We must face up to the reality of an opportunity for abusers to seek lawful death for women

There is currently no state provided death in the UK. So we cannot fully predict how abuse of women may play out in practice here.  However, most countries with lawful assisted dying do not look for domestic abuse of women within the operation of their safeguards.  The Australian states do recommend referral of those who are suffering domestic abuse, but not data is published on whether that happens. And it is no bar to receiving Assisted Dying. Most international assisted dying safeguards focus on what is essentially property crime: whether a will beneficiary might be looking out for their money.

But we can look at what has happened here in the UK, and abroad, in deaths which are ‘assisted’.  Our research shows that at least 5 UK men per year violently kill women who are disabled, elderly or infirm, under the guise of mercy killings. How will these homicidal men behave in a world where they can access legal death instead? We know that increases in care needs and transitions like needing to go into a care home can be a trigger for a small number of men to kill. We also know that some men are much more likely to leave a partner when they face a life-threatening illness 12. We should prepare for the reality that we see a new version of this if assisted dying is introduced: with women coerced by male partners who ‘cannot bear to see them suffer’ into seeking assisted dying. That these women may have been going to die anyway does not mean this is not a monstrous outcome.

Globally though, there is poor data availability: most academic and state research on Assisted Dying vulnerabilities looks at broad brush analysis of equalities data: e.g. are lower income people over or under represented in those seeking death? Is it good or bad if we see more women than men? This belies the lack of information available to researchers on those seeking state provided euthanasia or suicide.  We will not know if women are being abused, if we do not look for this, and crucially, if their deaths are secret. 

Abuses of power thrive on secrecy

Our current system has both inquiry and publicity

As we have seen, our existing law allows men to go free after committing terribly violent killings of women. But we only know this due to the layers of inquiry and publicity in our current system. Presently, when the state becomes aware of an “assisted” death, there will be:

• a criminal investigation by police to establish facts

• An inquest, usually public

• for assisted suicides: almost always no prosecution

• for mercy killings and failed suicide pacts, a policy of prosecution in all cases where there is sufficient evidence (until late 2023)

• A criminal trial, with additional background information to support sentencing

• Press reporting, so that the public can hear about what happened.

• Post trial Domestic Abuse Related Death Review, accessing family, friends, state databases in order to find evidence of domestic abuse and learnings for state agencies.

This approach means that some involved in the death of another will feel unfairly pressured and exposed at time of grief. But it means we have a chance at understanding what happened, and catching those who have murdered.

The 2006 killing of Mandy Horne in Shetland was widely reported as a Romeo and Juliet, mercy killing by her husband - Mandy had MS. Both died so there was no investigation. Only through Mandy’s father and a curious Times journalist was it later revealed to be a very violent murder and suicide by Mandy’s husband: he’d also killed their pets. The night before she died, Mandy had asked friends to stay because she was scared of her husband.

This paper includes only limited information on deaths that are deemed to be assisted suicides: because these are rarely prosecuted, we don’t know about them. Since 2023, 2 men have been convicted of murder in mercy killings. But we don’t know if there are others who might once have been prosecuted (and found guilty of manslaughter or not guilty). There is no public information on these decisions.

 But with state-provided assisted deaths, secrecy is built in

Secrecy is built into the latest assisted dying proposals in the UK.  This is also true of countries thought to be exemplars like Oregon and the Australian states.

In Oregon, death certificates do not include a note of assisted dying. All provider information on assisted deaths is deleted after the annual report is prepared 13. This simple data report does not, and would not, reveal the kind of abuses we fear here.

Here is the kind of safeguarding failure that could hide someone coerced into homicide:

“The other case of non- compliance was where someone signed an application document on behalf of an applicant and was also a witness to the document, which is prohibited by the Act. After investigating the case, the Review Board considered this was an oversight and the case   was considered clinically appropriate” Victorian Voluntary Assisted   Dying Review Board Report, 2021-22

Note there is no consideration of whether the applicant had in fact consented to assisted death. There is no criminal investigation, no public trial or hearing, or news reporting for anyone to understand if there was a different story.

Even this failed safeguard is greater than that in the Leadbeater bill in the Commons, which explicitly allows another person as “proxy” to sign the forms. This person can have known the person for 2 years, or just be someone of good standing in the community. Essentially anyone.

We can also learn from Canada, which has shared history and common language, and a legal system drawn from ours.  In Canada, there are stories now emerging of families who have tried to prevent their relative being given MAID—as they believe they are not terminally ill. Families cannot get access to medical records to understand if their relative was coerced 14.  The state protects itself and those who are involved in delivering death.

There is a tremendous push for secrecy around these deaths before they happen—in the name of patient privacy…. Feminists know to be suspicious of secrets, especially when the result is the death of women. Abuses of power thrive on secrecy. Professor Janine Benedet KC on Canada’s MAID 15.

Here in the UK, former head of the family court James Munby says this on the Kim Leadbeater bill before parliament. This Leadbeater bill asks High Court judges to review the assisted suicide applications.

“ If there is to be a judicial process, it must, as I have said, be open and transparent. The very suggestion that the process should be private, confidential, shrouded in secrecy, is surely anathema to any judge who might be involved… we face an impossible choice: between an open and transparent process that might deter those for whom the scheme is designed, and a secret process destructive of the integrity of the scheme and corrosive of the judicial function.” Sir James Munby, former head of the Family Court 16

 Scope for abuses of well intentioned law

Practical expansions of the definitions beyond parliament’s imagining

Even if the law does not change in response to campaigning and legal challenge, as it has elsewhere, day-to-day practice can widen definitions.

Providers—doctors tasked with approving and delivering assisted suicide—may expand the definition of terminal illness to encompass illness that they decide cannot be treated. This may include eating disorders, with more than 60 people killed by assisted suicide worldwide. This includes the US where only those with a terminal illness are supposed to access assisted suicide. One woman with anorexia, Jane, told researchers at Eat Breath Thrive charity that she was offered MAID in Colorado:

“I was told that, although I wasn’t yet 30 years old at the time, [my doctor] would ‘make an exception’ for me and ‘allow’ me to die, if that was my choice. It didn’t feel like my choice — I felt coerced... I’m not sure how to describe it, but something inside me wouldn’t let me take   the MAiD. Jane, anorexia survivor 17

There were 26,000 people admitted to hospital with eating disorders in 2023, 97% of them women 18. Without treatment, they may be deemed to be terminally ill and approved for assisted suicide under the Commons bill.

Further, in Canada, denying food and drink can allow people to meet the “reasonably foreseeable death” in the eligibility criteria for the MAID programme. This decision by the doctors who provide MAID assessments now wildly expands the scope of the law in Canada—even to those who say they don’t want certain treatments for future ailments.

“[a] person may meet the ‘reasonably foreseeable’ criterion if they have demonstrated a clear and serious intent to take steps to make their natural death happen soon or to cause their death to be predictable. Examples might include stated declarations to refuse antibiotic treatment of current or future serious infection, to stop use of oxygen therapy, or refuse turning if they have quadriplegia, or to voluntarily cease eating and drinking.” Canadian Association of MAiD Assessors and Providers 19

Softening the moral boundary on killing dying,   disabled or elderly women

If it becomes acceptable for women to seek death, will society care less if an already life limited, disabled or elderly woman is killed? In Canada, they do not have our long tradition of giving those who ‘mercy’ kill partners a suspended sentence. But since MAID was introduced, one man has successfully claimed so:

Consider the recent manslaughter conviction and compassionate sentence given to Francois Belzile, who deliberately gave multiple insulin injections to his disabled female partner, killing her. Although he was initially charged with first-degree murder, the prosecutor was willing to accept a guilty plea to manslaughter, and the judge sentenced him to house arrest because he allegedly suffered from “caregiver burnout.” It seems unimaginable that a woman who killed her husband in similar circumstances would be viewed so sympathetically. Professor Elizabeth Sheehy. 20

This is the opposite outcome to a previous and high profile Canadian carer killing, where a man called Latimer  was imprisoned for murdering his 12 year old daughter in the 1990s. Now MAID is here, Belzile’s lawyer told the judge in sentencing, “things have changed since Latimer… at least in Canada”.  This post-MAID argument appears to have worked in gaining only house arrest for the killing of Belzile’s female partner.

Encouraging suicidality of vulnerable women

Nowadays we know that normalisation and publicity around suicide can inspire suicidality in others. Assisted suicide provided by the state brings an alarming new dimension to this—particularly in the UK proposals in parliament which allow doctors to suggest assisted suicide to patients.

• The family of one victim of MAID track 1 in Canada describe how she was approved for death after suffering mental health conditions in response to a car crash. Otherwise healthy, she restricted her diet and this was enough to have her deemed terminally ill. Her daughters were able to seek temporary psychiatric hold for her but their mother was given euthanasia on release.21

• Canadian women seem 2 times more likely to seek MAID track 2—which allows for those with non “reasonably foreseeable” deaths to die 22.

• Women make up 69-80% of those given psychiatric euthanasia where this has been launched, such as in Belgium 23.

• In the 1980s young, sometimes disabled, women were commonly reported to have used suicide manuals provided by assisted dying campaign groups the Voluntary Euthanasia Society and Scottish EXIT, although these manuals were claimed to be for the incurably ill 24.

• One stalker in Scotland has already been convicted of repeatedly arranging calls from Dignitas for her victim 25.

Suicidality after domestic abuse

We are now recognising that suicide of women after domestic abuse is potentially more common than homicide by their abuse partners 26. As we have seen, women seem particularly vulnerable to the offer of suicide by state.  It is impossible not to imagine a scenario that a woman in abusive situations would find it easier to access NHS assisted dying than support to create new life away from her abuser.  The law’s safeguards must prevent this woman ever being given easier route to death by the state.

Coercion by ‘the process’

As others have raised, people can find themselves going along with a process if they feels it may please the doctor27.  And for those with conditions which are challenging to treat, it may feel like here is a clear, efficient process, and finally something that doctors know how to help with. Consider this family quote from the Australian VAD handout 28:

“The voluntary assisted dying process was really the first time that any medical and allied health practitioners had given such understanding and empathy to my sister's suffering, and that was such a relief."

This funnelling is to some extent built into the Leadbeater bill which requires any doctor who refuses a patient Assisted Dying, to automatically refer them to someone else who can reassess them.

This easy path is a particular worry for women who suffer with immune conditions or eating disorders which are deemed difficult by the medical profession.

This is playing out in Canada’s MAID Track 1 29:

“We're not collecting the data properly-or at least it's not being reported-except we have seen some increases in striking things. The largest area of increase, I believe, was the "other" category. That went up to 15%-and that's 15% of 13,000 deaths, I'll remind you. It is now the third most reported category. In that, there is a gender gap' its 17% women to 12.8% men.  The "other" category also includes frailty. You see a similar gender gap, with more women getting MAID for multiple comorbidities, such as arthritis and hearing loss, with 12% versus about 8.3% for males. In all of this, about one-third of people get it citing that they feel they are a burden on their family. There is even more of a gender gap if you then break it down to the non-reasonably foreseeable death, track two, numbers. There, the gender gaps go to up to 60% higher for females than for males.” Dr. K. Sonu Gaind

Self coercion—feeling a burden

Women live longer on average, with more years of poor health 30.  This leaves women in potentially more vulnerable position for longer, and likely to wonder if they are a burden. This is a feeling reported by many who seek assisted suicide:

· 35.3% in Canada perceiving they were a burden on family members31

· 43.3% in Oregon being a burden on family/friends or caregivers 32

· 35.2% of Western Australian patients approved for VAD said they were a burden on family, friends/caregivers, or concerned about it 33.

In Western Australia, 1.6% of all deaths are through assisted dying having only launched in 2021, ’feeling a burden’ should be a red flag for those making the assessments of coercion into dying:

“If a patient is requesting access to voluntary assisted dying because they are concerned that they are a burden on their carers or family, their situation should be explored. This may include investigating additional options for supportive care or respite care. The Coordinating Practitioner and Consulting Practitioner should also seek to understand why the patient has raised this concern and what they mean by it. Some people may say they feel like they are a burden because members of their family are struggling, while others may use this to start a conversation about their struggles with their current situation. Such comments should also raise a 'red flag'...“ Western Australia Practioner Handbook. 34

Despite more than a third of those approved reporting they felt a burden, Western Australian medics decided that everyone who applied for VAD was eligible in acting voluntarily and not being subject to coercion in 2023-24 35.  Feeling you are a burden is no bar to being given death by the state. It is startling that despite the prevalence of domestic and elder abuse in Australia, the assisted dying safeguards for these picked up absolutely no one at all.

 Coercion from those providing death—real lessons from private (and illegal) assisted dying in the UK

 In 1979 and 1980 the UK’s Voluntary Euthanasia Society (VES) would respond to calls from the public with a visit from Mark Lyons. The General Secretary of the VES– Labour Councillor and Oxford Don Nicholas Reed– would triage callers before sending Lyons to them. Lyons dreamed of saving the NHS from “the ailing population”, and would charge £30 per visit.

One woman called the VES in distress at her osteoarthritis as ‘I didn’t want to be a burden to anyone’. But she called again to tell them she did not want to die. Ignoring this, Lyons rang her doorbell, told her “you are not going to pull through” and gave her two violent options for death: he would force feed  her pills and suffocate her, or he would hold her head underwater in the bath. He told her “There will be no questioning of my commandment, none at all”. She gave evidence from a stretcher in court on his anger at her mind change: “I had tears in my eyes, I thought ‘this man has come to kill me’...now he was a devilish creature”.

Both men were investigated for 250 deaths, and convicted on charges relating to 7 people, 5 of them women: including sufferers of multiple sclerosis, fibromyalgia, depression and cancer. Reed was jailed (later attempting to appeal his case to the ECHR) and Lyons walked free with the “traditional penalty for Euthanasia, a suspended sentence”.

The VES was not a fringe organisation: the executive committee at the time included a leading author, a professor of philosophy, the chairman of the Liberals Lord Beaumont, and past Vice Presidents included Nobel Laureate Sir George Paget Thomson . One Labour MP protested outside Reed’s criminal trial in his support. VES (then also known as EXIT) now campaigns in the UK as Dignity in Dying 36.

There should be a lesson for us here: high calibre leadership, organisational safeguards and good intentions do not protect against individuals whose wish to kill overrides them.