{"id":2341,"date":"2026-02-20T22:09:00","date_gmt":"2026-02-20T22:09:00","guid":{"rendered":"https:\/\/blogs.bmj.com\/spcare\/?p=2341"},"modified":"2026-02-16T22:11:20","modified_gmt":"2026-02-16T22:11:20","slug":"are-we-debating-assisted-dying-while-ignoring-the-public-health-problems-behind-it","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/spcare\/2026\/02\/20\/are-we-debating-assisted-dying-while-ignoring-the-public-health-problems-behind-it\/","title":{"rendered":"Are We Debating Assisted Dying While Ignoring the Public Health Problems Behind It?"},"content":{"rendered":"

Author: Jim McManus<\/strong>
\nNational Director of Health and Wellbeing, Public Health Wales\u00a0 Writing in a personal capacity
\nEmail:\u00a0 Jim.McManus [at] wales.nhs.uk\u00a0 X: @jimmcmanusph\u00a0 Bluesky: @jimmcmanusph.bsky.social\u00a0 ORCID: 0000-0002-3541-8963<\/p>\n

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Introduction:<\/strong><\/p>\n

Public debate on assisted dying frames the issue as if individuals simply make free, autonomous choices. But no end\u2011of\u2011life 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.<\/p>\n

As peers in the UK House of Lords debate the Terminally Ill Adults (End of Life) Bill (England and Wales) <\/em>the biggest question is not abstract ethics but whether people can genuinely choose freely \u2014 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.<\/p>\n

Inequalities shape \u201cchoice\u201d<\/strong><\/p>\n

End\u2011of\u2011life care in the UK is uneven. The Care Quality Commission\u2019s review A Different Ending<\/em><\/a> shows stark variations in quality and access for people with dementia, learning disabilities, homeless people, and minoritised ethnic communities.<\/p>\n

The Marmot Review<\/a> highlights widening inequalities across health and social support, especially in the final years of life – exactly the conditions where \u201cchoice\u201d becomes blurred. When someone\u2019s 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.<\/p>\n

Public health science is clear that these patterns reflect structural determinants of health<\/a> \u2014 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<\/a>.<\/p>\n

During Lords Committee Stage debates, the possibility that personal financial hardship could legitimately influence a person\u2019s decision to seek assisted dying was debated<\/a>. 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.<\/p>\n

Financial hardship is a driver of health vulnerability, not an authentic expression of autonomous preference. Its presence in an assisted\u2011dying decision can signal structural failure, not genuine choice. Death as a \u201csolution\u201d to deprivation is a direct violation of public\u2011health 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.<\/p>\n

A clash with suicide\u2011prevention principles<\/strong><\/p>\n

The UK\u2019s suicide\u2011prevention strategy assumes on good evidence that suicides are preventable. Society should help people survive periods of acute distress. Sir Louis Appleby \u2014 the Government\u2019s suicide\u2011prevention adviser \u2014 has warned that legalising assisted dying risks undermining this foundation<\/a> by sending mixed messages about whose suicidal distress is \u201cunderstandable\u201d or \u201celigible.\u201d International evidence emphasises this. A major systematic review<\/a> found no reduction in non\u2011assisted 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\u2019s suicidal crisis, but assess another for an assisted death?<\/p>\n

From a population\u2011health viewpoint, such inconsistent signalling risks weakening suicide\u2011prevention norms. Vulnerability to suicidal ideation is not evenly distributed: it tracks deprivation, social isolation, disability and long\u2011term illness. That means assisted\u2011dying frameworks could inadvertently reinforce these inequalities unless safeguards fully account for the epidemiology of suicide risk.<\/p>\n

The inverse care law at the end of life<\/strong><\/p>\n

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<\/a> that the Bill\u2019s safeguards are insufficient to protect people in exactly these vulnerable states. In an NHS already struggling with mental\u2011health 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.<\/p>\n

International experience<\/strong><\/p>\n

Advocates frequently point to Oregon as the \u201csafest\u201d model. However, Oregon\u2019s 25\u2011year data shows<\/a> rising numbers of assisted deaths, falling rates of psychiatric assessments and growing numbers citing being a burden.\u00a0 Canada\u2019s MAiD (Medical Assistance in Dying)\u00a0 system provides similar warnings. Peer\u2011reviewed analyses<\/a> describe safeguarding failures and assisted dying without adequate palliative\u2011care access \u2014 sometimes within a single day of assessment. A consistent international pattern is emerging: palliative\u2011care services grow more slowly in jurisdictions with assisted dying. If policymakers become accustomed to an \u201cexit option,\u201d the urgency to invest in holistic end\u2011of\u2011life care may diminish.<\/p>\n

This matters because palliative care is<\/em><\/strong> a public\u2011health intervention \u2014 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\u2011care capacity. Assisted dying, can pull political and organisational attention away from improving living conditions towards facilitating death.<\/p>\n

System pressures are not neutral <\/strong><\/p>\n

When the health system is under strain, clinical pathways requiring fewer resources tend to become dominant \u2014 not because they are safer, but because they are structurally easier to deliver. Assisted dying, which requires less time, multidisciplinary input or long\u2011term follow\u2011up 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.<\/p>\n

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\u2011intensive pathway. That is not a reflection of patient preference \u2014 it is a reflection of system constraints.<\/p>\n

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.<\/p>\n

Legalising assisted dying will not fix poor access to palliative care, unmet mental\u2011health needs, gaps in social care and housing or socioeconomic inequality. The interventions that do<\/em> 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\u2011health perspective.<\/p>\n

Take Home Messages<\/strong><\/p>\n