No Autonomy in Austerity: The Case Against Legalising Assisted Dying in the UK
Lily Brough considers the case against the Terminally Ill Adults (End of Life) Bill, arguing it is not fit for purpose in the UK as it stands.
The UK House of Commons. Photo via: Wikimedia Commons
This Thursday, 29th November, the House of Commons is set to go through the second reading of a bill that would legalise assisted dying (AD) in the UK for terminally ill adults. Many groups have raised concerns over the possible passing of such a bill, citing several reasons for their opposition, including fears over insufficient safeguards against coercion and the infeasibility of introducing AD in an already strained NHS and judicial system. On Friday the 22nd of November I attended a public panel discussion on the issue where a number of advocates and doctors spoke of their concerns. Debates over the ethics of AD, or assisted suicide, are complicated and fraught with larger moral and political questions. Despite this, the Terminally Ill Adults (End of Life) Bill should be challenged on the grounds that the contents of the bill are both insufficient and dangerous.
Switzerland is perhaps the most well-known example of legalised assisted dying, with many Britons each year travelling to undergo the treatment at Dignitas, an organisation based in Switzerland. Dignitas has, as of 2023, assisted 571 UK nationals in assisted dying. Travelling to Switzerland to end your life is expensive, costing thousands of pounds, and risky for those who travel with you as they are liable to prosecution in the UK. During the panel on Friday, a member of the public expressed their plans to travel to Dignitas in the coming months. Many of those who travel to Switzerland to end their lives do so sooner than they would wish because they need to go while they are still able to travel. As it stands then, there are terminally ill adults in the UK who wish to end their lives, and travelling to Dignitas is not an accessible option for all of these individuals.
The Terminally Ill Adults (End of Life) Bill would allow residents of England and Wales who are over the age of 18 and diagnosed with a terminal illness to access AD, subject to both practitioner and judicial approval. There are various criteria and conditions which must be met: first, the individual must have a terminal illness that can be ‘reasonably expected’ to end their life in the next 6 months. On this point, Dr Baker, a speaker at the panel, stressed that medical prognostics are not wholly reliable and therefore confidently claiming someone has 6 months to live is exceedingly difficult. Secondly, the individual must be of medical capacity and able to make an informed and considered decision to end their life; such a decision must be free from coercion. Other criteria include needing to be registered with a GP and ordinarily be a resident in England or Wales. The government has elected to remain neutral on the issue and therefore Labour MPs will be able to vote independently on Thursday.
The speakers at Friday’s panel presented two main objections to AD: the proposed bill is badly constructed, and neither the NHS, nor broader social structures, are in a place where AD could be ethically implemented.
“Leaving the details up to ministers rather than subjecting them to the scrutiny of the House of Commons risks the implementation of AD without a firm democratic mandate.”
On Thursday the House of Commons will deliberate over this bill for just 5 hours before taking it to a vote. Many of the panellists expressed grave concerns that this is not enough time to thoroughly debate the bill, especially as the contents were only published a few weeks ago. Many of the essential details about how AD would be implemented remain unclear, and would only be finalised after the bill is passed into legislation. Once passed, the Health Secretary would have the power to decide on the procedures and regulations. Liberty, a UK-based human rights group has stated that given the gravity of the issue, this bill should not adopt a ‘details later’ approach and “MPs must know exactly what they are voting on”. Liberty points to the rapidly changeable COVID laws as an example of the volatile nature of healthcare policy when ministers are given such unilateral control. Leaving the details up to ministers rather than subjecting them to the scrutiny of the House of Commons risks the implementation of AD without a firm democratic mandate.
Now to consider the bill itself: One of the most overt concerns with this bill is the lack of sufficient safeguards against coercion and abuse. Dr Philip Murray, a constitutional law professor here at Cambridge, was among the speakers of Friday’s panel and stated that the bill as it stands is not ethical. While the bill explicitly states that a patient’s decision to seek AD should be made voluntarily and without pressure or coercion, it fails to propose procedural structures that would ensure this.
In the first instance, the bill does not prohibit doctors from raising the possibility of AD to their patients. Allowing doctors to present this option may covertly coerce patients into AD by believing it is their only viable choice. Australia does not allow doctors to discuss assisted dying unless the patient raises it themselves, precisely for this reason. The concern here is less about overt coercion from health practitioners and more about the internal coercion it may create. Internal coercion describes the pressures an individual may feel to choose AD without external pressures. For instance, a patient may feel they are a burden to their friends and family, or a strain on the health system, and therefore be inclined to seek AD for this reason.
The bill has no tangible procedures for identifying internal coercion. While two independent doctors and a judge are required to approve the decision, there is no requirement for psychological assessment or the presence of a social worker. Following approval from the patient’s physician and another independent doctor, the court then must approve the request but is not required to meet with the patient. The judge’s role in this process is largely unclear according to Dr Murray, who stated the bill doesn’t outline if the main onus for identifying coercion lies with the health practitioner or the judge. It is unreasonable to expect that judges would be able to detect coercion when considering each case, and doctors themselves are not trained to identify coercion. The procedures outlined in the bill also raise additional concerns over patients secretly seeking AD; there is no requirement for the next of kin to be told in advance, and doctors are not required to speak to friends or family to ascertain the mental state of the patient.
“it is unreasonable to believe that a doctor or judge would be able to identify when the economic or social situation of a patient is the motivating force for seeking AD.”
Also significant in the language of the bill is the fact that it states nowhere that the patient’s terminal illness must be the reason for seeking AD. The panel raised the example of Amir Fasoud in Canada, who suffers from a severe disability due to an accident, who sought assisted dying when changes in his housing situation made him concerned over homelessness. However, following a GoFundMe campaign that raised over $60,000 for Fasoud, he decided against AD. This highlights a critical point of consideration; internal coercion is greatly influenced by an individual’s financial status. Passing this bill in the same economic climate that has cut disability benefits by over £1 billion signals a gross blindness to the reality in which disabled and terminally ill adults are living. It is hard to believe that a patient could choose AD completely free from internal coercion when we consider this fact. This is not to say that nobody who chooses AD is doing so willingly, rather it shows that medical decisions can never be truly divorced from social contexts. But further still, it is unreasonable to believe that a doctor or judge would be able to identify when the economic or social situation of a patient is the motivating force for seeking AD.
This brings us to the second main objection to the bill, the current state of the UK’s medical and judicial institutions. Considering the judicial system first, AD would substantially increase the sitting hours of the higher court, placing a huge strain on an already strained system. Dr Murray stated that judicial sitting time would be around 34,000 hours per year if AD is legalised, compared to the current annual sitting time of 19,000 hours. With the role of the judge in this decision open to interpretation, and the sheer unmanageable workload this bill would create, it is hard to trust that AD could be safely and carefully implemented.
Now consider the impact on the healthcare system. All but one speaker at Friday’s panel argued that implementing AD in the UK is simply not realistic given the dire situation of the NHS. Our Duty Of Care, a group of medical professionals opposing AD in the UK, published an open letter to PM Keir Starmer emphatically opposing the passing of this bill on these grounds. They stated, “the thought of assisted suicide being introduced and managed safely at such a time is remarkably out of touch with the gravity of the current mental health crisis and pressures on staff”. They go on to stress that palliative care is insufficient which only increases the likelihood of internal coercion.
“implementing AD at such an unstable time for the UK’s healthcare is both naive and neglectful… the current provision of palliative care in the UK is in no shape to provide a reliable or favoured choice over AD.”
In September PM Keir Starmer stated that the NHS is ‘broken’ and years of Conservative austerity has brought it “to its knees”. With the government acknowledging that fixing the NHS will not be quick or cheap, is now really the time to bring AD into the mix? This is not a light change; implementing AD at such an unstable time for the UK’s healthcare is both naive and neglectful. Aside from the extra strain this would place on the NHS, the current provision of palliative care in the UK is in no shape to provide a reliable and favoured choice over AD. A recent Marie Curie report concluded that the current “workforce capacity is insufficient to meet demand for palliative and end of life care”. Dr Baker, who has extensive experience in palliative care argued that when implemented properly, palliative medicine can and does maintain a patient’s quality of life and in certain cases may improve it. He further argued that terminal illnesses do not inevitably lead to a loss of value in life. AD should only be an option when there is a meaningful choice to be made; if a patient isn’t receiving adequate palliative care they are more likely to seek AD. No amount of safeguards in this bill will prevent this.
It is important to consider who is most at risk from this bill - notably disabled people. George Palmer, a PhD candidate in history at Emmanuel College, was the last speaker at Friday’s panel, arguing that this bill risks worsening ableism in the UK and further entrenching health inequalities for disabled people. He stated that disabled people are most prone to internal coercion, and the UK as it stands consistently devalues the lives of those living with disabilities, meaning that this bill would risk reducing rather than increasing their autonomy. He pointed to the overwhelming opposition to this bill amongst disability charities in the UK, concluding that AD does not represent a ‘real choice’. While it is important to stress that this bill clearly states disabilities do not meet the criteria for AD, groups such as Liberty, and Palmer himself, cite this as a slippery slope. For instance, Liberty points to Canada where the initial criteria have been expanded in recent years to include non-terminal illnesses, with plans to include mental illnesses in the future. This is yet another reason why the ‘legalise now and refine later’ approach is dangerous.
This is not a question of whether assisted dying should be legalised in the UK. It is a focused question as to whether the Terminally Ill Adults (End of Life) Bill should be passed. Of course, in seeking to answer this question, the larger issue must be addressed, but as I see it, even those who believe AD should be legalised should be against this bill. It isn’t a ‘no’, it is a ‘not now’. Not now, when the bill is so shaky in its foundations and opens too many possibilities for abuse and harm. Not now, when palliative care is so deficient and our NHS is too underfunded. And especially not now when our society is structured to systematically undervalue disabled lives and the lives of those with terminal illnesses. We must first fix what we have before we turn to such a radical policy.