While I share your feeling on the misguided messaging and imagery of the UK ad campaign, I think you may benefit from learning about Australia’s experience.
The introduction of assisted dying in Australia provides clear evidence that well-designed voluntary assisted dying (VAD) laws can work safely and compassionately. Since Victoria first legalised VAD in 2019, followed by other states, our experience demonstrates none of the feared negative outcomes have materialised.
The Victorian Voluntary Assisted Dying Review Board reports consistently show that the system is working as intended, with robust safeguards. Between July 2019 and June 2023, there were 1,730 permits issued, with around 60% of eligible people proceeding with VAD. This clearly shows that even after qualifying, many people choose not to proceed - the mere availability of the option providing comfort in itself.
I can speak to this reality from personal experience. I witnessed a loved one's journey with terminal cancer who accessed VAD last year. Far from being pressured or coerced, they approached the decision with deep consideration - making and canceling four separate appointments before feeling ready. This reflects the profound seriousness with which these decisions are made, and how the system respects individual autonomy and timing.
The Australian model requires multiple independent assessments, mandatory waiting periods, and confirms decision-making capacity throughout the process. These safeguards work. After several years of operation across multiple states, there is no evidence of coercion or abuse that opponents feared.
Most importantly, VAD provides terminally ill individuals agency over their final days. My loved one's greatest wish was to avoid prolonged suffering, cognitive decline, and unmanageable pain. Having this choice available brought immense comfort, even before they were ready to use it.
This isn't about promoting death - it's about allowing individuals facing terminal illness to have control over their final chapter, while maintaining robust safeguards. The Australian experience proves this balance is achievable.
The thing that makes me worried that the UK (and Ireland, where I am) won't manage this well is that for the most part, people in favour of it don't seem worried or ambivalent about it. I keep seeing people say that assisted dying is a "no-brainer" or words to that effect. If there is a way to allow for it where it's a mercy and protect people from it where it's not, that won't be achieved by a society that doesn't realize how difficult this issue is.
In Australia do you think the debate around it was nuanced and thoughtful? I'm just wondering how Australia came to get it right when for example Canada got it so wrong.
Why would they change them if they're working? Isn't that a bit like saying, sure, speed limits are working now, but there's nothing to stop them from abolishing them altogether and then we'll have chaos.
Ian, as a Canadian, I agree with the Australian writer, hope your bill passes, and am surprised at the pushback here. Several of my friends, terminally ill, have been grateful for medical assistance in dying - MAID. As soon as my dearest friend was diagnosed with the hideous disease ALS, she went to her doctor to arrange for eventual MAID, which was an incredible relief for her. Of course she went through a rigorous investigation by several doctors. Three years later, she arranged everything about her death, including having the door of her small house removed so the bier carrying her body could get through. A friend sewed and sent her a shroud of fine silk. It was terrible and very strange to know my lifelong friend was going to die at twelve noon on May 25. For her, it was one of the greatest gifts she could have been given, to die at home surrounded by loving friends.
My father had terminal stomach cancer in 1988; after his death, we found out he'd stockpiled morphine and committed suicide. Though at home, he died alone, couldn’t tell anyone, because it was illegal. I will always regret we could not know about his choice not to prolong his suffering and accompany him.
The ads you refer to sound wrong-headed, as if medically assisted dying is a gleeful choice. Here the patient is carefully monitored by doctors all the way through. The statistics in Canada are that over 97% of those who’ve accessed it have a terminal disease. There's understandable controversy about extending MAID to those with mental illness, and that has not been done. But I am deeply grateful to know that if I'm diagnosed with something appalling, I will have a choice, with the help of doctors, how long to endure and when to exit.
You’ve made this argument very nicely. It highlights for me that this is not “state-managed death” but more an appropriate instance where the state recognizes the right of the individual, in certain well-defined circumstances, to determine their own destiny.
Extraordinary to see white people featured on adverts on the London Underground!
With all due respect and sympathy for those personally affected by this, it strikes me that personal anecdote is used to justify the arguments for legalised dying to a degree I'm not comfortable with. If Auntie Elsie had a very painful last month on earth and would have liked to die sooner then that's a fair statement, but this is not how policy should be arrived at. Though Starmer's justification is that he promised Esther Rantzen that he would pursue it, for God's sake. This is what we've come to!
Let us identify principles first before recourse to personal anecdote. One such principle might be that suicide is bad and if it is enabled through what we're calling legalised dying how are we supposed to convincingly persuade, say, young men not to take overdoses or hang themselves? And at the level of anecdote, a friend of mine hanged himself about three months ago, causing untold hell for his loved ones. But using the lexicon of the pro side of this argument then presumably that's okay so long as he was really sure he wanted to and was really sure he wasn't going to recover from whatever thing was ailing him?
Well put. Beyond the ‘don’t resort to emotional language’, I also object to the idea advanced by Lord Faulkner et al., that being opposed for religious belief reasons is illegitimate. I’ll be oppose for whatever reasons I like. People’s views on this are shaped by many things and that may or may not include theology.
"Protect the NHS" is why we can't have assisted dying. We stole two years of everyones lives under that slogan, and while it's no longer an outright conspiracy theory to think that was a bit overdone, it's certainly not something that's mentioned in polite society.
In a world where it's not a primary organising principle for large parts of society to (demand for other to) forfeit "selfish" desires to protect the health service, reasonable people can discuss how to design safeguards. But in a world where we can't eat burgers, smoke, drink, or for two years go to school or church to "protect the NHS" there are no safeguards. Everybody is pre-coerced.
Thank you for writing this. I feel the same way about these ads, and the ones in Canada and elsewhere. It staggers me that so many of the proponents are the sort of people who'd march to prevent the government re-introducing the death penalty.
The point about pets they always bring up is really telling- how many healthy, unloved cats and dogs have been "euthanised" over the years? A quick google tells me that around a thousand otherwise healthy but unloved and uncared-for animals are put down each year in the UK. It's around a million in the US according to the ASPCA. If that is the future proponents want for people, it is a deeply chilling one. And that's before we get to the meat industry.
Their going hence, even as their coming hither." Edgar, King Lear
and
One of my neighbours got Motor Neuron Disease. Before that point, she was in favour of euthanasia. Once ill, she wanted to experience the last drops of life however great her suffering.
Hugo Rifkind has written one of the best articles on this.
" I want to say something about how arguments, generally, are usually perceived to work. Because often, I think, we assume that if one side makes an argument and the other side can’t defeat it then the first side has won. Whereas actually, there can be unanswerable arguments all over the place. Not everything has a right and a wrong."
I do personally disagree with the OP almost entirely. I am prone to distaste and both political and moral doubts over "state organs killing citizens", tho the utilitarian argument speaks to me fully. Unlike many people seem to, I don't shudder with horror at the idea of someone who's nearly dead being (subtly) pressured to die earlier by worn out carers and relatives at all, in fact I'd LOVE IT if my carers actively helped me to push over the primitive, animal fear of death and dying into accepting the end at sensible time, if I ever got into relevant situation (I'm hoping for a heart attack if early or pneumonia if late, obviously).
So while coercion is undesirable, I don't see potential for coercion here as as terrible. As our bodies deteriorate, as we age and fall apart, necessarily, as our brains rot slowly but inevitably, even if we are spared the utter horror of dementia, as the "very slow decay" -- even the slowest possible -- becomes a dominant aspect of our lives, it seems to me that the hard wired survival drive becomes more salient, that we cling more and more desperately to the diminishing life we have left. Is being nudged out of this such a terrible thing, really?
All that said, this post feels like a good argument against my position, with a balance of reason and emotion that, while not persuasive to me, makes a good case.
Your article reminds me of similar arguments made by Michael Sandel in What Money Can't Buy—namely, that the expansion of "freedoms" can end up exploiting or coercing vulnerable individuals when not checked by forms of community or government supervision (as commenters from Canada and Australia point out here). You discuss assisted dying, but your concerns carry nicely to commercial surrogacy, sex work, gambling, and even debt contraction. Drawing the line between individual rights and societal values in each case isn't easy. Thank you, as usual, for a thoughtful piece.
As an Oregon resident, this situation in the UK leading up to the vote sounds unfortunate. But here it is working well. There is careful monitoring of patients, including why they are choosing assisted suicide.
The merits of the legislation aside, I marvel that Britain can have a debate about such a fraught issue. And for further reading on assisted dying, I might recommend "In Love" by Amy Bloom. https://www.amazon.com/Love-Memoir-Loss/dp/0593243943. Thanks for such a thoughtful post, and the ad, way more than the bill itself, is incredibly creepy.
Just wanted to say that I find this comments section (and the linked articles) quite helpful thinking through this after reading about the debate yesterday. As it happens, over this week I've moved from against the bill to in favour of the bill (but yes, with nervousness that there probably will be some worrying line calls about coercion).
The only thing I wanted to add (possibly of relevant to the theme of the Substack), is that I think anecdotes ARE really important here. In fact, reasoning on principles alone seems to me fruitless as I find both principles "the state mustn't murder" and "the state mustn't force people to suffer in distress for months" convincing, and conflicting.
Yes I said stories are important, and emotions are important. But no, reasoning from principles is not fruitless! Clarity of thinking is necessary on any issue and particularly one of such import. MPs need to have a grasp of the deeper questions involved otherwise they're just led by whatever experiences or stories they happen to have been exposed to. We deserve better from our representatives.
Well, maybe I'm expressing it badly. You describe the argument (the one that convinces me, but doesn't convince you) as coldly utilitarian. But for me, I think understanding that argument properly inevitably involves thinking about the anecdotes (examples of probable coercion in Canada, and examples of possibly needless suffering that many people will have experienced). Maybe an AI could aggregate all the anecdotes in a really systematic way, better than I can, but I still feel that I'm more generalising from anecdote than distilling from reason, because the two principles seem completely in opposition.
Very much this article. There's a tension in the nature of a vote of conscience. Politicians conducting a campaign have to challenge the reasoning which seems to underlie the conscience of those they oppose; I noticed Charlie Falconer arguing that the faith-based arguments of some are somehow not legitimate because they go beyond reason. But of course conscience and faith do that by definition, so the arguments end up in a denial of emotion and of the fundamentals of how people reach their most heartfelt positions. I respect those who support assisted dying here, but everywhere with older Assisted dying legislation - Oregon, Belgium, Netherlands, Canada - report high levels of people feeling under pressure to die. I suspect Australia will report the same in a couple more years. I think it's an unavoidable trade-off, to me a profoundly unacceptable one. If I may, too, suggest that people have to imagine a vast resource owned by an older adult compared to the vast debt their children might be in. This is common where an elderly person bought their council house 30 years ago, it's now worth £200k-£600k, and their children live in or below the poverty line, almost always with high levels of debt. They are the people most MP's likely have in mind when opposing assisted dying. It's not a question of someone sitting on an old person's chest demanding they die; it's a bending of the arc of reason towards death to 'do the best for the kids'.
Understandably you have resorted to emotional language in making your case - but I think it undermines your argument in some respects. Isn’t this more about “decriminalization of assisted dying” than “state-managed death”?
I’m not sure at this stage that I’m entirely convinced it’s a good idea but there might be a reason to support it on the basis of “levelling up”. For example, the status quo doesn’t stop those wealthy enough to pay for the necessities to assist their own death if they feel like it. So the counter-argument to your case is that, by not allowing assisted dying to be decriminalised (and therefore making it more widely accessible/affordable ), you are disproportionately penalising those who can’t afford to circumnavigate the law?
As I said, I’m not sold either way, but I do think this issue should be considered in the debate over the matter.
While I share your feeling on the misguided messaging and imagery of the UK ad campaign, I think you may benefit from learning about Australia’s experience.
The introduction of assisted dying in Australia provides clear evidence that well-designed voluntary assisted dying (VAD) laws can work safely and compassionately. Since Victoria first legalised VAD in 2019, followed by other states, our experience demonstrates none of the feared negative outcomes have materialised.
The Victorian Voluntary Assisted Dying Review Board reports consistently show that the system is working as intended, with robust safeguards. Between July 2019 and June 2023, there were 1,730 permits issued, with around 60% of eligible people proceeding with VAD. This clearly shows that even after qualifying, many people choose not to proceed - the mere availability of the option providing comfort in itself.
I can speak to this reality from personal experience. I witnessed a loved one's journey with terminal cancer who accessed VAD last year. Far from being pressured or coerced, they approached the decision with deep consideration - making and canceling four separate appointments before feeling ready. This reflects the profound seriousness with which these decisions are made, and how the system respects individual autonomy and timing.
The Australian model requires multiple independent assessments, mandatory waiting periods, and confirms decision-making capacity throughout the process. These safeguards work. After several years of operation across multiple states, there is no evidence of coercion or abuse that opponents feared.
Most importantly, VAD provides terminally ill individuals agency over their final days. My loved one's greatest wish was to avoid prolonged suffering, cognitive decline, and unmanageable pain. Having this choice available brought immense comfort, even before they were ready to use it.
This isn't about promoting death - it's about allowing individuals facing terminal illness to have control over their final chapter, while maintaining robust safeguards. The Australian experience proves this balance is achievable.
The thing that makes me worried that the UK (and Ireland, where I am) won't manage this well is that for the most part, people in favour of it don't seem worried or ambivalent about it. I keep seeing people say that assisted dying is a "no-brainer" or words to that effect. If there is a way to allow for it where it's a mercy and protect people from it where it's not, that won't be achieved by a society that doesn't realize how difficult this issue is.
In Australia do you think the debate around it was nuanced and thoughtful? I'm just wondering how Australia came to get it right when for example Canada got it so wrong.
The safeguards may work well for now but there's nothing to stop them changing and ending up as in Canada and the Netherlands.
Why would they change them if they're working? Isn't that a bit like saying, sure, speed limits are working now, but there's nothing to stop them from abolishing them altogether and then we'll have chaos.
Precisely
Ian, as a Canadian, I agree with the Australian writer, hope your bill passes, and am surprised at the pushback here. Several of my friends, terminally ill, have been grateful for medical assistance in dying - MAID. As soon as my dearest friend was diagnosed with the hideous disease ALS, she went to her doctor to arrange for eventual MAID, which was an incredible relief for her. Of course she went through a rigorous investigation by several doctors. Three years later, she arranged everything about her death, including having the door of her small house removed so the bier carrying her body could get through. A friend sewed and sent her a shroud of fine silk. It was terrible and very strange to know my lifelong friend was going to die at twelve noon on May 25. For her, it was one of the greatest gifts she could have been given, to die at home surrounded by loving friends.
My father had terminal stomach cancer in 1988; after his death, we found out he'd stockpiled morphine and committed suicide. Though at home, he died alone, couldn’t tell anyone, because it was illegal. I will always regret we could not know about his choice not to prolong his suffering and accompany him.
The ads you refer to sound wrong-headed, as if medically assisted dying is a gleeful choice. Here the patient is carefully monitored by doctors all the way through. The statistics in Canada are that over 97% of those who’ve accessed it have a terminal disease. There's understandable controversy about extending MAID to those with mental illness, and that has not been done. But I am deeply grateful to know that if I'm diagnosed with something appalling, I will have a choice, with the help of doctors, how long to endure and when to exit.
You’ve made this argument very nicely. It highlights for me that this is not “state-managed death” but more an appropriate instance where the state recognizes the right of the individual, in certain well-defined circumstances, to determine their own destiny.
Extraordinary to see white people featured on adverts on the London Underground!
With all due respect and sympathy for those personally affected by this, it strikes me that personal anecdote is used to justify the arguments for legalised dying to a degree I'm not comfortable with. If Auntie Elsie had a very painful last month on earth and would have liked to die sooner then that's a fair statement, but this is not how policy should be arrived at. Though Starmer's justification is that he promised Esther Rantzen that he would pursue it, for God's sake. This is what we've come to!
Let us identify principles first before recourse to personal anecdote. One such principle might be that suicide is bad and if it is enabled through what we're calling legalised dying how are we supposed to convincingly persuade, say, young men not to take overdoses or hang themselves? And at the level of anecdote, a friend of mine hanged himself about three months ago, causing untold hell for his loved ones. But using the lexicon of the pro side of this argument then presumably that's okay so long as he was really sure he wanted to and was really sure he wasn't going to recover from whatever thing was ailing him?
No. This must stay a flat No.
Well put. Beyond the ‘don’t resort to emotional language’, I also object to the idea advanced by Lord Faulkner et al., that being opposed for religious belief reasons is illegitimate. I’ll be oppose for whatever reasons I like. People’s views on this are shaped by many things and that may or may not include theology.
"Protect the NHS" is why we can't have assisted dying. We stole two years of everyones lives under that slogan, and while it's no longer an outright conspiracy theory to think that was a bit overdone, it's certainly not something that's mentioned in polite society.
In a world where it's not a primary organising principle for large parts of society to (demand for other to) forfeit "selfish" desires to protect the health service, reasonable people can discuss how to design safeguards. But in a world where we can't eat burgers, smoke, drink, or for two years go to school or church to "protect the NHS" there are no safeguards. Everybody is pre-coerced.
Thank you for writing this. I feel the same way about these ads, and the ones in Canada and elsewhere. It staggers me that so many of the proponents are the sort of people who'd march to prevent the government re-introducing the death penalty.
The point about pets they always bring up is really telling- how many healthy, unloved cats and dogs have been "euthanised" over the years? A quick google tells me that around a thousand otherwise healthy but unloved and uncared-for animals are put down each year in the UK. It's around a million in the US according to the ASPCA. If that is the future proponents want for people, it is a deeply chilling one. And that's before we get to the meat industry.
Some fun reading for a Wednesday lunchtime: https://metro.co.uk/2016/01/09/battersea-dogs-home-puts-down-almost-a-quarter-of-its-dogs-every-year-5611931/
https://www.aspca.org/helping-people-pets/shelter-intake-and-surrender/pet-statistics
"Men must endure
Their going hence, even as their coming hither." Edgar, King Lear
and
One of my neighbours got Motor Neuron Disease. Before that point, she was in favour of euthanasia. Once ill, she wanted to experience the last drops of life however great her suffering.
Hugo Rifkind has written one of the best articles on this.
" I want to say something about how arguments, generally, are usually perceived to work. Because often, I think, we assume that if one side makes an argument and the other side can’t defeat it then the first side has won. Whereas actually, there can be unanswerable arguments all over the place. Not everything has a right and a wrong."
https://www.thetimes.com/comment/columnists/article/an-assisted-dying-law-will-complicate-life-c7z0f3c80
Excellent, thoughtful article, thank you for the link.
I do personally disagree with the OP almost entirely. I am prone to distaste and both political and moral doubts over "state organs killing citizens", tho the utilitarian argument speaks to me fully. Unlike many people seem to, I don't shudder with horror at the idea of someone who's nearly dead being (subtly) pressured to die earlier by worn out carers and relatives at all, in fact I'd LOVE IT if my carers actively helped me to push over the primitive, animal fear of death and dying into accepting the end at sensible time, if I ever got into relevant situation (I'm hoping for a heart attack if early or pneumonia if late, obviously).
So while coercion is undesirable, I don't see potential for coercion here as as terrible. As our bodies deteriorate, as we age and fall apart, necessarily, as our brains rot slowly but inevitably, even if we are spared the utter horror of dementia, as the "very slow decay" -- even the slowest possible -- becomes a dominant aspect of our lives, it seems to me that the hard wired survival drive becomes more salient, that we cling more and more desperately to the diminishing life we have left. Is being nudged out of this such a terrible thing, really?
All that said, this post feels like a good argument against my position, with a balance of reason and emotion that, while not persuasive to me, makes a good case.
Your article reminds me of similar arguments made by Michael Sandel in What Money Can't Buy—namely, that the expansion of "freedoms" can end up exploiting or coercing vulnerable individuals when not checked by forms of community or government supervision (as commenters from Canada and Australia point out here). You discuss assisted dying, but your concerns carry nicely to commercial surrogacy, sex work, gambling, and even debt contraction. Drawing the line between individual rights and societal values in each case isn't easy. Thank you, as usual, for a thoughtful piece.
As an Oregon resident, this situation in the UK leading up to the vote sounds unfortunate. But here it is working well. There is careful monitoring of patients, including why they are choosing assisted suicide.
In California, which after some time picked up Oregon's lead, it is much the same.
The merits of the legislation aside, I marvel that Britain can have a debate about such a fraught issue. And for further reading on assisted dying, I might recommend "In Love" by Amy Bloom. https://www.amazon.com/Love-Memoir-Loss/dp/0593243943. Thanks for such a thoughtful post, and the ad, way more than the bill itself, is incredibly creepy.
Upvoted for "incredibly creepy".
Just wanted to say that I find this comments section (and the linked articles) quite helpful thinking through this after reading about the debate yesterday. As it happens, over this week I've moved from against the bill to in favour of the bill (but yes, with nervousness that there probably will be some worrying line calls about coercion).
The only thing I wanted to add (possibly of relevant to the theme of the Substack), is that I think anecdotes ARE really important here. In fact, reasoning on principles alone seems to me fruitless as I find both principles "the state mustn't murder" and "the state mustn't force people to suffer in distress for months" convincing, and conflicting.
Yes I said stories are important, and emotions are important. But no, reasoning from principles is not fruitless! Clarity of thinking is necessary on any issue and particularly one of such import. MPs need to have a grasp of the deeper questions involved otherwise they're just led by whatever experiences or stories they happen to have been exposed to. We deserve better from our representatives.
Well, maybe I'm expressing it badly. You describe the argument (the one that convinces me, but doesn't convince you) as coldly utilitarian. But for me, I think understanding that argument properly inevitably involves thinking about the anecdotes (examples of probable coercion in Canada, and examples of possibly needless suffering that many people will have experienced). Maybe an AI could aggregate all the anecdotes in a really systematic way, better than I can, but I still feel that I'm more generalising from anecdote than distilling from reason, because the two principles seem completely in opposition.
Very much this article. There's a tension in the nature of a vote of conscience. Politicians conducting a campaign have to challenge the reasoning which seems to underlie the conscience of those they oppose; I noticed Charlie Falconer arguing that the faith-based arguments of some are somehow not legitimate because they go beyond reason. But of course conscience and faith do that by definition, so the arguments end up in a denial of emotion and of the fundamentals of how people reach their most heartfelt positions. I respect those who support assisted dying here, but everywhere with older Assisted dying legislation - Oregon, Belgium, Netherlands, Canada - report high levels of people feeling under pressure to die. I suspect Australia will report the same in a couple more years. I think it's an unavoidable trade-off, to me a profoundly unacceptable one. If I may, too, suggest that people have to imagine a vast resource owned by an older adult compared to the vast debt their children might be in. This is common where an elderly person bought their council house 30 years ago, it's now worth £200k-£600k, and their children live in or below the poverty line, almost always with high levels of debt. They are the people most MP's likely have in mind when opposing assisted dying. It's not a question of someone sitting on an old person's chest demanding they die; it's a bending of the arc of reason towards death to 'do the best for the kids'.
It’s quite nice to hear someone of your intelligence argue against a position that I support, though you haven’t convinced me. Your abhorrence of the ads (which sound pretty awful) and your characterization of this as “state-managed death” don’t persuade me against the arguments that have led to Canada’s MAID approach. The recent “The Interview” podcast with MAID doctor Ellen Wiebe does a good job describing the “human rights” argument for assisted dying: https://www.nytimes.com/2024/11/16/magazine/doctor-ellen-wiebe-maid-interview.html?unlocked_article_code=1.dE4.JP1l.ZypPmryuJaf6&smid=nytcore-ios-share&referringSource=articleShare
Understandably you have resorted to emotional language in making your case - but I think it undermines your argument in some respects. Isn’t this more about “decriminalization of assisted dying” than “state-managed death”?
I’m not sure at this stage that I’m entirely convinced it’s a good idea but there might be a reason to support it on the basis of “levelling up”. For example, the status quo doesn’t stop those wealthy enough to pay for the necessities to assist their own death if they feel like it. So the counter-argument to your case is that, by not allowing assisted dying to be decriminalised (and therefore making it more widely accessible/affordable ), you are disproportionately penalising those who can’t afford to circumnavigate the law?
As I said, I’m not sold either way, but I do think this issue should be considered in the debate over the matter.
I’m not ‘resorting’ to emotional language - thinking through an issue like this should be emotional, as well as logical.
I agree we should consider the emotional impact of the decriminalization of assisted dying but think should do so with cold logic and reason.
Using the term "State-managed death" to attempt to re-frame the debate by provoking an emotional response is not the same thing!
It’s assisted suicide. The use of the euphemism hides that this is not just palliating the process of dying, but actively killing someone.