Limiting the Scope of the Terminal Illness Requirement

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. 

Dr Alexandra Mullock, University of Manchester 

Dr Alexandra Mullock. Image Credit: Author

While the debate on the Terminally Ill Adults (End of Life) Bill rumbles on in the House of Lords, death by 1000 amendments looks increasingly probable unless the obstruction can be effectively managed. Many amendments, such as the pregnancy test requirement, discussed here last week by Richard B. Gibson, appear to sharply divide opponents and supporters of lawful assisted dying, but others seem to be more constructively aimed at improving the Bill. One such constructive concern is the definitional parameters of terminal illness, and how best to avoid allowing lawful assisted dying (AD) to extend to those deemed vulnerable. This blog considers those considered vulnerable due to an eating disorder, or those suffering from other conditions who might refuse to eat and drink in order to attempt to be deemed terminally ill. 

The challenge of protecting those who might be vulnerable to lawful AD seems to be one of the main reasons why AD has hitherto been rejected by the English parliament. Limiting access to terminally ill adults expected to die within six months is intended to restrict access to those who are dying from an incurable physical condition, defined in clause 2(1)(a) as ‘an inevitably progressive illness or disease which cannot be reversed by treatment’. The risk that individuals suffering from an eating disorder, such as anorexia nervosa, might be eligible for AD has been a key concern. Opinions divide on whether it is ever clinically appropriate to regard intractable anorexia as a terminal condition, but the obvious concern is that doing so is detrimental to those suffering from this illness. Whichever view is preferred, the fact that anorexia nervosa can become a fatal condition is clear and has been reluctantly accepted by the courts. Allowing someone with advanced anorexia to die, however, is legally (and almost certainly morally) distinct from helping them to die. While there appears to be agreement in the English parliament that the law should hold that line, just how far the safeguards should go is a source of dispute. Whether a person should be able to refuse a treatment that they regard as too burdensome, but which might extend their life, is a related and crucial point of conflict. 

Debate on several amendments discussed on 6 Feb 2026 explored the grounds for compromise between opponents and supporters of the Bill on the issue of physical illness caused or accelerated by refusing nourishment, coupled with a refusal of treatment. While this concerns those with anorexia, it might include others with non-terminal conditions who choose to stop eating and drinking as a route to become terminally ill, and thus eligible. This was reported to have occurred in Oregon in the case of Cody Sontag, who suffered from early-stage Alzheimer’s disease. What is perhaps overlooked by opponents of the Bill is that if a person with capacity being treated in an end-of-life context wishes to hasten death and so chooses to stop eating/drinking, that wish must be respected with medical support provided to ease suffering. Thus, the current law respects a competent patient’s autonomy as a negative right (to refuse treatment). The issue here is, under the safeguards proposed in the TIA Bill, would a refusal of either treatment or nourishment, which would render a person sufficiently terminally ill, permit them to receive help to die?  

Without further amendment, requiring an inevitably progressive condition would appear to preclude any eating disorder, but not necessarily a progressive illness that is not (yet) sufficiently terminal, but could be if not eating/drinking was added into the mix. Amendment 87 seeks to avoid any possible obfuscation by clarifying clause 2(2): 

“Where— (a) a person does not eat or drink, or limits their eating or drinking, (my emphasis) because of a mental disorder, and (b) their not eating or drinking, or limited eating or drinking, causes them to have an illness or disease, the person is not regarded for the purposes of this Act as terminally ill by virtue of the illness or disease.” 

A further tweak (87A) is proposed, to add after ‘drinking’; ‘…either voluntarily or…’. While this would address the Cody Sontag scenario, it would leave such individuals with a stark choice: attempting other routes to death – stopping eating/drinking or suicide – or living on in hope that life will be bearable. Reflecting on the position of a person with a serious, progressive physical illness who is sufficiently determined to hasten death that they stop eating/drinking, the HL must now decide whether it is cruel to prevent them from accessing AD or necessary to attempt to prolong their life.  

Other amendments (92-95) deal with treatment refusal, such that refusing treatment that can ‘meaningfully halt, stabilise, or control the progression of an inevitably progressive’ condition should not be permitted to render a person eligible for AD. However, a treatment that ‘only temporarily relieves symptoms without affecting the course of the illness is not to be regarded as a treatment that prevents it from being terminal.’  This seems more compassionate than the eating/drinking amendment, although interpreting the wording is crucial. What might a meaningful stabilising or controlling of a person’s condition involve or look like? And what if there was disagreement? Would this be a purely objective, clinical assessment or would the patient’s subjective view prevail, or at least be important, as the Supreme Court has established on similar legal questions? 

Elsewhere in and around the UK (the Isle of Man, Jersey, and Scotland), similar questions about eligibility and the potential longevity of people seeking AD are being decided. As the respective proposals currently stand, the English bill is most similar to the Isle of Man law (currently awaiting Royal Assent), in terms of demanding ‘an inevitably progressive condition which cannot be reversed by treatment’, and which is reasonably expected to cause death within six months. The Manx law, however, is silent on the prospect of a person satisfying the terminal requirement by ceasing to eat or drink, which seems to leave this as a possible route to becoming eligible.  

The Jersey draft law is significantly less restrictive than its English counterpart. The ‘health criteria’ demands ‘a physical condition that is expected to cause their death within the required period of (i) 6 months; or (ii) 12 months if the condition is neurodegenerative.’ There is no mention of the physical condition being ‘inevitably progressive’, so anorexia causing a physical decline expected to cause death would appear to be included. Nor does the Jersey draft law demand that the condition be untreatable. Instead, treatment that is too burdensome from a subjective perspective may be refused.  

Finally, in Scotland, the draft bill limits eligibility to those with ‘an advanced and progressive disease, illness or condition from which they are unable to recover and that can reasonably be expected to cause their premature death.’ This flexible and subjective approach to terminal illness would seem to include anorexia or indeed any condition that the patient seemed unable to recover from, with no substantive limit to how long a person might survive. We therefore see that, with or without the amendments discussed here, if the TIA Bill becomes law, the eligibility requirement regarding the parameters of terminal illness will be stricter than in other neighbouring jurisdictions based on the current proposals for lawful assisted dying.