Beyond Legalisation: The Overlooked Challenges of Implementing Assisted Dying in the UK

The Terminally Ill Adults (End of Life) Bill has been described by many as one of the most significant shifts in the legal landscape of England and Wales in our generation. Whether this claim overstates the matter is open to debate. What is not in dispute, however, is that the Bill raises profound questions about the relationship between the state and those it governs. Unsurprisingly, its existence, proposals, and suggested amendments have generated extensive discussion and controversy. In this blog series, leading voices in the field of assisted dying reflect on the Bill, what it means for the state to sanction the deliberate and knowing ending of an individual’s life, and how we might tread a path forward.

Suzanne Ost, Lancaster University & Nancy Preston, Lancaster University

Introduction

The content of the Terminally Adults (End of Life) Bill (hereafter TIAB) and the model of assisted dying that it would legalise are at risk of being overshadowed by the continuing uncertainty regarding its fate. However, whilst the increasing likelihood of the TIAB falling in the House of Lords before the end of the current parliamentary session looms large due to the sheer, unprecedented volume of amendments at committee stage, the question of how assisted dying (AD) would be provided in a publicly funded health care system is still pressing. Lord Falcolner’s amendments at Committee Stage in the House of Lords would impose a duty on integrated care boards, NHS England or the Secretary of State to arrange for the provision of voluntary assisted dying services, allowing for these services to be commissioned, and requiring them to be regulated by either or both the Care Quality Commission and NHS England (amendments 749B and C). However, how these services will be provided remains absent from the TIAB.

Should the TIAB fall then, even if it were not to be resurrected through the Parliament Act 1911 in the next parliamentary session - thereby confirming the at least short-term demise of the opportunity for legal reform in England and Wales - steps towards legal reform continue at pace in Scotland and in the Crown Dependencies of Jersey and the Isle of Man.

Implementation challenges

The in-principle questions of whether AD should be lawful and, if so, how it should be regulated, often dominate the AD debate in the academic literature. However, the matter of how AD should be implemented once legalised has attracted less attention. Yet, in our view, this matter is just as significant as legalisation and regulation. This is supported by the extension of the implementation period for the TIAB from two years to four years (if it were to become law), and by the ‘very detailed yet cautiously ambiguous collection of estimations’ of the costs and resources of providing AD set out in the Department of Health and Social Care’s Impact Assessment, published in 2025.

In the event of any legislation of AD in one of the UK or Crown Dependency jurisdictions, it will be necessary to grapple with the challenge of how to provide AD free of charge to eligible residents. For Scotland, England and Wales, the AD model envisaged would be implemented through, or commissioned by, the NHS. The equitable case for a publicly funded AD service is strong, especially compared with the only currently available, costly option of travelling to Dignitas in Switzerland for those who can afford it. However, the reality of what ‘AD on the NHS’ would look like is less straightforward.

Elsewhere, with Alexandra Mullock, we have considered the possibilities and implications of situating AD within or alongside existing end-of-life NHS and other provision, or as a hybrid private/state-supported model. We emphasise the real challenge of achieving a more ‘holistic approach to end of life care and choice that assisted dying would be part of,’ as envisaged by Kim Leadbeater, within a system that provides complex end-of-life care across hospitals, hospices, care homes and at home. 

There are other alternative, less medicalised AD models, through which AD provision is offered by right-to-organisations with volunteer doctors assessing, prescribing. and assisting, such as in Switzerland. But the international landscape and the models under all the AD bills in and around the UK evidence a strong preference for the security and safeguards that some form of medicalised AD is considered to offer.

Post-implementation Challenges

If the TIAB were to become law, there would also likely be intersecting systems challenges in practice that would affect the accessibility of AD. Although there is no institutional-level right to conscientiously object under the Bill, an institution would be free to decide whether or not to be involved in or permit assisted dying on its premises. During the TIAB’s passage through the House of Commons, Kim Leadbeater explained the underlying rationale for this position as being one of leaving hospices, care homes, and palliative care providers free to decide whether to be involved in the provision of AD. However, the potential impact of an institutional-level decision not to have any involvement with AD on access to AD for those patients residing at that institution could be significant, especially if this decision is not made public. Research from Canada has shown that institutional attitudes towards AD can soften over time, but that some institutions, especially those with faith-based objections, maintain a firm stance of opposition, ‘resulting in forced transfers and negative emotional and psychological impacts on patients, family members, and health practitioners.’  There is also evidence from the US that even discussions about the possibility of an AD can remain inaccessible.

Additionally, there is the vital question of whether an AD service will be sufficiently staffed. In the Australian state of Victoria, where AD has been lawful since 2017, the Voluntary Assisted Dying Review Board has consistently highlighted sustainability concerns in recent years, stating in its most recent report that ‘continuing to rely on a small number of practitioners is a significant risk to the sustainable delivery of an equitable VAD program’. This also highlights the emotional labour experienced by health care professionals involved in delivering an AD service – not just those who actually provide the assistance, but also those who support patients and their families through the process (such as care navigators in Australian states and some Canadian provinces). The absence of provisions to ensure support for health care professionals’ wellbeing in the TIAB has been noted by the Royal College of Nursing. The College has recommended that the Secretary of State could be required ‘to lay regulations within a specified timeframe as a prerequisite for the substantive provisions of the Bill to come into effect,’ setting out ‘psychological support for healthcare professionals involved in assisted dying’. Just as importantly, the level of support that patients receive throughout the process - whether deemed eligible for AD or not - will be crucial. This remains an under-researched area.

Finally, we note the significance of cultural challenges. Whilst legalising AD should obviously have an impact on existing taboos that currently surround it, it will take some time to shift the culture of not openly discussing AD as an accepted end-of-life process and the stigma that may prevent some patients from revealing their choice to request an AD to their loved ones and friends. This underscores the need for parallel cultural and educational initiatives during the implementation stage to ensure that legal change translates into meaningful, stigma‑free access in practice.

The reality of AD provision in practice versus the law on paper

Medicalisation can offer an (albeit contested) means of regulation of and control over the boundary between the lawful and the unlawful, as demonstrated by abortion law and by AD laws elsewhere that have retained strict medical criteria. Certainly, it is a medicalised model that is most often seen in the growing number of jurisdictions that have legalised some form of AD. However, in any jurisdiction with a publicly funded health system, medicalisation generates reasonable expectations that AD will be accessible (‘free’ on the NHS) for those seeking AD who are eligible and sufficiently resourced. This in turn raises pressing questions about how such services would be delivered in practice, how to balance competing demands on limited healthcare resources, and how the wellbeing of patients, their families, and the healthcare professionals involved in the AD service would be supported.