A controversial Bill, titled Terminally Ill Adults (End of Life) Bill, was recently proposed in England. The primary aim of this Bill is to allow adults aged 18 and over who are terminally ill and have the mental capacity to request assistance from a doctor to end their lives. According to the Bill, a person is terminally ill if he has an inevitably progressive illness, disease, or medical condition that cannot be reversed by treatment, and his death in consequence of that illness, disease or medical condition can reasonably be expected within 6 months. Medications that can only alleviate the pain of a terminally ill patient do not alter the definition of the patient as terminally ill. According to the Bill, a person is not considered terminally ill if he has only a mental disorder. 

Under the proposal, two doctors (a coordinating doctor and an independent doctor) must independently assess the request at least seven days apart to confirm that the individual meets the required conditions. These conditions include, among other things, having a clear, settled, and informed wish to end their own life, being a resident of England or Wales, and making the decision voluntarily, free from coercion or pressure.

If both doctors agree that the criteria are satisfied, the individual can apply to the High Court for approval. Upon approval, a 14-day reflection period would follow. After this period, the applicant must make a second declaration to formally request assistance to end their life.

If the doctor remains satisfied that the applicant meets the criteria outlined in the Bill, a life-ending “approved substance” would be prescribed, which the individual would self-administer.

Against this Bill, several arguments can be raised, both practical and moral. Practical arguments include the concern that allowing physician-assisted suicide for terminally ill patients may expose those who do not initially wish to end their lives to undue pressure from doctors or family members. While the proposed law requires two doctors and the High Court to verify the decision, it would still be challenging to convincingly determine whether the patient was influenced by external factors, as such pressure can be exerted explicitly or implicitly.

Another concern is the slippery slope: granting legal permission for physician-assisted suicide for terminally ill patients could eventually lead to allowing it for individuals with mental illnesses. This is problematic because, unlike terminal illnesses where death is imminent and unavoidable, mental health conditions may improve over time, making assisted suicide a premature and irreversible decision. Furthermore, the desire to end one’s life in such cases may arise from impaired judgment rather than a rational and settled decision. Allowing this practice also raises ethical concerns, as it risks devaluing the lives of those with mental illnesses and perpetuating stigma by reinforcing the perception that such lives are less worthy of preservation. An example of such a development is Canada, where the authorization for physician-assisted suicide in cases of mental illness is set to take effect in 2027.

A further concern is that permitting physician-assisted suicide may eventually lead to the legalization of active euthanasia, which involves the physician administering a lethal injection to the patient rather than simply prescribing medication for the patient to self-administer. Active euthanasia is more susceptible to misuse or abuse because it gives the physician full control over the patient’s death. In contrast, assisted dying allows the patient to retain control by administering the medication themselves, which helps ensure the patient’s true, uncoerced consent.

According to these practical concerns, while allowing physician-assisted suicide for terminally ill patients may not be morally problematic, the law should be rejected due to the aforementioned practical risks.

On the other hand, some argue that assisted suicide for terminally ill patients should be prohibited on moral grounds. According to this perspective, a moral distinction should be made between passive euthanasia – Not connecting to a ventilator or not providing medication to a patient – which is permitted in certain conditions, and physician-assisted suicide, which should be prohibited, just as active euthanasia is forbidden. In passive euthanasia, the doctor does not cause the patient’s death. In contrast, in physician-assisted suicide, the doctor performs an active conduct leading to the patient’s death. Although the patient ultimately takes the medication themselves, without the doctor’s active involvement, the patient would not die. Thus, it can be argued that there is not much of a moral difference between physician-assisted suicide and active euthanasia.

The distinction between active and passive behavior leading to death also exists in criminal law, which differentiates between causing harm by act and by omission, in accordance with the distinction between killing and letting die. Indeed, some rulings in the United States have explained that there is a moral distinction between passive euthanasia, which is permitted, and assisted suicide, which is prohibited, based on the distinction between act and omission in criminal law.

Despite this, in my recently published book, I argue that the act/omission distinction in criminal law is not relevant to the differentiation between passive euthanasia and physician-assisted suicide. Therefore, this distinction should not be a reason to oppose the Bill. First, criminal law typically deals with cases where the victim’s death is undesirable and the victim does not wish for it. In contrast, when discussing euthanasia for a terminally ill patient with a life expectancy of only six months, death is not necessarily a bad thing but may be seen as a positive outcome. Second, the rationales given for the distinction between act and omission in criminal law are not necessarily applicable to the distinction between forms of euthanasia. Hence, if passive euthanasia is permitted on grounds of autonomy and human dignity, then it seems consistent to allow physician-assisted suicide for similar reasons.

Dr. Roni Rosenberg is a Senior Lecturer at the Faculty of Law at Ono Academic College and Reichman University.