Protecting care homes and hospices form forced participation in assisted suicide
What are conscience clauses?
Conscience clauses are explicit provisions in law that create exemptions from legal or contractual obligations that would otherwise be imposed upon citizens or bodies.
For example, in England from the mid-18th to the mid-20th century, the state compelled citizens to bear arms (1757);[1] swear an oath when giving evidence in court (1838);[2] to have their children vaccinated (1898);[3] to bear arms [again] (1916)[4] and to receive religious instruction (1944).[5] In each case the law provided exemptions on the grounds of conscience, though often these accommodations were conceded only after dissenters had been fined or imprisoned.[6]
The Abortion Act 1967 did not create a legal obligation to participate in abortion. After all, no one is obliged to become a nurse or a doctor. Nevertheless, a conscience clause was needed to protect healthcare professionals from being put under a contractual or professional obligation to perform abortion. This protection aimed to prevented conscientious professionals from being forced out of the profession.
These conscience clauses began as the recognition of the disproportionate negative impact of new legal or contractual obligations on members of minority communities. They are now understood as expressions of a fundamental human right to freedom of thought, conscience, and religion.[7]
This right of freedom of conscience is upheld in international instruments such as the Universal Declaration of Human Rights 1947 and the European Convention on Human Rights 1950. It is also recognised by many religious authorities including the Catholic Church in its 1965 document Dignitatis Humanae[8] and by many professional bodies including the World Medical Association International Code of Medical Ethics 1949 (updated 2022).[9] The European Convention on Human Rights was incorporated into UK law by the Human Rights Act 1998.
Since a general right to freedom of thought, conscience and religion is now enshrined in UK law, it might be imagined that specific conscience clauses are no longer needed. However, more specific laws provide more robust and more clearly defined protections. Where a required practice is known to be highly controversial there is a need for an overt conscience clause. It is widely agreed that any law on assisted dying (assisted suicide and/or euthanasia) merits overt conscience protection for professionals. No healthcare professional or associated worker should be forced to participate in the course of their professional duty or employment in the intentional ending of a patient’s life.[10]
Protection for institutions
The paradigm of a right to ‘conscientious objection’ is protection of an individual from an obligation to act against his or her deeply held beliefs. It concerns the rights of an individual over and against an institution (or over and against the state).
In this context, the language of ‘institutional conscientious objection’ seems novel and perplexing. For example, in response to a proposed amendment to the Assisted Dying for Terminally Adults (Scotland) Bill, the Cabinet Secretary for Health and Social Care (Neil Gray MSP), speaking for the Scottish Government, stated that:
Amendments 231 and 232 seek to provide for some form of institutional conscientious objection. It is not clear how an institution might demonstrate what its conscience position is, given that conscientious objection concerns the personal beliefs of individuals. Such a provision would be novel in our legal system.[11]
However, what is novel here is only the language of ‘institutional conscientious objection’. There is nothing novel in providing legal protection for the character, ethos or mission of an institution. All institutions act within the parameters of their mission, governance structures, and policies. The institutional ‘conscience’ position on a practice such as assisted suicide may be demonstrated clearly where it is explicit in the foundation documents or in the duly agreed policy statements of that organisation.
Indeed, charities are bound by law to follow their foundation documents insofar as those requirements are themselves lawful and, in general, it is lawful to limit what services a charity offers if its pursuing a legitimate aim.[12] For example, a hospital set up by a charitable trust can require that interventions are only offered if these are compatible with the ethical code of the institution that is agreed by the governing board and trustees.
In some cases, where the law creates new obligations, it creates specific protections for institutions. For example, there is now a general legal obligation (under the Equality Act 2010) not to discriminate on the basis of religion. Voluntary-aided faith schools have therefore had to be provided with express legal permission in order to allow them to give preference to pupils from a specific faith community.[13] Similarly, faith schools are permitted to specify religious beliefs or practices required for specific employees where this is justifiable as a genuine requirement of a role.[14] Such protections are defensible on the basis of broader principles of equality and diversity, and they are compatible with the aims of equality law. It is helpful, nevertheless, to have these protections also made explicit in statute law for the avoidance of doubt.
Protection for institutions from participation in ‘assisted dying’
There are several reasons for including overt protections for institutions in a Bill to legalise assisted dying (that is, assisted suicide and/or euthanasia).
- This practice is clearly contrary to the strongly held religious beliefs of some communities. If no institutions were able to respect these religious beliefs, this would disproportionately affect some minority communities.
- The provision of end-of-life care and of social care in England and Wales has benefited greatly from the contribution of hospices and care homes of religious foundation. In many cases participation in assisting suicide or euthanasia would be incompatible with the ethos of these institutions as reflected in their foundational documents. It is all but inevitable that a significant number of institutions might have to close if not provided with institutional protection.[15]
- More generally, the ability of institutions to govern themselves, where this is compatible with the common good, is a matter of justice. The principle of ‘subsidiarity’ recognises the importance of action by groups and communities between the level of the individual and the state.[16] Protection of the ethos of an institution should not be limited to religious foundations.
- Both hospices and care homes are under great financial pressures and struggle to recruit and to retain staff.[17] Participation in assisted suicide or euthanasia would alienate at least some supporters and at least some staff. Protection for institutions could help mitigate these pressures.
- There is clear public support for the freedom of hospices and care homes not to be forced to participate in ‘assisted dying’ if it is legalised (between 58% and 67% depending on how the question is asked).[18]
- While some people may welcome a change in the law, others will feel threatened by authorities providing people with the means to end life, and specifically by the possibility that staff or managers of care homes might offer or encourage this. The possibility of ‘safe spaces’ where patients or residents and their families could feel secure that this was not a possibility would be valued greatly by some.[19] It needs to be recognised that an atmosphere and ethos of genuine care that allows people to have the best experience at the end of their lives is hard to establish but easy to destroy.
- It cannot be argued that participation of these institutions is necessary for the implementation of the law, for it would clearly be possible, in principle, to set up a distinct ‘voluntary assisted dying service’ independent of existing institutions and care pathways. Such an independent ‘opt in’ services has been advocated by the British Medical Association, among others.[20] This is the model that has been adopted by Jersey for its assisted dying service.[21] This model would also help clarify the time and resource costs of the new ‘service’, which otherwise might would take resources covertly from existing services such as general practice and/or palliative care.[22]
Protection of institutions in the United States
During the debate over the Terminally Ill Adults (End of Life) Bill, it was alleged that protection for institutions, while it might seem desirable, was unworkable in practice. For example, it was claimed that ‘the service might not be available or could be much more difficult to access’ if institutions were able to be protected.[23]
This assertion can be tested by looking at those jurisdictions which have legalised assistance for terminally ill people to end their own lives. The first jurisdiction to pass such a law was Oregon. It legalised ‘physician-assisted suicide’ for ‘terminally ill Oregonians’ in 1997.[24] Oregon has provided the model for similar laws in eleven other States in the United States,[25] plus the District of Columbia.
The law in Oregon includes express provision both for individual conscientious objection and for protection of institutional healthcare providers.
In relation to individual conscientious objection and institutional protection, the statute stipulates that ‘no health care provider shall be under any duty, whether by contract, by statute or by any other legal requirement to participate in the provision to a qualified patient of medication to end his or her life’.[26]
The statute further stipulates that professionals cannot be censured either for participation or for non-participation: ‘No professional organization or association, or health care provider, may subject a person to censure, discipline, suspension… or other penalty for participating or refusing to participate’.[27]
However, the right of professionals to participate is qualified by the right of healthcare providers to prohibit participation ‘on the premises’ or while ‘in the course and scope’ of being an employee or contractor.[28] If an institution has a policy of prohibition, and has notified employees of the policy, then employees who violate the institutional policy can be penalised.
These three elements: that providers (individual or institutional) are under no duty to participate; that professionals cannot be censured either for participating or for not participating; and that the right for individuals to participate is qualified by the right of healthcare providers to prohibit employees and contractors from participating, are replicated in every US state that has legislated to allow terminally ill people to be given the means to end their life.
Protections for healthcare institutions not to have to participate in provision of assisted suicide are included in the laws of Oregon,[29] Washington,[30] Vermont,[31] Colorado,[32] California,[33] District of Columbia,[34] Hawaii,[35] New Jersey,[36] Maine,[37] New Mexico,[38] Illinois,[39] Delaware,[40] and New York.[41]
In some cases, these laws have been modified or contested. In California, the institutional protections were at first very strong. However, once the law was passed, a subsequent amendment weakened the institutional protections by placing further requirements on non-participating institutions.[42] In New Mexico, after the law was passed, a law suit led to a subsequent amendment strengthening the conscience protection provisions (excluding an obligation to refer).[43] In Colorado, the law allowing institutions not to participate did not prevent a dispute between a non-participating hospital and a doctor who wished to offer ‘medical aid in dying’ to a patient.[44] The case was settled out of court leaving uncertainty over the application of the law.
These laws vary somewhat in scope and strength and offer only partial protection for institutions. Some restrict what is included in ‘participation’. All include only healthcare entities, which would cover hospices and specialist nursing homes but not care homes more generally. Nevertheless, all these statutes concede the principle that the law can and should provide protection for the ethos of institutions. Such protection has been shown workable in the jurisdiction with the longest history of statutory provision of assisted dying (almost 30 years).
It should also be noted that the United States is the only country with experience of the model put forward in Scotland and in England and Wales: of providing terminally ill adults with the means to end their own life. All other jurisdictions with ‘assisted dying’ permit euthanasia (direct ending of life by a doctor or nurse)[45] and/or permit ending the life of people who do not have a terminal illness.[46] These practices (euthanasia and ending life of people who are not dying) are associated with far higher rates of death.[47]
Institutional protection in the Assisted Dying for Terminally Ill Adults (Scotland) Bill
The Assisted Dying for Terminally Ill Adults (Scotland) Bill was rejected by the Scottish Parliament on 17 March 2026 by 69 votes to 57.[48]
Among the concerns raised by the Bill was the removal of the conscience clause. The Scottish Government, in discussion with Westminster, determined that this aspect of Bill was beyond the competence of the Scottish Parliament.[49] The clause had to be removed so that, if the Bill passed, the Scottish Government would then ask Westminster to add legislation to protect conscience.
The lack of overt conscience safeguards on the face of the Bill led to it being opposed by the Royal College of Psychiatrists of Scotland, the Royal College of General Practitioners (RCGP) Scotland and the Royal College of Physicians and Surgeons of Glasgow, among others.[50] The concern was not that law would have no protection of conscience but that it was unclear what form this protection would take.[51]
The Bill as agreed at stage 2, before the section on conscience was removed, protected both professionals and institutions:
18 (1A) An individual or organisation must not be subject to any detriment for not participating in anything authorised by this Act to which that individual or organisation has a conscientious objection.
This clause had the advantage that its protection of institutions was not specific to healthcare providers, hence it would have protected care homes as well as hospices. Note that this protection would not require that all hospices or care homes had a policy of non-participation. It would be for the institution, in line with its foundation documents, ethos and its governance processes, to decide whether or not to participate.
Lack of Institutional protection in the Terminally Ill Adults (End of Life) Bill
In contrast to the laws in the United States, the Bill in Scotland at Stage 2, and the Assisted Dying (Jersey) Law 2026, the Terminally Adults (End of Life) Bill[52] has no provisions for protection of institutions.
The Bill does not use the word ‘conscience’ or ‘conscientious objector’. Instead, it includes a section entitled ‘No obligation to provide assistance etc’.[53] This section begins with what seems to be a clear statement that ‘No person is under any duty to participate in the provision of assistance in accordance with this Act.’[54] However, this seemingly broad protection is qualified by a later clause that imposes duties in relation to notification, record keeping, and provision of information, irrespective of conscience.[55]
The Bill is novel in English law in that it includes employment law protections for those who participate. These are set out in detail in Schedule 3 of the Bill. The protection from censure either for not participating or for participating is closely parallel to the law in Oregon. However, unlike the law in Oregon and in US States with similar laws, Schedule 3 does not qualify this right with the right of institutions not to participate. The unqualified right to participate has the implication that institutions could not discipline a healthcare professional who violated the policy of the institution not to participate.
In this context it is noteworthy that the Bill does not prohibit a professional from raising this issue with a patient who had not asked about it.[56] Nor does the Bill prevent a professional from actively and repeatedly encouraging a patient to make use of a lethal substance to end their life.[57] This is not an abstract possibility but one that has been realised in other jurisdictions, much to the distress of the patients involved.[58] There are also no requirements in the Bill about where the preliminary discussion about assistance with ending life occur, so these might occur in a communal area. Indeed, there is nothing in the Bill that prevents a doctor from giving a patient a lethal prescription knowing that the patient intends to take the substance in a communal area, for example in a garden, notwithstanding the distress this could cause to other residents.
Because of Schedule 3, there is no action that an institution could take against an employee who both violated the policy of the institution and caused distress to other patients, residents and their families, or staff, if the employee was performing some function under Act and was acting in accordance with its provisions.
It needs to be emphasised that the Bill does not simply lack protections for institutions or employers. By creating a specific protection in employment law to participate, the Bill undermines the reasonable rights of institutions and of employers that would otherwise apply. This is without precedent in any previous ‘conscience clause’ in UK law.
The Terminally Adults (End of Life) Bill in its current form is an existential threat to any institutions whose foundation documents are incompatible with participation in the act of intentionally ending human life. It takes from institutions the power to act only in accordance with their mission and ethos.
The Bill threatens not only the right to life of vulnerable patients but also harms all who would want to be cared for in safe spaces where assisted suicide would neither be offered nor be performed. It would leave them with nowhere to turn.
[1] Militia Act 1757: An Act for the better Ordering of the Militia Forces in the several Counties of that Part of Great Britain called England (30 Geo. II. c. 25)
[2] The Quakers and Moravians Act 1838 (1 & 2 Vict. c. 77)
[3] Vaccination Act 1898 (61 & 62 Vict. c. 49)
[4] Military Service Act 1916 (5 & 6 Geo .V c. 104)
[5] The Education Act 1944 (7 & 8 Geo. VI. c. 31)
[6] On this history of such clauses in UK law see C. Braithwaite, ‘Legal Problems of Conscientious Objection to Various Compulsions under British Law.’ Journal of the Friends’ Historical Society (1968) 52.1: 3-18.
[7] See, for example, D.P. Sulmasy, ‘What is conscience and why is respect for it so important?.’ Theoretical medicine and bioethics 29.3 (2008): 135-149; T.C. Saad, ‘Conscientious objection and clinical judgement: the right to refuse to harm.’ The new bioethics 25.3 (2019): 248-261; X. Symons, ‘Why conscience matters: A theory of conscience and its relevance to conscientious objection in medicine.’ Res Publica 29.1 (2023): 1-21.
[8] Second Vatican Council. Declaration on Religious Freedom. Dignitatis humanae December 7, 1965.
[9] World Medical Association International Code of Medical Ethics 2022
[10] Indeed, no one at all should ever be forced to end the life of an innocent human being, see John Paul II Evangelium Vitae: on the Value and Inviolability of Human Life. March 25, 1995, 73-74.
[11] Meeting of the Parliament March 10, 2026, Session 6: Official report, col. 120. This was a statement with which the Catholic Bishops of Scotland strongly disagreed, ‘noting that every organisation has guiding values that shape its mission and practice’.
[12] See Charity Commission of England and Wales Equality Act guidance for charities, 22 February 2013.
[13] Equality Act 2010 Schedule 11, part 2
[14] Equality Act 2010 Schedule 22, para 4.
[15] Cardinal Vincent Nichols and Archbishop John Sherrington, ‘Future of many care homes and hospices in doubt if assisted suicide legalised’ CBCEW June 18, 2025.
[16] A. Zimmermann, ‘Subsidiarity and a free society: The subsidiary role of the state in Catholic social teaching.’ Solidarity: The Journal of Catholic Social Thought and Secular Ethics 8.2 (2019): 3.
[17] Submission of Hospice UK to House of Commons Health and Social Care Committee Inquiry into Workforce: recruitment, training and retention in health and social care, 2022 (RTR0118)
[18] Whitestone Insight Poll for Care Not Killing, between 18th to 19th February 2026. Q.4 If assisted suicide becomes law, in your view should hospices and care homes be able to opt out of providing lethal drugs for patients to end their lives with [Yes 58%]. Q.8 The following safeguards are not currently included in the proposed law to permit assisted suicide. Whether or not you support it in principle, in the event that providing people with lethal drugs to end their own lives were to become legal, would you support or oppose a requirement that the following additional safeguards be put in place first?: Stronger optouts for hospices and care homes who may otherwise face pressure to facilitate the death [Yes 67%].
[19] For example, Dr Kathryn Mannix relates a story of a dying man who was living in the Netherlands but came home to the UK as he was ‘made uncomfortable by the frequent offers of euthanasia by Dutch medical staff’. For similar concerns about Canadian practice see K. Kirkey, ‘Canadian doctors encouraged to bring up medically assisted death before their patients do’. National Post Nov 02, 2022; Reinl, J. ‘Vancouver hospital offered “medical assistance in dying” to suicidal 37-year-old woman who was told it would take too long to see a psychiatrist’. Daily Mail 10 August 2023
[20] See BMA Physician-Assisted Dying see also D.A. Jones ‘Opposing not the principle but this Bill’ BMJ Rapid Response 15 July 2026 [note that BMJ Rapid Responses, while they may contain valuable insights, do not go through a peer review process and should not be quoted as BMJ publications].
[21] On the Jersey Assisted Dying Service, see the website Assisted Dying in Jersey. Note that the government states that ‘Premises owners, such as care home owners, may object to an assisted death taking place on their premises’.
[22] On the potential for ‘assisted dying’ to have a negative impact on existing provision of palliative care, see D.A. Jones, Evidence of Harm: Assessing the Impact of Assisted Dying / Assisted Suicide on Palliative Care. London: Augustine Bioethics Network, 2026.
[23] Comment by the Minister for Care, Stephen Kinnock MP during the Report stage of the Bill Hansard Terminally Ill Adults (End of Life) Bill Consideration (report stage) of Bill Friday 16 May
2025: Vol. 767 Col. 703. See also similar opinions expressed in the same debate by Kim Leadbeater MP (Col. 633) and Kit Malthouse MP (Col. 686).
[24] Introductory sentence in the first annual report: Oregon’s Death with Dignity Act: The First Year’s ExperienceDepartment of Human Resources, Oregon Health Division, Center for Disease Prevention and Epidemiology, February 18, 1999.
[25] Washington (2009), Vermont (2013), Colorado (2015), California (2015), Hawaii (2019), New Jersey (2019), Maine (2019), New Mexico (2021), Illinois (2025), Delaware (2025) and New York (2026), see endnotes 29 to 41 for details. Note that Montana legalised assistance in suicide through a legal case, Baxter v. Montana, (2009), but this has not been codified in statute law.
[26] Oregon Death with Dignity Act 1997. 127.885 §4.01 (4)
[27] Ibid. 127.885 §4.01 (2)
[28] Ibid. 127.885 §4.01 (5)(a) and (5)(b)(C)
[29] Oregon Death with Dignity Act 1997. 127.885 §4.01.
[30] Washington Death with Dignity Act 2009. RCW 70.245.190
[31] Vermont Act 39 Patient Choice and Control End of Life Act 2013 § 5286.
[32] Colorado End of Life Options Act 2015 (effective 2016) 25-48-118
[33] California End of Life Option Act 2015 (effective 2016) Health and Safety Code 1.85. 443.15
[34] D.C. Law 21-182 District of Columbia Death with Dignity Act 2017 Section 11 c and d.
[35] Hawaii Our Care, Our Choice Act 2019 §327L-19 b and c
[36] New Jersey Medical Aid in Dying for the Terminally Ill Act 2019. 26b 2.
[37] Maine Death with Dignity Act 2019 § 2140. 22 B and C
[38] New Mexico End-of-Life Options Act 2021 Section 7
[39] Illinois End-of-Life Options for Terminally Ill Patients Act 2025. 410 ILCS 22/65
[40] Delaware End of Life Options Act 2025. Title 16 Ch. 25C. 2513C. Immunity (c)
[41] New York Medical Aid in Dying Act 2026 Public health law 28-F, 2899-m. 2
[42] Jonah McKeown/CAN ‘California Rolls Back Assisted-Suicide Safeguards’ National Catholic Register October 7, 2021.
[43] CMDA ‘Christian Medical & Dental Associations celebrates New Mexico victory to protect healthcare professionals’ conscience objections against assisted suicide’ Press release, April 13, 2023.
[44] Associated Press, ‘Assisted Suicide: Centura Wants Clarity On Colorado’s Law’ CBS Colorado September 12, 2019.
[45] For example, New Zealand, and the six Australian States plus the Australian Capital Territory.
[46] For example, Switzerland (by assisted suicide, i.e. self-administration) and Netherlands, Belgium and Canada (predominantly by euthanasia, i.e. practitioner administration).
[47] Noted by Select Committee on Assisted Dying for the Terminally Ill Bill First Report, HL Paper 86-I , 2005, Abstract, see also para 243, also by C. Gamondi, et al. ‘Legalisation of assisted suicide: a safeguard to euthanasia’. Lancet, 384 (2014) 127: 61154–61155; D. Pullman, ‘Slowing the slide down the slippery slope of medical assistance in dying: mutual learnings for Canada and the US’. American journal of bioethics, 23.11 (2023): 64–72; D.A. Jones, ‘“Assisted dying” as a comforting heteronomy: the rejection of self-administration in the purported act of self-determination.’ The new bioethics 30.2 (2024): 103-122.
[48] Scottish Parliament, Votes and Motions S6M-21005: Assisted Dying for Terminally Ill Adults (Scotland) Bill, 17 March 2026.
[49] Letter from the Cabinet Secretary for Health and Social Care with an update on Legislative Competence and Stage 3 Approach, 5 March 2026
[50] A. Learmonth ‘Doctors raise concerns over Assisted Dying Bill safeguards’ Herald 23 February 2026.
[51] M. Neal, ‘Unconscionable – “assisted dying” without the right to opt out’ Scottish Legal News 24 February 2026.
[52] The Terminally Ill Adults (End of Life) Bill introduced by Lauren Edwards MP on 17 June 2026 is virtually identical to a previous Bill of the same name sponsored by Kim Leadbeater MP in the form that it received its Third Reading on 20 June 2025. There are two minor differences between the Bills, concerning eating disorders and implementation in Wales, but these do not concern conscience protections.
[53] Terminally Ill Adults (End of Life) Bill Section 31.
[54] Ibid. Section 31 (1)
[55] Ibid. Section 31 (7) See also Section 5 (6)
[56] Ibid Section 5 (2) an amendment to prevent professionals raising the issue was opposed by the Bill sponsor, Kim Leadbeater MP, and was ‘negatived on division’ at Public Bill Committee. On the inadequate and biased scrutiny of the Bill by the Public Bill Committee see D.A. Jones, Assisting Suicide: An Ever More Dangerous Bill (2nd edition). London: Politeia, September 2025, page 6-10.
[57] Ibid Section 32 (3) an amendment to prevent others from ‘encouraging’ people to take their life under this Bill was opposed by the Bill sponsor, Kim Leadbeater MP, and was ‘negatived on division’ at Public Bill Committee.
[58] See endnote 19 above.
