The Committee scrutinising Kim Leadbeater’s Terminally Ill Adults (End of Life) Bill, which passed its Second Reading on 29 November 2024, met to examine witnesses who gave evidence on the content of the Bill. Over three days between 28 and 30 January, MPs heard from 50 witnesses on the Bill, which seeks to legalise assisted suicide in England and Wales.
The Committee consists of 23 MPs, with 14 in favour of the Bill and 9 against. There has already been significant criticism of the makeup of the Committee, with some calling it a “complete stitch-up”.
Over the three days of examining witnesses, a number of key themes emerged, demonstrating widespread concerns about many aspects of the Bill.
Threat of coercion
Numerous witnesses from across different areas of expertise emphasised their serious concern over the extent to which individuals could feel coerced into an assisted suicide and how subtle coercion is extremely difficult to detect.
Disability Studies scholar at the University of Leeds, Dr Miro Griffiths, argued that society can coerce people towards assisted suicide by not providing adequate support and healthcare for disabled people. As an individual who has spinal muscular atrophy, Dr Griffiths stated that, if the Bill passes, it would create a network of practitioners sympathetic to assisted suicide, which undermines attempts to address issues of coercion.
The Head of Policy for Disability Rights UK, Fazilet Hadi, drew attention to the fact that many disabled people already feel like their lives are devalued by medical professionals. She underlined that “I do think the Bill will have a serious and profound negative impact against the valuing of disabled people’s lives”, as she told the Committee that 45% of older people have disabilities.
Other speakers expressed concern about minority groups being at particular risk of coercion. Speaking on Wednesday afternoon (29 January), palliative care consultant Dr Jamilla Hussain said that ethnic minority communities “are afraid that they are going to be targeted and they are saying that they will not access palliative care services. There are people who may want it because they feel coerced, even internally, because they feel like a burden, or due to social issues, especially those people who are structurally disadvantaged”. Her point was supported by Dr Alexandra Mullock, Senior Lecturer in Medical Law at the University of Manchester, who said that introducing assisted suicide is “absolutely a risk” to ethnic minorities.
Richard Robinson, CEO of Hourglass, a charity that campaigns against abuse of the elderly, warned that safeguarding is a significant issue and that coercion is already underplayed in cases of abuse against older people, despite the fact that 2.6 million people are affected by abuse each year. Baroness Falkner, Chair of the Equality and Human Rights Commission, underlined that coercion is often subtle and reminded MPs that lack of support could be a kind of pressure. Her point was reiterated by former Justice of the Supreme Court, Lord Sumption, who advised that coercion is extraordinarily difficult to detect. Dr Sarah Cox, President of the Association for Palliative Medicine said that “[a]fter the event, there is nobody to tell us about coercion, so it is very difficult to monitor”, reminding the Committee that the goal of assisted suicide is that the patient dies and so is not able to speak about what happened after the fact.
Even advocates for assisted suicide admitted the threat of coercion was real. Professor Aneez Esmail, trustee of assisted suicide pressure group Dignity in Dying and Professor of General Practice at the University of Manchester, could only say “I’m not saying there is no coercion, we don’t know”. Assisted suicide proponent Professor Meredith Blake, Deputy Head of the Law School at the University of Western Australia, was not concerned that 35% of assisted suicide patients in Western Australia cited “being a burden” as a reason for opting for an assisted suicide. She said “If there are people who are saying they are a burden, that does not mean that their decision is not voluntary. That does not mean that they do not have the capacity. It simply is an expression of how they feel”.
Indeed, a similar point was reiterated by pro-assisted suicide palliative care doctor, Dr Sam Ahmedzai, who said that loss of dignity and independence is “a legitimate reason for wishing that you were not a burden on somebody, or on the state even”.
Testimony from abroad repeatedly underlined problems around coercion. Professor of Law at Oxford University, Laura Hoyano highlighted a troubling statistic about coercion. In Canada in 2023, there were 41 cases where doctors determined the person had not made a voluntary request for assisted suicide/euthanasia without external pressure. Similarly, Naz Shah MP raised the issue that in Oregon, Canada, Western Australia and Washington State, between 35% to 59% of people cite being a burden as a reason for their assisted suicide/euthanasia. Alarmingly, despite such evidence, Californian GP and Senior Medical Director for Aid in Dying Service, Dr Ryan Spielvogal, claimed that coercion “just doesn’t happen”. Professor of psychiatry, Dr Gareth Owen, explained that in the UK, over 65s being treated by the NHS already “feel very burdened”.
Mental capacity assessments – is the decision for assisted suicide really voluntary?
Addressing a specific aspect of coercion, many witnesses spoke about the challenges in assessing whether a patient is making a free choice. Several said that whilst some medical colleagues are excellent at assessing a patient, others are not.
Glyn Berry, Co-Chair of the Association of Palliative Care Social Workers revealed the reality of detecting coercion, saying “[s]ome clinicians are fantastic with assessing capacity and being aware of the safeguarding aspects of situations, but not all are”. Professor Nicola Range, Chief Executive of the Royal College of Nurses also acknowledged that nurses do not always identify coercion when it takes place. Palliative care doctor, Dr Rachel Clarke, said “it is my clinical experience that not only are the majority of doctors not necessarily trained in spotting coercion explicitly, they’re often not trained explicitly in having so-called advanced care planning conversations with patients around the topic of death and dying”. She added that capacity assessments in the NHS are not “easy and routinely done well”.
Speaking specifically concerning individuals with a learning disability, Mencap’s Head of Policy and Information and Advice, Dan Scorer, said that the initial conversation about assisted suicide is potentially “an extremely risky and dangerous moment for people with a learning disability who are terminally ill”, and could be highly suggestive and push people down a course they may not want to go down.
Emeritus Professor of Psychiatry, Professor Allan House, expressed significant concern about the adequacy of the assessment proposed by the Bill. He stated that, in cases of assisted suicide, a psychological assessment would need to go beyond assessing mental illness and explore social issues like poor housing and financial insecurity, which can be related to feelings of worthlessness and low mood. Additionally, he said that the Bill does not acknowledge peoples’ psychological state. Depression is well known to be difficult to detect among the elderly, as they do not express distress as openly and obviously as younger people do. Depressive disorders are also far more common among people with a serious physical illness compared with the general population.
Sojan Joseph MP notably quoted the Royal College of Psychiatrists, which said that “65% of psychiatrists are not confident that consent can act as an adequate safeguard”. Consultant psychiatrist, Professor Gareth Owen, agreed that this is important evidence for the Committee to consider. Palliative care consultant Dr Jamilla Hussain added how even palliative care doctors sometimes make mistakes in determining mental capacity: “In the last few months we’ve had cases where we as a palliative care team thought someone had capacity, and the other team didn’t. That happens all the time in palliative care”.
Fundamental change to the doctor-patient relationship
Many witnesses spoke about the consequences of doctors raising the issue of assisted suicide with patients. Palliative care consultant, Dr Rachel Clarke, said that if a doctor brings up assisted suicide with a vulnerable patient who has just been given a terminal diagnosis, that could be a form of pressure, and the doctor could be unintentionally coercing the patient. Similarly, Chief Executive of the Royal College of Nurses, Professor Nicola Ranger, said “I don’t think it should be something that people ever say to a patient or individual, ‘is [assisted suicide] something you’ve considered?’”.
These statements felt particularly poignant in light of the observation by Danny Kruger MP that, in Leadbeater’s Bill, all doctors are indemnified against civil liability, even if they cause harm. Professor of Law at Oxford University, Laura Hoyano, agreed that this is an issue.
Proponents of the Bill were quick to argue that doctors should proactively raise the issue of assisted suicide with patients. Californian assisted suicide doctor, Ryan Spielvogal, revealed that several of his patients had no idea assisted suicide was an option, but ended up having assisted suicides after he suggested it to them. Dr Greg Mewett, an Australian palliative care doctor who has been involved with around 70 assessments for assisted suicide/euthanasia, including 30 patients who died through this means, labelled safeguards that prevent a doctor from raising assisted suicide with a patient as “impediments and barriers”.
Dr Andrew Green, Chair of the British Medical Association Medical Ethics Committee and its lead on physician-assisted dying, refused to agree to an explicit prohibition of doctors recommending assisted suicide to their patients.
Fazilet Hadi of Disability Rights UK expressed concern about giving doctors the power to steer disabled people towards assisted suicide and reminded the Committee of the dangers of treating doctors as if they are infallible on this issue. She said “I could probably get better equality at my railway station than the NHS. The days of treating doctors as the fount of all knowledge are gone – they aren’t a group that is always on the side of people with disabilities”.
The fallibility of medical professionals was also highlighted in discussions about the six-month prognosis of terminal illness currently stipulated by the Bill. Chief Medical Officer, Chris Whitty, explained that estimating how long someone has to live is “not a precise science”. Similarly, Mark Swindells, Assistant Director of the General Medical Council, said “there is inevitably a degree of uncertainty” in making judgements about how long someone has left to live”.
Notably, Dr Miro Griffiths explained that the 6-month limit is “arbitrary nonsense” because, for disabled people like him, simply removing his medical support could make him fall under the Bill’s definition of terminally ill and therefore make him eligible for assisted suicide.
Dr Annabel Price, representing the Royal College of Psychiatrists, related her experience of how people who want to die often change their minds when they get adequate pain relief. She said that “Unresolved physical symptoms make people want to die, and when that pain is better, people no longer feel that way”, reminding the Committee that even if someone decides to have an assisted suicide, they can change their minds when adequate support is provided. She added that depression is “common” near the end of life. However, if depression is treated, there is often a “significant change” in a wish to hasten death.
Conscience rights for professionals involved in assisted suicide
There were clashes among witnesses over the extent to which conscientious objection should be allowed. Chris Whitty, Chief Medical Officer said that doctors who are opposed to assisted suicide on principle should not have to be involved with referring a patient for assisted suicide to another medical professional. Chair of the British Medical Association’s Medical Ethics Committee, Dr Andrew Green, agreed saying “it is important that doctors should be able to opt out at any stage of [the assisted suicide process]”.
Danny Kruger MP, the only member of the Committee scrutinising the Bill who spoke against it at its Second Reading, reminded those present that “the great majority of doctors who work in palliative care and work with dying people remain firmly opposed to a change in the law”. This raises the question of whether people will leave the profession if they are required to be involved in assisted suicide. Dr Sarah Cox, President of the Association for Palliative Medicine (APM), spoke about how the palliative care workforce is already in crisis and that 43% of members of the APM have said they would have to leave their position if assisted suicide were implemented within their organisation.
Pro-assisted suicide witnesses argued that there should be no right to conscientious objection. Palliative care doctor, Dr Sam Ahmedzai, said assisted suicide training should be “mandatory training”. Speaking from her experience in Western Australia where assisted suicide is legal, Professor of Law, Meredith Blake, revealed that conscientious objectors in Western Australia are forced to provide information about assisted suicide/euthanasia if a patient is contemplating ending their life by state-assisted suicide/euthanasia.
Even if conscientious objection is enshrined in the Bill, Professor Nancy Preston, Associate Dean for Research & Co-Director of the International Observatory on End of Life Care at Lancaster University, observed that “People go doctor shopping—they are going to multiple doctors until they get the right answer”.
Baroness Falkner also raised concerns that legal professionals named in the Bill do not appear to have any conscience protections under its current formulation.
Inadequate resourcing for patient care
Throughout the three days, there was a substantial focus on the current lack of funding for good quality end-of-life care and the implications that this has on the legalisation of assisted suicide.
Voices representing the hospice sector echoed concern about the lack of palliative care provision. James Sanderson, CEO of the hospice Sue Ryder, said in “our survey, 77% of respondents said that they were concerned that the lack of availability of palliative care might enable more people to consider an assisted death than otherwise would. That concern went up to 84% for those who were in favour of assisted dying”.
Sam Royston, Executive Director for Policy and Research at Marie Curie warned that we know that some people will choose assisted suicide because of lack of palliative care. The crisis in palliative care cannot be the reason for introducing assisted suicide. He added that palliative care and assisted suicide are “fundamentally connected”. If palliative care is not available, people cannot make a free choice.
The CEO of Hospice UK, Toby Porter offered a similar caution. He spoke about the ways in which assisted suicide could damage palliative care provision by removing funding for the sector (charitable donations stopping because of the provision of assisted suicide), by perpetuating and reinforcing the myth that hospices hasten your journey to death, and by staff leaving the speciality because they do not want to be involved with assisted suicide in any way.
Co-Chair of the Association of Palliative Care Social Workers, Glyn Berry, warned that if assisted suicide is legalised, some people may feel driven to choose it simply because they are unable to access the palliative care they need.
Fazilet Hadi, representing Disability Rights UK, spoke about the health inequalities that exist in this country for people who are poorer and disabled. She said, “we already have an uphill struggle convincing people that our lives are of equal value, and this Bill hinders us in that aspiration and ambition, rather than helping us”.
A proponent of assisted suicide, Dr Greg Mewett, dismissed stories of patients choosing assisted suicide after unsuccessfully waiting nearly a year for care as “absolute minorities”. He also argued that assisted suicide should be considered “part of palliative care”. Psychiatry Professor, Gareth Owen, underlined that a problem with the debate about this Bill is precisely what is considered part of palliative care. He said that when people talk about assisted dying, some think that means access to palliative care rather than assisted suicide.
However, some evidence from abroad indicates worsening palliative care in places where assisted suicide has been legalised. Although Alex Greenwich, MP for Sydney, claimed that making assisted suicide and euthanasia legal has benefitted palliative care, the evidence suggests otherwise. While, in 2022, New South Wales committed to spend an extra $743 million on palliative care over five years when assisted suicide/euthanasia was legalised, in 2023 this decision was revisited and the palliative care budget was cut by $249 million in one year, resulting in cuts to palliative care staff and services. At the same time, New South Wales allocated $97.4 million in new funding over 4 years to rolling out its assisted suicide/euthanasia programme.
Danny Kruger MP highlighted how South Australia’s assisted suicide implementation should hardly be held up as an example. He noted major flaws including the lack of data on referrals for additional assessments of eligibility, decision-making capacity or reasons why people were considered ineligible. There is no provision for reporting on complications, the time between administration of the drugs and death. There is also no requirement for a doctor to be present.
Widening the scope of the assisted suicide Bill
Several witnesses to the Committee suggested that the Bill should be relaxed to allow more people to choose assisted suicide should it become law:
Sir Nicholas Mostyn, retired High Court Judge assigned to the Family Division, wants to redefine terminal illness. He wants the Bill to be for people with “intolerable suffering”, without the need to be terminally ill. Dr Jessica Khan, Medical Director of End of Life Washington, expressed concern about the Bill’s court approval safeguard will limit access to assisted suicide and suggests it should be removed. Dr Cam McLaren, Founder of Voluntary Assisted Dying Australia and New Zealand (VADANZ) and Oncologist, recommended removing waiting periods between a request of assisted suicide and it being carried out. He also argued that the 6-month requirement should be extended to 12 months. Professor Aneez Esmail, trustee of assisted suicide pressure group Dignity in Dying: “You do not want to pass a Bill that a lot of people cannot access”.
From a legal perspective, Conservative MP Danny Kruger questioned whether, under the European Convention on Human Rights (ECHR), there is a real danger that eligibility for assisted suicide would be expanded by the courts. This was supported by Alex Ruck Keene KC, who remarked “There is absolutely no way that you can stop people trying to challenge whatever Act is passed; there is no way you can stop people seeking to challenge that under the ECHR”.
A witness, whose sister would not have qualified for assisted suicide under Leadbeater’s Bill, said “I think that as it is the Bill is the best we can do at this time”, suggesting that he hopes it might expand later. Similarly, Dr Clare Fellingham, Deputy Director of Medical Services, Royal Perth Hospital, Australia, appeared to suggest these laws are a stepping stone: she said at the moment they apply to the terminally ill because that’s “easier for us to understand” and that it “would be incredibly challenging to legislate” for non-terminal illnesses such as dementia “at this early stage”.
Attention was drawn to the vagueness of the current definition of terminal illness, which witness Chelsea Roff said could allow for illnesses such as anorexia. The Executive Director of Eat Breathe Thrive, a charity supporting recovery from eating disorders, revealed at least 60 people around the world have been euthanised/assisted with suicide due to anorexia, without organ failure or comorbid terminal conditions. Ms Roff further argued that assisted suicide could be accessible to people with non-terminal, treatable conditions that would be terminal if they withheld treatment. This includes people with diabetes, HIV/AIDS and substance use disorders.
Dr Naomi Richards, Director of End of Life Studies at the University of Glasgow, called people dying from assisted suicide due to anorexia a “red herring” and a “minor issue” because the number is “really tiny”.
Flawed process and presentation of the Bill
Several witnesses also raised concerns about the process of the Bill.
Danny Kruger MP noted that the doctors who provided evidence from jurisdictions where assisted suicide is legal are all supporters and practitioners of assisted suicide. All eight witnesses invited from countries where assisted suicide has been legalised were supporters of assisted suicide, while no evidence at all was heard from Canada, the Netherlands or Belgium where there have been grave concerns about abuses and expansion of similar laws.
Baroness Falkner pointed out that there was no consultation about the Bill and said that she believed the process has not been transparent. Whilst Minister of State for Care, Stephen Kinnock MP, confirmed that the Government will publish an impact assessment before the Bill reaches Report Stage, Baroness Falkner responded that the Bill would still lack the Compatibility Assessment and the Delegated Powers Memorandum that Government Bills have.
Despite the reassurance from the Minister of State, Daniel Francis MP queried how the Committee can properly scrutinise the Bill, particularly the risks it presents to vulnerable and minority groups, without already having an impact assessment.
A number of legal concerns were highlighted too. Laura Hoyano, Professor of Law at the University of Oxford said “I have never before seen such a delegation of the most substantial procedural structures entirely to the rules of court. We don’t do it in the Family Division; we don’t do it in the Court of Protection”. Welsh legal Professor Emyr Lewis reminded MPs that the Senedd voted against assisted suicide last October. He then questioned whether it would be “prudent” or “constitutionally appropriate” for Westminster to impose assisted suicide on Wales after the Senedd’s clear rejection of the practice.
In terms of how the Bill has been presented to the public, Dr Sarah Cox, Association for Palliative Medicine President, warned that the way that assisted suicide proponents have presented being terminally ill to the public has made some people more frightened of dying than previously. She fears that this might push people toward choosing assisted suicide – even if they would not have chosen it otherwise.
Concerning change in attitudes towards suicide and family support
Emeritus Professor of Psychiatry, Professor Allan House, said that passage of Leadbeater’s Bill would mean a need to change the UK’s national suicide prevention strategy. At the moment, it includes identifying suicidal thoughts in people with severe physical illnesses as something that merits intervention, and the intervention is not an intervention to help people proceed to suicide. If this Bill were to pass, that would have to change. He also reminded the Committee that there is no evidence that introducing assisted suicide legislation reduces ‘unassisted’ suicide. In Oregon, a model for the assisted suicide Bill, since 2014 there has been a 500% increase in assisted suicides and a 20% increase in ‘unassisted’ suicides.
Alex Greenwich argued that legalising assisted suicide is a “form of suicide prevention”.
Dr Amanda Ward, whose research is part-sponsored by pro-assisted suicide campaign group Dignity in Dying, stated that assisted suicide “is the same as any other healthcare choice”, ignoring the fact that assisted suicide ends the suffering of a patient by ending the life of the patient, rather than by alleviating symptoms or healing the patient.
In addition to changing attitudes to suicide, witnesses also touched upon a change in family involvement with patients considering assisted suicide. Californian GP and Senior Medical Director for Aid in Dying Service, Dr Ryan Spielvogal, wants to make it illegal for families to try and persuade their relatives out of ending their life through assisted suicide.
