I risk being accused of hypocrisy with this article, as I am a strong advocate of going to Dignitas. So when it looked as if assisted dying might be legal in the UK, I was quite excited. But as the details of the Assisted Dying Bill became clear, I reconsidered.
What is the Assisted Dying Bill?
The Terminally-Ill Adults (End of Life) Private Member’s Bill, sponsored by MP Kim Leadbetter, passed its second reading in the UK Parliament in November 2024. The draft legislation proposes granting people medical assistance to die if they have six months or less to live, with the approval of two doctors and a judge.
The bill is currently at the committee stage, which is supposed to involve a detailed examination of the bill, scrutinised line-by-line, with full public transparency. The committee should hear evidence from witnesses and consider proposed amendments. After the first committee meeting in January, the amended Bill can be found here.
Problems with the conduct of the committee stage
The membership of the committee was heavily stacked (14:9) in favour of Leadbetter’s Bill, while requests to join from experienced Parliamentarians with relevant expertise were rejected. Four Labour MPs wrote an open letter expressing concern that the committee met in private to discuss what oral evidence to accept, thereby preventing public scrutiny; the selected witnesses were heavily skewed in favour of the bill.
Also of concern was the exclusion of evidence from:
- The Royal College of Psychiatrists
- Disability rights organisations
- The British Geriatrics Society
- Other countries which have assisted dying
After negative publicity, the Committee U-turned on evidence from the Royal College of Psychiatrists and Disability Rights UK.
Although Leadbetter continues to claim the bill offers the “strictest safeguards in the world”, nearly every one of her safeguards has now been removed or diluted.
Judges will no longer give approval for assisted dying
Although the bill passed its second reading containing the provision that the assisted death must be certified by two doctors and a judge, Leadbetter has now removed the need for a judge’s approval. The new proposals require an Assisted Dying Review Panel of three people, comprising lawyers, psychiatrists and social workers, to approve assisted dying applications. Leadbetter has called this new proposal “judge plus” but many were quick to point out that in fact it is ‘judge minus’.
It is this development in particular that could cost Leadbetter the bill. Up to 140 MPs who had previously backed the bill are said to be reconsidering their position.
Practicalities have not been addressed
No-one seems to have considered whether the ‘assisted dying’ service will be a part of the already overstretched NHS or be a separate service, or whether and to what extent it could be outsourced to private companies. The Times reports that assisted dying could be provided by private companies.
How much training will doctors and nurses need to participate in the assisted dying programme? How will outsourced private companies be regulated and quality control assured?
Opt-outs are important if the bill becomes law. Will doctors and nurses be able to opt out of being part of assisted dying without prejudice to their careers? Will care homes and hospices be able to decline it?
Apparently, there are not enough psychiatrists to take on the Assisted Dying Review Panel work. A poll on this issue only had a 10% response rate from psychiatrists; of those 10%, only a third said they would be willing to participate in an assisted dying service.
It’s the same with social workers. The Telegraph reports they are “too busy to sit on assisted dying panels… and will need more funding to meet the needs of the assisted dying bill”.
What happens in other countries where Assisted Dying has been introduced?
Canada offers assisted dying under the Medical Assistance in Dying (MAiD) programme. The Mail reports that Canada is now euthanising 10,000 of its citizens a year, representing more than 3% of all deaths. That’s an increase of a third on the previous year. The original 2016 legislation was restricted to the terminally ill, but was broadened three years later to cover “grievous and irremediable” non-fatal illnesses. It is likely to be expanded to include mental suffering in 2027. Fewer than 50% of patients who opt for euthanasia see a palliative care team.
Healthcare staff have been caught ‘suggest-selling’ assisted dying to people with costly medical conditions who have no desire to die. One of the most horrific examples is Christine Gauthier, who served 10 years in the Canadian armed forces, where she sustained a bad injury. She requested funding to install a stair lift in her home in 2018. When there had been no progress four years later, a caseworker from Veterans Affairs Canada contacted her to offer assisted dying.
Both Belgium and the Netherlands allow assisted dying for adults with non-terminal physical conditions or mental distress, and in some circumstances for children, thereby undermining the requirement for ‘capacity’ when giving informed consent. In all these countries, the scope of the original assisted dying legislation has been extended.
Evidence from the Royal College of Psychiatrists (RCPsych)
The Committee was shamed into hearing evidence from the Royal College of Psychiatrists (RCPsych), which was initially disallowed. RCPsych said it had several concerns:
- Whether it’s possible to assess reliably a person’s capacity to decide to end his or her own life, especially when mental health issues are involved.
- Can consent serve as an adequate safeguard against coercion? Vulnerable individuals might be pressurised into choosing assisted dying, with coercion coming from family members with personal or financial motivations but also from societal pressures.
- Individuals with mental disorders, intellectual disabilities and neurodevelopmental conditions often face barriers to accessing palliative care and may be more susceptible to coercion.
- The introduction of assisted dying legislation could undermine suicide prevention efforts.
An elder abuse charity also gave evidence after initially being excluded. It said it was “witnessing an epidemic of abuse against older people” and reiterated the legislation’s potential harm to vulnerable, elderly, mentally ill and disabled people.
‘Mission creep’
There is the very real danger of the legislation’s scope being extended, as we’ve seen in Canada, with assisted dying offered to those with mental health issues, eating disorders, chronic conditions and those who feel they are a burden. “Being a burden” is one of the leading reasons for patients requesting assisted suicide, cited by 50% in Canada 50%; 43% in Oregon and 60% in Washington. Studies have shown that often ‘being a burden’, not pain, is the main reason for requesting assisted dying. UK Medical Freedom Alliance (UKMFA) reports that Leadbeater admitted that under her bill a person would qualify for assisted death for the sole reason of saving his or her relatives money.
The Telegraph reports that Kim Leadbeater has already proposed an amendment to include people with terminal mental disorders or disabilities in the bill’s scope. This would be a particular risk for people suffering from eating disorders because the ‘terminal illness’ “may have arisen as a result of their mental illness and this needs to be properly considered”, according to the Telegraph. Assisted dying laws abroad have already enabled at least 60 patients with anorexia to end their lives. A representative from the UK’s leading eating disorder charity said “eating disorders should never be classified as terminal”.
What about palliative care?
Palliative care seems to be in a parlous state. HART points out that the sector is seriously underfunded, with only 30% of hospice funding provided by the Government. Hospices rely on fundraising to survive, which is much reduced with the cost of living crisis, while large NHS pay rises have pushed up wage bills for hospices. The Budget made things worse because hospices are not exempt from the rise in Employers’ National Insurance Contributions. The number of people dying each year in the UK is going up significantly, while hospices are making service reductions and redundancies.
The Spectator reports a palliative care consultant saying: “Every night in my hospital, and every weekend from Friday to Monday, you cannot see a palliative care nurse or doctor.” The equalities watchdog argues that “because provision of palliative care was so patchy… the terminally ill would have no viable alternative but to have an assisted death, thus denying them a free choice”.
If the money and energy that had gone into this bill had instead been used to improve palliative care, to allow terminally ill individuals to live their final days free of pain and with dignity, the clamour for some form of assisted dying might not have been so loud. The Telegraph notes that “unlike other similar assisted dying legislation in other countries, the bill failed to make any commitment to provide extra funding for palliative care”. But once we allow assisted dying, there is no longer any incentive to fund and support palliative care. A recent JL Partners survey of the public showed that 64% of respondents are in favour of palliative care over assisted dying legislation.
At the end of the day, assisted dying is just cheaper and easier for the state, particularly as healthcare spending is normally highest in the final year of life. UKMFA points out that assisted suicide would cost the equivalent of just one week of palliative care, whereas a good hospice can cost thousands of pounds a month.
Can doctors accurately predict death within six months?
No, and we shouldn’t expect them to. So many factors are involved that it’s impossible to be precise. In fact, the Telegraph reports hospital data indicating that doctors’ prognoses were wrong more than half the time and that patients given six months to live can still be alive three years later.
Furthermore, the Telegraph says that the draft bill proposes using the Department of Work and Pensions’ fast-tracked benefits scheme, which entitles patients with just six months left to live to be fast-tracked onto Universal Credit, highlighting eligible patients. But a doctor’s prognosis that is suitable for ascertaining who may receive Universal Credit is unlikely to be suitable for ascertaining their suitability for assisted dying. And it rather smacks of trying to avoid paying the Universal Credit. Furthermore, Department for Work and Pensions (DWP) data obtained by the Telegraph revealed that a fifth of those benefit claimants are living much longer than expected.
This is likely to alter forever the doctor-patient relationship
Up until now, we have always looked to doctors to act in our best interests. If we now have to consider that they could be involved in certifying suitability for assisted dying or even administering the drugs, a fair degree of patient suspicion could creep in. It makes a nonsense of the fundamental principle of medical ethics: “First, do no harm.”
And we have only to look back at the COVID-19 pandemic, when then Health Secretary Matt Hancock stockpiled the sedative and respiratory depressant Midazolam to give to care home patients with Covid. Midazolam, morphine and ‘Do Not Resuscitate’ notices were forced on patients without consultation or consent involving either the patient or their families. This resulted in a large number of patient deaths shortly after the Midazolam had been administered. We don’t need an Assisted Dying Bill when our health care system can already kill us indiscriminately in care homes.
As Dr Vernon Coleman reminds us: “The Nazis ran a euthanasia programme for a while. After a short period, Hitler abandoned it because he considered it morally indefensible.”
Dr Rachel Nicoll is a medical researcher, lecturer and writer. You can contact her here.
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