what is Kim Leadbeater proposing?

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With less than three weeks until MPs will be asked to debate and vote on her Bill, Kim Leadbeater has finally published the text of her ‘Terminally Ill Adults (End of Life) Bill’. Amidst busy schedules, this hardly seems a reasonable time frame for MPs to consider what Ms Leadbeater herself said is ‘potentially one of the most important changes in legislation that we will ever see in this country.’ And over 3,400 health professionals agree that ‘The shift from preserving life to taking life is enormous and should not be minimised’ so the minimal time afforded for MPs to consider this ahead of the second reading hardly seems proportionate.

But here we are. What is actually being proposed? Who will be eligible? What professionals will be involved? As I have read the Bill attempting to answer these questions, I have not found safeguards that reassure me that this Bill will thoroughly protect vulnerable groups or the doctor-patient relationship.

The bill seeks to amend the Suicide Act 1961 so that ‘encouraging or assisting suicide’ will no longer be illegal if it is done in accordance with this new Act.

who would be eligible?

To be eligible one must be 18 or older, an ordinary resident of England or Wales (for 12 months), registered with a GP in England or Wales and have a ‘clear, settled and informed wish to end their own life.’ There are also some other stipulations that are no doubt supposed to act as reassuring safeguards.

The patient must be:

1. terminally ill (but the definition has worrying holes)

This is defined as someone having ‘an inevitably progressive illness, disease or medical condition which cannot be reversed by treatment’, and which can reasonably be expected to cause the patient’s death within six months.

Here we find the first hole in these supposedly robust safeguards. Clinicians are not good at estimating prognoses, particularly for those who are neither imminently dying (who wouldn’t have time to apply for assisted suicide) nor expected to live for ‘years’. Predicting survival in the middle group (those with weeks or months to live – exactly those whom this Bill hopes to define) is the most hazardous, with a 2023 study finding only 32 per cent accuracy.

Furthermore, the Bill could also include others whom we wouldn’t initially consider. What about a patient after a renal transplant who says they plan to refuse to take any more of their anti-rejection drugs, for example? They have an inevitably progressive illness that cannot be reversed by treatment, and if they refuse other (slowing but not curing) treatments (which is already their legal right), they would reasonably be expected to die within six months. The potential application of the Bill, even before challenges are inevitably made over whether this arbitrary six-month limit is fair, may be considerably broader than some initially imagine.

2. have capacity and make the request voluntarily (but how will we know, and is that enough?)

The patient must be assessed as having capacity (as defined in the Mental Capacity Act 2005). Capacity is a very low bar. The first and second assessing doctors are not required to assess the patient’s mental state more broadly. There is no requirement to look for evidence of depression, for example. Patients who are currently detained under the Mental Health Act to prevent them from committing suicide are likely to retain the capacity to consent to medical treatments. Assuming they met the other criteria, would they be considered eligible under this Bill? The whole idea of assessing someone’s capacity to end their life by suicide is relatively new ground, as ‘capacity’ is not a generic quality but specific to each issue or decision being considered by the patient.

The patient must also be deemed to be requesting assisted suicide ‘voluntarily’, not having been ‘coerced or pressured by any other person’ into the request. To coerce or pressure someone towards suicide is deplorable, and the Bill acknowledges this both in this requirement and in making it an offence to ‘by dishonesty, coercion or pressure’ induce someone to apply for or progress with Assisted Suicide under the Bill. But it still seems hopelessly naïve to conclude that the inclusion of these safeguards will prevent some who are being coerced from taking up Assisted Suicide.

How is the doctor supposed to exclude coercion? The doctors are asked to sign statements saying:

To the best of my knowledge, the patient –

(a) has a clear, settled and informed wish to end their own life, and

(b) made the first declaration voluntarily and has not been coerced or pressured by any other person into making it.

This rather reminds me of a declaration one might be asked to sign when selling a house saying, ‘to the best of my knowledge, the garden is free from Japanese Knot Weed’! Ultimately the homeowner is saying nothing more than, ‘I haven’t instructed a Knot Weed expert to search for it (no one asked me to), but I’ve not seen any.’ When the danger is a coerced suicide, the parallel is rather more chilling. Doctors are not trained to detect coercion. Nor in the busy, underfunded NHS will they have much time to look for it thoroughly. This declaration seems to amount to little more than an acknowledgement that the doctor hasn’t personally seen any coercion in whatever time they were with the patient (and perhaps family, though they may not have met any relatives at all). Is this really the watertight safeguard we were promised?

what professionals would be involved?

While the Bill does not give a duty to every health professional to raise the subject of Assisted Suicide with terminally ill patients, it explicitly allows medical practitioners to decide if and when it is appropriate to discuss assisted suicide with them. If passed, this Bill would make it explicit that your doctor or nurse could decide to bring up the topic of assisted suicide with you, even if you’ve never asked about it. Could your doctor offering you assisted suicide as a treatment option actually be considered coercive in itself (even while the Bill attempts to make coercion illegal)?

No health professional will be required by the Bill to undertake the assessment or deliver the drugs for a patient to use in assisted suicide. However, if a patient requests assisted suicide, a medical practitioner must ‘refer them to another registered medical practitioner whom the first practitioner believes is willing and able to conduct that discussion’. This amounts to the requirement for ‘effective referral’, which, when enacted in Canada, caused regulatory bodies to threaten severe punishments on individuals who refused to do so.

Patients who show no sign of wanting to die could have assisted suicide raised as an option for their consideration. This introduces the troubling possibility of a doctor asking a patient to consider if they might, in fact, be better off dead. And patients who express they want to be considered for assisted suicide must be referred to someone willing to assess them and organise the drugs for them if they pass the assessment, even if their doctors would find this wholly incompatible with their duty to act only in the best interests of their patients. This is not the opt-in model the BMA’s Medical Ethics Committee recommended if a law were to be introduced.

The Bill requires two doctors to make assessments, the ‘coordinating doctor’ first and then (after the patient has had a seven-day period of reflection) they refer to the ‘independent doctor’ (who is not from the same practice or team) to check they agree. If the assessors are not sure if the patient meets the criteria of being terminally ill, they can ask for an opinion from an expert in the disease in question and if they’re not sure about capacity, they can ask a psychiatrist about this.

The coordinating doctor must explain to the patient the diagnosis, prognosis, any treatment available, and its likely effects. They should also explain and discuss ‘any available palliative, hospice or other care, including symptom management and psychological support’ – there is no mention of the options that could be but aren’t available to patients due to the chronic under-resourcing of both palliative care and psychological services. Finally, they need to explain what drugs they would be given to assist their suicide, how the drugs will bring about death and also what they would want to happen if there are complications (such as the cases of vomiting or seizures reported from Oregon) after the drugs are given.

After the two doctors offer approval, a High Court Judge reviews and signs it off and following a 14-day period of reflection (reduced to 48 hours if death is reasonably expected within a month) then the patient can be provided with drugs to end their life by suicide. The coordinating doctor, or someone with their delegated authority, can then prepare the drugs and take them to the patient. They can assist them to ingest or otherwise self-administer the drugs, but the final act should be the patient’s.

The coordinating doctor should then remain present (though they might be in a different room) until the patient either dies or they declare that ‘the procedure has failed’. Oregon’s 2023 data shows the longest duration from ingestion to death as 137 hours (5.7 days). Amongst a litany of more significant concerns, this might appear rather impractical.

There is more to be said about the detail of this Bill – it runs to over 30 pages (with another 20 pages of explanatory notes) but I have attempted to draw out some of the major features, including implications for health professionals following an initial digestion. I am quite sure there will be more to consider, but given the short time made available for the Bill’s consideration, it seems urgently important to begin this conversation around the specific proposals in the bill, several of which I find deeply concerning.

Our Duty of Care (a group of health professionals from any or no faith background who oppose assisted suicide and euthanasia) are holding a webinar tomorrow evening for health professionals who wish to discuss the details further. Sign up here.