MPs must understand the history of the assisted dying bill
4 min read
An assisted dying bill fit for the 21st century must break with its dangerous historic roots.
If enacted, the Terminally Ill Adults Bill will be one of the most consequential legislative changes in a generation. However, rather than resulting from an appraisal of options to address a clearly defined problem, it revives a nearly century-old proposal devised by medical eugenicist Dr Killick Millard. MPs must understand this history and its implications to develop a law that is fit for the 21st century.
When Millard proposed his Voluntary Euthanasia (Legalisation) Bill in 1931, he claimed it would prevent painful protracted deaths. Aligned with his eugenic beliefs, he also “applauded” the prospect of people ending their lives to alleviate the burden on others, calling this “heroic”, “courageous” and “highly altruistic”. Privately, Millard was open to eventual involuntary euthanasia and lobbied for the release of Nazi doctor Siegbert Ramsauer, whose killings he deemed justifiable.
Like the eugenicist policies of his day, Millard's proposal was centred around the medical profession. Access required a terminal medical diagnosis, with assessment conducted by two doctors and a doctor providing the lethal substance used to end life. Although decisively rejected by Parliament in 1936, this proposal has returned repeatedly since, championed by Millard’s Voluntary Euthanasia Society – renamed Dignity in Dying. It has also been promoted worldwide by an organised network of “right-to-die” societies.
The Terminally Ill Adults Bill adopts Millard’s approach unquestioningly, revising only the rationale to align with current values. As a result, the Bill fails to address the rhetorical claims made for it.
It would not stop people travelling abroad for an assisted death (most people who do so would not meet the eligibility criteria), nor prevent non-assisted suicides (which have not decreased in countries with similar laws), and suffering is not mentioned once, despite supposedly being the key concern. Moreover, instead of offering ‘choice', the Bill would deny patients with a terminal illness who express a desire to end their lives the healthcare response everyone else receives — support aimed at affirming their worth, alleviating their distress, and preventing suicide. Given that terminally ill patients respond to such interventions as well as anyone else, this amounts to an unprecedented legal infringement on the equitable provision of healthcare.
Millard’s medical approach to assisted dying brings additional consequences.
If framed as a medical treatment for the terminally ill, everyone with a terminal illness has to consider it, and to justify their decision to themselves and others. In turn, doctors are permitted to proactively offer it, despite the inevitable pressure this exerts. Pressure and indirect coercion are inherent to this approach, not risks to mitigate with safeguards. This was recognised by Keir Starmer, when, as Director of Public Prosecutions, he rejected terminal illness or disability as mitigating factors in assisted suicide cases and made medical involvement a factor favouring prosecution. Predictably, in line with Millard's original intentions, significant proportions of people receiving a medically-assisted death worldwide cite concerns about being a burden on others — 59 per cent in Washington State in 2022.
In addition, if classed as a medical procedure, arbitrary eligibility criteria cannot limit access. As a result, every jurisdiction that has introduced assisted dying into an equity-based healthcare system has had to expand eligibility over time. In Belgium and the Netherlands, which have the longest such experience, this has eventually included those unable to consent, including children and people with advanced dementia — who have the same right to healthcare as everyone else.
However, there is nothing inevitable about Millard’s approach. Ending a life is not a medical procedure and providing standard lethal doses of toxic substances requires no medical expertise. As with the death penalty, doctors should have no role in administering assisted deaths. Instead, MPs should explore options for training and regulating a new professional group to deliver this entirely novel service.
Regarding eligibility, MPs must first clarify what legalising assisted dying aims to achieve.
If the goal is to address intractable suffering, access should be limited to people whose suffering is intractable. Assisted dying would, then, be a measure of last resort, used only if every other effort to address someone’s suffering and support them to feel valued had been exhausted. The courts would be best placed to judge these exceptional cases.
If the goal is autonomy – the ‘right to choose how and when to die’ – then proponents must show they have objective evidence-based criteria that differentiate a ‘valid’ desire to end life from one that requires intervention to address suffering and prevent suicide. If autonomy is truly the goal, these criteria could clearly not depend on a person’s medical condition or life expectancy or on any other discriminatory judgement about what makes a life worth living.
Discriminatory attitudes rooted in our eugenicist past must not be allowed to underpin such a crucial piece of legislation. MPs must completely dissociate themselves from Millard’s legacy if they are to create a law that is safe, compassionate and fit for the 21st century.
Lucy Thomas is a palliative care and public health doctor.
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