Proposed amendments to the Health and Care Bill could change the law on assisted suicide.
Attempts are being made to introduce new clauses in the Health and Social Care Bill currently being debated in the House of Lords that would allow assisted suicide. One amendment is proposed by Baroness Meacher and the other by Lord Forsyth of Drumlean, Lord Falconer of Thoroton and Lord Warner. The clauses are reproduced below.
We understand that introducing clauses in this way is frowned upon by most Peers so it is possible that they will not be accepted. Nonetheless, it is yet another example of the lengths that our opponents will go to change the law on assisted suicide.
Here are a few of the essential points to be made regarding the amendments to the Health and Care Bill.
This is a Health and Care bill and therefore it should not be used to change the criminal law.
It is inappropriate to use amendments in this bill to open the door to assisted suicide when there is already an assisted dying bill in the House of Lords awaiting the committee stage.
The amendments made in the Health and Care Bill do not take into account the experience of other jurisdictions that have legalised assisted suicide and they contain no safeguards.
We urged the House of Lords to reject these proposed amendments.
203 Page 62, line 19, at end insert—
“(1AA) The regulations must make provision—
(a) for anyone with a diagnosis of terminal illness to be offered a conversation about their holistic needs, wishes and preferences for the end of their life, including addressing support for their mental and physical health and wellbeing, financial and practical support, and support for their social relationships,
(b) that, where that individual lacks capacity for such a conversation, it is offered to another relevant person, and
(c) that for the purposes of section 12ZB a relevant authority must have regard to the needs and preferences recorded in such conversations in making decisions about the procurement of services.”
297 Insert the following new Clause—
(1) The Secretary of State must, within the period of 12 months beginning with the day on which this Act is passed, lay before Parliament a draft Bill to permit terminally ill, mentally competent adults legally to end their own lives with
(2) In preparing the draft Bill and any accompanying documents and in making arrangements to lay them before Parliament, the Secretary of State must take account of the need—
(a) to respect that this is a matter of conscience, and
(b) to enable Parliament to consider the issue.”
Member’s explanatory statement
This amendment ensures that the scope of the regulations as to patient choice includes those atthe end of life.
Although it is early days it would seem that the latest attempt to change the law on Assisted Suicide will not make it through all the processes needed for the Meacher Bill to become law. This is not a great surprise as senior figures in government have indicated that it will not be supported.
Before we start cracking open the champagne bottles it’s important to recognise that this is just another step in a very long journey. The Bill may have further to go and will return in a different form perhaps, so we will once again have to deploy all of our resources to resist it.
Your continued support over the coming months will be crucial.
Now is the moment to say thank you to all of you who have helped us to get our points across and by so doing ensure that the voices of disabled people are heard.
Finally here is a link to Baroness Jane Campbell’s article in today’s Guardian which summarises our concerns.
Medics write a letter to Health Secretary against Assisted Suicide Bill which would let clinicians provide legal drugs for terminally ill people
By Christopher Hope, CHIEF POLITICAL CORRESPONDENT and Maighna Nanu Daily Telegraph
Nearly 1,700 doctors have written to Sajid Javid to oppose weakening assisted suicide laws, saying they will refuse to help patients take their own lives.
The intervention comes ahead of Friday when peers are expected to pass a Private Members’ Bill through the Lords which would allow doctors to provide lethal drugs to terminally ill people who want to end their lives.
Boris Johnson, the Prime Minister, and Mr Javid are understood to be against weakening the law – but the peers’ Bill is expected to go to the House of Commons within months when it will probably be put to a free vote of all MPs.
‘Enormous’ shift ‘should not be minimised’
The letter – signed by 1,689 doctors and sent to the Health Secretary on Tuesday – said: “The shift from preserving life to taking life is enormous and should not be minimised.
“It is impossible for any government to draft assisted suicide laws which include legal protection from future extension and expansion of those laws.”
They added: “Any change would threaten society’s ability to safeguard vulnerable patients from abuse, it would undermine the trust the public places in physicians, and it would send a clear message to our frail, elderly and disabled patients about the value that society places on them as people.
“Far from one person’s decision affecting no one else, it affects us all. Some patients may never consider assisted suicide unless it is suggested to them.
“The cruel irony of this path is that legislation introduced with the good intention of enhancing patient choice will diminish the choices of the most vulnerable.”
Signatories include Professor Johann de Bono, a professor in experimental cancer medicine at the Institute of Cancer Research; Prof David Galloway, the former president of the Royal College of Physicians and Surgeons of Glasgow; and Rob George, professor of palliative medicine at King’s College London.
They conclude: “We would not take patients’ lives – even if they asked us to – but for the sake of us all, and for future generations, we ask that the law remains unchanged.”
Concerns dismissed by Baroness behind the bill
It comes after the British Medical Association, the biggest union of doctors, dropped its opposition to assisted dying last month and adopted a neutral stance.
Baroness Meacher, pictured here speaking in the House of Lords, is the peer behind the Bill
The doctors’ concerns were brushed aside by Baroness Meacher, the peer behind the Assisted Dying Bill, who said: “It is always easy to find a list of people to support any position.
“More significant is that the BMA last month ended its opposition to assisted dying following their survey of their members showing a majority of doctors in favour of assisted dying.”
The Royal College of Physicians said it was neutral on the issue in 2019.
Recent research from the pro-assisted suicide campaign Dignity in Dying found that up to 6,500 terminally ill people try to take their own lives every year because of a ban on assisting their death.
The Bill states clearly that before assistance to die could occur the High Court (Family Division) would need to be satisfied that a person seeking assistance to die has the mental capacity to make that decision.
The attending doctor and independent doctor involved would need to be similarly satisfied of the person’s mental capacity. If they have doubt, they must refer the person for assessment to a specialist (any registered psychiatrist) and take account of any opinion given.
The Bill also states that the Secretary of State may issue Codes of Practice on issues including assessment of mental capacity; and taking account of depression and other psychological disorders that may impair a person’s decision-making (2 distinct topics, in one or more Codes).
On the face of it these sound like sensible safeguards; but they raise significant questions, some practical, some much more fundamental.
The fundamental challenge of providing safeguards linked to depression and other mental health challenges in the context of assessing capacity
The interaction between mental health challenges (‘psychological disorders’) and mental capacity is complex. Wesseley’s recent review of the Mental Health Act attempted to address its complex relationship with the Mental Capacity Act but there remain unresolved issues.
Assessing capacity in someone with both terminal illness and depression is not straightforward. Depression is common amongst people who are terminally ill: indeed a diagnosis of terminal illness is the kind of major loss that can trigger depression. A desire for suicide is a major symptom of depression, but it may also be a well-thought-through response to impending death. Weir argues that it is very hard to distinguish between the two. The person may be motivated by a combination of the two, in which case, how does the assessor decide whether the person’s desire to die is coloured more by depression or more by their rational response to terminal illness? And how do assessors across the country do so consistently?
In addition, depression tends to fluctuate, which presents both challenges in assessing what is truly the person’s ‘settled will’ – and opportunities to support people through their times of despair: with treatment and support, the wish to die can be ameliorated even if prognosis is short. Price et al (2014) summarise the research evidence as follows:
Depression is common in palliative care and desire for hastened death is strongly associated with depression in palliative populations. In Oregon it has been shown that depression is not always appropriately identified in patients requesting assisted suicide. There is evidence to suggest that treatment of depression can reduce the wish for hastened death
Even if the wish to die is coloured by depression, it is perfectly possible that she or he would still be assessed as having capacity (depending on the definition used – see discussion below). Many people experiencing depression or other mental health challenges meet the ‘capacity’ criteria of the Mental Capacity Act: they are quite able to understand information, weigh up options and communicate a decision on life issues large and small.
It is not straightforward to remove autonomy just because someone has depression; indeed it could be a case of disability discrimination if someone with depression, with capacity, were denied a ‘treatment’ option just because of their impairment (depression). If, as seems likely, large numbers of people with mental health challenges would be considered to have capacity, then the apparent safeguard for people with depression rather melts away.
It is also not clear that the attending independent doctors would always refer effectively for a capacity assessment. The Royal College of Psychiatrists pointed out that many doctors do not know how to assess for the presence of depression in people who are terminally ill.
The (potential) Code topic of ‘taking account of depression and other psychological disorders that may impair a person’s decision-making’ may sound like a safeguard that is additional to the (separately listed) safeguard of assuring that the person has mental capacity. However, the legal question (as laid out in this Bill) is simply whether the person has capacity to make this major decision. Therefore the ‘depression’ safeguard appears to be a subset of the ‘capacity’ safeguard – in effect a reminder to think about the impact of psychological disorders (alongside learning disability, dementia or other potential sources of incapacity) when assessing mental capacity to decide.
This would face mental health services and voluntary sector partners with a challenge. Should they sustain their long-standing commitment to prevent suicide amongst people experiencing mental health problems wherever possible, driven by a national policy agenda that has set targets for suicide reduction and ensured that every local area has an all-age multi-agency suicide prevention plan in place?  Should multiple agencies always start by reaching out to people who are seeking to die, listening, valuing them, supporting them to want to live? Or should they accept that for the sub-set of people with mental health problems who also have a terminal illness, the one question is whether they have the capacity to decide and have made a decision – in which case, would they ditch the whole approach to suicide prevention in favour of autonomy?
This dilemma brings into sharp focus some of the well-known contradictions between Mental Health and Mental Capacity law. Under Mental Health law, someone who DOES have capacity to make decisions can nonetheless be detained and treated against their will if they have a mental disorder and certain risk criteria are met. It seems possible that under this Bill someone could be given psychiatric treatment against their will – ie denied autonomy – but nonetheless have the right to assistance to die as long as they met the definition of mental capacity.
Much depends on how mental capacity is defined and assessed. Price et al note that where the ‘bar’ is set – on a continuum from a basic cognitive capability through to a full understanding of context and implications – has not been settled in jurisdictions with assisted dying legislation. Different clinicians set the bar at different points, influenced by factors including their own values. In a survey of US forensic psychiatrists, those with ethical objections to assisted suicide recommended higher thresholds for competence and a more extensive review of the decision . The Mental Capacity Act requires that clinicians first assume capacity and have to demonstrate a LACK of capacity to act in someone’s best interests. The Mental Capacity Act does not provide a clear framework for deciding whether someone DOES have capacity to make the major life and death decision of assisted suicide.
The Bill does not begin to address these dilemmas. It may gently imply that taking account of depression will offer safeguards; but these would risk being paternalistic if they applied to people with capacity (however defined). As drafted they may turn out to be a chimera.
In addition, there may be a question about whether some mental health problems ARE terminal illnesses. Someone with advanced anorexia, for instance, may be very reasonably expected to die within 6 months. Treatment options may have been exhausted. She or he might or might not have mental capacity to decide – but if they did, is there any reason they should not be assisted to die? The same could potentially apply to someone with severe depression who has not responded to treatment and makes repeated suicide attempts. In a climate of commitment to ‘parity of esteem’ between mental and physical ill-health, a non-discriminatory case could be made for accepting some people with mental health problems (and no other terminal illness) for assisted dying.
Finally, the Bill suggests another potential Code topic, on the information on treatment, support and end of life care that would be made available to the person. There is no requirement for actual availability of mental health support or end of life care – just a potential requirement to inform people of what does exist. This is a weak safeguard for people with mental health challenges in a context in which there are huge gaps and delays in getting mental health support: the Mental Health Foundation, for instance, estimates that 85% of over-50s with depression receive no help at all from the NHS. There are also of course no guarantees in the Bill of support with social isolation, financial challenges or inappropriate housing. These social determinants make mental health challenges (including suicidal depression) more likely in the first place; and once people have mental health problems, such social problems tend to intensify, in a vicious cycle. Surveys by the CQC of the experience of people receiving community mental health support consistently find that over 40% report that they would have liked support with finance, benefits and employment but did not get them. It would be quite possible for people to develop depression in the context of major social problems, subsequently become terminally ill, get no support with their isolation and poverty and opt to die while the opportunity to intervene with multi-faceted support went unaddressed.
On mental capacity assessments, the attendant and independent doctors must seek an opinion from a registered psychiatrist if there is any doubt about the person’s capacity. It is not clear, though, that every registered psychiatrist has the necessary assessment skills: many psychiatrists are much more familiar with assessing criteria for detention or treatment under the Mental Health Act (which do not include the mental capacity to make decisions) than criteria under the Mental Capacity Act. This increases the risk of inconsistent assessments of capacity. Assessing capacity amongst people with learning disabilities and autistic people has been found, in the Netherlands, to be inconsistent between clinicians and to be influenced by views of disabled people’s lives.
Secondly, we know that existing Codes of Practice are not implemented with sufficient effectiveness in relation to people with mental health challenges: the CQC’s 2019 evaluation of compliance with the Code under the Mental Health Act 1983 notes ‘particular areas of concern where we found that the guiding principles were not being routinely implemented to inform practice in the way they should’. This was true in fundamental areas such as using the least restrictive approach, and involving patients in their own care. ‘Through our review, we have not found evidence that the Code has prompted a substantial change in the way services are empowering and involving people in their care’. These are deep-rooted problems of culture and practice and we cannot assume that provision of one or more Codes on assisted dying would be sufficient to ensure that real engagement would take place with people with mental health challenges at a time when they were facing major decisions about their life and death. Similarly, the post legislative review of the Mental Capacity Act found that the Act was not being implemented in the way intended and that the duties imposed by the Act were not widely followed.
Parliament should think very carefully about these complexities rather than being reassured by potential Codes and safeguards that seem to melt away as they are examined. Ambiguities and complexities leave doors open to subsequent legal interpretation, challenge and legislative amendment that could expand the remit of this Bill and erode the apparent (but often flimsy) safeguards. There is a tension between the equality of disabled people and safeguards that have not been grappled with in this Bill. If there is an assumption that the presence of depression or other mental health challenges means someone should be denied autonomy, that flies in the face of the Mental Capacity Act and the equality of disabled people. If that is not the assumption, then the safeguards are very narrowly delimited, the Bill seems to drive a coach and horses through the mental health policy objective of suicide prevention and there may be risks of following countries like Belgium in making assisted dying increasingly available to people with mental health problems, and the Netherlands, where people with a learning disability and autistic people are being offered euthanasia by doctors who are unable to make consistent, competent capacity assessments.
People living with mental health challenges, learning disabilities, dementia and other cognitive impairments should be at the heart of a deeper discussion about assisted dying than has informed this Bill to date.
Liz Sayce. October 2021
This article is written in a personal capacity and does not reflect the views of any organization.
Liz Sayce chaired the Commission for Equality in Mental Health, hosted by the Centre for Mental Health, 2019-21. She is a Visiting Senior Fellow at the London School of Economics and was Chief Executive of Disability Rights UK (and its legacy charity Radar) from 2007-2017, where she led work for equal participation for all, through programmes on independent living, career opportunities and shifts in cultural attitudes and behaviour. Liz is a Trustee of ADD (Action on Disability and Development), Vice-Chair of the Social Security Advisory Committee and a member of the Disability Advisory Committee of the Equality and Human Rights Commission. She has been a Non-Executive Director of the Care Quality Commission and a member of the Healthwatch England Committee. With a background in mental health and disability policy, previous roles include Director of Policy and Communications at the Disability Rights Commission and Policy Director of Mind. She led an Independent Review into disability employment programmes for Government in 2011 and has published widely on mental health, disability and social participation. She undertook a Harkness Fellowship in the USA resulting in a book (From Psychiatric Patient to Citizen, 2000 – updated in 2016).
 A doctor ‘registered in the specialty of psychiatry in the Special Register kept by the General Medical Council’ according to the Bill
 Royal College of Psychiatrists Presidents’ Blog: Assisted suicide for the terminally ill 26/7/2014
 Price et al.: Concepts of mental capacity for patients requesting assisted suicide: a qualitative analysis of expert evidence presented to the Commission on Assisted Dying. BMC Medical Ethics 2014 15:32. doi:10.1186/1472-6939-15-32
 Rayner L, Lee W, Price A, Monroe B, Sykes N, Hansford P, Higginson IJ, Hotopf M: The clinical epidemiology of depression in palliative care and the predictive value of somatic symptoms: cross-sectional survey with four-week follow-up. Palliat Med 2011, 25(3):229–241
 Price A, Lee W, Goodwin L, Rayner L, Humphreys R, Hansford P, Sykes N, Monroe B, Higginson IJ, Hotopf M: Prevalence, course and associations of desire for hastened death in a UK palliative population: a cross-sectional study. BMJ Support Palliat Care 2011, 1:140–148
 Ganzini L, Goy ER, Dobscha SK: Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ 2008, 337:a1682
 Breitbart W, Rosenfeld B, Pessin H, Kaim M, Funesti-Esch J, Galietta M, Nelson CJ, Brescia R: Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA 2000, 284(22):2907–2911
First, a big “thank you” to all of you who managed to find a time to either send us messages of support or who put together one or two-minute videos explaining why you are so opposed to a change in the law on assisted suicide. These video messages are now being distributed to the House of Lords where we hope they will help persuade Peers not to progress the bill.
Our founder Baroness Campbell is preparing her speech for the debate to be held on the 22nd of October. As a precursor, she has written an article for the Parliament’s internal “newsletter” The House. You can read her article by clicking here.
Thank you for your response to our call for action. Tremendous!
Now we need more from you. Can you write to a member of the House of Lords?
As you know the debate on the Assisted Dying Bill takes place in the House of Lords on the 22nd of October so it is vital that as many disabled people as possible write to say why they are worried about a change in the law as proposed in the Meacher Bill.
Your email or letter doesn’t need to be more than one page or a couple of paragraphs.
We are urging you all to speak up because our voice needs to be heard in this vitally important debate. Remember Nothing About Us Without Us!
We have suggested some ideas to use. If you have any difficulties contact us at email@example.com
I’m/We are writing to you about the Assisted Dying Bill which has its second reading in the House of Lords on 22nd October 2021.
I/We really need your help in influencing other members of the House of Lords to reflect carefully on this Bill which will affect the lives of thousands of disabled and terminally ill people. As a disabled person, I am deeply concerned about the impact of the changes being proposed in the Meacher Bill. I/We am/are asking you to oppose the Bill.
(You could choose any one of these issues to include in your note)
– Non-existent and badly drafted safeguards to the Bill
– The inevitable change in the relationship between Doctor and Patient (Do no harm.)
– Potential abuse by Doctors of believing their patient will be better off dead (because they are subject to the same discriminatory attitudes as the rest of society)
– Possible coercion from family members
– Discrimination, for example between those with physical and/or learning disabilities.
– Slippery slope (for example other countries expanding the law to include non-terminal conditions and disabled people)
You only need to choose one or two of the above which directly affects your situation and/or that of someone who you advocate for.
If it helps, you can send your letters to us and we will address and send them on your behalf to firstname.lastname@example.org
Not Dead Yet UK urgently needs your help and there are easy ways here to join in and speak up.
We’re fighting for our lives again and the opposition will win if we don’t act now.
The Assisted Dying Bill goes back to the House of Lords on Friday 22nd October 2021 for its second reading when there is a big debate.
The Lords don’t realise how many people are very worried about this Bill.
The Bill is about making assisting suicide legal, including when people are not dyingyet – that’s why our opponents are trying to change the law.
The safeguards in the bill do not say assisted suicide must be a last resort and ONLY for people who are terminally ill.
End of life care is underfunded. This means people who are terminally ill don’t always get the help they need and they sometimes suffer.
But the bill is not about relieving suffering – it’s about ending many people’s lives early. Killing people isn’t the way to fix this problem.
We have a little time left to show how many of us (especially those with degenerative conditions, and long term illness), would rather see the government improve palliative care than make an assisted suicide Bill.
You can read more about NDY UK’s objections to the Bill here:
We know life can be a struggle – but we know someone’s suffering can be relieved without resorting to killing them.
Disabled people risk being killed because decent health care for us is seen by our opponents as too difficult, or too expensive to organise.
For example, young disabled people with mental health trauma are already being offered assisted suicides by doctors in other countries. In Canada, their government finance department has calculated that they save over £8,000 for every person killed.
We think the focus should be on improving the health and care support available – palliative care doctors and nurses are our allies in this and agree. After all, doctors and nurses have been supporting us to live!
We know many people who rely on life-saving health care are afraid of what will happen if assisting suicide becomes normalised, instead of trying to give us support for all our lifetime.
Those of us who can find a way to speak out need to advocate for many more people who can’t.
Click here to see the Ways You Can Help
Take Action Now!
We must fight for assistance to live – not assistance to die.
Help us ask the government to invest in life, not death
Share this notice everywhere you can.
Then share your views.
At the moment the Lords don’t know how many people are worried about this Bill.
We need to tell them!
Send us a one minute video or audio, or a short written message about your concerns – we will share these with Lords.
Here are some ideas and questions to help people get started – you could answer any of these.
Start your message by giving your name and your impairment if you can.
Why does this Bill which would make assisted suicide legal worry you?
Do you think the Bill is safe? If not say why you are worried.
How will it affect your health or social care?
How will it affect your mental well-being?
Will people treat you differently if assisted suicide is available?
Will it undermine your rights?
How will it affect other people?
Do you think there will be a widening of who this law would apply to after it came in?
Nobody chooses to feel so desperate that they want to commit suicide.
We all need to be able to choose a decent life and then have support to die comfortably, peacefully, and with the people who matter to us when our time eventually comes.
We know people are often unsupported and many will unnecessarily feel they have no choice but to die by suicide because of unmet care needs. It doesn’t need to be this way. We shouldn’t be ok with it.
Support to live a better life is not offered as a choice in this bill.
Investment in better palliative care is not a choice in this bill.
Our lives are worth living and we deserve a good quality of life – not a beastly choice between suffering or being put down like a pet with expensive health needs.
The recent Covid 19 pandemic has highlighted how disposable our lives are to this government.
There have been numbers of cases reported of disabled and older people having Do Not Attempt Resuscitation notices applied to them, without consent.
Many of us were formally ruled out of the right to intensive care support, in advance.
More than a million of us weren’t added to shielding lists.
Many learning disabled people living in shared housing died because of the lack of safe support and protection.
Suicides in our community have increased.
This is the worst time in modern history to offer people suicide instead of real help!
It’s About Us – Without Us
The opinions of the wider public show they want assisted suicide. But they may have no or little experience of the real lives of the disabled people this law will apply to. They do not understand or know about the many struggles that we overcome every day. They find it difficult to believe that our lives are meaningful.
We do know this – but views from people directly affected are not being heard – we need to speak up together! Our views should be central – because it’s about us.
No disabled people’s organisations have ever campaigned FOR this. Only against.
We believe that the majority view is that we cannot trust this erosion of our rights – please help us prove that is what many of you think.
More about public opinion and statistics are here:
Doctors and medical students at the BMA annual representative meeting on the 14th of September passed, by a narrow majority, a motion which said: ‘In order to represent the diversity of opinion demonstrated in the survey of its membership, the BMA should move to a position of neutrality on assisted dying including physician-assisted dying.’
The motion was carried by 49 per cent of representatives, with 48 per cent against and 3 per cent abstaining.
This supersedes the association’s previous policy of opposing assisted dying, which had been in place since 2006. Being neutral means the BMA will not support or oppose a change in the law.
Separately, the BMA representative body passed another motion calling for ‘robust conscience rights’ to be included in any future legislation on assisted dying in the UK, meaning healthcare workers should be able to object conscientiously to participating in assisted dying.
The move to a position of neutrality comes after the association polled its membership on the issue last year. When asked about a change in the law to permit doctors to prescribe life-ending drugs to eligible patients, the survey found:
40% of surveyed members said the BMA should actively support attempts to change the law, one in three (33%) favoured opposition and one in five (21%) felt the BMA should adopt a neutral position
Half (50%) of surveyed members personally believed that there should be a change in the law to permit doctors to prescribe life-ending drugs. 39% were opposed, with a further 11% undecided.