbels are well known, but less so is the link to asylum art. A number of key modernists had been intrigued and influenced by the work of apparently mad people – so-called art brut – a significant collection of which had been accrued by Hans Prinzhorn at Heidelberg and valued as being artistically important in its own right, not simply as a window into the mind of the insane.

The Nazis exploited this association in carefully managed presentations associated with the message – look how modern art is no different to the art of lunatics and imbeciles and yet you are duped into paying huge sums for the public galleries to own it. With the related message of course – it’s all part of a (Jew-orchestrated) conspiracy to undermine true Germanic society through undermining its culture.

The two stories inevitably intersect, with many (amazingly not all) of the asylum art works destroyed and the artists who made them perishing in the mass euthanasia programmes. This story is well told in a new book The Gallery of Miracles and Madness by Charlie English – unlike Burleigh a journalist rather than historian, with a predictably different but nonetheless well researched and engaging style.

The asylum artists who died in the T4 programme were caught in a perfect storm – of culture wars used by an authoritarian government to garner support for their wider political project; the motivating force of economic hardship coupled with the idea that alien enemies are to blame; the promotion of “euthanasia” as a solution to the societal problem of burdensome lives. Sound familiar?

Allan House

Tag: euthanasia