Twenty questions on assisted dying and suicide prevention
David Albert Jones[i]
[i] Professor of Bioethics, St Mary’s University, Twickenham and Research Fellow at Blackfriars Hall, Oxford University, but writing here in a personal capacity. This paper has not been through a formal peer review process, though it has benefited from comments from colleagues. It is intended as an individual contribution to ongoing discussion on the Terminally Ill Adults (End of Life) Bill.
David Albert Jones[1]
Twenty questions on assisted dying and suicide prevention
This paper concerns the Terminally Ill Adults (End of Life) Bill in the form that it was introduced to the House of Lords on 23 June 2025.[2]
The Bill has potential impact on diverse groups: palliative care professionals, medical examiners, people with disabilities, those experiencing domestic and elderly abuse, but the present paper considers the Bill only through the lens of suicide prevention.
The paper is structured as a set of questions and these aim to be free-standing so that it is not necessary to read them all nor to read them in order. It includes references to help fact check some claims made during the debate thus far.
It ends with an appendix of various areas where the Bill is in urgent need of amendment if it is adequately to address the issue of suicide prevention.
Assisted dying
1. How is the term ‘assisted dying’ generally understood?
The term ‘assisted dying’ is used in the Bill for the practice it legalises.[3] The phrase was cited over two hundred times across the two days of the Second Reading Debate in the House of Lords.[4]
In public debate more broadly, the term ‘assisted dying’ is used perhaps most commonly as an ‘umbrella term’,[5] to denote the intentional ending of the life of a patient either by or with the assistance of a doctor.[6] The definition given by the Parliamentary Office of Science and Technology is a good example of the term being applied to these two distinct practices:
‘Assisted dying’ refers here to the involvement of healthcare professionals in the provision of lethal drugs intended to end a patient’s life at their voluntary request, subject to eligibility criteria and safeguards. It includes healthcare professionals prescribing lethal drugs for the patient to self-administer (‘physician- assisted suicide’) and healthcare professionals administering lethal drugs (‘euthanasia’).[7]
Note that in jurisdictions such as the Netherlands, Canada and Victoria (Australia) a person might initially plan to administer the lethal dose themselves but as a result of some complication the doctor might take over, so that what begins as assisted suicide might end as euthanasia.
2. Where and how is the term ‘voluntary assisted dying’ (VAD) used in other jurisdictions?
The term ‘voluntary assisted dying’ (or VAD) is used in the Bill as brought from the Commons to refer to the structures that would provide or oversee this practice.[8] It was not used in the Bill as introduced,[9] but was included in later amendments by the sponsor of the Bill.
The incorporation of this term may reflect the influence of Australian witnesses at Committee stage.[10] The term VAD is used in existing legislation only in Australia, where this is the preferred term for the practice and is reflected and in the titles of all the relevant laws.[11] The term is not used in the laws in Canada, the United States, New Zealand, nor in any European legislation.
In all Australian jurisdictions with VAD, this term can apply both to self-administration (i.e. assisted suicide) and to practitioner administration (i.e. euthanasia). The term ‘voluntary assisted dying’ echoes the older language of ‘voluntary euthanasia’.[12] The qualifier ‘voluntary’ is needed to distinguish this from non-voluntary euthanasia, that is, a doctor ending the life of a patient without request or consent. The term ‘voluntary’ thus serves as an indication that death can be brought about directly by a healthcare professional but must only be done at the express request of the patient.
Furthermore, no Australian jurisdiction restricts eligibility only to patients with an expectation of death within six-months.[13] All extend this to twelve months for at least some patients, and the Australian Capital Territory does not require the expectation of death within a specific time frame. The requirements of Australian law have been weakened between states and, after only five years, the State of Victoria is planning to amend the law to lessen its requirements.
In these respects ‘Voluntary Assisted Dying’ in Australia differs importantly from the practice set out in the Terminally Ill Adults (End of Life) Bill. The use of the same terminology is potentially misleading and may encourage future expansion of the practice in the direction of the Australian model of VAD.
3. Is the term ‘assisted dying’ euphemistic or ambiguous?
Yes. Several Peers argued that the term assisted dying, and other language used in the Bill, was euphemistic. For example, Baroness Maclean referred to ‘the euphemism of “assisted dying”’[14] and Lord Moylan argued that the phrase ‘provision of assistance’ which is used throughout the Bill is euphemistic, asking rhetorically, ‘Is this something that is going to become part of our daily language? “Have you considered ‘assistance’, Mrs Smith?”’.[15]
The term ‘assisted dying’ is a euphemism because it refers to the process of ‘dying’ but glosses over the finality of ‘death’ and the question of who and what causes the death. In this way it lacks the transparency of the term ‘assisted suicide’. ‘Assisted dying’ is also a move away from the language of ‘euthanasia’, as used, for example, in the Voluntary Euthanasia (Legalisation) Bill which was debated in the House of Lords in 1936. The Voluntary Euthanasia Society used this term for most of its 80-year history but in 2006 changed its name to Dignity in Dying and began to campaign for ‘assisted dying’ rather than ‘euthanasia’. This was described by the organisation as a ‘major rebranding exercise’.[16]
Even some who supported legalisation of assisted suicide or euthanasia regarded this shift in language as euphemistic. For example, the late Baroness Warnock wrote that she preferred to use ‘the terms “euthanasia” and “assisted suicide” – not sanitising these words with euphemisms like “assisted dying”’.[17]
Nevertheless, while the term ‘assisted dying’ is certainly euphemistic, this would not prevent it from being used in law and public policy if people were clear what the practice involved. It should be noted that the term ‘euthanasia’ which was coined in the late nineteenth century was itself ‘christened with a euphemistic title, for euthanasia means simply ‘”good death”: eu-thanatos’.[18] Indeed, the word ‘suicide’ also originated as a less judgemental alternative to terms such as ‘self-murder’ and also became more prevalent in the nineteenth century,[19] not least as the title of Durkeim’s groundbreaking study Le Suicide: Étude de sociologie (1897). Nevertheless, while ‘euthanasia’ and ‘suicide’ began as euphemisms they have become the ordinary terms for these actions.
The term ‘assisted dying’ could likewise become the standard language in this area, but only if were clear what practice or practices the term refer to. Euphemisms need not always be dangerous[20] if they are unambiguous in practice. Regrettably, the term ‘assisted dying’ is not only euphemistic but also ambiguous in at least two ways:
In the first place, as mentioned above, in public and scholarly debate the term ‘assisted dying’ is used widely both for assisted suicide and for euthanasia. The same term can thus be used even if practices shift from the former to the latter.[21]
A second problem is that, when asked, many people believe that the term ‘assisted dying’ refers to the right to stop life-prolonging treatment (42%) or think that it applies to current hospice-type care (10%) rather than providing people who have less than six months to live with lethal drugs to end their life (43%).[22] It is clearly problematic if a term is being used for a new practice but a significant proportion of the population believe that the term covers practices that are already legal and accepted.
The term ‘assisted dying’, if it is to be clear and unambiguous, needs to be related overtly to the older and more well-established terminology, ‘euthanasia’ and ‘assisted suicide’.
4. Is ‘assisted dying’ as defined in the Bill a form of assisted suicide?
Yes. The central aim of the Terminally Ill Adults (End of Life) Bill is to amend the Suicide Act 1961 so as to create an exception to the current ‘blanket ban’ on assisting suicide.[23] This is not a secondary feature of the Bill but is absolutely necessary for it to achieve its stated purpose.
The Bill stipulates that providing someone with the means to end their own life, if done in accordance with the Bill, would no longer be an offence under the Suicide Act 1961. ‘Assisting dying’, as defined in the Bill, would not constitute the criminal offence of ‘encouraging or assisted suicide’.[24] However, the practice would still involve giving someone the means to take their own life. This is just what most people would understand by assisting suicide, notwithstanding that it would not longer be a criminal offence.
The Bill thus makes it legal for a healthcare professionals to prescribe lethal drugs for the patient to self-administer (i.e. assisted suicide). However, the Bill does not make it legal for healthcare professionals to administer lethal drugs directly to patients (i.e. euthanasia), even in cases where patients are physically incapable of self-administration.[25] The last action by which death is brought about must be that of the patient, not that of the doctor.[26]
5. Is the term ‘assisted suicide’ only used by opponents of the practice?
No. It is true that, in the context of the Second Reading Debate in the House of Lords, those who expressly defended the use of the term ‘assisted suicide’ were all opposed to the Bill,[27] and all those who opposed the use of this term were all in favour of the Bill.[28] Nevertheless, in the public debate more widely, the term ‘assisted suicide’ or ‘physician-assisted suicide’ is used very commonly by those who are neutral on the issue and also by some who are in favour of the practice.
As mentioned above, the Parliamentary Office of Science and Technology Briefing on ‘Assisted Dying’ uses the term ‘physician-assisted suicide’ for ‘prescribing lethal drugs for the patient to self-administer’.[29] The same terminology is also used in the House of Commons briefing ‘The law on assisted suicide’.[30]
Internationally, ‘assisted suicide’ is the normal term for self-administered forms of assisted dying, in contrast to practitioner-administered forms commonly termed ‘euthanasia’. The first official report on the first jurisdiction to introduce a law in this area begins : ‘On October 27, 1997 physician-assisted suicide became a legal medical option for terminally ill Oregonians.’[31] Similarly, the Swiss organisation Dignitas, founded in 1998 provides what it terms an ‘accompanied suicide.’[32] In 2002 the Netherlands introduced the ‘Termination of Life on Request and Assisted Suicide (Review Procedures) Act’.[33] This was followed by Luxembourg in the Law of 16 March 2009 on Euthanasia and Assisted Suicide.[34] As recently as 2013 in Scotland the Bill proposed by Margo MacDonald MSP to change the law was termed the Assisted Suicide (Scotland) Bill.[35]
A recent study found that the terms ‘euthanasia’, ‘assisted dying’ and ‘assisted suicide’ are all in common use in the scholarly literature, but the term ‘assisted suicide’ remains the most common. It is by no means restricted to opponents of the practice.[36]
The Terminally Ill Adults (End of Life) Bill follows the model of Oregon (and some other American States) in restricting assisted dying to assisted suicide. The Bill does not follow the model in Canada, New Zealand, Australia or the Low Countries, where not only assisted suicide but also euthanasia has been legalised. The scope of the Bill, as well as its implications, would be much clearer if the language of ‘assisted dying’ were related overtly, on the face of the Bill, to the widely used terms ‘assisted suicide’ and ‘euthanasia’.
Suicide
6. If someone with a terminal illness takes their own life, is this suicide?
Yes. Whether a person is close to death or may have many years to live, the act of intentionally taking one’s own life is suicide.
Several Peers argued that, if terminal illness makes death inevitable within a relatively short time,[37] then the action of anticipating this by taking one’s own life is no longer ‘suicide’ as it cannot be a choice of ‘death over life’[38] but can only be a choice of ‘how to die’.[39] However, it is important to recognise the dangerous implications of this argument.
Lord Browne cited evidence from the Royal College of Psychiatrists, according to whom, ‘terminal illness is a risk factor for suicide’.[40] This conclusion is also supported by evidence from the Office of National Statistics which found that one year after diagnosis, patients with low survival cancers had a suicide 2.4 times higher than the suicide rate for matched controls.[41]
If, however, people who take their lives after receiving a terminal diagnosis are not to be designated as ‘suicide’ then these deaths would not be included in the official suicide statistics and terminal illness would not be a risk factor for ‘suicide’. This seems to be the implication of the comments of Baroness Royall,
…around 300 terminally ill people end their own life at home every year in England. These deaths are recorded as suicides, but it is clear from talking to and listening to bereaved family members that these are not people who wish to end their own life but people who are taking drastic and often violent steps to control an inevitable an imminent death.[42]
Similarly Lord Oates said of the death of someone with a terminal illness who died from ingesting pesticide, ‘my friend’s death cannot in any meaningful way be described as suicide’.[43]
A failure to record such deaths as ‘suicide’ would undermine current attempts to address the risk of suicide among people with cancer and other terminal diseases. Research shows that the increase in risk of suicide is highest in the first six months after diagnosis.[44] If people can be helped during the period immediately after diagnosis, for example with the support of liaison psychiatrists, then the risk of them taking their own life can be reduced.[45] Such efforts are part of a wider national suicide prevention strategy which expressly includes people with severe physical health conditions.[46]
Irrespective of whether or how the law changes, there will be people with terminal illness who are at risk of taking their own lives. If the argument of Baroness Royall and Lord Oates were accepted then these deaths should not count as ‘suicide’, either for the purpose of official suicide statistics or for national suicide prevention strategy. Such an argument must be rejected as logically unsound and practically dangerous. This debate should not lead us to withdraw protection from those at risk of ending their own life by violent means.
7. If someone who ‘does not wish to die’ takes their own life, is this suicide?
Yes. If someone intentionally takes their own life then this is suicide, notwithstanding that they do not wish to die, that is, that they would prefer to live if the circumstances were different.
A number of Peers claimed that the debate was ‘not about people choosing to die’ but was ‘about people who do not wish to die’.[47] In this way people seeking an assisted death were contrasted with people who seek to take their life by ‘suicide’.
This contrast fails in both directions. On the one hand, the Bill is overtly about ‘choosing to die’ in the sense of enabling people ‘to make a decision to end their own life’.[48] Indeed doctors are required to explain the mechanism of action of the lethal substance and ‘how it will bring about death’.[49]
On the other hand, people who die by suicide outside the context of this kind of legislation often show ambivalence about seeking death. As Lord Moylan argued ‘In the case of suicides, most of them do not want to die.’[50] External circumstances and internal distress can seem overwhelming so that death seems preferable, but people who experience suicidal thoughts retain a wish to live, if only life were liveable. This is why suicide prevention is possible.
8. If someone who is not ‘suicidal’ takes their own life, is this suicide?
Yes. If someone intentionally takes their own life then this is suicide, notwithstanding that the person is not ‘suicidal’.
In the Second Reading Debate it was stated that ‘people who choose assisted dying are not suicidal’. Two Peers quoted letters by people with terminal illnesses making the same point:
We are not suicidal—we want to live—but we are dying, and we do not have the choice or ability to change that. Assisted dying is not suicide.[51]
This statement is clearly heartfelt and expresses the feeling of people who wish to change the current law on assisted suicide. However, it fails to do justice to people who die by suicide. This is not only because, as stated above, people who die by suicide do not necessarily want to die. It is also involves a problematic use of the word ‘suicidal’.
Those who are involved in suicide prevention caution against using the adjective ‘suicidal’ to refer to persons. Rather, we should speak of ‘suicidal thoughts’, ‘suicidal ideation’ or ‘suicidal behaviour’.[52] Many people experience suicidal thoughts or feelings but to describe the person themselves as ‘suicidal’ implies that these feelings are an expression of their settled character, of who they are. This way of framing suicidality is both disempowering and potentially stigmatising.
Those who are in favour of a change in the law on assisted suicide, and who would wish to make use of this option, are right to reject the label ‘suicidal’ of themselves. However, neither should this term be applied to people who experience suicidal thoughts or feelings or who are at increased risk of suicide. People who are at risk of suicide should not be labelled ‘suicidal’.
9. Should the term ‘suicide’ in the context of assisted dying be regarded as offensive?
No. While some Peers expressed or reported strong adverse reaction to the language of ‘assisted suicide’ the language need not and should not cause offence if understood properly.
It is clear that to use the term ‘suicide’ in this context can touch a raw nerve. In reaction to a speech by Baroness May on the first day of debate,[53] a number of supporters of the Bill wrote to Peers and to the media.[54] They were ‘very distressed’[55] and expressed their feeling that ‘to equate choice and control over the timing and manner of inevitable and imminent death with suicide is deeply insensitive those of us facing this position’.[56] Similarly, Baroness Blackstone stated that ‘because of [her] personal experience’ she was ‘affronted’ by this language.[57] It was a point to which Lord Falconer returned in his final remarks
For over 10 years of having been engaged in this debate, I have found that, for people who are terminally ill and want an assisted death, nothing upsets them more than saying that that is suicide.[58]
There are thus people who find this language deeply uncomfortable. However, it is important that the language of the law is clear and it is central to the Bill that it creates an exception to the current law law on ‘encouraging and assisting suicide’.[59] It is also evident from the discussion above that attempts to distinguish self-administered assisted dying from conventional suicide rely on a distorted understanding of suicide. People with terminal illness are at risk of suicide and can benefit from suicide prevention.[60] People who experience suicidal thoughts may also wish to live[61] and it is harmful to label them as ‘suicidal’.[62]
Some of the discomfort here is because of the stigma that surrounds suicide, but the danger is therefore that reaction against the term ‘assisted suicide’ both stems from and reinforces this stigma. It is for such reasons that Professor Louis Appleby, advisory group chair of our national suicide prevention strategy, ‘said the phrase “assisted suicide” should not be considered offensive’. Indeed, a failure to acknowledge this language puts at risk ‘our socially remarkable consensus that it is right to try to prevent all suicides’.[63]
Suicide prevention
10. Are some suicides inevitable?
No. It is inevitable that everyone will die but it is not inevitable that anyone will die by their own hand.
While external circumstances or psychological trauma can increase the risk of suicide, and suicide is more common among people with a psychiatric diagnosis than in the general population, in no circumstances is it inevitable. Most find some way to cope, with the help of those around them.[64]
There are interventions that have been shown to help prevent suicide and there is no reason to believe that anyone is beyond all help. The supposition that suicide is sometimes inevitable is a kind of prejudice that can become self-fulfilling. It is a pernicious idea. This is why the national suicide prevention strategy for England and includes ‘raising awareness that no suicide is inevitable’.[65]
From this perspective, the criterion in the Bill that the person asking for assisted suicide has ‘a clear and settled intention to end their own life’,[66] is problematic. It is not a criterion that would be accepted in the context of suicide prevention.
11. How does the prohibition on ‘encouraging’ suicide relate to suicide prevention?
According to the Suicide Act 1961, a person commits an offence who ‘aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide’. This was amended by the Coroners and Justice Act 2009[67] to ‘encourage or assist suicide or an attempt at suicide’.
The reason for this shift was to capture the actions of people who might not have provided practical assistance, but might still have encouraged suicide, for example via websites or chat-rooms. In this respect the Coroners and Justice Act anticipated concerns addressed more recently in the Online Safety Act.[68]
The current law prohibits the intentional encouragement of suicide, but it is clear that insensitive media reporting of suicide can also encourage suicide,[69] albeit unintentionally and indirectly. So also, signposting people to places where they could find information on how to take their own life can encourage people to end their lives. Encouragement of suicide, whether intentional or unintentional, is the very opposite of attempting to prevent suicide.
Currently for a healthcare professional to raise the issue of suicide is not necessarily to encourage this, for this would occur in a context where the professional would be prohibited from providing practical assistance. The prohibition creates a safe space for the conversation.[70] In contrast, if doctors were able to provide the means for people to end their lives, then for a doctor to raise the issue pro-actively would encourage a patient to consider it.
At Committee Stage in the Commons it was suggested that for a doctor to initiate discussion on assisted dying with a person with a learning disability ‘could move them towards or into potentially accepting a course of action that they had never considered before’.[71] The same could be true to a greater or lesser extent of any patient. Doctors can exercise great influence.
The Bill aims to permit doctors to provide eligible patients who have a ‘clear and settled intention’ to end their lives[72] with the means to do. However, it is not implied by this that doctors could or should also be permitted to encourage such actions. Those elements of the Bill that permit healthcare professionals proactively to encourage patients to take their own lives,[73] or which require doctors to signpost patients to information on how to be assisted to take their own life,[74] are both unnecessary from the perspective of the central aim of the Bill and are incompatible with the wider duty of suicide prevention.
12. How far was discussion of suicide in the Second Reading debate in line with guidance on reporting of suicide?
In general most Peers who discussed suicide did so in a sensitive manner and accordance with best practice on the reporting of suicide. For example, while the word ‘suicide’ was used over two hundred times,[75] the phrase ‘commit suicide’ was used only half a dozen times.[76] Professionals in suicide prevention have urged people to move away from this language because of the connotation of ‘commit’ with criminality[77] or with sin.[78] Attempting suicide is an act of self harm but it is not a crime and . Regrettable, Peers referred to persons as ‘suicidal’ which, as argued above, is problematic, more often than referring to ‘suicidal’ thoughts or ideation.[79]
In most cases, Peers also avoided discussion of the means of suicide or locations associated with suicide, which guidelines discourage so as to avoid the danger of imitation.[80] However, on a few occasions the means of death were described, sometimes in graphic language.[81] This was done, no doubt to emphasise the harmful character and impact of this form of death, but had the same language been used in the media it would have been at best insensitive and, at worse, sensationalism. One Peer made explicit reference to the location of ‘the number one suicide spot in the world’.[82] This is certainly contrary to best practice, however, this fault was mitigated by overt discussion of effective suicide prevention, the reporting of which has been shown to have a positive effect.[83]
Of greatest concern were a small number of reference that presented suicide as something noble or heroic. Lord Hogan-Howe, reacting against statements by other Peers that ‘suicide is wrong’ claimed that the resolution to take one’s own life ‘is a very brave decision for those who make it’.[84] Again Lord Roberts argued that, while theologians such as Augustine of Hippo and Thomas Aquinas had proscribed suicide, ‘the ancient Greeks and Romans recognised that there was nothing ignoble in it if the alternative is far worse’.[85]
Lord Mitchell, in describing the death of his mother-in-law by suicide was clear that this was both ‘psychologically damaging’ for those left behind and something that was in principle preventable. If they could have ‘talked about it openly’ and ‘engaged professional help’, then ‘I am certain that things would have turned out differently’.[86] In contrast, in the case of his father-in-law, the wish to take his own life is presented leaving no ‘room for doubt’. So also, the action of taking his own life is presented as an achievement, as ‘the brilliant scientist that he had become, there was no way he was going to get the dosage wrong’.[87] In his case, a lethal dose was the ‘right’ dose to achieve a ‘successful suicide’.[88]
To give account of the death of someone close is a deeply personal thing and often shaped by feelings of bereavement and admiration. For this reason media guidelines urge that reporters should be ‘particularly wary of overemphasising community expressions of grief as this can unintentionally suggest that people are honouring suicidal behaviour, rather than mourning a death.’[89]
Irrespective of one’s view on whether the law on assisting suicide should be changed, it is imperative that the debate is conducted responsibly, in a way that does not honour or encourage suicidal behaviour. The Second Reading Debate illustrates that it is possible to construe a change in the law in this area as weakening the universal imperative to prevent suicide. If this implication is to be avoided then it is necessary for the Bill to make more explicit the requirement for suicide prevention provision for all members of society, including those who would be eligible for assistance in suicide under the Bill.
13. Is there evidence that legal availability of ‘assisted dying’ prevents conventional suicide?
No. While a change in the law in this area has been proposed as a way to address the issue of suicide among people with a terminal illness, there is no evidence that similar legislative changes have been beneficial for suicide prevention.
During the debate a number of Peers drew attention to the fact that, under the current law, some people who express a wish for the legal availability of assisted dying may die by unassisted suicide: ‘When assisted dying is illegal, people sometimes take desperate or violent steps to end their lives.’[90] The argument implicit in this statement is that some people take violent steps to end their lives because assisted dying is illegal, and thus were assisted dying to have been legal then these violent unassisted suicides would not have occurred. They would have been prevented. This implication is made explicit by Lord Mitchell in relation to his mother-in-law: ‘had this Bill been law, she probably would have chosen life’.[91]
It is this context that Baroness Royall stated that ‘around 300 terminally ill people end their own life at home every year in England’.[92] She went on to state that some or all of these ‘are not people who wish to end their own life but people who are taking drastic and often violent steps to control an inevitable and imminent death’.[93] The implication is that passing the Bill could help prevent up to 300 unassisted and often violent suicides a year.
The same argument was very prominent in the Parliamentary debates over the Voluntary Assisted Dying Bill in Victoria in 2017. There it was stated repeatedly (fifteen times in the course of a single debate) that a change in the law could help prevent up to 50 suicides a year or ‘one a week’.[94] This argument helped convince legislators, but after the Bill can into force in 2019 there was no evidence of a decline in suicides. Indeed, among people over 65, who comprise the majority of deaths from VAD, the number of unassisted suicides rose by 50 a year (or around 50%),[95] a fact as pointed out by Lord Jackson[96] and Lord Morrow.[97]
In the Second Reading Debate, Baroness Royall claimed that ‘Figures from Victoria in Australia show a slight decrease in suicide rates since it introduced assisted dying’.[98] This was true overall in 2020 and 2021, which of course were also the years shaped by the pandemic, but since 2022 suicide rates in Victoria have increased markedly. Research published in 2024 showed that ‘the trend in the annualised monthly suicide rate was consistently between 10 and 11 suicides per 100,000 population during the period from 2012 to 2019’, this reduced to ‘around 10 per 100,000’, in 2020 and 2021, but from mid-2022 rose steadily to ‘around 12 per 100,000’ and in early 2024 reached ‘nearly 13 suicides per 100,000’.[99] Suicide rates are thus noticeably higher in Victoria now than they were before VAD was introduced.
For the best evidence of a possible impact of assisted suicide on suicide rates, it is better to look to the United States where a greater number of states have changed their laws and these have been in effect for a greater length of time. Jurisdictions in the United States that have legalised assisted dying are also a better match to the proposed Bill, in that they restrict assisted dying to assisted suicide for people with an expectation of death within six months.[100]
Baroness Hollins was correct to state that, ‘There is substantial evidence in 10 US states that legalisation is associated with a significant increase in suicide.’[101] A paper published in 2022 found that legalising assisted suicide was associated with an increase in unassisted suicides of ‘about a 6% increase overall, 13% increase for women’.[102] Baroness Berridge referred to a ‘meta-analysis’ of data from Oregon between 1998 and 2018 which ‘witnessed an increase of 50% in voluntary suicide of older women over the age of 65’.[103] The precise figures was 56.3% and this increase is without counting the large rise in assisted deaths in this group.[104]
A study from Switzerland published in 2023 also failed to find any beneficial effect of availability of assisted suicide on rates of unassisted suicide.[105] Researchers found that the number of assisted suicides among cancer patients had roughly doubled every five years. However, while the number of conventional suicides among cancer patients declined in the first five years, it then remained stable before increasing in the last five years. There was no evidence that increased acceptance and use of assisted suicide in Switzerland correlated with a reduction in unassisted suicide.
14. Is there evidence that legal availability of ‘assisted dying’ prevents suicide pacts?
No. There is no evidence that unregulated suicide pacts become less prevalent and there is evidence that double assisted suicide or double euthanasia is becoming more common.
During Second Reading Debate reference was made to a joint suicide by an elderly couple, one of whom had cancer,[106] and also to a homicide-suicide by a man whose wife had an incurable condition.[107] While all suicide complicates grief the case of double suicide is still more problematic because of the dynamic between the couple. In the media such cases tend to be reported through a romantic lens of a couple mutual wish to be ‘together in life and in death’. However, the question always remains as to how far the desire is mutual and how far one has a stronger wish to die than the other.
A rare study which followed a couple who were seeking to die together charted this tension:
Suzan suffered from this pressure from her husband, who was emphatically waiting for her to decide. She still needed more time. During the interview, she cursed emotionally several times: “Damn, why can’t he wait a little longer for me. (…) Damn it, give me another year!” At the same time, she realized that the longer she delayed, the longer he had to wait, while she knew that life had become an abomination to him. In a way, Suzan thought that she was being unreasonable by delaying the decision, that she was being unfaithful to their agreement.
…The case thereby clearly reveals the ambiguity of people’s volition, as choices can shift over time. It also highlights the difficulty of distinguishing between voluntary action and coercion in real life.[108]
If suicide pact raise questions of voluntary action and coercion this is still more that case with homicide-suicide among couples, where it will typically be the male partner who takes the life of the female partner and then his own.[109]
The double suicide study cited above was based in the Netherlands, but the death was by suicide not within the state regulated system of euthanasia. The authors refer to it as ‘self-euthanasia’.
The number of cases of suicide by couples is small and there have been no studies that have sought to assess the impact of a change in the law on its prevalence. However, the case above illustrates that even where assisted dying is legal, those who seek to die as a couple may seek suicide outside the law – not least because one or both would not fulfil the eligibility criteria.
It is also the case that romanticised reporting of double assisted suicide can encourage such deaths. This was already documented in Switzerland as early as the 1990s.[110] In the Netherlands this phenomenon has become so common that numbers are now included in the annual euthanasia report. In 2022, double euthanasia occurred 29 times (i.e. 58 deaths), in 2023 this had grown to 66 deaths, and in 2024 the figure was 108 such deaths.[111] There is less data from other jurisdictions but many have also reported cases of double assisted suicide or double euthanasia.[112]
There seems no reason to believe that changing the law will make unregulated homicide-suicide or suicide pacts less common[113] and every reason to believe it would lead to problematic cases of double assisted suicide where one chose to die at least in part due to the influence of their partner.
Law
15. Is forgoing of medical treatment legally equivalent to suicide?
No. While some Peers sought to draw a parallel between withdrawn or life-sustaining treatment and provision of lethal medication for the purpose of enabling someone to end their own life,[114] these are clinically, ethically and legally distinct.
The right to refuse medical treatment is based on the right to refuse unwanted touching and unwanted violations of bodily integrity. Where a person has capacity to consent, consent is required for medical treatment.[115] It is not that doctors have a duty to take ‘positive steps to implement your wish to end your life’,[116] it is simply that doctors cannot continue to treat someone without their consent, even if treatment would be in a person’s best interest.
The only exception to this is compulsory treatment for mental illness, or for physical illness ancillary to a mental illness, where that falls within the Mental Health Act 1983. Such treatment is justified as an exception only where the person is at risk of harm to themselves or others and where treatment could ameliorate this risk. It is an exception that is limited by specific procedural requirements.
The right to refuse treatment does not give any right to request treatment even if that treatment would be beneficial and still less does it imply a right to request lethal interventions. This distinction is made clear by Lord Wolfson, cited Lord Goff:
He [Goff] drew a clear—his word was “crucial”—distinction between the withdrawal of life-supporting treatment and actively causing death. The key point is that withdrawal of treatment by doctors does not cause death; it is the underlying disease that causes death. The doctors do not have any intention to kill; they want to discontinue something that is of no benefit to the patient.[117]
Baroness Finley emphasises that this legal assessment reflects clinical best practice:
Supporting a patient who wants to stop treatment is not assisted suicide. Stopping unwanted treatment allows life to close in a timely way. The person dies of their underlying disease; it is good care.[118]
16. Is forgoing food and drink legally equivalent to suicide?
No. While some Peers sought to draw a parallel between forgoing food and drink and provision of lethal medication for the purpose of enabling someone to end their own life,[119] these are also clinically, ethically and legally distinct.
There are particular concerns that are raised by the forgoing food or fluids. Here there are some important distinctions that should be made. Where a reluctance to eat is the result of an eating disorder, then it is the manifestation of a mental health condition and should be addressed as such.
Such avoidant eating disorders (for example, anorexia) typically restrict food intake but not fluids. These should be distinguished from voluntary stopping eating and drinking (VSED) used as a means to end one’s life. There is, nevertheless, an overlap as people with anorexia are at greater risk of seeking to end their life (whether by VSED or by other means) and, among those without a pre-existing eating disorder, the decision to seek death by VSED may also be influenced be a mental health condition. In either case where this behaviour puts someone’s life at risk then it may require compulsory treatment under the Mental Health Act.[120]
In the case of physical illness, there may be many reasons why a person is not eating or drinking sufficiently to maintain a healthy level of nutrition or hydration, and doctors have a duty to assess these reasons.
If a patient refuses food or drink, or has problems eating or drinking, you should first assess and address any underlying physical or psychological causes that could be improved with treatment or care. For example, some patients stop eating because of depression, or pain caused by mouth ulcers or dentures, or for other reasons that can be addressed. If a patient needs assistance in eating or drinking that is not being provided, or if underlying problems are not being effectively managed, you should take steps to rectify the situation, if you can. If you cannot, you should inform an appropriate person within the organisation that is responsible for the patient’s care.[121]
In the last phases of terminal illness there may be a reduction in appetite which is a reflection of the dying process and of a reduction in need for nutrition and hydration,[122] but again this should not be presumed but must be assessed. The need for nutrition and hydration must be assessed regularly and independently of one another.[123] Failure to address a person’s need for adequate food and drink can be a failure of care.[124]
In the Second Reading Debate, several Peers made reference to someone voluntarily refusing food and drink in order to hasten death.[125] The reflections above should make one wary of assuming that this is always what is occurring whenever a patient with a severe illness is not receiving adequate food or drink. Nevertheless, from an ethical and legal perspective it is clear that, if someone with capacity refuses food and fluids then doctors are legally constrained to respect this, not because people have a right to have their death hastened by doctors, but because treatment and care require consent.
17. Is there a legal right to suicide in England and Wales?
No. Since the enactment of the Suicide Act 1961, attempted suicide is not longer a crime. However, it does not follow that ‘you have a legal right to end your life’.[126]
Again this point was answered very clearly by Lord Wolfson:
[I]t is not correct to say that the law recognises a right to suicide. Suicide is no longer unlawful, but that does not mean that there is a right to commit suicide. Indeed, that point was emphasised by Lord Bingham, the former Master of the Rolls, in the earlier case of Pretty.[127]
To this is might be added that this principle has been upheld in case law since Pretty, not only in cases originating in the United Kingdom but also in the European Court of Human Rights, most recently in for example in Lings v Denmark and Karsai v Hungary.[128]
The decision in Purdy required the Director of Public Prosecutions to issue guidance on what factors weigh in favour or against prosecution.[129] This was presented by Lord Macdonald as a ‘de facto right to die’ in that ‘the vast majority of assisted dying cases abroad have, in effect, been decriminalised’.[130]
It is not accurate to say that assisting someone to obtain suicide abroad has been ‘decriminalised’, as is evident from the fact that people still face the possibility of investigation.[131] Nevertheless, such cases have not been prosecuted and a number of Peers raised the seeming inconsistency of tolerated a practice that is available only to people who can afford it and are healthy enough to travel.[132]
This argument might be stronger if assisted suicide in Switzerland, to which people of limited financial needs have less access, were clearly desirable. However, those who are in favour of the law also point out the problems with assisted suicide in Switzerland. It involves death in ‘exile’,[133] far away from familiar surroundings, and it leaves those who assist having to ‘risk investigation and prosecution’.[134] In relation to patient protection, ‘there are no safeguards at all’,[135] and organisations there assist the suicide of people who are not dying but who are disabled or have mental health conditions.[136] On any reasonable account this is a dangerous practice and easier access to this practice experienced by those with financial resources should not be construed as being ‘privileged’[137] but, paradoxically, as being at greater risk.
Lord Moylan and Lord Wolfson also pointed out that, in other contexts, we do not regard the ability to obtain in another country what is illegal in England and Wales as an argument to have to make it available here, on pain of inconsistency.[138] Lord Wolfson follows this with a more astute point. The Bill that is proposed does not reflect the law in Switzerland. Lord Wolfson states that the Bill ‘would not cover many, if not most, of those who travel to Switzerland’ for assisted suicide.[139] In fact a recent analysis indicated that ‘less than half would meet a 6-month prognosis criterion’.[140] The Bill does not address the issue of those with conditions outside the outside its scope who would continue to travel to Switzerland to obtain assisted suicide. The problem of ‘suicide tourism’[141] remains, unless we follow Switzerland and place no legal limits or requirements on who is eligible for assistance in suicide.
18. Is there a legal right to suicide prevention in England and Wales?
Yes. Jonathan Herring, Professor of Medical Law at Oxford University, makes a convincing case that the right to life, a fundamental right owed to all human beings, includes the right to be protected from suicide.
Our starting point should be that a suicide involves a breach of Article 2 of the European Convention on Human Rights (ECHR). The state has an obligation to protect citizens from breaches of their human rights’[142]
This right implies concomitant duties on individuals and institutions, and not least on the state, to do what is reasonable to prevent suicide. This duty is more obvious in the case of people with responsibility for prisons, mental hospitals, or residential educational establishments but applies to any and all relationships of care where a person might be at risk of suicide.
While human rights law provides strong grounds for the right to be suicide prevention. This is not currently overt in statute law. As the Bill makes an exception to the current law on ‘encouraging and assisted suicide’, there is a risk that the Bill could have an adverse impact on suicide prevention. This risk could be mitigated by including, on the face of the Bill, a clear statement that all persons have a right to reasonable measures to protect them from taking their own life. This measures will include enquiries as to the concerns that motivate the request for assistance ending their life, and efforts to seek alternative means to address these concerns.
19. Do doctors have a specific duty to prevent suicide?
Yes. In addition to the legal duties that apply to all in positions of responsibility, doctors have a specific ethical and professional duty to prevent suicide. This is because patients must be able to trust medical professionals with their lives and health. As stated above, mental ill health can increase the risk of suicide and where this is the case, the mitigation of this risk will be part of the doctor’s duty of of care.
It is noticeable that in the current prosecution guidance for the offence of ‘encouraging and assisting suicide’, being a doctor in a relationship of care for the person is a reason in favour of prosecution. This also reflected in surveys that show that, if the law changed, most doctors would be unwilling to provide their patients with the means to end their lives.
Medical associations, even when they have taken a neutral stance on whether the should change, have argued consistently that delivery of assisted dying must be though a separate system of provision independent of current healthcare structures. It cannot be that general practice, geriatric medicine, oncology or palliative care services are expected to combine their current role with this new focus.
Unfortunately the Bill as delivered from the Commons is radically indeterminate in relation to how ‘assisted dying’ is to be delivered in practice, whether within or outside the NHS, whether existing or new structures, whether opt in or opt out. Even if certain details of provision may reasonably be determined by future regulations, the Bill must clarify that delivery will be by a separate service which professionals could join not through existing structures which would require professionals to ‘opt out’.
In a similar way, independent, charitable or voluntary aided health and social care institutions such as hospices and nursing homes must be given power to set their own policies in relation to activities that occur on their premises or are performed by employees during the course of their duties. This is important in order to respect the distinct ethos or foundation documents of different institutions.
20. What are the implications of regarding assistance in suicide as ‘treatment’?
The British Medical Association is clear that provision patients with the means to end their own life does not constitute a ‘treatment option’ in the conventional sense.[143] Currently the Bill is ambiguous as to whether provision of the lethal substance is a form of medical treatment.
The Bill uses the term ‘treatment’ only for alternative palliative or curative treatments that a patient might be offered. On the other hand it requires that provision of the lethal substance is authorised and provided only by medical professionals. The Bill also includes over 80 references to the Secretary of State for Health and Social Care who ‘may’ (but may not) provide that references to health services in the National Health Service Act 2006 ‘ include references to commissioned VAD services’.
This point is not only rhetorical but has legal implications. Case law in this area requires that doctors discuss ‘treatment options’ with patients. Furthermore, if provision of a lethal substance constitutes ‘treatment’ then, under standards of good practice, it should sometimes be provided to patients who cannot consent but could benefit. For multiple reasons it seems better to make explicit that the provision of a lethal substance in accordance with the Bill does not constitute medical treatment for the purpose of law or professional and ethical standards.
Related to the question of whether providing the lethal substance is a ‘treatment’ is the question of whether such a death is ‘natural’, as would be the case of someone who died despite undergoing medical treatment. In the case of ‘assisted dying’ the aim of the intervention is to bring about death so the death is not natural but intentionally self-initiated. This has implications for how the cause of death is recorded and also for whether the death should be investigated by a coroner. As a former Chief Coroner of England and Wales has pointed out, the fact that the Bill would legalise assistance in suicide in specific circumstances does not reduce the need for coronial scrutiny of these deaths, which are not deaths from natural causes.
Since assisted deaths are by definition intentionally self-inflicted, they are, in my view, both in law and in reality, deaths by suicide and therefore unnatural. Our law has mandated for centuries that all such deaths should automatically go to the coroner for investigation.
My concern is that the proposed removal of what are called assisted deaths from the category of unnatural deaths would do nothing to address the real risks that are liable to accompany those deaths, risks which the Bill recognises in its long title by accepting that there have to be safeguards. Indeed, the risk, in my view, is that re-categorising assisted deaths—which are, in reality, deaths by suicide—as natural deaths may have the unfortunate and unintended consequence of tending to obscure and conceal those risks.[144]
Appendix: Areas requiring amendment
The following list of potential areas for amendments to the Bill are not intended to contradict the central aim of the Bill, which is to allow ‘adults who are terminally ill, subject to safeguards and protections, to request and be provided with assistance to end their own life’.
This following is, rather, a non-exhaustive list of areas where amendments to the Bill may mitigate the danger of an adverse impact on suicide prevention.
1. The term ‘Assisted Dying’
As argued above, the language of ‘assisted dying’ is both euphemistic and ambiguous. For greater legal and ethical clarity, it is essential that this language is related overtly on the face of the Bill to the terms ‘euthanasia’ and ‘physician-assisted suicide’.
2. The term ‘Voluntary Assisted Dying’
The language of ‘Voluntary Assisted Dying’ is used in legislation only in Australia where it refers to a practice that is distinct in important ways from that set out in the Bill, and is associated with expansion of provision and the abandonment of safeguards over time. The term ‘Voluntary’ should be removed as potentially misleading.
3. Maintaining the current legal prohibition on ‘encouraging’ people to end their life
The Bill permits a physician to provide an eligible patient with the means to end their own life, but this need not and should not allow doctors to encourage people to end their own life. The Bill must be amended so that ‘encouraging suicide’ remains illegal. To be valid a request need not be free from encouragement by another, but the act of encouragement by another is potentially harmful and contrary to the norms of suicide prevention. It should remain an offence.
4. Permitting the encouragement of seeking alternatives to ending one’s life
The Bill should state overtly that someone does not commit an offence if they encourage another person not to seek to end their own life. This overt permission is needed to prevent the Bill from inhibiting efforts at suicide prevention.
5. Including an overt right to suicide prevention
It is arguably that there is a right to reasonable means of suicide prevention based on human rights law. However, there is a danger that if the Bill passes then the means of suicide prevention might not be made available to those who are eligible for assistance ending their own life. The Bill needs to be amended to include an overt statement that everyone has a right to the means to prevent them from ending their own life.
6. A valid request must not be influenced by a mental health condition
As a valid request must be free from coercion and pressure, so the Bill should be amendment to that a valid request must not be influenced by a mental health conditio that could be alleviated by treatment.
7. It should only be for patients to raise this topic if they wish
The Bill permits a physician to provide an eligible patient with the means to end their own life, but does not permit a physician to administer the lethal dose. This must be under the control and at the initiative of the patient. So also the initial conversation must be under the control and at the initiative of the patient. The Bill must be amended to prohibit doctors from initiating this conversation. It is not their place.
8. No duty to direct people to information about how to end their lives
The Bill legalises actions that would otherwise constitute ‘assisting suicide’, including signposting people to information about how to obtain assistance ending their lives. While the Bill permits doctors to assist people end their lives it must not require doctors in the future to do what currently would be illegal, unprofessional and contrary to the norms of suicide prevention.
9. Prohibition of advertising
As the prohibition on encouraging suicide should remain, so there should be a prohibition on advertising services to assist people to end their life. This prohibition should be on the face of the Bill.
10. Duty to ask about concerns that motivate the request for the means to end life
Those assessing patients would have an ethical duty to ask patient about the concerns that motivated the request for the means to end their life. If the concerns could be addressed by other means, whether medical, social or financial, the person assessing the patient would have an ethical duty to refer the patient to services that could address these concerns. The Bill should be amended so that these duties are legal requirements.
11. Assisted dying is not medical treatment
The Bill is currently ambiguous about whether providing someone with the means to end life would constitute a ‘treatment option’. This creates potential tensions with case law and professional standards which require patients to be made aware of treatment options. It is essential that the Bill is amended to state that, for the purposes of law, ethical standards and professional regulation, assistance under the Bill does not constitute medical treatment.
12. Assisted dying is a cause of death and this is not a death from natural causes
While suicide is not an offence it is an unnatural death and is recorded as such, though in many cases suicide is subject to a narrative conclusion by a coroner. In the case of a death that is brought about by a substance provided by a doctor for that purpose, in accordance with the Bill, this substance is the cause of death and death should not be recorded as due to natural causes.
13. As assisted death is not natural death, it should be investigated by the coroner
While suicide is not an offence it is an unnatural death and is subject to investigation by the coroner. Similarly, if this Bill were to pass so that physician assisted suicide in specified circumstances were to be legalised, it would nevertheless remain an unnatural death. Such deaths should not be deprived of the safeguard of investigation by the coroner which currently applies to all suicides.
14. Removing the use of the Mental Capacity Act as the criteria for an autonomous decision
The Royal College of Psychiatrists, among others, has argued that the Mental Capacity Act 2005, with its presumption of capacity is not appropriate for decisions to end one’s own life. The Bill needs to be amended to take into account the duty of suicide prevention as this informs the Mental Health Act 1983. If a person’s decision to seek to end their own life is influenced by a treatable mental illness then the duty to safeguard the patient’s life should prevent the patient being given the means to end their own life.
[1] Professor of Bioethics, St Mary’s University, Twickenham and Research Fellow at Blackfriars Hall, Oxford University, but writing here in a personal capacity. This paper has not been through a formal peer review process, though it has benefited from comments from colleagues. It is intended as an individual contribution to ongoing discussion on the Terminally Ill Adults (End of Life) Bill.
[2] This paper was original written 10 November 2025, after the hearings of the House of Lords Select Committee on the Bill but before Committee Stage. On 15 June 2026, Lauren Edwards MP announced her plan to reintroduce the Bill in the form that it was previously sent to the House of Lords. The considerations here about the weaknesses of the Bill thus remain relevant.
[3] HL Bill 112 (as brought from the Commons), c. 1.
[4] Terminally Ill Adults (End of Life) Bill House of Lords Second Reading 12 September 2025 (128 times) and 19 September 2025 (116 times), Hansard Vol. 848.
[5] See for example, E. Jackson ‘In whose interests? the prohibition of assisted suicide in the United kingdom. In: I. Solanke ed. On Crime, Society, and Responsibility in the Work of Nicola Lacey. Oxford: Oxford University Press, p. 173.
[6] D.A. Jones ‘“Assisted dying” is assisted suicide and/or euthanasia’ JME Blog 31 January 2025 commenting D.A. Jones ‘How (not) to define “assisted dying”’ Journal of Medical Ethics 2025;51:657-661.
[7] D. Gajjar and A. Hobbs. Assisted dying. Postbrief 47. London: Parliamentary Office of Science and Technology; 2022, p. 4.
[8] HL Bill 112, cc. 4, 41, 42, Schedule 1.
[9] Bill 012 2024-25 (as introduced)
[10] D.A. Jones ‘Wrong Side of the World: The Misplaced Reliance on Australia in the UK Debate on “Assisted Dying”’ Oxford: Anscombe Bioethics Centre, 2025.
[11] Voluntary Assisted Dying Act 2017 (Victoria), Voluntary Assisted Dying Act 2019 (Western Australia), End-of-Life Choices (Voluntary Assisted Dying) Act 2021 (Tasmania), Voluntary Assisted Dying Act 2021 (South Australia), Voluntary Assisted Dying Act 2021 (Queensland), Voluntary Assisted Dying Act 2022 (New South Wales) and the Voluntary Assisted Dying Act 2024 (Australian Capital Territory).
[12] For example in the Voluntary Euthanasia (Legalisation) Bill of 1936.
[13] VAD Act 2017 (Victoria), s. 9(4), VAD Act 2019 (Western Australia), s. 16(1)(c)(ii), End-of Life Choices (VAD) Act 2021 (Tasmania), ss. 6(1)(c), 6(3), 6(4), VAD Act 2021 (South Australia) ss. 26(1)(d)(iii), 26(4), VAD Act 2021 (Queensland), s. 10(1)(a)(ii), VAD Act 2022 (NSW), s. 16(1)(d)(ii), VAD Act 2024 (ACT) s. 11(6).
[14] Hansard Vol. 848 Col. 1866 (Baroness Maclean) see also Hansard Vol. 848 Col. 1854 (Baroness Goudie), Hansard Vol. 848 Col. 2555 (Lord Moylan), Hansard Vol. 848 Col. 2594 (Lord Wolfson).
[15] Hansard Vol. 848 Col. 2555 (Lord Moylan).
[16] https://www.dignityindying.org.uk/news/voluntary-euthanasia-society-changes-name-70-years-become-dignity-dying-23-jan/
[17] M. Warnock. ‘Easeful death for the very elderly’. in C. Brewer and M Irwin eds. I’ll See Myself Out, Thank You. Newbold, Warwickshire: SkyScraper, 2014, p. 130.
[18] https://www.johnwyatt.com/essay-historical-perspectives-on-euthanasia-and-assisted-suicide/ See also I. Dowbiggin. A Concise History of Euthanasia Lanham, MD: Rowman & Littlefield, 2005.
[19] On the older history see B. Barraclough and D. Shepherd. ‘A necessary neologism: The origin and uses of suicide.’ Suicide and Life‐Threatening Behavior 24.2 (1994): 113-126.
[20] Hansard Vol. 848 Col. 1854 (Baroness Goudie).
[21] As has effectively happened in Australia where euthanasia has gone from an exception in Victoria, limited to those not physically capable of suicide, to the more common form of VAD in Western Australia and most other jurisdictions. In the context of the Bill it is noteworthy that there is some ambiguity about how a proposed device might work that is set up by the doctor for self-administration by the patient especially if the device needs to be re-adjusted in any way (see clauses 25 (7) to 25 (10))
[22] Conducted by Survation on behalf of the All-Party Parliamentary Group for Dying Well, 19-20 July 2021 https://www.dyingwell.co.uk/wp-content/uploads/2021/09/Survation-Assisted-Dying-Survey-July-2021-Summary-3.pdf
[23] See, for example, Written evidence submitted by The Equality and Human Rights Commission (ADY0317) to the House of Commons Health and Social Care Committee on Assisted Dying / Assisted Suicide (January 2023), para 7(h) but this phrase is used commonly both by opponents and defenders of the current law.
[24] HL Bill 112, c. 32 (3).
[25] HL Bill 112, cc. 25 (9), 25 (10).
[26] On the practical and ethical significance of self-administration see 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.
[27] Hansard Vol. 848 Col. 1784 (Baroness May), Hansard Vol. 848 Col. 1811 (Lord Morrow), Hansard Vol. 848 Col. 1826 (Lord McCrea), Hansard Vol. 848 Col. 1854 (Baroness Goudie),Hansard Vol. 848 Col. 1857 (Lord Dodds), Hansard Vol. 848 Col. 2541 (Baroness Fox), Hansard Vol. 848 Col. 2545 (Lord Harper), Hansard Vol. 848 Col. 2579 (Lord Bailey).
[28] Hansard Vol. 848 Col. 2518 (Baroness Thornton), Hansard Vol. 848 Col. 2523 (Baroness Blackstone), Hansard Vol. 848 Col. 2525 (Baroness Royall), Hansard Vol. 848 Col. 2570 (Lord Oates), Hansard Vol. 848 Col. 2599 (Lord Falconer).
[29] Gajjar and Hobbs Assisted dying, p. 4.
[30] S. Lipscombe, J. Dawson and E. Rough. The law on assisted suicide London: House of Commons Library Research Briefing Number CBP4857 (25 April 2024).
[31] Chin AE, Hedberg K, Higginson GK, et al. Oregon’s death with dignity act: the first year’s experience. Portland: Department of Human Resources Oregon Health Division Center for Disease Prevention and Epidemiology, 1999, p.1.
[32] https://dignitas.ch/en/knowledge/lexicon/
[33] https://www.government.nl/topics/euthanasia/is-euthanasia-allowed
[34] https://santesecu.public.lu/dam-assets/fr/publications/e/euthanasie-assistance-suicide-questions-reponses-fr-de-pt-en/euthanasie-assistance-suicide-questions-en.pdf
[35] https://webarchive.nrscotland.gov.uk/20240327012019/http://archive2021.parliament.scot/parliamentarybusiness/Bills/69604.aspx
[36] D.A. Jones ‘How (not) to define “assisted dying”’ Journal of Medical Ethics 2025;51:657-661
[37] People may, however, have very different understandings of what it means for an illness to be ‘terminal’ in relation to length of life. The last terminal phase of an illness may only be a few days, but the Bill categorises as terminal conditions with which someone could live for months or years (given the uncertainty of prognosis of 6 months and given the lack of clarity about how this may be shaped by non-treatment decisions).
[38] Hansard Vol. 848 Col. 2570 (Lord Oates) see also Hansard Vol. 848 Col. 1867 (Lord Purvis), Hansard Vol. 848 Col. 2525 (Baroness Royall).
[39] Hansard Vol. 848 Col. 2563 (Lord Moynihan).
[40] Hansard Vol. 848 Col. 2557 (Lord Browne) see RCPsych Press Release of 13 May 2025 https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2025/05/13/the-rcpsych-cannot-support-the-terminally-ill-adults-(end-of-life)-bill-for-england-and-wales-in-its-current-form
[41] V. Nafilyan, J. Morgan, A. Butt, and D. Mais. Suicide among people diagnosed with severe health conditions, England: 2017 to 2020 Office of National Statistics (20 April 2022)
[42] Hansard Vol. 848 Col. 2525 (Baroness Royall).
[43] Hansard Vol. 848 Col. 2570 (Lord Oates).
[44] V. Nafilyan et al. ‘Risk of suicide after diagnosis of severe physical health conditions: a retrospective cohort study of 47 million people.’ The Lancet Regional Health–Europe 25 (2023). Lord Morrow cited ‘90 days’ as a peak suicidality in chronic disease Hansard Vol. 848 Col. 1812 (Lord Morrow). It is not clear where this figure is from but it accords with research on people newly diagnosed with dementia, T. Schmutte et al. ‘Suicide risk in first year after dementia diagnosis in older adults.’ Alzheimer’s & Dementia 18.2 (2022): 262-271.
[45] See for example, B. Gascon, et al. ‘Suicide risk screening and suicide prevention in patients with cancer.’ JNCI cancer spectrum 5.4 (2021): pkab057; C.J. Bryan, K.M. Carpenter and T.M. Pawlik. ‘Evidence-based strategies to reduce suicide mortality among patients with cancer.’ JAMA oncology 9, no. 3 (2023): 303-304, though it is acknowledged that more research is needed on the effectiveness interventions.
[46] https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028/suicide-prevention-in-england-5-year-cross-sector-strategy#addressing-risk-factors
[47] Hansard Vol. 848 Col. 1867 (Lord Purvis)
[48] HL Bill 112, c. 1(a).
[49] HL Bill 112, c. 12 (2)(c)(iv).
[50] Hansard Vol. 848 Col. 2554 (Lord Moylan).
[51] Hansard Vol. 848 Col. 2518 (Baroness Thornton), see also Hansard Vol. 848 Col. 2525 (Baroness Royall).
[52] For example https://shiningalightonsuicide.org.uk/wp-content/uploads/2021/04/Language-guide-for-talking-about-suicide.pdf https://www.camh.ca/-/media/files/words-matter-suicide-language-guide.pdf https://www.shropshiretelfordandwrekin.nhs.uk/wp-content/uploads/Creating_hope_through_language_210__345_mm.pdf-3.pdf Some go further and question whether the use of terms such as ‘suicidal ideation’ and ‘suicidal behaviour’ involves an over-simplification which can miss important aspects of people’s thoughts and motivations, see for example. A. House,N. Kapur and D. Knipe. ‘Thinking about suicidal thinking.’ The Lancet Psychiatry 7.11 (2020): 997-1000.
[53] Hansard Vol. 848 Col. 1784 (Baroness May).
[54] M. Cooke. ‘Theresa May accused of being ‘deeply insensitive’ after referring to assisted dying as “suicide”’ Independent 18 September 2025.
[55] Hansard Vol. 848 Col. 2518 (Baroness Thornton).
[56] Hansard Vol. 848 Col. 2525 (Baroness Royall), citing the letter the Independent.
[57] Hansard Vol. 848 Col. 2523 (Baroness Blackstone).
[58] Hansard Vol. 848 Col. 2599 (Lord Falconer).
[59] HL Bill 112, c. 32 (3).
[60] See above question 6.
[61] See above question 7.
[62] See above question 8.
[63] Hansard Vol. 848 Col. 1833 (Lord Farmer) see J. Elgot ‘Legalising assisted dying in England and Wales “may hamper suicide prevention work”’ Guardian 21 February 2025.
[64] As many as 20% of the population experience suicidal thoughts at some point in their lives but only 0.1% die by suicide.
[65] https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028/suicide-prevention-in-england-5-year-cross-sector-strategy#introduction
[66] HL Bill 112, c. 39 (1)(a)
[67] Coroners and Justice Act 2009 s. 59
[68] Raised during the Second Reading debate Hansard Vol. 848 Col. 1832 (Baroness Debbonaire) and Hansard Vol. 848 Col. 2542 (Baroness Fox).
[69] T. Niederkrotenthaler et al. ‘Association between suicide reporting in the media and suicide: systematic review and meta-analysis.’ Bmj 368 (2020); M Sisask, Merike and A Värnik. ‘Media roles in suicide prevention: a systematic review.’ International journal of environmental research and public health 9.1 (2012): 123-138.
[70] See for example Written evidence submitted to the House of Commons Committee on the Bill by Dr Hannah Denno (TIAB99), ‘he disclosed his thoughts to me knowing that assisted suicide was not an option’.(emphasis in the original).
[71] Public Bill Committee Terminally Ill Adults (End of Life) Bill (Bill 012) 2024-2025 Compilation of All Debate sittings (2 April 2025), Col. 273 (Dan Scorer from Mencap)
[72] HL Bill 112, c. 39 (1)(a)
[73] HL Bill 112, c. 5 (2)
[74] HL Bill 112, c. 5 (6)
[75] On 12 September 2025 104 times and on 19 September 2025 106 times.
[76] Hansard Vol. 848 Col. 1811 (Baroness Noakes), Hansard Vol. 848 Col. 1832 (Baroness Debbonaire), Hansard Vol. 848 Col. 1869 (Baroness Lawlor), Hansard Vol. 848 Col. 1870 (Lord Mitchell), Hansard Vol. 848 Col. 2532 (Lord Empey) Hansard Vol. 848 Col. 2593 (Lord Wolfson), plus two references to ‘committed suicide’, Hansard Vol. 848 Col. 1870 (Lord Mitchell), Hansard Vol. 848 Col. 2541 (Baroness Fox).
[77] Samaritans Media Guidelines for Reporting Suicide (April 2020) p. 12 see also https://shiningalightonsuicide.org.uk/wp-content/uploads/2021/04/Language-guide-for-talking-about-suicide.pdf
[78] While the Catholic Church continues to regard suicide as ‘gravely contrary to love for the living God’ (Catechism of the Catholic Church 2281) there is an increasing awareness that ‘psychological disturbances… can diminish the responsibility of the one committing suicide’ (2282). Hence the Church does ‘not despair of the eternal salvation of persons who have taken their own lives’, but prays for them (2283).
[79] The word ‘suicidal’ was used 6 times for persons Hansard Vol. 848 Col. 1812 (Lord Morrow), Hansard Vol. 848 Col. 1861 (Lord Jackson), Hansard Vol. 848 Col. 1868 (Baroness Wheatcroft), Hansard Vol. 848 Col. 2518 (Baroness Thornton), Hansard Vol. 848 Col. 2524 (Baroness Royall), Hansard Vol. 848 Col. 2525 (Baroness Royall) and only 4 times for thoughts or ideation Hansard Vol. 848 Col. 1811 (Lord Morrow), Hansard Vol. 848 Col. 1812 (Lord Morrow), Hansard Vol. 848 Col. 1861 (Lord Jackson) Hansard Vol. 848 Col. 2528 (Lord Moore).
[80] Samaritans Media Guidelines, p. 4.
[81] Hansard Vol. 848 Col. 1774 (Lord Falconer) [sharp force], Hansard Vol. 848 Col. 1781 (Lord Alderdice) [drowning], Hansard Vol. 848 Col. 1864 (Lord Macdonald) [poisoning], Hansard Vol. 848 Col. 1870 (Lord Mitchell) [poisoning], Hansard Vol. 848 Col. 2528 (Lord Moore) [jumping], Hansard Vol. 848 Col. 2570 (Lord Oates) [poisoning], Hansard Vol. 848 Col. 2574 (Lord Cashman) [firearms].
[82] Hansard Vol. 848 Col. 2527 (Lord Moore)
[83] Samaritans Media Guidelines, p. 5-6. This positive impact is known as the Papageno effect T. Niederkrotenthaler et al. ‘Role of media reports in completed and prevented suicide: Werther v. Papageno effects.’ The British Journal of Psychiatry 197.3 (2010): 234-243.
[84] Hansard Vol. 848 Col. 1874 (Lord Hogan-Howe)
[85] Hansard Vol. 848 Col. 1838 (Lord Roberts)
[86] Hansard Vol. 848 Col. 1870 (Lord Mitchell)
[87] Ibid.
[88] Guidelines specifically caution against the phrase ‘successful suicide’ as though such a death represented a success (e.g. Samaritans Media Guidelines, p. 12) better to speak of ‘astonishingly successful’ Hansard Vol. 848 Col. 2528 (Lord Moore).
[89] Samaritans Media Guidelines, p. 10.
[90] Hansard Vol. 848 Col. 1789 (Baroness Featherstone).
[91] Hansard Vol. 848 Col. 1871 (Lord Mitchell).
[92] Hansard Vol. 848 Col. 2525 (Baroness Royall).
[93] Ibid.
[94] Hansard Victoria, Parliamentary Debates, Legislative Assembly. 17 October 2017. Book 13:3050-3135.
[95] D.A. Jones ‘Did the Voluntary Assisted Dying Act 2017 Prevent “at least one suicide every week”?’ Journal of Ethics in Mental Health Open Vol. 11 (21 Dec 2023). Available at https://www.jemh.ca/jemh-open-volume-11-2020
[96] Hansard Vol. 848 Col. 1861 (Lord Jackson).
[97] Hansard Vol. 848 Col. 1811 (Lord Morrow).
[98] Hansard Vol. 848 Col. 2525 (Baroness Royall).
[99] Coroners Court of Victoria ‘New research to understand Victoria’s suicide rate’ Press release 20 November 2024
[100] In contrast to Australia, Canada and New Zealand which also permit euthanasia.
[101] Hansard Vol. 848 Col. 2588 (Baroness Hollins).
[102] D. Paton and S. Girma ‘Assisted suicide laws increase suicide rates, especially among women’ VoxEU 29 Apr 2022, commenting on Girma, S., & Paton, D. ‘Is assisted suicide a substitute for unassisted suicide?’ Eur. Econ. Rev., 145 (2022), 104113.
[103] Hansard Vol. 848 Col. 2556 (Baroness Berridge).
[104] S.S. Canetto and J.L. McIntosh. ‘A comparison of physician-assisted/death-with-dignity-act death and suicide patterns in older adult women and men.’ The American Journal of Geriatric Psychiatry 30.2 (2022): 211-220.
[105] U. Güth et al. ‘Conventional and assisted suicide in Switzerland: Insights into a divergent development based on cancer‐associated self‐initiated deaths.’ Cancer medicine 12.16 (2023): 17296-17307.
[106] Hansard Vol. 848 Col. 1870 (Lord Mitchell).
[107] Hansard Vol. 848 Col. 1781 (Lord Alderdice).
[108] E.J. Van Wijngaarden, C.J. Leget and A. Goossensen, ‘Till death do us part: The lived experience of an elderly couple who chose to end their lives by spousal self-euthanasia’. The Gerontologist, 56.6 (2016) 1062-1071.
[109] This issue has been explored by F. Mackenzie. Safeguarding women in assisted dying. The Other Half, November 2024 see also S.T O’Dwyer et al. ‘From Caring to Killing: A Typology of Homicides and Homicide–Suicides Perpetrated by Caregivers.’ Social Sciences 14.6 (2025): 376.
[110] A. Frei et al. ‘The Werther effect and assisted suicide.’ Suicide and Life-Threatening Behavior 33.2 (2003): 192-200.
[111] Figures taken from respective annual reports available here https://english.euthanasiecommissie.nl/documents/annual-reports/2002/annual-reports/annual-reports
[112] In addition to Switzerland and the Netherlands: Australia: S. Rawson ‘When they chose to die together, my grandparents wrote the final chapter of a love story spanning 70 years’ Guardian 7 June 2025. Belgium: ‘Leopold Dauwe And Paula Raman, Belgian Elderly Couple, Euthanized Together’ HuffPost 26 Junes 2013. Canada: J. Ore ‘“There was no hesitation”: Why a couple married 73 years chose doctor-assisted death together’. CBC Radio 1 May 2018; R. Cave ‘Married 41 years and racked with pain, [New Brunswick] couple said goodbye together using MAID’ CBC News 25 March 2025. USA: J. Aleccia ‘This Couple Died By Assisted Suicide Together. Here’s Their Story’ Time Magazine 6 March 2018.
[113] In oral evidence to the House of Lords Select Committee (29 October 2025) Siobhan O’Dwyer suggested at one point that legalisation of assisted dying might help prevent such homicides but later acknowledged that ‘there has not been any research that has compared rates of family members taking matters into their own hands before and after the introduction of legislation’ (page 5).
[114] Hansard Vol. 848 Col. 1788 (Baroness Featherstone), Hansard Vol. 848 Col. 1811 (Baroness Noakes), Hansard Vol. 848 Col. 1827 (Lord Meston), Hansard Vol. 848 Col. 1848 (Lord Pannick), Hansard Vol. 848 Col. 1867 (Lord Purvis), Hansard Vol. 848 Col. 2585 (Viscount Astor).
[115] https://www.nhs.uk/tests-and-treatments/consent-to-treatment/
[116] Hansard Vol. 848 Col. 1848 (Lord Pannick).
[117] Hansard Vol. 848 Col. 2593 (Lord Wolfson).
[118] Hansard Vol. 848 Col. 2575 (Baroness Finlay). For further discussion of the legal and clinical distinction see G. Owen, A.R. Keene and K. Sleeman,The differences between treatment refusal and assisted death: synopsis and summary of case law: Terminally Ill Adults (End of Life) Second Reading Briefing. Complex Life and Death Decisions group King’s College London, September 2025.
[119] Hansard Vol. 848 Col. 1852 (Lord Tyrie), Hansard Vol. 848 Col. 1811 (Baroness Noakes), Hansard Vol. 848 Col. 1848 (Lord Pannick), Hansard Vol. 848 Col. 1867 (Lord Purvis), Hansard Vol. 848 Col. 2585 (Viscount Astor).
[120] For a discussion of current law on compulsory treatment, and the relation between the Mental Health Act 1983 and the Mental Capacity Act 2005 in the context of suicide see J. Herring. The Right to Be Protected from Committing Suicide Oxford: Hart Publishing, 2022, chapter 7.
[121] GMC Treatment and care towards the end of life: good practice in decision making. Meeting patients’ nutrition and hydration needs, para 110.
[122] P. Cotogni et al. ‘The role of nutritional support for cancer patients in palliative care.’ Nutrients 13.2 (2021): 306. M.E. Lokker, et al. ‘Hydration and symptoms in the last days of life.’ BMJ supportive & palliative care 11.3 (2021): 335-343.
[123] GMC Treatment and care towards the end of life, para 110
[124] M. Roberts. ‘Starving to death on NHS wards?’ BBC News online 9 January 2017.
[125] Hansard Vol. 848 Col. 1797 (Baroness Murphy), Hansard Vol. 848 Col. 1814 (Lord Barber), Hansard Vol. 848 Col. 1848 (Lord Pannick), Hansard Vol. 848 Col. 1867 (Lord Purvis), Hansard Vol. 848 Col. 2523 (Baroness Blackstone).
[126] Hansard Vol. 848 Col. 1847 (Lord Pannick), Hansard Vol. 848 Col. 2539 (Baroness Finn).
[127] Hansard Vol. 848 Col. 2593 (Lord Wolfson).
[128] Lings v. Denmark, no. 15136/20, § 52, 12 April 2022, Karsai v Hungary [2024] ECHR 516 on these and other cases see Owen, Keene and Sleeman, The difference between treatment refusal and assisted death.
[129] Purdy, R (on the application of) v Director of Public Prosecutions [2009] UKHL 45 the guidance is available online https://www.cps.gov.uk/prosecution-guidance/suicide-policy-prosecutors-respect-cases-encouraging-or-assisting-suicide
[130] Hansard Vol. 848 Col. 1865 (Lord Macdonald).
[131] Of 199 cases referred to the CPS for assisting suicide, the great majority were not taken forward by the CPS or were withdrawn by the police, but 5 were successfully prosecuted and 8 were referred on for prosecution for homicide or some other serious crime, which shows the need for investigation. See CPS Assisted Suicide (08 April 2024).
[132] Hansard Vol. 848 Col. 1800 (Duke of Wellington), Hansard Vol. 848 Col. 1803 (Lord Mohammed), Hansard Vol. 848 Col. 1829 (Dubs), Hansard Vol. 848 Col. 1848 (Pannick), Hansard Vol. 848 Col. 1862 (Baroness Bennett), Hansard Vol. 848 Col. 1865 (Lord Macdonald), Hansard Vol. 848 Col. 1872 (Lord Hogan-Howe), Hansard Vol. 848 Col. 2539 (Lord Young of Norwood Green), Hansard Vol. 848 Col. 2539 (Baroness Finn), Hansard Vol. 848 Col. 2541 (Lord Brooke), Hansard Vol. 848 Col. 2571 (Lord Freyberg),
[133] Hansard Vol. 848 Col. 2571 (Lord Freyberg), Hansard Vol. 848 Col. 2586 (Baroness Hayter), Hansard Vol. 848 Col. 2590 (Baroness Pidgeon).
[134] Hansard Vol. 848 Col. 1872 (Lord Hogan-Howe).
[135] Hansard Vol. 848 Col. 1829 (Lord Dubs).
[136] C. Bartsch et al. ‘Assisted suicide in Switzerland: An analysis of death records from Swiss institutes of forensic medicine.’ Deutsches Ärzteblatt International 116.33-34 (2019): 545.
[137] Hansard Vol. 848 Col. 1789 (Baroness Featherstone).
[138] Hansard Vol. 848 Col. 2555 (Lord Moylan), Hansard Vol. 848 Col. 2592 (Lord Wolfson).
[139] Hansard Vol. 848 Col. 2593 (Lord Wolfson).
[140]Brewer, Colin, Marie-Claire Hopwood, and Graham Winyard. “Assisted deaths in Switzerland for UK residents: diagnoses and their implications for palliative medicine and assisted dying legislation.” BMJ Supportive & Palliative Care 15.2 (2024): 259-261.
[141] For an exploration of this concept see D. Sperling. Suicide Tourism. Oxford: Oxford University Press. 2019.
[142] J. Herring. The Right to Be Protected from Committing Suicide Oxford: Hart Publishing, 2022, p. 135.
[143] https://www.bma.org.uk/advice-and-support/ethics/end-of-life/physician-assisted-dying
[144] Thomas Teague KC, Oral evidence to House of Lords Select Committee 23 October 2025.
