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Major unresolved problems with the Leadbeater Bill: an A-Z guide

Following the Commons Third Reading of Kim Leadbeater’s Terminally Ill Adults (End of Life) Bill, journalist Dan Hitchens compiled a list of 26 its defects, which members of the House of Lords must now address.

This work is reproduced by kind permission of Dan Hitchens. Do please share his original thread on X.

 

A is for Anorexia.

Eating disorder charities and experts have warned that the bill leaves the door open for sufferers to qualify and receive an assisted death:

  • Chelsea Roff, Executive Director of Eat Breathe Thrive, on “the many eating disorder experts” Kim Leadbeater “chose to ignore” (link).

 

B is for Burden.

Under the bill, if someone meets the criteria and their sole motive is feeling like a burden, they qualify for an assisted death.

If unamended this could open the way for large numbers of people to receive lethal drugs out of mere guilt.

  1. What happens, under the assisted suicide bill, if someone requests lethal drugs *because* they feel like a burden?
  2. The first thing to say is that—if they have a 6-month prognosis—they absolutely qualify. Here Kim Leadbeater confirms the point: if your sole motive is altruistic—i.e. “others would be better off if I was dead”—the doctors/panel don’t have any freedom to refuse your request.
  3. Leadbeater hopes there would be a “complex” conversation, the idea being presumably that people will have a chance to rethink if they really are a burden. However, she rejected an amendment which would have required doctors to ask “why” someone is seeking assisted suicide…
  4. Co-sponsor Rachel Hopkins said perhaps doctors shouldn’t ask: “It’s none of your business why I want to pursue this legal course of action.” If it is a matter of autonomy—and AS is a normal medical option—it’s hard to see why doctors should be pushing patients to reconsider.
  5. Leadbeater has said feeling like a burden could be seen as a “legitimate” reason. She hinted at some personal worries on this, but they are not reflected in the text of the bill.
  6. There are psychiatrists involved—possible capacity referral and on the panels. However, the psychiatrists are not tasked with asking whether applicants are depressed, how their situation could be changed, etc. Big part of why RCPsych oppose the bill.
  7. And part of why the Royal College of Physicians says: “The bill in its current form has concerning deficiencies. Notably the proposed mechanisms of decision making are not in line with good clinical and professional practice.”
  8. The panels don’t have to ask the applicant (or anyone) any questions, or speak to those who know the applicant. And there’s no requirement to inform family. So people might receive lethal drugs for their family’s sake, without the family having a chance to reassure them.
  9. So people who feel like a burden—for eg financial or emotional reasons—will qualify, if they meet the (quite broad) “six-month” criterion. And there is no stage where they would necessarily speak to anyone questioning, probing, or asking them to reflect on their reasoning.
  10. A review of international evidence found up to 65% of terminally ill people find feeling like a burden is a “significant problem”. Savanta ComRes, 2013: 84% of older people say “it is difficult for older people to say they feel lonely because they don’t want to be a burden.”
  11. On the issue of being a financial burden, the risks are obvious, and have been emphasised by the Orders of St John Care Trust, Britain’s second biggest not-for-profit care provider. “It is without question,” they say, that some people will consider assisted suicide “to protect the prospects of their loved ones, and not because they wish to die.”
  12. In written evidence to the bill committee, more than 50 doctors independently wrote of their fears on this point. It’s maybe the most-mentioned issue in the evidence.
  13. And evidence from abroad suggests that feeling like a burden is an important factor in the take-up of assisted suicide.
  14. Hugo Rifkind has written movingly on his family’s experience and what the bill would do: “Formerly the foremost victim of the catastrophe that has hit your family, you are now the perpetrator of it. You could have ended this yesterday, for everyone, but have chosen not to.”
  15. To sum up: the bill would make it easy for people who meet the broad eligibility criteria to receive lethal drugs, largely or even entirely because they feel like a burden.

 

C is for Care.

The crisis in the care system creates some terrible incentives.

The Coalition for Frontline Care, representing leading health and social care organisations with a combined workforce of 3 million, calls the bill “unworkable…and naïve”.

  1. Care is very expensive: around £949 a week in a care home and £1,267 in a nursing home, says Age UK. Councils can sometimes help—but that model faces an unprecedented crisis, with 500,000 people on assessment waiting lists.
  2. This provides a significant incentive for assisted suicide. The Orders of St John Care Trust—Britain’s second biggest not-for-profit care provider, with 61 care homes—has warned that people will request lethal drugs for financial reasons.
  3. In Australia, waiting for a care package has been a reason for assisted suicide.
  4. At this point, you might imagine that Kim Leadbeater’s “safeguards” would kick in. But there are no safeguards about people’s *reasons*. If you have a 6-month diagnosis and there’s no evidence of “coercion”—ie direct malevolent pressure—you qualify *whatever your reason*.
  5. Here, Kim Leadbeater admits that her bill allows someone to receive lethal drugs solely and simply to save their family money.
  6. What about the more sinister cases of malevolent pressure? In theory the panel would stop them. But bear in mind that 50% of coercive control cases are dropped for lack of evidence, and only 3.7% of recorded coercive control crimes result in a charge (Guardian, March 23 2024) and that the adjudicating panel has very limited powers. If it asks to interview a potential coercer, he can just say sorry but he can’t testify; if the panel thinks there’s only a 49% chance of coercion they *must approve the application*. (The panel in numbers.)
  7. The bill has been wrapped up in a lot of cleverly-constructed soundbites. But it will land in the real world—a world which often looks like this headline: “Care fees could leave us bankrupt, says husband.”

 

D is for Dame Caroline Swift.

The former leading counsel to the Shipman Inquiry predicts that “independent” doctor approval will become box-ticking.

“Those safeguards may seem adequate now but they are likely to be eroded over time. As Leading Counsel to the Shipman Inquiry, I saw how this had happened with the safeguards for the issuing of cremation certificates…

“Over the years, the second doctor’s role became diluted, they were seldom independent of the first, rarely examined the body and the signing of the second form became little more than a ‘tick box exercise’.”

(In Victoria in 2023, 10 doctors were involved with the approvals process for 55% of assisted suicides.)

 

E is for Encouragement.

The bill allows it (“Mum, have you considered…”). Doctors can raise AS unprompted even if you have learning disabilities. Some advertising is allowed.

Bill supporter Alexandra Mullock told the committee the bill was weak on this:

 

F is for False Prognosis.

The bill’s proponents say AS is only for people who are dying. But the 6-month test is so unreliable that clinicians compare it to a “coin toss”; a fifth of those who are given six months to live are still around 3 years later.

  • Paddy Stone, Professor Emeritus of Palliative and End of Life Care at UCL: his research shows, he says, that “six months to live” cannot be reliably established. There is “no method that would be reliable enough to act as any sort of ‘safeguard’.”
  • “Assisted dying row as patients given six months to live often survive for three years”, Janet Eastham for The Telegraph, January 2025

 

G is for G4S.

Not that we know if they would deliver it (they haven’t commented. I understand Serco have ruled out being involved).

But there’s a decent chance one or other big outsourcing firm will be involved. And the bill has no profit cap and no transparency requirements.

 

H is for Henry VIII Powers.

These are areas where ministers can amend primary legislation by fiat.

There are five of them in the bill, and 38 ministerial powers in all: as Paul Kohler MP complains here, “in large part the safeguards are left to be decided by regulations.”

 

I is for Institutional Opt-Out.

While individuals can opt out, hospices and care homes cannot. Leadbeater says there are “considerable harms that can come with the ability of institutions to opt out”.

Palliative care leaders say this could be disastrous:

  • “Assisted suicide could destroy the hospice movement”, Dan Hitchens for The Spectator, June 2025; for which Dan spoke to staff—pro-bill, anti, and somewhere in between—at 17 adult hospices across England and Wales, a tenth of the total.
  • Again and again I heard fears that, as one consultant at a Welsh hospice put it, ‘This could be the end of hospice care as we know it.’

 

J is for Jane Monckton Smith OBE.

The criminologist says: “Unless we do take this incredibly seriously, this bill is going to be the worst thing potentially that we have ever done to domestic abuse victims.”

Standing Together Against Domestic Abuse have given similar warnings.

 

K is for Kin, Next Of.

The bill has no requirement to inform family at any point; nothing in the bill gives family a right to contribute to the decision-making process.

The first you could learn of your 18-year-old’s AS is when you’re asked to make arrangements for the body.

  • “Parents ‘wouldn’t know about their child’s assisted death until too late’”, Genevieve Holl-Allen for The Telegraph, May 2025

 

L is for Lethal Drugs.

Internationally, AS/death penalty drugs are highly controversial; but we do not know which ones will be used, and a host of safeguards—including a requirement for the MHRA to licence them—were rejected in committee.

Assisted suicide drugs *may* cause “respiratory distress and suffocation” in some cases, says a new BMJ Supportive & Palliative Care article.

“The individual would be unable to move a muscle to show any signs of distress, and may even look peaceful.”

Article emphasises huge research gaps on this.

 

M is for Mental Capacity Act.

The bill relies on it; but the Royal Colleges of Physicians and Psychiatrists say the MCA is the wrong tool to use. Amendments to tighten the capacity criterion were rejected.

George Gillett writes powerfully about this:

“At the heart of the disagreement was confusion about what mental capacity involves – the framework the bill uses to assess people’s eligibility for an assisted death. Mental capacity assesses four criteria; a person’s ability to understand, remember and weigh up relevant information, and to communicate their decision. If (and only if) one of these criteria is not met, a patient is determined to lack capacity. Simply noticing that a patient has symptoms of a mental illness, or recognising that a patient’s decision is unwise, are not alone grounds to influence this assessment. If you can understand, retain, weigh and communicate your decision, you are judged to have capacity.

“This differs from how psychiatrists assess decision-making related to mental illness and suicide. The Mental Health Act requires clinicians to specifically assess for symptoms of a mental disorder, and to explore the consequences of them on a patient’s safety, including the risk of suicide or self-harm. Put simply the two concepts assess different things – someone can have a treatable mental disorder which is making them suicidal and still be deemed to have capacity. This is why the Mental Health Act is still in use over forty years after its introduction – it provides a more thorough, sensitive and specific test to check if a psychiatric disorder is affecting a patient’s decision-making.

“If the legislation is implemented in the form approved by MPs last week, it could lead to some perplexing situations. As a psychiatrist, I could find myself caring for a depressed, suicidal patient who has been sectioned to a psychiatric hospital with the explicit purpose of preventing them from taking their own life. Yet, if this patient were to have a concurrent terminal illness, they might at the same time be eligible for a government-sanctioned assisted death[i]. The same person could be presenting with the same symptoms, diagnoses and wishes to end their life, and yet at the same time be eligible for suicide prevention (an admission to psychiatric hospital) on the one hand, and suicide facilitation (an assisted death) on the other.”

 

N is for NHS.

1) Could our universal health system mean we accidentally create an AS conveyor belt?

2) What about [former Health Minister] Lord Bethell’s concerns here?

“I fear the NHS is ill-suited to support this proposed assisted-dying programme on so many levels incl culture, values, workforce, infrastructure, etc. Assisted dying will do to the NHS what HS2 did to our railways: a costly distraction that hobbles and demoralizes everything. Well done to Luciana for her work on this. Time for more Labour colleagues to make their voices heard”

3) Could the powers in Clause 41, as Dame Siobhain McDonagh warns, be “the Trojan Horse that breaks the NHS”?

 

O is for Options.

Gordon Brown argues (see below) that there is no real choice “if the alternative option, the freedom to draw on high-quality end-of-life care, is not available.”

“If the bill were to go through, anyone who was terminally ill might be faced with a dilemma: they could exercise the right to apply to die under the legislation by referring to two doctors and an expert panel, but they might continue to find it difficult to exercise their right to access quality end-of-life care. While I could apply directly to the proposed new panel to enforce my right to die, the process if denied quality palliative care is difficult and complex. I would first have to file a complaint with the healthcare provider – for example to the patient advice and liaison service for hospitals, or a localised complaint process for primary care. Once this process was exhausted, I would then have to ask my MP to make an application to the parliamentary and health service ombudsman (PHSO), whose website says that the current waiting time is seven months – and that would be before a caseworker was assigned, which also takes months, delaying still further the time before what should be an urgent judgment could be made.”

The BMA’s ARM meeting voted this week [23 June] to back an amendment to tackle this:

“Assisted dying must never be seen as a cheaper alternative to high-quality state-funded public services, and that funding for assisted dying is matched by additional funding for palliative care, mental health, and social care services… Any patient requesting assisted dying should be encouraged to attend face-to-face reviews by an independent palliative care doctor to ensure that the patient has received the best quality outcomes prior to commencement of the assisted dying pathway.”

 

P is for Psychiatrists.

Of all the bill’s critics—Disability Rights UK, Association for Palliative Medicine, British Geriatrics Society, Royal College of Physicians, Liberty, Standing Together Against Domestic Abuse, Beat—the Royal College of Psychiatrists’ objections are especially telling, as the panels rely on psychiatrists to be involved:

  • An absolute bombshell statement from the Royal College of Psychiatrists:
    • The bill “makes no provision to assess unmet needs” such as “intolerable pain, financial hardship and inadequate care or housing”
    • The role Leadbeater has given psychiatrists on the panel may not be “consistent with the core duties of the profession” and “does not honour” the “psychiatrist’s role” of helping the suicidal
    • There aren’t enough consultant psychiatrists: “mental health services simply do not have the resource required”
    • The conscience provisions are inadequate: medical professionals must provide information on AS, which for some is tantamount to involvement
    • The Mental Capacity Act, a key plank of Leadbeater’s bill, “does not provide a framework” for this kind of decision

 

Q is for Questions.

The bill doesn’t require doctors to ask the applicant why they want lethal drugs. (An amendment on this was rejected.)

The panel isn’t obliged to ask anyone a single question.

If you meet the broad criteria, you can receive AS for *any* reason including [in the words of Rebecca Paul MP’s rejected New Clause 16]:

(a) not wanting to be a burden on others or on public services,
(b) a mental disorder (including depression),
(c) a disability (other than the terminal illness),
(d) financial considerations, including lack of adequate housing,
(e) lack of access, or delayed access, to treatment or other service which a public authority is required (or can reasonably be expected to) provide,
(f) or suicidal ideation.

 

R is for Royal College of Physicians.

Inter alia, they’re concerned that doctors can judge prognosis/treatment/coercion etc on their own. (The panel checking criteria isn’t a real MDT.)

This is “not in line with good clinical and professional practice”:

  • ‘Deficiencies in protecting patients and professionals’ – RCP publishes its position on the Terminally Ill Adults (End of Life) Bill

 

S is for Strasbourg—and Slippery Slope.

According to some legal scholars—including Alex Ruck Keene KC, who’s neutral on the bill—the ECtHR might well require us to expand the law to other forms of “intolerable suffering”, eg disability or mental illness.

  • “Looking down the slippery slope: Can assisted suicide be restricted to the terminally ill?”, Philip Murray for UK Constitutional Law Association, October 2024

 

T is for Terminal Illness.

Baroness Finlay, palliative care professor and ex-BMA president, says the bill’s definition of this term is “incredibly broad”.

Clinicians warn it could mean diabetes, anorexia etc. Disability rights activists have said it could apply to disability:

 

U is for Under-Resourcing.

Palliative care already faces an unprecedented funding crisis. There’s good reason to think the bill will make it worse:

  1. How do assisted suicide laws affect palliative care? Big question this week [17 June], with Gordon Brown warning that the Leadbeater bill prioritises death over palliative care, and Leadbeater arguing “this is not an either-or”. Where does the evidence point?
  2. The most comprehensive recent study is by the bioethicist Professor David Albert Jones. Prof Jones found “clear indications in several jurisdictions of palliative and end-of-life care deteriorating in quality and provision following the introduction of AD / AS.”
  3. Some of his headline findings were as follows: 2012-2019: European countries without AS increased palliative care provision more than three times more than countries with AS.
  4. 2015-2022: “Belgium, Canada and the United States fell out of the top quartile in the world ranking for quality of death and dying, while the United Kingdom remains in first place.” (Switzerland is the exception that proves the rule: AS completely separated from healthcare)
  5. 2015-2019: “the number of palliative care teams in hospitals increased by 3.2% in US states with assisted dying, but by 9.4% in non-assisted dying states.”
  6. The Health and Social Care Committee had said they had not found “indications of palliative and end-of-life care deteriorating in quality” following AS laws. But Prof Jones argued the committee was relying on out-of-date and speculative evidence.
  7. Hence the warning from the President of the Association for Palliative Medicine, Dr Sarah Cox, who told the Leadbeater bill committee: “The implementation of assisted dying is impeding the development of palliative care services.”
  8. In theory, AS and palliative care could be seen as two approaches to the same goal: relieving suffering. That is Kim Leadbeater’s argument. On the ground, the reality seems different, with healthcare professionals and institutions needing to prioritise one or the other.
  9. What about those who want to prioritise palliative care? In written evidence to the committee, five Canadian clinicians, including professors from the Universities of McGill and Toronto, warned “doctors are expected to facilitate access to death,” which transforms their role.
  10. In New Zealand, similarly, there are reports that AS has undermined the practice and ethos of palliative care. “From our normal way of exploring what suffering is, instead of exploring it we’re saying, ‘Here’s the phone number.’”
    • “How Assisted Suicide Will Undo the NHS”, Dan Hitchens for Compact, March 2025
  11. The risk is obvious: doctors just leave palliative care, a sector already facing huge challenges. Dr Cox: “43% of members of the Association for Palliative Medicine said that if AD was implemented within their organisation, they would have to leave.”
  12. In the UK context, the results are likely to be especially severe, as Leadbeater has rejected any opt-out for hospices (something other jurisdictions allow). One former APM president says the bill “has the potential to destroy the sector.”
    • “Assisted suicide could destroy the hospice movement”, Dan Hitchens for The Spectator, June 2025.
  13. As Gordon Brown pointed out, palliative care faces an unprecedented funding crisis. (The government has provided only 6% of the estimated funding needed *just* to ensure hospices don’t have to close down; and is considering further PC cuts.)
  14. Leadbeater’s response to these concerns is to guarantee a PC review. The Association for Palliative Medicine has given a blunt verdict on this: “No further assessments are needed to demonstrate the state of palliative care services. What we need now is a national strategy.”
  15. The Bill could have done something to address Brown’s concerns: there was an amendment to guarantee every AS applicant a meeting with a palliative care specialist. Leadbeater opposed it, and it was voted down.
  16. Leadbeater ally Jake Richards went further, saying the bill could be a huge opportunity to improve palliative care—with an amendment forcing NHS Trusts to offer PC options. But he backtracked and never tabled the amendment. Nobody knows why (he blocked me when I raised it).
  17. Leadbeater sincerely wants palliative care to improve. But since October she has not taken concrete steps towards that goal. And the bill doesn’t address worries about resource competition, doctors leaving, etc. Overall Gordon Brown seems to have the better of the argument.

 

V is for Verification.

Under the bill, the doctors’ and panel’s decisions—Is it terminal illness? Is there coercion and capacity?—are only subject to a “balance of probabilities” test: are they 51% likely?

The panel also has no power to summon witnesses:

 

W is for Wills.

Ruth Hughes KC, a leading barrister in this area (and neutral on the bill), says in written evidence that, without more safeguards, the bill would be “profoundly disturbing and wrong” because of how it enables financial abuse.

“2. In summary, whilst I do not oppose the Bill, I am highly concerned that the safeguards proposed are insufficient to protect vulnerable people from exploitation for financial gain. I suggest it would be profoundly disturbing and wrong for Parliament to enact legislation which put vulnerable people at risk of being killed for financial gain without creating adequate safeguards to protect them.

3. I suggest that the judicial safeguard is fundamentally important. As to additional safeguards I recommend

(a) a reversal of the burden of proof in respect of mental capacity;

(b) notification of close family members;

(c) a requirement to hear from the person who wishes to die;

(d) disclosure of recent changes to testamentary dispositions; and

(e) an advocate to the Court to ensure that the evidence in support of a claim is appropriately tested.

Financial Abuse of the vulnerable

4. In my professional experience, financial abuse of the vulnerable and those who lack mental capacity, or are approaching the borderline, is depressingly common. As people’s capacity starts to decline they become much easier to influence. This happens when people are lonely and isolated but can also occur even where they have close and loving families.”

 

X is for (cut me some slack here) ex-High Court judge Sir James Munby.

He says the panel has a “wholly inadequate procedure” regarding evidence-gathering, evidence-testing, secrecy, and appeals; and that “the Bill still falls lamentably short of providing adequate safeguards.”

“These are matters that need to be made clear on the face of the Bill. They are too important to be left to the discretion of the panel or to any “guidance” given by the Commissioner under NS2 8(1).

I pause to take stock. All in all, in relation to the involvement of the panel in the process, the Bill still falls lamentably short of providing adequate safeguards.

Let us consider how an application to the panel could be dealt with by the panel in a manner entirely compatible with the requirements of NC16(4). The panel could:

  • Decide the matter without hearing from the patient and with no input of any sort from the patient’s partner or relatives.
  • Deal with the case in private – in secret – and without having to publish its reasons.
  • Adopt a procedure which, beyond whatever little the panel is required to do in accordance with NC16(4)(a), involves neither testing nor challenging the evidence nor any independent evidential investigation.

In short, an application could be dealt with:

  • In accordance with a wholly inadequate procedure, and.
  • Without the public knowing anything about it.

These difficulties are compounded by the extraordinary provision in proposed new clause NC17 providing that an application for reconsideration by the Commissioner under NC17(2) is possible only if the panel has refused to grant a certificate of eligibility: NC17(1)(a). What if the panel in granting a certificate has misunderstood its function under NC16(2)? What if the panel has adopted a procedure which, although compatible with the letter of NC16(4), would not pass muster with the Commissioner? Indeed, and even more alarmingly, what if the panel has arrived at a decision which the Commissioner, if given the opportunity, would require to be reconsidered? There can be no reference to the Commissioner – and the patient dies.

 

Y is for Year-On-Year Analysis.

If AS becomes a national scandal needing a public inquiry (as a few observers have predicted), what will be the early warning signs?

The bill lacks detailed reporting requirements, though Sarah Olney MP has proposed some:

“[Proposed New Schedule 2:] The Voluntary Assisted Dying Commissioner must collect the following information about persons requesting assisted dying… [plus statistics] on the following information about health and care support… statistics on the following information about the requests for assistance… following information about requests that are refused… on the following information about the process… on the following information about clinicians and pharmacies… on the following information about Assisted Dying Panel process… [and] on the following information about the approved substances…”

 

Z is for Zero Hour.

The bill must commence—in full—4 years after it passes. Will the NHS be ready? Will palliative care provision, hospitals, prisons, mental health services…?

Many MPs objected to this; one was so concerned he switched from Aye to No.

  • 65 MPs co-signed Adam Jogee’s proposed amendment number 42, which would have required that:
  • “In relation to England, the provisions of this Act not brought into force by subsection (1) come into force on such day or days as the Secretary of State may by regulations appoint.”

 

Reproduced by kind permission of Dan Hitchens. Do please share his original thread on X.

 

Image © Dennis Hill (Creative Commons)

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