Speaking during a debate in the House of Commons in November 2024, Kim Leadbeater, Labour MP for Spen Valley, West Yorkshire, described a surge of public opinion in favour of the legalisation of assisted dying for terminally ill patients.
“Polling shows consistently that around 75% of people would like to see the legalisation of assisted dying for terminally ill, mentally competent adults,” she told MPs.
“When four former directors of public prosecutions, including the prime minister, two former presidents of the Supreme Court and many lawyers all agree that the law needs to change, surely we have a duty to do something about it?”
The private members’ bill, which would apply to England and Wales, passed its second reading following the debate in November 2024 by 330 votes to 275 votes, with 38 abstentions.
A similar members’ bill — the Assisted Dying for Terminally Ill Adults (Scotland) Bill — was proposed in March 2024 by Liam McArthur, a Liberal Democrat MSP, to cover Scotland and is expected to be voted on for the first time later in 2025 (see Box).
Box: Assisted dying bills in England, Wales and Scotland
While both bills would allow terminally ill people to receive medical assistance with dying in certain circumstances, there are some crucial differences between the two bills. Some of the differences concern the criteria that patients must meet before being able to die with medical assistance.
For example, the Westminster bill stipulates that someone must be expected to die from their condition within six months to qualify, whereas the Scottish bill does not include such a time limit and would apply if someone’s condition is expected to cause a “premature death”.
Other differences include the age limit: the Westminster bill applies to those aged 18 years and over, while the Scottish bill would apply to those aged 16 years and over. The Westminster bill also requires an application to the High Court as part of process before medicines can be administered, which is not required under the Scottish bill.
While pharmacy organisations and representative bodies have taken predominantly neutral stances on the debate, there are still some unresolved questions about how changes to the law could affect practising pharmacists.
Conscientious objection
“All healthcare professionals, including pharmacists and pharmacy technicians, must have the ability to choose whether they participate in any of the processes involved in the provision of assisted dying,” says Claire Anderson, president of the Royal Pharmaceutical Society (RPS).
The Westminster bill sets out several protections, both for patients who may be close to death and for healthcare professionals involved in the process, making it clear that “a person who provides any assistance in accordance with this act is not guilty of an offence”.
Under current legislation, prosecutions for encouraging or assisting the suicide of another person are rare. Data from the Crown Prosecution Service (CPS), which covers England and Wales, show that 187 cases were referred to the CPS by the police between April 2009 and 31 March 2024 that had been recorded as assisted suicide. Of these, the CPS did not proceed with 127 of the cases and 36 cases were withdrawn by the police. Only four cases were successfully prosecuted during this time.
If/when there is a change in the law to legalise assisted dying, we will consider any necessary changes to our standards
General Pharmaceutical Council
However, the RPS has called for any bill related to assisted dying to go further and put “explicit protection in place” for pharmacists and pharmacy technicians when participating in an approved assisted dying procedure.
In its position statement on assisted dying, published in October 2024, the RPS also calls for a ‘conscience clause’ to make it clear that there would be “no obligation for any pharmacist to participate in any aspect of an assisted dying or similar procedure if he or she feels this is against their personal beliefs”. The statement says this avoids the need for anyone opposed to assisted dying to signpost to another pharmacist, which can also pose an ethical dilemma.
Currently, under the heading of ‘conscientious objection’, the Westminster bill states that a person “is not under any duty… to participate in anything authorised by this Act to which that person has a conscientious objection”.
Rather than having pharmacists ‘opt out’, Anderson clarifies that the RPS is “advocating that any pharmacists who do wish to offer care for patients in these circumstances would be able to opt-in to participate and therefore access any training and support which would be necessary for the delivery of appropriate and optimal care”.
In its evidence to House of Commons Health and Social Care Committee inquiry into assisted dying, given in February 2024, the Pharmacists’ Defence Association (PDA) agreed that the wording in the Bill “may not be sufficiently robust to protect the rights of healthcare workers from overzealous regulators who may make conflicting rules or impose ‘professional standards obliging participation’ via other legislation”.
When asked whether the proposed legislation would result in changes to standards for pharmacy professionals, a spokesperson for the General Pharmaceutical Council said: “If/when there is a change in the law to legalise assisted dying, we will consider any necessary changes to our standards and guidance for pharmacy professionals and pharmacy owners to reflect the legal position.”
Impact on palliative care
Hospice pharmacists, specifically, have expressed concern at how the legislation will impact their roles in palliative care, and the provision of end-of-life services more generally.
“There are many groups of patients who we struggle to reach in delivering effective palliative care and symptom relief,” says Tarun Nayyar, senior clinical pharmacist at Birmingham Hospice.
“Engagement with certain patient cohorts at present can be difficult; for example, those with young families or patients who fear the terminology of ‘hospice’ or ‘palliative’.”
He adds that this increases the risk of patients and their families “confounding our role with that of assisted dying” and presents a possible further barrier to our ability to provide end-of-life care.
“The biggest challenge will be to create a model of healthcare delivery that integrates a carefully placed role for assisted dying, within an exceptional palliative care service that offers patients a true choice on how they want to be cared for,” he says.
It is important that everyone is able to choose what type of support they need at the end of their life
The Health and Social Care Select Committee
Palliative care services have come under increased scrutiny since February 2024, when the Health and Social Care Select Committee published its ‘Assisted dying/assisted suicide’ report, which described access to palliative care services as “patchy” across the UK.
“It is important that everyone is able to choose what type of support they need at the end of their life,” the report said.
Owing to the difficulties around access to palliative care, Paul Perkins, chief medical director at Sue Ryder, a national palliative care and bereavement charity, says that the charity is concerned about “the idea that some terminally ill people may feel an assisted death is their only option because the end-of-life care they need is not available to them”.
He cites research that reveals how 90% of people would benefit from palliative care before they die, but one in four people do not receive all the care they need.
“No one should feel that an assisted death is the best option for them, simply because they can’t access the pain relief, emotional support and symptom control that they need,” he adds.
Anderson adds that patients “may present with a request for assisted dying when they are not aware of all the alternative options available to them”.
“Patients should be given the opportunity to discuss the alternative options available to them, to give a clearer understanding of the scope and range of the best practice available in palliative care, including pain management, as well as fully explaining the assisted dying procedure, covering risks and expectations,” she says.
“In the other countries where assisted dying has been established, distinct improvements in the quality of palliative care have been recognised and we commend and support this approach.”
International picture
In its conclusions, the Health and Social Care Select Committee said it “did not see any indications of palliative and end-of-life care deteriorating in quality or provision following the introduction of [assisted dying]”.
Canada legalised medical assistance in dying (MAiD) in 2016, with data from the 2022 annual report on MAiD in the country showing that 4 in 100 deaths in Canada were medically assisted in 2022. Any pharmacist or pharmacy technician who dispenses drugs for assisted dying must report it to an authority in Canada, depending on their province or territory; for example, in Ontario, it must be reported to the minister of health.
The 2022 report recorded that the vast majority of prescribing took place in hospital pharmacies but this varied by province, with 68% of drugs in British Columbia — the highest proportion among all provinces — being dispensed from community pharmacies.
Written evidence provided by James Downar, professor and head of the division of palliative care at the University of Ottawa in Canada, told MPs: “Funding/support for clinical palliative care has increased dramatically in much of the country since MAiD became legal.
This included “a large growth in funding and salaried positions for palliative care physicians”, and “CAN$3bn invested in home care in 2016, much of which went to palliative care services”.
“Even during the pandemic [in 2020], only 126 of 7,394 people (1.7%) who received MAiD were unable to access palliative care services that they needed”, he added, which suggests that the practice of assisted dying is not linked to poor palliative care access.
The introduction of voluntary assisted dying has provided funding and shone a spotlight on the activities of palliative care
Brian Owler, consultant neurosurgeon at Norwest Private Hospital
Equally, results from a study published in the Journal of Medical Ethics in 2015, which analysed how the 2002 legalisation of assisted dying has impacted palliative care in Belgium, revealed that “the hypothesis that legal regulation of physician-assisted dying slows development of palliative care is not supported”.
“On the contrary, regulation appears to have promoted the expansion of palliative care,” the researchers wrote.
Assisted dying has had a similar effect in Australia, where Brian Owler, a consultant neurosurgeon at Norwest Private Hospital, said the introduction of voluntary assisted dying “has provided funding and shone a spotlight on the activities of palliative care”.
Voluntary assisted dying was first made legal in the Australian state of Victoria in 2019, with all other states following suit in the years since. Many of the states use centralised dispensing for substances used for assisted dying, rather than individual pharmacies.
The PDA’s evidence highlighted the ‘conscience clause’ in the state of Victoria as one that “fully respects the right of all registered health practitioners to exercise their conscience”.
What’s next?
The Westminster assisted dying bill will now move to the committee stage in Parliament, where it will be examined in detail, before reaching the report stage, where amendments can be made. No timetable has been set for this, or for when the full bill will return for a further vote of the whole House of Commons at its third reading.
The Scottish bill has been passed to the Scottish parliament’s Health, Social Care and Sport Committee and it is expected to begin hearing evidence soon.
It is likely to be some time before either bill could become law, if they are approved at all, but the view among pharmacists and pharmacy bodies is perhaps best summed up in a joint position statement issued by all four UK chief pharmaceutical officers in November 2024.
It says that pharmacy professions “will be unanimous on two things”: that the provision of good end-of-life care for all, including work done by palliative care clinicians, must not be undermined; and “that individual pharmacists and pharmacy technicians… should be able to exercise freedom of conscience” in this area.
“This will, we are sure, be common ground for all sides involved in this complex societal decision.”
