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