The Proposed Law on Physician Assisted Dying in England and Wales Reaches the House of Lords: Concerns Remain
On 20th June 2025, the Terminally Ill Adults (End of Life) Bill proposed by the Labour MP Kim Leadbeater narrowly passed its third reading in the House of Commons (HC) (313 votes in favour, 291 against and 39 abstentions) and is now awaiting its second reading in the House of Lords. Since its introduction in the HC in October 2024, the Bill has undergone extensive amendments; however, the final draft presented to the House of Lords (HL) still contains a number of causes for concern. Before turning to these concerns, it is important to understand how the process for physician assisted suicide (PAD) would function.
The general requirements to access PAD are that the adult patient have clear capacity to make an informed decision (in accordance with the Mental Capacity Act 2005) (clause 3) and be affected by a terminal illness that cannot be reversed by treatment and whose prognosis is less than six months (disability and mental disorders per se do not count as terminal illnesses for the purpose of the Bill) (c.2). The patient needs also to be ordinarily resident in England and Wales for at least 12 months prior to their decision to end their life and to be registered with a general practitioner in England and Wales (c.2).
From the doctor’s perspective, it is not mandatory to raise the provision of PAD with a patient; however, if doctors think it would be appropriate to discuss the matter, even proactively, they can do so providing the patient is over 18 (c.6). A practitioner can decide to opt out of the PAD process (c.31) as long as he or she is able to reroute the patient towards getting further information (c. 5.6) and having a preliminary discussion about their wish to end their own life (c.6).
From the patient’s perspective the path to access PAD is the following. The preliminary discussion, when PAD is simply raised and informally discussed, would need to be followed by a first declaration signed and witnessed (c.8) by both a ‘coordinating doctor’ and another person (c.9). Following this first declaration, the coordinating doctor may begin their first assessment to determine whether the patient meets the eligibility criteria (c.10). After a first ‘7-day period of reflection’ (c.11.2(3)), a second doctor conducts an independent evaluation (second doctor’s assessment) to verify the findings of the first (c.11). It may also be necessary to obtain a further assessment should the previous doctor not be satisfied that the patient meets the required criteria.
Then, the first declaration alongside the two medical reports is sent to the Voluntary Assisted Dying Commissioner appointed by the Prime Minister. To be eligible for the role, the Commissioner has to occupy or to have held office as a judge of the Supreme Court, Court of Appeal or High Court and, among their responsibilities, the Commissioner oversees the multidisciplinary Assisted Dying Review Panel under many aspects (c.4). Afterwards the Commissioner needs to forward the documents to the Panel in order for them to assess whether the patient meets all the criteria to access PAD; in particular, whether the patient has capacity and has taken the decision to end their life without any form of pressure or coercion (c.16). Once the Panel has unanimously issued a certificate of eligibility (c.18) a second declaration needs to be granted certifying again, among other things, that the patient took their decision free from any form of coercion. It has to be witnessed by the coordinating doctor and another person. This is followed by a second ‘14-day period of reflection’ which can be shortened to 48 hours, if certain conditions apply (c.19). The Secretary of State needs to made provisions apt to the appointment of independent advocates whose role is to provide support to people with learning difficulties, mental disorders or autism in relation to PAD (c.22). Once all conditions apply, the coordinating doctor can provide the patient with the lethal substance to be self-administered. The coordinating doctor (or another authorised registered medical practitioner) must be available to the patient until the end of the process (c.26), though not necessarily in the same room (c.25).
A cause for concern relates to the suitability of the Assisted Dying Review Panel as a workable and reliable final safeguard for the patient. One of the most relevant changes introduced by the HC parliamentary committee on the Bill is the replacement of court oversight in PAD applications. In fact, in the original version of the Bill the safeguard was intended to be the High Court, and, possibly, the Court of Appeal (c.12). However, positive decisions delivered by the High Court could not be appealed. Sir James Munby, former President of the Family Division of the High Court of England and Wales, highlighted several potential issues related to this clause which made the proposal “wholly inadequate.” Not only could the wording of the clause allow too many interpretations of the role of the judge, but it was assumed that judges’ workload would significantly increase in a way impossible to sustain within the current judiciary system. It was also unclear whether the judicial process would have been carried out through public hearings or, more secretively, ‘on papers’ as a box-ticking exercise.
Along the same lines, Lord Sumption, former justice of the Supreme Court, while giving evidence to the HC Committee on the matter, raised a question that clearly summed up similar concerns regarding the role of the judge, asking: “[I]s he [the judge] there in order to ensure that the two doctors have done their job and that the ducks are all in a row, or is he there to form his own view on all of those matters, completely independently of those who have already given their certificates? If it is the latter, one is talking about quite a time-consuming process involving a lot of additional evidence.”
However, the current replacement of the court safeguard with panels of three professionals, namely, a legal member (chair), a psychiatrist and a social worker equally raises concerns. While the idea of multidisciplinary panels appears to offer a more hands-on safeguarding process, at the same time their merely bureaucratic role cannot be avoided by the simple wording of the Bill. In fact, the panel is not under any duty to question either the medical practitioners or the patient involved in the procedure or any family or persons relevant to the patient – the repeated use of may instead of must points in this direction (c.17.4). Moreover, the panel’s decision whether to grant a certificate of eligibility can be appealed only by the applicant to the Commissioner should a certificate be refused by the panel (c.18). However, it is worth noting that the Commissioner is also the person in charge of selecting members of panels and monitoring the Bill’s functioning; hence potential conflicts of interests or unintended bias within this safeguarding process are likely.
Furthermore, the parliamentary debate on the Bill raised issues about the feasibility of the panels in terms both of human resources necessary to cover these roles and also more fundamental issues related to safeguards in place. On the one hand, it is worth remembering that those bodies say that they do not have enough personnel to deploy for these positions. On the other hand, some more fundamental issues have been raised, such whether the Bill meets the needs of patients. The Royal College of Psychiatrists opposes its enactment because among other factors as Dr Annabel Price argues they not only lack sufficient psychiatrists to meet current needs, but there is also the pressing worry that the Bill, as it stands, cannot shield patients with mental disorders and intellectual disabilities from coercion. The aim of the Bill appears to be to empower patients to make autonomous decisions about their own death. However, to ensure that these choices are not unduly influenced, it is essential not only that patients are capable of making such decisions, but also that they have genuine options to choose from.
In regard to making informed medical decisions, the Bill relies on the Mental Capacity Act 2005, whose main purpose is to protect vulnerable people who lack capacity to make decisions about their care and finances. However, as the Royal College of Psychiatrists points out the goal of the Mental Capacity Act has never been stretched to assessing whether individuals could make informed decisions about ending their own lives through the use of a lethal substance – particularly within a very short timeframe of two to four weeks, at most – for a decision that is irreversible and where options to implement enhanced mental capacity tests have been rejected. Leadbeater argues that PAD, as it stands, would have more safeguards than refusing life-sustaining medical treatments. However, the withdrawal of unwanted treatments for patients who have capacity and can clearly articulate their decision (where they fully understand that it may hasten their death) is considered a cornerstone of patient autonomy – not merely because it is governed by protocols and overseen by the Court of Protection in case of disputes, but because unwanted medical treatments are seen as a form of abuse. The decision can also often be reversed if the patient later chooses to resume treatment they had previously declined.
Finally, at the end of life, palliative care should be a central option available. Even though Leadbeater is adamant that palliative care can go alongside PAD provision, the Association for Palliative Medicine in their written evidence submitted to the HC has been unwavering in saying that palliative care provision is currently inconsistent and that funding should be long-term and government-secured. At the moment, in fact, hospices, unlike NHS care (the umbrella under which PAD would fall) receive from the government only about a third of their income, relying on charitable funds for the rest. When it comes to end-of-life decisions, then, how can a choice be truly informed if palliative care access in the UK remains inadequate?As Krause and Boldt argue, patients’ autonomy and care need to be principles carefully balanced since autonomy guarantees a right to self-determination regarding unwanted medical treatments, while care ensures, not only that medical interventions do not unnecessarily harm patients, but, also, that management of pain and other symptoms becomes paramount in an holistic approach to healthcare. Hence, the question is whether the implementation of PAD may not only undermine this balance, but also irreversibly alter the very concept of healthcare, despite the legal safeguards in place.