What do opponents of assisted suicide fear? It isn’t just that thousands of people will request lethal drugs because they feel like a burden, because their care is too expensive, because they are depressed, because they were let down by the system. It isn’t just the deaths from coercion, manipulation and malpractice. There is something else as well, harder to describe but nevertheless important.
Last week, the MPs examining Britain’s assisted suicide bill voted through a very remarkable subclause. A single sentence, tabled by the bill’s chief architect Kim Leadbeater, quietly altered the definition of the National Health Service. The NHS’s original legislation in 1946 laid down that it must “secure improvement in the physical and mental health of the people of England…and the prevention, diagnosis and treatment of illness.” None of which really includes assisted suicide. If Leadbeater’s bill manages to pass its future votes in the Commons and Lords, this might have opened the government to a legal challenge.
Hence the subclause, which allows the Health Secretary to declare that “commissioned VAD [voluntary assisted dying] services” are in fact part of the NHS’s legislative charter. The subclause doesn’t explain why: It just ensures that the government can say so. Which, as the Tory MP Danny Kruger observed, effectively admits that the National Health Service would turn into a different kind of institution. It would, through this tweak to its founding legislation, become the National Health and Assisted Suicide Service. But the alarm was loudest on the other side of the Commons. Labour MPs tend to regard the NHS as their party’s definitive achievement, the greatest edifice of the postwar welfare state built by Clement Attlee’s government. After the subclause went through, six Labour MPs signed a letter calling the bill “irredeemably flawed and not fit to become law,” noting—among a dozen other issues—that it makes “a change to the founding language and purpose of our NHS.”
People sometimes roll their eyes about the British veneration of “our NHS”—so much taxpayer money, so many scandals and screw-ups—but overall the affection for the health service is to our credit. It is something to have made a national symbol out of looking after the sick and making it free at the point of use. Or it was something, anyway. Now the NHS’s role might become more ambiguous.
“Wherever assisted suicide is introduced, it redefines the meaning of care.”
Wherever assisted suicide is introduced, it redefines the meaning of care. Take suicide prevention. Professor Sir Louis Appleby, who leads the National Suicide Prevention Strategy for England, has noted that his work relies on a universal principle: “Of protecting people at their lowest point, helping them find something worth living for, however bleak life looks.” Whatever limits you place on an assisted suicide law, Sir Louis writes, it still threatens an entire social ethos. “Once the principle behind suicide prevention has been set aside, once any part of the ground has been ceded—not only to allow suicide but to assist it—we have lost something we may not get back.”
One answer to this is to suggest that it isn’t actually suicide if someone is, you know, really ill. “To me,” argues Kit Malthouse, Leadbeater’s Tory right-hand-man on the committee, “suicide is a healthy person taking their own life.” In a similar spirit, the Australian MP Alex Greenwich told British parliamentarians in January: “Voluntary assisted dying in New South Wales is an important form of suicide prevention.” (In truth, legalized assisted suicide seems to be correlated with a rise in non-assisted suicide rates.) Can the organized supply of lethal drugs to people who want to end their lives be described as suicide prevention? Yes, in the same sense that assisted suicide can be added to the principles of the National Health Service. All it takes is a little finessing of language.
But that finessing reveals that assisted suicide will steal the heart of our society. It will take what we thought we knew about caring for each other and throw it into doubt. Trying to persuade a loved one out of assisted suicide, according to Kim Leadbeater, may qualify as “coercion.” One California doctor, invited to address the committee, suggested that such interventions from relatives should be made illegal (“a misdemeanor, a felony, or whatever”); the Leadbeater bill contains no obligation to inform family, as well as no avenue for the family to appeal if they think a mistake has been made in granting an assisted suicide.
During the committee, a group of Labour MPs proposed a common-sense amendment: to prevent doctors from raising the subject of assisted suicide with under-18s (who are not eligible for the formal process of applying for lethal drugs). Leadbeater rejected the amendment on the grounds that “We should not prohibit open conversations with terminally ill young people and their families, as they create openness, transparency and safeguards.”
To recap: Taking your own life isn’t suicide, the provision of lethal drugs is suicide prevention, begging a loved one to stay alive is coercion, and the rejection of a safeguard “creates safeguards.” It is sometimes worth asking, in the words of WS Graham, what is the language using us for? This kind of language, this style of thought, uses us to obliterate what we thought we knew about our duties to each other.
Even the institutions known as beacons of compassion, once assisted suicide is legalized, take on a different character. Palliative care, and more specifically hospice care for those nearing the end of life, is one of the signal achievements of modern medicine. Both in removing physical pain, and in addressing the complex emotional needs of the terminally ill, it can be transformative. But in jurisdictions with assisted suicide, it begins to hold a more brutal meaning. One Oregon nurse has lamented that “There is an attitude among many of our clients that ‘If I go into hospice, they’re going to kill me because that’s what a hospice does.’”
The effect of these laws extends far beyond those actively involved in suicide provision. By incorporating killing as one solution among others, these laws re-engineer relationships within families, and between doctors and patients. That is the lesson of fascinating new research from the New Zealand palliative care doctor Sinéad Donnelly, which has not yet been published but about which I spoke to her earlier this month.Professor Donnelly and her colleagues interviewed 41 healthcare professionals—doctors, nurses, social workers—in 4 Wellington hospices. None of the hospices directly take part in assisted suicide (only one of New Zealand’s 30-odd hospices does); but all of them have been touched by the change since the law altered in 2019. Conversations in end-of-life care, according to Donnelly’s fieldwork, have changed fundamentally, and not for the better. One traditional strength of palliative medicine is that it treats the patient as a unique individual in all their complexity. That attentiveness is part of its definition of care. But on my reading of Donnelly’s work, assisted suicide has begun to erode that tradition. In practice, the patient becomes less of an individual, more of an instance of one of two categories: the eligible and the ineligible.
“Every one of those problems makes itself felt in the NHS.”
One social worker, Donnelly writes, “identified that the move to assisted dying as a response to suffering was already becoming very rapidly normalized.” Palliative care is meant to involve exploring the sources of patients’ suffering—not just physical pain, but the patient’s fears, questions, and individual needs. Now, the study suggested, palliative care staff are increasingly reluctant to engage in conversations about suffering. Partly because it could lead into fraught legal territory—it is an offense to obstruct somebody’s assisted suicide application—and partly because the conversations are no longer as open-ended as they used to be. As one doctor told Donnelly’s study: “From our normal way of exploring what suffering is, instead of exploring it we’re saying, ‘Here’s the phone number.’”
New Zealand, as with the proposed UK legislation, requires a 6-month diagnosis of an irreversible condition. It also, unlike the UK, includes a requirement for “unbearable suffering.” With assisted suicide in the background, there are suddenly two very different kinds of care pathway. Donnelly cites one doctor who was looking after a patient, went off shift, came back and discovered that while they had been away the patient had said, “I wish it was all over.” The staff had suggested assisted suicide, and the patient began looking into an application. Then the first doctor returned, worked out that the patient had a particular respiratory problem, adjusted their medication and the subject never came up again.
What is it to care for your patients? The question, which normally answers itself, becomes ambiguous and complex. One doctor told the study: “It brings my role into question.” Another doctor remarked: “People focus so much on the assisted dying that some of the palliative care just goes a little bit by the way.” And nurses found that the law had changed attitudes. “It’s just my observation,” said one, “that there’s a different attitude and a bit of a different journey. Because my experience is they don’t seem to want to accept our help.”
Within families, too, caregiving has a new cut-off point. One person’s sibling suggested assisted suicide: The person was devastated and the siblings’ relationship broke down. Nevertheless, they took up the suggestion and applied for the assisted suicide.
Donnelly cites another example: “A person didn’t want to go to a rest home, and a friend offered to look after them, and after a certain number of weeks the friend said, this is too much. And the person had to go to a rest home, and they’d rather die than go to a rest home, so they went on the assisted dying path.”
“It’s very human,” she adds. “These are not surprises to all of us who campaigned against it. There’s no surprises in any of these consequences.”
Listening to Donnelly, I was reminded of one of the most eloquent voices of criticism of the UK bill: the Orders of St John Care Trust, the second biggest non-profit care provider in the country. The Trust argues that the bill would create enormous distress for care workers, who become friends and confidants of care home residents. What if someone wants to receive an assisted suicide, and wants to be accompanied by the care worker they know best? And what if the procedure has complications, as is not at all unknown in assisted suicide? For residents of care homes, too,
a change in the law may unintentionally create a constant burden of deliberation, additional pressure through witnessing the choices of fellow residents to opt for assisted dying and potentially a stressful environment where residents perceive they are being continuously assessed about whether they qualify.
Again, knock out the universal principle—we will care for you until the very end—and the atmosphere shifts decisively. There are two kinds of existences: those worth living, and those not worth living. A colder, more impatient, more utilitarian logic begins to work its way into our relationships.
Stepping back a little, it is hard not to see a connection between the assisted suicide bill and the national condition in 2025: our crumbling public services, bewildered government, and extractive rentier economy. Hospices are struggling to stay open. The care sector survives on superhuman self-sacrifice and poverty wages (“a miracle sitting on top of a disgrace,” as one care manager has said.) Working-age parents are squeezed for every last penny and every last minute. There isn’t enough to go around—not enough cash, not enough time, not enough attention. And every one of those problems makes itself felt in the NHS, where waiting lists have hit record highs, 30 per cent of staff feel burnt out, and hospitals are so swamped that one hospital recently advertised for a “corridor care” doctor. Health and social care is perhaps the defining challenge for the current generation of politicians, and officially they all want to solve it. But wouldn’t it be easier, a voice seems to whisper, to just give up?