TERMINALLY ILL ADULTS (END OF LIFE) REPORT STAGE
15 May 2025
To the residents of Lowestoft, Beccles, and the villages,
Tomorrow, the Terminally Ill Adults (End of Life) Bill returns to the Commons chamber for Report Stage. As you may know, I have become increasingly concerned by this Bill and what it will mean for the most vulnerable as it has moved through the Parliamentary process. I remain unconvinced that this Bill will be safe for the public if it were to become law and, indeed, I believe it has only become less safe since Second Reading due to the removal of the role of the High Court Judge.
I want to start by recognising why many reach for a right for doctors to help take their life. It is understandable that those who live with pain, care for someone in pain, or simply want to avoid pain are motivated by a compassionate desire to take that pain away. I too could imagine a time where I might wish for a painless release at the time of my choosing. But as a Member of Parliament, I do not legislate for my own personal interests, nor that of my family, I do so for every person across the country. As John Donne famously put it: No man is an island, entire of it itself; every man is a piece of the continent, a part of the main. As a Labour MP I proudly represent a party which has the principles of collective solidarity, caring for the vulnerable and disadvantaged, and the commitment to reducing social inequality and injustice at its core. I am therefore incredibly conscious of vulnerable people who lack, in reality, a true choice and who, if this legislation passes, may die an avoidable and premature death.
It is no coincidence that those who are most worried about this Bill already face deep structural discrimination in our society: disabled people, older people, victims of abuse, and those from ethnic minority backgrounds. Likewise, those who work most intimately with the terminally ill and those who would provide specialist care as part of the assisted dying process also have expressed strong concerns. The Royal College of Psychiatrists for a number of reasons has taken a stance against this Bill, notably because it allows those with the physical side-effects of a mental disorder to qualify for an assisted death – including anorexia, for example. The British Geriatrics Society opposes the Bill, arguing that ‘the risk for safeguard failure is at least moderate in a modern, well-run AD service which we find unacceptable when considering the needs of older people’. The Association for Palliative Medicine opposes this legislation in part due to ‘the lack of adequately funded and equally available palliative care services’ and ‘concerns about trust and the impact on doctor-patient relationships’. Marie Curie, not taking a view on the Bill, nevertheless notes that ‘genuine choice at the end of life cannot exist unless dying people are able to choose to receive high quality palliative and end of life care’.
Given my background working with vulnerable women, I am particularly concerned about the impact this Bill will have on victims of domestic abuse. It seems inevitable to me that this legislation will be weaponised by perpetrators to exact a final act of control: coercing, either directly or indirectly, their victim to take their own life. Police data shows that 242 deaths a year are linked to domestic abuse – including homicides, suicides, staged suicides, and so-called ‘mercy-killings’. This number, sadly, will just be the tip of the iceberg. Analysis by the women’s organisation The Other Half suggests that, if the UK follows Australia and 1.65% of all deaths occur via assisted dying, between 500 and 1,400 domestic abuse victims could die each year through the process. The notion of ‘choice’, attractive in principle, in practice meets the limitations of what ‘choice’ actually means for those unable to freely choose.
I was glad that the Bill Committee agreed to my amendments that require the medical practitioners and panel members involved in the assisted dying process to undergo domestic abuse training. I am incredibly concerned, however, that the Government’s Impact Assessment of the Bill suggests that in practice all professionals involved other than the coordinating doctor would receive training that consists of a 90-minute e-learning module followed by a 60-minute interactive session. This is the opposite of what I intended when I laid those amendments, and no domestic abuse specialist would agree that two and a half hours of training is sufficient to actually safeguard against abuse. Sadly, we know that this is exactly what has happened in Australia where domestic abuse training makes up only a part of a single 40 to 60 minutes of self-guided e-learning.
Sometimes, the only person who may know if someone is being coerced or abused or suffering from a bout of mental ill-health is another family member. But this Bill actively excludes those around the person requesting an assisted death from the panel process, and many families will only hear that their loved one has decided to end their own life after it is too late. That is why I have submitted new amendments at this stage to require all the professionals involved in the process to ask the person whether they have discussed their desire with their family and if not, why not.
This Bill overwhelmingly targets two groups – older people and disabled people. These groups are particularly vulnerable to abuse and coercion, including by strangers or new partners, as with ‘cuckooing’. We know that older people are disproportionately the victims of severe abuse: over-60s make up over 25% of all domestic homicides despite only accounting for 18% of the general population. Older victims of abuse are less visible to professionals and others, and are more likely to hide their abuse and stay with their abusers. A prominent campaigner in favour of the Bill has argued that “Even if a few grannies get bullied into it, isn’t that a price worth paying for all the people who could die with dignity?” To that person I say no – we should not, as a society, endorse the notion that wrongful deaths are ‘worth it’ in the pursuit of any policy.
I know of no disability organisation which supports this Bill. The Government’s own Equality Impact Assessment for this Bill makes clear the point that disabled people are at a heightened risk of feeling like a burden and being subtly influenced by social pressures and a lack of appropriate services and support into choosing to die – a concern echoed by UN human rights experts. Disabled people rightly fear that, given society already views their lives as ‘lesser’, there might be a lack of professional curiosity if a disabled person was to request an assisted death and, as a result, a failure to uncover coercion.
We cannot say that we give people a free choice at the end of life if we already fail to offer them appropriate care. Much-needed palliative care can, in the vast majority of cases, manage the pain those with serious conditions may experience. Some of the most difficult personal stories I have heard from constituents reflect a serious failure of care, and, in some cases, medical negligence and the contravention of NICE guidelines. Palliative care experts, including the Association for Palliative Medicine’s Race Equity Committee, have also raised concerns that this Bill will ‘significantly’ set back efforts to build trust with ethnic minority communities. People from those backgrounds are already more likely to have low confidence in palliative care and often report thinking it involves shortening their lives, and this legislation risks pushing many further away from the high-quality palliative care they need and deserve. Indeed, the palliative care consultant Jamilla Hussein has argued that ‘the inclusion of AD within NHS settings could generate fear, leading some people [from ethnic minority backgrounds] to avoid healthcare services altogether’.
‘Self-perceived burden’ (SPB) is a common phenomenon in those with advanced or terminal illnesses, and it can often lead to a desire to die. This Bill not only validates that symptom but inevitably encourages it. Of those who received an assisted death in Oregon in 2021 (the jurisdiction which most influenced this Bill), 54% gave the reason that they felt like a burden and 8% had financial concerns. It is inevitable that people will choose an assisted death rather than burden their family with the financial costs and emotional toll of care, and studies suggest that there can often be a gendered dimension to this.
It should be noted that having a mental illness – including severe depression – does not disqualify someone from being eligible for an assisted death. The Bill also allows those with treatable and reversible conditions – such as anorexia nervosa – to qualify if their illnesses are left untreated. Imagine, for example, that this Bill passes and we are faced with two suicidal eighteen-year-old girls. The first is cutting her wrists, and so we treat her as a victim of her mental illness and try to get her the psychological help she needs to save her life. The second is starving herself and refuses food from doctors who tell her that her organs are beginning to shut down and she will likely die soon – to her we offer her the assistance and means to end her life. We know that globally, at least 60 people with eating disorders have been able to access an assisted death, two thirds under the age of 40.
If this Bill passes, we end up in a situation of trying to differentiate ‘good’ suicidal thoughts from ‘bad’ suicidal thoughts. The Government’s suicide prevention adviser, Professor Louis Appleby has warned that this Bill may undermine suicide prevention efforts: ‘I’m worried that once you say some suicides are acceptable, some self-inflicted deaths are understandable and we actually provide the means to facilitate [it]’. I believe it is dangerous to fundamentally change the responsibility we have to look out for every other human, to offer support, hope, and love.
This is not just a moral and societal change – it is a legal one. This Bill gives a future Secretary of State the power to change the foundational document of our National Health Service without Parliamentary oversight or approval. It will eradicate the core purpose of the NHS to preserve and enhance life that has stood the test of time since 1946 when a pioneering Labour Government decided that all of us should hold responsibility for caring for each other and the state should ‘free of charge’ ensure ‘improvement in the physical and mental health of the people […] and the prevention, diagnosis, and treatment of illness’. The Bill will also allow assisted dying to be delivered by private providers for profit, despite a wealth of research which consistently has shown that for-profit care, particularly where private equity is involved, delivers worse outcomes for patients.
The Bill requires those requesting an assisted death to have six months to live, but there is no medical consensus on what that means or looks like. Research has shown that doctors wrongly predict how long terminally-ill patients will survive in over half of cases. Government data shows that one in five people given a ‘six months to live’ prognosis are still alive three years later. Given the Government’s Impact Assessment estimates that up to 4,559 people will receive an assisted death within a decade, that suggests that as many as 1,500 of those could have lived for much longer than six months. Indeed, it is a prognosis that may push people to want to end their lives prematurely, when they could have had years more to spend with their loved ones.
Since I last wrote to you ahead of Second Reading, the Bill has undergone substantive revision by its sponsor. One of the largest changes has been the removal of the High Court Judge approval stage, which has been replaced by a panel of three people – a legal member, a psychiatrist, and a social worker. The Bill, however, is clear that the legal member of this panel does not act as a judge, and these panels will not have the powers or functions of a court or tribunal, and witnesses (including the medical professionals involved in the process) will not give evidence under oath and cannot be compelled to attend. The panel does not have to ask questions of any witnesses and there is no cross-examination which might elicit insight of possible coercion. Only the applicant can appeal the decision of the panel to reject their application; there is no route for family and friends who may be concerned about their loved one being coerced into an assisted death to challenge the approval. The Royal College of Psychiatrists have said that there are not enough psychiatrists to meet the demand of this Bill, and the Government’s Impact Assessment also noted the high vacancy rate of social workers. These panels then, with little real power and overstretched members, will undoubtedly become little more than a rubber-stamping exercise.
I am likewise concerned by changes to the Bill that create a Voluntary Assisted Dying Commissioner, appointed by the Prime Minister of the day. This Commissioner will not only run the system but also take over the responsibility of the Chief Medical Officers to oversee and regulate it. It is patently not right that one person – unaccountable to Parliament and only able to be removed by ministers – marks their own work.
Like many medical professionals, I am concerned that the Bill Committee rejected an amendment to stop doctors from being able to raise assisted dying with patients who have not raised it themselves. We already know that doctors hold great sway over vulnerable people in their care, and even a suggestion may be taken as a recommendation and subtly and unintentionally coerce the patient into choosing death. Likewise, the Committee rejected an amendment to stop doctors from raising assisted dying with those under eighteen. Young people are impressionable, and I am concerned that this will set us on the path of other countries, such as the Netherlands and Switzerland, which have, over time, allowed children to access an assisted death. Belgium, for example, has no minimum age requirement. For the safety of our most vulnerable young people, we must not follow suit.
I recognise that many people who believe in the principles of choice and autonomy think this Bill is a progressive, liberal thing to do. But the reality is: this Bill is not progressive. There is nothing progressive about giving perpetrators of domestic abuse a new way to kill their victims. There is nothing progressive about helping a suicidal person starving themselves to death to kill themselves quicker. There is nothing progressive about disabled people being told by society that their lives are lesser, and therefore not worth living.
This has consistently been promoted as an issue of ‘choice’ – but what true choice does a suicidal person have? What choice does an older victim of domestic abuse have when, for decades, they have incessantly been made to feel less than worthless? What choice does a grandparent have when care fees would swallow up their family’s savings?
‘Choice’ is a fallacy here. We do not live in an ideal world of equal paths and starting positions – we live in an imperfect world, and those imperfections – amplified by a state-run system to end lives – will be devastating. Those cracks we see in our daily lives will become chasms for vulnerable people in a world where this life-or-death decision hangs over them – and many of them will fall through.
Supporting this Bill would require me to make the utilitarian argument that those vulnerable people, who will wrongfully die because of the assisted dying process, are collateral damage to the greater good of autonomous people being able to have the choice of when they should die. I cannot in all good conscience support that. To return to John Donne: Any man’s death diminishes me, because I am involved in mankind. And therefore never send to know for whom the bell tolls; it tolls for thee.
I am grateful for those who have been in contact with me on this incredibly important issue; I’d encourage constituents to continue to do so by emailing me at jess.asato.mp@parliament.uk or writing to me at Jess Asato MP, House of Commons, London, SW1A 0AA.
Kind regards,
Jess