assisted suicide uk essay

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Should assisted dying be legalised?

• Thomas D G Frost 1 ,
• Devan Sinha 2 &
• Barnabas J Gilbert 3  

Philosophy, Ethics, and Humanities in Medicine volume  9 , Article number:  3 ( 2014 ) Cite this article

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When an individual facing intractable pain is given an estimate of a few months to live, does hastening death become a viable and legitimate alternative for willing patients? Has the time come for physicians to do away with the traditional notion of healthcare as maintaining or improving physical and mental health, and instead accept their own limitations by facilitating death when requested? The Universities of Oxford and Cambridge held the 2013 Varsity Medical Debate on the motion “This House Would Legalise Assisted Dying”. This article summarises the key arguments developed over the course of the debate. We will explore how assisted dying can affect both the patient and doctor; the nature of consent and limits of autonomy; the effects on society; the viability of a proposed model; and, perhaps most importantly, the potential need for the practice within our current medico-legal framework.

Introduction

Over the past two centuries, the United Kingdom has experienced rapid population growth associated with a substantial decline in mortality from acute infectious diseases and poor nutrition [ 1 ]. As the average life expectancy has increased, so too have the rates of debilitating chronic illness – particularly coronary artery disease and cancers [ 2 ]. These diseases require years of treatment instead of the mere days to weeks that medicine once operated within [ 2 ]. Although healthcare systems have sought to adapt to such changes, aiming to prevent and treat such disease wherever possible, debate has arisen regarding those patients in the latter stages of chronic, incurable, terminal conditions [ 3 , 4 ]. Moreover, there is increasing recognition that the patient must be at the centre of health care decision-making, such that outcomes must be tailored to their individual needs and views. By extension, assisted dying might seem a logical step to help achieve these goals within the realm of end-of-life decision making [ 5 ]. Several jurisdictions, notably Oregon (1997) and the Netherlands (2001) have already legalised assisted dying in some form. These factors have contributed to ongoing legislative discussions within Parliaments for almost a decade, with current opinion polling suggesting a majority of medical practitioners and the public in favour of physician-assisted suicide [ 6 ].

Viability of assisted dying in practice

In the UK, a model for assisted dying has been developed from the legal structure found within the Assisted Dying Bill introduced by Lord Falconer in the House of Lords in 2013 [ 7 ]. Assisted dying could only be considered under circumstances in which a patient of legal age is diagnosed with a progressive disease that is irreversible by treatment and is “reasonably expected to die within six months” [ 7 ]. Registered medical practitioners would make such decisions for patients with terminal illnesses. Addressing the technicalities of ‘assisted dying’ requires distinction between ‘physician-assisted suicide’ (offering patients medical actions or cessation of actions by which they can end their own life) and ‘euthanasia’ (whereby the medical practitioner actively induces death). In light of the strong hostility of the medical profession towards active euthanasia, this proposed model, as with previous attempts to legalise assisted dying, permitted only the former [ 8 – 10 ].

However, there is concern that such distinction may be unrealistic in practice because medical practitioners could find themselves with a patient who had failed to successfully end their own life and was subsequently left in a state of greater suffering. Were such a patient no longer able to give consent, a heavy burden would then be placed on the physician regarding how to proceed. Moreover, the practice of physician-assisted suicide might be deemed discriminatory, for example by giving only patients with good mobility control over their own method of death.

The Assisted Dying Bill 2013 included the provision that any terminal prognosis must be confirmed and attested by a second registered practitioner. The strictness of such criteria has parallels to a similar double-physician requirement when procuring a legal abortion under the 1967 Abortion Act. The stated aims of the provision in both cases are as follows: first, to check the accuracy of the prognosis upon which the decision was being made; second, to ensure that the situation meets the required criteria; and third, to check that such a decision was taken by the patient after full consideration of all available options [ 11 , 12 ]. By having a second independent doctor, the legislation ensures that all three checks are met without prejudice or mistake.

Problematic for any protocol for assisted dying is the fact that estimates of life expectancy in terminal prognoses are erroneous in 80.3% of cases [ 13 ]. Furthermore, the accuracy of such prognoses deteriorates with increased length of clinical predicted survival. Forecasts of survival times are based largely on past clinical experience, and the inherent variability between patients makes this more of an art than a science. This brings to concern both the accuracy of any prognosis meeting the six-month threshold and the validity of requests for assisted dying based partly or wholly on predicted survival times. Whilst the majority of errors in life expectancy forecasts are a matter of over-optimism and hence would not affect either of those two concerns, many cases remain unaccounted for. Overly pessimistic forecasts occur in 17.3% of prognoses; hence we must decide whether the one in six patients making a decision based on an inaccurate prognosis is too high a cost to justify the use of this system. Patients requesting an assisted death often cite future expectations of dependency, loss of dignity, or pain [ 14 ]. If the hypothetical point at which the progression of their illness means they would consider life to be not worth living is not, as informed, mere weeks away but in fact many more months, then this information would have resulted in a different decision outcome and potentiated unnecessary loss of life.

Whilst the presence of a second doctor would be expected to mitigate such forecasting errors, the anchoring bias of the initial prediction may be enough to similarly reduce the accuracy of the second estimate. It is prudent to question the true independence of a second medical practitioner, and whether this second consultation could become more of a formality, as has now become the case with abortion [ 15 ].

Another challenge for an assisted dying system would be to recognise whether patients requesting death were legally competent to make that decision. Consider that any request for suicide from a patient with clinical depression is generally categorised as a manifestation of that mental disorder, thereby lacking capacity. It is arguably impossible to separate out the natural reactions to terminal illness and clinical depression. Indeed, there is evidence that major depressive disorders afflict between 25% and 77% of patients with terminal illness [ 16 , 17 ]. Any protocol for assisted dying must first determine what qualifies as a ‘fit mental state’ for a terminal patient.

The need for assisted dying

It could be argued that a doctor’s fundamental duty is to alleviate forms of suffering in the best interests of the patient. The avoidance of physical pain, as an obvious manifestation of suffering, might explain why assisted dying would be both necessary and within the duties of a doctor to provide. The evolving principle in common law known as the ‘Doctrine of Double Effect’ offers a solution to this problem [ 18 ]. This legal judgement stated that “[a doctor] is entitled to do all that is proper and necessary to relieve pain even if the measures he takes may incidentally shorten life”. This entails that a protocol already exists for patients searching for an escape from chronic pain. Furthermore, numerous retrospective studies have revealed very little correlation between opioid dose and mean survival times: one study of over 700 opioid-treated patients found that the variation in survival time from high-dose opioid treatment is less than 10% [ 19 – 21 ]. It can therefore be said that pain alone, if appropriately managed, should never be cause for considering assisted dying as an alternative.

By contrast, the ‘Doctrine of Double Effect’ might be seen as a subjective interpretation that has been applied unequally due to a lack of specialist training or knowledge [ 22 ]. Despite this, the principle can be easily understood and poor awareness can be remedied by improvements in medical education and standardisation of protocols. Moreover, should we choose to accept arguments for assisted dying that are based upon inadequate administration of pain medication, we set a precedent for conceding shortcomings in palliative care and other end-of-life treatments. Offering hastened death could become an alternative to actively seeking to improve such failings.

Whilst much has been made of the ‘pain argument’ here, the call for assisted dying is rarely this simple. Many patients also suffer a loss of dignity, often due to their lack of mobility – the inability to relieve oneself without help is a potent example. Beyond this are additional fears of further debilitation and the emotional costs of dealing with chronic illness, both for the patient and for their relatives and friends. A study of terminal patients in Oregon showed that these were the most significant reasons behind requests for assisted suicide, the next commonest reason being the perception of themselves as a ‘burden’ [ 14 ]. Clearly, we could seek to provide balanced, compassionate medical care for these patients, and still fail to address these points.

Developments in healthcare and technology may reduce this emotional burden, but remain an imperfect solution.

Rights of patients and limitations of their autonomy

J.S. Mill’s pithy dictum describes autonomy as follows: “over himself, over his own body and mind, the individual is sovereign” [ 23 ]. Not only has the sanctity of bodily autonomy profoundly influenced the development of liberal democracies, it has also provoked a holistic shift in making our healthcare systems more patient-centred – “care that meets and responds to patients’ wants, needs and preferences and where patients are autonomous and able to decide for themselves” [ 5 ]. The ethical principle of controlling the fate of one’s own body is inherently relevant to the debate on assisted dying. It is difficult to reconcile that citizens may have the right to do almost anything to and with their own bodies– from participating in extreme sports to having elective plastic surgery – yet a terminal patient cannot choose to avoid experiencing additional months of discomfort or loss of dignity in their final months of life.

Expectation of individual liberty has been codified in law. The right to bodily autonomy has been interpreted to be included under Article 8 - the right to privacy - of the European Convention on Human Rights (ECHR) and subsequently the Human Rights Act (HRA) [ 24 , 25 ]. Moreover, the ECHR underpins the right of individuals to ‘inherent dignity’ [ 26 ]. Hence, if an individual feels that dignity is unattainable due to the progression of a terminal illness, then taking recourse though assisted dying ought to be a legitimate option.

Conversely, there are two notable oversights in this interpretation of a right to assisted dying as an extension of the principles of bodily autonomy:

First, it would be wrong to view individual liberty as absolute. The HRA allows for exceptions to Article 8 on grounds of ‘health or morals’ [ 25 ]. The principle of autonomy is not inviolable. Governments have limited such privileges for the protection of individuals and society, for example by criminalizing the use of recreational drugs or the selling of one’s own organs. The preservation of life by denying assisted dying could fall within this category.

Second, the right of autonomy is not necessarily intrinsic to human beings but, as Kant argued, is dependent on our ‘rational nature’ [ 27 ]. This concept sees autonomy as an exercise of ‘evaluative choice’ [ 27 ], requiring rationality on the part of individuals to appreciate the nature of options and their consequences. To achieve true autonomy, there must be sufficient information to make those rational decisions; this is the basis of informed consent and why it is a fundamental duty of a doctor to offer a patient an informed series of treatment options [ 28 ]. The logistical issue is that doctors are unable to advise patients regarding the point at which their situation becomes less preferable to being dead. No doctor (or individual) has any knowledge or experience of what ‘death’ may be like. Hence, in this case, the idea of exercising true autonomy through informed consent might be considered meaningless.

Legalising assisted dying by attempting to establish an absolute right to bodily autonomy may undermine other individual and group rights. Vulnerable patients may feel pressured into assisted dying because of social, emotional, or financial strains placed on family and/or friends. This is exemplified by the trend showing that the proportion of patients stating ‘relief of burden’ on others as the reason for requesting assisted dying has risen from 17% to 25% in Oregon since legalisation [ 29 ]. One could even consider the risk of assisted dying becoming an expected choice rather than a free one. Thus, assisted dying may erode the elemental right to life of terminal patients as the value of their life becomes tied to relative costs to society and to those around them.

Moreover, by creating one class of individuals for whom life is expendable, that particular view may be extended by society to all groups possessing such attributes (e.g. the permanently disabled). There would be a definite risk to the rights of these vulnerable groups in the form of society being less willing to provide for their health and social care.

It is often raised that the limited legalisation of assisted dying would inevitably become extended in scope, but this is not necessarily a flaw. Even if the right to determine the manner of death were later extended to a wider group of people, posterity may reflect positively on such a change, just as extending the franchise to women ultimately led to legislation demanding equal pay.

Effect on health professionals and their role

‘To act in the best interest of the patient’ is often cited as a central duty of the doctor [ 28 ]. This concept of ‘best interest’ guiding the doctor’s action has seen the development of two important ethical principles: beneficence and non-maleficence. Beneficence mandates that the actions of the doctor must be aimed to bring about benefit (clinical improvement) for the patient, usually measured in terms of reduced morbidity or mortality; non-maleficence requires that the doctor not carry out treatment that is likely to cause overall harm the patient [ 30 ]. These traditional ethical imperatives on a doctor both conflict with intentionally hastening the death of a patient, and a resolution of this tension would require redefining what constitutes ‘acting in the best interest’.

A further dimension is the potential reluctance of health professionals to engage in a practice that contravenes their own ethical beliefs, particularly as this would affect doctors who never entered training in the knowledge that assisting patients to die would be an expected duty. This is certainly no argument against the introduction of assisted dying; indeed, a recent survey of a cohort of NHS doctors found that 46% would seriously consider requests from patients to undertake steps to hasten death [ 31 ]. It merely expresses the point that any early model would have to account for the fact that an initial 54% of the doctors in the NHS would be required to advise qualifying patients of assisted dying as a legitimate option, despite disagreeing with it in principle.

Furthermore, doctors who agree ethically with this practice may find themselves facing conflicts of interest. It is expensive to treat chronically ill patients, particularly in the final months of life [ 32 ]. Moreover, it would be difficult for commissioners to ignore the fact that the sustained treatment of one individual could deprive many others from access to surgery or access to novel drugs. Such an argument does not suggest that doctors or any other hospital staff would treat this practice without appropriate respect or care; rather it acknowledges the need for appropriate rationing of care and questions the intentions of service providers. The perception of an ulterior motive could negatively impact patient trust. One survey showed that a reasonable minority of patients (27%) – and particularly particularly the elderly – believe that legalising assisted dying would lessen their trust in their personal physician [ 33 ]. The costs of weakened trust in the doctor-patient relationship could far outweigh the benefits of assisted dying, particularly given the importance of trust when treating a chronic patient for an extended period of time.

There is no doubt that assisted dying would empower some patients to maximise control over the timing and manner of their own death. Such expression of autonomy would surely solidify moves towards a patient-centred approach to healthcare. However, the capacity for such consensual requests remains in doubt. Clinically, the patient’s state of mind and the reliability of diagnostic predictions are of issue; philosophically, the idea of informed consent for death is contradictory. The implications for patients, physicians and society have been weighed extensively within this article. The central tenet throughout has been the balancing of an individual’s right to escape a circumstance that they find intolerable, alongside the consequential changes to their other rights, and the rights and responsibilities of third parties. Ultimately, the challenge is for us as a society to decide where this balance lies.

About the debate

The Varsity Medical Debate was started in 2008 with the aim of allowing students, professors and members of the polis, to engage in discussion about ethics and policy within healthcare. Utilising the age-old rivalry between the two Universities, the debate encourages medical students from both Oxford and Cambridge to consider and articulate the arguments behind topics that will feature heavily in their future careers.

The debate was judged on the logic, coherence, and evidence in arguments, as well as flair in presentation. Although the debaters may not have necessarily agreed with their allocated side, the debate format required them to acknowledge a particular school of thought and present the key arguments behind it. Oxford, who opposed the motion, was awarded the victory in the debate; however, this does not mean that the judges believe that position ought to become public policy.

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Acknowledgements

For Cambridge University: Hilmi Bayri (Trinity), Alistair Bolger (Jesus), Casey Swerner (St Johns).

For Oxford University: Devan Sinha (Brasenose), Thomas Frost (Lincoln), Collis Tahzib (Lincoln).

Martin Farrell (Cambridge).

Baroness Finlay: Professor of Palliative Care Medicine and former President of the Royal Society of Medicine.

Dr. Roger Armour: Vascular Surgeon and Inventor of the Lens Free Ophthalmoscope.

Mr. Robert Preston: Director of Living and Dying Well.

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All authors planned and elucidated the layout. TDGF and DS drafted the manuscript which was critically edited and added to by BJG. All authors have read and approved the final draft.

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Frost, T.D.G., Sinha, D. & Gilbert, B.J. Should assisted dying be legalised?. Philos Ethics Humanit Med 9 , 3 (2014). https://doi.org/10.1186/1747-5341-9-3

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Received : 12 November 2013

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DOI : https://doi.org/10.1186/1747-5341-9-3

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King's College London

An evidence-based approach to assisted dying.

11 May 2022

Stephen Matthews, Faculty Communications Manager

How do we clarify the law on Assisted Dying? Research by Professor Penney Lewis has contributed directly to legal changes in Australia and Canada, and significantly influenced debates in Ireland, and in England and Wales.

22 November 2017: Jaala Pulford is congratulated by Harriet Shing MP and Fiona Patten MP after the Parliament of Victoria’s Upper House voted to pass historic euthanasia laws. Victoria will be the first state in Australia to offer an assisted dying regime. (Photo by Scott Barbour/Getty Images)

The debate on medical assistance in dying (MAiD) – sometimes referred to as physician-assisted dying - raises important questions regarding consent, autonomy, and our criminal justice system, as well as the potential wider impact on society if we allow some individuals to end others’ lives. With MAiD already legal in some countries, and pressure in others to allow patients to opt for physician-assisted death in some circumstances, research by Professor Penney Lewis, from The Dickson Poon School of Law (prior to her appointment as a Law Commissioner) has provided the public, courts and policymakers with an informed critique of the options for regulation.

Her research into the evidence from jurisdictions where MAiD is permitted, conducted over the past 15 years, has demonstrated the importance of the route to decriminalisation; assessed the effectiveness of different legal and regulatory regimes; and successfully challenged a common argument against the practice.

Different paths

Different jurisdictions have found different ways to allow MAiD. In some countries, constitutional courts have found that individuals have a right to end their lives; in others, criminal courts have reinterpreted existing defences to criminal charges; in a third group, specific legislation has been passed.

Evidence from these different jurisdictions provides valuable insights for countries still debating the issue. To interpret this data meaningfully, however, it is essential to understand each approach in the context of the legal framework in which it exists.

Professor Lewis looked at the regulatory systems employed in Belgium, the Netherlands, Switzerland and the US state of Oregon, and assessed the informal, or ‘soft law’, approach adopted in England and Wales.

England and Wales - a ‘soft law’ approach

Assisted dying remains illegal in England and Wales, but the 2010 policy on assisted suicide, published by the Director of Public Prosecutions (DPP) and Crown Prosecution Service, advises against prosecution if “the victim had reached a voluntary, clear, settled and informed decision to commit suicide”, and any person assisting was “wholly motivated by compassion”.

Debbie Purdy, pictured outside Parliament in July 2009. Purdy, who suffered from multiple sclerosis, addressed the media following a historic decision by the Law Lords to clarify the law on assisted suicide.

Where it is suggested assistance was provided, the decision whether or not to prosecute rests with the DPP.

In 2011, Lewis published Informal Legal Change on Assisted Suicide: The Policy for Prosecutors (Legal Studies). She found the system adopted in England and Wales was flawed. Lewis concluded that the system’s focus on those helping, rather than the ‘victims’, together with the apparent desire to avoid appearing to create a regulatory regime, had facilitated suicide in cases that would not have been permitted by most regimes, while also exposing helpers to the risk of prosecution. Elements of the DPP’s guidance, Lewis found, resulted in an “amateur” approach: the involvement of inexpert individuals resulting in a higher risk of botched suicides.

Lewis recommended a twin-track approach, which would shift the focus to assessing cases before suicide is assisted, while also providing stronger scrutiny of cases after the assisted suicide has taken place. This stronger post-suicide scrutiny would still not necessarily result in prosecution.

Assessing a range of safeguards

In 2012, Professor Lewis and Isra Black, co-authored an expert briefing paper for the Commission on Assisted Dying, The effectiveness of legal safeguards in jurisdictions that allow assisted dying .

The authors identified eight types of safeguard, and looked at evidence from The Netherlands, Belgium, Switzerland and the American state of Oregon.

For their conclusions to be meaningful, they argued, the data from these jurisdictions had to be “understood in the context of the different legal and regulatory frameworks in operation in these countries.” Having explained these systems, they looked at the effectiveness of different safeguards in different jurisdictions, and made recommendations on “how these regimes could implement and regulate assisted dying more effectively.”

This briefing paper significantly influenced the debate on policy in England and Wales. In 2013, Lord Falconer, who had chaired the Commission on Assisted Dying, introduced the Assisted Dying Bill into the House of Lords, but the Bill ran out of time due to the 2015 General Election. In 2020, Lord Falconer introduced a new Bill .

A key element in Lewis and Black’s briefing paper had been the rebuttal of the “slippery slope” argument.

The Slippery Slope

Opponents of assisted dying have argued that legalisation is a “slippery slope”, often pointing to the example of The Netherlands.

In The Netherlands, euthanasia has been lawful since the 1970s. Doctors have used a statutory defence of necessity to avoid prosecution in cases where they had provided MAiD, justifying their involvement as a necessary step to prevent suffering.

In the early cases in which the necessity defence was used, the patient had requested MAiD. The same defence was then used to permit MAiD in cases where the patient was unable to communicate.

One of Lewis’ most important conclusions was that the use of the defence of necessity in the second set of cases was not evidence of a slippery slope. Instead, she argued, the two sets of cases were underpinned by the same principle – that Dutch doctors have a duty to relieve suffering. The acceptability of this defence in cases involving an incompetent patient was explained by the Dutch system’s focus on doctors’ duties, rather than patients’ rights.

Based on the data from Belgium and The Netherlands, Lewis’ research also concluded that there was no evidence that legalisation had led to either non-voluntary euthanasia or increases in the overall rate of assisted dying.

The impact of this argument in Canada

In Canada, Lewis’ argument was influential in a landmark decision by the Supreme Court, which led to the decriminalisation of assisted suicide in Canada in June 2016.

Lewis acted as an expert witness for the claimants Kay Carter and Gloria Taylor, both of whom were suffering from degenerative diseases. The claimants argued that the ban on assisted dying ran counter to the Canadian Charter of Rights and Freedoms.

The Canadian Government argued that decriminalisation would make it impossible to protect vulnerable people and that the country would descend into condoning murder.

Lewis’ affidavit drew on her original research, including her rebuttal of the ‘slippery slope’ argument and her evidence from the Netherlands of a decline, since legalisation, of life-ending acts without explicit request. Her affidavit was cited eleven times in the Court’s judgment to rebut the slippery slope argument.

The British Columbia Supreme Court’s decision was overturned on appeal but, in 2015, the Supreme Court of Canada overturned the appeal decision on the basis that since their earlier decision in 1993 in Rodriguez , there had been “a change in the evidence that fundamentally shifts the parameters of the debate”. The Supreme Court of Canada concluded: “… The trial judge, after an exhaustive review of the evidence [which included Lewis’s affidavit], rejected the argument that adoption of a regulatory regime would initiate a descent down a slippery slope into homicide… We find no error in the trial judge’s analysis”.

Since decriminalisation, over 13,000 Canadians have received MAiD, and medical practitioners can prescribe or administer drugs without fear of prosecution.

The Canadian experience has informed the debate in a number of other countries.

In Australia, the importance of Lewis’ research was acknowledged in legislative reports from the Australian States of Victoria and Western Australia, where assisted dying was legalised in 2017 and 2019 respectively. In Ireland, Lewis’s research also provided important evidence for the parliamentary debate on the Dying with Dignity Bill 2020. The Bill, which is currently progressing through the legislature, allows individuals to assist those meeting the qualifying criteria to achieve a dignified and peaceful end of life.

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Assisted dying: what are the laws in UK and what changes are proposed?

Scotland could become first part of UK to offer terminally ill adults assistance to end their lives if Holyrood approves bill

• UK politics – latest updates

A new bill to legalise assisted dying in Scotland has been published at Holyrood by the Scottish Liberal Democrat MSP Liam McArthur, in a fresh attempt by supporters to get the measure enacted for the first time in the UK.

What are the laws on assisted dying?

Assisting or encouraging another person to take their own life is an offence in England, Wales and Northern Ireland, with a maximum prison sentence of 14 years. In Scotland , helping someone to kill themselves could lead to prosecution for crimes such as murder, culpable homicide or other offences.

What is being proposed across the UK?

McArthur’s bill, which will offer terminally ill adults assistance to end their lives, is expected to be scrutinised by MSPs on Holyrood’s health committee and could be voted on by MSPs at its first stage later this year.

Proposals to legalise assisted dying for people who are terminally ill or have an incurable condition with unbearable suffering in Jersey – one of the UK’s three self-governing crown dependencies – will be debated in the states assembly in May , with a vote on whether to proceed with drawing up legislation.

An assisted-dying bill is also passing through the Isle of Man’s parliament, with further debate scheduled for April.

What is happening at Westminster?

In February, a report by MPs on the health and social care committee warned that approaches to this “difficult, sensitive and yet crucial” issue could soon diverge across the UK, and called on the Westminster government to be “actively involved in discussions”.

Keir Starmer has said he is “committed” to allowing a vote on decriminalising assisted dying should Labour win the general election. Downing Street has previously said it would be up to parliament to decide whether to debate assisted dying again. The last vote was held in 2015, when the Commons decided against changing the law by 330 votes to 118.

Does the bill reflect a change in public mood?

McArthur said cross-party support for his bill indicated that “politicians are catching up with where the public has been for some time”, citing polling for Dignity in Dying Scotland that found 78% of respondents supported legalisation.

There have been growing calls for a change in the law, with interventions from celebrities such as Esther Rantzen, who has described the UK government’s law on assisted dying as a “mess” , as well as individuals like Paola Marra, who spoke to the Guardian last week before she ended her life at the Dignitas clinic in Switzerland after suffering with terminal stage 4 bowel cancer since 2021.

The British Medical Association and the Royal College of Physicians in recent years ended their opposition to assisted dying and instead adopted neutral positions, with increasing numbers of doctors now endorsing the measure.

Another poll carried out by Opinium Research on behalf of Dignity in Dying this month, canvassing the views of more than 10,000 people across the UK, found that 75% of respondents would support making it lawful for dying adults to access assisted dying in the UK.

What are the concerns about assisted dying?

Some faith groups, disability rights campaigners and medical professionals continue to raise significant concerns about the effect of a law change on vulnerable, sick and dying people who fear becoming a financial or emotional burden on their loved ones. They prefer to characterise the process as “assisted suicide” and some have criticised the Holyrood bill for “euphemistic language”.

Healthcare professionals at the organisation Our Duty of Care, the British Islamic Medical Association, the Better Way campaign, Disability Equality Scotland and many others expressed their opposition to McArthur’s billafter its publication.

Dr Gillian Wright, a former palliative care registrar who is part of the Our Duty of Care campaign, spoke out against the proposals: “The primary danger of assisted suicide is that individual lives are devalued by society because they are ill, disabled, confused, or that their contribution to society is perceived to be minimal.

“We are encouraged that ordinary doctors and nurses from across Scotland have joined together to send a definite message to MSPs. We do understand that there is suffering at the end of life, but this should drive us as a society not to provide assisted suicide, but instead well-funded, accessible, high-quality palliative care for all.”

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Assisted Suicide and the European Convention on Human Rights

News articles.

Locating assisted suicide within the broader medical end-of-life context and drawing on the empirical data available from the increasing number of permissive jurisdictions, this book provides a novel examination of the human rights implications of the prohibition on assisted suicide in England and Wales and beyond. Assisted suicide is a contentious topic and one which has been the subject of judicial and academic debate internationally. The central objective of the book is to approach the question of the ban’s compatibility with the European Convention on Human Rights afresh; freed from the constraints of the existing case law and its erroneous approach to the legal issues and selective reliance on empirical data.

The book also examines the compatibility of the ban on assisted suicide with rights which have either been erroneously disregarded or not considered by either the domestic courts or the European Court of Human Rights. Having regard to human rights jurisprudence more broadly, including in the context of abortion, the research and analysis undertaken here demonstrates that the ban on assisted suicide violates the rights of a significant number of individuals to life, to freedom from torture or inhuman or degrading treatment and to private life. Such analysis does not depend on a strained or contrived approach to the rights at issue. Rather, the conclusions flow naturally from a coherent, logical application of the established principles governing those rights.

While the focus of the book is the Suicide Act 1961, the conclusions reached have implications beyond England and Wales, including for the other devolved jurisdictions and international jurisdictions. Beyond courts and legislators, it will be a valuable resource for students of human rights and medical law, as well as medical and legal practitioners and academics working in human rights and end-of-life care.

For more information about this book, please refer to the Routledge website . For information about other publications by Dr Martin, see her  Faculty profile .

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Hundreds of terminally ill Brits take their own lives in UK each year, latest estimates suggest

Press release | 17th October 2021

• As Parliament prepares to debate Assisted Dying Bill on Friday, new research reveals hidden truth about drastic measures dying people forced to resort to under assisted dying ban
• New estimates suggest 300-650 dying citizens take their own lives every year, with 3000-6500 attempting to do so, in addition to 50 Brits a year who travel to Switzerland for assisted death
• 7 in 10 Brits believe there is distinction between assisted dying and suicide, polling published today reveals
• 7 in 10 feel suicide prevention measures should not stop terminally ill people seeking assisted death

Hundreds of terminally ill Brits take their own lives each year in this country under the ban on assisted dying, latest estimates reveal today (Sunday 17 October 2021), with thousands more attempting to do so. As Parliament prepares to debate assisted dying legislation for the first time in six years on Friday (22 October 2021), new Dignity in Dying research uncovers the drastic measures many dying people feel forced to resort to in the UK under the current law.

The report, Last Resort: The hidden truth about how dying people take their own lives in the UK , for the first time brings together estimates from multiple sources, which suggest that between 300 and 650 terminally ill people take their own lives in the UK each year, with between 3,000 and 6,500 attempting to do so. This is in addition to the 50 Brits who travel to Switzerland for an assisted death each year on average, and 6,400 dying people who would suffer in pain in their final months in the UK even if there was universal access to palliative care.

This comes as the Assisted Dying Bill is due to receive its Second Reading in the House of Lords on Friday 22 October 2021. Assisted dying is currently banned in England and Wales under the 1961 Suicide Act, which carries a maximum jail term of 14 years.

The private member’s bill, proposed by Dignity in Dying chair and crossbench peer Baroness Meacher, would legalise assisted dying as a choice for terminally ill, mentally competent adults in their final months of life alongside existing end-of-life care options, enabling them to die in a manner and at a time of their choosing.

Polling conducted by YouGov, published today1 as part of Dignity in Dying’s new report, reveals that seven in 10 (73%) Brits recognise that there is a distinction between a terminally ill adult seeking assistance to end their life, and suicide. Around seven in 10 (68%) do not believe suicide prevention work should include trying to prevent terminally ill people from seeking an assisted death. Having been informed about the proposals in Baroness Meacher’s Bill, seven in 10 (73%) recognise that the most appropriate title for the legislation is the Assisted Dying Bill, with just one in 10 (10%) believing it should be called the Assisted Suicide Bill.

Polling released yesterday2 (16 October 2021), also by YouGov, found that half of Brits have personally experienced a loved one suffering at the end of life (52%). Seven in 10 (74%) call for Parliament to back the Assisted Dying Bill and want to see assisted dying legalised before the next general election (70%). Zoe Marley, 53 from Cromer, who is featured in the report, experienced the death of her mother from skin cancer in 2018 and the death of her husband Andrew from colon cancer in June 2021.

“By the end, my mother’s cancer had spread from her heel all the way to her brain and she was in terrible pain. Mum was determined not to let the cancer do its worse; that she would construct some kind of escape. Because she had no other viable alternative, she attempted to take her life out in the garden, alone.

“When we discovered her she was still breathing, and as it began to grow cold I rang an ambulance to help move her inside. I told them of Mum’s clearly defined wish not to be revived and showed them the legally-binding documents to prove it, but they would not listen. A doctor was called, who threatened me and called the police. Paramedics, doctors and police officers were all in my garden arguing about what to do, as my Mum lay dying on the ground.

“Hours later Mum regained consciousness and was in emotional and physical agony. She had written heartfelt notes to us, which the police confiscated. A few weeks later, Mum did finally manage to escape her pain. I was questioned by police for hours and made to sign a five page statement. Then she was subjected to an autopsy; the final insult.

“Eleven months later my husband Andrew was diagnosed with colon cancer. His death this year was full of horror, pain and indignity; we crossed every line we didn’t want to cross. I cannot put into words how different it would have been for them and for our family if my Mum and my husband could each have been assisted to go peacefully as they wished, and with the dignity they deserved.”

Dr Julian Neal, 66, retired GP from Sussex, was also interviewed for the report. He said:

“To deny patients the choice of an assisted death when we know that a significant minority of deaths are wretched, no matter how expert the provision of palliative care, seems to me utterly wrong. But this is what I was forced to do when asked for help to die by a patient with advanced metastatic melanoma. He was intelligent and knowledgeable about what lay ahead, wanting to avoid a lingering demise. I explained that I was unable to help him due to the very real threat of imprisonment. I was later horrified to learn that he had shot himself.

“An assisted dying law would provide a kinder, safer alternative which I and a growing number of doctors would be prepared to be involved in; a welcome and much-needed change from the cruelty of our current system.”

Marjorie Wallace CBE, Chief Executive of mental health charity SANE, said:

“Assisted dying and suicide are fundamentally different concepts, requiring fundamentally different responses. SANE’s experience and research shows that acute and chronic mental illness can drive a person to attempt to take their own life, but that many people are grateful to have a second chance and access to medical and therapeutic treatments. However, for people with terminal illnesses where death is inevitable and may be traumatic, assisted dying can offer an important choice.

“Suicide prevention efforts are designed to prevent loss of life and are therefore not an appropriate reaction to the desire of a terminally ill, mentally competent person to control the manner and timing of an unavoidable death. It does a disservice to both suicide prevention and to end-of-life care to conflate shortening life with shortening death. Recognition of this distinction is essential in order to ensure everyone receives optimal care and support for their needs.”

Sarah Wootton, Chief Executive of Dignity in Dying, said:

“This new research reveals that the UK’s blanket ban on assisted dying is not only uncompassionate but deeply unsafe and unequal. Denied the safe, legal choice they want in this country – with Dignitas only open to those with the funds or strength to travel – hundreds of terminally ill people every year are resorting to taking their own lives in violent and extreme ways, leaving untold devastation for loved ones, local communities and first responders.

“We need more robust data to understand the full extent of this problem, we need clearer guidance for health and care professionals on how to have open, honest conversations, and we need better guidance for police officers who are called to investigate suspected breaches of the 1961 Suicide Act.

“Most importantly, we call urgently for a change in the law to give terminally ill, mentally competent adults the choice of an assisted death alongside all current end-of-life care options, as proposed in the Assisted Dying Bill due for debate in the House of Lords on Friday. This Bill represents a safer, fairer, more compassionate response to the desire of many terminally ill citizens for greater choice at the end of their lives, providing comfort and helping to prevent the horrific deaths outlined in our report.”

For more information, photos or interview requests with Dignity in Dying spokespeople, Baroness Meacher, mental health experts or people with personal experiences, please contact Ellie Ball, Media & Campaigns Manager, at [email protected] or 07725 433 025.

Notes to Editor

Last Resort: The hidden truth about how dying people take their own lives in the UK A condensed version of the report can be accessed here: www.dignityindying.org.uk/lastresort

The full version can be accessed here: https://www.dignityindying.org.uk/wp-content/uploads/Last-Resort-Dignity-in-Dying-Oct-2021.pdf

YouGov polling

All figures, unless otherwise stated, are from YouGov Plc.

1. Total sample size was 1,767 adults. Fieldwork was undertaken between 12th – 13th August 2021. The survey was carried out online. The figures have been weighted and are representative of all GB adults (aged 18+).

2. Total sample size was 1,733 adults in GB. Fieldwork was undertaken between 7th – 8th October 2021. The survey was carried out online. The figures have been weighted and are representative of all GB adults (aged 18+).

Estimates on the number of terminally ill Brits who take and attempt to take their own lives every year

Dignity in Dying has for the first time brought together existing attempts to estimate the number of deaths recorded as suicides that involve terminally ill people. This includes Freedom of Information requests, localised public health audits and studies of coroner records as well as initial findings from the Office for National Statistics. Together they suggest that an indicative range of between 5% and 10% of suicides in the UK involve dying people, equating to between 300 and 650 cases a year. Notably, this estimate is consistent with more robust data collected by coroners courts in Australia. The report recommends that more accurate data must now be a priority for the UK.

A further problem highlighted in the report is the number of dying people who make an attempt on their own life that does not work as intended. Dignity in Dying conservatively estimates (based on statements from the World Health Organisation) that this affects up to ten times as many people, equating to between 3,000 and 6,500 cases a year.

More data on the numbers of terminally ill people who take their own lives is expected from the Office for National Statistics later this year, after the former Health Secretary Matt Hancock announced he had commissioned the research at a meeting of the All Party Parliamentary Group on Choice at the End of Life in April 2021.

Dignity in Dying campaigns for greater choice, control and access to services at the end of life. It campaigns within the law to change the law, to allow assisted dying as an option for terminally ill, mentally competent adults with six months or less to live.

Assisted dying is prohibited in England and Wales under the Suicide Act (1961), and in Northern Ireland under the Criminal Justice Act (1966) which states that anyone who “encourages or assists a suicide” is liable to up to 14 years in prison. There is no specific crime of assisting a suicide in Scotland, but it is possible that helping a person to die could lead to prosecution for culpable homicide.

Assisted Dying Bill

Baroness Meacher’s Assisted Dying Bill was selected seventh in the House of Lords private members ballot in May and received its First Reading on Wednesday 26th May 2021. It will receive its Second Reading on Friday 22 October 2021. The full text can be found here: https://bills.parliament.uk/bills/2875. It is based on a bill introduced by Lord Falconer in 2014. Rob Marris MP introduced a similar bill in 2015 which was defeated in the Commons.

The functioning of the current law on assisted dying was the subject of a Backbench Business Committee Debate in July 2019 and a Westminster Hall debate in January 2020, at which a majority of MPs speaking called for a review of present legislation.

Assisted Dying Scotland Bill

Liam McArthur, Lib Dem MSP for Orkney, lodged the ‘Assisted Dying Scotland’ Members Bill proposal with the Non-Government Bill Unit (NGBU) of the Scottish Parliament in June 2021. A Consultation on the contents of the bill launched in September 2021.The proposal seeks to introduce the right to choose an assisted death for terminally ill, mentally competent adults in Scotland.

Jersey’s citizen’s jury on assisted dying

The States of Jersey are expected to debate assisted dying proposals in November 2021, after a citizen’s jury strongly recommended a change in the law to enable islanders who are terminally ill and unbearably suffering to be able to request medical assistance to end their own life. As British Crown Dependencies, Jersey, Guernsey and the Isle of Man are each able to legislate on assisted dying independently from the rest of the British Isles.

Healthcare professionals

The British Medical Association (BMA) last month (Tuesday 14 September 2021) voted to drop its official opposition to a change in the law on assisted dying in favour of neutrality, following a debate at its Annual Representative Meeting.

The largest ever poll of British doctors on assisted dying, conducted by the BMA in February 2020, results of which were released in October 2020, found overwhelming support for a change to the BMA’s current stance of opposition to an assisted dying law (61%), and that half of doctors personally support a change in the law (50%).

In March 2019, the Royal College of Physicians (RCP) dropped its longstanding opposition to assisted dying in favour of neutrality following a member survey.

The Royal Society of Medicine, Royal College of Nursing (and Royal College of Nursing Scotland), the Royal College of Psychiatrists and the Royal Pharmaceutical Society all also hold neutral positions on assisted dying.

The Academy of Medical Royal Colleges, Association of British Neurologists, General Medical Council, General Pharmaceutical Council, Royal College of Anaesthetists, Royal College of Obstetricians and Gynaecologists, Royal College of Ophthalmologists, Royal College of Paediatrics and Child Health, Royal College of Pathologists, Royal College of Physicians of Edinburgh, Royal College of Radiologists and Royal College of Surgeons of Edinburgh have no stated position on a change in the law on assisted dying.

In September 2020, Eminent GPs Prof Aneez Esmail and Sir Sam Everington launched a legal challenge to the Royal College of GPs (RCGP) alongside the Good Law Project and Dignity in Dying over RCGP Council’s decision to maintain opposition to assisted dying despite its own survey showing a dramatic shift in GP opinion. The Association for Palliative Medicine and the Royal College of Surgeons of England also hold a stance of opposition to a change in the law on assisted dying.

International developments

In the US, assisted dying as an option for terminally ill, mentally competent adults in their final months of life is legal in 11 jurisdictions: Oregon (1997), Washington, Vermont, Montana, the District of Columbia, California, Colorado, Hawaii, New Jersey, Maine and New Mexico (legislation approved April 2021). In Australia, assisted dying is a legal choice for terminally ill citizens in Victoria (June 2019), Western Australia, Tasmania, South Australia and Queensland (legislation approved September 2021). A bill has also been tabled in New South Wales.

New Zealand is set to implement an assisted dying law allowing this option for terminally ill, mentally competent citizens in November 2021, following a public referendum on the End of Life Choice Act in October 2020.

Spain passed a law allowing assisted dying in March 2021 to be implemented later this year.

In Ireland, assisted dying is set to be examined by a Special Oireachtas Committee, as recommended by the Justice Committee in July 2021.

Austria’s Supreme Court ruled in December 2020 that its blanket ban on assisted dying is unconstitutional and the practice will be decriminalised in limited circumstances by 2022.

Germany began considering potential assisted dying legalisation in January 2021 after its Constitutional Court struck down the ban in 2020.

Canada introduced assisted dying legislation in 2016 permitting those suffering from a grievous and irremediable medical condition.

In Colombia legislation was passed in 2015 which permits those with terminal illness or unbearable suffering to request access to life-ending medication.

Assisted dying is permitted in Switzerland, including for foreign nationals, and broader right-to-die laws are in place in Belgium, the Netherlands and Luxembourg.

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• v.92(4); 2019 Dec

Focus: Death

Pros and cons of physician aid in dying, lydia s. dugdale.

a Department of Internal Medicine, Columbia University, New York, NY

Barron H. Lerner

b Department of Medicine and Population Health, New York University, New York, NY

Daniel Callahan

c formerly of the Hastings Center, Garrison, NY

The question of a physician’s involvement in aid in dying (or “assisted suicide”) is being debated across the country. This article adopts no one position because its authors hold contrasting views. It aims instead to articulate the strongest arguments in favor of aid in dying and the strongest arguments opposed. It also addresses relevant terminology and reviews the history of its legalization in the United States.

Physician aid in dying is a controversial subject raising issues central to the role of physicians. According to the American Medical Association, it occurs when a physician provides “the necessary means and/or information” to facilitate a patient’s choice to end his or her life [ 1 ].

This essay’s authors hold varying views on the ethics of aid in dying; thus, the essay explores the subject without taking a position. It addresses its terminology; history of legalization in the United States; arguments in favor of aid in dying; and arguments opposed.

Terminology

Physician aid in dying goes by many names. Perhaps the best recognized is “physician-assisted suicide.” Alternative terms include but are not limited to: death with dignity, doctor-prescribed death, right to die, and physician-assisted death. For simplicity’s sake, we use aid in dying (AID), although we recognize that there will be some who object, no matter the label.

A variety of factors have led to these various neologisms. Supplanting the word “physician” with “medical,” for example, makes it possible for non-physician clinicians to prescribe the lethal medications. Some advocates of AID prefer not to use the term “suicide;” they contend that AID is a medical practice, distinct from the act of suicide for a depressed or hopeless person [ 2 ]. By contrast, opponents maintain that the process of prematurely and deliberately ending one’s life is always suicide, regardless of motivation. Some insist that dissociating “physician-assisted suicide” from other types of suicide demeans those who die by suicide for other reasons, as if only medically-assisted suicides are legitimate [ 3 ]. People on both sides of the issue worry whether “aid in dying” or “assisted dying” might be confused with palliative, hospice, or other care of dying patients.

In the United States, physician-assisted suicide or aid in dying has always been carefully distinguished from euthanasia. Euthanasia, also called mercy killing, refers to the administration of a lethal medication to an incurably suffering patient. It may be voluntary (the patient requests it) or involuntary. Euthanasia is illegal in the United States, but voluntary euthanasia is legal in Belgium, Colombia, Luxembourg, and Canada. It is decriminalized in the Netherlands.

At risk of compounding terminology further, Canada legalized in June 2016 “medical assistance in dying” (MAiD), which includes both “voluntary euthanasia” and “medically-assisted suicide [ 4 ].”

A Brief History of Legalization in the United States

In the early 1900s, advocates argued forcefully for legalizing euthanasia, which was already being secretly practiced in the US. According to Jacob Appel’s work on this period, the eugenics movement strongly influenced discourse on euthanasia, and opponents of legalization tended to put forth practical rather than religious or moral arguments [ 5 ]. When efforts to legalize euthanasia failed, public discourse on the subject waned for many decades.

In the 1980s, the pathologist Jacob “Jack” Kevorkian began advertising in Detroit area newspapers as a death counselor [ 6 ]. He had studied the technique of Dutch physicians in the Netherlands, and created his own device with which patients could self-administer lethal medications. His first patient ended her life in 1990 while lying on a bed inside Kevorkian’s Volkswagen van. He went on to assist with some 130 deaths by suicide over the next eight years. In 1999, after Kevorkian publicly distributed a video of himself directly euthanizing a patient, he was convicted of second-degree murder and sent to prison. Although Kevorkian reignited national debate about dying, his off-putting approach and personal idiosyncrasies prevented his becoming a national leader on the issue.

Several of Kevorkian’s physician contemporaries filed suit against New York’s Attorney General, arguing that the State of New York’s prohibition against physician-assisted suicide violated the Equal Protection Clause of the Fourteenth Amendment. They argued, in effect, that the right to refuse treatment was effectively the same as the right to end one’s life. The Supreme Court ruled in response in Vacco v. Quill (1997) that there is no constitutionally-protected right to die. It left such decisions to the states. The Court also ruled in Washington v. Glucksberg (1997) that a right to aid in dying was not protected by the Due Process Clause.

Oregon became the first to pass its death with dignity law that same year. More than a decade later, Washington legalized AID in 2008. Montana decriminalized the practice a year later. Vermont legalized it in 2013.

In 2014, a young Californian named Brittany Maynard was diagnosed with an astrocytoma and became a spokesperson for the legalization of AID. She was a newlywed facing terminal illness, and her story quickly captured the public imagination. Her well-publicized death by lethal ingestion in Oregon in 2014 influenced her home state of California to legalize AID in 2015. This was subsequently followed by Colorado in 2016, the District of Columbia in 2017, Hawai'i in 2018, and New Jersey and Maine in 2019.

Pro Arguments

The two most common arguments in favor of legalizing AID are respect for patient autonomy and relief of suffering. A third, related, argument is that AID is a safe medical practice, requiring a health care professional.

Respect for Patient Autonomy

Bioethics as a discipline gained significant traction in the 1970s, at a time when the concept of patient rights was pushing back against physician paternalism. The philosophers Tom Beauchamp and James Childress, in their well-known textbook Principles of Biomedical Ethics, advanced four fundamental principles as a framework for addressing ethically-complex cases: autonomy, beneficence, non-maleficence, and justice. Of these principles, autonomy undeniably exerts the most influence on current US medical practice [ 7 ].

Autonomy refers to governance over one’s own actions. In the health care setting, this means a patient determines which medical interventions to elect or forgo. Patient autonomy serves as the justification for informed consent; only after a thorough explanation of risks and benefits can the patient have the agency to make a decision about treatments or participation in medical research. This logic, it is argued, naturally extends to AID; patients accustomed to making their own health care decisions throughout life should also be permitted to control the circumstances of their deaths.

Relief of Suffering

At its core, medicine has always aimed to relieve the suffering of patients from illness and disease. In the West, Hippocrates’s ancient oath pledged to use treatments to help the sick, but not “administer a poison to anybody when asked to do so [ 8 ].” In contrast, advocates of AID argue that relief of suffering through lethal ingestion is humane and compassionate – if the patient is dying and suffering is refractory. Indeed, some of the most compelling arguments made in favor of AID come from patients, such as Maynard, who suffer from life-threatening illnesses.

A Safe Medical Practice

Aid in dying is lauded by advocates for being a safe medical practice – that is, doctors can ensure death in a way that suicide by other means cannot. Aid in dying thus becomes one option among many possibilities for care of the dying. Although individual state laws vary, most propose a number of safeguards to prevent abuses and to provide structure for an act that some people will do anyway, albeit more haphazardly or even dangerously. Safeguards include requiring that a patient electing AID be informed of all end-of-life options; that two witnesses confirm that the patient is requesting AID autonomously; and that patients are free of coercion and able to ingest the lethal medication themselves [ 9 ].

Con Arguments

Although opponents of AID offer many arguments ranging from pragmatic to philosophical, we focus here on concerns that the expansion of AID might cause additional, unintended harm through suicide contagion, slippery slope, and the deaths of patients suffering from depression.

Suicide Contagion

The sociologist David Phillips first described suicide contagion in the 1970s. He showed that after high profile suicides, society would witness a broad spike in suicides [ 10 ]. This was particularly true for individuals whose demographic profiles were similar to those of the person who died by suicide [ 11 ]. Although Phillips’s work did not focus on AID, it has been corroborated recently by the spike in youth suicidality following the airing of Netflix’s 13 Reasons Why [ 12 ].

The publicly-available data from Oregon, however, reveal that in the months surrounding Maynard’s high-profile death in November 2014, the number of similarly situated individuals in Oregon who ended their lives by lethal ingestion more than doubled. Furthermore, from 1998 (when Oregon started recording data) to 2013, the number of lethal prescriptions written each year increased at an average of 12.1%. During 2014 and 2015, however, this increase doubled, suggesting that high-profile AID leads to more AID [ 13 ]. Although the data do not prove that an increase in AID causes more non-assisted suicide, a study by Jones and Paton found that the legalization of AID has been associated with “an increased rate of total suicides relative to other states and no decrease in non-assisted suicides [ 14 ].” They suggest that this means either AID does not inhibit non-assisted suicide or that AID makes non-assisted suicide more palatable for others.

Slippery Slope

Some opponents of AID express concern that once doctors are involved in the business of hastening patients’ deaths; they have already slid down the slippery slope [ 15 ]. Others suggest that the slope is best exemplified by an expanding list of reasons for electing AID. Refractory physical pain is no longer the most compelling reason for ending one’s life through lethal ingestion. Instead, cumulative Oregon data suggest that the vast majority of patients elect AID because they are concerned about “losing autonomy” (90.6%) or are “less able to engage in activities making life enjoyable” (89.1%). Some fear a “loss of dignity” (74.4%); being a “burden on family, friends/caregivers” (44.8%); or “losing control of bodily functions” (44.3%). Concern about inadequate pain control was the reason for pursuing a lethal ingestion in only 25.7% of cases [ 16 ].

Opponents also point to increasing calls in the US for euthanasia. In 2017, Senate Bill 893 was introduced to the Oregon State Legislature; it would have enabled patients to identify in a legal directive the person they wished to administer their lethal medications, effectively legalizing euthanasia [ 17 ]. Although this bill failed, the Oregon House passed HB2217 in 2019, which expanded the definition of “self-administer” to include options in addition to the oral ingestion of lethal drugs. The House also put forward HB2903, which seeks to expand the word “ingest” for lethal medication to “any means” and also proposes to expand the definition of “terminal disease” to include “a degenerative condition that at some point in the future” might cause death. It remains to be seen whether Oregon will become the first state to legalize euthanasia.

Although Belgium and The Netherlands permit both AID and euthanasia, the latter dominates. Over the years there has been a steady increase in acceptable criteria. Currently, patients who suffer from depression, dementia, or being “tired of life” may be euthanized. In some cases, minors may also be euthanized [ 18 ]. Published data from the Flanders region of Belgium highlights that vulnerable populations are especially likely to be euthanized. From 2007 to 2013, the largest increases in rates of granting euthanasia requests were among women, those 80 years or older, those with lower educational achievement, and those who died in nursing homes [ 19 ].

Depression in Advanced Illness

Up to half of patients with cancer suffer from symptoms of depression [ 20 ]. The elderly also suffer from high rates of depression and suicide [ 21 ]. Because depression often manifests somatically [ 22 ], if patients are not screened, clinicians miss half of all cases of clinical depression [ 23 - 25 ]. Opponents of AID are concerned that in Oregon, greater than 70 percent of patients who elect AID are elderly and have cancer, but fewer than five percent are referred to a psychiatrist or psychologist to rule out clinical depression.

Physician AID remains a controversial subject relevant to the care of patients. The Hippocratic model dominated medical practice for thousands of years. With the rise of euthanasia in Europe during the second half of the twentieth century, many began to rethink this stance, but hastening the death of patients still sits uncomfortably with many physicians. Although a number of medical societies have begun to reconsider their positions, the American Medical Association’s House of Delegates voted in June 2019 to maintain the organization’s long-held opposition to physician-assisted suicide and euthanasia [ 26 ]. Strong arguments remain both in favor and in opposition to the practice, and physicians have an ethical responsibility to remain informed on this timely issue.

Additional Information

Co-author Daniel Callahan, PhD, died after the first submission of this article.

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• Medical aid in dying is not assisted suicide . Compassion & Choices , 2016. https://www.compassionandchoices.org/wp-content/uploads/2016/07/FS-Medical-Aid-in-Dying-is-Not-Assisted-Suicide-FINAL-11.22.16-Approved-for-Public-Distribution.pdf Accessed January 19, 2017.
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• Senate Bill 893 . Oregon State Legislature , 2017. https://olis.leg.state.or.us/liz/2017R1/Measures/Overview/SB893 Accessed April 30, 2019.
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• https://www.medpagetoday.com/meetingcoverage/ama/80384

Is the UK any nearer to making assisted dying legal?

• Assisted dying
• Wednesday 15 May 2024 at 3:51pm

The Isle of Man has come one step closer to legalising assisted dying after the wording of the island's Assisted Dying Bill was debated on Tuesday.

Dr Alex Allinson, who is behind the Bill, said that after extensive debate and evidence taken from expert witnesses, the island's parliament, House of Keys (MHKs), approved "another landmark step in delivering assisted dying".

In the first stage of debate on the clauses stage of the Bill last week, MHKs voted that a person seeking an assisted death should have been resident on the island for five years instead of one, and that the life expectancy criteria be extended from six months to a year.

In Jersey, in the Channel Islands, there have been clashes over the island's proposed assisted dying law .

So, as several parts of the British Isles edge closer to legalising assisted dying, where does the UK stand? And what about the rest of Europe?

What is assisted dying?

The exact definition of assisted dying - sometimes referred to as assisted suicide or voluntary euthanasia - is still debated among medical professionals, and each term has a slightly different meaning, but broadly speaking it is the process of helping a person to end their life.

The NHS describes euthanasia as "the act of deliberately ending a person's life to relieve suffering".

Assisted suicide meanwhile is "the act of deliberately assisting another person to kill themselves".

Is it legal in the UK?

Both euthanasia and assisted suicide are illegal under current English and Welsh law.

Assisted suicide is illegal under the Suicide Act, which came into place in 1961, and it is punishable by up to 14 years in prison.

Depending on the circumstances, euthanasia is regarded as either manslaughter or murder. The maximum penalty is life imprisonment.

In Scotland the Assisted Dying Bill is set to enter its first stage in 2024, after 36 MSPs backed the move.

Could the law change across the UK?

In February the Health and Social Care Committee published a report on assisted dying, but it didn't make any recommendations that the law should be changed.

MPs last debated assisted dying on April 29 after a petition backed by journalist and campaigner Dame Esther Rantzen gained more than 200,000 signatures.

Ms Rantzen, 83, has stage four lung cancer and says that she supports assisted dying in order to protect her family from a "terrible memory".

The issue of legalising assisted dying was last voted on in the House of Commons in 2015, when it was defeated at the second reading stage by 330 votes to 118.

Labour leader Sir Keir Starmer has said that he wants assisted dying to be legalised after the next election.

Speaking in a phone call with Dame Esther in March, Sir Keir said he was "personally committed" to a change in the law.

Who is arguing for and against?

There are strong arguments on both sides of the debate in terms of whether assisted dying should be legalised.

The charity Humanists UK is among the groups that fully support assisted dying, as it explains in a policy on its website:

"We believe that any adult of sound mind who is intolerably suffering from an incurable, physical condition and has a clear and settled wish to die should have the option of an assisted death."

It states that the right to die in the way a person chooses should be "a fundamental human right".

The charity gives the following list of reasons as to why assisted dying should be legalised across the UK:

Assisted dying would give people control at the end of life;

There are tried and tested assisted dying safeguard regimes around the world;

Assisted dying would alleviate unnecessary suffering, indignity and fear;

Assisted dying would allow people to die on their own terms;

Assisted dying with safeguards would give legal clarity to families;

It's what the majority of people want (according to various public polling)

"Families are often forced to make an intolerable choice between either letting their loved ones suffer, or supporting them to travel abroad and risking criminal investigation," the charity says, referring to more than 200 UK citizens who have travelled abroad to end their lives since 2015.

Have you heard our new podcast Talking Politics? Every week Tom, Robert and Anushka dig into the biggest issues dominating the political agenda…

Meanwhile, there are numerous groups in the UK who have a strong position against legalising assisted dying, including an alliance called Care Not Killing.

The group is made up of disability and human rights groups, healthcare providers and faith-based bodies.

Care Not Killing lists the following arguments as to why assisted dying should not be legalised:

A c hange in the law would place pressure on vulnerable people to end their lives for fear of being a financial, emotional or care burden upon others; particularly in the case of people who are disabled, elderly, sick or depressed;

Persistent requests for euthanasia are extremely rare if people are properly cared for so the priority must be to ensure that good care addressing people's physical, psychological, social and spiritual needs is accessible to all;

The present law making assisted suicide and euthanasia illegal is clear and right and does not need changing;

The vast majority of UK doctors are opposed to legalising euthanasia along with the Royal College of General Practitioners, the Association for Palliative Medicine and the British Geriatric Society;

Parliament has rightly rejected the legalisation of assisted suicide and euthanasia in Britain four times since 2006 out of concern for public safety

What is the situation in Europe?

Assisted dying has been legal in Switzerland since 1942. Since then nearly 350 British people have ended their lives at the Dignitas centre, which is an organisation that offers physician-assisted suicide.

Switzerland specifies that assisted dying is only legal in that case that the motives are not selfish. Euthanasia in all forms is against the law.

Euthanasia is currently legal in five European countries: Germany, Spain, Belgium, the Netherlands and Luxembourg.

Assisted dying had been legal until 2015 in Germany, but its government ruled that "commercial promotion of assisted dying" was no longer allowed.

That decision was then overturned in February 2020, making assisted dying legal again.

In 2021 Spanish lawmakers legalised euthanasia and assisted dying for people who have serious, incurable or debilitating diseases, and who want to end their lives.

Before the ruling, anybody found to have helped somebody to end their life faced a prison sentence of up to 10 years.

The Netherlands brought its Euthanasia Act into force in 2002, after the national court concluded that the average Dutch physician no longer considered it their duty to prolong a patient's life under all circumstances.

Belgium passed a similar Act in the same year, while Luxembourg followed suit in 2009.

Each country has its own strict conditions under which assisted suicide is considered permissible, such as stringent rules for physicians who help with the procedure.

Meanwhile, in France a 'citizen's convention' concluded that assisted dying should be legalised, and a bill on the issue was introduced by the government in April.

If you have found the topics discussed in this article distressing, you can seek help and advice at the following places:

You can contact Samaritans ;

You can call the NHS on 111;

You can text "SHOUT" to 85258 if you would rather not speak to someone over the phone.

Want a quick and expert briefing on the biggest news stories? Listen to our latest podcasts to find out What You Need To Know…

Euthanasia and assisted suicide

Euthanasia is the act of deliberately ending a person's life to relieve suffering.

For example, it could be considered euthanasia if a doctor deliberately gave a patient with a terminal illness a drug they do not otherwise need, such as an overdose of sedatives or muscle relaxant, with the sole aim of ending their life.

Assisted suicide is the act of deliberately assisting another person to kill themselves. If a relative of a person with a terminal illness obtained strong sedatives, knowing the person intended to use them to kill themselves, the relative may be considered to be assisting suicide.

Both euthanasia and assisted suicide are illegal under English law.

Assisted suicide

Assisted suicide is illegal under the terms of the Suicide Act (1961) and is punishable by up to 14 years' imprisonment. Trying to kill yourself is not a criminal act.

Depending on the circumstances, euthanasia is regarded as either manslaughter or murder. The maximum penalty is life imprisonment.

Types of euthanasia

Euthanasia can be classified as:

• voluntary euthanasia – where a person makes a conscious decision to die and asks for help to do so
• non-voluntary euthanasia – where a person is unable to give their consent (for example, because they're in a  coma ) and another person takes the decision on their behalf, perhaps because the ill person previously expressed a wish for their life to be ended in such circumstances

End of life care

When you're approaching the last stage of your life, you have a right to high quality, personalised  end of life care  that helps you live as well as possible until you die.

Find out more about:

• where you can be cared for , including hospice care
• coping with a terminal illness
• starting to talk about your illness
• managing pain and other symptoms
• coping financially
• making a legally binding advance decision to refuse treatment (living will)
• creating a lasting power of attorney , so someone you trust can make decisions for you if you cannot make them in the future
• planning ahead for end of life care

Find palliative care services near you

Page last reviewed: 12 July 2023 Next review due: 12 July 2026

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In support of assisted dying

• Related content
• Peer review
• Colin Brewer , writer, researcher, and former psychiatrist, London, UK ,
• Michael Irwin , former medical director of the United Nations
• Correspondence to: C Brewer brewerismo{at}gmail.com

Prominent essayists explain their support for assisted dying, with extracts selected by Colin Brewer and Michael Irwin

The novelist Terry Pratchett, who died last month, although a proponent of medically assisted suicide, was not one of the 30 essayists featured in our new not-for-profit book I’ll See Myself Out, Thank You , but several similarly high profile people have contributed (some essays have been reprinted).

To help the debate, we propose a new term: medically assisted rational suicide (MARS). It emphasises the typically calm, sober, and unhurried decisions by at least averagely rational people to end their lives sooner than might otherwise happen without direct intervention.

Whether doctors inject a lethal drug (voluntary euthanasia)—or simply prescribe it for patients to swallow (MARS)—seems unimportant, provided that a quick and comfortable death is what the patient wants.

The book was timed to coincide with Lord Falconer’s assisted dying bill, which failed to be fully debated before this parliament ended, and it quotes from several supportive speeches during the second reading debate in November 2014. Many of the book’s essayists will be familiar to The BMJ ’s readers, and several mention Lord Dawson’s famous comment that legislation on assisted dying was unnecessary because “all good doctors do it anyway.” But if that was ever true, it is not true now.

Dementia, MARS, and voluntary euthanasia

By colin brewer.

For many people, an additional consideration is that they do not want their families to have to watch them living and dying in this sorry state. This may be a minor and secondary motivation for MARS for some patients but a primary and important one for others. As Baroness Warnock puts it [in her essay in our book], “I simply do not want to be remembered as someone wholly dependent on others, especially for the most personally private aspects of my life, nor can I tolerate the thought of outstaying my welcome, an increasing burden on my family, so that no one can be truly sorry when I die and they are free.” To our opponents, such sentiments are held to reflect dangerous pressures in society. To most people, I think they will be viewed as altruism.

A 2007 UK survey found that, in the face of severe dementia, less than 40% of respondents would wish to be resuscitated after a heart attack, nearly three quarters wanted to be allowed to die passively, and the majority agreed with various forms of euthanasia.

Dying with Dignitas

By silvan luley, ludwig a minelli, and sandra martino, dignitas, switzerland.

Dignitas’s experience, derived from 16 years of taking care of people who wish to end their lives for all sorts of reasons, is that society should focus much more on preventing suicide attempts. Receiving access to an accompanied suicide is an important part in this. And, most interestingly, only 14% of those Dignitas members who receive access to an assisted suicide actually make use of this option. Regaining control over the last stretch of life—having an “emergency exit”—is sufficient relief for many, and they do not need to take to ghastly methods with a high risk of failure. One third of our daily counselling work, by telephone, is with non-members. First and foremost, Dignitas is a suicide attempt prevention organisation, and therefore a help-to-live organisation.

The Christian case

By paul badham, priest and emeritus professor of theology at the university of wales trinity saint david.

The last two attempts to change the law on assisted dying were blocked by well organised lobbying from Christian organisations and by the unanimous opposition of the Bishops’ Bench in the House of Lords. This is sad, because this opposition does not represent what most Christians want. Recent opinion polls showed that 78% of occasional worshippers supported a change in the law. The figure was lower among more regular churchgoers; but, even so, 61% of weekly churchgoing Anglicans and 57% of weekly churchgoing Catholics would like the law changed.

The most important reason for this is that the religious arguments against assisted dying don’t stand up. To claim that only God should determine the hour of our death is something that no one today can consistently believe. If they did, they would be just as opposed to human interventions to prolong life as they are to assisted dying. If it were seriously thought that only God should choose the moment of our death, we would not resuscitate people whose hearts had stopped but would simply accept that God had chosen that moment to end that human life.

Thankfully, no one takes that line. Similarly, Pope John Paul II’s claim that “suffering in the final stages of life has a special place in God’s plan of salvation” would, in practice, run counter to all attempts to palliate human suffering and hence would be equally unacceptable on both sides of the debate.

A right to autonomy

By gillian tindall, writer.

I see that, in the Times in 1983, I wrote, “A generation is a long time in the field of what is considered right. I am willing to bet that, within my own lifetime, ordinary people will look back with as much disapproval on the days when there were no proper arrangements for a timely death as we now look back on the dark ages before contraception.”

I was in my 40s when I wrote that; a generation has passed, and “within my lifetime” now has a very different dimension. My contemporaries confide their fears about old age, which are never—contrary to “pro life” myth—about being bumped off too soon but about being forced by well intentioned but ill advised doctors to go on living too long.

Cancelling our captivity

By john harris, professor of bioethics, university of manchester.

Many objectors to medically assisted death emphasise their concern to protect vulnerable people. I yield to none in my concern for vulnerable people; but there are here two groups of vulnerable people to whom we owe concern, respect, and protection. One consists of those who might be pressured into requesting death. The others are those, like Tony Nicklinson, who are cruelly denied the death they seek. We are surely not entitled to abandon one group of vulnerable people in favour of another. We have somehow to protect both.

Those who might be encouraged to die remain free to refuse. They are not victims unless they make themselves victims. Those seeking assisted death are all the more vulnerable because they are absolutely prevented from obtaining the remedy they seek. They seek death and are denied it: these people are genuinely coerced and are certainly the victims of tyranny.

Thus, concern for vulnerable people does not, as so many falsely believe, tell us that we should forbid assisted dying. On the contrary, it tells us that we should permit it, with safeguards, thereby protecting both groups of vulnerable people to whom we have responsibilities.

Palliative care: the promise and the reality

By colin brewer and michael irwin.

Julia Lawton’s six month study of one hospice noted, “Hospices tried to keep such [refractory] patients out of view (which meant that they often had little of the contact with other patients that some of them valued) . . . One patient, Dolly, incontinent and with faecal vomiting, regularly requested voluntary euthanasia for a week after her final admission.

“Eventually she stopped asking for it, because she stopped talking entirely. When staff attended her, she closed her eyes and ‘totally ignored them.’ Another, Deborah, stopped eating and drinking—and also speaking to the staff—for a week until death released her; Kath also asked to be put out of her distress after saying on repeated occasions that ‘you wouldn’t put a dog through this.’ The stench created by Annie—who lingered for six weeks—reached to the reception area and was so dreadful that badly needed beds vacated by dead patients were not refilled.”

The well documented over-representation of Christian doctors in British palliative care means that many of them must find it very difficult or even impossible to accept patient autonomy in this most crucial and fundamental area. Is it unreasonable to suggest that such doctrinaire views make them, in some very important respects, unfit—or at any rate, much less than ideal—for a medical specialty that deals every day with human beings holding diverse views on one of the most important stages of our life?

Ethics of assisted dying

By antony lempert, gp and chairman of the secular medical forum.

Fifteen years of assisted dying in the Netherlands have shown a significant reduction in the number of people killed without their explicit consent—namely, non-voluntary euthanasia. A 2009 study showed that roughly 3000 deaths a year in the United Kingdom are already by euthanasia. Without legislation on assisted dying these patients have no automatic assessment for treatable symptoms, no safety net, and often no medical input. The current situation is an unsafe, unregulated, unmonitored, muddled mess. The 2012 Falconer commission on assisted dying described the current legal status of assisted dying in the United Kingdom as “inadequate and incoherent.”

For most dying patients, the greatest fear is not of death but of dying badly. Those of us who regularly care for dying patients know that suffering often extends beyond pain and may be compounded by loss of dignity, loss of sense of self, and the agony of watching a treasured life disappear. Each person will experience different emotions or responses to the same situation and will have different values; this is precisely why autonomy is so important.

In Oregon, USA, many more lethal prescriptions are approved than are eventually used. But the comfort that this option gives some people cannot be underestimated.

Leave it to the patient

By chris woodhead, former head of ofsted and patient with motor neurone disease.

One GP said to me recently that, prior to Shipman, doctors would do what was necessary to minimise suffering. Now, the prospect of an inquiry into the circumstances surrounding any death makes most doctors reluctant to do anything other than prolong life. It may not be what the patient wants. It may not be what the doctor wants, either. But that is where we are, and I would rather rely on the professional discretion of my GP than on the pusillanimity of a parliament fearful of rocking the media boat.

Cite this as: BMJ 2015;350:h1828

Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.

The essays from which these extracts were taken are published in a new not-for-profit book, I’ll See Myself Out, Thank You: Thirty Personal Views in Support of Assisted Suicide , edited by Colin Brewer and Michael Irwin, published by Skyscraper in January 2015.

Provenance and peer review: Commissioned; not externally peer reviewed.

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The Last Thing My Mother Wanted

Healthy at age 74, she decided there was nothing on earth still keeping her here, not even us..

This article was featured in One Great Story , New York ’s reading recommendation newsletter. Sign up here to get it nightly.

Do you know how many grams of Nembutal it takes to put an elephant to sleep?” asks the anesthesiologist from Pegasos, a voluntary-assisted-death organization in Switzerland, after an evaluative look at my mother.

We — my 74-year-old mother, my younger sister, and I — are sitting on a couch in the suite of a charming hotel near the center of Basel. Thin, contained, elegant, with a neat bob of white hair, Mom is at attention. The doctor seems at ease. As he tucks his hat under a red-and-gold Louis XV–style chair, he tells us that many people who avail themselves of Pegasos’s service, which costs more than $10,000, will sell their car or antique books to spend their last few nights at this hotel.

It is September 28, 2022, the day before my mother is scheduled to inject herself with 15 grams of Nembutal — enough to sedate three and a half elephants, the doctor says. She would not need to worry about waking up or being cremated alive. This was a relief to her, Mom says with a smile.

In June, my sister and I had learned, almost by accident, that she was seeking an assisted suicide. I was on the phone with Mom, listening to her complain about an annoying bureaucrat at the New York County Clerk’s Office, when she mentioned it. “I am putting in an application to Pegasos,” she said impassively, “so I was getting some documents for them.” I texted my sister while we were on the phone: “What the fuck? Why didn’t you tell me about Mom applying to die?” Three little dots. “Wait,” My sister wrote back. “What. What is she doing?”

Mom didn’t have cancer or Lou Gehrig’s disease or any of the illnesses that typically qualify you for assisted death. A cataract in her left eye had deteriorated, and though she had some foot pain and had gotten a pacemaker, all of which weighed on her, she was quite healthy for her age. She had completed a marathon just a few years before at 68.

But her long-term partner had been diagnosed with an incurable glioblastoma in February 2020 and had taken advantage of California’s “death with dignity” laws to die that May. Soon after, Mom left San Francisco, a city she hated for the 20 years she lived there, and moved back to her beloved New York. She bought an apartment near her childhood home on Fifth Avenue; reconnected with old friends; saw plays, art exhibits, and movies; ate good food; and traveled — and did not care about any of it. “Oh, I have nothing interesting to say,” she would say when I called, her voice animated only when she was describing a plan to smite anyone responsible for a grievance by writing a furious email or leaving an angry Yelp review. My mother had always been a flashlight of a person — shining a small but intense beam on things she wanted to explore — but now the radius had shrunk, the light weakened. She used to be curious about my husband’s hobbies, our children, my sister’s career, but those topics, like everything else, were now of only vague interest. She would come down to Virginia to see my family and go up to Connecticut to see my sister’s, but she wouldn’t play with the kids and didn’t seem to enjoy the trips, just expressed relief when they were over. In the last months of her life, the only thing that appeared to give her real joy was the hope that she would be ending it.

In the U.S., ten states allow physician-assisted death, which is available only to residents who are terminally ill with no more than six months to live. In Canada, the laws are more expansive, but citizens still need a diagnosis — if not a terminal condition, then an incurable one with intolerable suffering and an advanced state of decline. In Switzerland, where a foreigner can go to receive aid in dying, there are fewer restrictions on who is eligible. Pegasos is one of the only organizations that will help elderly people who have not been diagnosed with a terminal illness but who are tired of life. Its website notes that “old age is rarely kind” and that “for a person to be in the headspace of considering ending their lives, their quality of life must be qualitatively poor.”

My mother had pinned her hopes on this “tired of life” catchall. She had a three-pronged rationale, she told us over the phone: The world was going to hell, and she did not want to see more; she did not get joy out of the everyday pleasures of life or her relationships; and she did not want to face the degradations of aging.

My sister and I immediately believed she would go through with it. A lifelong libertarian, my mother believed firmly in maintaining her independence. Since she was 21, she had a living will with significant restrictions on when she wanted to be resuscitated. Mom had been brought up with a strict sense of what was appropriate, which was essentially a list of rules on how to avoid imposing on others (thank-you notes had to be sent within a week; navy is the safest color). As she aged, she was desperately afraid of deteriorating and becoming a burden — on taxpayers funding Medicaid, on the medical system, on us.

Our husbands, and our friends who had spent time with her, weren’t so sure about her resolve. Mom had a history of starting projects and then abandoning them. Over the years, her Farsi and Japanese had stayed at a beginner level, her massage-therapy degree went essentially unused, the beginning of her dissertation for an anthropology Ph.D. on upper-class lesbians sat in a stack of neatly filed index cards. And she often made threats she didn’t keep. Once, furious in the middle of an argument, she went to her filing cabinet, got out her will, and crossed out my name in the relevant sections, then initialed and dated every change. The next time she sent us a copy of her will, I was, without comment, back in it.

This uncertainty cast a strange shadow on the long, humid days of that Virginia summer. I wrote down memories, questions in case it was my last chance to ask them. Mostly, I hoped a deadline might compel her to give me the thing I’d been seeking for years: some accounting of who she was as a parent, some sign that she had thought about all the nicks and bangs she had given my sister and me.

In mid-June, my mother begins to gather the required documents: the birth and marriage certificates, the name changes, the medical records. None of her medical records have any documentation of any mental illness, which would prompt a closer review from Pegasos; Mom had refused therapy her entire life, believing it to be for the weak. But it had long been clear to the few people she had kept in her life and the many who had been excised or distanced themselves that something was not right.

When I was in preschool and my parents were still married and living together on the Upper East Side, my mother started an affair with the mother of one of my friends. I found out in kindergarten when my friend and I walked in on them in the bath. Once that secret was out, no secrets would be kept. My mother told me that my friend’s parents liked to have another mutual friend watch them have sex. This was unfathomable to me. I had only ever seen this voyeur — a kind, chubby woman — in slightly scuffed Ferragamos with a silk scarf draped dowdily around her neck. Now I imagined her in a bedroom I knew well, watching my friend’s parents do whatever noisy, naked thing made my parents lock the door at night sometimes.

When I was about 8, my mother started up with a professor of anthropology at Columbia, where she had begun the Ph.D. she wouldn’t finish. He smoked cigars and was fat. Mom was entranced. By his intellect, she said. One Sunday in late fall, my mother, my sister, and I were on our way back to the city from East Hampton when Mom decided to stop to get a poinsettia for the professor. When my father asked why we were late, my sister told him, innocently, that we stopped to buy a plant for “Mommy’s lover.” My father was not an arguer, but his face rearranged itself into fury and humiliation while my mother screeched at my sister, “How could you tell your father that?!” I grabbed my sister, and we hid under the mahogany dining table. My sister was shivering. I sat beside her, silent, a little resentful we were witnessing something that maybe should have stayed between grown-ups.

Some years later, after my parents had started and stopped divorce proceedings, my mother and I took a trip to India to hike for six weeks in Ladakh. It was, she said, a way for us to get to know each other in an environment where, unlike New York or Paris, she wasn’t the expert. To mark my turning 16 and the evolution of our relationship. When we crossed the threshold of the guesthouse in Delhi where the dozen or so travelers would be meeting, she saw a woman with bright-blue eyes and a subtle mullet, grabbed my hand, and said, “Fuck. I didn’t need to fall in love right now.” The trip became about that love — every night my mother would tell me every detail about her conversations with the woman and the growing lust she felt for her.

One night, there was an almost biblical storm and we heard someone outside our tent asking to come in. It was the blue-eyed woman, who would become my mother’s partner of 25 years. Her tent had blown away. We welcomed her into our two-person tent and within an hour, I was huddled on one side, trying desperately not to touch the wet polyester sidewall, singing “Mary Had a Little Lamb” silently with my fingers in my ears so I could muffle the wet sounds of their lovemaking. I knew I wouldn’t get an apology the next morning, but I didn’t expect pure triumph. My mother had now won this woman from her partner, the trip operator, and she was entirely focused on her.

Later, in high school, I was on the phone with a friend while heating something up in the kitchen. I was an absent-minded kid, and my mother had warned me before about the danger of not monitoring the stove. When I saw the flames, I ran to get my father, who was reading in his room. Twenty-three years before, he had lost his first wife and son in a freak house fire. He was 70 years old when our kitchen went ablaze, but I have never seen a human move that quickly. I was paralyzed. Not because of the fire but because I knew how angry my mother would be. When she came home, she didn’t ask my father how he was feeling. She told me to go to my room. I didn’t sleep. I was terrified and wrote a poem about how much I loved her. In the morning, I gave her the poem and she gave me my punishment. I would not be going on spring break with her and my sister, I needed to get a job to help pay for the damage, and I wasn’t allowed to say “I love you” to her for three months. I pushed back, telling her I did love her and had just made a mistake, but hit a wall of silence.

It was decades later, when I was in a healthy marriage with three children of my own, that I started to see how wrong it all was. Back then, I couldn’t let myself feel angry at my mother; it was too dangerous. Any hint of disapproval could be the moment she cut you off, and once out, there was no way back in. When she was 71, without warning, she stopped talking to her only sibling, apparently because an email her sister had sent related to the family business was the final straw in a lifetime of annoyance. The abandonment was total. Despite my aunt’s efforts, my mother never spoke to her again.

I struggle briefly with whether to email Pegasos and tell them the part of the story I knew, but I decide not to. Maybe, I think, it would be best for my mother to end her life. I love her, and in addition to the reasons she articulated, she seems terribly lonely. I don’t want to take from her the choice of a civilized, painless death. And I fear what would happen if she found out I had thrown roadblocks in her way. Even now, she has an enormous amount of power over me. When I was a teenager, my mother, after a fight with my father, forbade me from speaking to my youngest half-sister again. It took me until I was 40 to work up the courage to contact her, and even then, I did so in secret.

In July, Mom sends Pegasos the documents and gets conditional approval. She wires the money for the fee, and it takes far too much time, and many visits to her bank, to clear. “I can’t believe I have to go through this crap to not go through this crap anymore,” she texts.

The days in August are long. Pegasos has said it will get back to her with potential dates, and time drips by as my sister, my mother, and I wait. Her anxiety seems to increase with every day. Always goal-oriented, she is now determined to die. That month, I am visiting my mother-in-law when my mother calls. “I just want to hear back from them,” she says, her stress palpable. “They said it would be two weeks. If they don’t accept me, I am going to kill myself. I’ve been thinking about it.” She has been. She has stockpiled Valium and Ambien, bought over the internet, and has a few Zofrans left over from trips. She is going to rent a hotel room, take the anti-nausea medication and the Ambien, get into a bath, take a few Valium, and slit her arteries with a knife. She wants to do it in a hotel room because she doesn’t want her apartment to be difficult to sell, though, she says, she would prefer to die at home. The image of her tiny body, the curve of her lower stomach and the age spots on her chest, lying in a pool of pinkish water flashes into my brain. I try to shake it. She wouldn’t do that. I can’t imagine she would.

If I’m being honest, I am glad she has a backup plan, even if I hate the specifics. Though the idea of cutting ties with her has crossed my mind, I’ve refrained, more out of a sense of duty to her and my sister than from any joy I get from our relationship. The decades have refused to soften her, and on visits, I’d watch as she snapped at the children and then wondered why they retreated to their rooms to read. In the weeks leading up to those trips, I’d repeat the same thing I used to tell myself on flights with a toddler: You can get through anything in six-minute increments. It would be a struggle, I know, to care for her as she aged. But the anticipation of relief is accompanied by the guilt of knowing that my mother, on a microchimeric level, can sense my ambivalence and is feeling out how strongly my sister and I will fight to persuade her to stay on this earth. After she told us about her application to Pegasos, I called her. “What would make you happy this summer, Mom?” I asked. I suggested a girls’ weekend with her, my sister, and me; she declined. Later, she tells my sister that part of the reason she has decided to kill herself is that my sister does not love her enough. In August, she sends me a final birthday card. On the front, it reads MAY ALL YOUR VENGEFUL WISHES COME TRUE. She has written on the inside, “Dear Pussycat, I think this is the best birthday wish ever. xxoo. Mommy.”

I can see it clearly — the special brand of narcissistic sadism she has perfected. Still, in my bountiful moments, I think perhaps she is consciously attempting a last act of parenting: doing me the favor of severing the connection that has defined much of my life and that I am too scared to break.

On September 2, Pegasos offers my mother a slot on September 29. Time declares war on my sanity. Paucity and abundance. There are too many hours and definitely not enough. I get through every day: cooking, volunteering at school, taking one child to the orthodontist, then the next to a guitar lesson. The rhythms of life become unnatural. In my head is a clock: “Mom may be dead in two weeks and three days. Two weeks and two days.”

I stop sleeping almost entirely. I am pretty certain I am not going to miss her, but she is my mother. Two weeks. I can’t decide if I am more frightened of watching her die or of the week we will spend with her beforehand. What if my last memories are of her being cruel, even inadvertently?

Thirteen days. I’ve been calling her more frequently, panning for any evidence that we could speak truthfully. She tells me every time that she has nothing interesting to say. Once, my call goes to voice-mail and she texts an explanation; she’s getting her legs waxed. Twelve days. She’s having good-bye dinners and lunches. Some participants know, but some don’t.

I call her the Monday before we leave for Switzerland. I note that in two weeks I won’t be able to hear her voice and I am just calling to say “hi.” This seems to be an emotional curiosity for her; I can almost hear her rolling it around in her head. Finally, she advises me, chipper, that I should record her voice. I tell her I love her as we say good-bye and realize that she stopped saying “I love you” sometime in July.

In the meantime, I’ve continued to write down moments I think she would enjoy reliving — mostly from when my sister and I were young, when she was still tender and affectionate with us. Games of tickle monster on the stairs of our apartment, the half-hour every day she would read to us while we lay sprawled on the floor coloring or building houses of cards. Our summers spent as a trio on Long Island — jumping waves, catching crabs in the bay, eating dinner in the backyard before falling asleep in her bed, nut brown and worn out from the sun. On one of my first plane rides, she told me about the 1973 Rome-airport terrorist attacks ten years earlier. “Pussycat,” she said somberly, “if I fall on top of you and you hear gunshots, don’t move, even if I am not answering you.”

The school year begins. As I sit by the pool in the evenings watching my children swim, I debate forcing a conversation about who she was as a mother. Then old reflexes kick in: What if she gets angry and bans me from coming to Switzerland? I couldn’t make my little sister be the sole witness to her death. I start to fantasize that, at the least, we’ll talk in Basel. That she’ll tell us that she remembers how my breath always smelled like apple juice as a child and what joy that gave her, that she loved the weight of our bodies when we sat on her lap, that she is proud of raising women like us and enjoys the squeals of our children and the solicitousness of our husbands mixing her cocktails when she visits. After my sister and I approve of the hotel she wants to stay in in Basel, she writes us an email, telling us “I really appreciate the two of you :-). I am lucky that you are my daughters.” Though I should probably know better, I imagine finding a long note from her in the hotel telling us how much she cares, how even though the decision was the right one for her, it was hard to make.

Monday ends. Then Tuesday. Vicious eczema erupts on my chin. I lie in bed awake every night from midnight until 5 a.m. My husband still isn’t convinced she’ll go through with it. My sister and I contemplate how things will shift if she changes her mind at the last minute. We decide that, for this year, we’d just skip the holidays as a family.

There’s a strike at the Paris airport, and my mother is worried that her flight to Switzerland, which stops at Charles de Gaulle, will be affected. As backup, I buy refundable tickets directly to Zurich from New York. She’s effusively grateful. She tells a friend this purchase is the thing she has most loved about me. On Tuesday, when I call a week before she is scheduled to die, she tells me she is going to clean her apartment and wash her sheets in case my sister and I want to stay there (we don’t) and then pack. In the middle of our conversation, she says, “I just wish it was next week.” Then she remembers that she needs to buy razors in case there is a last-minute hitch with Pegasos. She tells me she plans to send my sister and me away and then kill herself in the hotel bathroom. Even in context, this seems histrionic: She shouldn’t put my sister and me in the position of flying to Switzerland to watch her kill herself and then ask us to leave and walk around Basel knowing she is taking her life in a painful way — and then I feel ungenerous for noting that.

I feel ungenerous often. In her recounting, my mother had a gilded but emotionally difficult early life. An apartment across from the Met in a building her family owned, skiing in Megève, summers in East Hampton. And then parents who left her and her sister in the care of a Swedish nanny to go on a round-the-world cruise when she was only 2 and a half, returning to find their offspring now spoke only Swedish, which neither of them did. A father who cheated on her mother, who returned the favor. A mother who literally thought she was Marie Antoinette reincarnated and then was hospitalized when my mother was 10.

My mother will tell us in Switzerland that, in the hospital, my grandmother was diagnosed with borderline personality disorder. Later, one of my half-sisters will mention that when I was a toddler, my mother told her, outraged, that her doctor had suggested my mother, too, had BPD. I had been trying to understand her for years, and the diagnosis finally makes the puzzle pieces fit: The illness is characterized by dichotomous thinking, impulsive actions without regard for the feelings of others, and trouble maintaining stable relationships. Still, there is no way to corroborate it.

Less than one week left. For the first time in my life, real rage. It bubbles up as dreams in which I shake her violently and only sawdust comes out. How can she value my sister and me — and our beautiful, kind, sparkly children — so little as to choose to leave us? And is she really going to go without any kind of reckoning with the person and parent she was, with the damage she has done? It feels horribly cyclical. When my grandmother died, my mother went through her apartment, searching for clues as to her personality, or perhaps some proof that her mother had loved and cherished her, and found a series of locked diaries dating back years. Hours later, she found the keys and was full of anticipation. All the diaries were blank.

My mother-in-law arrives on Friday, two days before I am scheduled to leave for Switzerland, to help my husband take care of our three children. She has been caring and unobtrusive throughout the summer, and seeing how easily she and my husband co-parent, and their affection for each other, is too painful. I avoid them and my kids all weekend. Saturday, my sister goes to New York to accompany my mother to the airport. She has to pee when she arrives, but my mother will not let her into her apartment as she has already cleaned it. She’s anxious about getting to the airport in time, though they end up arriving three and a half hours early.

We haven’t told the kids what is happening, and neither have my sister and her husband. We have a tentative plan to tell them when they are older. My mother would like us to. She feels her choice is ethical and brave — and, I think, wants us to honor that in our recounting.

I am not sure that I live the three days in Switzerland so much as watch them pass through leaded windows. Nothing seems solid. My mother certainly doesn’t. We walk around Basel, a charming city with a river flowing through it, on Monday. Tuesday and Wednesday are gray and rainy. We have lunch. We take the train to France. We talk about the music she listened to with her cousin when she was young and pull up a video of “Running Bear” on YouTube. I try to take advantage of the fact that she has her faculties to talk about our life, but I quickly realize there is no point. When I ask why she thinks our relationship has always been tenser than hers with my sister, she tells me, “You just became so nasty and difficult at 8.” She hands us no letters.

The night before she is scheduled to kill herself, we have a sumptuous dinner at the Brasserie au Violon, the site of a former prison; my mother chose the venue as a joke.

The procedure, or the appointment — none of us seem to want to say the word death — has been moved from Thursday morning to the early afternoon. Another lifetime of waiting. By 9 a.m., the clouds have broken, and my mother is already dressed, her hair in curlers. She is sitting on the bed, looking at her computer. My sister and I suggest a walk. My mother declines: “I’m doing emails. Just unsubscribing from Politico.” “Mom!” We splutter. “We can do that! It’s your last day on earth!” Which it is, and so we desist. Around noon, we go down to the hotel bar. My mother orders a whiskey-soda, ice cream, and a glass of Barolo. She enjoys the wine so much that I suggest she could just not go through with it and stay in this exact hotel and drink herself into oblivion for the rest of her life. Like Bartleby, she’d prefer not to.

At one, her internal alarm goes off. We get the check, the hotel gets a cab, and the three of us, together for the last time, get in. The 20-minute ride to an industrial suburb of the city passes in silence; we are all holding hands.

The head of the organization, dressed in an off-white linen top and flowing pants, greets us kindly as the car arrives and leads us into the Pegasos bay in the industrial park. Next to it is a place that appears to repair tire rims and then one that mixes paint. In the waiting room, to the left, large-scale photos of a beach frame a desk; on the right there is a seating area. All the colors are neutral, and there is an abundance of bottled waters and chocolates.

The train is in motion. We hand over our passports; the Swiss police, I think we are told, will need them so they can confirm our identities once we identify the body. My mother is nervous, the way she has been my whole life while traveling. The anesthesiologist is there, typing briskly. The head of the organization tells us there is no rush, but we can start if we are ready. My sister and I look at each other. We’ll never be ready, but when my mother says she is set, we follow her back to the second room. It’s the last time we will be her goslings. The air seems to have turned into corn syrup, and I waddle behind her, weighed down by hundreds of tiny memories, grievances, and love notes. This is it. This is it. My mother climbs into a queen-size hospital bed. The director comes in and my mother reminds him that she has a pacemaker and they should take it out before they cremate her so the crematorium will not explode. He laughs gently and says they will be sure to. “Don’t worry. We know. We already had that happen once.” I can’t tell if he is kidding.

Mom has opted to have an IV and not take the oral medication, as apparently the latter tastes terrible and has a tendency to make people vomit. The anesthesiologist begins a saline drip and asks Mom to experiment with the proprietary switch that will initiate the IV, and she has no problem; the doctor reminds us that we cannot get our fingerprints on the switch or there could be trouble with the Swiss authorities. My mother seems tiny in the big bed. We get the CD she wants us to play as she is dying — a recording of “Ave Maria.” We hand her the photo of her partner that has been on her bedside table for years, and she tucks it under her shirt, next to her heart. She puts some stuffed animals that they cherished as totems around her stomach.

The anesthesiologist puts the Nembutal into the drip and leaves the room. My sister and I climb into the bed, one on either side of her. Mom has the switch in her hand, and as “Ave Maria” starts to swell, my sister and I whisper softly, “I love you. I love you. Go in peace. I love you.” Mom pushes the switch and her breathing starts to slow. Her eyes lose focus, and in less than a minute and a half she is gone. My sister and I sit there for a few moments, petting her head, until it feels somehow untoward to continue. And then one of her eyes jumps. I get the anesthesiologist since Mom was terrified of being cremated alive, and he confirms it is normal for some muscles to twitch after the moment of death. The director tells us we have a little while before the police arrive, and my sister and I take a walk past the industrial noises and into a quiet park with a stream running through it. My sister cries; I want a cigarette. We walk back to Pegasos just as the Swiss police show up. They are quiet and efficient and don’t make eye contact.

When they have finished, my sister and I call an Uber and go back into Basel. In the hotel, we sit together in one of the tasteful, heavy studies to call my aunt to tell her. My aunt, shocked, has trouble breathing but manages to ask, “How could she leave you?” Facing my second motherless Mother’s Day, I still don’t know.

Evelyn Jouvenet is a pseudonym.

If you are in crisis, please call the National Suicide Prevention Lifeline at 800-273-8255 for free, anonymous support and resources.

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Teacher with no diagnosed illness took his own life at suicide clinic without family’s knowledge

Alastair Hamilton, 47, died by lethal injection after telling parents he was visiting a friend in Paris

A teacher with no diagnosed illness took his own life at a Swiss suicide clinic without the knowledge of his family.

Alastair Hamilton, 47, died by lethal injection at the Pegasos clinic in Basel after telling his parents he was visiting a friend in Paris.

His mother Judith, 81, visited the clinic for an ITV documentary after it apologised for failings surrounding the case.

She told the broadcaster: “We weren’t given that chance to either be with him or in my case, drag him home, tooth and nail if I had to.”

Pegasos, which is run by activist Ruedi Habegger, does not require people to be ill to have their death request approved, unlike Dignitas .

Mr Hamilton, a chemistry teacher from Hampton, south-west London, had been battling with low moods before he flew out to the clinic.

He had given up working full-time and moved back in with his parents as he began to lose weight and feel increasingly tired. 

Doctors were unable to diagnose him with any condition, despite several private health checks.

His brother Toby, 52, told The Mail on Sunday that he had started mentioning suicide “like he was talking about going for a pint down the pub”.

Mr Hamilton flew to Switzerland on Aug 10. His father Edward, 85, drove him to Gatwick Airport, believing that his son was meeting a friend in France.

‘Remember mum that I love you’

Mrs Hamilton told the newspaper that her son “put his arms around me and gave me a big kiss” the last time he saw her.

She added that he told her: “Always remember mum that I love you very much, I always have, I always will, no matter what.”

While abroad, Mr Hamilton stopped responding to his family’s calls, texts and voicemails and they soon phoned the police to report him as a missing person.

The Metropolitan Police traced Mr Hamilton to Pegasos through his bank details and were told by the clinic that he had died. 

The clinic refused to provide police with the date of his death or any other information.

In emails to Mr Hamilton’s family, a Met Police sergeant criticised Pegasos for its “lack of compassion and lack of transparency”.

The family were not sent his ashes until October and have still not received his personal items or letters which the clinic said he had left for them.

Pegasos has since apologised and promised to inform families in the future about their relatives’ deaths, according to ITV.

Standing outside the clinic, Mrs Hamilton told ITV: “It’s not the best place to be for your last view of Earth, is it?

“Bless him. I just keep saying to myself: ‘Oh Alastair’.”

Swiss law has allowed assisted suicide since 1942, while it is against the law in the UK and punishable by up to 14 years in prison.

Between 2016 and 2022, 405 UK residents had assisted deaths in Switzerland.

According to a study, most of them had non-terminal illnesses, including Parkinson’s disease, multiple sclerosis and locked-in syndrome.

Campaigner Dame Esther Rantzen has sparked a debate on assisted suicide in the UK after revealing she had joined Dignitas and was considering assisted dying as she battles stage four lung cancer.

Sir Keir Starmer has promised to give MPs a vote on legalising assisted dying if Labour wins the next general election.

The last parliamentary vote on assisted dying, which was defeated, took place in 2015 .

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Assisted dying clinic apologises after helping British man die in secret

The swiss voluntary assisted dying clinic has since apologised to the man's family.

Warning: This article contains discussion of suicide which some readers may find distressing.

A Swiss voluntary assisted dying (VAD) association has apologised to the family of a British man who took his own life without them knowing.

Chemistry teacher Alastair Hamilton, 47, travelled to Basel, Switzerland last August to undergo the procedure at Pegasos, despite telling his mother that he was flying to Paris .

His mum Judith Hamilton, 82, who waved goodbye to Alastair at the airport, told ITV News: "He put his arms around me, looked me straight in the eyes and he was smiling.

"And he said 'love you, mum, love you lots, always have, always will no matter what'."

After failing to return to the UK , his mum reported him as missing until bank records revealed that her son had paid £11,000 to Pegasos for 'voluntary assisted death' treatment.

The clinic accepted his online application form, which was seen by ITV News, where Alastair wrote about having an undiagnosed stomach condition, which he said caused him 'pain, fatigue and discomfort' and had 'devastated his life'.

He also said that 'there is no current, definitive medical explanation' for his health condition and that his family weren't aware that he had decided to take his own life.

Following the approval of his application, it is believed that Alastair died in an office block next to an asphalt factory in Basel.

His brother Bradley, along with Judith, were taken to see the building by ITV News, with Judith saying: "It’s not the best place to be for your last view of earth."

"It’s even more heart-breaking that someone could have been with him, but they didn't tell us and he didn't feel that [he could]," Bradley added.

His mother cried: "I keep saying to myself 'oh Alastair'."

With help from police and the British embassy, the clinic confirmed Alastair's death and returned his ashes to his family in the post.

Pegasos apologised for not letting the family know in person and said in a statement to ITV: "As conveyed by Mr. Habegger during the meeting, we would like to tell the family once again that we are very sorry that our communication caused them further distress last year.

"We were not sure how to deal with the situation in terms of communication and legally and therefore did not act as we would today. We hope that our meeting helped them to understand better the decision and path of Alastair.

"Pegasos has always respected the applicable Swiss law without exception and continues to do so... we always require reports from medical specialists. Only based on these reports, other documents and direct contact with the concerned person, a decision can be taken.

"We are conscious of our great responsibility. This is why, in those rare instances where we have reason to assume that no information has been provided to close family by the person seeking voluntary assisted death, we will abort the procedure on the spot.

"In 2022, the Swiss Medical Association revised its guidelines regarding assisted dying. It is important to understand that these guidelines are not legally binding for the associations but are policies for the medical professionals.

"Several organisations for assisted dying, including Exit, Dignitas and Pegasos, publicly spoke out against the revised guidelines, because they are putting at risk the self-determination of people planning a voluntary assisted death and the freedom of choice in Switzerland."

According to the Swiss Criminal Code 1942, assisted suicide is permitted so long as the motive for doing so is not 'selfish'.

LADbible has contacted Pegasos for additional comment.

If you’ve been affected by any of these issues and want to speak to someone in confidence, please don’t suffer alone. Call Samaritans for free on their anonymous 24-hour phone line on 116 123 .

Topics:  Health , UK News

Anish is a GG2 Young Journalist of the Year 2024 finalist. He has a Master's degree in Multimedia Journalism and a Bachelor's degree in International Business Management. Apart from that, his life revolves around the ‘Four F’s’ - family, friends, football and food. Email: [email protected]

@ Anish_Vij

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What do assisted dying, assisted suicide and euthanasia mean and what is the law?

• Oops! Something went wrong. Please try again later. More content below

Scotland, Jersey and the Isle of Man are all considering changing the law to let terminally ill people end their lives.

Campaigner Dame Esther Rantzen also wants Westminster MPs to vote on assisted dying after a report found some evidence that it had led to better end-of-life care in places where it is allowed.

A number of countries have legalised assisted dying, assisted suicide or euthanasia, which are all different.

What is assisted dying?

There is some debate over exactly what the various terms mean .

But assisted dying is generally used to describe a situation where someone who is terminally ill seeks medical help to obtain lethal drugs which they administer themselves.

What is assisted suicide?

Assisted suicide is intentionally helping another person to end their life . It can involve people who are not terminally ill .

Providing someone with a lethal dose of sedatives or helping them go to Switzerland (where assisted suicide is legal) could both be considered assisted suicide.

What is euthanasia?

Euthanasia is the act of deliberately ending a person's life to relieve suffering in which a lethal drug is administered by a physician .

It is legal in fewer places than assisted dying or assisted suicide and patients do not necessarily have to be terminally ill .

There are two types: voluntary euthanasia , where a patient has given consent, and non-voluntary , where they have not been able to, for example if they are in a coma.

Are euthanasia, assisted dying or assisted suicide legal in the UK?

The laws throughout the UK prevent people from asking for medical help to die.

More specifically, euthanasia is illegal under English law and is considered manslaughter or murder. The maximum penalty is life imprisonment.

The Suicide Act 1961 also makes it illegal to encourage or assist a suicide in England and Wales. Those found guilty could face up to 14 years in prison.

Similar laws also exist in Northern Ireland .

There is no specific crime of assisting a suicide in Scotland but it is possible that helping a person to die could lead to prosecution for culpable homicide.

However, a new bill drafted by the Lib Dem MSP Liam McArthur could see Scotland become the first UK nation to allow assisted suicide .

Mr McArthur expects the bill to be debated in the Scottish Parliament in the autumn.

In March 2024, a report from the Health and Social Care Committee highlighted confusion over the rules governing UK doctors providing medical evidence for people who wanted to go abroad to die .

The British Medical Association (BMA) advises doctors against producing medical reports to facilitate assisted suicide abroad.

UK membership of Dignitas, the Swiss assisted dying association, jumped to 1,900 people in 2023, according to the organisation. That is a 24% rise on the previous year.

It said 40 people from the UK ended their lives at Dignitas in 2023, the highest level since 2019. Between 1998 and 2023 it helped 571 Britons to die .

What is the situation in the Isle of Man and Jersey?

Jersey and the Isle of Man are part of the British Isles but set their own laws. Both islands are considering proposals to allow assisted dying.

On Tuesday the Isle of Man parliament is debating the clauses of the Assisted Dying Bill which was introduced by Dr Alex Allinson who serves as an independent member of the House of Keys, roughly equivalent to the House of Commons at Westminster.

If the legislation is passed, it would only apply to those who have been resident on the Isle of Man for five years, to discourage so-called "death tourism".

Jersey's politicians approved the principle of legalising assisted dying in 2021.

On 21 May, Jersey's States Assembly will vote on specific proposals detailing how an assisted dying service could work .

Who is calling for a change in the law in the UK?

Campaigners have made numerous attempts to alter the law over many years.

Broadcaster Dame Esther Rantzen, who has stage four lung cancer and has joined Dignitas, launched a petition in support of assisted dying in December 2023.

It received more than 200,000 signatures, well above the 100,000 threshold needed to trigger a debate in Parliament.

That took place on 29 April and Dame Esther urged MPs to attend, despite the lack of a binding vote .

In February, she welcomed the Health and Social Care Committee's findings that end-of-life care had improved in some places which had legalised assisted dying.

She added, however, that she was "disappointed" that the committee had not called for a formal vote.

The Westminster government says any change is a matter for Parliament.

Proposals on assisted dying were last rejected in July 2022 but the government said it would provide time to debate the subject again . It indicated that MPs would be free to vote as they wished.

Labour leader Sir Keir Starmer says that he is "personally in favour of changing the law" on assisted dying and is "committed" to holding a vote on the issue if elected prime minister.

The current law has also been challenged in the courts with a number of people with terminal and life-limiting illnesses arguing for their right to die.

Assisted suicide campaigner dies aged 65

Ex-England cricketer backs calls for assisted dying

Who opposes euthanasia or assisted dying?

Both the BMA and Royal College of Nursing have neutral positions on assisted dying.

Others argue the current legal position around all forms of assisted death should remain the same.

Baroness Tanni Grey-Thompson is concerned that vulnerable people could be coerced into pursuing assisted dying and that it is hard to put adequate safeguards in place.

"We need to make sure people are protected," she told BBC Breakfast, arguing that medical complications can arise once lethal drugs enter the body.

Dr Gordon Macdonald, of anti-assisted dying campaign group Care Not Killing, believes there are "many problems" with changing the law.

He is worried that criteria for assisted dying could, in time, be extended beyond terminally ill people to include those with disabilities and conditions such as dementia and depression.

Actor and disability rights campaigner Liz Carr shares that concern which she explores in a BBC documentary Better off Dead?

She fears a world in which the poor, disabled or mentally ill may eventually feel compelled to have an assisted death, a prospect she calls "terrifying" .

Where is euthanasia or assisted dying legal around the world?

The Dignity in Dying campaign group says more than 200 million people around the world have legal access to some form of assisted dying .

Switzerland has allowed assisted suicide since 1942. Its Dignitas facility began operating in 1998. However, all forms of euthanasia are against the law.

Assisted suicide is also legal in neighbouring Austria .

In the US ,11 states allow assisted dying. Known as "physician-assisted dying", it permits doctors to prescribe lethal drugs for self-administration.

Physician-assisted dying is legal in Oregon, California, New Mexico, Colorado, Washington, Hawaii, New Jersey, Vermont, Maine and Washington DC.

In Montana, court rulings allow doctors to defend themselves if they assist in a person's suicide.

Voluntary euthanasia is legal in Canada where it is called medical assistance in dying. It can be provided by a doctor or nurse practitioner, either in person or through the prescription of drugs for self-administration.

It is also legal in Spain and Colombia , both of which also permit assisted suicide.

Assisted dying is legal in some parts of Australia but the law differs across states. It is not permitted in either the Northern or Australian Capital territories which have separate legal systems.

New Zealand's End of Life Choice Act legalises assisted dying and allows adults in their final months of life to request assistance from a medical professional.

Three countries have laws that allow people who are not terminally ill to receive assistance to die: The Netherlands, Belgium and Luxembourg .

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