Terminally Ill Adults (End of Life) Bill

Written evidence submitted by Professor David Paton, Nottingham University Business School (TIAB125)

1. Introduction

1.1 I am Professor of Industrial Economics at Nottingham University Business School.

1.2 The evidence in this submission relates to research I have undertaken examining the aspects of physician assisted suicide (PAS) laws in the US and Canada. A list of my research outputs are included in the list of references at the end of this document.

1.3 There are three issues raised by this research which are relevant to the Terminally Ill Adults (End of Life) Bill (henceforth ‘the Bill’) should it be passed: (i) the likely impact of the Bill on suicide rates in England and Wales; (ii) the implications of the Bill for patients who are concerned about being a burden on families and carer; (iii) the likely cost of implementing PAS.

1.4 There is disagreement about the most appropriate terminology to describe doctors providing assistance to patients to end their own life. In this submission, I use the term ‘physician assisted suicide’ (PAS). This is consistent with the recent UK Parliament POSTBrief (Hobbs and Gajjar, 2022) which uses ‘assisted dying’ as an umbrella term covering both euthanasia (where doctors administer medication intended to cause death) and PAS (where doctors prescribe drug for self-administration).

2. Likely impact of the Bill on suicide rates in England and Wales.

2.1 Clause 24(3) of the Bill proposes to amend the Suicide Act 1961 so that a person encouraging or assisting suicide will not be liable under that Act if they reasonably believe they are acting in accordance with the Bill.

2.2 In common with many countries, the UK has a Suicide Prevention Strategy (DHSC 2023) which has the explicit aims of preventing self-harm and reducing suicide rates.

2.3 Given that suicide reduction is an important public health objective both in the UK and globally, the Committee should give consideration to the implications of this Clause for the Suicide Prevention Strategy.

2.4 In the Policy Background section of the Explanatory Notes, paragraph 14 suggests that high levels of suicide amongst terminally ill people are an important motivation for introducing the Bill. The implication is that it is hoped the Bill will lead to a reduction in rates of non-assisted suicides amongst terminally ill people.

2.5 The possibility that legalising PAS may lead to a reduction in non-assisted suicide and, even possibly a reduction in total (i.e. assisted plus non-assisted) suicides has been a common feature of debates regarding PAS laws. Examples include Carter vs Canada (Attorney General), 2015; Dignitas, 2014; Iacobucci, 2021.

2.6 The basic idea behind the hypothesis is that some people who would otherwise have committed non-assisted suicide in the face of a serious long-term illness, may choose instead to utilise PAS. In this event, legalising PAS may reduce non-assisted suicides.

2.7 ONS data commissioned by the then Secretary of State for Health, showed that people with severe illnesses are particularly vulnerable to suicide (ONS, 2022). It is important to note that these data do not provide evidence on the actual impact of PAS laws on suicide rates.

2.8 In addition, people in the early stages of a degenerative disease may worry that they when their quality of life has deteriorated significantly, they will no longer be able to die by suicide without assistance. Given this, in the absence of legalised PAS, they may be tempted to commit suicide at an earlier stage.

2.9 If such people have the assurance that PAS will be available should they end up wishing to die in the future, the suicide decision may be delayed. Further, some people who delay the suicide decision anticipating that they will access PAS at a point in the future, may find that they no longer wish to do so when they are actually in that situation.

2.10 In contrast, there are also mechanisms whereby legalising PAS might lead to an increase even in non-assisted suicides. For example, legalisation may reduce societal taboos against suicide in a way that conflicts with campaigns aimed at suicide prevention.

2.11 Given these conflicting hypotheses, the impact of PAS laws on suicide rates is an open question that can only be resolved by reference to the empirical evidence. There now exists a suitably large body of evidence which can shed light on this issue.

2.12 The empirical question cannot be answered by reference to cross-sectional data on different rates of suicide in areas with and without PAS laws as demographic and cultural factors affecting both suicide rates and the likelihood of such laws being passed may give rise to a spurious association.

2.13 A more appropriate empirical approach is to examine trends in suicide rates before and after PAS laws are implemented, compared to trends in other jurisdictions without such laws.

2.14 Girma and Paton (2022) undertake such an analysis using US state-level data including the 10 US states that had implemented a PAS law up to the end of 2019. This work builds on an earlier preliminary study by Jones and Paton (2015) and considers the impact of PAS laws both on total suicide rates (i.e. including PAS) and on non-assisted suicide rates alone.

2.15 Our study uses a variety of empirical techniques to establish any causal effect of PAS laws and controls for a range of potential confounding factors including pre-existing trends in suicide rates in particular states.

2.16 We find robust evidence that legalisation of PAS is associated with a significant increase in total suicide rates. The increase is observed most strongly for women.

2.17 The size of the effect is considerable: PAS laws are found, on average, to increase total suicide rates by about 18% overall and by about 40% for women.

2.18 We also find evidence that PAS is associated with an increase in non-assisted suicides. The effect is smaller (about 6% increase overall, 13% increase for women) but still statistically significant in most estimates.

2.19 The study finds no evidence that PAS laws are associated with a reduction in either total or non-assisted suicide rates.

2.20 Our evidence is consistent with other recent research. For example, Jones (2022) examines trends in European countries that have introduced either PAS or euthanasia and concludes that there is "no reduction in non-assisted suicide relative to the most similar [non-legalising] neighbour and, in some cases, there is a relative and/or an absolute increase in non-assisted suicide."

2.21 Most recently, Sutton and Kious (2024) re-examine US data using an alternative empirical approach. They find PAS laws are associated with a small increase in non-assisted suicide rates, but that this is statistically insignificant.

2.22 A recent systematic review by Doherty et al (2022) of the evidence regarding the impact of PAS on suicide rates concludes:

"The findings of this review do not support the hypothesis that introducing EAS reduces rates of non-assisted suicide. The disproportionate impact on older women indicates unmet suicide prevention needs in this population."

2.23 Research by Canetto and McIntosh (2022) supports the finding that PAS laws have a relatively bigger effect on women. The authors suggest that higher take-up of PAS by women may reflect disempowerment of those who are more vulnerable to social pressure to die by suicide, for example, through feeling a burden to relatives or society.

2.24 In summary, there is now strong evidence that PAS laws lead to increases in total suicide rates but (at least) do not reduce rates of non-assisted suicides.

2.25 Given the weight of evidence, the Committee should consider the implications for suicide reduction policy of exempting liability from the Suicide Act as suggested by Clause 24(3). The Committee should further consider whether and how the Bill might be amended to take account of the risk that its introduction is likely to increase the number of total suicides, particularly amongst women.

3. Implications of the Bill for patients who are concerned about being a burden on families and carer

3.1 Clause 26(1)-(3) of the Bill deals with cases in which someone uses coercion or pressure on a person to seek assistance to end their own life. However, the Bill does not currently consider cases where a person feels indirect pressure to seek PAS.

3.2 Indirect pressure may be felt by a person for a number of reasons, most obviously if they feel they are a burden on family or carers or if they are worried about financial consequences of end-of-life treatment.

3.3 There appear to be no provisions in the Bill aimed explicitly at protecting vulnerable people who feel such indirect pressure.

3.4 Evidence from US states such as Oregon (Oregon Health Authority, 2024) reveals that a significant proportion of patients who seek PAS indicate that concerns about being a burden families and carers was an important motivation for their decision.

3.5 My recent research on this issue (Jones, Paton and Rutaquio, 2025) provides evidence that in both Oregon and Washington state, concern over "being a burden" increased significantly over time since PAS was legalised. In 2024, over 40% patients raised this concern.

3.6 Clause 4(2) allows medical practitioners to raise the issue of PAS with a patient if they deem it appropriate. This increases the risk that vulnerable patients who feel that they are a burden may thereby be encouraged to seek assistance to end their own lives. This risk may, in some cases, be heightened by the fact that Clause 9(2)(f) of the Bill does not require medical practitioners to involve next of kin or other persons in the decision-making process.

3.7 Indirect pressure on vulnerable people to end their lives is likely to be at least one explanation of why PAS laws increase suicide rates.

3.8 The Committee should consider carefully how the Bill might be amended so as to protect vulnerable people who may feel indirect pressure to seek assistance to end their lives.

4. The likely cost of implementing physician assisted suicide (PAS)

4.1 The potential impact of the Bill on health care resources was raised in public debates, including by the Health Secretary, Wes Streeting, who argued in a BBC interview that ‘that financing an assisted dying law would come at the expense of other NHS services." [1]

Implementing PAS laws give rise to direct costs such as training, doctor’s time, medication and so on. They may also lead to healthcare savings due to the shortening of terminally ill patients’ lives when they might otherwise require care.

4.2 Given there is very limited academic literature analysing costs of PAS laws, I would like to draw the Committee’s attention to new research I have undertaken (Paton, 2025) that provides a framework for estimating costs and which gives indicative estimates of the likely cost per PAS case in England and Wales under the Bill.

4.3 The cost per completed PAS case under the Bill is estimated to be around £3,600 in England and Wales. If there were 5,000 such cases per year (a figure that would be consistent with PAS rates in Oregon), this would mean a cost of about £18 million per year. This figure does not include initial costs of implementing the Bill such as setting up processes and training costs.

4.4 These indicative costs are consistent with, though somewhat higher than, costs per case suggested by Bernier (2020) for Canada. The higher indicative costs for England and Wales reflect the requirements under the Bill that every case be subject to a legal process and that a doctor should be present with patients throughout the dying process.

4.5 The unique nature of the High Court involvement in the Bill means there is a relatively high level of uncertainty surrounding cost estimates for England and Wales.

References

Bernier G, SA Ahmed and C Busby (2020), Cost Estimate for Bill C-7 "Medical Assistance in Dying" October, Office of the Parliamentary Budget Officer: Ottawa.

Canetto SS and JL McIntosh (2022), ‘A comparison of physician-assisted/Death-with-Dignity death and suicide patterns in older adult women and men’ The American Journal of Geriatric Psychiatry 30 (2, Feb) 211-20.

Carter v. Canada (Attorney General) (2015), SCR, 1: 331 https://canlii.ca/t/gg5z4

Department of Health and Social Care (DHSC) (2023), Suicide prevention in England: 5-year cross-sector strategy September www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028

Dignitas (2014), Submission 67 by Dignitas to Medical Services (Dying with Dignity) Exposure Draft Bill 2014, August, Parliament of the Commonwealth of Australia. https://www.aph.gov.au/DocumentStore.ashx?id=9d3ff5aa-2732-4402-ba87-3e7912088f1e&subId=299804

Doherty AM, CJ Axe and DA Jones (2022), ‘Investigating the relationship between euthanasia and/or assisted suicide and rates of non-assisted suicide: systematic review’, BJPsych Open 8, e108, 1–8.

Girma S and D Paton (2022), ‘Is assisted suicide a substitute for unassisted suicide?’ European Economic Review 145(June) 104113.

Hobbs A and D Gajjar (2022), ‘Assisted Dying’ POSTBrief 47 (Sept), London: UK Parliament.

Iacobucci G (2021), ‘Assisted dying: Hancock asks for more data on suicides of terminally ill people’ BMJ (Clinical research ed.) 373: n1107 https://www.bmj.com/content/373/bmj.n1107

Jones DA (2022), ‘Euthanasia, assisted suicide, and suicide rates in Europe’, Journal of Ethics in Mental Health, Open volume (Feb): 1-35 https://jemh.ca/issues/open/documents/JEMH%20article%20EAS%20and%20suicide%20rates%20in%20Europe%20-%20copy-edited%20final.pdf

Jones DA, D Paton and P Rutaquio (2025), ‘Trends in end-of-life concerns after the legalization of assisted suicide’, SSRN January https://ssrn.com/abstract=5105556

Jones DA and D Paton (2015), ‘How does legalization of physician assisted suicide affect rates of suicide?’, Southern Medical Journal 108 (10, Oct): 599-604.

Office for National Statistics (ONS) (2022), Suicides among people diagnosed with severe health conditions, England: 2017 to 2020 https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesamongpeoplediagnosedwithseverehealthconditionsengland/2017to2020#suicide-rates-by-time-since-diagnosis

Oregon Health Authority (2024) Oregon Death with Dignity Act: 2023 data summary 20 March, Public Health Division.

Paton D (2025) ‘Estimating the cost of implementing assisted suicide in the UK’ SSRN January, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=5100702

Sutton OP and BM Kious (2024), ‘Associations Between the Legalization and Implementation of Medical Aid in Dying and Suicide Rates in the United States’, AJOB Empirical Bioethics https://doi.org/10.1080/23294515.2024.2433474

21 January 2025