Parliament House Passes Medical Aid in Dying Bill, Sparking Conversation and Controversy

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Parliament members in the United Kingdom voted to endorse a bill legalizing medical aid in dying (MAID) on November 29, 2024, the first step in the process of legalizing the highly contested practice. The Terminally Ill Adults Bill, if passed by both the House of Commons and House of Lords, would allow adults who are mentally competent and terminally ill with 6 months or less to live choose to end their life with medical assistance.¹

The bill requires 2 doctors and a High Court judge to verify the decision is being made voluntarily and that the patient had not been coerced. After approval from the High Court and a 14-day reflection period, the patient may make a second request to end their life. If a doctor approves and maintains the patient meets the criteria, the life-ending substance is to be self-administered.²Pressuring a patient into making the decision would be punishable by up to 14 years in prison.¹ If passed, the law would be changed in England and Wales.

Opponents of the bill argued the focus should instead be on bettering end-of-life care. Members of parliament also argued terminally ill patients may feel pressure to end their lives so as not to “be a burden” or due to cost of care.³ Parliament members were given a free vote, meaning they did not have to vote along party lines, due to the nature of the bill.¹

The Royal College of Psychiatrists released a comment following the vote, saying when surveyed, a similar number of psychiatrists support and oppose these similar proposals, showing how complex the issue is.⁴The organization is urging members of parliament to consider carefully the bill and the questions surrounding it. “It is also important to consider the potential implications for those with mental disorders, intellectual disabilities and neurodevelopmental conditions (who do not always have good access to palliative care), as well as on suicide prevention efforts, palliative care and the NHS,”the leaders of the college wrote in a statement published to their website.⁴

MAID for patients experiencing psychiatric disorders presents a special set of ethical dilemmas. A 2024 review of clinical-ethical arguments regarding MAID pared the issue down to 5 key aspects: a close relationship between suicide or suicidal ideation and mental disorders, a person’s decision-making being compromised by mental disorder, the strength in a person’s wish to die being variable over time, suffering being harder to comprehend in psychiatric patients, and the difficulty in determining if a psychiatric disorder is actually treatment-resistant.⁵

Researchers in the 2024 review found that of the 8720 cases of people who died using MAID in the Netherlands in 2022, 1.3% (115 patients) experienced at least 1 psychiatric disorder. Researchers wrote that the number of patients experiencing one or more psychiatric disorders who died using MAID more than quadrupled between 2011 and 2022, while the total number of patients who died by MAID only doubled in that time.⁵

Douglas W Heinrichs, MD, who has previously written⁶ in defense of MAID, told Psychiatric Times that the impact of the bill on practitioners will be minimal. Heinrichs said, “We psychiatrists need to remember that in our daily work the wish to end one’s life is almost always the product of mental illness, which can skew our perspective. In the case of medical aid in dying (MAID), this is almost never the case, as supported by 2 US studies totaling 261 patients where mandatory psychiatric assessments were required for anyone requesting MAID. Only 4 cases were judged not competent to opt for MAID, and these were all due to progression of cognitive impairment after the initial request was made. None were due to psychiatric illness.”

Heinrichs added that no psychiatric illness would qualify as a terminal illness in this bill or any legislation in the US.

Alternatively, Ronald W Pies, MD, and Cynthia M A Geppert, MD, have previously asserted that autonomy does not validate the decision to go through with MAID. In a 2023 article, they argued that patients pursuing MAID are operating out of an autonomy-based system, where patients may only follow through if a doctor approves.⁷

“We would contrast the PAS [physician-assisted suicide] process with one in which a patient in the final stages of a terminal illness decides to leave the medical system entirely and exercise true autonomy; ie, refuses further medical interventions; returns home; and elects to stop taking in fluids or food (voluntary stopping of eating and drinking, VSED). VSED is not only an act of genuine autonomy; it is also one that extricates the patient from a system that is not autonomy-based.”⁷

As clinicians and governments alike continue to weigh the benefits and drawbacks of MAID, psychiatric clinicians remain divided. The Terminally Ill Adults Bill must make its way through the House of Lords and, if approved, be presented to the Sovereign to sign into law.

References

1. Smout A, Young S, Macaskill A. British lawmakers give initial support to assisted dying Bill | Reuters. Reuters. November 29, 2024. Accessed December 3, 2024.

2. Lipscombe S, Dawson J, Rough E, Rowland L. The terminally ill adults (end of life) Bill 2024-25 - House of Commons Library. The Terminally Ill Adults (End of Life) Bill 2024-25. November 22, 2024. Accessed December 6, 2024.

3. Morton B. MPs back proposals to Legalise Assisted dying. BBC News. November 29, 2024. Accessed December 6, 2024.

4. RCPSYCH comments on vote for Assisted Dying Bill in England and Wales. www.rcpsych.ac.uk. November 29, 2024. Accessed December 3, 2024.

5. Marckmann G, Pollmächer T. Assisted suicide in persons with mental disorders: a review of clinical-ethical arguments and recommendations. Ann Palliat Med. 2024;13(3):708-718.

6. Heinrichs DW. Medical aid in dying and the “slippery slope” argument. Psychiatric Times. July 1, 2024. Accessed December 10, 2024.

7. Geppert CMA, Pies RW. Autonomy alone does not validate physician assisted suicide. Psychiatric Times. March 7, 2023. Accessed December 3, 2024.