Author: Jim McManus
National Director of Health and Wellbeing, Public Health Wales  Writing in a personal capacity
Email:  Jim.McManus [at] wales.nhs.uk  X: @jimmcmanusph  Bluesky: @jimmcmanusph.bsky.social  ORCID: 0000-0002-3541-8963

Introduction:

Public debate on assisted dying frames the issue as if individuals simply make free, autonomous choices. But no end‑of‑life decision happens in a vacuum. Choices are shaped by many things, and sometimes these are inequality, unmet need, patchy palliative care, and the grinding pressures of an overstretched NHS.

As peers in the UK House of Lords debate the Terminally Ill Adults (End of Life) Bill (England and Wales) the biggest question is not abstract ethics but whether people can genuinely choose freely — or whether assisted dying becomes the path of least resistance in a system under strain. I believe there are currently strong public health arguments against legalising assisted dying.

Inequalities shape “choice”

End‑of‑life care in the UK is uneven. The Care Quality Commission’s review A Different Ending shows stark variations in quality and access for people with dementia, learning disabilities, homeless people, and minoritised ethnic communities.

The Marmot Review highlights widening inequalities across health and social support, especially in the final years of life – exactly the conditions where “choice” becomes blurred. When someone’s pain is undertreated, or community support patchy, or families are overwhelmed, the availability of assisted dying risks becoming less about preference and more about lack of alternatives.

Public health science is clear that these patterns reflect structural determinants of health — the systems, policies, and power relations that shape opportunity and vulnerability, who benefits and who is harmed. Evidence shows that these determinants create predictable gradients of disadvantage, influencing who experiences unmet need, who lacks continuity of care, and who is most exposed to pressure. These structural conditions matter profoundly because they create differential risks of choosing assisted dying, especially where support systems are weak.

During Lords Committee Stage debates, the possibility that personal financial hardship could legitimately influence a person’s decision to seek assisted dying was debated. If poverty, care gaps, or feeling like a burden start to drive these decisions, we are no longer talking about free choice but about structural pressures.

Financial hardship is a driver of health vulnerability, not an authentic expression of autonomous preference. Its presence in an assisted‑dying decision can signal structural failure, not genuine choice. Death as a “solution” to deprivation is a direct violation of public‑health principles, which hold that society must address upstream drivers of suffering, not legitimise them by offering a lethal response. Any suggestion that financial hardship could legitimately motivate an assisted death should prompt alarm, not acceptance.

A clash with suicide‑prevention principles

The UK’s suicide‑prevention strategy assumes on good evidence that suicides are preventable. Society should help people survive periods of acute distress. Sir Louis Appleby — the Government’s suicide‑prevention adviser — has warned that legalising assisted dying risks undermining this foundation by sending mixed messages about whose suicidal distress is “understandable” or “eligible.” International evidence emphasises this. A major systematic review found no reduction in non‑assisted suicides after legalisation; in some jurisdictions, suicides increased among older women. This creates potential confusion for clinicians and families: why do we intervene for one person’s suicidal crisis, but assess another for an assisted death?

From a population‑health viewpoint, such inconsistent signalling risks weakening suicide‑prevention norms. Vulnerability to suicidal ideation is not evenly distributed: it tracks deprivation, social isolation, disability and long‑term illness. That means assisted‑dying frameworks could inadvertently reinforce these inequalities unless safeguards fully account for the epidemiology of suicide risk.

The inverse care law at the end of life

People expressing a wish to die may be experiencing treatable depression, loneliness, or feelings of being a burden. The Royal College of Psychiatrists has raised concerns that the Bill’s safeguards are insufficient to protect people in exactly these vulnerable states. In an NHS already struggling with mental‑health provision, continuity of care, and community support, the risk is clear: we may miss treatable causes of suffering and instead channel people into an irreversible option.

International experience

Advocates frequently point to Oregon as the “safest” model. However, Oregon’s 25‑year data shows rising numbers of assisted deaths, falling rates of psychiatric assessments and growing numbers citing being a burden.  Canada’s MAiD (Medical Assistance in Dying)  system provides similar warnings. Peer‑reviewed analyses describe safeguarding failures and assisted dying without adequate palliative‑care access — sometimes within a single day of assessment. A consistent international pattern is emerging: palliative‑care services grow more slowly in jurisdictions with assisted dying. If policymakers become accustomed to an “exit option,” the urgency to invest in holistic end‑of‑life care may diminish.

This matters because palliative care is a public‑health intervention — reducing symptom burden, improving quality of life, and mitigating the social determinants that drive despair. Yet international comparative analyses find jurisdictions permitting assisted dying often show slower expansion of palliative‑care capacity. Assisted dying, can pull political and organisational attention away from improving living conditions towards facilitating death.

System pressures are not neutral

When the health system is under strain, clinical pathways requiring fewer resources tend to become dominant — not because they are safer, but because they are structurally easier to deliver. Assisted dying, which requires less time, multidisciplinary input or long‑term follow‑up than palliative care, risks becoming the path of least resistance in pressured services. Structural pressure, not personal autonomy, can become an invisible driver of clinical decisions.

Staff shortages, overstretched hospitals, long waits for specialist palliative care, gaps in social care and limited community support are all structural pressures which are in no way neutral. In such an environment, assisted dying may become the fastest, least resource‑intensive pathway. That is not a reflection of patient preference — it is a reflection of system constraints.

Oregon and Canada show higher uptake among people with financial hardship, weak social support, or poor access to palliative care. The system shapes demand. If we legalise assisted dying without major investment and reform, we risk embedding those pressures into the very heart of the process.

Legalising assisted dying will not fix poor access to palliative care, unmet mental‑health needs, gaps in social care and housing or socioeconomic inequality. The interventions that do reduce suffering are the very ones our system currently struggles to provide consistently. Until we address those fundamentals across the UK, assisted dying cannot be considered a safe or equitable option from a public‑health perspective.

Take Home Messages

• Inequalities shape end‑of‑life decisions far more than individual preference.
  • Evidence from other jurisdictions raises serious concerns about suicide‑prevention signalling and system pressures.
  • The UK must strengthen palliative, mental‑health and social‑care provision before assisted dying can be safely considered.

 

Competing interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: writing in a personal capacity only; Trustee of St Joseph’s Hospice; former palliative‑care and suicide‑prevention commissioner; member of the Advisory Board for the Public Mental Health Centre of the Royal College of Psychiatrists.