Session 2024-25
Terminally Ill Adults (End of Life) Bill
Written evidence submitted by the VISION consortium (TIAB304)
1. Introduction
We welcome the opportunity to respond to the call for evidence to inform the committee scrutinising the upcoming Assisted Dying Bill. We are committed to dignity in end of life care and supporting personal autonomy. However, we have concerns about the potential for harm arising from the proposed legislation, particularly in relation to safeguarding against coercion and abuse and make a series of recommendations for improved safeguarding and capacity for monitoring (section 3).
2. Concerns r egarding c oercion
One of our principal concerns is the potential for individuals to be coerced, whether directly or indirectly, into requesting an assisted death. While we acknowledge that the Bill is intended to provide individuals with autonomy in choosing the manner of their death, the experiences of jurisdictions such as Canada indicate there are insufficient safeguards to ensure that requests for assisted death are fully voluntary and free from external pressures. The subtle and often unseen forms of coercion-such as emotional, psychological, or financial pressures-are of particular concern. In some cases, vulnerable individuals may elect to end their lives to alleviate perceived burdens on their families, friends, or the healthcare system. These pressures could be subtle or explicit, but either way can be difficult for healthcare providers to detect, and it is important to query whether the requirement for two independent doctors to sign off on the request, will be robust enough to fully mitigate this risk.
2.1. Domestic abuse
Domestic abuse, from an intimate partner or other family members, encompassing psychological, emotional, financial, sexual and physical abuse, often results in a profound loss of autonomy for victims. These individuals-predominantly women, and often older people (Havers et al., 2024)-may feel trapped in relationships or families that not only compromise their physical safety but also undermine their mental and emotional wellbeing. The introduction of assisted dying legislation, if not properly safeguarded, may exacerbate these vulnerabilities, leading some with terminal illness to view the option of assisted death as an escape from the emotional or psychological abuse they face within the domestic sphere. Recent evidence led to survivors of domestic abuse being recognised as a group of concern in England’s 2023 National Suicide Prevention Strategy (DHSC 2023).
2.2. Age and gender p atterns of feeling ‘burden’
In the context of disabled people and older people, especially older, disabled women, there is an added dimension of concern regarding societal attitudes that may influence their and others’ perception of their worth. If societal messages reinforce the idea that their life is less valuable, some individuals might feel encouraged to request an assisted death. We believe that the Bill should go further in addressing these risks, with more comprehensive and consistent safeguards, as well as support and care systems in place to ensure individuals are not influenced by coercion, whether explicit or implicit.
There is a growing body of evidence suggesting that gendered dynamics play a significant role in the ways in which people engage with healthcare and make end-of-life decisions. We are particularly concerned – looking to the experiences of Track 2 Medical Assistance in Dying (MAiD) in Canada - that women may be disproportionately affected by the legalisation of assisted dying (Grant et al., 2024). Women, especially older women and those with caring responsibilities, may be socialised to place the needs of others above their own. This social conditioning may lead to an increased sense of obligation to request an assisted death, in response to perceived burdens on family members, especially in cases where they may already be experiencing physical frailty or chronic illness (Grant et al., 2024; Grant 2023, Mackenzie, 2024). People may request assisted death in response to a range of external pressures, including domestic and other forms of abuse and adverse socioeconomic circumstances, rather than fully autonomous, independent decision-making (Mackenzie, 2024).
3. Recommendations
In light of these concerns, we recommend the following actions to help inform the committee and amend the Assisted Dying Bill to better safeguard against coercion and abuse:
3.1 Do not rush this B ill , take time to learn : Extend to a full consultation, with detailed input from a wide range of experts, full reviews of the experience in Canada, Oregon, Netherlands and Australia which includes contributions from those identifying negative outcomes (as well as those with positive experiences), hear from disability rights groups, groups representing older people, and perspectives informed by understandings of coercive control and domestic violence and abuse of all forms.
3.2 Transparency and monitoring must supersede confidentiality : Canada and Oregon’s experience is that secrecy in data coding means a lack of transparency. Family members are unable to know or challenge when someone they love has been granted assisted dying and they believe that this was coerced (in particular , by an intimate partner). This is also essential to evaluate any change in law and monitor trends. For example, Lyons , Lemmens and Kim (2025) note of Canada:
Ideally, we would have individual-level data to definitively answer whether a MAID (Medical Assistance in Dying) system is safe or is in need of more safeguards. Unfortunately, there is a paucity of these data available-even less than, for example, other jurisdictions such as the Netherlands, where every case is reviewed by a panel and where many of the cases, especially the controversial ones, are published to promote education and debate.
3.3 Build in review and accountability : In Canada, there are signs of abuse of Medical Assistance in Dying (MAID). Recent reporting cites briefings from the Ontario chief coroner pointing toward 428 cases of non-compliance issues in MAID deaths in that province between 2018 and 2023 - with not a single case referred to law enforcement (Raikin, 2024). Lyon et al., (2025) provide further examples that call into question the safety of the Canadian MAID system, and suggest failures to protect patients from wrongful, avoidable death (Lyon et al., 2025).
3.4 Build in limitations against scope expansion : In Canada the extension beyond terminal illnesses has been swift, with dementia and mental health conditions now being considered for eligib ility – these are conditions more prevalent in survivors of IPV, and with poor mental health and suicidality even caused by experiences of violence (McManus et al., 2022).
3.5 F irst appropriately f und support for disabled living and for palliative care : N o one must ever feel they choose AD because they cannot afford to live with dignity and independence. This risks exacerbating inequalities. ‘Feeling a burden’ should be a reason driving someone electing for AD.
3.6 Train healthcare practitioners : M any doctors will not recognise the signs that a person may be subject to domestic or other forms of abuse ( Cooper et al., 2009 ) . Australia recognised this risk – but the 40-minute online ‘specialist’ training does not seem to have been effective – with only a handful of AD requests turned down due to domestic abuse – likely indicating a failure to identify signs of coercion in practice ( Mackenzie et al., 2024 ) . Training should be specialist, face to face, and include clear referral pathways.
3.7 Enhanced identification procedures: Where someone requests AD, there should be thorough mandatory inquiry about domestic abuse, looking for signs coercive control. This should include psychological assessments specifically aimed at uncovering patterns of abuse, whether physical, emotional, or financial. Where there are any signs, they should be referred for further support, including domestic violence specialist services, prior to proceeding with an assisted death request. The Committee should consider the inclusion and resourcing of independent third-party advocates, especially for individuals who may be at risk of manipulation. These advocates could help ensure that the person requesting assisted death is doing so entirely voluntarily and with awareness of alternative support, without external pressures from family members or intimate partners.
3.8 Consider commercial context : We recommend that the committee ensure any future Act considers and aims to safeguards against potential perverse incentives in insurance and healthcare systems of the future.
Conclusion
The right to die with dignity is a fundamental human right and our current systems are flawed and in need of reform. However, assisted dying requires careful consideration to the potential risks of the influence of abuse and coercion, especially in relation to age, disability, socioeconomic, ethnic and gender inequalities. It is essential that the Assisted Dying Bill, if it becomes an Act, contains robust safeguards to prevent individuals being influenced by external pressures. We trust that the Committee will carefully consider these issues, listen to a wide range of voices and international perspectives, and work to build systems with specialist training, transparency and monitoring in place so that any legalisation of assisted dying is balanced with the necessary protections against coercion and recognising the influence of abuse, reinforcing individual dignity and autonomy.
4. References
Cooper, C., Selwood, A., & Livingston, G. (2009). Knowledge, detection, and reporting of abuse by health and social care professionals: a systematic review. The American Journal of Geriatric Psychiatry, 17(10), 826-838.
DHSC (2023) Suicide Prevention Strategy for England: 2023 to 2028. https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028
Grant, I. (2023). Legislated ableism: Bill C-7 and the rapid expansion of MAiD in Canada. Available at SSRN 4544454.
Grant, I., Benedet, J., Sheehy, E., & Frazee, C. (2024). A Conversation on Feminism, Ableism, and Medical Assistance in Dying. Canadian Journal of Women and the Law, 35(1), 31-72.
Havers, B., Tripathi, K., Burton, A., McManus, S., & Cooper, C. (2024). Cybercrime victimisation among older adults: A probability sample survey in England and Wales. PloS one, 19(12), e0314380. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0314380
Lyon, C., Lemmens, T., & Kim, S. Y. (2025). Canadian Medical Assistance in Dying: Provider Concentration, Policy Capture, and Need for Reform. The American journal of bioethics, 1-20. https://www.tandfonline.com/doi/full/10.1080/15265161.2024.2441695
Mackenzie F . (2024) Safeguarding women in assisted dying. The Other Half. https://theotherhalf.uk/safeguarding-women-in-assisted-dying
McManus, S., Walby, S., Barbosa, E. C., Appleby, L., Brugha, T., Bebbington, P. E., ... & Knipe, D. (2022). Intimate partner violence, suicidality, and self-harm: a probability sample survey of the general population in England. The Lancet Psychiatry, 9(7), 574-583. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(22)00151-1/fulltext
Raikin, A. 2024a. A pattern of noncompliance. The New Atlantis. Epub ahead of print 11 November 2024. https://www.thenewatlantis.com/publications/compliance-problems-maid-canada-leaked-documents
Woodhouse, T . (unpublished) DA and Real Time Suicide Surveillance Kent and the Medway (RTSS) .
5. About us
The UKRI VISION (Violence, Health and Society) consortium (Grant MR/V049879/1) is a collaboration of healthcare clinicians, epidemiologists, economists, data scientists, criminologists, evaluation experts, psychiatrists and more from multiple universities. Our research brings data together from health and crime surveys, health services, police, solicitors, and third sector domestic and sexual violence specialist services.
Our aim is to drive reductions in all kinds of violence and their associated inequalities by better measurement, integration and new findings about the contexts and consequences of violence. Our research findings and policy recommendations are framed by an intersectional understanding of violence, particularly the role of gender, age, disability, ethnicity, migration status and socioeconomics. In the first three years of the consortium, we produced a suite of evidence reviews, violence research guidance and primary research from health and crime surveys, health service, police and domestic and sexual violence specialist services data.
6. Contact s for further information:
7 February 2025