Dr Jennifer Dvorak explains how when considering a change in law for assisted dying we must consider social influences and ensure it does not become a normalised part of medical care.

The prospect of assisted dying is facing us square on as parts of the British Isles look set to change their laws – notably, Jersey, the Isle of Man and Scotland.  

Those advocating for the ‘right to die’ do so from the perspective that it is their personal choice; a right to a private life, which should also support choice in the manner and timing of their death. But is assisted dying a matter of personal choice, or is it a broader public issue?

It was C. Wright Mills who famously introduced the concept of the ‘sociological imagination’ – the significance of making connections between the challenges that individuals face and the social and economic inequalities and political and cultural barriers that give context to, and shape, these troubles. Since Mills, sociologists have long espoused the need to consider how the personal and the political intersect; in the field of medicine and, in particular public health, sociological thinking has informed a wide range of research into the importance of considering structural vulnerabilities in clinical groups, healthcare disparities, and the social determinants of health.

The problem of assisted dying cannot be simplified as an individual ‘right’ to die or only as a matter of personal choice, instead, it must be explicitly considered as a public issue.

Structural vulnerabilities as drivers for assisted dying

A significant wealth of evidence has focused on how social conditions can become drivers for assisted dying and that individuals do not, and should not, bear the responsibility for wider social issues like cuts to public health and social care provision and services, or rising living and care costs that cannot be met by personal finance.

This structural recognition and focus is important in the UK context in which demographic trends highlight longer but comprised lifespans. The Care Policy and Evaluation Centre have projected that these demographic pressures will increase adult social care demand and expenditure by 43% from 2018 to 2038.

Similarly, adequate access to support for terminally ill persons would need consideration – evidence suggests that families including someone with a terminal illnesses face significant financial pressures and the current welfare provision is inadequate – access to benefits is only possible if someone has less than 6 months to live –which may also present assisted dying as a way out of financial trouble and a desirable option when there appears to be no other alternative.

When considering the viability of assisted dying legalisation and regulation, it is essential to consider how assisted dying applications must be just that – applications – and how they must not be presented as an option as part of a normalised medical trajectory. This would run the risk of medicalising social inequalities, framing them as personal troubles to which assisted dying becomes an appropriate – and even ‘responsible’ – personal solution.

Learning from other jurisdictions

We ought to learn from other jurisdictions that have legalised assisted dying. Former Paralympic athlete and veteran, Christine Gauthier, has openly documented concerns over Canada’s MAID (Medical Assistance in Dying) model, noting that on request for a disability ramp she was instead offered advice on accessing MAID by Veterans Affairs Canada (VAC), information that at least four other veterans had similarly reported being offered. Veterans Affairs have denied the claims. But the normalisation of MAID as an option for those experiencing disability both reinforces their precarity and vulnerability and shapes their ‘choices’.

Reviewing and regulating assisted dying

Ensuring that social demographic review is built into any legalised assisted dying regulatory regime will be an essential consideration for the UK. The BMA recently updated their recommendations on assisted dying. Included in these recommendations, alongside an ‘opt in model’ and the delivery of assisted dying as a ‘separate service,’ is the incorporation of a ‘review of all assisted deaths’. But the significant question is in relation to the timing and purpose of a review. A prospective socio-legal model that assesses, approves, or declines requests for an assisted death before they take place would offer a protective mechanism for doctors who ought to be able to avoid prosecution.

More than this, a prospective socio-legal model would offer much better social care and would ensure that demographic trends are recorded, that social care and end of life care spending fully supports citizens, and that end of life decisions are not the result of poor social care provision or financial concerns but, instead, are autonomous choices.

This is essential if we are to ensure that assisted dying does not become a normalised part of medical care such that those deemed ‘the right kinds of people suitable’ for an assisted death (i.e. the disabled, elderly, or infirm) ‘choose’ this pathway when the onus would be better placed on societal change instead.

Dr Jennifer Dvorak is a Senior Lecturer in Sociology and Criminology for the School of Law, Policing and Social Sciences. In 2023 she had a BMJ Rapid Response published: Demedicalising assisted dying & safeguarding through a civil law model  (Rapid Response to Preston et al Breaching the stalemate on assisted dying: it’s time to move beyond a medicalised approach, BMJ, 2023 382: p. 1968)